Infections in OB/GYN: Vaginitis, STI ’ s

1. 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

2. 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

3. 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

4. Case: 26 yo w/ 2 wk h/o vaginal DC 26 yo 2 wk hx vag DC • Differential Diagnosis • HPI • Pertinent PMH • Pelvic Exam • MicroscopyLaboratory • Treatment • Counseling

5. Vaginal Discharge: Ddx • Candidiasis • Bacterial Vaginosis • Trichomonas • Atrophic • Physiologic (Leukorrhea) • MucopurulentCervicitis • Uncommon • Foreign Body

6. 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)

7. Vaginitis/Vaginosis • Characteristics of the discharge • pH • Amine odor • Wet mount • Cultures?

8. Vaginal Candidiasis • Part of normal flora • Majority Candida albicans • Predisposing factors: • Diabetes • Antibiotics • Increased estrogen levels (preg, OCP, HRT) • Immunosuppression • ?Contraceptive devices, behaviors

9. Vaginal Candidiasis • S/Sx • Pruritis • White, clumpy discharge • pH 4-4.5 • Dxs: KOH prep • Treatment • Fluconazole 150 mg PO x1 • Topical azoles (OTC)

10. Pelvic exam

11. 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

12. Bacterial Vaginosis

13. 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**

14. 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

15. Pelvic Exam

16. 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!

17. 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

18. 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

19. 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

20. Neisseria gonorrhea: Disseminated • Gonococcalbacteremia (rare) • Pustular or petechial skin lesions • Asymetricalarthralgia • Tenosynovitis • Septic arthritis • Rarely • Endocarditis • Meningitis

21. 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

22. C. trachomatis Obligate intracellular pathogen No cell wall, not susceptible to penicillins Difficult to culture Chlamydia trachomatis

23. Chlamydia trachomatis: Diagnosis • Usually asymptomatic • Best to screen susceptible young women • Mucopurulentcervicitis • Intermenstrual bleeding • Friable cervix • Postcoital bleeding • Elisa or DNA probe

24. 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

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

26. Case: 21 yo presents with RLQ pain 26 yo 2 wk hx vag DC • Differential Diagnosis: • GYN • OB • GI • Urologic • MSK

27. 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

28. PID: Symptoms • Acute or chronic abdominal/pelvic pain • Deep Dyspareunia • Fever and Chills • Nausea and Vomiting • Epigastric or RUQ pain (perihepatitis)

29. 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

30. 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 Abscess • Fluid in Culdesac nonspecific • Fluid in Morrison’s Pouch is suggestive if associated with epigastric/RUQ pain

31. 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

32. 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 Abscess (refer for surgical evaluation if patient not improving) • Pregnancy • *no evidence that adolescents require hospitalization • Consider referral to GYN if patient not improving

33. 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

34. Pelvic Adhesions chronic pelvic pain, dyspareunia infertility ectopic pregnancy Empiric Treatment Suspected Chlamydia, GC or PID Deemed valuable in preventing sequelae PID: Sequelae

35. 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

36. Case: 24 yo G0 w/ lesion on vulva 26 yo 2 wk hx vag DC • Differential Diagnosis • HPI • Pertinent ROS • Focused exam • Laboratory • Treatment • Counseling

37. Genital Ulcers • Syphilis • Herpes • Chanchroid • LymphogranulomaVenereum • GranulomaInguinale

38. 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

39. Herpes • Primary • Systemic symptoms • Multiple lesions • Urinary retention • Nonprimary First Episode • Few lesions • No systemic symptoms • preexisting Ab

40. 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

41. Syphilis • TreponemaPallidum- 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

42. 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

43. Primary and Secondary Syphilis

44. 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

45. 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

46. Chancroid • Endemic to some areas of US, outbreaks • HemophilusDucreyi • 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

47. 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

48. Granuloma Inguinale • Outside US, Tropics • Calymmatobacteriumgranulomatis • 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

49. Vulvar Lesions • Human Papilloma Virus • MolluscumContagiosum • Pediculosis Pubis • Scabies

50. 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