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Causes of Vaginal Discharge Including Sexually Transmitted Infections This is a nursing training presentation. Some of the images are sensitive in nature and reflect graphic disease processes. It may be inappropriate for certain audiences. Learning Objectives Describe common causes of vaginitis Provide education on risks, symptoms, treatment, and prevention strategies for common vaginal infections including those that are sexually transmitted Understand the components of a good sexual history Appropriately triage women who present with vaginal discharge Vaginitis Most frequent reason American women visit the provider More than 10 million office visits per year Many related to infections that are transmitted by sexual contact VETERANS HEALTH ADMINISTRATION Most Common Causes of Vaginitis Overgrowth of vaginal flora Sexually transmitted infections Non-infectious causes VETERANS HEALTH ADMINISTRATION The Pelvic Exam VETERANS HEALTH ADMINISTRATION Pelvic Exam Supplies Poll Question Which items would you set out for a vaginitis exam? A. Speculum, battery, pH paper, saline, KOH, ThinPrep (Pap solution), cotton swabs B. Speculum, battery, gloves, pH paper, culture set C. Speculum, battery, gloves, cultures, pH paper, KOH, saline, cotton swabs D. None of the above VETERANS HEALTH ADMINISTRATION Assessment of discharge (color, viscosity, odor, adherence to vaginal walls) Visualization of cervix to rule out cervicitis Vaginitis Exam Lab tests (pregnancy, pH, wet mount) Opportunity for birth control and Plan B discussions STI Evaluation HIV test Hepatitis B screen Chlamydia/gonorrhea culture VDRL/RPR for syphilis DNA probe (Affirm test) Rapid antigen test Consider Pap (if over 21 and due for Pap testing) Poll Answer Which items would you set out for a vaginitis exam? A. Speculum, battery, pH paper, saline, KOH, ThinPrep (Pap solution), cotton swabs B. Speculum, battery, gloves, pH paper, culture set C. Speculum, battery, gloves, cultures, pH paper, KOH, saline, cotton swabs D. None of the above VETERANS HEALTH ADMINISTRATION Common Causes of Vaginitis VETERANS HEALTH ADMINISTRATION Bacterial Vaginosis (BV) • Lack of protective lactobacilli which keep anaerobes (bad bacteria in check) • Present in 29% of women • Most common cause of discharge, although 50% of women are asymptomatic • ‘Fishy’ odor, milky-white discharge • 30% of women have a recurrence in 3 months, 50% in 12 VETERANS HEALTH ADMINISTRATION Bacterial Vaginosis (BV) • Women with BV may be at higher risk for: – Acquiring STIs including HIV, gonorrhea, chlamydia, and herpes – Post-op infections after gynecologic procedures – Pregnancy complications (premature rupture of membranes, premature delivery, low‐birth weight) – BV recurrence • Often identified in female-female partnerships VETERANS HEALTH ADMINISTRATION Patient Education for BV • Caused by a lack of protective lactobacilli • More likely to occur in situations where normal vaginal flora are altered such as douching or use of intravaginal preparations • Use prescription oral or intravaginal medication as directed • OTC medicines for yeast and other vaginal products don’t work • Recurrence in 3-12 mos is common; treating male partner will not help • Reduce risks: – Abstinence, mutual monogamy, latex condoms, limit number of sex partners – Wash sex toys – Avoid douches and deodorant sprays VETERANS HEALTH ADMINISTRATION Vulvovaginal Candidiasis (Yeast infection) • 75% of women experience it, and half have recurrences • Overgrowth of normal vaginal flora • Itching, redness, burning, ‘cottage cheese discharge’, no odor • Usually not sexually transmitted; often found when evaluating for STIs • Risk factors: – Diabetes, antibiotics, spermicides, douching, contraceptive devices, HIV, pregnancy, corticosteroids VETERANS HEALTH ADMINISTRATION Patient Education for Candidiasis • Lack of vaginal lactobacillus bacteria allows overgrowth of yeast fungus • Can be spread through oral-genital contact • Associated with antibiotics, pregnancy, diabetes, impaired immune system, douching, sexual activity • Take medicine as directed • Avoid douches or feminine sprays to treat or prevent recurrence • Mineral oil in topical antifungal preparations may erode latex condoms and diaphragms. Use plastic or polyethylene condoms. • Reduce risks: abstinence, mutual monogamy, latex condoms, limiting number of sex partners VETERANS HEALTH ADMINISTRATION Sexually Transmitted Infections (STIs) VETERANS HEALTH ADMINISTRATION Estimated number of new and existing (total) sexually transmitted infections United States, 2008 Syphilis Gonorrhea Hep B 117,000 270,000 422,000 50,627,400 HIV Chlamydia Trich 908,000 1.6 mil 3.7 mil 59,569,500 HSV-2 24 mil HPV 79 mil TOTAL 110,197,000 CDC Fact Sheet. Incidence, prevalence, and cost of sexually transmitted infections in the United States, Feb 2013. Trichomoniasis • Very common STI • Itching, burning, redness, pain during urination and intercourse • Frothy, thin, malodorous, yellowgreen discharge, although 85% of women are asymptomatic • Can be transmitted between female partners • Risk factors: multiple partners, low SES, hx of STIs • Pregnancy complications: associated with premature rupture of membranes, preterm delivery, and low birth weight • Trichomonas infection in HIV‐infected women may enhance HIV‐transmission to sexual partners VETERANS HEALTH ADMINISTRATION Patient Education for Trichomonas • Can last for years without treatment • Metronidazole can trigger cramps, nausea, vomiting, headaches and flushing if combined with alcohol – Avoid alcohol use during treatment and 24 hrs after – Some providers advise avoiding alcohol for up to 3 days after • Metronidazole should not be taken in first trimester of pregnancy • No sex until patient/partner(s) complete treatment • Douching may worsen discharge • Can recur. Re-evaluate if symptoms persist. • Trichomonas may facilitate HIV transmission • Reduce risks: abstinence, mutual monogamy, latex condoms, limiting number of sex partners VETERANS HEALTH ADMINISTRATION Cervicitis • Inflammation of the cervix (not always related to infection) • Causes − Chlamydia, gonorrhea most common (treat for both) − Foreign objects, radiation, malignancy • Mucopurulent discharge, pain during intercourse, bloody discharge or spotting between periods, burning upon urination if urethra is also infected. • Can spread to uterus, fallopian tubes, or ovaries, resulting in pelvic inflammatory disease (PID) VETERANS HEALTH ADMINISTRATION Gonorrhea • Common in cervix and vagina • Also grows in urethra, mouth, throat, eyes, anus • Painful urination, vaginal discharge, bleeding between periods; 50% of women asymptomatic • Associated with ectopic pregnancy, PID, infertility, Bartholin’s cyst Gonorrhea Diagnosis and Treatment • Diagnosis − NAATs (Nucleic Acid Amplification Testing) − Endocervical culture • Treatment – Dual antibiotic therapy • Ceftriaxone as single IM dose, plus either azithromycin orally in single dose or doxycycline twice daily x 7 days – Retest at 3-6 mos or whenever the patient seeks care in next 12 mos – Evaluate and treat partners VETERANS HEALTH ADMINISTRATION Patient Education for Gonorrhea • In 15% of infected women, untreated gonorrhea spreads to fallopian tubes, where it can cause scarring and infertility • Increases susceptibility to HIV infection • Treated with two medications. Take oral medication as directed. • Some strains are resistant. Retest in 3-6 months. Return earlier if symptoms persist. • No sex until patient/partner(s) complete treatment • Reduce risks: abstinence, mutual monogamy, latex condoms, limiting number of sex partners VETERANS HEALTH ADMINISTRATION Chlamydia • 1.6 million new infections/year • Found in cervix, urethra, throat, rectum • Frequent/urgent urination with burning, vaginal discharge, light bleeding post-intercourse, lower abdominal pain; however, 75% of women asymptomatic • Associated with infertility, PID, ectopic pregnancy • Perinatal transmission results in neonatal conjunctivitis in 30-50% of exposed babies VETERANS HEALTH ADMINISTRATION Chlamydia Screening US Preventative Services Task Force recommends screening asymptomatic women… Yearly for all sexually active women ≤ 24 years Yearly for sexually active women > 24 years with risk factors • African American, new male sex partner, two or more partners in preceding year, inconsistent barrier contraceptive use (condoms) and hx of prior STI All pregnant women at first prenatal visit VETERANS HEALTH ADMINISTRATION Chlamydia Diagnosis and Treatment • Diagnosis – NAATs – Endocervical swab – Urine test • Treatment – Antibiotics (azithromycin 1 g orally in single dose or doxycycline 100 mg orally twice daily x 7 days) – Retest at 3 mos or when patient seeks care in next 12 mos – Evaluate and treat partners VETERANS HEALTH ADMINISTRATION Patient Education for Chlamydia • If untreated, can lead to tubal pregnancy, chronic pelvic pain, infertility − 30% of women develop PID − 50,000 become infertile yearly due to untreated chlamydia and gonorrhea • Complete medication as directed • No sex until patient/partner(s) complete treatment • Women should be screened at least once a year if < 25 or if at high risk or if become pregnant • Pregnant women may need repeat testing 3 wks after treatment • Reduce risks: abstinence, mutual monogamy, latex condoms, limiting number of sex partners VETERANS HEALTH ADMINISTRATION Genital Herpes Simplex Virus (HSV) • 25% of population has serological evidence • HSV-2 is genital, most common (1 in 4 women, 1 in 5 men 15-45) • Transmission – Kissing, skin-to-skin contact, vaginal/oral/anal sex – Can be transmitted when symptoms are not present • Outbreaks can occur 4-5 times/year; most frequent in first year • C-section at delivery to prevent newborn infection • After resolution, asymptomatic intermittent viral shedding occurs even in absence of genital lesions • Complications: most common cause of viral encephalitis; 3rd most common cause of sexually transmitted proctitis VETERANS HEALTH ADMINISTRATION Primary outbreak occurs 1 wk after contact • Fever, chills, headache, painful lymph nodes in groin • Pain or itch usually precedes blisters/skin ulcers • 75% of patients with primary genital HSV infection are asymptomatic. Granulating ulcer Initial lesions VETERANS HEALTH ADMINISTRATION Genital Herpes Herpes Cervicitis Genital Herpes • Diagnosis − Often inaccurate if based on H&P − Viral culture for active lesions − PCR (polymerase chain reaction) to detect asymptomatic virus shedding − Direct fluorescent antibody for clinical specimens (can determine herpes subtype ) • Treatment − Antiviral meds treat primary herpes/suppress recurrent outbreaks (daily antivirals can decrease recurrences by 70-80% for patients with 6+ episodes/year) − Topical treatments do not work VETERANS HEALTH ADMINISTRATION Partner check! VETERANS HEALTH ADMINISTRATION Patient Education for Genital Herpes • • • • • • No cure. Symptoms may recur; recurrence varies by person. First attack is usually worst; 40% never have second outbreak. Outbreaks can be related to menses, intercourse, sunbathing, stress Inform all partners; abstain from sex when symptomatic Can be transmitted without symptoms; use latex condoms People with herpes more likely to become infected if exposed to HIV through sex; people with HIV + herpes more likely to spread HIV • Take meds to prevent symptoms from returning/make recurrences less severe • Topical treatments don’t work; analgesics help painful lesions • Inform provider if you become pregnant VETERANS HEALTH ADMINISTRATION Syphilis Stage 1: Primary • Chancre or ulcer Stage 2: Secondary • Skin rash • Lymphadenopathy Stage 3: Tertiary • Years later, neurologic infection through body VETERANS HEALTH ADMINISTRATION 40,000 new cases/year caused by bacterium Trepomema pallidum Condyloma lata lesions (secondary syphilis) Syphilis Diagnosis and Treatment • Diagnosis – Venereal Disease Research Laboratory (VDRL) and RPR (Rapid Plasma Reagin) – Treponemal test (FTA-ABS ) can confirm diagnosis • Treatment − Early infections: single-dose benzathine penicillin − Late latent infections of unknown duration: benzathine penicillin in 3 doses each at 1 wk intervals − Clinical and serological follow-up tests at 6 mos and 12 mos post-treatment − Treat partners presumptively VETERANS HEALTH ADMINISTRATION Patient Education for Syphilis • Comply with medication instructions • Return for 6 and 12 month follow-up appts • No sex until patient/partner(s) complete treatment • Pregnant women should have a blood test for syphilis to prevent passing infection to the baby • People with syphilis more likely to become infected if exposed to HIV through sex; people with HIV + syphilis more likely to spread HIV to others • Reduce risks: abstinence, mutual monogamy, latex condoms, limiting number of sex partners VETERANS HEALTH ADMINISTRATION HPV-Related Genital Warts • Caused by human papillomavirus (HPV) subtypes 6 and 11 • Benign but very contagious • Pink or flesh-colored, raised/flat spots resemble cauliflower • Inside/outside vagina or anus, on nearby skin, on cervix, lips, mouth, tongue, throat • Women can be infected and not have symptoms • Can take 6 mos to develop VETERANS HEALTH ADMINISTRATION HPV-Related Genital Warts Treatment: • Creams – Polophyllin TCA, Aldara or imiquimod 5% • Cryosurgery, laser therapy, electro-cauterization, surgical excision • Examine partners and treat if warranted VETERANS HEALTH ADMINISTRATION HPV Cervical Condyloma • If cervix is infected, follow with Pap smears every 3-6 mos after first treatment • Remember HPV vaccine for females ages 9-26 VETERANS HEALTH ADMINISTRATION Patient Education for Genital Warts • Even though warts may be removed, viral infection can't be cured • Warts often return; they are benign but very infectious • No sex until patient/partner(s) complete treatment • Get regular Pap smears • Best prevention is abstinence or sex with only one uninfected partner; condoms help prevent infection, but don’t cover all affected skin • Gardasil immunization for uninfected partners <27 years of age VETERANS HEALTH ADMINISTRATION HPV Infection Rectal condylomas sometimes require surgery VETERANS HEALTH ADMINISTRATION 25% of patients with first episode of genital ulceration have no detectable cause despite full diagnostic eval… Genital Ulcers Painless ulcers - think syphilis, but herpes can also present this way Multiple ulcers - think herpes, but could also be syphilis Diagnosis based on only a history and physical is often inadequate VETERANS HEALTH ADMINISTRATION Herpes patient: initial visit and 4 days later when ulcers have begun to heal with medication VETERANS HEALTH ADMINISTRATION Poll Question HIV testing is accurate immediately after exposure to the virus. A. True B. False VETERANS HEALTH ADMINISTRATION Poll Question HIV testing is accurate immediately after exposure to the virus. A. True B. False Most people develop detectable antibodies 2-8 wks after exposure (avg 25 days); 97% develop antibodies in first 3 mos. Some take longer. In very rare cases, it can take up to 6 mos to develop antibodies to HIV. Therefore, if initial negative HIV test was done in first 3 mos after possible exposure, CDC recommends considering repeat testing >3 mos after exposure to account for possibility of false-negative result. VETERANS HEALTH ADMINISTRATION Human Immunodeficiency Virus (HIV) • CDC recommends screening everyone for HIV, any time at any site at least once, and yearly for anyone at risk • Women are 4x more likely to contract HIV through vaginal sex with infected men, than men are to contract HIV through vaginal sex with infected women • Growing problem for women: Black/Hispanic women represent <29% of US women, but account for 79% of female AIDS cases • Patient education − Viral infection, not curable at this time − Transmitted by vaginal/anal/oral sex, needle sharing, occupational exposure, transplant, artificial insemination, and contaminated transfusions − Best prevention is abstinence or sex with only one uninfected partner. Condoms help prevent infection. Hepatitis B Encourage vaccination for prevention: 3 shots over 6 mos Patient education: − Preventable with vaccine − Adult recovery rate is 95% − Transmitted via intercourse, contaminated blood, occupational exposure − Can survive for 7 days outside the body − Don’t share needles, razors, toothbrushes, nail clippers, earrings − Reduce risks: abstinence, mutual monogamy, latex condoms, limiting number of sex partners VETERANS HEALTH ADMINISTRATION The Sexual History and Prevention Counseling This next section comes from the CDC publication, A Guide to Taking a Sexual History. A booklet version of it is on the CDC website… http://www.cdc.gov/std/see/HealthCareProviders/SexualHistory.pdf VETERANS HEALTH ADMINISTRATION Think of sharing these questions with your provider… Start the sexual hx by normalizing the discussion 1. I am going to ask you a few questions about your sexual health and sexual practices. I understand that these questions are very personal, but they are important for your overall health. 2. Just so you know, we ask these questions to all adult patients, regardless of age, gender, or marital status. These questions are as important as the questions about other areas of your physical and mental health. Add… Like the rest of our visit, this information is kept in strict confidence. Do you have any questions before we begin? VETERANS HEALTH ADMINISTRATION Sexual History Providers should utilize the “Five P’s” 1. Partners • Are your sex partners men, women, or both? • In the past 2 months, how many sex partners have you had? • In the past 12 months, how many sex partners have you had? One partner in last 12 mos: ask about length of relationship and partner’s risk factors (current or past sex partners, drug use) More than one partner in last 12 mos: explore more specific risk factors (condom use, or non-use, and partners’ risk factors) VETERANS HEALTH ADMINISTRATION Sexual History Providers should utilize the “Five P’s” 1. Partners 2. Prevention of pregnancy 3. Protection from STIs 4. Practices 5. Past history of STIs VETERANS HEALTH ADMINISTRATION When questioning and counseling, use a nonjudgmental and caring manner Be aware of factors that increase the risk for an STI… Illicit drug use Unprotected sex Young age Unmarried Multiple sexual partners Prior STI VETERANS HEALTH ADMINISTRATION Contact with sex workers New sex partner in past 60 days No vaccination (HPV, hepatitis) Summary of STI Screening for Women • HIV: Screen all women ≤ 65 regardless of risk at least once; annual screen for those at increased risk • HPV: Encourage vaccination for all women ≤ 26 • Chlamydia: Screen all women ≤ 24, and any at high risk • Trichomonas and Gonorrhea and Syphilis: Screen women at risk – Consider screening all women under ≤ 24 for gonorrhea • Hepatitis B: Consider vaccinating women at risk * At risk = Multiple current partners, new partner, inconsistent condom use, sex while under the influence of alcohol or drugs, sex in exchange for money or drugs. VETERANS HEALTH ADMINISTRATION STI Summary • STIs cost US health care system $17 billion/year • Young people represent only 25% of sexually experienced population, but account for nearly half of new STIs • Less than half of people who should be screened actually receive recommended STI screening services • Providers are required to report gonorrhea, chlamydia, and syphilis to local or state public health authorities ─ Nursing can help track/report VETERANS HEALTH ADMINISTRATION Case Study A call comes in from a woman veteran who complains of new vaginal discharge. What questions would you ask? VETERANS HEALTH ADMINISTRATION Helpful References • CDC. A Guide to Taking a Sexual History. http://www.cdc.gov/std/see/HealthCareProviders/SexualHistory.pdf • CDC. Self Study STD Modules/Vaginitis http://www2a.cdc.gov/stdtraining/self-study/vaginitis.asp • CDC. Sexually transmitted diseases treatment guidelines 2010. http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf • Seattle STD/HIV Prevention Training Center. The Practitioner’s Handbook for the Management of Sexually Transmitted Disease. http://www.stdhandbook.org/ • Workowski KA, Berman SM. Centers for Disease Control and Prevention sexually transmitted diseases treatment guidelines. Clin Infect Dis. 2007;44(s3):S73-6 VETERANS HEALTH ADMINISTRATION VETERANS HEALTH ADMINISTRATION