Genitourinary Medicine Flashcards
1
Q
what is BV?
A
an overgrowth of anaerobic bacteria in the vagina
2
Q
pathophysiology of BV?
A
- loss of lactobacilli in vaginal flora
- pH rises to >4.5
- this allows anaerobic bacteria to grow
3
Q
most common causative organism of BV?
A
gardnerella vaginalis
4
Q
risk factors for BV?
A
- multiple sexual partners
- vaginal douching
- recent ABx
- smoking
- copper coil
5
Q
protective factors against BV?
A
- COCP use
- effective use of condoms
6
Q
presentation of BV?
A
- thin, watery grey discharge
- fishy smell
- 50% are asymptomatic
7
Q
how can a diagnosis of BV be confirmed?
A
on speculum examination
8
Q
investigations for BV?
A
- vaginal pH measurement
- high (in speculum) / self-taken low vaginal charcoal swab and microscopy
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
10
Q
management of BV?
A
- if asymptomatic, nothing
- PO/ PV gel metronidazole
- alt: clindamycin, less effective
11
Q
what should be avoided whilst being treated with metronidazole? why?
A
- alcohol
- causes “disulfiram-like” reaction
- N+V, flushing, shock if severe
12
Q
main complication of BV in a non-pregnant person?
A
increases risk of catching STIs
13
Q
complications of BV in pregnancy?
A
- miscarriage
- preterm delivery
- premature rupture of membranes
- chorioamnionitis
- LBW
- postpartum endometritis
14
Q
commonest causative organism in vaginal candidiasis?
A
candida albicans
15
Q
risk factors for vaginal candidiasis?
A
- pregnancy
- poorly controlled DM
- immunosuppression (e.g. corticosteroid use)
- broad-spec ABx use
16
Q
presentation of vaginal candidiasis?
A
- thick, white, odourless discharge
- vulvovaginal itching, irritation and discomfort
17
Q
signs of a more severe vaginal candidiasis infection?
A
- erythema
- fissures
- oedema
- dyspareunia
- dysuria
- excoriation
18
Q
investigations for vaginal candidiasis?
A
- vaginal pH (<4.5, unlike BV and trich infections)
- charcoal swab with microscopy confirms Dx
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
20
Q
when is vaginal candidiasis classed as recurrent?
A
when there are >4 episodes in 1 year
21
Q
what type of bacteria is chlamydia trachomatis?
A
gram -ve
22
Q
most common STI in the UK?
A
chlamydia
23
Q
which STIs are screened for by GUM clinics?
A
- chlamydia
- gonorrhoea
- syphilis (blood test)
- HIV (blood test)
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
25
when should someone who tested positive for chlamydia be retested for it?
3m after treatment
26
what are the 2 types of vaginal swab?
- charcoal
| - NAAT
27
which diseases can be diagnosed on NAAT testing?
- chlamydia
| - gonorrhoea
28
which samples can be used for NAAT testing in women?
- endocervical swab (preferred)
- vulvovaginal swab
- first-catch urine sample (least preferred)
29
which samples can be used for NAAT testing in men?
- first-catch urine sample
| - urethral swab
30
which NAAT swabs should be used for those who have had anal or oral sex?
- rectal
| - pharyngeal
31
what is the next investigation where a NAAT test is positive for gonorrhoea?
endocervical charcoal swab for MCS
32
presentation of chlamydia in women?
- abnormal PV discharge or bleeding
- pelvic pain
- dyspareunia
- dysuria
33
presentation of chlamydia in men?
- urethral discharge or discomfort
- dysuria
- epididymo-orchitis
- reactive arthritis
34
presentation of rectal chlamydia? what is a differential for this?
- anorectal discharge or discomfort
- PR bleeding
- change in bowel habit
- LGV infection
35
findings O/E of chlamydia?
- pelvic / abdo tenderness
- cervical motion tenderness (excitation)
- cervicitis
- purulent discharge
36
how is chlamydia diagnosed?
on NAAT
37
management of chlamydia in non-pregnant person?
1st line: doxycycline 100mg BD for 7 days
| alt: azithromycin 1g PO one-off dose
38
management of chlamydia in pregnancy?
different options available:
- azithromycin 1g stat then 500mg OD for 2 days
- erythromycin 500mg QDS for 7 days
- amoxicillin 500mg TDS for 7 days
39
when should a "test of cure" be used in chlamydia treatment?
- rectal chlamydia
- pregnancy
- persistent symptoms
40
non-medical management of chlamydia?
- 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
41
complications of chlamydia in non-pregnant person?
- PID
- chronic pelvic pain
- infertility
- ectopic pregnancy
- epididymo-orchitis
- conjunctivitis
- LGV
- reactive arthritis
42
complications of chlamydia in pregnancy?
- preterm delivery
- PPROM
- LBW
- postpartum endometritis
- neonatal conjunctivitis / pneumonia
43
what is lymphogranuloma venereum (LGV)?
a variant of chlamydial bacteria which causes inflammation of lymphoid tissue
44
highest risk factor for LGV?
MSM
45
describe the 3 stages of LGV infection
- 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
46
treatment of LGV infection?
- doxycycline 100mg BD for 21 days
| - alt: erythromycin, azithromycin, ofloxacin
47
how does chlamydial conjunctivitis occur?
usually when genital fluid comes into contact with eye, e.g. hand to eye spread
48
typical demographics affected by chlamydial conjunctivitis?
- young people
| - neonates
49
key differential for chlamydial conjunctivitis?
- gonococcal conjunctivitis
| - should test for this too
50
what type of bacteria causes gonorrhoea?
- neisseria gonorrhoea
| - gram -ve diplococcus
51
which areas of the body can be infected with gonorrhoea?
- endocervix
- urethra
- rectum
- conjunctiva
- pharynx
52
risk factors for gonorrhoea?
- young
- sexually active
- multiple sexual partners
- having other STIs
53
is gonorrhoea ever asymptomatic?
- can be
- but more likely to give symptoms than chlamydia
- 90% men and 50% women have symptoms
54
presentation of gonorrhoea in females?
- may be asymptomatic
- odourless purulent discharge
- green / yellow discharge
- dysuria
- pelvic pain
55
presentation of gonorrhoea in males?
- odourless purulent discharge
- green / yellow discharge
- dysuria
- testicular pain / swelling (epididymo-orchitis)
56
presentation of rectal gonorrhoea infection?
- anal discomfort
| - anal discharge
57
how might prostatitis secondary to gonorrhoea infection present?
- perineal pain
- urinary symptoms
- soreness on DRE
58
how might pharyngeal gonorrhoea infection present?
sore throat
59
presentation of gonorrhoeal conjunctivitis?
- eye erythema
| - purulent discharge
60
how is gonorrhoea diagnosed?
- nucleic acid amplification testing (NAAT)
| - charcoal swab and MCS done to guide ABx choice
61
management of gonorrhoea?
- 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
when should a test of cure be completed after gonorrhoea treatment?
- 72h after treatment for culture
- 7d after treatment for RNA NAAT
- 14 after treatment for DNA NAAT
63
complications of gonorrhoea?
- PID
- chronic pelvic pain
- infertility
- conjunctivitis, esp in neonates
- urethral strictures
- disseminated gonococcal infection
- skin lesions
- fitz-hugh-curtis syndrome
- septic arthritis
- endocarditis
64
which complications of gonorrhoea are specific to men?
- epididymo-orchitis
| - prostatitis
65
what are the complications of neonatal gonococcal conjunctivitis?
- sepsis
- perforation of eye
- blindness
- medical emergency!!
66
how does disseminated gonococcal infection present?
- polyarthralgia
- migratory polyarthritis (moves)
- tenosynovitis (presents with hand / wrist pain)
- fever
- fatigue
67
presentation of mycoplasma genitalium?
- urethritis (key feature)
- epididymitis
- cervicitis
- endometritis
- PID
- reactive arthritis
- preterm delivery
- tubal infertility
68
investigations for mycoplasma genitalium?
NAAT done on:
- first catch urine in males
- vaginal swab in females
69
management of mycoplasma genitalium?
- check every positive sample for macrolide resistance first
- doxycycline 100mg BD for 7d, then:
- azithromycin 1g stat then:
- azithromycin 500mg OD for 2d
70
how does mycoplasma genitalium management differ in pregnancy?
- azithromycin only
| - doxycycline is contraindicated
71
common causes of PID?
- neisseria gonorrhoeae (gives more severe picture)
- chlamydia trachomatis
- mycoplasma genitalium
72
less common but possible causes of PID?
- gardnerella vaginalis (BV)
- Hib (resp infections)
- E. coli (UTIs)
73
risk factors for PID?
same as STIs:
- no condoms
- multiple partners
- younger age
- existing STIs
- prev PID
- IUD
74
presentation of PID?
- pelvic / lower abdo pain
- abnormal PV discharge
- abnormal PV bleeding
- dyspareunia
- fever
- dysuria
75
findings O/E in PID?
- pelvic tenderness
- cervical motion tenderness (excitation)
- cervicitis (inflamed)
- purulent discharge
- fever (if septic)
76
investigations for PID?
- NAAT swabs for gonorrhoea / chlamydia
- NAAT swabs for mycoplasma genitalium
- HIV test
- syphilis test
- high vaginal swab
- pregnancy test
- inflammatory markers (raised)
77
what could be picked up on the high vaginal swab in a pt with PID?
- BV
- candidiasis
- trichomoniasis
78
what can be used to rule out the diagnosis of PID?
absence of pus cells on swabs from vagina / endocervix
79
why is a pregnancy test particularly important in PID?
- rule out ectopic pregnancy
| - affects which ABx to give
80
management of PID?
- 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
management of a pelvic abscess secondary to PID?
surgical drainage
82
complications of PID?
- sepsis
- abscess
- infertility
- chronic pelvic pain
- ectopic pregnancy
- fitz-hugh-curtis syndrome
83
describe the pathophysiology of fitz-hugh-curtis syndrome
- liver capsule becomes inflamed in PID
- bacteria spread from pelvis to abdomen
- adhesions form
84
presentation of fitz-hugh-curtis syndrome?
- RUQ pain
| - referred right shoulder tip pain
85
management of fitz-hugh-curtis syndrome?
adhesiolysis
86
investigation in fitz-hugh-curtis syndrome?
laparascopy
87
what type of organism causes trichomoniasis?
- trichomonas vaginalis
| - protozoan
88
which other conditions does trichomoniasis increase the risk of developing?
- contracting HIV
- BV
- cervical Ca
- PID
- preterm devliery
89
presentation of trichomoniasis?
- 50% asymptomatic
- frothy, green, fishy vaginal discharge
- itching
- dysuria
- dyspareunia
- balanitis (inflamed glans penis)
90
findings O/E of trichomoniasis? what causes this?
- strawberry cervix
| - tiny haemorrhages all over the cervix
91
investigation findings in trichomoniasis?
pH >4.5 (like BV)
92
how is trichomoniasis diagnosed?
charcoal swab with microscopy
93
where should the swab be taken from in women for trichomoniasis?
- posterior fornix (behind cervix) of vagina
| - self-swab is alternative
94
investigations for trichomoniasis in men?
- urethral swab
| - first-catch urine
95
management of trichomoniasis?
- GUM referral
| - metronidazole
96
where does HSV-1 / HSV-2 lay dormant to cause oral cold sores? genital herpes?
- trigeminal nerve ganglion
| - sacral nerve ganglia
97
different presentations caused by the HSV virus?
- cold sores (on lip)
- genital herpes
- aphthous ulcers (in mouth)
- herpetic keratitis (inflamed cornea)
- herpetic whitlow
98
describe a herpetic whitlow
a painless skin lesion on the finger / thumb caused by HSV
99
how is HSV spread?
- direct contact between affected mucous membranes
- viral shedding in mucous secretions
- can shed even when asymptomatic
100
how does HSV-1 typically present? HSV-2?
- 1 gives cold sores
| - 2 gives genital herpes
101
presentation of genital herpes?
- 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
how long can symptoms last in a primary HSV infection?
up to 3 weeks
103
how is genital herpes diagnosed?
- can be done clinically
| - confirmed on viral PCR swab
104
management of genital herpes?
- refer to GUM
- aciclovir
- analgesia
- clean with warm salt water
- topical vaseline
- additional oral fluids
- wear loose underwear / clothes
- avoid sex while symptomatic
105
analgesia options for genital herpes?
- paracetamol
| - topical lidocaine
106
when is genital herpes classed as "primary" in pregnancy?
when contracted during pregnancy
107
how is primary genital herpes managed in pregnancy?
- initial aciclovir treatment
- then prophylactic aciclovir from 36w onwards
- C-section to reduce risk of transmission to neonate
108
when is genital herpes classed as "recurrent" in pregnancy? significance of this?
- woman is known to have it pre-pregnancy
| - far less likely to pass it on to the neonate
109
management of recurrent genital herpes in pregnancy?
prophylactic aciclovir from 36w
110
what type of organism is HIV?
RNA retrovirus
111
what are the 2 types of HIV viruses? which is more common?
- HIV-1 is more common
| - HIV-2 rare outside of west africa
112
pathophysiology of HIV infection?
virus enters and destroys CD4 T-helper cells
113
initial presentation in first few weeks of HIV infection?
seroconversion "flu-like" illness
114
how can HIV be transmitted?
- 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
examples of AIDS-defining illnesses?
- kaposi's sarcoma
- pneumocystis jirovecii pneumonia (PCP)
- CMV infection
- candidiasis (oesophageal or bronchial)
- lymphoma
- TB
116
how is HIV screened for?
- 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
how long after initial HIV infection are HIV antibody tests accurate?
- after 3 months
| - repeat testing if initially negative but you strongly suspect HIV and it has not yet been 3m
118
key consideration before testing for HIV?
- pts must consent to it
| - verbal consent is enough
119
methods of testing for HIV?
- antibody testing
- p24 antigen testing (shows positives earlier than antibody test)
- gold standard = antibody + antigen testing combined
- PCR testing (gives viral load)
120
how is HIV infection monitored?
- CD4 count
| - viral load (VL)
121
what is the range for a normal CD4 count?
500 - 1200
122
what CD4 count is classed as AIDS?
<200
123
what VL is classed as undetectable?
<50 HIV RNA copies / ml
124
drug treatment of HIV?
- 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
what does prophylactic septrin in HIV infection protect against?
PCP infection
126
non-drug management of HIV?
- 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
what mode of delivery is preferred in HIV+ pregnant women?
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
prophylactic treatment against HIV for baby?
depends on maternal VL:
- if <50, then zidovudine for 4w
- if >50, then zidovudine, lamivudine and nevirapine for 4w
129
can HIV be passed on via breastfeeding when VL is undetectable?
- yes
| - advise against this
130
time limit for taking post-exposure prophylaxis (PEP)?
72h
131
what is taken in PEP? for how long?
- truvada and raltegravir
| - 28d course
132
when is HIV tested for after exposure to be confirmed -ve?
- immediately
- then minimum 3m later
- pt should be abstinent until confirmed -ve
133
which organism causes syphilis?
- treponema pallidum
| - spirochete bacteria
134
how long is the incubation period of syphilis (initial infection to symptoms)?
21 days
135
modes of transmission of syphilis?
- oral / vaginal / anal sex with direct contact of infected area
- vertical transmission in pregnancy
- IVDU
- blood transfusions / other transplants (rare)
136
what are the stages of syphilis?
- primary
- secondary
- latent
- tertiary
137
presentation of primary syphilis?
- painless ulcer (chancre) at original site of infection (usually genitals)
- local lymphadenopathy (groin)
138
how long does it take a chancre to resolve?
3-8w
139
presentation of secondary syphilis?
- starts after chancre has healed
- maculopapular rash
- condylomata lata (grey warty lesions around genitals / anus)
- low-grade fever
- lymphadenopathy
- alopecia
- oral lesions
140
presentation of tertiary syphilis?
- gummatous lesions
- aortic aneurysms
- neurosyphilis
141
what are gummas? which condition are these seen in?
- granulomatous tissue
- affects skin, organs and bones
- seen in tertiary syphilis
142
at which stage of syphilis does neurosyphilis occur?
- can be at any stage
| - whenever the bacteria reaches the CNS
143
presentation of neurosyphilis?
- headache
- altered behaviour
- dementia
- tabes dorsalis
- ocular syphilis
- argyll-robertson pupil
- paralysis
- sensory impairment
144
describe tabes dorsalis. which condition is this seen in?
- demyelination of posterior SC columns
| - neurosyphilis
145
describe the argyll-robertson pupil. which condition is this seen in?
- "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
how can syphilis be screened for?
antibody testing for T. pallidum bacteria antibodies
147
how is syphilis diagnosed?
- antibody testing first
- refer to GUM if +ve
then get a sample from infection site to check:
- dark field microscopy
- PCR
148
give examples of tests which are used to assess for active syphilis infection. disadvantage of these?
- rapid plasma reagin (RPR)
- venereal disease research laboratory (VDRL)
- non-specific (high false +ve rate)
149
management of syphilis?
- 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
