women's health vaginal conditions

what is responsible for vaginal pH

vaginal flora composition

nutrient produced in vagina necessary for may vaginal ecosystem species

glycogen

how does glycogen affect pH

metabolized into lactic acid, keeping pH at 3.8-4.2

prepubertal/postmenopausal pH

6-7.5

what can shift flora makeup

changes in hormonal status specifically estrogen

what can lead to alteration of flora and lead to candida overgrowth

broad spectrum abx

what activities can raise vaginal pH

douching and unprotected sex

normal vaginal secretions consist of

desquamated vaginal mucosa, vaginal epithelium transudate, mucous secretions from endocervix, endometrial gland secretions, lactic acid, bartholin gland secretions, sebaceous gland secretions from vulva

dominant species in healthy microbiome

lactobacillus species, produces lactic acid which maintains acidic environment inhospitable to many bacteria

normal variants of flora

Atopobium vaginae, Megasphaera, Leptotrichia

wet prep

swab placed in saline solution and swirled, pipette used to transfer onto 3 slides, wet mount, potassium hydroxide mount, gram stain, should be examined immediately or w/i 2 hrs

bacterial vaginosis is

imbalance of normal vaginal flora

how does BV happen

loss of acidity leading to loss of Lactobacilli dominance leading to alkalization of vagina leading to overgrowth of pathogens

m/c BV pathogen

G vaginalis

BV risk factors

new/multiple sex partners, frequent douching, IUDs, pregnancy

what is associated w/ BV

PROM, PPROM, PTL, PID, endometriosis, STIs

nonirritating malodorous vaginal discharge, thin gray-white discharge, normal mucosa and epithelium, no CMT or pelvic pain

BV

BV dx

PE (can be clinical dx), pH testing, wet prep, Amsel’s dx criteria

Amsel’s dx criteria

3/4, thin/white/homogenous discharge, pH over 4.5, + amine whiff test, presence of clue cells on microscopic exam

BV tx

metronidazole PO/intravaginally, clindamycin intravaginally, abstain from EtOH, no evidence to support use of lactobacillus probiotics

intravaginal abx increases incidence of

yeast infection

yeast vulvovaginitis m/c secondary to

candida albicans, can also be glabrata, parapsilosis, tropicalis, krusei (all candida)

risk factors for pathologic overgrowth of candida

abx, combo OCP, estrogen therapy, pregnancy, DM, corticosteroid use, any immunosupression

genital burning, pruritis, dyspareunia, dysuria, curd like discharge, erythematous/friable vaginal mucosa/cervical epithelium, no CMT

yeast vulvovaginitis

uncomplicated yeast vulvovaginitis

sporadic/infrequent, mild to moderate, likely C albicans, non immunocompromised

complicated yeast vulvovaginitis

recurrent (4/yr), severe, non albicans, DM, HIV, debilitation, immunosuppressed

yeast vulvovaginitis dx

PE (may be clinical dx), wet prep budding yeasts/pseudohyphae/WBC/epithelial clumps, pH less than 4.5, negative amine whiff test, can order yeast culture

uncomplicated yeast vulvovaginitis tx

short course OTC topical antifungal or single dose of fluconazole

complicated yeast vulvovaginitis tx

7-14 days topical therapy or fluconazole q3 days for 3 doses

severe yeast vulvovaginitis tx

7-14 days topical azole or 2 doses fluconazole 72 hrs apart

non albicans yeast vulvovaginitis tx

7-14 onfluconazole azole tx PO or topical as first line

what is trichomonas

flagellated protozoan transmitted by sexual intercourse

trichomonas in women

vaginitis

trichomonas in men

occasionally urethritis, most are asx

trichomonas and other infections

associated w/ other STIs and can enhance transmission of HIV, dx should prompt further screening

trichomonas in pregnancy

associated w/ low birth weight, PROM, and preterm delivery

malodorous green/yellow frothy discharge, puritis/irritation, possibly dysuria/dyspareunia, strawberry cervix

trichomonas

trichomoniasis dx

wet prep, pH over 4.5, ± amine test (+), PCT test

trichomoniasis tx

metronidazole once or bid x1wk

how does atrophic vaginitis occur

inflammatory process in pts c vaginal atrophy secondary to lack of estrogen during menopause leading to changes in microbiome and shift in normal flora, decreased Lactobacillus and overgrowthof skin/rectal pathogens

atrophic vaginitis dx

wet mount shows high WBCs, decreased Lactobacilli

atrophic vaginitis tx

vaginal estrogen creams

vulvovaginal dryness, pruritis, dyspareunia, abnormal discharge, postcoital pain, recurrent UTIs, urethral pain, hematuria, urinary incontinence, sxs progressive or acute

atrophic vaginitis

gonorrhea

gram negative diplococci, infects site of inoculation, can become disseminated, more than 50% of females asx, 90% of males have sx

gonorrhea incubation period

2-6 days

male sx: dysuria, white/yellow/green discharge that may disappear 1-14 days later, urethral infrx+epididymitis=testicular pain

gonorrhea

female sx: asx, sx mild and nonspecific, often mistaken for UTI/vaginitis, dysuria, increased discharge, vaginal bleeding btwn periods

gonorrhea

rectal infx: discharge, anal itching, soreness, bleeding, painful BM, asx

gonorrhea

pharyngeal infx may cause sore throat, usually asx

gonorrhea

gonorrhea tx

single dose IM cetriaxone or erythromycin ophthalmic ointment in neonates

gonococcal arthritis

form of bacterial arthritis resulting from spread of Neisseria, clinical manifestation of disseminated gonococcal infection

major clinical forms of gonococcal arthritis

localized septic arthritis, arthritis-dermatitis sndrome

gonococcal arthritis risk factors

pregnancy, hx of pelvic surgery, IUD

gonococcal arthritis tx

ceftriaxone IV/IM preferred, IV admin qd in pt c purulent arthritis, doxycycline to cover coinfection w/ chlamydia trachomatis

when is gonococcal conjunctivitis considered in neonates

sx after first day of life, specifically days 2-5, in first day chemical conjunctivitis is often the cause

is vertical transmission of gonorrhea possible in C section

yes

PE: chemosis, mucopurulent discharge, eyelid edema, globe tenderness, preauricular LAD

gonococcal conjunctivitis

non-neonatal gonococcal conjunctivitis

may be present w/ similar sxs and should be considered even w/o genital sxs

gonococcal conjunctivitis neonatal prophylaxis

erythromycin or tetracycline ophthalmic ointment

GC sx or high risk neonate tx

1 dose ceftriaxone IV/IM or cefotaxime single dose may be preferred if available due to risk of increasing bilirubin associated w/ ceftriaxone

GC sx neonate

single dose ceftriaxone and treat possible coinfection w/ chlamydia

GC saline lavage

hourly, may not be necessary

responsible for greatest number of STIs and majority of infection related blindness

chlamydia

chlamydia cytology

GM- cocci

most infected site in females for chlamydia

cervix

cervicitis, urethritis, PID, perihepatitis, proctitis

chlamydia

chlamydia in pregnancy

increases risk of infertility and ectopic pregnancy, infants born vaginally to infected mothers may develop conjunctivitis and/or pneumonia in days 5-14 of life

asx/mild sx, discharge, bleeding, abdominal pain, dysuria, minority have cervicitis c discharge/easily inducible endocervical bleeding, some complain of postcoital bleeding/bleeding btwn menses

chlamydia

chlamydia tx

doxycycline BID 1 wk, azithromycin in pregnancy

leading infectious cause of blindness

trachoma

how is trachoma spread

direct or indirect transfer of eye/nasal secretions, particularly in preschoolers, can be spread by flies

how does trachoma cause blindness

years of repeat infection cause inside of eyelid to become severely scarred, turning lashes inward and causing them to rub on globe resulting in corneal scarring

what is PID

inflammation of upper genital tract due to infection, affects uterus/fallopian tubes/ovaries, ascending infection spreads form lower genital tract, majority related to STIs (gonorrhea/chlamydia m/c)

lower abdominal pain, pelvic pain, vaginal discharge, dyspareunia, abnormal vaginal bleeding

PID

PID risk factors

intercourse w/ multiple partners or partner w/ multiple partners, sexually active under 25 yo, previous STIs/PID, frequent douching, unprotected sex

lower abdominal pain, fever, ± N/V, + CMT (chandelier sign), + friable cervix

PID, clinical dx, confirmatory testing to determine pathogen

when should admission be considered in PID

suspected tubo ovarian abscess, pregnancy, N/V, high fever, outpt tx failure, pt compliance is questionable

outpt PID tx

ceftriaxone once and doxycycline PO BID x14 days

inpt PID tx

doxycycline PO/IV BID and ceftriaxone IV once daily and metronidazole IV BID

PID tx in pregnancy

azithromycin PO once in place of doxycycline

Fitz Hugh Curtis syndrome

inflammation of liver capsule w/ adhesion formation resulting in RUQ pain, uncommon chronic manifestation of PID affecting women of chlidbearing age

m/c cause of FHCS

ascending infection of chlamydia

how do microorganisms associated w/ PID spread

spontaneous ascending infection, lymphatic spread, hematogenous spread

FHCS risk factors

younger than 25 yo, age at first sexual encounter younger than 15 yo, hx of PID, IUD/OCP use, douching

what causes RUQ pain in FHCS

perihepatic inflammation/adhesion formation btwn anterior surface of liver and abdominal wall

RUQ pain worse w/ movement/breathing, lower abdominal/pelvic/back pain, fever, chills, N/V, discharge, dispareunia, dysuria, cramping, postcoital bleeding

FHCS

PE: fever over 38.3 C, RUQ tenderness, rebound tenderness, guarding, CMT, adnexal tenderness, uterine compression test on bimanual exam, cervical mucopus/friability

FHCS

FHCS CT

increased perihepatic enhancement, pelvic fat irritation, pyosalpinx, tubo ovarian abscess, fluid collection in pelvic cavity

transvaginal US FHCS

favorable for cases in which picture of PID unclear, hydrosalpinx, pyosalpinx endometritis, tubo ovarian abscess, oophoritis, ectopic pregnancy

FHCS MRI

tubo ovarian abscess, edematous tubes, free pelvic fluid collections

gold standard for FHCS/PID dx

laparoscopy, shows edema w/ exudates on tubal surfaces, ectopic pregnancy, tubo ovarian abscesses

FHCS direct dx

visualization of adhesions btwn diaphragam and liver or liver and anterior abdominal wall

FHCS tx

manage PID, most as outpt, abx successful in 75%, ceftriaxone, doxycycline, metronidazole

consider hospitalization for FHCS if

uncertain dx, pregnancy, severe illness, pelvic abscess, inability to tolerate anything PO, immunodeficiency, failure to improve after 72hrs of therapy, pts c persistent sxs should be reevaluated for possible surgical intervention

lymphogranuloma venereum

uncommon ulcerative STI caused by chlamydia, GM-, common in tropical/subtropical areas, typically in 15-40 yo, increased incidence in HIV+

primary LGV

3-13 days post exposure, painless genital ulcer or papules (or mouth/throat), inflammatory rxn at site of innoculation, lesions resolve spontaneously after a few days

secondary LGV

uni/bilateral tender inguinal and/or femoral lymphadenopathy aka buboes, 2-6 wks post primary stage, anorectal syndrome, generalized sx, systemic complications

LGV anoretal syndrome

pain during urination, rectal bleeding, pain during passing stools, abdominal pain, anal pain, tenesmus

LGV generalized sx

body aches, HA, fever, syndrome usually occurs when transmission is anal

LGV oral syndrome

may cause cervical lymphadenopathy