Gynae: STIs Flashcards
STI Hx: What you ask about in your HxPC?
- Explore HxPC: How long has this been going on for?
- Key Sx:
- Dyspareunia
- Pelvic pain
- Discharge: colour, odour, consistency, blood
- IMB or PCB: volume/colour, LMP, duration, frequency, regularity, volume, associated pain?
- Soreness, genital skin changes or ulceration
- Systemic symptoms (fever, malaise, rash, weight loss, joint pain in Reiter’s syndrome)
-Male patient: testicular swelling or pain, skin lesions, urethral discharge, blood in urine
STI history taking: what should you ask about for sexual history (including high risk sexual behaviour) gynae Hx and background Hx?
- Sexual history: number of partners in last 3 months, sex of partner (higher risk with bisexual and MSM partners), number of UPSI, contraception (barrier used?)
- High risk sexual behaviour: HIV +ve partners, have they paid or been paid for sex, recreational drug use, Injectable drug use, aware of any partners who have injected drugs
- Gynae Hx: PID/past infections, endometriosis, ectopics or ToPs, malignancy
- Background Hx: up to date with smears, last time was tested? HPV vaccine
- Contact tracing: attempt to gain information on partners in last 3 months to bring them in for testing
What examinations and investigations would you like to perform?
- Abdominal exam
- Speculum exam
- Bi-manual exam
- Triple swabs (NAAT testing): vulvo-vaginal (chlamydia), endocervical (gonorrhoea), high vaginal (BV/TV/Candida) + throat and rectal swabs. Can also do swab culture to diagnose gonorrhea
- Serological testing: Hepatitis B, HIV and syphilis
- Urine dipstick and MSU if +ve
- Pregnancy test
- If patient is systemically unwell or suspect PID/ectopic: TV US
*I have listed all possible ones: would pick and chose depending on situation and problem
Suggest 2 treatment regimens for chlamydia
- Doxycycline 100mg PO BD for 7/7
- Azithromycin 1mg PO stat dose
What further advice and follow up should you offer a patient who has had a recent chlamydia infection?
- Avoid sexual/oral intercourse until both partners have taken treatment, until end of doxy treatment or 7 days after azithromycin treatment
- If patient is under 25: should offer retesting in 3/12
Describe short and long term implications of untreated chlamydia infection or PID?
- Short term: deep pain, discharge, PV bleed, systemically unwell patient
- Long term: significantly increased risk of ectopic pregnancy (narrowing/scarring of fallopian tubes), tubo-ovarian abscess, chronic pelvic pain syndrome, Fitz-High-Curtis syndrome (perihepatitis)
What is differential for lower abdo pain in a young woman?
- Ectopic pregnancy
- Acute appaendicitis
- Endometriosis
- Ovarian cyst torsion or rupture
- UTI
- Functional pain
What is the treatment for PID?
- Analgesia (paracetamol) and rest
IV therapy: recommended if more severe clinical disease (pyrexia above 38), signs of tubo-ovarian abscess or pelvic peritonitis):
- IV ceftriaxone 2g OD + IV doxycycline 100mg BD (continue IV until 24 hours after clinical improvement and then switch to oral)
- followed by oral doxycycline 100mg BD for 14 days + oral metronidazole 400mg BD
Outpatient regime:
- 1st line: IM ceftriaxone 1g stat dose + oral doxycycline 100mg BD for 14 days + oral metronidazole 400mg BD for 14 days
- 2nd Line outpatient regime: oral ofloxacin 400mg BD for 14 days + oral metronidazole 400mg BD for 14 days
Describe signs and symptoms of gonorrhea
- Muculo-purulent discharge
- Testicular/epididimal pain on examination or adnexal tenderness (females)
- UTI
- Endocervical infection: lower abdo pain (menorrhagia and IMB are rare in gonorrhoea)
- Rectal discharge or peri-anal pain
What is the treatment for gonorrhea?
- Ceftriaxone 1g IM stat dose
- Leicester guidelines: Cefixime 400mg PO stat dose + azithromycin 1g PO stat (only if IM injection contra-indicated or refused)
- Treatment for gonocococcal PID: Ceftriaxone 1g IM stat dose + regiment to treat PID (see cards above)
- Epididymo-orchitis: ceftriaxone 500mg IM + doxycycline 100mg BD PO for 10-14 days
How can you distinguish between gonococcal urethritis and non-specific urethritis?
- microscopy: if gonorrhea will show gram -ve diplcocci
- Most NSU will be caused by chlamydia and small proportion by (mycoplasma genitalum, ureaplasma urealyticum, TV, HSV, HPV)
What are the types of HSV? How do you diagnose it?
- Incubation period of 3-14, then lives in nerve fibre and sheds every few months/years
- Type 1: normally causes cold sores but can also cause genital lesions – recurs every 1-2 years
- Type 2 HSV: exclusively genital, has much higher yearly recurrence rate (6x/year)
- Can make a clinical diagnosis (appearance/Hx) or do PCR of swabs from lesion (highly sensitive and type specific)
How do you manage HSV?
- Do not wait for test results if believe it is HSV
- Aciclovir: initial exposure (acyclovir 400mg TDS for 5 days)
- Rest, analgesia, saline washing, strict infection control measures and avoid sexual contact
How do you manage HSV in pregnancy?
- If mother gets recurrent infections: low risk pregnancy because Abs transfer to fetus – should start aciclovir from 30/52 until delivery to prevent outbreak.
- Primary infection in last semester is very bad (plan for section)
What causes syphilis? Describe the natural Hx of untreated syphilis and treatment
- Caused by Treponema pallidum – detected by serological testing
- Primary infection (lasts 4-10 weeks and get appearance of chancre), secondary (lasts few weeks and get florid painless rashes and/or neuro or systemic sx), latent (can last 10-30 years) and tertiary (CV/neuro/Gumma body destruction)
- Treatment: Stat dose Benzathine Penicillin G 2.4 MI IM
