6. Infections of the Genital Tract

Question 1

What are Genitourinary Medicine (GUM) Clinics for?

Answer 1

Open access to free, confidential sexual health services, including diagnosis and treatment of STIs.

Question 2

What do communicable disease surveillance centres receive information about?

Answer 2

Gonorrhoea, genital chlamydia, genital herpes, and syphilis through voluntary or statutory reporting.

Question 3

Who is at risk of STIs?

Answer 3

Young people, minority ethnic groups, poverty and social exclusion, low socio-economic status groups, poor educational opportunities, unemployed people, individuals born to teenage mothers.

Question 4

What are the morbidities associated with STIs?

Answer 4

Pelvic inflammatory disease (PID), impaired fertility, reproductive tract cancers, risk of infection with blood-borne viruses (HBV, HIV), risk of congenital or peripartum infections of neonate.

Question 5

What are the most common sexually transmitted infections?

Answer 5

HPV, herpes, chlamydia, gonorrhoea, syphilis, trichomoniasis.

Question 6

What is the infecting organisms in cases of HPV?

Answer 6

Human papillomaviruses.

Question 7

What is the infecting organisms in cases of herpes?

Answer 7

Herpes simplex virus types 1 and 2.

Question 8

What is the infecting organisms in cases of chlamydia?

Answer 8

Chlamydia trachomatis.

Question 9

What is the infecting organisms in cases of gonorrhoea?

Answer 9

Neisseria gonorrhoeae.

Question 10

What is the infecting organisms in cases of syphilis?

Answer 10

Treponema pallidum.

Question 11

What is the infecting organisms in cases of trichomoniasis?

Answer 11

Trichomonas vaginalis.

Question 12

What are the differential diagnoses for genital skin and mucous membrane lesions?

Answer 12

Genital ulcers, vesicles or bullae, genital papules, anogenital warts.

Question 13

What are the differential diagnoses for urethritis (discharge, dysuria, frequency)?

Answer 13

Gonococcal urethritis, chlamydial urethritis, non-specific urethritis, post-gonococcal urethritis, non-infectious urethrisis.

Question 14

What are the differential diagnoses for vulvo-vaginitis and cervicitis?

Answer 14

Vulvo-vaginitis, cervivitis, bacterial vaginosis, bartholinitis.

Question 15

What are the differential diagnoses for infection of the female pelvis?

Answer 15

Pregnancy-related, pelvic inflammatory disease.

Question 16

What have been the recent trends in incidence of STIs considering gonorrhoea, chlamydia, syphilis, and generally GUM clinic workload?

Answer 16

Since 1995: gonorrhoea 102% increase, genital chlamydia 107% increase, infectious syphilis 57% increase, GUM clinic workload 34% increase.

Question 17

What type of bacteria is Chlamydia trachomatis?

Answer 17

Gram negative obligate intracellular bacteria.

Question 18

What is the clinical presentation of chlamydial infections in males and females?

Answer 18

Males - urethritis, epididymitis, prostatitis, proctitis.

Females - urethritis, cervicitis, salpingitis, perihepatitis.

Question 19

How are chlamydial infections diagnosed?

Answer 19

Endocervical and urethral swabs.

Question 20

How are chlamydial infections treated?

Answer 20

Doxycycline or azithromycin.

Question 21

What type of bacteria is Neisseria gonorrhoea?

Answer 21

Gram negative intracellular diplococcus.

Question 22

What is the clinical presentation of gonorrhoea in males and females?

Answer 22

Males - urethritis, epididymitis, prostatitis, proctitis, pharyngitis.
Females - asymptomatic, endocervicitis, urethritis, PID.

Question 23

How are cases of gonorrhoea diagnosed?

Answer 23

Smear and culture.

Question 24

How are cases of gonorrhoea treated?

Answer 24

Ceftriaxone (intramuscular injection).

Question 25

What type of virus is herpes simplex virus?

Answer 25

Encapsulated, double stranded DNA virus.

Question 26

What is the clinical presentation of primary genital herpes?

Answer 26

Extensive, painful genital ulceration, dysuria, inguinal lymphadenopathy, fever.

Question 27

What is the clinical presentation of recurrent genital herpes?

Answer 27

Asymptomatic to moderate symptoms.

Question 28

How is genital herpes diagnosed?

Answer 28

Smear and swab of vesicle fluid and/or ulcer base.

Question 29

How is genital herpes treated?

Answer 29

Aciclovir.

Question 30

What type of virus is human papilloma virus (HPV)?

Answer 30

Small, double stranded DNA virus.

Question 31

What are the highest risk HPV types?

Answer 31

HPV 16 and 18.

Question 32

What is the clinical presentation of HPV?

Answer 32

Cutaneous, mucosal, anogenital warts; benign, painless, verrucous epithelial or mucosal outgrowths; penis, vulva, vagina, urethra, cervix, perianal skin.

Question 33

How is HPV diagnosed?

Answer 33

Clinical, biopsy and genome analysis, hybrid capture.

Question 34

How is HPV treated?

Answer 34

None - frequent spontaneous resolution. | Topical podophyllin, cryotherapy, intralesional interferon.

Question 35

Describe the progression of syphilis.

Answer 35

``` Indurated, painless ulcer - chancre. 6-8 weeks later - fever, rash, lymphadenopathy, mucosal lesions. Latent - symptom free years. Chronic granulomatous lesions. Cardiovascular and CNS pathology. ```

Question 36

How is syphilis diagnosed?

Answer 36

Dark field microscopy, serology.

Question 37

How is syphilis treated?

Answer 37

Penicillin and 'test of cure' follow up.

Question 38

What type of microbe is trichomonas vaginalis?

Answer 38

Flagellated protozoan.

Question 39

What is the clinical presentation of trichomonas vaginitis?

Answer 39

Thin, frothy, offensive discharge. Irritation, dysuria, vaginal inflammation.

Question 40

How is trichomonas vaginitis diagnosed?

Answer 40

Culture.

Question 41

How is trichomonas vaginitis treated?

Answer 41

Metronidazole.

Question 42

What are arthropods?

Answer 42

Scabies mites, pubic lice.

Question 43

What causes vulvovaginal candidiasis?

Answer 43

Candida albicans or other candida species from normal GI and genital tract flora.

Question 44

What are the risk factors for candida?

Answer 44

Antibiotics, oral contraceptives, pregnancy, obesity, steroids, diabetes.

Question 45

What is the presentation of vulvovaginal candidiasis?

Answer 45

Profuse, white, curd-like discharge; vaginal itch, discomfort, and erythema.

Question 46

How is vulvovaginal candidiasis diagnosed?

Answer 46

High vaginal smear and culture.

Question 47

How is vulvovaginal candidiasis treated?

Answer 47

Topic azoles or oral fluconazole.

Question 48

What causes bacterial vaginosis?

Answer 48

Unsettled normal flora by anaerobes, enteric gram negative bacteroides.

Question 49

What is the presentation of bacterial vaginosis?

Answer 49

Scanty but offensive, fishy discharge.

Question 50

How is bacterial vaginosis diagnosed?

Answer 50

pH>5, KOH whiff test, high vaginal smear - gram variable coccobacilli, reduced numbers of lactobacilli.

Question 51

How is bacterial vaginosis treated?

Answer 51

Metronidazole.

Question 52

What is pelvic inflammatory disease?

Answer 52

Ascending infection from the endocervix causing: endometritis, salpingitis, oophoritis, pelvic peritonitis, with or without tuboovarian abscess.

Question 53

What are the risk factors for PID?

Answer 53

Young age at first intercourse, multiple sexual partners, high frequency of sexual intercourse, high rate of acquiring new partners within previous 30 days, alcohol/drug use, cigarette smoking, IUDs at insertion/removal.

Question 54

What are the causative organisms of PID?

Answer 54

Neisseria gonorrhoea - gram negative intracellular diplococci. Chlamydia trachomatis - gram negative extracellular organism. Bacterial vaginosis - anaerobes, enteric gram negative bacteroides. Streptococci, haemophillis influenzae, cytomegalovirus, mycobacterium tuberculosis.

Question 55

What are the immediate sequelae of PID?

Answer 55

Tubo-ovarian abscess, pyo-salpinx.

Question 56

What are the long term sequelae of PID?

Answer 56

Ectopic pregnancy, infertility, dyspareunia (painful sex), chronic PID/pelvic pain, pelvic adhesions.

Question 57

What is the pathogenesis of PID?

Answer 57

Infection of endocervix spreads directly or via lymphatic to endometrium, uterine tubes, and pelvic peritoneum. Associated with: cervical dilation, coil insertion, hormonal changes (lower bacteriostatic effect of cervical secretion), retrograde menstruation.

Question 58

What are the laboratory investigations performed in PID?

Answer 58

Pregnancy test, triple and urethral swabs (high vaginal, endocervical for N. gonorrhoea then for C. trachomatis, urethral for C. trachomatis for males), midstream urine for leucocytes and nitrates, C-reactive protein.

Question 59

What are the differential diagnoses for PID?

Answer 59

Ectopic pregnancy, acute appendicitis, irritable bowel syndrome, ovarian cyst accidents, urinary tract infections, functional pelvic pain of unknown origin.

Question 60

What are the symptoms of chronic pelvic inflammatory disease?

Answer 60

>6 months, pelvic pain, secondary dysmenorrhoea, deep dyspareunia, menstrual disturbance, recurrent acute painful exacerbations.

Question 61

What are the sequelae of chronic PID?

Answer 61

Infertility, ectopic pregnancy, chronic pelvic pain, pelvic adhesions/tubo-ovarian complex, abnormal/painful periods.