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
