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LECTURE SCRIPT
SEXUALLY TRANSMITTED DISEASES:
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: 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) 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) doxycycline 100 mg PO BID X 14 days Regimen B ofloxacin 400 mg PO BID X 14 days 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 doxycycline 100 mg IV or PO q 12 hr Regimen B clindamycin 900 mg IV q 8 hr 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 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 |