Vaginal Infections, STIs, Vulvar Conditions Flashcards
(111 cards)
1
Q
bacterial vaginosis definiton
A
alteration of the normal vaginal flora of the vagina with dominance of anaerobic bacteria (not enough of that good Lacto B)
2
Q
etiology of BV
A
-loss of lactobacilli results in elevated pH and subsequent overgrowth of bacteria
-NOT an STI, however more common in women with new partners
-BV may increase risk for acquiring HIV or HSV 2
-may be asx with pp, post op infection, endometriosis, PID
3
Q
symptoms of BV (4)
-odor, color
A
-most often asymptomatic
-pruritis occasionally
-heavy grayish/yellowish/whitish malodorous discharge
-rancid or fishy odor during menses and after sex
4
Q
physical findings of BV
A
- homogenous, aderent, whitish-gray discharge
- normal appearing vulva and vaginal mucosa
- discharge may coat vaginal walls and vulva
- presence of foul odor
5
Q
diagnostic tests/findings for BV
A
-wet mount of vaginal secretions
6
Q
Amsel criteria diagnostic of BV include presence of three of the following:
A
a. vaginal pH > 4.5
b. clue cells on saline wet mount (epithelial cells with borders obscured); > 20% of epithelial cells are studded
c. homogeneous discharge, white, smoothly coating vaginal wall
d. positive “whiff” test- fishy amine odor of vaginal dc with addition of KOH
7
Q
treatment of BV includes
A
-Metronidazole (Flagyl) 500 mg BID for 7 days
-Metronidazole gel 0.75%, one full applicator intravaginally at bedtime for 5 days
-Clindamycin cream 2%, one full applicator intravaginally at bedtime for 7 days
alternative regimens:
-Clindamycin 300 mg orally BID for 7 days
8
Q
what should we counsel patients regarding metronidazole use?
A
can cause disulfiram effect (flushing, vomiting) when consumed with alcohol; counsel patient to avoid alcohol use during and for 24 hours after completion
SE: metallic taste, nausea, headache, dry mouth, dark-colored urine
9
Q
Trichomoniasis definition
A
vaginal infection caused by anareobic, flagellated protozoan parasite
10
Q
T/F trichomoniasis infection may be associated with preterm rupture of membranes and preterm labor
A
TRUE
why we test and treat in pregnancy/at amenorrhea visit
11
Q
symptoms of Trich
A
-copious, malodorous, yellowish-green discharge; vulva irritation; pruritis, and occasionally dysuria, urgency, frequency of urination, post coital and intermenstrual bleeding
-onset of symptoms occur after menses
12
Q
physical findings of patients with trich
A
-erythema, edema, excoriation of vulva
-red speckles “strawberry cervix” on vagina and cervix
-homogeneous, watery, yellow-green, grayish, foul smelling discharge
-ph>5
-cervix may bleed easily when touched
13
Q
diagnostic tests for trich
A
-saline wet mouth
-definitive test: culture
-detection on pap ok too
14
Q
treatment of trichomoniasis
A
- metronidazole 2g orally in a single dose (male)
- metronidazole 500 mg BID for 7 days (female)
- Tinidazole 2 g orally in single dose
15
Q
T/F trichomoniasis is not an STI so partners don’t need to be treated
A
false babe!!!
all sexual partners should be treated
16
Q
when should repeat testing be done? what if treatment failure has occured?
A
in 3 months
-exclude reinfection, consider treatment with metronidazole or tinidazole 2g orally for 7 days
17
Q
treatment of trich in pregnancy (1)
A
- metronidazole 2g PO in single dose
*NOTE: crosses the placenta BUT no teratogenicity effect found
18
Q
vulvovaginal candidiasis (VVC)
-predisposing factors??
A
inflammatory vulvovaginal process caused by yeast organism
predisposing factors to yeast infections: pregnancy, reproductive age, uncontrolled diabetes, immunosuppressive disorders, frequent intercourse, antibiotic use, high-dose corticosteroids
19
Q
symptoms and physical findings of yeast infection
A
-pruritis/irritation of vulva
-white, curd-like discharge
-dyspareunia
-erythema of vulva and vagina
-cervix normal on speculum exam
20
Q
diagnostic tests
A
wet mount of vaginal secretions
-vaginal pH usually < 4.5; amine test neg
-increased number of WBC (since its an inflammatory process)
21
Q
recommended regimens for yeast infections
A
-azole family of antifungals preferred
- Clotrimazole 1% cream, 5g intravaginally daily for 7-14 days
- Miconazole 2% cream, 5g intravaginally for 7 days
- Miconazole 4% cream, 5g intravaginally for 3 days
- oral agent: fluconazole 150 mg orally in single dose
22
Q
treatment for recurrent VVC in nonpregnant patients
-how many episodes is considered recurrent
A
-4 or more symptomatic episodes in one year
- culture to determine if non-albicans candida species
- consider longer-duration therapy: 150 mg oral fluconazole every 72 hours for 3 rounds
- consider use of intravaginal probiotics
23
Q
treatment of VVC in pregancy
A
- monistat OTC
- Miconazole 2% cream, in the vagina for 7 days
- Nystatin suppository for 14 nights
OVERALL: avoid oral agent for VVC in pregnancy!
24
Q
key point regarding use of azole creams an suppositories since they are oil-based…
A
may weaken latex condoms and diaphragms
25
severe VVC (extensive erythema, edema, fissure formation) usually requires...
7-14 days of topical azole regimen or repeat dose of fluconazole 72 hours after initial dose
26
why do we worry about chlamydia infections in pregnant patients?
may cause pneumonia or conjunctivitis in neonates
also can cause PROM or preterm labor
27
sequelae of chlamydia (lots)
cervicitis, endometritis, PID, ectopic, infertility, acute urethral syndrome, pp infections, premature labor and delivery, premature rupture of membranes, and perinatal morbidity
28
risk factors
-who is at highest risk?
1. sexually active women < 25 years old (should be tested annually in women <25 who are sexually active)
2. multiple partners
3. nonuse of barrier methods
29
symptoms of chlamydia
-mostly asymptomatic
-postcoital bleeding; intermenstrual bleeding or spotting
-symptoms of UTI (dysuria, frequency)
-vaginal discharge
-abdominal pain
-males: usually asymptomatic; may have dysuria, urethral discharge, pruritis
30
physical findings of chlamydia
-mucopurulent endocervical discharge; edematous, tender cervix with easily induced bleeding
-suprapubic pain or slight tenderness upon palpation
31
gold standard for diagnosis of chlamydia
-what else should you rule out?
1. NAAT aka nonculture method/urine test
2. culture- expensive
3. specimen source for women: vaginal is preferred (patient or provider collected)
4. specimen source for men: first catch urine
-gonococcal culture to rule out gonorrhea
-serologic testing for syphilis: wet-mount testing for vaginal infections; consider HIV screen
32
chlamydia treatment recommendations
-preferred treatment
-backup
-alternatives
1. Doxycycline 100 mg PO BID for 7 days
2. Azithromycin 1 g PO, single dose
Alternatives:
-amoxicillin 500 mg PO TID for 7 days
33
chlamydia in pregnancy treatment-
DO NOT USE DOXY
recommended treatment: azithromycin 1g PO single dose
those unable to use azithromycin: amoxicillin 500 mg TID for 7 days as alternative
34
how do we manage sex partners of patients with chlamydia?
-anybody they had sex with 60 days preceding onset of symptoms or diagnosis
-most recent sex partner should be treated if its been > 60 days
-expedited partner treatment should be considered
35
patient counseling for chlamydia infection/treatment
-intercourse should be avoided for 7 days after single-dose treatment of until 7-day regimen is completed
36
when should we retest for infection?
3 months post treatment is recommended; earliest is 3 weeks for TOC but may get false + if any sooner
37
Condylome Acuminata, anogenital warts
-etiology?
-caused by HPV
-sexually transmitted by skin to skin contact through viral shedding
-highly contagious!!!
38
incubation period of genital warts
4-6 weeks
39
symptoms and physical findings of anogenital warts
-wartlike lesions: pedunculated conical or cauliflower appearance; anywhere on the perineum
-may appear granular, macular, or cobblestone
-perineal area may bleed easily, be painful, or pruritic
-color varies from pink to gray, if dark highly suspicious of malignancy
40
diagnostic tests/findings for genital warts
-diagnosis made by visual inspection
-bx if diagnosis is uncertain
-serologic testing for syphilis; testing for other STIs; wet-mount for vaginal infections; consider HIV testing
41
management of genital warts
-patient counseling/education
GOAL: to eliminate visible disease and improve symptoms
-treatment depends on patient preference
-keep area dry and clean
-use condoms
42
medication/treatment of genital warts
1. cryotherapy with liquid nitrogen; repeat every 1-2 weeks for 6 weeks OR
2. surgical removal
3. Imiquidmod 3.75% or 5% cream; applied sparingly at bedtime three times a week for up to 16 weeks
43
HPV vaccination recommendations
-all young girls and women recommended starting at age 11-26 years
-boys and young men (9-26)
-adults aged 27-45: public health benefit is minimal
44
Gonorrhea etiology, sites of infection, transmission, resistance concerns
-sites: urethra, endocervix, Skene's glands, Bartholin's glands, pharynx, and or anus
-STI
-incubation period: 3-5 days
-sine 1976, some penicillinase-producing strains have been present; some are now resistant to tertracycline and quinolones
45
sequelae of gonorrhea include
PID, infertility, ectopic pregnancy, septic arthritis, bacteremia, infections of Bartholin's and Skene's glands, epididymitis, gonorrhea opthalmia neonatorum in neonates, premature ROM, chorioamnionitis, prematurity
46
gonorrhea symptoms
-female vs male
-both (think about sequelea)
FEMALES
-vaginal discharge
-postcoital bleeding
-dysuria
-vulvar pain with Bartholin's or Skene's gland infection
-pelvic pain with PID
MALES
-penile discharge, dysuria, severe testicular/scrotal pain and swelling with epididymitis
BOTH
anal bleeding, sore throat, joint pain, erythema and inflammation of joints
47
physical findings for gonorrhea infection
-mucopurulent discharge; inflamed Skene's or Bartholin's glands, easily induced bleeding of cervix
-20% of women: invades uterus after period leading to endometritis, etc.
48
T/F most common cause of epididymitis in young men are gonorrhea and chlamydia
true
sx: low grade fever, red, swollen, extremely swollen scrotum
49
recommended diagnosis technique for gonorrhea
NAAT/urine sample
serologic testing for syphilis; chlamydia testing
50
what three STIs should patient be screened for if any one of them comes back positive?
chlamydia, gonorrhea, and syphilis
51
management/treatment of gonorrhea in nonpregnant individuals (two step)
a. ceftriaxone (rocephin) 250 mg IM single dose and azithromyxin 1 g orally as a single dose
52
treatment of gonorrhea in pregnancy
ceftriaxone 250 mg IM in one single dose and azithromycin 1g orally as single dose
53
Key points regarding gonorrhea
-TOC
-testing partners/timeline
-retesting
-TOC not necessary
-avoid sexual intercourse until all partners treated and no symptoms
-partners within 60 days of + infection should be treated
-retesting in 3 months
54
HSV defintiion
chronic, incurable, recurrent viral disease
HSV 1- commonly found on the mouth
HSV 2- causes 85% of genital infections
asymptomatic shedding of virus accounts for majority of transmission/skin to skin contact
55
when is the risk to the neonate highest in mother with HSV?
when women has primary infection near time of birth
56
symptoms depend on HSV syndrome
1. primary infection
-course of genital lesions, timeline, symptoms
a. systemic symptoms- fever, malaise, headache; symptoms usually begin within one week of exposure, peak within 4 days and subside over the next week
b. localized genital pain
c. course of genital lesions:
(1) local prodrome; pruritis, erythema about 1-2 days before appearance of lesions
(2) formation of small, painful vesicles over labia majora, minora, mons pubis, vagina, etc. (4-10 days)
(3) vesicles rupture, forming shallow, painful, wet ulcerations lasting 1-2 weeks
(4) lesions heal without scarring
d. tender inguinal lymphandenopathy may be last symptom to resolve
e. cervix that bleeds easy
57
symptoms depend on HSV syndrome
2. nonprimary first-episode infection: initial clinical episode in patients with previous circulating antibodies to HSV-1 or HSV-2
-symptoms same as primary infection, but usually milder and shorter course
58
symptoms depend on HSV syndrome
3. reurrent genital herpes infection
-shorter duration of symptoms (resolves in 7-10 days)
1. prodrome: 1-2 days
2. vesicles: 3-5 days
3. dry out days: 2-3 days
59
diagnostic tests/findings with HSV infection
1. HSV culture from base of vesicle or ulcer
2. pap test
3. PCR assay (nonculture)
4. type-specific serologic tests to identify HSV 1 and HSV 2 antibodies
5. serologic testing for syphilis
60
Medical management of HSV
-first clinical episode
1. acyclovir 400 mg PO TID or 200 mg PO five times a day for 7-10 days
2. valacyclovir 1 g PO BID 7-10 days
61
episodic treatment of HSV
Acyclovir 400 mg PO TID or 800 mg PO BID for 5 days
Valacyclovir 1 g PO once a day for 5 days
62
suppressive treatment of recurrent genital herpes
*reduces frequency of recurrences, decreases rate of transmission
1. acyclovir 400 mg PO BID
2. Famciclovir 250 mg PO BID
3. Valacyclovir 500 mg or 1 g PO once a day
63
counseling patients with HSV
-advise condom use with all genital-genital contact
-advise no genital-genital contact when partner has genital lesions OR prodrome symptoms
-
64
what can be safely used in pregnancy for treatment/suppression of HSV
-acyclovir!
-suppressive therapy regimen for pregnant women with recurrent genital herpes starting at 36 weeks
-c/s for those with active lesions
65
nonpharm symptomatic relief of HSV lesions include...
cool, topical compresses with Burow's solution as needed to reduce inflammation and swelling
local hygiene, topical anesthetic , cool air with fan or hair dryer
66
Molluscum Contagiosum
-most common where in the world?
-age most affected?
-incubation period
-tropical or subtropical regions
-skin to skin, common in young adults and children
-incubation period: 2-7 weeks
67
Symptoms of Molluscum Contagiosum
-what does it look like
-where on the body is it usually found? (kids vs adults)
flesh-colored, white, or pink, waxy, smooth, firm spherical papules; usually fewer than 20 lesions, ranging from pinhead size to 2-5mm in diameter
-present on trunk and lower extremities in children
-present on lower abdominal wall, inner thigh, pubic area, genitalia in adults
68
classic physical findings of Molluscum Contagiosum
less than 20 light-colored papules with an umbilicated center
69
management/treatment of Molluscum Contagiosum
-usually resolves on its own without scarring
70
Syphilis's Stages
1. Primary
2. Secondary
3. Latent
4. Tertiary
1. Primary: primary lesion (chancre) arises at point of entry (10-90 days following contact); painless, ulcerated lesion with raised borders; spontaneously disappears in 3 to 6 weeks; painless lymphadenopathy may occur
2. Secondary: follows resolution of primary stage; symptoms become systemic: mucocutaneous lesions (palms, soles, mucous patchys) with generalized lymphadenopathy along with flu-like symptoms: fever, headache, sore throat, malaise, arthralgias; may begin 4-6 weeks after appearance of primary lesion and resolves in 1 week-2 months
3. Latent: begins after spontaneous resolution of secondary stage; no clinical manifestations; now detected by serologic testing; may remain in this stage or progress to tertiary
4. Tertiary: characterized by gummas (nodular lesions) involving skin, mucous membranes, skeletal system
-cardiac symptoms
-neurosyphilis: nerve dysfunction, meningitis, stroke, NOT infectious in tertiary stage `
71
early latent vs late latent with syphilis
early: within 1 year of acquiring the disease
late: > 1 year duration
72
diagnostic tests/findings for syphilis
1. nontreponemal serologic testing: VDRL, RPR
NOTE: a positive RPR or VDRL must be confirmed with a FTA-ABS or TP-PA (treponrmal)
73
T/F treponemal tests tend to remain positive for lifetime regardless of treatment
true!
74
nontreponemal test titers usually correlate with disease activity...
a foufold change in titer is equal to two dilutions (1:16, 1:4 or 1:8 to 1 :32)
75
Management/treatment
-who MUST be treated
a. pregnant women
b. patients with positive treponemal tests
c. people treated previously with fourfold rise in quantitative nontrep test
d. persons exposed within 90 days preceding diagnosis in sexual partner
76
primary or secondary treatment of syphilis
1. Benzathine penicillin G 2.4 million im in a single dose
2. Doxycycline 100 mg orally BID for 2 weeks or tetracycline 500 mg orally QID for 2 weeks, for non pregnant penicillin-allergic patients
77
latent syphilis treatment
-early vs late
early: benzathine penicillin 50,000 unites/kg IM
late: benzathine penicillin G 50,000 units/kg IM as three doses at 1-week intervals
78
tertiary syphilis treatment
with normal CSF examination: benzathine penicillin admin as three doses of 2.4 million unites IM each at 1 week intervals
79
follow up intervals for patients with syphilis
-titers should decline by...
quantitative nontreponemal serologic tests repeated at 6, 12, and 24 months
-titers should decline at least fourfold within 12 to 24 months
80
T/F you must report syphilis cases to proper agency
true
81
T/F pregnant women without a fourfold drop in titer in a 3 month period need repeat treatment
TRUE
82
chancroid
-physical findings
-differential
-treatment
NOTE: chancroid is rare and often associated with outbreaks r/t drug use, commercial sex
-deep ulceration with irregular, scalloped borders
-bilateral, tender inguinal lymphadenopathy
-differentials: genital herpes, syphilis, malignancy
Tx: azithromycin 1 g PO in a single dose
ceftriaxone 250 mg IM in a single dose
f/u: reexamine in 3-7 days
83
Lymphogranuloma Venerum
-presentation
-painless ulcerations that heal in a few days
-painful bowel movements, blood or pus from rectum
-unilateral lymphadenopathy
84
Pelvic Inflammatory Disease (PID)
-most commonly caused by...
chlamydia and gonorrhea!
85
Symptoms of PID + physical findings
-abdominal pain
-vaginal discharge
-fever
-dysuria
-dyspareunia
-N/V
-CMT, uterine tenderness, adnexal tenderness
-vaginal spotting or bleeding
86
additional criteria that enhance the specificity of PID diagnosis
-fever > 101
-mucopurulent discharge
-abundant WBCs on wet mount
-elevated ESR
-elevated CRP
-lab documentation of chlamydia or gonorrhea infection
87
differential diagnoses with PID
-ectopic pregnancy
-appendicitis
-ruptured ovarian cyst
-torsion of adnexal mass
88
diagnostic tests/working up patient with suspected PID includes...
-chlamydia and gonorrhea tests
-ESR and/or CRP (elevated)
-rule out pregnancy
89
treatment of presumptive PID is for patients who...
are sexually active young women who report lower abdominal or pelvic pain and have no other reason for illness and ONE of these clinical criteria is present:
a. CMT
b. uterine tenderness
c. adnexal tenderness
90
criteria for hospitalization
-fever > 101, N/V, severe illness
-patient is pregnant
-tubo-ovarian abscess seen on u/s
91
outpatient treatment/management of PID
a. Ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg PO BID for 14 days with or without metronidazole 500 mg PO BID for 14 days
92
what is absolutely necessary in patients you diagnose with PID?
FOLLOW UP and reexamine within 72 hours!!!
-if not significantly improved, review diagnosis and treatment and consider hospitalization
93
pregnant patients with PID treatment
hospitalization yo!!
94
vulvar conditions include (3)
1. vulvar dermatosis (lichen slcerosus, lichen planus, lichen simplex chronicus)
2. vulvodynia (chronic vulvar discomfort)
3. Bartholin's Gland cyst/Abscess
95
the three major vulvar dermatoses
1. lichen sclerosus
2. lichen planus
3. lichen simplex chronicus
96
etiology/incidence
1. lichen sclerosus
2. lichen planus
3. lichen simplex chronicus
1. lichen sclerosus: chronic, progressive inflammatory skin condition primarily affecting perineal areas; most common in postmenopausal women; genetic and/or autoimmune etiology suspected
2. lichen planus: inflamatory skin condition manifested in the vulva, vagina, other mucous membranes; typically seen in perimenopausal and menopausal women; flares and remits spontaneously
3. lichen simplex chronicus: thickening of skin in response to chronic rubbing and scratching; may be atopic rection
97
what disorders are often associated with lichen sclerosus?
-vitiligo
-thyroid disorder
-alopecia
-UC
98
differential diagnoses for lichens
1. vitiligo
2. vulvar carcinoma
3. seborrheic dermatitis
4. psoriasis (scaly rash)
5. tinea
99
lichen sclerosus vs lichen planus symptoms and physical findings
LICHEN SCLEROSUS
1. sxs: pruritus, dyspareunia, dysuria
2. physical findings: maculopapular lesion, plaques, loss of pigmentation, markedly thin, white epidermis, symmetry of distribution extends around anal region (figure 8), loss of vulvar architecture with obliteration of clitoris, introital stenosis
LICHEN PLANUS
1. sxs: pruritis, burning, raw sensation, vaginal discharge/bleeding, dyspareunia, dysuria
2. physical findings: sharply demarcated, shiny, erythematous papules/patches, gray-white lace strands of hyperkeratosis overlay patches; vaginal erythema, erosions, adhesions; loss of vulvovaginal architecture, may involve other mucosal tissues
100
lichen simplex chronicus symptoms and physical findings
1. sxs: chronic itch-scratch cycle, pruritis, dyspareunia, dysuria
2. physical findings: thickened, leathery plaques on labia majora, excoriations and erosions from scratching, may involve other body area
101
how do we confirm lichens diagnosis?
biospy confirms
can also be diagnosed with visual inspection
102
how do we manage/treat lichens?
1. high-potency topical corticosteroids (clobetasol), ointment base best for vulva instead of cream; taper as sxs improve
2. remove all contact irritants
3. skin protectants: vitamin a and D ointment
4. vaginal dilators if needed to maintain vaginal patency
103
T/F there is an increased risk for vulvar squamous cell carcinoma (4-5%) with lichen sclerosus
TRUE!!
yearly vulvar exam with biopsies as needed
104
Vulvodynia definition
chronic vulvar discomfort, often described as "burning pain" in absence of relevant physical findings/no visible dermatoses or inflammation or neuro disorder
multifactorial- altered immune inflammatory process, chronic inflammation
105
commonly associated conditions with vulvodynia
IBS, interstitial cystitis, fibromyalgia
106
differential diagnoses for vulvodynia
-vulvovaginal infection
-UTI
-allergy/hypersensitivity
-psychogenic disorder (hx of sexual abuse)
107
diagnostic tests/findings for chronic vulvar pain
1. cotton swab test- light touch applied to inner thighs, labia majora, vestibular duct opening, clitoris/hood, and perineum to localize areas of altered sensation
2. test for vulvovaginal or UTIS
3. colpo/biopsy to rule out dermatoses, pathology
108
management of vulva discomfort is largely empiric including...
-topical ointments: lidocaine, gabapentin
-oral neuropathi pain meds
-injections: steroids, botox
-physical therapy with pelvic floor
109
Bartholin's gland cyst/abscess
-symptoms and physical findings
usually nontender, unless abscess
may cause discomfort during sexual intercourse, walking or sitting
medially protruding cystic structure ant inferior aspect of labia (4 and 8 o clock positions), most 1-3 cm, usually unilateral
110
when is a biopsy warranted with bartholin's gland cyst?
if older than 40 to rule out carcinoma
111
management/treatment of Bartholin's Cyst depends on symptoms, size, recurrence, or infection
1. needle aspiration
2. incision and drainage with or without placement of Word catheter
3. word catheter allows for formation of epithelialize tract and continued drainage of the gland, reducing recurrences
4. duct marsupilization or gland excision
