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Zero to Finals: Women's Health > Genitourinary Medicine > Flashcards

Genitourinary Medicine Flashcards

1
Q

what is BV?

A

an overgrowth of anaerobic bacteria in the vagina

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2
Q

pathophysiology of BV?

A
  • loss of lactobacilli in vaginal flora
  • pH rises to >4.5
  • this allows anaerobic bacteria to grow
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3
Q

most common causative organism of BV?

A

gardnerella vaginalis

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4
Q

risk factors for BV?

A
  • multiple sexual partners
  • vaginal douching
  • recent ABx
  • smoking
  • copper coil
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5
Q

protective factors against BV?

A
  • COCP use

- effective use of condoms

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6
Q

presentation of BV?

A
  • thin, watery grey discharge
  • fishy smell
  • 50% are asymptomatic
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7
Q

how can a diagnosis of BV be confirmed?

A

on speculum examination

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8
Q

investigations for BV?

A
  • vaginal pH measurement

- high (in speculum) / self-taken low vaginal charcoal swab and microscopy

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9
Q

what is seen on microscopy in BV? what are these?

A
  • clue cells

- cells which have the gardnerella vaginalis / other bacteria stuck inside them

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10
Q

management of BV?

A
  • if asymptomatic, nothing
  • PO/ PV gel metronidazole
  • alt: clindamycin, less effective
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11
Q

what should be avoided whilst being treated with metronidazole? why?

A
  • alcohol
  • causes “disulfiram-like” reaction
  • N+V, flushing, shock if severe
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12
Q

main complication of BV in a non-pregnant person?

A

increases risk of catching STIs

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13
Q

complications of BV in pregnancy?

A
  • miscarriage
  • preterm delivery
  • premature rupture of membranes
  • chorioamnionitis
  • LBW
  • postpartum endometritis
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14
Q

commonest causative organism in vaginal candidiasis?

A

candida albicans

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15
Q

risk factors for vaginal candidiasis?

A
  • pregnancy
  • poorly controlled DM
  • immunosuppression (e.g. corticosteroid use)
  • broad-spec ABx use
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16
Q

presentation of vaginal candidiasis?

A
  • thick, white, odourless discharge

- vulvovaginal itching, irritation and discomfort

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17
Q

signs of a more severe vaginal candidiasis infection?

A
  • erythema
  • fissures
  • oedema
  • dyspareunia
  • dysuria
  • excoriation
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18
Q

investigations for vaginal candidiasis?

A
  • vaginal pH (<4.5, unlike BV and trich infections)

- charcoal swab with microscopy confirms Dx

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19
Q

management of vaginal candidiasis?

A

NICE guidelines gives the following options for uncomplicated cases:

  • 1 dose of clotrimazole 10% cream (5g)
  • 1 clotrimazole pessary 500mg for 1 night
  • 3 clotrimazole pessaries 200mg over 3 nights
  • 1 dose of PO fluconazole 150mg
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20
Q

when is vaginal candidiasis classed as recurrent?

A

when there are >4 episodes in 1 year

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21
Q

what type of bacteria is chlamydia trachomatis?

A

gram -ve

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22
Q

most common STI in the UK?

A

chlamydia

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23
Q

which STIs are screened for by GUM clinics?

A
  • chlamydia
  • gonorrhoea
  • syphilis (blood test)
  • HIV (blood test)
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24
Q

what is the aim of the national chlamydia screening program (NCSP)?

A

to test everyone sexually active under 25 for chlamydia annually or whenever they change partner

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25
Q

when should someone who tested positive for chlamydia be retested for it?

A

3m after treatment

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26
Q

what are the 2 types of vaginal swab?

A
  • charcoal

- NAAT

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27
Q

which diseases can be diagnosed on NAAT testing?

A
  • chlamydia

- gonorrhoea

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28
Q

which samples can be used for NAAT testing in women?

A
  • endocervical swab (preferred)
  • vulvovaginal swab
  • first-catch urine sample (least preferred)
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29
Q

which samples can be used for NAAT testing in men?

A
  • first-catch urine sample

- urethral swab

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30
Q

which NAAT swabs should be used for those who have had anal or oral sex?

A
  • rectal

- pharyngeal

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31
Q

what is the next investigation where a NAAT test is positive for gonorrhoea?

A

endocervical charcoal swab for MCS

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32
Q

presentation of chlamydia in women?

A
  • abnormal PV discharge or bleeding
  • pelvic pain
  • dyspareunia
  • dysuria
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33
Q

presentation of chlamydia in men?

A
  • urethral discharge or discomfort
  • dysuria
  • epididymo-orchitis
  • reactive arthritis
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34
Q

presentation of rectal chlamydia? what is a differential for this?

A
  • anorectal discharge or discomfort
  • PR bleeding
  • change in bowel habit
  • LGV infection
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35
Q

findings O/E of chlamydia?

A
  • pelvic / abdo tenderness
  • cervical motion tenderness (excitation)
  • cervicitis
  • purulent discharge
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36
Q

how is chlamydia diagnosed?

A

on NAAT

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37
Q

management of chlamydia in non-pregnant person?

A

1st line: doxycycline 100mg BD for 7 days

alt: azithromycin 1g PO one-off dose

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38
Q

management of chlamydia in pregnancy?

A

different options available:

  • azithromycin 1g stat then 500mg OD for 2 days
  • erythromycin 500mg QDS for 7 days
  • amoxicillin 500mg TDS for 7 days
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39
Q

when should a “test of cure” be used in chlamydia treatment?

A
  • rectal chlamydia
  • pregnancy
  • persistent symptoms
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40
Q

non-medical management of chlamydia?

A
  • abstain from sex until treatment completed
  • refer to GUM for contact tracing and partner notification
  • test and treat other STIs
  • advise on barrier contraception
  • consider safeguarding if children involved
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41
Q

complications of chlamydia in non-pregnant person?

A
  • PID
  • chronic pelvic pain
  • infertility
  • ectopic pregnancy
  • epididymo-orchitis
  • conjunctivitis
  • LGV
  • reactive arthritis
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42
Q

complications of chlamydia in pregnancy?

A
  • preterm delivery
  • PPROM
  • LBW
  • postpartum endometritis
  • neonatal conjunctivitis / pneumonia
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43
Q

what is lymphogranuloma venereum (LGV)?

A

a variant of chlamydial bacteria which causes inflammation of lymphoid tissue

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44
Q

highest risk factor for LGV?

A

MSM

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45
Q

describe the 3 stages of LGV infection

A
  • primary: painless ulcer on penis / vaginal wall / rectum
  • secondary: lymphadenitis, inguinal / femoral lymph nodes appear swollen
  • third: proctocolitis, causing pain, change in bowel habit, tenesmus and discharge
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46
Q

treatment of LGV infection?

A
  • doxycycline 100mg BD for 21 days

- alt: erythromycin, azithromycin, ofloxacin

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47
Q

how does chlamydial conjunctivitis occur?

A

usually when genital fluid comes into contact with eye, e.g. hand to eye spread

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48
Q

typical demographics affected by chlamydial conjunctivitis?

A
  • young people

- neonates

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49
Q

key differential for chlamydial conjunctivitis?

A
  • gonococcal conjunctivitis

- should test for this too

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50
Q

what type of bacteria causes gonorrhoea?

A
  • neisseria gonorrhoea

- gram -ve diplococcus

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51
Q

which areas of the body can be infected with gonorrhoea?

A
  • endocervix
  • urethra
  • rectum
  • conjunctiva
  • pharynx
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52
Q

risk factors for gonorrhoea?

A
  • young
  • sexually active
  • multiple sexual partners
  • having other STIs
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53
Q

is gonorrhoea ever asymptomatic?

A
  • can be
  • but more likely to give symptoms than chlamydia
  • 90% men and 50% women have symptoms
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54
Q

presentation of gonorrhoea in females?

A
  • may be asymptomatic
  • odourless purulent discharge
  • green / yellow discharge
  • dysuria
  • pelvic pain
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55
Q

presentation of gonorrhoea in males?

A
  • odourless purulent discharge
  • green / yellow discharge
  • dysuria
  • testicular pain / swelling (epididymo-orchitis)
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56
Q

presentation of rectal gonorrhoea infection?

A
  • anal discomfort

- anal discharge

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57
Q

how might prostatitis secondary to gonorrhoea infection present?

A
  • perineal pain
  • urinary symptoms
  • soreness on DRE
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58
Q

how might pharyngeal gonorrhoea infection present?

A

sore throat

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59
Q

presentation of gonorrhoeal conjunctivitis?

A
  • eye erythema

- purulent discharge

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60
Q

how is gonorrhoea diagnosed?

A
  • nucleic acid amplification testing (NAAT)

- charcoal swab and MCS done to guide ABx choice

61
Q

management of gonorrhoea?

A
  • refer to GUM
  • if sensitivities not known: IM ceftriaxone 1g single dose
  • if known: PO ciprofloxacin 500mg single dose
  • contact tracing
  • follow-up test of cure
  • advice on safe sex
  • abstain from sex for 7d after treatment
62
Q

when should a test of cure be completed after gonorrhoea treatment?

A
  • 72h after treatment for culture
  • 7d after treatment for RNA NAAT
  • 14 after treatment for DNA NAAT
63
Q

complications of gonorrhoea?

A
  • PID
  • chronic pelvic pain
  • infertility
  • conjunctivitis, esp in neonates
  • urethral strictures
  • disseminated gonococcal infection
  • skin lesions
  • fitz-hugh-curtis syndrome
  • septic arthritis
  • endocarditis
64
Q

which complications of gonorrhoea are specific to men?

A
  • epididymo-orchitis

- prostatitis

65
Q

what are the complications of neonatal gonococcal conjunctivitis?

A
  • sepsis
  • perforation of eye
  • blindness
  • medical emergency!!
66
Q

how does disseminated gonococcal infection present?

A
  • polyarthralgia
  • migratory polyarthritis (moves)
  • tenosynovitis (presents with hand / wrist pain)
  • fever
  • fatigue
67
Q

presentation of mycoplasma genitalium?

A
  • urethritis (key feature)
  • epididymitis
  • cervicitis
  • endometritis
  • PID
  • reactive arthritis
  • preterm delivery
  • tubal infertility
68
Q

investigations for mycoplasma genitalium?

A

NAAT done on:

  • first catch urine in males
  • vaginal swab in females
69
Q

management of mycoplasma genitalium?

A
  • check every positive sample for macrolide resistance first
  • doxycycline 100mg BD for 7d, then:
  • azithromycin 1g stat then:
  • azithromycin 500mg OD for 2d
70
Q

how does mycoplasma genitalium management differ in pregnancy?

A
  • azithromycin only

- doxycycline is contraindicated

71
Q

common causes of PID?

A
  • neisseria gonorrhoeae (gives more severe picture)
  • chlamydia trachomatis
  • mycoplasma genitalium
72
Q

less common but possible causes of PID?

A
  • gardnerella vaginalis (BV)
  • Hib (resp infections)
  • E. coli (UTIs)
73
Q

risk factors for PID?

A

same as STIs:

  • no condoms
  • multiple partners
  • younger age
  • existing STIs
  • prev PID
  • IUD
74
Q

presentation of PID?

A
  • pelvic / lower abdo pain
  • abnormal PV discharge
  • abnormal PV bleeding
  • dyspareunia
  • fever
  • dysuria
75
Q

findings O/E in PID?

A
  • pelvic tenderness
  • cervical motion tenderness (excitation)
  • cervicitis (inflamed)
  • purulent discharge
  • fever (if septic)
76
Q

investigations for PID?

A
  • NAAT swabs for gonorrhoea / chlamydia
  • NAAT swabs for mycoplasma genitalium
  • HIV test
  • syphilis test
  • high vaginal swab
  • pregnancy test
  • inflammatory markers (raised)
77
Q

what could be picked up on the high vaginal swab in a pt with PID?

A
  • BV
  • candidiasis
  • trichomoniasis
78
Q

what can be used to rule out the diagnosis of PID?

A

absence of pus cells on swabs from vagina / endocervix

79
Q

why is a pregnancy test particularly important in PID?

A
  • rule out ectopic pregnancy

- affects which ABx to give

80
Q

management of PID?

A
  • refer to GUM
  • start ABx empirically before swabs are back
  • contact tracing
  • IM ceftriaxone (covers gonorrhoea)
  • doxycycline (covers chlamydia and mycoplasma genitalium)
  • metronidazole (covers BV and trich)
  • hosp admission if septic / pregnant
81
Q

management of a pelvic abscess secondary to PID?

A

surgical drainage

82
Q

complications of PID?

A
  • sepsis
  • abscess
  • infertility
  • chronic pelvic pain
  • ectopic pregnancy
  • fitz-hugh-curtis syndrome
83
Q

describe the pathophysiology of fitz-hugh-curtis syndrome

A
  • liver capsule becomes inflamed in PID
  • bacteria spread from pelvis to abdomen
  • adhesions form
84
Q

presentation of fitz-hugh-curtis syndrome?

A
  • RUQ pain

- referred right shoulder tip pain

85
Q

management of fitz-hugh-curtis syndrome?

A

adhesiolysis

86
Q

investigation in fitz-hugh-curtis syndrome?

A

laparascopy

87
Q

what type of organism causes trichomoniasis?

A
  • trichomonas vaginalis

- protozoan

88
Q

which other conditions does trichomoniasis increase the risk of developing?

A
  • contracting HIV
  • BV
  • cervical Ca
  • PID
  • preterm devliery
89
Q

presentation of trichomoniasis?

A
  • 50% asymptomatic
  • frothy, green, fishy vaginal discharge
  • itching
  • dysuria
  • dyspareunia
  • balanitis (inflamed glans penis)
90
Q

findings O/E of trichomoniasis? what causes this?

A
  • strawberry cervix

- tiny haemorrhages all over the cervix

91
Q

investigation findings in trichomoniasis?

A

pH >4.5 (like BV)

92
Q

how is trichomoniasis diagnosed?

A

charcoal swab with microscopy

93
Q

where should the swab be taken from in women for trichomoniasis?

A
  • posterior fornix (behind cervix) of vagina

- self-swab is alternative

94
Q

investigations for trichomoniasis in men?

A
  • urethral swab

- first-catch urine

95
Q

management of trichomoniasis?

A
  • GUM referral

- metronidazole

96
Q

where does HSV-1 / HSV-2 lay dormant to cause oral cold sores? genital herpes?

A
  • trigeminal nerve ganglion

- sacral nerve ganglia

97
Q

different presentations caused by the HSV virus?

A
  • cold sores (on lip)
  • genital herpes
  • aphthous ulcers (in mouth)
  • herpetic keratitis (inflamed cornea)
  • herpetic whitlow
98
Q

describe a herpetic whitlow

A

a painless skin lesion on the finger / thumb caused by HSV

99
Q

how is HSV spread?

A
  • direct contact between affected mucous membranes
  • viral shedding in mucous secretions
  • can shed even when asymptomatic
100
Q

how does HSV-1 typically present? HSV-2?

A
  • 1 gives cold sores

- 2 gives genital herpes

101
Q

presentation of genital herpes?

A
  • may be asymptomatic for months - years
  • initial infection typically presents within 2 weeks, this one is usually the most severe presentation
  • ulcers / blisters on genitals
  • neuropathic pain
  • flu-like symptoms (fatigue, headache)
  • dysuria
  • inguinal lymphadenopathy
102
Q

how long can symptoms last in a primary HSV infection?

A

up to 3 weeks

103
Q

how is genital herpes diagnosed?

A
  • can be done clinically

- confirmed on viral PCR swab

104
Q

management of genital herpes?

A
  • refer to GUM
  • aciclovir
  • analgesia
  • clean with warm salt water
  • topical vaseline
  • additional oral fluids
  • wear loose underwear / clothes
  • avoid sex while symptomatic
105
Q

analgesia options for genital herpes?

A
  • paracetamol

- topical lidocaine

106
Q

when is genital herpes classed as “primary” in pregnancy?

A

when contracted during pregnancy

107
Q

how is primary genital herpes managed in pregnancy?

A
  • initial aciclovir treatment
  • then prophylactic aciclovir from 36w onwards
  • C-section to reduce risk of transmission to neonate
108
Q

when is genital herpes classed as “recurrent” in pregnancy? significance of this?

A
  • woman is known to have it pre-pregnancy

- far less likely to pass it on to the neonate

109
Q

management of recurrent genital herpes in pregnancy?

A

prophylactic aciclovir from 36w

110
Q

what type of organism is HIV?

A

RNA retrovirus

111
Q

what are the 2 types of HIV viruses? which is more common?

A
  • HIV-1 is more common

- HIV-2 rare outside of west africa

112
Q

pathophysiology of HIV infection?

A

virus enters and destroys CD4 T-helper cells

113
Q

initial presentation in first few weeks of HIV infection?

A

seroconversion “flu-like” illness

114
Q

how can HIV be transmitted?

A
  • unprotected anal / vaginal / oral sex
  • vertical transmission at any stage of pregnancy / birth / breastfeeding
  • mucous membrane, blood or open wound exposure to blood / bodily fluids (e.g. needles)
115
Q

examples of AIDS-defining illnesses?

A
  • kaposi’s sarcoma
  • pneumocystis jirovecii pneumonia (PCP)
  • CMV infection
  • candidiasis (oesophageal or bronchial)
  • lymphoma
  • TB
116
Q

how is HIV screened for?

A
  • anyone admitted to a hospital with an infectious disease should have antibody test for HIV
  • anyone with RFs for HIV infection should also get antibody test
117
Q

how long after initial HIV infection are HIV antibody tests accurate?

A
  • after 3 months

- repeat testing if initially negative but you strongly suspect HIV and it has not yet been 3m

118
Q

key consideration before testing for HIV?

A
  • pts must consent to it

- verbal consent is enough

119
Q

methods of testing for HIV?

A
  • antibody testing
  • p24 antigen testing (shows positives earlier than antibody test)
  • gold standard = antibody + antigen testing combined
  • PCR testing (gives viral load)
120
Q

how is HIV infection monitored?

A
  • CD4 count

- viral load (VL)

121
Q

what is the range for a normal CD4 count?

A

500 - 1200

122
Q

what CD4 count is classed as AIDS?

A

<200

123
Q

what VL is classed as undetectable?

A

<50 HIV RNA copies / ml

124
Q

drug treatment of HIV?

A
  • highly active anti-retroviral therapy (HAART) med combo
  • e.g. tenofovir and emtricitabine
  • prophylactic co-trimoxazole (septrin) if CD4 <200
  • statins for CVD risks
125
Q

what does prophylactic septrin in HIV infection protect against?

A

PCP infection

126
Q

non-drug management of HIV?

A
  • annual cervical smears for women
  • check immunisations are up to date
  • advise on condoms even when both partners are HIV+
  • sperm washing and IVF for conception where woman does not have HIV
  • advise on regular partner testing
127
Q

what mode of delivery is preferred in HIV+ pregnant women?

A

depends on maternal VL:

  • normal vaginal delivery if VL <50
  • C-section if >50
  • add IV zidovudine during C-section if VL unknown or >10,000
128
Q

prophylactic treatment against HIV for baby?

A

depends on maternal VL:

  • if <50, then zidovudine for 4w
  • if >50, then zidovudine, lamivudine and nevirapine for 4w
129
Q

can HIV be passed on via breastfeeding when VL is undetectable?

A
  • yes

- advise against this

130
Q

time limit for taking post-exposure prophylaxis (PEP)?

A

72h

131
Q

what is taken in PEP? for how long?

A
  • truvada and raltegravir

- 28d course

132
Q

when is HIV tested for after exposure to be confirmed -ve?

A
  • immediately
  • then minimum 3m later
  • pt should be abstinent until confirmed -ve
133
Q

which organism causes syphilis?

A
  • treponema pallidum

- spirochete bacteria

134
Q

how long is the incubation period of syphilis (initial infection to symptoms)?

A

21 days

135
Q

modes of transmission of syphilis?

A
  • oral / vaginal / anal sex with direct contact of infected area
  • vertical transmission in pregnancy
  • IVDU
  • blood transfusions / other transplants (rare)
136
Q

what are the stages of syphilis?

A
  • primary
  • secondary
  • latent
  • tertiary
137
Q

presentation of primary syphilis?

A
  • painless ulcer (chancre) at original site of infection (usually genitals)
  • local lymphadenopathy (groin)
138
Q

how long does it take a chancre to resolve?

A

3-8w

139
Q

presentation of secondary syphilis?

A
  • starts after chancre has healed
  • maculopapular rash
  • condylomata lata (grey warty lesions around genitals / anus)
  • low-grade fever
  • lymphadenopathy
  • alopecia
  • oral lesions
140
Q

presentation of tertiary syphilis?

A
  • gummatous lesions
  • aortic aneurysms
  • neurosyphilis
141
Q

what are gummas? which condition are these seen in?

A
  • granulomatous tissue
  • affects skin, organs and bones
  • seen in tertiary syphilis
142
Q

at which stage of syphilis does neurosyphilis occur?

A
  • can be at any stage

- whenever the bacteria reaches the CNS

143
Q

presentation of neurosyphilis?

A
  • headache
  • altered behaviour
  • dementia
  • tabes dorsalis
  • ocular syphilis
  • argyll-robertson pupil
  • paralysis
  • sensory impairment
144
Q

describe tabes dorsalis. which condition is this seen in?

A
  • demyelination of posterior SC columns

- neurosyphilis

145
Q

describe the argyll-robertson pupil. which condition is this seen in?

A
  • “prostitute’s pupil” = “accommodates, but doesn’t react”
  • constricted pupil which accommodates when focussed on an object
  • but does not react to light
  • often irregularly shaped
  • seen in neurosyphilis
146
Q

how can syphilis be screened for?

A

antibody testing for T. pallidum bacteria antibodies

147
Q

how is syphilis diagnosed?

A
  • antibody testing first
  • refer to GUM if +ve

then get a sample from infection site to check:

  • dark field microscopy
  • PCR
148
Q

give examples of tests which are used to assess for active syphilis infection. disadvantage of these?

A
  • rapid plasma reagin (RPR)
  • venereal disease research laboratory (VDRL)
  • non-specific (high false +ve rate)
149
Q

management of syphilis?

A
  • refer to GUM
  • full screening for other STIs
  • advise to abstain from sex until treated
  • single dose IM benzathine benzylpenicillin
  • contact tracing
  • advise on condoms

Zero to Finals: Women's Health (3 decks)

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