Gyn/GU Infections in Women

Question 1

Major Ddx for vaginal pain, itching, and foul smelling discharge

Answer 1

• Infectious:
  
  • Bacterial vaginosis (Gardnerella)
  • Candidiasis
  • Trichomoniasis

Question 2

Classic presentations for the three main vulvo-vaginal infections

Answer 2

• Candida: Thick, white discharge with itching
• Gardnerella: Thin, white discharge with fishy odor
• Trichomoniasis: Yellow, frothy discharge with atypical odor

Question 3

Diagnosing vulvo-vaginal infection

Answer 3

Wet mount is the standard approach

Question 4

Interpreting wet mount pH

Answer 4

1. Ensure no mucous in the sample! This messes with pH measurement
2. Normal is 3/8-4.5:
   
   • pH < 4.5: Usually Candida
   • pH > 4.5: Usually Gardnerella or Trichomonas

Question 5

“Whiff” test for Gardnerella

Answer 5

Add potassium hydroxide to dissolve keratin in a cervical swave sample

This should release the classic “fishy odor” of Gardnerella

Question 6

Clinical diagnosis of bacterial vaginosis

Answer 6

• Requires:
  
  • Abnormal vaginal discharge
  • pH > 4.5
  • and ONE OF:
    
    • Positive whiff test
    • Presence of clue cells on wet mount

Question 7

Clinical diagnosis of vulvovaginal candidiasis

Answer 7

• One of:
  
  • Visualization of pseudohyphae on wet mount + KOH
  • Positive yeast culture

Question 8

Treatment for vulvovaginal candidiasis

Answer 8

• Two options:
  
  • Vaginal imidazole (miconazole, clotrimazole, terconazole)
  • Single dose oral fluconazole

Question 9

How does one acquire trichomonal vulvovaginitis?

Answer 9

• Sexual contact
• Swimming pools or hot tubs

Question 10

Diagnosis of trichomonas vaginitis

Answer 10

Visualization of organism (with characteristic flagellae) on wet mount

Question 11

Treatment of trichomonas vaginitis

Answer 11

• Oral metronidazole or tinidazole
• Treat patient AND sexual partner(s)

Question 12

Ddx for vulvar itching

Answer 12

• Contact dermatitis
• Recurrent yeast infection
• Lichen sclerosis
• Lichen simplex chronicus
• Bacterial vaginosis
• Vulvar vesibulitis
• Atrophic vaginitis

Question 13

What are common irritants in vulvar contact dermatitis?

Answer 13

• Shampoo and body wash with fragrance
• “creative” underwear
• Maxi pads and panty liners

Question 14

If vulvovaginal itchiness does not improve with topical steroids or is of unclear etiology, then . . .

Answer 14

. . . it should be biopsied

It may be squamous cell carcinoma

Question 15

What is going on in this patient with vulvar itching?

Answer 15

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.

Question 16

Location of lichen sclerosus vs lichen planus

Answer 16

Lichen sclerosus can only affect the vulva

Lichen planus can affect the vulva or the vagina (or both)

Question 17

The next step after HSIL is indentified on a Pap smear

Answer 17

Colposcopy or immediate LEEP

Question 18

If vulvar herpes is suspected, __ must be used to confirm the diagnosis

Answer 18

If vulvar herpes is suspected, herpes viral culture must be used to confirm the diagnosis

REMEMBER THAT HERPES IS NOT A CLINICAL DIAGNOSIS

Question 19

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 ___.

Answer 19

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.

Question 20

Physiologic Leukorrhea

Answer 20

• 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

Question 21

Antimicrobial prophylaxis for patients undergoing hysterectomy

Answer 21

First-generation cephalosporin or amoxicillin-clavulanic acid within 60 minutes before skin incisions

Alternatively, if penacillin allergic, clindamyicn + gentamycin or a fluoroquinolone.

Question 22

When do you need to re-dose cefazolin?

Answer 22

• If the procedure duration exceeds 4 hours (2x the halflife of the med)
• If EBL exceeds 1500 mL

Question 23

The majority of HSV recurrences involve HSV-__

Answer 23

The majority of HSV recurrences involve HSV-2

Question 24

Why is E coli pyelonephritis more likely than other etiologies to be associated with ARDS?

Answer 24

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.

Question 25

If a pregnant woman has an episode of pyelonephritis, then following inpatient management and sending home with oral antibiotics, you should. . .

Answer 25

. . . 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

Question 26

If apparent pyelonephritis does not respond to oral antibiotics after 72 hours, then ___ is indicated

Answer 26

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

Question 27

Why do we treat asymptomatic bacteriuria in pregnant women?

Answer 27

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

Question 28

Antibiotic regimen for PID

Answer 28

Doxycycline plus ceftriaxone

. . . AND metronidazole

Anything in the peritoneum gets metronidazole. PID starts as gonococci and/or chlamydia, but often becomes polymicrobial.

Question 29

Vaccines that we don’t give during pregnancy

Answer 29

1. Rubella
2. Varicella
3. BCG
4. Yellow fever
5. Polio
6. HPV (not because it is live attenuated, but because there may be poor response during pregnancy and adverse events have not been ruled out)

Question 30

Post-C-section necrotizing fasciitis

Answer 30

Will be associated with tissue fluctuance and/or crepitus due to gas production

Treat w/ penicillin, gentamicin, and metronidazole

Question 31

Endomyometritis

Answer 31

• 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.

Question 32

Single most common etiology of postpartum mastitis

Answer 32

S. aureus infection of a galactocele

Question 33

___ of cases of mastitis will have an associated abscess

Answer 33

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)

Question 34

Treatment of choice for non-infected galactocele

Answer 34

Will present as a fluctuant mass with associated tenderness, but without signs of infection, in a breastfeeding woman

Treat w/ aspiration

Question 35

Presentation of septic abortion

Answer 35

• 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.

Question 36

Necrotizing metritis

Answer 36

• 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