Genital discharge and GUM Flashcards
physiological causes of vaginal discharge?
pregnancy
association with time in menstrual cycle
sexual stimulation
features-odourless clear/white discharge with no irritation, pH 4.5 or less
pathological causes of vaginal discharge?
infection-candida, trichomonas, bacterial vaginosis, gonorrhoea, chlamydia
neoplasia-cervical Ca
FB e.g. retained tampon
ectropion-endocervical columnar epithelium protrudes out of external os onto vaginal portion of the cervix and undergoes squamous metaplasia transforming to stratified squamous epithelium.
key features of genital candida infection?
cottage cheese discharge, thick, white vulvitis-vulval oedema not offensive itch/soreness superficial dyspareunia pH 4.5 or less
signs: vulvovaginitis, swelling
linear fissures
satellite lesions-pustules or erythema surrounding the margin
key features of trichomonas vaginalis (protozoal parasite) infection?
offensive, frothy yellow/green discharge strawberry cervix-punctate and papilliform appearance vulvovaginitis itchy/sore dysuria pH more than 5
key features of bacterial vaginosis?
fishy smelling offensive thin white/grey discharge
usually no irritation, but maybe burning
pH more than 5
can arise and remit spontaneously in women regardless of sexual activity
what association exists between bacterial vaginosis and HIV?
bacterial vaginosis increases risk of HIV acquisition and transmission
BV other complications:
post termination of pregnancy endometritis and PID
recurrent late miscarriage
risk factors for STIs?
young age-under 25, especially under 20
single, or more than 1 sexual partner in the last 6 months
non use of barrier contraception
ethnicity-hep B in asians and orientals, HIV in black africans, gonorrhoea and trichomoniasis in black caribbeans
sexual orientation
residence in metropolitan areas
most commonly diagnosed STI in GUM clinics in the UK?
anogenital warts
type of swab for candida infection?
high vaginal swab
type of swab for bacterial vaginosis?
high vaginal swab
type of swab for trichomonas vaginalis?
high vaginal swab
bacterial vaginosis causative organism?
characterised by reduction in lactobacilli and overgrowth of predominantly anaerobes: gardnerella vaginalis prevotella spp. mycoplasma hominis mobiluncus spp.
increase in vaginal pH
most specific criterion for diagnosing bacterial vaginosis?
demonstration of clue cells on saline smear of high vaginal swab under the microscope
=vaginal epithelial cells with bacteria adherent to their surfaces
what criteria are used to make a diagnosis of bacterial vaginosis?
Amsel’s criteria: (3 of 4 should be positive)
thin grey/white homogenous discharge
vaginal fluid pH more than 4.5
positive amine test (release of fishy odour on adding alkali-10% KOH)
clue cells on microscopy of high vaginal swab
bacterial vaginosis treatment?
indicated for symptomatic women and pregnant women with hx of recurrent miscarriage
metronidazole 400mg BD for 5 days, or 2g stat (stat best avoided in pregnancy)
alternatives:
intravaginal metronidazole gel OD for 5 days
intravaginal clindamycin cream OD for 7 days
clindamycin 300mg BD for 7 days
advise to avoid vaginal douching, use of shower gel and antiseptic agents/shampoo in the bath
no f/u necessary if symptoms resolve
how is vaginal candidiasis diagnosed in primary care?
clinically
vaginal pH less than 5
HVS-but 10-20% of women are asymptomatic vaginal carriers so symptom may not be due to the candida isolated, under microscope-hyphae
note tests may be -ve if recently self treated so check for use of OTC treatments
treatment of vaginal candida?
only treat if patient symptomatic, but can treat without +ve culture
antifungal pessary stat-clotrimazole, then cream for 2 wks
alternative: fluconazole 150mg stat
topical tment advised in pregnancy
ensure avoidance of precipitants in recurrent infections e.g. soaps, shower gel, sanitary towels
rule out RFs
RFs for recurrent vaginal candidiasis?
DM thyroid disease Fe deficiency with or without anaemia underlying immunodeficiency steroid use frequent use of Abx
presentation of candida in men?
balanitis with pruritus
may be 1st sign of previously undiagnosed DM
tment of candida infection in men?
saline bathing with or without azole cream
if recurrent, investigation and tment of female partner may be beneficial.
complications of perinatal transmission of chlamydia?
neonatal conjunctivitis, usually presenting in 2nd wk of life
pneumonitis-presents between 4 and 12 wks of age
other complications in pregnancy:
low birth weight
post partum endometritis
presentation of chlamydia in women?
asymptomatic (in 80%) IM/PC bleeding purulent vaginal discharge lower abdo pain proctitis
signs: normal
cervicitis, mucupurulent discharge
cervical contact bleeding
local complications-bartholinitis (inflammation of galnds located on either side of vaginal opening), signs of pelvic infection
presentation of chlamydia in men?
asymptomatic (in 50%) urethral discharge testicular/epididymal pain dysuria proctitis
signs: normal
urethral discharge
epididymitis
treatment recommended for chlamydia trachomatis?
doxycycline 100mg BD for 7 days
azithromycin 1g stat (if compliance an issue)
erythromycin 500mg BD for 2 weeks (if pregnancy possible or breast feeding)
f/u required with chlamydia infection?
ensure partner notification has taken place
exclude reinfection
ensure compliance of the medications
when is test of cure necessary in chlamydia infection?
pregnant women
any case where erythromycin used for treatment
performed between 3 and 5 wks after tment completion.
most common cause of epididymo-orchitis in men under 35yrs of age?
chlamydia trachomatis
which HPV strains are external genital warts most commonly caused by?
6 and 11
what is PID?
ascending infection of the upper genital tract from the endocervix, causing:
endometritis
salpingitis
parametritis (ligaments around the uterus)
oophoritis
tubo-ovarian abscess
pelvic peritonitis
most common causative organism of PID?
chlamydia trachomatis
why is chlamydia screening so important?
10% of untreated chlamydial infections result in PID, and PID has serious long term complications:
chronic pelvic pain
infertility
risk of ectopic pregnancy
when might PID arise NOT as a result of a sexually transmitted infection?
after instrumentation of the uterus
symptoms suggestive of PID?
- pelvic or lower abdo pain, usually bilateral
- deep dyspareunia, part. of recent onset
- abnormal vaginal bleeding-intermenstrual, postcoital, menorrhagia
- abnormal vaginal or cervical discharge, may be transient
- RUQ pain due to peri-hepatitis-occurs in 10-20% of PID patients-Fitz-Hugh-Curtis syndrome-adhesions between liver and peritoneum.
diagnosis is made clinically
-ve swabs do not rule it out, and tment should not be delayed whilst awaiting lab results
signs of PID?
- lower abdo/pelvic tenderness, commonly bilateral
- cervical motion tenderness, uterine tenderness, on bimanual vaginal examination
- adnexal tenderness (with/without a palpable mass)
- abnormal cervical or vaginal mucopurulent discharge on speculum
- pyrexia more than 38 degrees
investigations to consider in suspected PID?
- rule out other differentials-pregnancy test if possibility of being pregnant, urine dipstick +/- M,C+S
- endocervical swabs for gonorrhoea and chlamydia, use NAAT, gonorrhoea should be cultured within 24hrs
- high vaginal swab for other vaginal infections e.g. vaginosis, candidiasis
- also look for pus cells on a wet mount vaginal smear-absence has a good NPV
- blds-FBC-leucocytosis, CRP, ESR
- pelvic USS
- laparoscopy=gold standard.
differentials for lower abdominal pain in young women?
- ectopic pregnancy
- endometriosis, adenomyosis
- PID
- ovarian cyst-torsion, rupture
- UTI
- appendicitis
- IBS
PID Abx regimen if risk of gonococcal infection is low?
PO ofloxacin 400mg BD plus PO metronidazole 400mg BD, both for 2 weeks
or
IM ceftriaxone 500mg single dose, followed by PO doxycycline 100mg BD plus metronidazole 400mg BD, both for 2 weeks.
note increasing quinolone resistance so avoid ofloxacin if high risk of gonococcal disease
patient at high risk of gonococcal PID?
women’s partner as gonorrhoea
severe signs and symptoms
sexual contact whilst abroad
Abx regimen in PID if high risk of gonococcal infection?
IM ceftriaxone single dose 500mg, followed by PO doxycycline 100mg BD and PO metronidazole 400mg BD, both for 2 weeks.
when should pt with PID be admitted to hospital urgently?
- ectopic cannot be ruled out or patient is pregnant
- severe signs and symptoms
- signs of pelvic peritonitis
- suspected tubo-ovarian abscess
- surgical emergency cannot be ruled out
- women is unwell and there is diagnostic uncertainty
- women unable to tolerate or follow an OP regimen
consider seeking specialist advice if women immunocompromised or perihepatitis suspected.
specific characteristics of chlamydia trachomatis organism?
obligate intracellular pathogen
what type of samples may be tested with NAAT for chlamydia trachomatis?
1st void urine
vulvovaginal swab
endocervical swab
why might epididymitis/orchitis/testcular torsion present with RIF pain?
due to referred pain via T10 sympathetic innervation
what is a vulvovaginal swab used to detect?
gonorrhoea
chlamydia
what is the rapid HIV test?
used for HIV testing
antibody screening test, with results ready in 30mins or less
stages of syphilis infection?
primary
secondary
early latent-no clinical evidence of infection within 1st 2 yrs of infection, but +ve serological tests
late latent-asymptomatic, +ve serological tests for infection of more than 2 yrs duration
symptomatic late-neurosyphilis, CVS-aortitis-aortic regurge, aneurysm+angina, gummata-inflamm. fibrous nodules and plaques.
tment of uncomplicated gonorrhoea?
azithromycin and IM ceftriaxone, both single dose
tment of early latent syphilis?
benzathine benzylpenicillin single dose (rpt after 1wk for women in 3rd trimester of preg)
tment of late latent syphilis?
benzathine benzylpenicillin, once weekly for 2wks
CXR appearance of PCP pneumonia that may be seen in a pt with HIV?
areas of blackness-look like cysts (pneumo’cystis’)
reticular opacification
management of PID in pregnancy?
- rare, except in cases of septic miscarriage
- require hosp admission for IV antibiotics, due to increased risk of maternal and fetal morbidity, and risk of pre term delivery.
- neonatal complications of perinatal transmission= conjunctivitis and chlamydial pneumonitis.
what predicts progression to late-stage HIV disease (AIDS)?
viral load (number of circulating viruses)
CD4+ T cell count which defines AIDS?
count less than 200cells/microlitre
how can acute HIV infection be detected?
presence of p24 antigen or HIV RNA by PCR
these precede the appearance of IgM and IgG
what is the 4th generation test for diagnosing HIV?
combination test checking for HIV antibody and p24 antigen, done via enzyme linked immunosorbent assay (EIA/ELISA)
takes about 4 wks for results
features of HIV seroconversion?
- this occurs between 1 and 6 weeks after infection
- pharyngitis
- fever
- malaise
- myalgia
- maculopapular rash
- lympadenopathy
- headaches, diarrhoea, neuralgia, neuropathy
CDC classification of stages of HIV disease?
- seroconversion illness-1- 6wks after infection
- asymptomatic infection
- persistent generalised lymphadenopathy (PGL)
- symptomatic infection
- AIDS
risk of HIV transmission with needlestick injury from HIV +ve individual?
1 in 300
most common HIV virus around the world?
HIV-1
mainly HIV-1, subtype B in the UK.
modes of reducing HIV transmission risk?
barrier contraception
needle exchange
screening blood products
mechanisms of action of HAART?
- reverse transcriptase inhibtors-nucleoside and nucleotide reverse transcriptase inhibtors e.g. emtricitabine, tenofovir.
- entry to cell/fusion inhibitors
- integrase inhibitors-stop integration into host genome
- protease inhibitors-stop modification of proteins e.g. ritonavir.
usually 2 NRTIs and 1 other
