1. Genital Infections and Sexually Transmitted Diseases • Peter L. Stevenson, MD, FACOG • Associate Clinical Professor • Wayne State University • School of Medicine • Obstetrics and Gynecology

2. Pelvic Inflammatory Disease • Nonspecific & Inaccurate • Historically used to describe • long term sequelae of • STD infection • Especially untreated GC

3. Pelvic Inflammatory Disease • Nonspecific & Inaccurate • Now used INCORRECTLY • To describe (M)Any • Pts in the Emergency Room • Infections in the ♀Pelvis • Pelvic infectious disease is polymicrobial • (Including gut flora, clamydia and skin flora)

4. Pelvic Inflammatory Disease • Better to Replace with: • Acute and Chronic Pelvic Infx • Acute Cervicitis • Acute Endometritis • Acute Salpingitis • Tubo-Ovarian Abscess • Pyosalpinx • Peritonitis • Hydrosalpinx & Fitz-Hugh-Curtis Syndrome

5. Vaginal Flora • Aerobic Environment • Six common species • Lactobacilli • Normal pH 4.5 • Lactic Acid • Common Infections • Overgrowth of Normal Flora • Sexually Transmitted Diseases • Accurate Diagnosis: microscopy & pH

6. Vaginal Infections • Bacterial Vaginosis • Candidiasis • Inflammatory Vaginitis • = Lactobacilliosis • Desquamative Vaginitis • Trichomonas

7. Bacterial Vaginosis • Most Common Vaginitis • Gardnerella vaginallis overgrowth • Loss of lactobacilli • Creates anaerobic environment • Eitology unknown • ? Repeated alkalinization • Semen?

8. Bacterial Vaginosis • Difficult to replace lactobacilli • Recurrence common > 30 % • Diagnosis: • fishy odor 2° amines • + whiff test = liberates amines w/ 10% KOH • Thin white/grey/yellow discharge • pH > 4.5 • clue cells on wet prep

9. Bacterial Vaginosis

10. Bacterial Vaginosis • Treatment: • Metronidazole or Clindamycin • VaginalCream or Oral Tabs • Cx + recurrence consider Q wk Tx

11. Bacterial Vaginosis • Treatment: • Metrogel 0.75% 5 gm per vag q hs x 7 • Flagyl 2 gm po x one ( NO ETOH ) • Or 500 mg po bid x 7 d • Or 250 mg po tid x 10 d • Cleocin 2 % cream 5 gm per vag q hs x 7 • Or 300 mg po bid x 7 d • Partners Tx in Europe • Consider if partner uncircumcised or recurrence

12. Trichomonas Vaginitis • Trichomonas vaginalis • Sexually Transmitted Disease • Anaerobic parasite-flagellate protozoan • Highly contagious: • 70 % ♂ infected w/ one exposure • > 90 % for ♀ • Co-infection w/ BV VERY COMMON • > 60 % ♀ have both BV & Trich

13. Trichomonas Vaginitis • Profuse, purulent, puritic, malodorous • Secretions exiting vagina • Diagnosis: pH >5, motile Trichomonads • “strawberry” cervix • ?clue cells & Whiff test + only if co-infection • Treatment: Oral Metronidazole • 500 mg bid x 7 d pt & partner • Not vaginal Tx for female

14. Trichomonas

15. Vulvovaginal Candidiasis • C. albicans, glabrata, tropicalis • > 90% C. albicans (decreasing??) • 75 % of women once • 45 % of women 2x / year • Possibly occurs after antibx use • Increased in pregnancy & DM

16. Vulvovaginal Candidiasis Diagnosis • Discharge: • watery & grey - - - “cottage cheese” • Vulvar erythema & edema • dysparunia, burning, pruitis • pH< 4.5 whiff test negative • budding yeast or pseudohyphae • ”Can be diagnosed presumptively” • ONLY WITH CLINICAL EXPERIENCE • NOT over telephone

17. Candidiasis

18. Vulvovaginal Candidiasis • Treatment: • Oral fluconazole • Diflucan 150 mg po x 1 • (?generic less effective -> QOD x 2) • +/- 1 % cortisone or antihistamine • Vaginal azole Creams & Ointments • All work better than nystatin • 7 day better than 3 day • One day ointment only • Similar Cure Rates, but ? Sx relief (add anti-histamine)

19. Recurrent Vulvovaginal Candidiasis • Must be confirmed with C & S • Treatment: • Oral fluconazole • Diflucan 200 mg po Q O D x 3 dose • Consider Tx each month • Vaginal azole Creams • For additional sx relief

20. Inflammatory Vaginitis • More Recently described vaginitis • Least Common Vag Infection • Difficult Dx

21. Inflammatory Vaginitis • Complaints can mimic any vaginitis • Usually profuse d/c • Discharge irritates vulva • Usually before menses • Often recurrent every month • More Common in Menopause • Relapse > 30 % • More common in menopause

22. Inflammatory Vaginitis • Diagnosis • Microscopy: • Absence of lactobacilli • Many gram + cocci (usually strep) • Many WBC’s

23. Inflammatory Vaginitis • Treatment • Augmentin 250 mg po tid x 14 days • Will not cause yeast infection if correct dx • Clindamycin 2 % cream x 7 days for PCN allergy • Relapse – retreatment • 14 days vaginal cream • 21 days oral antibx • Add estrogen cream if menopausal • Consider Tx partner especially if uncircumcised

24. Desquamative Vaginitis • Usually only in Menopausal Pt • Recurrent Discharge • Negative Wet Prep • Lack of Lactobacilli • Many parabasal and basal cells • Difficult diagnosis

25. Desquamative Vaginitis • Treatment • 10% Hydocortisone cream • 3cc Q week for 4, 12 or 26 weeks • Relapse – retreatment • Consider Referral: Dr Jack Sobol

26. Pelvic Inflammatory Disease

27. Acute Pelvic Infections • Acute Cervicitis • Acute Endometritis • Acute Salpingitis • Tubo-Ovarian Abscess • Pyosalpinx • Peritonitis • Upper genital tract infections are USUALLY polymicrobial • May be culture negative, even from tube or peritoneal cavity

28. Acute Pelvic Infections • Sexually Transmitted Diseases: • Trich • Gonorrhoeae • Clamydia • Syphillis • Herpes • Condylomata / HPV • ? Molluscum Contagiosum • Chancroid • Lymphogranuloma Venereum LGV

29. Acute Pelvic Infections • Neisseria gonorrhoeae • Chlamydia trachomatis • Mucopurulent vaginal d/c • Index of Suspicion • New partner • Deep Dyspareunia

30. Acute Pelvic Infections • Neisseria gonorrhoeae • Chlamydia trachomatis • Polymicrobial Ascending Infection • Classic Triad: Pain, CMT & fever • Unreliable for Dx • All pt w/ CMT need Cervix Cx • Consider empiric Tx for GC & Clamydia

31. Acute Pelvic Infections • Classic Triad of pain, CMT & fever • Unreliable for Dx • Any pt w/ CMT needs Cervix Cx • Presumptive infection w/ GC & Clamydia • Empiric Tx for GC & Clamydia • Rocephin 250 mg IM with • Azithromycin 2 gm x 1 • For pt & partner

32. Acute Pelvic Infections • Classic Triad of pain, CMT & fever • If febrile, needs U/S • If + TOA, needs hospitalization • If persistent, needs laparoscopy • Drainage and / or resection

33. Syphillis - Treponema pallidum • Highly infectious – passes intact skin • Chancre • Indurated Nonpainful ulcer w/o nodes • Condyloma lata • + RPR, FTA abs • Primary • Secondary • Latent • Tertiary

34. Syphillis • Primary • Chancre evolves & heals 4 – 8 weeks • Indurated Nonpainful ulcer • at site of innoculation • Hands, Feet, Mouth & Genitals • Usually minimum sx--Often ignored • And resolves spontaneously!!! • ? Painless Groin Nodes

35. Syphillis -- Chancre

36. Syphillis • Secondary • Skin rashes appear 6 – 12 weeks • Florid 3 – 4 months • Most w/ general adenopathy • Mild malaise • Condylomata lata • Possible at all chancre sites & mucosa • Extremely Infectious

37. Syphillis • Condyloma lata

38. Syphillis • Tertiary • Benign Late Dz starts 3 – 10 years • Gumma = granulomata (like TB) • Skin Bone Viscera CV & Neuro • Dementia • Gumma usually indolent • Requires prolonged Tx

39. Syphillis • Latent • Infected & Infectious • Without Signs • Except + Serology • Usually < 2 years after infected • May last only months and progress • Others may remain latent for rest of life

40. Syphillis • Treatment • Primary • Benzathine penicillin G, 2.4 million units IM • Secondary & Early Latent • Benzathine penicillin G, 7.2 million units IM • As weekly 2.4 Million units IM • Surveillance • FTA abs @ 1, 3, 6 & 12 months • Until no reaction found • Until 24 months for Latent and after for Tertiary

41. Syphillis • Treatment • Jarisch-Herxheimer reaction • Acute febrile illness • Seen in 50 % of Primary & Early Secondary • < 12 hr after Tx w/ PCN • Malaise, Sweats, Headache, Rigors • Subsides in < 24 hr

42. Herpes Simplex • Diagnosis is CLINICAL • Grouped vesicles • Become small ulcers • yellow bases w/ erythematous rims • Scab over, entire course 14 – 21 days • Primary outbreak • c/o “UTI” • Secondary outbreak • Less bothersome • Culture or antigen test for HSV • Most adults + for anti-HSV Ig G in serum

43. HSV

44. Herpes Simplex • Treatment (7-14 d) Supression • Acyclovir (Zovirax) • 200 mg 5 x / day 400 mg bid • Valcyclovir (Valtrex) • 500 -1000 mg bid 500 mg Q D • Famciclovir (Famvir) • 125 – 250 mg tid 250 mg bid

45. Herpes Simplex • Treatment • Topical EFFECTIVE Tx (and soothing!) • peniciclovir 1 % ointment (Denivir) • acyclovir (Zovirax) (cheap!) • Apply Q 2 h while awake x 4 days

46. Chancroid - Haemophilis ducreyi • Previously rare, even exotic, in USA • 1-3 extremely painful ragged ulcers • Start as small papules, may coalesce • tender inguinal nodes differentiates • May be matted, fluctuant, even bubonic • Associated w/ HIV infection • Incubation 3 – 7 days • Culture

47. Chancroid

48. Chancroid • Treatment • Azythromycin 1g po • Ceftriaxone 250 mg im • Erythromycin 500 mg po qid x 7 days • Buboes drained, not excised • Follow Up STD testing essential • Including RPR & HIV

49. Lymphogranuloma Venereum LGV • Mostly found in tropical & subtropic • Caused by different Clamydia species • Genital ulcer forms & heals < 2 weeks • May pass unnoticed • Rapidly followed by painful buboes in groin • Tough to miss, even for the patient! • Fever, Malaise, Headache, N & V

50. Lymphogranuloma Venereum LGV • Treatment FOR 21 DAYS • Doxycycline 100 mg bid • Erythromycin 500 mg po qid • Tetracycline 500 mg po qid • Buboes drained, not excised • Fistulae & Abscesses req surgery • Follow Up for 6 months