ILA Sexual health Flashcards
1
Q
What are the key parts of a sexual history?
A
Introduction and explanation of rationale, confidentiality etc
HPC for females:
Dysuria, Abdo or pelvic pain, Abnormal vaginal discharge, Abnormal vaginal bleeding, Genital skin changes, Genital itching or soreness, Dyspareunia
HPC for males:
Dysuria, Urethral dischage, Testicular pain or swelling, Genital skin changes, Genital itching or soreness
Systemic:
- Malaise
- Fever (PID)
- Vomiting
- Weight loss (eg HIV)
- Rash (syphyllis)
- Swelling of joints, conjunctivitis and cervicitis (Reiter’s syndrome and chlamydia)
General sexual history:
• Do you have a regular sexual partner? How long have you been together?
• Any other sexual partners during this time?
• Was this a on-off sexual encounter?
• How many sexual partners have you had in the last year? Five years?
• When was your last sexual encounter
• Did this occur with their consent
• Sex and country of origin of the sexual partner
• Use of contraception? Barrier contraception? Any issues with this eg condom splitting? Was there any point where a condom was not used?
• Type of sex
• Did the sexual partner have any symptoms?
• Ask about the sexual partner’s age
• Previous sexual partners in the last 3 months – ask all the questions above with for each partner
• travel history and sexual partners abroad
2
Q
What questions would you ask specifically about vaginal discharge?
A
- is it different from normal?
- any relationship to the menstrual cycle?
Volume – watery or thick
Colour – green, yellow, blood stained
Consistency
Smell - eg fishy
3
Q
What type of discharge does bacterial vaginosis cause?
A
fishy
4
Q
What type of discharge does thrush cause?
A
thick and white like cottage cheese
5
Q
What type of discharge does trichomoniasis cause?
A
green, yellow or frothy
6
Q
How would discharge present in chlamydia or gonorrhoea cause?
A
with pelvic pain or bleeding
7
Q
Can you get discharge with genital herpes?
A
Yes - discharge plus blisters or sores
8
Q
What questions would you ask about vaginal bleeding?
A
Two types:
- Post-coital bleeding (after intercourse)
- Intermenstrual bleeding (between periods)
Have you noticed any vaginal bleeding after sex or between periods?
9
Q
What questions would you ask about dyspareunia?
A
- location of pain: Does the pain feel within the vagina or deep in your abdomen (tummy)
Superficial – eg genital herpes
Deep – eg gonorrhoea, chlamydia - character of pain: sharp, aching, burning
- how long the pain lasts and when it occurs around intercourse: before, during or after intercourse?
10
Q
What STIs causes of vaginal discharge?
A
Gonorrhoea Chlamydia Trichomonas vaginalis Bacterial vaginosis Genital herpes
11
Q
What are the causes of post-coital bleeding?
A
Cervical cancer
Cervical ectopion
Chlamydia
Gonorrhoea
12
Q
What are the causes of intermenstrual bleeding?
A
chlamydia, gonorrhoea cervical or endometrial cancer Uterine fibroids Endometriosis Hormonal contraception eg Mirena coil Pregnancy
13
Q
What are the causes of dyspareunia?
A
endometriosis STIs - gonorrhoea and chlamydia vaginal atrophy malignancy genital herpes
14
Q
What are the causes of vulval itching or soreness?
A
thrush chlamydia gonorrhoea bacterial vaginosis Herpes lichen sclerosis vaginal atrophy
15
Q
How would you ask about genital skin changes?
A
Have you noticed any skin changes down below? Such as blisters, spots, lumps or ulcers?
Are these tingling or painful or painless?
16
Q
What questions would you ask about periods?
A
LMP
How long do they usually last?
How often? Are they regular and predictable?
Do you get a lot of pain with your periods? Does this interfere with daily activities, work?
Blood clots larger than 10p?
17
Q
What questions would you ask about in PMH, DH and SH of a female with a gynae complaint?
A
PMH females:
- Menstrual history - LMP
- Past gynae history: cervical smear, STIs, ectopic pregnancy, endometriosis, gynae malignancies
- Past obstetrics history: gravida, parity, terminations and how many, currently pregnant
- data of last smear
General PMH:
- previous STIs and that of their sexual partner
- hepatitis vaccine and HPV vaccine
DH
- illicit substances - HIV, hep B
SH
- assess gillick competence if under 16
18
Q
What can cause genital itching and sore skin in men?
A
Candida
Herpes simplex
Genital warts
19
Q
What are the risk factors for STIs?
A
Multiple sexual partners Sex workers Young adult Previous STI Previous termination
20
Q
What type of pathogen is chlamydia?
A
obligate intracellular parasite
21
Q
What STI is the commonest in the UK?
A
Chlamydia - 5-10% of sexually active population
22
Q
How might chlamydia present in females and males?
A
Usually asymptomatic (50-70%) Female - Pelvic pain - Bleeding (post-coital or intermenstrual) - Increased vaginal discharge - dysuria - deep dyspareunia
Male
- dysuria
- urethral discharge
- epididymoorchitis
23
Q
What are the complications of chlamydia?
A
PID Ectopic pregnancy Tubal infertility Chronic pelvic pain Epididimoorchitis in men Reiter's syndrome Neonatal conjunctivitis and pneumonia
24
Q
What are the specific complications of chlamydia in pregnancy?
A
pre-term delivery
chorioamnionitis
25
How would you investigate for chlamydia?
Endocervical swab (done with speculum)
or
first void urine - but reduced sensitivity due to lower organism load in urine
or
vulvovaginal swabs (self-swab)
26
What test is done on the swabs or urine samples for chlamydia?
Nucleic Acid Amplification Tests (NAAT) eg PCR
27
How is chlamydia treated?
- Azithromycin 1g single dose orally
- OR doxycycline 100mg BD for 7 days
- OR erythromycin 500mg QDS for 7 days/500mg BD for 14 days
28
What other things would you think about/advise the pt when treating chlamydia?
- partner notification
- treat sexual partners
- abstain for sex for 7 days after they and their partners are treated
- test for other STIs which often coexist
29
Do you need to test to see whether the pt has been cured of chlamydia and when would this be done?
- no unless they are pregnant or have taken the erythromycin regimen
- dead DNA is still present after treatment for 6 weeks, so wait 3-6 months before testing again
30
What colour is the chlamydia and gonorrhoea swab?
Pink
31
What organism causes gonorrhoea?
Neisseria gonorrhoea
32
What type of organism is gonorrhoea?
Gram-negative diplococcus
33
What areas of the body can gonorrhoea infect?
```
endocervix
urethra
oropharynx
anorectum
Bartholin's glands (women)
Conunctivae in neonates
```
34
What are the symptoms of gonorrhoea in females?
```
Asymptomatic (50%)
Vaginal discharge (50%)
lower abdo pain
dysuria
deep dyspareunia
intermenstrual or post-coital bleeding
signs of PID
disseminated gonococcal infection
```
35
What are the symptoms of gonorrhoea in males?
```
Asymptomatic
purulent urethral discharge
dysuria
epididymitis and prostatitis happen rarely
disseminated gonococcal infection
```
36
What are the symptoms of oropharygeal infection with gonorrhoea?
Sore throat - but is not common
37
What are the symptoms of proctitis with gonorrhoea?
```
Anorectal infections are usually asymptomatic
Anorectal discharge
Discomfort
Bleeding
Tenesmus
```
38
What are the features of disseminated gonoccoal infection?
```
pustular rash
tenosynovitis
arthritis
fever
sometimes: meningitis and endocarditis
```
39
What investigations would you do for gonorrhoea?
endocervical swab (positive in 80-90%)
or
First void urine
or
vulval swab (self-swab)
40
How quickly should a gonorrhoea endocervical swab be sent to the lab?
As quickly as possible
41
What tests are done on the swabs for gonorrhoea?
Culture if endocervical swab
NAAT - Nucleic Acid Amplification Test if first void urine or vulval swab - sensitivity is higher than for culture
42
Can you get false positives when testing for gonorrhoea?
yes with the NAAT testing
43
How would you treat gonorrhoea?
- ceftriaxone 250mg IM single dose
- OR cefixime 400mg PO single dose
You would also treat for chlamydia at the same time with 1g Azithromycin (NICE guidance)
44
Summarise the main treatment for chlamydia and gonorrhoea
Chlamydia
- Azithromycin 1g single dose orally
Gonorrhoea
- ceftriaxone 250mg IM single dose
45
How would you treat upper genital tract infections and disseminated gonorrhoea?
Treat with antibiotics for longer
46
What type of organism causes Trichomoniasis?
Protozoa
47
What is the name of the organism that causes Trichomoniasis?
Trichomonas vaginalis
48
What type of environment does trichomoniasis prefer?
Acid ph - preferentially females are infected affected and transiently infect males
49
What are the symptoms of trichomoniasis in men and women?
Asymptomatic
Vaginal discharge - greenish, yellow and frothy, fishy smell
Signs: inflamed vulva, vagina and cervix (strawberry cervix appearance dye to punctate haemorrhages- colpitis macularis)
Men: usually have no symptoms, but when present have urethral discomfort, dysuria and some urethral discharge
50
How would you investigate for trichomoniasis?
1. Saline wet mount - this is where a drop of vaginal fluid from the posterior fornix is placed on a drop of saline with a coverslip on top
2. or culture - which is the gold standard
51
How would you treat trichomoniasis?
Metronidazole 2g single dose orally
52
would you ask pts with trichomoniasis to return for a test of cure?
Yes at least 1 week after finishing antibiotics
53
What are the consequences of trichomoniasis in pregnancy?
pre-term labour
| pre-term rupture of membranes
54
What types cause genital herpes simplex?
HSV 1 and 2
55
which is the second most common STI in the UK?
Herpes genitalis - ie HSV
56
What are the symptoms and signs of HSV genital infection?
Most are asymptomatic and 80% are unaware of their infection, a lot of women have their recurrent symptoms attributed to other causes eg recurrent thrush
1st episode: extensive genital ulceration, local regional lymphadenopathy, can last 3 weeks untreated
Recurrent episodes: prodromal neuralgia type pain radiating down thigh or buttocks, ulceration lasts 3-5 days
Signs: present initially as vesicles that burst to leave a superficial tender ulcer with a red halo and a greyish white exudate
57
What are the complications of HSV infection?
```
Dissemination to distal sites:
- fingers
- thighs
meningitis
- sacral radiculomyelopathy
- urinary retention
```
58
What factors lead to reactivation of HSV?
Stress
| Menstruation
59
Which type of HSV infections reoccur more often?
HSV-2
60
What investigations would you do for HSV?
Culture or NAAT (PCR) of swab of vesicular fluid or the ulcer base - use viral transport medium
61
How would you treat HSV?
Only need to treat the primary episode: Aciclovir 200mg 5 times daily for 5 days
reccurent episodes are self-limiting and do not need treatment
62
What treatment can you advise in HSV discordant couples?
Daily suppressive treatment with vaciclovir
63
Would you contact trace for HSV?
Not really used as symptoms may develop for the first time many years after infection
64
Which types of HPV are associated with intraepithelial neoplasia but not with exophytic warts?
HPV-16 and 18
65
Which types of HPV are associated with exophytic warts and are low risk?
HPV-6 and 7
66
What are genital warts also known as?
Condylomata acuminata
67
What are they symptoms of HPV infection?
Usually asymptomatic
| Warts are hard, raised and irregular in shape
68
What investigations would you do for genital warts?
Usually a clinical diagnosis
| As always, test for other STIs too
69
How would you treat and manage genital warts including advice?
There is no cure - it is only cosmetic, as the virus remains latent within the basal skin cells
- cryotherapy
- topical therapy
- electrocautery
- surgery
Advise pts to use condoms (but long-term partners are likely to be infected already), but this may not be protective as the virus sheds from a large area
Cervical smears
70
How is HPV transmission prevented?
HPV vaccination for boys and girls aged 12-13
71
What ages are invited for cervical screening and how often?
25-64
25 to 49 every 3 years
50 to 64 every 5 years
65 or older only if 1 of your last 3 tests was abnormal
72
What does the smear test for?
Presence or absence of HPV
73
What two types of positive result are there from the smear?
HPV found but no abnormal cells
| HPV found and abnormal cells
74
What happens if you have a positive result on the smear test for HPV?
HPV found but no abnormal cells
- invited for screening in 1 year and again in 2 years if you still have HPV. If you still have HPV after 3 years, you may need to have a colposcopy.
HPV found and abnormal cells
-colposcopy
75
What is a colposcopy?
medical diagnostic procedure to examine an illuminated, magnified view of the cervix as well as the vagina and vulva - can see malignant and premalignant lesions and take biopsies of lesions
Use aceitic acid to highlight abnormal lesions
Areas of the cervix that turn white after the application of acetic acid or have an abnormal vascular pattern are often considered for biopsy. If no lesions are visible, an iodine solution may be applied to the cervix to help highlight areas of abnormality.
76
What is the causative organism of syphilis and what type of organism is it?
Treponema pallidum
| Spirochete (spiral shaped bacteria)
77
What are the symptoms of primary syhpilis?
painless ulcer - primary chancre
| rubbery regional lyphadenopathy
78
What is the period for primary syphilis?
9-90 days
79
What is the period for secondary syphilis?
6 weeks to 6 months
80
What is the period for tertiary syphilis?
10-40 years
81
Can you get latent syphilis?
Yes
82
When are people most infectious from sphyliis?
in the first 2 years of infection
primary, secondary and early latent stage
83
How does secondary syphyilis present?
```
widespread maculopapular rash - affects palms and soles
generalised lyphadenopathy
mouth ulcers
alopecia
condylomata lata - wart-like lesions
```
84
What investigations would you do for shypilis
screening: Venereal Diseases Research Laboratory (VDRL) carbon antigen test or rapid plasma reagin test (RPR) are recommended for screening.
Smear from the primary lesion may demonstrate spirochaetes on dark field microscopy.
Fluorescent treponemal antibody absorption test (FTA-abs)—reported to be the most sensitive.
85
What are the features of tertiary syphilis?
- Neurosyphillis – tabes dorsalis and dementia
- Cardiovascular syphillis – aortic root
- Gummata – inflammatory plaques or nodules
86
How would you treat syphilis?
penicillin G 750 mg IM for 10 days
87
What type of virus is HPV?
DNA virus
88
What causes bacterial vaginosis?
Overgrowth of mixed anaerobes which replace lactobacilli
89
How do you diagnose bacterial vaginosis?
- Increased vaginal pH >5.5.
- ‘Whiff test’—characteristic fishy smell on adding 10% potassium hydroxide to the discharge.
- Microscopic detection of ‘clue cells’ (squamous epithelial cells with bacteria adherent to their walls).
90
How would you treat bacterial vaginosis?
Metronidazole 2g single dose orally
91
What is thrush?
A commensal diamorphic fungus
92
What are the causes of thrush?
pregnancy
diabetes
OCP
borad spec antibiotics
93
What are the symptoms of thrush in women?
```
vulval itching or soreness
superficial dyspareunia
vaginal discharge
vulval stinging on urination
erythema of vulva and vagina
fissuring and excoriation
White plaques
```
94
How do you treat thrush?
topical antifungal cream eg clotrimaxole
| oral fluconazole single dose
95
What is CIN and what causes it?
Cervical intraepithelial neoplasia - caused by HPV 16 and 18
96
What colour swab would you use for bacterial vaginosis?
black
97
What colour swab would you use for thrush?
black
98
What colour swab would you use for herpes?
green swab
99
What colour swab would you use for chlamydia and gonorrhoea?
pink
100
Which STIs would you test for with a blood test?
HIV
Hep B and C
syphyllis
101
How long does it take to show up on blood tests if you have HIV after exposure?
3 months (this is the quoted window period, but in practice it may be 4-6weeks)
102
How long does it take to show up on swab if you have chlamydia?
2 weeks
103
How long does it take to show up on swab if you have gonnorhoea?
5 days
104
How long does it take to show up on blood tests if you have hep b or c after exposure?
3 months
105
How long does it take to show whether you have syphillis on serology?
3 months (seems to be for the STIs that the blood tests take 3 months and the swabs take days-weeks)
106
What are the symptoms of pelvic inflammatory disease?
temperature
vaginal discharge
dyspareunia
lower abdo pain
107
How would you diagnose PID?
endocervical and high vaginal swabs
| FBC - elevated WCC and CRP
108
How would you treat PID?
outpt treatment - ceftriaxone 500 mg as a single intramuscular (IM) dose, followed by doxycycline and metronidazole for 14 days.
more severe cases need IV treatment in hospital
Do not delay antibiotic treatment while waiting for results as this causes increased risk of complications
109
What conditions cause abnormal vaginal discharge?
```
STIs
Malignancy
Foreign body - retained tampon or swab
Atrophic vaginitis
cervical ectropion
polyps (endocervical)
```
110
What are they key points in the history to ask about in a history of vaginal discharge?
HPC
• Duration (recent change in discharge?).
• Colour (clear, white, green, bloody).
• Consistency (watery, mucoid, frothy, curd-like).
• Amount (is a panty liner or pad required?).
• Associated symptoms (itching, burning, dysuria).
• Relationship of discharge to menstrual cycle.
• Precipitating factors (pregnancy, contraceptive pill).
* Hygiene practices (douches, bath products, talcum powder).
* Sexual history (risk factors for sexually transmitted infections).
PMH
• eg diabetes, genital tract carcinoma
• History of smear tests.
- previous STIs
DH
• Allergies.
111
What aspects of clinical examination may need to be done and why on a woman presenting with vaginal discharge?
Abdominal exam (masses, pain, tenderness).
Speculum:
o appearance of vulva and vagina (red, fissured, rash, excoriations)
o appearance of discharge
o cervix (inflammation, ectropion, evidence of carcinoma).
Bimanual examination (masses, adnexal tenderness, cervical excitation).
112
What types of investigations might you do for vaginal discharge?
tests for STIs eg endocervical swabs, self-swabs, urine test, swabs of lesions
Cervical smear
vaginal ph measurement (for bacterial vaginosis)
113
What type of virus is HIV?
retrovirus
114
Which receptor does HIV use to enter cells?
CD4 receptor
115
Which cells does HIV enter?
lymphocytes
macrophages
microglial cells (macrophages in the CNS)
116
How long can HIV infection by asymptomatic for?
Many years
117
Who are the greatest proportion of pts affected with HIV?
Heterosexual men
118
How does HIV present initially?
Seroconversion illness - presents 1-6weeks after infection
- sore throat
- fever
- rash and orogenital ulceration
(not rhinorrhoea)
119
How might symptomatic HIV infection present?
```
weight loss
fever
fatigue
lymphadenopathy
diarrhoea
night sweats
```
```
reccurrent candiasis either vulvovaginal or oral
Reccurent and extensive genital warts
shingles
oral hairy leukoplakia
moluscum contagiosum
```
120
Name 5 AIDS defining conditions
```
Pneumocystis carinii/jeroveci
Kaposi sarcoma
Oesophageal candiasis
Cerebral toxoplasmosis
CMV - cytomegalovirus
Non-hodgkin's Lyphoma
```
121
What investigations would you do for HIV?
Blood test for anti-HIV antibodies ELISA
or viral antigen
Also test for
- HIV viral load
- CD4 count
- screen for other STIs
122
What are the different classes of HAART that are used to treat HIV?
```
nucleoside anologues (NRTIs)
non-nucleoside analogues (NNRTIs)
neucleotide analogues (NtRTIs)
protease inhibitors
fusion inhibitors
```
123
What prophylaxis is given against PCP and toxoplasmosis until immune recovery occurs on HAART?
Co-trimoxazole
124
What are the other important points in managing HIV other than HAART?
- use condoms to prevent new infections and acquiring resistant forms of HIV from other people
- needle exchange for drug users
125
What are the contraindications to the oral contraceptive pill
Category 4
Migraine with aura
```
History of VTE or current VTE
Known mutations eg factor V Leiden
Smoking ≥15 cigs per day
Current breast cancer
AF
High BP
Vascular disease
Prolonged immobility after major surgery
Pulmonary hypertension
Less than 6 weeks post partum
Severe cirrhosis
Antiphospholipid antibodies
```
126
What is PreP and when is it taken?
Pre-exposure prophylaxis for HIV
| Taken every day before possible exposure
127
Who would use PreP?
People who don't have HIV and are at risk of exposure due to sex or drug use
128
What is PEP and when would you take it?
Post-exposure prophylaxis
