Genital tract infections

Question 1

What are the features of the vagina at reproductive age?

Answer 1

o Lined by squamous epithelium
o Colonised by bacterial flore- lactobacilli
o Acidic pH <4.5

Question 2

What are the features of the vagina at prepubertal and post-menopause?

Answer 2

o Thinner epithelium
o Higher pH- 6.5-7.5
o Reduced resistance to infection

Question 3

What is bacterial vaginosis?

Answer 3

• Most common cause of vaginal discharge in women of reproductive age- associated with a loss of lactobacilli and increase of anaerobic and highly specific BV-associated bacteria in the vagina
• The bacteria produce proteolytic enzymes- these break down vaginal peptides into volative, malodorous amines
• Rise in pH facilitates adherence of G.vaginalis (90%) and Atropbium vaginae to exfoliating epithelial cells-
allows development of a biofilm, which adheres to the epithelium

Question 4

How is bacterial vaginosis diagnosed?

Answer 4

• A grey-white discharge is present with a characteristic fishy odour, but no Vulvovaginitis
o Raised vaginal pH
o Typical discharge
o Positive ‘whiff’ test- fishy odour when 10% potassium hydroxide is added to secretion
o Presence of ‘clue cells’ on microscopy- epithelium with Gram-variable coccobacilli

Question 5

What is the treatment for bacterial vaginosis?

Answer 5

metronidazole or clindamycin cream
• These bacteria can cause secondary infection in pelvic inflammatory disorder (PID)- there is also an association with preterm labour

Question 6

What is candidiasis?

Answer 6

• Candida spp- a yeast like fungus is identified in the lower genital tract in
o 10-20% of healthy women of reproductive age
o 6-7% of menopausal women- higher if taking HRT
o 3-6% of prepubertal girls
• Symptomatic candidiasis is due to a hypersensitivity response to commensal-up to 50% of women report at least one symptomatic lifetime episode
most are due to C.albicans
prengnancy, diabetes and use of antibiotics are risk factors

Question 7

What are the symptoms of candidiasis?

Answer 7

cottage cheese’ discharge with vulval irritation and itching
superficial dyspareunia and dysuria may occur
vagina +/- vulva can be inflamed and red
Diagnosed by a culture

Question 8

What is the treatment for candidiasis?

Answer 8

topical imidazoles (eg. clotrimazole pessary) or oral fluconazole

Question 9

What is toxic shock syndrome?

Answer 9

rare complication of the retained tampon
a toxin producing Staphylococcus aureus
high fever, hypertension and multisystem organ failure
treatment is with antibiotics and intensive care

Question 10

What are the risk factors for acquisition of STIs?

Answer 10

• Number of partners- +2 partners in last 6 months, new partner in the last 3 months or concurrent partner
• Non-use of condoms- condoms greatly reduce the risk of blood-borne viruses (gonorrhoea & chlamydia), but are less effective against warts & herpes
• Other STIs- including STI (or symptoms) in partner and previous STI
• Young age- under 20 years a strong risk factor
• Sexual preference- men who have sex with men

Question 11

What is chlamydia?

Answer 11

• Caused by Chlamydia trachomatis (bacteria)

3% of 18-24y/o in UK have Chlamydia at any one time

Question 12

What are the symptoms of chlamydia?

Answer 12

•	More than 70% of infected women have no genital symptoms- most common symptoms include
o	Altered vaginal discharge
o	Intermenstrual bleeding
o	Post-coital bleeding
o	Low abdominal pain
o	Dyspareunia

Question 13

What are the complications of chlamydia?

Answer 13

pelvic infection, which may also be silent, can cause tubal damage leading to subfertility and/or chronic pelvic pain
may precipitate sexually active reactive arthritis (SARA)- triad of urethritis, conjunctivitis and arthritis

Question 14

How is chlamydia diagnosed and treated?

Answer 14

Nucleic acid amplification test (NAATs) on vaginal swab or urine
Treatment: azithromycin or doxycycline

Question 15

What is gonorrhoea?

Answer 15

• Caused by Neisseria gonorrhoeae (Gram –ve diplococcus)
• Men usually develop urethritis
Women are commonly asymptomatic, but can have
o Vaginal discharge
o Urethritis
o Bartholinitis
o Cervicitis
o Pelvic infection
Systemic complications include- bacteraemia and acute septic arthritis (monoarticular)

Question 16

What is the diagnosis for gonorrhoea?

Answer 16

NAATs of endocervical or vulvovaginal swabs- +ve NAAT should be followed by culture to check antibiotic sensitivities

Question 17

What is the treatment for gonorrhoea?

Answer 17

if not resistant quinolones, azithromycin or cefixime- IM ceftriazoe is usually required in combination

Question 18

What are genital warts?

Answer 18

• Caused by human papilloma virus (HPV)-pass through close physical contact
• External genital warts- HPV 6&11, rarely associated with sever dysplasia, do not cause genital or anal cancer
• Certain oncogenic types (16&18) are associated with developing CIN

Question 19

What are the common sites for warts?

Answer 19

may be hard, soft, solitary, multiple and may be pigmented and itch 
o	Vulva
o	Perianus
o	Cervix
o	Vagina
Diagnosed by clinical judgement

Question 20

What is the treatment for genital warts?

Answer 20

not able to eradicate the virus
no treatment possible as warts may regress- still infective even if warts are absent
o Chemical application: podophyllin, podophyllotoxin, trichloroacetic acid solution or imiquimod
o Physical ablation: cryotherapy
• There is a high recurrence rate (25%)- vaccine against HPV is now administered to adolescent girls to prevent cervical neoplasia

Question 21

What are genital herpes?

Answer 21

• Both HSV-1 & 2 can affect genital and anal area- HSV-1 causes cold sores, but can cause genital herpes (oral sex)
• Virus can lie dormant in dorsal root ganglion- reactivations may occur. a patient with HSV-2 will have 4-6 recurrences each year, people with HSV-1 will have infrequent recurrence
recurrences are usually much milder and clear quicker

Question 22

What are the clinical features of genital herpes?

Answer 22

1 in 3 will experience a primary infection within 4-14 days of becoming infected
may feel generally unwell with flu-like symptoms
often followed by stinging or itching in the genital or anal area
small vesicles then occur, which burst within a day or two and will crust over and eheal
• Local lymphadenopathy and dysuria is common
secondary bacterial infection, aseptic meningitis or acute urinary retention are rare
tingling sensation or mild flu-like symptoms before an outbreak

Question 23

What is the treatment for genital herpes?

Answer 23

aciclovir used in severe infections and will reduce duration of symptoms if started early in reactivation