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1

name 3 conditions that fall under vulvovaginitis

candidiasis
trichomoniasis
bacterial vaginosis

2

what causes vulvovaginitis

1. non-STI--> bacterial vaginosis (most common cause of vaginal discharge; is an overgrowth of genital tract organisms) or candidiasis (yeast infection, usually C. albicans)

2. STI-->trichomoniasis vaginalis (a protozoa)

3. non-infectious--> allergic dermatitis, excessive physiological secretion, atrophic vaginitis

3

how does trichomoniasis vaginalis present

erythema of cervix and vulva
increased vaginal pH

4

how do you diagnose vulvovaginitis

1. speculum exam to rule out cervicitis
2. collect sample of discharge and pH (microscopy on discharge)
3. test for other STIs

culture rarely needed

5

how does vulvovaginitis present

vaginal discharge
odor
puritis
erythema
dysuria

6

Tx for bacterial vaginosis

metronidazole or clindamycin

DONT treat partners
NOT reportable

7

Tx for vulvovaginal candidiasis

antifungals

8

Tx for trichomoniasis

Metronidazole

treat patient AND partner

9

what causes urethritis (+ cervicitis in women)

chlamydia trachomatis
N. gonorrhea

10

how does urethritis present in men

1. dysuria (burning/pain on urination)
2. discharge from penis (purulent or mucopurulent)
3. rectal pain
4. lesions
5. bleeding
6. meatal erythema

11

how does urethritis/cervicitis present in women

1. dyspareunia (pain during intercourse)
2. dysuria
3. vaginal discharge (purulent or mucopurulent)
4. abnormal vaginal bleeding/spotting
5. strawberry cervix
6. cervical friability

BUT can also be asymptomatic
urethritis can occur without cervicitis

12

how do you diagnose urethritis

specimen collection--> endourethral swab for symptomatic cases and when test of cure is needed; urine samples

lab diagnosis--> urethral swab--> gram stain for DIPLOCOCCI; culture for gonorrhea and susceptibility testing

in urine--> nucleic acid amplification test for gonorrhea and chlamydia

13

Tx for chlamydia

doxycycline

azythromycin

14

Tx for gonorrhea

cefixime

ceftriaxone M

antibiotic resistance is changing rapidly

15

what is PID

pelvic inflammatory disease

infection of upper genital tract in women--> endometrium, fallopian tubes, pelvic peritoneum

16

what causes PID

polymicrobial

1. STI--> chlamydia, gonorrhea + endogenous orgs
2. non-STI--> mycoplasma genitalium, bacteroides, E. coli, gardnerella vaginalis

rare STI--> HSV, T. vaginalis

17

how does PID present? what must you rule out?

abdominal pain
+/- fever
uterine, adnexal, cervical motion tenderness

must rule out ectopic pregnancy and acute appendicitis

18

what is genital ulcer disease

erosive, pustular, or vesicular ulcers

+/- regional lymphadenopathy

19

what causes genital ulcers

1. HSV
2. syphilis (T. pallidum)
3. lymphogranuloma verenum (LGV)
4. chanchroid (Haemophilus ducreyi)
5. granuloma inguinale (donovanosis; Klebsiella granulomatis)

20

what does HSV primary infection look like on presentation

-painful, extensive vesiculoulcerative lesions
-systemic symptoms like fever
-tender lymphadenopathy
-complications can include aseptic meningitis
-may be asymptomatic but can still SHED virus

atypical symptoms = urethritis, cervicitis, aseptic meningitis

appear as GROUPED VESICLES, SUPERFICIAL ULCERS with ERYTHEMATOUS BASE

PAINFUL and/or puritic

21

how does HSV become latent

virus invades local nerve endings and ascends axons

latency in SACRAL GANGLIA until reactivation

22

incubation period of HSV

6 days

23

what % of population is symptomatic with genital herpes infection

10%

24

what percent of canadians have HSV-1

60%

25

what percent of canadians have HSV-2

15-20%

26

how do you diagnose HSV

physical exam
PCR swab of lesion
serology for IgG

27

Tx of HSV

no cure

counseling
antiviral therapy for recurrent episodes--> ACYCLOVIR
risk of neonatal infections (i.e from HSV-1) if mother was not exposed due to no IgG passed from mother to child to protect (meningitis)

28

manifestations of primary syphilis

solitary, painless chancre at site of inoculation

regional lymphadenopathy

29

manifestations of secondary syphillis

rash and generalized lymphadenopathy

non-itchy and may be MORBILIFORM PAPULOSQUAMOUS--> rash is on SOLES and PALMS

may have systemic symptoms

30

manifestations of tertiary syphilis

develops 3-30 years after initial untreated infection

CV syphilis, neurosyphilis, gumma (destruction of any organ)

31

how does syphilis infection occur

invades mucous membrane or abraded skin--> enters lymphatics and bloodstream--> disseminates

32

incubation period of syphilis

about 3 weeks until primary symptoms

33

how is syphilis diagnosed

dark field microscopy

serology--> RPR or VRDL; treponema specific: special stain/PCR of fluid from chancre for primary syphilis

treponemal screen first (EIA) and then confirm with TPPA, LIA

34

how do you treat primary, secondary or early latent syphilis

benzathine penicillin IM 1 dose

35

how do you treat late latent and CV syphilis

benzathine penicillin IM weekly 3 times

36

how do you treat neurosyphilis

IV penicillin G daily for 10-14 days

37

what causes LGV

(lymphogranuloma verenum)

C. trachomatis serovars L1, L2, L3

38

what causes chancroid

haemophilus ducreyi

39

what causes donovanosis

klebsiella granulomatis (painless ulcers, beefy red appearance)

40

what do you screen all pregnant women for?

HIV
Hep B
chlamydia
gonorrhea
syphilis

41

what is chlamydia trachomatis

obligate intracellular organism
invades epithelial cells

infection can persist asymptomatically for months when the immune system response is not sufficient, resulting in scarring, adhesions, salpingitis and tubal occlusions

most common STI with increasing rates-- > often co-infected with gonorrhea

42

what is the most common STI

chlamydia trachomatis

43

how does N. gonorrhea infection occur

gram - diplococci

infect and penetrate the columnar epithelium through the submucosa

inflammatory response = sloughing off of epithelium, submucosal microabsesses, exudation of pus

evasion of immune response through INTRACELLULAR replication

44

list common uropathogens

1. enterobacteriaceae (E. coli - most common.... also Klebsiella and Proteus)
2. Enterococcus spp
3. Staph. saprophyticus (coagulase - staph... in women)
4. strep. agalactiae (Group B strep)

45

what are the bacterial virulence factors associated with uropathogenic E. coli

P. fimbriae allows uropathogenic E. coli to adhere to urethral and bladder epithelium

capsular polysaccharides (K) inhibits phagocytosis

HEMOLYSINS damage membrane

46

what factors predispose a host to a UTI

1. kidney stones
2. vesicoureteral reflux (more common in pediatrics--valves may not be as competent)
3. neurological problems (ie. neurogenic bladder from diabetes)--> unable to empty when full so get urine stasis and bacterial growth
4. prostate hypertrophy
5. short urethra (in women)
6. loss of sphincter control--> urine retention
7. URINARY CATHETERS--> avoid unless clinically indicated

47

what is the most common nosocomial infection?

catheter associated UTIs

48

signs and symptoms of UTI

increased frequency of urination
urgency
pain on urination

**cloudy urine is not diagnostic of a UTI

49

what is the problem with getting a urine sample from a Foley catheter

if its been in longer than 24 hours its likely to be colonized with bacteria anyway, messing up the sample

50

what do you detect on urinalysis
1. macroscopic
2. microscopic

1. leukocyte esterase (+ suggests WBCs are present)
nitrite (+ if bacteria are present that can reduce nitrate to nitrite like enterobacteriaceae can)

2. culture (usually avail after 18-24 hours

for mid stream urine sample, if more than 3 bacterial organisms are found, suspect contamination of sample

51

Tx for acure cystitis (bladder infection)

nitrofurantoin

or fosfymycin

52

clinical presentation of pyelonephritis

lower urinary tract symptoms
fever
costovertebral angle tenderness

renal function loss
may result in bacteremia

53

Tx for pyelonephritis

in community: cefixime

in hospital: ceftriaxone or gentamycin

54

how do catheter associated UTIs differ from other UTIs

typical symptoms are absent

assess for fever, rigors, CVA tenderness

55

Tx for catheter associated UTI

antibiotics
catheter removed or changed