Infections of the vagina and vulva

3.5-4.5 (anaerobes predominate - lactobacillus produces the acid)

Normal pH of the reproductive women

4.5+ (lower prevalence of lactobacillus)

Normal pH of the Pre-pubertal and Post-menopausal women

Menstrual cycle, antibiotics, douching, unprotected sex, lubes, intravaginal medication

What are somethings that can affect the pH of the vagina and lead to infection?

Bacterial Vaginosis (increased anaerobic rods)

The most common cause of abnormal vaginal discharge in a reproductive female - NOT an STD; produces a fishy-like odor and grey/clear discharge

Multiple or new sexual partners, female partners, oral sex, douching, smoking, IUD

Risk factors for bacterial vaginosis

Gram stain 🏆, Amsel’s Diagnostic Criteria, Single swab with PCR and DNA probe tech (promising - BD affirm VPIII system)

What are the preferred diagnostics for Bacterial Vaginosis

Exam, Swab placed in 10% KOH (whiff test), Swab to mix NS (microscopy), pH over 4.5

What are the Amsel’s Diagnostic Criteria - gotta go 3/4?

Metro PO or intravaginally, Clindamycin cream intravaginally, Secnidazole PO, Tinidazole PO, Clinda PO

Treatment for bacterial vaginosis

Treat acute episodes (2x weekly suppressive metronidazole or intravaginal boric acid followed by metro OR metro and Fluconazole), change abx or change course, condom use for 3-6 months, no benefit from lactobacillus

For refractory cases of bacterial vaginosis (3 documented episodes in 1 year)?

Trichomoniasis (trichomonas Vaginalis)

What is the most prevalent non-viral STD worldwide that can infect the vagina, urethra, endocervix, and bladder?

foul, thin yellow or green discharge; dysuria, dyspareunia, vulvar pruritus, vaginal spotting, and lower abdominal pain

Symptoms for trich (50% are asymptomatic)

Strawberry spots on the cervix, elevated vaginal pH

Clinical findings for Trich

Trichomonas on microscopy, NAAT (most sensitive and specific)

Diagnostics for Trich

metro 🥇, Tinidazole, if allergic to nitroimidazoles → desensitize

Treatment for Trich

3 weeks if preg 🤰, 3 months if not

When should you retest for trich

Vulvar pruritus, burning, erythema, edema with excoriation, cheese-like dischage

Symptoms of yeast infection candidiasis

immunosuppression, DM, preg, recent broad spectrum abx

Risk factors for a yeast infection

Saline and 10% KOH (budding hyphae), Culture 🏆, PCR

Diagnostics for yeast infection

1 dose of fluconazole, topical antifungal (tercazole)

1st occurence of vaginal candiasis

2-3 doses of fluconazole over 3 days

Treatment of DM patients with vaginal candiasis

10-14 days of induction therapy (topical agent or oral fluconazole) then 150 mg fluconazole for 6 months, workup for DM and HIV

4+ candida infections in 1 year

Dorsal root ganglion (sensory nerve)

Where does HSV like to live (life-long latency)

vesicles → ulcer → crusting; burning, severe pain, dysuria low-grade fever, HA, myalgia

Symptoms of HSV - mean incubation is 1 week (primary outbreaks are worse and more widespread)

Cell culture, NAAT 🏆, IgG antibody assay (not super recommended - seroconversion takes 3 weeks)

Diagnosis of HSV

Antiviral (acyclovir, valacyclovir), antipyretic, pain med, suppressive therapy

Treatment for HSV

Chancre (isolated, nontender ulcer with raised rounded border)

Primary syphilis is characterized by

maculopapular rash that develops on the palms, soles, and mucous membranes, condyloma lata

Secondary syphilis (6 weeks to 6 months later) is characterized by

Cardiovascular, CNS, and MSK involvement

Tertiary syphilis (20 years later) is characterized by

Treponema pallidum (spirochete)

Etiology of syphillis

Direct detection of spirochete 🏆, Treponemal and nontreponemal (RPR) testing (seroconversion occurs 3-6 weeks)

Diagnosis of syphilis

Benzathine pen G IM 1x (doxy as an alt)

Treatment for primary, secondary, early latent Syphilis

Benzathine Pen G 3x IM weekly

Treatment for latent, tertiary, cardiovascular syphilis

Chancroid

An STI caused by H.Ducreyi that is characterized by an ulcer with soft irregular margins and friable bases, tender inguinal lymphadenopathy (if large buboes may form)

H. Ducreyi in cell culture, NAAT

Diagnosis for Chancroid

Azithromycin, Ceftriaxone

Treatment for Chancroid

Granuloma Inguinale (Donovanosis)

An vulvar infection caused by Klebsiella Granulomatosis that is characterized by painless, inflammatory nodules that progress to highly vascular nontender ulcers that heal by fibrosis (keloids) - lymph nodes NOT affected

Donovan bodies (closed safety pin) on microscopic eval after wright-giemsa stain

Diagnosis for Granuloma Inguinale

Azithro 1g once weekly for at least 3 weeks

Treatment for Granuloma Inguinale

Chlamydia trachomatis serotypes L1, L2, L3

Etiology for lymphogranuloma venereum

Small painless papule → regional lymphadenopathy → anogenitorectal fibrosis

Stages of lymphogranuloma venereum

Culture/immunofluorescence, NAAT

Diagnosis of lymphogranuloma venereum

Doxy bid for 21 days

Treatment for lymphogranuloma venereum

HPV (86% from 6 and 11)

Etiology for genital warts

flat papulae or classic verrucous exophytic lesions

Findings for genital warts

Visualization on exam, biopsy if neoplasia is suspect, unclear diagnosis, immunosuppression

Diagnostics for genital warts

Sharp excision, electrosurgical needle tip excision, cryotherapy, laser ablation, topical agents (TCA, imiquimod, podofilox)

Treatment for genital warts - no treatment option boast 100% clearence

Multiple 2-5 mm flesh colored papules with central umbilication

Exam findings for Molluscum Contagiosum

Visual inspection if unclear biopsy

Diagnosis for Molluscum Contagiosum

Spontaneously resolve regress (6-12 months), treated by cryotherapy, electrosurgical needle coagulation, sharp needle tip curettage, topical trichloroacetic acid

Treatment for Molluscum Contagiosum