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Questions and Answers
What is a characteristic of a Nabothian cyst?
Which of the following is NOT a method for assessing a cervical or vaginal discharge?
What is the primary causative agent of syphilis?
In the context of herpes simplex virus management, which treatment is most effective for reducing the frequency of recurrences?
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What is typically considered a 'can’t miss' condition related to vulvar or cervical health?
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Which statement is true regarding HPV in relation to cervical disease?
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What common infectious agent is often associated with yeast vulvitis?
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What should be considered if herpes simplex lesions are present?
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What characterizes the primary lesion of syphilis during the incubation period?
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What is the most significant complication associated with a Bartholin gland abscess?
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Which treatment is best for a symptomatic Bartholin gland cyst in a patient over 40 years old?
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In diagnosing vulvovaginal candidiasis, which finding is expected during an examination?
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What is a characteristic symptom of bacterial vaginosis?
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What pH level is associated with bacterial vaginosis?
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Which organism is most commonly associated with vulvovaginal candidiasis?
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What is the typical first-line treatment for Trichomonas vaginalis infection?
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Which laboratory test is commonly used to diagnose syphilis?
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Which of the following best describes the discharge seen in trichomonas vaginalis infection?
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In cases of vulvovagitiis, what should be done to enhance the diagnosis?
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What is a common risk factor for recurrent vulvovaginal candidiasis?
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For a patient with Bartholin gland abscess, what is the recommended management?
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What symptom is NOT typically associated with bacterial vaginosis?
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What is the appropriate follow-up timeline for outpatients diagnosed with PID to demonstrate substantial improvement?
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Which of the following treatments is NOT included in the oral regimens for PID?
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When should women diagnosed with gonorrhea or chlamydia be retested after treatment?
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What should be the initial treatment course duration for PID before considering further action?
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Which group is recommended to receive annual chlamydia screening?
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What is the most common symptom of chlamydia in individuals with a vagina?
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Which of the following is NOT a high-risk population for gonorrhea/chlamydia?
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In the examination of a patient suspected to have gonorrhea or chlamydia, what finding is most likely to be observed?
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What diagnostic test is recommended for confirming gonorrhea or chlamydia?
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Which of the following is a complication that can arise from gonococcal or chlamydial salpingitis?
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What is true about the CDC recommendations for gonorrhea and chlamydia screening?
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What is the significance of elevated C-reactive protein (CRP) in the context of chlamydia and gonorrhea?
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What is a necessary criterion for hospitalizing a patient with PID?
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Study Notes
Vulvar and Vaginal Discharge Assessments
- Inspect the vulva and anal region carefully.
- Perform a speculum examination with pH testing, wet prep, and STD testing, including the examination of external genitalia for other lesions.
- Consider HPV subtyping and/or serum testing for STDs including HIV.
- Test the partner if the condition is an STI.
Cervical Disease
- Evaluate for vaginal discharge abnormalities.
- Use Nucleic Acid Amplification Testing (NAAT) for STD testing.
Normal Cervix
- The normal cervix can have variations in appearance.
- Nabothian Cyst: A mucous-filled inclusion gland whose exit is blocked; resembles "sebaceous cyst of the cervix" or "cervix acne".
- Ectropion: Happens when the uterus enlarges during late puberty and again at pregnancy, causing glands near the outer edge of the cervix to "pooch" out into the vagina.
Common Infectious Agents of the Vulva
- Herpes Simplex lesions
- Bartholin's Cysts/Abscesses
- Yeast Vulvitis
"Can't Miss" Vulvar Conditions
- Syphilis
- Cancer (covered later with HPV)
Herpes Simplex Virus
- The latent virus exists in the dorsal root ganglia (sensory neurons) – reactivation leads to recurrent episodes and shedding.
Herpes Simplex Virus Management
- Treat the symptoms:
- Oral acyclovir, famciclovir, or valacyclovir.
- Prevent/decrease recurrences and associated viral shedding:
- Abstain from sex during prodrome or while lesions are present.
- Episodic treatment of recurrent infection: Early intervention is crucial.
- Consider daily suppressive treatment for frequent recurrent infections.
- Assess the patient and partner for co-existing STDs (HIV, Syphilis) and counsel on transmission reduction.
Syphilis
- Causative agent: Treponema Pallidum
- Disease states: primary (vulvar lesion), secondary (systemic), tertiary (neurosyphilis)
- Current U.S. Status: increasing; reported cases of syphilis (all stages) have increased 74% since 2017.
- Congenital syphilis continues to surge, increasing 203 percent in the past five years (CDC).
- Diagnosis: serum test (Treponema pallidum is difficult to grow in culture).
- In primary syphilis, diagnosis is based on a positive darkfield result or (PCR) of material from chancres, or a combination of a clinical diagnosis + positive serology.
Syphilis Vulvitis
- Most common presentation: unilateral chancre.
- Primary lesion: Incubation period of 3 weeks (10 days to 3 months), highly contagious, resolves in 2-6 weeks.
- Secondary lesion: condyloma lata, highly contagious, appears 6 weeks to 6 months.
Syphilis Treatment
- Benzathine Penicillin
- For penicillin allergy, desensitize and treat with benzene penicillin.
Bartholin Gland Cyst/Abscess
- Bartholin Gland Cyst: Blocked Bartholin duct and mucus accumulates in the gland.
- Bartholin Gland Abscess: Obstructed duct becomes infected, higher risk in women with STIs.
Bartholin Gland Cyst Presentation
- Nontender, usually unilateral, soft mass in the lower medial labia majora.
Bartholin Gland Abscess Presentation
- Acute pain (difficulty walking, sitting, or having intercourse).
- Fever possible.
- Unilateral, warm, tender, fluctuant mass in the lower medial labia majora (can extend into the upper labia).
- Erythema and edema surrounding the mass.
- Possible purulent spontaneous drainage.
Bartholin Gland Cyst Management
- If asymptomatic, it can be left alone.
- In patients over 40 years old, drain and consider a biopsy to exclude malignancy.
- If symptomatic, manage like an abscess.
Bartholin Gland Abscess Management
- Treatment: Incision and drainage with placement of a Word Catheter.
- Culture the discharge (STI, MRSA).
- Refer for marsupialization procedure if recurrent.
- Antibiotics typically not needed (drainage is the treatment) except for MRSA or any STI.
Vulvovaginitis and Vaginitis
- Vulvitis often has associated vaginitis.
- Vagina: Reservoir for the source of vulvar irritation.
- Factors affecting vulvar warts/cancer also affect the vagina and cervix.
- Always perform a speculum exam when diagnosing vulvitis.
- Remember: Anything affecting the skin can affect the vulva. General rule: Treat for what you think it is, but biopsy and refer if it doesn't improve.
Normal Vaginal Physiology
- Physiologic vaginal pH: 4.0-4.5
- Protective against bacterial overgrowth and some protection against STIs.
- Lactobacilli predominate the vaginal flora:
- Glycogen from vaginal epithelial cells is their "food".
- Metabolized to lactic acid.
- Maintains bacterial community balance toward low pH, anaerobic species.
Factors Contributing to Vaginitis
- Medication changes and cyclic changes can disrupt pH, causing shifts in the bacterial community.
- Trauma, pH shifts, and decreased immunity increase vulnerability to vaginitis, including STIs.
- Trauma creates entrance points for infection.
- One infection can promote pH and discharge changes, increasing susceptibility to other infectious agents.
Vulvovaginal Candidiasis ("Yeast Infection")
- Sporadic, uncomplicated fungal overgrowth, typically caused by Candida Albicans.
- Risk factors:
- Underlying disease (DM, HIV)
- Medications (antibiotics, SGLT2 inhibitors)
- Chronic or recurrent issues may arise from other Candida species (C.glabrata).
Vulvovaginal Candidiasis Symptoms
- Vulvovaginal pruritus (itching)
- Vulvovaginal burning
- Thick white odorless "cottage cheese" discharge
Vulvovaginal Candidiasis Diagnosis
- Often self-diagnosed and treated.
- Examination reveals variable degrees of vulvovaginal erythema and edema.
- Thick adherent white odorless discharge ("cottage cheese").
- Normal pH.
- Wet prep: spores and/or hyphae.
- Culture: Only done if recurrent or treatment-resistant.
Vulvovaginal Candidiasis Treatment
- Numerous effective OTC antifungal products available.
- Prescription options:
- Oral Fluconazole 150 mg x 1 dose.
- Terconazole/Butoconazole/Nystatin Cream or Suppos. x 3-7 days.
- Symptomatic relief:
- Combined topical steroid + antifungal for vulvar inflammation.
- Cool shallow bath.
- Avoid other contact irritants.
- Prevention: Probiotics.
Bacterial Vaginosis (BV)
- Polymicrobial syndrome resulting from replacement of normal flora (lactobacilli) with anaerobic bacteria.
- Not an STI, but commonly associated with STIs.
Symptoms of BV
- Watery, white/gray discharge, often profuse.
- Typically no pruritus, burning, or pain.
- Foul "fishy" odor, especially after menses or sex.
BV Diagnostic Hallmarks ("Amsel Criteria")
- Thin, gray-white discharge present at the introitus and coating vaginal walls.
- pH 4.5 or greater.
- Positive "whiff" (amine) test with KOH wet mount.
- Presence of Clue cells on saline wet mount.
- Often no mucosal irritation/inflammation.
BV Treatment
- Goal: Decrease cocci overgrowth in the vagina and allow for regeneration of lactobacilli (restore vaginal homeostasis).
- First line: Metronidazole (Flagyl) 500 mg.po BID x 7 days.
- Second line: Clindamycin 300 mg.po BID x 7 days.
- Other creams are also effective.
Trichomonas Vaginalis
- Protozoal infection.
Symptoms of Trichomonas
- Copious yellow/gray/green discharge, may be frothy, malodorous, blood-streaked.
- Often have vulvar pruritus and dysuria.
Trichomonas Vaginalis (and Cervicitis) Examination
- Vaginal erythema and inflammation, frothy discharge.
- "Strawberry cervix"
- pH > 4.5
- Wet prep saline with numerous WBCs and motile Trichomonads.
Trichomonas Vaginalis (and Cervicitis) Diagnosis
- Wet prep with observed organisms.
- Rapid in-office Ag test.
- NAAT.
Trichomonas Vaginalis Treatment
- First line: Metronidazole 2 Gm. x 1 dose.
- Alternative regimens/Treatment failures: Metronidazole or Tinidazole 2 Gm.Daily x 5 days.
- This condition is sexually transmitted, test for other STIs.
- CDC recommends repeat testing with NAAT in 2-3 months due to the high reinfection rate.
Cervicitis
- Most vaginitis can also become cervicitis (Trichomonas, herpes).
- Some STIs cause cervicitis that is prone to spreading from the cervix into the uterus (endometritis).
- This is considered an upper genital tract infection.
- Upper genital tract infections almost always affect the fallopian tubes and often ascend into the peritoneum.
- Cervical mucus protects against ascending infections, but it's not perfect.
Gonorrhea & Chlamydia
- Gonorrhea is the 2nd most commonly reported communicable disease in the US.
- Chlamydia is the most commonly reported bacterial infection in the US.
- Gonorrhea and Chlamydia are most common in women ages 15-24 and men ages 20-24.
- Gonorrhea and Chlamydia can cause purulent urethral discharge, dysuria, and local pain in those with penises.
- Gonorrhea and Chlamydia can cause vaginal discharge in those with vaginas but often have no symptoms.
- Gonorrhea and Chlamydia can be diagnosed with a Nucleic acid amplification test (NAAT) or a wet prep with WBCs.
- The CDC recommends annual screening for all sexually active females under 25, and those with risk factors over 25.
- The CDC also recommends all sexually active women have one-time HIV screening.
Pelvic Inflammatory Disease (PID)
- PID is often caused by Gonorrhea or Chlamydia.
- PID treatment must cover N. gonorrhoeae, C. trachomatis, anaerobes, Gram-negative bacteria, and streptococci.
- If BV is present, anaerobic coverage must be included.
- Early treatment of PID is essential to prevent long-term sequelae. Do not wait for culture results to begin treatment.
- PID Criteria for Hospitalization:
- Inability to rule out surgical emergencies (e.g., appendicitis, ectopic pregnancy)
- Pregnancy
- Failure to respond clinically to outpatient antimicrobial therapy within 48-72 hours
- Inability to tolerate an outpatient oral regimen.
- Severe illness, nausea and vomiting, high fever
- tubo-ovarian abscess
- HIV infection with low CD4 count
- PID Intramuscular/Oral Regimens:
- Broad-spectrum antibiotics (Ceftriaxone, Doxycycline, Metronidazole)
- PID IV Regimens:
- Broad spectrum antibiotics (Cefotetan, Cefoxitin, Doxycycline, Clindamycin, Gentamicin)
- Continue these regimens for at least 24 hours after substantial clinical improvement, then complete a total of 14 days therapy with Doxycycline.
- PID Follow-Up:
- Outpatients should demonstrate substantial improvement within 72 hours. Patients who do not improve usually require hospitalization, additional diagnostic tests, and surgical intervention.
- All women diagnosed with gonorrhea or chlamydia should be retested 3 months after treatment regardless of whether their partner has been treated.
PID Screening
- Screen and treat for chlamydia to reduce the incidence of PID.
- Annual chlamydia screening is recommended for:
- Sexually active women 25 and under
- Sexually active women >25 at high risk
- Screen pregnant women in the 1st trimester.
Fitz-Hugh-Curtis Syndrome
- May be a complication of gonococcal or chlamydial salpingitis.
- Characterized by right upper quadrant pain in association with acute salpingitis, indicating perihepatitis.
- Acute cholecystitis may be suspected, but signs and symptoms of PID are present or develop rapidly.
Male sex partners of women with PID should be examined and treated.
- Treatment should occur if the male sex partners of women with PID had sexual contact with the patient during the 60 days preceding the onset of the patient’s symptoms.
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Description
This quiz focuses on assessing vulvar and cervical conditions, including discharge abnormalities and testing methods. Explore exam techniques, common infectious agents, and variations of the cervix. Enhance your understanding of proper evaluations and diagnostics in gynecological health.
