Overview History
Physical Exam
Laboratory
In addition to specific treatment of any organism identified by culture or other test...
Ectropion, Erosion or Eversion Ectropion, erosion or eversion (all synonyms) occurs when the normal squamo-columnar junction is extended outward from the its; normal position at the opening of the cervix. Grossly, the cervix has a red, friable ring of tissue around the os. Careful inspection with magnification (6-10x) will reveal that this red tissue is the normal tissue of the cervical canal, which has grown out onto the surface of the cervix. Cervical ectropion is very common, particularly in younger women and those taking BCPs. It usually causes no symptoms and need not be treated. If it is symptomatic, producing a more or less constant, annoying, mucous discharge, cervical cauterization will usually eliminate the problem. When faced with a fiery red button of tissue surrounding the cervical os, chlamydia culture (in high-risk populations) and Pap smear should be performed. If these are negative and the patient has no symptoms, this cervical ectropion should be ignored. Cervicitis Some patients with cervicitis note a purulent vaginal discharge, deep dyspareunia, and spotting after intercourse, while others may be symptom-free. The cervix is red, slightly tender, bleeds easily, and a mucopurulent cervical discharge from the os is usually seen. A Pap smear rules out malignancy. Chlamydia culture and gonorrhea culture (for gram negative diplococci) are routinely performed. No treatment is necessary if the patient is asymptomatic, the Pap smear is normal, and cultures are negative. Antibiotics specific to the organism are temporarily effective and may be curative. Cervical cautery may be needed to achieve permanent cure.
Chlamydia Most women harboring chlamydia will have no symptoms, but others complain of purulent vaginal discharge, deep dyspareunia, and pelvic pain. There may be no significant pelvic findings, but a friable cervix, mucopurulent cervical discharge, pain on motion of the cervix, and tenderness in the adnexa are suggestive. The diagnosis is often made on the basis of clinical suspicion but can be confirmed with chlamydia culture. Such cultures are frequently performed routinely in high-risk populations. Treatment is: Recommended Regimens
Alternative Regimens
Read the CDC Treatment Guidelines for Chlamydia Foreign Body As soon as you suspect or identify a lost tampon or other object in the vagina, immediately prepare a plastic bag to receive the object. As soon as it is retrieved, place it in the bag and seal the bag since the anaerobic odor from the object will be extremely penetrating and long-lasting. Have the patient return in a few days for follow-up examination. Normally, no other treatment is necessary, but patients who also complain of fever or demonstrate systemic signs/symptoms of illness should be evaluated for possible toxic shock syndrome, an extremely rare, but serious, complication of a retained tampon. Gardnerella (Hemophilus, Bacterial Vaginosis) The diagnosis is confirmed by the release of a bad odor when the discharge is mixed with KOH ("whiff test"), a vaginal pH greater than 5.0, or the presence of "clue cells" (vaginal epithelial cells studded with bacteria) in the vaginal secretions. Treatment is: Recommended Regimens (CDC 2002)
Alternative Regimens (CDC 2002)
Read the CDC Treatment Guidelines for Bacterial Vaginosis Watch a video showing Clue cells Gonorrhea Many (perhaps most) women harboring the gonococcus will have no symptoms, but others complain of purulent vaginal discharge, pelvic pain, and deep dyspareunia. There may be no significant pelvic findings, but mucopurulent cervical discharge, pain on motion of the cervix, and tenderness in the adnexa are all classical. The diagnosis is often made on the basis of clinical suspicion but can be confirmed with chocolate agar culture or gram stain. Treatment is: Recommended Regimens (CDC 2002)
Alternative Regimens (CDC 2002)
Sexual partners also need to be treated. Read the CDC Treatment Guidelines for Gonorrhea Sooner or later, as many as 5% of all intrauterine devices will become infected. Patients with this problem usually notice mild lower abdominal pain, sometimes have a vaginal discharge and fever, and may notice deep dyspareunia. The uterus is tender to touch and one or both adnexa may also be tender. Treatment consists of removal of the IUD and broad-spectrum antibiotics. If the symptoms are mild and the fever low-grade, oral antibiotics (amoxicillin, cephalosporins, tetracycline, etc.) are very suitable. If the patient's fever is high, the symptoms significant or she appears quite ill, IV antibiotics are a better choice (cefoxitin, or metronidazole plus gentamicin, or clindamycin plus gentamicin). If an IUD is present and the patient is complaining of any type of pelvic symptom, it is wisest to remove the IUD, give antibiotics, and then worry about other possible causes for the patient's symptoms. IUDs can also be rejected without infection. Such patients complain of pelvic pain and possibly bleeding. On pelvic exam, the IUD is seen protruding from the cervix. It should be grasped with an instrument and gently removed. It cannot be saved and should not be pushed back inside. PID: Mild Moderate pain on motion of the cervix and uterus with purulent or mucopurulent cervical discharge is found on examination. Gram-negative diplococci or positive chlamydia culture may or may not be present. WBC may be minimally elevated or normal. Treatment consists of: Regimen A (CDC 2002)
Regimen B (CDC 2002)
For further information, read the CDC Treatment Guidelines for PID
PID: Moderate to Severe Excruciating pain on movement of the cervix and uterus is characteristic of this condition. Hypoactive bowel sounds, purulent cervical discharge, and abdominal dissension are often present. Pelvic and abdominal tenderness is always bilateral except in the presence of an IUD. Gram-negative diplococci in cervical discharge or positive chlamydia culture may or may not be present. WBC and ESR are elevated. Treatment consists of bedrest, IV fluids, IV antibiotics, and NG suction if ileus is present. Since surgery may be required, transfer to a definitive surgical facility should be considered. Parenteral Regimen A (CDC 2002)
Parenteral Regimen B (CDC 2002)
Alternative Parenteral Regimens (CDC 2002)
For further information, read the CDC Treatment Guidelines for PID This microorganism, with its four flagella to propel it, is not a normal inhabitant of the vagina. When present, it causes a profuse, frothy white or greenish vaginal discharge. When the discharge is suspended in normal saline and examined under the microscope, the typical movement of these large organisms (larger than white blood cells) is obvious. Itching may be present, but this is inconsistent. Trichomonas is transmitted sexually and you may wish to treat the sexual partner, particularly if this is a recurrent trichomonad infection. Recommended Regimen (CDC 2002)
Alternative Regimen (CDC 2002)
Read the CDC Treatment Guidelines for Trichomonas Watch a video showing trichomonads under the microscope
Yeast (Monilia, Thrush) Yeast thrives in damp, hot environments and women in such circumstances are predisposed toward these infections. Women who take broad-spectrum antibiotics are also predisposed towards these infections because of loss of the normal vaginal bacterial flora. Yeast organisms are normally present in most vaginas, but in small numbers. A yeast infection, then, is not merely the presence of yeast, but the concentration of yeast in such large numbers as to cause the typical symptoms of itching, burning and discharge. Likewise, a "cure" doesn't mean eradication of all yeast organisms from the vagina. Even if eradicated, they would soon be back because that is where they normally live. A cure means that the concentration of yeast has been restored to normal and symptoms have resolved. The diagnosis is often made by history alone, and enhanced by the classical appearance of a dry, cheesy vaginal discharge. It can be confirmed by microscopic visualization of clusters of thread-like, branching Monilia organisms when the discharge is mixed with KOH. Recommended Regimens (CDC 2002)
Reoccurrences are common and can be treated the same as for initial infections. For chronic recurrences, many patients find the use of a single applicator of Monistat 7 at the onset of itching will abort the attack completely. Sexual partners need not be treated unless they are symptomatic. |
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