Repro Session 6 Flashcards
Are STIs acute or chronic/relapsing?
Both
What accounts for most STD cases in the UK but has a decreasing incidence due to vaccination programmes?
Papillomaviruses
What are the 5 most common causes of STDs in the UK?
Papillomaviruses, chlamydia, genital herpes, gonorrhoea and syphilis
Which population group are gonorrhoea and syphilis cases becoming more frequent in?
MSM
Who are the at risk groups of STDs?
Young people, certain ethnic groups, high number of partners, certain sexual orientations, unsafe sexual activity, young age at first sexual intercourse and low SES groups
Why has the incidence of STIs increased?
Changing sexual and social behaviour, increased density and mobility of populations, better social acceptance of GUM attendance and anonymity, awareness campaigns and improved diagnostic and screening programmes
What are the possible sequelae of STIs?
PID and infertility, cancer, disseminated infection, transmission to foetus/neonate
What is the difference between STI and STD?
STI includes symptomatic and asymptomatic cases whereas STD is symptomatic only
How are genital tract infections identified?
Pt presents to GP/GUM with symptoms. Clinician notices non-genital STI indications. Contact tracing/screening of asymptomatic cases
Why is a single dose or short course of Abx favoured in STI management?
Maximises compliance
How are STIs managed?
Abx, screen, +/- empiric Tx for other STIs, contact tracing and pt education
What proportion of young adults are infected with HPV at some point in their life?
~4%
Which are the two most common types of HPV?
6 and 11
How does an infection with HPV6 or 11 present?
Benign, painless verrucous epithelial or mucosal outgrowths on external genitals or perianal skin
Which are the two high risk types of HPV?
16 and 18
Why are HPV16 and 18 considered high-risk?
> 70% of cervical cancers are associated and is associated with anogenital cancer
How can HPV infection be diagnosed?
Clinically, biopsy and genome analysis/hybrid capture
What is the treatment for HPV infection?
Most spontaneously resolve but otherwise topical podophyllin, cryotherapy, intralesional interferon or surgery
What screening methods are in place for HPV?
Cervical Pap smear cytology or colposcopy with acetowhite test for abnormal cells. Cervical swab and hybrid capture
What vaccines are available for HPV infection?
Gardasil to protect against HPV6, 11, 16 and 18 given in 2 doses to girls aged 12-13
How effective is the HPV vaccine against HPV16 and 18 cervical abnormalities in an uninflected population?
99%
What is the most common causative agent in chlamydia?
Chlamydia trrachomatis
Which serotypes of chlamydia trachomatis cause non-specific genital chlamydial infections?
D-K
What are the male S/S of chlamydia trachomatis infection?
Urethritis, epipdidymitis, prostatitis, proctitis causing pain in perineal/scrotal/urethral areas
What are the female S/S of chlamydia trachomatis infection?
Urethritis, cervicitis, salpingitis, peri hepatitis, but majority asymptomatic
When does peri hepatitis arise in chlamydia trachomatis infection?
Chronic infection causes PID and subsequent adhesions between the liver and abdominal wall
How can chlamydia trachomatis infection lead to conjunctivitis?
Contact between secretions of genitalia and eye
Other than conjunctivitis, what can chlamydia trachomatis infection in the mother lead to in the neonate?
Pneumonia
How is diagnosis of chlamydia trachomatis made?
NAAT of endocervical/urethral swabs/first void urine/conjunctival swab
Why can first void urine be used to detect chlamydia trachomatis infection?
It will contain urethral cells
What are the treatment options for chlamydia trachomatis infection?
Single large dose of azithromycin, 1-2 wk course of doxycycline or erythromycin for children
Who is chlamydia trachomatis screening targeted at?
Sexually active
How is chlamydia trachomatis screening conducted?
Urine sample or cervical swab and NAAT +/- test for Neisseria gonorrhoea
What is associated with HSV2 infection?
Genital herpes
Which strain of HSV is associated with cold sores?
HSV1
What are the S/S of primary genital herpes?
Extensive painful genital ulceration, dysuria, inguinal lymphadenopathy and fever
How does recurrent genital herpes present differently to primary infection?
Primary symptoms diminish and reappear but are usually less severe
Where does latent HSV infection remain?
Dorsal root ganglia
How is HSV diagnosed?
PCR of vesicle fluid or swab from ulcer base
What is the treatment for HSV?
Aciclovir for severe primary infection and prophylaxis and advise barrier contraception use
What are the male S/S of Neisseria gonorrhoea infection?
Urethritis, epididymitis, prostatitis, proctitis, pharyngitis, purulent penile discharge
What are the female S/S of Neisseria gonorrhoea infection?
Often asymptomatic but may have endocervitis, urethritis, PID, infertility
What can be seen if gonococci like infection becomes disseminated?
Bacteraemia, skin lesions, and gonococcal arthritis
How is Neisseria gonorrhoea infection diagnosed?
Clinically preferred but can use NAAT of cervical, urethral, throat or rectal swab if indicated
Why is gram stain not routinely used for diagnosis of Neisseria gonorrhoea?
Fastidious and needs special media
What is the gold standard treatment for Neisseria gonorrhoea infection?
Single IM dose of ceftriaxone
Why is secondary treatment with azithromycin used in Neisseria gonorrhoea treatment?
For chlamydia as often co-infected and to prevent cephalosporin resistance
What is treponema pallidum?
Aetiological spirochaete agent of syphilis
How is treponema pallidum imaged?
Needs dark-field microscopy that reveals spiral-shaped bacteria
Who is mostly affected by treponema pallidum?
Mostly men, esp MSM. Can be congenital
How does primary treponema pallidum infection present?
Indicated painless ulcer (chancre)
How does secondary treponema pallidum infection present?
6-8 wks after primary disease, fever, rash, lymphadenopathy and mucosal lesions develop
How long can the latent period of treponema pallidum infection last?
Years
What is seen in tertiary treponema pallidum infection?
Neurosyphilis, cardiovascular syphilis, gummas
How is treponema pallidum infection diagnosed?
Intitial screening with EIA antibodies with +ves undoing more specific tests (cross-reacting antigen or particle agglutination) to establish timing
What is the treatment for treponema pallidum infection?
Penicillin
How is efficacy of treatment for treponema pallidum assessed?
Follow serological measures
How does lymphogranuloma venereum present?
Rapidly healing papule –> inguinal bubo
How does Haemophilus duareyi present?
Chancroid-painful genital ulcers
How does Klebsiella granulomatis present?
Genital nodules become ulcers known as granuloma inguinale
What is trichomonas vaginalis?
Flagellated protozoan that causes vaginal discharge
What are the S/S of trichomonas vaginalis infection?
Thin, frothy and offensive discharge from vagina with vaginal inflammation and dysuria
How is trichomonas vaginalis infection diagnosed?
Mainly clinical as discharge not candida and Tx same as for bacterial vaginosis so differentiation not needed. Vaginal wet preparation +/- culture enhancement
What is the treatment for trichomonas vaginalis infection?
Metronidazole
What are the causative agents of vulvovaginal candidiasis?
Candida albicans and other candida species from GI or genital flora
What are risk factors for developing vulvovaginal candidiasis?
Abx, OCP, pregnancy, obesity, steroids, diabetes
What are the S/S of vulvovaginal candidiasis?
Profuse, white, itchy curd-like discharge
How is vulvovaginal candidiasis diagnosed?
High vaginal smear +/- culture
How is vulvovaginal candidiasis treated?
Topical azoles, nystatin or oral Fluconazole if necessary
What is the pathogenesis of bacterial vaginosis?
Perturbed normal flora causes scanty but offensive fishy discharge
What are the causative agents of bacterial vaginosis?
Gardnella, anaerobes, mycoplasmas
How is bacterial vaginosis diagnosed?
Clinically by vaginal pH>5 or KOH whiff test. Laboratory by HVS gram stain
What may be visible on HVS gram stain from bacterial vaginosis?
Clue cells (epithelial and gram variable coccobacilli), reduced lactobacilli
What is the treatment for bacterial vaginosis?
Metronidazole
Are pubic and human body lice the same?
No
What is PID the result of?
Infection ascending from the endocervix
How does endometriosis lead to PID?
Inflammation and infection can be obstetric of non-obstetric. Non-obstetric –> PID
How does salpingitis lead to PID?
Infection causes inflammation and damages epithelium whose cilia cannot recover fully. Decilliation allows exudate to accumulate creating adhesions between mucosal folds
How does tubo-ovarian abscess form?
Pus exudes from fimbriae allowing an adhesion to form with the ovary
What are the sequelae of PID?
Ectopic pregnancy, infertility, chronic pelvic pain, Fitz-Hugh-Curtis syndrome, Reiter’s syndrome
What makes a tubo-ovarian abscess complex?
Tube and ovary are indistinguishable in the mass
What is Reiter’s syndrome?
Reactive arthritis leads to urethritis, conjunctivitis and arthritis
What is Fitz-Hugh-Curtis syndrome?
RUQ pain due to adhesions between abdominal wall and liver capsule (peri hepatitis)
Why is inflammation from PID uncommon in the upper abdomen?
Omentum usually localises infection
What is the aetiology of PID?
Often polymicrobial with endogenous vaginal flora, STIs and bacterial vaginosis microbes
In what group is peak incidence of PID seen?
Sexually active women aged 20-30 y.o.
What are the risk factors for developing PID?
Same as STIs and recent implant, recent removal of IUCD and recent termination of pregnancy
What is the typical history of PID?
Pyrexia, lower abdo pain, deep dyspareunia, abnormal discharge, abnormal vaginal bleeding, sexual Hx, previous STI, contraceptive Hx
What is found O/E in PID?
Fever, bilateral lower abdominal tenderness, bimanual examination shows adnexal tenderness and cervical motion tenderness, speculum examination shows cervicitis +/- purulent discharge
What are the differentials for PID?
Ectopic pregnancy, endometriosis, ovarian cyst complications, IBS, appendicitis, UTI, functional pain
What investigations are performed in suspected PID?
Pregnancy test, endocervical and HVS, WBC, CRP, STI screening, laparoscopy
What is the gold standard investigation for PID?
Laparoscopy
How is PID managed?
IM ceftriaxone, PO doxycycline, PO metronidazole or IV if severe disease
Why is PID management initiated STAT?
To minimise infertility risk
Why are Abx not useful in PID when tubo-ovarian abscess is present?
Will not be penetrated
What advice is given to a pt with PID?
Avoid unprotected sex until F/U for themselves and partner complete. Contact tracing, full STI screen, single dose azithromycin for partner, complete Abx course and use barrier contraception
Why must pts be advised to complete Abx courses and use barrier contraception in PID?
Risk of complications increases with repeat episodes
What are the indications for IV treatment in PID?
Severe disease with no response to oral Tx, pyrexia, signs of tubo-ovarian abscess or pelvic peritonitis
