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Yr4: Obstetrics & Gynaecology > Genitourinary Medicine (GUM) 2 > Flashcards

Genitourinary Medicine (GUM) 2 Flashcards

1
Q

What are the following strains of herpes simplex virus associated with:

  • HSV 1
  • HSV 2
A
  • HSV-1: cold sores
  • HSV-2: genital herpes (but can also cause lesions in mouth)

NOTE: genital herpes caused by HSV-1 is typically contracted through oro-genital sex from person with an oral infection

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2
Q

Alongside cold sores and genital herpes, what else can herpes simplex virus cause?

A
  • Aphthous ulcers
  • Herpes keratitis
  • Herpetic whitlow (painful skin lesion on fingers or thumbs)
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3
Q

How is HSV transmitted?

What does virus do after initial infection?

A
  • Direct contact with affected mucous membranes or viral shedding in mucous secretions
    • NOTE: virus can be shed even when asymptomatic (this is more common in first 12 months of infection)
  • After initial infection, lies dormant in sensory nerve ganglia- usually trigeminal nerve ganglia with cold sores and sacral nerve ganglia with genital herpes
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4
Q

How long, following initial infection, do symptoms of genital herpes usually appear?

A

Within 2 weeks

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5
Q

Initial episode of genital herpes is often most severe; true or false?

A

True; initial episode most severe and often lasts longer (can last 3 weeks)

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6
Q

Describe typical presentation of genital herpes

A

Remember, some people may be asymptomatic but typical presentation could be:

  • Ulcers or blistering lesions affecting the genital area
  • Neuropathic type pain (tingling, burning or shooting)
  • Flu-like symptoms (e.g. fatigue and headaches)
  • Dysuria (painful urination)
  • Inguinal lymphadenopathy
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7
Q

Discuss how genital herpes is diagnosed

A
  • Diagnosis is clinical based on hx and examination
  • Can do viral PCR swab from lesion to confirm
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8
Q

Discuss the management of genital herpes

A
  • Consider referral to GUM service (e.g. if think risk of other STIs)
  • Antiviral: oral aciclovir (alternatives are valaciclovir, famiciclovir)
  • Advice for managing symptoms:
    • Paracetamol
    • Topical lidocaine gel (e.g. instillagel)
    • Cleaning/bathing with warm salt water
    • Topical vaseline
    • Wear loose clothing
    • Avoid intercourse until sores have disappeared
    • Additional oral fluids
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9
Q

What is the main issue with pregnancy and genital herpes?

A

Risk of neonatal herpes simplex infection (genital herpes itself not known to cause complications during pregnancy)

*Remember that mother will have developed antibodies to virus and during pregnancy these antibodies can cross placenta giving fetus passive immunity which helps protect baby during labour & delivery

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10
Q

Discuss the management of genital herpes in pregnancy, consider:

  • Management of primary genital herpes before 28 weeks
  • Management of primary genital herpes after 28 weeks
  • Management of recurrent genital herpes
A

Management of primary genital herpes before 28 weeks

  • Aciclovir during initial infection
  • Followed by regular prophylactic aciclovir from 36 weeks onwards (to reduce risk of genital lesions during labour & delivery)

Management of primary genital herpes after 28 weeks

  • Aciclovir during initial infection
  • Followed immediately by regular prophylactic aciclovir
  • Caesarean section is recommended in ALL cases

Management of recurrent genital herpes

  • Regular prophylactic aciclovir can be considered from 36 weeks gestation (low risk of 0-3% even if lesions are present during delivery)
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11
Q

Discuss when you would do a caesarean section for women with genital herpes

A
  • Primary genital herpes before 28 weeks gestation and delivery is less than 6 weeks after initial infection
  • Primary genital herpes before 28 weeks gestation and have symptoms present at time of delivery
  • Primary genital herpes after 28 weeks- ALL CASES

NOTE: as mentioned, recurrent genital herpes carries low risk so C-section not necessarily required

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12
Q

What is non-gonococcal urethritis?

A

Non-gonococcal urethritis (NGU, sometimes referred to as non-specific urethritis) is a term used to describe the presence of urethritis when a gonococcal bacteria are not identifiable or the initial swab.

A typical case would be a male who presented to a GUM clinic with a purulent urethral discharge and dysuria. A swab would be taken in clinic, microscopy performed which showed neutrophils but no Gram negative diplococci (i.e. no evidence of gonorrhoea). Clearly this patient requires immediate treatment prior to waiting for the Chlamydia test to come back and hence an initial diagnosis of NGU is made.

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13
Q

What are the common causative organisms of non-gonococcal urethritis?

A
  • Chlamydia trachomatis (most common)
  • Mycoplasma genitalium
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14
Q

What is mycoplasma genitalium (MG)?

A

Mycoplasma genitalium (MG) is a bacteria that causes non-gonococcal urethritis. It is a STI.

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15
Q

Most cases of mycoplasma genitalium cause symptoms; true or false?

A

FALSE; mot cases do not cause symptoms. If does cause symptoms, symptoms similar to chlamydia.

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16
Q

If mycoplasma genitalium causes symptoms, what symptoms may it cause- highlight key one

A
  • Urethritis is key feature:
    • Dysuria
    • Burning, itching
    • Discharge
  • Others:
    • Pain in testicles (male)
    • Vaginal discharge (women)
    • Dyspareunia (women)
    • Post-coital bleeding (women)
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17
Q

What investigations are done to diagnose mycoplasma genitalium (MG)?

A

Cultures not helpful as it is slow growing hence do NAAT testing:

  • Men: first catch urine (most sensitive) & swab of urethral discharge if present
  • Women: self-taken low vaginal swabs (or can have clinician take high vaginal swab)

Guidelines recommend testing every positive sample for macrolide resistance (test for macrolide resistance mutations) and performing test of cure 5 weeks after treatment

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18
Q

Discuss the management of mycoplasma genitalium

A
  • Doxycycline 100mg BD for 7/7 followed by…
  • Azithromycin 1g STAT then 500mg OD for 2/7 (unless known resistance to macrolides)

NOTES:

  • Moxifloxacin used as alternative or in complicated infections (400mg PO OD 10/7 or 14/7 in complicated infections)
  • Doxycycline contraindicated in pregnancy so azithromycin alone is used
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19
Q

State some potential complications of mycoplasma genitalium

A
  • Epididymitis
  • Cervicitis
  • Endometritis
  • Pelvic inflammatory disease
  • Reactive arthritis
  • Preterm delivery in pregnancy
  • Tubal infertility
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20
Q

What bacteria causes syphilis?

A

Treponema pallidum

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21
Q

For Treponema pallidum, state:

  • Shape
  • Transmission
  • Incubation period
A
  • Spirochete/spiral shaped
  • Penetrates skin or mucous membranes then replicates & disseminates throughout body. May be contracted via:
    • Oral, vaginal or anal sex
    • Vertical transmission
    • IV drug use
    • Blood transfusions or other transplants (rare)
  • Incubation period ~21 days
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22
Q

State some risk factors for syphilis

A
  • Engaging in unprotected sex – especially with high risk partners.
  • Multiple sexual partners.
  • Men who have sex with men (MSM).
  • HIV infection.
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23
Q

State and briefly describe the 4 stages of syphilis

A
  • Primary: painless ulcer (called a chancre) at original site of infection- usually genitals
  • Secondary: systemic symptoms commonly affecting skin & mucous membranes
  • Latent: become asymptomatic despite still being infection
    • Early: occurs within 2yrs of initial infection
    • Late: occurs from 2yrs after initial infection onwards
  • Tertiary: affects many organs of body- gummas, CVS and neuro complications
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24
Q

What is neurosyphilis?

A

Infection in CNS causing neurological symptoms

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25
Q

Describe how primary syphilis may present

A
  • Painless ulcer at site of initial infection (usually genitals) “Chancre”
  • Local lymphadenopathy
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26
Q

Describe how secondary syphilis may present

A

Typically starts after chancre has healed:

  • Maculopapular rash
  • Condylomata lata (warty lesions on genitalia)
  • Low-grade fever
  • Lymphadenopathy
  • Alopecia (localised hair loss)
  • Oral lesions
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27
Q

Describe how tertiary syphilis may present

A

Presentation depends on affected organs but key ones:

  • Gummatous lesions (gummas= granulomatous lesions affecting skin, organs & bones)
  • Aortic aneurysm
  • Neurosyphilis
28
Q

Describe how neurosyphilis may present

A

NOTE: neurosyphilis can occur at any stage

  • Headache
  • Altered behaviour
  • Dementia
  • Tabes dorsalis (demyelination affecting the spinal cord posterior columns)
  • Ocular syphilis (affecting the eyes)
  • Paralysis
  • Sensory impairment
29
Q

What pupil finding is specific to neurosyphilis?

A
  • Argyll-Robertson pupil
  • Constricted pupil that accommodates but doesn’t react. Often irregularly shaped.
  • “Prostitutes pupil”
30
Q

Is syphilis contagious at all stages?

A

Tertiary syphilis is the only non-contagious phase of the infection. In the primary, secondary, and early latent stages, individuals with syphilis can transmit the disease through sexual contact with infectious lesions of the mucous membranes

31
Q

How is syphilis diagnosed?

A

Diagnosis usually based on combination of clinical features, serology & microscopic examination of infected tissue

  • Antibody testing:
    • Primary screening (test for antibodies specific to treponema pallidum):
      • Treponemal EIA (enzyme immunoassay) ****The British Association for Sexual Health and HIV (BASHH) recommend EIA/CLIA as the screening test of choice for syphilis.
      • or TPHA (T. pallidum HaemAgglutination test)
    • Positive antibody tests should be confirmed with different treponemal test
    • Non-treponemal tests e.g. RPR and VDRL can be used to help stage infection & monitor response to treatment
  • Dark field microscopy of sample from infected site
  • PCR of sample from infected site
  • Lumbar puncture to assess for CSF antibodies in neurosyphilis

*NOTE:

32
Q

Discuss the management of syphilis

A
  • First line= IM injection of benzathine penicillin (Single dose in early stage, 3 doses at weekly intervals in late stage. Alternatives include doxycycline, amoxicillin.)
  • Full screening for other STIs
  • Contact tracing
  • Avoid all sexual contact until diagnosis confirmed AND treated
  • Preventative measures include:
    • Increased use of condoms.
    • Avoidance of drugs and alcohol when having sex.
    • Risk-reduction counselling and regular syphilis screening for people at high risk— available through GUM.
    • Early recognition of the clinical features of syphilis, prompt treatment and prophylactic treatment of exposed contacts.
33
Q

Untreated syphilis during pregnancy may result in miscarriage, stillbirth, pre-term labour or congenital syphilis. State some features of congenital syphilis

A
  • blunted upper incisor teeth (Hutchinson’s teeth), ‘mulberry’ molars
  • rhagades (linear scars at the angle of the mouth)
  • keratitis
  • saber shins
  • saddle nose
  • deafness
34
Q

What type of virus is HIV (human immunodeficiency virus)?

What strain of HIV is most common?

What cells does it infect & destroy?

A
  • RNA retrovirus
  • HIV -1 is most common type (HIV-2 rare outside West Africa)
  • Infects & destroys CD4 T-Helper cells
35
Q

Discuss how HIV is transmitted

A
  • Unprotected anal, vaginal or oral sex
  • Vertical (could be during pregnancy, birth or breastfeeding)
  • When mucous membranes, blood or open wound exposure to infected blood or bodily fluids (e.g. sharing needles, blood splashed in eye etc…)
36
Q

Describe how HIV infects & replicates in cells

*HINT: asking for pathophysiology from infection module Yr2

A
37
Q

Briefly outline the typical progression of HIV

A
  • Initial sero-conversion flu-like illness within few weeks of infection (typically within 3-12 weeks of infection)
  • Then asymptomatic until condition progresses to immunodeficiency
  • Progresses to AIDS when CD4 count <200cells/mm3 or they develop AIDS-defining illnesses
38
Q

Discuss whether we should be screening pts for HIV

A
  • Early diagnosis of HIV infection enables better treatment outcomes and reduces the risk of transmitting the infection to others
  • We should test practically everyone admitted to hospital with an infectious disease for HIV- regardless of risk factors
  • Those with risk factors should have regular testing (e.g. MSM should have test at least annually)
  • Verbal consent is adequate e.g. Are you happy for us to test you for HIV? (used to have to give formal counselling & education before test)
39
Q

What tests are done to screen for HIV- discuss when each one should be done/is beneficial

A
  • Antibody testing: can take up to 3 months for antibodies to develop after initial infection hence repeat testing often necessary if antibody test negative within 3 months of exposure. Pts can be sent at home antibody test kit.
  • P24 antigen testing: usually positive from about week 1 to week 3-4
  • Combination test (antibody + P24): standard
  • PCR HIV RNA levels: gives indication of viral load

NOTE: testing for HIV in asymptomatic individuals should be done at 4 weeks after possible exposure

40
Q

What monitoring is done for HIV patients?

A
  • CD4 count
    • Normal= 500-1200 cells/mm3
    • End-stage HIV (AIDS)= <200cells/mm3
  • Viral load
41
Q

What are the aims of HIV treatment?

A

Have normal CD4 count and undetectable viral load

42
Q

Discuss the management of HIV

A
  • Combination of ARTs (antiretroviral therapy)- offered to EVERYONE
    • Recommended starting regime is 2 NRTIs (nucleoside reverse transcriptase inhibitors) + a third agent
  • Prophylactic co-trimoxazole (Septrin): for pts with CD4 <200/mm3 to protect against PCP
  • Immunisations should be kept up to date: influenza, pneumococcal, hepatitis A & B, tetanus, diphtheria
  • Yearly cervical smears for women with HIV
  • Close monitoring of CVD risk factors (e.g. lipids) and appropriate treatment
  • Education:
    • Advise condoms for vaginal & anal sex and dams for oral sex if viral load detectable
    • If viral load undetectable, transmission through unprotected sex is very rare
    • Partners should have regular HIV tests
    • Advice about contraception e.g. if have undetectable viral load unprotected sex and pregnancy may be an option. Other options include sperm washing & IVF
43
Q

Why do women with HIV need yearly cervical smears?

A

HIV predisposes to HPV infection & hence increases risk cervical cancer

44
Q

There are numerous classes of antiretroviral medications; state some example classes

A
  • Protease inhibitors (PIs)
  • Integrase inhibitors (IIs)
  • Nucleoside reverse transcriptase inhibitors (NRTIs)
  • Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
  • Entry inhibitors (EIs)
45
Q

Discuss how transmission of HIV is prevented during birth

A

**NOTE: this is simplified version of BHIVA guidelines but helpful to have rough idea that viral load determines both mode of delivery & prophylaxis

Mode of delivery is determined by mothers viral load:

  • Viral load <50 copies/ml → normal vaginal delivery
  • Viral load >50 copies/ml → consider caesarean section
  • Viral load >400 copies/ml → caesarean section
  • If viral load is unknown or >10,000 copies/ml should give IV zidovudine during caesarean section

Again, prophylaxis treatment for baby is dependent on mothers viral load:

  • Low risk babies where mothers viral load <50 copies /ml → zidovudine for 4/52
  • High risk babies where mothers viral load is >50copies/ml → zidovudine, lamivudine & nevirapine for 4/52
46
Q

Can HIV positive mothers breastfeed?

A

Not recommended (even with undetectable viral load) as can be transmitted

47
Q

Discuss post-exposure prophylaxis for HIV, include:

  • Time window
  • What is used
  • What testing is done
  • What advice given regarding sexual intercourse
A
  • Within 72hrs of exposure
  • Combination of ART (e.g. truvada & raltegravir for 28 days)
  • Do HIV tests immediately and minimum of 3 months after exposure
  • Advice to abstain from unprotected sexual activity for minimum of 3/12 until confirmed as negative
48
Q

State some examples of AIDS-defining illnesses

A
  • Kaposi’s sarcoma
  • Pneumocystis jirovecii pneumonia (PCP)
  • Cytomegalovirus infection
  • Candidiasis (oesophageal or bronchial)
  • Lymphomas
  • Tuberculosis
49
Q

What is the most common cause of oesophagitis in HIV patients?

A

Oesophageal candidiasis

50
Q

For Kaposi’s sarcoma, discuss:

  • What it is
  • Presentation
  • Management
A
  • Rare cancer caused by HHV-8; affects skin, mouth and sometimes internal organs
  • Presentation:
    • Main symptom= purple papules or plaques on skin or mucosa
    • Skin lesions may ulcerate
    • Haemoptysis (resp involvement)
    • Pulmonary effusion (resp involvement)
  • Management:
    • HIV medications
    • Radiotherapy
    • Chemotherapy
51
Q

What is PID (pelvic inflammatory disease)?

A

Inflammation & infection of the female pelvic organs as a result of an ascending infection from the endocervix

52
Q

Define the following:

  • Endometritis
  • Salpingitis
  • Oophoritis
  • Parametritis
  • Peritonitis
A
  • 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
53
Q

State the most common causes of PID- highlight most common the common causes

State some less common causes of PID

A

Most common causes:

  • Chlamydia trachomatis (most common)
  • Neisseria gonorrhoeae (often produces most severe PID)
  • Mycoplasma genitalium

Less common causes

  • Gardnerella vaginalis
  • Haemophilus influenza
  • Escherichia coli
54
Q

State some risk factors for PID

A
  • Not using barrier contraception
  • Multiple sexual partners
  • Younger age
  • Existing sexually transmitted infections
  • Previous pelvic inflammatory disease
  • Intrauterine device (e.g. copper coil)
55
Q

Describe typical presentation of PID

A
  • Pelvic or lower abdominal pain
  • Abnormal vaginal discharge
  • Abnormal bleeding (intermenstrual or postcoital)
  • Pain during sex (dyspareunia)
  • Fever
  • Dysuria
56
Q

What might you find on examination of woman with PID?

A
  • Pelvic tenderness
  • Cervical motion tenderness (cervical excitation)
  • Inflamed cervix (cervicitis)
  • Purulent discharge

**REMEMBER: could also have signs of sepsis

57
Q

What investigations would you do in suspected PID?

A
  • Test for causative STIs:
    • Endocervical NAAT swabs for chlamydia & gonorrhoea
    • Endocervical NAAT swabs for Mycoplasma genitalium
    • HIV test
    • Syphilis test
  • High vaginal swab to look for BV, candidiasis, trichomoniasis
  • Swab of vagina or endocervix and view under microscope to look for pus cells (absence of pus cells useful for excluding PID
  • Pregnancy test to exclude ectopic pregnancy
  • CRP & ESR: raised
  • Laparoscopy: only indicated in severe cases to obtain peritoneal biopsy
58
Q

Discuss the management of PID

A

If not seen in GUM services, need referral for management:

  • Empirical abx
    • Start before swab results come back. Combination of abx to cover all possible organisms e.g. ceftriaxone, doxycycline, metronidazole
  • There are some situations in which women should be admitted to hospital:
    • If pregnant and especially if there is a risk of ectopic pregnancy.
    • Severe symptoms: nausea, vomiting, high fever.
    • Signs of pelvic peritonitis.
    • Unresponsive to oral antibiotics, need for IV therapy.
    • Need for emergency surgery or suspicion of alternative diagnosis.
  • If abscess may need drainage by interventional radiology or surgery
  • If have IUD, consider removal
  • Advise to avoid sexual intercourse until abx completed and partner(s) treated
  • Contact tracing
59
Q

State some potential complications of PID

A
  • Sepsis
  • Abscess
  • Infertility
  • Chronic pelvic pain
  • Ectopic pregnancy
  • Fitz-Hugh-Curtis syndrome
60
Q

For Fitz-Hugh-Curtis syndrome, discuss:

  • What it is
  • Symptoms
  • Management
A
  • Inflammation of liver capsule (perihepatitis); leads to adhesions between liver & peritoneum
  • Symptoms:
    • RUQ pain
    • Fever
    • May have shoulder tip pain if irritation of diaphragm
  • May do adhesiolysis during laparoscopy
61
Q

CHECK IF NEED TO KNOW HOW TO ADVISE PTS TO TAKE SWABS & DO FC ON HOW TO TAKE SWABS AS MEDIC

A
62
Q

For hepatitis B, describe:

  • DNA or RNA
  • Transmission
  • Spontaneous recovery or progression
  • Vaccination
A
  • DNA
  • Direct contact with blood or bodily fluids
  • Most people fully recover in 2 months but 10% go on to be chronic carriers
  • Vaccination available
63
Q

For hepatitis B state which antibodies you can test for and what a positive result in each one means

A
  • Surface antigen (HBsAg): active infection
  • Core antibodies (HBcAb): past or current infection
  • Surface antibodies (HBsAb): vaccination, past or current infection
  • Hepatitis B virus DNA (HBV DNA): direct count of viral load
  • E antigen (HBeAg): marker of viral replication & implies high infectivity

*NOTE core antibodies imply past or current infection; if IgM high implies active infection if IgG high implies past infection

64
Q

Discuss the management of hepatitis B

A
  • Stop smoking & alcohol
  • Educate transmission
  • Anti-viral medication therapy to slow progress and reduce infectivity
  • Test for complications
  • Liver transplant (end stage liver disease)
65
Q

Discuss the management of hepatitis B in pregnancy

A
  • all pregnant women are offered screening for hepatitis B
  • babies born to mothers who are chronically infected with hepatitis B or to mothers who’ve had acute hepatitis B during pregnancy should receive a complete course of vaccination + hepatitis B immunoglobulin
  • studies are currently evaluating the role of oral antiviral treatment (e.g. Lamivudine) in the latter part of pregnancy
  • there is little evidence to suggest caesarean section reduces vertical transmission rates
  • hepatitis B cannot be transmitted via breastfeeding (in contrast to HIV)
66
Q

For hepatitis C, discuss:

  • RNA or DNA
  • Transmission
  • Spontaneous recovery or chronic
  • Vaccine
A
  • RNA
  • Blood & bodily fluids
  • 1 in 4 make spontaneous recovery, 3 in 4 develop chronic hepatitis
  • No vaccine

Management same as for hepatitis B

Yr4: Obstetrics & Gynaecology (24 decks)

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