Women’s Health Issues in Acute Care – STI & Vaginitis Master Notes

Vaginitis

• Definition & Spectrum
  • Any inflammatory or irritative condition of the vagina caused by infectious pathogens, allergic reactions, atrophy, or mechanical/frictional trauma.
• Normal Baseline Physiology
  • Vaginal pH normally ≤ $4.5$, maintained by predominant Lactobacillus flora → produces lactic acid (protective).
• Key Clinical Pearls
  • It is essential to distinguish physiologic discharge from pathologic discharge to avoid over-treatment.
  • Normal secretions may be misinterpreted as infection by patients; history & exam are critical.
• Symptoms Suggestive of Pathology
  • Vaginal irritation, pruritus, abnormal/malodorous discharge.
• Focused History Elements
  • Symptom onset, location, duration, triggers.
  • Recent sexual activity, contraceptive type, new medications.
• Physical Exam Sequence
  • Inspect vulva externally → speculum exam of vagina & cervix → bimanual exam to look for cervical motion tenderness or adnexal masses.
• Diagnostic Toolkit
  • Point-of-care tests for N. gonorrhoeae, C. trachomatis, yeast, BV, T. vaginalis.
  • Vaginal pH test: infectious etiologies typically raise pH > $4.5$.
  • Microscopy (wet prep, KOH prep) when available; NAATs increasingly preferred.

Pelvic Inflammatory Disease (PID)

• Pathophysiology
  • Polymicrobial infection ascends above the cervix to involve endometrium, fallopian tubes, ovaries, pelvis.
  • Common pathogens: N. gonorrhoeae, C. trachomatis; endogenous anaerobes, H. influenzae, enteric gram-negative rods, streptococci, Mycoplasma genitalium.
• Epidemiology & Impact
  • Highest incidence in young, sexually active women with multiple partners.
  • Leading preventable cause of infertility & ectopic pregnancy; barrier contraception is protective.
• Classic & Subtle Presentations
  • Classic triad: lower abdominal pain, AUB, abnormal vaginal discharge.
  • Severe disease: fever, pelvic abscess, RUQ pain (Fitz-Hugh-Curtis syndrome).
  • Subtle signs: post-coital bleeding, urinary frequency, low back pain.
• Minimum Diagnostic Criterion
  • Pelvic exam showing uterine, adnexal, or cervical motion tenderness.
• Additional Specificity Labs
  • Oral temperature > $38.3\ ^\circ \text{C}$, elevated ESR/CRP, WBCs on vaginal microscopy, NAAT positive for GC/CT.
• Differential Diagnosis
  • Appendicitis, ectopic pregnancy, septic abortion, torsion, TOA, degenerating myoma, acute enteritis.
• Investigations
  • Serum hCG to rule out pregnancy; pelvic US for TOA; laparoscopy if diagnostic uncertainty or no response.
• Antibiotic Regimens
  • Outpatient: ceftriaxone $500!–!1000\,\text{mg}$ IM + doxycycline $100\,\text{mg}$ PO BID × $14$ d ± metronidazole $500\,\text{mg}$ PO BID × $14$ d.
  • Inpatient/severe: IV cefotetan/cefoxitin/ceftriaxone + doxycycline ± metronidazole → switch to PO after clinical improvement.
• Procedural Intervention
  • Drainage or surgery for TOA > $8\,\text{cm}$, suspected rupture, or antibiotic failure; hysterectomy/BSO in selected chronic/severe cases.
• Prognosis
  • $25\%$ experience long-term sequelae despite therapy; infertility risk $10\%$ after first, $25\%$ after second, $50\%$ after third episode.
• Admission Criteria
  • Pregnancy, TOA, inability to tolerate PO, no response in $72$ h, severe illness, or surgical emergency.

Vulvovaginal Candidiasis (VVC)

• Microbiology
  • Overgrowth/invasion of Candida species (classic: C. albicans) → inflammation; second most common vaginitis.
• Risk Factors
  • Pregnancy, diabetes, recent antibiotics/corticosteroids, heat/moisture, tight clothing, immunosuppression (HIV).
• Symptoms & Exam
  • Pruritus, vulvovaginal erythema, thick non-malodorous "cottage-cheese" discharge.
• Diagnostics
  • KOH wet mount → pseudohyphae/spores; culture or PCR if microscopy negative but suspicion high.
• Treatment Algorithms
  • Uncomplicated: topical azoles $1!–!3$ d OR fluconazole $150\,\text{mg}$ PO × $1$.
  • Complicated (≥$3$ episodes/year, severe, non-albicans, uncontrolled DM, HIV, pregnancy): fluconazole $150\,\text{mg}$ PO on days $1,4,7$.
  • Recurrent non-albicans: boric acid $600\,\text{mg}$ PV daily × $2!–!3$ wks (≈$70\%$ success); refer if recalcitrant.
  • Maintenance: fluconazole $150\,\text{mg}$ weekly × $6$ mo after initial clearance.
  • Single-dose topical alternatives: miconazole $1200\,\text{mg}$, tioconazole $6.5\%$ $5\,\text{g}$, butoconazole $2\%$ $5\,\text{g}$.
  • 3-day & 7-day topical regimens listed (clotrimazole, terconazole, miconazole).

Bacterial Vaginosis (BV)

• Etiology & Pathogenesis
  • Polymicrobial dysbiosis with overgrowth of anaerobes (e.g., Gardnerella vaginalis, Prevotella) replacing lactobacilli; not a classic STI but sexual activity is risk.
• Clinical Features
  • Thin grey/frothy discharge with fishy odor (positive “whiff test” after KOH); minimal inflammation; pH $5.0!–!5.5$; clue cells ≥$20\%$ on wet mount.
• Complications
  • ↑ risk PID, post-procedural infections, susceptibility to HIV, CT, HSV-2; OB: prelabor ROM, preterm birth, intra-amniotic infection, postpartum endometritis.
• Treatment
  • Metronidazole $500\,\text{mg}$ PO BID × $7$ d OR metronidazole gel $0.75\%$ $5\,\text{g}$ BID × $5$ d OR clindamycin $2\%$ cream $5\,\text{g}$ QHS × $7$ d.

Trichomonas Vaginalis Vaginitis

• Organism: T. vaginalis protozoan (flagellated); true STI.
• Sites: women—vagina, Skene ducts, lower GU; men—urethra, prostate.
• Symptoms/Signs
  • Pruritus, malodorous frothy yellow-green discharge; diffuse erythema; severe → "strawberry cervix" (punctate hemorrhages).
• Diagnostics
  • Wet mount (motile trichomonads) sensitivity $60!–!70\%$; NAATs are gold standard; rapid tests (Affirm, OSOM) intermediate.
• Treatment & Partner Management
  • Women: metronidazole $500\,\text{mg}$ PO BID × $7$ d; men: metronidazole $2\,\text{g}$ PO × $1$.
  • Treat both partners simultaneously to prevent ping-pong reinfection.
• Failure Strategy
  • Re-treat with metronidazole or tinidazole $2\,\text{g}$ PO daily × $7$ d; request CDC resistance testing kit if organism persists.
  • Always offer full STI screening—coinfection common.

Genital Warts (Condyloma Acuminata)

• Virology & Risk Factors
  • HPV types $6$ & $11$ cause $90\%$ of genital warts; growth facilitated by pregnancy, immunosuppression.
• Morphology & Distribution
  • Diffuse hypertrophy, cobblestone or cauliflower-like lesions; involve vulva, perianal skin, vaginal walls, cervix.
• Therapeutic Modalities
  • Provider-applied: cryotherapy (liquid N$<em>2$, cryoprobe), trichloro-/bichloroacetic acid, surgical excision, electrocautery, CO$</em>2$ laser; manage pain with sodium bicarbonate paste.
  • Patient-applied: imiquimod $5\%$ cream, sinecatechins $15\%$ ointment.

Herpes Simplex Virus (HSV-1 & HSV-2)

• Tropism
  • HSV-1: predominantly orolabial; HSV-2: predominantly genital (latent in presacral ganglia).
• Asymptomatic Shedding
  • Common, especially HSV-2; most individuals shed monthly; persists lifelong though declines after first year.
  • Potentiates silent transmission; counseling essential.
• Clinical Spectrum
  • Primary infection: painful vesicles → ulcers healing in $1!–!2$ wks; recurrent episodes milder, triggered by stress, sunlight, illness, chemo.
  • Extra-genital: whitlow (healthcare), herpes gladiatorum (wrestlers).
  • HSV-2 in HIV: frequent, extensive lesions; increases HIV acquisition & transmission.
• Antivirals
  • First-line: acyclovir, valacyclovir, famciclovir.
  • Suspected resistance (large/atypical lesions esp. immunocompromised): foscarnet, cidofovir, trifluridine, vidarabine.
  • Pipeline: pritelivir & amenamevir (helicase-primase inhibitors), brincidofovir prophylaxis in trials.

Gonococcal Infections (Neisseria gonorrhoeae)

• Essentials
  • Incubation $2!–!8$ d; peak age $15!–!29$; NAAT preferred for diagnosis.
• Clinical Entities
  • Urethritis/cervicitis: purulent discharge, dysuria.
  • Disseminated: fever, rash, arthritis-dermatitis syndrome, purulent mono-articular arthritis, endocarditis, meningitis.
  • Conjunctivitis from autoinoculation.
• Differentials: CT, TV, Candida, BV; screen for HIV & syphilis.
• Treatment
  • Uncomplicated: ceftriaxone $500!–!1000\,\text{mg}$ IM (weight based) ± doxycycline $100\,\text{mg}$ BID × $7$ d for CT coverage; cefixime $800\,\text{mg}$ PO alt.
  • Severe/disseminated: ceftriaxone $1\,\text{g}$ IV/IM daily; endocarditis $2\,\text{g}$ IV; manage PID per PID protocol.
  • Penicillin allergy: gentamicin + azithromycin combo.
• Prevention & Public Health
  • Condom use, partner notification, expedited partner therapy, DoxyPEP $200\,\text{mg}$ single dose within $72$ h exposure for MSM on PrEP or with recurrent STIs.

Chlamydia trachomatis

• Overview
  • Most common reportable bacterial STI; infects urethra, cervix, rectum, oropharynx, eyes.
• Clinical Points
  • Often less painful & less purulent than GC; many asymptomatic → silent PID, ectopic, infertility.
• Diagnosis
  • NAAT on first-void urine or site-specific swabs (cervix, vagina, rectum, pharynx); high sensitivity/spec.
• Screening
  • All sexually active women ≤$25$ y and older women with risk factors, all pregnant persons under $25$ or at risk, MSM, PLWH.
• Treatment
  • Preferred: doxycycline $100\,\text{mg}$ BID × $7$ d.
  • Pregnancy: azithromycin $1\,\text{g}$ PO × $1$ (safe) or amoxicillin.
  • Alternatives: levofloxacin $500\,\text{mg}$ daily × $7$ d.
  • Always treat partners & test for GC/HIV/syphilis.

Chancroid (Haemophilus ducreyi)

• Presentation
  • Painful soft chancres with necrotic base & undermined edges; incubation $4!–!10$ d; unilateral painful bubo (lymphadenitis).
• Diagnosis
  • Special culture media; exclude syphilis & HSV (those ulcers typically painless or indurated).
• Treatment
  • Single dose: azithromycin $1\,\text{g}$ PO or ceftriaxone $250\,\text{mg}$ IM.
  • Multidose: erythromycin $500\,\text{mg}$ PO TID × $7$ d or ciprofloxacin $500\,\text{mg}$ PO BID × $3$ d.

Syphilis (Treponema pallidum)

• Transmission & Epidemiology
  • Sexual, vertical, rarely blood; $30!–!50\%$ risk per unprotected exposure; high in MSM.
• Classification
  • Early (<$1$ y): primary, secondary, early latent – highly infectious.
  • Late (≥$1$ y): late latent, tertiary – less infectious but destructive.
• Primary Syphilis
  • Chancre appears $10!–!90$ d (avg $21$ d): painless indurated ulcer + rubbery regional LAD; heals spontaneously $2!–!8$ wks.
• Secondary Syphilis
  • Disseminated $wks!–!6$ mo post-chancre; non-pruritic papulosquamous rash (palms/soles $80\%$), mucous patches, condyloma lata, systemic signs (fever, LAD); may involve meninges, liver, kidney, alopecia.
• Latent Syphilis
  • Early latent (first year) may relapse to secondary; late latent non-infectious to partners but can cross placenta.
• Tertiary Syphilis
  • Gummatous lesions skin/bone, CV (aortitis, aneurysm, AR), neurosyphilis (tabes dorsalis, general paresis), ocular disease; rare now.
• Diagnostics
  • Serology: nontreponemal (RPR/VDRL) + treponemal (FTA-ABS, TP-PA, EIA). Darkfield for chancre; CSF exam if neuro/ocular.
• Treatment Overview (see table)
  • Primary, secondary, early latent: benzathine PCN-G $2.4$ MU IM × $1$.
  • Late latent/tertiary (non-neuro): benzathine PCN-G $2.4$ MU weekly × $3$.
  • Neurosyphilis: aqueous PCN-G $18!–!24$ MU IV q $3!–!4$ h × $10!–!14$ d ± benzathine PCN-G follow-up.
  • PCN allergy (non-pregnant, non-neuro): doxycycline $100\,\text{mg}$ BID or tetracycline $500\,\text{mg}$ QID (duration per stage); ceftriaxone alt.
• Follow-Up
  • RPR/VDRL at $3$, $6$, $12$ mo (early) or $6$, $12$, $24$ mo (late). Expect ≥$4$-fold decline by $12$ mo; failure triggers neuro eval ± retreatment.
  • Always test for HIV at dx & during follow-up.
• Public Health
  • Notify & empirically treat partners exposed within $90$ d (primary) or $6$ mo (secondary) even if serology negative; evaluate for HIV PrEP.

Ethical, Practical & Public-Health Themes

• Early diagnosis & treatment of STIs prevents irreversible sequelae (infertility, neurologic deficits) and reduces community transmission.
• Partner notification, expedited partner therapy, and antimicrobial stewardship are cornerstones of STI control.
• Rising antimicrobial resistance (e.g., GC, HSV) underscores need for surveillance & novel therapies.
• Special populations (pregnant individuals, HIV-positive, adolescents) require nuanced management and follow-up.

Cross-Lecture Connections / Foundations

• All infections discussed align with principles of infectious disease: reservoir, transmission, pathogenesis, host response, antibiotic therapy, resistance.
• PID complications reflect broader concept of post-inflammatory scarring (analogous to bronchiectasis after pneumonia).
• Jarisch-Herxheimer reaction (noted in syphilis treatment elsewhere) parallels cytokine-mediated reactions in other spirochetal diseases (Lyme).

Quick Reference Dosing Table (condensed)