Genitourinary Medicine Flashcards
What is bacterial vaginosis ?
Refers to an overgrowth of bacteria in the vagina specifically anaerobic bacteria.
Not an STI and is caused by a loss of the lactobacilli bacteria in the vagina.
How does lactobacilli keep the vaginal pH low ?
These bacteria produce lactic acid that keeps the vaginal pH low
What is the most common pathogen to cause bacterial vaginosis ?
Gardnerella vaginalis
What are the risk factors for bacterial vaginosis ?
Multiple sexual partners
Excessive vaginal cleaning
Recent antibiotics
Smoking
Copper coil
How does bacterial vaginosis present ?
Fishy-smelling watery grey or white vaginal discharge
Can be asymptomatic
What are some investigations for bacterial vaginosis ?
Vaginal pH - swabs
High vaginal swab
What is seen on microscopy in bacterial vaginosis ?
Clue cells
What is the management of asymptomatic bacterial vaginosis ?
Requires no treatment
What is the management of symptomatic bacterial vaginosis ?
Metronidazole
Clindamycin - second
What is a complication of bacterial vaginosis ?
Increased risk of catching an STI - gonorrhoea, chlamydia and HIV
What are complications of bacterial vaginosis in pregnancy ?
Miscarriage
Preterm delivery
Premature rupture of membranes
Chorioamnionitis
Low birth weight
Postpartum Endometritis
What is vaginal candidiasis ?
Refers to vaginal infection with the yeast Candida albicans
What are some risk factors of vaginal candidiasis ?
Increased oestrogen
Poorly controlled DM
Immunosuppression
Broad spectrum antibiotics
How does vaginal candidiasis present ?
Thick white discharge that doesn’t smell
Vulval and vaginal itching, irritation or discomfort
What can severe vaginal candidiasis lead to ?
Erythema
Fissures
Oedema
Pain during sex
Dysuria
Excoriation
How is a diagnosis of vaginal candidiasis made ?
Clinical
Vaginal swab to exclude bacterial vaginosis
Charcoal swab with microscopy
What is the management of vaginal candidiasis ?
Over the counter - canesten duo
Antifungal cream inserted into the vagina with an applicator
Antifungal pessary - clotrimazole
Oral Antifungal tablets - fluconazole
What is chlamydia trachomatis ?
A gram negative bacteria - intracellular organism meaning it enter and replicates within cells before rupturing the cell and spreading to others
What is the most common STI in the UK ?
Chlamydia
What can charcoal swabs confirm the diagnosis of ?
Bacterial vaginosis
Candidiasis
Gonorrhoea
Trichomonas vaginalis
What test is used to confirm chlamydia or gonorrhoea ?
NAAT to directly check for DNA or RNA of the organism
How does chlamydia present ?
Mostly asymptomatic
Abnormal vaginal discharge
Pelvic pain
Abnormal vaginal bleeding
Painful sex
Painful urination
What examination findings indicate chlamydia ?
Pelvic or abdominal tenderness
Cervical motion tenderness
Inflamed cervix
Purulent discharge
What is the treatment for chlamydia ?
Doxycycline 100mg twice a day for 7 days
What is doxycycline contraindicated in ?
Pregnancy and breastfeeding
What are the complications of chlamydia ?
Pelvic inflammatory disease
Chronic pelvic pain
Infertility
Ectopic pregnancy
Epididymo-orchitis
Conjunctivitis
What are the complications of chlamydia in pregnancy ?
Preterm delivery
Premature rupture of membranes
Low birth weight
Postpartum Endometritis
Neonatal infection
How does chlamydial conjuctivitis occur ?
As a result of sexual activity where genital fluid comes into contact with the eye.
Through hand to eye contact
How does chlamydial conjuctivitis present ?
Chronic erythema
Irritation
Discharge lasting more than 2 weeks
Unilateral
What is neisseria gonorrhoea ?
Gram negative diplococcus bacteria
It infects mucous membranes with a columnar epithelium and spreads via contact with mucous secretions from infected areas.
STI
How does gonorrhoea present ?
Odourless purulent discharge possibly green or yellow
Dysuria
Pelvic pain
How is gonorrhoea investigated ?
NAAT using a endocervical swab
What is the management of gonorrhoea ?
If sensitivities are not known - single dose of IM ceftriaxone 1g
If sensitivities are known - single dose of oral ciprofloxacin 500mg
What are some complications of gonorrhoea ?
Pelvic inflammatory disease
Chronic pelvic pain
Infertility
Conjuctivitis
Urethral strictures
Disseminated gonococcal infection
Skin lesions
Fitz-Hugh Curtis syndrome
Septic arthritis
What is disseminated gonococcal infection ?
A complication of untreated gonococcal infection where the bacteria spreads to the skin and joints
What is disseminated gonococcal infection ?
A complication of untreated gonococcal infection where the bacteria spreads to the skin and joints.
What is mycoplasma genitalium ?
A bacteria that causes non-gonococccal urethritis.
STI
What can a mycoplasma genitalium infection lead to ?
Urethritis
Epididymitis
Cervicitis
Endometritis
Pelvic inflammatory disease
Reactive arthritis
Preterm delivery in pregnancy
Tubal infertility
What are some investigations for mycoplasma genitalium ?
NAAT - vaginal swabs
What is the management of mycoplasma genitalium ?
Doxycycline 100mg twice daily for 7 days
Azithromycin 1g stat then 500mg once a day for 2 days
What is the treatment of mycoplasma genitalium in pregnancy ?
Azithromycin only as doxycycline is contraindicated in pregnancy
What is pelvic inflammatory disease ?
Inflammation and infection of the organs of the pelvis caused by infection spreading up through the cervix.
What is salpingitis ?
Inflammation of the Fallopian tubes
What is oophoritis ?
Inflammation of the ovaries
What is Parametritis ?
Inflammation of the parametrium which is the connective tissue around the uterus
What is peritonitis ?
Inflammation of the peritoneal membrane
What pathogens cause pelvic inflammatory disease ?
STI’s :
Neisseria gonorrhoea ( more severe )
Chlamydia trachomatis
Mycoplasma genitalium
Non-STI :
Gardnerella vaginalis
E.Coli
What are some risk factors for pelvic inflammatory disease ?
Not using contraception
Multiple sexual partners
Younger age
Existing STI
Previous pelvic inflammatory disease
Intrauterine device
How does pelvic inflammatory disease present ?
Pelvic or lower abdominal pain
Abnormal vaginal discharge
Abnormal bleeding
Pain during sex
Fever
Dysuria
What are the examination findings for pelvic inflammatory disease ?
Pelvic tenderness
Cervical motion tenderness
Inflamed cervix
Purulent discharge
What investigations should be performed when suspecting pelvic inflammatory disease ?
NAAT swabs for gonorrhoea and chlamydia
HIV test
Syphilis test
High vaginal swab - bacterial vaginosis, candidiasis and trichomoniasis
Pregnancy test
What is the management of pelvic inflammatory disease ?
A single dose of IM ceftriaxone 1g
Doxycycline 100mg twice daily for 14 days
Metronidazole 400mg twice daily for 14 days
What are the complications of pelvic inflammatory disease ?
Sepsis
Abscess
Infertility
Chronic pelvic pain
Ectopic pregnancy
Fitz-Hugh-Curtis syndrome
What is Fitz-Hugh-Curtis syndrome ?
A complication of pelvis inflammatory disease and is caused by inflammation and infection of the liver capsule leading to adhesions between the liver and peritoneum.
How does fitz-Hugh-Curtis syndrome present ?
RUQ pain - referred to right shoulder tip if there is diaphragmatic irritation.
How is Fitz-Hugh-Curtis syndrome managed ?
Laparoscopy
Adhesiolysis - treat the adhesions
What is trichomonas vaginalis ?
A type of parasite that spreads through sexual intercourse.
It is classed as a protozoa - single celled organism with flagella.
What can trichomonas increase the risk of ?
Contracting HIV
Bacterial vaginosis
Cervical cancer
PID
Pregnancy related complications
How does trichomoniasis present ?
Asymptomatic
Vaginal discharge - frothy, yellow/green
Itching
Dysuria
Dyspareunia
Balanitis
How does trichomoniasis look on examination ?
Strawberry cervix - tiny haemorrhages
How is a diagnosis of trichomoniasis made ?
Charcoal swab with microscopy - posterior fornix swab
Urethral or first catch urine - men
What is the management of trichomoniasis ?
Referral to GUM
Treatment with metronidazole
Where does herpes remain latent in the body ?
Trigeminal nerve ganglion for cold sores
Sacral nerve ganglia for genital herpes
What are some signs and symptoms of genital herpes ?
Ulcers or blistering lesions
Neuropathic type pain - tingling, burning
Flu-like symptoms
Dysuria
Inguinal lymphadenopathy
How is a diagnosis of genital herpes made ?
Clinical
Viral PCR swab from a lesion
What is the management of genital herpes ?
GUM referral
Aciclovir
Paracetamol
Topical lidocaine
Oral fluids
Avoid intercourse
What is the main issue of genital herpes in pregnancy ?
Neonatal herpes simplex infection
What is the management of genital herpes in pregnancy ?
Aciclovir followed by prophylactic aciclovir starting from 36 weeks onwards
C section recommended
What is AIDS ?
AIDS occurs when HIV is not treated. The disease progresses and then the person becomes Immunocompromised leading to opportunistic infections and AIDS-defining illnesses
What is HIV ?
An RNA retrovirus which enters and destroys CD4 t helper cells of the immune system.
How does HIV present ?
An initial seroconversion flu-like illness occurs within a few weeks of infection. Then asymptomatic until the condition has progressed to immunodeficiency. This may occur years after initial infection.
How is HIV transmitted ?
Unprotected anal, vaginal or oral sexual activity
Mother to child - vertical
Mucous membrane, blood or open wound exposed to infected fluids
What is an AIDS defining illness ?
Illnesses associated with end stage HIV infection. These occur where the CD4 count has dropped to a level that allows for unusual opportunistic infections and malignancies to appear.
What are some AIDS defining illnesses ?
Kaposi’s sarcoma
Pneumocytitis jiroveci pneumonia
Cytomegalovirus infection
Candidiasis - oesophageal or bronchial
Lymphomas
TB
What investigations are performed when suspecting HIV ?
Antibodies to HIV and the p24 antigen
What is used to monitor HIV ?
Testing the CD4 count in the blood
HIV RNA indicated the viral load
What is the management of HIV ?
Specialist HIV, infectious disease or GUM centres
Antiretroviral therapy medications ( 2 NRTI’s like tenofovir + emtricitabine and a third agent like bictagravir )
What should be given as prophylactic treatment in HIV patients with a CD4 count below 200 ?
Prophylactic co-trimoxazole to protect against pneumocystis jiroveci pneumonia
What prophylaxis is given to the baby after delivery in a mother with a HIV count of under 50 copies ?
Given zidovudine for 2-4 weeks
What prophylaxis is given to a high risk baby after delivery in a mother with HIV ?
Zidovudine, lamivudine and nevirapine for 4 weeks
Is breastfeeding safe in HIV ?
No
When should post-exposure prophylaxis be started to reduce the risk of transmission of HIV ?
Less than 72 hours
What is medications are used as post-exposure prophylaxis in HIV ?
Combination of ART therapy
Emtricitabine / tenofovir and raltegravir for 28 dyas
What is the medication of choice for pre-exposure prophylaxis of HIV ?
Emtricitabine / tenofovir
What is syphilis caused by ?
Is caused by the bacteria treponema pallidum - it is a spirochete a spiral shaped bacteria.
STI
How is syphilis transmitted ?
Oral, vaginal or anal sex
Vertical transmission
IV drug use
Blood transfusions
What is primary syphilis ?
Involves a painless ulcer at the original site of infection
What is secondary syphilis ?
Involves systemic symptoms particularly of the skin and mucous membranes particularly of the skin and mucous membranes. These symptoms can resolve after 3-12 weeks then the patient enters the latent stage.
What is latent syphilis ?
Occurs after the secondary stage of syphilis where symptoms disappear and the patient becomes asymptomatic despite still being infected.
What is tertiary syphilis ?
Can occur many years after the initial infection and affect many organs of the body.
What is Neurosyphilis ?
Occurs if the infection involves the CNS presenting with neurological symptoms
How does primary syphilis present ?
A painless genital ulcer that tends to resolve over 3-8 weeks
Local lymphadenopathy
How does secondary syphilis present ?
Maculopapular rash
Condylomata lata
Low grade fever
Lymphadenopathy
Alopecia
Oral lesions
How does tertiary syphilis present ?
Gummatous lesions
Aortic aneurysms
Neurosyphilis
How does Neurosyphilis present ?
Headache
Altered behaviour
Dementia
Tabes dorsalis - demyelination affecting the spinal cord posterior columns
Ocular syphilis
Paralysis
Sensory impairment
What is an Argyll-Robertson pupil ??
It is a constricted pupil that accommodates when focusing on a near object but does not react to light.
What is used as a screening test for syphilis ?
Antibody testing to the T pallidum bacteria
What tests are used to confirm the presence of t.pallidum ?
Dark field microscopy
Polymerase cain reaction ( PCR )
What is the management of syphilis ?
GUM referral
Single deep IM benzathine benzylpenicillin
Contact tracing
