Sexual Health Flashcards
Contacts of which conditions are treated for chlamydia?
PID
epididymo-orchitis
Pharmacological management of chlamydia?
doxycycline 100mg BD 7 days
= CI in pregnancy
Counselling for chlamydia diagnosis?
no sex for 1 week + after partner treated
see health advisor for treatment and contact tracing
warning: oesophageal irritation and avoid direct sunlight
advise re-test in 3mo if <25yrs (document)
ToC in 6wks if pregnant or if rectal infection
After what positive tests is gonorrhoea treated?
not after +ve GC NAAT alone
always obtain cultures
Pharmacological management of gonorrhoea?
ceftriaxone 1g/3.5mls 1% lidocaine IM stat
OR
if cultures available: ciprofloxacin 500mg stat, if sensitive
Counselling for gonorrhoea diagnosis?
no sex for 1 week + after partner treated
see health advisor for contact tracing
ToC in 2 wks
Which contacts of gonorrhoea are treated?
empirical tx if sexual contact was in last 2wks
if >2wks ago: screen all 3 sites (incl cultures) + wait to treat
Management of BV? When is BV treated?
if symptomatic or grade II/III
metronidazole 2g stat
OR 400mg BD for 7 days if pregnant/risk of pregnancy
no alcohol for 48hrs after metronidazole (N&V, flushing)
aqeuous cream - mix with water for washing if desired
prevention advice: wash only with water, avoid soap/shower gell etc, avoid washing hair in bath
Counselling for TV diagnosis?
ToC if pregnant
see health advisor for contact tracing
Pharmacological management of thrush?
clotrimazole pessary 500mg stat
+/- clotrimazole 1% cream BD if vulval irritation
fluconazole 150mg PO stat if requested but NOT if pregnant/at risk of pregnancy
see GP if recurrent thrush
Management of 1st herpes outbreak?
Aciclovir 400mg TDS 5/7 with Instillagel topical PRN
if severe, f/u in 1wk
“task” yourself to chase result
if HSV -ve, write clinical note about further action - what was the sore?
write to gp if +ve in case of recurrences
Pharmacological management of recurrence of herpes?
aciclovir 800mg TDS 2/7
Counselling for HSV diagnosis?
obtain GC/CT blind swab if possible + HIV/STS bloods
advise saline baths/urinate in bath
attend a&e if can’t urinate
if pregnant, discuss with senior dr
if >6 outbreaks a yr, consider suppression and discuss with senior dr
What are the tx options and their SEs for genital warts?
creams = 1st line
- MUST be on reliable contraception
- SE: soreness, blisters, dermatitis
warticon (podophyllotoxin) topic 3 consecutive days BD
imiquimod topical nocte
- every other night across 6 days, need to wash off in morning
cyrotherapy - 3 freeze thaw cycles weekly
- SE: painful, hypopigmentation, scarring
Essential mx in women with abdo pain?
concerned about PID
check urine dip/pregnancy test + do PV
ie exclude UTI and pregnancy
Pharmacological management of PID?
take mycoplasma swab if treating
ceftriaxone 1g IM stat /3.5ml 1% lidocaine
AND
doxycycline 100mg BD 14/7
AND
metronidazole 400mg BD 14/7
regular ibuprofen
Counselling for PID diagnosis?
no sex for 2wks/1wk after partner treated
document given contact slips to give to partners + to abstain until treated
f/u in 2wks for results and review
at review:
give results
check abstained and compliant with abx
partner treated
sx improved?
repeat PV
mycoplasma +ve required further tx
Who should be tested for mycoplasma genitalium?
men with microscopically confirmed NGU (split initial urine into 2 - 1 for CT/GC, 1 for myco)
all women with PID - VVS
all current sexual contacts of +ve mycoplasma - only tx contacts if +ve
mycoplasma ToC in 5wks
How is NGU microscopically confirmed?
> 5 PC’s on microscopy (normally men have none)
Pharmacological management of epididymo-orchitis?
if likely gonorrhoea:
Ceftriaxone 1g IM stat / 3.5ml 1% lidocaine
AND
Doxycycline 100mg BD for 14 days
if likely chlamydia/other non-gonococcal organism (ie if microscopy was -ve for GC + no RFs):
Doxycycline 100mg PO daily for 14 days
regular analgesia
Counselling for epididymo-orchitis diagnosis?
no sex for 2 weeks/1 wk after partner tx
document given contact slips
f/u in 2 wks
at review:
give results
check abstained and compliant with abx
partner treated
sx improved?
repeat examination
Who is NGU tested for in?
men with dysuria, discharge or testicular pain
test for mycoplasma
Pharmacological management of NGU?
Doxycycline 100mg BD for 7 days
Counselling for NGU?
no sex for 1 wk and after partner treated
warn oesophageal irritation and avoid direct sunlight
document given contact slips
Tests done for asymptomatic woman?
self taken VVS (for GC/CT NAAT)
+ rectal if receive anal
bloods for HIV + STS
Tests done for symptomatic woman or contact of infection?
HSV swab if ulcers
VVS (for GC/CT NAAT + red topped one for mycoplasma)
+ rectal swab and culture if receive anal
bloods for HIV + STS
wet slide (use loop) of posterior fornix
dry slide (use cotton bud) of lateral walls
MOP CERVIX
slide + culture of cervix (use cotton bud) for GC
bimanual exam
if abdo pain/deep dyspareunia: urine dip/pregnancy test
When are pharyngeal swabs taken in women?
contact of gonorrhoea
CSW
patient request
= swab for GC/CT NAAT + culture for GC
Tests done for asymptomatic heterosexual men?
1st void urine for CT/GC NAAT
- should not have passed urine in last hr
bloods for HIV + STS
Tests done for symptomatic or contact of infection heterosexual men or ?
HSV swab if ulcers
urethral swab for slide and GC culture (small cotton bud)
bloods for HIV + STS
1st void urine
- if NGU - split urine and do M.gen PCR and resistance test
Tests done for asymptomatic MSM?
1st void urine for CT/GC NAAT
+ rectal and pharyngeal swabs
+ rectal and pharyngeal culture if sx/contact of GC
bloods for HIV, STS, Hep B Sag, Hep C ab
-doc should be vaccinated for hep b if -ve
offer hep a and b vaccine
offer hpv vaccine if <45
inform about PeP and PreP
Tests done for symptomatic MSM?
1st void urine for CT/GC NAAT
+ rectal and pharyngeal swabs
- if NGU - split urine and do M.gen PCR and resistance test
bloods for HIV, STS, Hep B Sag, Hep C ab
HSV swab if ulcers
urethral swab for slide and cultures (small cotton bud)
offer hep a and b vaccine
offer hpv vaccine if <45
inform about PeP and PreP
What is chlamydia caused by?
chlamydia trachomatis
(obligate IC bacteria)
How is chlamydia ad gonorrhoea transmitted?
sexual contact
vertical
RFs of chlamydia?
<25
new sexual partner
>1 sexual partner/yr
not using condoms
Clinical features of chlamydia in women and men?
- asymptomatic in 70%
- increased vaginal discharge
- dysuria
- pelvic pain
- post coital/intermenstrual bleeding
Complications of chlamydia?
epididymo-orchitis
PID (1-30%)
infertility
ectopic pregnancy
reactive arthritis
What organism must be tested for in MSM with rectal chlamydia?
LGV
type of chlamydia bacteria that attacks the lymph node
What is gonorrhoea caused by?
neisseria gonorrhoeae
gram -ve diplococcus
Clinical features of gonorrhoea in women?
- 50% asymptomatic
- mucopurulent discharge (50%)
- pelvic pain (25%)
- dysuria (12%)
Clinical features of gonorrhoea in men?
- <10% asymptomatic
- mucopurulent discharge (80%)
- dysuria (50%)
Clinical features of chlamydia in men?
- asymptomatic in 50%
- urethral discharge
- dysuria
- testicular pain
Complications of gonorrhoea?
epididymo-orchitis
PID
How is gonorrhoea diagnosed?
microscopy
NAAT
cultures prior to tx (due to increasing abx resistance)
How is chlamydia diagnosed?
NAAT
What is PID caused by?
ascending infection of chlamydia + gonorrhoea (25%), gardnerella vaginalis (BV), anaerobes, other vaginal commensals
Clinical features of PID?
bilateral lower abdominal pain
deep dyspareunia
abnormal vaginal bleeding
purulent discharge
fever
adnexal and cervical motion tenderness on bimanual
Differentials for PID?
ectopic - exclude pregnancy
appendicitis - vomiting
endometriosis - cyclical
ovarian cyst torsion/rupture - sudden onset
UTI - urinary sx
functional pain - longstanding
Inx for PID
full STI screen
pregnancy test
urinalysis
bimanual
mycoplasma PCR/resistance test
What additional abx are needed if PID is mycoplasma +ve?
moxifloxacin
Complications of PID?
infertility
ectopic
chronic pelvic pain
pelvic abscess
What is epididymo-orchitis caused by?
young pt: local extension of infection from STI (CT/GC)
older pt: UTI - gram -ve enteric organisms
rarely extrapulmonary TB
Clinical features of epididymo-orchitis?
unilateral pain, swelling and inflammation of epididymis/testes
possibly urethral discharge, pyrexia, secondary hydrocele, symptoms of UTI
Complications of epididymo-orchitis?
reactive hydrocele
abscess
tesicular infarction
infertility
Differentials of epididymo-orchitis?
EXCLUDE testicular torsion - sudden onset pain = surgical emergency - needs testicle salvage in 6hrs
mumps - headache, fever, parotid swelling, serology
Ivx for epididymo-orchitis?
- gram stained urethral smear and culture
- 1st void urine STI screen
- urinalysis
- MSU
- mycoplasma if >5PCs on microscopy
What organisms cause NGU?
no cause found in 50%
chlamydia trachomatis (45%)
mycoplasma genitalium
trichomonas vaginalis
ureaplasma urealyticum
UTI
adenoviruses
HSV
candida
trauma
irritation
urethral structure
lichen sclerosus
urinary calculi
RFs for NGU?
sexually active
unprotected sex
homo/biseuxal
aged <35
multiple partners
Complications of NGU?
epididymo-orchitis
sexually acquired RA
Clinical features of NGU?
asymptomatic
urethral discharge
dysuria
Inx of NGU?
gram stained urethral smear (>5PCs per field) + culture
1st pass urine
urinalysis
MSU
urine sample into two for GC/CT and mycoplasma PCR/resistance
What organism is TV caused by?
flagellated prozoon
Clinical features of TV in women?
asymptomatic (10-50%)
yellow frothy discharge
itching
dysuria
pelvic pain
Clinical features of TV in men?
asymptomatic (15-50%)
urethral discharge
dysuria
frequency
How is TV diagnosed?
wet slide from posterior fornix in females
urethral/urine culture in males
What is BV caused by?
if vaginal pH >4.5, normal vaginal flora (lactobacilli) dominated by anaerobes cause the sx
eg gardnereall vaginalis
How is TV transmitted?
sexual contact
How is BV transmitted?
not sexually
Clinical features of BV?
asymptomatic (50%)
thin white offensive smelling vaginal discharge
NO soreness, itching, irritation
Complications of BV?
a/w miscarriage, preterm birth/PROM, postpartum endometritis in pregnancy
How is BV diagnosed?
gram stained vaginal microscopy
- grade I - normal - only lactobacilli seen
grade II - intermediate - mixed flora, some lactobacilli
grade III - BC - few/no lactobacilli seen
What organism causes thrush?
candida albicans
sometimes other non-albican species
How is thrush transmitted?
not sexually
RFs for thrush?
uncontrolled DM
immunosuppression
hyperoestrogenaemia eg HRT< COCP
broad-spec abx
Clinical features of thrush in women?
vulval itch and soreness
vaginal discharge - curdy non-offensive
superficial dyspareunia
external dysuria
erythema
fissuring
excoriation
Clinical features of thrush in men?
red skin
swelling
irritation
soreness
itchiness
phimosis
dysuria
dyspareunia
Complications of thrush?
chronic/recurrent infection in men > phimosis
How is thrush diagnosed?
routine microscopy
What is the differences between HSV type 1 and 2?
type 1 - usual cause of oral herpes
type 2 - a/w sexual transmission
both can cause oral or genital herpes
How does herpes develop following primary infection?
primary infection > becomes latent in sensory ganglia > periodically reactivates to cause symptomatic lesions/asymptomatic viral shedding
Clinical features of herpes
asymptomatic (80%)
painful blisters and ulcers
dysuria
tender inguinal lymphadenitis
discharge
fever
myalgia
occasionally non-specific erythema, fissures or erosions
Complications of herpes?
urinary retention
aseptic meningitis
How is herpes diagnosed?
HSV DNA detection by PCR after swab at base of ulcer
How are genital warts transmitted?
skin to skin
Clinical features of genital warts?
most asymptomatic
more common in pregnancy due to immunosuppression
small fleshy lumps
itching
distorted flow of urine if present in urethra
Clinical features of M.gen in men?
asymptomatic majority
urethral discharge
dysuria
penile irritation
urethral discomfort
urethritis - acute, persistent, recurrent
balanoposthitis
Clinical features of M.gen in women?
asymptomatic
dysuria
post-coital bleeding
painful inter-menstrual bleeding
cervicitis
lower abdo pain
Complications of M.gen?
sexually acquired RA
epididymitis
PID
infertility in females
pre-term delivery
How is M.gen diagnosed?
NAAT and resistance testing
males - 1st void urine
females - vaginal swab
Who is tested for M.gen?
- men with confirmed NGU
- women with PID
- S&S of mucopurulent cervicitis (esp post-coital bleeding)
- men with epididymo-orchitis
people with sexually-acquired proctitis - sexual partners of people infected with M.gen
Treatment for an uncomplicated urogenital infection of M.gen eg urethritis, cervictis?
if macrolide sensitive/resistance status unknown:
doxycycline 100mg BF for 1wk
THEN immediately after:
azithromycin 1g PO STAT then orally once daily for 2 days
macrolide-resistant/azithromycin failed:
- moxifloxacin 400mg orally once daily for 10 days
Treatment for complication urogenital infection of M.gen eg PID, epididymo-orchitis?
moxifloxacin 400mg orally once daily for 14 days
Counselling for M.gen infection?
abstain until 14 days after start of tx/until sx resolve
only current partners should be tested + if +ve given same abx tx
TOC 5 weeks after start of tx
How is Hep B transmitted?
sexually
parenteral
vertical
Incubation period of Hep B?
40-160 days
Clinical features of hep B?
asymptomatic in 10-50% in acute phase (esp if HIV+ve)
chronic carrier usually asymptomatic - may have fatigue, loss of appetite
prodromal/icteric phase > similar to hep A, may be more severe/prolonged
Complications of Hep B
fulminant hepatitis
chronic infection
risk of miscarriage/premature labour in acute infection + vertical transmission
Ivx for Hep B?
serology - Hep B sAg, cAb
LFTs - only grossly abnormal in late stage
Mx for Hep B?
acute phase - rest, hydration, admit if unwell
refer to hepatologist
refer to health advisor for contact tracing
avoid unprotected sex until partners are vaccinated (any sexual contact/needle sharer 2 weeks before onset of jaundice > sAg -ve)
Hep B = notifiable disease
What vaccine is given for Hep B?
engerix B 1ml
0,1 ,6 months for most groups
accelerated course for assault/recent high risk exposure
check sAb 8 weeks after, if <10 = need repeat course/booster + recheck
How is hep C transmitted?
parenteral
vertical
rarely sexually transmitted
Complications of hep C?
50-85% become chronic carriers
severe liver disease (30%)
hepatocellular carcinoma
acute fulminant hepatitis
pregnancy complications
How is screened for hep c?
CSW
IVDU
sexual assault
HIV+ve MSM and partners
cocaine use
born outside of W europe/australia/N america
contact
blood transfusions/tattoos/piercings/acupuncture/dental procedures done abroad
Inv for Hep C?
screen for Hep C Ab
if ab +ve but RNA -ve > second RNA test
if still -ve > past infection
When is early and late STS defined?
> 2yrs
What organism causes STS?
treponema pallidum (gram -ve spirochete)
How is STS transmitted?
sexual
vertical
What are the sx of primary, secondary, early/late latent and tertiary STS?
primary:
- chancre - painless ulcer at site of invasion, 10-90 days after exposure, anywhere on body
2ndary:
- maculopapular rash on trunk, palms and soles
- headache
- hepatitis
- generalised adenopathy
- condylomata lata
- snail track ulcers
- moth-eaten alopecia
early/later latent:
- asymptomatic infection for >2yrx
tertiary
- CVS - aortic incompetence, aneurysms
- gummatous - chronic painless nodules that break down into ulcers and heal slowly
When can neurosyphilis develop? What are the sx?
any time
meningitis
optic neuritis
sensorineural hearing loss
Inv for STS?
dark ground microscopy from primary chancre
serology:
- treponemal EIA - may be +ve for life
- TPPA - may be +ve for life
- RPR - non-specific, used to measure response to tx, want it to decrease with tx
Tx for early + late STS?
early - benzathine pencillin G 2.4mu IM stat
late - benzathine pencillin G 2.4mu weekly for 3 doses
Follow up for STS?
blood tests on day of tx, then 3, 6 an 12 mo
then 6 monthly until RPR -ve or serofast
sustained 4-fold+ increase in RPR suggests re-finection of tx failure
How is HIV transmitted?
sexual
needle sharing/needlestick injury
vertical
blood transfusion
What are the 4 stages of HIV and their sx?
- acute infection - often asymptomatic
- seroconversion (2-6 weeks post exposure) - myalgia, fever, rash, severe sore throat
- asymptomatic phase (loss of CD4 cells) - generalised lymphadenopathy
- AIDS (CD4 count <200*10^6/L) - fatal if untreated
How is HIV diagnosed?
venous blood sample = GS
window period > repeat test 7 wks after last unprotected sex
if +ve need repeat to confirm
can see HA for same day result if anxious
PoCT is for HIV Ab only + STS
How is HIV monitored?
CD4 count
viral load - aim is undetectable
How is HIV treated?
anti-retroviral therapy combo
aim is U=U
integrase inhibitors eg bictergravir, raltegravir
NRTIs (nucleoside analogue reverse transcriptase inhibitors) ag abacavir, tenofovir
PI (protease inhibitor) eg darunavir
NNRTIs (non-NRTI) eg efavirenz
CCR5 inhibitors, entry inhibitors
lots of drug interactions
SEs - nausea, diarrhoea, tiredness, cholesterol changes, weight gain
What are signs of AIDS?
pneumocystis jiroveci
oesophageal candidiasis
AIDS related dementia
CMV encephalitis
toxoplasma gondii
Hodgkin’s lymphoma
Kaposi’s sarcoma
CMV retinitis
TB
What is PEP?
post exposure prophylaxis
28 day course of ART
start as soon as possible after exposure - within 72hrs
inform all MSM about PEP and PrEP
+ sexual assault in last 72hours
When is AIDS diagnosed?
CD4 count <200
Whats is PrEP?
pre-exposure prophylaxis
ART (tenofovir/emtricitabine tablet) for people at high risk of HIV acquisition
reduces risk by 86% if taken properly
document if discussed
MSM who have condomless anal sex, Black african heterosexuals
Incubation period ofr GC/CT?
2 wks
Incubation period of STS?
12 wks
