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127 Cards in this Set

  • Front
  • Back
normal bacteria in vagina
large spectrum of aerobic and anerobic, mostly lactobacillus
normal vagina: pH
prepuberty & postmenopausal
reproductive age
3.8-4.2 (due to lactobacilli)
pt comes in with vaginal irritation (vaginitis) you MUST _______
perform pelvic exam and microscopic eval of discharge ("wet mount")
Cultures etc. will be dictated by findings. Never rely on symptoms alone for dx
most common cause of vaginitis
BV (bacterial vaginosis)
BV: Sexually transmitted Infection?
considered sexually associated but not clearly an STI
Complications of BV?
preterm birth, PID, endometritis, post hysterectomy infxn
Dr. I have a homogeneous greyish milky vaginal d/c. It smells "fishy" It get's worse after intercourse.
BV: etiology
Etiology: altered vaginal ecology leading to a polymicrobial anaerobic ifxn.
(garderella, bacteroides, mobiluncus, prevotella and peptococcus (polymicrobial)

Suppression of Lactobacilli and peroxide producing bacteria
Bacterial Vaginosis - Diagnosis: what you need to make the dx
Diagnosis requires a pelvic exam with a ph and wet prep of vaginal discharge
BV dx Amsel criteria--Three of four criteria are needed
1) Homogenous vaginal discharge
2) Vaginal ph > 4.5
3) Positive whiff test on KOH wet mount
4) clue cells on microscopic exam of saline wet mount.----Clue cells are epithelial cells covered with bacteria, margins of cell are indistinct and cells have ground glass appearance, few WBC’s present
Bacterial Vaginosis - Treatment
Non pregnant - Oral or topical Metronidazole or Clindamycin

Treatment of male sex partner is not recommended

Pregnant with history of preterm birth or symptomatic- oral Metronidazole (after first trimester) or oral Clindamycin.
Second most common infectious cause of vaginitis is?
Candida Vaginitis
Candida is more likely to have _____ involvement than BV or trichomoniasis
Most frequent ?
Candida albicans
Candida glabrata
torulopsis glabrata
Candida albicans
Candida Vaginits - Risk Factors
Recent use of antibiotics
Exogenous estrogens
Sexual intercourse
Anything facilitating vulvar/vaginal warmth and moisture
dr. I have cottage cheesy vaginal discharge. My vagina is itchy and painful. It gets worse after sex. What is the dx?
Candida Vaginitis
Candida: what will pelvic show
10% KOH wet mount shows?
thick, white, "cottage cheese" d/c

Vaginal ph < 4.5 most of the time

- budding yeast and pseudohyphae
Candida Vaginitis Treatment
Try to treat predisposing cause if possible (e.g. diabetes)

3-7 days with topical azoles (miconazole, butoconazole, terconazole, clotrimazole). Available OTC and by prescription.
Candida Vaginitis Treatment-efficacy
Treatment is 80% effective
Candida Vaginitis Treatment-if unsure of pt compliance
Single dose oral fluconazole also effective (do not use if pregnant)
dr. I have a foul smelling d/c and vulvar itching. It hurts when I have sex & go to the bathroom.
What do you think?
Trichomonas Vaginitis (Trichomoniasis)
Trichomonas Vaginitis (Trichomoniasis)-sexually transmitted
Trichomonas Vaginitis (Trichomoniasis)-what is it?
flagellated protozoan
Pelvic exam for trichomonas shows
Saline wet mount shows?
Strawberry patches on vagina, cervix, (petechiae) may be present often there is a “frothy” thin discharge
color may be yellow, green, grey

ph >4.5

Saline wet mount - trichomonads along with epithelial cells and WBC’s
Trichomonas Vaginitis - Diagnosis in men?
In men wet mount is unreliable—so culture urethra, urine, semen (men are often asymptomatic but may present as non gonococcal urethritis, NGU)
Trichomonas Vaginitis - Treatment
Patient and sex partner need to be treated Metronidazole or Tinidazole- 2 grams orally - 90% effective
what cautions come with the tx meds for trich
Abstain from alcohol (disulfiram - type adverse response)
what if the pt is pregnant? how do you treat trich then?
In pregnancy treat after 1st trimester
trich can increase succeptibility to what infxn
pt still has STI symptoms after trich has been treated? what do you have to consider?
May coexist with BV or another STD
post-menopausal woman comes to you complaining of a yellowish discharge. Pelvic shows a thin vaginal mucosa & smooth, shiny, reddish, atrophied vulvar skin. what do you suspect?
Atrophic Vulvovaginitis
Atrophic Vaginitis:
Saline Wet Mount shows
parabasal cells, RBC’s, and WBC’s
Atrophic Vaginitis: BX?
Yes, to rule out Lichen Sclerosis
Atrophic Vaginitis: Rx?
local or systemic estrogens
Vulvitis: Work up?
history & pelvic exam

if appropriate, scrapings, culture, and occasionally biopsy (if suspicious lesion, or fails treatment)
pt presents w/ cc of itchy vulvar area. On examination there is a thinning of the skin with whitish,cigarette-paper appearance. What do you suspect?
Lichen sclerosis
What do you do do next?
Bx -needed to make dx & r/o neoplasia/carcinoma -
if Lichen sclerosis what does bx show
shows hyperkeratosis and chronic inflammation
Lichen sclerosis: TX?
potent steroids or testosterone cream
pt p w/ cc of itchy vulvar vaginal area. On examination skin appears thickened & excoriated. What do you think?
Squamous cell hyperplasia (neurodermitits)
SCH: What do you do next?
Do biopsy to confirm dx (squamous cell hyperplasia without atypia)
Remove aggravating factors and treat topically with potent steroids.
Vulvitis: Indications for biopsy (punch or excisional)
atypical lesion
non response to therapy

goals of biopsy are to make the correct diagnosis in order to guide Rx, detect premalignant condition neoplasia / cancer.
pt presents w/ cc of itchy vulvar area. On examination there is a thinning of the skin with whitish,cigarette-paper appearance. What do you suspect?
Lichen sclerosis
What do you do do next?
Bx -needed to make dx & r/o neoplasia/carcinoma -
if Lichen sclerosis what does bx show
shows hyperkeratosis and chronic inflammation
Lichen sclerosis: TX?
potent steroids or testosterone cream
which pts should you screen for STDs
high risk & pregnant pts
your pt wet mount has just shown trichomas. What do you do next
screen for other STDs (e.g., HIV, GC, chlamydia, syphilis, hep B
reportable STIs
GC, chlamydia, syphilis, HIV,hep B
HIV testing in pregnancy
do it unless pt opts out
your pregnant pt has just tested HIV+! What do you do?
antiretroviral therapy (AZT or nevirapine) & elective cesarean section at 38 weeks with avoidance of breast feeding
with tx moms chances of passing HIV to baby
< 2%
In the US all protocols for prevention of perinatal transmission include _______ antepartum, intrapartum and post-partum
T or F: Combination chemotherapy may prevent development of HIV symptoms
Your pt presents with genital ulcer/s. Chances are it is one of what 3 dzs if pt is sexually active
genital herpes
what is the work-up for a pt with genital ulcer/s.
Evaluation includes a test for syphilis (VDRL/RPR AND FTA-ABS/ TPA OR darkfield of ulcer), culture of ulcer or antigen test for HSV, and, in some settings, culture for H. ducreyi.
what are some less common causes in the US for genital ulcers and their diagnostic modalities
(suspect if pt has been doing international travel)
granuloma inguinale (GI)-tissue prep for Donovan bodies

lymphogranuloma venereum (LGV)-C.trachomatis cultures, immunofluorescence prep or complement fixation titers
19 y/o female prostitute w/ hx of IV drug abuse presents with a painful, genital ulcer with tender suppurative inguinal adenopathy. Her syphilis tests neg and Herpes c/s negative. What do you suspect and culture for?
H.ducreyi on special medium
H.ducreyi culture is neg are you convinced pt. doesn't have it?
no-(sensitivity less than 80%)
How do you tx pts w/ H.ducreyi?
Should you tx partners even if they have no lesions?
Rx--Azithromycin or Ceftriaxone

identify and treat partners if recent sexual contact even if no lesions
What is the most prevalent STI in the US (approx 50 million adults infected)
Genital Herpes Simplex Virus Infections (HSV)
pt asks you when his Herpes virus will be cured?
Never. Recurrent, life-long viral infection
what virus is responsible for herpes?
Most cases of recurrent genital herpes are due to HSV-2, but HSV-1 is possible cause
wife is in a monogamous relationship with husband and she develops herpes but husband doesn't have any evedence of lesions? Has she been cheating?
either her OR her husband--Most infected persons are undiagnosed and many are ASYMPTOMATIC viral shedders
describe Primary infection of HSV.
prodrome of burning, parasthesias 2-5 days post infection; painful anogenital ulcers/vesicles occur 3-7 days post infection
Primary infection can be severe: fever, malaise, adenopathy, meningitis, urinary retention.
May require hospitalization in 10% of cases
describe recurrances of HSV.
generally milder and of shorter duration (2-5 days)
what is the first step in diagnosing herpes?
describe pt experience and PE findings
History, exam of genitalia and perianal region for extremely tender, painful vesicles
what is the gold standard for herpes dx
Viral culture of lesion
what is important to emphasize to pts with herpes
herpes is incurable and recurrant. Pts should use a condom and not have sex when they have a flareup or a prodome. even when a pt is asymptomatic it is possible to spread herpes. antiviral tx can help prevent spread of dz. partners of infected persons can get type specific herpes tests.
why has there been a recent increase in syphalis infxn
Treponema pallidum a spirochete causes
Clinical presentation and treatment of syphallis is based on ________
whether disease is in the primary, secondary, tertiary, latent phase, or if neurosyphilis is present
Primary syphilis
firm chancre with rolled margins--can be painless. Appears after 10-60 day incubation period (chancres usually on ext gentalia and vagina but can be on rectum, anus, pharynx, tongue, lips and fingers)
Secondary syphilis
when does it occur?
describe it.
occurs 1-2 mos after primary. Fever, headache, malaise, DIFFUSE MACULOPAPULAR RASH (may be on palms and soles) and mucous patches or condylomata lata.
Lesions are highly infectious
Late stages of syphilis (latent, tertiary and CNS)
infectious potential
infectious transmission occurs usually only with blood transfusion or transplacental passage (mother to fetus)
Latent syphilis-
early latent (less than 1 year); late latent (more than 1 year) or latent of unknown origin--implies no clinical signs of disease.
Tertiary syphilis
aortitis, gumma’s (necrotic granulomatous lesions) and iritis
can occur at any stage of syphilis. Suggestive signs are cognitive defects, motor or sensory defects, opthalmic or auditory symptoms, cranial nerve palsies,or signs of meningitis
Non-Treponemal tests
VDRL (Venereal Disease Research Laboratory)
RPR (Rapid Plasma Reagin)
Syphilis—Definitive diagnosis
darkfield exam and direct fluorescent antibody test of lesion or tissue
Syphilis -Presumptive diagnosis
(used most of the time)
combines a non-treponemal test with a treponemal test (both are needed b/c of false positives)
significance of titers
Titers correlate with disease activity-
significance of titers in syphilis

4 fold increase?

Rx tx

conditions predisposing titers to false +
a 4 fold rise in titers (e.g. 1:4 to 1:16) implies reinfection or failed initial treatment.Patient must be reevaluated and re-treated (may need to r/o neurosyphilis).

Titers should eventually go to zero if Rx adequate

False positives occur with a variety of conditions (lupus, pregnancy, viral and bacterial infections etc)
Syphilis —Diagnosis
Treponemal tests
FTA-ABS (fluorescent treponemal antibody absorbed)
TP-PA (T. pallidum particle aggutination)
Treponemal tests-limitation
Not useful to follow disease activity, generally positive for life
Neurosyphilis dx
diagnosis requires lumbar puncture usually with a positive VDRL CSF
Syphilis—Treatment of Primary, secondary or early latent syphilis
Benzathine penicillin G 2.4 million units IM x l dose
Jarisch Herxheimer reaction with Benzathine penicillin G
fever, headache, myalgia within first 24 hrs of therapy—can cause labor or fetal distress if pregnant
Late latent, latent unknown duration, or tertiary syphilis
Benzathine penicillin G 2.4 million units IM x 3 doses at weekly intervals
Syphilis—Treatment of Neurosyphilis
IV aqueous penicillin G for 10-14 days
Pt who tests positive for GC (or clymidia) presents with mucopurulent exudate from endocervix, endocervical bleeding with passage of cotton swab through the cervical os & Leukorrhea-greater than 10WBC/HPF on exam of vaginal fluid
Mucopurulent Cervicitis***
whats more common GC or clamydia
Clamydia infects ________ of the endocervix, uterus, tubes, urethra and rectum
columnar epithelium
your 15 y/o pt comes in and tells you she is sexually active. She has no symptoms of an STI. What do you do?
GC & clamydia exam. asymptomatic infxns are common in sexually active woman. Do annually until age 25.
Clamydia may cause cervicitis, urethritis or _______
Pelvic Inflammatory Disease (PID)
Chlamydia often coexists with ______
Even clinically mild Chlamydia infection may result in infertility, chronic pain, increased risk of ________
ectopic pregnancy
Chlamydia infection in pregnancy is associated with amnionitis, ________ and neonatal chlamydial infection (conjunctivitis, pneumonia)
preterm birth
Suspect _________ if mucopurulent cervicitis or evidence of PID (female) or urethritis (male)
Diagnosis of Chlamydia
endocervical swab or urine sample submitted for culture, immunoassay or nucleic acid amplification test (NAAT)
Chlamydia Treatment-
azithromycin, doxycycline
Chlamydia Treatment if pregnant
erythromycin or amoxicillin
After start of clamydia tx how long should a person stay absent
7 D
T or F. Chlamydia is a reportable dz. You need to refer sexual contacts for tx.
T or F. Pts testing + for clamydia should get a screen for other STD’s (HIV, GC, syphilis, hep B)
What STD is a Gram-negative intracellular diplococcus
Neisseria gonorrhea
T or F: Neisseria gonorrhea can infect almost any part of body – urethra, cervix, oropharynx, rectum, Bartholin’s glands
For women, chance of infection after single gonorrhea exposure is ____
pt presents w/ a maloderous d/c she has a bartholin gland cyst. What do you suspect?
If disseminated GC can cause meningitis, endocarditis, dermatitis, arthritis. T or F.
Untreated maternal infection during pregnancy can lead to __________ and/or __________
preterm birth
neonatal conjunctivitis (opthalmia neonatorum)
N. gonorrhea/GC diagnosis
Obtain specimens from urine, cervix, anus, urethra, pharynx (based on symptoms and sexual history)—send for GC culture or NAAT (only culture technique is approved for non genital sites and culture provides info on antibiotic sensitivity)
Gram stain of discharge if present
N. gonorrhea/GC (uncomplicated infxns) TX
ceftriaxone (IM) or cefixime, ofloxacin or ciprofloxacin (all PO)
must also cover chlamydia (dual therapy--add azithromycin)
GC infections in MSM or heterosexuals with recent foreign travel or infections acquired in Calif and Hawaii
Ceftriaxone or cefixime plus therapy for chlamydia
Spectrum of disorders of the upper genital tract--- any combination of endometritis, salpingitis, tubo-ovarian abscess, pelvic peritonitis. Begins as ascending infection from the endocervix (mucopurulent cervicitis may be present). Gonorrhea and Chlamydia are important causes.
Pelvic Inflammatory Disease (PID)***
PID: Other organisms also involved (_______)--G.vaginalis, H. influenzae, enteric gram neg rods, other _______, CMV, mycoplasma and ureaplasma are all implicated

PID Symptoms
may be mild or severe--
long term sequelae of PID
includes infertility, adhesions, pain, tubal pregnancy
Pt presents with fever, abdominal/pelvic pain, vaginal discharge. She is a sexually active woman. No other cause of pain is identified.
On PE she shows signs of bilateral lower abdominal tenderness & cervical motion tenderness (positive chandelier sign). Wet mount or gram stain of discharge shows Mucopurulent cervical discharge with WBC’s.
DDx-(essentially the ddx of acute lower abdominal pain in a reproductive aged woman) includes:
appendicitis, tubal pregnancy, ruptured ovarian cyst, adnexal torsion
Long-term sequelae of Pelvic Inflammatory Disease (PID)***
Increases risk of ectopic pregnancy
Increases risk of chronic pelvic pain (4-fold?)
Increases risk of infertility: 11% after first episode, 23% after second, 54% after 3rd
broad antibiotic coverage: GC, chlamydia, aerobes, anaerobes
pt presents w/ several 1-5 mm umbilicated nodules. What do you suspect.
Molluscum Contagiosum
what virus causes MC
MC: contageous?
Mildly contagious
MC: Tx
infection is self limited so it spontaneously resolves---can also treat with excision, cautery, cryotherapy, imiquimod