Reproductive System - Level 2.1 Flashcards
Epidemiology of chlamydia?
- Commonest STI in the UK.
- Most important cause of tubal infertility
- 75% cases in under 25s
Causative organism of chlamydia?
• Chlamydia Trichomatis = obligate intracellular Gram-negative bacteria
• Initial sites of infection:
- Columnar and transitional epithelial cells of the urethra, cervix, rectum, pharynx and conjunctiva, depending on mode of exposure.
Risk factors of chlamydia?
- Age <25
- Sexual partner positive for chlamydia
- Two or more sexual partner in preceding year
- Recent change in partner
- Lack of barrier use
- Infection with another STI
- Poor socio-economic status
How many people asymptomatic in chlamydia?
Asymptomatic in 50% of men and 70% of women
- Found on screening, contact tracing and complications
Symptoms in females of chlamydia?
o Increased vaginal discharge secondary to cervicitis.
o Dysuria
o Urethritis
o Post coital and inter-menstrual bleeding
o Deep pain during sex (dyspareunia), lower abdomen
o Fever
Signs in females of chlamydia?
o Friable, inflamed cervix (cobblestone appearance) with contact bleeding
o Mucopurulent endocervical discharge
o Abdominal tenderness
Symptoms in males of chlamydia?
o Dysuria o Discharge – white, cloudy or water. o Unilateral testicular pain o Scrotal pain/swelling o Fever
Signs in males of chlamydia?
o Epididymal tenderness
o Mucoid or mucopurulent discharge
o Perineal fullness due to prostatitis
Symptoms in neonates with chlamydia?
- Neonatal conjunctivitis (30% within the first two weeks)
- Neonatal pneumonia (15% within the first four months)
- Otitis media
- Can develop vaginal infection
Complications in pregnancy of chlamydia?
- Infection can spread from the cervix into the uterine cavity causing chorioamnionitis.
- Can cause PROM, preterm delivery, low birth weight and post-partum infection
Who to test for chlamydia?
o Men or women with symptoms indicating infection
o Sexual partners of suspected/proven chlamydia
o All sexually active <25 people, annually or if changed partners
o People <25 treated for chlamydia in past 3 months
o People concerned about sexual exposure
o Two or more sexual partners in past year
o All presenting with TOP and to GUM clinic
o Mothers of infants with chlamydial infection
o Fitted with IUCD or IUS who are at risk of STI
Females investigations of chlamydia?
• Vulvovaginal swab (NAAT)
o 1st line for women, can use endocervical swab or urine sample
Window period 2 weeks – repeat test if indicated
Males investigations of chlamydia?
o Urine for NAAT PCR (men)
First catch, should not have passed urine for at least 1 hour
o GUM - Microscopy of urethral or rectal swab, NAAT
What screening programme is available for chlamydia?
- National screening programme for <25 year olds (urine test)
- Tests can be done at home, postal service
Management of chlamydia - general advice?
- Avoid sexual intercourse for a week after single-dose therapy or finishing longer regimen
- Do not resume sex with partner until they have completed treatment or received negative test
- Safe sex, contraception advice
- Full STI screen
Management of chlamydia - contact tracing?
o Four weeks prior to developing symptoms where a male has urethral symptoms and all contacts since
o All contacts in last six months of asymptomatic individuals and symptomatic women and men other than urethral
o Inform of risk and offer treatment, tracing and STI testing
Management of chlamydia - antibiotic management?
- Doxycycline 100mg BD for 7 days (CI in pregnancy) OR Azithromycin 1g single dose (4 tablets taken at once, >90% affective)
o Alternatives: Erythromycin, oflaxacin - In pregnancy – azithromycin 1g stat then 500mg for 2 days OR erythromycin 500mg QDS for 7 or BD for 14 days
o Test 3 weeks later
Management of chlamydia - test of cure?
- Performed on pregnant patient, persistent symptoms, non-compliance or re-exposed
- 3 weeks later
- In screening programme, <25 should repeat at 3 months
Complications of chlamydia?
- PID
- Ectopic pregnancy
- Reactive arthritis
- Reiter’s syndrome (triad of urethritis, arthritis and conjunctivitis)
- Tubal infertility, perihepatitis (Fitz-Hugh-Curtis syndrome) (women)
- Proctitis, epididymitis and epididymo-orchitis (men)
Epidemiology of genital herpes?
- Second most common STI in the UK.
- Seroprevalence of HS2 = ~20% of women.
- Most common in ages 15-24
Types of genital herpes?
- Herpes Simplex type 2 (genital) and type 1 (oral).
- HSV type 2 is responsible for ~70% of genital lesions.
- Both can affect mouth and/or genitals, due to oral sex or auto-inoculation
Incubation period of genital herpes?
- ~5-14 days
Transmission of genital herpes?
- Contact with infectious secretions on oral/genital/anal mucosa, or other anatomical sites (eyes, skin, herpetic whitlow)
Pathology of genital herpes?
- Enters the distal axonal processes of the sensory neuron and travels to the sensory (dorsal root) ganglion where it remains in a latent state
- Periodically reactivates, travelling down the axon and into the basal skin layers
- Some of these episodes will result in symptoms and signs while others will be asymptomatic
Risk factor of genital herpes?
- Multiple sexual partners
- Previous Hx of STI
- Early age of first sexual intercourse
- Unprotected sexual encounters
- MSM (and females with partners MSM)
- Female
- HIV infection
Symptoms of genital herpes - primary infection?
Asymptomatic
Symptoms
o Prodromal itching/tingling of affected skin
o Flu-like illness (muscle aches, malaise, headache)
o Inguinal lymphadenopathy
o Vulvitis and pain (may be severe enough to cause urinary retention)
o Small, characteristic vesicles and ulcers on the vulva (painful).
o Ulcers can coalesce to form larger superficial lesions with characteristic serpiginous edges.
Typically lasts around 3 weeks
Symptoms of genital herpes - recurrent infection?
Recurrent attacks result from reactivation of latent virus in the sacral ganglia (usually shorter and less severe).
- Triggered by: stress, sex, menstruation
Pregnancy implications of genital herpes?
- Primary infection may lead to miscarriage or preterm labour.
- Neonatal risks:
High transmission risk in 1st episode
Appears during the 1st two weeks of life.
o 25% is limited to eyes and mouth only.
o 75% is widely disseminated (~70% will die, survivors have long term morbidity)
Investigations to perform in genital herpes?
• Diagnosis is usually made on the history and appearance of the typical rash.
• Identification of virus
o Viral culture of vesicle fluid (gold standard)
o DNA PCR of swab from base of ulcer
When to perform type specific serology testing of genital herpes?
Person’s partner has genital herpes and person wants to know
Recurrent/atypical genital ulcers with negative culture or PCR
Pregnant women and partners
Screen in high risk people
Management of genital herpes - general advice?
- Condoms are recommended
- Safe sex and reduce transmission
- Abstain until follow-up or lesions have cleared
- There is no cure – average of 4-5 attacks per year, lasting 4-5 days, however symptoms improve over time
Management of genital herpes - referral?
- Any person with suspected genital herpes to GUM clinic
Management of genital herpes - supportive therapy?
- Saline bathing
- Oral analgesia
- Topical lidocaine 5% gel
- Micturition whilst sitting in bath, prevents retention
- Increase fluid intake to dilute urine/reduce pain in micturition
Management of genital herpes - antivirals?
- Aciclovir PO 400mg TDS 5-10 days (to be started within 5 days of start of episode or while new lesions forming)
o Alternatives – Famciclovir, valaciclovir
Management of genital herpes - immunocompromised?
o Refer to GUM clinic
o Aciclovir 400mg 5 times a day, for 10 days during 1st episode
o 400mg TDS for 5-10 days during recurrent infection
o If severe – admit for IV aciclovir
Management of genital herpes - recurrent attacks?
o Episodic Antivirals (if <6 attacks per year)
Oral aciclovir 800mg TDS for 2 days (or 5 days}
o Suppressive Antiviral (if >6 attacks per year)
Aciclovir 400mg BD for maximum of 1 year, after which stop and assess recurrence
Restart if >2 recurrences
Management of genital herpes - pregnancy - 1st and 2nd trimester?
o Refer to GUM clinic for confirmation and treatment
o Aciclovir if needed (not licenced)
400mg TDS for 5 days
o Symptomatic relief – paracetamol, lidocaine 5% gel
o Aciclovir from 36 weeks gestation if contracted during pregnancy
Management of genital herpes - pregnancy - 3rd trimester?
o Same as 1st and 2nd but continue suppressive therapy
o C-Section delivery recommended
Management of genital herpes - neonate?
- Urine and stool culture and swabs from oropharynx, eyes and surface sites
- IV aciclovir
Management of genital herpes - follow up?
- In GUM clinic, a week after initial appointment & once a year
Management of genital herpes - complications?
- Meningitis
- Sacral radiculopathy (causing urinary retention and constipation)
- Transverse Myelitis
- Disseminated infection
- Mylagia
- Autoinoculation to distant sites
- Erythema multiforme
- Anxiety, depression
- Radiculitis, transverse myelitis, autonomic neuropathy
Epidemiology of gonorrhoea?
- 3rd most common STI in the UK
- Highest rates in people aged 15-24
- > 35% of strains resistant to ciprofloxacin
Causative organisms of gonorrhoea?
Neisseria gonorrhoeae – intracellular gram-negative diplococcus
Initial sites of infection of gonorrhoea?
- Columnar epithelium of urethra, endocervix, rectum, pharynx or conjunctiva depending on mode of exposure
Transmission of gonorrhoea?
Direct inoculation of infected secretions from one mucous membrane to another
Incubation period of gonorrhoea?
- Two to five days in 80% of men who develop urethral symptoms.
- Asymptomatic infections common in both sexes, especially infections of pharynx, cervix and rectum
Risk factors of gonorrhoea?
- Urban areas
- Young age
- History of previous STI
- Co-existing STIs - 40% of MSM have co-existing HIV
- New or multiple sexual partners
- Recent sexual activity abroad
- Inconsistent condom use
- Hx of IVDU or commercial sex work
How many people are asymptomatic with gonorrhoea?
Asymptomatic in most men (90-95%) and women (50%)
Symptoms of gonorrhoea - female?
o Greenish vaginal discharge, 2-7 days after intercourse.
o Examination may show mucopurulent discharge from the cervical os, urethra, Skene’s glands or Bartholin’s glands.
o Dysuria
o Urethritis
o IMB/PCB (less common)
o Abdominal pain (less common)
Complications of gonorrhoea - female?
Lower abdominal pain, bartholinits and vulvo-vaginitis (pre-pubertal girls).
Pregnancy complications of gonorrhoea?
o Can cause chorioamnionitis
o PROM, preterm delivery, low birth weight and postpartum endometritis
Symptoms of gonorrhoea - males?
o Discharge – yellow, green, white o Dysuria o Urethritis o Swelling of the foreskin o Scrotal pain/swelling o Anal discharge, pain, bleeding o Tender inguinal lymph nodes
Complications of gonorrhoea - males?
o Epididymo-orchitis, abscesses of paraurethral glands and urethral stricture.
o Infection of the rectum, throat or eyes
Symptoms of gonorrhoea of neonates?
o Opthalmia neonatorum (40-50%)
o Can develop vaginal infection.
Complications of gonorrhoea?
o PID (~15% of infections) o Bartholin’s or Skene’s abscess o Disseminated gonorrhoea - Fever, pustular rash, migratory polyarthraliga o Septic arthritis o Tubal infertility o Increased risk of ectopic pregnancy o Rectal pain and discharge o Conjunctivitis o Fitz Hugh Curtis syndrome o Disseminated infection involving skin, joints and heart valves, secondary infertility after damage to fallopian tubes or epididymis
Investigations in gonorrhoea - females?
• Vulvovaginal or urethral swabs for NAAT testing
o Swab may be self-taken
o Can do pharyngeal, rectal swabs if symptomatic
• If NAAT positive, further swabs for culture for sensitivity (Amies charcoal transport medium)
Investigations in gonorrhoea - males?
- NAAT First-void urine test – screening
- Microscopy – gram stained urethral or rectal smear, NAAT, culture
Management of gonorrhoea - general advice?
- Refrain from sexual intercourse until treated and partner is treated completely
- Safe sex, contraception advice
- Full STI screen
Management of gonorrhoea - contact tracing?
o Men with symptomatic anogenital gonorrhoea, all partners within 2 weeks notified or most recent if longer than 2 weeks
o All others, partners within 3 months
o Inform of risk and offer treatment, tracing and STI testing
Management of gonorrhoea - antibiotics?
When susceptibility not known prior to treatment:
o Ceftriaxone 1g IM (single dose) (if penicillin allergic: Spectinomycin 2g IM (single dose))
o PLUS Azithromycin 1g stat-dose
When susceptibility known prior to treatment:
o Ciprofloxacin 500mg PO single-dose
Management of gonorrhoea - antibiotics in ophthalmia neonatorum?
- Opthalmia neonatorum – IV benzylpenicillin or cephalosporing with saline lavage and topical erythromycin
Management of gonorrhoea -test of cure?
Test of cure follow up
- With culture >72h or with NAAT >2 weeks following antibiotic treatment
Management of gonorrhoea - disseminated gonococcal infection?
Emergency medical advice
o Ceftriaxone 1g IM/IV every 24 hours OR
o Cefotaxime 1g IV every 8 hours OR
o Ciprofloxacin 500mg IV every 12 hours
Then convert to oral after 24-48 hours: o Cefixime 400mg BD OR o Ciprofloxacin 500mg BD OR o Ofloxacin 400mg BD o For 7 days
Stages of syphilis?
- Infection occurs in 3 stages: primary, secondary and tertiary syphilis.
Causative organism of syphilis?
o Treponemum pallidum – spirochaete.
o Enters via abrasion or intact mucous membrane and distributes via blood stream and lymph after incubation period of 3 weeks
o Sexually or vertically transmitted
Symptoms of syphilis - primary syphilis?
- Incubation period 2-3 weeks: local infection
- Primary lesion
o Solitary, painless, genital ulcer (chancre)
o Red macule progresses to a papuleand ulcerates
o Round and clean with an indurated base and defined red margin edges
o Discharging clear serum
o Found: coronary sulcus, glans, inner prepuce, shaft, anal canal, vulva, labia, cervix - Inguinal lymphadenopathy
Symptoms of syphilis - secondary syphilis?
- Incubation period 6-12 weeks: generalised infection
Symptoms
Night-time headaches, malaise, fever and aches
Rash
o Generalised polymorphic rash affecting palms and soles
o Symmetrical and non-itchy. They can be macular, papular, papulosquamous, and, very rarely, pustular.
o Papular lesions may occur on the trunk, palms, arms, legs, soles, face, and genitalia (condylomata lata)
o Skin lesions are commonly a mixture of macular and papular lesions (maculopapular)
Generalised lymphadenopathy
Anterior uveitis, meningitis, cranial nerve palsies, hepatitis, splenomegaly, glomerulonephritis
Symptoms of syphilis - latent syphilis?
- Untreated syphilis but no symptoms or signs of infection
- Divided into early (<2 years) and late (>2 years)
o Late
Gummatous disease (necrotic nodules or plaques), cardiovascular disease and late neurological complications
Symptoms of syphilis - tertiary syphilis - neurosyphilis?
o Asymptomatic
o Dorsal column loss (tabes dorsalis – sensory ataxia, absent lower limb reflexes, impaired vibration and lightning pains) o Dementia o Mood changes o Paralysis o Meningovascular involvement Argyll-Robertson pupil (lose pupillary light relex, maintain accomodation reflex) Headache, 3rd/6th/8th palsies Papilloedema Hemiplegia
Symptoms of syphilis - tertiary syphilis - cardiovascular syphilis?
o Commonly aortitis at aortic root, spreading distally
o Aortic regurgitation, aortic aneurysm and angina
Symptoms of syphilis - tertiary syphilis - gummata?
o Inflammatory plaques or nodules (found in the skin or bones)
o Usually nodular, found in small groups of painless lesions that are indolent, firm, coppery red and about 0.5-1cm in diameter
Symptoms of congenital syphilis?
- Early <2 years of life
- Late >2 years of life
- Symptoms
o Hutchinson’s triad (VIII nerve deafness, interstitial keratitis, notched pointed incisors (mulberry))
o Saddle nose
o Hepatosplenomegaly
o Sabre shins
Implications of syphilis in pregnancy?
- Preterm delivery
- Stillbirth
- Congenital syphilis
Investigations performed in syphilis?
- PCR Serology
o Smear from the primary lesion may demonstrate spirochaetes on dark ground microscopy - Screen for all STIs
- If neurological signs or symptoms – lumbar puncture and imaging
- If cardiac signs – ECG, echcardiogram
Types of assay specific tests in syphilis?
Treponemal enzyme immunoassay (EIA) for IgM early, IgG late
T.pallidum chemiluminescent assay (CLIA)
T.pallidum haemagglutination assay (TPHA)
T.pallidum particle agglutination assay (TPPA)
Fluorescent treponemal antibody absorbed test (FTA-abs)
Negative tests repeated at 6-12 weeks and 2 weeks after chancre and/or PCR negative
All positive tests must be confirmed with 2nd different serological test
o Non-specific (RPR, VDRL) – perform when treponemal tests positive to monitor
o Smear from the primary lesion may demonstrate spirochaetes on dark ground microscopy
When is syphilis screened?
- Blood test screening at GUM clinics
Routine screening at antenatal booking in pregnancy
Management of syphilis - general advice?
- Refrain from sexual intercourse with new partners until sores completely healed or with current partner until treated
- Use of condoms
Management of syphilis - contact tracing?
o Primary – within 90 days prior to symptoms beginning
o Secondary and early latent – within last 2 years prior to beginning of symptoms
o Late latent or tertiary – since last blood test which confirmed they didn’t have it
Management of syphilis - treatment of primary, secondary and early latent?
o Benzathine penicillin G 2.4MU IM single dose (oral azithromycin 2nd line)
o Alternatives: Procain penicillin, doxycycline
Management of syphilis - treatment of late latent syphilis, cardiovascular and gummatous?
o Benzathine penicillin G 2.4MU IM weekly for three weeks
o Give prednisolone in CV syphilis
Management of syphilis - treatment of neurosyphilis?
o Procaine penicillin 1.8-2.4MU IM, OD for 14 days with oral probenecid 500mg QDS
Management of syphilis - treatment of pregnancy?
o 1st and 2nd trimesters – single dose benzathine penicillin G 2.4MU IM
o 3rd trimester – two doses of benzathine penicillin G 2.4MU IM 1 week apart
What is Jarisch-Herxheimer reaction?
- Reaction to treatment – acute febrile illness with headache, myalgia, chills and rigors
- Resolves within 24h
- Use antipyretics and reassure
Definition of acute prostatitis?
- Acute prostatitis is severe, potentially life-threatening bacterial infection of prostate
o Can be accompanied by infection of urinary tract
Definition of chronic prostatitis?
o >3 months of urogenital pain and associated with lower UTI symptoms and sexual dysfunction (erectile dysfunction, painful ejaculation or postcoital pelvic pain)
o Classified:
Chronic prostatitis/Chronic pelvic pain syndrome – 90%
Chronic bacterial prostatitis – 10%
Causes of acute prostatitis?
o E.coli (50%)
o Pseudomonas aeruginosa, Klebsiella, Enterococcus, Enterobacter, Proteus
o Rarely – Chlamydia, Neisseria gonorrhoea
o Can follow instrumentation, trauma, bladder outflow obstruction or disseminated infection elsewhere
Causes of chronic bacterial prostatitis?
o Ascending urethral infection
o Lymph spread of rectal bacteria
o Undertreated acute prostatitis
o Recurrent UTI with prostatic reflux
Symptoms of acute prostatitis?
o UTI – dysuria, frequency, urgency
o Prostatitis – perineal, penile or rectal pain, urinary retention, difficulty voiding, hesitancy, straining, weak stream, low back pain, pain on ejaculation, tender prostate
o Bacteraemia – rigors, myalgia, fever, tachycardia
Symptoms of chronic prostatitis?
o Pain or discomfort > 3 months in:
Perineum, inguinal/suprapubic region, scrotum, testis or penis, lower back, abdomen, rectum
o Voiding symptoms – straining, hesistancy, weak stream
o Storage symptoms – urgency, frequency, nocturia
o Dysuria
o Erectile dysfunction, pain on ejaculation, premature ejaculation
Investigations in acute prostatitis?
o MSU dipstick, culture and sensitivity
o Bloods – FBC, blood cultures
o DRE – prostate tender, enlarged and boggy
o Consider screen for STIs if indicated
Investigations in chronic prostatitis?
o MSU dipstick & culture
o Consider STI screen (first pass urine) – if appropriate
o PSA – if wanted
o U&E – recurrent UTI, chronic retention
o DRE – may be enlarged, tender or normal
Management of acute prostatitis - admission if?
o Admission if:
Unable to take oral Abx
Severe symptoms
Signs of sepsis, retention
o Urgent referral to urology if immunocompromised or pre-existing urological conditions
Management of acute prostatitis - antibiotics?
Oral ciprofloxacin 500mg BDS for 14 days (or ofloxacin 200mg BDS) (trimethoprim 200mg BDS)
Second-line: Levofloxacin 500mg OD for 14 days
Management of acute prostatitis - general advice?
o PRN paracetamol + ibuprofen
o Drink lots of fluids
Management of acute prostatitis - follow up?
o Follow up 48 hours later:
Check urine cultures – review antibiotics
Admit if not improving
o Review after 14 days and stop treatment or continue for 14 days if needed
o Once recovered – refer for Ix to exclude structural abnormality
Management of chronic prostatitis - chronic pelvic pain syndrome?
Referral to urologist if uncertain or severe symptoms or persist
PRN paracetamol and ibuprofen
If defaecation painful – lactulose
4-6-week trial of alpha-blocker if LUTS present
IF symptoms <6 months, antibiotics:
• Trimethoprim 200mg BDS for 4-6 weeks – not at same time as alpha-blocker
Management of chronic prostatitis - chronic bacterial prostatitis?
Refer to urologist
Trimethoprim 200mg BDS for 4-6 weeks
PRN paracetamol and ibuprofen
If defaecation painful – lactulose
Prognosis of acute prostatitis?
Responds well to treatment however – 1 in 9 men with develop chronic prostatitis or chronic pelvic syndrome
Abscess
Prognosis of chronic prostatitis?
Improved in most men after 6 months
Complications of acute prostatitis?
Acute urinary retention Bacteraemia Chronic prostatitis Epididymitis Prostatic abscess Pyelonephritis
Complications of chronic prostatitis?
Reduced QoL
Recurrent UTI
Definition of balanitis?
- Balanitis - Inflammation of the glans penis (the head of the penis)
- Posthitis - Foreskin inflammation
- Balanoposthitis – inflammation of glans penis and foreskin
Epidemiology of balanitis?
- Commonly affects boys <4 years and also men who have not been circumcised.
Risk factors of balanitis?
- Diabetes mellitus
- Oral antibiotics
- Poor hygiene in uncircumcised males
- Immunosuppression
- Chemical or physical irritation of glans
Aetiology of balanitis?
- Simple intertrigo
- Candida
- Bacterial
o Staphylococci/Streptococci Group B
o Anaerobes
o Garderella vaginalis
o Trichomonas spp - Viral – HSV, HPV
- Drug eruption, psoriasis, leukoplakia
- Contact dermatitis – wet nappies, poor hygiene, smegma, soap, condoms
- Trauma
Symptoms of balanitis?
- Varies to florid erythema, which may be generalised, or appear as red patches or plaques
- Sore, inflamed, swollen glans/foreskin.
- Unpleasant odour
- Sometimes there is a thick lumpy discharge which comes from under the foreskin (smegma).
- Hard to retract the foreskin.
- Dysuria
- Pain during coitus/impotence
Investigations of balanitis?
- Blood/urine test for glucose if DM possible
- Urethral swab – microscopy, Gram staining, culture and sensitivity
- STI screening
Management of balanitis - general measures?
- Clean with warm water, gentle drying
- Avoid soaps
- Salt baths may be soothing
- Screen for STI if suspected
- Treat underlying dermatological cause
- Abstain from sex or other activities which may aggravate the skin until symptoms improve
Management of balanitis - if contact dermatitis?
o Avoid triggers
o Topical hydrocortisone 1% OD for up to 14 days
o If symptoms don’t improve by 7 days, swab to exclude infection
Management of balanitis - if Candida infection?
o Clotrimazole 1%/Miconazole 2% cream, apply BD until settled
o Alternatives: Fluconazole oral if severe, Nystatin cream, imidazole with 1% hydrocortisone
Management of balanitis -if bacterial infection?
o Swab and consider GUM referral
o Oral flucloaxacillin 500mg QDS for 7 days
(Alternative: clarithromycin 250mg BD for 7 days)
o Anaerobes – metronidazole 400mg BDS for one week
o Alternatives: co-amoxiclav, clindamycin
o May need IV antibiotics
Description of physiological phimosis?
o Almost all boys have non-retractile foreskins at birth
o Inner foreskin attached to glans, adhesions break down and form smegma pearls which are extruded
o Foreskin starts to retract after 2 years old and is spontaneous
Description of pathological phimosis?
o Results when prepuce is tight and unable to be pulled back over glans
o Can result in chronic infection and poor hygiene
o Usually results from balanoposthitis recurrently
Definition of paraphimosis?
o Tight prepuce retracted and unable to be replaced as glans swell
Risk factors of paraphimosis?
tight prepuce, catheterisation, scarring, vigorous sex, penile piercing
Symptoms of paraphimosis?
oedema, pain on erection, blue/black glans
Epidemiology of phimosis?
- Majority of boys have retractile foreskin by 10, and nearly all by 16
- 1% phimosis at 16-18
Symptoms of phimosis?
o Painful erections
o Haematuria
o Weak urinary streams, ballooning on micturition
o Swelling, redness and tenderness of prepuce
o Recurrent UTIs, balanoposthitis
Management of phimosis - if <2 and non-retractile or ballooning during micturition?
o Expectant approach – should resolve
o Avoid forcibly retracting, can scar and lead to phimosis
o General Management
Good hygiene and always replace foreskin
Topical Steroids
Management of phimosis - if >2 years old, recurrent UTI, pain and balanoposthitis?
o Plastic Surgery – partial circumcision, release adhesions, meatoplasty
o Circumcision
Management of paraphimosis?
o Analgesia o Methods of reduction Manual pressure to glans Dextrose-soaked gauze Dundee Technique (needle punctures into the glans penis, squeezing the area to allow drainage of oedematous fluid, before attempting reduction of the glans) Dorsal slit of prepuce Emergency Circumcision
Physiology of erection?
o Erections result from nitric oxide (NO) induced cGMP build up
o cGMP-dependent protein kinase activates large-conductance Ca-activated K channels so hyperpolarising and relaxing vascular and trabecular smooth muscle cells
o Allowing engorgement
Definition of erectile dysfunction?
o Persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance
Classes of erectile dysfunction?
o Organic
o Psychogenic
o Mixed
Epidemiology of erectile dysfunction?
- Very common
- Increases with age
Causes of erectile dysfunction - vascular?
Smoking, alcohol, diabetes
CVD, hypertension, hyperlipidaemia
Pelvic surgery (prostatectomy, radiotherapy)
Causes of erectile dysfunction - neurogenic?
MS, Parkinson’s, multiple atrophy, stroke, SCI, CNS tumours
Causes of erectile dysfunction - peripheral neuropathy?
DM, CKD, urethral surgery
Causes of erectile dysfunction - anatomical?
Peyronie’s disease, penile cancer, micropenis, hypospadias, epispadias, phimosis
Causes of erectile dysfunction - hormonal?
Hypogonadism, hyperprolactinaemia, hyperthyroidism, hypothyroidism, Cushing’s, panhypopituitarism
Causes of erectile dysfunction - drugs?
Beta blockers, verapamil, diuretics, TCAs, MOAIs, SSRIs, APs, digoxin, amiodarone, oestrogens, steroids, 5-alpha blockers
Alcohol, heroin, cocaine, marijuana
Causes of erectile dysfunction - psychogenic?
o Generalised – lack of arousability and disorders of sexual intimacy
o Situational – partner/performance related issues, stress and anxiety
Assessment of person with erectile dysfunction?
o Sexual orientation.
o Past and current sexual relationships.
o Current emotional status.
o Sexual function, including onset and duration of erectile problems; quality of erections (sexually-stimulated and morning erections); problems with sexual desire, arousal, ejaculation, and orgasm; and previous consultations and treatments.
o Issues with sexual aversion or pain, or issues for his partner (including menopause or vaginal pain)
History suggesting organic cause of erectile dysfunction?
o gradual onset of symptoms
o lack of tumescence
o normal libido
o presence of risk factors (such as the use of drug associated with erectile dysfunction [for example diuretics], smoking, and high alcohol consumption).
History suggesting psychogenic cause of erectile dysfunction?
o sudden onset of symptoms o decreased libido o good quality spontaneous or self-stimulated erections o major life events o problems or changes in a relationship o previous psychological problem
Examination to perform in erectile dysfunction?
o BP, HR, BMI
o Examine genitalia
o DRE if symptoms of enlarged prostate only
Investigations to perform in erectile dysfunction?
- Bloods o HbA1c o Lipids o Total testosterone – morning sample If low then FSH, LH and prolactin levels - Assess CVD risk of sexual activity in men with CVD disease - Other tests if indicated: o PSA
Cardiac risk stratification in erectile dysfunction - low risk?
No signification cardiac risk associated with sexual activity
Asymptomatic and <3 RF for CAD
Controlled hypertension, mild valvular disease, and NYHA class 1 & 2
Successful CABG, stenting
No testing needed
Cardiac risk stratification in erectile dysfunction - intermediate risk?
>3 RF for CAD Mild or moderate stable angina Past MI (within 2-8 weeks) awaiting exercise test NYHA class 3 PVD, Hx of CVA
Specialist testing recommended before sex resuming
Cardiac risk stratification in erectile dysfunction - high risk?
Unstable angina Uncontrolled hypertension NYHA Class 4 Recent MI <2 weeks VT, ICD with frequent shocks, poorly controlled AF OCM Moderate/Severe valve disease
Referred for cardiac testing and treatment – stop having sex until told to do so
When to admit person to hospital in erectile dysfunction?
- Admit to hospital if priapism (persistent erection)
When to make referral in erectile dysfunction?
o Urology – young men always had difficulty, men with trauma Hx, abnormal penis/scrotum
o Endocrine – hypogonadism
o Cardiology – severe CVD that would make sex unsafe
o Mental health – psychogenic and severe mental distress
Management of erectile dysfunction - lifestyle advice?
Lose weight
Stop smoking
Reduce alcohol consumption
Increase exercise
If cycle >3 hours/week – encourage trial period without cycling
Modify RF – DM, hypertension, lipids, weight
Management of erectile dysfunction -PDE-5 inhibitor?
Sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra) and avanfil (Spedra)
CI: on nitrates, severe CVD, hypotensive, unstable angina during sex, renal and hepatic impairment, MI <3 months ago
Caution – Peyronie’s, SCD, multiple myeloma, leukaemia, anatomical defect
SE: Back pain, dyspepsia, flushing, myalgia, dizziness, nausea and vomiting
Management of erectile dysfunction - dosing of PDE-5 inhibitor?
- Sildenafil – 1 hour before, lasts 4-5 hours
* Tadalafil – at least 30 minutes before sex, or if frequent sex (>2 weekly) then daily, lasts up to 36 hours
Management of erectile dysfunction - secondary care management?
o Vacuum erection device
o Alprostadil intracavernous injection/cream/intraurethral application
o Penile prosthesis
Complications of erectile dysfunction?
o Emotional health suffers – anxiety, depression, lack of sexual confidence, low self-esteem, relationship problems
o Increases risk of CVD
Definition of epididymo-orchitis?
Epididymo-orchitis
o Inflammation of epididymis, with or without inflammation of testes
o Most common local extension of infection from urethra (STIs/UTIs)
Chronic epididymitis = pain and inflammation lasting for >6 months
Epidemiology of epididymo-orchitis?
- Ages of 15-30 and over 60
Risk factors of epididymo-orchitis?
o Purulent discharge, MSM, black – gonorrhoea
o Instrumentation
o Indwelling catheters
o Structural abnormalities of urethral tract
Causes of epididymo-orchitis - <35 years old?
Chlamydia Gonorrhoea Ureaplasma urealyticum Mumps TB
Causes of epididymo-orchitis - >35 years old?
E.coli
Pseudomonas
Mumps
TB
Causes of epididymo-orchitis - others?
Behcet’s disease
CMV, candidiasis, brucellosis
Amiodarone
Causes of orchitis?
o Viral – mumps, Coxsackie A, varicella
o Bacterial – E.coli, Klebsiella, Pseudomonas, Staph
o Granulomatous – Syphilis, TB, leprosy
o Trauma
Symptoms of epididymo-orchitis?
o Sudden-onset unilateral scrotal pain Tender swelling o Dysuria o Sweats o Fever o Discharge (if STI) o Mumps – headache, fever, parotid swelling
Signs of epididymo-orchitis?
o Tenderness on palpation
o Palpable swelling of epididymis (starting with tail at lower pole of testis and spreading towards head)
o Discharge, erythema, oedema
o Pyrexia
o Prehn’s sign – tenderness relieved by elevating scrotum
Investigations of epididymo-orchitis?
- Urinalysis
- MSU microscopy and culture
Investigations of epididymo-orchitis - if STIs suspected?
o 1st catch urine sample – NAAT test for chlamydia & gonorrhoea
o If urethral discharge – swabs and gram-stain smear
o HIV if risk factors
o STI screen
Investigations of epididymo-orchitis - other tests?
o If TB suspected – 3 EMU samples, IV urography, renal tract US
o If mumps suspected – mumps IgM/IgG serology
o Doppler US – to assess blood flow and help differentiate between epididymo-orchitis
Management of epididymo-orchitis - referral?
- If possibility of torsion, severe symptoms or systemically unwell:
o Urgent urology opinion - Refer for same-day or next-day GUM specialist (if mumps orchitis not diagnosed)
Management of epididymo-orchitis - if referral not possible?
Identify most likely causative agent
o STI - <35, >1 sexual partner in last year, urethral discharge
o Gonorrhoea – previous infection, known contact, purulent urethral discharge, MSM, black
o Enteric - >35, low risk sexual history, Hx of penetrative anal intercourse, recent catheter
Management of epididymo-orchitis - general measure?
o Bed rest
o Scrotal support
o Symptoms sometimes worsen before improving
o PRN analgesia
Management of epididymo-orchitis - if possible STI?
Refer same/next day to GUM clinic for full STI screen, treatment and contact tracing
Avoid unprotected sex until treatment and partners been treated
Empirical antibiotics:
Doxycycline 100mg BD for 10-14 days + ceftriaxone 500mg IM stat
• Add azithromycin if gonorrhoea considered
• Partner notification and treatment
• If symptoms worsen, or do not begin to improve within 3 days – return for assessment and change of antibiotics
Refer to sexual health specialist for follow up and contact tracing
Management of epididymo-orchitis - if due to enteric organism?
o Oflaxacin 200mg BD for 14 days (or levofloaxcin 500mg OD for 10 days)
If quinolones CI – co-amoxiclav 500/125mg TDS for 10 days
If symptoms worsen, or do not begin to improve within 3 days – return for assessment and change of antibiotics
Management of epididymo-orchitis - surgical?
o If torsion cannot be ruled out – surgical exploration
Management of epididymo-orchitis - follow up?
o If not improved in 3 days – consider changing antibiotics and follow up in 2 weeks
o If swelling persists after Abx – refer for urgent outpatient urology appointment to exclude cancer
o If UTI confirmed – refer to urologist to investigate structural/obstruction of UT
Complications of epididymo-orchitis?
- Hydrocele
- Abscess
- Infertility
Types of urethritis?
o Gonococcal urethritis
o Non-gonococcal urethritis
o Persistent/Recurrent urethritis – occurs 30-90 days after treatment for acute NGU
Epidemiology of urethritis?
- NGU more common than GU
- Persistent urethritis in 15-25% of men treated for NGU
Causes of urethritis - gonococcal?
Neisseria gonorrhoeae
Causes of urethritis - Non-gonococcal?
Chlamydia trachomatis Mycoplasma genitalium Ureaplasma urealyticum Trichomonas vaginalis UTI (E.coli, staphylococcus saprophyticus, proteus) Adenovirus HSV Trauma Irritation – soaps, lotions, spermicide Urethral stricture
Symptoms in men of urethritis?
o Urethral discharge o Dysuria o Penile irritation o Balanoposthitis o Urethral discomfort
Symptoms in women of urethritis?
o Cervicitis
o Urethritis
o Salpingitis
Investigations in urethritis?
Assess likelihood of
STI
- Refer all men to GUM clinic for confirmation of diagnosis and treatment
Management of gonococcal urethritis - general advice?
- Adhere to treatment
- Safe sex practices
- Abstain from sex until 7 days after they and their partner have completed treatment
Management of gonococcal urethritis - antibiotics - indications?
o Intracellular gram-negative diplococci on microscopy
o Positive culture for gonorrhoea
o Positive NAAT for gonorrhoea
o Sexual partner confirmed gonococcal disease
Management of gonococcal urethritis - antibiotics - what?
o Ceftriaxone 1g IM single-dose
If susceptibility known prior to treatment – ciprofloxacin 500mg single dose
Management of non-gonococcal urethritis - general advice?
- Adhere to treatment
- Abstain from sex until he and partner has completed treatment (14 days after start of treatment)
- Safe sex practices
Management of non-gonococcal urethritis - antibiotics?
• Doxycycline 100mg BD for 7 days (Azithromycin 1g stat, then 500mg OD for next 2 days)
Management of recurrent/persistent non-gonococcal urethritis?
Azithromycin 1g stat then 500mg OD for next 2 days + metronidazole 400mg BD for 5 days
• Start within 2 week of finishing doxycycline
Management if unwilling to go to GUM clinic for urethritis - initial?
Make working diagnosis of urethritis if:
Man has mucopurulent or purulent urethral discharge
First-void urine sample positive for leukocytes
Screen for STIs – first-void NAAT urine test, urethral swabs, blood test
Management if unwilling to go to GUM clinic for urethritis - general advice?
Adhere to treatment
Abstain from sex until he and partner has completed treatment
Safe sex practices
Management if unwilling to go to GUM clinic for urethritis - empirical antibiotics?
Doxycycline 100mg BD for 7 days (azithromycin 1g single dose then 500mg for 2 days)
Treat suspected gonorrhoea or trichomonas
Management if unwilling to go to GUM clinic for urethritis - follow up?
1-2 weeks, review symptoms and contact tracing has happened
GUM if treatment failure
Epidemiology of testicular cancer?
- Most common malignancy in men aged 15-45
Risk factors of testicular cancer?
o Undescended testis o Infant hernia o Infertility o Klinefelter’s syndrome o Low birth weight
Types of testicular cancer?
- Types (95% arise from germ cells): o Seminoma o Non-Seminomatous germ cell tumour Teratomas, yolk sac tumours o Mixed germ cell tumour
Symptoms of testicular cancer?
o Painless testis lump o Testicular or abdominal pain o Dragging Sensation o Haemospermia o Gynaecomastia (from b-HCG) o Dyspnoea (lung mets)
Signs of testicular cancer?
o Lump - hard, craggy, rough
When to refer for 2-week appointment in testicular cancer?
- Refer for 2-week wait if:
o Non-painful enlargement or change in shape or texture of testis
Investigations in testicular cancer?
USS
If diagnosed on US:
Bloods (AFP (yolk sac), HCG, LDH)
CT scan of chest, abdomen and pelvis
CXR if lung symptoms
Staging of testicular cancer?
o Royal Marsden Staging
1 = no disease outside testis
2= infradiaphragmatic node involvement (para-aortic)
3= supradiaphragmatic and infradiaphragmatic node involvement
4= extralymphatic mets (haematogenous)
Management of testicular cancer - all patients?
MDT
Cancer nurse specialist
Surgery (unless malignant)
Orchidectomy & excisional biopsy - Insertion of prosthesis at primary surgery
Partial Orchidectomy – if patient’s only testis, bilateral or small mass <50%
Sperm Banking
Sperm analysis at 12 months post-treatment
Testosterone replacement therapy if anorchic or hypo-orchic patients
Management of testicular cancer -post-orchidectomy non-seminomatous germ cell & mixed - stage 1?
Low risk (no LVS invasion) • Surveillance
High Risk (LVS) • Adjuvant chemotherapy (Bleomycin + etoposide + cisplatin)
Management of testicular cancer -post-orchidectomy non-seminomatous germ cell & mixed - stage 2, 3 & 4?
Chemotherapy (BEP)
o Post-chemo residual disease
Surgical resection of para-aortic nodes
Management of testicular cancer -post-orchidectomy seminoma - stage 1?
Surveillance, adjuvant chemotherapy (carboplatin) or radiotherapy (if not fit for chemotherapy)
Management of testicular cancer -post-orchidectomy seminoma - stage 2?
Radiotherapy plus additional if recurs
Management of testicular cancer -post-orchidectomy seminoma - stage 3&4?
Chemotherapy – cisplatin + etoposide
Follow up of testicular cancer?
o Measure AFP, LDH, b-HCG – weekly until normal
o Post chemotherapy semen analysis at 12 months
o Continue for 5 years
