BV, STIs etc Flashcards
What is actinomycosis?
Actinomycosis is an uncommon, chronic granulomatous disease caused by filamentous, gram-positive, anaerobic bacteria. Actinomyces israelii is the major human pathogen.
Antibiotics that are commonly used in the treatment of PID (doxycycline, clindamycin, beta-lactams, fluoroquinolones) also have activity against actinomyces, although the treatment duration is longer (3 to 6 months).
Clinical features of PID
- Bilateral lower abdominal tenderness (sometimes radiating to legs)
- Abnormal vaginal or cervical discharge
- Fever >38
- Abnormal vaginal bleeding (IMB, PCB, BTB)
- Deep dyspareunia
- Cervical motion tenderness on bimanual VE
- Adnexal tenderness on bimanual VE (with or without palpable mass)
Indication for hospitalisation for PID
- Pregnancy
- Lack of response or tolerance to oral medications
- Non-adherence to therapy
- Inability to take oral medications due to nausea and vomiting
- Severe clinical illness (high fever, nausea, vomiting, severe abdominal pain)
- Pelvic abscess, including tuboovarian abscess
- Possible need for surgical intervention or diagnostic exploration for alternative etiology (appendicitis)
Indications for laparoscopy for PID
- Sick patient with high suspicion of a competing diagnosis (usually appendicitis)
• An acutely ill patient who has failed outpatient treatment for PID
• Any patient not clearly improving after approximately 72 hours of inpatient PID treatment
How do you counsel a patient with PID?
- Explanation of what treatment is being given and potential adverse effects
- Remains a risk of future infertility, chronic pelvic pain and ectopic pregnancy
- Repeat episodes of PID are associated with exponential increase in risk of infertility
- Use of barrier contraception will significantly reduce risk of future PID
- Advise full STI screen and discussion of safe sex practices
- Advise screening of sexual contacts to prevent re-infection
- More severe disease = greater risk of sequelae
- Early treatment = lower risk of future fertility problems
What are the complications of PID?
- Hydrosalpinx
- TOA
- Chronic pelvic pain
- Ectopic pregnancy
- Infertility
You are seeing a young woman who has been sexually assaulted. She has just spent two hours with a counselor and decided against the police report and forensic examination.
a) You take a medical history from this patient for NON forensic examination. What would you try to elicit in the history?
General principles:
• Acknowledge it difficult to talk of assault
• Permission to talk in own words
• Explain why information required
• Precise documentation
• Offer information about criminal nature of sexual assault and right to take legal action
Sexual assault history:
• Circumstances of the assault (date, time, location, use of weapons, force, restraints, or threats)
• Areas of trauma should be ascertained (mouth, breasts, vagina, and rectum)
• Specifics regarding oral, vaginal, or anorectal contact or penetration
• Presence or absence of ejaculation and/or condom use
• Bleeding on the part of either assailant or victim
• Whether the victim experienced loss of consciousness or memory loss
• Assailant’s physical description along with the assailant’s use of drugs or alcohol
• Recent consensual sexual activity before or after the assault including details
Gynaecological history:
• LMP and current contraception
• Previous STIs
• Previous pregnancies
Other history:
• Significant medical or surgical history (contraindications to emergency OCP)
• Medications and allergies
• D&A intake, smoking history
• Social history including relationships, living arrangements, work
b) List the immediate investigations and treatment you would do? (sexual assault)
Multidisciplinary team approach (obstetrician, psychologist, social worker)
Physical examination (chaperone or advocate present):
• Document any evidence of trauma
• Descriptive not diagnostic terms
• Photograph injuries on patient request
• Complete body examination
• Carefully attention to breasts, external genitalia, vagina, anus, and rectum
• Common sites of vaginal injury include the posterior vagina and the labia minora.
• Consider colposcopic examination can enhance detection of areas of milder genital trauma
Investigations:
• Trauma assessment;
o Radiographic imaging as indicated
• STI assessment;
o Any sites of contact (vagina, rectum, pharynx, mouth) can be swabbed for gonorrhea and chlamydia
o Wet prep vaginal smear can be examined to look for bacterial vaginosis and trichomonas.
o Baseline serologic tests for syphilis and hepatitis B should be done
o Baseline HIV test counseling with options of confidential/anonymous testing offered and explained
o Consider blood and urine drug screen
o Drug screening for flunitrazepam (Rohypnol, the “date rape drug”) and gamma-hydroxy butyrate (GHB) should be done selectively if the victim has amnesia for any time surrounding the event
• Pregnancy assessment
o Serum BhCG
Treatment:
• Trauma care;
o Fractures, soft tissue injuries, and other traumatic injuries should be treated appropriately.
• Sexually transmitted infections;
o Offer empiric antibiotic prophylaxis
Patients often prefer immediate treatment
Many assault victims will not return for a follow-up visit
Empiric therapy includes ceftriaxone 250mg IM for gonorrhea and either azithromycin 1 gram PO (single dose) or doxycycline 100 mg PO bd for 1/52 for chlamydia.
Metronidazole 2g PO (single dose) is also recommended to treat trichomoniasis.
o HBV empiric treatment following sexual assault is controversial
Consider HBV vaccination +/- HBIG
o Prophylactic treatment with antiviral drugs for HIV following sexual assault is controversial
Risks and benefits of HIV prophylaxis should be addressed with every patient
Prophylaxis should be offered despite the presumed low risk of transmission and the lack of evidence proving the efficacy of antiretroviral drugs after sexual assault
Antiretroviral drugs are best started within 4 hours of assault, and should probably not be prescribed >72 hours post incident
• Pregnancy:
o Postcoital emergency contraception should be offered without regard to the menstrual cycle
o Options include levononorgestrol, Yuzpe method, copper IUD
o Many patients will experience nausea and vomiting from the combination of antibiotics and contraceptives; antiemetics should be offered.
• Psychosocial issues;
o Sexual assault victims require extensive emotional support
o Victims should be offered mental health services.
o Acute crisis counselling should include safety planning
o Victims should be referred for ongoing counseling ideally through sexual assault crisis programs.
• Other;
o Consider notification to police
Rate of sexual violence amongst women
1 in 5 women have experienced a form of sexual violence
More common in younger women
78% of perpetrators are known by the woman
Likelihood of pregnancy depending on point in menstrual cycle?
Probability of pregnancy after unprotected intercourse by timing of coitus:
3 days before ovulation 15%,
1-2 days before ovulation 30%,
day of ovulation 12%,
1-2 days after ovulation NICE guideline says 8% SOGC says 8% pregnant 28% of women experience a delay of more than 3 days with their period
Sx of chlamydia?
75% asymptomatic PCB Dysuria Vaginal discharge Pain PID IMB Reactive arthritis
Swabs for chlamydia?
If examined- endocervical swab preferable - NAAT (Nucleic Acid Amplification Test)
Otherwise self swab acceptable
Who should be tested for chlamydia?
<30 years and sexually active
partner change in the last 12 months
have had an STI in past 12 months
have had a sexual partner with an STI
at increased risk of complications of an STI e.g. termination of pregnancy (TOP) or intrauterine device (IUD) insertion
signs or symptoms suggestive of chlamydia
patient requests a sexual health check.
Treatment of chlamydia?
1g azithromycin stat
or 100mg BD Doxycycline 7/7
Cause of genital warts?
HPV 6 and 11
