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2438408271510GeneralManagement00GeneralManagement15538458270875Commence if: lower abdominal tenderness + uterine and bilateral adnexal tenderness + cervical motion tendernessAdmit if: toxic; severe pain; unable to tolerate PO meds; pregnancy; pre-pubertal; HIV +; poor likelihood of compliance; IUD or recent instrumentationOther: Remove IUCD or RPOC; consider sexual abuse; treat sexual contacts (partner infected in 40%; not needed in bacterial vaginosis; needed in trichomonas and candida); counselling; always follow up at 72 hours; refer to sexual health clinic; abstain from sex at least 2/52; candida prophylaxis; gonorrhoea and chlamydia = reportable disease00Commence if: lower abdominal tenderness + uterine and bilateral adnexal tenderness + cervical motion tendernessAdmit if: toxic; severe pain; unable to tolerate PO meds; pregnancy; pre-pubertal; HIV +; poor likelihood of compliance; IUD or recent instrumentationOther: Remove IUCD or RPOC; consider sexual abuse; treat sexual contacts (partner infected in 40%; not needed in bacterial vaginosis; needed in trichomonas and candida); counselling; always follow up at 72 hours; refer to sexual health clinic; abstain from sex at least 2/52; candida prophylaxis; gonorrhoea and chlamydia = reportable disease2489207009765Investigation00Investigation15538457009765Bloods: WBC >10 in 50%Swab: gonorrhoea culture (urethral or endocervical) 97% sensitivityitivity, gram stain 50% sensitivity; cheap; reasonable sensitivity and specificity; PCR 99% sensitivity and specificity on swab; chlamydia culture 95% sensitivity, 99% specificity; self collected samples and urine samples as goodUrine: gonorrhoea PCR 90% sensitivity, 99% specificity; Chlamydia PCR in malesUSS: if abscess suspected (ie. Toxic, asymmetrical findings)Laparoscopy: will be +ive in 50% of those diagnosed with PID clinically00Bloods: WBC >10 in 50%Swab: gonorrhoea culture (urethral or endocervical) 97% sensitivityitivity, gram stain 50% sensitivity; cheap; reasonable sensitivity and specificity; PCR 99% sensitivity and specificity on swab; chlamydia culture 95% sensitivity, 99% specificity; self collected samples and urine samples as goodUrine: gonorrhoea PCR 90% sensitivity, 99% specificity; Chlamydia PCR in malesUSS: if abscess suspected (ie. Toxic, asymmetrical findings)Laparoscopy: will be +ive in 50% of those diagnosed with PID clinically2489206354445Assessment00Assessment15538456355080History: 90% pelvic pain (usually bilateral); 75% vaginal discharge; >30% irregular PV bleeding; systemic toxicityExamination: poor sensitivity and specificity; low grade fever, adnexal mass00History: 90% pelvic pain (usually bilateral); 75% vaginal discharge; >30% irregular PV bleeding; systemic toxicityExamination: poor sensitivity and specificity; low grade fever, adnexal mass15513055346699Infertility (12-50%; 10% after first episode; risk doubles with each infection; 2 infections = 20%, 3 infections = >50%); chronic salpingitis (25%); chronic pain, adhesions, dysparaeunia (20%), ectopic (12- 15% higher incidence; incidence 1:120 normally, 1:16 with PID); tubo-ovarian abscess (5% mortality if rupture; occurs in 1/3 hospitalised patients); Fitz-Hugh-Curtis syndrome (transcoelemic spread of inflammatory peritoneal fluid to subphrenic and subdiaphragmatic spaces)00Infertility (12-50%; 10% after first episode; risk doubles with each infection; 2 infections = 20%, 3 infections = >50%); chronic salpingitis (25%); chronic pain, adhesions, dysparaeunia (20%), ectopic (12- 15% higher incidence; incidence 1:120 normally, 1:16 with PID); tubo-ovarian abscess (5% mortality if rupture; occurs in 1/3 hospitalised patients); Fitz-Hugh-Curtis syndrome (transcoelemic spread of inflammatory peritoneal fluid to subphrenic and subdiaphragmatic spaces)2438405346700Complications00Complications2489204970780Risk Factors00Risk Factors15538454970780? with sexual activity; ? with progesterones and pregnancy (especially after 12/40)00? with sexual activity; ? with progesterones and pregnancy (especially after 12/40)2489204598670Aetiology00Aetiology15513054598670Direct; haematogenous (TB, mumps); iatrogenic (IUCD, RPOC); >50% have no cause detected for cervicitis00Direct; haematogenous (TB, mumps); iatrogenic (IUCD, RPOC); >50% have no cause detected for cervicitis2463801492250Symptoms00Symptoms15513051492251Non-sexual: mixed pathogens from vaginal flora; anaerobes, facultative bacteria, mycoplasma, ureaplasma, gut coliforms (E coli, H influenzae); PV discharge not usually STD (candida most common cause of PV discharge, bacterial vaginosis)Sexual: often polymicrobialChlamydia - most common cause of cervicitis; most common in hetero; usually asymptomatic in women Intracellular parasite; incubation 1-3/52 or longer; More watery discharge, less painful than gonorrhoea; can also cause proctitis / prostatitis; lymphogranuloma venereum (males get vesicles/ulcers on genitals inguinal buboe after 1-4/52 fuse, breakdown, discharge)Gonorrohea – rates increasing; more common in homos / Maoris etc… / overseas sex; 50% have co- existant chlamydia; incr penicillin and quinolone resistance; G-ive intracellular diplococci; incubation 3-7/7; Urinary symptoms and penile discharge in men; 10-20% of untreated infections become PID; disseminated in 3% Septic arthritis (2x more common in women, occurs in 0.2%, onset 3-17/7 after infection, may be preceded by migratory polyarthritis; 75% poly, 80% asymmetric) Rash (in 2/3; petechiae / painful red papules on digits; may become vesicular / pustular grey necrotic centre, often on haemorrhagic base; usually <20 lesions) Can also cause pharyngeal, anal, conjunctivitis, tenosynovitis, meningitis, myocarditis, pericardititsTrichomonas: has fishy smellGardnerella = bacterial vaginosis: has clue cells00Non-sexual: mixed pathogens from vaginal flora; anaerobes, facultative bacteria, mycoplasma, ureaplasma, gut coliforms (E coli, H influenzae); PV discharge not usually STD (candida most common cause of PV discharge, bacterial vaginosis)Sexual: often polymicrobialChlamydia - most common cause of cervicitis; most common in hetero; usually asymptomatic in women Intracellular parasite; incubation 1-3/52 or longer; More watery discharge, less painful than gonorrhoea; can also cause proctitis / prostatitis; lymphogranuloma venereum (males get vesicles/ulcers on genitals inguinal buboe after 1-4/52 fuse, breakdown, discharge)Gonorrohea – rates increasing; more common in homos / Maoris etc… / overseas sex; 50% have co- existant chlamydia; incr penicillin and quinolone resistance; G-ive intracellular diplococci; incubation 3-7/7; Urinary symptoms and penile discharge in men; 10-20% of untreated infections become PID; disseminated in 3% Septic arthritis (2x more common in women, occurs in 0.2%, onset 3-17/7 after infection, may be preceded by migratory polyarthritis; 75% poly, 80% asymmetric) Rash (in 2/3; petechiae / painful red papules on digits; may become vesicular / pustular grey necrotic centre, often on haemorrhagic base; usually <20 lesions) Can also cause pharyngeal, anal, conjunctivitis, tenosynovitis, meningitis, myocarditis, pericardititsTrichomonas: has fishy smellGardnerella = bacterial vaginosis: has clue cells243840963930Definition00Definition1551305962660Spread of primary lower genital tract infection to upper (inc. endometritis, salpingitis, tubo-ovarian abscess, peritonitis)00Spread of primary lower genital tract infection to upper (inc. endometritis, salpingitis, tubo-ovarian abscess, peritonitis)246380330200Pelvic Inflammatory Disease00Pelvic Inflammatory Disease2438406019800Syphilis00Syphilis15195556019800Very uncommon (? in homosexual); usually detected in latent phaseTreponema pallidum: spirochete; STDPrimary syphilis: 2-6/52 after contact 1 firm, nontender, raised red lesion (chancre) on penis, cervix, vagina, anus in 70% men, 50% women; up tos severeal cm’s in diameter; erodes to create shallow based ulcer; regional lymph nodes heals in 3-6/52 without treatmentSecondary syphilis: 2-10/52 after primary, in 75% dissemination in skin and muco- cutaneous tissues; lasts several weeks latent phase Maculopapular / scaly / pustular lesions on soles of feet / palms – discrete red/brown spots <5mm diameter Condylomata lata on moist areas (eg. Anogenital / axilla / inner thigh) – broad based, elevated plaques, painless, highly infectious Silver/gray superficial erosions on mucous membranes (especially mouth / external genitalia / oropharynx) ulcerate – these are most infectious Fever, malaise, weight loss, lymphandenopathy, arthralgia; maybe asceptic meningitis (1-2%), hepatitis, nephrotic syndrome00Very uncommon (? in homosexual); usually detected in latent phaseTreponema pallidum: spirochete; STDPrimary syphilis: 2-6/52 after contact 1 firm, nontender, raised red lesion (chancre) on penis, cervix, vagina, anus in 70% men, 50% women; up tos severeal cm’s in diameter; erodes to create shallow based ulcer; regional lymph nodes heals in 3-6/52 without treatmentSecondary syphilis: 2-10/52 after primary, in 75% dissemination in skin and muco- cutaneous tissues; lasts several weeks latent phase Maculopapular / scaly / pustular lesions on soles of feet / palms – discrete red/brown spots <5mm diameter Condylomata lata on moist areas (eg. Anogenital / axilla / inner thigh) – broad based, elevated plaques, painless, highly infectious Silver/gray superficial erosions on mucous membranes (especially mouth / external genitalia / oropharynx) ulcerate – these are most infectious Fever, malaise, weight loss, lymphandenopathy, arthralgia; maybe asceptic meningitis (1-2%), hepatitis, nephrotic syndrome40195507160260557085571596250039928806019800005709920601980000243840488950Pelvic Inflammatory Disease Antibiotics00Pelvic Inflammatory Disease Antibiotics23685505527040IV gentamicin + clindamycin00IV gentamicin + clindamycin15278105527040Penicillin Allergy00Penicillin Allergy23685504810125Use roxithromycin instead of doxycycline00Use roxithromycin instead of doxycycline15278104810125Pregnant / breast-feeding00Pregnant / breast-feeding15278104032250Puer-pueral00Puer-pueral23685504490720Severe00Severe30397454490720As per septicaemia00As per septicaemia23685504032250Mild00Mild30397454032250Augmentin BD 5-7/7 (add roxithromycin 300mg OD / clindamycin 300mg TDS if ongoing >48 hours)00Augmentin BD 5-7/7 (add roxithromycin 300mg OD / clindamycin 300mg TDS if ongoing >48 hours)15278103498850Septi-caemia00Septi-caemia23685503498849Ampicillin 2g IV Q6h + metronidazole 500mg BD + gentamicin 4-6mg/kg OD00Ampicillin 2g IV Q6h + metronidazole 500mg BD + gentamicin 4-6mg/kg OD30397453181350As per septicaemia or severe sexually acquired00As per septicaemia or severe sexually acquired23685503181350Severe00Severe23685502834004Mild00Mild30397452833370Augmentin + doxycycline00Augmentin + doxycycline15278102833370Non-Sexually Acquired00Non-Sexually Acquired1527810488950Sexually Acquired00Sexually Acquired23685502353310Severe00Severe30397452353311Doxycycline + metronidazole + ceftriaxone as per empirical treatment above; continue IV for 48 hours after symptoms improve PO)00Doxycycline + metronidazole + ceftriaxone as per empirical treatment above; continue IV for 48 hours after symptoms improve PO)2368550488950Mild00Mild3039745488315Empirical Treatment: Azithromycin 1g PO single dose (or doxycycline 100mg BD for 14/7)+ metronidazole 400mg BD for 14/7+ ceftriaxone 250mg IM/IV stat (if gonorrhoea suspected; always give if community incidence high)If gonorrhoea only, no PID: Azithromycin 1g PO single dose (or doxycycline 100mg BD for 1/52)+ ceftriaxoneIf chlamydia only, no PID: Azithromycin 1g PO single dose (or doxycycline 100mg BD for 1/52)00Empirical Treatment: Azithromycin 1g PO single dose (or doxycycline 100mg BD for 14/7)+ metronidazole 400mg BD for 14/7+ ceftriaxone 250mg IM/IV stat (if gonorrhoea suspected; always give if community incidence high)If gonorrhoea only, no PID: Azithromycin 1g PO single dose (or doxycycline 100mg BD for 1/52)+ ceftriaxoneIf chlamydia only, no PID: Azithromycin 1g PO single dose (or doxycycline 100mg BD for 1/52)334645685165Syphilis(cntd)00Syphilis(cntd)1628140685800Tertiary syphilis: in 1/3 untreated after >5yrs CV syphilis: aortitis dilatation of aortic root and arch aortic valve regurgitation, aneurysms; accounts for 80% Neurosyphilis: may be asymptomatic (1/3); chronic meningovascular disease, tabes dorsalis, general paresis; dementia, psychosis, cranial nerve palsy, spinal cord syndrome; in 5-10% Benign 3Y syphilis: gummas in various sites; white/gray, rubbery, single / multiple, small/large nodular lesions due to delayed hypersensitivity; mostly in bone ( pain, tenderness, swelling, pathological fracture), skin, subcutaneous tissue; mucous membranes of upper respiratory tract and mouth, testes; rarely causes destructive ulcerative lesionsCongenital syphiliis: during primary or secondary syphilis in mother; 25% intrauterine / perinatal death Infantile (early): first 2yrs; nasal discharge and congestion; desquamating / bullous rash sloughing of skin (especially hands, feet, mouth, anus); hepatomegaly, skeletal abnormalities (syphilitic osteochonritis and periostitis – especially nose with saddle nose deformity and lower leg new bone growth on anterior tibia sabre shin) Tardive (late): later; occur in >50% untreated; Hutchinson triad: notched central incisors (may be screwdriver shaped), interstital keratitis (or choroiditis) with blindness, deafness due to VIII injury (and optic nerve atrophy); skeletal, neurological and facial abnormalitiesInvestigation: identified on MC+S of 95% chancres; VDRL 80% sens (>95% in stage 2 and 3), 1-2% false +ive if +ive, need to confirm with treponeal antibody test (80% sensitivity in primary, 100% later)Management: penicillin (doxycycline if allergy); give IM in secondaryTertiary syphilis: in 1/3 untreated after >5yrs CV syphilis: aortitis dilatation of aortic root and arch aortic valve regurgitation, aneurysms; accounts for 80% Neurosyphilis: may be asymptomatic (1/3); chronic meningovascular disease, tabes dorsalis, general paresis; dementia, psychosis, cranial nerve palsy, spinal cord syndrome; in 5-10% Benign 3Y syphilis: gummas in various sites; white/gray, rubbery, single / multiple, small/large nodular lesions due to delayed hypersensitivity; mostly in bone ( pain, tenderness, swelling, pathological fracture), skin, subcutaneous tissue; mucous membranes of upper respiratory tract and mouth, testes; rarely causes destructive ulcerative lesionsCongenital syphiliis: during primary or secondary syphilis in mother; 25% intrauterine / perinatal death Infantile (early): first 2yrs; nasal discharge and congestion; desquamating / bullous rash sloughing of skin (especially hands, feet, mouth, anus); hepatomegaly, skeletal abnormalities (syphilitic osteochonritis and periostitis – especially nose with saddle nose deformity and lower leg new bone growth on anterior tibia sabre shin) Tardive (late): later; occur in >50% untreated; Hutchinson triad: notched central incisors (may be screwdriver shaped), interstital keratitis (or choroiditis) with blindness, deafness due to VIII injury (and optic nerve atrophy); skeletal, neurological and facial abnormalitiesInvestigation: identified on MC+S of 95% chancres; VDRL 80% sens (>95% in stage 2 and 3), 1-2% false +ive if +ive, need to confirm with treponeal antibody test (80% sensitivity in primary, 100% later)Management: penicillin (doxycycline if allergy); give IM in secondary49256952485390006200140248539000591439084963000 ................
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