Genito-Urinary Medicine Flashcards
What are the key features of chancroid?
painful genital ulcer, tender inguinal lymphadenopathy
What organism causes chancroid?
Haemophilus ducreyi
What are the features of lymphogranuloma venereum?
painless genital ulceration, painful lymphadenopathy ‘buboes’ or abscesses
What organism causes lymphogranuloma venereum?
Chlamydia trachomatis
What is cryptococcosis?
opportunistic fungal infection causes by Cryptococcus species; lungs usually primary locus, with extrapulmonary dissemination; meningoencephalitis is common presentation in HIV
What are the treatment options for cryptococcosis?
- asymptomatic + mild/moderate + no CNS involvement: fluconazole
- severe / CNS involved: amphotericin B + flucocytosine; then fluconazole
What is cryptosporidiosis?
protozoan parasite; causes watery diarrhoea, abdo cramps, appetite loss, fever, nausea/vomiting
can be life-threatening in patients with HIV
What are the treatment options for cryptosporidiosis-induced GI disease?
- immunocompetent + age >1y: nitazoxanide
- immunosuppression: antiretroviral therapy + restore CD4 count >100
When do symptoms of genito-urinary TB usually develop?
10-15 years after primary infection
What are 10 possible symptoms of genito-urinary TB?
- repeated UTIs, poor response abx
- increased frequency of urination
- dysuria
- suprapubic pain
- blood / pus in urine (sterile pyruria)
- fever
- painful testicular swelling
- perianal sinus
- genital ulcer
- unexplained infertility
What is the classic finding on urine dip in GU TB?
sterile pyuria
What is the management of vulvovaginal candidiasis in non-pregnant patients?
- oral fluconazole first line (150mg stat)
- clotrimazole 500mg pessary as single dose (if PO CI)
- +- topical imidazole if vulval sx
What is the management of vulvovaginal candidiasis in pregnant patients?
local treatments only (cream or pessaries)
What is the definition of recurrent vaginal candidiasis?
4 or more episodes / year
What are 4 aspects of the management of recurrent vulvovaginal candidiasis?
- confirm diagnosis - high vaginal swab
- consider blood glucose / HbA1c
- exclude differentials e.g. lichen sclerosus
- consider induction-maintenance regime
What does an induction-maintenance regime for recurrent vaginal candidiasis involve?
- INDUCTION: oral fluconazole every 3 days for 3 doses
- MAINTENANCE: oral fluconazole weekly for 6 months
What causes bacterial vaginosis?
Overgrowth of Gardnerella vaginalis most commonly; gram positive and negative bacteria may be seen on gram stain
replace normal Lactobacilli
What are the clinical features of bacterial vaginosis?
- Fishy malodorous discharge.
- Lack of itch
- Increased vaginal pH
What are the criteria for diagnosis of bacterial vaginosis?
Amsel’s criteria - 3 of the following 4 points:
- 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)
-
What is the management of bacterial vaginosis?
- if asymptomatic - may not require treatment (unless undergoing TOP)
- if symptomatic - oral metronidazole 5-7 days
- if adherence likely to be an issue - stat metronidazole 2g
What is the management of bacterial vaginosis in pregnancy?
If symptomatic oral metronidazole can be used (PO 5-7 days), if asymptomatic discuss with woman’s obstetrician if treatment is indicated (avoid stat dose)
What are the risks of bacterial vaginosis in pregnancy? Give 4
- Preterm labour
- Low birth weight
- Chorioamnionitis
- Late miscarriage
What are 5 key features of trichomoniasis?
- Frothy, offensive yellow-green discharge
- Vulvovaginitis
- Strawberry cervix
- pH > 4.5
- Wet mount: motile trophozoites
What is the management of suspected epididymo-orchitis when the organism is unknown?
- ceftriaxone 500mg IM STAT
- doxycycline 100mg BD PO 10-14days
+ refer urgently to local GUM clinic
What are most commonly the organisms causing epididymo-orchitis?
- Chlamydia trachomatis + Neisseria gonorrhoeae
- OR
- organisms from bladder- E. coli
What guides the investigations for suspected epididymo-orchitis?
- younger adults - assess for STI
- older adults + low-risk sexual history: MSU for microscopy + culture
What is the management if enteric organisms are the most likely cause of epididymo-orchitis?
treat empirically with oral quinolone for 2 weeks e.g. ofloxacin
How many trichomoniasis present in men?
usually asymptomatic but can cause urethritis
What does microscopy show in trichomonas vaginalis?
motile trophozoites
What is the organism that causes trichomonas vaginalis and how is it transmitted?
trichomonas vaginalis is a highly motiles, flagellated protozoan parasite - is an STI
What is the management of Trichomonas vaginalis?
oral metronidazole for 5-7 days (BNF also supports one-off 2g metronidazole)
What is recommended first line to treat chlamydia?
doxycyline or azithromycin
What is recommended first line to treat PID?
- ofloxacin + metronidazole OR
- IM ceftriaxone + doxycycline + metronidazole
What is first line to treat syphilis?
benzathine penicillin
or doxycycline or erythromycin
What is the management of chlamydia infection in pregnancy?
azithromycin, erythromycin or amoxicillin
NOT doxycycline
What is the incubation period of chlamydia?
7-21 days
In what proportion of cases is chlamydia asymptomatic?
50& men, 70% women
What is the investigation of choice for chlamydia?
NAAT using first void urine sample (first line in men), vulvovaginal swab (first line in women) or cervical swab
At what time after possible exposure should chlamydia testing be performed?
2 weeks after a possible exposure
What is the first line treatment for chlamydia?
doxycycline - 7 day course
Why is doxycycline preferred to azithromycin to treat chlamydia?
due to concerns about Mycoplasma genitalium - often coexistant in patients with chlamydia, rising resistance to macrolides
Which contacts should be contacted for treatment in men with chlamydia and urethral symptoms?
all contacts since and in the 4 weeks prior to the onset of symptoms
Which contacts should be treated for chlamydia in women with chlamydia and asymptomatic men?
all partners from the last 6 months, or the most recent sexual partner
What is the approach to testing/treating contacts of chlamydia?
should be offered treatment prior to results of their investigations being known (treat then test)
What are 3 causes of painless penile ulcers?
- lymphogranuloma venereum
- syphilis
- donavanosis (granuloma inguinale)
What are 3 causes of painful penile ulcers?
- herpes simplex
- Behcet’s
- chancroid
What are 3 stages of lymphogranuloma venereum?
- stage 1: small painless pustule which later forms an ulcer
- stage 2: painful inguinal lymphadenopathy
- stage 3: proctolitis
What is the treatment of lymphogranuloa venereum?
doxycycline
What should be monitored iaftern the treatment of syphilis?
nontreponemal titres (rapid plasma reagin RPR or venereal disease research laboratory VDRL) - fourfold decilne considered adequate response
What reaction is sometimes seen in response to syphilis treatment?
Jarisch-Herxheimer reaction - fever/rash/tachycardia (no hypotension or wheeze)
What is thought to cause the Jarisch-Herxheimer reaction?
release of endotoxins following bacterial death, occurs within a few hours
What is the treatment of a Jarish-Herxheimer reaction?
no treatment other than antipyretics if required
Which types of HPV cause genital warts?
6 + 11
What is the first line management for single, keratinised genital warts?
cryotherapy
What is the first line treatment for multiple, non-keratinised genital warts?
topical podophyllum (imiquimod second-line)
How well do genital warts respond to treatment?
often resistant to treatment - recurrence common, but majority of infections clear without intervention within 1-2 years
What are 2 symptoms that may appear with painful ulceration in genital herpes?
- tender inguinal lymphadenopathy
- urinary retention
What is the investigation of choice in genital herpes?
NAAT
What are 3 aspects of the management of genital herpes?
- oral aciclovir (long term in some patients with frequent exacerbations)
- saline bathing
- analgesia, topical anaesthetic e.g. lidocaine
What is advised in pregnancy if a primary attach occurs > 28 weeks?
elective caesarean at term
What is the risk of transmission to the baby in a patient with recurrent herpes during pregnancy?
risk of transmission is low
What are the features of secondary syphilis?
fever, rash (trunk and palms), lymphadenopathy, buccal ulcers, condylomata
What is the management of gonorrhoea?
- IM ceftriaxone (single dose)
- if sensitivities known + sensitive to ciprofloxacin - single dose cipro 500mg PO
2nd line PO cefixime 400mg (1 dose) + azithromycin 2g (1 dose)
What is the commonest cause of septic arthritis in young adults?
gonococcal infection
What is the classic triad seen in Disseminated gonococcal infection (DGI) ?
- tenosynovitis
- migratory polyarthritis
- dermatitis
What are 3 late complications in disseminated gonococcal infection (DGI)?
- septic arthritis
- endocarditis
- perihepatitis (Fitz-Hugh-Curtis syndrome)
