{"id":418,"date":"2020-08-13T20:35:20","date_gmt":"2020-08-13T20:35:20","guid":{"rendered":"https:\/\/brooksidepress.org\/basic_obgyn\/?page_id=418"},"modified":"2020-08-13T20:35:20","modified_gmt":"2020-08-13T20:35:20","slug":"infectious-disease-and-trauma-of-the-genital-tract","status":"publish","type":"page","link":"https:\/\/brooksidepress.org\/pa_obgyn\/advanced-training\/infectious-disease-and-trauma-of-the-genital-tract\/","title":{"rendered":"Infectious Disease and Trauma"},"content":{"rendered":"<p><iframe loading=\"lazy\" src=\"https:\/\/www.youtube.com\/embed\/50S-cLyGttM\" width=\"560\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>Duration 10:17<\/p>\n<input type='hidden' bg_collapse_expand='69e9b57bac8210004799568' value='69e9b57bac8210004799568'><input type='hidden' id='bg-show-more-text-69e9b57bac8210004799568' value='Show Teaching Script'><input type='hidden' id='bg-show-less-text-69e9b57bac8210004799568' value='Hide Teaching Script'><button id='bg-showmore-action-69e9b57bac8210004799568' class='bg-showmore-plg-button bg-blue-button  '   style=\" color:#ffffff;\">Show Teaching Script<\/button><div id='bg-showmore-hidden-69e9b57bac8210004799568' ><\/p>\n<p><a href=\"https:\/\/21stcenturymeded.com\/wp-content\/uploads\/2019\/06\/Teaching-Script-Sexually-transmitted-infections_Page_1.jpg\" target=\"_blank\" rel=\"noopener\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-large wp-image-2440\" src=\"https:\/\/21stcenturymeded.com\/wp-content\/uploads\/2019\/06\/Teaching-Script-Sexually-transmitted-infections_Page_1-791x1024.jpg\" alt=\"\" width=\"525\" height=\"680\" title=\"\"><\/a><\/p>\n<p><a href=\"https:\/\/21stcenturymeded.com\/wp-content\/uploads\/2019\/06\/Teaching-Script-Sexually-transmitted-infections_Page_2.jpg\" target=\"_blank\" rel=\"noopener\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-large wp-image-2441\" src=\"https:\/\/21stcenturymeded.com\/wp-content\/uploads\/2019\/06\/Teaching-Script-Sexually-transmitted-infections_Page_2-791x1024.jpg\" alt=\"\" width=\"525\" height=\"680\" title=\"\"><\/a><\/p>\n<p>&nbsp;<\/p>\n<p class=\"p2\">Sexually Transmitted Infections<\/p>\n<p class=\"p3\">Plummer XD, Liang A<\/p>\n<p class=\"p2\"><b>Clinical Case Applicability: <\/b>pelvic inflammatory disease, infertility, chronic pelvic pain<\/p>\n<p class=\"p2\"><b>Learning Objectives: <\/b><\/p>\n<p class=\"p2\">1. Understand the pathophysiology of common STIs<\/p>\n<p class=\"p2\">2. Describe the long-term sequelae of STIs<\/p>\n<p class=\"p2\">3. Understand the mechanism of action for treatment of common STIs<\/p>\n<p class=\"p2\"><b>What is the pathophysiology of infectivity &amp; treatment of these organisms? <\/b><i>(<\/i>HPV: see CIN script)<\/p>\n<p class=\"p2\"><i>HSV (herpes) (figure 1): <\/i><\/p>\n<p class=\"p2\"><i>&#8211; <\/i>Primary infection: entry through mucous membrane -&gt; viral entry into sensory nerves -&gt; retrograde axonal transport to dorsal root ganglion -&gt; lifelong latency<\/p>\n<p class=\"p2\">&#8211; Reactivation: viral particles\/proteins transported anterograde into skin\/mucous membranes -&gt; viral shedding and cell lysis -&gt; vesicles\/ulceration<\/p>\n<p class=\"p2\">&#8211; Treatment: Not curable; Nucleoside analogs (acyclovir) can \u2193 frequency and severity of flares<\/p>\n<p class=\"p2\">&#8211;<b>Acyclovir <\/b>-&gt; converted to acyclovir triphosphate -&gt; acyclovir triphosphate competitively inhibits and inactivates HSV DNA polymerases -&gt; prevents further viral DNA synthesis<\/p>\n<p class=\"p2\"><i>C trachomatis (chlamydia<\/i>) <i>(figure 2): <\/i>Obligate intracellular organism that exists in 2 forms: extracellular infectious elementary bodies (EBs) and intracellular non-infectious reticulate bodies (RBs)<\/p>\n<p class=\"p2\">&#8211; EBs attach and invade vaginal epithelial cells through cell surface receptors -&gt; EBs reorganize into a large RB inside a phagosome that migrates towards the cell nucleus -&gt; RBs replicate via binary fission and forms an inclusion -&gt; inclusion condenses into EBs -&gt; cell lysis releases EBs that infect other cells<\/p>\n<p class=\"p2\">&#8211; Treatment: Curable with a single dose of <b>azithromycin <\/b>-&gt; binds to 50S subunit of bacterial ribosome -&gt; inhibits mRNA translation -&gt; arrests RNA-dependent bacterial protein synthesis -&gt; inhibits bacterial growth<\/p>\n<p class=\"p2\"><i>N gonorrhoeae (gonorrhea)<\/i>: Gram-negative diplococci that are obligate intracellular bacterium<\/p>\n<p class=\"p2\">&#8211; Pili allows <i>N gonorrhoeae <\/i>to adhere to mucosal membrane -&gt; bacteria penetrate mucosal membrane &amp; invade cells<\/p>\n<p class=\"p2\">&#8211; Treatment: Curable with a single dose of <b>ceftriaxone <\/b><span class=\"s2\">\uf0e0<\/span>binds to bacterial transpeptidases <span class=\"s2\">\uf0e0 <\/span>disruption of bacterial cell wall cross-linking <span class=\"s2\">\uf0e0<\/span>damage to cell wall<span class=\"s2\">\uf0e0 <\/span>cell lysis<\/p>\n<p class=\"p2\"><i>T. pallidum (syphilis)<\/i>: Gram negative spirochetes<\/p>\n<p class=\"p2\">&#8211; Outer membrane promotes attachment to mucous membranes -&gt; travels via lymphatic system to regional lymph nodes -&gt; production of hyaluronidase which facilitate perivascular invasion -&gt; disseminated disease<\/p>\n<p class=\"p2\">&#8211; Treatment: Curable in early stages with single dose of intramuscular <b>penicillin <\/b><span class=\"s2\">\uf0e0<\/span>binds bacterial transpeptidases<span class=\"s2\">\uf0e0<\/span>disruption of bacterial cell wall cross-linking<span class=\"s2\">\uf0e0<\/span>damage to cell wall<span class=\"s2\">\uf0e0 <\/span>cell lysis<\/p>\n<p class=\"p2\"><i>T. vaginalis (trichimonas): <\/i>Anaerobic flagellated protozoan<\/p>\n<p class=\"p2\">&#8211; Pathogenesis not well understood: postulated to involve contact-dependent and contact-independent mechanisms<\/p>\n<p class=\"p2\">&#8211; Treatment: Curable with a single dose of <b>metronidazole <\/b><span class=\"s2\">\uf0e0 <\/span>nitro group of metronidazole reduced by ferredoxin in anaerobic bacteria<span class=\"s2\">\uf0e0<\/span>nitro radical causes oxidative damage to bacterial DNA<span class=\"s2\">\uf0e0<\/span>cell death<\/p>\n<p class=\"p2\"><b>What are the long-term consequences of untreated STIs? <\/b><\/p>\n<p class=\"p2\">&#8211; Pelvic inflammatory disease (PID): ascending infection to the uterus &amp; tubes<span class=\"s2\">\uf0e0<\/span>can cause infertility<\/p>\n<p class=\"p2\">&#8211; \u2191 susceptibility to HIV: inflammation caused by trichomoniasis can \u2191 risk of acquiring and spreading HIV<\/p>\n<p class=\"p2\">&#8211; Tertiary disease: untreated, disseminated syphilis can infect many organs including the CNS<\/p>\n<p class=\"p2\"><b>What is the pathophysiology underlying PID? <\/b><\/p>\n<p class=\"p2\">&#8211; Proliferative phase of the menstrual cycle<span class=\"s2\">\uf0e0 <\/span>cervical mucosal barrier is thinner <span class=\"s2\">\uf0e0 <\/span>allows bacteria to enter the uterus and subsequently the fallopian tubes<\/p>\n<p class=\"p2\">&#8211; Bacteria cause destruction of the epithelial cells, cilia and microvilli <span class=\"s2\">\uf0e0 <\/span>localized inflammatory reaction<span class=\"s2\">\uf0e0<\/span>chronic inflammation with tissue remodeling and scarring <span class=\"s3\">Plummer XD, Liang A <\/span><\/p>\n<p class=\"p2\"><b>Figure 1 <\/b><\/p>\n<p class=\"p2\"><b>Figure 2 <\/b><\/p>\n<p class=\"p4\"><b>References <\/b><\/p>\n<p class=\"p4\">-Cunningham AL, Diefenbach RJ, Moranda-Saksena M, Bosnjak L, Kim M, Jones C, Douglas MW. The cycle of human herpes simplex virus infection: virus transport and immune control. <i>J Infect Dis <\/i>2006 Sep;194:S11-S18.<\/p>\n<p class=\"p4\">-DeCherney AH, Nathan L, Laufer N, Roman AS (2013). Current Diagnosis &amp; Treatment:<\/p>\n<p class=\"p4\">Obstetrics &amp; Gynecology. 11e. McGraw-Hill.<\/p>\n<p class=\"p4\">-Elwell C, Mirrashidi K, Engel J. Chlamydia cell biology and pathogenesis. <i>Nat Rev Microbiol <\/i>2016 Jun;14(6):385-400.<\/p>\n<p class=\"p4\">-LaFond RE, Lukehart SA. Biological basis for syphilis. <i>Clin Microbiol Rev <\/i>2006 Jan;19(1):29-49.<\/p>\n<p class=\"p4\">-Lemke TL, Williams DA (2013). <i>Foye\u2019s Principles of Medicinal Chemistry<\/i>. 7e. Lippincott Williams &amp; Wilkins.<\/p>\n<p class=\"p4\">-Mitchell C, Prabhu M. Pelvic inflammatory disease: current concepts in pathogenesis, diagnosis, and treatment. <i>Infect Dis Clin North Am <\/i>2009 Dec;27(4):10.<\/p>\n<p class=\"p4\">-Petrin D, Delgaty K, Bhatt R, Garber G. Clinical and microbiological aspects of trichomonas vaginalis. <i>Clin Microbiol Rev <\/i>1998 Apr;11(2):300-17.<\/p>\n<p class=\"p4\">-Ryan KJ, Ray CG (2004). <i>Sherris Medical Microbiology<\/i>. 4e. McGraw Hill.<\/p>\n<p><\/div>\n<hr \/>\n<p><iframe loading=\"lazy\" src=\"https:\/\/www.youtube.com\/embed\/cdY0tN3OcNw\" width=\"560\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>Duration 11:33<\/p>\n<input type='hidden' bg_collapse_expand='69e9b57bacdd93057054573' value='69e9b57bacdd93057054573'><input type='hidden' id='bg-show-more-text-69e9b57bacdd93057054573' value='Show Transcript'><input type='hidden' id='bg-show-less-text-69e9b57bacdd93057054573' value='Hide Transcript'><button id='bg-showmore-action-69e9b57bacdd93057054573' class='bg-showmore-plg-button bg-blue-button  '   style=\" color:#fcf7f7;\">Show Transcript<\/button><div id='bg-showmore-hidden-69e9b57bacdd93057054573' ><\/p>\n<p>00:00<br \/>\nThis VAP is on vagina discharge.<br \/>\n00:03<br \/>\n00:07<br \/>\nBy the end of this VAP,<br \/>\n00:08<br \/>\n[AUDIO OUT]<br \/>\n00:09<br \/>\n00:21<br \/>\nThe normal vaginal environment<br \/>\n00:22<br \/>\nis acidic, with a pH of 3.8<br \/>\n00:25<br \/>\nto 4.4, thus discouraging<br \/>\n00:27<br \/>\ninfections.<br \/>\n00:29<br \/>\nThis environment is created<br \/>\n00:30<br \/>\nby normally occurring bacteria,<br \/>\n00:31<br \/>\nlactobacilli.<br \/>\n00:34<br \/>\nAny disruption to the pH balance<br \/>\n00:36<br \/>\nof the vaginal environment<br \/>\n00:37<br \/>\ncan make it more<br \/>\n00:38<br \/>\nconducive to infection.<br \/>\n00:40<br \/>\nPhysiological vaginal discharge<br \/>\n00:42<br \/>\nis normal and consists<br \/>\n00:44<br \/>\nof vaginal secretions.<br \/>\n00:46<br \/>\nContribution<br \/>\n00:46<br \/>\nto vaginal secretions<br \/>\n00:47<br \/>\ninclude secretions<br \/>\n00:49<br \/>\nfrom sebaceous, sweat, Bartholin<br \/>\n00:52<br \/>\nand Skene glands,<br \/>\n00:53<br \/>\ntransudate<br \/>\n00:54<br \/>\nfrom the vaginal wall,<br \/>\n00:55<br \/>\nexfoliated vaginal and cervical<br \/>\n00:58<br \/>\ncells, cervical mucus,<br \/>\n01:00<br \/>\nendometrial and oviductal fluid.<br \/>\n01:03<br \/>\nPhysiological discharge is also<br \/>\n01:05<br \/>\ninfluenced by hormone levels.<br \/>\n01:07<br \/>\nThe pH balance of the vagina<br \/>\n01:09<br \/>\nis the least acidic on the days<br \/>\n01:11<br \/>\njust prior<br \/>\n01:11<br \/>\nto and during menstruation.<br \/>\n01:14<br \/>\nInfections are thus most common<br \/>\n01:15<br \/>\nat this time.<br \/>\n01:17<br \/>\nThere is also a normal increase<br \/>\n01:19<br \/>\nof discharge around mid-cycle.<br \/>\n01:22<br \/>\nPregnancy also increases<br \/>\n01:23<br \/>\nphysiological discharge.<br \/>\n01:24<br \/>\n01:28<br \/>\nVaginal discharge can be<br \/>\n01:29<br \/>\neither physiological or<br \/>\n01:31<br \/>\npathological.<br \/>\n01:32<br \/>\nPathological causes can be<br \/>\n01:34<br \/>\nfurther divided<br \/>\n01:35<br \/>\ninto infective or non-infective<br \/>\n01:37<br \/>\ncauses.<br \/>\n01:38<br \/>\nThe commonest cause<br \/>\n01:39<br \/>\nis physiological,<br \/>\n01:41<br \/>\nbut infective causes should be<br \/>\n01:42<br \/>\nexcluded.<br \/>\n01:44<br \/>\nWe will be focusing<br \/>\n01:44<br \/>\non the major common causes<br \/>\n01:46<br \/>\nof infective vaginal discharge&#8211;<br \/>\n01:48<br \/>\nnamely bacterial vaginosis,<br \/>\n01:51<br \/>\nvulvovaginal candidiasis,<br \/>\n01:53<br \/>\nand trichomonas vaginalis.<br \/>\n01:54<br \/>\n01:58<br \/>\nThe following diagnostic<br \/>\n01:59<br \/>\napproach is recommended.<br \/>\n02:01<br \/>\nFirst, a thorough history must<br \/>\n02:03<br \/>\nbe obtained.<br \/>\n02:04<br \/>\nDetails<br \/>\n02:05<br \/>\nabout the vaginal discharge<br \/>\n02:06<br \/>\ninclude the onset, duration,<br \/>\n02:09<br \/>\ncolor, and odor.<br \/>\n02:11<br \/>\nAssociated symptoms<br \/>\n02:12<br \/>\nsuch as vaginal itch, rash,<br \/>\n02:14<br \/>\nand dysuria<br \/>\n02:15<br \/>\nare<br \/>\n02:16<br \/>\nsuggestive of infective vaginal<br \/>\n02:18<br \/>\ndischarge.<br \/>\n02:19<br \/>\nA sexual history is used<br \/>\n02:21<br \/>\nto assess the risk of STIs.<br \/>\n02:24<br \/>\nRisk factors include age less<br \/>\n02:26<br \/>\nthan 25 years,<br \/>\n02:27<br \/>\nchange of new sexual partner<br \/>\n02:29<br \/>\nin the last year,<br \/>\n02:30<br \/>\nand more than one sexual partner<br \/>\n02:32<br \/>\nin the last year.<br \/>\n02:33<br \/>\nSimilar symptoms in partners<br \/>\n02:35<br \/>\nshould be covered.<br \/>\n02:37<br \/>\nMedical history is important<br \/>\n02:38<br \/>\nas immunocompromised states<br \/>\n02:40<br \/>\nlike diabetes and HIV<br \/>\n02:42<br \/>\ncan predispose to infection.<br \/>\n02:44<br \/>\nCurrent and previous medication,<br \/>\n02:46<br \/>\nmenstrual history,<br \/>\n02:47<br \/>\nand obstetric history<br \/>\n02:49<br \/>\nshould be obtained, too.<br \/>\n02:51<br \/>\nNext, perform<br \/>\n02:53<br \/>\na physical examination,<br \/>\n02:54<br \/>\ninspection<br \/>\n02:55<br \/>\nof the external genitalia<br \/>\n02:57<br \/>\nand perianal areas<br \/>\n02:59<br \/>\nare done to look<br \/>\n02:59<br \/>\nfor inflammation and other<br \/>\n03:01<br \/>\nlesions.<br \/>\n03:02<br \/>\nA speculum examination allows<br \/>\n03:04<br \/>\none to inspect<br \/>\n03:05<br \/>\nthe vaginal and cervical region.<br \/>\n03:08<br \/>\nAttention to the appearance<br \/>\n03:09<br \/>\nand character of discharge<br \/>\n03:10<br \/>\nis important, including<br \/>\n03:12<br \/>\nthe consistency and odor.<br \/>\n03:16<br \/>\nNot all women<br \/>\n03:17<br \/>\nwith vaginal discharge<br \/>\n03:18<br \/>\nrequire investigations.<br \/>\n03:20<br \/>\nEmpirical treatment can be given<br \/>\n03:22<br \/>\nif the patient is at low risk<br \/>\n03:23<br \/>\nof STI and has no symptoms<br \/>\n03:26<br \/>\nto suggest upper genital tract<br \/>\n03:27<br \/>\ninfection.<br \/>\n03:29<br \/>\nThe description<br \/>\n03:30<br \/>\nin the top right blue box<br \/>\n03:32<br \/>\ngives a clue<br \/>\n03:33<br \/>\nas to the potential infection.<br \/>\n03:36<br \/>\nInvestigations are indicated<br \/>\n03:37<br \/>\nif a woman is at high risk<br \/>\n03:39<br \/>\nof STIs, has symptoms suggestive<br \/>\n03:42<br \/>\nof upper genital tract<br \/>\n03:44<br \/>\ninfection&#8211; for example,<br \/>\n03:46<br \/>\nabdominal pain, dyspareunia,<br \/>\n03:49<br \/>\nor fever, has previous treatment<br \/>\n03:51<br \/>\nwhich has failed, is post-natal,<br \/>\n03:54<br \/>\npost-miscarriage,<br \/>\n03:55<br \/>\nor post-abortion,<br \/>\n03:57<br \/>\nbut is within three weeks<br \/>\n03:58<br \/>\nof insertion<br \/>\n03:59<br \/>\nof an intrauterine contraceptive<br \/>\n04:01<br \/>\ndevice.<br \/>\n04:03<br \/>\nInvestigations include<br \/>\n04:04<br \/>\nhigh vaginal swabs, which are<br \/>\n04:06<br \/>\nused to diagnose a common cause<br \/>\n04:08<br \/>\nsuch as candida,<br \/>\n04:09<br \/>\nbacterial vaginosis,<br \/>\n04:11<br \/>\nand trichomonas.<br \/>\n04:13<br \/>\nEndocervical swabs are used<br \/>\n04:15<br \/>\nto diagnose certain sexually<br \/>\n04:16<br \/>\ntransmitted diseases<br \/>\n04:18<br \/>\nlike chlamydia and gonorrhea.<br \/>\n04:20<br \/>\n04:23<br \/>\nBacterial vaginosis is the most<br \/>\n04:25<br \/>\ncommon cause<br \/>\n04:26<br \/>\nof vaginal discharge in women<br \/>\n04:27<br \/>\nof reproductive age.<br \/>\n04:29<br \/>\nHowever, up to 50%<br \/>\n04:31<br \/>\nof women<br \/>\n04:31<br \/>\nwith a clinical diagnosis of BV<br \/>\n04:33<br \/>\nare asymptomatic.<br \/>\n04:36<br \/>\nBV is due to an overgrowth<br \/>\n04:37<br \/>\nof organisms.<br \/>\n04:38<br \/>\nThis occurs when there is<br \/>\n04:39<br \/>\nan alteration<br \/>\n04:40<br \/>\nof normal vaginal flora,<br \/>\n04:42<br \/>\ncausing a loss of lactobacilli,<br \/>\n04:44<br \/>\nthus disrupting the pH balance<br \/>\n04:46<br \/>\nof the vaginal environment<br \/>\n04:47<br \/>\nand increasing the pH.<br \/>\n04:50<br \/>\nThe organisms responsible<br \/>\n04:51<br \/>\nare predominantly anaerobic,<br \/>\n04:53<br \/>\nand include Gardnerella<br \/>\n04:55<br \/>\nvaginalis, Mycoplasma hominis,<br \/>\n04:57<br \/>\nand Mobiluncus.<br \/>\n04:59<br \/>\nAn isolation of Gardnerella<br \/>\n05:01<br \/>\nvaginalis alone should not<br \/>\n05:03<br \/>\nbe used as a diagnostic test<br \/>\n05:04<br \/>\nfor BV, as between 35% to 55%<br \/>\n05:07<br \/>\nof women<br \/>\n05:08<br \/>\nare carriers of this organism.<br \/>\n05:11<br \/>\nPredisposing factors include<br \/>\n05:13<br \/>\nrepeated alkalinization<br \/>\n05:14<br \/>\nof the vagina&#8211; for example,<br \/>\n05:16<br \/>\ndouching<br \/>\n05:17<br \/>\nand frequent sexual intercourse.<br \/>\n05:20<br \/>\nBV increases the risk<br \/>\n05:21<br \/>\nof post-abortion endometritis<br \/>\n05:23<br \/>\nand pelvic inflammatory disease.<br \/>\n05:26<br \/>\nIn pregnancy, it is associated<br \/>\n05:28<br \/>\nwith late miscarriage, preterm<br \/>\n05:30<br \/>\ndelivery<br \/>\n05:31<br \/>\nin high-risk pregnancies,<br \/>\n05:33<br \/>\npreterm premature rupture<br \/>\n05:34<br \/>\nof membranes,<br \/>\n05:35<br \/>\nand postpartum endometritis.<br \/>\n05:36<br \/>\n05:40<br \/>\nBV is usually diagnosed using<br \/>\n05:42<br \/>\nAmsel&#8217;s criteria,<br \/>\n05:43<br \/>\nwhere at least three<br \/>\n05:44<br \/>\nof the following four conditions<br \/>\n05:46<br \/>\nmust be met.<br \/>\n05:48<br \/>\nNumber one, a raised vaginal pH<br \/>\n05:50<br \/>\nof more than 4.5; number two,<br \/>\n05:53<br \/>\nthin, homogenous grey or white<br \/>\n05:55<br \/>\nvaginal discharge; number three,<br \/>\n05:58<br \/>\nthe presence of clue cells<br \/>\n06:00<br \/>\non wet preparation microscopy;<br \/>\n06:02<br \/>\nand number four, a positive<br \/>\n06:04<br \/>\namine test demonstrated<br \/>\n06:05<br \/>\nby the release of the fishy odor<br \/>\n06:07<br \/>\non mixing vaginal discharge with<br \/>\n06:09<br \/>\n10% potassium hydroxide.<br \/>\n06:11<br \/>\nOrganisms are cultured<br \/>\n06:13<br \/>\nfrom a high vaginal swab<br \/>\n06:14<br \/>\nfor diagnosis.<br \/>\n06:14<br \/>\n06:18<br \/>\nAll symptomatic women<br \/>\n06:19<br \/>\nwith bacterial vaginosis<br \/>\n06:21<br \/>\nor asymptomatic women with BV<br \/>\n06:23<br \/>\nbefore surgical procedures<br \/>\n06:25<br \/>\nshould be treated.<br \/>\n06:27<br \/>\nBV can be treated<br \/>\n06:28<br \/>\nwith either oral Metronidazole<br \/>\n06:30<br \/>\nor Clindamycin for seven days.<br \/>\n06:33<br \/>\nTreatment in pregnancy<br \/>\n06:34<br \/>\nis the same as<br \/>\n06:35<br \/>\nin non-pregnant women.<br \/>\n06:37<br \/>\nOverall cure rates range<br \/>\n06:38<br \/>\nfrom 75% to 85% and followup is<br \/>\n06:41<br \/>\nnot necessary if symptoms<br \/>\n06:43<br \/>\nresolve.<br \/>\n06:44<br \/>\nRecurring BV occurs within three<br \/>\n06:46<br \/>\nmonths of treatment in about 15%<br \/>\n06:49<br \/>\nof women.<br \/>\n06:50<br \/>\nSuppressive regimens may be<br \/>\n06:52<br \/>\nconsidered, but evidence<br \/>\n06:53<br \/>\nto support their effectiveness<br \/>\n06:55<br \/>\nis limited.<br \/>\n06:56<br \/>\nMaintenance<br \/>\n06:57<br \/>\nwith acetic acid vaginal gel<br \/>\n06:59<br \/>\nat the time of menstruation<br \/>\n07:01<br \/>\nand following unprotected<br \/>\n07:02<br \/>\nsexual intercourse maintains<br \/>\n07:04<br \/>\nacidic vaginal pH.<br \/>\n07:05<br \/>\n07:08<br \/>\nCandidiasis is<br \/>\n07:09<br \/>\na fungal infection mostly caused<br \/>\n07:11<br \/>\nby the species Candida albicans.<br \/>\n07:15<br \/>\nCandida albicans<br \/>\n07:16<br \/>\nis responsible for 80% to 92%<br \/>\n07:18<br \/>\nof cases.<br \/>\n07:20<br \/>\nOther species of Candida<br \/>\n07:21<br \/>\nsuch as Candida glabrata<br \/>\n07:23<br \/>\nand Candida tropicalis<br \/>\n07:24<br \/>\ntend to be resistant to therapy.<br \/>\n07:27<br \/>\nPredisposing factors<br \/>\n07:28<br \/>\nto infection<br \/>\n07:29<br \/>\ninclude immunosuppression,<br \/>\n07:32<br \/>\nantibiotic use, high estrogen<br \/>\n07:34<br \/>\nlevels that occur<br \/>\n07:35<br \/>\nwith oral contraceptive pills<br \/>\n07:37<br \/>\nand hormone replacement therapy<br \/>\n07:39<br \/>\nusage, pregnancy, diabetes<br \/>\n07:42<br \/>\nmellitus, and prolonged<br \/>\n07:43<br \/>\ncorticosteriod therapy.<br \/>\n07:45<br \/>\n07:48<br \/>\nTypical Candida infection<br \/>\n07:50<br \/>\npresents<br \/>\n07:50<br \/>\nwith thick, white, curdy cottage<br \/>\n07:52<br \/>\ncheese-like discharge<br \/>\n07:54<br \/>\nassociated with vaginal itch<br \/>\n07:56<br \/>\nand soreness.<br \/>\n07:57<br \/>\nOccasionally, it can be<br \/>\n07:59<br \/>\nassociated<br \/>\n07:59<br \/>\nwith superficial dyspareunia<br \/>\n08:02<br \/>\nor external dysuria.<br \/>\n08:04<br \/>\nClinically,<br \/>\n08:05<br \/>\nvulvovaginal erythema<br \/>\n08:07<br \/>\nand excoriation is common.<br \/>\n08:09<br \/>\nThe high vaginal swab is used<br \/>\n08:11<br \/>\nfor diagnosis.<br \/>\n08:12<br \/>\nYeast cells are seen on gram<br \/>\n08:14<br \/>\nstain microscopy.<br \/>\n08:15<br \/>\n08:18<br \/>\nThere are various preparations<br \/>\n08:20<br \/>\nof drugs that can be used<br \/>\n08:21<br \/>\nfor treatment.<br \/>\n08:22<br \/>\nAll topical and oral azole<br \/>\n08:24<br \/>\ntherapies give a cure rate<br \/>\n08:26<br \/>\nof 80% to 90%.<br \/>\n08:28<br \/>\nIn pregnancy,<br \/>\n08:29<br \/>\nasymptomatic colonization<br \/>\n08:31<br \/>\nwith Candida is common at 30%<br \/>\n08:33<br \/>\nto 40%.<br \/>\n08:35<br \/>\nNo treatment is necessary,<br \/>\n08:37<br \/>\nunless patients are symptomatic.<br \/>\n08:39<br \/>\nOral azole is contraindicated<br \/>\n08:42<br \/>\nand should not be used<br \/>\n08:42<br \/>\nin pregnancy.<br \/>\n08:44<br \/>\nLonger courses of topical azole<br \/>\n08:46<br \/>\nfor 7 days is recommended<br \/>\n08:48<br \/>\ninstead.<br \/>\n08:49<br \/>\nNystatin preparations have a 70%<br \/>\n08:51<br \/>\nto 90% cure rate.<br \/>\n08:53<br \/>\nThey are the first line<br \/>\n08:54<br \/>\ntreatment<br \/>\n08:55<br \/>\nfor non-albicans infection.<br \/>\n08:58<br \/>\nPatients should avoid<br \/>\n08:59<br \/>\nlocal irritants<br \/>\n09:00<br \/>\nsuch as tight clothing<br \/>\n09:02<br \/>\nor perfumed vaginal douche.<br \/>\n09:04<br \/>\nTopical creams or antihistamines<br \/>\n09:06<br \/>\ncan be used to relieve itch.<br \/>\n09:08<br \/>\n09:11<br \/>\nRecurrent infection is defined<br \/>\n09:13<br \/>\nas four or more episodes<br \/>\n09:15<br \/>\nof symptomatic infection<br \/>\n09:16<br \/>\nannually,<br \/>\n09:17<br \/>\nwith positive microscopy<br \/>\n09:18<br \/>\nof Candida on at least two<br \/>\n09:20<br \/>\nepisodes.<br \/>\n09:21<br \/>\nFor acute treatment<br \/>\n09:23<br \/>\nof the infection, an induction<br \/>\n09:24<br \/>\nregimen of oral azole<br \/>\n09:26<br \/>\nis repeated every three days<br \/>\n09:27<br \/>\nfor three doses.<br \/>\n09:29<br \/>\nFollowing that, [INAUDIBLE]<br \/>\n09:30<br \/>\nmaintenance regimen is used<br \/>\n09:32<br \/>\nfor six months.<br \/>\n09:33<br \/>\n09:35<br \/>\nTrichomonal vaginitis is caused<br \/>\n09:38<br \/>\nby the parasite Trichomonas<br \/>\n09:40<br \/>\nvaginalis.<br \/>\n09:41<br \/>\nIt is<br \/>\n09:41<br \/>\nthe only sexually transmitted<br \/>\n09:43<br \/>\nvaginal infection of the three<br \/>\n09:45<br \/>\ninfections discussed.<br \/>\n09:47<br \/>\nHowever, unlike chlamydia<br \/>\n09:49<br \/>\nand gonorrhea, it does not<br \/>\n09:51<br \/>\naffect extragenital sites,<br \/>\n09:53<br \/>\nbut can infect the vagina,<br \/>\n09:54<br \/>\nurethra, and periurethral<br \/>\n09:56<br \/>\n[INAUDIBLE].<br \/>\n09:58<br \/>\nPartners in the last two months<br \/>\n09:59<br \/>\nshould be screened and treated.<br \/>\n10:01<br \/>\nTesting for other sections<br \/>\n10:03<br \/>\nincluding BV and other STIs<br \/>\n10:05<br \/>\nshould be considered,<br \/>\n10:06<br \/>\nas 60% of patients<br \/>\n10:08<br \/>\nhave BV and 30%<br \/>\n10:09<br \/>\nhave chlamydia or gonorrhea.<br \/>\n10:12<br \/>\nThe graph shows<br \/>\n10:13<br \/>\nthe concurrent STIs found<br \/>\n10:14<br \/>\nin a survey of women<br \/>\n10:15<br \/>\nwith a Trichomonas infection.<br \/>\n10:17<br \/>\n10:20<br \/>\nClinical diagnosis is typically<br \/>\n10:22<br \/>\nidentified<br \/>\n10:23<br \/>\nby a yellow green foul-smelling<br \/>\n10:24<br \/>\ndischarge associated<br \/>\n10:26<br \/>\nwith vulvovaginal erythema<br \/>\n10:28<br \/>\nand excoriation<br \/>\n10:29<br \/>\nwith a &#8220;strawberry cervix&#8221;<br \/>\n10:31<br \/>\npresenting in 2% of patients.<br \/>\n10:33<br \/>\nInvestigations will review<br \/>\n10:35<br \/>\na raised pH<br \/>\n10:36<br \/>\nwith motile trichomonads seen<br \/>\n10:38<br \/>\non microscopy.<br \/>\n10:39<br \/>\n10:42<br \/>\nFirst line treatment requires<br \/>\n10:44<br \/>\nsystemic rather than<br \/>\n10:45<br \/>\ntopical treatment,<br \/>\n10:46<br \/>\nbecause the infection is not<br \/>\n10:47<br \/>\nalways confined to the vagina<br \/>\n10:49<br \/>\nbut may involve other parts<br \/>\n10:50<br \/>\nof urogenital tract.<br \/>\n10:53<br \/>\nOral Metronidazole for one week<br \/>\n10:55<br \/>\ngives a cure rate of 90% to 95%,<br \/>\n10:57<br \/>\ncompared to 50%<br \/>\n10:59<br \/>\nwith topical treatment.<br \/>\n11:01<br \/>\nPatients<br \/>\n11:02<br \/>\nwith persistent symptoms<br \/>\n11:03<br \/>\nshould be retreated<br \/>\n11:04<br \/>\nwith oral Metronidazole 400 mg<br \/>\n11:06<br \/>\nb.i.d.<br \/>\n11:07<br \/>\nfor another seven days.<br \/>\n11:09<br \/>\nRepeated failure of treatment<br \/>\n11:10<br \/>\nmay require high dose<br \/>\n11:12<br \/>\noral Metronidazole of two grams<br \/>\n11:13<br \/>\ndaily for three days.<br \/>\n11:15<br \/>\nSexual partners should also<br \/>\n11:17<br \/>\nbe treated as this will improve<br \/>\n11:18<br \/>\ncure rates.<br \/>\n11:19<br \/>\n11:22<br \/>\nThis is the end of the VAP.<br \/>\n11:24<br \/>\nFurther reading references are<br \/>\n11:25<br \/>\nas stated.<\/p>\n<p><\/div>\n<hr \/>\n<p><iframe loading=\"lazy\" src=\"https:\/\/www.youtube.com\/embed\/Q1RQTNq83_s\" width=\"560\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>Duration 6:55<\/p>\n<input type='hidden' bg_collapse_expand='69e9b57badef78035023299' value='69e9b57badef78035023299'><input type='hidden' id='bg-show-more-text-69e9b57badef78035023299' value='Show Transcript'><input type='hidden' id='bg-show-less-text-69e9b57badef78035023299' value='Hide Transcript'><button id='bg-showmore-action-69e9b57badef78035023299' class='bg-showmore-plg-button bg-blue-button  '   style=\" color:#fcf7f7;\">Show Transcript<\/button><div id='bg-showmore-hidden-69e9b57badef78035023299' ><\/p>\n<p>Welcome.<br \/>\n00:02<br \/>\nToday, we will review<br \/>\n00:03<br \/>\npelvic inflammatory disease.<br \/>\n00:05<br \/>\n00:08<br \/>\nOur objective today will be<br \/>\n00:09<br \/>\nto briefly review<br \/>\n00:10<br \/>\nthe definition, epidemiology,<br \/>\n00:12<br \/>\nand pathogenesis<br \/>\n00:13<br \/>\nof pelvic inflammatory disease,<br \/>\n00:16<br \/>\nwhich I will refer to as PID<br \/>\n00:18<br \/>\nin this presentation.<br \/>\n00:19<br \/>\nWe&#8217;ll review<br \/>\n00:20<br \/>\nthe important long term sequelae<br \/>\n00:22<br \/>\nassociated with PID<br \/>\n00:24<br \/>\nthat makes it<br \/>\n00:24<br \/>\nsuch a public health concern.<br \/>\n00:26<br \/>\nWe will also discuss diagnosis<br \/>\n00:28<br \/>\nand first line treatment<br \/>\n00:29<br \/>\nfor PID.<br \/>\n00:30<br \/>\n00:33<br \/>\nHere is an outline<br \/>\n00:34<br \/>\nof the presentation today.<br \/>\n00:36<br \/>\n00:42<br \/>\nPelvic inflammatory disease<br \/>\n00:44<br \/>\nis a spectrum<br \/>\n00:45<br \/>\nof inflammatory disorders<br \/>\n00:46<br \/>\nof the upper female genital<br \/>\n00:48<br \/>\ntract, which includes<br \/>\n00:49<br \/>\nthe uterus, fallopian tubes,<br \/>\n00:51<br \/>\nand ovaries.<br \/>\n00:52<br \/>\nIt is believed to be caused<br \/>\n00:54<br \/>\nby ascending spread<br \/>\n00:55<br \/>\nof microorganisms<br \/>\n00:56<br \/>\nfrom the vagina<br \/>\n00:57<br \/>\nto the cervix, endometrium,<br \/>\n00:59<br \/>\nfallopian tubes,<br \/>\n01:00<br \/>\nand\/or adjacent structures.<br \/>\n01:02<br \/>\n01:05<br \/>\nThe rate of PID in the United<br \/>\n01:07<br \/>\nStates population has gone down<br \/>\n01:09<br \/>\nover the last 10 to 20 years.<br \/>\n01:11<br \/>\nMost likely, this<br \/>\n01:12<br \/>\nis due to the use<br \/>\n01:13<br \/>\nof prophylactic antibiotics<br \/>\n01:15<br \/>\nprior to surgical procedures,<br \/>\n01:17<br \/>\nroutine screening of high risk<br \/>\n01:18<br \/>\npopulations for sexually<br \/>\n01:20<br \/>\ntransmitted infection,<br \/>\n01:21<br \/>\nand to the use of antibiotics<br \/>\n01:23<br \/>\nearly in patients in which lower<br \/>\n01:25<br \/>\ngenital infections,<br \/>\n01:26<br \/>\nsuch as cervicitis,<br \/>\n01:27<br \/>\nis suspected.<br \/>\n01:28<br \/>\n01:31<br \/>\nPID it&#8217;s<br \/>\n01:32<br \/>\na polymicrobial infection.<br \/>\n01:35<br \/>\nThe most common bacteria<br \/>\n01:36<br \/>\nisolated in cases of PID<br \/>\n01:38<br \/>\nare anaerobic bacteria,<br \/>\n01:40<br \/>\nchlamydia trarchomatis,<br \/>\n01:42<br \/>\nand neisseria gonorrhea.<br \/>\n01:43<br \/>\n01:46<br \/>\nCertain high risk populations<br \/>\n01:48<br \/>\nshould be watched closely<br \/>\n01:49<br \/>\nfor evidence of PID.<br \/>\n01:51<br \/>\nIn particular, sexually active<br \/>\n01:53<br \/>\nyoung women, patients attending<br \/>\n01:54<br \/>\nsexually transmitted disease<br \/>\n01:56<br \/>\nclinics, and patients who live<br \/>\n01:57<br \/>\nin other settings<br \/>\n01:58<br \/>\nwhere there are high rates<br \/>\n01:59<br \/>\nof gonorrhea or chlamydia<br \/>\n02:01<br \/>\nare at risk.<br \/>\n02:02<br \/>\n02:05<br \/>\nA clinical diagnosis<br \/>\n02:06<br \/>\nof symptomatic PID<br \/>\n02:08<br \/>\nhas a positive predictive value<br \/>\n02:10<br \/>\nat 65% and 90%,<br \/>\n02:12<br \/>\ncompared with laparoscopy, which<br \/>\n02:14<br \/>\nis thought to be<br \/>\n02:14<br \/>\nthe gold standard for diagnosis<br \/>\n02:17<br \/>\nbased on early studies.<br \/>\n02:19<br \/>\nToday, the diagnosis of PID<br \/>\n02:21<br \/>\nis primarily made using<br \/>\n02:22<br \/>\nthis clinical criteria.<br \/>\n02:24<br \/>\nOf note, the diagnosis of PID<br \/>\n02:27<br \/>\nrequires ruling out other causes<br \/>\n02:29<br \/>\nof abdominal pain,<br \/>\n02:30<br \/>\nsuch as appendicitis,<br \/>\n02:32<br \/>\nectopic pregnancy,<br \/>\n02:33<br \/>\nor other surgical emergencies.<br \/>\n02:36<br \/>\nTreatment should be initiated<br \/>\n02:37<br \/>\nif patients have at least one<br \/>\n02:38<br \/>\nof the minimum criteria listed<br \/>\n02:40<br \/>\nhere,<br \/>\n02:41<br \/>\nwhich are cervical motion<br \/>\n02:42<br \/>\ntenderness, uterine,<br \/>\n02:43<br \/>\nor adnexal tenderness.<br \/>\n02:45<br \/>\nFurther work<br \/>\n02:46<br \/>\nup for alternative etiology<br \/>\n02:47<br \/>\nof pain should not delay<br \/>\n02:48<br \/>\ntreatment.<br \/>\n02:50<br \/>\nAccording to the Center<br \/>\n02:51<br \/>\nfor Disease Control<br \/>\n02:52<br \/>\nand Prevention, other criteria<br \/>\n02:54<br \/>\nthat may increase<br \/>\n02:55<br \/>\nyour specificity<br \/>\n02:56<br \/>\nfor the diagnosis of PID<br \/>\n02:58<br \/>\ninclude fever,<br \/>\n02:59<br \/>\nmucopurulent vaginal discharge,<br \/>\n03:02<br \/>\nnumerous white blood cells<br \/>\n03:04<br \/>\non a wet mount, and\/or detection<br \/>\n03:06<br \/>\nof gonorrhea or chlamydia.<br \/>\n03:08<br \/>\nThe most specific tests<br \/>\n03:10<br \/>\nfor diagnosis<br \/>\n03:11<br \/>\ninclude endometrial biopsy,<br \/>\n03:13<br \/>\nultrasound evidence<br \/>\n03:14<br \/>\nof tubo-ovarian abscess,<br \/>\n03:16<br \/>\nand\/or diagnostic laparoscopy.<br \/>\n03:19<br \/>\nHowever, due to the increased<br \/>\n03:21<br \/>\nrisk of long term morbidity<br \/>\n03:23<br \/>\nassociated with failing to treat<br \/>\n03:24<br \/>\na patient with PID,<br \/>\n03:26<br \/>\nit is recommended<br \/>\n03:27<br \/>\nthat a high level<br \/>\n03:27<br \/>\nof clinical suspicion<br \/>\n03:29<br \/>\nbe maintained<br \/>\n03:29<br \/>\nand that patients<br \/>\n03:30<br \/>\nwith minimum criteria<br \/>\n03:31<br \/>\nbe empirically treated early.<br \/>\n03:33<br \/>\n03:36<br \/>\nIn the short term, treatment<br \/>\n03:38<br \/>\nis aimed<br \/>\n03:39<br \/>\nat clinical and microbiologic<br \/>\n03:41<br \/>\ncure.<br \/>\n03:42<br \/>\nThis can be reliably achieved<br \/>\n03:43<br \/>\nwith antibiotic regimens,<br \/>\n03:45<br \/>\nas described<br \/>\n03:46<br \/>\non the next few slides.<br \/>\n03:48<br \/>\nLess is known about the effect<br \/>\n03:49<br \/>\nof current regimens<br \/>\n03:50<br \/>\non long term outcomes.<br \/>\n03:52<br \/>\nHowever, it is thought<br \/>\n03:53<br \/>\nthat by early detection<br \/>\n03:55<br \/>\nand treatment of PID,<br \/>\n03:56<br \/>\nit is possible to decrease<br \/>\n03:58<br \/>\nthe rates of infertility,<br \/>\n03:59<br \/>\nectopic pregnancy,<br \/>\n04:01<br \/>\nrecurrent infection,<br \/>\n04:02<br \/>\nand chronic pelvic pain<br \/>\n04:03<br \/>\nthat can be the long term<br \/>\n04:04<br \/>\nsequelae.<br \/>\n04:05<br \/>\n04:08<br \/>\nCertain patients are candidates<br \/>\n04:10<br \/>\nfor outpatient treatment<br \/>\n04:11<br \/>\nin the setting of PID,<br \/>\n04:13<br \/>\nand there does not appear to be<br \/>\n04:14<br \/>\nany benefit of inpatient<br \/>\n04:15<br \/>\nover outpatient therapy<br \/>\n04:17<br \/>\nif they meet criteria<br \/>\n04:18<br \/>\nfor outpatient management.<br \/>\n04:20<br \/>\nAppropriate regimens should<br \/>\n04:21<br \/>\nempirically cover gonorrhea<br \/>\n04:23<br \/>\nand chlamydia.<br \/>\n04:24<br \/>\nIf the clinical picture is<br \/>\n04:25<br \/>\nconcerning<br \/>\n04:26<br \/>\nfor anaerobic infection&#8211;<br \/>\n04:27<br \/>\nfor instance,<br \/>\n04:28<br \/>\nif bacterial vaginosis is<br \/>\n04:29<br \/>\ndetected&#8211; then consideration<br \/>\n04:31<br \/>\nmay be given to adding<br \/>\n04:33<br \/>\nan antibiotic with broader<br \/>\n04:34<br \/>\nanaeorbic coverage,<br \/>\n04:35<br \/>\nsuch as Metronidazole.<br \/>\n04:36<br \/>\n04:39<br \/>\nCertain populations will require<br \/>\n04:41<br \/>\ncloser monitoring<br \/>\n04:42<br \/>\nand in patient parenteral<br \/>\n04:43<br \/>\ntherapy.<br \/>\n04:44<br \/>\nThese include patients who are<br \/>\n04:46<br \/>\npregnant, those in whom<br \/>\n04:48<br \/>\na surgical emergency may<br \/>\n04:49<br \/>\nbe suspected,<br \/>\n04:50<br \/>\nsuch as appendicitis, patients<br \/>\n04:52<br \/>\nwho have not responded<br \/>\n04:53<br \/>\nto oral medications<br \/>\n04:55<br \/>\nor are unable to tolerate<br \/>\n04:56<br \/>\noutpatient oral regimen, those<br \/>\n04:58<br \/>\nwho demonstrate<br \/>\n04:59<br \/>\nother signs of severe illness,<br \/>\n05:00<br \/>\nor have radiologic findings<br \/>\n05:02<br \/>\nconcerning<br \/>\n05:03<br \/>\nfor a tubo-ovarian abscess.<br \/>\n05:04<br \/>\n05:07<br \/>\nPer the Center for Disease<br \/>\n05:09<br \/>\nControl, the recommended<br \/>\n05:10<br \/>\nfirst line treatment<br \/>\n05:11<br \/>\nincludes a cephalosporin<br \/>\n05:12<br \/>\nwith broader anaerobic coverage,<br \/>\n05:14<br \/>\nsuch Cefotetan or Cefotxitin,<br \/>\n05:16<br \/>\nwith Doxycycline for a total<br \/>\n05:18<br \/>\nof 14 days.<br \/>\n05:19<br \/>\nAfter clinical symptoms improve,<br \/>\n05:21<br \/>\npatients may continue<br \/>\n05:22<br \/>\nDoxycycline<br \/>\n05:23<br \/>\nwith or without Metronidazole<br \/>\n05:25<br \/>\nfor a total of 14 days.<br \/>\n05:27<br \/>\nThere are many alternatives<br \/>\n05:28<br \/>\nto this regimen, and there&#8217;s<br \/>\n05:29<br \/>\nlimited evidence<br \/>\n05:30<br \/>\nthat any regimen is better<br \/>\n05:31<br \/>\nthan the other.<br \/>\n05:32<br \/>\n05:35<br \/>\nWhether patients are treated<br \/>\n05:36<br \/>\nas inpatients or outpatients,<br \/>\n05:38<br \/>\nthe patient should be followed<br \/>\n05:40<br \/>\nclosely and clinical improvement<br \/>\n05:42<br \/>\nshould be seen within three days<br \/>\n05:43<br \/>\nof initiation of therapy.<br \/>\n05:45<br \/>\nRepeat testing and completion<br \/>\n05:47<br \/>\nof screening for any sexually<br \/>\n05:48<br \/>\ntransmitted diseases<br \/>\n05:49<br \/>\nwithin three to six months<br \/>\n05:50<br \/>\nshould be performed.<br \/>\n05:52<br \/>\nPatients<br \/>\n05:52<br \/>\nwith pelvic inflammatory disease<br \/>\n05:54<br \/>\nare at high risk of recurrence.<br \/>\n05:56<br \/>\nAll patients diagnosed<br \/>\n05:57<br \/>\nwith gonorrhea and\/or chlamydia<br \/>\n05:59<br \/>\nshould also have testing<br \/>\n06:00<br \/>\nin treatment<br \/>\n06:00<br \/>\nof their sexual partners.<br \/>\n06:01<br \/>\n06:05<br \/>\nIn summary, pelvic inflammatory<br \/>\n06:07<br \/>\ndisease<br \/>\n06:08<br \/>\nis a polymicrobial disease<br \/>\n06:09<br \/>\nwith significant public health<br \/>\n06:10<br \/>\nimplications,<br \/>\n06:11<br \/>\nincluding increased risk<br \/>\n06:13<br \/>\nof ectopic pregnancy,<br \/>\n06:14<br \/>\ninfertility,<br \/>\n06:15<br \/>\nand chronic pelvic pain.<br \/>\n06:17<br \/>\nEarly detection<br \/>\n06:18<br \/>\nand effective treatment<br \/>\n06:19<br \/>\nis required to decrease<br \/>\n06:21<br \/>\nlong terms sequelae.<br \/>\n06:22<br \/>\nEvidence suggests<br \/>\n06:23<br \/>\nthat outpatient oral therapy is<br \/>\n06:25<br \/>\nequally effective for treatment<br \/>\n06:27<br \/>\nof mild<br \/>\n06:27<br \/>\nto moderate PID<br \/>\n06:29<br \/>\nas inpatient parenteral therapy<br \/>\n06:31<br \/>\nin certain clinical situations.<br \/>\n06:33<br \/>\nIt is very important to remember<br \/>\n06:34<br \/>\nto screen for other sexually<br \/>\n06:36<br \/>\ntransmitted diseases in patients<br \/>\n06:38<br \/>\ndiagnosed with PID,<br \/>\n06:39<br \/>\nand their partners.<br \/>\n06:40<br \/>\n06:43<br \/>\nHere are my key references.<br \/>\n06:44<br \/>\n06:47<br \/>\nHere are acknowledgements.<br \/>\n06:48<br \/>\n06:52<br \/>\nThank you.<\/p>\n<p><\/div>\n<hr \/>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Duration 10:17 Duration 11:33 Duration 6:55 &nbsp;<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":160,"menu_order":6,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-418","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/418","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/comments?post=418"}],"version-history":[{"count":0,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/418\/revisions"}],"up":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/160"}],"wp:attachment":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/media?parent=418"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}