Genitourinary Medicine (GUM) 1 Flashcards
State some common causes of vaginal discharge
Common
- Physiological
- Candida
- Trichomonas vaginalis
- Bacterial vaginosis
Less common
- Gonorrhoea
- Chlamydia
- Ectropion
- Foreign body
How could you differentiate between vaginal discharge due to candida, trichomonas vaginalis & bacterial vaginosis based on features of discharge
When pts attend a GUM clinic for STI screening, what are they tested for as a minimum?
- Chlamydia
- Gonorrhoea
- Syphilis (blood test)
- HIV (blood test)
There are two types of swabs involved in sexual health screening: charcoal swabs & nucleic acid amplification test (NAAT) swabs. For charcoal swabs, discuss:
- What they do/allow
- Transport medium
- What type of swabbing charcoal swabs can be used for e.g. vulvovaginal, urethral etc…
- What infections can be confirmed via charcoal swabs
- Charcoal swabs can be used for microscopy, culture & sensitivities
- Transport medium= Amies transport medium
- Charcoal swabs can be used for:
- Endocervical swabs
- High vaginal swabs
- Urethral swabs
- Can confirm infection with:
- Bacterial vaginosis
- Candidiasis
- Gonorrhoea (specifically endocervical swabs)
- Trichomonas vaginalis (particularly swab from posterior fornix)
- Other bacteria e.g. GBS
There are two types of swabs involved in sexual health screening: charcoal swabs & nucleic acid amplification test (NAAT) swabs. For NAAT swabs, discuss:
- What they do/allow
- What infections can be confirmed via charcoal swabs
- What type of swabbing charcoal swabs can be used for e.g. vulvovaginal, urethral etc…
- Check for DNA or RNA of organism
- Test for chlamydia & gonorrhoea (NOTE: if NAAT +ve for gonorrhoea also need to do charcoal swab for M, C & S)
- Type of swabbing (note: it will say on NAAT packet what type of swabbing should be used):
-
Women:
- Endocervical (1st preference)
- Vulvovaginal (2nd preference)
- First catch urine (3rd preference)
- Rectal (anal)
- Pharyngeal (oral)
-
Men:
- First catch urine
- Urethral swab
- Rectal
- Pharyngeal
-
Women:
For Neisseria gonorrhoea state:
- Gram stain
- Shape
- What mucous membranes it infections
- How it spreads
- Gram -ve
- Diplococcus
- Mucous membranes with columnar epithelium e.g. endocervix, urethra, rectum, conjunctiva & pharynx
- Spread via mucous secretions from infected area
There is a high level of abx resistance to gonorrhoea; true or false?
True
Describe presentation of Neisseria gonorrhoea; include both male & female symptoms
Female
- Odourless discharge
- Discharge may be green or yellow
- Dysuria
- Pelvic pain
Male
- Odourless discharge
- Discharge may be green or yellow
- Dysuria
- Testicular pain and/or swelling (epididymo-orchitis)
May have:
- Rectal infection causing discomfort & discharge (often asymptomatic)
- Pharyngeal infection causing sore throat (often asymptomatic)
- Conjunctivititis
Is gonorrhoea often symptomatic; discuss for both mena & women
- Men: 90% symptomatic
- Women: 50% symptomatic
*Gonorrhoea more likely to be symptomatic than chlamydia
All pts with suspected gonorrhoea should be referred to GUM clinic for diagnosis and treatment. Discuss how gonorrhoea is diagnosed
*If pt won’t go to GUM clinic or unable to access can do in GP
Diagnose via NAAT testing; how testing is done depends on whether symptomatic or not:
Women
- Asymptomatic: woman take own vulvovaginal swab
- Symptomatic: endocervical swab during speculum examination
Men
- Asymptomatic: first catch urine
- Symptomatic: swab of urethral discharge
If applicable may need rectal and/or pharyngeal swabs.
If NAAT is positive for gonorrhoea may need further endocervical charcoal swab (women) or urethral charcoal swabs (men) to check abx sensitivities.
- If applicable, should have rectal swabs and pharyngeal swabs for NA
Why do we do charcoal swabs aswell as NAATs?
NAATS only test if infection is present or not by looking for gonococcal RNA or DNA; do not tell us about sensitivities and resistance. This info is required to guide treatment
What would you see on microscopy of urethral swab of someone wit gonorrhoea?
Gram -ve intracellular diplococci in polymorphonuclear leucocytes
Discuss the pharmacological management of gonorrhoea
- Sensitivities unknown= single dose of IM ceftriaxone 1g
- Sensitives known= single dose oral ciprofloxacin 500mg (only use if sensitivities known as there is increasing resistance to ciprofloxacin)
- If ceftriaxone is refused (e.g. needle-phobic) then oral cefixime 400mg (single dose) + oral azithromycin 2g (single dose) should be used
AND TEST CONTACTS!
*NOTE: regimes may vary dependent on local guidelines and complications
All pts treated for gonorrhoea should have a follow up “test of cure” due to high abx resistance. Tests can be cultures, NAAT for DNA and NAAT for RNA. When can you do each?
If asymptomatic do NAAT, if symptomatic do cultures. BASHH recommends test of cure at least:
- 72hrs post treatment if using a culture as test of cure
- RNA NAAT 7 days post treatment
- DNA NAAT 14 days post treatment
*Geeky medics say usually do NAAT 14 days after treatment
Discuss the conservative management of gonorrhoea
- Test contacts
- Test for (and treat) any other infections
- Abstain from sex for 7 days following treatment of all partners to reduce risk reinfection (so 7 days after IM injection)
- Advice about reducing infection risk in future
- Consider safeguarding issues & sexual abuse in children & young people
State some potential complications of gonorrhoea
- PID
- Infertility
- Prostatitis
- Conjunctivitis
- Urethral strictures
- Fitz-Hugh Curtis syndrome
- Septic arthritis
- Gonococcal conjunctivities in neonate (ophthalmia neonatorum)
What is a disseminated gonococcal infection?
GDI= complication untreated gonoccoal infection where bacteria spreads to skin & joints causing:
- Skin lesions
- Polyarthralgia
- Migratory polyarthritis
- Tenosynovitis
- Systemic symptoms e.g. fever, fatigue
For Chlamydia trachomatis, state:
- Gram stain
- Shape
- Intra- or extra-cellular
- Gram -ve
- Rod
- Intra-cellular
What is the most common STI in the UK?
Chlamydia
Is chlamydia often symptomatic; discuss for men & women
- Men: 50% symptomatic
- Women: 25% symptomatic
Majority of women with chlamydia are asymptomatic; if they do get symptoms, state some symptoms they can experience
- Vaginal discharge
- Pelvic pain
- Abnormal vaginal bleeding
- Dyspareunia
- Dysuria
50% of men with chlamydia are symptomatic; state some symptoms they may present with
- Urethral discharge
- Urethral discomfort
- Dysuria
- Epididymo-orchitis
What may you find on examination of woman with chlamydia?
- Pelvic or abdominal tenderness
- Cervical motion tenderness
- Cervicitis
- Purulent discharge
All pts with suspected chlamydia should be referred to GUM clinic for diagnosis and treatment. Discuss how chlamydia is diagnosed
Diagnose via NAAT testing; how testing is done depends on whether symptomatic or not:
Women
- Asymptomatic: woman take own vulvovaginal swab
- Symptomatic: endocervical swab during speculum examination
Men
- Asymptomatic: first catch urine
- Symptomatic: swab of urethral discharge
If applicable may have pharyngeal and/or rectal swabs.
What might you find on microscopy & gram stain of urethral discharge in chlamydia?
Gram-ve rods covering epithelial cells
OR might see neutrophils but no organisms
Discuss the conservative management of chlamydia
- Abstain from sex for the duration of treatment (seven days)- for 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
Discuss the pharmacological management of chlamydia
- Doxycycline 100mg BD for 7 days
- **NOTE:* The guidelines previously recommended a single dose of azithromycin 1g orally followed by 500mg OD for 2/7 as an alternative. This recommendation has been removed due to Mycoplasma genitalium resistance to azithromycin, and azithromycin being less effective for rectal chlamydia infection.
State some potential pregnancy-related complications of chlamydia
- Preterm delivery
- Premature rupture of membranes
- Low birth weight
- Postpartum endometritis
- Neonatal infection (conjunctivitis and pneumonia)
Doxycycline is contraindicated in pregnancy; state some alternatives
- Azithromycin 1g stat, then 500mg for 2 days
- … and others e.g. erythromycin, amoxicillin
Is a test of cure recommended in chlamydia?
- No not routinely; only in cases of rectal chlamydia, pregnancy and if symptoms persist
- BASH recommend repeat testing at 3/12 for those under 25yrs
State some potential complications of chlamydia
- PID
- Infertility
- Ectopic pregnancy
- Reactive arthritis
- Lymphogranuloma venereum
What is lymphogranuloma venereum (LGV)?
Who does it most commonly occur in?
- LGV is caused by stain of chlamydia that attacks lymphoid tissue around site of infection with chlamydia
- Presents as a triad of inguinal lymphadenopathy, proctocolitis and fever.
- Most common in MSM (men who have sex with men)
There are three stages of LGV (lymphogranuloma venereum); describe presentation of each
- Primary stage: painless ulcer typically on penis in men, vaginal wall in women or rectum after anal sex
- Secondary stage: lymphadenitis causing swelling and pain in lymph nodes (typically inguinal & femoral)
- Tertiary stage: proctocolitis causing anal pain, change in bowel habit, tenesmus & discharge
Discuss the management of LGV (lymphogranuloma venereum)
Doxycycline 100mg BD for 21 days
For chlamydial conjunctivitis, discuss:
- Presentation
- Who it most commonly occurs in
- Chronic erythema, irritation, discharge lasting > 2 weeks. Often unilateral.
- Young adults (can affect neonates if mother has chlamydia but gonococcal conjunctivitis is more crucial differential to rule out in neonatal conjunctivitis)
Bacterial vaginosis is an overgrowth of anaerobic bacteria of vagina; remind yourself of the most common bacteria that can cause it
- Gardnerella vaginalis (most common)
- Mycoplasma hominis
- Prevotella species
*Remember BV can occur alongside other infections e.g. chlamydia, gonorrhoea etc…
Discuss the pathophysiology of bacterial vaginosis
- Loss of lactobacilli
- They usually produce lactic acid to keep pH <4.5
- Acidic environment helps prevent other bacteria from overgrowing
- Hence loss of lactobacilli increases pH allowing other bacteria to grow
State some risk factors for bacterial vaginosis
- Excessive vagina cleaning (douching, use of cleaning products)
- Recent abx
- Smoking
- IUD
- Multiple sexual partners (BUT NOT SEXUALLY TRANSMITTED)
50% of women with BV are asymptomatic; if they do get symptoms describe the presentation of bacterial vaginosis
- Fishy smelling watery grey or white vaginal discharge
- *NOTE: itching, irritation and pain not usually associated so suggest alternative cause or co-occurring infection*
Discuss how BV is diagnosed
- Vaginal pH (using swab & pH paper. Normal vaginal pH is 3.5-4.5)
- Vaginal swab for microscopy (high vaginal swab taken during speculum examination or self-taken low vaginal swab)
What would you see on microscopy if woman has BV?
Clue cells (epithelial cells that have bacteria stuck inside them)
Discuss the management of bacterial vaginosis
Asymptomatic BV doesn’t usually require treatment.
Conservative
- Avoid douching
- Clean with gentle soaps e.g. femfresh, baby wash
- Assess and test for STIs if appropriate
Pharmacological
- Metronidazole (PO or vaginal gel)
- 400–500 mg PO twice daily for 5–7 day
- Clindamycin is alternative
What must you advise pts when prescribing metronidazole?
Avoid alcohol for duration of treatment as it can cause disulfiram-like reaction with N&V, flushing and sometimes severe symptoms of shock & angioedema
State some potential complications of BV
- Increased risk of catching STIs
- Pregnancy complications:
- Miscarriage
- Preterm delivery
- Low birth weight
- Premature rupture of membranes
- Chorioamnionitis
- Post-partum endometritis
What is vaginal candidiasis?
Vaginal infection with yeast of candida family- most commonly Candida albicans
Candida can colonise in vagina without causing symptoms then progresses to infection when right environment occurs e.g. pregnancy, abx
State some risk factors for candidiasis
- Increased oestrogen (this is why can occur in pregnancy as oestrogen is higher)
- Poorly controlled diabetes
- Immunosuppression
- Broad spec abx
Describe presentation of vaginal candidiasis
Typical presentation:
- Thick white discharge “cottage cheese”
- Not smelly
- Vulval or vaginal itching, irritation, discomfort
More severe infections can lead to:
- Erythema
- Fissures
- Oedema
- Pain during sex (dyspareunia)
- Dysuria
- Excoriation
Vaginal candidiasis is mainly clinical diagnosis (hence investigations not required); however, what investigations may be done?
-
Test vaginal pH using swab & pH paper
- BV & trichomonas= >4.5
- Vaginal candidiasis= <4.5
- Charcoal swab with microscopy
Discuss the management of vaginal candidiasis
- Correct modifiable conditions (such as uncontrolled diabetes mellitus), where possible.
-
Antifungal medications:
- Cream e.g. clotrimazole inserted into vagina using applicator (single dose)
- Pessary e.g. clotrimazole (single 500mg or three 200mg doses at night)
- Tablet e.g. fluconazole (150mg single dose)
Canesten Duo is an OTC treatment which contains fluconazole tablet and clotrimazole cream.
NICE CKS say offer either oral or vaginal pessary and consider addition of cream if there are vulval symptoms also.
- ***NOTE: immunocompromised or diabetic pts may require longer treatment e.g. 10 days*
- ***NOTE: if pregnant can only use local treatments e.g. creams or pepsaries*
- ***NOTE: if pts have recurrent infection (e.g. ≥ 4 in a yr) can be treated with induction & maintenance regime over 6 months using oral or vaginal antifungal medications. E.g. PO fluconazole every 3 days for 3 doses, then PO fluconazole weekly for 6 months*
What must you warn pts when giving them antifungal creams and pessaries?
Can damage latex condoms & prevent spermicides working so use alternative contraception for 5 days after use
For trichomoniasis, discuss:
- What is is
- Presentation
- Appearance of cervix
- Infection with trichomonas vaginalis; a protzoan with flagella
- Presentation (up to 50% asymptomatic):
- Vaginal discharge- frothy yellow green, +/- fishy smell
- Itching
- Dysuria
- Dyspareunia
- Balanitis
- Strawberry cervix (also called colpitis macularis) **Inflamed cervix with tiny haemorrhages on surface
How is trichomoniasis diagnosed?
-
Diagnosis is with charcoal swab with microscopy
- Women: high vaginal swab by clinician is best (low vaginal swab as alternative)
- Men: urethral swab or first catch urine
- Can also test vaginal pH (will be >4.5, similar to BV)
- Strawberry cervix on examination
Pts with trichomoniasis should be referred to GUM; what medication will they be given?
Metronidazole (200mg, TDS, 7 days)
Trichomonas can increase risk of other conditions; state some of these
- Contracting HIV by damaging the vaginal mucosa
- Bacterial vaginosis
- Cervical cancer
- Pelvic inflammatory disease
- Pregnancy-related complications such as preterm delivery.
What is the difference between:
- Endocervical swab
- High vaginal swab
- Vulvovaginal swab
- Endocervical: gently insert swab into external cervical os and rotate for 10-15 seconds
- High vaginal: rotate swab in posterior fornix for 10-15 seconds
-
Vulvovaginal:
- If pt taking themselves, advise to lie or stand like putting tampon in, point tip toward lower back, insert no more than 2 inches, gently rotate
- If doing during speculum, rotate in posterior fornix for 10-15 seconds, as you remove swab rotate over vaginal walls
