Candida Vulvovaginitis
- 80-90% caused by candida albicans
- discharge: white curdy, cottage cheese
- complaints: itching/burning
- pH: <4.5
- usually no odor
- microscope: mycelia, budding yeast, psuedohyphae w/KOH prep
- treatment: PO fluconazole (diflucan), topical/vaginal terconazole, miconazole
Bacterial Vaginosis
- caused by overgrowth of normal flora usually g. vaginalis, m. hominis
- discharge: thin homogenous, white gray, adherent, often increased
- complaints: discharge, foul odor, itcing present
- fishy odor, + whiff test
- high vaginal pH 5-7 (distinct finding)
- microscopic: >20 clue cells, few or no WBC
Treatment
* topical metronidazole (metrogel)
* PO metronidazole (Flagyl)
* topical clindamycin
Genourinary syndrome of Menopause
(atrophic vaginitis)
- caused by decreased estrogen
- discharge: scant white-clear
- complaints: itching, burning, discharge, often without symptoms
- pH > 5 due to decreased estrogen
- mricoscope: few or absent lactobacilli
- treatmetn: topical or vaginal estrogen if symptomatic and/or recrrent UTI
Genital Herpes
- Caused by human herpes virus 2, less commonly HHV-1
- classic presentation of painful ulcerated lesions, marked lymphadenopathy
- in women thin vaginal discharge
- asymptomatic transmission common
Treatment
* serologic test reccomended
* oral acyclovir, famciclovir, valacyclovir
* used for intial, subsequent episode, and outbreak prevention
Nongonococcal urethritis and cervicitis
- Chlamydia thrachomatis- #1 bacterial STI
- s/s: irritative voiding, occasional mucopurulent discharge, cervicitis common. Often without symptoms regaurdless of gender
- microscopic: large number of WBCs
Treatment:
* Doxycycline 100mg po BID x7days (1st line)
* azithromycin 1 g PO singel dose (alternative)
Gonococcal urethritis and vaginitis
- neisseria gonorrhoeae (#2 bacterial STI)
- s/s: irritative voiding, occasional purulent discharge. often without symptoms in either gender
- microscopic: Lage amnt WBC
Treatment
* Ceftriaxone 500mg IM +doxycycline100mg po BID x7 days chlamydia is not ruled out
Trichomoniasis
- caused by trichomonas vaginalis (protozoan pathogen)
- s/s: dysuria, itching, vulvovaginal irritation, yellow green discharge, occationaly frothy, cervical petechial hemorrhages (stawberry spots). Often without symptoms in either gender.
- microscopic: motile organisms and lage number of WBC, alkaline pH
Treatment:
* metronidazole (Flagyl) 500mg PO BID x7 days in females
* metronidazole 2g PO 1 time dose for males
* abstain from alcohol for 24hrs
Treatment of Uncomplicated Acute UTI in women
- usual pathogen: E. coli (gram -) 75%, klebsiella (gram-), S. saprophyticus (gram+)
Primary
* TMP/SMX (bactrim PO BID x3 days if local resistance <20%
* if resistance or sulfa allergry: nitrofurantoin (macrobid) 100mg PO BID x5 days
* add phenazopyridine (pyridium) for symptom control
alternative tx/2nd line
1. Cipro
2. levofloxacin
3. cefdinir
Epididymo-orchitis in men <35
upper reproductive tract infection with inflammation of epididymis/testis
* casued by N. gonorrhea, c. trachomatis
* presentation: irritative voiding, fever and painful swelling of epididymis and scrotum
* infertility potential post infection due to scaring of vas defrens
Treatment
* Ceftriaxone 500mg IM + doxycycline 100mg PO BID x10 days
* advise elevation of scrotumto help with symptom relief
* Prehn’s sign - relife of discomfort withscrotal elevation
Epididymo-orchitis in men >35 who have anal intercourse
usually caused by enterobacteriaceae (coliforms)
* presentation: irritative voiding, fever and painful swelling of epididymis and scrotum
* infertility potential post infection due to scaring of vas defrens
Treatment:
Ceftriaxone 500mg one time + levofloxacin 500mg PO x10 days
Acute bacterial prostatitis in men <35
caused by N. gonorrhoeae or C. trachomatitis
* S/S: irritative voiding, suprapubic, perineal pain (pain when sitting), fever, tender boggy prostate, leukocytosis
Treatment
* Ceftriaxone 500mg IM OR cefixime 400mg PO once, then doxycycline 100mf PO BID x10 days
Acute bacterial prostatitis in men with low risk of STI
caused by enterobacteriaceae
* S/S: irritative voiding, suprapubic, perineal pain (pain when sitting), fever, tender boggy prostate, leukocytosis
Treatment
* Ciprofloxacin OR
* Levofloxacin OR
* TMP/SMX DS
* 10-14 days
Urge incontinence
- most common form of incontinence in older adults
- strong sensation of needing to empty th ebladder that cannot be suppresed, often coupled with involuntary loss of urine
Tx
* behavioral therapy
* antimuscarinics (anticholinergics): tolterodine (detrol), oxybutinin (ditropan), solifenacin succinated (vesicare),
* ADE: drymouth, sedation, mental status change inhigher doses
* Alternative: B3-agonist: mirabegron (mybetriq), vibegron (gemtesa)
* botulinum toxin injections
Stress Incontinence
- most common form in women, rare in men, occasionally noted post prostate/bladder surgery
- loss of urine with activity that causes increase intra-abdominal pressure such as coughing, sneezing, exercise.
Treatment:
* Support to the area with vaginal tampon, urethral stents, periurethral bulking agent injections, pessary use.
* Kegel and PT helpful in younger, premenopausal pt
* pelvic floor rehab with biofeedback, electrical stim, and bladder training.
* surgical intervention
Ovarian cancer
Risk factors
* post menopause, obesity, nulliparity or first birth >35, some fertility drugs, use of estrogen after menopause (>5-10yrs), family hx and genetic mutation (BRCA), shared etilogy with breast cancer
Clinical presentation
* minimal non specific symtoms in early stage
* bloating, bladder pressure, constipation, vaginal bleeding, indigestion, SOB, lethargy, weight loss
Diagnostics
* CT with contrast abd/pelvis, US, MRI
* Tumor marker CA125 (not specific)
* Fine needle aspiration or percutaneous BX not reccomended due to delay in treatmetn
Treatment
* surgery follwed by chemotherapy
Cervical cancer
Risk factors
* Virtually all caused by HPV (70% by 16, 18)
Clincial presentation
* abnormal vaginal bleeding, vaginal discomfort during intercourse, malodorus discharge, dysuria
* with routine screening, typically asymptomatic with first abnormal pap
Dx
* pap test followed by colposcopy, and biopsy
* Pelvic CT and/or MRI, or Pet scan can be used to guide treatment
Treatment
* based on stage
* surgery for early invasive disease
* radiation and/or chemo for advanced/disseminated disease
Endometrial Cancer
Risk factors
* older age, estrogen therapy, nulliparity, obesity, tamoxifen use, Hx of breast or ovarian ca, PCOS, T2DM, family hx
Presentation
* abnormal vaginal bleeding (postmenopausal, or heavy frequent menstral periods, or intermenstrual bleeding in pre/perimenopause)
Dx.
* Transvaginal US
* hysteroscopy
* Endometrial Bx
* Fractional D&C
Treatment
* surgery followed by chemo with or without RT
HPV associated cancer screening
- average risk women: begin at 21. Q3-5 years. Stop at 65 with adequate negative cytology. HPV Vaccination considered average risk
- WMN at higher risk: more frequent testing. Includes women HIV+, immunosupressed, or exposed to DES
- Women with hysterectomy: total hysterectomy with removal of cervix for benign reasons can stop. Cervix intact, of Hx of cervical cancer, or pre-cancer (CIN2/3) continue Pap
- Women with CIN2/3: continue screening for at least 20yrs following abnormal.
- Anal Pap only in high risk populations: HIV+, recieve anal sex, Hx of anal warts, women with hx of cervicle or vulvar cancer. Test every 2-5yrs
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Primary and Secondary Prevention43
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Hematologic disorders15
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EENT30
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Derm disorders22
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Thyroid disorders10
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Headache13
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GI and Hepatic Disorders20
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Lower respiratory disease26
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HTN, Dyslipidemia, Heart Failure29
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Diabetes Mellitus11
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GYN/GU18
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mental health6
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Older adult14
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Cardiac Exam22
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Musculoskeletal problems32
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Family planning11
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Prescribing in the elderly16
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Supplemental topics15
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Peds35
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Pregnancy care13
