1
Q
what are the 5 P’s? What’s it for?
A
- gather sexual history information in organized and nonjudgmental way
- Partners
- men, women, both, how many?
- Practices
- vaginal, anus, oral
- Pregnancy plans
- prevention?
- Protection from STDs
- protection?
- Past Hx of STDs
- u, partner had? drugs? $$ for sex?
2
Q
normal pH in vagina
A
3.5-4.5
3
Q
who should be screened for STIs?
A
- all sexually active women
- hx any STI
- >1 partner in past 12 months
- new partner in past 90 days
- believe partner is having sex with another
- concerned that she’s exposed
- have 1 STI
4
Q
what is the expedited partner therapy prescription?
A
can give an extra dose for partner in prescription OR a separate prescription for partner + fact sheet
legal protection
5
Q
what are mandatory reportable STI’s
A
gonorrhea
chlamydia
syphilis
chancroid (rare)
HIV/AIDs
6
Q
what is bacterial vaginosis (BV)?
A
Form of vaginitis or vaginal inflammation; has vaginal discharge with WBC, blood cells.
Change in microflora of the vagina, decreased lactobacilli (good bacteria) and overgrowth of anaerobic bacteria (gardnerella bad bacteria)
not really spread via sexual activity
7
Q
BV risk factors
A
- smoking, douching, new sexual partner, no condom use, race/ethnicity, low vitamin D levels, women sex women (WSW) [exchanging vag secretions]
8
Q
BV s/sx’s
A
- Excessive thin, gray, or white vaginal discharge that sticks to vaginal walls
- mild itching
- Fishy odor (after semen)
- painful intercourse
- maybe asymptomatic
- risk of PID
- pH > 4.5 (N: 3.5-4.5)
9
Q
BV diagnosis
A
Amsel Criteria: have 3 out of 4 of these for diagnosis of BV:
- white thin milky vaginal discharge
- Clue cells (>20% of epithelial cells are clue cells)
- pH > 4.5
- positive whiff/KOH test
10
Q
BV management / counseling
A
- Can cause preterm labor if preg, low birth weight, PID even if not preg
- metronidazole 500mg oral BID
- or metro gel vaginal 0.75% x 5 days
- NO ALCOHOL 24 hrs after completion
- alt: tinidazole
- no alc 72 hrs
- alt: clindamycin
- may weaken latex condoms or contraceptive diaphragms
- or metro gel vaginal 0.75% x 5 days
- no sex until completion of meds
- no douching
- metallic taste
- no alcohol, coffee, fast food, processed foods, sugar
- STI/HIV testing
- relapse common
- don’t have to tx partners
11
Q
vulvovaginal candidiasis (VVC): uncomplicated vs complicated
A
overgrowth of Candida albicans or (other candida species) in the vagina, the vulva, the groin, and other moist areas and skin folds of the body
- Uncomplicated VVC:
- mild-to-moderate symptoms
- infrequently or sporadic
- C albicans
- not immunocompromised
- Complicated VVC:
- > 4 times a year
- severe symptoms
- not albicans
- immunocompromised (diabetes, HIV, debilitation, immunosuppressive therapy)
12
Q
vulvovaginal candidiasis risk factors
A
- tight-fitting clothing
- douching
- uncontrolled diabetes, immunocompromised states
- menopause, pregnancy
- poor personal hygiene
- humid conditions
- COCs
- Steroids
- antibiotics
13
Q
VVC physical exam findings
A
- thick, white, and curd-like vaginal discharge
- “cottage cheese discharge”
- Vulva erythematous; slight swelling
- vagina edematous and red
- most common: itchy vagina, burning and/or discharge
- dysuria, and dyspareunia
- pH < 4.5
- Men
- Burning during sex
- Rash
14
Q
VVC under microscope
A
- on wet mount, see budding yeast and hyphae.
- Blue arrow: budding yeast
- Red arrow: long strand of hyphae.
15
Q
VVC diagnosis
A
KOH wet smear to see buds
pH < 4.5 (normal)
treat presumptively
16
Q
VVC Treatment / Counseling
A
- antifungals (must finish entire course)
- vaginal creams (weaken condoms)
- no tampons
- sitz baths
- diabetes screening with recurrent infections
- test for chlam/gon, HIV
- no sex (or use non latex condom)
- no feminine hygiene sprays, deodorants, scented pads
- vitamin c, probiotics, yogurt
- educate:
- cotton underwear
- no tight clothing
- dry vulva after bath
- no douching
17
Q
chlamydia screening rec’s
A
- All sexually active women and young women < 25 years screened annually
- if > 25 with risk factors (new partners, STI) screened too
18
Q
chlamydia s/sx’s
A
- MOST asymptomatic
- post coital bleeding (friable cervix)
- mucopurulent cervical discharge or cervicitis
- dysuria, dyspareunia, lower abdominal pain, pelvic pain (mimics UTI)
- cervical motion tenderness, and adnexal fullness (uterine tenderness) Blood prep may show increased white blood cell
19
Q
chlamydia diagnosis
A
first urine catch or swab of vagina, NAAT (nucleic acid amplification)
20
Q
chlamydia treatment / counseling
A
- doxycycline 100 mg oral 2x/day x 7 days
- or
- azithromycin 1 gram oral single dose
- educate:
- treat current & recent partners
- prescreen 3 months after tx for reinfection
- tx given asap so no PID
- no sex for 1 week after treatment
- don’t need test of cure (retesting after 4 week) except for pregnant
21
Q
gonorrhea
A
- Neisseria gonorrhoeae 2nd most STI in US
- spread via sexual (genitals, oral-genital, anal-genital) of cervix, urethra, oropharynx, bartholins gland
- main complication: PID
22
Q
CDC recommends all treatments for gonorrhea includes treating _____ simultaneously to reduce incidence of _____ and combat ___
A
chlamydia, PID, antibiotic resistance
23
Q
gonorrhea sx’s
A
- 80% asymptomatic
- change in vaginal discharge
- Bartholinitis common in undx gonorrhea
- lower abdominal pain
- abnormal vaginal bleeding with spotting.
- Dysuria, unilateral labial edema, pain, and dyspareunia
- later sx’s: fever, nausea, vomiting, joint pain, upper abdominal pain (liver)
- disseminated gonococcal infection = rare life threatening from undo gonorrhea affecting joints
24
Q
gonorrhea PE
A
- Disseminated gonococcal infection (DGI) lesions can lead to arthritis joint pain
- cervical lymphadenopathy, cervical motion tenderness, or cervicitis, uterine or adnexal tenderness (PID)
- Cervicitis (inflamed cervix; purulent)
- friable cervix
25
gonorrhea diagnosis
* **NAAT testing (most optimal for screening) (may be called “culture”)**
* Swab testing of specimens from the cervix, vagina, anus, or pharynx
* Cell swab or urine sample
* *No blood test is reliable*
26
Gonorrhea treatment / couseling
* **Ceftriaxone 500 mg IM (\<150kg/300lbs) or 1 gram IM (_\>_ 150 kg/300lbs)**
* Alternatives:
* Gentamicin 240 mg IM single dose + azithromycin 2 gm orally single dose OR
* Cefixime 800 mg single dose + doxycycline 100 mg BID x 7 days if chlam has not been excluded
* Penicillin or cephalosporin allergy: Gentamicin + Azithromycin or Gemifloxacin and Azithromycin a
* Only if Ceftriaxone is not available or allergies exist.
* A test of a cure for GC or CT is **not** recommended, except in pregnancy or if symptoms persist following treatment.
* Strongest risk factor for infection:
* past infection with gonorrhea
* 2nd infection increases the risk for PID and ectopic pregnancies.
* **treat ALL** sexual partners in the past 60 days empirically
* EPT
* No sex 1 week after shot
27
pelvic inflammatory disease
* gonorrhea, chlamydia trachomatis, gardnerella, haemophilus, or mycoplasma.
* ascend from the vagina to upper GU tract causing inflammation and scarring
* causes tubal abscess, peritonitis, endometritis, inflammation and scarring of tubes = infertility, ectopic pregnancy, chronic pelvic pain
28
PID risk factors
* recent insertion of an IUD (within last month)
* adolescence (highest risk bc decrease immunity)and young-age women
* new or multiple sexual partners
* Recent abortion
* pelvic surgery
* Childbirth
* Douching (push bacteria up)
29
PID s/sx's
* Dyspareunia
* Lower dull abdominal pain, pelvic pain, low back pain
* Purulent /cervical discharge
* Fever (101+)
* Post coital bleeding
* pelvic pain worsening with Valsalva, sex, or movement
30
PID diagnosis criteria and
* **Pelvic or lower abdominal pain AND:**
* **cervical motion tenderness = palpate; chandelier's sign (if there's pain)**
* **uterine pain**
* **adnexal tenderness**
* pH test, wet mount
* severe: U/S with mass
* fever 101+
* mucopurulent discharge
* WBC on wet mount
* elv ESR, CRP
31
PID differentials
* Ectopic pregnancy
* acute appendicitis
* endometritis
* ovarian cyst
* pelvic adhesions, inflammatory bowel disease
32
PID treatment/management
empirically
* **Ceftriaxone 500 mg IM single dose + doxycycline 100 mg oral 2x/day x 14 days + metronidazole 500 mg BID x 14 days**
* hospitalization if:
* r/o surgical emergencies (appendicitis)
* pregnant
* no response to oral antimicrobial therapy
* can't do oral meds
* high fever
* \< 18 yrs old
* severe PID: high fever, n/v, appendicitis, ovarian abscess
* should improve w/in 72 hrs
* educate:
* no sex til finish tx
* condoms
33
syphilis
systemic disease c/b *treponema palladium* (spirochete)
transmit via cuts during sex, kissing (sores), biting, oral-genital sex
34
primary stage of syphilis
* 21 days after exposed
* PAINLESS chancre
* indurated, ulcerated lesion
* Single, round, oval ulcer
* No visible purulent exudate
* May have regional lymphadenopathy
* very highly infectious
* ulcerates and heals spontaneously within 2-8 weeks = unnoticed
35
Secondary stage of syphilis
* 4 to 10 weeks later
* Skin lesions
* papulosquamous *non pruritic* skin rash on palms, soles)
* Alopecia
* Systemic:
* low-grade fever, malaise, headaches, weightloss
* lymphadenopathy
36
Early latent and latent syphilis
* early latent:
* _1 year_
* no sx's
* late latent: \> 1 year
* no sx's
37
tertiary stage of syphilis
* 1 - 30 years later
* High morbidity and mortality
* Cardiovascular:
* aortitis
* Skin lesions:
* Gummatous granulomas throughout the body and = extensive damage or cardiovascular disease (aortic valve disease, aortic aneurysm, coronary artery disease, or neurosyphilis can occur during any stage)
* Cranial nerve dysfunction, meningitis, stroke, altered mental status, and auditory or ophthalmic abnormalities.
38
syphilis diagnosis
* 2 Serology test needed:
* **1**. Nontreponemal antibody test
* VDRL or RPR, sensitive test but not specific
* 2. Treponemal Test (FTA/ABS)
* To confirm results of non treponemal test and this test is + indefinitely
39
syphilis treatment & in pregnant women
* **First line: Penicillin Benzathine G penicillin 2.4 million units** 1 dose
* if allergic to PCN:
* Doxycycline 100 milligrams BID for 14 days
* Ceftriaxone 1 g daily IV or IM x 8-10 days OR
* Azithromycin 2g orally once
* Late latent or tertiary → need 3 weeks tx
* if pregnant → penicillin G IM
* watch out for Jarisch Herxheimer reaction (causes preterm labor/fetal distress first 24 hrs)
40
syphilis management and education
* treat all sexual partners w/in 3 months of being diagnosed should be treated even if serology testing is negative
* no sexual contact until chancre healed, condom use, HIV testing
* SCREEN ALL PREGNANT WOMEN
* transmission: 1st year
41
chancroid
* PAINFUL lesion
* bacterial infection of GU tract transmitted through mucous membranes during sexual contact
* genital ulcer
* Rare in U.S.
* Painful genital macule to pustule then to ulcerated lesion
* inguinal lymph nodes erythematous and ulcerated
42
chancroid
* PAINFUL lesion
* bacterial infection of GU tract transmitted through mucous membranes during sexual contact
* genital ulcer
* Rare in U.S. (ask about recent travel)
* Painful genital macule to pustule then to ulcerated lesion
* inguinal lymph nodes erythematous and ulcerated
43
chancroid diagnosis & treatment
* Culture
* Clinical diagnosis can be presumed, with one or more painful genital ulcers in regional lymphadenopathy.
* Rule out syphilis and HSV
* First line: **Azithromycin 1 g oral 1 dose**
* Or
* Ceftriaxone, Ciprofloxacin, or erythromycin
* evaluate sexual partneres w/in 10 days before on set of sx's
44
Herpes Simplex Virus (HSV) 1
* gingivostomatitis and oral ulcers (fever blisters)
45
Herpes simplex virus 2
* sexually transmitted; most recurrent genital herpes outbreak
* **increases risk of HIV** (not HSV1)
* Recurrent painful genital ulcers
* cervicitis common
46
primary outbreak herpes outbreak
* Systemic and local sx's for 3 weeks
* fever, malaise, myalgia 1 week after exposure
* bilateral, tender lymphadenopathy
* 1st outbreak more severe
* Sx’s subside; then painful genital lesions
* small clusters in the anogenital area and sometimes the cervix.
* prodromal symptoms
* itching, tingling, burning at the site
47
secondary herpes outbreak
* Recurrent lesions are less severe and last 7 - 10 days.
* vesicles progress rapidly to ulcers
48
HSV diagnosis & lab
* History and physical
* **PCR**
* **Culture (need fresh vesicle lesion)**
* Labs:
* Immunoglobulin, IgG-based assay (blood test)
* Glycoprotein G to confirm the diagnosis & subtype
49
HSV treatment & management
* 1st episode = Antiviral therapy (no topicals)
* Test for syphilis
* Primary outbreaks:
* Acyclovir, 400 mg TID for 7 to 10 days
* Initial outbreak:
* Valacyclovir (Valtrex) , 1 gram p.o. BID x 10 days
* Episodic recurrent outbreak:
* Valacyclovir (Valtrex) 500 mg BID x 3 days or 1 g orally qd x 5 days
* Suppressive:
* Valacyclovir (Valtrex) 500 mg or 1 g daily
* Sitz baths
* Pain relievers, ASN, ice, creams, anesthetic
* Loose clothes
* Urinate in cool bath or peri bottle
* no sex during proximal sx' or lesions til healed
50
Does treating an outbreak change the subsequent risk for further outbreaks, the frequency, or rate of recurrence of HSV?
no!
51
HSV in pregnancy
* prenatal screening and pregnancy risk assessment
* Acquiring HSV during the first half of pregnancy or recurrent infection→ little risk
* if get late pregnancy or near delivery, the risk for transmission to the neonate 30% - 50%
* if no lesions or prodromal sx's = can deliver vaginal
* if lesions = C section
* acyclovir safe
52
human papillomavirus (HPV) management
* Can cause genital warts (6 & 11) and cervical cancer (16 & 18)
* can be asymptomatic
* dormant for years
* \> 100 different strains
* Can clear on it’s own or manage
* 50% of all sexually active men/women have it
* Age 50, 80% of sexually women have HPV
* Management
* Can’t cure; can clear virus on own though
* Trichloroacetic acid
* Podofilin
* Imiquimode (aldara)
* Laser
* Cryo
* Prevention
* No genital contact/condoms ish
* Safe sex
53
molluscum
* Normal skin to grow into bumps
* Appears as small, waxy, hollow umbilicate lesions (tiny depression in the middle)
* “Little belly buttons”
54
molluscum transmission and management
* Sx’s
* None, itch, scaling around lesion
* Transmission
* Direct skin to skin
* Non sexual intimate contact
* Intercourse
* Common in children
* Prevention
* Avoid skin to skin
* Condoms
* Don’t share towels
* Don’t squeeze lesions
* Tx
* No tx, disappear on own (months to years to resolve on own)
* TCA
* Decore lesions
* Liquid nitrogen
* Retin A
55
Trichomoniasis sx's
* Strawberry appearing cervix
* Asymptomatic in 50% to 70%
* Blood spotting discharge
* Malodorous, copious, thin, **Frothy, yellow-green vaginal discharge**
* vulvar vaginal irritation, itching, dysuria
* vaginal and cervical -→ red or pink
* Lower abdomen pain
* Swelling in groin
56
trichomoniasis diagnosis
* visualization of trichomonads on microscope of vaginal discharge
* don't let wet prep dry
* NAAT
* Culture
57
Trich treatment
* Metronidazole 2mg single dose or tinidazole 2 g oral single dose
* NO alcohol on meds or 24 hrs after treatment (disulfiram like reaction: severe abdominal pain, n/v, h/a)
* treat all partners even if no sx's
58
Trichomonias in pregnancy / Breast feeding
* Risk of ROM, PROM or low birth weight
* Treatment does NOT decrease these outcomes
* Metronidazole 2 g
* treated immediately or wait until 37 weeks if the symptoms are not troubling to the patient.
* NO breastfeeding for 12 - 24 hours after treatment
* Breastfeeding should be timed to coincide with low plasma levels,
* feed baby first thing in the morning and then take her dose.
* feed her baby continuously up until the next 12 hours, when her second dose might be due.
* feeds the baby at bedtime, then take 2nd dose
* Tindamax is not recommended in breastfeeding.
59
HIV pathology & screening
* targets CD4 cells by depleting cells and a gradual loss of immune faction
* progressive depletion of CD4 cells
* routine 13-64 years old, STI treatment with new sx's, high risk once a year
60
HIV diagnosis
ELISA or EIA tests
* if screening is reactive, western blot or indirect immunofluorescence assay done
61
Pubic lice / pediculosis pubis
* in genitals, hair bearing areas (axilla, chest, thighs, eyelash, head)
* pruritus
* permethrin 1% cream rinse and pyrethrins with piperonyl bubtoxide (applied and washed off after 10 mins)
* ivermectin
62
pubic lice pt education
* wash all clothing, bed, linens, towels in hot water and dry in hot cycle
* no sex until everyone treated and clothing decontaminated
63
how to ask for pronouns
“How would you like to be addressed?” “What name would you like to be called?” “Which pronoun is appropriate?”
64
Before counseling on STI/HIV prevention, you should have knowledge of patient's \_\_\_\_\_\_
current anatomy and patterns of sexual behavior
65
when discussing STI prevention, talk about prevention of \_\_\_\_
oral or anal GC/CT/HSV and HPV
