upper genital tract STI + Acute Pelvic Pain Flashcards

1
Q

Infections causing vaginitis or ectocervicitis

A

candida, trichomonas, HSV, BV

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2
Q

upper genital tract infections

A

chlamydia + gonorrhea

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3
Q

signs of cervicitis

A

mucopurulent cervical discharge, cervical friability, vaginal discharge, strawberry cervix

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4
Q

work-up for cervicitis

A

endocervical swabs for gram staining, gonorrhea culture, and chlamydia NAAT

gram stain >20 PMNs per HPF –> chlamydial and or gonorrhea (not sensitive or specific)

vaginal swabs for wet mount + gram stain (for trich, BV)

note on cervical swab:

  • vaginal swab if pre-pubertal
  • if hysterectomy: urine NAAT or vaginal swab for NAAT (can be used for G, C, and trich)
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5
Q

how to perform cervical + vaginal swab

A

cervical: rotate 180 degrees in endocervix
vaginal: swab pooled secretions or posterior fornix

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6
Q

chlamydia testing

A

NAAT - best

urine, urethral or cervical swab
use urine if asymptomatic + pelvic exam not needed

effected by blood + mucous

test-of-cure unnescessary

culture only for legal - assault

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7
Q

Gonorrhoea testing

A

urethral or endocervical swab for gram

gram-neg diplococci inside PMNs = predictive (outside is non-specific)

culture for sensitivities (sex assault, treatment failure), may be neg <48hrs from exposure

NAAT: cervical, urethral, urine, +/- vaginal. Use if no cervix or not want exam

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8
Q

trichomonas testing

A

whiff neg - no bad odour

vaginal pH >4.5

microscopy (but not sensitive), culture if available (urethral, vaginal swabs, prostate fluid, urine sediment)

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9
Q

candida testing

A

pH normal, whiff neg

wet-mount prep /w KOH shows budding or branching pseudohyphae

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10
Q

BV testing

A

pH >4.5, whiff positive

gram stain: less gram positive rods (lactobacilli), more coccobacili and clue cells

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11
Q

PID definition

A

infection involving endometrium, fallopian tubes, pelvic peritoneum, and/or adjacent structures

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12
Q

organisms that cause PID

A

STI: C + G

Endogenous: genital mycoplasmas

anaerobes: bacertoides, peptostreptococcus, prevotella

facultative aerobes: E.Coli, gardnerella vaignalis, streptococcus, haemophilus influenza

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13
Q

diagnostic criteria for PID

A

minimal diagnostic criteria:

1) lower abdo tenderness
2) adnexal tenderness
3) CMT

additional criteria:

1) oral T >38.3
2) leukocytosis
3) WBC on vag wet mount
4) elevated ESR
5) elevated CRP
6) +ve for G or C

definitive:

1) endo bx shows endometritis
2) TVUS: thickend fluid filled tubes +/- free fluid or TOA
3) gold standard: laparoscopy see erythema/exudates

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14
Q

criteria for PID admission

A

1) can’t r/o other surg emergency
2) pregnancy
3) failure of outpatient tx
4) can’t tolerate/follow PO meds
5) severe illness, vomiting, fever
6) can’t follow-up after 72 hrs
7) adolescence
8) co-existing HIV/immune

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15
Q

treatment overview

A

broad spectrum antibiotics

if parenteral: can stop after 24hrs if improve, then PO for 14 days

if no improvement: laparoscopy + alternative dx considered

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16
Q

outpatient Tx for PID

A

1) ceftriaxone 250mg IM + doxycycline PO bid x 14 days

2) cefoxitin 2g IM +
probenecid 1g PO +
doxycyline 100mg PO bid x 14 days

3) other parental third gen cephalosporin (ceftizomine or cefotaxime) PLUS doxycylince 100mg PO bid x 14 days

1, 2, and 3 can add metronidazole 500mg PO bid for more anaerobes/BV

4) Ofloxacin 400mg PO bid x 14 days +/- metronidazole 500mg PO bid x14d
5) levofloxacin 500mg PO qd +/- metronidazole 500mg PO bid x14d

17
Q

CI antibiotics in preg + BFing

A

ofloxaxin, ciprofloxacin, levofloxacin, doxycycline

18
Q

In patient tx for PID

A

1) cefoxitin 2g IV q6h + doxycycline 100mg IV/PO q12h
2) Clindamycin 900mg IV q8h + gentamicin loading IV/IM 2mg/kg, then 1.5mg/kg q8hrs

Alternatives: ofloxacin or levofloxacin + metronidazole,

amplicillin + doxycycline

cirprofloxaxin + doxycycline + metronidazole

19
Q

chlamydia tx

A

treat if positive, if suspect and don’t want to wait for results, if sexual partner dx, if gonorrhoea is dx

test of cure at 3-4 wks only if: poor compliance, symptoms, re-exposure, alt regimen, pre-pubertal, pregnant

meds:
doxycycline 100mg PO bid x 7 days
OR
azithromycin 1g PO single dose

alts: ofloxacin, erythromycin, amoxicillin (if preg)

20
Q

gonorrhoea treatment

A

ceftriaxone 250mg IM

alt: cefixime 800mg PO x1

ok if pregnant

21
Q

reporting

A

G + C reportable to public health, partners from 60 days since onset contacted + treated

for trichomonas partners don’t need to be treated

22
Q

follow-up for G + C

A

repeat screen in 6 months, re-infection rate high

23
Q

Differential diagnosis for acute pelvic pain

A

preg: SA, septic abortion, ectopic
gyne: endometritis, PID/salpingitis, TOA, dsymenorrhea, fibroids, endometriosis, mittelschmerz, ovarian cyst (rupture/hemorrhage), torsion, cancer, ovarian hyperstim syndrome

non-gyne: appendicitis, bowel stuff, UTI, kidney, MSK, joints, hernia, aortic aneyrusm/dissection, prophyria

24
Q

workup for acute pelvic pain

A

hx + physical (abdo + pelvic exam)

labs

  • BCHG
  • Rh if preg
  • urinalysis
  • cervical + vag swabs
  • CBC
  • others PRN

Imaging

  • US
  • CT in specific cases (MRI if preg)

laparoscopy
- if can’t dx and are considering dangerous pathology (appendicitis, PID, torsion)