Sexual health Flashcards
Conditions and Presentations
Syphilis
sexually transmitted infection caused by the spirochaete Treponema pallidum.
Infection is characterised by primary, secondary and tertiary stages.
The incubation period is between 9-90 days
Primary features Syphilis
chancre - painless ulcer at the site of sexual contact
local non-tender lymphadenopathy
often not seen in women (the lesion may be on the cervix)
secondary features Syphilis
- occurs 6-10 weeks after primary infection
systemic symptoms: fevers, lymphadenopathy
rash on trunk, palms and soles
buccal ‘snail track’ ulcers (30%)
condylomata lata (painless, warty lesions on the genitalia )
Tertiary features of Syphilis
gummas (granulomatous lesions of the skin and bones)
ascending aortic aneurysms
general paralysis of the insane
tabes dorsalis
Argyll-Robertson pupil
Features of congenital syphilis
- blunted upper incisor teeth (Hutchinson’s teeth), ‘mulberry’ molars
- rhagades (linear scars at the angle of the mouth)
- keratitis
- saber shins
- saddle nose
- deafness
Investigations of syphilis
Treponema pallidum is a very sensitive organism and cannot be grown on artificial media.
The diagnosis is therefore usually based on clinical features, serology and microscopic examination of infected tissue.
Non-treponemal tests
- not specific for syphilis, therefore may result in false positives
- based upon the reactivity of serum from infected patients to a cardiolipin-cholesterol-lecithin antigen
- assesses the quantity of antibodies being produced
- becomes negative after treatment
- examples include: rapid plasma reagin (RPR) and Venereal Disease Research Laboratory (VDRL)
treponemal-specific tests
generally more complex and expensive but specific for syphilis
qualitative only and are reported as ‘reactive’ or ‘non-reactive’
examples include: TP-EIA (T. pallidum enzyme immunoassay), TPHA (T. pallidum HaemAgglutination test)
the TP-EIA test has become increasingly popular in recent years
Reasons for false positives on non-treponemal tests
pregnancy
SLE, anti-phospholipid syndrome
tuberculosis
leprosy
malaria
HIV
Interpretating test results for syphilis
Positive non-treponemal test + positive treponemal test
consistent with active syphilis infection
Positive non-treponemal test + negative treponemal test
consistent with a false-positive syphilis result e.g. due to pregnancy or SLE (see list above)
Negative non-treponemal test + positive treponemal test :
consistent with successfully treated syphilis
Managment of syphilis
intramuscular benzathine penicillin is the first-line management
alternatives: doxycycline
Jarisch-Herxheimer reaction
fever, rash, tachycardia after the first dose of antibiotic
in contrast to anaphylaxis, there is no wheeze or hypotension
it is thought to be due to the release of endotoxins following bacterial death and typically occurs within a few hours of treatment
no treatment is needed other than antipyretics if required
Gonorrhea
Gonorrhea is a sexually transmitted infection (STI) caused by the bacterium Neisseria gonorrhoeae. It primarily affects the mucous membranes of the genital tract, but it can also infect the rectum, throat, and eyes
gram positive diplococci
Transmission of gonorrhea
Gonorrhea is spread through sexual contact with an infected person, including vaginal, anal, or oral sex. It can also be transmitted from mother to baby during childbirth.
Male symptoms of gonnorhea
Urethral discharge (pus-like or milky discharge from the penis)
Pain or burning sensation during urination
Testicular pain or swelling
Female symtpoms of gonorrhea
Vaginal discharge (often greenish or yellowish)
Pain or burning sensation during urination
Pelvic pain
Abnormal vaginal bleeding
asymptomatic causes
complications of gonorrhea
Pelvic inflammatory disease (PID) in women, leading to infertility or ectopic pregnancy
Epididymitis (inflammation of the epididymis) in men, leading to infertility
Disseminated gonococcal infection (DGI), causing joint pain, skin rash, and fever
Increased risk of HIV transmission
Conjunctivitis (eye infection) in newborns born to infected mothers
Diagnosis of gonorrhea
Nucleic acid amplification tests (NAATs) on urine, vaginal, cervical, rectal, or throat swabs
Gram stain or culture of urethral, cervical, or rectal specimens
Examination of discharge or lesions under a microscope
Treatment of gonorrhea
Antibiotic therapy with dual therapy (typically ceftriaxone plus azithromycin) to reduce the risk of antibiotic resistance
Treatment of sexual partners to prevent reinfection and further transmission
Follow-up testing to ensure successful treatment and to detect reinfection
Prevention of gonorrhea
Abstinence or mutual monogamy with an uninfected partner
Correct and consistent use of condoms during sexual activity
Routine screening for gonorrhea and other STIs, especially in high-risk populations
Vaccination (if available in the future)
Prognosis of Gonorrhea
Gonorrhea is curable with appropriate antibiotic treatment, but reinfection is common without behavioral changes or partner treatment.
Early detection and treatment are essential to prevent complications and reduce the risk of transmission.
Chlamydia
most prevalent sexually transmitted infection in the UK and is caused by Chlamydia trachomatis, an obligate intracellular pathogen
1 in 10 young women in the UK have Chlamydia. The incubation period is around 7-21 days, although it should be remembered a large percentage of cases are asymptomatic
Features of Chlamydia
asymptomatic in around 70% of women and 50% of men
women: cervicitis (discharge, bleeding), dysuria
men: urethral discharge, dysuria
complications of Chlamydia
epididymitis
pelvic inflammatory disease
endometritis
increased incidence of ectopic pregnancies
infertility
reactive arthritis
perihepatitis (Fitz-Hugh-Curtis syndrome)
Investigations of Chlamydia
traditional cell culture is no longer widely used
nuclear acid amplification tests (NAATs) are now the investigation of choice
urine (first void urine sample), vulvovaginal swab or cervical swab may be tested using the NAAT technique
for women: the vulvovaginal swab is first-line
for men: the urine test is first-line
Chlamydiatesting should be carried out two weeks after a possible exposure
Screening of Chalmydia
in England the National Chlamydia Screening Programme is open to all men and women aged 15-24 years
the 2009 SIGN guidelines support this approach, suggesting screening all sexually active patients aged 15-24 years
relies heavily on opportunistic testing
Managment of Chlamydia
-doxycycline (7 day course) if first-line
-if doxycycline is contraindicated / not tolerated then either azithromycin (1g od for one day, then 500mg od for two days) should be used
if pregnant then azithromycin, erythromycin or amoxicillin may be used.
contact tracing chlamidya
offered a choice of provider for initial partner notification - either trained practice nurses with support from GUM, or referral to GUM
for men with urethral symptoms: all contacts since, and in the four weeks prior to, the onset of symptoms
for women and asymptomatic men all partners from the last six months or the most recent sexual partner should be contacted
contacts of confirmed Chlamydia cases should be offered treatment prior to the results of their investigations being known (treat then test
risk factors for ED
- ageing
-cardiovascular disease
-risk factors: obesity, diabetes mellitus, dyslipidaemia, metabolic syndrome, hypertension, -smoking
-alcohol use
-drugs: SSRIs, beta-blockers
treatment of ED
PDE-5 inhibitors (such as sildenafil, ‘Viagra’) have revolutionised the management of ED
they should be prescribed (in the absence of contraindications) to all patients regardless of aetiology
sildenafil can be purchased over-the-counter without a prescription.
-Vacuum erection devices are recommended as first-line treatment in those who can’t/won’t take a PDE-5 inhibitor.
ED referrals and exercise
for a young man who has always had difficulty achieving an erection, referral to urology is appropriate
people with erectile dysfunction who cycle for more than three hours per week should be advised to stop
sildenafil (Viagra)
this was the first phosphodiesterase type V inhibitor
short-acting - usually taken 1 hour before sexual activity
tadalafil (Cialis)
longer acting than sildenafil, may be taken on a regular basis (e.g. once daily)
contradictions to taking Phosphodiesterase type V inhibitors
patients taking nitrates and related drugs such as nicorandil
hypotension
recent stroke or myocardial infarction (NICE recommend waiting 6 months)
side effects of Phosphodiesterase type V inhibitors
visual disturbances
blue discolouration
non-arteritic anterior ischaemic neuropathy
nasal congestion
flushing
gastrointestinal side-effects
headache
priapism
Atrophic vaginitis
-Atrophic vaginitis often occurs in women who are post-menopausal women.
- It presents with vaginal dryness, dyspareunia and occasional spotting.
-On examination, the vagina may appear pale and dry.
-Treatment is with vaginal lubricants and moisturisers - if these do not help then topical oestrogen cream can be used.
Pelvic inflammatory disease
Pelvic inflammatory disease (PID) is a term used to describe infection and inflammation of the female pelvic organs including the uterus, fallopian tubes, ovaries and the surrounding peritoneum. It is usually the result of ascending infection from the endocervix.
causative agents of PID
Chlamydia trachomatis
+ the most common cause
Neisseria gonorrhoeae
Mycoplasma genitalium
Mycoplasma hominis
Features of PID
lower abdominal pain
fever
deep dyspareunia
dysuria and menstrual irregularities may occur
vaginal or cervical discharge
cervical excitation
Investigations for PID
a pregnancy test should be done to exclude an ectopic pregnancy
high vaginal swab
these are often negative
screen for Chlamydia and Gonorrhoea
Managment of PID
oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole
Removal of the IUD should be considered and may be associated with better short term clinical outcomes’
Complications of PID
perihepatitis (Fitz-Hugh Curtis Syndrome)
occurs in around 10% of cases
it is characterised by right upper quadrant pain and may be confused with cholecystitis
infertility - the risk may be as high as 10-20% after a single episode
chronic pelvic pain
ectopic pregnancy
Fitz-Hugh Curtis Syndrome
Inflammation of the liver capsule, without the involvement of the liver parenchyma, with adhesion formation accompanied by right upper quadrant pain.
Thrush/ candidasis
Vaginal candidiasis (‘thrush’) is an extremely common condition which many women diagnose and treat themselves
common cause is Candida albicans
predispositioning factors to thrush
diabetes mellitus
drugs: antibiotics, steroids
pregnancy
immunosuppression: HIV
Signs and symptoms of Thrush
‘cottage cheese’, non-offensive discharge
vulvitis: superficial dyspareunia, dysuria
itch
vulval erythema, fissuring, satellite lesions may be seen
Investigations of thrush
a high vaginal swab is not routinely indicated if the clinical features are consistent with candidiasis
Managment of thrush
options include local or oral treatment
NICE Clinical Knowledge Summaries recommends:
oral fluconazole 150 mg as a single dose first-line
clotrimazole 500 mg intravaginal pessary as a single dose if oral therapy is contraindicated
If there are vulval symptoms, consider adding a topical imidazole in addition to an oral or intravaginal antifungal
if pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated
Recurrent thrush managment
- BASHH define recurrent vaginal candidiasis as 4 or more episodes per year
-compliance with previous treatment should be checked
-confirm the diagnosis of candidiasis
-high vaginal swab for microscopy and culture
consider a blood glucose test to exclude diabetes
exclude differential diagnoses such as lichen sclerosus
consider the use of an induction-maintenance regime
induction: oral fluconazole every 3 days for 3 doses
maintenance: oral fluconazole weekly for 6 months
what is the definitive treatment of Bartholin’s abcess called?
-marsupialization.
- Insertion of a catheter to treat the abcess with antibioitics
Bartholins abcess
Bartholin’s abscess is a painful swelling or lump that forms when the Bartholin’s gland becomes blocked, causing fluid buildup and infection.
Symptoms of Bartholin’s abcess
Pain and tenderness in the vaginal area
Swelling or lump near the vaginal opening
Discomfort or pain during sexual intercourse
Difficulty walking or sitting
Fever and chills (if infection is present)
Pain with urination or bowel movements (if the abscess is large)
Causes of Bartholin’s abcess
Blockage of the ducts of the Bartholin’s glands, often due to infection or inflammation
Bacterial infection, usually by bacteria such as Escherichia coli (E. coli), Streptococcus, or Staphylococcus aureus
Treatment of Bartholin’s abcess
Warm compresses or sitz baths to relieve pain and promote drainage
Incision and drainage (I&D) of the abscess to remove pus and relieve pressure
Antibiotics to treat bacterial infection, if present
Marsupialization (surgical procedure to create a permanent opening) for recurrent or large abscesses
Bartholin’s gland excision in severe or recurrent cases
Prevention of Bartholin’s abcess
Good genital hygiene
Avoidance of vaginal irritants (such as harsh soaps or douches)
Safe sexual practices (including condom use)
Prompt treatment of genital infections
Bartholin’s cyst
-Bartholin’s cyst develops when the entrance to the Bartholin duct becomes blocked.
-The gland continues to produce mucus which builds up behind the blockage, eventually leading to the formation of a mass.
-The initial blockage is most commonly caused by vulvar oedema. These are usually sterile.
Symptoms of Bartholin’s cyst
Small painless lump or swelling near the vaginal opening
Discomfort or pressure in the vaginal area
Difficulty walking or sitting if the cyst is large
Discharge from the cyst (if it becomes infected)
Treatment
-Warm compresses or sitz baths to promote drainage and relieve discomfort
-Surgical drainage (incision and drainage) for symptomatic or recurrent cysts
-Marsupialization (surgical procedure to create a permanent opening) for recurrent or large cysts
-Antibiotics to treat infection, if present
Vulval carcinoma
Vulval carcinoma is a type of cancer that develops in the tissues of the vulva, which is the external part of the female genitalia.
types of vulval cancers
Squamous cell carcinoma: The most common type, accounting for the majority of vulvar cancers.
Melanoma: A less common but more aggressive type that arises from melanocytes in the skin of the vulva.
Adenocarcinoma: Arises from the glandular cells in the vulva.
Risk factors of vulvar cancer
Age (risk increases with age, most common in women over 60)
Human papillomavirus (HPV) infection
Smoking
Chronic vulvar inflammation or irritation (such as lichen sclerosus)
Immunodeficiency
Previous history of cervical, vaginal, or anal cancer
History of vulvar intraepithelial neoplasia (VIN)
Symptoms of vulvar cancer
Persistent itching, pain, or tenderness in the vulvar area
Lump, mass, or ulcer on the vulva that doesn’t heal
Changes in the color or texture of the skin of the vulva
Bleeding or discharge not related to menstruation
Burning or pain during urination
Diagnosis of vulvar cancer
Physical examination of the vulva, including visual inspection and palpation
Biopsy of suspicious lesions for pathological examination
Imaging tests (such as ultrasound, CT scan, or MRI) to assess the extent of the cancer and identify metastasis
Preventative measures of vulvar cancer
HPV vaccination (for prevention of HPV-related vulvar cancers)
Avoidance of smoking
Regular gynecological examinations and screening tests (Pap smear, HPV testing)
risk factors for vulvar cancer
Human papilloma virus (HPV) infection
Vulval intraepithelial neoplasia (VIN)
Immunosuppression
Lichen sclerosus
Features of vulvar cancer
lump or ulcer on the labia majora
inguinal lymphadenopathy
may be associated with itching, irritation
features of genital herpes
painful genital ulceration
may be associated with dysuria and pruritus
the primary infection is often more severe than recurrent episodes
systemic features such as headache, fever and malaise are more common in primary episodes
tender inguinal lymphadenopathy
urinary retention may occur
Genital herpes investigation
nucleic acid amplification tests (NAAT) is the investigation of choice in genital herpes and are now considered superior to viral culture
HSV serology may be useful in certain situations such as recurrent genital ulceration of unknown cause
Managment of genital herpes
general measures include:
saline bathing
analgesia
topical anaesthetic agents e.g. lidocaine
oral aciclovir
some patients with frequent exacerbations may benefit from longer-term aciclovir
Pregnancy and genital herpes
elective caesarean section at term is advised if a primary attack of herpes occurs during pregnancy at greater than 28 weeks gestation
women with recurrent herpes who are pregnant should be treated with suppressive therapy and be advised that the risk of transmission to their baby is low
Causes of genital herpes
There are two strains of the herpes simplex virus (HSV) in humans: HSV-1 and HSV-2.
Transmission of genital herpes
Direct skin-to-skin contact with an infected person during vaginal, anal, or oral sex
Transmission can occur even if the infected person does not have visible sores or symptoms (asymptomatic shedding)
Vertical transmission from mother to baby during childbirth (can lead to neonatal herpes, a potentially serious condition)
Lichen Sclerosus
Lichen sclerosus is a chronic inflammatory skin condition characterized by thin, white patches of skin that may appear shiny, smooth, or wrinkled.
