10.1 Reproductive Tract Infections Flashcards
Give 3 broad ways in which you can acquire an RTI
1) STIs
2) Endogenous
3) Iatrogenic
Give 6 types of STI related RTIs
1) Gonorrhoea
2) Chlamydia Trachomatis
3) Trichomoniasis
4) Genital Herpes, HPV (warts)
5) Syphillis
6) HIV
Give 4 sources of Iatrogenic RTIs
1) transcervical procedure
2) termination of pregnancy
3) postpartum infections
4) Intrauterine devices
5) improper sterilised equipment
Give 4 sources of endogenous RTIs
1) Candida albicans
2) BV
3) overgrowth of organisms normally found in vagina
4) Sexual transmission +/-
Give 3 reasons for the dramatic rise in cases of STI recently?
1) less stigma around getting tested
2) more public awareness
3) screening programmes
4) changing in sexual practices (introduction of the pill)
5) increased partners (more “casual relationships”)
Give 4 risk factors for STI’s
- young people <25
- mutiple partners
- pregnancy before 20 years
- vertical transmission from mother to baby
- preveous history of STI
- unprotected intercourse
Others: alchol, recreational drug use, I/V drug users, commercial sex workers
Explain how you would take someone sexual history if you suspect an STI, include what questions should be asked
- *HPC ➞** SOCRATES or similar
1) Pain: ask about dyspareunia and check for dysuria
2) Discharge: colour, consistency, smell, bleeding
3) Skin changes: lumps or bumps seen or felt, Itching/soreness
4) Systems review: fever, eye problems, joint pain, weight loss, malaises etc..
Detailed sexual history including:
- Last sexual intercourse .
- type of sexual intercourse (vaginal, oral, anal)
- contraception use (barrier, hormonal, none)
- details of partner/s in past 3 months (gender, casual/long-term, traceable/non- traceable, multiple)
- history of previous STI/PID in themselves or partner
- travel h/o, risk for BBV
- date of last smear
What is meant by the “Iceberg effect”?
Very few of the cases actually present due to the high rate of asymptomatic infection
What is the lay persons term used to describe Vulvovaginal Candidiasis?
Thrush
What bacteria causes Vulvovaginal Candidiasis and how does it present?
Candida albicans presents with:
- Profuse, white, curd-like discharge
- vaginal itch, discomfort and erythema
- inflammation can lead to dysuria and dyspareunia
Give 4 risk factors for aquiring Candida (SOAP)
- antibiotics
- oral contraceptives
- pregnancy
- obesity
- steroids
- diabetes
How would you diagnose and treat vulvovaginal candidiasis?
Diagnosis: high vaginal swab for microscopy and culture
Treatment: topical azolesornystatin (antibiotics) OR oral fluconazole (anti-fungal)
What is the normal flora in the vagina and what is its function?
How can disruption lead to development of BV?
In a normal healthy vagina the predominant bacteria is lactobacillus, which metabolises the glycogen to produce lactic acid. This maintains the normal vagina pH at around 4.5.
When this normal flora is disturbed the predominant bacteria now becomes the Gardnerella vaginalis. As this does not metabolise glycogen the pH rises leading to development of BV
Give a common risk factor for development of BV and state how does it present?
Risk factor: excessive washing with soap around the vulvovaginal area
Presentation: increase in discharge (white or grey) that is thin a homogenous with a distinct fishy odour (no pain/itching)
What criteria is used to diagnose BV and what does this incl
How would you treat?
Diagnose using AMSEL’S CRITERIA: 3 out of 4 required
- Vaginal fluid ph >4.5
- Release of fishy odour on adding alkali (10% KOH) –whiff test
- Thin, white homogenous discharge
- Clue cells on microscopy of wet mount
Treatment: Metronidazole oral for 5-7 days (no need to treat partner)
What is Trichomonas vaginalis
Give the most common clinical features in males and females
Trichomonas vaginalis is an STI
Female: 10-50% asymptomatic
- classical thin, frothy, offensive discharge (yellow/green)
- vulvo-vaginitis
- dysuria and dyspareunia
- “strawberry cervix” (on speculum exam)
Male: 5-50% asymptomatic
- dysuria
- urinary frequency
- discharge
How is Trichomonas vaginalis diagnosed and treated?
Investigation
- Women: high vaginal swab or self-taken swabs.
- Men: urethral culture or culture of first void urine
Treatment: as per local guidelines
- usually a course of metronidazole
- refer to GUM for further testing
Give 3 potential complications of Trichomonas Vaginalis if it goes untreated during pregnancy
1) Preterm delivery
2) Low birth weight
3) Postpartum sepsis
What is a GUM clinic?
GUM clinic (Genito-Urinary Medicine) is an NHS. run clinic for all aspects of sexual health
What is the most common curable STI in the UK?
70% of all cases affect what age group?
Is screening availble?
Chlamydia trachomatis
70% of cases in under 25s
Screening available for the under 25s on request
Describe the Chlamydia trachomatis bacteria
What parts of the body does it commonly affect?
What non-specific genital chlamydia infections can be caused in males and females?
Obligate intra-cellular bacterium: cannot synthesise its own ATP so must rely on the host cell. Has Serotypes D – K
Commonly affects the endocervix, urethra, rectum, pharynx (oral) and conjuctiva (eyes)
Can cause non-specific genital chlamydial infections:
- males: non-specific urethritis
- females: mucopurulent cervicitis
What are the clinical features of Chlamydia trachomatis in males and females?
Female: asymptomatic ± 70%
- dysuria and dyspareunia
- purulent vaginal discharge
- post-coital/inter-menstrual bleeding
- lower abdominal pain
Males: asymptomatic ± 50%
- dysuria
- urethral discharge
Give 3 complications of an untreated chlamydia trachomatis infection (Hint: “can’t see, can’t pee, can’t climb a tree”)
Give 3 other complications including one specific to each sex and one for both sexes
Give 2 complication for a newborn if passed on from mother?
“can’t see, can’t pee, can’t climb a tree”
- conjunctivitis (can’t see)
- PID (can’t pee)
- reactive arthritis (can’t climb a tree)
Others:
- ectopic pregnancy (f)
- epididymo-orchitis (m)
- subfertility/infertility (both)
Newborn:
- pneumonia
- conjunctivitis
How is Chlamydia trachomatis diagnosed?
How is it treated and what must you do after?
Give 2 things would you advise to your patient?
Investigation:
- Swab with NAAT
- Women: endo-cervical swab or vulvo-vaginal swab ± rectal swab
- Men: 1st void urine ± rectal swab and/or urethral swab
Treatment
- One of course of azithromycin or longer cource of doxycycline
- Referral to GUM for exclusion of other STIs
Advise patient to have their partner tested and to abstain from sex until all parties are treated
What does NAAT stand for?
What is meant by “test of cure”?
Nucleic Acid Amplification Technique (eg. PCR)
Test of cure means the individual should be re-tested after treatment following the given number of weeks reccomended
50% of people with Gonorrhoea will have a concurrent infection with what?
Chlamydia ➞ all patients with gonorrhoea are treated for chlamydia aswell
What bacteria causes Gonorrhoea and describe its structure
What parts of the body does it commonly affect?
How does it present in males vs females?
Neisseria gonorrhoea: gram negative intracellular diplococcus
Commonly affects mucus membranes of the urethra, endocervix, conjunctiva, rectum and pharynx
Males: commonly symptomatic
- urethral discharge
- (acute) dysuria
Females: asymptomatic up to 50%
- Increased vaginal discharge
- lower abdominal pain
- dysuria
How would you diagnose and treat Gonorrhoea?
What 2 things would you advise patient?
Diagnosis:
- NAAT testing
- females: endocervical or urethral swab (+ rectal and pharyngeal swabs)
- males: genital swabs and first void urine
Treatment:
- Ceftriaxone IM and azithromycin PO
- Referral to Gum clinic for exclusion of other STIs and contact tracing
- Test of cure
Advise patient to inform partner(s) and abstain from sex until all parties have been treated
When diagnosing Chlymidia and Gonorrhoea why are first void urine not reccomended in females?
What should you always do when testing males and why?
Female urine test sensitivity is < 30% compared to males >90%
In males first void urine required 2 samples to reduce false positive rate
3% of untreated Gonorrhoes develop disseminated gonococcal infection, how would this present?
Give 2 specific presentations of females and one other of both sexes
Give 3 specific to pregnancy
DCI presents with: Tenosynovitis, arthritis, dermatitis
Females: endometriosis, salphingitis, PID, infertility
Both: Increased risk of HIV
Pregnancy: miscarriages, preterm birth, septicaemia
What bacteria causes Syphilis?
How is it transmitted and what is the most common group affected?
Syphilis is a “multi-stage” disease, what are the 4 stages?
Treponema pallidum (spherocyte)
Transmitted via contact with infectious lesion, infected blood products or vertically (congenital syphilis) 81% are men who have sex with men
Stages: primary, secondary, latent, tertiary
Why is Syphillis known as “The Great Imitator” and what does this mean for diagnosis?
Syphillis can cause a number of different features and syndromes and is known as the “great imitator” as it can mimic many other diseases
A higher degree of suspicion is needed as it mimics other things and people may not realise they have the infection
What is seen in primary syphilis and what can therefore be said about diagnosis and transmission?
What would blood serology show?
Chancres (single painless indurated ulcer) that usually presents at the site of sexual contact. The ulcers have a smooth clear boarder and if not directly visualised or felt they can can be easily missed by the patient.
The lesion heals spontaneously after several weeks
At this stage the patient is highly infective hence syphilis can easily be transmitted to sexual partern(s) however, blood serology will be negative
What is seen in secondary syphillis?
What would be seen in blood serology?
Multi-system involvement that generally presents with a macular-papular rash on the limbs, palms and soles of the feet AND condylomas
This is accompanied by flue-like symptoms ➞ fever, lymphadenopathy, malaise, wart-like papules on the genitals and mucosal lesions
Blood serology is now usually positive
What is seen in Latent Syphillis?
No signs or symptoms
What is seen in tertiary Syphilis, include the various presentations
Occurs ~2 years after initial symptoms. This is the stage in which syphillis is most likly to imitate other diseases as it presents in various ways:
1) Gummatous Syphilis: tumour like growths that are hard granulomatous lesions of the skin and bone
2) Cardiovascular syphilis: aneurysms, aortic regurgitation, heart failure
3) Neurosyphilis: CN palseys, stroke, Tabes Dorsalis (an ataxia with numbness + loss of reflexes) and general paresis of the insane causing dementia and psychosis
How is Syphilis diagnosed and treated?
Diagnosis: blood test-MHA-TP and serology mainly, along with dark ground microscopy or PCR of swab samples
Treatment: dependant on stage but are mainly penicillin based
Test of cure recommended and patient should be reffered to the GUM clinic for exclusion of other sti’s and contact tracing
What is the prevelance of Herpes Simplex Virus across age groups?
What are the 2 types and what is meant by “periodical reactivation” of the virus?
Same prevelance across all age groups but more common in those already infected with HIV.
Types:
- HSV-1: Oral Herpes
- HSV-2: Genital Herpes
The virus can remain latent in local sensory ganglia, periodically reactivating
What is characteristic of the Herpes Simplex Virus?
Compare presentation of primary vs recurrent genital herpes
Characteristic fluid filled vesicles that burst to produce ulcers.
Primary genital herpes: extensive painful multiple genital ulcerations that cause dysuria, inguinal lymphadenopathy, fever and pain on wiping/sitting/in contact with clothes
Recurrent genital herpes: generally asymptomatic to moderate
How do we diagnose and manage Herpes Simplex Virus (HSV)?
What are patients advised?
Diagnosis: swab usually taken from ulcer base or vesicle fluid and tested using NAATs (best) or PCR
Management for primary infection involves analgesia, salt bathing, aciclovir
For future outbreaks, patients are advised barrier contraception to reduce transmission and full disclosure to partner in relationships
Note: Pregnant women with HSV infection require special care
What is the most common STI?
Human Papilloma Viruses
What are the 4 important types of HPV and what does each cause?
6 and 11 cause >90% of anogential warts
16 and 18 are oncogenic HPV types are are associated with cervical, vulval, vaginal, anal, penile and oropharyngeal cancers
What are the clinical features of HPV warts?
HPV produces different warts depending on where it effects:
- Warts on dry, hairy skin tend to be hard and keratinised
- Warts on soft, non-hairy skin tend to be soft and non-keratinised
These are usually painless and resolve spontaneously
How is HPV diagnosed and managed?
Diagnosis is based on a clinical examination, swabs and smear tests
Treatment is normally to do nothing as they usually resolve on their own BUT… if they are causing irritation they can be treated with topical podophyllotoxin or ablation with cryotherapy
What is the main complication of HPV?
The main complication of HPV comes from the oncogenic properties of typer 16 and 18 which increase risk of vulval, vaginal, anal, penile and oropharyngeal cancers
What vaccinations are available for HPV and who is this available too?
Vaccinations available for girls and boys ages 12-13 for HPV 6, 11, 16 and 18.
A repeat vaccine given 6 months to a year later
During smear for cervical cancer in women, HPV virus will also be tested. Explain what the protocol states for a smear that is:
- normal and HPV negative
- normal and HPV positive
- boarderline/mild dyskaryosis and negative HPV
- boarderline/mild dyskaryosis and positive HPV
Also state what dyskaryosis means
Dyskaryosis means abnormal nucleus and refers to the abnormal epithelial cell which may be found in cervical sample
Give 3 differential diagnosis for genital skin and mucous membrane lesions
- Herpes
- Syphilis
- anogenital warts
Give 5 differential diagnosis for urethritis with discharge, dysuria and frequency
- Chlamydia
- Gonnorhoea
- Non-infectious urethritis
- Trichomonas
- Herpes
Give 4 differential diagnosis for vulvo-vaginitis and cervicitis
- Candidiasis
- Trichomonas
- Bacterial vaginitis
- Chlamydia
Review this summary
What are the 4 key management strategies for decreasing prevelance of STIs
1) Prevention of STI
2) Screening
3) Treatment
4) EDUCATION
Give 4 preventative measures against STIs
1) abstain from sex if suffering from an STI
2) stay with one uninfected partner
3) barrier contraception
4) sexual health education
5) screening
6) vaccination for HPV boys and girls between 11-12years
Give the 4 general principles for treatment of STIs
1) screen for other STIs as co-infections are common
2) antibiotic or antiviral treatment should be started at at first visit and aim to be a short course regimen with low side effect profile
3) treat both partners simultaneously + contact tracing and advise patient to abstain from sex until all parties are treated
4) education of safe sex practices
All STIs should be reffered on to the GUM clinic
