Sexual Health

Question 1

. Determinants of STI Incidence equation and meaning

Answer 1

. Determinants of STI Incidence: R0 = ßcD
• Epidemiology of STIs in populations results from interaction between
o ß = probability of transmission (organism and host characteristics)
 Cellular, immune response, host susceptibility, asymptomatic, prevalence
o C = behaviours that facilitate transmission
 Rate of partner change, sexual timing, number of sex acts/partner, non-use of barrier protection
o D = duration of infectiousness
 Host response, variations in infectivity during infectious period, time to treat infected contacts

Question 2

R0 = ßcD

what is B?

Answer 2

o ß = probability of transmission (organism and host characteristics)
 Cellular, immune response, host susceptibility, asymptomatic, prevalence

Question 3

R0 = ßcD

what is c?

Answer 3

o C = behaviours that facilitate transmission
 Rate of partner change, sexual timing, number of sex acts/partner, non-use of barrier protection

c for condom

Question 4

R0 = ßcD

what is D?

Answer 4

o D = duration of infectiousness
 Host response, variations in infectivity during infectious period, time to treat infected contacts

D for duration

Question 5

most common STIS in UK

Answer 5

1. Chlamydia
2. Genital warts (HPV)
3. Gonorrhea
4. Herpes
5. HIV
6. Syphilis

Question 6

age men and women have highest rates of STIs

Answer 6

Men - rates of new STI diagnoses are highest in 20-29-year olds
Women - rates are highest in 15-24-year olds

Question 7

what is HIV 90:90:90

Answer 7

aim for 2020 - 90% of people will know HIV status, 90% with new HIV infection will receive sustained antiretroviral therapy, 90% of all people receiving antiretroviral therapy will have viral suppression

UK exceeded target in 2017

Question 8

Window Periods for STI testing

Answer 8

• GC/CT = 2 weeks
• HIV = 4 weeks
• Syphilis = 12 weeks

Question 9

complications of chlamydia in Pregnancy

Answer 9

Pregnancy
• Associated with low birth weight, post-partum endometritis and neonatal conjunctivitis and pneumonitis
• Patients should be advised to avoid SI for 1/52 and until partner(s) notification and treatment
• Test of cure (TOC) is recommended in pregnancy; poor compliance is suspected if symptoms persist.
o This should be done 6 weeks after treatment

doxycycline contraindicated in pregnancy/ breast feeding –> erythromyicn?

Question 10

management of chlamydia

Answer 10

Recommended Regimens
• Doxycycline 100mg BD for 7 days
o Contraindicated in pregnancy/breastfeeding  higher chance of miscarriage
o Advice
 Take with plenty of water, sitting or standing
 Avoid bright sunlight/sunbeds (potential severe photosensitive skin rash)
 Avoid taking minerals such as Calcium, Iron & Zinc
• OR azithromycin 1g stat

Alternative Regimens
• Erythromycin 500mg BD for 10-14 days
• Erythromycin 500mg QDS for 7 days
• Ofloxacin 200mg BD or 400mg OD for 7 days
o Contraindicated in pregnancy/breastfeeding

Question 11

how can gonorhoea present in neonate?

Answer 11

eye infection in neonate, presenting in the first week of life and is a notifiable disease
• In older children  should raise suspicion of abuse

Question 12

Differentials for vaginal discharge

Answer 12

Normal
 White, curd-like - Candida
 Watery/malodorous - Bacterial Vaginosis (white/ grey) or Trichomonas Vaginalis (green/yellow/frothy)
 Mucopurulent - Gonorrhoea
 White/clear - Chlamydia

Question 13

Differentials for dysuria

Answer 13

May be associated with Chlamydia, Gonorrhoea, Trichomonas, Herpes Simplex or NSU

Question 14

Differentials for PCB/IMB

Answer 14

May be caused by Chlamydia or Gonorrhoea

Question 15

Differentials for ulcers

Answer 15

Herpes simplex (HSV) is the commonest UK cause but consider primary syphilis, trauma, bacterial infection, carcinoma and tropical ulcer disease

Question 16

Differentials for lymphadenopathy

Answer 16

Seen in HSV, Syphilis, HIV and other infections

Question 17

Differentials for balanitis

Answer 17

Inflammation of the glans can be caused by Candida and anaerobic bacteria

Question 18

Differentials for genital itchiness

Answer 18

Itching caused by scabies, pubic lice or Candida

Question 19

Differentials for swelling and tenderness of testes

Answer 19

Can be caused by Chlamydia, Gonorrhoea or Gram negative enteric organisms

Question 20

Differentials for pelvic pain and dyspareunia

Answer 20

May suggest pelvic inflammatory disease secondary to Chlamydia, Gonorrhoea or anaerobic infection.

Question 21

Differentials for psychosexual

Answer 21

Including: hypoactive sexual desire disorder, sexual arousal disorder, erectile dysfunction, premature ejaculation and anorgasmia.

Question 22

4 systemic conditions and complications from STIS

Answer 22

 Pelvic inflammatory disease
 Epididymitis/Orchitis
 Sexually acquired reactive arthritis SARA
 Prostatitis

Question 23

infective causes of PID

Answer 23

 Chlamydia trachomatis
 Neisseria gonorrhoea (30% will have chlamydia)
 Anaerobes
 Mycoplasma / ureaplasma
 Streptococci

Question 24

complications of PID

Answer 24

PID may be acute (<1 month) or chronic (>1 month). The infection may result in endometeriosis, salpingitis, parametritis, oophoritis, tubular abscess and/or pelvic peritonitis.

Common long-term sequelae of untreated infection are:
 Chronic pelvic pain
 Ectopic pregnancy
 Infertility

Question 25

what are pus cells used to show?

Answer 25

PID investigation

Endocervical swab for microscopy – look for evidence of pus cells on Gram stain,
 indicative of cervcitis

Question 26

what is EPIDIDYMITIS /ORCHITIS?

Answer 26

Epididymo-orchitis is defined as pain, swelling and inflammation of the epididymides +/- testicular inflammation triggered by an infectious agent.

Question 27

4 infective causes of Epididymo-orchitis

Answer 27

 N. gonorrhoeae (50% also have Chlamydia)
 C. trachomatis (< 35 years of age)
 E. coli, enterobacteriacae (>35 years of age / structural
 M. tuberculosis (rare)

Question 28

clinical features of Epididymo-orchitis

Answer 28

Usually unilateral but may be bilateral.
 Scrotal pain, swelling, erythema
 Testicular pain
 Torsion

Question 29

complications of Epididymo-orchitis

Answer 29

Complications
 Reactive hydrocele
 Abscess formation
 Infertility

Question 30

Differential Diagnosis of Epididymo-orchitis

Answer 30

 Torsion (< 20 years);
 Inguinal hernia;
 Tumour (uncommon, usually non painful).

Question 31

investigations for Epididymo-orchitis

Answer 31

First pass urine – CT/GC
 Midstream urinalysis – UTI, TB
 Serology – HIV, syphilis, mumps
 Doppler USS – Torsion
 Refer to urology - structural abnormalities

Question 32

Management of Epididymo-orchitis

Answer 32

General advice:
 Rest and analgesia
 Abstain from sexual intercourse until they and their partner(s) have been treated
If severe, treat as inpatient with fluids/electrolyte management

Recommended Regimen if STI likely cause:
- Ceftriaxone 500mg IM STAT
+ PLUS Doxycyline 100mg PO BD 14 days
OR Ofloxacin 200mg PO BD 14 days

Recommended Regimen if UTI likely cause:

• Ofloxacin 200mg PO BD 14 days
• Ciprofloxacin 500mg PO BD 10 days