GUM + Breast Flashcards
What is bacterial vaginosis?
An overgrowth of bacteria in the vagina, specifically anaerobic bacteria. It is not a sexually transmitted infection. It is caused by a loss of the lactobacilli “friendly bacteria” in the vagina causing an increase in pH. Bacterial vaginosis can increase the risk of women developing sexually transmitted infections. It is the most common cause of abnormal vaginal discharge in women of childbearing age.
What is the pathophysiology of 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.
Which bacteria cause BV?
Gardnerella vaginalis (most common)
Mycoplasma hominis
Prevotella species
What are the RF for BV?
Sexual activity – particularly a new partner or multiple sexual partners
The use of a contraceptive intrauterine device (IUD)
Receptive oral sex
Presence of an STI
Vaginal douching, or the use of scented soaps/vaginal deodorant
Recent antibiotic use
Ethnicity – more common in black women
Smoking
Women who have sex with women are more at risk due to shared vaginal flora patterns.
What are the clinical features of BV?
Fishy-smelling (especially after sex) watery grey or white homogenous vaginal discharge. Half of women with BV are asymptomatic.
Itching, irritation and pain are not typically associated with BV and suggest an alternative cause or co-occurring infection.
How is BV investigated and diagnosed? What criteria is used?
the Amstel criteria are often used. Three out of four features are needed to confer a diagnosis:
Vaginal pH >4.5
Homogenous grey or milky discharge
Positive whiff test (addition of 10% potassium hydroxide produces fishy odour)
Clue cells present on wet mount
What are clue cells?
Clue cells are epithelial cells from the cervix that have bacteria stuck inside them, usually Gardnerella vaginalis.
Microscopy may also show reduced numbers of lactobacilli and absence of pus cells
How is BV managed?
Asymptomatic does not require treatment
Metronidazole specifically targets anaerobic bacteria. This is given orally, or by vaginal gel. Clindamycin is an alternative but less optimal antibiotic choice.
Assess for additional infections, educate about how to reduce BV in the future and remind patients about how you can’t drink with Metronidazole. It causes “disulfiram-like reaction”, with nausea and vomiting, flushing and sometimes severe symptoms of shock and angioedema.
What does BV in pregnancy increase risks of and how is it managed?
Untreated symptomatic BV can increase the risk of pregnancy-related complications such as premature birth or rupture of membranes, miscarriage and chorioamnionitis, low birth weight and postpartum endometritis.
Treatment is the same as for non-pregnant women however if receiving treatment following birth, lactating women are advised to be treated with lower doses of metronidazole which can affect the taste of the breast milk.
What is vaginal candidiasis?
It refers to vaginal infection with a yeast of the Candida family. The most common is Candida albicans.
Candida may colonise the vagina without causing symptoms. It then progresses to infection when the right environment occurs, for example, during pregnancy or after treatment with broad-spectrum antibiotics that alter the vaginal flora.
What are the RF for thrush?
Pregnancy
Diabetes
Use of broad spectrum antibiotics- alters normal vaginal micro-biota
Use of corticosteroids - immunosuppressive action of corticosteroids can allow commensal candida the opportunity to thrive excessively.
Immunosuppression or compromised immune system
For example in HIV or cancer patients.
How does thrush present?
itching, white curdy or lumpy discharge, non-offensive or sour milk odour, dysuria, superficial dyspareunia, pruritus, tenderness, burning sensation
Examination - redness, fissuring, swelling, intertrigo, thick white discharge, satellite lesions (red, pustular lesions with superficial white/creamy pseudomembranous plaques that can be scraped off)
How is thrush diagnosed?
If uncomplicated then can give empiracal treatment.
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 charcoal swab with microscopy can confirm the diagnosis. May show spores and mycelia which are indicative of candida infection but it is commensal in a lot of women so not always cause of symptoms
How is thrush managed?
Oral (-azoles) e.g. fluconazole, itraconazole
Intravaginal e.g. clotrimazole pessary
Vulval e.g. topical clotrimazole cream
Canesten Duo is a standard over-the-counter treatment worth knowing. It contains a single fluconazole tablet and clotrimazole cream to use externally for vulval symptoms. Cream can damage condoms and diaphragms so need to use alternative contraception for at least 5 days
Recurrent infections (more than 4 in a year) can be treated with an induction and maintenance regime over six months with oral or vaginal antifungal medications.
Why is thrush more common in pregnancy?
By stimulating increased glycogen production, this provides a more favourable environment for microorganisms to thrive. It is also thought that oestrogen may have a direct influence on the candida organism by promoting its growth and encouraging it to ‘stick’ to the walls of the vagina.
How is thrush treated in pregnancy?
Treat infection with intravaginal antifungal (e.g. clotrimazole)
Do not give oral antifungals such as fluconazole and itraconazole
Treat vulval symptoms with topical antifungal
Advise the patient to be careful to avoid physical damage when inserting intravaginal treatment applicator
Return if symptoms have not resolved within 7-14 days
What is chlamydia?
Chlamydia trachomatis is a gram-negative bacteria. It is an intracellular organism, meaning it enters and replicates within cells before rupturing the cell and spreading to others. Chlamydia is the most common sexually transmitted infection in the UK and a significant cause of infertility.
How does the national chlamydia screening programme work?
aims to screen every sexually active person under 25 years of age for chlamydia annually or when they change their sexual partner. Everyone that tests positive should have a re-test three months after treatment. This re-testing is to ensure they have not contracted chlamydia again, rather than to check the treatment has worked.
In general, when a patient attends a GUM clinic for STI screening, as a minimum, they are tested for:
Chlamydia
Gonorrhoea
Syphilis (blood test)
HIV (blood test)
How does chlamydia present?
Asymptomatic
Abnormal vaginal discharge
Pelvic pain
Abnormal vaginal bleeding (intermenstrual or postcoital)
Painful sex (dyspareunia)
Painful urination (dysuria)
Men:
Urethral discharge or discomfort
Dysuria
Epididymo-orchitis
Reactive arthritis
NB. consider anal chlamydia or LV when someone has anorectal symptoms, such as discomfort, discharge, bleeding and change in bowel habits.
What are the clinical findings of chlamydia on examination?
Pelvic or abdominal tenderness
Cervical motion tenderness (cervical excitation)
Inflamed cervix (cervicitis)
Purulent discharge
In men:
Epididymal tenderness
Mucopurulent discharge
What are the Ix for chlamydia?
nucleic acid amplification test (NAAT):
Women: Vulvo-vaginal swab (first choice), endocervical swab or first catch urine sample.
Men: first catch urine sample (first choice) or urethral swab.
If indicated, swabs may also need to be taken from the rectum, eye(s) and throat.
Patients recommended to have full STI screen to check for co-infection
How is chlamydia managed?
Doxycycline 100mg 2x day for 7 days, abstain during treatment, contact tracing, screen and treat other STIs, advise on how to prevent in the future and screen for safeguarding and abuse
Contraindicated in pregnancy and breastfeeding, other options are azithromycin, erythromycin or amoxicillin
Test of cure only needed if rectal, pregnant or persistant symptoms
What are the complications of chlamydia?
Pelvic inflammatory disease
Chronic pelvic pain
Infertility
Ectopic pregnancy
Epididymo-orchitis
Conjunctivitis
Lymphogranuloma venereum
Reactive arthritis
Pregnancy-related complications include:
Preterm delivery
Premature rupture of membranes
Low birth weight
Postpartum endometritis
Neonatal infection (conjunctivitis and pneumonia)
What infections do the different serotypes of chlamydia cause?
Serotypes A-C – cause ocular infection.
Serotypes D-K – responsible for classical genitourinary infection.
Serotypes L1-L3 – cause lymphogranuloma venereum (LGV), an emerging infection in men who have sex with men, often resulting in proctitis.
How does chlamydia spread within the body to infect you?
C. trachomatis enters the host cell as an elementary body (infectious form). Once inside the cell it becomes a reticular body, the non-infectious form capable of replication. Following replication, these reticular bodies mature back to elementary bodies, and following cell rupture the elementary bodies infect other cells resulting in inflammation and tissue damage.
What is Lymphogranuloma venereum?
a sexually transmitted infection caused by serovars L1, L2 or L3 of Chlamydia trachomatis. L2 is most common
Which patients have the highest incidence of LGV?
Men who have sex with men
99% of cases are in this group
Often co-infection with HIV
What are the stages of LGV?
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. If they’re matted together or suppurative, which is termed a buboe.
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.
How does LGV present?
Typically identified on the coronal sulcus of the glans penis in men or posterior vaginal wall and/or vulva in women.
Painless papule
Painless pustule
Painless shallow ulcer
Proctitis
Rectal pain
Rectal bleeding
Rectal discharge
Tenesmus
Secondary stage:
Lymphadenopathy: inguinal/femoral, typically unilateral and painful
Lymphadenitis: infected lymph nodes
Buboes: marked lymphadenitis that becomes suppurative. At risk of chronic fistulae formation
Groove sign (15-20%): femoral and inguinal lymphadenopathy are separated by the inguinal ligament
Systemic upset: rarely fever, pneumonitis, hepatitis, aseptic meningitis or arthritis can occur
Tertiary stage:
Proctitis/proctocolitis: bleeding, pain, tenesmus
Fistulae
Strictures
Chronic lymphoedema
How is LGV diagnosed?
NAAT:
Genital swab: ideally taken from base of an ulcer
Rectal swabs
Urethral swab
First-catch urine
Aspiration from lymph nodes: often utilised in presence of buboes
Also refer to GUM for full STI screen
How is LGV managed?
Oral doxycycline 100 mg twice daily for 21 days or tetracycline 2g daily for 21 days (2nd line is azithromycin or erythromycin)
Abstinence and all sexual contacts within 4 weeks of symptomatic LGV or 3 months of asymptomatic carriage of LGV will need to be contacted, screened and receive empirical treatment.
What causes gonorrhoea?
Neisseria gonorrhoeae is a gram-negative diplococcus bacteria. It infects mucous membranes with a columnar epithelium, such as the endocervix in women, urethra, rectum, conjunctiva and pharynx. It spreads via contact with mucous secretions from infected areas. Common in MSM.
How does gonorrhoea present?
Infection with gonorrhoea is more likely to be symptomatic than infection with chlamydia.
Odourless purulent discharge, possibly green or yellow
Abnormal bleeding
Tender lymph nodes
Dysuria
Dyspareunia
Pelvic pain
Testicular pain or swelling
Rectal, pharyngeal and conjunctival infection can also occur
Rarely there is disseminated infection - tendinitis, tenosynovitis, septic arthritis, meningitis and endocarditis
How is gonorrhoea diagnosed?
Nucleic acid amplification testing (NAAT) - endocervical, vulvovaginal or urethral swabs, or in a first-catch urine sample. Rectal and pharyngeal swab are recommended in all men who have sex with men (MSM), and in those with risk factors
Charcoal endocervical swab should be taken for microscopy, culture and antibiotic sensitivities before initiating antibiotics.
What would you see on microscopy for someone with a gonorrhoea infection?
presence of monomorphic Gram-negative diplococci within polymorphonuclear leukocytes
How is gonorrhoea managed?
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
When and how do you do a test of cure for gonorrhoea?
NAAT testing if they are asymptomatic, or cultures where they are symptomatic
72 hours after treatment for culture
7 days after treatment for RNA NAAT
14 days after treatment for DNA NAAT
Other than prescribing antibiotics, what else must you do when a patient is diagnosed with gonorrhoea?
Advise to abstain from sex for seven days of treatment of all partners to reduce the risk of re-infection
Test for and treat any other sexually transmitted infections
Provide advice about ways to prevent future infection
Consider safeguarding issues and sexual abuse in children and young people
What are the complications of gonorrhoea?
Pelvic inflammatory disease
Chronic pelvic pain
Infertility
Epididymo-orchitis (men)
Prostatitis (men)
Conjunctivitis
Urethral strictures
Disseminated gonococcal infection
Skin lesions
Fitz-Hugh-Curtis syndrome
Septic arthritis
Endocarditis
Higher risk of getting HIV
Neonatal conjunctivitis - emergency
What is mycoplasma genitalium?
Mycoplasma genitalium (MG) is a bacteria that causes non-gonococcal urethritis. It is a sexually transmitted infection. There are developing problems with antibiotic resistance, particularly with azithromycin.
Most cases of MG do not cause symptoms. The presentation is very similar to chlamydia, and patients may be infected with both organisms. Urethritis is a key feature.
What are the complications of M. Gen?
Urethritis
Epididymitis
Cervicitis
Endometritis
Pelvic inflammatory disease
Reactive arthritis
Preterm delivery in pregnancy
Tubal infertility
How is M.Gen diagnosed?
Traditional cultures are not helpful in isolating MG, as it is a very slow-growing organism. Therefore, testing involves nucleic acid amplification tests (NAAT)
First urine sample in the morning for men
Vaginal swabs (can be self-taken) for women
Check for macrolide resistance and do test of cure
How is M.Gen managed?
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).
What is trichomaniasis?
Trichomoniasis is a curable sexually transmitted infection (STI) caused by the protozoan Trichomonas vaginalis (TV).
Trichomonas has four flagella at the front and a single flagellum at the back, giving a characteristic appearance to the organism. The flagella are used for movement, attaching to tissues and causing damage.
What is the epidemiology of trichomoniasis?
Trichomoniasis is the most common non-viral sexually transmitted infections worldwide but it’s relatively rare in the UK
What is the pathophysiology of trichomoniasis?
infect squamous cells of the urogenital epithelium. It most commonly infects areas of the vagina and urethra. Other sites of infection include the cervix, bladder, Bartholin glands, and prostate.
Humans are the only known reservoir for T. vaginalis and it is almost always sexually transmitted. The Protozoa can be transmitted between women and men, women and women, but rarely between two men. Co-infection with other conditions is common
What are the RF for Trichomoniasis?
Multiple sexual partners
Unprotected sexual intercourse
A history of other STIs
Older women are more at risk of TV
How does Trichomoniasis present?
Asymptomatic
Vaginal discharge: frothy, green-yellow
Vulval itching or soreness
Malodorous
Dysuria
Dyspareunia
Urethral discharge in men
Urethral irritation
Abdominal pain
Cervical inflammation (often described as ‘strawberry cervix’ = colpitis macularis, caused by tiny haemorrhages on the cervix)
Rarely balanitis or balanoposthitis (inflammation of glans penis and foreskin)
How is Trichomoniasis diagnosed?
- pH > 4.5
- The diagnosis can be confirmed with a standard charcoal swab with gram staining, microscopy and culture from the posterior fornix of the vagina in women. A self-taken low vaginal swab may be used as an alternative.
- NAAT
- Rapid antigen test
- Cytology - can be incidental on smears
- A urethral swab or first-catch urine is used in men
Screen for other STIs
What is the management for trichomoniasis?
Oral metronidazole. Either 400–500mg twice a day for 5–7 days, or 2g as a single oral dose
Advise abstinence for at least one week, and until the person and all partners have completed treatment
Screening for other sexually transmitted infections
Contact tracing
What conditions does trichomoniasis infection increase the risk of?
Contracting HIV by damaging the vaginal mucosa
Bacterial vaginosis
Cervical and prostate cancer
Pelvic inflammatory disease
Pregnancy-related complications such as preterm delivery.
What is genital herpes?
a sexually transmitted infection caused by the Herpes simplex virus 1&2. 1 also affects mouth and nose and is the most common in the UK. It is transmitted via skin-to-skin contact through vaginal, anal or oral sex. Once infected people may be asymptomatic for a long period of time, until the first flare up. Following the primary symptomatic infection, the virus can lie dormant until it recurs later in life causing recurrent outbreaks.
What is the pathophysiology of genital herpes?
HSV enters the body through small cracks in the skin or through the mucous membranes of the mouth, vagina, rectum, urethra or under the foreskin. After infecting the surface, the virus travels up the nearest nerve to the ganglion and remains there.
Asymptomatic shedding is also an important cause of transmission as many people can shed and transmit the virus even if they are unaware they have the infection.
Which ganglia do the different types of HSV normally lie dormant in?
Oro-labial herpes: trigeminal ganglia
Anogenital herpes: sacral nerve root ganglia
How does genital herpes present?
Asymptomatic
Painful vesicle, pustule or ulceration: usually multiple lesions of different ages
Vaginal/urethral discharge
Dysuria
Systemic symptoms: fever, headache, malaise, myalgia (more common in primary infection)
Proctitis: bleeding, tenesmus, pain, discharge (more common in MSM)
Vesicles
Pustules
Ulceration: usually evidence of crusting over
Lymphadenopathy/lymphadenitis (inguinal): usually tender and bilateral. Seen in around 30%. Unilateral more common in recurrent infection
Urinary retention: if pelvic autonomic nerves affected
Describe recurrent herpes
Once primary infection has cleared the virus remains dormant in the body. It can reactivate causing recurrent outbreaks. These are shorter and less severe and over time reduce in severity and length bcos of antibody production. Usually presents with burning, itching and painful red blisters around the genitals.
What are complications of herpes?
Superinfection (lesions may become infected by bacteria or fungi), Autonomic neuropathy (urinary retention), Autoinoculation (lesions can be passed to other areas of skin through direct contact), CNS complications (aseptic meningitis and encephalitis but more likely in patients with HIV co-infection or marked immunosuppression), hepatitis, oesophagitis, keratitis, etc
What Ix do you do for herpes?
NAAT from base of the ulcer
Other STI screen
Serology for antibodies
How is herpes managed?
Acyclovir
Abstain
Salt baths
Analgesia (topical lidocaine 2% gel e.g. Instillagel and paracetamol)
Loose clothing
Refer to GUM
Does maternal herpes affect pregnancy? How is herpes managed in pregnancy?
No but there is a worry of transmission causing neonatal herpes simplex infection through delivery. Management depends on whether it is first episode or recurrent.
Primary before 28 weeks = aciclovir then regular prophylactic aciclovir starting from 36 weeks gestation onwards to reduce the risk of genital lesions during labour and delivery. Women that are asymptomatic at delivery can have a vaginal delivery (provided it is more than six weeks after the initial infection). Caesarean section is recommended when symptoms are present.
Primary after 28 weeks = aciclovir during the initial infection followed immediately by regular prophylactic aciclovir. Caesarean section is recommended in all cases to reduce the risk of neonatal infection.
Recurrent 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.
What causes syphilis?
Treponema pallidum. This bacteria is a spirochete, a type of spiral-shaped bacteria. The bacteria gets in through skin or mucous membranes, replicates and then disseminates throughout the body. It is mainly a sexually transmitted infection. The incubation period between the initial infection and symptoms is 21 days on average.
How is syphilis spread?
Oral, vaginal or anal sex involving direct contact with an infected area
Vertical transmission from mother to baby during pregnancy
Intravenous drug use
Blood transfusions and other transplants
What is primary syphilis?
a papule will appear before ulcerating into a chancre. A chancre is a painless ulcer and typically develops 9-90 days post infection on a genital site. Usually singular, hard and non-itchy. However, chancres may be atypical in that they can appear at other sites e.g. oral, be multiple and painful. Classically chancres heal within 3-10 weeks with or without symptoms but may persist during secondary syphilis.
What is secondary syphilis?
Occurs 4-10 weeks after primary infection. It typically presents with a maculopapular symmetrical rash on the palms, legs, soles and face which is not itchy or painful. There also may be fever, malaise, arthralgia, weight loss, headaches and painless lymphadenopathy. Other less common features include malaise, fever, hepatitis, glomerulonephritis and neurological complications.
Condylomata lata- elevated plaques like warts at moist areas of skin e.g. inner thighs, anogenital region, axillae
Moth eaten alopecia
Mucus patches (snail tract lesions)
Silvery-gray mucous membrane lesions – oral, pharyngeal, genital
What is latent syphilis?
Latent syphilis occurs after the secondary stage of syphilis, where symptoms disappear and the patient becomes asymptomatic despite still being infected. Early latent syphilis occurs within two years of the initial infection, and late latent syphilis occurs from two years after the initial infection onwards.
What is tertiary syphilis?
Can occur many years after the initial infection and affect many organs of the body as gummatous, cardiovascular or neurological syphilis.
