Infections in OB/GYN: Vaginitis, STIs Lisa Rahangdale, MD, MPH Dept. of OB/GYN Objectives Diagnose and treat a patient with vaginitis Interpret a wet.
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Transcript Infections in OB/GYN: Vaginitis, STIs Lisa Rahangdale, MD, MPH Dept. of OB/GYN Objectives Diagnose and treat a patient with vaginitis Interpret a wet.
Infections in OB/GYN:
Vaginitis, STIs
Lisa Rahangdale, MD, MPH
Dept. of OB/GYN
Objectives
Diagnose and treat a patient with vaginitis
Interpret a wet prep
Differentiate the signs and symptoms, PE
findings, diagnostic evaluation of the following
STI’s:
Gonnorhea
Chlamydia
Herpes
Syphillis
HPV
Describe pathogenesis, signs and symptoms
and management of PID
Vaginal Discharge DDXS
Candidiasis
Bacterial Vaginosis
Trichomonas
Atrophic
Physiologic (Leukorrhea)
Mucopurulent Cervicitis
Uncommon
Foreign Body
Desquamative
Vaginitis/Vaginosis
Characteristics of the discharge
pH
Amine odor
Wet mount
Cultures?
Vaginal Candidiasis
Part of normal flora
Majority Candida albicans
Predisposing factors:
Diabetes
Antibiotics
Increased estrogen levels (preg, OCP, HRT)
Immunosuppression
?Contraceptive devices, behaviors
Vaginal Candidiasis
S/Sx
Pruritis
White, clumpy discharge
pH 4-4.5
Dxs: KOH prep
Treatment
Fluconazole 150 mg PO x1
Topical azoles (OTC)
Bacterial
Vaginosis
Disruption of healthy
vaginal flora
Gardnerella, mycoplasmas,
anaerobic overgrowth
Dxs criteria: Gram stain OR 3 out of 4
Homogenous, thin, white d/c
“CLUE CELLS”
Whiff test: “amine odor” when d/c mixed w/ KOH
pH >4.5
Bacterial Vaginosis
BV Treatment
Metronidazole 500 mg BID x 7 days
OR
Metronidazole gel, 0.75%, one full
applicator (5g) PV QD x 5 days
OR
Clindamycin cream, 2%, one full
applicator (5g) PV QHS x 7 days
**Avoid alcohol during metronidazole use**
Trichomonas
Flagellate parasite
“Strawberry”Cervix
pruritis, frothy green discharge
Vag pH >4, neg KOH whiff test
NaCl Microscopy: +WBCs, Trichomonads
Rx: Metronidazole 2 gm po X 1
Tinidazole 2 gm PO x 1
Partner tx
Same doses in pregnancy
SEXUALLY TRANSMITTED
DISEASES
Causative Agent
Method of Transmission
Symptoms
Physical Signs
Diagnostic Methods
Treatment
Screening
Neisseria gonnorhea:
Symptoms
A single encounter with an infected
partner
80-90% transmission rate
Arise 3-5 days after exposure
Initially so mild as to be overlooked
Malodorous, purulent vaginal discharge
15% develop acute PID
Physical Diagnosis
Mucopurulent discharge flowing from
cervix
To be distinguished from normal thick yellow
white cervical mucous(adherent to
ectropion)
Cervical Motion Tenderness
Gonorrhea: DXS
Elisa or DNA specific test
Cervical swab
Combined with Chlamydia
Urine tests
Culture for legal purposes
Gram Stain for WBCs with intracellular gram
negative diplococci
Physical Diagnosis
Mucopurulent discharge flowing from
cervix
To be distinguished from normal thick yellow
white cervical mucous(adherent to
ectropion)
Cervical Motion Tenderness
Disseminated GC
Gonococcal bacteremia (rare)
Pustular or petechial skin lesions
Asymetrical arthralgia
Tenosynovitis
Septic arthritis
Rarely
Endocarditis
Meningitis
Gonorrhea Rx
Ceftriaxone 125 mg IM in a single dose
OR
Cefixime400 mg orally in a single dose
PLUS
Tx FOR CHLAMYDIA IF NOT RULED
OUT
Do NOT use Quinolones in U.S. - resistant GC common
Chlamydia trachomatis
C. trachomatis
Obligate intracellular
pathogen
No cell wall, not
susceptible to
penicillins
Difficult to culture
Chlamydia Diagnosis
Usually asymptomatic
Best to screen susceptible young women
Mucopurulent cervicitis
Intermenstrual bleeding
Friable cervix
Postcoital bleeding
Elisa or DNA probe
Chlamydia Rx
Uncomplicated cervicitis (no PID)
Azithromycin 1 gm po
OR
Doxycycline 100 mg BID for 7 days
Repeat testing in 3 mons
Annual screen in age < 25
Chlamydia in Pregnancy
Azithromycin 1 g orally in a single dose
OR
Amoxicillin 500 mg orally three times a
day for 7 days
(2006 - Poor efficacy of erythromycin – now alternative regimen)
Test of cure in 3 weeks
Pelvic Inflammatory
Disease
Polymicrobial
Initiated by GC, Chlamydia, Mycoplasmas
Overgrowth by anaerobic bacteria, GNRs
and other vaginal flora (Strep, Peptostrep)
Bacterial Vaginosis - associated with PID
PID Symptoms
Acute or chronic abdominal/pelvic pain
Deep Dyspareunia
Fever and Chills
Nausea and Vomiting
Epigastric or RUQ pain (perihepatitis)
PID Physical Diagnosis
Minimum criteria: one or more of the following Uterine Tenderness
Cervical Motion Tenderness
Adnexal Tenderness
Additional support:
Fever > 101/38.4
Mucopurulent Discharge
Abdominal tenderness +/- rebound
Adnexal fullness or mass
Hydrosalpinx or TOA
PID Diagnostic Tests
WBC may be elevated, *often WNL
ESR >40, Elevated CRP-neither reliable
Ultrasound
Hydrosalpinx or a TuboOvarian Complex
due to Adhesions are to be distinguished
from TuboOvarian Abcess
Fluid in Culdesac nonspecific
Fluid in Morrison’s Pouch is suggestive if
associated with epigastric/RUQ pain
PID Treatment
Needs to incorporate Rx of GC and
Chlamydia (tests pending)
Outpatient
Ceftriaxone 250mg IM + Doxycycline x 14 d
w/ or w/out Metronidazole 500mg bid x 14 d
Levofloxacin 500 mg QD or Ofloxacin 400
mg BID + Metronidazole x14 days
(No Quinolone unless allergy)
Regimens:http://www.cdc.gov/std/treatment/
2006/pid.htm
PID Inpatient Rx
Criteria (2006 CDC STD guidelines)
Peritoneal signs
Surgical emergencies not excluded (appy)
Unable to tolerate/comply with oral Rx
Failed OP tx
Nausea, Vomiting, High Fever
TuboOvarian Abcess
Pregnancy
PID Inpatient Rx
Cefoxitin 2 gm IV q 6 hr
OR Cefotetan 2 gm q 12 hr
Plus
Doxycycline 100mg IV or po q 12 hr
For maximal anaerobic
coverage/penetration of TOA:
Clindamycin 900mg q 8 hr and
Gentamycin 2 mg/kg then 1.5mg/kg q 8 hr
PID Sequelae
Pelvic Adhesions
chronic pelvic pain,
dyspareunia
infertility
ectopic pregnancy
Empiric Treatment
Suspected Chlamydia, GC
or PID
Deemed valuable in
preventing sequelae
Recommended Screening
GC/Chlamydia:
women < 25 (**remember urine testing!)
Pregnancy
Syphilis
Pregnancy
HIV
age 13-64, (? Screening time interval)
One STD, consider screening for others
PE, Wet mounts, PAP, GC/CT, VDRL, HIV
24 yo G 0 lesion on vulva
HPI
Pertinent review of systems
Focused exam
Laboratory
Treatment
Counseling re partner
Genital Ulcers
Syphilis
Herpes
Chanchroid
Lymphogranuloma Venereum
Granuloma Inguinale
Herpes
Herpes Simplex Virus I and II
Spread by direct contact
“mucous membrane to mucous membrane”
Painful ulcers
Irregular border on erythematous base
Exquisitely tender to Qtip exam
Culture, PCR low sensitivity after Day 2
Herpes
Primary
Systemic symptoms
Multiple lesions
Urinary retention
Nonprimary First Episode
Few lesions
No systemic symptoms
preexisting Ab
Herpes Rx
First Episode
Acyclovir, famciclovir, valcyclovir x 7–10
days
Recurrent Episodic Rx:
In prodrome or w/in 1 day of lesion)
1-5 day regimens
Suppressive therapy
Important for last 4 weeks of pregnancy
Syphilis
Treponema Pallidum- spirochete
Direct contact with chancre: cervix,
vagina, vulva, any mucous membrane
Painless ulceration
Reddish brown surface, depressed
center
Raised indurated edges
Dx: smear for DFA, Serologic Testing
Syphilis Stages
Clinically Manifest vs. Latent
Primary- painless ulcer
chancre must be present for at least 7 days for
VDRL to be positive
Secondary Rash (diffuse asymptomatic maculopapular)
lymphadenopathy, low grade fever, HA, malaise,
30% have mucocutaneous lesions
Tertiary gummas develop in CNS, aorta
Primary & Secondary Syph
Latent Syphilis
Definition: Asx, found on screen
Early 1 year duration
Late >1 year or unknown duration
Testing
Screening: VDRL, RPR- nontreponemal
Confirmatory: FTA, MHATP- treponemal
Syphilis Treatment
Primary, Secondary and Early Latent
Benzathine Penicillin 2.4 mU IM
Tertiary, Late Latent
Benzathine Penicillin 2.4 mU IM q week X 3
Organisms are dividing more slowly later on
NeuroSyphilis
IV Pen G for 10-14 days
Chancroid
Endemic to some areas of US, outbreaks
Hemophilus Ducreyi
Painful ulcers, tender LNs
Can aspirate a suppurative LN for Dx
Coexists with HIV, HSV, Syphilis
Culture is < 80% sensitive, PCR ?
Rx: Azithro, Rocephin, Cipro
Lymphogranuloma
Venereum
Chlamydia trachomatis
Different serovars
Rare in US
Brief ulcer, inflammation of perirectal
lymphatic tissues, strictures, fistulas
Lymph nodes may require drainage
Dx: Serologic Testing CT serovars L1-3
Rx: Doxycycline, Erythromycin
Granuloma Inguinale
Outside US, Tropics
Calymmatobacterium granulomatis
Highly Vascular, Painless progressive
ulcers without LAD
Dx: Histologic ID of Donovan bodies
Coexists with other STDs or get
secondarily infected with genital flora
Rx: Septra, Doxycycline, Cipro, Erythro
Vulvar Lesions
Human Papilloma Virus
Molluscum Contagiosum
Pediculosis Pubis
Scabies
HPV –
genital warts
Most common STD
HPV 6 and 11 – low risk types
Verruccous, pink/skin colored, papillaform
DDxs: condyloma lata, squamous cell ca, other
Treatment:
Chemical/physical destruction (cryo, podophyllin, 5%
podofilox, TCA)
Immune modulation (imiquimod)
Excision
Laser
Other: 5-FU, interferon-alpha, sinecatchins
High rate of RECURRENCE