Common Genital Symptoms

Question 1

Possible causes of genital symptoms

Answer 1

• MICROBIAL e.g. CANDIDA, BACTERIAL VAGINOSIS, BALANOPOSTHITIS
  
  • OTHER e.g. DERMATOSES, TRAUMA, CANCER, NEUROMUSCULAR, HYPERVIGILANCE, IATROGENIC, IDIOPATHIC

Question 2

Genital symptoms

Answer 2

• DISCHARGE from an orifice
  
  • PAIN
  • ITCHING
  • SKIN CHANGES = RASHES, CUTS, SORES, ULCERS
  • LUMPS & SWELLINGS
  • CHANGE in APPEARANCE
  • VAGUE SENSE of THINGS NOT BEING RIGHT

Question 3

Aetiology of symptoms

Answer 3

STD - public + individual health problem - not always curable, but is treatable

Other microbial problem - individual health problem, treatable + usually curable

Non-microbial - individual health issue

Question 4

Microbial conditions not regarded as STDs

Answer 4

• VULVOVAGINAL CANDIDOSIS
  
  • BACTERIAL VAGINOSIS
  • BALANOPOSTHITIS - ANEROBIC/CANDIDAL
  • TINEA CRURIS (MOIST CREVICES)
  • ERYTHRASMA
  • INFECTED SEBACEOUS GLANDS
  • IMPETIGO
  • CELLULITS

etc.

can be passed through sexual contact

Question 5

Vulvovaginal candidiasis: presentation

Answer 5

• Often ASYMPTOMATIC carriage = CHANGES in HOST ENVIRONMENT trigger pathogenicity
  
  • SYMPTOMATIC = THRUSH e.g.○ ITCH
    ○ DISCHARGE - classically THICK, “COTTAGE CHEESE”, often just INCREASED AMOUNT

Question 6

Vulvovaginal candidiasis: pathogen

Answer 6

• 90% = CANDIDA ALBICANS (YEAST COMMENSAL on SKIN & IN BOWEL)

Question 7

Vulvovaginal candidiasis: risk factors

Answer 7

• DIABETES
  
  • ORAL STEROIDS + CORTICOSTEROID INHALERS (if poor inhaler technique)
  • IMMUNE SUPPRESSION incl. HIV
  • PREGNANCY (state of immune suppression)
  • REPRODUCTIVE AGE GROUP - MID-TEENS to 50s (oestrogen conversion to glycogen = food for yeast)

Question 8

Vulvovaginal candidiasis: investigations/diagnosis

Answer 8

CHARACTERISTIC Hx

EXAMINATION FINDINGS

	○ FISSURING
	○ ERYTHEMA w/ SATELLITE LESIONS
	○ CHARACTERISTIC DISCHARGE

VAGINAL SWAB = for discharge

	○ GRAM STAINED PREPARATION = LOW SENSITIVITY as it might be looking at an UNREPRESENTATIVE PATCH

CULTURE e.g. Sabouraud’s medium = LOW SPECIFICITY as YEAST are COMMENSAL ORGANISMS (as yeast are commensals, could another pathogen be causing symptoms)

Question 9

Vulvovaginal candidiasis: management

Answer 9

• AZOLE ANTIFUNGALS - clotrimazole (500mg PV once)/fluconazole (150mg PO once)
  
  • RESISTANT CASE = REFRACTORY to INITIAL Rx: DETERMINE SPECIES + SENSITIVITIES & TREAT ACCORDINGLY
  • OTHER = MAINTAIN SKIN as optimally as poss. By AVOIDING IRRITANTS, TREATING DERMATITIS

Question 10

Bacterial Vaginosis: presentation

Answer 10

• ASYMPTOMATIC in 50%

• WATERY GREY/YELLOW "FISHY" OFFENSIVE DISCHARGE
	○ LOTS of DISCHARGE = UNLIKELY to be BV

* May be WORSE AFTER PERIOD/SEX
* Sometime SORE/ITCH from DAMPNESS

Question 11

Bacterial Vaginosis: pathogen

Answer 11

• IMBALANCE of BACTERIA RATHER THAN INFECTION
  
  • BIOFILM PROBLEM (like dental caries) = REDUCED LACTOBACILLI, INCREASED GARDNERELLA VAGINALIS, ENTEROCOCCUS FAECALIS, ACTINOMYCES NEUII

Question 12

Bacterial Vaginosis: complications

Answer 12

• Usually ASYMPTOMATIC/MILD SYMPTOMS
  
  • ASS. w/ ENDOMETRITIS if UTERINE INSTRUMENTATION/DELIVERY
  • ASS. w/ PREMATURE LABOUR
  • INCREASES RISK of HIV ACQUISITION

Question 13

Bacterial Vaginosis: investigations/diagnosis

Answer 13

CHARACTERISTIC Hx

EXAMINATION FINDINGS = THIN, HOMOGENOUS DISCHARGE

VAGINAL SWAB

	○ pH = looking for RISE, other causes incl. TRICHOMONIASIS
	○ GRAM STAINED SMEAR of VAGINAL DISCHARGE

Question 14

Aetiology of Balanitis/Posthitis

Answer 14

Candida
Zoon’s balanitis/plasma cell balanitis
Impetigo
Erysipela
Dermatophyte infection - trichophyton rubrum (tinea infection e.g. tinea cruris)
Erythrasma - Corynebacterium minutissimum

Question 15

Non-microbial origin: functional symptoms, other lines of questioning, management

Answer 15

Symptoms: normal/physiological findings

* VAGINAL DISCHARGE
* URETHRAL DISCHARGE
* DYSURIA
* GENITAL/PELVIC DISCOMFORT
* RASHES
* SKIN LUMPS
* PENIS SIZE, SCROTAL LUMPS, LABIAL SHAPE - TEMPORARY/MORE PERSISTENT (body dysmorphia)

Other lines of questioning:

* REGRETTED SEXUAL ENCOUNTER
* PROBLEMS IN LIFE
* CO-EXISTING MENTAL ILL-HEALTH - ANXIETY
* WHEN DID THEY NOTICE PROBLEM?
* WHEN WERE THINGS LAST NORMAL?

Management:

* ACKNOWLEDGE PERCEPTION - don't tell pt. they're not experiencing symptoms
* WHAT DO THEY THINK IS CAUSING SYMPTOMS? - CANCER, INFERTILITY, STD
* VARIANTS of REASSURANCE (alternative explanations)
* DISCUSS LIMITATIONS of MEDICAL APPROACH

Question 16

Non-microbial origin: organic problems

Answer 16

• DERMATOSES

* STRUCTURAL ABNORMALITIES - CONGENITAL/ACQUIRED

Question 17

Physiological findings

Answer 17

Fox-Fordyce spots
Vaginal papillomatosis
Pearly papules/coronal papillae
Tyson’s glands

Question 18

Other causes of genital symptoms

Answer 18

• PAIN SYNDROMES (the ‘dynias’)
  
  • DERMATOSES
  • CONGENITAL
  • TRAUMATIC
  • NEOPLASTIC
  • MANIFESTATIONS of SYSTEMIC DISEASE

etc.

Question 19

Pain syndromes

Answer 19

• VESTIBULODYNIA = PROVOKED INTROITAL TENDERNESS
  
  • VULVODYNIA = PERSISTENT BURNING/ACHING
  • CHRONIC PELVIC PAIN SYNDROME = sometimes labelled prostatitis (but not inflammatory), UNCLEAR CAUSE BUT MUSCULAR DYSFUNCTION IMPLICATED