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   ORCefixime400 mg orally in a single dose  

   PLUS

Tx FOR CHLAMYDIA IF NOT RULED OUT

Do NOT use Quinolones in U.S. - resistant GC commonDo 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/pid.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