Sexual Health Flashcards
– Cluster 1: Sexual Health Overview –
What are the key symptoms presenting with STI [5]?
- urethral, vaginal discharge
- lower abdo pain
- genital lumps, ulceration
- genital itching
- rectal symptoms
What are the four ‘core’ STIs tested for at sexual health clinics, and how are they tested for in men and women?
- Chlamydia trachomatis (CT)
- Neisseria gonorrhoeae (GC; gonococcus)
- HIV
- Syphilis
- GC/CT NAAT: vulvovaginal swab (VVS) in women, and first void urine (FVU) in men. consider throat and rectum swabs in MSM
- high vaginal swab (HVS, Amies swab) in recurrent/persistent discharge, postpartum or post gynae surgery, PID etc.
- HIV and syphilis via serology
Name the partner notification (PN) periods for CT, GC, NGU, TV, PID, HIV, and syphilis.
- CT: 4w (male urethral), 6m
- GC: 2w (male urethral), 3m
- NGU/TV: 4w
- PID: 6m
- HIV: 4w before last negative result, or 4w before most likely infection
- syphilis: primary 90 days, secondary 2yr
For which sexual infections is partner notification (PN) not required?
- warts, herpes
- thrush
- bacterial vaginosis
Name the three categories of serovar seen in CT and which infection types they may cause.
- A-B: ocular infection
- D-K: urethritis, epididymo-orchitis, neonatal pneumonia and conjunctivitis
- L1-3: LGV (lymphogranuloma venereum), mainly MSM with rectal symptoms
Name the clinical features of CT.
- milky urethral discharge, irregular bleeding, abdominal pain, dysuria
- inflammation of urethra, cervix, epididymis, rectum
- [neonatal pnuemonia, conjunctivitis]
What is Fitz Hugh-Curtis Syndrome?
A very rare presentation of CT, with perihepatitis and piano-string adhesions
Describe the management of CT.
- doxycycline 100mg BD/wk
- azithromycin 1g stat + 500mg OD/2days; this is second line and should only be used when tetracyclines genuinely cannot be taken (e.g., during pregnancy) due to antibiotic resistance
What are the complications of CT?
- ectopic pregnancy
- PID (manage with ceftriaxone, doxycycline, metronidazole)
- reactive arthritis
- reinfection (1/5)
Describe the symptoms of NG [4].
4D’s: Discharge (mucopurulent), dysuria, ‘Damn that hurts’ (anterior urethritis, lower abdominal pain), Disruption to menstrual cycle (PCB/IMB)
- rarer: proctitis, sepsis/DGI, tenosynovitis, arthritis, erythematous skin
Describe the management of GC.
- 1st line: ceftriaxone, 1g IM stat
- 2nd line: ceftaime, 400mg PO + azithromycin 2g PO
- test of cure in all patients 2 weeks after completing treatment
Describe the swab findings in a positive case of GC infection.
- > 5 polymorphs per high powered field indicates urethritis
- look for gonococcal cells (these are purple gonococci within cells)
- NB CT cannot be seen on gram stain
What are the complications of GC?
In men (PENIS):
- P: prostatitis
- E: epididymo-orchitis
- N: nasty infection of Mullerian or Cowper glands
- I: infertility
- S: strictures (of the urethra)
In women (3P’s):
- PID (in ~33%), resulting in chronic pelvic pain, tubal infertility, ectopic pregnancy
- Peritoneal spread (Fitz-Hugh-Curtis syndrome)
- Pregnancy complications (spontaneous abortion, premature labour, PROM, perinatal mortality, gonococcal conjunctivitis in the newborn)
In both sexes, disseminated gonorrhoea (DGI) is a potentially serious complication thought to occur in 0.5-3% of untreated cases
- septic arthritis, polyarthralgia, tenosynovitis
- petechial/pustular skin lesions
- endocarditis or meningitis
What are the most common causes of non-gonococcal urethritis (NGU)?
CT, mycoplasma genitalium, ureaplasma urealyticum, TV, HSV 1/2, adenoviruses
Describe the natural history of syphilis.
- a chronic systemic disease caused by Treponema pallidum, a motile spirochete
- primary: incubation 9-90 days with primary papule at site of inoculation which ulcerates to form a chancre. 25% of untreated primary cases will go on to develop into secondary syphilis
- secondary: widespread rash on palms/soles, anterior uveitis, condylomata lata (highly infectious plaques). may also include hepatitis, glomerulonephritis, and splenomegaly.
- tertiary: gummatous syphilis. can affect cardiovascular and neurological systems
Describe the clinical examination of suspected syphilis.
Primary and secondary
- genital examination
- skin examination (inc. mucosal surfaces such as eyes and mouth, scalp, palms, and soles of feet)
- neurological examination (if neurological symptoms elicited)
Late-stage disease
- skin examination
- MSK examination (congenital)
- cardiovascular (?aortic regurgitation)
- neurological examination (paresis, dysarthria, hypotonia, intention tremor, reflex abnormalities, Tabes dorsalis, pupil abnormalities, impaired vibration/joint position sense, sensory ataxia, optic atrophy)
Describe the investigation options for syphilis.
- cannot be cultured
- dark field microscopy, PCR, or serology (IgM/IgG ELISA)
- dark field microscopy requires highly skilled microscopists, is less reliable in rectal and non-penile lesions, and is not suitable for oral lesions (commensal treponemes)
- therefore serology remains the main lab diagnosis
Serology
- non-treponemal tests: VDRL, RPR. titres can be used to monitor response to treatment, and NTTs revert to negative after treatment.
- treponemal tests: TPPA, ELISA, INNO-LIA, FTS antibodies. remain positive even after treatment.
TPPA: Treponenum pallidum particle agglutination; TPHA: TP haem agglutination; TP-EIA: TP enzyme immunoassay
VDRL: venereal disease research laboratory; RPR: rapid plasma reagin
Describe the investigation algorithm used for suspected syphilis.
Traditional vs contemporary
- a non-treponemal test (NTT) has previously been used prior to a treponemal test (TT). However, this produces a subjective result, and there is a higher rate of false positives in low incidence settings.
- the positive predictive value (PPV) of a lab is affected by incidence. a lower incidence of syphilis worldwide now means the NTT –> TT approach is less accurate.
Current algorithm
- a TT (e.g. TP-EIA) is first used, then followed up by a NTT if positive. if both are positive, there is evidence of current syphilis.
- a positive TT and negative NTT (TT+, NTT-) is open to interpretation (e.g. past, successfully treated syphilis; early or late/latent syphilis; false positive). in these situations, a second, different TT is performed (e.g. TPPA).
Describe the management of syphilis.
- single dose of 2.4 MU benzthine penicillin G IM stat
- doxycycline 100mg BD 2/52
- late syphilis: penicillin G IM weekly for 3 wk
- followup until RPR -ve or serofast. Titres should decrease fourfold by 3-6m
Describe the main adverse effect observed with treatment of syphilis.
- Jarisch-Herxheimer reaction (JHR)
- caused by a release of inflammatory cytokines, most commonly associated in spirochete infection (e.g. also associated with Lyme disease, leptospirosis)
- occurs within 24 hours of treatment
- usually consists of mild fever, malaise, headache, and flu-like symptoms lasting several hours
- treatment is with reassurance and antipyretics (e.g. paracetamol)
– Cluster 2a: Urethritis –
Describe the presentation and classification of urethritis.
- the term ‘urethritis’ is usually reserved for men to describe urethral discharge and dysuria, although it is asymptomatic in up to 30% of men
- it is typically divided into gonococcal or non-gonococcal urethritis (NGU)
- infectious causes include GC, CT, MG, UU, TV, HSV, UTI, and adenoviruses
- non-infective causes include physical and chemical trauma and urethral stricture
Describe the investigations used for urethritis.
- microscopy of urethral discharge or urethral swab; NAAT and culture for GC; NAAT for CT and MG; serology for syphilis and HIV
- tests for TV and HSV are not usually performed routinely; there is no commercial test available for Ureaplasma urealyticum
- midstream specimen of urine (MSSU) if symptoms are suggestive of UTI
– Cluster 2b: Vaginal discharge –
Describe the aetiology of vaginal discharge as a presenting complaint.
Vaginal discharge is a common presenting symptom and is not always pathological.
- infective: vaginal (BV, candida, TV) or cervical (CT, NG, HSV)
- physiological discharge
- non-infective: cervical ectropion, cervical polyps, neoplasms, retained products of conception, retained products (e.g. tampons), chemical irritation etc.
Describe the aetiology of physiologic vaginal discharge.
- regulated by hormone levels in the body
- around ovulation, discharge is thin and clear to allow sperm to swim easier, and occurs with high levels of oestrogen in the body
- as the cycle progresses, cervical mucus becomes thicker and more hostile to sperm
Describe the investigation of vaginal discharge.
- microscopy for BV, candida, and TV
- culture for candida
- NAAT for TV, CT, GC
- serology for syphilis, HIV
Describe the pathology of most cases of bacterial vaginosis (BV).
A lack of lactobacilli allows overgrowth of pathogenic bacteria (including Gardnerella vaginalis, anaerobes, mycoplasmas, and Mobiluncus spp.)
An increased pH can lead to prolonged/heavy periods
Describe the diagnostic criteria for bacterial vaginosis.
3/4 of the Amsel’s criteria
- creamy-white homogenous discharge
- clue cells (stippled vaginal epithelial cells) on microscopy
- vaginal pH >4.5
- positive whiff test (characteristic fishy odour released by mixing vaginal discharge with potassium hydroxide)
Describe the clinical features and management of BV.
- increased vaginal discharge, offensive fishy odour, creamy-white homogenous discharge which may be frothy
- amine production causes offensive odour and froth
- metronidazole 400mg BD 5-7/7
- alternatives: intravaginal metronidazole, intravaginal clindamycin
Describe the microscopy and presentation of trichomonas vaginalis (TV).
- highly motile, flagellated protozoan
- nearly all men are asymptomatic, as are 10-50% of women
- in women, the most common symptoms are increased purulent vaginal discharge (grey-green) and malodour, pruritis, dysuria, dyspareunia, and strawberry cervix (vulvar erythema)
Describe the management of TV.
- metronidazole 2g orally as a single dose, or 400mg BD for 7/7
- TV infects areas beyond the vagina (e.g. the urethra) and as such intravaginal metronidazole gel has poor cure rates
Describe the complications associated with BV and TV in pregnancy.
- BV: increased risk of miscarriage, preterm birth
- TV: increased risk of preterm birth and low birth weight
- increases risk of acquisition and transmission of HIV
– Cluster 3: Anogenital ulcers –
What is the wider differential diagnosis for genital ulceration?
vIndIcATe
- infectious (HSV, VZV, EBV, HIV)
- iatrogenic (drug eruption, SJS)
- autoimmune (Crohn’s, Behcet’s, lichen sclerosus)
- trauma (self-harm, artefacta)
Describe the investigation of anogenital ulceration.
- ulcer swab for HSV PCR, +/- syphilis (condylomata lata is a differential)
- NAAT for CT, NG
- in MSM, consider genotyping for LGV
Describe the timeline of HSV infections.
- primary: virus ascends peripheral sensory nerves to DRG, establishing latency.
- symptoms: ulcers, inguinal lymphadenopathy, viraemia, dysuria, vulval pain
- non-primary genital infection: those with previous HSV1/2 who acquire the other type.
- cross-protection from other type means a milder illness
- recurrent infection: 4x more common in HSV2 than 1
- tingling, itching, pain, unilateral ulcer, can be asymptomatic
- usually resolves 5-7days, although all episodes potentially infectious
Describe the management of HSV-caused genital ulceration.
- primary infection: saltwater bathing, topical anaesthetic (5% lidocaine), and acyclovir (400mg TDS 6/7 days).
- avoid sharing towels, etc. to prevent autoinoculation
- suppressive therapy offered with >6 recurrences/yr. This is acyclovir 400mg OD
Describe the management of HSV in pregnancy.
The main risk of HSV in pregnancy is vertical transmission, with risk highest within the first 6 weeks of infection.
- first trimester: women who acquire primary HSV in the first trimester are not at increased risk of miscarriage
- women with recurrent genital herpes in the first and second trimesters are advised to take acyclovir from 36 weeks
- tertiary infection, primary: manage with C/S
- tertiary, recurrent: suppressive acyclovir from 36 weeks and vaginal delivery
Describe the aetiology, presentation, investigation and management of chancroid.
- chancroid is caused by Haemophilus ducreyi
- a tender papule develops at site of inoculation, with a short incubation of 4-7 days. the papule breaks into a painful, ragged-edged ulcer with a necrotic base that bleeds easily. there is often tender inguinal lymphadenopathy.
- diagnosis is most sensitive with PCR
- azithromycin 1g PO or ceftriaxone 250mg IM
- other options: ciprofloxacin 500mg BD 3/7; erythromycin 500mg QDS 7/7
Describe the microbiology and presentation of Donovanosis.
- also known as granuloma inguinale; caused by Klebsiella granulomatis
- K granulomatis are gram-negative rods that develop into Donovan bodies
- exceedingly rare, confined to southeast Asia, south America, and the Caribbean
- nodules at the site of inoculation develop into friable, non-painful ulcers or hypertrophic lesions that increase in size