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EOY4 > GenitoUrinary Medicine (GUM) > Flashcards

GenitoUrinary Medicine (GUM) Flashcards

1
Q

What are the risk factors for getting and STI? (4)

A
  • Age <25
  • Previous Hx
  • No condom use
  • Partners - frequent change/ lots at one time
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2
Q

What are the 7 main principles of STI management?

A

Testing

Treatment

Partner Notification

Prophylaxis e.g. for procedures that may cause ascending infections e.g. insertion of IUS

Vaccine (Hep B, HPV)

Low threshold for assessment and treatment

Don’t shag until both parties have completed treatment

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3
Q

Why should partners be notified?

A

To trace and treat +/- test

Prevents complications

Prevents partner transmitting to anyone else

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4
Q

How can partners be notified?

A

Patient referral (pt tells partner themselves)

Provider referral (service tells partner = preserves anonymity)

Conditional referral (service tells partner if pt does not within a specific time frame)

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5
Q

For which infections is NAAT needed?

A

Chlamydia

Gonorrhoea

HSV

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6
Q

For which infections is a blood sample needed?

A

HIV

Syphilis

Hep B (Woman or partner from high risk country)

Hep C (if woman or partner has ever injected drugs)

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7
Q

What is included in the sexual health MOT?

A

Chlamydia and Gonorrheoa

HIV and Syphilis

Trichomonas Vaginalis

Candida

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8
Q

What is chlamydia trachomatis?

A

An obligate intracellular gram -ve organism

Mainly STI but can cause other infection depending on what has gone where

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9
Q

What is the incubation period of Chlamydia Trachomatis?

A

2 weeks

So won’t show within this period of having unprotected sex

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10
Q

What are the serotypes of Chlamydia and what can they cause?

A

Chlamydia D to K = genitourinary infection

Chlamydia L1 to L3 = Lymphogranuloma Verenum (LGV)

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11
Q

What are the risk factors for Chlamydia?

A

Non-modifiable = age below 25, bacterial flora, genetic predisposition

Modifiable = no condom use, multiple/frequently changing partners, non-barrier contraception, partner has chlamyd, low socio-economic status

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12
Q

What are the symptoms of chlamydia often seen in females?

A

OFTEN ASYMPTOMATIC (70%)

Dysuria
Abnormal discharge
PCB/IMB
Lower abdominal pain

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13
Q

What are the signs of chlamydia often seen in females?

A

Cervix - excited, inflamed, cobblestoned, contact bleeding

Mucopurulent

Abdo/adnexal tenderness

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14
Q

What change in the bacterial flora can increase the risk of getting chlamydia?

A

If the flora is lactobacillus iners dominant

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15
Q

What are the symptoms of chlamydia often seen in males?

A

OFTEN ASYMPTOMATIC (50%)

Dysuria +/- discharge
Epididymo-orchitis (unilateral testicle pain +/- swelling +/- fever)

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16
Q

What are the signs of chlamydia often seen in males?

A

Epididymal tenderness

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17
Q

Give 3 other ways in which chlamydia can present?

A

Reiter’s Syndrome/ REACTIVE ARTHRITIS (urethritis, conjunctivitis, arthritis - HLA-B27 associated, males)

Fitz-Hugh-Curtis (RUQ pain due to perihepatitis from PID)

Proctitis (rectal chlamydia)

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18
Q

When should sexual abuse be considered?

A

+ve test in 13-15 unless clear evidence from a consensual peer

All young people unless clear evidence showing consent

Esp if clear difference in mental capacity or power

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19
Q

Which investigations should be done if someone presents with chlamydia symptoms?

A

Bed
Bloods - do HIV and syphilis too
Imaging
Other - vulvovaginal swab/first catch urine specimen for NAAT

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20
Q

Which groups of people should be tested for chlamydia?

A

Everyone:

  • presenting to GUM clinic
  • with symptoms
  • partner has symptoms
  • under 25 and has had treatment within the past 3 months
  • concerned about exposure

Women:

  • undergoing procedures that can cause ascending infection
  • Presenting for a TOP
  • mothers to neonates with infection
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21
Q

What is the conservative management of Chlamydia Trachomatis?

A

Advice:

  • condom use
  • Treat current partner despite result
  • Don’t have sex until finish treatment/1 week after starting

Refer if:

  • Complicated management
  • Pregnant
  • Symptoms persist despite treatment
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22
Q

What is the medical management of Chlamydia Trachomatis?

A

1) Doxycycline PO BD for 7/7
2) Azithromycin PO as a one off
3) Ofloxacin/Erythromycin

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23
Q

What is Neisseria Gonrorrhoea?

A

Gram negative diplococcus

Incubation period of 2 weeks

Resistant to Ceftriaxone

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24
Q

How is gonorrhoea transmitted?

A

Direct inoculation of infected secretions from one mucous membrane to another

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25
Q

What are the risk factors for N Gonorrhoea?

A

Non-modifiable:
- Age (young)

Modifiable:

  • Hx previous STI
  • Co-existent STI
  • New/multiple partners
  • no condoms
  • Hx of drug use/commercial sex work
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26
Q

What are the symptoms of N. Gonorrhoea in males?

A

Urethral:

  • Discharge
  • Dysuria

Rectal:

  • Asymptomatic
  • Discharge
  • Bleeding
  • Pruritus
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27
Q

What are the signs of N. Gonorrhoea in males?

A

Mucopurulent urethral discharge

Epididymal tenderness

Balanitis (inflammation of the glans penis/foreskin)

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28
Q

What are the symptoms of N. Gonorrhoea in women?

A

Endocervical:

  • Asymptomatic (50%)
  • Change in discharge
  • Lower abdominal pain

Bartholinitis
Cervicitis
Dysuria

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29
Q

What are the signs of N. Gonorrhoea in women?

A

Mucopurulent endocervical discharge

Contact bleeding

Often normal

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30
Q

What are the signs of a neonatal infection with N. Gonorrhoea?

A

Acute conjuctivitis

Bilateral
Within 48 hours of birth
Chemosis + lid oedema

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31
Q

How is N. Gonorrhoea diagnosed?

A

Rapid = light microscopy of gram stained specimen

NAAT

Culture if +ve NAAT or symptoms

Take another sample 2 weeks later if pt has only had contact with known Dx

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32
Q

What advice should be given to someone presenting with N. Gonorrhoea?

A

Safe sex info

Avoid unprotected sex until both have completed treatment

Explain condition + long term effects

Explain routine screening

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33
Q

When should partner’s be notified if a patient has N. Gonorrhoea?

A

Males + symptoms = all partners within 2 weeks

Asymptomatic/non-urethral infection = all partners within past 3 months

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34
Q

Should follow-up be offered to individuals with N. Gonorrhoea?

A

YES

Check compliance and that symptoms have resolved

Partner notification

Health promotion

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35
Q

What is the medical management of N. Gonorrhoea?

A

Ceftriaxone IM STAT + Azithromycin PO STAT (or Doxy instead of Cef if penicillin allergic)

Or can give high dose Azithromycin/Cefotaxime as a one off

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36
Q

How should pregnant ladies with N. Gonorrhoea be managed medically?

A

The same as normal

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37
Q

What is haematogenous dissemination of gonoccocal disease?

A

Complication of n gonorrhoea

Skin lesions - papules/bullae/necrosis

Reiter’s syndrome

Meningitis/endocarditis/myocarditis

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38
Q

What is non-gonococcal urethritis? What are the most common causative organisms?

A

urethritis caused by other organisms and non-infective agents

Chlamydia trachomatis
mycoplasma genitalium
UTI
Adenovirus + conjunctivitis 
HSV
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39
Q

What is Syphilis?

A

STI caused by the spirochete Treponema Pallidum

Lies latent between episodes

Spread through close contact with an infected sore

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40
Q

What is the incubation period for Syphilis?

A

3 months!

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41
Q

What are the risk factors for syphilis?

A

PWID (people who inject drugs)

MSM

Hx STIs

Unprotected sex/sharing sex toys

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42
Q

What is the natural history of Syphilis?

A

Primary - Development of a deep, painless ulcer within 3-90 days of exposure

Secondary

  • Development of a painless, generalised rash even on palms and soles of feet within 4-10 weeks
  • Signs of systemic infection

Latent

  • Early = within 2 years
  • Late = after 2 years.

Tertiary

  • Gummatous
  • Neuro (Argyll Robertson pupil)
  • CVS
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43
Q

What are the investigations for Syphilis?

A

Bed
Bloods - Treponemal Enzyme Immunoassay (EIA) and Venereal Disease Referent Laboratory for stage and monitoring
Imaging
Other

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44
Q

What does EIA test for?

A

IgM for early infection
IgG for after 5 weeks

if both are -ve then repeat at 6 and 12 weeks after a high risk event

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45
Q

What is the medical management of Syphilis?

A

1) Large dose of BenPen IM Stat
2) PO Azithromycin Stat
3) Procain Penicillin IM OD for 10 days
4) Doxy for 2 weeks

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46
Q

What is the management of late latent syphilis?

A

BenPen weekly for 3 weeks

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47
Q

What is the management of neurosyphilis?

A

Procaine penicillin OD IM for 3 weeks with Probenecid

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48
Q

What is the management of syphilis in pregnancy?

A

1st and 2nd trimester = single dose BenPen

3rd trimester= 2x benpen 1 week apart

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49
Q

What is the Jarisch-Herxheimer reaction?

A

Acute febrile illness with headache, myalgia, chills, riggers (like flu)

Reaction to treatment

Only an issue if neuo or ophthalmic involvement or in pregnancy

Manage with antipyretics and reassurance

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50
Q

Describe the presentation of primary syphilis

A

primary lesion at site of infection that heals within 6 weeks

Starts as a small, painless papule then quickly turns into a chancre

51
Q

What is a chancre?

A

A single round, painless lesion that is surrounded by a red margin, indurated with a clean base and discharges clear serum

52
Q

Describe the presentation of secondary syphillis

A

Appears 6 weeks after primary lesion and can mimic any condition under the bloody sun e.g. night time headache, polymorphic generalised rash, CN palsies

53
Q

How is early latent syphilis characterised?

A

+ve serology but no clinical signs of a treponemal infection

Within first two years of infection

54
Q

How is late latent syphilis characterised?

A

+ve serology but no clinical signs of a treponemal infection

After two years

Gummatous/CVS/Neuro

55
Q

Describe the presentation of tertiary syphilis

A

Neuro - dorsal column loss (tabes dorsalis)/ Dementia

CVS - Aortitis (regurg/aneurysm/angina)

Gummata - inflammatory fibrous nodules that are local destructive

56
Q

What is an anogenital wart?

A

A benign, proliferative epithelia growth caused by a HPV infection

57
Q

What are the modifiable risk factors for contracting anogenital warts?

A

smoking

multiple sexual partners

Hx of other STIs (often coexist)

early first sexual experience

Anal sex

58
Q

What is the conservative management of anogenital warts?

A

Leave them alone

1/3 regress spontaneously within 6 months

59
Q

What is the medical management of anogenital warts?

A

Podophyllotoxin cream (For soft, non-keratinised external genital warts)

Imiquimod
Trichloracetic acid

All need to be avoided in pregnancy so do cryo instead

60
Q

What is the ‘surgical’ management of anogenital warts?

A

Ablation
Cryotherapy (you have seen this)
Excision etc

61
Q

How does Herpes Simplex Virus 1 present?

A

The oral one!

Lesions around the mouth

62
Q

How does Herpes Simplex Virus 2 present?

A

The genital one!

Lesions on the genitals

63
Q

How is HSV transmitted?

A

Genital = contact with infectious secretions or lesions from other anatomical sites

Individual can be asymptomatic but still shedding

64
Q

How does HSV lead to a recurrent infection?

A

Becomes latent in local sensory ganglia near the skin

Moves to skin when reactivates = lesions

Shedding becomes less frequent over time

65
Q

What are the non-modifiable risk factors for HSV contraction?

A

Female gender

66
Q

What are the modifiable risk factors for HSV contraction?

A 
Multiple partners
Previous Hx
Early age of first sexual intercourse
Unprotected sex
MSM
HIV
67
Q

How does the primary infection of HSV present?

A

1 week long prodrome - flu like symptoms

Tingling neuropathic pain in perineal areas

BILATERAL crops of ulcers in the genital area + tender lymph nodes

68
Q

How does the presentation of a recurrent HSV infection present?

A

UNILATERAL

Shorter episodes (~10 days)

Milder symptoms

69
Q

What investigations should be done to diagnose HSV?

A

Swab vesicles for PCR and viral culture

70
Q

Give 4 complications of HSV

A

Eczema herpeticum

Dendritic ulcer

Erythema multiforme

CN palsies

71
Q

What is the conservative/supportive management of HSV?

A

Refer to GUM + other STI screening

Salt water bath

Pain relief - oral analgesia, topical lidocaine

72
Q

What is the medical management of HSV?

A

Primary attack = Aciclovir for 5 days

Recurrent = still the same but only as required

73
Q

What is the suppressive therapy for HSV and when is it needeD?

A

Aciclovir for 1 year

Give if >6 attacks per year

Takes 5 days to start working

74
Q

What happens if a primary HSV attack occurs during pregnancy?

A

C section required if in 3rd trimester

Don’t have unprotected sex with partner if he has herpes. swab him and blood test

75
Q

What is bacterial vaginosis?

A

A bacterial infection of the vagina caused by an overgrowth of MIXED ANAEROBES

Gardenella and Mycoplasma hominis usually replace Lactobacilli

Vaginosis = not inflammatory but BV is most common cause of vaginitis

76
Q

What type of bacteria is gardnerella vaginalis?

A

A faculatively anaerobic gram -ve rod

77
Q

How does bac vag normally present?

A

↑ amount of vaginal discharge

Discharge is grey, thin, homogenous and sticks to mucosa

Malodorous - smells fishy

Not itchy or sore

78
Q

What factors may increase risk of bac bag?

A

New/increased number of sexual partners

More common with:
TOP
IUCD
PID

79
Q

What are the investigations for bac vag?

A

Clinical

Whiff test - fishy smell when add 10% KCl to discharge

Vaginal pH >5.5

80
Q

What is the conservative management of bac vag?

A

Usually self limiting

Avoid precipitates - douching, washing vag loads, scented soaps

81
Q

What is the medical management of bac vag?

A

Metronidazole for 5-7days

82
Q

What is the management of bac vag in a pregnant lady and why?

A

Symptomatic treatment = Metronidazole
Asymptomatic = discuss with obstetrician

Hx = risk of PPROM, SGA, PROM

83
Q

Give 3 causative agents of thrush

A

Candida albicans (80-90%)

Candida glabrata
Candida tropicalis

84
Q

Give 3 non-modifiable risk factors for thrush

A

Extremes of age

Associated with atopy (recurrent)

Local factors - heat, moisture

85
Q

Give 5 modifiable risk factors for thrush

A

Immunosuppression - HIV, steroids, chemo, radio

Pregnancy! (high oestrogen phases)

Metabolic - DM, cushings

Iatrogenic - broad spec abx, ITU, central venous catheter

Iron deficiency

86
Q

What are 5 symptoms of thrush?

A

Itchy vag

Sore vulva

Discharge - white, cottage cheese like, non-offensive smell

Superficial dysparenuina

? external dysuria

** Thrush symptoms are exacerbated before the period and get better during

87
Q

What are 3 signs of thrush?

A

Vulval erythema

Vulval oedema

Excoriations

88
Q

What are the investigations for thrush?

A

Clinical diagnosis

Only test if suspected bacterial infection or not responding to treatment

Vag wall swab + culture

89
Q

What is the conservative management of thrush?

A

Soap substitutes (not more than once daily)

Emollients to moisturise

Loose fitting, cotton underwear

Avoid topical irritants

90
Q

What is the medical management of thrush?

A

Basically an antifunfal pessary e.g. Clotrimazole* PV, Miconazole

*Can get with hydrocortisone

Or fluconazole PO if elsewhere

91
Q

What advice should you give when starting someone on thrush treatments?

A

Topical treatments might make burning worse for first few days - is oral better?

Return in 1-2 weeks if not resolved. Otherwise no follow up

Treatments might damage condoms - safe sex

Treat partner only if they are symptomatic

92
Q

When would a woman need to return to the GP instead of self treating with OTC for thrush?

A

<16 or >60

Pregnant/breastfeeding

Atypical symptoms/not resolving

Recurrent (>4 symptomatic episodes in 1 year with partial/complete resolution in between)

93
Q

What is trichomoniasis?

A

A flagellated protozoa that can lead to vaginitis, cervicitis and urethritis

Increases vag pH and polymporphs

94
Q

How does trichomoniasis present in women?

A

Has an incubation period of 4-28 days

Frothy, greenish discharge that smells REALLY REALLY BAD

Vulval itching + Sore

Dysuria

95
Q

What are the signs of trichomoniasis in women?

A

Strawberry cervix (exclusive to TV)

Vulvitis/vaginitis

96
Q

How does Trichomoniasis present in males?

A

usually asymptomatic

Non-Gonococcal urethritis

97
Q

What are the Ix for trichomoniasis in a woman?

A

High vaginal swab + wet microscopy at GUM clinic

Nucleic Amplification Tests - self taken VVS

(men is a urethral culture or first void urine)

+ test for other STIs and contact trace

98
Q

What is the management for trichomoniasis?

A

Metronidazole - treat both partners regardless of result

+ Contact tracing
+ don’t have sex until partner has been treated for 1 week

99
Q

Give 3 complications of trichomoniasis?

A

May enhance His transmission

PROM, low birth weight

Maternal sepsis

100
Q

Define Balanitis

A

Inflammation of the glans penis (the head)

101
Q

What is lichen sclerosis?

A

Chronic, recurrent pruritus in older women

Autoimmune associated e.g SLE, DM, thyroid disease

Associated with vulval squamous cell

102
Q

What does lichen sclerosis look like?

A

Figure of 8 round the Introits and anus = thin, white skin

103
Q

What is the incubation period for HIV?

A

4 weeks

104
Q

What is the pathophysiology behind HIV?

A

Retrovirus, penetrates host CD4 cells and infects it with own RNA

CD4 migrate to lymphoid tissue

Infected cells combine with normal and proliferate and make viral proteins

Viral proteins infect other cells and kill them = immune dysfunction

105
Q

What are the 5 stages of HIV?

A

Primary infection/seroconversion (asymptomatic with transient illness - temporary drop in CD4)

Stage 1 - asymptomatic + CD4 >500

Stage 2 - mild (fever, night sweats, weight loss) + CD4 350-500

Stage 3 - advanced (opportunistic infections) CD4 200-350

Stage 4/AIDS - Severe/AIDS defining illness CD4 <200

106
Q

What are the 5 AIDS defining illnesses?

A

Pneumocystis Pneumonia

Candida

Toxoplasmosis

TB

Kaposi’s sarcoma (HHV 8)

107
Q

What are 5 risk factors for HIV?

A

MSM

PWID (people who inject drugs)

Unprotected sex with multiple partners

Mothers have HIV

Blood transfusions

108
Q

What is the classic triad of symptoms for primary HIV infection?

A

Sore throat, high temperature, maculopapular truncal rash

109
Q

Give 5 key symptoms for AIDS?

A

Weight loss
Night sweats

Opportunistic infections
muscle aches
Oral infections/ulcers

110
Q

What are the blood tests that should be done to investigate HIV?

A

FBC
HIV antigen and Antibody (ELISA + Western blot) - +ve after 4-6 weeks

Can do a rapid finger prick and saliva test but do 2 because of false positives

111
Q

give 4 preventative measures for HIV?

A

Screening - test high risk people e.g. presenting with other STIs

Accessible screening/testing

Antiretrovirals for HIV +ve mothers

Sexual education: condoms!

112
Q

What is HAART?

A

Highly Active Antiretroviral Therapy

Use 3+ HIV drugs from at least 2 drug classes

113
Q

What are the goals of HAART?

A

Reduce HIV viral load below detectable limit

Restore immune function

Good QOL, normal life span, reduced risk of transmission

114
Q

What are the indications for HAART?

A

Hx AIDS defining illness/ CD4 <350

Pregnant Women

HIV associated nephropathy

Co-Existing HBV

Rapid decline in CD4

115
Q

What is Kaposi’s sarcoma?

A

Neoplasm from capillary endothelium caused by Human Herpes Virus 8

Purple papules/plaques on skin or mucosa

Mets to nodes

116
Q

What is Pneumocystis Pneumonia?

A

Pneumonia caused by fungus Pneumocystis Jiroveci

Bilateral diffuse/peri-hilar patches + cystic lesions

Co-trimoxazole if CD4 <200 + red

117
Q

What is post-exposure prophylaxis?

A

Anyone who has had unprotected sex/needle stick with a high risk source within last 72 hours

Report to occy health and get blood from both parties and retest at 3 and 6 months and again at 7 months

118
Q

What is pre-exposure prophylaxis?

A

Medications for those v high risk for HIV e.g. are -ve but have a sexual relationship with someone who is +ve who take anti HIV medications daily to lower chances of infection

Have to take every day

119
Q

Give 2 examples of when disclosing a diagnosis is unavoidable?

A

Confirming HIV status if court/police want the info

If pt is placing another person at risk of serious harm

120
Q

What is the law on underage sex?

A

Sexual intercourse and all forms of sexual touching of someone under 16 is illegal in England and Wales

Children under 13 are deemed incapable of consenting so it is classed as rape/SA and HAS TO BE REPORTED

There is no legal obligation to report underage sex unless exploitation is suspected

121
Q

What are the basic 5 principles of the Fraser guidelines?

A

1) understands the advice and what is involved
2) Doctor cannot persuade to inform parents/let doctor inform them
3) V likely to begin/continue having sex with or without contraception
4) In best interests to give advice/treatment without parental consent
5) Physical/mental health would suffer without contraception

122
Q

In which situations should information be disclosed to social services?

A

Child/young person is at risk of neglect/sexual/physical/emotional abuse

Info helps prevention/detection/prosecution of a serious crime

Child/young person is involved in behaviour that puts them or others at serious risk of harm

123
Q

When is the HIV transmission risk for someone on stable ARV similar to the risks of daily life?

A

Undetectable viral load for 6 months

Excellent adherence

No other STIs

EOY4 (22 decks)

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