Infections in OB/GYN: Vaginitis, STIs

1. Infections in OB/GYN: Vaginitis, STIs Lisa Rahangdale, MD, MPH Dept. of OB/GYN

2. 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

3. 26 yo 2 wk hx vag DC • Differential Diagnosis • HPI • Pertinent PMH • Pelvic Exam • MicroscopyLaboratory • Treatment • Counseling

4. Vaginal Discharge DDXS • Candidiasis • Bacterial Vaginosis • Trichomonas • Atrophic • Physiologic (Leukorrhea) • Mucopurulent Cervicitis • Uncommon • Foreign Body • Desquamative

5. HPI • Age • Characteristics of discharge • color, odor, consistency • Symptoms • Itching, burning • erythema, bumps • Bleeding, pain • Prior occurences, treatments • Risk factors • Sexual activity, medications, PMH

6. PMH • Pregnancy • Menopause • Immunosuppression • Diabetes, HIV, medications

7. Pelvic exam

8. Microscopy

9. Pelvic Exam

10. Microscopy

11. Treatment & Counseling • Rx: Metronidazole 2 gm po X 1 Tinidazole 2 gm PO x 1 • Counseling • Partner treatment • Safe sex

12. Pelvic exam

13. Microscopy

14. Pelvic exam

15. Neisseria gonnorhea • Symptoms • Arise 3-5 days after exposure • Initially so mild as to be overlooked • Malodorous, purulent vaginal discharge • Physical Exam • Mucopurulent discharge flowing from cervix • Cervical Motion Tenderness

16. Gonorrhea Rx Ceftriaxone 125 mg IM in a single doseORCefixime400 mg orally in a single dose PLUS Tx FOR CHLAMYDIA IF NOT RULED OUT Do NOT use Quinolones in U.S. - resistant GC common

17. Chlamydia S/Sx/Dxs • Usually asymptomatic • Best to screen susceptible young women • Mucopurulent cervicitis • Intermenstrual bleeding • Friable cervix • Postcoital bleeding • Elisa or DNA probe (difficult to culture)

18. 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

19. Chlamydia in Pregnancy • Azithromycin 1 g orally in a single dose ORAmoxicillin 500 mg orally three times a day for 7 days (2006 - Poor efficacy of erythromycin – now alternative regimen) • Test of cure in 3 weeks

20. 21 YO presents with RLQ pain • Differential diagnosis • GYN • OB • GI • Urologic • MSK • She has CMT on pelvic examination. Does this rule anything out?

21. HPI • LMP = 5 days ago • Pelvic pain, vaginal discharge x 2 days • New sexual partner in last 3 months • Uses condoms “all of the time except sometimes when we forget.”

22. 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

23. PID Symptoms • Acute or chronic abdominal/pelvic pain • Deep Dyspareunia • Fever and Chills • Nausea and Vomiting • Epigastric or RUQ pain (perihepatitis)

24. 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

25. PID Diagnostic Tests • WBC may be elevated, *often WNL • ESR >40, Elevated CRP-neither reliable • Ultrasound • Hydrosalpinx or a TuboOvarian Complex/Abcess • Fluid in Culdesac nonspecific • Fluid in Morrison’s Pouch is suggestive if associated with epigastric/RUQ pain

26. “Am I going to have to go the hospital?” • Inpatient tx Criteria • Peritoneal signs • Surgical emergencies not excluded (appy) • Unable to tolerate/comply with oral Rx • Failed OP tx • Nausea, Vomiting, High Fever • TuboOvarian Abcess • Pregnancy 2006 CDC STD guidelines

27. 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

28. 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

29. PID SEQUELAE Pelvic Adhesions chronic pelvic pain, dyspareunia infertility ectopic pregnancy Empiric Treatment Suspected Chlamydia, GC or PID Deemed valuable in preventing sequelae “Am I going to be OK after I take these antibiotics?”

30. 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

31. 24 yo G 0 lesion on vulva • HPI • Pertinent review of systems • Focused exam • Laboratory • Treatment • Counseling re partner

32. Genital Ulcers Herpes Syphilis Chanchroid Lymphogranuloma Venereum Granuloma Inguinale Vulvar lesions HPV Molluscum Contagiosum Pediculosis Pubis Scabies Vulvar lesions: DDxs

33. 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

34. Herpes • Primary • Systemic symptoms • Multiple lesions • Urinary retention • Nonprimary First Episode • Few lesions • No systemic symptoms • preexisting Ab

35. 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

36. 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

37. 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

38. Primary & Secondary Syph

39. 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

40. 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

41. Vulvar Lesions • Human Papilloma Virus • Molluscum Contagiosum • Pediculosis Pubis • Scabies

42. 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