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Etiology

  • Neisseria gonorrheae (Gram negative diplococcus)
  • Risk factors same as with chlamydia.

Clinical Features

  • 50% patients are asymptomaticv
  • M/ c symptom is of excessive, irritant vaginal discharge
  • Patients may have lower abdominal pain,· urethral infection manifesting as dysuria.

Investigations

 

Nucleic acid amplication testing (NAAT) of urine or endocervical discharge is done. First void morning urine sample (preferred) or at least one hour since the last void sample should be tested. NAAT is very sensitive and specific (95%). In the acute phase, secretions from the urethra, Bartholin's gland, and endocervix are collected for Gram stain and culture.

 

A presumptive diagnosis is made following detection of Gram-negative intracellular diplococci on staining. Culture of the discharge in Thayer- Martin medium further confirms the diagnosis.

 

Treatment

 

Single dose of ceftriaxone 125 mg 1M, or ,cefixime 400 mg oral, or ciprofloxacin 500 mg oral plus doxycycline or azithromycin to treat chlamydia, because of high rate of co-infection If pregnant - cephalosporin regimen (i.e. ceftriaxone or spectinomycin 1M if patient is allergic to β-lactam antibiotics.

 

Condyloma Acuminata (Genital Warts)

  • Most common viral STI
  • Causative agent: HPV (human papilloma virus)
  • >200 subtypes of which more than are genital subtypes
  • HPV types 6 and 11 are classically associated with anogenital warts/ condylomata acuminata
  • HPV types of 16 and 18 are the most oncogenic (classically associated with CIN and Ca cervix).
  • Anatomical distribution of anogenital HPV infection is: cervix 70%, vulva 25%, vagina 10% and anus 20%.

Clinical Features

  • Soft, multiple warts on any dermal or mucosal surface. Mostly seen in the posterior introitus, the labia majora and minora.
  • Genital warts can be diagnosed by gross inspection and colposcopic examination may help to rule out other cervicaljvaginallesions.

Treatment

  • Patient applied-
    • Podofilox 0.5% solution or gel (Pregnancy category C)
    • Imiquimod 5% cream (Pregnancy category C).
  • Provider administered-
    • Cryotherapy with liquid nitrogen (safe in pregnancy)
    • Podophyllin resin in tincture of benzoin (pregnancy category C)
    • Trichloroacetic acid (TCA) or bichloroacetic acid weekly (80-90%) (safe in
    • pregnancy)
    • Surgical removal/laser
    • Intralesional interferon (not appoved by FDA).

Prevention

 

HPV types 6, 11, 16 and 18 are preventable with Gardasil (quadrivalent HPV recombinant) vaccine. Details of vaccine given in chapter on Cancer Cervix -14B

 

Herpes Simplex Virus

  • Etiology-90% cases are due to HSV-2; 10% cases are due to HSV-1
  • Classically
     
    HSV-1-causes disease above the belt (i.e. oral lesions)
     
    HSV-2-causes disease below the belt (i.e. genital lesion)
  • Lesion first appears as erythematous plaque which later forms vessicles and then small ulcers with an erythematous halo and yellow base. Ulcers are extremely tender and inguinal lymph nodes are enlarged
  • DOC - Acyclovir (200 mg 5 times a day x 5 days)
  • Gold standard for diagnosis - Tissue culture (William's Gynecology 2nd ed., p. 77).

Syphilis

  • Etiologic agent - Treponema pallidum
  • Primary syphilis presents as a hard, painless, solitary chancre on the vulva, vagina or cervix, although non-genital lesions may also be present. Non-tender inguinal lymphodenopathy is present. Primay chancre resolves spontaneously within 2 - 6 weeks
  • DOC - Benzathine penicillin.

Molluscum Contagiosum

  • Caused by Pox virus
  • M/ c in developing countries
  • M/c route of spread = Skin contact (sexual/non sexual)
  • Characteristic lesion = Multiple dome-shaped papules with central umblication
  • Diagnosis = Bygross inspection
  • Management = Self-limiting condition

If required - cryofreezing/ curettage of core material should be done
 

Extra Edge:

 

Culture Medium

 

Organism

Culture Medium

Trichomonas

Feinberg-Whittington medial

Diamond media

Candida

Sabouraud's media

Chlamydia

McCoy cells/HeLa cells

TB

L J mediai Bactec

 

DOC

 

Condition

Drug of choice

Trichomonas vaginitis

Nonpregnant

Pregnant

 

Metronidazole

(2 g single dose)

Metronidazole in 2nd & 3'd

trimester

Candidiasis

Antifungals

Bacterial vaginosis

 

HSV

Acyclovir or Fancyclovir

Syphilis

Benzathine penicillin

Chancroid

 

Azithromycin or Ceftriaxone

or Erythromycin

Granuloma Inguinalel

Donovanosis caused by

Calymmatobacterium

(Klebsiella) granulomatis

Doxycycline or Azithromycin

Ciprofloxacin or

Erythromycin

 

Gonococcal infection:

Uncomplicated:

Nonpregnant

Pregnant

 

Single dose = Ceftriaxone +

Azithromycin or Doxycycline

(100 mg BID x 7 days)

Cefriaxone or Cefexime.

If patient is allergic

to cephalosporin ->

Spectinomycin

Note: for Gonococcal endo-

carditis antimicrobials should

be continued for 4 weeks &

for meningitis 1 0-14 days

Chlamydia

Non pregnant

Pregnant

 

1st Choice

Single dose = Azithromycin

+ contact tracing

2nd choice = Doxycycline or

Erythromycin

1st Choice

Azithromycin or Amoxicillin

2nd choice = Erythromycin

Genital warts/HPV

Pregnancy

 

see the text

Trichloroacetic acid (80-

90% solution" applied once

a week) or cryotherapy or

Laser ablation or surgery

Scabies

Non pregnant

Pregnant & young children

Lindane

10% Crotamine lotion cream

or 5% Permethrin cream





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