Gynaecological infections Flashcards
What is bacterial vaginosis
Where other bacteria overgrow (e.g. Gardnerella vaginalis) and reduce the lactobacilli in the vagina, bacterial vaginosis occurs.
What is lactobacilli
- healthy vaginal bacteria, and produce lactic acid that keeps the pH low and prevents other bacteria overgrowing.
What is the presentation of bacterial vaginosis
Fishy smelling watery / grey discharge
Dysuria
High vaginal pH
“Clue cells” on microscopy
What is the management of bacterial vaginosis
- Vaginal swabs to exclude other causes of symptoms (including chlamydia and gonorrhoea)
- Avoid vaginal irrigation or cleaning with soaps that may disrupt the natural flora
- Metronidazole is the first line antibiotic
What risks are thought o be associated with bacterial vaginosis
- Pre term delivery in pregnancy
- Increased susceptibility of picking up other STIs
What is candidiasis
Candidiasis is a common fungal infection. It is commonly called “thrush”. It is more common in immunosuppressed patients and those with diabetes.
What is the presentation of candidiasis
Itchy
Thick, white discharge, like “cottage cheese”
Vulval and vaginal irritation / pain
What is the management of cadidiasis
Clotrimazole cream
One off clotrimazole pessary
One off oral fluconazole dose (150mg)
What is the presentation of Gonorrhoea
More often symptomatic than chlamydia (90% men, 50% women) Odourless, green, purulent discharge Dysuria Pelvic pain Testicular pain
What type of pathogen causes Gonorrhoea
Neisseria gonorrhoeae is a gram negative diplococcus.
How do you diagnose gonorrhoea
- Nucleic acid amplification testing (NATT) can detect the DNA of gonorrhoea on endocervical swabs or urine
- An endocervical swab should be taken for culture and sensitivities prior to antibiotics
What is the management of Gonorrhoea
- Single dose of ceftriaxone 500mg IM and azithromycin 1g oral
- Test again to assess response to treatment (“test of cure”)
What pathogen causes Chlamydia
- Chlamydia trachomatis (gram negative bacteria) is an intracellular organism
- most common STI in UK
What is the presentation of Chlamydia
Asymptomatic in 50% men Asymptomatic in 75% of women PV discharge Pelvic pain Abnormal bleeding Painful sex
What is the most common cause of infertility in the UK
Chlamydia
What may you find on examination of a patient with chlamydia
Cervical excitation Fever Purulent discharge Pelvic/abdominal tenderness Fever
How do you diagnose chlamydia
- Vulvovaginal swab in females
- Urine sample in males (catching urine as it is first produced – “first catch”)
- Tested using nucleic acid amplification tests (multiplying the DNA of the pathogen and testing by PCR to get an early results)
What must you do for all patients with an STI
Contact tracing for partners
Education to prevent future infection
Test and treat any other STDs
What is the management of Chlamydia
Doxycycline for 7 days or
Single dose of 1g azithromycin (better for compliance)
No need to test for cure
What is Lymphogranuloma Venereum
a condition affecting the lymphoid tissue around the site of infection in patients infected with chlamydia. Treatment is the same as for chlamydia.
What is the first stage of Lymphogranuloma Venereum
Painless ulcer. This can occur on the penis in men, vaginal wall in women or rectum after anal sex.
What is the second stage of Lymphogranuloma Venereum
Lymphadenitis. This is swelling, inflammation and pain in the lymph nodes infected with the bacteria. This could be the inguinal or femoral lymph nodes.
What is the third stage of Lymphogranuloma Venereum
This is where there is inflammation of the rectum and anus. Proctocolitis leads to anal pain and discharge.
What is PID
inflammation, most commonly caused by infection, of the organs of the pelvis, usually from infection spreading up through the cervix. It is a major cause of infertility and pelvic pain.
What are the most common pathogens to cause PID
Chlamydia trachomatis
Neisseria gonorrhoeae
What is the presentation of PID
Pelvic pain / pain in lower abdomen Fever Dysuria Deep dyspareunia Vaginal discharge Abnormal bleeding (intermenstrual / postcoital) Menorrhagia Cervical excitation
What is the management of PID
- Antibiotics as per local guidelines
NICE suggest: - Oral ofloxacin 400mg twice daily with oral metronidazole 400mg twice daily for 14 days
OR IM ceftriaxone 500mg single dose with oral doxycycline 100mg twice daily with oral metronidazole 400mg twice daily for 14 days
Treat based on clinical diagnosis (no need to wait for microbiology)
Consider removing intrauterine devices
What is Fitz-Hugh-Curtis Syndrome
This is where pelvic inflammatory disease causes inflammation of the liver capsule, leading to adhesions between the liver and peritoneum.
It results in right upper quadrant pain that can be referred to the right shoulder tip if there is diaphragmatic irritation.
What is Herpes Simplex
- Herpes simplex virus (HSV) causes both coldsores and genital herpes.
- HSV-1 causes coldsores
- HSV-2 causes genital herpes (some overlap)
- Painful ulcers called stomatitis herpetiformis.
What is presentation of genital herpes
Labial ulceration / vesicular lesions
Pain
No discharge
Ask about sexual contacts (including those with coldsores)
How do you diagnose genital herpes
Diagnosis can be made clinically
A swab can be taken for a viral PCR to identify the cause
How do you manage genital herpes
- aciclovir (oral in stomatitis and genital herpes and topical with cold sores).
- Treatment can be slow and require long term aciclovir.
How do you treat genital herpes in pregnancy
- first presentation >28 weeks gestation then elective caesarean at term is advised (it takes 6 weeks for the fetus to develop passive immunity).
- recurrent genital herpes: start aciclovir and it is thought that the risk of transmission in vaginal delivery is low.
What are the risks of genital herpes during pregnancy
- Neonatal herpes simplex infection has high morbidity and mortality.
- It should be avoided as much as possible and treated early if identified.
What is Bartholin’s Cyst
- The ducts of the Bartholins gland become blocked leading them to swell and become tender
- 1-5cm fluid filled cyst
What are the Bartholin glands
pair glands either side of the posterior part of the vaginal introitus (the vaginal opening). Normally they are responsible for vaginal lubrication.
What is the management of a Bartholins cyst
usually resolve with simple treatment such as good hygiene, analgesia and warm compresses.
What is Bartholins Abscess
- Bartholins Cyst which becomes infected
- hot, tender, red and may be draining pus.
What bacteria typically cause a Bartholins Abscess
- staph and strep.
- E. Coli and gonorrhoea can also cause an abscess.
What is the management of a Bartholins Abscess
- Swab of pus or fluid
- antibiotics: flucloxicillan or erythromycin if pen alllergy
- May require surgical drainage
What is Lichen Sclerosus
- Thought to be an autoimmune condition.
- Symptoms and signs are made worse by friction to the skin – “Koebner phenomenon”.
What are the symptoms of Lichen Sclerosus
Itching
Soreness and pain
Tight skin
Painful sex (superficial dyspareunia)
What is the appearance of Lichen Sclerosus
- labia, perianal and perineal skin.
- associated fissures, cracks, erosions or haemorrhages under the skin.
- “Porcelain-white”
- Shiny
- Papules / plaques
- Tight
- Thin
- Slightly raised
What are the complications of Lichen Sclerosus
Pain and discomfort
Bleeding
Narrowing of the vaginal or urethral openings
There is a 5% risk of developing vulval cancer. This is usually squamous cell carcinoma.
What is the management of Lichen Sclerosus
- It can’t be cured.
- Followed up in secondary care.
- Vulval biopsy can be performed if any lesions are suspicious or the diagnosis is in doubt.
- Strong topic steroids are the mainstay of treatment (reduce risk of Ca too)
- Emollients should be used regularly
What topical steroid should be used in Lichen Sclerosus
- Often clobetasol propionate 0.05% (dermovate).
- initially once a day for 4 weeks then reduce the frequency down (e.g. to three times weekly then once weekly).
- When the condition flares they can go back to using it daily until it is under control.
- A 30g tube should last at least 3 months
What are Nabothian Cysts
- fluid filled cysts that are often seen on the surface of the cervix.
- also called nabothian follicles.
- up to 1cm in size, but rarely can be larger.
- harmless.
- May occasionally by biopsied to exclude other pathology
What is Meig’s Syndrome
- Occurs in older women.
- Benign ovarian fibroma that generates the associated pleural effusion and ascites.
- Once the tumour is removed, the effusion and ascites resolve and the prognosis is excellent.
What is the triad of Meig’s Syndrome
Pleural Effusion
Ascites
Benign ovarian tumour
