STIs: General, Vaginosis, VCC, BV Flashcards
Most common age to get STDs
15-24 year olds = most common age
Number of partners w/ prevalence of STI correlation (3)
- 1 partner = 20.4 prevalence
- 2 partners = 43.1 prevalence
- over or equal to 3 partners = 54.7 prevalence
Health consequences of untreated STIs (4)
- Women’s reproductive health (ex: scarring)
- Scarring leads to adherence and can cause a more difficult time getting pregnant - Untreated Chlamydia (CT) or gonorrhea (GC) may lead to pelvic inflammatory disease (PID)
- PID can cause infertility - When a women develops and STI, she can pass it on to an infant
- Infant mortality/morbidity:
o Neonatal HIV
o Herpes simplex virus (HSV)
o Congenital syphilis – HIV transmission
Population at greatest risk (3)
- Youth: Nearly 50% of STDs estimated to occur in 15-24 year olds
- Racial/ethnic minorities:
o STDs among highest of all racial/ethnic health disparities
• Highest among African-Americans:
• CT: 5.8 times the rates among whites
• GC: 12.4 times the rate among whites
• PandS: 5.6 times the rates among whites - Men having sex with men; account for 75% of syphillis cases
- high rates of HIV co-infection
Adolescent STIs: Greatest risks (7)
- Progression through a stage that emphasizes sexual risk taking
- Sexual identity formation
- Vulnerable cervix
- Less likely to use condoms
- Less likely to have health insurance
- More concerned about privacy/confidentiality
- Less likely to understand importance of health care screening.
CDC 5 Ps
- Partners
- Practices
- Prevention of pregnancy
- Protection from STDs
- Past history of STDs
Newborn physiology (5)
- Thick white vaginal discharge during the first few weeks of life
- Due to estrogen - As estrogen decreases, mucosa is atrophic until menarche
- Mucous with occasional squamous cells can be seen
- Childhood mucosa is red and dry
- When a 5 year old has discharge and pale mucosa – are they having estrogen secreted? This would not be normal
Physiological Discharge (5)
- An increase in vaginal secretions precede menarche by 6‐12 months
a. Normal pre-menarche - Estrogen dominance tends to produce water and profuse discharge
- Progesterone production induces thicker, mucoid discharge
- Experienced by all pubertal adolescents
a. Physiologic leukorrhea→ vaginal discharge related to going into puberty - Will notice increase in discharge prior to menses
Prepubertal physiologic discharge (2
- Pre-menarchal female at Tanner stage 3‐4
2. Discharge should be clear to white without odor or pruritus.
Pathophysiology of the Adolescent-Adolescents and STI (5)
- Cervix important physical barrier to ascending infection
- Fetal cervix: At the squamous epithelial junction there are columnar cells.
- Adolescent‐‐columnar epithelial cells are on the ectocervix
- C. Trachomatis and gonorrhea adhere to columnar epithelial cells
- Transition cells have even higher affinity for gonococci (gonorrhea)
* Gonorrhea is very problematic
* Symptomatic gonorrhea: purulent green discharge
Protective components for adolescents and STDs
- Secretions of genital tract (which can be disturbed by douching):
- Lysozymes
- Lactoferrin slows down bacterial growth through competition for iron
- Immunoglobulins (IgA): A layer on all mucosal surfaces
- Primary antibody
- Phagocytic cells, PMN and monocytes
- These are not fully developed yet in adolescents
Pathophysiology of the Vagina: Defense mechanisms (6)
- Acid pH 3.8‐4.5
* Also damaged by douching
* Acidic environment doesn’t promote growth of bacterial flora - Thick epithelial cell layer
- Presence of normal bacteria flora including lactobacillus to maintain acid pH
- Mucous secretions from vaginal wall
- Estrogen effect
- Vaginal Discharge
Pathophysiology of the Vagina: Cervical Plug (3)
- May provide an environment where the phagocyte can act
- During the 7 days of menstrual cycle, this plug is absent and therefore PID is more likely to develop if you’ve had sex within 7 days of menses onset
- When mucus plug is absent, PID more likely to develop symptoms
* Occurs within 7 days of onset of menses.
Pathophysiology of the Adolescent – Adolescents and STI: Proinfectious Component (6)
- Retrograde menstrual flow occurs in normal women with patent fallopian tubes
- May provide a good media for bacteria
- Uterine factors facilitate bacterial ascent muscular activity of myometrium
- Coital frequency increases PID rates since myometrial contracts more and sperm may aid transport upward
- If someone has a lot of sex, the act of having sex causes myometrial contractions, and aids the sperm to go upward and therefore causing PID
- Female adolescent is more likely to get STD from male than vice versa
Vagina (5)
- Vaginal discharge is clear to white, odorless, and of high viscosity
- Normal bacterial flora is dominated by lactobacilli, but a variety of other organisms, including some potential pathogens, are also present at lower levels.
a. Ex: candiasis can hang around, but it’s at lower levels in the vagina - Lactobacilli convert glycogen to lactic acid.
- Lactic acid helps to maintain a normal acidic vaginal pH of 3.8 to 4.2.
- Some lactobacilli produce H2O2 (hydrogen peroxide), which kills bacteria and viruses.
Vagina exam (4)
Vaginal discharge should be noted during examination:
i. Color
ii. Viscosity
iii. Adherence to vaginal walls
iv. Presence of an odor
Types of STIs (7)
- Vaginitis
a. Itch and excessive discharge
b. Big overriding umbrella; vaginosis is underneath it - Vaginosis
a. Has an odor associated - Epididymitis
- Cervicitis
a. When the infection is localized to the cervix and has not ascended; when it ascends up into pelvic cavity is when it becomes PID - Pelvic Inflammatory Disease
a. More acute presentation - Genital Warts
- Genital Ulcers
Differential Dx of Vaginal Discharge (5)
- Infection
- Cervicitis
- Vaginitis
a. Ex: Candiasis, Trich, bacterial vaginosis
b. Trichomosis causes frothy discharge*** - Environmental
a. Ex: Tight jeans with polyster underwear - Chemical
a. Ex: Taking a bubble bath
Vaginitis Symptoms (4)
- Vaginal discharge
- Vulvar itching
- Irritation
- Vaginal odor
• Hallmark of vaginosis
• Candiasis does not smell
Causes of Vaginitis (3)
- Bacterial vaginosis (40%-45%)
- Vulvovaginal candidiasis (20%-25%)
- Trichomoniasis (15%-20%)
Other Causes of Vaginal Irritation (8)
- Normal physiologic variation
- Allergic reactions, e.g., spermicides, deodorants
- Herpes Simplex Virus (HSV)
- Mucopurulent cervicitis → may be related to Chlamydia trachomatis or Neisseria gonorrhoeae infection
- Atrophic vaginitis → found in lactating and post-menopausal women and related to a lack of estrogen
a. There is a group of genetically programmed children who go into menopause early, around 20, and they can have atrophic vaginitis - Vulvar vestibulitis, lichen simplex chronicus, and lichen sclerosis (especially pruritis)
- Foreign bodies, e.g., retained tampons
- Desquamative inflammatory vaginitis
Bacterial Vaginosis (Symptoms, Discharge, Exam Findings, pH, KOH Whiff test, NaCl Wet mount)
Symptoms: odor, discharge, itch
Discharge: adherent homogenous, thin, milky white malodorous, foul, fishy
Exam Findings: n/a
pH: >4.5
KOH Whiff test: +
NaCl Wet Mount: >20% clue cells
Candida Vaginitis (Symptoms, Discharge, Exam Findings, pH, KOH Whiff test, NaCl Wet mount)
Symptoms: itch, discomfort, dysuria, thick discharge
Discharge: white, thick, cheesy discharge, clumpy cottage cheese
Exam Findings: inflammation erythematous
pH: usually less than 4.5
KOH Whiff test: n/a
NaCl Wet Mount: Few WBX
Trichomonas (Symptoms, Discharge, Exam Findings, pH, KOH Whiff test, NaCl Wet mount)
Symptoms: itch, discharge, 50% is asymptomatic
Discharge: frothy, grey, yellow, green malodorous
Exam Findings: cervical petechial lesion, strawberry cervix
pH: >4.5
KOH Whiff test: +
NaCl Wet Mount: mobile flagellated protozoa
Normal Vagina discharge, pH and NaCl wet mount
Discharge: clear to white
pH: 3.8-4.5
NaCl wet mount: lactobacilli
culture tests for vaginitis (3)
- T. vaginalis and Candida spp.
- Culture for T. vaginalis is more sensitive than wet mount but not widely available.
- Culture for bacterial vaginosis is not recommended.
Vaginitis DNA probe-Affirm TM V.P. III (2)
- T. vaginalis, C. albicans, and Gardnerella vaginalis.
2. The sensitivity, specificity, and clinical utility of these tests are higher than wet mount but lower than culture.
Vaginitis Rapid antigen test (OSOM TV, Genzyme Diagnostics, Inc.)
T. vaginalis is an available point of care test. Sensitivity higher than wet mount but similar to culture.
Other bacterial vaginosis test (2)
- PIP activity (Proline aminopeptidase)
2. BV-blue® (Genzyme Diagnostics, Inc.) – Detects sialidase produced by G. vaginalis and other species.
Vulvovaginal Candidiasis (VVC) (3)
- Occurs commonly after use of antibiotics because it throws off the normal flora
- Affects most females at least once during their lives.
- 50% of these women will experience a recurrence during their lifetime. - Diagnosis and therapy of VVC results in an estimated cost of one billion dollars annually in the United States.
- Second most common cause of vaginal infections after bacterial vaginosis.
Causes and Risk Factors for Vulvovaginal Candidiasis (2 causes, 5 risk factors)
- Candida albicans (85%-90%)
- C. glabrata and C. parapsilosis (5%-10% of cases)
Frequent infections may be linked to:
- Diabetes
- Corticosteroids
- Repeated courses of antibiotics
- Pregnancy
- HIV disease
- Changes in the host vaginal environment are usually necessary before the organism induces pathologic effects.
VCC Diagnosis (3)
- Cultures are not useful!
* Positive cultures may detect colonization (which is normal) rather than clinically significant infections - Cultures may be useful to detect non-albicans species or resistant organisms in women with recurrent disease
- Diagnosis should be done clinically
VCC Intravaginal Agent Treatments (14 lol)
- Butoconazole 2% cream, 5 g intravaginally for 3 days
OR - Butoconazole 2% sustained release cream, 5 g single intravaginally application
OR - Clotrimazole 1% cream 5 g intravaginally for 7-14 days
OR - Clotrimazole 100 mg vaginal tablet for 7 days
OR - Clotrimazole 100 mg vaginal tablet, 2 tablets for 3 days
OR - Miconazole 2% cream 5 g intravaginally for 7 days
OR - Miconazole 100 mg vaginal suppository, 1 suppository for 7 days
OR - Miconazole 200 mg vaginal suppository, 1 suppository for 3 days
OR - Miconazole 1,200 mg vaginal suppository, 1 suppository for 1 days
OR - Nystatin 100,000-unit vaginal tablet, 1 tablet for 14 days
OR - Tioconazole 6.5% ointment 5 g intravaginally in a single application
OR - Terconazole 0.4% cream 5 g intravaginally for 7 days
OR - Terconazole 0.8% cream 5 g intravaginally for 3 days
OR - Terconazole 80 mg vaginal suppository, 1 suppository for 3 days
VCC Oral agent
Fluconazole 150 mg oral tablet, 1 tablet in a single dose
*Use if patients will not put something in their vaginal area or recurrent/severe
Recurrent VCC Definition
Usually defined as four or more episodes each year
Recurrent VCC Treatment (2)
- 7-14 days of topical therapy
OR
- 100 mg,150 mg, 200 mg oral dose of fluconozole every third day for a total of 3 doses (day 1, 4, 7)
Severe VCC Treatment (2)
- 7-14 days of topical therapy
OR - 150 mg oral dose of fluconozole repeated in 72 hours
Non-albicans VVC treatment (3)
- Optimal treatment is unknown
- 7-14 days non-fluconozole therapy
or - 600 mg boric acid in gelatin capsule vaginally once a day for 14 days for recurrences
*Can be helpful; changing the pH
VCC Diflucan and Liver Toxicity (3)
- Administer with caution to patients with liver dysfunction.
- Associated with rare cases of serious hepatic toxicity, including fatalities primarily in patients with serious underlying medical conditions.
- In cases of DIFLUCAN-associated hepatotoxicity, no obvious relationship to total daily dose, duration of therapy, sex, or age of the patient has been observed.
Risk reduction for VCC (3)
- Avoid douching
- Avoid unnecessary antibiotic use
- Complete the course of treatment
Bacterial Vaginosis (5)
- Associated with the decrease or absence of protective lactobacilli, which are normally present in the vagina.
- Lactobacilli produce lactic acid from glycogen, maintaining the vagina’s acidic pH.
- Acid environment inhibits the growth of other bacterial species found in the vagina in low levels.
- When lactobacilli are lacking, overgrowth of bacteria, such as Haemophilus spp., Gardnerella vaginalis, Bacteroides spp., Mycoplasma hominis, Mobiluncus spp., peptostreptococci, ureaplasma, and other anaerobes can occur.
- One species of lactobacillus also produces hydrogen peroxide (H2O2), which is in vitro, toxic to viruses such as HIV as well as to bacteria.
- Present in approximately 42%-74% of females, and is under investigation as a probiotic.
- The prevalence of BV in these women is low (4%).
AMSEL CRITERIA FOR BV (4)
The presence of three of the following four criteria provides sufficient evidence for a clinical diagnosis of BV.
- Vaginal pH >4.5, which is most sensitive but least specific sign.
- Presence of clue cells (bacterial clumping upon the borders of epithelial cells) on wet mount examination
• Clue cells should constitute at least 20% of all epithelial cells (an occasional clue cell does not fulfill this criteria) - Positive amine, “whiff” or “fishy odor” test (liberation of biologic amines with or without the addition of 10% KOH)
- Homogeneous, non-viscous, milky-white discharge adherent to the vaginal walls
BV Testing in women with vaginal discharge (2)
- Consider screening in high prevalence settings (STD clinics, corrections) or asymptomatic persons at high risk of infection
- Lack data on screening/treatment reduces adverse health events or reduces community burden of infection
BV Diagnostic testing (nucleic acid amplification test ) (3)
- Gram Stain
- Affirm VP III (Becton Dickinson, Sparks, MD), a DNA hybridization
• Probe test for high concentrations of G. vaginalis - OSOM BV Blue test (Sekisui Diagnostics, Framingham, MA
• Vaginal fluid sialidase activity, have acceptable performance characteristics compared with Gram stain (CDC 2015)
Who gets treated for BV?
- Women with symptoms.
- Benefits of therapy in non-pregnant women are to relieve vaginal symptoms and signs of infection.
- Other potential benefits to treatment include reduction in the risk for acquiring C. trachomatis, N. gonorrhoeae, T. vaginalis, HIV, and herpes simplex type 2
Recommended BV Treatments (3)
- Metronidazole (Flagyl) 500 mg orally twice a day for 7 days
OR - Metronidazole (Flagyl) 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
Alternative BV Regimens (4)
- Tinidazole 2 g orally once daily for 2 days OR
- Tinidazole 1 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 (CDC, 2015)
