Genitourinary Key

Question 1

PID

Question 2

After Broad-spectrum antibiotic course → death of normal vaginal flora
→ a good chance for the development of bacterial vaginosis and/or vaginal
candidiasis.

Answer 2

Bacterial
Vaginosis
(Gardnerella
Vaginalis)

√ Thin, grey-white, fishy (VERY
offensive) smelling discharge.

√ Vaginal itching is uncommon.

√ Positive Whiff test
(Potassium Hydroxide).

√ Vaginal pH: > 4.5

Rx → Metronidazole
+ Clindamycin

Question 3

Trichomoniasis
(Trichomonas
Vaginalis)

Rx → Oral
Metronidazole

Answer 3

√ Frothy, yellowish-greenish
smelly vaginal discharge.

√ Vaginal itching is common.

√ Strawberry Cervix.

√ Vaginal pH: > 4.5

√ signs of vulvovaginitis

Question 4

√ Thick white (Cheese-like)
odourless (non-offensive)
vaginal discharge.
√ Vaginal pH: 4-4.5

Rx → Local
Clotrimazole
(Anti-fungal)
Thrush”

Answer 4

(Candida
Albicans)

Note, normal vaginal pH is 3.8 to 4.5.

Answer 5

To Recap,
♣ White Thick discharge, non-offensive discharge
→ Vaginal candidiasis (Vaginal Thrush).
→ Topical clotrimazole.

♣ Yellow-greenish offensive discharge + vaginal itching ± Strawberry Cervix ±
pH > 4.5 ± Vulvovaginitis
→ Trichomonas Vaginalis (Trichomoniasis).
→ Oral metronidazole.

♣ Offensive discharge Without itching ± fishy smell ± pH > 4.5
→ Bacterial Vaginosis (Gardnerella Vaginalis).

Question 6

◙ The likely diagnosis → ◙

The Likely causative organism → Vulvovaginal Candidiasis
“Vaginal Thrush”.

Candida Albicans.

Answer 6

Example
A pregnant woman has taken antibiotic for her dental abscess. On the 3rd day,
she developed thick white vaginal discharge.

Question 7

A young lady presents with offensive vaginal discharge. She is sexually active
with a single partner. Her vaginal pH is 5.5. High vaginal swabs are taken for
culture.

Answer 7

The likely organism → Gardnerella Vaginalis. (Bacterial Vaginosis)

Both Bacterial Vaginosis (Gardnerella Vaginalis) and Trichomoniasis

(Trichomonas Vaginalis) can cause offensive vaginal discharge and pH >4.5.

However,
♦ Bacterial Vaginosis “Gardnerella Vaginalis” is more common.

Question 8

♦ Trichomoniasis “Trichomonas Vaginalis” has yellow-greenish offensive
vaginal discharge + itching.

Answer 8

♦ Both are treated by Metronidazole.
[All sexual partners need to be treated and followed up as well]

Question 9

Note:
Although Bacterial Vaginosis

“Gardnerella Vaginalis” is not a sexually-
transmitted disease, it is the most common cause of abnormal vaginal
discharge in ♀ in childbearing age.

Answer 9

◙ Amsel’s Criteria: 3 of 4 criteria are diagnostic for Bacterial Vaginosis:

1) Homogenous grey-white discharge.

2) When adding Potassium Hydroxide 10% (KOH) to the discharge → fishy
smell (Whiff test).

3) “Clue Cells” under microscopy.

4) Vaginal pH > 4.5

Question 10

Scenario 2

A 24 YO woman presents with foul-smelling vaginal discharge and vaginal
itching.
She feels sore in her vagina. She has a new sexual male partner.

O/E,
there are signs of vulvovaginitis. The vaginal pH is 5.3.
What is the most likely causative organism?

Answer 10

We have 2 likely options: Gardnerella vaginalis and Trichomonas vaginalis.
They both can cause similar presentations.

However,
Vaginal itching and signs of

Vulvovaginitis are more common with
→ Trichomonas vaginalis. √

Question 11

HPV (Human Papilloma Virus)

◙ Genital warts: Sexually transmitted painless growth- like lesions
“benign epithelia skin tumours”.

Answer 11

◙ Prevention and Treatment of Genital Warts.
√ Gardasil → Not for treatment, but for prevention.

(A vaccine to protect against HPV 6, 11, 16 and 18). If genital warts have
developed, Gardasil is of no benefit.

√ Ablation (Cryotherapy).

√ 30% of cases have spontaneous resolution in 6 months.

Question 12

hpv types

Answer 12

◙ HPV 6 and 11 → Responsible for Genital warts (benign Cauliflower like-
growths).
◙ HPV 16 and 18 → Responsible for most cervical cancers in the UK.

Question 13

◙ Prevention and Treatment of Genital Warts.

Answer 13

√ Gardasil → Not for treatment, but for prevention.
(A vaccine to protect against HPV 6, 11, 16 and 18). If genital warts have
developed, Gardasil is of no benefit.

√ Ablation (Cryotherapy).

√ 30% of cases have spontaneous resolution in 6 months.

Question 15

Genital herpes
H.ducreyi

Answer 15

Genital Ulcers (♂, ♀)
◙ Multiple, Painful Ulcers ± Dysuria → HSV “Genital Herpes”.
→ give Acyclovir

◙ Single, Not-painful ulcer → Syphilis. “Syphilis painless”
.
◙ Single, Painful ulcer → Hemophilus Ducreyi (Chancroid).

(“I Do cry” from Pain and being Single)

Caution, Hemophilus Ducreyi can sometimes present with MULTIPLE and
PAINFUL ulcers similar to that of Herpes Simplex Virus (HSV).

To differentiate → Viral Culture (obtained from the ulcer base) or PCR.

Question 16

Example,
A 37 YO ♀ presents with numerous, painful blisters and sores on her vulva
with flu-like illness and mild fever.

She is afraid to go urinate as the pain is so
severe.

Answer 16

♦ The likely Dx →
♦ The appropriate Rx →
Genital Herpes

Aciclovir (HSV).
(Anti-viral).

Question 17

Example,
A 25 YO ♂ presents complaining of Dysuria and 3 Painful ulcers on his penis.
He is sexually active.

Answer 17

♦ The likely Dx →
♦ The appropriate Rx →

Genital Herpes
Aciclovir (HSV).
(Anti-viral)

Question 18

Genital ulcers in short

Answer 18

In short:

◘ Painless multiple → HPV (6 and 11).

◘ Painful multiple → HSV (give analgesics and Aciclovir).

◘ Painless single (Chancre) → Syphilis (Treponema Pallidum).

◘ Painful single (Chancroid) → H. Ducreyi (can be multiple, painful)

Question 19

Scenario
A 30 YO ♀ presents with a very strong foul-smelling vaginal discharge.

Which of these organisms is likely responsible?
(Chlamydia / N. Gonorrhea / Gardnerella / or All of them)?

Answer 19

The answer is → Gardnerella.

Do not get tricked!

The vaginal discharge in Chlamydia and N. Gonorrhea is NOT usually foul-
smelling.

Question 20

The important organisms that present with Offensive Vaginal Discharge are:

√ Both are treated with → √ pH in both is > 4.5

Answer 20

• Trichomonas Vaginalis (Trichomoniasis)

→ Frothy, Yellow-greenish,
Offensive ± Strawberry Cervix
and inflamed
vulva “vulvovaginitis” ± Vaginal Itching

• Gardnerella Vaginalis (Bacterial Vaginosis)

→ Thin, grey-white, Offensive (fishy) smell. ± clue cells

Question 22

Scenario

29 YO ♀ presents complaining of a few-weeks vaginal discharge that is frothy,
yellow, bad-smelling and with mild vaginal itching. She is sexually active with 2
regular partners.

Vaginal pH is 4.8. No pelvic or abdominal pain. Her vulva
looks slightly inflamed.

Answer 22

The likely Dx →
The appropriate treatment → Dx →

Trichomoniasis (The Organism is Trichomonas Vaginalis).

Metronidazole.

Observing motile flagellates on microscopy.

Question 23

Complications of Syphilis include →

Aortic Aneurysm,

Granulomatous lesions
of skin and bones (Tertiary stage syphilis)

◙ Note: Chlamydial infection is the most common Sexually Transmitted
Infection

“STI” in the UK. It is caused by Chlamydia Trachomatis.

Answer 23

◙ Chlamydia in Males
→ Urethritis (Dysuria + Urethral Discharge).

√ Important
The major complication of untreated chlamydia “and N. Gonorrhea” in males
is: → (Epididymo-Orchitis) or (Epididymitis).

→ Unilateral Testicular Pain.
The major complication of untreated chlamydia “and N. Gonorrhea” in
Females is: → (Salpingitis).

Question 24

◙ An 18 YO ♀ with new sexual partner presents with:

Vaginal Discharge, Post-coital bleeding, Red and Inflamed vulva
and cervix, tender pelvis but non-tender abdomen.

Answer 24

√ The likely Dx →

Chlamydial Cervicitis.

√ Rx? →

◙ 1st line → Doxycycline 100 mg BID for 7 Days.

◙ Another line:

Azithromycin 1-gram PO
▐ Followed by 500 mg PO OD for 2 days.
√ The likely cause in this case? → infection due to the new partner.

♣ Why not Cervical Ectropion?

Cervical Ectropion presents only with post-coital bleeding. No other
problems. Resolves spontaneously but if treatment is required →

Cauterising with silver nitrate.

Question 25

◙ A 22 YO ♀ presents with Vaginal Discharge, Post-coital bleeding,
intermenstrual bleeding. A vulvovaginal swab tested +ve for
Neisseria Gonorrhea

Answer 25

.
√ Treatment? →

♦ Neisseria Gonorrhea: (C or C)

◙ Ceftriaxone 1 gm IM (single dose stat). “of choice”
Or:
◙ Ciprofloxacin 500 mg PO (Single dose).

Question 26

Anal “Anogenital” warts are caused by

Answer 26

→ Human Papilloma Virus (HPV 6 and 11) in both ♂ and ♀.

Question 27

◙ A 20 YO ♀ with a new sexual partner presents with: Increasing Vaginal Discharge that is yellow-greenish.

Answer 27

The single best Investigation → Endocervical and High Vaginal Swab √ While self-collected vulvovaginal swab is good for chlamydia, Endocervical and High vaginal swab can detect all possible organisms such as chlamydia, N. Gonorrhea and Trichomonas Vaginalis. √ Trichomonas Vaginalis needs high vaginal swab and can be diagnosed by seeing the motile organisms under the microscope.

Question 28

Screening With signs and symptoms of n.gonorrhoe and chlamydia

Answer 28

In short: ◘ Suspected case (asymptomatic) → Self-collected vulvovaginal swab i.e. [Screening for Chlamydia and N. Gonorrhea]. ◘ Signs and symptoms of Chlamydia/ N. Gonorrhea → Endocervical swab. ◘ Suspected Trichomonas Vaginalis → High vaginal swab. ◘ To cover all possibilities at once → Endocervical swab + High vaginal swab. Important note: If the question asks specifically about the most sensitive (screening) test for Chlamydia and Gonorrhea, the answer should be → Self-collected vulvovaginal swab for NAAT.

Question 29

Multiple + Painful genital Ulcers → suspect Genital Herpes (HSV) ◙ Investigations of HSV:

Answer 29

√ First Line → “ It is now superior to viral culture and PCR”. That is NAAT Testing = Nucleic acid amplification tests. √ Other test → “Polymerase Chain Reaction”. Viral Culture of the lesion + DNA detection using PCR √ If Negative and the ulcers are recurrent/ atypical? → Anti-HSV antibody. ◙ Rx of HSV → oral Aciclovir

Question 30

Rash in both Palms AND Soles occurs in 3 conditions:

Answer 30

1) Hand, foot and mouth disease → Coxsackie Virus. 2) Rocky Mountain Spotted Fever → Tick (Rickettsia). 3) Secondary Syphilis → Treponema Pallidum.

Question 31

Syphilis stages

Answer 31

Syphilis is caused by → Treponema Pallidum Primary Stage: Only Chancre (Single Painless Genital Ulcer at the site of sexual contact). Secondary Stage (6 weeks after chancre appears): √ Fever, lymphadenopathy, malaise (systemic symptoms). √ Rash on Soles, Palms and face. √ Condyloma Lata Tertiary Stage: √ Gummas (Granulomatous lesions commonly affect skin and bones). √ Cardiovascular Syphilis (ascending aortic aneurysms / aortic regurgitation). √ Neurological Syphilis (Dementia / tabes dorsalis).

Question 32

◙ Syphilis Investigations in Short (Commonly Asked)

Answer 32

√ If the penile ulcer is still present → Swab the penile ulcer for Dark field microscopy (if in Genitourinary clinic) or swab the penile ulcer for PCR (if the patient is in a GP clinic).

Question 33

Syphilis √ If the penile ulcer has healed but the mouth ulcers are present

Answer 33

→ Swab of the mouth ulcers for PCR. Bear in in mind that swabs of oral lesion cannot be tested under dark field microscopy. If there no (swab of oral ulcers for PCR) in the options, pick syphilis serology.

Question 34

√ If both penile and mouth ulcers have healed Syphilis

Answer 34

→ Serology for syphilis.

Question 35

Mng of syphilis

Answer 35

◙ Management of Syphilis √ First-line → √ alternatives (e.g., if penicillin-allergic) → intramuscular benzathine penicillin. doxycycline.

Question 36

Example 30 YO ♂ presents with maculopapular rash on his palms, soles and mouth. He had a penile ulcer 6 weeks ago that is now healed.

Answer 36

Dx → Organism → Secondary Syphilis. Treponema Pallidum.

Question 37

Example 28 YO ♂ who is homosexual presents with urethral discharge. He has had a painless penile ulcer that healed a few weeks ago.

Answer 37

Syphilis. ◙ Dx → ◙ Investigations: since the penile ulcer has healed: √ If there are still oral ulcers → Oral swabs for PCR. (Not for dark microscopy) √ If no oral ulcers, or oral swab for PCR is not given → Serology for syphilis.

Question 38

◙ If a man has a “Receptive” anal intercourse → for Chlamydia/ N. Gonorrhea “NAAT” is needed

Answer 38

Rectal swab for screening

Question 39

◙ If a man has a “Penile sexual contact” = “Insertive”

Answer 39

“first 20 ml of urine” should be sent for culture and microscopy. First void plus urethral swab

Question 40

In other words, √ During anal sex, the partner inserting the penis is called the “insertive” partner (or top)

Answer 40

→ Urethral Swab is needed + First Void Urine Sample

Question 41

The partner receiving the penis is called the “receptive” partner (or bottom)

Answer 41

→ Rectal Swab is needed. Receptive anal sex is much riskier for getting HIV. Screening Tests for → HIV, Hepatitis B, Chlamydia and N. Gonorrhea are needed.

Question 42

Investigations of HSV (Herpes Simplex Virus): “Important” √ First Line → Other test

Answer 42

NAAT testing (including PCR): • NAAT, which includes PCR, is the gold standard for detecting HSV. It is superior to viral culture for sensitivity and accuracy. First line test!! √ Other tests → Viral culture + DNA detection using PCR (Polymerase Chain Reaction): • Viral culture is less sensitive than NAAT/PCR but may still be used where NAAT is unavailable. The sample collection method for both is a viral swab from the lesion. So, in the exam: NAAT → PCR → Culture (Method of collection: Swab). √ If Negative and the ulcers are recurrent/atypical? → Anti-HSV antibody: • Serology can detect past exposure to HSV (types 1 and 2) but is not useful for diagnosing acute infections . It may help in cases of atypical or recurrent presentations when swabs are negative. ◙ Rx of HSV → oral Aciclovir.

Question 43

A 30-year-old woman comes to the GP with a 3-day history of painful sores on her genital area. She reports that the lesions are small, numerous, and tender to touch. She also mentions experiencing a mild fever and general fatigue. Her sexual history includes recent unprotected intercourse with a new partner about three weeks ago. There is no record of similar occurrences in her past. On examination, several small, painful, shallow ulcers with a red base are observed in the vulval region. What is the most suitable investigation for this case? A) Mid-stream urine culture. B) High vaginal swab. C) VDRL testing. D) Serology for herpes simplex virus. E) Viral swab for herpes simplex virus.

Answer 43

The correct answer is → E) Viral swab for herpes simplex virus. Here’s why: • The patient's presentation of multiple small, painful ulcers, fever, and recent sexual contact is highly suggestive of genital herpes, likely caused by the herpes simplex virus (HSV). • The most appropriate test in this situation is a viral swab, which can be sent for either PCR or culture. • Both PCR and viral culture are highly effective in diagnosing active HSV infection by detecting the virus directly from the ulcer. Other options: A) Mid-stream urine culture: This is used for diagnosing urinary tract infections, which do not present with genital sores. It is not appropriate for this patient's symptoms.

Question 44

Sti Tests

Answer 44

B) High vaginal swab: This test is used for investigating conditions such as bacterial vaginosis or candidiasis, which do not typically cause painful genital ulcers. C) VDRL testing: This test screens for syphilis, which can cause genital ulcers. However, syphilitic chancres are typically painless, making it less likely in this scenario. D) Serology for herpes simplex virus: Serology detects antibodies to HSV but cannot differentiate between past and current infections. It is not as useful as a viral swab in confirming an active infection during an acute outbreak. In summary, the best test for diagnosing active genital herpes is a viral swab, which can be tested via PCR or culture to confirm the presence of the herpes simplex virus.

Question 45

A 29-year-old woman presents with 2-week history of lower abdominal pain, dyspareunia (painful intercourse), and a noticeable increase in vaginal discharge. She is 2 months pregnant. She has a known allergy to cephalosporins. On examination, the following are noticed: Her vitals are stable, there is lower abdominal tenderness, and yellowish vaginal discharge. There is no cervical motion tenderness. What is the most appropriate antibiotic to prescribe to this patient?

Answer 45

→ Azithromycin. This is likely a case of lower genital tract infection or pelvic inflammatory disease (mostly chlamydia): Rx of Chlamydia: 1st line for chlamydia → Doxycycline. (contraindicated during pregnancy X). 2nd line → Azithromycin. (safe during pregnancy √).

Question 46

Pregnancy and drugs

Answer 46

Important Notes: • In pregnancy → avoid doxycycline, ciprofloxacin, and ofloxacin. (X) • On the other hand, → Azithromycin is safe in pregnancy. • She is allergic to cephalosporins (eg, cefalexin, ceftriaxone). • Co-amoxiclav (amoxicillin + Clavulanic acid) → safe in pregnancy. However, it is not the first choice for pelvic inflammatory disease or lower genital tract infections. Also, although amoxicillin (penicillin) is not a cephalosporin, there is a structural similarity between both classes, which makes an allergy reaction possible.

Question 47

A 33-year-old sexually active female presents with a non-malodorous vaginal discharge, itchiness, and soreness. Speculum examination shows vaginal erythema and white thick discharge.

Answer 47

• The most likely diagnosis → Vaginal candidiasis (vaginal thrush). Topical clotrimazole. • The most appropriate treatment → (Be careful! Topical not oral – Clotrimazole not metronidazole).

Question 48

Important Vaginal Infections DDx

Answer 48

♣ White Thick discharge, non-offensive discharge → Vaginal candidiasis (Vaginal Thrush) = (vulvovaginal candidiasis) (Candida albicans). → Topical clotrimazole (antifungal). ♣ Yellow-greenish offensive discharge + vaginal itching ± Strawberry Cervix ± pH > 4.5 ± Vulvovaginitis → Trichomonas Vaginalis (Trichomoniasis). → Oral metronidazole. ♣ Offensive discharge Without itching ± fishy smell ± pH > 4.5 → Bacterial Vaginosis (Gardnerella Vaginalis). → Oral metronidazole.

Question 49

A patient who has maculopapular rash in his palms and trunk for the past 9 days. He also still has mouth ulcers. There was a painless penile ulcer that has healed for the past one week. What is the most appropriate investigation? A) Swab the rash for microscopy and culture. B)Serology for syphilis. C) Swab of the mouth ulcers for dark field microscopy. D) PCR of antigen in blood.

Answer 49

E) Treponema specific and non-specific antibodies. Do not get fooled and pick ©: mouth lesion swab cannot be tested under dark microscopy B

Question 50

◙ Syphilis (treponema palladium) Investigations in Short (Commonly Asked)

Answer 50

√ If the penile ulcer is still present → Swab the penile ulcer for Dark field microscopy (if in Genitourinary clinic) or swab the penile ulcer for PCR (if the patient is in a GP clinic). √ If the penile ulcer has healed but the mouth ulcers are present → Swab of the mouth ulcers for PCR. Bear in in mind that swabs of oral lesion cannot be tested under dark field microscopy. If there no (swab of oral ulcers for PCR) in the options, pick syphilis serology. √ If both penile and mouth ulcers have healed → Serology for syphilis.

Question 51

Example A 20 YO ♀ with Hx of travel several weeks ago present with cauliflower like growths of varying size on her vulva. She wants a treatment

Answer 51

. Genital warts The likely Dx → The possible treatment option → ( HPV 6 and 11) Cryotherapy.

Question 52

Caution, Although h.ducreyi usually presents with Single Painful ulcer, it can sometimes present with MULTIPLE and PAINFUL ulcers similar to that of Herpes Simplex Virus (HSV).

Answer 52

To differentiate → Viral Culture (obtained from the ulcer base) or PCR “better”.

Question 53

A patient who has maculopapular rash in his palms and trunk for the past 9 days. He also still has mouth ulcers. There was a painless penile ulcer that has healed for the past one week. What is the most appropriate investigation? A) Swab the rash for microscopy and culture. B) Serology for syphilis. C) Swab of the mouth ulcers for dark field microscopy. D) Swab of the mouth ulcer for PCR. E) Treponema specific and non-specific antibodies.

Answer 53

√ Swabs of oral lesions cannot be tested under dark microscopy. √ They can be tested by PCR. √ If the penile ulcer has not healed yet → swab it for dark microscopy. √ The second-best answer here → Serology for syphilis. (In case D was not given).

Question 54

y 32 A 24 YO woman presents with foul-smelling vaginal discharge and vaginal itching. She feels sore in her vagina. She has a new sexual male partner. O/E, there are signs of vulvovaginitis. The vaginal pH is 5.3. What is the most likely causative organism?

Answer 54

We have 2 likely options: Gardnerella vaginalis and Trichomonas vaginalis. They both can cause similar presentations. However, Vaginal itching and signs of Vulvovaginitis are more common with → Trichomonas vaginalis. √

Question 55

The most sensitive test for Chlamydia and Gonorrhea

Answer 55

NAAT = Nucleic Acid Amplification Test). It is more sensitive than cultures. → Self-collected vulvovaginal swab for NAAT

Question 56

Chancre

Answer 56

Caused by T. Pallidum Painless Single Bilateral regional lymphadenopathy Typical exude serum Hard indurated base with sloping edge

Question 57

√ Condyloma Lata → 2ry Syphilis (Treponema Pallidum). √ Condyloma Acuminata → Human papilloma virus.

Answer 57

√ Condyloma Lata → 2ry Syphilis (Treponema Pallidum). Painless Hypopigmented Firm moist Flat topped Pink to Reddish papules Containing numerous spirocheates √ Condyloma Acuminata → Human papilloma virus. Skin coloured palules Cauliflower polyploid Painless Papules of varying size

Question 58

A patient who has maculopapular rash in his palms and trunk for the past 9 days. He had mouth ulcers for one month and healed now, and a painless penile ulcer that has healed for the past one week. What is the most appropriate investigation? a. Treponema PCR Serology for syphilis b. c. Dark microscopy d. Swab of the mouth ulcer for PCR e. Treponema specific and non-specific antibody

Answer 58

Single Painless → Syphilis Take care that penile ulcers and also (mouth ulcers) have healed. So, Dark microscopy for penile ulcer is wrong. Also, Swab of mouth ulcers for PCR is also wrong. The remaining option is serology for syphilis. Rash in both Palms AND Soles occurs in 3 conditions: √ Hand, foot and mouth disease → Coxsackie Virus. √ Rocky Mountain Spotted Fever → Tick (Rickettsia). √ Secondary Syphilis → Treponema Pallidum.

Question 59

Important Notes on Syphilis Investigations:

Answer 59

√ If the penile ulcer is still present → Swab the penile ulcer for Dark field microscopy (if in Genitourinary clinic) or swab the penile ulcer for PCR (if the patient is in a GP clinic). √ If the penile ulcer has healed but the mouth ulcers are present → Swab of the mouth ulcers for PCR. Bear in in mind that swabs of oral lesion cannot be tested under dark field microscopy. If there no (swab of oral ulcers for PCR) in the options, pick syphilis serology. √ If both penile and mouth ulcers have healed → Serology for syphilis.

Question 60

Genital Ulcers (♂, ♀)

Answer 60

◙ Multiple, Painful Ulcers ± Dysuria → HSV “Genital Herpes”. → give Acyclovir ◙ Single, Not-painful ulcer → Syphilis. “Syphilis painless” ◙ Single, Painful ulcer → Hemophilus Ducreyi (Chancroid). (“I Do cry” from Pain and being Single). Although usually presents with Single Painful ulcer, it can sometimes present with MULTIPLE and PAINFUL ulcers similar to that of Hemophilus Ducreyi Herpes Simplex Virus (HSV). To differentiate → Viral Culture (obtained from the ulcer base) or PCR “better”.

Question 61

Investigations of HSV:

Answer 61

√ First Line NAAT testing → √ Other test → viral culture and dna detection using PCR √ If Negative and the ulcers are recurrent/ atypical? → So, careful, Anti-HSV antibody

Question 62

For the past 3 days, a 30-year-old man has been having penile pain when he urinates. He is otherwise fit and well. There are four tender ulcers on his penile glans. The ulcer is 2mm in diameter and indurated. What is the most likely diagnosis? A. Bechet disease B. Chlamydia infection C. Gonorrhea infection D. Herpes simplex infection E. Primary syphilitic infection

Answer 62

D

Question 63

25 ◙ An 18 YO ♀ with new sexual partner presents with: Vaginal Discharge, Post-coital bleeding, Red and Inflamed vulva and cervix, tender pelvis but non-tender abdomen.

Answer 63

√ The likely Dx → Chlamydial Cervicitis. √ Rx? → ◙ 1st line → Doxycycline 100 mg BID for 7 Days. ◙ Another line: Azithromycin 1-gram PO ▐ Followed by 500 mg PO OD for 2 days. (According to the recent guidelines). Note: In pregnancy → avoid doxycycline, ciprofloxacin, and ofloxacin. (X) On the other hand, → Azithromycin is safe in pregnancy.

Question 64

Genital Lesions

Answer 64

◙ Multiple, Painful Ulcers ± Dysuria → HSV “Genital Herpes”. → give Acyclovir ◙ Single, Not-painful ulcer → Syphilis. “Syphilis painless, chancre”. ◙ Painless Papules on genitalia → Human papilloma virus. ◙ Single, Painful ulcer → Hemophilus Ducreyi (Chancroid). (“I Do cry” from Pain and from being Single)

Question 65

Caution, Hemophilus Ducreyi can sometimes present with MULTIPLE and PAINFUL ulcers similar to that of Herpes Simplex Virus (HSV).

Answer 65

To differentiate → Viral Culture (obtained from the ulcer base) or PCR.

Question 66

◙ The major complication of untreated chlamydia “and N. Gonorrhea” in males

Answer 66

is: → (Epididymo-Orchitis) or (Epididymitis). → Unilateral Testicular Pain.

Question 67

The major complication of untreated chlamydia “and N. Gonorrhea” in

Answer 67

Females is: → (Salpingitis).

Question 68

Yellow-greenish offensive discharge + vaginal itching ± Strawberry Cervix ± pH > 4.5 →

Answer 68

Trichomonas Vaginalis (Trichomoniasis).

Question 69

20 YO ♀ with new sexual partner presents with: Increasing Vaginal Discharge that is yellow-greenish.

Answer 69

The single best Investigation → Endocervical and High Vaginal Swab. √ While self-collected vulvovaginal swab is good for detecting chlamydia, Endocervical and High vaginal swab can detect all possible organisms such as chlamydia, N. Gonorrhea and Trichomonas Vaginalis. √ Trichomonas Vaginalis needs high vaginal swab and can be diagnosed by seeing the motile organism under the microscope.

Question 70

Bacterial vaginosis Trichomonas vaginalis

Answer 70

Yellow-greenish offensive discharge + vaginal itching ± Strawberry Cervix ± pH > 4.5 → Trichomonas Vaginalis (Trichomoniasis). Rx → Metronidazole. √ ♣ Offensive discharge Without itching ± fishy smell ± pH > 4.5 → Bacterial Vaginosis (Gardnerella Vaginalis). Rx → Metronidazole. √

Question 71

Warts anal

Answer 71

◙ Anal warts. The likely organism → HPV ◙ Genital warts (benign, painless Cauliflower like-growths) → HPV (Human papilloma virus) ◙ Painless Papules/ growths on genitalia → HPV

Question 72

Pregnant woman presents with UTI.

Answer 72

Rx → Cefalexin.

Question 74

Chancroid

Answer 74

Caused by H.ducreyi Painful Multiple Unilaterally regional lymphadenopathy Purulent exudate Soft base with undermined edge