Genital Symptoms

Question 1

Microbial causes of genital symptoms

Answer 1

• Candida
• bacterial vaginosis
• Balanoposthitis

Question 2

Other causes of genital symptoms

Answer 2

• Dermatoses
• Trauma
• Cancer
• Neuromuscular
• Hypervigilance
• Iatrogenic
• Idiopathic

Question 3

What are common presenting complaints of genital symptoms

Answer 3

• Discharge from orifice
• Pain from somewhere
• Rashes
• Lumps & swelling
• Cuts, sores, ulcers, Itching
• Change in appearance

Question 4

Microbial conditions not considered STDs

Answer 4

• Vulvovaginal candidosis
• Bacterial vaginosis
• Balanoposthitis - anaerobic/candida
• Tinea cruris
• Ethrasma
• Infected sebaceous glands
• Impetigo
• Cellulitis

Question 5

Epidemiology of vulvovaginal candidosis

Answer 5

• Very common
• Usually trivial but can cause misery in a minority

Question 6

Cause of vulvovaginal candidosis

Answer 6

• 90% candida albicans
  
  • Can be C. galbrata et al
• Usually acquired from bowel

Question 7

When does vulvovaginal candidosis present

Answer 7

• Often asymptomatic carriage
  
  • Changes in hosts environment trigger pathogenicity
• If symptomatic - thrush

Question 8

What is the presentation of vulvovaginal candidosis

Answer 8

• Itch
• Discharge - classically thick, ‘cottage cheese’ but often just increased

Question 9

Risk/predisposing factors for vulvovaginal candidosis

Answer 9

• Diabetes, oral steroids
• Immune suppression - e.g. HIV
• Pregnancy
• Reproductive age group
  
  • Oestrogen, glycogen = food for yeast

Question 10

Diagnosis of vulvovaginal candidosis

Answer 10

• Characteristic history
• Examination findings
  
  • Fissuring
  • Erythema with satellite lesions
  • Characteristic discharge

Question 11

Investigations of vulvovaginal candidosis

Answer 11

• Gram stain preparation
  
  • Low sensitivity - might look at an unrepresentative patch
• Culture - e.g. Sabourad’s medium
  
  • Low specificity - yeasts are common organisms

Question 12

Treatment of vulvovaginal candidosis

Answer 12

• Azole antifungals
  
  • Clotrimazole 500mg PV once
    
    • Plus clotrimazole if vulvitis
  • Fluconazoole 150mg PO once
• Resistant case
  
  • Determine species and sensitivities and treat accordingly
• Other
  
  • Maintain skin - avoid irritants, treat dermatitis

Question 13

Epidemiology of bacterial vaginosis

Answer 13

• Commonest cause of abnormal vaginal discharge
  
  • 10-40% of women at any one time

Question 14

Symptoms of bacterial vaginosis

Answer 14

• Asymptomatic - 50%
• Watery grey/yellow ‘fishy’ discharge
• May worse after period/sex
• Sometimes sore/itch from dampness

Question 15

Cause of bacterial vaginosis

Answer 15

• A biofilm problem
  
  • Increased Gardnerella vaginalis, Enterococcus faecalis and Actinomyces neuji
  • Reduced lactobacilli
  • Possible sexual transmissibility
  • Associated with vitamin D deficiency but significance unclear

Question 16

Diagnosis of bacterial vaginosis

Answer 16

• Characteristic history
• Examination findings
  
  • Thin, homogenous discharge
• pH
• Gram-stained smear of vaginal discharge

Question 17

Problems/complications with bacterial vaginosis

Answer 17

• Usually asymptomatic or very mild symptoms
• But
  
  • Associated with endometritis if uterine instrumentation/delivery
  • Associated with premature labour
  • Increases risk of HIV acquisition

Question 18

Treatment of bacterial vaginosis

Answer 18

• Antibiotics
  
  • Metronidacole
    
    • oral (avoid ethanol)
    • Vaginal gel
  • Clindamycin
    
    • Vaginal
• Probiotics
• Vaginal acidification

Question 19

Types of balanitis and posthitis etc.

Answer 19

• Candid balanitis
• Zoon’s balanitis (aka. plasma cell balanitis)
• Impetigo
• Erysipelas
• Dermatophyte infection
• Tinea cruris
• Erythrasma

Question 20

Cause of Zoon’s balanitis

Answer 20

• Chronic inflammation secondary to overgrowth of commensal organisms plus ‘foreskin malfunction’

Question 21

Cause of impetigo

Answer 21

• Staph aureus or strep pyogenes

Question 22

Cause of erysipelas

Answer 22

• Strep pyogenes

Question 23

Cause of dermatophyte infection

Answer 23

• Trichophyton rubrum

Question 24

Cause of tinea cruris

Answer 24

• Dermatophytes - ‘athletes groin’

Question 25

Cause of erythrasma

Answer 25

* Corynebacterium minuutissimum

Question 26

Physiological problems (non-microbial origin)

Answer 26

* Fox-fordyce spots * Vulval papillomatosis * Penile pearly papules aka. Coronal papillae * Tyson's glands

Question 27

Genital symptoms of 'perceived' problems

Answer 27

* Vaginal discharge * Urtherthal discharge * Dysuria * Genital/pelvic discomfort * Rashes * Skin lumps * Penis size, scrotal lumps, labial shape * Temporary * Persistent - body dysmorphia

Question 28

Lines of questioning for genital symptoms

Answer 28

* Regretted sexual encounter * Problems in life * Co-existing mental ill health - anxiety * When * When last normal * Family illness * Friend with illness * Media story

Question 29

Management approach for perceived genital symptoms

Answer 29

* Acknowledge perception * Ask what they think causing * variants of reassurance * Discuss limitation of medical approach

Question 30

Other causes of genital symptoms

Answer 30

* Congenital cyst * Torn frenulum and ecchymosis * Torn frenulum and secondary infection * Lichen sclerosus * Penile carcinoma * Lichen planus

Question 31

Pain syndromes causing genital symptoms

Answer 31

* Vestibulodynia * Provoked introital tenderness * Vulvodynia * Persistent burning or aching * Chronic pelvic pain syndrome * Sometimes labelled as prostatitis * Cause unclear but muscular dysfunction implicated