Genitourinary Medicine Flashcards
1
Q
What is the most common cause of abnormal discharge in women of reproductive age?
A
Bacterial vaginosis (BV)
It is worth remembering that BV can occur alongside other infections, including candidiasis, chlamydia and gonorrhoea.
2
Q
Pathophysiology of BV?
A
BV is caused by a loss of the lactobacili (‘friendly bacteria’) in the vaginal canal - this can be trigged by environmental factors.
This leads to a rise in pH (more alkaline) which enables anaerobic bacteria to multiply.
This leads to alterations in the consistency, composition and odour of vaginal discharge.
3
Q
What are the main component of the healthy vaginal bacterial flora?
A
Lactobacili
4
Q
How do lactobacili keep the vaginal pH low?
A
They produce lactic acid
5
Q
What is the ideal pH of the vaginal canal?
A
3.8-4.5
6
Q
Give 3 examples of anaerobic bacteria associated with BV
A
- Gardnerella vaginalis (most common)
- Mycoplasma hominis
- Prevotella species
7
Q
Risk factors for BV?
A
- Sexual activity: especially unprotected cunnilingus. It is important to note that whilst BV is sexually associated, it is NOT a sexually transmitted infection
- Existing sexually transmitted infection (STI): such as chlamydia and gonorrhoea
- New sexual partner/multiple sexual partners
- Afro-Caribbean ethnicity
- Excessive vaginal douching: introduction of cleaning solutions into the vagina
- Bubble baths, shower gels and “feminine hygiene” products
- Copper coil (not known if the IUS such as the “Mirena” has the same effect)
- Smoking
- Recent antibiotics
8
Q
When taking a history from someone with typical symptoms of bacterial vaginosis, the diagnosis can be quite obvious based on the fishy-smelling discharge.
What else should you assess for?
A
Assess for causes and give advice.
Example - sensitively ask about the use of soaps to clean the vagina and vaginal douching and provide information about how these can increase the risk.
9
Q
Clinical presentation of BV?
A
Half of women with BV are asymptomatic.
- Fishy-smelling watery grey or white vaginal discharge (standard presenting feature)
- A cyclical appearance of symptoms which worsen after sexual intercourse, cunnilingus or menstruation
- Larger volumes of vaginal discharge, occasionally requiring a panty liner to control
- Discharge takes on a thin consistency compared to physiological discharge
10
Q
Are itching, irritation and pain typically associated with BV?
A
No - suggest an alternative cause or co-occurring infection.
11
Q
What investigation should be conducted for patients with suspected BV?
A
A thorough female pelvic examination
Speculum + high vaginal swab (to exclude other causes of symptoms)
N.B. Examination is not always required where the symptoms are typical, and the women is low risk of sexually transmitted infections.
12
Q
What clinical findings may there be on a thorough female pelvic examination in BV?
A
- A thin white discharge coating the vaginal walls or the speculum
- Offensive smell to discharge
- An alkali pH if a litmus test is used
Patients are unlikely to be tender on bimanual examination.
13
Q
What are some potential protective factors for BV?
A
- Using barrier methods during sexual activity, such as condoms and dams
- Washing genitals externally with water alone
- The combined oral contraceptive pill
14
Q
How can vaginal pH be tested?
A
Vaginal pH can be tested using a swab and pH paper.
15
Q
What is a normal vaginal pH?
A
3.5-4.5
16
Q
What vaginal pH does BV occur at?
A
> 4.5
17
Q
Potential differentials for BV?
A
- Candida (thrush)
- STIs: chlamydia, gonorrhoea, herpes simplex virus (HSV), trichomoniasis vaginalis (TV)
- Physiological discharge
- Pregnancy
- Atrophic vaginitis
- Chemical irritants: lead to allergic vaginitis
- Foreign body: most commonly tampons, but also consider other objects which could have been used during sexual intercourse or contaminants if following a sexual assault
- Post gynaecological surgery
- Cervical ectropion
- Tumour (vulva, vagina, cervix or endometrium): this can be benign or malignant and will require an urgent gynae-oncology review
18
Q
What is the most likely cause of discharge changes in post-menopausal women?
A
Atrophic vaginitis
19
Q
What causes discharge changes in atrophic vaginitis?
A
A reduction in oestrogen leading to localised irritation
20
Q
When considering chemical irritants as a differential to BV, what should you ask about?
A
- Changes in body wash
- Laundry detergents
- Lubricants
- Use of sex toys
21
Q
What foreign body is most likely to cause changes to discharge?
A
Tampons
22
Q
Describe discharge & odour in
a) BV
b) Candida
c) Trichomonias vaginalis
d) Physiological
A
a) thin, white-grey, fishy
b) thick, white, non-offensive
c) thin, frothy, fishy
d) changes through menstrual cycle, often clear or white, odourless
23
Q
Describe vulval irritation in
a) BV
b) Candida
c) Trichomonias vaginalis
d) Physiological
A
a) usually none but occasional burning and itching
b) vulvovaginitis causing itching, fissures and swelling
c) Itching, soreness and dysuria
d) nil
24
Q
Describe vaginal pH in
a) BV
b) Candida
c) Trichomonias vaginalis
d) Physiological
A
a) >4.5
b) <4.5
c) >5
d) <4.5
25
Investigations in BV?
- A standard charcoal vaginal swab can be taken for microscopy as well as STI screening (can be a high vaginal swab taken during a speculum examination or a self-taken low vaginal swab)
- Vaginal pH can be tested using a swab and pH paper
26
What is seen on microscopy in BV?
Bacterial vaginosis gives “clue cells” on microscopy.
27
What are 'clue cells'?
Clue cells are epithelial cells from the cervix that have bacteria stuck inside them, usually Gardnerella vaginalis.
28
A diagnosis of BV can be made based on bedside investigations using what 2 criteria?
1) Amsel criteria
2) Hay/Ison criteria
29
What are the Amsel criteria?
How many must be met to make a diagnosis of BV?
Homogeneous discharge on clinical examination
Microscopy showing vaginal epithelial cells coated with many bacilli (“clue cells”)
Vaginal pH >4.5: assessed with litmus paper
Fishy odour on adding 10% potassium hydroxide to vaginal fluid
30
What do the Hay/Ison criteria take into account?
The Hay/Ison criteria take into account the microscopic appearance of gram-stained vaginal smear.
31
The appearance of vaginal flora is graded in the Hay/Ison Criteria.
What are the gradings?
Grade 1 (normal): lactobacillus morphotypes predominate
Grade 2 (intermediate): mixed flora with some Lactobacilli present, but Gardnerella or Mobiluncus morphotypes also present
Grade 3 (BV): predominantly Gardnerella and/or Mobiluncus morphotypes. Few or absent lactobacilli
Grade 4: gram-positive bacteria predominate
32
Management of asymptomatic BV?
Asymptomatic BV does not usually require treatment. Additionally, it may resolve without treatment.
33
What is the Abx of choice in treating BV?
Metronidazole
Usually oral metronidazole 400-500 mg BD for 5-7 days
34
Why is metronidazole the Abx of choice in BV?
Metronidazole specifically targets anaerobic bacteria.
35
What is an alternative (but less optimal) Abx than Metronidazole in BV?
Clindamycin
36
How is metronidazole in the treatment of BV managed?
This is given orally, or by vaginal gel.
Oral metronidazole 400-500 mg BD for 5-7 days
37
In the management of BV, what else should you assess & discuss?
Always assess the risk of additional pelvic infections, with swabs for chlamydia and gonorrhoea where appropriate.
Provide advice and information about measures that can reduce the risk of further episodes of bacterial vaginosis, such as avoiding vaginal irrigation or cleaning with soaps that may disrupt the natural flora.
38
Whenever prescribing metronidazole, what should you advise patients?
Advise patients to avoid alcohol for the duration of treatment
39
Why should you not drink alcohol with metronidazole?
Alcohol and metronidazole can cause a “disulfiram-like reaction”, with nausea and vomiting, flushing and sometimes severe symptoms of shock and angioedema.
40
General advice for patients with BV?
Avoid vaginal douching
Avoid bubble baths, shower gel and antiseptic products near the genitals
Some patients find probiotics useful. This can be in the form of dietary intake (kimchi, kefir, kombucha etc), tablet or vaginal pessary. Research suggests this can be useful, though there is no conclusive evidence yet.
41
Medical treatment is recommended for certain groups of individuals with BV.
What are these groups?
- Anyone with symptoms
- Any pregnant individuals (regardless of choice in continuation of pregnancy)
42
Is metronidazole safe for use in pregnancy?
Low-dose metronidazole is safe for use in pregnancy. However, high dose metronidazole (2g stat) should be avoided in pregnancy.
43
What should individuals who are breastfeeding be offered for the treatment of BV?
Vaginal preparations of metronidazole.
When prescribing vaginal preparations, it is important to warn patients that the ingredients may degrade condoms, th
44
Complications of BV?
BV places patients at higher risk of acquiring and transmitting STIs, including chlamydia, gonorrhoea and HIV.
45
What are the complications of BV in pregnant women?
- First-trimester miscarriage (77%)
- Late miscarriage (after 12 weeks – 23%)
- Preterm labour (12.5%)
- Premature rupture of membranes
- Low birth weight
- Postpartum endometritis
46
What is candidiasis ("thrust")?
A vaginal infection with a yeast of the Candida family. The most common is Candida albicans.
Candida may colonise the vagina without causing symptoms. It then progresses to infection when the right environment occurs, for example, during pregnancy or after treatment with broad-spectrum antibiotics that alter the vaginal flora.
47
Risk factors for candidiasis?
- Increased oestrogen (higher in pregnancy, lower pre-puberty and post-menopause)
- Poorly controlled diabetes
- Immunosuppression (e.g. using corticosteroids)
- Broad-spectrum antibiotics
48
What is the main causative organism in candidiasis?
Candida Albicans
49
What defines recurrent vulvovaginal candidiasis?
Four or more symptomatic episodes in one year, with at least two episodes confirmed by microscopy or culture when symptomatic.
50
What are the symptoms of vaginal candidiasis?
Women:
- Thick, white discharge that does not typically smell
- Vulval and vaginal itching, irritation or discomfort, burning sensation
Males:
- Symptoms: Soreness, pruritus, redness.
- Examination findings: Dry, dull, red glazed plaques and papules.
51
What can a more severe candidiasis infection lead to?
Erythema
Fissures
Oedema
Pain during sex (dyspareunia)
Dysuria
Excoriation
52
Investigations in candididias?
Routine investigations are not typically required for acute, uncomplicated vulvovaginal candidiasis cases.
However, in instances where the clinical presentation is unclear or recurrent episodes occur, investigations may be necessary:
- Testing the vaginal pH using a swab and pH paper can be helpful in differentiating between bacterial vaginosis and trichomonas (pH > 4.5) and candidiasis (pH < 4.5).
- A charcoal swab with microscopy can confirm the diagnosis.
- Culture: Recommended for recurrent vulvovaginal candidiasis cases to identify the Candida species.
53
Management of candidiasis?
Antifungal medications:
- Creams (i.e. clotrimazole)
- Pessary (i.e. clotrimazole)
- Oral tablets (i.e. fluconazole)
54
What antifungal agent is present in topical antifungal cream for candidiasis?
clotrimazole
55
What antifungal agent is present in a vaginal pessary for candidiasis?
clotrimazole
56
Treatment options for initial uncomplicated cases of candidiasis:
1) A single dose of intravaginal clotrimazole cream (5g of 10% cream) at night
2) A single dose of clotrimazole pessary (500mg) at night
3) Three doses of clotrimazole pessaries (200mg) over three nights
4) A single dose of fluconazole (150mg)
57
What is canesten duo?
Canesten Duo is a standard over-the-counter treatment for candidiasis --> it contains a single fluconazole tablet and clotrimazole cream to use externally for vulval symptoms.
58
What must you warn sexually active women using antifungal creams and pessaries?
Antifungal creams and pessaries can damage latex condoms and prevent spermicides from working, so alternative contraceptive is required for at least five days after use.
59
Contraindications of oral antifungal tablets for candidiasis?
Oral therapies should be avoided in pregnant women, women at risk of pregnancy, and breastfeeding women.
60
What is pelvic inflammatory disease (PID)?
Pelvic inflammatory disease (PID) is inflammation and infection of the organs of the pelvis, caused by infection spreading up through the cervix from the vagina.
It is a significant cause of tubular infertility and chronic pelvic pain.
61
What organs of the pelvis are affected in PID?
Endometritis is inflammation of the endometrium
Salpingitis is inflammation of the fallopian tubes
Oophoritis is inflammation of the ovaries
Parametritis is inflammation of the parametrium, which is the connective tissue around the uterus
Peritonitis is inflammation of the peritoneal membrane
62
What are the 3 most common causes of PID?
- Neisseria gonorrhoeae tends to produce more severe PID
- Chlamydia trachomatis
- Mycoplasma genitalium
63
Pelvic inflammatory disease can less commonly be caused by non-sexually transmitted infections, such as what?
- Gardnerella vaginalis (associated with bacterial vaginosis)
- Haemophilus influenzae (a bacteria often associated with respiratory infections)
- Escherichia coli (an enteric bacteria commonly associated with urinary tract infections)
64
Risk factors for PID?
The same as any other sexually transmitted infection:
- Not using barrier contraception
- Multiple sexual partners
- Younger age
- Existing sexually transmitted infections
- Previous pelvic inflammatory disease
- Intrauterine device (e.g. copper coil)
65
Symptoms of PID?
- Pelvic or lower bilateral abdominal pain
- Abnormal vaginal discharge
- Abnormal bleeding (intermenstrual or postcoital)
- Pain during sex (dyspareunia)
- Fever
- Dysuria
66
Examination findings in PID?
- Pelvic tenderness
- Cervical motion tenderness (cervical excitation)
- Inflamed cervix (cervicitis)
- Purulent discharge
Patients may have a fever and other signs of sepsis.
67
What is Fitz-Hugh-Curtis Syndrome?
Fitz-Hugh-Curtis syndrome is a complication of PID (10%).
It is caused by inflammation and infection of the liver capsule (Glisson’s capsule), leading to adhesions between the liver and peritoneum. Bacteria may spread from the pelvis via the peritoneal cavity, lymphatic system or blood.
68
How does Fitz-Hugh-Curtis Syndrome present?
Fitz-Hugh-Curtis syndrome results in right upper quadrant (RUQ) pain that can be referred to the right shoulder tip if there is diaphragmatic irritation.
May be confused with cholecystitis.
69
Differentials for PID?
Appendicitis: Presents with right lower quadrant abdominal pain, fever, nausea, and vomiting.
Ectopic Pregnancy: Symptoms may include unilateral lower abdominal pain and vaginal bleeding. A positive pregnancy test is a key distinguishing factor.
Endometriosis: Chronic pelvic pain, dysmenorrhea, and dyspareunia are common. Pain typically worsens during menstruation.
Ovarian Cyst: Symptoms can include unilateral lower abdominal pain, bloating, and a palpable mass on examination.
Urinary Tract Infection: Symptoms usually include dysuria, frequency, urgency, suprapubic pain, and possible fever.
70
Investigations in PID?
Testing for causative organisms and other sexually transmitted infections:
- NAAT swabs for gonorrhoea and chlamydia
- NAAT swabs for Mycoplasma genitalium if available
- HIV test
- Syphilis test
Others:
- Pelvic examination
- Pregnancy test
- Blood tests
- Transvaginal ultrasound
- A high vaginal swab can be used to look for bacterial vaginosis, candidiasis and trichomoniasis.
71
What test should be be performed on sexually active women presenting with lower abdominal pain? Why?
Pregnancy test - exclude ectopic pregnancy
72
Complications of PID?
- Sepsis
- Abscess
- Infertility (10-20% after single episode)
- Chronic pelvic pain
- Ectopic pregnancy
- Fitz-Hugh-Curtis syndrome
73
Management of PID?
Where appropriate patients should be referred to a genitourinary medicine (GUM) specialist service for management and contact tracing.
Antibiotics are started empirically, before swab results are obtained, to avoid a delay and complications.
74
When are antibiotics started in PID?
Empirically
75
A typical outpatient regime for PID:
1) A single dose of intramuscular ceftriaxone 1g (to cover gonorrhoea)
2) Doxycycline 100mg twice daily for 14 days (to cover chlamydia and Mycoplasma genitalium)
3) Metronidazole 400mg twice daily for 14 days (to cover anaerobes such as Gardnerella vaginalis)
Ceftriaxone and doxycycline will cover many other bacteria, including H. influenzae and E. coli.
76
What should you always look for signs of in PID?
Sepsis!
77
In which cases of PID require admission for IV Abx?
- Sepsis
- Pregnancy
78
What is bladder pain syndrome also known as?
Interstitial cystitis (and hypersensitive bladder syndrome)
79
What is bladder pain syndrome?
A chronic condition causing inflammation in the bladder, resulting in lower urinary tract symptoms and suprapubic pain
80
Aetiology of bladder pain syndrome?
No cause known - likely combination
81
Is bladder pain syndrome more common in men or women?
Women - can have a significant impact on quality of life and mental health.
82
Presentation of bladder pain syndrome?
The symptoms are similar to a lower urinary tract infection, but are more persistent.
The typical presentation is more than 6 weeks of:
- Suprapubic pain, worse with a full bladder and often relieved by emptying the bladder
- Frequency of urination
- Urgency of urination
- Symptoms may be worse during menstruation
83
How to distinguish bladder pain syndrome from lower UTI?
Bladder pain syndrome symptoms are more persistent (>6 weeks)
84
Investigations in bladder pain syndrome?
Need to EXCLUDE other causes of symptoms:
- Urinalysis for urinary tract infections
- Swabs for sexually transmitted infections
- Cystoscopy for bladder cancer
- Prostate examination for prostatitis, hypertrophy or cancer
85
What can be seen during cytoscopy in interstitial nephritis (in approx 20% of patients)?
1) Hunner lesions - red, inflamed patches of the bladder mucosa associated with small blood vessels.
2) Granulations - tiny haemorrhages on the bladder wall
86
Supportive management of interstitial cystitis?
Can be difficult to manage and supportive management is used initially:
- Diet changes such as avoiding alcohol, caffeine and tomatoes
- Stopping smoking
- Pelvic floor exercises
- Bladder retraining
- Cognitive behavioural therapy
- Transcutaneous electrical nerve stimulation (TENS)
87
What oral medications may be useful in interstitial cystitis?
- Analgesia
- Antihistamines
- Anticholinergic medications (e.g., solifenacin or oxybutynin)
- Mirebegron (beta-3-adrenergic-receptor agonist)
- Cimetidine (histamine-2-receptor antagonist)
- Pentosan polysulfate sodium
- Ciclosporin (an immunosuppressant)
88
What is intravesical medication?
Drugs are put directly into bladder
89
What intravesical medications may be used in interstitial cystitis?
Lidocaine
Pentosan polysulfate sodium
Hyaluronic acid
Chondroitin sulphate
90
What is hydrodistension?
Purpose of it in interstitial nephritis?
Hydrodistention involves filling the bladder with water, to high pressure, during a cystoscopy. Requires general anaesthetic.
This can give a temporary (3-6 month) improvement in symptoms.
91
Surgical procedures possibly used in bladder pain syndrome?
- Cauterisation of Hunner lesions during cystoscopy
- Butulinum toxin injections during cystoscopy
- Neuromodulation with an implanted electrical nerve stimulator
- Augmentation of the bladder, using a section of ileum, to increase the capacity (ileocystoplasty)
- Cystectomy (removal of the bladder)
NOTE - don’t need to remember all the treatments, and they are unlikely to be tested. Just keep it in mind as a differential diagnosis and be generally aware of the investigations (including cystoscopy) and treatment options.
92
