Lower and Upper Genital Tract Infections
Lower and Upper Genital Tract Infections
Lower and Upper Genital Tract Infections
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OUTLINE
INFECTIONS OF THE VULVA
Acute Bacterial Cystitis Infections of Bartholins Glands Pediculosis Pubis and Scabies Molluscum Contagiosum
Condyloma Acuminatum
Genital Ulcers
Genital Herpes Granuloma Inguinale (Donovanosis) Lymphogranuloma Venereum Chancroid Syphilis
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VAGINITIS
Candida Vaginitis
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Etiologic agent
Diagnostic work up Management of first episode acute uncomplicated cystitis Management of recurrent cystitis
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BARTHOLINS ABSCESS
HOMEWORK Causes of Bartholins gland enlargement Diagnosis and differentials of Bartholins gland cyst Diagnosing Bartholins gland abscess
PEDICULOSIS PUBIS
Crab louse or pubic louse Phthirus pubis
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PEDICULOSIS PUBIS
Transmitted by direct sexual contact
Non-sexual transmission also documented
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PEDICULOSIS PUBIS
Diagnosis
Examination of the vulvar area without magnification demonstrates eggs and adult lice, and pepper grain feces adjacent to the hair shaft Definitive diagnosis: microscopy (obtain specimen by scratching the skin papule with a needle and placing the crust under a drop of mineral oil)
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Microscopy
Adult louse and nit containing larvae
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PEDICULOSIS PUBIS
Treatment: kill both the adult parasite and eggs
Permethrin 1% cream rinse (Nix crme) applied to affected areas and washed off after ten minutes Lindane 1% shampoo(Kwell)applied for 4 minutes then washed off Pyrethrins with piperonyl butoxide
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SCABIES
Parasitic infection of the itch mite Sarcoptes scabiei Transmitted by close contact Infection is widespread over the body without a predilection for hairy areas
the mite travels rapidly over the skin and may move up to 2.5 cm in 1 minute.
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SCABIES
Predominant clinical symptom: severe but intermittent itching; pruritus is more intense at night papules, vesicles or burrows Burrows pathognomonic sign of scabies infection; appears as a twisted line on the skin surface, with a small vesicle at one end May involve the hands, wrists, breasts, vulva, and buttocks
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SCABIES
Note the burrows Laboratory work up: microscopy using scratch technique; mites lack lateral claw legs but have 2 triangular hairy buds Differential diagnosis: virtually all dermatologic diseases causing pruritus
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Microscopy
Adult mite
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SCABIES
Treatment: kill both the adult parasite and the eggs
Permethrin cream 5% applied to all areas of the body from the neck down and washed off after814 hours Ivermectin 02 mg/kg orally, repeated in 2 weeks if necessary
Lindane 1% 1 oz of lotion or 30g of cream applied thinly to all areas of the body from the neck down and thoroughly washed after 8 hours.
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Etiologic Agent
Phthirus pubis
Sarcoptes scabiei
Site of Infection
Non-hairy areas
Movement
Slow
Rapid
Lesions
S/Sx
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MOLLUSCUM CONTAGIOSUM
Pox virus Chronic localized infection Spread by skin to skin contact, autoinoculation or by fomites Widespread infection closely related to underlying cellular immunodeficiency (HIV infection, chemotherapy or corticosteroid administration)
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MOLLUSCUM CONTAGIOSUM
Characteristic appearance of lesion: fleshcolored small nodules or domed papules usually 1-5 mm in diameter with umbilicated center
Complication - superinfection
Diagnosis:
Microscopy of the white waxy material from inside the nodule: intracytoplasmic molluscum bodies with Wright or Giemsa stain Clinical
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MOLLUSCUM CONTAGIOSUM
Treatment
Self-limiting infection Individual papules
injection of local anesthetic evacuation of caseous material excision of nodule with a sharp dermal curette base of the papule chemically treated with ferric subsulfate (Monsel solution) or 85% TCA
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CONDYLOMA ACUMINATUM
Genital, venereal, or anogenital warts
Most common viral STD of the vulva, vagina, rectum and cervix caused by Human Papilloma Virus (HPV virus) 30% of infected women - clinically recognizable macroscopic lesion
70% - unrecognized subclinical infection
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CONDYLOMA ACUMINATUM
Sexual transmission
Autoinoculation
Conditions that predispose women to HPV infection: Immunosuppression, Diabetes, pregnancy, local trauma Signs & symptoms: Asymptomatic Pain, itching, tendency to bleed when friable, (+) odor when secondarily infected
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HPV Type 6, 11 40, 42, 53, 54, 57, 66, 84 16, 18, 31, 33, 35, 39 45, 51, 52, 56, 58, 59 68, 73, 82 61, 62, 67, 69, 70
High
Uncertain
HPV 16 & 18 aneuploid, premalignant and malignant lesions HPV 6 & 11 benign, euploidus intraepithelial lesion; LSIL, low-grade squamous intraepithelial lesion;
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Male Partner
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CONDYLOMA ACUMINATUM
Diagnosis:
Direct inspection Biopsy:
When lesions do not respond to standard therapy
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Microscopy:
Biopsy - koilocytes
Koilocytes
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CONDYLOMA ACUMINATUM
Management:
Depends on the location, size, and extent of the condyloma and whether the woman is pregnant
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Dose
Bid for 3 days, 4 days Daily and qhs, 3 off up to 4 cycles times/week up to 16 weeks, wash 610 min after Rx Antimitotic Immune enhancer Mild to moderate pain, Mild to moderate local local irritation inflammation NO NO
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Treatment of Warts: Provider-Administered Trichloroacetic Podophyllin Resin Acid (TCA) Weekly, frosting
Cryotherapy Dose
Weekly every 12 Weekly weeks (no cryoprobe in vagina) Thermal-induced cytolysis Pain, necrosis + blistering OK Antimitotic
Mode of action
Side effects
Local irritation
Pregnancy
MMWR 55(RR-11), 2006.
NO
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GENITAL ULCERS
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Herpes
27 days Vesicle Multiple, may coalesce 12
Chancroid
114 days Papule or pustule
LGV
3 days6 weeks Papule, pustule, or vesicle
Donovanosis
14 weeks (up to 6 months) Papule Variable
515
Depth
Base Induration Pain Lymphadenopathy
Excavated
Purulent Soft Usually very tender
Superficial or deep
Variable
Elevated
Red and rough (beefy)
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GENITAL HERPES
Recurrent, incurable, highly contagious and one of the most frequently encountered STD Transmitted by asymptomatic shedding Not a debilitating physical disease, but may present an overwhelming psychological burden
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GENITAL HERPES
HERPES SIMPLEX VIRUS
TYPE 1 infection above the waist but may cause LGT infections; most commonly acquired genital herpes in women younger than 25; does not protect against HSV-2 TYPE 2 infection below the waist; offers some protection against HSV-1
GENITAL HERPES
Signs & Symptoms of Primary Infection:
Paresthesia of the vulvar skin Papule and vesicle formation
Multiple vesicles become shallow then develop as superficial ulcers over a large area of the vulva
Severe vulvar pain, tenderness and inguinal adenopathy General malaise and fever
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GENITAL HERPES
Recurrences
Related to the onset of menstrual period or emotional stress
May be asymptomatic; most are half as severe as primary infection Prodrome: sacroneuralgia, vulvar burning, tenderness and pruritus vor a few hours to 5 days before vesicle formation HSV resides in a latent phase in the dorsal root ganglia of S2, S3 and S4
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GENITAL HERPES
Diagnosis:
Clinical inspection
Prevention: vaccine
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Male Partner
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Microscopy:
Tzanck
Electron microphotograph
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Antiviral Treatment for HSV-Nonpregnant Patient Indication First clinical episode Recurrent episodes Valacyclovir Acyclovir Famciclovir
GENITAL HERPES
1000 mg bid for 7 200 mg five times a 250 mg tid for 710 10 days day or 400 mg tid days for 710 days 1000 mg daily or 500 mg bid for 5 days (or 3 days) 500 mg daily (8 recurrences per year) or 1000 mg/day or 250 mg bid (>9 recurrences/year) 400 mg tid for 5 125 mg bid for 5 days or 800 mg bid days 1000 mg bid for 5 days or 800 for 1 day mg tid for 3 days 400 mg bid 250 mg bid
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GRANULOMA INGUINALE
Initially appears as asymptomatic nodule which ulcerates (beefy-red ulcer with fresh granulation tissue), coalesce and if untreated eventually destroy the normal vulvar architecture
Subcutaneous involvement- pseudobubo
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GRANULOMA INGUINALE
(DONOVANOSIS)
Diagnosis: Donovan bodies (clusters of dark-staining bacteria with a bipolar or safety-pin appearance) in smears and specimen taken from the ulcers; special Silver stain is used to identify the Donovan bodies
Differential Diagnosis: Lymphogranuloma venereum, vulvar carcinoma, Syphilis, chancroid, genital herpes, amebiasis
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Minimum treatment duration three weeks and until lesions have completely healed
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LGV-Three Phases
Primary infection shallow painless ulcer of the vestibule or labia, resolves spontaneously
Secondary infection painful adenopathy in inguinal and perirectal areas when untreated becomes enlarged, tender and matted Groove sign
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extensive destruction of the external genitalia and anorectal region leading to secondary extensive scarring elephantiasis, multiple fistulas, stricture formation of the anal canal and rectum
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Alternative:
Azithromycin 1g oraly 1x per week for 3 weks Erythromycin base 500 mg4x daily for 21 days
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CHANCROID
Sexually transmitted, acute, ulcerative disease of the vulva painful and tender ulcer Tender suppurative inguinal adenopathy (buboes) Genital ulcers of chancroid facilitate the transmission of HIV infection
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CHANCROID
Haemophilus ducreyi highly contagious small gram-negative rod non-motile, facultative anaerobe Tissue trauma or excoriation must precede initial infection since H. Ducreyi is unable to penetrate and invade normal skin
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Chancroid: Diagnosis
Gram stain
school of fish
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CHANCROID
Treatment:
Azithromycin 1 gm orally Ceftriaxone 250 mg IM in a single dose
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SYPHILIS
Chronic complex systemic disease cause by Treponema pallidum T. pallidum- anaerobic, elongated, tightly wound spirochete; can penetrate the skin or mucous membrane Patients are contagious during the primary, secondary and probably the 1st year of latent syphilis
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Microscopy:
Darkfield - thin, silvery spiral motile organism
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SYPHILIS Transmission is by sexual contact, or by kissing or touching a person who has an active lesion on the lips, oral cavity, breast or genitals. Case transmission can occur with oralgenital contact.
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SYPHILIS
Diagnosis:
VDRL( Venereal Disease Research Laboratories) or RPR (Rapid Plasma Reagin)
Screening test Index for response to treatment
SYPHILIS
Primary Syphilis
Solitary, painless ulcer (chancre); heals spontaneously
Secondary
Result of hematogenous dissemination of the spirochetes and is a systemic disease Rashes red macules and papules over the palms of the hands and the soles of the feet Vulvar lesions mucous patches and condyloma latum associated with painless adenopathy
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SYPHILIS
Latent Stage
Follows secondary stage Positive serology without symptoms or signs of her disease
Tertiary
Potentially destructive effects on the central nervous, cardiovascular, and musculoskeletal systems
Late syphilis: optic atrophy, tabes dorsalis, generalized paresis, aortic aneurysm, gummas (similar to a cold abscess with a necrotic center and the obliteration of small vessels by endarteritis) of the skin and bones
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Primary Syphilis
Small ulcerated lesion on the labia majora Q-tip probing - hard, non-tender ulcer base Non-tender nodulations in the inguinal areas
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Male partner
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Secondary stage
Hyperpigmented skin eruptions-pink to dull coppery-red
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Secondary stage
Condylomata lata - pale brown or pale pinky gray 5-20 mm diameter
Slightly raised surface, flat, clean, moist from exudates
Highly infectious
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Tertiary Syphilis
Gumma: area of tissue necrosis resulting to ischemia caused by endarteritis and surrounded by granulation tissue
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SYPHILIS
Treatment:
Primary, Secondary and Early Latent Phase
Benzathine Penicillin G, 2.4 million units IM Penicillin Allergy / non-pregnant Doxycycline 100 mg twice daily x 14 days or Ceftriaxone 1 gm IM/IV daily x 8-10 days (limited) or Azithromycin 2 gm single oral dose (preliminary data)
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SYPHILIS
Latent Phase
Benzathine penicillin G 2.4 million units IM at one week intervals x 3 doses Penicillin allergy / non-pregnant Doxycycline 100 mg orally twice daily Tetracycline 500 mg orally four times daily
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SYPHILIS
Neurosyphilis
Aqueous crystalline penicillin G, 18-24 million units administered 3-4 million units IV every 4 hours for 10-14 days Alternative regimen Procaine penicillin 2.4 million units IM daily plus probenecid 500 mg po 4 x daily for 10-14 days
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SYPHILIS
Some experts administer benzathine penicillin 2.4 million units IM wkly x 3 after completion of these regimens to provide comparable duration of treatment with latent syphilis
Management of Sex Partners
Sexual partners of women with syphilis at any stage should be evaluated both clinically and serologically
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SYPHILIS
Management of Sex Partners
Time intervals used to identify an at-risk sex partner are:
3 months plus duration of symptoms for primary sy 3 months plus duration of symptoms for secondary sy 1 year for early latent syphilis
Individuals who are exposed within the 90 days preceding the diagnosis of primary, secondary, or early latent syphilis in their sexual partners should be treated presumptively because they may be infected even if seronegative
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VAGINITIS
Normal physiologic vaginal discharge:
cervical and vaginal epithelial cells, normal bacterial flora, water, electrolytes, other chemicals pH 4.0 Lactobacilli, S. epidermidis, E.coli, diphtheroids, streptococci
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VAGINITIS
Three common infections infections of the vagina are produced by: Fungus (candidiasis) Protozoon (trichomonas) Synergistic bacterial infection (bacterial vaginosis) Symptoms associated with vaginal infection: Vaginal discharge, superficial dyspareunia, dysuria, odor, vulvar burning
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pH
Wet Mount
Comment
Increased odor
Amine odor after adding potassium hydroxide to wet mount Thick, curdy discharge <4.5 Hyphae or spores
Greatly increased cocci, bacilli small curved rods Can be mixed infection with bacterial vaginosis, T. vaginalis, or both, and have higher pH
Candidiasis
Pruritus
Dysuria Burning Trichomoniasis[] Increased discharge (yellow, frothy) Increased odor Pruritus Dysuria JTC2007
Vaginal erythema
Motile trichomonads
BACTERIAL VAGINOSIS
Reflects a shift in vaginal flora from lactobacilli-dominant to mixed flora (genital microplasmas, G.vaginalis, and anaerobes, such as peptostreptococci, and Prevotella, and Mobiluncus species)
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BACTERIAL VAGINOSIS
Risk factors New or multiple sexual partners Women who have sex with women Douching at least monthly or within the prior 7 days Social stressors Associated with Upper tract infections (endomyometritis, PID) Vaginal cuff cellulitis In pregnancy preterm rupture of the membranes and endomyometritis; decreased success of IVF and increased pregnancy loss <20 weeks gestation
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BACTERIAL VAGINOSIS
Criteria: Amsels Clinical Criteria
Homogenous vaginal discharge pH 4.5 Amine-like odor when mixed with KOH (whiff test) Wet smear demonstrates clue cells greater in number than 20% of the of vaginal epithelial cells *** 3 out of 4 criteria is sufficient for diagnosis
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Clue cells
Microscopy:
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0 1 2 3 4
Nugent evaluation of Gram's stained vaginal smears A, Normal smear; score 0. B, Normal smear; score 2. C, Intermediate smear; score 4. D, Intermediate smear; score 6. E, Bacterial vaginosis smear; score 8. F, Bacterial vaginosis smear; score 10. (Nugent RP, Krohn MA, Hillier SL: Reliability of diagnosing bacterial vaginosis is improved by a standardized method of Gram stain interpretation. J Clin Microbiol 1991, 9:297-301.)
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BACTERIAL VAGINOSIS
Treatment:
Metronidazole 500 mg twice daily for 7 days Metronidazole gel 0.75%, 5 g intravaginally once daily for 5 days Clindamycin cream 5%, 5 g intravaginally qhs for 7 days
Alternative regimen
Clindamycin 300 mg BID daily for 7 days Clindamycin ovules 100 g intravaginally at HS for 3 days
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dysuria
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Diagnosis:
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Alternative regimen
Metronidazole 500 mg twice a day for 7 days
Pregnancy
Metronidazole 2 gm orally in a single dose
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CANDIDA VAGINITIS
Produced by a ubiquitous, airborne, grampositive fungus (Candida albicans, C.glabrata, C.tropicalis)
commensal saprophytic organisms on the mucosal surface of the vagina, which become opportunistic when the vaginal ecosystem is disturbed.
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CANDIDA VAGINITIS
Predisposing factors:
Hormonal Menstrual period Pregnancy Depressed cell-mediated immunity AIDS Diabetes mellitus, obesity and debilitating disease Antibiotic use Broad spectrum antibiotics (penicillin, tetracycline, cephalosporins)
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CANDIDA VAGINITIS
Classification:
Uncomplicated: Sporadic, infrequent, Mild-tomoderate, Likely C albicans Complicated or Recurrent: Severe, Non-albicans, DM, Pregnancy, Immunosuppression
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Male Partner
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CANDIDA VAGINITIS
Diagnosis:
KOH (10-20%) smear filamentous forms, mycelia, hyphae, pseudohyphae Culture with Nickerson or Saboraud medium (useful when KOH smear is negative or when a woman has recently treated herself with an antifungal)
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Microscopy
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CANDIDA VAGINITIS
Treatment:
Intravaginal regimens
Butoconazole, clotrimazole, miconazole, nystatin, tioconazole, terconazole
Oral regimen
Fluconazole 150 mg in a single dose
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Disease
Drug
Dose
Bacterial vaginosis
Metronidazole (Flagyl)
0.75% Metronidazole gel (Metrogel) 2% Clindamycin cream (Cleocin vaginal) 2% Extended-release clindamycin cream (Clindesse)
Vulvovaginal candidiasis uncomplicated Intravaginal therapy Azoles 2% Butoconazole cream (Mycelex-3) 2% Sustained-release butoconazole cream (Gynazole) 1% Clotrimazole cream (Mycelex-7) Clotrimazole (Gyne-Lotrimin 3) 5 g per day for 4 days One 5-g dose 5 g for 714 day Two 100-mg vaginal tablets per day for 3 days One 500-mg vaginal tablet 5 g per day for 7 days One 100-mg vaginal suppository per day for 7 days One 200-mg vaginal suppository per day for 3 days
2% Miconazole cream Miconazole (Monistat-7) Miconazole (Monistat-3) Miconazole (Monistat-1) 6.5% Tioconazole oinment (Monistat 1-day) 0.4% Terconazole cream (Terazol 7) 0.8% Terconazole cream (Terazol 3) Terconazole vaginal Nystatin vaginal Oral therapy Intravaginal therapy Oral therapy[] Trichomoniasis Fluconazole (Diflucan) Azole Fluconazole (Diflucan) Metronidazole (Flagyl)
One 5-g dose 5 g per day for 7 days 5 g per day for 3 days One 80-mg vaginal suppository per day for 3 days One 100,000-U vaginal tablet per day for 14 days One 150-mg dose orally 714 days Two 150-mg doses orally 72 hr apart One 2-g dose orally 500 mg orally twice daily for 7 days
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Tinidazole (Tindamax)
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CERVICITIS
Inflammatory process associated with trauma, inflammatory systemic disease, neoplasia, and infection Ectocervicitis or endocervicitis Ectocervicitis - viral (HSV) or from a severe vaginitis (e.g., strawberry cervix associated with T. vaginalis infection) or C. albicans Endocervicitis - C. trachomatis or N. gonorrhoeae
Bacterial vaginosis and M. genitalium have also been associated with endocervicitis
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MUCOPURULENT CERVICITIS
Criteria:
gross visualization of yellow mucopurulent material on a white cotton swab
presence of 10 or more PMN leukocytes per microscopic field (magnification 1000) on Gram-stained smears obtained from the endocervix
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MUCOPURULENT CERVICITIS
Alternative clinical criteria:
erythema and edema in an area of cervical ectopy or associated with bleeding secondary to endocervical ulceration friability when the endocervical smear is obtained
MUCOPURULENT CERVICITIS
Signs & symptoms:
hypertrophic and edematous cervix
NEISSERIA GONORRHOEAE
gram-negative diplococci - epithelium of the genitourinary tract, rectum, pharynx or the eye localized acute infection resulting to bacteremia / disseminated infection
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NEISSERIA GONORRHOEAE
Diagnosis:
Culture Gram stain Enzyme immunoassay sensitivity 50 100% Nucleic Acid Amplification test: GOLD STANDARD
sensitivity 91 100%; specificity 97 100%
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Microscopy
Gram - stained smear of the endocervical swab: gram negative intracellular diplococci
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NEISSERIA GONORRHOEAE
Treatment:
Priorities when choosing an antibiotic:
single-dose efficacy and simultaneously treating coexisting CT infection
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NEISSERIA GONORRHOEAE
Recommended Regimens (CDC 2006)
Ceftriaxone 125 mg IM in a single dose OR Cefixime 400 mg orally in a single dose OR Ciprofloxacin 500 mg orally in a single dose OR Ofloxacin 400 mg orally in a single dose OR Levofloxacin 250 mg orally in a single dose PLUS TREATMENT FOR CHLAMYDIA IF NOT RULED OUT
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NEISSERIA GONORRHOEAE
Treatment: April 2007 Cefixime 400 mg po or Ceftriaxone 125mg IM
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NESSERIA GONORRHOEAE
Alternative regimens (CDC 2006)
Spectinomycin 2 grams IM in a single dose or Ceftizoxime 500 mg IM; or Cefoxitin 2 g IM, administered with probenecid 1 g orally; or Cefotaxime 500 mg IM Single dose quinolones - Norfloxacin 800mg, Lomefloxacin 400mg, Gatifloxacin 400mg
NESSERIA GONORRHOEAE
Alternative regimens (April 2007)
Spectinomycin 2 grams IM in a single dose or Ceftizoxime 500 mg IM; or Cefoxitin 2 g IM, administered with probenecid 1 g orally; or Cefotaxime 500 mg IM Some evidence indicates that cefpodoxime 400 mg and cefuroxime axetil 1 g might be oral alternatives
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Male Partner
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GOLD STANDARD Cell culture - sensitivity 70-80% Direct fluorescent antigen (DFA)
sensitivity 90% / specificity 98%
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Microscopy
Direct immunoflourescence test - elementary bodies
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Alternative regimen:
Erythromycin base 500 mg qid for 7 days Erythromycin ethylsuccinate 800 mg qid for 7 days
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Infection in the upper genital tract not associated with pregnancy or intraperitoneal pelvic operations. Include infection of any or all of the following anatomic locations:
endometrium (endometritis) oviducts (salpingitis) most characteristic and common componenet of PID, ovary (oophoritis), uterine wall (myometritis), uterine serosa broad ligaments (parametritis)
pelvic peritoneum
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ASCENDING INFECTION
> 99% of cases result from ascending infection from the bacterial flora of the vagina and cervix
Infection occurs along the mucosal surface bacterial colonization and infection of the endometrium and fallopian tubes may extends to the surface of the ovaries and nearby peritoneum (rarely into the adjacent soft tissues, such as the broad ligament and pelvic blood vessels)
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Less than 1 % - from transperitoneal spread of infectious material from a perforated appendix or intraabdominal abscess Hematogenous and lymphatic spread to the tubes or ovaries - rare
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Polymicrobial infection
Two classic sexually transmitted organisms, N. gonorrhoeae and C. trachomatis are involved
gonococci ascends to the fallopian tube and selectively adheres to nonciliated mucus-secreting cells majority of damage occurs to the ciliated cells, ( acute complement-mediated inflammatory response with migration of polymorphonuclear leukocytes, vasodilation, and transudation of plasma into the tissues ) cell death and tissue damage
The process of repair with removal of dead cells and fibroblast scarring and tubal adhesions
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may remain in the tubes for months after initial colonization of the upper genital tract Cell-mediated immune mechanisms appear to be important in tissue destruction Primary infection appears to be self-limited with mild symptoms and little permanent damage
Antibodies to chlamydial heat shock protein severe tubal scarring and Fitz-HughCurtis syndrome
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Rate of isolation of genital mycoplasmas from the cervix is approximately 75% and similar in populations of women who are sexually active both with and without PID.
Direct tubal cultures demonstrated M. hominis in 4% to 17% and U. urealyticum in 2% to 20% of women with acute PID. Pathology is in the parametria and the tissue surrounding the tubes, not in the tubal lumen
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RISK FACTORS
RISK FACTORS
Previous tubal ligation rare and less severe
Previous PID - 25% subsequently develop another episode Transcervical penetration with instrumentation - iatrogenic
Virulence factors
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Adnexal tenderness
Plus Gram stain of endocervixpositive for gramnegative intracellular diplococci Temperature (>38 C) Leukocytosis (>10,000) Purulent material (white blood cells present) from peritoneal cavity by culdocentesis or laparoscopy Pelvic abscess or inflammatory complex on bimanual examination or on sonography
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CDC Guidelines for Diagnosis of Acute PID Clinical Criteria for Initiating Therapy
Minimum Diagnostic Criteria
Uterine tenderness or Adnexal tenderness or
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WBCs/saline microscopy
Elevated ESR Elevated CRP Cervical discharge
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MANAGEMENT OBJECTIVES
SHORT TERM- elimination of signs and symptoms and eradication of infecting organisms LONG TERM- reduction of tubal damage and preservation of fertility capacity
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Regimen B - OPD
Ceftriaxone 250 mg IM SD (or cefoxitim 2 g IM + probenecid 1 g PO SD) OR
Other parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime) PLUS Doxycycline 100 mg twice daily for 14 days WITH or WITHOUT Metronidazole 500 mg twice daily for 14 days
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ORAL REGIMEN
Ceftriaxone 250 mg IM SD (or cefoxitim 2 g IM + probenecid 1 g PO SD) Other parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime) PLUS Doxycycline 100 mg twice daily for 14 days WITH or WITHOUT Metronidazole 500 mg twice daily for 14 days
ALTERNATIVE REGIMEN
Ofloxacin 400 mg twice daily for 14 days OR Levofloxacin 500 mg once daily for 14 days WITH OR WITHOUT Metronidazole 500 mg twice daily for 14 days
Outpatient Therapy
Reexamine women within 48 to 72 hours of initiating outpatient therapy Hospitalization warranted if not responding
Reevaluate 4 to 6 weeks after therapy to assess resolution of clinical symptoms and establish post therapy baseline
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Parenteral Regimen B
Clindamycin 900 mg IV every 8 hours PLUS Gentamicin loading dose IV or IM (2 mg/kg of body weight) followed by a maintenance dose (1.5 mg/kd) every 8 hours. Single daily dosing may be substituted
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Regimen A
excellent for community-acquired infection
Doxycycline and cefoxitin provide excellent coverage for N. gonorrhoeae, C. trachomatis, and also penicillinaseproducing N. gonorrhoeae. Cefoxitin Peptococcus, Peptostreptococcus, and E. coli Disadvantage less ideal for pelvic Doxycycline should be included in the regimen of followup oral therapy (2 weeks)
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Regimen B
Excellent coverage for anaerobic infections and facultative gramnegative rods. For patients with an abscess, IUD-related infections, and pelvic infections after a diagnostic or operative procedure
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In-Patient: Reassess
After three days of treatment Continue regimen if improving With no improvement, consider
wrong diagnosis
resistant organism (e.g. enterococcus) mixed abscess, or rupture septic thrombophlebitis
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Operative Treatment
Indications:
life-threatening infections ruptured tuboovarian abscesses laparoscopic drainage of a pelvic abscess persistent masses in older women for whom future childbearing is not a consideration removal of a persistent symptomatic mass.
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Operative Treatment
Procedures:
Drainage of a cul-de-sac abscess via percutaneous drainage or a culpotomy incision Unilateral Salpingooophorectomy TAHBSO
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Short-term Sequelae
Perihepatitis (Fitz-Hugh-Curtis syndrome)
Tubo-ovarian abscess
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Long-term Sequelae
Infertility Ectopic pregnancy
10% to 15% of pregnancies will be ectopic after laparoscopically mild-to-moderate PID 50% after severe PID
Recurrent PID
approximately 25% of women
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Long-term Sequelae
Chronic pelvic pain
hydrosalpinx (end-stage of a pyosalpinx develops in a woman with normal pelvic examination 4 to 8 weeks following acute infection
PARTNER
Examine and treat sex partners
Health education
Culture discharge Empiric treatment:
Cefixime 400 mg SD or
Ceftriaxone 250 mg SD Doxycycline 100 mg BID for 7 days or
Azithromycin 1 gm SD
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Method
Behavioral Monogamy Reducing number of partners Avoiding certain sexual practices Inspecting and questioning partners Barriers Condom
Mechanism
Decreases likelihood of exposure to infected Not well studied; theoretic efficacy persons Decreases likelihood of contact with infectious agents
Protects partner from direct contact with semen, urethral discharge, or penile lesion Protects wearer from direct contact with partner's mucosal secretions
Effective in vitro barrier to chlamydiae, CMV, and HIV, partial protection HSV Appears to decrease risk of acquiring urethral/cervical GC, PID, and male urethral Ureaplasma colonization; partial HPV protection Effect on risk of acquiring NGU not established Nonvaginal use has not been studied Inactivates gonococci, syphilis spirochetes, trichomonads, HSC, ureaplasmas, and HIV in vitro. In vivo studies disappointing. 100 mg gel dose and contraceptive sponge associated with epithelial ulcers and abrasiors
Spermicide
Diaphragm/spermicide
Diaphragm alone has not been studies Appears to decrease risk of acquiring cervical GC and PID
JTC2007
Vaccines
Induce antibody response that renders Commercially available hepatitis B host immune to disease vaccine is safe and effective Results of clinical trials of gonococcal and herpes simplex vaccines ongoing Gonococcal, HIV, and HSV vaccines research in progress Effective guardravalent HPV vaccine safe and effective
Oral Antibiotics Penicillin Sulfathioazole Tetracycline analogues Kill infectious agent on or shortly after No studies among women or civilian exposure before infection is men established Appears to decrease risk of acquiring GC and hard and soft chancres, but use not recommended
Local Postcoital urination Postcoital washing Flushes infectious agents out of Poorly studied urethra and washes infectious agents of genital skin and mucous membrane Inactivates and washes infectious agents out of vagina Poorly studied. Not recommended. Increases risk of endometritis
JTC2007
PELVIC TUBERCULOSIS
HOMEWORK
Clinical features of pelvic TB Diagnostic work-up for pelvic TB Differential diagnosis PTB treatment - Directly Observed Treatment Strategy (short course) Sequelae of pelvic TB Preventive strategies
JTC2007
ACTINOMYCOSIS
HOMEWORK
Describe the etiologic agent Clinical manifestations Explain the relationship of actinomycosis with IUD use Management
JTC2007
JTC2007