cervicitis Flashcards
complications of cervicitis?
If untreated, cervicitis can result in Pelvic Inflammatory Disease & lead to higher risk of infertility, ectopic pregnancy & chronic pelvic pain
what causes the s/sx of cervicitis?
edema and increased vascularity, making the cervix appear swollen and reddened → Presence of hypervascularity, erythema & ectopy may be found with either squamous metaplasia or inflammatory changes requiring therapy
how can cervicitis be diagnosed?
histologically when polymorphonuclear leukocytes, lymphocytes, or histiocytes are noted
can cervicitis occur w/o a vaginal dz?
YES
WHAT Is acute cervicitis?
Purulent vaginal discharge is the primary sign and symptom of acute cervicitis → Some women have vaginal bleeding, most frequently after sexual intercourse, although intermenstrual bleeding and bleeding during examination can also occur
what is chronic cervicitis?
-leukorrhea
-may have purulent d/c or thick tenacious, turbid
Intermenstrual or postcoital bleeding may occur → Also associated with lower abdominal pain, lumbosacral backache, dysmenorrhea, dyspareunia, urinary frequency, urgency and dysuria
chlamydia etiology?
Chlamydia Trachomatis
Most common cause of cervicitis
Causes LGV in developing countries → Rare in U
s/sx of chlamydia
May be asymptomatic Mucopurulent cervicitis Increased frequency, dysuria Abd pain, PID, post coital bleeding LVG → PAINLESS genital ulcer → PAINFUL inguinal lymphadenopathy
dx of chlamydia?
Nucleic Acid Amplification → PCR test most spp/sensitive
Cultures, DNA probe
tx of chlamydia
Azithromycin → 1g PO x 1 dose
OR
Doxycycline → 100mg PO BID x 10d
2cd line tx of chlamydia
Erythromycin, Ofloxacin, Levofloxacin
can co-treat with gonorrhea- cetriaxone
complications of chlamydia?
PID, infertility, ectopic pregnancy, premature labor
Reactive arthritis
gonorrhea etiology
Neisseria Gonorrhoeae
IP 3-5 day
s/sx of gonorrhea
May be asymptomatic Vaginal discharge Cervicitis Increased frequency Dysuria
dx of gonorrhea
Nucleic Acid Amplification → PCR most specific/sensitive
Cultures, DNA
tx of gonorrhea
Ceftriaxone → 250mg IM x 1
CO-TREAT for Chlamydia
Azithromycin → 1g PO x 1
Doxycycline →PO BID x 10d
2cd line tx of gonorrhea
Cefixme
Azithromycin 2g can also be given as an alternative but associated w/GI sxs
complications of gonorrhea
PID, infertility, ectopic pregnancy
Reactive arthritis
HSV etiology
HSV-2 causes most genital herpes infxns
HSV-1 causes some through oral–genital or genital–genital contact
s/sx of HSV
Produces cervical lesions similar to those found on vulva
First the lesion is vesicular → becomes ulcer → Heal w/o scarring
what is important to know about HSV primary infxn?
extensive & severe → constitutional sxs of low-grade fever, myalgia & malaise x ~ 2 weeks
pt educations for HSV
Virus continues to reside in the nerve cells of the affected area for life → Can shed when asymptomatic
dx of HSV
Viral culture, PCR, and direct fluorescence Ab
Most laboratories moving toward non-culture assays such as PCR → high sensitivity and specificity
what will you see on a wet prep with HSV
Enlarged, multinucleated cells w/ ground-glass cytoplasm & nuclei containing inclusion bodie
tx of HSV
Acyclovir
Valacyclovir
complications of HSV
Women w/ active infxn or asymptomatic HSV shedding from normal-appearing skin can infect their infants during vaginal delivery
HPV etiology
+↑Oncogenic → 16 & 18, 31, 33, 35
+Also causes genital warts
Genital warts → 6, 11 have low oncogenic potential
s/sx of HPV
May be asymptomatic
Flat, pedunculated or papular flesh-colored growths → ‘cauliflower-like’ lesions
+ postcoital bleeding
dx of HPV
Whitening with 4% acetic acid application
Clinical diagnosis
+/- Colposcopy, biopsy → Look for dysplasia or cancer
tx of HPV in office
Trichloroacetic acid
Podophyllin → Wash off after 4h to minimize irritation - NOT used on bleeding lesions
Cryotherapy
Surgical removal
tx of HPV outpt
Podofilox Imiquimod (Aldara)
complications of HPV
Cervical Dysplasia
Cervical Cancer
chancroid etiology
Haemophilus Ducreyi → Gram - bacillus
Uncommon in US
IP 3-5 days
s/sx of a chancroid
Genital Ulcer → Soft, shallow, painful, may have foul discharge from the ulcer
+/- Small vesicles or papules
PAINFUL inguinal lymphadenopathy
dx of chancroid
clinicla
culture
tx of chancroid
Azithromycin (first line)
Ceftriaxone 250mg IM x 1 dose
Erythromycin
Ciprofloxacin
complications of chancroid
Secondary infections
Scarring
what is syphilis aka?
Known as ‘the great imitator’ because the rash and disease can present in many different ways similar to other diseases
what causes syphilis
spirochete Treponema pallidum
how is syphilis transmitted
Direct Contact → Of an infected lesion during sexual activity & contact with lesions (including mucous membranes)
May also be transmitted to the fetus via the placenta
Organism enters tissue from direct contact, forming a chancre at the inoculation site and from there, goes to the regional lymph nodes before disseminating
what is the incubation period of syphilis?
3 days and 3 months → 3 phases
what is the primary incubation phase?
Chancre → Painless ulcer at/near the inoculation site with raised indurated edges
Usually begins as a papule that ulcerates
Chancres heal spontaneously → Average within 3-4 weeks even without medical management
Non-tender regional lymphadenopathy near the chancre site lasting 3-4 weeks
what is the secondary incubation phase?
Secondary sxs may occur a few weeks to 6 months after the initial sxs
what are s/sx of secondary phase?
maculopapular rash, chondyloma lata
systemic sx: Fever, lymphadenopathy (may be tender), arthritis, meningitis, headache, hepatitis (elevated alkaline phosphatase)
describe the secondary maculopapular rash of syphilis
Diffuse bilateral maculopapular lesions → Involvement of the palms/soles common
Lesions may be pustular in some patients
what is a condyloma lata?
Wart-like, moist lesions involving the mucous membranes & other moist areas → Especially near the chancre site → Highly contagious
tertiary/late phase of syphilis? (when does it occur?)
May occur from 1 to >20 years after initial infection or after latent infection
s/sx of tertiary/late phase?
- GUMMA
- neruosyphilis
- Argyll-Robertson pupil
- cardiovascular
what is GUMMA?
Non-cancerous granulomas on skin & body tissues (ex: bones)
describe neurosyphilis
Headache, meningitis, dementia, vision/hearing loss, incontinence
what is tabes dorsalis?
Demyelination of posterior columns → Ataxia, areflexia, burning pain, weakness
argyll-robertson pupil
Small, irregular pupil that constricts normally to near accommodation but does not constrict/react to light
cardiovascular sx of syphilis
Aortitis, aortic regurgitation, aortic aneurysms
describe early syphilis
Clinical syndrome that occurs within the first year of infection → Includes primary, secondary and early latent syphilis
describe latent syphilis
Asymptomatic infection + Normal physical exam but positive serologic testing
stages of latent syphilis
Early Latent → If <1 year → Patients are usually highly infectious
Late Latent → > 1 year → Associated with lower transmission rate → Except in fetal transmission
describe symptoms of congenital syphilis
+Hutchinson Teeth → Notches on teeth
+Sensorineural hearing loss, +CNS abnormalities
+Saddle-nose deformity
+ToRCH Syndrome
dx of syphilis in pts with chancre of condyloma lata
Darkfield Microscopy → Allows for direct visualization of the spirochete
Indications → Used in patients with a chancre or condyloma lata
screening tests for syphilis
Non-treponemal testing → Nonspecific → False positives can be seen with antiphospholipid syndrome, pregnancy, TB, rickettsial infections (RMSF)
Rapid Plasma Reagent (RPR) → These tests look at titers (Ex: Positive test indicated a titer of 1:32 or greater)
Changes in titers help determine therapeutic response → However, these tests are also nonspecific in initial testing & must be confirmed by more specific treponemal testing (ex: FTA) → RPR is usually positive 4-6 wks after infection
VDRL → Venereal Disease Research Laboratory
what are the confimatory tests for syphilis?
FTA-ABS → Fluorescent Treponemal Antibody Absorption
Microhemagglutination test for T. pallidum antibodies
tx of syphilis in all stages
Pen G
what are adr of pen g
Jarisch-Herxheimer Reaction → Acute febrile response due to rapid lysis of many spirochetes with antibiotic administration → Associated with myalgias & headaches
Antipyretics during the 1st 24 hours reduces the incidence of the reaction
what if pt is allergic to pen g
Doxycycline or Tetracycline, Macrolide, Ceftriaxone → None are as effective as PCN
pt f/u after syphilis tx
All patients should be reexamined clinically & serologically @ 6 & 12 mos after tx → 4 fold reduction in the titer of the nontreponemal antibody serologic tests within 6 mos denotes adequate management → If not, may indicate re-infection or treatment failure → ALL patients with syphilis should be tested for HIV
describe lymphogranuloma venereum
Genital/Rectal lesion with softening, suppuration & lymphadenopathy
what is LGV causes by?
aggressive L serotypes (L1, L2 or L3) of Chlamydia trachomatis
where is LGV most commonly found?
tropical and subtropical nations of Africa & Asia but also seen in southeastern US
how is LGV transmitted?
sexual contact → Men > Women (6:1) → Incubation Period = 7-21 days
what other infection is LGV associated with?
HIV
what is the MC s/sx of LGV in heterosexuals
Tender, usually unilateral inguinal and/or femoral lymphadenopathy
what may occur at the site of inoculation?
genital ulcers
what s/sx of rectal exposure in LGV?
Can result in proctocolitis, including mucoid and/or hemorrhagic rectal discharge, pain, constipation, fever or tenesmus
sx of late phase
fever, headache, arthralgia, chills and abdominal cramps may develop
how is LGV dx?
Based on clinical suspicion, epidemiologic info & exclusion of other etiologies → Proven only by isolating C. trachomatis from genital or lymph node specimens and confirming immunotype
what is a complement fixation test?
heat-stable antigen that is group-specific for all Chlamydia species available
Titer of >1:64 is considered positive, whereas a titer of <1:32 is considered negative
what are some complications of LGV?
lead to chronic, colorectal fistulas and strictures, which can involve the entire sigmoid
Vulvar elephantiasis can cause marked distortion of the external genitalia
Vaginal narrowing and distortion may result in severe dyspareunia
how is LGV prevented
condome/avoid screwing infected pt
tx of LGV
first line: doxy 100 mg po bid 21 days (repeated of dz persists)
what is 2cd line tx for LGV?
erythromycin
what is local/surgical tx for LGV
Anal strictures should be dilated manually at weekly intervals → Severe stricture may require diversionary colostomy
If disease is arrested → Complete vulvectomy may be done for cosmetic reasons
Abscesses should be aspirate
what is PID?
scending infection of the upper reproductive tract
what are complications of PID?
sepsis, ectopic prego, infertility, chronic pelvic pain
Fitz-hugh Curtis syndrome
what is fitz-hugh curtis syndrome?
Hepatic fibrosis/scarring & peritoneal involvement
RUQ pain due to PERIHEPATITIS (liver capsule involvement) → May radiate to the right shoulder
Often have normal LFTs
‘Violin String’ Adhesions on the anterior liver surface
what are the main etiologies of PID?
Most commonly N.gonorrhoeae & Chlamydia, G. vaginalis, anaerobes, H. flu, etc.
RF for PID?
Multiple sex partners, unprotected sex, prior PID, age 15-19, nulliparous, IUD placement
s/sx of PID?
- Lower abdominal tenderness
- Fever
- Purulent cervical discharge + bleeding
- CHANDELIER SIGN → CERVICAL MOTION TENDERNESS to palpation & rotation so severe they seem to rise off the bed as if ‘reaching for the chandelier’
how is PID dx?
rimarily a clinical diagnosis → Obtain a 𝛃-hCG to rule out ectopic pregnancy
pelvic US-may be used if adnexal or abscess suspected
laparoscopy
PID dx criteria
Abdominal tenderness + rebound tenderness if severe + cervical motion tenderness + adnexal tenderness + > 1 of the following:
\+gram stain, temperature >38℃, WBC > 10,000, pus on culdocentesis or laparoscopy, pelvic abnormality on bimanual exam or US, ↑ESR/CRP
out pt tx of PID
doxy + ceftriaxone +/-metronidazole
inpt tx of PID
IV doxy + 2cd gen cephalosponre (cefoxitin or cefotetan)
OR
clinda + genta
