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

by Lynae Brayboy, MD

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    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.

    02:51 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.

    05:41 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.

    07:59 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.

    08:12 Let's now talk about the outpatient treatment of PID.

    08:15 Again, I don't think this will be on your exam but it's helpful to know as you start rounding on the wards.

    08:22 What's recommended is ceftriaxone plus doxycycline with or without flagyl or metronidazole.

    08:29 There are other combinations as well.

    08:32 Please download the slide for more information.

    08:36 Let's now talk about Trichomonas vaginalis.

    08:39 This is a sexually transmitted parasite.

    08:42 There are lots of cases worldwide.

    08:45 This is from a figure from the WHO and it had been almost 250 million new cases.

    08:52 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.

    09:05 The prevalence of trichomonas actually increases with age and the highest rates are in African-American women.

    09:12 We find trichomonas in 2.5 to 23.2% of adolescents.

    09:18 And we also find a higher prevalence in women who abuse drugs at 8.6 to 38%.

    09:25 This is what you might see upon speculum examination.

    09:29 Here you see a cervix that has a copious discharge.

    09:33 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.

    09:44 Let's now talk about the treatment.

    09:46 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.

    09:55 There are alternatives such as tinidazole.

    10:00 Remember that metronidazole is the preferred agent in women who are HIV infected.

    10:08 Thank you for listening and good luck on your exam.


    About the Lecture

    The lecture Sexually Transmitted Infections: Drips/Discharges, Pelvic Inflammatory Disease und Trichomonas Vaginalis by Lynae Brayboy, MD is from the course Gynecologic Pathology: Infections, Neoplasms and Screening. It contains the following chapters:

    • Case Study and Drips/Discharges: Gonorrhea, Nongonococcal Urethritis and Chlamydia
    • Pelvic Infammatory Disease (PID)
    • Trichomonas Vaginalis

    Included Quiz Questions

    1. Endocervical canal
    2. Ovary
    3. Fallopian tube
    4. Vagina
    5. Endometrium
    1. Chlamydia trachomatis
    2. Neisseria gonnorhea
    3. HIV
    4. Trichomonas vaginalis
    5. Herpes simplex
    1. PAP smear testing
    2. Culture
    3. Nucleic acid amplification test
    4. Non-culture and non-amplified tests
    5. Serology
    1. Azithromycin 1 gm PO X 1
    2. Erythromycin base 500 mg PO QID X 7 days
    3. Erythromycin base EES 800mg po QID X 7 days
    4. Levofloxacin 250mg po qd X 7 days
    5. Ofloxacin 300mg po BID X 7 days
    1. Endometriosis
    2. Infertility
    3. Chronic pelvic pain
    4. Ectopic pregnancy
    5. Tubo-ovarian abscess
    1. Adhesions from anterior abdominal wall to the liver
    2. Adhesions from anterior abdominal wall to the spleen
    3. Adhesions from anterior abdominal wall to the pancreas
    4. Adhesions from anterior abdominal wall to the colon
    5. Adhesions from anterior abdominal wall to the urinary bladder
    1. Ceftriaxone Doxycycline /- metronidazole
    2. Ceftriaxone ciprofloxacin /- metronidazole
    3. Cefexime Doxycycline /- metronidazole
    4. Ceftriaxone Ampicillin /- metronidazole
    5. Cefotaxime Doxycycline /- metronidazole
    1. Metronidazole
    2. Ciprofloxacin
    3. Ampicillin
    4. Ceftriaxone
    5. Azithromycin

    Author of lecture Sexually Transmitted Infections: Drips/Discharges, Pelvic Inflammatory Disease und Trichomonas Vaginalis

     Lynae Brayboy, MD

    Lynae Brayboy, MD


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