STIs Flashcards
5 Ps of taking sexual history
Partners: men, women, both; how many in past year; last time you had sex?
Practices: anatomic sites of exposure
Prevention: desire to be pregnant? what are they doing to prevent?
Protection from STIs: frequency of condom use
Past hx of STI: pt and partners
special populations: youth
why do we take extra time with these populations
15-24
account for half of all new STIs
other special populations
men who have sex with men
pregnant women
HIV-infected pts
individuals entering correctional facilities
symptoms of vaginitis
discharge
odor
pruritus/discomfort
3 most common causes of vaginitis
candida vulvovaginitis
bacterial vaginosis
trichomoniasis
pt comes in with vaginal discharge. how do you approach it?
differentials
important hx
important components of physical exam
testing
is vulvovaginal candidiasis an STI
no
causative organ of vulvovaginal candidiasis
c. albicans
c. glabrata
clinical presentation of vulvovaginal candidiasis
pruritis
external dysuria
vulvar soreness
dysparaunia (painful sex)
abnormal vaginal discharge
physical exam vulvovaginal candidiasis
white, thick curd like vaginal discharge adherent to vaginal walls
maybe edema, fissures, excoriations, erythema
risk factors of vulvovaginal candidiasis (VVC)
DM
antibiotic use
increased estrogen levels
immunosuppressed
dx of vulvovaginal candidiasis
clinical + (definitive) wet mount (10% KOH) - looking for budding yeast, hyphae, or pseudohyphage; normal vaginal pH (less than 4.5) which supports dx of VVC or rules out trich!
culture - if we want to figure out what species it is
VVC tx is for what: to eradicate candida OR for tx of symptoms
ONLY FOR RELIEF OF SYMPTOMS!!!!
uncomplicated of complicated VVC
sporadic or infrequent
mild to moderate symptoms
candida albicans
healthy, nonpregnant women
uncomplicated
uncomplicated or complicated VVC
severe symptoms
recurrent yeast infections
nonalbicans species
pregnancy, poorly controlled DM, immunosuppression
complicated
tx regiment for uncomplicated VVC
short course (1-3 days) of topical azole (OTC)
or
oral fluconazole (diflucan) 150 mg PO - one dose
tx regimen complicated for VVC
what happens if nonalbicans?
treat for longer duration (7-17 days) of topical azole (OTC)
or
oral fluconazole (150mg q 72 hours for 2-3 doses)
IF NONALBICANS, do not use fluconazole
what tx is preferred for pregnancy
topical tx for 7 days
do we tx sex partners for VVC?
nope
is bacterial vaginosis classified as STI
no
most common cause of vaginal discharge in women of childbearing age
bacterial vaginosis
causative organism of bacterial vaginosis
polymicrobial
clinical presentation of bacterial vaginosis
asymptomatic (50-75%)
symptomatic: vaginal discharge and/or vaginal odor: thin, white, or grey discharge with a strong “fishy smell”
risk factors for bacterial vaginosis
sexual activity - new or multiple
presence of other STIs
Race/ethnicity (AA, MA)
Douching (regularly)
Smoking
Lack of condom use
Dx considerations for bacterial vaginosis
clinical by Amsel’s dx criteral
can do gram stain
what is Amsel’s criteria for bacterial vaginosis?
presence of at least three:
thin, white, homogenous discharge
clue cells on saline wet mount
vaginal fluid over 4.5
positive whiff test - presence of fishy odor when drop of 10% KOH is added to sample of vaginal discharge
clue cells - indicate what
bacterial vaginosis
tx pts with or without symptoms
ONLY WITH SYMPTOMS
a woman comes in with NO symptoms for her pap smear and bacterial vaginosis, what do you do
NOT TX. THERE ARE NO SYMPTOMS
most commonly used tx for bacterial vaginosis (3)
metro (500 mg PO BID x 7 days)
metro gel (.75% intravaginally QD times 5 days)
clindamycin cream 2% intravaginally QHS times 7 days
what do you avoid when taking metro?
ETOH
tell your pts NOT to drink with metro~
FDA approved in 2017 for tx of bacterial vaginosis
secnidazole - single 2 gram oral dose
complications of bacterial vaginosis
increases risk of acquiring and transmitting HIV
increases risk of acquiring HSV-2, N. gonorrhea, C. trach, T. vaginalis
Bacterial vaginosis is more common among women with PID
causative organism of trichomoniasis
t. vaginalis (flagellated protozoan)
most common nonviral STI wordwide
trichomoniasis
coexistence of ___ and ___ pathogens are common
t. vaginalis and bacterial vaginosis
clinical presentation of trichomoniasis
asymptomatic
vaginal discharge +/- vulvar irritation: malodorous, frothy, yellow-green vaginal discharge; burning, pruritus, dysuria, dyspareunia
postcoital bleeding!!!!
physical exam of trichomoniasis
punctuate hemorrhages on vagina and cervix - strawberry cervix
vaginal pH over 4.5
strawberry cervix
trichomoniasis
highly sensitive and specific trichomoniaiss dx tool - GOLD STANDARD
nucleic acid amplification test - do on vaginal, endocervical, or urine speciments
if trichomoniasis goes untreated, what can happen (complications)
urethritis or cystitis
PID (those with HIV)
cervical neoplasia
infertility
increased risk of acquireing and trasnmitting HIV
increased risk of premature rupture of membranes; preterm delivery; low birth weight
tx of trichomoniasis: symptomatic, asymptomatic, or both
BOTH
do we treat sexual partners with trichomoniasis
YES - expedited partner tx
tx regimen for trichomoniasis
metro 2 grams single dose
tinidazole 2 grams single dose
tx of trichomoniasis in pregnancy
metro 2g single dose
for how long do you suggest abstainance from sex
7 days after tx of BOTH self and partner
must be asymptomatic
what must you test for with trichomoniasis
other STIs
repeat testing with what dx
trichomoniasis
when do you repeat test for trich and why
within 3 months following initial tx
reinfection rates up to 17% have been reported in women tx for trichomoniasis
CDC recommends screening for t. vaginalis in ____
all HIV infected women - annually and at prenatal visits
what are high prevalance settings in which you should consider trich screening
STI clinics
correctional facilities
most frequently reported infectious disease in US
chlamydia
majority of women present how with chlamydia
asymptomatic (85%)
causative agent of chlyamida
chlamydia trachomatis
most common site involved with clamydia
cervix
symptoms related to chlamydia with cervicitis
change in vaginal discharge
+/- intermenstrual or postcoital bleeding
THESE ARE IF THEY ARE SYMPTOMATIC. Most often asymptomatic.
symptoms related to chlamydia with urethritis
frequency and dysuria
physical exam of chlamydia
cervix: mucopurulent, endocervical discharge
friability, erythmea, edema
dx of chlamydia
NAAT: dx test of choice
vaginal swab preferred: endocervical swab or urine
complications of chlamydia
PID, ectopic preg, infertilty, chronic pelvic pain
pregnancy complications - increased risk of premature rupture of membranes, preterm delivery, transmittable to neonate during delivery
tx chlamydia
regular population and pregnancy
regular: tx pt and sex partners:
azithromycin 1 gm PO single dose
doxy 100mg PO BID for 7 days
Pregnancy: tx with azithrymycin; test for cure
avoid what with chlamydia
intercourse until tx is complete and resolution of sx - 7 days after single dose or after 7-day tx course is done
what else must you test for with chlamydia
other STIs
do you repeat testing for chlamydia
YES
annual screening for whom with chlamydia
all sexually active women less than 25 y/o
screen older women for chlamydia with what risk factors
new or multple sex partners
sex partner recently tx for STI (or has STI)
no or inconsistent condom use outside a mutually monogamous relationship
Hx of prior STI
exchange sex for drugs or money
2nd most commonly reported communicable disease in US
gonorrhea
most common clinical presentation of gonorrhea
asymptomatic
what is of increasing concern with gonorrhea
antimicrobial resistance!
causative agent with gonorrhea
n. gonorrhea
if people present with gonorrhea and symptoms, clinical presentation is
change in vaginal discharge
+/- intermenstrual or postcoital bleeding
frequency and dysuria
mucopurulent endocervical discharge
friable, erythema, and edema cervix
dx of gonorrhea
NAAT - vaginal swab perferred (can do endocervical swab or urine)
cultre when antibiotic resistance suspected
gonorrhea complications
PID, ectopic preg, infertility, chronic pelvic pain
Disseminated gonococcal infection
complications: risk of preterm birh, low birth weight,
ifnection; transmissable to neonate
gonorrhea tx for regular people and pregnant people
regular: tx pt and sex partner:
ceftriaxone 250 mg IM AND azithromycin 1 gram PO single dose
SAME FOR PREGNANCY
avoid what with gonorrhea tx
sexual intercourse for 7 days after tx + resolution of symptoms
screening for gonorrhea:
same as chlamydia
ALL sexually active women ages less than 25
older women with risk factors
initiated by sexually transmitted agent which ascends into upper genital tract
PID
what two organisms cause PID
n. gonorrhea
c. trachomatis
others: BV assoc pathogens and emerging: mycoplasms genitalium
PID represents a ____ of infection
spectrum - combo of endometritis, salpingitis, tubo-ovarian abscess, pelvic peritonitis
1 in 8 women with hx of PID have trouble getting preg
PID pts at risk?
what population at highest risk
highest risk: women with multiple partners
younger age (less than 25)
hx of prior PID or STI
IUD - 3 weeks after insertion
disruption of normal vaginal flora - certain types of BV
PID symptoms
lower abdominal pain - onset during or shortly after menses
abnormal vaginal discharge
abnormal uterine bleeding
dyspareunia
fever
physical exam of PID
Abdominal or uterine tenderness
cervical motion tenderness - chandelier sign
purulent endocervical discahrge and/or vaginal discharge
chandelier sign
PID
PID: what must you get
pregnancy test
PID: what dx
microscopy vaginal discharge (wet mount) - check for WBCs (leukorrhea, greater than 10 WBC hpf)
leukorrhea
PID
when unsure, what additional test can be done for PID dx
pelvic ultrasound
dx of PID
difficult – can be clinical with sexually active young women + pelvic or lower abdominal pain + evidence of cervical motion, uterine, or adnexal tenderness on exam
additional findings that can aid in dx of PID
over 101F temp
abnormal cervical or vaginal mucopurlent discharge or cervical friability
presence of abundant numbers of WVS on saline microscopy
elevated EST or CRP
documented cervical infection with c. trach or n. gonnorhea
PID tx: outpatient
ceftriaxone 250 mg IM single dose AND doxy 100 mg BID for 14 days
with or without metro (500mg PO BID for 14 days)
close follow up is essential - 48-72 hours
When to hospitalize with PID
preg
lack of response to oral meds (within 72 hours)
concern for nonadherence
inability to take oral meds due to N/V
severe clinical illness - high fever, N/V
complicated PID with pelvic abscess
surgical emergencies are not excluded (may be appendicitis)
PID complications
infertility
chronic pelvic pain
risk of ectopic preg
perihepatitis (fitx-hugh curtis syndrome): RUQ pain and adhesions!! BOARDS!
abstain from sexual intercourse with PID tx until
therapy is completed
symptoms have resolved
partners tx
repeat testing for those with positive chlyamydial or gonococcal PID in 3 months
if PID is positive, do you treat for both chylamida and gonorrhea
YEP
most common STI in the US
HPV
how is HPV transmitted
through contact with infected skin or mucosa (JUST NEED SKIN TO SKIN CONTACT - DO NOT NEED TO HAVE WARTS)
40 types of HPV can be transmitted how
through sexual contact and infect the anogenital region
aka anogential warts
condyloma acuminata
risk factors for anogenital warts
sexual activity (main one)
smoking
immunosuppression (assoc with more treatment-resistant disease, higher rates of recurrence, malignant transformation of anogenital warts)
6 or 11 - oncogenic or not
not - low oncogenic activity
what types are most commonly detected with HPV
6 and 11
are co-infections with HPV 6 and 11 common with malignant HPV types
yep
what are the two types of HPV with high oncogenic activity
16/18
clinical presentation with anogenital warts
usually asymptomatic but may be pruritic
soft, flesh colored smooth or plaque like (cauliflower like)
where are anogenital warts found
vulva
penis
groin
vagina
perianal skin
suprapubic skin
dx for anogenital warts
clinical ususally
can do anoscopy
tx for anogenital warts
cyto-destructive (podofilox, trichloracetic acid, bichloracetic acid)
immune mediated (imiquimod, sinecatechins)
surgical (cryotherapy, laser, electrcautery, excision)
prevention of HPV
vaccine!!!!!!!
condoms used consistently and correctly
limiting number of sex partners
genital warts can be tx but no cure
can the body clear itself of HPV
yes - sometimes
can you tx HPV with vaccine
nope - prevention only
genital herpes subtypes
genital - subtype 2
oral - subtype 1
how is HSV transmitted
mucosal surfaces, genital, oral secretions - contact with HSV
many have minimal or no symptoms - 70% of transmission occurs during times of asymptomatic HSV shedding
avg incubation: 4 days
primary infection: HSV
infection without preexisting antibodies to either HSV-1 or 2
longer duration, increased viral shedding, and systemic symptoms
may last 2-4 weeks if left untreated
non-primary first episode genital herpes
acquisition of genital HSV 2 in pt with preexisting antibodies to HSV 1 (or vice versa)
symptoms usually milder than primary infection
recurrent infection genital herpes
reactivation of genital HSV
disease usually less severe and shorter in duration
clinical presentation of genital herpes - primary infection
painful genital ulcers, dysuria, fever, tender local inguinal lymphadenopathy, headache
some may be mild or even asymptomatic
recurrent infection genital herpes clinical presentation
prodromal symptoms BEFORE eruption (tingling)
less severe than primary infection
viral culture for genital herpes dx
more or less sensitive than PCR
dx yield is highest in early stages of disease
less sensitive than PCR
PCR: more sensitive or less sensitive than culture
more sensitive
Serologic tests - how do they work and what are their limitations
detect antibodies
false-negatives might be frequent in early stages of infection
what does genital herpes testing mean?
HSV-2 antibodies
HSV-1 antobodies
do you screen for both?
2 - anogenital infection
1 - can be either anogenital or orolabial infection
do not need to screen both in general population - not indicated
tx of genital herpes: first clinical episode
valtrex or zoviraz or famiciclovir for 7-10 days; START WITHIN 72 HOURS
tx of genital herpes:
episodic tx for recurrent outbreaks
same meds; 1-5 day regimen
suppression of genital herpes:
once a day or BID dosing
reduces frequency of recurrences and risk of transmission to partner
periodically reassess as needed
why should you counsel your genital herpes pt?
prevention of sexual transmission
disclose HSV status to sexual partners
use condoms
identify concerns or miconceptions
describe vertical transmission with HSV
transmitting to infants before during and after delivery
