Safe practices, testing lower risks of infectious chlamydia
Could A Heavy Discharge Mean I Have An STD? - Independent.ie
Dr Derek Freedman
Tue 26 Aug 2008 at 13:00QI'm a 24-year-old woman and lately I've noticed a discharge that is heavier than usual. I've had three sexual partners -- I'm worried that it could be something I caught from one of them? Or is this normal?
ADischarge is such a common condition for women. While it occasionally can be the sign of an infection, it is usually just a sign of a simple vaginitis, which is not sexually transmitted. The important infections, such as Gonorrhoea or Chlamydia, are usually silent in women and do not cause any noticeable discharge or secretion.
Discharge can even be a normal variant. Girls have no way of comparing what is normal and what is not. The normal discharge varies with the monthly cycle, hormone treatment and medical conditions.
Vaginitis can be caused by Candida, which gives an itchy discharge, or by anaerobes, which cause a watery, whiffy discharge. Sometimes you can have both.
To find out which condition you have and to get the best treatment, you need to see a doctor and have the secretions examined under a microscope.
QI have some spots on my vulva and I am worried they may be Herpes. What should I do?
AThere are many causes of spots on the genital area. Genital Herpes is just one of them. If you are worried, it is essential to have a careful examination. Herpes sores usually start as blisters, become sores and then crust over. They tend to be painful. But there are several other conditions than can look the same.
To make a precise diagnosis, it is essential to take a culture from the lesion and grow the virus. You can only do this if the spot is at an early stage and moist. If you put on any cream, or take anti-viral medication before you are tested, the culture test will not work.
People are often very frightened by Herpes. Don't be! It is simply a cold sore in a less socially obvious location. The worst damage that the virus can do to you, if you allow it, is to make you feel soiled or unattractive, and to set back your social development. The best way to control that is to be open and talk easily about it.
The Importance Of Routine STD Screening - Clinical Advisor
Just three months after having a normal physical examination, a young woman complains of lower-abdominal pain. What did her clinician miss?
This is the second of a three-part series on sexually transmitted diseases. Part 3 will appear in the July issue.
A 19-year-old woman requests a physical exam required for her application as a camp counselor. She has no significant medical history, takes no medications, and has no known drug allergies. Immunizations are up to date. Her menses started at age 14 and are regular, with the last menstrual period (LMP) two weeks earlier. Findings on her physical exam are normal.
Three months later, she presents with a complaint of intermittent lower-abdominal pain during the previous week. The pain is not related to food intake, and she has no nausea, vomiting, diarrhea, fever, or chills. She reports no vaginal discharge or dyspareunia, and she has no dysuria, frequency, or urgency. Her LMP was a week before. She has one current boyfriend.
Gather additional historyA sexual history should be part of the usual workup, particularly in this scenario. The patient, who has been sexually active for one year, has no history of sexually transmitted disease (STD). She has been with her current boyfriend for two months (before him, she had two other partners). She engages in vaginal and occasional oral sex. With her current partner, she uses condoms most of the time for vaginal sex but not for oral sex. He has no symptoms. Her last sexual encounter occurred approximately two weeks ago.
On examination, her temperature is 98.4°F, pulse 70 beats per minute, BP 110/74 mm Hg; the patient is in no distress.
Abdominal examination reveals normal bowel sounds and liver and spleen of normal size. There is no abdominal tenderness, costovertebral angle tenderness, rigidity, or rebound. The patient has normal external genitalia without any lesions and scant vaginal discharge. There is no cervical discharge or friability. On bimanual exam, cervical motion tenderness is found. The uterus appears of normal size and is slightly tender. The adnexa are within normal limits and nontender, with no masses palpable.
Search for a probable diagnosisThere is a broad differential for lower-abdominal pain in a young woman, but this patient's symptoms are most consistent with pelvic inflammatory disease (PID), given the cervical motion and uterine tenderness. Women with PID can experience lower-abdominal pain, cramping, dyspareunia, postcoital bleeding, vaginal discharge, and/or dysuria. The clinical presentation varies in intensity and may be minimal.1 Many cases of acute salpingitis cause no symptoms.
Because PID is difficult to accurately diagnose in an office setting without ultrasound or laparoscopy, the CDC has developed minimum criteria: uterine tenderness or adnexal tenderness or cervical motion tenderness. The criteria are useful in sexually active young women and other women at risk for STDs. The clinical diagnosis of PID is imprecise, but the potential long-term repercussions of missing a case are thought to outweigh the risk of overdiagnosis.2
Other possible diagnoses include ectopic pregnancy, ovarian cyst, appendicitis, UTI, and mittelschmerz. These diagnoses are unlikely. Even less likely are more chronic causes of lower-abdominal pain, such as endometriosis, inflammatory bowel disease, and other GI conditions.
Clarify the diagnosis with laboratory testingEctopic pregnancy can present with similar symptoms, and even though this patient had a period since her last sexual encounter, a urine pregnancy test should be done to rule out early pregnancy with vaginal spotting.
A wet mount of vaginal discharge to assess for WBCs and evidence of bacterial vaginosis (BV) should be done. The presence of abundant WBCs on saline microscopy of vaginal discharge provides additional support for a diagnosis of PID.2,3 BV, which has been linked to PID,2,4 is diagnosed when any three of the following are found: homogeneous adherent discharge, clue cells on microscopy, vaginal fluid pH >4.5, and positive whiff test (amine/fishy odor of vaginal fluid alone or with the addition of 10% KOH solution).
Other criteria that enhance the specificity of a clinical PID diagnosis are oral temperature >101ºF (>38.3°C), abnormal cervical or vaginal mucopurulent discharge, elevated erythrocyte sedimentation rate, elevated C-reactive protein, and laboratory documentation of chlamydia or gonorrhea infection.
Nucleic acid amplification tests (NAATs) for cervical chlamydia and gonorrhea should be performed. While Chlamydia trachomatis and Neisseria gonorrhoeae are frequent PID pathogens, negative screening results do not rule out upper-tract infection. Some experts would recommend screening for syphilis and HIV because having one STD puts a woman at risk for others.
In this case, the wet mount reveals numerous WBCs. Vaginal pH is normal (4.0). No trichomonads, clue cells, hyphae, or yeast cells are seen. The whiff test is negative, as is the pregnancy test. NAATs are sent for gonorrhea and chlamydia, with results pending. HIV and syphilis testing is also performed.
Presumptive treatment firstEmpiric outpatient treatment for PID is warranted.5 Since the etiology of PID is polymicrobial, broad-spectrum regimens are utilized.2 Inpatient treatment is recommended in any of the following scenarios: inability to rule out surgical emergencies, such as appendicitis; pregnancy; failure to respond to outpatient oral therapy; inability to tolerate outpatient oral regimen; severe illness, nausea and vomiting, or high fever; or tubo-ovarian abscess.
The patient is treated with ceftriaxone 250 mg IM and doxycycline 100 mg orally twice a day for 14 days. Fluoroquinolone regimens should be used with caution in areas with high rates of drug-resistant gonorrhea (e.G., California and Hawaii). She is counseled about PID and how to reduce her risk for re-infection as well as other STDs. In addition, she is instructed to maintain abstinence until completion of therapy and to avoid douching. Birth-control options are also discussed.
Don't forget to treat the partner(s)All sexual partners during the 60 days prior to the appearance of symptoms should be evaluated and treated. Empiric treatment for both chlamydia and gonorrhea are recommended regardless of the patient's test results.
Ensure close follow-upAt follow-up three days later, the patient is showing improvement. The lower-abdominal pain has almost resolved. Her partner has been tested and started on treatment. The woman's lab results are positive for chlamydia and negative for gonorrhea. All other tests are negative.
Women recently diagnosed with chlamydia are at high risk for reinfection.2 Retest the patient for chlamydia in three months.
Prevent PID in the next patientThe patient's exam for her summer job was a missed opportunity to assess STD risk and to perform chlamydia and gonorrhea screening. The U.S. Preventive Services Task Force, CDC, and other medical associations recommend routine chlamydia screening for women 25 years and younger.6 Studies show chlamydia screening reduces the incidence of PID.7 Gonorrhea screening is similarly recommended for women 25 years and younger.8
For more information about STDs, see the resources page of the California STD/HIV Prevention Training Center at www.Stdhivtraining.Org. For further information about STD training, visit www.Stdhivpreventiontraining, the Web site of the National Network of STD/HIV Prevention Training Centers (NNPTC).
Dr. Adler, a family physician by training, is a clinical instructor at the California STD/HIV Prevention Training Center in Oakland. She wishes to credit her colleagues Heidi Bauer, MD, MS, MPH, Helene Calvet, MD, and Linda Creegan, MS, FNP, for their assistance.References
1. Crossman SH. The challenge of pelvic inflammatory disease. Am Fam Physician. 2006;73:859-864.
2. Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2006. MMWR. 2006;55(RR-11):1-94. Available at: www.Cdc.Gov/std/treatment/default.Htm. Accessed May 14, 2007.
3. Yudin MH, Hillier SL, Wiesenfeld HC, et al. Vaginal polymorphonuclear leukocytes and bacterial vaginosis as markers for histologic endometritis among women without symptoms of pelvic inflammatory disease. Am J Obstet Gynecol. 2003;188:318-323.
4. Ness RB, Hillier SL, Kip KE, et al. Bacterial vaginosis and risk of pelvic inflammatory disease. Obstet Gynecol. 2004;104:761-769.
5. Ness RB, Soper DE, Holley RL, et al. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial. Am J Obstet Gynecol. 2002;186:929-937.
6. U.S. Preventive Services Task Force. Screening for chlamydial infection: recommendations and rationale. Am J Prev Med. 2001;20(3 Suppl):90-94. Available at www.Ahrq.Gov/clinic/ajpmsuppl/chlarr.Pdf. Accessed May 14, 2007.
7. Scholes D, Stergachis A, Heidrich FE, et al. Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection. N Engl J Med. 1996;334:1362-1366.
8. U.S. Preventive Services Task Force. Screening for gonorrhea: recommendation statement. Ann Fam Med. 2005;3:263-267. Available at www.Ahrq.Gov/clinic/uspstf05/gonorrhea/gonrs.Htm. Accessed May 14, 2007.
Is This More Than Just A Yeast Infection? - Clinical Advisor
Two lesions on the patient's labia arouse suspicion of a second problem. An STD expert tracks down a diagnosis other clinicians might miss.
This is the third of a three-part series on sexually transmitted infections. The previous installments appeared in the May and June issues.
A 32-year-old woman presents with complaints of vaginal discharge, discomfort, and itch of two days' duration. In the past year, she has had three yeast infections, which she self-treated, with good response. She reports no other symptoms. Her menses are regular, with the last menstrual period (LMP) two weeks before. She had a normal Pap smear at her annual visit six months ago.
When she was 20, she had chlamydia but has had no other sexually transmitted diseases (STDs). She reports five lifetime sexual partners and has been with her new partner one month. They use condoms "most of the time" for vaginal sex. Her partner is asymptomatic.
Her external genitalia are shown in Figure 1. On speculum examination, the vaginal mucosa is noted to be slightly erythematous and a white cheesy discharge is found. The cervix appears normal, without lesions or discharge. A swab test of the cervix is negative, and no friability is noted. A bimanual exam is normal, with no cervical motion tenderness. The normal-sized uterus is nontender, with no masses, and normal adnexa. There is no inguinal lymphadenopathy.
Q: Is a microscopic assessment of her vaginal discharge necessary to make a diagnosis?Yes. Even though her exam reveals a cheesy white discharge that is the classic presentation of candidiasis, it is important to perform stat laboratory tests to make an accurate diagnosis. Trichomoniasis and bacterial vaginosis (BV) also present with vaginal discharge, and the sensitivity and specificity of symptoms plus exam findings is not adequate for diagnosis.1 Another consideration is that co-infections can occur. A complete evaluation of vaginal discharge includes pH, amine whiff test (positive in BV and often in trichomoniasis), normal saline, and KOH microscopy.
The lab results for the vaginal discharge show the following: The pH is 4.0, the amine whiff test is negative, the normal saline and KOH microscopy reveal numerous budding yeast and pseudohyphae. Few WBCs are present. No clue cells or trichomonads are seen.
Q: What is the diagnosis?She has candidiasis. Typical symptoms of candidiasis are thick, white, curdlike discharge with vulvar pruritus, irritation, and occasionally dysuria. Vaginal discharge assessment findings of candidiasis include normal pH (<4.5) with pseudohyphae and/or budding yeast on KOH or saline wet mount. WBCs are also often found on microscopy.
Q: Is there anything on examination that makes you suspicious of another problem?While the patient does have candidiasis, a careful inspection reveals a small crusted lesion on the left labia majora and a small shallow ulcer on the left labia minora (Figure 1). Vulvar signs of candidiasis include edema and/or erythema, fissures, excoriations and/or occasionally erythematous "satellite" papule lesions. Diffuse vaginal erosions can also occur in women with candidiasis. This patient's findings are not typical of candidal infection and should raise concern for an unrelated etiology.
Q: What is your differential of these lesions?It is likely that both lesions were ulcers, one of which appears partially healed. The differential for genital ulcer disease (GUD) is broad and includes STD and non-STD etiologies. Genital herpes and syphilis are more common STD etiologies of GUD in the United States; chancroid, lymphogranuloma venereum, granuloma inguinale, and acute HIV infection are less common causes. Non-STD causes include psoriasis, trauma, Reiter's syndrome, Behçet's syndrome, fixed drug eruption, and scabies.
Q: What laboratory testing should be done?Direct virologic testing of the open lesion with a herpes viral culture is recommended. Herpes culture testing has variable sensitivity and is much less sensitive in healing and recurrent lesions.
A more sensitive polymerase chain reaction test can also be used, but it is a costly method of virus detection and is not FDA-approved for genital specimens.2Since there are limitations to direct virologic testing, type-specific glycoprotein G (gG) serologic testing for HSV-2 is also recommended.3 There are several FDA-cleared gG type-specific test options: HerpesSelect-2 enzyme-linked immunosorbent assay (ELISA) Immunoglobulin G (IgG); and HerpesSelect-2 Immunoblot IgG, both from Focus Technologies; HSV-2 ELISA, from Trinity Biotech; and two point-of-care assays, Biokit HSV-2 from Biokit and SureVue HSV-2 from Fisher Scientific. These tests all have high specificity (≥96%), while the sensitivities vary from 80% to 98%, with false-negative results more likely in early primary infection.2
Older assays that aren't able to accurately distinguish between HSV-1 and HSV-2 are not recommended, nor is the type-specific HSV-1 serologic test, because of its limited utility. Orolabial herpes caused by HSV-1 is very common; seroprevalence of HSV-1 is estimated at 58% among 14- to 49-year-olds.4 Most patients with a positive HSV-1 serology have oral infection, which can be symptomatic or asymptomatic. 2
Testing for syphilis with a nontreponemal test (RPR or VDRL) is also recommended in the evaluation of GUD. Biopsy is not part of the initial workup but is an option if the initial workup does not reveal an etiology.
Q: Should she have any other laboratory testing?Yes. Nucleic acid amplification testing for gonorrhea and chlamydia is advised. Chlamydia and gonorrhea screening is recommended in young women (younger than 25 years) and in older women with risk factors.5,6 This patient's history of a new partner along with her presentation of a possible new STD diagnosis indicate her risk for chlamydia and gonorrhea. HIV testing also should be offered.
Q: What treatment should she receive today, before the test results are in?Treatment for candidiasis includes one of many intravaginal options or oral therapy with fluconazole 150 mg in a single dose (see the CDC's STD treatment guidelines for a list of all possible regimens).2 (In this patient, the clotrimazole 100-mg vaginal tablet for seven days is prescribed.) Empiric treatment for herpes could be considered if strongly desired by the patient but is not recommended since the presentation is atypical and the symptoms are mild.
Empiric treatment for herpes would be recommended if the clinical presentation was classic for herpes with vesicles and ulcers.
Empiric treatment for syphilis is not recommended since the lesions are not classic syphilitic-appearing, and based on current epidemiology (men who have sex with men account for 60% of new syphilis cases), the woman is at low risk for syphilis.7
A few days later, the lab results arrive. The patient has a positive HSV-2 culture and positive HSV-2 serology. The chlamydia, gonorrhea, syphilis, and HIV tests are all negative.
Q: What is your diagnosis?The positive HSV-2 culture along with a positive HSV-2 serology are evidence of recurrent herpes. The time frame for when she acquired herpes cannot be determined. Negative HSV-2 serology and a positive HSV-2 culture would be evidence of a new infection.
Q: Now that you have a diagnosis how should you counsel her about herpes?A complete discussion regarding HSV-2 should be initiated. Information regarding HSV-2 ought to include the following: natural history of disease with possibility of future recurrent episodes; medication options (episodic therapy and suppressive therapy); transmission risks (asymptomatic shedding, abstinence during outbreaks, condom effectiveness, suppressive therapy to reduce transmission); and risk of neonatal herpes.
New research demonstrates that daily suppressive therapy can reduce transmission by nearly 50%.8 The patient should be counseled about informing current and future partners as to her HSV-2 status. Since transmission is a significant concern, the option of type-specific HSV-2 testing of her partner should be discussed. If her partner is positive, transmission of HSV-2 is not a concern. If he is negative, methods to reduce transmission, such as abstinence during outbreaks, condoms, and consideration of suppressive therapy are recommended.
This case demonstrates that herpes can present with minimal symptoms and that the diagnosis may be missed, particularly when there is coexisting vaginal infection. Clinicians may overlook small external genitalia lesions if the patient does not point them out. Manifestations of recurrent herpes in women can range from more pronounced vesicular lesions or ulcers to atypical presentations with minimal symptoms, such as vaginal pruritus or slight vaginal erythema. A history of recurrent vaginal symptoms (such as this patient's self-diagnosed yeast infections) should raise suspicion for atypical herpes symptoms.For more information about herpes, visit the National Network of Prevention Training Centers (NNPTC) STD Case Series online(www.Stdhivtraining.Org). To find out about STD training, go to the NNPTC Web site (www.Depts.Washington.Edu/nnptc).
Dr. Adler, a family physician by training, is clinical instructor at the California STD/HIV Prevention Training Center in Oakland. She wishes to credit her colleagues Heidi Bauer, MD, MS, MPH, Helene Calvet, MD, and Linda Creegan, MS, FNP, for their assistance.References
1. Eckert LO. Clinical practice. Acute vulvovaginitis. N Engl J Med. 2006;355: 1244-1252.
2. Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2006. MMWR. 2006;55 (No. RR-11):16-20,54-56. Available at www.Cdc.Gov/std/treatment/default.Htm. Accessed May 24, 2007.
3. Guerry SL, Bauer HM, Klausner JD, et al. Recommendations for the selective use of herpes simplex virus type 2 serological tests. Clin Infect Dis. 2005;40:38-45.
4. Xu F, Sternberg MR, Kottiri BJ, et al. Trends in herpes simplex virus types 1 and 2 seroprevalence in the United States. JAMA. 2006;296:964-973.
5. U.S. Preventive Services Task Force. Screening for chlamydial infection: recommendations and rationale. Am J Prev Med. 2001;20(Suppl 3):90-93. Available at www.Ahrq.Gov/clinic/ajpmsuppl/chlarr.Pdf. Accessed May 24, 2007.
6. U.S. Preventive Services Task Force. Screening for gonorrhea: recommendation statement. Ann Fam Med. 2005;3:263-267. Available at http://www.Ahrq.Gov/clinic/uspstf05/gonorrhea/gonrs.Htm. Accessed May 24, 2007.
7. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2004. Available at: www.Cdc.Gov/std/stats/04pdf/2004SurveillanceAll.Pdf. Accessed May 24, 2007.
8. Corey L, Wald A, Patel R, et al. Once-daily valacyclovir to reduce the risk of transmission of genital herpes. N Engl J Med. 2004;350:11-20.
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