10.1: Infections of the Repro Tract Flashcards
Name three ways reproductive tract infections be spread
- Endogenous: part of normal flora, but an overgrowth can cause symptoms
- Iatrogenic
- STIs
What are the four most common curable STIs and where geographically are they most common?
Gonorrhea, chlamydia, syphilis and trichomoniasis
Most common in the americas
How have the rates of STIs changed over the last decade? Name four things that can possibly explain this
Increasing rates,
- Some (such as chlamydia and gonorrhea) are more commonly asymptomatic and can be transmitted easier
- Less stigma about getting tested
- Greater public awareness and more screening available
- Pregnant women are screened
Name seven risk factors for STIs
- Young <25
- Multiple partners and unprotected intercourse
- Pregnancy before age 20
- Commercial sex workers
- Vertical transmission
- Previous history of STIs
- IV drug users
What are four notable things that are part of the ‘history of presenting complaint’ in a patient with an STI? What further questioning should you ask for each?
- Pain: SQITARS, dyspareunia, dysuria
- Discharge: colour, consistency, smell, blood
- Skin changes: itchiness, soreness, lumps
- Review of systems: fever, eye problems, joint pain, weight loss, malaise, etc
Try to name seven aspects of sexual history that would you ask about in a patient with a suspected STI
- Last sexual intercourse
- Type of sexual intercourse (vaginal, anal, oral)
- Contraception
- Details of partnered for the last 3 months (casual, gender, multiple, traceable)
- History of previous STIs in themselves or partner
- Travel history (risk of blood borne viruses)
- Date of last smear
STIs often show an ‘iceberg effect’, what does this mean?
Very few present due to the majority of the infection being asymptomatic
What disease does Candida albicans cause? Name six risk factors
Causes thrush, risk factors include
- Pregnancy
- Obesity
- Diabetes
- Oral contraceptive
- Antibiotics
- Steroids
Describe the symptoms of thrush
- Profuse, white curd-like discharge
2. Vaginal itch (be weary of patients that present with multiple episodes of vaginal itching), discomfort and erythema
How is thrush tested for? Can you provide treatment without formal tests?
High vaginal swab for microscopy and culture, but if on history and examination the diagnosis is clear you can start treatment
How is thrush treated?
*4 things
Anti-fungal topical creams, and steroids which may reduce itch and inflammation, or one-off oral dose of anti-fungal, nystatin is for oral thrush
In bacterial vaginosis (BV) the normal flora of the vagina is disturbed (lactobacilli are no longer the dominant organism), which bacterium then dominates and what is one thing that causes this disturbance? How does this affect the vaginal pH?
Gardnerella vaginalis, as this doesn’t metabolize glycogen (into lactic acid) the pH rises. This disturbance can be caused by excessive washing with soap to the vulvovaginal area
How is BV diagnosed?
AMSEL’S CRITERIA: 3/4 required
- Vaginal fluid ph >4.5
- Release of fishy odour on adding alkali (whiff test) (discharge smell often worse during intercourse or menstruation)
- Increase in thin, white homogenous charge
- Clue cells on microscopy
Not often any pain or itching and the patient is otherwise well
How is BV and trichomonas vaginalis treated, who else needs to be treated in BV?
With metronidazole oral for 5-7 days
Trichomonas vaginalis should be checked for other STIs, but you don’t have to check or treat anyone other than the patient for BV since it isn’t sexually transmitted.
Name two diseases with endogenous causes
- Thrush - Candida albicans
2. BV - imbalance of vaginal flora (gardnerella vaginalis)
Name six clinical features of trichomonas vaginalis in females
*including the % of those who are asymptomatic
- 10-50% are asymptomatic
- Yellow-green, thin, frothy, offensive discharge
- Vulvo-vaginitis
- Dysuria
- Dyspareunia
- “Strawberry cervix”: red/inflamed with haemorrhages
Name three clinical features of trichomonas vaginalis in males
*including the % of those who are asymptomatic
- 15-50% asymptomatic
- Dysuria
- Urinary discharge
How is trichomonas vaginalis investigated in men and women?
Women: high vaginal swab or self-taken swab
Men: First void urine culture is preferred or urethral culture
What are three complications that can occur if trichomonas vaginalis goes untreated in pregnancy
- Preterm delivery
- Low birth weight
- Postpartum sepsis
What screening programmes are available for chlamydia and why?
Screening available for under 25s on request as 70% of cases are under 25
What is the pathology for chlamydia? Name five areas it commonly affects
It’s an obligate intracellular bacteria that cannot synthesize its own ATP so it relies on the host cell’s, commonly affects the endocervix, urethra, rectum, pharynx and conjunctiva
Name six clinical features of chlamydia in females
*including the % of those who are asymptomatic
- asymptomatic >=70%
- Dysuria
- Purulent vaginal discharge
- Post-coital/inter-menstrual bleeding
- Dyspareunia
- Lower abdominal pain
Name three clinical features of chlamydia in males
*including the % of those who are asymptomatic
- Asymptomatic >=50%
- Dysuria
- Urethral discharge (also usually purulent)
Name six complications that can be caused by chlamydia, star the three most common ones
- Ectopic pregnancy*
- Subfertility/infertility*
- PID*
- Reactive arthritis aka reiter’s syndrome
- Pneumonia
- Conjunctivitis
Name three complications that can arise in a newborn if vertically transmitted chlamydia goes untreated
Pneumonia, conjunctivitis and fitz-Hugh Curtis syndrome/perihepatitis; a chronic manifestation of PID
How are chlamydia and gonorrhea investigated in both men and women
*specify the area that samples are taken for investigation in both genders
Swab with NAAT (nucleic acid amplification technique)
Women: endo-cervical or vulvovaginal swab +- rectal swab preferred OR 1st void urine
Men: 1st void urine + rectal swab OR urethral swab
Name three things that are part of the treatment process for chlamydia
One-off antibiotic course; azithromycin, abstinence until all parties are treated and referral to GUM clinic to be checked for other STIs
Name one population group that appears to be at a greater risk of N. gonorrhea, why is it not for certain?
MSM - however men also report more symptoms as females are often asymptomatic
Describe the N. gonorrhea bacterium and name five things it affects
Gram -ve intracellular diplococcus that affects the mucus membranes, urethra, endocervix, conjunctiva and pharynx
Name three clinical features of N. gonorrhea in males and four in women
*including the percentage of those who are asymptomatic
Males:
- Asymptomatic <10%
- Urethral discharge
- Dysuria
Females:
- Asymptomatic: up to 50%
- Increased vaginal discharge
- Dysuria
- Lower abdominal pain
How is gonorrhea treated?
- One-off injection of IM ceftriaxone
- Since 50% of those infected with gonorrhea ALSO have chlamydia they are also treated for chlamydia (usually with azithromycin)
Name four complications that can occur if N. gonorrhea is left untreated in females and two that can occur in either gender
Females:
- endometriosis
- PID
- Infertility
- Salpingitis; inflammation of fallopian tubes
Both:
- Increased risk of HIV
- ~3% develop disseminated gonococcal infections
What are five complications that can occur if N. gonorrhea goes untreated in pregnancy?
Miscarriages, preterm birth, septicemia, eye infections/conjunctivitis and/or blindness, scalp abscess
Name three examples of disseminated gonococcal infections
Tenosynovitis, arthritis, dermatitis
What intervention caused a mass drop in the prevalence of syphilis? Which gender and population group is more commonly affected?
Penicillin, men are more affected (specifically MSM)
What is endometriosis?
When endometrial tissue grows outside the uterus causing pain
How is syphilis transmitted and why is it called “the great imitator”? Briefly describe the four stages of the disease, including when blood serology is positive
Vertical, infected blood products, contact with infectious lesion. It is called “the great imitator” as it mimics many other diseases
Four stages: For the first few years no signs/symptoms observed
1. Primary syphilis; chancre (single painless ulcer) at the site of sexual contact, lesion spontaneously heals (after ~2 weeks). At this stage, the patient is highly infective but the serology is usually negative
- Secondary syphilis: multi-system involvement; condyloma (spirocytes disseminate throughout body and proliferate). Macular papular rash on trunks, limbs, palms and foot soles. Lymphadenopathy, fever, malaise and potentially papules on the genitals (like HIV). Blood serology is now usually positive
- Latent syphilis: No signs/symptoms
- Tertiary syphilis
Name three complications that can occur during tertiary syphilis
- Gummatous syphilis: tumour like growths
- CVS syphilis: aneurysms, aortic regurgitation, HF
- Neurosyphilis: cranial nerve palses, dementia, stroke, tabes dorsalis
What is tabes dorsalis?
Loss of coordinated movement (especially as a result of syphilis infection in the spinal chord)
How is syphilis diagnosed and how is it managed?
Diagnosis: Blood test or ‘dark ground’ microscopy from swab samples
Management: mainly penicillin, referred to GUM clinic to look for other STIs
What are the two versions of Herpes simplex virus, which is more common and which more commonly causes warts and/or cold sores?
HSV-1 more common*, usually just causes cold sores
HSV-2 more commonly causes warts and cold sores
What is the pathology of the herpes virus and what is its prevalence?
Remains latent in the sensory ganglia and can periodically reactivate. Has an even distribution throughout the ages but is more common in those also infected with HIV
What is the main clinical feature of herpes simplex virus? List four symptoms that they cause, how do they differ between a primary and recurrent infection?
Multiple fluid-filled ulcers causing pain, dysuria, inguinal lymphadenopathy and fever.
Primary genital herpes will be very painful, whereas recurrent genital herpes is likely to be asymptomatic - moderate
How is herpes diagnosed?
Swab (taken from base or fluid of ulcer) and processed with NAAT or PCR
How is a primary infection of herpes managed?
Analgesia (for symptoms) and salt bathing, aciclovir can be used to reduce the severity and duration of the attack but doesn’t prevent future attacks
Once the primary herpes infection has resolved, what is the individual recommended doing to reduce transmission?
Barrier contraception and full disclosure in relationships
If herpes is vertically transmitted what is the newborn at risk of?
Neurological problems, hyperpigmented/scaling erosion on the skin
Which strains of HPV cause the majority of anogenital warts and increase the risk of cervical cancer?
Anogenital warts: strains 6 and 11
Risk of cervical cancer: strains 16 and 18
Describe the most prominent clinical feature of HPV, including how it varies and resolves
Different warts depending on area of skin
- Dry hairy skin: hard and keratinised
- Soft non-hairy skin: soft and non-kerartinised
Usually painless and resolve on their own
How is HPV diagnosed? *including follow up plans if smear is normal vs abnormal/mild dyskaryosis
With swabs and smear tests:
If smear test is normal but HPV positive: repeat smear in a year, 2 positives = colposcopy (type of cervical cancer test)
If smear test is abnormal/mild dyskaryosis and HPV positive you’ll return for an urgent colposcopy
When is HPV treated?
- If the warts are not resolving/ are painful they can be treated with topical solutions or ablation (surgical removal of body tissue) with cryotherapy
- Vaccine for ages 12-13 (repeated dose given 6 months-1 year after the first)
What is the main complication of HPV and where does it come from?
Comes from the oncogenic property of the virus, making it associated with cervical, vulval, anal, penile and oropharyngeal cancers
Name three conditions that cause genital skin and mucous membrane lesions
- Herpes
- Syphilis
- Anogenital warts (i.e HPV)
Name five conditions that cause urethritis (including discharge, dysuria and frequency)
- Chlamydia
- Gonorrhea
- Non-infectious urethritis
- Trichomonas
- Herpes
Name four conditions that cause inflammation (Vulvo-vaginitis and cervicitis)
- Candidiasis
- Trichomonas
- Bacterial vaginitis
- Chlamydia
What are the four major pillars behind managing STIs?
- Prevention; abstinence if infected, barrier contraceptive
- Screening
- Treatment; short course with low side effects, treat both partners/contact tracing
- EDUCATION
What is the triad of Reiter’s syndrome? Name one causative agent and what is it also known as?
AKA Reactive arthritis, can be caused by chlamydia
Conjunctivitis, urethritis and arthritis
*Can’t see, can’t pee, can’t climb tree
