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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. of OB/GYN
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
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
Case:
2 wkhxh/o
vaginal
2626yoyo w/
2 wk
vag
DC DC
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Differential Diagnosis
HPI
Pertinent PMH
Pelvic Exam
MicroscopyLaboratory
Treatment
Counseling
Vaginal Discharge: Ddx
Candidiasis
Bacterial Vaginosis
Trichomonas
Atrophic
Physiologic (Leukorrhea)
Mucopurulent Cervicitis
Uncommon
Foreign Body
HPI
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)
Vaginitis/Vaginosis
Characteristics of the discharge
pH
Amine odor
Wet mount
Cultures?
Vaginal Candidiasis
Part of normal flora
Majority Candida albicans
Predisposing factors:
Diabetes
Antibiotics
Increased estrogen levels (preg, OCP, HRT)
Immunosuppression
?Contraceptive devices, behaviors
Vaginal Candidiasis
S/Sx
Pruritis
White, clumpy discharge
pH 4-4.5
Dxs: KOH prep
Treatment
Fluconazole 150 mg PO x1
Topical azoles (OTC)
Pelvic exam
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
Bacterial Vaginosis
Bacterial Vaginosis: 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**
Trichomonas
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
Pelvic Exam
Sexually Transmitted Diseases (STI’s)
Causative Agent
Method of Transmission
Symptoms
Physical Signs
Diagnostic Methods
Treatment
Screening
Prevention: don’t forget the obvious! Counsel
your patients about condom use!
Neisseria gonorrhea: 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
Neisseria gonorrhea: Diagnosis
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
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: Disseminated
Gonococcal bacteremia (rare)
Pustular or petechial skin lesions
Asymetrical arthralgia
Tenosynovitis
Septic arthritis
Rarely
Endocarditis
Meningitis
Neisseria gonorrhea: Treatment
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
Chlamydia trachomatis
C. trachomatis
Obligate intracellular
pathogen
No cell wall, not
susceptible to
penicillins
Difficult to culture
Chlamydia trachomatis: Diagnosis
Usually asymptomatic
Best to screen susceptible young women
Mucopurulent cervicitis
Intermenstrual bleeding
Friable cervix
Postcoital bleeding
Elisa or DNA probe
Chlamydia trachomatis: Treatment
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: Pregnancy
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
Case:
2621yoyo presents
2 wk hxwith
vagRLQ
DCpain
• Differential Diagnosis:
–
–
–
–
–
GYN
OB
GI
Urologic
MSK
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
Acute or chronic abdominal/pelvic pain
Deep Dyspareunia
Fever and Chills
Nausea and Vomiting
Epigastric or RUQ pain (perihepatitis)
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
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
Abscess
Fluid in Culdesac nonspecific
Fluid in Morrison’s Pouch is suggestive if associated with
epigastric/RUQ pain
PID: Outpatient Treatment
http://www.cdc.gov/std/treatment/2010/pid.htm#a2
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 3rd generation cephalosporin + Doxy
x 14 d w/ or with Metronidazole x 14 d
PID: Inpatient Treatment
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 Abscess (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
http://www.cdc.gov/std/treatment/2010/pid.htm#a2
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: Sequelae
Pelvic Adhesions
chronic pelvic pain,
dyspareunia
infertility
ectopic pregnancy
Empiric Treatment
Suspected Chlamydia, GC or
PID
Deemed valuable in
preventing sequelae
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
Case:
w/hx
lesion
vulva
26 24
yoyo 2G0wk
vagonDC
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Differential Diagnosis
HPI
Pertinent ROS
Focused exam
Laboratory
Treatment
Counseling
Genital Ulcers
Syphilis
Herpes
Chanchroid
Lymphogranuloma Venereum
Granuloma Inguinale
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
Herpes
Primary
Systemic symptoms
Multiple lesions
Urinary retention
Nonprimary First Episode
Few lesions
No systemic symptoms
preexisting Ab
Herpes: Treatment
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
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
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
Primary and Secondary 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
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
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
Lymphogranuloma Venerum
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
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
Vulvar Lesions
Human Papilloma Virus
Molluscum Contagiosum
Pediculosis Pubis
Scabies
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
Gardasil covers HPV 6, 11
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.
References and Resources
APGO Medical Student Educational Objectives, 9th 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 (p241258).
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 (p265-275).
CDC 2010 STD Treatment guidelines:
http://www.cdc.gov/std/treatment/2010/toc.htm