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:
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Gonnorhea
Chlamydia
Herpes
Syphillis
HPV
 Describe pathogenesis, signs and symptoms
and management of PID
Vaginal Discharge DDXS
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Candidiasis
Bacterial Vaginosis
Trichomonas
Atrophic
Physiologic (Leukorrhea)
Mucopurulent Cervicitis
Uncommon
 Foreign Body
 Desquamative
Vaginitis/Vaginosis
 Characteristics of the discharge
 pH
 Amine odor
 Wet mount
 Cultures?
Vaginal Candidiasis
 Part of normal flora
 Majority Candida albicans
 Predisposing factors:
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Diabetes
Antibiotics
Increased estrogen levels (preg, OCP, HRT)
Immunosuppression
?Contraceptive devices, behaviors
Vaginal Candidiasis
 S/Sx
 Pruritis
 White, clumpy discharge
 pH 4-4.5
 Dxs: KOH prep
 Treatment
 Fluconazole 150 mg PO x1
 Topical azoles (OTC)
Bacterial
Vaginosis
 Disruption of healthy
vaginal flora
 Gardnerella, mycoplasmas,
anaerobic overgrowth
 Dxs criteria: Gram stain OR 3 out of 4
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Homogenous, thin, white d/c
“CLUE CELLS”
Whiff test: “amine odor” when d/c mixed w/ KOH
pH >4.5
Bacterial Vaginosis
BV Treatment
 Metronidazole 500 mg BID x 7 days
OR
 Metronidazole gel, 0.75%, one full
applicator (5g) PV QD x 5 days
OR
 Clindamycin cream, 2%, one full
applicator (5g) PV QHS x 7 days
**Avoid alcohol during metronidazole use**
Trichomonas
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Flagellate parasite
“Strawberry”Cervix
pruritis, frothy green discharge
Vag pH >4, neg KOH whiff test
NaCl Microscopy: +WBCs, Trichomonads
Rx: Metronidazole 2 gm po X 1
Tinidazole 2 gm PO x 1
 Partner tx
 Same doses in pregnancy
SEXUALLY TRANSMITTED
DISEASES
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Causative Agent
Method of Transmission
Symptoms
Physical Signs
Diagnostic Methods
Treatment
Screening
Neisseria gonnorhea:
Symptoms
 A single encounter with an infected
partner
 80-90% transmission rate
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Arise 3-5 days after exposure
Initially so mild as to be overlooked
Malodorous, purulent vaginal discharge
15% develop acute PID
Physical Diagnosis
 Mucopurulent discharge flowing from
cervix
 To be distinguished from normal thick yellow
white cervical mucous(adherent to
ectropion)
 Cervical Motion Tenderness
Gonorrhea: DXS
 Elisa or DNA specific test
 Cervical swab
 Combined with Chlamydia
 Urine tests
 Culture for legal purposes
 Gram Stain for WBCs with intracellular gram
negative diplococci
Physical Diagnosis
 Mucopurulent discharge flowing from
cervix
 To be distinguished from normal thick yellow
white cervical mucous(adherent to
ectropion)
 Cervical Motion Tenderness
Disseminated GC
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Gonococcal bacteremia (rare)
Pustular or petechial skin lesions
Asymetrical arthralgia
Tenosynovitis
Septic arthritis
Rarely
 Endocarditis
 Meningitis
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 trachomatis
 C. trachomatis
 Obligate intracellular
pathogen
 No cell wall, not
susceptible to
penicillins
 Difficult to culture
Chlamydia Diagnosis
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Usually asymptomatic
Best to screen susceptible young women
Mucopurulent cervicitis
Intermenstrual bleeding
Friable cervix
Postcoital bleeding
 Elisa or DNA probe
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
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:
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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
due to Adhesions are to be distinguished
from TuboOvarian Abcess
 Fluid in Culdesac nonspecific
 Fluid in Morrison’s Pouch is suggestive if
associated with epigastric/RUQ pain
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/pid.htm
PID Inpatient Rx
 Criteria (2006 CDC STD guidelines)
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Peritoneal signs
Surgical emergencies not excluded (appy)
Unable to tolerate/comply with oral Rx
Failed OP tx
Nausea, Vomiting, High Fever
TuboOvarian Abcess
Pregnancy
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
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
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HPI
Pertinent review of systems
Focused exam
Laboratory
Treatment
Counseling re partner
Genital Ulcers
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Syphilis
Herpes
Chanchroid
Lymphogranuloma Venereum
Granuloma Inguinale
Herpes
 Herpes Simplex Virus I and II
 Spread by direct contact
 “mucous membrane to mucous membrane”
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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
Chancroid
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Endemic to some areas of US, outbreaks
Hemophilus Ducreyi
Painful ulcers, tender LNs
Can aspirate a suppurative LN for Dx
Coexists with HIV, HSV, Syphilis
Culture is < 80% sensitive, PCR ?
Rx: Azithro, Rocephin, Cipro
Lymphogranuloma
Venereum
 Chlamydia trachomatis
 Different serovars
 Rare in US
 Brief ulcer, inflammation of perirectal
lymphatic tissues, strictures, fistulas
 Lymph nodes may require drainage
 Dx: Serologic Testing CT serovars L1-3
 Rx: Doxycycline, Erythromycin
Granuloma Inguinale
 Outside US, Tropics
 Calymmatobacterium granulomatis
 Highly Vascular, Painless progressive
ulcers without LAD
 Dx: Histologic ID of Donovan bodies
 Coexists with other STDs or get
secondarily infected with genital flora
 Rx: Septra, Doxycycline, Cipro, Erythro
Vulvar Lesions
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Human Papilloma Virus
Molluscum Contagiosum
Pediculosis Pubis
Scabies
HPV –
genital warts
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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