Sexual health Flashcards
What are genital warts?
- condylomata acuminata
- lesions usually affecting the introitus and vulva but can occur on cervix, anus,
- caused by HPV 6 and 11 most commonly
How are genital warts transmitted?
- sexual activity
- autoinocculation
How are genital warts transmitted?
- sexual activity
- autoinnoculation
List 4 differential diagnoses of genital warts
- molluscum contagiosum
- sebaceous cysts
- condolymata lata of secondary syphilis
- tumours
List 3 types of management options for genital warts
- conservative
- medical
- surgical
What are the conservative management options for warts?
- let immune system recognise and clear itself
What are the medical management options for genital warts?
Imiquimod - immune modulator
podophyllotoxin - cytotoxic agent
What regimen of podophyllotoxin would you recommend?
Clinician applied or patient applied
Clinician applied regimen twice weekly
patient applied regiment twice daily
What regimen of imiquimod would you recommend for genital wart treatment?
5% once daily
3x weekly for 10 hours at a time fo 16 weeks if hasn’t responded to podophyllotoxin
What are the surgical management options for treatment of genital warts?
excisional
diathermy or cold knife used
clearance of 90-100%
recurrence 20-30%
What is the clearance rate using imiquimod for genital wart treatment?
40-70%
What is the risk of recurrence of genital warts following treatment with imiquimod?
1/4 recur
What is the clearance rate of genital warts treated with podophyllotoxin?
45-80%
What is the risk of recurrence following treatment with podophyllotoxin for genital warts?
15-100%
How can genital warts be treated in pregnancy?
Best treatment is cryotherapy or electrocautery
Avoid cytotoxic medications - podophyllotoxin + imiquimod
A pregnant woman wants to know the risks of genital warts during pregnancy what would you advise her?
vertical transmission is rare but can occur
It causes laryngeal papillomas which can develop as late as 12 years after exposure
genital warts are not an indication for CS unless they are obstructive
What is molluscum contagious?
a common, contagious infection caused by the pox virus
presents with multiple small lesions that are pearly white in colour and have a small dimple in the middleH
How are molluscum contaigiosum treated?
self limiting - will resolve in several months
cryotherapy or electrocautery
How could you categorise genital ulcerative lesions?
infectious - sexually transmitted and non sexually transmitted
non infectious - BAMI - blistering, aphthous, malignant and inflammatory
List 6 causes of infectious sexually transmitted ulcerative genital lesions
- HSV 1 and 2
- syphilis
- gonorrhoea/trichomonas vaginitis
- lymphogranluma vereneum (chlamydia trichomatis)
- chancroid (haemophilia ducreyii)
- donavanosis (klebsiella granulomatosis)
List 7 causes of infectious but non sexually transmitted genital ulcers
- severe candidiasis
- herpes zoster affecting lumbar or sacral roots
- TB
- CMV
- EBV
- Mycoplasma
- group A strep
list 4 possible causes of aphthous genital ulcers
- Chrons
- SLE
- HIV
- Post infection e.g. EBV
List 5 causes of inflammatory ulcers (non STI)
- dermatitis
- lichen planus
- lichen sclerosis
- fixed drug eruption
- Steven johnson syndrome
List 3 causes of blistering ulcers
pemphigus vulgaris
bullous pemphigoid
erythema multiforme
List 3 causes of malignant ulcers
vulval SCC
VIN
BCC
What investigations would you undertake to review a genital ulcer
- swab for HSV 1 and 2
- NAAT for chlamydia and gonorrhoea
- bacterial swab for gram staining
- blood for syphilis/HIV serology
- consider bloods for; HSV, EBV, CMV, mycoplasma, FBC, CRP, ANA
- consider biopsy if diagnosis cannot be made otherwise
What are the general management principles for genital ulcers?
- minimise irritants
- sitz bath
- cool compress
- topical anaesthetic
- oral analgesia
What is the treatment for Lymphogranuloma venereum?
oral doxycyclineW
What is the treatment for chancroid (haemophilia ducreyii)
ceftriaxone/azithromycin/ciprofloxacin or erythromycin
How are HSV1 and HSV2 transmitted?
HSV 1 - oral to genital
HSV 2 - genital to genital
What are the symptoms of primary HSV infection?
fever, myalgia dysuria vaginal discharge painful ulceration lymphadenopathy
What are the symptoms of secondary HSV infection?
asymptomatic
ulcers - usually less painful than primary
prodromal symptoms such as tingling
How do you investigate for HSV?
- swab base of HSV lesion with viral PCR swab
- HSV serology only recommended in suspected primary episode in pregnancy
- syphilis serology recommended
How would you counsel a patient who has just been diagnosed with HSV and is upset at diagnosis?
- very common 1:3-5 people affected
- only 20% of people have symptoms
- shedding occurs even when not symptomatic
- does not affect long term health, fertility, cancer risk
What are the management principles for HSV infection?
Primary infection - valaciclovir 500mg PO BD 7 days
Sitz bath, passing urine in bath, loose clothing, cool compress
oral analgesia
IDC if retention
local anaesthetic topically
Fully sexual health screen
What are the management principles for secondary infection?
avoid triggers
avoid tampon use while menstruating
COCP continuously to suppress menstruation
episodic treatment - valaciclovir 500mg BD for 3/7
suppressive treatment - valaciclovir 500mg daily for 1 year then break for 3 months
What causes syphilis
infection with bacteria treponema pallidum
gram -ve spirochete
spread by close contact and sexual contact
separated into primary, secondary, tertiary and latent
What is the pattern on syphilis serology re; progress
IgM –> IgG –> TPPA —> VDRL
what is the normal vaginal pH
3.8-4.5
List 6 factors that can impact on vaginal discharge
menses intercourse douching intravaginal preparations (medications) contraception antibiotics pregnancy
List your female screening tests for STI (if symptomatic)
- Speculum exam - HVS + endocervical NAAT for chlamydia, trich, gonorrhoea
- anorectal swab - chlamydia and gonorrhoea
- throat swab - gonorrhoea
- serology - syphilis, HIV, Hep B
Should asymptomatic people get screened for mycoplasma genitalium?
No - no evidence as to what the clinical implications are for asymptomatic MG
What are the common causative microbes associated with PID
E. Coli Chlamydia gonorrhoea BV vaginal anaerobes streptococci mycoplasma genitalium
what percentage of PID has no known causative agent
70%
What is the recommended antibiotic regimen for PID?
ceftriaxone 500mg in 2mL of 1% lignocaine IMI
+/- 1g azithromycin STAT orally
metronidazole 400mg PO BD for 14 days
doxycycline 100mg BD for 14 days
*if breast feeding replace doxy with 2nd dose of azithromycin day 7
What extra precautions would you give to someone who has been diagnosed with PID
no sex for 1/52 following treatment
simple analgesia
follow up in 2-3 days
an IUD may be kept in situ if symptoms improve
NB - most PID is sexually transmitted but most swabs are negative therefore still recommend partner treatment with STAT azithromycin and contact tracing
what is the incidence of chlamydia?
what is the reinfection rate of chlamydia?
22%
28% occur in 3/12 following diagnosis
when should chlamydia testing be repeated?
3/12 after first test
what is the best treatment for rectal chlamydia
doxycycline
what are the impacts of chlamydia on pregnancy?
- increased risk of PTB
- increased rate of post partum fever
what are the risks of chlamydia on a neonate?
conjunctivitis 50%
pneumonia 30%
what is the treatment for chlamydia
1g PO azithromycin STAT
- 100mg BD 7/7 of doxy if anorectal infection
what percentage of gonorrhoea infections cases are asymptomatic for women?
50%
list 3 high risk groups for gonrrhoea
- MSM
- aboriginal
- recent overseas travel
what is the treatment for gonorrhoea
1g azithromycin
500mg IM ceftriaxone
what are the impacts of gonorrhoea infection on pregnancy?
- PTB rate increases
- post partum fever rate increases
what is the effect of gonorrhoea on neonates?
conjunctivitis - blindness 5%
disseminated infection 1%
what is Amsel’s criteria?
- used to diagnose BV
- 3 of 4 findings to make diagnosis:
- offensive vaginal discharge
- vaginal pH >4.5 (alkaline)
- positive amine test with KOH
- clue cells on microscopy of wet film
List 3 possible treatment options for recurrent BV
• Attempts with colonisation with exogenous L. crispatus – can be helpful in some women but causes worsened symptoms in others
• Suppressive treatment : metronidazole gel twice weekly for 16 weeks after initial 10 days
of treatment 26% vs 60% recurrence Sobel 2006 Am J Obstet Gynae
• Suppressive clindamycin cream → can lead to secondary fungal infections
