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Phase 3A 'The List' conditions > GU medicine (sexual health) > Flashcards

GU medicine (sexual health) Flashcards

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1
Q

Structure of sexual history for both sexes?

A

PC, HPC, past GUM/ STI history, past medical/ surgical hx, drug hx- prescribed, OTC and recreational and allergies
Sexual hx- may need to go back 3-12 months :
last sexual intercourse, past/ previous sexual intercourse, regular/ casual partner/ friend/ one-night stand etc, sexual orientation, condom usage, type of sexual activity

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2
Q

Sexual hx for women/ men?

A

Menstrual hx (LMP and cycle), pregnancy hx, contraception- including condom use, cervical cytology hx

Last void urine- recent micturition may invalidate some clinical findings and tests

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3
Q

Examination for both sexes/ men/ women?

A

Skin, pubic hair, inguinal nodes
Penis, retraction and foreskin and meatus, scrotum, MSM= perianal area/ anal canal and oropharynx
Vulva, perineum and perianal area, vagina, cervix, bimanual pelvic examination if symptomatic, possibly anus and oropharynx

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4
Q

Investigations for asymptomatic/ symptomatic men?

A 
Heterosexual= first void urine for dual chlamydia and gonorrhoea nucleic acid amplification test (NAAT), venous blood sample for serological testing for syphilis (STS) and HIV
MSM= pharyngeal and rectal swabs for CT/ GC NAAT, add Hep B serology HepBsAg, HepBcAb and/ or AntiHBs if hx of vaccination

Hetero= urethral swab for gram staining with immediate microscopy and for GC culture on selective media, first void urine for CT/ GC NAAT, dipstick urinalysis, venous blood for STS/ HIV
MSM= add pharyngeal swabs for CT/ GC NAAT and GC culture and rectal swabs for CT/ GC NAAT and gram staining and GC culture, add Hep B serology
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5
Q

Investigations for asymptomatic/ symptomatic women?

A

Endocervical/ self-taken vulvo-vaginal swab for CT/ GC NAAT, venous blood for STS/ HIV

High vaginal swabs for wet mount preparation and gram staining for immediate microscopy to look for candida, bacterial vaginosis and trichomonas; microbial and fungal culture/ sensitivity testing, endocervical swabs for CT/ GC NAAT and gram staining and GC culture, venous blood for STS/ HIV

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6
Q

Ix for both asymp and symp women?

A

Pharyngeal and/ or rectal swabs where hx of oral sex on male partner, or receiving anal sex, of a contact of GC
Opportunistic cervical cytology if appropriate e.g. >25 y/o never had a smear/ overdue

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7
Q

Ix for both sexes?

A

Hep B serology in risk groups, hep C serology if hx of injecting drugs, MSM with HIV etc, herpes simplex PCR if genital ulceration/ fissures, dark ground wet mount microscopy for direct visualisation of treponema pallidum if genital ulceration and suspected syphilis

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8
Q

Common presentation for both sexes?

A

None- ‘check-up,’ or screening, genital ulceration- genital herpes (HSV types 1 and 2), syphilis, trauma, candida, genital dermatoses, tropical STIs, neoplasia

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9
Q

Common presentation in men?

A

Urethral discharge- chlamydia, gonorrhoea, non-specific urethritis, trichomonas, HSV
Balanitis/ balanoposthitis- candida/ anaerobes, HSV, genital dermatosis, allergy, neoplasia
Testicular pain/ swelling- epididymoorchitis due to chlamydia, NSU, gonorrhoea/ urinary tract pathogens e.g. e.coli

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10
Q

Common presentation in women?

A

Vaginal discharge- candida, bacterial vaginosis, trichomoniasis, chlamydia, gonorrhoea, HSV, physiological, foreign body, neoplasia
Lower abdominal/ pelvic pain- chlamydial or gonococcal pelvic inflammatory disease (PID), ectopic pregnancy, UTI, adhesions/ chronic pelvic pain
Irregular bleeding- chlamydia, gonorrhoea, pregnancy, contraception, cervical ectropion, neoplasia

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11
Q

Types of female sexual dysfunction?

A

Sexual interest/ arousal disorder- reduced/ absent interest in sex, reduced responsiveness, erotic thoughts/ masturbation and/ or reduced pleasure
Female orgasmic disorder- don’t/ can’t have orgasms, delayed/ have a reduction in intensity
Genito-pelvic pain/ penetration disorder- difficulty/ pain during penetration, fear/ anxiety about pain before/ during/ after, tightening/ tensing of pelvic floor muscles which prevent penetration

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12
Q

Epidemiology of FSD?

A

4/10 all women, 8/10 postmenopausal

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13
Q

Causes of FSD?

A

Age, menopause- low oestrogen, thyroid, DM, pituitary adenoma, atherosclerosis, neuro, meds- especially SSRI, urogenital atrophy (atrophic vaginitis,) thin dry skin, pain
Psycho= previous abuse, body image, depression/ anxiety, social= relationship issues, life stresses, pressure to perform

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14
Q

Causes of superficial dyspareunia? Deep?

A

Vaginismus(pelvic floor muscle spasm,) insufficient lube, thrush, herpes, vestibulo/ vulvodynia (with hypersensitivity)- , intact hymen, bartholinitis, lichen sclerosus, FGM

Insufficient lube, PID, endometriosis, cervical pathology, ovarian cysts, fibroids, womb position, bowel pain, bladder pain

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15
Q

Ix for FSD?

A

Hx- incl sexual, exam esp c.pain, BP, bloods- TFT, prolactin, testosterone, oestrogen, SHBG, glucose, lipids, FBC

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16
Q

Tx for FSD?

A

Lifestyle- stopping smoking and keeping alcohol consumption below the limit, weight loss
Couple counselling and psychosexual counselling, Sensate focus= 3-stage programme
CBT and psychotherapy- may help remove inhibitions and help libido and arousal and therefore orgasm
Kegel exercises - esp after childbirth
Topical/ systemic oestrogen
Devices- arousal and orgasmic disorders
Hormone tx after menopause e.g. Tibolone/ androgen supplementation, apomorphine for arousal and hypoactive sexual disorders
PDE-5 inhibitors e.g. sildenafil

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17
Q

What is loss of libido also known as? What can cause this?

A

Hypoactive sexual desire disorder
Mental illness, chronic tiredness, falling hormone levels, post- birth, chronic high alcohol, ED/ premature ejaculation, dyspareunia, poor relationship, ritualistic/ mundane sex

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18
Q

Ix for loss of libido?

A

The HADS tool, FBC- raised MCV due to excessive alcohol, U&E- Na and K may be deranged in adrenal disease, LFTs- esp if raised gamma GT–> excess alcohol, TFTs- hypothyroidism, FSH/ LH/ prolactin/ testosterone due to drugs/ alcohol, pelvic exam, BP check, tests for heart disease, prostate gland exam

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19
Q

Tx for hypoactive sexual desire disorder?

A

Counselling, lifestyle changes, antidepressants for depression, change in hypotensive tx, oestrogen in some women, transdermal testosterone patch in menopausal women

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20
Q

Causes of GPP?

A

Same as poor arousal and those directly causing increased pain in the pelvic area- lack of lube, reduced blood flow, soreness, scarring, fear, gynae conditions, pregnancy, partner technique, non-standard sexual practices, bowel conditions- IBS, Crohn’s, joint pain, fibromyalgia/ chronic pain

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21
Q

What is dyspareunia?

A

Pain in the genital area/ pelvis during/ after having vaginal sex- most commonly early in sexual lives/ around menopause

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22
Q

What is vaginismus?

A

Powerful often painful contraction of muscles around entrance to vagina- makes penetration painful/ impossible

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23
Q

What is vulvodynia? Cause? Tx?

A

The vulval area becomes painful and extremely sensitive to pressure and touch, can be painful on attempted penetration
Uncertain- may involve nerves in the area
Use of emollient soap substitutes, creams that numb the area, medicines to lessen pain, physio and CBT

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24
Q

What are paraphilias?

A

Sexual arousal to atypical objects, situations, and/ or targets e.g. children, corpses, animals
Considered pathologic disorders only when both: intense and persistent and cause significant distress/ impairment in social, occupational, or other important areas of functioning, or they harm or have the potential to harm others e.g. children, nonconsenting adults
May have impaired/ nonexistent capacity for affectionate, reciprocal emotional and sexual intimacy with consenting partner

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25
At least what 3 processes involved in paraphilia?
Anxiety/ early emotional trauma interfering with normal psychosexual development, standard arousal pattern= replaced by another pattern, pattern often acquires symbolic and conditioning elements
26
Most common paraphilias?
Pedophilia, voyeurism- watching others, transvestic disorder- cross-dressing, exhibitionism- exposing to others Some= have significant personality disorders, making tx difficult, often more than one= present
27
Epidemio and causes of ED?
50% aged 40-70 years, 60%= organic, 15%= psychogenic, 25% mixed Lifestyle: obesity, smoking, alcohol, recreational drugs Trauma- bike riding, prostatic surgery, pelvic fracture, local radiation, drugs- ADs, antipsychotics, hypotensives, androgen inhibitors, vascular- IHD, HTN, PVD, endocrine- diabetes, neuro- MS, Parkinson's, psychogenic- increase symp tone
28
Assessing ED?
Hx for RFs, libido, shaving, exam- genital abnormalities e.g. hypogonadism, facial/ body hair, S2-S4 dermatomes, BP/ peripheral pulses Exclude diabetes- urinalysis/ blood glucose, serum testosterone
29
Causes of androgen deficiency?
Lack of testosterone, older men, obesity, chemo/ mumps/ radiotherapy, adenoma, prolactinoma, hypothalamus issue, absent gonads
30
1st line tx for ED?
Psychosexual therapy- alone/ in combination, phosphodiesterase-5 inhibitors- CI in taking nitrates, hypotension, unstable angina, recent CBV event/ MI e.g. sildenafil 50mg 1 hour pre-intercourse in 24 hrs Vardenafil 10mg 25-60min pre-intercourse Tadalafil 10mg 30 mins- 12 hours pre-intercourse
31
ED tx alternatives?
Central dopamine agonist- apomorphine 2mg sublingually 20 mins before intercourse Synthetic prostaglandin E1 agent e.g. alprostadil- intraurethral pellets/ intracavernosal injection Testosterone- IM/ transdermal when related--> hypogonadism Pelvic floor exercises with biofeedback if related to venous leakage/ occlusion Mechanical- vacuum devices(sucks venous blood into penis,) implants: inflatable devices, malleable rods
32
What is a premature ejaculation? Usually when? Causes?
Inability to control ejaculation (usually within a minute of penetration or up to 3 minutes if it is a new problem,) most common in under 40 years- 40% Psycho predominantly, penile hypersensitive, hyperthyroid, young, early stages of relationship, some medicine- cabergoline, recreational drugs- cocaine and amphetamine, chronic prostatitis, MS and peripheral neuropathy
33
Tx for premature ejaculation?
Increasing sex frequency, wearing a condom, 'squeeze technique'- squeeze head of penis for 1-20 seconds just before ejaculation, must be repeated 3 times before having an orgasm, 'start-stop technique'- stop stimulation/ intercourse just before ejaculating, ejaculation 1-2 hours before coitus, couples therapylocal anaesthetic gel/ ointment e.g. lidocaine/ prilocaine, less sensitive condoms
34
Medication for premature ejaculation?
SSRIs- paroxetine, citalopram, escitalopram, fluoxetine, sertraline Clomipramine just when going to have sex Dapoxetine (Priligy)- new SSRI for PE 1-3 hours before sex, review after 4 weeks, then every 6 months Sildenafil+ SSRI Surgery for short frenulum
35
Dapoxetine not recommended in who? Common SEs?
Those with heart, kidney, and liver issues, can also interact with other antidepressants Headaches, dizziness, feeling sick
36
Delayed ejaculation classed as either what or what?
Experiencing delay before ejaculation/ being unable to ejaculate at all even though erection is normal 30-60 minutes, at least 1/2 times have sex
37
Causes of delayed ejaculation?
Psychological- early sexual trauma, strict upbringing, relationship issues, stress/ depression Physical- diabetes, spinal cord injuries, MS, surgery to bladder/ prostate, increasing age
38
Medicines causing delayed ejaculation? Can occur when?
Antidepressants- SSRIs particularly, BP meds- beta- blockers, antipsychotics, muscle relaxants- baclofen, powerful painkillers- methadone With no previous issues, have always experienced it, in all sexual situations, only in certain situations, can when masturbating but not during sex
39
Tx for delayed ejaculation?
Sex therapy- psychotherapy+ structural changes in sex life, service 'Relate' Switching medicine- amantadine( viral infections,) buproprion- quit smoking, yohimbine- erectile dysfunction Addressing alcohol and drugs Pseudoephedrine Help block some of chemical effects of SSRIs contributing to delayed ejaculation
40
What is retrograde ejaculation?
When semen travels into bladder instead of through urethra- no semen during ejaculation/ cloudy urine, still experience orgasm
41
Causes of retrograde ejaculation?
Damage to nerves/ muscles surrounding neck of bladder, prostate/ bladder surgery= most common Diabetes, MS, alpha blockers
42
Tx for retrograde ejaculation?
Most still enjoy sex life, need no tx Pseudoephedrine- caused by diabetes/ surgery Stop medication causing If muscle/ nerve damage, tx may not be possible Take sperm from urine for use in artificial insemination/ IVF
43
What is Peyronie's disease? Fraction of men?
When you have a curved/ bent penis- fibrous infiltration of the penile intracavernous septum, leads to plaque formation causing curvature and angulation of the erect penis 1/20 men, most in middle-aged men, can be in teenage boys
44
Symptoms of Peyronie's disease?
First= painful erections, over few months= curved/ bent, most common= upwards, also downwards/ to the side After about a year= curving will stop and stay the same, pain usually goes away at this point Occasionally curved penis goes back to normal without any treatment, usually penis looks normal when soft, curve only visible in erection
45
Causes of Peyronie's disease?
Generally= some damage to the penis, either during sex/ masturbation, some= heals normally, others= genetic predisposition to scar tissue forming, gathers on one side of your penis Diabetes, high BP, high cholesterol, Dupuytren's contracture, smoking, high alcohol intake
46
Ix for Peyronie's disease?
Painful erections and curved/ bent penis= usually enough, measure bend/ distortion of the penis whilst it is erect using photographs from home/ more accurately using a vacuum pump/ injection into the shaft to stimulate an erection May be asked to undergo a duplex ultrasound- blood circulation of the penis
47
Tx of Peyronie's disease?
Traction device- 2 hours a day, straightens out curve Vacuum device- gradually straightens out Shock wave therapy- sound waves by large machine, in hospital/ a clinic Meds injected into scar tissue- verapamil, interferon alpha 2B in curved bit, collagenase- dissolves scar tissue Surgery= anaesthetic and long recovery time
48
What is aspermia?
The failure to produce semen/ absence of sperm from the semen
49
What is hypospadias? How is it fixed?
The opening of the penis is anywhere along the underside of the penis, may be caused by issues with hormones Surgery
50
What is anejaculation?
Absence of ejaculation during sexual activity, despite normal erections/ nocturnal emissions Either primary/ secondary
51
Causes of anejaculation?
Situational, total- can be subdivided, anorgasmic= can both orgasm and ejaculate when asleep, orgasmic- can orgasm but not ejaculate Drugs- alcohol, prescription, stress, psychological issues, spinal cord injury, Parkinson's, MS and diabetes, infection/ trauma to pelvis and groin, previous surgery to pelvic area/ abdominal ops
52
Tx for anejaculation?
Change meds, reduce/ stop drinking/ other drugs, reduce stress, retrieve sperm for AI/ IVF in future for fertility Penile vibratory stimulation- in about 60% of men Electroejaculation therapy- usually under general anaesthetic, sperm= analysed for quality
53
How long after a sexual risk should someone be swabbed for an STD? Fraction people young people infected with chlamydia?
7-14 days | 3-7 in 100
54
Where does chlamydia affected in men and women? Fraction on men and women have no symptoms?
Men= urethra, women= cervix, uterus and sometimes infection of the eye, throat and lungs 5/10 and 7/10
55
Chlamydia symptoms in women if they do happen?
Post-coital or IM bleeding, increased/ purulent vaginal discharge, mucopurulent cervical discharge, deep dyspareunia, dysuria, pelvic pain and tenderness, inflamed/ friable cervix
56
Chlamydia symptoms in men if they do happen? Consider what with anorectal sx- discomfort, discharge, bleeding & CIB habits?
Dysuria, urethral discharge, urethral discomfort, epididymo-orchitis/ reactive arthritis Lymphogranuloma venereum- by serovars L1, L2 or L3 of chlamydia trachomatis, more common in MSM Painless genital ulcer=3-12 days after infection, inguinal lymphadenopathy, proctitis, rectal pain/ discharge, fever & malaise PCR of ulcer swab Oral doxy 100mg BD for 21 days/ oral tetracycline 2g daily for 21 days/ oral erythromycin 500mg QDS for 21 days
57
Chlamydia tests in men and women?
Vulvo-vaginal swab/ endocervical swab/ first- void urine sample Men= first- void urine sample/ urethral swab Anal/ oral sex= rectal/ throat swab
58
Tx for chlamydia?
Doxycycline 100mg BD for 7 days- CI in pregnancy, + breastfeeding= azithromycin, amoxicillin or erythromycin/ azithromycin one tablet daily- single dose 2nd line/ in pregnancy= PO azithromycin OD for 7 days Any other sexual partners within previous 6 months should be tested
59
Possible complications from chlamydia?
Can cause PID= 10-40 women in 100--> high fever and pain, silent PID over months/ years Damage to the fallopian tubes--> persistent pelvic pain, infertility, increased risk of ectopic pregnancy, miscarriages, premature birth and stillbirth, reduced fertility in men, reactive arthritis
60
Who can be screened for chlamydia?
Sexually active men and women under age 25 y/o, yearly/ each time have a new sexual partner Get other STI tests if positive too
61
Gonorrhoea accounts for what fraction of STIs diagnosed in sexual health clinics in England? What can it affect?
9/10 | Mainly the genital areas, men= usually the urethra, mouth and anus of both sexes
62
Sx of gonorrhoea in women?
Dysuria without urinary frequency Endocervical infection may present with increased/ altered vaginal discharge, lower abdominal pain, and/ or IM bleeding Rectal & pharyngeal infections= usually asymptomatic
63
Symptoms of gonorrhoea in men?
Men= mucopurulent/ purulent urethral discharge and/ or dysuria appearing 2-8 days after exposure, rare= testicular and epididymal pain
64
Tests for gonorrhoea?
NAAT (vulvovaginal/ 1st- pass urine) Rectal and pharyngeal swab in all MSM
65
Tx for gonorrhoea?
Oral ciprofloxacin 500mg (if sensitivities ARE known) + IM ceftriaxone 1g (sensitivities ARE known) Standard charcoal endocervical swab for microscopy, culture and ABx sensitivities before initiating
66
Complications from gonorrhoea?
Men= epididymitis, infertility, prostatitis, urethral stricture Women= PID and comps of pregnancy, rarely= Fitz- Hugh- Curtis syndrome Disseminated gonorrhoea- w/ bacteraemia--> septic arthritis, polyarthralgia, tenosynovitis, skin lesions, endocarditis/ meningitis
67
What is a triple swab? Each detects what? Charcoal swabs used for what? Can be used for what? NAAT tests?
An endocervical NAAT swab, endocervical charcoal media swab and a high-vaginal charcoal media swab Chlamydia and gonorrhoea Gonorrhoea Bacterial vaginosis, trichomonas vaginalis, candida, group B strep Microscopy, culture and sensitivities- endocervical and high vaginal swabs Check directly for DNA/ RNA- vulvovaginal/ endocervical swabs/ first-catch urine, rectal & pharyngeal
68
Fraction genital herpes don't know they're infected? Symptoms?
8/10 Primary= mild fever and aches and pains, groups of small painful blisters around genitals and/ or back passage, erupt over 1-2 weeks--> ulcers Swollen groins, dysuria- especially women Vaginal discharge, blisters and ulcers on cervix for up to 10-28 days Small raw area, one/ two small ulcers/ area of irritation Recurrences= shorter and less severe, 7-10 days, no fever usually, tingling itch in genital area for 12-24 hours Become less frequent over time, can vary between people, tend to be 1-4 per year Triggers= sunlight, illness, excess alcohol, stress
69
Type herpes causing genital herpes? Passed on how?
Type 2- can sometimes cause cold sores Skin-to-skin contact with affected area, moist skin lining mouth, genitals and anus= most susceptible, can pass through breaks in skin
70
Test for herpes? Tx?
Swab for viral culture- PCR= more accurate | PO acyclovir- within 5 days of onset symptoms
71
What is syphilis?
An infectious disease caused by a bacterium called Treponema pallidum- there are several stages of syphilis
72
Symptoms of syphilis?
Single painless papule erodes deeper into an ulcer- one or more on genital region/ mouth, usually painless and go away on their own after about 6 weeks (primary syphilis= 9-90 days after contact with germ) Secondary(4-10 weeks after)- non-painful rash, especially on hands and feet; feel generally unwell and tired; swollen glands; joint pains and warty lumps on the genitals (usually month after contact) Tertiary(20-40 years after primary)- serious complications affecting nervous system, heart, blood vessels and skin (many years post-infection)- aortic regurgitation/ aortitis/ arteritis, dementia, tabes dorsalis and gummata in skin and bone, Argyll- Robertson pupil(CSF examination for CNS involvement)
73
How is syphilis passed on? Type of bacterium? Name of wart like lesions on genitals? Soft balls of inflammation in skin, bone and liver?
Through contact with a syphilis sore/ through placenta- through vaginal, anal/ oral sex - highest in men who have sex with men Spirochaete bacterium Condylomata lata Chronic gummas
74
Chancre commonly found where? Test for syphilis? Ulcer lasts how long?
On penis in men, vulva/ vagina in women/ anus in men/ women | 6 weeks
75
Tertiary syphilis complications?
Neurosyphilis CV- aorta most commonly--> aneurysms, murmurs Gummatous disease- can grow on skeleton, in/ under skin, on internal organs
76
S+S of untreated congenital syphilis?
Rashes- peeling rash of palms, soles and around mouth and anus Enlarged liver and/ or spleen, abnormal bone X-rays, anaemia, enlarged glands, yellowing of skin/ whites of eyes- jaundice
77
Ix of syphilis?
Blood serology- treponemal serology, cardiolipin (non-treponemal,) swab from sore under microscope, blood test if ulcer has gone- antibodies Tertiary- CXR, ultrasound of heart, CT/MRI brain
78
Tx for syphilis? Reaction to penicillin tx in syphillis?
IM benzylpenicillin- single dose for primary and secondary(during pregnancy will prevent but not reverse fetal damage) Jarisch- Herxheimer reaction= fever, rash, rigors and tachycardia(as bacteria are lysed by antibiotic secrete an endotoxin--> inflammatory response)- may need admit and monitor patient & hydrate Later may need course of 3 injections at weekly intervals Azithromycin if allergic
79
Look of thrush? Symptoms? Recurrent infections?
Cottage cheese discharge- not smell and is white/ creamy Itchy red, inflamed vulva/ glans, superficial dyspareunia, dysuria 4 or more symptomatic episodes in one year
80
RFs for thrush? Ix?
DM, broad-spec Abx, AIDs/ immunosuppr/ steroids, HRT/ COCP Duration, frequency and severity of sx/ RFs/ txs tried, examination of external genitalia, high vaginal swab & culture
81
Tx for thrush?
Antifungal e.g. oral fluconazole/ itraconazole- two doses over one day, topical cream/ pessary clotrimazole- single large dose/ lower dose for several days
82
What is bacterial vaginosis? Symptoms? Cause?
An overgrowth of bacteria (including anaerobes, Gardnerella and mycoplasma hominis) in the vagina Fishy discharge from amines released by bacterial proteolysis- most common cause of discharge- particularly after sexual intercourse- can be watery and greyish in colour, NO red/ itchy vagina Overgrowth of anaerobic bacteria> lactobacilli, sexually active, recently changed sexual partner, past hx of STIs, Afro-Caribbean origins, use bubble bath, prolonged/ heavy periods, hormonal changes, following antibiotic course, too much washing, wearing thongs etc, IUD, smoking
83
Risks of BV?
Infection of womb higher following certain operations, increased HIV risk, more likely to pass on HIV, PID, early labour, miscarriage, preterm birth, low birth-weight, postpartum endometritis, lower IVF success rate
84
Normal pH of vagina? Tests for BV?
3.8-4.5, >4.5--> overgrowth of anaerobic bacteria Whiff test +ve- add alkaline--> distinctive smell, microscopy, increased pH Clue cells on microscopy- vaginal squamous epithelial cells coated with Gardenerella vaginosis
85
Tx for BV?
PO metronidazole BD for 7 days/ intravaginal clindamycin cream or metronidazole gel
86
What is trichomoniasis?
An STI caused by trichomonas vaginalis More common in younger people <25 y/o, x10 in black ethnic minority Flagella protozoa parasite
87
Symptoms of trichomoniasis?
Women: 50%= asymptomatic, vaginal discharge, vulval itching, dysuria, offensive odour Men: 15-50% asymptomatic, urethral discharge and/ or dysuria
88
Comps of trichomoniasis?
More risk of early labour and low birth weight, sepsis when born, PID, bacterial vaginosis, HIV, infertility
89
Ix of trichomoniasis?
Women: high vaginal swab from posterior fornix Men: urethral swab and/ or urine sample Other STI tests
90
Tx for trichomoniasis?
Oral metronidazole 400-500 mg BD for 5-7 days/ single 2g dose oral metronidazole/ tinidazole 2g dose not recommended in breastfeeding and symptomatic pregnant women
91
What causes genital warts? How passed on? Fraction of people get them?
By a virus called the HPV- over 100 types, most= types 6 and 11 Close skin-to-skin contact, sharing sex toys, when woman gives birth Can take weeks/ months to develop Can get anal warts without anal sex 1 in 10
92
Where do warts usually develop?
Men= outer skin of penis, women= on vulva, around anus in men + women Sometimes on cervix, inside vagina, on scrotum/ inside anus, inside urethra
93
What do genital warts look like?
May be one/ more, may be skin-coloured, red/ pink/ grey/ white On skin warm, moist and non-hairy= soft, dry and hairy= firm Some= only some and others= many Sometimes soreness and irritation, can bleed/ cause pain on intercourse/ bleeding/ difference in urine stream
94
Tx for genital warts?
No tx Chemical- podophyllotoxin, imiquimod cream Physical- freezing w/ liquid nitrogen(cryotherapy), surgical removal under local anaesthetic, electrocautery- burning, laser tx
95
3 most common HIV symptoms? Cancer usually only seen in people with AIDs? Other AIDs defining illnesses? Yearly what are recommended?
Sore throat, high temperature, blotchy red rash Reduced CD4 T cells<200 cells/mm3--> lymphadenopathy/ night sweats Kaposi's sarcoma, candidiasis of oesophagus, bronchi, trachea/ lungs, invasive cervical cancer, cryptococcosis, cryptosporidiosis, CMV inc CMV retinitis, HIV encephalopathy, histoplasmosis, lymphoma, mycobacterium tuberculosis, pneumocystis pneumonia, recurrent pneumonia, progressive multifocal leukoencephalopathy, toxoplasmosis
96
Features of primary HIV infection? Ix? Offer what?
Flu-like illness 2-6 weeks post-infection- fever, lymphadenopathy(highly infectious,) MP rash on upper chest, mucosal ulcers, myalgia, arthralgia & fatigue ELISA--> HIV viral load(HIV-1 & HIV-2 antibodies & HIV-1 p24 antigen, p24= usually earlier than HIV antibody, as early as 14 days post-exposure,) FBC, lymphocyte subset panel inc CD4 count, other STI screening- viral hepatitis, kidney function, liver function, glucose, lipids cART, contact tracing needed
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How does HIV progress?
Asymptomatic once sx of PHI resolve- some--> advanced within 1-2 years, other= immunocompetent>10 years later
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When should HIV testing be offered in primary care? Routine test?
Routine antenatal care, requests a test, has a RF/ another STI, newly registered not in past 12 months where prevalence =>2 in 1000, sx of PHI/ longstanding infection AIDs-defining illness, Ix with a STI, sexual partners of those known to be +ve, MSM, female contacts of MSM, injected drugs, from countries with high HIV prevalence, sexual contact abroad/ in UK with individuals from countries of high HIV prevalence, blood donors, dialysis patients, organ transplant donors and recipients
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Indications for cART in HIV?
Patients with hIV TB co-infection, hep B/C co-infection, AIDs- defining malignancy, symptomatic HIV- associated neurocognitive disorders, HIV- associated nephropathy(HIVAN)
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Features of CMV retinitis in HIV? On fundoscopy? Tx?
Reduced visual acuity- classic pizza pie appearance Intraocular injections of ganciclovir and systemic oral valganciclovir
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Eye features of herpes simplex virus infection in HIV? Tx?
May affect the anterior/ posterior segment, if central area of cornea involved- vision may be permanently affected Topical aciclovir
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Eye features of VSV infection in HIV? TB? Ocular malignancies found where?
Herpes zoster ophthalmicus--> eyelids red & swollen, keratitis, uveitis, progressive outer retinal necrosis, cerebral vasculitis Uveitis or discrete ocular granulomas within the retina- respond to regular TB tx Discrete lesions on the eyelid or growing within the conjunctiva- respond to cART
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Resp differentials in HIV?
Bacterial infection- URTI and acute bronchitis Bronchitis- mimics exacerbation of COPD Pneumonia- similar pathogens to non-HIV, radiographs can be atypical Pneumocystis pneumonia(PCP) Cryptococcal infection- can be ass w/ disseminated infection/ isolated infection, tx w/ antifungals e.g. fluconazole Histoplasmosis- almost always part of disseminated infection--> subacute infection w/ fever & weight loss, CXR= bilateral widespread nodules, tx= antifungal liposomal amphotericin Aspergillus- tx with voriconazole/ liposomal amphotericin
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What is Fitz- Hugh Curtis syndrome? Causes?
Peri-hepatitis that causes inflammation of the liver capsule-- adhesions N.gonorrhoea infection Chlamydia trachomatis infection
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Presentation and Ix/tx of Fitz-Hugh Curtis syndrome?
RUQ pain, referred--> shoulder tip if diaphragmatic irritation May be hx of PID, sx of chlamydial and gonorrhoeal= identical NAAT for both organisms, laparoscopy to visualise and tx adhesions by adhesiolysis, ABx
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Sx of PID? Signs? 10% what sx?
Bilateral abdominal pain, discharge, post-coital bleeding, deep dyspareunia, secondary dysmenorrhoea Adnexal tenderness, cervical motion tenderness on bi-manual, fever>38 degrees, cervical excitation, cervicitis, purulent discharge RUQ= due to Fitz- Hugh Curtis syndrome
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Causes of PID? RFs?
N.gonorrhoea--> more severe, chlamydia trachomatis, mycoplasma genitalium Less commonly= gardnerella vaginalis ass w/ BV, h.influenzae- resp, e.coli- UTIs <25 y/o, early age first coitus, multiple sexual partners, recent new partner<3 months, hx STI in the woman/ her partner, recent instrumentation of the uterus/ interruption of cervical barrier, not using barrier contraception, previous PID
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Comps of PID? Ix?
Tubal infertility, ectopic pregnancy, chronic pelvic pain, sepsis, abscess, Fitz-Hugh Curtis syndrome NAAT swabs + for mycoplasma genitalium if available, HIV+ syphilis test, high vaginal swab Pregnancy test exclude ectopic Inflammatory markers raised
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Tx of PID? Urgent admission if what?
Empirical ABx ASAP before swab results obtained, trace sexual contacts Ectopic can't be ruled out, severe sx, signs of pelvic peritonitis, surgical emergency can't be ruled out, woman= pregnant, tubo-ovarian abscess suspected, can't tolerate outpatient tx regimen
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Example outpatient regime for PID?
Single dose IM ceftriaxone 1g cover gonorrhoea Doxy 100mg BD for 14 days Metronidazole 400mg BD for 14 days
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What is pneumocystis pneumonia? Common presentation in who? Sx?
An infection with the fungus pneumocystis jiroveci Individuals w/ HIV who are non-compliant with their cART regimens/ ABx prophylaxis Fever, non-productive cough, exertional breathlessness ass w/ onset of infection Sometimes end inspiratory crackles on chest
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Ix and tx for pneumocystis pneumonia?
CXR= bilateral bihilar interstitial infiltrates, if CXR normal- high resolution CT can be requested for cysts & nodules Definitive Ix= bronchoscopy w/ bronchoalveolar lavage, samples stained using Grocott's silver stain--> Mexican hat appearance Blood gas for severity of disease(pO2<9.3kPa & arterial alveolar O2 gradient>4.7kPa= consider adjuvant corticosteroids) ABx e.g. trimoxazole/ clindamycin- primaquine, dapsone, IV pentamidine

Phase 3A 'The List' conditions (8 decks)

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