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Gynaecology > Genital Tract Infections > Flashcards

Genital Tract Infections Flashcards

1
Q

Describe the normal vaginal environment.

A

Normal vagina: colonised by bacterial flora – most = lactopacillus
pH <4.5
Role in defence against pathogens

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2
Q

What is the consequence of having a lack of oestrogen?

A

Lack of oestrogen in young prepubertal girls and postmenopausal womenthin, atrophic epithelium with higher pH (6.5-7.5) and low resistance to infection

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3
Q

What are the non-sexually transmitted infections of the vagina and the vulva?

A
  • Candidiasis
  • Bacterial vaginosis
  • Foreign bodies
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4
Q

what most commonly causes candidiasis?

A

Candida albicans

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5
Q

What does candida colonisation do?

A

Candida may colonise the vagina without causing symptoms. It then progresses to infection when the right environment occurs, for example, during pregnancy or after treatment with broad-spectrum antibiotics that alter the vaginal flora.

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6
Q

What are the risk factors for candidiasis?

A

Increased oestrogen (higher in pregnancy, lower pre-puberty and post-menopause)
Poorly controlled diabetes
Immunosuppression (e.g. using corticosteroids)
Broad-spectrum antibiotics

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7
Q

How does candidiasis present?

A

o Cottage cheese discharge - not typically smelly
o Vulval irritation
o Itchy
o Superficial dyspareunia
o Dysuria
o Vagina and/or vulva are inflamed and read

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8
Q

How do we investigate candidiasis?

A

Often treatment for candidiasis is started empirically, based on the presentation.

Testing the vaginal pH using a swab and pH paper can be helpful in differentiating between bacterial vaginosis and trichomonas (pH > 4.5) and candidiasis (pH < 4.5).

A charcoal swab with microscopy can confirm the diagnosis.

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9
Q

What are the management options for candidiasis?

A
  • Antifungal Treatment
    • Most women:
      • Local: clotrimazole pessary or cream (e.g.clotrimazole 500 mg PV stat)
      • Oral: itraconazole 200mg PO BD for 1 day or fluconazole 150 mg PO stat
    • Girls aged 12-15 years: consider prescribing topical clotrimazole 1% or 2% applied 2-3 times per day (do not prescribe intravaginal or oral antifungal)
    • Pregnant women: intravaginal clotrimazole (Do not use oral antifungals)
    • If vulval symptoms: topical imidazole (clotrimazole, ketoconazole) in addition to an oral or intravaginal antifungal
    • NOTE: intravaginal clotrimazole (Canesten), oral fluconazole, topical clotrimazole → OTC
      *
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10
Q

What advice should be given regarding candidiasis?

A
  • Return if symptoms have not resolved in 7-14 days
  • Avoid predisposing factors:
    • Washing and cleaning the vulval area with soap or shower gels, wipes and feminine hygiene products
    • Cleaning the vulval area more than once per day
    • Washing underwear in biological washing powder and using fabric conditioners
    • Vaginal douching
    • Wearing tight-fitting and/or non-absorbent clothing
  • Wash the vulval area with a soap substitute - used externally and not more than once per day
  • Use simple emollient to moisturise vulval area
  • Consider probiotics (e.g. live yoghurts) orally or topically to relieve symptoms
  • Do not routinely treat asymptomatic sexual partner → Male partner could get candida balanitis
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11
Q

How should we counsel on candidiasis?

A
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12
Q

Define bacterial vaginosis.

A

Bacterial vaginosis (BV) refers to an overgrowth of bacteria in the vagina, specifically anaerobic bacteria. It is caused by a loss of the lactobacilli “friendly bacteria” in the vagina. Bacterial vaginosis can increase the risk of women developing sexually transmitted infections.

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13
Q

What is lactobacilli? What does it do?

A

Lactobacilli are the main component of the healthy vaginal bacterial flora. These bacteria produce lactic acid that keeps the vaginal pH low (under 4.5). The acidic environment prevents other bacteria from overgrowing. When there are reduced numbers of lactobacilli in the vagina, the pH rises. This more alkaline environment enables anaerobic bacteria to multiply.

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14
Q

What bacteria are associated with bacterial vaginosis?

A
  • Gardnerella vaginalis (most common)
  • Mycoplasma hominis
  • Prevotella species

It is worth remembering that bacterial vaginosis can occur alongside other infections, including candidiasis, chlamydia and gonorrhoea.

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15
Q

What are the RFs for bacterial vaginosis?

A
  • Multiple sexual partners (although it is not sexually transmitted)
  • Excessive vaginal cleaning (douching, use of cleaning products and vaginal washes)
  • Recent antibiotics
  • Smoking
  • Copper coil

Bacterial vaginosis occurs less frequently in women taking the combined pill or using condoms effectively.

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16
Q

How does bacterial vaginosis present?

A
  • fishy-smelling watery grey or white vaginal discharge
  • Half of women with BV are asymptomatic.
  • NO itching, irritation and pain
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17
Q

What are the investigations for bacterial vaginosis?

A
  • Vaginal pH can be tested using a swab and pH paper. The normal vaginal pH is 3.5 – 4.5. BV occurs with a pH above 4.5.
  • A standard charcoal vaginal swab can be taken for microscopy. This can be a high vaginal swab taken during a speculum examination or a self-taken low vaginal swab.
  • Bacterial vaginosis gives “clue cells” on microscopy. Clue cells are epithelial cells from the cervix that have bacteria stuck inside them, usually Gardnerella vaginalis.
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18
Q

What is the management of Bacterial vaginosis?

A

Oral or intravaginal treatment with metronidazole 400mg BD (5-7 days) - avoid alcohol

o Alternative: intravagainal metronidazole/ clindamycin gel

Always assess the risk of additional pelvic infections with swabs for chlamydia and gonorrhoea

Advice: vaginal douching and excessive genital washing should be avoided

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19
Q

What complications is BV associated with in pregnancy?

A
  • Miscarriage
  • Preterm delivery
  • Premature rupture of membranes
  • Chorioamnionitis
  • Low birth weight
  • Postpartum endometritis
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20
Q

What are the sexually transmitted infections of the vulva and vagina?

A
  • Chlamydia - most common and significant cause of infertility
  • Gonorrhoea
  • Genital warts
  • Genital herpes
  • Syphilis
  • Trichomoniasis
  • HIV
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21
Q

What are the principles of management for treating sexually acquired infections?

A
  • Screen for concurrent infection
  • Regular sexual partner should be treated and screened
  • Partner notification/contact tracing → for screening and tx, usually performed by pt
  • Confidentiality important
    • Cannot inform partner of diagnosis without permission → STIs can occur in monogamous relationships
    • Genital herpes
  • Frequently changing partners → risk of STIs
  • Barrier methods are best for preventing transmission
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22
Q

What organism causes chlamydia?

A

Chlamydia trachomatis is a gram-negative bacteria. It is an intracellular organism, meaning it enters and replicates within cells before rupturing the cell and spreading to others

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23
Q

What are the risk factors of chlamydia?

A
  • Young
  • Sexually active
  • Multiple partners
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24
Q

Describe the clinical presentation of chlamydia?

A

The majority of cases of chlamydia in women are asymptomatic. Consider chlamydia in women that are sexually active and present with:

  • Abnormal vaginal discharge
  • Pelvic pain
  • Abnormal vaginal bleeding (intermenstrual or postcoital)
  • Painful sex (dyspareunia)
  • Painful urination (dysuria)

Consider chlamydia in men that are sexually active and present with:

  • Urethral discharge or discomfort
  • Painful urination (dysuria)
  • Epididymo-orchitis
  • Reactive arthritis

It is worth considering rectal chlamydia and lymphogranuloma venereum in patients presenting with anorectal symptoms, such as discomfort, discharge, bleeding and change in bowel habits.

Examination Findings

  • Pelvic or abdominal tenderness
  • Cervical motion tenderness (cervical excitation)
  • Inflamed cervix (cervicitis)
  • Purulent discharge
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25
Q

What are the investigations for chlamydia?

A

Nucleic acid amplification tests (NAAT) are used to diagnose chlamydia. This can involve a:

  • Vulvovaginal swab
  • Endocervical swab
  • First-catch urine sample (in women or men)
  • Urethral swab in men
  • Rectal swab (after anal sex)
  • Pharyngeal swab (after oral sex)
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26
Q

How do we manage chlamydia?

A
  • First-line for uncomplicated chlamydia infection is doxycycline 100mg twice a day for 7 days.
  • Doxycycline is contraindicated in pregnancy and breastfeeding. Alternatives options listed in the BASHH guidelines (always check guidelines) for treatment in pregnant or breastfeeding women are:
    • Azithromycin 1g stat then 500mg once a day for 2 days
    • Erythromycin 500mg four times daily for 7 days
    • Erythromycin 500mg twice daily for 14 days
    • Amoxicillin 500mg three times daily for 7 days

Other factors to consider are:

  • Abstain from sex for seven days of treatment of all partners to reduce the risk of re-infection
  • Refer all patients to genitourinary medicine (GUM) for contact tracing and notification of sexual partners
  • Test for and treat any other sexually transmitted infections
  • Provide advice about ways to prevent future infection
  • Consider safeguarding issues and sexual abuse in children and young people
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27
Q

What are the complication fo chalmydia infection?

A
  • Pelvic inflammatory disease
  • Chronic pelvic pain
  • Infertility
  • Ectopic pregnancy
  • Epididymo-orchitis
  • Conjunctivitis
  • Lymphogranuloma venereum
  • Reactive arthritis
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28
Q

What are the pregnancy related complications of chlamydia infection?

A
  • Preterm delivery
  • Premature rupture of membranes
  • Low birth weight
  • Postpartum endometritis
  • Neonatal infection (conjunctivitis and pneumonia)
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29
Q

What causes gonorrhoea? How does the organism do it?

A

Neisseria gonorrhoeae is a Gram-negative diplococcus bacteria.

It infects mucous membranes with a columnar epithelium, such as the endocervix in women, urethra, rectum, conjunctiva and pharynx.

It spreads via contact with mucous secretions from infected areas.

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30
Q

What are the RFs for gonorrhoea?

A

Gonorrhoea is a sexually transmitted infection.

RFs

  • young
  • sexually active
  • having multiple partners
  • Having other sexually transmitted infections, such as chlamydia or HIV, also increases the risk.
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31
Q

Describe the presentation of gonorrhoeal infections.

A

Infection with gonorrhoea is more likely to be symptomatic than infection with chlamydia. 90% of men and 50% of women are symptomatic.

The presentation will vary depending on the site. Female genital infections can present with:

  • Odourless purulent discharge, possibly green or yellow
  • Dysuria
  • Pelvic pain

Male genital infections can present with:

  • Odourless purulent discharge, possibly green or yellow
  • Dysuria
  • Testicular pain or swelling (epididymo-orchitis)

Rectal infection may cause anal or rectal discomfort and discharge, but is often asymptomatic. Pharyngeal infection may cause a sore throat, but is often asymptomatic.

Prostatitis causes perineal pain, urinary symptoms and prostate tenderness on examination. Conjunctivitis causes erythema and a purulent discharge.

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32
Q

How do we diagnose gonorrhoea?

A

Nucleic acid amplification testing (NATT) is use to detect the RNA or DNA of gonorrhoea.

Genital infection can be diagnosed with endocervical, vulvovaginal or urethral swabs, or in a first-catch urine sample.

Rectal and pharyngeal swab are recommended in all men who have sex with men (MSM), and in those with risk factors (e.g. anal and oral sex) or symptoms of infection in these areas.

A standard charcoal endocervical swab should be taken for microscopy, culture and antibiotic sensitivities before initiating antibiotics. This is particularly important given the high rates of antibiotic resistance.

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33
Q

How do we manage gonorrhoea?

A

Patients should be referred to GUM clinics (or local equivalent) to coordinate testing, treatment and contact tracing. Management depends on whether antibiotic sensitivities are known. For uncomplicated gonococcal infections:

  • A single dose of intramuscular ceftriaxone 1g if the sensitivities are NOT known
  • A single dose of oral ciprofloxacin 500mg if the sensitivities ARE known

Different regimes are recommended for complicated infections, infections in other sites and pregnant women. Most regimes involve a single dose of intramuscular ceftriaxone.

All patients should have a follow up “test of cure” given the high antibiotic resistance. This is with NAAT testing if they are asymptomatic, or cultures where they are symptomatic. BASHH recommend a test of cure at least:

  • 72 hours after treatment for culture
  • 7 days after treatment for RNA NATT
  • 14 days after treatment for DNA NATT

Other factors to consider are:

  • Abstain from sex for seven days of treatment of all partners to reduce the risk of re-infection
  • Test for and treat any other sexually transmitted infections
  • Provide advice about ways to prevent future infection
  • Consider safeguarding issues and sexual abuse in children and young people
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34
Q

What are the complications of gonorrhoeal infection?

A
  • Pelvic inflammatory disease
  • Chronic pelvic pain
  • Infertility
  • Epididymo-orchitis (men)
  • Prostatitis (men)
  • Conjunctivitis
  • Urethral strictures
  • Disseminated gonococcal infection
  • Skin lesions
  • Fitz-Hugh-Curtis syndrome
  • Septic arthritis
  • Endocarditis

A key complication to remember is gonococcal conjunctivitis in a neonate. Gonococcal infection is contracted from the mother during birth. Neonatal conjunctivitis is called ophthalmia neonatorum. This is a medical emergency and is associated with sepsis, perforation of the eye and blindness.

35
Q

What organism causes genital warts?

A

HPV

36
Q

What do genital warts look liike?

A

Appearances vary

o Tiny flat patches on vulval skin
o Small papilliform (cauliflower) swellings

o Usually multiple

37
Q

How do we manage genital warts?

A
  • No treatment — treatment is not always indicated, as in about 30% of people, warts disappear spontaneously within 6 months.
  • Self-applied treatments
    • Podophyllotoxin 0.5% solution
    • Imiquimod 5% cream
    • Sinecatechins 10% ointment
  • Specialist application — trichloroacetic acid (TCA) 80-90% solution.
  • Ablative methods (such as cryotherapy, excision, and electrocautery): consider if appropriately trained and resourced. These may be better for people with a small number of low-volume warts (regardless of type).

Refer to GUM services.

  • Inform the person that active treatments:
    • May take 1–6 months to work.
    • Have significant failure rates.
    • Have significant relapse rates (because they do not eliminate the human papillomavirus).
    • Often involve discomfort and skin reactions.
  • Advise women that no changes are recommended in the screening intervals of cervical cytology.
  • Recommend condom use and smoking cessation to improve response to treatment.
    • However, explain that latex condoms may be weakened if in contact with imiquimod.
  • If psychological distress is an issue, explain that psychological counselling is available.
  • If asked, reassure that the presence of anogenital warts does not always imply recent partner infidelity because human papillomavirus is thought to have a long latency period (3 weeks to 8 months).
  • Suggest that, with consent, the person’s current sexual partner may benefit from assessment for undetected genital warts or other undetected sexually transmitted infections, or for explanation and advice about the disease process in their par
38
Q

What organism causes genital herpes? How does it spread?

A

The herpes simplex virus (HSV)

HSV-1 is most associated with cold sores. It is often contracted initially in childhood (before five years), remains dormant in the trigeminal nerve ganglion and reactivates as cold sores, particularly in times of stress. Genital herpes caused by HSV-1 is usually contracted through oro-genital sex, where the virus spreads from a person with an oral infection to the person that develops a genital infection.

HSV-2 typically causes genital herpes and is mostly a sexually transmitted infection. It can also cause lesions in the mouth.

The herpes simplex virus is spread through direct contact with affected mucous membranes or viral shedding in mucous secretions. The virus can be shed even when no symptoms are present, meaning it can be contracted from asymptomatic individuals. Asymptomatic shedding is more common in the first 12 months of infection and where recurrent symptoms are present.

39
Q

How do genital herpes present?

A

Patients affected by herpes simplex may display no symptoms, or develop symptoms months or years after an initial infection when the latent virus is reactivated.

The symptoms of an initial infection with genital herpes usually appear within two weeks. The initial episode is often the most severe, and recurrent episodes are milder.

Signs and symptoms include:

  • Ulcers or blistering lesions affecting the genital area
  • Neuropathic type pain (tingling, burning or shooting)
  • Flu-like symptoms (e.g. fatigue and headaches)
  • Dysuria (painful urination)
  • Inguinal lymphadenopathy

Symptoms can last three weeks in a primary infection. Recurrent episodes are usually milder and resolve more quickly.

40
Q

How do we investigate genital herpes?

A

The diagnosis can be made clinically based on the history and examination findings.

A viral PCR swab from a lesion can confirm the diagnosis and causative organism.

41
Q

How do we manage genital herpes?

A

Where appropriate, patients should be referred to a genitourinary medicine (GUM) specialist service.

Aciclovir is used to treat genital herpes. There are various aciclovir regimes listed in the BNF, depending on the individual circumstances. Alternatives are valaciclovir and famciclovir.

Additional measures, including to manage the symptoms include:

  • Paracetamol
  • Topical lidocaine 2% gel (e.g. Instillagel)
  • Cleaning with warm salt water
  • Topical vaseline
  • Additional oral fluids
  • Wear loose clothing
  • Avoid intercourse with symptoms
42
Q

What organism causes syphilis? How does it infect? What is the incubation period?

A

Syphilis is caused by bacteria called Treponema pallidum.

This bacteria is a spirochete, a type of spiral-shaped bacteria.

The bacteria gets in through skin or mucous membranes, replicates and then disseminates throughout the body. It is mainly a sexually transmitted infection.

The incubation period between the initial infection and symptoms is 21 days on average.

43
Q

What are the different route of transmission of syphillis?

A
  • Oral, vaginal or anal sex involving direct contact with an infected area
  • Vertical transmission from mother to baby during pregnancy
  • Intravenous drug use
  • Blood transfusions and other transplants (although this is rare due to screening of blood products)
44
Q

What are the different stages of syphillis?

A

Primary syphilis involves a painless ulcer called a chancre at the original site of infection (usually on the genitals).

Secondary syphilis involves systemic symptoms, particularly of the skin and mucous membranes. These symptoms can resolve after 3 – 12 weeks and the patient can enter the latent stage.

Latent syphilis occurs after the secondary stage of syphilis, where symptoms disappear and the patient becomes asymptomatic despite still being infected. Early latent syphilis occurs within two years of the initial infection, and late latent syphilis occurs from two years after the initial infection onwards.

Tertiary syphilis can occur many years after the initial infection and affect many organs of the body, particularly with the development of gummas and cardiovascular and neurological complications.

Neurosyphilis occurs if the infection involves the central nervous system, presenting with neurological symptoms.

45
Q

Describe the presentation primary syphilis.

A
  • A painless genital ulcer (chancre). This tends to resolve over 3 – 8 weeks.
  • Local lymphadenopathy
46
Q

Describe the presentation fo secondary syphilis.

A

Secondary syphilis typically starts after the chancre has healed, with symptoms of:

  • Maculopapular rash
  • Condylomata lata (grey wart-like lesions around the genitals and anus)
  • Low-grade fever
  • Lymphadenopathy
  • Alopecia (localised hair loss)
  • Oral lesions
47
Q

Describe the presentation of tertiary syphilis?

A

Tertiary syphilis can present with several symptoms depending on the affected organs. Key features to be aware of are:

  • Gummatous lesions (gummas are granulomatous lesions that can affect the skin, organs and bones)
  • Aortic aneurysms
  • Neurosyphilis
48
Q

Describe the presentation of neurosyphilis.

A

Neurosyphilis can occur at any stage if the infection reaches the central nervous system, and present with symptoms of:

  • Headache
  • Altered behaviour
  • Dementia
  • Tabes dorsalis (demyelination affecting the spinal cord posterior columns)
  • Ocular syphilis (affecting the eyes)
  • Paralysis
  • Sensory impairment
49
Q

How do we diagnose syphilis?

A

Antibody testing for antibodies to the T. pallidum bacteria can be used as a screening test for syphilis.

Patients with suspected syphilis or positive antibodies should be referred to a specialist GUM centre for further testing.

Samples from sites of infection can be tested to confirm the presence of T. pallidum with:

  • Dark field microscopy
  • Polymerase chain reaction (PCR)

The rapid plasma reagin (RPR) and venereal disease research laboratory (VDRL) tests are two non-specific but sensitive tests used to assess for active syphilis infection. These tests assess the quantity of antibodies being produced by the body to an infection with syphilis. A higher number indicates a greater chance of active disease. These tests involve introducing a sample of serum to a solution containing antigens and assessing the reaction. A more significant reaction suggests a higher quantity of antibodies. The tests are non-specific, meaning they often produce false-positive results. There is a skill to both performing and interpreting the results of these tests.

50
Q

How do we manage syphillis?

A

All patients should be managed and followed up by a specialist service, such as GUM. As with all sexually transmitted infections, patients need:

  • Full screening for other STIs
  • Advice about avoiding sexual activity until treated
  • Contact tracing
  • Prevention of future infections

A single deep intramuscular dose of benzathine benzylpenicillin (penicillin) is the standard treatment for syphilis.

Alternative regimes and types of penicillin are used in different scenarios, for example, late syphilis and neurosyphilis. Ceftriaxone, amoxicillin and doxycycline are alternatives.

51
Q

What organism causes trichomoniasis? How is it transmitted? What does the organism look like?

A
  • Trichomonas vaginalis is a type of parasite spread through sexual intercourse.
  • Trichomonas is classed as a protozoan, and is a single-celled organism with flagella.
  • Flagella are appendages stretching from the body, similar to limbs.
    • Trichomonas has four flagella at the front and a single flagellum at the back, giving a characteristic appearance to the organism.
    • The flagella are used for movement, attaching to tissues and causing damage.

Trichomonas is spread through sexual activity and lives in the urethra of men and women and the vagina of women.

52
Q

What does trichomonad increase the risk of?

A
  • Contracting HIV by damaging the vaginal mucosa
  • Bacterial vaginosis
  • Cervical cancer
  • Pelvic inflammatory disease
  • Pregnancy-related complications such as preterm delivery.
53
Q

How does trichomoniasis present?

A

Up to 50% of cases of trichomoniasis are asymptomatic. When symptoms occur, they are non-specific:

  • Vaginal discharge
  • Itching
  • Dysuria (painful urination)
  • Dyspareunia (painful sex)
  • Balanitis (inflammation to the glans penis)

The typical description of the vaginal discharge is frothy and yellow-green, although this can vary significantly. It may have a fishy smell.

Examination of the cervix can reveal a characteristic “strawberry cervix” (also called colpitis macularis). A strawberry cervix is caused by inflammation (cervicitis) relating to the trichomonas infection. There are tiny haemorrhages across the surface of the cervix, giving the appearance of a strawberry.

54
Q

How is trichomoniasis diagnosed?

A

The diagnosis can be confirmed with a standard charcoal swab with microscopy (examination under a microscope).

Swabs should be taken from the posterior fornix of the vagina (behind the cervix) in women. A self-taken low vaginal swab may be used as an alternative.

A urethral swab or first-catch urine is used in men.

vaginal pH - above 4.5 - similar to bacterial vaginosis

55
Q

How Is trichomoniasis managed?

A

Patients should be referred to a genitourinary medicine (GUM) specialist service for diagnosis, treatment and contact tracing.

Treatment is with metronidazole.

56
Q

What causes HIV infection? what are the consequences?

A

HIV refers to the human immunodeficiency virus.

Being infected with HIV is referred to as being HIV positive.

AIDS refers to acquired immunodeficiency syndrome.

AIDS occurs as an HIV infection progresses, and the person becomes immunodeficient.

This immunodeficiency leads to opportunistic infections and several AIDS-defining illnesses, such as Kaposi’s sarcoma. AIDS is now mostly referred to as late-stage HIV.

57
Q

How is HIV transmitted?

A

HIV is not transmitted through day-to-day activities, including kissing. It is spread through:

  • Unprotected anal, vaginal or oral sexual activity
  • Mother to child at any stage of pregnancy, birth or breastfeeding (called vertical transmission)
  • Mucous membrane, blood or open wound exposure to infected blood or bodily fluids, for example, through sharing needles, needle-stick injuries or blood splashed in an eye
58
Q

How do we test HIV infection?

A

Antibody testing is the typical screening test for HIV. This is a simple blood test. Patients can request an antibody testing kit online for self sampling at home, which they post to the lab for testing.

Testing for the p24 antigen, checking directly for this specific HIV antigen in the blood. This can give a positive result earlier in the infection compared with the antibody test.

PCR testing for the HIV RNA levels tests directly for the number of viral copies in the blood, giving a viral load.

59
Q

What do we monitor with HIV?

A

CD4 Count

The CD4 count is the number of CD4 cells in the blood. These are the cells destroyed by the virus. The lower the count, the higher the risk of opportunistic infection:

  • 500-1200 cells/mm3 is the normal range
  • Under 200 cells/mm3 is considered end-stage HIV (AIDS) and puts the patient at high risk of opportunistic infections

Viral Load (VL)

Viral load is the number of copies of HIV RNA per ml of blood. “Undetectable” refers to a viral load below the lab’s recordable range (usually 50 – 100 copies/ml). The viral load can be in the hundreds of thousands in untreated HIV.

60
Q

What is the main management for HIV?

A
  • Specialist HIV, infectious disease or GUM centres manage patients with HIV.
  • Treatment involves a combination of antiretroviral therapy (ART) medications.
  • ART is offered to everyone with a diagnosis of HIV irrespective of viral load or CD4 count.
  • Some regimes involve only a single combination tablet, taken once daily, with the potential to suppress the infection completely.
  • Specialist blood tests can establish the resistance of each HIV strain to different medications and help tailor treatment.
  • The BHIVA guidelines (2015) recommend a starting regime of two NRTIs (e.g. tenofovir and emtricitabine) plus a third agent.

There are a number of classes of HAART medications that work slightly differently on the virus:

  • Protease inhibitors (PIs)
  • Integrase inhibitors (IIs)
  • Nucleoside reverse transcriptase inhibitors (NRTIs)
  • Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
  • Entry inhibitors (EIs)
61
Q

What is the additional management for HIV?

A

Prophylactic co-trimoxazole (Septrin) is given to patients with a CD4 under 200/mm3 to protect against pneumocystis jirovecii pneumonia (PCP).

HIV infection increases the risk of developing cardiovascular disease. Patients with HIV have close monitoring of cardiovascular risk factors and blood lipids. Appropriate treatment (e.g. statins) may be required to reduce their risk of developing cardiovascular disease.

Yearly cervical smears are required for women with HIV. HIV predisposes to developing human papillomavirus (HPV) infection and cervical cancer, so female patients need close monitoring to ensure early detection of these complications.

Vaccinations should be up to date, including influenza, pneumococcal, hepatitis A and B, tetanus, diphtheria and polio vaccines. Patients should avoid live vaccines.

62
Q

What advice should we give regarding HIV?

A

Advise condoms for vaginal and anal sex and dams for oral sex, even when both partners are HIV positive. If the viral load is undetectable, transmission through unprotected sex is unheard of, even in extensive studies, although infection is not impossible. Partners should have regular HIV tests.

Where the affected partner has an undetectable viral load, unprotected sex and pregnancy may be considered. It is also possible to conceive safely through techniques like sperm washing and IVF.

63
Q

What is post exposure prophylaxis?

A

Post-exposure prophylaxis (PEP) can be used after exposure to HIV to reduce the risk of transmission. PEP is not 100% effective and must be commenced within a short window of opportunity (less than 72 hours). The sooner it is started, the better. A risk assessment of the probability of developing HIV should be balanced against the side effects of PEP.

PEP involves a combination of ART therapy. The current regime is Truvada (emtricitabine and tenofovir) and raltegravir for 28 days.

HIV tests are done immediately and also a minimum of three months after exposure to confirm a negative status. Individuals should abstain from unprotected sexual activity for a minimum of three months until confirmed as negative.

64
Q

Define endometritis.

A

Endometritis refers to infection or inflammation of the endometrium, the inner lining of the uterus. It can be divided into pregnancy-related (obstetric) or non-obstetric.

65
Q

What is the difference between acute and chronic endometritis?

A
  • Acute endometritis is characterised by the presence of more than five neutrophils in a 400 power field in the endometrial glands.
  • Chronic endometritis is characterised by the presence of more than one plasma cell, (and lymphocytes) in a 120 power field in the endometrial stroma.
66
Q

What are the causative organisms of endometritis?

A

There is usually a mix of 2-3 organisms involved; some will be found in normal vaginal flora. It is often a mixed aerobic and anaerobic infection. There is rarely microbiological confirmation of the cause, as an uncontaminated endometrial sample or positive blood culture would be required. Causative organisms include:

  • Gram-positive cocci - Staphylococcus spp., Group A and B Streptococcus spp.
  • Gram-negative - Escherichia coli, Klebsiella spp., Chlamydia trachomatis, Proteus spp., Enterobacter spp., Gardnerella vaginalis, Neisseria spp.
  • Anaerobes - Bacteroides spp., Peptostreptococcus spp.
  • Others - Mycoplasma spp., Ureaplasma spp., tuberculosis.
67
Q

What are the risk factors of endometritis?

A

Result of

o Instrumentation of the uterus o Complication of pregnancy o BothResult of

o Instrumentation of the uterus o Complication of pregnancy o Both

68
Q

What are the risk factors of endometritis?

A

Result of

o Instrumentation of the uterus

o Complication of pregnancy

o Both

69
Q

How does endometritis present?

A

Number and severity of symptoms can vary markedly from patient to patient but usually include:

  • Fever.
  • Abdominal pain.
  • Offensive-smelling lochia.
  • Abnormal vaginal bleeding - postpartum haemorrhage.
  • Abnormal vaginal discharge.
  • Dyspareunia.
  • Dysuria.
  • General malaise.

Signs

  • Raised temperature.
  • Pain and uterine tenderness, which may radiate to the adnexae.
  • Tachycardia.
70
Q

What are the Ix for endometritis?

A
  • Blood cultures should be performed.
  • FBC may reveal a raised white cell count.
  • Check midstream urine.
  • High vaginal swab, including swab for gonorrhoea/chlamydia.
  • Endometrial biopsy is diagnostic, although rarely appropriate.

Ultrasound is unhelpful in this situatio

71
Q

How should endometritis be treated?

A
  • Abx
  • Consider admission → tx on admission
72
Q

What are the first line abx for endometritis?

A

Combination of clindamycin and gentamicin as the optimal first-line antibiotic treatment

Abdominal pain, fever (>38°C) and tachycardia (>90 bpm) are indications for admission for intravenous antibiotics

73
Q

When should hospital admission be considered from endometritis? What tx should be given?

A

If sepsis is suspected in the community, urgent referral to hospital is indicated where ‘red flag’ signs and symptoms are present:

  • If the woman appears seriously unwell, transfer by emergency ambulance[6]:
    • Pyrexia >38°C.
    • Sustained tachycardia (more than 90 bpm).
    • Breathlessness (respiratory rate >20 breaths per minute - a serious symptom).
    • Abdominal or chest pain.
    • Diarrhoea and/or vomiting.
    • Uterine or renal angle pain and tenderness.
    • The woman is generally unwell or seems unduly anxious/distressed.
  • Intravenous (IV) antibiotics if there are signs of severe sepsis. If less systemically unwell, oral treatment may be sufficient. Most women are best managed in a hospital environment.
  • The Royal College of Obstetricians and Gynaecologists (RCOG) guideline for sepsis following pregnancy recommends IV piperacillin/tazobactam or a carbapenem plus clindamycin for severe sepsis. Other options for less severe infections include co-amoxiclav, metronidazole and gentamicin. However, i_t stresses guidelines based on local resistance should be followed._
74
Q

Define pelvic inflammatory disease.

A
  • Spectrum of inflammatory disease comprising of the upper female genital tract including combination of endometritis, salpingitis, tubo-ovarian abscess and pelvic peritonitis
75
Q

What causes PID?

A

Most cases of pelvic inflammatory disease are caused by one of the sexually transmitted pelvic infections:

  • Neisseria gonorrhoeae tends to produce more severe PID
  • Chlamydia trachomatis
  • Mycoplasma genitalium

Pelvic inflammatory disease can less commonly be caused by non-sexually transmitted infections, such as:

  • Gardnerella vaginalis (associated with bacterial vaginosis)
  • Haemophilus influenzae (a bacteria often associated with respiratory infections)
  • Escherichia coli (an enteric bacteria commonly associated with urinary tract infections)
76
Q

What are the RFS for PID¿

A
  • Not using barrier contraception
  • Multiple sexual partners
  • Younger age
  • Existing sexually transmitted infections
  • Previous pelvic inflammatory disease
  • Intrauterine device (e.g. copper coil)
77
Q

How does PID present?

A

Women may present with symptoms of:

  • Pelvic or lower abdominal pain
  • Abnormal vaginal discharge
  • Abnormal bleeding (intermenstrual or postcoital)
  • Pain during sex (dyspareunia)
  • Fever
  • Dysuria

Examination findings may reveal:

  • Pelvic tenderness
  • Cervical motion tenderness (cervical excitation)
  • Inflamed cervix (cervicitis)
  • Purulent discharge

Patients may have a fever and other signs of sepsis.

Oishi infertility, chronic pelvic pain, fever, vomiting, back pain, dyspareunia, bilateral abdominal pain, lower genital tract infection, itching, bleeding or discharge

78
Q

What Ix need to be done for PID?

A

Patients with pelvic inflammatory disease should have testing for causative organisms and other sexually transmitted infections:

  • NAAT swabs for gonorrhoea and chlamydia
  • NAAT swabs for Mycoplasma genitalium if available
  • HIV test
  • Syphilis test

A high vaginal swab can be used to look for bacterial vaginosis, candidiasis and trichomoniasis.

A microscope can be used to look for pus cells on swabs from the vagina or endocervix. The absence of pus cells is useful for excluding PID.

A pregnancy test should be performed on sexually active women presenting with lower abdominal pain to exclude an ectopic pregnancy.

Inflammatory markers (CRP and ESR) are raised in PID and can help support the diagnosis.

HIV serology

USS: tubo-ovarian abscess (TVUS)- You would see increased tubal wall thickness

79
Q

What is the management of PID?

A

Consider removal of IUD if it is in situ
o Usually if the patient has failed to respond to treatment after 72hours

Outpatient Antibiotic Regimen
o Ceftriaxone 1g IM (single dose) - covers gonorrhoea
o Doxycycline 100 mg BD (oral) for 14 days - covers chlamydia and mycoplasma genitalium
o Metronidazole 400 mg BD (oral) for 14 days - cover anaerobes such as Gardnerella vaginalis

Alternative: ofloxacin + metronidazole for 14 days

If pyrexial or oral management has failed

o 1st line: IV cefoxitin + doxycycline - covers other bacteria including H.influenzae and E.coli

o 2nd line: IV clindamycin + gentamicin

STI screening and contact tracing

o Chlamydia and gonorrhoea tests should be offered
o Current and recent partners (within last 6 months) should be contacted and offered advice, screening and treatment

Advise about barrier contraception

Counsel about the small risk of subfertility (increased risk with recurrence)

More severe cases, particularly where there are signs of sepsis or the patient is pregnant, require admission to hospital for IV antibiotics. Where a pelvic abscess develops, this may need drainage by interventional radiology or surgery.

Follow-up

80
Q

What is the follow-up of PID?

A

If managed as outpatients, should be seen within 72 hours to assess response

If no improvement, admit for IV antibiotics

Further follow-up at 2-4 weeks to:

o Ensure resolution
o Reiterate importance of STIs
o Reassure that if compliant, fertility is not affected

Complications:

o Infertility

o Ectopic pregnancy

o Chronic pelvic pain

81
Q

What are the complications of PID?

A
  • Sepsis
  • Abscess
  • Infertility
  • Chronic pelvic pain
  • Ectopic pregnancy
  • Fitz-Hugh-Curtis syndrome
82
Q

What is Fitz-Hugh-Curtis syndrome?

A

Fitz-Hugh-Curtis syndrome is a complication of pelvic inflammatory disease. It is caused by inflammation and infection of the liver capsule (Glisson’s capsule), leading to adhesions between the liver and peritoneum. Bacteria may spread from the pelvis via the peritoneal cavity, lymphatic system or blood.

Fitz-Hugh-Curtis syndrome results in right upper quadrant pain that can be referred to the right shoulder tip if there is diaphragmatic irritation. Laparoscopy can be used to visualise and also treat the adhesions by adhesiolysis.

83
Q

How should we counsel on PID?

A
84
Q
A

Gynaecology (15 decks)

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