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Flashcards in STD Deck (59):
1

Vaginitis – Non STD Related

Monilia--fungal
Bacterial Vaginosis--bacterial


Normal vagina
Acidic environment PH 3.8 – 4.2

Maintained by Lactic Acid produced by lactobacilli

In the healthy vagina there is homeostatic co-existence of
anaerobes and aerobes with non-exfoliated epithelial cells.

Affected by products, practices, nutrition (ie excessive sugar intake/diabetes, douching, bubble bath, sprays, scented products, fancy condoms/toys)

2

Vulvovaginal Candidiasis

Candida – fungal resident flora, overgrowth creates infectious process
Albicans – most common genus
Over 50 different types of candida – most responsive to “azole” therapy
Glabrata & Rugosa types are becoming more resistant to current therapies

3

Vulvovaginal Candidiasis
symptoms

Symptoms: severe pruritis, curdy vaginal discharge, vaginal soreness, dysuria, white or erythemic skin

4

Vulvovaginal Candidiasis
treatment

External – antifungal creams (clotrimazole, nystatin)
Internal – antifungal suppositories, creams (miconazole, terconazole)
Systemic – antifungal oral pills (fluconazole)

5

BACTERIAL VAGINOS

Infection occurs when “good” bacteria go bad

One term used to describe a polymicrobial ascending infection caused by one or more organisms
Gardnerella
Mobiluncus
Coccobacilli
Mycoplasma hominis

involve organisms transmitted sexually and/or may be confined to anaerobic organisms

6

BACTERIAL VAGINOS
Causes

Douching
Sexual activity
Recent antibiotic use
Hormonal changes

**Essentially anything that disrupts the balance of normal resident flora (lactobacilli)**

7

Bacterial Vaginosis
Subjective

Gray/white homogeneous milky white discharge
fishy odor typically worse following sex

8

Bacterial Vaginosis
Objective

homogeneous, thin, white discharge that smoothly coats the vaginal walls;
• presence of clue cells on microscopic examination;
• pH of vaginal fluid >4.5; or
• a fishy odor of vaginal discharge before or after addition of 10% KOH (i.e., the whiff test)

9

Bacterial Vaginosis Treatment

Recommended Regimens

Metronidazole 500 mg orally twice a day for 7 days*
OR
Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days
OR
Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days**

*Consuming alcohol should be avoided during treatment and for 24 hours thereafter.

**Clindamycin cream is oil-based and might weaken latex condoms and diaphragms for 5 days after use)

10

Bacterial Vaginosis Treatment

Alternative Regimens
Tinidazole 2 g orally once daily for 2 days
OR
Tinidazole1 g orally once daily for 5 days
OR
Clindamycin 300 mg orally twice daily for 7 days
OR
Clindamycin ovules 100 mg intravaginally once at bedtime for 3 days
OR
Clindesse 1 1 applicatorfull intravaginally x 1 dose

11

Sexually Transmitted Infections
Parasitic

Pediculosis pubis (crab lice)
Trichomoniasis

12

Sexually Transmitted
Infections
Bacterial

Chlamydia
Gonorrhea
Syphilis - spirochete (bacterium)

13

Sexually Transmitted
Infections
Viral

Herpes simplex virus—Types I and II
Human papillomavirus (HPV)
Human Immunodeficiency virus (HIV)
Hepatitis Types B, C

14

Trichomonas Vaginalis
Subjective

Men: usually asymptomatic
Women: bad smelling, yellow/green
frothy discharge, irritation and excoriation of genital area strawberry cervix, can also present with dysuria as the only subjective symptom

15

Trichomonas Vaginalis
Objective

Wet mount of vaginal discharge shows protozoan is alive and moving. It has a tail or flagella for propulsion. + Whiff when KOH is added to wet prep. Cervix is erythemic with a “strawberry” appearing cervix .

16

Trichomoniasis treatment

Recommended Regimens
Metronidazole 2 g orally in a single dose
OR
Tinidazole 2 g orally in a single dose
 
Alternative Regimen
Metronidazole 500 mg orally twice a day for 7 days*

Important to treat partner to prevent re-infection

17

Patient Education

Important to treat partner to prevent re-infection

Review safe sex practices

Patients should be advised to avoid consuming alcohol during treatment with metronidazole or tinidazole.

Abstinence from alcohol use should continue for 24 hours after completion of metronidazole or 72 hours
after completion of tinidazole

18

Pediculosis Pubis

Pubic Lice…”crabs”

Parasite
- Louse eggs seen on hair shafts – hatch in 7-9 days causes severe itching

- Transmitted by sexual contact, contaminated
bedding,etc

19

Pediculosis Pubis
Treatment

Treatment:
Kwell, RID, Permethrin, Lindane
Treat partner(s) and household contacts, clean fomites

20

CHLAMYDIA

Caused by: bacterium chlamydia trachomatis
Most rapidly increasing STD especially in young adults
Leading cause of infertility
1 episode …12% infertility
2 episodes…30% infertility
3 episodes...50% infertility
Estimated than 1 million people in US have it now
Becoming known as the “silent epidemic”
Commonly concurrent with Gonorrhea (Treat both)
In 70% – 80 % of cases patients are asymptomatic.

21

SCREENING GUIDELINES
for chlamydia infections

USING THESE SCREENING GUIDELINES, 90% OF ALL CHLAMYDIA INFECTIONS WOULD BE DETECTED


24 years of age or younger
Intercourse with a new partner
Suspicious cervical discharge
Cervical bleeding cause by swabbing / post-coital bleeding
No contraception usage or non-barrier methods

22

Chlamydia
Subjective

Often asymptomatic
Increased thick yellow vaginal discharge
Post-coital bleeding
Abnormal vaginal bleeding / inter-menstrual bleeding
Urinary s/s (dysuria, frequency)

23

Chlamydia
Objective

Irritated appearing cervix with “contact” bleeding
Painful bimanual exam
Chlamydial cervicitis in a female patient characterized by mucopurulent cervical discharge, erythema, and inflammation .

24

Treatment of CHLAMYDIA

Recommended Regimens
Azithromycin 1 g orally in a single dose
OR
Doxycycline 100 mg orally twice a day for 7 days*



Alternative Regimens
Erythromycin base 500 mg orally four times a day for 7 days
OR
Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days
OR
Levofloxacin 500 mg orally once daily for 7 days
OR
Ofloxacin 300 mg orally twice a day for 7 days

25

GONORRHEA

Neisseria Gonorrhoeae
Caused by N. gonococcus bacterium
46% have coexistence with Chlamydia
Spread through vaginal, anal, or oral sex
Women have a 60–80% risk of getting the infection from a single act of vaginal intercourse with an infected man

26

GONORRHEA Screening & Prevention

CDC recommends screening sexually active females aged 25 and younger
Females at risk for STDs
Pregnant females
Symptomatic males

27

GONORRHEA Symptoms

Increase or change in vaginal discharge
Post-coital bleeding / inter-menstrual bleeding
Dysuria
Pelvic Pain
Dyspareunia

½ of all infected women will be asymptomatic

28

Gonorrhea Objective

Irritated appearing cervix with “contact” bleeding
Painful bimanual exam

29

Gonorrhea
Diagnosis

PCR testing via cervical culture

30

Gonorrhea
Treatment

**Due to increase in resistant gonorrhea CDC updated recommended treatment regimen in 2012**

Updated Recommended regimen (2012)
Ceftriaxone 250 mg in a single intramuscular dose
PLUS
Azithromycin 1 g orally in a single dose
or
doxycycline 100 mg orally twice daily for 7 days*

31

Gonorrhea Alternative Treatment

Alternative regimens
If ceftriaxone is not available:
Cefixime 400 mg in a single oral dose
PLUS
Azithromycin 1 g orally in a single dose
or doxycycline 100 mg orally twice daily for 7 days*
PLUS
Test-of-cure in 1 week
If the patient has severe cephalosporin allergy:
Azithromycin 2 g in a single oral dose
PLUS
Test-of-cure in 1 week

32

Gonorrhea Patient Education

Test of cure necessary to ensure effective treatment and prevention of spread
Partner treatment necessary
If not treated can lead to Pelvic Inflammatory Disease and Permanent Sterility
Prevention is key
Abstinence
Mutually monogamous sex with an uninfected partner
Safe sex (strict condom use)
Routine screening for those at increased risk

33

Syphilis

Treponema Pallidum—spirochete
Four Potential Stages
Primary Syphilis--first symptoms appear 10-90 days (Average 21 days) after exposure
Secondary Syphilis
Latent Syphilis can last from 1-40 years
Tertiary Syphilis—can result in:
Late benign syphilis
Cardiovascular syphilis
Neurosyphilis

34

Primary Syphilis

INCUBATION – average of 3 WEEKS from exposure
Chancre can be anywhere on body – usually somewhere in the genital area or mouth area
Painless – heals in 3-9 wks without treatment

35

Primary Syphilis Diagnosis

Non-treponemal blood tests (VDRL, STS, RPR) will become reactive within 2 weeks of chancre

FTA tests for the actual organism (spirochete) and takes longer to appear—about 4 wks from exposure
“ the gold standard” (takes 2 weeks to process) Stays positive for life.

36

Primary Syphilis treatment

Bicillin 2.4 million units IM (1.2 million units in each buttock, deep Z track)
Treat partner(s). Follow titres. Should be decreasing.

37

Secondary Syphilis Symptoms

Symptoms appear 2-12 weeks from exposure
Most common symptom – skin rash on palms, soles, body
Other less common symptoms – lymphadenopathy, mucus patch ulcers, alopecia, condylomata lata (pale moist flat topped papules on moist surfaces)
Most spontaneously resolve

38

Early latent Syphilis

Up to one year after became infected
Asymptomatic
Non-treponemal titers (RPR. STS, VDRL) are decreasing

39

Late latent Syphilis

1-40 years after infected
Asymptomatic
Non-treponemal tests very low or negative
Most common transfer from mother to baby or through blood transfusions

40

Tertiary Syphilis

Late benign syphilis
Gumma formations (soft tissue necrosis) in throat, abdomen, bones (granulatomatus lesions that can lead to soft tissue and bone destruction)
Cardiovascular - Aortic insufficiency, thoracic aortic aneurysm
Neurosyphilis - Optic atrophy/pupils sluggish to light, tabes dorsalis (degradation of dorsal columns of spinal cord=loss of proprioception etc), locomotor ataxia general paresis, gumma formations in the brain meningitis

41

Tertiary Syphilis Late benign syphilis treatment

Bicillin 2.4 million units IM x 3 doses on week apart. Treat partner(s). Do follow-up titres.

42

Quantitative Screening

Non-treponemal screening tests (VDRL,RPR,) can be positive for other reasons thus confirmatory testing (FTA) must be completed if the screening test is positive.

43

Quantitative Screening False Positives

Malaria Hemolytic anemia
Narcotic addiction Viral syndrome
Lyme disease Hansen’s disease (Leprosy)
Recent immunizations Lupus
Infectious hepatitis Chicken pox
Measles Rheumatoid arthritis
Rheumatic fever Common cold
Pregnancy Collagen diseases

44

Herpes Simplex Virus (HSV)

The herpes simplex virus (HSV) is a double-stranded DNA virus

2 known types
Type 1
Type 2

45

Herpes Simplex Virus Types I & II What’s the Difference?

The primary difference between the two viral types is in where they typically establish latency in the body- their "site of preference." HSV-1 usually establishes latency in the trigeminal ganglion, a collection of nerve cells near the ear. From there, it tends to recur on the lower lip or face. HSV-2 usually sets up residence in the sacral ganglion at the base of the spine. From there, it recurs in the genital area.
Even this difference is not absolute either type can reside in either or both parts of the body and infect oral and/or genital areas. Unfortunately, many people aren't aware of this, which contributes both to the spread of type 1 and to the misperception that the two types are fundamentally different.

46

HSV Incidence

About 1 in 6 Americans between the ages of 14 – 49 is infected with HSV type 2
One of the most common STDs
Prevalence twice as high among women
3x higher among black women
+ HSV patients are 2-3x more likely to acquire HIV
CDC estimates that over 80 percent of those with HSV-2 are unaware of their infection

47

HSV Diagnosis
Primary Infection- Initial outbreak

Most severe
Often present with systemic symptoms / complaints

48

HSV Diagnosis
Secondary Infection- Recurrence

Less severe
Can be without lesions – remain in prodromal stage
Yet – still very contagious

49

HSV Diagnosis

Should be included in routine STD screening in those at increased risk
Screening via serum antibody testing (IgG / IgM) for type specific HSV


Episodic testing in symptomatic patients
Can be done via viral cultures obtained at source
What are the limitations of diagnosing via cultures ?

50

Clinical manifestations of Genital Herpes
Initial Infection

Vesiculopustular lesions (bilateral)
Cervicitis, urethritis
Lymphadenopahty
Neuropathic manifestations
Systemic inflammation (fever, etc.)
Duration typically 2-4 wk

51

Clinical Manifestations of Genital Herpes
Recurrent outbreaks

Unilateral lesions
nonspecific symptoms (discharge, dysuria, ect. )
Neuropathic prodrome
Duration 1-2 wk

52

Common misdiagnoses of Genital Herpes

Vulvovaginal candidiasis and other vaginal infections
Syphilis, chancroid,
UTI, Genital trauma

53

HSV Treatment Primary Outbreak

Recommended Regimens*

Acyclovir 400 mg orally three times a day for 7–10 days
OR
Acyclovir 200 mg orally five times a day for 7–10 days
OR
Famciclovir 250 mg orally three times a day for 7–10 days
OR
Valacyclovir 1 g orally twice a day for 7–10 days

*Treatment can be extended if healing is incomplete after 10 days of therapy.

54

HSV Treatment Secondary (Episodic) Outbreak

Recommended Regimens
Acyclovir 400 mg orally three times a day for 5 days
OR
Acyclovir 800 mg orally twice a day for 5 days
OR
Acyclovir 800 mg orally three times a day for 2 days
OR
Famciclovir 125 mg orally twice daily for 5 days
OR
Famciclovir 1000 mg orally twice daily for 1 day
OR
Famciclovir 500 mg once followed by 250 mg twice daily for 2 days
OR
Valacyclovir 500 mg orally twice a day for 3 days
OR
Valacyclovir 1 g orally once a day for 5 days

55

HSV Suppression Therapy

Suppression therapy can reduce outbreaks by up to 80%
Goals
Decrease number of outbreaks
Shorten duration / severity of outbreaks
Decrease viral load

Indications
Decrease risk of spreading virus from infected partner to an uninfected partner
Pregnancy
Immunosuppressed patients
Patient request

56

HSV Patient Education

Focus on prevention

After diagnosis is made
Counseling / Patient support is an absolute
Treatment options
Risks of spreading to others
Risks of future outbreaks
How to identify outbreaks early on (prodromal stage)
Lifelong disease with likely implications on patients health & relationships
May take several visits to educate / counsel patient after initial HSV diagnosis

57

(HPV) Human Papillomavirus

Human Papillomavirus
Most common viral STD
Over 150 types
High risk types are linked to cervical cancer
Types:16, 18, 31, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68, 69,
Gardasil Vaccine for: 6, 11, 16, 18 only
Passed by all types of sexual contact

58

HPV

More prevalent in young women in 20s
Highest STD in teens – 40-45%
50% have clinical lesions and 25% non-clinical
Can accumulate lesions – like grape clusters
6-11 cause Genital warts
16,18,45 most likely to progress to cancer
Body can rid itself of virus especially in teens therefore change in Pap guidelines

59

HPV and Cancer

16, 18, and 45 found in 70% of patient with invasive cancers

16 – Vulvar squamous carcinoma
55-60% penile
Risk for squamous cell carcinoma of head and neck with oral sex
Risk factor for cancer of throat

18 – Adenocarcinoma
Small cell carcinoma of cervix
More significant in risk for invasive neoplasm
Has worse prognosis