Male Reproductive and STDs

Question 1

Danger Signals

Pria___

Para______

T_____ Cancer

Pr_____ Cancer

Torsion of the ______ Testis (Blue Dot Sign)

Testicular T_____

F______ Gangrene

Answer 1

Priapism

Paraphimosis

Testicular Cancer

Prostate Cancer

Torsion of the Appendix Testis (Blue Dot Sign)

Testicular Torsion

Fournier’s Gangrene

Question 2

(1)

Male complains of a prolonged and painful erection for several hours (≥2–4 hours) that is not associated with sexual stimulation or desire. Patient may awaken with an erection. It has a bimodal distribution with peak incidence in children aged 5 to 10 years and adults aged 20 to 50 years.

Answer 2

Priapism

Question 3

Priapism

(2) Types

Priapism can be id______ or caused by certain medications and disease states (secondary priapism).

The most common cause in adults (25%) is m______, such as intracavernosal injections to treat erectile dysfunction.

• Males with (1) disease are at very high risk (35%–45%) of ischemic priapism.
• Other risk factors include high doses of _____ dysfunction drugs, coc____, and quadri_____.
• Ischemic priapism is considered a urologic _______.

Answer 3

Types = Ischemic and Nonischemic Priapism

Priapism can be idiopathic or caused by certain medications and disease states (secondary priapism).

The most common cause in adults (25%) is medications, such as intracavernosal injections to treat erectile dysfunction.

• Males with sickle cell disease are at very high risk (35%–45%) of ischemic priapism.
• Other risk factors include high doses of erectile dysfunction drugs, cocaine, and quadriplegia.
• Ischemic priapism is considered a urologic emergency.

Question 4

(1)

Condition when the foreskin cannot be returned back to its original position because of swelling of the head (glans) of the penis. The glans is swollen, reddened, and painful.

Answer 4

Paraphimosis

Question 5

Paraphimosis

The highest incidence is among un______ infants and toddlers.

Treatment =

Answer 5

The highest incidence is among uncircumcised infants and toddlers.

Treatment =

A urologic emergency because may cause ischemic changes, refer to ED. A small slit in the foreskin (with topical anesthesia) can help relieve the pressure.

In severe cases, a circumcision may be needed. Paraphimosis is considered a urologic emergency. Refer to ED.

Question 6

(1)

Teenage to young adult male complains of nodule, sensation of heaviness or aching, one larger testicle, and/or tenderness in one testicle.

Can present as a new onset of a hydrocele (from tumor pressing on vessels). Usually painless and asymptomatic until metastasis.

More common in (1) race males aged ___ to ___years. _____ in African Americans.

Answer 6

Testicular Cancer

Teenage to young adult male complains of nodule, sensation of heaviness or aching, one larger testicle, and/or tenderness in one testicle.

Can present as a new onset of a hydrocele (from tumor pressing on vessels). Usually painless and asymptomatic until metastasis.

More common in White males aged 15 to 30 years. Rare in African Americans.

Question 7

(1)

Older to elderly man complains of a new onset of low-back pain and rectal area/perineal pain or discomfort accompanied by obstructive voiding symptoms such as weaker stream and nocturia. May be asymptomatic. More common in older (>50 years), obese, and African Americans, as well as men with a family history (father, brother).

Answer 7

Prostate Cancer

Question 8

(1)

School-age boy complains of an abrupt onset of a blue-colored round mass located on the testicular surface. The mass resembles a “blue dot.”

Describe the structure, and what causes the blue dot?

Is the cremasteric reflex present?

Most cases in what age of males?

Answer 8

Torsion of Appendix Testis

The appendix testis is a round, small (0.03 cm), pedunculated polyp-like structure that is attached to the testicular surface (on the anterior superior area). The blue dot is caused by infarction and necrosis of the appendix testis due to torsion.

Cremasteric reflex is present, not testicular torsion.

Torsion of the appendix testes rarely happens in adults. Most cases occur in children aged 7 to 14 years (mean age is approximately 10.5 years).

Question 9

(1)

A male (usually adolescent) reports waking up in the middle of the night or in the morning with abrupt onset of an extremely painful and swollen red scrotum, usually <12 hours in duration. Some have inguinal pain or lower abdominal pain as presenting complaint, frequently accompanied by nausea and vomiting.

Affected testicle/scrotum is located ____ and closer to the body than the unaffected testicle. The cremasteric reflex is ______. The majority of cases (two-thirds) occur between the ages of 10 and 20 years. Surgical ______; refer to ED.

Answer 9

Testicular Torsion

Affected testicle/scrotum is located higher and closer to the body than the unaffected testicle. The cremasteric reflex is missing. The majority of cases (two-thirds) occur between the ages of 10 and 20 years. Surgical emergency; refer to ED.

Question 10

(1)

A rare, rapidly progressing polymicrobial necrotizing fasciitis of the external genitalia and the perineum. Diabetes, trauma to the urethral/penile area, and the use of sodium-glucose cotransporter-2 (SGLT2) inhibitors (canagliflozin, dapagliflozin, empagliflozin) increase risk for this infection. Patient will complain of abrupt onset of severe pain, redness, and swelling of the skin in the perineum. It spreads rapidly, and the skin will turn black (gangrene). Can include the scrotum and penis or the labia in females. Considered a surgical emergency; requires surgical debridement and intravenous (IV) antibiotics.

Answer 10

Fournier’s Gangrene

Question 11

Spermatogenesis (Spermarche)

Ideal temperature (for sperm production) is 1°C to 2°C (33.8°F–35.6°F) _____ than core body temperature.

Sperm production begins in late puberty (Tanner stage ___) and continues for the entire lifetime.

Sperms are produced in semi______ tubules of the testes.

Sperms require 64 days (about ___ months) to mature.

Answer 11

Ideal temperature (for sperm production) is 1°C to 2°C (33.8°F–35.6°F) lower than core body temperature.

Sperm production begins in late puberty (Tanner stage IV) and continues for the entire lifetime.

Sperms are produced in seminiferous tubules of the testes.

Sperms require 64 days (about 3 months) to mature.

Question 12

Testes

(1) (undescended testes) increases risk of testicular _______.

Production of testosterone/androgens is stimulated by the release of _______ hormone.

Spermatogenesis is stimulated by both testosterone and (1) hormone.

The _____ testicle usually hangs lower than the _____.

Answer 12

Cryptorchidism (undescended testes) increases risk of testicular cancer.

Production of testosterone/androgens is stimulated by the release of luteinizing hormone.

Spermatogenesis is stimulated by both testosterone and follicle-stimulating hormone.

The left testicle usually hangs lower than the right.

Question 13

Prostate Gland

Heart-shaped gland that _____ throughout the life cycle of the male

Produces prostate-specific antigen (PSA) and prostatic fluid

Prostatic fluid (_____ pH) helps the sperm _____ in the vagina (acidic pH)

Up to ____% of 50-year-old men have (1), an enlargement of the prostate.

Answer 13

Heart-shaped gland that grows throughout the life cycle of the male

Produces prostate-specific antigen (PSA) and prostatic fluid

Prostatic fluid (alkaline pH) helps the sperm survive in the vagina (acidic pH)

Up to 50% of 50-year-old men have benign prostatic hypertrophy (BPH), an enlargement of the prostate.

Question 14

(1)

Coiled tubular organ that is located at the posterior aspect of the testis. It is the storage area for (1). Resembles a “beret” on the upper pole of the testes

Answer 14

Epididymis

Coiled tubular organ that is located at the posterior aspect of the testis. It is the storage area for immature sperm (sperm takes 3 months to mature). Resembles a “beret” on the upper pole of the testes

Question 15

(1)

Tubular structures that transport sperm from the epididymis toward the urethra in preparation for ejaculation. These tubes are cut/clipped during a vasectomy procedure.

Answer 15

Vas Deferens (Ductus Deferens)

Question 16

Cremasteric Reflex

=

This reflex is absent in?

Answer 16

The testicle is elevated toward the body in response to stroking or lightly pinching the ipsilateral inner thigh (or the thigh on the same side as the testicle).

The cremasteric reflex is absent with testicular torsion.

Question 17

(1): Scrotum

Useful for evaluating for undescended testicle (cryptorchidism), hydrocele, spermatocele, and other types of scrotal mass.

How do you perform this test?

Hydrocele =

Testicular tumor =

Varicocele =

Answer 17

Transillumination: Scrotum

Direct a beam of light behind one scrotum (turn off room light

Hydrocele will transilluminate* (serous fluid inside scrotum) and will have a larger glow than unaffected side.

Testicular tumor will not transilluminate (solid tumor blocks light).

Varicocele (“bag of worms”) will not transilluminate.

Question 18

Testicular Cancer

Most common tumor in males aged ___ to ____ years; more common in (1) race males.

Classic Case

T_____ to young adult male complains of nodule, sensation of h_____ess or a___ing, one larger testicle, or tenderness in one testicle. May present as a new onset of a ___cele (from tumor pressing on vessels). Usually painless and asymptomatic until _______.

Answer 18

Most common tumor in males aged 15 to 30 years; more common in White males.

Classic Case

Teenage to young adult male complains of nodule, sensation of heaviness or aching, one larger testicle, or tenderness in one testicle. May present as a new onset of a hydrocele (from tumor pressing on vessels). Usually painless and asymptomatic until metastasis.

Question 19

Testicular Cancer Objective Findings

Affected testicle feels “h______” and more solid

May palpate a h___, fi____ nodule (most common site is the ___er pole of the testes)

Twenty percent of cases will have a concomitant ______.

Answer 19

Affected testicle feels “heavier” and more solid

May palpate a hard, fixed nodule (most common site is the lower pole of the testes)

Twenty percent of cases will have a concomitant hydrocele.

Question 20

Testicular Cancer Diagnosis and Treatment

1st test =

Gold standard of diagnosis =

Refer to (1) for biopsy and management, usually surgical removal (1)*

Answer 20

Ultrasound of the testicle reveals solid mass.

Gold standard of diagnosis: Testicular biopsy

Refer to urologist for biopsy and management; surgical removal (orchiectomy).

Question 21

Testicular Torsion

When the spermatic cord becomes tw_____, the testis’s blood supply is interrupted.

. More common in males with the “**(1) deformity**,” which causes the testicle to lay more _____ways than longitudinally.

• Permanent testicular damage results if not corrected within the first few hours (
• If not corrected within ___ hours, 100% of testicles become gangrenous and must be surgically removed

Answer 21

When the spermatic cord becomes twisted, the testis’s blood supply is interrupted.

. More common in males with the “**bell clapper deformity**” which causes the testicle to lay more sideways than longitudinally.

• Permanent testicular damage results if not corrected within the first few hours (<6 hours).
• If not corrected within 24 hours, 100% of testicles become gangrenous and must be surgically removed

Question 22

Classic Case of Testicular Torsion

An adolescent or adult male reports a sudden onset of s______ testicular pain with an extremely sw_____ red scrotum. Some may have acute ___cele (severe edema). Complains of severe n____ and v_____ . The affected testicle is _____ than the normal testicle. Cremasteric reflex is _____.

Answer 22

An adolescent or adult male reports a sudden onset of severe testicular pain with an extremely swollen red scrotum. Some may have acute hydrocele (severe edema). Complains of severe nausea and vomiting. The affected testicle is higher than the normal testicle. Cremasteric reflex is missing.

Question 23

Testicular Torsion Treatment Plan

Call ____ as soon as possible.

Preferred test in the ED is the Doppler _______ with c_____ flow study.

Treatment can be manual re______ or surgery with testicular f______ using sutures.

Answer 23

Call 911 as soon as possible.

Preferred test in the ED is the Doppler ultrasound with color flow study.

Treatment can be manual reduction or surgery with testicular fixation using sutures.

Question 24

Prostate Cancer

_____ common cancer in men (incidence).

______ American males have a higher risk of prostate cancer. Average age of diagnosis is ___ years.

Risk factors are age older than ___ years, ____ American, ob____, and positive _____history (first-degree relative will double the risk).

USPSTF screening recommendations =

Answer 24

Most common cancer in men (incidence).

African American males have a higher risk of prostate cancer. Average age of diagnosis is 71 years.

Risk factors are age older than 50 years, African American, obesity, and positive family history (first-degree relative will double the risk).

Routine prostate cancer screening (digital rectal exam [DRE] with PSA) is not recommended (U.S. Preventive Services Task Force [USPSTF], 2018).

• Studies show that absolute risk reduction of prostate cancer deaths with screening is very small. Individualize management, based on patient’s risk factors and age.

Question 25

Prostate Cancer Objective Findings

Pain____ and hard fixed _____ (or indurated area) on the prostate gland on an older male that is detected by DRE.

• Elevated PSA: >____ ng/mL
• Diagnostic test:
• Screening test: ____ recommended. If patient wants to be tested, order ____ level with ____; if limited life span (<10 years), ____recommended.

Answer 25

Painless and hard fixed nodule (or indurated area) on the prostate gland on an older male that is detected by DRE.

• Elevated PSA: >4.0 ng/mL
• Diagnostic test: Biopsy of prostatic tissue (obtained by transurethral ultrasound)
• Screening test: Not recommended. If patient wants to be tested, order PSA level with DRE; if limited life span (<10 years), not recommended.

Question 26

Prostate Cancer Treatment Plan

Refer to ______ if PSA >4.0 ng/mL; suspect prostate cancer.

In_______ screening is based on risk factors; discuss risk (bleeding, infection, impotence, procedures, and psychological trauma) versus benefits.

Most cancers are not aggressive and are _____ growing; watchful ______/monitoring by urologist is common.

If symptomatic (nocturia, weak stream, hesitancy, dribbling), (1)Rx (terazosin/Hytrin) are first-line therapy. Initiate drug therapy with anti______ (Proscar), hormone blockers (e.g., Lupron), and others.

Answer 26

Refer to urologist if PSA >4.0 ng/mL; suspect prostate cancer.

Individualize screening is based on risk factors; discuss risk (bleeding, infection, impotence, procedures, and psychological trauma) versus benefits.

Most cancers are not aggressive and are slow growing; watchful waiting/monitoring by urologist is common.

If symptomatic (nocturia, weak stream, hesitancy, dribbling), alpha-blockers (terazosin/Hytrin) are first-line therapy. Initiate drug therapy with antiandrogens (Proscar), hormone blockers (e.g., Lupron), and others.

Question 27

Benign Prostatic Hyperplasia

Seen in ___% of men older than age ___ (up to 80% of men >70 years) and rarely in those younger than age 40; rule out prostate ____.

Use the (1) (AUA) urinary symptom score/(1) (IPSS) questionnaire to assess the severity of the patient’s BPH ______.

Answer 27

Seen in 50% of men older than age 50 (up to 80% of men >70 years) and rarely in those younger than age 40; rule out prostate cancer.

Use the American Urological Association (AUA) urinary symptom score/International Prostate Symptom Score (IPSS) questionnaire to assess the severity of the patient’s BPH symptoms.

Question 28

Classic Case of BPH

Older man complains of gradual development (years) of urinary obstructive symptoms such as weak urinary st____, postvoid dr______, feelings of incomplete em_____, and occasional urinary re______. N___turia is very common.

Answer 28

Older man complains of gradual development (years) of urinary obstructive symptoms such as weak urinary stream, postvoid dribbling, feelings of incomplete emptying, and occasional urinary retention. Nocturia is very common.

Question 29

BPH Objective Findings

PSA is _____ (norm is 0–4 ng/mL).

Prostate that is symm______ in texture and size (r_____ texture) is enlarged.

Lifestyle changes may help decrease symptoms and include reduction of c_____ and al____ intake, avoidance of fluids before ____time, and avoidance of d______ medications (if possible).

Answer 29

PSA is elevated (norm is 0–4 ng/mL).

Prostate that is symmetrical in texture and size (rubbery texture) is enlarged.

Lifestyle changes may help decrease symptoms and include reduction of caffeine and alcohol intake, avoidance of fluids before bedtime, and avoidance of diuretic medications (if possible).

Question 30

Medications for BPH

First Line (1)-(3)

(1) inhibitors -(1)

Answer 30

Alpha-adrenergic antagonist

(Tamsulosin (Flomax), terazosin (Hytrin) 5 mg, doxazosin (Cardura)

5-alpha-reductase inhibitors

Finasteride (Proscar) - binds to prostate gland directly

Question 31

BPH Medications

• Avoid drugs that worsen symptoms:* Anti_____ and s______mimetics (cause urine retention); examples include antihistamines, decongestants, cold medications, caffeine, atropine, antipsychotics, and tricyclic antidepressants (TCA).
• Herbal:* Saw ______ (mild improvement for some); does not work for everyone.

Answer 31

• Avoid drugs that worsen symptoms:* Anticholinergics and sympathomimetics (cause urine retention); examples include antihistamines, decongestants, cold medications, caffeine, atropine, antipsychotics, and tricyclic antidepressants (TCA).
• Herbal:* Saw palmetto (mild improvement for some); does not work for everyone.

Question 32

BPH Medication Notes

Duration of treatment ranges from a few m____ to daily for many ____.

Watch for an adverse effect of alpha-blockers, which is (1)*

Advise patients that they may have ____ness due to low blood pressure (BP).

Patients with ______ and BPH can use alpha-blockers that lower BP (terazosin, doxazosin).

Instruct patients to take medication when?

(1)Rx may have less effect on BP than the other alpha-blockers.

If hypotension is a problem, discontinue and start on a trial of ______ (Proscar)

Answer 32

Duration of treatment ranges from a few months to daily for many years.

Watch for an adverse effect of alpha-blockers, which is orthostatic hypotension.

Advise patients that they may have dizziness due to low blood pressure (BP).

Patients with hypertension and BPH can use alpha-blockers that lower BP (terazosin, doxazosin).

Instruct patients to take medication at bedtime.

Tamsulosin may have less effect on BP than the other alpha-blockers.

If hypotension is a problem, discontinue and start on a trial of finasteride (Proscar)

Question 33

Exam Tips

Finasteride (Proscar) inhibits type 2 (1) (it blocks the androgen receptor) and acts directly on the prostate gland to ____ it (temporarily) while on the medication. If patient stops taking Proscar, the size of the prostate gland returns back to its _______ size.

The prostate shrinks by ____% while on Proscar, so what should PSA levels be adjusted to?

Proscar is a category ___ drug (teratogenic). It should not be touched with bare hands by?

Male with BPH and hypertension: Start with _____-blocker that affects BP (Hytrin, Cardura) first. Works by r_______ smooth muscles on prostate gland and bladder neck.

Answer 33

Finasteride (Proscar) inhibits type 2 5-alpha-reductase (it blocks the androgen receptor) and acts directly on the prostate gland to shrink it (temporarily) while on the medication. If patient stops taking Proscar, the size of the prostate gland returns back to its original size.

The prostate shrinks by 50% while on Proscar (so PSA must be doubled or multiplied by 2).

Proscar is a category X drug (teratogenic). It should not be touched with bare hands by reproductive-aged females (adversely affects male fetus).

Male with BPH and hypertension: Start with alpha-blocker that affects BP (Hytrin, Cardura) first. Works by relaxing smooth muscles on prostate gland and bladder neck.

Question 34

Chronic Bacterial Prostatitis

Chronic >__ weeks infection of the prostate.

Caused most commonly by (2) bacteria

Nonbacterial prostatitis has same symptoms but is culture ______.

More common in younger or older men?

Some men report a history of acute U _ _ or acute bacterial prostatitis. Others are asymptomatic.

Answer 34

Chronic >6 weeks infection of the prostate.

Caused most commonly by Escherichia coli and Proteus.

Nonbacterial prostatitis has same symptoms but is culture negative.

More common in older men.

Some men report a history of acute urinary tract infection (UTI) or acute bacterial prostatitis. Others are asymptomatic.

Question 35

Chronic Bacterial Prostatitis Classic Case

Elderly man with a history of several weeks of ____pubic or perineal discomfort that is accompanied by irritative voiding symptoms such as d___uria, ____turia, and fr_____. ____ accompanied by systemic symptoms. Some men are __symptomatic.

Answer 35

Elderly man with a history of several weeks of suprapubic or perineal discomfort that is accompanied by irritative voiding symptoms such as dysuria, nocturia, and frequency. Not accompanied by systemic symptoms. Some men are asymptomatic.

Question 36

Chronic Bacterial Prostatitis Objective Findings and Labs

Objective Findings

Prostate may feel normal (or slightly “_____”) to palpation; ___ tender

Urinalysis (UA) =

Labs

Collect (2) urine, (1) prostate lab

PSA goes up with BPH, after s____, inf_____, or inflammation.

Transurethral ______ can measure prostate volume.

Answer 36

Objective Findings

Prostate may feel normal (or slightly “boggy”) to palpation; not tender

Urinalysis (UA): Normal (unless patient has prostatitis, epididymitis, cystitis)

Labs

UA, urine culture and sensitivity (C&S), PSA

PSA goes up with BPH, after sexual intercourse, infection, or inflammation.

Transurethral ultrasound can measure prostate volume.

Question 37

Chronic Bacterial Prostatitis Treatment

(1) Rx
* Alternatives* (1)Rx

Refer to (1)

Answer 37

Ciprofloxacin (Cipro) 500 mg PO BID × 4 weeks

Alternatives: Trimethoprim–sulfamethoxazole (Bactrim DS) one tablet PO BID × 1 to 3 months

Refer to urologist

Question 38

Acute Prostatitis

Acute infection of the prostate. Infection ascends into urinary tract. Most common non–sexually transmitted cause is Enterobacteriaceae (2). If condition occurs in a male

Answer 38

Acute infection of the prostate. Infection ascends into urinary tract. Most common non–sexually transmitted cause is Enterobacteriaceae (E. coli, Proteus). If condition occurs in a male <35 years of age, it is treated like gonococcal or chlamydial urethritis.

Question 39

Classic Case of Acute Prostatitis

Adult to older man complains of sudden onset of high _____ and chills with supra____ and/or peri____ pain/discomfort. Pain sometimes radiates to b____ or r_____ .

Accompanied by (1) symptoms such as dysuria, frequency, and nocturia with cl______ urine. DRE reveals extremely t_____ prostate that is warm and b_____. The patient may have an accompanying infection of the bladder (___titis) or _____dymitis.

Answer 39

Adult to older man complains of sudden onset of high fever and chills with suprapubic and/or perineal pain/discomfort. Pain sometimes radiates to back or rectum.

Accompanied by UTI symptoms such as dysuria, frequency, and nocturia with cloudy urine. DRE reveals extremely tender prostate that is warm and boggy. The patient may have an accompanying infection of the bladder (cystitis) or epididymitis.

Question 40

Acute Prostatitis Findings and Labs

Objective Findings

Gently examine prostate; prostate will be extremely t____ and w_____.

Warning: Vigorous palpation and massage of an infected prostate can cause (1).

Labs

Complete blood count (CBC): ____cytosis with shift to the ___(presence of band cells)

UA: Large amount of (1) cells (pyuria), h____turia

Urine C&S: If possible, also obtain urine after gentle prostatic m______.

Answer 40

Objective Findings

Gently examine prostate; prostate will be extremely tender and warm.

Warning: Vigorous palpation and massage of an infected prostate can cause bacteremia.

Labs

Complete blood count (CBC): Leukocytosis with shift to the left (presence of band cells)

UA: Large amount of white blood cells (pyuria), hematuria

Urine C&S: If possible, also obtain urine after gentle prostatic massage.

Question 41

Acute Prostatitis Medications

• Based on age and presumptive organism:*
• Age <35 years (or high risk for STD):* (1) + (1) x 10 days
• Age >35 years or unlikely sexual transmission*: (1) or (1) or (1) × 10 to 14 days (minimum); some experts recommend __ to __ weeks of therapy

Answer 41

• Age <35 years (or high risk for STD):* Ceftriaxone 250 mg IM and doxycycline 100 mg BID × 10 days
• Age >35 years or unlikely sexual transmission*: Ciprofloxacin or ofloxacin PO BID or levofloxacin (Levaquin) by mouth daily × 10 to 14 days (minimum); some experts recommend 4 to 6 weeks of therapy

Question 42

Acute Prostatitis Medications

• Antip______, stool softener without laxative (1), s____ baths, hydration
• Patient should be hospitalized if s_____ or toxic.

Answer 42

• Antipyretics, stool softener without laxative (Colace), sitz baths, hydration
• Patient should be hospitalized if septic or toxic.

Question 43

Acute Bacterial Epididymitis

Bacteria as_____ the urethra (urethritis) and reach the epididymis, causing an infection. Also known as bacterial epididymo-orchitis. Rule out testicular t_____ (can mimic condition).

• Sexually active males <35 years:* More likely to be infected with an?
• Males >35 years:* Usually due to gram-negative (1)

Answer 43

Bacteria ascend the urethra (urethritis) and reach the epididymis, causing an infection. Also known as bacterial epididymo-orchitis. Rule out testicular torsion (can mimic condition).

• Sexually active males <35 years:* More likely to be infected with an STD (chlamydia, gonorrhea)
• Males >35 years:* Usually due to gram-negative E. coli

Question 44

Acute Bacterial Epididymitis Classic Case

Adult to older man complains of acute onset of a swollen red sc_____ that hurts. Accompanied by unilateral testicular t_____ness with urethral discharge. Scrotum is sw____ and ery______ with induration of the posterior epididymis. Sometimes accompanied by a hydrocele and signs and symptoms of UTI. May have systemic symptoms such as fever.

Discharge: _____-colored purulent or serous _____ (e.g., chlamydia, viral, chemical)

Positive Prehn’s sign =

Answer 44

Adult to older man complains of acute onset of a swollen red scrotum that hurts. Accompanied by unilateral testicular tenderness with urethral discharge. Scrotum is swollen and erythematous with induration of the posterior epididymis. Sometimes accompanied by a hydrocele and signs and symptoms of UTI. May have systemic symptoms such as fever.

Discharge: Green-colored purulent or serous clear (e.g., chlamydia, viral, chemical)

Positive Prehn’s sign: Relief of pain with scrotal elevation

Question 45

Acute Bacterial Epididymitis Labs

• CBC:* ____cytosis
• UA:* Leukocytes (__uria), blood (_____turia), ni____

Urine (1) & (1)

Urine NAAT for (1) and (1)

Answer 45

• CBC:* Leukocytosis
• UA:* Leukocytes (pyuria), blood (hematuria), nitrites

Urine C&S

Urine nucleic acid amplification test (NAAT) for gonorrhea and chlamydia

Question 46

Acute Bacterial Epididymitis Medications

• Age <35 years (or suspect STD):* (1) + (1), do not forget to treat (1)
• Age >35 years:* (1) or (1), caution patient regarding (1)

Answer 46

• Age <35 years (or suspect STD):* Doxycycline orally twice a day × 10 days plus ceftriaxone 250 mg intramuscularly × one dose; do not forget to treat sex partner.
• Age >35 years:* Ofloxacin (Floxin) 300 mg orally × 10 days or levofloxacin (Levaquin) 500 mg orally × 10 days; caution patient regarding risk of tendon injury and discourage vigorous lower extremity exercise while on fluoroquinolone.

Question 47

Acute Bacterial Epididymitis Medications

Treat pain with (1) (ibuprofen, naproxen) or acetaminophen with codeine (severe pain)

Employ scrotal el______ and scrotal ___packs; bed ___ for few days

Give stool softeners (e.g., (1)Rx) if constipated

Refer to ED if s_____, severe intractable pain, abscessed, and so forth

Answer 47

Treat pain with NSAIDs (ibuprofen, naproxen) or acetaminophen with codeine (severe pain)

Employ scrotal elevation and scrotal ice packs; bed rest for few days

Give stool softeners (e.g., docusate sodium or Colace) if constipated

Refer to ED if septic, severe intractable pain, abscessed, and so forth

Question 48

Erectile Dysfunction

Erectile dysfunction is the inability to produce an erection f___ enough to perform sexual intercourse.

There are several kinds of male sexual dysfunction. Incidence increases with ____: men aged 50 to 59 (18%), men aged 60 to 69 (25%), men aged 70 to 79 (37%), and men aged 80 to 89 (80%).

In men 50 years or older, it is more likely to be related to org____ causes. Check medication history; contraindication is n______.

Answer 48

Erectile dysfunction is the inability to produce an erection firm enough to perform sexual intercourse.

There are several kinds of male sexual dysfunction. Incidence increases with age: men aged 50 to 59 (18%), men aged 60 to 69 (25%), men aged 70 to 79 (37%), and men aged 80 to 89 (80%).

In men 50 years or older, it is more likely to be related to organic causes. Check medication history; contraindication is nitrates.

Question 49

Erectile Dysfunction

• (1) cause:* Inability to have a satisfactory erection. Can be caused by aging, neurologic (diabetic neuropathy, multiple sclerosis [MS], spinal cord damage), vascular or hormonal (hypogonadism), or other disorders.
• (1)-induced:* SSRIs (especially (1)]), antipsychotics, recreational drugs, alcohol (large amount), _____-blockers, thiazide diuretics. If smoker, advise smoking cessation.
• (1) cause:* Spontaneously has early-morning erection or normal nocturnal tumescence or can achieve a firm erection with masturbation. Can be caused by performance anxiety, depression, relationship issues, and stress.
• Reduced l______:* Affects 5% to 15% of men, increases with age.

Check cremasteric reflex; if missing, rule out n_____ causes.

Answer 49

• Organic* cause: Inability to have a satisfactory erection. Can be caused by aging, neurologic (diabetic neuropathy, multiple sclerosis [MS], spinal cord damage), vascular or hormonal (hypogonadism), or other disorders.
• Drug-induced:* SSRIs (especially paroxetine [Paxil]), antipsychotics, recreational drugs, alcohol (large amount), beta-blockers, thiazide diuretics. If smoker, advise smoking cessation.
• Psychogenic cause:* Spontaneously has early-morning erection or normal nocturnal tumescence or can achieve a firm erection with masturbation. Can be caused by performance anxiety, depression, relationship issues, and stress.
• Reduced libido:* Affects 5% to 15% of men, increases with age.

Check cremasteric reflex; if missing, rule out neurologic causes.

Question 50

Erectile Dysfunction Labs

Rule out (1) (FBG, A1C), (1)disorder (TSH), morning serum (1)

Answer 50

Rule out diabetes (FBG, A1C), thyroid disorder (TSH), morning serum testosterone

Question 51

Erectile Dysfunction Medications

First Line (1)-**(3)

Answer 51

Phosphodiesterase type 5 inhibitor drug class

• Sildenafil citrate (Viagra)*
• Vardenafil (Levitra)*
• Tadalafil (Cialis)*

Question 52

Sildenafil citrate (Viagra)

• 25/50/100 mg; take one dose when before sex? duration of ____ hours; use only ____ dose every 24 hours.
• Another use for sildenafil is for ______ hypertension (brand name Revatio).
• Do not Viagra with Revatio or guanylate cyclase-C medications such as riociguat (Adempas); it will cause severe ____tension.

Answer 52

• 25/50/100 mg; take one dose 30 to 60 minutes before sex; duration of 4 hours; use only one dose every 24 hours.
• Another use for sildenafil is for pulmonary hypertension (brand name Revatio).
• Do not combine Viagra with Revatio or guanylate cyclase-C medications such as riociguat (Adempas); it will cause severe hypotension.

Question 53

Sildenafil citrate (Viagra)

Careful with a____-blockers, history of MI in past 6 months, or unstable _____; risk of h______.

Do not use with drugs that prolong ___ interval (macrolides).

Advise patient to take medication on an ____ stomach and avoid _____ foods for optimal effectiveness; food and fats de____ drug action.

Warning: Viagra can decrease blood flow to the optic nerve, causing sudden _____ loss; it has occurred in patients with diabetes, heart disease, hypertension, or other preexisting eye problems.

Answer 53

Careful with alpha-blockers, history of myocardial infarction (MI) in past 6 months, or unstable angina; risk of hypotension.

Do not use with drugs that prolong QT interval (macrolides).

Advise patient to take medication on an empty stomach and avoid fatty foods for optimal effectiveness; food and fats delay drug action.

Warning: Viagra can decrease blood flow to the optic nerve, causing sudden vision loss; it has occurred in patients with diabetes, heart disease, hypertension, or other preexisting eye problems.

Question 54

ED Meds

• Vardenafil (Levitra):* Take one dose __ to __ minutes before sex; duration is __ hours.
• Tadalafil (Cialis):* 5 mg to 20 mg; can be taken several hours before sex due to _____ duration (up to 36 hours); may also be prescribed as a daily dose for combined BPH and erectile dysfunction (5–10 mg).

Answer 54

• Vardenafil (Levitra):* Take one dose 30 to 60 minutes before sex; duration is 4 hours.
• Tadalafil (Cialis):* 5 mg to 20 mg; can be taken several hours before sex due to long duration (up to 36 hours); may also be prescribed as a daily dose for combined BPH and erectile dysfunction (5–10 mg).

Question 55

ED Meds Notes

• Contraindications:* Concomitant n______ (increase hypertensive effects). Use caution with ____-blockers, recent post-M__, post–___ accident, major surgery, or any condition in which exertion is contraindicated. Avoid combining with grapefruit juice or alcoholic drinks.
• Adverse effects:*
• Other forms of treatment:* V_____-assisted erection devices, penile self-injection (intra______ injection of alprostadil), penile im______, (1) (for psychogenic cause).

Answer 55

• Contraindications:* Concomitant nitrates (increase hypertensive effects). Use caution with alpha-blockers, recent post-MI, post–cerebrovascular accident, major surgery, or any condition in which exertion is contraindicated. Avoid combining with grapefruit juice or alcoholic drinks.
• Adverse effects:* May cause headache, facial flushing, dizziness, hypotension, nasal congestion, priapism, or changes in vision.
• Other forms of treatment:* Vacuum-assisted erection devices, penile self-injection (intracavernosal injection of alprostadil), penile implant, cognitive behavioral therapy (for psychogenic cause).

Question 56

Exam Tips

Learn to distinguish between chronic and acute prostatitis

Chronic is of gradual onset; prostate can feel ____ with DRE (older males).

Acute prostatitis presents as ____ onset; prostate is sw_____ and very t_____ (younger males).

Selective serotonin reuptake inhibitors (SSRIs) cause erectile dysfunction in men. The SSRI that has the highest risk of erectile dysfunction is (1)

Answer 56

Learn to distinguish between chronic prostatitis and acute prostatitis.

Chronic is of gradual onset; prostate can feel normal with DRE (older males).

Acute prostatitis presents as sudden onset; prostate is swollen and very tender (younger males).

Selective serotonin reuptake inhibitors (SSRIs) cause erectile dysfunction in men. The SSRI that has the highest risk of erectile dysfunction is paroxetine (Paxil)

Question 57

Peyronie’s Disease

An inflammatory and localized disorder of the penis that results in f______ plaques on the t_____ alb_____.

Results in penile pain that primarily occurs during _____; palpable n_____ and penile deformity (cr____ penile erections) occur. May resolve sp______ in small number of cases, but nearly half of cases worsen over time. There are psychological issues because it can affect a man’s ability to have an erection, which can be dis______. S_____ correction if needed.

Answer 57

An inflammatory and localized disorder of the penis that results in fibrotic plaques on the tunica albuginea.

Results in penile pain that primarily occurs during erection; palpable nodules and penile deformity (crooked penile erections) occur. May resolve spontaneously in small number of cases, but nearly half of cases worsen over time. There are psychological issues because it can affect a man’s ability to have an erection, which can be distressing. Surgical correction if needed.

Question 58

Peyronie’s Disease Diagnosis and Treatment

Any labs needed for diagnosis?

Treatment =

Answer 58

None; clinical diagnosis is used.

Refer patient to urologist.

Question 59

(1)

Candidal infection of the glans penis.

When the foreskin (prepuce) is involved, it is called (1).

More common in un______ men, di_____, and/or _____compromised men.

Use of (1) inhibitors for diabetes management, such as canagliflozin (Invokana), dapagliflozin (Farxiga), and empagliflozin (Jardiance), increases the risk of balanitis, UTIs, and vaginal yeast infection.

Answer 59

Balanitis

Candidal infection of the glans penis.

When the foreskin (prepuce) is involved, it is called balanoposthitis.

More common in uncircumcised men, diabetics, and/or immunocompromised men.

Use of SGLT2 inhibitors for diabetes management, such as canagliflozin (Invokana), dapagliflozin (Farxiga), and empagliflozin (Jardiance), increases the risk of balanitis, UTIs, and vaginal yeast infection.

Question 60

Classic Case of Balanitis

Complains of ____ness, p___, tenderness, or pr_____ of the g____ and/or f______ that developed over 3 to 7 days. Physical exam of penis will show redness and shallow _____ with c_____-like discharge on the glans penis.

Answer 60

Complains of redness, pain, tenderness, or pruritis of the glans and/or foreskin that developed over 3 to 7 days. Physical exam of penis will show redness and shallow ulcers with curd-like discharge on the glans penis.

Question 61

Balanitis Treatment

=

Answer 61

Treated with topicalazole creams (OTC) such as clotrimazole 1% or miconazole 2% twice daily for 7 to 14 days. If partner has candidiasis, treat at the same time.

Question 62

(1)

Testicle that does not descend spontaneously by 4 months of age.

Up to 30% premature infants are born with undescended testes. Can affect both or only one testicle. Majority (70%) will descend spontaneously by age ___ months. Markedly increases the risk of (1). Usually corrected during infancy. Look for e_____ scrotal sac.

Answer 62

Cryptorchidism

Up to 30% premature infants are born with undescended testes. Can affect both or only one testicle. Majority (70%) will descend spontaneously by age 12 months. Markedly increases the risk of testicular cancer. Usually corrected during infancy. Look for empty scrotal sac.

Question 63

(1)

defined as the inability to retract the skin (foreskin or prepuce) covering the head (glans) of the penis

Physiologic phimosis =

Pathologic phimosis =

Answer 63

Phimosis

Physiologic phimosis = is seen in almost all newborn males and is considered normal (Figure 1A). The foreskin should not be red or swollen. Avoid forcible retraction, because it can cause tearing, which will cause scarring and development of pathologic phimosis.

Pathologic phimosis = is when the foreskin is truly nonretractable. The foreskin cannot be pushed back from the glans penis because of inflammation. In adults it is due to chronic inflammation and edema of the foreskin. It can complicate sexual function, voiding, and hygiene. Refer to urologist.

Question 64

(1)

When the foreskin cannot be returned back to its original position because of swelling of the head (glans) of the penis.

The glans is swollen, reddened, and painful. It may not return back to its original state.

The highest incidence is among ___circumcised in_____ and toddlers.

Answer 64

Paraphimosis

The glans is swollen, reddened, and painful. It may not return back to its original state.

The highest incidence is among uncircumcised infants and toddlers.

Question 65

Paraphimosis Treatment

=

What can be done to relieve pressure?

What may be needed in severe cases?

Answer 65

Urologic Emergency - Refer to ED- because it may cause ischemic changes

A small slit in the foreskin (with topical anesthesia) can help relieve the pressure.

In severe cases, a circumcision may be needed.

Question 66

(1)

Varicose veins in scrotal sac (feels like “bag of worms”) New-onset can signal testicular ____ (20%) or a mass that is impeding venous drainage.

Diagnostic =

Can contribute to male (1) if large enough (increases temperature of affected testicle).

Treatment is (1) of varicosities if infertile. Most benign varicoceles are ____ sided.

Answer 66

Varicose veins in scrotal sac (feels like “bag of worms”) New-onset can signal testicular tumor (20%) or a mass that is impeding venous drainage.

US of scrotum

Can contribute to male infertility if large enough (increases temperature of affected testicle).

Treatment is surgical removal of varicosities if infertile. Most benign varicoceles are left sided.

Question 67

Abnormal Varicocele

Unilateral ____-sided varicoceles may be indicative of a tumor inside the chest, abdomen, or pelvis that is compressing a large vein, such as the vena cava.

Another abnormal finding is a varicocele that does not reduce (or drain) in the ____ position.

Benign varicoceles reduce in volume when the patient is supine due to the blood draining (gravity) from the abnormally dilated scrotal veins.

Answer 67

Unilateral right-sided varicoceles may be indicative of a tumor inside the chest, abdomen, or pelvis that is compressing a large vein, such as the vena cava.

Another abnormal finding is a varicocele that does not reduce (or drain) in the supine position.

Benign varicoceles reduce in volume when the patient is supine due to the blood draining (gravity) from the abnormally dilated scrotal veins.

Question 68

(1)

Serous fluid collects inside the tunica vaginalis. During scrotal exam, located superior and anterior to the testes. Most are asymptomatic.

More common in _______; most cases resolve ______.

Answer 68

Hydrocele

More common in newborns; most cases resolve spontaneously.

Question 69

Hydrocele Diagnosis and Treatment

Diagnosis =

Treatment =

Answer 69

Will glow with transillumination. The glow is larger on the affected scrotum compared with the unaffected scrotum.

If complaints of testicular pain and scrotal swelling or new-onset hydrocele in an adult or enlarging hydrocele, order scrotal Doppler ultrasound to rule out tumor, testicular hematoma, rupture, testicular torsion, orchitis, or epididymitis. Refer to urologist.

Question 70

(1)

An epididymal cyst) is a fluid-filled cyst that contains nonviable sperm.

Transillumination Test =

Imaging of Choice =

What does it feel like on palpation?

Do they effect fertility?

Treatment only if? by what?

Answer 70

Spermatocele

Will transilluminate bc filled with fluid

Imaging of choice = US

It can be palpated as a separate smooth and firm lump at the head of the epididymis, which lies above and behind each testicle.

Spermatoceles do not affect fertility.

They are treated only if they cause pain, discomfort, or embarrassment (surgical excision).

Question 71

Danger Signals

Acute ____ Infection (Acute Retroviral Syndrome)

Acquired _______ Syndrome

D______ Gonococcal Infection

Answer 71

Acute HIV Infection (Acute Retroviral Syndrome)

Acquired Immunodeficiency Syndrome

Disseminated Gonococcal Infection

Question 72

Acute HIV Infection (Acute Retroviral Syndrome)

An estimated 10% to 60% of individuals with early HIV infection may be asymptomatic. It takes approximately __ to __ weeks to develop symptoms.

The initial immune response may mimic ____nucleosis (fever, headache, sore throat, lymphadenopathy, rash, joint ache, myalgia) and may be accompanied by di____ and weight ___. May have painful ____ative lesions in the mouth due to HIV or from coinfection with herpes simplex, syphilis, or chancroid.

Very inf_____ due to extremely ____ viral load (>100,000 copies/mL) in blood and genital secretions. Most people (97%) develop antibodies within 3 months after exposure.

If acute HIV infection is strongly suspected, order the HIV ____ polymerase chain reaction (____) test, which can detect infection 7 to 28 days after exposure.

Answer 72

An estimated 10% to 60% of individuals with early HIV infection may be asymptomatic. It takes approximately 2 to 4 weeks to develop symptoms.

The initial immune response may mimic mononucleosis (fever, headache, sore throat, lymphadenopathy, rash, joint ache, myalgia) and may be accompanied by diarrhea and weight loss. May have painful ulcerative lesions in the mouth due to HIV or from coinfection with herpes simplex, syphilis, or chancroid.

Very infectious due to extremely high viral load (>100,000 copies/mL) in blood and genital secretions. Most people (97%) develop antibodies within 3 months after exposure.

If acute HIV infection is strongly suspected, order the HIV RNA polymerase chain reaction (PCR) test, which can detect infection 7 to 28 days after exposure.

Question 73

Acquired Immunodeficiency Syndrome

Without treatment, people with AIDS typically survive about __ years. Without antiretroviral therapy, HIV infection usually advances to AIDS within __ years.

AIDS is defined by an absolute CD4 cell count of fewer than ____ cells/mm³along with certain opp______ infections and malignancies.

CD4 levels in healthy people range from ___ to _____ cells/mm³.

Signs and symptoms that suggest AIDS include those caused by AIDS-defining opportunistic infections such as oral can_____, tub______, Pneumocystis j______ pneumonia, central nervous system (CNS) tox_______, h____plasmosis, cryptosporidiosis, K_____ sarcoma (purple to bluish-red bumps on the skin), and many others.

P. _______ is the infection that causes the most deaths in patients with HIV.

Answer 73

Without treatment, people with AIDS typically survive about 3 years. Without antiretroviral therapy, HIV infection usually advances to AIDS within 10 years.

AIDS is defined by an absolute CD4 cell count of fewer than 200 cells/mm³along with certain opportunistic infections and malignancies.

CD4 levels in healthy people range from 500 to 16,000 cells/mm³.

Signs and symptoms that suggest AIDS include those caused by AIDS-defining opportunistic infections such as oral candidiasis, tuberculosis, Pneumocystis jirovecii pneumonia, central nervous system (CNS) toxoplasmosis, histoplasmosis, cryptosporidiosis, Kaposi’s sarcoma (purple to bluish-red bumps on the skin), and many others.

P. jirovecii is the infection that causes the most deaths in patients with HIV.

Question 74

Disseminated Gonococcal Infection

A very s____ percentage (0.5%–3.0%) of individuals with gonococcal infection may progress to disseminated gonococcal infection (DGI).

Sexually active adult from high-risk population complains of pet____ or pus____ s___lesions of h____/s____ (ac___ lesions); tenos______; and swollen, red, and tender j_____.

In young, healthy patients with ____-onset polyarthr____, polyarthr____, or oligoarthritis (arthritis in one large joint such as the knee), DGI is one of the most common causes. Look for the characteristic ____ lesions of DGI (Figure 1). May be accompanied by signs of STD (e.g., cervicitis, urethritis).

If pharyngitis, will have severe sore throat with g____ purulent throat exudate that does ____ respond to usual antibiotics used for strep throat.

Occasionally complicated by perihepatitis ((1) syndrome) and rarely endocarditis or meningitis. Refer to ______ disease specialist.

Answer 74

A very small percentage (0.5%–3.0%) of individuals with gonococcal infection may progress to disseminated gonococcal infection (DGI).

Sexually active adult from high-risk population complains of petechial or pustular skin lesions of hands/soles (acral lesions); tenosynovitis; and swollen, red, and tender joints.

In young, healthy patients with new-onset polyarthralgias, polyarthritis, or oligoarthritis (arthritis in one large joint such as the knee), DGI is one of the most common causes. Look for the characteristic skin lesions of DGI (Figure 1). May be accompanied by signs of STD (e.g., cervicitis, urethritis).

If pharyngitis, will have severe sore throat with green purulent throat exudate that does not respond to usual antibiotics used for strep throat.

Occasionally complicated by perihepatitis (Fitz-Hugh–Curtis syndrome) and rarely endocarditis or meningitis. Refer to infectious disease specialist.

Question 75

STD Screening (CDC)

Complications of untreated STD/sexually transmitted infection (STI) are inf____, e_____ pregnancy, con_____ infections, cervical c_____, chronic pelvic pain, chronic h____titis, chronic sy_____, and HIV/____.

Some STDs such as (3) can be passed from mother to infant during vaginal delivery. Others such as HIV, herpes, syphilis, and hepatitis can cause serious con______ infections in the fetus.

There are approximately 20 million new STD infections every year; almost half are in young people aged __ to ___.

Answer 75

Complications of untreated STD/sexually transmitted infection (STI) are infertility, ectopic pregnancy, congenital infections, cervical cancer, chronic pelvic pain, chronic hepatitis, chronic syphilis, and HIV/AIDS.

Some STDs such as chlamydia, gonorrhea, and genital herpes can be passed from mother to infant during vaginal delivery. Others such as HIV, herpes, syphilis, and hepatitis can cause serious congenital infections in the fetus.

There are approximately 20 million new STD infections every year; almost half are in young people aged 15 to 24.

Question 76

STD Screening (CDC)

Routine Annual Screening for who?

If infected, when to retest for chlamydia and gonorrhea after treatment to test for cure?

Annual testing for syphilis, chlamydia, and gonorrhea in persons with (1)

Do minors need parental consent for clinic visits related to testing or treating STDs and birth control?

STD screening includes obtaining the sexual history and assessment of risk factors for STDs; think of the five Ps =

Physical exam for STDs includes inspection of the sk___, ph____, ____nodes, anus, pelvic/genital area, and n______ system.

Answer 76

Routine annual screening of all sexually active females aged 25 years or younger for Chlamydia trachomatis and gonorrhea.

If infected, retest for chlamydia and gonorrhea 3 months after treatment (to check for reinfection, not for test-of-cure).

Annual testing for syphilis, chlamydia, and gonorrhea in persons with HIV infection.

Minors do not need parental consent if the clinic visit is related to testing or treating STDs and birth control; no state requires parental consent for STD care.

STD screening includes obtaining the sexual history and assessment of risk factors for STDs; think of the five Ps (partners, practices, protection, past history of STDs, and prevention of pregnancy).

Physical exam for STDs includes inspection of the skin, pharynx, lymph nodes, anus, pelvic/genital area, and neurologic system.

Question 77

Men Who Have Sex With Men STD Screening

Annual screening for (2) at sites of contact (urethra, rectum), regardless of condom use. Screen every 3 to 6 months if at increased risk.

Annual screening recommended for _____ gonorrhea (throat). Screen every 3 to 6 months if at increased risk.

Annual testing recommended for H__, sy_____, and (1) surface antigen. Retest more frequently if at risk.

If history of anal-receptive intercourse, an ano____ can be offered as part of STD care.

Answer 77

Annual screening for chlamydia and gonorrhea at sites of contact (urethra, rectum), regardless of condom use. Screen every 3 to 6 months if at increased risk.

Annual screening recommended for pharyngeal gonorrhea (throat). Screen every 3 to 6 months if at increased risk.

Annual testing recommended for HIV, syphilis, and hepatitis B surface antigen (HBsAg). Retest more frequently if at risk.

If history of anal-receptive intercourse, an anoscopy can be offered as part of STD care.

Question 78

Pregnant Women STD Screening

Screen pregnant women for H__, ch____, g____, s____, and HB____ at first prenatal visit.

Pregnant women treated for chlamydia and/or gonorrhea should have a test-of-cure within __ to __ weeks after treatment.

Retest at ___ months for chlamydia and gonorrhea (check for reinfection, not test-of-cure).

Answer 78

Screen pregnant women for HIV, chlamydia, gonorrhea, syphilis, and HBsAg at first prenatal visit.

Pregnant women treated for chlamydia and/or gonorrhea should have a test-of-cure within 3 to 4 weeks after treatment.

Retest at 3 months for chlamydia and gonorrhea (check for reinfection, not test-of-cure).

Question 79

STD RISK FACTORS

Younger ages (_____ aged __–__ years); sex initiated at a younger age

Mult______ sexual partners; n___ sexual partner in past 60 days

Inconsistent c_____ use; unm____ status

H_____ of previous STD infection; illicit ____ use

Genital ul______ (increases risk of HIV transmission)

Use of al____ or illicit drugs

Ad______

Answer 79

Younger ages (females aged 15–24 years); sex initiated at a younger age

Multiple sexual partners; new sexual partner in past 60 days

Inconsistent condom use; unmarried status

History of previous STD infection; illicit drug use

Genital ulceration (increases risk of HIV transmission)

Use of alcohol or illicit drugs

Adolescents

Question 80

Chlamydia Trachomatis

C. trachomatis is the ____ common bacterial STD in the United States.

Most chlamydial infections are symptomatic? The highest prevalence is among persons ___ years of age or younger.

It is an obligate intracellular bacteria (__typical bacteria).

Annual screening of all sexually active ____ younger than ___years of age is recommended, as is screening of older women at increased ___ for infection (e.g., those who have a new sexual partner, more than one sexual partner, a sexual partner with concurrent partners, or a sexual partner with an STI (CDC)

During ____ prenatal visit, screen all pr_____ women <25 years and older pregnant women at increased risk. Rescreen younger women <25 years of age in the ____ trimester.

Answer 80

C. trachomatis is the most common bacterial STD in the United States.

Most chlamydial infections are asymptomatic. The highest prevalence is among persons 25 years of age or younger.

It is an obligate intracellular bacteria (atypical bacteria).

Annual screening of all sexually active women younger than 25 years of age is recommended, as is screening of older women at increased risk for infection (e.g., those who have a new sexual partner, more than one sexual partner, a sexual partner with concurrent partners, or a sexual partner with an STI (CDC)

During first prenatal visit, screen all pregnant women <25 years and older pregnant women at increased risk. Rescreen younger women <25 years of age in the third trimester.

Question 81

Chlamydia Trachomatis Possible Sites of Infection and Complications

• Females:* C___tis, e___metritis, s____gitis (fallopian tubes), _____ inflammatory disease (PID)
• Males:* E____ymitis, p____tatitis
• Both genders:* Ur____ritis, ph____gitis, pr___titis (from receptive anal intercourse)
• Complications:* P_ _ , tubal sc_____, ec_____ pregnancy, in____, R_____ syndrome (males), F___-H___–Curtis syndrome

Answer 81

• Females:* Cervicitis, endometritis, salpingitis (fallopian tubes), pelvic inflammatory disease (PID)
• Males:* Epididymitis, prostatitis
• Both genders:* Urethritis, pharyngitis, proctitis (from receptive anal intercourse)
• Complications:* PID, tubal scarring, ectopic pregnancy, infertility, Reiter’s syndrome (males), Fitz-Hugh–Curtis syndrome

Question 82

Labs (Both Gonorrhea and Chlamydia)

(1)

highly sensitive tests for both gonorrhea and chlamydia. Be careful to use the correct testing kit. Swab samples (vagina, cervix, urethra, rectum, pharynx) or urine specimen can be collected for both males and females.

Answer 82

Nucleic acid amplification tests (NAATs)

Question 83

NAATS for Gonorrhea and Chlamydia

Who should collect vaginal swabs, the provider or patient? Is there a difference?

What is the preferred diagnostic test for men?

For pharynx or rectum swab using (1). Another option for gonorrhea is a gonorrhea (1) (Thayer-M____ or Chocolate ____) which can take __-__ days

What about chlamydia cultures?

Answer 83

Vaginal swab specimens can be collected by a provider or self-collected in a clinical setting. Self-collected vaginal swab specimens are equivalent in sensitivity and specificity to those collected by a clinician using NAATs

Urine specimen collected from first part (15-20mL) of first void of the day is the preferred diagnostic test for men

For samples from pharynx or rectum, swab using a NAAT test. Another option for gonorrhea is to order gonorrheal culture (Thayer–Martin or chocolate agar), which can take 2 to 3 days.

Chlamydial cultures are not used in primary care (use NAAT test).

Question 84

(1) (symptomatic men):

If patient shows ___itis symptoms, obtain this. Polymorphonuclear leukocytes with gram-negative intracellular diplo____ can be used for males with ________ urethritis (considered diagnostic). Not commonly used in primary care.

Answer 84

Gram stain (symptomatic men):

If patient shows urethritis symptoms, obtain Gram stain. Polymorphonuclear leukocytes with gram-negative intracellular diplococci can be used for males with gonorrheal urethritis (considered diagnostic). Not commonly used in primary care.

Question 85

• Uncomplicated Chlamydia Treatment Plan*
• (Cervicitis, Urethritis [Nongonococcal Urethritis], Sexual Partners)*

(2)

Answer 85

Azithromycin 1 g PO in a single dose (directly observed therapy preferred)

or

Doxycycline 100 mg BID × 7 days

Question 86

Doxycycline for Chlamydia Notes

Category __ drug (____ growing tooth enamel)

How should you advise the patient to take this medication? why?

Can cause nausea, GI upset, and ____sensitivity (patient education to?)

Answer 86

Category D drug (stains growing tooth enamel)

Swallow with large amount of water; doxycycline may cause esophagitis if tablet gets stuck in throat (difficulty and/or pain with swallowing, acute-onset heartburn, nausea/vomiting).

Nausea, gastrointestinal (GI) upset, photosensitivity (avoid sun or use sunscreen)

Question 87

Azithromycin and Doxycycline for Chlamydia Notes

If patient is treated with the one dose of azithromycin, how long does it take for treatment to be effective?

If cervicitis, perform (1) to assess if infection ascended to upper genital tract, you are ruling out (1)

Should you test for cure after azithro or doxycycline regimen?

Answer 87

Azithromycin = 7 days for treatment to be effective

Cervicitis → perform bimanual to rule out PID

No test of cure necessary for azithro/doxy regimen

Question 88

Treatment of Sexual Partners (Chlamydia)

Do you treat the sexual partner? if so with what?

What else should you advise the couple to do?

Do you have to physically see/evaluate the partner to treat them? What is this practice called?

Answer 88

Yes, treat with Azithromycin 1g PO single dose

Abstain from sex for 7 days

Do not have to physically see the partner to treat, this practice is called Expedited Partner Therapy (EPT) - permissible in 45 states

Question 89

Treatment of Pregnant Women with Chlamydia

(1) or (1)

Do you have to test for cure, if so when? Retest again for chlamydia when?

Answer 89

Azithromycin 1 g PO in a single dose or

Amoxicillin 500 mg PO TID × 7 days

Test-of-cure recommended 3 to 4 weeks after treatment and retest again in the third trimester

Question 90

Neisseria Gonorrhoeae

A gram-negative bacteria that infects the urinary and genital tracts, anorectum, ph____, and conj_____ (gonococcal ophthalmia neonatorum).

What is the difference between when gonorrhea is left untreated vs. chlamydia?

Do you need to cotreat for chlamydia?

• (1) gender are more likely to be asymptomatic or present with PID.
• (1) gender are more likely to present with urethritis.

During first ______ visit, screen all pregnant women

Answer 90

A gram-negative bacteria that infects the urinary and genital tracts, anorectum, pharynx, and conjunctiva (gonococcal ophthalmia neonatorum).

Unlike chlamydia, gonorrhea can become systemic or disseminated if left untreated.

Cotreat for chlamydia only when chlamydial infection has not been excluded. Do not cotreat if chlamydia status is confirmed negative.

• Women are more likely to be asymptomatic or present with PID.
• Males are more likely to present with urethritis.

During first prenatal visit, screen all pregnant women <25 years, and older pregnant women at increased risk. Rescreen again in the third trimester if high risk.

Question 91

Classic Case of Neisseria Gonorrhoeae

Sexually active f____ who is __ years of age with history of a new sexual partner (<3 months) or multiple partners with inconsistent or no condom use.

During the speculum examination, cervix can appear normal or with pur_____ discharge and may bleed easily (fr_____).

Males with urethritis may have penile discharge and ___uria and may report staining of underwear with gr_____ purulent discharge. Signs and symptoms depend on the sites infected.

Answer 91

Sexually active female who is 25 years of age with history of a new sexual partner (<3 months) or multiple partners with inconsistent or no condom use.

During the speculum examination, cervix can appear normal or with purulent discharge and may bleed easily (friable).

Males with urethritis may have penile discharge and dysuria and may report staining of underwear with green purulent discharge. Signs and symptoms depend on the sites infected.

Question 92

Neisseria Gonorrhoeae S/S by Site

Cervicitis = (mucop______ cervix, pain, mild bl_____ after intercourse)

Urethritis = (scant to copious pur_____ discharge, d___uria, frequency, urgency)

Proctitis = (pruritus, r_____ pain, tenes____, urge to defecate even if rectum is empty, or avoidance of defecation due to pain)

Pharyngitis = (severe sore throat unresponsive to typical antibiotics, pur_____ gr____-colored discharge on the posterior pharynx)

B______ gland abscess = (cystic lump that is red and warm [or has purulent discharge] that is located on each side of the introitus or vestibule)

Answer 92

Cervicitis = (mucopurulent cervix, pain, mild bleeding after intercourse)

Urethritis = (scant to copious purulent discharge, dysuria, frequency, urgency)

Proctitis = (pruritus, rectal pain, tenesmus, urge to defecate even if rectum is empty, or avoidance of defecation due to pain)

Pharyngitis = (severe sore throat unresponsive to typical antibiotics, purulent green-colored discharge on the posterior pharynx)

Bartholin’s gland abscess = (cystic lump that is red and warm [or has purulent discharge] that is located on each side of the introitus or vestibule)

Question 93

Neisseria Gonorrhoeae S/S by Site

Endometritis (menometrorrh____, or heavy, prolonged menstrual bl____)

_______ gonococcal infection results in petechial or pustular ____ lesions of the hands/fingers, asymmetric poly_____, tenosynovitis, oligoarticular septic arth______ (arthritis-dermatitis syndrome), or m___ngitis or e____carditis

PID signs, symptoms, and treatment discussed under the section “C______ Gonorrheal Infections”

E_____ymitis and pr___tatitis

Answer 93

Endometritis (menometrorrhagia, or heavy, prolonged menstrual bleeding)

Disseminated gonococcal infection results in petechial or pustular skin lesions of the hands/fingers, asymmetric polyarthralgia, tenosynovitis, oligoarticular septic arthritis (arthritis-dermatitis syndrome), or meningitis or endocarditis

PID signs, symptoms, and treatment discussed under the section “Complicated Gonorrheal Infections”

Epididymitis and prostatitis

Question 94

Labs for Gonorrhea

(1)

Alternative is gonococcal culture by (2)

Do you need to retest after treatment?

Answer 94

NAATS

. Another alternative is a gonococcal culture (Thayer–Martin medium/ Chocolate agar)

Retesting recommended at 3 months after treatment for all patients (due to high rates of reinfection)

Question 95

Syphilis

Screen for syphilis if H___ infection, men (1), presence of any genital ul___ (especially if painless chancre), previous STD, pr_____, intravenous ____ use, or high risk.

Majority of patients are (1) gender (90%). Treponema pallidum (spirochete) infection becomes _____ if untreated.

Answer 95

Screen for syphilis if HIV infection, MSM, presence of any genital ulcer (especially if painless chancre), previous STD, pregnancy, intravenous drug use, or high risk.

Majority of patients are male (90%). Treponema pallidum (spirochete) infection becomes systemic if untreated.

Question 96

Classic Case of Syphilis

S/S dependent on stage of infection

• Primary =* (1)
• Secondary (more than 2y) =* (2)
• Latent Stage =*
• Tertiary (3-10 years) =* (4)

Answer 96

• Primary =* Painless chancre (heals in 6–9 weeks if not treated), Chancre has clean base, well demarcated with indurated margins
• Secondary (more than 2y) =* Condyloma lata (infectious white papules [that look like white warts] in moist areas), Maculopapular rash on palms and soles that is not pruritic (may be generalized
• Latent Stage =* Asymptomatic but will have positive titers
• Tertiary (3-10 years) =* Neurosyphilis, gumma (soft tissue tumors), aneurysms, valvular damage

Question 97

Syphilis Labs

Treponemal Tests (2)

Nontreponemal Tests (3)

Answer 97

Treponemal Tests

1. RPR (rapid plasma reagin)
2. VDRL (Venereal Disease Research Laboratory)

Nontreponemal Tests

1. FTA-ABS (Fluorescent treponemal antibody absorption)
2. MHA-TP (microhemagglutination test for antibodies to T. pallidum)
3. TPPA (T. pallidum particle agglutination assay)

Question 98

Syphilis Labs

• Step 1*
• Step 2*

Diagnostic for syphilis =

Answer 98

• Step 1 =* order nontreponemal tests (RPR, VLDRL), if reactive order confirmatory test
• Step 2 =* order these confirmatory tests (FTA-ABS, MHA-TP, TPPA, darkfield microscopy not used anymore)

Diagnostic for syphilis = If both RPR or VDRL (nontreponemal test) and FTA-ABS (or other treponemal test) are reactive

Question 99

Syphilis Lab Monitoring

Depending on what test you order, what lab test should you use to monitor treatment response?

What trend in the titers will show treatment response?

Answer 99

Use the same laboratory to monitor during treatment, if initial test used is RPR, order sequential RPR to document treatment response. If initial test is VDRL, order sequential VDRL.

Decrease in titers shows treatment response, If RPR or VDRL shows a fourfold or higher (>1:4)

Question 100

Syphilis Treatment

(1) Rx

Answer 100

Benzathine penicillin G

(Bicillin L-A) 2.4 million units IM × one dose

Question 101

Primary Syphilis (Chancre), Secondary Syphilis, or Early Latent Syphilis (<1 Year)

Benzathine penicillin G (Bicillin L-A) 2.4 million units IM × how many doses?

Latent Syphilis (>1 Year), Latent Unknown Duration, Tertiary Without Evidence of Neurosyphilis

Benzathine penicillin G 2.4 million units IM how many doses?

Answer 101

Primary Syphilis (Chancre), Secondary Syphilis, or Early Latent Syphilis (<1 Year)

Benzathine penicillin G (Bicillin L-A) 2.4 million units IM × one dose

Latent Syphilis (>1 Year), Latent Unknown Duration, Tertiary Without Evidence of Neurosyphilis

Benzathine penicillin G 2.4 million units IM once per week × 3 consecutive weeks

Question 102

Syphilis Treatment If Penicillin Allergy

Rx (1) or (1) × 28 days,

For neurosyphilis, Rx (1)

use these therapies with close clinical and laboratory follow-up; refer to specialist

Answer 102

Doxycycline or tetracycline × 28 days,

For neurosyphilis, ceftriaxone

use these therapies with close clinical and laboratory follow-up; refer to specialist

Question 103

Syphilis Treatment in Pregnancy

=

Answer 103

Same treatment as nonpregnant. For penicillin-allergic patients, refer to allergist for penicillin desensitization.

Screen all pregnant women; repeat at 28 weeks and at delivery.

Question 104

Follow Up after Syphilis Treatment

When should you recheck labs after treatment?

What amount of decrease are you looking at in pre and post treatment titers?

Should you treat sexual partners, even if labs negative? Test patient and partner for H___ and other STDs?

When should you refer to infectious disease specialist?

Answer 104

6 and 12 months after

Fourfold decrease

Treat sexual partner(s) from previous 90 days before patient’s diagnosis, even if their RPR or VDRL is negative. Test patient and partner(s) for HIV and other STDs.

Refer to infectious disease specialist for suspected neurosyphilis, poor response to treatment, penicillin allergy, or if primary clinician is not familiar with syphilis management.

Question 105

Exam Tips

R___ and V____ are the screening tests for syphilis.

If positive RPR or VDRL (nontreponemal test), confirm with (1) (treponemal test). If r____ RPR and reactive FTA-ABS, this is d______ for syphilis.

Learn treatment of PID and proctitis = (3)

Answer 105

RPR and VDRL are the screening tests for syphilis.

If positive RPR or VDRL (nontreponemal test), confirm with FTA-ABS (treponemal test). If reactive RPR and reactive FTA-ABS, this is diagnostic for syphilis.

Learn treatment of PID and proctitis.

• Ceftriaxone (Rocephin) 500 mg IM × one dose plus
• Doxycycline 100 mg PO BID × 14 days plus
• Metronidazole (Flagyl) 500 mg PO BID × 14 days (for anaerobic coverage)

Question 106

Exam Tips

Do not confuse condyloma ______ (genital warts) with condyloma _____ (secondary syphilis).

Know tertiary syphilis treatment =

Acute retroviral syndrome (or primary HIV infection) with ___-like or m____-like infection is very infectious at this stage of HIV infection. Best if HIV is treated as ____ as possible.

Answer 106

Do not confuse condyloma acuminata (genital warts) with condyloma lata (secondary syphilis).

Know tertiary syphilis treatment = Benzathine penicillin G 2.4 million units IM weekly for 3 consecutive weeks

Acute retroviral syndrome (or primary HIV infection) with flu-like or mono-like infection is very infectious at this stage of HIV infection. Best if HIV is treated as early as possible.

Question 107

Clinical Pearls

NAAT can remain positive for __-__ weeks after treatment because of the presence of nonviable organisms.

(1) RPR can be caused by pregnancy, Lyme disease, autoimmune diseases, or chronic or acute disease.

Recheck syphilitic chancre in __ to __ days after injection (should start healing).

Answer 107

NAAT can remain positive for 2 to 3 weeks after treatment because of the presence of nonviable organisms.

False-positive RPR can be caused by pregnancy, Lyme disease, autoimmune diseases, or chronic or acute disease.

Recheck syphilitic chancre in 3 to 7 days after injection (should start healing).

Question 108

Clinical Pearls

Nontreponemal (2) usually decline after treatment, but in some people can?

Most patients with reactive nontreponemal tests will be reactive for how long? but 15% to 25% revert to being serologically nonreactive in __ to __ years.

Answer 108

Nontreponemal titers (RPR or VDRL) usually decline after treatment, but in some persons, nontreponemal antibodies can persist for a long time (serofast reaction).

Most patients with reactive nontreponemal tests will be reactive for the rest of their lives (low titers), but 15% to 25% revert to being serologically nonreactive in 2 to 3 years.

Question 109

CDC–Recommended STD Treatment Regimens

(3)

Answer 109

• Chlamydia trachomatis*
• Neisseria Gonorrhoeae*
• Treponema pallidum*

Question 110

Chlamydia trachomatis

Uncomplicated Infections

• Indications*: Mucopurulent c_____itis, u____ritis, sexual _____ treatment
• Treatment*: (1) or (1)
• Pregnancy*: (1)

Answer 110

• Indications*: Mucopurulent cervicitis, urethritis, sexual partner treatment
• Treatment*: Azithromycin 1 g × one dose or doxycycline 100 mg BID × 7 days
• Pregnancy*: Azithromycin 1 g × one dose

Question 111

Chlamydia trachomatis

Complicated Infections

• Indications*: P___, s____itis, tubo-ov___ abscess, e____mitis, p____titis, m____
• Treatment*: (1) 100 mg BID × ___ days

Answer 111

• Indications*: PID, salpingitis, tubo-ovarian abscess, epididymitis, prostatitis, males
• Treatment*: Doxycycline 100 mg BID × 14 days

Question 112

Gonorrhea

Uncomplicated Infections

• Indications*: Mucopurulent c_____itis, u____itis, p___titis, sexual ____ treatment
• Treatment*: (1)
• Weight ≥150 kg (300 lb*): Ceftriaxone __ g IM × one dose

Answer 112

• Indications*: Mucopurulent cervicitis, urethritis, proctitis, sexual partner treatment
• Treatment*: Ceftriaxone 500 mg IM × one dose
• Weight ≥150 kg (300 lb)*: Ceftriaxone 1 g IM × one dose

Question 113

Gonorrhea Complicated Infections

Indications: P___, s____gitis, t___-ovarian abscess, e____mitis, o___itis, pr___itis, dis______ gonorrhea, asymmetric a___ritis and maculopapular r____, m____

Treatment: (1)× one dose plus (1) × ___days plus (1) 500 mg BID × 14 days

Answer 113

Indications: PID, salpingitis, tubo-ovarian abscess, epididymitis, orchitis, prostatitis, disseminated gonorrhea, asymmetric arthritis and maculopapular rash, males

Treatment: Ceftriaxone 500 mg IM × one dose plus doxycycline 100 mg BID × 14 days plus metronidazole 500 mg BID × 14 days

Question 114

Syphilis Uncomplicated Infections

• Indications*: P____ or s_____ syphilis or ____ latent <1 year, sexual ____ treatment
• Treatment*: (1) 2.4 mU IM × one dose

_____ if clinical signs recur or sustained fourfold titers

Answer 114

• Indications*: Primary or secondary syphilis or early latent <1 year, sexual partner treatment
• Treatment*: Benzathine penicillin G 2.4 mU IM × one dose

Retreat if clinical signs recur or sustained fourfold titers

Question 115

Syphilis Complicated Infections

• Indications*: __1-year duration or l____syphilis, n_____syphilis; refer
• Treatment*: Benzathine penicillin G 2.4 mU IM weekly × __ consecutive weeks

______-up of cases is mandatory (any stage of disease)

Answer 115

• Indications*: >1-year duration or latent syphilis, neurosyphilis; refer
• Treatment*: Benzathine penicillin G 2.4 mU IM weekly × 3 consecutive weeks

Follow-up of cases is mandatory (any stage of disease)

Question 116

Uncomplicated Gonorrheal Infections

Of the Cervix, Urethra, Rectum, and Pharynx

First-Line Therapy

________ (Rocephin) ____mg IM × one dose. If weight ≥150 kg (300 lb), ceftriaxone (Rocephin) ___ g IM × one dose.

If chlamydial infection has not been excluded, cotreat with _______ 100 mg PO BID × 7 days. During pregnancy, _______ 1 g PO × one dose.

If NAAT for chlamydia is negative?

Answer 116

Ceftriaxone (Rocephin) 500 mg IM × one dose. If weight ≥150 kg (300 lb), ceftriaxone (Rocephin) 1 g IM × one dose.

If chlamydial infection has not been excluded, cotreat with doxycycline 100 mg PO BID × 7 days. During pregnancy, azithromycin 1 g PO × one dose.

Do not cotreat if NAAT for chlamydia is negative.

Question 117

Uncomplicated Gonorrheal Infections

When do you not need to test for cure after treatment of uncomplicated gonorrhea?

When do you NEED to test for cure? and when do you test after treatment?

Answer 117

test-of-cure is unnecessary for uncomplicated urogenital or rectal gonorrhea.

test of cure NECESSARY for pharyngeal gonorrhea,

test-of-cure 7 to 14 days after initial treatment, using using culture or NAAT, is recommended regardless of the treatment regimen.

Question 118

Gonorrhea Management of Sexual Partners

Treat male partners of women with ___ if sexual contact during the __ days preceding the patient’s symptoms.

Can the couple continue having sexual intercourse?

Answer 118

Treat male partners of women with PID if sexual contact during the 60 days preceding the patient’s symptoms.

Avoid sex until both partners finish treatment and no longer have symptoms.

Question 119

Complicated Gonorrheal Infections Treatment

Pelvic Inflammatory Disease, Acute Epididymitis, Acute Prostatitis, Acute Proctitis

(3)

Answer 119

Ceftriaxone (Rocephin) 500 mg IM × one dose plus

Doxycycline 100 mg PO BID × 14 days plus

Metronidazole (Flagyl) 500 mg PO BID × 14 days (for anaerobic coverage)

Question 120

Complicated Gonorrheal Infection Treatment

Disseminated Gonococcal Infection (Arthritis-Dermatitis Syndrome, Meningitis, Endocarditis)

=

Answer 120

Refer to ED or infectious disease specialist for hospitalization.

Question 121

Pelvic Inflammatory Disease Risk Factors

______ of PID: ___% recurrence

M_____ partners

Age ___ years or younger

Answer 121

History of PID: 25% recurrence

Multiple partners

Age 25 years or younger

Question 122

Classic Case of PID

Acute onset of lower ab_____ or p____ pain that is one-sided or bilateral. Painful intercourse (dys______), with adnexal pain and cervical motion _____ness on bimanual exam. Inflammation of (1) (salpingitis). May walk in a sh______ gait to avoid jarring pelvis, which is painful. Jumping/r______ aggravates pelvic pain. Some develop peritonitis and tubo-ovarian pelvic ______.

Answer 122

Acute onset of lower abdominal or pelvic pain that is one-sided or bilateral. Painful intercourse (dyspareunia), with adnexal pain and cervical motion tenderness on bimanual exam. Inflammation of fallopian tubes (salpingitis). May walk in a shuffling gait to avoid jarring pelvis, which is painful. Jumping/running aggravates pelvic pain. Some develop peritonitis and tubo-ovarian pelvic abscess.

Question 123

PID Labs

Reproductive-aged females: Rule out ______ first.

• Women can insert a swab inside the vagina for (1) test (vaginal fluid).
• Both men and women can obtain (1) specimen for NAAT by using initial urinary stream (____ urine of the day).
• Gonorrhea testing (anaerobic _____), such as the Thayer–Martin or chocolate agar, is an alternative to test for r____ or ph_____ infection.

Answer 123

Reproductive-aged females: Rule out pregnancy first.

• Women can insert a swab inside the vagina for NAAT test (vaginal fluid).
• Both men and women can obtain urine specimen for NAAT by using initial urinary stream (first urine of the day).
• Gonorrhea testing (anaerobic cultures), such as the Thayer–Martin or chocolate agar, is an alternative to test for rectum or pharynx infection.

Question 124

Pelvic Inflammatory Disease Gram Stain

Useful only for (1)

Look for (1)

Answer 124

Gonorrheal Urethritis

Gram-negative diplococci in clusters inside polymorphonuclear leukocytes.

Question 125

PID Test for Other STDs

H___, s_____, HB____, H___-2

Treat partners? Okay to have sex?

Answer 125

HIV, syphilis, hepatitis B (HBsAg), HSV-2

Partners should be tested and treated; no sex until both complete treatment.

Question 126

Unusual Complications

(1)

Complication of PID (10%). Chlamydial and/or gonococcal infection ascend to the liver capsule (not the liver itself). There is extensive scarring between the liver capsule and abdominal contents (e.g., colon). Scars look like “____ strings” (seen on laparoscopy).

Answer 126

Fitz-Hugh-Curtis Syndrome (Perihepatitis)

Complication of PID (10%). Chlamydial and/or gonococcal infection ascend to the liver capsule (not the liver itself). There is extensive scarring between the liver capsule and abdominal contents (e.g., colon). Scars look like “violin strings” (seen on laparoscopy).

Question 127

Fitz-Hugh–Curtis Syndrome (Perihepatitis) Classic Case

Sexually active female with symptoms of P____ complains of (1) quadrant abdominal pain and tenderness on palpation. The liver function tests are _____.

Treated as a complicated gonorrheal/chlamydial infection (1) IM once plus (1) 14 days plus (1) × 14 days

Answer 127

Sexually active female with symptoms of PID complains of right upper quadrant (RUQ) abdominal pain and tenderness on palpation. The liver function tests are normal.

Treated as a complicated gonorrheal/chlamydial infection (ceftriaxone [Rocephin] 500 mg IM plus doxycycline PO BID × 14 days plus metronidazole [Flagyl] 500 mg PO BID × 14 days).

Question 128

(1)

Warn patients being treated for syphilis that within a few hours (peaks in 6–8 hours), they may experience a host immune reaction due to destruction of T. pallidum

Answer 128

Jarisch–Herxheimer Reaction (Perihepatitis)

Question 129

Jarisch–Herxheimer Reaction (Perihepatitis) S/S and Tx

Host immune reaction that happens when you are being treated for ______ (dt destruction of T.pallidum)

The reaction can also occur with _____ disease (caused by Borrelia burgdorferi, a spirochete-type bacteria) and leptospirosis (Weil’s disease, swamp fever).

The symptoms are f____, chills, headache, my____, ____cardia, and __crease in respiratory rate.

It is a ____-limited reaction.

Treatment is with general _______ measures such as antipyretics/NSAIDs and corticosteroids.

Answer 129

Host immune reaction that happens when you are being treated for syphilis (dt destruction of T.pallidum)

The reaction can also occur with Lyme disease (caused by Borrelia burgdorferi, a spirochete-type bacteria) and leptospirosis (Weil’s disease, swamp fever).

The symptoms are fever, chills, headache, myalgia, tachycardia, and increase in respiratory rate.

It is a self-limited reaction.

Treatment is with general supportive measures such as antipyretics/NSAIDs and corticosteroids.

Question 130

(1) (Reactive Arthritis)

A rare disease that is more common in males and young adults. An immune-mediated reaction secondary to infection with certain bacteria (e.g., chlamydia, salmonella, shigella, campylobacter, yersinia) that spontaneously resolves. form of arthritis that affects the joints, eyes, urethra (the tube that carries urine from the bladder to the outside of the body), and skin. Treatment is supportive (e.g., NSAIDs).

Answer 130

Reiter’s Syndrome (Reactive Arthritis)

Question 131

Reiter’s Syndrome (Reactive Arthritis) Classic Case

A male with current history of chlamydia genital infection (e.g., ur___ritis) complains of red and swollen ____ that come and go (mig_____ arthritis in large joints such as knee) and ulcers on the skin of the glans penis.

Mnemonic: “I can’t see (1), pee (1), or climb up a tree (1).”

Answer 131

A male with current history of chlamydia genital infection (e.g., urethritis) complains of red and swollen joints that come and go (migratory arthritis in large joints such as knee) and ulcers on the skin of the glans penis.

Mnemonic: “I can’t see (conjunctivitis), pee (urethritis), or climb up a tree (migratory arthritis in large joints such as the knee).”

Question 131

Reiter’s Syndrome (Reactive Arthritis) Classic Case

A male with current history of chlamydia genital infection (e.g., ur___ritis) complains of red and swollen ____ that come and go (mig_____ arthritis in large joints such as knee) and ulcers on the skin of the glans penis.

Mnemonic: “I can’t see (1), pee (1), or climb up a tree (1).”

Answer 131

A male with current history of chlamydia genital infection (e.g., urethritis) complains of red and swollen joints that come and go (migratory arthritis in large joints such as knee) and ulcers on the skin of the glans penis.

Mnemonic: “I can’t see (conjunctivitis), pee (urethritis), or climb up a tree (migratory arthritis in large joints such as the knee).”

Question 132

Exam Tips

Become familiar with the treatment regimens for chlamydia and gonorrhea =

Treat uncomplicated gonorrhea with Rx(1) × one dose. Cotreat for chlamydia only when?

If chlamydia, do not give prophylaxis against gonorrhea unless in_____

Rx(1) used for pregnant women who have chlamydia. Test-of-_____ needed ___ to ___ weeks after treatment.

Answer 132

Become familiar with the treatment regimens for chlamydia and gonorrhea

• Azithro or Doxy x 7d for chlamydia
• Ceftriaxone 500mg IM one dose for gonorrhea

Treat uncomplicated gonorrhea with ceftriaxone 500 mg IM × one dose. Cotreat for chlamydia only when chlamydial infection has not been excluded.

If chlamydia, do not give prophylaxis against gonorrhea unless indicated.

Azithromycin used for pregnant women who have chlamydia. Test-of-cure needed 3 to 4 weeks after treatment.

Question 133

Exam Tips

Recognize proctitis symptoms and treatment =

HSV-__ infection more common on oral mucosa and HSV-__ more common on the genitals.

Learn presentation of Fitz-Hugh–Curtis or Jarisch–Herxheimer syndrome.

If STD symptoms with new onset of swollen red knee on side (or another joint), may be caused by (1)

Answer 133

Recognize proctitis symptoms and treatment

• Inflammation of the lining of the rectum
• Tenesmus—an uncomfortable and frequent urge to have a bowel movement—is one of the most common symptoms of proctitis. Other symptoms may include:
  
  • Bloody bowel movements.
  • Rectal bleeding.
  • A feeling of rectal fullness.
  • Anal or rectal pain.
  • Crampy abdominal pain.
  • Rectal discharge of mucus or pus.
  • Diarrhea or frequent passage of loose or liquid stools.
• Anti-inflammatory medications by mouth/suppository/enema such as mesalamine, corticosteroids (prednisone)

HSV-1 infection more common on oral mucosa and HSV-2 more common on the genitals.

Learn presentation of Fitz-Hugh–Curtis or Jarisch–Herxheimer syndrome.

• Fitz-Hugh-Curtis = “violin strings” gonococcal infection ascending around liver capsule, female with PID complains of RUQ pain and tenderness on palpation, LFTs normal
• Jarisch-Herxheimer = 6-8h after tx of syphilis will feel fever, chills, headache, myalgia, tachy, increased RR - self limited, supportive care with antipyretics/NSAIDs

If STD symptoms with new onset of swollen red knee on side (or another joint), may be caused by disseminated gonococcal infection (DGI).

Question 134

Clinical Pearls

Up to 20% of women with cervicitis due to (1) STD will develop (1).

PID is a _____ diagnosis. Do you treat if both gonorrheal and chlamydial tests are negative?

Answer 134

Up to 20% of women with cervicitis due to gonorrhea will develop PID.

PID is a clinical diagnosis. Even if both gonorrheal and chlamydial tests are negative, treat a sexually active patient who has signs and symptoms of PID combined with a sexual history.

Question 135

Clinical Pearls

Probably better to “____treat” than to miss treating possible PID infections.

• A large study found that ad_____ tenderness (what is this?) is the most sensitive physical exam finding for PID (compared with cervical motion tenderness, which may be negative).

For STDs treated with azithromycin 1 g × one dose (chlamydia), instruct patient and partner to (1) for at least 7 days.

Answer 135

Probably better to “overtreat” than to miss treating possible PID infections.

• A large study found that adnexal tenderness (pain in the area of a woman’s uterus) is the most sensitive physical exam finding for PID (compared with cervical motion tenderness, which may be negative).

For STDs treated with azithromycin 1 g × one dose (chlamydia), instruct patient and partner to abstain from sex for at least 7 days.

Question 136

HIV Infection

HIV attacks the ____ T-lymphocytes.

In the United States, HIV is spread mainly by having anal or vaginal ____ with someone who has HIV without using a ____ (or who is not taking ______ to prevent or treat HIV).

HIV _____infection is when a person with HIV gets infected with another strain of the virus.

Without treatment, the average patient will progress to AIDS in about ___ years.

Answer 136

HIV attacks the CD4 T-lymphocytes.

In the United States, HIV is spread mainly by having anal or vaginal sex with someone who has HIV without using a condom (or who is not taking medicines to prevent or treat HIV).

HIV superinfection is when a person with HIV gets infected with another strain of the virus.

Without treatment, the average patient will progress to AIDS in about 10 years.

Question 137

HIV Infection

. In the United States and worldwide, HIV-__ is the most common strain; HIV-__ accounts for fewer than 0.2% of infections.

Currently, there are an estimated 1.1 _____ people in the United States who have HIV infection.

Almost 15% of HIV-infected persons in the United States are un____ of their HIV infection.

The CDC recommends that primary care providers (PCPs) conduct routine HIV screening at least ____ in a lifetime for individuals aged __ to __years.

Answer 137

In the United States and worldwide, HIV-1 is the most common strain; HIV-2 accounts for fewer than 0.2% of infections.

Currently, there are an estimated 1.1 million people in the United States who have HIV infection.

Almost 15% of HIV-infected persons in the United States are unaware of their HIV infection.

The CDC recommends that primary care providers (PCPs) conduct routine HIV screening at least once in a lifetime for individuals aged 13 to 64 years.

Question 138

HIV Risk Factors

(1) with an HIV-infected person or with gay or bisexual men

Received (1) products between 1975 and March 1985

History of injection (1) use/partner

History of other S___, m_____ partners, _____less status, prisoner in j____, and others

Answer 138

Sexual intercourse with an HIV-infected person or with gay or bisexual men

Received blood products between 1975 and March 1985

History of injection drug use/partner

History of other STDs, multiple partners, homeless status, prisoner in jail, and others

Question 139

Recommendations for Routine HIV Screening (Once a Year)

Injection ____ users and their sex _____

People who exchange sex for _____ and drugs

Sex partners of people with ____

_____sexuals (or their partners) who had ____ or more sex partners since their most recent HIV test

People receiving treatment for h___titis, t____ulosis, or an S__

M_ _ and bisexuals may benefit from more frequent screening (every 3–__ months)

Answer 139

Injection drug users and their sex partners

People who exchange sex for money and drugs

Sex partners of people with HIV

Heterosexuals (or their partners) who had one or more sex partners since their most recent HIV test

People receiving treatment for hepatitis, tuberculosis, or an STD

MSM and bisexuals may benefit from more frequent screening (every 3–6 months)

Question 140

Opt-out screening for HIV

Patients should be informed (through practice form/literature/discussion) that an HIV test is included in their _____ preventive screening tests and that they may de____ the test (opt-out screening); the patient’s decline for HIV testing should be n____ in their records.

Answer 140

Patients should be informed (through practice form/literature/discussion) that an HIV test is included in their standard preventive screening tests and that they may decline the test (opt-out screening); the patient’s decline for HIV testing should be noted in their records.

Question 141

Diagnostic Tests: CDC Fourth-Generation Testing

• Step 1*
• Step 2*

Answer 141

• Step 1:* Order HIV-1/HIV-2 antibodies and p24 antigen (fourth-generation antibody/antigen combination assay) with reflexes.
• Step 2:* If positive, the lab will perform the confirmatory HIV-1/HIV-2 antibody differentiation immunoassay (to confirm the result of the initial combination assay)

Question 142

Step 1 HIV Testing

Order HIV-1/HIV-2 ______ and ____ antigen (fourth-generation antibody/antigen combination assay) with reflexes.

• Detects infection at e____ stages because the p24 antigen is produced _____ antibodies (window period).
• If negative, ___ HIV infection.

Answer 142

Order HIV-1/HIV-2 antibodies and p24 antigen (fourth-generation antibody/antigen combination assay) with reflexes.

• Detects infection at earlier stages because the p24 antigen is produced before antibodies (window period).
• If negative, no HIV infection.

Question 143

Step 2 HIV Testing

If positive, the lab will perform the confirmatory HIV-1/HIV-2 antibody ________ immunoassay (to confirm the result of the initial combination assay).

• Detects if infection is from HIV-__, HIV-__, or both viruses.
• If test result is indeterminate, order an HIV ____ test (either qualitative or quantitative).

Answer 143

If positive, the lab will perform the confirmatory HIV-1/HIV-2 antibody differentiation immunoassay (to confirm the result of the initial combination assay).

• Detects if infection is from HIV-1, HIV-2, or both viruses.
• If test result is indeterminate, order an HIV RNA test (either qualitative or quantitative).

Question 144

HIV RNA PCR

=

Can detect HIV infection as early as __ to 28 days after exposure.

Order to test _____ if HIV(+) mother or if the HIV-1/HIV-2 antibody ______ test is indeterminate.

Suspect HIV infection in someone who is in the _____ period of HIV seroconversion.

Answer 144

Detects VIRAL LOAD (actual viral presence)

Can detect HIV infection as early as 7 to 28 days after exposure.

Order to test infant if HIV(+) mother or if the HIV-1/HIV-2 antibody differentiation test is indeterminate.

Suspect HIV infection in someone who is in the window period of HIV seroconversion.

Question 145

HIV Screening: Other Labs

HIV ____ PCR, ___ count and percentage, HIV RNA viral load, (1) with differential, l____.

(1) A/B/C, s_____ and other STDs, c____ cytology.
(1) testing by PPD or IGRA, (1) if pulmonary symptoms, HLAB____ if abacavir treatment, g____typic testing for antiviral resistance.

Answer 145

HIV RNA PCR, CD4 count and percentage, HIV RNA viral load, complete blood count (CBC) with differential, lipids.

Hepatitis A/B/C, syphilis and other STDs, cervical cytology.

TB testing by PPD or IGRA, CXR if pulmonary symptoms, HLAB5701 if abacavir treatment, genotypic testing for antiviral resistance.

Question 146

Normal CD4 T-Cell Counts

=

Answer 146

500–1,500 Cells/mL

Question 147

CD4 T-Cell Counts

Used to s____ HIV infection and determine _____ to antiretroviral therapy (ART).

If CD4 count goes up (with decrease in viral load), it means that patient is?

Values vary throughout the day. Check at the ____ time of the day using the same laboratory each time you remeasure CD4.

Answer 147

Used to stage HIV infection and determine response to antiretroviral therapy (ART).

If CD4 count goes up (with decrease in viral load), it means that patient is responding to ART (immune system improved).

Values vary throughout the day. Check at the same time of the day using the same laboratory each time you remeasure CD4.

Question 148

Viral Load

Number of HIV RNA copies in 1 mL of plasma. Test measures actively rep______ HIV virus; progression of disease and response to anti______ treatment.

The best sign of treatment success is an undetectable viral load (

If suspect acute or early HIV infection, order _____-generation c______ antibody/antigen immunoassay with viral _____ test.

Answer 148

Number of HIV RNA copies in 1 mL of plasma. Test measures actively replicating HIV virus; progression of disease and response to antiretroviral treatment.

The best sign of treatment success is an undetectable viral load (<50 copies/μL).

If suspect acute or early HIV infection, order fourth-generation combination antibody/antigen immunoassay with viral load test.

Question 149

Types of HIV Tests

HIV-1/HIV-2 _____ with p24 _____ with reflexes

E____

_____ Blot

R____ HIV testing kits or point of care tests

HIV RNA ____

CD4 T cell count (normally >____cells/mm3)

Viral ____ (antigen)

Answer 149

HIV-1/HIV-2 antibody with p24 antigen with reflexes

Elisa

Western Blot

Rapid HIV testing kits or point of care tests

HIV RNA PCR

CD4 T cell count (normally >500 cells/mm3)

Viral load (antigen)

Question 150

(1)

Also known as the combination antibody/antigen assay (fourth generation). Screening test to diagnose HIV infection. If positive, lab will perform HIV-1/HIV-2 antibody differentiation immunoassay to confirm initial test.

Answer 150

HIV-1/HIV-2 antibody with p24 antigen with reflexes

Question 151

(1)

Older screening test (antibody test). If positive, next step is Western blot test (done automatically by lab if positive for this)

Answer 151

ELISA

Question 152

(1)

Older confirmatory test. If positive, next step is HIV RNA PCR test

Answer 152

Western blot

Question 153

(1)

Also used for screening for HIV. Result available in <30 minutes (antibody test). Can be done at home. If positive, follow-up with blood testing

Answer 153

Rapid HIV testing kits or point-of-care tests

Question 154

(1)

Tests for HIV virus directly. Used for infants of HIV-positive mothers. Diagnoses acute HIV infection (window stage). Use if indeterminate result on antibody-antigen testing

Answer 154

HIV RNA PCR

Question 155

(1)

(normally >____cells/mm³)

Check before starting ART, staging HIV infection, disease progression, and treatment response to ART. If on ART, check at same time as viral load

Answer 155

CD4 T-cell counts

(normally >500 cells/mm³)

Check before starting ART, staging HIV infection, disease progression, and treatment response to ART. If on ART, check at same time as viral load

Question 156

(1)

HIV test that monitors treatment response.

If on ART, monitor every 1–2 months until nondetectable, then every 3–4 months.

Answer 156

Viral load (antigen)

Question 157

Prophylaxis for Opportunistic Infections (Primary Prevention)

(1) Rx

P. _____ pneumonia (previously known as P. carinii pneumonia [PCP]).

CD4 lymphocyte count is 3.

If develops a severe reaction to sulfas, the next step is _____ plus trimethoprim.

Alternatives: Use dapsone, at_____, or pent_____.

Answer 157

Bactrim DS one tablet daily

P. jirovecii pneumonia (previously known as P. carinii pneumonia [PCP]).

CD4 lymphocyte count is <200 cells/mm³.

If develops a severe reaction to sulfas, the next step is dapsone plus trimethoprim.

Alternatives: Use dapsone, atovaquone, or pentamidine.

Question 158

HIV Note

If you need to use Dapsone for opportunistic infection prophylaxis, what should you first check?

Answer 158

With dapsone, first check patient for e (G6PD) anemia due to risk of hemolysis (10% of African American males have G6PD).

Question 159

Toxoplasma gondii Infections (Protozoa)

CD4 count is 3. The most common ____ infection in AIDS patients.

First-line: Administer ____diazine PO QID plus _____thamine × 6 weeks or (1) one tablet BID × 6 weeks.

Infection causes enc______/br____ abscesses (headaches, blurred vision, confusion).

Avoid cleaning (1) boxes and eating undercooked (1).

Answer 159

CD4 count is <100 cells/mm³. The most common CNS infection in AIDS patients.

First-line: Administer sulfadiazine PO QID plus pyrimethamine × 6 weeks or trimethoprim–sulfamethoxazole (Bactrim) one tablet BID × 6 weeks.

Infection causes encephalitis/brain abscesses (headaches, blurred vision, confusion).

Avoid cleaning cat litter boxes and eating undercooked meats.

Question 160

Monitoring Viral Load: Antiretroviral Therapy

Best response if HIV infection is treated with ART in ____ stage.

The goal is to ___crease the HIV viral load.

ART will suppress HIV and __crease CD4 counts.

Increased CD4 counts indicate that the patient is responding to ART and their _____ system is improving.

Answer 160

Best response if HIV infection is treated with ART in early stage.

The goal is to decrease the HIV viral load.

ART will suppress HIV and increase CD4 counts.

Increased CD4 counts indicate that the patient is responding to ART and their immune system is improving.

Question 161

Monitoring Viral Load: Antiretroviral Therapy

When to check HIV RNA (viral load) after starting therapy?

Then check how often until viral load falls to undetectable levels?

______ cervical cytology (Pap) regardless of age until ____ negative screens, then every __ years.

Answer 161

Check HIV RNA (viral load) in 2 to 8 weeks after starting therapy, then every 1 to 2 months (or every 4–8 weeks) until the viral load falls to undetectable levels.

Monitor viral load, CD4, and CBC every 3 to 4 months the first 2 years of ART.

Annual cervical cytology (Pap) regardless of age until three negative screens, then every 3 years.

Question 162

Recommended Vaccines for HIV

Can receive what type of vaccines?

(6) main ones

Can receive what type of vaccines?

Vaccines work best if CD4 count exceeds?

Answer 162

Can receive inactivated vaccines

Hepatitis A and B

Inactivated influenza vaccine

Pneumococcal

Td/Tdap Q10 years

HPV until age 26

Vaccines work best if CD4 count >200 copies/mm3

Question 163

HIV Education

Do not handle cat ____ or eat uncooked or undercooked ____ (risk of toxo______).

Avoid bird _____, since it contains histoplasmosis spores.

Turtles, snakes, and other amphibians may be infected with _______.

Use gloves when cleaning animal c____ or when handling st____.

Healthy lifestyle, follow-up visits, and taking ART as directed reduce the risk of infection.

Answer 163

Do not handle cat litter or eat uncooked or undercooked meat (risk of toxoplasmosis).

Avoid bird stool, since it contains histoplasmosis spores.

Turtles, snakes, and other amphibians may be infected with salmonella.

Use gloves when cleaning animal cages or when handling stool.

Healthy lifestyle, follow-up visits, and taking ART as directed reduce the risk of infection.

Question 164

Preventing HIV Transmission

Use _____ every single time you have sex. Genital ul____ increase risk for HIV.

Do not share n_____ or syringes if you inject drugs.

Do not share any t___brushes, r_____, or other items that may have blood on them.

Can mothers with HIV breastfeed their babies?

_____ number of sexual partners.

Answer 164

Use condom every single time you have sex. Genital ulcers increase risk for HIV.

Do not share needles or syringes if you inject drugs.

Do not share any toothbrushes, razors, or other items that may have blood on them.

Mothers with HIV infection should not breastfeed their baby.

Limit number of sexual partners.

Question 165

Occupationally Acquired HIV Infection

Of all healthcare occupations, n____ have the highest rate of occupationally acquired HIV/AIDS.

The following factors increase risk of acquisition after needlestick injury: D___ injury, device visibly contaminated with patient’s bl____, needle placement in a v____ or artery, and t______ illness in a source patient.

Infectious fluids are bl____, s____/preseminal fluid, v_____ fluids, and breast ____.

The fluid must come in contact with m____ membrane or dam____ tissue or be directly injected into bloodstream for transmission to occur. Mucous membranes are found inside rectum, vagina, penis, and mouth.

Answer 165

Of all healthcare occupations, nurses have the highest rate of occupationally acquired HIV/AIDS.

The following factors increase risk of acquisition after needlestick injury: Deep injury, device visibly contaminated with patient’s blood, needle placement in a vein or artery, and terminal illness in a source patient.

Infectious fluids are blood, semen/preseminal fluid, vaginal fluids, and breast milk.

The fluid must come in contact with mucous membrane or damaged tissue or be directly injected into bloodstream for transmission to occur. Mucous membranes are found inside rectum, vagina, penis, and mouth.

Question 166

Postexposure Prophylaxis: Healthcare Workers

When is the best time to start PEP If you think you have been exposed to HIV at work, during sex, through sharing needles, or through sexual assault, who should you go to?

Do you have to wait for HIV lab results before starting PEP?

Answer 166

The best time to start PEP is as soon as possible. If you think you have been exposed to HIV at work, during sex, through sharing needles, or through sexual assault, go to your health provider or ED right away.

If source patient HIV status unknown, start PEP while awaiting rapid HIV testing (do not wait for lab results before starting PEP).

Question 166

Preexposure Prophylaxis

(1) has been shown to reduce HIV transmission by more than 90%.

Daily oral PrEP medications are recommended as a prevention option for sexually active individuals at substantial risk of HIV such as (2)

Do not confuse with postexposure prophylaxis (___). Check for HIV infection _____ starting medications and check for HIV every ___ months thereafter.

Answer 166

Preexposure Prophylaxis (PrEP) has been shown to reduce HIV transmission by more than 90%.

Daily oral PrEP medications are recommended as a prevention option for sexually active individuals at substantial risk of HIV such as:

• Anyone with ongoing sexual relationship with an HIV-infected partner
• Gay, heterosexual, bisexual, or transgender men who do not use condoms and engage in high-risk sexual behaviors

Do not confuse with postexposure prophylaxis (PEP). Check for HIV infection before starting medications and check for HIV every 3 months thereafter.

Question 167

Postexposure Prophylaxis: Healthcare Workers

What should you do immediately to the site after a potential exposure?

What should you cleanse it with?

What about for mucosal surfaces?

Answer 167

Initial action following exposure is immediate cleansing or irrigation of the exposed site.

Small wounds/punctures can also be cleansed with antiseptic or alcohol. Alcohol is virucidal to HIV, hepatitis B virus, and hepatitis C virus.

For mucosal surfaces, flush exposed mucous membranes with copious amount of water. Irrigate eyes with saline or water.

Question 168

Postexposure Prophylaxis: Healthcare Workers

Baseline labs: HIV (_____ HIV test and HIV ant____/ant____ immunoassay), hepatitis __ virus RNA, Hep __ surface antigen and antibody. Consider HIV (1) if acute HIV suspected.

A minimum of ____ antiretroviral drugs are used.

About ___ hours postexposure is the outer limit of effective PEP.

Answer 168

Baseline labs: HIV (rapid HIV test and HIV antibody/antigen immunoassay), hepatitis C virus RNA, HBsAg, hepatitis B virus surface antibody. Consider HIV RNA PCR if acute HIV suspected.

A minimum of three antiretroviral drugs are used.

About 72 hours postexposure is the outer limit of effective PEP.

Question 169

Exam Tips

PCP prophylaxis is advised when CD4 is

If a patient on ART has a CD4 count that increases (from CD4 200 to 400 copies/mL), it means that their immune system is getting ____.

Rx(1) PO is first-line; if allergic to sulfa, use Rx(1) 100 mg PO daily.

Bactrim DS is used for both prophylaxis and ______ of PCP.

Answer 169

PCP prophylaxis is advised when CD4 is <200 copies/mL.

If a patient on ART has a CD4 count that increases (from CD4 200 to 400 copies/mL), it means that their immune system is getting better.

Bactrim DS PO is first-line; if allergic to sulfa, use dapsone 100 mg PO daily.

Bactrim DS is used for both prophylaxis and treatment of PCP.

Question 170

Exam Tips

• HIV-infected pregnant women:* Start Rx(1) as soon as possible.
• Hairy leuko____ of tongue, recurrent can_____, thr____:* Rule out HIV infection.
• Acute retroviral syndrome or primary HIV infection:* _____-like or similar to _____infection, ____ infectious at this stage of HIV infection. Best if HIV treated as ____ as possible.

Answer 170

• HIV-infected pregnant women:* Start AZT (azidothymidine)aka (Zidovudine (ZDV) as soon as possible.
• Hairy leukoplakia of tongue, recurrent candidiasis, thrush:* Rule out HIV infection.
• Acute retroviral syndrome or primary HIV infection:* Influenza-like or similar to mononucleosis infection, very infectious at this stage of HIV infection. Best if HIV treated as early as possible.
• Zidovudine is in a class of medications called* nucleoside reverse transcriptase inhibitors (NRTIs) - backbone of HIV tx

Question 171

Clinical Pearls

The HIV antibody/antigen test (fourth generation) can detect infection in __ to 6 weeks (may be positive within __ weeks after infection).

NAAT can detect HIV infection in __ to 28 days.

For job-related exposures, contact National Cl______ Postexposure Prophylaxis Hotline (1) toll free at (888) 448-4911 for advice (11 a.m.–8 p.m. ET, 7 days/week).

Answer 171

The HIV antibody/antigen test (fourth generation) can detect infection in 2 to 6 weeks (may be positive within 2 weeks after infection).

NAAT can detect HIV infection in 7 to 28 days.

For job-related exposures, contact National Clinician’s Postexposure Prophylaxis Hotline (Pipeline) toll free at (888) 448-4911 for advice (11 a.m.–8 p.m. ET, 7 days/week).

Question 172

HIV Infection: Pregnant Women

Fully sup_____ ART treatment markedly decreases HIV transmission from mother to infant. It can be given ___time in pregnancy, as early as when pregnancy is diagnosed. Starting _____ in pregnancy is more effective. Prenatal v_____ important. _____ breastfeeding.

(1) (DTG) exposure at time of conception is associated with increased risk of neural tube defects.
* Newborns:* Start prophylaxis with (1) (Retrovir) within 8 hours after birth. Recommended for most infants to decrease vertical transmission.

Answer 172

Fully suppressive ART treatment markedly decreases HIV transmission from mother to infant. It can be given anytime in pregnancy, as early as when pregnancy is diagnosed. Starting earlier in pregnancy is more effective. Prenatal vitamins important. Avoid breastfeeding.

Dolutegravir (DTG) exposure at time of conception is associated with increased risk of neural tube defects.

Newborns: Start prophylaxis with zidovudine (Retrovir) within 8 hours after birth. Recommended for most infants to decrease vertical transmission.

Question 173

HIV Infection Pregnant Women

Drug of Choice (1)

Check baseline (1) with differential baseline and monitor for (1) suppression.

Reduces rate of perinatal transmission by ___%.

When to start ZDV?

Answer 173

Zidovudine

Check baseline CBC with differential baseline and monitor for bone marrow suppression.

Reduces rate of perinatal transmission by 70%.

Start ZDV as soon as HIV is diagnosed, or if established HIV diagnosis, start as soon as pregnancy is diagnosed.

Question 174

(1)

External anogenital warts appear as soft flesh-colored pedunculated, flat, or papular growths.

HPV high-risk oncogenic (2) types are sexually transmitted.

Cervical HPV infection is usually __symptomatic. Infected cervix can appear “_____.”

HPV vaccine (e.g., Gardasil 9): Give at age __ to __ years (both girls and boys). Only __ doses are needed (6–12 months apart) for adolescents aged 9 to 14 years. If first dose is started at age __ years or older, will need total of __ doses (0, 1–2, 6 schedule).

Answer 174

Condyloma Acuminata (Genital Warts)

External anogenital warts appear as soft flesh-colored pedunculated, flat, or papular growths.

HPV high-risk oncogenic types 16 and 18 are sexually transmitted.

Cervical HPV infection is usually asymptomatic. Infected cervix can appear “normal.”

HPV vaccine (e.g., Gardasil 9): Give at age 11 to 12 years (both girls and boys). Only two doses are needed (6–12 months apart) for adolescents aged 9 to 14 years. If first dose is started at age 15 years or older, will need total of 3 doses (0, 1–2, 6 schedule).

Question 175

Condyloma Acuminata (Genital Warts)

Genital sites: Warts may appear on the v____, ternal genitals, thra, and an__.

Other sites are the anus, penis, n___ mucosa, oro_____, and con_____.

Do you need to biopsy the lesion before initiating therapy? If so, in what cases should you (3)?

Answer 175

Genital sites: Warts may appear on the vagina, external genitals, urethra, and anus.

Other sites are the anus, penis, nasal mucosa, oropharynx, and conjunctiva.

Indications for pretreatment biopsy: Biopsy to rule out underlying cancer is not mandatory before initiating therapy, but it is recommended if lesion has suspicious characteristics (fixation, irregular, bleeding, ulceration, red/blue/black/brown pigmentation, induration, sudden recent growth) or patient is postmenopausal or immunocompromised. Obtain biopsy from the most abnormal area(s), or refer to dermatologist.

Question 176

Condyloma Acuminata (Genital Warts) Treatment

(1)-(4)

Answer 176

Self Administered Topical Medications

Podofilox (Condylox)

Imiquimod (Aldara) 5%

Zyclara (3.75% imiquimod)

Sinecatechins 10% ointment (Veregne)

Question 177

Podofilox (Condylox)

0.5% gel or cream (antimitotic drug). Contraindicated in ______.

Apply to external anogenital warts _ID x __ consecutive days (max 0.5 mL/d).

Hold treatment for __ days, then repeat this cycle up to ____ times.

Answer 177

0.5% gel or cream (antimitotic drug). Contraindicated in pregnancy.

Apply to external anogenital warts BID x 3 consecutive days (max 0.5 mL/d).

Hold treatment for 4 days, then repeat this cycle up to four times.

Question 178

Imiquimod (Aldara) 5% or Zyclara (3.75% imiquimod)

_____-modulating (or immune response modifier) drug that stimulates the local production of interferon and other cy_____. Contraindicated in _____.

Apply a thin layer ____ times per week at bedtime for up to __ weeks. Do not cover with dressing.

Leave cream on skin for 6 to __ hours. Wash off skin with soap and water after.

Side effects: May cause irr_____, ulc_____/erosions, h___pigmentation.

Answer 178

immune-modulating (or immune response modifier) drug that stimulates the local production of interferon and other cytokines. Contraindicated in pregnancy.

Apply a thin layer three times per week at bedtime for up to 16 weeks. Do not cover with dressing.

Leave cream on skin for 6 to 10 hours. Wash off skin with soap and water after.

Side effects: May cause irritation, ulceration/erosions, hypopigmentation.

Question 179

Sinecatechins 10% ointment (Veregne).

Sinecatechins is a botanical, derived from green ___ polyphenols, used for external anogenital warts (not for vagina or anus).

Apply 0.5-cm strand of ointment on each wart with a finger (use gloves), up to ____ times per day for up to __ weeks.

____ off skin before sexual contact or before inserting tampon in vagina.

Can w_____ condoms and diaphragms.

Answer 179

Sinecatechins is a botanical, derived from green tea polyphenols, used for external anogenital warts (not for vagina or anus).

Apply 0.5-cm strand of ointment on each wart with a finger (use gloves), up to three times per day for up to 16 weeks.

Wash off skin before sexual contact or before inserting tampon in vagina.

Can weaken condoms and diaphragms.

Question 180

Condyloma Acuminata (Genital Warts) Provider-Applied Methods

Treatment methods include ab_____ (laser, electrocautery), c____therapy, topicals (podophyllum resin, imiq____, sine______, dichloroacetic or trichloroacetic acid), and surgical __cision.

Internal vaginal warts are treated with tr____acetic acid, dichloro_____ acid, or inter____ by a clinician.

Answer 180

Treatment methods include ablation (laser, electrocautery), cryotherapy, topicals (podophyllum resin, imiquimod, sinecatechins, dichloroacetic or trichloroacetic acid), and surgical excision.

Internal vaginal warts are treated with trichloroacetic acid, dichloroacetic acid, or interferons by a clinician.

Question 181

(1)

STD that has asymptomatic shedding (intact skin) occurs intermittently, and patient is still contagious. Becomes latent in the neural ganglia and reactivates on mucosa and skin. Transmission is usually by oral contact with its lesions, mucosal secretions, or direct skin contact. It can be transmitted by oral-oral, oral-genital, and genital-to-genital contact. Other populations at risk are athletes involved in contact sports (especially wrestlers) and teenagers.

Answer 181

Herpes Simplex: HSV-1 And HSV-2

Question 182

HSV-1 and HSV-2

• HSV-1:* Usually ___ infection, sometimes ____
• HSV-2:* Causes most cases of recurrent _____ herpes, can be ____

Answer 182

• HSV-1:* Usually oral infection, sometimes genital
• HSV-2:* Causes most cases of recurrent genital herpes, can be oral
• (HSV-1 for oral - you have 1 mouth)*

Question 183

HSV Classic Case

HSV-__ lesions are usually located on the lips and mouth (gingivostomatitis), the eyes (herpes keratitis), or the pharynx. HSV-__ lesions are usually located on the genitals.

But with o___-g____ contact, either type of HSV can be located on the face or genitals.

Acute onset of small v_____ on a ___dened base that rupture easily and become small shallow painful ul____.

Oral ulcers are aggravated by eating/drinking/swallowing ____ foods (e.g., lemon, orange juice, tomato sauce).

Children may require hospitalization for de______ and p____control. _____ infection is when the greatest viral shedding occurs (vesicular fl___ and c____ are contagious).

It is more severe than subsequent recurrences and can last from 2 to 4 weeks. Subsequent recurrences tend to become ____ severe with time.

Answer 183

HSV-1 lesions are usually located on the lips and mouth (gingivostomatitis), the eyes (herpes keratitis), or the pharynx. HSV-2 lesions are usually located on the genitals.

But with oral-genital contact, either type of HSV can be located on the face or genitals.

Acute onset of small vesicles on a reddened base that rupture easily and become small shallow painful ulcers.

Oral ulcers are aggravated by eating/drinking/swallowing acidic foods (e.g., lemon, orange juice, tomato sauce).

Children may require hospitalization for dehydration and pain control. Primary infection is when the greatest viral shedding occurs (vesicular fluid and crusts are contagious).

It is more severe than subsequent recurrences and can last from 2 to 4 weeks. Subsequent recurrences tend to become less severe with time.

Question 184

HSV Diagnostic test

(1) or (1)

Female patient may be unable to void due to the _____ pain; advise patient how to void?

Answer 184

Herpes viral culture or PCR assay for HSV-1 and HSV-2 RNA (more sensitive).

Female patient may be unable to void due to the burning pain; advise patient to void in a tub filled with warm water or pour warm water over genitals when voiding in the toilet.

Question 185

(1)

An “old test.” If positive for herpes virus infection (herpes simplex or varicella), it shows multinucleated giant cells. It has poor sensitivity and specificity.

Answer 185

Tzanck Smear

Question 186

• First Episode (Primary Genital Herpes) Treatment*
• Rx(1)-(3)*
• Suppressive Treatment*
• (1) or (1)*

Answer 186

Antivirals

Acyclovir (Zovirax) 400 mg TID × 7 to 10 days (or 200 mg five times/d x 7–10 days)

Famciclovir (Famvir) 1 g BID × 7 to 10 days

Valacyclovir (Valtrex) TID × 7 to 10 days

Suppressive Treatment

Acyclovir (Zovirax) 400 mg PO BID or famciclovir (Favier) 250 mg PO BID

Question 187

• HSV Episodic Treatment (Flare-Up)*
• (2)*

main difference between flare up and initial treatment is?

Best if treatment started within 1 day of?

Answer 187

amciclovir (Famvir) 125 mg BID × 5 days

Zovirax BID or TID × 5 days or Valtrex BID × 5 days

Main difference is 5 days vs. 7-10 days

Best if treatment started within 1 day of lesion onset

Question 188

What should you always rule out if a patient presents with genital ulcers?

Answer 188

Always rule out syphilis.

Question 189

Human Papillomavirus

Almost all cases of cervical cancer are caused by ___, which is transmitted through unprotected penile-vaginal contact. Most cases (70%) are caused by HPV __ and HPV __.

Other HPV types can cause cancer of the oro____, an__, vulva/v_____, and p____.

HPV vaccine (1) can help prevent infections with the oncogenic HPV types.

Answer 189

Almost all cases of cervical cancer are caused by HPV, which is transmitted through unprotected penile-vaginal contact. Most cases (70%) are caused by HPV 16 and HPV 18.

Other HPV types can cause cancer of the oropharynx, anus, vulva/vagina, and penis.

HPV vaccine (Gardasil 9) can help prevent infections with the oncogenic HPV types.

Question 190

HPV Vaccine Guidelines

Age (1) → # of doses (1)

Age (1) → # of doses (1)

Answer 190

Age 11-12 → 2 doses (0, 6-12m)

_>_15 yo → 3 doses (0, 1-2, 6m)

Question 191

Exam Tips

Know first-episode treatment for herpes ((1) five times/d or (1) TID or (1) BID × __ to __ days).

Know flare-up treatment ((1) or (1) or (1) _ID × __ days).

(1) smear shows multinucleated (1) cells with (1) virus infection (varicella, herpes simplex).

Genital herpes treatment duration for __ to __ days for treating primary genital herpes infection. For breakouts, duration is __ days.

Answer 191

Know first-episode treatment for herpes (Acyclovir (Zovirax) five times/d or Valacyclovir (Valtrex) TID or Famciclovir (Favier) BID × 7 to 10 days).

Know flare-up treatment (Zovirax or Valtrex or Favier BID × 5 days).

Tzanck smear shows multinucleated giant cells with herpes virus infection (varicella, herpes simplex).

Genital herpes treatment duration for 7 to 10 days for treating primary genital herpes infection. For breakouts, duration is 5 days.

Question 192

Exam Tips

Imiquimod is an _____-modulator treatment for (1), and patient can use at home.

Treatments contraindicated in ______ are podofilox, podophylla, and imiquimod.

For pregnant women, _______ methods are used to destroy genital warts (e.g., curio, laser, excision).

HPV strains (2) are oncogenic/carcinogenic (memorize for exam).

Answer 192

Imiquimod is an immune-modulator treatment for genital warts, and patient can use at home.

Treatments contraindicated in pregnancy are podofilox, podophylla, and imiquimod.

For pregnant women, mechanical methods are used to destroy genital warts (e.g., curio, laser, excision).

HPV strains 16 and 18 are oncogenic/carcinogenic (memorize for exam).