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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

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infections in ob gyn vaginitis stis

Infections in OB/GYN: Vaginitis, STIs

Lisa Rahangdale, MD, MPH

Dept. of OB/GYN

objectives
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
26 yo 2 wk hx vag dc
26 yo 2 wk hx vag DC
  • Differential Diagnosis
  • HPI
  • Pertinent PMH
  • Pelvic Exam
  • MicroscopyLaboratory
  • Treatment
  • Counseling
vaginal discharge ddxs
Vaginal Discharge DDXS
  • Candidiasis
  • Bacterial Vaginosis
  • Trichomonas
  • Atrophic
  • Physiologic (Leukorrhea)
  • Mucopurulent Cervicitis
  • Uncommon
    • Foreign Body
    • Desquamative
slide5
HPI
  • Age
  • Characteristics of discharge
    • color, odor, consistency
  • Symptoms
    • Itching, burning
    • erythema, bumps
    • Bleeding, pain
  • Prior occurences, treatments
  • Risk factors
    • Sexual activity, medications, PMH
slide6
PMH
  • Pregnancy
  • Menopause
  • Immunosuppression
    • Diabetes, HIV, medications
treatment counseling
Treatment & Counseling
  • Rx: Metronidazole 2 gm po X 1

Tinidazole 2 gm PO x 1

  • Counseling
    • Partner treatment
    • Safe sex
neisseria gonnorhea
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
gonorrhea rx
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

chlamydia s sx dxs
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)

chlamydia rx
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
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
21 yo presents with rlq pain
21 YO presents with RLQ pain
  • Differential diagnosis
    • GYN
    • OB
    • GI
    • Urologic
    • MSK
  • She has CMT on pelvic examination. Does this rule anything out?
slide21
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.”
pelvic inflammatory disease
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
PID Symptoms
  • Acute or chronic abdominal/pelvic pain
  • Deep Dyspareunia
  • Fever and Chills
  • Nausea and Vomiting
  • Epigastric or RUQ pain (perihepatitis)
pid physical diagnosis
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
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
am i going to have to go the hospital
“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

pid treatment
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
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
am i going to be ok after i take these antibiotics
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?”
recommended screening
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
24 yo G 0 lesion on vulva
  • HPI
  • Pertinent review of systems
  • Focused exam
  • Laboratory
  • Treatment
  • Counseling re partner
vulvar lesions ddxs
Genital Ulcers

Herpes

Syphilis

Chanchroid

Lymphogranuloma Venereum

Granuloma Inguinale

Vulvar lesions

HPV

Molluscum Contagiosum

Pediculosis Pubis

Scabies

Vulvar lesions: DDxs
herpes
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
herpes1
Herpes
  • Primary
    • Systemic symptoms
    • Multiple lesions
    • Urinary retention
  • Nonprimary First Episode
    • Few lesions
    • No systemic symptoms
    • preexisting Ab
herpes rx
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
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
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
latent syphilis
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
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
vulvar lesions
Vulvar Lesions
  • Human Papilloma Virus
  • Molluscum Contagiosum
  • Pediculosis Pubis
  • Scabies
hpv genital warts
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
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