8. Vulvar itch, vaginal discharge, and sexually transmitted disease Flashcards
Describe history: Vulvar itch, vaginal discharge, and STDs (14)
- Vulvar Sx (burning or pruritus)
- Vaginal discharge (consistency, color, odor)
- Progression of Sx
- Previous investigations, including cultures, swabs, etc.
- Rx attempted, including antibiotics, antifungals, etc.
- Hygienic practices
- Dysuria (internal vs. external)
- Abdo pain
- Presence of IUD
- Prev. infections
- Menstrual Hx
- Sexual activity, including number of partners, new partners, barrier protection use
- Pregnancy Hx
- PM H x, including H x of diabetes
Describe physical exam: Vulvar itch, vaginal discharge, and STDs (6)
- Inspect external genitalia
- Edema, excoriations, ulceration, condylomas, discharge on the perineum or introitus
- Assessment of inguinal and/or femoral lymph nodes: lymphadenopathy
- Speculum exam:
- Vaginal discharge and lesions, evidence of characteristic lesions (e.g., strawberry cervix of trichomoniasis), presence of cervical discharge
- Assess the presence of cervical and upper genital tract inflammation: Cervical motion tenderness, adnexal tenderness
- Assess the presence of systemic Sx: Fevers, abdo tenderness
- Perform perianal inspection, pharyngeal inspection
Describe investigations: Vulvar itch, vaginal discharge, and STDs (7)
- Vaginal swabs
- Vaginal discharge sample wet mount
- Culture of the endocervix for gonorrhea or chlamydia infection
- Pap test (biopsy if any suspicious areas)
- UrineR&M, C&S
- Vaginal pH (using phenaphthazine paper)—may be altered by lubricating gel, semen, douches, or intravaginal medication
- CBC, specific blood tests (VDRL, treponemal tests, HSV PCR, HAV, HBV, HIV)
Describe: Normal vaginal Discharge (3)
- Physiologic vaginal discharge (1–4 mL of fluid daily)
- pH of normal flora is acidic (4.0–4.5)
- Discharge may ↑at times (pregnancy, use of E contraceptives, mid-cycle).
- ↑mid- cycle due to ↑ cervical mucus → can be malodorous and can be accompanied by irritative Sx
Describe: Vulvovaginitis (2)
- Inflammation of the vulva and vagina due to both infectious and noninfectious causes
- Sx of vaginitis are nonspecific → physical exam and lab findings are required to make a definitive Dx
Name types of infectious vaginitis (4)
- Bacterial vaginosis (40% –50% of cases—most common cause of vaginitis in women of reproductive age)
- Vaginal candidiasis (20%–25% of cases)
- Trichomoniasis (15% –20% of cases)
- Other (less common):
- Atrophic vaginitis with 2° bacterial infection
- Foreign body with 2° infection
- Streptococcal vaginitis (group A)
- Ulcerative vaginitis TSS
- Idiopathic vulvovaginal ulceration related to HIV
Name types of noninfectious vaginitis (5)
- Atrophic vaginitis
- Chemical or other irritant
- Allergic, hypersensitivity, and contact dermatitis
- Neoplastic
- Other:
- Traumatic vaginitis
- Postpuerperal atrophic vaginitis
- Desquamativein ammatoryvaginitis
- Erosive lichen planus
- Lichen sclerosis
- Lichen simplex chronicus
- Collagen vascular disease, Crohn disease
- Behçet syndrome
Name causative agents: Bacterial vaginosis (4)
- G. vaginalis
- Bacteroides
- Peptostreptococcus
- M. hominis
Why is it important to treat Bacterial vaginosis in pregnancy? (1)
↑ Risk of preterm birth
Name signs and sx: Bacterial vaginosis (2)
- Predominant complaint of vaginal odor
- ↑ Risk with uterine manipulation
Name Diagnostic Criteria: Bacterial vaginosis (4)
Amsel criteria (3 of 4):
- Thin homogeneous vaginal discharge
- Clue cells on N/S wet mount or Gram stain
- Positive Whiff test on KOH wet mount (presence of characteristically “ shy” [amine] odor)
- Vaginal pH > 4.5
Name RX options: Bacterial vaginosis (3)
- Metronidazole 500 mg PO b.i.d. × 7d
- Metronidazole 5 g pv daily × 5d
- Clindamycin 5g pv × 7d
Name causative agents: Vaginal candidiasis (3)
- C. albicans
- C. glabrata (less common)
- Associated with antibiotics use, DM, immunosuppression
Name signs and sx: Vaginal candidiasis (3)
- Vulvar/vaginal pruritus
- Vulvar erythema, edema, fissures excoriations, external dysuria
- Thick occulent white discharge
Name Diagnostic Criteria: Vaginal candidiasis (3)
- Normal vaginal pH (4–4.5)
- Hyphae and buds on saline wet mount (yeast)
- Positive yeast culture from the vagina (many asymptomatic women have vaginal yeast colonization)
Name RX Options: Vaginal candidiasis (2)
- Fluconazole 150 mg PO once
- Clotrimazole 500 mg tablet p.v. ×1 or 5 g pv × 3d
Name causative agents: Vaginal trichomoniasis (2)
- T. vaginalis
- Facilitates HIV transmission, associated with PROM
Name signs and sx: Vaginal trichomoniasis (3)
- Dyspareunia
- Vaginal pruritus, vulvovaginal erythema “Strawberry” cervixon exam
- Timing: ↑ common during/ immediately after menses
Name diagnostic criteria: Vaginal trichomoniasis (4)
- Trichomonas (motile agellum) seen on N/S wet mount
- High number of Polymorphonuclear leukocytes (PMNs) on saline microscopy
- Positive culture for T. vaginalis
- Vaginal pH 5–6.0
Name rx options: Vaginal trichomoniasis (3)
- Metronidazole 2 g PO × 1
- Metronidazole 500 mg PO b.i.d. × 7 d
- *Must treat sexual partners simultaneously to prevent reinfection
Who to Test for Gonorrhea and Chlamydia (5)
- Sexually active and < 25 yr
- In all patients who have a fever and lower abdo pain
- A symptomatic sexual partner
- A new sexual partner or more than one sexual partner
- Other STI diagnosed
Name causative agent: Gonorrhea (1)
N. Gonorrhea (diplococci)
Name signs and sx: Gonorrhea (12)
- Cervicitis, PID
- Mucopurulent discharge vagina
- Rectal pain and discharge
- Dysuria, dyspareunia
- Perihepatitis (Fitz-Hugh-Curtis)
- Lower abdo pain
- Abnormal vaginal bleeding
- Chorioamnionitis/endometritis
- Bartholinities
- Conjunctivitis
- Pharyngeal infection
- Disseminated infection (arthritis, dermatitis, endocarditis, meningitis)
Name dx criteria: Gonorrhea (4)
- Nucleic acid testing from endocervical specimens (sensitivity 96% )
- Gram stain of cervical swab sample
- Culture from endocervix, pharynx, rectum, conjunctiva
- Usual incubation period is 2–7 d
Name rx options: Gonorrhea (6)
- Recommended: Cefixime 800 mg PO × 1
- or: Ceftriaxone 250 mg IM × 1 plus Azithromycin 1 g PO × 1
- or Doxycycline 100 mg PO b.i.d. × 7d
-
Alternative
- Azithromycin 2 g PO × 1
- or Spectinomycin 2 g IM × 1
- plus Co-treatment for chlamydia
- Mandatory reporting
- Rx/F/U of partners with contact within 60 d of Sx onset
Name causal agent: Chlamydia (2)
- C. trachomatis
- Serotypes D, E, F, G, H, I, J, K (obligate intracellular bacteria)
Name signs and sx: Chlamydia (8)
- Majority of cases → asymptomatic
- Vaginal discharge
- Dysuria, dyspareunia
- Lower abdo pain
- Conjunctivitis
- Proctitis
- Reactive arthritis
- Incubation period can be up to 6 wk
Name dx criteria: Chlamydia (2)
- Nucleic acid testing assay from endocervical, urethral, or urinary specimen
- Throat and/or rectal culture of C. trachomatisc
Name rx options: Chlamydia (5)
- Recommended: Doxycycline 100 mg PO b.i.d. × 7 d
- or Azithromycin 1 g PO × 1b
-
Alternative :
- Erythromycin 500 mg PO q.i.d. × 7 d
- or Erythromycin 250 mg PO q.i.d. × 14 d
- Mandatory reporting
- Rx/F/U of partners with contact within 60 d of Sx onset
Name repeat screening of Gonorrhea indications (8)
- All cases 6 mo post-Rx
- Test of cure with culture 3 to 7 d after initiation of treatment when:
- Gonococcal pharyngeal infection
- Patient treated with non recommended regimen, including known antimicrobial resistance
- Suspected treatment failure
- Uncertain compliance
- Reexposure to untreated partner
- PID or disseminated infection
- Pregnancy
Name STI RFs (11)
- Previous STI
- Sexually active < 25 yr of age
- Sexual contact with person(s) with a known STI
- A new sexual partner or > 2 sexual partners in the past year/serially monogamous patients
- IV drug use
- No contraception or sole use of a nonbarrier method
- Sex workers and their clients
- Street involvement, homelessness
- Victims of sexual assault/abuse
- Anonymous sexual partnering
- “Survival sex” (i.e., exchanging sex for money, drugs, etc.)
Name C. trachomatis Repeat testing indications (7)
- All cases 6 mo post-Rx
- Test of cure in 3 to 4 wk recommended when:
- Uncertain compliance
- Patient treated with nonrecommended regiment
- Pregnancy
- Test of cure at 3 to 4 wk is not recommended when:
- Standard treatment regimen has been completed
- Signs and Sx have resolved
- No reexposure to an untreated partner
Must consider ____ in any child diagnosed with gonorrhea and/or chlamydia after the immediate neonatal period.
Must consider sexual abuse in any child diagnosed with gonorrhea and/or chlamydia after the immediate neonatal period.
Suspected or known sexual abuse of children must be reported to child protection agencies.
What is the great imitator as it is associated with a variety of signs and Sx (1)
Syphilis
Describe signs and sx: Primary Syphilis (5)
- chancre (genital ulcer), regional
- LAD
- Ulcer is classically painless
- Resolves in 2–8 wk
- Incubation period: 3-90d
Name dx criteria: Primary Syphilis (1)
Dark field microscopy of serous fluid from genital lesions for observation of spirochetes
Name rx options: Primary Syphilis (2)
1°, 2°, early latent:
- Benzathine Penicillin G 2.4 million units IM × 1
- Doxycycline 100 mg PO b.i.d. × 28 d (if allergic to PCN)
Describe signs and sx: Secondary Syphilis (12)
- widespread symmetric maculopapular rash (palms and soles)
- fever
- malaise
- LAD
- mucous lesions
- condyloma lata
- alopecia
- meningitis
- headaches
- uveitis
- retinitis
- Incubation period: 2 wk to 6 mo
Name dx criteria: Secondary Syphilis (1)
Initial screening with non-treponemal antibody tests (VDRL and RPR)
Name rx options: Secondary Syphilis (2)
- Benzathine Penicillin G 2.4 million units IM×1b
- Doxycycline 100 mg PO b.i.d. × 28 d (if allergic to PCN)
Describe: Latent Syphilis (1)
- asx
- incubation period: 10-30 yr
Describe: Tertiary syphilis (6)
- aortic aneurysm
- aortic regurgitation
- coronary artery ostial stenosis
- Early < 1 yr
- Late > 1 yr
- Incubation period: 10-30 yr
Name dx criteria: Tertiary Syphilis and Latent (1)
If nontreponemal tests positive, perform confirmatory testing
Name Rx options: Late latent,CVS syphilis, and other syphilis not involving CNS (2)
- Benzathine Penicillin G 2.4 million units IM weekly × 3 dosesb
- Doxycycline 100 mg PO b.i.d.× 28 d (if allergic to PCN)
Describe: Neurosyphilis (3)
- form of 3°
- Argyll-Robertson pupil
- Incubation period: 2-20 yr
Name dx criteria: Neurosyphilis (1)
The treponemal tests remain positive for life, even after successful Rx.
Name rx options: Neurosyphilis (1)
Penicillin G 3–4 million units IV q4h × 10–14 db
Describe: Gumma syphilis (4)
- form of 3°
- tissue destruction in any organ
- The specific manifestations depend on the site involved.
- Incubation period: 1-46 yr
Name dx criteria: Gumma syphilis (1)
CSF samples should be taken in those with neurologic or ophthalmic Sx.
Name rx options: Gumma syphilis (1)
Sexual contacts (last 30 d): Benzathine Penicillin G 2.4 million units weekly × 3 doses
Name mode of transmission: Syphilis (3)
- direct sexual contact with infected lesions
- contact with infected blood
- vertical transmission (congenital syphilis)
Name syphilis forms that are considered infectious (3)
1°, 2°, and early latent phases are considered infectious (60% risk of transmission per partner)
Name Syphilis Follow-up Considerations (4)
- Test for other STIs, including HIV, HPV, hepatitis B, chlamydia, and gonorrhea
- Genital ulcers should be tested for HSV, chancroid, and/or lymphogranuloma venereum
- Immunization against HPV and hepatitis A and B if not already immunized
- Syphilis is reportable to public health (1°,2°,and early latent); sexual and perinatal contacts must be tested
Name signs and sx: Herpes HSV types 1 and 2 (11)
- Painful ulcerating genital lesions (80%)
- Atypical presentation (20% ) including genital pain, urethritis, cervicitis
- 1°outreak:
- Painful ulcerative genital lesions
- Systemic Sx (fever, myalgias)
- lymphadenopathy
- Aseptic meningitis (16% –26% )
- Extragenital lesions (10% –28% )
- 2°outreak:
- Residual latent sensory ganglion infection leads to late recurrence(s) in tissues innervated by sacral sensory nerves.
- Prodromal Sx: itching, burning, tingling, or discomfort
- Triggers: stress, illness, or certain medications
- Clinical Presentation: systemic sx (16%), ↓severity/durationof sx, meningitis (1% ), extragenital lesions (8%)
Name dx criteria: Herpes HSV types 1 and 2 (5)
- Cultures from HSV lesions (70% sensitive—ulcers, 94% —vesicles)
- HSV PCR : 100% specific
- Antibody response: early → IgM, followed by IgG
- 3–6 wk to seroconversion after 1° outbreak
- NAAT assay—vesicle fluid or ulcer swab (~100% sensitivity and specificity)
Name Measures to ↓ transmission of HSV (3)
- Counseling (i.e., HSV is not curable, potential for recurrent episodes, sexual transmission, asymptomatic shedding)
- Condom use
- Antiviral Rx to ↓ asymptomatic shedding and recurrent lesions NOTE: greatest RF for neonatal herpes → primary maternal genital HSV-1 or -2
For HSV, must inform which sexual partners? (1)
sexual partners from the preceding 60 d before Sx (due to risk of asymptomatic shedding)
Describe Rx of first episode of HSV (4)
- Urinary retention may be an indication for hospitalization
- Acyclovir 400 mg PO × t.i.d. ×7–10d
- Famciclovir 250 mg PO t.i.d. ×5–7d
- If severe: IV acyclovir 5 mg/ kg over 60 min q8h until improvement
Describe Rx of recurrent episode of HSV (episodic therapy) (3)
- Acyclovir 400 mg PO t.i.d. ×5d
- Valacyclovir 500 mg b.i.d. ×3d
- Famciclovir 125 mg PO b.i.d. ×5d
Name HSV Suppressive Rx for nonpregnant patients (6–9 yr) (3)
- Acyclovir 400 mg PO b.i.d. × 6–12 mo
- Famciclovir 250 mg b.i.d. × 6–12 mo
- Valacyclovir 500 mg daily × 6–12 mo
Name HSV suppressive Rx for pregnant patients (1)
Acyclovir 400 mg PO t.i.d., start- ing at 36 wk gestational age
Name causative agent: Chancroid (1)
H. ducreyi
Known cofactor in HIV transmission
Name signs and sx: Chancroid (3)
- Painful genital ulcers with granulomatous bases
- May progress to inguinal ulcers, painful inguinal LAD
Note: 50% of those exposed develop the disease (incubation period 5–14 d)
Name dx criteria: Chancroid (3)
- Culture of H. ducreyi
- Gram stain of GN coccobacilli with “school of sh” pattern
- Must also R/O T. Pallidum or HSV
Name RX options: Chancroid (5)
- Ciprofloxacin 500 mg PO × 1
- Erythromycin 500 mg PO t.i.d. ×7d
- Azithromycin 1 g PO × 1
- Ceftriaxone 250 mg IM × 1
- Must empirically treat all individuals with sexual exposure in the last 2 wk from onset
True or False
HPV is not reportable in Canada
True
Once genital warts are healed, what is recommended? (1)
routine F/U for cervical CA is recommended
Consider what in children presenting with genital warts? (1)
sexual abuse
Is C/S recommended in HPV? (1)
C/S is not indicated unless warts obstruct the birth canal
Name signs and sx: HPV (5)
- Hpv in infection is requently asymptomatic.
- HPV lesion:
- external genital warts (condyloma acuminata)—multifocal cauli ower-like exophytic fronds → ± pruritus or local discharge
- On cervix, vagina, vulva, or perianal
- D in size and number of warts with pregnancy
- Intraepithelial lesions on Pap smear → cervical involvement (LSIL, HSIL, invasive carcinoma)
- HIV : collaborative care with other specialists is required in patients with HIV due to ↑ risk of cervical CA.
- 90% of patients with external genital warts experience clearance within 2 yr with medical intervention.
Name DX criteria: HPV (6)
- pap test
- HPV typing not indicated for routine. Dx/management of visible genital warts. HPV typing is indicated > 30 with ASCUS
- Coloscopy if high grade squamous intraepithelial lesion (HSIL), atypical glandular cells or invasive carcinoma on Pap test or positive high-risk HPV subtype and negative cytology or persistent ASCUS or LSIL × 2 yr
- Anoscopy: in patients with anal warts due to the risk of anal CA
- Urethroscopy in patients with extensive urethral warts
-
Suspect neoplasia if:
- Pigmented lesion
- Bleeding
- Persistent ulceration
- Persistent pruritus
- Recalcitrant lesions
- Biopsy if lesion suspicious
What RX guarantees eradication of HPV? (1)
No RX
Name Patient applied RX for HPV (2)
- Imiquimod × 3/wk for up to 16 wk. Cream must be washed off after 6–8 h.
- Podophyllotoxin 0.5%, 0.5 mL q 12h × 3/wk for 6 wk
Name Provider-based RX for HPV (4)
- Cryotherapy (liquid nitrogen, CO2)
- Podophyllin resin 10% –25% for 1–4 h, repeated at weekly intervals
- Bi- or trichloroacetic acid (50% –80% solution) weekly for 4–6 wk
- CO2 laser ablation, excision
Name RX for extensive or resistant lesions of HPV (2)
- Excision with electrosurgery
- CO2 laser removal
Describe: Pelvic Inflammatory Disease (5)
- Ascending infection of the upper genital tract from the vagina and/or cervix.
- Sx range from asymptomatic to severe Sx.
- Up to two-thirds of cases go unrecognized.
- 10% to 15% of women of reproductive age will have at least one episode of PID.
- PID is the most common infectious cause of lower abdo pain in women.
Name signs and sx: Pelvic Inflammatory Disease (11)
- Fever > 38.3°C
- Mucopurulent discharge
- Dyspareunia
- RUQ pain
- Dysuria
- Adnexal mass
- Vaginal bleeding
- Nausea/vomiting
- ↑ESR, CRP
- WBC > 10,000/mm3
- Lab confirmation of cervical Dx of chlamydia and/or gonorrhea
Name Risk factors for PID (3)
- STI RFs
- IUDs
- Frequent vaginal douching
Most common causative agent in PID (12)
- C.trachomatis
- N.gonorrhea
- Other:
- E.coli
- Peptostreptococcus
- G. vaginalis
- Prevotella
- Bacteroides
- Streptococcus
- H. influenzae
- T.vaginalis
- M. genitalium
- M. hominis
Name acute complications of PID (5)
- Pelvic peritonitis
- Endometritis
- Salpingitis
- Tubo-ovarian abscess
- Sepsis
Name chronic complications of PID (5)
- Infertility
- Chronic pelvic or abdo pain
- Pelvic/Abdo adhesions
- Fitz-Hugh-Curtis syndrome
- EP
Name PID Minimum Triad (3)
Lower abdo pain + oneofthe following:
- Adnexal tenderness
- Cervical motion tenderness
- Uterine tenderness
Describe: Fitz-Hugh-Curtis Syndrome (2)
- Perihepatitis resulting in adhesions between the liver capsule and the abdo wall.
- Perihepatitis resolves with Rx of PID.
Describe: Inpatient Rx of PID (4)
- Cefotetan 2 g IV q12h + doxycycline 100 mg PO b.i.d. until clinical improvement > 24 h, then continue doxycycline PO only for a total of 14 d
- Cefoxitin 2 g IV q6h + doxycycline 100 mg PO b.i.d. until clinical improvement > 24 h, then continue doxycycline PO only for a total of 14 d
- Clindamycin 900 mg IV q8h + gentamicin 2 mg/kg IV load, then 1.5 mg/kg IV q8h until clinical improvement × 24 h, then doxycycline 100 mg PO b.i.d. or clindamycin 450 mg PO q6h for a total of 14 d
- Note: consider adding metronidazole 500 mg PO b.i.d. × 14 d to all the above regimens
Describe: Outpatient Rx of PID (4)
- Ceftriaxone IM × 1 + either doxycycline 100 mg PO q12h × 14 d or azithromycin 1 g PO × 1 dose, then q weekly × 2 wk
- Cefixime 800 mg PO × 1 dose + either doxycycline 100 mg PO q12h× 14d or azithromycin 1g PO × 1dose, then q weekly × 2 wk
- Levofloxacin 500 mg PO b.i.d. × 14 d
- Note: consider adding metronidazole 500 mg PO b.i.d. × 14 d to all the above regimens
Gold Standard Dx for PID (1)
Laparoscopy demonstrating abnormalities consistent with PID, including fallopian tube erythema and/or mucopurulent exudates
What to do with IUD if PID? (2)
- IUD: the device does not have to be removed during treatment of PID.
- If the patient prefers removal, it should not be removed until at least 2 doses of antibiotic Rx have been administered.
Name Criteria for Inpatient Rx in PID (10)
- Pregnancy
- Appendicitis/EP cannot be excluded
- Adolescence/poor compliance
- Inability to follow or tolerate an oral regimen
- If pelvic or tubo-ovarian abscess is suspected
- Patient previously failed to respond to outpatient Rx
- Patient is immunocompromised
- Dx is uncertain (i.e., need for laparoscopy)
- The patient has severe illness (vomiting, fever, pain)
- HIV-positive patient
Describe: Management of tubo-ovarian abscesses (Figure)
