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
Post test counselling HIV
Supports
HIV vs AIDs
Education re transmission
Partner notification + protection
Treatment + goals
Ix for HIV testing
3w for ELISA test
If positive: HIV resistance testing, viral load, CD4
Management of HIV: what imms to recommend, what ART regime 1st line, when to give prophylaxis against PJP + mycobacterium based on CD4 count
Immunisations: Hep A, B, Tdap, pneumococcal, HPV4, influenza, MMR + varicella
ART: 2 NRTI (tenofovir, entracitabine (Truvada)) + integrase inhibitor (dolutegravir)
Prophylaxis:
CD4<0.2 = Septra DS d/t risk of PJP
CD4 <0.05 = Azithromycin d/t risk of mycobacterium
Pre-exposure prophylaxis for HIV - who and what
Who: MSM + condomless sex + 1) syphilis or 2) HIV positive partner not on ART OR VL >200 or 3) HIV RF >10
Tenofovir + emtricitabine
Meds for post-exposure prophylaxis for HIV
Truvada + Dolutegravir x28d
Sx of GC + CT
Asymptomatic - could present after exposure or partner testing positive
Sx - dysuria, urethral/ vaginal/ rectal discharge, itchy, lower abdo/ testest/ rectal pain, conjunctivitis
Ix for CT + GC
first catch urine or urethral/ cervical swab NAAT - nucleic acid amplification test. Urine microscopy good for post pubertal males. Must be at least 2 days post exposure. Send for gonoccal culture to help with tracking resistance patterns
Management of CT
Tx: if tests are positive or if sx are suggestive of STI or if partner was diagnosed
Treatment also for pregnant women, victims of sexual assault and those with inadequate FU
Chlamydia: doxycycline 100mg PO BID x 7 days or 1g azithromycin PO single dose if 7 day course is difficult
Lab will notify public health if result is positive
Wait 7 days after start of meds before having sex
Management of GC
Tx: if tests are positive or if sx are suggestive of STI or if partner was diagnosed
Treatment also for pregnant women, victims of sexual assault and those with inadequate FU
Gonorrhea: ceftriaxone 250mg IM single dose + 1g azithromycin PO single dose, or cefixime 800mg PO single dose + 1g azithromycin PO single dose
Lab will notify public health if result is positive
Notify public health if cefixime, ceftriaxone or azithromycin FAILURE for gonoccocal infection
Wait 7 days after start of meds before having sex
Sx of urethritis
Sx: 2-6d after exposure, urethral d/c/itch, dysuria, urinary freq
Abstain for 7d
Bacterial vaginosis sx + rx
Sx: fishy odor, white/ grey thin d/c
Rx: metronidazole 500mg BID x 10/7
Candidiasis sx
Sx: itchy, dysuria, dyspareunia, white clumpy d/c
Trichomoniasis sx + rx
Sx: itchy, white/ yellow dc, strawberry cervix
Rx: metronidazole 2g x 1 dose for men, 500mg BID x7/7 for women
Lymphogranuloma venereum sx + rx
Sx: painless papule, ulcers, tender inguinal nodes
Rx: doxycycline 100mg BID x 3w
Test of cure
HSV sx + rx
Painful vesiculoulcerative genital lesions, systemic sx of fever, myalgias, tender lymphadenopathy
Confirm with lab testing
Partner notification not required
Rx: acyclovir 400mg TID x 10 days
HPV sx + rx
Sx: cauliflower like growth
Rx: imiquimod 3.75% QHS up to 8w or cryotherapy q1-2 wks
Chancroid sx, ix + rx
Sx: papules -> pustules -> painful ulcers
Ix: swab
Rx: ciprofloxacin 500mg BID x3/7
Treat partners empirically
Pubic lice sx + rx
24hr life span off host
Sx: itching, erythema, small blue spots
Rx: permethrin 1% cream
Sx + rx of scabies
Sx: nocturnal itching, burrows/ tracking
Rx: permethrin 5% cream + ivermectin 200ug/kg PO x1 dose
Wash clothing + bedding in hot water, vacuum mattress
Sx of primary, secondary, latent + tertiary syphilis
Primary: chancre, painless ulcer with raised border, lymphadenopathy
Secondary: fever, flu like illness, rash (pink macules on palms + soles), oral lesions, genito-inguinal rash, diffuse alopecia
Latent: asymptomatic
Tertiary: aortic aneurysm, AR, HA, vertigo, dementia, ataxia
Rx for syphilis
Penicillin G
FU w/ serology at 6 + 12mo
Causes, RF + sx of epididymitis
Causes: CT, GC, E coli
RF: UTI, unprotected sex, catheter, reflux
Sx: testicular pain + swelling, urethritis, Phren’s sign (pain relief w/ elevation of testicle)
Complications, dx, rx and Phren sign in epididymitis
Complications: testicular atrophy + infertility
Dx: STI testing, midstream urine culture
Management:
Suspected STI: doxy 100mg BID + ceftriaxone 250mg IM
Suspected enteric organism (MSM): levofloxacin 500mg x 14d
Phren sign: Scrotal elevation relieves pain in epididymitis but not in testicular torsion.
Most common bacteria causing epidydimitis
E.Coli
Gram Negative Bacilli
Sx + rx for PID
Sx: bilateral lower abdo pain, cervical motion tenderness
Dx: R/O ectopic
Rx: cefixime 800mg x1 + doxycycline 100mg BID x14d
Add metronidazole if adnexal mass, abscess, peritonitis or BV
Genetic causes of infertility in males
Klinefelter’s, Kallmann, CF, Kartageners
Causes of gynaecomastia
familial, obesity, hyperthyroidism, Klinefelter’s, Kallmann, secondary hypogonadism, hyperprolactinemia, testicular tumor, chronic renal dz
Genetic causes of infertility in males
Klinefelter’s, Kallmann, CF, Kartageners
When to urgently refer gynaecomastia
bloody nipple discharge, unilateral sub-areolar mass
Causes of genital itching
yeast, eczema, psoriasis, lichen sclerosis, vulvar cancer, herpes, BV
Complication of fertility treatment
ovarian hyperstimulation syndrome
Non pharmacological methods of treating ED
penile implants, sexual counselling, vacuum devices
Sudden penis pain after using viagra
priapism, penile fracture/ trauma
How and when to test for ovarian reserves
anti-mullerian hormone in women >35, or <35 w/ RF: single ovary, ovarian surgery, chemo or RT
PID rx, 1st line and if penicillin allergic
ceftriaxone + doxy OR clindamycin + gentamicin
Counselling for PID
partner treatment, contact tracing, abstinence x1 wk
What are the ABCs of sex?
Abuse, babies, cancer, STIs
Age of consent
18 if exploitative, 16 if non-exploitative, age 12-13 up to 2 yrs older, age 14-15 up to 5 years older
Priapism Ix
doppler US, cavernosal blood gas
Zika virus - transmission + sx
spread by mosquitos or sexual, fever, HA, arthralgia, myalgia
Types of priapism and management of each
non-ischemic: watch + wait, finasteride, lupron (GnRH agonist)
Ischemic: needle drainage, intracavernosal phenylephrine, surgical shunt if >48hrs
undescended testes can increase risk of what?
torsion, trauma, tumors, inguinal hernias + infertility
TWIST >6 - what to do
call peds uro
Cisgender definition
gender identity congruent with sex assigned at birth
Trans definition
individual who does not identify as cisgender
Transgender definition
gender identity different to gender assigned at birth
HIV PrEP med name
Truvada
RF for ED
smoking, HTN, PVD, depression
Meds that cause ED
H2 blockers, diuretics, BB
Sexual minorities are at higher risk for….
obesity, smoking, SU, MH issues, intimate partner violence, STIs, cancer
