Genital Tract Infections Flashcards
History
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
Examination
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
Investigations
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
Treatment, Prevention and Control
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
Gonorrhoea
Gram negative intracellular diplococcus infecting urogenital epithelium, rectum, pharynx, conjunctive
Incubation: 2-14 days
Most symptoms on day 2-5
Clinical Features of Gonorrhoea
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
Management of Gonorrhoea
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
Chlamydia
Obligate intracellular gram negative bacterium
Most common site of infection is endocervix, 80% asymptomatic
Regularly found in association with gonorrhoea
Clinical features of chlamydia
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
Management of Chlamydia
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
Lymphogranuloma Venerum
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
Syphilis
Treponema pallidum; Motile Spirochaete through Intimate contact or Transplacental; Enters host through breaches in Squamous or Columnar Epithelium
Primary Stage of Syphilis
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
Secondary Stage of Syphilis
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%
Tertiary Syphilis
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
Investigation of Syphilis
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
Treatment of Syphilis
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
Herpes Simplex
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
Clinical Features of Primary Genital Herpes
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
Management of Genital Herpes
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
HSV in Pregnancy
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
HPV Warts
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
Management of HPV warts
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
Trichomonas
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’)
