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
�Diagnose and treat a patient with vaginitis�Interpret a wet prep�Differentiate the signs and symptoms, physical exam findings, diagnostic evaluation and management of the following STI痴: Gonorrhea, Chlamydia, herpes simplex virus, Syphilis, Human papillomavirus infection, �Describe the pathogenesis, signs

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
Part of nl flora 20-50% women
Candida Albicans 80-92% (C. glabrata and C. parapsilosis)
Antibiotics — One-quarter to one-third

6. Vaginal Candidiasis S/Sx Dxs: KOH prep Treatment Pruritis
White, clumpy discharge
pH 4-4.5
Dxs: KOH prep
Treatment
Fluconazole 150 mg PO x1
Topical azoles (OTC)

7. 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

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
**No gels during pregnancy, different dosing**
**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
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 Culture for legal purposes
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  
   PLUS
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
Doxycycline 100 mg BID for 7 days
Repeat testing in 3 mons
Annual screen in age < 25

21. 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)
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)
Bacterial Vaginosis - associated with PID
flora characteristic of BV isolated from endometrium/fallopian tubes in 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:

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 Empiric Treatment
chronic pelvic pain, dyspareunia
infertility
ectopic pregnancy
Empiric Treatment
Suspected Chlamydia, GC or PID
Deemed valuable in preventing sequelae
Alt regimens
Levofloxacin 500 mg IV once daily*    WITH OR WITHOUT Metronidazole 500 mg IV every 8 hours
   OR Ofloxacin 400 mg IV every 12 hours*    WITH OR WITHOUT Metronidazole 500 mg IV every 8 hours
   OR Ampicillin/Sulbactam 3 g IV every 6 hours     PLUS Doxycycline 100 mg orally or IV every 12 hours

30. Recommended Screening
GC/Chlamydia:
women < 25 (**remember urine testing!)
Pregnancy
Syphilis
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 Nonprimary First Episode Systemic symptoms
Multiple lesions
Urinary retention
Nonprimary First Episode
Few lesions
No systemic symptoms
preexisting Ab

35. Herpes Rx First Episode Recurrent Episodic Rx: Suppressive therapy
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
Treatment might be extended if healing is incomplete after 10 days of therapy

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 Testing
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
Low risk – do not integrate into host genome
Podophyllin, an extract of Podophyllum peltatum, contains the antimitotic agent podophyllotoxin, which arrests the cell cycle in metaphase and leads to cell death.
Imiquimod is a positive immune response modifier, which acts by local cytokine induction