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CASE DISCUSSION

Common Reproductive Tract Infections in Women

Identifying Data
RDC 25 y/o, nulligravid Single Filipina Catholic Call center agent From Cubao, QC

Chief Complaint
Hypogastric pain (1 day)

LMP: 03/18/12 (Day 6 of cycle)

03/23/12 Informant: patient Reliability: good

History of Present Illness


8 days PTC Vaginal discharge
Scanty, yellowish, non foul-smelling

No fever, abdominal pain, dysuria or urinary frequency No meds taken; No consult

History of Present Illness


5 days PTC Had her regular menstruation; no note of other vaginal discharge (lasted for 4 days, 3pads/day)

No fever, abdominal pain or dysuria

History of Present Illness


1 day PTC
Hypogastric pain
Crampy, 6-7/10 PAS, non-radiating, aggravated by truncal flexion

Vaginal discharge
Copious, purulent, non foul-smelling

No fever or dysuria Took mefenamic acid


No relief

No consult

History of Present Illness


AM PTC
Fever
Tmax 38.4oC, temporarily lysed with intake of paracetamol

Hypogastric pain
Crampy/stabbing, 9-10/10 PAS, non-radiating, aggravated by truncal movement

Vaginal discharge
Copious, purulent, foul-smelling

Consult

Obstetric/Gynecologic History
Nulligravid LMP: 18 March 2012 PMP: February 2012

MIDAS: 13 y/o, regular (28-30 days), lasting for 4 days, consuming 3 pads/day, no dysmenorrhea Sexually active for 2 years; 1 sexual partner No history of STI No previous pap smear/ultrasound

ROS
Unremarkable

PMH
No DM, hypertension, asthma, TB, heart/kidney/liver diseases No known allergies

FH
(+) DM maternal (+) HTN paternal

PSH
College graduate, call center agent, non-smoker, (-) EtOH, no history of illicit drug use

Physical Examination
Alert, oriented, not in cardio-respiratory distress; 157cm 56 kg BMI 22.7 BP 124/83, HR 88, RR 18, T 38.4, 9/10 PAS Pink conjunctivae, anicteric sclerae, no TPC/CLAD Symmetric chest expansion, clear breath sounds Adynamic precordium, PMI at 5th ICS LMCL, normal cardiac rate with regular rhythm, no murmur

Physical Examination
Abdomen
Flat, hypoactive bowel sounds, (+) direct tenderness hypogastric, no rebound tenderness, no guarding, no organomegaly, no palpable masses

Pelvic
Speculum: moderate yellowish, foul smelling vaginal discharge, erythematous external os, no erosions, no polyp IE: Closed, firm cervix; (+) cervical motion tenderness

Extremities
No cyanosis, no edema, full and equal pulses, good skin turgor, CRT <2 sec

Initial Assessment

Pelvic Inflammatory disease

Plan
Diagnostics:
CBC: WBC 15, neutrophilic predominance 90% Urinalysis: 7WBC/hpf (mild pyuria), no bacteriuria Pregnancy test: negative Vaginal discharge GS: gram negative diplococci

Plan
Therapeutics:
Ceftriaxone: 250 mg IM once + doxycycline 100 mg PO BID X 14 days

Follow-up after 14 days Advise on:


Screening of sexual partners Safe sexual practices Annual pap smear and regular gynecologic checkups

Pelvic Inflammatory Disease

Pelvic Inflammatory Disease


Represents a spectrum of infections of the uterus, fallopian tubes, and adjacent pelvic structures May include combination of endometritis, salpingitis, tubo-ovarian abscess, oophoritis, or pelvic peritonitis

Pelvic Inflammatory Disease


Results from pathogenic microorganisms spreading from cervix to the vagina to upper portions of the genital tract Most common etiologic agent: Chlamydia, followed by Gonorrhea Occurs exclusively in sexually active women and adolescents Risk factors: sexual activity, high risk sexual behavior, young age, IUD users

Pelvic Inflammatory Disease


Degree of urgency of the illness Not usually life threatening unless complicated by ruptured TOA Incidence of TOA in PID is about 15% Presence of TOA may require surgical intervention if therapy fails or rupture occurs

Pelvic Inflammatory Disease


Diagnosis and Evaluation
Major determinants
Lower abdominal pain Cervical motion tenderness Uterine or adnexal tenderness

Minor determinants
Fever Vaginal discharge STD history ESR, CRP Systemic signs Dyspareunia

Pelvic Inflammatory Disease


Hospitalization based on:
Severity of the clinical illness Patient compliance with an outpatient regimen Anaerobic infection and certainty of the diagnosis.

Pelvic Inflammatory Disease


What to request for:
CBC Urinalysis Pregnancy test Screening Tests
RPR or VDRL Chlamydia and Gonorrhea

Pelvic Inflammatory Disease

Pelvic Inflammatory Disease

Pelvic Inflammatory Disease

Pelvic Inflammatory Disease

Complications
Infertility Ectopic pregnancy Chronic pelvic pain TOA Pelvic adhesions

Sexually Transmitted Infections


Discussion

Chlamydia trachomatis
Most prevalent STI Common in women age 15-19 years Routine screening is recommended for the asymptomatic and sexually active Annual screening should be done for women 20-24 years of age
High-risk sexual behavior Multiple sexual partners

Chlamydia trachomatis
Diagnostic method
Direct fluorescent antibody Enzyme immunoassay DNA probe Cell culture DNA amplification

Chlamydia trachomatis
Recommended Treatment
Doxycycline 100 mg PO BID for 7 days or Azithromycin 1 g PO

Alternative Treatment
Ofloxacin 300 mg PO BID for 7 days Erythromycin 500 mg PO 4 times a day for 7 days Erythromycin ethylsuccinate 800 mg PO 4 times a day for 7 days

Chlamydia trachomatis

Inclusion Cells

Gonorrhea
800,000 cases annually Routine screening recommended for women with high risk sexual behavior

Gonorrhea

Gonorrhea
Diagnostic method
Culture DNA probe

Recommended Treatment
Ceftriaxone 125 mg IM or Cefixime 400 mg PO or Ciprofloxacin 500 mg PO or Ofloxaxin 400 mg PO PLUS Doxycycline 100 mg BID for 7 days or Azithromycin 1 g PO

Syphillis
Treponema pallidum Incidence of 100,000 annually Common among 20-24 year old women Routine screening recommended for those with high risk sexual behavior

Syphillis
Diagnostic methods
Clinical appearance Dark-field microscopy RPR, VDRL MHA-TP, FTA-ABS

Recommended treatment
Primary, secondary and latent syphillis (<1 year duration): Benzathine penicillin G 2.4 M units IM in a single dose

Syphillis
Recommended treatment
Penicillin allergy: Doxycycline 100 mg PO BID for 2 weeks

Syphillis

Pubic Infections

Human Papilloma Virus


Causes genital warts
Benign or malignant hyperplasias

Genital warts
External genitalia: HPV 6 & 11 (low-risk) Perianal area Vagina, cervix, urethra, anus

Lesions: Condyloma acuminata, Papular warts, Keratotic warts, Flat-topped warts

Human Papilloma Virus


Diagnostic methods
Visualization of condyloma papules Cytology

Recommended treatment
External warts
Imiquimod Podofilox 0.5% solution or gel BID for 3 days followed by 4 days without treatment ~ 4 cycles Cryotherapy with liquid nitrogen or cryoprobe

Human Papilloma Virus

Molluscum contagiosum
Poxviridae Spread by sexual or close personal contact Usually asymptomatic, multiple, with central umbilication Spread by autoinoculation and last from 6 months to years Diagnosis: visualization of lesion or biopsy Treatment: dermal curette, cryosurgery or electrodessication

Molluscum contagiosum

Pediculosis pubis
Blood-sucking louse unable to survive more than 24 hours off the human body Transmitted sexually Found in pubic hair Diagnosis: visualization of nits or adult lice on hair shafts Treatment
Permethrin cream 5% applied for 10 minutes then washed off Kwell shampoo lathered for 4 minutes (contraindicated in pregnancy) Linen and clothing should be decontaminated

Pediculosis pubis

Pubic Scabies
Highly contagious infestation of Sarcoptes scabiei Transmitted by intimate skin contact Female mite burrows into the skin and after 1 month severe pruritus develops Multiple eruption may develop Diagnosis: confirmed by visualization of burrows and observation of parasites etc on microscopy Treatment: Permethrin 5% cream massaged from neck down and washed off after 8 hours

Vaginitis

Vaginitis
Most common gynecologic infection Etiology may be bacterial, fungal, protozoal, contact dermatitis, atrophic vaginitis or allergic reaction

Pathophysiology
Alterations in vaginal ecosystem
Introduction of an organism Disturbance of existing organism

Diagnostic method
Clinical evaluation Vaginal fluid pH Saline wet mount KOH preparation Screening for STDs

Clinical Manifestations of Vaginitis


Candidal Vaginitis
Second most common vaginitis Usually in patients with DM and immunosuppressive conditions Most common symptom: pruritus Other symptoms: vaginal discharge, vulvar burning

Clinical Manifestations of Vaginitis


Candidal Vaginitis
Physical examination
Nonmalodorous, thick, white, cottage cheese-like adhering to vaginal walls Hyphal forms or budding year cells on wet mount Pruritus Normal pH <4.5

Clinical Manifestations of Vaginitis


Candidal Vaginitis
Treatment
Clotrimazole or Miconazole

Clinical Manifestations of Vaginitis


Bacterial Vaginosis
Shift in normal vaginal ecosystem causing replacement of predominant lactobacilli mixed with bacterial flora Most common vaginitis Little itching, no pain, fishy vaginal discharge Little or no inflammation of vulva or vaginal epithelium Thin, dark or dull grey, homogenous, malodorous discharge adhering to the vaginal walls

Clinical Manifestations of Vaginitis


Bacterial Vaginosis
Criteria 3 out of 4
Elevated pH level (>4.5) Positive KOH (whiff test) Clue cells on wet-mount microscopic evaluation Homogenous discharge

Clinical Manifestations of Vaginitis


Bacterial Vaginosis
Treatment regimens
Topical/Intravaginal regimen
Metronidazole gel BID for 5 days Clindamycin cream 5g for 7 days

Oral regimen
Metronidazole 500 mg BID for 7 days

Routine treatment of partners is not necessary Persistent cases should be reevaluated and treated with Clindamycin 300 mg PO BID for 7 days Pregnant patients should not be given Clindamycin

Bacterial vaginosis

Clinical Manifestations of Vaginitis


Trichomonas vaginalis
Flagellated anaerobic protozoan Sexually transmitted Non-sexual transmission is still possible

Clinical Manifestations of Vaginitis


Trichomonas vaginalis
Copious, yellow-gray or green, homogenous or frothy, malodorous discharge Elevated pH level > 4.5 Mobile, flagellated organisms and leukocytes on wet-mount Vulvovaginal irritation, dysuria

Trichomonas Vaginalis

Clinical Manifestations of Vaginitis


Trichomonas vaginalis
Treatment
Metronidazole 2 g PO in a single dose for patient and sexual partner or 500 mg PO BID for 7 days Topical therapy with topical metronidazole is NOT recommended: organism may persist in the urethra and skenes glands Screen patient for other STDs