Morning Report

Lu Lu Waterhouse, MD PGY-3 December 31, 2012

Adolescent Clinic at SMC

HPI: 17yo female with 2 days of white vaginal discharge and dysuria

PMH: No hospitalizations or surgeries. H/o 3 UTIs. Sexual History:

No fevers, vomiting, diarrhea, or back pain. Mild nausea and abdominal pain. No urinary urgency or frequency. Just finished course of amoxicillin for wisdom teeth extraction. LMP 2 weeks ago

Social History:

H/o Chlamydia 2 years ago treated. No other STIs 5 partners, all males; vaginal and oral sex only Uses condoms and OCP as birth control No h/o pregnancies Last sexual activity 5 months ago

Recovering alcoholic, in residential treatment currently Occasional tobacco and marijuana use; no other drugs In 11th grade, would like to attend college

Physical Exam

Vitals: Temp 37.3, HR 76, RR 12, BP 116/72 GEN: WDWN in NAD. Pleasant teen. HEENT: NC/AT, PERRL, EOMI, TMs normal, O/P clear Neck: Supple without LAD CV: RRR, no murmurs, 2+ radial pulse RESP: CTAB, easy work of breathing ABD: Soft, non-distended, normal bowel sounds, mild suprapubic tenderness on palpation. GU: external exam showed erythematous labia majora with white discharge Pelvic Exam: not performed

Labs & Imaging

U/A: SG 1.025, pH 6.0, 1+ leuk esterase, negative for nitrites, blood, protein, glucose, and ketones Urine -hcg: negative Could also get urine GC/Chlamydia

17 year old female with history of UTIs and Chlamydia presents with 2 days of white vaginal discharge and mild dysuria. DDx???

Differential Diagnosis

Renal:

GU:

UTI Pyelonephritis Vaginitis:

Chlamydia Gonorrhea PID Vaginal foreign body (i.e. tampon) Other STIs: syphilis, herpes, pubic lice

Bacterial Vaginosis Candidal Infection Trichomonas

Candidiasis

Symptoms: Most have pruritis and thick, white, cheesy, non-odorous discharge Often have dysuria or dyspareunia Diagnosis: Wet prep: pseudohyphae and budding yeast on KOH, pH<5, negative whiff test Can also test with DNA probe or culture Treatment: Fluconazole 150mg PO single dose, or can repeat dose in 72hrs if symptoms persist OTC creams often not curative No partner treatment necessary

Bacterial Vaginosis

Symptoms: Thin, adherent, grey-white discharge of women do not experience vaginal symptoms Diagnosis: 3 of 4 Amsels Criteria 1. homogenous thin, white discharge that uniformly coats vaginal walls 2. Wet prep (KOH) positive whiff test 3. Wet prep (Normal Saline) Clue cells (epithelial cells stippled with bacteria) 4. pH>4.5 Gold standard is gram stain Treatment: Metronidazole 500mg PO BID x 7 days (no EtOH) Cream treatments: Metronidazole gel 0.75% or Clindamycin cream 2%, full applicator qhs x 7 days No partner treatment necessary

Symptoms:

Trichomonas

Diagnosis:

Intermittent foul-smelling, yellowgreen, frothy discharge Can have itching, burning, dysuria Symptomatic around menses (can cause increased bleeding)

Treatment:

Pelvic exam strawberry cervix Wet prep (NS) trichomonads (smaller than epithelial cells, larger than PMNs, rarely see flagella), pH>4.5 Other tests (higher sensitivity) culture, antigen, DNA probe
Metronidazole 2g PO once Alternative: Metronidazole 500mg PO BID x 7 days Partner does need to be treated.

Trichomonas under the Microscope

CORE Study Objectives for Vaginitis

Know that most pathologic vaginal discharges of adolescence are generally linked to sexual activity. Know the appropriate management of the uncomplicated pathologic vaginal discharges. Know the clinical characteristics of BV that would suggest the diagnosis. Know that trichomoniasis and genital warts are often asymptomatic in boys.

Cervicitis: Chlamydia

Symptoms:

Vaginal discharge Heavy or prolonged menses, spotting, dysmenorrhea Dyspareunia Up to 75% are asymptomatic

Diagnosis: NAAT urine/swab equally accurate Treatment:

Azithromycin 1g PO (single dose) Doxycycline 100mg PO BID x 7 days Reportable; partner needs to be treated If left untreated:

Up to 40% develop PID 3-5 fold increased risk of HIV transmission

Screening: yearly or q6 months if high risk

Cervicitis: Gonorrhea

Symptoms:

Diagnosis:

Yellow or bloody vaginal discharge Dysuria, dysmenorrhea Up to 50% are asymptomatic Preferred: NAAT (joint chlamydia testing) Culture slightly more sensitive Ceftriaxone 250mg IM (single dose) Should also treat for chlamydia Reportable; partner needs to be treated If left untreated:

Treatment:

Screening: usually done with chlamydia

Up to 10-20% develop PID Chronic pelvic pain

CORE study objectives for Cervicitis

Know that gonorrhea and Chlamydial infections produce cervicitis, not vaginitis, in adolescents. Know the current recommended treatment regimens for a Chlamydial infection. Know that the most common microbiology of PID: N. gonorrhea and C. trachomatis, but anaerobes and GNR may also be implicated. Recognize the association in girls of perihepatitis with both gonococcal and Chlamydial infections.