STI's Flashcards
Frothy gray or yellow-green vaginal DC, pruritis or cervical petechiae
Trichomonas vaginalis
Thick white, curdy, cottage cheese like vaginal DC. Vulvar pruritis, erythema, irritation. External dysuria
Candida albicans
Malodorous vaginal DC that is reported more commonly after sexual intercourse or menses
Bacterial vaginosis
Dysuria, muccopurulent DC, abd pain, intermenstrual bleeding, whitish or clear DC from penis
Chlamydia
Dysuria, white, yellow or green DC, mucopurulent DC
Gonorrhea
What is normal vaginal DC like?
Clear to white, odorless, high viscosity.
Normal vaginal pH?
3.8-4.2. Lactobacilli helps maintain this.
Why is such an acidic environment okay for the vagina?
Acidic environment and other host immune factors inhibits the growth of bacteria
Three most common types of vaginitis
Bacterial Vaginosis
Vulvovaginal candidiasis
Trichomoniasis
Of the three most common types of vaginitis, which is most common?
Bacterial vaginosis
Second most common form of vaginitis?
Candida. Affects most females during their lifetime.
Most prevalent non-viral STI?
Trichomonas
Major bacteria in bacterial vaginosis?
Gardnerella vaginalis
Pathogenesis of bacterial vaginosis
Overgrowth of bacteria normally present in vagina paired with a decrease/loss of protective lactobacilli
Pathogenesis of vulvovaginal candidiasis?
Overgrowth of Candida albicans, a normal flora of the skin/vagina. Symptomatic clinical infection occurs w/ excessive growth of yeast
What predisposes you to candidiasis?
Disruption of the normal vaginal flora (doucheing) or host immunity will predispose you to vaginal yeast infections
What;s the only protozoan that affects the genital tract?
Trichomonoas vaginalis
RF for bacterial vaginosis
AA >2 partners in last 6 mo Douching NO CONDOMS absence/lack of lactobacilli
RF for candidiasis
DM IC Abx UNDERWEAR (EAT SHIT EVERYBODY) Douching
RF for trich
Multiple partners
Being poor
Hx of STI
NO CONDOMS
Classic sx of bacterial vaginosis
Asymp!
Malodorous or fishy smell
Pruritic DC
thin, milky white, sometimes grey DC
Classic sx of candidiasis
Pruritic discomfort
Dysuria
Thick cottage cheese DC
Classic sx of trich
Asymp!
Pruritic DC sometimes green, yellow-green, frothy
Strawberry cervix
Vaginal pH <4.5?
Candidiasis or normal
Vaginal pH >4.5?
BV or trich
What would bacterial vaginosis show on a wet prep slide?
Clue cells! Few/no WBC
What would candidiasis look like on a wet prep?
Few to many WBC. Other stuff is seen on the KOH
Trich on a wet prep?
Motile flagellated protozoa, many WBC
What is a KOH test?
Wet prep + 10% KOH prep
What will a KOH show on candidiasis?
Yeast psuedohyphae and budding yeast
What’s a fun test for BV?
Whiff test. Stick it up to your nose, “does this smell fishy”
Which type of vaginitis uses the Amsel Criteria?
Bacterial vaginosis
Best mode of diagnosing Trich
NAAT- Nucleic acid amplification. Aptima? Dunno, it was bolded. Done via swab
Best mode for diagnosing candidiasis
KOH, Hx and PE. Mostly a clinical diag
Best mode for diagnosing BV
Whiff test and Amsel Crit
Layout the Amsel Criteria
At least 3 of the following:
1) Basic vagina (>4.5)
2) Presence of clue cells on wet mount
3) Positive whiff test
4) Homogenous, non-viscous, milky white discharge that’s adherent to vaginal walls
Recurrence rate of BV and why
Recurrence of 20-40% one month after tx. This can be a result of the BV-causing pathogens persisting, or just the normal lactobacilli failing to recolonize.
Avoidance education: BV
Condoms, avoid douching.
Avoidance education: Candidiasis
Avoid douching & unnecessary abx (keep it natural)
Avoidance education: Trich
Condoms
How is transmission of G/C
Sexual or vertical
What’s more common G or C
C is the most common infection worldwide
RF for G/C
Multiple partners Young age <25 Minority Low education/socioeconomic RxAx Hx of other STI MSM
Complications of G/C
PID- infertility goes with that
Fitz-Hugh Curtis (adhesions)
Neonatal conjunctivitis
Inc risk of HIV
Gonorrhea specific complication
Disseminated gonococcal infection (DIC)
Arthritis, tenosynovitis, dermatitis (from disseminated G)
Chlamydia specific complication
Reactive arthritis (Reiters syndrome)
Lymphogranuloma
Neonatal pneumonia
What is Reiter’s Syndrome
Joint pain & swelling triggered by an infection in another part of the body
Difference between G/C symptoms in women
Nothing! They’re exactly the same
Women G/C Symptoms
*Can be asymp* Dysuria Mucopurulent dc Tender uterus PID sx Cervicitis in 85% of pts ****
Men G symptoms
Dysuria
White/yellow/green dx
Men C symptoms
Mucoid or watery urethral dc. Oftentimes only seen when milking the penis. Can also have LA, ewie
Pharyngeal G sx
Sore throat. Ick
Women’s GC cervix w/ cervicitis
Red/friable cervix on internal exam
Preferred method of testing for G/C
NAAT. Done with a vaginal swab or a urine culture for men. NAAT can be used as a screening tool as well
Who gets screened for G/C
Sx and/or partner w/ STI High risk behavior (prostitute) Hx of STD Pregnant MSM Military service
Recommended Regimen for Txing Gonorrhea
Ceftriaxone 250mg IM AND Azithromycin 1g PO single dose.
No azithromycin? Doxycycline 100mg PO BID for 7 days works too
Txing Gonorrhea when Ceftriaxone is not available
Cefixime 400mg PO one dose AND azithromycin 1g PO one dose.
***since you’re not getting the ideal coverage you need a test of cure in a week
Txing Gonorrhea when pt has a ceph allergy
Azithromycin 2g PO single dose
***since you’re not getting the ideal coverage you need a test of cure in a week
When do you need test of cure for gonorrhea
When you’re not getting the exact ideal management
Recommended Management for Chlamydia
Azithromycin 1g PO single dose.
No azith? Can use Doxy 100mg PO BID for 7 days
What are some other drug regimens we can use for chlamydia
Sweet jesus don’t bother remember the doses. It’s just not worth it.
Erythromycin
Ofloxacin
Levofloxacin
When is test of cure recommended?
If non-ideal regimen is used, compliance is in question, symptoms persist or suspected reinfection. And if you’re pregnant
Repeat testing in pregnant women
Test via NAAT 3 weeks after completion of therapy
When do we recommend repeat testing in normal (non pregnant) pop
3-4 months after treatment. Especially in adolescents. All patients will be screened at their next health care visit
What microbe(s) cause PID
It’s polymicrobial!
Gonorrhea, Chlamydia trach or both!
How do you get PID?
Ascending spread of microorganisms from the vagina/cervix up to the endometrium, fallopian tubes, ovaries and pelvic peritoneum
Evolution of PID
Cervicitis ->
Endometritis ->
Salpingitis/oophoritis/tuboovarian abscess ->
Peritonitis
Is there a national surveillance of PID
Nah. But there’s been a modest decline in hospitalizations/new cases
RF for PID
Hx of PID G/C Douching IUD insertion BV OCP Demographics
PID Complications
Ectopic pregnancy
Infertility
Chronic PP
“Must haves” for PID diagnosis
Uterine tenderness OR
Adnexal tenderness OR
Cervical motion tenderness (exquisite pain on speculum exam)
Not “must haves” but are nice to have for diagnosing PID
Fever Abnormal mucopurulent dc WBC on wet slide ESR CRP
When to consider admitting PID
Pregnant Non responsive to PO tx Cannot take PO Severe illness Abscess Cannot exclude surgical emergencies
PID Recommended Tx
Ceftriaxone (250 IM) and Doxy (100mg PO BID x14days)
WITH OR WITHOUT FLAGYL
When should PID pts start improving
72 hours post abx
When to do repeat testing for PID in women who have G/C
3-6 months after tx
What kind of testing should be offered to women with PID?
HIV
Male partners of women with PID show what kind of symptoms?
None! They may be G/C pos, but totally asymptomatic. Should be txed empirally for both
Two types of HPV
Low risk and High risk
Low risk HPV is associated with ____
genital warts and mild pap abnormalities
High risk HPV is associated with ____
Moderate/severe pap abnormalities, cervical dysplasia/cancer
Which types of HPV are low risk
6 and 11
Which types of HPV are high risk
16 and 18
Does having high risk HPV mean you’ll get cancer?
Nope. In fact, most women with high risk HPV have totally normal paps and never develop any cellular changes or cancers.
What is HPV clearance dependent on
Your immune system.
Is HPV a DNA or RNA virus
DNA
Most important RF for cervical dysplasia
Persistent oncogenic HPV infection
___% of infections clear in 2 years
90%
___% of sexually active men and women acquire HPV at some point in their lives
100% Penis
Since pap screening programs, cervical cancer rates have dropped by __%
75%
Most genital HPV infections are…
Transient! Totally asymptomatic without any clinical symptoms or consequences… PPEINS
Genital HPV transmission
Sex
HPV RF
Young age
Sex
Not being circumcised
IC
HPV Sx
Asymptomatic usually*** Dyspareunia Pruritus Burning Bleeding on defecation (anal warts) & PENIS... PENIS
HPV PE findings
Genital warts
Positive Paps
Usually just asymptomatic though
Types of genital warts
Condylomata acuminata (cauliflower)
Smooth papules
Flat papules (usually on internal structures)
Keratotic warts
Two types of mild cervical changes on pap (Bethesda criteria-pathology speak)
ASC-US and ASC-H
Which type of mild cervical change is more likely to be precancerous
ASC-H
(Bethesda Criteria) Pathology-speak for moderate change on pap smear
Low grade squamous intraepithelial lesion (LSIL). These are our Low risk HPV’s
Bethesda Criteria pathology speak for significant changes on pap
High Grade squamous intraepithelial lesion HSIL. These are our persistent HPV
How to diagnose HPV
It’s a clinical diagnosis. But there’s also a role for acetic acid and (rarely) a wart biopsy
Recommended Patient-Applied genital warts tx
Podofilox (condilox) 0.5% gel or solution.
Dosing instructions for patient-applied podofilox
Apply solution w/swab or gel& finger BID for 3 days, then do 4 days of no tx.
***This cycle may need to be repeated like 4 times
Are any of the patient-applied tx for genital warts established to be safe in pregnancy?
Nah, there’s a few provider applied options that are though
Recommended Provider-applied therapy for genital warts
Cryotherapy w/ liquid nitrogen or cryoprobe.
This will have to be reapplied every 1-2 weeks
Other forms of provider-applied therapies
Resin, Trichloracetic acid, or surgical removal
How long does it take for genital herpes to clear?
It doesn’t. This is a chronic, lifelong condition
Two types of HSV?
HSV 1 and HSV 2
What causes most cases of recurrent genital herpes in the US?
HSV 2
HSV 2, more common in women or men?
Women :(
How is HSV transmitted?
Sexually and perinatally
Which type of HSV is more likely to recur?
HSV2
Can HSV-2 be transmitted when not flaring?
YES. Most cases are transmitted when the carrier is asymptomatic. Asymptomatic shedding is huge. This virus can be latent indefinitely
Why should we ask pregnant women if they have a hx of HSV
Because there’s a crazy high risk of transmitting it to the kiddo (30-50%)
HSV likes to lay low for a long time, but what happens when it reactivates?
When it gets reactivated, we’ll see an outbreak of herpetic lesions and some viral replication. Even more virus will be shed
Scary fun fact about HSV2
90% of patients who are seropositive for HSV ab have NOT been diagnosed with herpes
When is most HSV-2 transmitted?
During asymptomatic shedding
Effect of antiviral suppressive therapy on viral shedding
Dramatically reduces it, but does not completely eliminate
Ab presence and sx during primary HSV infection
No antibody present! This is their first exposure to HSV1/2
Primary infection will have more severe sx than recurrent. Lesions will be severe and bilateral
Non primary HSV infection Ab and Sx
This is when someone who was previously seropositive to an HSV gets another one.
Milder symptoms! These lesions will be moderate, since they have some form of ab coverage
This is technically a new infection, so it will take a few weeks/months for an appear
Recurrent symptomatic HSV infection, Ab and sx
Ab is present, disease is mild and short in duration. It’s the same HSV your body is used to
Asymptomatic HSV Ab and Sx
Serum ab is present
No sx
Life cycle of genital lesions
Papules -> Vesicules -> Pustules -> ulcers -> crusts -> healed
Sx of Symptomatic HSV
Numerous, bilateral, painful genital lesions.
Can also have GU sx like pain, itching, dysuria, dc and tenderness
Sx of Symptomatic Primary HSV
IE What are the lesions like, how long does the illness last
Systemic complaints, like fever,HA,malaise.
The lesions are more severe and last longer.
Illness lasts 2-4wks. Avg is 11 days
Sx of Symptomatic Recurrent HSV
What are the lesions like, how long does it last, what type of symptoms are unique to recurrent
Recurrent tends to have prodomal sx, like localized tingling/irritation beginning 12-24 hours before the lesions occur.
The lesions are much less severe than the primary infection.
Illness lasts 4-6 days
Gold standard for diagnosing HSV and its one caveat
Viral culture. Must get the culture from an open lesion, if it’s already healing then its no good to you
What test is more sensitive than a viral culture and preferred for detecting HSV in CSF
PCR!
When to get HSV serology
1) Recurrent gential symptoms but negative HSV viral cultures
2) Clinical diag of genital HSV but no lab confirm
3) Partner has herpes
4) Part of comp. STD eval
Use of antiviral chemotherapy in HSV (what does it do, what does it not do)
Partially controls the sx of herpes and lowers viral shedding.
Does not eradicate the latent virus or affect risk/freq/severity of recurrences after d/cing drug.
Two methods of tx in HSV
Episodic and supressive
HSV First episode tx
Valacyclovir 1g PO BID for 7-10 days
HSV Episodic tx (not first)
Valacyclovir 500mg PO BID for 3 days
OR
Valacyclovir 1g PO QD for 5 days
HSV Supressive tx
Valacyclovir 1g QD PO
HSV patient education key points
Potential for recurrent episodes, asymptomatic shedding and viral transmission
Disease progression of syphilis
Primary ->
Secondary ->
Latent ->
Tertiary/Late
Bug in syphilis
Treponema Pallidum
Which stages of syphilis are the most contagious
Primary and secondary
Syphilis transmission
Sexual and vertical (congenital syph)
Major Sx of Primary Syphilis
Chancre lesion! It develops at the site of inoculation.
Are chancre painful?
Nah. Totally painless
Testing serology during early stages of syphilis?
May or may not be positive. This is not a reliable testing form
Secondary Syph major sx. When do these occur?
Occurs several weeks/months after primary chancre. Can last for that long too.
Rash! Think palms and feet, but it sure as heck can be on your chest and back too. There’s other stuff too but it’s super vague. LA is a thing I guess. Think of syph when you see non resolving ulcerative skin lesions
Serologic titers during secondary syph?
Wicked high. This is when the titers will be highest, serologically reliable at shit
Only signs of latent syphilis
Positive serology! Their lesions will have gone away and they’ll have no clinically apparent signs
When does latent syph occur
Anytime! Even in between secondary relapses
Two categories of latent syph
Early Syph: <1 yr post intial infection
Late Syph: >1 yr post initial infection OR we just don’t know when the initial infection was
Sx of tertiary syph
Gummatous lesions and CV syph
Working up syph: PE
Oral cav LN Skin-torso Palms & ankles Genitalia and perianal area Neuro exam Abdomen
Why is tertiary syph rare
Because we have abx now :)
Can we diagnose syph based on one serologic test?
NO. Need to have multiple
Three types of serologic testing for syphilis
1) Darkfield microscsopy
2) Non-treponemal
3) Treponemal
Which kind of serologic testing is used to evaluate therapeutic effect and reinfection
Non treponemal
Which serologic syph testing can be used as a confirmatory test
Non treponemal and treponemal
What does treponemal testing measure?
Direct antibodies against T pallidium. These will stay positive for life.
What does non-treponemal measure?
Reagin ab. Whatever that is
What does darkfield microscopy measure?
It’s literally a wet slide performed immediately from the bugs in the lesion/ulcer. You look at all the little sphirocetes
Diagnosing CNS Syph
1) Need to be serologically positive
2) Need a Positive CSF WU.
Positive CSF Syph WU
1) CSF for pleocytosis (>5WBC)
2) Inc Protein conc (>45)
3) Positive VDRL and/or FTA-ABS
What is VDRL
Blood test for syph (venereal disease research lab)
Tx for syph
Everything but tert/late-latent:
Benzathine PCN G 2.4 mill units IM
Tert/late-latent:
Benzathine PCN G 7.2 mill units given as 3 doses IM at one week intervals
