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RANZCOG -Gynaecology 2024 Edward > Sexual health > Flashcards

Sexual health Flashcards

1
Q

Discuss gonorrhoea
-Pathogen
-Site (5) and cell type targeted
-Period of incubation
-Symptoms (5)
-Investigations (3)
-Treatment (5)
-Complications (3)
-Follow-up

A
  1. Pathogen
    -Neisseria gonorrhoea
    -Gram negative diplococcus
  2. Site and cell of infection
    -Endocervix, rectum, urethra, conjunctiva, pharynx
    -Infects collumnar epithelia in mucous membranes
  3. Period of incubation - 3 days
  4. Symptoms
    -50% aSx
    -Mucopurulant discharge 50%
    -Lower abdo pain 25%
    -Dysuria 12%
    -IMB and PCB
  5. Investigations
    -Vulvovaginal NAAT
    -Endocervical swab for microscopy and culture
    -Investigate for other STI
  6. 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
  7. Complications
    -PID <10%
    -Haematogenous spread to skin and joints - arthritis and tenosynovitis
    -Disseminated infection - rare
  8. 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
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2
Q

Discuss gonorrhoea in pregnancy
-Complications to neonate (6)
-Complications to mother (1)
-Risk of transmission
-Who to test
-When to follow-up

A

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

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3
Q

Discuss trichomonas
-Pathogen
-Symptoms (6)
-Investigations
-Management
-Follow-up
-Complications

A
  1. Pathogen
    -Flagellates protozoa - trichomonas vaginalis
    -Sexually transmitted
    -Incubation period 5-28 days
  2. Symptoms
    -Asx - 50%
    -Frothy yellow discharge - 10-30%. 70% vaginal discharge
    -Classic strawberry cervix - 2%
    -Vaginal puritis, vulvitis, vaginitis
  3. Investigations
    -NAAT - 10% sensitivity
    -Culture or wet slide
    -Check for BV - 60-80% co-existant
  4. Management
    -Metronidazole 2g stat or 400mg BD 7 days
    -Avoid unprotected sex 1/52 from start of treatment
    -Partner notification
  5. Follow-up
    -Chance of re-infection
    -Test of cure only if symptomatic
  6. Complications
    -Enhanced HIV transmission
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4
Q

What are the complications to pregnancy associated with trichomonas infection
-Complications to pregnancy (3)
-Complications for neonate (1)

A
  1. PPROM, PTD, LBW
  2. Neonatal vulvoaginitis - 5%, respiratory infection
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5
Q

Discuss chlamydia
-Pathogen
-Sites and cells infected
-Incubation period
-Symptoms (4)
-Investigations
-Management
-Follow-up
-Complications (4)

A
  1. Pathogen
    -Chlamydia trachomatis
    -Gram negative
    -Different subtypes - A-C = conjunctivits, D-K = genital L1-L3 = lymphogranuloma venerum
  2. Site and cell
    -Obligate intracellular
    -Infects cervix, urethra, rectum, conjunctiva, pharynx
  3. Incubation period = 1 day to 6 weeks
  4. Symptoms
    -Asx - 70%
    -PCB or IMB
    -Purulent discharge
    -Dysuria
  5. NAAT - 95% sensitivity. Remains + up to 5 weeks post Rx
  6. 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
  7. Follow-up
    -Test for cure if ongoing symptoms or pregnant - 6 weeks post Rx
  8. Complications
    -PID 10-40% if untreated
    -Fitz-Hugh-Curtis
    -Chronic pelvic pain
    -Reiters syndrome - reactive arthritis, urethritis, uveitis
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6
Q

Discuss complications of chlamydia associated with pregnancy
-Complications to pregnancy (5)
-Complications to neonate (3)

A
  1. Complications to pregnancy
    -Tubal infertility
    -Ectopic pregnancy
    -No impact on early pregnancy loss
    -PPROM
    -LBW
  2. Complications to neonate
    -Conjunctivitis - 50%
    -Pneumonia - 10-20%
    -Asx vaginal or rectal infection 15%-
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7
Q

Discuss Lymphogranuloma venereum
-Pathogen
-Site of infection
-Stages of disease
-Management

A
  1. Pathogen
    -Chlmaydia trichomatis serovars L1-L3
  2. Site of infection - lymphatic tissue
  3. 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
  4. Management
    -Doxycycline for at least 3/52
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8
Q

What are the causes of genital ulcers
-Infectious causes
-Sexually transmitted (6)
-Not sexually transmitted (7)
-Non infectious causes (4 groups)

A
  1. 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
  2. Non-sexually transmitted
    -Candidiasis - severe
    -Herpes zoster
    -TB
    CMV
    -EBV
    -Mycoplasma
    -Group A strep
  3. 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
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9
Q

How should genital ulcers be investigated? (5)

A

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

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10
Q

Discuss herpes
-Incidence
-Symptoms - primary and secondary
-Investigations

A
  1. Incidence
    -20% of adults have HSV-2
  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
  3. 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
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11
Q

Discuss the pathophysiology of HSV 1
-Area infects
-Transmission
-Asymtpomtic sheadding risk
-Risk of recurrence

A
  1. Infects genitals and oral areas
  2. Transmission through oral genital contact
  3. Less asymptomatic sheeding cf HSV 2
  4. Fewer clinically apparent recurrences cf HSV 2
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12
Q

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

A
  1. Genital area
  2. Incubation period 1-2 weeks
  3. Transmitted genital to genital
  4. More asymptomatic shedding cf HSV 1. More common if HIV+, more common in first 12 months post primary infection
  5. More recurrence - 4 per year cf HSV 1
  6. Cause of recurrence - stress, menstruation, UV light
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13
Q

Discuss the management of herpes
-Reduction of transmission
-General principles
-Medication regimens
-Secondary prevention

A
  1. Reduction in transmission
    -Condoms - not 100% effective
    -Avoid sexual intercourse when active lesions
    -Suppression with antivirals - reduces asymptomtic shedding 80-95%
  2. 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
  3. Antivirals
    -Give regardless of time of onset
    -Valciclovir 500mg PO BD 7/7
    -Aciclovir 400mg PO TDS 7/7
  4. 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
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14
Q

Describe the pathophysiology of HIV/AIDS
-Transmission
-Cell invasion
-Replication
-AIDS defining illnesses (5)

A
  1. Transmission by: sex, vertical, parenteral
  2. HIV invades T cells through CD4 receptor and co-receptor
  3. Replication
    -Uses reverse transcriptase to change from viral RNA to proviral DNA.
    -Inserts into host DNA
    -T cells apoptose on viral spread
  4. AIDS defining illnesses
    -Kaposi sarcoma
    -Oesophageal candidiasis
    -Pneumocystis Jiroveci pneumonia
    -Cerebral toxoplasmosis
    -HIV encephalopathy
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15
Q

Discuss HIV
-Presentation
-Investigations

A
  1. Presentation
    -Acute infection - flu like illness - malaise, lymphadenopathy, pharyngitis, rash
    -Development of antibodies to core protiens p24 and surface protiens GP 41, 120, 160
  2. Chronic infection
    - Asx until CD4 count decreases
    - B symtpoms - night sweats, fevers, weight loss, diarrhoea
    - Increase in opportunistic infections - TB, CMV retinitis, PCP
  3. Investigations
    -Pretest counselling important
    -Enzyme immunoassay for antibodies
    -PCR for viral RNA
    -Full sexual health screen
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16
Q

Discuss management of HIV
-Reduction of transmission (6)
-Antivirals

A
  1. 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
  2. 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
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17
Q

Discuss HPV (Human papillomavirus)
-Relation to cervical cancer
-Prevalance
-Association with other cancers (6)

A
  1. HPV causes 99.7% of cervical cancers
  2. 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
  3. Associated with following cancers
    -Vulval, vaginal, penis, anus, head and neck
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18
Q

Describe the pathophysiology of HPV

A

-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.

19
Q

Discuss the HPV vaccination
-Type of vaccine
-Serotypes in vaccine
-Efficacy (5)
-Schedule
-Safety considerations (5)
-Advantages (2)
-Disadvantages (2)
-Advice if pregnant

A
  1. Type of vaccine
    -Recombinant DNA virus like protien. Mimics virus structurally. Results in high titres of neutralising antibodies.
  2. Serotypes covered in gardisil 9
    -6,11,16,18,31,33,45,52,58
  3. 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
  4. 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.
  5. 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
  6. Advantages
    -Reduces HPV infection, CIN and cancers
    -Protects against other strains even if previous HPV infection
  7. Disadvantages
    -Doesn’t treat infection
    -Not a substitiute for cervical screening
  8. Advice if pregnant
    -No evidence of harm
    -Delay completion of course until PN but do not need to start from start of course
20
Q

Discuss genital warts
-Cause
-Areas most affected
-Complications

A
  1. Cause
    -HPV most commonly 6 and 11
    -Also 16,18, 31,33, 35
  2. Areas most affected
    -Vulva and introitus
    -cervix, perianal area, anus, rectum
  3. Complications
    -Asociated with cervical neoplasia
    -Can increase in size in pregnancy
    -Can recur
21
Q

Discuss the management of genital warts (6)
-regimen
-clearence rate
-recurrence rates
-contraindications

A
  1. Conservative treatment - await immune system clearence
  2. Cryotherapy/electrocautery
    -good for small lesions
    -Weekly for 3-4 weeks
    -Clearence 44-75%
    -Recurrence 21-42%
    -Only option in pregnancy
  3. 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
  4. 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
  5. Excisional therapy
    -diathermy or cold knife
    -Clearence rate 89-100%
    -Recurrence rate 19-29%
  6. Laser therapy
    -Treatment in single visit
    -Good for large warts in difficult places
22
Q

Discuss genital warts and pregnancy
-Implications (4)
-Treatments
-neonatal implcations (1)

A
  1. Implications
    -Increase in size in pregnancy
    -Can cause obstruction in delivery
    -Not an indication for CS except if pobstruction
    -Regress postnatally
  2. Treatment
    -Cyrotherapy or electrocautery best option
    -Imiquimod, podophyllin, flurouracil contra-indicated
  3. Neonatal implications
    -vertical transmission rare but can cause laryngeal papillomas
23
Q

Discuss molloscum contagiosum
-Pathogen
-Mode of infection
-Presentation
-Diagnosis
-Management (4)

A
  1. Pox virus
  2. Spead by close contact, towel, clothing, sexual contact
  3. Multiple small pearly white papules with central dimple
  4. Diagnosed clinically
  5. Management
    -Screen for other STI and HIV
    -Self limiting, resolves over several months
    -cryotherapy, electrocautery
    -Phenol applied to dimple
    -No need for contact tracing
24
Q

Discuss pediculosis pubis
-Pathogen
-Mode of infection
-Incubation period
-Presentation
-Diagnosis
-Management (5)

A
  1. Crab louse phthrius pubis
  2. Close body contact
  3. 5 days to several weeks
  4. Itch, visible lica and eggs at hair base, blue macules at feeding sites
  5. Diagnosis is clinical
  6. Management
    -Treat both parties
    -Full STI screen
    -Lotions better than shampoo. Permethrin
    -Re-examine after 1 week
    -Re-infection common if partner not treated
25
Q

Discuss scabies
-Pathogen
-Mode of infection
-Presentation
-Management (7)

A
  1. Mite Sarcoptes scabiei
  2. Close body contact
  3. Presentation
    -Itch - worse at night
    -silver lines 5-15mm long indicating mite burrows
    -Excoritation
    -Skin scraping at burrows may reveal mites
  4. 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
26
Q

Discuss toxic shock syndrome
-Pathogens
-Toxins
-Risk factors (6)
-Investigations
-Presentation
-Management
-Prognosis

A
  1. Pathogens
    -Staphlococcus aurus
    -Steptococcus pyogenes
  2. Toxins
    -TSST-1
    -Enterotoxins A-E
  3. Risk factors
    -Menstration
    -Tampons
    -Postparum
    -Post surgery
    -Post miscarriage
    -Burns patients
  4. Investigations
    -Bloods:
    Raised WCC
    Thrombocyctopenia
    Derranged LFTs
    AKI
    Prolonged PR
    -Cultures: confirms diagnosis of toxin producing organism but is often negative
  5. Presentation
    -Fever
    -Rash - macular erythrodermal
    -Desquamation
    -Hypotension
    -Multisystem involvement
  6. Management
    -Antibiotics (Clindamycin suppresses txin production)
    -IgG
    -IVF - Hypotension may not respond
    -Vassopressors
  7. Prognosis
    -2.5% mortality for menstrual cases
27
Q

Discuss bacterial vaginosis
1. Incidence
2. Risk factors (6)
3. Pathogens (4)
4. Presentation (4)
5. Diagnosis (4)
6. Management (6)

A
  1. Incidence - commonest cause of abnormal discharge 5-50%
  2. Risk factors
    -Sexual activity, smokers, IUD users, douching, harsh soaps, feminine hygiene products
  3. Pathogens
    -Caused by an over growth of anaerobic organisms
    -Gardnerella vaginalis
    -Atopobium species
    -Mobiluncus species
    -Prevotella species
  4. Presentation
    -Fishy odour
    -Worse after sex or menstruation
    -Thin white or grey discharge
    -Not usually itchy or irritated
  5. 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
  6. 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
28
Q

Discuss candida
-Incidence
-Causative pathogens (4)
-Risk factors (4)
-Presentation
-Management

A
  1. Incidence
    -Affects 75% of women during their lifetime
    -Associated with oestrogenised environments (COC, young women, pregnancy)
    -Not in children or PM (Unless HRT)
  2. 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
  3. Risk factors
    -Diabetes, immunocompromised, antibiotic use, synthetic underwear, COC, oestrogenised women
  4. Presentation
    -Discomfort, superficial dysparenunia, pruritis, erythema, fissures, thick white discharge, vuvla oedema
    -Asx in 10-20%
  5. 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
29
Q

Discuss management of recurrent candida
-definition
-incidence
-Presentation
-Treatment

A
  1. 4 or more episodes in 12 months
  2. <5% of women with candidiasis
  3. Presentation
    -Predominantly burning and itch not discharge
    -Cyclical with onset of periods
    -Co-exists with dermatitis which may be from overuse of antifungal creams
  4. 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
30
Q

Discuss pelvic inflammatory disease
-Pathogens (7)
-Pathophysiology
-Risk factors (10)

A
  1. Pathogens
    -Gonorrhoea
    -Chlamydia
    -Gardenella
    -Trichomonas
    -Mycoplasma, GBS, Bacteroides
    -TB and actinomyces = chronic PID
  2. Pathophysiology
    -Acending infection causing inflammation of endometrium, fallopian tubes, parametrium, ovaries, pelvic peritoneum
  3. 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
31
Q

Discuss pelvic inlammatory disease
-Investigations (4)
-Management (2 categories)

A
  1. 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
  2. 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
32
Q

What ar ethe complications of pelvic inflammatory disease (4)

A
  1. Infertility
    -12% after first episode
    -20% after second episode
    -50% after third episode
  2. Ectopic pregnancy 10%
  3. Chronic pelvic pain 20%
  4. 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
33
Q

Discuss tubo-ovarian abscess
-Pathogenensis
-Pathogens

A
  1. 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
  2. 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
34
Q

Discuss tubo ovarian abscess
-Findings on imaging
-Management

A
  1. Imaging
    -USS - complex multilocular mass that obliterates adnexa
    -CT - thick walled rim enhancing adnexal mass with adjacent bowel thickening and mesenteric stranding
  2. 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
35
Q

What are the complications of tubo-ovarian abscess (3)

A
  1. Rupture 15%
  2. Sepsis 10-20%
  3. Malignancy - esp in post menopausal women
36
Q

Discuss syphilis
-Pathogen
-Stages (4) and associated timing and symptoms

A
  1. Pathogen
    -Treponema pallidum
    -Gram negative spirochette
    -Spread by close contact, vertical transmission, sexual contact
  2. 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
37
Q

Discuss investigations for syphillis

A
  1. Microscopy
    -Dark ground microscopy from chancre in primary syphillis or mucous patch in secondary syphillis to look for microbe
  2. 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.
  3. STI screen as usual
38
Q

Discuss managament of syphillis

A
  1. 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
  2. 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
39
Q

Discuss the stages of female sexual response cycle (5)

A
  1. Desire / Libido
  2. Arousal/Excitment
    -vasocongestion of clitoris and labia minora, secretion of vaginal lubricant from Batholins, expansion of vagina inlength and circumference
  3. Plateau
    -Florid discolouration of labia minora, retraction of clittoris behind prepubce, generalised myotonic spastic contractions of hands and feet
  4. Orgasm
    -Rythmic contractions and release of vasocongestive adn myotonic tension
  5. Resolution
    -Decongestion of labia, detumescence of clitoris, relaxation of vagina
40
Q

Discuss psychosexual disorders
1. Incidence
2. Criteria for diagnosis (5)
3. Causes (4 categories)

A
  1. Incidence
    - 40% of women world wide
    - 12% with distressing symptoms
  2. 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
  3. 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
41
Q

Discuss the management of psychosexual disorders

A

-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

42
Q

Discuss sexual arousal/interest disorder
-Diagnostic criteria
-Management

A
  1. 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
  2. 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
43
Q

Discuss female orgasmic disorder
1. Diagnosis
2. Casues
3. Management

A
  1. 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
  2. Causes
    -Medical conditions: MS, Pelvic nerve damage, Spinal cord injury
    -Medication or illicit drug use
    -Partner issue
  3. Management
    -Can use PDE% inhibitor to reverse efects of SSRI

RANZCOG -Gynaecology 2024 Edward (11 decks)

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