Non-Complex Genitourinary Tract Presentations Flashcards
1
Q
90% of genital warts are caused by which HPV?
A
Types 6 or 11
2
Q
What is the incubation for genital warts?
A
Between 3 weeks to 8 months
3
Q
Where can extra-genital HPV wart lesions be found?
A
- Oral cavity
- Larynx
- Conjunctivae
- Nasal cavity
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
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
6
Q
When should a meatoscopy be performed for GW?
A
- If difficulty in visualising the full extent of intra-meatal warts
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
8
Q
What caution should be given to those who use condoms with treatment of GW?
A
- Imiquimod (Aldara) may weaken condoms
9
Q
How do you treat soft, non-keratinised warts?
A
- Podophyllotoxin (Warticon) or Trichloroacetic acid (TCA)
10
Q
How do you treat keratinised warts?
A
- Physical ablative methods
- TCA
- Electrocautery
11
Q
Which type of wart is imiquimod (Aldara) good for?
A
Both keratinised and non-keratinised
12
Q
How is podophyllotoxin (Warticon) applied
A
BD for 3 days, followed by 4 days rest
For 4-5 cycles
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
14
Q
When can you use catephen 10% ointment for GW?
A
Immunocompetent patients
Apply 3x per day for up to 16 weeks
15
Q
When would you use TCA for GW?
A
Specialist setting only
Weekly application
16
Q
How do you treat intra vaginal GW?
A
- No treatment
- Cryotherapy
- Electrosurgery
- TCA
- Podophyllotoxcin if <2cm
17
Q
How do you treat cervical GW?
A
- Doesn’t need colp
- No treatment
- Cryotherapy
- Electrosurgery
- Laser
- Excision
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)
19
Q
How do you treat intra-anal GW?
A
- Cryo
- Imiquimod
- Electrosurgery
- Laser
- TCA
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
21
Q
Which serotypes of Chlamydia cause urogenital infection?
A
Serotypes D-K
22
Q
Which serotypes of Chlamydia cause LGV?
A
L1-L3
23
Q
What is Chlamydia
A
Obligate intracellular bacterium Chlamydia trachomatis
24
Q
70% of cases of CT in the UK are in what age group?
A
15-24 year olds
25
What is the rate of transmission of CT?
75%
26
What are the risk factors for having CT?
- Age <25
- New sexual partner
- >1 sexual partner in past year
- Inconsistent condom use
27
How many cases of CT will spontaneously resolve
50% of infections spontaneously resolve 12 months from initial diagnosis
28
Name some extra genital sites of CT infection
- Rectal (usually asymptomatic but anal discharge / discomfort may occur)
- Pharyngeal (usually asymptomatic)
- Conjunctival (unilateral, low-grade irritation)
29
Name some complications from CT infection
- PID (risk is 1-30%)
- Endometritis
- Salpingitis
- Ectopic pregnancy
- SARA
- Perihepatitis
- Epididymo-orchitis
- LGV (mostly in HIV +ve MSM)
30
Which are more sensitive and specific for CT: NAAT or EIA?
NAAT
31
Why VVS rather than endocervical sample for detecting CT?
- VVS has sensitivity of 96% and can be self-taken
- Endocervical is less sensitive and requires a speculum
32
First-line management for CT
Doxycycline 100mg BD for 7 days
33
Second line management for CT
Azithromycin 1g stat, followed by 500mg OD for 2 days
34
If cannot have azithromycin or doxycycline for CT, what other abx options are there?
- Erythromycin 500mg BD for 10-14 days
- Ofloxacin 200mg BD (or 400mg OD) for 7 days
35
How do you treat chlamydia in pregnancy?
- Azithromycin 1g stat followed by 500mg OD for two days
- Or erythromycin or amoxicillin
- Doxy and ofloxacin are contraindicated
TOC in 5 weeks
36
How can CT infection present if it has been vertically transmitted?
- Opthalmia neonatorum (5-12 days post birth)
- Pneumonia (between aged of 1 and 3 months
Treat with erythromycin
37
A 3 week old baby develops conjunctivitis, what should you consider?
- Chlamydia infection should be considered in all infants who develop conjunctivitis within 30 days of birth
38
What is Gonorrhoea?
Gram negative diplococcus Neisseria Gonorrhoeae
39
What are the primary sites of GC infection?
Columnar, epithelium-lined mucous membranes of
- Urethra
- Endocervix
- Rectum
- Pharynx
- Conjunctivae
40
Give some examples of complicated GC infection
- Epididymo-orchitis
- Prostatitis
- PID (14% of those with GC)
- Disseminated gonococcal infection (haematogenous dissemination causing skin lesions, arthralgia, arthritis, tenosynovitis)
41
Describe microscopy in detecting GC
- Gram-stained genital specimens
- Direct visualisation of n. gonorrhoeae
- Monomorphic gram negative diplococci within polymorphonuclea leucocytes
42
What is the sensitivity of microscopy from penile urethral samples?
- 90-95% if discharge present
- 50-75% without symptoms
43
What is the sensitivity of microscopy from female genital tract samples?
- 50% sensitivity from endocervix
- 30% sensitivity from urethra
44
What is the sensitivity of NAAT for GC ?
>95% in both symptomatic and asymptomatic infection
45
A woman has had a hysterectomy, which site for NAAT testing can you do ?
Both urine and VVS
46
Who would you perform NAAT rectal swabs in for GC?
- Routine for all MSM
- Consider in women who are sexual contacts of GC
47
What is the optimal testing in transgender women who have had genital reconstruction surgery?
- Swabs from neovagina and FVU
48
What is the optimal testing in transgender men who have had genital reconstruction surgery?
- FVU from neopenis
- If vagina still present, VVS
49
What is first line treatment for GC when antimicrobial sensitivity is unknown?
Ceftriaxone 1g stat
50
What is first line treatment for GC when antimicrobial susceptibility is known?
Cipro 500mg orally stat (presence of cipro resistance is high at 35%)
51
How would you treat GC in someone who is pen allergic and sensitivities say resistant to cipro?
Options include
- Cefixime 400mg orally + azithro 3g
- Gent 240mg IM + azithro 2g
- Spectinomycn 2g IM + azithro 2g
- Azithro 2g single dose
52
How do you treat gonococcal PID?
Ceftriaxone 1g stat in addition to PID tx
53
How do you treat gonococcal epididymo-orchitis?
Ceftriaxone 1g stat in addition to EO treatment
54
How do you treat gonococcal conjunctivitis?
Ceftriaxone 1g stat and eye irrigation with saline / water
55
How do you treat disseminated gonococcal infection?
- Ceftriaxone 1g IM or IV every 24 hours (cipro if pen allergic), continued for 7 days and then stepped down to oral abx
56
How do you treat GC in pregnancy ?
- Do not give quinolones or tetracyclines
- Ceftriaxone
57
Who is treated empirically as contact tracing when someone has GC?
- 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
58
What is the incubation period of HSV?
2 days to 2 weeks
59
What is the median recurrence rate for genital herpes?
- 4 per year for HSV-2
- HSV-2 is 4x more likely to be recurrent than HSV-1
60
How does HIV affect transmission rate for HSV?
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
61
Name some complications of HSV
- 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
62
What conservative mx options are there for genital herpes?
- Saline bathing
- Analgesia
- Topical anaesthetic agents e.g. 5% lidocaine ointment prior to micturition
63
When would you commence antiviral drugs for genital herpes?
- Within 5 days of start of episode, or
- While new lesions are still forming, or
- Systemic symptoms persist
64
What are the recommended regimes of antiviral medication for HSV?
- 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
65
What do you give for recurrent genital herpes?
- Aciclovir 800mg TDS for 2 days, or
- Famciclovir 1g BD for 1 day, or
- Valaciclovir 500mg BD for 3 days
66
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?
- Increase dose to 400mg TDS
67
Name some manifestations of neonatal herpes
- Localised to skin, eye, mouth
- Local CNS disease (encephalitis alone)
- Disseminated infection with multiple organ involvement
68
What affects HSV transmission to neonate?
- Infection from mother
- Presence of transplacental maternal neutralising antibodies
- Duration of rupture of membranes
- Use of FSE
- Mode of delivery
69
What risks are there if mother acquires primary genital herpes in 1st trimester?
- No increased risk of miscarriage
- No increased risk of congenital abnormalities
- Can plan for vaginal delivery, will need suppression from 36 weeks
70
When is neonatal risk of HSV at its highest?
- 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%
71
In recurrent genital herpes, what is the risk of transmission to neonate if mum has a vaginal delivery?
0-3%
72
How do you manage a patient with suspected primary episode of genital herpes in 1st or 2nd trimester (before 27+6 weeks)
- 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
73
How do you manage a patient with suspected primary episode of genital herpes in the 3rd trimester? (from 28 weeks)
- 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
74
How do you manage recurrent genital herpes in pregnancy?
- Vaginal delivery can happen
- Consider daily suppression therapy aciclovir 400mg TDS from 36 weeks
75
What happens if a primary episode of HSV is found at onset of labour?
- 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
76
A pregnant woman has PPROM, and a primary genital herpes infection outbreak. What do you do?
- MDT
- C-section if immediate delivery decided
- If not immediate delivery, mother should receive IV aciclovir
- Consider prophylactic steroids
77
When would a pregnant HIV positive HSV recurrence patient commence suppression therapy?
From 32 weeks (higher risk of preterm labour in HIV positive women)
78
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) 48 hours
b) 5 days
79
What factors influence efficacy of PEP?
- Delayed initiation
- Poor/non adherence
- Further high risk sexual exposures after cessation of PEP
- Early primary HIV acquisition already established when PEP initiated
80
How do you calculate the risk of HIV transmission?
Risk that source is HIV positive x risk per exposure
81
At what transmission risk is PEP recommended?
Significant risk (>1/1000)
82
What what transmission risk is PEP considered?
Between 1/1000 and 1/10 000
83
What four main categories are now in the 2021 PEP guideline?
- 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
84
What is the risk of HIV transmission with receptive anal intercourse?
1/90 (1%)
85
What is the risk of HIV transmission in insertive anal intercourse?
1/666 (0.15%)
86
What is the risk of HIV transmission in receptive vaginal intercourse?
1/1000 (0.1%)
87
What is the risk of HIV transmission in insertive vaginal intercourse?
1/1219 (0.08%)
88
What is the risk of HIV transmission from a semen splash to eye?
<1/10 000 (0.01%)
89
What is the risk of HIV transmission with receptive oral sex?
<1/10 000 (0.01%)
90
What is the risk of HIV transmission with insertive oral sex?
<1/10 000 (0.01%)
91
What is the risk of HIV transmission with a blood transfusion?
1/1 (100%)
92
What is the risk of HIV transmission with a needlestick injury?
1/333 (0.3%)
93
What is the risk of HIV transmission when sharing needles?
1/149 (0.7%)
94
What is the risk of HIV transmission from a human bite?
<1 / 10 000 (0.01%)
95
Name three infectious bodily fluids (re. HIV transmission and occupational exposures)
- Blood
- Semen
- Vaginal secretions
96
Name some potentially infectious fluids (re. HIV transmission and occupational exposures)
- CSF
- Synovial
- Pleural
- Peritoneal
- Pericardial
- Amniotic fluid
97
Name some fluids NOT considered infectious (re. HIV transmission and occupational exposures, unless the fluid contains blood)
- Faeces
- Nasal secretions
- Saliva
- Gastric secretions
- Sputum
- Sweat
- Tears
- Urine
- Vomit
98
If the source is known to be HIV positive, when would PEP be recommended?
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
When is PEP recommended if partner is of unknown HIV status?
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
Index HIV positive
HIV VL unknown or detectable
Which exposures is PEP recommended?
- Receptive anal sex
- Insertive anal sex
- Receptive vaginal sex
- Sharing of injecting equipment
- Sharps injury
- Mucosal splash injury
101
Index HIV positive
HIV VL unknown or detectable
Which exposures is PEP considered?
- Insertive vaginal sex
102
Index HIV positive
HIV VL unknown or detectable
Which exposures is PEP not recommended?
- Fellatio with ejaculation
- Fellatio without ejaculation
- Splash of semen into eye
- Cunnilingus
- Human bite (generally not recommended)
103
Index HIV positive
HIV VL undetectable
Which exposures is PEP recommended?
Not recommended for all exposure
104
Index of unknown HIV status
From high prevalence country / risk-group (e.g. MSM)
Which exposures is PEP recommended?
- Receptive anal sex
- Insertive anal sex CONSIDER
105
Index of unknown HIV status
From low prevalence country / group
Which exposures is PEP recommended?
None
106
What medication is used in PEP?
- Truvada and Raltegravir OD for 28 days
- Truvada (emtricitabine 200mg/tenofovir 245mg)
- Raltegravir 1200mg
107
What types of ART are truvada and raltegravir?
- Emtricitabine is an NRTI
- Tenofovir is an NRTI
- Raltegravir is an integrate inhibitor
108
What is used as PEP for pregnant women?
Just reduce the raltegravir and give as BD dosing
- Truvada + raltegravir 400mg BD
109
Name the 13 items to discuss with an individual commencing PEP
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
A patient on PEP has a further high risk exposure on day 27 of their 28 day course. What should they do?
Continue the course for a further 48 hours after the last high-risk exposure
111
You commenced PEP, and the patient's 4th generation HIV test done at baseline comes back as positive, what do you do?
Continue PEP pending review by HIV specialist
112
What baseline tests do you do at initiation of PEP?
- STI testing
- U&E
- LFT (ALT mainly)
- PT
- HIV
- Hep B
- Hep C
113
When would you repeat bloods 2 weeks after starting PEP?
- If baseline U&E or LFTs were abnormal
114
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?
As <24 hours since missed dose, take it immediately and then take the subsequent one at the usual time
115
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?
Continue PEP as usual
116
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?
Recommend stopping PEP
117
PrEP for MSM
Who is eligible?
- On demand or daily PrEP for HIV neg MSM having condomless anal sex in previous 6 months and ongoing condomless anal sex
118
PrEP for heterosexual people
Who is eligible?
- 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
PrEP for PWID
Who is eligible?
- 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
PrEP trans people
Who is eligible?
- 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
Does PrEP interact with hormones used in gender transitioning?
No
122
What extra consideration is there for initiating PrEP in a young person (aged 15-25) [ not including safeguarding etc ]
BMD risks
123
What timeline is recommended for starting and stopping PrEP for anal sex?
- 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
What timeline is recommended for starting and stopping PrEP for vaginal sex?
- 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
What timeline is recommended for starting and stopping PrEP for PWID?
- 7 days before and 7 days after
- Takes longer to achieve protective concentrations in blood than in rectal tissues
126
Who can have same-day initiation of PrEP?
- 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
Can a pregnant woman take PrEP?
Yes, may continue on PrEP in pregnancy and during breastfeeding
Report use of PrEP during pregnancy to the antiretroviral pregnancy registry
128
What baseline tests are done for PrEP?
- STI screen
- Baseline screening for hep B, hep C, hep A (if indicated)
- U&E and urinalysis
129
What % of PIDs are caused by CT or GC?
25%
130
Absence of endocervical or vaginal pus cells means what for a diagnosis of PID?
Good negative predictive value (95%)
131
Presence of endocervical or vaginal pus cells means what for PID?
Non-specific (poor positive predictive value of 17%)
132
When would you give IV therapy for PID?
Fever >38, signs of TO abscess, pelvic peritonitis, generally unwell in other ways such as poor oral tolerance
133
Name 3x outpatient regimes for PID
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
Why do we worry about routine use of quinolones?
- 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
Name some inpatient regimes for PID
- 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
How do you treat PID in pregnancy?
Insufficient data to recommend a regime
Probably consider ceftriaxone, erythromycin, metronidazole
137
If m. gen positive for PID, how do you then treat?
Moxifloxacin
138
What do you treat male contacts of PID with?
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
What is different with cervical screening for women living with HIV?
- Annual screening
- Colposcopy recommended at diagnosis (if over 25)
140
What folic acid doses are recommended pre-conception for women with HIV?
- Routine 400 micrograms, unless
- On long-term septrin (co-trimoxazole) as this is a folate antagonist, so 5mg
141
In an HIV sero-different couple trying to conceive, what options do they have?
- 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
An HIV positive female has a CD4 count 190 and wishes to conceive, what do you advise?
Defer +++
Optimise ARTs
Optimise drugs to prevent opportunistic infections
All of this will reduce maternal and fetal complications in pregnancy
143
What advice do you give re. spermicide and HIV?
- 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
What is the incubation period for primary syphilis?
Usually 21 days, but can be up to 90 days
145
When will a primary chancre resolve?
Usually over 3-8 weeks
146
What % of people with primary syphilis will go on to develop secondary syphilis?
25% if untreated (4-10 weeks after initial chancre)
147
When will secondary syphilis resolve?
Will resolve spontaneously in 3-12 weeks and become asymptomatic latent stage
25% will develop a recurrence of secondary syphilis
148
How many untreated syphilis cases will turn into tertiary syphilis?
1/3 of untreated patients
149
When would you do dark ground microscopy to look for T. pallidum?
- Genital chancre
- Less reliable for rectal and non-penile lesions
- Not suitable for oral lesions due to presence of commensal treponemes
150
When can you do PCR for T. Pallidum?
- Oral lesions
- CSF and tissue samples
151
You do DGM on a penile ulcer and no spirochetes were found, and syphilis serology was negative. When should you repeat it?
Two weeks later
152
What is the first line tx for early syphilis (primary, secondary, and early latent)
- 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
What is the first-line treatment for late latent, cardiovascular and gummatous syphilis?
- 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
How do you treat neurosyphilis?
- Procaine penicillin 1.8 MU - 2.4 MU IM OD plus probenecid 500mg PO QDS for 14 days
155
How do you treat early syphilis in pregnancy (first and second trimester)?
Benzathine penicillin G 2.4MU IM single dose
156
How do you treat early syphilis in pregnancy (third trimester)?
Benzathine penicillin G 2.4MU IM on days 1 and 8
157
Someone who has syphilis in pregnancy but is penicillin allergic, what do you do?
Using erythromycin may result in treatment failure
Needs referring to immunology/ allergy services for desensitisation
158
How do you treat late syphilis in pregnancy?
Benzathine penicillin G 2.4MU IM weekly on days 1, 8 and 15
159
What is the follow-up monitoring after treatment for syphilis?
- 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
A patient feels unwell after being treated for primary syphilis with headache, myalgia, chills and rigors
What is the diagnosis?
Jarisch-Herxheimer reaction
161
A patient received procaine penicillin and started having hallucinations, what's the diagnosis?
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
Who should be offered Hep A vaccine?
MSM
PWID
HBV+
HCV+
HIV+
163
Who do you contact trace for acute Hep A?
- PN for at-risk contacts within 2 weeks prior to and 1 week after developing jaundice
- Employment history
164
What is the ultra-rapid Hep B vaccination course?
- 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
Someone with acute Hep B, how long should they avoid UPSI for?
- Until they have become HBsAg negative
- Until their regular partners have been successfully vaccinated
166
You diagnose chronic Hep B, why refer to hepatology?
- Disease monitoring
- Liver cancer screening
- Liver cirrhosis monitoring
- Possible therapy
167
What complications in pregnancy can TV give?
- Preterm delivery
- Low birth weight
- May predispose to maternal postpartum sepsis
168
Which males would be tested for TV?
- TV contacts
- Persistent urethritis
(first-void urine)
169
Name some treatment options for TV
- 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
Urethral infection of TV is found in what percentage of infected women?
- 90% in infected women (although only 5% is the sole site of infection)
171
What percentage of women are asymptomatic of TV?
What percentage of men are asymptomatic of TV?
- Women: 10-50% asymptomatic
- Men: 15-50% asymptomatic
172
Vaginal discharge for TV - how many women will have it, and how many women will have the classical frothy yellow discharge?
- 70% will have discharge in general
- 10-30% will have the frothy yellow discharge
173
What is the association between TV and HIV?
- Epidemiological association between the two
- TV may enhance HIV transmission
- May be increased risk of TV in those who are HIV positive
174
Who should be tested for TV?
- Patients complaining of vaginal discharge or vulvitis
- Found to have evidence of vulvitis and/or vaginitis
- TV contacts
- Persistent penile urethritis
175
What are the preferred sites to sample for a female for TV?
- 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
What is the preferred site to sample for a male for TV?
- Clinician-taken urethral swab or self-taken penile-meatal swab will diagnose 80% of cases using NAAT
- Urine NAAT can be used
177
What is the sensitivity of microscopy for TV?
40-60% (is higher if the patient is complaining of discharge)
178
How long should a patient be advised to abstain from sex after TV tx?
- At least 1 week and until their partner(s) have completed treatment
179
What is first-line treatment for TV in women?
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
What is the treatment protocol for non-response to standard TV therapy (having excluded re-infection and non-adherence)
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
What is the pathophysiology of BV?
- 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
Describe Amsel's criteria to diagnose BV
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
What is the Hay/Ison criteria for diagnosing BV?
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
Who should be treated for BV?
- Symptomatic women
- Women undergoing surgical procedure
- Women who do not volunteer symptoms but may elect for treatment if offered
185
Name 4 recommended regimes for BV
- 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
Name 2 alternative regimes for BV
- Tinidazole 2g single dose
- Clindamycin 300mg BD for 7 days
187
What additional precautions should someone know about clindamycin cream?
Can weaken condoms
188
How should / could metronidazole be used for recurrent BV?
- 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
How could probiotics be used for recurrent BV?
- Probiotic lactobacilli OD days 1-7 and 15-21
190
Define recurrent vulvovaginal candidiasis
- Four episodes per 12 months, with two episodes confirmed by microscopy or culture when symptomatic (at least one must be culture)
191
What % of women will have
a) 1 episode, and
b) 2+ episodes
of VVC in their lifetime?
a) 75% of women
b) 40-45% of women
192
What are risk factors for recurrent VVC?
- 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
If sending a culture for recurrent VVC, what do you request?
- 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
What general advice can you give women with VVC symptoms?
- 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
What additional tests can you do for someone with recurrent VVC?
- Diabetes check - urinalysis, random blood glucose, HbA1c
- IDA with FBC or serum ferritin
196
What additional features would make you suspect mannose binding lectin deficiency in recurrent VVC?
- History of URTI, otitis media, auto immune conditions
197
What is first line treatment for acute VVC?
- 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
Can you give oral fluconazole in pregnancy?
No, avoid in pregnancy and breastfeeding
Topical tx is fine
199
What about condom use and VVC treatment?
- Intravaginal and topical treatments can damage latex condoms and diaphragms
200
What medical considerations need to be had with giving/prescribing fluconazole?
- 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
What is treatment recommendation for severe VVC?
- 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
What is treatment recommendation for recurrent VVC?
Induction: fluconazole 150mg orally every 72h x 3 doses
Maintenance: fluconazole 150mg orally once a week for 6 months
203
What is the recommended regime for non-albicans Candida species and azole resistance?
- Nystatin pessaries 100,000 units PV at night for 14 nights
204
What is the regime for recurrent VVC in pregnancy?
- Induction: topical imidazole therapy for 14 days
- Maintenance: clotrimazole pessary once weekly
205
What about fluconazole and breast feeding?
- Continue breastfeeding after a single dose of 150mg fluconazole
- More doses / higher doses should be avoided
206
What about VVC in HIV positive women?
- Treat the same as HIV negative women
- Tends to occur more frequently
207
What about hormones/contraception and VVC?
- 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
Balanitis - what investigations can be done if uncertain re. diagnosis?
- 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
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?
- Trial of hydrocortisone 1% BD for 14 days
210
What would make you suspect candidal balanitis, and how would you treat?
- 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
What would make you suspect an anaerobic infection balanitis, and how would you treat?
- Foul-smelling discharge, swelling, inflamed glans
- Preputial oedema, superficial erosions
- Sub-preputial culture and HSV swab if ulcerated
- Metronidazole 400mg BD 7 days
212
What would make you suspect lichen sclerosis causing the balanitis, and how would you treat?
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
What would make you suspect Zoon's balanitis (plasma cell) and how would you treat?
- 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
What would make you suspect psoriasis balanitis and how would you treat?
- Red, scaly plaques
- Look for psoriasis elsewhere
- Biopsy if looks like pre-malignant conditions
- Emollient, mild-mod topical steroids
215
What would make you suspect circinate balanitis, and how do you treat?
- 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
What would make you suspect irritant/allergic balanitis, and how would you treat this?
- 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
What would make you suspect a fixed drug eruption as a cause of balanitis?
- 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
What is erythroplasia of Queyrat?
- 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
What is Bowen's disease?
- Cutaneous carcinoma in situ
- Scaly, discrete, erythematous plaque
- 20% will develop SCC
- Biopsy essential
- Local excision
220
What is Bowenoid papulosis?
- Carcinoma in-situ, linked to HPV 18
- Discrete papules to plaques which are often pigmented
- Risk of development to SCC
- Biopsy essential
- Surgical excision
