Pelvic Inflammatory Disease (PID)/STDs

Question 1

What are the management options for PID (& organisms)

Answer 1

-IM 1g Ceftriaxone (gonorrhoea)
-100g Doxycycline (BD, PO) for 14 days (chlamydia and mycoplasma genitalium)
-400g Metronidazole (BD, PO) for 14 days (anaerobes eg Gardnerella vaginalis which causes BV)

Question 2

What are management options for penicillin allergy?

Answer 2

PO ofloxacin and metronidazole for 14 days (400mg, BD)

Question 3

What are some organisms that cause PID (severe,3, vs less common,3,)

Answer 3

Severe:
1.Chlamydia trachomatis (most common, C>G)
2. Neisseria gonorrhoea
3. Mycoplasma genitalium

Less common:
1. Gardnerella vaginalis (BV)
2. Haemophilus influenza
2. Escherichia coli

Question 4

What are some investigations for PID?

Answer 4

Bedside:
-Basic obs (signs of shock)
-Abdominal exam (tenderness, masses eg tuboovarian abscess)
-Bimanual exam (cervical motion tenderness)
-Speculum
-NAAT swabs
-pregnancy test

Bloods:
-FBC (WCC)
-CRP
-Blood culture

Imaging:
-TVUSS (eg for tuboovarian abscess, perihepatitis)
-Laporoscopy (gold standard for Fitz-Hugh-Curtis syndrome)

Question 5

What are other considerations for patients?

Answer 5

1. contact tracing
2. STI screen
3. Consider IUD removal
4. Counsel about subfertility/contraception

Question 6

what is normal vaginal pH?

Answer 6

The vaginal pH is normal in such patients (around 4.0-4.5 in women of reproductive age, although this can vary slightly)

Question 7

how is vaginal PH affected by BV?

Answer 7

the vaginal pH would be raised (> 4.5).

Question 8

how is recurrent thrush defined?

Answer 8

> 4 episodes a year

Question 9

what is the induction/maintenance regime for thrush?

Answer 9

-induction: oral fluconazole every 3 days for 3 doses (150mg once on day 1, 150mg once on day 4, 150mg once on day 7)

-maintenance: oral fluconazole weekly for 6 months

Question 10

what is the criteria for BV diagnosis?

Answer 10

Amsel’s criteria for diagnosis of bacterial vaginosis - 3 of the following 4 points should be present:
1. thin, white homogenous discharge
2. clue cells on microscopy: stippled vaginal epithelial cells
3. vaginal pH > 4.5
4. positive whiff test (addition of potassium hydroxide results in fishy odour)

Question 11

what is the criteria for BV diagnosis?

Answer 11

Amsel’s criteria for diagnosis of bacterial vaginosis - 3 of the following 4 points should be present:
1. thin, white homogenous discharge
2. clue cells on microscopy: stippled vaginal epithelial cells (loss of lactobacilli)
3. vaginal pH > 4.5
4. positive whiff test (addition of potassium hydroxide results in fishy odour)

Question 12

vaginal discharge most common causes

Answer 12

Question 13

what % of men and women are asymptomatic for chlamydia?

Answer 13

In women, 80% have no symptoms – hence screening is important. In men approximately 50% are asymptomatic.

Question 14

what swabs should be done for STDS?

Answer 14

-A high vaginal Amies swab for bacterial and fungal culture (NAAT for chlamydia and gonorrhoea) should be performed

-endocervical culture for gonorrhoea (due to increasing rates of resistance to first line cephalosporin therapies).

Question 15

what % of PID are organisms detected? what are the most common organisms?

Answer 15

50% (50% no organism)
-the majority will be due to Chlamydia trachomatis and Neisseria gonorrhoeae.

Question 16

what is alternative treatment for gonorrhoea (if all sites of exposure are cultured and found to be sensitive)

Answer 16

ciprofloxacin (alternative to IM 1g STAT ceftriaxone)

Question 17

what is used to treat chlamydia in pregnant women?

Answer 17

-Azithromycin 1g STAT, followed by 500mg OD for 2 days is first line therapy in pregnancy.

-Erythromycin 500mg QDS for 7 days is an acceptable second line therapy as per BASHH Guidelines 2017 for Chlamydia management

Question 18

what are some non-STD causes of vaginal discharge?

Answer 18

-Allergies to soaps and spermicides e.g.nonoxynol-9 can also cause vaginal discharge
-Lichen sclerosis if severe

Question 19

Bacteria present in BV (bacterial vaginosis):

Answer 19

Gardnerella vaginalis

Question 20

organism that causes syphilis:

Answer 20

Treponema pallidum

Question 21

symptoms & treatment of syphilis:

Answer 21

chancre (painless hard ulcer in genital area)
-1st line = IM stat benzylpenicillin or doxycycline BD for 14 days.

Question 22

syphilis stages

Answer 22

Question 23

Management of severe PID:

Answer 23

IV ceftriaxone (until improving clinically), oral doxycycline and metronidazole (for 14 d)

Question 24

complications of PID:

Answer 24

Chronic pelvic pain (40%)
Infertility (15%)
Ectopic pregnancy (1%)

Fitz-Hugh-Curtis syndrome occurs when adhesions form between the anterior liver capsule to the anterior abdominal wall or diaphragm, on a background of pelvic inflammatory disease. Liver function tests are often normal. An abdominal ultrasound should be used to exclude stones. Laparoscopy is required for a definitive diagnosis and treatment involves the use of antibiotics.

Question 25

symptoms/signs of thrush:

Answer 25

The symptoms of vaginal candidiasis are:

-Thick, white discharge that does not typically smell
-Vulval and vaginal itching, irritation or discomfort

More severe infection can lead to:

Erythema
Fissures
Oedema
Pain during sex (dyspareunia)
Dysuria
Excoriation

Question 26

investigations for candida:

Answer 26

Often treatment for candidiasis is started empirically, based on the presentation.

Testing the vaginal pH using a swab and pH paper can be helpful in differentiating between bacterial vaginosis and trichomonas (pH > 4.5) and candidiasis (pH < 4.5).

A charcoal swab with microscopy can confirm the diagnosis.

Question 27

management options for thrush:

Answer 27

Treatment of candidiasis is with antifungal medications. These can be delivered in several ways:

Antifungal cream (i.e. clotrimazole) inserted into the vagina with an applicator
Antifungal pessary (i.e. clotrimazole)
Oral antifungal tablets (i.e. fluconazole)

The NICE Clinical Knowledge Summaries (2017) recommend for initial uncomplicated cases the options of:

A single dose of intravaginal clotrimazole cream (5g of 10% cream) at night
A single dose of clotrimazole pessary (500mg) at night
Three doses of clotrimazole pessaries (200mg) over three nights
A single dose of fluconazole (150mg)

Canesten Duo is a standard over-the-counter treatment worth knowing. It contains a single fluconazole tablet and clotrimazole cream to use externally for vulval symptoms.

They also recommend recurrent infections (more than 4 in a year) can be treated with an induction and maintenance regime over six months with oral or vaginal antifungal medications. This is an off-label use.

Warn women that antifungal creams and pessaries can damage latex condoms and prevent spermicides from working, so alternative contraceptive is required for at least five days after use.

Question 28

thrush counselling:

Answer 28

o Given the history you have given us and the findings of the investigations, we think that you have got thrush
o It’s a common fungal infections that tends to cause some irritation but can be treated using this medication
o It is not regarded an ‘STI’ however it can be triggered by sexual contact
o It is possible that, in your case, the thrush has happened because the control of your diabetes hasn’t been quite as good as it usually is recently
o If you are struggling with managing your diabetic medication we can arrange an appointment with a diabetic nurse or a doctor specialising in diabetes (or their own diabetes consultant) to review it

Advice:

o Return if symptoms have not resolved in 7-14 days
o Avoid predisposing factors: washing and cleaning the vulval area with soap or shower gels, cleaning the vulval area more than once per day, washing underwear with biological washing powder and fabric conditioners, vaginal douching, wearing tight-fitting or non-absorbent clothing
o Wash vulval area with a soap substitute and use simple emollients to moisturise the vulval area
o Consider probiotics (e.g. yoghurts) oral or topical

Question 29

how is thrush managed in pregnancy?

Answer 29

cream (topical) or a tablet inserted in the vagina (a pessary) that contains clotrimazole (not oral medication!)

Question 30

how is thrush managed in 12-15 yr olds?

Answer 30

topical antifungals only (not oral or pessary)