Infections in OB/GYN:Infections in OB/GYN:Vaginitis, STIsVaginitis, STIs

Lisa Rahangdale, MD, MPHLisa Rahangdale, MD, MPH

Dept. of OB/GYNDept. of OB/GYN

ObjectivesObjectives Diagnose and treat a patient with vaginitisDiagnose and treat a patient with vaginitis Interpret a wet prepInterpret a wet prep Differentiate the signs and symptoms, PE findings, Differentiate the signs and symptoms, PE findings,

diagnostic evaluation of the following STI’s:diagnostic evaluation of the following STI’s: GonnorheaGonnorhea ChlamydiaChlamydia HerpesHerpes SyphillisSyphillis HPVHPV

Describe pathogenesis, signs and symptoms and Describe pathogenesis, signs and symptoms and management of PIDmanagement of PID

Vaginal Discharge DDXSVaginal Discharge DDXS

CandidiasisCandidiasis Bacterial VaginosisBacterial Vaginosis TrichomonasTrichomonas AtrophicAtrophic Physiologic (Leukorrhea)Physiologic (Leukorrhea) Mucopurulent CervicitisMucopurulent Cervicitis UncommonUncommon

Foreign BodyForeign Body Desquamative Desquamative

Vaginitis/VaginosisVaginitis/Vaginosis

Characteristics of the dischargeCharacteristics of the discharge pHpH Amine odorAmine odor Wet mount Wet mount Cultures?Cultures?

Vaginal CandidiasisVaginal Candidiasis

Part of normal floraPart of normal flora Majority Majority Candida albicansCandida albicans Predisposing factors:Predisposing factors:

DiabetesDiabetes AntibioticsAntibiotics Increased estrogen levels (preg, OCP, HRT)Increased estrogen levels (preg, OCP, HRT) ImmunosuppressionImmunosuppression ?Contraceptive devices, behaviors?Contraceptive devices, behaviors

Vaginal CandidiasisVaginal Candidiasis

S/SxS/Sx PruritisPruritis White, clumpy dischargeWhite, clumpy discharge pH 4-4.5pH 4-4.5

Dxs: KOH prepDxs: KOH prep TreatmentTreatment

Fluconazole 150 mg PO x1Fluconazole 150 mg PO x1 Topical azoles (OTC)Topical azoles (OTC)

BacterialBacterial Vaginosis Vaginosis Disruption of healthy Disruption of healthy

vaginal floravaginal flora Gardnerella, mycoplasmas,Gardnerella, mycoplasmas,

anaerobic overgrowthanaerobic overgrowth

Dxs criteria: Gram stain Dxs criteria: Gram stain OROR 3 out of 4 3 out of 4 Homogenous, thin, white d/cHomogenous, thin, white d/c ““CLUE CELLS”CLUE CELLS” Whiff test: “amine odor” when d/c mixed w/ KOH Whiff test: “amine odor” when d/c mixed w/ KOH pH >4.5pH >4.5

Bacterial VaginosisBacterial Vaginosis

BV TreatmentBV Treatment

MetronidazoleMetronidazole 500 mg BID x 7 days 500 mg BID x 7 days OROR

Metronidazole gelMetronidazole gel, 0.75%, one full , 0.75%, one full applicator (5g) PV QD x 5 days applicator (5g) PV QD x 5 days OROR

Clindamycin creamClindamycin cream, 2%, one full , 2%, one full applicator (5g) PV QHS x 7 days applicator (5g) PV QHS x 7 days

**Avoid alcohol during metronidazole use**

TrichomonasTrichomonas

Flagellate parasiteFlagellate parasite ““Strawberry”CervixStrawberry”Cervix pruritis, frothy green dischargepruritis, frothy green discharge Vag pH >4, neg KOH whiff testVag pH >4, neg KOH whiff test NaCl Microscopy: +WBCs, TrichomonadsNaCl Microscopy: +WBCs, Trichomonads Rx: Metronidazole 2 gm po X 1 Rx: Metronidazole 2 gm po X 1 Tinidazole 2 gm PO x 1Tinidazole 2 gm PO x 1

Partner txPartner tx Same doses in pregnancySame doses in pregnancy

SEXUALLY TRANSMITTED SEXUALLY TRANSMITTED DISEASESDISEASES

Causative AgentCausative Agent Method of TransmissionMethod of Transmission SymptomsSymptoms Physical SignsPhysical Signs Diagnostic MethodsDiagnostic Methods TreatmentTreatment ScreeningScreening

Neisseria gonnorheaNeisseria gonnorhea: : SymptomsSymptoms

A single encounter with an infected A single encounter with an infected partnerpartner 80-90% transmission rate 80-90% transmission rate

Arise 3-5 days after exposure Arise 3-5 days after exposure Initially so mild as to be overlookedInitially so mild as to be overlooked Malodorous, purulent vaginal discharge Malodorous, purulent vaginal discharge 15% develop acute PID15% develop acute PID

Physical DiagnosisPhysical Diagnosis

Mucopurulent discharge flowing from Mucopurulent discharge flowing from cervixcervix To be distinguished from normal thick yellow To be distinguished from normal thick yellow

white cervical mucous(adherent to white cervical mucous(adherent to ectropion)ectropion)

Cervical Motion TendernessCervical Motion Tenderness

Gonorrhea: DXSGonorrhea: DXS

Elisa or DNA specific testElisa or DNA specific test Cervical swabCervical swab Combined with ChlamydiaCombined with Chlamydia Urine testsUrine tests

Culture for legal purposes Culture for legal purposes Gram Stain for WBCs with intracellular gram Gram Stain for WBCs with intracellular gram

negative diplococcinegative diplococci

Physical DiagnosisPhysical Diagnosis

Mucopurulent discharge flowing from Mucopurulent discharge flowing from cervixcervix To be distinguished from normal thick yellow To be distinguished from normal thick yellow

white cervical mucous(adherent to white cervical mucous(adherent to ectropion)ectropion)

Cervical Motion TendernessCervical Motion Tenderness

Disseminated GCDisseminated GC

Gonococcal bacteremia (rare)Gonococcal bacteremia (rare) Pustular or petechial skin lesionsPustular or petechial skin lesions Asymetrical arthralgiaAsymetrical arthralgia TenosynovitisTenosynovitis Septic arthritisSeptic arthritis RarelyRarely

EndocarditisEndocarditis Meningitis Meningitis

Gonorrhea RxGonorrhea Rx

CeftriaxoneCeftriaxone 125 mg IM in a single dose 125 mg IM in a single dose      ORORCefiximeCefixime400 mg orally in a single dose 400 mg orally in a single dose   

      PLUSPLUS

Tx FOR CHLAMYDIA IF NOT RULED Tx FOR CHLAMYDIA IF NOT RULED OUT OUT

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

Chlamydia trachomatisChlamydia trachomatis

C. trachomatisC. trachomatis Obligate intracellular Obligate intracellular

pathogenpathogen No cell wall, not No cell wall, not

susceptible to susceptible to penicillinspenicillins

Difficult to cultureDifficult to culture

Chlamydia DiagnosisChlamydia Diagnosis

Usually asymptomaticUsually asymptomatic Best to screen susceptible young womenBest to screen susceptible young women Mucopurulent cervicitisMucopurulent cervicitis Intermenstrual bleedingIntermenstrual bleeding Friable cervixFriable cervix Postcoital bleedingPostcoital bleeding

Elisa or DNA probeElisa or DNA probe

Chlamydia RxChlamydia Rx

Uncomplicated cervicitis (no PID)Uncomplicated cervicitis (no PID) Azithromycin 1 gm po Azithromycin 1 gm po

OROR

Doxycycline 100 mg BID for 7 daysDoxycycline 100 mg BID for 7 days

Repeat testing in 3 monsRepeat testing in 3 mons Annual screen in age Annual screen in age << 25 25

Chlamydia in PregnancyChlamydia in Pregnancy

AzithromycinAzithromycin 1 g orally in a single dose 1 g orally in a single dose OROR AmoxicillinAmoxicillin 500 mg orally three times a 500 mg orally three times a day for 7 days day for 7 days

(2006 - Poor efficacy of erythromycin – now alternative regimen)(2006 - Poor efficacy of erythromycin – now alternative regimen)

Test of cure in 3 weeksTest of cure in 3 weeks

Pelvic Inflammatory Pelvic Inflammatory DiseaseDisease

PolymicrobialPolymicrobial Initiated by GC, Chlamydia, MycoplasmasInitiated by GC, Chlamydia, Mycoplasmas Overgrowth by anaerobic bacteria, GNRsOvergrowth by anaerobic bacteria, GNRs

and other vaginal flora (Strep, Peptostrep)and other vaginal flora (Strep, Peptostrep) Bacterial Vaginosis - associated with PIDBacterial Vaginosis - associated with PID

PID SymptomsPID Symptoms

Acute or chronic abdominal/pelvic painAcute or chronic abdominal/pelvic pain Deep DyspareuniaDeep Dyspareunia

Fever and ChillsFever and Chills Nausea and VomitingNausea and Vomiting Epigastric or RUQ pain (perihepatitis)Epigastric or RUQ pain (perihepatitis)

PID Physical DiagnosisPID Physical Diagnosis

Minimum criteria: Minimum criteria: oneone or more of the following- or more of the following- Uterine Tenderness Uterine Tenderness Cervical Motion Tenderness Cervical Motion Tenderness Adnexal TendernessAdnexal Tenderness

Additional support:Additional support: Fever > 101/38.4Fever > 101/38.4 Mucopurulent DischargeMucopurulent Discharge Abdominal tenderness +/- reboundAbdominal tenderness +/- rebound Adnexal fullness or massAdnexal fullness or mass

Hydrosalpinx or TOAHydrosalpinx or TOA

PID Diagnostic TestsPID Diagnostic Tests

WBC may be elevated, *often WNLWBC may be elevated, *often WNL ESR >40, Elevated CRP-neither reliableESR >40, Elevated CRP-neither reliable UltrasoundUltrasound

Hydrosalpinx or a TuboOvarian Complex Hydrosalpinx or a TuboOvarian Complex due to Adhesions are to be distinguished due to Adhesions are to be distinguished from TuboOvarian Abcessfrom TuboOvarian Abcess

Fluid in Culdesac nonspecificFluid in Culdesac nonspecific Fluid in Morrison’s Pouch is suggestive if Fluid in Morrison’s Pouch is suggestive if

associated with epigastric/RUQ painassociated with epigastric/RUQ pain

PID TreatmentPID Treatment Needs to incorporate Rx of GC and Needs to incorporate Rx of GC and

Chlamydia (tests pending)Chlamydia (tests pending) OutpatientOutpatient

Ceftriaxone 250mg IM + Doxycycline x 14 d Ceftriaxone 250mg IM + Doxycycline x 14 d w/ or w/out Metronidazole 500mg bid x 14 dw/ or w/out Metronidazole 500mg bid x 14 d

Levofloxacin 500 mg QD or Ofloxacin 400 Levofloxacin 500 mg QD or Ofloxacin 400 mg BID + Metronidazole x14 days mg BID + Metronidazole x14 days

(No Quinolone unless allergy)(No Quinolone unless allergy) Regimens:http://www.cdc.gov/std/treatment/Regimens:http://www.cdc.gov/std/treatment/2006/pid.htm2006/pid.htm

PID Inpatient RxPID Inpatient Rx

Criteria (2006 CDC STD guidelines)Criteria (2006 CDC STD guidelines) Peritoneal signsPeritoneal signs Surgical emergencies not excluded (appy)Surgical emergencies not excluded (appy) Unable to tolerate/comply with oral RxUnable to tolerate/comply with oral Rx Failed OP txFailed OP tx Nausea, Vomiting, High FeverNausea, Vomiting, High Fever TuboOvarian AbcessTuboOvarian Abcess PregnancyPregnancy

PID Inpatient RxPID Inpatient Rx

Cefoxitin 2 gm IV q 6 hrCefoxitin 2 gm IV q 6 hr OR Cefotetan 2 gm q 12 hrOR Cefotetan 2 gm q 12 hr

PlusPlus Doxycycline 100mg IV or po q 12 hrDoxycycline 100mg IV or po q 12 hr For maximal anaerobic For maximal anaerobic

coverage/penetration of TOA:coverage/penetration of TOA: Clindamycin 900mg q 8 hr andClindamycin 900mg q 8 hr and Gentamycin 2 mg/kg then 1.5mg/kg q 8 hrGentamycin 2 mg/kg then 1.5mg/kg q 8 hr

PID SequelaePID Sequelae

Pelvic AdhesionsPelvic Adhesions chronic pelvic pain, chronic pelvic pain,

dyspareuniadyspareunia infertilityinfertility ectopic pregnancyectopic pregnancy

Empiric Treatment Empiric Treatment Suspected Chlamydia, GC Suspected Chlamydia, GC

or PIDor PID Deemed valuable in Deemed valuable in

preventing sequelaepreventing sequelae

Recommended ScreeningRecommended Screening

GC/Chlamydia: GC/Chlamydia: women < 25 (**remember urine testing!)women < 25 (**remember urine testing!) PregnancyPregnancy

SyphilisSyphilis PregnancyPregnancy

HIV HIV age 13-64, (? Screening time interval)age 13-64, (? Screening time interval)

One STD, consider screening for othersOne STD, consider screening for others PE, Wet mounts, PAP, GC/CT, VDRL, HIVPE, Wet mounts, PAP, GC/CT, VDRL, HIV

24 yo G 0 lesion on 24 yo G 0 lesion on vulvavulva

HPIHPI Pertinent review of systemsPertinent review of systems Focused examFocused exam LaboratoryLaboratory TreatmentTreatment Counseling re partnerCounseling re partner

Genital UlcersGenital Ulcers

SyphilisSyphilis HerpesHerpes ChanchroidChanchroid Lymphogranuloma VenereumLymphogranuloma Venereum Granuloma InguinaleGranuloma Inguinale

HerpesHerpes

Herpes Simplex Virus I and IIHerpes Simplex Virus I and II Spread by direct contact Spread by direct contact

““mucous membrane to mucous membrane”mucous membrane to mucous membrane”

Painful ulcersPainful ulcers Irregular border on erythematous baseIrregular border on erythematous base Exquisitely tender to Qtip examExquisitely tender to Qtip exam Culture, PCR low sensitivity after Day 2Culture, PCR low sensitivity after Day 2

HerpesHerpes

PrimaryPrimary Systemic symptomsSystemic symptoms Multiple lesionsMultiple lesions Urinary retentionUrinary retention

Nonprimary First EpisodeNonprimary First Episode Few lesionsFew lesions No systemic symptomsNo systemic symptoms preexisting Abpreexisting Ab

Herpes RxHerpes Rx

First EpisodeFirst Episode Acyclovir, famciclovir, valcyclovir x 7–10 Acyclovir, famciclovir, valcyclovir x 7–10

daysdays

Recurrent Episodic Rx: Recurrent Episodic Rx: In prodrome or w/in 1 day of lesion)In prodrome or w/in 1 day of lesion) 1-5 day regimens1-5 day regimens

Suppressive therapySuppressive therapy Important for last 4 weeks of pregnancyImportant for last 4 weeks of pregnancy

SyphilisSyphilis Treponema Pallidum- spirocheteTreponema Pallidum- spirochete Direct contact with chancre: cervix, vagina, Direct contact with chancre: cervix, vagina,

vulva, any mucous membranevulva, any mucous membrane Painless ulcerationPainless ulceration Reddish brown surface, depressed centerReddish brown surface, depressed center Raised indurated edgesRaised indurated edges Dx: smear for DFA, Serologic TestingDx: smear for DFA, Serologic Testing

Syphilis StagesSyphilis Stages

Clinically Manifest vs. LatentClinically Manifest vs. Latent Primary- painless ulcer Primary- painless ulcer

chancre must be present for at least 7 days for chancre must be present for at least 7 days for VDRL to be positiveVDRL to be positive

Secondary- Secondary- Rash (diffuse asymptomatic maculopapular) Rash (diffuse asymptomatic maculopapular)

lymphadenopathy, low grade fever, HA, malaise, lymphadenopathy, low grade fever, HA, malaise, 30% have mucocutaneous lesions30% have mucocutaneous lesions

Tertiary gummas develop in CNS, aortaTertiary gummas develop in CNS, aorta

Primary & Secondary Primary & Secondary SyphSyph

Latent SyphilisLatent Syphilis

Definition: Asx, found on screenDefinition: Asx, found on screen Early 1 year duration Early 1 year duration Late >1 year or unknown durationLate >1 year or unknown duration

TestingTesting Screening: VDRL, RPR- nontreponemal Screening: VDRL, RPR- nontreponemal Confirmatory: FTA, MHATP- treponemal Confirmatory: FTA, MHATP- treponemal

Syphilis TreatmentSyphilis Treatment Primary, Secondary and Early LatentPrimary, Secondary and Early Latent

Benzathine Penicillin 2.4 mU IMBenzathine Penicillin 2.4 mU IM

Tertiary, Late LatentTertiary, Late Latent Benzathine Penicillin 2.4 mU IM q week X 3Benzathine Penicillin 2.4 mU IM q week X 3 Organisms are dividing more slowly later onOrganisms are dividing more slowly later on

NeuroSyphilisNeuroSyphilis IV Pen G for 10-14 daysIV Pen G for 10-14 days

ChancroidChancroid Endemic to some areas of US, outbreaksEndemic to some areas of US, outbreaks Hemophilus DucreyiHemophilus Ducreyi Painful ulcers, tender LNsPainful ulcers, tender LNs Can aspirate a suppurative LN for DxCan aspirate a suppurative LN for Dx Coexists with HIV, HSV, SyphilisCoexists with HIV, HSV, Syphilis Culture is < 80% sensitive, PCR ?Culture is < 80% sensitive, PCR ? Rx: Azithro, Rocephin, CiproRx: Azithro, Rocephin, Cipro

Lymphogranuloma Lymphogranuloma VenereumVenereum

Chlamydia trachomatisChlamydia trachomatis Different serovarsDifferent serovars

Rare in USRare in US Brief ulcer, inflammation of perirectal Brief ulcer, inflammation of perirectal

lymphatic tissues, strictures, fistulaslymphatic tissues, strictures, fistulas Lymph nodes may require drainageLymph nodes may require drainage Dx: Serologic Testing CT serovars L1-3Dx: Serologic Testing CT serovars L1-3 Rx: Doxycycline, ErythromycinRx: Doxycycline, Erythromycin

Granuloma InguinaleGranuloma Inguinale

Outside US, TropicsOutside US, Tropics Calymmatobacterium granulomatisCalymmatobacterium granulomatis Highly Vascular, Painless progressive Highly Vascular, Painless progressive

ulcers without LADulcers without LAD Dx: Histologic ID of Donovan bodiesDx: Histologic ID of Donovan bodies Coexists with other STDs or get Coexists with other STDs or get

secondarily infected with genital florasecondarily infected with genital flora Rx: Septra, Doxycycline, Cipro, ErythroRx: Septra, Doxycycline, Cipro, Erythro

Vulvar LesionsVulvar Lesions

Human Papilloma VirusHuman Papilloma Virus Molluscum ContagiosumMolluscum Contagiosum Pediculosis PubisPediculosis Pubis ScabiesScabies

HPV – HPV – genital wartsgenital warts

Most common STDMost common STD HPV 6 and 11 – low risk typesHPV 6 and 11 – low risk types Verruccous, pink/skin colored, papillaformVerruccous, pink/skin colored, papillaform DDxs: condyloma lata, squamous cell ca, otherDDxs: condyloma lata, squamous cell ca, other Treatment:Treatment:

Chemical/physical destruction (cryo, podophyllin, 5% Chemical/physical destruction (cryo, podophyllin, 5% podofilox, TCA)podofilox, TCA)

Immune modulation (imiquimod)Immune modulation (imiquimod) ExcisionExcision LaserLaser Other: 5-FU, interferon-alpha, sinecatchinsOther: 5-FU, interferon-alpha, sinecatchins

High rate of RECURRENCEHigh rate of RECURRENCE