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GY30 Gynaecology Toronto Notes 2023

provider administered

cryotherapy with liquid nitrogen: repeat ql-2 wk

podophyllin resin in tincture of benzoin: weekly

trichloroacetic acid (TCA) (80-90%) or bichloroacetic acid weekly x 4-6 wk;safe in pregnancy

surgical removal/laser

•intraepithelial lesions and cancers (See Gynaecological Oncology, GY42)

Prevention

•vaccination:Gardasil‘9, Gardasil",Cervarix* (see Table 28, GY49)

•condoms may not fully protect (areas not covered, must be used every time throughout entire sexual

act)

HERPES SIMPLEX VIRUS OF VULVA

Etiology

. 90% are HSV-2, 10% are HSV-1

Clinical Features

• may be asymptomatic

• initial symptoms: average incubation is 4 d after exposure (range 2-12 d)

• prodromal symptoms: tingling, burning, and pruritus

• multiple, painful,shallow ulcerations with small vesicles appear 7-10 d after Initial infection (absent in

many infected persons);lesions are infectious

• inguinal lymphadenopathy, malaise, and fever often with first infection

• dysuria and urinary retention if urethral mucosa affected

• recurrent infections: common but less severe,lessfrequent, and shorter in duration (usually only

HSV-2)

Investigations

• viral culture preferred in patients with ulcer present; however, decreased sensitivity aslesions heal

• HSVDNAPCR

• cytologic smear (Tzanck smear) shows multinucleated giant cells, limited use due to low sensitivity

and specificity

• type specific serologic testsfor antibodiesto HSV-1 and HSV-2 (not routinely available in Canada)

Treatment

• first episode:acyclovir 200 mg PO five times daily x 7-10 d,famciclovir 250 mg PO T1D x 7-10 d, or

valacydovir 1 g PO BID x 7-10 d

• recurrent episode: acyclovir 400 mg PO TTD x 5 d,famciclovir 125 mg PO BID x 5 d, or valacydovir I g

PO once daily x 5 d

• daily suppressive therapy

consider for >6 recurrences per yr or recurrence every 2 mo

• acyclovir 400 mg PO BID, famciclovir 250 mg PO BID, valacydovir 500 mg PO once daily,or

valacydovir 1 g PO once daily

• severe disease: IV acyclovir 5-10 mg/kg IV q8 h x 2-7 d or until clinical improvement observed

followed by oral antiviral therapy to complete 10 d of total therapy

• education regarding transmission: avoid sexual contact from onset of prodrome until lesions have

cleared, use barrier contraception

SYPHILIS

Etiology

• Treponema pallidum

Epidemiology of Genital Ulcere Classifications

• primary syphilis

• 3-4 wk after exposure (median incubation 21 d)

painless chancre on vulva, vagina,or cervix

painless inguinal lymphadenopathy

• serological tests usually negative, local infection only

• secondary syphilis (can resolve spontaneously)

• 2-6 mo after initial infection, in 25% of patients with untreated primary syphilis

• nonspecific symptoms: malaise, anorexia, headache, and diffuse lymphadenopathy

• generalized maculopapular rash: palms,soles, trunk, and limbs

• condylomata lata:anogenital, broad-based, fleshy,grey lesions

serological tests usually positive

hills

inical manifestations; detected by serology only

HSV 7080%

r Syphilis

Chancroid

IHaemophilus ducreyi)

5%

<1%

ri

LJ

• latentsyp

no cli +

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GY31 Gynaecology Toronto Notes 2023

•tertiary syphilis

• may involve any organ system

• neurological: tabes dorsalis, and general paresis

cardiovascular:aortic aneurysm and dilated aortic root

vulvar gumma:nodules that enlarge, ulcerate, and become necrotic (rare)

•congenitalsyphilis

« may cause fetal anomalies,stillbirths,or neonatal death

Investigations

.aspiration of ulcerserum or node

•dark field microscopy (most sensitive and specific diagnostic test for syphilis):look for spirochetes

•non-treponemal screening tests(VDKL. RPK); non-reactive after treatment, can be positive with other

conditions

•specific anti

-treponemal antibody tests (FT'A-ABS,MHA-TF, I F-PA)

• confirmatory tests; remain reactive for life (even after adequate treatment)

Treatment

•reportable disease, partnersshould be referred for treatment

•treatment of primary',secondary,latentsyphilis of <1 vr duration

benzathine penicillin G 2.4 million units1M single dose

•treatment of latentsyphilis of >1 yr duration

benzathine penicillin G 2.4 million units 1M ql wk x 3 wk

•treatment of neurosyphilis

• IV aqueous penicillin G 3-4 million units q4 h x 10-14 d

•screening

high-risk groups (partner with syphilis, HIV-infected individuals, high risk sexual behaviour,

history of incarceration)

in pregnancy (see Obstetrics. Infections During Pregnancy, OB3I )

Complications

•if untreated, 25-40% will experience late complications

HIV

•see Infectious Diseases,1D27

Bartholin Gland Abscess

Etiology

• follows the infection of an obstructed Bartholin duct

• most commonly t. coli, polymicrobial,.S'

, aureus, and Group B Strep

Clinical Features

• unilateral swelling and pain in inferior lateral opening of vagina

• sitting and walking may become difficult and/or painful

Treatment

• large mass >3cm

1st or 2nd episode:l&D under local anesthesia with placement of Word catheter (10 French latex

catheter) for 2-3wk

recurrence after two failed attempts with Word catheter: marsupialization in OK

• small mass <3 cm

l&D with Word catheter, sitz baths, warm compresses

• antibiotics:reserved for patients with recurrence, high risk of complicated infection, culture-positive

MKSA,systemic infection

«t> Marina ChnnQ 2QI3y

Figure 14.Bartholin gland abscess

n

L J

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GY32 Gynaecology Toronlo Notes 2023

Pelvic Inflammatory Disease

• up to 20% of all gynaecology-related hospital admissions

• infection of the upper genital tract (above the cervix) including endometrium, fallopian tubes, ovaries,

pelvic peritoneum ± contiguous structuresthat primarily affects young,sexually active women

P!D accounts for up to 20% of all

gynaecological hospital admissions

Etiology

• microbial etiology unknown in most cases, often considered a polymicrobial infection

• causative organisms(in order of frequency)

• C.trachomatis

• N.gonorrhoeas

gonorrhea and chlamydia often co-exist

M.genitalium

• E. coli and colonic anaerobesfound in rare cases of P1D in postmenopausal women

very rare pathogens: M.tuberculosis, H.influenzae, S.pneumoniae,and the agents of

actinomycosis

Risk Factors

• age 15-25 yr

• multiple partners, S'

l

'

l in partner

• previous P1D

• 1UD (extremely rare,occurs within first 3 wk after insertion)

Clinical Features

• wide spectrum of clinical presentation: time course typically acute although many women will have

subdinical HID that does not prompt a patient to present for medical care but severe enough to cause

significant sequelae (fertility issues)

• clinical diagnosis of PID:fever >38.3°C, lower abdominal pain and tenderness, and abnormal

discharge (cervical or vaginal)

• uncommon: N/V, dysuria, and AUB

• chronic disease (often due to chlamydia)

constant pelvic pain

dyspareunia

• palpable mass

very difficult to treat, may require surgery

PID Diagnosis

Minimum diagnostic criteria

. Cervical motion tenderness

• Uterine tenderness

• Adnexal tenderness

Additional diagnostic criteria

• Oral temperature >38.3"C

• Leukocytosis on saline microscopy of

vaginal secretlons/wet mount

. Elevated ESR or CRP

• Laboratory documentation of cervical

infection with N. gonorrhoeas or C

trachomatis

Definitive diagnostic criteria

• Endometrial biopsy with

histopathologic evidence of

endometritis

• Transvaginal sonography or MRI

showing thickened fluid-filled tubes,

free fluid or tubo-ovarian complex

• Gold standard:laparoscopy

demonstrating abnormalities

consistent with PID Investigations

• blood work

p-hCG (must rule out ectopic pregnancy), CBC, blood cultures if suspect septicemia

• urine routine and microscopy (R&M )

• speculum exam, bimanual exam

vaginal swab for Gram stain,C&S

nucleic acid amplification tests (NAAT)for N. gonorrhoeas,C. trachomatis, M.genitalium

HIV testing and serologic testing forsyphilis

• ultrasound

may be normal

free fluid in cul

-de-sac

• pelvic or tubo-ovarian abscess

hydrosalpinx (dilated fallopian tube)

• laparoscopy

only done in patients that have failed outpatient treatment,symptoms not improving after 72 h of

inpatient treatment, or unclear diagnosis

surgery has high specificity but low sensitivity

Treatment

• must treat with polymicrobial coverage

• percutaneous drainage of abscess under U/S guidance

• laparoscopic drainage when no response to treatment,surgical (salpingectomy,TAH/BSO) if failure

• consider removing IUD after a minimum of 24 h of treatment

• reportable disease, treat partners

• consider re-testing for C. trachomatis and N.gonorrhoeas 4-6 wk after treatment if documented

infection n

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GY33 Gynaecology Toronto Notes 2023

Table 16. Inpatient and Outpatient Management Options for Pelvic Inflammatory Disease

Inpatient Outpatient

Indications typical findings

Mild tomoderate illness

Oral antibiotics tolerated

Compliance ensured

follow up within 48- 72 h|to ensure symptoms not

worsening)

Moderate to severe illness

Atypical infection

Adnexal mass,tuboovarian mass,or pelvic abscess

Failed or cannot lolerale oral therapy

Immunocompromised

Pregnant

Adolescent (first episode)

Surgical emergency cannot be excluded (e.g.ovarian

torsion)

PIO issecondary to instrumentation

Cefoxitin 2 gIV q6 li doxycycline 100 mg PO/IVq12 h or 1st line:ceftriaxone 500 mg IM x 1dose •doxycydine

Clindamycin 000 mg IV q8 li •gentamydn 2 mg/kg

IV/IM loading dose then gentamydn1.5 mg/kg q8 h

maintenance dose

Continue IV antibiotics for 24h after symptoms have

improved then doxycycline100 mg P0BID to complete

14 d (add metronidarole 500 mg P0 BIO x 14 d in patients P0 BID x 14 d

with tubo ovarian abscess)

Antibiotic Regimen

100 mg PO BID x 14 d or cefoxitin 2 g IM x 1dose *

probenecid 1g P0 doxycydine100mg P0 8IDi

metronidarole 500 mg P0 BID x 14 d

2nd line: ofloxacin 400 mg P0 8ID x 14 d or levofloxacin

500 mg P0 once daily x14 dimetronidarole 500 mg

Complications of Untreated Pelvic Inflammatory Disease

• chronic pelvic pain

• persistent hydrosalpinx

• abscess, peritonitis

• adhesion formation

• ectopic pregnancy

• infertility

1 episode of P1D: 13% infertility

• 2 episodes of PID: 36% infertility

• bacteremia

• septic arthritis, endocarditis

[ Pelvic Pain J

Acute Chronic

I T

Non

—-gynaecological

Referred pain

Urinary retention

Urethral syndrome

Interstitial cystitis

Gl neoplasm

^

Gynaecological) fNon-gynaecologicall Gynaecological

Chronic PID

Endometriosis

Adcnomyosis

Adhesions

Dysmenorrhea

Ovarian cyst

Pelvic congestion

syndrome

Ovarian remnant

syndrome

Fibroid fraro)

Uterine prolapse

(rare)

Pregnancyrelated

Labour

Ectopic

pregnancy

Spontaneous

abortion

Placental

abruption

i 1

Gl GU

Appendicitis

Mesenteric adenitis

Diverticulitis

UTI (e g cystitis,

pyelonephritis)

Renal colic

IBS

IBD IBO Constipation

Partial bowel

obstruction

Diverticulitis

Horma formation

Nerve entrapment

Scxuat/physical/

psychological

abuse

Depression

Anxiety

Somauzation

t i 1

Adnexal

Mittclschmcrz

Ruptured

ovarian cyst

Ruptured ectopic

pregnancy

Hemorrhage into

cyst/nooplasm

Ovarian/tubal

torsion

Uterina

Fibroid

degeneration

Torsion of

pedunculated

fibroid

Pyomotra/

hematometra

Infectious

Acute PID

Endometritis

Figure 15. Approach to pelvic pain

Toxic Shock Syndrome (TSS)

•see Infectious Diseases, 1D22

•Staphylococcal toxic shock syndrome (TSS) is a clinical illness characterized by rapid onset of fever,

rash, hypotension,and multiorgan system involvement

Risk Factors

•menstrual TSS

significantly decreased as a result of the withdrawal of highly-absorbent tampons and

polyacrvlate rayon-containing productsfrom the market; however, tampon use remains a risk

factor for TSS (high absorbency, tampons used continuously for more days of their cycle, and

keeping a single tampon in place for a longer period of time)

r n

L J Toxic Shock Syndrome

Multiple organ system failure due to

S. aureus exotoxin (rare condition)

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GYM Gynaecology Toronto Notes 2023

•non-menstrual TSS (gynaecologic)

diaphragm, cervical cap, or sponge use (prolonged use, i.e. >24 h)

surgical and postpartum wound infections, mastitis,sinusitis,osteomyelitis,arthritis, burns,

cutaneous lesions,etc.

Clinical Features

•sudden high fever/chills

•sore throat, headache,and diarrhea

•macular erythroderma followed by desquamation 1-2 wk later

•signs of multisystem organ failure

•refractory hypotension

Treatment

•treatment of shock

•remove potential sources of infection (foreign objects)

•surgical debridement (if warranted)

•adequate hydration

•empiric antibiotic therapy with vancomycin (load 20-35 mg/kg and maintenance 15-20 mg/kg q8-12

h) t clindamycin 900 mg IV q8 h + piperacillin-ta /.obactam 4.5 g IV q6 h

•continue combination therapy until patient is hemodynamically stable for at least 48-72 h

Surgical Infections

Postoperative Infections in Gynaecological Surgery

• pelvic cellulitis

common post hysterectomy, affects vaginal vault

* erythema, induration, tenderness, and discharge involving vaginal cuff

if fever and leukocytosis,treat with broad-spectrum ABx (i.e. clindamycin and gentamicin)

drain if excessive purulence or large mass

• can result in intra-abdominal and pelvic abscess

• see General and Thoracic Surgery, Postoperative Fever,6S8

Sexual Abuse

• see Emergency Medicine,ER27 and Family Medicine, F

'