Presentation is loading. Please wait.

Presentation is loading. Please wait.

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

Similar presentations


Presentation on theme: "Infections in OB/GYN: Vaginitis, STIs Lisa Rahangdale, MD, MPH Dept. of OB/GYN."— Presentation transcript:

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

4 Vaginitis/Vaginosis  Characteristics of the discharge  pH  Amine odor  Wet mount  Cultures?

5 Vaginal Candidiasis  Part of normal flora  Majority Candida albicans  Predisposing factors:  Diabetes  Antibiotics  Increased estrogen levels (preg, OCP, HRT)  Immunosuppression  ?Contraceptive devices, behaviors

6 Vaginal Candidiasis  S/Sx  Pruritis  White, clumpy discharge  pH  Dxs: KOH prep  Treatment  Fluconazole 150 mg PO x1  Topical azoles (OTC)

7 Bacterial Vaginosis  Disruption of healthy vaginal flora 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

8 Bacterial Vaginosis

9 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**

10 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 Tinidazole 2 gm PO x 1  Partner tx  Same doses in pregnancy

11 SEXUALLY TRANSMITTED DISEASES  Causative Agent  Method of Transmission  Symptoms  Physical Signs  Diagnostic Methods  Treatment  Screening

12 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

13 Physical Diagnosis  Mucopurulent discharge flowing from cervix  To be distinguished from normal thick yellow white cervical mucous(adherent to ectropion)  Cervical Motion Tenderness

14 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

15 Physical Diagnosis  Mucopurulent discharge flowing from cervix  To be distinguished from normal thick yellow white cervical mucous(adherent to ectropion)  Cervical Motion Tenderness

16 Disseminated GC  Gonococcal bacteremia (rare)  Pustular or petechial skin lesions  Asymetrical arthralgia  Tenosynovitis  Septic arthritis  Rarely  Endocarditis  Meningitis

17 Gonorrhea Rx Ceftriaxone 125 mg IM in a single dose OR Cefixime400 mg orally in a single dose Ceftriaxone 125 mg IM in a single dose OR Cefixime400 mg orally in a single dose PLUS PLUS Tx FOR CHLAMYDIA IF NOT RULED OUT Tx FOR CHLAMYDIA IF NOT RULED OUT Do NOT use Quinolones in U.S. - resistant GC common

18 Chlamydia trachomatis  C. trachomatis  Obligate intracellular pathogen  No cell wall, not susceptible to penicillins  Difficult to culture

19 Chlamydia Diagnosis  Usually asymptomatic  Best to screen susceptible young women  Mucopurulent cervicitis  Intermenstrual bleeding  Friable cervix  Postcoital bleeding  Elisa or DNA probe

20 Chlamydia Rx  Uncomplicated cervicitis (no PID)  Azithromycin 1 gm po OR OR  Doxycycline 100 mg BID for 7 days  Repeat testing in 3 mons  Annual screen in age < 25

21 Chlamydia in Pregnancy Chlamydia in Pregnancy  Azithromycin 1 g orally in a single dose OR Amoxicillin 500 mg orally three times a day for 7 days ( Poor efficacy of erythromycin – now alternative regimen) ( Poor efficacy of erythromycin – now alternative regimen)  Test of cure in 3 weeks

22 Pelvic Inflammatory Disease  Polymicrobial  Initiated by GC, Chlamydia, Mycoplasmas  Overgrowth by anaerobic bacteria, GNRs and other vaginal flora (Strep, Peptostrep) 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 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

26 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 (No Quinolone unless allergy) Regimens:http://www.cdc.gov/std/treatment/ 2006/pid.htm

27 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

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

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  Syphilis  Herpes  Chanchroid  Lymphogranuloma Venereum  Granuloma Inguinale

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 days

41 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

42 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

43 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

44 Vulvar Lesions  Human Papilloma Virus  Molluscum Contagiosum  Pediculosis Pubis  Scabies

45 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


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

Similar presentations


Ads by Google