Gynecology [GYN INFECTIONS]

Introduction
Infections in a female can be either of the vagina or the cervix. Discharge Micro pH Abx
Candida Sticky white, Pseudohyphae 4 Anti-Fungals
Vaginal Infections adherent to (KOH prep) normal topical then
Patients with a vaginal infection come down to three diseases: wall oral
Candida, Gardnerella, and Trichomonas. The patient presentation Gardnerella Fishy odor, Clue Cells >5 Metronidazole
(Bacterial KOH, whiff (saline prep) Basic
is very nonspecific but involves pruritus, odor, and discharge.
Vaginosis) test
Nothing is very sensitive or specific from patient history so
Trich Yellow- Motile >5 Metronidazole
always do a pelvic exam and run some tests before treating. Green and Flagellated Basic Both partners!
Though it’s the best test, a culture often isn’t necessary. Frothy (saline prep)
However do these in order: speculum exam, microscopic exam,
and then antibiotics. The microscopic exam should be of the
cervical mucous. There should be two samples on one slide - one
with normal saline the other with KOH.

Cervical Infections Speculum Wet Mount Cx Abx

Cervical infections come in three varieties: cervicitis, acute PID Exam
and chronic PID. All involve cervical motion tenderness. The
pathogenesis, organisms, and physical findings separate the
diseases.
Only use a culture when your speculum and
1) Cervicitis Wet Mount/KOH are negative, otherwise, just
Cervicitis is essentially the same thing as a vaginal infection - treat by what you see!
including the same bugs. The difference is there’ll be cervical
motion tenderness, cervical discharge, but in the absence of
PID symptoms. Do a wet mount as well as a
Gonorrhea/Chlamydia PCR + treat accordingly.

2) Acute Pelvic Inflammatory Disease

Acute PID is essentially cervicitis “plus.” The distinction often Acute PID Chronic PID
isn’t necessary except on a Board exam. Acute PID is caused by Cervicitis Tubo-Ovarian
gonorrhea or Chlamydia. There will be cervical motion + Abscess
tenderness and coital pain with cervical discharge. Essentially Salpingitis
assume the diagnosis by history and physical; treat with
antibiotics while Gc/Chla PCR is pending. Treat Gonorrhea with Ceftriaxone Amp-Gent x 72 H
ceftriaxone IM x 1 and Chlamydia with Doxy po x 14 days (Gonorrhea) Clinda or MTZ
(azithromycin can also be used). These are STDs, and because Doxycycline x 14 days I&D if no improvement
chronic PID (ectopic, tubo-ovarian abscess, infertility, and (Chlamydia)
chronic pain) is possible she should be educated towards safe sex
practice. Ampicillin Gentamycin
Metronidazole
3) Chronic PID Tubo ovarian abscess
Salpingitis
After repeated trauma to the cervix from Acute PID, vaginal
organisms are able to penetrate the mucosal barrier and get into
the should-be-sterile uterus. They create an ascending infection
with or without abscess. Chronic PID will present with chronic
abdominal pain and a pelvic mass. There will be cervical
motion tenderness and adnexal tenderness. Often there’s fever.
Initially, assume there’s no abscess and treat with Amp-Gen and
Metronidazole. This can be continued if there’s improvement. If
Acute PID / Cervicitis Ceftriaxone
there isn’t it’s time to investigate for an abscess. Use ultrasound
Gonorrhea and
or CT scan. An abscess can be drained percutaneously or with a
Chlamydia Doxycycline
colpotomy. If peritonitis, perform ex-lap (best
diagnosis/treatment for abscess).

Normal Vaginal Flora

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