Sexually Transmitted Infections/Pelvic Infections

sexually transmitted infections are disorders spread by ?

intimate contact

what STI can spread via lactation from mom to baby?

HIV

herpes genitalis

A sexually transmitted infection caused by a DNA virus, herpes simplex virus (HSV) (in and out of the nervous tissue)

Incubation period is 2-7 days

what is the clinical presentation of a prodrome of herpes genitalis?

Tingling, burning, itching; sensation/feeling before an outbreak starts

Fever, malaise, HA, myalgias

Inguinal lymphadenopathy

what is the clinical presentation of the initial outbreak of herpes genitalis?

Extensive lesions

Lasting 2-6 weeks without treatment

Systemic symptoms and lymphadenopathy are common

what is the clinical presentation of subsuquent outbreaks of herpes genitalis?

Lesions are localized, smaller, fewer in number, and typically confined to a constant area

Last 1-3 weeks without treatment

Systemic symptoms and lymphadenopathy are rare

what is the gold standard/most sensitive test for herpes genitalis?

HSV PCR

what are the 3 antiviral therapies that can be prescribed for herpes genitalis for the initial outbreak, subsequent outbreaks, and suppressive therapy?

Valacyclovir

Acyclovir

Famcyclovir

what are complications to herpes genitalis?

Psychological implications

Neonatal herpes

Cervicitis

Secondary infection

HIV patient with HSV should receive ? due to prolonged outbreaks and increased HSV shedding

suppressive therapy

Women with any potential history of HSV or a partner with HSV should be given suppressive therapy starting at how many weeks gestation?

36

condyloma acuminatum

Papillary growths affecting the perineum, anus, vulva, vagina, cervix, and oropharynx

Incubation period ranges from weeks to years

Caused by “low risk” strains of single stranded DNA virus, human papilloma virus (HPV)

what strains of HPV typically cause condyloma acuminatum?

HPV 6 and 11

how does condyloma acuminatum present?

Whitish or flesh-colored papillomatous growths with “cauliflower” appearance ranging from small single lesions to large coalescing growths

Recurrence is common

why can you diagnosis condyloma acuminatum with acetic acid application?

HPV has large nucleus so it will look white with acid

what are treatment options for condyloma acuminatum?

Trichloroacetic acid (office)

Podophyllin (office)

Surgical options: Cryosurgery, electrosurgery, laser surgery, simple resection

Home treatments: Imiquimod (Aldara, Zyclara)

Podofilox (Condylox)

Sinecatechin (Veregen®)

condyloma in pregnancy

Grow fast, bleed more

Risk of transmission to infant during vaginal delivery

Genital warts, laryngeal papilloma, and rarely infection of the pulmonary parenchyma

what is a great way to prevent condyloma acuminatum other than condom use?

Gardasil vaccine

bacterial vaginosis is NOT sexually transmitted but what is it associated with?

high risk behavior (multiple sex partners, new sex partners, lack of condom use)

trichomoniasis

Sexually transmitted vaginal infection caused by Flagellated protozoan Trichamonas vaginalis

Incubation period is unknown

Excellent cure rate

how does trichomoniasis present?

Asymptomatic

Purulent malodorous thin discharge, frothy, bubbly, (green, yellow, thin)

Vaginal irritation

Dyspareunia

Dysuria

Erythema of the vulva/vagina

Punctate hemorrhages on the cervix “strawberry cervix”

what is the treatment for trichomoniasis?

Metronidazole (Flagyl) or Tinidazole

Metronidazole, Tinidazole, or Secnidazole

Empiric treatment for trichomoniasis is appropriate in certain circumstances t/f

true

1 multiple choice option

what are complications of trichomoniasis?

Cervicitis

Salipingitis

PPROM and preterm delivery

gonorrhea

A highly contagious sexually transmitted infection that caused by Gram-negative diplococcus, Neisseria gonorrhoeae

Can involve any mucous membrane, most common site of infection is the genitourinary tract

Incubation period of 2-7 days

Excellent cure rate

how does a localized infection of gonorrhea present?

Purulent vaginal discharge (yellow, green)

Vaginal irritation

Urinary frequency

Dysuria

Rectal discomfort

Pelvic pain

Acute pharyngitis/tonsillitis

Conjunctivitis

how does a disseminated infection of gonorrhea present?

Septicemia

purulent arthritis

Endocarditis

Meningitis

what is the gold standard way to diagnosis gonorrhea?

nucleic acid amplification

what is the treatment for gonorrhea?

Ceftriaxone

Empiric treatment for gonorrhea is NOT appropriate in certain circumstances t/f

false

1 multiple choice option

what are complications of gonorrhea?

Cervicitis

Pelvic inflammatory disease

Salpingitis

PPROM and preterm delivery

Opthalmia neonatorum

High rates of Chlamydia coinfection

Reinfection is common

chlamydia

A highly contagious sexually transmitted infection caused by Gram-negative bacteria, Chlamydia trachomatis

Incubation period of 7-14 days

Excellent cure rate

how does chlamydia present?

Asymptomatic

Mucopurulent discharge

Urinary symptoms

Pelvic pain

Cervical erythema and hypertrophy

what is the gold standard way to diagnose chlamydia?

nucleic acid amplification

how do you treat chlamydia?

azithromycin or doxycycline

Empiric treatment of chlamydia is appropriate in certain circumstances t/f

true

1 multiple choice option

what are complications of chlamydia?

Cervicitis

Pelvic inflammatory disease

Salpingitis

PPROM and preterm delivery

Fitz-Hugh Curtis Syndrome

Conjunctivitis, otitis media, or chlamydial pneumonia from vaginal delivery

Lymphogranuloma Vereneum

High rates of Gonorrhea coinfection

Reinfection is common

lymphogranuloma venereum

Sexually transmitted infections of inguinal lymphatic channels caused by L serotypes of gram-negative bacteria, Chlamydia trachomatis

Rare in the US

M > F

how does lymphogranuloma venereum present?

Extremely tender inguinal or femoral lymphadenopathy above and below the inguinal ligament, with a groove along the ligament

Genital ulcer may be present at the exposure site

Rectal symptoms

Constitutional symptoms

how is lymphogranuloma venereum treated?

Doxycyline

what are complications of lymphogranuloma venereum?

Scarring

Vulvar elephantiasis

Vulvar narrowing

Colorectal fistula

Sigmoid stricture

Frozen pelvis

Infertility

how do you prevent lymphogranuloma venereum?

Condom use

Any person who has had intimate contact with the patient within 60 days of diagnosis should be screened, cultured, and offered treatment

chancroid

A sexually transmitted bacterial infection of the genitals caused by Gram-negative rod, Haemophilus ducreyi

Incubation period of 4-10 days

Rare in the US

how does chancroid present?

Multiple painful necrotizing ulcerations

Foul smelling discharge

Painful inguinal lymphadenopathy

how is chancroid managed?

Genital hygiene

Fine needle aspiration of fluctuant lymph nodes

Azithromycin

Ceftriaxone

what are complications of chancroid?

Inguinal Scarring

Fistula formation

Secondary infection

what is the prevention for chancroid?

Any person who has had intimate contact with the patient within 10 days of diagnosis needs to be treated

granuloma inguinale

Sexually transmitted chronic ulcerative vulvitis caused by Gram-negative rod, Klebsiella granulomatis

Incubation period is 8-12 weeks

Rare in the US

M>F

how does granuloma inguinale present?

Papule -> painless ulceration associated with well demarcated erythema

Ulcers are slowly progressing

Involve vulva, perineum, inguinal region

Malodorous discharge and bleeding from the ulcer

Poor healing, susceptible to secondary infection

"Kissing ulcers" from autoinoculation on adjacent skin

how is granuloma inguinale diagnosed?

Donovan bodies identified by staining of culture or biopsy

how is granuloma inguinale treated?

Azithromycin

what are complications of granuloma inguinale?

Scarring

Hypopigmentation

Damage to lymphatic system

Secondary infection

Narrowing of urethra, vagina, or anus

Osteomyelitis, polyarthritis

how do you prevent granuloma inguinale?

Initiation of therapy immediately after exposure may offer suppression

Any person who has had intimate contact with the patient within 60 days of diagnosis should be screening and offered treatment

syphillis

A sexually transmitted disease caused by Spirochete, Treponema pallidum affecting multiple systems

Can be passed from mother to fetus via transplacental vertical transmission

Incubation period is 10-90 days

primary syphilis

10-90 days after initial infection

Chancre: firm, painless, papule or ulceration with a raised border

Regional lymphadenopathy

secondary syphilis

2 weeks to 6 months after initial infection

Systemic infection from homogenous spread

Viral syndrome

Rash: Diffuse, B/L papulosquamous lesions involving the palm, soles, and other skin surfaces

Other possible symptoms: pharyngitis, hepatitis, alopecia

tertiary syphilis

Years after initial infection

Occurs in 1/3 of untreated cases

Skin, subcutaneous tissue, bone, viscera: Granulomatous lesions (of subcutaneous tissues)

Cardiovascular: Aortic insufficiency or aortic aneurysm

Psychiatric: Memory loss/dementia, personality changes

Neurologic: Numbness, paresthesias, paralysis, seizures

EENT: Eye pain, vision changes, blindness, pupillary changes, hearing loss; Argyll-Robertson pupil

neurosyphilis

an infection of the CNS that can occur in any stage of syphilis (most common in tertiary)

early neurosyphilis vs late presentation

Early: meningitis, meningovascular disease, ophthalmic or auditory dysfunction, cranial nerve palsy

Late: gait disturbance, dementia

latent syphilis

serologic evidence of infection but no symptoms

what are 2 serological tests for syphilis? explain each

Nontreponemal tests

Generalized antibody detection

Titers may correlate with disease activity and can be used to follow treatment success

Treponemal tests

Detection of anti-treponemal antibodies

Cannot be used to follow treatment success

how do you treat syphilis?

Benzathine Pen G

Jarisch-Herxheimer reaction

Febrile reaction that occurs in 50-75% of patients treated with PCN in early syphilis

how do you treat syphilis for your patient is allergic to pencillin?

doxcycline, tetracycline, or densenitiation

a patient comes into your obgyn office. she is sexually active patient, has pelvic pain and, no other definitive cause can be identified for the pain. she has cervical, uterine, and adnexal motion tenderness. what is her suspected diagnosis?

PID

pelvic inflammatory disease (PID)

Inflammation of the upper female genital tract caused by a microbial infection often C trachomatis &/or N gonorrhoeae

how does PID present?

Symptoms may be subtle

Acute onset of pelvic pain

Purulent vaginal discharge

Associated pelvic pressure or LBP

Nausea

Headache

Fever

Abdominal/pelvic tenderness to palpation

Cervical, uterine, or adnexal motion tenderness

Decreased bowel sounds

Painful bimanual exam!

what are lab findings that would be present for PID?

Numerous WBCs on wet mount

Elevated WBCs

Elevated C-reactive protein or SED rate

Positive STD culture

Endometrial biopsy showing endometritis

you do a transvaginal sono on your patient with suspected PID. what may you see?

Hyperemia

Dilated uterine cavity

Thickening of the tubes

Fluid in the uterus or tubes

Free-fluid in the pelvis

what does early PID look like

fluid-filled distended endocervical canal (*) with surrounding hyperemia (arrow)

what does late PID look like?

dilated endometrial canal (long arrows), hyperemia of myometrium (short arrow), uterine wall thinning

what is the treatment for PID?

broad spectrum antibiotic!

Cefoxitin + Doxycyclin IV x 24 hours OR Clindamycin + Gentamycin IV x 24 hours Then Doxycyclin PO x 14 days OR Azithromyin PO x 7 days W/ OR W/O Metronidazole PO x 14 days for anaerobic coverage

when should a patient with PID be hospitalized and be on inpatient therapy?

Surgical emergency

Pregnancy

No response to outpatient therapy within 72 hours

Severe systemic illness

Tubo-ovarian abscess

Non-compliance

what are complications to PID?

Peritonitis

Ileus

Pelvic thrombophlebitis

Abscess

Infertility

Ectopic pregnancy

Chronic pelvic pain

Adhesions

Gonococcal arthritis

Sepsis/shock

what if your patient with PID has an IUD?

IUD does not need to be removed unless infection is not responding to treatment

Risk of PID with IUD is only elevated for the first 21 days after insertion

Actinomyces should be considered in cases of PID with IUD

tubo-ovarian abscess

Abscess of the adnexa associated with PID

Symptoms can vary to Mild ---- acute abdomen ---- to septic shock

Tubo-ovarian abscess in postmenopausal women is typically due to what?

malignancy

how do you diagnose tubo-ovarian abscess?

Sonography reveals a multiloculated adnexal mass

CT can rule out other causes of an acute abdomen

Bilateral involvement can occur

how do you manage a tubo-ovarian abscess?

IV antibiotics followed by oral antibiotics

Image guided drainage or surgeries

Rupture is a surgical emergency due to resulting peritonitis

If IUD is present it should be removed

postpartum endomyometritis

Postpartum polymicrobial infection of the uterus from genital tract organisms

Presents with fever and uterine tenderness in the early postpartum period

what is the treatment for postpartum endomyometritis?

Broad spectrum antibiotics

Clindamycin IV, PLUS

Gentamicin IV, PLUS

Ampicillin IV

what are complications and prevention for postpartum endomyometritis?

Complications: Peritonitis, Pelvic abscess

Prevention:Prophylactic antibiotics, Decrease rates of chorioamnionitis

what are examples of postoperative infection of any remaining pelvic structure following gynecologic surgery caused by vaginal organisms?

Vaginal cuff cellulitis

Infected vaginal cuff hematoma

Salpingitis

Pelvic cellulitis

how do patients with postop pelvic infections present?

Edematous vaginal cuff

Purulent discharge

Induration and tenderness of the vaginal cuff

Pelvic pain

Fever

what is the broad spectrum antibiotics used to treat post op pelvic infections outpatient and inpatient?

Outpatient: Clindamycin PO x 10 days, PLUS Flagyl PO x 7 days

Inpatient: Clindamycin IV, PLUS Gentamicin IV, PLUS Ampicillin IV

what are complications of a post op pelvic infection?

Pelvic abscess

Tubo-ovarian abscess

Adhesions

Septic pelvic thrombophlebitis

Septicemia

how do you prevent postop pelvic infections?

Preoperative treatment of cervicitis/vulvovaginitis

Iodine-like preparation to the vagina

Preoperative antimicrobial prophylaxis

Adequate hemostasis intraoperatively

toxic shock syndrome

A febrile illness caused by bacterial toxins entering the bloodstream, usually associated with gram positive Staph aureaus or Strep pyogenes, rare

how does toxic shock present?

Symptom onset is rapid

Fever

Hypotension

Diffuse macular rash

Dizziness/syncope

Constitutional symptoms

Desquamation of palms and soles

how is toxic shock diagnosed?

Vaginal culture for S. aureus and group A strep

CBC reflecting thrombocytopenia and anemia

Abnormal coagulation studies

Abnormal renal and liver studies

how is toxic shock treated?

Removal of anything that could be the cause

Antibiotics coverage to include MRSA (Clindamycin IV for 10-14 days, PLUS Vancomycin IV)

what are complications of toxic shock?

Recurrence

Disseminated intravascular coagulation

Shock

Organ failure

Death

what are prevention measures to acoid toxic shock?

Lower absorbency tampons

Regularly change tampons, avoid overnight use

Practice good hygiene