inflammation of cervix yellow-green mucopurulent discharge from cervix chandelier sign Cause

cervicitis / mucopurulent cervicitis (MPC) typically STI - gonorrhea/chlamydia MC

inflammation of external genetalia soaps, detergents, lotions, shaving, pads, tight clothing vaginal infections spread to labia Treatment

vulvodynia (vulvitis, vestibulitis, vulvovestibulitis) Tx avoid irritants, wear loose clothing behavioral tx topical xylocaine topical or systemic antidressants botox of affected nerve vestibulectomy

Sexually Transmitted Infection spread by intimate/sexual contact includes hepatitis and TB prevalent in ALL socioeconomic, racial, ethnic groups adolescents at greatest risk of exposure/infection

Infection and Pelvic Pain Flashcards by Gordon Scott

Inflammation/Irritation of the Vagina

S/s, Dx, Tx

vaginitis / vaginosis

S/s
- copious, maodorous, or irritating discharge
Dx
- wet mount prep to analyze vaginal secretions
Tx
- maintain protective acidic environment
- relieve symptoms (usually pruritis)
- antimicrobial/antifungal meds
- probiotic supplements

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sexually associate (not always STI)
Gardnerella vaginalis or other anaerobe
grey vaginal discharge, fishy odor

S/s, Dx, Tx

Bacterial Vaginosis (BV)

Dx
- clue cells on wet mount (vaginal epithelial cells covered w/ bacteria)
Tx**
- Metronidazole (Flagyl) 500mg PO bid 7d
- Tx of partners NOT necessary

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copious, frothy, malodorous, yellow/gray-green discharge**
internal pruritis**

S/s, Dx, Tx

Trichomoniasis (Trichomonas vaginalis)

anaerobic, unicellular flagellated protozoan that adheres to urethra, vagina, skene/bartholin glands

Dx
- strawberry cervix**
Tx
- Metronidazole (Flagyl) or Tinidazole
- MUST tx partners

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BV vs. Trich

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vulvar/vaginal pruritis, burning, dysuria, dyspareunia, vaginal discharge
scant vaginal discharge (20% thick, curdy)

S/s, Dx, Tx

Candidiasis (Candida albicans)

Dx**
- antibiotics, diabetes, immuno
- 10% KOH prep of vag. discharge
  - branching hyphae and spores
- culture on sabouraud’s agar if negative
Tx**
- Fluconazole (Diflucan) 150mg PO 1 dose

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inflammation of cervix
yellow-green mucopurulent discharge from cervix
chandelier sign

Cause

cervicitis / mucopurulent cervicitis (MPC)

typically STI - gonorrhea/chlamydia MC

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inflammation of external genetalia
soaps, detergents, lotions, shaving, pads, tight clothing
vaginal infections spread to labia

Treatment

vulvodynia

(vulvitis, vestibulitis, vulvovestibulitis)

Tx
- avoid irritants, wear loose clothing
- behavioral tx
- topical xylocaine
- topical or systemic antidressants
- botox of affected nerve
- vestibulectomy

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reddened/painful cyst +/- puss at vaginal opening to ducts

Treatment

Bartholinitis or Bartholin Cyst

(bartholin or greater vestibular glands)

Tx
- broad-spetrum antibiotics
- drain cyst w/ hot soaks, needle aspiration, catheter, or marsupialization of gland

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STI definition

Sexually Transmitted Infection

spread by intimate/sexual contact
includes hepatitis and TB
prevalent in ALL socioeconomic, racial, ethnic groups
adolescents at greatest risk of exposure/infection

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Gonorrhea

Cause, S/s, Dx, Complications, Tx

Bacterial: Neisseria gonorrhoeae

S/s
- endocervical canal MC site
- asymptomatic
- dysuria, vag. discharge, dysmenorrhea, lower abdominal/pelvic pain
- fever, mucopurulent discharge from OS
Dx
- gram stain microscopy
- N. gonorrhoeae cultured (mainstay)
- NAAT is new norm
Complications
- PID, sterility, disseminated infection (joints- polyarthralgia)
- pass from mother to fetus/infant
Tx**
- Ceftriaxone (Recephin) 250mg IM

AND

Azithromycin 1g orally (chlamydia coverage)
MUST tx partners
no sex until infection resolved

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Syphilis

Cause, S/s, Dx, Complications, Tx

REPORTABLE

Bacterial: Treponema pallidum

(corkscrew spirochete, anaerobic bacteria)

screen in pregnancy: TORCH

S/s- Stages
- Primary (local manifestations)
  - granulomatous rxn: hard, painless chancre w/ yellowish discharge
  - firm, large, nontender regional lymph nodes
- Secondary (systemic)
  - 6w after chancre appears
  - low fever, malaise, sore throat
  - anorexia, gen. adenopathy, HA, joint pain, skin/mucous membrane rash
  - condylomata lata
- Latent
  - 1y - lifetime, asymptomatic but medical evidence
- Tertiary
  - most severe, after latent
  - gummus formation: destructive skin, bone, soft-tissue lesions
  - neurosyphilis- reversible dementia
Dx
- Darkfield microscopy and serologic tests
  - VRDL antigen and RPR tests
  - FTA-ABS if RPR postitive
Tx
- Benzathine Pen G parenteral injection
- MUST tx partners
- condoms until tx verified

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Chancroid

Cause, S/s, Dx, Complications, Tx

Bacterial: Haemophilus ducreyi (G- bacillus)

S/s
- painful, tender, soft chancre
- women: asymptomatic, dysuria, dyspareunia, vag. discharge, painful defecation, rectal bleeding
Tx
- 3rd gen cephalosporin
- MUST tx partners
- condom use

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Granuloma inguinale (donovanosis)

Cause, S/s, Dx, Complications, Tx

Bacterial: Klebsiella granulomatis

(G-, non-spore forming, encapsulated bacteria)

S/s
- commonly concurrent w/ syphilis
- rare in US
- painful nodule w/ itching, ulcers on labia
Dx
- donovan bodies- bacteria filled vacuoles within white cells of ulcer smear
Tx
- Abx for at least 3 weeks

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Chlamydia

Cause, S/s, Dx, Complications, Tx

Bacteria: Chlamydia trachomatis

MC STI in U.S.**

S/s
- can be asymptomatic
- acute urethral syndrome (dysuria, frequency, sterile pus in urine)
- mimics UTI
Dx
- NAATs of genital swab recommended
Complication
- leading cause of tubal infertility
- C. trachomatis MCC cervicitis
- infects:
  - cervix, urethra, rectum, conjuntiva***
Tx
- Azithromycin 1 dose
- MUST tx all sexual contacts
- abstinence/condoms during tx + 7 days

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Lymphogranuloma venereum

Cause, S/s, Dx, Complications, Tx

Chlamydial Infection

S/s
- skin lesion spreading to lymphatic tissue
- inflammation, necrosis, abscesses
- buboes- pus draining lymph node
- 1’: cervix, vaginal wall, labia
- 2’: large buboes that rupture and drain
Tx
- Doxycycline or Erythromycin PO 21d
- MUST tx partners

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Nongonococcal / Nonspecific Urethritis

Cause, S/s, Dx, Complications, Tx

(Nonreportable STI)

Chlamydial infection MCC

S/s
- asymptomatic
- dysuria w/ mild to moderate white or clear urethral discharge
Tx
- Azithromycin 1 dose or Doxycycline 7d

Genital Herpes

S/s, Dx, Tx

(non-reportable disease)

HSV Type 1 and HSV Type 2

(Type 2 is 80% of initial and 98% or recurrent)

S/s
- vesicles that progress to ulceration w/ pain, lymphadenopathy, fever
- persists in latent stages
- recurrent infections milder
Dx
- serum PCR test
Tx
- no cure- symptom management
- Acyclovir

Human Papillomavirus (HPV)

S/s, Dx, Tx

Viral STD

S/s
- condylomata acuminata (genital warts) - soft, skin-colored, whitish pink-to-reddish brown benign cauliflower painless growths
Dx
- Papanicolaou test (Pap smear)
Tx
- patient applied
  - Podofilox, Imiquimod, Sinecathechin
- provider applied
  - cryotherapy, Podophyllin resin, Trichloroacetic acid (TCA), Bichloroacetic acid (BCA), surgery
- vaginal/urethral/anal warts
  - TCA, BCA, cryotherapy, surgery

Molluscum Contagiosum

S/s, Dx, Tx

S/s
- benign viral infection of skin of face, hands, lower abdomen, genitalia
- taken into epithelial cells by phagocytosis
Dx - clinical
Tx
- spontaneous healing after months - but contageous until then
- curettage, liquid nitrogen (cryotherapy), silver nitrate, topical creams
- lifetime immunity once lesions heal

Human Immunodeficiency Virus (HIV)

Approach During Pregnancy

retrovirus that infects CD4 (helper) T cells - destroys T and B cell function

perinatal transmission around L&D MCC of HIV infection in children
HAART: highly active antiretroviral therapy
- initiated if viral load > 1,000 copies/mL
- undetectable load is the goal
C-section and NO breastfeeding
screen all pregnant patients w/ consent

Pediculosis Pubis

S/s, Dx, Tx

Parasite - Phthirus pubis (the crab louse)

S/s
- mild to severe itching
- allergic sensations
- 2’ infections from scratching
Dx - clinical
Tx
- creme rinse
- shampoo
- lotion
- tx of clothes and bedding

Pelvic Inflammatory Disease (PID)

S/s, Complications, Tx

accute inflammation caused by infection -

possibly migrated STI (untreated C/G MCC)

S/s
- sudden, severe ab pain w/ fever or no sx
- cervical motion, uterine, adnexial tenderness
- salpingitis- inflammation of fallopian tubes
- oophoritis- inflammation of ovaries
Complications
- infertility, ectopic pregancies
Tx
- Admit if failed PO, questionable compliance, severe systemic illness, tubo-ovarian abscess (TOA)
  - IV Cefotetan or Cefoxitin + Doxy
  - IV Clindamycin + Gentamycin
  - 25% require drainage
- MUST tx partners

Urinary Tract Infection (UTI)

Classifications, Pathogens, Protective

inflammation of urinary epithelium after colonization

Classification
- complicated vs. uncomplicated
- cycstitis- bladder inflammation
- pyeloneprhitis- upper urinary tract
MC pathogens
- E. coli, Staph. saprophyticus
- virulence: evade/overwhelm defense, adherance to uroepithelium (pili, fimbriae), resist defense (biofilms)
Protective mechanisms
- washed out during micturition
- low pH, high osmolality of urea
- Tamm-Horsfall proteins
- uroepithelium secretions
- ureterovesical junction
- women: mucus-secreting glands

Acute Pyelonephritis

S/s, Dx, Tx

infection of ureter, renal pelvis and/or parenchyma

S/s
- flank pain
- fever, chills
- CVA tenderness
- purulent urine
Dx
- WBC casts
Tx
- antibiotics

Cystitis S/s, Dx, Tx

acute/chronic inflammation of bladder * S/s * asymptomatic * frequency, dysuria, urgency, low back/suprapubic pain * Dx * urine culture of specific organisms 10K+ * Tx * antimicrobial therapy

Painful Bladder Syndrome (aka Interstitial Cystitis) 3 Causes, S/s, Dx, Tx

non-bacterial infectious, noninfectious cystitis (radiation, chemical) interstitial cystitis (autoimmune, hypersensitivity) * S/s and Dx * sx of cystitis for 6+ weeks w/ negative urine culture and no other know cause * Tx * oral and intravesical therapies * sacral nerve stimulation * Onabotulinum toxin A * surgery

Chorioamnionitis Risk factors, S/s, Dx, Tx

intraamniotic infection syndrome - vaginal microorganisms ascend into uterine cavity after rupture of membranes * Risks * prolonged labor, rupture of membranes, mult. vaginal exams, young, low socioeconomics, nulliparity, BV * S/s and Dx * fever +2 other * maternal/fetal tachycardia * maternal leukocytosis * uterine tenderness * foul-smelling amniotic fluid (rare) * **ruptured membranes** * Tx * Ampicillin + Gentamicin intrapartum * delivery of fetus

Postpartum Endometriosis Risk factors, S/s, Dx, Tx

Endomyometriosis * Risks * prolonged labor, rupture of membranes, BV, frequent vaginal exams, internal fetal monitoring, polymicrobial infection, chlamydia trachomatis late form * S/s and Dx * 1st or 2nd post partum day fever * lower abdominal pain * uterine tenderness * leukocytosis * delayed bowel function * Tx * Clindamycin + Gentamicin until fever/WBC count resolve * if fever persists- consider wound or pelvic abscess

Chronic Pelvic Pain | (2 types)

1. Cyclic - dysmenorrhea 2. Non-cyclic * LEAPING * Leiomyoma * Endometriosis (MC \>30) / Endometritis * Adhesions/Adenomyosis * PID (MC \<30) * Infections * Neoplasm * Gastrointestinal * also: psych, MSK, fibromyalgia, UTI, Mittelschmerz

Chronic Pelvic Pain | (workup)

* detailed history (including prior surgeries) * PE * labs * imaging (laproscopic is conclusive) * referrals

Chronic Pelvic Pain | (treatment)

* multidisciplinary * ovulation or menstrual suppression * NSAIDs * surgery not effective w/out abnormal pathology * injections

Chronic Pelvic Pain | (clinical pearls)

* accounts for 12% hysterectomies, 20% laparoscopies, 40% repeat office visits * PID is MCC in women \< 30 * endometriosis MCC in women \> 30 * laparoscopy is GOLD standard for dx * ONLY done after psychogenic and GI evaluated