Sexual health Flashcards
Chlamydia trachomatis
Most common STI, up to 10% of people under 25 are infected. Often asymptomatic.
Presentation:
- Men - urethritis, mucopurulent discharge (milky), dysuria
- Women - increased vaginal discharge, dysuria, postcoital/intermenstrual bleeding, lower abdo pain
- Proctitis
Investigation:
- If any symptoms or even if asymptomatic but have been in contact with anyone - full STI screen
- NAATs for chlamydia - for women, self-taken vulvo-vaginal swabs; for men - first pass urine sample. (Triple site - oral and anal too if relevant)
Management:
- Doxycycline 100mg twice daily for 7 days
- 1g azithromycin - second line and pregnancy
- Don’t have sex for 7 days/until treatment finished
Gonorrhoea
Can be asymptomatic. Coinfection with CT is common.
Presentation:
- Men - urethritis, mucopurulent discharge (green), dysuria
- Women - increased vaginal discharge, dysuria, postcoital/ontermenstrual bleeding, lower abdo pain.
- Proctitis
Investigation:
- If any symptoms or even if asymptomatic but have been in contact with anyone - full STI screen
- NAATs from self-taken vulvovaginal swabs / first pass urine - men
- Urethral swab for men, endocervical, rectal, pharyngeal swab for GC culture (need to do culture for sensitivities due to increasing gonorrhoea antimicrobial resistance)
- Microscopy - intracellular, gram neg diplococci
Management:
- Single dose ceftriaxone 1g IM (can give empirically if confirmed contact)
- If sensitivity known and sensitive to ciprofloxacin 500mg give this
- For pen allergy, combination includes azithromycin
- No sex for 7 days
- Contact tracing
- Follow up 14 days after treatment - test of cure (NAAT)
Mycoplasma genitalium (M. gen.)
Often CT confection - don’t often go looking for it unless have CT because it’s common and high anti-microbial resistance
Presentation:
- Causes non-gonococcal urethritis in men - mucopurulent urethral discharge, dysuria
Investigations:
- Full STI screen - NAATs
Management:
- Doxycyline 7 days
PID
Happens when infections from cervix/vagina go further up - causes endometritis, salpingitis, pelvic peritonitis. Usually due to CT, GC or M gen. One episode can cause infertility in 10% of women
Presentation:
- Lower abdo pain, increased discharge, irregular bleeding, deep dyspareunia, dysuria
- Adnexal tenderness on bimanual examination
Investigations:
- Clinical signs/symptoms are key to diagnosis
- Microscopy of discharge for BV
- NAATs from swab for CT and GC
- Do a pregnancy test as ectopic is an important differential
- Consider urine dip for UTI
Management:
- Early treatment key - treat empirically with broad spec - 1g IM ceftriaxone, doxycycline for 7 days, metronidazole for 14 days
- No sex until treatment finished
- Contact tracing
Bacterial vaginosis
Most common cause of changes in vaginal discharge. Happens when normal lactobacilli get replaced by gardnerella vaginalis, anaerobes
Presentation:
- Increased vaginal discharge
- Fishy odour
Investigations:
- Microscopy (gram stain) vaginal discharge
- Vaginal pH (will be raised)
Management:
- Oral metronidazole for 7 days
Candida
Not an STI. Very common (75% of women will have symptomatic candida at some point)
Presentation:
- Women - vulva itching, thick vaginal discharge, burning, dysuria
- Men - penile irritation, rash immediately following sex, spotty red itching rash
Investigation:
- Clinical
- (Microscopy )
Management:
- Fluconazole 150mg single dose (if recurrent can have this weekly)
- Clotrimazole pessaries, topical creams
Risk factors:
- Immunosupression
- Diabetes
Trichomoniasis
Most common STI worldwide but not that common in Europe. Often asymptomatic
Presentation:
- Women - purulent discharge (yellow or grey) , malodour, puritis, dysuria. ‘Strawberry cervix’ OE
- Men - mostly no symptoms, if symptoms - urethral discharge, irritation, dysuria
Diagnosis:
- NAATs, first pass urine - men
Management:
- Metronidazole for 7 days
- No sex for 7 days
- Contact tracing
Anogenital warts
Caused by HPV
Skin-to-skin contact with someone who has clinical/subclinical infection - common, people often don’t have signs.. No risk of malignant transformation
Presentation:
- Painless, growing lumps
Investigation:
- Clinical
- No test for HPV
- Differential to consider - molluscum, if very atypical in older patients - ?malignancy
Management:
- STI screen as co-infection common
- Topical podophyllotoxin (not for pregnancy)
- Keratinized warts (on hair skin) respond better to cryotherapy
- Advise condoms to protect
- Vaccination
Herpes simplex
More common in women - larger area of susceptible mucous membrane. Can pass on even if asymptomatic - and only 20% of people who do have it serologically have ever had symptoms.
Presentation:
- Primary genital infection - first exposure - if symptomatic - multiple painful, ulcers, generalised malaise, proctitis if rectal infection
- Recurrent - reactivation of infection (latent in dorsal root ganglia) - prodrome of itching, tingling, pain
- Worse if immunosuppressed
Investigation:
- Swab ulcer - DNA detection
- Full STI screen - confection
Management:
- Aciclovir - reduces severity - also fine to give in pregnancy
- Avoid sex during symptomatic episodes
Syphilis
Treponema palidum
More common in MSM in UK
Presentation:
- Primary - a few weeks after exposure - 1 painless ulcer which goes after 2-6 weeks
- Secondary - occurs in 25% with untreated syphilis. 6 - 10 weeks later - general malaise, widespread skin rash - maculopapular over whole body, lymphadenopathy. Can disappear and reoccur without treatment
- Latent - no symptoms, untreated but syphillis serology - early=<2 years after infection
- Tertiary - 1/3 of people with untreated latent syphillis will get this anything from 2 years to 30 years later - lesions, cardiovascular problems, neuosyphillis
Investigation:
- Immunoassays to detect IgG and IGM. If positive - treponemal tests - this remains positive for life tho. Non -treponemal tests - RPR tests - to see if current infection but can lead to false positives if have other infections/autoimmun disease.
Management:
- Benzathine penicillin
- Doxy if pen allergy
- STI scrren
- No sex for 14 days
- Contact tracing
Lymphogranuloma venereum
Tropical. More common in MSM in UK. Caused by chlamydia trachomatis - but a more invasive type
Presentation:
- Painless papule/ulcer
- Proctitis, mucopurulent discharge, bleeding, tenesmus
Investigation:
- Swab from ulcer for chlamydia NAAT, then type for LGV
- Associated with Hep C so test for that too
Management:
- Full STI screen
- Doxycline for 21 days
- No sex until end of treatment
- Contact tracing
Window period for chlamydia/gonorhoea tests
2 weeks
Window period for HIV test
45 days
When does levonelle need to be taken
within 72 hrs
When does Ella one need to be taken
within 5 days
when can copper IUD be used for emergency contraception
within 5 days of UPSI or earliest expected ovulation date
Time window for giving PEP
72 hours and taken for 28 days
Options for PrEP regime
Event based - double dose 2-24hrs before sex, 1 dose 24hrs later, 1 more dose 24hrs later - need to continue until 48hrs after last sex
Daily - 1 daily dose
Side effects of PrEP
Nausea, vomiting, GI - mild, usually resolves after a couple of weeks
Can affect kidney function and bone density - so annual blood test monitoring, reversible once come off
Respiratory indications to test for HIV
- TB
- Pneumonia - CAP generally
- Recurrent pneumonia
- Atypical pneumonias (typical - pneumonias - one lobe affected)
- Fungal pneumonias - histoplasmosis, cryptococcal
- Lung cancer
Other malignancies - lymphoma, Kaposi’s sarcoma
GI indications to test for HIV
- Chronic diarrhoea
- Crypto sporidia (stool test)
- Proctitis - rectal STI - indicates risk
- Hep A, B, C
- Anal cancer - HPV
- Malignancies - rectal bleeding - lymphoma, Kaposi’s
- Oral candidiasis - odynaphagia, dysphagia
- Oral hairy leukoplakia
- Unexplained weight loss - cacetctic
Neuro indications to test for HIV
- Symptoms of space occupying lesion - headaches, vomiting, altered consciousness, focal motor or sensory problems, seizures
- Cryptococcal meningitis [crypto means hidden - doesn’t show on gram stain] (test CSF with India ink prep)
- Progressive multifocal leukoencephalopathy -
- Cerebral toxoplasmosis
- HSV/VZVZ/CMZ encephalitis
- CMV retinitis
- Neuropathies
Derm indications to test for HIV
- Kaposi’s sarcoma
- Shingles
- HSV - for longer than 1 month
- Maculo-papular rash - ?seroconversion
- Severe sudden onsent psoriasis
What is IRIS?
describes a collection of inflammatory disorders associated with paradoxical worsening of preexisting infectious processes following the initiation of antiretroviral therapy (ART) in HIV-infected individuals - i.e. when you give ARTs, the immune system wakes up as it’s not being so destroyed, if someone is infected by an opportunistic infection at that time, the immune system will realise and attack that area. It can cause oedema, inflammation etc which can be very very dangerous if in places like brain (e.g. toxoplasmosis) or heart (TB pericarditis). So don’t start ARTs too early - stabilise first
