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Gynae Infection Flashcards

1
Q

What are the investigations for suspected gynae infections?

A
  • pH
    • Normal pH = 3-5-4.5
    • Low pH = candida
    • Normal pH = physiological, candida
    • Raised pH = contamination (blood, semen, lubrication), BV, TV
  • Swabs
    • Double swabs
      • Endocervical swab - gonorrhoea, chlamydia
      • High vaginal - (fungal and bacterial) BV, TV, candida, GBS
    • Triple swabs:
      • Endocervical - chlamydia
      • Endocervical – charcoal swab - gonorrhoea
      • High vaginal - fungal and bacterial (BV, TV, candida, GBS)
  • Bloods: HIV, syphilis
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2
Q

What are the general signs and symptoms of gynae infections?

A
  • Discharge – smell, consistency, colour, amount
  • Itch
  • Blood
  • FLAWS – infection, immunosuppression, cancer
  • Pain
  • Pregnant
  • Urinary symptoms – frequency, urgency, pain
  • Sexual history – partners, barrier, STIs
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3
Q

What is the diagnosis?

A

Physiological

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4
Q

What is the diagnosis?

A

Polyp

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5
Q

What is the diagnosis?

A

Ectropion

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6
Q

What is the diagnosis?

A

Candida

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7
Q

What is the diagnosis?

A

Trichomoniasis

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8
Q

What is the diagnosis?

A

Gonorrhoea

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9
Q

What is the most common cause of vaginal discharge?

A

Bacterial vaginosis

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10
Q

What are the risk factors for bacterial vaginosis?

A
  • Smoking
  • Vaginal Douching
  • Bubble Bathing
  • Sexual activity
  • New sexual partner
  • Other STIs - vaginosis isn’t a STI
  • Copper IUD
  • Vaginal pH increase
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11
Q

What are the protective factors for bacterial vaginosis?

A
  • Condoms
  • Circumcised partner
  • COCP
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12
Q

What are the signs and symptoms of bacterial vaginosis?

A
  • Asymptomatic (50%)
  • Offensive, fishy-smelling discharge
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13
Q

What are the appropriate investigations for suspected bacterial vaginosis?

A
  • Diagnosis = clinical + microscopy
  • Hay-Ison criteria or Amsel’s criteria
    • Amsel’s criteria = 3 out of 4:
      • Thin, white, homogenous discharge
      • Clue cells on microscopy
      • Vaginal pH >4.5
      • Fishy odour on adding 10% KOH
    • Hay-Ison criteria applied to gram stain
      • Grade 3 = BV
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14
Q

What is the management of bacterial vaginosis?

A
  • No treatment is needed if asymptomatic
  • 1st line – metronidazole
  • 2nd line – intravaginal clindamycin PV cream
  • Avoid vaginal douching, shower gel, use of shampoo in bath
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15
Q

What is the complication of bacterial vaginosis?

A
  • Associated with:
    • Late miscarriage
    • Preterm birth
    • PROM
    • Postpartum endometritis
  • Increases risk of acquiring and transmitting STIs
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16
Q

What is the route of transmission of trichomonas vaginalis?

A

STI - more common in developing countries

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17
Q

What are the signs and symptoms of trichomonas vaginalis?

A
  • Asymptomatic in 50%
  • Symptomatic:
    • Green/yellow “frothy” vaginal discharge
    • Vulval itch or vaginal soreness
    • Offensive odour
    • Lower abdominal pain and dysuria
    • Dyspareunia
  • O/E = strawberry cervix
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18
Q

What are the appropriate investigations for suspected trichomonas vaginalis?

A
  • High vaginal swab
  • Endocervical swabs for other STIs
  • Culture and gram stain
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19
Q

What is the management of trichomonas vaginalis?

A
  • 1st line = Metronidazole
  • 2nd line = Metronidazole
  • Contact tracing, abstinence for 7 days, follow-up
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20
Q

What are the complications of trichomonas vaginalis?

A
  • Pregnancy = PTL, LBW, PPROM
  • Enhance HIV/STI transmission
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21
Q

What are the risk factors for candidiasis?

A
  • Oestrogen exposure
  • Pregnancy
  • Reproductive years
  • Immunocompromise (HIV)
  • Diabetes (poorly controlled)
  • Recent ABx (i.e. for a UTI)
  • Intercourse
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22
Q

What are the signs and symptoms of candidiasis?

A
  • Vulva itching
  • Soreness
  • Irritation
  • ‘Cottage-cheese’-type discharge
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23
Q

What are the appropriate investigations for suspected candidiasis?

A
  • No investigations usually required
  • Diagnostic = HVS – microscopy, culture and gram stain
    • Speckled gram +ve spores, pseudohyphae
  • Other = MSU (UTIs), HbA1c (diabetes)
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24
Q

What is the management of candidiasis?

A
  • 1st line – clotrimazole pessary + 1% clotrimazole cream
  • 2nd line/Severe – fluconazole
  • General advice:
    • Avoid tight fitting synthetic clothing
    • Avoid local irritants
    • Do not wash female genitalia with soap/shower gels
    • Do not douche
  • If pregnant, only use topical treatment
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25
What are the complications of candidiasis?
* Hepatotoxicity associated with systemic azole antifungal therapy *– monitor LFT* * Oesophageal candidiasis or disseminated candidiasis in immunocompromised
26
What are the causes of cutaneous warts?
HPV infection – HPV **6** and **11**
27
What subtypes of HPV cause cutaneous warts and cervical cancers?
* 6, 11 → 90% of cutaneous warts * 16, 18 → over 70% of cervical cancers
28
What strategy can be used to prevent cutaneous warts?
HPV vaccine - Gardasil
29
What are the signs and symptoms of cutaneous warts?
* 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*
30
What are the appropriate investigations for cutaneous warts?
* STI screen → triple swab, HIV, syphilis, HBV
31
What is the management of cutaneous warts?
* No treatment required in most cases - *might refer to GUM if STI risk factors* * Medical (contraindicated in pregnancy): * Keratinised warts → imiquimod cream * Non-keratinised warts → podophyllin/tri-chloro-acetic acid * Surgical: * Cryotherapy, laser, electrocautery
32
What are the complications of cutaneous warts?
* High-risk HPV leading to increased risk of anogenital cancers * Disfiguring – distress or psychosexual dysfunction
33
What are the risk factors for chlamydia?
* Most common bacterial STI in UK * Sexual history * Multiple sexual partners * No barrier use * History of STIs * Low socioeconomic status
34
What are the signs and symptoms of chlamydia?
* Asymptomatic in at least 70-80% of women * Symptomatic * Purulent PV discharge * Dyspareunia * IMB * PCB * Abdominal pain * Dysuria * Affects the endocervix ± urethra
35
What are the appropriate investigations for suspected chlamydia?
* Can treat on suspicion alone → unlike gonorrhoea * Direct microscopy * 1st (NAAT) - Urethral/Vulvovaginal swab or first catch urine * 2nd - Culture and sensitivities
36
What is the management of of chlamydia?
* Can treat on suspicion before lab results * 1st line – doxycycline (contra-indicated in pregnancy and breastfeeding) * 2nd line/Pregnant/Breastfeeding – azithromycin * Contact tracing (6 months) * Avoid sex until treatment has been completed * Recommend STI screen * Follow-up appointment by 5-weeks
37
What are the complications of chlamydia?
* PID - infertility, ectopic * Reactive arthritis * Fitz-Hugh-Curtis * Pregnancy - PTL, PPROM, post-partum endometritis
38
What are the risk factors for gonorrhoea?
* Unprotected sex * Multiple partners * Presence of other STI * HIV * Age\<25 * MSM
39
What are the symptoms of gonorrhoea?
* Asymptomatic in up to 50% patients * Symptomatic * PV discharge * IMB * PCB * Dysuria * Dyspareunia * Lower abdominal pain
40
What are the signs of chlamydia on examination?
* Speculum * Mucopurulent endocervical discharge * Easily induced endocervical bleeding * Bimanual Exam (assess for PID) * Cervical motion / adnexal tenderness * Uterine tenderness
41
What are the appropriate investigations of gonorrhoea?
* Direct microscopy - neutrophils, gram -ve diplococci → prescribe antibiotics * 1st (NAAT) * Men: first catch urine sample * Women: vulvovaginal swab * 2nd: Culture and sensitivities → prescribe antibiotics
42
What is the management of gonorrhoea?
* **1st line** – ceftriaxone 1g * Empirical treatment only if recent sexual contact with confirmed gonococcal infection * Screening for other STIs/HIV * Contact tracing * Avoid sex for 1-week * Follow-up appointment 1-week later * Cure rate = 95% with treatment
43
What are the complications of gonorrhoea?
* PID - infertility, ectopic * Fitz-Hugh-Curtiz syndrome * Conjunctivitis * Increased HIV susceptibility * Disseminated disease - *fever, rash, arthralgia, septic arthritis, meningitis, endocarditis* * Vertical transmission - *ophthalmia neonatorum – bilateral conjunctivitis*
44
What is syphilis?
* A systemic infection caused by the gram -ve spirochete (Treponema pallidum) * Aetiology – sexual contact, blood-borne, or vertical
45
What are the risk factors for syphillis?
* Young (age \<29 years) * African American * Use of illicit drugs * Infection with other STIs * Sex worker
46
What are the signs and symptoms of primary syphilis?
* Painless chancres ± local lymphadenopathy * *Resolves in 3-8w*
47
What are the signs and symptoms of secondary syphilis?
* 4-10w after chancre – only 25% get symptoms * Rough papulonodular rash (hands, feet, trunk) * Uveitis * Condylomata Lata * Lymphadenopathy + systemic symptoms * “Snail track oral ulcer” * *Resolves in 2-12w*
48
What are the signs and symptoms of tertiary syphilis?
* 1 to 20 years – affects 1/3rd of untreated illness * Gummatous syphilis - erosive skin and bone lesions * Cardiovascular syphilis - aortitis, aortic regurgitation *(early diastolic decrescendo)*, heart failure * Neurosyphilis * Meningovascular (5-10 years) → ischaemia, insomnia, emotionally labile * General paresis (10-25 years) → dementia * Tabes dorsalis (15-20 years) → sensory problems, lightning pains, absent reflexes
49
What are the appropriate investigations for suspected syphilis?
* Microbiology * Dark-ground with dark-field illuminations * PCR * Serology – routine antenatal screening → detects treponemal antibodies * Takes 3 months for syphilis serology * Non-treponemal tests – high false positive rate * Treponemal tests - EIA, TPPA, FTA-ABS * Neurosyphilis * CT/MRI head * LP (raised WCC, raised protein) * TPPA \>1: 320
50
What is the management of 1st, 2nd and early latent syphilis?
* Benzathine-Pen (IM, STAT) OR * Doxycycline (BD, 14/7) * Follow-up - partner notification, repeat bloods at 3/12 (4-fold drop in RPR)
51
What is the management of late latent or non-neuro 3rd stage syphilis?
* Benzathine-Pen (IM, OW, 3/52) OR * Doxycycline (BD, 28/7) * Follow-up - partner notification, repeat bloods at 3/12 (4-fold drop in RPR)
52
What is the management of neurosyphilis?
* Penicillin (IV, 4-hourly, 14/7) OR * Doxycycline (BD, 28/7) * Prednisolone 24 hours before treatment to avoid Jarish-Herxheimer reaction * *Release of proinflammatory cytokines in response to dying organisms* * Admit mothers \>22w when treating * Follow-up - partner notification, repeat bloods at 3/12 (4-fold drop in RPR)
53
What are the complications of syphilis?
* Risks in Pregnancy - *benzathine penicillin greatly improves foetus outcomes* * FGR * Foetal hydrops * Congenital syphilis * Stillbirth * Preterm birth * Neonatal death
54
Define Pelvic Inflammatory Disease.
The result of ascending infection of the genital tract *(endometritis, salpingitis, tubo-ovarian abscess)*
55
What are the most common organisms that cause of PID?
* **Chlamydia trachomatis** * *N. gonorrhoea* * *M. genitalium* * *M. hominis*
56
What are the risk factors for PID?
* \<25yo * Early age of first coitus * Multiple sexual partners * Recent new partner * History of STI (partner/woman)
57
What are the signs and symptoms of PID?
* **Asymptomatic** - with infertility ± chronic pelvic pain * **Acutely** * Bilateral lower abdominal pain * PV discharge * Fever * Irregular PVB * Dyspareunia
58
What are the appropriate investigations for suspected PID?
* Triple swabs - 2x endocervical, 1x HVS * Speculum - looks for signs of inflammation/discharge * Bimanual - cervical excitation, adnexal masses * If tubo-ovarian abscess possible, confirm with TVUSS * If febrile = Blood cultures, FBC, CRP
59
What is the management of PID?
* Assess patient for admission * If pyrexial (\>38C) or septic * If managed as OP * 2-3 days to assess response to Abx → further follow-up in 2-4 weeks * Ceftriaxone 500 mg IM (single dose) * Doxycycline 100 mg BD (oral) for 14 days * Metronidazole 400 mg BD (oral) for 14 days * Inpatient Antibiotics * *IV cefoxitin* * *IV doxycycline* * *IV clindamycin* * *IV gentamycin* * Other = STI screening, contact tracing, discuss contraception, removal of any IUD, avoid sex
60
What are the complications of PID?
* Infertility * Ectopic pregnancy (paralyse cilia in Fallopian tubes) * Chronic pelvic pain * Up to 30% require hospital admissions
61
What is a Bartholin's cyst?
* 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
62
What are the risk factors for Bartholin's cysts?
* Nulliparous * Previous Bartholin’s cyst * Sexually active
63
What is the difference between a Bartholin's and labial cysts?
* Bartholin’s cysts may extend into the vaginal canal * Labial cysts will remain in the labia
64
What are the signs and symptoms of a Bartholin's cysts?
* Unilateral labial swelling * Often asymptomatic/painless * Infected: * Abscess with cardinal signs of infection * Dyspareunia * Pain on sitting or walking
65
What are the appropriate investigations for a suspected Bartholin's cyst?
* ≥40yo, consider a vulval biopsy **but is a clinical diagnosis** * If infected → MC&S from abscess – most are sterile but may help organism differentiation
66
What is the management of a Bartholin's cysts?
* Conservative (if draining and patient well) * Incision and drainage ± Flucloxacillin (OD) * Marsupialisation (forming an open pouch to stop the cyst from reforming)
67
What are the complications of a Bartholin's cyst?
* Rupture * Recurrence
68
What are the high-risk HPV sub-types?
**16 and 18** → CIN, VIN, VAIN → implicated in 70% of cervical cancers
69
What are the low-risk HPV sub-types?
**6 and 11** → benign genital warts
70
What are the risk factors for HPV?
* Smoking * Multiple sexual partners - 50% of sexually active adults have HPV * Unprotected intercourse * Immunosuppression
71
What are the signs and symptoms of HPV?
* Asymptomatic * Genital warts on vulva, vagina, cervix and anus * Painless - may itch/bleed ± become inflamed * Pink/red/brown warty papules * Four types – small popular, cauliflower, keratotic, flat papules/plaques
72
What are the appropriate investigations for suspected HPV?
* Clinical diagnosis - dermatoscope * Histology (biopsy) and cytology (smear)
73
What is the management of HPV?
* Medical * Imiquimod cream * Podophyllin/trichloroacetic acid * *Both contraindicated in pregnancy* * Surgical * Cryotherapy * Laser * Electrocautery * Prevention = HPV vaccine * Sub-types in vaccine = 6, 11, 16, 18

Y5 O&G (69 decks)

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