GYN- STIs

skipped over hepatitis and HIV

What should all pts who seek screening for STIs receive?

Testing and counseling for HIV infx (recommended screening ages 13-75 y/o)

What is the optimal interval for STI screening in a previously infected woman due to high rates of reinfection?

3-4 mos

What are the 5 P’s you should obtain in history?

Partners, Prevention of pregnancy, Protection from STIs, Practices, Past hx STIs

What does BUS stand for in the physical exam?

Bartholin glands, Urethra, Skene’s ducts

What viral infx results in formation of contagious sores MC around mouth or genitals and anus?

HSV

What is the MCC of herpes labialis / cold sores?

HSV 1

What is the MCC of anogenital blisters & associated with more severe sx?

HSV 2

Where does HSV-1 associated with oral herpes lie dormant?

Trigeminal ganglion

Where does HSV-2 lie dormant?

Sacral ganglia

What does it mean for HSV strains to lay dormant in a group of nerve cells?

Inactive, unlikely to shed and therefor not contagious

Where is herpes keratitis?

Cornea

Where is herpetic whitlow?

Nail or finger

Where is herpes esophagitis?

Esophagus

Where is herpes encephalitis?

CNS

What is the prodrome associated with HSV?

Onset 2-5 days after inoculation & occur 24 hrs prior to outbreak

Flu like sx (fever, myalgia, malaise, HA), burning, paresthesia, itching at infx site

What is HSV incubation period?

4 days

The following sx describe what STI?

• painful, grouped clear vesicles on erythematous base

• can turn into painful ulcers - yellow-gray w/ erythematous ring/halo

• “mini cigarrette burns”; can coalesce or lead to secondary bacterial infx

HSV

Which outbreak with HSV is most severe and longest in duration?

First

Why are subsequent HSV outbreaks milder and shorter?

Immune response/memory

What type of HSV lesion?

• Primary infx; MC in kids

• MC caused by HSV1

• fever and anorexia → gingivitis, mouth / tongue / lip vesicles that turn into grayish-yellow lesions

Acute herpetic gingivostomatitis

What type of HSV lesion?

• Primary infx; MC in adults

• Vesicle formation of tonsils that ulcerate into grayish lesions w/ exudate on posterior pharyngeal mucosa

Acute herpetic pharyngotonsillitis

What type of HSV lesion?

• MC secondary infx

• Cold sores/fever blisters

• Triggered by stress, illness, steroids, sun, wind, extreme temps

Herpes labialis

What HSV lesion?

• MCC by HSV-2

• vulva, vagina, cervix, perineum, perianal skin, buttocks

Genital lesions

What is the most sensitive and specific test for HSV?

PCR / NAAT

What reduces PCR sensitivity for HSV?

More time bt onset and time of culture

What are diagnostic measures for HSV?

PCR/NAAT, viral culture, tzanck smear (cytodiagnostic/microscopic), direct fluorescence ab, serology (not diagnostic but only option if pt presents lat and blisters ulcerated/resolved)

Is asymptomatic screening in HSV recommended?

No

What is the most critical time to treat a primary HSV episode?

first 48-72 hours (best if rx initiated in first 24 hrs)

Why is the treatment for primary HSV episode?

7-10 days of acyclovir, famciclovir, or valacyclovir

What is the treatment for recurrent HSV episodes?

Antivirals- start at FIRST prodromal sign

Which antiviral is the least effective for the suppression of HSV viral shedding?

Famciclovir

What should be considered in HSV patients that have > 6 outbreaks per year or are at risk of being immunocompromised?

Suppression- acyclovir or valacyclovir daily

What prevents HSV horizontal transmission?

Suppressive therapy, condoms, abstinence

What is indicated for a an active HSV outbreak at the time of labor?

C section

When should suppressive treatment be started in a pregnant patient with HSV?

35-36 weeks gestation (sooner if frequent outbreaks)

What does the first tingle/prodromal HSV symptom mean?

Pt is contagious

What STI is by a gram negative bacterium chlamydia trachomatis affecting the cervix, vagina, urethra, and can extend into upper reproductive tract?

Chalmydia / “The clam”

What is the MC bacterial STI in the US?

Chalmydia

What is the primary site of chlamydia in females?

Cervix

What sx are associated with chlamydia?

Asx (MC), urethritis, cervicitis (MC primary site), PID, salpingitis

How does chlamydia present in a neonate infected from mother?

Conjunctivitis and PNA

How often should women be screened for chlamydia?

Annually in sexually active F ≤ 25

Annually in sexually active F w/ RF > 25 y/o

Every 3-4 mos if prior infx

35-36 weeks gestation if pregnant

How is chlamydia dx?

Nucleic acid amp test (NAAT), Test of cure (TOC), rescreen x 3-4 mos if positive

What is the primary way to test for chlamydia in men?

NAAT from urine collection

What is test of cure (TOC)>

Ensure successful eradication of infx 4 weeks after completion of medication & r/o reinfection

What is the MCC of positive chlamydia rescreen?

Untreated partner or new sexual partner

What is the preferred first line treatment for chlamydia?

Doxy

What are alternative treatments for chlamydia in those allergic, can’t tolerate doxy?

Azithro (esp if noncompiant), FQs (levy or oflaxacin),

What is chlamdyia tx options in pregnancy?

Azithro or amoxicillin

How long should a pt w/ chlamdyia avoid sexual intercourse?

24-48 hours after medication completion (7 days if single dose regimen)

What STI is by chlamydia trachomatis strain that affects the lymph tract and nodes?

Lymphogranuloma Venereum (LGV)

Who is LGV MC In?

MSM

What are the 2 phases of LGV?

Primary: genital ulcers, discarge

Secondary: climatic bubos fom ascending infx into inguinal/femoral LNs (MC presenting sx)

What sx are seen in LGV with rectal exposure?

Proctolitis- mucoid/hemorrhagic rectal discharge, anal pain, constipation, tenesmus, fever

*can lead to chronic colorectal fistula and strictures of not tx early

What is the MC presentation of LGV in MSM?

Proctocolitis

What is the dx for LGV?

Chalmydia serology, direct ulcer swab, bubo aspirate

What is the treatment for LGV?

1st line: doxy

2nd line: azithro (preferred in pregnancy) or erythro

What STI is caused by gram negative diplococci known as neisseria gonorrhea?

Gonorrhea / “the drip” or “the clap”

What is the 2nd MC STI in the US & MC in adolescents, young adults, minorities, and people living in SE US?

Gonorrhea

What is the MCC of urethritis in men?

Gonorrhea

What are sx seen with gonorrhea?

Urethritis (MC men), mucopurulent cervicitis, salpingitis, PID

Bartholins gland infx

Anal dc

Pharyngitis w/ dc (often asx)

How is gonorrhea dx?

NAAT (MC), culture, screening, TOC, rescreen 3-4 wk if pos

What should be treated along with gonorrhea unless r/o?

Chlamydia

What is the treatment for gonorrhea?

Ceftriaxone + doxy or azithro

Ceph allergy: Gentamicin + azithro

What STI?

• caused by mycoplasma genitalium

• common co-infx w/ other STIs (HIV)

• sx: nongonococcal urethritis in M, vaginitis / cervicitis / PID in F

• dx: NAAT- urine for M, vaginal swab for F

Mycoplasma Genitalium

What is the treatment for mycoplasma genitalium?

Macrolide sensitive: Doxy + axithro

Macrolide resistant: Doxy + moxifloxacin

Resistance testing not available: Doxy + moxifloxacin

What are PID sequelae secondary to STIs?

Chronic infx, chronic pelvic pain, infertility, ectopic pregnancy, perihepatitis (Fitz-Hugh-Curtis syndrome)

What is Fitz-Hugh-Curtis syndrome?

Inflammation of liver capsules and adhesions (peri-hepatitis)

What viral infx of keratinized skin causes excessive proliferation and retention of stratum cornea leading to papule formation?

HPV / anogenital warts

When do HPV lesions occur after contact?

1.5 - 3 mos

What type of HPV?

• cutaneous & non STI related

Warts - vulgaris, plantaris, plana

What type of HPV?

• anogenital warts aka condyloma accuminatum

• MCC strains 6 or 11

• Can occur anywhere but MC vulva, vagina, cervix, urethral meatus, perineum, anus, tongue, oral cavity

• cervial inflammation, dysplasia, or malignancy if cervical strain (16, 18, 45, etc)

• anogenital carcinoma

Mucosal HPV

Condylomata acuminata is seen with _____

Condylomata lata is seen with ______

HPV ; Syphillis

What is the treatment for HPV genital warts?

Topicals- TCA, podophyllin, condylox, 5-FU

Surgical- cryotherapy, laser, electrodissection, excision

When is C section indicated with HPV?

Extensive on vaginal, vulva, or cervix and preparing to deliver

When can an HPV pregnant patient usually deliver vaginally?

Positive for cervical HPV & non-wart related

What are high risk cervical HPV strains?

16, 18, 45

When is it best to receive HPV vaccine?

Adolescence BEFORE becoming sexually active

What sx are seen with cervical HPV?

MC asx, intermenstrual or contact bleeding, PM bleeding, dyspareunia, ± pelvic pain

What is the dx for cervical HPV?

Pap smear w/ HPV co testing, colposcopy w/ bx (diagnostic)

What is the treatment for cervical HPV?

Routine surveillance, immune supporting supplement (folate, vit D3, zinc, DIM), barrier method 12-18 mos after dx/until negative, cryoablation or laser ablation, LEEP or conization

Once HPV testing turns negative, does that mean it is truly gone?

No, could be eradicated or dormant. No way to tell

What is a chronic infection caused by treponema pallidum (sphirochete, gram negative bacteria)?

Syphilis

What phase of syphilis?

• Chancre- painless ulcer w/ punched out appearance and rolled edges

• non tender regional LAD

• onsets 10-60 days after infx, resolves spontaneously in 3-9 wks

• usually seronegative

Primary syphilis

What phase of syphilis?

• onsets 4-8 wks after primary chancre

• systemic flu sx- low fever, HA, malaise, sore throat, anorexia, generalized LAD

• rash: diffuse, symmetric & asx maculopapular rash

  • money spots on palms and soles

• mucous patches: highly contagious, moist w/ grayish necrotic exudate

• Condyloma lata

• clears spontaneously 2-6 wks

Secondary syphilis

What is a warty like, slightly raised, round or oval, flat plaque seen in secondary phase of syphilis at the same site chancre occurred, and is highly contagious?

Condyloma lata

What phase of syphilis?

• onset from 1 to 20+ years after initial or latent infx

• low rate of transmission, now as contagious

• Gumma

• neurosyphilis

• CV- aortas, AR, AAs

Tertiary syphilis

What is a noncancerous, destructive granuloma on skin and body tissues (including bone) seen in the tertiary phase of syphilis?

Gumma

How does neurosyphilis in the tertiary phase present?

Ha, meningitis, dementia, vision/hearing loss, incontinence, tabes dorsalis

What is tabes dorsalis / syphilitic myelopathy?

Ataxia, areflexia, burning pain, weakness associated with neurosyphilis resulting from demyelination of posterior columns of spinal cord

What is the mnemonic for tabes dorsalis?

Dorsal column degeneration

Ortho pain (Charcot joints)

Reflexes dec (deep tendon)

Shooting pain

Argyll robertson pupils

Locomotor ataxia

Impaired proprioception

Syphillis

What phase of syphilis?

• asymptomatic infx

• normal exam

• positive sero testing

Latent syphilis

What phase of syphilis?

• crosses placenta after 16 week (as early as 6 wks in some)

• inc miscarriage, stillbirth, neonatal death if mother untreated

• “snuffles”

• affects brain, eyes, ears, teeth, bones, skin

Congenital syphilis

What is the screening for syphilis?

RPR (must be confirmed by FTA/MHA-TP), VDRL

What are the confirmatory diagnostics for syphilis?

FTA-ABS, MHA-TP, dark field microscopy

What is the treatment for syphilis in a non pregnant patient?

Benzathine PCN G

Alt: doxy or tetra

What are syphilis treatment options in pregnancy?

Benzathine PCN G preferred, even if allergic

last resort: azithro (reserved for anaphylaxis)

What is a skin infection caused by a virus of poxviridae family?

Molluscum contagiosum

Who is molluscum contagiosum MC in?

Kids (suspect sexual contact or abuse if genital areas in young children)

What condition?

• raised, waxy papule w/ waxy core or umbilication

• occurs in groups along scratch lines or scattered

• nontender, non pruritic

Molluscum contagiosum