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Case. 19 y/o white female comes to ED Cc: I think I have a bladder infection. HPI: 3 days of Low Abdominal pain, nausea, vomiting, anorexia, dysuria, and yellow/white d/c in underwear. Increasing achy, dull pain for last 3 days and worse with walking or other movement. More Case.

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Case

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  1. Case • 19 y/o white female comes to ED • Cc: I think I have a bladder infection. • HPI: 3 days of Low Abdominal pain, nausea, vomiting, anorexia, dysuria, and yellow/white d/c in underwear. • Increasing achy, dull pain for last 3 days and worse with walking or other movement.

  2. More Case • PMH: Sexually active w/ one partner for last 1 year. Treated for episode 6 months ago of vaginal d/c and told she had “an STD”, but partner check and he was asymptomatic. Rarely uses condoms, because they are both monogamous. Otherwise healthy.

  3. Case Physical • PE: Temp 100.8, Resp. 22, HR 105 • Uncomfortable, lying in bed • Abd – bilateral LAP, guarding. No masses. No flank tenderness • Pelvic – large amount of yellowish/white discharge, no lesions noted, has CMT, bilateral adnexa tenderness • WBC – 12,500 with left shift; UPT –negative; UA: Leukocytes, no nitrates.

  4. Pelvic inflammatory disease Appendicitis Ovarian torsion Renal colic Pyelonephritis Ovarian cyst Endometriosis Gastroenteritis Diverticulitis Cervicitis Differential Dx:

  5. Pelvic Inflammatory Disease and Vaginitis Curtis Johnson, MD PGY 2, Emergency Medicine, UAMS October 2, 2003

  6. PID - Definition • An ascending infection of the otherwise sterile upper reproductive tract, often initiated by a sexually transmitted organism, but polymicrobial at the time of presentation.

  7. Types of PID • Acute – Vaginal d/c, pelvic pain, CMT, symptoms of urethritis, occurs 3-5 days after menses, High WBC. • Intermediate – Symptoms ranging between Acute and Chronic, Normal WBC. • Chronic – achy pelvic pain worsened by trauma, sex, and menses; diffuse tenderness; no d/c, may have lost reproductive capability, Normal WBC.

  8. PID – a costly disease • Costs about 4 billion dollars a year in health care costs. • Accounts for about 300,000 hospital admissions a year. • Affects about 1 million women per year. • The most costly and serious infection in post menarchal women.

  9. PID – the Emotional cost • A quarter of all diagnosed patients suffer Chronic pain, ectopic pregnancies, or infertility. • ½ of all cases of ectopic pregnancy in US can be attributed to PID • Ectopics have increased 5 fold in 20 years and are the leading cause of pregnancy deaths in African American women.

  10. PID - Risk factors • Multiple Sexual Partners • Recent Menses or Abortion • Trauma • Presence of an intrauterine device • Previous STD’s • Frequent Douching • Substance abuse

  11. Pathologic Chlamydia N. gonorrhea Mycoplasma homonis Ureaplasma urealyticum Opportunistic Gardinella Vaginalis E.coli (Gram –rods) Streptococcus agalactiae H. influenzae Usual Suspects

  12. How to Work up • History of risk factors • Physical exam – CMT, d/c, tenderness, fever • Labs • CBC - elevated WBC or normal • ESR – elevated or normal • Wet mount, KOH – trichamonas, clue cells • UA, UPT – important for treatment and dx • Cultures – for GC, Chlamydia, syphilis, bacteria • DNA probes – for GC and Chlamydia

  13. Diagnosis • Clinical suspension – based on Work up • Transvaginal Ultrasound – Thicken Fluid Filled Fallopian tubes, free fluid, abscess • Endometrial Biopsy – culture and histological confirmation • Culdocentesis – Leukocytes and bacteria • Laparoscopy – Gold standard – fluid, exudate, hyperemia, abscesses.

  14. The Big Decision – Who to Admit • Uncertain Diagnosis • Suspect Abscess – Tuboovarian or Pelvic • Pregnant • N/V to point of unable to take oral meds • Unable to follow Outpatient oral regimen • Failure to respond to Outpatient therapy • Noncompliant patients • Patients with HIV • IUD in place

  15. PID – Outpatient Management

  16. Inpatient Therapy

  17. But, I’m Allergic

  18. Fitz-Hugh-Curtis • Inflammation of liver capsule and development of adhesions between liver and abdominal wall caused by Neiserria gonorrhea. • Symptoms include right upper quadrant pain and pleuritic pain a few days to weeks after acute PID. • Due to lymphatic drainage or bacteremia. • May require laparoscopy and lysis of adhesions.

  19. PID – Other complications • In first trimester of pregnancy can result in miscarriages and fetal death. • All pregnant patients should be treated with in patient therapy. • Can result in tuboovarian abscess, peritonitis, endometritis, and salpingitis.

  20. Before you send them home • Explain the severity of the PID and probably mode of transportation. • Recommend follow up to be tested for other STD’s (i.e. HIV) • Strongly recommend testing for partner and discourage intercourse until both are treated.

  21. VulvoVaginitis • Irritation of Vulva and Vaginal tissues. • Accompanied by vaginal d/c and/or vulvar itching and irritation. • Accounts for 10 million physician visits per year. • Most common gynecologic complaint in prepubertal girls.

  22. Causes of Vaginitis • Infections • Irritant and allergic contact vulvovaginitis • Local response to vaginal foreign body • Atrophic Vaginitis

  23. Infections – the troublesome trio • Trichamonas Vaginalis • Bacterial Vaginosis • Candidiasis

  24. Trichomonas Vaginalis • Estimated 2-3 million women contract this bacteria per year • Almost solely transmitted as a STD • Associated with PTL, PROM, and Low Birth Weight. • Facilitates infection with HIV • Oral contraceptives, spermicides, and barrier contraceptives may decrease transmission rate.

  25. Symptoms of Trich • May range from asymptomatic carrier to severe. • Vulvovaginal irritation/puritis • Dysuria • Dyspareunia • Feeling of vulvovaginal fullness • Symptoms worse around menses

  26. Signs of Trichamonas • Strawberry Cervix – due to punctate hemorrhage (present in only 2% of cases) • Diffuse erythema • Vaginal Discharge – yellow-green to gray

  27. Diagnosis of Trich • Wet mount slide using Normal saline • Geimsa Stain

  28. Treatment of Trich

  29. You’ve got a Bun in the Oven • Women who are symptomatic for Trichomoniasis should be treated to eliminate symptoms. • Metronidazole is relatively contraindicated in the first trimester of pregnancy. • In symptomatic disease in early pregnancy local therapies (clotrimazole pessaries 100mg daily for 7 days or Aci-jel) could be used. • Systemic treatment will ultimately be necessary to eradicate the infection.

  30. What should we do? • Studies out of the National Institute of Child Health and Human Development and another out of National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network have shown interesting findings. • Metronidazole treatment of women with trichomoniasis significantly increased the risk of preterm birth compared to placebo. • These results formed the basis of the US Preventive Services Task Force recommendation that screening for bacterial vaginosis not be undertaken in low-risk pregnant women.

  31. Bacterial Vaginosis • Clinical syndrome where lactobacilli are replaced with anaerobic bacteria, Gardenella vaginalis, and Mycoplasma hominis • 50% of women are asymptomatic • Rarely occurs in women who are not sexually active.

  32. Signs and symptoms • Clue cells – epithelial cells coated with bacteria • Homogenous white discharge coating walls of vagina • pH greater than 4.5 • Fishy odor after addition of KOH to discharge on a slide.

  33. Complications • Can cause preterm labor, PROM • Associated with PID • Can cause endometritis • Causes vaginal cuff cellulitis after surgery

  34. We’ve Got Controversy • On study found that 2% clindamycin cream was found to increase the risk of PTL by changing the vaginal flora make up (Neatherlands) • Another study found that Clindamycin cream in the early 2nd trimeseter would reduce complications (UK). • Several studies have shown that treating Bacterial Vaginosis has no effect on the rate of preterm labor or low birth weight.

  35. Research • Recent research suggests that Interleukin-1β, Interleukin-6, and Interleukin-8 levels are directly related to abnormalities in vaginal flora resulting in BV.

  36. Candidal Vaginitis • Estimated that 75% of women will experience at least one infection during childbearing years. • Second most common vaginal infection • Not a sexually transmitted disease • Hormone dependant • Rare in premenarchal girls and decreased in postmenopausal women.

  37. Risk Factors for Candida • Pregnancy • Oral Contraceptives • Uncontrolled Diabetes Mellitus • Frequent Antibiotic therapies • Impaired Cell Mediated Immunity

  38. Signs and Symptoms of VVC • Leukorrhea • Vaginal pruritis • External dysuria • Dyspareunia • Vulvar edema and erythema • Vaginal erythema • Thick “cottage cheese” discharge

  39. Diagnosis of Candida • Wet mount and KOH smears on slide – psuedohyphae and yeast buds

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