GUM/Sexual Health Flashcards
1
Q
How does pelvic inflammatory disease (PID) occur?
A
When infection spreads from vagina, through into cervix and then into upper genital tract
2
Q
What is the most common cause of PID?
A
Chlamydia trachomatis
3
Q
What is the second most common cause of PID?
A
Neisseria gonorrhoea
4
Q
Which pathogens can cause PID?
A
1) Chlamydia
2) Gonorrhoea
3) Anaerobic bacteria
Sometimes no pathogen can be isolated
5
Q
How is PID spread?
A
Sexually
6
Q
How is PID diagnosed?
A
Clinical diagnosis
7
Q
What are the symptoms of PID?
A
1) Severe bilateral abdominal pain (like a band across front of lower abdomen)
2) Discharge
3) Post-coital bleeding (inter-menstrual bleeding)
4) Dyspareunia
8
Q
What are the signs of PID?
A
1) Adnexal tenderness
2) Cervical motion tenderness on bimanual examination - unable to tolerate bimanual or speculum
3) Fever
4) Abdominal tenderness
5) Recent STI
9
Q
What condition does cervical motion tenderness on bimanual examination indicate?
A
PID
10
Q
What is Fitz Hugh Curtis syndrome?
A
When adhesions form between the anterior liver capsule to the anterior abdominal wall or diaphragm, on a background of PID (10% of PID patients present like this)
11
Q
How does Fitz Hugh Curtis syndrome present?
A
RUQ pain (secondary to inflammation of liver capsule) on background of PID symptoms
12
Q
How are liver function tests in Fitz Hugh Curtis syndrome?
A
Normal
13
Q
What investigations are done in PID?
A
1) Pelvic examination
2) Pregnancy test
3) Swabs for gonorrhoea and chlamydia
4) Bloods
5) Transvaginal ultrasound
14
Q
Which combination of antibiotics are given for PID?
A
1) IM ceftriaxone
2) Doxycycline
3) Metronidazole
OR ofloxacin + metronidazole
15
Q
How is PID managed?
A
1) Outpatient antibiotic treatment
2) Analgesia
3) Review patient in 4 weeks
16
Q
Which patients are given empirical treatment for PID and why?
A
All young sexually active women with bilateral lower abdominal pain with adnexal tenderness - due to significant number of women not diagnosed
17
Q
What are three complications of PID?
A
1) Chronic pelvic pain (40%)
2) Infertility (15%)
3) Ectopic pregnancy (1%)
18
Q
How is Fitz Hugh Curtis syndrome investigated?
A
1) Abdominal ultrasound - to exclude stones
2) Laparoscopy - for definitive diagnosis
19
Q
How is Fitz Hugh Curtis syndrome treated?
A
Antibiotics
20
Q
Which blood marker can be high in PID?
A
Ca-125
21
Q
What increases your risk of developing PID?
A
STIs in the past
22
Q
What are the two possible causes of genital herpes?
A
1) HSV- 1 - most common
2) HSV-2 - more likely to cause recurrent anogenital symptoms
23
Q
What is the most common cause of oral herpes?
A
HSV-1 (HSV2 rarely affects the mouth and lips)
24
Q
What is the most common cause of genital herpes?
A
HSV-1
25
How do you differentiate between HSV-1 and HSV-2 herpes infection?
They are clinically indistinguishable
26
How does genital herpes present?
Asymptomatic OR
1) Multiple painful genital ulcers/lesions on vulva
2) Dysuria ± urinary retention
3) Vaginal/urethral discharge
4) Lesions typically crust and heal - at this point the virus ceases to be shed from the lesions
5) May have fever, malaise, headache
6) Palpable inguinal lymphadenopathy
27
What are the features of recurrent episodes of genital herpes?
1) Recurrent episodes are usually less severe than a primary episode
2) There may not be a clearly identifiable trigger
3) The recurrent episode may have a prodromal phase e.g. tingling
28
How is genital herpes diagnosed?
1) Clinical - history & examination
2) NAAT
29
What is the most effective method of diagnosing genital herpes?
Obtain a swab from the base of the ulcer + analyse using nucleic acid amplification tests (NAAT)
30
How is HSV transmitted?
1) Skin-to-skin
2) The virus can be shed in the prodromal phase + during phases of recurrence or when displaying clinical symptoms for the first time
3) The virus can also be shed when the patient is asymptomatic
31
What is the current guidance with abstinence in genital herpes?
The current guidance advises patients to abstain from sex during clinical recurrence or when they are experiencing prodromal symptoms
32
What is the primary treatment for genital herpes simplex infection?
Oral antivirals
33
When should genital herpes be treated?
1) Treatment should commence within 5 days of the start of the episode OR
2) While new lesions are forming for people with a first clinical episode of genital herpes
34
What is first line treatment for genital herpes?
Aciclovir 400mg TDS for 5 days ± topical lidocaine 2% gel for symptomatic analgesic relief
35
What common treatment regimes used for genital herpes?
1) Aciclovir 400mg TDS for 5 days
2) Aciclovir 200mg five times daily for 5 days
3) Valaciclovir 500mg BD for 5 days
4) Famciclovir 250mg TDS for 5 days
36
How do you manage a first time episode of HSV (genital herpes) in pregnancy?
1) Refer to GUM clinic
2) Do not delay treatment - 400mg aciclovir TDS for 5 days
3) Acquisition of primary genital herpes simplex in the first or second trimester does not preclude vaginal delivery, however suppressive therapy with oral Aciclovir may be given from week 36 to reduce the risk of HSV lesions at term
37
How do you manage recurrent HSV (genital herpes) in pregnancy?
1) Women with recurrent genital herpes should be informed that the risk of neonatal herpes is low, even if lesions are present at the time of delivery (0–3% for vaginal delivery) - if a woman has HSV lesions at term, delivery via caesarean section is recommended to reduce the risk of vertical transmission to the newborn
2) Although there is no evidence that aciclovir is unsafe in early pregnancy, the majority of recurrent episodes of genital herpes are short-lasting and resolve within 7–10 days without antiviral treatment
3) Supportive treatment measures using saline bathing and analgesia with standard doses of paracetamol alone will usually suffice
38
Which virus is associated with the development of cervical cancer in women and vulval, anal and throat cancers?
HPV16 or HPV18
39
Which virus is associated with the development of Kaposi's sarcoma in patients with HIV?
Human herpesvirus 8 (HHV8)
40
What are two normal variant/self-limiting skin conditions affecting the glans and prepuce of the penis?
1) Pearly penile papules (multiple uniform smooth flesh coloured lesions around the coronal margin of the glans) - reassure that they are not sexually transmitted + discharge
2) Angiokeratomas
41
Which inflammatory skin conditions can affect the penis?
1) Eczema
2) Psoriasis
3) Lichen planus
4) Lichen sclerosus
5) Zoon's balanitis
42
What is Erythroplasia of Queyrat?
1) A squamous cell carcinoma in situ that affects the penis
2) Should be referred immediately in the primary care setting
3) More likely to affect older patients
4) Presents with a red, well circumscribed and painless lesion on the prepuce or the glans
43
How do you treat keratinised genital warts?
Cryotherapy
44
How do you treat non-keratinised genital warts?
Podophyllotoxin or imiquimod
45
What would you see on urinalysis in PID?
Negative
46
What is the most common bacterial STI in the UK?
Chlamydia (highest in sexually active young adults 15-24)
47
What type of bacteria is chlamydia trachomatis?
Obligate intracellular bacterium - appears as small, round, elementary bodies within infected cells
48
How does chlamydia present?
Asymptomatic (esp. in women) OR
1) Men - urethral discharge + dysuria
2) Women - dysuria, intermenstrual bleeding + vaginal discharge
3) If anal infection - discharge or anorectal discomfort
4) History of unprotected sex
49
How can neonates become infected with chlamydia?
From exposure to the infected mother's genital tract during delivery
50
How does neonatal chlamydia present?
Pneumonia and conjunctivitis
51
How do you diagnose vaginal chlamydia?
Vulvovaginal swab (self or clinician taken) or endocervical swab or first catch urine sample - analysed using NAAT
52
How do you diagnose penile chlamydia?
Urine or urethral swab - analysed using NAAT
53
How do you diagnose anal chlamydia?
Anal swab - analysed using NAAT
54
In which GUM conditions is a test of cure normally recommended?
1) Rectal chlamydia
2) Gonorrhoea - to monitor disease clearance and decide on whether the antibiotic regimen used was effective or needs altering
55
What is the treatment for chlamydia?
Oral doxycycline BD for 7 days
56
What does nucleic acid amplification tests (NAAT) look for?
DNA or RNA of chlamydia trachomatis (or other bacterial infections incl. gonorrhoea
57
What investigations are done in bacterial vaginosis (BV)?
1) Microscopy and culture - clue cells (epithelial cells from the cervix that have bacteria stuck inside them, usually Gardnerella vaginalis) present on wet mount
2) Vaginal pH testing - vaginal pH > 4.5 suggests BV
3) Whiff test
58
What is a cervical smear used for?
To screen for HPV infection and cervical cancer
59
Microscopy and culture can be used to diagnose which GUM conditions?
1) Bacterial vaginosis
2) Candidiasis
3) Gonorrhoea
4) Trichomonas vaginalis
60
What type of bacteria is neisseria gonorrhoeae?
Gram negative intracellular diplococcus
61
In which patient groups is gonorrhoea most common?
1) Young adults (15-24)
2) MSM
62
How does gonorrhoea present?
1) Men - asymptomatic OR discharge (odourless, purulent, green/yellow), dysuria, tender inguinal nodes, testicular pain/swelling
2) Women - discharge (odourless, purulent, green/yellow), dysuria, abnormal bleeding, pelvic/abdominal pain ± cervical motion tenderness
3) Extra-genital complications - pharyngitis, rectal pain and discharge and disseminated infection
63
What might you see on examination of a women with gonorrhoea?
Discharge from the os, Skene's gland or Bartholin's gland
64
What are extra-genital complications of gonorrhoea?
1) Pharyngitis
2) Rectal pain + discharge
3) Disseminated infection
65
Which types of swabs can be used to diagnose gonorrhoea?
1) Self taken vulvovaginal swab in women
2) Self-obtained first pass urine in men
3) Self-obtained rectal swab
4) Clinician-obtained endocervical or penile swab
66
How do you diagnose gonorrhoea?
1) Microscopy - presence of monomorphic gram-negative diplococci within polymorphonuclear cells
2) Culture
3) ± NAAT
67
What would you see on microscopy of gonorrhoea?
Presence of monomorphic Gram-negative diplococci within polymorphonuclear leukocytes
68
How do you treat gonorrhoea?
Ceftriaxone 1g IM (if sensitivities are known then single dose of PO ciprofloxacin)
69
What are major complications of untreated gonorrhoea?
1) Infertility in women
2) Infertility in men
3) Infection that spreads to the joints and other areas of the body
4) Increased risk of HIV/AIDs
70
How can gonorrhoea lead to infertility in women?
1) Gonorrhoea can spread into the uterus and fallopian tubes, causing PID
2) PID can result in scarring of the tubes, greater risk of pregnancy complications and infertility
71
How can gonorrhoea lead to infertility in men?
1) Gonorrhoea can cause a small, coiled tube in the rear portion of the testicles where the sperm ducts are located (epididymis) to become inflamed (epididymitis)
2) Untreated epididymitis can lead to infertility
72
What are the features of disseminated gonorrhoea infection?
1) The bacterium that causes gonorrhoea can spread through the bloodstream and infect other parts of your body, including your joints
2) Fever, rash, skin sores, joint pain, swelling and stiffness are possible results
73
What is the link between gonorrhoea and HIV/AIDS?
1) Having gonorrhoea makes you more susceptible to infection with HIV, the virus that leads to AIDS
2) People who have both gonorrhoea and HIV are able to pass both diseases more readily to their partners
74
What is candida albicans?
A fungal infection caused by yeast
75
What does candida albicans look like on microscopy?
Round, budding years with pseudohyphae
76
How does trichomonas appear on microscopy?
Small, pear shaped parasites with a single nucleus and flagella
77
What is bacterial vaginosis?
A bacterial imbalance of the vagina caused by an overgrowth of anaerobic bacteria and a loss of lactobacilli - bacterial overgrowth leading to vaginal discharge with an associated fishy odour
78
What are the clinical features of BV?
1) Increased vaginal discharge - uncomfortable, may increase around menses/worse after bleeds
2) Grey-white watery discharge
3) Characteristic fishy smelling discharge esp. after intercourse (maybe just on bimanual/speculum examination)
NOT itching or pain
79
What is the most common cause of abnormal vaginal discharge in women of childbearing age?
Bacterial vaginosis - prevalence as high as 50% in some communities
80
Which criteria are used to diagnose BV?
Amstel criteria
81
How do you diagnose BV?
Clinical - 3 out of 4 Amstel criteria need to be present:
1) Vaginal pH > 4.5
2) Homogenous grey or milky discharge
3) Positive whiff test - addition of 10% potassium hydroxide produces fishy odour
4) Clue cells present on wet mount
82
How do you treat BV (if asymptomatic don't need treatment)?
1) First line = metronidazole (PO or vaginal pessary) - ?avoid in first trimester
2) Second line = clindamycin (PO or vaginal pessary)
83
What are the features of BV and pregnancy?
1) Pregnant women are at increased risk of bacterial vaginosis due to changes in hormone
2) If you have BV during pregnancy, your baby is at increased risk for premature birth and low birthweight, however bacterial vaginosis causes no problems in the majority of pregnancies
84
What is the first line treatment for candida albicans infection (thrush)?
Clotrimazole pessary
85
What is the treatment of choice in women with recurrent candida infection?
Nystatin pessary
86
What treatment is used for treating resistant strains of candida infection e.g. candida glabrata?
Oral fluconazole
87
Which bacteria is associated with BV?
Gardnerella vaginalis
88
What is the most common cause of thrush?
Candida albicans (85-90%)
89
How does thrush (candidiasis) present in women?
1) Cottage-cheese like discharge - white curdy discharge with sour milk odour
2) Dysuria
3) Superficial dyspareunia
4) Itching
5) Examination - swelling, fissuring, erythema, intertrigo, thick white discharge
90
How does trichomonas vaginalis present?
Asymptomatic OR
1) Profuse, frothy, yellow vaginal discharge
2) Vulval irritation
3) Dyspareunia
4) Strawberry cervix (rare)
5) Men - non-gonococcal urethritis
91
What are the lesions like in female genital herpes?
Multiple wet ulcer-like vesicles on vulva and perineum which are painful to touch, with surrounding erythema
92
When would IV aciclovir be used to treat herpes simplex?
Patients with evidence of disseminated herpes simplex disease e.g. involving more than one mucosal site, fever or evidence of meningitis
93
Why is a higher dose of aciclovir recommended for genital herpes in pregnancy?
Bc pregnancy results in a higher circulating blood volume and therefore a higher volume of distribution for any drug
94
Would you remove an IUD in uncomplicated chlamydia infection?
No
95
What are risk factors for candida infection?
1) Pregnancy
2) Antibiotic use
3) Immunosuppression
96
What is the method of transmission for candida?
Non-sexual
97
How does thrush present in men?
1) Soreness
2) Pruritis
3) Erythema
4) Examination - dry, dull, red glazed plaques and papules
98
What are risk factors for BV?
1) Unprotected sexual intercourse/multiple sexual partners
2) Excessive vaginal cleaning
3) Recent abx
4) Smoking
5) Copper coil
99
What is trichomoniasis caused by?
Sexual transmission of trichomonas vaginalis (flagellated protozoan) - incubation period ~ 7 days
100
How do you diagnose trichomonas?
Microscopy and culture (small, pear shaped parasites with a single nucleus and flagella)
101
How do you treat trichomonas?
1) Metronidazole PO BD for 7 days
2) Follow up in one week
3) Screen sexual contacts
102
Which three GUM conditions are treated with metronidazole?
BV, trichomonas and PID (PID also with ceftriaxone and doxycycline)
103
Which virus causes genital warts?
HPV
