Sexually Transmitted Infections Flashcards
Describe normal vaginal discharge.
Clear-white, odorless, and of high viscosity
What is the dominant bacteria present in the vagina?
Lactobacilli
What is the normal vagina pH range?
3.8-4.2 (acidic environment- to help inhibit overgrowth of bacteria)
What are the 3 most common types of vaginitis?
(1) bacterial vaginosis (2) vulvovaginal candidiasis (3) trichomoniasis
What is the major bacteria detected in bacterial vaginosis?
Gardnerella vaginalis
What is candidiasis vaginitis most commonly caused by?
C. albicans
What is the most prevalent nonviral STI?
Trichomoniasis vaginitis
What are the 2 aspects of bacterial vaginosis microbiology?
(1) overgrowth of bacteria species normally present in vagina w/anaerobic bacteria
(2) dec or loss of protective lactobacilli
What is produced by some lactobacilli that helps maintain a low pH to inhibit bacteria overgrowth?
H2O2
What is the only protozoan that affects the genital tract?
Trichomonas vaginalis
What are 6 risk factors for bacterial vaginosis?
(1) African American
(2) 2+ sex partners in previous 6 months/new sex partner
(3) douching-b/c gets rid of good bacteria
(4) lack of condom use
(5) absence of or dec in lactobacilli
(6) lack of H2O2 producing lactobacilli
What are 5 risk factors for candidiasis?
(1) diabetes
(2) immunosuppression
(3) abx use
(4) prolonged exposure to moist, damp underwear
(5) non-cotton underwear
What are 4 risk factors for trichomoniasis?
(1) multiple sex partners
(2) lower socioeconomic status
(3) hx of STDs
(4) lack of condom use
What is an important question to ask pts regarding pain and urination and why?
Does it hurt WHILE you pee or AFTER you pee? → open lesions= while peeing, dysuria from UTIs= after peeing
What are 4 si/sx of bacterial vaginosis?
(1) asymptomatic
(2) malodorous or fishy smell
(3) pruritic discharge
(4) thin, milky white sometimes grey discharge
What are 3 si/sx of candidiasis?
(1) pruritic discomfort
(2) dysuria
(3) thick cottage cheese like discharge
What are 3 si/sx of trichomoniasis?
(1) asymptomatic ~70%
(2) pruritic discharge sometimes green, yellow-green, and frothy
(3) strawberry cervix
What are 3 diagnostic aides for vaginitis?
(1) vaginal pH
(2) wet prep (NaCl)
(3) KOH test
What are pH findings consistent with candidiasis? With BV and trichomoniasis?
Candidiasis: <4.5
BV and trich: >4.5
What are findings on wet prep indicative of bacterial vaginosis?
Clue cells, no/few WBCs
What are findings on wet prep indicative of candidiasis?
Few-many WBCs
What are findings on wet prep indicative of trichomoniasis?
Motile flagellated protozoa, many WBCs
What are findings on KOH test indicative of candida?
Pseudohyphae and budding yeast
What do you do w/KOH test to help dx bacterial vaginosis?
Whiff test
What do you do w/KOH test to help dx trichomoniasis?
Whiff test
List the 6 key identifiers to dx bacterial vaginosis. (hint: recap of previous questions)
1) Sx: odor, discharge, itch
2) Discharge: homogenous, adherent, thin, milky white; malodorous “fishy” smell
3) Clinical findings: odor, white or gray discharge
4) pH: >4.5
5) Whiff test: positive
6) NaCl wet mount: clue cells, no/few WBCs
List the 7 key identifiers to dx candidiasis. (hint: recap of previous questions)
1) Sx: itch, discomfort, dysuria, thick discharge
2) Discharge: thick clumpy white “cottage cheese”
3) Clinical findings: inflammation and erythema
4) pH: < 4.5
5) Whiff test: negative
6) NaCl wet mount: few to many WBCs
7) KOH wet mount: pseudohyphae (or spores if non-albicans species)
List the 6 key identifiers to dx trichomoniasis. (hint: recap of previous questions)
1) Sx: itch, discharge, ~70% asymptomatic
2) Discharge: frothy, gray or yellow-green; malodorous
3) Clinical findings: cervical petechiae, “strawberry cervix”
4) pH: > 4.5
5) Whiff test: usually positive
6) NaCl wet mount: motile flagellated protozoa, many WBCs
What is the preferred way to dx trichomoniasis?
Nucleic acid amplification test (NAAT)
How is candidiasis typically diagnosed?
History and PE (clinically)– also: normal pH, KOH prep, wet mount, +/- culture if all else is negative
How is bacterial vaginosis typically diagnosed?
Amsel criteria– also: DNA probe based test for G. vaginalis, vaginal sialidase activity test, +/- gram stain (research only typically)
What are the four components of the Amsel criteria, and at least how many must be present to dx BV?
Amsel criteria-must have at least 3 of the 4:
1) Vaginal pH > 4.5
2) Presence of >20% per HPF of “clue cells” on wet mount examination
3) (+) amine or “whiff” test- fishy smell
4) Homogeneous, non-viscous, milky-white discharge adherent to the vaginal walls
What are 3 tx options for bacterial vaginosis?
(1) metronidazole 500 mg BID x 7 days- usual tx
(2) metronidazole gel 0.75% one full applicator intravaginally 1-2x/day for 5 days
(3) clindamycin cream 2% one full applicator (5g) intravaginally at bedtime for 7 days
What is the tx of candidiasis? In severe cases? If pt is pregnant?
Fluconazole 150 mg x 1
Severe: fluconazole 150 mg repeated in 72 hrs
Pregnancy: OTC, 7 day topical txs (fluconazole is C/I in first trimester)
What are 3 tx options for trichomoniasis?
(1) metronidazole 2gm orally in a single dose
(2) metronidazole 500 mg BID x 7 days
(3) tinidazole 2 gm orally in a single dose
What are 2 counseling points for metronidazole?
(1) metronidazole is safe in pregnancy
(2) do not drink alcohol while taking or after taking
What are 2 tx options for pts with multiple recurrences of BV?
(1) twice weekly metronidazole gel for 4-6 months
(2) oral nitroimidazole followed by intravaginal boric acid suppressive metronidazole gel
What are 3 risk reduction counseling points for BV?
(1) correct and consistent condom use
(2) avoid douching
(3) limit number of sex partners
What are 2 tx instruction counseling points for BV?
(1) avoid alcohol if taking metronidazole
(2) latex condoms may dissolve intravaginal creams
What are 3 risk reduction counseling points for candidiasis?
(1) avoid douching
(2) avoid unnecessary abx use
(3) complete course of tx
What is a tx instruction counseling point for candidiasis?
Latex condoms may dissolve intravaginal creams
What are 2 risk reduction counseling points for trichomoniasis?
(1) correct and consistent condom use
(2) limit number of sex partners
What are 4 tx instruction counseling points for trichomoniasis?
(1) avoid alcohol if taking metronidazole
(2) avoid sex until pt and partners tx and cured and asymptomatic
(3) any sex partners in last 60 days should be treated
(4) report to local DPH
What type of organism is gonorrhea?
Gram (-) diplococci
What is the typical incubation period of chlamydia and why is it so easily transmissible?
7-21 days–significant asymptomatic reservoir
What sx does vertical transmission of chlamydia result in in babies?
Neonatal conjunctivitis
What is the most common infection worldwide?
Chlamydia
What are 9 risk factors for Gonorrhea/Chlamydia?
1) Multiple partners
2) New sex partner in last 3 months
3) Young age <25 yrs
4) Minority ethnicity
5) Low educational and socioeconomic levels
6) Substance abuse
7) Inconsistent use of condoms
8) Hx of other STIs
9) MSM population
What are 8 sx of GC/chlamydia in women?
(1) dysuria
(2) mucopurulent discharge
(3) CMT
(4) pruritus
(5) tender uterus
(6) PID sx
(7) intermenstrual bleeding
(8) cervicitis 85%- red or friable cervix
What are 3 sx of GC in men?
(1) dysuria
(2) white, yellow or green discharge
(3) +/- penile edema
What are 2 sx of chlamydia in men?
(1) mucoid or watery urethral discharge
(2) clear discharge, sometimes seen only w/milking the penis
What is an additional finding of GC outside of the reproductive system? (hint: pharynx)
Sore throat
What is the preferred test to dx GC/chlamydia and what are 3 ways of obtaining the specimen used?
Nucleic acid amplification testing (NAAT):
(1) first catch urine
(2) vaginal swab
(3) endocervical swab
T/F: it is better to wait for culture test results to come back (+) to start tx.
False: better to tx right away to be safe than to wait for culture results to come back
What is the tx regimen for gonorrhea?
Ceftriaxone 250mg in a single IM dose + Azithromycin 1g orally in a single dose (or Doxycycline 100mg orally BID x 7 days)
What are 2 complications of GC/chlamydia in men and how do you tx each?
(1) epididymitis: Ceftriaxone 250mg IM + Doxycycline 100mg BID x 10-21 days
(2) proctitis: Ceftriaxone 250mg IM + Doxycycline 100mg BID x 7-21 days
What are 2 recommended tx regimens for chlamydia?
(1) azithromycin 1g orally in a single dose OR
(2) doxycycline 100mg orally BID x 7 days
What are 3 follow-up instructions for GC/chlamydia?
(1) avoid sex until pt and partners txed and cured (therapy has been completed AND pt and partners are asx~ 7 days)
(2) sex partners last 60 days should be treated
(3) report to local DPH
What is PID and what disorders does it all encompass?
PID: a clinical syndrome associated w/ascending spread of microorganisms from the vagina or cervix to the endometrium, fallopian tubes, ovaries, and contiguous structures; includes any combo of: endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis
What is the pathogenesis order of PID?
cervicitis→ endometritis→ salpingitis/oophoritis/tubo-ovarian abscess→ peritonitis
What are the 2 most common pathogens of PID?
N. gonorrhoeae and C. trachomatis
What are 3 complications of PID?
(1) ectopic pregnancy
(2) infertility
(3) chronic pelvic pain
What are 3 types of tenderness possible to dx PID?
(1) uterine tenderness
(2) adnexal tenderness
(3) cervical motion tenderness
What is the recommended oral tx regimen for PID?
Ceftriaxone 250mg IM single dose + doxycycline 100mg orally BID x 14 days +/- metronidazole 500mg orally BID x 14 days
What are 2 big follow up recommendations for PID?
(1) repeat testing of all women who have been diagnosed w/chlamydia or gonorrhea is recommended 3-6 mo after tx
(2) all women diagnosed w/clinical acute PID should be offered HIV testing
What are 3 recommendations for PID male/sex partner management?
(1) male sex partners of women w/PID should be examined and treated (esp partners w/in last 60 days)
(2) male partners of women are often asymptomatic
(3) sex partners should be treated empirically w/regimens effective against both C. trach and N. gonorrhoeae regardless of etiology
What 2 types of HPV are low-risk types associated with genital warts?
HPV types 6 and 11
What 2 types of HPV are high-risk oncogenic types?
HPV types 16 and 18 (most women w/these have normal Pap results and never develop cellular changes or cervical cancer)
What is the likely mechanism for HPV DNA clearance?
Gradual development of an effective immune response
What is the most important risk factor for precancerous cervical cellular changes and cervical cancer?
Persistent oncogenic HPV infection
T/F: most genital HPV infections are transient, asymptomatic, w/o clinical sx or consequences.
True
What are 5 HPV risk factors?
(1) young age
(2) sexual behavior (risk inc w/inc # of sex partners)
(3) sexual behavior of sex partners-risk inc for women whose sex partners had multiple sex partners
(4) uncircumcised men inc risk
(5) immunocompromised
What is an important thing to remember about HPV?
It is asymptomatic most of the time
What are 2 possible findings on PE of HPV?
(1) genital warts
(2) cervical cellular abnormalities detected by Pap tests
What are 4 different appearance of genital warts?
(1) condylomata acuminata
(2) smooth papules
(3) flat papules
(4) keratotic warts
What are condylomata acuminata?
Cauliflower-like appearance, skin-colored, pink or hyperpigmented
What is the pt applied tx of genital warts?
Podofilox (Condilox) 0.5% gel or solution applied BID for 3 days, followed by 4 days of no therapy- repeated as needed up to 4 cycles
What is the provider applied tx of genital warts?
Cryotherapy w/liquid nitrogen or cyroprobe-repeat applications every 1-2 weeks
Which type of HSV causes genital herpes?
Type 2
T/F: most genital herpes infections are transmitted by people who are asx or unaware of infection.
True
When is most HSV-2 transmitted?
during asymptomatic viral shedding
Is the disease more or less severe in the first ever primary infection of HSV?
More: primary infection is more severe than recurrent disease
T/F: antibody is present in primary infection of HSV.
False: no antibody present when symptoms appear
What is a non-primary infection of HSV?
Newly acquired HSV-1 or -2 infection in an individual previously seropositive to the other virus
Is the serum antibody present in asymptomatic infection of HSV?
Yes: serum antibody is present in asx infection
What is the progression of HSV genital lesions starting with papules?
papules→ vesicles→ pusutules→ ulcers→ crusts→ healed
What are si/sx and characteristics of primary HSV (inc. sx, quality of lesions, and how long sx last)?
Fever, headache, malaise, myalgia; multiple lesions more severe, last longer, and have higher titers of virus than recurrent infections; illness lasts 2-4 weeks-average 11-12 days
What are si/sx and characteristics of recurrent HSV (inc. sx, quality of lesions, and how long sx last)?
Prodromal sx are common- localized tingling, irritation→ begin 12-24 hrs before lesions; sx tend to be less severe than in primary infection; less lesions at times; illness lasts 4-6 days
What is the gold standard dx test for HSV?
Viral culture
What does the sensitivity of viral cultures depend on with HSV dx?
Stage of the lesion-declines rapidly as lesion begins to heal
What dx test is more sensitive than viral culture for HSV and becoming more frequently used?
PCR
What is the tx of the first episode of genital herpes?
Valacyclovir 1g orally BID x 7-10 days
What is the suppressive tx of genital herpes?
Valacyclovir 1g orally 1x/day
What is the episodic tx of genital herpes?
Valacyclovir 500mg orally BID x 3 days OR 1 g orally 1x/day for 5 days
What is the etiologic agent of syphilis?
Treponema pallidum
What is the primary lesion of primary syphilis and is it painful or painless?
Chancre: painless
What is found in secondary syphilis?
Secondary lesions-weeks to months after primary chancre that may persist for weeks-months; rash of the palms and feet
Are serologic tests higher or lower in titer during the secondary syphilis stage?
Higher
What is a finding in secondary syphilis that will not resolve in immunocompromised pts?
Lues maligna
What is the only evidence of latent syphilis?
A positive serologic test
What is the early latent phase of syphilis?
<1 yr duration of initial infection-risk of transmitting is higher
What is the late latent phase of syphilis?
> 1 yr duration of initial infection or time since infection is unknown-typically not considered infectious
T/F: late/tertiary syphilis is infectious.
False
What are 2 manifestations of tertiary syphilis?
(1) gummatous lesions
(2) cardiovascular syphilis
What are the 3 types of serologic tests used in syphilis dx?
(1) darkfield microscopy
(2) non-treponemal
(3) treponemal
What does darkfield microscopy assist with in syphilis dx?
Identification in lesion or ulcer; quick test that must be performed immediately
What does non-treponemal test for in syphilis pts, what are 2 non-treponemal test options, and what does it evaluate?
- Test for reagin Ab
- options: VDRL and RPR
- follows titers to measure therapeutic effect and evaluate reinfection
What does treponemal test for in syphilis pts, what are 2 treponemal test options, and what can it not measure?
- Measures antibody directed against T. pallidum antigen
- options: FTA-ABS and TP-EIA
- cannot measure tx effectiveness
What is needed to dx CNS disease in syphilis pts?
Reactive serological test results plus CSF interpretation (CSF for pleocytosis, inc protein concentration, positive VDRL +/or FTA-ABS)
What is the tx of primary, secondary and early latent syphilis, assuming no allergies (dose included)? Tx options if PCN allergy?
Benzathine penicillin G 2.4 million units IM in a single dose
If PCN allergy: doxycycline 100mg orally BID x 14 days or tetracycline 500mg orally 4x/day x 14 days
What is the tx of tertiary and late latent syphilis, assuming no allergies (dose included)? Tx options if PCN allergy?
Benzathine penicillin G 7.2 million units IM total, admin as 3 doses of 2.4 million units IM each at 1 week intervals
If PCN allergy: doxycycline 100mg orally BID x 28 days or tetracycline 500mg orally 4x/day x 28 days
What is the follow up for primary or secondary syphilis?
Reexamine at 6 and 12 months; compare follow up titers to baseline non-treponemal titer obtained on day of tx
What is the follow up for latent syphilis?
Reexamine at 6, 12, and 24 months
What is the follow up for HIV-infected pts w/primary or secondary syphilis?
Reexamine at 3, 6, 9, 12, and 24 months
What is the follow up for HIV-infected pts w/latent syphilis?
Reexamine at 6, 12, 18, and 24 months
What is the follow up for neurosyphilis?
Serologic testing; repeat CSF examination at 6 month intervals until normal
What are 4 types of lesions?
(1) chancre
(2) lymphanogranuloma venire
(3) HSV
(4) chancroid
