Let's now review another case.
A 35 year old woman who is HIV-positive
presents with a one week history
of yellow vaginal discharge
and mild dysuria.
What about her HIV status concerns you?
I'll let you think about that.
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.
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.
Offer the patient testing for her
partner in case she does have a partner.
Could she possibly have an STI?
Well, she does have an
You also wanna ask the patient,
is she taking her HIV meds?
this is important as it
keeps the virus titers low.
Typically, patients are treated
What else should she be screened for?
Let's go on as you think about that.
Well, let's now talk about the second criteria
for the CDC's diagnosis of clinical drips.
So, gonorrhea is a very common
cause of a discharge in a woman.
You can also have nongonococcal urethritis,
chlamydia, mucopurulent cervicitis
and trichomonas vaginalis that causes vaginitis and
urethritis and of course, bacterial vaginosis.
Remember that bacterial
vaginosis is not an STI
but it is sexually associated
and let's not discuss that now.
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.
This leads to a fishy, vaginal discharge that
these patients can suffer from recurrently.
Let's now talk about gonorrhea.
Gonorrhea is a urogenital
infection in the female
and can cause infection specifically
in the endocervical canal.
70 to 90% also colonize the urethra.
The incubation period is unclear
but usually signs and symptoms
occur within ten days of an infection.
Most patients complain of a vaginal discharge,
painful urination or dysuria
and labial pain, swelling
or abdominal pain.
There are other forms of urethritis
besides those caused by gonorrhea.
They can be nongonococcal urethritis.
20 to 40% actually is
caused by chlamydia.
Another 20 to 30% is caused by mycoplasma,
another half is actually unknown.
And occassionally, trichomonas vaginalis
and HSV can cause urethritis.
You can have mild dysuria
or pain upon urination
and sometimes a vaginal discharge
that is mucoid.
You can see polymorphonuclear
cells on a urethral smear.
but that's typically very
painful and hard to tolerate.
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.
Let's now talk about chlamydia.
Chlamydia can mostly be asymptomatic.
It's actually asymptomatic but causes a lot of
morbidity especially to the female GYN tract.
Clinical manifestations of chlamydia
include cervicitis, urethritis and PID.
PID can be very devastating
to a woman's fertility.
Complications include potential
transmission to a newborn during delivery.
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.
Let's now look at what a
normal cervix looks like.
Here you can see the cervix is pink and
looks to have no discharge or lesion.
However, this cervix appears intensely
red and angry and has a discharge.
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.
You can also do a gram stain
to look for gonorrhea.
You can do a non-culture,
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.
But we typically don't use a
PAP smear to screen for STIs.
And don't forget, you can do serology
especially when you have LGV present.
Let's now just briefly go over the treatment.
I don't think this will be on your exam,
but in case you wanna know more information,
just quickly look through this slide.
If you have gonorrhea, it's recommended
that you have IM ceftriaxone.
And you should also be treated for a co-infection
with chlamydia even if you tested negative.
This includes azithromycin
If you have chlamydia, you can just
take azithromycin or doxycycline.
As an alternative, you can take
or other medications
such as ofloxacin.
Let's now review PID.
10 to 20% of women who have gonorrhea
and chlamydia actually develop PID.
In north America, there is a high proportion
of chlamydia than gonorrhea in
patients who have PID symptoms.
Let's now review the CDC minimal criteria.
You may have uterine tenderness,
or you may have cervical
Remember that the adnexa is
a zip code, not an address.
There are many things that live in the adnexa
including the ovaries and the fallopian tubes.
However, we also have bowel and
also sometimes the ureter.
Other symptoms include: endocervical
discharge, fever, lower abdominal pain.
And the complications result in infertility.
With one episode of PID, you could
have a rate of 15- 24% of infertility
secondary to gonorrhea or chlamydia.
You have an increased risk of ectopic
pregnancy with just one episode of PID.
And of course, chronic pelvic pain is increased
in the population who has suffered from PID.
Prevention is best.
Let's now talk about some of the pathologic
findings that you see upon laparoscopy.
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.
This is called Fitz-Hugh Curtis syndrome.
It look like violin strings
and if you see this,
this is pretty much confirms
that the patient has had PID.
Also, if a patient becomes
pregnant after PID,
remember that her ectopic pregnancy risk is increased
seven times after a single incidence of PID.
This is a fatal emergency and depending
on the location of the ectopic
and the status of the patient, may sometimes
need to be managed surgically or medically.
Let's now talk about the
outpatient treatment of PID.
Again, I don't think this
will be on your exam
but it's helpful to know as you
start rounding on the wards.
What's recommended is
ceftriaxone plus doxycycline
with or without flagyl
There are other combinations as well.
Please download the slide
for more information.
Let's now talk about Trichomonas vaginalis.
This is a sexually transmitted parasite.
There are lots of cases worldwide.
This is from a figure from the WHO and it
had been almost 250 million new cases.
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.
The prevalence of trichomonas
actually increases with age
and the highest rates are
in African-American women.
We find trichomonas in
2.5 to 23.2% of adolescents.
And we also find a higher prevalence in
women who abuse drugs at 8.6 to 38%.
This is what you might see
upon speculum examination.
Here you see a cervix
that has a copious discharge.
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.
Let's now talk about the treatment.
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
There are alternatives such
Remember that metronidazole is the preferred
agent in women who are HIV infected.
Thank you for listening and
good luck on your exam.