Genitourinary Medicine (GUM) Flashcards
What are the causes for vaginal discharge?
Physiological
Candida
Trichimonas vaginalis Bacterial vaginosis Gonorrhoea Chlamydia Ectropion Foreign body Cervical cancer
What type of discharge is seen in candida infections?
Curd like
Non-offensive
White
What type of discharge is seen in trichimonas?
Yellow, frothy, offensive
Strawberry cervix
What type of discharge is seen in bacterial vaginosis?
Thin
White/grey
Fishy
What type of discharge is seen in gonorrhoea?
Thin
Watery
Yellow
What type of discharge is seen in chlamydia?
Copious amounts of purulent yellow discharge
What type of discharge is seen in ectropion?
Increased amounts of normal discharge
What type of discharge may be seen with foreign bodies?
Foul smelling
+ blood
What type of discharge is seen in cervical cancer?
Persistent discharge which doesn’t respond to treatment
What are the main risk factors for STIs?
Age <25
Sexual partner positive
Recent change in sexual partner
Co-infection with another STI
Non-barrier contraception
How are STIs managed in general?
Abstain from sex until both treated
Offer screening for other STI’s
Encourage talking to previous partners
Talk about safe sex in future
What is bacterial vaginosis?
Not an STI
Normal vaginal flora disturbed leading to reduced lactobacilli
Other micro-organisms grow - Gardnerella Vaginalis, anaerobes and mycoplasmas
Why do you have a raised pH in bacterial vaginosis?
Lactobacilli produce hydrogen peroxide to maintain acidity
Reduced lactobacilli
What are the main risk factors for bacterial vaginosis?
Multiple sexual partners
Receptive oral sex
IUD Concurrent STI Vaginal douching or soaps Recent Abx use Smoking Copper coil
How does bacterial vaginosis present?
Offensive fishy discharge
Thin white/grey discharge
Not normally sore or itchy
Speculum examination can be performed to confirm with high vaginal swab
How is bacterial vaginosis diagnosed?
High vaginal swab for microscopy:
- Clue cells (vaginal epithelia studded with coccobacilli)
- Reduced lactobacilli
- Absence of pus cells
Vaginal pH >4.5 - 3.5-4.5
Positive whiff test - add alkali to discharge and strong fishy odour smelt
How is bacterial vaginosis managed?
Asymptomatic - dont need treating
Oral metronidazole - can be vaginal
Clindamycin second line
Advice regarding risk factors
Consider IUD removal
Assess the risk of chlamydia and gonorrhoea with swabs
What must be avoided during treatment with metronidazole?
Alcohol
Alcohol and metronidazole can cause a disulfarim like reaction with n+v, flushing and sometimes symptoms of shock or angioedema.
What is the recurrence rate of bacterial vaginosis and how is it managed?
> 50% in 3 months
Oral metronidazole
What is important to know about bacterial vaginosis in pregnancy?
Symptomatic BV can increase risks of premature birth, miscarriage and chorioamnionitis
Treat with metronidazole
What are the complications of bacterial vaginosis?
Can increase the risk of catching STIs, including chlamydia, gonorrhoea, HIV.
Complications in pregnant women Miscarriage Preterm delivery Preterm rupture of membranes Chorioamnionitis Low birth weight Postpartum endometritis
What is candidiasis?
Not an STI
Also called thrush
Overgrown of Candida albicans
What is the peak incidence of candidiasis?
20-40yo
What are the main risk factors for thrush?
Pregnancy
Diabetes
Recent abx use
Corticosteroid use
Immunocompromised
How does thrush present?
Vulval itching
White curd like discharge - non-offensive
Dysuria
On examination:
- erythematous vulva
- satellite lesions - red pustular lesions with superficial white pseudomembranous plaques that can be scraped off
Can have fissures, dyspareunia, excoriation, oedema
What are the investigations for thrush?
Often treatment is started empirically
Test vaginal pH using swab and pH paper to differentiate between BV and trichomonas and candidiasis pH <4.5
Charcoal swab with microscopy can confirm diagnosis
What are the management options for thrush?
Antifungal medications
Cream - clotrimazole inserted into the vagina with an applicator
Antifungal pessary - clotrimazole
Antifungal tablets - fluconazole
For initial uncomplicated cases options are:
Single dose of cream at night
Single dose of pessary at night
Three doses of pessaries over three nights
Single dose of oral fluconazole
Canesten Duo available over the counter containing single fluconazole tablet and clotrimazole cream
Antifungal creams and pessaries can damage latex condoms
Alternative contraception needed 5 days after use
What should you do if thrush management fails?
Measure vaginal pH (<4.5 in thrush) and swab for microscopy
Address risk factors
Treat for longer period
Why is thrush more likely in pregnancy? How is it managed?
Oestrogen levels - increased glycogen create favourable environment. Promote growth and sticks it to walls
Treat with intravaginal not oral meds
What organism causes chlamydia and how long is the incubation period?
Chlamydia trachomatis
Intracellular gram -ve cocci/rod shaped
7-21 day incubation
How is chlamydia transmitted?
Vaginal, oral or anal sex
Skin-skin genital contact
Can infect eye, pharynx and rectum
How does chlamydia present in women?
70% asymptomatic
Cervicitis - discharge and bleeding
Dysuria
Pelvic pain
Cervical excitation
Painful urination and sex
Consider rectal chlamydia and lymphogranuloma venereum in patients presenting with anorectal symptoms e.g. discomfort, discharge, bleeding or change in bowel habits after anal sex.
How does chlamydia present in males?
50% asymptomatic
Dysuria
Discharge
Urethral discomfort
Testicular pain
Reactive arthritis
Consider rectal chlamydia and lymphogranuloma venereum in patients presenting with anorectal symptoms e.g. discomfort, discharge, bleeding or change in bowel habits after anal sex.
How is chlamydia investigated?
NAAT technique on:
Vulvo-vaginal swab
First void urine
What swabs are used in sexual health testing?
Charcoal swabs
Nucleic acid amplification test
Charcoal swabs allow for microscopy, culture and sensitivities.
Allows for gram staining for endocervical swabs and high vaginal swabs - confirms BV, candidiasis, gonorrhoea, trichomonas, GBS
NAAT checks DNA or RNA of organism, used specifically for chlamydia and gonorrhoea. Vulvovaginal swab (self taken) endocervical swab or first catch urine. In men, first catch or urethral swab.
Rectal or oral NAAT swabs for chlamydia in rectum or mouth.
If gonorrhoea on NAAT, then endocervical charcoal swab for MCS.
What are the examination findings in chlamydia?
Pelvic or abdominal tenderness
Cervical motion tenderness - cervical excitation
Inflamed cervix - cervicitis
Purulent discharge
How is chlamydia diagnosed?
NAAT
Nucleic acid amplification tests
Vulvovaginal swab Endocervical swab First catch urine sample Urethral swab in men Rectal swab - after anal sex Pharyngeal swab after oral sex
What is the management of chlamydia?
First line for uncomplicated - doxycycline 100mg twice a day for 7 days
Erythromycin if CI
When is doxycycline contraindicated in treatment for chlamydia?
In pregnancy and breastfeeding
Alternatives include
Azithromycin 1mg stat, then 500mg once a day for 2 days
Erythromycin 500mg four times daily for 7 days
Erythromycin 500mg twice daily for 14 days
Amoxicillin 500mg three times daily for 7 days
What are important factors to consider during the treatment of chlamydia?
Test of cure not usually routinely recommended.
Abstain from sex for seven days of treatment of all partners
refer to GUM for contact Tracing and notification of sexual partners
Test for and treat any other sexually transmitted infections
Provide advice about how to prevent future infections
Consider safeguarding and sexual abuse in young people
What are the complications of chlamydia?
Pelvic inflammatory disease Chronic pelvic pain Infertility Ectopic pregnancy Epididymo-orchitis Conjunctivitis Lymphogranuloma venereum Reactive arthritis
What are the pregnancy related complications of chlamydia?
Preterm delivery Premature rupture of membranes Low birth weight Postpartum endometritis Neonatal infection - conjunctivitis and pneumonia
What is lymphogranuloma venereum?
Condition affecting the lymphoid tissue around the site of infection with chlamydia.
Primary stage - painless ulcer, primary lesion - on penis in men, vaginal wall or rectum.
Secondary stage - lymphadenitis; swelling, inflammation and pain in lymph nodes infected with bacteria - inguinal or femoral lymph nodes.
Tertiary - inflammation of the rectum and anus, proctitis leads to anal pain, changes in bowel habits, tenesmus.
What is the treatment of lymphogranuloma venereum?
Doxycycline 100mg twice daily for 21 days
Erythromycin or azithromycin are second line options
What is chlamydial conjunctivitis?
When genital fluid comes into contact with the eye e.g. hand to eye spread.
Presents with chronic erythema, irritation and discharge lasting more than two weeks.
What organism causes gonorrhoea? how long is the incubation period?
Neisseria gonorrhoea - gram -ve cocci
2-5 day incubation
How is gonorrhoea transmitted?
Vaginal, oral or anal sex
Vertical transmission - mother to child
Can infect rectum and pharynx
What is the main additional risk factor for gonorrhoea?
MSM
How does gonorrhoea present in women?
50% asymptomatic
Cervicitis - thin watery yellow discharge
Dysuria
Pelvic pain
Easily induced cevical bleeding
How does gonorrhoea present in men?
Purulent discharge
Dysuria
Epididymal tenderness
Testicular pain or swelling
Rectal infection may cause anal or rectal discomfort and discharge, often asymptomatic
Pharyngeal infection - sore throat
Prostatitis
Conjunctivitis - erythema, purulent discharge
How is gonorrhoea investigated?
NAAT technique - endocervical/vaginal swab or first pass urine
Microscopy and culture - endocervical/urethral swabs
NATT does not provide info on specific bacteria, sensitivities and resistance hence microscopy is needed.
How is gonorrhoea managed?
Referred to GUM for coordinate testing, treatment and contact tracing.
If uncomplicated - single dose of intramuscular ceftriaxone 1g if the sensitivities not known
Single dose of oral ciprofloxacin 500mg if sensitivities are known
How is gonorrhoea followed up?
TOC
With NAAT testing if asymptomatic or cultures if symptomatic
at least 72 hours after treatment for culture
7 days after treatment RNA NATT
14 days after treatment for DNA NATT
What are the main complications associated with gonorrhoea?
PID
Epididymo-orchitis
Prostatits
Salpingitis –> infertility
Disseminated gonococcal infection
How would you contact trace for gonorrhoea?
Symptomatic men - all partners 2 weeks
Women and asymptomatic men - all partners 3 months
What is important to know about gonorrhoea in pregnancy?
Risk of spontaneous abortion, premature labour and early rupture of membranes
IM ceftriaxone and oral azithromycin
How does a disseminated gonococcal infection present and how is it managed?
Skin lesions and joint pain
Admit to hospital for management - can lead to sepsis
What are other factors is it important to consider during treatment for gonorrhoea?
Abstain from sex for 7 days of treatment of all partners
Test for and treat any other STIs
Provide advice about ways to prevent future infection
Consider safeguarding
What are the complications of gonorrhoea?
Pelvic inflammatory disease Chronic pelvic pain Infertility Epididymo-orchitis Prostatitis Conjunctivities Urethral strictures Disseminated gonococcal infection Skin lesions Fitz-Hugh curtis syndrome Septic arthritis Endocarditis
What is disseminated gonococcal infection?
Complication of untreated gonococcal infection
Bacteria spreads to skin and joints
Skin lesions
Polyarthralgia - joint aches and pains
Migratory polyarthritis
Tenosynovitis
Systemic symptoms e.g. fever and fatigue.
What is mycoplasma genitalium?
Bacteria that causes non gonococcal urethritis
What may a MG infection lead to?
Urethritis Epididymitis Cervicitis Endometritis PID Reactive arthritis Preterm delivery in pregnancy Tubal infertility
What are the investigations for MG?
NAAT testing as traditional cultures not helpful in isolating MG as it is a slow growing organism.
First urine sample in the morning for men.
Vaginal swabs for women
Check every positive sample for macrolide resistance and perform a test of cure after treatment.
What is the management of MG?
Doxycycline 100mg twice daily for 7 days then
Azithromycin 1g stat, then 500mg once a day for 2 days unless there is known to be resistance.
Moxifloxacin can be used as an alternative.
Azithromycin alone 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 are the common causes of PID?
Neisseria gonorrhoea - produces most severe PID
Chlamydia trachomatis
Mycoplasma genitalium
Can also be caused less commonly by non sexually transmitted infections e.g. Gardnerella, haemophils influenzae, e. coli
What are the risk factors for PID?
Not using barrier contraception Multiple sexual partners Younger age Existing sexually transmitted infections Previous PID Intrauterine device e.g. copper coil
What is the presentation of PID?
Pelvic or lower abdominal pain Abnormal vaginal discharge Abnormal bleeding - intermenstrual or postcoital Pain during sex - dyspareunia Fever Dysuria
What may be findings on examination in PID?
Pelvic tenderness
Cervical motion tenderness
Inflamed cervix - cervicitis
Purulent discharge
What are the investigations for PID?
NAAT swabs for gonorrhoea and chlamydia
NAAT swabs for MG if available
HIV test
Syphilis test
A high vaginal swab for BV, candidiasis, trichomoniasis
Microscope to look for pus cells
Pregnancy test if presenting with lower abdominal pain to rule out ectopic pregnancy.
Inflammatory markers CRP and ESR
What is the management of PID?
Referral to GUM and contact tracing
Start antibiotics empiricallly
Single dose of IM ceftriaxone to cover gonorrhoea
Doxycycline 100mg twice daily for 14 days to cover chlamydia and MG
Metronidazole 400mg twice daily for 14 days to cover anaerobes e.g. Gardnerella
If signs of sepsis admit to hospital, IV antibiotics
Pelvic abscess may develop
What are the complications of PID?
Sepsis Abscess Infertility Chronic pelvic pain Ectopic pregnancy Fitz Hugh Curtis syndrome
What is Fitz Hugh Curtis syndrome?
A complication of PID, due to inflammation and infection of the liver capsule - Glisson’s capsule
Leads to adhesions between the liver and the peritoneum. Bacteria may spread from pelvis via peritoneal cavity, lymphatic system or blood.
Results in RUQ pain, can be referred to shoulder tip.
Laparoscopy needed to visualise and treat adhesions.
What is trichomonas vaginalis?
A parasite spread through sez
Lives in urethra of men and women, and vagina of women
What can trichomoniasis increase the risk of?
Contracting HIV by damaging vaginal mucosa
Bacterial vaginosis
Cervical cancer
Pelvic inflammatory disease
Pregnancy related complications e.g. preterm delivery
What is the presentation of trichomoniasis?
Up to 50% asymptomatic Vaginal discharge - frothy, yellow-green, fishy Itching Dysuria - painful urination Dyspareunia Balanitis - inflammation to glands penis
What is seen on examination in trichomoniasis?
Strawberry cervix - colpitis macularis
Due to inflammation - cervicitis, tiny haemorrhages across the surface of the cervix making it look like a strawberry.
pH testing - raised pH above 4.5
What can be done to confirm the diagnosis of trichomoniasis?
Charcoal swab with microscopy
Swabs taken from posterior fornix of vagina, behind the cervix, or self taken swab as alternative
For men - urethral swab or first catch urine.
What is the management of trichomoniasis?
Referral to GUM clinic, diagnosis, treatment, contact tracing. Treatment with metronidazole
What causes trichomonas vaginalis? what is the incubation period?
A protozoa
1 month incubation
How is trichomonas vaginalis transmitted? what are the additional risk factors?
Vaginal sex (NOT ORAL OR ANAL) Vertical transmission - mother to child at delivery
Older women
What is important to know about trichomonas vaginalis in pregnancy?
Risk of premature labour and low birth weight
Metronidazole can be used but affect taste of breast milk
What are the similarities between BV and trichomonas?
“Offensive” vaginal discharge
Vaginal pH >4.5
Treat with metronidazole
How does BV vary from trichomonas?
Thin white discharge
Microscopy - clue cells
How does trichomonas vary from BV?
Frothy yellow green discharge
Vulvovaginitis
Strawberry cervix
Wet mount - motile trophozoites
What is the herpes simplex virus?
Responsible for cold sores and genital herpes.
Strains HSV-1 and HSV-2.
What is the pathophysiology of recurrent infection?
After initial infection, virus becomes latent in associated sensory nerve ganglia.
Trigeminal nerve ganglion - cold sores.
Sacral nerve ganglion - genital herpes.
Reactivated, particularly in times of stress.
How is herpes spread?
Through direct contact with affected mucous membranes or viral shedding in mucous secretions. Can shed even when asymptomatic, more common in first 12 months of infection.
What is the presentation of genital herpes?
May be asymptomatic, or develop symptoms months or years after an initial infection when latent virus reactivated.
Symptoms appear within two weeks. Initial episode most severe, recurrent episodes more mild.
Ulcers, blistering lesions on genital area
Neuropathic type pain - burning, tingling, shooting
Flu like symptoms e.g. fatigue, headache
Dysuria
Inguinal lymphadenopathy
How can herpes infection be diagnosed?
Ask about sexual contact including those with cold sores
Diagnosis made clinically based on history and exam
Viral PCR swab from lesion can confirm diagnosis
What is the management of herpes?
Aciclovir
Additional measures: Paracetamol Topical lidocaine e.g. Instillagel Cleaning with warm salt water Topical vaseline Additional oral fluids Wear loose clothing Avoid intercourse with symptoms
What is the risk of pregnancy with genital herpes?
Not known to cause any pregnancy related complications
But risk of neonatal herpes simplex infection during labour and delivery.
If develops infection, woman will develop antibodies to the virus which can cross placenta and give the fetus passive immunity.
What is the management of genital herpes in pregnancy?
Primary herpes before 28 weeks - aciclovir then regular prophylactic aciclovir from 36 weeks.
Asymptomatic can have vaginal otherwise c-section.
Primary genital herpes after 28 weeks treated with aciclovir during initial infection then regular prophylactic aciclovir. C-section in all causes.
Recurrent genital herpes - low risk of infection, known to have genital herpes before becoming pregnant.
Regular prophylactic aciclovir considered from 36 weeks.
What is HIV and AIDS?
Human immunodeficiency virus
Acquired immunodeficiency syndrome occurs as HIV progresses, leads to opportunistic infections - several AIDS defining illnesses e.g. Karposi’s sarcoma.
What sort of virus is HIV?
RNA retrovirus
HIV-1 most common type, HIV-2 rare outside west africa
Enters and destroys CD4 T helper cells
Initial seroconversion flu like illness, then asymptomatic until condition progresses to immunodeficiency.
How is HIV transmitted?
Unprotected anal, vaginal or oral sexual activity
Mother to child at any stage of pregnancy, birth or breastfeeding - vertical transmission
Mucous membrane, blood or open wound exposure to blood or bodily fluids; sharing needles, needle stick injuries, blood splashed in an eye.
What are examples of AIDS defining illnesses?
Occurs at end stage HIV, where CD4 count very low
Kaposi's sarcoma Pneumocystis jirovecii pneumonia Cytomegalovirus infection Candidiasis - oesophageal or bronchial Lymphomas Tuberculosis
How long can it take for HIV tests to be positive?
Can take up to three months to develop antibodies after infection
Repeat testing necessary if initial test negative within three months of exposure
Verbal consent needed to test for HIV
How is HIV tested?
Antibody testing with simple blood test, self sampling kit
Tests for p24 antigen in the blood which can give an earlier result than the antibody test.
PCR testing for HIV RNA - detects number of viral copies and viral load.
How can HIV be monitored?
CD4 count
500-1200 is in normal range, under 200 cells mm3 is considered end stage HIV
Viral load - number of copies of HIV RNA per ml blood
Undetectable usually 50-100 copies
What is the treatment of HIV?
Antiretroviral therapy medications
Offered to everyone irrespective of viral load or CD4 count
Start on regime of two NRTIs (nucleoside reverse transcriptase inhibitors) r.g. tenofovir and emtricitabine
Aims to achieve normal CD4 count and undetectable viral load, then can treat physical health problems as normal.
What are examples of highly active anti-retrovirus therapy HAART medications?
Protease inhibitors
Integrase inhibitors
Nucleoside reverse transcriptase inhibitors
Non-nucleoside reverse transcriptase inhibitors
Entry inhibitors
What additional management is available for HIV?
Prophylactic co trimoxazole given to patients with CD4 count under 200 to protect against pneumocystis.
Close monitoring of CV risk factors and blood lipids, may also need statins, increased risk of CVD.
Yearly cervical smears as HIV predisposes to developing HPV and cervical cancer.
Vaccinations up to date, including flu, pneumococcal, Hep A and B, tetanus, diptheria, polio. No live vaccines.
What is important in HIV and reproductive health?
Advise condoms for vaginal and anal sex Dams for oral sex Even when both partners HIV positive If viral load undetectable - transmission through unprotected sex unlikely, but not impossible. Partners should be regularly tested.
Possible to conceive safely through e.g. sperm washing and HIV.
How can HIV transmission be prevented during birth?
Normal vaginal delivery if viral load < 50 copies
Caesarean section considered >50 and all women >400
IV zidovudine given during c-section if viral load unknown or >10,000 copies.
Prophylaxis treatment may be given to baby.
Low risk if copies <50, zidovudine for 4 weeks
High risk copies >50, zidovudine, lamivudine and nevirapine for 4 weeks.
Can HIV be transmitted during breastfeeding?
Yes, even if mother’s load is undetectable
Not recommended
What is PEP for HIV?
Post exposure prophylaxis after exposure to reduce risk of transmission. Must be commenced in short window of opportunity - less than 72 hours.
Is a combination of ART therapy, HIV tests done immediately and minimum of three months after exposure to confirm negative status.
Individuals to abstain from unprotected sex for minimum of three months until confirmed as negative.
What is syphilis?
Caused by bacteria Treponema pallidum
What is the incubation period of syphilis?
21 days on average
How is syphilis transmitted?
Oral, vaginal or anal sex involving direct contact with infected area
Vertical transmission from mother to baby in pregnancy
Intravenous drug use
Blood transfusions and other transplants - rare due to screening of blood products
What are the stages of syphilis?
Primary - painless ulcer/chancre at original site of infection, usually genitals.
Secondary - systemic symptoms, particularly of the skin and mucous membranes, resolves after 3-12 weeks.
Latent - symptoms disappear, patient asymptomatic but still infected, early latent within two years.
Tertiary - occurs many years after initial infection, affects many organs of body, development of gummas.
Neurosyphilis if infection involves CNS, neurological symptoms.
What is the presentation of primary syphilis?
Painless genital ulcer - chancre, resolves over 3-8 weeks
local lymphadenopathy
What is the presentation of secondary syphilis?
Starts after chancre has healed Maculopapular rash Condylomata lata - grey, wart like lesions around the genitals and anus Low grade fever Lymphadenopathy Alopecia Oral lesions
What is the presentation of tertiary syphilis?
Depends on affected organs
Gummatous lesions - granulomatous lesions affecting skin, organs and bones
Aortic aneurysms
Neurosyphilis
What is the presentation of neurosyphilis?
Headache Altered behaviour Dementia Tabes dorsalis - demyelination affecting spinal cord posterior columns Ocular syphilis affecting the eyes Paralysis Sensory impairment
What is an Argyll-Robertson pupil?
A specific finding in neurosyphilis
Constricted pupil that accommodates when focusing on near object, but doesn’t react to light.
Irregularly shaped
How is syphilis diagnosed?
Antibody testing for antibodies to T pallidum
Samples from sights of infection to detect T pallidum with dark field microscopy or PCR.
What is the management of syphilis?
GUM referral Full screening for other STIs Advice about avoiding sexual activity until treated Contact tracing Prevention of future infections
Single deep IM dose of benzathine benzylpenicillin
Alternatives include for e.g. late syphilis or neurosyphilis = ceftriaxone, amoxicillin, doxycycline.
