Podcast
Questions and Answers
Which of the following are long-term consequences of Pelvic Inflammatory Disease (PID)?
Which of the following are long-term consequences of Pelvic Inflammatory Disease (PID)?
- Chronic headaches
- Skin rashes
- Ectopic pregnancy (correct)
- Infertility (correct)
Metronidazole should be avoided while consuming alcohol.
Metronidazole should be avoided while consuming alcohol.
True (A)
What is the recommended duration for taking oral antibiotics in the management of PID?
What is the recommended duration for taking oral antibiotics in the management of PID?
14 days
In cases of PID, if a patient is not responding to oral treatment, the _____ should consider admission.
In cases of PID, if a patient is not responding to oral treatment, the _____ should consider admission.
Match the types of treatment kits with their corresponding details:
Match the types of treatment kits with their corresponding details:
What is the gold standard test for Chlamydia?
What is the gold standard test for Chlamydia?
In non-pregnant patients, the treatment for Gonorrhoea includes injecting Ceftriaxone.
In non-pregnant patients, the treatment for Gonorrhoea includes injecting Ceftriaxone.
What procedure shows >10 neutrophils/field when testing for Chlamydia?
What procedure shows >10 neutrophils/field when testing for Chlamydia?
The treatment for a pregnant patient with Chlamydia is a single dose of ___________ given orally.
The treatment for a pregnant patient with Chlamydia is a single dose of ___________ given orally.
Match the following conditions with their associated symptoms or characteristics:
Match the following conditions with their associated symptoms or characteristics:
What is the drug of choice (DOC) for bacterial vaginosis during the first trimester of pregnancy?
What is the drug of choice (DOC) for bacterial vaginosis during the first trimester of pregnancy?
Candidiasis treatment with oral fluconazole is indicated during pregnancy.
Candidiasis treatment with oral fluconazole is indicated during pregnancy.
What is the primary symptom of cervicitis?
What is the primary symptom of cervicitis?
The ectocervix is lined by __________ epithelium while the endocervix is lined by __________ epithelium.
The ectocervix is lined by __________ epithelium while the endocervix is lined by __________ epithelium.
Match the type of cervicitis with its most common causative agent:
Match the type of cervicitis with its most common causative agent:
What is included in the Green Kit 2 for treating vaginitis with discharge and pruritis?
What is included in the Green Kit 2 for treating vaginitis with discharge and pruritis?
Antibiotic treatment for partner cervicitis is indicated in cases of vaginitis.
Antibiotic treatment for partner cervicitis is indicated in cases of vaginitis.
What are the recommended contraceptive methods mentioned for supportive treatment?
What are the recommended contraceptive methods mentioned for supportive treatment?
The presentation for lower abdominal pain may include _____ tenderness, cervical movement tenderness, or adnexal tenderness.
The presentation for lower abdominal pain may include _____ tenderness, cervical movement tenderness, or adnexal tenderness.
Match the treatment kits to their indications:
Match the treatment kits to their indications:
What is the primary causative organism of genital tuberculosis?
What is the primary causative organism of genital tuberculosis?
Genital tuberculosis can only spread through sexual transmission.
Genital tuberculosis can only spread through sexual transmission.
What condition can result from inflammation of the fallopian tubes due to genital tuberculosis?
What condition can result from inflammation of the fallopian tubes due to genital tuberculosis?
The infection can spread to the uterine lining (endometrium) via the _______.
The infection can spread to the uterine lining (endometrium) via the _______.
Match the symptoms of genital tuberculosis with their descriptions:
Match the symptoms of genital tuberculosis with their descriptions:
Which of the following infections is the most common cause of PID in reproductive-aged women?
Which of the following infections is the most common cause of PID in reproductive-aged women?
PID can only occur in sexually active females aged 15 to 35 years.
PID can only occur in sexually active females aged 15 to 35 years.
Name one protective measure that can help prevent PID.
Name one protective measure that can help prevent PID.
What is the gold standard test for diagnosing Bacterial Vaginosis?
What is the gold standard test for diagnosing Bacterial Vaginosis?
The spread of infection in PID primarily occurs through _______ infection along with sperms.
The spread of infection in PID primarily occurs through _______ infection along with sperms.
The Whiff test is positive for Trichomonas Vaginitis.
The Whiff test is positive for Trichomonas Vaginitis.
Which of the following is NOT a symptom commonly associated with the acute phase of Pelvic Inflammatory Disease (PID)?
Which of the following is NOT a symptom commonly associated with the acute phase of Pelvic Inflammatory Disease (PID)?
Match the following types of PID infections to their associated characteristics:
Match the following types of PID infections to their associated characteristics:
Right upper quadrant pain is a symptom associated with Fitz-Hugh-Curtis Syndrome, a complication of PID.
Right upper quadrant pain is a symptom associated with Fitz-Hugh-Curtis Syndrome, a complication of PID.
What is the microscopic appearance of Candidiasis?
What is the microscopic appearance of Candidiasis?
What is the gold standard diagnostic method for Pelvic Inflammatory Disease?
What is the gold standard diagnostic method for Pelvic Inflammatory Disease?
In Bacterial Vaginosis, the pH of vaginal discharge is typically __________.
In Bacterial Vaginosis, the pH of vaginal discharge is typically __________.
An elevated _____ and an elevated C-reactive protein (CRP) can help in diagnosing Chlamydia or Gonorrhea associated with PID.
An elevated _____ and an elevated C-reactive protein (CRP) can help in diagnosing Chlamydia or Gonorrhea associated with PID.
Match the following conditions with their associated symptoms:
Match the following conditions with their associated symptoms:
Match the symptom with its corresponding characteristic related to PID:
Match the symptom with its corresponding characteristic related to PID:
What is the surest sign of Pelvic Inflammatory Disease (PID) during laparoscopy?
What is the surest sign of Pelvic Inflammatory Disease (PID) during laparoscopy?
The Boer-misel score is a scoring system used to assess the severity of a pelvic abscess.
The Boer-misel score is a scoring system used to assess the severity of a pelvic abscess.
What imaging technique is used as a diagnostic method for genital tuberculosis (TB)?
What imaging technique is used as a diagnostic method for genital tuberculosis (TB)?
The type of organism causing infections was not ________ in the study.
The type of organism causing infections was not ________ in the study.
Match the ultrasound sign with its corresponding description:
Match the ultrasound sign with its corresponding description:
Which of the following organisms are associated with bacterial vaginosis?
Which of the following organisms are associated with bacterial vaginosis?
Candidiasis is characterized by a discharge that is curdy white and a main complaint of intense pruritis.
Candidiasis is characterized by a discharge that is curdy white and a main complaint of intense pruritis.
What is the pH level associated with Bacterial Vaginosis?
What is the pH level associated with Bacterial Vaginosis?
The organism responsible for Trichomonas Vaginitis is __________.
The organism responsible for Trichomonas Vaginitis is __________.
Match the type of vaginitis with its corresponding characteristic:
Match the type of vaginitis with its corresponding characteristic:
Study Notes
Chlamydia
- Greater than 10 neutrophils per field on Gram stain
- Collected from endocervical swab or urine if urethritis is positive
- Gold standard is culture on McCoy cell lines
- Non-pregnant treatment is doxycycline 100 mg once daily for 7 days
- Pregnant women cannot take doxycycline, use azithromycin 1 g orally as a single dose
Gonorrhea
- Gram-negative diplococci on Gram stain
- Gold standard is culture on Thayer-Martin media
Per Speculum Examination
- Unhealthy cervix: friable (easily crumbles), bleeds on touch, erosion/ulcer present
Per Vaginal Examination
- Normal uterus, normal adnexa
Differential Diagnosis
- PID can be differentiated by uterine and adnexal tenderness
Complications
- PID: Due to ascending infection
- Perihepatitis: Fitz-Hugh-Curtis syndrome
Management
- Syndromic management is advised by NACO
- Color-coded kits are used, based on history, physical examination, and minimal investigations
Bacterial Vaginosis
- Metronidazole is the drug of choice
- Vaginal metronidazole in the 1st trimester
- Oral metronidazole in the 2nd and 3rd trimester
Candidiasis
- Oral fluconazole is contraindicated
- Topical clotrimazole is used
Trichomonas Vaginitis
- Metronidazole is the drug of choice
- Vaginal in the 1st trimester
- Oral in the 2nd and 3rd trimester
- Same dose is used
Partner Treatment
- Partner treatment is indicated
Cervicitis
- Ectocervix is lined by stratified squamous epithelium similar to the vagina
- Endocervix is lined by columnar epithelium
Ectocervix
- Infections include:
- Candida
- Trichomonas
- HSV
- HPV
Endocervix
- Infections include Chlamydia and Gonorrhea
Chlamydial & Gonococcal Cervicitis
- Most common route of spread is ascending infection along with sperm (STD)
- Most common site is the endocervix, followed by the urethra
Clinical Presentation
- 50-80% are asymptomatic
- Discharge is the most common presentation, mucoid or purulent
- Other clinical presentations include:
- Dysuria
- Dyspareunia
- Post-coital bleeding
Pelvic Inflammatory Disease (PID)
- Long-term consequences include:
- Infertility
- Ectopic pregnancy
- Chronic pelvic pain
- Hydrosalpinx: fluid accumulation within the fallopian tube
- Recurrent PID
- Fitz-Hugh-Curtis syndrome
Management
- Broad-spectrum antibiotics are used:
- Ceftriaxone 250 mg IM single dose
- Doxycycline 100 mg twice daily for 14 days
- Metronidazole 400 mg twice daily for 14 days
Advice for PID Management
- Abstinence for 7-14 days
- Partner treatment is essential
- Barrier contraception, such as condoms
- Avoid alcohol while taking metronidazole
Indications for Admission
- No response to oral treatment
- Pelvic abscess
- Pregnant females with severe disease
- Pregnant females unable to take oral medications
IV Antibiotics
- Continue for 24 hours after patient becomes afebrile
- Oral antibiotics are continued for 14 days
Syndromic Approach
- Indicates lower abdominal pain with any of the following findings:
- Uterine tenderness
- Cervical motion tenderness
- Adnexal tenderness
- Ensure a negative urine pregnancy test
Syndromic Treatment
-
Patient receives:
- Cefixime 400 mg stat
- Metronidazole 400 mg twice daily for 14 days
-
Partner receives:
- Doxycycline 100 mg twice daily for 14 days
- Azithromycin 1 g
Syndromic Approach Advice
- Abstinence for 7-14 days
- Use condoms
Bacterial Vaginosis
- Microscopic appearance shows epithelial cells with adhered bacteria, called clue cells
- Saline microscopy reveals normal vaginal flora and clue cells
- Gram staining is the gold standard with a Nugent score of 7-10
- Whiff test: Adding 10% KOH to discharge results in a fishy or amine-like odor
- Amsel's criteria: At least 3/4 of the following are positive:
- Greyish-white discharge
- pH ≥ 4.5
-
20% of epithelial cells are clue cells
- Positive whiff test
Candidiasis
- Microscopic appearance shows pseudohyphae and spores of Candida
- Culture is performed on Sabouraud media
Trichomonas Vaginitis
- Microscopic appearance shows motility or a tennis racket appearance
- Culture is performed on Sabouraud media
- Whiff test is negative
- Strawberry cervix or angry-looking vagina may be seen on physical examination
Diagnostic Treatment
- Drug of choice:
- Non-pregnant: Oral metronidazole 500 mg twice daily for 7 days or 2 g as a single dose
- Non-pregnant: Oral fluconazole 150 mg as a single dose
Pelvic Inflammatory Disease (PID)
-
Most common symptoms:
- Lower abdominal pain, typically bilateral
- Painful intercourse
-
Acute phase symptoms:
- Fever
- Abnormal uterine bleeding (AUB)
- Intermenstrual bleeding
- Post-coital bleeding
- Dysmenorrhea
- Infertility
- Vaginal discharge
Fitz-Hugh-Curtis Syndrome
- A complication of PID, causing perihepatitis
- Characterized by violin string adhesions between the liver capsule and the anterior abdominal wall
- Presents with right upper quadrant pain
- Commonly associated with Chlamydia or Gonorrhea infections
PID Clinical Diagnosis
- Centers for Disease Control and Prevention (CDC) criteria:
- Minimal criteria: Lower abdominal pain with any of the following on pelvic exam:
- Cervical tenderness
- Adnexal tenderness
- Uterine tenderness
- Additional criteria:
- Temperature > 101°F
- Abnormal cervical/vaginal discharge
- Saline microscopy of vaginal discharge showing abundant white blood cells (WBCs)
- Lab diagnosis of Chlamydia/Gonorrhea
- Elevated erythrocyte sedimentation rate (ESR)
- Elevated C-reactive protein (CRP)
- Minimal criteria: Lower abdominal pain with any of the following on pelvic exam:
Pelvic Inflammatory Disease (PID) Investigations for Definitive Diagnosis
- Ultrasound (USG)
- Tubo-ovarian mass
- Swollen fallopian tubes
- Signs during Pelvic Exam
- Waist sign
- Beads on a string sign
- Cogwheel sign
- Endometrial biopsy
- Can indicate endometritis
- Laparoscopy
- Gold standard
- Allows direct visualization of fallopian tubes, ovaries, and uterus
- Can be used for specimen collection
- Can be used for scoring conception potential
- Rules out ectopic pregnancy and appendicitis
Vaginitis
- Organisms responsible:
- Bacterial vaginosis: Gardnerella vaginalis, mycoplasma, mobiluncus
- Candidiasis: Candida albicans (fungus)
- Trichomonas vaginitis: Trichomonas vaginalis (flagellated protozoan)
Predisposing Factors
- Bacterial vaginosis:
- Alteration of vaginal pH (alkaline)
- Pregnancy - most common vaginitis in pregnant women
- Immunocompromised state
- Antibiotic use
- Steroids
- Oral contraceptive pill consumption
Vaginal Discharge
- Bacterial vaginosis: Greyish-white or dirty-white, foul smell
- Candidiasis: Scanty, curdy white/cottage cheese-like discharge, not the primary complaint
- Trichomonas vaginitis: Frothy, yellowish-green color, foul smell
Vaginal pH
- Bacterial vaginosis: ≥ 4.5
- Candidiasis: < 4.5
- Trichomonas vaginitis: ≥ 4.5
Pruritis
- Bacterial vaginosis: No inflammation, so absent
- Candidiasis: Intense pruritis, excoriation - primary complaint
- Trichomonas vaginitis: Intense pruritis
Dysuria
- Bacterial vaginosis: No inflammation, so absent
- Candidiasis: Splash dysuria
- Trichomonas vaginitis: Present
Polymorphonucleocytes (PMNs)/ Epithelial Cells
- Bacterial vaginosis: PMNs are not found, but epithelial cells are present with bacteria adhered (clue cell)
- Candidiasis: PMNs are present with the spores and hyphae
- Trichomonas vaginitis: PMNs are present with the organism
Studying That Suits You
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Description
Test your knowledge on the diagnosis and management of sexually transmitted diseases focusing on Chlamydia and Gonorrhea. This quiz covers clinical findings, treatment options, and complications associated with these infections. Gain insights into the differential diagnosis and effective management strategies as recommended by health authorities.
