NR 602 MIDTERM EXAM STUDY GUIDE TEST
BOX 20-6 Treatment of Uncomplicated Gonococcal Infections of
the Cervix, Urethra, and Rectum
Ceftriaxone 250 mg IM in a single dose
or
Cefixime 400 mg orally in a single dosea
or
Other single-dose injectable cephalosporin regimensb (ceftizoxime 500 mg
IM, cefoxitin 2g IM with probenecid 1 gm orally, or cefotaxime 500 mg IM)
plus
Azithromycin 1 gm orally in a single dose (preferred)
or
Doxycycline 100 mg orally 2 times a day for 7 days
Women with gonorrhea often remain asymptomatic, with as many as 80%
of women having no symptoms from this infection (Hawkins et al., 2016).
When symptoms are present, they are often less specific than the
symptoms in men. Women may report dyspareunia, a change in vaginal
discharge, unilateral labial pain and swelling, or lower abdominal discomfort.
Later in the infection’s course, women may describe a history of purulent,
irritating vaginal discharge, or rectal pain and discharge. Menstrual
irregularities may be the presenting symptom, with longer, more painful
menses being noted. Women may also report chronic or acute lower
abdominal pain. Unilateral labial pain and swelling may indicate Bartholin’s
gland infection (see Chapter 19), whereas periurethral pain and swelling
may indicate inflamed Skene’s glands. Infrequently, dysuria, vague
abdominal pain, or low backache prompts women to seek care. Later
symptoms may include fever (possibly high), nausea, vomiting, joint pain
and swelling, or upper abdominal pain (liver involvement) (Hawkins et al.,
2016; Marrazzo & Cates, 2011).
Women may develop a gonococcal rectal infection following anal
intercourse, in which case they may report symptoms of profuse purulent
,anal discharge, rectal pain, and
,blood in the stool. Rectal itching, fullness, pressure, and pain are also
commonly noted symptoms. Women with gonococcal pharyngitis may
appear to have viral pharyngitis, as some individuals will have a red,
swollen uvula and pustule vesicles on the soft palate and tonsils similar to
streptococcal infections (Hawkins et al., 2016).
Physical examination is individualized based on the woman’s presenting
symptoms. The clinician should obtain vital signs and perform a general skin
inspection for signs of classic DGI lesions, which are painful necrotic pustules
on an erythematous base, approximately 1 mm to 2 cm in diameter. Inspect
the pharynx and oral cavity for erythema, edema, and lesions. Assess for
cervical lymphadenopathy. Palpate the abdomen for masses, tenderness,
and rebound tenderness. During the speculum examination, inspect the
vaginal walls for discharge and redness, and examine the cervix for
mucopurulent discharge, ectopy, and friability (see Color Plate 25). During
the bimanual examination, observe for cervical motion tenderness, uterine
tenderness, adnexal tenderness, and adnexal masses—all of these findings
are associated with PID (Hawkins et al., 2016).
Annual screening for gonorrhea is recommended for all sexually active
women younger than 25 years. Women who are 25 or older should be
screened based on risk factors such as inconsistent or absent condom use,
new or multiple partners, partner with an STI or other partners, and
exchange of sex for drugs or money. Clinicians should also inquire about
recent travel that included sexual partners outside the United States (CDC,
2015d).
Gonorrhea testing can be performed by culture and NAATs. NAATs can be
performed using urine or swab specimens from the endocervix or vagina.
Although the U.S. Food and Drug Administration (FDA) has not formally
approved NAATs for use in the rectum or pharynx, some laboratories have
established performance specifications for using these tests with specimens
from these sites. NAAT products vary, however, and clinicians must be
certain that the test they are using is appropriate for the specimen type
(CDC, 2015d). Culture is also available for the detection of gonorrhea
infection of the rectum and pharynx. All patients with gonorrhea should be
, offered testing for other STIs, including chlamydia, syphilis, and HIV.
Diagnosis and treatment of vaginal masses
Asymptomatic simple ovarian cysts less than 10 cm in diameter, including
functional cysts and benign neoplasms, have a low probability of
malignancy and can be followed with serial imaging. There is little
evidence-based guidance for timing of repeat ultrasounds, but they are
generally obtained at 3-or 6-month intervals to establish stability (Ackerman,
Irshad, Lewis, & Munazza, 2013). Many functional cysts will resolve within 3
months. In one study, benign-appearing cysts (e.g., unilocular or cysts with
septations but no solid component) resolved within 1 year of follow-up in
approximately 40% of participating women (Pavlik et al., 2013). Women who
are receiving serial follow-up should be educated to report any increase in
pain or other symptoms (e.g., bowel or bladder status). While unlikely to
promote resolution of an existing cyst, hormonal contraceptives can be
used to control repeated episodes of
BOX 20-6 Treatment of Uncomplicated Gonococcal Infections of
the Cervix, Urethra, and Rectum
Ceftriaxone 250 mg IM in a single dose
or
Cefixime 400 mg orally in a single dosea
or
Other single-dose injectable cephalosporin regimensb (ceftizoxime 500 mg
IM, cefoxitin 2g IM with probenecid 1 gm orally, or cefotaxime 500 mg IM)
plus
Azithromycin 1 gm orally in a single dose (preferred)
or
Doxycycline 100 mg orally 2 times a day for 7 days
Women with gonorrhea often remain asymptomatic, with as many as 80%
of women having no symptoms from this infection (Hawkins et al., 2016).
When symptoms are present, they are often less specific than the
symptoms in men. Women may report dyspareunia, a change in vaginal
discharge, unilateral labial pain and swelling, or lower abdominal discomfort.
Later in the infection’s course, women may describe a history of purulent,
irritating vaginal discharge, or rectal pain and discharge. Menstrual
irregularities may be the presenting symptom, with longer, more painful
menses being noted. Women may also report chronic or acute lower
abdominal pain. Unilateral labial pain and swelling may indicate Bartholin’s
gland infection (see Chapter 19), whereas periurethral pain and swelling
may indicate inflamed Skene’s glands. Infrequently, dysuria, vague
abdominal pain, or low backache prompts women to seek care. Later
symptoms may include fever (possibly high), nausea, vomiting, joint pain
and swelling, or upper abdominal pain (liver involvement) (Hawkins et al.,
2016; Marrazzo & Cates, 2011).
Women may develop a gonococcal rectal infection following anal
intercourse, in which case they may report symptoms of profuse purulent
,anal discharge, rectal pain, and
,blood in the stool. Rectal itching, fullness, pressure, and pain are also
commonly noted symptoms. Women with gonococcal pharyngitis may
appear to have viral pharyngitis, as some individuals will have a red,
swollen uvula and pustule vesicles on the soft palate and tonsils similar to
streptococcal infections (Hawkins et al., 2016).
Physical examination is individualized based on the woman’s presenting
symptoms. The clinician should obtain vital signs and perform a general skin
inspection for signs of classic DGI lesions, which are painful necrotic pustules
on an erythematous base, approximately 1 mm to 2 cm in diameter. Inspect
the pharynx and oral cavity for erythema, edema, and lesions. Assess for
cervical lymphadenopathy. Palpate the abdomen for masses, tenderness,
and rebound tenderness. During the speculum examination, inspect the
vaginal walls for discharge and redness, and examine the cervix for
mucopurulent discharge, ectopy, and friability (see Color Plate 25). During
the bimanual examination, observe for cervical motion tenderness, uterine
tenderness, adnexal tenderness, and adnexal masses—all of these findings
are associated with PID (Hawkins et al., 2016).
Annual screening for gonorrhea is recommended for all sexually active
women younger than 25 years. Women who are 25 or older should be
screened based on risk factors such as inconsistent or absent condom use,
new or multiple partners, partner with an STI or other partners, and
exchange of sex for drugs or money. Clinicians should also inquire about
recent travel that included sexual partners outside the United States (CDC,
2015d).
Gonorrhea testing can be performed by culture and NAATs. NAATs can be
performed using urine or swab specimens from the endocervix or vagina.
Although the U.S. Food and Drug Administration (FDA) has not formally
approved NAATs for use in the rectum or pharynx, some laboratories have
established performance specifications for using these tests with specimens
from these sites. NAAT products vary, however, and clinicians must be
certain that the test they are using is appropriate for the specimen type
(CDC, 2015d). Culture is also available for the detection of gonorrhea
infection of the rectum and pharynx. All patients with gonorrhea should be
, offered testing for other STIs, including chlamydia, syphilis, and HIV.
Diagnosis and treatment of vaginal masses
Asymptomatic simple ovarian cysts less than 10 cm in diameter, including
functional cysts and benign neoplasms, have a low probability of
malignancy and can be followed with serial imaging. There is little
evidence-based guidance for timing of repeat ultrasounds, but they are
generally obtained at 3-or 6-month intervals to establish stability (Ackerman,
Irshad, Lewis, & Munazza, 2013). Many functional cysts will resolve within 3
months. In one study, benign-appearing cysts (e.g., unilocular or cysts with
septations but no solid component) resolved within 1 year of follow-up in
approximately 40% of participating women (Pavlik et al., 2013). Women who
are receiving serial follow-up should be educated to report any increase in
pain or other symptoms (e.g., bowel or bladder status). While unlikely to
promote resolution of an existing cyst, hormonal contraceptives can be
used to control repeated episodes of
