2025 – PAGE 97 – OB/GYN AND SOME STDs

CANDIDA VULVOVAGINITIS

Candida vulvovaginitis causes vulvar erythema and pruritis. If vaginal discharge is present, it is classically white, adherent, and clumpy (like cottage cheese curds). The pH is typically normal (4 to 4.5), and a wet mount may show budding yeast and hyphae. Treat with a topical azole or oral fluconazole.

(DOUBLE TAKE) HERPES SIMPLEX VIRUS (HSV)

• HERPES SIMPLEX VIRUS (HSV) AS AN STD: The initial flare is often very painful. Pain may precede the presentation of lesions. Look for multiple, painful ulcers or vesicles on the labia or penis. The patient can have lymphadenopathy. The vesicles are CLUSTERED on an ERYTHEMATOUS BASE. Lesions can also be ULCERATIVE. Diagnose by obtaining HSV PCR and a viral culture. The Tzancksmear is not specific for HSV. Treat with ORAL (not topical) Acyclovir x 7 days. Treat babies with IV Note that valacyclovir and famciclovir are also similarly efficacious, but they tend to be more expensive.
  • IMAGE: www.pbrlinks.com/HSV1
  • PEARL: HSV can be associated with a very painful infection called a HERPETIC WHITLOW(typically of a thumb or finger).
  • IMAGE: www.pbrlinks.com/HSV2
• HERPES SIMPLEX VIRUS ENCEPHALITIS(HSV ENCEPHALITIS): Look for fever, seizures and mentioning of the temporal lobe on CT brain. Treatment is STAT IV acyclovir, followed by a lumbar puncture to obtain fluid for PCR testing. An EEG might show PLEDs (periodic lateralizing epileptiform discharges).
• (DOUBLE TAKE) HERPES SIMPLEX VIRUS GINGIVOSTOMATITIS: Herpes simplex virus gingivostomatitispresents with oral and perioral/vermillion border lesions/vesicles. Gingiva is friable and malodorous. There is associated lymphadenopathy. Usually caused by HSV-1. Can treat with oral acyclovir. Treat immunocompromised hosts with IV acyclovir.
  • IMAGE: www.pbrlinks.com/HSVSTOMATITIS1

VAGINAL FOREIGN BODY

If a patient presents with malodorous (or bloody) vaginal discharge, think foreign body. Remove the object and prescribe sitz baths.

ULCERS VERSUS DISCHARGE

Sometimes treating by clinical suspicion alone is fine while the workup is pending. Use some of these high-yield facts to help guide your decision.

• DISCHARGE: Think Chlamydia, Gonorrhea, Bacterial Vaginosis, Trichomonas, Candida, or a foreign body. Anytime you treat for suspected Gonorrhea, ALSO treat for Chlamydia (which is much more common).
• PAINLESS ULCERS: Think Syphilis or LYMPHOGRANULOMA VENEREUM/LGV (due to CHLAMYDIA).
• PAINFUL ULCERS: HSV (painful, coalesce and can have a herpetic whitlow on the thumb), HAEMOPHILUS DECREYI: “DO CRY,” BEHCET’S SYNDROME (aphthous & genital ulcers + uveitis + arthritis + GI symptoms).