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Obstetrics and Gynecology Revalida > Lower Genital Tract Infections > Flashcards

Lower Genital Tract Infections Flashcards

1
Q

What does vulvar itching or burning suggest in an OPD visit?

A

infection or contact dermatitis

along with itching you may also see skin fissures and excoriation which also points to infection and contact dermatitis

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2
Q

What is the most common cause of enlargement of the Bartholin glands?

A

Cystic dilatation of the Bartholin duct

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3
Q

Give the differences between Bartholin gland cysts and abscess in terms of (1) location, (2) size, (3) Laterality, (4) Signs, (5) Symptoms

A
  1. They are both similar such that both cysts and abscesses are found in the labia majora and duct orifices at the base of the labia minora
  2. they re both 1-8 cm
  3. They are both often unilateral, but can be bilateral
  4. For signs, cysts are tense, mostly unilocular, and may have multiple compartments when it is chronic/recurring cyst

Abscesses on the other hand, develops rapidly (2-4 days) and is accompanied by erythema, acute tenderness, and edema with occasional cellulitis in the subcutaneous tissue.

  1. for symptoms cysts are asymptomatic and non-painful, while abscesses have acute pain and tenderness, with difficulty in movement and dyspareunia
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4
Q

Give the treatment of Bartholin gland enlargement in women at varying stages

A

Asymptomatic women <40 yrs = no treatment required

Acute adenitis without abscess formation = broad spectrum antibiotics and sitz bath

Symptomatic cysts or abscesses = Marsupialization (drainage plus allow drainage of future infections (tx of choice).
Word catheter - alternative
Antibiotics not necessary UNLESS there is associated cellulitis in the surrounding tissue

Women >40 with symptomatic gland enlargement = excision biopsy

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5
Q

What are the two most common vulvar parasites?

A

crab louse (pediculosis pubis) and Itch mite (scabies)

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6
Q

What are the areas occupied by the crab louse (causes pediculosis pubis), how fast does it travel? what is its incubation period? and what does it feed on primarily?

What is its life cycle?

What is the predominant clinical symptom?

Transmission?

Diagnosis?

Treatment?

A
  1. Hairy areas or the vulva and occasionally the eyelids
  2. it travels slowly
  3. its incubation period is 30 days
  4. its major nourishment is human blood
  5. egg (deposited in hair follicles)
  6. nymph
  7. adult parasites
  8. Constant pubic pruritus due to allergic sensitization (to parasite). (this is constant while in scabies it is intermittent)
  9. Since sensitization, may take 5 days to weeks before itching occurs.
  10. direct sexual contact, but can also be thru towel or bedding
  11. MOST CONTAGIOUS of all STIs, >90% of partners are infected after a single exposure
  12. eggs, adult lice, pepper grain feces, rough spots
  13. Microscopy for DEFINITIVE diagnosis = miniature crab with six legs
  14. Permethrin 1% cream applied to the area and washed off after 10 minutes
  15. alternatives: Malathion 0.5% lotion applied 8-12 hours then washed off. Ivermectin 250 microgram per kg repeated in 2 weeks
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7
Q

For scabies, what is/are its:
1. transmission?
2. preference of location? predilections to any areas?
3. predominant clinical symptoms? what is the pathognomonic sign?
4 laboratory work-ups? differential diagnoses?
5. treatment?
6. prevention? (applies for both crab louse and itch mite)

A
  1. close contact
  2. it is widespread all over the body with no preference anywhere and no predilection to hairy areas
  3. predominant clinical symptom includes: severe INTERMITTENT itching. pruritus MORE INTENSE AT NIGHT,
    papules, vesicles and burrows -> PATHOGNOMONIC SIGN -> twisted line on the skin surface with small vesicle on the end.
  4. handheld magnifying glass. ddx include all dermatologic stuff that cause pruritus
  5. Permethrin 5% cream applied to all areas of the body from neck down and washed off after 8-14 hours
    Ivermectin 200micrograms/kg PO repeated in 2 weeks if necessary
  6. Treatment should be prescribed for sexual contacts within 6 weeks and other close household contacts.
    Clothing and bedding should be decontaminated.
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8
Q

Molluscum contagiosum is a pox virus and often a chronic localized infection, what is/are its:

  1. transmission?
    1. clinical symptoms?
  3. Lesions?
  4. Diagnosis?
  5. Treatment?
A
  1. Skin to skin contact, fomites.
    1. In adults, it is primarily asymptomatic. but unlike most STIs it is only mildly contagious
  3. Flesh colored domed papules with umbilicated center
  4. Microscopy of white waxy material from inside the nodule. intracytoplasmic molluscum bodies in giemsa stain
  5. Usually a self limiting infection that resolves after a few months in immunocompetent individuals. but you can treat individual nodules to decrease sexual transmission and autoinoculation of the organism
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9
Q

When does the transmission of Genital Herpes occur?

A

Episodes of asymptomatic shedding, may occur as frequently as once in 5 days

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10
Q

Is HSV 1 only limited to the the upper half of the body?

A

no, HSV 1 can also infect the genital area. it is the most commonly acquired genital herpes in women <25 years old

HSV 1 may cause genital herpes in 13-40% of infections.

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11
Q

What are the symptoms of Primary infection of genital herpes (4)?

A
  1. paresthesia of the vulvar skin
  2. Papule and vesicle formation -> multiple vesicles develop into superficial ulcers which heal spontaneously without scarring
  3. Severe vulvar pain, tenderness and inguinal adenopathy
  4. General malaise and fever
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12
Q

What are the symptoms of recurrent infection of genital herpes?

what is its prodrome?

Where does HSV reside during its latent phase?

How do you diagnose genital herpes?

How do you treat and prevent genital herpes? (give the 3 agents and dosage)

A

First of all, recurrent infection is related to emotional stress and onset of menstrual period

  1. May be asymptomatic at least but at most can be half as severe as the primary infection.
  2. Prodrome includes sacroneuralgia, vulvar tenderness and pruritus 5 days before vesicle formation
  3. it resides in dorsal root ganglia of S2-S4
  4. Diagnosis includes:
    - clinical inspection -> Herpetic ulcers are PAINFUL, while syphilis ulcers are PAINLESS
    - Viral culture
    - PCR test -> most accurate and sensitive for detecting HSV
  5. Treatment includes: Valacyclovir, Acyclovir, and Famciclovir

Valacyclovir
1000mg bid for 7-10 days for first episode,
1000mg daily or 500mg bid for 5 days for recurrent infection. same doses for suppression

-Acyclovir
200mg 5x/day or 400mg 3x/day for 7-10 days for first clinical infection
400mg 3x/day or 800mg 2x/day for 5 days for recurrent infections
400mg 2x/day for suppression

-Famciclovir
250mg 3x/day for first clinical infection
125mg 2x/day for recurrent infection
250mg 2x/day for suppression

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13
Q

Give three characteristics of granuloma inguinale

what is the etiology?

What is the transmission?

A
  1. Chronic
  2. Slowly progressive
  3. Ulcerative
  4. Klebsiella granulomatosis
  5. Sexual transmission and close non-contact transmission. It is not very contagious however and needs chronic exposure to contract disease
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14
Q

What are the clinical manifestations of granuloma inguinale?

How do you diagnose granuloma inguinale?

What is its treatment?

A
  1. Clinical manifestations include: an asymptomatic nodule that becomes an ulcer (beefy red ulcer appearance)
    - If subcutaneous exposure, it becomes a pseudobub
    - unless there is secondary bacterial infection, the ulcers and nodules will remain painless with no regional adenopathy
  2. clinical manifestations are needed in endemic areas
  3. Donovan bodies or bacteria with a SAFETY PIN appearance (pIn INGUINALE) from samples taken from the ulcers. a special SILVER STAIN is used to identify these.
  4. Its drug of choice is Azithromycin, 1g PO once per week for at least 3 weeks
  5. alternatives include doxycycline, ciprofloxacin, erythromycin, Trimethoprim sulfamethoxazole
  6. If therapy does not work, GENTAMYCIN (or aminoglycosides can be used)

may relapse 6-18 months after effective therapy

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15
Q

What is the etiology of lymphogranuloma venereum?

Majority of the cases occur in which sex?

What is the most frequent site?

A
  1. The etiology is Chlamydia trachomatis it is a chronic infection of the lymphatic tissue
  2. Majority of the cases occur in men
  3. Vulva
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16
Q

What are the three distinct phases of lymphogranuloma venereum?

A
  1. Primary infection = shallow painless ulcer in the vestibule or labia that heals spontaneously
  2. Secondary infection = painful adenopathy in the inguinal and perirectal areas along with general malaise and fever.
    - if untreated, becomes increasingly tender, enlarged, matted, adherent to the overlaying skin forming a bubo (tender lymph nodes)
    - GROOVE SIGN = classic sign, depression between two inflamed nodes
  3. Tertiary infection = Bubo ruptures spontaneously, formation of multiple sinuses and fistulas. destruction of external genitalia and anorectal region leading to scarring and fibrosis.
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17
Q

How do you diagnose lymphogranuloma venereum?

What is its treatment?

A
  • Clinical suspicion, exclusion of other causes
  • Genital lesions and bubo can be tested for C. trachomatis using culture.
  1. Drug of choice: Doxycycline 100mg PO 2x/day for 21 days
    OR
  2. Erythromycin 500mg PO 4x/day for at least 21 days
    OR
  3. Azithromycin 1g PO weekly for 3 weeks
18
Q

What is the etiology of chancroid?

Give a small description of the appearance of its lesions as well as its characteristics

How is it transmitted?

A
  1. Genital chancroids are cause by Haemophilus ducreyi, small gram negattive, rod, non-motile, facultative anaerobes
  2. Painful, tender ulcer with tender suppurative inguinal adenopathy.
  3. sexually transmitted
19
Q

Can Haemophilus ducreyi invade skin tissue?

A

NO, there must be trauma or excoriation to precede initial infection since H. ducreyi is unable to penetrate or invade normal skin.

20
Q

How do you diagnose chancroid?

-Differentiate vs chancroid and syphilis

A
  1. via gram-stain and appearance of the organism (gram negative, rod, non-motile anaerobe
    - APPEARS AS SCHOOL OF FISH

2.Chancroid: soft chancre; always painful and tender

Syphilis: Hard chancre, often asymptomatic

21
Q

What is the clinical manifestation of chancroid?

  • what is its incubation period?
  • describe the formation of the ulcer
  • Describe the appearance of the ulcer

What is its treatment?

A
  1. The incubation period is 3-6 days
  2. it begins as a small papule that evolves into a pustule that ruptures in 48 to 72 hours which forms an ulcer
  3. the ulcer is shallow, with a ragged edge, that usually occurs in the vestibule. They have a dirty, gray foul smelling exudate and lack of induration (hardening) at the base.
  4. Treatment includes:
    - Azithromycin 1g PO single dose
    - Ceftriaxone 250mg IM single dose
    - Ciprofloxacin 500mg PO BID for 3 days
    - Erythromycin 500mg PO TID for 7 days
22
Q

What is the etiology of syphilis?

All women diagnosed with syphilis should be screen for what?

What stages are patients with syphilis contagious? When is it most contagious?

How is syphilis transmitted?

A
  1. Treponema pallidum
  2. HIV
  3. Primary, secondary and first year of latent syphilis. 1 to 2 years after start of disease
  4. Kissing or touching of the part with an active ulcer. (may occur with oral-genital contact)
23
Q

What are the different stages of syphilis and explain each one

A

Primary Syphilis:

  • Painless papule appears at the site of inoculation 2-3weeks after exposure. -> ulcerates to produce a chancre (differentiate from chancroid)
  • Chancre = classic finding of primary syphilis, painless, solitary ulcer, 1-2cm, with a raised, indurated margin and non-exudative base
  • Heals spontaneously within 6 weeks

Secondary Syphilis:

  • Result of hematogenous dissemination of spirochetes
  • Systemic disease that occurs 6 weeks to 6 months after the primary chancre.
  • Symptoms include: rash, fever, headache, malaise, lymphadenopathy and anorexia
  • CLASSIC RASH = red macules and papules over the PALMS of hands and SOLES of feet.
  • Vulvar lesions of condyloma acuminatum are large, raised, flattened, grayiish white areas
  • papules may fuse to form ulcers which are PAINLESS unless with secondary infection

Latent stage:

  • follows after 2nd stage and may vary in length from 2-20 years
  • positive serology without any signs and symptoms of disease
  • may still be infectious

Tertiary Syphilis

  • potentially destructive effect on central nervous, cardiovascular, and musculoskeletal systems
  • Involves gummas = similar to cold abscess, with a necrotic center and obliteration of small vessels
24
Q

How do you screen for syphilis?

How do you diagnose syphilis?

A
  1. Non-treponemal
    - Rapid Plasma Reagin
    - VDRL
  2. Treponemal (confirmatory)
    - Treponema immobilization test
    - FTA-ABS (Fluorescent-labeled Treponema Ab absorption)
    - MHA-TP (Microhemaagglutination assay for T. pallidum)
  3. Darkfield microscopy: Thin, silvery, spiral motile orgnanism
25
Q

What is the treatment for syphilis in its primary, secondary, and early latent VS late latent?

A
  1. For Primary, Secondary, and Early Latent:
    -Benzathine Penicillin G, 2.4 million units IM Single Dose
    OR
    -Doxycycline 100mg bid for 14 days
    -Tetracycline 500mg, PO 4x/day for 2 weeks
  2. For Late Latent:
    -Benzathine Penicillin G 2.4 million units IM at 1 week intervals 3x doses
    OR
    -Doxycycline 100mg bid for 4 weeks
    -Tetracycline 500mg po qid for 4 weeks
26
Q

What are the 3 most common causes of vaginitis?

A

Fungi (candidiasis)

Protozoon (Trichomoniasis)

Disruption of vaginal bacterial ecosystem (Bacterial vaginosis)

27
Q

What is the normal vaginal PH in premenopausal women?

Why is it acidic?

A

4.0

because the lactobacilli produce lactic acid which maintains the vaginal oh of 3.8-4.5

28
Q

What is the most prevalent cause of symptomatic vaginitis?

A

Bacterial vaginosis

29
Q

What are the risk factors of bacterial vaginosis? (4)

A
  1. new or multiple sexual partners
  2. Prevalent in wsw where toys are shared without cleaning
  3. Douching at least monthly and social stressors
  4. lack of hydrogen peroxide producing lactobacilli
30
Q

Give complications of bacterial vaginosis

A
  1. upper genital tract infections
  2. preterm premature rupture of membranes, increased pregnancy loss within 20 weeks of gestation, decreased success with in vitro fertilization
31
Q

How do you diagnose bacterial vaginosis? Explain

A

Use the Amsel’s criteria, there are four:

  1. homogenous vaginal discharge
  2. vaginal PH is 4.5 or higher
  3. whiff test - vaginal discharge has amine-like odor when mixed with potassium hydroxide.
  4. wet smear demonstrates clue cells of more than 20% of the number of vaginal epithelial cells

3 of 4 must be met for presumptive diagnosis

Second is the Gram staining using Nugent’s score:
(0-3) = normal
(4-6) = intermediate
(7-10) = bacterial vaginosis

you will be checking the presence of lactobacilli, gardnerella, bacteroides, curved gram-variable rods

32
Q

What is the treatment for bacterial vaginosis?

A
  1. Metronidazole 500mg PO BID for 7 days
    OR Metronidazole gel 0.75% intravaginally once a day for 5 days
    OR Clindamycin cream 2% intravaginally at bedtime for 7 days
33
Q

Where does Trichomonas vaginalis (flagellated protozoon) inhabit?

A
  1. inhabits the vagina and lower urinary tract in SKENE’S DUCTS
34
Q

Give the signs and symptoms of T. vaginalis (5)

How is it diagnosed?

What is its treatment?

A
  1. Frothy discharge with foul odor. Primary complain of trichomonas infection is profuse vaginal discharge giving the women a feeling of being “wet”
  2. erythema and edema of the vagina and vulva
  3. STRAWBERRY CERVIX and UPPER VAGINA
  4. vulvar pruritus
  5. dysuria
  6. NSS smear/ wet smear = visualization of the organism
  7. Metronidazole 2g PO in a single dose
    OR
    Tinidazole 2g PO in a single dose
35
Q

What are risk factors for vulvovaginal candidiasis?

How is it diagnosed?

What are the two classifications for vulvovaginal candidiasis?

A
  1. Hormonal - menstrual period, pregnancy
  2. Depressed cell-mediated immunity
  3. Broad spectrum antibiotic use
  4. KOH smear
  5. Culture with Nickerson or Saboraud medium
  6. Uncomplicated = infrequent vvc, mild candidiasis, more likeely to be C. albicans, nonimmunocompromised women
  7. Complicated = recurrent or severe VVC or non-albicans or immunocompromised women
36
Q

What is the treatment for VVC?

which treatment is contraindicated in pregnant women?

A
  1. if UNCOMPLICATED = topical antifungal agents for 1-3 days
    OR
    Single oral dose of fluconazole
2. if COMPLICATED = topical azoles are recommended for 7-14 days
OR 
Fluconazole (150mg) oral then a second dose taken 72 hours after the first oral therapy

Topical antifungal agents include: clotrimazole, miconazole, ticonazole

FLUCONAZOLE IS CONTRAINDICATED in pregnant women

treatment for pregnant women = topical azoles for 7 days

37
Q

Differentiate between ectocervical and endocervical infection

A

Ectocervical: can be HSV or severe vaginitis (strawberry vaginitis from T. vaginalis) or C. albicans

Endocervical: Secondary to C. trachomatis or N. gonorrhea.

  • Also associated with bacterial vaginosis and mycoplasma genitalium
  • Primary endocervical infections may result in secondary ascending infections or PID and perinatal infections
  • can become a reservoir of infection
38
Q

What are the criteria for mucopurulent cervicitis?

What are alternative criteria?

What are the signs and symptoms of mucopurulent cervicitis?

What are the pathogens responsible for mucopurulent cervicitis?

A
  1. visualization of gross yellow mucopurulent material. >10 PMN per microscopic field from specimens obtained from the endocervix
  2. Erythema and edema in the area of the cervix. Bleeding secondary to cervical ulceration. Friability when cervical smear is obtained. Increased vaginal discharge or intermenstrual bleeding
  3. Hypertrophic and edematous cervix
  4. Vaginal discharge
  5. Deep dyspareunia
  6. Postcoital bleeding
  7. Neisseria gonorrhea
  8. Chlamydia trachomatis
39
Q

What is the shape and gram stain of NG? where does it reside?

How do you diagnose N. gonorrhea infection in the cervix?

What are the treatment?

What are follow up requirements?

A
  1. Gram-negative diplococci, can be found in the rectum, eye, pharynx, or epithelium of the genitourinary tract
  2. Gram stain and culture of the obtained specimen.
  3. The gold standard is nucleic acid amplification test
  4. Nucleic acid hybridization test 91-100% sensitivity and 97-100% specificity
  5. Ceftriaxone 250mg IM, single dose
    OR
  6. Cefixime 400mg PO single dose + Azithromycin 1g orally single dose
  7. If asymptomatic, no need for follow up. There is high rate of reinfection so screening is prudent.
  8. screen for syphilis in 4-6 weeks
  9. Offered testing for HIV
40
Q

When should empiric therapy be offered for women that have increased risk for chlamydia trachomatis?

How do you diagnose C. trachomatis?

How do you treat C. trachomatis?

A
  1. for women >25, new or multiple sex partners, and unprotected sex
  2. It is diagnosed via nucleic acid amplification test. -> GOLD STANDARD (98 sensitivity, 99 specificity)
  3. others include immunoassay, culture, direct fluorescent antigen
  4. Treatment includes Azithromycin 1g PO single dose
    OR
  5. Doxycyclin 100mg BID for 7 days
  6. Alternatives include erythromycin, levofloxacin, ofloxacin

Obstetrics and Gynecology Revalida (8 decks)

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