Women's Health: Infections

Bacterial Vaginosis

Infectious vaginitis that is most commonly due to Gardnerella Vaginalis

-Presentation: white homogenous vaginal discharge, fishy odor that is exacerbated by menses/intercourse

-Physical Exam: “spilled milk over the tissue” white discharge, no erythema or inflammation of vaginal mucosa

-Dx: wet mount shows clue cells, vaginal pH > 4.5, and gram stain is gold standard

-Tx: Metronidazole

Lactobacillus

What endogenous flora keeps the vagina acidic?

BV

What vaginal infection can be the cause of preterm labor and late miscarriage in pregnancy?

Gram Stain

What is the gold standard diagnostic for BV?

Candida Vaginitis

Vaginal infection due to candida albicans, which is not considered to be an STI

-RF: immunocompromised, obesity, pregnancy, OCP use

-Presentation: vulvar itching, burning, dysuria, dyspareunia, and vaginal discharge that is “thick, adherent, cottage cheese discharge”

-Dx: pseudohyphae on KOH prep

-Tx: topical miconazole/clotrimazole/terconazole or PO fluconazole

Diabetes, autoimmune disease

If a patient has recurrent yeast infections, what should the patient be worked up for?

Chancroid

STI leading to genital ulcers, lymphadenopathy, and bubo formation

-10% coinfection with HSV or syphilis

-Presentation: 1 or more painful genital ulcers that are well-defined with irregular orders, followed by painful inguinal lymphadenopathy that can liquify and become fluctuant

-Dx: clinical, PCR to rule out HSV, RPR/VRDL to rule out syphilis

-Tx: Ceftriaxone or azithromycin

H. Ducreyi

What gram - fastidious coccobacillus bacteria causes chancroid?

-”School of fish” or “railroad track” appearance

Chlamydia

MC reported STI in the US

-Presentation: Most women are asx but can present with mucopurulent discharge, hypertrophic cervical inflammation

-Dx: NAAT, UA shows pyuria

-Tx: Doxycycline, Azithromycin if pregnant

Azithromycin

What antibiotic should be used in pregnant patients with chlamydia?

Test of cure

What is required after 3-4 weeks of chlamydia treatment in pregnant patients, followed by repeat testing of gonorrhea or chlamydia 3 months later?

Doxycyline

What is the antibiotic of choice for chlamydia?

Gonorrhea

STI cause by Neisseria Gonorrhea, which most commonly affects the urethra, cervix, anal canal, conjunctiva, or pharynx

-Presentation: Most women are asymptomatic but can present with mucopurulent discharge, vulvar itching/burning, sore throat

-Dx: NAAT, gram stain shows gram - diplococci

-Tx: Ceftriaxone

Ceftriaxone

What is the antibiotic of choice in gonorrhea?

Salpingitis

What is the most common complication of gonorrhea?

Herpes Simplex (HSV 2)

STI due to HSV 2

-Presentation: painful genital ulcers often preceded by prodromal symptoms of burning, paresthesias, numbness, dysuria, and fever. Physical exam reveals multiple, shallow, tender ulcers that are grouped on an erythematous base

-Dx: PCR, Tzanck smear shows multinucleated giant cells

-Tx: Acyclovir

Valacyclovir

If a patient has > 6 episodes of HSV in 1 year, suppressive therapy with what agent is indicated?

HPV

STI due to different strains of the human papilloma virus

-Presentation: cauliflower-like vaginal lesions that are normally flat, pedunculated flesh-colored growths

-Dx: clinical, biopsy if immunocompromised/refractory to treatment/postmenopausal

-Tx: Podofilax/imiquimod (self-applied), TCA or cryoablation, TCA preferred in pregnancy

TCA

What is the preferred treatment for HPV during pregnancy?

6, 11

What two strains of HPV cause genital condyloma?

16, 18

Out of the 5 strains of HPV associated with cervical cancer, what two have the highest association?

16, 18, 31, 33, 35

What are the five strains of HPV associated with cervical cancer?

Gardasil 9 Vaccine

What is the only preventative agent for HPV?

-Covers 6, 11, 18, 31, 33, 45, 52, 58

PID

Ascending infection of the upper reproductive tract, which is most commonly due to chlamydia/gonorrhea

-RF: multiple sex partners, unprotected sex, prior PID diagnosis, age 15-19, nulliparous, and IUD placement

-Presentation: pelvic or lower abdominal pain, dysuria, dyspareunia, vaginal discharge or bleeding, N/V, purulent cervical discharge, and cervical motion tenderness (Chandelier sign)

-Dx: presumptive diagnosis made in any sexually active woman presenting with pelvic or lower abdominal pain and have evidence of tenderness on exam, UPT, NAAT, U/S if needed

-Tx: Ceftriaxone + Doxycycline + Metronidazole

Tubo-Ovarian Abscess

Complication of PID characterized by acute lower abdominal pain, vaginal discharge, systemic symptoms, and unilateral adnexal tenderness on physical exam

-Ruptured leads to sx of acute abdomen + sepsis

-Dx: TVUS

-Tx: inpatient abx (ceftriaxone + doxy + metro) and surgical intervention

Fitz Hugh-Curtis Syndrome

Inflammation of the liver capsule with adhesion formation resulting in RUQ pain, which is seen in 10% of women with PID

-Presentation: RUQ pain due to perihepatitis that may radiate to the right shoulder

-Dx: laparoscopy shows “violin string” adhesions on anterior liver surface

Trichomoniasis

Common cause of vaginitis due to flagellated protozoan (T. Vaginalis)

-Presentation: green/yellow malodorous vaginal discharge, burning, pruritus, dysuria, postcoital bleeding, erythematous vaginal mucosa, and strawberry cervix on exam

-Dx: wet prep shows mobile flagellated organisms and many leukocytes

-Tx: Metronidazole

Alcohol

What should be avoided while taking metronidazole, in an effort to avoid a disulfiram reaction?

Atrophic Vaginitis

Atrophy of the vaginal epithelium due to diminished estrogen levels, MC in postmenopausal women

-Presentation: vaginal dryness, dyspareunia, vaginal inflammation, infection and recurrent UTIs with increased pH

-Dx: clinical, pH > 5

-Tx: vaginal moisturizers help with symptoms, topical vaginal estrogens, or Ospemifene (SERM)

Topical Estrogen

ADRs: vaginal bleeding, breast pain, nausea, thromboembolism, and endometrial cancer

Treponema Pallidum

What causes syphilis?

Primary

What stage of syphilis is being described?

-Lasts 3-6 weeks

-Presentation: painless chancre at inoculation site, mild-moderate regional lymphadenopathy that is often bilateral

Secondary

What stage of syphilis is being described?

-Weeks to a few months after chancre

-Presentation: diffuse symmetrical pink-brown rash that is maculopapular and found on trunk and extremities, white erosions in the oral mucosa, fever, headache, pharyngitis, myalgias, weight loss, chorioretinitis

Tertiary

What stage of syphilis is being described?

-Late

-Presentation: ascending thoracic aorta causes dilation and AVR, granulomatous disease of skin and subcutaneous tissues, bones, or viscera

Early Neurosyphilis

What complication of syphilis is being described?

-Involves the CSF, meninges, and vasculature

-Presentation: asymptomatic, meningitis, posterior uveitis, hearing loss, ischemia, stroke

Late Neurosyphilis

What complication of syphilis is being described?

-Involves the brain, spinal cord, and parenchyma

-Presentation: progressive deficits in memory/judgement leading to severe dementia, Argyll-Robertson pupil, sensory ataxia, lancinating pains, absence of LE reflexes

VRDL, RPR

What two tests are used for initial screening in patients with suspected syphilis?

FTA-ABS

What is the most specific test for syphilis?

Motile Spirochetes

What does dark field microscopy show on a smear of a syphilitic ulcer?

LP

What additional diagnostic test should be performed in a patient with suspected neurosyphilis?

PCN G

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

Doxycycline

What antibiotic should be used for syphilis in someone with a penicillin allergy?

6, 12, 24

In patients with syphilis that have been treated with PCN G, when should they be monitored after treatment?

-Primary/Secondary/Early Latent are the first two

-Tertiary or Late Latent are all three