Pelvic Pain and vaginal discharge

Question 1

PALM COIEN For DDX of AUB

Answer 1

Structural 
- Polpys
- Adeniomyosis
- Leiomyoma - Submucosa or other
- Malignancy
Not structural
- Coagulopathy - VWF
- Ovarian - PCOS
- Endometriosis
- Iatrogenic
- Not otherwise specified

Question 2

Tx of Heavy periods that are regular

Answer 2

Transexamic acid for first 3 to 5 days of menses. (50%)
Mefenamic acid (NSAID) if pain.
COCP only if excluded RF - Smoking, ^BMI, diabetes, ^BP
Levonorgestrel intrauterine system
Progestogens at high doses throughout cycle.

Question 3

Tx of irregular heavy period

Answer 3

?

Question 4

Tx for Chylamdia

Answer 4

Azithromycin single dose
also treat gonorrhoea as they often co exist.
Reportable disease
treat partners
Test of cure required if pregnant

Question 5

Tx of gonrrhoea

Answer 5

Ceftriaxone IM single dose
Treat chlamydia as well
treat partners
reportable disease

Question 6

Tx of syphillis

Answer 6

Benzylpencillin 1g
if greater then 1 year then repeat weekly for 3 weeks
Neurosyphilis = IV penicillin QDS for 10days

Question 7

What is normal vaginal discharge

Answer 7

Clear, white, flocculent, odourless
pH 3.8-4.2
Smear contains epithelial cells and Lactobacilli
Increase with oestrogen e.g. pregnancy, OCP, mid cycle, PCOS, premenarchal

Question 8

Tx of vulvovaginitis

Answer 8

Hygiene and local measure e.g. white cotton, no tight clothes, avoid bubble baths, stop fabric softener, use ild detergent.
Vitamin A and D ointment
IF infectious Abx.

Question 9

DDX of vulvovaginitis in prepubertal girls

Answer 9

Infections
Foreign body e.g. toilet paper
Candida if on diapers
Pinworms
Polyps, tumor
Skin disease e.g. lichen sclerosis, condyloma acuminata 
Contact dermatitis
Trauma
endocrine (bleeding)
Blood dyscrasia (bleeding)

Question 10

Atrophic vaginitis

Answer 10

visual diagnosis: thinning of tissues, erythema, petechiae, bleeding points, dryness on speculum exam.
Rule out Malignancy especially endometrial cancer
Tx: Local oestrogen replacement or oral or transdermal hormone replacement therapy
Good hygiene

Question 11

Presentation of Candidiasis

Answer 11

Predisposing factors: immunosuppressed, recent antibiotic use, increase oestrogen levels e.g. pregnancy, OCP
Discharge: whitish cottage cheese minimal.
20% asymptomatic
Intense itch
swollen inflamed genitals
vulvar burning dysuria and dyspareunia
Not sexually transmitted disease

Question 12

Ix of candidiasis

Answer 12

pH less than 4.5

KOH wet mount reveals hyphae and spores

Question 13

Tx of Candidiasis

Answer 13

Clotrimazole creams for vaping amount of days

Fluconazole - not in pregnancy

Question 14

Presentation of bacterial vaginosis

Answer 14

Discharge: Gray, thin, diffuse, fishy odour after coitus
50-75% asymptomatic
absence of vulvar/vaginal irritation
Not sexually transmitted

Question 15

Ix of Bacterial Vaginosis

Answer 15

pH greater then 4.5

Clue cells coccobacili organisms

Question 16

Tx of bacterial vaginosis

Answer 16

if pregnant or asymptomatic no tx
Oral or topical metronidazole 7days
warm them not to drink alcohol
Clindamycin in pregnancy

Question 17

risk of bacterial vaginosis in pregnancy

Answer 17

Associated with recurrent preterm labor

preterm birth and postpartum endometritis

Question 18

Presentation of trichomoniasis infections

Answer 18

Sexual transmission
Yellow green, alodorous, diffuse, frothy
25% asymptomatic
Petechiae on vagina and cervix
Occasionally irritated tender vulva
Dysuria, frequency

Question 19

Ix for trichomoniasis

Answer 19

greater then 4.5 pH
motile flagellated organisms
Many WBC
Inflammatory cells

Question 20

Tx of trichomoniasis

Answer 20

Tx even if symptomatic
Metronidazole 2g oral once.
Treat partners
Pregnant: treat once with 2g metronidazole

Question 21

Notifiable diseases for STI

Answer 21

Chancroid
Chlamydia
Gonorrhea
Hepatitis A,B,C
HIV
Syphilis

Question 22

Presentation of chlamydia

Answer 22

asymptomatic in 80%
Muco-purulent endocervical discharge
Urethral syndrome: dysuria, frequency, pyuria, no bacteria on culture
Pelvic pain
postcoital bleeding or inter menstrual bleeding
symptomatic sexual partner

Question 23

Ix for chlamydia

Answer 23

cervical culture or PCR

first catch urine PCR

Question 24

When to screen for chlamydia

Answer 24

High risk groups
15 to 30 yr old
pregnancy

Question 25

Complications of Chlamydia

Answer 25

Acute salpingitis, PID Fitx-hugh-curtis syndrome - liver capsule inflammation Reactive arthritis (male predominance, HLA-B27 associated), Conjunctivitis Urethritis Infertility from tubal obstruction from low grade salpingitis ectopic pregnancy chronic pelvic pain Perinatal infection: conductivity or pneumonia

Question 26

Presentation of Gonorrhea

Answer 26

Same as chlamydia

Question 27

Ix for Gonorrhea

Answer 27

Gram -ve intracellular diplococci | Cervical rectal, and throat culutre

Question 28

Genital warts

Answer 28

HPV 6, 11 Clinical features - Latent infection: asymptomatic, only detected by DNA hybridisation - Subclinical infection: visible lesion found during colposcopy - Clinical infection: visible wart-like lesion without magnification, vulvar edema Ix - cytology: koilocytosis, Biopsy Tx- Cryotherapy, Topical imiquimod Prevention: Gardasil or Cervarix

Question 29

Presentation of Herpes simplex

Answer 29

Asymptomatic Initially: present 2-21 days following contact Prodrome: tingling, burning, pruritus Multiple painful, shallow ulceration with small vesicles appear 7-10 days after initial infection Lesions are infectious Inguinal lymphadenopathy, malaise, and fever with 1st infection Urinary symptoms if in UTi

Question 30

Ix for herpes

Answer 30

viral culture of lesions Cytologic smear - Tzanck smear: giant cells and acidophilic intranuclear inclusion bodies Serologic HSV DNA PCR

Question 31

Tx of herpes

Answer 31

1st episode: acyclovir or famciclovir or valacyclovir Daily suppressive therapy: if recurrent more then 6 times per year. Severe : IV acyclovir education regarding transmission Avoid contact from onset of prodrome until lesions have cleared use barrier contraception.

Question 32

Concerns with herpes in pregnancy

Answer 32

treat from 36 weeks gestation onward should have C-section if active at time of delivery Tx: acyclovir

Question 33

Classifications of syphilis

Answer 33

Primary syphilis: 3-4 wk, painless chancre and inguinal lymphadenopathy, serology is usually negative Secondary syphilis: 2-6m, - nonspecific symptoms: malaise, anorexia, headache, diffuse lymphadenopathy - generalised maculopapular rash: palms, soles, trunk, limbs - Condylomata lata: anogenital, broad-based fleshy grey lesions. - Serology tests usually positive Latent syphilis: no signs, only serology Tertiary syphilis: any organ - Neuro: tabes dorsalis, general paresis - CVS: aortic aneurysm, dilated aortic root - Vulvar gumma:nodules that enlarge, ulcerate and become necrotic Congenital syphilis: fetal anomalies, still births, and neonatal death. Hutchining teeth.

Question 34

Ix for syphilis

Answer 34

Aspiration of ulcer Darkfield microscopy for spirochetes Non-treponemal screening test e.g. VDRL, RPR - non reactive after tx, can be positive in other conditions Specific antitreponemal antibody e.g. FTA-ABS, MHA-TP, TP-PA) remains reactive for life

Question 35

Bartholin gland abscess

Answer 35

Organisms: anaerobic or polymicrobial e.g. gonorrhoea, chlamdyia, E.Coli, Stretp or staph Feature: unilateral swelling and pain in inferior lateral opening of vagina, Sitting and walking may become difficult or painful Tx: sitz bath, warm compresses, Antibiotic e.g. cephalexin, incision and drainage, marsupialisation

Question 36

PID causes

Answer 36

Inflammation of upper genital tract including endometrium, fallopian tubes, ovaries, pelvic, peritoneum, and contiguous structure C. Trachomatic N. Gonorrhoeae Endogenous flora e.g. e.coli, staph, strep, enterococcus, bacteroids, peptostrptococcus, H, Influenzae,

Question 37

RF for PID

Answer 37

``` age less then 30 RF as for chlamydia or gonorrhea vaginal bouching IUD in the first 10 days invasive gynecologic procedures ```

Question 38

Presentation of PID

Answer 38

2/3 asymptomatic Commonly: - fever greater then 38.3, lower abdo pain and tenderness, abnormal discharge Uncommonly: - N/V, dysuria, AUB Chronic disease (often due to chlamdyia) - Constant pelvic pain, dyspareunia, palpable mass, very difficult to treat, may require surgery

Question 39

Ix for PID

Answer 39

B HCG FBC BC Urine MCS speculum and bimanual, swab- vaginal for gram neg, cervical for Chlamdyia and gonorrhoea USS: free fluid in cul-de-sac, abscess, hydrosalpinx Laparoscopy if gold standard

Question 40

Cx of PID

Answer 40

``` I FACE PID Infertility Fitx-Hugh-Curtis syndrome Abscess Chronic pelvic pain Ectopic pregnancy Peritonitis Intestinal obstruction Disseminated infection e.g. sepsis, endocarditis, arthritis, meningitis ```

Question 41

Tx for PID

Answer 41

Abx - ceftriaxone and doxycycline +/-metronidazole Inpatient or outpatient If outpatient follow up within 48hrs

Question 42

Toxic shock syndrome

Answer 42

multiple orang system failure due to S.aureaus exotoxin presents: sudden high fever, sore throat, headache, diarrhoea, erythroderma, signs of multi system organ failure, refractory hypotension, exfoliate of palmer and plantar surfaces of hands and feet 1-2 wk after onset of illness Tx - remove source of infection, decried necrotic tissues, hydration, ABx, +/-steroids