GUM Flashcards
causes of genital ulceration?
- infectious (viral: HCV, varicella, CMV. bcaterial: syphilis, staph/strep, LGV, chancroid, donovanosis. fungal)
- inflammatory/immune (crohns, blistering skin conditions, aphthous)
- durg-related (FDE, topical reaction, IVDU)
- traumatic
- malignant
What tests are done for herpes?
- take a swab (send for PCR) on a wet blister/ulcer not crusted over
also offer full STI screen, syphilis serology, HIV antibody test
management of herpes?
- course of oral antiviral (e.g. aciclovir) 400mg TDS for 5 days
- 5% lidocaine ointment
- rest and analgesia
- salt watering bathing
- vaseline
- avoid sexual contact while symptomatic
- advise to disclose to partner
complications of herpes?
- urinary retention (due to extreme pain when passing)
- adhesions
- meningism
- emotional distress
- recurrences
are herpes ulcers painless or painful?
painful !
differential diagnose for genital ulcers?
- syphilis
- herpes simples
- lymphogranuloma venereum
- aphthous ulceration
- trauma
- Mpox
how do you diagnose syphilis?
from lesions:
- dark ground microscopy
- treponemal PCR
in blood:
- treponemal enzyme immunoassay (EIA)
- treponema pallidum particule agglutination assay (TPPA)
- rapid plasma reagin test (RPR)
- always perform full STI screen including HIV testing
first line treatment for syphilis?
early: benzathine pencillin IM one dose
late: benzathine penicillin IM 3 doses
what tests would you do on a symptomatic female?
- high vaginal loop swab fro microscopy and pH testing - TV, BV, candida
- vulvovaginal swab ‘dual NAAT’ - chlamydia and gonorrhea. may need throat and rectal
- bloods: HIV.syph +/- Hep B/C
+/-:
- high vaginal charcoal swab
- gonorrhea cultures
- HSV PCR
- urinalysis
- preg test
what tests would you do on a symptomatic male?
- urethral smear - GC/NSU, GC culture
- first pass urine - GC/CT dual NAATs test
- bloods HIV/syphilis +/- hep B/C
MSM may need rectal and pharyngeal swabs and culutres
other swabs - MC&S/candida/herpes
other test - urine dip
what tests would you do on a symptomatic male?
- urethral smear - GC/NSU, GC culture
- first pass urine - GC/CT dual NAATs test
- bloods HIV/syphilis +/- hep B/C
MSM may need rectal and pharyngeal swabs and culutres
other swabs - MC&S/candida/herpes
other test - urine dip
what tests would you do on a symptomatic male?
- urethral smear - GC/NSU, GC culture
- first pass urine - GC/CT dual NAATs test
- bloods HIV/syphilis +/- hep B/C
MSM may need rectal and pharyngeal swabs and culutres
other swabs - MC&S/candida/herpes
other test - urine dip
risk factors for candiasis?
- immunosupression (hiv, steroids, chemo)
- high oestrogen levels (preg, luteal phase, somes COCPs)
- recent ABx
- diabetes
- mucosal breakdown (sexual contact, dermatitis)
- recurrent candidiasis
how to treat candidal infection?
fluconazole 150mg stat or
clotrimazole 500mg pessary PV stat or
clotrimazole 1% cream for 2 wks
what are some important questions to ask regarding vaginal discharge?
colour
consistency
odour
associated symptoms: pain, bleeding, itchy, rash, triggers
what examinatons do you want to do on female patient?
- external + vulval examination
- speculum examination
- bimanual examination (if abdo pain/deep dyspareunia )
what swabs are used for different organisms?
- high vaginal swab - trichomonas vaginalis/candida/bacterial vaginosis
- vulvovaginal swab - N. gonorrhoeae and C.trachomatis
what are the clinical features of vaginal candida?
- thick, white discharge (cottage cheese like)
- itching
- soreness
- vulval erythema +/- fissures, pH 4
what investigations need to be done when suspecting candida?
- swabs taken from high vaginal walls
(- culture may grow candida but doesn’t distinguish colonisation)
risk factors for candida infection
- immunouspression
- high oestrogen levels
- recent ABx (up to 3 months before)
- diabetes mellitus
- mucosal breakdown (sexual contact, mucosal breakdown)
Tx for candida?
- fluconazole 150mg PO STAT or clotrimazole 500mg pessary PV stat
PLUS clotrimazole 1% cream top BD for 2 wks
what is the treatment fro recurrent candidiasis?
recurrent = > 4 times a yr
induction followed by maintenance:
- fluconazole 150mg every 72 hrs for 3 doses
- then fluconazole 150mg x1 a week for 6 months
- clotrimazole pessaries can be used if flucon. contraind.
(+ advice on douching, remove oestrogen e.g. POP)
what is bacterial vaginosis + how is it caused?
- imbalance of vaginal flora
loss of lactobacilli that maintain pH of vagina
= overgrowth of normal, commensal, anaerobic and facultative bacteria
rise in vaginal pH
NOT AN STI
triggers for bacterial vaginosis?
- sex
- menses
- receptive oral SI
- vaginal douching
- perfumed bath product
s- change in sexual partners - presence of STI
Tx of bacterial vaginosis?
metronidazole 400mg BD for 5 days
clincial features of trichonmonas vaginalis?
- frothy vaginal discharge
- dysuria
- vulval soreness/itching -> vulvitis, vaginitis
- strawberry cervix seen in 2%
how to diagnose trichomonas vaginalis
swab posterior fornix (HVS) - microscopy, culture, NAATs
Tx of trichomonas vaginalis?
- metronidazole 400mg PO BD 5-7 days
what investigations need to be doen in men who have genital diascharge ?
- urine NAATs for gonnorrhea and chlamydia
- swab from urethra (having held urine) - gram stained smear
- gonorrhoea culture (if clinical suspicion high)
(- MSU/urinalysis)
what is non specific urethritis (NSU) ?
inflammation of the urethra in the absence of a diagnosis of chlamydia or gonorrhoea
what are the clincial features os NSU?
urethral diacharge
dysuria
penile irritation
how woudl you diahnose NSU?
gram stain and microscopy of urethral sample
Tx of NSU?
- send STI screening
- treat with 1/52 of doxycycline 100mg PO BD
- abstain during treatment and treat partners
clicncial features of chlamydia in men and women ?
men:
- discharge
- dysuria
- testicular pain
women:
- discharge
- post coital bleeding
- intermenstrual bleeding
- lower abdo pain/ PID
- dysuria
50% asymptomatic in MEN and 70% asymptomatic in WOMEN !!!
Tx of chlamydia?
- doxycycline 100mg PO BD 7 days (azithromycin in pregnancy)
no test of cure needed
clincial features fo gonorrhea?
men: - purulent dscharge or epididymoorchitis, proctitis
women: - purulent dishcarge, IMB or PCB, PID, proctitis
how to diagnose gonorrhoea?
NAAT testing - vulvovaginal, urine, rectal, pharyngeal (dependign on expsosure)
culture - alwasy require prior to treatment for ABx sensitivities
test of cure required !!!! @ 2 wks
Tx for gonorrhoea?
ceftriaxone 1g STAT IM, single dose
- if sensitivities back back consider ciprofloxacin 500mg PO STAT
what are genital warts
condyloma acuminata (genital warts) are benign lesiosn caused by HPV (mostly 6 and 11) - sexually transmitted
small skin coloured or pink growths on genital skin
symptoms of genital warts
warty growths in genital skin, painless and often asymptomatic
little discomfort (sometimes itchy)
distorted urinary stream with urethral lesions
bleeding from cervical/urethral/anal lesions
rarely - secondary infection
name some lesions that can be mistaken for genital warts
- skin tags
- pearly penile papules
- fordyce spots
- molluscum contagiosum
- condylomata lata (occur in secondary syphilis)
- malignant or pre malignant conditions
Mx for genital warts?
- screen for other STIs
- encourgae condom use
- reassure that HPV is common and will resolve sponteneously
- or can discuss through Tx options
Tx for genital warts?
- destruction (cryotherapy)
- anti-mitotic agents (podophyllotoxin)
- immune modifiers (imiquimod cream)
- surgery
what is teh Tx/Mx for genital warts in pregnancy
- watch and wait, resolve post partum
- topical cream treatments contraindicated
- cryoablation is safe
- surgical removal possible in extreme cases
nmae some infective cuases of genital ulcers/sores
herpes simplex
herpes zoster
syphilis
topcial diseases: LGV, granuloma inguinale, chancroid
name the derm condition that can cause genital sorenss?
- fixed drug reactions
- bechets
- apthosis
- lichen planus
- pemphigus
- malignancy
4 stages of herpes simplex virus ulcers?
- painful tingly red macular lesions
- fluid filled ulcers
- burst and become painful ulcers
- heal forming fry cakey lesion
how long is the incubation period for HSV?
3-14 days
what can HSV look like on the cervix?
confluent necrotic type lesions
how can HSV interfer with pregnancy?
if recurrent episode then low risk
if primary infection !! in last trimester! then c section required
occasional use of prophylactic aciclovir in last trimester
cliincial featuyres of syphilis?
single, painless, undurated ulcer known as chancre
lymphadenopathy near lesion
what commonly causes PID?
- chlamydia and gonorrhoea
- gardnerella vaginalis / anaerobes
- mycoplasma genitalium
long term effects of PID?
- ifnertility
- increased risk of ectopic pregnancy
- chronic pelvic pain
- tuboovarian abscess
- fitz hugh curtis syndrome - RUQ pain, perihepatitis (= violin strign adhesions in peritoneal cavity attached to liver)
risk factors for PID?
- Hx of multiple partners
- Coil insertion
- chlamydia, gonorrhoea
- young age < 25
- previous PID
- TOP/miscarriage
- douching/BV
- new sexual partner
- instrumentation of uterus
symptoms/signs of PID?
- lower abdo pain
- deep dyspareunia
- abnormal PV discharge, often purulent
- PCB, IMB
- fever, chills
**can be aysmptomatic - cervical motion tenderness
- adnexal tenderness
- adnexal mass (if tuboovarian abscess)
- contact bleeding from cervix
hwo to diagnose PID?
- very difficult !! based on clinical features of infection on examination
- preggo test - to rule out ectopic
- test for chlam + gonorr
- dont wait for test results to come back to start Tx
- elevated ESR/WCC/CRP
- gram stained microscopy - look for endocervical pus cells
- USS may show hydrosalpinx/free fluid/ abscess
- MRI/CT may exclude/confirm other DDs
(- laparoscopy if still unknown)
Mx of PID?
- rest
- analgesia
- broad spec ABx (500mg IM ceftrixone + 100mg doxy BD for 2 wks + 400mg metronidazole BD for 2 wks)
- admit for obs if severe disease, pregnant, suspected tubo-ovarian abscess
- abstain sex
what is the reasonign for partners notification?
- break the chain of transmission
- prevent re-infection of the index patient
- prevent complications of untreated infection
- moral duty/ethics to inform
what are the partner notification methods?
- pt referral
- provider referral
- conditional or contract referral
Tx for trichomonas?
Metronidazole 2g PO STAT
