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Toronto Notes 2019
Gynecological Infections
Gynecology GY27
TRICHOMONIASIS
• seeInfectiousVulvovaginitis,Table15
CHLAMYDIA
Etiology
• Chlamydiatrachomatis
Epidemiology
• mostcommonbacterialSTIinCanada • oftenassociatedwithN.gonorrhoeae
Clinical Features
• asymptomatic(80%ofwomen)
• muco-purulentendocervicaldischarge
• urethralsyndrome:dysuria,frequency,pyuria,nobacteriaonculture
• pelvicpain
• postcoitalbleedingorintermenstrualbleeding(particularlyifonOCPandpriorhistoryofgoodcycle
control)
• symptomaticsexualpartner
Investigations
• cervicalcultureornucleicacidamplificationtest
• obligateintracellularparasite:tissuecultureisthedefinitivestandard
• urineandselfvaginaltestsnowavailable,whichareequallyormoreeffectivethancervicalculture
Treatment
• doxycycline100mgPObidfor7dorazithromycin1gPOinasingledose.Doxycyclineiscontra- indictated in the 2nd and 3rd trimesters of pregnancy
• alsotreatgonorrheabecauseofhighrateofco-infection
• reportabledisease,partnersshouldalsobereferredfortreatment
• testofcureforchlamydiarequiredinpregnancy(curerateslowerinpregnantpatients)→retest3-4wk
after initiation of therapy
Screening
• highriskgroups
• duringpregnancy
• wheninitiatingOCPifsexuallyactive(independentriskfactor)
Complications
• PID–lowgradesalpingitisandadhesionsresultingintubalobstruction • infertility
• ectopicpregnancy
• chronicpelvicpain
• Fitz-Hugh-Curtissyndrome(livercapsuleinflammation)
• reactivearthritis(malepredominance,HLA-B27associated),conjunctivitis,urethritis • perinatal infection: conjunctivitis, pneumonia
GONORRHEA
Etiology
• Neisseriagonorrhoeae
• symptomsandriskfactorssameaswithchlamydia
Investigations
• GramstainshowsGram-negativeintracellulardiplococci • cervical,rectal,andthroatculture(ifclinicallyindicated)
Treatment
• singledoseofceftriaxone250mgIMplusazithromycin1gPO
■ if pregnant: above regimen or 2 g spectinomycin IM plus azithromycin 1 g PO (avoid quinolones) ■ also treat chlamydia, because of high rate of co-infection
• treatpartners
■ reportable disease
■ screening as with chlamydia
STI Testing
• Vaginal swab
• Tests for bacterial vaginosis,
trichomoniasis, candida • Cervical swab
• Tests for gonorrhea and chlamydia
Test of cure for C. trachomatis and
N. gonorrhoeae is not routinely indicated Repeat testing if symptomatic, if compliance with treatment is uncertain, or if pregnant