ch 12 GU GYN Flashcards
physiologic leukorrhea
physiologic; white clear flocculent discharge
-normal/healthy women of reproductive age
-1-2 tsp/day (antimicrobial/viral properties)
vaginal pH
3.8-4.2
lactobiacilli makes lactic acid and Hydrogen peroxide and kills pathogens; resist infections
white curdy cottage cheese discharge
candida vulvovaginitis (candida albicans)
candida vulvovaginitis: patient complaints:
pH?
KOH whiff test?
Microscopic exam on saline wet mount?
itching/burning discharge
pH: < 4.5 (usually)
KOH: absent
Micrscope: mycelia, budding yeast pseudohyphae with kOH prep
candida vulvovaginitis intervention
-azole antifungal (oral fluconazole [Diflucan] or vaginal miconazole [Monistat], terconazole [Terazol])
bacterial vaginosis (BV) discharge
thin, homogenous. white gray, adherent, often increased
-overgrowth of bacterial that exists in the vagina
etiology: unclear, likely polymicrobial a/s wit hG. vaginalis
bacterial vaginosis patient complaints:
pH?
KOH whiff test?
Microscopic exam on saline wet mount?
foul odor, itching sometimes, discharge
pH? 5-7 (less lactobacilli to make the acid environment)
KOH: Present (fishy)
Microscopic exam on saline wet mount? >20 clue cell (vaginal epithelial cells) and few WBC
bacterial vaginosis intervention
metronidazole (Metrogel) or oral Flagyl
clindamycin vaginal cream
ovules (Cleocin, oral tinidazole (Tindamax)
oral secnidazole (Solosec $$$)
genitourinary syndrome of menopause (GSM) aka atrophic vaginitis
etiology? discharge?
-estrogen deficiency; women after menopause
-discharge is less and is scant, white clear
-more prone to infections and STI’s
-reversible with supplemental estrogen
GSM aka atrophic vaginitis complaints:
pH?
KOH whiff test?
Microscopic exam on saline wet mount?
itching/burning (can be entire urethra region but not UTI), discharge, but can have no sx’s
- > 5 (once estrogen leaves, lactobacilli leaves)
-KOH absent
-few lactobacilli
GSM aka atrophic vaginitis intervention
give topical and/or vaginal estrogen IF symptomatic and/or recurrent UTI
if estrogen lvls go down= lacto goes down and includes urethra region. using topical estrogen, lacto recolonizes = fewer UTI
oral estrogen ALONE is NOT effective , can be effective WITH topical
human herpes virus/herpes simplex 2
clinical findings
genital herpes
-with initial outbreak, painful ulceratedlesions, marked lymphadenopathy (ie: L mark inguinal lymphadenopathy if L labial ulcer)
-women: thin vaginal discharge if lesion IN vagina or introitus
-can be few lesions, sx’s vary
-can transmit even if asymptomatic
herpes simplex 2 intervention
1st line: oral valacylovir (Valtrex)
-acyclovir (Zovirax)
-famciclovir (Famvir)
nongonococcal urethritis and cervicitis clinical findings
-irritative voiding sx’s; occassional mucopurulent discharge
-women: cervicitis common
-often w/o sx’s regardless of gender
-culture to see large # of WBC
nongonococcal urethritis and cervicitis treatment
1st line: doxycycline 100 mg PO BID x 7 days
alt: azithromycin 1 g PO x1 or levofloxacin 500 mg PO QD x 7 days
nongonococcal urethritis and cervicitis organisms
chlamydia trachomatis
ureaplasma urealyticum
mycoplasma genitalium
gonococcal urethritis and vaginitis causative organism
neisseria gonorrhaoeae (Gram - bacteria)
gonococcal urethritis and vaginitis clinical findings
irritavei voiding sx’s, occasional purulent discharge
often w/o sx’s
-large # of WBC
gonococcal urethritis and vaginitis treatment
1st line: ceftriazone 500 mg IM x 1 PLUS doxycycline 100 mg PO BID x 7 days IF chlamydia trachomatis infection has NOT been ruled out
alternative if cef not available: gentamicin 240 mg IM x1, azithromycin 2 g PO as single dose, or cefixime 800 mg PO x1
trichomoniasis organism
trichomonas vaginalis (protozoan)
(protozoan pathogen)
trichomoniasis clinical finding
dysuria
itching
vulvovaginal irritation
frothy yellow-green vaginal discharge (only 30% have tho)
strawberry spots: cervical petechial hemorrhage (only 30% have tho)
often NO symptoms
motile organisms and lots of WBC
alkaline pH
trichomoniasis intervention
1st line:
female: metronidazole 500 mg PO BID x 7 days
males: metronidazole 2 g PO x 1
[not gel; need oral]
alt: tinidazole 2 g PO x 1
EDUCATE NO ALCOHOL FOR 24 HRS after metronidazole completion (abdominal pain!) or 72 hrs after completion of tinidazole
most chamydial infections occur in what age groups
teen and < 25 yrs old
acute UNcomplicated UTI (cystitis, urethrtis) in non pregnant women organisms
E. coli (gram - ) 75% of all UTI’s
Klebseilla
S saprophyticus
acute UNcomplicated UTI (cystitis, urethrtis) in non pregnant women treatment
-if local E. coli resistance to TMP/SMX < 20% and no allergy, then give TMP/SMX-DS PO BID x 3 days
or ***choose-if local E coli resistance to TMP/SMX > 20% or sulfa allergy, give nitrofurantoin (Macrobid) 100 mg PO BID x 5 days
-ADD urinary analgesic phenazopyridine (Pyridium) PO for sx control (urethra inflammation lingers even after day 2 of therapy)
2nd line: levofloxacin, Augmentin, ciprofloxacin, cephalexin,
which medication can’t be given if pt is allergic to sulfa?
bactrim (TMP-SMX)
epididymo-orchitis in those 35 and under years old, most likely what organisms?
N gonorrhoeae
Chlamydia trachnomatis
epididymo-orchitis clinical presentation
irritive voiding sx’s (frequency, hematuria, dysuria)
fever,
painful swelling of epididymis and scrotum
-infertility potential post infection
epididymo-orchitis treatment under 35 yrs old
ceftriaxone 500 mg IM x 1 PLUS doxycycline 100 mg PO BID x 10 d
-educate scrotal elevation to help with symptom relief (Preh’s sign)
Preh’s sign
relief of discomfort with scrotal elevation
epididym-orchitis over 35 years old or anal sex partern, most likely organism?
entrobacteriaceae (coliforms) (think lower GU organsms)
exact same sx’s and infertility potential
epididym-orchitis over 35 years old or anal sex partner treatment
Levofloxacin 750 mg PO QD or ofloxacin 300 mg PO BID x 10-14 days
acute bacterial prostatits (< 35 years old) organisms & sx’s
N gonorrhoeae
Chamlydia trachomatis
-irritive voiding sx’s
-suprapubic, perineal pain
-fever
-tender, boggy prostate from DRE
-leukocytosis
acute bacterial prostatitis (<35 years old) treatment
ceftriaxone 500 mg IM x1 or cefixime 400 mg PO x1 THEN doxycycline 100 mg PO BID x10 days
acute bacterial prostatitis (uncomplicated disease in men with low risk for STI) organism
enterobacteriaceae (coliforms)
older men
-irritive voiding sx’s, suprapubic, perineal pain, fever,
-tender, boggy prostate from DRE
-leukocytosis
acute bacterial prostatitis ( >35; uncomplicated disease in men with low risk for STI) treatment
ciprofloxacin or levofloxacin or TMP-SXM
epididymo-orchitis or prostatitis? or both
irrititive voiding sx’s?
perineal pain (hurts when sit on chair)?
prehn’s sign?
usu with fever?
scrotal swelling?
irrititive voiding sx’s? both
perineal pain (hurts when sit on chair)? prostatitis
prehn’s sign? Epididymo-orchitis
usu with fever? both
scrotal swelling? Epididymo-orchitis
balanitis
inflammation/swelling of head of penis
genital candida albicans in men
balanitis
groin fold involvement
scrotal excoriation
tinea cruris
aka jock itch
red rash upper bilateral thighs, groin, or vulva involvement ONLY
benign prostatic hyperplasia (BPH) sx’s & management
lower urinary tract sx’s (nocturia, weak stream, urgency, incontinence, voiding difficulties)
- get UA, PSA
-alpha 1 receptor blockage (tamsulosin)
normal prostate physical finding
firm (touching tip of nose), smooth, non tender
acute prostatitis DRE finding
tender, boggy, indurated
(as firm as touching skin of cheekbone)
prostate cancer DRE finding
nodular, firm, nontender
-malignant lesions are usu NOT palpable until advanced
loss of urine with lifting, coughing, sneezing
stress incontinence
transient continence
-there was an underlying condition
urge incontinence
-sudden onset; overactive detruser muscle
81 year old in wheelchair can’t use toilet w/o assistance
functional incontinence
-consider other meds like diuretics and wheelchair
urge incontinence
-most common in older adults
-strong sensation of needing to empty bladder that cannot be suppressed
-involuntary loss of urine
urge incontinence management
antimuscarinic (anticholinergic): tolterodine (Detrol), oxybutynin (Ditropan), solifenacin succinate (VESIcare), darifenacin (Enablex), fesoterodine fumarate (Toviaz)
AE: dry mouth, sedation, mental status change (in higher doses)
alts: Beta agonists: mirabegron (Myrbetriq), vibegron (Gemtesa) and botox injections to bladder
stress incontinence
most common in women (men rare)
loss of urine with activity that causes inc and pressure (coughing, sneezing, exercise)
functional incontinence management
having an assistance who can recognize voiding cues and help with toileting activities
stress incontinence management
-support area via vaginal tampon, urethral stents, periurethral bulking agent injections, and pessary
-kegal exercises most helpful in younger, premenopausal women
-pelvic floor rehab with electrical stimulation and bladder training
-surgical intervention
functional incontinence
inability to get to toilet or lack of awareness of need to void
-usu in mobility issues or altered cognition
-worsen by unavailability of a hleper to assist in toileting activities
transient incontinence
-a/s with acute events (delirium, UTI, med use, restricted activity)
transient incontinence management
treating underlying process, discontinuation of offending medication
treatable causes of urinary incontinence
DIAPPERS
-delirium
-infection (urinary)
-atrophic urethritis and vaginitis
-pharmaceuticals (diuretics, others)
-psychologic disorders (depression)
-excessive urine output (heart failure, hyperglycemia due to undetected or poorly controlled DM)
-restricted mobility
-stool impaction
no pap smears needed if
total hysterectomy including cervix
if a pt acquires 1 hpv type (genital warts which is 6 & 11)
they’re more likely to get other types of HPV
ovarian risk factors
post menopausal (older age)
obesity
nulliparity or 1st preg > 35 years
fertility drugs
using estrogen post menopause (>5-10 years)
family hx/genetics (BRCA1, BRCA2)
shared etiology with breast cancer
ovarian cancer sx’s
non specific sx’s in early stage
-esp 50yrs old+x
-bloating
-bladder pressure, constipation, vaginal bleeding, indigestion, SOB, lethargy, weight loss
ovarian cancer management
abdominal CT with contrast and pelvis, US, MRI
-tumor marker (cancer antigen 125)
-surgery then chemo
cervical cancer causes
persistent infection with HPV:
70% are HPV 16 & 18
~20% HPV 31, 33, 52, 58
cervical cancer clinical presentation
abnormal vaginal bleeding
vaginal discomfort during sex
malodour discharge, dysuria
typically asx with 1st abnormal pap result
cervical cancer diagnostics and tx
pap test then colposcopy and bx
-pelvic CT and/or MRI or PET scan
-tx based on cancer stage
-surgery for early stage
-radiation /chemo for advanced
endometrial cancer risk factors
older age
estrogen therapy
nulliparity
tamoxifen use (cancer risk < 1% per year)
hx of breast or ovarian cancer
PCOS
DM 2
family hx
endometrial cancer clinical presentation
abnormal vaginal bleeding (post menopausal bleeding; or heavy frequent menstrual periods or intermenstrual bleeding in pre/perimenopausal women)
endometrial cancer diagnostics
-transvaginal U/S
-hydroultrasonography
-hysterectomy
-endometrial biopsy
-fractional D&C
endometrial cancer treatment
surgery then chemo w/ or w/o radiation
cervical cancer screening in what ages?
start age 21 or 25 and stop 65 yrs
do women with hysterecomy need cervical cancer screening?
total hysterecomty with cervical removal
can stop UNLESS hysterectomy was for cervical cancer or precancer (CIN 2 or 3)
-but if have hysterectomy with cervix still intact, continue screening guidelines
women with hx of CIN 2 or CIN 3
continue cervical screening for at least 20 yrs (more frequent the first few yrs to make surer all cancer cells were removed)
anal testing in men and women
routine testing NOT rec if asx
-test high risk: HIV, anal sex, hx of anal warts, hx of cervical or vulvar cancer
-test every year for HIV + and every 2-3 yrs for HIV negative
antiretroviral therapy (ART)
HIV care in all adults/adolescents that are HIV +
-start ASAP after diagnosing
-lifelong
preexposure prophylaxis (PrEP)
use of ART for high risk of being infected but don’t have HIV (sex, injection)
-start ASAP after a risk behavior assessment that determines they’re high risk of HIV and lab testing confirms absence of HIV infection
-daily treatment until risk of HIV is low from less exposure
Postexposure prophylaxis (PEP)
use of ART after a single high risk event exposure (within 72 hrs) to minimize possibility of HIV seroconversion
-duration: 28 days
