NM701 Module 7: Urinary Conditions, Gynecologic and Sexually Transmitted Infections, and Sexual Assault

acute uncomplicated urinary tract infections

healthy women

involves only bladder and urethra

no decreased immunity

no other symptoms

What are the three most common reasons for vaginitis?

BV

candidiasis

trich

vaginosis (rhymes with halitosis)

Imbalance of the vaginal microbiome NOT related to an infection but tends to produce an odor

Burning on urination may be associated with

UTI

cystitis

yeast vaginitis

PRIMARY genital herpes

complicated UTI's

involves pregnancy

N/V

hypotensive

immunodeficient

recent tx with abx

UTI in last 6 or 2 in last 12mos

recurrent UTI's

2 in 6 months; or three in 1 year

recurrent C&S found no increase in follow up visits

pyelonephritis

UPPER TRACT - kidney infection

SS:

flank pain/CVA tenderness

fever

chills

myalgia

dysuria

hematuria

n/v/d

frequency/urgency

UNCOMPLICATED: ss but with no preg/N/V

COMPLICATED: usually need hospitalization-Pregnant, vomiting, hypotensive, or immunodeficient

hallmark of a UTI

Dysuria, urgency and frequency

Clue cells are indicative of

BV

A patient has the following sx:

+ motile organisms the size of WBC's

+ clue cells

+ whiff

pH 5.0

- psudohyphae

- budding yeast

DX: Trich and BV

TX: metronidazole oral 500mg BID x 7

not gel bc its only good for BV not trich bc it cant get into the perivaginal glands

Offer STI testing

Offer tx partner for trich, not for BV

When is a urine culture indicated and when is it not?

Not needed for symptomatic patients who meet criteria for uncomplicated bacterial cystitis

Indicated - complicated cystitis or s/sx of upper tract disease, pregnancy, immunocompromised

Empiric tx initiated before results and then modified labor

Interstitial cystitis

dysuria, urgency and frequency.

However, no microorganism is responsible. Instead, sterile inflammation and irritation of the bladder epithelium is the cause

General management plan for urinary incontinence

Behavior modifications first:

The Knack

pelvic floor PT

voiding diaries with TIMED voids

Fluids

Smoking cessation (if lax conncective tissue is the problem)

Weight reduction as needed (5% BMI reduction markedly improves sx) - 1st LINE TX

history, physical examination, and diagnostic testing) and management for acute uncomplicated UTI

sulfa x 3 days + phenazopyridine OTC

STI testing if under 25

Education: RX, fluids, void in demand

post coital urination and cranberry juice are not evidence based

have pt call back if sx not improving in 48hrs

When is inpatient therapy for pyelonephritis warranted?

Severe illness

Pregnancy

Immunocompromised

Inability to tolerate PO tx d/t vomiting

Inability to adhere to PO tx or return for f/u d/t age, living situation, lack of social support

roles of the urinary bladder, urethra, and pelvic floor structure in maintaining continence.

Continence maintained w/ bladder pressure

What are factors that contribute to urinary incontinence?

obesity

smoking

family hx

neurological issues (dementia/stroke/back issues)

work

pregnancy

medications

older age

rectocele - posterior prolapse

when the rectum loses its ligament support

can cause problems with constipation and emtying

when should we suspect prolapse?

complaints of urinary urgency

pelvic fullness/heaviness

something falling down

Anterior prolapse (cystocele)

Cause: ligaments that hold up the iterus, bladder or rectum become weak due to aging, smoking or weight. Can cause incomplete bladder emptying, contributing to incontinence

SS: urinary urgency, sense of pelvic fullness or heaviness.

Exam: ask client to bear down during exam, kegels during exam for pelvic floor tone

TX: kegels

pessary

sx

symptoms associated with complicated incontinence

pain

hematuria

recurrent infection sx

pelvic irradiation

radical pelvic surgery

suspected fistula

What is normal vaginal discharge?

pH 3.5-4.5

clear to white, thin, mucoid, slippery

mild odor

Pessaries

increase urethral pressure by supporting anterior vaginal wall

Describe the evaluation (history, physical examination, and diagnostic testing) of urinary incontinence.

History (short screening tool) - *get the degree of bother**

Urinalysis - to rule out blood that could be an infection/cancer and to check for glycosuria and pysuria

Paper towel test (can help determine degree of stress leakage)

Bimanual exam for anterior prolapse, cystocele, pelvic mass and to see if she cna squeeze muscle which will determine how we manage stress incontinence

Voiding diary (1st aid for bladder/incontinence problems)

PHYSICAL EXAM & DX TESTING

Assessing bladder tone - least invasive is voiding diary Largest void in diary is an estimate of capacity

Cystometrogram - bladder capacity, invasive and uncomfortable, specialty settings

Quantified standing stress test - paper towel test Standing w/ a comfortably full bladder Cough very hard 3 times holding tri fold paper towel against perineum Urine loss on towel quantified visually or measured

Urethral pressure profile - urethral sphincter deficiency, expensive and specialty

Levator ani muscle laceration degree MRI 3-D ultrasound Palpation for presence and bulk - poor reliability and validity

Levator ani functional capacity to lift and stabilize - 2D ultrasound w/ external perineal probe

Differentiate stress incontinence with assessment findings, testing, and treatment.

Primarily a mechanical problem where the urethra does not close completely causing incontinence when abdominal pressure arises such as coughing and sneezing

contributions: obesity , High impact exercise, smoking (reduces connective tissue strength), birth trauma, chronic constipation and heavy lifting

TX: no meds

maybe sudafed off label - evidence is mixed

Differentiate URGE urinary incontinence assessment findings, testing, and treatment.

Cause: MOSTLY UNKNOWN *IDIOPATHIC* - possibly thought to be neuro, muscle fibers, aging, genetics, the microbiome—we don’t know, most of the time. no warning and having to go frequently is a HALLMARK of this. disrupts sleep,

MS, parkinsons or nerve inj can cause this

TX: (PROS) 1st line -behavioral and lifestyle changes

2nd line- Anti-cholinergics/anti-muscarinics: maybe helpful in reducing sensitivity/urge to void• Vaginal estrogen may be helpful if GSMis contributing to incontinence

sacral nerve stimulator

Botox

TX: (CONS) Won’t work for stress incontinence• Side effects: dry mouth, blurry vision,constipation, nausea, dizziness, headaches.• May not work long-term.

When do we refer for issues with incontinence?

Blood without infection (frank hematuria)

• Suspected overflow or neurological issues underlying sensation problems

• You can't fix it with your initial steps

• Surgery candidate

Differentiate mixed urinary incontinence assessment findings, testing, and treatment.

both stress and urge

TX: tx most bothersome sx first but same as other incontinence

1.lifestyle changes

2.pelvic floor training

3.bladder retraining for OAB

4. duloxetine or antimuscarinic

5.other therapies: electrical stimulation, devices, urethral inserts

Functional incontinence

problems getting to the bathroom in time

Ex: dementia

mobility issues

non pharmacologic tx for urinary incontinence

Lifestyle

Often first step d/t low invasive and risk

Voiding diary evaluation → beverage management and healthy toilet habits

Beverage management - eliminate caffeine, artificial sweeteners, ETOH

Bladder training - 1 cup of urine every 3-4 hours Especially for URGE, overactive bladder or detrusor instability Holding back until approx 8 oz produced on voiding Voiding by the clock every hour and increasing increments by 15 minutes weekly Contracting pelvic floor to sensation Distraction strategies to ignore the urge

Reverse bladder retraining Selected URGE as late signaling or detrusor underactivity - no urge sensation until bladder excessively full Voiding by clock until normalized urge sensations can be relied upon Reduce internal void time to → no more than 300cc per void except first AM void

Knack skill - pelvic muscle contraction strategically timed to moment of expected urine loss STRESS and URGE Awareness of triggers Not effective if unable to achieve voluntary pelvic muscle contraction d/t muscle loss or pelvic organ prolapse below the hymenal ring

Pelvic muscle exercise - kegels for weakened but not torn, need to assess ability to contract levator ani muscle first

Weight management

Barrier device - pessaries to increase urethral pressure by supporting anterior vaginal wall

Complementary and alternative Biofeedback - used w/ pelvic exercise esp in early stages Acupuncture - the evidence doesn’t support Yoga, Pilates, tai chi - the evidence doesn’t support

medication options for urge urinary incontinence

anticholinergic, antimuscarinic:Target smooth muscle, reduce involuntary contractions

SE - dry mouth, blurred vision, constipation, nausea, dizziness, and headaches (remember can’t see, can’t, pee, can’t spit)

91% d/c after 1 yr - question long term effectiveness

Short trial not effective? Specialty referral

Oxybutynin (Ditropan), tolterodine (Detrol), fesoterodine (Toviaz), darifenacin (Enablex), solifenacin (Vesicare)

TCAs - off-label, not first line

Risk factors with BV

RARELY can cause PID

increases likelihood of HIV or preterm birth

significantly impacts sexual functioning

douching, abx and smoking decreases lactobacilli and allows bv to reproduce

multiple/new sex partners

lack of condom use

uncircumcised partner

copper IUD

current period

woman has HSV-2

Discharge associated with BV

runny, watery, thin, homogenous, grayish whitish with a fishy odor

worse after pd/sex

a few will itch but generally NOT a presentation

adherent

positive whiff/KOH test

Symptoms associated with vaginal candidiasis

white and CLUMPY

itching, burning, painful urination/sex and redness

no odor

commonly cause vulvitis and vaginitis

mostly by candida albicans (can be candida glabrata or non candida)

an inflammatory condition - may see WBC on microscopy

in pregnancy: can have discharge but no other sx

Screening for gonorrhea, chlamydia, HIV

all women under 25 who are sexually active

women over 25 with risk factors

everyone 13-64 screened for HIV

differential diagnosis for chlamydia

§Gonorrhea

§PID

§Vaginitis (if vaginal discharge)

§Trichomoniasis (if vaginal discharge and irritated cervix)

§Endometriosis (if pain present)

§Ectopic pregnancy (if unilateral pain and positive pregnancy test)

§Ovarian cyst (if unilateral pain)

What are STI's that manifest in the mucosa or the skin?

HPV/gential warts

Herpes

Trich (vagina, urethra, bladder and rectum)

STI's that are bloodborne or systemic?

HIV

Hep B

Syphyllis (also appear as a rash on palms/soles of feet in second stage)

Gonorrhea

Presents the same as Chlamydia except more REGIONAL

same partner guidelines and follow up chlamydia

Chlamydia

More common in women than men

rarely causes symptoms (10% of men and 5-30% women)

can cause PID> infertility if left untreated

can cause increase in ectopic/pelvic pain

Most common STI mandated to be reported

**mucopurulent cervicitis may be the only sx we see**

routine screening is NOT recommended

A 23yo female has mucopurulent discharge. vaginal and oral sex but not anal sex. transport is unreliable. its been 4 wks with sx. Negative for tenderness. No lymphadenopathy no pharyngitis and no exudate. Trich is negative. No clue cells or hyphae. What does she have and what do we need to do TODAY?

Cervicitis

3 multiple choice options

mucopurulent discharge in the abscence of other symptoms is likely?

cervicitis

A 23yo female has mucopurulent discharge. vaginal and oral sex but not anal sex. transport is unreliable. its been 4 wks with sx. Negative for tenderness. No lymphadenopathy no pharyngitis and no exudate. Trich is negative. No clue cells or hyphae. What does she have and what do we need to do TODAY? **what is the rationale for the correct answer cervicitis?***

NO PID bc none of the 3 cardinal signs (cervical, motion, adnexal tenderness)

IF she had any cardinal signs, we TREAT for PID, send off NAAT, gonorrhea and chlamydia screening

she does not have vaginitis bc wet mount was negative for BV and yeast

No need to treat partners or report to CDC today but if results are positive we will

we should test for other reportable STI's - syphyllis, HIV and Hep B

What are risk factors for Hepatitis B?

from an endemic country

MSM

HIV infection/drug user

Occupational exposure

*bloodborne* so through sex, birth, work

Who should we test for Hepatitis B?

anyone in the risk factor group

anyone not vaccinated as a baby

*reportable*

presumptive treatment for mucopurulent cervicitis?

do not wait for labs IF:

patient is under 25 and in a high risk group or not sure if will be seen again

same TX as for chlamydia: DOXY 100mg BID x 7

cotest with gonorrhea, trich and BV

Doxy PEP

prevent bacterial sexually transmitted infections (STIs) such as gonorrhea, chlamydia, and syphilis, and can reduce risk of contracting these diseases by up to 50%

The regimen is Doxycycline 200 mg orally 24-72 hours after a potential exposure to an STI (i.e. oral, anal, or vaginal/frontal condomless sex)

Individuals recommended to be counseled about and offered DoxyPEP include MSM and transgender women who have had a bacterial STI in the past 12 months, using shared decision-making.

Per CDC, “Persons who are prescribed doxy PEP should undergo bacterial STI testing at anatomic sites of exposure at baseline and every 3–6 months thereafter. Ongoing need for doxy PEP should be assessed every 3–6 months as well. HIV screening should be performed for HIV-negative MSM and TGW according to current recommendations.”

Discharge associated with trichomoniasis

asymptomatic in most women/men BUT when it is . . .

copious, frothy, yellow/green, strong fishy odor

maybe itching, freq and urgency, redness

strawberry colored cervix (cervical petechiae)

What is the etiology, predisposing factors, clinical presentation, assessment (history, physical examination, diagnostic testing), differential diagnoses, and management plan for bacterial vaginosis

most common GYN health problem

What is the etiology, predisposing factors, clinical presentation, assessment (history, physical examination, diagnostic testing), differential diagnoses, and management plan for vulvovaginal candidiasis

Predisposing - repeated abx, DM, pregnancy, steroids, HIV, postmenopausal HT

s/sx - vaginal/vulvar itching, burning, cottage cheese discharge, erythema, excoriation

Testing Wet mount slide with KOH

will see: yeast buds or yeast hyphae, may see WBCs

Usually normal pH

Collect from mid-vaginal wall, not at the cervix

Dx criteria - Speculum exam and KOH

Tx - Topical or PO azoles → antifungals, fluconazole clotrimazole -

culture if tx not effective or recurrent, may need a broader spectrum

Miconazole 2% vaginal cream, 5g vaginally for 3 days

about 90% of yeast infections are caused by candida

about 10% causes by glabrata or tropicalis (harder to treat)

most OTC/fluconazole cover albicans species

UNcomplicated Yeast infection (candidiasis)

sporadic, infrequent

mild>moderate

from Candida albicans

no immunocompromising conditions

complicated yeast infection (candidiasis)

3 or more episodes per year

Severe signs and/or symptoms (extensive vulvar erythema, edema, excoriation, and fissure formation)

non albicans bacteria

women with diabetes or are immunocompromised

What is the etiology, predisposing factors, clinical presentation, assessment (history, physical examination, diagnostic testing), differential diagnoses, and management plan for toxic shock syndrome?

Etiology - staph aureus

s/sx - fever, hypotension, myalgia, vomiting, macular rash, non-pitting edema, erythema on palms & soles, hyperemic vaginal mucosa, vulvar & vaginal tenderness

Dx criteria Macular rash Non-pitting edema Erythema on palms and soles Pelvic exam Hyperemic vaginal mucosa Vulvar and vaginal tenderness

Testing: Negative blood or CSF cultures

Differential Diagnoses: rocky mountain spotted fever, leptospirosis, or measles

Tx - ER eval and medical care

What is the etiology, predisposing factors, clinical presentation, assessment (history, physical examination, diagnostic testing), differential diagnoses, and management plan for bartholins cyst or abscess?

If Small? No treatment needed

I&D - irrigation, packing, catheter

Routine culture and draining not recommended

Non-tender mass, may cause→ obstruction, fluid secretion after obstruction → cyst formation → abscess if there is an infection

Most caused by opportunistic infection

Round/oval mass → crescent-shaped vestibular entrance

Nontender, tense, palpable swelling, usually unilateral, w/o erythema or inflammation

Abscess - very tender, edematous, fluctuant mass w/ erythema of overlying skin, Labial edema and distortion

Routine bathing and hygiene, avoid STIs, seek prompt evaluation for pain

What is the difference between the "-azoles" like clotrimazole or fluconazole and the "nidazoles" like metronidazole?

Metronidazole is an antibiotic and antiprotozoal

Clotrimazole and fluconazole are antifungals.

Which vaginal infections need partner treatment and which do not? Does it matter if the partner is the same sex?

BV → treat female partners only

Partner tx - gonorrhea, trich, lice, syphilis, HSV, HPV if symptomatic, chancroid, granuloma, lymph venereum

Which vaginal infections do not need partner treatment?

Yeast Infections

Identify the impact of biologic factors, social factors, social interactions, relationships, societal norms, and substance use on the transmission of STIs.

BIOLOGIC

Women more likely to become infected and also from a single heterosexual encounter

Vagina has more mucous membranes exposed and conducive to infection

Frequently asymptomatic in women → more likely to go undetected that delays dx and tx, chronic untreated infection and complications

more difficult to diagnose STIs in women d/t anatomy

Adolescents - lack immunity and more susceptibility

Risk - douching, risky sex practices, hormonal contraceptives, and BV Risk for → PID - douching

Predisposing sex - anal, during menses, w/o enough lube OCPs- HPV, chlamydia, HSV, high-risk sex workers

SOCIAL FACTORS

Community and individual issues

Poverty, education, inequity, immigration status, inadequate access

SOCIAL INTERACTIONS AND RELATIONSHIPS

Sexual behavior w/in relationships is critical in preventing and acquiring STIs

Negotiation on condom use, gender power imbalances

Young may lack negotiating skills, self-efficacy, and confidence

Abusive partner dependence

Past and current violence experiences

Partner’s practices including sex and IV drug use

SOCIETAL NORMS

Women socialized to place men’s needs and desires first → difficulty insisting on safe sex

Cultural values w/ passivity and subordination

Power imbalances

Traditional gender roles/norms

Talking about sex, safe sex, and related topics w/ partners and providers

SUBSTANCE USE

Increased risk of HIV and STIs

Poverty, lack of access/treatment options, education or economic opportunities

Individual factors - high-risk taking, survival sex, exchange of sex for money or drugs, low self-esteem

Risk of needle sharing, not cleaning drug paraphernalia

Undermining of cognitive and social skills → not engaging in protective factors

Depression/psych problems

Hx of sexual abuse associated w/ substance abuse

Sex activity while using

Know how to assess an individual (male or female) for STIs, including sexual risk history and physical examination to include with STI screening, and how to counsel regarding STI prevention.

SCREENING

Screen all sexually active ppl regularly and based on risk factors

Five P’s of sex health

Self-identifying risk

filling out questionnaires

HISTORY

Sexual history

Potential sites of infection

Hx that affects management: allergies, previous dx w/ chronic illness, general health status

Menstrual and contraceptive hx including LMP and pregnancy

OLDCARTS of any pertinent s/s

PHYSICAL EXAM

External genitalia

Note erythema, edema, distortions, lesions, trauma, and other abnormalities

Palpation for tenderness and inguinal area

Speculum-vagina/cervix-edema, thinning, lesions, abnormal color, trauma, discharge, bleeding

Bimanual for pelvic organs

Milk urethra for discharge

Vaginal odors

Lab studies by hx and PE Wet mount - Microscopic exam of secretions Chlamydia and gonorrhea testing

Treponemal tests w/ reflex to VDRL or RPR for syphilis

Hep B/C panel If one STI dx - important to test for others

HIV testing notification unless specifically declines

Other - CBC, UA, urine C&S, hCG if hx indicated

PREVENTION AND EDUCATION

Educate about infection, transmission, and why tx is necessary

Refrain from intercourse until tx is complete

Condom use

Comfort measures

Psychosocial

Other partners need to be seen and notified

molluscum

STD that is benign, mild

resolves in 6-12 mos up to 4 yrs

only tx if near genitals

white, pink, pearly flesh colored with a dimple

smooth and firm

Differential diagnosis for genital warts - HPV

syphyllis

molluscum

Know the etiology, predisposing factors, clinical presentation, assessment (history, physical examination, diagnostic testing), differential diagnoses, and management plan for human papillomavirus (HPV) - genital WARTS

most common STI

over half infected at some point in their lives

90% caused by HPV 6 and 11 (covered by vaccine gardasil)

Diagnosed by INSPECTION

TX: if left untreated, can stay the same/better/worse - 75% resolve within 2yrs

It is unknown whether tx affects transmission and barrier methods are ineffective

Visible warts can be removed but often recur

Gardasil is effective against this

Know the etiology, predisposing factors, clinical presentation, assessment (history, physical examination, diagnostic testing), differential diagnoses, and management plan for genital HERPES(HSV)

nonreportable CHRONIC lifelong infection

most caused by HSV2, but 1 more common now with 1st episode outbreaks (40% of all cases), with young women and male couples and under 25

erythematous papules that evolve into clear fluid filled vesicles. erode into painful shallow areas

most ppl are undiagnosed (87%). only 20% W/10%M aged 14-49 are diagnosed

W more infected than M

SS:

PRIMARY OUTBREAK - viral illness with fever, myalgias, headache, regional lymphadenopathy, fatigue

intense inflammation of the genitals, with possible occlusion of the urethra in extreme cases. Burning on urination is common, as is a fever.

DX:

NAAT (PCR) is preferred bc it has a much higher sensitivity that culture. HSV cell culture is highly specific but not sensitive.

should be confirmed with lab testing not inspection

if blood serologic test is ordered - also order syphyllis and HIV

*routine testing not indicated in pregnancy or in the general population**

Education for HSV - genital herpes

viral shedding between outbreaks is common

condoms can only reduce risk

avoid contact with an outbreak

In what cases do we use blood serum testing for HSV patients?

Recurrent sx with negative culture

Clinical dx without lab confirmation

Partner with HSV

Comprehensive testing in high risk population

General screening is NOT indicated

Diagnoses that are types of ulcers

Syphylis

HSV 1/2

chancroid

granuloma inguinale

LGV

Differential Diagnoses for Genital Herpes HSV

Chancre

Contact Dermatitis

Apthous ulcer

Becets ulcer (clinically indistinguishable from HSV when located on the genitals)

Know the etiology, predisposing factors, clinical presentation, assessment (history, physical examination, diagnostic testing), differential diagnoses, and management plan for pediculosis (Lice)?

Etiology - parasite, lice species that transmits by contact through sex, clothing, or bedding

Predisposing factors

Clinical presentation and assessment Pruritus May report seeing lice or known exposure Shared clothing, bathing equipment, or bedding Crusts or scabs in pubic area

Diagnostic testing Direct exam of egg cases - hand lens and light may be helpful if needed Black dots on surrounding skin and under clothing

Differential dx - anogenital eczema and pruritus, seborrheic dermatitis, pruritus vulvae, folliculitis, tinea cruris, scabies

Management Test for other STIs

Permethrin 1% cream rinse and pyrethrins w/ piperonyl butoxide Apply to area and wash off after 10 minutes Sx do not resolve w/in 1 week & tx failure thought to be drug resistance → Malathion 0.5% lotion applied for 8-12 hrs then washed off Alternative regimen - oral ivermectin once then repeat in 2 wks - limited ovicidal activity Wash all clothes, linens, towels in hot and dry in hot Topicals - avoid contact w/ eyes Avoid sex contact until tx of body and environment complete

Pregnant - permethrin or pyrethrins w/ piperonyl butoxide recommended; ivermectin is compatible w/ pregnancy and lactation

Lindane → fetal harm, do not use

Differentials for the BIG 3 (BV, candidiasis, trich)

physiologic leukorrhea? - ask if itchy, burns, irritate, erythema or abnormal on wet prep

retained tampon/foreign body) - ask discharge

gonorrhea/chlamydia/PID - ask fever,chills, back/abdominal pain, postsex pain, tenderness

Genital herpes HSV - lesions, fever, lymphadenopathy, discharge

Atrophic vaginitis - ask BF/perimenopausal, look for atrophic appearing tissue (thin, pale, lack of rugae)

Contact dermatitis/allergic reaction - new products? ask if pattern is consistent with use of products

lichen sclerosis/ vulvar cancer (remember consistent itching is often the only sign of VAIN until it metastasizes)

**if any cervical/motion/adnexal tenderness CDC states treat presumptively for PID**

Know the etiology, predisposing factors, clinical presentation, assessment (history, physical examination, diagnostic testing), differential diagnoses, and management plan for trichomoniasis

Protozoan that attaches to mucous membranes and lactobacilli disppear

ALWAYS a STI unlike other GYN issues

NAAT preferred

TX: TOPICAL THERAPY DOES NOT WORK bc it affects other areas

astrodimer (Vivagel)

TX of BV

NOT AN ANTIBIOTIC

This gel prevents bacterial biofilms from forming on the vaginal epithelium, achieving clinical cures with rates similar to metronidazole. Side effects include rebound yeast vaginitis, which occurred equally in participants given placebo.

Brexafemme (generic name: ibrexafungerp)

TX for Candida

NOT FOR PREGNANT CLIENTS

can cause diarrhea

It is not yet on the CDC list of recommended or alternative therapies

How is the population affected by STIs?

1 in 5 will have one

almost half of new STI's are ages 15-24

Solosec (Secnidazole)

an alternative regimen for BV

NOT a recommended one

What does the CDC recommend if a patient is positive with chlamydida?

Test for gonorrhea, syphyllis & HIV

Report to health dept once results are in

Know the etiology, predisposing factors, clinical presentation, assessment (history, physical examination, diagnostic testing), differential diagnoses, and management plan for chlamydia and gonorrhea

Diagnostic Testing for chlamydia:

NAAT by urine or urethral swab (self collect swabs are equal in sensitivity and specificity vs clinician collected)

Treatment Chlamydia:

NONPREGNANT WOMEN: doxycycline 100mg BID x7d

alternatives: zith 1g single dose

levofloxacin 500mg QD x7d

Follow up:

treat patient AND partner w/in last 60d or most recent partner

NO TOC (TEST OF CURE) for chlamydia UNLESS:

they did not complete tx

sx persist

reinfection suspected

**reinfection is common** more than 30% w/in 1 yr

retest in 3 mos and annually but at least 4 wks since last tx

Treatment Gonorrhea:

IM inj of Ceftriaxone 500mg unless over 150kg(330LBS) get 1g and NO SEX for 7 days

TOC recommended for gonorrhea in pharynx 7-14d after tx - if positive run a sensitivity test

Know the etiology, predisposing factors, clinical presentation, assessment (history, physical examination, diagnostic testing), differential diagnoses, and management plan for syphylis

Etiology Highest rate of primary and secondary cases - blacks

Predisposing factors

Clinical presentation and assessment Painless well-circumscribed ulcer/chancre w/ clean base Persists for 1-5 weeks Primary - chancre on penis, labia, or oral mucosa, usually painless; regional firm, raised, non-tender, lymphadenopathy in proximity to primary syphilitic lesions Secondary - rash, fever, malaise, mucous patches, lymphadenopathy - systemic manifestations Condylomata lata - flat, broad, and round; some appear moist, heaped-up, wart-like papules in warm intertriginous areas; most commonly gluteal folds, perineum, and perianal; highly contagious Neurosyphilis and ocular syphilis can occur at any stage Latent - refers to infection of at least 1 year Primary and secondary effect skin and mucosal surfaces

Diagnostic testing Screen - pregnancy and high risk High risk - hx incarceration, commercial sex work, on prophylaxis for being pre-exposed to HIV RPR or VDRL Primary - darkfield microscopy

Differential Dx

Management Benzathine PCN G 2.4 million units IM x1

SS of primary syphyllis

lesions that are:

within 3-90 days

raised

painless

indurated

hardened

anogenital

Tx for syphyllis?

Penicillin G 2.4 mill units IM OR

Doxycycline 100mg given for PCN allergy

SS of secondary sypyllis

4-10wks

rash on palms/soles

condyloma acuminata

fever

chills

malaise

lumphadenpathy

Know the etiology, predisposing factors, clinical presentation, assessment (history, physical examination, diagnostic testing), differential diagnoses, and management plan for PID (pelvic inflammatory disease)

Etiology Upper genital tract - includes any combo of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis

Predisposing factors:

Adolescents - highest risk d/t ↓immunity & ↑risk of contracting G/C

IUD - increased risk in first 3 weeks after insertion

BV - facilitates ascent of microorganisms

Clinical presentation and assessment -

Recent pelvic surgery, abortion, childbirth, cervix dilation, IUD w/in last month

Sex risk hx Abrupt onset of acute low abd pain following menses = characteristic presenting sx

Can be mild and nonspecific Abd, pelvic, lower back pain Minimal discomfort, dull, cramping, intermittent Severe, persistent, incapacitating

Worse w/ Valsalva, intercourse, movement Abnormal vag discharge Intermenstrual or postcoital bleeding Fever (most afebrile), N/V, urinary frequency

Note s/s of STI in partners

PE - tenderness adnexal, abdominal, uterine, cervical - usually bilateral

Dx testing

No single lab test

pH and wet mount

C/G testing

Severe PID - CBC, ESR Offer syphilis and HIV testing

Differential Dx - ectopic, endometriosis, ovarian cyst w/ torsion, pelvic adhesions, IBS, acute appendicitis

Management Ceftriaxone 250mg IM x1 PLUS doxycycline 100mg PO BID x 14 days PLUS metronidazole 500mg PO BID x14 days s/s should improve w/in 72 hours or reevaluate to confirm dx or may need hospitalized

Prevent - avoid STIs, prompt tx of lower tract infections, safe sex, barrier methods No sex until tx done, sx resolved, and partners tx as indicated Pregnant - risk for maternal morbidity and preterm birth, need hospitalized for IV abx Avoid doxycycline in 2nd and 3rd-trimester d/t discoloration of teeth

Complications- reproductive sequelae including tubo-ovarian abscess, ectopic, infertility, chronic pelvic and abd pain, dyspareunia, recurring PID

What are the reportable diseases?

Chlamydia

Gonorrhea

Syphilis/chancroid

HIV

Hep B+

Know the clinical presentation and assessment (history, physical examination, diagnostic testing) for chancroid (men/women)

Know the clinical presentation and assessment (history, physical examination, diagnostic testing) for granuloma inguinale (men/women)

Bacterial infection caused by Haemophilus ducreyi, uncommon in US

Genital ulcer → risk factor for HIV

Transmitted by sex and trauma

Assessment/Hx/PE/Dx Painful macule on external genitalia rapidly changes to a pustule then ulcerated lesion

May also develop enlarged uni or bilateral inguinal nodes aka buboes 1-2 wks skin overlying ode becomes erythematous, center necroses, then ulcerates

Probably dx - one or more painful ulcers present w/o evidence of syphilis per dark-field exam of ulcer exudate or serologic testing at least 7 days after ulcer onset

Presentation, ulcer appearance, and regional lymphadenopathy (if present) are typical for chancroid and HSV testing of exudate is negative

Dx testing Organism difficult to culture → definitive dx difficult Testing for HIV and syphilis should be done at time of dx

Know the clinical presentation and assessment (history, physical examination, diagnostic testing) for lymphogranuloma venereum (men/women)

LVG is caused by C. trachomatis serovars (strains) L1, L2, L3

Can cause severe inflammation and invasive infection (unlike serovars A-K that cause mild or asymptomatic infection)

Assessment/Hx/PE/Dx Genital ulcer disease (GUD), lymphadenopathy, or proctocolitis

Rectal exposure among MSM or women can result in proctocolitis (most common presentation)

Can mimic inflammatory bowel disease w/clinical findings of mucoid or hemorrhagic rectal discharge, anal pain, constipation, fever, or tenesmus.

Outbreaks among MSM w/high rates of HIV Can be invasive and systemic

if not treated early, can lead to chronic colorectal fistulas and strictures and reactive arthropathy

Can be asymptomatic

Common manifestation among heterosexual:

– tender inguinal/femoral lymphadenopathy

– unilateral Self-limited genital ulcer sometimes at site of inoculation

Lymphadenopathy can be severe - Groove sign

Oral ulceration can occur and might be associated with cervical adenopathy

Secondary bacterial infection – or infection w/other STI possible

Dx testing

PCR-based genotyping for LGV-specific molecules

Tests not widely available and results take long so – Diagnosis made on clinical suspicion, epidemiologic information and C. trachomatis

NAAT at the symptomatic site, along with exclusion of other etiologies for proctocolitis, inguinal lympadenopathy, or genital, oral or rectal ulcers

Tests for chlamydia with NAAT

Treatment: Doxy 100mg BID x 21d

Partners who are asymptomatic get regular doxy bid x 7, if they have sx, they receive 21 d regimen

What are the two hallmark signs of LGV?

inguinal lymphadenopathy

proctitis or proctocolitis

Know the etiology, predisposing factors, minimum required criteria for diagnosis and empiric treatment, and initial management of pelvic inflammatory disease (PID).

Etiology Common causative agents include N. gonorrhoeae and C. trachomatis Anaerobic and aerobic microorganisms: Gardnerella vaginalis Haemophilus influenzae Mycoplasma genitalium BV is common in women with PID

Predisposing factors: STIs such as N. gonorrhoeae and C. trachomatis

Minimum required criteria for diagnosis Sexually active and at risk for STIs Experiencing pelvic pain or lower abdominal pain No cause for the illness other than PID AND, one or more of the following: Cervical motion tenderness (CMT) Uterine tenderness Adnexal tenderness

Initial management Decide if hospitalization necessary If able to tolerate - tx with oral abx

Should have substantial improvement w/in 72 hours

Pregnant should be hospitalized for IV abx

why it is important to diagnose PID as early as possible.

Minimize long-term sequelae

Delay of dx is associated with severe sequelae

What is the most common causes of PID?

gonorrhea (most common)

Chlamydia (2nd most common)

Describe appropriate assessment, documentation, prophylactic treatment, reporting requirements, and follow-up care for a person who has experienced a sexual assault but who declines a forensic (medico-legal) exam.

Women must give two types of informed consent 1. general consent that signifies the woman has agreed to receive medical evaluation and treatment 2. consent granting the clinician permission to collect evidence and gives the woman the option to release the evidence to the appropriate law enforcement and criminal justice agencies if desired

Medical forensic exam should be deferred if the patient is reversible incapacitated: medication, drug, alcohol ingestion/intoxication)

A comatose patient, one younger than the age of consent, or one suffering from permanent cognitive or developmental disability consent is obtained from HCP

Follow state statutes regarding age of consent

Documentation:

Pts medical record is not part of the evidence kit and should not be released unless required by law

Prophylactic tx: Testing would detect STIs already acquired - provide prophylactic tx

Testing: use

NAAT for G/C/TRICH

serologic testing for HIV, hepatitis B and syphilis

TX: PROPHYACTICALLY

ceftriaxone (gonorrhea), doxy (chlamydia) and metronidazole (trich)

empiric x for syphylis is not currently recommended

While taking a sexual history the clinician asks the patient, "What do you use for protection?" The patient will understand that the clinician is asking about:

Who knows? It would be better to ask "Do you use condoms with intercourse?"

gonorrhea/chlamydia

live in the cervix

can present very similarly and in the mouth or rectum

diaphragms and condoms are somewhat effective

NAAT

used for gonorrhea, chlamydia, HSV, Trich

does not have a sensitivity component

Resistance for Gonorrhea

harder to treat due to antibiotic resistance

especially in the pharynx

Testing for chlamydia

1st line: NAAT (95-98% sensitivity)

2nd: urine (93%)

self swab from patient

NAAT point of care tests

What test is used for Chlamydia/Gonorrhea, Trichomoniasis, Herpes screening?

NAAT

gonorrhea uses culture on thayer martin media

Trich can also use a wet mount

Herpes Simplex can also use viral culture

What test is used for Syphyllis screening?

RPR or VDRL

What test is used for condyloma acuminata screening?

visual confirmation and biopsy if necessary

What is the treatment for Gonorrhea?

ceftriaxone 500mg IM once with Doxycycline 100 mg orally 2 times/day for 7 days if they have chlamydia too

Diagnosis of BV

Through microscopy and

GOLD STANDARD: Amsel's criteria:

MUST HAVE 3/4 features