Gynecologic Infections Flashcards
(52 cards)
1
Q
vaginal discharge
A
- Estrogen thickens the vaginal epithelium → large glycogen production by epithelial cells
- Intraepithelial glycogen → production of lactic acid
- pH 3.5-4.0 in the vagina promotes growth of normal vaginal flora
- Lactobacilli
- Corynebacteria
- Prepubertal girls at higher risk of vaginal infections due to thin epithelium
- Postmenopausal women lose glycogen and acidity as estrogen declines → vaginal atrophy, dryness, increased risk of infection and trauma
- Postmenopausal women also at risk for urinary incontinence, further predisposing to vaginal infections
- Vaginal discharge is always present
- Acidic
- Clear or white mucoid
- No odor
- Not itchy or painful
- May increase at the time of ovulation (cervical mucus increases)
- Epithelial secretions, desquamation; vulvar secretions from sebaceous, sweat and apocrine glands
- Vaginal discharge is abnormal if:
- Increased volume, especially if soiling the clothes
- Bad odor
- Change in consistency or color
- Irritation or pruritis, pain, burning
- Dyspareunia or dysuria
2
Q
diagnosis of vaginal discharge
A
- History including:
- Personal hygiene – soaps, perfumes, douching
- Sexual activity – use of lubricants, condoms, etc.
- Medications that may alter vaginal pH or flora
- Oral contraceptive pills, antibiotics
- Underlying medical illness – diabetes, HIV
- History of STD
- Use of synthetic undergarments or tight clothing
- Examine the vulva, vaginal walls, and cervix
- Check pH of vaginal discharge
- Collect specimens to send to the lab
- GC, Chlamydia, HSV, etc.
- Prepare a wet mount
- Diluted with normal saline on a glass slide
- Prepare a KOH smear
- 10% potassium hydroxide solution on a slide
- “Whiff” test or sniff test
3
Q
non-sexually transmitted infections
A
- Candidiasis (Candida albicans)
- Bacterial vaginosis (Gardnerella vaginalis)
- Bartholin’s gland cyst/abscess
-
Mycoplasma hominis and Ureaplasma urealyticum also cause bacterial vaginal disease, but much less commonly
- Diagnosis by vaginal culture or PCR for identification
- Treatment is Doxycycline 100mg po bid x 10 days
4
Q
sexually transmitted infections
A
- Trichomoniasis (Trichomonas vaginalis)
- Gonorrhea (Neisseria gonorrhoeae)
- Chlamydia (Chlamydia trachomatis)
- Herpes simplex virus (HSV)
- Syphilis
- Human papillomavirus (HPV)
- Human immunodeficiency virus (HIV)
5
Q
bartholin cyst
A
- Glands that excrete mucous to provide moisture to the vulva
- Bilaterally in vulvovaginal orifice at 4:00 & 8:00; Posterolateral introitus
- Gland is 0.5cm in size with narrow duct 2.5cm
- Enlargement of gland
- Trauma or perineal inflammation can obstruct the duct proximal to the obstruction
- Intervention usually not necessary because most cases are asymptomatic
- Conservatively treat with warm compresses
- Cyst vs abscess
- Symptomatic, size, tenderness, erythema
6
Q
bartholin abscess
A
- Incision and drainage has no role in management of abscess
- High risk of recurrence
7
Q
word catheter
A
- Allows contents to drain and over time to form around the catheter a fistulous tract from the dilated duct or abscess to the vestibule
8
Q
supplies for word placement
A
- Sterile gloves
- Sterilizing solution/prep surgical site
- Lidocaine 1-2% in 3cc syringe
- 25-30 G needle
- Small forceps
- # 11 scalpel for stab incision
- Gauze pads
- Culturette for sending abscess contents for microbiological identification
- Hemostat for breaking loculations
- Word catheter – balloon tipped device
- Small syringe 3mL saline
9
Q
word catheter procedure
A
- Informed consent
- Risks, benefits and alternatives discussed
- Recurrence, infection, scarring, bleeding, dyspareunia
- Prep area
- Inject anesthesia
- Hold cyst with forceps
- Incise with 5mm stab incision, 1.5cm deep in the introitus at/behind the hymenal ring to prevent vulvar scarring; if incision is too large the catheter will fall out
- Drain the cyst, break loculations
- Place Word catheter, holding onto cyst wall with forceps helps to prevent creation of false passage separate from the cavity
- Inflate the balloon with 2-3mL saline injected into the catheter
- Tuck the end of the catheter into the vagina
- Empiric broad spectrum abx
- Ceftriaxone 250mg IM or Cefixime 400m po
- Clindamycin 300mg po x 7 days
- Add azithromycin 1gm po if C. trachomatis
10
Q
word follow up
A
- Wear peripad to absorb drainage
- Pelvic rest (no sex)
- Sitz baths and mild analgesics 48 hrs
- Catheter in place 2-4 wks (poss 6 wks)
- Call for any increase in pain, swelling, fever or unusual vaginal discharge
11
Q
marsupialization
A
- Marsupialization
- Less chance of recurrence
- Outpatient surgery
12
Q
candidiasis
A
- Candida albicans is most common species
- 75% of women will experience an episode of vulvovaginal candidiasis
- May be associated with systemic disorder, pregnancy, medications
- Diabetes, HIV, obesity
- Antibiotics, steroids, oral contraceptives
- May worsen prior to menses
13
Q
candidiasis - presentation
A
- Intense vulvar pruritis
- White “cottage cheese” vaginal discharge
- Vulvar, vaginal erythema
- Burning sensation of the vulva; dysuria
- May be vulvar excoriations
- Extensive erythema and edema may indicate underlying systemic illness
14
Q
candidiasis - vaginal discharge
A
- Thick, white, curdlike, cheesy
- pH ≤ 4.5
- Buds and hyphae on wet mount and KOH prep
- Vaginal secretions may also be cultured for definitive diagnosis
15
Q
candidiasis management
A
- Treat all patients with Candida infections
- Control underlying medical illness if present
- Discontinue offending medications
- Avoid douching, nonabsorbent undergarments, tight clothing such as pantyhose
- Not typically sexually transmitted
16
Q
candidiasis - treatment
A
- Topical (intravaginal)
- OTC or Rx imidazoles
- 85-95% cure rate
- Combining with steroids for itching – a good idea?
- Systemic
- Oral fluconazole (Diflucan) 150mg po x 1
- Oral itraconazole 200mg po bid x 1 day
- During pregnancy
- Avoid imidazoles in the first trimester
- Nystatin vaginal tabs 100,000 units qhs x 2 weeks
17
Q
candidiasis - treating chronic infections
A
- ≥4 infections per year in 5-8% of women
- Treat the partner if he/she also has Candida
- Look for underlying illness or medications
- Send a vaginal culture to confirm C albicans and sensitivity to therapy
- Relation to antibiotic use or menstruation
- Prophylaxis during abx use if indicated
- Prophylaxis 3-5 days prior to menses if associated
- May use topical or oral treatments for prophylaxis
- Treatment options include:
- Prolonged therapy for 7-14 days
- Self medication for 3-5 days at the first sign of infection
- Oral fluconazole 150mg po qd x 3 days, then 150mg po q week x 6 months
- >90% eradication rate after 6 mos
- Almost 50% remain free of infection after 6 mos off Rx
- Monitor LFT’s with prolonged oral therapy
18
Q
bacterial vaginosis
A
- Caused by bacteria Gardnerella vaginalis
- Most common cause of symptomatic bacterial infections
- Normal vaginal flora is altered, causing overgrowth of Gardnerella and other species
- Increases the risk of preterm delivery in pregnant women
- Watery vaginal dc and petechiae on cervix
- Severe BV infection
19
Q
bacterial vaginosis presentation
A
- Malodorous, nonirritating vaginal discharge
- “Fishy” smell more noticeable after sexual intercourse
- May be found incidentally on well woman exam if asymptomatic
- Not considered sexually transmitted infection
- Women who are not sexually active rarely present with BV
20
Q
bacterial vaginosis - vaginal discharge
A
- Homogeneous, gray-white
- pH >4.5
- Fishy odor on KOH prep – positive Whiff test
- Wet mount shows Clue cells
- Numerous stippled or granulated epithelial cells
- Adherence of bacteria to cell membrane
- Gram negative bacilli, absence of lactobacilli
- Cultures often not helpful
- DNA testing useful
21
Q
bacterial vaginosis - treatment
A
- Only treat symptomatic or pregnant women
- No evidence to support Rx the male partner
- Nonpregnant women
- Metronidazole 500mg po bid x 7 days
- Metronidazole vag gel: 1 (5g) applicator qhs x 5 d
- Clindamycin vaginal ovules 100mg qhs x 3 d
- Pregnant women – no topical clinda
- Metronidazole 500mg po bid x 7 days
- Clindamycin 300mg po bid x 7 days
22
Q
trichomoniasis
A
- Unicellular flagellate protozoan Trichomonas vaginalis
- Larger than PMN leukocytes, smaller than epithelial cells
- Sexually transmitted
- If one STD is present, look for others
- Increased incidence in transmission of HIV
- Associated with many perinatal complications
- Frothy vaginal discharge
- Strawberry cervix
23
Q
trichomoniasis - presentation
A
- Persistent, copious vaginal discharge, usually without vulvar pruritis
- Worse after menstruation and during pregnancy
- Dysuria may be associated if vulvitis present
- Vaginal erythema with strawberry spots
- Multiple small petechiae on vaginal epithelium
24
Q
trichomoniasis - vaginal discharge
A
- Profuse, greenish, extremely frothy, thin
- May be foul smelling
- pH >5.0
- Wet mount increased PMN leukocytes and motile flagellates (trichomonads)
- Culture and DNA probes for definitive diagnosis
25
vaginal discharge treatment
* Treat sexual partners simultaneously and avoid unprotected sex until treatment is finished
* Metronidazole 2g po x 1 *or* 500mg po bid x 7 days
26
gonorrhea
* Etiology is bacteria *Neisseria gonorrhoeae*
* Sexually transmitted; reportable to PHD
* Recover organism from urethra, cervix, anus, or pharynx
* Always check pt for Chlamydia, other STDs
* Major complication is salpingitis; can lead to tubal scarring, infertility, increased risk of ectopic pregnancy
27
gonorrhea - presentation
* Most women (85%) are asymptomatic
* Purulent vaginal discharge, urinary frequency and dysuria, perineal or rectal discomfort
* May cause conjunctivitis, arthritis, pharyngitis
* On PE: erythematous vulva, vagina, cervix, urethra with purulent discharge
28
gonorrhea - vaginal discharge
* Copious, mucopurulent
* Gram negative diplococci within leukocytes; oxidase positive
* Culture or DNA probe for definitive diagnosis
* Endocervical sample
* Urine sample
29
gonorrhea - managment
* Condoms will protect against gonorrhea
* Screen high-risk patients with DNA probes of cervix or urine
* Treat partner concurrently and abstain from sexual contact for 7 days after start of treatment
* Treat presumptively for Chlamydia infection
* Test patient for syphilis; consider HIV testing
30
gonorrhea - treatment
* Ceftriaxone 125mg IM x 1 dose *or* Cefixime 400mg po x 1 dose
* _PLUS_ Azithromycin 1g po x 1 or Doxycycline 100mg po bid x 7 days for Chlamydia coverage
* Do NOT use quinolones anymore for GC
* High resistance rates in US, Asia
* Retest patient in 3 weeks with DNA probe to ensure successful treatment
31
pelvic inflammatory disease
* Acute salpingitis-peritonitis
* Usually a complication of acute gonococcal infection
* May be chronic or non-gonococcal (usually Chlamydia)
* Infection and inflammation of the uterus, tubes, ovaries; varying degrees of peritonitis
* Can lead to tube scarring and infertility
* Lower abdominal and pelvic pain with purulent vaginal discharge
* Abdominal, uterine, adnexal and cervical motion tenderness on exam
* Fever above 101˚F
* WBC \> 10K and/or elevated CRP
* Inflammatory mass on exam or US
* Gram negative intracellular diplococci
* Purulent discharge on culdocentesis
* Elevated ESR
32
pelvic inflammatory disease outpatient and inpatient treatment
* Outpatient treatment
* Temp \<102.2˚F, mild to moderate symptoms, nontoxic patient, able to take oral meds
* Oral analgesics, remove IUD if present, bed rest, antibiotics
* Ceftriaxone 250mg IM with Probenecid 1g PO + Doxycycline 100mg po bid x 14 days +/- metronidazole 500mg po bid
* Admit if no response in 72 hours
* Inpatient treatment
* Temp \>102.2˚F, guarding or rebound tenderness, toxic patients; adolescents and pregnant women
* Patients who do not respond to oral treatment
* Bed rest, NPO, IVF, NG suction if abdominal distention or ileus, IV antibiotics
* Doxycycline 100mg IV bid + Cefoxitin 2g IV qid x 24-48 hrs until patient improves, followed by complete 14 day oral course of doxycycline
* Exploratory laparotomy if TOA suspected
33
chlamydia
* Most common STD among women
* Etiology is *Chlamydia trachomatis*; obligate intracellular bacteria
* Sexually transmitted; reportable to PHD
* Usually localized infection, but may cause salpingitis and sequelae
* Increased risk of abortion, premature delivery and postpartum infections in pregnancy
34
chlamydia - presentation
* Many patients may be asymptomatic
* Mucopurulent vaginal discharge
* Hypertrophic cervical inflammation
* Cervical motion tenderness may be present
35
chlamydia - vaginal discharge
* Mucopurulent
* Giemsa stain identifies inclusions in only 40% of vaginal samples
* Culture and DNA probe of endocervical discharge or urine for definitive diagnosis
36
chlamydia - managment
* Condoms will protect against Chlamydia
* Screen high-risk patients with DNA probes of cervix or urine
* Treat partner concurrently and abstain from sexual contact for 7 days after start of treatment
* Treat for assumed gonorrhea co-infection
* Test patient for syphilis; consider HIV testing
37
chlamydia - treatment
* Non-pregnant women
* Azithromycin 1g po x 1 dose *or*
* Doxycycline 100mg po bid x 7 days
* Pregnant women
* Erythromycin 500mg po qid x 7 days *or*
* Amoxicillin 500mg po tid x 7 days
* PLUS ceftriaxone 125mg IM x 1 dose for GC
* Retest patient in 3 weeks with DNA probe to ensure successful treatment
38
herpes simplex virus
* Herpesvirus hominis types I & II
* Type I causes genital infection in 10-15%
* Type II causes genital infection in 85%
* Sexually transmitted by direct contact
* Most common cause of genital ulcers
* Incubation period 2-7 days
* Lesions last 2-6 weeks without scarring
39
HSV - presentation
* Prodrome of tingling, burning, or itching
* Vesicles erupt and rapidly erode to form painful ulcers in small patches on vulva, vagina, and/or cervix
* Fever, malaise, inguinal lymphadenopathy typically in primary infection
* Dysuria or urinary symptoms may develop
* Profuse watery vaginal discharge in herpetic cervicitis
* Diagnosis is clinical – definitive laboratory results are difficult to obtain
* Viral culture on vesicle fluid in the first 2 wks
* Scraping of ulcer and stained as Pap smear is nonspecific
* Serologic tests best for evidence of past infection
* Infections may recur
* 50% of patients have recurrence within 6 mos of primary infection
* Ulcers smaller, fewer in number, confined to one area of the vulva, vagina, or cervix
* Healing in 1-3 weeks
* Systemic symptoms, lymphadenopathy usually do not occur
* Extragenital sites include fingers, buttocks, trunk, mouth
40
HSV - management
* Lesions are self-limiting
* Good genital hygiene, loose clothing, sitz baths, oral analgesics
* Oral antivirals for primary and recurrent infections
* Topical treatments not effective
* Start within 72 hours of outbreak or ineffective
41
HSV - treatment
* Primary infection
* Acyclovir 400mg po tid x 7-10 days
* Valacyclovir 1g po bid x 10 days
* Recurrent genital herpes infection
* Acyclovir 400mg po tid x 5 days
* Valacyclovir 500mg po bid x 5 days
* Prophylaxis for genital herpes
* Acyclovir 400mg po bid
* Valacyclovir 500mg po qd
42
HSV - prevention
* Pregnancy
* Vaginal delivery if no active lesions
* Prophylaxis may be initiated at 36 wks gestation
* Prevention of dissemination
* Avoid direct contact with active lesions
* Cover small lesions with adhesive
* Precautions unnecessary in absence of active lesions
* Viral shedding may be present; no good data regarding spread during latent period
43
syphilis
* Caused by spirochete *Treponema pallidum*
* Sexually transmitted by direct contact; reportable to PHD
* Primary chancre develops 10-90 days after infection, persists 1-5 weeks and heals spontaneously
* Cutaneous eruption of secondary syphilis occurs 2-6 months after initial lesion, heals spontaneously after 2-6 weeks
44
syphilis presentation
* Primary syphilis
* Painless genital chancre: indurated, firm papule or ulcer with raised borders on labia, vulva, vagina, cervix, anus, lips or nipples
* Painless, rubbery regional lymphadenopathy followed by generalized lymphadenopathy in the 3rd-6th week
* Darkfield microscopic identification of specimens from cutaneous lesions
* Positive serologic tests in 1-4 weeks in 70% of pts
* Secondary syphilis
* Diffuse bilaterally symmetric extragenital papulosquamous eruption involving palms, soles
* Condyloma lata: moist papules in perineum, darkfield microscopy positive
* Mucous patches, darkfield microscopy positive
* Viral-like syndrome, diffuse lymphadenopathy
* Positive serologic tests
* Diffuse rash of secondary syphilis; Palmar rash of secondady syphilis
* Latent syphilis
* Resolution of primary and secondary infection without therapy
* Absence of lesions
* Positive serologic tests
* May last a lifetime without developing tertiary syphilis
* Infection of the CNS leading to neurosyphilis
* Tertiary syphilis
* Cardiac, neurologic, ophthalmic, auditory lesions may develop
* Gummas: skin or bone lesions
* CSF testing for cell count, protein, VDRL, and FTA-ABS
* Fatal in about 25% of patients
* Indications for LP: neurologic symptoms, treatment failure, serum non-treponemal titer \>1:32, evidence of tertiary syphilis, HIV+ patients
45
syphilis laboratory
* Identification of *T pallidum* organism
* Darkfield microscopy
* Silver staining of tissues
* PCR of amniotic fluid, spinal fluid
* Serologic tests
* Nontreponemal tests for screening
* VDRL, RPR
* Titers will decrease after treatment
* Treponemal tests more sensitive and specific
* FTA-ABS, MHA-TP
* Remain positive despite treatment
46
syphilis managment
* Give prophylactic treatment to exposed patient without waiting for reactive serology
* Treat the partner and avoid unprotected sexual contact until both patients have decreased serologic titers
* Use of a condom or barrier contraception will prevent most cases
47
syphilis treatment
* Early syphilis: primary, secondary, and early latent (less than 1 year duration)
* Benzathine penicillin G, 2.4 million units IM once
* Doxycycline 100mg po bid x 14 d if PCN allergic
* Late syphilis or unknown duration
* Benzathine penicillin G, 2.4 mU IM q wk x 3 wks
* Doxycycline 100mg po bid x 28 d if PCN allergic
* Neurosyphilis – very difficult to treat
* Penicillin G 3-4 mU IV q4h x 10-14 days
48
syphilis follow up
* Follow-up is mandatory
* Repeat RPR or VDRL at 0, 3, 6, 12, and 24 months after treatment
* Serologic criteria for response to treatment is 4-fold decrease in titer over 6-12 months
49
human papillomavirus (HPV)
* Papovavirus responsible for condyloma acuminata, genital dysplasia and cancer
* More than 20 types of HPV can infect the genital tract
* Types 16, 18, 31, 33, 35 most oncogenic
* Types 6, 11 associated with genital condyloma
* Sexually transmitted
* Rate is high and rising: estimated 85% of people have had HPV at some point
* \<1% clinically significant
50
HPV - condyloma acuminata
* Commonly known as genital warts
* Exophytic or papillomatous white or flesh-colored verrugous papules with fingerlike projections
* May also be flat, spiked, or inverted
* Pruritis is common; vaginal discharge from inflammation or irritation; postcoital bleeding may occur
* Immunosuppressed patients may have florid proliferation of condyloma
* Colposcopy allows better identification of lesions and evaluation for dysplasia
* Biopsy of lesions for definitive diagnosis
* Use of condoms or barrier protection may help decrease transmission
* Multiple treatments available; pt preference
* Unclear if treatments actually affect natural progression or eradicate infection
* Prevention of recurrence is difficult
* Provider applied treatments
* Bichloroacetic acid or trichloroacetic acid, 50-80% soln: apply q week as necessary until resolved
* Podophyllin 10-25% in tincture of benzoin: apply q week for 1-4 hrs, then rinse, use x 6 wks
* Intralesional injections of interferon α-2b or interferon α-n3, 1 mU (0.1mL) 3x/wk x 3 wks
* Cryosurgery, laser vaporization, electrosurgery, simple surgical excision
* Patient applied treatments
* Podofilox 0.5% solution or gel: apply bid x 3 days, rest x 4 days, repeat cycle 4-6 times as needed
* Imiquimod 5% cream: apply 3x/wk qhs, remove in am, until resolved or maximum of 16 wks
* Pregnant women
* TCA may be applied in last 4 weeks of pregnancy
* Cryosurgery, electrosurgery, laser therapy can be used prior to 32 weeks gestation
51
Human Immunodeficiency Virus (HIV)
* Most cases in USA due to HIV-1
* 20% of cases in North America in women
* 80% of women with HIV are reproductive age
* 40% cases in American women due to heterosexual contact
* High-risk groups for women: IVDA, prostitutes, heterosexual contact with men in high-risk groups
52
HIV in women
* Transmission via sexual contact, blood, or vertical transmission from mother to fetus
* Viral-like syndrome with weight loss, fever, night sweats, lymphadenopathy, pharyngitis, erythematous maculopapular rash
* Neurologic involvement
* Opportunistic infections or unusual neoplasias such as KS or cervical cancer
* Diagnosis by serologic tests
* HIV ELISA followed by confirmatory Western blot
* Recommended by CDC that everyone is tested
* All women diagnosed with HIV require
* Counseling
* Extensive STD evaluation
* Pap smear
* CBC, Chem panel, Toxoplasma Ab, hepatitis panel
* PPD, CXR
* Vaccinations for Hep B, Influenza, Pneumococcus
* Treatment includes antiretroviral medications
