Genital Tract Infections

Question 1

History

Answer 1

Need to be sensitive to patient anxiety and concerns about confidentiality and privacy prior to consultation
Genital symptoms (discharge and ulceration), febrile illness, pain, itch, odour, swelling, rash, joint pain, eye symptoms
Ask about UTI, haematuria, loin pain
General medical hx, PMH, FH, Allergies, DH
Women: menstrual, contraception, obstetric hx
Detailed Sexual Hx: Partners, type of contact, sex of partners, use of contraception, previous STIs, HIV testing, Hep B
Travel: sex abroad with foreign individuals
Risk assessment: Frequency of partner change, UPSI, Drugs, ETOH

Question 2

Examination

Answer 2

Mouth, throat, skin, LN, inguinal, genital and perianal areas are inspected
Pubic hair examined for nits and lice
External genitalia: Erythema, fissures, ulcers, chancres, pigmentation, warts, signs of trauma should be noted
Bartholin’s glands should be examined
Cervix inspected for ulceration, discharge, bleeding and ectopy
Vaginal walls: Warts
Bimanual: Tenderness, masses, position size and mobility of uterus
Rectal exam if symptomatic or anoreceptive intercourse

Question 3

Investigations

Answer 3

HIV testing should be performed on opt out basis: if declined, document reasons
Asymptomatic screening for hepatitis viruses in high risk groups and offer vaccination :
HBsAg (Current Infection), IgG Anti-HBc (Past infection and natural immunity)
Anti HBs positive with anti-HBc negative-immune due to vaccination
Symptomatic Women: Cervical swabs for GC, Chlamydia NAAT, MC+S for GC, Vaginal swabs for candida, TV, GC, Chlamydia
Rectal or oral swabs if indicated
Ulcerative: Microscopy, PCR for Herpes, Syphilis
Serological: Syphilis IgM, IgG, Cardiolipin, TPPA, HSV IgG

Question 4

Treatment, Prevention and Control

Answer 4

GUM Clinics keep basic stocks of meds and dispense directly to patients
Treatment of asymptomatic conditions prevents onward transmission
Tracing crucial in stopping spread of STDs
Prevention begins with education and information
Public health campaigns

Question 5

Gonorrhoea

Answer 5

Gram negative intracellular diplococcus infecting urogenital epithelium, rectum, pharynx, conjunctive
Incubation: 2-14 days
Most symptoms on day 2-5

Question 6

Clinical Features of Gonorrhoea

Answer 6

Endocervical canal: Increased or altered vaginal discharge, pelvic pain, dysuria, IMB
Complications: Bartholin’s abscess and rarely, peri hepatitis
One of the most common causes of female infertility
Conjunctival infection in neonates born to infected mothers
Disseminated gonorrhoea leads to characteristic popular or pustular rash with erythematous base in association with fever and malaise

Question 7

Management of Gonorrhoea

Answer 7

Diagnosis by culture; NAAT using urine, rapid diagnosis can be performed with gram staining and microscopy
Blood cultures and synovial investigations If disseminated disease
Often co-existing pathogens can be identified
Empirical treatment in clinic after rapid microscopic diagnosis prior to MC+S
Single dose Ceftriaxone IM, alternatively oral amoxicillin with probenecid
Follow up assessment and culture repeated 72h after treatment completion
All sexual contacts should be notified and examined and treated as necessary

Question 8

Chlamydia

Answer 8

Obligate intracellular gram negative bacterium
Most common site of infection is endocervix, 80% asymptomatic
Regularly found in association with gonorrhoea

Question 9

Clinical features of chlamydia

Answer 9

Can present vaginal discharge, PCB or IMB, lower abdominal pain
Ascending infection leads to acute salpingitis
Neonatal infection acquired from birth canal can result in mucopurulent conjunctivitis and pneumonia

Question 10

Management of Chlamydia

Answer 10

NAAT is diagnostic test of choice
Cell culture is gold standard but is expensive
Endocervical swabs and urethral swabs
Treatment with tetracyclines or macrolides e.g. doxycycline or azithromycin for uncomplicated infection
Tetracyclines CI in pregnancy
Routine test for cure unnecessary only if persistent
NAAT might remain positive for up to 5 weeks

Question 11

Lymphogranuloma Venerum

Answer 11

Caused by C trachomatis as well
Endemic to tropic
Primary lesion is ulcerating papule on genitalia 7-21 days post-exposure, painful, fixed, dusky erythema
Clinical diagnosis after ruling out syphilis and herpes
NAAT now available
Doxycycline, erythromycin for 21 days follow up until signs and symptoms resolved
Surgical drainage if abscess
Sexual partners in 30 days prior to onset should be notified

Question 12

Syphilis

Answer 12

Treponema pallidum; Motile Spirochaete through Intimate contact or Transplacental; Enters host through breaches in Squamous or Columnar Epithelium

Question 13

Primary Stage of Syphilis

Answer 13

10-90 days incubation (mean 21); Papule at site of inoculation; Ulcerates into Painless, Firm Chancre, associated with Painless, Regional LNA
o May go unnoticed especially if Endocervical or Rectal; Healing spontaneously 2-3/52

Question 14

Secondary Stage of Syphilis

Answer 14

4 – 10/52 after Primary Lesion;
Systemic symptoms (Fever, Sore Throat, Malaise, Arthralgia; Hepatitis, Nephritis, Arthritis, Meningitis can occur
o Generalised LNA in 50%, Skin rashes excluding the face in 75%, Condylomata Iata (Warty lesions in moist areas), Superficial Confluent Ulcers (=Snail Track)
o Untreated Early Syphilis in Pregnancy leads to Foetal Infection in 70%, may result in Stillbirth in up to 30%

Question 15

Tertiary Syphilis

Answer 15

Characteristic Gumma (Granulomatous and Ulcerating Lesions); Commonly on Skull, Tibia, Fibula and Clavicle; Visceral Gumma mainly in Liver and Testis
o Cardiovascular and Neurosyphilis is rare but serious in late infections

Question 16

Investigation of Syphilis

Answer 16

Dark ground microscopy of swabs of primary chancres or mucous patches
Treponema specific serology-EIA, T pallidum hemagglutination or particle agglutination assay, highly specific but wont differentiate between other treponemal infections e.g. Yaws
EIA is a screening test of choice-detects IgM and IgG antibodies
Treponema non-specific serology-VDRL and rapid plasma regain are positive 3-4 weeks from primary infection, negative 6 months from treatment

Question 17

Treatment of Syphilis

Answer 17

Antibiotics must be sufficiently high in serum for min 7 days to cover slow division time of treponema
Early Syphilis: Procaine Benpen IM for 10days, Doxycycline or erythromycin for 2-4 weeks if allergic
Jarisch-Herxheimer reaction: release of TNF, IL6, IL8 following 8 hours after first injection
Follow up at regular intervals

Question 18

Herpes Simplex

Answer 18

Infection is lifelong
Most genital is due to HSV2 but genital contact with oral HSV1 can also cause infection
Susceptible mucous membranes include Genital Tract, Rectum, Mouth and Oropharynx; Latency within DRG by Ascending Peripheral Sensory nerves

Question 19

Clinical Features of Primary Genital Herpes

Answer 19

Primary Genital Herpes usually accompanied by Systemic symptoms – Fever, Myalgia, Headache; Ulcers are Painful and may Coalesce; Tender Inguinal LNA common
o In women with Vulvar lesions, Cervix is almost always involved

Question 20

Management of Genital Herpes

Answer 20

Diagnosis based on Swabs from base of lesions; HSV DNA by PCR
o Viral Serology may have false negatives; IgM assays are unreliable
Saltwater Bath, Warm baths is soothing
• Aciclovir 200mg 5 times daily, Famciclovir 250mg TDS or Valaciclovir 500mg BD for five days useful if new lesions still forming; If already crusting, not effective
o Secondary Bacterial infection occasionally occurs and treated with Abx
• Long term suppressive therapy if frequent recurrences; Reassess after 12 months

Question 21

HSV in Pregnancy

Answer 21

Rarely Transplacental infection or Birth Canal; Aciclovir can be prescribed at standard doses during first and second trimester to the mother
o In late pregnancy, Aciclovir 400mg TDS is used instead due to altered pharmacokinetics; Prevents recurrence at term
• Symptomatic Primary acquisition at third trimester, or High levels of viral shedding at term, or lesions at onset of Labour usually managed with delivery by Caesarean

Question 22

HPV Warts

Answer 22

HPV 6 and 11 most commonly causing Genital Warts; Direct Sexual Contact, only small proportion are symptomatic
• Warts develop around External Genitalia; Vagina may be infected, Flat warts might develop within the Cervix, which can also be associated with CIN
• Clinical diagnosis; Important to differentiate from Condylomata Iata of Secondary Syphilis; Biopsy unusual lesions if in doubt
o Up to 30% have co-existent STI; Full screening must be performed

Question 23

Management of HPV warts

Answer 23

Topical Podophyllin extract, Tricholoracetic acid for Non-keratinised lesions;
If Keratinised, Physical therapies such as Cryo, Electro or Lasers more effective
• Imiquimod – Induces Cytokine response when applied to skin affected by HPV
• Prevention/Vaccination – Gardasil covers Wart causing strains and Cervical cancer associated strains; Given over 6 months in 3 divided doses; Most beneficial to people who have not been exposed yet; Routine HPV vaccination at age 12-13 and catch-up at 18yrs for girls

Question 24

Trichomonas

Answer 24

Trichomonas vaginalis – Flagellated Protozoon; Attaches to Squamous Epithelium and infects Vagina and Urethra; Can be acquired from the Birth Canal
o Trichomonas infection in Pregnancy associated with Prem and Low birthweight
• Infected women usually asymptomatic; Can present as Discharge, often offensive and causes local irritation;
Frothy yellowish Vaginal Discharge and Erythematous Vaginal Walls
o Cervix might have small haemorrhagic areas (‘Strawberry Cervix’)

Question 25

Management of TV

Answer 25

• Diagnosis by Dark Ground Microscopy of discharge – Characteristic swimming motion in 40 – 80% of female patients; Many PMN cells seen; PCR tests are being developed
• Metronidazole single dose or twice daily for 7 days; Nimorazole might be used if resistance; Male partners should be treated as might be asymptomatic in men, harder to detect

Question 26

Candidiasis

Answer 26

Extremely common; Unknown if Pathogenic or Commensal;
Predisposing factors include Pregnancy, Diabetes, Broad-spectrum Antibiotics and Steroids; Immunocompromised patients can have more florid infections
• Pruritus Vulvae is dominant symptom ± Discharge; Erythema, Swelling with broken skin in severe cases; Microscopic examination reviews Spores and Mycelia; MC+S
• Trichomonas and Bacterial Vaginosis considered as well
• Treated with Imidazole Antifungals, such as Clotrimazole 500mg or Nystatin; Oral drugs where topical therapy has failed

Question 27

Bacterial Vaginosis

Answer 27

Offensive Vaginal Discharge; Unknown aetiology or pathogenesis (Not regarded as STD) but mixed flora of Gardnerella vaginalis, anaerobes (e.g. Bacteroides, Mobiluncus and Mycoplasma) replaces normal Lactobacillus of vagina
o Amines and breakdown products from abnormal flora
o Vaginal inflammation is not part of syndrome (C/f Vaginitis)
• Homogenous, Grey-white Adherent Discharge with raised pH (>5)
o Diagnosed based on Discharge, Amine test (pH), Fishy odour when mixed with 10% Potassium Hydroxide, and ‘Clue’ cells (Vaginal Squamous Epithelium surrounded by adherent bacteria) on Microscopy; Partial Gram uptake
• Metronidazole 400mg BD for 5-7 days; Single 2g dose less effective; Alt Intravag Clinda
o Treatment of Asymptomatic women not recommended currently

Question 28

Pediculosis Pubis

Answer 28

• Phthirus pubis (Pubic louse) – Blood-sucking insect that attaches to pubic hair, eyelashes and eyebrows; Host-specific; Transferred by close body contact
o Eggs (Nits) are laid at hair baes and hatch within week
o Asymptomatic; Most common complaint is itch
• Treatment with 0.5% Malathion, 1% Permethrin or 0.5% Carbaryl; Applied to all body areas from neck down and washed after 12hrs; Further application after 1/52 might be necessary
• All sexual partners should be screened

Question 29

HIV Testing

Answer 29

Detection of Virus-Specific Antibodies (Anti-HIV) or Direct Identification of Viral Material
o First line is Anti-HIV Antibodies and p24 Antigen simultaneously
Anti-HIV Antibodies/IgG to Envelope Components – Most commonly used; Based on ELISA and Western Blot; Up to 3 months (Mean 6 weeks) from initial infection and detection
• IgG to p24 – Detected from earliest weeks of infection through asymptomatic phase; Lost as the disease progresses
• Viral p24 – Shortly after infection but disappears 8 – 10 weeks after exposure; Useful for very recent infection but not in time to mount antibody response

Question 30

HIV Associated Indicator Conditions

Answer 30

PJP
HIV dementia
Cryptococcal meningitis
Kaposi's sarcoma
Oral candidiasis
Castleman's disease
Cervical cancer
CMV
Burkitt's Lymphoma