Sexually Transmitted Infections Flashcards
1 cause of vaginal discharge
bacterial vaginosis
Bacterial Vaginosis Pathophysiology
not fully understood:
vaginal dysbiosis - overgrowth of gardnerella, haemophilus and other anaerobic bacteria
??Altered vaginal pH
Risk factors for BV
multiple male/female partners, new partner, not using condoms, douching, menses, copper IUD, >1 partner
BV Presentation
most patients are asymptomatic
some pts come reporting more vaginal discharge - may be more grayish and usually has odor
milky with a fish odor after addition of KOH prep or unprotected intercourse
non irritating - no vaginal irritation
Bacterial Vaginosis Amsel’s Criteria
requires 3 out of 4
homogenous vaginal d/c
fishy (amine) odor w/ KOH prep (+whiff test)
Clue cells on microscopy
Vaginal pH > 4.5
BV treatment
First line - metronidazole PO 7 days
metronidazole intravaginal gel
clindamycin intravaginal gel
What should you warn pts about when being treated for BV
metronidazole may cause n/v with ETOH
should refrain from intercourse or use condoms regularly during treatment
clindamycin preps may weaken condoms or diaphragms
Risk of untreated BV
because of the friability of the epithelium:
increased risk for STIs including HIV
increased risk of pre-term delivery
risk of candidiasis infection after treatment
Gonorrhea is a common co-infection with
Chlamydia
Gonorrhea increases risk for
HIV infection
Gonorrhea presentation
often asymptomatic
wide range of presenting sx - dysuria, purulent d/c (white, green, yellow)
increased vaginal discharge
friable cervix
vaginal bleeding
scrotal pain (epididymitis)
possible extra-genital infections (conjunctivitis, arthritis, disseminated)
Gonorrhea diagnosis
Nucleic acid amplification test (NAAT) - urine or swab
Treatment of Gonorrhea
Ceftriaxone IM single dose plus azithromycin or doxycycline (azithro/doxy for likely co-infection with Chlamydia)
no intercourse for 7 days
Treat partners
re-test at 3 months after treatment
Gonorrhea complications
PID –> intertility, abscess, chronic pain, ectopic preg
Epididymitis –> infertility
Mom-to-baby transmission –> blindness, joint infection, sepsis
Chlamydia is an infection of
chlamydia trachomatis - intracellular gram negative bacterium
Chlamydia presentation
primarily asymptomatic
presentation similar to gonorrhea - dysuria, pyuria, increased urinary frequency, mucopurulent d/c, mucoid, watery d/c, friable cervix, vaginal bleeding, scrotal pain, scrotal tenderness, edema
Chlamydia dx
Nucleic acid amplification test (NAAT) - urine or swab
Chlamydia treatment
doxycycline for 7 days
consider addition of ceftriaxone IM single dose to cover gonorrhea
no intercourse for 7 days
treat partners
re-test at 3 months after treatment
Trichomonas Vaginitis is the most prevalent
non-bacterial STI (flagellate protozoan)
Trich risk factors
Incarceration
2 plus partners in one year
less than HS education
poverty
BV
douching
Trich can be prevented with
condom use
Trich presentation
many pts asymptomatic
females –> frothy yellow greenish vaginal discharge, +/- vaginal irritation, +/- burning with urination, pH > 5.0, strawberry cervix - small red dots on cervix, punctate hemorrhages
males –> urethritis, epididymitis, prostatitis
Trich dx
microscopy/ wet mount (POC) - must do immediately after sampling, will have increased number of PMNs and motile flagellates
nucleic acid type testing
culture - most sensitive and specific –> do if wet mount is inconclusive but high suspicion
Trich treatment
first line- metronidazole
females - 7 days
males - one day
tinidazole is alternative
NO GELS - don’t reach therapeutic concentrations
non-reportable disease
treat partners
no intercourse until treatment completed and infection cleared
Candidiasis aka vulvovaginal candidiasis primary cause is
candida albicans
Candidiasis aka vulvovaginal candidiasis risk factors
DM
obesity
HIV+
preg
antibiotic use
steroid use
OCP use
debilitation
moist vaginal environment
Candidiasis can be _____ or ______
uncomplicated or complicated
Candidiasis presentation
usually people report vaginal pain, itching, burning, vaginal d/c thick, curdy, cheesy
Candidiasis dx
presence of budding yeast and hyphae on KOH wet mount
if negative or complicated –> Culture (gold standard)
vaginal pH < 4.5
Some patients - empirically treat
Candidiasis treatment
OTCs - clotrimazole cream, miconazole cream, miconazole suppository
RX - Butoconazole cream, terconazole cream/ supp, PO fluconazole x one day
if complicated - longer regimen and/or add 3 doses of PO fluconazole (immunocompromised pts)
Syphilis is caused by
Treponema pallidum (spirochete)
can cause infection of virtually any tissue/organ
Syphilis has 3 categories
primary syphilis
secondary syphilis
tertiary syphilis
Primary syphilis presentation
single painless ulcer (chancre)
Nontender, nonpurulent, indurated
3-4 weeks after infection
Secondary Syphilis presentation
Skin rash, mucocutaneous lesions, lymphadenopathy
Both primary and secondary lesions are
self limiting and infectious
Syphilis dx
early syphilis - dark microscopy or molecular testing - ID spirochetes on dark microscopy of lesional tissue or exudates
pts dx with syphilis should also be tested for
HIV
Syphilis screening
MSM every 6-12 months
high risk every 3 months
preg women - first prenatal visit, 3rd trimester, at delivery
anyone treated for another STI
Syphilis treatment
parenteral penicillin G first line for all stages
doxycycline second line
no intercourse 7-10 days
reportable disease
ID and treat contacts within the last 3 months
Jarisch-Herxheimer reaction is when
you treat Syphilis and there is a lysis of spirochetes which releases endotoxin
starts within hours of treatment
Chancroid is a (what kind of infection)
rare STI
Presentation of Chancroid
Ulcerations - painful, soft, irregular borders, friable, necrotic base with yellow gray exudates
+/- fever malaise
+/- unilateral lymphadenopathy
Clinical dx of a chancroid if all of the following
painful genital ulcer
SSx consistent with chancroid
no evidence of syphilis on darkfield microscopy or serology
Gold standard for dx of chancroid is
lesion culture (requires special medium)
Treatment of chancroid
azithromycin 1g PO x 1
Ceftriaxone 250mg IM x 1
Herpes Simplex:
Type 1 =
Type 2 =
primarily oral ulcers
primarily genital ulcers
Both Herpes simplex virus infect _______ cells
epithelial cells
How does HSV spread?
Infection via viral particles in body fluids or direct contact with open lesions - individual must be shedding virus can not be latent
HSV can be primary or secondary
Primary = initial outbreak
Secondary = recurrence
virus lays dormant in sensory nerves - reactivated - recurrent mucocutaneous lesions
Presentation HSV
+/- tingling prodrome
macular or papular lesion -> vesicles on an erythematous base -> ulcerations
ulcerations are shallow and severely painful
tender lymphadenopathy
edema, burning, itching, dysuria, vaginal or urethral discharge
HSV lesions are ____ over ~ ____
self limiting over ~3 weeks
Dx of HSV
can be clinical if vesicles are present
swab lesions for HSV PCR
HSV serology (antibodies)
HSV serum PCR
Tzanck smear - multinucleated giant cells
Treatment of HSV
lifelong infection
acyclovir or valacyclovir (oral, IV, topical)
no intercourse while active lesions
Genital Warts AKA condyloma acuminata are related to what types of HPV
6 or 11 (90%)
What has decreased the incidence of HPV
HPV vaccine
Gardasil 9
(prevention but not treatment of genital warts)
Presentation of genital warts
many infections are asymptomatic
characterized by flat papular or pedunculated lesions near introitus, under foreskin or penile shaft
+/- pain, puritis
Genital warts dx
primarily clinical dx
definitive dx - bx of lesion
Genital Warts treatment
likely doesn’t resolve HPV infection - no gold standard treatment shared decision making
recommended:
Cryotherapy
surgical removal
TCA or BCA (caustic agents)
When removing genital warts it is important for the provider to wera
mask and eye covering because you need to protect your own mucus membranes
PID is
inflammation of the upper genital tract - uterus, fallopian tubes, ovaries
PID is usually secondary to
an ascending infection from the lower genital tract - m/c related to gonorrhea/chlamydia
Why is an IUD a risk factor for PID
strings hang out which leaves the cervix open allowing for bacteria to get in easily
PID presentation
abnormal or lower pelvic pain
vaginal d/c
dyspareunia
AUB
On cervical exam for PID what are you going to find
cervical d/c
cervical motion tenderness (chandelier sign)
uterine tenderness
adnexal tenderness
+/- pelvic masses
Clinical Dx of PID if it has these 3 things
reliable dx if 3 clinical criteria present:
cervical motion tenderness
uterine tenderness
adnexal tenderness
Symptoms that might also present with a dx of PID
temp > 101
mucopurulent cervical discharge
cervical friability
increased WBCs on wet mount
elevated ESR/CRP
Documented GC infection
What test are we always checking on every patient with a uterus of reproductive age?
bHCG
“best” lab test for PID
WBCs on wet mount
what do you do for a definitive dx of PID
laparoscopic endometrial bx - will show scaring
Presumptive treatment of PID treatment requirements
presumptive treatment if sexually active F at risk for STI
+ pelvic or lower abdominal pain
3 clinical criteria are met
no other cause is more likely
treatment of PID
ceftriaxone IM or IV
doxycycline PO or IV
metronidazole PO or IV
treat for 14 days
treat partners
no intercourse till resolved
re-test 3 months after treatment
Indications for admission
need to r/o other surgical emergency
presence of tubo-ovarian abscess
patient is pregnant
severe infection (+ n/v, temp > 101)
patient cant tolerate PO treatment
No response to PO treatment
How long should it take for pts with PID to improve after initiation of treatment
within 72 hours - if not reconsider dx, bx? or step up to IV abx
Complications of PID
tubo-ovarian abscess
pelvic abscess
ectopic pregnancy (due to scarring of fallopians)
infertility
chronic pelvic pain
scaring –> adhesions
Acute Pelvic pain =
< 3 months duration
Chronic pelvic pain =
persistent, noncyclic pain perceived to be in structures related to the pelvis and lasting more than six months
often no etiology identified
