VISUAL INSPECTION WITH ACETIC

ACID (VIA)
 VISUAL INSPECTION WITH ACETIC ACID (VIA)
• Cervical cancer screening test
• Rationale: application of 3%- 5% dilute acetic acid turns abnormal tissue
(areas of nuclear density) to temporarily become white
• Methods:
• (1) Direct Visual Inspection (DVI)
• (2) Visual Inspection with Magnification (VIAM)
Colposcope
• Low power binocular
microscope placed just
outside the vagina after
speculum has been inserted
• Brings to view the cervix
STEPS
• Apply speculum
• Remove obscuring mucus with swab
• Visualize for presence of any cervical lesions
• Apply 3% - 5% dilute acetic acid to cervix
• After 30 secs, visualize and examine again
• Visualize transformation zone in its entirety
Source: http://screening.iarc.fr/doc/RH_via_evidence.pdf
TRICHOMONAS
TRICHOMONIASIS
Etiologic agent: Trichomonas vaginalis

• Anaerobic sexually-transmitted protozoan

parasite
• Pyriform shape, 20 um long and 10 um wide
• Flagellated
• 4 free flagella arising from single stalk
• 1 flagellum forming an undulating
membrane
• Exists as trophozoite only (no cyst stage)
SIGNS AND SYMPTOMS
• Incubation: 5 – 28 days
• Usually limited to vulva, vagina, and cervix
• Mucosal surfaces may be tender, inflamed, or
eroded
• Strawberry cervix: punctate hemorrhages in
cervix and vagina
• Vulval pruritus and burning may occur
• Dysuria, urinary frequency, and dyspareunia can
be experienced
• Profuse, frothy, malodorous yellow or cream-
colored discharge
DIAGNOSIS - NUCLEIC ACID AMPLIFICATION TEST
(NAATS)
• Most sensitive test for T. Vaginalis
• Gold standard, recommended by CDC
• Vaginal swabs from women, first – catch urine for men
• PCR, transcription – mediated amplification
DIAGNOSIS – WET MOUNT
• Sample is placed on a slide and examined under a microscope
for the presence of parasite
• Practical, rapid but low sensitivity (esp. for men)
• CDC recommends following up with a more sensitive test
DIAGNOSIS - CULTURE
• Very sensitive and specific
• Requires up to 7 days
• Standard broth is Diamond’s TYI medium in glass
tubes
TREATMENT
RECOMMENDED REGIMEN
• Metronidazole 2 g orally in a single dose or
• Tinidazole 2 g orally in a single dose

ALTERNATIVE REGIMEN
• Metronidazole 500 mg orally twice a day for 7 days
OTHER MANAGEMENT CONSIDERATIONS

• Alcohol consumption should be avoided during treatment with

nitroimidazoles (disulfiram-like reaction)
• Abstinence from sex
• Sex partners should also be referred for presumptive therapy
BACTERIAL VAGINOSIS
BACTERIAL VAGINOSIS
• Maldistribution of normal vaginal flora
• Numbers of lactobacilli are decreased
• Overrepresentation of anaerobic bacteria that include Gardnerella vaginalis,
Mobiluncus, and some Bacteroides species.
• Vitamin D deficiency; a risk factor for vaginosis in pregnancy
• Douching, multiple partners, young age, smoking, and black race are associated
with vaginosis in both pregnant and non-pregnant
• In pregnancy, it is associated with preterm birth, early and late miscarriage, low
birthweight, and increased neonatal morbidity
SIGNS AND SYMPTOMS

• Vaginal odor; often recognized only after sexual intercourse

• Vulvar irritation
• Dysuria or dyspareunia
• Gray, thin, and homogeneous vaginal discharge, which adheres to the vaginal
mucosa
• Some cases, with evidence of cervicitis
DIAGNOSIS
3 out of 4 Amsel criteria:
 demonstration of clue cells on
a saline smear
 pH greater than 4.5
 Characteristic thin, gray, and
homogenous discharge
 Positive whiff test
TREATMENT
• It is reserved for symptomatic women, complaining of fishy-
smelling discharge.
• Metronidazole, 500 mg twice daily orally for 7 days; 250 mg
three times daily orally for 7 days
• Clindamycin 300 mg orally twice daily for 7 days.
CANDIDIASIS
CANDIDIASIS
• Candida albicans or other Candida species can be identified by
culture from the vagina during pregnancy in approximately 25
percent of women.
• Asymptomatic colonization requires no treatment.
• Can cause an extremely profuse, irritating discharge associated
with a pruritic, tender, edematous vulva.
SIGNS AND SYMPTOMS
• Vulvovaginal Pruritisaginal itching
• Erythema and swelling
• Pain
• Pain during sexual intercourse
• Dysuria
• Vaginal discharge characterized as thin, but may contain whitish
“curds”
• Vaginal ulcerations (severe)
DIAGNOSIS
• Visualization of pseudohyphae or
filamentous fungal hyphae on wet mount
(Saline 10% KOH) or in PAP Smear
• Tissue Gram’s stain
• Periodic acid-Schiff stain
• Methenamine silver stain in the presence
of inflammation
Fig. 1 Long threadlike, filamentous, septated, spore
forming, in aggregates
TREATMENT
Effective treatment is given with a number of azole creams applied for 7 days
 2-percent butoconazole
 1-percent clotrimazole
 2-percent miconazole
 0.4- or 0.8-percent terconazole
Topical treatment is recommended
Oral azoles are generally considered safe (Pitsouni, 2008).

In some women, infection is likely to recur and require repeated treatment during
pregnancy

In these cases, symptomatic infection usually subsides after pregnancy.

GONORRHEA
GONORRHEA
• Caused by Neisseria gonorrhoeae
• Transmitted thru sexual contact with the penis, vagina, mouth, or anus of an infected
partner, and perinatally from mother to baby during childbirth
SIGNS AND SYMPTOMS
In MEN In WOMEN
Mostly asymptomatic Mostly asymptomatic
Dysuria Dysuria
Yellow or green urethral discharge (1-14 Increased vaginal discharge (watery,
days after infection) creamy, slightly green)
Testicular or scrotal pain Vaginal bleeding in between periods
At risk for developing serious
complications (Pelvic Inflammatory
Disease)
DIAGNOSIS/TESTING
• Any sexually active person especially one with genital symptoms, anyone with a
sexual partner who has been recently diagnosed with STD
• Pharyngeal, rectal, endocervical or vaginal specimen using nucleic acid
amplification testing (NAAT)
• Gonorrhea culture (Chocolate agar) of pharyngeal, rectal, endocervical or urethral
swab specimens
• Test for other sexually transmitted diseases
TREATMENT
Uncomplicated infections can be treated with a single dose of:
-Ceftriaxone 250 mg IM (if unavailable, Cefixime 400 mg PO) with Azithromycin 1 g
PO

If cephalosporin allergic, alternant dual therapy with single doses of:

-Gemifloxacin 320 mg PO with Azithromycin 2 g PO

If azithromycin allergic, Doxycyline 100 mg PO BID for 7 days can be used in place
of azithromycin in combination with a cephalosporin
CHLAMYDIA
CHLAMYDIA
• Chlamydia is a bacterial infection caused by Chlamydia trachomatis. Genital
tract infections are usually caused by Serovars D-K.

• Transmission is usually caused by sexual contact via oral, anal, or vaginal

intercourse.
SIGNS AND SYMPTOMS
Usually asymptomatic but could present with:

-Dysuria
-Vaginal discharge
-Abnormal vaginal bleeding
-Dyspareunia
-Proctitis, rectal discharge, or both
-Fever
DIAGNOSIS
Whom to test
 Symptomatic and at-risk patients
 Patients with persistent symptoms
 Recurrence of symtpoms

Detection methods
 NAAT, culture, antigen detection, serology

Choice of specimen
 Cervical and vaginal swabs
 Urine
TREATMENT
Uncomplicated chlamydial infection
 7-day course of tetracycline (500mg 4x a day), doxycycline (100mg BID),
erythromycin (500mg 4x daily)
 7-day course of fluoroquinolone (ofloxacin 300mg BID or levofloxacin
500mg)
 Single dose of azithromycin 1g
TREATMENT
Pregnant women
 Amoxicillin 500mg TID for 7 days
 Single dose of azithromycin 1g (not FDA approved)

Complicated chlamydial infection

 2 week course treatment (eg PID)
 3 week course treatment of doxycycline (100mg BID) or erythromycin base (500mg 4x
daily) for LGV

Treat sexual partners

REFERENCES
• William’s Obstetrics 24th edition
• Centers for Disease Control and Prevention. Trichomoniasis—2015 STD Treatment Guidelines.
http://www.cdc.gov/std/tg2015/trichomoniasis.htm. June 4, 2015. Accessed September 2, 2017.
• Garber, G. E. (2005). The laboratory diagnosis of Trichomonas vaginalis. Retrieved September 02, 2017, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2095007/
• Centers for Disease Control and Prevention. Detailed STD Facts - Gonorrhea. https://www.cdc.gov/std/gonorrhea/stdfact-
gonorrhea-detailed.htm. October 28, 2016. Accessed September 2, 2017.