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Y4 Obs and Gynae > Gynaecology: Infections (Discharge, Lumps, Ulcers, Blood Borne) > Flashcards

Gynaecology: Infections (Discharge, Lumps, Ulcers, Blood Borne) Flashcards

1
Q

What ae the significant history points to get from a patient presenting with discharge?

A
  • 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)
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2
Q

How would you examine a patient presenting with discharge and what signs are you looking for?

A

External exam:

  • Rashes
  • Fissures
  • Lumps
  • Ulcers

Speculum:

  • Internal lesions
  • Cervical health (any inflammation, lesions, polyps, strawberry…)
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3
Q

What is a strawberry cervix indicative of?

A

Trichomonas Vaginalis

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4
Q

What tests would you consider in a patient with discharge?

A

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
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5
Q

What are some physiological causes of vaginal discharge?

A
  • Sexual arousal
  • Menstrual cyclical variation
  • Pregnancy
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6
Q

What are some pathological, vaginal causes of discharge?

A
  • Candidiasis
  • Trichomoniasis
  • Bacterial Vaginosis
  • Post menopausal vaginitis
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7
Q

What are some pathological, cervical causes of discharge?

A
  • Gonorrhoea
  • Non-specific infection
  • Herpes
  • Cervical ectopy
  • Cervical neoplasm
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8
Q

What would you suspect in a woman presenting with thick, white, cottage-cheese like discharge + itchiness and soreness?

A

Candida infection (thrush).

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9
Q

What signs would you look for and investigations would you order in a suspected thrush case?

A

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
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10
Q

What are some risk factors for candida/thrush?

A
  • Immunosuppression (common in HIV patients)
  • Steroids or Chemo
  • High oestrogen levels (pregnancy)
  • Antibiotics in last 3 months
  • DM
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11
Q

How is candidiasis managed?

A

Normally =

  • Fluconazole, 150mg, PO, stat
  • Clotrimazole 1% cream BD for 2 weeks

If pregnant or breastfeeding give Clotrimazole 500mg pessary PV instead of Fluconazole.

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12
Q

How is recurrent candidiasis defined and managed?

A

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
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13
Q

What is the medication of choice for thrush?

A

FLUCLONAZOLE (150MG PO)

+ Clotrimazole 1% cream (BD)

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14
Q

What would you be thinking if a woman presents with a thin, white, homogenous discharge coating the walls of the vagina and vestibule?

A

Eww.

Probably bacterial vaginosis though.

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15
Q

What is the commonest cause of vaginal discharge in a woman of child bearing age?

A

Bacterial vaginosis.

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16
Q

What triggers bacterial vaginosis infections?

A

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
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17
Q

What are the two diagnostic criteria used for bacterial vaginosis?

A

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
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18
Q

When do you treat bacterial vaginosis?

A
  • Symptomatic
  • Pre-surgery
  • Patient request

Consider in asymptomatic pregnant women (BV increases miscarriage risk)

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19
Q

What is the treatment for bacterial vaginosis?

A

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.

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20
Q

What is your first thought if a woman presents with frothy white vaginal discharge (+/- vulval itchiness and soreness)

A

Trichomonas Vaginalis.

Look for strawberry cervix, classic sign but actually only seen in 2% of patients.

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21
Q

How is Trichomonas Vaginalis contracted?

A

STI. Rarely detected in men but commonly in women, inoculated into genital tract and grows in vagina, urethra, para-urethral glands

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22
Q

What are the main complications of TV?

A

In pregnancy leads –> pre-term delivery and low birth weight

Can also increase HIV transmission

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23
Q

How is TV diagnosed?

A

Can use a

  • Wet mount (70% sensitive)
  • Culture (with a charcoal swab 95%)
  • NAAT (98%)
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24
Q

How do men present with TV infections?

A

NSU (non-specific urethritis), test for TV if G and C come back -ve

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25
Q

How is TV treated?

A

Same as BV:

  • Metronidazole, 400mg, PO, BD for 5-7 days
  • Metronidazole 2g, PO, STAT
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26
Q

What are the main causes of male discharge?

A

STIs:

  • Chlamydia
  • Gonorrhoea
  • Mycoplasma Genitalium
  • Trichomonas Vaginalis
  • HSV

Non-STI:

  • UTI
  • Adenovirus
  • Candida

Non-Infective:

  • Drugs
  • Alcohol
  • Trauma
  • Foreign body
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27
Q

What Ix would you order for male urethral discharge?

A
  • Urine NAAT for G and C
  • Gram stained smear from urethra
  • G culture (if clinically suspicious)

Can also do:

  • MSU/urinalysis
  • HSV PCR
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28
Q

How is NSU defined?

A

Non specific Urethritis = Inflammation of the urethra in the absence of a diagnosis of Chlamydia or Gonorrhoea

Commonly associated with discharge, dysuria, penile irritation

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29
Q

How is NSU diagnosed?

A

Gram stain + microscopy of urethral sample. Look for 5+ polymorphonuclear leucocytes per field.

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30
Q

How do you manage a patient with NSU?

A
  • 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.
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31
Q

Why is Chlamydia the most common STI in the UK?

A

Most cases are asymptomatic.

Common symptoms are quite vague e.g. rogue pain from cervicitis and urethritis.

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32
Q

What complications can arise from Chlamydia?

A
  • PID
  • Epididymoorchitis
  • SARA
  • Tubal factor infertility
  • Increased risk of ectopic pregnancy
33
Q

How does Chlamydia present in men and women?

A

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!

34
Q

What are some extra-genital symptoms of chlamydia?

A
  • Conjunctivitis
  • Pharyngitis
  • SARA
  • Proctitis
35
Q

How is Chlamydia treated?

A

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

36
Q

How does Gonorrhoea typically present?

A 
Men and women =
PURULENT URETHRAL DISCHARGE
- Proctitis
- Asymptomatic
- Disseminated infection (e.g. rash, joint pain, erythema)

Men:
- Epididymoorchitis

Women:

  • IMB, PCB
  • PID
37
Q

How can you diagnose Gonorrhoea?

A

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
38
Q

Other than near-patient and NAAT testing, what investigation is crucial for the management of Gonorrhoea?

A

CULTURE! Must test sensitivity to antibiotics before starting treatment.

Furthermore, must perform a test of cure post-treatment (not necessarily required in Chlamydia)

39
Q

How is Gonorrhoea treated?

A

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.

40
Q

What is Mycoplasma Genitalium?

A
  • 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
41
Q

What is Condyloma Acuminata?

A
  • 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.
42
Q

How are genital warts contracted?

A

Through sexual contact (vaginal, oral, anal…) or hand to genital contact.

CONDOMS DO NOT GIVE FULL PROTECTION.

43
Q

What are the symptoms of genital warts?

A
  • 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
44
Q

What is essential to check in a woman presenting with external genital warts?

A

Cervix on speculum!

Need to evaluate for internal warts

45
Q

What are some differentials for penile lesions other than warts?

A

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)
46
Q

How is molluscum contagiosum managed?

A
  • 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
47
Q

What features of a genital lesion would make you suspicious of neoplasia and consider sending off a biopsy?

A
  • Pigmentation
  • Depigmentation
  • Pruritus
  • Immune deficiency
  • Prior history of intraepithelial neoplasia
48
Q

When do you refer a patient presenting with warts?

A
  • 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)
49
Q

How would you manage a patient presenting with genital warts?

A

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
50
Q

What conditions are Podophyllotoxin or Imiquimod cream used for?

A

Molluscum contagiosum and general HPV genital warts

51
Q

Why are warts so common in pregnancy? How should they be managed?

A

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.

52
Q

What are the potential causes of genital ulcers/sores?

A

Infective: Herpes Simplex, Herpes Zoster, Syphilis, Tropical infections (e.g. LGC)

Non-Infective: Trauma, Physical damage, Chemical damage

Dermatological: Bechets. Apthosis, Lichen Planus

MALIGNANCY

53
Q

How does Herpes Simplex typically present?

A

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
54
Q

What are the main differences between HSV 1 and HSV 2?

A

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

55
Q

Describe the life cycle of a Herpes infection?

A

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
56
Q

What investigations do you order for a patient presenting with suspected Herpes?

A

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)

57
Q

How is HSV managed?

A
  • Rest
  • Analgesia
  • Saline washing to prevent secondary infections or adhesions forming
  • Systemic antivirals (ACYCLOVIR, 400mg, 3 times a day, 5 days)
58
Q

What are the potential complications seen in HSV patients?

A
  • Adhesions
  • Urinary retention (HSV irritates sacral nerve preventing bladder contraction, probably requires catheterisation)
  • Emotional distress (must be managed with counselling)
  • Recurrence
  • Meningism (systemic infection)
59
Q

What reassurance can you give someone distressed about their first episode of HSV?

A

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.

60
Q

When is HSV in pregnancy a serious concern?

A

If it’s a primary infection and in the last trimester.

Manage with CS and treatment for baby after birth

61
Q

How does Herpes zoster present?

A

Unilateral infection that follows a dermatome. Can present in the genital regions and important DD for ulcers.

62
Q

How does Syphilis present?

A
  • 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.
63
Q

How is syphilis diagnosed?

A

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

64
Q

How is Syphilis treated?

A

IM Benzyl Penicillin G.

  • If primary, 1 single dose
  • If secondary 3 doses in 3 consecutive weeks.
65
Q

What are the two most common causes of genital ulcers in the UK?

A

Syphilis and Herpes Simplex.

66
Q

What are the risks of developing a BBI after exposure?

A

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

67
Q

In instances of needlestick injury, what risk factors must be assessed?

A
  • 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
68
Q

For what BBIs is PEP availabe?

A

HIV and Hep B but NOT Hep C

69
Q

What PEP is given for HIV exposure?

A
  • Starter pack of triple anti-retroviral drugs
  • For 28 days
  • Ideally start within 24 hours but no later than 72
70
Q

What PEP is given for Hep B exposure?

A
  • May need booster immunisation if adequately vaccinated

- If incompletely vaccinated OR poor responder may need Hep B Immunoglobulin

71
Q

What testing needs to be arranged after a needlestick injury?

A
  • 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.

72
Q

What are the stages of HIV infection?

A
  • 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)
73
Q

What test should be ordered if HIV is suspected?

A

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.

74
Q

How is the age Hep B is contracted relevant to outcome?

A

Childhood infection is more likely to lead to chronic disease and cirrhosis (40% vs 15% in adult infection)

75
Q

How does Hep B present?

A
  • Often subclinical or flu-like illness
  • Acute presentation of jaundice, dark urine or pale stools, rash, polyarthritis, fever, tender hepatomegaly
  • Chronic- decompensated liver disease
76
Q

What measures should be taken to prevent Hep B spread?

A
  • 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

77
Q

How does Hep C prevent?

A
  • Usually asymptomatic or mild
  • Incubation period normally around 6 weeks
  • 80% develop a chronic infection, leading to cirrhosis or hepatocellular carcinoma
78
Q

What tests are available for Hep C?

A

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.

Y4 Obs and Gynae (13 decks)

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