Vaginitides, STIs, PID Flashcards
A 21 yo G0 LMP 1 week ago complains of a foul smelling, watery, slightly pruritic vaginal discharge for 3 weeks. She denies douching. She also states she does not use condoms with her male partner, with whom she has been having sex for about a month.
You diagnose your patient with bacterial vaginosis, and reassure her that this is not classified as a sexually transmitted infection. You prescribe metronidazole 500 mg PO BID x 1 week. She visits you two months later for a routine visit and tells you that the infection got much better very quickly.
normal vaginal discharge in pts of reproductive age
-White, yellow or clear
-May change through menstrual cycle
-Nonpruritic
-Non-malodorous
-Not associated with any kind of pain
vaginal ecology
-reproductive age- pH of 3.5-4.5
-Lactobacillus spp. are produced in an estrogenized vagina
-Lactobacilli maintain this acidic pH by producing H2O2
MC vaginitides
-abnormal vaginal discharge:
-20-50% have bacterial vaginosis
-15-40% have vulvovaginal candidiasis
-5-35% have trichomoniasis
-Of these, only trichomoniasis is considered to be a sexually transmitted disease (STI)
-These can also coexist among each other, and/or with STIs
prevalence and pathophysiology of bacterial vaginosis (BV)
-Prevalence: about 29.2% worldwide
-Due to an unknown event that changes the microbial flora of the vagina,
-Lactobacilli decline
-Facultative and strict anaerobes predominate
-Many associated organisms, including but not limited to:
-Atopobium vaginae
-Gardnerella vaginalis
-Bacteroides spp
-Mobiluncus spp
-Prevotella spp
-Porphyromonas spp
possible pathophysiology of BV: other etiologies
-An intravaginal event or exposure triggers the change in flora
-Vaginal exposure to:
-Semen
-Tampons
-Douching
-Could BV be an STI?
-Condoms seem to prevent BV
-Circumcision in male partners reduces incidence of BV in female partners by 40-60%
-Gardnerella vaginalis was thought to be a true pathogen in the past
-It is capable of forming a biofilm that can reduce the number of lactobacilli and that can increase BVAB
hx of the pt with BV
-Length of symptoms
-History of similar episodes
-Sexual history- new partner?
-Use of sanitary products (douching, soaps, feminine hygiene)
-Relationship of symptoms to menses
PE in BV and dx
-Thin, homogenous, gray to white discharge
-Fishy odor
-Pruritus
-Dysuria
-pt feels systemically well
-Dx:
-Amsel’s criteria:
-Thin, gray, homogenous vaginal D/C
-Presence of clue cells (>4 per HPF) seen on wet mount -> Clue cells: epithelial cells whose borders are obscured by adherent bacteria
-+KOH whiff test
-Vaginal pH>4.5!
-Gold standard: Gram stain with Nugent scoring
-DNA hybridization and detection of vaginal fluid sialidase are most common tests performed today
-Do not treat based only on Pap results suggesting BV
-tests for:
-Lactobacillus crispatus
-Lactobacillus jensenii
-Gardnerella vaginalis
-Atopobium vaginae
-BVAB-2
-Megasphera 1
BV tx
-Metronidazole
-Oral: !metronidazole 500 mg orally twice daily x 7 days; preferred initial therapy!
-Topical: metronidazole 0.75% vaginal gel, 1 applicator intravaginally once daily x 5 days
-Clindamycin
-Vaginal: clindamycin cream 2%, 1 applicator intravaginally at bedtime x 7 days
-Alternatives: (dont need to know)
-Secnidazole - 2 gm orally in a single dose
-Tinidazole- 2 gm orally once daily x 2 days, OR 1 gm orally once daily x 5 days
-Clindamycin- 300 mg orally twice daily x 7 days, OR Clindamycin ovules, 100 mg intravaginally once at bedtime x 3 days
BV sequelae
-Complications of pregnancy
-Prelabor rupture of membranes
-Premature prelabor rupture of membranes
-Complications of gynecologic surgery in which the vagina is entered
-Cellulitis or abscess formation
-HIV transmission to male partners
-Increased risk of infection with genital herpes, gonorrhea and chlamydia
management of recurrent BV
-30% of pts treated for BV will have a recurrence within 1 month
-58% will have recurrence within 1 year
-Research indicates that G. vaginalis and other anaerobes form a biofilm that persists even after treatment
-Risk factors for recurrent BV:
-Douching
-Inability to restore lactobacilli to vaginal flora
-Regimen 1: metronidazole vaginal gel 0.75% 1 applicator intravaginally once daily x 10 days, then 2x/week x 6mo
-Regimen 2: Boric acid vaginal suppositories 600 mg intravaginally once daily at HS x 3 weeks AND simultaneously prescribe a standard regimen
-Regimen 3: metronidazole 2 gm orally and fluconazole 150 mg orally both administered monthly AFTER completion of a standard regimen
-In AFAB pts who have sex with AFAB people: Tx partner if sx
-In AFAB patients who have sex with AMAB people:
-Encourage condom use
-Consider circumcision
-No indication at present for treatment of AMAB people
-Evidence is mixed regarding the efficacy of probiotics
-Vaginal microbiome transplantation trials have demonstrated remission of intractable BV in a small group of patients -> More investigation is needed
prevalence and patho of vulvovaginal candidiasis (VVC)
-70% of pts will ahve VVC at least once
-caused by overgrowth of Candida spp. often due to:
-Recent antibiotic use
-Pregnancy
-Hormonal contraceptive use
-Uncontrolled diabetes mellitus
-Sexual activity
-HIV infection
-Steroid use
Candida species responsible for VVC
-Candida albicans (>70%)
-Candida glabrata
-Candida guilliermondii
-Candida krusei
-Candida parapsilosis
-Candida tropicalis
hx of pt with VVC
-intense pruritus of vulva and vagina
-white curdlike discharge
-dysuria
-dyspareunia
PE and Dx: vulvovaginal candidiasis
-White curdlike discharge
-Hyperemic vulvovaginal tissues
-Excoriations of vulva and vagina
-pruritus, dysuria, dyspareunia
-pH < 4.5
-Dx:
-!Should not be based on hx and PE alone
-Include one of the following:
-Microscopy with visualization of pseudohyphae, hyphae, or spores
-Laboratory data- Culture, DNA probe technology, or PCR testing
-Do not treat based alone on Pap smear that identified fungal organisms
-Do not treat presumptively without clinical evaluations
-Pseudohyphae of C. albicans seen on wet mount
-PCR: 97% sensitive, 93% specific for: Candida albicans, Candida tropicalis, Candida glabrata, Candida parapsilosis, Candida krusei
uncomplicated vs complicated VVC
-UNCOMPLICATED VVC:
-infrequent episodes
-mild-moderate sx or findings
-infection with candida albicans
-no hx of compromised immune system
-COMPLICATED VVC:
-4 or more episodes annually
-severe symtpoms
-infection with non-C. albicans organism
-hx of compromised immune system
over the counter tx options for uncomplicated VVC
-Clotrimazole:
-1% cream, 5 gm intravaginally once daily x 7-14 days
-2% cream, 5 gm intravaginally once daily x 3 days
-Tioconazole 6.5% ointment, 5 gm intravaginally once
-miconazole creams:
-2% cream, 5 gm intravaginally once daily x 7 days
-4% cream, 5 gm intravaginally once daily x 3 days
-miconazole suppositories:
-100 mg, 1 suppository intravaginally at bedtime x 7 days
-200 mg, 1 suppository intravaginally at bedtime x 3 days
-1200 mg, 1 suppository intravaginally at bedtime x 1 day
-Topical OTC imidazoles are highly effective BUT approx 33% dx correctly with VVC
-Correct dx include BV, contact dermatitis, and trichomoniasis
-Pts may confuse OTC imidazole preparations with:
-Vaginal anti-itch preparations
-Homeopathic preparations
prescription only tx for uncomplicated VVC
-Fluconazole 150 mg, 1 tablet orally x 1 dose
-Butoconazole 2% cream, 5 gm intravaginally once
-Terconazole 0.4% cream, 5 gm intravaginally at bedtime x 7 days
-Terconazole 0.8% cream, 5 gm intravaginally at bedtime x 3 days
-Terconazole 80 mg, 1 suppository intravaginally at bedtime x 3 days
-terconazole -> Candida glabrata
management of complicated VVC: current C. albicans infections
-RF:
-Immunosuppression
-Diabetes mellitus
-Antibiotic use
-Recurrent bacterial vaginosis
-At least 3 episodes in 12 month period
-Must be documented with lab data
-Culture is the preferred means of diagnosis -> Includes identification of Candida spp and sensitivities
-MC species:
-Candida glabrata
-Candida parapsilosis
-Candida tropicalis
-Candida lusitaniae
-Candida krusei
-Obtain culture for identification of species and sensitivities
-Fluconazole 150 mg, 1 tab orally every 72 hours x 3 doses, THEN
-Fluconazole 150 mg, 1 tab orally every week x 6 months -> 50% of pts relapse within 6mo of completion of suppressive therapy
tx of complicated VVC: non-C. albicans VVC
-Boric acid 600 mg suppository, 1 intravaginally at bedtime, for a minimum of 14 days
-Caution pts about avoiding accidental exposure to children or animals
-Flucytosine 5 gm intravaginally at bedtime x 14 days (for C. glabrata)
-Current cost is estimated between $182-$2000 per day
management of complicated VVC: severe sx
-marked by fissures, edema, erosion
-prolonged intravaginal agent like terconazole x 10-14 days, OR
-Oral fluconazole (150mg or 200mg) taken daily every 72 hours x 3 doses
prevalence and patho of trichomoniasis
-Approx 276 million cases worldwide annually
-About 3-5 million annual cases in the United States
-Caused by Trichomonas vaginalis, a flagellated protozoan
-A sexually transmitted infection (STI) -> Fomite transmission is theoretically possible but is generally unlikely
-Adherence of the organism to epithelial cells and parasite-mediated apoptosis results in lysis of the cell and erosion of the epithelium
-In the female lower genital tract, T. vaginalis may be able to persist due to the presence of iron due to menstrual blood
risk factors of trichomoniasis
-MC in young pts of reproductive age
-Risk factors include:
-Oral contraceptive use
-Low socioeconomic status
-Smoking
-Non-monogamous relationships
-One of the only STIs that causes more symptoms in AFAB patients than in AMAB people
-Asymptomatic in 25-50% of all cisgender women
hx of pt with trichomoniasis
-vaginal pruritus
-vaginal pain
-dysuria
-dyspareunia
-frothy!!! vaginal discharge
-worsened infection with menses
-abdominopelvic pain in assoc with PID
PE and dx in trichomoniasis
-green to yellow, frothy discharge
-Strawberry cervix in 2% of patients
-Possible infection of the urethra or of Skene’s glands
-Possible signs of pelvic inflammatory disease:
-Cervical motion tenderness
-Uterine tenderness
-Adnexal tenderness
-Dx:
-Microscopy- Identification of motile!!! trichomonads on wet mount -> Sensitivity: 38-82%
-Nuclear acid amplification testing (NAAT)- Equally sensitive when performed on cervical, vaginal or urine samples -> Sensitivity: 95.3-100%; specificity: 95.2-100%
-Antigen detection testing- POC testing; results available in 10 mins -> Sensitivity: 88.3%; specificity: 98.8%
-Culture- Requires special media that most labs do not possess -> Takes over 5 days for results
sequelae of trichomoniasis
-PID
-infertility
-preterm birth
-HIV infection and transmission
-cervical intraepithelial neoplasia (CIN)
management of trichomoniasis
-In US, only 2 5-nitroimidazole agents are approved for tx
-Recommended regimen:
-Metronidazole 500 mg orally twice daily x 7 days
-Alternative regimen:
-Tinidazole 2 gm orally x 1 dose
-Test for other STIs! -> HIV, syphilis, gonorrhea, chlamydia
-In NY, trichomoniasis is not a reportable infection
gonorrhea
-Neisseria gonorrhoeae
-Gram negative diplococcus
-Usually silent in AFAB pts
-May cause cervicitis
-purulent discharge, dyspareunia, BLQ abdominal pain
-reportable infection
-Dx:
-Gold standard: culture
-Nuclear acid amplification
-DNA probe
-Cannot be distinguished clinically from chlamydia
-Tx:
-If mucopurulent cervicitis is noted, treat empirically with:
-Ceftriaxone 500 mg IM x 1 dose (or 1 gm IM if the patient weighs >150 kg) AND doxycycline 100 mg PO BID x 7 days
-If gonorrhea is not suspected but is diagnosed by lab, treat with ceftriaxone 500 mg IM x 1 dose alone
-Test for CT, syphilis, HIV
-Treat partner(s) (or suggest treatment)
-A reportable infection
-Becoming resistant to quinolones, tetracyclines and cephalosporins
chlamydia
-Chlamydia trachomatis
-Gram indeterminate, obligate intracellular pathogen
-May be silent or may cause cervicitis with s/s identical to GC
-Purulent discharge, dyspareunia, BLQ abdominal pain
-Cannot be distinguished clinically from GC
-Dx:
-Nucleic acid amplification test (replacing culture as the gold standard)
-Culture
-Tx:
-Treat empirically if cervicitis is suspected as noted above under gonorrhea
-Ceftriaxone 500 mg IM x 1 dose; doxycycline 100 mg PO BID x 7 days
-However, treatment for chlamydia is doxycycline 100 mg PO BID hours x 7 days
-Test for GC, syphilis, HIV
-Treat partner(s) (or suggest treatment) -> In NYS, may Rx partner(s) via expedited partner therapy
-A reportable infection
syphilis
-Treponema pallidum, a spirochete
-3 phases in natural hx:
-Primary syphilis: painless ulcer with rolled borders at site of inoculation; usually lasts 1-2wks -> CHANCRE (may not know)
-2ndary syphilis: maculopapular rash that does not spare the palms or soles, usually 1-2wks after resolution of chancre (contagious by touch)
-Tertiary syphilis: multiple sx (gummatous lesions, aortic aneurysm, etc.) that may develop decades after initial infection
-picture- gummatous lesion
MC STI
-MC STI- HPV
-MC REPORTED- CHLAMYDIA
neurosyphilis
-May occur at any stage of ds
-Sx:
-AMS (acute or chronic)
-CN dysfunction
-Hearing or visual changes
-Stroke
-Meningitis
-positive test from CSF with these sx is considered dx of neurosyphilis
dx of syphilis
-RPR (rapid plasma reagin)/VDRL (Venereal Disease Research Laboratory)
-Same lab with 2 different names
-Results are binary (positive or negative; also reports titer)
-A fourfold change in titer (represents two dilutions) is considered significant in a patient with h/o syphilis
-may represent reinfection if the patient has engaged in high risk behavior
-RPR/VDRL is performed with with confirmatory treponemal testing
-Fluorescent treponemal antibody (FTA)
-Obtain VDRL of CSF if neurosyphilis is suspected
-False positive results for RPR/VDRL:
-Infection
-Autoimmune disease
-HIV infection
-Pregnancy
-Drug use
-Advancing age
tx of syphilis
-Primary or secondary syphilis:
-PCN G 2.4 million units IM x 1 dose
-Tertiary syphilis with normal CSF examination:
-PCN G 7.2 million units (2.4 million units IM weekly x 3 weeks)
-Neurosyphilis:
-aqueous crystalline PCN G 3-4 million units IV Q4H x 10-14 days
asymptomatic pts with syphilis identified through routine screening: latent syphilis
-early latent or late latent syphilis
-EARLY:
-4x increase in titer in a year
-h/o primary or secondary syphilis S/S in the past year
-h/o sex partner with primary, secondary or early latent syphilis in last year
-Conversion in past year of RPR/treponemal testing
-Treatment- PCN G 2.4 million units IM x 1 dose
-LATE:
-Exists in anyone whose findings or history as noted above is or are > 1 year ago, OR in a patient with unknown prior history of testing
-Treatment: PCN G 2.4 million units IM weekly x 3 doses
herpes simplex virus involving the genitalia
-2 types to consider: 1 & 2
-Type 1 generally affects the mouth (“above the waist”)
-Type 2 generally affects the anogenital area (“below the waist”)
-However, Type 1 lesions can affect the anogenital area
-Incidence: Approx 16% of adults (50 million individuals) have a history of HSV II infection
-There is no cure for HSV
-A lifelong infection
-Outbreaks vary widely in frequency and severity
presentation of primary HSV
-Prodrome of fever, myalgias, etc. for few days
-Hypersensitivity of anogenital area
-Appearance of multiple vesicular lesions accompanied by pain
-Lesions are unroofed and pain increases
-Gradually, lesions heal
-Dx:
-Appearance of classic lesions
-Many patients do not have the “classic” lesion
-Lesions may appear as linear lesions resembling an abrasion
-Viral culture or PCR
-Viral culture may be falsely negative, especially as lesions heal
-!!PCR is best option
HSV screening
-Antibody (serology) testing
-High sensitivity but may be falsely positive
-IgM not considered useful as it may be positive during an outbreak
-Do not screen routinely for HSV
-Best to use PCR rather than antibody testing if one must screen
HSV tx
-Primary episode:
-Must start within 72 hrs of presentation for maximum benefit
-Will attenuate and shorten course of outbreak
-Acyclovir 400 mg PO Q8H x 7-10 days
-Acyclovir 200 mg PO Q4H x 5 doses x 7-10 days
-Valacyclovir 1 gm PO Q12H x 7-10 days
-Famciclovir 250 mg PO Q8H x 7-10 days
-Episodic tx of recurrence of HSV:
-Acyclovir or
-Famciclovir or
-Valacyclovir
-if pt is having 3-4 episodes a year
-Suppressive therapy:
-Generally indicated in patients having >9 episodes/year with HSV-2
-Acyclovir 400 mg PO Q12H
-Valacyclovir 500 mg PO Q12H
-Valacyclovir 1 gm PO daily
-Famciclovir 250 mg PO Q12H
-HSV-1 infections tend to decrease in frequency after the first year
-Suppressive therapy may be used in pts with frequent outbreaks after consideration of risks, benefits and alternatives
HSV counseling
-dx can be devastating
-These patients need a great deal of support
-May believe that sex life is over
-May be profoundly depressed, even suicidal
-Perceive great difficulty in finding a partner
-May believe that they cannot reproduce
-Offer counseling, support groups
-Advise the patient to avoid sex during prodrome, outbreak
-Condoms are helpful but not 100% effective
HPV
-MC STI
-Virtually every human being who has ever been sexually active has been exposed to HPV
-The overwhelming majority clear the infection within several years without any effect on the patient’s health
-Discussion of HPV and its role in cervical carcinoma will be discussed elsewhere in the semester
-Prevention:
-Nonavalent HPV vaccine (Gardasil-9) from age 9 years on
-2 doses (at 0 and 6-12 month intervals) if series is begun before 15th birthday
-3 doses (at 0, 1-2, and 6 month intervals) if series is begun thereafter, or if the patient is immuncompromised
-Catch-up immunization for patients not previously immunized up to age 26
-Discussion with unimmunized patients between 26-45 years about possible vaccination
genital warts
->90% are caused by HPV types 6 & 11
-5% of all cancers come from HPV
-most will not cause any long-lasting problem except for cosmesis
-may be treated in a variety of ways, depending on location and size
-Dx:
-Usually made clinically
-May bx if:
-The dx is uncertain
-The condition does not resolve with treatment
-The condition worsens
-pic- right is neoplasia
tx of condylomata acuminata
-May observe, since most will resolve within 1 year
-May use:
-Podophyllin (Podofilox®) gel or solution
-An antimitotic agent that causes necrosis of warts
-Applied by patient 2x/day x 3 days, then 4 days off for up to 4 cycles for patients with total wart area <10 cm2
-Not to be used during pregnancy
-Sinecatechins 15% ointment
-A green tea extract
-Patient applies 0.5 cm strand of ointment to each lesion 3x/day until resolution for up to 16 weeks
-Avoid genital, sexual and oral contact while ointment is present
-Immune modulators
-!Imiquimod (Aldara) 3.75% or 5% cream -> 3x/wk for up to 16 weeks -> Wash area 6-10 hours after application
-Cryotherapy - Logistically difficult
-Cautery
-Sharp dissection
-Laser fulguration- Protect larynges of staff during fulguration by use of specialized masks and proper evacuation of vapor
counseling for genital warts
-Does not affect fertility in either partner
-Condoms can protect partner to some degree but nothing is 100% effective
-Warts rarely become malignant
PID
-lower genital tract infection that ascends from cervix or vagina to upper genital tract to involve the EM, tubes, ovaries, and sometimes the peritoneal cavity
-most severe form of an STI in women
-MC involves GC/CT
-only 50% of pts have + test for either GC or CT
-A polymicrobial event- Bacteroides, E. coli, Peptococcus, Streptococcus, Peptostreptococcus, Staphylococus, Actinomyces, others
->1 million cases annually in the US
-Risk factors:
-Younger age
-Multiple partners
-Prior h/o PID
-Current or prior h/o STI, or partners with STI
-H/O douching, BV
-Use of oral contraceptives
-Lower socioeconomic status
PID sx and dx
-abdominal pain
-vaginal d/c
-abnormal vaginal bleeding
-N/V
-fever
-dyspareunia
-Dx:
-Treat for PID if:
-abdominal pain
-No other cause of the pain is identified
-At least 1 of the following is present:
-Uterine tenderness
-Cervical motion tenderness
-Adnexal tenderness
-These also support dx:
-WBCs on wet mount
-Cervical exudate or friability
-Fever >38.3o C
-Elevated CRP, ESR
-Evidence of +GC or +CT
-Elaborate dx:
-US with- tubo-ovarian abscess, hydrosalpinx, edematous tubes or tubal hyperemia
-Endometrial bx
-laparoscopy
PID ddx
-The abundance of differential diagnoses makes it very difficult to diagnose PID reliably
-Ectopic or intrauterine pregnancy
-UTI
-Pyelonephritis
-Appendicitis
-Ovarian cyst or torsion
-Endometriosis
-Diverticulitis
-Mesenteric adenitis
-Leiomyomata uteri
-Et cetera!
hydrosalpinx in PID
-TOA in PID
ancillary studies or consults that may be helpful: PID
-bHCG
-CBC with differential
-LFTs
-GC, CT
-T vaginalis
-RPR
-HIV Ab
-Pelvic ultrasound
-Endometrial biopsy
-Wet mount
-Surgical consult
-ID consult
when to admit PID
-Dx is uncertain
-pregnant
-cannot tolerate oral medication
-severely ill, has a high fever, and/or is septic
-tubo-ovarian abscess
-surgical emergency cannot be excluded
-Inpt tx:
-Ceftriaxone 1 gm IV every 24 hours AND
-Doxycycline 100 mg PO Q12 hours AND
-Metronidazole 500 mg orally or IV every 12 hours
-Transition to oral regimen with doxycycline and metronidazole within 24-48 hours of clinical improvement
-Patients should complete a total of 14 days of treatment (inpt and outpt)
PID outpt tx
-Ceftriaxone 500 mg IM x 1 dose AND
-Doxycycline 100 mg PO Q12H x 14 days AND
-Metronidazole 500 mg PO Q12H x 14 days
hydrosalpinx in PID
tubo-ovarian abscess
-A complication of pelvic inflammatory disease
-An adnexal abscess forms
-Requires surgical or IR drainage
-drainage of TOA via IR
PID f/u and complications
-should be examined (preferably by same examiner) within 72 hrs of initiation of antibiotic tx
-If not improved, strongly consider admission, additional workup, and surgical management
-Short-term sequelae
-Tubo-ovarian abscess (see above)
-May be managed via percutaneous drainage
-May require TAH/BSO
-Fitz-Hugh-Curtis syndrome (perihepatitis)
-“Violin string” adhesions seen between liver and diaphragm
-Secondary to chlamydial infection
-Sepsis and, rarely, death
-Long term sequelae
-Infertility
-Chronic pelvic pain
-Ectopic pregnancy
fitz hugh curtis syndrome
-Adhesions between liver and diaphragm
-“Violin strings”
-Associated with PID caused by chlamydia
-perihepatitis
