Sexual health Flashcards
How would you investigate for primary herpes simplex
Swab ulcers - send for HSV PCR
Syphilis serology
Vulvovaginal swabs for chlamydia and gonorrhoea NAAT
What is the treatment for primary herpes simple
Aciclovir 400mg tds for 5 days Saline baths Antibiotics - flucloxacillin for any infection Loose clothing Avoid intercourse with symptoms Topical Vaseline Topical 2% lidocaine gel
What tests are done for gonorrhoea
Light microscopy - gram negative intracellular diplococci inside the neutrophils
GC culture and chlamydia/gonorrhoea NAAT from 3 sites in MSM rectum, pharynx and urethra
Syphilis and HIV serology Hep B and c s
How is gonorrhoea treated?
1g IM ceftriaxone
What are the causes of non-gonococcal urethritis (NGU)
Chlamydia trachomatis
Mycoplasma genitalium
HSV
Adenovirus
What tests would you do for someone with NGU
Chlamydia/gonorrhoea NAAT urine
HIV/syphilis serology
How do you treat epididymo-orchitis caused by chlamydia
Doxycycline 100mg
What are the symptoms of reactive arthritis
Cant see - conjunctivitis
Cant pee - urethritis
Cant climb a tree - immune inflammation of joint
How do you treat reactive arthritis
Doxycycline 100mg bd 7 days
List some causes of vaginal discharge
Non sexually transmitted - candida albicans, bacterial vaginosis
Sexually transmitted - chlamydia, gonorrhoea, trichomonas vaginalis
What would you find on examination in PID
Pain on superficial and/or deep palpation of pelvis
Mucopurulent discharge at cervix
Contact bleeding at cervix
Bimanual examination - cervical motion tenderness, uterine tenderness and adnexal tenderness
Pyrexia
What tests would you do to look for candida
Microscopy vaginal specimen lunking for fungal spores and candida culture
Which organisms cause PID
Chlamydia Gonorrhoea BV - gardnerella vaginalis Mycoplasma genitalium E.coli H.influenzae
Describe the treatment of PID
Ceftriaxone 1g IM stat, doxycycline 100mg bd 2weeks, metronidazole bd 5 days
Or Moxifloxacin 400mg od 2 weeks
Describe the secondary syphilis rash
Hands and soles of feet
6 weeks to 6 months post inoculation
Describe the primary syphilis rash
9-90 days after
Chancre - ulcer - usually not painful - tend to be solitary
How do you investigate for syphilis
Dark field microscopy - corkscrew moving
Serology - 3 different tests and at least 2 should be positive
How is syphilis treated
IM benzathine penicillin 2.4mega units
IM procaine penicillin for HIV positive individuals
Describe how HIV is tested
Point of care test - HIV Ag/Ab
Blood for 4th generation test - can test for earlier disease (3-4 weeks)
How long is the window period for chlamydia and gonorrhoea
2 weeks
What is the window period for syphilis
6 weeks
How long is the window period for HIV
45 days
Describe cerebral toxoplasmosis
Multiple abscesses in the brain
Caused by immunosuppression for a long time
How is pneumocystis jivoreci pneumonia (PCP) treated
IV septrin 3 weeks
How is some antiviral therapy metabolised
CY450 - watch out for interactions
Describe the drug reaction in HIV and asthma
Cushing’s syndrome from the flixonase in Seretide inhaler with the ART
TB interactions
When should HIV be considered
In non specific illness
Describe what happens in bacterial vaginosis to vaginal flora and pH
Lactobacilli (friendly bacteria - produce lactic acid to keep pH <4.5) are lost
The pH rises, the more alkaline the vagina, the more able other bacteria are to multiply
Give some examples of bacteria associated with BV
Gardnerella vaginalis
Mycoplasma hominis
Prevotella species
Chlamydia, gonorrhoea and candidiasis
List some risk factors for bacterial vaginosis
Multiple sexual partners Excessive vaginal cleaning Recent antibiotics Smoking Copper coil
Describe the presentation of bacterial vaginosis
Fishy smelling watery grey or white vaginal discharge
Itching and pain are not typically associated with BV but may present with co-occuring infection
Describe the Investigations in bacterial vaginosis
Vaginal pH - 3.5-4.5
Charcoal vaginal swab taken for microscopy - high vaginal swab taken during speculum examination or self taken low vaginal swab
Clue cells on microscopy
What are clue cells
Epithelial cells from the cervix that have bacteria (Gardnerella vaginalis) stuck inside them
Describe the management of bacterial vaginosis
Metronidazole - targets anaerobic bacteria - 400mg bd PO, vaginally
Clindamycin - alternative but less optimal antibiotic choice
Assess the risk of additional pelvic infections with chlamydia and gonorrhoea swabs
Provide advice and information about measures to reduce risk of further episodes of BV
Why should alcohol be avoided when taking metronidazole
Causes a disulfiram like reaction with nausea and vomiting, flushing and sometimes shock and angioedema
List the complications of BV
Associated with and increases the risk of STIs
Complications in pregnancy - miscarriage, preterm delivery, premature rupture of membranes, Chorioamniotis, low birth weight, post partum endometritis
What causes thrush
Candida albicans - colonise the vagina causing symptoms
Progress to infection when in right environments
List some risk factors for candidiasis
Increased oestrogen
Poorly controlled diabetes
Immunosuppression - corticosteroids
Broad spectrum antibiotics
Describe the presentation of candidiasis
Thick, white discharge - does not smell
Vulval and vaginal itching, irritation and discomfort
Erythema, fissures, oedema, pain during sex, dysuria and excoriations
Describe the treatment of thrush
Single dose intravaginal clotrimazole cream (5g 10%) or pessary at night (500mg ON)
Three doses of clotrimazole pessaries 200mg over 3 nights
Single dose of fluconazole 150mg
How does antifungal medication affect condoms
Destroys the latex - women need to use alternative contraception or abstain for 5 days
Describe chlamydia trachomatis
Gram negative bacteria
Intracellular organism - enters and replicates within cells before rupturing the cell and spreading to others
Describe charcoal swabs
Microscopy, culture and sensitivities
Gram staining and light microscopy of endocervical and high vaginal swabs
Describe nucleic acid amplification tests (NAAT)
Check directly for the DNA/RNA of the organism
Chlamydia and gonorrhoea
Vulvovaginal, endocervical, rectal, pharyngeal and first catch urine
What swabs are required in gonorrhoea
NAAT
Endocervical charcoal swab for MC&S
Describe the presentation of chlamydia in women
Abnormal vaginal discharge Pelvic pain Abnormal vaginal bleeding Painful sex Painful urination
Describe the presentation of chlamydia in men
Urethral discharge/discomfort
Painful urination
Epididymo-orchitis
Reactive arthritis
Describe the examination findings in chlamydia
Pelvic/abdo tenderness
Cervical motion tenderness
Inflamed cervix
Purulent discharge
Describe the treatment of chlamydia
Doxycycline 100mg bd for 7 days
Azithromycin 1g stat then 500mg OD for 2 days/ erythromycin 500mg for 7 days in pregnant and breast feeding
List the complications of chlamydia
PID Chronic pelvic pain Infertility Ectopic pregnancy Epididymoorchitis Conjunctivitis Lymphogranuloma venereum Reactive arthritis
List some complications of chlamydia in pregnancy
Preterm delivery Premature rupture of membranes Low birth weight Postpartum endometritis Neonatal infection - conjunctivitis and pneumonia
Describe Fitz-hugh-curtis syndrome
PID complication - liver capsule becomes inflamed causing right upper quadrant pain, scar tissue formation and peri-hepatic adhesions
What swabs are required in chlamydia
Vulvovaginal NAAT
Describe Neisseria gonorrhoea
Gram negative diplococcus bacteria
Infects mucous membranes with columnar epithelium - endocervix in women, urethra, rectum and conjunctiva
Spread via contact with mucus secretions from infected areas
High level of antibiotic resistance
How does gonorrhoea present in women
Odourless purulent discharge - yellow or green
Dysuria
Pelvic pain
How does gonorrhoea present in men
Odourless purulent discharge - yellow or green
Dysuria
Testicular pain and swelling
How is gonorrhoea diagnosed
NAAT - RNA/DNA
Charcoal endocervical swab for MC&S - high rate of antibiotic resistance
Describe the management of gonorrhoea
Testing Treatment - IM ceftriaxone 1g or oral ciprofloxacin 500mg Contact tracing Abstain from sex for 7 days Test of cure
List some complications of gonorrhoea
PID Chronic pelvic pain Infertility Epididymoorchitis Prostatitis DIC Urethral strictures Septic arthritis Endocarditis Gonococcal gonorrhoea
Describe disseminated gonococcal infection
Complication of untreated gonococcal infection - bacteria spreads to the skin and joints Various non-specific skin lesions Polyarthralgia Migratory polyarthritis Tenosynovitis Systemic symptoms
What is mycoplasma genitalium a cause of
Non-gonococcal urethritis
STI
List the symptoms of mycoplasma genitalium
Urethritis Epididymitis Cervicitis Endometritis PID RA Preterm delivery in pregnancy Tubal infertility
Describe the investigations of mycoplasma genitalium
NAAT - DNA and RNA as it is slow growing bacteria so culture not possible
First urine sample in the morning - men
Vaginal swab - women
Check for macrolide resistance and test of cure after treatment
Describe the treatment of mycoplasma genitalium
Doxycycline 100mg bd 7days then azithromycin 1g stat then 500mg od for 2 days
Moxifloxacin is alternative for complicated infection
Azithromycin used alone in pregnancy
List some symptoms of PID
Pelvic/abdo pain Abnormal vaginal discharge/bleeding Pain during sex Fever Dysuria
Describe trichomonas vaginalis
Parasite spread via sex and lives in the urethra and vagina
Protozoan and is a singled celled organism with 4 flagella (appendages stretching from the body) on the front and one on the back. Use the flagella for movement, attaching to tissues and causing damage
What can trichomonas increase the risk of
Contracting HIV - damages the vaginal mucosa
BV
Cervical Ca
PID
Pregnancy related complication - preterm delivery
Describe the presentation of trichomonas vaginalis
Up to 50% asymptomatic
Vaginal discharge(frothy/yellow/green with a fishy smell), itching, dysuria, dyspareunia, balanitis
Strawberry cervix (colpitis macularis) - inflammation relating to the infection with tiny haemorrhages seen across the cervix
Vaginal pH >4.5
How is trichomonas vaginalis diagnosed
Charcoal swabs from the posterior fornix with microscopy or self taken low vaginal swab or urethral swab or first catch urine
What is the treatment of trichomonas
Metronidazole
What are the two types of herpes simplex virus
1 (cold sore)
2 (genital)
HSV 1 may occur on genitals via orogenital sex
Where does oral herpes simplex lay dormant
Trigeminal nerve ganglion
Where does genital herpes lay dormant
Sacral nerve ganglion
How is herpes simplex spread
Direct contact with mucous membranes or viral shedding in mucous secretions
When is asymptomatic viral shedding most common
First 12 months of infection
Describe the presentation of genital herpes
Ulcers or blistering lesions Neuropathic pain - tingling, burning, shooting Flu like symptoms Dysuria Inguinal lymphadenopathy
Symptoms can last 3 weeks in primary infection
Recurrent symptoms usually milder and resolve more quickly
How is genital herpes diagnosed
Clinical diagnosis but viral PCR swab from lesion can confirm the organism
How is primary genital herpes contracted before 28 weeks gestation treated
Aciclovir during inital infection followed by regular prophylatic aciclovir from 36weeks onwards to reduce risk of genital lesions during labour and delivery
Women with symptoms recommend C-section
How is primary genital herpes contracted after 28weeks gestation managed
Treat with aciclovir during initial infection followed by immediate regular prophylactic Aciclovir.
C-section in all cases
How is recurrent genital herpes managed in a woman known to have genital herpes before pregnancy
Prophylatic acidlovir from 26 weeks although risk of neonatal infection is low even if lesions present during delivery
List some AIDs (immunodeficient/late stage HIV) defining illnesses
Kaposi's sarcoma Pneumocystis jivoreci pneumonia CMV Candidiasis - oesophageal/bronchial Lymphoma TB
Describe HIV
RNA retrovirus
HIV1 (common) and 2 (rare outside of africa)
Virus enters and destroys CD4 T helper cells
Transmitted via unprotected anal, vaginal or oral sexual activity, mother to child at any stage of pregnancy birth or breastfeeding, mucous membrane, blood or open wound exposure to infected blood or bodily fluids
Describe the initial seroconversion of HIV
Flu like illness within few weeks of infection
Which antigen is tested for in HIV antigen testing
p24
Describe monitoring in HIV
CD4 count 500-1200 (normal range), <200 is end stage HIV
Viral load - HIV RNA, undetectable <50 copies
What are some HIV management
2 NRTIs (Nucleoside reverse transcriptase inhibitors - tenofovir and emtricitabine) plus a third agent
Prophylactic co-trimoxazole (septrin) - protect against PCP if CD4 <200
Statins for cardiovascular disease
Yearly cervical smears
Vaccinations - influenza, pneumococcal, hep A and B, tetanus diphtheria and polio
What drug can be given during delivery or to the baby in a HIV mother
Zidovudine
Is breastfeeding safe in HIV
No
How long can post exposure prophylaxis be commenced after HIV exposure
72hrs
Describe PEP
ART therapy - Truvada (emtricitabine and tenofovir) and raltegravir for 28 days
HIV test immediately and 3 months after
What class of drugs are HIV drugs ending in -navir
Protease inhibitors
Describe toxoplasmosis
HIV
Neuro symptoms
Multiple brain lesions with ring
enhancement
What is the most common cause of diarrhoea in HIV patients
Cryptosporidium
Describe Kaposi’s sarcoma
Caused by HHV8
Purple papules or plaques on the skin or mucosa
Skin lesions may ulcerate
Respiratory involvement may cause haemoptysis or pleural effusion
How is Kaposi’s sarcoma managed
Radiotherapy and resection
Describe Cryptococcus neoformans on LP
Stains with india ink
Name and describe the bacteria which causes syphilis
Treponema pallidum - spirochete - spiral shaped bacteria
How is syphilis spread
Oral, vaginal, anal sex
Vertical transmission
IVDU
Blood transfusions and other transplants
Describe the stages of syphilis
Primary - painless ulcer (chancre) and lymphadenopathy 3-8 weeks
Secondary syphilis - systemic symptoms - maculopapular rash, condylomata lata (grey wart like lesion around genitals and anus), low grade fever, lymphadenopathy, alopecia, oral lesions, these resolve after 3-12 weeks
Latent syphilis - early latent <2yrs and late latent >2yrs
Tertiary syphilis - development of gummas (granulomatous lesions), cardiovascular (aortic aneurysms) and neurosyphilis (headache, altered behaviour, dementia, ocular syphilis, argyll-robertson pupil (constricted pupil that accommodates but does not react to light), paralysis, sensory impairment. tabes dorsalis (demyelination affecting the spinal cord posterior columns)
How is syphilis diagnosed
Antibody testing to the T.pallidum bacteria
Samples tested for T.pallidum with dark field microscopy and PCR
What is the treatment for syphilis
Deep IM injection of benzathine benzylpenicillin
