GUM - Sexual Health Flashcards
What is bacterial vaginosis?
- Bacterial vaginosis (BV) is overgrowth of anaerobic bacteria in the vagina
- Not a sexually transmitted infection.
- Loss of the lactobacilli “friendly bacteria” in the vagina.
- Increases the risk of STIs
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.
What bacteria are associated with bacterial vaginosis?
- Gardnerella vaginalis (most common)
- Mycoplasma hominis
- Prevotella species
It is worth remembering that bacterial vaginosis can occur alongside other infections, including candidiasis, chlamydia and gonorrhoea.
Risk factors for BV?
- Multiple sexual partners (although it is not sexually transmitted)
- Excessive vaginal cleaning (douching, use of cleaning products and vaginal washes)
- Recent antibiotics
- Smoking
- Copper coil
Bacterial vaginosis occurs less frequently in women taking the combined pill or using condoms effectively.
TOM TIP for when you are taking a history from someone with BV?
TOM TIP:
- typical Sx of BV make Dx easy based on the fishy-smelling discharge.
- assess for causes and give advice
- ask about the use of soaps to clean the vagina and vaginal douching and provide information about how these can increase the risk.
Presentation of BV?
- Fishy-smelling watery grey or white vaginal discharge
- Half of women with BV are asymptomatic.
Not: Itching, irritation and pain as these suggest an alternative cause or co-occurring infection.
- a speculum examination can be performed to confirm the typical discharge
- complete a high vaginal swab and exclude other causes of symptoms.
Examination is not always required where the symptoms are typical, and the women is low risk of sexually transmitted infections.
Investigation in BV?
Vaginal pH can be tested using a swab and pH paper. The normal vaginal pH is 3.5 – 4.5. BV occurs with a pH above 4.5.
A standard charcoal vaginal swab can be taken for microscopy. This can be a high vaginal swab taken during a speculum examination or a self-taken low vaginal swab.
Bacterial vaginosis gives “clue cells” on microscopy. Clue cells are epithelial cells from the cervix that have bacteria stuck inside them, usually Gardnerella vaginalis.
TOM TIP: Remember that clue cells on microscopy mean bacterial vaginosis. This is a common association tested in MCQ exams.
Management of BV?
Asymptomatic BV does not usually require treatment. Additionally, it may resolve without treatment.
Metronidazole is the antibiotic of choice for treating bacterial vaginosis. Metronidazole specifically targets anaerobic bacteria. This is given orally, or by vaginal gel. Clindamycin is an alternative but less optimal antibiotic choice.
Always assess the risk of additional pelvic infections, with swabs for chlamydia and gonorrhoea where appropriate.
Provide advice and information about measures that can reduce the risk of further episodes of bacterial vaginosis, such as avoiding vaginal irrigation or cleaning with soaps that may disrupt the natural flora.
TOM TIP when prescribing metronidazole?
TOM TIP: Whenever prescribing metronidazole advise patients to avoid alcohol for the duration of treatment. This is a crucial association you should remember, and something examiners will look out for when you are explaining the treatment to a patient. Alcohol and metronidazole can cause a “disulfiram-like reaction”, with nausea and vomiting, flushing and sometimes severe symptoms of shock and angioedema.
Complications of bacterial vaginosis?
Bacterial vaginosis can increase the risk of catching sexually transmitted infections, including chlamydia, gonorrhoea and HIV.
It is also associated with several complications in pregnant women:
- Miscarriage
- Preterm delivery
- Premature rupture of membranes
- Chorioamnionitis
- Low birth weight
- Postpartum endometritis
What is candidiasis?
Vaginal candidiasis is commonly referred to as “thrush”. 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.
Risk factors for candidiasis?
- Increased oestrogen (higher in pregnancy, lower pre-puberty and post-menopause)
- Poorly controlled diabetes
- Immunosuppression (e.g. using corticosteroids)
- Broad-spectrum antibiotics
Presentation of vaginal candidiasis?
The symptoms of vaginal candidiasis are:
- Thick, white discharge that does not typically smell
- Vulval and vaginal itching, irritation or discomfort
More severe infection can lead to:
- Erythema
- Fissures
- Oedema
- Pain during sex (dyspareunia)
- Dysuria
- Excoriation
Investigations for candidiasis?
Often treatment for candidiasis is started empirically, based on the presentation.
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.
Management of vaginal candidiasis?
Treatment of candidiasis is with antifungal medications. These can be delivered in several ways:
- Antifungal cream (i.e. clotrimazole) inserted into the vagina with an applicator
- Antifungal pessary (i.e. clotrimazole)
- Oral antifungal tablets (i.e. fluconazole)
The NICE Clinical Knowledge Summaries (2017) recommend for initial uncomplicated cases the options of:
- A single dose of intravaginal clotrimazole cream (5g of 10% cream) at night
- A single dose of clotrimazole pessary (500mg) at night
- Three doses of clotrimazole pessaries (200mg) over three nights
- A single dose of fluconazole (150mg)
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.
They also recommend 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. This is an off-label use.
Warn women that antifungal creams and pessaries can damage latex condoms and prevent spermicides from working, so alternative contraceptive is required for at least five days after use.
What is chlamydia?
Chlamydia trachomatis is a gram-negative intracellular bacteria (enters and replicates within cells before rupturing the cell and spreading).
Chlamydia is the most common sexually transmitted infection in the UK and a significant cause of infertility.
Being young, sexually active and having multiple partners increase the risk of catching the infection.
A large number of cases are asymptomatic (50% in men and 75% in woman). Asymptomatic patients can still pass the infection on.
How does the National Chlamydia Screening Programme work?
PHE has set out a National Chlamydia Screening Programme (NCSP).
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)
What swabs can be used in sexual health testing?
It can be tricky to get your head around the swabs used for sexual health screening. There are many different swab types and uses. The FSRH Clinical Guideline on vaginal discharge (2012) has helpful guidance on the investigation with different swabs in different clinical scenarios.
There are two types of swabs involved in sexual health testing:
- Charcoal swabs
- Nucleic acid amplification test (NAAT) swabs
How are charcoal swabs used?
Charcoal swabs allow for microscopy, culture and sensitivities. Charcoal swabs look like a long cotton bud that goes into a tube with a black transport medium at the end. The transport medium is called Amies transport medium, and contains a chemical solution for keeping microorganisms alive during transport.
Charcoal swabs can be used for endocervical swabs and high vaginal swabs (HVS). Charcoal swabs can confirm:
- Bacterial vaginosis
- Candidiasis
- Gonorrhoeae (specifically endocervical swab)
- Trichomonas vaginalis (specifically a swab from the posterior fornix)
- Other bacteria, such as group B streptococcus (GBS)
How are NAAT swabs used?
Nucleic acid amplification tests (NAAT) check for the DNA or RNA of the organism. NAAT is used for chlamydia and gonorrhoea (not useful for other pelvic infections).
In women, a NAAT test can be performed on an endocervical swab, a vulvovaginal swab (a self-taken lower vaginal swab), or a first-catch urine sample. That is also the order of preference.
In men, a NAAT test can be performed on a first-catch urine sample or a urethral swab. It is worth noting that the NAAT swabs will specify on the packet whether the swabs are for endocervical, vulvovaginal or urethral use. A specific kit is used for first-catch urine NATT testing.
Rectal and pharyngeal NAAT swabs can also be taken to diagnose chlamydia in the rectum and throat. Consider these swabs where anal or oral sex has occurred.
Where gonorrhoea is suspected or demonstrated on a NAAT test, an endocervical charcoal swab is required for microscopy, culture and sensitivities.
How might chlamydia present in men and women?
The majority of cases of chlamydia in women are asymptomatic. Consider chlamydia in women that are sexually active and present with:
- Abnormal vaginal discharge
- Painful urination (dysuria)
- Pelvic pain
- Abnormal vaginal bleeding (intermenstrual or postcoital)
- Painful sex (dyspareunia)
Consider chlamydia in men that are sexually active and present with:
- Urethral discharge or discomfort
- Painful urination (dysuria)
- Epididymo-orchitis
- Reactive arthritis
It is worth considering rectal chlamydia and lymphogranuloma venereum in patients presenting with anorectal symptoms, such as discomfort, discharge, bleeding and change in bowel habits.
Examination findings in chlamydia?
- Pelvic or abdominal tenderness
- Cervical motion tenderness (cervical excitation)
- Inflamed cervix (cervicitis)
- Purulent discharge
Diagnosis of chlamydia?
Nucleic acid amplification tests (NAAT) are used to diagnose chlamydia. This can involve a:
- Endocervical swab
- Vulvovaginal swab
- First-catch urine sample (in women or men)
- Urethral swab in men
- Rectal swab (after anal sex)
- Pharyngeal swab (after oral sex)
Management of chlamydia?
BASSH guidelines:
First-line for uncomplicated chlamydia infection is doxycycline 100mg twice a day for 7 days.
The guidelines previously recommended a single dose of azithromycin 1g orally as an alternative. This recommendation has been removed due to Mycoplasma genitalium resistance to azithromycin, and azithromycin being less effective for rectal chlamydia infection.
A test of cure is not routinely recommended. However, a test of cure should be used for rectal cases of chlamydia, in pregnancy and where symptoms persist.
Treatment of chlamydia in pregnancy and breastfeeding?
Doxycycline is contraindicated in pregnancy and breastfeeding. Alternatives options listed in the BASHH guidelines for treatment in pregnant or breastfeeding women are:
- Azithromycin 1g stat then 500mg once a day for 2 days
- Erythromycin 500mg four times daily for 7 days
- Erythromycin 500mg twice daily for 14 days
- Amoxicillin 500mg three times daily for 7 days
Complications of chlamydia?
Lots of complications:
- 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 is lymphogranuloma venereum? What happens?
Lymphogranuloma venereum (LGV) is a condition affecting the lymphoid tissue around the site of infection with chlamydia. It most commonly occurs in men who have sex with men (MSM). LGV occurs in three stages:
- 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.
- 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.
Doxycycline 100mg twice daily for 21 days is the first-line treatment for LGV recommended by BASHH. Erythromycin, azithromycin and ofloxacin are alternatives.
Chlamydial conjunctivitis?
Chlamydia can infect the conjunctiva of the eye. Conjunctival infection is usually as a result of sexual activity, when genital fluid comes in contact with the eye, for example, through hand-to-eye spread. It presents with chronic erythema, irritation and discharge lasting more than two weeks. Most cases are unilateral.
Chlamydial conjunctivitis occurs more frequently in young adults. It can also affect neonates with mothers infected with chlamydia. Gonococcal conjunctivitis is a crucial differential diagnosis and should be tested.
What is 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.
Gonorrhoea is a sexually transmitted infection. Being young, sexually active and having multiple partners increases the risk of infection with gonorrhoea. Having other sexually transmitted infections, such as chlamydia or HIV, also increases the risk.
High level of antibiotic resistance to gonorrhoea. Traditionally ciprofloxacin or azithromycin was used to treat gonorrhoea. However, there are now high levels of resistance to these antibiotics.
Presentation of gonorrhoea in men and women?
Infection with gonorrhoea is more likely to be symptomatic than infection with chlamydia. 90% of men and 50% of women are symptomatic. The presentation will vary depending on the site. Female genital infections can present with:
- Odourless purulent discharge, possibly green or yellow
- Dysuria
- Pelvic pain
Male genital infections can present with:
- Odourless purulent discharge, possibly green or yellow
- Dysuria
- Testicular pain or swelling (epididymo-orchitis)
Others:
Rectal infection may cause anal or rectal discomfort and discharge, but is often asymptomatic.
Pharyngeal infection may cause a sore throat, but is often asymptomatic. Prostatitis causes perineal pain, urinary symptoms and prostate tenderness on examination.
Conjunctivitis causes erythema and a purulent discharge.
