clin med obgyn pt. 2

Normal vaginal pH

About 4.5

Lactobacillus keep and acidic environment

MCC vaginitis

BV

Cause of BV

Overgrowth of bacteria (imbalance of vaginal flora)

Typically overgrowth of gardnerella vaginalis

Lactobacilli

Produces lactic acid in the vagina creating an acidic environment

Protective against overgrowth of anaerobic bacteria

Sxs BV

Thin, grayish, white, homogenous discharge (predominant reported symptom)

Vaginal odor (fishy smell that may be worse after sex)

Dx BV

Clue cells on saline wet mount

Nugent gram stain

NAAT (afirm)

Amsel criteria

Gray, thin homogenous discharge

Vaginal pH over 4.5

Positive whiff test

Presence of clue cells

If 3+ can empirically dx BV

BV Tx

If asymptomatic and not pregnant no need to treat, but all pregnant pts must be treated

Change hygiene practices if applicable

Metronidazole 1st line medical tx (no ETOH, can cause HA)

Clindamycin 2nd line

Vaginal candidiasis

Candidal organisms invade vaginal tissue and cause mucosal infection and inflammation resulting in vaginal symptoms

Sxs vaginal candidiasis

Itchiness

White, chunky, cottage cheese discharge that can stick to the vaginal walls

Erythema and swelling of vulva and vaginal mucosa

vaginal candidiasis dx

microscopy on KOH prep: budding yeast and pseudohyphae

gram stain: budding yeast

candida on NAAT “affirm” panel

vaginal candidiasis tx

may self-resolve, but tx helps resolve symptoms

uncomplicated: topical intravaginal antifungals or oral fluconazole

can consider prophylaxis for people prone after abx use

cause of trichomoniasis

motile flagellate protozoan trichomonas vaginalis

infects men as well as women

T. vaginalis

can only survive if it colonizes the female lower genital tract, male urethra or prostate

destroys vaginal epithelial cells causing increased neutrophils

vaginal pH in candidiasis and trichomoniasis

candidiasis: normal

trich: above 4.5 due to loss of lactobacilli from t. vaginalis colonization

sxs trichomoniasis

70% are asymmptomatic

sxs when present are similar to BV but more severe

discharge: frothy, yellowish, thick, foul odor

can have itching, burning, soreness, dyspareunia and dysuria

strawberry cervix

inflamed cervix on speculum exam

trichomoniasis

trichomoniasis dx

vaginal microscopy with flagellated pyriform protozoa

can have positive whiff test

if positive must screen for other STIs as well

trichomoniasis tx

pt and their sexual partners need abx

systemic metronidazole (men have single dose)

2nd line: tinidazole

follow up testing for STIs

test for cure 3 weeks-3 months post tx

atrophic vaginitis

atrophy of vaginal epithelium due to diminished estrogen levels

usually postpartum women

thinned epithelium and pH over 7

loss of elasticity and connective tissue

atrophic vaginitis dx and tx

dx: clinically based on hx and exam

tx: topical or oral estrogen therapy, lubricating agents as adjunct/supportive care

STIs are associated with

infertility, cancer, and death

MCC preventible infertility

5 MC STIs

human papilloma virus (HPV)

herpes simplex virus (HSV)

chlamydia (non-gonococcal urethritis)

gonorrhea

human immunodeficiency virus (HIV)

transmission of STIs

skin-to-skin or exchange of bodily fluids

anal intercourse has high risk of transmission since tissues break very easily (can add on anal swab)

can also be transmitted via oral-genital intercourse (can add on throat swab)

urethritis and cervicitis are ____ reproductive tract infections

lower

PID is a complication of ____ affecting the female _____

STIs

upper reproductive tract

MCC urethritis and cervicitis

N gonorrhea and C trachomatis

urethritis and cervicitis dx

NAAT testing available for C trachomatis, N gonorrheae and HSV is gold standard

most frequently reported STI in the US

chlamydia

chlamydia sxs

most individuals are asymptomatic

women: may present as cervicitis and/or urethritis

men: may develop urethritis

chlamydia dx

NAAT collected from urine (men) or swab (women)

untreated chlamydia can cause

Men: epididymitis and prostatitis

women: PID and infertility

chlamydia tx

doxycycline 1st line

2nd line: azithromycin

pregnant pts: amoxicillin

chlamydia complications

PID

Fitz-Hugh-curtis syndrome (perihepatitis)

infertility, pelvic pain

chlamydial conjunctivitis in newborns (typically 5-14 days after birth)

fitz-hugh-curtis syndrome

complication of PID
perihepatitis

inflammation of hepatic capsule and diaphragm

pleuritic chest pain

violin string sign: adhesions between the liver and abdominal wall

up to ___ of pts with gonorrhea are co-infected with _____

40%

chlamydia

gonorrhea affects the ____ and enhances transmission and acquisition of _____

mucous membranes of cervix, uterus, fallopian tubes, urethra, mouth, throat, eyes, and anus

HIV/AIDs

gonorrhea sxs

most are asymptomatic, esp for women

men: purulent urethral discharge and urethritis (typically within 5 days)

women: cervical infection (typically within 14 days)

untreated gonorrhea

infection can spread to deeper structures causing abscess formation and disseminated gonococcal infection (DGI)

gonorrhea dx

NAAT test of choice

gram stain: gram negative intracellular diplococci

culture with modified Thayer-Martin medium

if positive should also be screened for chlamydia, syphilis, and HIV

gonorrhea tx

standard is dual therapy for C and G: ceftriaxone IM once with doxycycline PO for 7 days

give 1 g rocephin for pts weighing over 150 kg

gonorrhea complications

PID, infertility, perihepatitis

epididymitis and prostatitis in men

disseminated gonococcal infection (septic arthritis)

gonococcal ophthalmia neonatorum (conjunctivitis in infants): 2-5 days after birth

most common STI worldwide

HPV

HPV is associated with

many types of cancer: cervical, vulvar, vaginal, anal, oropharyngeal

serotypes 16 and 18: cause most cervical cancers

serotypes 6 and 11: cause most genital warts

children delivered vaginally to mothers with genital HPV infection

at risk for developing recurrent respiratory papillomatosis later in life

HPV sxs

often asymptomatic

if warts are present, pts are typically bothered by cosmetic appearance

HPV dx

warts dx clinically on exam

otherwise most often diagnosed through routine screening for cervical cancer

biopsy performed to diagnose HPV-related cancers

HPV genital warts tx

liquid nitrogen (cryotherapy)

podophyllum resin cream: preferred “pt applied tx” for men

imiquimod cream: preferred “pt applied tx” for women (not recommended in pregnant pts)\

operative removal used for large (over 2cm) and/or pedunculate lesions

ACOG recommendation for HPV and cervical cancer screening

females and males age 9-26 be immunized against HPV, ages 27-45 with shared decision making

vaccine not substitute for cancer screening

genital HSV caused by

both HSV-1 and HSV-2

most HSV cases are

unrecognized primary infections

asymptomatic

HSV1: acquired in childhood

highly contagious

HSV sxs

painful, grouped vesicles on an erythematous base

may have systemic sxs

recurrent dz less severe than primary

HSV dx

clinical dx confirmed by viral culture or PCR

serology can be performed if no active lesions are present

Tzank smear: multinucleated giant cells

+antibodies to HSV-2

typically implies anogenital infx

+antibodies to HSV-1

may be either orolabial or genital infx

HSV tx

oral antivirals 7-10 days: acyclovir, valacyclovir, famiciclovir

recurrent infx: to be effective, tx must be initiated at onset of recurrence (within 24 hrs)

frequent or severe recurrences: suppressive therapy daily

lymphogranuloma venereum pt population

diagnosed more often in men than women

increasingly reported among men who have sex with men

LGV cause

caused by 3 unique strains of chlamydia trachomatis

LGV sxs

small, often asymptomatic skin lesions followed by regional lymphadenopathy in groin or pelvis

if LGV acquired by anal sex may manifest as

severe proctitis

without tx LGV may cause

obstruction of lymph flow and chronic swelling of genital tissues

LGV dx

clinical signs with laboratory confirmation

LGV tx

21 days of tetracycline or erythromycin

chancroid cause

haemophilus ducreyi

chancroid sxs

small, painful papules appear on the genitals, rapidly breakdown into shallow, soft, painful ulcers

results in enlargement of inguinal lymph nodes and suppurination: painful unilateral inguinal lymphadenopathy (buboes)

deeper erosion and marked tissue destruction

what may result from chancroid

urethral strictures and urethral fistula

chancroid dx

usually clinical

serologic testing for syphilis and HIV and cultures for herpes shoudl be done

cofactor for HIV transmission

chancroid tx

single-dose azithromycin oral or ceftriaxone IM

molluscum contagiosum is characterized by

clusters of pink, dome-shaped, smooth, waxy, or pearly and umbilicate papules

molluscum contagiosum cause

pox virus

where is molluscum contagiosum mostly found

face, arms, legs, torso, and armpits in children

adults typically have lesions in the genital region: considered an STI

molluscum contagiosum dx

clinical

molluscum contagiosum tx

usually resolve spontaneously 6 months to 1 year

cryotherapy (liquid nitrogen), expression with forceps, currettage under anesthesia

syphilis cause

treponema pallidum

major routes of infection for syphilis

sex and mother to fetus

classifications of syphilis

primary, secondary, tertiary, neurosyphilis

primary syphilis

begins as a painless chancre (single, painless, papule)

quickly erodes and becomes indurated with a clean base and raised, firm borders

often accompanied by regional painless bilateral adenopathy

serologic tests usually negative

secondary syphilis

begins about 2-8 weeks after appearance of the chancre

associated with systemic symptoms

characterisitc rash involving the body, palms, and soles that may be macular, maculopapular, papular or pustular

condylomata lata: highly infectious, moist, smooth, painless, gray-white lesions that develop in the intertrigenous areas and mucous membranes

latent syphilis

lack of clinical manifestations with positive serology

early: less than 1 year

late: over 1 year, less contagious

tertiary syphilis

average time of onset is 4-12 years after infection

trnasmission unlikely at this stag

involves severe damage to CNS

ophthalmic and auditory abnormalities

cardiovascular: causes endarteritis (aortic aneurysm or aortic valve insufficiency)

gummatous syphilis or “gummas”: skeletal, mucosal, ocular, and visceral lesions

tertiary syphilis is often referred to as

neurosyphilis

early neurosyphilis

presents the 1st year after infection as meningitis, particularly among HIV-infected persons

late neurosyphilis

more common, follows typical timeline (years after primary infection)

may be meningovascular (presents as stroke)

may manifest as tabes dorsalis (dorsal roots of spinal cord affected with sensory deficits, rhomberg sign), personality changes, and hallucinations

syphilis dx

identify spirochetes from primary or secondary lesions with swab (not always available)

often presumptive dx based on hx/exm and confirm with serology

may have false positives and one test is insufficient

what test is confirmatory for syphilis

treponemal test

a confirmed positive treponemal test and negative nontreponemal test may be seen with

old treated syphilis

old untreated syphilis

prozone reaction

early syphilis

if neurosyphilis is suspected

LP to run VDRL on CSF

CSF: greater than 5 WBC with positive VDRL

syphilis tx

parenteral penicillin G IM

PCN allergic: doxycycline PO

PCN allergy and pregnant: PCN with desensitization

PID MC organisms

N gonorrheae and C trachomatis

PID is often

polymicrobial

what does PID encompass

endometritis, salpingitis, tubo-ovarian abscess, pelvic peritonitis

PID sxs

fever and lower abdominal pain

may have RUQ tenderness from perihepatitis

pelvic: cervical motion tenderness (chandelier sign), adnexal tenderness, purulent discharge

PID dx

clinical dx

definitive: histopathological evidence, radiologic evidence with TVUS, laparoscopic evidence of PID

PID tx

outpatient: ceftriaxone with doxycycline and metronidazole

inpatient: cefotetan or cefoxitin or ceftriaxone with doxycycline (if using ceftriaxone add metronidazole)

HIV-1 and HIV-2 are ____ that cause ____

RNA retroviruses

AIDs

HIV infection selectively depletes _____

CD4 cells, resulting in immunodeficiency

HIV-1 vs HIV-2

HIV-1: predominant subtype in the US and worldwide

HIV-2: found mainly in west Africa and has a slower clinical course

HIV/AIDs is an

acute retroviral syndrome

occurs in 1-6 weeks after exposure to HIV

sxs mimic mono: fever, lymphadenopathy, pharyngitis, rash, myalgias, arthralgia

sxs resolve without tx within 1-2 weeks

chronic HIV infection

may be clinically silent for years

clinical manifestations depend on CD4 count