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SPM- GUM > Questions from Specific Conditions Section > Flashcards

Questions from Specific Conditions Section Flashcards

1
Q

What are three common causes of vaginal discharge?

A

Bacterial Vaginosis
Candidiasis
Trichomoniasis- caused by trichomonas vaginalis (TV)

Note- discharge can also be physiological

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2
Q

Which conditions cause a fishy smelling vaginal discharge?

A

Bacterial vaginosis

Trichomonas vaginalis

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3
Q

What does the discharge look like in bacterial vaginosis?

A

Thin and white/grey

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4
Q

What does the discharge look like in trichomonas vaginalis?

A

Thin/frothy

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5
Q

What does the discharge due to candida smell like?

A

It is does not have an odour

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6
Q

What are the features of normal physiological vaginal discharge?

A

Clear
Odourless
pH <4.5

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7
Q

What associated features may be seen with candida?

A

Itching
Burning when urinating
Vulval oedema

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8
Q

What does the discharge look like with candida?

A

Thick and white

Like cottage cheese

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9
Q

If suspecting candida what investigation should be done?

A

High vaginal swab for candida culture

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10
Q

What associated features are there for bacterial vaginosis?

A

Usually none and around 50% are asymptomatic
No itch or soreness
Fish smelling discharge that is thing and grey.white

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11
Q

What pH is typically seen for bacterial vaginosis?

A

pH>5

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12
Q

What associated features are seen with trichomoniasis?

A

Itching

May be asymptomatic

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13
Q

What investigation should be done for any abnormal discharge>

A

High vaginal swabs

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14
Q

What is the causative organism in bacterial vaginosis?

A

Loss of lactobacilli and an overgrowth of other bacterial species- typically anaerobic organisms

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15
Q

How is the pH different in bacterial vaginosis?

A

There is an increase in pH as and the vagina becomes less acidic/more alkali

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16
Q

What are the signs and symptoms of bacterial vaginosis?

A 
May be asymptomatic
Fish smelling discharge
Thin discharge that is white/grey
Vaginal irritation (less commonly)
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17
Q

What is the amsels criteria and what is it used for?

A

It is a criteria used for diagnosing bacterial vaginosis, at least three of the following should be positive:

1) Thin grey/white homogenous discharge
2) Positive amine test- release of fishy odour on adding alkali/10% KOH
3) Clue cells on microscopy (epithelial cells coated in bacteria)
4) pH of vaginal fluid >4.5

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18
Q

What investigation should be requested if someone has symptomatic bacterial vaginosis?

A

High vaginal swabs- Gram stain to examine vaginal flora, microscopy for clue cells and pH measurement

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19
Q

What is the Hay-Ison scoring system?

A

This is based on the results of the high vaginal swabs gram stain and microscopy
Grade 0= Epithelial cells only with no bacteria
Grade 1= Normal Vaginal flora (predominance of lactobacilli)
Grade 2= Intermediate vaginal flora (reduced number of lactobacilli with mixed bacterial flora)
Grade 3- Mixed bacterial flora only
Grave 4= Gram +Ve Cocci only

Grades 2 and 3 are consistent with a diagnosis of BV

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20
Q

Do all cases of bacterial vaginosis require treatment?

A

No- only if symptomatic

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21
Q

What is the recommended treatment for bacterial vaginosis?

A

Metronidazole 400mg Twice daily for 5 days

Or 2 g stat (Not in pregnancy, use BD course)

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22
Q

What topical therapies may be used in the treatment of bacterial vaginosis?

A

Intravaginal metronidazole gel (0.75%) OD for 5 days
Intravaginal clindamycin cream (2%) OD for 7 days
Lactic Acid Intravaginal Gel for 7 days- lack of evidence but also use weekly before and after periods for prevention of recurrence

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23
Q

How should bacterial vaginosis be treated in pregnant women?

A

Metronidazole 400mg for 5 days

Not 2g stat

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24
Q

What are some complications of BV?

A

Associated with a post-termination of pregnancy endometriosis and pelvic inflammatory disease
Associated with recurrent late miscarriage

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25
Q

How might recurrence of BV be reduced?

A

Metronidazole before and after periods- Days 1-3 and repeated at days 14-17
Or intravaginal lactic acid gel

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26
Q

What general measures should be recommended to women with BV?

A

Avoid vaginal douching
Avoid use of shampoo or anti-septic agents in the bath
Use of condoms during sex

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27
Q

What is the most common species that causes candida in women?

A

Candida albicans

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28
Q

What are the symptoms of a candida infection? (Thrush)

A

Cottage cheese like discharge- thick and white
Itching
Discomfort
Superficial Dyspareunia- painful sexual intercourse

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29
Q

Describe the discharge seen in a candida infection

A

Cottage cheese like
Thick and white
Non-offensive odour

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30
Q

If suspecting a candida infection what investigation should be done?

A

High vaginal swabs- microscopy and culture for candida

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31
Q

What is the treatment for a candida infection?

A

If asymptomatic and no problems are being caused no treatment is required- many women harbour candida species without any issues

If problematic-

  • Anti-fungal pessary +/- cream for external areas
  • Azole creams
  • Fluconazole 150mg stat (avoid in pregnancy)
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32
Q

What pH changes are seen with a candida infection?

A

Vaginal pH is normally still acidic and less than 5 (unlike BV and TV which cause the vagina to be less acidic)

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33
Q

What are some risk factors for candida overgrowth?

A

Diabetes mellitus
Corticosteroid use
Frequent ABx usage
Immuno-suppression

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34
Q

What can be done for recurrent candida infections?

A

Oral anti-fungal agents or pessaries weekly or every two weeks or 4-6 months

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35
Q

How should candida be treated in pregnant women?

A

Topical azoles is recommended

Oral therapy is contra indicated

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36
Q

Do male partners of women with candida require treatment?

A

No they dont

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37
Q

Give an example of an azole cream

A

Canestan- cotrimazole cream

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38
Q

How does candida in men normally present?

A

Mild balanitis with pruritis (inflammation of the head of the penis with some associated itching

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39
Q

What might candida in men be an important sign of?

A

Sign of un-diagnosed diabetes (do a urine dip)

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40
Q

What is the treatment for candida in men?

A

Avoid irritants and drying agents like soap

Use emollient cream with or without azole cream

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41
Q

What is chlamydia trachomatis?

A

A sexually transmitted infection of an obligate intra-cellular bacterium

Note- chlamydia can also have vertical transmission and an infected pregnancy mother can transmit it to the neonate which can cause neonatal conjunctivitis or less commonly pneumonitis

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42
Q

What is the most common STI in the UK?

A

Chlamydia

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43
Q

What are symptoms of chlamydia infection in a women?

A

Most commonly asymptomatic (80%)
Post-coital bleeding or inter-menstrual bleeding
Lower abdominal pain (inflammatory process)
Purulent vaginal discharge
Dysuria- painful urination

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44
Q

What are the symptoms of chlamydia infection in a male?

A

Asymptomatic in up to 50%
Urethritis- dysuria (painful urination)
Urethral discharge (purulent)
Testicular/epididymal pain (epididymitis is the most common complication in men)

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45
Q

What are the main complications of chlamydia infection in women?

A

Pelvic inflammatory disease (PID) due to spread- this increases the risk of ectopic pregnancy and infertility

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46
Q

What ocular complication may be seen in patients with a chlamydia infection?

A

Conjunctivitis- due to auto-innoculation. Opacities can form in the cornea and this is called trachoma

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47
Q

What rheumatological complication may be seen in patients with chlamydia infection?

A

Can cause reactive arthritis- Abs attack bacteria and the components of the joint.

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48
Q

What tests need to be done to diagnose chlamydia?

A

Swabs need to be taken and sent for Nucleic Acid Amplification Tests (NAATs). This uses different technologies including PCR for example.

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49
Q

What tests may be used in a male if suspecting a chlamydia infection?

A

Urethral swabs may be done or alternatively first void urinary (FSU)- this is not a MSU and urine should be held for at least 1 hour. Nucleic acid amplification tests are then done on this to investigate if it is chlamydia.

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50
Q

Where should swabs be taken from if suspecting chlamydia in a woman?

A

Vulvo-Vaginal (may be done by self)
Anus/Rectum if anal sex
Mouth if oral sex

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51
Q

Where should swabs me taken from in a man who has sex with other men if suspecting chlamydia?

A

Urethra/ or do FVU
Anus/Rectum
Oral cavity

Send all for Nucleic Acid Amplification Tests

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52
Q

What is the treatment for chlamydia?

A

Doxycycline 100mg BD for 7 days (Not if pregnant or breastfeeding)
Or Azithromycin 1 g stat
Or ofloxacin 200mg BD or 400mg od for 7 days

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53
Q

What is an important complication of chlamydia infection in women?

A

Pelvic inflammatory disease- risk of ectopic pregnancy and infertility
Transmission to neonate- neonatal conjunctivitis and pneumocytitis

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54
Q

If diagnosing a patient with chlamydia, what need to be done to prevent further spread/re-infection?

A

Partner Notification- all recent (within last 6 months) and current sexual partners need to be informed . They need be informed and encouraged to seek medical help

Also encourage sexual abstinence till completion of therapy

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55
Q

How can the risk of contracting chlamydia be reduced?

A

Use a condom

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56
Q

What needs to be done at follow up for a patient treated for chlamydia?

A

Ensure partner notification has taken place
Exclude re-infection
Ensure compliance of the medications

(Routine tests of cure are not indicated- but are essential in pregnant women to prevent transfer to the neonate, NAAT may detect dead organisms up to 4 weeks after commencing therapy- so if testing for a cure do it at least 4 weeks after completing therapy)

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57
Q

Who should be checked using Nucleic Acid Amplification Tests after treatment for chlamydia to check for treatment success?

A

Pregnant women- essential to check for cure due to transfer to the neonate

Also- patients aged <25 years should be considered for re-test 3-6 months later as there is a higher risk of re-infection.

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58
Q

What is epididymo-orchitis?

A

Inflammation of the epididymis and testicles that is triggered by an infective agent

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59
Q

What are the symptoms of epididymitis?

A 
Unilateral scrotal/testicular pain
Scrotal swelling
Orchitis- testicular tenderness
Erythema of overlying skin
Relieved on elevation of the testicle- this is called Phren's Sign. Important as testicular tortion is a not relieved by elevation of the testicles and is a surgical emergency requiring urgent surgical exploration
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60
Q

How can testicular torsion be differentiated from epididymitis?

A

Elevate the testicles
If pain reduces- epididymitis
If pain unchanged- torsion

Called Phren’s Sign

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61
Q

What are some other differentials of unilateral testicular pain?

A

Epididymitis
Orchitis
Inguinal hernia
Tumours- rarely painful

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62
Q

What should be considered the causative organism for epididymo-orchitis in patients aged below 35? How is this treated?

A

STI- Gonorrhoea and Chlamydia

Doxycycline 100mg BD for 14 days + Ceftriaxone 500mg IM
Or- Ofloxacin 200mg BD for 14 days

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63
Q

What should be considered the causative organism for epididymo-orchitis in patients aged over 35?

A

UTI causing organisms- treat according to local policy

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64
Q

How should a patient with epididymo-orchitis be assessed?

A

Take a sexual history
STI Screen
MSU

If STI isolated partner notification should take place

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65
Q

What simple measures should be recommend for patients with epididymo-orchitis?

A

Simple analgesics- e.g. paracetamol
Rest
Supportive underwear

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66
Q

What is the prevalence of HIV in the UK?

A

0.16%

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67
Q

Which mucosal surfaces does gonorrhoea infect?

A

Pharynx
Rectum
Genital tract
Eye

68
Q

What is the main route of transmission of gonorrhoea in adults?

A

Sexual Transmission

69
Q

What does peri-natal gonorrhoea infection result in?

A

Eye infection which can cause permanent blindness in a newborn baby without treatment

70
Q

What STI does gonorrhoea tend to occur at the same time as?

A

Chlamydia

Similar risk factors for both of them

71
Q

What are some of the symptoms of gonorrhoea infection?

Note- depends upon the site of infection so answer according to these

A

This depends upon the site of the infection- reproductive mucosa, pharynx, eye, rectum

Male- Reproductive Mucosa- muco-purulent discharge, dysuria, some are asymptomatic

Female Reproductive Mucosa- Inflammation of mucosal surfaces can cause cervicitis, this can cause pain during sex with muco-purulent discharge. Also lower abdominal pain.

Pharynx- 90% Asymptomatic, 10% develop a sore throat. Infection can come from oral sex.

Eye- Conjunctivitis

Rectum- Asymptomatic but can cause some pain

72
Q

What signs may be seen from gonorrhoea infection of the urethra?

A

Discharge- muco-purulent

Meatitis

73
Q

What signs may be seen from gonorrhoea infection of the pharynx?

A

Exudate
Pharyngitis
(~90% are asymptomatic though)

74
Q

Why are pregnant women screened for gonorrhoea infection?

A

As gonorrhoea can result in eye disease of the new born which if untreated can cause permanent blindness

75
Q

What is a worrying complication of gonorrhoea infection?

A

Disseminated gonorrhoea infection- involving haematogenous spread

This can result in conjunctivitis, meningitis, infective arthritis and septicaemia

76
Q

How is gonorrhoea diagnosed in men? What investigations should be done?

A
  • Take urethral, rectal and pharyngeal swabs
  • Gram stain and microscopy of the discharge for presumptive diagnosis (Gonorrhoea is gram -ve diplococci)
  • Gonorrhoea culture and/or NAAT from samples
77
Q

What is the investigation of choice for asymptomatic men when investigating gonorrhoea infection?

A

NAATs on First Void Urine (Not midstream and first void brings the discharge and cells)

According to BASHH Guidelines

If a result comes back positive a culture should be undertaken to check for resistance to antibiotics

78
Q

Why is it important to do a culture for gonorrhoea?

A

Strains of gonorrhoea have become resistant to treatments and so anti-biotic sensitivities can be tested if requesting a culture

79
Q

How is gonorrhoea diagnosed in symptomatic women? What investigations should be done?

A

Endo-cervical swab for culture and NAAT +/- urethral culture.

Note- other STIs such as chlamydia and TV often co-exist and so these should also be tested for/ Always culture so sensitivities can be checked.

80
Q

How should gonorrhoea be investigated for in asymptomatic women?

A

Dual NAATs which also test for chlamydia

Samples should be obtained using self taken vulvo-vaginal swabs

81
Q

What is the treatment for gonorrhoea?

A

Ceftriaxone 500mg IM + Azithromycin 1g PO (Both as stat dose)

Guidelines differ depending on location so check local guidelines. Azithromycin 1g PO Stat is included as 30% also have chlamydia infection.

82
Q

What is the recommended follow up for a patient treated for gonorrhoea?

A

Test-of cure usually 2-4 weeks after treatment

Microscopy, NAATs and culture

83
Q

When diagnosing someone with gonorrhoea what else is a very important thing to do?

A

Parter notification- all recent (e.g last three months) and current sexual partners must be seen and tested

This is important to prevent the spread of infection, prevent re-infection of the index case.

84
Q

How many types of herpes simplex virus are there?

A

HSV 1 and HSV 2 (Two types)

85
Q

Where does each types of HSV infect?

A

HSV 1 above the waist

HSV 2 below the waist

86
Q

What can happen after initial infection with HSV?

A

Asymptomatic (70-80%)
Development of minor lesions
Minority develop a severe primary attack within 2-12 days after acquisition of the virus

87
Q

What are the features of a primary HSV attack?

A 
Febrile illness
Dysuria
Painful inguinal lymphadenopathy
Tingling/neuropathic pain in the genital area, buttocks or legs
Genital blisters, ulcers and fissures
88
Q

How long may an untreated episode of herpes simplex virus last?

A

Around three weeks

If lasts longer than 4 weeks suspect underlying immunodeficiency

89
Q

What are the symptoms of HSV generally?

A

Blisters and ulcers- small, painful and fluid filled
Neuropathic prodrome- tingling, burning (Infect sensory neurones where they enter the latent cycle)
Usually resolve within 3-4 days

90
Q

What are some risk factors for symptomatic recurrence?

A

Young <20 years of age
Severe first episode
Genital HSV-2 infection
HIV infection or other immunodeficiency problems

91
Q

How can HSV be diagnosed?

A

Swabs can be taken during an acute episode (this should be as soon as possible)
HSV PCR can then be done

(Don’t delay treatment for a PCR test result)

92
Q

What is the treatment for a primary/first episode of HSV?

A

(Anti-Viral Therapy)
Acyclovir 400mg 3 times a day for 5 days or 200mg five times a day for 5 days
Valaciclovir 500mg twice daily for 5 days
Famciclovir 250mg three times daily for 5 days

(If within 5 days of lesions developing or if after 5 days and still forming new lesions)

  • Regular analgesics
  • Bathing in a dilute saline solution to relieve symptoms , reduce secondary infections and promote healing
93
Q

Is treatment required for recurrent episodes?

A

No- simple analgesics and saline washes may be recommended

Anti-viral treatment may be used to abort a recurrent attack if there is a clear neuronal prodrome (burning/tingling)

94
Q

What can be done if patients are having frequent attacks?

A

If experiencing six or more episodes a year suppressive therapy may be given

400mg Aciclovir BD for 6 months

95
Q

What type of corneal ulcer is seen with viral keratitis due to HSV?

A

Dendritic lesion

96
Q

What should be done if a primary HSV attack occurs in the third trimester of pregnancy?

A

C-Section should be offered if primary attack during third trimester

97
Q

What should be done if a recurrent HSV attack occurs during the third trimester?

A

Previous practice was to offer C-section if lesions present at the time of delivery but vaginal delivery can now be offered

98
Q

What should be offered to women who have symptomatic recurrence of HSV during pregnancy?

A

Suppressive therapy should be offered during the third trimester to reduce the risk of transmission to the child and recurrence at the time of delivery

99
Q

What should pregnant partners without HSV of men with herpes be advised?

A

If active lesions/recurrence avoid sexual contact

Use of condoms may reduce the risk of transmission

100
Q

How is hepatitis B spread?

A

Blood and bodily fluids- sexual transmission

101
Q

What groups are at risk of hepatitis B infection?

A

MSM
IVDU
Healthcare Workers
Sex workers

102
Q

How is hepatitis B diagnosed?

A

Hepatitis B Serology Testing

Hep B Surface Antigen- Marker of infection, acute or chronic
Hepatitis B Core Antibody- Marker of previous infection with Hep B, remains positive in resolved infection but is negative in vaccinated individuals
Hepatitis B Surface Antibody- Marker of exposure to Hepatitis B infection or Vaccination (Titre level determines immunity)
Hepatitis E Antigen- Marker of viral activity

DO LFTs too- ALT and AST rises but this is often mild. In late stages they become grossly abnormal.

103
Q

What are some symptoms of fulminant hepatitis B infection?

A 
Fever
Malise
Nausea
RUQ Pain
Jaundice
Hepatomegaly
104
Q

What is the incubation period for hepatitis B?

A

1-6 months

Asymptomatic infection is found in 10-50% of adults in the acute phase and is more likely in those with HIV co-infection. (As damage is due to immune reaction not the virus itself). Almost all infants and children have asymptomatic acute infection.

105
Q

What are some complications of acute hepatitis B infection?

A

Fulminant hepatitis
5-10% will develop chronic hepatitis B infection- more commonly in those taking immunosuppressive drugs and HIV positive
In pregnancy there is an increased risk of miscarriage and premature labour
Increased risk of transmission the the neonate

106
Q

What are some of the complications of chronic hepatitis B infection?

A

Long standing inflammation increases the risk of HCC
Super-infection with delta virus
Progression to cirrhosis with long-standing inflammation
Complications related to cirrhosis and liver failure- e.g. bleeding, ascites

107
Q

What might be done if a pregnant woman if found to have hepatitis B infection?

A

Vaccination of the new-born and give it hepatitis B specific antibodies to reduce vertical transmission

108
Q

Should mothers who are hepatitis B +ve still breast-feed?

A

Yes as there is no additional risk of transmission

109
Q

Is contact tracing required for someone with hepatitis B infection?

A

Yes, this should include any sexual partners or needle sharers during the period when the index case may have been infective.

The infectious period is two weeks before the onset of jaundice and development of antibodies, before the surface antigen becomes negative.

110
Q

If found to have chronic hepatitis B infection what should be done?

A

Explain the mode of transmission and ensure vaccination for all future sexual partners
Test any children if they were not vaccinated at birth (note that Hep B testing is done in pregnancy anyway)

111
Q

If someone is exposed to hepatitis B (un-protected sex, needle stick) and is un-vaccinated, what may be given?

A

Hepatitis B Specific Immunoglobulin (HBIG) can be given if the person was thought to be infectious. Works best within 48 hours and is no use if after more than 7 days

112
Q

What else should be given to people who have come into contact with Hep B and were given HBIG?

A

Vaccinate them-

Standard- 0, 1 and 6 months
Accelerated course- 0,1,2 and 12 months
Ultra rapid course- 0,7,21 days and then 12 months

113
Q

Who should be screened for hepatitis B?

A 
MSM
IVDU
Commercial sex workers
Pregnant women
Health care workers
HIV +ve patients
Sexual assault victims
Needle stick injuries
114
Q

What is pelvic inflammatory disease?

A

This is a complication of an STI which leads to inflammation from the cervix to endometrium, fallopian tubes and other pelvic structures. Usually the result of infection spreading from the endo-cervix (e.g. chlamydia, gonorrhoea)

115
Q

What are some of the symptoms of pelvic inflammatory disease?

A

Pelvic pain
Ectopic pregnancies
Infertility

116
Q

What are some causative organisms for PID?

A

Chlamydia
Gonorrhoea
Streptococci (post surgery but must exclude above two)

117
Q

What type of examination is required to make the diagnosis of PID?

A

Bimanual examination- palpating internally and at the lower abdomen

118
Q

Why is it important to have a low threshold to treating PID?

A

PID can cause damage to the fallopian tubes leading to increased risk of infertility and ectopic pregnancy

119
Q

What are some symptoms of PID?

A 
Lower abdominal/pelvic pain
Dysuria
Discharge
Painful sexual intercourse
Bleeding between periods or after sex
120
Q

What are some signs of PID?

A

Bi-manual examination required

Uterine tenderness
Cervical excitation
Adnexal tenderness

121
Q

Which patients should a diagnosis of PID be considered for?

A 
Multiple sexual partners
Young (below 25)
Diagnosis of gonorrhoea or chlamydia
Symptoms of PID
Doesn't sue condoms
Intra-uterine device for contraception
122
Q

What are some differential diagnoses for PID?

A

Ectopic pregnancy (any abdominal pain in a female of child bearing age)
IBS
Endometriosis
Diverticular disease
Appendicitis
Ovarian cysts
Uterine crams related to insertion of an IUD

123
Q

What investigations should be done for suspected PID?

A 
Pregnancy test
Endo-cervical swabs for N.gonorrhoea
Vulvo-vaginal swabs for Chlamydia and N.gonorrhoea
MSU if history of urinary sx
If any pelvic massess- USS
124
Q

What is the treatment for PID?

A

Empirical treatment is given

Outpatient-
Doxycylcine 100mg BD for 14 days 
AND Metronidazole 400mg BD for 15 days
AND Ceftriaxone 500mg IM Stat 
(Covers gonorrhoea infection)
125
Q

If uncertain of the diagnosis what investigation can be done for PID?

A

Laparoscopy if there is failure to respond to empirical therapy

126
Q

Should an IUD be removed if a patient fails to respond to empirical therapy?

A

Yes, but empirical therapy should be trialed before this is done. Also if failure to respond, laparoscopy should be considered.

127
Q

Which patients with PID should be considered for inpatient treatment?

A 
Clinically unstable
High temperature
High inflammatory markers
Tachycardia and low blood pressure
Presence of a tubo-ovarian abscess (this would require drainage)
Pregnant women

Also if diagnostic uncertainty if could be another cause of acute abdomen- e.g. acute appendicitis

128
Q

Is partner notification/tracing required for PID?

A

Yes, chlamydia and gonorrhoea are leading causes

Partners should be swabbed and investigated for these.

Empirical treatment with Doxycycline 100mg BD for 7 days is recommended for all (covers chlamydia)

129
Q

What general advice should be given to women with PID?

A

Avoid sexual activity until treatment has been completed
Partner should be tested
Rest is recommended
Use analgesia if required

130
Q

What is the causative organism for syphilis?

A

Treponema pallidum- a spirochaete

131
Q

What are the two ways in which syphilis can be transmitted?

A

Acquired syphilis- spread through bodily fluids with sexual activity, IVDU or contact with a lesion

Congenital Syphilis- Infection to the neonate

132
Q

What are the three stages of syphilis?

A

Primary- Early localised syphilis
Secondary Syphilis- Dissemination stage
Latent Syphilis- Dormant or Asymptomatic Phase

Then Tertiary Syphilis/ Symptomatic Late Syphilis (Found in up to 40% untreated)

133
Q

What are the symptoms of primary syphilis?

A

Ulcer (called a syphilitic chancre) with regional lymphadenopathy (near to the ulcer- can spread from lymph into the blood).

The ulcers are painless, have an indurated base and discharge clear serum. Often found in the anogenital region

134
Q

Describe the features of an ulcer due to syphilis?

A 
Painless
Indurated with raised borders
Clean base
Discharge clear serum
Often found in the anogenital region if acquired from sexual contact

Note- may be painful, purulent, destructive or extra-genital so any ulcer should have syphilis as a differential

135
Q

When does primary syphilis often occur following exposure? What are the features?

A

9-90 days

Painless ulcer with raised borders that secreted a clear fluid. There is regional lymphadenopathy.

136
Q

What is secondary syphilis?

A

Disseminated syphilis, syphilis spircohaetes enter the blood stream. This is the most infectious stage.

Features are widespread and there is multi-system involvement:

  • Non-itchy maculopapular rash- starts at trunk and spreads to involve the arms, legs, palms, soles of feet and genitalia.
  • Generalised lymphadenopathy
  • Patchy alopecia
  • Anterior uveitis
  • Meningitis
  • Cranial nerve palsies
  • Hepatitis
  • Glomerulonephritis
  • Splenomegaly
137
Q

Describe the skin features of a rash due to secondary syphilis?

A

Non-itchy maculopapular rash
Starts at trunk and spreads to involve arms, legs, soles , palms and genital region
May be:
- Pustular > fluid filled pustules (small bumps)
- Papulosquamous > scaly with papule (small raised lumps of skin with no visible fluid
- Condyloma Lata > Smooth, white, painless bumps that appear in moist areas like genitals and armpits.

138
Q

How is latent syphilis divided?

A

Latent syphilis is having serological evidence of syphilis infection without clinical features

Early is within two years
Late is after two years

(After secondary syphilis symptoms)

139
Q

What is tertiary syphilis?

A

This is bad. Type 4 Hypersensitivity reaction to the spirochaetes leading to swelling and inflammation around the location of spirochates.

The major clinical manifestations of this are:

  • Neurosyphilis > Can be asymptomatic (abnormal CSF), dorsal column loss or dementia (general paralysis of the insane)
  • Cardiovascular Syphilis > aortitis, aortic regurgitation, aortic aneurysms
  • Gummata > Inflammatory fibrous nodules
140
Q

What can congenital syphilis cause?

A 
Still birth
Enlarged liver and spleen
Rash
Fever
Neurosyphilis
Facial deformities
Snuffles- nose blocked by increased secretions
141
Q

How is syphilis diagnosed?

A

T.Pallidum on dark field microscopy
Syphilis Serology
DNA test (using material obtained from lesions, also tests for HSV which is another cause of ulcer)

142
Q

What is the treatment for syphilis?

A

Long acting penicillin

143
Q

Are pregnant women screen for syphilis?

A

Yes all pregnant women are screen for syphilis

144
Q

What else must be done when a patient is diagnosed with syphilis?

A

Partner notification

145
Q

What does TV stand for?

A

Trichomonas vaginalis

146
Q

What symptoms does TV cause in women?

A

50% are asymptomatic
Discharge- thin, frothy, yellow and offensive smell
Painful sex- anterior/superficial
Painful urination
Vulvitis and Vaginitis
Post coital bleeding with cervicitis (seen on examination)

147
Q

What symptoms does TV cause in men?

A

Usually asymptomatic

Sometimes urethritis and balanitis

148
Q

How is TV diagnosed?

A

Females- High Vaginal swabs for NAAT (or microscopy or culture)

Diagnosis is more difficult in men so if female partner tests positive treat them too

149
Q

What is the treatment for TV?

A

Metronidazole 400mg BD for 5 days

Advice sexual abstinence till treatment is completed. If giving to a female male partners should be treated too.

Second course may be required if first course fails.

150
Q

What is urethritis?

A

Inflammation of the urethra characterised by dysuria and/or discharge

151
Q

What are some causative organisms of urethritis?

A

N.Gonorrhoeae (Gonorrhoea)
C.trachomatis (Chlamydia)
Mycoplasma genitalium
Trichomonas vaginalis

If a specific pathogen is isolated it is named according to the causative pathogen- e.g. Gonococcal Urethritis or Chlamydial Urethritis

If no specific pathogen is found it is called non-specific urethritis

152
Q

What is non specific urethritis?

A

When no specific pathogen is found for urethritis (inflammation of the urethra- dysuria or discharge)

153
Q

How is NSU acquired?

A

Through sexual contact

154
Q

What are the most common causes of urinary symptoms in young men?

A

STIs- Urethritis

Therefore different to UTIs

155
Q

What tests should be done to investigate urethritis?

A

Urethral swabs- For NAAT and culture (test for chlamydia and gonorrhoea)
First void urine- NAAT for Gonorrhoea and Chlamydia
Urethral smear for gram stain and microscopy
Consider MSU if suspecting a UTI (e.g no causative organism found from swabs)

156
Q

What does the diagnosis of NSU require?

A
  • Gram stained urethral smear taken at least 2 hours after last voiding shows more than 5 leucocytes per high powered field
  • Tests for specific pathogens are negative
  • No evidence of other possible causes
157
Q

How is non-specific urethritis/ non-gonoccocal urethritis treated?

A

Doxycycline 100mg BD for 7 days (Covers Chlamydia)
Or Azithromycin 1g Stat
Or Azithromycin 500mg Stat + 250mg OD for four days

158
Q

What else needs to be done for patients being treated for NGU?

A

Contact tracing recommended they get tested themselves

159
Q

What is the causative organism of genital warts?

A

Human papilloma virus (HPV)

160
Q

How is HPV transmitted?

A

Close physical (skin to skin contact)

161
Q

Can HPV be asymptomatic?

A

Yes, many people with the virus never develop visible warts but can still transmit the virus to others

162
Q

What are the symptoms of HPV infection?

A

External warts- lumps which may be hard/soft or be solitary or have multiple
Bleeding- especially urethral
Itching
Sometimes hyperpigmentatio

163
Q

How is HPV diagnosed?

A

Diagnosis is usually clinical based on the characteristic appearance of genital warts

Biopsy can be taken if there is any uncertainty/failure to respond to treatment.

164
Q

What is the treatment for extra-genital warts?

A

It’s not possible to eradicate the virus but the warts can be removed.

Simple external warts-
Podophyllotoxin cream (avoid if nut allergy or pregnancy)
Weekly cryotherapy
Imiquimod (Aldara)- applied 3x weekly patient (CI in pregnancy)

Cervical warts- colposcopy

165
Q

What is an important complication of HPV infection?

A

Increased risk of cancers due to oncogenic strains (HPV 16, 18, 31). Associated with increased risk of skin, head, neck and cervical cancers.

These strains rarely cause externally visible warts (mostly caused by HPV 6, 11)

166
Q

What strains of HPV does the vaccine cover?

A

Bivalent - HPV 16 and 18

Quadravalent- HPV 6, 11, 16 and 18 (Covers against warts too)

167
Q

Who is the HPV vaccine offered to?

A

Girls aged 11-17

Men who have sex with men

SPM- GUM (5 decks)

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