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Lower Genital Tract Infections

Lower Genital Tract Infections. Case 1. Healthy 33 yo c/o foul-smelling vaginal discharge. She is sexually active with 1 male partner. This is the first time she has had these symptoms and is worried it may represent a serious health problem.

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Lower Genital Tract Infections

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  1. Lower Genital Tract Infections

  2. Case 1 • Healthy 33 yo c/o foul-smelling vaginal discharge. She is sexually active with 1 male partner. This is the first time she has had these symptoms and is worried it may represent a serious health problem. • What history & physical, and office labs should be done?

  3. Case 2 • 35 yo female with 2 sexual partners in the last year complains of an itchy, smelly discharge. The pelvic exam reveals no vulvar or vaginal inflammation; a foamy, thin discharge with pH of 5.0; and some bleeding at the cervix. Wet prep reveals 2 clue cells and no motile organisms. Your diagnosis?

  4. Vaginal Complaints • Most common reason for gyn visits • 10 million office visits annually • PE and laboratory data are recommended • 3 most common etiologies are • vaginal candidiasis • bacterial vaginosis • trichomoniasis

  5. Prevalence • Varies by clinical setting • National figures show: • 40% - 50% bacterial vaginosis • 20% - 25% vaginal candidiasis • 15% - 20% trichomoniasis • Up to 30% with complaints go without a clear diagnosis

  6. “Normal” Vaginal Discharge? • The distinction is problematic • Scant primary literature on “normal vaginal discharge” • Normal increase in cervical mucous production mid-cycle, OCP use • Can be malodorous and accompanied by irritative symptoms

  7. Making the Diagnosis • Symptoms • discharge, odor, irritation, or itch • discharge • Clear, white, green, gray, yellow • Consistency – thin, thick, or curd like • Signs • excoriations • erythema • discharge

  8. Wet Preps (Wet Mounts) • Sample vaginal discharge from the posterior fornix • pH • Microscopy • Leukocytes, lactobacilli, clue cells, yeast, or trichomonads • Whiff test – 10% KOH • Characteristic fishy (amine) odor of BV

  9. Accuracy of Symptoms • Discharge characteristics • If described as “cheesy”, more likely to be yeast (LR, 2.4 95% CI 1.4-4.2) • Less likely if described as “watery” (LR 0.12 95% CI 0.02 – 0.82) • No other characteristics were helpful in making the diagnosis JAMA. 2004;291:1368-79

  10. Accuracy of Symptoms • Itching • think yeast, LR 1.4 – 3.3 • 70% - 90% with yeast itch • Not helpful for BV or trich • Odor • If present, decreases chances of yeast • Absence of malodor practically rules out BV (NPV 93%, Thomason et al. Am J Obstet Gynecol 1990) • Malodor makes BV more likely (PPV 90%)

  11. Accuracy of Signs • Discharge • Thick, curdy, white strongly predicts yeast • Otherwise, difficult to interpret • Inflammation • Vulvar/vaginal edema, erythema, fissures, or excoriations • If present, increases likelihood of yeast or trich • Odor – if present, associated w/ BV

  12. Accuracy of Office Tests • Microscopy • Sensitivity for yeast varies 38% - 83% • Absence of yeast rules against it, but cannot rule it out • Normal lactobacilli makes BV less likely • Presence of trichomonads makes diagnosis, but absence can’t rule it out (LR 0.34 CI 0.17-0.64)

  13. Accuracy of Office Tests • pH level • Normal is 4.0 - 4.5 • Yeast is associated w/ normal pH, but not always • BV has a high pH • Trich usually has a high pH • Whiff test • Positively associated with BV and trich • Less likely to be yeast if positive

  14. Bottom Line • Symptoms and signs can help to suggest a diagnosis • Canididiasis is associated with itching, a cheesy discharge, and redness • BV is associated with increased discharge and malodor • Other sxs and signs overlap too much • Wet prep is the best way to make a diagnosis

  15. Bacterial Vaginosis • Most common cause of vaginitis in premenopausal women • Represents a complex change vaginal flora • Decrease in lactobacilli • Increase in gardnerella vaginalis, mycoplasma hominis, anaerobic G- rods, and peptostreptococci • Exact mechanism by which change takes place is unclear

  16. Bacterial Vaginosis

  17. Clinical Features • 50% are asymptomatic • Unpleasant, “fishy smelling” discharge • Itching and inflammation are uncommon

  18. Amstel Criteria • Homogenous, grayish-whitish discharge • Vaginal pH > 4.5 • Positive Whiff test • Clue cells on wet mount • First three can overlap with trich • Clue cells are the most reliable predictor of BV

  19. Clue Cells

  20. Complications • Increases risk for: • Preterm labor in pregnant women • Endometritis and postpartum fever • Post-hysterectomy vaginal-cuff cellulitis • Postabortal infection • Acquiring other STDs, especially HIV

  21. Therapy • May resolve spontaneously • Treat if: • Symptomatic • Asymptomatic prior to TAB or hysterectomy, IUD placement • Pregnant and have history of PTL or PTD • No need to treat sexual partners

  22. Therapy • Metronidazole • Oral divided doses achieve early clinical cure in excess of 90%, cure rates of approx 80% at four weeks • 500mg PO BID x 7 days or metro-gel 1 applicator full qd x 5d • Single dose therapy (2gm) achieves same early clinical cure, but known to have a higher relapse rate

  23. Therapy • Clindamycin • Topical vaginal cream (2%), 5g once daily x 7 days • As effective as metronidazole • Can use oral but less effective • Pseudomembranous colitis • Vaginal cream weakens condoms • ? Preferred choice in pregnancy

  24. Candida Vulvovaginitis • About 1/3 of vaginitis cases • Up to 75% of premenopausal women have at least one episode • Rare before menarche, but 50% will have it by age 25 • Less common in postmenopausal women, unless taking estrogen

  25. Candida albicans • Causes the majority of yeast infections (80-92%) • Some report an increase in c. glabrata • Predisposing factors • Antibiotics • Diabetes mellitus • OCPs • Contraceptive devices (IUD, sponge) • Pregnancy

  26. Clinical Features • Vulvar/vaginal pruritis • “Burning” when they void (externally) • Irritation, soreness, dyspareunia • White, clumpy discharge

  27. Wet Mount • pH 4- 4.5 (normal) • Yeast buds or spores or hyphae • KOH prep destroys cellular elements to facilitate recognition of budding yeasts or hyphae (sensitivity 70%) • Negative in up to 50% of culture proven candidal infections

  28. Therapy • Most uncomplicated infections improve with therapy within 2 days • Severe infections may require up to 14 days to improve • Most tx achieve clinical cure rates in excess of 80% • No one therapy or route of administration better than any other

  29. Therapy – “Azole” Antifungals • Imidazoles – effective against C. albicans • Miconazole, clotrimazole, butoconazole, tioconazole, all OTC • Triazoles – effective against C. albicans, and C. glabrata and tropicalis • Terconazole, fluconazole, ketoconazole • Good for recurrent infections if suspecting resisitant organism or elimination of rectal reservoir

  30. Trichomoniasis • Affects 2 – 3 million American women annually • 3rd most common vaginitis • Flagellated protozoan – trichomonas vaginalis • Infects vagina, urethra and paraurethral glands • Virtually always sexually transmitted

  31. Clinical Features • Ranges from asymptomatic infxn to severe, acute inflammatory disease • Purulent, malodorous, thin, frothy discharge • Dysuria (external), dyspareunia and pruritis are common • “strawberry cervix”

  32. Trichomoniasis

  33. Wet Mount • Trichomonads seen only in 50 – 70% • Elevated pH • Can increase leukocytes • Paps

  34. Therapy • Metronidazole 2gm x 1 or 500mg bid x 7 days • Avoid topical therapy • Treat sexual partners simultaneously • If refractory to treatment • Retreat with 7 day course • If fails again, try 2gm dose daily x 3 – 5 days • Assure compliance with partner/culture

  35. Other Causes of Vaginitis • Atrophic vaginitis • High vaginal pH, thin epithelium, d/c • Parabasal cells on wet mount • Topical estrogen cream • Atypical manifestations: HSV, HPV • Noninfectious vulvovaginitis • Irritants/allergens • Lichens syndromes (sclerosus, simplex chronicus, planus) • Cytolytic vaginitis

  36. Herpes Simplex Virus • The “silent epidemic” • > 45 million in the US • > 1 million newly diagnosed annually • The most common STD in US, and likely the world • Almost 25% of Americans have HSV2 antibodies by the age of 30

  37. Herpes Simplex Virus • HSV – 1 • Mostly oro-labial, but increasing cause of genital herpes • HSV – 2 • Almost entirely genital • > 95% of recurrent genital lesions • Primary infections • Recurrent infections • Latency

  38. Transmission • Horizontal Transmission • Intimate sexual contact (oral/genital) • Aerosol and fomite transmission is rare • Vertical Transmission • Maternal-infant via infected cervico-vaginal secretions, blood or amniotic fluid at birth • Autoinoculation • From one site to another

  39. Primary Herpes – Classic Symptoms • Systemic – fever, myalgia, malaise • Can have meningitis, encephalitis, or hepatitis • Local – clusters of small, painful blisters that ulcerate and crust outside of mucous membranes • Itching, dysuria, vaginal discharge, inguinal adenopathy, bleeding from cervicitis

  40. Primary Herpes • New lesions form for about 10 days after initial infection, but can last up to 3 weeks • Shedding of virus lasts 2 – 10 days

  41. Recurrent Herpes • Reactivation of virus • Mild, self-limited • Localized, lasting 6-7 days • Shedding: 4-5 days • Prodrome: 1-2 days

  42. Subclinical Viral Shedding • > 90% of persons with genital HSV-2 shed virus asymptomatically • Shed 1-10% of asymptomatic days (without recognized symptoms) in persons with recurrent HSV-2 • Uncommon in HSV-1 genital infection • Frequency highest in first year after acquisition • Responsible for most transmission

  43. The Clinical Spectrum of HSV - 2 • Of the HSV-2 positive people Truly Asymptomatic 20% 60% Recognized genital herpes 20% Unrecognized with symptoms

  44. Diagnosis • Viral isolation (culture) • High specificity, low sensitivity • 50% for primary infxn • 20% for recurrent infxn • Direct detection of virus (Tzcank smears, PCR) • Serology • Newer tests that are specific for type of virus (HerpesSelect 2, herpes glycoprotein for IgG, ELISA)

  45. Who Is a Candidate for Serologic Testing? • Suspicious symptoms or hx suggesting atypical or undiagnosed herpes • Doesn’t believe the clinical dx • Anyone requesting an “STD” test • Partner has genital herpes • Pregnant women with unrecognized genital HSV-2

  46. Management Goals • Relieve symptoms • Heal lesions • Reduce frequency of recurrent episodes • Reduce viral transmission • Patient support and counseling

  47. Oral Antiviral Therapy • Valacyclovir (Valtrex) • Famciclovir (Famvir) • Acyclovir (Zovirax)

  48. Summary • History, vaginal exam and wet prep to diagnose vaginitis • Don’t forget about the “other” causes of vaginitis • Remember HSV – the Silent Epidemic • Educate without judgment

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