Gyn/GU Infections in Women Flashcards
Major Ddx for vaginal pain, itching, and foul smelling discharge
- Infectious:
- Bacterial vaginosis (Gardnerella)
- Candidiasis
- Trichomoniasis
Classic presentations for the three main vulvo-vaginal infections
- Candida: Thick, white discharge with itching
- Gardnerella: Thin, white discharge with fishy odor
- Trichomoniasis: Yellow, frothy discharge with atypical odor
Diagnosing vulvo-vaginal infection
Wet mount is the standard approach
Interpreting wet mount pH
- Ensure no mucous in the sample! This messes with pH measurement
- Normal is 3/8-4.5:
- pH < 4.5: Usually Candida
- pH > 4.5: Usually Gardnerella or Trichomonas
“Whiff” test for Gardnerella
Add potassium hydroxide to dissolve keratin in a cervical swave sample
This should release the classic “fishy odor” of Gardnerella
Clinical diagnosis of bacterial vaginosis
- Requires:
- Abnormal vaginal discharge
- pH > 4.5
-
and ONE OF:
- Positive whiff test
- Presence of clue cells on wet mount
Clinical diagnosis of vulvovaginal candidiasis
- One of:
- Visualization of pseudohyphae on wet mount + KOH
- Positive yeast culture
Treatment for vulvovaginal candidiasis
- Two options:
- Vaginal imidazole (miconazole, clotrimazole, terconazole)
- Single dose oral fluconazole
How does one acquire trichomonal vulvovaginitis?
- Sexual contact
- Swimming pools or hot tubs
Diagnosis of trichomonas vaginitis
Visualization of organism (with characteristic flagellae) on wet mount
Treatment of trichomonas vaginitis
- Oral metronidazole or tinidazole
- Treat patient AND sexual partner(s)
Ddx for vulvar itching
- Contact dermatitis
- Recurrent yeast infection
- Lichen sclerosis
- Lichen simplex chronicus
- Bacterial vaginosis
- Vulvar vesibulitis
- Atrophic vaginitis
What are common irritants in vulvar contact dermatitis?
- Shampoo and body wash with fragrance
- “creative” underwear
- Maxi pads and panty liners
If vulvovaginal itchiness does not improve with topical steroids or is of unclear etiology, then . . .
. . . it should be biopsied
It may be squamous cell carcinoma
What is going on in this patient with vulvar itching?
Lichen sclerosus
Look at the discoloration of the labia majora. This is what people mean when they say “cigarette paper” apperance in lichen sclerosus. It is highly specific.
Location of lichen sclerosus vs lichen planus
Lichen sclerosus can only affect the vulva
Lichen planus can affect the vulva or the vagina (or both)
The next step after HSIL is indentified on a Pap smear
Colposcopy or immediate LEEP
If vulvar herpes is suspected, __ must be used to confirm the diagnosis
If vulvar herpes is suspected, herpes viral culture must be used to confirm the diagnosis
REMEMBER THAT HERPES IS NOT A CLINICAL DIAGNOSIS
Colposcopy is only indicated for patients with atypical squamous cells of unknown significance positive high-risk HPV strain test without cervical morphologic changes if they are over the age of ___.
Colposcopy is only indicated for patients with atypical squamous cells of unknown significance positive high-risk HPV strain test without cervical morphologic changes if they are over the age of 25.
For patients who are 21-24, we would instead manage expectantly and check again in one year. If the next test also showed ASCUS, then we would proceed with colposcopy.
If this same scenario happened in someone over age 25, we would start with colposcopy and forgo the expectant management.
Physiologic Leukorrhea
- Vaginal discharge that is white or yellow and non-malodorous in a patient with no findings that would indicate pathology, such as vaginal pruritus or tenderness. Even profuse discharge is, by itself, not a sign of pathology. The amount of vaginal discharge can vary based on a woman’s menstrual stage and age.
- Typically seen at the onset of puberty (due to a surge in the levels of estrogen), around the time of ovulation (due to a peak in estrogen levels), prior to menstruation (due to pelvic congestion), and during pregnancy
- Often mistaken for infection
Antimicrobial prophylaxis for patients undergoing hysterectomy
First-generation cephalosporin or amoxicillin-clavulanic acid within 60 minutes before skin incisions
Alternatively, if penacillin allergic, clindamyicn + gentamycin or a fluoroquinolone.
When do you need to re-dose cefazolin?
- If the procedure duration exceeds 4 hours (2x the halflife of the med)
- If EBL exceeds 1500 mL
The majority of HSV recurrences involve HSV-__
The majority of HSV recurrences involve HSV-2
Why is E coli pyelonephritis more likely than other etiologies to be associated with ARDS?
Because E. coli are notorious for their endotoxin production!!!
LPS everywhere! TLR4s going haywire!
Often the ARDS symptoms will only occur when you start treating with antibiotics (typically ampicillin and gentamicin together) since the killing of the bacteria releases LPS on bulk.
The same goes for other gram negatives, but E. coli in particular is notorious for this.
If a pregnant woman has an episode of pyelonephritis, then following inpatient management and sending home with oral antibiotics, you should. . .
. . . obtain followup urinalysis and culture to ensure cleraance AND have them stay on suppressive therapy for the rest of the pregnancy
If you don’t, then up to 1/3 will develop recurrent pyelonephritis
If apparent pyelonephritis does not respond to oral antibiotics after 72 hours, then ___ is indicated
If apparent pyelonephritis does not respond to oral antibiotics after 72 hours, then ultrasoimd or CT scan is indicated
To rule out kidney stone or perinephric abscess
Why do we treat asymptomatic bacteriuria in pregnant women?
Because it reduces the incidence of pyelonephritis by a 80% in this population
For the same reason, urine culture should always be performed at the first prenatal visit to screen for asymptomatic bacteriuria
Antibiotic regimen for PID
Doxycycline plus ceftriaxone
. . . AND metronidazole
Anything in the peritoneum gets metronidazole. PID starts as gonococci and/or chlamydia, but often becomes polymicrobial.
Vaccines that we don’t give during pregnancy
- Rubella
- Varicella
- BCG
- Yellow fever
- Polio
- HPV (not because it is live attenuated, but because there may be poor response during pregnancy and adverse events have not been ruled out)
Post-C-section necrotizing fasciitis
Will be associated with tissue fluctuance and/or crepitus due to gas production
Treat w/ penicillin, gentamicin, and metronidazole
Endomyometritis
- Single most common cause of fever following Caesarean delivery
- Infection of the decidua, myometrium, and sometimes parametrial tissues
- Almost always polymicrobial
- Combination of vaginal and skin flora
- Dominant genus is Bacterioides
- If pre-delivery, treat with gentamicin and ampicillin
- If post-delivery, treat with gentamicin and clindamycin
- If unresponsive for 48 hr, add ampicillin (to cover Enterococci)
- If still unresponsive, screening CT for septic pelvic thrombophlebitis is warranted. If positive, add heparin.
Single most common etiology of postpartum mastitis
S. aureus infection of a galactocele
___ of cases of mastitis will have an associated abscess
10% of cases of mastitis will have an associated abscess
That is high!!! Screen these patients for presence of a fluctuant mass on exam. If positive, confirm with ultrasound and then drain with aspiration.
Also, remember that nonresponsiveness to antibiotics may indicate abscess OR inflammatory breast cancer (this would present with ipsilateral axillary lymphadenopathy)
Treatment of choice for non-infected galactocele
Will present as a fluctuant mass with associated tenderness, but without signs of infection, in a breastfeeding woman
Treat w/ aspiration
Presentation of septic abortion
- Definition: abortion with associated uterine infection
- Presents w/ signs of systemic infection in the context of abortion often with retained products of conception
- Cervix will often be parially open
- Often occurs following D&C which fails to completely evacuate contents
- Organisms involved ascend from vagina via cervix
- On exam: Lower abdominal tenderness, cervical motion tenderness, purulent vaginal discharge
- Treat w/ gentamicin plus clindamycin, fluids/BP management, D&C (primary or repeat) at 4 hours following initiation of Abx. Place Foley to monitor urine output in order to titrate fluids.
Necrotizing metritis
- Clostridial infection of the myometrium
- Equivalent of necrotizing fasciitis
- Characterized by pockets of air within the myometrium
- Indication for urgent hysterectomy to prevent spread of bacteria and need for amputation
