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Gynae 3 Flashcards

1
Q

What are cutaneous / genital warts?

A

AKA condylomata acuminata

  • Caused by HPV infection (HPV 6 and 11)
  • Most are sexually transmitted (10% prevalence in the sexually active population)
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2
Q

How are cutaneous warts prevented?

A

HPV vaccine ‘Gardasil’ – protects against subtypes 6, 11, 16, 18

  • 6, 11 > 90% of cutaneous warts
  • 16, 18 > over 70% of cervical cancers
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3
Q

What are the S/S of cutaneous warts?

A
  • Often asymptomatic
  • Vaginal discharge, PCB or IMB (local trauma), pain
  • Genital warts on vulva, vagina, cervix, anus > generally painless but may itch or bleed or become inflamed
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4
Q

What are the investigations for cutaneous warts?

A

(Often a clinical diagnosis):

  • STI screen > triple swab, HIV, syphilis, HBV
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5
Q

What is the management of cutaneous warts?

A

Often, no treatment required
>Might refer to GUM if STI risk factors

Medical (contraindicated in pregnancy):

  • Keratinised warts = imiquimod cream
  • Non-keratinised warts = podophyllin toxin cream / trichloroacetic acid (TCAA)

Surgical

  • Cryotherapy
  • Laser
  • Electrocautery
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6
Q

What are the complications of cutaneous warts?

A
  • May be high-risk HPV leading to increased risk of anogenital cancers
  • Disfiguring – distress or psychosexual dysfunction
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7
Q

What is chlamydia?

A
  • Chlamydia trachomatis - obligate intracellular gram -ve parasite (cannot see under microscope)
  • Most common bacterial STI in UK
  • In women affects endocervix ± urethra (in men affects urethra)
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8
Q

What factors in a sexual history might suggest chlamydia?

A

Multiple sexual partners, no barrier use, history of STIs, low socioeconomic status

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9
Q

What are the S/S of chlamydia?

A
  • Asymptomatic in at least 70-80% of women
  • Symptomatic (<30%) = purulent PV discharge, dyspareunia, IMB, PCB, abdominal pain, dysuria
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10
Q

What are the investigations for chlamydia?

A

N.b. if S/S of chlamydia, you can treat on suspicion alone (unlike gonorrhoea)

Direct microscopy

  • Non-gonococcal urethritis – just neutrophils, no organisms

1st (NAAT):

  • Women: vulvovaginal swab OR first catch urine NAAT

2nd:

  • Culture and sensitivities
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11
Q

What is the management for chlamydia?

A

1st line:

  • Doxycycline, 100mg, BD 7 days (contra-indicated in pregnancy and breastfeeding)

2nd line / pregnant / breastfeeding:

  • Azithromycin (1g STAT)
  • (or erythromycin, amoxicillin)

Advice:

  • Contact tracing (6 months)
  • Avoid sex until treatment has been completed
  • Recommend STI screen
  • Follow-up appointment by 5-weeks
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12
Q

What are the complications of chlamydia?

A
  • PID (up to 16%)
  • Infertility, ectopic
  • Reactive arthritis (arthritis, conjunctivitis, urethritis)
  • Fitz-Hugh-Curtis (perihepatitis)
  • Pregnancy (PTL, PPROM, post-partum endometritis)
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13
Q

What is gonorrhoea?

A
  • Neisseria gonorrhoeae
  • Gram -ve intracellular diplococci
  • 2nd most common STI (behind Chlamydia)
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14
Q

What are the RFs for gonorrhoea?

A
  • Unprotected sex
  • multiple partners
  • presence of other STI
  • HIV
  • age<25
  • MSM
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15
Q

What are the S/S of gonorrhoea?

A
  • Asymptomatic in up to 50% patients
  • Symptomatic = PV discharge, IMB, PCB, dysuria, dyspareunia, lower abdominal pain

Speculum:

  • Mucopurulent endocervical discharge
  • Easily induced endocervical bleeding

Bimanual Exam: (assess for PID)

  • Cervical motion / adnexal tenderness
  • Uterine tenderness
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16
Q

What are the investigations for gonorrhoea?

A

N.b. empirical treatment ONLY if recent sexual contact with confirmed gonococcal infection

Direct microscopy:

  • Neutrophils, gram -ve diplococci > prescribe antibiotics

1st (NAAT):

  • Women: vulvovaginal swab NAAT > prescribe antibiotics

2nd: Culture and sensitivities

  • Prescribe antibiotics
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17
Q

What is the management of gonorrhoea?

A

(After confirmation by NAAT, confirmation by culture (& sensitivities), or direct microscopy +ve):

1st line – ceftriaxone 1g (IM)

Plus:

  • Screening for other STIs/HIV
  • Contact tracing
  • Avoid sex for 1-week
  • Follow-up appointment 1-week later

Cure rate = 95% with treatment

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18
Q

What are the complications of gonorrhoea?

A
  • PID
  • Infertility, ectopic, conjunctivitis
  • Fitz-Hugh-Curtiz syndrome
  • Increased HIV susceptibility
  • Disseminated disease in 1% (fever, rash, arthralgia, septic arthritis, meningitis, endocarditis)
  • Vertical transmission – ophthalmia neonatorum – bilateral conjunctivitis
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19
Q

What is syphilis?

A

Syphilis is a systemic infection caused by the gram -ve spirochete (Treponema pallidum)

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20
Q

How is syphillis transmitted?

A

Sexual contact, blood-borne, or vertical

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21
Q

What are the RFs for syphilis?

A
  • Young (age <29 years)
  • African American
  • Use of illicit drugs
  • Infection with other STIs
  • Sex worker
22
Q

What are the S/S of syphilis?

A

Primary (1-3w after infection):

  • Syphilitic chancres (painless ulcers) ± local lymphadenopathy
  • If from sexual contact - primary chancre on external genitalia
  • If acquired elsewhere - primary chancre on hands / other body parts
  • Heal on their own over a few months

Secondary (6-12w after infection):
Only 25% get symptoms…

  • Lymphadenopathy + systemic symptoms
  • Non-itchy maculopapular rash (trunk > arms/legs > palms/soles/genitals)
  • Can be pustular / papulosquamous
  • Condylomata Lata (smooth, white, painless lesions - genitals/anus/armpits)
  • “Snail track oral ulcer”

Latent (no symptoms; detected on routine tests):

  • Early phase: within 1 year of infection (spirochetes still in blood, can have sx of secondary syphilis)
  • Late phase: after 1 year of infection (spirochetes stay in organs/tissues)

Tertiary (1 to 20 years):
Affects 1/3rd of untreated illness
Caused by Type IV Hypersensitivity Reaction

  • Gummatous syphilis (erosive skin and bone lesions)
  • Cardiovascular syphilis (aortitis, aortic aneurysms, aortic regurgitation, HF)
  • Neurosyphilis:
    -Meningovascular (ischaemia, insomnia, emotionally labile)
    -General paresis
    -Tabes dorsalis (affects the dorsal columns - sensory problems, lightning pains, absent reflexes)
23
Q

What are the investigations for syphilis?

A

Diagnosis usually based on clinical features, serology and microscopic examination of infected tissue.

Microbiology:

  • Dark-ground (from chancre with dark-field illuminations)
  • PCR

Serology:

Non-treponemal tests:

  • Not specific for syphilis, therefore may result in false positives due to cross-reactivity (i.e. with EBV)
  • Based upon the reactivity of serum from infected patient to a cardiolipin-cholesterol-lecithin antigen
  • Becomes negative after treatment
  • E.g. Rapid plasma reagin (RPR) and Venereal Disease Research Laboratory (VDRL)
  • If positive, must be followed up by a more specific treponemal test

Treponemal-specific tests:

  • P-EIA (T. pallidum enzyme immunoassay)
  • TPHA (T. pallidum HaemAgglutination test)
  • Reported as reactive or not-reactive

N.B. routine antenatal screening offered to all pregnant women

N.B. it takes 3/12 for syphilis to become positive in serology…

Example results:

Positive non-treponemal test + positive treponemal test

  • Consistent with active syphilis infection

Positive non-treponemal test + negative treponemal test

  • Consistent with a false-positive syphilis result

Negative non-treponemal test + positive treponemal test:

  • Consistent with successfully treated syphilis
24
Q

What are the causes of false positive non-treponemal (cardiolipin) tests?

A
  • Pregnancy
  • SLE
  • APLS
  • TB
  • Leprosy
  • Malaria
  • HIV
25
Q

What are the investigations for neurosyphilis?

A
  • CT/MRI head
  • LP (raised WCC, raised protein)
26
Q

What is the management of syphilis?

A

Early (1st and 2nd, early latent):

  • Benzathine-Pen (IM, STAT)
    OR
  • Doxycycline (BD, 14/7)

Late (late latent, non-neuro 3rd):

  • Benzathine-Pen (IM, OW, 3/52)
    OR
  • Doxycycline (BD, 28/7)

Neurosyphilis:

  • Penicillin (IV, 4-hourly, 14/7)
    OR
  • Doxycycline (BD, 28/7)
  • Prednisolone (OD, 3/7) started 24 hours before treatment to avoid Jarish-Herxheimer reaction

Follow-up:

  • Partner notification, repeat bloods at 3/12 (4-fold drop in RPR)
27
Q

What is a Jarish-Herxheimer reaction?

A

Transient clinical phenomenon that occurs in patients infected by spirochetes who undergo antibiotic treatment. The reaction occurs within 24 hours of antibiotic treatment

  • Caused by release of proinflammatory cytokines in response to dying organisms
  • S/S: 24 hours of a febrile myalgia – rare/serious consequences
  • Admit mothers >22w when treating
28
Q

What are the risks of syphilis during pregnancy?

A

>Benzathine penicillin greatly improves foetus outcomes

  • FGR
  • Foetal hydrops
  • Congenital syphilis (may cause long-term disability)
  • Stillbirth
  • Preterm birth
  • Neonatal death

Congenital syphilis: > (see obstetrics)

  • Rash on soles of feet and hands ± bone lesions
29
Q

What is pelvic inflammatory disease (PID)?

A

The result of ascending infection of the genital tract (endometritis, salpingitis, tuboovarian abscess)

  • Most common organism = chlamydia trachomatis (other = N. gonorrhoea, M. genitalium, M. hominis)
  • Other bacteria – anaerobes, coliforms, mycoplasma genitalium
30
Q

What are the RFs for PID?

A
  • <25yo
  • early age of first coitus
  • multiple sexual partners
  • recent new partner
  • history of STI (partner/woman)
31
Q

What are the S/S of PID?

A
  • Asymptomatic (with infertility ± chronic pelvic pain)
  • Acutely – bilateral lower abdominal pain, PV discharge, fever, irregular PVB, dyspareunia
32
Q

What are the investigations for PID?

A

Start the ABx before swabs if you suspect PID…

  • Triple swabs (2x endocervical, 1x HVS)
  • Speculum > looks for signs of inflammation/discharge
  • Bimanual > cervical excitation, adnexal masses (tubo-ovarian abscess)
  • If tubo-ovarian abscess possible, confirm with TVUSS
  • If febrile > blood cultures, FBC, CRP
  • Bloods - HIV, syphilis
33
Q

What is the management of PID?

A

ASSESS PATIENT FOR ADMISSION:

  • Admit if pyrexial (>38C) or septic or turbo-ovarian abscess suspected
  • Otherwise, treat in the community
  • If managed as OP, see within 2-3 days to assess response to Abx > further follow-up in 2-4 weeks

Outpatient Antibiotics:
All of…

  • Ceftriaxone 500 mg IM (single dose)
  • Doxycycline 100 mg BD (oral) for 14 days
  • Metronidazole 400 mg BD (oral) for 14 days

Alternative (treat for 14 days):

  • Ofloxacin
  • Metronidazole

Inpatient Antibiotics: (if pyrexial or oral tx failed)

  • IV cefoxitin
  • IV doxycycline

Alternative treatment:

  • IV clindamycin
  • IV gentamycin

Other = STI screening, contact tracing, discuss contraception, removal of any IUD, avoid sex

34
Q

What are the complications of PID?

A
  • Fitz-Hugh-Curtis syndrome
  • Infertility
  • Ectopic pregnancy (paralyse cilia in Fallopian tubes)
  • Chronic pelvic pain
  • Up to 30% require hospital admissions
35
Q

What is a Bartholin’s Cyst?

A

A Cyst or abscess of Bartholin’s gland (greater vestibular glands)

  • Overlying superinfection by Staphylococcus or GBS
  • Blockage of a duct to a gland in vagina has become infected
36
Q

What are the RFs for a Bartholin’s Cyst?

A
  • nulliparous,
  • previous Bartholin’s cyst,
  • sexually active
  • age 20-30
37
Q

What is the difference between a Bartholin’s cyst and a labial cyst?

A

Bartholin’s cysts may extend into the vaginal canal, but labial cysts will remain in the labia

38
Q

What are the S/S of a Bartholin’s cyst?

A
  • Unilateral labial swelling, often asymptomatic/painless
  • Infected: Abscess with cardinal signs of infection, Fever, dyspareunia, pain on sitting or walking
39
Q

What are the investigations for a bartholin’s cyst?

A

(N.b. if ≥40yo, consider a vulval biopsy)

  • Clinical
  • If infected > MC&S from abscess – most are sterile but may help organism differentiation
40
Q

What is the management of a Bartholin’s cyst?

A

Asymptomatic:

  • Conservative management with sitz baths or warm compresses to aid drainage

Symptomatic:

  • Marsupialisation (cyst cut open and fluid drained out, then open pouch formed to allow any further fluid to drain and stop cyst from reforming) - GA/SA
    OR
  • Word catheter drainage (local anaesthetic, outpatient, catheter remains for weeks)

Abscess:

  • Spontaneous drainage & conservative management with regular sitz baths and analgesia, OR
  • Incision and drainage
  • Plus flucloxacillin / trimethoprim
41
Q

What are the complications of a bartholin’s cyst?

A
  • Rupture
  • Recurrence
42
Q

What is cervical intraepithelial neoplasia?

A

Premalignant cellular atypia within squamous epithelium of cervix

  • FIGO stage 0 – this is BEFORE cervical cancer
  • HPV (type 16 and 18) is indicated in >95% cases
  • Peak 25-29yo; cancer peak age 45-50yo
43
Q

What are the RFs for CIN?

A
  • Smoking
  • multiple sexual partners
  • early age of first intercourse
  • HIV
44
Q

Describe HPV vaccination

A
  • National vaccination for girls and boys aged 12-13yo
  • If pregnant > invite ≥12w post-partum
  • Quadrivalent vaccine (Gardasil ©) against HPV 6, 11, 16, 18
45
Q

Describe smear invitation

A
  • <6m before turning 25yo = first smear
  • 25-50yo = every 3 years
  • 50-65yo = every 5 years
  • 65+ = only if one of your last 3 tests was abnormal
  • High-risk (i.e. HIV +ve) = every 1 year
  • Pregnancy = if due when pregnant, delay until ≥3m post-partum
  • Never sexually active = can opt out
46
Q

What can cause inadequate results on a smear?

A
  • Inflammation
  • Age-related atrophic change
  • Blood on smear
47
Q

Describe dysplastic epithelial changes

A
  • ↑ nuclear size
  • ↓ cytoplasm
  • ↑ nuclear to cytoplasmic ratio
  • Abnormal nuclear shape – poikilocytosis
  • ↑ nuclear density – koilocytosis
48
Q

Describe the CIN grades

A

CIN 1 (low grade)
Mild dysplasia confined to lower 1/3 of epithelium

CIN 2 (high grade)
Moderate dysplasia affecting lower 2/3 of epithelial thickness

CIN 3 (high grade)
Severe dysplasia extending to full thickness of epithelium (carcinoma in situ) - risk of stage Ia1 FIGO (see cancer)

49
Q

What are the S/S of CID?

A

Symptoms of cervical cancer (PV bleeding – IMB, PCB, PMB)

50
Q

What smear advice should be given to women?

A
  • Speculum is a ‘small plastic tube’
  • Cytology available in 2 weeks, explain role of smear (screen for potentially dangerous changes), mild > HPV test, worst > colposcopy, inadequate sample x3 > colposcopy
51
Q

What is the management of CIN?

A

Conservative for CIN1 > smear in 12 months

LLETZ

  • Involves removal of abnormal cells using a thin wire loop that is heated by electric current under LA
  • SEs: cervical stenosis (cervix narrows or completely closes off), cervical incontinence, pyometra (accumulation of pus in uterine cavity), smear follow-up difficulties
  • Risks = increased risk of miscarriage (bigger lumen to cervix so harder to close fully)

Cone biopsy:

  • Used less frequently and under a GA
  • Only performed if a large area of tissue needs to be removed

Other:

  • Cryotherapy, laser treatment, cold coagulation, hysterectomy
  • If hysterectomy for CIN > a vault smear must be done at 6m and 18m

Follow-up test of cure (6 months later):
= Smear and HPV test:

  • NEGATIVE > routine recall (3 years irrespective of age)
  • POSITIVE > repeat colposcopy to identify residual/untreated CIN
52
Q

What are the complications of CID?

A

(incl. general procedural risks such as bleeding and infection):

  • Miscarriage and PTL
  • CIN can progress to cervical carcinoma (but may also regress spontaneously, esp. when young)

O&G (17 decks)

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