Repro 6 STIs and PID Flashcards

1
Q

Why is the term STI instead of STD used?

A

STI - symptomatic and asymtomatic infection - still potential problems and potential to spread it
STD - symptomatic infection only

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2
Q

Where is the national data for STIs collected from?

A

GUM clinics - Gentio Urinary Medicine, which notify STDs centrally

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3
Q

Why is there a gradual and sustained increase in STI prevalence from 1995 to 99?

A

Increased transmission
Acceptability of GUM services
Greater public awareness
Development in diagnostic methods

Behavioural, socio-economic, healthcare provision and biological factors all contribute

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4
Q

What is the suspected reason for the fall in STI diagnosis prior to 95?

A

Thought to reflect changes in behaviour in response to the HIV epidemic

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5
Q

Why is data from GUM clinics an underestimation of the true incidence of STIs?

A

Patients may be seen in other settings e.g. GP or family planning clinics
Many infections are asymptomatic and only approx 10% of cases attend GUM

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6
Q

Who are the at risk groups in society of contracting STIs?

A
Young people
Ethnic minority (stigma)
Poverty/social exclusion
Low socio-economic status
Poorly educated
Unemployed
Teenage mothers (at risk behaviour)
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7
Q

What factors contribute to the risk of contracting STIs?

A
Age at first intercourse
Total number of sexual partners
Frequency of change of partners
Concurrent partners
Sexual orientation (with other factors)
Practice of unsafe sex
Lack of skills ad confidence to negotiate safe sex
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8
Q

What STIs might cause genital ulcers?

A

HSV (herpes simplex virus)
Syphilis
Chanchroid (Haemophilus ducreyi)

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9
Q

What STIs might cause vesicles of bullae?

A

HSV

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10
Q

When might an STI cause genital papules? Give some examples.

A

Transient manifestation of STIs - condylomata acuminata (anogenital warts), umbilicated lesions of Molluscum contagiosum virus

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11
Q

What should aspects of genital ulcers should be assessed?

A
Number
Size
Tenderness
Base
Edges
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12
Q

What are the various types of urethritis and what might cause them?

A
Gonococcal urethritis
NGU (nongonococcal urethritis) - chlamidia trachomatis, ureaplasma, mycoplasma, trichomonas HSV
Post-gonococcal urethritis
Non-specific urethritis
Non-infectious urethritis
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13
Q

What is vulvovaginitis and what might cause it?

A

Vaginal infection - candidias, trichomoniasis, staphylococcal, foreign body, HSV

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14
Q

What might cause cervicitis?

A

C. trachomatis, N. gonorrhoeae, HSV, HPV

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15
Q

What is bartholinitis and what might cause it?

A

Inflammation of one or both of the bartholin glands. Caused by polymicrobial infections with endogenous flora or rarely STIs

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16
Q

What are the symptoms of bacterial vaginosis?

A
Discharge
Odour
Itch
Dyspareunia
Soreness
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17
Q

How is bacterial vaginosis diagnosed?

A

Vaginal pH >4.5
Pungent odour with KOH (whiff test)
Presence of clue cells on a wet mount lacking many PNMs

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18
Q

What is the cause of bacterial vaginalis?

A

Thought to be the result of a synergistic infection involving the overgrowth of normal flora including gardnerella vaginalis

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19
Q

What are the potential pregnancy related causes of infections of the female pelvis?

A
Chorioamnionitis
Post-partum
Endometriosis
Episiotomy infections
Peurperal ovarian vein thrombophlebitis
Osteomyelitis pubis
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20
Q

What are the different types of prostatitis?

A

Acute bacterial
Chronic bacterial
Chronic pelvic pain syndrome

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21
Q

What are the different types of epididymitis?

A

Non-specific bacterial

Sexually transmitted

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22
Q

What are the causes of orhchitis?

A

(inflammation of the testes)
Viral (mumps, coxsackie B)
Pyogenic bacterial

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23
Q

Why do chlamydia trachomatis not grow on routine lab media?

A

They are obligate intracellular bacteria

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24
Q

What is the infective form of chlamydia trachomatis?

A

Elementary body which develops within the host cell into the reticulate body

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25
What does the reticulate body of chlamydia trachomatis do?
Replicates eventually reverting back to elementary bodies which leave the cell to infect other cells
26
Where in the female reproductive tract does chlamydia replicate?
Epithelium of the cervix and urethra
27
What are the consequences of an infection of C. trachomatis?
An ascending infection with involvement of the upper genital tract occurs and can result in clinical or subclinical PID presenting as endometritis or salpingitis. Perihepatitis is a rare complication (more likely from gonorrhoea)
28
What results from a cervical infection of C. trachomatis?
The majority of infections are symptomatic but it is an important cause of muopurulent cervicitis
29
What are the manifestations of a urethral infection of chlamydia?
Acute urethral syndrome - dysuria and frequency (most common in young sexually active women)
30
What are the common symptoms of chlamydia infection in males?
Urethritis Prostatitis Proctitis
31
What ar epotential complication of chlamydia infection in males?
Acute epididymitis
32
What is Reiters syndrome?
Urethritis, conjunctivitis, and arthritis are the classical triad f clinical manifestations Predominantly occurs in male patients affected with chlamydia
33
Where other than the genital tract may there be a manifestation of chlamydia?
Eye - ocular infections
34
What is the cause of chlamydia in neonates?
Cervical infection in pregnant women
35
What are the manifestations and complications of chlamydia in neonates?
Neonatal conjunctivitis | Neonatal pneumonia
36
How are specimen collected from males to test for chlamydia?
Urethral swab or first catch urine
37
How are specimen collected from females to test for chlamydia?
Endocervical swab. It is important that any pus is first removed from the cervix and that good quality cellular material is obtained
38
What are the pros and cons for urine samples as a specimen collection for chlamydia testing?
Less sensitive than swabs Patients may provide their own samples whereas swabs are time consuming and requires a trained member of staff to take the specimen and is less acceptable to the patient
39
How are specimens collected from neonates to test for chlamydia?
Eye swab - remove pus, invert eyelid and scrape conjunctiva surface to obtain cellular material For pneumonia, serology is useful. A differential on a WCC may show eosinophilia
40
How are diagnoses of chlamydia made?
``` Used to employ tissue culture but this is expensive and requires highly specialised labs Antigen detection (immunofluorescence) Enzyme Immunoassays (EIA) Molecular methods (PCR) Nucleic acid amplification from first void urine ```
41
Describe the method of antigen detection in diagnosing chlamydia.
Specimens may be fixed to a slide and stained with a monoclonal antibody that is tagged with fluorescein Slides are examined under a UV microscope
42
What are the drawbacks and advantages to antigen detection in diagnosing chlamydia?
Results are subject to observer error and the method is time consuming (only suitable for small number of specimens) Quality of specimen can be assessed
43
Describe the advantages and disadvantages of EIA in assessing specimens for chlamydia.
Allow a large number of specimens to be processed relatively easily Relatively cheap Comercial kits may vary in sensitivity and specificity
44
What are the advantages and disadvantages to molecular methods use in diagnosing chlamydia?
High sensitivity and specificity Clinical specimens may contain inhibitors that will interfere with the assay Commercial kits may yield significant false positives and negatives
45
What is the mainstay treatment for chlamydia?
Macrolides (erythromycin/clarithromycin/azithromycin) Tetracyclines (doxycycline (Typically used for atypical resp infection)
46
Why are systemic antibiotics used in the treatment of chlamydia?
Conjunctivitis is part of a more widespread infection
47
Why are beta lactam antibiotics not used in the treatment of chlamydia?
Chlamydia trachomatis contain relatively little peptidoglycan
48
Classify the gonorrhoea bacteria.
Neisseriaceae | Gram-negative diplococci that only grow on enriched media
49
Where do gonococcal infections generally occur in the female?
Cervix | Urethra
50
What are the clinical manifestations of gonococcal infection?
Acute cervicitis Vaginal discharge Urethral syndrome where the urethra is infected (male and female)
51
What are the potential complications of gonococcal infection?
PID (occasionally with tubo-ovarian abscess) Bartholins abscess Disseminated gonococcal infection (male and female) Epididymitis Proctitis Pharyngitis Prostatitis
52
What is a disseminated gonococcal infection?
Bacteraemia. A rare complication that affects women more than men Common symptoms: pain on joints (lesions), tensynovitis and rash
53
How should specimens for testing of gonorrhoea be taken?
Taken and plated directly on to media at the bedside as it is a fragile organism and does not survive transportation well
54
Where are specimen collected from in males and females to test for gonorrhoea?
Female - endocervical, urethral, rectal or pharyngeal swab Male - Urethral, rectal and pharyngeal swabs Smear and culture
55
How are gonococcal infections diagnosed in the lab?
Gram stain - gram-negative diplococci | Culture is more sensitive than microscopy - biochemical tests must be done to confirm potential neisseria on a culture
56
Why is sensitivity testing important for gonococcal infections?
Antibiotic resistance patterns are valuable in guiding future management guidelines
57
What is the treatment for a gonococcal infection?
Neisseria gonorrhoea may vary in its sensitivity. Initial therapy is usually guided by severity of symptoms an local knowledge of sensitivity patterns. Penicillin resistance common Ceftriaxone (IM) is now mainstay treatment. Used to be ciprofoxacin but resistance built
58
What is the most commonly diagnosed STI?
Genital warts caused by HPV
59
How many types of HPV are there?
Over 100
60
Do all individuals infected with HPV develop warts?
No
61
What are the risks carried with HPV?
Difficult to treat | Certain high risk types are associated with cervical carcinoma (HPV 16 and 18)
62
What are the methods of HPV screening?
Cervical pap smear cytology Colposcopy and acetowhite test Cervical swab - HPV hybrid capture -> high/intermediate risk of differentiation
63
What are the symptoms of HPV?
Benign Painless Verucous epithelia or mucosal outgrowths
64
How is HPV diagnosed?
Clinical biopsy + genome analysis | Hybrid capture
65
What is the treatment for HPV?
``` No treatment - spontaneous resolution topical podophyllin Cryotherapy Intralesional interferon Imiquimod Surgery ```
66
Why should patients presenting with one STI be screened for others, including BBV?
Multiple infections are common - at risk behaviour, identical transmission mode, long-term asymptomatic and chlamydia is common
67
What type of microorganism is Trichomonas vaginalis?
Flagellated protozoan
68
What are the clinical presentations of Trichomonas vaginalis?
``` Trichomonas vaginitis Thin, frothy, offensive discharge Irritation Dysuria Vaginal inflammation ```
69
How is a diagnosis of trichomonas vaginalis made?
Vaginal wet preparation +/- culture enhancement
70
WHat is the treatment of trichomonas vaginalis?
Metronidazole (active against anaerobes and protozoa)
71
What is the name of the bacterium causing syphilis?
Treponema pallidum
72
How is the disease of syphilis described?
Multi-stage disease - progressive, manifests in different ways 'The great pretender'
73
Describe the stages of syphilis.
1. Indurated painless ulcer (chancre) 2. 6-8 weeks later: fever, rash, lymphadenopathy, mucosal lesions (can be latent and symptom free for years) 3. Chronic granulomatous lesions 4. CVS and CNS pathology
74
How is syphilis diagnosed?
Serology, dark field microscopy
75
What is the treatment of syphilis?
Penicillin and 'test of cure' follow up
76
What are the 2 types of HSV?
1. Oral 2. Genital Exposure to type 1 provides some immunity to type 2
77
What are the clinical presentations of type 2 HSV?
``` Extensive, painful genital ulceration Dysuria Inguinal lymphadenopathy Fever Urinary retention common in women ``` Recurrent = asymptomatic -> moderate
78
How is herpes diagnosed?
Smear and swab (viral culture) of vesicle fluid and/or ulcer base
79
How is HSV treated?
Primary and severe with aciclovir (only active in infected cells - activated by virus) Prophylactic aciclovir May need hospitalised if severe primary disease
80
What is the most common cause of vulvovaginal candidiasis?
Candida albicans - normal flora of the GI and genital tracts
81
What are risk factors for the development of vulvovaginal candidiasis?
``` Antibiotics Oral contraceptives Pregnancy Obesity Steroids Diabetes ```
82
What are the clinical presentations of vulvovaginal candidiasis?
Profuse, whites, curd like discharge Vaginal itch Discomfort Erythema
83
How is a diagnosis of vulvovaginal candidiasis made?
High vaginal smear and culture
84
What is the treatment of vulvovaginal candidiasis?
Topical azoles or nystatin | Oral fluconazole
85
What causes bacterial vaginosis?
perturbed normal flora - garderella, anaerobes, mycoplasmas
86
How is bacterial vaginosis treated?
Metronidazole
87
What treatment is generally given when a diagnosis of Neisseria gonorrhoea has been made?
Ceftriaxone IM + doxycycline for 7 days for possible chlamydial infection or azithromycin if pregnant of unlikely to be complient
88
What is Fitz-Hugh-Curtis syndrome?
Right upper quadrant pain from perihepatitis (inflammation of the liver capsule or diaphragm) following the transabdominal spread from PID. Adhesions form between the liver and abdominal wall or diaphragm, classically called violin strings
89
What causes Fits-Hugh-Curtis syndrome?
Most commonly, chlamydia, less commonly, gonorrhoea
90
What advice should patients with STIs be given?
``` Abstinence during treatment Tell recent sexual partners Advice to decrease STI risks Return visit to test for cure Sexual health education ```
91
How does the illness iceberg relate to STIs?
Many asymptomatic unknown cases - higher prevalence than known
92
What conditions in the vagina will promote growth of candida?
``` High pH Antibiotics Warmth and humidity OC and pregnancy High glucose Steroid therapy Menstrual cycle association ```
93
Why does the OC increase risk of development of thrush?
High oestrogen levels promote overgrowth of the yeast
94
What is PID?
Infection ascending from the endocervix, causing endometritis, salpingitis, parmetritis, oophoritis, tubo-ovairan abscess and/or pelvic peritonitis
95
Who gets PID?
Sexually active women High incidence in urban areas Peak incidence 20 per 1000 Highest incidence in 20-24yr olds
96
What microorganisms can cause PID?
Gonorrhoea (14%) Chlamydia Garderella, mycoplasma and anaerobes also implicated
97
What are the chances of concurrent infection?
40%
98
What are the risk factors for PID?
Sexual behaviour Type of contraception used - IUCD carries risk of infection for 1st week of insertion (foreign body), COCP considered protective Alcohol/drug use Cigarette smoking
99
What are the clinical features of PID?
Pyrexia (>38 degrees) Pain Abnormal vaginal discharge Abnormal vaginal bleeding
100
What pain is associated with PID?
Bilateral lower abdominal tenderness Adnexal tenderness Tenderness on cervical excitation Deep dyspareunia
101
What investigations should be carried out for PID?
Ultrasound, laproscopy, endocervical swabs, swabs from peritoneum if laproscopy done *Positive swabs confirm but negative do not exclude
102
How would you manage a patient with PID?
analgesia, antibiotics/antimicrobial against specific organisms and broad spectrum antibiotics with good anaerobic coverage advice: bed rest. If hospitalised adopt semi fowler position to drain pus out of pelvis
103
What are the potential complications of PID?
Ectopic pregnancy Infertility Chronic pelvic pain Fitz-Hugh-Curtis syndrome
104
How can patients prevent PID?
Safe sex - barrier contraception STI screening and partner Early STI treatment Avoid promiscuity
105
What are the differentials for PID?
Gynae - ectopic pregnancy, endometritis, complications of ovarian cyst, torsion GI - IBSm acute appendicitis, IBD Renal - UTI, cystitis, bladder stones Other - functional pain of unknown physical origin