00:01
Let's now review another case.
00:03
A 35 year old woman who is HIV-positive
presents with a one week history
of yellow vaginal discharge
and mild dysuria.
00:11
What about her HIV status concerns you?
I'll let you think about that.
00:25
Well, what's in your differential diagnosis?
What would you do next?
If you're taught to ask the patient,
"is she using condoms during sex?"
That's a good question.
00:38
You want to ask every patient,
"Do you use barrier contraception
to avoid STIs?"
But especially in HIV-positive patient as
she can transmit the virus to her partner.
00:49
Offer the patient testing for her
partner in case she does have a partner.
00:55
Could she possibly have an STI?
Well, she does have an
abnormal discharge.
01:01
You also wanna ask the patient,
is she taking her HIV meds?
this is important as it
keeps the virus titers low.
01:09
Typically, patients are treated
with anti-retrovirals.
01:13
What else should she be screened for?
Let's go on as you think about that.
01:20
Well, let's now talk about the second criteria
for the CDC's diagnosis of clinical drips.
01:27
So, gonorrhea is a very common
cause of a discharge in a woman.
01:33
You can also have nongonococcal urethritis,
chlamydia, mucopurulent cervicitis
and trichomonas vaginalis that causes vaginitis and
urethritis and of course, bacterial vaginosis.
01:48
Remember that bacterial
vaginosis is not an STI
but it is sexually associated
and let's not discuss that now.
01:56
The vagina typically has an
acidic ph but with intercourse,
the sperm increases the ph
of the vagina
and actually causes an
overgrowth of certain bacteria.
02:07
This leads to a fishy, vaginal discharge that
these patients can suffer from recurrently.
02:16
Let's now talk about gonorrhea.
02:18
Gonorrhea is a urogenital
infection in the female
and can cause infection specifically
in the endocervical canal.
02:26
70 to 90% also colonize the urethra.
02:30
The incubation period is unclear
but usually signs and symptoms
occur within ten days of an infection.
02:37
Most patients complain of a vaginal discharge,
painful urination or dysuria
and labial pain, swelling
or abdominal pain.
02:45
There are other forms of urethritis
besides those caused by gonorrhea.
02:50
They can be nongonococcal urethritis.
02:53
20 to 40% actually is
caused by chlamydia.
02:57
Another 20 to 30% is caused by mycoplasma,
another half is actually unknown.
03:05
And occassionally, trichomonas vaginalis
and HSV can cause urethritis.
03:11
You can have mild dysuria
or pain upon urination
and sometimes a vaginal discharge
that is mucoid.
03:19
You can see polymorphonuclear
cells on a urethral smear.
03:24
but that's typically very
painful and hard to tolerate.
03:28
You can see on microscopy in the urine that there
would be the presence of white blood cells
and you may see the presence
of leukocyte esterase.
03:38
Let's now talk about chlamydia.
03:40
Chlamydia can mostly be asymptomatic.
03:43
It's actually asymptomatic but causes a lot of
morbidity especially to the female GYN tract.
03:50
Clinical manifestations of chlamydia
include cervicitis, urethritis and PID.
03:56
PID can be very devastating
to a woman's fertility.
04:00
Complications include potential
transmission to a newborn during delivery.
04:05
This can cause conjunctivitis
and pneumonia in a newborn
and the pediatricians need to be alerted
to the status of mom if she has chlamydia.
04:16
Let's now look at what a
normal cervix looks like.
04:19
Here you can see the cervix is pink and
looks to have no discharge or lesion.
04:24
However, this cervix appears intensely
red and angry and has a discharge.
04:31
So typically, when you wanna
test for chlamydia,
you would insert a Q-tip that allows
us to obtain some of the mucus
and send that off for PCR
or nucleic acid testing.
04:46
You can also do a gram stain
to look for gonorrhea.
04:52
You can do a non-culture,
non-amplified test
or you can do a
nucleic acid amplification test
and you can use urine, cervical
swabs as I just described,
urethral swabs, vaginal swabs
and also a PAP smear.
05:09
But we typically don't use a
PAP smear to screen for STIs.
05:14
And don't forget, you can do serology
especially when you have LGV present.
05:20
Let's now just briefly go over the treatment.
05:23
I don't think this will be on your exam,
but in case you wanna know more information,
just quickly look through this slide.
05:30
If you have gonorrhea, it's recommended
that you have IM ceftriaxone.
05:35
And you should also be treated for a co-infection
with chlamydia even if you tested negative.
05:40
This includes azithromycin
and doxycycline.
05:45
If you have chlamydia, you can just
take azithromycin or doxycycline.
05:50
As an alternative, you can take
erythromycin, levofloxacin
or other medications
such as ofloxacin.
06:01
Let's now review PID.
06:04
10 to 20% of women who have gonorrhea
and chlamydia actually develop PID.
06:10
In north America, there is a high proportion
of chlamydia than gonorrhea in
patients who have PID symptoms.
06:18
Let's now review the CDC minimal criteria.
06:21
You may have uterine tenderness,
adnexal tenderness
or you may have cervical
motion tenderness.
06:28
Remember that the adnexa is
a zip code, not an address.
06:32
There are many things that live in the adnexa
including the ovaries and the fallopian tubes.
06:37
However, we also have bowel and
also sometimes the ureter.
06:44
Other symptoms include: endocervical
discharge, fever, lower abdominal pain.
06:50
And the complications result in infertility.
06:53
With one episode of PID, you could
have a rate of 15- 24% of infertility
secondary to gonorrhea or chlamydia.
07:01
You have an increased risk of ectopic
pregnancy with just one episode of PID.
07:07
And of course, chronic pelvic pain is increased
in the population who has suffered from PID.
07:13
Prevention is best.
07:16
Let's now talk about some of the pathologic
findings that you see upon laparoscopy.
07:22
This may not be too clear here but
this is a laparoscopic picture
what we would look up at the liver
and see that there are adhesions
forming from the anterior
abdominal wall to the liver.
07:35
This is called Fitz-Hugh Curtis syndrome.
07:37
It look like violin strings
and if you see this,
this is pretty much confirms
that the patient has had PID.
07:47
Also, if a patient becomes
pregnant after PID,
remember that her ectopic pregnancy risk is increased
seven times after a single incidence of PID.
07:58
And ectopic pregnancy is a medical emergency
and can be potentially fatal
if not promptly diagnosed and managed.
08:07
Let's now talk about the
outpatient treatment of PID.
08:11
Again, I don't think this
will be on your exam
but it's helpful to know as you
start rounding on the wards.
08:18
What's recommended is
ceftriaxone plus doxycycline
plus metronidazole.
08:23
There are other combinations as well.
08:26
Please download the slide
for more information.
08:30
Let's now talk about Trichomonas vaginalis.
08:33
This is a sexually transmitted parasite.
08:36
There are lots of cases worldwide.
08:39
This is from a figure from the WHO and it
had been almost 250 million new cases.
08:46
This occurs in about 3.1% of the US
female population but don't forget
we have a large immigrant
population in the US
and can be higher in those who
do not originate from the US.
08:59
The prevalence of trichomonas
actually increases with age
and the highest rates are
in African-American women.
09:05
We find trichomonas in
2.5 to 23.2% of adolescents.
09:12
And we also find a higher prevalence in
women who abuse drugs at 8.6 to 38%.
09:19
This is what you might see
upon speculum examination.
09:23
Here you see a cervix
that has a copious discharge.
09:27
It may not always be colored but it can be
yellow or white and sometimes appear as frothy
but that varies and is
difficult to ascertain.
09:38
Let's now talk about the treatment.
09:40
Again, I don't think this will be on your test,
but just know for the boards and the wards
that metronidazole is the primary
treatment.
09:49
There are alternatives such
as tinidazole.
09:54
Remember that metronidazole is the preferred
agent in women who are HIV infected.
10:02
Thank you for listening and
good luck on your exam.