Sexual Health Flashcards
1
Q
What does normal physiological discharge look like ?
A
- Clear to white, nonadherent to the vaginal wall and pooled in the posterior fornix
- Nonhomogeneous with clumps of desquamated epithelial cells
- pH of less than 4.5, no offensive odor and an abundance of epithelial cells on saline microscopy
2
Q
What is atrophic vaginitis ?
A
- Dryness and atrophy of the vaginal mucosa due to a lack of oestrogen
- Occurs in women entering the menopause
3
Q
How does atrophic vaginitis present ?
A
- Itching, dryness, dyspareunia and bleeding
- Discharge can be watery and irritating or can be mixed with blood
4
Q
How is atrophic vaginitis managed ?
A
- Vaginal lubricants and moisturisers
- Oestrogen cream is 2nd line
5
Q
What is cervical ectropion ?
A
- When the columnar epithelium of the endocervix has extended out to the ectocervix (outer area of the cervix)
6
Q
How does cervical ectropion present ?
A
- Vaginal bleeding or dyspareunia
- Post-coital bleeding
- Increased vaginal discharge
7
Q
What are cervical polyps and how could they present ?
A
- Benign growths, usually protruding from the surface of the cervical canal
- Intermenstrual bleeding
8
Q
What is Thrush ?
A
- Also known as vaginal candidiasis
- Common condition caused by candida albicans
9
Q
RFs for Thrush
A
- Increased oestrogen
- Poorly controlled DM
- Immunosuppression e.g. corticosteroids
- Broad-spectrum ABs
10
Q
Features of Thrush
A
- Cottage cheese non-offensive discharge
- Vulvitis: superficial dyspareunia, dysuria
- Itch
- Vulval erythema, fissuring, satellite lesions may be seen
11
Q
How is Thrush managed ?
A
- Oral fluconazole 150mg as a single dose
- Clotrimazole 500mg intravaginal pessary as a single dose if the oral therapy is contraindicated (e.g. pregnant)
12
Q
What counts as recurrent vaginal candidiasis and how would you manage it ?
A
- 4 or more episodes per year
- Compliance with previous treatments should be checked
- Confirm diagnosis, high vaginal swab for microscopy and culture
- Consider BM to exclude diabetes
- Consider alternative diagnosis of lichen sclerosus
- Induction and maintenance oral fluconazole
13
Q
What is induction and maintenance oral fluconazole
A
- Oral fluconazole every 3 days for 3 doses
- Maintenance: oral fluconazole weekly for every 6 months
14
Q
What is bacterial vaginosis ?
A
- Loss of the lactobacilli (friendly bacteria) and colonisation of an anerobic bacteria
- Not an STI but does increase the chance of infection
- (Fishy/offensive smelling vaginal discharge)
15
Q
What is amsel’s criteria ?
A
- Thin, white homogenous discharge
- Clue cells on microscopy
- Vaginal pH > 4.5
- Positive whiff test (potassium hydroxide gives fishy odour)
16
Q
- What is the classic term for bacterial vaginosis ?
A
- Foul fishy smelling thin white discharge
- Positive whiff test – addition of potassium hydroxide
17
Q
Bacterial vaginosis pathology
A
- Friendly lactobacilli produce lactic acid that keeps the vaginal pH acidic < 4.5
- When lactobacilli numbers are reduced pH increases and anaerobic bacteria are able to colonies
18
Q
Bacterial vaginosis anaerobic bacteria
A
- MCC - Gardnerella vaginalis
- Mycoplasma hominis
- Prevotella species
18
Q
Bacterial vaginosis investigations
A
- pH paper and a high vaginal swab during speculum examination
19
Q
How is bacterial vaginosis managed ?
A
- Can spontaneously resolve
- Oral metronidazole 500mg 7 days
- Alternative single dose of 2g stat dose
20
Q
Bacterial vaginosis RFs
A
- Multiple sexual partners
- Excessive vaginal cleaning
- Recent ABs
- Smoko
- Copper coil
21
Q
What is trichomoniasis ?
A
- A protozoan single celled organism with a flagella (four at the front and one at the back)
- Trichomonas vaginalis
22
Q
Complications of Trichomonas vaginalis
A
- Contracting HIV
- Bacterial vaginosis
- Cervical cancer
- PID
- Pregnancy related complications e.g. preterm
23
Q
How does trichomoniasis present ?
A
- Itching and frothy yellow-green discharge (may be fishy)
- Dysuria and dyspareunia
- Balanitis
- Strawberry cervix
- Raised vaginal pH
24
Q
What are investigations for trichomoniasis ?
A
- Urethral and first catch urine in men
- Charcoal swab of the posterior fornix (of the vagina) and microscopy of a wet mount shows motile trophozoites
25
Q
What is the management for trichomoniasis ?
A
- oral metronidazole for 5-7 days, although the BNF also supports the use of a one-off dose of 2g metronidazole
26
Q
What is Chlamydia ?
A
- The most prevalent STI in the UK
27
Q
What causes Chlamydia ?
A
- Chlamydia trachomatis
- A gram-negative intracellular bacteria
28
Q
What are RFs of Chlamydia
A
- Young age
- Sexually active with multiple partners
29
Q
What % of Chlamydia is asymptomatic
A
- 50% in men
- 75% in women
30
Q
How does Chlamydia present ?
A
- Men: urethral discharge, dysuria, Epididymo-orchitis and reactive arthritis
- Women: discharge, bleeding, dysuria and dyspareunia
- Discharge is white, yellow or gray discharge and smelly
- Cervical motion tenderness
31
Q
Examination findings in Chlamydia ?
A
- Pelvic or abdominal tenderness
- Cervical motion tenderness
- Inflamed cervix
- Purulent discharge
32
Q
How is Chlamydia investigated ?
A
- Nucleic acid amplification test (NAAT)
- Men – First catch urine sample is 1st line
- Women – vulvovaginal swab is 1st line
- Test should be carried out 2 weeks after possible exposure
- Rectal swab if indicated
33
Q
How is Chlamydia managed ?
A
- Doxycycline 100mg twice d day for 7 days
- In pregnancy azithromycin, erythromycin or amoxicillin e.g. azithromycin 1g stat dose
34
Q
- What are complications of Chlamydia ?
A
- Epididymitis
- PID
- Endometritis
- Increased incidence of ectopic pregnancies
- Infertility
- Reactive arthritis
- Perihepatitis (Fitz-Hugh-Curtis syndrome)
35
Q
What STIs are screened in a patient who attends a GUM clinic for an STI screen at a minimum
A
- Chlamydia
- Gonorrhoea
- Syphilis
- HIV
36
Q
When is Chlamydia screened for ?
A
- Open to all men and women aged 15-24 years
37
Q
What is Gonorrhoea ?
A
- A condition caused by Neisseria gonorrhoeae
- Acute infections can occur on any mucous membrane surface typically the genitourinary tract but also the rectum and pharynx
38
Q
What causes Gonorrhoea ?
A
- Neisseria gonorrhoeae
- A gram-negative diplococcus
39
Q
What % of gonorrhoea cases are asymptomatic ?
A
- 90% of male
- 50% of female
40
Q
How does Gonorrhoea present ?
A
- Males: urethral discharge, dysuria
- Women: Odourless purulent discharge, possibly green or yellow, dysuria and pelvic pain
- Rectal infection may cause discomfort or discharge but often symptomatic
41
Q
How is Gonorrhoea investigated ?
A
- Nucleic acid amplification testing (NATT)
- Rectal and pharyngeal swabs are recommended in all men who have sex with men
- Endocervical, vulvovaginal or urethral swabs as well as first catch urine.
- Charcoal swab endocervical should be taken for microscopy, culture and AB sensitivities before imitating ABs
42
Q
How is Gonorrhoea managed ?
A
- A single dose of intramuscular ceftriaxone 1g if the sensitivities are NOT known
- A single dose of oral ciprofloxacin 500mg if the sensitivities ARE known
- All patients should be followed-up for a test of cure (NAAT testing if asymptomatic or cultures if still symptomatic)
43
Q
When do BASHH recommend a test of cure for Gonorrhoea ?
A
- 72 hours after treatment for culture
- 7 days after treatment for RNA NAAT
- 14 days after treatment for DNA NAAT
44
Q
Gonorrhoea complication ?
A
- PID
- Chronic pelvic pain
- Infertility
- Epididymo-orchitis (men)
- Prostatitis (men)
- Conjunctivitis – if passed onto neonate then this is a medical emergency associated with sepsis, perforation of the eye and blindness
- Urethral strictures
- Disseminated gonococcal infection
- Skin lesions
- Fitz-Hugh-Curtis syndrome
- Septic arthritis
- Endocarditis
45
Q
What is disseminated gonococcal infection ?
A
- A complication of untreated gonococcal infection, where the bacteria spreads to the skin and joints.
- Various non-specific skin lesions
- Polyarthralgia (joint aches and pains)
- Migratory polyarthritis (arthritis that moves between joints)
- Tenosynovitis
- Systemic symptoms such as fever and fatigue
46
Q
What is PID ?
A
- Infection of the female pelvic organs including the uterus, fallopian tubes, ovaries and surrounding peritoneum
- Usually the result of ascending infection from the endocervix
47
Q
What causes PID ?
A
- Chlamydia trachomatis
- Neisseria gonorrhoeae tends to produce more severe PID
- Mycoplasma genitalium
48
Q
What are RFs for PID
A
- Not using barrier contraception
- Multiple sexual partners
- Younger age
- Existing sexually transmitted infections
- Previous pelvic inflammatory disease
- Intrauterine device (e.g. copper coil)
49
Q
How does PID present ?
A
- Pelvic or lower abdominal pain
- Abnormal vaginal discharge
- Abnormal bleeding (intermenstrual or postcoital)
- Pain during sex (dyspareunia)
- Fever
- Dysuria
- Cervical excitation
50
Q
What would you find on examination of PID ?
A
- Pelvic tenderness
- Cervical motion tenderness (cervical excitation)
- Inflamed cervix (cervicitis)
- Purulent discharge
- Patients may have a fever and other signs of sepsis
51
Q
How is PID investigated ?
A
- A pregnancy test should be done to exclude an ectopic pregnancy
- High vaginal swab - these are often negative
- Screen for Chlamydia, Gonorrhoea and mycoplasma genitalium (NAAT), HIV and syphilis, bacterial vaginosis, candidiasis and trichomoniasis
- Pus cells from vagina or endocervix swab
- Inflammatory markers (CSP and ESR) are both raised in PID and can help support diagnosis
52
Q
How is PID managed ?
A
- Genitourinary medicine (GUM) referral
- Contact tracing
- oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole
53
Q
How could PID be managed ?
A
- Single dose of IM ceftriaxone (to cover gonorrhea)
- Doxycycline 100mg BD for 14 days (chlamydia and mycoplasma)
- Metronidazole 400mg BD for 14 days (to cover anaerobes such as Gardnerella vaginalis)
54
Q
What are complications of PID ?
A
- Sepsis
- Abscess
- Infertility
- Chronic pelvic pain
- Ectopic pregnancy
- Fitz-Hugh-Curtis syndrome
55
Q
What is Fritz-Huge-Curtis syndrome ?
A
- A complication of PID where there is inflammation and infection of the liver capsule leading to adhesions between the liver and peritoneum
- Bacteria may spread from the pelvis to the peritoneal cavity, lymphatic system or blood
- Presents as right upper quadrant pain that can be referred to the right shoulder tip if there is diaphragmatic irritation
- Laparoscopy can be used to visualise and also treat the adhesions by adhesiolysis .
56
Q
What is Syphilis
A
- Caused by bacteria called Treponema pallidum.
- This bacteria is a spirochete, a type of spiral-shaped bacteria.
- The bacteria gets in through skin or mucous membranes, replicates and then disseminates throughout the body
- 21 day incubation period
57
Q
What causes Syphilis ?
A
- Treponema pallidum
58
Q
How is Syphilis transmitted ?
A
- Oral, vaginal or anal sex
- Vertical transmission
- IV drug use
- Blood transfusions
59
Q
How does primary Syphilis present ?
A
- A painless genital ulcer – chancre which tends to resolve 3-8 weeks
- Local lymphadenopathy
60
Q
- How does secondary syphilis present ?
A
- Typical starts after chancre have healed
- Maculopapular rash
- Grey-wart lie lesions around genitals and auns
- Low grade fever, lymphadenopathy, alopecia and oral lesions
61
Q
How does tertiary syphilis present ?
A
- Gummatous lesions (granulomatous lesions that can affect the skin organs and bones)
- Aortic aneurysms
- Neurosyphilis
62
Q
How does neurosyphilis present ?
A
- Part of tertiary syphilis
- Headache
- Altered behaviour
- Dementia
- Tabes dorsalis (demyelination affecting the spinal cord posterior columns)
- Ocular syphilis (affecting the eyes)
- Paralysis
- Sensory impairment
63
Q
What is an Argyll-Robertson Pupil ?
A
- A specific finding of neurosyphilis
- Argyll-Robertson pupil is a specific finding in neurosyphilis.
- It is a constricted pupil that accommodates when focusing on a near object but does not react to light.
- They are often irregularly shaped. It is commonly called a “prostitutes pupil” due to the relation to neurosyphilis and because “it accommodates but does not react“.
64
Q
How is syphilis investigated ?
A
- Antibody testing for antibodies to the T. pallidum bacteria can be used as a screening test for syphilis.
- Samples from sites of infection can be tested to confirm the presence of T. pallidum with:
- Dark field microscopy
- Polymerase chain reaction (PCR)
65
Q
What are specific markers for syphilis infection
A
- VDRL – active infection
- TPHA – specific AB test
66
Q
How is syphilis managed ?
A
- IM benzathine penicillin 1st line
- Doxycycline 2nd line
67
Q
HIV
A
- Being infected with human immunodeficiency virus is referred to as being HIV positive
- Acquired immunodeficiency syndrome (AIDS) occurs when HIV is not treated, the disease progresses, and the person becomes immunocompromised. Immunodeficiency leads to opportunistic infections and AIDS-defining illnesses.
68
Q
What causes HIV
A
- HIV is an RNA retrovirus. HIV-1 is the most common type. HIV-2 is mainly found in West Africa. The virus enters and destroys the CD4 T-helper cells of the immune system.
69
Q
How does HIV present ?
A
- An initial seroconversion flu-like illness occurs within a few weeks of infection. The infection is then asymptomatic until the condition progresses to immunodeficiency. Disease progression may occur years after the initial infection.
70
Q
How is HIV transmitted ?
A
- Unprotected sex (all types)
- Vertical transmission
- Mucous membrane, blood or open wound exposure to infected blood or bodily fluids e.g. need sharing, needle-stick injuries or blood splashed in an eye
71
Q
When do AIDS-defining illnesses occur ?
A
- Where the CD4 count has dropped to a level that allows for unusual opportunistic infections and malignancies to appear.
72
Q
What are AIDS-defining illnesses ?
A
- Kaposi’s sarcoma
- Pneumocystis jirovecii pneumonia (PCP)
- Cytomegalovirus infection
- Candidiasis (oesophageal or bronchial)
- Lymphomas
- Tuberculosis
73
Q
What is a normal CD4 count and what is considered pathological ?
A
- 500-1200 cells/mm3 is the normal range
- Under 200 cells/mm3 puts the patient at high risk of opportunistic infections
74
Q
How is HIV treated ?
A
- Treatment involves a combination of antiretroviral therapy (ART) medications. ART is offered to everyone diagnosed with HIV, irrespective of viral load or CD4 count.
75
Q
What classes of antiretroviral therapy medications are used in HIV treatment ?
A
- Protease inhibitors (PI)
- Integrase inhibitors (II)
- Nucleoside reverse transcriptase inhibitors (NRTI)
- Non-nucleoside reverse transcriptase inhibitors (NNRTI)
- Entry inhibitors (EI)
76
Q
What are the usual starting regimes used in HIV ?
A
- Tenofovir (NRTI)
- Emtricitabine (NRTI)
- Bictegravir
77
Q
Additional Management of HIV
A
- Prophylactic co-trimoxazole (against pneumocystis jirovecii pneumonia (PCP))
- Cardiovascular monitoring
- Yearly smears – increased risk of cervical cancer
- Vaccinations (avoid live vaccines e.g. BCG or typhoid)
78
Q
How vertical transmission of HIV managed during birth ?
A
- Under 50 copies/ml = normal vaginal delivery
- Over 50 copies/ml = consider a pre-labour CS
- Over 400 copies/ml = pre-labour CS is recommended
- IV zidovudine is given as an infusion during labour and delivery if the viral load is unknown or above 1000 copies/ml.
- Breast feeding is contraindicated
79
Q
Prophylaxis HIV
A
- PEP involves a combination of ART therapy. The current regime is emtricitabine/tenofovir (Truvada) and raltegravir for 28 days.
80
Q
What is Mycoplasma Genitalium ?
A
- A bacteria that causes non-gonococcal urethritis
81
Q
How does Mycoplasma Genitalium present ?
A
- Most cases of MG do not cause symptoms. The presentation is very similar to chlamydia, and patients may be infected with both organisms. Urethritis is a key feature.
82
Q
Complications of mycoplasma genitalium
A
- Urethritis
- Epididymitis
- Cervicitis
- Endometritis
- Pelvic inflammatory disease
- Reactive arthritis
- Preterm delivery in pregnancy
- Tubal infertility
83
Q
How is Mycoplasma Genitalium investigated ?
A
- First urine sample in the morning for men
- Vaginal swabs (can be self-taken) for women
- Nucleic acid amplification test
84
Q
How is Mycoplasma Genitalium managed ?
A
- Both Doxycycline 100mg twice daily for 7 days then;
- Azithromycin 1g stat then 500mg once a day for 2 days (unless it is known to be resistant to macrolides)
