Infections in OB/GYN:
Vaginitis, STI’s
UNC School of Medicine
Obstetrics and Gynecology Clerkship
Case Based Seminar Series
Lisa Rahangdale, MD, MPH
Dept. of OB/GYN
Objectives for Vaginitis
 Formulate a differential diagnosis for vulvovaginitis
 Interpret a wet mount microscopic examination
 Describe the variety of dermatologic disorders of the
vulva
 Discuss the steps in the evaluation and management
of a patient with vulvovaginal symptoms
Objectives for STI’s
 Describe the guidelines for STI screening and partner notification and
treatment
 Describe STI prevention strategies, including immunization
 Describe the symptoms and physical exam findings associated with
common STI’s
 Discuss the steps in the evaluation and initial management of common
STI’s including appropriate referral
 Describe the pathophysiology of salpingitis and pelvic inflammatory
disease
 Describe the evaluation, diagnostic criteria and initial management of
salpingitis/pelvic inflammatory disease
 Identify the possible long-term sequelae of salpingitis/pelvic
inflammatory disease
Case:
2 wkhxh/o
vaginal
2626yoyo w/
2 wk
vag
DC DC
•
•
•
•
•
•
•
Differential Diagnosis
HPI
Pertinent PMH
Pelvic Exam
MicroscopyLaboratory
Treatment
Counseling
Vaginal Discharge: Ddx







Candidiasis
Bacterial Vaginosis
Trichomonas
Atrophic
Physiologic (Leukorrhea)
Mucopurulent Cervicitis
Uncommon
 Foreign Body
HPI
 Age
 Characteristics of discharge
 color, odor, consistency
 Symptoms
 Itching, burning
 erythema, bumps
 Bleeding, pain
 Prior occurences, treatments
 Risk factors
 Sexual activity, medications, PMH (pregnancy,
menopause, immunosuppression)
Vaginitis/Vaginosis





Characteristics of the discharge
pH
Amine odor
Wet mount
Cultures?
Vaginal Candidiasis
 Part of normal flora
 Majority Candida albicans
 Predisposing factors:





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)
Pelvic exam
Bacterial Vaginosis
 Disruption of healthy vaginal flora
 Gardnerella, mycoplasmas, anaerobic overgrowth
 Dxs criteria: Gram stain OR 3 out of 4
 Homogenous, thin, white d/c
 “CLUE CELLS”
 Whiff test: “amine odor”
when d/c mixed w/ KOH
 pH >4.5
Bacterial Vaginosis
Bacterial Vaginosis: 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






Flagellate parasite
“Strawberry”Cervix
Pruritis, frothy green discharge
Vaginal 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
Pelvic Exam
Sexually Transmitted Diseases (STI’s)








Causative Agent
Method of Transmission
Symptoms
Physical Signs
Diagnostic Methods
Treatment
Screening
Prevention: don’t forget the obvious! Counsel
your patients about condom use!
Neisseria gonorrhea: Symptoms
 A single encounter with an infected partner
 80-90% transmission rate




Arise 3-5 days after exposure
Initially so mild as to be overlooked
Malodorous, purulent vaginal discharge
15% develop acute PID
Neisseria gonorrhea: Diagnosis
 Physical Exam:
 Mucopurulent discharge flowing from cervix
 To be distinguished from normal thick yellow white
cervical mucous (adherent to ectropion)
 Cervical Motion Tenderness
Neisseria gonorrhea: Diagnosis
 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
Neisseria gonorrhea: Disseminated






Gonococcal bacteremia (rare)
Pustular or petechial skin lesions
Asymetrical arthralgia
Tenosynovitis
Septic arthritis
Rarely
 Endocarditis
 Meningitis
Neisseria gonorrhea: Treatment
 Ceftriaxone 125 mg IM in a single dose
OR
 Cefixime 400 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 trachomatis: Diagnosis






Usually asymptomatic
Best to screen susceptible young women
Mucopurulent cervicitis
Intermenstrual bleeding
Friable cervix
Postcoital bleeding
 Elisa or DNA probe
Chlamydia trachomatis: Treatment
 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 trachomatis: Pregnancy
 Azithromycin 1 g orally in a single dose
OR
 Amoxicillin 500 mg orally three times a day for 7 days
 Test of cure in 3 weeks
Case:
2621yoyo presents
2 wk hxwith
vagRLQ
DCpain
• Differential Diagnosis:
–
–
–
–
–
GYN
OB
GI
Urologic
MSK
Pelvic
Inflammatory Disease
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 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: Outpatient Treatment
http://www.cdc.gov/std/treatment/2010/pid.htm#a2
 Outpatient
 Ceftriaxone 250mg IM + Doxycycline x 14 d w/ or
without Metronidazole x 14 d
 Cefoxitin 2 g IM + Probenecid 1 g PM concurrently +
Doxy x 14 d w/ or without Metronidazole x 14 d
 Other parenteral 3rd generation cephalosporin + Doxy
x 14 d w/ or with Metronidazole x 14 d
PID: Inpatient Treatment
 Criteria (2010 CDC STD guidelines)





Surgical emergencies not excluded (appy)
Unable to tolerate/comply with oral Rx
Failed outpatient tx (no improvement 72 hrs)
Severe illness, Nausea, Vomiting, High Fever
TuboOvarian Abcess (refer for surgical evaluation if
patient not improving)
 Pregnancy
 *no evidence that adolescents require hospitalization
 Consider referral to GYN if patient not improving
PID: Inpatient Treatment
http://www.cdc.gov/std/treatment/2010/pid.htm#a2
A:
 Cefoxitin 2 gm IV q 6 hr
 OR Cefotetan 2 gm q 12 hr
 Plus
 Doxycycline 100mg IV or po q 12 hr
B:
 Clindamycin 900mg q 8 hr and
 Gentamycin 2 mg/kg then 1.5mg/kg q 8 hr
* Can d/c IV therapy 24 hrs after clinical
improvement, complete 14 days
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
Case:
w/hx
lesion
vulva
26 24
yoyo 2G0wk
vagonDC
•
•
•
•
•
•
•
Differential Diagnosis
HPI
Pertinent ROS
Focused exam
Laboratory
Treatment
Counseling
Genital Ulcers





Syphilis
Herpes
Chanchroid
Lymphogranuloma Venereum
Granuloma Inguinale
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: Treatment
 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 and Secondary Syphilis
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







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 Venerum
 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




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
 Gardasil covers HPV 6, 11
Bottom Line Concepts
 Appropriate diagnosis of vaginitis will ensure appropriate
treatment. The various forms of vulvovaginitis are easily
confused by patients.
 Be familiar with appropriate STI screening guidelines and
review them at all preventive care visits.
 The CDC provides excellent information on treatment of STI’s.
 The only truly effective preventive measures is abstinence
from sexual activity.
 Condoms and dental dams are the only preventive measure
we have for patients who are sexually active.
References and Resources
 APGO Medical Student Educational Objectives, 9th edition, (2009),
Educational Topic 35, 36 (p74-77).
 Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010),
Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William
NP Herbert, Douglas W Laube, Roger P Smith. Chapter 26, 27 (p241258).
 Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and
Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone,
Calvin J Hobel. Chapter 22 (p265-275).
 CDC 2010 STD Treatment guidelines:
http://www.cdc.gov/std/treatment/2010/toc.htm