GUM

Question 1

CHLAMYDIA:

1. Epidemiology
2. Incubation period
3. Features
4. Complications
5. Investigations
6. Management

Answer 1

1. 10% young women in UK
2. 7-21d
3. • Asymptomatic in about 70% women, 50% men
     - Women: Cervicitis(discharge, bleeding), dysuria
     - Men: Urethral discharge, dysuria
4. • Epididymitis
     - PID
     - Endometritis
     - Increased incidence of ectopic pregnancies
     - Infertility
     - Reactive arthritis
     - Perihepatitis(Fitz-Hugh-Curtis syndrome)
5. nucleic acid amplification test(NAAT)
   - first void urine sample in men
   - vulvovaginal/cervical(less sensitive) swab
6. a) Doxycycline(7d) or azithromycin 1g stat(first-line)
   b) Partner notification
   - for men with urethral symptoms, all contacts since 4w prior to onset.
   - for women and asymptomatic men, all partners from last 6/12
   - Retest after 3-6 months

Question 2

SYPHILIS(TREPONEMA PALLIDUM):

1. Incubation
2. Primary features
3. Secondary features(6-10w after primary infection)
4. Tertiary features
5. Congenital syphilis
6. Management
7. Pregnancy complications:

Answer 2

1. 9-90d(primary); up to 6/12(secondary); after 2y(tertiary)
2. • Chancre(painless ulcer)
     - local, non-tender lymphadenopathy
     - often not seen in women(lesion on cervix)
3. • systemic Sx: fevers, lymphadenopathy
     - Rash on trunk, palms, soles
     - Buccal ‘snail track’ ulcers(30%)
     - condylomata lata
4. • Gummas(granulomatous lesions of skin and bones)
     - ascending aortic aneurysms
     - general paralysis of the insane
     - tabes dorsalis
     - Argyll-Robertson pupil
5. • Blunted upper incisor teeth(Hutchinson’s teeth), mulberry molars
     - Rhagades(linear scars at angle of mouth)
     - Keratitis
     - saber shins
     - saddle nose
     - deafness
6. Benzylpenicillin, alt: doxycycline
7. • Miscarriage
     - Stillbirth
     - Premature delivery
     - Low birth weight

Question 3

STI ULCERS:

Answer 3

1. HSV type 2
   - most common
   - fever
2. Syphilis
   - painless ulcer in primary stage
3. Haemophilus ducreyi(chancroid)
   - painful genital ulcers
   - unilateral, painful inguinal lymph node enlargement
4. Chlamydia(LGV type)
   - treated using doxycycline
   - Stage 1: small painless pustule later forming ulcer. Stage 2: painful inguinal lymphadenopathy. Stage 3: proctocolitis
5. Other causes: Behcet’s, carcinoma, granuloma inguinale(Klebsiella granulomatis)

Question 4

GENITAL WARTS(Condylomata accuminata):

1. Cause
2. Treatment
3. Anogenital warts in pregnancy

Answer 4

1. HPV especially types 6 and 11. Condylomata lata(feature of secondary syphilis)
2. First line: topical podophyllum for multiple, non-keratinised warts/Cryotherapy for solitary, keratinised warts.
   - Second-line: topical imiquimod
   - often resistant but majority clear within 1-2y even without treatment.
3. Treatment options limited(avoid imiquimod and podophyllum). Risk of transmission to neonate very low.

Question 5

VAGINAL DISCHARGE:

Answer 5

1. Candida
   - Cottage cheese
   - Vulvitis
   - Itch
   - Risk f: diabetes, recent antibiotic use, pregnancy, immunodeficiency
   - Treatment: topical azoles or oral triazoles
2. Trichomonas vaginalis
   - Offensive, yellow/green, frothy discharge
   - Vulvovaginitis
   - Strawberry cervix
3. Bacterial vaginosis
   - Offensive thin, grey/white discharge
   - Clue cells on microscopy

Question 6

TRICHOMONAS VAGINALIS:

1. Features
2. Investigation
3. Management

Answer 6

1. • Vaginal discharge: offensive, yellow/green, frothy
     - Vulvovaginitis
     - Strawberry cervix
     - pH>4.5
     - Usually asymptomatic in men but can cause urethritis
2. Microscopy of wet mount slide
3. Oral metronidazole for 5-7d or one-off 2g metronidazole. Test of cure at 2w.

Question 7

NEISSERIA GONORRHOEAE

1. Symptoms
2. Complicaitons
3. Investigations
4. Management

Answer 7

1. • usually symptomless in women(>80%)
     - Acute PID: fever, lower abdominal and pelvic pain, deep dyspareunia, malaise. on examination: lower abdominal tenderness and guarding, adnexial tenderness, cervical excitation
     - symptomatic in men(>95% male urethritis)
     - urethral discharge, dysuria, testicular pain/swelling
2. -PID with tubo-ovarian abcess, Bartholin gland infection and abcess
   - epididymo-orchitis
   - Neonatal conjunctivitis
3. NAAT
   - FVU in men. Pharynx and rectum in MSM
   - Vaginal swab in women(cervical swab less sensitive)
4. • Culture before treatment
     - Treatment usually initiated before results of antibiotic susceptibility tests available: IM Ceftriaxone 500 mg and oral Azithromycin 1mg. Alternatives: Spectinomycin and Ciprofloxacin
     - Test of cure at 3-4w with NAAT
     - Partner treatment

Question 8

BACTERIAL VAGINOSIS(BV)

1. Features
2. Symptoms
3. Risk f
4. Complications
5. Treatment

Answer 8

1. • On microscopy, absence of lactobacilli, presence of clue cells
     - vaginal pH >4.5
     - positive amine whiff test
2. Up to 50% asymptomatic, increased smelly(fish-like odour) gray/white discharge
3. Excessive genital cleaning, vaginal douching and use of feminine hygiene products, unprotected sexual intercourse, menstruation, smoking, use of intrauterine contraception.
4. Pregnancy prob:
   - Chorioamnionitis
   - preterm delivery
   - low birth weight
   - postpartum endometritis

also an increased risk of HIV acquisition

5. Oral and vaginal clindamycin/metronidazole

Question 9

HERPES SIMPLEX VIRUS(HSV)

1. Types
2. Incubation period
3. Diagnosis
4. Features
5. Treatment
6. Complications
7. Pregnancy complications

Answer 9

1. a) Type 1: oro-labial herpes(cold sores)
   - 0-1 episodes/year
   b) Type 2: ano-genital.
   - more frequent and severe symptomatic recurrences compared to type 1
2. 3-10d
   - 4-6 episodes/year
3. PCR to identify virus from lesions
4. a) Initial episode
   - most severe
   - genital lesions
   - preceding flu-like symptoms
   - cervicitis and urethritis causing discharge and dysuria
   - bilateral tender inguinal lymphadenopathy
   - neuropathic manifestations eg: sacral radiculitis leading to urinary retention
   b) Symptomatic recurrences
   - neuropathic prodrome eg: tingling/burning sensation with associated dermatome
   - oro-labial HSV linked to other illnesses causing stress to immune system, menstruation, stress, local trauma
5. a) Initial episode: Aciclovir 200 mg x5/d with analgesia and saline washes
   b) Recurrence:
   - none if mild
   - Episodic treatment with aciclovir 400 mg TDS for 5d if severe symptomatic but infrequent recurrences
   - If very frequent symptomatic recurrences(>6/year), long-term suppressive therapy with aciclovir 400 mg BD
6. a) Genital:
   - chronic non-healing ulcer disease in immunocompromised
   - phimosis, paraphimosis and labial adhesions after symptomatic episodes

b) Extra-genital:
- auto-inoculation leading to conjunctivitis, keratitis, herpetic whitlow
- neurological: aseptic meningitis, encephalitis, transverse myelitis, sacral radiculomyelopathy
- erythema multiforme
- Increased HIV transmission

7. • only an issue if acquire infection in 3rd trimester(especially final 10w)
     - risk of neonatal transmission. Given empirical treatment at birth if vaginal delivery
     - Treated with Aciclovir and high-dose suppressive therapy to mother
     - C-section indicated