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YEAR 4 REPRO > GUM: STIs > Flashcards

GUM: STIs Flashcards

1
Q

Causes of genital ulceration?

A
  • Infectious: viral- HSV, varicella, CMV; Bacterial: syphilis, staph/strep. LGV, chancroid, donovanosis, fungal
  • Inflammatory/ immune- behcets, apthous, Crohns, blistering skin conditions
  • Drug-related- FDE, topical reaction, IVDU, foscarnet
  • Traumatic
  • Malignant
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2
Q

What to ask pt with genital ulcers initially?

A

Local symptoms- rash?
Systemic symptoms? fever or
Change in washing/poducts used?
Significant PMH and sexual history?

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3
Q

Clinial features HSV?

A

Abnormal erythema on the skin
Blisters form
Blisters break down and become ulcers
Ulcers scab over

Lasts 10 days

Once you have it, have it for life
No treatment to control it from body, can give aciclovir in an outbreak–> to reduce the ulcers

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4
Q

Types of herpes and where they tend to affect

A

1 - more likely to be face
2- more likely to be genital, can have more frequent outbreaks

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5
Q

Management of herpes?

A

Rest, analgesia, saline washing (once a day until lesions resolved)
Antiviral (aciclovir)- systemic
Do not wait for test results as it takes 5 days and is very uncomfortable

Intial episode:
Course of oral antiviral
5% lidocaine ointment
Rest and analgesia
saline bathing
vaseline

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6
Q

Complications of herpes?

A

Urinary retention- as pain is too much to pee- admitted for a suprapubic catheter
Adhesions- importance of salt water bathing- helps prevent these
Meningism
Emotional distress
Recurrences

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7
Q

Barriers to sexual hx taking?

A

Embarrassment
Misunderstanding language- medical jargon or slang
Fear of judgment or stigmatisation
Lack of privacy
Time pressure
Difficulty understanding the patients concerns and expecations

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8
Q

Sexual hx?

A

Intro and confirm pts identity
PC
PMH
Drug Hx
Social Hx
Sexual Hx
BBI screen

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9
Q

Common PC for females?

A
  • Vaginal discharge
  • Gential lumps/ulcers
  • intermentrual/ post coital bleeding
  • deep and superficial dyspareunia
  • dysuir and frquency
  • STI contact
  • Sexual assaults
  • Rectal symptoms
  • Asymptomatic screens
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10
Q

Common PC for males?

A

Ureteral discharge
Dysuria/urinary symptoms
genital lumps/ulcers
testicular pain/swelling
rectal symptoms
sexual dysfunction and assaults
asymptomatic screens

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11
Q

Sexual Hx - what specifically should you ask

A

Past hx of STI
Last episode of sex: Male/Femal/trans?
Sexual contact- regular or casual? did you know the person you had sex with?
duration fo sexual relationship?
Condoms?
Type of sex- in MSM- insertive/receptive, active/passive, top/bottom
Oral sex- the reciepient is the one with genitals in their mouth
Partner symptoms
Partner details for contact tracing

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11
Q

BBI risk factors?

A

IVDU/ partner IVDU
Sexual partner MSM
Swingers
Partners from high risk countries
Blood products before 1985 or abroad
Paid for sex or been paid for sex
Tattoos or piercings- reputable place?

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12
Q

Tips for successful history taking?

A

Explain confidentially and what to expect
Maintain privacy
Listen and minimise distraction
use simple language, check pts meaning
consider seeing pt on their own
Be non-judgemental and don’t make assumptions
Ask confidentially- if you’re embarrassed, the patient is more likely to be also
Ask only what you need to know, you should be able to explain you rationale for asking certain questions

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13
Q

General principles of intimate examination?

A

Explain the rationale/expectations for the exam
Consent with the option to stop the exam at any point
Offer a chaperone and document (declined/accepted/chaperone name)
Privacy for dressing/undressing
Expose only the are needed for examination
Keep discussion relevant: no personal comments
Inspect and palapate in systematic way
Good lighting

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14
Q

Male gential exam?

A

Inspect and palapte inguinal region
Inspect pubic are and scrotum
Inspect penis (fully retract foreskin)
Palpate scrotal area
Prehns test
Cremasteric reflex

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15
Q

Symptomatic male Investigations

A

Uretheral smear- GC/NSU, GC culture
First pass urine- GC/CT dual Naats test
Bloods HIV/syphilia +/- hep B/C

NB 1. MSM- may need rectl and pharyngeal swabs and cultures
2. Other swabs- MC&S/ candida/herpes
3. Other test-urine dip

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16
Q

Definition of partner notifications?

A

Process of contactin the sexual partners of an individual with a STI incl HIV and advising them that they have been exposed to infection.
By this means, people who are high risk of SITHIV, many of whom are unaware that they have been exposed, are contacted and encouraged to attend for counselling, testing and other prevention and treatment services

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17
Q

Securing co-operation with PN?

A

Voluntary
Non-judgemental and supportive approach
Emphasize patient choice/control
Confidentialtiy
Patient risk of re-infection
Partner at risk from untreated infection
Risk of transmission to others

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18
Q

Partner notification methods?

A

Patient referral
Provider referral: phone, encouraging attendance

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19
Q

Identifying partners at risk?

A

Look-back periods- usually 2 week (gonorrhoea with uretheral discharge- we know its been caught within last 2 weeks), chlamidya (6months)
Refer to sexual hx
Condom use/ safer sex advice
Memory prompts may help recall
Document details to track progress

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20
Q

Asymptomatic male investigations?

A

First pass urine- GC/CT dual Naats test
Bloods HIV/syphilis +/1 hep B/C

NB. MSM may need rectal and pharyngeal swabs

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21
Q

Female genital exam?

A

Lithotomy position (ideally)
Speculum exam- ensure use of lots of lubricant

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22
Q

What additional exams would you do if someone presented with ?STI or ?GUM infection

A

Anorectal
Oral cavity
Skin
Eyes
Joints

23
Q

What tests would you do for a symptomatic female?

A

High vaginal loop swab for microscopy and pH testing- TV, BV, Candida
Vulvovaginal, swab ‘dual NAAT’- Chlamydia and gonorrhoea. May need throat and rectal
Blood- HIV/syph +/- Hep B/C
History examination dependent:
* high vaginal charcoal swab- TV also for microscopy
* Gonorrhoea cultures- endocervical
* Herpes Simplex virus PCR
* Urinanlysis
* Pregenency test (pt request, ?PID)

24
Q

Questions to ask with patient presenting with discharge?

A

Further info on the discharge
* Colour
* Odour
* Consistency
* Bloodstaining
Other symptoms:
* associated itch or soreness
* Intermenstrual/ post-coital bleeding
* Dysparaunia
* Gential rash/ lesions
Sexual Histroy

25
Q

Aetiology of increased vaginal secretions?

A

Physiological
* pregnancy
* sexual arousal
* Menstrual cycle variation
Pathological: Vaginal
* Candidosis
* Trichomoniasis
* Gardenerelia associated
* other bacteria e.g. due to a foregin body
* Post menopausal vaginitis
Pathological: Cervical
* Gonorrhoea
* Non-specific genital infection
* Herpes
* Cervical ectopy
* Cervical neoplasm e.g. polyp

26
Q

Investigations of vaginal discharge?

A

Examination (incl vaginal pH)
High vaginal swab:
* culture for T.vaginalis, candida spp
* Wet mount
* Gram stain
Vulvovaginal swab
* NAAT for N. gonorrhoeae and C. trachomatis
Endocervical
* Gonorrhoea culture
Other tests
* Culture for other organisms if relevant
* HSV PCR from cervix

27
Q

Risk factors for Candidiasis?

A
  • Immunosuppression (HIV, steroids, chemotherapy)
  • High oestrogen levels (pregnancy, luteal phase, some COCs)
  • Recent Abx
  • DM
  • Mucosal breakdown (sexual contact, dermatitis)
  • Recurrent candidiasis ?associated with atopy
28
Q

Treatment of Candidal Infection?

A

Fluconazole 150mg stat or Clotrimazole 500mg pessary PV stat
Clotrimazole 1% (+/- hydrocortisone 1%) cream top BD for 2 weeks

NICE Clinical Knowledge Summaries recommends:
* oral fluconazole 150 mg as a single dose first-line
* clotrimazole 500 mg intravaginal pessary as a single dose if oral therapy is contraindicated
* If there are vulval symptoms, consider adding a topical imidazole in addition to an oral or intravaginal antifungal
* if pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated

29
Q

Diagnosis of BV?

A

Hay-Ison- based on gram- stained smear of swab from posterior vaginal fornix

Amsel Criteria- 3 of any of the following
1) characteristic discharge
2) Clue cells on wet mount-epithelial cells
3) Raised pH
4) Odour with KOH (‘whiff test’)

30
Q

What is BV?

A
  • Describes an overgrowth of predominately anaerobic organisms such as Gardnerella vaginalis.
  • Leads to a consequent fall in lactic acid producing aerobic lactobacilli resulting in a raised vaginal pH.
  • NOT STI- but seen almost exclusively in sexually active women
31
Q

Management of BV?

A

oral metronidazole for 5-7 days- 400mg BD
70-80% initial cure rate
relapse rate > 50% within 3 months
the BNF suggests topical metronidazole or topical clindamycin as alternatives

32
Q

Bacterial Vaginosis risks in pregnancy?

A

Results in an increased risk of preterm labour, low birth weight and chorioamnionitis, late miscarriage

Recent guidelines recommend that oral metronidazole is used throughout pregnancy.

33
Q

What is trichomonas vaginalis?

A

highly motile, flagellated protozoan parasite
STI

34
Q

Features of Trichomonas?

A
  • Vaginal discharge: offensive, yellow/green, frothy
  • Vulvovaginitis
  • Strawberry cervix
  • pH >4.5
  • Usually asymptomatic in men but may have urethritis
35
Q

Diagnosis of Trichomonas?

A

Sample sites- posterior fornix, self taken vulvo-vaginal swab
Urethra/centrifuged first void urine in men
Wet mount: 70% sensitive compared to culture degrades over time.
shows motile trophozoites

36
Q

Managment of trichomonas?

A

400mg BD oral metronidazole for 5-7 days, although the BNF also supports the use of a one-off dose of 2g metronidazole

37
Q

Investigation of uretheral discharge in men?

A

Examination
Gram-stained smear from urethra (having held urine)- gram negative intracellular diplocci (working diagnosis of gonorrhoea) if polymorphonuclear leucocyte and no Gram -ve non-gonoccal urethritis.
Gonorrhoea culture- if clinically suspicious
First catch Urine NAAT for gonorrhoea and chlamydia
Consider: microscopy of urine threads, wet smear for TV, MSU, herpes simplex PCR

38
Q

Male presents with discharge and burning whilst urinating, DDx?

A

Gonococcal urethritis
Non-specific urethritis

39
Q

Causes of Non- specific urethritis?

A

STIs:
* Chlamydia tachomatis (> 60-70%)
* Mycoplasma genitalium
* Ureaplasma urealyticum
* Trichomonase vaginalis
* Herpes simplex
* HPV

40
Q

What is Chalmydia?

A

Most prevalent STI
Obligate intracellular pathogen
Incubation period is around 7-21 days

41
Q

Feature of chalmydia?

A

asymptomatic in around 70% of women and 50% of men

women: cervicitis (discharge, bleeding), dysuria

men: urethral discharge, dysuria

42
Q

Complications of chlamydia?

A

epididymitis
pelvic inflammatory disease
endometritis
increased incidence of ectopic pregnancies
infertility
reactive arthritis
perihepatitis (Fitz-Hugh-Curtis syndrome)

43
Q

Diagnosis of chlamydia?

A

NAAT is the investigation of choice
for women: the vulvovaginal swab is first-line
for men: the urine test is first-line

urine (first void urine sample), vulvovaginal swab or cervical swab may be tested using the NAAT technique

Testing should be carried out 2 weeks after first exposure

44
Q

Screening programme for Chlamydia?

A

in England the National Chlamydia Screening Programme is open to all men and women aged 15-24 years
t
he 2009 SIGN guidelines support this approach, suggesting screening all sexually active patients aged 15-24 years

relies heavily on opportunistic testing

45
Q

Treatment of Chlamydia?

A

drug therapy
* First line: Doxycycline 7 days
* if doxycycline is contraindicated azithromycin (1g od for one day, then 500mg od for two days) should be used
* if pregnant then azithromycin, erythromycin or amoxicillin may be used. The SIGN guidelines suggest azithromycin 1g stat is the drug of choice ‘following discussion of the balance of benefits and risks with the patient’
**Partner contact **
* offered a choice of provider for initial partner notification - either trained practice nurses with support from GUM, or referral to GUM
* Men with urethral symptoms: all contacts since, and in the four weeks prior to, the onset of symptoms
* Women and asymptomatic men all partners from the last six months or the most recent sexual partner should be contacted
* contacts of confirmed Chlamydia cases should be offered treatment prior to the results of their investigations being known (treat then test)

46
Q

What is Gonorrhoea?

A
  • Gram-negative diplococcus Neisseria gonorrhoeae
  • occurs on any mucous membrane- usually GUM but also rectum and phayrnx
  • Incubation period 2-5 days
47
Q

Features of gonorrhoea?

A

males: urethral discharge, dysuria
females: cervicitis e.g. leading to vaginal discharge
rectal and pharyngeal infection is usually asymptomatic

48
Q

Why is reinfection with gonorrhoea common?

A

antigen variation of type IV pili (proteins which adhere to surfaces) and Opa proteins (surface proteins which bind to receptors on immune cells)

49
Q

Complications of gonorrhoea?

A

Uretheral strictures
Epididymitis
Salpingitis (may lead to infertility)
Disseminated infection
Septic arthritis
Endocarditis
Perihepatitis

50
Q

Treamtent of gonorrhoea?

A

When antimicrobial susceptibility is not know: Ceftriaxone 1g IM (in 2ml 1% lidocaine) stat dose

When antimicrobial susceptibility is known: ciprofloxacin 500mgs stat dose

If ceftriaxone is refused (e.g. needle-phobic) then oral cefixime 400mg (single dose) + oral azithromycin 2g (single dose) should be used

51
Q

What is the pathophysiology of disseminated gonorrhoeal infection (DGI)?

A

not fully understood but is thought to be due to haematogenous spread from mucosal infection (e.g. Asymptomatic genital infection)

52
Q

Symptoms of DGI?

A

tenosynovitis
migratory polyarthritis
dermatitis (lesions can be maculopapular or vesicular)

53
Q

What is Mycoplasma Genitalium?

A

Unique. flask shaped, slightly curved organelle
Smallest bacterium- Gram +ve ancestors
Insensitive to Beta-lactams and emerging resistance to macrolides and quinolones

54
Q

Factors that make an STI more likely?

A

Recent partner changes
Multiple contacts
Recurrent symptoms
Symptoms in partner
Other symptoms: women: abdo pain, menstrual problems
Men: Testicular pain
Extragenital signs and symptoms of STI

YEAR 4 REPRO (26 decks)

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