Genital Symptoms & Conditions Flashcards
What are some common genital symptoms?
- 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…
STDs are treatable but not always ..?..
Curable
Why is there a grey area when it comes to whether its an STD or not?
Can think of most organisms as being in that central zone – assessment of where its main transmission mode is, whether it is an STI or not
In a microbial infection, what’s causing the symptom?
Could be symptom caused by infecting organism or caused by host response to organism or combination.
Look at how pathogenic the organism itself is or if its something else that has caused the problem
What is the majority of Vulvovaginal candidiasis caused by and where is it acquired from?
90% Candida Albicans
Usually acquired from bowel (Could be common commensals in the vagina & in the bowel)
Is Vulvovaginal candidiasis common & how does it present?
V common. Usually trivial but can cause misery in a minority.
Often asymptomatic carriage
* Changes in host’s environment trigger pathogenicity
If symptomatic: “thrush”
* Itch
* Discharge – classically thick, ‘cottage cheese’ but often just a report of increased amount
What are the reasons that Vulvovaginal candidiasis is more likely to happen?
- Diabetes, oral steroids
- Immune suppression incl HIV
- Pregnancy
- Reproductive age group (oestrogen…glycogen=food for yeast)
But many cases occur in people with no pre-disposing factors
How is Vulvovaginal candidiasis diagnosed/examination findings?
Characteristic history
Examination findings
* Fissuring
* Erythema with satellite lesions
* Characteristic discharge
What is the Canes test (OTC Test)?
pH test kit - misleading as vaginal pH is the same as the vaginal pH of thrush so is not a diagnostic test for thrush
Normally self swab done -stained in clinic & then checked under microscope
If have vaginal pH normal of about 4.5 what can you know?
It is probably not bacterial vaginosis
Where else is common for a thrush presentation?
May see this in the back of peoples mouths too (e.g overuse of oral or inhaled steroids, undiagnosed HIV etc)
How is Vulvovaginal candidiasis investigated (think actually figuring out what organism is)?
- Gram stained preparation
– Low sensitivity – might look at an unrepresentative patch - Culture – eg Sabouraud’s medium
– Low specificity – yeast are commensal organisms
– Higher sensitivity-but labour intensive
PCR-largely used in research setting-as has the lowest specificity (& highest sensitivity)- so even more likely to find ‘innocent bystander’ organisms
How is Vulvovaginal candidiasis treated & how do you manage a resistant case of it?
- Azole antifungals:
- Clotrimazole 500mg PV once + Clotrimazole HC if vulvitis
- Fluconazole 150mg PO once
- Resistant case?
Determine species and sensitivities and treat accordingly
What is other management for Vulvovaginal candidiasis?
Maintain skin-avoid irritants, treat dermatitis
Some women’s skin is particularly prone to thrush symptoms, maybe tendency to atopy
Does Vulvovaginal candidiasis often need to be treated?
Often will self correct- so doesn’t need to be treated necessarily
What is classed as recurrent thrush?
4 episodes a year
What is the commonest cause of abnormal vaginal discharge?
BACTERIAL VAGINOSIS
What are the symptoms of bacterial vaginosis?
- Asymptomatic in 50%
- Watery grey/yellow ‘fishy’ discharge
- May be worse after period / sex
- Sometimes sore/itch from dampness
How is bacterial vaginosis caused?
A biofilm problem – like dental caries
* increased Gardnerella vaginalis, Enterococcus faecalis and Actinomyces neuii
- Reduced lactobacilli
- Possible sexual transmissibility is a hot topic
- Associated with vitamin D deficiency but significance unclear
Does bacterial vaginosis require treatment?
Bacterial imbalance – isn’t always symptomatic – often doesn’t need any treatment
How are some organisms able to survive the hydrogen peroxide & acid environments which are normally present in the vagina?
Certain organisms have an electrostatic attraction to the vaginal wall & create a layer under which they are able to produce chemicals which are able to survive in the environment
In bacterial vaginosis: Cycle of reduction of lactobacilli & reduction in H202 production- Raised pH- Overgrowth of BV associated bacteria
What are some of the more harmful things associated with BV
*Associated with endometritis if uterine instrumentation / delivery
*Associated with premature labour
*Increases risk of HIV acquisition-through mechanism on the vaginal immune system
How is BV diagnosed?
- Characteristic Hx
- Examination findings= Thin, homogenous discharge
- pH (can become more alkaline)
- Gram stained smear of vaginal discharge (self swab typically)
How is BV treated?
Abx
- Metronidazole (oral (avoid ethanol) or vaginal gel)
- Clindamycin-vaginal
Probiotics
Vaginal acidification-maintain pH of 4.5 by vaginal acidifying gel
What type of organisms cause Balanoposthitis?
Anaerobic/candidal
What organism causes balanitis & posthitis etc & what is it?
Candida balantitis
Inflammation of head of penis-blotchy dry spots
What is Zoon’s balanitis (aka plasma cell balanitis) and what is the short term treatment for it?
-Chronic inflam secondary to overgrowth of commensal organisms plus ‘foreskin’ malfunction
-Short term treatment=mixed antimicrobial steroid preparation – improve symptoms
What organisms cause impetigo and how is it treated?
- Staph aureus or Strep pyogens
- Can be mistaken for Herpes
- Swab & treat with Abx
What condition is caused by strep pyogenes and if its not treated properly can get permanent lymph vessel damage?
Erysipelas
What does a dermatophyte infection present with & how is it treated?
- E.g. Trichophyton rubrum
- Scaly patch of skin
- Antifungal steroid preparation
What is Tinea cruris & how is it managed?
-Dermatophytes- ‘athletes’s’ groin
-Hygiene- keep dry area around groin
What is erythrasma, what’s it caused by & how is it managed?
-Corynebacterium minutissimum
-Smooth edge-bacterial condition
-Mild steroid & antifungal preparation interestingly works surprisingly well
What are some possible microbial causes of genital symptoms?
- Candida
- Bacterial vaginosis
- Balanoposthitis
What are some possible other causes of genital symptoms?
- Pain syndromes – the ‘dynias’
- Dermatoses
- Trauma
- Cancer/Neoplastic
- Neuromuscular
- ‘Hypervigilance’
- Iatrogenic
- Congenital
- Idiopathic
- Manifestations of systemic disease
What are some symptoms of non microbial origin?
Perceived problem only - normal findings.
- No clinical findings
- Only findings are physiological
‘Real’ problems:
*Dermatoses
*Structural abnormalities
- Congenital
- Acquired
What kind of things can be perceived as an abnormality when there is actually nil to find?
- Vaginal discharge
- Urethral discharge
- Dysuria
- Genital/pelvic discomfort
- Rashes
- Skin lumps
- Change in appearance of skin
- Penis size, scrotal lumps, labial shape
- Temporary
- More persistent – body dysmorphia
What are some physiological clinical findings can be mistaken for STDs but are just normal parts of anatomy?
- Fox Fordyce spots=sebaceous glands of the skin that some men have more prominently than others (‘Normal as fingerprints’)
- Vulval papillomatosis=Projections that can sometimes be mistaken for warts
- Penile pearly papules aka Coronal papillae
- Tyson’s glands=Vestigial glands either side of the frenulum
What is vestibulodynia & what is Vulvodynia (pain syndromes)?
Vestibulodynia=Provoked introital tenderness
Vulvodynia=Persistent burning or aching
What is the cause of chronic pelvic pain syndrome and what is it?
- Sometimes labelled as prostatitis, but usually no ‘itis’.
- Cause unclear but muscular dysfunction implicated
Chronic-persistent aching of the genitals even though there is nothing to actually find in the genitals
(Sometimes gets attributed to prostatitis but is more likely to be a sort of neuromuscular dysfunction problem, causing chronic pelvic pain syndrome, and vulvodynia.)
What is a lymphocele & how does it resolve?
oBlocked lymph duct-increased friction or secondary to an infection
oSettles down spontaneously given a few days of avoiding friction
Are congenital cysts always removed?
Can be left as are or if they are large & causing a problem they can be removed
Describe a torn frenulum & ecchymosis?
oEcchymosis=blood blisters under the skin
oLittle artery in the frenulum which can bleed a lot
oCan get a torn frenulum & then a secondary infection
What is lichen sclerosis and how is it treated?
o Autoimmune disease that causes thinning & scarring of the skin & can totally close off the urethral meatus
o Affects women as well & sometimes it can cause scarring around the vagina
Steroid treatment
For what condition is the cause not entirely clear but is thought to be another autoimmune condition and is treated with steroid treatment like lichen sclerosis?
Lichen Planus
What should you be wary of in terms of ulcers that would make you think penile carcinoma?
Ulcer with a very firm base to it
Do STDs just cause genital symptoms?
NO
A lot of things can cause genital symptoms – not just STDs. And the other side is that…Correctly categorising the cause of genital symptoms is the most important step. A precise diagnosis is important but a secondary concern for many patients.
