Infections in OB/GYN:
Vaginitis, STIs
Lisa Rahangdale, MD, MPH
Dept. of OB/GYN
Objectives
• Diagnose and treat a patient with vaginitis
• Interpret a wet prep
• Differentiate the signs and symptoms, PE findings,
diagnostic evaluation of the following STI’s:
–
–
–
–
–
Gonnorhea
Chlamydia
Herpes
Syphillis
HPV
• Describe pathogenesis, signs and symptoms and
management of PID
26 yo 2 wk hx vag DC
•
•
•
•
•
•
•
Differential Diagnosis
HPI
Pertinent PMH
Pelvic Exam
MicroscopyLaboratory
Treatment
Counseling
Vaginal Discharge DDXS
•
•
•
•
•
•
•
Candidiasis
Bacterial Vaginosis
Trichomonas
Atrophic
Physiologic (Leukorrhea)
Mucopurulent Cervicitis
Uncommon
– Foreign Body
– Desquamative
HPI
• Age
• Characteristics of discharge
– color, odor, consistency
• Symptoms
– Itching, burning
– erythema, bumps
– Bleeding, pain
• Prior occurences, treatments
• Risk factors
– Sexual activity, medications, PMH
PMH
• Pregnancy
• Menopause
• Immunosuppression
– Diabetes, HIV, medications
Pelvic exam
Microscopy
Pelvic Exam
Microscopy
Treatment & Counseling
• Rx: Metronidazole 2 gm po X 1
Tinidazole 2 gm PO x 1
• Counseling
– Partner treatment
– Safe sex
Pelvic exam
Microscopy
Pelvic exam
Neisseria gonnorhea
• Symptoms
– Arise 3-5 days after exposure
– Initially so mild as to be overlooked
– Malodorous, purulent vaginal discharge
• Physical Exam
– Mucopurulent discharge flowing from cervix
– Cervical Motion Tenderness
Gonorrhea Rx
Ceftriaxone 125 mg IM in a single dose
OR
Cefixime400 mg orally in a single dose
PLUS
Tx FOR CHLAMYDIA IF NOT RULED
OUT
Do NOT use Quinolones in U.S. - resistant GC common
Chlamydia S/Sx/Dxs
•
•
•
•
•
•
Usually asymptomatic
Best to screen susceptible young women
Mucopurulent cervicitis
Intermenstrual bleeding
Friable cervix
Postcoital bleeding
• Elisa or DNA probe
(difficult to culture)
Chlamydia Rx
• Uncomplicated cervicitis (no PID)
– Azithromycin 1 gm po
OR
– Doxycycline 100 mg BID for 7 days
• Repeat testing in 3 mons
• Annual screen in age < 25
Chlamydia in Pregnancy
• Azithromycin 1 g orally in a single
dose
OR
Amoxicillin 500 mg orally three times a
day for 7 days
(2006 - Poor efficacy of erythromycin – now alternative regimen)
• Test of cure in 3 weeks
21 YO presents with RLQ pain
• Differential diagnosis
– GYN
– OB
– GI
– Urologic
– MSK
• She has CMT on pelvic examination.
Does this rule anything out?
HPI
•
•
•
•
LMP = 5 days ago
Pelvic pain, vaginal discharge x 2 days
New sexual partner in last 3 months
Uses condoms “all of the time except
sometimes when we forget.”
Pelvic Inflammatory Disease
• Polymicrobial
– Initiated by GC, Chlamydia, Mycoplasmas
– Overgrowth by anaerobic bacteria, GNRs
and other vaginal flora (Strep, Peptostrep)
– Bacterial Vaginosis - associated with PID
PID Symptoms
• Acute or chronic abdominal/pelvic pain
• Deep Dyspareunia
• Fever and Chills
• Nausea and Vomiting
• Epigastric or RUQ pain (perihepatitis)
PID Physical Diagnosis
• Minimum criteria: one or more of the following– Uterine Tenderness
– Cervical Motion Tenderness
– Adnexal Tenderness
• Additional support:
–
–
–
–
Fever > 101/38.4
Mucopurulent Discharge
Abdominal tenderness +/- rebound
Adnexal fullness or mass
• Hydrosalpinx or TOA
PID Diagnostic Tests
• WBC may be elevated, *often WNL
• ESR >40, Elevated CRP-neither reliable
• Ultrasound
– Hydrosalpinx or a TuboOvarian Complex/Abcess
– Fluid in Culdesac nonspecific
– Fluid in Morrison’s Pouch is suggestive if
associated with epigastric/RUQ pain
“Am I going to have to go the
hospital?”
• Inpatient tx Criteria
–
–
–
–
–
–
–
Peritoneal signs
Surgical emergencies not excluded (appy)
Unable to tolerate/comply with oral Rx
Failed OP tx
Nausea, Vomiting, High Fever
TuboOvarian Abcess
Pregnancy
2006 CDC STD guidelines
PID Treatment
• Needs to incorporate Rx of GC and Chlamydia
(tests pending)
• Outpatient
– Ceftriaxone 250mg IM + Doxycycline x 14 d w/ or
w/out Metronidazole 500mg bid x 14 d
– Levofloxacin 500 mg QD or Ofloxacin 400 mg BID +
Metronidazole x14 days
(No Quinolone unless allergy)
Regimens:http://www.cdc.gov/std/treatment/2006/pi
d.htm
PID Inpatient Rx
• Cefoxitin 2 gm IV q 6 hr
• OR Cefotetan 2 gm q 12 hr
– Plus
• Doxycycline 100mg IV or po q 12 hr
• For maximal anaerobic
coverage/penetration of TOA:
– Clindamycin 900mg q 8 hr and
– Gentamycin 2 mg/kg then 1.5mg/kg q 8 hr
“Am I going to be OK after I
take these antibiotics?”
PID SEQUELAE
• Pelvic Adhesions
– chronic pelvic pain,
dyspareunia
– infertility
– ectopic pregnancy
• Empiric Treatment
– Suspected Chlamydia, GC
or PID
– Deemed valuable in
preventing sequelae
Recommended Screening
• GC/Chlamydia:
– women < 25 (**remember urine testing!)
– Pregnancy
• Syphilis
– Pregnancy
• HIV
– age 13-64, (? Screening time interval)
• One STD, consider screening for others
– PE, Wet mounts, PAP, GC/CT, VDRL, HIV
24 yo G 0 lesion on vulva
•
•
•
•
•
•
HPI
Pertinent review of systems
Focused exam
Laboratory
Treatment
Counseling re partner
Vulvar lesions: DDxs
• Genital Ulcers
–
–
–
–
Herpes
Syphilis
Chanchroid
Lymphogranuloma
Venereum
– Granuloma Inguinale
• Vulvar lesions
– HPV
– Molluscum
Contagiosum
– Pediculosis Pubis
– Scabies
Herpes
• Herpes Simplex Virus I and II
• Spread by direct contact
– “mucous membrane to mucous membrane”
•
•
•
•
Painful ulcers
Irregular border on erythematous base
Exquisitely tender to Qtip exam
Culture, PCR low sensitivity after Day 2
Herpes
• Primary
– Systemic symptoms
– Multiple lesions
– Urinary retention
• Nonprimary First Episode
– Few lesions
– No systemic symptoms
– preexisting Ab
Herpes Rx
• First Episode
– Acyclovir, famciclovir, valcyclovir x 7–10 days
• Recurrent Episodic Rx:
– In prodrome or w/in 1 day of lesion)
– 1-5 day regimens
• Suppressive therapy
– Important for last 4 weeks of pregnancy
Syphilis
• Treponema Pallidum- spirochete
• Direct contact with chancre: cervix,
vagina, vulva, any mucous membrane
• Painless ulceration
• Reddish brown surface, depressed
center
• Raised indurated edges
• Dx: smear for DFA, Serologic Testing
Syphilis Stages
• Clinically Manifest vs. Latent
• Primary- painless ulcer
– chancre must be present for at least 7 days for VDRL to be
positive
• Secondary– Rash (diffuse asymptomatic maculopapular)
lymphadenopathy, low grade fever, HA, malaise, 30% have
mucocutaneous lesions
• Tertiary gummas develop in CNS, aorta
Primary & Secondary Syph
Latent Syphilis
• Definition: Asx, found on screen
– Early 1 year duration
– Late >1 year or unknown duration
• Testing
– Screening: VDRL, RPR- nontreponemal
– Confirmatory: FTA, MHATP- treponemal
Syphilis Treatment
• Primary, Secondary and Early Latent
– Benzathine Penicillin 2.4 mU IM
• Tertiary, Late Latent
• Benzathine Penicillin 2.4 mU IM q week X 3
• Organisms are dividing more slowly later on
• NeuroSyphilis
• IV Pen G for 10-14 days
Vulvar Lesions
•
•
•
•
Human Papilloma Virus
Molluscum Contagiosum
Pediculosis Pubis
Scabies
HPV – genital warts
•
•
•
•
•
Most common STD
HPV 6 and 11 – low risk types
Verruccous, pink/skin colored, papillaform
DDxs: condyloma lata, squamous cell ca, other
Treatment:
–
–
–
–
–
Chemical/physical destruction (cryo, podophyllin, 5% podofilox, TCA)
Immune modulation (imiquimod)
Excision
Laser
Other: 5-FU, interferon-alpha, sinecatchins
• High rate of RECURRENCE