GUM Flashcards
What causes bacterial vaginosis?
overgrowth of anaerobic bacteria in the vagina due to loss of lactobacilli
Give examples of bacteria associated with BV
gardnerella vaginalis (most common)
mycoplasma hominis
prevotella species
What are the risk factors for BV?
multiple sexual partners (although it is not sexually transmitted)
excessive vaginal cleaning
recent antibiotics
smoking
copper coil
What is the standard presenting feature of BV?
fishy-smelling watery grey or white vaginal discharge
What investigations should be done for suspected BV?
vaginal pH (>4.5 = possible BV)
high vaginal or self-taken low vaginal swabs for microscopy
What is seen on microscopy in BV?
clue cells
What is Amsel’s criteria for diagnosis of BV?
3 of the following 4 points should be present:
thin, white homogenous discharge
clue cells on microscopy - stippled vaginal epithelial cells
vaginal pH >4.5
positive whiff test (addition of potassium hydroxide results in fishy odour)
What is the management of BV?
no treatment if asymptomatic - will self resolve
first line = metronidazole
2nd line = clindamycin
assess risk of other pelvic infections
provide advice about reducing the risk of further episodes (e.g. avoiding vaginal irrigation)
What happens if a patient drinks alcohol whilst taking metronidazole?
disfulfiram-like reaction - nausea, vomiting, flushing
What are the complications of BV?
increased risk of catching STIs
pregnant people:
miscarriage
preterm delivery
premature rupture of membranes
chorioamnionitis
low birth weight
postpartum endometritis
What are the risk factors for candidiasis?
increased oestrogen
poorly controlled diabetes
immunosuppression
broad-spectrum antibiotics
What is the presentation of vaginal candidiasis?
thick, white discharge that does not typically smell
vulval and vaginal itching, irritation or discomfort
severe infection = erythema, fissures, oedema, dyspareunia, dysuria, excoriation
What can testing the vaginal pH be used for?
differentiating between BV and trichomonas (pH >4.5) and candidiasis (pH <4.5)
What is the management of thrush?
first line = single dose of oral fluconazole 150mg
alternative = single dose of clotrimazole 500mg intravaginal pessary
vulval symptoms = add topical imidazole
pregnancy = only local treatments (e.g. cream or pessaries)
What information is important to give patients about antifungal creams and pessaries?
can damage latex condoms and prevent spermicides from working - alternative contraception is required for at least five days after use
What is defined as recurrent vaginal candidiasis?
4 or more episodes per year
What is the management of recurrent vaginal candidiasis?
check compliance with previous treatment
confirm diagnosis of candidiasis - high vaginal swab for microscopy and culture
consider a blood glucose test to exclude diabetes
exclude lichen sclerosus
consider the use of an induction-maintenance regime:
induction = oral fluconazole every 3 days for 3 doses
maintenance = oral fluconazole weekly for 6 months
What type of bacteria is Chlamydia trachomatis?
intracellular
gram-negative
What are the two types of swabs involved in sexual health testing?
charcoal swabs
nucleic acid amplification test (NAAT) swabs
How are charcoal swabs analysed?
microscopy, culture and sensitivities
What is the transport medium for charcoal swabs?
Amies transport medium
Where can charcoal swabs be taken from?
endocervical
high vaginal
What can charcoal swabs confirm?
BV
candidiasis
gonorrhoeae (specifically endocervical swab)
trichomonas vaginalis (specifically a swab from the posterior fornix)
other bacteria (e.g. group B strep)
How are NAAT swabs analysed?
check for DNA or RNA of the organism
What do NAAT swabs confirm?
chlamydia
gonorrhoea
Where can NAAT swabs be taken in a female patient?
highest to lowest preference:
endocervical
vulvovaginal
first catch urine
Where can NAAT swabs be taken in a male patient?
first-catch urine
urethral
What is the presentation of chlamydia in female patients?
abnormal vaginal discharge
pelvic pain
abnormal vaginal bleeding (intermenstrual or postcoital)
dyspareunia
dysuria
What is the presentation of chlamydia in male patients?
urethral discharge or discomfort
dysuria
epididymo-orchitis
reactive arthritis
What may be found on examination in suspected chlamydia?
pelvic or abdominal tenderness
cervical motion tenderness
inflamed cervix (cervicitis)
purulent discharge
What is the management of chlamydia?
1st line = doxycycline for 7 days
alternatives (e.g. in pregnant or breastfeeding patients) = azithromycin, erythromycin, amoxicillin
When should a test of cure be performed following treatment for chlamydia?
rectal cases
pregnancy
symptoms persist
What are the non-pregnancy complications of chlamydia infection?
PID
chronic pelvic pain
infertility
epididymo-orchitis
conjunctivitis
lymphogranuloma venereum
reactive arthritis
ectopic pregnancy
What are the pregnancy related complications of chlamydia?
preterm delivery
premature rupture of membranes
low birth weight
postpartum endometritis
neonatal infection (conjunctivitis, pneumonia)
What is lymphogranuloma venereum (LGV)?
condition affecting the lymphoid tissue around the site of infection with chlamydia
What patients does LGV most commonly occur in?
MSM
What are the three stages of LGV?
primary = painless ulcer on penis, vaginal wall or rectum (depends on site of sex)
secondary = lymphadenitis (swelling, inflammation and pain in the lymph nodes infected with the bacteria)
tertiary = proctocolitis
What are the symptoms of the tertiary stage of LGV?
anal pain
change in bowel habit
tenesmus (feeling of needing to empty the bowels, even after completing a bowel motion0
discharge
What is the treatment for LGV?
first line = 21 days of doxycycline
alternatives = erythromycin, azithromycin and ofloxacin
What type of bacteria is Neisseria gonorrhoeae?
gram-negative diplococcus
What is the presentation of gonorrhoea in female patients?
odourless purulent discharge - possible green or yellow
dysuria
pelvic pain
What is the presentation of gonorrhoea in male patients?
odourless purulent discharge - possibly green or yellow
dysuria
testicular pain or swelling (epididymo-orchitis)
What is the treatment of gonorrhoea?
first line:
single dose of IM ceftriaxone if the sensitivities are not known
single dose of oral ciprofloxacin if sensitivities are known
second line = oral cefixime + oral azithromycin
When should a test of cure be carried out for gonorrhoea?
all patients at least:
72 hrs after treatment for culture
7 days after treatment for RNA NAAT
14 days after treatment for DNA NAAT
What tests are used for test of cure in gonorrhoea?
asymptomatic = NAAT testing
symptomatic = cultures
How long should patients abstain from sex for after having an STI to reduce risk of reinfection?
seven days from treatment of all partners
What are the complications of gonorrhoea?
PID
chronic pelvic pain
infertility
epididymo-orchitis
prostatitis
conjunctivitis
urethral strictures
disseminated gonococcal infection
skin lesions
Fitz-Hugh-Curtis syndrome
septic arthritis
endocarditis
neonatal gonococcal conjunctivitis
Why is neonatal gonococcal conjunctivitis/ophthalmia neonatorum a medical emergency?
associated with sepsis, perforation of the eye and blindness
What are the symptoms of disseminated gonococcal infection?
various non-specific skin lesions
polyarthralgia (joint aches and pains)
migratory polyarthritis (arthritis that moves between joints)
tenosynovitis
systemic symptoms such as fever and fatigue
What does mycoplasma genitalium cause?
non-gonococcal urethritis
What is used to test for mycoplasma genitalium?
NAAT to look specifically for it
What is the management of mycoplasma genitalium?
1st line = doxycycline for 7 days, followed by azithromycin for 2 days (unless resistant to macrolides)
alternative = moxifloxacin
pregnancy and breastfeeding = azithromycin alone
What is endometritis?
inflammation of the endometrium
What is salpingitis?
inflammation of the fallopian tubes
What is oophoritis?
inflammation of the ovaries
What is parametritis?
inflammation of the parametrium (connective tissue around the uterus)
What is peritonitis?
inflammation of the peritoneal membrane
What causes PID?
most common = STIs:
Neisseria gonorrhoea
Chlamydia trachomatis
Mycoplasma genitalium
less common:
Gardnerlella vaginalis
Haemophilus influenzae
E. coli
What are the risk factors for PID?
not using barrier contraception
multiple sexual partners
younger age
existing STIs
previous PID
intrauterine device
What is the presentation of PID?
pelvic or lower abdominal pain
abnormal vaginal discharge
abnormal bleeding (intermenstrual or postcoital)
dyspareunia
fever
dysuria
What are the examination findings suggestive of PID?
pelvic tenderness
cervical motion tenderness (cervical excitation)
inflamed cervix (cervicitis)
purulent discharge
What is the management of PID?
single dose of IM ceftriaxone (to cover gonorrhoea)
14 days oral doxycycline (cover chlamydia and MG) and metronidazole (to cover Gardnella vaginalis)
What are the complications of PID?
sepsis
abscess
infertility
chronic pelvic pain
ectopic pregnancy
Fitz-Hugh-Curtis syndrome
What is Fitz-Hugh-Curtis syndrome?
inflammation and infection of the liver capsule (Glisson’s capsule) leading to adhesions between the liver and the peritoneum
What is the presenting feature of Fitz-Hugh-Curtis syndrome?
RUQ pain - can be referred to the right shoulder if there is any diaphragmatic irritation
How is Fitz-Hugh-Curtis syndrome managed?
laparoscopy can be used to visualise and also treat the adhesions by adhesiolysis
What type of organism is trichomonas vaginalis?
parasite
protozoan (single celled organism) with flagella (4 at the front, 1 at the back)
How is trichomonas spread?
sexual activity
What does trichomonas increase the risk of?
contracting HIV (damages vaginal mucosa)
BV
cervical cancer
PID
pregnancy complications (e.g. preterm delivery)
What are the symptoms of trichomoniasis?
vaginal discharge - often frothy and yellow-green with a fishy smell
pruritis
dysuria
dyspareunia
balanitis (inflammation to the glans penis)
What is seen on examination in trichomoniasis?
strawberry cervix/colpitis macularis (tiny haemorrhages across the surface)
What is the treatment of trichomoniasis?
metronidazole
What causes cold sores and genital herpes?
HSV-1 = mainly cold sores, can cause genital herpes via oral-genital sex
HSV-2 = mainly genital herpes
What sensory nerve ganglia does HSV become latent in?
cold sores = trigeminal nerve ganglion
genital herpes = sacral nerve ganglia
What does HSV cause?
cold sores
genital herpes
aphthous ulcers (small painful oral sores in the mouth)
herpes keratitis (inflammation of the cornea in the eye)
herpetic whitlow (painful skin lesion on a finger or thumb)
When is asymptomatic shedding of HSV most common?
first 12 months of infection
What is the presentation of genital herpes?
ulcers or blistering lesions affecting the genital area
neuropathic type pain
flu-like symptoms
dysuria
inguinal lymphadenopathy
(usually occur within 2 weeks of infection, symptoms can last three weeks in primary infection, recurrent episodes are usually milder and resolve more quickly)
What is the management of genital herpes?
aciclovir
symptoms control:
paracetamol
topical lidocaine 2% gel (e.g. Instillagel)
cleaning with warm salt water
topical vaseline
additional oral fluids
wear loose clothing
avoid intercourse with symptoms
What is the risk of genital herpes during pregnancy?
neonatal herpes simplex infection contracted during labour and delivery
What is the management of primary genital herpes during pregnancy?
contracted before 28 weeks = aciclovir during the initial infection, prophylactic aciclovir from 36 weeks onwards, SVD if asymptomatic, C section if symptomatic
contracted after 28 weeks = aciclovir during the initial infection, followed immediately by regular prophylactic aciclovir, C section recommended
What is the management of recurrent genital herpes during pregnancy?
prophylactic aciclovir from 36 weeks
What type of virus is HIV?
RNA retrovirus
What are the types of HIV?
HIV-1 (most common)
HIV-2 (rare outside West Africa)
What cells does HIV enter and destroy?
CD4 T-helper cells
What is the presentation of HIV infection?
initial seroconversion flu-like illness within a few weeks of infection
asymptomatic until it progresses to immunodeficiency - AIDs-defining illnesses and opportunistic infections
How is HIV transmitted?
unprotected anal, vaginal or oral sexual activity
mother to child at any stage of pregnancy, birth or breastfeeding (vertical transmission)
mucous membrane, blood or open wound exposure to infected blood or bodily fluids (e.g. sharing needles, needle-stick injuries, blood splashed in an eye)
Give examples of AIDS-defining illnesses
Kaposi’s sarcoma
pneumocystis jirovecii pneumonia (PCP)
CMV infection
candidiasis (oesophageal or bronchial)
lymphomas
TB
How long after contracting HIV can HIV testing be negative?
three months
What are the tests for HIV?
screening test = antibody testing (takes three months to develop antibodies)
p24 antigen test (can detect HIV infection quicker than antibody testing)
PCR testing for HIV RNA levels to determine viral load
How is HIV monitored?
CD4 count
viral load
What is a normal CD4 count?
500-1200 cells/mm3
What CD4 count indicates end-stage HIV (AIDs)?
<200 cells/mm3
What is the suggested starting regime of highly active anti-retrovirus therapy (HAART)?
two NRTIs plus a third agent
Give examples of NRTIs
tenofovir
emtricitabine
Give examples of the classes of HAART
protease inhibitors (PIs)
integrase inhibitors (IIs)
nucleoside reverse transcriptase inhibitors (NRTIs)
non-nucleoside reverse transcriptase inhibitors (NNRTIs)
entry inhibitors (EIs)
What is the management of HIV in addition to HAART?
prophylactic co-trimoxazole (Septrin) if CD4 <200 to protect against PCP
yearly cervical smears
avoid live vaccines
How are the babies of mothers with HIV delivered?
<50 copies/ml = normal vaginal delivery
>50 copies/ml = consider C section
>400 copies/ml = C section
>10000 copies/ml or unknown viral load = IV zidovudine during C section
What prophylaxis treatment is given to babies of mothers with HIV?
mothers viral load <50 = four weeks of zidovudine
mothers viral load >50 = four weeks of zidovudine, lamivudine and nevirapine
What is the advice for breastfeeding if the mother has HIV?
not recommended even if the viral load is undetectable
What is done to reduce the risk of transmission of HIV after exposure?
PEP within 72 hrs
combination of ART therapy = Truvada (emtricitabine and tenofovir) and raltegravir for 28 days
immediate HIV test and one a minimum of three months after exposure
What causes syphilis?
Treponema pallidum
What is the incubation period of Treponema pallidum?
21 days
How is syphilis transmitted?
oral, vaginal or anal sex involving direct contact with an infected area
vertical transmission
IV drug use
blood transfusions
What are the stages of syphilis?
primary
secondary
latent
tertiary
What is the presentation of primary syphilis?
painless genital ulcer (chancre) - resolves over 3-8 weeks
local lymphadenopathy
What is the presentation of secondary syphilis?
starts after chancre has healed
maculopapular rash
condylomata lata (grey-wart like lesions around the genitals and anus)
low-grade fever
lymphadenopathy
alopecia
oral lesions
What are the symptoms of tertiary syphilis?
gummatous lesions (gummas are granulomatous lesions that can affect the skin, organs and bones)
aortic aneurysms
neurosyphilis
What are the symptoms of neurosyphilis?
headache
altered behaviour
dementia
tabes dorsalis (demyelination affecting the spinal cord posterior columns)
ocular syphilis
paralysis
sensory impairment
Argyll-Robertson pupil (accommodates but doesn’t react - prostitutes pupil)
What are the tests for syphilis?
screening = antibody testing
diagnosis = samples from site of infection for dark field microscopy or PCR
What is the treatment of syphilis?
single deep IM dose of benzathine benzylpenicillin
alternatives = ceftriaxone, amoxicillin, doxycycline
How is thew response to syphilis treatment monitored?
nontreponemal titres should be monitored - fourfold decline is considered an adequate response
What reaction can occur following treatment for syphilis?
Jarisch-Herxheimer
What are the features of the Jarisch-Herxheimer reaction?
fever, rash and tachycardia after first dose of antibiotic
(in contrast to anaphylaxis, there is no wheeze or hypotension)
What is thought to be the cause of the Jarisch-Herxheimer reaction?
release of endotoxins following bacterial death
What is the treatment of the Jarisch-Herxheimer reaction?
supportive
antipyretics
What is the post-exposure prophylaxis for hepatitis A?
human normal immunoglobulin (HNIG) or a vaccine
What is the post-exposure prophylaxis for hepatitis B?
HBsAg positive source:
known responder to HBV vaccine = booster dose
non-responder (anti-HBs <10mIU/ml 1-2 months post-immunisation) = hepatitis B immune globulin (HBIG) and a booster vaccine
unknown source:
known responders = booster dose of HBV vaccine
known not responders = HBIG + vaccine, in process of being vaccinated should have an accelerated course
What is the post exposure prophylaxis for hepatitis C?
monthly PCR
if seroconversion then interferon +/- ribavirin
What is the post exposure prophylaxis for HIV?
combination or oral antiretrovirals started within 72 hrs of exposure and continued for 4 weeks
serological testing at 12 weeks
What is the most common opportunistic infection in AIDs?
pneumocystis jiroveci pneumonia (PCP)
What patients with HIV should receive PCP prophylaxis?
CD4 count <200
What are the features of pneumocystis jiroveci pneumonia?
dyspnoea
dry cough
fever
very few chest signs
extrapulmonary manifestations (rare) = hepatosplenomegaly, lymphadenopathy, choroid lesions
What is a common complication of PCP?
pneumothorax
What are the investigations for PCP?
CXR
exercise induced desaturation
sputum often fails to show PCP - bronchoalveolar lavage often needed to demonstrate PCP
What is seen on a CXR in PCP?
bilateral interstitial pulmonary infiltrates
What is the management of PCP?
co-trimoxazole
severe cases = IV pentamidine
steroids if hypoxic
What causes Kaposi’s sarcoma?
HH-V (human herpes virus 8)
How does Kaposi’s sarcoma present?
purple papules or plaques on the skin or mucosa
skin lesions may later ulcerate
respiratory involvement may cause massive haemoptysis and pleural effusion
What is the management of Kaposi’s sarcoma?
radiotherapy
resection
