Firecracker - Gynecologic Infectious Disease

Question 1

What is the cause of bacterial vaginosis?

Answer 1

• BV is caused by Gardnerella vaginalis. It is the most common cause of abnormal vaginal discharge in women of child bearing age.
  
  • Note - BV does not cause vaginal inflammation. Inflammation suggests a mixed vaginitis
• BV is an overgrowth of abnormal bacterial flora that replaces the normal vaginal flora (lactobacilli) and it is not a sexually transmitted disease
• Potassium hydroxide wet mount will cause an increase in odor (positive ‘‘Whiff’’ test)
• The vaginal discharge in bacterial vaginosis is thin, white and ‘fishy’ smelling with pH > 4.5 (normal vagina pH is <4.0)
• Saline white mount of the discharge will show ‘‘Clue cels’’ - epithelial cells covered with multiple attached bacteria
• Bacterial vaingosis is treated with metronidazole. Recall metronidazole causes a disulfiram-like reaction when drinking alcohol and therefore patients must be counseled not to drink alcohol when using this medication.

Question 2

How are relapsing urinary tract infections treated?

Answer 2

• Uncomplicated UTIs are treated with 3 days of TMP-SMX or a fluroquinolone
• If the UTIs are relapsing, antibiotics should be given for 14 days
• Recall that fluoroquinolones and TMP-SMX are teratogenic - common antibiotics used to treated UTIs in pregnancy include nitrofurantoin and cephalosporins.

Question 3

What are the symptoms in the different stages of lymphogranuluoma venerum?

Answer 3

• The primary stage of lymphogranuloma venerum occurs in the first two weeks of contraction and presents with the following symptoms:
  
  • Malaise
  • Headache
  • Fever
  • Papule formation at contact site that transforms to a painless ulcer healing after a few days
• The secondary stage occurs a month following contraction and is marked by the development of inguinal buboes (painful inflammation and enlargement of the lymph nodes). This finding is more common in men than in women
• The tertirary stage (anogenital syndrome) is charactersised by the following symptoms:
  
  • Proctitis
  • Rectal stricture
  • Rectovaginal fistula
  • Elephantiasis (swelling due to lymphatic obstruciton)

Question 4

What is trichomoniasis?

Answer 4

• Trichomans vaginitis or trichomoniasis is caused by Trichomonas vaginalis, an anaerobic, sexually transmitted protozoan and often causes intense vulvar pruiritus and inflammation
• Trichomoniasis presents with profuse, malodorous, frothy vaginal dischage which may have greenish discolouration. It has a pH > 4.5
• The characteristic ‘‘strawberry cervix’’ of a patient with trichomoniasis is caused by punctate epithelial papillae but occurs in less than 10% of patients.
• Saline wet mount shows motile trichomonads
• Ptoassium hydroxide wet mount may yield a positive whiff test
• Trichomoniasis is also treated with metronidazole - because this is a sexually transmitted infection - it is imperative that the partner (s) be treated as well.

Question 5

What is the role of Thayer-Martin growth media in the diagnosis of cervicitis?

Answer 5

Culturing on Thayer-Martin agar can be used to detect the presence of Neisseria gonorrhoeae.

Question 6

What are common urinalysis findings in a patient with a urinary tract infection?

Answer 6

Urinalysis of a patient with UTI will often show:

Increased nitrates
Increased leukocyte esterase
White blood cells, but not WBC casts

Question 7

What are the characteristics of the discharge seen in trichomoniasis?

Answer 7

Trichomoniasis presents with profuse, malodorous, frothy vaginal discharge, which may havegreenish discoloration. It has a pH > 4.5.

Question 8

How are uncomplicated urinary tract infections treated?

Answer 8

Uncomplicated UTIs are treated with 3 days of TMP-SMX or a fluoroquinolone.

Question 9

In addition to vaginal discharge and bleeding, what other symptoms may be associated with cervicitis?

Answer 9

• Many women with cervicitis will be asymptomatic (more than 50% of patients with Chlamydia infection are asymptomatic) and the finding is incidental during a cervical examination
• When symptomatic, women will present with purulent or mucopurulent discharge (milder if Chlamydia) and/or intermenstrual or postcoital bleeding
• In addition to vaginal discharge and bleeding, women may present with:
  
  • Dyspareunia
  • Dysuria (if urethral infection is also present)
  • Vaginal irritation

Question 10

What are possible complications of urinary tract infections?

Answer 10

• Complications of UTIs include:
  
  • Pyelonephritis
  • Renal failure
  • Abscesses

Question 11

What saline wet-mount finding is associated with bacterial vaginosis?

Answer 11

Saline wet-mount of the discharge will show “Clue cells” – epithelial cells covered with multiple attached bacteria.

Question 12

What does a potassium hydroxide wet-mount of bacterial vaginosis yield?

Answer 12

Potassium hydroxide wet-mount will cause an increase in odor (positive “Whiff” test).

Question 13

What is PID?

Answer 13

Pelvic inflammatory disease (PID), also known as acute salpingitis, is a long-term consequence of untreated STDs and is a major cause for infertility and ectopic pregnancies.

The infection results from ascending infection from the vagina through the cervix to the uterus. It can pass through the fallopian tubes into the peritoneal cavity.
Gonorrhea and Chlamydia are the principal causative agents and account for 40% of cases. However, most cases of PID are thought to be polymicrobial, caused by anaerobic bacteria and bacteria from the GI tract, such as E coli.

Question 14

What are the risk factors for the development of PID?

Answer 14

Risk factors for the development of PID include:

Multiple partners
Recent history of douching
Prior history of PID
Cigarette smoking

Question 15

Who most often develops pelvic inflammatory disease?

Answer 15

PID most commonly affects sexually active women in the 15-25 age range.

Question 16

How is lymphogranuloma venerum diagnosed?

Answer 16

Diagnosis of lymphogranuloma venerum is usually made based on clinical suspicion. However, genital and lymph node samples can be tested for Chlamydia.

Question 17

What is endometritis?

Answer 17

• Endometritis is an infection of the uterine endometrium, most commonly caused by delivery (especially after C-section) or instrumentation of the uterus (i.e. after procedure such as abortion or IUD insertion)
• It is commonly thought to co-exist with PID, because as PID progresses it ascends upward into the uterine cavity
• Signs and symptoms include:
  
  • Fever
  • Lower abdominal pain secondary to uterine and/or adnexal tenderness
  • Notable tenderness of bimanual exam
  • Vaginal bleeding or discharge
  • Foul smelling lochia (in post partum patients)
  • Leukocytosis
• Chronic endometritis is often a polymicrobial infection and is associated with:
  
  • retained placenta
  • intrauterine device (actinomyces israelii)
  • Chlamydia
• treatment of endometritis involves the use of broad spectrum antibiotics with anaerobic coverage. IV clindamycin and gentamycin are often used.

Question 18

What is cervicitis and how is it diagnosed?

Answer 18

Cervicitis is a clinical diagnosis and is usually made based on the findings of purulent or mucopurulent vaginal discharge combined with cervical friability, which is sustained endocervical bleeding after contacting the area with a cotton swab.

Gram staining of cervical scraping will show nothing if cervicitis is a result of Chlamydia, but will show gram-negative diplococci if cervicitis is a result of Neisseria gonorrhoeae.

Culturing on Thayer-Martin agar can be used to detect the presence of Neisseria gonorrhoeae.

Enzyme immunoassays, such as nucleic acid amplification tests (NAAT) can be used to detect the presence of both Chlamydia and N. gonorrhoeae.
DNA probes and PCR are highly sensitive ways to detect either Chlamydia or N. gonorrhoeae from samples of cervical fluid.

Question 19

A UTI is an ascending infection that can infect what structures?

Answer 19

Urinary tract infections (UTIs) are ascending infections of the urethra, bladder, and ureters. Most often they result from bacteria from the perineal region (rarely from hematogenous spread).

Question 20

What are some of the pathogenic agents respsonible for UTIs?

Answer 20

The most common infectious agent implicated in UTIs is E. Coli.
Other common bacteria include:

S. saprophyticus
Proteus
Klebsiella
Pseudomonas
Enterobacter
Enterococci

Question 21

What are some of the risk factors for UTIs?

Answer 21

Female sex (female urethra is much shorter than the male urethra)
Immunocompromised status
Diabetes
Foley catheter
Pregnancy
Vesicoureteral reflux
Sexual intercourse

Question 22

How is PID treated?

Answer 22

Treatment is typically broad-spectrum IV antibiotics, such as IV cefoxitin and doxycycline.

Most tubo-ovarian abscesses can be managed with broad-spectrum IV antibiotics, such as Ampicillin (for gram positive coverage) and Gentamycin (for gram negative coverage), plus Metronidazole or Clindamycin (for anaerobes). In some women, surgical drainage of the abscess must be performed in addition to antibiotic therapy.

Question 23

What is vulvovaginal candidiasis and how can it be treated?

Answer 23

Candida vaginitis, or vulvovaginal candidiasis, is caused by Candida albicans and is easily distinguished from bacterial vaginosis and trichomonas vaginitis by pseudohyphae on potassium hydroxide wet-mount.

Candida albicans overgrowth is more common in patients with:

Antibiotic use
Diabetics
Immunosuppressed patients (immunosuppressive therapy, those with HIV/AIDS)

Vaginal discharge is thick, white, often likened to “cottage cheese”, with a pH between 3.5-4.5.
Saline wet-mount in vulvovaginal candidiasis normal.
Vulvovaginal candidiasis is treated with clotrimazole, miconazole, nystatin, or oral fluconazole.

Question 24

What would your diagnostic work up for pelvic inflammatory disease include?

Answer 24

• When working up pelvic inflammatory disease, a pregnancy test should be ordered to rule out ectopic pregnancy
  
  • Serum findings associated with PID include increased WBC and ESR
• Gram stain, culture and immunoassays should be ordered to identify the causative agent
• Culdocentesis which is aspiration of intraperitoneal fluid behind the uterus, will reveal pus behind the uterus
• Ultrasound findings associated with PID can include:
  
  • Inflammaed enlarged uterus
  • Abscess in fallopian tubes or the ovaries
  • Free fluid in the peritoneum

Question 25

What cervical finding is associated with trichomoniasis?

Answer 25

The characteristic “strawberry cervix” of a patient with trichomoniasis is caused by punctate epithelial papillae, but occurs in < 10% of patients.

Question 26

What culdocentesis finding is associated with pelvic inflammatory disease?

Answer 26

Culdocentesis, which is aspiration of intraperitoneal fluid behind the behind the uterus, will reveal pus behind the uterus.

Question 27

How do urinary tract infections typically present?

Answer 27

UTIs typically present with the following symptoms:

• Frequency
• Dysuria
• Urgency
• Suprapubic pain

Question 28

What is vaginitis and how is it treated?

Answer 28

• Vaginitis is the overgrowth of abnormal organisms (most commonly Trichomonas vaginalis or Candida albicans) in the vagina, resulting in inflammation and irritation or changes in the normal vaginal flora
• Risk factors for developing vaginitis and vaginosis include:
  
  • Diabetes Mellitus
  • HIV
  • Unprotected sex, multiple partners and young age at first intercourse
  • Intrauterine device use
  • Smoking
• Patients typically present with a history of vaginal discomfort or pruritis and vaginal discharge
• Note:
  
  • Flagyl (metronidazole) and fluconazole are considered safe in pregnancy and treatment is the same in pregnant and non-pregnant women.

Question 29

How is cervicitis treated?

Answer 29

Acute cervicitis is treated with ceftriaxone if the cause is N. gonorrhoeae and eitherazithromycin or doxycycline (not pregnant patients) if the cause is Chlamydia. Because the rate of coinfection is so high, both antibiotics are often given together.

Sexual partners must also be treated because of the risk of reinfection.
Noninfectious cervicitis related to a foreign body or chemical irritation often resolves with removal of the offending agent.

Question 30

How is cervicitis diagnosed?

Answer 30

• Cervicitis is a clinical diagnosis and is usually mde based on the findings of purulent or mucopurulent vaginal discharge combined with cervical friability, which is sustained endocervical bleeding after contacting the area with a cotton swab
• Gram staining of cervical scrapping will show nothing if cervicitis is a result of Chlamydia but will show gram negative diplococci if cervicitis is a result of N.gonorrhoeae.
• Culturing on Thayer-Martin agar can be used to detect the presence of N.gonorrhoeae.
• Enzyme immunoassays such as nucleic acid amplification test (NAAT) can be used to detect the presence of both chlamydia and n.gonorrhoeae
• DNA probes and PCR are highly sensitive ways to detect either Chlamydia or N.gonorrhoeae from samples of cervical fluid.

Question 31

What complications are associated with cervicitis?

Answer 31

• complications associated with cervicitis include PID, reactive arthritis in chlamydia infections, septic arthritis in gonococcal infections.
• Untreated PID can lead to female infertility,

Question 32

What is the pathology behind cervicitis?

Answer 32

• Cervicitis refers to inflammation of the cervical columnar epithelium. It primarily affets the endocervical glands but can also affect the epithelium of the ectocervix.
• Acute cervicitis is usually due to an infectious cause, most notably Chlamydia trachomatis and Neisseria gonorrhoeae. Note: Chlamydia is the most common reportable STD and is often asymptomatic and because of its higher prevelance is a more common cause of cervicitis.
• Chronic cervicitis is usually due to noninfectious reasons such as mechanical trauma (a pessary, diaphragm or tampon) or chemical irritation (latex, vaginal douches or contraceptive creams)
• Remember that because of sexual contact, the urethra, oral cavity or rectal area can also become infected.

Question 33

How are tubo-ovarian abscesses treated?

Answer 33

• Treatment is typically broad spectrum IV antibiotics such as IV cefoxitin and doxycycline
• Most tubo-ovarian abscesses can be managed with broad spectrum IV antibiotics such as Ampicillin (gram positive coverage) and Gentamycin (gram negative coverage, plus Metronidazole or Clindamycin (for anaerobes).
• In some women surgical drainage of the abscess must be performed in addition to antibiotic therapy .

Question 34

What is lymphogranuloma venerum?

Answer 34

Lymphogranuloma venerum is a systemic disease caused by C. trachomatis, specifically serotypes L1-3. It is different from the cervicitis caused by other serotypes.

Question 35

What complications are associated with pelvic inflammatory disease?

Answer 35

• Complications of pelvic inflammatory disease include:
  
  • Infertility
  • Development of tubo-ovarian abscess (TOA)
  • Fitzhugh-Curtis syndrome which is a perihepatitis from the ascending infection that results in right upper quadrant pain and tenderness and elevated liver function tests.

Question 36

What is the clinical presentation of vaginitis?

Answer 36

Vaginitis is the overgrowth of abnormal organisms (most commonly Trichomonas vaginalis orCandida albicans) in the vagina, resulting in inflammation and irritation or changes in the normal vaginal flora.

Risk factors for developing vaginitis and vaginosis include:

Diabetes Mellitus
HIV
Unprotected sex, multiple partners, and young age at first intercourse
Intrauterine device use
Smoking

Patients typically present with a history of vaginal discomfort or pruritis and vaginal discharge.
Note: flagyl (metronidazole) and fluconazole are considered safe in pregnancy and treatment is the same in pregnant and non-pregnant women

Question 37

How is lymphogranuloma venerum treated?

Answer 37

Treatment of lymphogranuloma venerum involves the antibiotics erythromycin or doxycycline.

Question 38

What symptoms are associated with pelvic inflammatory disease?

Answer 38

Signs and symptoms of pelvic inflammatory disease include:

Lower abdominal pain secondary to uterine and/or adnexal tenderness, with notable tenderness of bimanual exam (unilateral or bilateral)
Cervical motion tenderness; so tender they may jump off table during pelvic exam (chandelier sign)
Vaginal bleeding/discharge, foul-smelling discharge
GI distress, diarrhea
Painful urination

Question 39

In order to diagnose a patient with a urinary tract infection, how many organisms must be seen in a urine culture if the patient has lower urinary symptoms?

Answer 39

A definitive diagnosis of a UTI requires a positive urine culture with demonstrable organisms. The amount of organisms depends on the clinical scenario.

If a patient is symptomatic with lower urinary tract symptoms, the urine culture only needs to show 104 organisms/mL.

Question 40

n order to diagnose a patient with a urinary tract infection, how many organisms must be seen in a urine culture if the patient has symptoms of pyelonephritis?

Answer 40

If a patient is febrile with pyelonephritis, 104 organisms/mL are needed to diagnose a UTI.

Question 41

In order to diagnose a patient with a urinary tract infection, how many organisms must be seen in a urine culture if the patient is asymptomatic?

Answer 41

In asymptomatic patients a diagnosis of UTI requires a urine culture with >105 organisms/mL from two separate urine samples.

Why obtain a urine sample if a patient is asymptomatic? Pregnant women are routinely screened for asymptomatic bacteriuria.