Vagina/Cervix

Vaginitis

Vagina is typically acidic pH < 4.5

Bacterial vaginosis - pH > 4.5

    • Gardnerella vaginalis ➔ clue cells (vaginal epithelium covered with bx)

    • Positive whiff test (10% KOH ➔ amine odor)

    • TX with metronidazole

Trichomoniasis - pH > 4.5

    • Trichomonas vaginalis (flagellated protozoan) ➔ frothy, purulent/foul odor

    • Cervicitis ➔ strawberry cervix

    • TX with metronidazole

Vaginal yeast infection - pH 4-4.5

    • Candida albicans ➔ cottage cheese discharge

    • Pseudohyphae on KOH

    • TX with topical azole/nystatin/PO fluconazole

      • Pregnant: topical imidazole clotrimazole or miconazole

Chlamydia

  • Chlamydia trachomatis ➔ purulent, bloody, odorless

  • CAN'T BE SEEN ON LIGHT MICROSCOPY/GRAM STAIN

    • Gram-negative intracellular with cytopasmic inclusion bodies on Giemsa stain

    • Can infect eyes, GU, lungs

      • LGV (Lymphogranuloma venereum) - painless genital ulcers and b/l inguinal LN swelling

  • NAAT is test of choice

    • TX with PO azithro (if pregnant) or doxycycline

      • TX partner too

Gonorrhea

  • Neisseria gonorrhoeae ➔ purulent discharge

  • Gram-negative, intracellular, diplococci

  • Can disseminate ➔ polyarthralgias, tenosynovitis, gonococcal arthritis

  • NAAT is test of choice

  • Tx with Ceftriaxone 500mg IM and doxycycline 100mg PO BID x7d (azithro if pregnant)

    • Gentamicin 240mg IM and azithromycin 2g PO if allergic to cephalosporin

    • TX partner too

Syphilis

  • Treponema pallidum ➔ painless ulcer

  • Spirhochete

  • Weeks later ➔ diffuse maculopapular rash on trunk, palms and soles

  • Darkfield microscopy or PCR or direct fluorescent antibody (DFA) of lesions

  • Nontreponemal tests (RPR, VDRL) followed by treponemal tests enzyme immunoassay (EIA) or FTA-ABS

  • TX with Penicillin G benzathine IM

    • Penicillin G IV for neurosyphilis

Cervicitis: Inflammation limited to cervix

  • Typically from infection

    • Chlamydia, gonorrhea (MC) typically affect columnar epithelium of endocervix

    • Trichomonas typically affects squamous epithelium of ectocervix

    • Trauma/irritation (tampons/creams), malignancy typically ➔ chronic cervicitis

  • SSX

    • Mucopurulent discharge

    • Friable cervix (bleeds easily) ➔ spotting, postcoital bleeding, dyspareunia

    • Trichomonas ➔ punctate hemorrhages (strawberry cervix)

    • ± LUTS

  • DX is clinical but NAAT is test of choice in Gonorrhea/Chlamydia

  • TX empirically for chlamydia, gonorrhea: ceftriaxone IM and PO azithromycin or doxy

Pelvic Inflammatory Disease: Infection that spreads beyond cervix

  • Upper genital tract infection (beyond just the cervix) uterus, fallopian tubes, ovaries, pelvic organs, peritoneum

    • MCC by Chlamydia, gonorrhea (< 15% caused by E. coli, H. influenza, strep, staph)

  • SSX

    • Cervicitis with b/l ABD pain, fever, N/V

    • Cervical motion/uterine/adnexal tenderness

  • DX is clinical

    • US not needed but shows signs of inflammation (thick, fluid-filled tubes/oviducts, tubal hyperemia on doppler)

  • TX empirically for chlamydia, gonorrhea: ceftriaxone 500mg (if <150kg) IM and PO doxy 100mg BID x 14-21d (or azithromycin)

    • If n/v ⊣ PO intake: inpt for IV cefotetan and doxy

    • 1/2021 guidelines suggest adding metronidazole in outpt tx

Incompetent cervix/Cervical insufficiency

    • Painless cervical dilation ➔ second-trimester pregnancy losses

    • MCC is cervical trauma (forceps/vacuum-assist, cesarean, LEEP)

  • DX

    • Cerclage short cervix at 12-14wks and avoid coitus

  • SSX

    • Pregnant pts (14-20wks) pelvic pressure, Braxton-Hicks, cramping , discharge or ∆ discharge

    • Short cervical length on US: perform Valsalva to check if fetal membranes in endocervical canal

  • TX

    • Cerclage placement at 12-14wks gestation with hx of second-trimester losses

    • Avoid coitus

    • ± progesterone at 16wks gestation until 36+6wks gestation