Case 7: Mary Jane Morrison

Cervix Anatomy

Uterus neck

Sections:

• Internal Os: Opening into uterus

• Cervical canal

• External Os: Opening into vagina

Cervix: Histology

Endocervical Mucosa: Simple columnar epithelium

• Inside canal

Exocervical Mucosa: Stratified squamous epithelium

• Around external os → Upper vagina (continuous)

Transformation Zone: Squamous-columnar epithelium

• Transition between endo and exocervical mucosa

  • Around external os

• Vaginal environment exposure = Reprogram epithelial stem cells = Neoplasia

Chlamydia: Pathogen + Transmission

Chlamydia trachomatis (bacteria)

Transmission:

• Sexual contact

• Vertical transmission

Chlamydia: Pathophysiology

Bacteria into urogenital tract = Infect endocervical epithelium (female) or urethral epithelium (male)

Chlamydia: Clinical Presentation

Asymptomatic: Most women

Symptomatic:

• Urethritis (dysuria, polyuria)

• Proctitis (rectal inflammation)

• Female:

  • Vaginal discharge

  • Postcoital/intermenstrual bleeding

  • Dyspareunia

  • PID

• Male:

  • Urethral discharge

  • Epididymitis

  • Prostatitis

Chlamydia: Treatment

Antibiotics

• Axithromycin (1g x 1 dose)

• Doxycycline

• Levofloxacin

Abstinence

• 7 days after treatment

Chlamydia: Prevention

Safe sex (barrier contraception)

Screening:

• Sexually active women: Annual for ≥ 25 years + STI risk factors

• Prenatal: STI risk factors

Gonorrhea: Pathogen + Transmission

Neisseria gonorrhoeae (bacteria)

Transmission:

• Sexual contact

• Perinatal (before and after birth)

Gonorrhea: Pathophysiology

Bacteria invade epithelium cells = Inflammation + phagocyte recruitment = Tumor necrosis factor from phagocytes damage epithelial cells = Deeper infection

Gonorrhea: Clinical Presentation

Urethritis

• Discharge

• Dysuria

• Increase urinary frequency

Cervicitis

• Asymptomatic

• Discharge

• Pain

PID

• Discharge

• Fever

• Pain

• Fitz-Hugh-Curtis syndrome (RUQ from hepatitis)

Epididymitis

Orchitis

• Swollen/tender testicles

Gonorrhea: Treatment

Antibiotics

• Ceftriazone

• Complicated: + doxycycline and metronidazole

• Treat partners

Abstinence

• 7 days after treatment

• Symptoms resolved

Gonorrhea: Prevention

Barrier contraception

Antibiotic prophylaxis (sexual assault)

Screening:

• Sexually active women: Annual for ≥ 25 years + STI risk factors

• Prenatal: STI risk factors

HPV: Pathogen + Transmission

Human papillomavirus

Transmission:

• Sexual contact

• Fomites

• Vertical transmission (rare)

HPV: Pathophysiology

HPV express oncoproteins E6 and E7 = Epidermal hyperplasia + hyperkeratosis = Warts

HPV: Clinical Presentation

Warts

• Anogenital

• Cutaneous

HPV: Treatment

NO CURE

Spontaneously resolve in < 2 years

Wart removal

HPV: Prevention

Barrier contraception

HPV vaccine (gardasil) → 11-12 years

Circumcision

Screening:

• > 25 years = Every 5 years

Syphilis: Pathogen + Transmission

Treponema pallidum (bacteria)

Transmission:

• Sexual contact (mucocutaneous lesions)

• Vertical transmission

• Blood transfusion + organ donation (rare)

Syphilis: Pathophysiology

Bacteria bind endothelial cells = Inflammatory reaction = Endarteritis (artery intima proliferation + inflammation)

Syphilis: Clinical Presentation

Localized primary lesions (chancre)

Lymphadenopathy

Syphilis: Treatment

Penicillin G (first-line)

• Allergy:

  • Allergen desensitization + penicillin

  • Doxycycline

  • Ceftriaxone

Syphilis: Prevention

Barrier contraception

Doxycyline PEP

Circumcision

Screening: Annual

• HIV infection

• MSM

• Pregnancy

HBV: Pathogen + Transmission

Hep B virus (HBV)

Transmission:

• Sexual contact (mucocutaneous lesions)

• Parenteral (needles, blood transfusion, organ transplant)

• Vertical transmission

HBV: Pathophysiology

Virus invade hepatocytes = Produce viral DNA = CD8+ T cells attack infected hepatocytes = Liver inflammation + destruction

HBV: Clinical Presentation

Fever

Fatigue

Myalgia

Nausea

Jaundice

RUQ pain

HBV: Treatment

Supportive care

• Avoid hepatotoxic meds

• Stop alcohol

AVT: Chronic infection

HBV: Prevention

HBV vaccine

• At birth OR childhood

Circumcision

Screening:

• 18+: 1 time

• Pregnant: 1 time

• Tissue/blood donors

HCV: Pathogen + Transmission

Hep C virus (HCV)

Transmission:

• Parenteral

• Vertical transmission

• Sexual contact (rare)

HCV: Pathophysiology

Virus invade hepatocytes = Produce viral RNA = Host immune response cause liver inflammation + destruction

HCV: Clinical Presentation

Asymptomatic

Symptomatic:

• Fever

• Malaise

• Myalgia

• RUQ pain

• Nausea/vomiting

• Jaundice

HCV: Treatment

AVT: All patients

Supportive care

• Avoid hepatotoxic drugs

• Stop alcohol

HCV: Prevention

NO VACCINE OR PREP

Education

• PPE

• Needle sharing

Screening:

• 18+: 1 time

• Pregnancy: 1 time

STI Testing/Screening Methods

Nucleic acid amplification testing (NAAT): PCR

• Vaginal swab (pap smear) or urine

Serology

• BBI (HBV, HCV, HIV, syphilis)

STI Test of Cure

F/U diagnostic test to determine if STI (chlamydia, gonorrhea) cleared from treatment

Failure Reasons:

• Poor compliance

• Reinfection from untreated partner

• Antibiotic resistance

STI Complications

PID

Fitz-Hugh-Curtis syndrome

Sepsis

Infertility

Ectopic pregnancy

Cervical cancer (HPV)

STI Complications: PID

Ascending bacterial infection infecting structures above cervix

• Endometrium

• Fallopian tubes

• Ovaries

• Peritoneum

PID Management

Empiric antibiotics

• Parenteral: Cephalosporin + doxycycline

• Oral: Switch after 24-48 h improvement

Partner treatment

• Test + treat chlamydia and gonorrhea

• STI screening

Education

• Stop intercourse until treatment complete

• Barrier contraception

PID Complication

Infertility

Increased from…

• Chronic chlamydia

• Failure to treat

• Severe inflammation → Fallopian tube scarring

• Multiple infections

STI Complications: Fitz-Hugh-Curtis Syndrome

Perihepatitis: Liver capsule inflammation → RUQ + right shoulder pain

STI Prevention

Primary: Decrease risk factors

• Behavioural counselling

• PrEP

  • Vaccines

  • AVT

Secondary: Early detection

• Screening

  • Pap: ≥ 25 years + sexually active → Every 3 years

  • PEP

    • Antibiotics

    • ARVT

STI Reporting

Chlamydia

Gonorrhea

Syphilis

HBV

HCV

HIV/AIDS

Infectious Vulvovaginitis

Yeast infection (vulvovaginal candidiasis)

Bacterial vaginosis (BV)

Trichomoniasis

Yeast Infection: Pathogen

Candida albicans (fungus)

Yeast Infection: Pathophysiology

Fungal overgrowth

Risk factors:

• Pregnancy

• Immune deficiency

• Antimicrobials

Yeast Infection: Clinical Presentation

Vaginal discharge

• White

• Crumbly

• Sticky

Vulvovaginal erythema

Vaginal burning + pruritis

Dysuria

Dyspareunia

Yeast Infection: Treatment

Antifungals

• Topical azole

BV: Pathogen

Gardnerella vaginalis

Atopobium vaginae

Prevotella spp.

Mobiluncus spp.

BV: Pathophysiology

Low bactobacillus in vagina = Pathogenic bacteria overgrowth

• NO inflammation

Risk factors:

• Sexual intercourse

• IUD

• Vaginal douching

• Pregnancy

BV: Clinical Presentation

Asymptomatic

Vaginal discharge

• Grey

• Milky

• Fishy odour

BV: Treatment

Antibiotics: For symptoms

• Oral/intravaginal metronidazole

• Intravaginal clindamycin

Trichomoniasis: Pathogen

Trichomonas vaginalis (parasite)

• Sexual contact transmission

Trichomoniasis: Pathophysiology

Parasite attach to genital epithelium (cytotoxic) = Epithelial cell lysis

Trichomoniasis: Clinical Presentation

Vaginal discharge

• Yellow-green

• Purulent

• Frothy

• Foul-smelling

Vulvovaginal pruritis

Vaginal burning

Dyspareunia

Dysuria

Strawberry cervix (erythema + petechiae)

Trichomoniasis: Treatment

Antimicrobial

• Oral metronidazole

• Oral tinidazole

• Treat partners