Gynecologic Infections

Question 1

vaginal discharge

Answer 1

• Estrogen thickens the vaginal epithelium → large glycogen production by epithelial cells
• Intraepithelial glycogen → production of lactic acid
• pH 3.5-4.0 in the vagina promotes growth of normal vaginal flora
  
  • Lactobacilli
  • Corynebacteria
• Prepubertal girls at higher risk of vaginal infections due to thin epithelium
• Postmenopausal women lose glycogen and acidity as estrogen declines → vaginal atrophy, dryness, increased risk of infection and trauma
• Postmenopausal women also at risk for urinary incontinence, further predisposing to vaginal infections
• Vaginal discharge is always present
  
  • Acidic
  • Clear or white mucoid
  • No odor
  • Not itchy or painful
  • May increase at the time of ovulation (cervical mucus increases)
• Epithelial secretions, desquamation; vulvar secretions from sebaceous, sweat and apocrine glands
• Vaginal discharge is abnormal if:
  
  • Increased volume, especially if soiling the clothes
  • Bad odor
  • Change in consistency or color
  • Irritation or pruritis, pain, burning
  • Dyspareunia or dysuria

Question 2

diagnosis of vaginal discharge

Answer 2

• History including:
  
  • Personal hygiene – soaps, perfumes, douching
  • Sexual activity – use of lubricants, condoms, etc.
  • Medications that may alter vaginal pH or flora
    
    • Oral contraceptive pills, antibiotics
  • Underlying medical illness – diabetes, HIV
  • History of STD
  • Use of synthetic undergarments or tight clothing
• Examine the vulva, vaginal walls, and cervix
• Check pH of vaginal discharge
• Collect specimens to send to the lab
  
  • GC, Chlamydia, HSV, etc.
• Prepare a wet mount
  
  • Diluted with normal saline on a glass slide
• Prepare a KOH smear
  
  • 10% potassium hydroxide solution on a slide
  • “Whiff” test or sniff test

Question 3

non-sexually transmitted infections

Answer 3

• Candidiasis (Candida albicans)
• Bacterial vaginosis (Gardnerella vaginalis)
• Bartholin’s gland cyst/abscess
• Mycoplasma hominis and Ureaplasma urealyticum also cause bacterial vaginal disease, but much less commonly
  
  • Diagnosis by vaginal culture or PCR for identification
  • Treatment is Doxycycline 100mg po bid x 10 days

Question 4

sexually transmitted infections

Answer 4

• Trichomoniasis (Trichomonas vaginalis)
• Gonorrhea (Neisseria gonorrhoeae)
• Chlamydia (Chlamydia trachomatis)
• Herpes simplex virus (HSV)
• Syphilis
• Human papillomavirus (HPV)
• Human immunodeficiency virus (HIV)

Question 5

bartholin cyst

Answer 5

• Glands that excrete mucous to provide moisture to the vulva
• Bilaterally in vulvovaginal orifice at 4:00 & 8:00; Posterolateral introitus
• Gland is 0.5cm in size with narrow duct 2.5cm
• Enlargement of gland
  
  • Trauma or perineal inflammation can obstruct the duct proximal to the obstruction
  • Intervention usually not necessary because most cases are asymptomatic
  • Conservatively treat with warm compresses
  • Cyst vs abscess
    
    • Symptomatic, size, tenderness, erythema

Question 6

bartholin abscess

Answer 6

• Incision and drainage has no role in management of abscess
• High risk of recurrence

Question 7

word catheter

Answer 7

• Allows contents to drain and over time to form around the catheter a fistulous tract from the dilated duct or abscess to the vestibule

Question 8

supplies for word placement

Answer 8

• Sterile gloves
• Sterilizing solution/prep surgical site
• Lidocaine 1-2% in 3cc syringe
• 25-30 G needle
• Small forceps
• # 11 scalpel for stab incision
• Gauze pads
• Culturette for sending abscess contents for microbiological identification
• Hemostat for breaking loculations
• Word catheter – balloon tipped device
• Small syringe 3mL saline

Question 9

word catheter procedure

Answer 9

• Informed consent
  
  • Risks, benefits and alternatives discussed
  • Recurrence, infection, scarring, bleeding, dyspareunia
• Prep area
• Inject anesthesia
• Hold cyst with forceps
• Incise with 5mm stab incision, 1.5cm deep in the introitus at/behind the hymenal ring to prevent vulvar scarring; if incision is too large the catheter will fall out
• Drain the cyst, break loculations
• Place Word catheter, holding onto cyst wall with forceps helps to prevent creation of false passage separate from the cavity
• Inflate the balloon with 2-3mL saline injected into the catheter
• Tuck the end of the catheter into the vagina
• Empiric broad spectrum abx
  
  • Ceftriaxone 250mg IM or Cefixime 400m po
  • Clindamycin 300mg po x 7 days
  • Add azithromycin 1gm po if C. trachomatis

Question 10

word follow up

Answer 10

• Wear peripad to absorb drainage
• Pelvic rest (no sex)
• Sitz baths and mild analgesics 48 hrs
• Catheter in place 2-4 wks (poss 6 wks)
• Call for any increase in pain, swelling, fever or unusual vaginal discharge

Question 11

marsupialization

Answer 11

• Marsupialization
  
  • Less chance of recurrence
  • Outpatient surgery

Question 12

candidiasis

Answer 12

• Candida albicans is most common species
• 75% of women will experience an episode of vulvovaginal candidiasis
• May be associated with systemic disorder, pregnancy, medications
  
  • Diabetes, HIV, obesity
  • Antibiotics, steroids, oral contraceptives
• May worsen prior to menses

Question 13

candidiasis - presentation

Answer 13

• Intense vulvar pruritis
• White “cottage cheese” vaginal discharge
• Vulvar, vaginal erythema
• Burning sensation of the vulva; dysuria
• May be vulvar excoriations
• Extensive erythema and edema may indicate underlying systemic illness

Question 14

candidiasis - vaginal discharge

Answer 14

• Thick, white, curdlike, cheesy
• pH ≤ 4.5
• Buds and hyphae on wet mount and KOH prep
• Vaginal secretions may also be cultured for definitive diagnosis

Question 15

candidiasis management

Answer 15

• Treat all patients with Candida infections
• Control underlying medical illness if present
• Discontinue offending medications
• Avoid douching, nonabsorbent undergarments, tight clothing such as pantyhose
• Not typically sexually transmitted

Question 16

candidiasis - treatment

Answer 16

• Topical (intravaginal)
  
  • OTC or Rx imidazoles
  • 85-95% cure rate
  • Combining with steroids for itching – a good idea?
• Systemic
  
  • Oral fluconazole (Diflucan) 150mg po x 1
  • Oral itraconazole 200mg po bid x 1 day
• During pregnancy
  
  • Avoid imidazoles in the first trimester
  • Nystatin vaginal tabs 100,000 units qhs x 2 weeks

Question 17

candidiasis - treating chronic infections

Answer 17

• ≥4 infections per year in 5-8% of women
• Treat the partner if he/she also has Candida
• Look for underlying illness or medications
• Send a vaginal culture to confirm C albicans and sensitivity to therapy
• Relation to antibiotic use or menstruation
  
  • Prophylaxis during abx use if indicated
  • Prophylaxis 3-5 days prior to menses if associated
  • May use topical or oral treatments for prophylaxis
• Treatment options include:
  
  • Prolonged therapy for 7-14 days
  • Self medication for 3-5 days at the first sign of infection
  • Oral fluconazole 150mg po qd x 3 days, then 150mg po q week x 6 months
    
    • >90% eradication rate after 6 mos
    • Almost 50% remain free of infection after 6 mos off Rx
    • Monitor LFT’s with prolonged oral therapy

Question 18

bacterial vaginosis

Answer 18

• Caused by bacteria Gardnerella vaginalis
• Most common cause of symptomatic bacterial infections
• Normal vaginal flora is altered, causing overgrowth of Gardnerella and other species
• Increases the risk of preterm delivery in pregnant women
• Watery vaginal dc and petechiae on cervix
• Severe BV infection

Question 19

bacterial vaginosis presentation

Answer 19

• Malodorous, nonirritating vaginal discharge
• “Fishy” smell more noticeable after sexual intercourse
• May be found incidentally on well woman exam if asymptomatic
• Not considered sexually transmitted infection
  
  • Women who are not sexually active rarely present with BV

Question 20

bacterial vaginosis - vaginal discharge

Answer 20

• Homogeneous, gray-white
• pH >4.5
• Fishy odor on KOH prep – positive Whiff test
• Wet mount shows Clue cells
  
  • Numerous stippled or granulated epithelial cells
  • Adherence of bacteria to cell membrane
• Gram negative bacilli, absence of lactobacilli
• Cultures often not helpful
• DNA testing useful

Question 21

bacterial vaginosis - treatment

Answer 21

• Only treat symptomatic or pregnant women
• No evidence to support Rx the male partner
• Nonpregnant women
  
  • Metronidazole 500mg po bid x 7 days
  • Metronidazole vag gel: 1 (5g) applicator qhs x 5 d
  • Clindamycin vaginal ovules 100mg qhs x 3 d
• Pregnant women – no topical clinda
  
  • Metronidazole 500mg po bid x 7 days
  • Clindamycin 300mg po bid x 7 days

Question 22

trichomoniasis

Answer 22

• Unicellular flagellate protozoan Trichomonas vaginalis
• Larger than PMN leukocytes, smaller than epithelial cells
• Sexually transmitted
  
  • If one STD is present, look for others
  • Increased incidence in transmission of HIV
• Associated with many perinatal complications
• Frothy vaginal discharge
• Strawberry cervix

Question 23

trichomoniasis - presentation

Answer 23

• Persistent, copious vaginal discharge, usually without vulvar pruritis
• Worse after menstruation and during pregnancy
• Dysuria may be associated if vulvitis present
• Vaginal erythema with strawberry spots
  
  • Multiple small petechiae on vaginal epithelium

Question 24

trichomoniasis - vaginal discharge

Answer 24

• Profuse, greenish, extremely frothy, thin
• May be foul smelling
• pH >5.0
• Wet mount increased PMN leukocytes and motile flagellates (trichomonads)
• Culture and DNA probes for definitive diagnosis

Question 25

vaginal discharge treatment

Answer 25

• Treat sexual partners simultaneously and avoid unprotected sex until treatment is finished
• Metronidazole 2g po x 1 or 500mg po bid x 7 days

Question 26

gonorrhea

Answer 26

• Etiology is bacteria Neisseria gonorrhoeae
• Sexually transmitted; reportable to PHD
• Recover organism from urethra, cervix, anus, or pharynx
• Always check pt for Chlamydia, other STDs
• Major complication is salpingitis; can lead to tubal scarring, infertility, increased risk of ectopic pregnancy

Question 27

gonorrhea - presentation

Answer 27

• Most women (85%) are asymptomatic
• Purulent vaginal discharge, urinary frequency and dysuria, perineal or rectal discomfort
• May cause conjunctivitis, arthritis, pharyngitis
• On PE: erythematous vulva, vagina, cervix, urethra with purulent discharge

Question 28

gonorrhea - vaginal discharge

Answer 28

• Copious, mucopurulent
• Gram negative diplococci within leukocytes; oxidase positive
• Culture or DNA probe for definitive diagnosis
  
  • Endocervical sample
  • Urine sample

Question 29

gonorrhea - managment

Answer 29

• Condoms will protect against gonorrhea
• Screen high-risk patients with DNA probes of cervix or urine
• Treat partner concurrently and abstain from sexual contact for 7 days after start of treatment
• Treat presumptively for Chlamydia infection
• Test patient for syphilis; consider HIV testing

Question 30

gonorrhea - treatment

Answer 30

• Ceftriaxone 125mg IM x 1 dose or Cefixime 400mg po x 1 dose
  
  • PLUS Azithromycin 1g po x 1 or Doxycycline 100mg po bid x 7 days for Chlamydia coverage
• Do NOT use quinolones anymore for GC
  
  • High resistance rates in US, Asia
• Retest patient in 3 weeks with DNA probe to ensure successful treatment

Question 31

pelvic inflammatory disease

Answer 31

• Acute salpingitis-peritonitis
• Usually a complication of acute gonococcal infection
• May be chronic or non-gonococcal (usually Chlamydia)
• Infection and inflammation of the uterus, tubes, ovaries; varying degrees of peritonitis
• Can lead to tube scarring and infertility
• Lower abdominal and pelvic pain with purulent vaginal discharge
• Abdominal, uterine, adnexal and cervical motion tenderness on exam
• Fever above 101˚F
• WBC > 10K and/or elevated CRP
• Inflammatory mass on exam or US
• Gram negative intracellular diplococci
• Purulent discharge on culdocentesis
• Elevated ESR

Question 32

pelvic inflammatory disease outpatient and inpatient treatment

Answer 32

• Outpatient treatment
  
  • Temp <102.2˚F, mild to moderate symptoms, nontoxic patient, able to take oral meds
  • Oral analgesics, remove IUD if present, bed rest, antibiotics
    
    • Ceftriaxone 250mg IM with Probenecid 1g PO + Doxycycline 100mg po bid x 14 days +/- metronidazole 500mg po bid
• Admit if no response in 72 hours
• Inpatient treatment
  
  • Temp >102.2˚F, guarding or rebound tenderness, toxic patients; adolescents and pregnant women
  • Patients who do not respond to oral treatment
  • Bed rest, NPO, IVF, NG suction if abdominal distention or ileus, IV antibiotics
  • Doxycycline 100mg IV bid + Cefoxitin 2g IV qid x 24-48 hrs until patient improves, followed by complete 14 day oral course of doxycycline
• Exploratory laparotomy if TOA suspected

Question 33

chlamydia

Answer 33

• Most common STD among women
• Etiology is Chlamydia trachomatis; obligate intracellular bacteria
• Sexually transmitted; reportable to PHD
• Usually localized infection, but may cause salpingitis and sequelae
• Increased risk of abortion, premature delivery and postpartum infections in pregnancy

Question 34

chlamydia - presentation

Answer 34

• Many patients may be asymptomatic
• Mucopurulent vaginal discharge
• Hypertrophic cervical inflammation
• Cervical motion tenderness may be present

Question 35

chlamydia - vaginal discharge

Answer 35

• Mucopurulent
• Giemsa stain identifies inclusions in only 40% of vaginal samples
• Culture and DNA probe of endocervical discharge or urine for definitive diagnosis

Question 36

chlamydia - managment

Answer 36

• Condoms will protect against Chlamydia
• Screen high-risk patients with DNA probes of cervix or urine
• Treat partner concurrently and abstain from sexual contact for 7 days after start of treatment
• Treat for assumed gonorrhea co-infection
• Test patient for syphilis; consider HIV testing

Question 37

chlamydia - treatment

Answer 37

• Non-pregnant women
  
  • Azithromycin 1g po x 1 dose or
  • Doxycycline 100mg po bid x 7 days
• Pregnant women
  
  • Erythromycin 500mg po qid x 7 days or
  • Amoxicillin 500mg po tid x 7 days
• PLUS ceftriaxone 125mg IM x 1 dose for GC
• Retest patient in 3 weeks with DNA probe to ensure successful treatment

Question 38

herpes simplex virus

Answer 38

• Herpesvirus hominis types I & II
  
  • Type I causes genital infection in 10-15%
  • Type II causes genital infection in 85%
• Sexually transmitted by direct contact
• Most common cause of genital ulcers
• Incubation period 2-7 days
• Lesions last 2-6 weeks without scarring

Question 39

HSV - presentation

Answer 39

• Prodrome of tingling, burning, or itching
• Vesicles erupt and rapidly erode to form painful ulcers in small patches on vulva, vagina, and/or cervix
• Fever, malaise, inguinal lymphadenopathy typically in primary infection
• Dysuria or urinary symptoms may develop
• Profuse watery vaginal discharge in herpetic cervicitis
• Diagnosis is clinical – definitive laboratory results are difficult to obtain
• Viral culture on vesicle fluid in the first 2 wks
• Scraping of ulcer and stained as Pap smear is nonspecific
• Serologic tests best for evidence of past infection
• Infections may recur
  
  • 50% of patients have recurrence within 6 mos of primary infection
  • Ulcers smaller, fewer in number, confined to one area of the vulva, vagina, or cervix
  • Healing in 1-3 weeks
  • Systemic symptoms, lymphadenopathy usually do not occur
  • Extragenital sites include fingers, buttocks, trunk, mouth

Question 40

HSV - management

Answer 40

• Lesions are self-limiting
• Good genital hygiene, loose clothing, sitz baths, oral analgesics
• Oral antivirals for primary and recurrent infections
  
  • Topical treatments not effective
  • Start within 72 hours of outbreak or ineffective

Question 41

HSV - treatment

Answer 41

• Primary infection
  
  • Acyclovir 400mg po tid x 7-10 days
  • Valacyclovir 1g po bid x 10 days
• Recurrent genital herpes infection
  
  • Acyclovir 400mg po tid x 5 days
  • Valacyclovir 500mg po bid x 5 days
• Prophylaxis for genital herpes
  
  • Acyclovir 400mg po bid
  • Valacyclovir 500mg po qd

Question 42

HSV - prevention

Answer 42

• Pregnancy
  
  • Vaginal delivery if no active lesions
  • Prophylaxis may be initiated at 36 wks gestation
• Prevention of dissemination
  
  • Avoid direct contact with active lesions
  • Cover small lesions with adhesive
  • Precautions unnecessary in absence of active lesions
    
    • Viral shedding may be present; no good data regarding spread during latent period

Question 43

syphilis

Answer 43

• Caused by spirochete Treponema pallidum
• Sexually transmitted by direct contact; reportable to PHD
• Primary chancre develops 10-90 days after infection, persists 1-5 weeks and heals spontaneously
• Cutaneous eruption of secondary syphilis occurs 2-6 months after initial lesion, heals spontaneously after 2-6 weeks

Question 44

syphilis presentation

Answer 44

• Primary syphilis
  
  • Painless genital chancre: indurated, firm papule or ulcer with raised borders on labia, vulva, vagina, cervix, anus, lips or nipples
  • Painless, rubbery regional lymphadenopathy followed by generalized lymphadenopathy in the 3^rd-6^th week
  • Darkfield microscopic identification of specimens from cutaneous lesions
  • Positive serologic tests in 1-4 weeks in 70% of pts
• Secondary syphilis
  
  • Diffuse bilaterally symmetric extragenital papulosquamous eruption involving palms, soles
  • Condyloma lata: moist papules in perineum, darkfield microscopy positive
  • Mucous patches, darkfield microscopy positive
  • Viral-like syndrome, diffuse lymphadenopathy
  • Positive serologic tests
  • Diffuse rash of secondary syphilis; Palmar rash of secondady syphilis
• Latent syphilis
  
  • Resolution of primary and secondary infection without therapy
  • Absence of lesions
  • Positive serologic tests
  • May last a lifetime without developing tertiary syphilis
  • Infection of the CNS leading to neurosyphilis
• Tertiary syphilis
  
  • Cardiac, neurologic, ophthalmic, auditory lesions may develop
  • Gummas: skin or bone lesions
  • CSF testing for cell count, protein, VDRL, and FTA-ABS
  • Fatal in about 25% of patients
  • Indications for LP: neurologic symptoms, treatment failure, serum non-treponemal titer >1:32, evidence of tertiary syphilis, HIV+ patients

Question 45

syphilis laboratory

Answer 45

• Identification of T pallidum organism
  
  • Darkfield microscopy
  • Silver staining of tissues
  • PCR of amniotic fluid, spinal fluid
• Serologic tests
  
  • Nontreponemal tests for screening
    
    • VDRL, RPR
    • Titers will decrease after treatment
  • Treponemal tests more sensitive and specific
    
    • FTA-ABS, MHA-TP
    • Remain positive despite treatment

Question 46

syphilis managment

Answer 46

• Give prophylactic treatment to exposed patient without waiting for reactive serology
• Treat the partner and avoid unprotected sexual contact until both patients have decreased serologic titers
• Use of a condom or barrier contraception will prevent most cases

Question 47

syphilis treatment

Answer 47

• Early syphilis: primary, secondary, and early latent (less than 1 year duration)
  
  • Benzathine penicillin G, 2.4 million units IM once
  • Doxycycline 100mg po bid x 14 d if PCN allergic
• Late syphilis or unknown duration
  
  • Benzathine penicillin G, 2.4 mU IM q wk x 3 wks
  • Doxycycline 100mg po bid x 28 d if PCN allergic
• Neurosyphilis – very difficult to treat
  
  • Penicillin G 3-4 mU IV q4h x 10-14 days

Question 48

syphilis follow up

Answer 48

• Follow-up is mandatory
• Repeat RPR or VDRL at 0, 3, 6, 12, and 24 months after treatment
• Serologic criteria for response to treatment is 4-fold decrease in titer over 6-12 months

Question 49

human papillomavirus (HPV)

Answer 49

• Papovavirus responsible for condyloma acuminata, genital dysplasia and cancer
• More than 20 types of HPV can infect the genital tract
  
  • Types 16, 18, 31, 33, 35 most oncogenic
  • Types 6, 11 associated with genital condyloma
• Sexually transmitted
• Rate is high and rising: estimated 85% of people have had HPV at some point
  
  • <1% clinically significant

Question 50

HPV - condyloma acuminata

Answer 50

• Commonly known as genital warts
• Exophytic or papillomatous white or flesh-colored verrugous papules with fingerlike projections
• May also be flat, spiked, or inverted
• Pruritis is common; vaginal discharge from inflammation or irritation; postcoital bleeding may occur
• Immunosuppressed patients may have florid proliferation of condyloma
• Colposcopy allows better identification of lesions and evaluation for dysplasia
• Biopsy of lesions for definitive diagnosis
• Use of condoms or barrier protection may help decrease transmission
• Multiple treatments available; pt preference
  
  • Unclear if treatments actually affect natural progression or eradicate infection
• Prevention of recurrence is difficult
• Provider applied treatments
  
  • Bichloroacetic acid or trichloroacetic acid, 50-80% soln: apply q week as necessary until resolved
  • Podophyllin 10-25% in tincture of benzoin: apply q week for 1-4 hrs, then rinse, use x 6 wks
  • Intralesional injections of interferon α-2b or interferon α-n3, 1 mU (0.1mL) 3x/wk x 3 wks
  • Cryosurgery, laser vaporization, electrosurgery, simple surgical excision
• Patient applied treatments
  
  • Podofilox 0.5% solution or gel: apply bid x 3 days, rest x 4 days, repeat cycle 4-6 times as needed
  • Imiquimod 5% cream: apply 3x/wk qhs, remove in am, until resolved or maximum of 16 wks
• Pregnant women
  
  • TCA may be applied in last 4 weeks of pregnancy
  • Cryosurgery, electrosurgery, laser therapy can be used prior to 32 weeks gestation

Question 51

Human Immunodeficiency Virus (HIV)

Answer 51

• Most cases in USA due to HIV-1
• 20% of cases in North America in women
• 80% of women with HIV are reproductive age
• 40% cases in American women due to heterosexual contact
• High-risk groups for women: IVDA, prostitutes, heterosexual contact with men in high-risk groups

Question 52

HIV in women

Answer 52

• Transmission via sexual contact, blood, or vertical transmission from mother to fetus
• Viral-like syndrome with weight loss, fever, night sweats, lymphadenopathy, pharyngitis, erythematous maculopapular rash
• Neurologic involvement
• Opportunistic infections or unusual neoplasias such as KS or cervical cancer
• Diagnosis by serologic tests
  
  • HIV ELISA followed by confirmatory Western blot
  • Recommended by CDC that everyone is tested
• All women diagnosed with HIV require
  
  • Counseling
  • Extensive STD evaluation
  • Pap smear
  • CBC, Chem panel, Toxoplasma Ab, hepatitis panel
  • PPD, CXR
  • Vaccinations for Hep B, Influenza, Pneumococcus
• Treatment includes antiretroviral medications