GenitoUrinary Medicine (GUM) Flashcards
What are the risk factors for getting and STI? (4)
- Age <25
- Previous Hx
- No condom use
- Partners - frequent change/ lots at one time
What are the 7 main principles of STI management?
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
Why should partners be notified?
To trace and treat +/- test
Prevents complications
Prevents partner transmitting to anyone else
How can partners be notified?
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)
For which infections is NAAT needed?
Chlamydia
Gonorrhoea
HSV
For which infections is a blood sample needed?
HIV
Syphilis
Hep B (Woman or partner from high risk country)
Hep C (if woman or partner has ever injected drugs)
What is included in the sexual health MOT?
Chlamydia and Gonorrheoa
HIV and Syphilis
Trichomonas Vaginalis
Candida
What is chlamydia trachomatis?
An obligate intracellular gram -ve organism
Mainly STI but can cause other infection depending on what has gone where
What is the incubation period of Chlamydia Trachomatis?
2 weeks
So won’t show within this period of having unprotected sex
What are the serotypes of Chlamydia and what can they cause?
Chlamydia D to K = genitourinary infection
Chlamydia L1 to L3 = Lymphogranuloma Verenum (LGV)
What are the risk factors for Chlamydia?
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
What are the symptoms of chlamydia often seen in females?
OFTEN ASYMPTOMATIC (70%)
Dysuria
Abnormal discharge
PCB/IMB
Lower abdominal pain
What are the signs of chlamydia often seen in females?
Cervix - excited, inflamed, cobblestoned, contact bleeding
Mucopurulent
Abdo/adnexal tenderness
What change in the bacterial flora can increase the risk of getting chlamydia?
If the flora is lactobacillus iners dominant
What are the symptoms of chlamydia often seen in males?
OFTEN ASYMPTOMATIC (50%)
Dysuria +/- discharge
Epididymo-orchitis (unilateral testicle pain +/- swelling +/- fever)
What are the signs of chlamydia often seen in males?
Epididymal tenderness
Give 3 other ways in which chlamydia can present?
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)
When should sexual abuse be considered?
+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
Which investigations should be done if someone presents with chlamydia symptoms?
Bed
Bloods - do HIV and syphilis too
Imaging
Other - vulvovaginal swab/first catch urine specimen for NAAT
Which groups of people should be tested for chlamydia?
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
What is the conservative management of Chlamydia Trachomatis?
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
What is the medical management of Chlamydia Trachomatis?
1) Doxycycline PO BD for 7/7
2) Azithromycin PO as a one off
3) Ofloxacin/Erythromycin
What is Neisseria Gonrorrhoea?
Gram negative diplococcus
Incubation period of 2 weeks
Resistant to Ceftriaxone
How is gonorrhoea transmitted?
Direct inoculation of infected secretions from one mucous membrane to another
What are the risk factors for N Gonorrhoea?
Non-modifiable:
- Age (young)
Modifiable:
- Hx previous STI
- Co-existent STI
- New/multiple partners
- no condoms
- Hx of drug use/commercial sex work
What are the symptoms of N. Gonorrhoea in males?
Urethral:
- Discharge
- Dysuria
Rectal:
- Asymptomatic
- Discharge
- Bleeding
- Pruritus
What are the signs of N. Gonorrhoea in males?
Mucopurulent urethral discharge
Epididymal tenderness
Balanitis (inflammation of the glans penis/foreskin)
What are the symptoms of N. Gonorrhoea in women?
Endocervical:
- Asymptomatic (50%)
- Change in discharge
- Lower abdominal pain
Bartholinitis
Cervicitis
Dysuria
What are the signs of N. Gonorrhoea in women?
Mucopurulent endocervical discharge
Contact bleeding
Often normal
What are the signs of a neonatal infection with N. Gonorrhoea?
Acute conjuctivitis
Bilateral
Within 48 hours of birth
Chemosis + lid oedema
How is N. Gonorrhoea diagnosed?
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
What advice should be given to someone presenting with N. Gonorrhoea?
Safe sex info
Avoid unprotected sex until both have completed treatment
Explain condition + long term effects
Explain routine screening
When should partner’s be notified if a patient has N. Gonorrhoea?
Males + symptoms = all partners within 2 weeks
Asymptomatic/non-urethral infection = all partners within past 3 months
Should follow-up be offered to individuals with N. Gonorrhoea?
YES
Check compliance and that symptoms have resolved
Partner notification
Health promotion
What is the medical management of N. Gonorrhoea?
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
How should pregnant ladies with N. Gonorrhoea be managed medically?
The same as normal
What is haematogenous dissemination of gonoccocal disease?
Complication of n gonorrhoea
Skin lesions - papules/bullae/necrosis
Reiter’s syndrome
Meningitis/endocarditis/myocarditis
What is non-gonococcal urethritis? What are the most common causative organisms?
urethritis caused by other organisms and non-infective agents
Chlamydia trachomatis mycoplasma genitalium UTI Adenovirus + conjunctivitis HSV
What is Syphilis?
STI caused by the spirochete Treponema Pallidum
Lies latent between episodes
Spread through close contact with an infected sore
What is the incubation period for Syphilis?
3 months!
What are the risk factors for syphilis?
PWID (people who inject drugs)
MSM
Hx STIs
Unprotected sex/sharing sex toys
What is the natural history of Syphilis?
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
What are the investigations for Syphilis?
Bed
Bloods - Treponemal Enzyme Immunoassay (EIA) and Venereal Disease Referent Laboratory for stage and monitoring
Imaging
Other
What does EIA test for?
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
What is the medical management of Syphilis?
1) Large dose of BenPen IM Stat
2) PO Azithromycin Stat
3) Procain Penicillin IM OD for 10 days
4) Doxy for 2 weeks
What is the management of late latent syphilis?
BenPen weekly for 3 weeks
What is the management of neurosyphilis?
Procaine penicillin OD IM for 3 weeks with Probenecid
What is the management of syphilis in pregnancy?
1st and 2nd trimester = single dose BenPen
3rd trimester= 2x benpen 1 week apart
What is the Jarisch-Herxheimer reaction?
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
Describe the presentation of primary syphilis
primary lesion at site of infection that heals within 6 weeks
Starts as a small, painless papule then quickly turns into a chancre
What is a chancre?
A single round, painless lesion that is surrounded by a red margin, indurated with a clean base and discharges clear serum
Describe the presentation of secondary syphillis
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
How is early latent syphilis characterised?
+ve serology but no clinical signs of a treponemal infection
Within first two years of infection
How is late latent syphilis characterised?
+ve serology but no clinical signs of a treponemal infection
After two years
Gummatous/CVS/Neuro
Describe the presentation of tertiary syphilis
Neuro - dorsal column loss (tabes dorsalis)/ Dementia
CVS - Aortitis (regurg/aneurysm/angina)
Gummata - inflammatory fibrous nodules that are local destructive
What is an anogenital wart?
A benign, proliferative epithelia growth caused by a HPV infection
What are the modifiable risk factors for contracting anogenital warts?
smoking
multiple sexual partners
Hx of other STIs (often coexist)
early first sexual experience
Anal sex
What is the conservative management of anogenital warts?
Leave them alone
1/3 regress spontaneously within 6 months
What is the medical management of anogenital warts?
Podophyllotoxin cream (For soft, non-keratinised external genital warts)
Imiquimod
Trichloracetic acid
All need to be avoided in pregnancy so do cryo instead
What is the ‘surgical’ management of anogenital warts?
Ablation
Cryotherapy (you have seen this)
Excision etc
How does Herpes Simplex Virus 1 present?
The oral one!
Lesions around the mouth
How does Herpes Simplex Virus 2 present?
The genital one!
Lesions on the genitals
How is HSV transmitted?
Genital = contact with infectious secretions or lesions from other anatomical sites
Individual can be asymptomatic but still shedding
How does HSV lead to a recurrent infection?
Becomes latent in local sensory ganglia near the skin
Moves to skin when reactivates = lesions
Shedding becomes less frequent over time
What are the non-modifiable risk factors for HSV contraction?
Female gender
What are the modifiable risk factors for HSV contraction?
Multiple partners Previous Hx Early age of first sexual intercourse Unprotected sex MSM HIV
How does the primary infection of HSV present?
1 week long prodrome - flu like symptoms
Tingling neuropathic pain in perineal areas
BILATERAL crops of ulcers in the genital area + tender lymph nodes
How does the presentation of a recurrent HSV infection present?
UNILATERAL
Shorter episodes (~10 days)
Milder symptoms
What investigations should be done to diagnose HSV?
Swab vesicles for PCR and viral culture
Give 4 complications of HSV
Eczema herpeticum
Dendritic ulcer
Erythema multiforme
CN palsies
What is the conservative/supportive management of HSV?
Refer to GUM + other STI screening
Salt water bath
Pain relief - oral analgesia, topical lidocaine
What is the medical management of HSV?
Primary attack = Aciclovir for 5 days
Recurrent = still the same but only as required
What is the suppressive therapy for HSV and when is it needeD?
Aciclovir for 1 year
Give if >6 attacks per year
Takes 5 days to start working
What happens if a primary HSV attack occurs during pregnancy?
C section required if in 3rd trimester
Don’t have unprotected sex with partner if he has herpes. swab him and blood test
What is bacterial vaginosis?
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
What type of bacteria is gardnerella vaginalis?
A faculatively anaerobic gram -ve rod
How does bac vag normally present?
↑ amount of vaginal discharge
Discharge is grey, thin, homogenous and sticks to mucosa
Malodorous - smells fishy
Not itchy or sore
What factors may increase risk of bac bag?
New/increased number of sexual partners
More common with:
TOP
IUCD
PID
What are the investigations for bac vag?
Clinical
Whiff test - fishy smell when add 10% KCl to discharge
Vaginal pH >5.5
What is the conservative management of bac vag?
Usually self limiting
Avoid precipitates - douching, washing vag loads, scented soaps
What is the medical management of bac vag?
Metronidazole for 5-7days
What is the management of bac vag in a pregnant lady and why?
Symptomatic treatment = Metronidazole
Asymptomatic = discuss with obstetrician
Hx = risk of PPROM, SGA, PROM
Give 3 causative agents of thrush
Candida albicans (80-90%)
Candida glabrata
Candida tropicalis
Give 3 non-modifiable risk factors for thrush
Extremes of age
Associated with atopy (recurrent)
Local factors - heat, moisture
Give 5 modifiable risk factors for thrush
Immunosuppression - HIV, steroids, chemo, radio
Pregnancy! (high oestrogen phases)
Metabolic - DM, cushings
Iatrogenic - broad spec abx, ITU, central venous catheter
Iron deficiency
What are 5 symptoms of thrush?
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
What are 3 signs of thrush?
Vulval erythema
Vulval oedema
Excoriations
What are the investigations for thrush?
Clinical diagnosis
Only test if suspected bacterial infection or not responding to treatment
Vag wall swab + culture
What is the conservative management of thrush?
Soap substitutes (not more than once daily)
Emollients to moisturise
Loose fitting, cotton underwear
Avoid topical irritants
What is the medical management of thrush?
Basically an antifunfal pessary e.g. Clotrimazole* PV, Miconazole
*Can get with hydrocortisone
Or fluconazole PO if elsewhere
What advice should you give when starting someone on thrush treatments?
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
When would a woman need to return to the GP instead of self treating with OTC for thrush?
<16 or >60
Pregnant/breastfeeding
Atypical symptoms/not resolving
Recurrent (>4 symptomatic episodes in 1 year with partial/complete resolution in between)
What is trichomoniasis?
A flagellated protozoa that can lead to vaginitis, cervicitis and urethritis
Increases vag pH and polymporphs
How does trichomoniasis present in women?
Has an incubation period of 4-28 days
Frothy, greenish discharge that smells REALLY REALLY BAD
Vulval itching + Sore
Dysuria
What are the signs of trichomoniasis in women?
Strawberry cervix (exclusive to TV)
Vulvitis/vaginitis
How does Trichomoniasis present in males?
usually asymptomatic
Non-Gonococcal urethritis
What are the Ix for trichomoniasis in a woman?
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
What is the management for trichomoniasis?
Metronidazole - treat both partners regardless of result
+ Contact tracing
+ don’t have sex until partner has been treated for 1 week
Give 3 complications of trichomoniasis?
May enhance His transmission
PROM, low birth weight
Maternal sepsis
Define Balanitis
Inflammation of the glans penis (the head)
What is lichen sclerosis?
Chronic, recurrent pruritus in older women
Autoimmune associated e.g SLE, DM, thyroid disease
Associated with vulval squamous cell
What does lichen sclerosis look like?
Figure of 8 round the Introits and anus = thin, white skin
What is the incubation period for HIV?
4 weeks
What is the pathophysiology behind HIV?
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
What are the 5 stages of HIV?
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
What are the 5 AIDS defining illnesses?
Pneumocystis Pneumonia
Candida
Toxoplasmosis
TB
Kaposi’s sarcoma (HHV 8)
What are 5 risk factors for HIV?
MSM
PWID (people who inject drugs)
Unprotected sex with multiple partners
Mothers have HIV
Blood transfusions
What is the classic triad of symptoms for primary HIV infection?
Sore throat, high temperature, maculopapular truncal rash
Give 5 key symptoms for AIDS?
Weight loss
Night sweats
Opportunistic infections
muscle aches
Oral infections/ulcers
What are the blood tests that should be done to investigate HIV?
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
give 4 preventative measures for HIV?
Screening - test high risk people e.g. presenting with other STIs
Accessible screening/testing
Antiretrovirals for HIV +ve mothers
Sexual education: condoms!
What is HAART?
Highly Active Antiretroviral Therapy
Use 3+ HIV drugs from at least 2 drug classes
What are the goals of HAART?
Reduce HIV viral load below detectable limit
Restore immune function
Good QOL, normal life span, reduced risk of transmission
What are the indications for HAART?
Hx AIDS defining illness/ CD4 <350
Pregnant Women
HIV associated nephropathy
Co-Existing HBV
Rapid decline in CD4
What is Kaposi’s sarcoma?
Neoplasm from capillary endothelium caused by Human Herpes Virus 8
Purple papules/plaques on skin or mucosa
Mets to nodes
What is Pneumocystis Pneumonia?
Pneumonia caused by fungus Pneumocystis Jiroveci
Bilateral diffuse/peri-hilar patches + cystic lesions
Co-trimoxazole if CD4 <200 + red
What is post-exposure prophylaxis?
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
What is pre-exposure prophylaxis?
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
Give 2 examples of when disclosing a diagnosis is unavoidable?
Confirming HIV status if court/police want the info
If pt is placing another person at risk of serious harm
What is the law on underage sex?
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
What are the basic 5 principles of the Fraser guidelines?
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
In which situations should information be disclosed to social services?
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
When is the HIV transmission risk for someone on stable ARV similar to the risks of daily life?
Undetectable viral load for 6 months
Excellent adherence
No other STIs
