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Core clinical problems > GUM > Flashcards

GUM Flashcards

1
Q

History GUM

A
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2
Q

Examination GUM men

A
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3
Q

Examination GUM women

A
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4
Q

Investigations GUM

A
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5
Q

Important microbiology GUM

A
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6
Q

balanitis

A

inflammation of glans/head of penis

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7
Q

Epididymo-orchitis

A

inflammation of epididymis (tube at back of testicle) and testicle

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8
Q

Epididymitis

A

inflammation of epididymis (tube at back of testicle)

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9
Q

Orchitis

A

inflammation of the testicle

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10
Q

Papules

A

small lumps on the skin

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11
Q

Macules

A

flat marks on the skin

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12
Q

typical history thrush in men

A

erythematous rash of head of penis
itching
white/creamy discharge
dysuria
dysparenunia
difficult to pull foreskin back

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13
Q

typical history thrush in women

A

thick white discharge
no smell
vulval and vaginal itching
irritation or discomfort

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14
Q

typical history gonorrhoea in men

A

odourless purulent discharge - may be green/yellow
dysuria
testicular pain or swelling (epididymo-orchitis)

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15
Q

typical history gonorrhoea in women

A

odourless purulent discharge
may be green/yellow
dysuria
pelvic pain

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16
Q

typical history disseminated gonococcal infection

A

non-specific skin lesions (petechial or pustular)
septic arthritis
Polyarthralgia (joint aches and pains)
Tenosynovitis
Systemic symptoms such as fever and fatigue

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17
Q

typical history chlamydia men

A

urethral discharge or discomfort
dysuria
epididymo-orchitis
reactive arthritis

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18
Q

typical history chlamydia women

A

abnormal vaginal discharge
pelvic pain
abnormal vaginal bleeding
dysparenunia
dysuria
intermenstrual bleeding

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19
Q

typical history lymphogranuloma venereum

A

affects lymphoid tissue around chlamydia infection,

1st stage: painless ulcer on vaginal wall/penis or rectum
2nd stage: lymphadenitis
3rd stage: inflammation of the rectum (proctitis) and anus causing anal pain, change in bowel habit, tenesmus,

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20
Q

typical history trichomonas men

A

balanitis (inflammation of glans penis)

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21
Q

typical history trichomonas women

A

vaginal discharge (frothy green/yellow-green, fishy smelling)
itching
dysuria
dyspareunia
strawberry cervix

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22
Q

typical history mycoplasma genitalium

A

urethritis

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23
Q

typical history bacterial vaginosis

A

fishy smelling watery grey or white vaginal discharge

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24
Q

typical history PID

A

Pelvic or lower abdominal pain
Abnormal vaginal discharge
Abnormal bleeding (intermenstrual or postcoital)
Pain during sex (dyspareunia)
Fever
Dysuria

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25
Q

typical history genital herpes

A

ulcers or blistering lesions
neuropathic type pain (tingling, burning or shooting)
dysuria
flu-like symptoms
inguinal lymphadenopathy

can also get urianry retention

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26
Q

typical history primary syphillis

A

painless ulcer

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27
Q

typical history secondary syphillis

A

3 weeks or more after painless ulcer formation: widespread rash of pink to brown macules
involves palms and soles of feet
small tracks in oral mucosa
lymphadenopathy

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28
Q

typical history tertiary syphillis

A

gummatous lesions
tabes dorsalis (demyelination affecting posterior columns)
ocular including anterior uveitis
aortic aneurysm,

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29
Q

typical history genital warts

A

small fleshy protuberances which are slightly pigmented, might bleed or itch

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30
Q

test for thrush

A

Often treatment for candidiasis is started empirically, based on the presentation.

Testing the vaginal pH using a swab and pH paper can be helpful in differentiating between bacterial vaginosis and trichomonas (pH > 4.5) and candidiasis (pH < 4.5).

A high vaginal charcoal swab with microscopy can confirm the diagnosis.

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31
Q

management thrush

A
  1. oral fluconazole 150 mg as a single dose first-line

clotrimazole 500 mg intravaginal pessary as a single dose if oral therapy is contraindicated

If there are vulval symptoms, consider adding a topical imidazole in addition to an oral or intravaginal antifungal

  1. if pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated
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32
Q

diagnosis gonnorrhoea

A

NAAT

A standard charcoal endocervical swab should be taken for microscopy, culture and antibiotic sensitivities before initiating antibiotics. This is particularly important given the high rates of antibiotic resistance.

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33
Q

Management gonorrhoea

A

A single dose of intramuscular ceftriaxone 1g if the sensitivities are NOT known

A single dose of oral ciprofloxacin 500mg if the sensitivities ARE known

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34
Q

test of cure gonorrhoea

A

This is with NAAT testing if they are asymptomatic, or cultures where they are symptomatic. BASHH recommend a test of cure at least:

72 hours after treatment for culture
7 days after treatment for RNA NATT
14 days after treatment for DNA NATT

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35
Q

Disseminated Gonococcal Infection

A

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
septic arthritis

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36
Q

test for chlamydia

A

NAAT

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37
Q

management of chlamydia

A

First-line for uncomplicated chlamydia infection is doxycycline 100mg twice a day for 7 days.

The guidelines previously recommended a single dose of azithromycin 1g orally as an alternative.

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38
Q

management of chlamydia in pregnancy and breast feeding

A

Azithromycin 1g stat then 500mg once a day for 2 days

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39
Q

Lymphogranuloma Venereum

A

Lymphogranuloma venereum (LGV) is a condition affecting the lymphoid tissue around the site of infection with chlamydia. It most commonly occurs in men who have sex with men (MSM). LGV occurs in three stages:

The primary stage involves a painless ulcer (primary lesion). This typically occurs on the penis in men, vaginal wall in women or rectum after anal sex.

The secondary stage involves lymphadenitis. This is swelling, inflammation and pain in the lymph nodes infected with the bacteria. The inguinal or femoral lymph nodes may be affected.

The tertiary stage involves inflammation of the rectum (proctitis) and anus. Proctocolitis leads to anal pain, change in bowel habit, tenesmus and discharge. Tenesmus is a feeling of needing to empty the bowels, even after completing a bowel motion.

Doxycycline 100mg twice daily for 21 days is the first-line treatment for LGV recommended by BASHH

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40
Q

unilateral conjunctivitis

A

Chlamydial conjunctivitis

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41
Q

what is trichomonas

A

Trichomonas vaginalis is a type of parasite spread through sexual intercourse. Trichomonas is classed as a protozoan, and is a single-celled organism with flagella.

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42
Q

complications of chlamydia?

A

Pelvic inflammatory disease
Chronic pelvic pain
Infertility
Ectopic pregnancy
Epididymo-orchitis
Conjunctivitis
Lymphogranuloma venereum
Reactive arthritis

43
Q

trichomonas complications

A

Contracting HIV by damaging the vaginal mucosa
Bacterial vaginosis
Cervical cancer
Pelvic inflammatory disease
Pregnancy-related complications such as preterm delivery.

44
Q

pregnancy complications chlamydia

A

Preterm delivery
Premature rupture of membranes
Low birth weight
Postpartum endometritis
Neonatal infection (conjunctivitis and pneumonia)

45
Q

investigation trichomonas

A

high vaginal charcoal swab with microscopy

46
Q

management trichomonas

A

metronidazole

47
Q

raised vaginal pH - value? indicate?

A

> 4.5

  • BV
  • trichomonas
48
Q

investigation genital herpes

A

clinical but can do:

Viral PCR swab from a lesion can confirm the diagnosis and causative organism.

49
Q

management genital herpes

A

Aciclovir

additional measures:
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

50
Q

genital herpes and pregnancy

A

Primary HSV-2 <28 weeks gestation
- aciclovir during the initial infection
- regular prophylactic aciclovir starting from 36 weeks gestation
- if asymptomatic at delivery can have a vaginal delivery (provided it is more than six weeks after the initial infection)

Primary HSV-2 >28 weeks gestation
- aciclovir during the initial infection followed immediately by regular prophylactic aciclovir.
- Caesarean section

Recurrent HSV-2
carries a low risk of neonatal infection (0-3%), even if the lesions are present during delivery. Regular prophylactic aciclovir is considered from 36 weeks gestation to reduce the risk of symptoms at the time of delivery.

51
Q

tests for syphillis

A

screening:
Antibody testing for antibodies to the T. pallidum bacteria can be used as a screening test for syphilis.

Samples from sites of infection can be tested to confirm the presence of T. pallidum with:
- Dark field microscopy
- Polymerase chain reaction (PCR)

The rapid plasma reagin (RPR) and venereal disease research laboratory (VDRL) tests (assessing for active infection) 2481632 thing

52
Q

treatment syphillis

A

deep intramuscular dose of benzathine benzylpenicillin (penicillin)

53
Q

Mycoplasma genitalium (MG)

A

bacteria that causes non-gonococcal urethritis

54
Q

investigation mycoplasma genitalium

A

Nucleic acid amplification tests (NAAT)

55
Q

management mycoplasma genitalium

A

Course of doxycycline followed by azithromycin for uncomplicated genital infections:

Doxycycline 100mg twice daily for 7 days then;
Azithromycin 1g stat then 500mg once a day for 2 days (unless it is known to be resistant to macrolides)

Moxifloxacin is used as an alternative or in complicated infections. Azithromycin alone is used in pregnancy and breastfeeding (remember doxycycline is contraindicated).

56
Q

testing for HIV

A

Antibody testing for screening (blood test) - needs 3 months to show up

Testing for the p24 antigen. This can give a positive result earlier in the infection compared with the antibody test.

PCR testing for the HIV RNA levels tests directly for the number of viral copies in the blood, giving a viral load.

57
Q

CD4 count

A

500-1200 cells/mm3 is the normal range

Under 200 cells/mm3 is considered end-stage HIV (AIDS) and puts the patient at high risk of opportunistic infections

58
Q

Viral load HIV - undetectable level?

A

Viral load is the number of copies of HIV RNA per ml of blood.

“Undetectable” refers to a viral load below the lab’s recordable range (usually 50 – 100 copies/ml).

The viral load can be in the hundreds of thousands in untreated HIV.

59
Q

management of HIV

A

Two NRTIs nucleotide reverse transcriptase inhibitors
- tenofovir
- emtricitabine

One other agent, usually integrase inhibitor
- doultegravir or raltegravir

60
Q

management if CD4 is less than 200

A

Prophylactic co-trimoxazole (Septrin) to protect against pneumocystis jirovecii pneumonia (PCP)

61
Q

cervical smears women with HIV

A

Yearly cervical smears

62
Q

how to prevent transmission of HIV during birth

A

Normal vaginal delivery is recommended for women with a viral load < 50 copies / ml

Caesarean section is considered in patients with > 50 copies copies / ml and in all women with > 400 copies / ml

IV zidovudine should be given during the caesarean if the viral load is unknown or there are > 10000 copies / ml

63
Q

can you breastfeed with HIV

A

not recommended

64
Q

what is PEP

A

PEP involves a combination of ART therapy. The current regime is Truvada (emtricitabine and tenofovir) and raltegravir for 28 days.

PEP is not 100% effective and must be commenced within a short window of opportunity (less than 72 hours)

HIV tests are done immediately and also a minimum of three months after exposure to confirm a negative status. Individuals should abstain from unprotected sexual activity for a minimum of three months until confirmed as negative.

65
Q

Pathophysiology BV

A

Lactobacilli are the main component of the healthy vaginal bacterial flora. These bacteria produce lactic acid that keeps the vaginal pH low (under 4.5). The acidic environment prevents other bacteria from overgrowing. When there are reduced numbers of lactobacilli in the vagina, the pH rises. This more alkaline environment enables anaerobic bacteria to multiply.

66
Q

Risk factors BV

A

Multiple sexual partners (although it is not sexually transmitted)
Excessive vaginal cleaning (douching, use of cleaning products and vaginal washes)
Recent antibiotics
Smoking
Copper coil
Bacterial vaginosis occurs less frequently in women taking the combined pill or using condoms effectively.

67
Q

Investigations BV

A

Vaginal pH can be tested using a swab and pH paper. The normal vaginal pH is 3.5 – 4.5. BV occurs with a pH above 4.5.

68
Q

Management BV

A

Metronidazole is the antibiotic of choice for treating bacterial vaginosis

This is given orally, or by vaginal gel. Clindamycin is an alternative but less optimal antibiotic choice.

69
Q

What do you need to remember to say when prescribing metronidazole

A

Whenever prescribing metronidazole advise patients to avoid alcohol for the duration of treatment. This is a crucial association you should remember, and something examiners will look out for when you are explaining the treatment to a patient. Alcohol and metronidazole can cause a “disulfiram-like reaction”, with nausea and vomiting, flushing and sometimes severe symptoms of shock and angioedema.

70
Q

What is pelvic inflammatory disease

A

inflammation and infection of the organs of the pelvis, caused by infection spreading up through the cervix

Most common causes:
Neisseria gonorrhoeae tends to produce more severe PID
Chlamydia trachomatis
Mycoplasma genitalium

71
Q

Invetsigation markers pelvic inflammatory disease

A

Pus cells on microscopy. The absence of pus cells is useful for excluding PID.

Raised CRP/ESR

72
Q

Management PID

A

refer to GUM

A single dose of intramuscular ceftriaxone 1g (to cover gonorrhoea)
Doxycycline 100mg twice daily for 14 days (to cover chlamydia and Mycoplasma genitalium)
Metronidazole 400mg twice daily for 14 days (to cover anaerobes such as Gardnerella vaginalis)

73
Q

management genital warts

A

topical podophyllum or cryotherapy are commonly used as first-line treatments depending on the location and type of lesion

multiple, non-keratinised warts are generally best treated with topical agents

solitary, keratinised warts respond better to cryotherapy

74
Q

pathogen genital warts

A

HPV 6 and 11

75
Q

whats a double/triple swab

A

Double swabs: a NAAT swab (endocervical or vulvovaginal) and a high vaginal charcoal media swab.

Triple swabs: a NAAT swab (endocervical or vulvovaginal), a high-vaginal charcoal media swab and an endocervical charcoal media swab.

76
Q

What CF colonising bacteria is bad

A

Pseudomonas aerginosa

77
Q

management of recurrent thrush

A

> 4 times a year

consider the use of an induction-maintenance regime
induction: oral fluconazole every 3 days for 3 doses
maintenance: oral fluconazole weekly for 6 months

78
Q

‘musty’, frothy, green vaginal discharge. On examination you an erythematous cervix with pinpoint areas of exudation.

A

trichomonas - erythema refers to strawberry cervix!

79
Q

discharge in gonorrhoea

A

purulent odorless, yellow or green

80
Q

what symptom in women do you get in chlamydia but not gonnorrhoea

A

PV bleeding

81
Q

Presentation secondary syphillis

A

Secondary syphilis typically starts after the chancre has healed, with symptoms of:
Maculopapular rash
Condylomata lata (grey wart-like lesions around the genitals and anus)
Low-grade fever
Lymphadenopathy
Alopecia (localised hair loss)
Oral lesions

82
Q

Presentation tertiary syphilis

A

Gummatous lesions (gummas are granulomatous lesions that can affect the skin, organs and bones)
Aortic aneurysms
Neurosyphilis

83
Q

Neurosyphilis presentation

A

Headache
Altered behaviour
Dementia
Tabes dorsalis (demyelination affecting the spinal cord posterior columns) therefore loss of fine touch and proprioception below level of lesion as dorsal column affected
Ocular syphilis (affecting the eyes)
Paralysis
Sensory impairment

Argyll-Robertson pupil (accomodate but doesn’t react)

84
Q

Thick, white discharge that does not typically smell
Vulval and vaginal itching, irritation or discomfort

A

thrush
Candida albicans

85
Q

Female
Odourless purulent discharge, possibly green or yellow
Dysuria
Pelvic pain

A

Gonorrhoea

86
Q

Male
Odourless purulent discharge, possibly green or yellow
Dysuria
Testicular pain or swelling (epididymo-orchitis)

A

Gonorrhoea

87
Q

Vaginal discharge
Itching
Dysuria (painful urination)
Dyspareunia (painful sex)
Balanitis (inflammation to the glans penis)
The typical description of the vaginal discharge is frothy and yellow-green, although this can vary significantly. It may have a fishy smell.

Examination of the cervix can reveal a characteristic “strawberry cervix”

A

trichomonas

88
Q

Ulcers or blistering lesions affecting the genital area
Neuropathic type pain (tingling, burning or shooting)
Flu-like symptoms (e.g. fatigue and headaches)
Dysuria (painful urination)
Inguinal lymphadenopathy
Symptoms can last three weeks in a primary infection. Recurrent episodes are usually milder and resolve more quickly.

A

herpes-2

89
Q

A painless genital ulcer (chancre). This tends to resolve over 3 – 8 weeks.
Local lymphadenopathy

A

primary syphillis

90
Q

Chancre has healed, with symptoms of:
Maculopapular rash
Condylomata lata (grey wart-like lesions around the genitals and anus)
Low-grade fever
Lymphadenopathy
Alopecia (localised hair loss)
Oral lesions

A

secondary syphillis

These symptoms can resolve after 3 – 12 weeks and the patient can enter the latent stage

91
Q

presentations tertiary syphillis

A

Gummatous lesions (gummas are granulomatous lesions that can affect the skin, organs and bones)
Aortic aneurysms
Neurosyphilis

92
Q

Headache
Altered behaviour
Dementia
Tabes dorsalis (demyelination affecting the spinal cord posterior columns)
Ocular syphilis (affecting the eyes)
Paralysis
Sensory impairment
pupils that accomodate but don’t react

A

neurosyphillis

Argyll-Robertson pupil

93
Q

fishy-smelling watery grey or white vaginal discharge

not itchy

A

bacterial vaginosis

94
Q

“clue cells” on microscopy

A

bacterial vaginosis

95
Q

Pelvic or lower abdominal pain
Abnormal vaginal discharge
Abnormal bleeding (intermenstrual or postcoital)
Pain during sex (dyspareunia)
Fever
Dysuria

Examination findings may reveal:
Pelvic tenderness
Cervical motion tenderness (cervical excitation)
Inflamed cervix (cervicitis)
Purulent discharge
Patients may have a fever and other signs of sepsis.

A

PID

96
Q

on genitals/anus
small (2 - 5 mm) fleshy protuberances which are slightly pigmented
may bleed or itch

A

genital warts (condylomata accuminata)

HPV 6 and 11

97
Q

Amsel criteria

A

Criteria for BV : 3 of 4 must be present

clue cells
white thin discharge
fishy smelling discharge / positive whiff test with addition of KOH
pH > 4.5

98
Q

Histology chlamydia

A

gram negative coccobacilli

99
Q

Histology syphillis

A

gram negative coil
spirochaete

100
Q

Histology gonorrhoea

A

gram negative diplococci

101
Q

why is HIV related to hypertension/CVD

A
  • as one part of immune system is downregulated, other parts upregulate and cause systemic inflammation
102
Q

What is Fitz-Hugh-Curtis syndrome

A

A complication of PID

Inflammation and infection of the liver capsule (Glisson’s capsule), leading to adhesions between the liver and peritoneum. Bacteria may spread from the pelvis via the peritoneal cavity, lymphatic system or blood.

PC: RUQ pain, reffered to right shoulder if diaphragmatic irritation

Management:
Laparoscopy can be used to visualise and also treat the adhesions by adhesiolysis.

103
Q

What is important to test for after making a diagnosis of lymphogranuloma venereum?

A

HIV

majority of patients with LV will have HIV

104
Q

What is proctitis?

A

Inflammation of rectum

Core clinical problems (94 decks)

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