Sexual health Flashcards
Discuss gonorrhoea
-Pathogen
-Site (5) and cell type targeted
-Period of incubation
-Symptoms (5)
-Investigations (3)
-Treatment (5)
-Complications (3)
-Follow-up
- Pathogen
-Neisseria gonorrhoea
-Gram negative diplococcus - Site and cell of infection
-Endocervix, rectum, urethra, conjunctiva, pharynx
-Infects collumnar epithelia in mucous membranes - Period of incubation - 3 days
- Symptoms
-50% aSx
-Mucopurulant discharge 50%
-Lower abdo pain 25%
-Dysuria 12%
-IMB and PCB - Investigations
-Vulvovaginal NAAT
-Endocervical swab for microscopy and culture
-Investigate for other STI - Treatment
-Ceftriaxone 500mg IM stat
-Given 40% coinfection with chlamydia also treat with:
-Doxycycline 100mg BD 7/7 or Azithromycin 1g Stat
-No unprotected intercourse 7 days
-Contact tracing 3 months
-Notify MOH - Complications
-PID <10%
-Haematogenous spread to skin and joints - arthritis and tenosynovitis
-Disseminated infection - rare - Follow-up
-Contact tracing done
-Ensure not reinfection may require retreatment
-Reinfection common. Offer sexual health check in 3/12
-Test for cure only if symptoms don’t resolve
Discuss gonorrhoea in pregnancy
-Complications to neonate (6)
-Complications to mother (1)
-Risk of transmission
-Who to test
-When to follow-up
Notify MOH for any infection in neonate
1. Complications regarding neonate
-Gonococcal ophthalmia - within 21 days
-Disseminated gonococcal infection - 7-28 days
-Scalp abscess if FSE used
-Septic abortion
-PPROM
-PTL
2. Complications for mother
-Endometritis
3. Risk of transmission
-30-50%
4. Who to test
-Those with sx, at high risk STI, contact with known case
5. Follow-up
-Review after 1 week
-Test of cure only if symptoms do not resolve in a week
Discuss trichomonas
-Pathogen
-Symptoms (6)
-Investigations
-Management
-Follow-up
-Complications
- Pathogen
-Flagellates protozoa - trichomonas vaginalis
-Sexually transmitted
-Incubation period 5-28 days - Symptoms
-Asx - 50%
-Frothy yellow discharge - 10-30%. 70% vaginal discharge
-Classic strawberry cervix - 2%
-Vaginal puritis, vulvitis, vaginitis - Investigations
-NAAT - 10% sensitivity
-Culture or wet slide
-Check for BV - 60-80% co-existant - Management
-Metronidazole 2g stat or 400mg BD 7 days
-Avoid unprotected sex 1/52 from start of treatment
-Partner notification - Follow-up
-Chance of re-infection
-Test of cure only if symptomatic - Complications
-Enhanced HIV transmission
What are the complications to pregnancy associated with trichomonas infection
-Complications to pregnancy (3)
-Complications for neonate (1)
- PPROM, PTD, LBW
- Neonatal vulvoaginitis - 5%, respiratory infection
Discuss chlamydia
-Pathogen
-Sites and cells infected
-Incubation period
-Symptoms (4)
-Investigations
-Management
-Follow-up
-Complications (4)
- Pathogen
-Chlamydia trachomatis
-Gram negative
-Different subtypes - A-C = conjunctivits, D-K = genital L1-L3 = lymphogranuloma venerum - Site and cell
-Obligate intracellular
-Infects cervix, urethra, rectum, conjunctiva, pharynx - Incubation period = 1 day to 6 weeks
- Symptoms
-Asx - 70%
-PCB or IMB
-Purulent discharge
-Dysuria - NAAT - 95% sensitivity. Remains + up to 5 weeks post Rx
- Management
-Firstline doxycycline 100mg PO BD 7/7
-Azythromycin 1g Stat
-Erythromycin 500mg PO BD 7/7 if pregnant
-Partner notification 3/12
-Abstain from sex 1 week from start of treatment - Follow-up
-Test for cure if ongoing symptoms or pregnant - 6 weeks post Rx - Complications
-PID 10-40% if untreated
-Fitz-Hugh-Curtis
-Chronic pelvic pain
-Reiters syndrome - reactive arthritis, urethritis, uveitis
Discuss complications of chlamydia associated with pregnancy
-Complications to pregnancy (5)
-Complications to neonate (3)
- Complications to pregnancy
-Tubal infertility
-Ectopic pregnancy
-No impact on early pregnancy loss
-PPROM
-LBW - Complications to neonate
-Conjunctivitis - 50%
-Pneumonia - 10-20%
-Asx vaginal or rectal infection 15%-
Discuss Lymphogranuloma venereum
-Pathogen
-Site of infection
-Stages of disease
-Management
- Pathogen
-Chlmaydia trichomatis serovars L1-L3 - Site of infection - lymphatic tissue
- Stages of disease
-Primary infection - small painless papules, pustules or ulcers.
-Secndary infection - lymphadenopathy, malaise, fever, joint and muscle aches
-Late phase - abscess,lymphatic obstruction, genital oedema - Management
-Doxycycline for at least 3/52
What are the causes of genital ulcers
-Infectious causes
-Sexually transmitted (6)
-Not sexually transmitted (7)
-Non infectious causes (4 groups)
- Sexually transmitted infectious cause of genital ulcers
-HSV 1-2 small blisters which form red based painful ulcers
-Syphillis - single painless ulcer with clean base and firm edges
-Gono/Trich
-Lymphogranuloma venereum - single painless ulcer
-Chancroid - unilateral papule that becomes pustular an dulcerates with yellow discharge
-Donovanosis/ Granuloma inguinale - chronic red indurated painless ulcer - Non-sexually transmitted
-Candidiasis - severe
-Herpes zoster
-TB
CMV
-EBV
-Mycoplasma
-Group A strep - Non infectious causes of genital ulcers
-Apthous ulcers - painful punched out ulcers, yellow/white base with red boarder. Due to autoimmune, spontaneous, post infection (EBV) trauma
-Inflammatory causes - dermatitis, lichen planus etc
-Blistering - pemphigus vulgaris, erythema multiforme
-Malignant - Vulval SCC, VIN, BCC
How should genital ulcers be investigated? (5)
Investigations:
1. Viral swab - HSV 1+2
2. NAAT for chlamydia/Trich/Gono
3. Serology for syphillis, HIV, Hep B+C, HSV, EBV, CMV
4. ANA if concerned for autoimmune
5. Biopsy if dx cannot be made or suspect malignancy
Discuss herpes
-Incidence
-Symptoms - primary and secondary
-Investigations
- Incidence
-20% of adults have HSV-2 - Symptoms
-25% Asx, 50% mild sx, 25% modreate to severe sx
-Primary sx
-Fever, Malaise, myalgia
-Dysuria, vaginal discharge, painful ulceration, lymphadenopathy
-Secondary sx
-Asx, ulcers - usually less painful, prodromal sx such as tinglind - Investigations
-Viral swab of base for PCR. Neg result doesn’t exclude infection
-HSV serology - not routine as not accurate.
-Only indicates past infection
-Not all people sertoconvert
-Doesn’t distinguish site
-Perform if suspect primary infection in pregnancy
-Syphillis serology
Discuss the pathophysiology of HSV 1
-Area infects
-Transmission
-Asymtpomtic sheadding risk
-Risk of recurrence
- Infects genitals and oral areas
- Transmission through oral genital contact
- Less asymptomatic sheeding cf HSV 2
- Fewer clinically apparent recurrences cf HSV 2
Discuss the pathophysiology of HSV 2
1. Site of infection
2. Incubation period
3. Transmission
4. Asymptomatic shedding risk
5. Risk of recurrence and causes
- Genital area
- Incubation period 1-2 weeks
- Transmitted genital to genital
- More asymptomatic shedding cf HSV 1. More common if HIV+, more common in first 12 months post primary infection
- More recurrence - 4 per year cf HSV 1
- Cause of recurrence - stress, menstruation, UV light
Discuss the management of herpes
-Reduction of transmission
-General principles
-Medication regimens
-Secondary prevention
- Reduction in transmission
-Condoms - not 100% effective
-Avoid sexual intercourse when active lesions
-Suppression with antivirals - reduces asymptomtic shedding 80-95% - General principles
-Patient education
-Psychological - referral for counselling if needed
-Sits baths
-Analgesia - topical and oral. Cold compress
-IDC or void in bath if urinary retention
-Loose clothing
-Full sexual health screen
-Partner notification - Antivirals
-Give regardless of time of onset
-Valciclovir 500mg PO BD 7/7
-Aciclovir 400mg PO TDS 7/7 - Secondary prevention
-Avoid triggers
-Avoid tampons when symptomatic
-Consider menstrual suppression if a tripper
-Episodic treatment - valciclovir 500mg PO BD 3/7 or Aciclovir 800mg PO TDS 2/7
-Suppressive continuous treatment - 500mg PO OD valciclovir or 400mg PO OD aciclovir. Reassess at 1 yr
Describe the pathophysiology of HIV/AIDS
-Transmission
-Cell invasion
-Replication
-AIDS defining illnesses (5)
- Transmission by: sex, vertical, parenteral
- HIV invades T cells through CD4 receptor and co-receptor
- Replication
-Uses reverse transcriptase to change from viral RNA to proviral DNA.
-Inserts into host DNA
-T cells apoptose on viral spread - AIDS defining illnesses
-Kaposi sarcoma
-Oesophageal candidiasis
-Pneumocystis Jiroveci pneumonia
-Cerebral toxoplasmosis
-HIV encephalopathy
Discuss HIV
-Presentation
-Investigations
- Presentation
-Acute infection - flu like illness - malaise, lymphadenopathy, pharyngitis, rash
-Development of antibodies to core protiens p24 and surface protiens GP 41, 120, 160 - Chronic infection
- Asx until CD4 count decreases
- B symtpoms - night sweats, fevers, weight loss, diarrhoea
- Increase in opportunistic infections - TB, CMV retinitis, PCP - Investigations
-Pretest counselling important
-Enzyme immunoassay for antibodies
-PCR for viral RNA
-Full sexual health screen
Discuss management of HIV
-Reduction of transmission (6)
-Antivirals
- Reduction of transmission
-Condom use - almost 100% effective
-Reduce viral load to undetectable
-PrEP - pre exposure prophylaxis - Truvada
-PEP - post exposure prophylaxis - Triple HAART within 72hrs for 1 month
-Antenatal screening and treatment for mother and baby
-Partner notification - Antiviral treatment
-Treat if symptomatic or CD4 count <350
-Use triple therapy
-Neocleoside reverse transcriptaase inhibitor, non-neucleoside reverse transcriptase inhibitor, Protease inhibitors.
-HAART toxic - peripheral neuropathy, lactic acidosis, hepatitis, pancreatitis
-Aim for viral load <50
Discuss HPV (Human papillomavirus)
-Relation to cervical cancer
-Prevalance
-Association with other cancers (6)
- HPV causes 99.7% of cervical cancers
- Prevalence
-80% of sexually active adults will acquire HPV
-80% of people clear HPV, 20% it is persisitent
-Higher prevalnce but faster clearence in women <20yrs - Associated with following cancers
-Vulval, vaginal, penis, anus, head and neck
Describe the pathophysiology of HPV
-Papilloma virus is non-enveloped DNA virus
-It enters the genital tract during sexual intercourse
-It infects the parabasal epithelial cells via microabrasions
-In the cell it either
-remains in the cytoplasms and replicates
-enters the nucleus and replicates
-enters the the nucleus and incorperates into the DNA. Oncogenic subtypes do this. Results in uncontrolled cell proliferation
-Cells infected with HPV are koilocytes. These migrate up from the basment membrane.
-Koilocytes lyse and virus is shead.
Discuss the HPV vaccination
-Type of vaccine
-Serotypes in vaccine
-Efficacy (5)
-Schedule
-Safety considerations (5)
-Advantages (2)
-Disadvantages (2)
-Advice if pregnant
- Type of vaccine
-Recombinant DNA virus like protien. Mimics virus structurally. Results in high titres of neutralising antibodies. - Serotypes covered in gardisil 9
-6,11,16,18,31,33,45,52,58 - Efficacy
-Prevents infection by HPV vaccine types.
-Shown to reduce premalignant and malignant lesions
-50% decrease in high grade CIN and 70% decrease in cervical cancer in UK
-Seroconversion rates in 95-100% for all strains in Gardisil 9
-Most effective if given <15yrs of age and prior to onset of sexual activity - Schedule
-Females 9-45yrs. Males 9-26yrs
-2 doses 6 months appart age 11 or 12
-If immunocompromised or >15yrs of age 3 doses at 0,2 and 6 months. - Saftey considerations
-Safe in breastfeeding
-Pregnancy cat B2. No evidence of harm but defer till PN
-Anaphylaxis 1-3 per million
-Adverse reactions - fevers, local reaction, headache, muscle pain
-Less effective in immunocompromised - Advantages
-Reduces HPV infection, CIN and cancers
-Protects against other strains even if previous HPV infection - Disadvantages
-Doesn’t treat infection
-Not a substitiute for cervical screening - Advice if pregnant
-No evidence of harm
-Delay completion of course until PN but do not need to start from start of course
Discuss genital warts
-Cause
-Areas most affected
-Complications
- Cause
-HPV most commonly 6 and 11
-Also 16,18, 31,33, 35 - Areas most affected
-Vulva and introitus
-cervix, perianal area, anus, rectum - Complications
-Asociated with cervical neoplasia
-Can increase in size in pregnancy
-Can recur
Discuss the management of genital warts (6)
-regimen
-clearence rate
-recurrence rates
-contraindications
- Conservative treatment - await immune system clearence
- Cryotherapy/electrocautery
-good for small lesions
-Weekly for 3-4 weeks
-Clearence 44-75%
-Recurrence 21-42%
-Only option in pregnancy - Podophyllotoxin - cytotoxic agent
-0.5% twice a day for 3 days then weekly for 4-6 weeks. Wash off 4 hrs after applying
-Clearence rate 45-83%
-Recurrence rate 13-100%
-Contraindicated in pregnancy - Imiquimod 5% - immune modulator
-Apply 3 x a week. Wash off 10hrs after application. Use for 4-16 weeks.
-Clearence rate - 35-68%
-Recurrence rate 6-26%
-Contra-indicated in pregnancy - Excisional therapy
-diathermy or cold knife
-Clearence rate 89-100%
-Recurrence rate 19-29% - Laser therapy
-Treatment in single visit
-Good for large warts in difficult places
Discuss genital warts and pregnancy
-Implications (4)
-Treatments
-neonatal implcations (1)
- Implications
-Increase in size in pregnancy
-Can cause obstruction in delivery
-Not an indication for CS except if pobstruction
-Regress postnatally - Treatment
-Cyrotherapy or electrocautery best option
-Imiquimod, podophyllin, flurouracil contra-indicated - Neonatal implications
-vertical transmission rare but can cause laryngeal papillomas
Discuss molloscum contagiosum
-Pathogen
-Mode of infection
-Presentation
-Diagnosis
-Management (4)
- Pox virus
- Spead by close contact, towel, clothing, sexual contact
- Multiple small pearly white papules with central dimple
- Diagnosed clinically
- Management
-Screen for other STI and HIV
-Self limiting, resolves over several months
-cryotherapy, electrocautery
-Phenol applied to dimple
-No need for contact tracing
Discuss pediculosis pubis
-Pathogen
-Mode of infection
-Incubation period
-Presentation
-Diagnosis
-Management (5)
- Crab louse phthrius pubis
- Close body contact
- 5 days to several weeks
- Itch, visible lica and eggs at hair base, blue macules at feeding sites
- Diagnosis is clinical
- Management
-Treat both parties
-Full STI screen
-Lotions better than shampoo. Permethrin
-Re-examine after 1 week
-Re-infection common if partner not treated
Discuss scabies
-Pathogen
-Mode of infection
-Presentation
-Management (7)
- Mite Sarcoptes scabiei
- Close body contact
- Presentation
-Itch - worse at night
-silver lines 5-15mm long indicating mite burrows
-Excoritation
-Skin scraping at burrows may reveal mites - Management
-Avoid contact till both parties treated
-Offer STI screen
-Permethrin 5% to whole body for 12hrs
-Antihistamines
-Hot wash clothes, bedding, towels
-No role for contact tracing
-No need to FU
Discuss toxic shock syndrome
-Pathogens
-Toxins
-Risk factors (6)
-Investigations
-Presentation
-Management
-Prognosis
- Pathogens
-Staphlococcus aurus
-Steptococcus pyogenes - Toxins
-TSST-1
-Enterotoxins A-E - Risk factors
-Menstration
-Tampons
-Postparum
-Post surgery
-Post miscarriage
-Burns patients - Investigations
-Bloods:
Raised WCC
Thrombocyctopenia
Derranged LFTs
AKI
Prolonged PR
-Cultures: confirms diagnosis of toxin producing organism but is often negative - Presentation
-Fever
-Rash - macular erythrodermal
-Desquamation
-Hypotension
-Multisystem involvement - Management
-Antibiotics (Clindamycin suppresses txin production)
-IgG
-IVF - Hypotension may not respond
-Vassopressors - Prognosis
-2.5% mortality for menstrual cases
Discuss bacterial vaginosis
1. Incidence
2. Risk factors (6)
3. Pathogens (4)
4. Presentation (4)
5. Diagnosis (4)
6. Management (6)
- Incidence - commonest cause of abnormal discharge 5-50%
- Risk factors
-Sexual activity, smokers, IUD users, douching, harsh soaps, feminine hygiene products - Pathogens
-Caused by an over growth of anaerobic organisms
-Gardnerella vaginalis
-Atopobium species
-Mobiluncus species
-Prevotella species - Presentation
-Fishy odour
-Worse after sex or menstruation
-Thin white or grey discharge
-Not usually itchy or irritated - Diagnosis
-Vaginal pH >4.5 (Replace lactobacilli and increase pH)
-Characteristic discharge
-Clue cells on wet microscopy
-Positive whiff test - fishy odour when alkali added to slide - Management
-Treat if symptomatic, undergoing surgery, pregnant
-Avoid or change modifiable risk factors
-Metronidazole 400mg PO BD 7/7 or 2g stat
-Clindamycin 300mg BD 7/7
-If recurrent consider
-metronidazole pre and post period.
-pH regulators - boric acid pessaries, AciJel
-No contact tracing or test of cure required
Discuss candida
-Incidence
-Causative pathogens (4)
-Risk factors (4)
-Presentation
-Management
- Incidence
-Affects 75% of women during their lifetime
-Associated with oestrogenised environments (COC, young women, pregnancy)
-Not in children or PM (Unless HRT) - Causative pathogens
-Candida albicans 80-90%
-C. glabrata - most common, C. Tropicalis, C. Krussei (10-15%) - needs longer course of treatment. Only treat if Sx - Risk factors
-Diabetes, immunocompromised, antibiotic use, synthetic underwear, COC, oestrogenised women - Presentation
-Discomfort, superficial dysparenunia, pruritis, erythema, fissures, thick white discharge, vuvla oedema
-Asx in 10-20% - Management
-Avoid irritants
-Topical clotrimazole, nystatin
-Fluconazole 150mg stat
-Itraconazole 200mg BD 1 day
-Probiotics don’t impact long term clinical cure
-If pregnant use 7 days of clotrimazole. (Longer course and avoid PO meds - can cause spont mc, cardiac abnormalities)
-Can consider short course topical hydrocortisone to manage associated inflammation
Discuss management of recurrent candida
-definition
-incidence
-Presentation
-Treatment
- 4 or more episodes in 12 months
- <5% of women with candidiasis
- Presentation
-Predominantly burning and itch not discharge
-Cyclical with onset of periods
-Co-exists with dermatitis which may be from overuse of antifungal creams - Treatment
-Fluconazole 150mg every 72hrs for 3 doses then weekly for 6 months (regimens vary)
-Itraconazole 100mg daily for 1 month then weekly for 6 months
-Clotirmazole topical cream for 10-14 days then 500mg clotrimazole pessaries weekly for 6 months
-Hydrocortisone in short term for inflammation
Discuss pelvic inflammatory disease
-Pathogens (7)
-Pathophysiology
-Risk factors (10)
- Pathogens
-Gonorrhoea
-Chlamydia
-Gardenella
-Trichomonas
-Mycoplasma, GBS, Bacteroides
-TB and actinomyces = chronic PID - Pathophysiology
-Acending infection causing inflammation of endometrium, fallopian tubes, parametrium, ovaries, pelvic peritoneum - Risk factors
-Most important is previous chlamydia, gonorrhoea or PID
-Age <30
-Lack of barrier contraception
-Change in sexual partners, or multiple sexual partners
-Vaginl douching
-Sex just after or during menstruation
-IUD insertion within 4 weeks
-TOP/ERPOC
-Upper genital trct instrumentation
-Postpartum
Discuss pelvic inlammatory disease
-Investigations (4)
-Management (2 categories)
- Investigations:
-Bloods, swabs LVS and HVS (NAAT and Culture)
-USS for salpingitis or TOA >90% sens and spec
-Diagnostic lap (gold standard but 15-30% of PID missed because mild or endometritis only - Management
Medical
-Outpatient - Ceftriaxone 500mg IM stat, Doxy 100mg PO BD 14/7, Metronidazole 400mg PO BD 14/7.
-Inpatient - Ceftriaxone 2g IV Q24H Metronidazole 500mg IV BD, Doxy 100mg PO BD. Step down to PO Metronidazole and doxy for 14/7
-If breastfeeding or pregnant switch doxy for 2 x stat doses azythromycin 1 wek apart
Surgical
-If no response to therapy or severe disease or TOA
-Drain abscess, Salpinectomy
-IR drainage
Other
-Consider removing IUD if no improvement after 48-72hrs of abx or if actinomyces
-Encourage sexual contact tracing for previous 3 months
What ar ethe complications of pelvic inflammatory disease (4)
- Infertility
-12% after first episode
-20% after second episode
-50% after third episode - Ectopic pregnancy 10%
- Chronic pelvic pain 20%
- Fitz hugh curtis 15%
-Liver capsule inflammation and viloin string adhesions
-Presents with RUQ pain and shoulder tip radiaiton
-Normal transaminases
-No role for adhesiolysis
Discuss tubo-ovarian abscess
-Pathogenensis
-Pathogens
- Pathogenesis
-Inflammatory mass involving the tube +/- ovary +/- pelvic side wall
-Results from upper genital tract infection - usally PID
-May arise from local spread of infection - appendix, IBD, adnexal surgery, haematological spread
-Tubal infection results in oedema and necrosis of tissue. Results in anerobic cavities which form abscesses - Pathogens
-Polymicrobial
-Ecoli, aerobic strep, bacteroides fragilis, prevotella, TB, actinomyces
-Gono and Chlamydia thought to facillitate in invasion of upper genital tract by other microbes
Discuss tubo ovarian abscess
-Findings on imaging
-Management
- Imaging
-USS - complex multilocular mass that obliterates adnexa
-CT - thick walled rim enhancing adnexal mass with adjacent bowel thickening and mesenteric stranding - Management
Medical
-Abx same as for PID - minimum of 2 weeks. Some recommend until abscess resolved on imaging
-Abx alone effective in 70% of cases
-Consider Abx alone if:
-Haemodynamically stable, no signs of rupture
-TOA <9cm (30-40% require surgery too)
-Not good surgical candidate
-Premenopausal
Surgical
-Do immediately if signs of rupture or haemodynamically unstable
-Do if TOA >9cm (60% require surgery)
-Do if failed Abx therapy after 48-72hrs
-Remove as much of cavity and pus as possible with irrigation ++
-May require USO or TH + BSO
-Allows for culture of microbes, confirmation of TOA, biopsy if malignancy suspected
Interventional drainage
-Good option if medically co-morbid
-Difficult if poor location or multiloculated
What are the complications of tubo-ovarian abscess (3)
- Rupture 15%
- Sepsis 10-20%
- Malignancy - esp in post menopausal women
Discuss syphilis
-Pathogen
-Stages (4) and associated timing and symptoms
- Pathogen
-Treponema pallidum
-Gram negative spirochette
-Spread by close contact, vertical transmission, sexual contact - Stages
Primary syphillis
-Presents 9-90 days (average 3 weeks) post exposure
-Solitary painless paupule - ulcerates to a chancre
-Assoicated with painless lymphandenopathy
-Resolves in 3-8 weeks
Secondary syphillis
- 1-6 months after primary syphillis (average 6 weeks)
- Lethargy, malaise, myalgias, anorexia, fever, headache
-Rash - generalised macular of skin and mucous membranes
-Mucous patch - snail track ulcer
- Condylomata lata
-Alopcia
Latent syphillis
-Lasts 3-30 yrs
-Asymptomatic
-All untreated infected people become asymptomatic in 12-24 months.
-No longer infectious after 24 months but can still have vertical transmission
Tertiary syphillis
-Gummatous syphillis
-Neuro syphillis
-Meningovascula and cardiovascular syphillis
Discuss investigations for syphillis
- Microscopy
-Dark ground microscopy from chancre in primary syphillis or mucous patch in secondary syphillis to look for microbe - Serology
Specific tests
-TP EIA - enzyme immunoassay. Detects IgM and IgG. Will always remain positive after infection. Becomes positive after 3-4 weeks post infection
-TPPA - partial agglutination assay. Confirmation test if EIA is positive
-TPHA - also used to confirm EIA positivity
Non-Specific tests
RPR - rapid plasma reagin. Perform if EIA positive to confirm. Can be non-reactive after treatment
VDRL - Titre used to confirm treatment success or reinfection. - STI screen as usual
Discuss managament of syphillis
- Management
-Notifiable disease
-Contact trace for partners and children. How far back depends on stage syphillis diagnosed.
-Refer to sexual health physician
-Full STI screen
-Avoid sex until assessment, treatment and all lesions healed
-Get baseline VDRL
Medical regimen
-Primary or secondary syphillis - Benzathine Penicillin G 2.4MU IM one off dose
-Latent syphillis or > 1yr since infection or unknown duration of infection - 3 doses (once a week) of Benzathine Penicillin G 2.4 MU IM - Follow-up for confirmation of treatment success
-Repeat serology at 3,6,12 months
-4 fold drop in RPR titre shows serological cure
-<4 fold drop in titre shows inadequate treatment
-4 fold rise in RPR titre suggests reinfection
Discuss the stages of female sexual response cycle (5)
- Desire / Libido
- Arousal/Excitment
-vasocongestion of clitoris and labia minora, secretion of vaginal lubricant from Batholins, expansion of vagina inlength and circumference - Plateau
-Florid discolouration of labia minora, retraction of clittoris behind prepubce, generalised myotonic spastic contractions of hands and feet - Orgasm
-Rythmic contractions and release of vasocongestive adn myotonic tension - Resolution
-Decongestion of labia, detumescence of clitoris, relaxation of vagina
Discuss psychosexual disorders
1. Incidence
2. Criteria for diagnosis (5)
3. Causes (4 categories)
- Incidence
- 40% of women world wide
- 12% with distressing symptoms - Criteria
-Minimum duration 6 months
-Occurs 75-100% of sexual encounters
-Causes significant distress
-Non explained y organic causes
-Not explainedby nonsexual mental disorder or relationship distress - Causes
Physical Gynae related: Endometriosis, prolapse, atrophy,
Physical non Gynae: MS, Arthritis, spinabifidam stoma, chronic illness
Drugs: SSRI, EtOH, Beno’s, Antipyschotics
Psychological: Anxiety/depression, fatigue, stress, shame
Context: Relationship conflict, prior abuse, lack of privacy
Discuss the management of psychosexual disorders
-Management depends on cause which is often multifactorial
-Identify all issues and prioritise/co-ordinate treatments
-Address goals for woman
-Address partner issues
-Treatment should be multidisciplinary and multifactorial
-Counselling
-psychotherapy
-Life style changes
-Pharmacology (Testosterone)
-Physiotherapy
-Treat physical gynae issue
Discuss sexual arousal/interest disorder
-Diagnostic criteria
-Management
- Diagnosed if 3 of the following present
-Little interest in sex
-Few thoughts related to sex
-Decreased start and rejection of sex
-Little pleasure during sex most of the time
-Decreased interest in sex even with exposure to erotic stimuli
-Little genital sensation during sex most of the time - Management
-Reassurance of normalisation of normal sexual activity
-Suggest ways of invigorating long term relationship
-Hormone therapy: Estrogen cream, testosterone - Andofeme 1% - Androgenic side effects
-Psychotropic agents
-Buproprion
-Flibanserin
Discuss female orgasmic disorder
1. Diagnosis
2. Casues
3. Management
- Diagnosis
-Marked delayed , infrequent or absent orgasm
-Present in 75-100% of sexual activity
-Present for > 6 months
-Distressing
-Must be alone as well as with partner - Causes
-Medical conditions: MS, Pelvic nerve damage, Spinal cord injury
-Medication or illicit drug use
-Partner issue - Management
-Can use PDE% inhibitor to reverse efects of SSRI
