LECTURE SCRIPT

SEXUALLY TRANSMITTED DISEASES:
THE EMERGENCY DEPARTMENT PERSPECTIVE

Major Robert A. Leibold, MD, US Army
Darnall Army Community Hospital
Fort Hood, Texas


Pelvic Inflammatory Disease is a spectrum of inflammatory diseases of the upper female genital tract and may include endometritis, salpingitis, tuboovarian abscess, and pelvic peritonitis, or any combination thereof

It is most commonly due to the ascending spread of organisms from the vagina and cervix to the endometrium and adnexa which are usually sterile

Sexual transmission accounts for the majority of the cases, with instrumentation (e.g. D & C) being less common

Neisseria gonorrhea and Chlamydia trachomatis are the two most common etiologic agents, however, the infection is often polymicrobial and anaerobes, enteric gram- negative rods, or Gardnerella vaginalis may also be involved

Gonorrhea is more common among inner city women, and chlamydia is more common among college students

The following are risk factors for developing PID:
multiple sex partners
young age
use of an intrauterine contraceptive device (IUD)
previous STD or PID
recent instrumentation
note that oral contraceptives and barrier methods are protective

The clinical features of PID are variable, but usually involve lower abdominal pain

Other associated symptoms that may or may not be present include an abnormal vaginal discharge, nausea, vomiting, anorexia, fever, dyspareunia, dysuria, and vaginal bleeding

It is classically taught that PID is more common just after the menses, however, this holds true for gonorrhea induced PID, whereas chlamydia induced PID has a more uniform incidence throughout the menstrual cycle

Gonorrhea is also associated with a more acute form of PID, and is more likely to present with fever and peritoneal signs compared with chlamydia, however, this does not always hold true

The clinical diagnosis is very difficult

One study reported only a 66% accuracy rate in clinical diagnosis by experienced gynecologists

The differential diagnosis includes appendicitis, ectopic pregnancy, ovarian cyst, ruptured hemorrhagic ovarian cyst, ovarian torsion, threatened abortion, cystitis, pyelonephritis, mesenteric adenitis, gastroenteritis, dysmenorrhea, inguinal hernia, vulvovaginitis, and mucopurulent cervicitis to name a few

Some criteria were developed to help improve the clinical diagnosis; the use of these criteria should help in solving the differential diagnosis, but the presence or absence of the findings does not guarantee the presence or absence of PID (ie. the presence of all the criteria is not pathognomonic of PID)

The clinical criteria consists of three major criteria that must be met as well as at least one of five minor criteria

Three major criteria must be present:

direct abdominal tenderness (with or without peritoneal signs)

cervical motion tenderness

adnexal tenderness

One or more of the following five criteria must be present in addition to all three of the major criteria:

temperature > 100.4oF

leukocytosis > 10,000/mm3

gram stain positive for gram-negative intracellular diplococci (GNID)

purulent peritoneal fluid on laparoscopy or culdocentesis

pelvic abscess by palpation or sonography

laparoscopy can definitively diagnose salpingitis and TOA, but can not necessarily detect endometritis

the cervix should be cultured for gonorrhea and chlamydia

culturing for other organisms is recommended by a few, but most would say that the above cultures are all that is required

once the patient has been diagnosed with PID, then you must determine whether or not they require admission (when in doubt, err on the side of consulting for admission, due to the potential sequelae of under-treated PID)
- the following are criteria for admission:

diagnosed or suspected pyosalpinx or tuboovarian abscess (TOA)

temperature > 100.4oF

pregnancy

nausea and vomiting that precludes oral therapy

upper peritoneal signs

presence of an IUD

failure to respond to outpatient treatment in 48 - 72 hr

uncertain diagnosis

unable to arrange specific and reliable follow up within 48 to 72 hr

immunocompromised (e.g. HIV)

? adolescent (poor compliance)

? nulliparity

- for outpatient treatment one should include all of the following:

antibiotics (follow CDC guidelines, given below)

anti-gonorrhea

anti-chlamydia

perhaps broad spectrum coverage of anaerobes, GNRs, and others

analgesics

evaluation and treatment of sexual partners

mandatory follow up by Ob/Gyn within 48 hr to rule out TOA and treatment failures

there are several CDC recommended regimens for the outpatient treatment of PID, and most believe that a proper eradication of gonorrhea and/or chlamydia is the only antibiotic therapy required for sexually transmitted PID treated on an outpatient basis

the outpatient regimens are as follows:

Regimen A

cefoxitin 2 g IM plus probenecid 1 g orally in a single dose concurrently, or ceftriaxone 250 mg IM or other 3rd-generation cephalosporin (e.g., ceftizoxime, or cefotaxime)
plus

doxycycline 100 mg PO BID X 14 days

Regimen B

ofloxacin 400 mg PO BID X 14 days
plus

clindamycin 450 mg PO QID X 14 days, or metronidazole 500 mg PO BID X 14 days

regimen B has broader coverage, but is also more expensive

note that several drugs which are recommended for uncomplicated gonorrhea or chlamydia infections (e.g. mucopurulent cervicitis, etc.) are not recommended for PID, such as cefixime, azithromycin, and ciprofloxacin; however, single dose azithromycin may be given in addition to doxycycline to help increase compliance

inpatient treatment is similar except that IV antibiotics are used and the patient is more closely monitored

the inpatient antibiotic regimens are as follows:

Regimen A

cefoxitin 2 g IV q 6 hr, or cefotetan 2 g IV q 12 hr
plus

doxycycline 100 mg IV or PO q 12 hr

Regimen B

clindamycin 900 mg IV q 8 hr
plus

gentamicin loading dose IV or IM (2 mg/kg) followed by a maintenance dose of 1.5 mg/kg IV q 8 hr

consult your admitting service as to which antibiotics they'd like you to begin while in the E.D.

the sequelae of untreated (or presumably under-treated) PID includes the following:

infertility

increased risk of ectopic pregnancy - due to adnexal scarring from the inflammation

chronic pelvic pain

tuboovarian abscess

dyspareunia

most commonly due to gonorrhea and/or chlamydia

may also be due to Ureaplasma urealyticum > Trichomonas vaginalis > or HSV

usually presents with symptoms of a urethral discharge and/or dysuria

ask the patient if there are any stains on the underwear indicating any unrecognized discharge

the patient may be asymptomatic

the presence of flank pain, fever, abdominal pain, and/or hematuria should suggest another diagnosis


the genital exam is unremarkable except for possibly a penile discharge and/or mild tenderness along the urethra

examine the discharge under a microscope for PMNs (> 5 PMNs per oil immersion field) and gram-stain for GNIDs

if the patient does not have a discharge, then you may attempt to "milk" one from the urethra, or use a urethral swab

the UA may have a positive leukocyte esterase reaction and pyuria and/or bacteriuria

the treatment regimen should include antibiotics effective against chlamydia in all cases, and against gonorrhea when suspected

the following antibiotics are acceptable:

doxycycline 100 mg PO BID X 7 days, or erythromycin 500 mg PO QID X 7 days, or erythromycin ethylsuccinate 800 mg PO QID X 7 days, or erythromycin base 250 mg PO QID X 14 days (for those who can not tolerate high dose erythromycin)

the patient should abstain from sexual intercourse until he has received the full treatment regimen and is asymptomatic

sex partners should be evaluated and treated if their last sexual contact with the index case was within 30 days of the onset of symptoms

treatment of patients with HIV is the same

this is the female counterpart to male urethritis

usually due to gonorrhea, chlamydia, Trichomonas vaginalis, or HSV

as many as 50% of infected patients are asymptomatic

symptoms may include a vaginal discharge, dysuria, increased urinary frequency, vaginal bleeding (esp. after intercourse), or rarely mild abdominal pain

examination will show inflammation of the cervical os with an associated mucopurulent discharge (> 10 PMNs per oil immersion field (1,000X))

it may be difficult for the emergency physician to distinguish between inflammation of the cervical os and cervical ectropion

cervical vesicles and ulcers with a mucoid discharge suggests HSV

the cervix should be cultured for gonorrhea and chlamydia

treatment is similar to male urethritis

a symptom complex of vaginal itching/discomfort and/or a vaginal discharge

there are both infectious and noninfectious causes

the common infectious etiologies are:

candidiasis - due to Candida albicans

trichomoniasis - due Trichomonas vaginalis

bacterial vaginosis - due to an alteration of the normal vaginal flora with an overgrowth of Gardnerella vaginalis and anaerobes

noninfectious etiologies include:

atrophic vaginitis - due to hormonal changes, esp. common in postmenopausal women

contact vulvovaginitis - due to local irritation, esp. common in children

vaginal foreign bodies

when examining the vaginal discharge, one should take a sample from the vaginal wall, not the endocervix

if the pH of the discharge is > 4.5, then trichomoniasis and/or bacterial vaginosis is more likely

prepare two slides, one with 1 - 2 drops of NS, and the other with 1 - 2 drops of 10% potassium hydroxide (KOH);

a sample of the secretions are placed on each slide, and a cover slip is then used

the presence of an amine or "fish-like" odor upon addition of the secretion to the KOH slide suggests bacterial vaginosis or trichomoniasis

each slide is examined under a microscope at low and high dry-power; the detection of yeast and/or pseudohyphae on the KOH slide is highly suggestive of Candida albicans, which will not be detected on the NS slide; the presence of motile, flagellated "pear shaped" cells on the NS slide is highly suggestive of trichomoniasis; the presence of "clue cells" is highly suggestive of bacterial vaginosis; "clue cells" are clusters of bacilli clinging to the surface of desquamated epithelial cells

Candida albicans is the most common infectious cause

it is not transmitted sexually

it is part of the normal flora in up to 50% of women, but becomes symptomatic when the normal vaginal environment is changed

the following predispose to infection:

antibiotic usage

decreased glycogen stores in the vaginal epithelium (DM, pregnancy, BCPs, and postmenopausal)

increased vaginal pH (semen, blood)

symptoms include vaginal itching, leukorrhea, and possibly dysuria or dyspareunia

often have a "cottage cheese" discharge

there may be mild erythema and/or edema of the vulva

a KOH prep of the vaginal secretions may reveal yeast or pseudohyphae

treat with a 3 or 7 day course of antifungal creams or suppositories

sexual partners do not need to be treated

trichomoniasis is almost always due to sexual transmission in alkaline semen

only 10% of men who transmit the disease are symptomatic, and only 50% of women

there will be a malodorous, frothy vaginal discharge of varying color

they may also have pruritus, dysuria, dyspareunia, or vaginal discomfort

diffuse erythema of the vagina is common, and 20% will have a "strawberry cervix"

the saline wet mount prep will show motile, flagellated trichomonads

treat with metronidazole 2 g PO X 1, or 500 mg PO BID X 7 days unless the patient is pregnant

refer the sexual partners for evaluation and treatment

bacterial vaginosis is usually due to a change in the vaginal microflora with an overgrowth of Gardnerella vaginalis; the presence of Gardnerella alone is not diagnostic

the CDC requires 3 of 4 criteria be met:

homogeneous discharge

pH > 4.5

positive amine odor test presence of "clue cells"

the patient may have mild pruritus and a copious discharge

the vaginal exam is usually normal except for the discharge and occasional mild erythema

"clue cells" are found in about 60% of cases

treat the symptomatic patients with metronidazole 500 mg PO BID X 7 days, or clindamycin 300 mg PO BID X 7 days; note that metronidazole is contraindicated during pregnancy

sex partners do not require treatment

asymptomatic women do not require treatment