GUM (-treatments) Flashcards
Why does taking the oral contraceptive pill increase your chances of getting chlamydia?
It increases cervical ectopy
Is partner notification required for HSV and HPV?
No - they can be latent and subclinical. Should disclose to their current sexual contacts though.
What do 4th generation HIV tests detect? How long may it take for these to be present in the blood? Does the test have to repeated?
Detect HIV antigen and Ab
There is a window period of 4-6 weeks
Repeat tests @ 3 months BUT if a pt has signs of seroconversion illness and a negative HIV test, repeat after 2 weeks.
How does PEPSE work?
It inhibits viral replication and prevents the virus entering the blood
How do you determine HIV risk?
Risk of source being positive x risk of exposure (Act)
What is the most important factor influencing transmission?
VIRAL LOAD
What medications are used as PEPSE?
Truvada (once a day) and Raltegravir (twice a day) for 28 days
In what period must PEP be taken by to be effective?
72 hours
What follow up is required after a patient has received PEPSE?
Review 2 months after completing PEPSE for repeat HIV test
Why are rates of genital warts decreasing?
Due to quadivalent HPV vaccination
What is the most common STI in MSM?
Syphilis
What can lymphogranuloma venerum (LGV) lead to in MSM?
Severe proctitis
In which vaginal infection would you expect the pH of the discharge to be <4.5?
Candida
In which vaginal infections would you expect the discharge to smell fishy?
Bacterial vaginosis and trichomoniasis
In which vaginal infections would you expect to have associated itchy/soreness?
Candida and trichomoniasis
In which vaginal infection would you expect the vaginal discharge to be thin/frothy?
Trichomoniasis
In which vaginal infection would you expect to see associated vulval oedema?
Candida
What are the 4 features in the Amsels Criteria and how many are needed for the diagnosis of bacterial vaginosis?
1) Thin grey/white discharge
2) Positive amine test
3) Clue cells on microscopy
4) pH over 4.5
3/4 are needed for diagnosis
What is the Hay-Ison score used to diagnose? What is it based on? What does a grade or 2 and 3 mean?
Used to diagnose Bacterial vaginosis Based on gram stain Grade 2 = intermediate vaginal flora Grade 3 = Mixed bacterial flora Grades 2 and 3 = BV
What signs are associated with candida?
Itch, superficial dyspareunia, linear fissures, satellite lesions
What are some risk factors for candida?
DM, corticosteroids, frequent antibiotics, pregnancy
How is candida treated in pregnant women?
Topical azoles as oral TX is contraindicated
How may candida present in a man?
Mild balanitis w/ pruritis
What signs and symptoms are associated with chlamydia trachomatis in a woman?
- 80% asymptomatic
- Post-coital or inter-menstrual bleeding
- Purulent vaginal discharge
- Lower abdo pain
- Proctitis
- Cervicitis
- Cervical contact bleeding
- Bartholinitis
Name 3 complications of chlamydia
PID, Peri hepatitis, Reiter’s syndrome
What signs and symptoms are associated with chlamydia trachomatis in a man?
- Asymptomatic in around 50%
- Urethral discharge
- Dysuria
- Testicular/ epidydimal pain
- Proctitis
- Epididymitis
How is chlamydia diagnosed?
NAATs. Swab taken from urethra/ endocervix/ vulvovaginal swab. Rectal swab if anal sex. Oral swab if oral sex.
NAATs on 1st void urine sample.
How does epididymo-orchitis typically present?
Usually unilateral, scrotal swelling and pain. tender, erythema
A 25 year old male presents with epididymo-orchitis - what are the most likely causative organisms?
N. gonorrhoea, C. trachomatis (STI more likely if young and no significant urinary symptoms)
A 45 year old male presents with epididymo-orchitis - what are the most likely causative organisms?
E. Coli, Enterobacteriaceae
How is gonorrhoea diagnosed in men?
Gram stain from urethral swab if symptomatic
NAATs on first void urine if asymptomatic
Culture both to check for antibiotic resistance
How is gonorrhoea diagnosed in women in primary care?
Primary care: Endocervical swab
How is gonorrhoea diagnosed in asymptomatic women in secondary care?
NAATs from vulvo vaginal swab
How is gonorrhoea diagnosed in symptomatic women in secondary care?
Endocervical swab for culture + NAAT +/- urethral swab
When should a test of cure occur in people treated with chlamydia?
At least 4 weeks after the completion of treatment. A test of cure is essential in pregnant women.
When should a test of cure occur in people treated with gonorrhea?
2-4 weeks after treatment
When can someone transmit the herpes simplex virus to someone else?
Only when they are shedding the virus - this happens sporadically, not necessarily in association with symptoms
What are the symptoms of a primary attack of herpes simplex virus?
Febrile (prodrome) lasting 5 - 7 days, dysuria, painful inguinal lymphadenopathy, tingling/neuropathic pain in genitals/buttocks/legs, genital ulcers.
How common is a primary attack of herpes (NB this is different to the 1st clinical episode), and when would it occur?
A primary attack of herpes is uncommon and would occur 2 - 12 days after acquiring the virus.
How long may a 1st episode of herpes last? When would you start suspecting immunodeficiency?
1st episode may last 3 weeks
Suspect immunodeficiency if symptoms last over 4 weeks
List 3 complications of the primary infection of herpes
Acute urinary retention
Constipation
Aseptic meningitis
What should you do with a patient who is experiencing an acute episode of herpes?
Take swabs for HSV PCR from lesions but do not delay anti-viral treatment if this is not available.
What type of delivery should a pregnant woman have who has herpes but no lesions present?
Vaginal
What should be given to pregnant women with herpes in their 3rd trimester of pregnancy?
Suppressive therapy to reduce risk of recurrence
What should happen with the management of a pregnant woman if a primary attack of herpes occurs in the 3rd trimester?
She should have a Caesarean section
What test can you do to distinguish between a primary or recurrent attack of herpes in pregnancy?
HSV type serology
What is the incubation period for Hep B?
1 - 6 months
When does Hep B SAg appear after a person becomes infected?
Within 3 months of infection
When would Hep B SAg disappear in a patient who has been infected with Hep B?
Hep B SAg disappears in resolved infection but is present in acute and chronic infection
Would Hep B cAb be positive or negative in a patient who has been vaccinated against Hep B?
Negative
Would Hep B cAb be positive or negative in a patient who has had Hep B but the infection is now resolved?
Positive as Hep B cAb is a marker of acquired infection
Which finding in a Hep B blood screen would most suggest that a patient with Hep B is highly contagious?
High Hep B eAg
If a person has a Hep B screen and only Hep B sAb is positive, what does that suggest?
Successful vaccination
In most people with chronic Hep B infection, what would you expect to happen to their LFTs?
In most patients their LFTs are normal!
They only become grossly abnormal in severe, late stage
What should you advise new mothers with Hep B in regards to breastfeeding their child?
They should continue to breastfeed
When is the infectious period of Hep B?
From 2 weeks before the onset of jaundice until the patient becomes surface antigen negative.
When would Specific Hep B Immunoglobulins (HBIG) be offered to patients? When does it work best and when is it too late to give to be of any use?
It may be given to a non-immune contact after a single unprotected sex/ parental exposure/ needlestick injury if donor known to be infectious.
Works best within 48 hours, is of no use after 7 days
How can you determine a successful Hep B vaccination?
If anti-Hbs titres are >100 i.u./L
What is the standard vaccination programme for Hep B?
0, 1 and 6 months. Booster after 5 years
Name 3 complications of Pelvic Inflammatory Disease?
- Chronic pelvic pain
- Ectopic pregnancy
- Infertility
How do you diagnose Pelvic Inflammatory Disease?
Bimanual examination would reveal cervical excitation
What test MUST you do with someone who is presenting with Pelvic Inflammatory Disease?
A pregnancy test!
A woman comes to clinic with symptoms highly suggestive of pelvic inflammatory disease. However, no organism was isolated on testing. You treat her. She asks if her boyfriend will need to be tested - what do you tell her?
Yes - all current male partners should be screened even if no organism was isolated in the woman.
Which organism causes Syphilis? What family is it apart of and how does it look like?
Treponeme pallidum (a spirochaete). Looks like a corkscrew.
What phase of syphilis is NOT infectious?
Tertiary syphilis
Over what time period would the primary phase of syphilis occur?
9 to 90 days after exposure
How does primary syphilis present?
Chancre and regional lymphadenopathy
How would you describe typical chancre?
Classically single, painless, indurated with clean base discharging clear serum in the anogenital region
Over what time period would the secondary phase of syphilis occur?
Within 2 years of infection
List as many symptoms of secondary syphilis as you can.
- Generalised polymorphic rash (classically non-itchy) often affecting palms and soles
- Condylomata lata (wart-like lesions on genitals)
- Mucocutaneous lesions
- Generalised lymphadenopathy
- Patchy alopecia
- Anterior uveitis
- Meningitis
- CN palsies
- Hepatitis
- Splenomegaly
- Glomerulonephritis
- Periostitis
What is early latent syphilis? What is the cut-off point before it is considered ‘late’ latent syphilis?
When the serological tests are positive but with no clinical evidence of treponemal infection and within the first 2 years (‘late’ if over 2 years)
What are the 3 most common ways that symptomatic late syphilis can present?
- Neurosyphilis
- Cardiovascular syphilis: aortitis (which may lead to AR, aortic aneurysms and angina
- Gummata
How does neurosyphilis present?
Dorsal (sensory) column loss (tabes dorsalis) and dementia
What presentation/ investigation would point towards a diagnosis of neurosyphilis?
Abnormal CSF but with no associated neuro signs or symptoms
What are gummata and where do they most commonly occur?
They are inflammatory fibrous nodules and plaques - can be locally destructive.
Most common on skin and bone.
How do you diagnose syphilis?
Syphilis serology/ T. pallidum on dark field microscopy/ DNA test.
What is the treatment for syphilis?
Long acting penicillin.
What is the minimum follow-up required for patients infected with syphilis?
Minimum of 1 year follow up with repeat serology
What causes Trichomonas?
A parasite (flagellated protozoon) called trichomonas vaginalis
Of the 50% with TV who are symptomatic, what symptoms may they experience?
- Vaginal discharge: Offensive, yellow, thin and frothy
- Vulval irritation
- Superficial dyspareunia
- Dysuria
- Contact bleeding
Name 2 complications of pregnancy can arise due to TV?
Preterm delivery
Low birth weight
How would you diagnose TV in in women?
TV NAAT
Can also be done with a high vaginal swab - the pH would be >5.0.
How would you diagnose TV in men?
It is hard to diagnose in men so male partners of female patients should always be treated.
What investigations would you order for someone presenting with suspected urethritis?
- Urethral smear for gram stain
- Urine dual NAATs test for C. Trachomatis + N. gonorrhoea
- +/- Urethral swab for N. gonorrhoeae culture
How would you diagnose urethritis?
On gram-stained urethral smear taken at least 2 hours after last voiding, of +5 leucocytes per high-powered field.
Someone has been diagnosed with urethritis. How far backwards in time must you go to contact their sexual contacts?
All sexual contacts from the last 3 months should be treated.
What is the cause of external genital warts?
Human Papilloma Virus
How is Human Papilloma Virus transmitted when it causes external genital warts?
Skin to skin contact
What is the incubation period for external genital warts?
3 - 18 months
How many people who are infected with HPV develop genital warts? Can it still be transmitted without the carrier having visible warts?
Many people with the virus will never develop visible warts but can still transmit the virus.
What are the treatment options for simple external warts? Which of these are contraindicated in pregnancy?
- Podophyllotoxin cream (CI: pregnancy and nut allergy)- Weekly cryotherapy
- Imiquimod (CI in pregnancy)
A pregnant woman is due to deliver. She has external genital warts. How does this influence the delivery?
Genital warts do not influence the delivery!
Which 2 strains of HPV most commonly cause genital warts?
HPV 6 + 11
Which strains of HPV are oncogenic (cervical cancer)?
HPV 16 + 18
Who is offered the quadrivalent vaccine? Which strains of HPV are included in this vaccine?
Girls (11 - 17 year olds)
MSM
What are the 3 options of emergency contraception?
1) Intrauterine device AKA ‘copper coil’
2) Levonorgestrel 1500 mcg (progesterone only) AKA Levonelle
3) Ulipristal Acetate 30mg (progesterone receptor modulator) AKA ‘ellaone’
How long after unprotected sex can the intrauterine device be fitted and still be effective?
5 days (120 hours) after unprotected sex or up to day 19 of a 28 day cycle
What should be the 1st choice emergency contraception?
Intrauterine device
How does the intrauterine device work?
It makes the uterus toxic to sperm and ovum which therefore inhibits fertilisation
Can also be left in situ as an ongoing method :)
How long after unprotected sex can Levonorgestrel 1500 mcg (progesterone only) AKA Levonelle
be used and still be effective?
Up to 72 hours
How long after unprotected sex can Ulipristal Acetate 30mg (progesterone receptor modulator) AKA ‘ellaone’ be used and still be effective?
Up to 5 days (120 hours)
How does Ulipristal Acetate AKA ‘ellaone’ work?
It is a progesterone receptor modulator that delays/ suppresses ovulation.
How does Levonorgestrel 1500 mcg (progesterone only) AKA Levonelle work?
It delays ovulation for 5 to 7 days - by which time the sperm is then not viable
