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 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

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 OR Amoxicillin 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/pi d.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. “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

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

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