GUM Flashcards
1
Q
What is bacterial vaginosis (BV)?
A
BV is an overgrowth of anaerobic bacteria in the vagina due to a loss of lactobacilli, the “friendly bacteria,” which normally help maintain a low vaginal pH. Not an STI.
The vaginal pH rises above 4.5 due to the reduction of lactobacilli, creating an alkaline environment that promotes the growth of anaerobic bacteria.
2
Q
What is the role of lactobacilli in the vaginal flora?
A
Lactobacilli produce lactic acid to keep the vaginal pH low (under 4.5), preventing overgrowth of harmful bacteria.
3
Q
Name some anaerobic bacteria associated with BV.
A
Gardnerella vaginalis, Mycoplasma hominis, and Prevotella species.
4
Q
What are the risk factors for developing bacterial vaginosis?
A
Risk factors include multiple sexual partners, excessive vaginal cleaning, recent antibiotic use, smoking, and the use of a copper coil.
5
Q
What is the typical presenting feature of bacterial vaginosis?
A
A fishy-smelling, watery grey or white vaginal discharge.
NO itching, irritation, or pain (suggest other infection).
6
Q
What are “clue cells,” and what do they indicate?
A
Clue cells are cervical epithelial cells coated with bacteria, usually Gardnerella vaginalis, and they indicate bacterial vaginosis.
7
Q
What is the antibiotic of choice for treating BV?
A
Metronidazole, given orally or as a vaginal gel, is the first-line antibiotic for BV.
Treatment is not usually necessary for asymptomatic cases, as BV may resolve on its own.
8
Q
What important advice should be given when prescribing metronidazole?
A
Patients should avoid alcohol during metronidazole treatment due to the risk of a disulfiram-like reaction (nausea, vomiting, and flushing).
9
Q
What are some complications of BV in pregnant women?
A
BV in pregnancy is associated with miscarriage, preterm delivery, premature rupture of membranes, chorioamnionitis, low birth weight, and postpartum endometritis.
10
Q
Which yeast species is most commonly responsible for vaginal candidiasis?
A
Candida albicans.
11
Q
Name some factors that increase the risk of developing vaginal candidiasis.
A
Increased estrogen levels, poorly controlled diabetes, immunosuppression, and broad-spectrum antibiotic use.
12
Q
What are the main symptoms of vaginal candidiasis?
A
Thick, white discharge without odor, along with vulval and vaginal itching, irritation, or discomfort.
13
Q
What additional symptoms may indicate a more severe vaginal candidiasis infection?
A
Erythema, fissures, edema, dyspareunia (pain during sex), dysuria, and excoriation.
14
Q
How can vaginal pH help in diagnosing vaginal candidiasis?
A
Candidiasis typically has a vaginal pH below 4.5, whereas BV and trichomonas infections present with a pH above 4.5.
15
Q
What is the main approach to diagnosing vaginal candidiasis?
A
Often empirically based on symptoms, with confirmation through a charcoal swab and microscopy if needed.
16
Q
What are the primary treatment options for vaginal candidiasis?
A
Antifungal medications such as intravaginal clotrimazole cream, clotrimazole pessaries, or oral fluconazole tablets.
17
Q
What does Canesten Duo contain, and when is it used?
A
It contains a single dose of fluconazole and clotrimazole cream for external vulval symptoms, and is available over the counter.
18
Q
How should recurrent vaginal candidiasis (more than 4 infections per year) be managed?
A
With an induction and maintenance antifungal treatment regime over six months, using oral or vaginal antifungals.
19
Q
What should patients be cautioned about when using antifungal creams or pessaries?
A
These can damage latex condoms and interfere with spermicides, so alternative contraception is recommended for at least five days after use.
20
Q
What type of bacteria is Chlamydia trachomatis, and where does it replicate?
A
It is a gram-negative, intracellular bacterium, meaning it replicates inside cells.
21
Q
What factors increase the risk of Chlamydia infection?
A
Young age, being sexually active, and having multiple sexual partners.
22
Q
What is the National Chlamydia Screening Programme (NCSP) in the UK?
A
A program that screens sexually active people under 25 annually or when they change partners. A re-test is recommended three months after treatment for those who test positive.
23
Q
Which infections are typically screened for during a GUM clinic visit?
A
Chlamydia, gonorrhea, syphilis (via blood test), and HIV (via blood test).
24
Q
What types of swabs are used in sexual health screening, and what do they test for?
A
Charcoal swabs (for microscopy, culture, sensitivities) and NAAT swabs (for DNA/RNA testing, specifically for chlamydia and gonorrhea).
25
Which NAAT sample methods are used for testing chlamydia in women?
Vulvovaginal swab, endocervical swab, or first-catch urine.
26
How is a NAAT swab for gonorrhea confirmed?
With a charcoal endocervical swab for microscopy, culture, and sensitivity testing.
27
What are common symptoms of chlamydia in women?
Abnormal vaginal discharge, pelvic pain, abnormal bleeding, dyspareunia, and dysuria.
28
What are common symptoms of chlamydia in men?
Urethral discharge, dysuria, epididymo-orchitis, and reactive arthritis.
29
What additional symptoms may suggest rectal chlamydia or lymphogranuloma venereum?
Anorectal discomfort, discharge, bleeding, and bowel habit changes.
30
What is the first-line treatment for uncomplicated chlamydia infection?
Doxycycline 100 mg twice daily for 7 days.
31
Which treatment options are recommended for chlamydia in pregnancy or breastfeeding?
Options include azithromycin, erythromycin, or amoxicillin.
32
When is a test of cure recommended for chlamydia?
For rectal infections, during pregnancy, or if symptoms persist after treatment.
33
What advice is given regarding sexual activity during chlamydia treatment?
Abstain from sex for seven days of treatment for both the patient and their partners.
34
Name complications associated with untreated chlamydia infection.
Pelvic inflammatory disease, chronic pelvic pain, infertility, ectopic pregnancy, and conjunctivitis.
35
What are pregnancy-related complications of chlamydia?
Preterm delivery, premature rupture of membranes, low birth weight, postpartum endometritis, and neonatal conjunctivitis or pneumonia.
36
What is lymphogranuloma venereum (LGV), and who is primarily affected?
An infection of lymph tissue by Chlamydia commonly affecting men who have sex with men (MSM).
37
What is the treatment for lymphogranuloma venereum (LGV)?
Doxycycline 100 mg twice daily for 21 days.
38
How does chlamydial conjunctivitis present, and who is typically affected?
Presents with chronic redness, irritation, and unilateral discharge, most common in young adults and neonates exposed to infected mothers.
39
What type of bacteria is Neisseria gonorrhoeae, and where does it infect?
A gram-negative diplococcus that infects mucous membranes with columnar epithelium, such as the endocervix, urethra, rectum, conjunctiva, and pharynx.
40
How is Neisseria gonorrhoeae transmitted, and what increases the risk of infection?
It is sexually transmitted; risk factors include being young, sexually active, having multiple partners, and having other STIs.
41
Why is antibiotic resistance significant in gonorrhea, and which antibiotics are commonly ineffective?
High resistance exists, particularly to ciprofloxacin and azithromycin, which were traditionally used but now show reduced efficacy.
42
What are common symptoms of genital gonorrhea in women?
Purulent discharge (green/yellow, odourless), dysuria, and pelvic pain.
43
What are common symptoms of genital gonorrhea in men?
Purulent discharge (green/yellow, odourless), dysuria, and testicular pain/swelling (epididymo-orchitis).
44
What are the symptoms of rectal and pharyngeal gonorrhea infections?
Rectal infection may cause discomfort and discharge (often asymptomatic); pharyngeal infection may cause a sore throat but is often asymptomatic.
45
Which diagnostic test is used to detect gonorrhea DNA or RNA, and what is its limitation?
Nucleic acid amplification testing (NAAT) detects gonococcal DNA/RNA but does not provide antibiotic sensitivities.
46
Why is a charcoal swab needed in gonorrhea diagnosis, and what does it test for?
It allows for microscopy, culture, and sensitivity testing, crucial for identifying effective antibiotics due to high resistance rates.
47
What is the first-line treatment for uncomplicated gonococcal infections when sensitivities are unknown?
A single intramuscular dose of ceftriaxone 1g.
48
What is the follow-up recommendation after treatment of gonorrhea?
A “test of cure” is recommended: 72 hours after treatment for culture, 7 days for RNA NAAT, and 14 days for DNA NAAT.
49
What advice should be given regarding sexual activity during and after gonorrhea treatment?
Abstain from sex for seven days post-treatment to prevent reinfection.
50
List some complications of untreated gonorrhea.
Pelvic inflammatory disease,
chronic pelvic pain, infertility,
epididymo-orchitis,
prostatitis,
conjunctivitis,
urethral strictures,
disseminated gonococcal infection (GDI),
septic arthritis,
and endocarditis.
51
What is gonococcal conjunctivitis in neonates, and why is it an emergency?
Also called ophthalmia neonatorum, it is contracted from the mother during birth and can lead to sepsis, eye perforation, and blindness.
52
What is disseminated gonococcal infection (GDI), and what are its symptoms?
GDI occurs when gonorrhea spreads to the skin and joints, causing skin lesions, polyarthralgia, migratory polyarthritis, tenosynovitis, and systemic symptoms like fever.
53
What type of infection is caused by Mycoplasma genitalium (MG)?
MG is a sexually transmitted bacterial infection that primarily causes non-gonococcal urethritis.
54
What are the symptoms and potential complications of Mycoplasma genitalium?
Most cases are asymptomatic, but MG can cause symptoms similar to chlamydia. Key features and complications include:
- Urethritis
- Epididymitis
- Cervicitis
- Endometritis
- Pelvic inflammatory disease
- Reactive arthritis
- Tubal infertility
- Preterm delivery in pregnancy
55
Why is MG challenging to culture, and what test is used to diagnose it?
MG is slow-growing, making traditional cultures ineffective. Diagnosis relies on nucleic acid amplification tests (NAAT) to detect DNA or RNA.
56
What sample types are recommended by BASHH guidelines (2018) for MG testing?
- First morning urine sample for men
- Self-taken vaginal swabs for women
57
What is the recommended treatment regimen for uncomplicated MG infections according to BASHH guidelines (2018)?
1. Doxycycline 100mg twice daily for 7 days, followed by:
2. Azithromycin 1g single dose, then 500mg once daily for 2 days (if not resistant to macrolides).
58
What is the recommended treatment for MG in pregnancy and breastfeeding?
Azithromycin alone is recommended, as doxycycline is contraindicated.
59
Why is macrolide resistance significant in treating MG, and what alternative treatment is used in resistant or complicated cases?
Due to rising azithromycin resistance, testing for macrolide resistance is essential. Moxifloxacin is used as an alternative, especially in complicated infections.
60
When is a “test of cure” recommended after Mycoplasma genitalium treatment?
A test of cure is performed in every patient after treatment, especially given the antibiotic resistance concerns.
61
What is Pelvic Inflammatory Disease (PID) and which organs are affected?
PID is an infection and inflammation of pelvic organs due to infection spreading through the cervix. Affected organs and terms include:
- Endometritis: Endometrium
- Salpingitis: Fallopian tubes
- Oophoritis: Ovaries
- Parametritis: Connective tissue around the uterus
- Peritonitis: Peritoneal membrane
62
What are the main causes of PID?
Common causes are sexually transmitted infections, including:
- Neisseria gonorrhoeae (often severe cases)
- Chlamydia trachomatis
- Mycoplasma genitalium
Non-STI causes include:
- Gardnerella vaginalis
- Haemophilus influenzae
- Escherichia coli
63
What are key risk factors for developing PID?
Risk factors include:
- Lack of barrier contraception
- Multiple sexual partners
- Younger age
- Existing STIs
- Previous PID
- Intrauterine devices (e.g., copper coil)
64
What symptoms and exam findings are common in PID?
Symptoms:
- Pelvic/lower abdominal pain
- Abnormal discharge or bleeding
- Dyspareunia (pain during sex)
- Dysuria
- Fever
Examination findings:
- Pelvic tenderness
- Cervical motion tenderness
- Inflamed cervix and purulent discharge
65
How is PID diagnosed?
Diagnostic investigations include:
- NAAT swabs for gonorrhea, chlamydia, and Mycoplasma genitalium
- HIV and syphilis tests
- High vaginal swab for bacterial vaginosis, candidiasis, trichomoniasis
- Pregnancy test (to rule out ectopic pregnancy)
- CRP and ESR (inflammatory markers)
66
What is the general approach to treating PID, including the BASSH outpatient regimen?
Early empirical antibiotic therapy is crucial, and a typical outpatient regimen includes:
1. Ceftriaxone 1g IM single dose (for gonorrhea)
2. Doxycycline 100mg twice daily for 14 days (for chlamydia, Mycoplasma genitalium)
3. Metronidazole 400mg twice daily for 14 days (for anaerobes)
Severe cases may require IV antibiotics or surgical intervention for abscesse
67
What is Fitz-Hugh-Curtis syndrome and its main symptom?
A complication of PID involving inflammation of the liver capsule, causing right upper quadrant pain that may refer to the right shoulder. It is confirmed and treated through laparoscopy
68
What is Trichomonas vaginalis?
Trichomonas vaginalis is a sexually transmitted protozoan parasite, a single-celled organism with flagella used for movement and tissue attachment.
69
How does Trichomonas vaginalis increase health risks?
Infection with Trichomonas can increase the risk of:
- Contracting HIV (damages vaginal mucosa)
- Bacterial vaginosis
- Cervical cancer
- Pelvic inflammatory disease (PID)
- Pregnancy complications (e.g., preterm delivery)
70
What are common symptoms of trichomoniasis, and how often are cases asymptomatic?
Up to 50% of cases are asymptomatic. When symptoms appear, they include:
- Vaginal discharge (often frothy, yellow-green, possibly with a fishy smell)
- Itching
- Dysuria (painful urination)
- Dyspareunia (painful sex)
- Balanitis (inflammation of the glans penis)
71
What characteristic cervical finding is associated with trichomoniasis?
A **"strawberry cervix"** (or colpitis macularis), seen as tiny hemorrhages across the cervix caused by inflammation from Trichomonas vaginalis.
72
How is trichomoniasis diagnosed?
Diagnosis involves:
- Charcoal swab with microscopy from the posterior fornix in women or a self-taken low vaginal swab
- Urethral swab or first-catch urine in men
- A raised vaginal pH (above 4.5), similar to bacterial vaginosis
73
What is the treatment for trichomoniasis?
Metronidazole is the antibiotic treatment, and referral to a genitourinary medicine (GUM) specialist is recommended for diagnosis, treatment, and contact tracing.
74
What are the two main strains of Herpes Simplex Virus (HSV), and what do they commonly cause?
HSV-1 is usually responsible for cold sores (herpes labialis), while HSV-2 commonly causes genital herpes. Both can infect oral and genital areas.
75
How does HSV spread and remain in the body?
HSV spreads through direct contact with mucous membranes or viral shedding, often from asymptomatic carriers. After infection, it becomes latent in sensory nerve ganglia (trigeminal nerve for HSV-1; sacral ganglia for HSV-2).
76
What are key complications HSV can cause outside of cold sores and genital lesions?
HSV can lead to:
- Aphthous ulcers (oral sores)
- Herpes keratitis (corneal inflammation)
- Herpetic whitlow (painful finger lesions)
77
What symptoms are associated with an initial episode of genital herpes?
Initial symptoms include:
- Genital ulcers or blisters
- Neuropathic pain (tingling, burning)
- Flu-like symptoms (fatigue, headache)
- Painful urination (dysuria)
- Inguinal lymphadenopathy
Initial symptoms last about three weeks; recurrent episodes are milder.
78
How is genital herpes diagnosed?
Diagnosis is often based on clinical symptoms and history. A viral PCR swab from a lesion can confirm HSV type.
79
What is the primary treatment for genital herpes, and what are symptom management options?
Aciclovir (antiviral) is the main treatment; alternatives include valaciclovir and famciclovir. Symptom management includes:
- Paracetamol
- Topical lidocaine gel
- Warm salt water cleaning
- Topical vaseline, loose clothing, hydration
80
How is genital herpes managed in pregnancy?
Primary infection before 28 weeks: Aciclovir initially, then prophylactic aciclovir from 36 weeks.
Primary infection after 28 weeks: Immediate aciclovir followed by prophylaxis; caesarean section recommended.
Recurrent genital herpes: Prophylactic aciclovir from 36 weeks if prior HSV infection, with a low risk of neonatal transmission.
81
What is the risk of neonatal HSV infection, and how is it mitigated?
Neonatal HSV has high morbidity and mortality. Passive immunity from maternal antibodies reduces risk, but caesarean is recommended for active lesions at delivery.
82
How is HIV transmitted?
- Unprotected sexual contact
- Mother-to-child transmission during pregnancy, birth, or breastfeeding
- Exposure to infected blood or bodily fluids, often via shared needles or needle-stick injuries
83
Name some AIDS-defining illnesses
- Kaposi’s sarcoma,
- pneumocystis jirovecii pneumonia (PCP),
- cytomegalovirus infection,
- esophageal or bronchial candidiasis,
- lymphomas, and
- tuberculosis.
84
Describe HIV testing options and their window periods.
Fourth-generation lab test: Detects HIV antibodies and p24 antigen, with a 45-day window.
Point-of-care tests: Detect antibodies only, with a 90-day window. Self-sampling and home test kits are also available.
85
What does a low CD4 count indicate in HIV?
Lower CD4 counts mean higher susceptibility to infections:
Normal: 500-1200 cells/mm³
High risk for opportunistic infections: <200 cells/mm³
86
What is the goal of antiretroviral therapy (ART)?
ART aims to achieve normal CD4 levels and an undetectable viral load, which allows people with HIV to remain healthy. Typical regimes include two nucleoside reverse transcriptase inhibitors (NRTIs) and a third agent (e.g., integrase inhibitor)
87
What additional supportive management is recommended for people with HIV?
- Prophylactic co-trimoxazole if CD4 <200/mm³ to prevent PCP
- Yearly cervical screening
- Vaccinations (influenza, pneumococcal, HPV, hepatitis A and B)
- Avoid live vaccines
88
How can HIV transmission be reduced during childbirth?
Delivery method depends on viral load:
- Under 50 copies/ml: Vaginal delivery possible
- Over 50 copies/ml: Consider caesarean
- Over 400 copies/ml: Caesarean recommended
IV zidovudine is given during labor if viral load is unknown or >1000 copies/ml. Baby prophylaxis may include zidovudine or additional antivirals
89
What is the recommended action regarding breastfeeding for HIV-positive mothers?
Breastfeeding is generally avoided to prevent transmission. If the mother has an undetectable viral load and insists, breastfeeding may be done under close monitoring.
90
What is the role of PEP and PrEP in HIV prevention?
PEP (Post-exposure prophylaxis): ART after potential exposure, within 72 hours.
PrEP (Pre-exposure prophylaxis): Taken before exposure to reduce infection risk, typically emtricitabine/tenofovir.
91
What is syphilis, and how is it caused?
Syphilis is a sexually transmitted infection caused by Treponema pallidum, a spiral-shaped spirochete bacteria that enters through skin or mucous membranes.
92
How is syphilis transmitted?
Mainly through sexual contact (oral, vaginal, anal) with an infected area, but it can also spread via vertical transmission (mother to baby), IV drug use, and, rarely, blood transfusions.
93
What are the stages of syphilis?
Primary (painless chancre), Secondary (systemic symptoms, rash), Latent (asymptomatic), and Tertiary (gummas, cardiovascular, and neurological issues).
94
Describe primary syphilis symptoms.
A painless genital ulcer (chancre) and local lymphadenopathy, with the chancre resolving in 3-8 weeks.
95
Describe secondary syphilis symptoms.
Maculopapular rash, condylomata lata, fever, lymphadenopathy, alopecia, and oral lesions. This stage follows the healing of the chancre.
96
What complications can arise in tertiary syphilis?
Development of gummas, aortic aneurysms, and neurosyphilis, which may include dementia, paralysis, and sensory impairment.
97
What is neurosyphilis and its key symptom?
It is syphilis involving the CNS, presenting with headaches, altered behavior, and symptoms like Argyll-Robertson pupil (constriction with accommodation but not with light).
98
How is syphilis diagnosed?
Antibody testing (screening), dark-field microscopy, PCR, and the non-specific RPR and VDRL tests to indicate active infection. Positive screens require referral to a specialist.
99
What is the standard treatment for syphilis?
A single IM dose of benzathine benzylpenicillin. Alternatives like ceftriaxone or doxycycline may be used for late or neurosyphilis cases.
100
What additional management is required for syphilis patients?
Full STI screening, avoidance of sexual activity until treatment, contact tracing, and education on preventing future infections.
101
What are the rules for chlamydia partner notification for men and women?
- symptomatic men: all partners from the 4 weeks prior to the onset of symptoms
- women + asymptomatic men: all partners from the last 6 months or the most recent sexual partner
102
What causes genital warts?
Genital warts are caused by the human papillomavirus (HPV), especially types 6 and 11. Other types, like 16, 18, and 33, are associated with a higher risk of cervical cancer
103
What are the common features of genital warts?
They are small (2-5 mm) fleshy protuberances that may be slightly pigmented, and they may bleed or itch.
104
What is the first-line treatment for multiple, non-keratinised genital warts?
Topical agents, such as podophyllum, are preferred for treating multiple, non-keratinised warts.
105
How are solitary, keratinised genital warts typically treated?
Solitary, keratinised warts generally respond better to cryotherapy.
106
What is a second-line treatment option for genital warts?
Imiquimod cream is commonly used as a second-line treatment.
107
Are genital warts resistant to treatment?
Yes, genital warts are often resistant to treatment, and recurrence is common. However, most anogenital HPV infections clear within 1-2 years without intervention.
108
What type of cancer is penile cancer usually classified as?
Penile cancer is typically a squamous cell carcinoma.
109
What are common features of penile cancer?
Penile lump and penile ulceration are common signs.
110
List some risk factors for penile cancer.
- HIV infection
- HPV infection
- Genital warts
- Poor hygiene
- Phimosis (inability to retract foreskin)
- Paraphimosis (inability to return foreskin to normal position)
- Balanitis (inflammation of the glans)
- Age >50
111
What are the main treatment options for penile cancer?
Treatment options include radiotherapy, chemotherapy, and surgery.
112
What is the 5-year prognosis for penile cancer?
The approximate 5-year survival rate is 50%.
113
What is the first-line treatment for Pneumocystis jiroveci pneumonia in HIV +?
co-trimoxazole
