STD

Question 1

Vaginitis – Non STD Related

Answer 1

Monilia–fungal
Bacterial Vaginosis–bacterial

Normal vagina
Acidic environment PH 3.8 – 4.2

Maintained by Lactic Acid produced by lactobacilli

In the healthy vagina there is homeostatic co-existence of
anaerobes and aerobes with non-exfoliated epithelial cells.

Affected by products, practices, nutrition (ie excessive sugar intake/diabetes, douching, bubble bath, sprays, scented products, fancy condoms/toys)

Question 2

Vulvovaginal Candidiasis

Answer 2

Candida – fungal resident flora, overgrowth creates infectious process
Albicans – most common genus
Over 50 different types of candida – most responsive to “azole” therapy
Glabrata & Rugosa types are becoming more resistant to current therapies

Question 3

Vulvovaginal Candidiasis

symptoms

Answer 3

Symptoms: severe pruritis, curdy vaginal discharge, vaginal soreness, dysuria, white or erythemic skin

Question 4

Vulvovaginal Candidiasis

treatment

Answer 4

External – antifungal creams (clotrimazole, nystatin)
Internal – antifungal suppositories, creams (miconazole, terconazole)
Systemic – antifungal oral pills (fluconazole)

Question 5

BACTERIAL VAGINOS

Answer 5

Infection occurs when “good” bacteria go bad

One term used to describe a polymicrobial ascending infection caused by one or more organisms 
Gardnerella
Mobiluncus
Coccobacilli
Mycoplasma hominis

involve organisms transmitted sexually and/or may be confined to anaerobic organisms

Question 6

BACTERIAL VAGINOS

Causes

Answer 6

Douching
Sexual activity
Recent antibiotic use
Hormonal changes

Essentially anything that disrupts the balance of normal resident flora (lactobacilli)

Question 7

Bacterial Vaginosis

Subjective

Answer 7

Gray/white homogeneous milky white discharge

fishy odor typically worse following sex

Question 8

Bacterial Vaginosis

Objective

Answer 8

homogeneous, thin, white discharge that smoothly coats the vaginal walls;
• presence of clue cells on microscopic examination;
• pH of vaginal fluid >4.5; or
• a fishy odor of vaginal discharge before or after addition of 10% KOH (i.e., the whiff test)

Question 9

Bacterial VaginosisTreatment

Answer 9

Recommended Regimens

Metronidazole 500 mg orally twice a day for 7 days*
OR
Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days
OR
Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days**

*Consuming alcohol should be avoided during treatment and for 24 hours thereafter.

**Clindamycin cream is oil-based and might weaken latex condoms and diaphragms for 5 days after use)

Question 10

Bacterial VaginosisTreatment

Answer 10

Alternative Regimens
Tinidazole 2 g orally once daily for 2 days
OR
Tinidazole1 g orally once daily for 5 days
OR
Clindamycin 300 mg orally twice daily for 7 days
OR
Clindamycin ovules 100 mg intravaginally once at bedtime for 3 days
OR
Clindesse 1 1 applicatorfull intravaginally x 1 dose

Question 11

Sexually Transmitted Infections

Parasitic

Answer 11

Pediculosis pubis (crab lice)
Trichomoniasis

Question 12

Sexually Transmitted
Infections
Bacterial

Answer 12

Chlamydia
Gonorrhea
Syphilis - spirochete (bacterium)

Question 13

Sexually Transmitted
Infections
Viral

Answer 13

Herpes simplex virus—Types I and II
Human papillomavirus (HPV)
Human Immunodeficiency virus (HIV)
Hepatitis Types B, C

Question 14

Trichomonas Vaginalis

Subjective

Answer 14

Men: usually asymptomatic
Women: bad smelling, yellow/green
frothy discharge, irritation and excoriation of genital area strawberry cervix, can also present with dysuria as the only subjective symptom

Question 15

Trichomonas Vaginalis

Objective

Answer 15

Wet mount of vaginal discharge shows protozoan is alive and moving. It has a tail or flagella for propulsion. + Whiff when KOH is added to wet prep. Cervix is erythemic with a “strawberry” appearing cervix .

Question 16

Trichomoniasis treatment

Answer 16

Recommended Regimens
Metronidazole 2 g orally in a single dose
OR
Tinidazole 2 g orally in a single dose

Alternative Regimen
Metronidazole 500 mg orally twice a day for 7 days*

Important to treat partner to prevent re-infection

Question 17

Patient Education

Answer 17

Important to treat partner to prevent re-infection

Review safe sex practices

Patients should be advised to avoid consuming alcohol during treatment with metronidazole or tinidazole.

Abstinence from alcohol use should continue for 24 hours after completion of metronidazole or 72 hours
after completion of tinidazole

Question 18

Pediculosis Pubis

Answer 18

Pubic Lice…”crabs”

Parasite
- Louse eggs seen on hair shafts – hatch in 7-9 days causes severe itching

- Transmitted by sexual contact, contaminated

         bedding,etc

Question 19

Pediculosis Pubis

Treatment

Answer 19

Treatment:
Kwell, RID, Permethrin, Lindane
Treat partner(s) and household contacts, clean fomites

Question 20

CHLAMYDIA

Answer 20

Caused by: bacterium chlamydia trachomatis
Most rapidly increasing STD especially in young adults
Leading cause of infertility
1 episode …12% infertility
2 episodes…30% infertility
3 episodes…50% infertility
Estimated than 1 million people in US have it now
Becoming known as the “silent epidemic”
Commonly concurrent with Gonorrhea (Treat both)
In 70% – 80 % of cases patients are asymptomatic.

Question 21

SCREENING GUIDELINES

for chlamydia infections

Answer 21

USING THESE SCREENING GUIDELINES, 90% OF ALL CHLAMYDIA INFECTIONS WOULD BE DETECTED

24 years of age or younger
Intercourse with a new partner
Suspicious cervical discharge
Cervical bleeding cause by swabbing / post-coital bleeding
No contraception usage or non-barrier methods

Question 22

Chlamydia

Subjective

Answer 22

Often asymptomatic 
Increased thick yellow vaginal discharge
Post-coital bleeding
Abnormal vaginal bleeding / inter-menstrual bleeding 
Urinary s/s (dysuria, frequency)

Question 23

Chlamydia

Objective

Answer 23

Irritated appearing cervix with “contact” bleeding
Painful bimanual exam
Chlamydial cervicitis in a female patient characterized by mucopurulent cervical discharge, erythema, and inflammation .

Question 24

Treatment of CHLAMYDIA

Answer 24

Recommended Regimens
Azithromycin 1 g orally in a single dose
OR
Doxycycline 100 mg orally twice a day for 7 days*

Alternative Regimens
Erythromycin base 500 mg orally four times a day for 7 days
OR
Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days
OR
Levofloxacin 500 mg orally once daily for 7 days
OR
Ofloxacin 300 mg orally twice a day for 7 days

Question 25

GONORRHEA

Answer 25

Neisseria Gonorrhoeae Caused by N. gonococcus bacterium 46% have coexistence with Chlamydia Spread through vaginal, anal, or oral sex Women have a 60–80% risk of getting the infection from a single act of vaginal intercourse with an infected man

Question 26

GONORRHEAScreening & Prevention

Answer 26

CDC recommends screening sexually active females aged 25 and younger Females at risk for STDs Pregnant females Symptomatic males

Question 27

GONORRHEA Symptoms

Answer 27

``` Increase or change in vaginal discharge Post-coital bleeding / inter-menstrual bleeding Dysuria Pelvic Pain Dyspareunia ``` ½ of all infected women will be asymptomatic

Question 28

Gonorrhea Objective

Answer 28

Irritated appearing cervix with “contact” bleeding | Painful bimanual exam

Question 29

Gonorrhea | Diagnosis

Answer 29

PCR testing via cervical culture

Question 30

Gonorrhea | Treatment

Answer 30

**Due to increase in resistant gonorrhea CDC updated recommended treatment regimen in 2012** Updated Recommended regimen (2012) Ceftriaxone 250 mg in a single intramuscular dose PLUS Azithromycin 1 g orally in a single dose or doxycycline 100 mg orally twice daily for 7 days*

Question 31

Gonorrhea Alternative Treatment

Answer 31

``` Alternative regimens If ceftriaxone is not available: Cefixime 400 mg in a single oral dose PLUS Azithromycin 1 g orally in a single dose or doxycycline 100 mg orally twice daily for 7 days* PLUS Test-of-cure in 1 week If the patient has severe cephalosporin allergy: Azithromycin 2 g in a single oral dose PLUS Test-of-cure in 1 week ```

Question 32

Gonorrhea Patient Education

Answer 32

Test of cure necessary to ensure effective treatment and prevention of spread Partner treatment necessary If not treated can lead to Pelvic Inflammatory Disease and Permanent Sterility Prevention is key Abstinence Mutually monogamous sex with an uninfected partner Safe sex (strict condom use) Routine screening for those at increased risk

Question 33

Syphilis

Answer 33

``` Treponema Pallidum—spirochete Four Potential Stages Primary Syphilis--first symptoms appear 10-90 days (Average 21 days) after exposure Secondary Syphilis Latent Syphilis can last from 1-40 years Tertiary Syphilis—can result in: Late benign syphilis Cardiovascular syphilis Neurosyphilis ```

Question 34

Primary Syphilis

Answer 34

INCUBATION – average of 3 WEEKS from exposure Chancre can be anywhere on body – usually somewhere in the genital area or mouth area Painless – heals in 3-9 wks without treatment

Question 35

Primary Syphilis Diagnosis

Answer 35

Non-treponemal blood tests (VDRL, STS, RPR) will become reactive within 2 weeks of chancre FTA tests for the actual organism (spirochete) and takes longer to appear—about 4 wks from exposure “ the gold standard” (takes 2 weeks to process) Stays positive for life.

Question 36

Primary Syphilis treatment

Answer 36

``` Bicillin 2.4 million units IM (1.2 million units in each buttock, deep Z track) Treat partner(s). Follow titres. Should be decreasing. ```

Question 37

Secondary Syphilis Symptoms

Answer 37

Symptoms appear 2-12 weeks from exposure Most common symptom – skin rash on palms, soles, body Other less common symptoms – lymphadenopathy, mucus patch ulcers, alopecia, condylomata lata (pale moist flat topped papules on moist surfaces) Most spontaneously resolve

Question 38

Early latent Syphilis

Answer 38

Up to one year after became infected Asymptomatic Non-treponemal titers (RPR. STS, VDRL) are decreasing

Question 39

Late latent Syphilis

Answer 39

1-40 years after infected Asymptomatic Non-treponemal tests very low or negative Most common transfer from mother to baby or through blood transfusions

Question 40

Tertiary Syphilis

Answer 40

Late benign syphilis Gumma formations (soft tissue necrosis) in throat, abdomen, bones (granulatomatus lesions that can lead to soft tissue and bone destruction) Cardiovascular - Aortic insufficiency, thoracic aortic aneurysm Neurosyphilis - Optic atrophy/pupils sluggish to light, tabes dorsalis (degradation of dorsal columns of spinal cord=loss of proprioception etc), locomotor ataxia general paresis, gumma formations in the brain meningitis

Question 41

Tertiary Syphilis Late benign syphilis treatment

Answer 41

Bicillin 2.4 million units IM x 3 doses on week apart. Treat partner(s). Do follow-up titres.

Question 42

Quantitative Screening

Answer 42

Non-treponemal screening tests (VDRL,RPR,) can be positive for other reasons thus confirmatory testing (FTA) must be completed if the screening test is positive.

Question 43

Quantitative Screening False Positives

Answer 43

Malaria Hemolytic anemia Narcotic addiction Viral syndrome Lyme disease Hansen’s disease (Leprosy) Recent immunizations Lupus Infectious hepatitis Chicken pox Measles Rheumatoid arthritis Rheumatic fever Common cold Pregnancy Collagen diseases

Question 44

Herpes Simplex Virus (HSV)

Answer 44

The herpes simplex virus (HSV) is a double-stranded DNA virus 2 known types Type 1 Type 2

Question 45

Herpes Simplex Virus Types I & IIWhat’s the Difference?

Answer 45

The primary difference between the two viral types is in where they typically establish latency in the body- their "site of preference." HSV-1 usually establishes latency in the trigeminal ganglion, a collection of nerve cells near the ear. From there, it tends to recur on the lower lip or face. HSV-2 usually sets up residence in the sacral ganglion at the base of the spine. From there, it recurs in the genital area. Even this difference is not absolute either type can reside in either or both parts of the body and infect oral and/or genital areas. Unfortunately, many people aren't aware of this, which contributes both to the spread of type 1 and to the misperception that the two types are fundamentally different.

Question 46

HSV Incidence

Answer 46

About 1 in 6 Americans between the ages of 14 – 49 is infected with HSV type 2 One of the most common STDs Prevalence twice as high among women 3x higher among black women + HSV patients are 2-3x more likely to acquire HIV CDC estimates that over 80 percent of those with HSV-2 are unaware of their infection

Question 47

HSV Diagnosis | Primary Infection- Initial outbreak

Answer 47

Most severe | Often present with systemic symptoms / complaints

Question 48

HSV Diagnosis | Secondary Infection- Recurrence

Answer 48

Less severe Can be without lesions – remain in prodromal stage Yet – still very contagious

Question 49

HSV Diagnosis

Answer 49

Should be included in routine STD screening in those at increased risk Screening via serum antibody testing (IgG / IgM) for type specific HSV Episodic testing in symptomatic patients Can be done via viral cultures obtained at source What are the limitations of diagnosing via cultures ?

Question 50

Clinical manifestations of Genital Herpes | Initial Infection

Answer 50

``` Vesiculopustular lesions (bilateral) Cervicitis, urethritis Lymphadenopahty Neuropathic manifestations Systemic inflammation (fever, etc.) Duration typically 2-4 wk ```

Question 51

Clinical Manifestations of Genital Herpes | Recurrent outbreaks

Answer 51

Unilateral lesions nonspecific symptoms (discharge, dysuria, ect. ) Neuropathic prodrome Duration 1-2 wk

Question 52

Common misdiagnoses of Genital Herpes

Answer 52

Vulvovaginal candidiasis and other vaginal infections Syphilis, chancroid, UTI, Genital trauma

Question 53

HSV Treatment Primary Outbreak

Answer 53

Recommended Regimens* Acyclovir 400 mg orally three times a day for 7–10 days OR Acyclovir 200 mg orally five times a day for 7–10 days OR Famciclovir 250 mg orally three times a day for 7–10 days OR Valacyclovir 1 g orally twice a day for 7–10 days *Treatment can be extended if healing is incomplete after 10 days of therapy.

Question 54

HSV TreatmentSecondary (Episodic) Outbreak

Answer 54

Recommended Regimens Acyclovir 400 mg orally three times a day for 5 days OR Acyclovir 800 mg orally twice a day for 5 days OR Acyclovir 800 mg orally three times a day for 2 days OR Famciclovir 125 mg orally twice daily for 5 days OR Famciclovir 1000 mg orally twice daily for 1 day OR Famciclovir 500 mg once followed by 250 mg twice daily for 2 days OR Valacyclovir 500 mg orally twice a day for 3 days OR Valacyclovir 1 g orally once a day for 5 days

Question 55

HSV Suppression Therapy

Answer 55

``` Suppression therapy can reduce outbreaks by up to 80% Goals Decrease number of outbreaks Shorten duration / severity of outbreaks Decrease viral load ``` ``` Indications Decrease risk of spreading virus from infected partner to an uninfected partner Pregnancy Immunosuppressed patients Patient request ```

Question 56

HSV Patient Education

Answer 56

Focus on prevention After diagnosis is made Counseling / Patient support is an absolute Treatment options Risks of spreading to others Risks of future outbreaks How to identify outbreaks early on (prodromal stage) Lifelong disease with likely implications on patients health & relationships May take several visits to educate / counsel patient after initial HSV diagnosis

Question 57

(HPV) Human Papillomavirus

Answer 57

Human Papillomavirus Most common viral STD Over 150 types High risk types are linked to cervical cancer Types:16, 18, 31, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68, 69, Gardasil Vaccine for: 6, 11, 16, 18 only Passed by all types of sexual contact

Question 58

HPV

Answer 58

More prevalent in young women in 20s Highest STD in teens – 40-45% 50% have clinical lesions and 25% non-clinical Can accumulate lesions – like grape clusters 6-11 cause Genital warts 16,18,45 most likely to progress to cancer Body can rid itself of virus especially in teens therefore change in Pap guidelines

Question 59

HPV and Cancer

Answer 59

16, 18, and 45 found in 70% of patient with invasive cancers 16 – Vulvar squamous carcinoma 55-60% penile Risk for squamous cell carcinoma of head and neck with oral sex Risk factor for cancer of throat 18 – Adenocarcinoma Small cell carcinoma of cervix More significant in risk for invasive neoplasm Has worse prognosis