Lower Genital Tract Infections

1. Lower Genital Tract Infections Basim Abu-Rafea, MBBS, FRCSC, FACOG Consultant OBGYN Reproductive Endocrinology & Infertility Advanced Minimally Invasive Gynecologic Surgery

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

41. 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

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

43. 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

44. The Clinical Spectrum of HSV - 2 Of the HSV-2 positive people

45. 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)

46. 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

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

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

49. 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