Women's Health EOR: Infections (Smarty PANCE)

What is the most common cause of purulent cervicitis?

Neisseria gonorrhoeae - gram-negative intracellular diplococci causing mucopurulent cervical discharge

What are the clinical features of gonococcal cervicitis?

Often asymptomatic (50%); when symptomatic: mucopurulent discharge, dysuria, intermenstrual bleeding, cervical friability

What is the first-line treatment for uncomplicated gonococcal cervicitis?

Ceftriaxone 500mg IM single dose (1g if weight ≥150kg) - treat presumptively for chlamydia with doxycycline 100mg BID x 7 days

What are the complications of untreated gonococcal cervicitis?

Pelvic inflammatory disease (10-20%), disseminated gonococcal infection, Fitz-Hugh-Curtis syndrome, infertility, ectopic pregnancy

What is the recommended test for gonorrhea diagnosis?

Nucleic acid amplification test (NAAT) - most sensitive; can use cervical, vaginal, or urine samples

What is disseminated gonococcal infection (DGI)?

Systemic infection with triad: migratory polyarthralgia, tenosynovitis, dermatitis (pustular skin lesions on extremities)

What organism causes chlamydial cervicitis?

Chlamydia trachomatis (serovars D-K) - obligate intracellular bacteria, most common bacterial STI in US

What are the clinical features of chlamydial cervicitis?

Often asymptomatic (70-80%); mucopurulent discharge, dysuria, postcoital bleeding, cervical ectropion, friable cervix

What is the first-line treatment for chlamydial cervicitis?

Doxycycline 100mg PO BID x 7 days (preferred) OR Azithromycin 1g PO single dose

What screening is recommended for chlamydia?

Annual screening for all sexually active women <25 years old and older women with risk factors

What are the complications of untreated chlamydia?

PID (major cause), chronic pelvic pain, infertility, ectopic pregnancy, Fitz-Hugh-Curtis syndrome

What is Fitz-Hugh-Curtis syndrome?

Perihepatitis from chlamydia or gonorrhea causing right upper quadrant pain with "violin string" adhesions between liver and peritoneum

Which HSV type most commonly causes genital herpes?

HSV-2 (70-90% of genital herpes), though HSV-1 increasingly common (oral-genital transmission)

What are the classic symptoms of primary HSV genital infection?

Painful grouped vesicles/ulcers on vulva/cervix, dysuria, inguinal lymphadenopathy, systemic symptoms (fever, myalgias) - lasts 2-3 weeks

What is the treatment for first episode genital herpes?

Acyclovir 400mg PO TID x 7-10 days OR Valacyclovir 1g PO BID x 7-10 days OR Famciclovir 250mg PO TID x 7-10 days

What is the difference between primary and recurrent HSV?

Primary: first infection, more severe, lasts longer; Recurrent: milder, shorter duration (5-7 days), often prodromal symptoms

When is suppressive therapy indicated for genital herpes?

≥6 outbreaks per year, desire to reduce transmission risk, or psychosocial impact

What is the most sensitive test for HSV diagnosis?

PCR of lesion sample (most sensitive) or viral culture from vesicle fluid; type-specific serology for diagnosis without active lesions

Which HPV types cause cervical cancer?

High-risk types 16 and 18 (cause 70% of cervical cancers), also types 31, 33, 45, 52, 58

Which HPV types cause genital warts?

Low-risk types 6 and 11 (cause 90% of genital warts) - not associated with cancer

What is the peak age for HPV acquisition?

Late teens to mid-20s - most sexually active individuals acquire HPV; 90% clear infection within 2 years

What are the treatment options for genital warts?

Patient-applied: imiquimod 5% cream or podofilox 0.5% solution; Provider-applied: cryotherapy, TCA/BCA, surgical excision

What HPV vaccines are currently available?

Gardasil 9 (9-valent) - protects against HPV types 6, 11, 16, 18, 31, 33, 45, 52, 58

What is the recommended HPV vaccination schedule?

Ages 11-12 (can start age 9); 2-dose series if started <15 years (0, 6-12 months); 3-dose series if ≥15 years

What organism causes chancroid?

Haemophilus ducreyi - gram-negative coccobacillus ("school of fish" appearance on Gram stain)

What are the classic features of chancroid?

Painful genital ulcer with irregular undermined borders, purulent base, tender suppurative inguinal lymphadenopathy (buboes)

How is chancroid differentiated from syphilis and herpes?

Chancroid: painful ulcer, tender adenopathy; Syphilis: painless ulcer, firm non-tender adenopathy; Herpes: grouped vesicles/ulcers

What is the first-line treatment for chancroid?

Azithromycin 1g PO single dose OR Ceftriaxone 250mg IM single dose OR Ciprofloxacin 500mg PO BID x 3 days

What is the epidemiology of chancroid?

Rare in US, more common in developing countries, associated with sex work and uncircumcised males

What organism causes lymphogranuloma venereum?

Chlamydia trachomatis serovars L1, L2, L3 (different from genital chlamydia which is serovars D-K)

What are the three stages of LGV?

Primary: painless genital papule/ulcer (often unnoticed); Secondary: painful inguinal lymphadenopathy; Tertiary: proctocolitis, genital elephantiasis

What is the classic presentation of LGV?

Painful inguinal and/or femoral lymphadenopathy (buboes) that may rupture, "groove sign" (nodes above/below inguinal ligament)

What is the treatment for lymphogranuloma venereum?

Doxycycline 100mg PO BID x 21 days (3 weeks - longer than standard chlamydia treatment)

What populations are at highest risk for LGV?

Men who have sex with men (MSM), especially with HIV; presents as proctocolitis in receptive anal intercourse

What is pelvic inflammatory disease (PID)?

Infection and inflammation of upper female genital tract - endometritis, salpingitis, tubo-ovarian abscess, pelvic peritonitis

What are the most common organisms causing PID?

Neisseria gonorrhoeae and Chlamydia trachomatis (most common); also anaerobes, Mycoplasma genitalium, polymicrobial

What are the clinical criteria for diagnosing PID?

Minimum criteria: cervical motion tenderness, uterine tenderness, OR adnexal tenderness in sexually active woman with pelvic pain

What additional criteria support PID diagnosis?

Fever >38.3°C, mucopurulent cervical discharge, cervical friability, elevated ESR/CRP, positive NAAT for GC/CT

What is the outpatient treatment regimen for PID?

Ceftriaxone 500mg IM once PLUS Doxycycline 100mg PO BID x 14 days PLUS Metronidazole 500mg PO BID x 14 days

When should patients with PID be hospitalized?

Pregnancy, failed outpatient therapy, severe illness, tubo-ovarian abscess, inability to tolerate oral medications, uncertain diagnosis

What is the inpatient treatment regimen for PID?

Cefotetan or cefoxitin IV PLUS doxycycline 100mg IV/PO BID OR Clindamycin IV PLUS gentamicin IV

What are the long-term complications of PID?

Chronic pelvic pain (20%), infertility (10-20%), ectopic pregnancy (6-10x increased risk), recurrent PID

What is a tubo-ovarian abscess (TOA)?

Complication of PID with pelvic abscess formation - presents with severe pelvic pain, fever, adnexal mass on exam/imaging

How is tubo-ovarian abscess managed?

Hospitalization, IV antibiotics, drainage if ruptured or failed medical therapy, surgical intervention if needed

What organism causes syphilis?

Treponema pallidum - spirochete bacteria that cannot be cultured on artificial media

What are the stages of syphilis and their timeframes?

Primary (3-90 days): chancre; Secondary (4-10 weeks): rash; Latent (asymptomatic); Tertiary (years): cardiovascular, gummas, neurosyphilis

What are the classic features of primary syphilis?

Painless, indurated ulcer (chancre) with clean base and firm borders, non-tender firm inguinal lymphadenopathy

What are the classic features of secondary syphilis?

Maculopapular rash involving palms and soles, condyloma lata, mucous patches, generalized lymphadenopathy, constitutional symptoms

What is the difference between early and late latent syphilis?

Early latent: <1 year duration, higher transmission risk; Late latent: >1 year duration, lower transmission risk

What is the screening test for syphilis?

Nontreponemal tests (RPR or VDRL) - inexpensive, quantitative, used for screening and monitoring treatment response

What is the confirmatory test for syphilis?

Treponemal tests (FTA-ABS, TP-PA, EIA) - confirm positive nontreponemal test; remain positive for life

What is the treatment for primary, secondary, or early latent syphilis?

Benzathine penicillin G 2.4 million units IM single dose

What is the treatment for late latent or tertiary syphilis?

Benzathine penicillin G 2.4 million units IM weekly x 3 doses (total 7.2 million units)

What is the Jarisch-Herxheimer reaction?

Acute febrile reaction within 24 hours of treating syphilis due to release of treponemal antigens - self-limited, treat with antipyretics

What organism causes trichomoniasis?

Trichomonas vaginalis - flagellated protozoan parasite, only STI caused by a protozoan

What are the classic symptoms of trichomoniasis?

Profuse yellow-green frothy malodorous discharge, vulvovaginal irritation, dysuria, dyspareunia, "strawberry cervix" (colpitis macularis)

What are the characteristic findings on wet mount for trichomoniasis?

Motile trichomonads (flagellated organisms), increased WBCs, pH >4.5

What is the treatment for trichomoniasis?

Metronidazole 500mg PO BID x 7 days (preferred) OR Metronidazole 2g PO single dose OR Tinidazole 2g PO single dose

Should sexual partners be treated for trichomoniasis?

Yes - treat all partners simultaneously; avoid sexual contact until both partners complete treatment and are asymptomatic

What are the complications of trichomoniasis in pregnancy?

Preterm delivery, premature rupture of membranes, low birth weight - treat symptomatic pregnant women with metronidazole

What is bacterial vaginosis (BV)?

Disruption of normal vaginal flora with overgrowth of anaerobes (Gardnerella vaginalis, Mobiluncus) and loss of lactobacilli

What are the Amsel criteria for diagnosing BV (need 3 of 4)?

Thin gray-white discharge, pH >4.5, positive whiff test (fishy odor with KOH), clue cells on wet mount

What are clue cells?

Vaginal epithelial cells with adherent bacteria obscuring cell borders - pathognomonic for bacterial vaginosis

What is the first-line treatment for bacterial vaginosis?

Metronidazole 500mg PO BID x 7 days OR Metronidazole gel 0.75% intravaginally daily x 5 days OR Clindamycin cream 2% intravaginally x 7 days

Should sexual partners be treated for BV?

No - BV is not considered an STI; partner treatment does not reduce recurrence rates

What are the complications of untreated BV in pregnancy?

Preterm delivery, preterm rupture of membranes, postpartum endometritis, increased risk of acquiring STIs

What causes atrophic vaginitis?

Estrogen deficiency (menopause, breastfeeding, oophorectomy) leading to thinning of vaginal epithelium and decreased glycogen

What are the symptoms of atrophic vaginitis?

Vaginal dryness, dyspareunia, burning, itching, vaginal bleeding, recurrent UTIs, urinary urgency

What are the physical exam findings in atrophic vaginitis?

Pale, thin, dry vaginal mucosa, loss of rugae, petechiae, pH >5.0, sparse pubic hair

What is the first-line treatment for atrophic vaginitis?

Vaginal estrogen therapy: estradiol vaginal cream, estradiol vaginal tablet, or estradiol vaginal ring

What non-hormonal options are available for atrophic vaginitis?

Vaginal moisturizers (long-acting lubricants), water-based lubricants for intercourse, DHEA vaginal suppository

When is systemic hormone therapy preferred over vaginal estrogen?

When patient has moderate-severe vasomotor symptoms (hot flashes) in addition to genitourinary symptoms

What organism most commonly causes vulvovaginal candidiasis?

Candida albicans (80-90% of cases); non-albicans species include C. glabrata, C. tropicalis

What are the classic symptoms of vulvovaginal candidiasis?

Vulvar pruritus (most common), thick white "cottage cheese" discharge, vulvar erythema, dyspareunia, external dysuria

What are the risk factors for vulvovaginal candidiasis?

Antibiotics, diabetes, pregnancy, immunosuppression, corticosteroids, tight-fitting clothing, increased estrogen states

What are the diagnostic findings for candidiasis?

pH <4.5 (normal), budding yeast and pseudohyphae on KOH prep, negative whiff test

What is the treatment for uncomplicated vulvovaginal candidiasis?

Fluconazole 150mg PO single dose OR Intravaginal azoles (miconazole, clotrimazole, terconazole) x 1-7 days

What defines complicated vulvovaginal candidiasis?

Severe symptoms, recurrent (≥4 episodes/year), non-albicans species, diabetes, immunocompromised, pregnancy

What is the treatment for recurrent vulvovaginal candidiasis?

Induction: fluconazole 150mg PO days 1, 4, 7; Maintenance: fluconazole 150mg PO weekly x 6 months

What is the treatment for candidiasis in pregnancy?

Topical azoles only (7-day course preferred) - oral fluconazole contraindicated in pregnancy