Common genital symptoms and non-genital causes

Question 1

Genital symptoms

Answer 1

• Discharge
• Pain from somewhere
• Rashes
• Lumps and swellings
• Cuts, sores, ulcers
• Itching
• Changes in appearance
• Vague sense things aren’t right

Question 2

What could be causing genital symptoms

Answer 2

• Sexually transmitted disease
• Other microbial causes
• Non-microbial

Question 3

Microbial conditions not regarded as STD’s in the UK

Answer 3

• Vulvovaginal candidiasis
• Bacterial vaginosis
• Balanoposthitis - anaerobic/ candidate
• Tinea cruris
• Erythrasma
• Infected sebaceous glands
• Impetigo
• Folliculitis
• Cellulitis

Question 4

Vulvovaginal candidosis

Answer 4

• 70% Candida albicans
• Usually from bowel
• Often asymptomatic carrier
• Symptomatic
  
  • Itch
  • Discharge (cottage cheese appearance)
• Common commensal in vagina

Question 5

Thrush

Answer 5

• Itch
• Discharge

Question 6

Predisposing factors to candidosis

Answer 6

• Immunosuppression
• Pregnancy
• Diabetes, oral steroids
• Reproductive age group (oestrogen = glycogen = food for yeast)

Question 7

Diagnosis of of vulvovaginal candidiasis

Answer 7

• Characteristic history
• Vaginal Ph
• Examination finding
  
  • Fissuring
  • Erythema and saterlitte lesions
  • Discharge

Question 8

Investigations for vulvovaginal candidiasis

Answer 8

• Gram staining (low sensitivity)
• Culture (high sensitivity, low specificity)
• PCR (hight sensitivity, low specificity)

Question 9

Treatment of candida

Answer 9

• Self-limiting if mild
• Azole anti fungal treatment (clotimazole, fluconazole)
• Other management
  
  • Maintain skin barrier
  • Avoid irritants
  • Treat dermatitis

Question 10

Bacterial vaginosis

Answer 10

• Commonest cause of abnormal vaginal discharge
• Caused by an imbalance of commensal bacteria in vagina
• Symptoms
  
  • Asymptomatic
  • Watery grey/ yellow ‘fishy’ discharge
  • Worst after period/ sex
  • Sore/ itch from dampness

Question 11

Cause of biofilm in bacterial vaginosis

Answer 11

• Structure produced by bacteria to aid colonisation
• Increased gardnerella vaginalis, enterococcus faecalis and actinomyces neuii
• Reduced lactobacilli → reduced production of H2020
• Associated with vitamin D deficiency
• Raised pH

Question 12

Complications of bacterial vaginosis

Answer 12

• Associated with endometritis (in association with uterine instrumentation/ delivery)
• Associated with premature labour
• Risk of increased HIV acquisition

Question 13

Diagnosis of bacterial vaginosis

Answer 13

• Characteristic history
• Examination → thin homogenous discharge
• pH (will be higher)
• Gram stained smear of vaginal discharge

Question 14

Treatment of bacterial vaginosis

Answer 14

• Antibiotics
  
  • Metronidazole (oral/ vaginal)
  • Clindamycin (vaginal)
• Probiotics
• Vaginal acidification

Question 15

Other microbial causes of genital symptoms

Answer 15

• Zoon’s balanitis (
• Impetigo (staph A./ strep P.
• Erysipelas (strep. progenies)
• Dermatophyte infection
• Tinea cruris (athletes groin)
• Erythrasma

Question 16

Non microbial causes of genital symptoms

Answer 16

• Perceived problem
  
  • No clinical findings
  • Only findings are physiological
• Dermaroses
• Structural abnormalities
  
  • Congential
  • Acquired

Question 17

Symptoms of a perception of abnormality with nil to find

Answer 17

• Vaginal discharge
• Urethral discharge
• Dysuria
• Genital/ pelvic discomfort
• Rashes
• Skin lumps
• Penis size, scrotal lumps, labial shape

Question 18

Questions to ask when nil found on examination/ test results

Answer 18

• Regretted sexual encounter
• Problems in life
• Co-exisitng mental illness
• When were things last ‘normal’?

Question 19

Approach to management of genital symptoms

Answer 19

• Patients perception
• What do they think might be causing the problem (HIV, cancer, STD)
• Variants of reassurance (benign cause of symptoms
• Discuss limitations in medical approach

Question 20

Physiological clinical signs

Answer 20

• Fox-fordyce spot
• Vulval papillomatosis
• Penile pearly papule (coronal papillae)
• Tyson’s glands

Question 21

Other non-microbial causes of genital symptoms

Answer 21

• Pain syndromes (‘dynias’)
• Dermatoses
• Congenital
• Traumatic/ iatrogenic
• Neoplastic
• Neuromuscular
• Systemic disease manifestation
• Idiopathic
• Trauma
• ‘Hypervigilance’

Question 22

Pain syndromes

Answer 22

• Vestibulodynia (provoked introital tenderness)
• Vulvodynia (persistent burning or aching)
• Chronic pelvic pains syndrome (unclear cause maybe muscular dysfunction)