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Infections and Inflammation of the Genital Tract

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Infections and Inflammation of the Genital Tract Powered By Docstoc
					Genital Tract Infections

      Michael Emerson, M.D.




                              1
Vulva                                                                         The incidence has dramatically gone up. In the United States there are probably
                                                                              about 500,000 new cases annually. The hard part about herpes is once you have
I. Herpes Genitalis                                                           it you always have it so there are approximately 25-30 million Americans with
                                                                              herpes.
   A.   Etiology
        1. Herpes simplex hominis is an all enveloped DNA virus               They did a study on 7,500 patients with herpes and 84% had periodic depression,
                                                                              53% avoided even potentially intimate situations, 20% were rejected by their
        2. Herpes virus is usually transmitted sexually                       partners when they told them they had it and somewhere between 5 and 10% gave
                                                                              up sex altogether.
        3. Incubation 2-20 days; average 6 days
                                                                              Type-I is more commonly above the waist, maybe 85-90%. Type-II, commonly
   B.   Incidence                                                             below the waist. Either can cross the belt line and probably clinically the only
        1.   Herpes is the most common cause of vulvar ulcers, second         significance, type-I above the waist is more likely to occur above the waist. If you
                                                                              have type-I below the waist, it is less likely to recur and vice versa. Type-II is much
             only to gonorrhea as a reason for patients visits to sexually    more common to recur genitally, whereas type-II on the lip is much less likely to
                                                                              recur. So it has some clinical significance.
             transmitted disease (STD) clinics
                                                                              Classically, what happens is a patient comes in contact with somebody with the
        2.   Herpes virus type II antibodies have been found in 20% of        virus. It has a very short incubation period - two to six days - but only about 25%
             control patients and 100% of prostitutes                         will have clinical disease. Often it becomes subclinical so when a patient presents
                                                                              with symptoms, it doesn't mean it was from a recent contact. If they have had a
        3.   500,000 of cases that occur annually:                            monogamous relationship, they shouldn't go home and have a major confrontation
                                                                              with their partner. It could have been something that happened years ago but this
        4.   Approximately 25 million cases in the United States              is the first clinical episode.
   C.   Signs and symptoms                                                    Typically, in a primary episode, multiple lesions which everybody in the room here
        1.   Sudden onset of painful erythema and swelling of the vulva       is familiar with. What happens after a couple of weeks is the virus moves down
                                                                              along the sacral ganglia, sits there and periodically comes back to the surface. If
        2.   Purulent, odorous discharge                                      it is type-II below the waist, you may get three, four, five or more outbreaks a year.
                                                                              Recurrences usually return to the same location. So if a patient comes in and says,
        3.   Followed by diffuse swelling and clear vesicles                  "I have a couple of lesions every couple of months and in the same place and they
                                                                              look like little blisters and they break." You are pretty convinced that the diagnosis
        4.   Later, the vesicles break, and ulcers form. With an initial
                                                                              is herpes.
             infection, lesions last 15-21 days and shedding lasts 8-10.4
                                                                              Classically, primary lesions last about three weeks going through vesicles,
             days                                                             ulceration and secondary crusted lesions which may get infected. The same thing
                                                                              with recurrences only every episode is a much shorter duration. Most of the
        5.   Cystitis. dysuria, and urinary retention may be associated       infectious material is in the vesicle stage when the vesicle first breaks. If you are
        6.   Malaise, myalgia, and low grade fever sometimes occur            doing cultures, what you should always do, at least the first time, is to confirm the
                                                                              diagnosis. The most ideal is clearly when the vesicle is there, you erupt the vesicle
        7.   Many subclinical cases occur                                     and you actually get clear fluid. That material may have 109 viral particles. It is
                                                                              very easy to culture because the virus is virulent. As it progresses and becomes
   D.   Diagnosis                                                             more dry and crusted, you may be less likely to get a positive culture. In
                                                                              recurrences, most patients will tell you they feel a little funny, they know
        1.   Inspection of vulva, vagina, and cervix                          something is going to happen the day before it happens and that will give us
        2.   Routine pap smear of lesion and/or cervix will detect 60-        another clue to how we may choose to treat those patients.

             80%; cytologic changes include the following:                    A significant difference between primary and secondary herpes, much more in the
                                                                              way of systemic infections. Cervical involvement, all with primary. If you look at
             a.     Glassy, degenerated appearance of the nuclei              the involvement of the cervix in cervicitis with primary lesions, 90% to almost
                                                                              100% are affected with primary episodes which is why really in the unusual case
             b.     Acidophilic nuclear inclusions (Cowdry type A)            where a primary episode occurs at term there is so much risk to the baby. The baby
             c.     Less commonly, multinuclear giant cell with either        is going through a cervix that has a high degree of viral particles and the risk may
                                                                              actually be in the 50% range. With recurrences, because the cervix is so minimally
                    balloon degeneration or inclusion bodies in its nuclei    involved, the risk to the baby is much, much less and literally under 5%. It may
                                                                              only be in the 1-2% range.
        3.   Culture of the lesion
                                                                              Primary lesions, multiple lesions in a very painful situation. Ulceration and
   E.   Treatment                                                             secondary infection. Especially with primary lesions, it affects the cervix with
        1.   Acyclovir (Zovirax): a cyclic nucleoside analogue preferen-      recurrences maybe 10%. A very destructive process and I have had patients
                                                                              referred looking like this because somebody thought it may be cervical cancer. But
             tially transports into herpes-infected cells and competitively   if you take a pap smear, instead of getting neoplastic cells you should see
                                                                              multinucleated giant cells which are pretty much pathognomonic of herpes.
             inhibits viral DNA
                                                                              Recurrences have fewer lesions and usually are in the same location. So if the
        2.   Future possibilities
                                                                              patient comes back, you can just say, "As soon as there is any sensation there, come
             a. Interferon                                                    back early" because you are more likely to get a positive culture in the first 48
                                                                              hours and culture the area where the occurrences occur in.
             b. Vaccine
                                                                              Here is a type-II above the waist and as I said, 10-15% but actually, clinically, this
        3.   Symptomatic relief                                               is less likely to occur because it is type-II above the waist.
             a.     Sitz bath (4 oz Betadine)
                                                                              It is highly infectious and easy to transmit to different parts of your body. This was
             b.     Topical anesthetics                                       a nurse who was taking care of a patient with genital herpes. She had a little
                                                                              hangnail and got a herpetic whitlow on her finger. It periodically recurs and creates
             c.     Oral analgesics                                           a problem because how do you come back to the hospital to take care of patients
                                                                              when you have herpes on your finger? Careful hygiene extremely important.
             d.     Keep area clean and dry

                                                                                                                                                                        2
                  (1) Corn starch                                             Patients have to know they can transmit it either from themselves or to their
                                                                              partners. I have one patient that has about three or four lesions on different parts
                  (2) Baby powder                                             of her body and all she does is she is very nervous and she just scratches from one
                                                                              part to the other.
                  (3) Use a hair dryer
            e.    Phenazopyridine tablets (Pyridium) may be useful            Clean lesions hurt less. Just even soaking it in a tub, patting the area dry, baby
                                                                              powder or corn starch all are very soothing. Again, avoiding direct contact. When
  F.   Recurrent herpes genitalis                                             lesions are present, probably any direct contact or intimate relations are best
                                                                              avoided. Using a condom is not going to be adequate. It is not going to cover all of
       1.   Lesions last for an average of 10 days, with pain and viral       the areas involved. Maybe a wet suit would do but I don't think too many people
                                                                              are into that so it is probably best to avoid it all together. What we do is just say
            shedding for 5 days                                               "Soak, pat the area dry or just use a hair dryer on low." because it is that sensitive.
       2.   Recurrence can occur with menses, stress, fever, or               Then, obviously we will get to acyclovir in a minute.

            pregnancy                                                         Acyclovir in healthy nonpregnant woman. It comes in topical, oral and intravenous.
                                                                              The intravenous is really reserved for those really severe cases or
       3.   During a latent period, the virus resides within paraspinal       immunocompromised patients. The topical I think has very little place. It still is
                                                                              30% of the market but compared to the oral it does so little that I really never
            ganglia                                                           prescribe the topical. It just doesn't have any advantage. The oral works extremely
       4.   At intervals, it travels along the axon to the surface            well. There is a marked decrease in the amount of new lesions and symptoms and
                                                                              pain. It shortens the duration of viral shedding. So I would say the treatment of
       5.   Over time, it seems the recurrences become less frequent;         choice would be the oral. As everybody in the room knows, there are now a couple
                                                                              of new ones. The patent for acyclovir is over so they have valacyclovir which is
            they peak during the early adult years                            500 mg b.i.d. for five days, famciclovir which is 125 mg. Possibly convenience and
                                                                              less dosing because of the b.i.d. But even with acyclovir, now it is available in the
       6.   Eighty percent have prodromal symptoms prior to lesions
                                                                              400 mg tablets. If you use that, it is 400 mg four times a day for initial episodes,
       7.   Recurrence is four times more common during pregnancy             three times a day for recurrences or even as little as twice a day for continuous
                                                                              suppressive therapy.
  G. Herpes in pregnancy
                                                                              For recurrences, you can either just give the patient a prescription and as soon as
       1.   In patients with a history of herpes or their partner, docu-      they have a prodrome, use it for five days. What we do with any patients who have
            ment the expected date of confinement (serial ultrasound          more than three or four episodes a year is to put them on continuous suppressive
                                                                              acyclovir, 400 mg b.i.d. We will use it for a year straight. Take them off. As soon
            may be helpful), and start weekly exams at 34-36 weeks            as they have an outbreak, put them back on. There is good evidence that that not
                                                                              only decreases new recurrences but that it actually decreases asymptomatic viral
       2.   Women without clinical evidence of infection at labor should      shedding and probably has a significant advantage that way as well.
                                                                              Immunocompromised patients, certainly patients on Imuran, prednisone, patients
            be allowed to give birth vaginally                                with HIV or various organ transplants, intravenous acyclovir is the treatment of
       3.   If there is clinical or cultural evidence of herpes and the bag   choice.

            of waters (BOW) ruptures, try to perform a C-section within       There is some controversy in pregnancy. For years, we just said it is really not
                                                                              approved for use in pregnancy. We do use it if it is life threatening to the mother
            4 hours. In the presence of herpes, a C-section is indicated,     without a doubt and there is an acyclovir registry. There really hasn't been shown
                                                                              to be any negative impact on the baby and in fact there is probably a positive
            even if the membranes have been ruptured over 4 hours             impact. But because of the potential side effects, because we don't know for sure
  H.   Herpes and cancer                                                      what effect it has on the baby, it is not routinely used for that. At this point, there
                                                                              are a number of studies going on where they are actually using acyclovir in the last
       1.   Herpes virus infection could induce atypical metaplasia and       trimester or in the last six weeks to decrease the chances of an outbreak at term to
                                                                              allow vaginal delivery. So there are a number of studies going on and eventually
            dysplasia, and this influences the receptivity of the epithe-     we may get to that approach. So it is certainly an evolving area.
            lium to potential mutagens, such as sperm
                                                                              Primary maternal infections can cause abortion, preterm labor and delivery, IUGR
       2.   No definite conclusions can be drawn as of yet                    and neonatal infection but fortunately those are uncommon because you are not
                                                                              usually going to have a primary episode during the pregnancy. If you do you, can
II. Condyloma Acuminatum                                                      get transplacental infection but this is less than 50 cases annually in the United
                                                                              States. So it is really at a lower end of the spectrum and not a… we don't go around
  A.   Etiology                                                               doing amniocentesis looking for the virus.
       1.   A recognized disease entity since antiquity, it antedates
                                                                              Far and away the most common, are lesions present at the time of delivery? As I
            syphilis and gonorrhea                                            said before, if they are primary lesions, the risk to the baby may be in the range of
                                                                              50%. Recurrent lesions have a much lower risk to the baby, probably only 1-2%.
       2.   The cause is a papilloma virus                                    If lesions are present, vaginal deliveries are usually contraindicated. We will do a
                                                                              cesarean section even if the bag has ruptured for 8, 10, 12, 24 hours. Initially, we
       3.   Incubation period varies from weeks to months                     used to say if it was more than 6 hours, you weren't sure of the benefit. That study
  B.   Incidence: by far, the most common tumor of the vulva.                 was based on a study of 6 individuals which is clearly not enough to make any
                                                                              difference. So we just simply say doing the section as soon as you can but I don't
  C.   Signs and symptoms                                                     care if it is 18 hours. I would still do a section because you are decreasing the viral
                                                                              shedding to the baby or at least the viral contact to the baby.
       1.   Rough, warty papillomas on the genitalia
                                                                              No matter what you do, there are no guarantees. They did a study for an 18 month
       2.   Secondary pyogenic infections can occur                           period of time and tried to find as many herpes neonatal cases as they could in the
       3.   There is almost always a concomitant vaginitis.                   United States. Only 22% of the women even had a history of herpes and this was
                                                                              out of 150 babies with herpes. About 8% of the total actually had had cesarean
       4.   Thrive during pregnancy                                           sections and still the baby had herpes. So no matter what we do there are no
                                                                              guarantees but at least we have to have a protocol that minimizes the risk.
       5.   Sometimes they disappear spontaneously
                                                                              What do you do in cases like if there is a herpes lesion on the buttocks or on the
  D.   Diagnosis

                                                                                                                                                                        3
     1.   Inspection of vulva, vagina, and cervix                         thigh? What we would do is try to do a cervical culture close to term to try to
                                                                          guarantee that there isn't cervical shedding and then if the woman comes in in
     2.   Larger lesions or lesions in older women may need biopsy        labor, we just put a Betadine Vi-drape across the lesion to allow vaginal delivery.
                                                                          The closer it is to the vulva or vagina, the less likely we are to do that. But we have
E.   Treatment                                                            certainly delivered babies with a lesion on the thigh, on the buttocks, with negative
     1.   Few isolated lesions less than 1 cm                             cultures. The majority are HSV-II. If the baby gets congenital herpes, about half
                                                                          will die. Out of those that survive, about half will have permanent neurologic
          a.   Twenty-five percent podophyllin in compound tincture       damage so it is clearly not something to take lightly.

               of benzoin. Wash it off I-4 hours later; may need two      The history… but as we've said, even in those cases that the baby had congenital
                                                                          herpes, the majority did not have a positive history. If lesions are present, cesarean
               or three applications one week apart. Do not use           section. No lesions, vaginal delivery and we would reserve cultures for those
               podophyllin on vagina or cervix                            patients that have lesions close to term in hopes that the culture is negative by the
                                                                          time they come in in labor or if they have other lesions on other parts of their body
          b.   Bi- or trichloracetic acid (80-90%): observe for 5-10      just to try to make sure they are not also shedding the virus from the cervix.

               minute, may need two or three applications 1 week          Is anybody using Zovirax or acyclovir in the last part of pregnancy routinely?
                                                                          There are some people doing it but it is certainly experimental and not something
               apart. Burning can occur keep soda bicarbonate             that I am going around recommending.
               around to neutralize if necessary
                                                                          Moving on to the next virus - HPV - this is truly epidemic. Think this virus is
          c.   Surgical excision and electrocoagulation of the base       probably on some of the chairs in the room. It just is that common. There are over
                                                                          60-70 different types - about 22 different types that are of interest to us as
          d.   Cryosurgery with liquid nitrogen or cryoprobe              OB/GYNs because they affect the general area. They are 6, 11, 16, 18, 31, 33, 35,
                                                                          45 and 56 seem to be the major players. It affects the entire genital tract and causes
          e.   Laser
                                                                          a whole spectrum of signs and symptoms - genital warts being the most obvious.
          f.   Stop smoking: 50% lower cure-rate in smokers               But itching, dyspareunia, burning, discomfort. When patients complain of
                                                                          symptoms like that, they are all just variations of how the nerve is getting irritated
     2.   Large, bulky or extensive lesion                                and it doesn't really rule in or rule out any specific.
          a.   General anesthesia and wire loop cautery                   A couple of percent will be clinical. The vast majority of patients with HPV will
          b.   Topical 5-fluorouracil (5-FU) cream may eradicate the      have subclinical disease. You may only see it on the pap. You may only see it if
                                                                          you add your 3% acetic acid or on colposcopy.
               lesions or reduce their size
                                                                          Lots of evidence of associating HPV with both condyloma and now with cervical
          c.   Laser                                                      vaginal vulvar and perianal carcinoma. You can actually see the particles with
                                                                          electron microscopy. With some of the different stains, the viral particles will show
     3.   Condyloma in pregnancy                                          up as these brown stains and then we have all of these sophisticated tests. Things
          a    Do not use podophyllin; fetal death has been reported      like DNA hybridization, hybrid capture and now PCR which are all very sensitive
                                                                          ways of finding the virus which have really created a whole new concept on how
               following its use                                          common the occurrence of this virus is.

          b.   For small lesions, freezing, electrocauterization, or      This is sexually transmitted certainly most of the time. Probably 2.5% clinically
                                                                          visible but much higher as far as you go to subclinical ways of looking for it. One
               laser                                                      of the most common, if not the most common reason, for consultations in STDs.
          c.   For large lesions, present at the time of delivery, C-     Three times more common than herpes. In one study at Berkeley, they looked at
                                                                          467 coeds who came in for regular exams or for the pill or something. On pap
               section may be performed to prevent massive bleed-         smears, about 2-3% had either some changes, ascus or some koilocytosis. Using
                                                                          viropap, 11% were positive for HPV. Using PCR, what do you think was the
               ing and to protect the newborn from possible laryngeal     percentage of positive PCR for HPV in 467 coeds at Berkeley? It was 46%. That
                                                                          is why I say I think it is in the drinking water but that it is at least extremely
               papillomas
                                                                          common. Obviously, most of them didn't have symptoms. They didn't have any
          d.   Condyloma from birth canal can cause laryngeal             findings on either paps or even putting on 3% acetic acid but the virus is there.

               papillomas in the newborn approximately 3-7 months         We talked a little bit about how it effects the entire generative tract so you can't get
                                                                          rid of it so the treatment is obviously going to be to try to do the minimal amount
               after birth, as well as a low passage rate. C-section is   that is causing the patient symptoms. But even this one says that 15-40%, including
                                                                          the study I just said, you can bring that up to 46%. Macroscopic, colposcopic, paps
               not recommended, but do inform pediatrician
                                                                          and obviously biopsies. Nobody would have trouble making the diagnosis in that
     4.   Condyloma and neoplasia                                         patient but sometimes it is obviously much more subtle and you may want to take
                                                                          a biopsy as well.
          a.   The cytologic changes for cervical intraepithelial
                                                                          At least 50-70% of the partners will have evidence of HPV as well. If it is clinical
               neoplasia 1 (CIN 1) and condyloma are the same.            in the female, it often will be clinical in the male as well. We have changed the
               They are clinically equivalent and should be managed       thinking quite a bit on what we do. But talking about the partner, at some points
                                                                          in time we used to go ahead and send the partner to… we have a urologist who also
               the same way (ie, colposcopy, extracorporeal circula-      sees patients in the clinic and he would see the males and he would often find little
                                                                          lesions on the shaft of the penis or on the scrotum. When he was learning, he would
               tion ECC, and cervical biopsy). Rule out invasive          kind of first laser them away. Well, sometimes on the scrotal skin that was a little
                                                                          bit of a problem because there wasn't any skin left after you lasered it and
               disease and then use appropriate therapy with careful      obviously it took a very long time to heal. The truth is at this point we are not
               follow-up                                                  doing that. The data says you don't get any higher cure rate in the female whether
                                                                          the male is treated or not. We treat the males and the females equally the way they
          b.   Human papillomavirus (HPV) types 6 and 11 have             should be. If there are signs or symptoms, if there are lesions, if there are problems,
                                                                          we treat the problem. If there are no signs or symptoms, we don't treat. Again, you
               been associated with early CIN and types 16 and 18         can't get rid of the virus so the goal of treatment is not to get rid of the virus. The
                                                                          goal is to get rid of a lesion or the symptoms or in the male or female if there is
               have been associated with advanced CIN or invasive

                                                                                                                                                                     4
                      cancer                                                     neoplasia, we treat that. So a different concept and it is just another one of the
                                                                                 things that continues to evolve as to what makes the best sense.
           5.   For recurrences, careful inspection of entire generative tract
                                                                                 This is just showing you the value of the 3% acetic acid. It will actually show just
                should be completed; all patients with condyloma should          some of the white areas. If you want to make a specific diagnosis, you can use a
                have any concomitant vaginitides treated, and other factors      little Xylocaine in a 3 mm Keyes punch and take a little sample of the skin and
                                                                                 make the diagnosis. The same thing again. Nothing obvious and then after you put
                contributing to "wetness" eliminated                             on your acetic acid, you see the whitish areas. Again, Xylocaine and 3 mm Keyes
                                                                                 punch will confirm the diagnosis for you. Lots of different appearances. Again,
           6.   For resistant cases, interferon has been tried                   patients are referred because people aren't quite sure what they are looking at. HPV
                                                                                 has a whole spectrum of presentations.
III. Chancroid
      A.   Etiology and transmission                                             Evaluating patients with genital condyloma - genital warts. A pap smear because
                                                                                 you want to know if the cervix and/or the vagina are involved as well. Biopsies if
           1.   Hemophilus ducreyi, a small ram negative, nonmotile rod,         you are not sure if they look different. Treat concomitant infections because many
                                                                                 of the sexually transmitted diseases, where you find one you are going to find
                frequently occurs in chains and may occur in parallel chains     others. But specifically with HPV there is a good advantage to treating any other
                                                                                 STDs or treating any other vaginal infections because the secretions themselves
           2.   It spreads by direct contact, appearing 2-6 days after           increase the growth of the virus. So you are going to get a better response if you
                exposure                                                         treat the concomitant infections. Occasionally, a flat lesion, a large lesion or if you
                                                                                 are really not sure, we do biopsies. We do not routinely biopsy. Most of the time
      B.   Incidence: an uncommon disease in the United States, approxi-         we just treat. I did have one patient. She was an elderly woman who had a single
                                                                                 solitary large condyloma and I did biopsy it and it was verrucous carcinoma. Those
           mately 1,400 cases annually                                           are few and far between but if it is really distinct and doesn't quite make sense, then
                                                                                 it is worth taking a biopsy.
      C.   Signs and symptoms
           1.   May be asymptomatic in women, or present as a mild               If you do your biopsy, you should see koilocytosis, dry hollow cells. The viral
                                                                                 particles are pushing the nucleus off to the side and pushing away the cytoplasm
                vaginitis                                                        and that is pretty much pathognomonic if it is truly koilocytosis and not just
                                                                                 artifact. If there really is a question, go down and look at the slide with a
           2.   The disease occurs more in men; women constitute only 10-        pathologist and be sure that is really what it is.
                25 % of the reported incidences
                                                                                 Most of the time, the office will use Bi- or trichloroacetic acid. It is 50-70%. It is
           3.   In the symptomatic female, lesions progress through stages       acid and it is something you really have to be careful with. One day the nurse went
                                                                                 and got the bottle of the shelf for me and the cover wasn't on tight. She spilled a
                of macule, papule, and pustule with erythema                     little bit on her uniform and by the time she came into the room, she had holes
                                                                                 throughout her uniform. This is acid. It is potent stuff but it is what we think works
           4.   The lesions have a jagged edge, with an irregular ulcerated      most expeditiously and you get direct effect. Podophyllin, 5-FU certainly can be
                necrotic base. which is tender and highly            infec-      used. Not in pregnancy. There have been reported deaths from podophyllin in
                                                                                 pregnancy. 5-FU or any of the cytotoxic agents should not be used in pregnancy
                                                                     tious       and 5-FU, although we use it sometimes when there is extensive vaginal
                                                                                 condyloma, is very potent stuff and you've got to be very careful using it. It is
           5.   In 25--60% of cases, the regional lymph nodes are en-            destructive.
                larged, tender, and matted together, usually         unilater-   How many use BCA routinely in the office? BCA or TCA? How many use
                                                                     ally        podophyllin? How many use 5-FU? It really is potent stuff and sometimes you look
                                                                                 in the vagina 10 days later and it looks like a hand grenade went off. There have
           6.   The nodes may gradually soften and resolve or they may           actually been reported cases of the vagina healing together because it is so denuded
                                                                                 that it sticks together and you don't have a vagina after 5-FU. So carefully to be
                suppurate and rupture                                            sure.
           7.   The disease is usually self-limiting
                                                                                 Cryolaser depends if they are extensive. Sometimes we just put local anesthesia and
      D. Diagnosis                                                               some hot cautery in the office. If it is really extensive and recurrent we will go to
                                                                                 laser. Not that there is anything magical about laser. It is just that by the time you
           1.   Clinical picture consists of tender necrotic ulceration and      do that, you are usually even being more thorough, more cautious and probably
                                                                                 getting all the lesions and hopefully decreasing the viral load to the patient.
                regional, tender, usually unilateral lymphadenopathy             Another thing. Dryness, hygiene and treating any other things are useful, but if the
                                                                                 patient smokes, you will get a 50% less cure rate. So the first thing I tell a patient
           2.   Recovery of H. ducreyi from lesion or bubo aspirates
                                                                                 right off the bat is if they smoke that they have just cut my chance of success and
           3.   Identification by gram stain or Wright's stain                   their chance of success in half. The same reason that cervical cancer is much, much
                                                                                 higher in smokers versus non-smokers. It is doing something to the immune system.
           4.   Culture can be done on selective medium                          It increases the viral load and in the patients who are susceptible, it increases the
                                                                                 risk of neoplasia.
      E.   Treatment
           1.   Ceftriaxone (Rocephin), 250 mg IM in a single dose, or           We do use interferon occasionally. It is expensive and can have a little bit of
                                                                                 general systemic side effects like nausea but when everything else fails, we will
           2.   Erythromycin, 500 mg qid, or                                     inject interferon. You can do it a couple of times a week or even just once a week.

           3.   Trimethoprim/sulfamethoxazole (Bactrim), double-strength,        Most people today would say HPV is a very necessary cofactor for cervical-
                                                                                 vaginal-vulvar-perianal carcinoma in situ. There must be some other cofactors as
                160/800 mg bid                                                   well. Some people would say smoking, irritation, even herpes may be a cofactor.
           4.   Treat for a minimum of 7 days and until ulcers and/or lymph      But clearly, smoking increases the risk and there is good evidence of that. We treat
                                                                                 the CIN and VIN all just depending on the amount of neoplasia and ignore the
                nodes have healed                                                virus.

IV.        Granuloma Inguinale(Donovanosis)                                      We treat the neoplasia. We treat the symptoms. People don't want warts on their
                                                                                 bottoms. We will burn those away. We will treat things that cause symptoms and
      A.   Etiology and transmission

                                                                                                                                                                           5
       1.   Calymmatobacterium granulomeres. A pleomorphic gram                 then just follow the patient because we cannot eliminate the virus.

            negative rod with an incubation period from a week to a few         We talked a little bit about 6 and 11, the most benign. Usually condyloma
                                                                                acuminatum genital warts. Then 16, 18, 31, 33, 35, 45 and 56 being more
            months                                                              associated with malignant changes and in fact HPV 16 and 18 have been shown to
       2.   Spread by sexual contact seems likely                               go from CIN 1 to CIN 3 in one year's time.

  B.   Incidence                                                                It can be transmitted and it does affect the larynx as well but not often. Juveniles.
                                                                                Probably the most commonly is transmitted through vertical transmission from the
       1    Granuloma inguinale is of low incidence and low communi-            mother to the child. Low vertical transmission rate not an indication for cesarean
                                                                                section. Again, in a study they followed 106 women with extensive genital
            cability                                                            condyloma at the time of delivery, they followed the babies for five years. Over the
       2.   Recently, only seventeen cases were reported in a year,             course of the five years, only one baby developed a nasal polyp so the risk is
                                                                                obviously low. We do tell the pediatricians that if the baby has a hoarse cry or
       making it the least common of the STDs                                   something, they probably should do a laryngoscope and check.

  C.   Signs and symptoms                                                       In adults, it is transmitted most likely by oral-genital contact. In another study, 101
                                                                                patients, I think it was about two-thirds female and one-third male, extensive
       1.   Insidious onset of a painless papule, nodule, or vesicle            genital condyloma. They sent them all to a dentist. The dentist explored the oral
       2.   Progresses to a soft granulomatous ulcer with a beef, red           cavity and in 9% he saw something that he was suspicious of but biopsied
                                                                                everybody. What percent showed histologic evidence of HPV in the oral mucosa
            base and rolled margin                                              in patients who had extensive genital condyloma? 48%. So if a patient asks if they
                                                                                can transmit this through oral-genital contact, the answer is a definite yes. I am not
       3.   After a secondary infection, progressive putrid and painful         sure what to make out of that clinically. These patients didn't have any signs or
                                                                                symptoms but certainly as far as a factual piece of information, yes, the virus is
            ulceration and anatomic distortion may occur
                                                                                transmitted.
       4.   In 20%, secondary elephantoid, enlargement of the external
                                                                                This virus probably does live on toilet seats. It probably does live in health clubs.
            genitals may occur                                                  It does live on our speculum if we don't autoclave them and they have done
                                                                                cultures of speculums and gotten back positive cultures. They have even gotten
       5.   Tubo-ovarian and bladder complications may occur                    positive cultures in the plume of the laser smoke so I would even be careful with
       6.   Fistulas or stenosis may occur in the vagina, rectum, or            that. I don't know of any gynecologists, but there are dermatologists who have been
                                                                                reported to have lesions in their nose or on their skin, probably from treating
            bladder                                                             patients with laser. For awhile, we had these real tight masks that were supposed
                                                                                to even be able to filter out viral particles. The only problem was you couldn't
       7.   Pseudobuboes may be observed                                        breathe through them either because they filtered out air so we had to kind of give
                                                                                that part up but a caution is appropriate. Obviously having a very good suction
       8.   Extragenital areas (eg, mouth, face), occur in approximately        device is important. So it is easily transmitted.
            6% of cases
                                                                                I want to mention kind of in general, we talked about both herpes and HPV.
       9    Hematogenous spread to liver, spleen, and bones has been            Herpes, although far and away most commonly they are transmitted sexually, I
                                                                                don't think we have all of the answers. I don't think we should be too judgmental.
            reported                                                            The incubation period for herpes is short but for HPV it's maybe three months to
                                                                                five years. Nobody really knows so if somebody comes in, again, don't assume that
  D.   Diagnosis: clinical findings plus lab data                               it is their current partner. Also, they may have picked it up at a health club or from
       1.   Crushed tissue smear showing C. granulomatis                        a toilet seat. If you plate herpes on a toilet seat and go back and do cultures every
                                                                                half hour, how long will you still get positive cultures? It is about 3 hours before
       2.   Pathognomonic microscopically are the relatively large              it dries. On a moist towel or wet sponge, 12 hours. So I just don't think we should
                                                                                think we kind of know it all and say that obviously this is sexually transmitted and
            mononuclear cells containing intracytoplasmic cysts filled          that is where you got it. That is probably the most likely but it is not the only way
                                                                                so I give everybody the benefit of the doubt. I don't know where it came from and
            with pleomorphic Donovan bodies
                                                                                I try to act and treat accordingly.
       3.   Tissue biopsy may be needed to demonstrate the
                                                                                It does occasionally move down into the larynx and we talked about a possibility
            pathognomonic cell                                                  of that but fortunately it is not common. But when the larynx looks like that or the
                                                                                trachea like that, you have a major problem because now you have a difficult area
       4.   Culture is not routinely necessary, but the organism car, be        to treat. They will laser the larynx except that it also does some damage to the
                                                                                larynx. Very rarely it actually moves down all the way into the lung fields which
            cultured in the yolk sac of chick embryos
                                                                                fortunately is very uncommon but can occur.
  E.   Treatment
                                                                                I skipped lymphogranuloma venereum and granuloma inguinale. They are
       1.   Tetracycline, 500 mg qid, for 3 weeks                               relatively uncommon but can occur. We went on to molluscum contagiosum which
                                                                                is a member of the pox virus which is one of the few viruses that doesn't seem to do
       2.   For resistant cases, gentamicin (Garamycin), 40 mg IM bid           any serious harm. Probably the main significance is where you see one sexually
            should be used for 2 weeks                                          transmitted disease, you may see another and any time you have one, you should
                                                                                kind of probably look for the others. Also, look for GC and Chlamydia and any
V. Lymphogranuloma Venereum                                                     vulvar lesions. Do an RPR. It is important to make that diagnosis and treat it and
                                                                                when we get to syphilis I will tell you about how the incidence is going up and that
  A.   Etiology and transmission                                                kind of thing. So it think it is just kind of being aware of looking for the other
                                                                                STDs as well.
       1.   Chlamydia trachomatis, an agent that also causes inclusion
            conjunctivitis, urethritis of cervicitis, and pelvic inflammatory   An individual umbilicated lesion for molluscum contagiosum. If you scrape this
                                                                                and make a slide, you will get molluscum bodies but its main clinical significance
            disease (PID)                                                       is just to look for other STDs.

       2.   Chlamydia are small G- obligate, intracellular bacteria-like        Phthirus pubis. A bloodsucking ectoparasitic louse unable to survive without a
                                                                                blood meal for more than 24 hours. It reminds us of some of the other people we
            agents that form characteristic microcolonies

                                                                                                                                                                          6
           3.   Usually transmitted through coitus or anogenital contact          have to deal with sometimes. The organisms like pubic hair and eyebrows. Those
                                                                                  are the two places where the diameter of the distance of hair is just right for them
           4.   Average incubation period of 7-12 days                            to hang onto. It is often transmitted sexually but they can occur in nurseries and
                                                                                  nursery schools, stuff like that, where little kids are kind of climbing all over each
      B.   Incidence: relatively minor in reported incidence. Only about 200      other. They can stay in the linen or bedding. Probably renting a motel by the hour
           cases reported in the United States per annum                          is not a good idea.

      C.   Signs and symptoms                                                     The life cycle, the eggs hatch. They do need a blood meal. They will self-sterilize.
                                                                                  Even both the bedding and clothing if left unused for two weeks will self-sterilize.
           1.   Primary lesions begin on the external genitalis, vagina, or       Treatment is just Kwell shampoo. Because they are outside, on the skin and on the
                                                                                  hair, it is easy to treat. Kwell shampoo left on for about 4 or 5 minutes is all that
                cervix as a small, painless, red, puffy erosion or ulcer; they    you need to do. In nursing mothers, children under the age of 10, lactating or
                last a few days and then adenitis develops                        pregnant, we use RID. It is a little less potent. There hasn't been any reported fetal
                                                                                  harm and you leave that on for 10 minutes.
           2.   In a few days to weeks, satellite adenitis develops
                                                                                  Sarcoptes scabiei or the itch mite was actually the first human disease that we knew
           3.   Inguinal buboes are common, and perirectal or intrapelvic         the etiology of and back in 1654 they saw these little creatures crawling around
                                                                                  under the skin. What happens is one drops on the skin, emits a little enzyme and
                nodes may be involved                                             in about 3 minutes dissolves the skin and crawls under the skin and sets up
           4.   Systemic involvement may cause malaise, anorexia, fever,          household. What you do is just kind of unroof the lesion and you will actually see
                                                                                  the organism, the fecal matter or eggs which make the diagnosis.
                chills, abdominal and joint pain, weight loss, pneumonitis,
                                                                                  The same kind of life cycle, same kind of natural history but the treatment has got
                tachycardia, and rarely, meningitis or splenomegaly               to be Kwell creme because it is under the skin. You actually shower, put the cream
                                                                                  on overnight so it can absorb through the skin and kill the organisms. In pregnant
           5.   Complications include intestinal obstruction, hepatitis, liver
                                                                                  women, nursing mothers, children under the age of 10, use Eurax or crotamiton
                abscess, salpingitis, pelvic abscess, anorexia, arthritis, and    and use it two nights in a row.

                occasionally death                                                Syphilis. The incidence is dramatically going up.
      D.   Diagnosis                                                              It used to be down at 10, 20, 30,000. They are now reporting 50,000 cases of
           1.   Observation of typical clinical picture and a positive            syphilis, primary and secondary, annually in the United States. The CDC assumes
                                                                                  that any time… you've got to play with all the numbers because if they say that
                chlamydial complement fixation test. The test has a 95%           there are 50,000 reported, there may actually be 150,000 cases out there. They
                                                                                  always assume there at least two to three times the number of cases that are not
                sensitivity, or 5% false-negative. Test becomes positive 2-4      getting reported.
                weeks after the onset of illness. A simple titer of 1:32 is       Often presents as a primary chancre - a painless lesion - but has a whole multitude
                suggestive, a fourfold rise in titer indicates active infection   of presentations. Syphilis used to be called the great imitator and can present in a
                                                                                  number of fashions. It can be very subtle. It can look like herpes, it can look like
           2.   Chlamydia trachomatis can be cultured or detected by other        condyloma. It can look like a whole number of things. Again, if there is a vulvar
                                                                                  lesion, do an RPR. Just check it. Be sure because it is certainly important to make
                selective tests                                                   the diagnosis. Again, not all chancres occur below the waist and this is a syphilitic
                                                                                  chancre on the lip.
           3.   Sedimentation rate is elevated, white blood cells WBCs) are
                elevated, liver enzymes frequently elevated and there is a        Initially, the patient may be too early in the disease process to get a positive RDR
                                                                                  or VDRL. If you scrape the lesion and look at it you may actually see the
                change in albumin/globulin ratio, due to an increase in           spirochetes.

                globulins                                                         Left untreated, after about six weeks at most it often will progress to secondary
                                                                                  syphilis which could be very mild like this or it could actually affect more of the
           4.   Biopsy may be confirmatory, and help rule out malignancy
                                                                                  skin and actually cause more obvious lesions. What is somewhat pathognomonic
           5.   A serologic false-positive test for syphilis is found in up to    is that it actually affects the palms and the soles. There are very few dermatologic
                                                                                  conditions that affect the palms and the soles, syphilis being one of them. About
                20% of patients with buboes                                       20% affect mucous membranes and can cause irritation or even condyloma lata
                                                                                  which we have another slide of. This is really just an inflammatory reaction from
      E.   Treatment                                                              the spirochete. It is condyloma lata, not condyloma acuminatum which is from
                                                                                  HPV which are the genital warts. It looks different but it is an inflammatory
           1.   Doxycycline, 100 mg po bid for 21 days, or
                                                                                  reaction.
           2.   Tetracycline, 500 mg qid, for 21 days. or
                                                                                  But the incidence has dramatically gone up. Part of the reason for that is sex for
           3.   Erythromycin, 500 mg qid, for 21 days is generally effective      crack cocaine. When you are looking for drugs, I guess apparently you don't much
                                                                                  care who your partner is or what they have and that is why most of the CDC
           4.   Surgical revision of destructive or cicatricial lesions may be    believes the incidence has gone up as much as it has.
                required
                                                                                  A patient with alopecia areata secondary to syphilis and it is the great imitator.
VI.        Molluscum Contagiosum.                                                 Time will go by in most of these patients, 10, 20, 30 years. Some of them will
                                                                                  never develop anything. Left untreated, two different studies, 30-50% will develop
      A.   Etiology and transmission                                              tertiary syphilis. It may have a benign gumma in an extremity. They may have it
                                                                                  in the cerebellum which obviously creates a few problems. They may have it in the
           1.   Produced by a member of the pox virus family'                     descending arch of the aorta which is life-threatening and actually obviously causes
           2.   Spread by sexual or close personal contact                        dissecting aneurysms and death.

      B.   Clinical features                                                      There are two studies done, the Oslo study and the Tuskegee study. The Oslo study
                                                                                  was actually back at the turn of the century - 1890, 1900 - and obviously there was
           1.   These lesions are common                                          no treatment. They followed those patients and actually that is where some of the
                                                                                  data came from on the incidence of cardiovascular effects, neurologic effects, soft
           2.   They are asymptomatic and easily overlooked

                                                                                                                                                                           7
        3.   Usually multiple and far apart                                    tissue effects. The Tuskegee study, on the other hand, which has gotten a lot of
                                                                               appropriate negative press was begun in 1932 and was actually carried out until
        4.   Central umbilication is frequent                                  1972. They followed several hundred men in Tuskegee, Alabama and just treated
                                                                               kind of minor things but never really even when medications became available…
        5.   The lesions can be spread by autoinoculation                      at first, I guess they were using arsenic rubs and then they just kind of quit that but
        6.   They last from 6 months to many years                             even when penicillin became available, they just didn't use it. The arguments they
                                                                               used were, "Well, you may get a reaction to it. You may be allergic to penicillin
   C.   Diagnosis                                                              or you may get a Jarisch-Herxheimer reaction." The truth was they were just doing
                                                                               a study and they didn't really stop the study until the public became aware and they
        1.   Confirmed by biopsy or by potassium hydroxide (KOH) prep          had national congressional hearings on it in 1972 by which time about half of the
                                                                               males had died. So the study is lousy but there is the data there and it did say that
             of a curetted lesion, crushed between the slide and cover         30-50% progressed with either aortic or central nervous system damage.
             slip
                                                                               As we said, the incidence of adult, primary and secondary syphilis has dramatically
        2.   Both show characteristic intracytoplasmic inclusions              gone up. So has the incidence of congenital syphilis. In 1978, the total number of
                                                                               cases of congenital syphilis in the United States was 108. In 1991, there were over
   D.   Treatment                                                              100 cases in Chicago. It has dramatically gone up just the same way the incidence
                                                                               has in women. The incidence is directly related to whether the woman has syphilis
        1.   Sharp dermal curette                                              in the pregnancy, close to the pregnancy or further removed. It is inversely
        2.   Cryosurgery with liquid nitrogen                                  proportional. The closer to the pregnancy, the more likely the baby will be affected.
                                                                               If the mother has syphilis during the pregnancy, there will be like an 80% effect,
        3.   Electrodesiccation                                                a 40% miscarriage rate and 40% of the babies will be born with congenital
                                                                               syphilis. It does affect hepatosplenomegaly, the skin, snuffles, obviously very
        4.   Topical caustics are not recommended                              potentially sick babies.
VII.    Pediculosis Pubis (Crabs)
                                                                               All pregnant women have an RPR or a VDRL at the first prenatal visit and again
   A.   Etiology and transmission                                              in the third trimester just in case they developed it during the pregnancy because
                                                                               we can treat it and we can make a difference. If you are doing your nonspecific test,
        1.   Phthirus pubis, a blood sucking, ectoparasitic louse, unable      VDRL, RPR, it takes a little while, 4-6 weeks for them to become positive. They
                                                                               will stay positive and even untreated, eventually they become negative. The
             to survive more than 24 hours off the body                        specific test, fluorescent treponemal antibody absorption, stays positive for life.
        2.   Often transmitted sexually
                                                                               Patients want to know if you do treat it, will the test become negative because in
   B.   Clinical features                                                      some states for marriage licenses or for some jobs you get an RPR or a VDRL.
                                                                               Two studies, appropriately treated with primary syphilis, all of the RPRs became
        1.   Severe itching, may lead to excoriations and secondary            negative after 12 months. If you had done an FTA absorption, it would still be
                                                                               positive but nobody is going to do that if the screening test is negative. With
             bacterial infection                                               secondary syphilis, the same result, only it took 24 months.
        2.   In long-standing cases, nonblanching, blue-gray macules,
                                                                               Treatment is 2.4 million units of Bicillin - long acting penicillin - for primary
             averaging 0.5-1.0 cm, appear on the abdomen and flanks            syphilis. For secondary syphilis, three weekly doses, 2.4 million units a week apart
                                                                               is the treatment. The CDC says the treatment is the same whether they are pregnant
        3.   The louse is principally found on the pubic hairs                 or not pregnant. I think that is somewhat archaic because if you treat a patient with
                                                                               primary or secondary syphilis with 2.4 million units of Bicillin in pregnancy, you
   C.   Diagnosis is made by locating nits or adult lice on the hair shafts    have like a 35% failure rate. So what we would do is bring the patient into the
   D.   Treatment                                                              hospital just as an outpatient, put 5 million units of aqueous penicillin in a bottle
                                                                               and hang it. If they are far enough along in the pregnancy to monitor the fetus, we
        1.   Permethrin cream 1% should be applied for 10 minutes and          would do that and see what kind of a reaction you are getting. After you give 5
                                                                               million units, you can even give another 5 million.
             washed off
                                                                               If you don't get an adverse effect, if you don't get a Jarisch-Herxheimer reaction
        2.   Kwell shampoo, lathered for at least 4 minutes, can be used
                                                                               which is really the penicillin killing so many spirochetes, then all of the enzymes
             (not recommended for pregnant or lactating women)                 in the organisms are released into the body at the same time and some of them are
                                                                               toxic and they can cause kidney shutdown and kidney damage and liver damage.
        3.   RID (pyrethrins, piperonyl butoxide, petroleum distillate, and    If you see any negative reaction, you back off and just gradually repeat it. We
                                                                               would then give the 2.4 Bicillins. We are still doing what the CDC says but then
             benzyl alcohol) nonprescription, applied to the infected and      we would send the patient home and 2 gm of ampicillin b.i.d. for 10 days because
                                                                               the body still maintains low doses, treats the mother, but doesn't really get high
             adjacent hairy, area and washed off after 10 minutes. No
                                                                               enough doses in the baby, whereas ampicillin readily crosses the placenta and will
             cases of fetal harm or teratogenicity have been reported          treat the baby.

        4.   All contaminated clothing and linen need to be laundered,         There are a significant number of sexually transmitted diseases out there and in an
                                                                               ideal world, everybody should have a mutually monogamous relationship. Seeing
             dry cleaned or sprayed: they will become self-sterilized if not   as how it is not an ideal world, at least in they are not going to have monogamous
             worn or used for 2 weeks                                          relationships, they should use foam and condoms. At least it significantly decreases
                                                                               the risk of many of the STDs. It won't really necessarily protect or prevent either
VIII. Pubic Scabies                                                            herpes or HPV because of the areas involved. It may affect the scrotum, even
                                                                               further out than the condom is going to cover but condoms do offer significant
   A.   Etiology and transmission                                              protection and certainly as part of our teaching our patients, if they are not going
                                                                               to be monogamous, then this at least is another reasonable thing to do.
        1.   A highly contagious infestation caused by the ectoparasitic
             itch mite, Sarcoptes scabiei, which varies in length from 0.2-    This is moving up the generative tract and I just want to kind of show the normal
                                                                               vaginal flora in the vagina. There are five to nine different organisms, more
             0.4 mm                                                            anaerobes than aerobes and ratios vary but all of your usual Bacteroides, fragilis,
                                                                               bivius, the Enterococcus, the Klebsiella, the proteus, all those are normal flora.
        2.   It is transmitted by intimate contact; it may infrequently be     Group B strep is probably present in 10-20% of female vaginas and rarely
                                                                               important except in pregnancy. So if you can do a culture and you see any of those,
             transmitted by infested clothing

                                                                                                                                                                         8
      B.   Clinical features                                                     it is not really telling you anything. Now, Group A strep, if it is GC or chlamydia
                                                                                 it may be telling you something. But all the rest of these are normal vaginal flora.
           1.   The impregnated female mite burrows into the skin
           2.   After 1 month, symptoms begin; by 6 weeks, pruritus is
                sufficient to cause sleep disturbances
           3.   A multiform eruption, papules, vesicles, pustules, urticarial
                wheals, and secondary infectious occur on the hands,
                wrists, elbows, belt line, buttocks, genitalia, and outer
                borders of the feet
      C.   Diagnosis is confirmed by burrows and observing the parasites,
           their eggs, larvae, or red fecal compactions under low power
      D.   Treatment
           1.   Kwell cream or lotion for 8-12 hours, but this time applied to
                the total body from the neck down (not recommended for
                pregnant or lactating women)
           2.   Kwell shampoo is not adequate therapy
           3.   In infants, children under 10, pregnant and lactating women:
                crotamiton 105% (Eurax), applied to the entire body from
                the neck down nightly for 2 nights and wash off thoroughly
                24 hours after the second application
IX.        Syphilis
      A.   Etiology, incubation period, and transmission
           1.   Treponema pallidum is a slender, corkscrew-like treponeme
                with regular, evenly spaced spirals
           2.   It varies in length from 5-15 microns
           3.   The incubation period is 10-90 days; 21 days is average
           4.   The disease is almost always transmitted by intimate sexual
                contact; it may be transmitted in utero to the unborn child
                after the first 2-3 months of pregnancy
      B.   Incidence: recently, there has been a significant increase in the
           number of primary and secondary cases of syphilis reported in
           the United States per year
      C. Primary syphilis
           1.   Solitary lesion, beginning as a nodule, becomes an
                indurated ulceration (chancre) with a ham-colored, eroded
                surface and a serous discharge
           2.   Usually accompanied by painless, enlarged regional lymph
                nodes
           3.   Ninety-five percent of primary lesions are found on or near
                the genitalia
           4.   Atypical lesions are frequent and may consist of small
                multiple lesions
           5.   Untreated lesions heal in 1-5 weeks
           6.   The diagnosis is made by clinical appearance and positive
                darkfield examination: the serologic test is sometimes
                negative

                                                                                                                                                                        9
D.   Secondary syphilis
     1.   Secondary signs appear 6-8 weeks after exposure
     2.   Bilateral,       symmetrical       macular,      papular,    or
          papulosquamous        skin     lesions   are   widespread   and
          nonpruritic, and frequently involve the palms, soles, and
          face, in addition to the trunk and extremities
     3.   Mucous membranes are often involved
     4.   Generalized nontender lymphadenopathy
     5.   Fever
     6.   Patchy alopecia
     7.   A small percentage have iritis, hepatitis, meningitis
     8.   Serologic test is positive in more than 99% of cases: could
     be negative because of prozone phenomenon
E.   Latent syphilis: the interval between secondary syphilis and late
     syphilis. The patient has no signs or symptoms, only positive
     serological tests
F.   Late syphilis: characterized by destruction of tissue, organs, and
     organ systems
     1.   Late benign: gummas occur in skin or bone and do not
          result in severe incapacity or death
     2.   Cardiovascular: medial necrosis of the aorta with dilation of
          the ascending aorta; this leads to aortic insufficiency or
          saccular aneurysm of the thoracic aorta
     3.   Neurosyphilis
          a.    Spinal fluid shows elevated WBCs up, elevated total
                protein, and positive serology
          b.    Meningovascular pathology can occur, pupillary
                changes are common: Argyll Robertson pupil accom-
                modates but does not react to light
          c.    Parenchymatous pathology can result in general
                paresis or tabes dorsalis: degeneration of the ascend-
                ing sensory neurons in the posterior column of the
                spinal cord
G. Congenital syphilis
     1.   Symptoms at birth
          a.    Upper respiratory infection (URI)
          b.    Rhinitis
          c.    Prematurity
          d.    Lymphadenitis
          e.    Jaundice
          f.    Anemia
     2.   Late congenital syphilis: if it persists beyond 2 years of age,
          may see Hutchinson's triad
          a.    Hutchinson's teeth
          b.    Interstitial keratitis

                                                                            10
                      c.     Eighth nerve deafness
     H.        Serology: tests for syphilis are nontreponemal and treponemal            Vaginitides. I have Nitrisine paper in every examination room. If someone comes
                                                                                        in with the common vaginitides, you just touch the Nitrisine paper to the secretions.
               1.     Nontreponemal tests are complement fixation tests [eg,            Normal secretions and candida are usually under a pH of 5, both BV and trich are
                      VDRL or rigid plasma reagin (RPR)]. These are the most            over 5. If they have a pH over 5 and they are itching, they have trich. If they have
                                                                                        a pH over 5 and they don't have itching, they have BV. It is a very simple screening
                      widely used tests- they become positive 4--6 weeks after          mechanism especially if you are running late in the office and I use it every day and
                                                                                        it really does work.
                      infection. They start in low titration and over several weeks
                                                                                        Candida, far and away the most obstinate. It causes most itching and is very
                      may reach 1:32 or higher. After adequate treatment of             common. Again, a pH under 5. Classically, the cottage cheese kind of thing but
                      primary syphilis, the titer falls and, in most cases, is          that is probably only in 70% of pregnant patients with candida. But also affects the
                                                                                        skin and goes more beyond the vaginal introitus. When something goes that far out
                      nonreactive within 9-18 months                                    it is most likely candida because it is yeast. It is more diverse on the skin.

               2.     Treponemal tests are fluorescent treponemal antibody              Whether we use our KOH or whether we make pap smears, you may actually see
                                                                                        the hyphae. Albicans, glabrata, tropicalis. Different kinds. The importance there
                      absorption test (FTA-ABS) test, treponemal mobilization test      may be that the over the counter Gyne-Lotrimin, Monistat kind of things may cover
                      (cardiolipin) (TPI) test, and microhemagglutination assay-T,      some better than others whereas the Terazol prescription may have a little broader
                                                                                        coverage. At least, certainly that is what the drug companies say so there is an
                      pallidium (MHA-TP): ie microhemagglutination assay for T.         advantage. Any of the creams if you use them usually for a week. I have no strong
                                                                                        preference whether you like Gyne-Lotrimin or Monistat or use the Terazol. Again,
                      pallidium                                                         they all work pretty well. Taking nystatin orally, all you are trying to do is
                                                                                        decrease the amount of yeast in the GI tract which may or may not have any effect
     I.        Treatment: see STD Treatment Guidelines
                                                                                        on treating the patient.
     J.        Follow-up and retreatment
                                                                                        Most of the time, candida is easy to treat. You use it for three days or a week but
               1.     Early syphilis and congenital syphilis: repeat VDRL at 3, 6,      there are patients who are going to have more complex situations. Either they are
                                                                                        immunocompromised or their body is just not handling that fungus. They are going
                      and 12 months                                                     to need to be treated differently for more prolonged periods of time and they are
               2.     Syphilis more than 1 year. Also repeat VDRL at 24 months.         going to be a nuisance and they are going to be hard to treat. I think it is advanta-
                                                                                        geous for us to know that up front because then we can say, "Hey. In part, we've
                      Examine cerebrospinal fluid at last follow-up visit if patient    got to work on this together. Your body's immune system has to take care of this.
                                                                                        It is not just what medication I am giving you." Hopefully, they quit smoking. I do
                      was treated with alternative antibiotics                          simple things like tell them to get eight hours of sleep and take vitamins. It is just
                                                                                        really that their immune system has to help us because we could go on and on
               3.     Neurosyphilis: repeat VDRL for 3 years                            treating it and we may not be successful.
               4.     Retreatment if
                                                                                        We will sometimes go to the oral medications. Sometimes they are helpful in those
                      a.     Clinical signs or symptoms persist or recur                complex patients that just don't respond to our normal treatment, whether it is
                                                                                        ketoconazole or Diflucan. Commonly we will just use something like Terazol for
                      b.     A fourfold increase in the titer of a nontreponemal test   two weeks straight and then use it for three days before the next three periods trying
                                                                                        to keep it in check but you need to go onto additional treatments. Sometimes, we
                      c.     Failure of an initially high titer nontreponemal test to   will use boric acid tablets in the vagina for two weeks straight and then for two or
                             show a four-fold decrease within a year                    three times a week for months because the patient just has persistent recurrences.

               5.     Only retreat once; use schedule for syphilis of more than 1       How many people use Diflucan commonly? How many use it as their first line? I
                                                                                        presume the rest are using either over the counter or Terazol. How many use
                      year duration                                                     Terazol? A good number. I think it is just sometimes that you have to use it for
                                                                                        longer periods of time to really get the results we want.

Vagina                                                                                  Trichomoniasis is very irritating. Lots of discharge, unpleasant for the patient
                                                                                        because it literally can be kind of messy. High pH. It creates a great deal of
I.        Normal Secretions Prevent Dryness                                             inflammation. If you touch the Nitrisine paper to that, what color is it going to be?
                                                                                        Dark blue. Trichomoniasis doesn't live at a pH under 5. It is usually pH 6 or 7 and
          Normal secretions are clear and odorless and do not cause                     if you take your finger along either side of the urethra and milk Skene's ducts in
                                                                                        this patient, you will see the pus coming out of there as well which is why any local
          external wetness                                                              treatment is not going to be very successful and why we use metronidazole.
          A.        Principal source is mucus from cervical columnar epithelium
                                                                                        Debris, trich, polys, and if you look at the epithelial cells from the vaginal wall,
          B.        Transudation from vaginal epithelium                                they are not mature because the amount of inflammation is truly a vaginitis. So if
                                                                                        you've got a lot of debris and immature or intermediate vaginal cells, it is
          C. Secretions from sebaceous sweat glands and Bartholin’s                     trichomoniasis. If you've got a lot of debris and white blood cells in the secretions,
                                                                                        but normal vaginal cells, what do you have? This is a written board question.
                    glands
                                                                                        Cervicitis. Coming from the cervix not the vagina because you've got a dirty
          D. During reproductive years, average pH 3.8--4.2 %; acidity is               background. You've got inflammation, white blood cells, debris, but you've got
                                                                                        normal vaginal cells so that is not a vaginitis it is a cervicitis and that is a written
                    produced by                                                         question on the boards, or at least it was. Here is just kind of showing a lot of
                                                                                        debris. If you look at the vaginal cells, they are intermediate. The nucleus to
                    Lactobacillus bifidus                                               cytoplasmic ratio is increased.
          E.        Normal vaginal flora include Döderlein's bacillus, hemolytic
                                                                                        Treatment. Most of us would probably use just the 2 gm of metronidazole. You
                    and nonhemolytic streptococci, enterococci, Escherichia coli,       could use the 375 mg capsules b.i.d. for a week. Sometimes you may get a little
                                                                                        better cure rate with that but minimally different. You can go as high as like 2 gm
                    diphtheroids, and strains of Micrococcus                            a day for longer periods of time if you really have resistant trich. You can't go any
                                                                                        higher than that because it starts causing neurologic damage.
                    pyogenes

                                                                                                                                                                              11
II.   Leukorrhea                                                             In pregnancy, there is some controversy. Most everything we use is contraindicated
                                                                             in the first trimester. We don't even use Terazol or any of the creams the first
      Any abnormal vaginal discharge not associated with menstruation:       trimester. We try to wait until we get to the second trimester. Certainly,
                                                                             metronidazole is contraindicated in the first trimester. The CDC says that you can
      occurs in more than 1/3 of all ,gynecologic patients                   use 2 gm after the first trimester but we kind of even just limit it to really severely
      A. Physiologic factors                                                 affected patients. I will even give Metrogel or something during the pregnancy and
                                                                             wait until after they deliver and even if they are nursing, just have them not nurse
           1.   Neonatal leukorrhea: several days after birth there is a     for 24 hours and then give your 2 gm of metronidazole. There is no real data
                                                                             available and there is certainly some controversy. With either the CDC or PDR it
           withdrawal effect with cellular debridement                       says to use it cautiously. I am not sure how you use something cautiously. You
                                                                             either use it or you don't.
           2.   Leukorrhea of puberty
                a.   Production of estrogen increases cervical discharge     Gardnerella. Probably the most common. Also, the most benign but the thinking
                                                                             on that has changed and we are being more aggressive in treating it and we will
                b.   Ceases with onset of cyclic progesterone                show you a couple of reasons why. Again, the pH is higher than 5. Clue cells.
                                                                             Gardnerella has multiple different names and it really depends on how far back in
           3.   Leukorrhea of pregnancy: increased steroids cause            history you want to go. It is an imbalance in bacteria and nobody really knew
                                                                             which bacteria to blame. Herman Gardner came out with describing the
                hypersecretion of cervical glands                            Gardnerella organism so he got some credit and now we call it bacterial vaginosis
      B.   Inflammatory factors                                              because it is really just an imbalance in the bacteria.

           1.   During the prepubertal and postmenopausal years, the         It is very common and in some STD clinics, 30-60%. In the OB population, there
                                                                             are now seven different studies that say that there is an increased risk of premature
                thin vaginal epithelium is easily infected by a variety of   labor, probably 2 to 3-fold. There is an increased risk in the gynecological
                                                                             population of PID. If you operate on a patient, do a hist on a patient with BV, you
                agents, including the gonococcus and many, nonspecific
                                                                             have a significant increased risk of postoperative infection. You have a significant
                organisms                                                    increased risk of postpartum infection because what you have done is just
                                                                             dramatically change the ecosystem in the vagina. Many more anaerobes, many
           2.   During the reproductive years, the most frequent offend-     more Mobiluncus. Fewer of the good guys - the Lactobacillus - and because of this
                                                                             change in bacteria there is greater risk of infection so we do want to treat it.
                ers are Hemophilus vaginalis (Gardnerella vaginalis),
                Candida, Trichomonas vaginalis, herpes virus, and            We kind of touched on each of those. There is an increased incidence of non
                                                                             pueperalendometritis, PID, post surgical cuff infection, post abortion. If you put an
                Chlamydia                                                    IUD in somebody with BV, there is a greater risk of infection because you are
                                                                             really taking all of these organisms from the lower generative tract and bringing
           3.   A recent analysis of 10,000 consecutive cases of vaginal     them up into the upper generative tract. There are seven different studies that say
                                                                             there is an increased risk of premature labor and so we really do want to diagnose
                discharge found the following causes of the discharge        this and we do want to treat it.
                a.   Gardnerella vaginalis: 32 %
                                                                             If you are looking for BV and you want to look for your clue cells, you don't want
                b.   Cervicitis: 25%. Most cases of cervicitis are due to    the specimen to come from the cervix, you don't want it to come from a cul-de-sac.
                                                                             You want it from the vaginal side wall or the anterior wall of the vagina and you
                     the following                                           should see clue cells. Clean background because there is not very much in the way
                                                                             of inflammation so you don't see a lot of white blood cells or debris. You see nice
                     (1)   Gonorrhea                                         superficial pyknotic cells but covered with bacteria. Same thing on a pap smear.
                     (2)   Chlamydia
                                                                             If you do your KOH and your normal saline, if you put on KOH in a patient with
                     (3)   Herpes                                            BV, because there are so many bacteria there, the KOH dissolves all this bacteria.
                                                                             Those bacteria have enzymes in them like cadaverine and putrescine and
                c.   Cancer: 19%                                             everything starts getting a little fishy. So we have a little fish up there and actually
                                                                             some people would say that is the easiest way of making the diagnosis. The patient
                d.   Trichomonas: 11%
                                                                             can do that test for you if they say there are secretions and that the odor is worse
                e.   Excess mucus from the cervix or an increased            after their period or after intercourse because blood and seminal fluid tends to be
                                                                             more alkaline and so it is going to do somewhat of the same test for you.
                     discharge of healthy vaginal epithelial cells: 13%
                                                                             The treatment is metronidazole, p.o. or intravaginally. In pregnancy, we wouldn't
      C. Conditions                                                          use that. We would use the Cleocin and obviously it comes in gel form too as both
                                                                             Metrogel and as Cleocin vaginal cream. The organisms we are interested in do
           1.   Candidiasis
                                                                             respond to those.
                a.   Etiology,
                                                                             This is a rare bug - vaginitis emphysematosa. Pregnant patient with either BV or
                     (1)   Candida not a true yeast, but is a “yeast-like"   trich and you treat either the BV or the trich and this goes away. That is vaginal
                                                                             mucosa with a cystic cavity under it and sometimes things like this do appear on
                           organism                                          exams even though they are relatively uncommon. This one is desquamative
                     (2)   Candida albicans is the most common:              vaginitis. A patient in the reproductive years and has normal hormones but if you
                                                                             look at it, you would say it looked atrophic because the vaginal cells have not
                           Candida tropicalis is also common                 matured and there is a lot of inflammation. Cortone suppositories for prolonged
                                                                             periods of time are the treatment of choice.
                b.   Incidence
                                                                             Chlamydia which does act as a good jumping off point to move off the generative
                     (1)   Most obstinate cause of vaginitis, present in     tract. Probably 50% of cervicitis is caused by chlamydia. In other countries, it is
                           25-50% of all women                               a common cause of endemic trichoma. In men, probably one of the most common
                                                                             causes of epididymitis and nongonococcal urethritis.
                     (2)   In 1,000 consecutive gynecological patients,
                                                                             Cervicitis, half the cases of cervicitis. Probably about 20% of PID, 25% Fitz-
                           5.9% had candidiasis                              Hugh-Curtis as part of the PID. What is Fitz-Hugh-Curtis as part of the PID? Both
                                                                             GC and chlamydia can cause it and how does it present? Right upper quadrant
                c.   Predisposing factors

                                                                                                                                                                   12
     (1)   Pregnancy                                           pain. In 5% of the patients, they can present with right upper quadrant pain. What
                                                               it is, is in the PID and I've got a slide on it later, the pus goes up the right colic
     (2)   Just prior to menses                                gutter and causes a perihepatitis so the pain is really up here. If you scope the
                                                               patient, you will actually see adhesions between the peritoneum and the liver
     (3)   Contraceptive pills                                 capsule because there is enough inflammation to cause that and they are called
     (4)   Antibiotics                                         banjo strings.

     (5)   Systemic corticosteroids
     (6)   Diabetes mellitus: high percentage of diabetics
           have candidiasis
     (7)   Nondiabetic glycosuria
     (8)   Diet: especially fruit workers and sweets lovers
     (9)   Debilitation
     (10) Obesity
     (11) Male factor: may culture Candida from urethra
           of regular sex partner
d.   Symptoms
     (1)   Vulvar pruritus is cardinal symptom
     (2)   Dysuria
     (3)   Usually abrupt onset before menstruation
     (4)   Meager discharge
e.   Signs
     (1)   Erythema of vagina and labia minora
     (2)   Edema of labia minora
     (3)   Fissuring
     (4)   Traumatic excoriation
     (5)   Thick, white, adherent discharge, classic, but in
           most, it is essentially normal
     (6)   Overall, 20% have thrush patches, 70% if
           pregnant
     (7)   pH 4.0--4.7, 4.5 is most common; slightly less
           acid than the normal range of pH 3.8-4.2
f.   Diagnosis: demonstrate Candida and have clinical
     features present
     (1)   Wet mount
           (a)   400-1,000 times in normal saline or 10%
                 KOH on a warmed slide, with the sample
                 taken from the cul de sac
           (b)   Overall sensitivity 40--80%
     (2)   Pap smear
           (a)   Sample from vaginal pool
           (b)   Sensitivity 20-50%
     (3)   Can be cultured on Sabouraud's or Nickerson's
           media, sensitivity 70-100%
g.   Treatment
     (1)   Nystatin (Mycostatin) antifungal antibiotic
           (a)   Available in powder, tablets, cream, and
                 ointment

                                                                                                                                                   13
                (b)   Prescribe nystatin vaginal tabs: #30, 1
                      bid for 15 days
          (2)   Miconazole nitrate 2% (Monistat), prescribe 1
                applicatorful qhs for 7 days
          (3)   Clotrimazole (Mycelex)
                (a)   In pregnant patient, prescribe 1 tab in
                      vagina qhs for 7 days
                (b)   In nonpregnant patient. 1 tab bid for 3
                      days
          (4)   Terconazole (Terazol): prescribe 80 mg in
                vagina qhs for 3 days
     h.   Treatment for chronic or recurrent candidiasis: the
          patient candida may have a problem of host de-
          fenses
          (1)   Aci Jel daily for 3 weeks and then 3 times per
                week for another 3 weeks; continue to use it 5
                days prior to each menses
          (2)   Povidone iodine (Betadine) qhs for 1 month,
                with Betadine douche in AM is valuable
          (3)   Avoid antiseptic soaps
          (4)   Stop birth control pills
          (5)   Decrease simple sugars in the diet
          (6)   Treat the male partner
                (a)   Can use "Borafax," a 5% boric acid in
                      lanolin, applied locally bid for 10 days
                (b)   Condoms help:
          (7)   Avoid cunnilingus
          (8)   Avoid tub baths; shower instead
          (9)   Avoid pantyhose or nylon panties: use white
                cotton panties
          (10) More complicated problems may require
                ketoconazole (Nizoral)
2.   Trichomoniasis
     a.   Etiology
          (1)   A flagellated protozoa, Trichomonas vaginalis
                lives in the periurethral glands of males and
                females, usually begins with deposit of a large
                inoculum passed in alkaline semen
          (2)   It has been shown to survive up to 24 hours in
                swimming pools
     b.   Incidence
          (1)   One of the most frequently acquired STDs
          (2)   Incubation period of 4-28 days
          (3)   Approximately 2.5 million annual cases in the
                United States

                                                                  14
     (4)   Prevalence       ranges       from   13-23%     of
           gynecological patients
c.   Predisposing factors
     (1)   Women with high estrogen levels
     (2)   Hypoacidity in the vagina
     (3)   Bacterial flora: gram positive cocci and gram
           negative bacilli function symbiotically with
           Trichomonas
     (4)   Frequently seen in patients with other STDs,
           approximately 50% of patients with GC also
           have trichomoniasis
d.   Symptoms
     (1)   Malodorous discharge is cardinal symptom
     (2)   Pruritus is second most common problem
     (3)   Dysuria
     (4)   Dyspareunia
     (5)   Chronic symptoms often flare-up just after
           menstruation
e.   Signs
     (1)   40% have gross disease of the vulva; ery-
           thema, edema, intertrigo, and excoriation can
           occur
     (2)   Chafing is almost pathognomic of trichomonas
     (3)   Discharge from Skene's duct is fairly common
     (4)   "Cervical erosion": 90%
     (5)   Profuse, frothy discharge
           (a)     In acute cases, light green or yellow
           (b)     In chronic cases, grey and homogeneous
     (6)   pH 5.2-5.5; pH less than 5 essentially elimi-
           nates Trichomonas
     (7)   Any patient with vaginitis in the childbearing
           age and/or with a vaginal pH of greater than or
           equal to 5 with pruritus is likely to have
           Trichomonas; in absence of pruritus, the infec-
           tion is likely H. vaginalis
f.   Diagnosis
     (1)   Wet mount-sample from cervix and vaginal
           vault in normal saline
           (a)     motile pear-shaped unicellular flagellates,
                   about two times the size of a WBC
           (b)     Numerous WBCs and parabasal cells are
                   usually present
     (2)   Pap smears: 60-80% reliable
     (3)   Can be cultured, but seldom necessary
g.   Treatment: 96.8% have extravaginal sites, so vaginal

                                                                 15
          suppository will not cure
          (1)   Metronidazole (Flagyl) 500 mg bid for 7 days,
                approximately 95% cure rate; treat partner
                simultaneously
          (2)   2 g po in 1 day is accepted prescription: ap-
                proximately 85% cure rate
          (3)   In the pregnant patient
                (a)    Treat locally, eg, 20% salt solution, Aci
                       JeI, clotrimazole, or sitz bath may help
                (b)    Treat partner with oral metronidazole
3.   Hemophilus vaginalis vaginitis (bacterial vaginosis)
     a.   Etiology
          (3)   This is primarily a STD
     b.   Incidence
          (1)   Women in the reproductive years: 10--20%
          (2)   Probably accounts for more than 90% of
                vaginitides previously classified as nonspecific
     c.   Symptoms
          (1)   Most benign of the common vaginitides
          (2)   Mild pruritus and burning
          (3)   Only 25 % will complain of discharge, but the
                majority of patients will report a discharge if
                asked
          (4)   Malodor may be the most significant symptom,
                less than trichomonas
     d.   Signs
          (1)   Because it is a surface parasite, it rarely pro-
                duces gross vaginal or vulvar changes
          (2)   Grey homogeneous malodorous discharge
          (3)   pH greater than 5
     e.   Diagnosis:
          (1)   Wet mount is rapid and reliable
                (a)    Many epithelial cells are stippled with a
                       tiny, pleomorphic coccobacilli
                (b)     Only superficial epithelial cells are pres-
                       ent
                (c)    There are few WBCs and a motile organ-
                ism
          (2)   "Whiff test:" when KOH is applied, amines are
                released which cause a fishy odor
          (3)   Gram's stain is 90% sensitive
          (4)   Cultures for G. vaginalis are not routinely
                available and are not needed
     f.   Treatment
          (1)   Metronidazole 500 mg po bid for 7 days is the

                                                                      16
                most effective regimen
          (2)   Clindamycin (Cleocin) 300 mg bid for 7 days is
                usually effective
4.   Atrophic vaginitis
     a.   Etiology: as estrogen declines, the vagina atrophies,
          glycogen diminishes, pH rises, there is a shift to
          parabasal cells; vaginal folds and rugae disappear,
          and the walls become smooth and tubular
     b.   Symptoms may be mild but dysuria, pruritus, and
          dyspareunia may develop
     c.   Treatment
          (1)   Estrogen replacement: conjugated estrogen
                tablets (Premarin) or Dienestrol cream 0.1%
                qhs for 7 nights, then 2-3 times per week
          (2)   Must consider risks of endometrial carcinoma
                as it is absorbed
          (3)   Personal lubricant. Are helpful
5.   Foreign bodies can produce infections and discharge
     (toilet tissue common in children, forgotten tampons in
     reproductive years, and neglected pessaries in older
     women)
     a.   Diagnosis is made by speculum exam
     b.   Treatment consists of complete removal of the object
     and possibly a local sulfa cream
6.   Allergic vaginitis
     a.   Etiology
          (1)   Contact dermatitis is an eruption from contact
                with allergenic substances in susceptible indi-
                viduals
                (a)   Cleansing agents
                (b)   Perfumes
                (c)   Bubble baths
          (2)   May cause allergic reactions
                (a)   Hygienic sprays
                (b)   Disposable douches
                (c)   Contraceptive foam
     b.   Treatment includes lavage of inflamed tissue
          (1)   Can douche with 4 tablespoons of baking soda
                in 2 quarts of water
          (2)   Cortisone or antihistamine creams are helpful
7.   Nonvenereal bacterial vulvovaginitides may cause 1% of
     vaginidites
     a.   Only consider after the common pathogens have
          been ruled out: rare causes include Streptococcus
          pyogens, Staphylococcus aureus, and E. coli

                                                                  17
     b.   Treatment is based on culture and sensitivity
8.   Vaginitis emphysematosa                                        PID, post partum endometritis, prematurity. High vertical transmission rate in
                                                                    babies. If the mother has significant chlamydia, half the babies will have
     a.   Rare condition characterize by multiple discrete gas-     conjunctivitis. Probably is the most… if we don't count HPV which is not reported
          filled cystoid cavities of the vaginal and cervical       to the CDC so the numbers are hard to come by, there are probably 4 million cases
                                                                    of chlamydia annually in the United States. Several million gonorrhea, 500,000
          mucosa                                                    herpes and probably 150,000 cases of syphilis annually in the United States. Taken
                                                                    as a group, far and away the most infectious disease and actually chlamydia,
     b.   More likely to occur in patients with heart failure or    gonorrhea and probably HIV are some of the most common. If you consider
                                                                    infectious disease in pregnant women, it is probably the most common medical
          pregnancy                                                 complication in pregnancy. A million cases of GC in men. Probably a million cases
     c.   Etiology: probably a manifestation of trichomoniasis      of PID with chlamydia causing about 25% of them. Again, conjunctivitis and even
                                                                    pneumonia in the newborn.
          or occasionally H. vaginalis
                                                                    Interesting bug. Intracellular. It needs to be within the cell to reproduce. It is a
     d.   Clinical features                                         bacteria. It does have both its RNA and DNA but can't produce any energy itself
                                                                    so it needs the cell's mitochondria to reproduce.
          (1)   Discharge
          (2)   Gas-filled cystoid cavities line the vagina and     In a patient like this, without doing anything else, 50% have… or actually, with
                                                                    this, 80% have chlamydia. The columnar epithelium is raised up above the
                may pop on exam or intercourse                      squamous epithelium, so without doing any other testing, this is chlamydia.
          (3)   Foreign body giant cells in the walls of the        If you do a biopsy, you can see chlamydia inclusions in the cervical cells.
                                                                    Occasionally, it will actually exfoliate and you will see it on the pap smear. You
                cavities
                                                                    will see the inclusions in your exfoliated cells with a lot of polys as well.
          (4)   Treatment: directed at associated vaginal
                                                                    Culture is certainly one way but very difficult to do. We used to microtrack where
                pathogen                                            you wipe away the debris, get endocervical cells on the slide, stain them with a
                                                                    monoclonal antibody that is tagged with fluorescein, wash off the debris and try to
9.   Desquamative inflammatory vaginitis: clinical and micro-       see these little green spots which are actual chlamydia. What we do in the office
     scopic features of postmenopausal atrophic vaginitis           and in the hospital now is PCR. PCR is certainly the most sensitive and the most
                                                                    specific and easy to do. Again you wipe off the debris because you want
     occurring in a woman with high estrogen levels                 endocervical cells and all you do is you take a cyto brush, take the swab and then
                                                                    shake it in solution and send the solution to the lab. PCR should be 95% sensitive
     a.   Diagnosis                                                 and like 98-99% specific. It is so easy to do. In males, you can just do it on the
                                                                    urine because it is that sensitive and that specific.
          (1)   Normal ovarian function
          (2)   Persistent localized vaginitis (upper half of       Chlamydia responds especially to the tetracyclines, doxycycline and erythromycin.
                                                                    In pregnancy, we obviously do not use doxycycline. Non-pregnant, doxicycline
                vagina) with a discharge                            100 mg b.i.d. for ten days. Probably one of the treatments of choice. In pregnancy,
                                                                    erythromycin is very effective. There are two newer drugs that are also currently
          (3)   Many WBCs                                           available. One you could use in pregnancy and one not, where the two newer drugs
                                                                    are effective against chlamydia. Quinoline Floxin is very effective in huge doses,
          (4)   Immature epithelial cells                           400 mg b.i.d. which you also cannot use in pregnancy. But Zithromax,
          (5)   No specific cause                                   azithromycin is the same category as erythromycin. It is a class B drug. You take
                                                                    1 gm at one time and it is curative. You can either take four of the 250 mg caps or
     b.   Treatment                                                 they now have a powder. You just open the package of powder, pour it in a glass
                                                                    of water and it is 1 gm of Zithromax. You drink the glass of water and it is an
          (1)   Estrogens have no effect from estrogens. Little     appropriate treatment.
                effect from antibiotics
                                                                    Seeing as how the organism reproduces very slowly and all of the other treatments
          (2)   Intravaginal   corticosteroids    over 3-month      are 10-14 days, how can we use the Zithromax one dose, one time. How does it
                                                                    work? Very long half life. The half life is three to four days, so if you take a gram,
                period may be helpful                               three days later you still have 500 mg around and a week later you still have 250
                                                                    mg of the stuff in your system. So it is a very useful drug.
10. Chronic cervical discharge
                                                                    This is just kind of showing moving up the generative tract. We talked about
     a.   Most common causes
                                                                    chlamydia and cervicitis. It also affects endometritis, salpingitis and salpingo-
          (1)   Trichomonas                                         oophoritis which leads us to PID. One million cases annually in the United States.
                                                                    A significant number of patients have sequelae. There is a 6 to 10-fold increase in
          (2)   Herpes                                              ectopics and 18-20% chronic pelvic pain.
          (3)   Gonorrhea                                           GC, at least in these series of studies, anywhere from 30-50% of the PID with 40-
          (4)   Chlamydia                                           50% Neisseria gonorrhoeae. Probably 25-30% chlamydia. A significant percent
                                                                    nongonococcal, nonchlamydial. A whole spectrum of organisms that cause this
     b.   Incidence: second most common cause of vaginal            disease which probably accounts for why it presents in so many different fashions.
                                                                    PID is not really one distinct entity. It is a series of diseases that present in various
          discharge                                                 fashions. Instead of a "pelvic inflammatory disease", maybe it should be "pretty
                                                                    indistinct diagnosis".
     c.   Signs and symptoms
          (1)   Patients complain of a mucoid and sometimes         Penicillinase producing Neisseria gonorrhoeae. It was thought to be really a curse
                                                                    because we didn't even know how we could treat it because it didn't respond to
                yellow discharge; odor or irritation is absent      penicillin.

          (2)   Postcoital or intermenstrual spotting is frequent   The incidence has progressed. In Miami, 50% of the GC is penicillinase producing
                                                                    Neisseria gonorrhoeae. The only treatment for GC is ceftriaxone, not penicillin. So
          (3)   Patients often spot or bleed after a Pap smear

                                                                                                                                                          18
                      (4)   Chlamydia infections often produce purulent            in other words, we need to take all of these into account because when we start
                                                                                   getting into specific diagnosis and treatment of PID, you need to pick appropriate
                            discharges and hypertrophic cervicitis. The            antibiotics that are going to cover all of the bugs we talked about.
                            columnar epithelium may be elevated above              IUDs, especially if the patient has BV, the patient has a lot of organisms in the
                            the plane of the squamous epithelium.                  lower generative tract, just mechanically putting the IUD up through that into the
                                                                                   uterus is going to increase the risk of infection, especially the first four to five
                 d. Diagnosis                                                      months. Probably treating the patient ahead of time, especially if they had BV or
                                                                                   something would decrease the incidence.
                      (1)   Cervicitis is due to Chlamydia trachomatis is
                                                                                   Cultures, we talked about. In an ideal world, we would have this nice one swab
                            present in about half of the cases; if negative        that we do PCR for both GC and chlamydia but there are obviously a lot of
                            for herpes, gonorrhea, and Trichomonas,                different mechanisms out there, gene probes and things. If you do a culture for GC,
                                                                                   make sure the transport media is warm. If the transport media just came out of the
                            chlamydia is the likely cause.                         refrigerator, you will never get a positive culture. You will chill it and it will die.
                                                                                   It should be brought the lab very quickly or it should be but in an incubator and
                      (2)   Most sensitive method of diagnosing chlamydia          then brought to the lab because it is a very sensitive, fastidious organism.
                            is to culture the organism on irradiated or            Mucopus. GC or chlamydia. Seeing as how we are not talking about GC, I would
                            idoxuridine-treated McCoy or HeLa cells.               guess that is what she has. The proof of that is she has her Gram-negative
                                                                                   intracellular diplococci on her Gram-stain. With GC, or chlamydia for that matter,
                      (3)   Antigen detection available through enzyme             in the endocervix, some will progress up to an endometritis-salpingitis-salpingo-
                                                                                   oophoritis.
                            immunoassay       (EIA).     One   example        is
                                                                                   How virulent is this bug? What percent of women with GC in the endocervix will
                            chlamydiazynase, which uses an enzyme-
                                                                                   progress to PID? High or low? Low. About 15%, maybe 10-15%. Many will just
                            linked immunoabsorbent assay (ELISA) to                be carriers. There are even male carriers as well although more males will have
                                                                                   symptoms. There are male carriers as well for GC.
                            measure antigen-antibody reaction
                                                                                   How easily is this spread? If a woman has GC in the cervix and a male has
                            (a)    Sensitivity: 90%                                intercourse with her, what is the risk to the male of getting GC? What is the
                            (b)    Specificity: 92-97%                             transmission rate (and then how did they do the study)? High or low? One in 20.
                                                                                   They did it in a Guatemalan prison. They brought in prostitutes with positive GC
                      (4)   Direct smear of material with fluorescein-conju-       cultures and asked for volunteers to have intercourse and then cultured the males
                                                                                   and 1 in 20 were positive. So a relatively low rate of transmission.
                            gated monoclonal antibody is examined under
                                                                                   Here there are Fitz-Hugh-Curtis in both GC and chlamydia. It can move up the
                            a fluorescent microscope. One example is               right colic gutter, either colic gutter and cause a perihepatitis and that can occur in
                            Microtrak                                              like 5% of patients with PID.

                            (a)    Sensitivity: greater than or equal to 90%       Classically, the patient with PID has a fever, elevated white count, discharge,
                                                                                   nobody would miss the diagnosis. The problem is that only 20% of patients with
                            (b)    Specificity: greater than or equal to 98        PID have the classic symptoms so you would be very specific but not very sensitive
                                                                                   to making the diagnosis. If we don't make the diagnosis, then obviously all the
                 e.   Treatment for chlamydia cervicitis                           sequelae are potentially there.
                      (1)   Doxycycline: 100 mg po bid for 7 days
                                                                                   Only 40% with laparoscope diagnosed PID had a fever, a temperature of 100.4º.
                      (2)   For patients for whom tetracyclines are contra-        Only two-thirds had an elevated white count greater than 10.5, so if you look for
                                                                                   just a fever or an elevated white count you are going to frequently miss the
                            indicated or not tolerated                             diagnosis of PID.
                            (a)    Erythromycin base or stearate: 500 mg
                                                                                   Have a low threshold for making the diagnosis. If you aren't concerned about other
                                   po qid for 7 days                               major diseases, make the diagnosis and treat it. All you need to make the diagnosis
                                                                                   of PID is low abdominal pain and tenderness, cervical motion tenderness and
                            (b)    Erythromycin ethyl succinate: 800 mg po)        adnexal tenderness without a competing diagnosis. If the patient has nausea, doesn't
                                                                                   feel like eating and has pin point tenderness over McBurney's point, I don't think
                                   qid for 7 days                                  I would make the diagnosis of PID. If they are a couple of days late with their
                                                                                   period and spotting and have a positive pregnancy test, I think I would entertain
                      (4)   For patients who cannot tolerate the above
                                                                                   other diagnoses. Short of another major diagnoses, I will make the diagnosis of PID
                            regimen: erythromycin base 250 mg qid for 14           on this basis alone and treat.

                            days                                                   The idea is to try to prevent the serious sequelae and treat early and treat often so
                                                                                   that you don't have infertility and chronic pelvic pain and all of those kinds of
III.   Significance of Chlamydia Trachomatis Infections in Pregnancy               things. The more criteria you add, obviously the more specific the diagnosis. If
       A.   Prevalence                                                             there is a fever, white count, inflammatory mass, if you do a culdocentesis and get
                                                                                   back pus, that is pretty obvious or any test for either GC or chlamydia that is
            1.   The prevalence of C. trachomatis infection in women seen          positive.

                 in STD clinics is 10-40%                                          Treatment. You usually need two drugs to treat PID, even outpatient or just
                                                                                   inpatient. Floxin is now being said that it can be used as a single agent but
            2.   Highest prevalence (30-40%) occurs among partners of              obviously if you have too many anaerobes it is not going to work. Ceftriaxone and
                 men with nongonococcal urethritis. Lower prevalence (8-           doxycycline can be used or if you want to stick with pure p.o. medication Floxin
                                                                                   and Flagyl. 400 mg of Floxin b.i.d for 10-14 days. 500 mg of Flagyl b.i.d. for 10-
                 20%) is found in gynecologic outpatient clinics and in            14 days.

                 family planning centers (1-6%)                                    If the patient is sicker, if the patient has more symptoms, has an abscess, an IUD,
                                                                                   they belong in the hospital. In the hospital, the usual regimes are either doxicycline
            4.   Trachomatis infection generally is much more prevalent

                                                                                                                                                                        19
          in STD clinics than in gynecological clinics.                  and Mefoxin or Gentamycin and Cleocin. Community acquired, I usually use
                                                                         doxicycline and Mefoxin. If there is an abscess and IUD, I use Gentamycin and
B.   Postpartum endometritis                                             Cleocin which are very effective. Certainly, if somebody lags, you could use
                                                                         Unasyn. It covers the bugs as well but I would also add doxicycline to make sure
     1.   C. trachomatis has been linked to puerperal infections         I am covering the chlamydia.
     2.   Women with antepartum C. trachomatis infection who
                                                                         The idea again is to make the diagnosis early and give appropriate treatment so that
          deliver vaginally have a five- to sixfold increased risk of    you can prevent sequelae. So the idea again is early treatment, minimal criteria for
                                                                         treatment and prevent the sequelae.
          intrapartum fever and late postpartum endometritis,
                                                                         Different things increase or decrease the chances of tubal occlusion. Each episode
          occurring between 48 hours and 6 weeks postpartum              of PID significantly increases the risk of tubal occlusion. We want to try to catch
C. Prematurity                                                           it early to prevent total destruction of the ovaries. Patients with abscesses. About
                                                                         5% may come in and actually have a ruptured abscess and need immediate surgery
     1.   The mean duration of pregnancy for women with                  and 95% we are going to treat medically. Most of those, two-thirds, will respond
                                                                         if you pick the right drugs. Those that don't may need to go to laparoscopy. You
          antepartum C. trachomatis infection was significantly          need the appropriate incisions. A vertical incision or a Maylard so you can explore
                                                                         the entire abdomen. Look for abscesses, restore all the anatomy, as much as you
          shorter than for controls without such infection               can. Copious, copious irrigation and then really evaluate what is the minimal
     2.   Furthermore, stillbirth or neonatal death occurred more        amount of tissue you can take out and have a reasonable post-op course.

          often among C. trachomatis-infected women than among           If it is totally infected, the patient has said she has completed her family and that,
                                                                         probably the smoothest course is to be able to do a TAH-BSO. But anything in
          controls.                                                      between is acceptable. You can leave an ovary and the uterus. You can leave one
                                                                         ovary, a tube and a uterus. The more infected tissue, the rockier the course but at
D. Eye infections
                                                                         least you are preserving either hormone function or potential fertility. Copious
     1.   Chlamydial inclusion conjunctivitis is the most common         irrigation, drains and appropriate antibiotics. Leave the wound open because there
                                                                         is a greater risk of infection.
          specific cause of purulent conjunctivitis in newborns
                                                                         Hopefully, we treat early and rarely get to this point where you do a TH-BSO but
          a.   This eye infection develops in 20-50% of infants born     by being aware and by treating early, you are going to prevent the sequelae and it
               to mothers infected with C. trachomatis                   is going to be cost effective if you add infertility, ectopic pregnancy, chronic pelvic
                                                                         pain to the picture. PID costs 3.5 billion of health care dollars annually in the
          b.   It occurs in 1-2 % of all newborn infants                 United States but with early diagnosis and treatment, our patients are going to do
                                                                         fine.
          c.   The incubation period is 5-14 days
          d.   Erythromycin eye ointment is effective against C.
               trachomatis
     2.   Chlamydial conjunctivitis is difficult to distinguish clini-
          cally from other forms of ophthalmia neonatorum. Thus,
          the diagnosis must be based on specific cultures and
          microscopic examination of conjunctival smears
E.   Pneumonia
     1.   C. trachomatis, respiratory syncytial virus (RSV), and
          cytomegalovirus (CMV) are the most common causes of
          pneumonia in infants less than 6 months of age
     2.   10-20% of infants born to mothers with C. trachomatis
          cervicitis will develop chlamydial pneumonia
     3.   The incidence of C. trachomatis pneumonia is estimated
          to be 3-8 per 1,000 live births
     4.   Symptoms of chlamydial pneumonia
          a.   Tachypnea
          b.   Staccato cough
          c.   Nasopharyngeal congestion
          d.   Afebrile course
          e. Inspiratory rales on examination
     5.   Lung x-ray usually shows bilateral interstitial pneumonia
          and hyperinflation
     6.   Increased peripheral blood eosinophils (300 mm3) and
          elevated serum immunoglobulins are often found

                                                                                                                                                              20
           7.   The incubation period varies from 1-3 months, and at
                least half of the infants present with a history of preceding
                conjunctivitis
      F.   Other infections in neonates
           1.   C. trachomatis can also cause otitis media in infants
                a.   Middle ear abnormalities are present in 59% of 37
                     infants with chlamydial pneumonia
                b.   Myringotomies were done on one or both ears in
                     eleven of these infants
                c.   C. trachomatis was recovered from the ear aspirates
                     of three of the eleven infants
                d.   None had significant bacterial cultures
           2.   In infants with ocular or respiratory tract infection, C.
                trachomatis can also be recovered from the vagina and/or
                rectum


Upper Genital Tract
I.   PID
      A. Etiology
           1.   PID is a great number of diseases with a diversity in
                etiology and presentation. Multiple bacteria are usually
                isolated.
                a.   Neisseria gonorrhoeae in 40-50 %
                b.   Chlamydia trachomatis in 25-30 %
                c.   Nongonococcal, nonchlamydial organisms only from
                     the upper genital tract in 40-50 %
                d.   Enterobacteriaceae and anaerobic species are
                     frequently present
           2.   Intercourse with multiple partners confers a relative risk
                factor of 4.6 for PID. IUD use confers a relative risk of 3.5
      B.   Incidence
           1.   Approximately one million American women are treated
                for PID each year and 250,000 are hospitalized
           2.   Between the ages of 15-24, one female in sixty acquires
                PID each year
      C. Epidemiology
           1.   Gonorrhea is spread almost entirely by coitus
           2.   It has a short (3 to 5 day) incubation and essential
                immunity to repeat infection. It is not highly infectious; in
                a Guatemalan prison study, only one man in twenty
                exposed to an infected prostitute developed the disease
           3.   For every symptomatic woman treated for gonococcal
                infection, there are nine asymptomatic carriers
           4.   Approximately 60% of gonococcal or chlamydial infec-
                tions occurred within 1 week from the first day of the last

                                                                                21
          menstrual period
     5.   Only 14 % of the nongonococcal, nonchlamydial
          salpingitis patients reported onset of symptoms within 1
          week
D. The organism
     1.   Neisseria gonorrhoeae is a nonmotile, nonspore-forming,
          nonencapsulated gram negative oval coccus measuring
          0.8 by 0.6 u, frequently seen in pairs
     2.   The organism succumbs to drying in 1-2 hours and is
          killed by silver nitrate in a 1:4000 dilution in 2 minutes
E.   Signs and symptoms
     1.   Most women with gonorrhea are asymptomatic
     2.   Once the organism spreads up to the fallopian tubes, the
          clinical features of acute PID may develop.
          a.   Wet smear shows marked increase in inflammatory
               cells: 100%
          b.   Abdominal pain: 94%
          c.   Elevated WBC greater than 10,500: 66%
          d.   Fever (greater than 38EC [100.4EF]): 40%
          e.   ESR greater than 15 mm: 75%
     3.   Occasionally, the purulent exudate migrates to the right
          colic gutter; the patient may experience right subcostal
          pain from perihepatitis, ie, the Curtis-Fitz-Hugh syndrome
     4.   Development of chronic pelvic pain: 18%. The incidence
          of ectopic pregnancy is increased 6-10 fold. 20-25% have
          at least 1 recurrence
     5.   Development of tubal occlusion after episodes of gonor-
          rhea
          a.   After one episode: 13%
          b.   After two episodes: 2.4 %
          c.   After three episodes: 52%
     6.   Tubo-ovarian abscess (TOA) is a well-known sequela,
          and it occurs in as many as 34% of patients hospitalized
          with salpingitis
F.   Diagnosis
     1.   Based on clinical picture and positive culture, gram's stain
          may be helpful in the male, but one cannot establish the
          diagnosis on this basis in the female
     2.   Saprophytic Neisseria or Mima species can be found in
          women not infected with N. gonorrhoeae
     3.   A single cervical culture will detect about 82% of gonor-
          rhea in women; adding culture from the anus and the
          oropharynx can increase the detection rate to 90%.
G. Treatment
     1.   See the attached Tables

                                                                         22
2.   Surgical intervention does not normally play a role in the
     treatment of acute PID). It may be necessary in patients
     with pelvic masses who fall to respond to appropriate
     drugs after 72 hours of treatment
3.   TOA
     a.   Positive response to medical therapy: 60--70%.
          Failure to respond may require surgical intervention.
          Ultrasonography or computed tomographic scans
          can be helpful
     b.   Percutaneous directed catheter drainage with or
          without laparoscopy is being used. Occasionally,
          colpotomy for a very low, dependent abscess point-
          ing in the cul de sac can be used. A needle should be
          inserted into the mass to determine the contents. If
          purulent material is obtained, a scalpel should be
          used to incise the abscess wall and blunt dissection
          done to complete the drainage. The patient may still
          require a later laparotomy
     c.   If patients require a laparotomy
          (1)   The incision must allow adequate exposure:
                either a subumbilical vertical or a Mallard
                incision
          (2)   Explore entire abdomen for concealed pockets
                of pus
          (3)   Careful dissection of distorted tissue plans
          (4)   Adenectomy or hysterectomy, depending on
                extent of disease: if hysterectomy, leave vagi-
                nal cuff open
          (5)   Copious irrigation with 3-4 liters of Ringer's
                lactate
          (6)   Malecot or multiple Jackson-Pratt drains
                through cuff or posterior colpotomy are at-
                tached to closed suction
          (7)   Closure
                (a)   The fascia should be closed with either
                      permanent suture or delayed-absorbable
                      sutures
                (b)   In vertical incisions, the Sinearl-Jones
                      technique is preferred
                (c)   A delayed primary closure of the skin and
                      subcutaneous tissue is the procedure of
                      choice
                (d)   A pack of moist gauze is placed in the
                      subcutaneous layer and covered with a
                      sterile       dressing for 3-4 days, then

                                                                  23
                                                   the incision is rinsed and,
                                                   if clean, closed with Steri-
                                                   Strips
           4.     Ruptured TOA
                  a.   Demands operative intervention. The patient is
                       stabilized, antibiotics begun, and immediate surgical
                       intervention undertaken
                  b.   Clinical evidence for rupture includes diffuse peritoni-
                       tis, sudden change in the character and intensity, of
                       pain, tachycardia out of proportion to fever, critically
                       ill appearance, or the development of shock in a
                       patient with a tubo-ovarian complex
                  c.   In treating a patient with a ruptured TOA, the physi-
                       cian must be aware of potential lethal complications
                       (1)   Acute respiratory distress syndrome (ARDS)
                       (2)   Septic shock
                       (3)   Acute tubular necrosis
                       (4)   Septic thrombophlebitis
                       (5)   Local or distant abscesses
                       (6)   Wound infection and/or wound dehiscence
II.   Tuberculosis (TB)
      A.   Approximately 35 million people in the United States have
           positive TB reaction, and thousands of Americans die of TB
           annually. Genital TB is secondary to TB elsewhere in the
           body, usually in the lungs


Table 2
The Frequency of TB Involvement of Various Organs in Genital TB
           Organ               Percent
           Tubes               95-100
           Uterus              50-60
           Ovaries             20--30
           Cervix              5-15
           Vagina              1


      B.   Incidence: in women who died from pulmonary TB, 8 % had
           genital TB. In infertility clinics in the United States, approxi-
           mately 1% have genital TB
      C. Presenting manifestations in female genital TB
      Table 3
      Manifestation                      Percent
      Sterility                          45-55
      Pelvic pain                        50
      Poor general condition             26
      Menstrual disturbances             20

                                                                                  24
Vaginal discharge                 4
D. Diagnosis
     1.   Clinical symptoms
     2.   "Dough” sensation on palpation of abdomen
     3.   Pelvic may show bilateral tubo-ovarian masses; less
          tender than usual
     4.   Chest x-ray (screening)
     5.   PPD skin test (screening)
     6.   Endometrial curettage
          a.   Best time is several days before the expected men-
               strual period, at which time the tubercles reach their
               maximum growth
          b.   Curettings should also be sent to bacteriology for
               culture
     7.   Menstrual blood can be sent for culture
E. Treatment
     1.   Minimal genital TB
          a.   Isoniazid,   300       mg   doses,   and   ethambutol
               (Myambutol), 20 mg/kg or approximately 1,200
               mg/day
          b.   Endometrial curettings are examined at 6 and 12
               months
               (1)   If they become positive or if tubo-ovarian
                     masses appear, rifampin 600 mg daily is added
                     for 3 months
               (2)   If no complications arise, continue isoniazid
                     and ethambutol for 2 years and then use
                     isoniazid alone indefinitely
     2.   Advanced genital TB, ie, tubo-ovarian masses present: as
          above, plus re-exam every 3--4 weeks
     3.   If tubo-ovarian masses are still present after 3--4 months,
          surgery is indicated
          a.   Total abdominal hysterectomy and bilateral salpingo-
               -oophorectomy on all patients over 40
          b.   In younger women who desire to maintain some
               function, the extent of surgery depends on findings
               during the operation
               (1)   One week before the operation, start strepto-
                     mycin IM 1 g daily and continue it for 3 weeks
                     postoperatively
               (2)   If residual tuberculous foci are left in the abdo-
                     men, continue streptomycin twice weekly for a
                     total of 3 months
F.   Pregnancy following treatment of genital TB: review of over
     7,000 cases

                                                                          25
            1.   Full-term pregnancies: 155
            2.   Abortions: 67
            3.   Ectopic pregnancies: 125


Urinary Tract


Urinary tract infections (UTIs) are second only to respiratory infections
in frequency. In about 60% of patients, the infection is limited to the
bladder: in about 40%, there is renal involvement
I.     Incidence
       A.   School-age girls: approximately 1%
       B.   Women of childbearing age: 4%
       C. Women over age 60:7%
II.    Clinical Syndromes
       A.   Asymptomatic bacteriuria: The patient has no symptoms but
            has a urine culture demonstrating 100,000 colonies of a single
            bacteria genus in two consecutive specimens
       B.   Acute infection
            1.   Usually seen in young or middle-aged women and often
                 not associated with detectable underlying uropathy
            2.   Usually responds to minimal medical management, but
                 on follow-up, at least 20% of the patients have residual
                 asymptomatic bacteriuria
       C. Recurrent infection
            1.   Patients require complete investigation
                 a.   C&S
                 b.   Cystoscopy
                 c.   Excretory urography
                 d.   Voiding cystourethrography
            2.   May reflect
                 a.   Reinfection
                 b.   Relapse
                 c.   Superinfection
       D. Chronic infection
            1.   Unlike acute simple or recurrent infection, often has
                 underlying uropathy: impaired drainage of urine second-
                 ary to congenital or acquired obstruction
            2.   As many as half may be asymptomatic
            3.   Findings
                 a.   Abnormal urinary sediment
                 b.   Proteinuria
                 c.   Azotemia
                 d.   Calyceal changes noted on programs
III.   Symptoms
       A.   Most patients with acute disease have dysuria frequency and

                                                                             26
           urgency but up to 10% do not
      B.   Bladder infections: 50% of patients with lower urinary tract
           symptoms do not have bladder infections
      C. Bacterium may increase the incidence of prematurity, princi-
           pally in women with
           renal involvement
      D. Hypertension and its sequelae may be the presenting manifes-
           tations
      E    Rarely, acute infections erode into a blood vessel and
           hematuria results
IV.   Etiology
      A.   The source is usually within the host's own intestinal tract
           Colonic bacteria ÿ perianal region ÿ urethra ÿ bladder ÿ
kidney
      B.   Single catheterization is followed by infection in 2-4% of
           patients. When the catheter is indwelling, infection is inevitable
      C. Over 75% of all UTIs axe caused by the Enterobacteriaceae
           family
      D. Occurrence of bacterial species in asymptomatic bacteria of
           pregnancy


      Table 4
      Genus                            Percent
      E. coli                          76
      Klebsiella-Enterobacter          16
      Proteus species                  5
      Pseudomonas                      1
      Staphylococcus species           1
      Streptococcus faecalis           1


V.    Diagnosis
      A.   Two consecutive clean voided specimens with recovery of the
           same organism with a colony count of at least 100,000 have
           a 91% chance of indicating a UTI; 80% with one specimen
           and 96 % with three
      B.   Correlation: there is a good correlation between the finding on
           the microscopic examination of a 's-stained drop of urine that
           has not been centrifuged and positive results of urine cultures
      C. Use of chemicals such as triphemytetrazolium chloride (TTC)
           for mass detection of significant bacteriuria is simple and
           inexpensive
VI.   Treatment
      A.   Asymptomatic bacterium and acute simple infection may be
           treated with short-acting sulfonamides, 1 g qid for 10 days
           1.    This gives cure rates of 80--90 % in ambulatory patients

                                                                                27
               with acute infection and of 70-80% in pregnant women
               with asymptomatic bacteriuria
          2.   If this is ineffective, the choice of drug should be gov-
               erned by the results of in vitro susceptibility studies
          3.   If the patient is allergic to sulfonamides, nitrofurantoin 50-
               100 mg qid, or nalidixic acid 0.5-1 g qid may be used
          4.   Repeat culture 10-14 clays after therapy to ensure cure
     B.   Recurrent infection same as above, but if work-up is negative
          and infection continues to recur, may use the following
          medications bid to qid for 5-10 days monthly for 6 months
          1.   Sulfonamide 0.5 g
          2.   Nitrofurantoin 50-100 mg
          3.   Nalidixic acid 0.5-1 g
     C. Chronic infection may need prolonged treatment, followed by
          suppressive therapy indefinitely. Nitrofurantoin should be
          avoided in these patients because of danger of neuropathy or
          of interstitial pulmonary fibrosis
     D. For more serious urinary infection, other drugs must be used.
          Individual drugs must be selected on the basis of C & S and
          patient response


Toxic Shock Syndrome


I.   Background
     A.   A new phage type strain of Staphylococcus aureus 29 + 52,
          first recognized in 1978
     B.   Clinical aspects
          1.   Acute febrile illness (102EF), associated with multisystem
               involvement, scarlatiniform skin eruption and shock
          2.   Between 1978 and May of 1981, 1,233 cases were
               reported with a mortality rate between 7 and 10%; nearly
               50 cases per month are still being reported to the CDC
               a.   Women: 94% of cases (especially between ages 19-
                    24)
               b.   Men and children:
                    (1)   Postoperative wounds
                    (2)   Furuncles
                    (3)   Burns
                    (4)   Abscesses
          3.   Tampons carry a mandatory warning about toxic shock
               syndrome (TSS)
               a.   All types of tampons involved, but especially the
                    superabsorbent
               b.   Usually occurs after the second or third day of
                    menses

                                                                                28
                c.   The risk can be reduced by using less absorbent
                     tampons and/or alternating tampon use with sanitary
                     napkin use
II.    Diagnosis/Toxic Shock Symptoms
       A.   Sudden onset of high fever (104EF), usually second or third
            day of menses
       B.   Headache
       C. Confusion
       D. Conjunctival hyperemia
       E.   Muscular weakness
       F.   Scarlatiniform rash (often starts on lower abdomen and
            perineum and spreads)
       G. Vomiting
       H. Watery diarrhea (often more than 10 stools/day)
       I.   Shock (usually occurs 40-72 hours after onset of fever)
       J.   Oliguria, acute renal failure, and DIC may occur
       K.   Desquamation over trunk and extremities (particularly palms,
            soles), usually occurring 1-2 weeks after onset of fever
III.   Treatment
       A.   Remove tampon
       B.   Irrigate vagina
       C. Stabilize and support patient
       D. Antibiotics like Keflin or Staphcillin, 1 g q4h until afebrile for 48
            hours
IV.    Additional Information
       A.   A high level of 29-52 phage type Staph aureus has reached a
            plateau and is expected to recede spontaneously in 3-5 years
       B.   TSS is due to an enterotoxin of this staph
       C. One-fourth of recurrences in menses-related disease devel-
            oped in subsequent menstrual periods; warn patients not to
            resume tampons


Actinomyces
I.     Family Actinomycetaceae
II.    Several Species
       A.   Actinomyces israelii
       B.   A. naeslundii
       C. Arachnia propionica
III.   Anaerobic to Microaerophilic, gram positive, Non-acid Fast,
       Pleomorphic Parasites
       A.   They are bacteria, not fungi, although they have mycelial
            forms
       B.   Diameter only 0.3/u
IV.    Clumps of Actinomycetes with Other Bacteria May Be on Pap
       Smears

                                                                                  29
       These are called "Gupta bodies'
V.     Sulfur Granules
       A.   Mycelial colonies of actinomycetes with filamentous branches
            may become embedded in an amorphous granular material
            that contains calcium phos, antigen, and antibody complexes
       B.   Characterized by radiating clubs
       C. A tissue response to invasive organisms
VI.    8% of IUD Wearers Have Actinomycetes
VII. The Ideal Management for the Asymptomatic Patient with
       Actinomycetes
       A.   Remove the IUD, treat the patient with penicillin, 500 mg qid,
            or tetracycline, 500 mg qid, for 2 weeks, and repeat Pap
            smear after the next menses Antibiotic Prophylaxis


I.     Studies
       A.   Most studies say prophylaxis is indicated for the following
            1.   Vaginal hysterectomy
            2.   High-risk C-sections
       B.   Possibly indicated
            1.   Abdominal hysterectomy
            2.   Infertility surgery
            3.   Vaginal reconstruction
            4.   Radical operations for cancer
       C. Five of eight studies suggest prophylaxis is beneficial in
            abdominal hysterectomies. Some studies find little or no
            difference, while others show a reduced rate of infections
       D. In one study of 400 abdominal hysterectomies, the infection
            rate was reduced from 21%, to 14% using antibiotic prophy-
            laxis
            1.   When prophylaxis was used for high-risk C-section
                 patients, 10-14 trials demonstrated a significant reduction
                 in pelvic and wound infections
            2.   Even two of the negative trials show a trend in favor of
                 antibiotics
II.    Regimens
       A.   In hysterectomy patients, ampicillin or a cephalosporin
            (cefazolin), 30 minutes to 1 hour prior to surgery and then q6h
            to q8h, from 3--6 doses, is effective
       B.   A randomized double-blind study of 266 high-risk cesarean
            section patients, given three perioperative doses of 2 g
            cefoxitin had significantly fewer serious infections (19.5% vs.
            4.3%), fewer UTIs (10.7% vs. 4.4%), and less standard febrile
            morbidity (9.4% vs. 3.6%). It has been shown to be effective
            when the first dose is given after the cord is clamped
III.   Protocol for Antibiotic Prophylaxis for C-Sections

                                                                               30
      A.   Antibiotic prophylaxis is effective in reducing the expected
           incidence of postcesarean febrile morbidity. Infectious morbid-
           ity following C-section has been reported to range from 29-
           85%.
V.    What Agent to Use
      A.   Many different antibiotics have been used
           1.   Two commonly used drugs
                a.   First-generation cephalosporins, namely, cefazolin
                     (Ancef, Kefzol)
                b.   Second-generation cephalosporin, cefoxitin (Mefoxin)
           2.   Both of these antibiotics have been shown to be effective
           3.   Once the membranes have been raptured, there is an
                increase in anaerobic organisms in the lower uterine
                segment, and cefoxitin may be better able to handle this
                condition
      B.   Specific doses
           1.   Cefazolin, 1 g IV piggyback, immediately upon clamping
                the cord, and then q6h to cover for 24 hours
           2.   If cefoxitin were being used, the dose is 2 g IV piggyback
                immediately on clamping the cord and then 2 g q4h twice
                and q6h thereafter to complete 24--hour period
           3.   In general, the antibiotics would be used to cover the first
                24-hour period: however, in patients with multiple high-
                risk factors, a longer course of antibiotics may be appro-
                priate when subclinical infection was present at the time
                of the surgery
VI.   Patients With Allergies or Other Problems
      A.   The cephalosporins can be used cautiously in patients who
           are allergic to penicillin. A small dose could be given subcuta-
           neously and the site can be observed
           1.   For prophylaxis of a patient in whom cephalosporins are
                contraindicated because of a history of recent penicillin
                anaphylaxis or cephalosporin allergy, an alternate drug
                selection would be clindamycin together with gentamicin
           2.   In patients with valvular heart disease, the American
                Heart Association recommendations should be followed
      B. In summary, the use of prophylactic antibiotics for C-section
           has to be individualized. Probably, patients undergoing
           elective repeat C-sections do not need prophylactic antibiotics
           1.   Patients at moderate risk should have the 24-hour dose
                schedule
           2.   Patients with marked risk of significant postoperative
                morbidity should be covered for a longer period of time


        $
Group B-$-Hemolytic Streptococci

                                                                               31
I.     BASIC CHARACTERISTICS
       A.   The group B-b-hemolytic streptococcus (GBS or Streptococ-
            cus agalactiae) is a gram-positive coccus which grows in
            chains in vitro and in vivo
       B.   GBS lacks the M protein that is characteristic of the group A
            organisms
       C. GBS has been a leading cause of bacteremia/meningitis in the
            first 2 months of life since the early 1970s
       D. GBS is a significant cause of post-partum febrile morbidity,
            and 20-30% of these women have bacteremia
       E.   The incidence of GBS
            I.   Early-onset infection: 1.5-3.0/1,000 live births
            2.   Late-onset infection: 0.5-1.5/1,000 live births
       D. Mean mortality rates for early- and late-onset GBS neonatal
            disease remain 50% and 20%, respectively
III.   GBS Infections in Pregnant Women
       A.   Clinical features
            1.   Most women with genital colonization are asymptomatic
            2.   Relationship to fetal demise, premature rupture of mem-
                 branes (PROM), spontaneous abortion is unknown
            3.   May     cause     UTI    (5-29%     of    infections)   and
                 chorioamnionitis (rarely)
            4.   Common cause of early first 48 hours) postpartum febrile
                 morbidity, especially when C-section delivery
                 a.    Patients with postpartum endometritis attributed to
                       GBS: 14%
                 b.    Postpartum bacteremias due to GBS: 20--25%
                 c.    Rarely, fatal puerperal sepsis, endocarditis
       B.   Diagnosis
            1.   Cultures
                 a.    Blood
                 b.    Amniotic fluid
                 c.    Endometrium
                 d.    Wound
            2.   CIE
       C. Treatment
            1.   Aqueous penicillin G IV, 1-2 MU q4h
            2.   If penicillin-allergic, cephalosporins
            3.   Duration dependent on severity of infection
IV.    Epidemiology of GBS in Women
       A.   Colonization: presence of bacteria at one or more mucous
            membrane sites
            1.   Pharynx: 5-10%
            2.   Genital tract: 5-30% (rates increase as one moves from
                 cervix to introitus)

                                                                               32
           3.   Anorectum: 15-20%
      B.   Prevalence of colonization
           1.   Rates increase in:
                a.   Primigravidas
                b.   Less than 20 years of age
                c.   Gravida three or less
                d.   IUD users
                e.   Patients of STD clinics
                f.   Sexually active women
           2.   Colonization not influenced by the following
                a.   Oral contraceptives
                b.   Race (may be less in Mexican Americans)
                c.   Number of sexual partners
                d.   GC infection
                e.   Pregnancy
      C. GBS colonization in pregnancy
           1.   Single culture, positive or negative, cannot accurately
                predict culture status at delivery
                a.   One-third chronic careers
                b.   One-third intermittent
                c.   One-third negative at delivery
           2.   Colonized women who have baby with GBS sepsis: 1%;
                approximately 65% have baby with asymptomatic mu-
                cous membrane colonization
           3.   Maternal genital inoculum determines risk for colonization
                and sepsis
           4.   Mother to infant transmission: may occur with C-section
VI.   Pathogenesis of Early-onset GBS Infection
      A. Maternal risk factors
           1.   Presence of GBS at delivery in high inoculum: 1-2
           2.   Prolonged rupture of membrane more than 24 hours:
                11%
           3.   For type III infections, low levels of maternal type-specific
                antibody: 10%
           4.   Postpartum bacteremia: 10%
           5.   Twin pregnancy (if one twin affected, 35% risk to other
                twin)
      B. Neonatal risk factors
           1.   Gestation less that 37 weeks (15% if the mother is culture
                positive at delivery)
           2.   Defective WBC function?
           3.   "Physiologic" deficiencies in complement function
           4.   Low levels of type Ill-specific antibody either due to
                maternal deficiency or gestation less than 34 weeks
      C. Clinical features

                                                                                33
          1.   Up to 50% of neonates are symptomatic at birth
               (intrauterine infection): 40% have respiratory distress
               syndrome (RDS)
          2.   Term infants are more likely to develop symptoms at age
               2 or 3 days, and frequently have meningitis (up to 30%)
          3.   The lower the birth weight, the higher the attack rate for
          GBS infection if
          the mother is culture-positive at delivery
VII. Management Suggestions
     A.   Treatment of women with previously documented GBS baby
          1.   Culture several times during pregnancy for GBS
          2.   If all cultures negative, no treatment necessary
          3.   If any culture positive, ampicillin 1 g q6h during labor
     B.   Treat   infected   patients   with   penicillin,   ampicillin,   or
     erythromycin
          1.   Attempts to treat asymptomatic vaginal colonization
               during pregnancy have been only partially successful
          2.   Transmission of GBS to the fetus during labor and
               delivery, can be interrupted by giving are ampicillin IV
               during labor, 1 g q6h
     C. Treat patients who have PROM and a positive culture as soon
          as the culture result is known, without waiting for maternal or
          fetal symptoms
     D. Treat all patients with positive urine cultures, whether or not
          they have symptoms. Ten-day courses of treatment may be
          repeated if there is recurrent significant urinary colonization
     E.   Give patients with postpartum endometritis broad-spectrum
          antibiotics even before the culture result is available. The
          antibiotics effective against gram-positive bacteria usually are
          adequate against GBS
     F.   Since the organism is a significant pathogen for newborns,
          notify the pediatrician about any GBS infection that may occur
          during pregnancy or the immediate postpartum period
     G. Consider treating a patient who has a history of pregnancy
          loss and a positive culture as a possible way of preventing
          future loss
          1.   It is reasonable to include the patient's sexual partner in
               the treatment effort because this organism can be trans-
               mitted by intimate contact
          2.   Advise the patient that repeated doses, including treat-
               ment during labor may be required


Criteria for the Diagnosis of Acute PID


I.   All must Be Present

                                                                                34
       A.   Lower abdominal pain and tenderness with or without rebound
       B.   Cervical motion tenderness
       C. Adnexal tenderness
II.    In Addition, One or More of the Following must Be Present
       A.   Fever above 100.4EF
       B.   Leukocytosis (greater than 10,500 WBC/mm3)
       C. Inflammatory mass documented by pelvic examination and/or
            sonogram
       D. Culdocentesis revealing WBCs and bacteria on gram's stain
            of peritoneal fluid
       E.   Gram-negative intracellular diplococci on gram's stain from
            cervix
III.   Indications for Hospitalization of Acute PID
       A.   Temperature above 100.40 F
       B.   Presence of adnexal mass
       C. Coexisting pregnancy
       D. IUD present
       E.   Uncertain diagnosis
       F.   Upper peritoneal signs
       G. Unable to tolerate oral medications
       H. Failure to respond to outpatient therapy in 24--48 hours
       I.   Possibly all salpingitis


Group B Streptococcal Infection in Pregnant: ACOG Recommendations
1.     In the absence of lower urogenital tract screening cultures for GBS,
       the following risk factors identify women who should receive
       intrapartum antibiotic chemoprophylaxis: preterm labor ( <37
       weeks), preterm PROM ( <37 weeks), prolonged rupture of
       membranes ( >18 hours), previous child affected by symptomatic
       GBS infection, or maternal fever during labor.
2.     In the nonallergic patient, first-line intrapartum chemoprophylaxis
       should consist of either ampicillin (2 g q6h) or penicillin G (5
       million U q6h) until delivery. Penicillin-allergic women may be
       given clindamycin or erythromycin intravenously.
3.     In populations in which the incidence of neonatal GBS infection is
       inordinately high, selective or routine screening cultures can be
       considered. Candidates for selective culture might include women
       with threatened or arrested premature labor, women with PROM
       remote from term undergoing expectant management, and women
       undergoing surgical procedures of the cervix in pregnancy.
4.     One technique for culturing is to obtain a sample through a single
       swab of the lower vagina and anorectum at 26-28 weeks of
       gestation, place the sample in selective broth medium, and
       subculture it onto solid media. If the culture is positive, intrapartum
       intravenous antibiotics as previously outlined should be used to

                                                                                 35
treat women with the following risk factors: preterm labor (<37
weeks), PROM (<37 weeks), and ruptured membranes (>18
hours). Regardless of maternal carrier status, treatment is
indicated if the patient has had a child affected by GBS or if
maternal fever is present intrapartum.




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