Lower reproductive tract infections

Question 1

UTIs

Answer 1

Need to r/o pyelo (no fever, no CVA tenderness)

Treat for E. coli, etc. with oral abx.

Question 2

DDx of UTIs

Answer 2

Interstitial cystitis: chronic inflammation of bladder → recurrent irritative urinary sx (urgency, frequency) for long time w/o infection, also pelvic pain (dyspareunia, etc).

Question 3

Vulvitis

Answer 3

Usually candidasis
If chronic, always rule out malignancy
Could also be 2/2 irritants, etc.

Question 4

Syphilis (T. pallidum): primary

Answer 4

Primary = chancre on exposed mucosa, painless / red / round / firm / well circumscribed.

Develops 3wks after exposure; some LAD too.

Question 5

Syphilis (T. pallidum): secondary

Answer 5

Disseminated. Maculopapular rash including palms / soles 1-3 mo after exposure

Question 6

Syphilis (T. pallidum): latent

Answer 6

Early if < 1yr, late if > 1 yr

Question 7

Syphilis (T. pallidum): tertiary

Answer 7

Uncommon, years later.

Granulomas / gummas of skin, cardiovascular syphilis (aortitis), neurosyphilis (tabes dorsalis, general paresis).

Question 8

Diagnose syphilis

Answer 8

Dark field microscopy from chancre / granuloma is gold standard

RPR/STS → FTA-ABS for serology / screening.

Question 9

Syphilis management

Answer 9

PCN G 2.4M units x 1; if late latent, do it weekly x 3 wks.

Alternatives: tetracycline PO 4x/day x 2wks, doxy 100mg PO BID x 2wks, or ceftriaxone 1gm IM/IV daily x 8-10d, but desensitize & give PCN, especially in pregnancy!

If neurosyphilis, need IV PCN G q4h x 10-13d.

Follow RPR / VRDL titers - should see decrease @ 6mo, nonreactive @ 12-24mo

Question 10

Jarisch-herxheimer rxn

Answer 10

After starting PCN
From death of spirochetes
Fever, chills, H/A, myalgia,malaise, pharyngitis, rash w/in 24h
Shouldn’t prevent / delay therapy

Question 11

HSV symptoms

Answer 11

Grouped vesicles / ulcers with burning, pruritis.

Question 12

HSV Dx

Answer 12

DNA PCR, or Tzanck smear classically.

Question 13

HSV management

Answer 13

Primary infection: acyclovir, famciclovir, valacyclovir
If severe or immunocompromised, IV acyclovir
If recurrent, oral acyclovir x 5d
Chronic infection: valacyclovir can lessen transmission, reduce outbreaks
If pregnant, C/S

Question 14

Chancroid (H. ducreyi) symptoms

Answer 14

Painful, well-demarcated, non-indurated ulcer with painful supperative inguinal LAD
Very rare in USA

Question 15

Chancroid (H. ducreyi) diagnosis

Answer 15

Dx with culture (chocolate agar), hard to do.

Question 16

Chancroid (H. ducreyi) treatment

Answer 16

Tx with ceftriaxone IM x1, azithro PO x 1, or longer cipro / erythro regimens.
Treat partners too

Question 17

LGV (C. trach L1-3): first stage

Answer 17

Painless, transient local lesion (papule / ulcer)

Question 18

LGV (C. trach L1-3): second stage

Answer 18

Inguinal syndrome (painful enlargment / inflammation of inguinal nodes, fever / H/A / malaise, anorexia)

Question 19

LGV (C. trach L1-3): tertiary stage

Answer 19

Anogenital syndrome (proctocolitis, rectal stricture, rectovaginal stricture, elephantiasis.

Question 20

LGV (C. trach L1-3) diagnosis

Answer 20

Clinical suspicion, can also use cx / immunofluorescence / NAAT

Question 21

LGV (C. trach L1-3) treatment

Answer 21

Doxycycline 100 mg PO BID or erithroymycin x 21 days.

Question 22

Condyloma acuminata (genital warts)

Answer 22

Caused by HPV
Raised papillomatous wart → can grow to large pedunculated lesions
Bx if uncertain
Prevent with gardasil

Question 23

Condyloma acuminata (genital warts) treatment

Answer 23

Treat with local excision, cryo, topical TCA or 5FU

Can also use imiquimod or podofilox self-treatment if motivated

Question 24

Molluscum contagiosum (pox virus) symptoms/ dx

Answer 24

Small umbilicated “water warts”, anywhere except hands / feet. Clinical dx.

Question 25

Molluscum contagiosum (pox virus) treatment

Answer 25

Local excision or Trichloracetic acid (TCA) / cryotherapy

Question 26

Bacterial vaginosis:

Answer 26

shift from lactobacillis → other microorganisms, incl Gardnerella

Question 27

Dx of bacterial vaginosis

Answer 27

Dx: 3 of [whiff test, thin white homogenous discharge, > 20% clue cells, nitrazine pH > 4.5]

Question 28

Treatment of bacterial vaginosis

Answer 28

Metranidazole 500mg PO BID x 7d or clinda. PO > topical for efficacy. No EtOH with metro

Question 29

Candidiasis risk factors: | ○ Dx: KOH prep showing branching hyphae & spores

Answer 29

A/w diabetes, recent abx, immunocompromise, intercourse, etc.

Question 30

Candidiasis signs and symptoms

Answer 30

Sx: Pruritis, burning, dysuria, dyspareunia, discharge | On exam: satellite lesions, cottage cheese-like discharge

Question 31

Treatment of candidiasis

Answer 31

Tx: azoles ■ Topical / suppository = miconazole, terconazole; Nystatin too ■ PO: fluconazole = Diflucan 150 mg PO x 1 ■ If recurrent, consider non-albicans species (can be resistant to azoles); try longer duration and may need weekly PO fluconazole x 6mo

Question 32

Trichomonas vaginalis:

Answer 32

STD, unicellular anaerobic flagellated protozoa

Question 33

Trichmonas vaginalis symptoms

Answer 33

Profuse discharge (yellow / gray / green / frothy) with unpleasant odor, pruritis, worse just after menses 2/2 vaginal pH increase

Question 34

Trichomonas vaginalis examination

Answer 34

pH in 6-7 range, vulvar erythema / edema / pruritis, “strawberry cervix” (but only 10%)

Question 35

Trichomonas dx

Answer 35

Wet prep → trichomonads; NAAT is more sensitive, cx rarely done but most sensitive / specific

Question 36

Treatment of trichomonas

Answer 36

Metronidazole 2g PO x1 and treat partner as well | Vs BV tx, which is for 7d and no partner treatment needed

Question 37

Mucopurulent cervicitis:

Answer 37

Cervical motion tenderness without other PID sx

Question 38

Gonorrheal cervicitis:

Answer 38

Classically sx peak during & after menses. Can infect anal canal, urethra, oropharynx, bartholin glands too. In neonates, can cause conjunctivitis. Disseminated = fevers, erythematous macular skin rash, arthritis, etc.

Question 39

Diagnosis of gonorrheal cervicitis

Answer 39

Gram negative dipplococcus; can gram stain or isolate with Thayer-Martin media, although NAAT on urine / cervical specimens is now #1

Question 40

Treatment of gonorrheal cervicitis

Answer 40

Ceftriaxone 125 mg IM x 1 or cefixime 400mg PO x 1; | Also treat with azithro PO x1 for CT unless ruled out by NAAT

Question 41

Chlamydia trachomatis

Answer 41

Ocular, respiratory, reproductive tract infections. Urethritis, etc. too.

Question 42

Diagnosis of Chlamydia trachomatis

Answer 42

NAAT (intracellular, so gram stain / cx not good)

Question 43

Chlamydia trachomatis treatment

Answer 43

Azithromycin 1g PO x1 or BID doxy x 7d (but not in pregnancy)