GUM Lectures Flashcards
Causes of proctitis
LGV lymphomagranuoma venerum Gonorrhoea non-LGV chlamydia herpes shigella Hep A
Other: IBS, haemorrhoids,/polyps, malignancy
What causes LGV
1/3 invasive servers of chlamydia trachomatis. L1,L2, L3. Rectal chlamydia, seen most commonly in homosexual men
Classical presentation of LGV
proctitis
ulceration
inguinal lymphadenopathy
buboes
D.D testicular pain
infections
trauma
torsion
tumours (rare)
investigations for testicular pain
infection:
- first void urine (chlamydia & gonnorhea)- more likely
- mid-stream (urinary pathogens)
- swabs
what is acute epididymis-orchitis
what must u exclude
Clinical syndrome of pain, swelling and inflammation of the epididymis +/- testes (MUST EXCLUDE TORSION)
Where does the infections come from?
- local from utethra (STI or enteric organism)
- bladder (urinary)
- MUMPS orchitis & TB (high risk groups)
Signs of acute epididymis-orchitis on examination
Tenderness on affected side, may be bilat
Palpable swelling of epididymis (tail to head)
There may also be:
o urethral discharge
o secondary hydrocele
o erythema and/or oedema of the scrotum on the affected side
o pyrexia
Investigation for acute epididymo-orchitis
Microscopy: urethral or FPU
Urethral culture
NAATs (FPU)
Dipstick & MSU
Other: consider MUMPS & TB
Treatment
Abstain
Ceftriaxone + prolonged course of doxycycline
What skins/musuc membranes and STIs spread to
Eye: bacterial conjunctivitis (chlamydia & gonorrhoea)
Sexually acquired reactive arthritis: <1% chlamydia
Disseminated gonococcal infection
What is reiter’s syndrome?
triad of urethritis, arthritis, conjunctivitis
complication of chlamydia in pregnancy
Associations with IUGR, Premature rupture of membranes, pre-term delivery, low birth weight
Need to treat quickly to prevent complications to baby & prevent reinfection.
Risk already have complications
(azythromycin + follow up)
complication of gonoorhoea in pregnancy
Low birth weight, preterm birth
complications in neonatal period?
ophthalmia neonatorum: presents 1-2 weeks due to chlamydia = conjunctivitis & purulent discharge
neonatal pneumonitis due to chlamydia
both need systemic antibiotics (erythromycin)
Causes of ulcers on foreskin
Herpes simplex
Genital warts (HPV)
syphilius
What investigations would you do?
Swab from ulcer
Blood test:
HIV/Syphilis
Urine test: chlamydia & gonorrhoea
Describe the two types of herpes
Median recurrence rates after primary for each?
HSV1: oral & genital (more common), recurrent 1 x year
HSV2: recurrent anogenital symtoms, approx 4 x year
Very painful
Outbreaks tend to be in same dermatome
Are reactivations always symptomatic?
No: can be asymptomatic (20%): viral shielding (still infectious)
Treatment of herpes simplex.
- Treat the pain!
- Salt water bathing + urinate in the shower
- Topical anaesthetic/oral analgesia.
- Aciclovir 400mg 3 x a day for 5 days.
Patient info:
1) How is HSV spread?
2) is it going to come back?
3) Can I pass it on to someone else?
4) Can they have sex?
1) Direct contact with mucous membrane or skin
2) This was probably a primary episode Frequency of recurrence depends on type HSV 1 (orolabial and genital) ~1 / year HSV 2 (genital) ~4 / year Recurrence rates usually decrease over time Asymptomatic in 20%
3) Virus now latent in local sensory ganglia. Most infectious during a recurrence.
Asymptomatic viral shedding occurs
4)
- Acknowledge distress
- Condoms reduce transmission
- Avoid sex during recurrences
- Disclosure is advised and should be documented
Single, non tender ulcer on penis.
MSM/homosexual
Likely cause?
Tests?
Discussion?
Syphilis, cancer
Blood test
Swab: Dark ground microscopy (diplococci & pus cells: urithtitis) & PCR
- Heb B vaccine (accelerated) course.
- Partner notification
- HIV risk
- Safer sex
- Repeat ‘window period’ bloods
Single, non tender ulcer on penis. MSM/homosexual
Likely cause?
Tests?
Discussion?
- Syphilis.
shingles, apthous ulcers, lichen sclerosus/planus/ malignancy (PIN,VIN). severe eczema, Crohns, moon’s blaanitis/
Blood test
Swab: Dark ground microscopy (diplococci & pus cells: urithtitis) & PCR
Urine
- Heb B vaccine (accelerated) course.
- Partner notification
- HIV risk
- Safer sex
- Repeat ‘window period’ bloods
What bacteria causes syphilis & appearance on dark-field microscopy
Treponema pallidum
spirochaete bacterium
What are the early stages & signs of syphilis
Primary: chancre (site of inoculation)
Secondary: systemic signs: rash (maculo, papula), alopecia, hepatitis, neurological, condyloma lata
Signs last up to 3 months.
Then become asymptomatic and becomes latent.
How to know if its early latent
Confirmed negative test in last 20 years
How to know if its early latent
Confirmed negative test in last 2 years
What are the late stages & signs of syphilis
1st asymptomatic then….
CV: aortic root involvement
Gummatous nodules
Neurological problems
How to treat late syphilis
3 injections
Do full CV, neuro exam
What is coronal papilli
normal variant, small pearly papule around edge of glans of penis
Also can get vulval
epidermal cyst?
lumps on penis, normal variant, may get bigger or shrink
How to diagnose warts?
D.D
Clinical: small fleshy growths, bumps or skin changes that appear on or around the genital or anal area.
Molluscum contangiosum
What causes warts?
Transmission
HPV: 6,11 >90% genital warts
Cancer: 16&18: unlikely to cause warts
Skin to skin contact during sexual contact
When did I get them?
Incubation period: average 3 months
3 weeks-2yrs
often from asymptomatic partner. Most infectious when visible warts
how long will i have them?
- usually resolve in 3 months
- median duration of HPV : 1 yr
- often reoccur
Do condoms eliminate risk of transmission?
No, only reduce it. Still advised.
Treatment
“Ablative” therapies
Cryotherapy
Podophyllotoxin cream/solution
Electrocautery
Immune modulation
Imiquimod 5% cream: keratinised warts, persistent or recurrent warts
Lower recurrence rate (30%)
Surgical
Curettage
Excision
Debulking
Will my girlfriend get cervical cancer?
Low risk HPV subtypes (6,11) exceptionally unlikely to cause pre-malignant change
High risk HPV subtypes (16,18) unlikely to cause visible warts
Girlfriend should attend for cervical screening as normal
HPV vaccination for girls since 2008 (initially 16/18 only, quadrivalent vaccine since 2012) – MSM vaccination pilot started
Universal vaccination advocated
What are fordyce spots
are visible sebaceous glands that are present in most individuals. They appear on the genitals and/or on the face and in the mouth.
Man detected with gonorrhoea, has pregnant wife & multiple males partners.
He refuses to tell wife/partners and does not come to appoitment.
What should u do? Can you break confidentiality?
Can break confidentiality:
-To protect individuals or society from risk of serious harm e.g. serious communicable diseases or serious crime
- Always seek patient’s consent if practicable
- Consider any reasons for refusal of consent
Teenager comes with friend/person to GU clinic? What do u want to know
Name of teenager, school attending.
Who is the friend, sex, relationship, age.
What are the Fraser guidelines?
Who do they apply to?
young person will
- understand advice
- cannot be persuaded to inform parents
- likely to begin, or continue having sex with or without contraceptive treatment
- w/o contraceptive - physical, mental or both health will suffer
- best interest
13-16 sexually active
what if under 13?
legally rape- requires investigation. Incapable of consenting.
Is there a legal obligation to report sex aged 13-16?
Not unless exploitation is suspected.
0-18 when can info be disclosed?
- risk of neglect or sexual, physical or emotional abuse
- information would help in the prevention, detection or prosecution of serious crime
- child saviour at risk of others- serious harm: addiction, self-harm, joy-riding?
3 top counselling priorities for underage sex?
- Contraception
- STI screening
- She should Inform parents
What is the Swiss Statement 2008
Described the HIV transmission risk for someone on stable ARV therapy with (VL < 50) as “negligible” and “similar to risks of daily life”
- Has an undetectable viral load for at least 6 months
- Has excellent adherence
- Has no other STIs
Partner should still be informed & it should be their decision to have unprotected sex- the risk is not 0
Can you disclose HIV status to a partner?
Yes (but encourage her first)
Break confidentiality
HIV/AIDs
Gon
Syphilis
