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Infections in OB/GYN: Vaginitis, STI’s UNC School of Medicine Obstetrics and Gynecology Clerkship Case Based Seminar Series Lisa Rahangdale, MD, MPH Dept.

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Presentation on theme: "Infections in OB/GYN: Vaginitis, STI’s UNC School of Medicine Obstetrics and Gynecology Clerkship Case Based Seminar Series Lisa Rahangdale, MD, MPH Dept."— Presentation transcript:

1 Infections in OB/GYN: Vaginitis, STI’s UNC School of Medicine Obstetrics and Gynecology Clerkship Case Based Seminar Series Lisa Rahangdale, MD, MPH Dept. of OB/GYN

2 Objectives for Vaginitis  Formulate a differential diagnosis for vulvovaginitis  Interpret a wet mount microscopic examination  Describe the variety of dermatologic disorders of the vulva  Discuss the steps in the evaluation and management of a patient with vulvovaginal symptoms

3 Objectives for STI’s  Describe the guidelines for STI screening and partner notification and treatment  Describe STI prevention strategies, including immunization  Describe the symptoms and physical exam findings associated with common STI’s  Discuss the steps in the evaluation and initial management of common STI’s including appropriate referral  Describe the pathophysiology of salpingitis and pelvic inflammatory disease  Describe the evaluation, diagnostic criteria and initial management of salpingitis/pelvic inflammatory disease  Identify the possible long-term sequelae of salpingitis/pelvic inflammatory disease

4 26 yo 2 wk hx vag DC Differential Diagnosis HPI Pertinent PMH Pelvic Exam MicroscopyLaboratory Treatment Counseling Case: 26 yo w/ 2 wk h/o vaginal DC

5  Candidiasis  Bacterial Vaginosis  Trichomonas  Atrophic  Physiologic (Leukorrhea)  Mucopurulent Cervicitis  Uncommon  Foreign Body Vaginal Discharge: Ddx

6  Age  Characteristics of discharge  color, odor, consistency  Symptoms  Itching, burning  erythema, bumps  Bleeding, pain  Prior occurences, treatments  Risk factors  Sexual activity, medications, PMH (pregnancy, menopause, immunosuppression) HPI

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

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

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

10 Pelvic exam

11  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

12

13  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** Bacterial Vaginosis: Treatment

14  Flagellate parasite  “Strawberry”Cervix  Pruritis, frothy green discharge  Vaginal 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 Trichomonas

15 Pelvic Exam

16  Causative Agent  Method of Transmission  Symptoms  Physical Signs  Diagnostic Methods  Treatment  Screening  Prevention: don’t forget the obvious! Counsel your patients about condom use! Sexually Transmitted Diseases (STI’s)

17  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 Neisseria gonorrhea: Symptoms

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

19  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 Neisseria gonorrhea: Diagnosis

20  Gonococcal bacteremia (rare)  Pustular or petechial skin lesions  Asymetrical arthralgia  Tenosynovitis  Septic arthritis  Rarely  Endocarditis  Meningitis Neisseria gonorrhea: Disseminated

21  Ceftriaxone 125 mg IM in a single dose OR  Cefixime 400 mg orally in a single dose PLUS  Tx FOR CHLAMYDIA IF NOT RULED OUT Do NOT use Quinolones in U.S. - resistant GC common Neisseria gonorrhea: Treatment

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

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

24  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 trachomatis: Treatment

25  Azithromycin 1 g orally in a single dose OR  Amoxicillin 500 mg orally three times a day for 7 days  Test of cure in 3 weeks Chlamydia trachomatis: Pregnancy

26 26 yo 2 wk hx vag DC Differential Diagnosis: – GYN – OB – GI – Urologic – MSK Case: 21 yo presents with RLQ pain

27 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 Pelvic Inflammatory Disease

28  Acute or chronic abdominal/pelvic pain  Deep Dyspareunia  Fever and Chills  Nausea and Vomiting  Epigastric or RUQ pain (perihepatitis) PID: Symptoms

29  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: Physical Diagnosis

30  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: Diagnostic Tests

31  Outpatient  Ceftriaxone 250mg IM + Doxycycline x 14 d w/ or without Metronidazole x 14 d  Cefoxitin 2 g IM + Probenecid 1 g PM concurrently + Doxy x 14 d w/ or without Metronidazole x 14 d  Other parenteral 3 rd generation cephalosporin + Doxy x 14 d w/ or with Metronidazole x 14 d PID: Outpatient Treatment

32  Criteria (2010 CDC STD guidelines)  Surgical emergencies not excluded (appy)  Unable to tolerate/comply with oral Rx  Failed outpatient tx (no improvement 72 hrs)  Severe illness, Nausea, Vomiting, High Fever  TuboOvarian Abcess (refer for surgical evaluation if patient not improving)  Pregnancy  *no evidence that adolescents require hospitalization  Consider referral to GYN if patient not improving PID: Inpatient Treatment

33 A:  Cefoxitin 2 gm IV q 6 hr  OR Cefotetan 2 gm q 12 hr  Plus  Doxycycline 100mg IV or po q 12 hr B:  Clindamycin 900mg q 8 hr and  Gentamycin 2 mg/kg then 1.5mg/kg q 8 hr * Can d/c IV therapy 24 hrs after clinical improvement, complete 14 days PID: Inpatient Treatment

34  Pelvic Adhesions  chronic pelvic pain, dyspareunia  infertility  ectopic pregnancy  Empiric Treatment  Suspected Chlamydia, GC or PID  Deemed valuable in preventing sequelae PID: Sequelae

35  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 Recommended Screening

36 26 yo 2 wk hx vag DC Differential Diagnosis HPI Pertinent ROS Focused exam Laboratory Treatment Counseling Case: 24 yo G0 w/ lesion on vulva

37  Syphilis  Herpes  Chanchroid  Lymphogranuloma Venereum  Granuloma Inguinale Genital Ulcers

38  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

39  Primary  Systemic symptoms  Multiple lesions  Urinary retention  Nonprimary First Episode  Few lesions  No systemic symptoms  preexisting Ab Herpes

40  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 Herpes: Treatment

41  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

42  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 Syphilis Stages

43 Primary and Secondary Syphilis

44  Definition: Asx, found on screen  Early 1 year duration  Late >1 year or unknown duration  Testing  Screening: VDRL, RPR- nontreponemal  Confirmatory: FTA, MHATP- treponemal Latent Syphilis

45  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 Syphilis: Treatment

46  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 Chancroid

47  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 Lymphogranuloma Venerum

48  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 Granuloma Inguinale

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

50  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  Gardasil covers HPV 6, 11 HPV: Genital Warts

51 Bottom Line Concepts  Appropriate diagnosis of vaginitis will ensure appropriate treatment. The various forms of vulvovaginitis are easily confused by patients.  Be familiar with appropriate STI screening guidelines and review them at all preventive care visits.  The CDC provides excellent information on treatment of STI’s.  The only truly effective preventive measures is abstinence from sexual activity.  Condoms and dental dams are the only preventive measure we have for patients who are sexually active.

52 References and Resources  APGO Medical Student Educational Objectives, 9 th edition, (2009), Educational Topic 35, 36 (p74-77).  Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010), Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William NP Herbert, Douglas W Laube, Roger P Smith. Chapter 26, 27 (p ).  Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone, Calvin J Hobel. Chapter 22 (p ).  CDC 2010 STD Treatment guidelines:


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