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Phase 3a GP > ILA Sexual health > Flashcards

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

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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
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3
Q

What type of discharge does bacterial vaginosis cause?

A

fishy

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4
Q

What type of discharge does thrush cause?

A

thick and white like cottage cheese

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5
Q

What type of discharge does trichomoniasis cause?

A

green, yellow or frothy

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6
Q

How would discharge present in chlamydia or gonorrhoea cause?

A

with pelvic pain or bleeding

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7
Q

Can you get discharge with genital herpes?

A

Yes - discharge plus blisters or sores

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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?

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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?
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10
Q

What STIs causes of vaginal discharge?

A 
	Gonorrhoea 
	Chlamydia 
	Trichomonas vaginalis  
	Bacterial vaginosis
	Genital herpes
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11
Q

What are the causes of post-coital bleeding?

A

Cervical cancer
Cervical ectopion
Chlamydia
Gonorrhoea

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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
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13
Q

What are the causes of dyspareunia?

A 
endometriosis 
STIs - gonorrhoea and chlamydia 
vaginal atrophy 
malignancy 
genital herpes
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14
Q

What are the causes of vulval itching or soreness?

A 
thrush 
chlamydia 
gonorrhoea
bacterial vaginosis 
Herpes 
lichen sclerosis 
vaginal atrophy
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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?

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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?

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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

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18
Q

What can cause genital itching and sore skin in men?

A

Candida
Herpes simplex
Genital warts

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19
Q

What are the risk factors for STIs?

A 
Multiple sexual partners 
Sex workers 
Young adult
Previous STI 
Previous termination
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20
Q

What type of pathogen is chlamydia?

A

obligate intracellular parasite

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21
Q

What STI is the commonest in the UK?

A

Chlamydia - 5-10% of sexually active population

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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
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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
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24
Q

What are the specific complications of chlamydia in pregnancy?

A

pre-term delivery

chorioamnionitis

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25
Q

How would you investigate for chlamydia?

A

Endocervical swab (done with speculum)

or

first void urine - but reduced sensitivity due to lower organism load in urine

or

vulvovaginal swabs (self-swab)

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26
Q

What test is done on the swabs or urine samples for chlamydia?

A

Nucleic Acid Amplification Tests (NAAT) eg PCR

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27
Q

How is chlamydia treated?

A
  • Azithromycin 1g single dose orally
  • OR doxycycline 100mg BD for 7 days
  • OR erythromycin 500mg QDS for 7 days/500mg BD for 14 days
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28
Q

What other things would you think about/advise the pt when treating chlamydia?

A
  • 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
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29
Q

Do you need to test to see whether the pt has been cured of chlamydia and when would this be done?

A
  • 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
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30
Q

What colour is the chlamydia and gonorrhoea swab?

A

Pink

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31
Q

What organism causes gonorrhoea?

A

Neisseria gonorrhoea

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32
Q

What type of organism is gonorrhoea?

A

Gram-negative diplococcus

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33
Q

What areas of the body can gonorrhoea infect?

A 
endocervix 
urethra 
oropharynx 
anorectum 
Bartholin's glands (women) 
Conunctivae in neonates
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34
Q

What are the symptoms of gonorrhoea in females?

A 
Asymptomatic (50%) 
Vaginal discharge (50%) 
lower abdo pain 
dysuria 
deep dyspareunia 
intermenstrual or post-coital bleeding 
signs of PID 
disseminated gonococcal infection
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35
Q

What are the symptoms of gonorrhoea in males?

A 
Asymptomatic 
purulent urethral discharge 
dysuria 
epididymitis and prostatitis happen rarely 
disseminated gonococcal infection
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36
Q

What are the symptoms of oropharygeal infection with gonorrhoea?

A

Sore throat - but is not common

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37
Q

What are the symptoms of proctitis with gonorrhoea?

A 
Anorectal infections are usually asymptomatic 
Anorectal discharge 
Discomfort 
Bleeding 
Tenesmus
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38
Q

What are the features of disseminated gonoccoal infection?

A 
pustular rash 
tenosynovitis 
arthritis 
fever 
sometimes: meningitis and endocarditis
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39
Q

What investigations would you do for gonorrhoea?

A

endocervical swab (positive in 80-90%)

or

First void urine

or

vulval swab (self-swab)

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40
Q

How quickly should a gonorrhoea endocervical swab be sent to the lab?

A

As quickly as possible

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41
Q

What tests are done on the swabs for gonorrhoea?

A

Culture if endocervical swab

NAAT - Nucleic Acid Amplification Test if first void urine or vulval swab - sensitivity is higher than for culture

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42
Q

Can you get false positives when testing for gonorrhoea?

A

yes with the NAAT testing

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43
Q

How would you treat gonorrhoea?

A
  • 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)

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44
Q

Summarise the main treatment for chlamydia and gonorrhoea

A

Chlamydia
- Azithromycin 1g single dose orally
Gonorrhoea
- ceftriaxone 250mg IM single dose

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45
Q

How would you treat upper genital tract infections and disseminated gonorrhoea?

A

Treat with antibiotics for longer

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46
Q

What type of organism causes Trichomoniasis?

A

Protozoa

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47
Q

What is the name of the organism that causes Trichomoniasis?

A

Trichomonas vaginalis

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48
Q

What type of environment does trichomoniasis prefer?

A

Acid ph - preferentially females are infected affected and transiently infect males

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49
Q

What are the symptoms of trichomoniasis in men and women?

A

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

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50
Q

How would you investigate for trichomoniasis?

A
  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
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51
Q

How would you treat trichomoniasis?

A

Metronidazole 2g single dose orally

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52
Q

would you ask pts with trichomoniasis to return for a test of cure?

A

Yes at least 1 week after finishing antibiotics

53
Q

What are the consequences of trichomoniasis in pregnancy?

A

pre-term labour

pre-term rupture of membranes

54
Q

What types cause genital herpes simplex?

A

HSV 1 and 2

55
Q

which is the second most common STI in the UK?

A

Herpes genitalis - ie HSV

56
Q

What are the symptoms and signs of HSV genital infection?

A

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
Q

What are the complications of HSV infection?

A 
Dissemination to distal sites:
- fingers 
- thighs 
meningitis 
- sacral radiculomyelopathy 
- urinary retention
58
Q

What factors lead to reactivation of HSV?

A

Stress

Menstruation

59
Q

Which type of HSV infections reoccur more often?

A

HSV-2

60
Q

What investigations would you do for HSV?

A

Culture or NAAT (PCR) of swab of vesicular fluid or the ulcer base - use viral transport medium

61
Q

How would you treat HSV?

A

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
Q

What treatment can you advise in HSV discordant couples?

A

Daily suppressive treatment with vaciclovir

63
Q

Would you contact trace for HSV?

A

Not really used as symptoms may develop for the first time many years after infection

64
Q

Which types of HPV are associated with intraepithelial neoplasia but not with exophytic warts?

A

HPV-16 and 18

65
Q

Which types of HPV are associated with exophytic warts and are low risk?

A

HPV-6 and 7

66
Q

What are genital warts also known as?

A

Condylomata acuminata

67
Q

What are they symptoms of HPV infection?

A

Usually asymptomatic

Warts are hard, raised and irregular in shape

68
Q

What investigations would you do for genital warts?

A

Usually a clinical diagnosis

As always, test for other STIs too

69
Q

How would you treat and manage genital warts including advice?

A

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
Q

How is HPV transmission prevented?

A

HPV vaccination for boys and girls aged 12-13

71
Q

What ages are invited for cervical screening and how often?

A

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
Q

What does the smear test for?

A

Presence or absence of HPV

73
Q

What two types of positive result are there from the smear?

A

HPV found but no abnormal cells

HPV found and abnormal cells

74
Q

What happens if you have a positive result on the smear test for HPV?

A

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
Q

What is a colposcopy?

A

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
Q

What is the causative organism of syphilis and what type of organism is it?

A

Treponema pallidum

Spirochete (spiral shaped bacteria)

77
Q

What are the symptoms of primary syhpilis?

A

painless ulcer - primary chancre

rubbery regional lyphadenopathy

78
Q

What is the period for primary syphilis?

A

9-90 days

79
Q

What is the period for secondary syphilis?

A

6 weeks to 6 months

80
Q

What is the period for tertiary syphilis?

A

10-40 years

81
Q

Can you get latent syphilis?

A

Yes

82
Q

When are people most infectious from sphyliis?

A

in the first 2 years of infection

primary, secondary and early latent stage

83
Q

How does secondary syphyilis present?

A 
widespread maculopapular rash - affects palms and soles 
generalised lyphadenopathy 
mouth ulcers 
alopecia 
condylomata lata - wart-like lesions
84
Q

What investigations would you do for shypilis

A

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
Q

What are the features of tertiary syphilis?

A
  • Neurosyphillis – tabes dorsalis and dementia
  • Cardiovascular syphillis – aortic root
  • Gummata – inflammatory plaques or nodules
86
Q

How would you treat syphilis?

A

penicillin G 750 mg IM for 10 days

87
Q

What type of virus is HPV?

A

DNA virus

88
Q

What causes bacterial vaginosis?

A

Overgrowth of mixed anaerobes which replace lactobacilli

89
Q

How do you diagnose bacterial vaginosis?

A
  • 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
Q

How would you treat bacterial vaginosis?

A

Metronidazole 2g single dose orally

91
Q

What is thrush?

A

A commensal diamorphic fungus

92
Q

What are the causes of thrush?

A

pregnancy
diabetes
OCP
borad spec antibiotics

93
Q

What are the symptoms of thrush in women?

A 
vulval itching or soreness 
superficial dyspareunia 
vaginal discharge 
vulval stinging on urination 
erythema of vulva and vagina 
fissuring and excoriation
White plaques
94
Q

How do you treat thrush?

A

topical antifungal cream eg clotrimaxole

oral fluconazole single dose

95
Q

What is CIN and what causes it?

A

Cervical intraepithelial neoplasia - caused by HPV 16 and 18

96
Q

What colour swab would you use for bacterial vaginosis?

A

black

97
Q

What colour swab would you use for thrush?

A

black

98
Q

What colour swab would you use for herpes?

A

green swab

99
Q

What colour swab would you use for chlamydia and gonorrhoea?

A

pink

100
Q

Which STIs would you test for with a blood test?

A

HIV
Hep B and C
syphyllis

101
Q

How long does it take to show up on blood tests if you have HIV after exposure?

A

3 months (this is the quoted window period, but in practice it may be 4-6weeks)

102
Q

How long does it take to show up on swab if you have chlamydia?

A

2 weeks

103
Q

How long does it take to show up on swab if you have gonnorhoea?

A

5 days

104
Q

How long does it take to show up on blood tests if you have hep b or c after exposure?

A

3 months

105
Q

How long does it take to show whether you have syphillis on serology?

A

3 months (seems to be for the STIs that the blood tests take 3 months and the swabs take days-weeks)

106
Q

What are the symptoms of pelvic inflammatory disease?

A

temperature
vaginal discharge
dyspareunia
lower abdo pain

107
Q

How would you diagnose PID?

A

endocervical and high vaginal swabs

FBC - elevated WCC and CRP

108
Q

How would you treat PID?

A

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
Q

What conditions cause abnormal vaginal discharge?

A 
STIs 
Malignancy 
Foreign body - retained tampon or swab 
Atrophic vaginitis 
cervical ectropion 
polyps (endocervical)
110
Q

What are they key points in the history to ask about in a history of vaginal discharge?

A

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
Q

What aspects of clinical examination may need to be done and why on a woman presenting with vaginal discharge?

A

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
Q

What types of investigations might you do for vaginal discharge?

A

tests for STIs eg endocervical swabs, self-swabs, urine test, swabs of lesions

Cervical smear

vaginal ph measurement (for bacterial vaginosis)

113
Q

What type of virus is HIV?

A

retrovirus

114
Q

Which receptor does HIV use to enter cells?

A

CD4 receptor

115
Q

Which cells does HIV enter?

A

lymphocytes
macrophages
microglial cells (macrophages in the CNS)

116
Q

How long can HIV infection by asymptomatic for?

A

Many years

117
Q

Who are the greatest proportion of pts affected with HIV?

A

Heterosexual men

118
Q

How does HIV present initially?

A

Seroconversion illness - presents 1-6weeks after infection

  • sore throat
  • fever
  • rash and orogenital ulceration

(not rhinorrhoea)

119
Q

How might symptomatic HIV infection present?

A 
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
Q

Name 5 AIDS defining conditions

A 
Pneumocystis carinii/jeroveci 
Kaposi sarcoma 
Oesophageal candiasis 
Cerebral toxoplasmosis 
CMV - cytomegalovirus
Non-hodgkin's Lyphoma
121
Q

What investigations would you do for HIV?

A

Blood test for anti-HIV antibodies ELISA
or viral antigen

Also test for

  • HIV viral load
  • CD4 count
  • screen for other STIs
122
Q

What are the different classes of HAART that are used to treat HIV?

A 
nucleoside anologues (NRTIs) 
non-nucleoside analogues (NNRTIs)
neucleotide analogues (NtRTIs)
protease inhibitors
fusion inhibitors
123
Q

What prophylaxis is given against PCP and toxoplasmosis until immune recovery occurs on HAART?

A

Co-trimoxazole

124
Q

What are the other important points in managing HIV other than HAART?

A
  • use condoms to prevent new infections and acquiring resistant forms of HIV from other people
  • needle exchange for drug users
125
Q

What are the contraindications to the oral contraceptive pill

A

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
Q

What is PreP and when is it taken?

A

Pre-exposure prophylaxis for HIV

Taken every day before possible exposure

127
Q

Who would use PreP?

A

People who don’t have HIV and are at risk of exposure due to sex or drug use

128
Q

What is PEP and when would you take it?

A

Post-exposure prophylaxis

Phase 3a GP (7 decks)

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