Module 13.0 - Sexually Transmitted Diseases Flashcards
What is pelvic inflammatory disease?
An acute bacterial infection of the upper genital tract structures of women, involving any or all of the uterus, fallopian tubes, and ovaries and may involve neighboring pelvic organs.
Describe the etiology of pelvic inflammatory disease
- 1 million cases in U.S. annually
- Polymicrobial causation
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Pathogens of concern (Most common):
- Chlamydia trachomatis
- Neisseria gonorrhoeae
- Other etiology agents:
- Haemophilus influenza and Garnerella
- Streptococci
- Mycoplasma hominis
- Enteric gram negative rods
What are the risk factors associated with pelvic inflammatory disease?
- Sexually active women with multiple partners
- Younger than 25 years of age
- Sexual exposure to a partner with urethritis
- Douching
- Smoking- alters protective nature of cervical mucus
- Prior hx of PID or cervicitis
- Pelvic surgery
What are some complications associated with pelvic inflammatory disease?
- Infertility
- Tubal pregnancy
- Recurrent PID
- Chronic pelvic pain
- Tubo-ovarian abscess
What are subjective findings associated with pelvic inflammatory disease?
- Clinical presentation varies
- Lower pelvic pain
- Fever
- Purulent vaginal discharge
- Dyspareunia and painful defecation
Patient history should include: last normal menstrual period, STD history, contraceptive use, sexual history, Drug allergies
What are some physical exam findings associated with pelvic inflammatory disease?
- Mucopurulent cervical/vaginal discharge
- Friable cervix
- Cervical motion tenderness (CMT) and /or uterine-adnexal tenderness
- Abdominal rebound tenderness
What are some labs/diagnostic tests used to diagnose pelvic inflammatory disease?
Centersfor Disease Control and Prevention (CDC) Diagnostic Criteria includes (at least 1):
- Presence of CMT or,
- Presence of uterine-adnexal tenderness
Other Common Lab findings include:
- WBCs noted on vaginal microscopy
- Elevated ESR
- Elevated C-reactive protein
- Lab evidence of gonococcal or chlamydial infection
- Leukocytosis (WBC > 10,000/mm)
Definitive diagnostic criteria for PID:
- Histopathologic evidence on endometrial biopsy
- Tubo-ovarian abscess on transvaginal ultrasound
- Laparoscopic abnormalities c/w PID
How do you manage a patient with pelvic inflammatory disease in an outpatient setting?
Regimen 1:
- Cetriaxone 250mg IM single dose plus
- Doxycycline 100mg bid x 14 days with or without,
- Metronidazole 500mg bid x 14 days
Regimen 2:
- Cefoxitin 2mgs IM plus probenecid, 1 gm po single dose concurrently plus
- Doxycycline 100mg bid x 14 days with or without
- Metronidazole 500mg bid x 10-14 days
Regimen 3:
- Other parenteral 3rd generation cephalosporin plus doxycycline with or without metronidazole
How do you manage a patient with pelvic inflammatory disease in an inpatient setting?
Regimen 1:
- Cefotetan, 2 gms IV q 12 hours or cefoxitin sodium 2 gms IV q 6 hours plus,
- Doxycycline 100mg IV or po q 12 hours x 10-14 days
- If tubo-ovarian abscess is present, include clindamycin or metronidazole with doxycycline to provide more effect anaerobic coverage.
Regimen 2:
- Clindamycin 900mg IV q 8 hours plus
- Gentamycin loading dose 2mg/kg body weight followed by a maintenance dose (1.5mg/kg ) q 8 hours- *Renal dosage if appropriate
- Regimen continues until at least 48 hours post clinical improvement.
- Discharge on doxycycline 100mg q 12 hours x 14 days or clindamycin 450mg po qid x 10-14 days.
What are the CDC recommendations for admitting a patient with pelvic inflammatory disease?
- Coexisting pregnancy
- Failed outpatient management
- Surgical emergency – r/o appendicitis, ectopic pregnancy
- Tubo-ovarian abscess- adnexal mass palpated on PE or noted on imaging studies
What is bacterial vaginosis?
Condition characterized by a shift in vaginal flora away from Lactobacillus and associated with a rise in vaginal pH to > 4.5 and production of volatile amines by the new bacterial flora.
What causes bacterial vaginosis?
- Most common cause of vaginal discharge of women in childbearing age
- Major bacteria detected include:
- Gardnerella vaginalis
- Prevotella species
- Porphyromonas species
- Production of amines: Loss of hydrogen peroxide producing lactobacilli normally present in vaginal flora causing overgrowth of anaerobes which cause malodorous , itchy vaginal discharge
What are the physical exam findings associated with bacterial vaginosis?
Discharge will be present and is homogenous, adherent, thin, milky white, malodorous with a fishy odor (positive amine or ‘whiff’ test)
What are some lab/diagnostic tests used to diagnose bacterial vaginosis?
- Vaginal pH > 4.5
- Presence of clue cells on wet mount
- Positive amine, ‘whiff’ test
- Homogenous, non-viscous milky white discharge adherent to vaginal walls
How do you treat a patient with bacterial vaginosis?
- Metronidazole 500mg po bid x 7 days or metronidazole gel 0.75% intravaginally daily x 5 days
- Alternative regimen: Tinidazole 2gms po daily x 2 days or tinidazole 1 gm po daily x 5 days; clindamycin 300mg po bid x 7 days
- For pregnancy: use metronidazole 500mg po bid 7 days
What is and what causes trichomoniasis?
A sexually transmitted genitourinary infection with the protozoan Trichomonas vaginalis.
- Most common non-viral sexually transmitted disease worldwide. Over 1 million people diagnosed in the U.S. each year
- May be asymptomatic
- Coexistence with bacterial vaginosis is common, with coinfection rates of 60-80%
- Untreated trichomonal vaginitis may progress to urethritis (in men) and cystitis (in women)
- Associated with adverse reproductive health outcomes- including cervical neoplasia, PID and infertility in women and prostatitis, epididymitis, infertility and prostate cancer in men.
- Increases a women’s susceptibility to HIV 2 fold
- In pregnancy, associated with:
- Low birth weight
- Preterm delivery
- Premature rupture of the membranes
What physical exam findings are seen with Trichomoniasis on speculum examination?
- Discharge: frothy gray or yellow/green and malodorous
- Cervical petechiae may be present and is referred to as ‘strawberry cervix’
What lab/diagnostic tests are used to diagnose trichomoniasis?
- Wet mount: motile trichomonads are visualized and diagnostic of infection
- Vaginal pH > 4.5
- Culture
- Nucleic acid amplification test – gold standard for diagnosis- uses vaginal swab or urine specimen; detects RNA by transcription mediated amplification
What findings are seen on speculum examination for chlamydia?
- Reddened vaginal walls
- Cervical erythema and friability
- Mucopurulent discharge may or may not be present
- Cervical erosion (cervical lips inflamed and eroded)
What are some subjective findings associated with gonorrhea?
Female: dysuria and frequency early sign with malodorous mucopurulent vaginal discharge or pharyngitis, later fever, n/v, lower pelvic pain, joint pain
Male: dysuria with frequency, whitish urethral discharge, pharyngitis early symptoms; later yellow green profuse purulent urethral discharge with meatal edema and erythema
What is and what causes HPV?
- Double-stranded DNA virus belonging to the Papillomaviridae family causing a viral infection which occurs at the basal cell layer of stratified squamous epithelial cells and is associated with genital warts, cervical dysplasia and cancer.
Multiple types: low and high risk
- Low risk (non-oncogenic):
- Types 6 and 11 responsible for most genital warts and low grade cervical cellular changes
- High risk (oncogenic):
- Types 16 and 18 responsible for 70% of cervical cancers and high grade cervical dysplasia
What are the subjective findings associated with HPV?
- Usually without clinical manifestations
- Genital warts visualized upon exam:
- Condylomata acuminate- cauliflower like
- Smooth papules
- Flat papules
- Keratotic warts
- Tend to accumulate in areas of coital friction
- If located on cervix or rectum should be treated by expert
What are the physical exam findings associated with secondary syphilis?
- Flu like symptoms
- Maculopapular rash on palms and soles of feed 2-6 weeks after infection- heals spontaneously in 4-10 weeks
- Condyloma lata (wartlike lesions) in mouth, throat and cervix
- Genital lesions highly infectious by direct contact – resolve in 3-12 weeks
