Genitourinary Flashcards
what is chlamydia?
Urogenital chlamydia infection is a common sexually transmitted infection
The causative organism is Chlamydia trachomatis. Infection is usually asymptomatic in both men and women
what are the symptoms of chlamydia?
often asymptomatic
can have cervical discharge, friable cervix, abnormal vaginal bleeding, penile discharge, vaginal discharge
what are the investigations for chlamydia?
nucleic acid amplification test (NAAT) - non invasive sampling (urine or vaginal) is as effective as invasive sampling (vaginal, endocervical or penile urethral swab)
how is chlamydia treated?
azithromycin
or
doxycycline (should not be used in pregnant women)
what are the complications of chlamydia?
epididymitis reactive arthritis ophthalmia neonatorum chlamydia pneumonia ectopic pregnancy infertility cervical cancer PID
what is the screening programme for chlamydia?
in England the National Chlamydia Screening Programme is open to all men and women aged 15-24 years
the 2009 SIGN guidelines support this approach, suggesting screening all sexually active patients aged 15-24 years
relies heavily on opportunistic testing
what is bacterial vaginosis?
Bacterial vaginosis (BV) describes an overgrowth of predominately anaerobic organisms such as Gardnerella vaginalis. This leads to a consequent fall in lactic acid producing aerobic lactobacilli resulting in a raised vaginal pH.
is BV an STI?
Whilst BV is not a sexually transmitted infection it is seen almost exclusively in sexually active women.
what are the clinical features of BV?
vaginal discharge - fishy and offensive
asymptomatic in half
what is the criteria for diagnosis BV?
Amsel’s criteria
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)
how is BV managed?
oral metronidazole for 5-7 days
70-80% initial cure rate
relapse rate >50% within 3 months
clindamycin intravaginal cream can be used
what are the problems of BV in pregnancy ?
results in an increased risk of preterm labour, low birth weight and chorioamnionitis, late miscarriage
it was previously taught that oral metronidazole should be avoided in the first trimester and topical clindamycin used instead. Recent guidelines however recommend that oral metronidazole is used throughout pregnancy. The BNF still advises against the use of high dose metronidazole regimes
what is candidiasis?
thrush
a type of vaginitis
caused by a yeast like fungus
very common
what are some predisposing factors to thrush?
immunosuppression antibiotics pregnancy DM anaemia
what are the symptoms of thrush?
may be asymptomatic but usually presents with
- vulval itching and soreness
- thick, curd like white vaginal discharge
- dysuria
- superficial dyspareunia
how is thrush diagnosed?
characteristic appearance of: vulval and vaginal erythema, vulval fissuring, typical whit plaques adherent to the vaginal wall.
Culture from HVS or LVS
microscopic detection of spores and pseudohypae on wet slides
how is thrush treated?
should only be treated if symptomatic
clotrimazole pessary
Fluconazole oral
what are some risk factors for STIs
multiple partners (two or more in the last year)
concurrent partners
recent partner change
non-use of barrier protection
STI in partner
younger age particularly <25
involvement in the commercial sex industry
what is genital herpes?
Genital herpes is caused by infection with either HSV-1 or HSV-2
Sexual contact passes infection to the patient
third most common STI in England
what are the symptoms of herpes simplex virus?
prodrome (tingle/itching of the skin in affected area)
flu-like illness +/= inguinal lymphadenopathy
vulvitis and pain
small characteristic vesicles on the vulva, but can be atypical with fissures, erosions, erythema of the skin
recurrent attacks are thought to result from reactivation of the latent virus in the sacral ganglia and are normally shorter and less severe
what can recurrent herpes attacks be triggered by?
stress
sexual intercourse
menstruation
what are the complications of HSV infection?
usually complications are of primary infection
- meningitis
- sacral radiculopathy - causing urinary retention and constipation
- transverse myelitis
- disseminated infection
how is herpes diagnosed?
usually from the appearance of a typical rash
PCR testing of vesicular fluid viral culture
how do you treat herpes?
no cure
symptomatic relief with simple analgesia
oral acyclovir
suppressive treatment if >6 recurrences in a year
what is gonorrhoea?
A common STI caused by Neisseria gonorrhoeae, a gram-negative diplococcus bacterium that is closely related to other human Neisseria species.
what are the symptoms of gonorrhoea?
usually asymptomatic
men may get urethral discharge and they may get dysuria
they may present with vaginal discharge, low abdominal pain, IMB or PCB
what investigations would you perform for gonorrhoea?
endocervical or vulvovaginal swab with nucleic acid amplification test. If in contact with gonorrhoea - urethral, pharyngeal and rectal swabs should be done
culture - there will be a positive chocolate agar culture
what are the complications of gonorrhoea?
pelvic inflammatory disease Bartholin's or Skene's abscess disseminated gonorrhoea may cause - fever, pustular rash , migratory polyarthralgia, septic arthritis tubal infertility risk of ectopic pregnancy
how is gonorrhoea managed?
ceftriaxone IM plus azithromycin
if history of sexual abuse add metronidazole
what are the problems of gonorrhoea in pregnancy?
PPROM
chorioamnionitis
the risks to the baby are of opthalmia neonatarum
what is trichomonas vaginalis?
Trichomonas vaginalis is a highly motile, flagellated protozoan parasite. Trichomoniasis is a sexually transmitted infection (STI).
what are the features of trichomonas?
vaginal discharge: offensive, yellow/green, frothy
vulvovaginitis
strawberry cervix
pH > 4.5
in men is usually asymptomatic but may cause urethritis
dysuria
how do you diagnose trichomonas?
direct observation of motile trophozoites of the organism by a wet smear or acridine orange stained slide from the posterior vaginal fornix
culture and media
NAATs
what are the complications of trichomonas?
there is some evidence that trichomonal infection may enhance HIV transmission
how is trichomonas managed?
metronidazole
what are the complications of trichomonas in pregnancy?
preterm delivery
low birth weight
what is syphilis?
Syphilis is a sexually transmitted infection caused by the spirochaete Treponema pallidum. Infection is characterised by primary, secondary and tertiary stages. The incubation period is between 9-90 days
what are the primary features of syphilis?
chancre - painless ulcer at the site of sexual contact
local non-tender lymphadenopathy
often not seen in women (the lesion may be on the cervix)
what are the secondary features syphilis?
occurs within the first 2 years of infection
generalised polymorphic rash affecting palms and soles
generalised lymphadenopathy
genital condyloma lata (painless, warty lesions on the genitalia)
anterior uvitis
what are the tertiary symptoms of syphilis?
presents in up to 40% of people infected for at least 2 years, but may take 4+ years to develop
neurosyphilis - tabes dorsalis and dementia
CV syphilis - commonly affecting the aortic root - ascending aortic aneurysm
Gummata - inflammatory plaques or nodes of the skin and bones
what are the features of congenital syphilis?
blunted upper incisor teeth (Hutchinson’s teeth), ‘mulberry’ molars
rhagades (linear scars at the angle of the mouth)
keratitis
saber shins
saddle nose
deafness
how would you diagnose syphilis?
Treponema pallidum is a very sensitive organism and cannot be grown on artificial media. The diagnosis is therefore usually based on clinical features, serology and microscopic examination of infected tissue
- dark field microscopy of swab from lesion
- specific serum treponemal enzyme immunoassay
cardiolipin test - rapid plasma regain (RPR), serum venereal disease research laboratory test (VDRL)
what can cause false positive cardiolipin tests?
pregnancy SLE, anti-phospholipid syndrome TB leprosy malaria HIV
how is syphilis managed?
IM benzathine benzylpenicillin
alternative is doxycycline
what is the Jarisch-Herxheimer reaction
seen following syphilis treatment
fever, rash, tachycardia after the first dose of antibiotic
in contrast to anaphylaxis, there is no wheeze or hypotension
it is thought to be due to the release of endotoxins following bacterial death and typically occurs within a few hours of treatment
No treatment is needed other than antipyretics if required
what are the problems of syphilis in pregnancy?
preterm delivery
still birth
congenital syphilis
miscarriage
what are genital warts?
Genital warts are the most prevalent form of viral genital mucosal lesions and are caused by infection with several types of human papillomavirus (HPV). The infection manifests as verrucous fleshy papules that may coalesce into plaques. Lesion size ranges from a few millimetres to several centimetres. The warts may be located anywhere in the anogenital or genital area, including on mucosal surfaces
what types of the HPV virus cause genital warts?
6 and 11
what are the symptoms of genital warts?
majority are asymptomatic
painless lumps anywhere is the genitoanal area
(senssile exophytic papilloma’s - usually 1-3mm, discrete, sessile, smooth surfaced exophytic papilloma’s or they may coalesce into larger plaques
how are genital warts diagnosed?
mainly a clinical diagnosis
how is genital warts treated?
removal of the visible warts - high rate of recurrence due to the latent virus in the surrounding epithelial cells
clinic treatment: cryotherapy, trichloroacetic acid
home treatment - both contraindicated if there is a risk of pregnancy
- podophyllotoxin cream/solution
- imiquimod cream
** the HPV vaccine now protects against strains 6 and 11
what are the problems of genital wards in pregnancy?
genital warts tend to grow rapidly in pregnancy but usually regress after delivery
very rarely, babies are exposed perinatally and may develop laryngeal or genital warts
it is not an indication for c section
