Pelvic Pain and vaginal discharge Flashcards
PALM COIEN For DDX of AUB
Structural - Polpys - Adeniomyosis - Leiomyoma - Submucosa or other - Malignancy Not structural - Coagulopathy - VWF - Ovarian - PCOS - Endometriosis - Iatrogenic - Not otherwise specified
Tx of Heavy periods that are regular
Transexamic acid for first 3 to 5 days of menses. (50%)
Mefenamic acid (NSAID) if pain.
COCP only if excluded RF - Smoking, ^BMI, diabetes, ^BP
Levonorgestrel intrauterine system
Progestogens at high doses throughout cycle.
Tx of irregular heavy period
?
Tx for Chylamdia
Azithromycin single dose also treat gonorrhoea as they often co exist. Reportable disease treat partners Test of cure required if pregnant
Tx of gonrrhoea
Ceftriaxone IM single dose
Treat chlamydia as well
treat partners
reportable disease
Tx of syphillis
Benzylpencillin 1g
if greater then 1 year then repeat weekly for 3 weeks
Neurosyphilis = IV penicillin QDS for 10days
What is normal vaginal discharge
Clear, white, flocculent, odourless
pH 3.8-4.2
Smear contains epithelial cells and Lactobacilli
Increase with oestrogen e.g. pregnancy, OCP, mid cycle, PCOS, premenarchal
Tx of vulvovaginitis
Hygiene and local measure e.g. white cotton, no tight clothes, avoid bubble baths, stop fabric softener, use ild detergent.
Vitamin A and D ointment
IF infectious Abx.
DDX of vulvovaginitis in prepubertal girls
Infections Foreign body e.g. toilet paper Candida if on diapers Pinworms Polyps, tumor Skin disease e.g. lichen sclerosis, condyloma acuminata Contact dermatitis Trauma endocrine (bleeding) Blood dyscrasia (bleeding)
Atrophic vaginitis
visual diagnosis: thinning of tissues, erythema, petechiae, bleeding points, dryness on speculum exam.
Rule out Malignancy especially endometrial cancer
Tx: Local oestrogen replacement or oral or transdermal hormone replacement therapy
Good hygiene
Presentation of Candidiasis
Predisposing factors: immunosuppressed, recent antibiotic use, increase oestrogen levels e.g. pregnancy, OCP
Discharge: whitish cottage cheese minimal.
20% asymptomatic
Intense itch
swollen inflamed genitals
vulvar burning dysuria and dyspareunia
Not sexually transmitted disease
Ix of candidiasis
pH less than 4.5
KOH wet mount reveals hyphae and spores
Tx of Candidiasis
Clotrimazole creams for vaping amount of days
Fluconazole - not in pregnancy
Presentation of bacterial vaginosis
Discharge: Gray, thin, diffuse, fishy odour after coitus
50-75% asymptomatic
absence of vulvar/vaginal irritation
Not sexually transmitted
Ix of Bacterial Vaginosis
pH greater then 4.5
Clue cells coccobacili organisms
Tx of bacterial vaginosis
if pregnant or asymptomatic no tx
Oral or topical metronidazole 7days
warm them not to drink alcohol
Clindamycin in pregnancy
risk of bacterial vaginosis in pregnancy
Associated with recurrent preterm labor
preterm birth and postpartum endometritis
Presentation of trichomoniasis infections
Sexual transmission Yellow green, alodorous, diffuse, frothy 25% asymptomatic Petechiae on vagina and cervix Occasionally irritated tender vulva Dysuria, frequency
Ix for trichomoniasis
greater then 4.5 pH
motile flagellated organisms
Many WBC
Inflammatory cells
Tx of trichomoniasis
Tx even if symptomatic
Metronidazole 2g oral once.
Treat partners
Pregnant: treat once with 2g metronidazole
Notifiable diseases for STI
Chancroid Chlamydia Gonorrhea Hepatitis A,B,C HIV Syphilis
Presentation of chlamydia
asymptomatic in 80%
Muco-purulent endocervical discharge
Urethral syndrome: dysuria, frequency, pyuria, no bacteria on culture
Pelvic pain
postcoital bleeding or inter menstrual bleeding
symptomatic sexual partner
Ix for chlamydia
cervical culture or PCR
first catch urine PCR
When to screen for chlamydia
High risk groups
15 to 30 yr old
pregnancy
Complications of Chlamydia
Acute salpingitis, PID
Fitx-hugh-curtis syndrome - liver capsule inflammation
Reactive arthritis (male predominance, HLA-B27 associated),
Conjunctivitis
Urethritis
Infertility from tubal obstruction from low grade salpingitis
ectopic pregnancy
chronic pelvic pain
Perinatal infection: conductivity or pneumonia
Presentation of Gonorrhea
Same as chlamydia
Ix for Gonorrhea
Gram -ve intracellular diplococci
Cervical rectal, and throat culutre
Genital warts
HPV 6, 11
Clinical features
- Latent infection: asymptomatic, only detected by DNA hybridisation
- Subclinical infection: visible lesion found during colposcopy
- Clinical infection: visible wart-like lesion without magnification, vulvar edema
Ix - cytology: koilocytosis, Biopsy
Tx- Cryotherapy, Topical imiquimod
Prevention: Gardasil or Cervarix
Presentation of Herpes simplex
Asymptomatic
Initially: present 2-21 days following contact
Prodrome: tingling, burning, pruritus
Multiple painful, shallow ulceration with small vesicles appear 7-10 days after initial infection
Lesions are infectious
Inguinal lymphadenopathy, malaise, and fever with 1st infection
Urinary symptoms if in UTi
Ix for herpes
viral culture of lesions
Cytologic smear - Tzanck smear: giant cells and acidophilic intranuclear inclusion bodies
Serologic
HSV DNA PCR
Tx of herpes
1st episode: acyclovir or famciclovir or valacyclovir
Daily suppressive therapy: if recurrent more then 6 times per year.
Severe : IV acyclovir
education regarding transmission
Avoid contact from onset of prodrome until lesions have cleared
use barrier contraception.
Concerns with herpes in pregnancy
treat from 36 weeks gestation onward
should have C-section if active at time of delivery
Tx: acyclovir
Classifications of syphilis
Primary syphilis: 3-4 wk, painless chancre and inguinal lymphadenopathy, serology is usually negative
Secondary syphilis: 2-6m,
- nonspecific symptoms: malaise, anorexia, headache, diffuse lymphadenopathy
- generalised maculopapular rash: palms, soles, trunk, limbs
- Condylomata lata: anogenital, broad-based fleshy grey lesions.
- Serology tests usually positive
Latent syphilis: no signs, only serology
Tertiary syphilis: any organ
- Neuro: tabes dorsalis, general paresis
- CVS: aortic aneurysm, dilated aortic root
- Vulvar gumma:nodules that enlarge, ulcerate and become necrotic
Congenital syphilis: fetal anomalies, still births, and neonatal death. Hutchining teeth.
Ix for syphilis
Aspiration of ulcer
Darkfield microscopy for spirochetes
Non-treponemal screening test e.g. VDRL, RPR - non reactive after tx, can be positive in other conditions
Specific antitreponemal antibody e.g. FTA-ABS, MHA-TP, TP-PA) remains reactive for life
Bartholin gland abscess
Organisms: anaerobic or polymicrobial e.g. gonorrhoea, chlamdyia, E.Coli, Stretp or staph
Feature: unilateral swelling and pain in inferior lateral opening of vagina, Sitting and walking may become difficult or painful
Tx: sitz bath, warm compresses, Antibiotic e.g. cephalexin, incision and drainage, marsupialisation
PID causes
Inflammation of upper genital tract including endometrium, fallopian tubes, ovaries, pelvic, peritoneum, and contiguous structure
C. Trachomatic
N. Gonorrhoeae
Endogenous flora e.g. e.coli, staph, strep, enterococcus, bacteroids, peptostrptococcus, H, Influenzae,
RF for PID
age less then 30 RF as for chlamydia or gonorrhea vaginal bouching IUD in the first 10 days invasive gynecologic procedures
Presentation of PID
2/3 asymptomatic
Commonly:
- fever greater then 38.3, lower abdo pain and tenderness, abnormal discharge
Uncommonly:
- N/V, dysuria, AUB
Chronic disease (often due to chlamdyia)
- Constant pelvic pain, dyspareunia, palpable mass, very difficult to treat, may require surgery
Ix for PID
B HCG
FBC
BC
Urine MCS
speculum and bimanual, swab- vaginal for gram neg, cervical for Chlamdyia and gonorrhoea
USS: free fluid in cul-de-sac, abscess, hydrosalpinx
Laparoscopy if gold standard
Cx of PID
I FACE PID Infertility Fitx-Hugh-Curtis syndrome Abscess Chronic pelvic pain Ectopic pregnancy Peritonitis Intestinal obstruction Disseminated infection e.g. sepsis, endocarditis, arthritis, meningitis
Tx for PID
Abx - ceftriaxone and doxycycline +/-metronidazole
Inpatient or outpatient
If outpatient follow up within 48hrs
Toxic shock syndrome
multiple orang system failure due to S.aureaus exotoxin
presents: sudden high fever, sore throat, headache, diarrhoea, erythroderma, signs of multi system organ failure, refractory hypotension, exfoliate of palmer and plantar surfaces of hands and feet 1-2 wk after onset of illness
Tx - remove source of infection, decried necrotic tissues, hydration, ABx, +/-steroids
