Sexually Transmitted Infections: Drips/Discharges, Pelvic Inflammatory Disease, and Trichomonas Vaginalis

00:01 Let's now review another case.

00:03 A 35 year old woman who is HIV-positive presents with a one week history of yellow vaginal discharge and mild dysuria.

00:11 What about her HIV status concerns you? I'll let you think about that.

00:25 Well, what's in your differential diagnosis? What would you do next? If you're taught to ask the patient, "is she using condoms during sex?" That's a good question.

00:38 You want to ask every patient, "Do you use barrier contraception to avoid STIs?" But especially in HIV-positive patient as she can transmit the virus to her partner.

00:49 Offer the patient testing for her partner in case she does have a partner.

00:55 Could she possibly have an STI? Well, she does have an abnormal discharge.

01:01 You also wanna ask the patient, is she taking her HIV meds? this is important as it keeps the virus titers low.

01:09 Typically, patients are treated with anti-retrovirals.

01:13 What else should she be screened for? Let's go on as you think about that.

01:20 Well, let's now talk about the second criteria for the CDC's diagnosis of clinical drips.

01:27 So, gonorrhea is a very common cause of a discharge in a woman.

01:33 You can also have nongonococcal urethritis, chlamydia, mucopurulent cervicitis and trichomonas vaginalis that causes vaginitis and urethritis and of course, bacterial vaginosis.

01:48 Remember that bacterial vaginosis is not an STI but it is sexually associated and let's not discuss that now.

01:56 The vagina typically has an acidic ph but with intercourse, the sperm increases the ph of the vagina and actually causes an overgrowth of certain bacteria.

02:07 This leads to a fishy, vaginal discharge that these patients can suffer from recurrently.

02:16 Let's now talk about gonorrhea.

02:18 Gonorrhea is a urogenital infection in the female and can cause infection specifically in the endocervical canal.

02:26 70 to 90% also colonize the urethra.

02:30 The incubation period is unclear but usually signs and symptoms occur within ten days of an infection.

02:37 Most patients complain of a vaginal discharge, painful urination or dysuria and labial pain, swelling or abdominal pain.

02:45 There are other forms of urethritis besides those caused by gonorrhea.

02:50 They can be nongonococcal urethritis.

02:53 20 to 40% actually is caused by chlamydia.

02:57 Another 20 to 30% is caused by mycoplasma, another half is actually unknown.

03:05 And occassionally, trichomonas vaginalis and HSV can cause urethritis.

03:11 You can have mild dysuria or pain upon urination and sometimes a vaginal discharge that is mucoid.

03:19 You can see polymorphonuclear cells on a urethral smear.

03:24 but that's typically very painful and hard to tolerate.

03:28 You can see on microscopy in the urine that there would be the presence of white blood cells and you may see the presence of leukocyte esterase.

03:38 Let's now talk about chlamydia.

03:40 Chlamydia can mostly be asymptomatic.

03:43 It's actually asymptomatic but causes a lot of morbidity especially to the female GYN tract.

03:50 Clinical manifestations of chlamydia include cervicitis, urethritis and PID.

03:56 PID can be very devastating to a woman's fertility.

04:00 Complications include potential transmission to a newborn during delivery.

04:05 This can cause conjunctivitis and pneumonia in a newborn and the pediatricians need to be alerted to the status of mom if she has chlamydia.

04:16 Let's now look at what a normal cervix looks like.

04:19 Here you can see the cervix is pink and looks to have no discharge or lesion.

04:24 However, this cervix appears intensely red and angry and has a discharge.

04:31 So typically, when you wanna test for chlamydia, you would insert a Q-tip that allows us to obtain some of the mucus and send that off for PCR or nucleic acid testing.

04:46 You can also do a gram stain to look for gonorrhea.

04:52 You can do a non-culture, non-amplified test or you can do a nucleic acid amplification test and you can use urine, cervical swabs as I just described, urethral swabs, vaginal swabs and also a PAP smear.

05:09 But we typically don't use a PAP smear to screen for STIs.

05:14 And don't forget, you can do serology especially when you have LGV present.

05:20 Let's now just briefly go over the treatment.

05:23 I don't think this will be on your exam, but in case you wanna know more information, just quickly look through this slide.

05:30 If you have gonorrhea, it's recommended that you have IM ceftriaxone.

05:35 And you should also be treated for a co-infection with chlamydia even if you tested negative.

05:40 This includes azithromycin and doxycycline.

05:45 If you have chlamydia, you can just take azithromycin or doxycycline.

05:50 As an alternative, you can take erythromycin, levofloxacin or other medications such as ofloxacin.

06:01 Let's now review PID.

06:04 10 to 20% of women who have gonorrhea and chlamydia actually develop PID.

06:10 In north America, there is a high proportion of chlamydia than gonorrhea in patients who have PID symptoms.

06:18 Let's now review the CDC minimal criteria.

06:21 You may have uterine tenderness, adnexal tenderness or you may have cervical motion tenderness.

06:28 Remember that the adnexa is a zip code, not an address.

06:32 There are many things that live in the adnexa including the ovaries and the fallopian tubes.

06:37 However, we also have bowel and also sometimes the ureter.

06:44 Other symptoms include: endocervical discharge, fever, lower abdominal pain.

06:50 And the complications result in infertility.

06:53 With one episode of PID, you could have a rate of 15- 24% of infertility secondary to gonorrhea or chlamydia.

07:01 You have an increased risk of ectopic pregnancy with just one episode of PID.

07:07 And of course, chronic pelvic pain is increased in the population who has suffered from PID.

07:13 Prevention is best.

07:16 Let's now talk about some of the pathologic findings that you see upon laparoscopy.

07:22 This may not be too clear here but this is a laparoscopic picture what we would look up at the liver and see that there are adhesions forming from the anterior abdominal wall to the liver.

07:35 This is called Fitz-Hugh Curtis syndrome.

07:37 It look like violin strings and if you see this, this is pretty much confirms that the patient has had PID.

07:47 Also, if a patient becomes pregnant after PID, remember that her ectopic pregnancy risk is increased seven times after a single incidence of PID.

07:58 And ectopic pregnancy is a medical emergency and can be potentially fatal if not promptly diagnosed and managed.

08:07 Let's now talk about the outpatient treatment of PID.

08:11 Again, I don't think this will be on your exam but it's helpful to know as you start rounding on the wards.

08:18 What's recommended is ceftriaxone plus doxycycline plus metronidazole.

08:23 There are other combinations as well.

08:26 Please download the slide for more information.

08:30 Let's now talk about Trichomonas vaginalis.

08:33 This is a sexually transmitted parasite.

08:36 There are lots of cases worldwide.

08:39 This is from a figure from the WHO and it had been almost 250 million new cases.

08:46 This occurs in about 3.1% of the US female population but don't forget we have a large immigrant population in the US and can be higher in those who do not originate from the US.

08:59 The prevalence of trichomonas actually increases with age and the highest rates are in African-American women.

09:05 We find trichomonas in 2.5 to 23.2% of adolescents.

09:12 And we also find a higher prevalence in women who abuse drugs at 8.6 to 38%.

09:19 This is what you might see upon speculum examination.

09:23 Here you see a cervix that has a copious discharge.

09:27 It may not always be colored but it can be yellow or white and sometimes appear as frothy but that varies and is difficult to ascertain.

09:38 Let's now talk about the treatment.

09:40 Again, I don't think this will be on your test, but just know for the boards and the wards that metronidazole is the primary treatment.

09:49 There are alternatives such as tinidazole.

09:54 Remember that metronidazole is the preferred agent in women who are HIV infected.

10:02 Thank you for listening and good luck on your exam.