Infectious diseases of the female reproductive and urinary tract Flashcards
What triad of symptoms is classically associated with PID?
1) Pelvic pain
2) Cervical and Adnexal tenderness
3) Fever
What are clue cells? What are they associated with?
- Superficial vaginal epithelial cells with adherent bacteria
- Associated with bacterial vaginosis
- Most commonly Gardnerella vaginalis *
What is bacterial vaginosis?
- Alteration in the normal vaginal flora that results in a loss of hydrogen peroxide producing lactobacilli and an overgrowth of anaerobic bacteria
Which two anaerobic bacteria are found in much higher concentrations of women during bacterial vaginosis infection?
1) Gardnerella vaginalis
2) Mycoplasma hominis
* Note lactobacilli are usually absent
Women with BV are at increased risk of which gynecological problems?
- Pelvic inflammatory disease
- Postabortal PID
- Postoperative cuff infections after hysterectomy
- Abnormal cervical cytology
- Due to change in flora making more suceptable to infection *
- Also, although not an STI, increased sexual activity is a risk factor for BV (which also increases change of other STI and HPV)
Pregnanct women with BV have increased risk of what?
- PROM
- Pre-term labour
- Chorioamnionitis
- Postcesarean endometritis
What is the Whiff test?
- Addition of potassium hydroxide to vaginal secretions releases a fishy odor
- Associated with BV
How is BV diagnosed?
- Clue cells of microscopy
- Fishy smelling whiff test
- pH testing
How would you treat a patient with BV? explain your choice
Metronidazole (vaginal gel or PO)
- Antibiotic with excellent anaerobic coverage, but poor coverage of lactobacilli (kills anaerobes and allows lactobacilli to repopulate)
- Clindamycin (gel) may also be used
What type of infection is trichomonas vaginitis?
- Parasitic infection
Why is Trichomonas vaginitis commonly associated with BV?
- Trichomonas creates an anaerobic environment which favors the development of BV
What are the clinical symptoms of Trichomonas?
- Profuse, purulent, and malodorous vaginal discharge
- Vulvar pruritis
- Patchy vaginal erythema
- Colpitis macularis (STRAWBERRY CERVIX)
Strawberry cervic is associated with which condition?
- Trichomonas vaginitis
How may trichomonas vaginitis be diagnosed on microscopy?
- Viewing motile trichomonads
- Cells with visible flagella (kind of look like kites)
How is trichomonas vaginitis treated?
- Metronidazole
- 2g PO once
- or 500mg BID x 7d
- Treat sexual partners to avoid reinfection
Which pathogen is most commonly responsible for vulvovaginal candidiasis?
- Candida albicans (85-90%)
What are risk factors for the development of vulvovaginal candidiasis?
- Antibiotic use
- Pregnancy
- Diabetes
- Both are associated will decrease in cell mediated immunity (making immunocompromised)
What are the clinical features associated with vulvovaginal candidiasis?
- Vulvar pruritis
- Discharge (can be watery to homogenous and thick)
- Vaginal pain, burning
- dyspareunia
- erythema or edema of labia and vulvar skin
What would candidiasis look like under microscope?
- Budding yeast
How is vulvovaginal candidiasis treated?
1) Topical “azole” drugs (typically 1-7 days)
- clotrimazole
- miconazole
- tioconazole
2) Oral “azole”
- fluconozole 150mg PO once
- Note: Treatment will kill yeast quickly, but symptoms, from irritation, will last for 2-3 days *
What is atrophic vaginitis?
- Atrophy of the vaginal and vulvar epithelium
- Due to lack of estrogen
- Can result in post-coital bleeding, dyspareunia
What is the treatment of atrophic vaginitis?
- Topical vaginal estrogen cream
What is your differential diagnosis for endocervicitis with discharge?
- N. gonorrhoeae
- C. trachomatis
- Above 2 cause 50% of time
- M. genitalium
- Bacterial vaginosis
- Birth control pill use
Why is dual therapy recommended in the treatment of gonoccocal infection of the cervix, urethra or rectum? What therapy is recommended?
- Dual therapy due to increasing rates of resistant gonoccocal infection
- Dual therapy is
1) IM ceftriaxone 250mg OR Cefixime 400-800mg single dose
2) 1g single dose of PO azithromycin OR Doxycycline 100mg BID for 7 days
* Note that the azithro is not presumtive treatment for chlamydia it is incase there is resistance to cephalosporins
What is the treatment for chlamydial infection of the cervix, urethra or rectum?
- Azithromycin 1g PO once
OR - Doxycycline 100mg PO BID for 7 days
- Note doxy has been shown to be more effective IF observed doses are possible, but this is not very practical
What is pelvic inflammatory disease?
- Microorganisms colonizing the endocervix and ascending to the endometrium and fallopian tubes
- Upper genital tract infection
Which STI’s are commonly implicated in PID infection (2)
- N. gonorrheoeae
- C. trachomatis
Less common
- Mycoplasma genitalium
- Respiratory pathogens
1) Strep
2) Pneumococci
What does cervical motion tenderness suggest?
Peritoneal inflammation
- Pain when the peritoneum is stretched by moving the cervix
- In PID you get pelvic organ tenderness (uterus, adnexa)
- Ectopic pregnancy - bleeding into peritoneum causing cervical motion tenderness
What would you expect to see on histology of vaginal and endocervical secretions in a patient with PID?
- Increased polymorphonuclear leukocytes
How would you treat a patient with pelvic inflammatory disease?
- Ceftriaxone IM 250-500mg OR Cefixime 800mg single dose PLUS - Doxycycline 100mg BID for 14 days WITH OR WITHOUT - Metronidazole 500mg PO BID x14d
- Need broad spectrum coverage for gonorrhea, chlamydia, M. genitalium, gram negative facultative bacteria, anaerobes and strep
What is a tubo-ovarian abscess?
- Endstage process of acute PID
- Diagnosed when a patient has a palpable pelvic mass on exam
Which two infections would you suspect if a patient came in complaining of genital ulcers?
1) Herpes simplex virus
2) Syphilis
A painless and minimally tender ulcer is most likely to be associated with what?
- Syphilis
What tests can be performed to investigate for possible T. pallidum infection?
- nontreponemal rapid plasma reagin test (RPR)
- venereal diseas research laboratory (VRDL)
A patient comes in with groups vesicles mixed with small ulcers and has had a history of these lesions previously. What do you suspect?
- HSV
A patient comes in with 1-3 extremely painful ulcers which is accompanied by tender inguial nodes. What do you suspect?
- Chancroid
How would you manage a patient with HSV?
- Acyclovir or - Famciclovir or - Valacyclovir
How do you treat a patient with syphilis?
- Penicillin G 2.4 million units IM
- Single dose
What is Chancroid?
- STI causing painful genital ulcers
- Caused by Haemophilus ducreyi
- NOT COMMON IN N.AMERICA
What is the treatment of Chancroid?
- Azithromycin 1g PO weekly for 3 weeks
Genital warts are most commonly caused by which strains of HPV? Are they oncogenic?
- 6 and 11
- No they are non-oncogenic
- 16 and 18 are responsible for most cervical cancers
How contagious are genital warts?
- Very
- 75% of sexual partners develop them when exposed
What is the treatment for genital warts?
Removal of warts
-Irradication of the virus not possible
What is intraamniotic infection syndrome?
- AKA Chorioamnionitis
- clinically detectable infection of the amniotic fluid and fetal membranes during pregnancy
- Due to ascending vaginal microorganisms following rupture of membranes
What are the two most common pathogens associated with Chorioamnionitis?
- Group B Strep
- E. coli
What are the criteria needed for diagnosis of chorioamnionitis? When would you treat the mother?
1) Fever > 38 degrees
2) 2+ of the following
- maternal or fetal tachycardia
- Maternal WBC > 15,000
- Uterine tenderness (usually unable to assess due to anesthesia)
- Foul smelling amniotic fluid (rare)
- Due to impreision of the diagnosis - Any mother with a fever over 38 may be considered for antibiotic tx.
Which antibiotics would you use in a patient with chorioamnionitis?
- Ampicillin and gentamicin
Same bacteria as neonatal infections
