Fm: Vaginitis

Front 1

Case: 25-year old woman presents with a foul-smelling vaginal discharge. She has a greenish, frothy discharge and a "strawberry cervix" noted on exam.

What is the most likely organism causing this infection?

Back 1

Trichomonas vaginalis

Front 2

Case: 25-year old woman presents with a foul-smelling vaginal discharge. She has a greenish, frothy discharge and a "strawberry cervix" noted on exam.

What is the expected microscopic finding?

Back 2

Motile, flagellated trichomonads, and many WBCs

Front 3

Case: 25-year old woman presents with a foul-smelling vaginal discharge. She has a greenish, frothy discharge and a "strawberry cervix" noted on exam.

What is the recommended treatment?

Back 3

Metronidazole 2g by mouth in a single dose for both the patient and her sexual partner.

Metronidazole 500mg BID for a week is an alternative regimen.

Front 4

What are the common causes of vaginitis?

Back 4

- Candida albicans

- Trichomonas vaginalis

- Gardnerella vaginalis

Front 5

A patient with vaginitis and recent antibiotic use is most likely to have what cause?

Back 5

Candida albicans (because antibiotic may alter normal vaginal flora and allow the overgrowth of a fungal organism)

Front 6

A patient with vaginitis and diabetes mellitus is most likely to have what cause?

Back 6

Candida albicans (predisposed to yeast infections)

Front 7

A patient with vaginitis and a history of multiple sexual partners is most likely to have what cause?

Back 7

A sexually transmitted infection, such as trichomonas

Front 8

What are the typical signs/symptoms of candidal vaginitis?

Back 8

- Thick discharge

- Significant pruritus

Front 9

What are the typical signs/symptoms of bacterial vaginosis?

Back 9

- Thinner discharge

- "Fishy" odor

Front 10

What are the typical signs/symptoms of trichomonas vaginitis?

Back 10

- Frothy discharge

- Patient's cervix is frequently very erythematous

Front 11

How do you establish the cause of vaginal discharge?

Back 11

Microscopic exam of discharge

- Sample is examined as a "wet mount" (mixed with small amount of saline) and as a "KOH prep" (mixed with small amount of 10% KOH)

Front 12

What do you look for on "wet mount"?

Back 12

- Evaluate normal epithelial cells

- Look for WBCs, RBCs, clue cells, motile trichomonads

Front 13

What do you best visualize on "KOH prep"?

Back 13

Hyphae or pseudohyphae of Candida

Front 14

What is the definition of bacterial vaginosis (type of organism, pH)?

Back 14

Condition of excessive anaerobic bacteria in the vagina, leading to an alkaline discharge

Front 15

What is the definition of candida vulvovaginitis?

Back 15

Vaginal and/or vulvar infection caused by Candida species, usually with heterogenous discharge and inflammation

Front 16

What is the definition of Trichomonas vaginitis?

Back 16

Infection of the vagina caused by the protozoa Trichomonas vaginalis, usually associated with a frothy green discharge and intense inflammatory response

Front 17

How likely is a woman to have an episode of vulvovaginal candidiasis in her lifetime?

Back 17

>75%

Front 18

What are the presenting symptoms of vulvovaginal candidiasis?

Back 18

- Thick, whitish discharge

- No odor

- Significant pruritus of external and internal genitalia

Front 19

What is the appearance of patients with vulvovaginal candidiasis?

Back 19

Vaginal area can be edematous with erythema present

Front 20

What is the typical pH associated with vulvovaginal candidiasis?

Back 20

4.0 - 5.0 (normal)

Front 21

How do you diagnose vulvovaginal candidiasis?

Back 21

Confirmed by wet mount or KOH prep showing budding yeast or pseudohyphae; fungal cultures are not needed to confirm the diagnosis (but they can be useful if the infection recurs or is unresponsive to treatment)

Front 22

How should you treat a patient with vulvovaginal candidiasis?

Back 22

- Uncomplicated can be treated effectively with short-term intravaginal preps (creams or vaginal suppositories) or single-dose oral therapies (fluconazole 150 mg)

- Complicated or recurrent infections can be treated with higher doses for 10-14 days followed by 6 months of maintenance therapy to reduce chance of recurrence

Front 23

Do sexual partners need to be treated for vulvovaginal candidiasis?

Back 23

Not indicated unless symptomatic (e.g., man partners with balanitis = inflammation of glans)

Front 24

How long does trichomoniasis take to incubate prior to presentation?

Back 24

3-21 days post-exposure

Front 25

What factors can predispose to trichomoniasis?

Back 25

- Multiple sexual partners

- Pregnancy

- Menopause

Front 26

What is the presenting complaint for trichomoniasis?

Back 26

- Copious amounts of thin, frothy, green-yellow or gray discharge

- Malodorous

- May have vaginal soreness or dyspareunia

- Symptoms may start or be exacerbated during the time of their menses

Front 27

What findings might there be on vaginal exam in a woman with trichomoniasis?

Back 27

- Cervix may have a "strawberry" appearance (red and inflamed with punctations)

- May also have redness of vagina and perineum

Front 28

How do you diagnose trichomoniasis?

Back 28

Wet mount prep can demonstrate motile trichomonads, although cultures may be necessary because of significant number of false negatives

Front 29

What is the recommended treatment for trichomoniasis?

Back 29

Oral metronidazole, given in a single 2g oral dose or a 1-week regimen of 500mg BID (for both patient and partner)

Should also screen for other STIs

Front 30

What causes bacterial vaginosis?

Back 30

Normal vaginal bacteria are replaced with overgrowth of anaerobic bacteria and G vaginalis

Front 31

What is bacterial vaginosis associated with?

Back 31

Multiple sexual partners

Front 32

What are the diagnostic criteria for bacterial vaginosis?

Back 32

3 of 4 criteria:

- Thin, homogenous vaginal discharge

- Vaginal pH >4.5

- Positive KOH whiff test (fishy odor after adding 10% KOH to sample)

- Presence of clue cells on wet mount

Front 33

How do you treat bacterial vaginosis?

Back 33

Oral or topical vaginal prep of metronidazole or clindamycin; no advantage to either regimen but women do report more satisfaction with vaginal prep

No need to test / treat sexual partners

Front 34

Should you check for bacterial vaginosis in pregnant women? Why or why not?

Back 34

Treatment of BV in asymptomatic pregnant women may reduce the incidence of preterm delivery

Front 35

What is mucopurulent cervicitis?

Back 35

Infection by Chlamydia or Gonorrhea that causes purulent or mucopurulent discharge from the endocervix, may be associated with vaginal discharge and/or cervical bleeding

Front 36

How often is chlamydial infection asymptomatic?

Back 36

70% in women

Front 37

How often is gonorrheal infection asymptomatic?

Back 37

50% in women

Front 38

What is the gold standard for diagnosing chlamydia / gonorrhea?

Back 38

Culture of the cervical discharge

Front 39

How should you treat suspected chlamydia / gonorrhea infections?

Back 39

Empiric treatment should be considered in areas of high prevalence of infection or if follow-up is unlikely

Front 40

What are the treatment recommendations for gonorrhea?

Back 40

Ceftriaxone 125 mg IM

- Quinolone antibiotics (e.g., ciprofloxacin) are NO longer recommended due to resistance

Front 41

What are the treatment recommendations for chlamydia?

Back 41

Doxycycline 100 mg orally BID for 7 days OR

Azithromycin in single 1g oral dose when compliance is a concern

Recommended to treat sexual partners

Front 42

What is pelvic inflammatory disease (PID)?

Back 42

Inflammation of the upper genital tract, including pelvic peritonitis, endometritis, salpingitis, and tuboovarian abscess caused by infection with gonorrhea, chlamydia, or vagina/bowel flora

Front 43

How do you diagnose pelvic inflammatory disease (PID)?

Back 43

- Lower abdominal tenderness +

- Adnexal tenderness +

- Cervical motion tenderness

Without other explanation of illness is enough to diagnose PID

Front 44

What other criteria enhance the specificity of the diagnosis of pelvic inflammatory disease (PID)?

Back 44

- Fever >101 degrees F

- Abnormal cervical or vaginal discharge

- Elevated sed rate

- Elevated C-reactive protein

- Cervical infection with gonorrhea or Chlamydia

Front 45

What is the way to definitively diagnose pelvic inflammatory disease (PID) which is not often used?

Back 45

- Laparoscopic findings consistent with PID

- Endometrial biopsy showing endometritis

- U/S exam findings showing thickened fluid-filled tubes with or without free pelvic fluid or tuboovarian complex

Front 46

How do you differentiate pelvic inflammatory disease (PID) from ectopic pregnancy?

Back 46

Pregnancy test - should be performed in all patients suspected of having PID

Front 47

How should you determine the treatment plan for a patient with pelvic inflammatory disease (PID)?

Back 47

Consider pregnancy status, severity of illness, and compliance

Front 48

What factors require in-patient treatment with IV antibiotics for pelvic inflammatory disease (PID)?

Back 48

- Pregnancy

- HIV

- Severe disease

Front 49

What are the oral regimens for pelvic inflammatory disease (PID)?

Back 49

Regimen A:

- Ceftriaxone 250 mg IM single dose OR Cefoxitin 2 g IM with Probenecid 1g PO given concurrently

- PLUS Doxycycline 100 mg PO BID for 14 days

- With or without Metronidazole 500 mg PO BID for 14 days

Regimen B:

- Cefotaxime 1g IM single dose OR Ceftizoxime 1g IM single dose

- PLUS Doxycycline 100 mg PO BID for 14 days

- With or without Metronidazole 500 mg PO BID for 14 days

Front 50

What are the parenteral regimens for pelvic inflammatory disease (PID)?

Back 50

Regimen A:

- Cefotetan 2 g IV q12h OR Cefoxitin 2 g IV q6h

- PLUS Doxycycline 100 mg PO or IV q12h

Regimen B:

- Clindamycin 900 mg IV q8h

- PLUS Gentamicin 2 mg/kg loading dose followed by 1.5 mg/kg IV q2h

Regimen C:

- Ampicillin / Sulbactam 3 g IV q6h

- PLUS Doxycycline 100 mg PO or IV q8h

Front 51

What are the potential complications of PID?

Back 51

- Potential for recurrence

- Development of tuboovarian abscess

- Chronic abdominal pain

- Infertility

- Increased risk of ectopic pregnancy

Front 52

A 24-year old nulliparous woman is noted to have a bothersome vaginal discharge. On exam, she is found to have a homogenous discharge with a fishy odor.

Which is the most likely finding on examination of the discharge?

a) motile protozoa on wet mount

b) pH >4.5

c) strawberry cervix

d) budding hyphae on KOH exam

Back 52

pH >4.5

Discharge of homogenous and fishy odor is most likely bacterial vaginosis associated with an alkaline pH. Partner treatment is not necessary for bacterial vaginosis. Oral metronidazole is one treatment.

Front 53

A 38-year old woman complains of vaginal discharge and irritation. She notes having had a UTI 10 days previously, with resolution of her symptoms.

What is the best therapy for her condition?

Back 53

Oral fluconazole

This patient most likely has candida vulvovaginitis, since her discharge appeared after her cystitis, likely treated with antibiotics. A treatment for this includes fluconazole or topical azalea agents such as miconazole

Front 54

A 24-year old woman is noted to have lower abdominal tenderness, cervical motion tenderness, and a vaginal discharge. She has a low grade fever of 100.5.

What is the best therapy for her condition?

Back 54

Ceftriaxone IM + Doxycycline orally

Front 55

What STIs should you check for in a patient with another STI?

Back 55

- HIV

- Hepatitis B, C

- Syphilis