STIs Flashcards
Sexual history
(5 P’s)
Partners: men/women, #, last time u had sex
Practices: anatomic sites of exposure
Prevention of pregnancy: desired? contraception?
Protection from STI’s: frequency of condom use
Past hx of STIs: patient and their partners
Special STI populations
Youth (15-24) Men who have sex w/ men (MSM) Pregnant women HIV-infected patients Individuals entering correctional facilities
Symptoms of vaginitis
d/c
odor
pruritus and/or discomfort
Most common causes of vaginitis
Candida vulvovaginitis
BV
Trichomoniasis
Cause of yeast infection
C. albicans (most common)
Presentation of vulvovaginal candidiasis
pruritus! external dysuria vulvar soreness dyspareunia abnormal vaginal d/c
PE for yeast infection
white, thick, curd-like d/c (adherent to vaginal walls)
may seem vulvar erythema, edema, fissures, excoriations
Risk factors for yeast infections
DM
Abx use
increased estrogen levels
Immunosuppressed
Dx of vulvovaginal candidiasis
Wet mount (10% KOH) - budding yeast, hyphae, pseudohyphae Normal pH (<4.5) Others: vaginal culture
uncomplicated candidiasis
mild-mod sx
sporadic/infrequent
caused by candida albicans
healthy, non-prego
Complicated candidiasis
severe
recurrent
nonalbicans species
prego, poorly controlled DM, immunosuppression
Tx for uncomplicated candidiasis
1-3 days of topical Clotrimazole (OTC)
oral fluconazole 150 mg po x 1
tx for complicated candidiasis
topical azole 7-14d
oral fluconazole 150 mg po q 72 hours x 2-3 doses (if nonalbicans, avoid fluconazole)
maintenance for recurrent
Tx of candida in pregos
topical clotrimazole x 7 days
Most common cause of d/c in women of chidlbearing age
BV
Etiology of BV
polymicrobial: gardnerella vaginalis, mobiluncus, prevotella
Presentation of BV
asymptomatic
Symptomatic: d/c & odor (thin, white gray d/c with fishy smell)
Risk factors for BV
sex (new/multiple partners) presence of other STIs African-American, Mexican-American Douching Smoking Lack of condom use
Dx of BV
Amsel’s diagnostic criteria
Gram stain
DNA probe
Amsel’s diagnostic criteria
- Thin, white homogenous discharge
- Clue cells on saline
- pH >4.5
- whiff test
Tx of BV
Only treat symptomatic
- Metro 500 mg PO BID x 7 days
- Metro gel 0.75% vaginally QD x 5 days
- Clinda cream 2% intravaginally QHS x 7 d
Complications of BV
increased risk of acquiring/transmitting HIV, and other STIs
more common in those w/ PID
Most common nonviral STI
trichomoniasis
Often coexist
BV and trich
Chlamydia + gonorrhea
Presentation of trich
vaginal d/c +/- vulvar irritation
Malodorous, frothy, yellow-green d/c
Burning/pruritus/dysuria/dyspareunia
Postcoital bleeding
PE for trich
punctate hemorrhages on vagina/cervix (“strawberry cervix”
pH >4.5
Strawberry cervix
trich
Dx of trich
Wet mount (motile organisms) NAAT - gold standard (vaginal, endocervical, urine)
Culture (rarely used)
Rapid antigen and DNA hybridization probes
Trich complications
urethritis/cystitis
PID (those w/ HIV)
Cervical neoplasia
infertility
increased risk of acquiring/transmitting HIV
Prego: premature rupture, preterm delivery, LBW
Tx for trich
symptomatic & asymptomatic
- treat sex partners (EPT)
- Metro (or Tinidazole) 2g (single dose)
- metro = pregnancy
education for trich tx
wait 7 days after treatment for sex
Test for other STIs
Repeat testing in 3 months (reinfection high)
Repeat testing
Trich
Chlamydia
Gonorrhea
Screening for trich
HIV infected
High prevalence settings (STI clinics, correctional facilities)
Asymptomatic @ high risk of infection
Most frequently reported STI
chlamydia
Age group for chlamydia
<24 hours
sx of chlamydia
cervicitis (d/c, intermenstrual/postcoital bleeding)
Sx of urethritis (frequency & dysuria)
PE for chlamydia
mucopurulent endocervical d/c
friability, erythema, edema
Dx of chlamydia
NAAT (test of choice)
- Vaginal swab (preferred), endocervical swab, urine
Complications of chlamydia
PID ectopic pregnancy infertility chronic pelvic pain Prego: premature rupture, preterm deliver, conjunctivitis in newborn
Tx for chlamydia
pt + sex partner
Azithro 1 gm PO single dose
OR
Doxy 100 mg PO BID x 7 days
Prego: only azithro
Screening for chlamydia
annually <25 YO Older w/ risk factors: - new/multiple sex partners - sex partner recently treated for STI no or inconsistent condom use outside of monogamous relationship - hx of prior STI - exchange for drugs/money
Presentation of gonorrhea
Cervicitis sx
urethritis
PE for gonorrhea
mucopurpulent cervcal d/c
friability, erythema, edema
Dx of Gonorrhea
NAAT (vaginal swab preferred)
Culture (abx resistance)
Complications of gonorrhea
PID, ectopic preg, infertility, chronic pelvic pain
Disseminated gonococcal infection (DGI)
Preg: LBW, preterm, infection (chorioamnionitis), transmit to neonate (opthalmia neonatorum)
Tx for gonorrhea
Ceftriaxone 250 mg IM + azithro 1 gm PO single dose
Screening for gonorrhea
same as chlamydia
PID spectrum
endometritis
salpingitis
tubo-ovarian abscess
pelvic peritonitis
Risk of PID
sexually active (multiple partners) Younger <25 Partner w/ STI Hx of prior PID or STI IUD (1st 3 weeks after insertion) Disruption of normal vaginal flora (BV)
Sx of PID
lower abdominal pain (during or shortly after menses) Abnormal vaginal d/c abnormal uterine bleeding dyspareunia fever
PE for PID
ab/uterine/adnexal tenderness
Cervical motion tenderness (chandelier sign)
Purulent endocervcal d/c and/or vaginal d/c
Eval for PID
Pregnancy test Microscopy of d/c (wet mount) - WBC (leukorrhea >10 WBC) NAAT for chlamydia/gonorrhea NAAT for mycoplasma genitalium HIV screen, syphilis CBC, ESR, CRP UA Pelvic US, CT/MRI
Dx PID
presumptive: sexually active, pelvic/lower ab pain, cervical motion, uterine OR adnexal tenderness on exam
Findings supporting clinical dx of PID
temp >10
abnormal cervical/vaginal d/c or friability
WBC on wet mount
elevated ESR/CRP
Documented infection of chlamydia/gonorrhea
Tx of PID
ceftriaxone 250 mg IMI + doxy 100 mg BID x 14 d
Outpatient: w/wo metronidazole (500mg PO BID x 14 days)
F/u 48-72 hours
Hospitalize for PID
pregnancy
lack of response to oral (w/i 72 hours)
concern for nonadherence
inability to take PO due to N/V
severe illness (high fever, n/v/, ab pain)
Complicated w/ abscess
Surgical emergencies (appendicitis ) cannot be excluded
Complications of PID
infertility
chronic pelvic pain
risk of ectopic
perihepatitis (Fitz-Hugh-Curtis syndrome)
Perihepatitis
RUQ pain & adhesions
Condyloma Acuminata
HPV (anogenital warts)
Most common STI in US
HPV
Most common types of HPV
6 and/or 11
Risk factors of HPV
sex
smoking
immunosuppression (more severe/malignant)
Types of HPV associated w/ malignancy
6 or 11
Presentation of HPV
asymptomatic, may be pruritic
flesh colored, plaque-like
single or multiple, flat cauliflower like
Dx for HPV
visualize warts on PE (anoscopy, speculum exam)
bx if uncertain
Tx for HPV
Cyto-destructive (pdofilox, trichloracetic acid or bicloracetic acid)
Immune-mediated (imiquimoid, sinecatechins)
Surgical (cryo, laser, electrocautery, excision)
Vaccine
HPV
Genital herpes caused by
HSV-2
Primary HSV infection
no preexisting antibodies
longer duration, increased viral shedding & systemic sx
sx last 2-4 weeks if left untreated
Non-primary first episode
acquisition of HSV-2 in patient w/ preexisting antibodies to HSV-1
Milder sx
Recurrent HSV
reactivation of HSV
less severe/shorter
Sx of primary infection
painful genital ulcers!
dysuria, fever, tender local inguinal LAD, h/a
some mild/asymptomatic
Sx of recurrent infection
prodrome before eruption (tingling)
less severe sx
Dx of herpes
Viral culture (good early) PCR (more sensitive than culture)
Serologic tests - HSV1/2 antibodies
Limitations to serologic tests for herpes
false negative frequent in early stages of infection
Tx for herpes
1st episode: Valacyclovir, famciclovir, or acyclovir 7-10 d (start w/i 72 hours)
Recurrent outbreak: 1-5 day regiment
Suppression: QD or BID dosing
