Gynaecology: Infections (Discharge, Lumps, Ulcers, Blood Borne) Flashcards
What ae the significant history points to get from a patient presenting with discharge?
- What discharge is normal for you
- Colour/ consistency/ odour
- Associated pain (dysuria, dyspareunia)
- Associated bleeding (PCB, IMB)
- Associated itchiness
- Triggers (e.g. cyclical, after sex, recent antibiotics)
- Sexual history and contraception
- Pregnancy risk
- Washing habits (e.g douching, products)
How would you examine a patient presenting with discharge and what signs are you looking for?
External exam:
- Rashes
- Fissures
- Lumps
- Ulcers
Speculum:
- Internal lesions
- Cervical health (any inflammation, lesions, polyps, strawberry…)
What is a strawberry cervix indicative of?
Trichomonas Vaginalis
What tests would you consider in a patient with discharge?
Should do…
- High vaginal swab (use charcoal swab for microscopy and culture for Trichomonas, Candida)
- Vulvovaginal swab (NAAT for NG and CT)
Can do…
- Culture for other organisms if relevant e.g. endocervical culture for NG if high clinical suspision
- HSV PCR if required
What are some physiological causes of vaginal discharge?
- Sexual arousal
- Menstrual cyclical variation
- Pregnancy
What are some pathological, vaginal causes of discharge?
- Candidiasis
- Trichomoniasis
- Bacterial Vaginosis
- Post menopausal vaginitis
What are some pathological, cervical causes of discharge?
- Gonorrhoea
- Non-specific infection
- Herpes
- Cervical ectopy
- Cervical neoplasm
What would you suspect in a woman presenting with thick, white, cottage-cheese like discharge + itchiness and soreness?
Candida infection (thrush).
What signs would you look for and investigations would you order in a suspected thrush case?
Signs:
- Vulval erythema
- Possibly fissures
- Classic discharge
Investigations
- Swabs taken from high vaginal walls
- Should show spores + neutrophils
- Culture (from a charcoal swab) may grow candida but lack of growth does not rule out infection
What are some risk factors for candida/thrush?
- Immunosuppression (common in HIV patients)
- Steroids or Chemo
- High oestrogen levels (pregnancy)
- Antibiotics in last 3 months
- DM
How is candidiasis managed?
Normally =
- Fluconazole, 150mg, PO, stat
- Clotrimazole 1% cream BD for 2 weeks
If pregnant or breastfeeding give Clotrimazole 500mg pessary PV instead of Fluconazole.
How is recurrent candidiasis defined and managed?
4 symptomatic episodes a year.
Mx with induction therapy then maintenance:
- I = Flu 150mg, every 72 hours, 3 times
- M = Flu 150mg, once a week for 6 months
- Again use Clotrimazole pessaries if CI
What is the medication of choice for thrush?
FLUCLONAZOLE (150MG PO)
+ Clotrimazole 1% cream (BD)
What would you be thinking if a woman presents with a thin, white, homogenous discharge coating the walls of the vagina and vestibule?
Eww.
Probably bacterial vaginosis though.
What is the commonest cause of vaginal discharge in a woman of child bearing age?
Bacterial vaginosis.
What triggers bacterial vaginosis infections?
Anything that upsets the normal balance of vaginal flora/ causes a rise in vaginal pH
- Sex
- Menses
- Receptive oral SI
- Vaginal douching
- Perfumed bath products
- Change in sexual partners
- Presence of an STI
What are the two diagnostic criteria used for bacterial vaginosis?
Hay-Ison criteria based on microscopy. 1-4 based on loss or reduction of lactobacili + domination of gram positive cocci.
Amsel criteria based on:
- Characteristic discharge
- Clue cells on wet mount
- Raised pH
- Whiff test
When do you treat bacterial vaginosis?
- Symptomatic
- Pre-surgery
- Patient request
Consider in asymptomatic pregnant women (BV increases miscarriage risk)
What is the treatment for bacterial vaginosis?
Metronidazole 400mg, BD for 5 days. (can also give 2g all at once.
Generic: give advice relating to triggers and how to avoid e.g. change washing habits, invest in condoms.
What is your first thought if a woman presents with frothy white vaginal discharge (+/- vulval itchiness and soreness)
Trichomonas Vaginalis.
Look for strawberry cervix, classic sign but actually only seen in 2% of patients.
How is Trichomonas Vaginalis contracted?
STI. Rarely detected in men but commonly in women, inoculated into genital tract and grows in vagina, urethra, para-urethral glands
What are the main complications of TV?
In pregnancy leads –> pre-term delivery and low birth weight
Can also increase HIV transmission
How is TV diagnosed?
Can use a
- Wet mount (70% sensitive)
- Culture (with a charcoal swab 95%)
- NAAT (98%)
How do men present with TV infections?
NSU (non-specific urethritis), test for TV if G and C come back -ve
How is TV treated?
Same as BV:
- Metronidazole, 400mg, PO, BD for 5-7 days
- Metronidazole 2g, PO, STAT
What are the main causes of male discharge?
STIs:
- Chlamydia
- Gonorrhoea
- Mycoplasma Genitalium
- Trichomonas Vaginalis
- HSV
Non-STI:
- UTI
- Adenovirus
- Candida
Non-Infective:
- Drugs
- Alcohol
- Trauma
- Foreign body
What Ix would you order for male urethral discharge?
- Urine NAAT for G and C
- Gram stained smear from urethra
- G culture (if clinically suspicious)
Can also do:
- MSU/urinalysis
- HSV PCR
How is NSU defined?
Non specific Urethritis = Inflammation of the urethra in the absence of a diagnosis of Chlamydia or Gonorrhoea
Commonly associated with discharge, dysuria, penile irritation
How is NSU diagnosed?
Gram stain + microscopy of urethral sample. Look for 5+ polymorphonuclear leucocytes per field.
How do you manage a patient with NSU?
- Send STI screen
- Treat empirically with 1 week of Doxycycline, 100mg, PO, BD (empirical treatment for Chlamydia)
- Tell them to abstain from sex during their and their partner’s treatment.
- Refer to GUM if recurrent.
Why is Chlamydia the most common STI in the UK?
Most cases are asymptomatic.
Common symptoms are quite vague e.g. rogue pain from cervicitis and urethritis.
What complications can arise from Chlamydia?
- PID
- Epididymoorchitis
- SARA
- Tubal factor infertility
- Increased risk of ectopic pregnancy
How does Chlamydia present in men and women?
Men:
- Discharge (often clear)
- Dysuria (be especially suspicious of dysuria w/o other LUTS e.g. urgency or frequency)
- Testicular pain
Women:
- Discharge
- PCB
- IMB
- Lower abdominal pain/PID
- Dysuria
BOTH can present asymptomatically or with extra-genital symptoms!
What are some extra-genital symptoms of chlamydia?
- Conjunctivitis
- Pharyngitis
- SARA
- Proctitis
How is Chlamydia treated?
1st line = Doxycycline 100mg, PO, BD over 7 days (CI in pregnancy)
2nd line = Azithromycin 1g PO stat, followed by 500mg PO, OD for 2 days
How does Gonorrhoea typically present?
Men and women = PURULENT URETHRAL DISCHARGE - Proctitis - Asymptomatic - Disseminated infection (e.g. rash, joint pain, erythema)
Men:
- Epididymoorchitis
Women:
- IMB, PCB
- PID
How can you diagnose Gonorrhoea?
Near-patient testing (microscopy):
- Male Urethral specimens are 90% sensitive
- Female Cervical ones only 50%
NAAT testing:
- 95% sensitive
- Vulvovaginal for women
- Urinal for men
- Rectal if anal sex
- Pharyngeal if oral
Other than near-patient and NAAT testing, what investigation is crucial for the management of Gonorrhoea?
CULTURE! Must test sensitivity to antibiotics before starting treatment.
Furthermore, must perform a test of cure post-treatment (not necessarily required in Chlamydia)
How is Gonorrhoea treated?
Ceftriaxone 1g STAT IM, single dose
N.B: Can’t give if allergic to penicillin due to cross-reactivity
Ciprofloxacin 500mg, PO, Stat is ideal but issues with resistance.
What is Mycoplasma Genitalium?
- Emerging superbug or super-STI
- Linked with many cases of urethritis, cervicitis, PID, epididymoorchitis, proctitis
- Current Mx is one week of Doxy followed by 3 days of Azithromycin
What is Condyloma Acuminata?
- Genital warts
- Benign lesion caused by HPV (6 or 11)
- Sexually transmitted infection that causes small skin or pink coloured growths on the genital skin
- Most common viral STI in GUM services.
How are genital warts contracted?
Through sexual contact (vaginal, oral, anal…) or hand to genital contact.
CONDOMS DO NOT GIVE FULL PROTECTION.
What are the symptoms of genital warts?
- Warty growths in and around genital skin, often asymptomatic, painless and skin-coloured
- Can cause discomfort or itchiness
- Psychological distress
- Distorted urinary stream (if urethral lesions)
- Bleeding from cervical, urethral or anal lesions
- Can also present with secondary infection
What is essential to check in a woman presenting with external genital warts?
Cervix on speculum!
Need to evaluate for internal warts
What are some differentials for penile lesions other than warts?
Non-pathological:
- Skin tags
- Pearly penile papules
- Fordyce spots.
Pathological:
- Molluscum Contagiosum (small pearly lesion caused by self-limiting pox virus infection- common in children.
- Condylomata Lata (occurs in secondary syphilis)
- MALIGNANCY (PIN,VIN, VaIN, AIN)
How is molluscum contagiosum managed?
- Reassure, not serious
- Avoid autoinoculation by avoiding shaving or waxing the area.
- Don’t share towels or bed linens
- Watch and wait
- Can give podophyllotoxin or imiquimod
What features of a genital lesion would make you suspicious of neoplasia and consider sending off a biopsy?
- Pigmentation
- Depigmentation
- Pruritus
- Immune deficiency
- Prior history of intraepithelial neoplasia
When do you refer a patient presenting with warts?
- Unsure
- Internal lesions (requires colposcopy)
- Suspicious lesions
- Recalcitrant lesions (HIV test for immuno-suppression)
- Immunosuppressed patients
- Pregnant women
- Children
- Elderly patients (increased index of suspicion for malignancy)
How would you manage a patient presenting with genital warts?
Cons:
- Screen for other STIs!!
- Give written information
- Encourage condom use always (but also inform this isn’t 100% effective, is good for other STIs)
- Acknowledge psychological distress and provide support
- Reassure it is common and clears spontaneously
Medical Mx:
- Watch and wait is a strong option, works well
- Any management is essentially cosmetic
- Cryotherapy
- Podophyllotoxin
- Imiquod cream
- Surgery
What conditions are Podophyllotoxin or Imiquimod cream used for?
Molluscum contagiosum and general HPV genital warts
Why are warts so common in pregnancy? How should they be managed?
Pregnancy causes relative immunodeficiency.
Very low risk to baby and risk of complications.
Nonetheless should be treated, avoid medication as generally teratogenic. Cryoablation is safest route. Surgical removal or C section in severest cases.
What are the potential causes of genital ulcers/sores?
Infective: Herpes Simplex, Herpes Zoster, Syphilis, Tropical infections (e.g. LGC)
Non-Infective: Trauma, Physical damage, Chemical damage
Dermatological: Bechets. Apthosis, Lichen Planus
MALIGNANCY
How does Herpes Simplex typically present?
Hx:
- Vulval blisters and soreness
- Dysuria
- Can get chills and muscle aches
- Somewhere in sexual history will either be new partner or current partner who has Herpes/ history of cold sores
O/E:
- Swollen, red vulva
- Bilateral herpetic lesions (Sloughy, shallow, yellow based lesions)
- Very painful to touch
What are the main differences between HSV 1 and HSV 2?
HSV 1 is typically orofacial, 80% seropositive in the UK, rarely recurs beyond first year.
HSV 2 is primarily a genital infection, much less common in the UK (4%), far more likely to recur.
N.B: Due to oral sex, you do see HSV1 in the genitals and HSV2 in the face
Describe the life cycle of a Herpes infection?
Incubation period = 3-14 days
- Starts off as irritated red lesion
- Develops into painful fluid filled ulcers
- These then burst leaving painful open ulcers
- Which eventually dry up into
What investigations do you order for a patient presenting with suspected Herpes?
Immediately: HSV PCR swab, confirms infection and gives type. START TREATMENT BEFORE SWAB RESULTS.
Eventually: Full STI screen + Syphilis serology (important as DD for ulcers of this kind)
How is HSV managed?
- Rest
- Analgesia
- Saline washing to prevent secondary infections or adhesions forming
- Systemic antivirals (ACYCLOVIR, 400mg, 3 times a day, 5 days)
What are the potential complications seen in HSV patients?
- Adhesions
- Urinary retention (HSV irritates sacral nerve preventing bladder contraction, probably requires catheterisation)
- Emotional distress (must be managed with counselling)
- Recurrence
- Meningism (systemic infection)
What reassurance can you give someone distressed about their first episode of HSV?
While it is a recurrent condition, the recurrences are nowhere near as bad, tend to only be a lesion or two and unilateral, and get less common with time.
If they have Type 1 tell them recurrence rates are much lower.
When is HSV in pregnancy a serious concern?
If it’s a primary infection and in the last trimester.
Manage with CS and treatment for baby after birth
How does Herpes zoster present?
Unilateral infection that follows a dermatome. Can present in the genital regions and important DD for ulcers.
How does Syphilis present?
- Primary Syphilis typically presents with a CHANCRE (a large, painless, indurated (“punched out”) ulcer with associated lymphadenopathy)
- Typically present 9-90 days after exposure
- However due to these lesions being painless and often occurring in hard to see areas, they may get missed in which case the patient will present with secondary syphilis
- 6 weeks- 6 months after exposure
- Systemically unwell, maculopapular rash, patchy hair loss, systemic complications
- Years of secondary syphilis causes tertiary syphilis, whereby lesions in the CNS and CVS cause neuro and cardio issues.
How is syphilis diagnosed?
Typically with a blood test:
- Syphilis EIA (Treponemal Enzyme Immunoassay)
- OR Rapid plasma reagin test.
N.B: Must always do full STI screen as well as HIV screen
How is Syphilis treated?
IM Benzyl Penicillin G.
- If primary, 1 single dose
- If secondary 3 doses in 3 consecutive weeks.
What are the two most common causes of genital ulcers in the UK?
Syphilis and Herpes Simplex.
What are the risks of developing a BBI after exposure?
Depends on which BBI, but does not depend on exposure (sex = needlestick = vertical etc…)
Hep B = 1/3
Hep C = 1/30
HIV = 1/300
In instances of needlestick injury, what risk factors must be assessed?
- Is the patient known positive
- If so what’s their viral load
- Skin punctured vs broken vs scratched
- Hollow vs solid needle
- Gloves?
- Time to first aid measures
- Has recipient been vaccinated
For what BBIs is PEP availabe?
HIV and Hep B but NOT Hep C
What PEP is given for HIV exposure?
- Starter pack of triple anti-retroviral drugs
- For 28 days
- Ideally start within 24 hours but no later than 72
What PEP is given for Hep B exposure?
- May need booster immunisation if adequately vaccinated
- If incompletely vaccinated OR poor responder may need Hep B Immunoglobulin
What testing needs to be arranged after a needlestick injury?
- Source patient needs to be tested for HIV, HBsAg, HCV
- Recipient must have an original blood sample recorded, and follow up blood tests at 6, 12, 24 weeks
N.B: Recipient must abstain from sex during this time.
What are the stages of HIV infection?
- Seroconversion illness (non-specific symptoms, resolves in 2-3 weeks)
- Asymptomatic stage of HIV (can last years)
- Symptomatic HIV (weakened immune system, opportunistic infections)
- Late stage HIV-AIDS (defined by cancer, TB, pneumonia)
What test should be ordered if HIV is suspected?
4th generation combo assay (EIA) which detects Anti-HIV antibodies as well as p24 antigens
Can also do a PCR detection for RNA, gives idea of viral load.
How is the age Hep B is contracted relevant to outcome?
Childhood infection is more likely to lead to chronic disease and cirrhosis (40% vs 15% in adult infection)
How does Hep B present?
- Often subclinical or flu-like illness
- Acute presentation of jaundice, dark urine or pale stools, rash, polyarthritis, fever, tender hepatomegaly
- Chronic- decompensated liver disease
What measures should be taken to prevent Hep B spread?
- Patients should inform GP and dentist
- Do not donate blood
- DO not share needles
- Use condoms for all sexual intercourse
- Cover wounds and clean blood spills thoroughly
In pregnancy, mother may require antivirals and neonate may require vaccine
Sexual contracts will need vaccination + HBIG if recent exposure
Do not share razors or tooth brushes with household contacts
How does Hep C prevent?
- Usually asymptomatic or mild
- Incubation period normally around 6 weeks
- 80% develop a chronic infection, leading to cirrhosis or hepatocellular carcinoma
What tests are available for Hep C?
Anti-HCV total is used for initial screening, indicated either past or current infection (N.B: presence of antibody does not guarantee future immunity)
Next test is HCV RNA which distinguishes current from past infection.
