GUM Flashcards
History GUM
Examination GUM men
Examination GUM women
Investigations GUM
Important microbiology GUM
balanitis
inflammation of glans/head of penis
Epididymo-orchitis
inflammation of epididymis (tube at back of testicle) and testicle
Epididymitis
inflammation of epididymis (tube at back of testicle)
Orchitis
inflammation of the testicle
Papules
small lumps on the skin
Macules
flat marks on the skin
typical history thrush in men
erythematous rash of head of penis
itching
white/creamy discharge
dysuria
dysparenunia
difficult to pull foreskin back
typical history thrush in women
thick white discharge
no smell
vulval and vaginal itching
irritation or discomfort
typical history gonorrhoea in men
odourless purulent discharge - may be green/yellow
dysuria
testicular pain or swelling (epididymo-orchitis)
typical history gonorrhoea in women
odourless purulent discharge
may be green/yellow
dysuria
pelvic pain
typical history disseminated gonococcal infection
non-specific skin lesions (petechial or pustular)
septic arthritis
Polyarthralgia (joint aches and pains)
Tenosynovitis
Systemic symptoms such as fever and fatigue
typical history chlamydia men
urethral discharge or discomfort
dysuria
epididymo-orchitis
reactive arthritis
typical history chlamydia women
abnormal vaginal discharge
pelvic pain
abnormal vaginal bleeding
dysparenunia
dysuria
intermenstrual bleeding
typical history lymphogranuloma venereum
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,
typical history trichomonas men
balanitis (inflammation of glans penis)
typical history trichomonas women
vaginal discharge (frothy green/yellow-green, fishy smelling)
itching
dysuria
dyspareunia
strawberry cervix
typical history mycoplasma genitalium
urethritis
typical history bacterial vaginosis
fishy smelling watery grey or white vaginal discharge
typical history PID
Pelvic or lower abdominal pain
Abnormal vaginal discharge
Abnormal bleeding (intermenstrual or postcoital)
Pain during sex (dyspareunia)
Fever
Dysuria
typical history genital herpes
ulcers or blistering lesions
neuropathic type pain (tingling, burning or shooting)
dysuria
flu-like symptoms
inguinal lymphadenopathy
can also get urianry retention
typical history primary syphillis
painless ulcer
typical history secondary syphillis
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
typical history tertiary syphillis
gummatous lesions
tabes dorsalis (demyelination affecting posterior columns)
ocular including anterior uveitis
aortic aneurysm,
typical history genital warts
small fleshy protuberances which are slightly pigmented, might bleed or itch
test for thrush
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.
management thrush
- 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
- if pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated
diagnosis gonnorrhoea
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.
Management gonorrhoea
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
test of cure gonorrhoea
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
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
septic arthritis
test for chlamydia
NAAT
management of chlamydia
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.
management of chlamydia in pregnancy and breast feeding
Azithromycin 1g stat then 500mg once a day for 2 days
Lymphogranuloma Venereum
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
unilateral conjunctivitis
Chlamydial conjunctivitis
what is trichomonas
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.
complications of chlamydia?
Pelvic inflammatory disease
Chronic pelvic pain
Infertility
Ectopic pregnancy
Epididymo-orchitis
Conjunctivitis
Lymphogranuloma venereum
Reactive arthritis
trichomonas complications
Contracting HIV by damaging the vaginal mucosa
Bacterial vaginosis
Cervical cancer
Pelvic inflammatory disease
Pregnancy-related complications such as preterm delivery.
pregnancy complications chlamydia
Preterm delivery
Premature rupture of membranes
Low birth weight
Postpartum endometritis
Neonatal infection (conjunctivitis and pneumonia)
investigation trichomonas
high vaginal charcoal swab with microscopy
management trichomonas
metronidazole
raised vaginal pH - value? indicate?
> 4.5
- BV
- trichomonas
investigation genital herpes
clinical but can do:
Viral PCR swab from a lesion can confirm the diagnosis and causative organism.
management genital herpes
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
genital herpes and pregnancy
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.
tests for syphillis
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
treatment syphillis
deep intramuscular dose of benzathine benzylpenicillin (penicillin)
Mycoplasma genitalium (MG)
bacteria that causes non-gonococcal urethritis
investigation mycoplasma genitalium
Nucleic acid amplification tests (NAAT)
management mycoplasma genitalium
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).
testing for HIV
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.
CD4 count
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
Viral load HIV - undetectable level?
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.
management of HIV
Two NRTIs nucleotide reverse transcriptase inhibitors
- tenofovir
- emtricitabine
One other agent, usually integrase inhibitor
- doultegravir or raltegravir
management if CD4 is less than 200
Prophylactic co-trimoxazole (Septrin) to protect against pneumocystis jirovecii pneumonia (PCP)
cervical smears women with HIV
Yearly cervical smears
how to prevent transmission of HIV during birth
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
can you breastfeed with HIV
not recommended
what is PEP
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.
Pathophysiology BV
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.
Risk factors BV
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.
Investigations BV
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.
Management BV
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.
What do you need to remember to say when prescribing metronidazole
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.
What is pelvic inflammatory disease
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
Invetsigation markers pelvic inflammatory disease
Pus cells on microscopy. The absence of pus cells is useful for excluding PID.
Raised CRP/ESR
Management PID
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)
management genital warts
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
pathogen genital warts
HPV 6 and 11
whats a double/triple swab
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.
What CF colonising bacteria is bad
Pseudomonas aerginosa
management of recurrent thrush
> 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
‘musty’, frothy, green vaginal discharge. On examination you an erythematous cervix with pinpoint areas of exudation.
trichomonas - erythema refers to strawberry cervix!
discharge in gonorrhoea
purulent odorless, yellow or green
what symptom in women do you get in chlamydia but not gonnorrhoea
PV bleeding
Presentation secondary syphillis
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
Presentation tertiary syphilis
Gummatous lesions (gummas are granulomatous lesions that can affect the skin, organs and bones)
Aortic aneurysms
Neurosyphilis
Neurosyphilis presentation
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)
Thick, white discharge that does not typically smell
Vulval and vaginal itching, irritation or discomfort
thrush
Candida albicans
Female
Odourless purulent discharge, possibly green or yellow
Dysuria
Pelvic pain
Gonorrhoea
Male
Odourless purulent discharge, possibly green or yellow
Dysuria
Testicular pain or swelling (epididymo-orchitis)
Gonorrhoea
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”
trichomonas
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.
herpes-2
A painless genital ulcer (chancre). This tends to resolve over 3 – 8 weeks.
Local lymphadenopathy
primary syphillis
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
secondary syphillis
These symptoms can resolve after 3 – 12 weeks and the patient can enter the latent stage
presentations tertiary syphillis
Gummatous lesions (gummas are granulomatous lesions that can affect the skin, organs and bones)
Aortic aneurysms
Neurosyphilis
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
neurosyphillis
Argyll-Robertson pupil
fishy-smelling watery grey or white vaginal discharge
not itchy
bacterial vaginosis
“clue cells” on microscopy
bacterial vaginosis
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.
PID
on genitals/anus
small (2 - 5 mm) fleshy protuberances which are slightly pigmented
may bleed or itch
genital warts (condylomata accuminata)
HPV 6 and 11
Amsel criteria
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
Histology chlamydia
gram negative coccobacilli
Histology syphillis
gram negative coil
spirochaete
Histology gonorrhoea
gram negative diplococci
why is HIV related to hypertension/CVD
- as one part of immune system is downregulated, other parts upregulate and cause systemic inflammation
What is Fitz-Hugh-Curtis syndrome
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.
What is important to test for after making a diagnosis of lymphogranuloma venereum?
HIV
majority of patients with LV will have HIV
What is proctitis?
Inflammation of rectum
