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Gynae, Breast & Sexual Health > Genital tract infection & PID > Flashcards

Genital tract infection & PID Flashcards

1
Q

What are the 4 key presenting symptoms of STI in women?

A
  • pain - abdo and dyspareunia (pain on sex)
  • discharge
  • dysuria
  • bleeding
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2
Q

What investigations are done for general check up as sexual health clinic?

A
  • Urine - bHCG
  • endocervical swab (e.g. endocervix is near to uterus e.g. endometrium lining)
    • –> chlamydia,
    • gonorrhoea
  • high vagina –> posterior fornix -
    • Tri. Vaginalis,
    • Bact Vaginalis,
    • Candida
  • Blood =
    • HIV and
    • syphilis
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3
Q

What subcategories is urethritis in men divided into?

A

gonococcal vs non-gonococcal urethritis (NGU)

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4
Q

What is this the treatment for?

  • Azithromycin 1g PO stat,
    • or doxycycline 100mg/12h PO for 7days.
    • erythromycin 500mg/6h PO for 14 days,
      • or ofloxacin 400mg/24h for 7 days.
  • Track contacts.
  • Avoid intercourse during treatment and alcohol for 4 weeks. 
A
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5
Q

What does it mean if lactobacillus is found in the vagina?

A

lactobacillus = normal vaginal flora

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6
Q

A patient has presented with plainless fleshy genital warts. What iare the likely causative organisms?

A

HPV 6 & 11

  • Syx can also be asymptomatic
  • spread by Skin-skin contact
  • the plainless fleshy warts can appear up to years after the initial infection
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7
Q

What are the RF’s for HIV 6 & 11 infection –> painless fleshy genital warts?

A
  • multiple partners
  • early age of 1st sex
  • immunosupression
  • smoking
  • DM (associated with persistence of the warts)
  • low socioeconomic status
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8
Q

WHat investigations should be done for a patient presenting with painless fleshy warts?

A

(AKA genital warts: HPV 6 & 11)

  • clinical examination
  • if there is atypical lesions or suspected intra-epithelial neoplasia –> biopsy maybe required
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9
Q

A patient presents with painless fleshy genital warts. O/E This is not an atypical lesion and there is no intraepithelial neoplasia so no biopsy is needed.

  1. What is the management of the lesions generally?
  2. If the lesions are in clusters of small warts (non keratinised)?
  3. if the lesions are in larger, keratinised warts?
A
  1. Generally = lesions will most likely resolve spontaneously over time

But there are topical Rx depending on if keratinised (Imiquiod), or smaLL - podophyLLOtoxin

  1. Clusters of small warts, better for non-keratinised lesions –> podophyllotoxin BD 3d followed by 4d rest (4-5 cycles)
  2. larger warts, particularly keratinised warts –> Imiquimod 3x weekly for 6-10hours (up to 16 weeks)
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10
Q

A patient presents with painless fleshy genital warts. What is the Rx if O/E…

  1. there is a pedunculated/large ward or accessible small hard warts?
  2. there are multiple small warts (e.g. but the Rx isnt podophyllotoxin for small wart clumps)?
  3. large warts that havent responsed to imiquimod? (lartger warts, particularly keratinised)
  4. difficult to access warts e.g. inside the anus?
A
  1. pedunculated/large wrts or accessible small hard warts –> EXCISION UNDER LA
  2. multiple small warts –> CRYOTHERAPY - consider alternative if no response @4wks
  3. large warts that havent responsed to topical rx (imiquimod) - ELECTROSURGERY
  4. difficult to access warts e.g. inside anus - LASER SURGERY
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11
Q

When treating HPV 6 & 11 warts e.g. painless, fleshy genital warts. When is a change in therapy recommended e.g. deemed as not working?

A

A change in therapy is recommended if there is

  • <50% response to treatment
  • after 4-5 weeks
    • ​ (8-12 for imiquimod e.g. topocal rx for keratinised large warts).
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12
Q

What HPV types are verruca’s associated with?

A

HPV 1 & 2

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13
Q
  1. What HPV types are non-genital warts associated with?
  2. plane warts? (aka round, flat and smooth on sun-exposed skin)
  3. genital warts?
A
  1. 2 & 7
  2. 3 & 10
  3. 6 & 11
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14
Q

What type of HPV is cervical cancer associated with?

A
  • 16 & 18
  • (+ 33)
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15
Q

HPV 1 & 2 cause what type of warts?

A

verrucas

(sole of your foot warts)

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16
Q
  1. HPV 2 & 7
  2. HPV 3 & 10
  3. HPV 6 & 11

cause what types of warts?

A
  1. non-genital warts
  2. plane warts.. (aka round, flat and smooth on sun-exposed skin)
  3. genital warts
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17
Q

HPV

  • 16 & 18
  • (+ 33)

cause what problems?

A

HPV 16, 18 (+33) are associated with cervical cancer

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18
Q

Name this organism:

  • It is an intracellular G-ve bacterium,
  • Found in endocervical epithelium
  • incubation is 7-21D?
A

Chlamydia trachomatis e.g. chlamydia

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19
Q

a male patient is expereincing yellow-green & offensive, fishy discharge & dysuric.

What is the likely causative organism?

A

Trichomonas vaginalis (TV)

    • a protozoa with a flagellum
  • 1-3 wks incubation
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20
Q

A woman presents with vaginal discharge, vulvular irritation and strawberry cervix. Her vaginal pH is >4.5 (normal ~3.8-4.5).

What is the most likely causative organism?

A

Trichomonas vaginalis

  • flagellate protozoa
  • 1-3wk incubation

NB: 10-50% of women and most men are asymptomatic with TV.

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21
Q

10-50% of women and most men are asymptomatic with TV.

What are the complications of trichomonas vaginalis?

A
  • preterm delivery
  • low birth weight
  • PID
  • ?facilitates HIV acquisition
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22
Q

a male patient presents with: [asymptomatic (mostly)] urethral discharge (yellow-green & offensive, fishy), dysuria

a female patient presents with: [asymptomatic (10-50%)], vaginal discharge, vulvar irritation + strawberry cervix. pH >4.5

What Ix should be done?

A

do microscopy of the discharge

“saline stop test”

–> you see motile protozoa (from flagellum)

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23
Q

a male patient presents with: [asymptomatic (mostly)] urethral discharge (yellow-green & offensive, fishy), dysuria

a female patient presents with: [asymptomatic (10-50%)], vaginal discharge, vulvar irritation + strawberry cervix. pH >4.5

What Rx should be done?

A

Metronidazole 400mg BD PO 5d

or 2g PO stat

  • (if pregnant, use 5 day regime) (alcohol CI’d on this antibiotic- think you actually get physically sick on this)  
  • Abstinence while completing course
  • Contact tracing (all partners in 3 months)
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24
Q

A woman is experiencing inter menstrual and post coital bleeding & has a watery discharge.

What is the most likely causative agent?

A

Chlamydia trachomatis (2)

  • -intracellular bacterium G-ve
    • (BUT gives a weird gram stain?? so if in qs its discharge and g-ve, it maybe gonnorhoea more (esp if discharge is purulent/white/yellow as chalmydia discharge is non-purulent?? NB: gonorrhoa = DIPLOCOCCUS)
  • -endocervical epithelium
  • -incubation 7-21d

NB: 70-80% asymptomatic, can also present as urethritis –> dysuria

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25
Q

A man is experiencing pain in his testicles/epidiymo-orchiditis, dysuria & discharge. What is the most likely causative organism?

A

Chlamydia trachomatis

  • -intracellular bacterium G-ve (BUT gives a weird gram stain?? so if in qs its discharge and g-ve, it maybe gonnorhoea more (esp if discharge is purulent/white/yellow as chalmydia discharge is non-purulent?? NB: gonorrhoa = DIPLOCOCCUS)
  • -endocervical epithelium
  • -incubation 7-21d

NB: 50% of men are asymptomatic w/chlamydia

26
Q

What complications do both chalmydia trachomatis and neisseria gonorrhoeae both have in common?

A

both C. Trachomatis & N. Gonnorhoeae have complications of:

  • PID in women –> tubal infertility (fallop. tubes get blocked)
  • epididymoorchiditis in men
  • reactive arthritis/reiters syntrome
    • (arthritis and uveitis e.g. can’t, see, pee (urethritis) or climb a tree)
  • OPTHALMIA NEONATORUM
27
Q

Which of chlamydia trachomatis and neisseria gonorrhoeae can cause conjunctivitis?

A

Chlamydia trachomatis

(both can cause reactive arthritis though which includes uveitis + arthritis + urethritis; + both cause opthalmia neonatorum)

28
Q

Which of chlamydia trachomatis and neisseria gonorrhoeae can cause strictures?

A

Neissera Gonorrhoeae

29
Q

Lymphogranuloma venereum (LGV) is an ulcerative disease of the genital area, it is uncommon but happens as a result of which organism?

You get the symptoms lymphadenopathy, fever, arthritis and pneumonitis (so LYmphogranuloma = Lungs, lymph, joints + fever) - how does this differ for the biggest RF group?

A

Chlamydia Trachomatis is causative

MSM population get this & if directly to the anal mucosa can get haemorrhagic proctitis –>

  • pain,
  • rectal bleeding,
  • tenesmus
  • (e.g. so may ?cancer or ?gastroenteritis or ?haemorrhoids until further hx taken)
  • BUT GET DISCHARGE too (?penile i guess–>sti)
30
Q

Which STI has the life cycle where elementary bodies attach to sperm. intracellularly they produce numerous elementary bodies which are released with cell lysis?

(once released it is responsible for the bacterias spread from person to person - analogous to a SPORE e.g. but acts like a virus!)

A

Chlamydia Trachomatis

31
Q

If urethritis in men is divided into gonococcal causes or non-gonococcal (G is a diplococci) urethritis. What are the causes of non-gonococcal?

A
  • Chlamydia Trachomatis
  • mycoplasm genitalia
32
Q

Which of chlamydia trachomatis vs neisseria gonorrhoeae are you more likely to get bartholinitis (to the Lower left & right of vaginal opening) and septicaemia with?

A

N. gonorrhoeae

33
Q

What is opthlamia naonatorum?

A

Conjuntivitis in the first month of life (neonatal conjuntivitis)

Causes include gonococcal (hyperactue), , HSimplexV (acute), chlamydia (subactue). passage through the birth canal –>

CHLAMYDIA STI in mother is the most important factor

34
Q

What is treponema pallidum?

A

Syphilis!

35
Q

What is the other name for syphilis?

A

Treponema pallidum

36
Q

Chlamydia and gonorrhoeae are transfered on endocervical epithelium. How is syphilis transferred?

A
  • infected blood products!
  • vertical transmission (childbirth)
37
Q

A patient presents with genital ulcers (NOT warts e.g. fleshy = HPapillomaV)

What things would you like to ask about to lead you to indicate a causative pathogen?

A

How many?

Are they painful?

If PAINLESS and NOT many (few) –> syphilis/treponema pallidum

if PAINFUL and MANY (numerous) –> HSimplexV

38
Q

If syphilis aka treponema pallidum has 3 stages of presentation times and presents with painless and few ulcer. what is this called and when does this occur/what stage?

A

A painless, hard, NON-itchy, solitary ulcer + lymphadenopathy

= CHANCRE

(can be oral or genital)

this is a primary syphylis infection occuring at 9-90days (e.g. ~1-12weeks)

NB: starts as macule-papulse (flat then raised <1cm) and then to the painless singular ulcer, defined with rolled edge)

39
Q

if primary syphylis is

  • A painless, hard, NON-itchy, solitary ulcer + lymphadenopathy
  • = CHANCRE
  • (can be oral or genital)
  • this is a primary syphylis infection occuring at 9-90days (e.g. ~1-12weeks)

What is secondary treponema pallidum (syphylis)?

A

2ndry treponema pallidum: occurs up to 2 years later! ~10w post chancre…

  • disseminated maculo-papular rash - can be on palms and soles
  • condylomata lata (plaques on sexual surfaces); silvery-gray mucous membrane lesions
  • constitutional syx: fever, malaise, weight loss
  • arthralgia
  • headaches
  • painless lymphadenopathy
    *
40
Q

What are the signs of tertiary syphilis and when can it occur?

(1o (9- 90d): chancre, painless hard non-itchy solitary ulcer, lymphadenopathy

2o (up to 2yrs): maculopapular rash, fever, malaise, arthralgia, weight loss, headaches, condylomata lata (plaques), painless lymphadenopathy, silvery-gray mucous membrane lesions)

A

neuro, cardiac & skin - in 3o syphilis

  • Gummatous syphilis:
    • granulomas in bone, skin, mucous membranes of URT, mouth, viscera, connective tisse
  • Neurosyphilis:
    • Tabes dorsalis – ataxia, numb legs, absence of deep tendon reflexes, lightning pains, loss of pain & temp, skin and joint damage.
    • Dementia – cognitive, mood, psychosis.
    • Meningovascular complications – CN palsies, stroke, cerebral gummas.
    • Argyll Robertson pupil – pupil is constricted and unreactive to light, but reacts to accommodation
  • Cardiovascular syphilis:
    • Aortic regurgitation due to aortic valvulitis & aortic root dilatation.
    • Angina due to stenosis of the coronary ostia
    • Dilation and calcification of the ascending aorta
41
Q

A child is born with Hutchinson’s triad - HT (

  • ?Hutchinson’s teeth),
  • deafness,
  • keratitis;
  • also - skeletal abnormalities, saddle nose, bossed forehead
A

What is the most likely causative STI?

Congenital syphilys

most transmission from 16-28th week pregnancy (most from early syphilis);

NB: chlamydia w.STI in mother is the most importnant factor in opthalmia neonatorum e.g. congenital conjuntivitis (chlamydia can also cause conjunctivits in adults etc too)

42
Q

A patient has painful and numerous genital ulcers.

(They even report that the ulcers are inside their urethra causing dysuria!) - (some can get urinary retention becuase of this)

What is the likely causative organism and what may have the patient also experienced?

A

HSV infection!

  • a flu like prodrome e.g. fever and arthralgia… (before the ulcers showed)
  • At sidte of infection (e.g. mouth/anus/vagina depending on sex) = papules (rasied <1cm) –> vesicles –> that burst –> ulcers - HIGHLY INFECTIOUS
  • Urethral discharge +/- dysuria
  • Urinary retention
  • Tender regional lymphadenopathy
  • Local neuropathology & complications (as live in dorsal root ganglion- where sensation is)

[HSV is a lifelong infection that can give prophylactic acivlovir if keeps recurring frequently]

43
Q

A patient is experiencing vaginal discharge. However on Hx taking they say they have had no partner changes/infedelity over past year or so (etc). What differentials does this change?

A

No other partner/partner changes (except from infedelity) means that the vaginal discharge could be NON-SEXUALLY transmitted VS SEXUALLY transmitted

Non sexually transmitted:

  • candida albicans (thrush)
  • bacterial vaginosis (gardnerella)

Sexually transmitted:

  • Trichimonas vaginalis,
  • nisseria gonorrhoea,
  • chlamydia trachomatis
44
Q
  • A woman presents with white curds/cottage cheese like discharge.
  • O/E her vulva & vagina is red, fissuring
  • & reported as sore , itchy, burning and painful during sex (dysparenuia)
  • she has has no change in sexual partners.

What is the likely causative organism?

A

Candida albicans - thrush.

vaginal Commensal in 30%

(?wont necesserily spread unless the other person has disrupted flora too e.g. 2 women with distrupted flora vagina)

45
Q
  • A woman presents with white curds/cottage cheese like discharge.
  • O/E her vulva & vagina is red, fissuring
  • & reported as sore , itchy, burning and painful during sex (dysparenuia)
  • she has has no change in sexual partners.

What risk factors may this pt have to have caused this?

A

(organism= candida albicans)

RFs:

  • pregnancy,
  • immunodeficiency,
  • diabetes,
  • the pill,
  • antibiotics

(NB: oral thrush may occur in asthmatics using inhaler steroids OR in immunosupression e.g. HIV)

46
Q
  • A woman presents with grey and fishy vaginal discharge (white, grey and/or watery)
  • there is minimal/no itch/soreness
  • her vaginal pH is alkaline e.g. >4.5
  • She reports no change in sexual partners
  1. Cauative organism?
  2. What are the RFs that this woman may have to get this infection?
A
  1. Bacterial Vaginosis (Gardnerella)
  2. RF’s
      • common in Afro-Caribbean women
    • sexual activity (but not STI),
    • douching/intra-vaginal perfumed products
    • SMOKING
47
Q
  • A woman presents with grey and fishy vaginal discharge (white, grey and/or watery)
  • there is minimal/no itch
  • her vaginal pH is alkaline e.g. >4.5
  • She reports no change in sexual partners
  1. associations/complications with this organism infection?
  2. What are the DDx for this infection?
A

(the organism is BV/gardnerella, is non sexually transmitted)

Associations:

  • miscarriage,
  • preterm birth,
  • preterm ROM,
  • post-partum endometritis
      • SO CHECK IN PREGNANCY, if a pregnant lady has a CHANGE IN DISCHARGE = come in

DDx for BV:

  • retained tampon,
  • TV
  • (yellow-green & offensive discharge, fishy, + dysuria though and strawberry cervix)
48
Q

A patient comes in feeling systemically unwell with a maculopapular rash (not on soles/palms), feeling “generally awful” with fever and headache. They reveal they had (MSM or risky etc) sexual acitvity 2-4 weeks prior…

What is this?

A

HIV seroconversion e.g. 1o HIV

80% are symptomatic for seroconversion 2-4w post exposure!!

  • in seroconversion = virus is bursting around the body
  • –> very high viral load & genital shedding
  • = HIGH transmission risk - so important to treat until undetectable viral load before they have sex again

[NB: is a similar px to 2o syphilis (headache,myalgia, fever)so chacking the timeframe of sexual acitivy as in 2o syph = ~10w/2yrs and will see condylomatalata and soles/feet maculopapular rash]

49
Q

on microscopy of an organism you see hyphae.

What is the treatment for this?

A

microscopy w/ hyphae = candida albicans (thrush)

Rx is only if SYMPTOMATIC (white curds, sore vagina/vulva etc)

  • Clotrimazole 500g pessary (Canesten) + cream for the vulva or
  • Fluconazole 150mg PO stat
    • (is the -azole’s)
50
Q

A patient has come back many times for treatment of thrush, previously they have had Clotrimazole 500g pessary (Canesten) + cream for the vulva and also Fluconazole 150mg PO stat…

What do you do now?

A

test for DM with HbA1c!!

as recurrent vaginal candidiasis indicates DM testing

51
Q

ON microscopy you see clue cells (ciliated) and “heavy growth of anaerobes”

what is the treatment for this STI?

A

Metronidazole 400mg BD PO 5d or

Clindamycin PV cream

Probiotic Lactobacillus (normal flora) GR-1 and RC-14 for 28 increase cure rates

52
Q

When testing for chlamydia and gonorrhoea you should test for both -

40-50% of those with gonorrhoea have chlamydia too, so test for gonorrhea with chlamydia sx too…

How do you test for these?

A
  • Both can be done with endocervical swab if female; or first catch urine if male –> NAAT (nucleic acid amplification test)
  • NB: can also be vaginal/oral/anal swabs too
    • a very accurate Ix, means people can do the kits themselves at home and send off
    • HOWEVER 2w wait for results so could spread if not Rx empirically

For instant results use the swabs e.g. if the Sexual health clinic has a LAB (not all do)–> can do MC+S or smear & gram stain

NB: microscopy would be quick but C&S takes time to grow on the agar plates

53
Q

What is the Rx for Chlamydia trachomatis?

  1. preferentially stat?
  2. over a week?
  3. if pregnant?
A

Pharma:

  1. Azithromycin 1g PO stat dose (preferred)
  2. Doxycycline 100mg BD 7d (teratogenic)
  3. Erythromycin 500mg BD 10-14d (good in pregnancy)

Non pharma rx (do these for all STI Rx)

  • Abstinence while completing course e.g. 7D (or 2wks)
  • Contact tracing (all partners in 3 months - sex health centre can send anon text)
  • contraception discussion e.g. barriers etc as RF for STI is PMHx STI
  • Some centres also treat for co-existent Gonorrhoea (ceftriaxone)
54
Q

What is the Rx of N. gonorrhoeae?

A

Pharma:

  • Ceftriaxone 500mg IM stat (or cefixime 400mg PO stat)
  • Penicillin
  • Ciprofloxacin

+ test for cure (due to resistance problem)

Non-Pharma:

    • treatment for chlamydia
  • Abstinence while completing course
  • Contact tracing (all partners in 3 months- sex heath centre can send anon text)
  • contraception discussion
  • social problems
    *
55
Q

What is the Rx for treponema pallidum (syphylis)?

  1. early
  2. late
  3. neurosyphylis (dementia, tabes, dorsalis, meningovascular complications, argyll robertson pupil/constricted)
  4. if pregnant & penicillin allergic
A
  1. Early syphilis: Benzathine penicillin 2.4 MU IM stat.
  2. Late syphilis: Benzathine penicillin 2.4 MU IM 3 doses at weekly intervals.
  3. Neurosyphilis: Procaine penicillin 1.8 MU IM OD 14d + probenecid 500mg PO QDS 14d
      • test for cure (due to resistance problem)
    • + Follow up serology to determine treatment response
    • Contact tracing (all partners in 3 months - centre can send anon texts)
  4. If pregnant & penicillin allergic: Doxycycline or erythromycin (penicillin allergy & pregnant)
56
Q

What bacteria do you use gram staining and what do you use dark field microscopy for?

A
  • Gonorrhoea, Chlamydia, BV, candida, T. vaginalis = gram staining; t vaginalis = saline drop test- motile protozoa
  • Dark ground/field microscopy - for syphilis (treonema pallidum) - do it on the chancre fluid
57
Q

Besides dark field microscopy what other Ix can be done for syphilis?

A
  • Bloods - TPPA/HA, EIA (specific tests) or VDRL/RPR (indirect –> confirm with specific tests)
  • Dark ground microscopy (of chancre fluid)
  • PCTR
  • LP for CSF antibody tests in neurosyphilis
58
Q

What is the Ix for HIV?

A

recent infection = antigen test, ELISA (enzyme linked immunosorbent assay: for antibodies or antigens or proteins), rapid point of care test

later on = NAAT (nucleic acid amplification test) ~2w wait

NB: with HIV you get a false negative before 1 month and even before 3m so often get poeple to come back for a repeat test; if HIV should be abstinent until undetectable (which = untransmissible) viral load

59
Q

What is the time period before

  1. syphilis,
  2. HIV and
  3. C &G can be detected w/NAAT in blood (window period), will show false negs before?
A
  1. Syphilis = 3-6wks before shows in blood
  2. HIV = 1 - 3 months
  3. C&G = 2 weeks
60
Q

Why is microscopy less accurate than NAAT?

A

As only get a snapshot of their discharge fluid etc under the microscope - the causative agent maybe missed in that part…

it also requires skilled staff to look down the microscope

Gynae, Breast & Sexual Health (7 decks)

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