Rape, Sex, STIs Flashcards
What to include in hx of rape
medical history, identifying info about assailant, circumstances, details of sexual contact, physical restraints/weapons/drugs, activities of victim after assault, gynae hx (LMP, contraception, pregnancy hx, last voluntary sexual encounter, gynae sx)
What evidence to collect after rape
Pt’s clothing
Fingernail scrapings
Hair strands
Oropharyngeal swabs
Pubic hair
Vaginal swabs
Vaginal washing
Pap
Rectal swab
Blood samples
Ix after rape + when to perform
Pregnancy test
VDRL (syphilis): initial visit, repeat at 12 + 24 wks
Hepatitis (if not immune, repeat at 1 + 6mo
HIV: initial visit, 6, 12 + 24wks)
Pregnancy prophylaxis after rape
Ulipristal 30mg up to 5 days
Levonorgestrel 1.5mg up to 72hrs
Copper IUD up to 7 days
STI prevention after rape
If unsure of FU, assailant has known STI, pt has sx of STI, pt requests it
Cefixime 400mg x1, azithromycin 1g x1
Complications + management after rape
Depression
Sexual dysfunction
Offer counselling to victim, family, friends, partners
Posthitis
Inflammation of foreskin
Phimosis
Narrowing of foreskin preventing retraction over glans
Paraphimosis
Narrowing of foreskin below glans preventing return to normal
Management congenital phimosis
Reassurance (a good majority can resolve spontaneously with time)
Corticosteroids (betamethasone 0.05-0.1% applied bid x 6-8 weeks with gradual retractions)
Consider Circumcision (if failure of medical treatment or concerning physical exam findings)
When to consider surgery in phimosis
Recurrent Infections
Foreskin Scarring (fibrous ring formation)
Meatal Stenosis
Excessive Ballooning with Urination
Painful Erections
Sx of andropause
Low Libido
Erectile Dysfunction
Decreased Morning Erections
Increased Body Fat
Low Muscle Mass
Decreased Physical Strength
Hair Loss
Fatigue
Low Energy
Low/Depressed Mood
Irritability
Decreased Concentration
Insomnia
Low Bone Mass
Anemia
Flushing
Ix for andropause
2x morning total testosterone serum level
FSH
LH
PRL
TSH
sHBG (sex-hormone binding globulin)
Free Testosterone
Bioavailable Testosterone
Meds/ substances that lower testosterone
Opiods
Marijuana
Ethanol
Corticosteroids
Spironolactone
Ketoconazole
Cimetidine
Neuroleptics (increases PRL)
Metoclopramide (increases PRL)
Chemotherapy
When to ask about sexual health and function
In conditions that are high risk for sexual dysfunction (post MI, diabetes)
Through life cycle transitions (adolescent, pregnant, menopause)
RF for ED
CVD: obesity, DM, dyslipidemia, metabolic syndrome, smoking
Age
OSA
Liver dz
Vit D deficiency
Causes of ED
Psychogenic: sudden acute onset, normal nocturnal + AM erections, situational
Organic: gradual onset
Vascular:
5 yrs after stroke or MI
Atherosclerosis, PVD
Substances:
Antihypertensives (BB, CCB, spironolactone)
Opiates
Antidepressants
Ranitidine
Hormones (steroids, anti-androgens)
Methotrexate
Cannabis
Cocaine
Alcohol
Psychologic: MDD, GAD, stress
Neuro:
Spinal cord injury
Polyneuropathy (DM, alcohol)
MS
Parkinsons
Alzheimers
Hormonal
Hypogonadism
Hyperprolactinemia
Thyroid
Cushings
Addisons
What to do on physical exam for ED
Peripheral pulses, BP, HR, BMI
Thyroid exam
Penis: Peyronie’s, micropenis, plaques, phimosis, frenula tether, meatal stenosis, femoral pulses
Penis sensation
Ix for ED
Lipids, a1c, TSH, ECG
Rx for ED
Counsel r.e. risk marker for CVD
Weight loss
Diet + exercise
Reduce alcohol, smoking + drugs
Meds:
PDE5i (sildenafil, tadalafil)
CI: unstable angina, uncontrolled HTN, HF, recent MI, arrhythmias, HOCM, nitrate use
SE: sudden, severe vision loss. HA, flushing, dyspepsia, congestion, visual disturbance, hypotension
Vacuum constriction device
Intracavernosal injection (alprostadil)
Surgical prosthesis
CI to viagra
Recent Myocardial Infarction
Recent Stroke
Recent Arrhythmias
Uncontrolled Hypertension/Hypotension
SE of viagra
Headaches
Flushing/Rhinitis
Abnormal Vision (blue dots)
Dizziness
Myalgia
Nausea/Dyspepsia
Priapism
Sx of testicular torsion
sudden onset, severe, unrelenting unilateral scrotal pain, N/V
What score to assess testicular torsion, and what Ix?
TWIST score
Testicular swelling (2), hard testicle (2), high riding testes (1), absent cremasteric reflex (1), N/V (1)
5/7 = positive predictive value of 100%
Doppler US
Management of testicular torsion
manual detorsion if surgery not available. Golden window is 4-8 hrs from sx onset
Sx fourniers gangrene
Groin pain
Bilateral testicular pain
Erythematous skin
SC emphysema
Ix fourniers gangrene
CT abdo
General prevention of STIs
HPV
Hep A + B
Condom use
Male circumcision
PrEP
Reduce partners
Screening for STIs
<30 + sexually active = screen annually
Sx acute HIV +
Sx chronic HIV
Sx acute HIV: flu like illness, fever, fatigue, malaise, arthralgias, HA, anorexia, rash, nightsweats, oral ulcers, pharyngitis
Sx chronic HIV: fever, fatigue, wt loss, anemia, candidiasis, SOB, cough, dysphagia, Kaposi sarcoma, HSV
AIDs-defining conditions
CMV, encephalopathy, dementia
HSV
Candidiasis, recurrent PNA, TB
Cervical cancer
Kaposi sarcoma
Lymphoma
PJP
Salmonella sepsis (recurrent)
Screening for HIV
exposure, high risk, preg, once for all 15-65
Pre test counselling hiv
Consent
Confidentiality
Counselling
Correct test results
Connect to prevention/ care/ treatment