Gynecology [GYN INFECTIONS] Vaginal Infections Patients with a vaginal infection come down to three diseases: Candida, Gardnerella (BV), and Trichomonas. The patient presentation is very nonspecific but involves pruritis, odor, and discharge. Nothing is very sensitive or specific from patient history so always do a pelvic exam and run some tests before treating. Though it’s the best test, a culture often isn’t necessary. However do these in order: speculum exam, microscopic exam, and then antibiotics. The microscopic exam should be of the cervical mucous. There should be two samples on one slide - one with normal saline the other with KOH. Cervicitis Cervicitis is inflammation of the cervix caused by the same bugs as vaginal infections plus gonorrhea and chlamydia. There will be yellow-green mucopurulent discharge and cervical motion tenderness but there will be the absence of other PID symptoms. To figure out the cause do a wet mount, KOH prep, and Gc/Chla PCR and treat accordingly.
Candida BV Trich
Test Gram Stain Culture
Outpatient Regimens include: 1) Ceftriaxone IM x 1 + Doxycycline + Metronidazole 2) Cefoxitin + Probenecid + Doxycycline + Metronidazole
Grey-white, fishy odor, most common Yellow-Green and Frothy, Strawberry Cervix
Clue Cells (saline prep)
KOH fishy smell PingPong
Motile Flagellated (saline prep)
Abx Anti-Fungals OTC: Topical Rx: Fluconazole Metronidazole Metronidazole Both partners!
Gc Gram negative diplococci Chocolate agar required Preferred, 48 hrs Rapid Ceftriaxone IM (no orals)
Salpingitis
Cervicitis (Gc / Chla) = Ceftriaxone IM x 1 = Azithro or Doxy
Normal Vaginal Flora CDC Diagnosis:
Additional Criteria:
Surgery is required for abscess drainage or frank peritonitis. Pitfalls:
Notes DM, Abx
Tubo ovarian abscess
Admission is required for severe disease – high fever, nausea/vomiting, or TOA. Antibiotic coverage must include gonorrhea, chlamydia, and the gram negatives / anaerobes of the vaginal fauna. Inpatient regimens are either: 1) Cefoxitin + Doxycycline 2) Clindamycin + Gentamycin
Micro Hyphae (KOH prep)
Cla Polys, but no organisms Gold standard, not needed Preferred, 48 hrs Rapid Doxy or Azithro
PCR Urine Abx
Pelvic Inflammatory Disease This is actually a clinical spectrum of disorders of the upper genital tract including endometritis, salpingitis, tubo-ovarian abscess, and florid pelvic peritonitis. It comes from either Gonorrhea (1/3), Chlamydia (1/3), and organisms of the vaginal flora. The idea is that it is possible for an infection of the cervix to progress into an ascending infection into the sterile uterus. But it’s also possible that the protective barrier gets compromised and normal vaginal flora can ascend into the uterus and fallopian tubes. The person is usually quite ill. Pelvic pain and mucopurulent cervical discharge is almost always present. There will be cervical motion tenderness (“chandelier sign”), uterine tenderness, or adnexal tenderness. Only 1 of 3 is necessary. Often there’s high fever and the patient is quite toxic. Imaging is not necessary, but a transvaginal ultrasound may reveal free fluid or tubo-ovarian abscess.
Discharge Thick, white, adherent to wall
1) Pelvic pain or Abdominal Pain 2) No other cause except PID 3) One of the following Cervical motion tenderness Adnexal tenderness Uterine tenderness 1) Fever 2) Mucopurulent discharge 3) WBC on wet mount Absence of leukocytosis is irrelevant Leave in IUD Outpatient therapy attempted first unless severe or pregnant
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