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Obstetrics and Gynaecology > Genital discharge and GUM > Flashcards

Genital discharge and GUM Flashcards

1
Q

physiological causes of vaginal discharge?

A

pregnancy
association with time in menstrual cycle
sexual stimulation

features-odourless clear/white discharge with no irritation, pH 4.5 or less

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2
Q

pathological causes of vaginal discharge?

A

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.

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3
Q

key features of genital candida infection?

A 
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

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4
Q

key features of trichomonas vaginalis (protozoal parasite) infection?

A 
offensive, frothy yellow/green discharge
strawberry cervix-punctate and papilliform appearance
vulvovaginitis
itchy/sore
dysuria
pH more than 5
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5
Q

key features of bacterial vaginosis?

A

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

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6
Q

what association exists between bacterial vaginosis and HIV?

A

bacterial vaginosis increases risk of HIV acquisition and transmission

BV other complications:
post termination of pregnancy endometritis and PID
recurrent late miscarriage

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7
Q

risk factors for STIs?

A

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

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8
Q

most commonly diagnosed STI in GUM clinics in the UK?

A

anogenital warts

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9
Q

type of swab for candida infection?

A

high vaginal swab

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10
Q

type of swab for bacterial vaginosis?

A

high vaginal swab

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11
Q

type of swab for trichomonas vaginalis?

A

high vaginal swab

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12
Q

bacterial vaginosis causative organism?

A 
characterised by reduction in lactobacilli and overgrowth of predominantly anaerobes:
gardnerella vaginalis
prevotella spp.
mycoplasma hominis
mobiluncus spp.

increase in vaginal pH

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13
Q

most specific criterion for diagnosing bacterial vaginosis?

A

demonstration of clue cells on saline smear of high vaginal swab under the microscope
=vaginal epithelial cells with bacteria adherent to their surfaces

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14
Q

what criteria are used to make a diagnosis of bacterial vaginosis?

A

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

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15
Q

bacterial vaginosis treatment?

A

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

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16
Q

how is vaginal candidiasis diagnosed in primary care?

A

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

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17
Q

treatment of vaginal candida?

A

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

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18
Q

RFs for recurrent vaginal candidiasis?

A 
DM
thyroid disease
Fe deficiency with or without anaemia
underlying immunodeficiency
steroid use
frequent use of Abx
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19
Q

presentation of candida in men?

A

balanitis with pruritus

may be 1st sign of previously undiagnosed DM

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20
Q

tment of candida infection in men?

A

saline bathing with or without azole cream

if recurrent, investigation and tment of female partner may be beneficial.

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21
Q

complications of perinatal transmission of chlamydia?

A

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

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22
Q

presentation of chlamydia in women?

A 
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

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23
Q

presentation of chlamydia in men?

A 
asymptomatic (in 50%)
urethral discharge
testicular/epididymal pain
dysuria
proctitis

signs: normal
urethral discharge
epididymitis

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24
Q

treatment recommended for chlamydia trachomatis?

A

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)

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25
Q

f/u required with chlamydia infection?

A

ensure partner notification has taken place
exclude reinfection
ensure compliance of the medications

26
Q

when is test of cure necessary in chlamydia infection?

A

pregnant women
any case where erythromycin used for treatment

performed between 3 and 5 wks after tment completion.

27
Q

most common cause of epididymo-orchitis in men under 35yrs of age?

A

chlamydia trachomatis

28
Q

which HPV strains are external genital warts most commonly caused by?

A

6 and 11

29
Q

what is PID?

A

ascending infection of the upper genital tract from the endocervix, causing:
endometritis
salpingitis
parametritis (ligaments around the uterus)
oophoritis
tubo-ovarian abscess
pelvic peritonitis

30
Q

most common causative organism of PID?

A

chlamydia trachomatis

31
Q

why is chlamydia screening so important?

A

10% of untreated chlamydial infections result in PID, and PID has serious long term complications:
chronic pelvic pain
infertility
risk of ectopic pregnancy

32
Q

when might PID arise NOT as a result of a sexually transmitted infection?

A

after instrumentation of the uterus

33
Q

symptoms suggestive of PID?

A
  • 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

34
Q

signs of PID?

A
  • 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
35
Q

investigations to consider in suspected PID?

A
  • 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.
36
Q

differentials for lower abdominal pain in young women?

A
  • ectopic pregnancy
  • endometriosis, adenomyosis
  • PID
  • ovarian cyst-torsion, rupture
  • UTI
  • appendicitis
  • IBS
37
Q

PID Abx regimen if risk of gonococcal infection is low?

A

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

38
Q

patient at high risk of gonococcal PID?

A

women’s partner as gonorrhoea
severe signs and symptoms
sexual contact whilst abroad

39
Q

Abx regimen in PID if high risk of gonococcal infection?

A

IM ceftriaxone single dose 500mg, followed by PO doxycycline 100mg BD and PO metronidazole 400mg BD, both for 2 weeks.

40
Q

when should pt with PID be admitted to hospital urgently?

A
  • 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.

41
Q

specific characteristics of chlamydia trachomatis organism?

A

obligate intracellular pathogen

42
Q

what type of samples may be tested with NAAT for chlamydia trachomatis?

A

1st void urine
vulvovaginal swab
endocervical swab

43
Q

why might epididymitis/orchitis/testcular torsion present with RIF pain?

A

due to referred pain via T10 sympathetic innervation

44
Q

what is a vulvovaginal swab used to detect?

A

gonorrhoea

chlamydia

45
Q

what is the rapid HIV test?

A

used for HIV testing

antibody screening test, with results ready in 30mins or less

46
Q

stages of syphilis infection?

A

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.

47
Q

tment of uncomplicated gonorrhoea?

A

azithromycin and IM ceftriaxone, both single dose

48
Q

tment of early latent syphilis?

A

benzathine benzylpenicillin single dose (rpt after 1wk for women in 3rd trimester of preg)

49
Q

tment of late latent syphilis?

A

benzathine benzylpenicillin, once weekly for 2wks

50
Q

CXR appearance of PCP pneumonia that may be seen in a pt with HIV?

A

areas of blackness-look like cysts (pneumo’cystis’)

reticular opacification

51
Q

management of PID in pregnancy?

A
  • 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.
52
Q

what predicts progression to late-stage HIV disease (AIDS)?

A

viral load (number of circulating viruses)

53
Q

CD4+ T cell count which defines AIDS?

A

count less than 200cells/microlitre

54
Q

how can acute HIV infection be detected?

A

presence of p24 antigen or HIV RNA by PCR

these precede the appearance of IgM and IgG

55
Q

what is the 4th generation test for diagnosing HIV?

A

combination test checking for HIV antibody and p24 antigen, done via enzyme linked immunosorbent assay (EIA/ELISA)
takes about 4 wks for results

56
Q

features of HIV seroconversion?

A
  • this occurs between 1 and 6 weeks after infection
  • pharyngitis
  • fever
  • malaise
  • myalgia
  • maculopapular rash
  • lympadenopathy
  • headaches, diarrhoea, neuralgia, neuropathy
57
Q

CDC classification of stages of HIV disease?

A
  • seroconversion illness-1- 6wks after infection
  • asymptomatic infection
  • persistent generalised lymphadenopathy (PGL)
  • symptomatic infection
  • AIDS
58
Q

risk of HIV transmission with needlestick injury from HIV +ve individual?

A

1 in 300

59
Q

most common HIV virus around the world?

A

HIV-1

mainly HIV-1, subtype B in the UK.

60
Q

modes of reducing HIV transmission risk?

A

barrier contraception
needle exchange
screening blood products

61
Q

mechanisms of action of HAART?

A
  • 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

Obstetrics and Gynaecology (18 decks)

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