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YEAR 4-GYNAECOLOGY > Genitourinary Medicine > Flashcards

Genitourinary Medicine Flashcards

1
Q

What is bacterial vaginosis?

A

An infection in the vagina caused by a disruption in the normal vaginal flora.

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2
Q

Is bacterial vaginosis a STI?

A

No, it isnt.

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3
Q

Explain the pathophysiology of bacterial vaginosis with reference to the normal vaginal flora?

A

Lactobacilli are the main component of the vaginal flora.

Lactobacilli produce lactic acid to keep the vaginal pH low/acidic.

This acidic enviroment prevents other bacteria from growing.

If the number/amount of lactobacilli reduces, then the vaginal pH rises.

This more alkaline environment allows anaerobic bacteria (E.g. Gardnerella vaginalis) to grow and develop.

Thus resulting in bacterial vaginosis

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4
Q

Can bacterial vaginosis co-exist alongside other infections e.g. Candidiasis or chlamydia?

A

Yes it can

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5
Q

Suggets 5 risk factors for developing bacterial vaginosis?

A
  1. Multiple sexual partners (although it is not sexually transmitted)
  2. Excessive vaginal cleaning (douching, use of cleaning products and vaginal washes)
  3. Recent antibiotics
  4. Smoking
  5. Copper coil
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6
Q

Explain how excessive vaginal cleaning can increase the risk of bacterial vaginosis?

A

-Excessive vaginal cleaning removes the normal vaginal flora (lactobacilli)

-This increases the pH of the vagina making it more alkali so anaerobic bacteria can grow.

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7
Q

Explain how antibiotics increase the risk of bacterial vaginosis?

A

-Antibiotics also kill off the ‘good’ bacteria such as lactobacilli, the normal vaginal flora.

-This allows the vaginal pH to rise.

This more alkaline environment allows anaerobic bacteria (E.g. Gardnerella vaginalis) to grow and develop.

Thus resulting in bacterial vaginosis

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8
Q

Explain how the copper coil increases the risk of bacterial vaginosis?

A

-The copper coil reduces the number of lactobacilli.
-This allows for the vaginal pH to increase and become more alkali.
-Anaerobic bacteria grow in this alkali enviroment and thus bacterial vaginosis develops.

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9
Q

Suggest 3 symptoms and 3 signs of bacterial vaginosis?

A

Symptoms:
1.Fishy-smelling discharge
2. Pain/ itching in the vagina
3.

Signs:
1.Grey or white discharge
2.

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10
Q

How is bacterial vaginosis investigated?

A
  1. History
  2. Speculum +/-
  3. Bimanual examination +/-
  4. A standard charcoal vaginal swab can be taken for microscopy
  5. pH paper
  6. STI screen
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11
Q

What cells are seen on microscopy that are consistent with bacterial vaginosis?

A

Clue cells on microscopy mean bacterial vaginosis.

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12
Q

How is asymptomatic bacterial vaginosis managed?

A

It doesnt require any treatment

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13
Q

How is symptomatic bacterial vaginosis managed?

A

Antibitoics-Metronidazole
(Oral or vaginal gel)

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14
Q

Why is metronidazole good for treating bacterial vaginosis?

A

Because it targets anaerobic bacteria

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15
Q

Why is it important to advise patients to avoid alcohol for the duration of treatment when prescribed metronidazole?

A

Alcohol and metronidazole can cause a “disulfiram-like reaction”, with nausea and vomiting, flushing and sometimes severe symptoms of shock and angioedema.

This also applies to when using the vaginal gel

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16
Q

True or False.

Bacterial vaginosis can increase the risk of catching sexually transmitted infections such as Chalmydia and Gonorrohoea.

A

True

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17
Q

Bacterial vaginosis is associated with several complications in pregnant women.
Suggest 4.

A
  1. Miscarriage
  2. Preterm delivery
  3. Premature rupture of membranes
  4. Low birth weight
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18
Q

Vaginal candidiasis is commonly referred to as what?

A

Thrush

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19
Q

What is Vaginal candidiasis?

A

A vaginal infection with a yeast of the Candida family, most commonly Candida albicans.

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20
Q

Suggest 4 risk factors for vaginal candidasis.

A
  1. Increased oestrogen (higher in pregnancy, lower pre-puberty and post-menopause)
  2. Poorly controlled diabetes
  3. Immunosuppression (e.g. using corticosteroids)

4.Broad-spectrum antibiotics

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21
Q

Suggest 3 symptoms of vaginal candidasis?

A
  1. Thick, white discharge
  2. Vulval and vaginal itching, irritation or discomfort
  3. Discharge does not smell
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22
Q

How is vaginal candidasis investigated?

A
  1. History
  2. pH paper (pH below 4.5=candidasis)
  3. Charcoal vaginal swab & microscopy
  4. STI screen
  5. Speculum +/-
  6. Bimanual examination +/-
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23
Q

How is vaginal candidasis managed?

A

Antifungal medication:

1.Antifungal cream (i.e. clotrimazole) inserted into the vagina with an applicator

2.Antifungal pessary (i.e. clotrimazole)

3.Oral antifungal tablets (i.e. fluconazole)

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24
Q

What is Canesten Duo?

A

A standard over-the-counter treatment, it contains a single fluconazole tablet and clotrimazole cream to use externally for vulval symptoms.

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25
Q

What do you need to warn women about with reference to antifungal treatment and contraception.

A

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.

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26
Q

What is the most common STI?

A

Chlamydia

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27
Q

What is the proper name for Chlamydia?

A

Chlamydia trachomatis

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28
Q

What is the gram stain of Chlamydia trachomatis?

A

Gram negative intracellular bacteria

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29
Q

Suggets 3 risk factors for chlamydia?

A

1.Young
2.Sexually active
3.Increased number of sexual partners
4.Unprotected sex

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30
Q

A large number of people with chlamydia are asymptomatic.

If you are asymptomatic can you still pass on chlamydia?

A

Yes.

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31
Q

Suggest 5 symptoms of chlamydia in women?

A

1.Abnormal vaginal discharge
2.Pelvic pain
3.Abnormal vaginal bleeding (intermenstrual or postcoital)
4.Painful sex (dyspareunia)
5.Painful urination (dysuria)

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32
Q

Suggest 4 symptoms of chlamydia in men?

A

1.Urethral discharge or discomfort
2.Painful urination (dysuria)
3.Fever
4.Testicular tenderness

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33
Q

How is chlamydia investigated?

A
  1. History
  2. Abdominal examination
  3. Genital examination
  4. Speculum (female)
  5. Nucleic acid amplification tests (NAAT)
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34
Q

In order to do nucleic acid amplification testing we need to do a swab or urine sample.
What swabs can we do?

A

Vulvovaginal swab (women)
Endocervical swab (women)
Urethral swab in men
Rectal swab (after anal sex)
Pharyngeal swab (after oral sex)

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35
Q

In order to do nucleic acid amplification testing we need to do a swab or urine sample.
What urine sample do we need?

A

First-catch urine sample (in women or men)

NB-The first part of a person’s urine stream, usually the first 10–20 milliliters

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36
Q

What is the treatment for chlamydia?

A

First-line for uncomplicated chlamydia infection is

Doxycycline 100mg twice a day for 7 days.

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37
Q

Doxycycline is contraindicated in pregnancy and breastfeeding.

What is the treatment for chlamydia for these patients?

A

Azithromycin 1g stat then 500mg once a day for 2 days
or

Erythromycin 500mg, four times day, for 7 days

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38
Q

What other management is recommended for managing chlamydia besides antibiotics.

A
  • Abstain from sex for seven days of treatment of all partners to reduce the risk of re-infection.
  • Refer all patients to genitourinary medicine (GUM) for contact tracing and notification of sexual partners
  • Test for and treat any other sexually transmitted infections
  • Provide advice about ways to prevent future infection
  • Consider safeguarding issues and sexual abuse in children and young people
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39
Q

Suggest 8 complications from infection with chlamydia?

A
  1. Pelvic inflammatory disease
  2. Chronic pelvic pain
  3. Infertility
  4. Ectopic pregnancy
  5. Epididymo-orchitis
  6. Conjunctivitis
  7. Lymphogranuloma venereum
  8. Reactive arthritis
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40
Q

Lymphogranuloma venereum is a complication of infection with chlamydia.

What is Lymphogranuloma venereum?

A

Lymphogranuloma venereum (LGV) is a condition affecting the lymphoid tissue around the site of infection with chlamydia

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41
Q

What is the treatment for Lymphogranuloma venereum?

A

Doxycycline 100mg twice daily for 21 days

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42
Q

What is the pathophysiology of Lymphogranuloma venereum?

A

The primary stage involves a painless ulcer (primary lesion). This typically occurs on the penis in men, vaginal wall in women or rectum after anal sex.

The secondary stage involves lymphadenitis. This is swelling, inflammation and pain in the lymph nodes infected with the bacteria. The inguinal or femoral lymph nodes may be affected.

The tertiary stage involves inflammation of the rectum (proctitis) and anus. Proctocolitis leads to anal pain, change in bowel habit, tenesmus and discharge. Tenesmus is a feeling of needing to empty the bowels, even after completing a bowel motion.

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43
Q

What is Chlamydial Conjunctivitis?

A

Chlamydia can infect the conjunctiva of the eye.
Conjunctival infection is usually as a result of sexual activity, when genital fluid comes in contact with the eye.

44
Q

Suggest 4 pregnancy related complications of chlamydia infection?

A

1.Low birth weight
2.Pre term delivery
3.Premature rupture of memebranes
4.Neonatal infection

45
Q

What is the proper term for gonorrhoeae?

A

Neisseria gonorrhoeae

46
Q

What is Neisseria gonorrhoeae?

A

A sexually transmitted infection

47
Q

What gram stain is Neisseria gonorrhoeae?

A

A gram-negative diplococcus bacteria.

48
Q

Suggest 4 risk fatcors for Gonorrhoea?

A
  1. Multiple sexual partners
  2. Sexually active
  3. Young
  4. Unprotected sex
  5. Having other STIs
49
Q

Gonorrhoea is likely to cause symptoms.
Suggest 3 symptoms women may present with?

A
  1. Odourless purulent discharge, possibly green or yellow
  2. Dysuria
  3. Pelvic pain
50
Q

Gonorrhoea is likely to cause symptoms.
Suggest 3 symptoms men may present with?

A
  1. Odourless purulent discharge, possibly green or yellow
  2. Dysuria
  3. Testicular pain or swelling (epididymo-orchitis)
51
Q

How is Gonorrhoea investigated?

A
  1. History
  2. Clinical examination e.g. abomindal, genitalia
  3. STI screen & swabs
  4. NAAT
52
Q

Why are both NAAT and charcoal swabs needed to diagnose gonorrhoea?

A

NAAT tests are used to check if a gonococcal infection is present or not by looking for gonococcal RNA or DNA.

NAAT tests do not provide any info about specific bacteria and their sensitivities and resistance.

A standard charcoal endocervical swab gives information on microscopy, culture and antibiotic sensitivities.

Both are therfore needed to confirm gonorrhoea infection with NAAT testing and to confirm which antibiotics should be used for treatment with charcoal swabs.

53
Q

How is gonorrhoea treated?

A

A single dose of intramuscular ceftriaxone 1g if the sensitivities are NOT known

A single dose of oral ciprofloxacin 500mg if the sensitivities ARE known

54
Q

How else should patients with gonorrhoea infection be managed?

A
  • Refer to GUM clinic
  • Abstain from sex for seven days of treatment of all partners to reduce the risk of re-infection
  • Test for and treat any other sexually transmitted infections
  • Provide advice about ways to prevent future infection
  • Consider safeguarding issues and sexual abuse in children and young people
55
Q

What is a ‘test of cure’
and for which infections is it needed.

A

A test of cure is a follow up NAAT to ensure the patient is clear of infection.

Follow up testing is needed for those with gonorrhoea and Mycoplasma genitalium but NOT chlamydia.

56
Q

Suggest 7 complications of gonorrhoea?

A
  1. Pelvic inflammatory disease
  2. Chronic pelvic pain
  3. Infertility
  4. Epididymo-orchitis (men)
  5. Prostatitis (men)
  6. Conjunctivitis
  7. Disseminated gonococcal infection
57
Q

What is Disseminated gonococcal infection (GDI)?

A

Disseminated gonococcal infection (GDI) is a complication of untreated gonococcal infection, where the bacteria spreads to the skin and joints.

58
Q

Suggest 4 symptoms of Disseminated gonococcal infection?

A

1.Polyarthralgia (joint aches and pains)
2.Skin lesions
3.Fever
4.Tenosynovitis (inflammation of tendon sheath)

59
Q

Gonococcal conjunctivitis in a neonate is a complication of gonorrhoea in pregnancy.

Explain its pathophysiology and consequences.

A

Gonococcal infection is contracted from the mother during birth.

Neonatal conjunctivitis is called ophthalmia neonatorum.

This is a medical emergency and is associated with sepsis, perforation of the eye and blindness.

60
Q

What is Mycoplasma genitalium?

A

It is a sexullay transmitted infection causes inflammation of the urethra.

61
Q

Most cases of Mycoplsma Genitalium do not cause symptoms.
Suggest 3 complications of MG.

A
  1. Urethritis
  2. Epididymitis
  3. Cervicitis
62
Q

How is Mycoplsma Genitalium investigated?

A
  1. History
  2. Clinical exmination ( abodminal, genitalia)
  3. NAAT (urine for men, vaginal swab for women)
  4. Screen for other STIs, co infection with chlamydia is common
63
Q

How is Mycoplsma Genitalium treated?

A

Doxycycline 100mg twice daily for 7 days
then
Azithromycin 1g stat then 500mg once a day for 2 days
(unless it is known to be resistant to macrolides)

64
Q

What is the proper term for Trichomonas?

A

Trichomonas vaginalis

65
Q

What is Trichomonas vaginalis?

A

A type of parasite ( a protazoa) spread through sexual intercourse.

66
Q

50% of cases of trichomoniasis are asymptomatic.

Suggest 4 symptoms of trichomoniasis?

A
  • Vaginal discharge
  • Itching
  • Dysuria (painful urination)
  • Dyspareunia (painful sex)
  • Balanitis (inflammation to the glans penis)
67
Q

What colour is the discharge associated with trichomoniasis?

A

Frothy and yellow-green

68
Q

How would you investiagte for trichomoniasis?

A

1.History
2.Clinical examination (abdominal exam, genital exam)
3.NAAT (endocervical or vulvovaginal swab -women) & (urethral swab or urine-men)
4.Charcoal Swab (high vaginal) for microscopy
5.STI screen

69
Q

How is trichomoniasis managed?

A
  • Referred to a genitourinary medicine (GUM) clinic
  • Advised to abstain from intercourse until treatment is completed
  • Advice given on contraception and STI protection.
  • Contact tracing
  • Antibiotics- Metronidazole.
70
Q

What is HSV?

A

Herpes Simplex Virus

71
Q

What are the 2 main strains of HSV?

A

HSV-1
and
HSV-2

72
Q

What is HSV-1 assoicated with?

A

HSV-1 is most associated with cold sores.
It is often contracted initially in childhood (before five years), remains dormant in the trigeminal nerve ganglion and reactivates as cold sores, particularly in times of stress

73
Q

What is HSV-2 associated with?

A

HSV-2 typically causes genital herpes and is mostly a sexually transmitted infection.

74
Q

The symptoms of an initial infection with genital herpes usually appear within two weeks.
Suggest 3 symptoms.

A
  • Ulcers or blistering lesions on the genitals
  • Neuropathic type pain
  • Fatigue
  • Headache
75
Q

How is genital herpes diagnosed?

A

1.History
2.Clinical examination (abdominal & gential)
3.Viral PCR swab (confirms causative organism)
4.STI screen

76
Q

How is genital herpes managed?

A
  • Referral to GUM clinic
  • Antiviral medication- Aciclovir
  • Wear loose clothing
  • Avoid intercourse during flare up/symptoms
  • Clean with warm salt water
  • Analgesia-paracetamol, ibuprofen
77
Q

What is neonatal herpes?

A

When a baby catches the herpes virus at birth.

78
Q

When is a C-section offered to women with genital herpes?

A

If the womens first episode of genital herpes is within 6 weeks of her due date.

79
Q

Medication can be given to mum to reduce the chance of baby getting neonatal herpes.

What medication is given at:
a) First episode before 28 weeks pregnancy
b) First epsiode at or after 28 weeks of pregnancy

A

A) First episode is before 28 weeks of pregnancy, you may be offered antiviral treatment at that time and again from 36 weeks of pregnancy until your baby is born

B) First episode is at or after 28 weeks of pregnancy, you will be advised to continue your treatment until your baby is born.

80
Q

What is HIV?

(Give 4 points)

A
  • Human immunodeficiency Virus
  • RNA retrovirus
  • The virus enters and destroys the CD4 T-helper cells of the immune system.
  • HIV-1 (most common) & HIV-2
81
Q

What is Acquired immunodeficiency syndrome (AIDS)?

A
  • When HIV is not treated, the disease progresse.
  • The person becomes immunocompromised.
  • Immunodeficiency leads to opportunistic infections and AIDS-defining illnesses.
82
Q

What affect does HIV have on CD4 T-helper cells?

A

It destroys them and reduces them.

83
Q

HIV is not transmitted through day-to-day activities, including kissing.

Suggets 3 ways it is transmitted.

A
  1. Unprotected anal, vaginal or oral sexual activity
  2. Vertical Transmission- Mother to child at any stage of pregnancy, birth or breastfeeding.
  3. Mucous membrane, blood or open wound exposure to infected blood or bodily fluids (e.g., sharing needles, needle-stick injuries or blood splashed in an eye)
84
Q

What are AIDS-defining illnesses?

A

Unusual opportunistic infections and malignancies which appear when the CD4 count drops to a level which allows this illnesses to occur which otherwise would not.

85
Q

Give 4 examples of AIDS defining illnesses?

A
  1. Kaposi’s sarcoma
  2. Pneumocystis jirovecii pneumonia (PCP)
  3. Cytomegalovirus infection
  4. Lymphomas
86
Q

Testing the CD4 count gives the number of CD4 cells in the blood. The lower the count, the higher the risk of opportunistic infection.

At what CD4 level is the patient at risk of opportunitistc infection?

A
  • 500-1200 cells/mm3 = normal range
  • Under 200 cells/mm3 = at high risk of opportunistic infections
87
Q

In relation to HIV.
What does U=U mean?

A

U=U
Undetectable = Untransmittable

If the viral load is undetectable (below a recordable range) than the individual is unable to transmit the virus.

88
Q

How is the viral load for HIV measured?

A

Testing for HIV RNA per ml of blood indicates the viral load.

89
Q

How is HIV managed?

A
  • Referral to GUM clinic, infectious disease specialist
  • Combination of antiretroviral therapy (ART) medications.
  • Yearly cervical smears (Increases risk of cervical cancer)
  • Vaccinations should be up to date (but Live vaccines (e.g., BCG and typhoid) are avoided.)
  • Increased risk of cardiovascular disease, so close monitoring of cardiovascular risk factors e.g. Blood pressure, cholesterol.
90
Q

There are several classes of antiretroviral therapy medications.

What is the usual starting regime for HIV?

A

The usual starting regime is:

  • Two Nucleoside reverse transcriptase inhibitors (NRTIs) (e.g., tenofovir and emtricitabine
  • Plus a third agent (e.g., bictegravir).
91
Q

Who is antiretroviral therapy therapy offered to?

A

ART is offered to everyone diagnosed with HIV, irrespective of viral load or CD4 count.

92
Q

What is the aim of antiretroviral therapy when treating HIV?

A

Treatment aims to achieve a normal CD4 count and undetectable viral load

93
Q

In pregnant women with HIV, the womens viral load determines the mode of delivery.

Explain what level of viral load would allow for 1)a vaginal birth, 2) considered c section, 3) recommended c section.

A
94
Q

Can women with HIV breastfeed?

A
  • HIV can be transmitted during breastfeeding.
  • The risk is reduced if the mother’s viral load is undetectable but not eliminated.
  • Therefore, the safest option is to avoid breastfeeding.
  • However, if the mother is adamant and the viral load is undetectable, sometimes it is attempted with close monitoring by the HIV team.
95
Q

What is PEP?

A
  • Post-exposure prophylaxis (PEP)
  • This is medication that you can take to reduce the risk of HIV infecting your body AFTER you may have been exposed.
  • PEP involves a combination of ART therapy
96
Q

What is the current PEP regime?

A

The current regime is emtricitabine/tenofovir (Truvada) and raltegravir for 28 days.

97
Q

What is Pre-exposure prophylaxis (PrEP)?

A

ART therapy which can be taken daily or on demand (if only anal sex) prior to intercourse to protect from HIV transmission.

98
Q

Syphilis is caused by what bacteria?

A

Treponema pallidum

99
Q

Syphilis is mainly a sexually transmitted infection.

Suggest 3 ways it can be transmitted.

A
  1. Oral, vaginal and anal sex with infected area
  2. Vertical transmission from mother to baby during pregnancy
  3. IV drug use
100
Q

Syphilis has 3 stages.
What are they?

A

Primary-a painless ulcer called a chancre at the original site of infection
Secondary-systemic symptoms, particularly of the skin and mucous membranes.
Tertiary-occur many years after the initial infection and affect many organs of the body, particularly with the development of gummas and cardiovascular and neurological complications.

101
Q

What is neurosyphilis?

A

When the infection involves the central nervous system, presenting with neurological symptoms.

102
Q

In relation to syphilis what is a Chancre?

A

A painless genital ulcer

103
Q

In relation to Syphilis, what is a Gumma?

A

Gummas are sfot granulomatous lesions that can affect the skin, organs and bones as a result of tertiary syphilis.

104
Q

How is syphilis diagnosed?

A
  • History
  • Clinical examination (abdomen and external genitalia)
  • STI screen
  • Antibody testing for antibodies to the T. pallidum bacteria (screening)
  • Samples from sites of infection can be tested to confirm the presence of T. pallidum with Dark field microscopy
    and Polymerase chain reaction (PCR)
105
Q

How is syphillis managed?

A
  • Gum referral
  • Full screening for other STIs
  • Advice about avoiding sexual activity until treated
  • Contact tracing
  • Prevention of future infections
  • Treatment-IM dose of benzathine benzylpenicillin

YEAR 4-GYNAECOLOGY (7 decks)

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