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Obstetrics and Gynaecology > Genital Tract Infections > Flashcards

Genital Tract Infections Flashcards

1
Q

What type of epithelium is the vagina normally lined with?

A

Squamous epithelium

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2
Q

How is a vaginal epithelium and pH different in prepubertal girls and postmenopausal women?

A

The lack of oestrogen results in a thin, atrophic epithelium, a higher pH (6.5-7.5 vs <4.5pH) and reduced resistance to infection

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3
Q

What are some non-STI infections of the vulva and vagina?

A

Candidiasis (thrush); bacterial vaginosis; infection associated with foreign bodies

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4
Q

What causes candidiasis and what type of organism is it?

A

Candida albicans, a yeast-like fungus

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5
Q

What is the most common cause of vaginal infection?

A

Candidiasis

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6
Q

What are the risk factors for candidiasis?

A

Pregnancy, diabetes and the use of antibiotics

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7
Q

What are the symptoms (if any) of candidiasis?

A

‘Cottage cheese’ discharge with vulval irritation and itching. Superficial dyspareunia and dysuria may occur. The vagina and/or vulva are inflamed and red.

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8
Q

How do you investigate candidiasis?

A

A high vaginal swab is not routinely indicated if the clinical features are consistent with candidiasis

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9
Q

How do you treat candidiasis?

A

options include local or oral treatment
local treatments include clotrimazole pessary (e.g. clotrimazole 500mg PV stat)
oral treatments include itraconazole 200mg PO bd for 1 day or fluconazole 150mg PO stat
if pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated

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10
Q

What is the pathology behind bacterial vaginosis?

A

It is when normal lactobacilli are overgrown and a mixed flora including anaerobes. Gardnerella vaginalis and Mycoplasma hominis.

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11
Q

What are the clinical features of bacterial vaginosis?

A

A grey-white discharge is present, but the vagina is not red or itchy. There is a characteristic ‘fishy’ odour from amines released by a bacterial proteolysis

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12
Q

How do you diagnose bacterial vaginosis?

A

Amsel’s criteria for diagnosis of BV - 3 of the following 4 points should be present:

  • thin, white homogenous discharge
  • clue cells on microscopy: stippled vaginal epithelial cells
  • vaginal pH > 4.5
  • positive whiff test (addition of potassium hydroxide results in fishy odour)
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13
Q

How do you treat bacterial vaginosis?

A

oral metronidazole for 5-7 days
70-80% initial cure rate
relapse rate > 50% within 3 months
the BNF suggests topical metronidazole or topical clindamycin as alternatives

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14
Q

What type of labour is BV linked to?

A

Preterm labour

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15
Q

What is the main cause of discharge in children?

A

Foreign body. Sexual abuse must also be considered but discharge is more often due to atrophic vaginitis due to low oestrogen levels

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16
Q

What is the organism responsible for toxic shock syndrome?

A

A toxin-producing staph aureus is responsible.

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17
Q

What are the clinical features of toxic shock syndrome?

A

Centers for Disease Control and Prevention diagnostic criteria:
-fever: temperature > 38.9ºC
-hypotension: systolic blood pressure < 90 mmHg
diffuse erythematous rash
-desquamation of rash, especially of the palms and soles
-involvement of three or more organ systems: e.g. gastrointestinal (diarrhoea and vomiting), mucous membrane erythema, renal failure, hepatitis, thrombocytopenia, CNS involvement (e.g. confusion)

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18
Q

How do you treat toxic shock syndrome?

A

Antibiotics and intensive care

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19
Q

What bacteria causes chlamydia?

A

Chlamydia trachomatis

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20
Q

What are the clinical features (if any) of chlamydia?

A

Urethritis and a vaginal discharge. The principal complication is pelvic infection, which may also be silent.

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21
Q

What syndrome can chlamydia cause?

A

Reiter’s syndrome

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22
Q

What are the clinical features of Reiter’s syndrome?

A

Urethritis, conjunctivitis an arthritis

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23
Q

How do you treat chlamydia?

A

Azithromycin

If pregnant then azithromycin, erythromycin or amoxicillin

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24
Q

What bacteria, and what type, causes gonorrhoea?

A

Neisseria gonorrhoea, a gram negative diplococci

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25
Q

What are the clinical features (if any) of gonorrhoea?

A

Vaginal discharge, urethritis, bartholinits, and cervicitis can occur and the pelvis is often infected. Men usually develop urethritis. Systemically, bacteraemia and acute septic arthritis

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26
Q

How do you diagnose gonorrhoea?

A
  • nuclear acid amplification tests (NAATs) are now the investigation of choice
  • urine (first void urine sample), vulvovaginal swab or cervical swab may be tested using the NAAT technique
  • for women: the vulvovaginal swab is first-line
  • for men: the urine test is first-line
  • Chlamydia testing should be carried out two weeks after a possible exposure
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27
Q

How do you treat gonorrhoea?

A

IM ceftriaxone

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28
Q

What virus causes genital warts?

A

HPV 6 and 8

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29
Q

What are the clinical features of genital warts?

A

Appearances vary from tiny flat patches on the vulval skin to small papilliform (cauliflower-like) swellings. Warts are usually multiple and may affect the cervix

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30
Q

What cell change are genital warts linked to?

A

Certain oncogenic HPV types (mostly 16 and 18) and are associated with the development of cervical intraepithelial neoplasia

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31
Q

How do you treat genital warts?

A

1st line: Podophyllotoxin / imiquimod / sinecatechins

Cryotherapy or electrocautery is used for resistant warts

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32
Q

Is there a high recurrence rate for genital warts?

A

Yes (up to 25%)

33
Q

Is the first herpes infection to the others?

A

The primary infection is the worst, the recurring attacks are less painful, less severe and often preceded by localised tingling

34
Q

What are the clinical features of genital herpes?

A

Multiple small painful vesicles and ulcers around the introitus. Local lymphadenopathy, dysuria and systemic symptoms are common; secondary bacterial infection, aseptic meningitis or acute urinary retention are rarer

35
Q

How often is reactivation in herpes?

A

Very common, in about 75% of patients

36
Q

How is a diagnosis of herpes made?

A

It is established from examination and viral swabs.

37
Q

How do you treat herpes?

A

Aciclovir is used in severe infections and will reduce the duration of the symptoms if started early in a reactivation.

38
Q

What organism causes syphilis?

A

The spriochaete Treponema pallidum

39
Q

What are the clinical features of primary syphilis?

A

It is characterised by a solitary painless vulval ulcer (chancre)

40
Q

What happens if primary syphilis is untreated?

A

Secondary syphilis may develop weeks later, often with a rash, influenza symptoms and warty genital or perioral growths.

41
Q

What is latent syphilis?

A

It follows as secondary syphilis resolves spontaneously.

42
Q

How do you treat any stage of syphilis?

A

Parenteral (usually intramuscular) penicillin

43
Q

What organism causes trichomoniasis?

A

Trichomonas vaginalis is a flagellate protozoan.

44
Q

What are the clinical features of trichomoniasis?

A
  • vaginal discharge: offensive, yellow/green, frothy
  • vulvovaginitis
  • strawberry cervix
  • pH > 4.5
  • in men is usually asymptomatic but may cause urethritis
45
Q

How do you diagnose trichomoniasis?

A

Wet film microscopy, special staining or culture of vaginal swabs

46
Q

How do you treat trichomoniasis?

A

Metronidazole.

47
Q

What is endometritis?

A

This is infection confined to the cavity of the uterus alone.

48
Q

What are the main causes of endometritis?

A

The result of either instrumentation of the uterus or as a complication of pregnancy, or both. Infecting organisms include Chlamydia or gonococcus, E.coli, staphylococci and even clostridia.

49
Q

After what events are endometritis common?

A

C section, miscarriage or termination of pregnancy, particularly if some products of conception are retained

50
Q

What are the clinical features of Endometritis?

A

Persistent and often heavy vaginal bleeding, usually accompanied by pain. The uterus is tender and the cervical os is commonly open. A fever may initially be absent but septicaemia can ensue.

51
Q

What investigations would you perform in Endometritis?

A

Vaginal and cervical swabs and FBC; pelvic ultrasound is not very reliable.

52
Q

How would you treat Endometritis?

A

Broad-spectrum antibiotics are given. An evacuation of retained products of conception is then performed if symptoms do not subside or if there are ‘products’ in the uterus at US.

53
Q

What is pelvic inflammatory disease or salpingitis?

A

Pelvic infection, Endometritis usually co-exists

54
Q

What are the risk factors for PID?

A

Younger, poorer, sexually active nulliparous women are at most risk. Pelvic infection almost never occurs in the presence of a viable pregnancy

55
Q

What causes PID?

A

Ascending infection of bacteria in the vagina and cervix. Sexual factors account for 80%. Descending infection from local organs such as the appendix can also occur

56
Q

What are the main bacteria that cause PID?

A

Chlamydia trachomatis - the most common cause
Neisseria gonorrhoeae
Mycoplasma genitalium
Mycoplasma hominis

57
Q

How does PID often present?

A

Many have no symptoms and present later with subfertility or menstrual problems. Bilateral lower abdominal pain with deep dyspareunia is the hallmark, usually with abnormal vaginal bleeding or discharge.

58
Q

What would you find on examination of PID?

A

In severe cases examination reveal a tachycardia and high fever, signs of lower abdominal peritonism with bilateral adnexal tenderness and cervical excitation. A mass (pelvic abscess) may be palpable vaginally

59
Q

What is cervical excitation?

A

Pain on moving the cervix

60
Q

What investigations would you perform in PID?

A

Endocervical swabs for chlamydia and gonococcus and blood cultures if there is a fever. WBC and CRP may be raised. Pelvic US helps to exclude an abscess or ovarian cysts. Laparoscopy with fimbrial biopsy

61
Q

How would you treat PID?

A

Analgesics and either a parenteral cephalosporin (IM ceftriaxone) followed by doxycycline and metronidazole are most effective. Be aware that a large pelvic abscess can be life-threatening

62
Q

What are the complications of PID?

A

The main early complication is the formation of an abscess or pyosalpinx. Later, many women develop tubular obstruction and subfertility, chornic pelvic infection or chronic pelvic pain. Ectopic pregnancy is six times more common after PID.

63
Q

What is chronic pelvic inflammatory disease?

A

This is a persisting infection and is the result of non-treatment or inadequate treatment of PID.

64
Q

What is the pathology of chronic pelvic inflammatory disease?

A

Typically, there are dense pelvic adhesions and the fallopian tubes may be obstructed and dilated with fluid (hydrosalpinx) or pus (pyosalpinx).

65
Q

What are the common symptoms of chronic pelvic inflammatory disease?

A

Chronic pelvic pain or dysmenorrhoea, deep dyspareunia, heavy and irregular menstruation, chronic vaginal discharge and subfertility.

66
Q

What would you find on examination of chronic pelvic inflammatory disease?

A

Features similar to endometriosis: abdominal and adnexal tenderness and a fixed retroverted uterus.

67
Q

What would transvaginal US of chronic pelvic inflammatory disease show?

A

It may reveal fluid collections within the fallopian tubes or surrounding adhesions.

68
Q

What it the best diagnostic tool for chronic pelvic inflammatory disease?

A

Laparoscopy

69
Q

How do you treat chronic pelvic inflammatory disease?

A

Analgesic and antibiotics if evidence of infection. Severe cases occasionally respond to cutting of the adhesions (adhesiolysis), but sometimes removal of affected tubes (salpingectomy) is required

70
Q

What are the typical features of PID?

A 
Silent (particularly chlamydia)
Bilateral pain
Vaginal discharge
Cervical excitation
Adnexal tenderness
Fever
WBC and CRP raised
71
Q

What are the late complications of PID?

A

Subfertility
Chronic PID
Chronic pelvic pain
Ectopic pregnancy

72
Q

What are the main causes of vaginal discharge?

A 
Physiological
Infection
Atrophic vaginitis
Foreign body
Malignancy
73
Q

When does physiological vaginal discharge increase?

A

It increases around ovulation, during pregnancy and in women taking the combined oral contraceptive.

74
Q

What are the main infection causes of vaginal discharge?

A

BV and candidiasis are the most common; chlamydial infection, gonorrhoea and trichomonas vaginalis all can cause a discharge, particularly with cervicitis and PID.

75
Q

What is atrophic vaginitis and when is it common?

A

It is due to oestrogen deficiency and is common before the menarche, during lactation and after the menopause.

76
Q

How do you treat vaginal discharge due to atrophic vaginitis?

A

Treatment of symptomatic discharge is with oestrogen cream; systemic HRT may be preferred in postmenopausal women.

77
Q

What is specific about vaginal discharge due to a foreign body?

A

It is usually very offensive

78
Q

What is specific about vaginal discharge due to malignancy?

A

A bloody and offensive discharge is suggestive of cervical carcinoma, but any genital tract malignancy can be responsible.

79
Q

List 4 predisposing factors for candidiasis.

A

diabetes mellitus
drugs: antibiotics, steroids
pregnancy
immunosuppression: HIV, iatrogenic

Obstetrics and Gynaecology (27 decks)

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