Gynecology: Cervicitis & Vaginitis

• Sexually Transmitted Diseases are those in which sexual contact is epidemiologically significant, though not necessarily the only mechanism of infection.

Urethritis

• Urethritis is the most common STD recognized in men.
• Urethritis can be Gonococcal, Non-gonococcal, or Non-infectious.

Gonococcal Urethritis

• Caused by N.gonorrhoeae, a gram-negative intracellular diplococcus.
• Incubation period is 2 to 7 days.
• Symptoms onset is abrupt.
• Purulent urethral discharge is present in 75% of cases.
• Dysuria is usually present.

Non-gonococcal Urethritis

• Caused by C.trachomatis.
• Incubation period is 7-21 days.
• Other causes include U-urealyticum, T.vaginalis, Herpes simplex, and Candida.
• Presentation includes purulent urethral discharge in 15% of cases.
• Dysuria may be present.

Non-infectious Urethritis

• Non-infectious urethritis may be caused by systemic diseases like Wegener's granulomatosis and Steven's Johnson Syndrome.
• Chemical irritants such as alcohol (dysuria) and spermicides can cause it.
• Renal stones, urethral trauma, and indwelling catheters are other potential causes.

Herpes Urethritis

• Herpes urethritis symptoms include severe dysuria and mucoid urethral discharge.
• Regional lymphadenopathy and constitutional symptoms are usually present.
• Genital lesions are not always present.

Gonococcal Urethritis Diagnosis and Treatment

• Diagnosis is achieved via Gram stain of urethral exudate.
• Culture on Thayer-Martin media is necessary to grow fastidious organisms that require CO2 and a rich environment.
• Treatment includes Ceftriaxone 125mg IM, or Ciprofloxacin 500mg PO plus Doxycycline 100mg P.O. bid x 7 days.

Non-gonococcal Urethritis Diagnosis and Treatment

• Diagnosis involves testing for C. trachomatis via NAAT's or DNA probe.
• U.urealyticum is diagnosed by cultures of T.vaginalis.
• T.vaginalis is diagnosed via culture and wet mount to see motile protozoa.
• Treatment involves Doxycycline 100mg P.O. bid x 7 days or Azithromycin 1 gram P.O.
• For T. vaginalis, metronidazole 2gms P.O. can be used.

Cervicitis

• The most common STD in women is cervicitis.
• It may be caused by N.gonorrohoeae, C. trachomatis, H. simplex virus, or human papilloma virus.

Gonococcal Cervicitis

• Symptoms include purulent cervical discharge and cervical edema.
• Dysmenorrhea, dyspareunia, and dysuria are also symptoms.
• 50% of cases have urethritis associated.

Cervicitis (C. trachomatis and Herpes Simplex)

• C. trachomatis causes mucopurulent cervicitis, abdominal pain, and spotting with intercourse.
• Only 30% show vaginal discharge.
• Herpes simplex causes mucoid discharge and lower abdominal pain.
• Cervix becomes friable, ulcers and necrosis can be seen.
• External lesions are often clinically absent.

Cervicitis Diagnosis

• Diagnosis includes Gram stain of endocervical mucus with >10 WBC's.
• Cervical biopsy may be required for HSV detection.
• Colposcopy may be used for diagnosis.
• Treatment is for N. gonorrohoeae and C. trachomatis.

Cervicitis Complications

• Endometritis, salpingitis PID, ectopic pregnancies, and infertility may occur.
• During pregnancy, PROM, premature birth, low birth weight, spontaneous abortion, and intrauterine death can occur.
• Cervical neoplasia and perinatal infections during delivery are additional complications.

Vulvovaginitis

• The three types of vulvovaginitis are vulvovaginal candidiasis, bacterial vaginosis, and trichomoniasis.

Vulvovaginal Candidiasis

• Approximately 75% of women experience at least 1 episode of vulvovaginal candidiasis.
• Infections may be present also in healthy women.
• Symptoms include Pruritus, dyspareunia, and white discharge.
• Antibiotics, oral contraceptives, corticosteroids, pregnancy, and DM can cause infections.
• It is often caused by C. albicans (90%).
• Normal vaginal fluid pH is common.

Bacterial Vaginosis

• It is the most common cause of infectious vaginitis.
• It may be asymptomatic.
• Patients experience moderate gray discharge.
• pH vaginal fluid is >4.5.
• A positive Amine test (+) reveals a "fishy odor."
• Gram stain shows "clue cells."

Trichomona Vaginitis

• Copious amounts of green-yellow discharge, dyspareunia are symptoms.
• pH Vaginal fluid is between 5-6.
• Amine test reveals (+) presence.
• Approximately 40% of male partners are identified.
• During menses, pH increases.

Treatment of Infectious Vaginitis

• For vulvovaginal candidiasis, use topical antifugal-clotrimazole, miconazole, or Fluconazole 150mg.
• Bacterial vaginosis is treated with Metronidazole 500mg P.O. bid x 7 days or topical metronidazole.
• Trichomoniasis is treated with Metronidazole 2gms. P.O.

Human Papilloma Virus (HPV)

• HPV is the most common STD.
• Symptoms may develop after years.
• May disappear in two years with a rate of 9/10.
• Some strains of Human Papilloma Virus can cause cancer.
• Cancer can affect the vulva, vagina, penis, anus, and oropharynx.
• Prevention includes vaccination for boys and girls aged 9-26, screening, condoms, and monogamous relationships.

Genital Ulcers

• Common types of ulcers include Syphilis, Chancroid, Genital herpes, Lymphogranuloma venereum, and Donovanosis.
• Syphilis is caused by T. pallidum (spirochete).
• Incubation period is 21 to 90 days.
• Lesions may be single or multiple, sharply demarcated, with smooth base or crusty, firm, and painless.
• Unilateral or bilateral lymph nodes.
• Diagnosis through darkfield microscopy, VDRL, and FTA testing.
• Treatable with Penicillin/Doxycycline or Ceftriaxone.

Chancroid

• It is caused by H. ducrey (GNB).
• Incubation is 2-7 days up to 35 days.
• Lesions may be multiple, erythematous borders, undermined, and yellow-gray rough base.
• Unilateral lymph nodes may be fluctuant.
• Diagnose via culture with supplement agar, CO2, and Vancomycin.
• Treat with ceftriaxone, azithromycin, and ciprofloxacin.

Genital Herpes

• An incubation period of 2 - 7 days.
• Lesions may coalesce, erythematous borders, red smooth base, and painful.
• Bilateral firm tender nodes.
• Diagnosis via Tzanck smear and viral culture.
• Treatment includes Acyclovir, Valacyclovir, and Famciclovir.

Lymphogranuloma Venereum (LGV)

• Caused by Chlamydia trachomatis
• It incubates for 10-14 days up to 3 weeks.
• Lesions are usually single, variable borders, variable base, non-indurated, and may be tender.
• Unilateral firm tender nodes may fluctuate suppurate, fistulas and sinuses.
• A groove sign-pathognomonic is present in 30% of cases.
• Diagnose through culture < 30%.
• Treat with Doxycycline and Tetracycline.

Granuloma Inguinale

• Caused by Klebsiella granulomatis.
• Incubation period is 3-180 days.
• Lesion appears as a small painless papule or nodule, with elevated borders, red, rough friable base, and beefy granulations that may be hypertrophic and necrotic.
• Symptoms also include Inguinal swelling and pseudoadenopathy.
• Diagnosed via Giemsa and Wright's stains looking for “Donovan bodies”.
• Treat with Trimetroprim-sulfamethoxiazole and Ciprofloxacin .

Herpes Infection During Pregnancy

• Can cause abortion, premature labor, and skin lesions.
• It may also cause chorioretinitis, microcephaly, and uterine growth retardation.

Neonatal Infections

• Can be localized and disseminated, and have a higher incidence of premature occurrence.

Syphilis

• Syphilis is a subacute to chronic infectious disease caused by Treponema pallidum, usually acquired by sexual contact.
• Pathogenesis of syphilis includes that T. pallidum penetrates through normal mucosal membranes and minor abrasions of epithelial surfaces.
• The first lesion appears at the site of primary inoculation.
• Only one treponema may establish infection.
• Primary pathologic lesion-focal endarteritis obliterates the vessel lumen.

Primary Syphilis

• Presents a typical lesion known as a chancre: a painless indurated ulcer with regional adenopathy.
• Starts as a papule, then superficial erosion resulting in a typical ulcer.
• Borders are raised, firm, and indurated.
• Heals in several weeks.

Chancre

• Occurs in the genital region in 90% of cases.
• Rectal chancres may mimic rectal fissures.
• Wounds may be seen in the pharynx, tongue, lips, fingers, and nipples.
• Appearance may be confused with genital herpes.

Secondary Syphilis

• Occurs 4 to 8 weeks after the chancre.
• May develop malaise, fever, headache, sore throat, and lymphadenopathies.
• Cutaneous eruption-widespread and symmetric in distribution, non pruritic.
• Wounds ofetn have pink, coppery, red, indurated appearance with a superficial scaly papulosquamous lesion.
• Condyloma lata, larges pale flat papules, may coalesce, verrucous lesions, are highly infectious.
• These condyloma can be seen in axilla, perineum, perianal.
• Mucous patches appear as raised oval areas covered with a grayish-white membrane in genitalia, mouth, and tongue.
• Wounds are highly infections.

Late Syphilis

• Consists of late benign syphilis (gummatous).
• Cardiovascular and neurosyphilis are frequent complications.

Congenital Syphilis

• Results from transplacental, hematogenous spread.
• VDRL is obtained in all expectant mothers.
• Spirochetes can be found in abortus.
• Treatment of mother prior to 16th week of gestation stops neonatal illness of the fetus.
• Presentation resembles secondary syphilis.
• Possible symptoms include rhinitis, hepatosplenomegaly, hemolytic anemia, jaundice, and thrombocytopenia.