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MFSRH Part 2 (2023) > Non-Complex Genitourinary Tract Presentations > Flashcards

Non-Complex Genitourinary Tract Presentations Flashcards

1
Q

90% of genital warts are caused by which HPV?

A

Types 6 or 11

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2
Q

What is the incubation for genital warts?

A

Between 3 weeks to 8 months

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3
Q

Where can extra-genital HPV wart lesions be found?

A
  • Oral cavity
  • Larynx
  • Conjunctivae
  • Nasal cavity
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4
Q

When should you do a speculum in a female presenting with GW?

A
  • At initial presentation, not required at follow-up if no internal lesions are found
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5
Q

When should you do a proctoscopy for GW?

A
  • If warts found at anal margin where upper limit cannot be visualised
  • If anal canal symptoms e.g. irritation, bleeding or discharge
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6
Q

When should a meatoscopy be performed for GW?

A
  • If difficulty in visualising the full extent of intra-meatal warts
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7
Q

What features of GW would make you suspicious of intraepithelial neoplastic lesions?

A
  • Pigmentation
  • Depigmentation
  • Pruritis
  • Immune-deficiency
  • Previous history of intraepithelial neoplasia
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8
Q

What caution should be given to those who use condoms with treatment of GW?

A
  • Imiquimod (Aldara) may weaken condoms
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9
Q

How do you treat soft, non-keratinised warts?

A
  • Podophyllotoxin (Warticon) or Trichloroacetic acid (TCA)
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10
Q

How do you treat keratinised warts?

A
  • Physical ablative methods
  • TCA
  • Electrocautery
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11
Q

Which type of wart is imiquimod (Aldara) good for?

A

Both keratinised and non-keratinised

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12
Q

How is podophyllotoxin (Warticon) applied

A

BD for 3 days, followed by 4 days rest
For 4-5 cycles

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13
Q

How is imiquimod (Aldara) applied

A

Three times a week, wash off 6-10 hours later
Continue for up to 16 weeks
UPSI should be avoided after application due to irritation to partner

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14
Q

When can you use catephen 10% ointment for GW?

A

Immunocompetent patients
Apply 3x per day for up to 16 weeks

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15
Q

When would you use TCA for GW?

A

Specialist setting only
Weekly application

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16
Q

How do you treat intra vaginal GW?

A
  • No treatment
  • Cryotherapy
  • Electrosurgery
  • TCA
  • Podophyllotoxcin if <2cm
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17
Q

How do you treat cervical GW?

A
  • Doesn’t need colp
  • No treatment
  • Cryotherapy
  • Electrosurgery
  • Laser
  • Excision
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18
Q

How do you treat GW at urethral meatus?

A

Base of lesion visible
- Cryo, electrosurgery, laser, podophyllotoxin or imiquimod
Deeper lesions
- Surgical ablation under direct supervision (urology referral vs use of meatoscope)

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19
Q

How do you treat intra-anal GW?

A
  • Cryo
  • Imiquimod
  • Electrosurgery
  • Laser
  • TCA
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20
Q

How do you treat GW in pregnancy?

A
  • Podophyllotoxin and 5-fluorouracil are teratogenic
  • Imiquimod is not approved for use in pregnancy as no data available
  • Cryo, excision, ablative methods are safer

Breastfeeding
- No data on imiquimod
- Not recommended for podophyllotoxin

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21
Q

Which serotypes of Chlamydia cause urogenital infection?

A

Serotypes D-K

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22
Q

Which serotypes of Chlamydia cause LGV?

A

L1-L3

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23
Q

What is Chlamydia

A

Obligate intracellular bacterium Chlamydia trachomatis

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24
Q

70% of cases of CT in the UK are in what age group?

A

15-24 year olds

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25
Q

What is the rate of transmission of CT?

A

75%

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26
Q

What are the risk factors for having CT?

A
  • Age <25
  • New sexual partner
  • > 1 sexual partner in past year
  • Inconsistent condom use
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27
Q

How many cases of CT will spontaneously resolve

A

50% of infections spontaneously resolve 12 months from initial diagnosis

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28
Q

Name some extra genital sites of CT infection

A
  • Rectal (usually asymptomatic but anal discharge / discomfort may occur)
  • Pharyngeal (usually asymptomatic)
  • Conjunctival (unilateral, low-grade irritation)
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29
Q

Name some complications from CT infection

A
  • PID (risk is 1-30%)
  • Endometritis
  • Salpingitis
  • Ectopic pregnancy
  • SARA
  • Perihepatitis
  • Epididymo-orchitis
  • LGV (mostly in HIV +ve MSM)
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30
Q

Which are more sensitive and specific for CT: NAAT or EIA?

A

NAAT

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31
Q

Why VVS rather than endocervical sample for detecting CT?

A
  • VVS has sensitivity of 96% and can be self-taken
  • Endocervical is less sensitive and requires a speculum
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32
Q

First-line management for CT

A

Doxycycline 100mg BD for 7 days

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33
Q

Second line management for CT

A

Azithromycin 1g stat, followed by 500mg OD for 2 days

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34
Q

If cannot have azithromycin or doxycycline for CT, what other abx options are there?

A
  • Erythromycin 500mg BD for 10-14 days
  • Ofloxacin 200mg BD (or 400mg OD) for 7 days
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35
Q

How do you treat chlamydia in pregnancy?

A
  • Azithromycin 1g stat followed by 500mg OD for two days
  • Or erythromycin or amoxicillin
  • Doxy and ofloxacin are contraindicated

TOC in 5 weeks

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36
Q

How can CT infection present if it has been vertically transmitted?

A
  • Opthalmia neonatorum (5-12 days post birth)
  • Pneumonia (between aged of 1 and 3 months
    Treat with erythromycin
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37
Q

A 3 week old baby develops conjunctivitis, what should you consider?

A
  • Chlamydia infection should be considered in all infants who develop conjunctivitis within 30 days of birth
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38
Q

What is Gonorrhoea?

A

Gram negative diplococcus Neisseria Gonorrhoeae

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39
Q

What are the primary sites of GC infection?

A

Columnar, epithelium-lined mucous membranes of
- Urethra
- Endocervix
- Rectum
- Pharynx
- Conjunctivae

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40
Q

Give some examples of complicated GC infection

A
  • Epididymo-orchitis
  • Prostatitis
  • PID (14% of those with GC)
  • Disseminated gonococcal infection (haematogenous dissemination causing skin lesions, arthralgia, arthritis, tenosynovitis)
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41
Q

Describe microscopy in detecting GC

A
  • Gram-stained genital specimens
  • Direct visualisation of n. gonorrhoeae
  • Monomorphic gram negative diplococci within polymorphonuclea leucocytes
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42
Q

What is the sensitivity of microscopy from penile urethral samples?

A
  • 90-95% if discharge present
  • 50-75% without symptoms
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43
Q

What is the sensitivity of microscopy from female genital tract samples?

A
  • 50% sensitivity from endocervix
  • 30% sensitivity from urethra
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44
Q

What is the sensitivity of NAAT for GC ?

A

> 95% in both symptomatic and asymptomatic infection

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45
Q

A woman has had a hysterectomy, which site for NAAT testing can you do ?

A

Both urine and VVS

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46
Q

Who would you perform NAAT rectal swabs in for GC?

A
  • Routine for all MSM
  • Consider in women who are sexual contacts of GC
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47
Q

What is the optimal testing in transgender women who have had genital reconstruction surgery?

A
  • Swabs from neovagina and FVU
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48
Q

What is the optimal testing in transgender men who have had genital reconstruction surgery?

A
  • FVU from neopenis
  • If vagina still present, VVS
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49
Q

What is first line treatment for GC when antimicrobial sensitivity is unknown?

A

Ceftriaxone 1g stat

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50
Q

What is first line treatment for GC when antimicrobial susceptibility is known?

A

Cipro 500mg orally stat (presence of cipro resistance is high at 35%)

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51
Q

How would you treat GC in someone who is pen allergic and sensitivities say resistant to cipro?

A

Options include
- Cefixime 400mg orally + azithro 3g
- Gent 240mg IM + azithro 2g
- Spectinomycn 2g IM + azithro 2g
- Azithro 2g single dose

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52
Q

How do you treat gonococcal PID?

A

Ceftriaxone 1g stat in addition to PID tx

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53
Q

How do you treat gonococcal epididymo-orchitis?

A

Ceftriaxone 1g stat in addition to EO treatment

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54
Q

How do you treat gonococcal conjunctivitis?

A

Ceftriaxone 1g stat and eye irrigation with saline / water

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55
Q

How do you treat disseminated gonococcal infection?

A
  • Ceftriaxone 1g IM or IV every 24 hours (cipro if pen allergic), continued for 7 days and then stepped down to oral abx
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56
Q

How do you treat GC in pregnancy ?

A
  • Do not give quinolones or tetracyclines
  • Ceftriaxone
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57
Q

Who is treated empirically as contact tracing when someone has GC?

A
  • All partners within preceding two weeks of male patients with symptomatic urethral infection
  • Contact all partners within preceding 3 months of patients with infection at other sites, or asymptomatic infection
  • For those presenting after 14 days of exposure, recommend treatment following a positive test for GC
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58
Q

What is the incubation period of HSV?

A

2 days to 2 weeks

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59
Q

What is the median recurrence rate for genital herpes?

A
  • 4 per year for HSV-2
  • HSV-2 is 4x more likely to be recurrent than HSV-1
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60
Q

How does HIV affect transmission rate for HSV?

A

In HIV +ve HSV-2 individuals, both symptomatic and asymptomatic shedding is increased
- Especially in those with low CD4 counts
- Especially those who are also HSV-1 seropositive

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61
Q

Name some complications of HSV

A
  • Superinfection with candida and streptococcus (typically occurs during 2nd week of lesion progression)
  • Autonomic neuropathy – urinary retention
  • Autoinoculation to fingers and thighs
  • Autoinoculation to damaged skin
  • Aseptic meningitis
  • Herpes proctisis
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62
Q

What conservative mx options are there for genital herpes?

A
  • Saline bathing
  • Analgesia
  • Topical anaesthetic agents e.g. 5% lidocaine ointment prior to micturition
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63
Q

When would you commence antiviral drugs for genital herpes?

A
  • Within 5 days of start of episode, or
  • While new lesions are still forming, or
  • Systemic symptoms persist
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64
Q

What are the recommended regimes of antiviral medication for HSV?

A
  • Aciclovir 400mg TDS for 5 days / 200mg 5x a day for 5 days
  • Valaciclovir 500mg BD for 5 days
  • Famciclovir 250mg TDS for 5 days
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65
Q

What do you give for recurrent genital herpes?

A
  • Aciclovir 800mg TDS for 2 days, or
  • Famciclovir 1g BD for 1 day, or
  • Valaciclovir 500mg BD for 3 days
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66
Q

Someone is on aciclovir 400mg BD as suppression therapy, but has started having a lot of breakthroughs of genital herpes lesions. What can be done now?

A
  • Increase dose to 400mg TDS
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67
Q

Name some manifestations of neonatal herpes

A
  • Localised to skin, eye, mouth
  • Local CNS disease (encephalitis alone)
  • Disseminated infection with multiple organ involvement
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68
Q

What affects HSV transmission to neonate?

A
  • Infection from mother
  • Presence of transplacental maternal neutralising antibodies
  • Duration of rupture of membranes
  • Use of FSE
  • Mode of delivery
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69
Q

What risks are there if mother acquires primary genital herpes in 1st trimester?

A
  • No increased risk of miscarriage
  • No increased risk of congenital abnormalities
  • Can plan for vaginal delivery, will need suppression from 36 weeks
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70
Q

When is neonatal risk of HSV at its highest?

A
  • If mum acquires primary infection in 3rd trimester
  • Particularly if within 6 weeks of delivery
  • If a vaginal delivery ensues, risk of neonatal herpes is 41%
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71
Q

In recurrent genital herpes, what is the risk of transmission to neonate if mum has a vaginal delivery?

A

0-3%

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72
Q

How do you manage a patient with suspected primary episode of genital herpes in 1st or 2nd trimester (before 27+6 weeks)

A
  • Confirm diagnosis with HSV PCR
  • Vaginal delivery can be anticipated (as long as not within the next 6 weeks)
  • Treat acute flare
  • Daily suppression with aciclovir 400mg TDS from 36 weeks
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73
Q

How do you manage a patient with suspected primary episode of genital herpes in the 3rd trimester? (from 28 weeks)

A
  • Treat acute flare
  • Continue daily suppression of aciclovir 400mg TDS until delivery
  • Recommend c-section
  • Type-specific HSV antibody IgG testing can distinguish between primary and secondary infection
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74
Q

How do you manage recurrent genital herpes in pregnancy?

A
  • Vaginal delivery can happen
  • Consider daily suppression therapy aciclovir 400mg TDS from 36 weeks
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75
Q

What happens if a primary episode of HSV is found at onset of labour?

A
  • Recommend c-section
  • Benefits of c-section may be reduced if membranes have been ruptured for >4 hours however
  • Consider intrapartum aciclovir for mother and then for the neonate if has a vaginal delivery
  • Avoid invasive procedures at vaginal delivery
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76
Q

A pregnant woman has PPROM, and a primary genital herpes infection outbreak. What do you do?

A
  • MDT
  • C-section if immediate delivery decided
  • If not immediate delivery, mother should receive IV aciclovir
  • Consider prophylactic steroids
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77
Q

When would a pregnant HIV positive HSV recurrence patient commence suppression therapy?

A

From 32 weeks (higher risk of preterm labour in HIV positive women)

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78
Q

Once HIV crosses a mucosal barrier, how long
a) for it to begin to replicate, and
b) before it can be detected in the blood?

A

a) 48 hours
b) 5 days

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79
Q

What factors influence efficacy of PEP?

A
  • Delayed initiation
  • Poor/non adherence
  • Further high risk sexual exposures after cessation of PEP
  • Early primary HIV acquisition already established when PEP initiated
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80
Q

How do you calculate the risk of HIV transmission?

A

Risk that source is HIV positive x risk per exposure

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81
Q

At what transmission risk is PEP recommended?

A

Significant risk (>1/1000)

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82
Q

What what transmission risk is PEP considered?

A

Between 1/1000 and 1/10 000

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83
Q

What four main categories are now in the 2021 PEP guideline?

A
  • Recommended: benefits likely outweigh risks
  • Consider: risk/benefit less clear as transmission risk is low
  • Generally not recommended: risk is very low, potential toxicity and inconvenience of PEP outweigh the benefit
  • Not recommended: risk is negligible
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84
Q

What is the risk of HIV transmission with receptive anal intercourse?

A

1/90 (1%)

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85
Q

What is the risk of HIV transmission in insertive anal intercourse?

A

1/666 (0.15%)

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86
Q

What is the risk of HIV transmission in receptive vaginal intercourse?

A

1/1000 (0.1%)

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87
Q

What is the risk of HIV transmission in insertive vaginal intercourse?

A

1/1219 (0.08%)

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88
Q

What is the risk of HIV transmission from a semen splash to eye?

A

<1/10 000 (0.01%)

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89
Q

What is the risk of HIV transmission with receptive oral sex?

A

<1/10 000 (0.01%)

90
Q

What is the risk of HIV transmission with insertive oral sex?

A

<1/10 000 (0.01%)

91
Q

What is the risk of HIV transmission with a blood transfusion?

A

1/1 (100%)

92
Q

What is the risk of HIV transmission with a needlestick injury?

A

1/333 (0.3%)

93
Q

What is the risk of HIV transmission when sharing needles?

A

1/149 (0.7%)

94
Q

What is the risk of HIV transmission from a human bite?

A

<1 / 10 000 (0.01%)

95
Q

Name three infectious bodily fluids (re. HIV transmission and occupational exposures)

A
  • Blood
  • Semen
  • Vaginal secretions
96
Q

Name some potentially infectious fluids (re. HIV transmission and occupational exposures)

A
  • CSF
  • Synovial
  • Pleural
  • Peritoneal
  • Pericardial
  • Amniotic fluid
97
Q

Name some fluids NOT considered infectious (re. HIV transmission and occupational exposures, unless the fluid contains blood)

A
  • Faeces
  • Nasal secretions
  • Saliva
  • Gastric secretions
  • Sputum
  • Sweat
  • Tears
  • Urine
  • Vomit
98
Q

If the source is known to be HIV positive, when would PEP be recommended?

A

Attempts should be made to identify the HIV viral load, resistance profile and treatment history

  • PEP not recommended if source is on ART for 6 months and undetectable viral load
  • PEP recommended if viral load >200 copies and receptive and/or insertive anal sex, receptive vaginal sex, sharing needles
99
Q

When is PEP recommended if partner is of unknown HIV status?

A

If index partner is from at risk group, a country of high HIV prevalence (>1%) and is not known to be on suppressive ART, PEP would be recommended following receptive anal sex

100
Q

Index HIV positive
HIV VL unknown or detectable
Which exposures is PEP recommended?

A
  • Receptive anal sex
  • Insertive anal sex
  • Receptive vaginal sex
  • Sharing of injecting equipment
  • Sharps injury
  • Mucosal splash injury
101
Q

Index HIV positive
HIV VL unknown or detectable
Which exposures is PEP considered?

A
  • Insertive vaginal sex
102
Q

Index HIV positive
HIV VL unknown or detectable
Which exposures is PEP not recommended?

A
  • Fellatio with ejaculation
  • Fellatio without ejaculation
  • Splash of semen into eye
  • Cunnilingus
  • Human bite (generally not recommended)
103
Q

Index HIV positive
HIV VL undetectable
Which exposures is PEP recommended?

A

Not recommended for all exposure

104
Q

Index of unknown HIV status
From high prevalence country / risk-group (e.g. MSM)
Which exposures is PEP recommended?

A
  • Receptive anal sex
  • Insertive anal sex CONSIDER
105
Q

Index of unknown HIV status
From low prevalence country / group
Which exposures is PEP recommended?

A

None

106
Q

What medication is used in PEP?

A
  • Truvada and Raltegravir OD for 28 days
  • Truvada (emtricitabine 200mg/tenofovir 245mg)
  • Raltegravir 1200mg
107
Q

What types of ART are truvada and raltegravir?

A
  • Emtricitabine is an NRTI
  • Tenofovir is an NRTI
  • Raltegravir is an integrate inhibitor
108
Q

What is used as PEP for pregnant women?

A

Just reduce the raltegravir and give as BD dosing
- Truvada + raltegravir 400mg BD

109
Q

Name the 13 items to discuss with an individual commencing PEP

A
  1. Rationale for PEP
  2. Lack of conclusive data for efficacy of PEP
  3. Start PEP ASAP and importance of adherence
  4. Potential side-effects
  5. Drug-interactions (stop iron with OD raltegravir)
  6. EC
  7. Signs of seroconversion
  8. Early follow-up if needed
  9. Verbal consent for HIV test
  10. Continue PEP for minimum 28 days if baseline HIV test negative
  11. Follow-up HIV test 45 days after completion of the course
  12. Use condoms until follow-up HIV test is negative
  13. Coping strategies, vulnerabilities and social support
110
Q

A patient on PEP has a further high risk exposure on day 27 of their 28 day course. What should they do?

A

Continue the course for a further 48 hours after the last high-risk exposure

111
Q

You commenced PEP, and the patient’s 4th generation HIV test done at baseline comes back as positive, what do you do?

A

Continue PEP pending review by HIV specialist

112
Q

What baseline tests do you do at initiation of PEP?

A
  • STI testing
  • U&E
  • LFT (ALT mainly)
  • PT
  • HIV
  • Hep B
  • Hep C
113
Q

When would you repeat bloods 2 weeks after starting PEP?

A
  • If baseline U&E or LFTs were abnormal
114
Q

A patient is on PEP and forgot to take his next dose. It’s been 20 hours since his missed dose, what do you advise next?

A

As <24 hours since missed dose, take it immediately and then take the subsequent one at the usual time

115
Q

A patient is on PEP and forgot to take his next dose. It’s been 40 hours since his missed dose, what do you advise next?

A

Continue PEP as usual

116
Q

A patient is on PEP and forgot to take his next dose. It’s been 50 hours since his missed dose, what do you advise next?

A

Recommend stopping PEP

117
Q

PrEP for MSM
Who is eligible?

A
  • On demand or daily PrEP for HIV neg MSM having condomless anal sex in previous 6 months and ongoing condomless anal sex
118
Q

PrEP for heterosexual people
Who is eligible?

A
  • Daily PrEP to HIV neg heterosexual men and women having condomless sex with partners who are HIV positive (unless partner has been on ART for 6 months and their viral load is <200)
  • Case by case basis for heterosexual men and women with current factors that may put them at risk of HIV acquisition
119
Q

PrEP for PWID
Who is eligible?

A
  • Not recommended where needle exchange and opiate substitution programmes are accessed by the individual
  • Consider PrEP on a case-by-case basis in PWID in an outbreak situation or with other factors that put them at risk of HIV
120
Q

PrEP trans people
Who is eligible?

A
  • Daily PrEP HIV neg trans women who are having condomless anal sex in previous 6 months and ongoing condomless anal sex
  • Daily PrEP to HIV neg trans women and trans men having condomless sex with HIV pos partners (unless they’ve been on ART for 6 months and VL <200)
  • In trans people who are having ONLY anal sex, on-demand PrEP can be used
121
Q

Does PrEP interact with hormones used in gender transitioning?

A

No

122
Q

What extra consideration is there for initiating PrEP in a young person (aged 15-25) [ not including safeguarding etc ]

A

BMD risks

123
Q

What timeline is recommended for starting and stopping PrEP for anal sex?

A
  • Double dose truvada 2-24 hours before sex
  • Continued one dose daily until 48 hours after last sex
  • If PrEP for anal sex has been interrupted and it is less than 7 days since the last Truvada dose, PrEP can be re-started at a single dose
124
Q

What timeline is recommended for starting and stopping PrEP for vaginal sex?

A
  • PrEP should be started 7 days ahead of likely risk
  • Continued for 7 days after last sexual risk
  • If Full 7 days not possible, can suggest double dose but no evidence to support this
125
Q

What timeline is recommended for starting and stopping PrEP for PWID?

A
  • 7 days before and 7 days after
  • Takes longer to achieve protective concentrations in blood than in rectal tissues
126
Q

Who can have same-day initiation of PrEP?

A
  • Negative POCT on the day
  • Negative HIV antigen/antibody test within past 4 weeks
  • Recommend viral load if high-risk exposure within past 4 weeks
  • Defer in people reporting condomless anal sex within previous 4 weeks who have symptoms of HIV seroconversion until HIV RNA result available
127
Q

Can a pregnant woman take PrEP?

A

Yes, may continue on PrEP in pregnancy and during breastfeeding
Report use of PrEP during pregnancy to the antiretroviral pregnancy registry

128
Q

What baseline tests are done for PrEP?

A
  • STI screen
  • Baseline screening for hep B, hep C, hep A (if indicated)
  • U&E and urinalysis
129
Q

What % of PIDs are caused by CT or GC?

A

25%

130
Q

Absence of endocervical or vaginal pus cells means what for a diagnosis of PID?

A

Good negative predictive value (95%)

131
Q

Presence of endocervical or vaginal pus cells means what for PID?

A

Non-specific (poor positive predictive value of 17%)

132
Q

When would you give IV therapy for PID?

A

Fever >38, signs of TO abscess, pelvic peritonitis, generally unwell in other ways such as poor oral tolerance

133
Q

Name 3x outpatient regimes for PID

A
  1. IM ceftriaxone 1g stat + PO doxy 100mg BD 14 days + PO metro 400mg BD 14 days
  2. Oral ofloxacin 400mg BD 14 days and oral metro 400mg BD 14 days
  3. Oral moxifloxacin 400mg OD for 14 days
134
Q

Why do we worry about routine use of quinolones?

A
  • Avoid in high risk of GC PID because of quinolone resistance
  • Quinolones are not licensed in <18s
  • Can cause tendinopathy so only recommend as second line therapy
135
Q

Name some inpatient regimes for PID

A
  • IV ceftriaxone 2g stat plus IV doxy 100mg BD (oral once tolerated) 14 days plus oral metro BD 14 days
  • IV clindamycin and IV gent, followed by oral clinda, oral doxy, oral metro
  • IV ofloxacin and IV metro
136
Q

How do you treat PID in pregnancy?

A

Insufficient data to recommend a regime
Probably consider ceftriaxone, erythromycin, metronidazole

137
Q

If m. gen positive for PID, how do you then treat?

A

Moxifloxacin

138
Q

What do you treat male contacts of PID with?

A

Doxy 100mg BD for 7 days
If confirmed m.gen, then consider treating with moxi / whichever abx the index patient is sensitive to from the m.gen

139
Q

What is different with cervical screening for women living with HIV?

A
  • Annual screening
  • Colposcopy recommended at diagnosis (if over 25)
140
Q

What folic acid doses are recommended pre-conception for women with HIV?

A
  • Routine 400 micrograms, unless
  • On long-term septrin (co-trimoxazole) as this is a folate antagonist, so 5mg
141
Q

In an HIV sero-different couple trying to conceive, what options do they have?

A
  • Waiting until optimal ART management with undetectable VL, and can then have UPSI
  • PrEP
  • Self-insemination (if female is HIV positive and male is HIV negative)
  • Sperm washing / assisted conception (if female is HIV negative and male is HIV positive)
142
Q

An HIV positive female has a CD4 count 190 and wishes to conceive, what do you advise?

A

Defer +++
Optimise ARTs
Optimise drugs to prevent opportunistic infections
All of this will reduce maternal and fetal complications in pregnancy

143
Q

What advice do you give re. spermicide and HIV?

A
  • N-9 is a mucosal irritant that can cause epithelial disruption
  • Therefore lesions in the vagina or rectum
  • This may increase HIV acquisition/transmission
144
Q

What is the incubation period for primary syphilis?

A

Usually 21 days, but can be up to 90 days

145
Q

When will a primary chancre resolve?

A

Usually over 3-8 weeks

146
Q

What % of people with primary syphilis will go on to develop secondary syphilis?

A

25% if untreated (4-10 weeks after initial chancre)

147
Q

When will secondary syphilis resolve?

A

Will resolve spontaneously in 3-12 weeks and become asymptomatic latent stage

25% will develop a recurrence of secondary syphilis

148
Q

How many untreated syphilis cases will turn into tertiary syphilis?

A

1/3 of untreated patients

149
Q

When would you do dark ground microscopy to look for T. pallidum?

A
  • Genital chancre
  • Less reliable for rectal and non-penile lesions
  • Not suitable for oral lesions due to presence of commensal treponemes
150
Q

When can you do PCR for T. Pallidum?

A
  • Oral lesions
  • CSF and tissue samples
151
Q

You do DGM on a penile ulcer and no spirochetes were found, and syphilis serology was negative. When should you repeat it?

A

Two weeks later

152
Q

What is the first line tx for early syphilis (primary, secondary, and early latent)

A
  • Benzathine penicillin G 2.4MU IM single dose
  • Alternative regimens are doxy PO BD 14 days, ceftriaxone 500mg IM daily for 10 days (if no anaphylaxis to penicillin)
153
Q

What is the first-line treatment for late latent, cardiovascular and gummatous syphilis?

A
  • Benzathine penicillin 2.4MU IM weekly for 3 weeks
  • Doxycycline 100mg PO BD 28 days, or amoxicillin 2g PO TDS plus probenacid 500mg QDS for 28 days
  • Steroids should be given for cardiovascular syphilis: 40-60mg pred OD for 3 days, starting 24 hours before abx
154
Q

How do you treat neurosyphilis?

A
  • Procaine penicillin 1.8 MU - 2.4 MU IM OD plus probenecid 500mg PO QDS for 14 days
155
Q

How do you treat early syphilis in pregnancy (first and second trimester)?

A

Benzathine penicillin G 2.4MU IM single dose

156
Q

How do you treat early syphilis in pregnancy (third trimester)?

A

Benzathine penicillin G 2.4MU IM on days 1 and 8

157
Q

Someone who has syphilis in pregnancy but is penicillin allergic, what do you do?

A

Using erythromycin may result in treatment failure
Needs referring to immunology/ allergy services for desensitisation

158
Q

How do you treat late syphilis in pregnancy?

A

Benzathine penicillin G 2.4MU IM weekly on days 1, 8 and 15

159
Q

What is the follow-up monitoring after treatment for syphilis?

A
  • Clinical and serological follow-up at 3, 6, and 12 months
  • After then, if needed, 6-monthly until VDRL/RPR negative or serofast
  • A sustained four-fold or greater increase in VDRL/RPR suggests re-infection or treatment failure
160
Q

A patient feels unwell after being treated for primary syphilis with headache, myalgia, chills and rigors
What is the diagnosis?

A

Jarisch-Herxheimer reaction

161
Q

A patient received procaine penicillin and started having hallucinations, what’s the diagnosis?

A

Procaine reaction / procaine psychosis / mania
- Due to inadvertent IV injection of procaine penicillin
- Fear of impending death and hallucinations / seizures immediately after injection, which lasts <20 mins

162
Q

Who should be offered Hep A vaccine?

A

MSM
PWID
HBV+
HCV+
HIV+

163
Q

Who do you contact trace for acute Hep A?

A
  • PN for at-risk contacts within 2 weeks prior to and 1 week after developing jaundice
  • Employment history
164
Q

What is the ultra-rapid Hep B vaccination course?

A
  • Day 0, 7, 21 and then 12 months
  • Leads to antibody response in 80% of recipients 4-12 weeks after the third dose
  • Antibody response rises to 95% after the 12 month dose
165
Q

Someone with acute Hep B, how long should they avoid UPSI for?

A
  • Until they have become HBsAg negative
  • Until their regular partners have been successfully vaccinated
166
Q

You diagnose chronic Hep B, why refer to hepatology?

A
  • Disease monitoring
  • Liver cancer screening
  • Liver cirrhosis monitoring
  • Possible therapy
167
Q

What complications in pregnancy can TV give?

A
  • Preterm delivery
  • Low birth weight
  • May predispose to maternal postpartum sepsis
168
Q

Which males would be tested for TV?

A
  • TV contacts
  • Persistent urethritis
    (first-void urine)
169
Q

Name some treatment options for TV

A
  • Metronidazole 400mg BD for 5-7 days
  • Metronidazole 2g stat (not routinely recommended anymore)
  • Metronidazole 500mg BD for 7 days in HIV positive women
  • Tinidazole 2g orally stat single dose
170
Q

Urethral infection of TV is found in what percentage of infected women?

A
  • 90% in infected women (although only 5% is the sole site of infection)
171
Q

What percentage of women are asymptomatic of TV?
What percentage of men are asymptomatic of TV?

A
  • Women: 10-50% asymptomatic
  • Men: 15-50% asymptomatic
172
Q

Vaginal discharge for TV - how many women will have it, and how many women will have the classical frothy yellow discharge?

A
  • 70% will have discharge in general
  • 10-30% will have the frothy yellow discharge
173
Q

What is the association between TV and HIV?

A
  • Epidemiological association between the two
  • TV may enhance HIV transmission
  • May be increased risk of TV in those who are HIV positive
174
Q

Who should be tested for TV?

A
  • Patients complaining of vaginal discharge or vulvitis
  • Found to have evidence of vulvitis and/or vaginitis
  • TV contacts
  • Persistent penile urethritis
175
Q

What are the preferred sites to sample for a female for TV?

A
  • If symptomatic, swab from posterior fornix for microscopy
  • For NAAT, self-taken vaginal swabs are equivalent to clinician taken vaginal swabs
  • Urine testing sensitivity in range 88-90%
176
Q

What is the preferred site to sample for a male for TV?

A
  • Clinician-taken urethral swab or self-taken penile-meatal swab will diagnose 80% of cases using NAAT
  • Urine NAAT can be used
177
Q

What is the sensitivity of microscopy for TV?

A

40-60% (is higher if the patient is complaining of discharge)

178
Q

How long should a patient be advised to abstain from sex after TV tx?

A
  • At least 1 week and until their partner(s) have completed treatment
179
Q

What is first-line treatment for TV in women?

A

Metronidazole 400-500mg BD for 7 days (disulfiram type reactions can occur in 10% of people, avoid alcohol during use and for 48 hours post last dose)

180
Q

What is the treatment protocol for non-response to standard TV therapy (having excluded re-infection and non-adherence)

A
  1. Repeat course of 7-day standard therapy
  2. Higher dose (i.e. metronidazole 2g OD for 5-7 days)
  3. Metronidazole 2g BD 14 days plus metronidazole vaginal gel 5g BD 14 days
181
Q

What is the pathophysiology of BV?

A
  • The healthy vagina has a pH <4.5, and lactobacilli are the dominant bacteria
  • In BV, the pH is elevated above 4.5 and up to 6.0
  • Lactobacilli may still be present, but anaerobic bacteria are now present
  • Gardnerella vaginalis, Prevotella spp, Mycoplasma hominis, mobiluncus spp. most commonly found
182
Q

Describe Amsel’s criteria to diagnose BV

A

3 out of 4 must be present

  1. Thin, white, homogenous discharge
  2. Clue cells on microscopy of wet mount
  3. pH of vaginal fluid >4.5
  4. Release of fishy odor on adding alkali (10% KOH)
183
Q

What is the Hay/Ison criteria for diagnosing BV?

A

Gram-stained vaginal smear

Grade 0: no bacteria present

Grade 1: lactobacilli predominate (normal)

Grade 2: Mixed flora with some lacto, but gardnerella or mobiluncus are also present (intermediate)

Grade 3: Predominantly gardnerella and/or mobiluncus morphotypes. Few or absent lacto (BV)

Grade 4: gram-positive cocci predominate

184
Q

Who should be treated for BV?

A
  • Symptomatic women
  • Women undergoing surgical procedure
  • Women who do not volunteer symptoms but may elect for treatment if offered
185
Q

Name 4 recommended regimes for BV

A
  • Metronidazole 400mg BD for 5-7 days (probably the most effective)
  • Metronidazole 2g single dose
  • PV metronidazole gel (0.75%) OD for 5 days
  • PV clindamycin cream (2%) OD for 7 days
186
Q

Name 2 alternative regimes for BV

A
  • Tinidazole 2g single dose
  • Clindamycin 300mg BD for 7 days
187
Q

What additional precautions should someone know about clindamycin cream?

A

Can weaken condoms

188
Q

How should / could metronidazole be used for recurrent BV?

A
  • Suppressive tx with 0.75% metronidazole vaginal gel
  • Could trial BD gel for 16 weeks
  • Only 34% remained cumulatively free of recurrence 12 weeks after stopping treatment
  • Excess candidosis in these women too
189
Q

How could probiotics be used for recurrent BV?

A
  • Probiotic lactobacilli OD days 1-7 and 15-21
190
Q

Define recurrent vulvovaginal candidiasis

A
  • Four episodes per 12 months, with two episodes confirmed by microscopy or culture when symptomatic (at least one must be culture)
191
Q

What % of women will have
a) 1 episode, and
b) 2+ episodes
of VVC in their lifetime?

A

a) 75% of women
b) 40-45% of women

192
Q

What are risk factors for recurrent VVC?

A
  • Persistence of Candida sp.
  • Poorly controlled DM
  • Immunosuppression
  • Endogenous and exogenous estrogen (pregnancy, HRT, ?CHC)
  • Recent (up to 3 months ago) use of antibiotics

Some thoughts re. iron deficiency anaemia, low zinc/mg/ca levels, and mannose binding lectin deficiency (a genetic condition that affects the immune system)

193
Q

If sending a culture for recurrent VVC, what do you request?

A
  • Identify fungal growth to the species level
  • At least as C. albicans / non-albicans Candida and sensitivity to fluconazole
  • Can request ‘full speciation and sensitivity testing’
194
Q

What general advice can you give women with VVC symptoms?

A
  • Avoid local irritants such as perfumed soaps and wipes
  • Use emollient as soap substitute
  • Shower, not bathe
  • Avoid excessive cleaning
  • Avoid non-breathable fabrics
  • Avoid daily panty liners
  • Avoid vaginal douching
  • If patient reports a link with sex, consider water-based lube
  • Discuss any psychosexual / libido issues
195
Q

What additional tests can you do for someone with recurrent VVC?

A
  • Diabetes check - urinalysis, random blood glucose, HbA1c
  • IDA with FBC or serum ferritin
196
Q

What additional features would make you suspect mannose binding lectin deficiency in recurrent VVC?

A
  • History of URTI, otitis media, auto immune conditions
197
Q

What is first line treatment for acute VVC?

A
  • Fluconazole capsule 150mg PO stat
    or
  • Clotrimazole pessary 500mg PV stat (or for up to 7 nights in pregnancy)

80% cure rate in acute VVC

198
Q

Can you give oral fluconazole in pregnancy?

A

No, avoid in pregnancy and breastfeeding
Topical tx is fine

199
Q

What about condom use and VVC treatment?

A
  • Intravaginal and topical treatments can damage latex condoms and diaphragms
200
Q

What medical considerations need to be had with giving/prescribing fluconazole?

A
  • Moderate inhibitor of cytochrome P450
  • Can prolong QT interval
  • Should not give with erythromycin as these both inhibit cytochrome P450 and prolong QT interval
201
Q

What is treatment recommendation for severe VVC?

A
  • Fluconazole 150mg orally day 1 and 4
    or
  • Clotrimazole 500mg pessary PV day 1 and 4 and
  • Miconazole vaginal capsule 1200mg day 1 and 4

Consider topical low-dose corticosteroid cream

202
Q

What is treatment recommendation for recurrent VVC?

A

Induction: fluconazole 150mg orally every 72h x 3 doses
Maintenance: fluconazole 150mg orally once a week for 6 months

203
Q

What is the recommended regime for non-albicans Candida species and azole resistance?

A
  • Nystatin pessaries 100,000 units PV at night for 14 nights
204
Q

What is the regime for recurrent VVC in pregnancy?

A
  • Induction: topical imidazole therapy for 14 days
  • Maintenance: clotrimazole pessary once weekly
205
Q

What about fluconazole and breast feeding?

A
  • Continue breastfeeding after a single dose of 150mg fluconazole
  • More doses / higher doses should be avoided
206
Q

What about VVC in HIV positive women?

A
  • Treat the same as HIV negative women
  • Tends to occur more frequently
207
Q

What about hormones/contraception and VVC?

A
  • HRT associated with increased risk of VVC
  • Women with recurrent VVC using COC, IUD/IUS may wish to trial alternative contraception (but weak evidence)
208
Q

Balanitis - what investigations can be done if uncertain re. diagnosis?

A
  • Sub-preputial swab for candida spp and bacterial culture - to exclude infective cause
  • Urinalysis for glucose if candidal infection suspected
  • HSV PCR if ulcer
  • DGM/treponemal PCR if ulcer
  • Trich PCR (urine)
  • Screen for other STIs
  • Biopsy if uncertain and condition persists
209
Q

Non-specific balanitis - you take a culture, no pathogen found, continues with good hygiene/emollients/washing advice, but no improvement. What do you do now?

A
  • Trial of hydrocortisone 1% BD for 14 days
210
Q

What would make you suspect candidal balanitis, and how would you treat?

A
  • Rash with soreness and/or itch
  • Blotchy erythema with small papules, can have a glazed appearance
  • Sub-preputial culture swab
  • Clotrimazole cream 1% BD
211
Q

What would make you suspect an anaerobic infection balanitis, and how would you treat?

A
  • Foul-smelling discharge, swelling, inflamed glans
  • Preputial oedema, superficial erosions
  • Sub-preputial culture and HSV swab if ulcerated
  • Metronidazole 400mg BD 7 days
212
Q

What would make you suspect lichen sclerosis causing the balanitis, and how would you treat?

A

Also known as balanitis xerotica obliterans (BXO)
- Itching, soreness, splitting, white patches on glans, blunting of coronal sulcus, phimosis
- Diagnosis is clinical, or biopsy if uncertain
- Potent topical steroids (e.g. clobetasol proprionate)

213
Q

What would make you suspect Zoon’s balanitis (plasma cell) and how would you treat?

A
  • Usually occurs in older men who are uncircumcised
  • Thought to be due to irritation
  • Well-circumscribed, orange-red glazed areas with multiple pin-point redder spots
  • Biopsy is advisable as pre-malignant conditions can be similar
  • Circumcision can lead to resolution of lesions
  • Trial trimovate cream
214
Q

What would make you suspect psoriasis balanitis and how would you treat?

A
  • Red, scaly plaques
  • Look for psoriasis elsewhere
  • Biopsy if looks like pre-malignant conditions
  • Emollient, mild-mod topical steroids
215
Q

What would make you suspect circinate balanitis, and how do you treat?

A
  • Inflammatory condition that occurs in Reiter’s disease
  • Greyish white areas on the glans which coalesce to form geographical areas with a white margin
  • Screen for STIs, syphilis can cause these symptoms
  • Treat the underlying condition, can also treat with emollients and mild-mod topical steroids
216
Q

What would make you suspect irritant/allergic balanitis, and how would you treat this?

A
  • Symptoms can be associated with irritants (such as more frequent washing with soap, history of atopy, latex in condoms)
  • Eczematous reaction (can be mild erythema)
  • Could have patch test / intradermal skin test
  • Avoid precipitants - especially soaps
  • Emollients and soap substitute
  • Hydrocortisone 1% BD
217
Q

What would make you suspect a fixed drug eruption as a cause of balanitis?

A
  • Aetiology can be tetracyclines, salicylates, paracetamol, some hypnotics
  • Lesions are usually well demarcated and erythematous, but can be bullous with subsequent ulceration
  • Condition will settle without treatment
  • Topical steroids mild-mod BD
218
Q

What is erythroplasia of Queyrat?

A
  • Pre-malignant condition affecting penis, usually glans/prepuce/meatus
  • 30% of cases progress to invasive cancer
  • Could be triggered by co-infection of papilloma viruses
  • Red, velvety, well-circumscribed area on the glans, may have raised white areas
  • Biopsy essential - squamous carcinoma in situ
  • Surgical excision
219
Q

What is Bowen’s disease?

A
  • Cutaneous carcinoma in situ
  • Scaly, discrete, erythematous plaque
  • 20% will develop SCC
  • Biopsy essential
  • Local excision
220
Q

What is Bowenoid papulosis?

A
  • Carcinoma in-situ, linked to HPV 18
  • Discrete papules to plaques which are often pigmented
  • Risk of development to SCC
  • Biopsy essential
  • Surgical excision

MFSRH Part 2 (2023) (22 decks)

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