Vaginitides, STIs, PID Flashcards

Question

PE and dx in trichomoniasis

Answer 1

-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

Answer 2

-PID -infertility -preterm birth -HIV infection and transmission -cervical intraepithelial neoplasia (CIN)

Answer 3

-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

Answer 4

-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

Answer 5

-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

Answer 6

-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

Answer 7

-MC STI- HPV -MC REPORTED- CHLAMYDIA

Answer 8

-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

Answer 9

-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

Answer 10

-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

Answer 11

-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

Answer 12

-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

Answer 13

-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

Answer 14

-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

Answer 15

-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

Answer 16

-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

Answer 17

-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

Answer 18

->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

Answer 19

-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

Answer 20

-Does not affect fertility in either partner -Condoms can protect partner to some degree but nothing is 100% effective -Warts rarely become malignant

Answer 21

-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

Answer 22

-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

Answer 23

-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!

Answer 24

hydrosalpinx in PID

Answer 25

-TOA in PID

Answer 26

-bHCG -CBC with differential -LFTs -GC, CT -T vaginalis -RPR -HIV Ab -Pelvic ultrasound -Endometrial biopsy -Wet mount -Surgical consult -ID consult

Answer 27

-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)

Answer 28

-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

Answer 29

hydrosalpinx in PID

Answer 30

-A complication of pelvic inflammatory disease -An adnexal abscess forms -Requires surgical or IR drainage

Answer 31

-drainage of TOA via IR

Answer 32

-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

Answer 33

-Adhesions between liver and diaphragm -“Violin strings” -Associated with PID caused by chlamydia -perihepatitis