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

GU medicine (sexual health) Flashcards

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
Q

At least what 3 processes involved in paraphilia?

A

Anxiety/ early emotional trauma interfering with normal psychosexual development, standard arousal pattern= replaced by another pattern, pattern often acquires symbolic and conditioning elements

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26
Q

Most common paraphilias?

A

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

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27
Q

Epidemio and causes of ED?

A

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

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28
Q

Assessing ED?

A

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

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29
Q

Causes of androgen deficiency?

A

Lack of testosterone, older men, obesity, chemo/ mumps/ radiotherapy, adenoma, prolactinoma, hypothalamus issue, absent gonads

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30
Q

1st line tx for ED?

A

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

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31
Q

ED tx alternatives?

A

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

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32
Q

What is a premature ejaculation? Usually when? Causes?

A

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

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33
Q

Tx for premature ejaculation?

A

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

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34
Q

Medication for premature ejaculation?

A

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

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35
Q

Dapoxetine not recommended in who? Common SEs?

A

Those with heart, kidney, and liver issues, can also interact with other antidepressants
Headaches, dizziness, feeling sick

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36
Q

Delayed ejaculation classed as either what or what?

A

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

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37
Q

Causes of delayed ejaculation?

A

Psychological- early sexual trauma, strict upbringing, relationship issues, stress/ depression
Physical- diabetes, spinal cord injuries, MS, surgery to bladder/ prostate, increasing age

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38
Q

Medicines causing delayed ejaculation? Can occur when?

A

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

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39
Q

Tx for delayed ejaculation?

A

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

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40
Q

What is retrograde ejaculation?

A

When semen travels into bladder instead of through urethra- no semen during ejaculation/ cloudy urine, still experience orgasm

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41
Q

Causes of retrograde ejaculation?

A

Damage to nerves/ muscles surrounding neck of bladder, prostate/ bladder surgery= most common
Diabetes, MS, alpha blockers

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42
Q

Tx for retrograde ejaculation?

A

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

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43
Q

What is Peyronie’s disease? Fraction of men?

A

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

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44
Q

Symptoms of Peyronie’s disease?

A

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

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45
Q

Causes of Peyronie’s disease?

A

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
Q

Ix for Peyronie’s disease?

A

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
Q

Tx of Peyronie’s disease?

A

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
Q

What is aspermia?

A

The failure to produce semen/ absence of sperm from the semen

49
Q

What is hypospadias? How is it fixed?

A

The opening of the penis is anywhere along the underside of the penis, may be caused by issues with hormones
Surgery

50
Q

What is anejaculation?

A

Absence of ejaculation during sexual activity, despite normal erections/ nocturnal emissions
Either primary/ secondary

51
Q

Causes of anejaculation?

A

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
Q

Tx for anejaculation?

A

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
Q

How long after a sexual risk should someone be swabbed for an STD? Fraction people young people infected with chlamydia?

A

7-14 days

3-7 in 100

54
Q

Where does chlamydia affected in men and women? Fraction on men and women have no symptoms?

A

Men= urethra, women= cervix, uterus and sometimes infection of the eye, throat and lungs
5/10 and 7/10

55
Q

Chlamydia symptoms in women if they do happen?

A

Post-coital or IM bleeding, increased/ purulent vaginal discharge, mucopurulent cervical discharge, deep dyspareunia, dysuria, pelvic pain and tenderness, inflamed/ friable cervix

56
Q

Chlamydia symptoms in men if they do happen? Consider what with anorectal sx- discomfort, discharge, bleeding & CIB habits?

A

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
Q

Chlamydia tests in men and women?

A

Vulvo-vaginal swab/ endocervical swab/ first- void urine sample

Men= first- void urine sample/ urethral swab

Anal/ oral sex= rectal/ throat swab

58
Q

Tx for chlamydia?

A

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
Q

Possible complications from chlamydia?

A

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
Q

Who can be screened for chlamydia?

A

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
Q

Gonorrhoea accounts for what fraction of STIs diagnosed in sexual health clinics in England? What can it affect?

A

9/10

Mainly the genital areas, men= usually the urethra, mouth and anus of both sexes

62
Q

Sx of gonorrhoea in women?

A

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
Q

Symptoms of gonorrhoea in men?

A

Men= mucopurulent/ purulent urethral discharge and/ or dysuria appearing 2-8 days after exposure, rare= testicular and epididymal pain

64
Q

Tests for gonorrhoea?

A

NAAT (vulvovaginal/ 1st- pass urine)
Rectal and pharyngeal swab in all MSM

65
Q

Tx for gonorrhoea?

A

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
Q

Complications from gonorrhoea?

A

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
Q

What is a triple swab? Each detects what? Charcoal swabs used for what? Can be used for what? NAAT tests?

A

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
Q

Fraction genital herpes don’t know they’re infected? Symptoms?

A

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
Q

Type herpes causing genital herpes? Passed on how?

A

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
Q

Test for herpes? Tx?

A

Swab for viral culture- PCR= more accurate

PO acyclovir- within 5 days of onset symptoms

71
Q

What is syphilis?

A

An infectious disease caused by a bacterium called Treponema pallidum- there are several stages of syphilis

72
Q

Symptoms of syphilis?

A

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
Q

How is syphilis passed on? Type of bacterium? Name of wart like lesions on genitals? Soft balls of inflammation in skin, bone and liver?

A

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
Q

Chancre commonly found where? Test for syphilis? Ulcer lasts how long?

A

On penis in men, vulva/ vagina in women/ anus in men/ women

6 weeks

75
Q

Tertiary syphilis complications?

A

Neurosyphilis
CV- aorta most commonly–> aneurysms, murmurs
Gummatous disease- can grow on skeleton, in/ under skin, on internal organs

76
Q

S+S of untreated congenital syphilis?

A

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
Q

Ix of syphilis?

A

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
Q

Tx for syphilis? Reaction to penicillin tx in syphillis?

A

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
Q

Look of thrush? Symptoms? Recurrent infections?

A

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
Q

RFs for thrush? Ix?

A

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
Q

Tx for thrush?

A

Antifungal e.g. oral fluconazole/ itraconazole- two doses over one day, topical cream/ pessary clotrimazole- single large dose/ lower dose for several days

82
Q

What is bacterial vaginosis? Symptoms? Cause?

A

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
Q

Risks of BV?

A

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
Q

Normal pH of vagina? Tests for BV?

A

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
Q

Tx for BV?

A

PO metronidazole BD for 7 days/ intravaginal clindamycin cream or metronidazole gel

86
Q

What is trichomoniasis?

A

An STI caused by trichomonas vaginalis
More common in younger people <25 y/o, x10 in black ethnic minority
Flagella protozoa parasite

87
Q

Symptoms of trichomoniasis?

A

Women: 50%= asymptomatic, vaginal discharge, vulval itching, dysuria, offensive odour
Men: 15-50% asymptomatic, urethral discharge and/ or dysuria

88
Q

Comps of trichomoniasis?

A

More risk of early labour and low birth weight, sepsis when born, PID, bacterial vaginosis, HIV, infertility

89
Q

Ix of trichomoniasis?

A

Women: high vaginal swab from posterior fornix
Men: urethral swab and/ or urine sample
Other STI tests

90
Q

Tx for trichomoniasis?

A

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
Q

What causes genital warts? How passed on? Fraction of people get them?

A

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
Q

Where do warts usually develop?

A

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
Q

What do genital warts look like?

A

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
Q

Tx for genital warts?

A

No tx
Chemical- podophyllotoxin, imiquimod cream
Physical- freezing w/ liquid nitrogen(cryotherapy), surgical removal under local anaesthetic, electrocautery- burning, laser tx

95
Q

3 most common HIV symptoms? Cancer usually only seen in people with AIDs? Other AIDs defining illnesses? Yearly what are recommended?

A

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
Q

Features of primary HIV infection? Ix? Offer what?

A

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

97
Q

How does HIV progress?

A

Asymptomatic once sx of PHI resolve- some–> advanced within 1-2 years, other= immunocompetent>10 years later

98
Q

When should HIV testing be offered in primary care? Routine test?

A

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

99
Q

Indications for cART in HIV?

A

Patients with hIV TB co-infection, hep B/C co-infection, AIDs- defining malignancy, symptomatic HIV- associated neurocognitive disorders, HIV- associated nephropathy(HIVAN)

100
Q

Features of CMV retinitis in HIV? On fundoscopy? Tx?

A

Reduced visual acuity- classic pizza pie appearance
Intraocular injections of ganciclovir and systemic oral valganciclovir

101
Q

Eye features of herpes simplex virus infection in HIV? Tx?

A

May affect the anterior/ posterior segment, if central area of cornea involved- vision may be permanently affected
Topical aciclovir

102
Q

Eye features of VSV infection in HIV? TB? Ocular malignancies found where?

A

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

103
Q

Resp differentials in HIV?

A

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

104
Q

What is Fitz- Hugh Curtis syndrome? Causes?

A

Peri-hepatitis that causes inflammation of the liver capsule– adhesions
N.gonorrhoea infection
Chlamydia trachomatis infection

105
Q

Presentation and Ix/tx of Fitz-Hugh Curtis syndrome?

A

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

106
Q

Sx of PID? Signs? 10% what sx?

A

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

107
Q

Causes of PID? RFs?

A

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

108
Q

Comps of PID? Ix?

A

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

109
Q

Tx of PID? Urgent admission if what?

A

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

110
Q

Example outpatient regime for PID?

A

Single dose IM ceftriaxone 1g cover gonorrhoea
Doxy 100mg BD for 14 days
Metronidazole 400mg BD for 14 days

111
Q

What is pneumocystis pneumonia? Common presentation in who? Sx?

A

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

112
Q

Ix and tx for pneumocystis pneumonia?

A

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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