CLINICAL CASES
Unit 3: Gynecology
Section A: General Gynecology
Objective 36: Sexually Transmitted Infections (STIs) & Urinary Tract Infections (UTIs)
Case 1
A 26-year-old gravida 3 presents to the clinic complaining of growths on her vulva.
These growths were noted one week ago, but she may have had similar lesions 4 years
ago during her last pregnancy. Of concern to her are the size of the growths and the
fact they are on both sides of her perineum and vulva. She has not sought treatment
before today.
PMH
Medical – unremarkable
Surgical – Postpartum tubal ligation 4 years ago
Obstetric – 3 living children ages 10, 8, and 4
all uncomplicated vaginal deliveries
Physical examination
Abdomen: Soft, benign, no hepatosplenomegaly
Pelvic: NEED INFO HERE
Vulva: multiple small (4mm) and large (14mm) fleshy soft “wart like” lesions
on both right and left labia and vulva
Vagina: soft, moist and pink, no lesions
Cervix: multiparous, no gross visible lesions
Uterus: slightly enlarged, firm, mid-position, anteverted and anteflexed
AP
Condyloma acuminate with plans for patient applied therapy with Imiquimod.
Discussion
Human papillomavirus infections, although common, are frequently asymptomatic,
unrecognized and maybe subclinical. Overall, there are 70 viral subtypes of HPV.
HPV 6 and 11 are generally associated with visible genital warts, while viral types 6,
18, 31, 33 and 35, as well as 45 and 56, have been associated with cervical neoplasia.
Genital warts generally occur on the perineum and vulva as well as the perianal skin
but may be identified on the uterine cervix as well as the vagina, urethra, anal canal
and mouth. Clinically these lesions are described as fleshy and vary in size from very
small to very large. Classically, the lesions are described as soft fleshy growth and are
termed condyloma acuminata or venereal warts.
The diagnosis of condyloma acuminata is based not only on physical findings, but
may be confirmed by biopsy of the genital warts. Management options include
destruction of the lesions using either electrocautery laser or local incision, as well as
chemical destruction using podophyllotoxin or trichloroacetic acid. Other methods of
therapy include immunological means using interferon, intralesional or Imiquimod
patient-applied therapy. The current CDC recommendations are that the first line of
therapy includes patient applied therapy using Podofilox 5% solution or gel or
Imiquimod 5% cream. There is no evidence that would suggest that any of these
regimens are superior to the others and the treatment should be guided based on the
preference of the patient. Importantly, if the patient has not improved
symptomatically and the lesions begun resolving after 3 weeks therapy, the therapy
should be changed to provider administered treatment. In the case of women with
cervical warts, high-grade squamous intraepithelial lesions must be excluded before
treatment is initiated. Treatment for cervical warts and/or vaginal warts includes
cryotherapy or TCA. Follow up of women who have had genital warts includes
regular annual examinations and Pap smears.
Teaching points
HPV is a most common STD with more than 70 DNA subtypes.
HPV 6, 11 are associated with genital warts.
HPV 16, 18, 31, 33, 35, 45, 56 associated with cervical cancer.
Diagnosis based on clinical exam and/or biopsy.
Treatment involves physical destruction of lesions using electrocautery, laser, local
excision, or chemical destruction (Podophyllotoxin or trichloroacetic acid) or
immunological (Interferon or Imiquimod).
Case 2
A 16-year-old G1P1 where LMP was one week ago presents with a one-week history of
severe lower abdominal pain. Pain is constant, bilateral and accompanied by fever
and chills. She has had some nausea and several episodes of vomiting. She has been
sexually active for 3 years and has had unprotected intercourse with several partners.
She denies irregular bleeding, dysmenorrhea or dyspareunia.
PMH
Medical – negative except childhood illness
Surgical – Tonsillectomy as a child
Obstetrical – Gravida1, para1, uncomplicated vaginal delivery one year ago
Physical exam
Ill appearing 16-year-old
T 38.6o
P 94
BP 124/82
R 22
Abd: Bilateral lower abdominal tenderness, slightly distended with
rebound, negative psoas and Murphy’s signs
Pelvic: BUS negative
vag – pink, moist,
cervix - purulent discharge from os, indurated
uterus – midline position, soft, tender
adnexa – bilateral fullness and moderately tender
Labs
GC: positive
RPR: negative
WBC: 17.6 with left shift
UA: few WBC’s, no bacteria, 3 plus ketones
UHCG: negative
Diagnosis
Acute salpingitis with peritoneal findings. Admit for parenteral antibiotics.
Discussion
The most common presenting complaint of women who have PID is lower abdominal
pain. Associated symptoms include vaginal discharge, irregular bleeding,
dysmenorrhea, dyspareunia, dysuria, nausea, vomiting and fever. Women who have
gonococcal infection have evidence of more acute inflammation (peritoneal signs,
fever, leukocytosis) than those who have nongonococcal infection because of the
endotoxin produced by N gonorrhoeae. Most women who have acute PID present
during the first half of the menstrual cycle. Presentation later in the cycle indicates
an infection of longer duration and increases the likelihood that a TOA has organized.
Atypical presentations of PID are common and complicate the differential diagnosis.
For example, the symptoms of Fitz-Hugh-Curtis syndrome may mimic hepatitis or
cholecystitis.
All PID treatment regimens must provide broad-spectrum coverage of likely
pathogens, including N gonorrhoeae, C trachomatis, anaerobes, gram-negative bacteria
and streptococci. Although broad-spectrum antibiotic coverage results in
symptomatic improvement in most patients, the risk of long-term sequelae remains
high. Adolescents are at particularly high risk for future reproductive complications
because of their tendency not to complete prescribed treatment regimens. The CDC,
therefore, recommends serious consideration of hospitalization for all adolescents who
have PID. Hospitalization is especially recommended if compliance is unpredictable,
the diagnosis is uncertain, or pelvic abscess is suspected. Hospitalization is essential if
the patient is pregnant, has HIV infection or is too ill to tolerate or has failed to
respond to outpatient therapy. All patients who are managed as outpatients must be
reevaluated within 72 hours of the initiation of antibiotics.
Sex partners of patients with PID should be examined and treated if they had sexual
contact with the patient in the 60 days prior to the onset of symptoms. Partners
should be treated empirically for N gonorrhoeae and C trachomatis, regardless of the
apparent etiology of the PID or pathogens isolated from the infected woman.
Without treatment of infected partners, risk of reinfection is high.
Teaching points
Pelvic pain, fever and vaginal discharge are the most common findings if secondary to
gonococcal infection. Patients maybe asymptomatic if chlamydia is the
causative organism.
Salpingitis is usually secondary to gonorrhea or chlamydia infections or both.
Diagnostic gold standard is laparoscopy.
Treatment regimens consist of an inpatient or outpatient protocol.
Sequelae include chronic pelvic pain, ectopic pregnancy and infertility.
References
Centers for Disease Control and Prevention. Sexually Transmitted Disease Treatment
Guideline 2002. MMWR 2002; S1:48-52; www.cdc.gov/std/treatment/default.htm.
McCormack WM. “Pelvic inflammatory disease.” N Engl J Med. 1994;330:115-119.
Paavonen J. Dermatol Clin 1998 Oct; 16(4): 747-56, xii.
Pletcher JR. Pediatr Rev 1998 Nov; 19(11):363-7.
Smith M, Shimp L. Women’s Health Care, 20 Common Problems 2000, 433-6.
Case 3
Ms. Sandy R is a 32-year-old, G2P0020 female who comes into the ER having
experienced 8 hours of right lower quadrant pain.
The pain is sharp, stabbing and intermittent in nature and non-radiating to the back.
It is associated with 3-4 episodes of nausea and vomiting that preceded the pain. She
also complains of dizziness and has had loose bowel movements since the onset of the
pain. The pain increases with movement. Fetal position is least painful. She had a
similar episode of pain 10 years ago. A laparoscopy was performed at that time and
was negative for pathology.
Ms. R states that her last menstrual period ended yesterday. She denies being
sexually active currently. She denies fever, chills, dysuria, increased urinary
frequency, hematuria, melena, vaginal discharge, or vaginal bleeding or spotting. Ms
R has allergies to penicillin and no other known allergies. Ms. R is not taking any
medications currently. Menstrual history is menarche at age 13, cycles every 26 days
with 5 days of bleeding. She had a chlamydia infection 9 years ago that was treated
with antibiotics. Two years ago she had a vaginal monilia infection that was treated
with Monistat. Her last Pap smear (1 year ago) was normal. She has used oral
contraceptives intermittently for 8-10 years and last used them 2 years ago. Ms. R
has never used an intrauterine device. She is presently not using any type of birth
control method.
She denies having a history of hypertension, diabetes, heart disease, asthma or kidney
disease.
Surgical history
Tonsillectomy 17 years ago, laparoscopy 10 years ago and elective abortions without
complications 6 and 8 years ago.
Social history
Ms. R lives alone in an apartment and works as a sales clerk. She denies smoking,
drinks 1-2 beers on the weekend and denies use of recreational drugs. She has no
family history of hypertension, heart disease, asthma, kidney disease, diabetes or
bleeding disorders.
Review of symptoms
Unremarkable.
Physical examination
The physical examination reveals a 32-year-old female in no apparent distress. She is
alert and oriented x 3.
Vital Signs:
Temperature:
99.2° F (oral)
Blood pressure:
112/70 mm Hg, supine
116/72 mm Hg, sitting
Pulse:
96 beats/minute, supine
100 beats/minute, sitting
Respirations:
16 breaths/minute
Weight/height:
128lbs; 4’11”
HEENT:
Unremarkable
Neck Exam
Reveals no cervical lymphadenopathy or
thyromegaly
Lung Exam:
Clear
Heart Exam:
Heart tones normal without a murmur. She has
good peripheral pulses.
Abdomen:
Obese with positive bowel sounds and is tender to
palpation throughout; uterine tenderness greater
in the right lower quadrant. There is positive
guarding and rebound tenderness.
Pelvic Exam:
Reveals normal external genitalia, pink, rugose
vaginal walls and a closed os with green
discharge. The uterus and adnexa cannot be
evaluated completely secondary to pain.
Cervical motion tenderness cannot be ruled out.
Rectal Exam:
Guaiac negative and without masses.
Extremities:
Without cyanosis, clubbing, or edema. Few
superficial varicosities are seen on upper legs.
Neurologic Exam:
Grossly within normal limits.
On admission
WBC:
11.1
Hemoglobin:
14.3
Hematocrit:
41.7
Urinalysis:
Negative
Segs:
77
Bands:
18
Platelets:
Normal estimate
PT:
115%
PTT:
23 seconds
Pregnancy Test:
Negative
Hospital course
Ms. R. is prepared for the OR.
Surgical report
Ms. R. was anesthetized, placed in the dorsal lithotomy position, prepped and
draped in the usual manner. An infraumbilical incision was made and a Trocar was
inserted without complications. Vaginally, a single-toothed tenaculum was used to
grab the anterior lip of the cervix and a Hulka manipulator was placed. A
suprapubic incision was made and a second Trocar was inserted under direct
visualization.
Upon entering the peritoneum, free pus was encountered. The appendix was
inflamed, but it appeared to be a periappendicitis without evidence of any acute
perforation or intrinsic inflammation of the appendiceal wall. Some of the rest of the
serosa of the terminal ileum and cecum also appeared inflamed. Upon exploring Ms.
R a little more inferiorly, a pocket of pus is entered and approximately 100cc of
fairly liquid pus found; this was cultured. Upon inspection of the right tube and
ovary, there appeared to be a luteinized cyst in the right ovary that was in the
process of decompressing. The right tube had marked scarring with what appeared
to be a hydrosalpinx with fimbriae scarring at the end. On inspection of the left
tube, there was marked dilatation of the distal tube with fairly normal diameter,
approximately 1cm from the left cornu of the uterus. At this point, there was a
marked hydrosalpinx with a pyogenic component, with creamy pus emanating from
the area just by the fimbriae, which appeared almost necrotic. The left ovary was
not involved. The diagnosis of acute left salpingitis was made. The pelvis was
irrigated and the instruments were removed. The incision was closed with 3-0 Vicryl.
The patient was extubated and taken to the recovery room in stable condition.
Post-operative diagnosis
Peritonitis with acute salpingitis of the left tube. Hydrosalpinx of the right tube with
fimbria scarring. Peri-appendiceal inflammation.
Procedure
Diagnostic laparoscopy
Post-operative
Ms. R. continued to spike fevers. Her cultures from the OR revealed Escherichia coli,
Neisseria gonorrhoeae and Bacteroides fragilis. Blood cultures were subsequently
drawn during one of the temperature spikes, which revealed E. coli. Eventually, 3
days post-operatively, Ms. R. developed induration and redness at the wound site.
The sutures were removed and the wound was packed open for the duration of her
hospital stay. Ms. R. was maintained on Gentamicin and Cleocin for 5 days postoperatively. She had Gentamicin levels drawn, which were in the therapeutic range.
The organisms which grew from the wound, blood and abscess were sensitive to
Gentamicin. The Neisseria is penicillin resistant. Ms. R. eventually defervesced
several days prior to discharge. The wound continued to improve throughout her
hospital stay. The induration and redness had dissipated by the time of discharge.
The antibiotics were switched to Ciprofloxacin in anticipation of discharge; however,
Ms. Rose developed a rash that was pruritic in nature. This was treated with
Benadryl. The Ciprofloxacin was stopped and the rash resolved. She remained afebrile
and was discharged home on Benadryl 50 mg po q.i.d., PRN, Doxycycline 200 mg po
b.i.d. x 7 days and Tylenol #3, 1-2 tabs po q3-4 hours PRN pain.
Ms. R. was given instructions for wound care and a clinic appointment for follow-up
in 2 weeks.