Gyn Infections I and II -Castro Flashcards
Which cell type lines the vulva? Vagina?
stratified squamous epithelium
vulvar is keratinized
What is the normal vaginal pH for prepubertal and postmenopausal women? Reproductive aged women?
Prepubertal and postmenopausal women: normal vaginal ph is 6-8
Reproductive aged women: increasing number of lactobacilli cause normal vaginal ph to drop to 3.8 - 4.2
What is normal “physiologic” vaginal discharge?
cervical mucus and vaginal transudate and normal vaginal flora with exfoliated squamous cells
whitish and does not cause itching, burning or smell
What do most vaginitis patients present with?
Increased vaginal discharge-often with foul odor and vulvar, vaginal itching or burning and sometimes dysuria
How do you diagnose vaginitis?
must perform a pelvic exam and microscopic exam of the discharge (wet mount)
cultures and biopsies might be indicated, depending on findings
What is the most common cause of vaginitis? Is this an STI?
bacterial vaginosis
it is “sexually associated” but not clearly an STI (do NOT treat the partner)
What does a patient with bacterial vaginosis present with?
- “fishy” odor
- inc grayish vaginal discharge
- homogenous discharge (vaginal vault looks like milk has been poured into it)
- often after vaginal intercourse
What is the etiology of bacterial vaginosis (BV)?
altered vaginal ecology–> increased ratio of anaerobic to aerobic bacteria (suppression of lactobacilli and peroxide producing bacteria and an increase in garderella, bactericides, mobiluncus, prevotella, ureoplasma, mycoplasma and peptococcus (polymicrobial))
What is the diagnostic criteria for BV?
Amsel's Criteria: (3 of the 4): -Homogenous vaginal discharge -Vaginal ph > 4.5 -Positive whiff test on -KOH wet prep -Presence of clue cells on microscopic exam of saline wet mount (epithelial cells covered with bacteria, margins of cell are indistinct, cells have ground glass appearance, few WBC’s present
What is the treatment for bacterial vaginosis? Should the male partner be treated as well?
Oral metroidazole or topical metronidazole gel or clindamycin cream
do NOT treat the male partner
What is the second most common cause of vaginitis? Is this sexually transmitted?
candida vaginitis (more likely to have vulvar involvement than BV or trichomoniasis)
NOT considered sexually transmitted
What are the risk factors for candida vaginitis (8)?
Diabetes Obesity Pregnancy Immunosuppressed Recent use of antibiotics Exogenous estrogens Sexual intercourse Anything facilitating vulvar/vaginal warmth and moisture
What will a patient with candida vaginitis present with?
- Vaginal discharge and burning
- Vulvar itching and burning with erythema
- Dysuria
- Dyspareunia (pain with intercourse)
How is candida vaginitis diagnosed?
- Based on history, pelvic exam and KOH wet mount (culture in Nickerson’s if suspect false negative wet mount)
- Thick, white “cottage cheese” discharge
- Vaginal ph < 4.5 most of the time
- 10% KOH wet mount - budding yeast and pseudohyphae
What is the treatment for candida vaginitis? Should the male partner be treated as well?
- Try to treat predisposing cause if possible (e.g. diabetes)
- Treat for 3-7 days with topical azoles (miconazole, butoconazole, terconazole, clotrimazole). Available OTC and by prescription. 80% effective
- Treatment of male sex partner not recommended unless clinical evidence of infection (balanitis)
What can recurrent candida vaginitis be indicative of?
diabetes
Is trichomonas vaginitis (trichomoniasis) a sexually transmitted disease? What are the major presenting symptoms?
YES!
Major patient symptoms:
- increased discharge
- foul smelling
- vulvar itching and burning
- dysuria
- dyspareunia
How is the diagnosis of Trichomonas Vaginitis made in women? Men?
- Pelvic exam - “frothy” thin discharge; ph >4.5; color may be yellow, green, grey
- Strawberry patches on vagina, cervix, (petechiae) may be present
- “fishy” odor may be present
women:
-Saline wet mount - trichomonads (flagellated protozoan) along with epithelial cells and WBC’s
Men:
-wet mount is unreliable–> culture urethra, urine and semen
How is Trichomonas Vaginitis treated? Should the male sex partner also be treated?
- Patient and sex partner need to be treated Metronidazole or Tinidazole 2 grams orally - 90% effective
- Abstain from alcohol (disulfiram - type adverse response)
What is the typical presentation of atrophic vulvovaginitis?
-Older women, secondary to decreased estrogen
-Thin vaginal mucosa
Yellowish discharge, ph >4.5
-Smooth, shiny, reddish, atrophied vulvar skin
How is a diagnosis of atrophic vaginitis made? What other diagnosis has to be ruled out?
Saline wet mount showing rounded parabasal cells. May need biopsy to distinguish from Lichen Sclerosis
When should you biopsy vulvitis?
atypical lesion
non response to therapy
recurrence
goals of biopsy are to make the correct diagnosis in order to guide Rx, detect premalignant condition neoplasia / cancer.
What are the differences in the vulvar dystrophies? What type of patient population is this normally found in?
Seen in older women
-Lichen Sclerosis (atrophic dystrophy):
thinning skin with whitish, cigarette-paper appearance, very itchy, hyperkaratosis and chronic inflammation on biopsy
-Squamous Cell Hyperplasia (hyperplastic dystrophy):
scratch-itch-scratch cycle with thickened, excoriated skin (do biopsy to confirm)
-Mixed Dystrophy: leukoplakia might be present–> need biopsy to rule out neoplasia/carcinoma
Who should be screened for STDs? What are the reportable STDs?
- high risk patients
- all pregnant women
- screen for other STDs if one is identified
- reportable: GC, Chlamydia, syphilis, chancroid, HIV/ AIDS
What are the 5 P’s in taking a sexual history?
Partners
Prevention of Pregnancy
Protection from STD’s
Practices
Past History of STD’s
How is HIV diagnosed? Monitored?
enzyme immunoassay (EIA) and then Western Blot or immunofluorescence assay
monitored with viral load and CD-4 counts
How should an HIV + pregnant woman be treated?
-antiretroviral therapy and elective cesarean section at 38 weeks with avoidance of breast feeding can decrease perinatal transmission ( give zidovudine or nevirapine
What are the most common causes of anal or genital ulcers? How are these diagnosed?
Herpes (HSV) (viral culture or PCR is gold standard)
syphilis (VDRL/RPR with reflex FTA-ABS/TPA or dark field)
chancroid
What is the clinical presentation of general herpes?
Primary infection-prodrome of burning, parasthesias 2-5 days post infection; painful anogenital ulcers/vesicles occur 3-7 days post infection
Primary infection can be severe: fever, malaise, adenopathy, meningitis, urinary retention (systemic –> more severe)
Recurrences- generally milder and of shorter duration (2-5 days)
What is the treatment of genital herpes infection? Does this get rid of the virus?
First episode: oral antiviral therapy with Acyclovir, Famciclovir or Valacyclovir for 7-10 days
helps control signs and symptoms but does not eradicate latent virus –> no effect on frequency/severity of recurrences
If a person has HSV-2, what can be given to reduce recurrences, subclinical shedding and risk of spreading to a partner?
suppressive therapy ==> use acyclovir, famciclovir or valacyclovir daily
What can be used to treat a severe systemic HSV-2 infection?
IV acyclovir
When is risk of HSV transmission highest for a pregnant woman?
primary infection in the 3rd trimester
do a c-section if herpetic lesions are present in labor –> can cause neonatal lesions or meningitis
What counseling is advised if a pregnant non-infected female has a male partner with herpes?
treat the male
suggest abstinence (preferably, especially with a lesion) or condoms throughout pregnancy to avoid the preggo getting the primary infection
What is the difference between primary and secondary syphilis? In what stage are the lesions infectious?
primary: firm, painless chancre with rolled margins
secondary: occurs 1-2 months later. fever, HA, malaise, diffuse maculopapular rash (palms and soles) and mucous patches or condylomata lata
* highly infectious lesions*
What are the signs/symptoms of tertiary syphilis?
aortitis, gumma’s (necrotic granulomatous lesions) and iritis
Neurosyphilis-can occur at any stage *
How is syphilis diagnosed?
Early syphilis: dark field exam or direct fluorescent antibody test of lesion or exudate is definitive for early syphilis
Otherwise BOTH:
-A nontreponemal or non specific test (VDRL or RPR)
AND
-a treponemal or specfic test (FTA-ABS or T. pallidum particle agglutination [TP-PA]) (+ for life)
Both types of tests (nontreponemal and treponemal must be positive)
How is syphilis transmitted in the late stages?
blood transfusion or transplacental passage (mother-> fetus)
What is latent syphilis?
No clinical signs of disease
What is used to monitor syphilis activity? What implies reinfection or failed initial treatment?
Titers correlate with disease activity –> a 4 fold rise in titers (e.g. 1:4 to 1:16) implies reinfection or failed initial treatment.
Patient must be reevaluated (may need to r/o neurosyphilis) and retreated.
Titers should go to zero if Rx adequate
How is neurosyphilis diagnosed?
required lumbar puncture with a + VDRL CSF
How is primary, secondary or early latent syphilis treated? What reaction should the patient look for?
Benzathine penicillin G (IM one time)
Jarisch Herxheimer reaction (fever, headache, myalgia within first 24 hrs of therapy—can cause labor or fetal distress if pregnant)
How is late latent, latent of unknown duration or tertiary syphilis treated?
Benzathine penicillin G
IM x 3 doses at weekly intervals
How should neurosyphilis be treated?
IV aqueous penicillin G for 10-14 days
What can syphilis in a pregnant woman lead to?
Screen pregnant women with VDRL or RPR.
Untreated maternal infection can result in non-immune hydrops fetalis, fetal demise and preterm birth
What is chancroid? What patient populations is this generally seen in?
Painful, genital ulcer with tender suppurative inguinal adenopathy (bubos)
in setting of drug abuse, prostitution, HIV infection, travel to an African or Caribbean country
How is chancroid diagnosed? How is it treated?
clinically –> diagnosis of exclusion (syphilis tests neg and herpes culture negative)
caused by H. ducreyi but hard to culture on a special medium
treat with azithromycin or ceftriaxone –> also treat recent sexual contacts (even if asymptomatic)
What is granuloma inguinale (donovanosis)? Where is this generally found?
Painless, ulcerative, vascular lesions without adenopathy
endemic in tropical areas (India, Papua, New Guinea, Australia, southern Africa)
caused by intracellular gram neg bacterium (Klebsiella granulomatis – formerly Calymmatobacterium granulomatis)
What is the diagnostic criteria and treatment for Donovanosis?
Diagnosis–Donovan bodies on tissue prep
Treatment-Doxycycline for three weeks
What is mucopurulent cervicitis? What are the most common causes?
Mucopurulent exudate from endocervix
Endocervical bleeding with passage of cotton swab through the cervical os
Leukorrhea-greater than 10WBC/HPF on exam of vaginal fluid
most commonly identifiable causes are chlamydia or gonorrhea
What does chlamydia normally present with in sexually active young adult women? What can this lead to?
asymptomatic!
can lead to cervicitis, urethritis, or PID
risk of infertility, chronic pain and increased risk of ectopic pregnancy
If a female presents with mucopurulent cervicitis, what should you suspect? What diagnostic test should be done?
chlamydia
endocervical swab or urine sample sent for culture, immunoassay or nucleic acid amplification test (NAAT)
What is the treatment for chlamydia?
azithromycin
abstinence until 7 days after therapy was started
screen for other STD (HIV, GC, syphilis, hep B)
If a male presents with urethritis, what should be suspected?
chlamydia
How should chlamydia be treated in pregnancy??
screen all pregnant women at first visit and treat with azithromycin if +
test of cure in 3 weeks
test for reinfection in 3rd trimester
What is neisseria gonorrhea? What does this normally present with?
Gram-negative intracellular diplococcus
May have malodorous discharge
can infect anything and become disseminated (meningitis, endocarditis, etc)
Intraabdominal spread can lead to perihepatitis “Fitz-Hugh-Curtis” syndrome
What can an untreated maternal infection during pregnancy lead to?
preterm birth and/or neonatal conjunctivitis (opthalmia neonatorum)
How should uncomplicated N. gonorrhea be treated?
ceftriaxone (IM) or cefixime
must also cover Chlamydia (dual therapy–add azithromycin)
refer partners for evaluation and treatment, avoid sexual intercourse until therapy is completed and symptoms resolved
What is PID?
Spectrum of disorders of the upper genital tract— any combination of endometritis (uterus), salpingitis (tubes), tubo-ovarian abscess, pelvic peritonitis
begins as ascending infection from the endocervix (mucopurulent cervicitis may be present but is NOT PID. it is a risk factor for PID)
What is the minimum criteria for a PID diagnosis?
CLINICAL!
Pelvic or lower abdominal pain in a sexually active woman with no other apparent cause
AND
one or more of the following findings on pelvic exam:
- Cervical motion tenderness (Chandelier sign)
- uterine tenderness
- adnexal tenderness
What is the more specific criteria for PID?
In addition to the minimum diagnostic criteria, if the following are present the diagnosis is more likely:
- Fever (Temp greater than 101);
- Mucopurulent cervical discharge with WBC’s on wet mount
- Right upper quadrant pain suggests Fitz-Hugh-Curtis
- Rebound suggests peritonitis
- Presence of adnexal mass on exam or ultrasound
- Hydrosalpinx or /TOA
What is the treatment for PID?
Broad spectrum* –> wide range of organisms can cause it
outpatient:
- Ceftriaxone IM PLUS doxycycline WITH OR WITHOUT metronidazole
In patient:
- IV cefotetan or cefoxitan AND oral doxycycline
- TOA present, ADD clindamycin or metrodnidazole to above regimen for better anaerobic coverage
What are the long term sequelae associated with PID?
Increases risk of ectopic pregnancy
Increases risk of chronic pelvic pain (4-fold?)
Increases risk of infertility: 11% after first episode, 23% after second, 54% after 3rd
When is new insertion of an IUD contraindicated?
a current STD infection –> increases risk of PID
