Lecture 21 Women’s Reproductive Infectious Diseases and Genitourinary Infections Elwood VULVOVAGINITIS: TRICHOMONIASIS: INFECTIOUS Protozoan• Trichomoniasis OVERVIEW: RISK FACTORS: Bacterial • Bacterial vaginosis (BV) • Protozoan! • Sexual contact with a confirmed or • Syphilis • Anaerobic parasitic flagellated suspected case • Gonorrhea protozoal infection • Unprotected sex with a resident of • Chlamydia • Most common non-viral STI an area with high burden and/or Viral • HSV • 3.1% reproductive-aged women high risk of antimicrobial resistance • HPV • 180 million infectious annually • History of previous infection Fungal • Yeast • Not reportable • History of other STIs, including HIV NON- Dermatosis• Lichen sclerosis • Sex workers & their sexual partners INFECTIOUS • Eczema • Contact dermatitis SYMPTOMS: • Sexually active youth < 25 yrs old • Atopic dermatitis FEMALES: • Street-involved youth and other • Psoriasis • Asymptomatic homeless populations • Bechet’s • Abdominal pain, dysuria • Individuals who have sex with Malignancy• Vulvar intraepithelial neoplasia • Vulvitis, vaginitis, pruritus, multiple partners • Vaginal intraepithelial neoplasia dyspareunia • Profuse discharge; frothy TESTING: yellow/green CORE PRINCIPLES: • Antigen • Wet mount – • Associated with infertility • Correct diagnosis • Culture must be received • PPROM, PTB, PP w/in 1 hr • Understand the organism you are targeting • NAAT endometritis • Correct medication, at the correct dose for the correct duration MALES: • “Treatment failure” • Asymptomatic TREATMENT: • Urethritis, prostatitis, • Metronidazole 2 g PO x 1 dose VAGINAL MICROBIOMES: vagina is seen as a microbiome rather than epididymitis • Metronidazole 500 mg PO BID x 7 d occupied by single organisms BACTERIAL VAGINOSIS: OVERVIEW: CLINICAL DIAGNOSIS OF BV: • The most prevalent cause of vaginal discharge and odour AMSEL’S CRITERIA – 3 of the following 4 criteria • The most common cause of infectious vaginitis in both Vaginal pH > • Normal 3.8 – 4.5 pregnant and non-pregnant women 4.7 • Low pH • Prevalence rates are 10-30% in pregnant and 10% in non- o Inhibits bacterial growth pregnant women presenting to their GP o Decreases bacterial attachment • Elevated in: POTENTIAL COMPLICATIONS: o Menstruation o Intercourse • Preterm labor & delivery • Postpartum endometritis o Lack of estrogen (post-menopausal) • PPROM • SSI • Elevated pH associated with BV & trich • SA • Subclinical PID Discharge • • Chorioamnionitis • Increased rates of HIV Homogenous appearance of discharge Amine odour • Produced by products from anaerobic bacterial metabolism • Elevation of pH (KOH, seminal fluid) RISK FACTORS: • Volatilizes amines from protein attachment • Black race • Using vaginal douches or Clue cells on • Represent bacteria attached to vaginal epithelial cell • Smokers intravaginal products microscopy • Most specific when: o 400 x power • Although not currently considered a STI, BV has been o > 20% of epithelial cells are clue cells consistently associated with sexual activity • Gram stain diagnosis: Nugent’s Criteria o It is more common in those sexually active, and the risk seems to increase with both number of sexual partners ALTERNATIVE THERAPIES: and frequency of intercourse PROBIOTICS • Species & strains of Lactobacillus are species tropic • To date, no strains commercially available in Canada which TREATMENT OF BACTERIAL VAGINOSIS: colonize the human vagina • Metronidazole 500 mg PO BID x 7 days* (* 75-85% effective) • Therefore, little utility in txt of BV or yeast with probiotics • Metronidazole gel 0.75%, one applicator (5g) PV daily x 5 days* VAGINAL • More women in placebo group still had BV at end of F/U • Clindamycin cream 2%, one applicator (5g) PV x 7 days VITAMIN C • Total length of F/U in vitamin C study = 20 days TABLETS • Further studies show mixed results ALTERNATIVES: • Metronidazole 2 g PO x single dose BV IN PREGNANCY: • Clindamycin 300 mg PO BID x 7 days • If bacterial vaginosis is diagnosed in a symptomatic woman, treatment is indicated o Metronidazole 500 mg PO BID x 7 days RECURRENT BV: 1/3 will recur in 3 mo (important to reconfirm dx) o Clindamycin 300 mg PO BID x 7 days (as alternative) 1. Metronidazole 500 mg PO BID x 10-14 days • Topical agents are not recommended 2. If PO metronidazole is ineffective, use metronidazole gel 0.75%, • High rates of recurrence in some women one applicator (5g) daily x 10 days, then 2x/week x 3-6 months • Evidence for screening women with history of pre-term birth at 12-16 weeks and treat regardless of symptoms • Condoms may ↓ likelihood of recurrence in sexually active ♀ • Avoid douching Lecture 21 Women’s Reproductive Infectious Diseases and Genitourinary Infections Elwood VULVOVAGINAL CANDIDIASIS: Candida albicans (mostly) OVERVIEW: TREATMENT OPTIONS FOR UNCOMPLICATED VVC: • Common – 75% women will be affected in their lifetime Clotrimazole (OTC) Cream/ointment 1% once daily x 7 days • Common member of vaginal microbiome (20% of women) 2% once daily x 3 days 10% once only RISK FACTORS: Insert/ovule/suppository 200 mg once daily x 3 days 500 mg once only • Sexual activity • Immunosuppression Miconazole (OTC) Cream/ointment 2% once daily x 7 days • Antibiotic use (ex// poorly controlled HIV 4% once daily x 3 days • Pregnancy infection or diabetes) Insert/ovule/suppository 100 mg once daily x 7 days 400 mg once daily x 3 days SIGNS AND SYMPTOMS: 1200 mg once only • A thick cottage-cheese-like discharge associated with Fluconazole (OTC) Oral 150 mg once only vaginal and vulvar: Terconazole (Rx) Cream 0.4% once daily x 7 days o Pruritus o Edema o Pain o External dysuria TREATMENT IN PREGNANCY: o Burning o Dyspareunia • o Erythema Yeast infections are more common in pregnancy • Require longer courses of therapy o Topical azole treatments = safe and first line INDICATIONS FOR CULTURES: o Nystatin = alternative • Treatment failure • AVOID oral fluconazole and boric acid • Unclear diagnosis COMPLICATED VCC: DEFINITION: RECURRENT VCC: • Recurrent (≥ 4 episodes in 12 months) Induction Imidazole cream 10-14 days (dose as uncomplicated) • Associated with severe symptoms Fluconazole (oral) 150 mg x 3 doses (72 hours apart) • Result of a non-albicans species Boric acid insert 300-600 mg daily x 14 days • Present in a compromised host Maintenance Clotrimazole insert 500 mg once monthly x 6 months Fluconazole (oral) 150 mg once weekly PELVIC EXAMINATION (DIAGNOSIS): Boric acid insert 300 mg daily x 5 days at beginning of each menstrual cycle • Thick discharge and pruritis non-specific Ketoconazole (oral) 100 mg once daily • Erythema/edema • Thick, white clumped vaginal discharge NON-VAGINAL VCC: • pH < 4.5 Boric acid insert 300-600 mg nightly x 14 nights • Gram stain: budding yeast and pseudohyphae and PMNs Flucytosine cream 5 g once daily x 14 days • Whiff test is negative Amphotericin B suppository 50 mg once daily x 14 days Nystatin suppository 100,000 U once daily x 3-6 months COMPARING BV vs. VVC vs. TRICH: BV VVC TRICH Predisposing factors • Sexually active • Sexually active • Multiple partners • New partner • Current/recent antibiotics • IUD • Pregnancy • Corticosteroids • Diabetes • Immunocompromised Symptoms • Vaginal discharge • Vaginal discharge • Vaginal discharge • Fishy odor • Itch • Itch • Asymptomatic • Dyspareunia • Dysuria • Asymptomatic • Asymptomatic Signs • White/grey thin discharge • White, clumpy & curdy discharge • Frothy discharge (yellow/green) • +ve whiff test • Erythema and edema of the vagina and vulva • “Strawberry cervix” HERPES SIMPLEX: HSV PATHOGENESIS: CLINICAL CLASSIFICATION OF HSV INFECTION: • Enters body thru mucocutaneous sites due to direct contact First Primary • First outbreak • DNA virus – latent in cells, causing long-term evasion of episode infection • New infection immune system and capability of reactivation • No previous exposure to HSV • Seronegative for HSV-1 & HSV-2 DIAGNOSIS: Non-primary • First outbreak • Culture or viral PCR of lesion infection • New infection • If unable to detect virus, do NOT assume it is not herpes • Previous infection with HSV • Seropositive for HSV-1 or HSV-2 • Type specific serology helpful in select circumstances Recurrent • Recurrent HSV outbreak that follows a first outbreak of HSV infection Lecture 21 Women’s Reproductive Infectious Diseases and Genitourinary Infections Elwood HERPES SIMPLEX (CONTINUED): HSV TRANSMISSION: WHICH TREATMENT OPTIONS TO USE? • Need to counsel about risks of transmission EPISODIC CONTINUOUS o 70% of transmission during asymptomatic shedding • Minimum impact on QOL • Severe impact on QOL o 30% of transmission during symptomatic outbreak • No psycho- sexual, social problems • Not coping • Use of condoms to lessen transmission • Infrequent recurrence • Sexual, social disturbances • Can reduce risks with suppressive antivirals • Mild recurrences • Frequent recurrences • Role of serology to determine partner discordance • Well-defined prodrome • Severe recurrences • Issues for pregnancy (vertical transmission risk) • Episodes not well defined o Primary infection lesion = 50% risk • Acyclovir 200 mg PO 5x/d x 5 days • Acyclovir 200 mg 5x/day o Or 400 mg PO TID o Or 400 mg PO BID o Recurrent lesion = 2.5% risk • Valacyclovir 500 mg PO BID x 5 d • Famciclovir 250 mg BID o Risk of shedding = 1% • Famciclovir 125 mg PO BID x 5 days • Valacyclovir 500 – 1000 mg daily o Overall risk in HSV-infected woman = 0.025% on any given delivery day (calculated) HSV IN PREGNANCY: • Common – 30-40% of seroprevalence in most obstetrical populations HSV PREGNANCY MANAGEMENT: •