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Common STI presentations Flashcards

1
Q

What are some causes of dysuria in young women?

A 
UTI
Chlamydia trachomatis
Gonorrhoea
Genital herpes 
Genital candidiasis 
Trichomonas vaginalis
Vulval dermatoses
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2
Q

What diagnosis would a Hx of vaginal discharge, PCB or IMB and pelvic pain make you consider?

A

Chlamydia
Gonorrhoea
PID

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3
Q

What diagnosis would a Hx of frequent, nocturne, haematuria and loin pain make you consider?

A

UTI

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4
Q

What diagnoses would a presentation of vulval ulcers, itching or soreness and external dysuria make you consider?

A

Herpes

Candida

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5
Q

If someone presents with vaginal skin problems, and skin problems elsewhere, what diagnosis might you consider?

A

Lichoplanus

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6
Q

What examinations and investigations would you do for a woman who presents with:
14 day Hx of dysuria
Trimethoprim not helped
Canesten not helped

A

Examinations:
vulva - looking for excoriation, fissuring, erythema, oedema, ulceration

Investigations:
MSU
Swabs
- any ulcers (herpes/T. pallidum)
- VV swab (chlamydia and gonorrhoea NAAT)
- High vaginal swabs (candida, BV and TV)
- Endocervical swab (gonorrhoea culture)

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7
Q

How should you treat chlamydia?

A

Azithromycin 1g stat (safe in pregnancy)
OR
doxycycline 100mg bd 1/52

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8
Q

Can 1g of azithromycin be given in pregnancy?

A

Yes - safe in pregnancy

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9
Q

Can doxycycline be given in pregnancy?

A

No

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10
Q

What is important to tell someone who has just been diagnosed with chlamydia?

A

Discuss partner notification

Don’t have sex until both partners have completed their ABX

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11
Q

Do patients who have been given azithromycin for chlamydia have to wait 7-10 days before having sex again?

A

Yes

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12
Q

What are some potential causes of vaginal discharge in a young woman?

A

Normal (?genitally aware)

Vaginal infections - BV, TV and candida

Cervical infections - chlamydia trachoma’s
N. gonorrhoea

Physiological - cervical ectopy
pregnancy

Other: retained tampon, foreign body

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13
Q

How would you diagnose a female genital infection?

A

Look at vaginal discharge

Vaginal pH swab (BV)

High vaginal swab: BV, candida, trichomonas

VV swab: chlamydia and gonorrhoea NAAT

Endocervical swab: gonorrhoea culture

Syphilis serology
HIV antibody/antigen testing

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14
Q

What pH should the vagina have? Acidic or alkaline?

A

Acidic

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15
Q

What pH do TV and BV cause on a swab? Acidic or alkaline?

A

alkaline

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16
Q

What are some causes of post coital bleeding?

A

Infection: chlamydia
gonorrhoea

Cervical abnormality: polyp
premalignant
malignancy
ectopy

Pill not strong enough

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17
Q

What are some signs of cervicitis?

A

mucopurulent discharge

contact bleeding

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18
Q

What are some causes of dysuria and urethral discharge in men?

A

STI: chlamydia
gonorrhoea
NGU

UTI

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19
Q

If a young male presents with UTI, what should you do?

A

Consider further investigation of renal tract or referral to urology

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20
Q

In a male presenting with dysuria and penile discharge, how would you distinguish between STI and UTI?

A

other urinary Sx - UTI

testicular pain 
spots/blisters
sexual Hx
PMH
drug Hx
allergies
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21
Q

How would you investigate a male with dysuria and penile discharge?

A

urine: - MSU for microscopy and culture
- first void urine (chlamydia and gonorrhoea)

Swabs: - urethral swab (culture for gonorrhoea)
- Rectal and pharyngeal (chlamydia and gonorrhoea in all MSM. NAAT and culture if going to give ABX on this visit)

Bloods: - syphilis serology
- HIV antibody test

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22
Q

how would you treat a man with chlamydia?

A

azithromycin 1g single dose
OR
doxycycline 100mg bd 7 days

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23
Q

how would you treat a man with gonorrhoea?

A

ceftriaxone 500mg IM single dose
azithromycin 1g PO

site of infection may alter ABX choice eg. pharyngeal gonorrhoea or rectal chlamydia - speak to GUM

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24
Q

What are the two key things to mention to patients with an STI?

A

Avoid unprotected sex until both they and their partner have been treated

Partner notification - text etc.

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25
Q

what is balanitis?

A

inflammation of the glans penis, it is a collection of disparate conditions with a similar clinical picture and varying aetiologies.

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26
Q

What are infective causes of balanitis, genital itch, rash and vulvitis?

A

Candidiasis
Trichomoniasis (females)
Scabies
Pthyris pubis

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27
Q

What are non-infective causes of balanitis, genital itch, rash and vulvitis?

A 
Non-infective
Dermatitis
Irritant vulvitis (females)
Irritant balanitis (males)
Lichen sclerosis
Lichen planus
Lichen simplex
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28
Q

What investigations would you do for someone who presented with balanitis?

A

Subpreputial swab for candida and bacterial culture

urinalysis (candida)

Viral swab (HSV)

Syphilis serology

STI screen

Biopsy if uncertain and condition persists

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29
Q

What conservative management would you suggest for someone with balanitis?

A

Salt water bathing
Avoid soaps while inflammation persists
Use aqueous cream/E45

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30
Q

What management would you suggest for someone with balanitis caused by chlamydia?

A

topical antifungals eg. canesten cream BD until symptoms resolve

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31
Q

What management would you suggest for someone with balanitis caused by eczema/psoriasis?

A

moderately potent topical steroid (betnovate)

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32
Q

What management would you suggest for someone with balanitis caused by lichen plants?

A

usually self-limiting

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33
Q

What management would you suggest for someone with balanitis caused by lichen sclerosis?

A

potent topical steroid

requires long-term follow up as small risk of malignant transformation

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34
Q

What management would you suggest for someone with balanitis caused by scabies/pubic lice?

A

topical permethrin

treat all household/sexual contacts

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35
Q

How does candida balanitis present? how would you treat it?

A

red papules
Superficie erosions or white plaques

Topical therapy eg. clotrimazole cream OR oral fluconazole

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36
Q

What things do you need to exclude/consider in someone who presents with candida balanitis?

A

Diabetes

?immunosupression

Lichen planes and penile intraepithelial neoplasia - mimic candida balanitis

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37
Q

How does circinate balanitis? What is it almost indistinguishable from?

A

Painless mucocutaneous lesions

Psoriasis

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38
Q

What is circinate balanitis associated with?

A

SARA

Sexually acquired reactive arthritis

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39
Q

How might scabies present?

A

widespread pyritic dermatitis

genital nodules

burrows in finger spaces

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40
Q

How would you diagnose scabies?

A

Clinical

Skin scrapings

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41
Q

How would you treat scabies?

A

Permethrin 5% cream

Treat household and close contacts

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42
Q

What is pthyris pubis?

A

pubic lice

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43
Q

How might pthyris pubis present? how is it diagnosed?

A

genital itch
blue spots
perifolliculitis

clinically

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44
Q

How would you treat pthyris pubis?

A

Permethrin 1% OR malathion 0.5%

Treat sexual partners

45
Q

What can cause genital dermatitis?

A

Irritant
Atopy
Allergic
Seborrhoeic

46
Q

How would you treat dermatological eczema?

A

avoid precipitants
General skin care advice
+/- topical steroids

47
Q

What causes lichen simplex?

A

Chronic rubbing or scratching

48
Q

How does lichen simplex present?

A

Poorly demarcated plaques of thickened skin

Usually effects scrtoum in men and labia major in women

49
Q

How would you treat lichen simplex?

A

Avoid irritants

Emollients/moisteriser

Mild topical steroid

50
Q

what are symptoms and signs of lichen sclerosis?

A

itch

soreness

atrophic skin

erosions

telangiectasia

loss of architecture

51
Q

How would you diagnose lichen sclerosis?

A

Clinical or biopsy

52
Q

What is the treatment for lichen sclerosis?

A

General skin care advice

Potent topical steroids

53
Q

What is a complication (rare) of lichen sclerosis?

A

Squamous cell carcinoma

54
Q

What causes lichen planus?

A

Unknown

55
Q

How might lichen plants present?

A

Different morphological appearances:

Violaceous, flat-topped papule, white lacy papules, plaques and erosions

56
Q

What is the main symptom of lichen planus?

A

itching

57
Q

What is the treatment for lichen planus?

A

Generally self-limiting

58
Q

What diagnosis would you suspect in someone who presented with a 2 day Hx of a sore spotty penis, sore left groin and generally feeling unwell?

A

Herpes

59
Q

What do herpes ulcers look like on penises?

A

shallow ulcers under foreskin

60
Q

How long does a primary infection of HSV take to present? What happens after this time?

A

2 days -2 weeks

Becomes a latent virus in local sensory ganglia

outbreaks occur when the virus is reactivated

61
Q

When does viral shedding generally occur in HSV?

A

First year of infection

Those with frequent outbreaks

62
Q

What are the different types of HSV? What organisms cause these?

A

HSV1 - usual cause of oral (now most common cause of genital disease)
Caused by 6, 11

HSV2 - more likely to cause anogenital symptoms
Caused by 16, 18

63
Q

Which type of HSV is more associated with recurrent outbreaks?

A

HSV2 (about 4 per year)

HSV1 (about 1 per year)

Recurrent outbreaks limited to infected dermatome

Recurrence rate decreases over time

64
Q

If someone presents with genital warts/ulcers and have a history of unprotected sex, what tests might you do?

A

Swabs (NAAT): Chlamydia
Gonorrhoea

HIV serology

Syphilis serology

Swab from ulcers for HSV 1& 2 and syphilis (PCR)

65
Q

How would you treat someone with herpes simplex virus?

A

Salt water bathing

Topical anaesthetic/oral analgesia

Acicolvir 300mg 3 x a day for 5 days

66
Q

How is Herpes spread?

A

Direct contact with mucous membrane or skin

67
Q

When is herpes simplex most infectious?

A

During recurrence
BUT
asymptomatic viral shedding occurs

68
Q

How would you counsel someone who’s got HSV?

A

acknowledge distress

Info about disease, recurrence rate etc.

Condoms reduce transmission

Avoid sex during recurrences

Disclosure is advised and should be documented

69
Q

How might syphilis present?

A

single non-tender ulcer on penis

non-tender lymph nodes in groin

70
Q

How might you investigate someone you thought had syphilis?

A 
Chlamydia
Gonorrhoea
HIV
Hepatitis
Syphilis
71
Q

What would you want to discuss with someone who has suspected syphilis?

A

Sexual health screen

Partner notification

Discuss HIV risk since last test

Repeat ‘window period’ bloods

Hep B vaccination

Safer sex advice

72
Q

How is syphilis spread?

A

Oral contact

Skin to skin contact with chancres/mucosal lesions

73
Q

How do you treat primary syphilis?

A

First line: benzathine penicillin 2.4MU IM stat

74
Q

How might early primary syphilis present?

A

Chancre

Regional lymphadenopathy

75
Q

When does secondary syphilis occur? How does it present?

A

If patient doesn’t seek treatment or not fully treated

Systemic infection: 
flat red rash on chest, torso, palms or feet. 
Snail trail in mouth
splenomegaly
neurological (eg. hearing)
76
Q

After 4-12 weeks of primary/secondary syphilis, what happens? What stage of disease could this be?

A

Sx disappear

Symptoms can be silent for up to 2 years

Early latent (up to 2 years)
Late latent (after 2 years)
77
Q

If someone has no symptoms, but screens positive for syphilis, what is it important to know? Why?

A

Syphilis can be asymptomatic after initial presentation

Need to know when they were last screened -ve for syphilis. Tells you when they acquired syphilis. Decides whether early latent or late latent. Effects treatment.

78
Q

What type of syphilis does someone have if they HAVE had a NEGATIVE syphilis screen within the last 2 years?

A

Early latent - acquired within the last 2 years

79
Q

What type of syphilis does someone have if they HAVEN’T had a NEGATIVE syphilis screen within the last 2 years?

A

Assume late latent - unsure whether this was acquired within the last 2 years, could be longer

80
Q

How would you treat early latent syphilis?

A

1 injection of

81
Q

How would you treat late latent syphilis?

A

1 injection every 3 weeks

82
Q

What is a cardiovascular manifestation of syphilis?

A

aortic root involvement

83
Q

What is a gummatous manifestation of syphilis?

A

nodules

84
Q

What is a neurological manifestation of syphilis?

A

meningovascular
tabes dorsalis
general paresis

85
Q

How does genital ulceration impact the risk of HIV transmission?

A

Increases the risk of transmission

86
Q

What are other (non-syphilitic) causes of genital ulceration?

A 
Chancroid
Shingles
Lichen sclerosis and planus
Aphthous ulcer
Malignancy
Zion's balanitis
Eczema or psoriasis
Pyoderma gangrenosum
Behcets
Crohns
SJS
87
Q

If a patient comes back with recurrent genital ulcers, what is an important differential to keep in mind?

A

Behcets

88
Q

What is molluscum contagiosum?

A

Self-limiting infection

Caused by molluscs virus (DNA poxvirus)

89
Q

How do you diagnose molluscum contagiosum?

A

Clinically

90
Q

How long can molluscum contagious take to go away?

A

6-12 months

91
Q

What is the treatment for molluscum contagiosum?

A

Watch and wait

If no resolution: cryotherapy
curette
enucleation
podophyllotoxin

92
Q

If someone has lumps that are well defined, itchy and darker than flesh, what diagnosis might this lead you to?

A

Genital warts

93
Q

What type of HPV is considered ‘low risk’?

A

6
11

Most likely to cause warts

94
Q

What HPV is most commonly associated with cancer?

A

16, 18

Unlikely to cause warts

95
Q

What causes genital warts?

A

HPV infection

96
Q

How are genital warts transmitted?

A

through micro abrasions in genital skin during sexual contact

6 and 11 can be transmitted via oral-genital contact

Likely to have acquired HPV from ‘asymptomatic’ partner

97
Q

In which was is HPV unlikely to be transmitted?

A

digital-genital contact

via fomite transmission

98
Q

What is the average incubation period for HPV (6/11)?

A

median: 3 months
Can be as short as 3 weeks
Can be as long as 2 years

99
Q

How long do genital warts tend to last?

A

3 months with appropriate treatment BUT
HPV DNA can be found in skin for a median duration of about a year

Small minority may have warts for longer than a year

100
Q

When are people with HPV most infectious?

A

When they have visible warts

transmission can still occur via sub-clinical lesions and latent infection

101
Q

Do condoms prevent the transmission of HPV?

A

NO - they just reduce it

102
Q

How can we treat genital warts?

A

Ablative therapies:
cryotherapy
podophyllotoxin cream/solution
electrocautery

Immune modulation:
imiquimod 5% cream - keratinised/persistent/recurrent warts
Reduced recurrence rate

Surgical:
curettage
excision
debulking

103
Q

Why wouldn’t you treat a pregnant woman with genital warts?

A

Cream is teratogenic

104
Q

Why is only cryotherapy used for anal warts?

A

More difficult to treat

105
Q

How should you counsel a man with genital warts who is concerned about giving his girlfriend cervical cancer?

A

Low risk subtypes (6, 11) EXCEPTIONALLY UNLIKELY TO CAUSE PRE-MALIGNANT CHANGE

High risk subtypes (16,18)
UNLIKELY TO CAUSE VISIBLE WARTS

Girlfriend should attend cervical screening as normal

GF is likely to have been vaccinated against 16 and 18 (if younger, 6, 11, 16, 18)

106
Q

Why might someone get anal warts without having had anal sex?

A

HPV is a multi-centric infection

Not limited to initial site of inoculation

107
Q

What might you tell a woman who has warts during her pregnancy/who is trying to get pregnant?

A

Warts may appear, recur or persist in pregnancy

treatment options are limited

Warts usually resolve after delivery

108
Q

Why isn’t HPV screened for in sexual health screening?

A

No clear link between detection of HPV and visible warts

Used in cervical screening

109
Q

How is HPV testing used in cervical screening?

A

Used in samples with borderline or low grade dyskariosis

HPV positive: refer to colposcopy

HPV negative: refer back to routine screening

GOSH (33 decks)

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