POM II - Gyn D/O and Infxns - Exam 4

Lichen Sclerosus

-most common benign epithelial vulvar disorders

-caused by chronic inflammation

-typically occurs in women >60 years old

-biopsy required for dx (to rule out cancer)

Lichen Sclerosus - etiologies

-autoimmune

-genetic predisposition

-vitamin A deficiency

-low testosterone

Lichen Sclerosus S/S

-causes intense pruritus, vulvar skin to be thin, wrinkled, and white

-areas of lichenification and hyperkeratosis

-anterior parts of the B/L labia minora may fuse

-erosions, fissures, hemorrhages, ulcerations result from scratching

Lichen Sclerosus Tx

-Goal: stop itching/scratching and minimize inflammation

-General vulvar hygiene measures

-oral antihistamines

-clobetasol dipropionate 0.05% topical (make sure u taper)

-alternatives: tacrolimus cream, retinoid, antimalarial agents, photodynamic therapy

-surgical therapy reserved for introital narrowing or neoplasia

Lichen Planus

-more often affects vagina > vulva, can also be seen in oral membranes

-pathogenesis unknown

-consists of leukoplastic lesions and erosive lesions

-burning, vaginal pain, dyspareunia

-monitor for adhesions of labia

-diagnose by biopsy, risk of cancer

Lichen Planus Tx

-mainly topical -> hydrocortisone vaginal foam, ultrapotent topical corticosteroids or topical tacrolimus 0.1%

-severe cases may need systemic steroids

-management of stenosis and adhesions -> vaginal dilators, surgical tx

Vaginal Atrophy

-thinning, drying, and inflammation of vaginal walls associated with a decrease in estrogen

-menopause

-post-childbirth

-breastfeeding

-CA treatments (hormonal therapies, ovary removal)

Vaginal Atrophy - Presentation

-vaginal dryness

-itching or burning

-dyspareunia

-bleeding after intercourse

-urinary symptoms of increased frequency or urgency

Vaginal Atrophy Tx

-Hormone Replacement Therapy (HRT): local estrogen therapy first line; systemic estrogen

-non-hormonal approaches -> moisturizers and lubricants

Vulvar Lichen Simplex Chronicus

umbrella term for previously defined hyperplastic dystrophy, squamous cell hyperplasia, atopic dermatitis, atopic eczema, and neurodermatitis

Vulvar LSC Presentation

-benign epithelial thickening/hyperkeratosis d/t chronic irritation

-pruritus leads to involuntary rubbing and scratching

-epithelial thickening causes maceration and a raised white lesion may spread to adjacent thighs, perineum, or perianal skin

Vulvar LSC Dx

-biopsy necessary to exclude neoplasia

-no dermal inflammatory infiltrate, distinguishing it from lichen sclerosus

Vulvar LSC Tx

-vulvar hygiene

-oral antihistamines

-topical medium-potency steroids

-vulvar epithelium healing takes at least 6 weeks

-intractable cases: consider antidepressants or subQ intralesional steroid injections

Vulvodynia

-vulvar pain

-acute localized "provoked" --> known cause

-generalized unprovoked --> large surface area, chronic, idiopathic

Vulvodynia Presentation

constant pain or burning with periods of relief and flares

Vulvodynia Dx

-Dx of Exclusion!

-need to rule out: infxns, dermatoses, pudendal nerve entrapment, referred pain, neuropathic viruses, neuro disease (MS)

Vulvodynia Tx

-First line: oral TCAs (amitriptyline), initial relief after a few weeks

-supportive: topical local anesthetics during the initial tx phase, counseling on irritant elimination

Vulvodynia - Secondary Tx

-start if there is no improvement in 3 mos

-anticonvulsants (gabapentin)

-referral to pain management

-epidural, regional blocks, opiates

Bartholin's Gland

gland secretes mucus to provide vaginal and vulval lubrication

Bartholin Cyst

-orifice obstructed

-mucus build up

Bartholin Abscess

-orifice obstructed

-mucus build up with multiple organisms

-basically cyst + infection

bartholin Gland Disruption - Etiology

-infection (G/C and E. coli)

-increased secretions

-congenital narrowing

Bartholin Gland Disruption - Presentation

-vulvodynia

-dyspareunia

-edema

-inflammation

-palpable fluctuant mass

-can lead to difficulty walking

high

is the chance of recurrence for a bartholin gland disruption low or high?

Bartholin Cyst/Abscess Tx

-refer to gyn when possible

-supportive: sitz baths x 15 min, up to 4 times daily

-abscess: abx for suspected pathogen

-Most need drained: marsupialization preferred for recurrent; simple needle aspiration or I&D may only provide temporary relief

Pediculosis Pubis

-Pubic lice or "crabs"

-transmitted by close contact (sexual contact, shared bedding/clothing)

-lives in pubic hair - attaches to hair shaft

Pediculosis Pubis - Presentation

-itching

-visible nits

-something crawling

Scabies

-sarcoptes scabiei

-tiny mite burrows in skin to lay eggs

-may take 2-6 weeks for sx to appear

-spread through close (skin to skin) contact

-presentation: intractable itching, papular rash across body

Scabies Dx

-observe burrows

-microscope exam of skin shaving

Lice/Scabies Tx

-wash all clothing, towels, and linen in hot water

-put items that cannot be washed in garbage bag x 72 hr

-pediculosis pubis: remove nits with fine tooth comb

-permethrin cream

-Lindane 1% shampoo (not in pregnant/lactating patients)

Diethylstilbestrol

-a synthetic nonsteroidal estrogen used between 1940s and 1971 that crosses the placenta

-was used to prevent premature birth, miscarriages, and obstetric complicattions

DES - in utero exposure

-Cervical abnormalities

-vaginal clear cell carcinoma

-infertility

-pregnancy comp -> miscarriage, ectopic, premature delivery

Cervical Cerclage

____________ is used prophylactically for cervical incompetence d/t DES

Cervical Dysplasia

-cervical intraepithelial neoplasia: abnormal changes in the cells of the cervix

-benign, but indicates the presence of precancerous or abnormal cells

Low grade Dysplasia (CIN1)

mild changes in the cells that are often temporary and may resolve on their own

High Grade Dysplasia (CIN 2 or CIN 3)

more significant changes in the cells that indicate a higher risk of progressing to cervical cancer

Cervical Dysplasia Causes and RF

-HPV infxn most common

-immunosuppressed state

-early sexual activity

-multiple sexual partners

-smoking

CIN Clinical Presentation/Tx

-usually asx

-may be abnormal bleeding between periods, after sex, or after menopause

-Dx: pap smear, HPV testing

CIN Tx

-low grade dysplasia: monitor

-high grade dysplasia: may require cryotherapy, laser therapy, or conization

-surgery may be recommended if dysplasia progresses to cervical cancer

-close follow up, altered pap schedule

Molluscum Contagiosum

benign poxvirus tumor

-painless umbilicated papules

-transmitted by skin-to-skin contact; incubation about 6 wks

Molluscum Contagiosum Tx

-watch and wait

-office based: cryotherapy, curettage, laser

-home-based: imiquimod, podophyllin, salicylic acid

Condylomata Acuminatum

-caused by human papilloma virus

-incubation from weeks to months to years

-clinical presentation: asymptomatic, lesions may be painful/itchy

-pink, flesh colored lesions that can be flat or raised, can coalesce into cauliflower-like lesions

-biopsy to confirm dx, serotyping

6 and 11

what are the most common types of HPV that cause condyloma acuminatum?

HPV Tx

-office-based: cryotherapy, laser therapy, surgical excision, podophyllin resin

-home-based: podofilox sol'n/gel, imiquimod cream

HPV prevention

-Gardasil vaxx --> protects against 9 types of HPV (primarily 16, 18, 6, 11 (the ones that cause CA and warts))

-Cervarix --> protects against two types of HPV that cause cervical CA (16, 18)

Genital HSV

-HSV1, HSV2 (most cases), most infxns are undiagnosed

-transmission through intimate contact; incubation 2-7 days

Genital HSV Dx

-viral culture --> gold standard

-serologic tests --> detect IgG and IgM antibodies

-do not differentiate between acute/chronic infxn

HSV Primary Infxn

-prodrome phase: tingling/itching of skin

-appearance of painful vesicles in clusters on an erythematous base

-vesicles ulcerate then crust over and heal within 7-14 days

-viral shedding continues for up to 2-3 weeks

HSV Recurrent Dz

-after primary infxn, virus migrates to sacral ganglion and lies dormant

-reactivation occurs due to various triggers (Stress, illness, trauma)

-reoccurrence is usually milder and shorter in duration

HSV Tx

-Antiviral agents reduce duration and severity of disease

-should be started within 72 hours of lesion appearance

-Valacyclovir BID, acyclovir TID, Famciclovir TID

7-10 days

how long should the first episode of HSV be treated for?

Recurrent HSV Tx

if caught quickly, can be treated within 1-3 days

Suppressive Therapy - HSV

-for those with severe or frequent (>=6 per year) episodes to reduce transmission risk to uninfected partners

-once daily dosing, taper as needed to prevent outbreaks

HSV Screening

-may be indicated in a pt with unknown status with a known positive partner

-can be helpful in pts with previous negative status to determine new exposure

-do not do routine serologic screening d/t mental harm

Syphilis Etiology

-chronic, systemic disease caused by spirochete Treponema pallidum

-transmitted by direct contact with moist active lesion to mucous membranes or open skin

-sexual contact, can be mother-to-fetus

Primary Syphilis

-10-90 days, median 21

-painLESS chancre appears at site of exposure

Secondary Syphilis

-2 weeks to 6 months later, avg 6 wks

-viral syndrome of skin rash, systemic sx

Latent Syphilis

-may last years

-asymptomatic, but still contagious

-early latent: < 1 yr of acquisition

-late latent: > 1 yr

Tertiary Syphilis

-4-20 years after exposure

-involvement of the brain (neurosyphilis), heart, kidney, and bones

-25% fatality if untreated

Primary Syphilis

-Lesion may occur on any mucous membrane (genital, oropharyngeal, nasal, breast, perineal)

-may be internal and not visualized on external exam

-indurated, firm, painless papule, or ulcer with raised borders

-may have non-tender enlarged inguinal LNs

secondary syphilis

-dermatitis: diffuse, bil, symmetric, papulosquamous lesions

-typically involve palms and soles, may involve trunk, arms/legs

-Diffuse LAD, fever, malaise

-patchy alopecia, hepatitis, nephritis, condyloma lata

Neurosyphilis

-common manifestation in tertiary syphilis

-ophthalmic and auditory system dysfunction

-cranial nerve palsies

-mental nerve status changes

Congenital syphilis

-systemic dz from placental inoculation

-wide spectrum of presentations

HIV

syphilis has high rates of co-infection with _________

PCN G benzathine 2.4 mil units IM single dose

what is the treatment for primary/secondary/early latent syphilis?

Late Latent (>1 yr) Syphilis Tx

-PCN G benzathine 2.4 mil units IM weekly x 3 wks

-regimen used for asx pts with unknown timeline

PCN G IV x10-14 d

what is the treatment for neurosyphilis?

Syphilis - PCN Allergy

-confirm if true allergy

-desensitization therapy if possible

-doxy 100 mg PO BID x14 days alternative for primary/secondary

PCN G

what is the ONLY approved treatment for syphilis in pregnancy (even if allergic)?

Chancroid

ulcerative condition caused by Haemophilus decreyi that affects the genital region

Chancroid - Presntation

-erythematous papule -> pustule -> ulcer circumscribed by inflammatory wheal -> fluctuant buboes

-Painful, TTP, produces heavy contagious discharge

-typically have multiple lesions

Azithromycin 1g PO or Ceftriaxone 250 mg IM

what is the treatment for a chancroid?

repeat

what do you to for chancroid treatment if there is no improvement in 7 days?

Vaginitis

-inflammation of vagina

-vaginal itching, burning sensation

-redness or swelling of the vaginal tissues

-dyspareunia

-abnormal vaginal discharge

-most commonly caused by infections

-can be acute or chronic

Cervicitis

-inflammation of the cervix

-may be asx

-dysuria

-lower abd pain

-abnormal vaginal discharge

-post-coital bleeding -> friable cervix

-most commonly caused by infections

-can be acute or chronic

Neisseria Gonorrheae

-gram neg diplococci -> incubation 2-7 days

-purulent vagina discharge -> thicker, white pus

Chlamydia Trachomatis

-obligate intracellular organism similar to gram-negative bacteria -> incubation 7-14 days

-mucopurulent vaginal discharge -> can be white/yellow/green, mucus + pus

Chlamydia and Gonorrhea

-can be isolated from urethra, vaginal canal, cervix, anus, pharynx

-dx by gram stain, culture, or NAAT

-Comp: PID, disseminated infxn, salpingitis

Salpingitis Comp

-tubal scarring

-ectopic pregnancies

-infertility

Gonorrhea Tx

-Ceftriaxone IM single dose

-500 mg for <150 kg

-1000 mg for >=150 kg

Gonorrhea Urogenital/Anorectal FU Testing

-if sx resolve, no need to test for cure; retest in 3 mos for reinfection

-if sx persist or recur shortly (3-5 d) after tx completion, retest for gonorrhea + other infxn

Gonorrhea Oropharyngeal FU Tx

-test of cure recommended at 7-14 days post-treatment to ensure eradication

-retest in 3 mos for reinfection

Doxycycline 100 mg BID x7 days

what is the treatment for chlamydia?

Chlamydia - Azithro

-1g single dose

-preferred in pregnancy

-option if concerned about treatment adherence, observed dose

Chlamydia FU Testing

-all patients: retest in 3 mos for reinfection

-Test of Cure: recommended no sooner than 4 wks post treatment, pregnancy, persistent sx, concern for nonadherence, use of alternative regimens

G/C Tx Principles

-Screen sexually active pts

-empiric therapy for both infxns unless able to confirm at time of tx

-reportable to health department

-all partners (w/in 60 days) should be notified and tested/treated promptly

-include comprehensive sex education for prevention of future episodes

Lymphogranuloma Venereum

-disseminated dz caused by aggressive serotype of Chlamydia trachomatis

-more common in Africa/Asia but seen in SE US

-strongly associated with HIV-positive individuals

Lymphogranuloma Venereum Presentation

-tender, unilateral inguinal/femoral LAD

-possible genital ulcer

-if rectal exposure --> proctocolitis

-late phase can develop systemic symptoms

Doxy 100 mg BID x 21 days

what is the tx for lymphogranuloma venereum?

Bacterial Vaginosis

-bacterial overgrowth within normal vaginal flora

-increased amount of Gardnerella vaginalis, ureaplasma, mycoplasma hominis, mobiluncus, prevotella

-reduced amount of Lactobacillus that are protective

BV - RF

-multiple sex partners

-new sex partners

-vaginal douching

-unprotected vaginal intercourse

-lack of vaginal lactobacilli

BV - Presentation

-inflammation, increase in vaginal pH

-vaginitis

-white discharge with "fishy" odor

BV Tx

-Metronidazole 500 mg PO BID x 7 days

-clindamycin cream 2% intravaginally QHS x7 days

-Metronidazole gel 0.75% daily x5 days

-educate on vaginal hygiene, safe sex, partner education

Metro PO + topical clindamycin

in the ACOG updated guidelines, in recurrent cases of BV, you should treat male partners with what?

Trichomoniasis

-infection caused by flagellated protozoan Trichomonas vaginalis

-incubation period 4-28 days

-most common nonviral STI in US

Trich - Presentation

-purulent, malodorous, thin vaginal discharge

-urethritis common

-PX: erythema of vulva/vagina; strawberry cervix -> punctate hemorrhages

-many will be asx (esp men!)

Trich Dx

-wet prep microscopy

-NAAT

Trich Tx

-Metronidazole 500 mg PO BID x7 days

-intravaginal agents are NOT effective

-partner notification and treatment

Vaginal Candidiasis

vulvovaginitis caused by fungal Candida species, most commonly candida albicans (90%)

Vaginal Candidiasis - RF

-uncontrolled DM

-immunocompromised state (HIV)

-pregnancy

-meds (abx, OCPs, CCS, SGLT2i)