Lower reproductive tract infections Flashcards
UTIs
Need to r/o pyelo (no fever, no CVA tenderness)
Treat for E. coli, etc. with oral abx.
DDx of UTIs
Interstitial cystitis: chronic inflammation of bladder → recurrent irritative urinary sx (urgency, frequency) for long time w/o infection, also pelvic pain (dyspareunia, etc).
Vulvitis
Usually candidasis
If chronic, always rule out malignancy
Could also be 2/2 irritants, etc.
Syphilis (T. pallidum): primary
Primary = chancre on exposed mucosa, painless / red / round / firm / well circumscribed.
Develops 3wks after exposure; some LAD too.
Syphilis (T. pallidum): secondary
Disseminated. Maculopapular rash including palms / soles 1-3 mo after exposure
Syphilis (T. pallidum): latent
Early if < 1yr, late if > 1 yr
Syphilis (T. pallidum): tertiary
Uncommon, years later.
Granulomas / gummas of skin, cardiovascular syphilis (aortitis), neurosyphilis (tabes dorsalis, general paresis).
Diagnose syphilis
Dark field microscopy from chancre / granuloma is gold standard
RPR/STS → FTA-ABS for serology / screening.
Syphilis management
PCN G 2.4M units x 1; if late latent, do it weekly x 3 wks.
Alternatives: tetracycline PO 4x/day x 2wks, doxy 100mg PO BID x 2wks, or ceftriaxone 1gm IM/IV daily x 8-10d, but desensitize & give PCN, especially in pregnancy!
If neurosyphilis, need IV PCN G q4h x 10-13d.
Follow RPR / VRDL titers - should see decrease @ 6mo, nonreactive @ 12-24mo
Jarisch-herxheimer rxn
After starting PCN
From death of spirochetes
Fever, chills, H/A, myalgia,malaise, pharyngitis, rash w/in 24h
Shouldn’t prevent / delay therapy
HSV symptoms
Grouped vesicles / ulcers with burning, pruritis.
HSV Dx
DNA PCR, or Tzanck smear classically.
HSV management
Primary infection: acyclovir, famciclovir, valacyclovir
If severe or immunocompromised, IV acyclovir
If recurrent, oral acyclovir x 5d
Chronic infection: valacyclovir can lessen transmission, reduce outbreaks
If pregnant, C/S
Chancroid (H. ducreyi) symptoms
Painful, well-demarcated, non-indurated ulcer with painful supperative inguinal LAD
Very rare in USA
Chancroid (H. ducreyi) diagnosis
Dx with culture (chocolate agar), hard to do.
Chancroid (H. ducreyi) treatment
Tx with ceftriaxone IM x1, azithro PO x 1, or longer cipro / erythro regimens.
Treat partners too
LGV (C. trach L1-3): first stage
Painless, transient local lesion (papule / ulcer)
LGV (C. trach L1-3): second stage
Inguinal syndrome (painful enlargment / inflammation of inguinal nodes, fever / H/A / malaise, anorexia)
LGV (C. trach L1-3): tertiary stage
Anogenital syndrome (proctocolitis, rectal stricture, rectovaginal stricture, elephantiasis.
LGV (C. trach L1-3) diagnosis
Clinical suspicion, can also use cx / immunofluorescence / NAAT
LGV (C. trach L1-3) treatment
Doxycycline 100 mg PO BID or erithroymycin x 21 days.
Condyloma acuminata (genital warts)
Caused by HPV
Raised papillomatous wart → can grow to large pedunculated lesions
Bx if uncertain
Prevent with gardasil
Condyloma acuminata (genital warts) treatment
Treat with local excision, cryo, topical TCA or 5FU
Can also use imiquimod or podofilox self-treatment if motivated
Molluscum contagiosum (pox virus) symptoms/ dx
Small umbilicated “water warts”, anywhere except hands / feet. Clinical dx.
Molluscum contagiosum (pox virus) treatment
Local excision or Trichloracetic acid (TCA) / cryotherapy
Bacterial vaginosis:
shift from lactobacillis → other microorganisms, incl Gardnerella
Dx of bacterial vaginosis
Dx: 3 of [whiff test, thin white homogenous discharge, > 20% clue cells, nitrazine pH > 4.5]
Treatment of bacterial vaginosis
Metranidazole 500mg PO BID x 7d or clinda. PO > topical for efficacy. No EtOH with metro
Candidiasis risk factors:
○ Dx: KOH prep showing branching hyphae & spores
A/w diabetes, recent abx, immunocompromise, intercourse, etc.
Candidiasis signs and symptoms
Sx: Pruritis, burning, dysuria, dyspareunia, discharge
On exam: satellite lesions, cottage cheese-like discharge
Treatment of candidiasis
Tx: azoles
■ Topical / suppository = miconazole, terconazole; Nystatin too
■ PO: fluconazole = Diflucan 150 mg PO x 1
■ If recurrent, consider non-albicans species (can be resistant to azoles); try longer duration and may need weekly PO fluconazole x 6mo
Trichomonas vaginalis:
STD, unicellular anaerobic flagellated protozoa
Trichmonas vaginalis symptoms
Profuse discharge (yellow / gray / green / frothy) with unpleasant odor, pruritis, worse just after menses 2/2 vaginal pH increase
Trichomonas vaginalis examination
pH in 6-7 range, vulvar erythema / edema / pruritis, “strawberry cervix” (but only 10%)
Trichomonas dx
Wet prep → trichomonads; NAAT is more sensitive, cx rarely done but most sensitive / specific
Treatment of trichomonas
Metronidazole 2g PO x1 and treat partner as well
Vs BV tx, which is for 7d and no partner treatment needed
Mucopurulent cervicitis:
Cervical motion tenderness without other PID sx
Gonorrheal cervicitis:
Classically sx peak during & after menses. Can infect anal canal, urethra, oropharynx, bartholin glands too.
In neonates, can cause conjunctivitis. Disseminated = fevers, erythematous macular skin rash, arthritis, etc.
Diagnosis of gonorrheal cervicitis
Gram negative dipplococcus; can gram stain or isolate with Thayer-Martin media, although
NAAT on urine / cervical specimens is now #1
Treatment of gonorrheal cervicitis
Ceftriaxone 125 mg IM x 1 or cefixime 400mg PO x 1;
Also treat with azithro PO x1 for CT unless ruled out by NAAT
Chlamydia trachomatis
Ocular, respiratory, reproductive tract infections. Urethritis, etc. too.
Diagnosis of Chlamydia trachomatis
NAAT (intracellular, so gram stain / cx not good)
Chlamydia trachomatis treatment
Azithromycin 1g PO x1 or BID doxy x 7d (but not in pregnancy)
