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FINALS > Genito-urinary med > Flashcards

Genito-urinary med Flashcards

1
Q

CONTRACEPTION

What are certain cancers you need to be aware of in relation to the contraceptives you need to avoid?

A
  • Breast cancer = avoid any hormonal contraception > IUD or barrier methods
  • Cervical or endometrial cancer = avoid IUS
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2
Q

CONTRACEPTION
When is contraception needed after birth?
What natural method might be trialled?
What contraceptives can be used at any time?

A
  • Fertility not considered to return until 21d after birth
  • Lactational amenorrhoea very effective for up to 6m after birth but must be fully breastfeeding + amenorrhoeic
  • POP + implant safe
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3
Q

COCP
What is the COCP?
How can it be taken?

A
  • Pill containing supraphysiological level of oestrogen AND progesterone (of varying types).
  • 21d on then 7d off (withdrawal bleed), tricycle or B2B packs
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4
Q

COCP

What are the benefits of using the COCP?

A
  • Very effective
  • Improves acne
  • Decreased risk of endometrial, ovarian + colorectal cancer
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5
Q

COCP

What are some risks of using the COCP?

A
  • Small risk of heart attacks + strokes
  • Small risk of blood clots
  • Increased risk of breast + cervical cancer
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6
Q

COCP

What are some side effects with the COCP?

A
  • Headaches
  • Nausea
  • Breast tenderness
  • Abnormal bleeding
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7
Q

COCP

What are the UKMEC4 criteria for the COCP?

A
  • Active breast cancer
  • Migraine with aura
  • Hx of VTE, stroke or IHD
  • > 35 smoking >15/d
  • Antiphospholipid syndrome + SLE
  • Breastfeeding <6w postpartum
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8
Q

COCP
What are the important starting instructions for the COCP?
Rules for switching from POP to COCP?

A
  • Start within first 5 days of cycle = immediate protection.
  • Start after day 5 = extra contraception for first 7d.
  • Can switch from traditional POP at any time but 7d extra contraception unless desogestrel then no additional
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9
Q

COCP
What is classified as a missed pill for the COCP?
What are the missed pill rules for…

i) 1 pill?
ii) 2 pills?

A
  • Taken >24h late
    i) Take missed pill and normal, even if 2 pills > continue
    ii) Take missed pill and normal, even if 2 pills > 7d extra protection
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10
Q

COCP

If someone has missed 2 pills and had unprotected sexual intercourse, what action is required?

A
  • Day 1–7 packet = emergency contraception
  • Day 8–14 packet = no action
  • Day 15–21 = next pack B2B (skip pill-free period)
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11
Q

POP
What is the POP?
What is the only UKMEC4 contraindication?

A
  • Pill containing only progesterone, taken continuously

- Active breast cancer

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12
Q

POP

What different types of POP are there and what are their mechanisms?

A
  • Traditional POP (norgeston) = thickens cervical mucus

- Desogestrel POP (Cerazette) = inhibits ovulation and thickens cervical mucus

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13
Q

POP
What are the benefits of the POP?
What are the risks/side effects of the POP?

A
  • Very effective, role in menorrhagia Mx

- Irregular vaginal bleeding #1 in first 3m, acne, headaches, ovarian cysts

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14
Q

POP
What are the important starting instructions for the POP?
Rules for switching from COCP to POP?

A
  • Start within first 5 days of cycle = immediate protection
  • Start after day 5 = extra contraception for 48h
  • Best time is days 22–28 (hormone-free period) as no extra protection, if not 48h
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15
Q

POP
What is classified as a missed pill for the POP?
What are the missed pill rules for POP?
What are the rules about UPSI?

A
  • > 3h in traditional POP, >12h late for desogestrel POP
  • Take pill ASAP, continue with next pill as usual and extra contraception for 48h
  • UPSI since missing pill or within 48h restarting = emergency contraception
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16
Q

PROGESTERONE INJECTION
What is the progesterone only injection, how often is it given and what is the mechanism?
What is the only UKMEC4 contraindication?

A
  • Depo-Provera = depot medroxyprogesterone acetate every 12w to inhibit ovulation
  • Active breast cancer
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17
Q

PROGESTERONE INJECTION

What are some adverse effects of the progesterone injection?

A
  • Irregular bleeding
  • Weight gain
  • Osteoporosis (stopped before 50 due to this risk)
  • Can take 12m for fertility to return after stopping injections
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18
Q

PROGESTERONE INJECTION

What are the important starting instructions for the progesterone injection?

A
  • Day 1–5 = immediate protection.

- Beyond day 5 = extra contraception for 7d

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19
Q

PROGESTERONE IMPLANT
What is the progesterone implant and the ages it’s used for?
What is the mechanism of action?
What is the only UKMEC4 contraindication?

A
  • Nexplanon used in UK, 68mg of etonogestrel, licensed 18–40y/o.
  • Inhibits ovulation + thickens cervical mucus
  • Active breast cancer
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20
Q

PROGESTERONE IMPLANT
What are the important starting instructions for the progesterone implant?
How long do they last for?

A
  • Day 1–5 = immediate protection.
  • Beyond day 5 = 7d contraception.
  • Lasts 3y then needs replacing.
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21
Q

PROGESTERONE IMPLANT

What are the benefits of the progesterone implant?

A
  • Effective
  • Can improve menorrhagia
  • Don’t have to remember taking a pill
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22
Q

PROGESTERONE IMPLANT

What are the drawbacks of the progesterone implant?

A
  • Irregular bleeding

- Pain on insertion

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23
Q

PROGESTERONE IMPLANT

What are the risks with the progesterone implant?

A
  • Can be bent/fractured or impalpable/deeply implanted needing extra contraception until located (USS/XR), may need specialist removal.
  • Very rarely can enter vessels + migrate through body to lungs.
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24
Q

PROGESTERONE IMPLANT

What is the UKMEC4 criteria for the progesterone implant?

A
  • Active breast cancer.
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25
Q

COILS
What are the 2 types of coils?
What are the contraindications to insertion?

A
  • Copper IUD or levonorgestrel intrauterine system (IUS)
  • PID, immunosuppression, unexplained bleeding, uterine cavity distortion (fibroids), UKMEC3 48h–4w after birth (before or after is okay)
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26
Q

COILS
What is the copper coil licensed for?
What is the mechanism of action?
Is extra contraception required?

A
  • 5–10y after insertion device dependent, emergency contraception as well as long-term
  • Inhibits implantation
  • No it’s effective immediately
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27
Q

COILS
What are the benefits of the copper IUD?
What are the drawbacks?

A
  • Reliable, no hormones so safe in cancer

- Pain on insertion, irregular bleeding

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28
Q

COILS
What is the IUS licensed for?
What is the mechanism of action?
Is extra contraception required?

A
  • Main type Mirena effective for 5y for contraception, 4y for HRT
  • Thickens cervical mucus + inhibits implantation
  • No if inserted up to day 7 if not yes
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29
Q

COILS
What are the benefits of the IUS?
What are the drawbacks?

A
  • Treats menorrhagia, reliable, can improve dysmenorrhoea

- Pain on insertion, irregular bleeding

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30
Q

COILS
What must you do prior to and after insertion of a coil?
What happens if there’s an infection?
What should you advise patients before removal?

A
  • Screen for STIs prior and at 3–6w check threads visible
  • Treat with coil in place
  • Abstain from sex or use extra contraception for 7d before coil removed
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31
Q

EMERGENCY CONTRACEPTION

What 3 types of contraception can be used as emergency contraception?

A
  • Copper IUD
  • PO Ulipristal acetate (ellaOne)
  • PO levonorgestrel (levonelle)
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32
Q

EMERGENCY CONTRACEPTION
What is the time frame after UPSI that you can use the various emergency contraceptives and their relative effectiveness?

A
  • Levonorgestrel = <72h, 84% + decreases with time
  • Ulipristal acetate = <120h, in between the two
  • Copper IUD = <120h or up to 5d after likely ovulation date, 99%
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33
Q

EMERGENCY CONTRACEPTION

What is the mechanism of action of the various emergency contraceptives?

A
  • Levonorgestrel = stops ovulation + inhibits implantation
  • Ulipristal acetate = inhibits ovulation
  • Copper IUD = inhibits implantation + fertilisation
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34
Q

EMERGENCY CONTRACEPTION

What is important cautions should be remembered for the various emergency contraceptives?

A
  • Levonorgestrel = 1.5mg single dose, 3mg if BMI >26 or >70kg
  • Ulipristal acetate = avoid in severe asthma and avoid breastfeeding for 1w after use
  • Copper IUD = keep in until at least next period
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35
Q

EMERGENCY CONTRACEPTION

Can the various emergency contraceptives be used more than once in the same cycle?

A
  • Yes for levonorgestrel and ulipristal

- Copper IUD N/A

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36
Q

EMERGENCY CONTRACEPTION

In terms of long-term contraception after the use of emergency contraception, what is the information to tell patients?

A
  • Levonorgestrel = hormonal contraception starts immediately after
  • Ulipristal acetate = wait 5d before starting contraception
  • Copper IUD = offers long term contraception
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37
Q

STERILISATION
What is female sterilisation?
How effective is it?

A
  • Tubal occlusion by laparoscopy under GA

- Less effective than male sterilisation

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38
Q

STERILISATION
What is male sterilisation?
What are the benefits?
What follow up is required?

A
  • Vasectomy performed under LA = vas deferens ligated + excised
  • Relatively quick, less invasive + more effective
  • Contraception until semen analysis at 16w + 20w
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39
Q

INFERTILITY
What is primary and secondary infertility?
What is the epidemiology?

A
  • Primary = no pregnancy after at least 1 year of regular intercourse
  • Secondary = couples who have been pregnant ≥1 before but now cannot
  • Very common, 1 in 6 of whom most will conceive after 2y
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40
Q

INFERTILITY

When would you consider referring to a specialist before 1 year?

A
  • Female >35y
  • Previous STI
  • Abnormal examination
  • Previous pelvic or uro-genital surgery
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41
Q

INFERTILITY

What are some causes of female infertility?

A
  • Ovulatory = PCOS, age, hyperprolactinaemia, Turner’s syndrome
  • Tubal/uterine/cervical = PID, Asherman’s, endometriosis, fibroids
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42
Q

INFERTILITY

What are some causes of male infertility?

A
  • Testicular = cryptorchidism, testicular cancer, Klinefelter’s, mumps
  • Post-testicular = retrograde ejaculation, CF
  • Azoospermia = steroid abuse, hypogonadotropic hypogonadism
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43
Q

INFERTILITY

What are some risk factors of infertility?

A
  • Obesity
  • Smoking
  • Excessive alcohol/drugs
  • Occupational risks
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44
Q

INFERTILITY

What are some first line investigations for infertility?

A
  • STI screens (particularly chlamydia).
  • Ovulatory tests (mid-luteal progesterone levels)
  • Semen analysis (>15million/ml)
  • FSH (high in testicular/premature ovarian failure), LH
  • TFTs + prolactin if clinical suspicion
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45
Q

INFERTILITY
When do you perform mid-luteal progesterone levels?
What results would you expect?

A
  • 7d before end of cycle (usually day 21)

- <16 = anovulation, 16–30 repeat, >30 is ovular

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46
Q

INFERTILITY

What are the ovarian reserve tests?

A
  • Pelvic USS, CF screen, Karyotyping

- Tubal patency = hysterosalpinogram if no risk factors, laparoscopy + dye test gold standard in high risk

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47
Q

INFERTILITY
What pre-conception advice would you give to couples?
To females?
To males?

A
  • Intercourse 2–3 a week, regular smear tests
  • Healthy BMI, smoking + drinking advice
  • F = take 0.4mg folic acid (or 5mg if high risk).
  • M = looser underwear, avoid extreme heat near genitals, zinc
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48
Q

INFERTILITY

How would you manage anovulation?

A
  • Weight loss
  • Clomifene days 2–6 to inhibit oestrogen > more GnRH > more FSH/LH
  • GnRH if clomifene resistant
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49
Q

INFERTILITY

How would you manage tubal disease?

A
  • Tubal surgery e.g., catheterization or cannulation
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50
Q

INFERTILITY

How do you manage male infertility?

A
  • Depends on abnormality
  • Intrauterine insemination (IUI), IVF, intracytoplasmic sperm injection (ICSI), donor insemination if no sperm
  • Surgical sperm retrieval if obstructive azoospermia (epididymal obstruction)
  • Gonadotropins if hypogonadotropic hypogonadism
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51
Q

INFERTILITY

How does IVF work?

A
  • Suppression of natural menstrual cycle with GnRH agonist
  • Ovarian stimulation + oocyte collection
  • Insemination then embryo culture + transfer
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52
Q

INFERTILITY

What is a key complication of IVD and what is the pathophysiology?

A
  • Ovarian hyperstimulation syndrome
  • Occurs after iatrogenic induction of ovulation (HCG) due to mass maturation of follicles becoming corpus luteum + so lots of vascular endothelial growth factors > increased vascular permeability
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53
Q

INFERTILITY

What are the various severities of ovarian hyperstimulation syndrome?

A
  • Abdo pain + vomiting = mild
  • N+V + USS showing ascites = moderate
  • Ascites, oliguria = severe
  • Anuria, VTE, ARDS = critical
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54
Q

INFERTILITY

What is the management of ovarian hyperstimulation syndrome?

A
  • USS + serum oestrogen (high) may be monitored

- Supportive = IV crystalloids, monitor urine output, LMWH, paracentesis

55
Q

CHLAMYDIA
What is chlamydia?
What is it caused by?
What is the incubation period?

A
  • Most common STI in UK (approx 1 in 10 young women have it)
  • Chlamydia trachomatis – obligate intracellular gram -ve cocci
  • 7–21d
56
Q

CHLAMYDIA

What are the risk factors for chlamydia, and STIs in general?

A
  • Age <25
  • Multiple sexual partners
  • Lack of barrier methods
  • Poor socioeconomic status
  • Other STIs
57
Q

CHLAMYDIA

What is the clinical presentation of chlamydia?

A
  • No symptoms in 70% F, 50% M
  • Women = cervicitis (discharge, bleeding), dysuria, dyspareunia
  • Men = urethral discharge, dysuria
58
Q

CHLAMYDIA
What is the investigation of choice for chlamydia?
Who is screening offered to?

A
  • Nucleic acid amplification tests (NAAT) = M first void urine sample, F vulvo-vaginal swab, MSM pharyngeal and rectal swab too
  • Screening 15–24y but relies heavily on opportunistic testing
59
Q

CHLAMYDIA

What are some complications with chlamydia?

A
  • Reactive arthritis
  • Epididymitis
  • PID
  • Ectopic pregnancies
  • # 1 preventable cause of infertility
60
Q

CHLAMYDIA
What is the conservative management of chlamydia?
What is the medical management?

A
  • Partner notification (treat too), contact tracing, contraceptive advice, ?child protection services
  • Test for other STIs, test 3m after treatment if <25y to ensure not re-contracted
61
Q

CHLAMYDIA

What is the medical management of chlamydia?

A
  • First line = doxycyline 100mg BD for 7d (C/I pregnancy + breastfeeding)
  • Second line = azithromycin (1g stat, 500mg OD for 2d), erythromycin or amoxicillin
62
Q

GONORRHOEA
What is gonorrhoea caused by?
What is the incubation period?

A
  • Neisseria gonorrhoea –gram -ve diplococcus

- 2–5d

63
Q

GONORRHOEA

What is the clinical presentation of gonorrhoea?

A
  • Males = urethral discharge (purulent green/yellow), dysuria
  • Females = cervicitis with discharge (purulent green yellow)
  • Rectal + pharyngeal usually asymptomatic
64
Q

GONORRHOEA

How would you investigate for gonorrhoea?

A
  • Nucleic acid amplification tests (NAAT) = M first void urine sample, F vulvo-vaginal swab, MSM pharyngeal and rectal swab too
65
Q

GONORRHOEA

What are the local complications of gonorrhoea?

A
  • Urethral strictures
  • Epididymo-orchitis
  • Salpingitis
  • Subfertility
66
Q

GONORRHOEA

What are the systemic complications of gonorrhoea?

A
  • PID
  • Septic arthritis
  • Disseminated gonococcal infection as triad of tenosynovitis, migratory polyarthritis, dermatitis lesions (can be maculopapular or vesicular)
67
Q

GONORRHOEA

What complication of gonorrhoea may present in neonates?

A
  • Ophthalmia neonatorum (gonococcal conjunctivitis)
68
Q

GONORRHOEA
What is the management of gonorrhoea?
What if that first line management is refused?

A
  • 1g single dose IM ceftriaxone (add PO ciprofloxacin 500mg but only if sensitive as high antibiotic resistance)
  • PO cefixime + PO azithromycin if refuses IM
  • Follow-up test of cure with NAAT testing or cultures
69
Q

PID

What is pelvic inflammatory disease?

A
  • Inflammation + infection of the pelvic organs (upper genital tract), caused by ascending infection through the cervix.
70
Q

PID

What are the causes of PID?

A
  • Chlamydia trachomatis = most common cause
  • Neisseria gonorrhoea, Mycoplasma genitalium
  • Less commonly non-STI like Gardnerella vaginalis, E. coli
71
Q

PID

What are some risk factors for PID?

A
  • Younger age
  • Existing STIs
  • Multiple sexual partners
  • Copper IUD
  • Previous PID
72
Q

PID

What is the clinical presentation of PID?

A
  • Pelvic/lower abdo pain (chronic)
  • Abnormal PV discharge (purulent), dysuria
  • Abnormal bleeding
  • Deep dyspareunia
  • Exam = fever, bimanual (Adnexal tenderness, cervical motion tenderness/excitation)
73
Q

PID

What investigations would you do in PID?

A
  • Urinary pregnancy test to exclude ectopic
  • NAAT swabs for gonorrhoea + chlamydia
  • HVS for BV, candidiasis + trichomoniasis
  • HIV + syphilis bloods
  • FBC, blood cultures + CRP/ESR if acutely unwell/septic
  • TV USS if abscess suspected
74
Q

PID
What might you look for on microscopy in PID?
What is the relevance?

A
  • Pus cells on swabs from vagina or endocervix

- Absence is useful to exclude PID

75
Q

PID

What are the complications of PID?

A
  • Chronic pelvic pain
  • Ectopic pregnancy
  • Infertility
  • Fitz-Hugh-Curtis syndrome
76
Q 
PID
What is Fitz-Hugh-Curtis syndrome?
What does it cause?
How does it present?
How is it managed?
A
  • Inflammation + infection of liver (Glisson’s) capsule leading to adhesions between liver + peritoneum
  • RUQ pain ± referred R shoulder pain if diaphragmatic irritation
  • LFTs + USS to exclude stones, laparoscopy for Dx + adhesiolysis
77
Q

PID

What is the management of PID?

A
  • STAT IM ceftriaxone 1g then doxycycline 100mg BD + metronidazole 400mg BD for 14d
  • OR ofloxacin 400mg + metronidazole 400mg BD for 14d
78
Q

BACTERIAL VAGINOSIS

What is the pathophysiology of BV?

A
  • Overgrowth of mostly anaerobic organisms (#1 = Gardnerella vaginalis) leading to consequent drop in lactic acid producing aerobic lactobacilli > raised vaginal pH
79
Q

BACTERIAL VAGINOSIS
What are the risk factors of bacterial vaginosis?
What causes BV to occur less frequently?

A
  • Multiple sexual partners
  • Excessive vaginal cleaning (douching)
  • Recent Abx
80
Q

BACTERIAL VAGINOSIS

What is the clinical presentation of BV?

A

Amsel’s diagnostic criteria (3/4) –

  • Thin, white homogenous discharge
  • Vaginal pH using swab + pH paper >4.5
  • Clue cells on charcoal MC&S
  • Positive whiff test = add potassium hydroxide > strong fishy odour
81
Q

BACTERIAL VAGINOSIS

What is the management of BV?

A
  • PO metronidazole 5–7d to target anaerobic bacteria, even in pregnancy
  • Topical metronidazole or clindamycin alternatives
82
Q

TRICHOMONAS VAGINALIS
What is TV caused by?
What can it increase the risk of?

A
  • Trichomonas vaginalis = highly motile, flagellated protozoan parasite
83
Q

TRICHOMONAS VAGINALIS

What is the clinical presentation of TV?

A
  • Vaginal discharge = offensive, yellow/green, frothy
  • Vulvovaginitis = itchy, dyspareunia
  • Cervix = “strawberry cervix” due to cervicitis + haemorrhages on surface
84
Q

TRICHOMONAS VAGINALIS

What investigations would you do for TV?

A
  • Vaginal pH >4.5

- Charcoal swab for MC&S = wet microscopy showing motile trophozoites

85
Q

TRICHOMONAS VAGINALIS

What is the management of TV?

A
  • PO metronidazole 5–7d (or stat 2g dose)
86
Q

SYPHILIS
What causes syphilis?
What are the modes of transmission?

A
  • Treponema pallidum – spirochete (spiral-shaped) bacteria

- Sexual contact (esp. MSM), vertical transmission, IVDU

87
Q

SYPHILIS
What are the three stages of syphilis?
How does the first stage present?

A
  • Primary, secondary + tertiary
  • Painless genital ulcer (chancre) at site of sexual contact)
  • Non-tender local lymphadenopathy
88
Q

SYPHILIS
What indicates secondary syphilis?
What is the clinical presentation?

A
  • Chancre healed
  • Systemic = fever, lymphadenopathy
  • Rash (trunk, soles + palms)
  • Condylomata lata (painless, warty lesions on genitalia)
  • Buccal ‘snail track ulcers’
89
Q

SYPHILIS
When does tertiary syphilis develop?
What is the clinical presentation?

A
  • > 2y
  • Gummas = granulomatous lesions of skin + bones
  • Ascending aortic aneurysms
  • Neurosyphilis = tabes dorsalis (gait issues), paralysis, dementia, Argyll-Robertson pupil
90
Q

SYPHILIS

What is an Argyll-Robertson pupil?

A

“Accommodates but does not react”

  • Constricted pupil that accommodates when focusing on near object but does not react to light, often irregularly (small) shaped
91
Q

SYPHILIS

What investigations would you do for syphilis?

A

Non-treponemal + treponemal tests –

  • +ve non, +ve treponemal = active syphilis
  • +ve non, -ve treponemal = false positive (pregnancy, SLE, TB, HIV)
  • -ve non, -ve treponemal = successfully treated syphilis
92
Q

SYPHILIS

How would you manage syphilis?

A
  • Single dose IM benzathine benzylpenicillin or PO doxycycline if allergic
93
Q 
SYPHILIS
What is a potential adverse effect of treating syphilis?
How does it present?
What is an important differential?
How is it managed?
A
  • Jarisch-Herxheimer reaction within a few hours of treatment
  • Fever, rash + tachycardia after dose, thought to be due to release of endotoxins following bacterial death
  • DDx = anaphylaxis but no wheeze or hypotension
  • Mx = antipyretics
94
Q

GENITAL HERPES

What causes genital herpes?

A
  • Herpes simplex virus (HSV) causes both cold sores (HSV-1) + genital herpes (HSV-2) but considerable overlap
95
Q

GENITAL HERPES

What is the clinical presentation of genital herpes?

A
  • Painful genital ulcers (neuropathic type pain)
  • Flu like Sx (headache, fever) + inguinal lymphadenopathy
  • Herpetic whitlow = painful skin lesion on finger/thumb
96
Q

GENITAL HERPES
What is the investigation for genital herpes?
How is it managed?

A
  • NAAT swab from lesion can confirm
  • PO anti-viral aciclovir within 5d of start of episode
  • Conservative = paracetamol, lidocaine 2% gel, warm saltwater clean, vaseline
97
Q

GENITAL HERPES

What time can genital herpes be dangerous and what is the main risk?

A
  • During pregnancy as risk of neonatal herpes simplex infection
98
Q

GENITAL HERPES

What is the management of primary genital herpes contracted before 28w gestation?

A
  • Aciclovir during initial infection + prophylaxis from 36w
  • No Sx at delivery = vaginal delivery (if >6w from initial infection)
  • Sx at delivery or <6w = c-section
99
Q

GENITAL HERPES

What is the management of primary genital herpes contracted after 28w gestation?

A
  • Aciclovir during initial infection + immediate prophylactic aciclovir
  • C-section in all cases
100
Q

GENITAL HERPES

What is the management of recurrent genital herpes in pregnancy?

A
  • Prophylactic aciclovir from 36w gestation but transmission risk low
101
Q

GENITAL WARTS

What causes genital warts?

A
  • Human papilloma virus 6 + 11
102
Q

GENITAL WARTS

What is the clinical presentation of genital warts?

A
  • Asymptomatic fleshy, slightly pigmented warts around genitals
  • Itching or bleeding, abnormal urinary stream
103
Q

GENITAL WARTS

What are the investigations for genital warts?

A
  • Clinical diagnosis (may use magnifying glass or colposcope)
  • Biopsy if atypical
104
Q

GENITAL WARTS

How is genital warts managed?

A
  • Prophylaxis with HPV vaccine for 12–13y (may be given to MSM + sex workers)
  • First line = topical podophyllum (multiple non-keratinised) or or cryotherapy (solitary keratinised)
  • Second line = topical imiquimod
105
Q

CANDIDIASIS
What is candidiasis?
What are some risk factors?

A
  • Thrush secondary to Candida yeast infection (#1 albicans)

- Increased oestrogen (pregnancy), poorly controlled DM, immunosuppression, broad spectrum Abx

106
Q

CANDIDIASIS

What is the clinical presentation of candidiasis?

A
  • Thick, white, non-offensive discharge (cottage cheese)
  • Superficial dyspareunia, dysuria, itching
  • Erythema, fissuring, “satellite” lesions
107
Q

CANDIDIASIS

What are the investigations for candidiasis?

A
  • Clinical Dx

- Vaginal pH <4.5

108
Q

CANDIDIASIS
What is the management of candidiasis?
What treatment should be used in pregnancy?

A
  • Recurrent candidiasis = ≥4 episodes a year
  • Confirm diagnosis with high vaginal charcoal swab MC&S
  • Consider blood glucose for ?DM
  • Induction-maintenance regime of PO fluconazole
109
Q

CANDIDIASIS
What is the management of candidiasis?
How does this differ in pregnancy?

A
  • Local = clotrimazole pessary, PO = itraconazole, fluconazole
  • Pregnancy = local only (clotrimazole)
110
Q

LICHEN SCLEROSUS

What is lichen sclerosus?

A
  • Chronic inflammatory condition which usually affects the genitalia in elderly females causing epidermis atrophy + formation of white plaques
111
Q

LICHEN SCLEROSUS

What is the suspected cause of lichen sclerosus?

A
  • Thought to be autoimmune as associated with other autoimmune conditions
112
Q

LICHEN SCLEROSUS

What is the clinical presentation of lichen sclerosus in women?

A
  • White patches which might scar, Koebner phenomenon
  • Prominent itch
  • Dyspareunia + dysuria
  • Often affects vulva + perianal areas but not perineum = hourglass/’8’ shape
113
Q

LICHEN SCLEROSUS

What are the investigations for lichen sclerosus?

A
  • Clinical Dx but biopsy if atypical = failure to respond to treatment or ?VIN/cancer (SCC of vulva)
114
Q

LICHEN SCLEROSUS

What is the management of lichen sclerosus?

A
  • Topical steroids + emollients
115
Q

HIV
What is HIV?
What is the pathophysiology of HIV?

A
  • RNA retrovirus that encodes reverse transcriptase
  • Binds to GP120 envelope on CD4 T helper cells
  • Virus enters + reverse transcriptase makes single stranded RNA > DNA
  • DNA integrated into host DNA via integrase enzyme + then core viral proteins are synthesised and cleaved by viral protease enzyme
116
Q

HIV
What is the aetiology of HIV?
What are high risk groups for HIV?

A
  • HIV-1 is most common type
  • HIV-2 is rare outside West Africa
  • MSM, IVDU, commercial sex workers
117
Q

HIV

How is HIV transmitted?

A
  • Unprotected sex (co-existing STIs can enhance transmission)
  • Vertical transmission (pregnancy, breastfeeding)
  • IVDU
  • Blood exposure
118
Q

HIV

What is the initial clinical presentation of HIV?

A
  • Initial seroconversion 3–12w post infection = fever, maculopapular rash, flu symptoms, lymphadenopathy, diarrhoea
  • Clinical latency with progressive loss of CD4 count = poor immunity but no symptoms
119
Q

HIV
After a period of clinical latency, what happens in terms of clinical presentation of HIV?
What is AIDS?

A
  • Early symptomatic HIV = rise in viral load + fall in CD4 count > fever, night sweats, diarrhoea, opportunistic infections (AIDS-related complex)
  • AIDS = Sx of immune deficiency + CD4 count <200
120
Q

HIV

What tests can be used to investigation HIV?

A
  • Combination tests (HIV p24 antigen and HIV antibody) for diagnosis and screening
  • CD4 count
  • PCR for HIV RNA (viral load)
121
Q

HIV
Explain the management of the results from combination tests?
What are self-testing kits and how are they used?

A
  • Combined test +ve = repeat to confirm
  • Test 4w after possible exposure = repeat at 12w if negative
  • Self-testing kits are antibody tests and can be -ve for 3m
122
Q

HIV

How can HIV infection be monitored?

A
  • Monitoring CD4 count

- Monitoring viral load

123
Q

HIV
What would you monitor with CD4 count?
What does viral load measure?

A
  • 500–1200cells/mm^3 = normal range, <200 risk of AIDS

- Measure of viral replication + indicator of prognosis (undetectable <50copies/ml)

124
Q

HIV

What are the considerations with HIV and pregnancy?

A
  • Normal vaginal delivery if viral load <50 copies/ml
  • Consider c-section if >50, but mandatory in >400 with IV zidovudine 4h before c-section
  • Neonatal PO zidovudine if maternal viral load <50 if not triple ART both for 4–6w
  • No breastfeeding AT ALL, even undetectable
125
Q

HIV

What are AIDS defining illnesses?

A
  • All associated with end-stage HIV infection where CD4 count dropped to level that allows unusual opportunistic infections + malignancies to occur
126
Q

HIV

What opportunistic infections can occur with a CD4 count of 200–500?

A
  • Oral thrush (Candida), shingles, hairy leukoplakia (EBV)

- Kaposi’s sarcoma = vascular tumour 2º to HHV-8, purple papules on skin, conjunctiva + GI/resp tract

127
Q

HIV

What opportunistic infections can occur with a CD4 count of 100–200?

A
  • Cryptosporidium #1 cause of diarrhoea
  • Cerebral toxoplasmosis = MULTIPLE lesions with ring or nodular enhancement
  • Progressive multifocal leukoencephalopathy = neuro Sx, widespread demyelination
  • Pneumocystis jirovecci pneumonia, HIV dementia
128
Q

HIV

What opportunistic infections can occur with a CD4 count of 50–100?

A
  • Aspergillosis, oesophageal candidiasis
  • Cryptococcal meningitis = #1 CNS fungal infection, ring enhanced lesion
  • Primary CNS lymphoma 2º to EBV = SINGLE homogenous enhancing lesion
129
Q

HIV

What opportunistic infections can occur with a CD4 count <50?

A
  • Cytomegalovirus retinitis

- Mycobacterium avium-intracellulare

130
Q

HIV

What is the management of HIV and give some classes of drugs?

A
  • Highly active antiretroviral therapy (HAART) = 2 NRTIs + third agent
  • Nucleoside reverse transcriptase inhibitors (NRTIs)
  • Protease inhibitors
  • Integrase inhibitors
  • Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
131
Q

HIV
Give some examples of and explain the mechanism of action of…

i) NRTIs?
ii) protease inhibitors?

A

i) Tenofovir, zidovudine = inhibits synthesis of DNA by reverse transcriptase
ii) Indinavir (–navir) = acts comptetitively on HIV enzyme involved in production of functional viral proteins

132
Q

HIV
Give some examples of and explain the mechanism of action of…

i) integrase inhibitors?
ii) NNRTIs?

A

i) Raltegravir (–gravir) = inhibits insertion of HIV DNA to the genome
ii) Nevirapine = binds directly to + inhibits reverse transcriptase

133
Q

HIV

What is the management of potential exposure to HIV?

A
  • Combination anti-retrovirals within 72h of exposure for 4w (post-exposure prophylaxis/PEP)
  • HIV test done immediately + after 3m of exposure (abstain for 3m)
134
Q

HIV

What is the general management of HIV?

A
  • Education (safe sex, sexual partners, regular testing)
  • Prophylactic co-trimoxazole if CD4 <200 (PCP)
  • Pre-exposure prophylaxis (PrEP) + PEP
  • Yearly cervical smears for women
  • Vaccinations up to date but avoid live ones
  • Conceive safely if undetectable or via sperm washing or IVF

FINALS (20 decks)

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