22 - Lower Genital Tract Infections

5 and 7 o’clock

Location of openings of Bartholin glands, in the groove between the hymen and the labia minora

Marsupialization

Treatment of choice for Bartholin cysts; the entire cyst or abscess is incised and sutured to the vaginal mucosa

Word catheter placement

Alternative treatment for Bartholin cysts

Excision biopsy

Treatment options for Bartholin abscess for persistent deep infection, multiple recurrences of abscesses, or recurrent enlargement of the gland in women older than 40 years

No, unless there is evidence of cellulitis

Are antibiotics necessary for Bartholin abscess treatment?

Pediculosis

Infection characterized by eggs, lice & pepper grain feces in hair shafts of the crab louse

Scabies

Infection characterized by severe intermittent itching at night, caused by burrowing of Sarcoptes scabiei in the skin

Molluscum contagiosum

Infection characterized by flesh-colored, dome-shaped papules with an umbilicated center

Condyloma acuminatum

Another term for genital, venereal, or anogenital warts; most common viral STD of the vulva, vagina, rectum and cervix

Permethrin 1%

Treatment for pediculosis

Permethrin 5%

Treatment for scabies

Excision with Monsel solution- or TCA-treated scalpel

Treatment for molluscum contagiosum

Podofilox 0.5%, imiquimode 5%

Patient-administered treatment options for condyloma

Genital herpes

Recurrent viral infection that is incurable and highly contagious, caused by HSV-1 and -2

Chancroid

Ulcers caused by the highly contagious, small, nonmotile, gram-negative rod H. ducreyi

Lymphogranuloma venereum

Chronic infection of lymphatic tissue produced by Chlamydia trachomatis

Granuloma inguinale (donovanosis)

Infection characterized by a painless, slowly progressing beefy-red ulcer surrounded by granulation tissue that coalesce

Syphilis

Chronic complex systemic disease cause by Treponema pallidum

Primary syphilis

Syphilis stage characterized by a chancre

Secondary syphilis

Syphilis stage characterized with a systemic disease (rashes, vulvar lesions)

Tertiary syphilis

Syphilis stage characterized by optic atrophy, tabes dorsalis, paresis, aortic aneurysms, and gummas

Latent syphilis

Syphilis stage characterized by positive serology but without symptoms

• Benzathine Penicillin G, 2.4M units IM

• If early latent: SD, if late latent: 3 doses q weekly

Treatment for primary, secondary, and latent syphilis

Aqueous crystalline penicillin G, 18-24M units

• 3-4M units IV q 4 hours OR

• Continuous infusion for 10-14 days

Treatment for neurosyphilis

Procaine penicillin G 2.4M units IM once daily PLUS Probenecid 500mg orally 4x/day, both for 10 to 14 days

Alternative regimen for neurosyphilis

Benzathine Penicillin G 7.2M units total

• 3 doses of 2.4M units IM q weekly

Treatment for tertiary syphilis with normal CSF exam

Orolabial lesions

HSV-1 infection leads to this kind of herpes lesions

Genital herpes

HSV-2 infection leads to this type of herpes

PCR

Most accurate assay for herpes diagnosis

Western blot for anti-HSV antibodies

Most specific method for diagnosing recurrent, unrecognized or subclinical herpes

Valacyclovir, acyclovir, famciclovir

Three drugs used for herpes infection

School of fish

Characteristic microscopy finding for H. ducreyi

L1, L2, L3

Serotypes of C. trachomatis that cause LGV

Bubo

Painful adenopathy in inguinal and perirectal areas in LGV infections

Groove sign

Enlarged lymph node, tender and matted in LGV infection

Safety pin or bipolar appearance

Characteristic microscopy finding for K. granulomatosis

• Candidiasis: caused by a fungus

• Trichomoniasis: caused by a protozoon

• Bacterial vaginosis: caused by a disruption of the vaginal bacterial ecosystem

Three common causes of vaginitis

Bacterial vaginosis

Vaginitis characterized by thin, whitish gray, homogeneous discharge, cocci, sometimes frothy

Bacterial vaginosis

Most prevalent cause of vaginitis

“musty or fishy” odor of vaginal discharge

Most common symptom of bacterial vaginosis

Gram Stain with Nugent Scoring System

Gold standard for diagnosis of bacterial vaginosis

Clue cells

Vaginal epithelial cells lined with bacteria; characteristic finding in wet smears of bacterial vaginosis

• Homogenous vaginal discharge

• pH ≥ 4.5

• Amine-like odor when mixed with KOH (whiff test)

• Wet smear demonstrates clue cells greater in number than 20%

Amsel criteria

• Metronidazole 500 mg twice daily for 7 days

• Metronidazole gel 0.75%, 5 g intravaginally once daily for 5 d

• Clindamycin cream 2%, 5 g intravaginally ODHS for 7 days

Recommended treatment regimen for bacterial vaginosis

Trichomoniasis

Vaginitis characterized by yellow-green, frothy malodorous discharge, with or without vaginal or cervical erythema

Trichomoniasis

The most prevalent nonviral, nonchlamydial STI

Trichomonas vaginalis

Unicellular intracellular, anaerobic, flagellated protozoan that causes trichomoniasis

NAAT

Diagnostic test for trichomoniasis

Metronidazole, 500mg 2x a day for 7 days

Recommended treatment regimen for trichomoniasis

Candidiasis

Vaginitis characterized by thick, curdy discharge, and vaginal erythema

≥4 documented episodes

Recurrent vulvovaginal candidiasis (RVVC) is characterized by how many episodes per year?

KOH smear

Diagnostic test for fungal candidiasis

Culture with Nickerson or Saboraud medium

Alternative diagnostic test for fungal candidiasis, especially if KOH smear is negative but highly suspicious of infection, or if patient recently self-treated with an antifungal drug

Fluconazole 150 mg, single dose

Oral regimen for fungal candidiasis

Oral fluconazole

(100-mg, 150-mg, or 200-mg dose) weekly for 6 months

Suppressive maintenance therapy for fungal candidiasis

Toxic shock syndrome

Infection due to a bacterial exotoxin, with a fulminating downhill course involving dysfunction of multiple organ systems

TSST-1

Exotoxin implicated in TSS

Clindamycin plus vancomycin or linezolid

Treatment regimen for MRSA TSS

Clindamycin plus nafcillin

Treatment regimen for MSSA TSS

Cervicitis

An inflammatory process in the cervical epithelium and stroma, can be associated with trauma, inflammatory systemic disease, neoplasia, and infection

HSV, T. vaginalis, C. albicans

Three etiologic agents for ectocervicitis

C. trachomatis or N. gonorrhoeae

Two common etiologic agents for mucopurulent endocervicitis

C. trachomatis

Obligatory intracellular organism that causes mucopurulent cervicitis

Doxycycline 100 mg BID x 7days

Preferred treatment regimen for C. trachomatis cervicitis

N. gonorrhea

Gram-negative diplococci that that causes mucopurulent cervicitis

Ceftriaxone 500 mg IM single dose for persons weighing <150kg

Preferred treatment regimen for N. gonorrhea cervicitis