Case
19 y/o white female comes to ED
Cc: I think I have a bladder infection.
HPI: 3 days of Low Abdominal pain,
nausea, vomiting, anorexia, dysuria, and
yellow/white d/c in underwear.
Increasing achy, dull pain for last 3 days
and worse with walking or other
movement.
More Case
PMH: Sexually active w/ one partner for
last 1 year. Treated for episode 6 months
ago of vaginal d/c and told she had “an
STD”, but partner check and he was
asymptomatic. Rarely uses condoms,
because they are both monogamous.
Otherwise healthy.
Case Physical
PE: Temp 100.8, Resp. 22, HR 105
Uncomfortable, lying in bed
Abd – bilateral LAP, guarding. No masses. No
flank tenderness
Pelvic – large amount of yellowish/white
discharge, no lesions noted, has CMT, bilateral
adnexa tenderness
WBC – 12,500 with left shift; UPT –negative;
UA: Leukocytes, no nitrates.
Differential Dx:
Pelvic inflammatory disease
Appendicitis
Endometriosis
Ovarian torsion
Gastroenteritis
Renal colic
Diverticulitis
Pyelonephritis
Cervicitis
Ovarian cyst
Pelvic Inflammatory
Disease and
Vaginitis
Curtis Johnson, MD
PGY 2, Emergency Medicine, UAMS
October 2, 2003
PID - Definition
An ascending infection of the
otherwise sterile upper
reproductive tract, often initiated
by a sexually transmitted
organism, but polymicrobial at the
time of presentation.
Types of PID
Acute – Vaginal d/c, pelvic pain, CMT,
symptoms of urethritis, occurs 3-5 days
after menses, High WBC.
Intermediate – Symptoms ranging
between Acute and Chronic, Normal WBC.
Chronic – achy pelvic pain worsened by
trauma, sex, and menses; diffuse
tenderness; no d/c, may have lost
reproductive capability, Normal WBC.
PID – a costly disease
Costs about 4 billion dollars a year in
health care costs.
Accounts for about 300,000 hospital
admissions a year.
Affects about 1 million women per year.
The most costly and serious infection in
post menarchal women.
PID – the Emotional cost
A quarter of all diagnosed patients suffer
Chronic pain, ectopic pregnancies, or
infertility.
½ of all cases of ectopic pregnancy in US
can be attributed to PID
Ectopics have increased 5 fold in 20 years
and are the leading cause of pregnancy
deaths in African American women.
PID - Risk factors
Multiple Sexual Partners
Recent Menses or Abortion
Trauma
Presence of an intrauterine device
Previous STD’s
Frequent Douching
Substance abuse
Usual Suspects
Pathologic
Chlamydia
N. gonorrhea
Mycoplasma homonis
Ureaplasma
urealyticum
Opportunistic
Gardinella Vaginalis
E.coli (Gram – rods)
Streptococcus
agalactiae
H. influenzae
How to Work up
History of risk factors
Physical exam – CMT, d/c, tenderness, fever
Labs
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CBC - elevated WBC or normal
ESR – elevated or normal
Wet mount, KOH – trichamonas, clue cells
UA, UPT – important for treatment and dx
Cultures – for GC, Chlamydia, syphilis, bacteria
DNA probes – for GC and Chlamydia
Diagnosis
Clinical suspension – based on Work up
Transvaginal Ultrasound – Thicken Fluid
Filled Fallopian tubes, free fluid, abscess
Endometrial Biopsy – culture and
histological confirmation
Culdocentesis – Leukocytes and bacteria
Laparoscopy – Gold standard – fluid,
exudate, hyperemia, abscesses.
The Big Decision – Who to Admit
Uncertain Diagnosis
Suspect Abscess – Tuboovarian or Pelvic
Pregnant
N/V to point of unable to take oral meds
Unable to follow Outpatient oral regimen
Failure to respond to Outpatient therapy
Noncompliant patients
Patients with HIV
IUD in place
PID – Outpatient Management
Rocephin 250 mg IM x1
OR
Cefoxitin 2 g IM and
Probenicid 1 g PO
Doxycyline 100 mg
and
PO BID x 10-14 days
OR
Ofloxacin 400 mg PO
BID x 14 days
Clindamycin 400 mg
PO QID x 14 days
and
OR
Flagyl 500 mg PO
BID x 14 days
Inpatient Therapy
Cefoxitin 2g IV q6 or
Cefotetan 2g IV q12
or Zithromax 500mg
IV qD x 2, then 250
mg PO qD x 5
Doxycyline 100 mg
and IV or PO q12 until
improved
OR
Gentamicin 2mg/kg
Clindamycin 900 mg
and IV or IM bolus then
IV q8
1.5 mg/kg q8
THEN
Doxycyline 100 mg PO BID for rest of 14 days
But, I’m Allergic
Ofloxacin
400 mg IV
q12°
Flagyl
500 mg
IV q8°
Doxycyline
100 mg
orally or IV
q12°
WITH
OR
Levofloxacin
500 mg IV
qD
OR
WITHOUT
OR
Unasyn
3g IV q6°
PLUS
Fitz-Hugh-Curtis
Inflammation of liver capsule and
development of adhesions between liver
and abdominal wall caused by Neiserria
gonorrhea.
Symptoms include right upper quadrant
pain and pleuritic pain a few days to
weeks after acute PID.
Due to lymphatic drainage or bacteremia.
May require laparoscopy and lysis of
adhesions.
PID – Other complications
In first trimester of pregnancy can result in
miscarriages and fetal death.
All pregnant patients should be treated
with in patient therapy.
Can result in tuboovarian abscess,
peritonitis, endometritis, and salpingitis.
Before you send them home
Explain the severity of the PID and
probably mode of transportation.
Recommend follow up to be tested for
other STD’s (i.e. HIV)
Strongly recommend testing for partner
and discourage intercourse until both are
treated.
VulvoVaginitis
Irritation of Vulva and Vaginal tissues.
Accompanied by vaginal d/c and/or vulvar
itching and irritation.
Accounts for 10 million physician visits per
year.
Most common gynecologic complaint in
prepubertal girls.
Causes of Vaginitis
Infections
Irritant and allergic contact
vulvovaginitis
Local response to vaginal foreign
body
Atrophic Vaginitis
Infections – the troublesome trio
Trichamonas Vaginalis
Bacterial Vaginosis
Candidiasis
Trichomonas Vaginalis
Estimated 2-3 million women contract this
bacteria per year
Almost solely transmitted as a STD
Associated with PTL, PROM, and Low
Birth Weight.
Facilitates infection with HIV
Oral contraceptives, spermicides, and
barrier contraceptives may decrease
transmission rate.
Symptoms of Trich
May range from asymptomatic carrier
to severe.
Vulvovaginal irritation/puritis
Dysuria
Dyspareunia
Feeling of vulvovaginal fullness
Symptoms worse around menses
Signs of Trichamonas
Strawberry Cervix – due to punctate
hemorrhage (present in only 2% of cases)
Diffuse erythema
Vaginal Discharge – yellow-green to gray
Diagnosis of Trich
Wet mount slide using Normal saline
Geimsa Stain
Treatment of Trich
Preferred
Metronidazole (Flagyl) 2g PO x1 dose
Alternatively
Metronidazole (Flagyl) 500 mg PO BID x 7
days
You’ve got a Bun in the Oven
Women who are symptomatic for Trichomoniasis
should be treated to eliminate symptoms.
Metronidazole is relatively contraindicated in the
first trimester of pregnancy.
In symptomatic disease in early pregnancy local
therapies (clotrimazole pessaries 100mg daily
for 7 days or Aci-jel) could be used.
Systemic treatment will ultimately be necessary
to eradicate the infection.
What should we do?
Studies out of the National Institute of Child Health and
Human Development and another out of National
Institute of Child Health and Human Development
Maternal-Fetal Medicine Units Network have shown
interesting findings.
Metronidazole treatment of women with trichomoniasis
significantly increased the risk of preterm birth compared
to placebo.
These results formed the basis of the US Preventive
Services Task Force recommendation that screening for
bacterial vaginosis not be undertaken in low-risk
pregnant women.
Bacterial Vaginosis
Clinical syndrome where lactobacilli are
replaced with anaerobic bacteria,
Gardenella vaginalis, and Mycoplasma
hominis
50% of women are asymptomatic
Rarely occurs in women who are not
sexually active.
Signs and symptoms
Clue cells – epithelial cells coated with
bacteria
Homogenous white discharge coating
walls of vagina
pH greater than 4.5
Fishy odor after addition of KOH to
discharge on a slide.
Complications
Can cause preterm labor, PROM
Associated with PID
Can cause endometritis
Causes vaginal cuff cellulitis after
surgery
We’ve Got Controversy
On study found that 2% clindamycin cream was
found to increase the risk of PTL by changing
the vaginal flora make up (Neatherlands)
Another study found that Clindamycin cream in
the early 2nd trimeseter would reduce
complications (UK).
Several studies have shown that treating
Bacterial Vaginosis has no effect on the rate of
preterm labor or low birth weight.
Research
Recent research suggests that Interleukin1β, Interleukin-6, and Interleukin-8 levels
are directly related to abnormalities in
vaginal flora resulting in BV.
Candidal Vaginitis
Estimated that 75% of women will
experience at least one infection during
childbearing years.
Second most common vaginal infection
Not a sexually transmitted disease
Hormone dependant
Rare in premenarchal girls and decreased
in postmenopausal women.
Risk Factors for Candida
Pregnancy
Oral Contraceptives
Uncontrolled Diabetes Mellitus
Frequent Antibiotic therapies
Impaired Cell Mediated Immunity
Signs and Symptoms of VVC
Leukorrhea
Vaginal pruritis
External dysuria
Dyspareunia
Vulvar edema and erythema
Vaginal erythema
Thick “cottage cheese” discharge
Diagnosis of Candida
Wet mount and KOH smears on slide –
psuedohyphae and yeast buds
Treatment drawbacks
Recurrence of symptoms common
Oral agents can cause nausea, vomitting,
abdominal pain and headache
Ketoconazole can cause liver toxicity and
adverse reactions to other medications
Genitial Herpes
Caused by sexually transmitted HSV – 1
or HSV – 2.
Transmission can occur during
asymptomatic period
Most frequent cause of painful genital
lesions.
Recurrent disease with no cure at this
time.
Genitial Herpes
Presents 1 to 45 days after exposure.
Initial presentation usually the most painful
and severe.
Symptoms peak at 8-10 days, with usual
complete healing at 21 days or so.
Recurrent infections less severe and
shorter lasting.
Genitial Herpes Complications
Aseptic Meningitis
Urethritis
Hepatitis
Pneumonitis
Pharyngitis
Spread to other parts of the body.
Contact Vulvovaginitis
Contact Dermatitis of the vulva and vagina
Symptoms include pruritis, erythema, and
edema
Mild causes go away without treatment
Severe cases may be treated with topical
steroids, sitz baths, and oral histamines.
Can be superinfected by Candida,
requiring treatment.
What about the Children?
Vaginal Foreign Bodies
Most common in children and adolescents.
If left in, longer than 48 hours may result in
infection with E. coli, anaerobes or other
vaginal flora.
May result in foul or bloody discharge.
Only treatment required is removal of
foreign body.
Pinworms
Migrate from anus to vagina in children.
Mature female worms lay eggs in perianal
area resulting in itching.
Diagnosed with Scotch tape test
Entire family needs treatment
Treatment is a single dose of
Mebendazole 100 mg chewed or pyrantel
palmoate 11 mg/kg and then repeat
treatment in 2 weeks.
Atrophic Vaginitis
Occurs during lactation, menarche,
pregnancy and menopause.
Caused by lack of estrogen to stimulate
vaginal epithelia
Can result in increased infection with
Lactobacilli
Treated with Hormone replacement, oral
estrogen or estrogen cream.
References
References
References
medlib.med.utah.edu/parasitology/ tvagim.html
www.hc-sc.gc.ca/.../slmmaa/slides/other/pages/15.html
www.medicine.mcgill.ca/tropmed/txt/lecture1.htm
www.dpd.cdc.gov/.../body_Trichomoniasis_mic1.
htm
www.verhuetung-abc.de/ html/Candida.html
ww.mrcophth.com/pathology/selftests/test26.html
www.upstate.edu/courseware/cytotech/gyn/bact2
.html
References
Mandell: Principles and Practices of
Infectious Diseases, 5th ed. Churchill
Livingstone, Inc: 2000.
AAP 2000 Red Book: Report of the
Committee on Infectious Diseases, 25th
ed. American Academy of Pediatrics:2000
Ryan: Kistner’s Gynecology & Women’s
Health, 7th ed. Mosby, Inc: 1999.
References
2001 National Guideline on the Management of Trichomonas
vaginalis Clinical Effectiveness Group (Association for Genitourinary
Medicine and the Medical Society for the Study of Venereal
Diseases)
N Engl J Med. 2001 Aug 16;345(7):487-93. Failure of metronidazole
to prevent preterm delivery among pregnant women with
asymptomatic Trichomonas vaginalis infection. Klebanoff MA, et al;
National Institute of Child Health and Human Development Network
of Maternal-Fetal Medicine Units.
BJOG. 2001 Jul;108(7):697-700 Changes in the vaginal flora after
two percent clindamycin vaginal cream in women at high risk of
spontaneous preterm birth.
Vermeulen GM, van Zwet AA, Bruinse HW.
References
Eur J Obstet Gynecol Reprod Biol. 2003 Oct 10;110(2):149-52. Treatment
of asymptomatic bacterial vaginosis to prevent pre-term delivery: a
randomised trial. Guaschino S, Ricci E, Franchi M, Frate GD, Tibaldi C,
Santo DD, Ghezzi F, Benedetto C, Seta FD, Parazzini F.
Obstet Gynecol. 2003 Sep;102(3):527-34. Clinical and cervical cytokine
response to treatment with oral or vaginal metronidazole for bacterial
vaginosis during pregnancy: a randomized trial. Yudin MH, Landers DV,
Meyn L, Hillier SL.
Lancet. 2003 Mar 22;361(9362):983-8. Effect of early oral clindamycin on
late miscarriage and preterm delivery in asymptomatic women with
abnormal vaginal flora and bacterial vaginosis: a randomised controlled trial.
Ugwumadu A, Manyonda I, Reid F, Hay P.
Semin Perinatol. 2003 Jun;27(3):212-6. What have we learned about
vaginal infections and preterm birth? Carey JC, Klebanoff MA; National
Institute of Child Health and Human Development Maternal-Fetal Medicine
Units Network.