Genital discharge

Question 1

How does chlamydia present?

Answer 1

-50% men and 75% women asymptomatic
-Dysuria or discharge
-IMB or PCB
-Deep dyspareunia
-Testicular / pelvic / abdo pain
-Ascending infection (acute salpingitis or PID)
-Mucopurulent cervicitis +/- contact bleeding

Question 2

What is the incubation period for chlamydia?

Answer 2

-1-3 weeks

Question 3

How would you test for chlamydia?

Answer 3

2 week window period
-WOMEN = VVS NAAT
-MEN = first void urine
-May need rectal and pharyngeal swabs also (women with rectal symptoms should be referred to GUM)
-Difficult to culture as it is an intracellular organism

Question 4

What complications can arise from chlamydia?

Answer 4

-PID, endometritis, salpingitis
-Tubal infertility
-Ectopic pregnancy
-Sexually acquired reactive arthritis (SARA)
-Perihepatitis (Fitz-Hugh-Curtis syndrome)
-Lymphogranuloma Venerum (small painless pustule progressing to ulcers, lymphadenopathy and proctocolitis)

Question 5

Where in the reproductive tract does chlamydia colonise?

Answer 5

-Urethra
-Endocervix

Question 6

How is chlamydia managed?

Answer 6

-DOXYCYCLINE 100mg BD for 7 days
-If pregnant / BF / allergy: azithromycin 1g single dose + 500mg OD on day 2 + 3
-Avoid sex for 1 week and until patient + partner has completed treatment
-Test of cure 4 weeks later if pregnant

Question 7

Where does gonorrhoea colonise?

Answer 7

Mucous membranes
-Urethra
-Endocervix
-Rectum
-Pharynx
-Conjunctiva

Question 8

How does gonorrhoea present?

Answer 8

-Asymptomatic in 50%
-Increases or altered discharge
-IMB / PCB / menorrhagia
-Lower abdomen pain
-Urethral infection may cause dysuria
-Mucopurulent endocervical discharge / contact bleeding

Question 9

How is gonorrhoea tested for?

Answer 9

-VVS NAAT
-Bacterial swab for gram-staining microscopy and culture from infected sites to test for antibiotic sensitivity (pharynx, rectum, urethra)

Question 10

How would you manage gonorrhoea

Answer 10

-Ceftriaxone 1g IM single dose
-Refer to GUM for treatment and partner notification
-Avoid sex for 1 week
-Test of cure for all at 3 weeks

Question 11

Where does trichomonas colonise?

Answer 11

-Vagina, urethra + paraurethral glands in women
-Protozoan

Question 12

How does trichomonas present?

Answer 12

-Many asymptomatic
-Increased vaginal discharge
–Frothy yellow
-Vulval itch / vulvitis
-Vaginitis
-Dysuria
-‘Strawberry cervix’

Question 13

How do you test for trichomonas?

Answer 13

-VVS NAAT
-Swab posterior fornix during speculum examination for wet mount microscopy (GUM only)

Question 14

How do you manage trichomonas?

Answer 14

-Metronidazole 400mg BD for 7 days
–CANNOT DRINK ALCOHOL
-Sexual partner should be treated and avoid sex for 1 week

Question 15

What complications can arise from gonorrhoea infection?

Answer 15

WOMEN:
-PID, chronic pelvic pain
-Ectopic pregnancy
-Infertility
-Dyspareunia
-Perihepatitis
-Urethral stricture
-Gonococcal arthritis
-Pregnancy:
–Conjunctivitis within 3 days of birth
–Can cause joint problems
–PROM
–Chorioamnionitis
MEN:
-Epididymo-orchitis
-Proctitis
-Disseminated gonorrhoea

Question 16

What complications can arise from trichomonas?

Answer 16

-Persistent infection can increase STI susceptibility
-Pregnancy:
–LBW, PPROM, preterm birth

Question 17

What is the most common cause of abnormal discharge in women of childbearing age?

Answer 17

-Bacterial vaginosis - non-STI
-Lactobacilli are dominant in a healthy vagina

Question 18

What changes occur to vaginal bacteria in bacterial vaginosis infection?

Answer 18

-Flora becomes dominated by anaerobic bacteria
-Reduced numbers of lactobacilli
-pH 4.5-6.0

Question 19

What is a normal vaginal pH?

Answer 19

-pH <4.5

Question 20

How does BV present?

Answer 20

-Offensive smelling vaginal discharge (‘fishy’)
-Increased volume discharge, thin, watery
-Not associated with soreness, itching or irritation

Question 21

What risk factors are there for developing BV?

Answer 21

-Vaginal douching
-Receptive cunnilingus
-Recent partner change

Question 22

How would you test for BV?

Answer 22

-pH >4.5
-Low vaginal swab (sent to lab for Hay/Ison criteria gram stain)

Question 23

How should you manage BV?

Answer 23

-Only treat if symptomatic or patient choice / undergoing surgery
–Metronidazole (oral / topical)
-Advice:
–Avoid douching
–Avoid antiseptic agents / bath products

Question 24

What complications can arise from BV?

Answer 24

-Cellulitis / abscess formation following TV hysterectomy
-Risk of late miscarriage, preterm birth, PROM, PP endometritis

Question 25

How does candida infection present?

Answer 25

-Vulval itch / soreness
-Thick vaginal discharge
-Superficial dyspareunia
-Oedema

Question 26

How would you investigate candida?

Answer 26

-Microscopy gram-stain in specialist settings / culture of LVS for yeast typing and sensitivities

Question 27

How should you manage candida?

Answer 27

-Only treat if symptomatic / patient choice:
–Clotrimazole pessary 500mg single dose
–Fluconazole 150mg oral single dose
-Advice:
–Soap substitute and emollient use
–Avoid tight fitting clothing and local irritants