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Repro Final > Gyn Infections I and II -Castro > Flashcards

Gyn Infections I and II -Castro Flashcards

1
Q

Which cell type lines the vulva? Vagina?

A

stratified squamous epithelium

vulvar is keratinized

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2
Q

What is the normal vaginal pH for prepubertal and postmenopausal women? Reproductive aged women?

A

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

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3
Q

What is normal “physiologic” vaginal discharge?

A

cervical mucus and vaginal transudate and normal vaginal flora with exfoliated squamous cells

whitish and does not cause itching, burning or smell

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4
Q

What do most vaginitis patients present with?

A

Increased vaginal discharge-often with foul odor and vulvar, vaginal itching or burning and sometimes dysuria

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5
Q

How do you diagnose vaginitis?

A

must perform a pelvic exam and microscopic exam of the discharge (wet mount)

cultures and biopsies might be indicated, depending on findings

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6
Q

What is the most common cause of vaginitis? Is this an STI?

A

bacterial vaginosis

it is “sexually associated” but not clearly an STI (do NOT treat the partner)

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7
Q

What does a patient with bacterial vaginosis present with?

A
  • “fishy” odor
  • inc grayish vaginal discharge
  • homogenous discharge (vaginal vault looks like milk has been poured into it)
  • often after vaginal intercourse
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8
Q

What is the etiology of bacterial vaginosis (BV)?

A

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))

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9
Q

What is the diagnostic criteria for BV?

A 
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
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10
Q

What is the treatment for bacterial vaginosis? Should the male partner be treated as well?

A

Oral metroidazole or topical metronidazole gel or clindamycin cream

do NOT treat the male partner

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11
Q

What is the second most common cause of vaginitis? Is this sexually transmitted?

A

candida vaginitis (more likely to have vulvar involvement than BV or trichomoniasis)

NOT considered sexually transmitted

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12
Q

What are the risk factors for candida vaginitis (8)?

A 
Diabetes
Obesity
Pregnancy
Immunosuppressed
Recent use of antibiotics
Exogenous estrogens
Sexual intercourse
Anything facilitating vulvar/vaginal warmth and moisture
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13
Q

What will a patient with candida vaginitis present with?

A
  • Vaginal discharge and burning
  • Vulvar itching and burning with erythema
  • Dysuria
  • Dyspareunia (pain with intercourse)
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14
Q

How is candida vaginitis diagnosed?

A
  • 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
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15
Q

What is the treatment for candida vaginitis? Should the male partner be treated as well?

A
  • 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)
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16
Q

What can recurrent candida vaginitis be indicative of?

A

diabetes

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17
Q

Is trichomonas vaginitis (trichomoniasis) a sexually transmitted disease? What are the major presenting symptoms?

A

YES!

Major patient symptoms:

  • increased discharge
  • foul smelling
  • vulvar itching and burning
  • dysuria
  • dyspareunia
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18
Q

How is the diagnosis of Trichomonas Vaginitis made in women? Men?

A
  • 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

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19
Q

How is Trichomonas Vaginitis treated? Should the male sex partner also be treated?

A
  • Patient and sex partner need to be treated Metronidazole or Tinidazole 2 grams orally - 90% effective
  • Abstain from alcohol (disulfiram - type adverse response)
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20
Q

What is the typical presentation of atrophic vulvovaginitis?

A

-Older women, secondary to decreased estrogen

-Thin vaginal mucosa
Yellowish discharge, ph >4.5

-Smooth, shiny, reddish, atrophied vulvar skin

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21
Q

How is a diagnosis of atrophic vaginitis made? What other diagnosis has to be ruled out?

A

Saline wet mount showing rounded parabasal cells. May need biopsy to distinguish from Lichen Sclerosis

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22
Q

When should you biopsy vulvitis?

A

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.

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23
Q

What are the differences in the vulvar dystrophies? What type of patient population is this normally found in?

A

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

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24
Q

Who should be screened for STDs? What are the reportable STDs?

A
  • high risk patients
  • all pregnant women
  • screen for other STDs if one is identified
  • reportable: GC, Chlamydia, syphilis, chancroid, HIV/ AIDS
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25
Q

What are the 5 P’s in taking a sexual history?

A

Partners

Prevention of Pregnancy

Protection from STD’s

Practices

Past History of STD’s

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26
Q

How is HIV diagnosed? Monitored?

A

enzyme immunoassay (EIA) and then Western Blot or immunofluorescence assay

monitored with viral load and CD-4 counts

27
Q

How should an HIV + pregnant woman be treated?

A

-antiretroviral therapy and elective cesarean section at 38 weeks with avoidance of breast feeding can decrease perinatal transmission ( give zidovudine or nevirapine

28
Q

What are the most common causes of anal or genital ulcers? How are these diagnosed?

A

Herpes (HSV) (viral culture or PCR is gold standard)

syphilis (VDRL/RPR with reflex FTA-ABS/TPA or dark field)

chancroid

29
Q

What is the clinical presentation of general herpes?

A

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)

30
Q

What is the treatment of genital herpes infection? Does this get rid of the virus?

A

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

31
Q

If a person has HSV-2, what can be given to reduce recurrences, subclinical shedding and risk of spreading to a partner?

A

suppressive therapy ==> use acyclovir, famciclovir or valacyclovir daily

32
Q

What can be used to treat a severe systemic HSV-2 infection?

A

IV acyclovir

33
Q

When is risk of HSV transmission highest for a pregnant woman?

A

primary infection in the 3rd trimester

do a c-section if herpetic lesions are present in labor –> can cause neonatal lesions or meningitis

34
Q

What counseling is advised if a pregnant non-infected female has a male partner with herpes?

A

treat the male

suggest abstinence (preferably, especially with a lesion) or condoms throughout pregnancy to avoid the preggo getting the primary infection

35
Q

What is the difference between primary and secondary syphilis? In what stage are the lesions infectious?

A

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*

36
Q

What are the signs/symptoms of tertiary syphilis?

A

aortitis, gumma’s (necrotic granulomatous lesions) and iritis

Neurosyphilis-can occur at any stage *

37
Q

How is syphilis diagnosed?

A

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)

38
Q

How is syphilis transmitted in the late stages?

A

blood transfusion or transplacental passage (mother-> fetus)

39
Q

What is latent syphilis?

A

No clinical signs of disease

40
Q

What is used to monitor syphilis activity? What implies reinfection or failed initial treatment?

A

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

41
Q

How is neurosyphilis diagnosed?

A

required lumbar puncture with a + VDRL CSF

42
Q

How is primary, secondary or early latent syphilis treated? What reaction should the patient look for?

A

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)

43
Q

How is late latent, latent of unknown duration or tertiary syphilis treated?

A

Benzathine penicillin G

IM x 3 doses at weekly intervals

44
Q

How should neurosyphilis be treated?

A

IV aqueous penicillin G for 10-14 days

45
Q

What can syphilis in a pregnant woman lead to?

A

Screen pregnant women with VDRL or RPR.

Untreated maternal infection can result in non-immune hydrops fetalis, fetal demise and preterm birth

46
Q

What is chancroid? What patient populations is this generally seen in?

A

Painful, genital ulcer with tender suppurative inguinal adenopathy (bubos)

in setting of drug abuse, prostitution, HIV infection, travel to an African or Caribbean country

47
Q

How is chancroid diagnosed? How is it treated?

A

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)

48
Q

What is granuloma inguinale (donovanosis)? Where is this generally found?

A

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)

49
Q

What is the diagnostic criteria and treatment for Donovanosis?

A

Diagnosis–Donovan bodies on tissue prep

Treatment-Doxycycline for three weeks

50
Q

What is mucopurulent cervicitis? What are the most common causes?

A

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

51
Q

What does chlamydia normally present with in sexually active young adult women? What can this lead to?

A

asymptomatic!

can lead to cervicitis, urethritis, or PID

risk of infertility, chronic pain and increased risk of ectopic pregnancy

52
Q

If a female presents with mucopurulent cervicitis, what should you suspect? What diagnostic test should be done?

A

chlamydia

endocervical swab or urine sample sent for culture, immunoassay or nucleic acid amplification test (NAAT)

53
Q

What is the treatment for chlamydia?

A

azithromycin

abstinence until 7 days after therapy was started

screen for other STD (HIV, GC, syphilis, hep B)

54
Q

If a male presents with urethritis, what should be suspected?

A

chlamydia

55
Q

How should chlamydia be treated in pregnancy??

A

screen all pregnant women at first visit and treat with azithromycin if +

test of cure in 3 weeks

test for reinfection in 3rd trimester

56
Q

What is neisseria gonorrhea? What does this normally present with?

A

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

57
Q

What can an untreated maternal infection during pregnancy lead to?

A

preterm birth and/or neonatal conjunctivitis (opthalmia neonatorum)

58
Q

How should uncomplicated N. gonorrhea be treated?

A

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

59
Q

What is PID?

A

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)

60
Q

What is the minimum criteria for a PID diagnosis?

A

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
61
Q

What is the more specific criteria for PID?

A

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
62
Q

What is the treatment for PID?

A

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
63
Q

What are the long term sequelae associated with PID?

A

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

64
Q

When is new insertion of an IUD contraindicated?

A

a current STD infection –> increases risk of PID

Repro Final (17 decks)

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