Gen Sexual health Flashcards
Gonorrhoea treatment?
IM ceftriaxone
Chlamydia
Doxycycline or azithromycin
Pelvic inflammatory disease
Oral ofloxacin + oral metronidazole
OR
IM ceftriaxone + oral doxycycline + oral metronidazole
Syphilis
Benzathine benzylpenicillin
OR
doxycycline
OR
erythromycin
Bacterial vaginosis
Oral or topical metronidazole
OR
topical clindamycin
HSV, VZV
Aciclovir
Chancroid?
Chancroid is a tropical disease caused by Haemophilus ducreyi. It causes painful genital ulcers associated with unilateral, painful inguinal lymph node enlargement. The ulcers typically have a sharply defined, ragged, undermined border.
Bacterial Vaginosis:
- What is it?
- Features?
- Criteria for Diagnosis?
- Management
What is it?
- describes an overgrowth of predominately anaerobic organisms such as Gardnerella vaginalis. This leads to a consequent fall in lactic acid producing aerobic lactobacilli resulting in a raised vaginal pH.
Features?
- vaginal discharge: ‘fishy’, offensive
- asymptomatic in 50%
Criteria for Diagnosis?
- Amsel’s criteria for diagnosis of BV - 3 of the following 4 points should be present
- thin, white homogenous discharge
- clue cells on microscopy: stippled vaginal epithelial cells
- vaginal pH > 4.5
- positive whiff test (addition of potassium hydroxide results in fishy odour)
Management?
- oral metronidazole for 5-7 days
- 70-80% initial cure rate
- relapse rate > 50% within 3 months
- the BNF suggests topical metronidazole or topical clindamycin as alternatives
Genital herpes:
- Types of strains
- Features
- Investigations
- Management
- Pregnancy
HSV-1 and HSV-2. Whilst it was previously thought HSV-1 accounted for oral lesions (cold sores) and HSV-2 for genital herpes it is now known there is considerable overlap
Features
- painful genital ulceration
- may be associated with dysuria and pruritus
- the primary infection is often more severe than recurrent episodes
- systemic features such as headache, fever and malaise are more common in primary episodes
- tender inguinal lymphadenopathy
- urinary retention may occur
Investigations
- NAAT is the investigation of choice in genital herpes and are now considered superior to viral culture
- HSV serology may be useful in certain situations such as recurrent genital ulceration of unknown cause
Management
general measures include:
- saline bathing
- analgesia
- topical anaesthetic agents e.g. lidocaine
- PRIMARY ATTACK: oral aciclovir 400 mg three times a day for 5–10 days, or 200 mg five times a day for 5–10 days
- EPISODIC ANTIVIRAL TREATMENT — if attacks are infrequent (less than six attacks per year) - Prescribe oral aciclovir 800 mg three times a day for 2 days, Alternatively, for 5-day treatment regimens: prescribe aciclovir 200 mg five times a day (or 400 mg three times a day)
- Consider self-initiated treatment, so antiviral medication can be started early in the next attack.
- SUPPRESSIVE ANTIVIRAL TREATMENT — if attacks are frequent (six or more attacks per year), causing psychological distress, or affecting the person’s social life.
Prescribe aciclovir 400 mg twice a day (or 200 mg four times a day)
If breakthrough recurrences occur, the dosage should be increased. Consider seeking specialist advice.
Continue treatment for a maximum of one year, after which it should be stopped to assess recurrence (for a minimum of two recurrences). Consider restarting treatment in people who have high rates of recurrence.
Pregnancy
- elective caesarean section at term is advised if a primary attack of herpes occurs during pregnancy at greater than 28 weeks gestation
- women with recurrent herpes who are pregnant should be treated with suppressive therapy and be advised that the risk of transmission to their baby is low
Genital warts
Types: They are caused by the many varieties of the human papillomavirus HPV, especially types 6 & 11
Features:
- small (2 - 5 mm) fleshy protuberances which are slightly pigmented
- may bleed or itch
Management:
- topical podophyllum or cryotherapy are commonly used as first-line treatments depending on the location and type of lesion
–multiple, non-keratinised warts are generally best treated with topical agents
–solitary, keratinised warts respond better to cryotherapy
imiquimod is a topical cream that is generally used second line
- genital warts are often resistant to treatment and recurrence is common although the majority of anogenital infections with HPV clear without intervention within 1-2 years
Gonorrhoea
- Bacteria
- Incubation
- Features
- Microbiology
- Management
- Complications
Bacteria - Gram-negative diplococcus Neisseria gonorrhoeae. Acute infection can occur on any mucous membrane surface, typically genitourinary but also rectum and pharynx.
Incubation - incubation period of gonorrhoea is 2-5 days
Features:
- males: urethral discharge, dysuria
- females: cervicitis e.g. leading to vaginal discharge
rectal and pharyngeal infection is usually asymptomatic
Microbiology: reinfection is common due to antigen variation of type IV pili (proteins which adhere to surfaces) and Opa proteins (surface proteins which bind to receptors on immune cells)
Management:
- IM ceftriaxone 1g
- If ceftriaxone is refused (e.g. needle-phobic) then oral cefixime 400mg (single dose) + oral azithromycin 2g (single dose) should be used
Complications: Local complications that may develop include urethral strictures, epididymitis and salpingitis (hence may lead to infertility). Disseminated infection may occur
Disseminated gonococcal infection
Disseminated gonococcal infection (DGI) and gonococcal arthritis may also occur, with gonococcal infection being the most common cause of septic arthritis in young adults.
The pathophysiology of DGI is not fully understood but is thought to be due to haematogenous spread from mucosal infection (e.g. Asymptomatic genital infection). Initially there may be a classic triad of symptoms: tenosynovitis, migratory polyarthritis and dermatitis. Later complications include septic arthritis, endocarditis and perihepatitis (Fitz-Hugh-Curtis syndrome)
Key features of disseminated gonococcal infection
tenosynovitis
migratory polyarthritis
dermatitis (lesions can be maculopapular or vesicular)
What colour will gram +ve bacteria turn on gram staining?
Gram-positive bacteria will turn purple/blue following the gram staining. Microscopy will then reveal the shape, either cocci or rods.
Reaction after starting treatment in Syphillis?
- Jarisch-Herxheimer reaction is sometimes seen after initiating therapy
- Fever, rash, tachycardia after first dose of antibiotic (more commonly seen in syphilis, another spirochaetal disease)
Lymphogranuloma venereum (LGV)
- Caused by?
- RF
- Stages of infection
- Tx
LGV is caused by Chlamydia trachomatis serovars L1, L2 and L3
Risk factors:
- men who have sex with men
- the majority of patients who present in developed countries have HIV
historically was seen more in the tropics
Typically infection comprises of three stages:
- stage 1: small painless pustule which later forms an ulcer
- stage 2: painful inguinal lymphadenopathy
may occasionally form fistulating buboes
stage 3: proctocolitis
LGV is treated using doxycycline.
- ‘Normal’ Chlamydia resulting in urethritis and pelvic inflammatory disease is caused by Chlamydia trachomatis serovars D through K.
Non-gonococcal urethritis?
Non-gonococcal urethritis (NGU, sometimes referred to as non-specific urethritis) is a term used to describe the presence of urethritis when a gonococcal bacteria are not identifiable or the initial swab.
A typical case would be a male who presented to a GUM clinic with a purulent urethral discharge and dysuria.
A swab would be taken in clinic, microscopy performed which showed neutrophils but no Gram negative diplococci (i.e. no evidence of gonorrhoea). Clearly this patient requires immediate treatment prior to waiting for the Chlamydia test to come back and hence an initial diagnosis of NGU is made.
Causative organisms include:
- Chlamydia trachomatis - most common cause
- Mycoplasma genitalium - thought to cause more symptoms than Chlamydia
Management
contact tracing
the BNF and British Association for Sexual Health and HIV (BASHH) both recommend either oral azithromycin or doxycycline
PID
- Causes?
- Causative organisms?
- Features?
- Ix
- Management?
- Complications?
Causes?
usually the result of ascending infection from the endocervix
Causative organisms?
- Chlamydia trachomatis - the most common cause
- Neisseria gonorrhoeae
- Mycoplasma genitalium
- Mycoplasma hominis
- Features?
- lower abdominal pain
- fever
- deep dyspareunia
- dysuria and menstrual irregularities may occur
- vaginal or cervical discharge
- cervical excitation
Ix:
- a pregnancy test should be done to exclude an ectopic pregnancy
- high vaginal swab
these are often negative
screen for Chlamydia and Gonorrhoea
Management?
- low threshold for treatment
- oral ofloxacin + oral metronidazole OR
- intramuscular ceftriaxone + oral doxycycline + oral metronidazole
Complications:
- perihepatitis (Fitz-Hugh Curtis Syndrome)
occurs in around 10% of cases
it is characterised by right upper quadrant pain and may be confused with cholecystitis
- infertility - the risk may be as high as 10-20% after a single episode
- chronic pelvic pain
- ectopic pregnancy
Pubic lice treatment?
- Management
Clothing and bed linen should be decontaminated, either by washing at >50ºC or by placing in a sealed plastic bag for >7 days.
Management of pubic lice involves application of either: malathion 0.5%, permethrin 1%, phenothrin 0.2% or carbaryl 0.5% All of these creams or lotions are applied to all body hair and left on the hair for the recommended ‘treatment time’ before being washed off.
-Treatment should be re-applied after 3-7 days: this is due to the presence of lice and eggs being at different stages of their life cycle.
-Mechanical removal should also be employed using nit-combs or similar techniques. However, shaving does not have a role in the management of pubic lice and should not be recommended.
-Re-examination should be performed approximately 1 week after treatment to ensure response to treatment.
Contact tracing should also be performed and any sexual partners within the past 3 months should be examined and treated where appropriate.
STI: Ulcers
Genital herpes: HSV 2 (cold sores by HSV 1). Primary attacks are often severe and associated with fever whilst subsequent attacks are generally less severe and localised to one site. There is typically multiple painful ulcers.
Syphilis:
caused by the spirochaete Treponema pallidum. Infection is characterised by primary, secondary and tertiary stages. A painless ulcer (chancre) is seen in the primary stage. The incubation period= 9-90 days.
Chancroid - a tropical disease caused by Haemophilus ducreyi. It causes painful genital ulcers associated with unilateral, painful inguinal lymph node enlargement. The ulcers typically have a sharply defined, ragged, undermined border.
LGV - caused by Chlamydia trachomatis. Typically infection comprises of three stages
stage 1: small painless pustule which later forms an ulcer
stage 2: painful inguinal lymphadenopathy
stage 3: proctocolitis
- Treated with doxycycline
OTHER:
- Behcet’s disease
- carcinoma
- granuloma inguinale: Klebsiella granulomatis*
Behcets triad?
Cause?
- Features
classically: 1) oral ulcers 2) genital ulcers 3) anterior uveitis - thrombophlebitis and deep vein thrombosis
- arthritis
- neurological involvement (e.g. aseptic meningitis)
GI: abdo pain, diarrhoea, colitis
erythema nodosum
Diagnosis:
- no definitive test
- diagnosis based on clinical findings
positive pathergy test is suggestive (puncture site following needle prick becomes inflamed with small pustule forming)
