Genital symptoms Flashcards
What are some common genital symptoms? (8)
- Discharge from an orifice
- Pain from somewhere
- Rashes
- Lumps and swellings
- Cuts, sores, ulcers
- Itching
- Change in appearance
- Vague sense of things not being right…
The cause of genital symptoms can be divided into which 3 main categories?
- STD
- Other microbial problem
- Non-microbial
What are some microbial conditions that are not regarded as STDs?
- Vulvovaginal candidosis
- Bacterial vaginosis
- Balanoposthitis – anaerobic/candidal - inflammation of the glans penis and foreskin
- Tinea cruris - ‘athlete’s groin’
- Erythrasma
- Athlete’s penis
- Infected sebaceous glands
- Impetigo
- Cellulitis
What is the most common cause of abnormal vaginal discharge?
Bacterial Vaginosis (BV)
Symptoms of Bacterial Vaginosis (BV)
- Asymptomatic in 50%
- Watery grey/yellow ‘fishy’ discharge
- May be worse after period / sex
- Sometimes sore/itch from dampness
Bacterial vaginosis is characterised by a biofilm. Explain why this is problematic.
- Highly structured polymicrobial biofilm, which is strongly adhered to the vaginal epithelium and primarily consists of the bacterium Gardnerella vaginalis. Also Enterococcus faecalis and Actinomyces neuii.
- Reduced lactobacilli - ‘friendly bacteria’
- The biofilm allows the bacteria to effectively hide away from antibiotics and makes it particularly hard to treat in some women
BV is said to be the result of the interplay of 3 problems. What are they?
- Overgrowth of BV associated bacteria
- Raised pH
- Reduction of lactobacilli and reduction in H202 production as a result
Usually women with BV are asymptomatic or have very mild symptoms however the minority get some serious complications. Give 3 examples of late complications of BV.
- Endometritis if uterine instrumentation/delivery - pushes abnormal mix of bacteria up into the uterus
- Associated with premature labour
- Increases risk of HIV acquisition - fairly low chance in the UK however
How is BV diagnosed?
- Characteristic history - symptoms
- Examination findings
- Thin, homogenous discharge
- pH – abnormal in BV. It becomes more alkaline (7.5 approx)
- Gram stained smear of vaginal discharge – self swab or clinician
Treatment of BV
The aim of treatment is to target one of the 3 main problem areas i.e lactobacilli replacement, fighting overgrowth of bacteria or adressing the vaginal pH
- Antibiotics
- Metronidazole - Oral ( avoid ethanol) or Vaginal gel
- Clindamycin - Vaginal
- Probiotics - replace lactobacilli
- Vaginal acidification – to return/maintain pH at 4.5 – OTC
What is Vulvovaginal candidosis?
- Vaginal and vulval symptoms caused by a yeast infection
- Very common
- 90% Candida albicans - usually acquired form the bowel
- Often asymptomatic carriage
- If symptomatic it is called ‘thrush’
- itch
- discharge - classically thick, ‘cottage cheese’ like
Why might a woman be more likely to get Vulvovaginal candidosis/Thrush?
- They are immunosuppressed - diabetes, oral steroids, HIV
- Slightly more common in pregnancy
- Reproductive age group (oestrogen…glycogen = food for yeast)
How is vulvovaginal candidosis (thrush) diagnosed?
- Characteristic history
- Vaginal pH? – this is not a diagnostic test for thrush as the vaginal pH is usually the same unlike in BV
- Examination findings
- Fissuring (linear)
- Erythema with satellite lesions – red patches away from the central area
- Characteristic discharge
What investigations are done to diagnose thrush?
Woman do a self swab and then it is studied under a microscope and can be cultured.
- Gram stained preparation
- Low sensitivity – might look at an unrepresentative patch
- Culture – eg Sabouraud’s medium
- Low specificity – yeast are commensal organisms
Treatment of Candida/thrush?
- May not need treatment – if it is mild it will often self correct
- Single dose pessary of clotrimazole or if in clinic a single pill oral fluconazole
- If woman is experiencing recurrent symptoms and you think the bacteria are resistant to the antibiotic then determine species and sensitivites and treat accordingly
- Maintain skin - avoid irritants, treat dermatitis
What is Balanitis?
- Means inflammation of the head of the penis
- Caused by Candidal balanitis
- One of the commonest conditions seen in men
- Rash at end of penis – almost always on men that have foreskin
What is Zoon’s balanitis?
It is the main type of balanitis
Chronic inflammation of the glans penis, secondary to overgrowth of commensal organisms plus ‘foreskin malfunction’. Red and sore. Often in older non-circumcised males.
- Short term treatment = mixed antimicrobial steroid preparation
- Often cured by circumcision
Impetigo is caused by which organisms?
Staph aureus or strep pyogenes
Describe Erysipelas of the penis
A superficial form of cellulitis, a potentially serious bacterial infection affecting the skin. It affects the upper dermis and extends into the superficial cutaneous lymphatics.
- Caused by strep pyogenes
- Antibiotics required
- Can sometimes get permanent lymph damage if not treated promptly
What is Dermatophyte infection in the penis otherwise known?
Athlete’s penis as it is the same organisms as athlete’s foot
- Trichophyton rubrum = causative organism
- Treat symptomatically with anti-fungal steroid preparation
- Can do skin scrapings for analysis too
What organisms cause Erythrasma? What are the symptoms?
Corynebacterium minutissimum
- Darkening of the skin in moist areas i.e groin, armpits
- May itch
Non-microbial symptoms can be divided into 2 categories - what are they?
- Perceived problem - patient is concerned but no clinical findings on examination. Or they are normal physiologically
- Real problems - dermatoses, structural abnormalities
What are some things that a patient may become concerned about that turn out to actually be normal?
- Vaginal discharge
- Urethral discharge
- Dysuria
- Genital/pelvic discomfort
- Rashes
- Skin lumps
- Penis size, scrotal lumps, labial shape
Management approach for a patient that has come in with a concern that turns out to be normal.
- Acknowledge the perception. We shouldn’t tell a person that they’re not experiencing a symptom.
- What do they think might be causing the symptom? – Cancer, infertility, STD. Allows those conditions to be specifically covered and ruled out. “I can say with 100% certainty that it’s not HIV”
- Variants of reassurance. Provide an alternative, benign explanation for symptoms. Telling someone “It’s nothing to worry about” doesn’t usually help much.
- Discuss limitations of medical approach. “We’re really here to exclude the bad stuff – cancer, infections, etc. We can’t always explain every symptom.” “In my experience these symptoms usually settle on their own.”
What are some clinical findings that are just physiological?
- Fox-fordyce spots on the penis
- Vulva papillomatosis
- Penile pearly papules
- Tyson’s glands - either side of the frenulum
- Lymphocele - blocked lymph duct
- Congenital cyst - can be left or removed
What can a torn frenulum cause?
Ecchymosis (blood blisters)
Secondary infection
