Gynaecological Infections 2 Flashcards
What are causes of Genital Warts?
Benign lesion caused by HPV (90% HPV 6 or 11)
- Sexually transmitted infection that causes small, skin-coloured or pink growth on the genital skin
- Most common viral STI diagnosed in sexual health services
What is the mode of transmission of HPV?
- Skin to skin contact during sex
- No good evidence for formites.
- Incubation periods can be from 2 weeks to 8 months. The average is 3 months
What is pathophysiology of HPV in genital warts?
- Cells of the basal layer of the epidermis are invaded by HPV through mucosal micro-abrasions.
- Latent virus phase begins with no signs and symptoms and may lay dormant for months or years
- Following latency, production of viral DNA/particles begins
- Development of genital warts occurs
What are symptoms of Genital Warts?
- Wart growth in and around genital skin often asymptomatic, painless and skin colours. Warts can be solitary or multiple. They can be broad based, pedunculated, pigmented or flat and plaque like
- Non keratinised warts on warm, moist, non-hairy skin
- Keratinised on hairy skin firm
- Little discomfort but often psychological distress
- Distorted urinary stream with urethral lesions
- Bleeding from cervical/urethral/anal lesions
- Rarely secondary infection
What is the investigation for Genital Warts?
- Speculum examination to evaluate internal warts.
- Possible colposcopy
What are some differentials for Genital Warts?
- Non pathological: pearly penile papule, skin tags, fordyce spots
- Molluscum contagiosum: umbilicated pearly lesions
- Condylomata Lata: occur in secondary syphilis and highly infectious. Send syphilis serology and seek GUM advice
-
Malignancy and Pre-malignancy: PIN, VIB, AIN, VaIN
- Features raising suspicious are pigmentation, depigmentation, pruritis, immune deficiency, prior history of intraepithelial neoplasia
- Buscke-Lowenstein: giant condyloma acuminatum. HPV contributes to it. Slow growing, locally aggressive and destructive
When should genital warts be referred for investigation?
- If you are unsure.
- Suspicious lesions or Recalcitrant lesions or internal lesions
- Immunosuppressed paints/ Pregnancy patients/Children/Elderly patient
What is the management of Genital Warts?
- Screen for STIs
- Encourage condom use to reduced risk of transmission
- Support for psychological distress
- No treatment is an option and await spontaneous resolution. Can try
- Anti-mitotic agents
- Immune modifiers
- Surgery
- Destruction – Cryotherapy
- In pregnancy, low risk to baby so can just wait it out. Cryoablation may be used and in extreme cases, caesarean or surgical removal of warts
What causes Bacterial Vaginosis?
Commonest cause of discharge in childbearing age.
- Due to imbalance of vaginal flora
- Loss of lactobacilli that maintain acidic pH of vagina (<4.5).
- This causes overgrowth of normal, commensal, anaerobic and facultative bacteria which leads to rise in vaginal pH and allows bacteria to grow.
Not an STI but enhances risk of HIV transmission and STIs
What are characteristic symptoms of Bacterial Vaginosis?
Offensive, thin, white/grey, ‘fishy’ discharge
What are triggers for Bacterial Vaginosis?
- Sex
- Menses
- Receptive Oral STI
- Vaginal douching
- Perfumed bath products
- Change in sexual partners
- Presence of STI
What are methods of diagnosing Bacterial Vaginosis?
- Hay-Ison criteria (used primarily)
- Ansel Criteria
What is the Hay-Ison Criteria?
Gram stain of posterior fornix shows
- = No bacteria
- = Normal
- = Reduced lactobacilli plus mixed flora (intermediate)
- = Few or absent lactobacilli and mixed flora, predominantly Gardnerella morphotypes (BV)
- = Gram positive cocci dominate
Describe the Ansel Criteria?
How is Bacterial Vaginosis managed?
Treat symptomatic mainly unless pre-surgery or patient request but consider asymptomatic pregnancy women due to risk of miscarriage
- Metronidazole 400 mg BD for 5 days
- Metronidazole 2g PO single dose
- Metronidazole 0.75% gel PV once a day for 5 days
- Clindamycin 2% cream PV OD for 7 days
Avoid precipitants
How does Trichomonas Vaginalis occur?
- It is an STI that needs direct inoculation intravaginally or urethra
- It lives in vagina, urethra, or para-urethral glands.
- Predominantly diagnosed in women
What are clinical signs and symptoms of Trichomonas Vaginalis?
- Offensive, yellow/green, frothy discharge
- Vulvovaginitis/Vulvitis
- Strawberry cervix
- Dysuria, Urethritis (test if persistent urethritis)
What are complications of Trichomonas Vaginalis?
- In pregnancy can cause preterm birth and low birth weight
- HIV transmission enhancement
How is a diagnosis of Trichomonas Vaginalis made?
Swab the posterior fornix
- Wet mount: 70% sensitive compared to culture. Degrade over time
- Culture using charcoal swab: 95% sensitive in women
- NAATs: 98-100% (not widely availble)
What is the management of Trichomonas Vaginalis?
- 1st line: Metronidazole 400 mg PO BD 5-7 days
- 2nd Line: Metronidazole 2g PO stat
Treat sexual partners empirically
How should a history for Urethral discharge be made?
- Discharge: Timing, Colour, Consistency
- Associated Symptoms: Dysuria, Urinary symptoms, Testicular pain, Extra-genital symptoms
- Sexual History
- Relevant PMH
What are causes of Urethral Discharge?
STI:
- Chlamydia (60%)
- Gonorrhoea
- Mycoplasma Genitalium
- Trichomonas Vaginalis
- Herpes Simplex
- NSU
Non STI:
- UTI
- Adenovirus
- Candida
- Drugs
- Alcohol
- Trauma
- Foreign body
What are investigations for Urethral Discharge?
- Urine NAAT for Gonorrhoea and Chlamydia
- Gram-stained smear from urethra after patient has held urine for 1hr for:
- Polymorphonuclear leucocytes
- Gram negative intracellular diplococci (gonorrhoea)
- Gonorrhoea culture if suspicious
- Consider: MSU, Herpes simplex PCR, Wet mount for TV/culture, look for urine threads in microscopy
What is Non-specific Urethritis?
- Inflammation of the urethra in absence of a diagnosis of chlamydia or gonorrhoea
What is the clinical features of Non-specific Urethritis?
- Urethral discharge
- Dysuria
- Penile irritation
What is investigation of non-specific Urethritis?
Diagnosed through gram stain and microscopy of urethral sample.
- Shows 5+ polymorphonuclear leucocyte per high power field
What is the management of Non-specific Urethritis?
- Send STI screening
- Treat with 1/52 doxycycline 100mg PO BD
- Abstain during treatment and treat partners
What is the morphology of Chlamydia Trachomatis?
Obligate intracellular bacterium
- Serovars D-K cause genital disease.
- Serovars L1, L2 and L3 cause LGV
What are the clinical features of Chlamydia?
- Commonly causes cervicitis and urethritis
- Males
- Discharge, Dysuria, Testicular pain
- Females
- Discharge, Post-Coital bleeding, Intermenstrual bleeding, Lower abdominal pain/PID, Dysuria
- Extra-genital symptoms: Conjunctivitis, Pharyngitis, SARA, Proctitis
What are complications of Chlamydia?
- PID
- Epididymoorchitis
- Seronegative autoimmune reactive Arthritis
- Tubal factor infertility
- Increased risk of ectopic pregnancies
What is the treatment of Chlamydia?
- 1st line: Doxycycline 100 mg PO BD 7 days (contraindicated in pregnancy)
- 2nd line: Azithromycin 1g PO stat followed by 500 mg PO OD x2 days
- Complicated infections require longer treatment. Liaise with GUM
- No test of cure unless pregnant or suspicion of reinfection/relapse
What are characteristics of Mycoplasma Genitalium?
- Implicated in urethritis, cervicitis, PID, epidydimorhcitis, proctitis
- Develops resistance to macrolides easily
What is the management of Mycoplasma Genitalium?
- 1 week of doxycycline followed by 3 day course of azithromycin
- Alternative is Moxifloxacin
What is the appearance of Neissarae Gonorrhoea?
- Gram negative intracellular diplococci
What are signs and symptoms of Gonorrhoea?
- Asymptomatic
- Males: Purulent urethral discharge and Epididymoorchitis
- Females: Purulent Discharge, Intermenstrual Bleeding, Post Coital Bleeding, Pelvic Inflammatory Disease
- Proctitis
What are complications of Gonorrhoea?
- Neonatal infection.
- Disseminated infection (rash, joint pain, erythema)
- Rapidly develop resistance to antibiotics
How is Gonorrhoea diagnosed?
- Near patient testing – microscopy
- Urethral specimens (more sensitive), cervical specimen
- NAAT testing
- Vulvovaginal, urine, rectal, pharyngeal depending on exposure. >95% sensitive at genital sites.
- Culture required prior to treatment for antibiotic sensitivities
- Endocervical, urethral, rectal, pharyngeal as appropriate based on exposure
- Test of cure required post treatment in all cases
What is the management of Gonorrhoea?
- Ceftriaxone 1g IM
- Ciprofloxacin 500 mg PO stat (if identified by culture as sensitive)
No sex within a week post treatment and until sexual partner has also received treatment. Partner notification
