Infections of the reproductive tract Flashcards
Give some examples of STIs
- Chlamydia
- Gonorrhoea
- Genital herpes
- Genital warts
- HIV
- Syphilis
- Trichomoniasis
Give some examples of non STI infections affecting the reproductive tract
- Thrush
- Bacterial vaginosis
What are the sexual behaviours that are risk factors for developing an STI?
- Multiple sexual partners
- Not using barrier contraception
- Early age first intercourse
- Certain sexual practices
- Men who have sex with men
- Sex workers
What are the other risk factors for developing an STI (non-sexual behaviour related)?
- Low socio-economic status
- Race/ethnicity (black Caribbean/African)
- Lack of immunisation (Hep B, HPV)
- Younger age 15-24
Which infections cause discharge in males?
- Discharge comes from urethra
- Chlamydia
- Gonorrhoea
- Non-gonococcal urethritis
Outline Chlamydia trachomatis
- Most common STI in the UK
- Unique cell wall; inhibits phagolysosome fusion (virulence factor)
- Typically asymptomatic in men
- Can cause testicular pain, dysuria
- May have discharge
Outline Neisseria gonorrhoeae
- Gonococcus
- Gram negative
- Diplococci
- Unencapsulated, pilated
- Most men are symptomatic
- Only 50% of women are symptomatic
- Causes thick, yellow discharge +/- dysuria
Outline non-gonococcal urethritis
- Inflammation of urethra with associated discharge
- Not caused by gonorrhoea
- Can be sexually transmitted (chlamydia trichomatis, mycoplasma genitalium, trichomonas vaginalis)
- Can be pathogen negative (less common, older men)
What investigations are done to find out why a man has urethral discharge?
- Gonorrhoea: microscopy and culture, NAATs
- Chlamydia: NAATs (most sensitive and specific)
- Urethritis: NAATs
- Excludes UTI as a cause of dysuria
- Remember to screen for other STIs
Outline physiological discharge
- Progesterone in secretory phase (post-ovulation)
- Thicker cervical mucus
- Cyclical
- No other associations
- Clear
How does N. gonorrhoeae affect women?
- 50% asymptomatic
- Dysuria
- Increased or altered vaginal discharge
- Lower abdominal pain
- Intermenstrual bleeding or menorrhagia
- Dyspareunia
How does C. trachomatis affect women?
- Asymptomatic in 70%
- Increased or purulent vaginal discharge
- Post-coital or intermenstrual bleeding
- Deep dyspareunia
- Dysuria
Outline trichomoniasis infection (trichomonas vaginalis)
- Protozoa (flagellates)
- Presence of flagella allows mobility
- Optimal growth ~pH 6.0 (vaginal pH ~4.0)
- Increased alkalinity of vagina favours acquisition of disease
- Causes copious, yellow, odorous discharge
- Discharge is frothy
- Vulval itching/soreness or ulceration
What is the treatment for trichomoniasis infection (trichomonas vaginalis)?
- Metronidazole
Outline candidiasis (candida albicans)
- Yeast: normal vaginal flora
- Activated in immunocompromised states, diabetes or post antibiotics
- Favours high oestrogen
Outline the symptoms of candidiasis
- Vulval or vaginal itching
- Vulval or vaginal soreness and irritation
- Vaginal discharge (usually white, cheese-like and non-malodorous)
- Superficial dyspareunia
- Dysuria
Outline bacterial vaginosis (Gardnerella)
- Characterised by an overgrowth of predominantly anaerobic organisms
- E.g. Gardnerella vaginalis, prevotella species, mycoplasma hominis
- Vagina loses its normal acidity and vaginal pH increases to greater than 4.5
What are the risk factors for bacterial vaginosis?
- Not an STI; however prevalence is higher amongst sexually active women and in those with a new partner
- Receiving oral sex
- Vaginal washes/douching
- Smoking
What are the symptoms of bacterial vaginosis?
- Fishy-smelling, thin, grey/white homogeneous discharge
- Not associated with itching or soreness
How are STIs investigated in women?
- Chlamydia: vulvo-vaginal swabs (VVS), endocervical swab
- Gonorrhoea: VVS, endocervical swab
- Trichomoniasis: high vaginal swab (HVS) in posterior fornix
- BV: HVS, vaginal pH >4.5, whiff test
- Candida: HVS; microscopy > culture
Define physiological vaginal discharge
- Thickened cervical mucus in latter stage of menstrual cycle
What are the causes of infective vaginal discharge?
- Sexually transmitted e.g. N. Gonorrhoeae, C. trachomatis, T. vaginalis
- Non-sexually transmitted e.g. bacterial vaginosis, candidiasis
Outline HPV
- DNA virus (non-enveloped)
- Can cause genital or cutaneous warts
- Many many different types
- 6 and 11 cause 90% of genital infections
- 16 and 18 have highest association with cervical cancer
- Can do PCR to identify high risk types
- Vaccination exists
Outline herpes simplex virus
- DNA virus (enveloped)
- Lifelong infection
- Initial then recurrent infection
- Can be asymptomatic initially or present with painful ulcers/blisters
- Can be accompanied by systemic symptoms
Which areas need to be checked for evidence of herpes infection?
- Genitals
- Mouth
- Anus
How do we diagnose herpes?
- PCR
- NAATs
How do we manage herpes?
- Management: antivirals e.g. acyclovir
- Cannot eradicate infection
- Reduce severity and duration of current episode
- Limited effect frequency/severity of repeated episodes
Outline syphilis (treponema pallidum)
- Transmitted by direct contact and vertical transmission
- Not as common generally
- 40% co-infected with HIV
What are the symptoms of primary syphilis?
- Typically painless ulcers
What are the symptoms of secondary syphilis?
- 4-10 weeks after initial infection
- Multi-system
- Can enter a latent phase
What are the symptoms of tertiary syphilis?
- 1-46 years after exposure
- Neurological/cardiovascular/gummatous
How do we diagnose syphilis?
- Microscopy
- PCR
- Serology
How do we manage syphilis?
- Penicillin based antibiotics
What is the general management of STIs?
- Co-infections are common
- Consider screening for others
- Consider presenting complaint
- Appropriate investigation and therapy
- Contact tracing
How are bacterial STIs treated?
- Can give multiple antibiotics (co-infections)
- E.g. azithromycin and ceftriaxone
- Targets different organisms
- One antibiotic can augment the effect of the other
How can we educate patients about STIs?
- Barrier contraception
- Other ‘safe sex’ advice
- Avoid sex until course of treatment is completed
How do we treat non-sexually transmitted infections?
- Use appropriate therapy for organism (Candida treated with antifungals and BV treated with antibiotics)
- Try and remove precipitating features
- Patient education (COCP and vaginal hygiene)
Define PID
- Pelvic inflammatory disease is a general term for infection of the upper genital tract
What does PID result from?
Ascending infection from the endocervix causing one or more of the following:
- Endometriosis
- Salpingitis
- Parametritis
- Oophoritis
- Tubo-ovarian abscess
- Pelvic peritonitis
What normally causes PID?
- Chlamydia trachomatis
- Neisseria gonorrhoeae
- Mycoplasma genitalium
- Organisms in normal vaginal flora
What are the symptoms of PID?
- Pelvic pain/lower abdominal pain
- Discharge
- Post coital/intermenstrual bleeding
- Fever
- Dyspareunia
- Right upper quadrant pain due to peri-hepatitis (Fitz-Hugh-Curtis syndrome)
- Secondary dysmenorrhoea
What are the signs of PID?
- Lower abdominal tenderness (usually bilateral)
- Adnexal tenderness (with or without a palpable mass)
- Cervical motion tenderness or uterine tenderness
- Abnormal cervical or vaginal mucopurulent discharge
- Fever greater than 38 0C
What are the differentials for pelvic/lower abdominal pain?
- Ectopic pregnancy
- Appendicitis
- Endometriosis
- Ovarian cyst
- UTI
What are the early complications of PID?
- Sepsis
- Peritonitis
What are the late complications of PID?
- Chronic pelvic pain
- Pelvic abscess
- Can lead to subfertility (adhesions from chronic inflammation, increased risk of ectopic pregnancy, reduced likelihood of successful fertilisation)
- Peritonitis Fitz-Hugh Curtis Syndrome
How is PID managed?
- Admit if unwell
- Start empirical antibiotics as soon as a presumptive diagnosis of PID is made clinically
- Screen for other STIs
- Contact tracing
- Advise re completing course, potential complications, barrier contraceptive
