Sexual health Flashcards
Name 3 STIs
Chlamydia
Genital warts
Gonorrhoea
Genital herpes
PID
Trichomonas vaginalis
Non-specific urethritis
Syphilis
HIV
Epididymorchitis
Hep B and C
Name 3 non-STIs that are dealt with in sexual health
Candidiasis
Bacterial vaginosis
Genital dermatoses - lichen sclerosis, balanitis
Vulval condition - vulvodynia, vestibulitis
Psychosexual problems
Sexually acquired reactive arthritis
Sexual assault victims
What should you ask about in a general sexual history?
HPC
Past GU history
Past general Medical/surgical history
Drugs (any antibiotics in last month)
Sexual history - last 3-12 months
- Last sexual intercourse
- Regular/casual partner
- Male/female
- Condom use
- Type of SI
What should you ask in a sexual history specific to women?
Menstrual history
Pregnancy history
Contraception
Cervical cytology history
What should you ask in a sexual history specific to men?
When last voided urine
What is important in a sexual health examination?
Privacy
Dignity
Chaperone
Explanation
What should you examine in both sexes in a sexual health examination?
Genital skin
Inguinal nodes
Pubic hair
What should you examine in women in a sexual health examination?
Vulva
Perineum
Vagina
Cervix
Bimanual pelvic examination
Possibly anus and oropharynx
What should you examine in men in a sexual health examination?
Penis
Scrotum
Urethral meatus
Anus and oropharynx in MSMs
What asymptomatic screening is done for women?
Self-taken vulvo-vaginal swab for gonorrhoea/chlamydia NAAT
Bld for STS + HIV
What asymptomatic screening is done for heterosexual men?
First void urine for chlamydia/gonorrhoea NAAT
Bld test for STS + HIV
What asymptomatic screening is done for MSM?
First void urine for chlamydia/gonorrhoea NAAT
Pharyngeal swab for chlamydia/gonorrhoea NAAT
Rectal swab for chlamydia/gonorrhoea NAAT
Bld for STS, HIV, hep B (+ hep C if indicated)
How might women present symptomatically with an STI?
Vaginal discharge
Vulval discomfort/soreness, itching or pain
Superficial dyspaerunia
Pelvic pain/deep dyspaerunia
Vulval lumps/ulcers
Intermenstrual bleeding
Post-coital bleeding
How might men present symptomatically with an STI?
Pain/burning during micturition
Pain/discomfort in the urethra
Urethral discharge
Genital ulcers, sores, or blisters
Genital lumps
Rash on penis or genital area
Testicular pain/swelling
What symptomatic screening is done for women?
Vulvo-vaginal swab for gonorrhoea + chlamydia NAAT
High vaginal swab (wet + dry slides) for
- Bacterial vaginosis
- Trichomonas vaginalis
- Candida
Cervical swab for slide + gonorrhoea culture
Dipstick urinalysis (if dysuria)
Bld for STS + HIV
What symptomatic screening is done for heterosexual men?
Urethral swab for slide + gonorrhoea culture
First void urine for gonorrhoea + chlamydia NAAT
Dipstick urinalysis (if dysuria)
Bld for STS + HIV
What symptomatic screening is done for MSM?
Test as for asymptomatic MSM
+ urethral and rectal slides
+ urethral, rectal, pharyngeal culture plates
Who should be screened for hep B?
MSM
Commercial sex workers (CSW) and their sexual partners
IVDUs current/past and their sexual partners
People from high risk areas and their sexual partners - Africa, Asia, Eastern Europe
Aim to vaccinate if non-immune
Why are partners treated?
Central activity in GUM
Necessary to prevent re-infection of index patient
To identify and treat asymptomatic infected individuals as a public health measure
Role of health advisers
Importance of confidentiality in maintaining patient trust
How common are STIs?
Predominantly affect adolescent and young adult population, however anyone who is sexually active is at risk
STIs commonly occur in multiples - if you find one look for others
Asymptomatic infections common
Balance of individual patient treatment and public health function
What is chronic pelvic pain?
Non-cyclical pain that persists for 6 or more months
Localised to pelvis or lower abdomen
Not occurring exclusively with sexual intercourse or periods
Not associated with pregnancy
May affect as much as 1 in 6 women
What can cause chronic pelvic pain?
Not well understood
Often more than one cause of the pain is identified
Social, psychological and physical factors play a role
Sometimes no cause found
Endometriosis
Adenomyosis
Leiomyoma (fibroids)
Pelvic congestion syndrome
Pelvic inflammatory infection (PID)
Pelvic organ prolapse
IBS
Diverticular disease
Interstitial cystitis
Degenerative joint disease
Somatisation
Nerve entrapment
What do you need to ask in a history about chronic pelvic pain?
Pain - SOCRATES
Urinary, bowel symptoms, MSK
Sexual history - deep dyspareunia, contraception, STIs
Menstruation history - frequency and character of periods, intermenstrual bleeding, pain
Vaginal discharge
Cervical smear history
Psychological and social issues (especially sexual abuse)
DH, SH, FH
What examination should you do in a chronic pelvic pain examination?
General demeanour
Vital signs
Abdominal examination - distension, masses, tenderness, guarding, rebound
Vaginal speculum + bimanual examination
What does tenderness or pain on bimanual examination suggest?
Infective cause - PID or non-infective inflammatory cause - endometriosis
What does cervical motion tenderness suggest?
Ectopic pregnancy
Or PID
What does pain within anterior vaginal wall suggest?
Interstitial cystitis
What does a large uterus suggest?
Fibroids
What does a fixed mobile uterus suggest?
Adhesions
What investigations should you do for chronic pelvic pain?
Urinalysis + MSU
Pregnancy test
FBC, CRP, TFT, LFTs
High vaginal swab and endocervical swab
Transvaginal USS for adnexal masses
MRI useful for adenomyosis
Diagnostic laparoscopy
What is endometriosis?
Presence of endometrial-like tissue outside of the uterus
Induces a chronic inflammatory reaction
Usually found within pelvis, especially within pouch of Douglas and uterosacral ligaments behind to uterus
Rarely found in distant sits such as the umbilicus, abdominal scars, perineal scars, pleural cavity, and nasal mucosa
Responds to cyclical hormonal changes and bleeds during menstruation just like true endometrium
Associated with infertility
Who does endometriosis affect most?
Women between 25 and 35
Oestrogen-dependent, so rarely diagnosed after menopause
What are the symptoms of endometriosis?
Severe dysmenorrhoea
CPP
Deep dyspareunia
Pain during ovulation
Cyclical symptoms
Pain of defecation (dyschezia)
Infertility
What investigations can you do to diagnosed endometriosis?
TVS could identify gross endometriosis in ovaries
Diagnostic laparoscopy (gold standard)
What is the management of endometriosis?
Medical
- Simple analgesia - NSAIDs + tranexamic acid
- Ovulation suppression - tricyclic COCP, mirena coil, GnRH analogues
Surgical
- Conservative with laser or diathermy ablation of lesions
- Radical with hysterectomy and oophorectomy
What is adenomyosis?
Presence of endometrial tissue within the myometrium
Oestrogen-dependent so regresses after menopause
In it’s most severe form, pools of blood can form within myometrium
Who does adenomyosis affect most?
Tends to affect older women who have had children
What are the symptoms of adenomyosis?
Painful and heavy menstruation
Cyclical pain
Uterus enlarged and mildly tender
What are the investigations of adenomyosis?
TSH and MRI
What is the management of adenomyosis?
Medical
- Simple analgesia - NSAIDs + tranexamic acid
- Ovulation suppression - tricyclic COCP, mirena coil, GnRH analogues
Surgical
- Conservative with laser or diathermy ablation of lesions
- Radical with hysterectomy and oophorectomy
What is a leiomyoma?
Fibroids
Benign smooth muscle tumours of myometrium
Oestrogen-dependent
Pedunculated, submucosal, intramural, subserosal
How common are leiomyomas?
Occurs in 30% women > 30
What are the symptoms of leiomyomas?
Asymptomatic
Menorrhagia
Urgency, frequency, retention
Pelvic pain
What investigations can you do for leiomyomas?
TVS
Hysteroscopy
Diagnostic laparoscopy
What is the management for leiomyomas?
NSAIDs +/- tranexamic acid
COCP/minerna coil
Myomectomy
Hysterectomy
What are the complications of leiomyomas?
Fibroid torsion
Subfertility
Miscarriage
Red degeneration during 1st and 2nd trimester (fever, pain, vomiting)
0.1% transform into leiomyosarcoma
What is pelvic congestion syndrome?
Incompetence of pelvic vein valves
Typically occurs after pregnancy
Who does pelvic congestion syndrome affect most?
Occurs in 1 in 5 women with varicose veins
What are the symptoms of pelvic congestion syndrome?
Constant dull ache in lower abdomen
Worse after standing/prolonged activities/prior to periods or during or after intercourse
Pressure from veins could irritate the bladder and cause interstitial cystits
What investigations are there for pelvic congestion syndrome?
Transvaginal duplex USS
MRI venogram
What is the management for pelvic congestion syndrome?
Analgesia
Non-invasive transcatheter vein embolization
What is PID?
Infection of upper genital tract (cervix, uterus, fallopian tubes)
Most commonly due to STI (chlamydia, gonorrhoea)
Rarely due to descending infection eg appendicitis
What can increase your risk of PID?
Young age
Multiple sexual partners
Not using barrier contraception
Surgical TOP
ICUD (especially inserted within last 20 days)
Previous STIs
What are the symptoms of PID?
Bilateral lower abdominal pain, could be chronic
Deep dyspareunia
Abnormal vaginal bleeding - postcoital, intermenstrual, menorrhagia
Vaginal/cervical discharge that is purulent
What are the signs of PID?
Lower abdominal tenderness
Mucopurulent cervical discharge
Cervical motion tenderness and adnexal tenderness on bimanual vaginal examination
Fever > 38
What investigations should you do in PID?
Bloods - FBC, CRP, ESR
HSV and endocervical swabs
Diagnostic laparoscopy - PID could lead to subfertility and ectopic pregnancy due to inflammation, scarring, and adhesion in the fallopian tubes
How can you manage PID?
Ceftriaxone 500mg as single IM dose, followed by doxycycline 100mg orally twice daily and metronidazole 400mg BD for 14 days
Could require admission for IV antibiotics if infection severe enough
IUCD removed
Contact tracing
What is a pelvic organ prolapse?
Vaginal wall/uterus protrude beyond the normal anatomical confines
What is a cystocele?
Anterior wall involvement prolapse
What is a rectocele?
Posterior wall involvement prolapse
What are the stages of prolapse?
0 - no prolapse
1 - more than 1cm above hymen
2 - within 1cm proximal or distal to plane of hymen
3 - more than 1cm below plane of hymen but protrudes no further than 2cm less than total length of vagina
4 - complete eversion of vagina
What can increase your risk of prolapse?
Menopause
Multiparity
Vaginal delivery (especially forceps/ventouse)
Obesity
Chronic cough
Pelvic surgery
What are the symptoms of prolapse?
Dragging sensation
Something coming down
Dyspareunia
Urgency, frequency, dysuria
Constipation