Sexual health Flashcards
Describe the microbiology of chlamydia trachomatis
intracellular gram-negative bacteria
How is chlamydia transmitted
vertical transmission`
sexual contact
Give 3 RFs for chlamydia
- under 25
- new/multiple sexual partners
- not using condoms
Give 4 ways chlamydia may present in women
asymptomatic (70%)
* abnormal vaginal discharge - cloudy/ yellow
* pelvic pain
* dysuria
* post coital/intermenstrual bleeding
Give 4 ways chlamydia may present in men
asymptomatic (50%)
* urethral discharge
* dysuria
* testicular pain
How is chlamydia diagnosed
- nucelic acid amplification test (NAAT) - first catch urine (men) and vulvovaginal swab (women)
- test for lymphogranuloma venereum in MSM with rectal chlamydia
How is chlamydia managed in men and non pregnant women
- doxycycline 100mg orally BD for 7d
How is chlamydia managed in a pregnant woman
Any of:
* azithromycin 1g stat then 500mg oral OD for 2 days
* erythromycin
* amoxicillin 500mg oral TDS for 7d
What advice should be given to patients with chlamydia
- no sex for 1 week
- refer to GUM for contact tracing
- leaflet on condition
Give 5 complications of chlamydia
- epididymo-orchitis
- ectopic pregnancy
- reactive arthritis
- pelvic inflammatory disease
- infertility
When should a test of cure be done for chlamydia
after 6 weeks if pregnant or rectal infection
What type of bacteria is neisseria gonorrhoea
gram negative diplococcus
3 ways gonorrhoea may present in females
- odourless mucopurulent discharge (50%)
- pelvic pain
- dysuria
2 ways gonorrhoea may present in males
- mucopurulent discharge (80%)
- dysuria
2 investigations done for gonorrhoea
- NAAT
- charcoal swab for culture, microscopy and antibiotic sensitivities
- swabs in women should be taken from the vulvo-vaginal area
How is gonorrhoea managed
depends on whether antibiotic sensitivities are known
* first line: Single dose IM ceftriaxone 1g
* sensitive: single dose oral ciprofloxacin 500mg
Alternative: single dose oral cefixime + azithromycin
When is test of cure done for gonorrhoea
after a week for all people who have been treated
What is the most common cause of vaginal discharge in women of reproductive age
bacterial vaginosis
What is bacterial vaginosis
overgrowth of predominately anaerobic bacteria in the vagina
Describe the pathophysiology of bacterial vaginosis
- lactobacilli are the main component of the healthy vaginal flora
- lactobacilli produce lactic acid that keep the vag ph low (<4.5)
- loss of lactobacilli results in a raised vaginal pH which enables anaerobic bacteria to multiply
Give an example of an anaerobic bacteria associated with bacterial vaginosis
Gardnerella vaginalis
Give 4 RFs for bacterial vaginosis
- multiple sexual partners
- excessive vaginal cleaning - douching, cleaning products
- recent antibiotics
- smoking
Describe the presentation of bacterial vaginosis
- half of women are asymptomatic
- grey-white discharge with characteristic fishy odour
How is bacterial vaginosis diagnosed
- vaginal pH >4.5
- positive whiff test(addition of KOH = fishy odour)
- thin,white homogenous discharge
- clue cells on microscopy
How is bacterial vaginosis managed
- asymptomatic: don’t usually require treatment unless undergoing termination
- symptomatic: oral metronidazole for 5-7 days or topical clindamycin
What advice should be given to patients when prescribing metronidazole and why
avoid alcohol for duration of treatment as together they can cause a disulfiram-like reaction
* N+V,flushing and in severe cases shock
What are 4 complications of bacterial vaginosis
- preterm labour
- chorioamnionitis
- late miscarriage
- STIs
What is vaginal candidiasis
aka thrush
* vaginal infection with a yeast of the candida family
Which species of candida is the most common in vaginal candidiasis
candida albicans
Give 4 RFs for vaginal candidiasis
- pregnancy
- Poorly controlled diabetes
- Immunosuppression (e.g. using corticosteroids)
- Broad-spectrum antibiotics
Give 4 ways vaginal candidiasis may present
- thick, white, non-offensive discharge (‘cottage cheese’)
- itching
- superficial dyspareunia and dysuria
- vulval erythema
How is vaginal candidiasis investigated
- pH < 4.5 (normal)
- high vaginal swab for culture and microscopy
- Investigations are not routinely indicated if clinical features are consistent with candidiasis
How is vaginal candidiasis managed
- oral antifungal - fluconazole 150mg as single dose
- antifungal pessary - clotrimazole as single dose
- topical antifungal - clotrimazole
- if pregnant only manage with creams/ pessaries.
How are recurrent vaginal candidiasis defined and managed
- 4 or more episodes in a year
- consider blood glucose test to exclude diabetes
- confirm diagnosis with HVS
- induction-maintenance regime of oral fluconazole for 6 months
What is the most common cause of genital warts
human papillomavirus 6 and 11
Give 3 clinical features of genital warts
- most asymptomatic
- painless non-ulcerative lesion
- may itch
How are genital warts managed
first-line treatments depend on the location and type of lesion
* multiple, non-keratinised warts are generally best treated with topical podophyllum/ podophyllotoxin
* solitary, keratinised warts respond better to cryotherapy
* topical imiquimod is 2nd line
What causes genital herpes
herpes simplex virus 1 and/or 2
How may genital herpes present
- asymptomatic
- multiple painful genital ulcers
- dysuria and itching
- primary infections may have systemic features e.g. fever and headache
- the primary episode is often more severe than recurrent episodes
What occurs after an initial infection with herpes simplex virus
following primary infection, virus becomes latent in sensory ganglia, periodically reactivating to cause symptomatic lesions or asymptomatic viral shedding
How is genital herpes investigated
NAAT: HSV DNA detection by PCR
* sample base of ulcer
How is genital herpes managed
- primary herpes: oral aciclovir 400mg TDS for 5d
- Recurrences of herpes – Aciclovir 800mg TDS for 2 days
- If >6 outbreaks a year consider suppressive therapy with Aciclovir 400mg BD for 12 months
- advice: saline bathing, analgesia
What is syphilis
STI caused by treponema pallidum (gram -ve spirochete)
How is syphilis transmitted
- sexual contact
- vertically
- IVDU
Give 2 features of primary syphilis
- painless genital ulcer (chancre) at site of invasion
- local non-tender lymphadenopathy
Give 5 features of secondary syphilis
- non-itchy maculopapular rash on trunk, palms and soles
- systemic: lymphadenopathy, fever, headache
- condylomata lata - painless, grey warty lesions on genitalia
- buccal ‘snail track’ ulcers
Give 2 features of tertiary syphilis
- gummatous in skin and bones - Chronic painless nodules that break down into ulcers which heal slowly
- aortic aneurysms
At what stages can neurosyphilis occur, and how does it develop?
Neurosyphilis can occur at any stage of syphilis if the infection reaches the central nervous system
Give 5 symptoms of neurosyphilis
- meningitis
- optic neuritis
- sensorineural hearing loss
- Tabes dorsalis (demyelination affecting the spinal cord posterior columns)
- Argyll-Robertson pupil - constricted pupil that accommodates when focusing on a near object but does not react to light
How is syphilis investigated
- Dark ground microscopy from the primary chancre
Serology: - Treponemal-specific test: e.g. T.pallidum enzyme immunoassay (TP-EIA)
- Non-specific tests: rapid plasma reagin (RPR) and venereal disease research laboratory (VDRL) tests. used to measure response to treatment
How is syphilis managed
- IM benzathine penicillin stat
- late syphilis (>2y) - IM benzathine penicillin weekly for 3 doses
- follow up 3,6 and 12m
- A sustained four-fold or greater increase in the VDRL titre suggests re-infection or treatment failure
What is Trichomonas vaginalis
highly motile flagellated protozoan parasite
How is Trichomonas vaginalis transmitted
sexual contact
Give 5 clinical features of Trichomonas vaginalis
50% asymptomatic
* vaginal discharge: offensive, yellow/green, frothy
* dysuria
* itching
* strawberry cervix
* pH > 4.5
* may cause urethritis in men
How is Trichomonas vaginalis investigated
- microscopy of wet slide from posterior fornix of vagina
- urethral swab/ first catch urine in men
How is trichomonas vaginalis treated
oral metronidazole for 5-7 day
What advice should be given to people with trichomonas vaginalis
- no sexual contact for 1 week after patient and partner treated
- patient information leaflet
- See health advisor for contact tracing
What type of virus is the human immunodeficiency virus and what is the most common type
RNA retrovirus
HIV-1
How is HIV transmitted
- sexual contact
- needle sharing
- vertical
- needle stick injury
- blood transfusion
Describe the stages of HIV
- Acute infection: often asymptomatic
- seroconversion (3-12 weeks after exposure): myalgia, fever, rash, severe sore throat
- Asymptomatic phase: loss of CD4 cells, persistent generalised lymphadenopathy (30%)
- AIDS: CD4 count <200 x 106/L, fatal if untreated
How is HIV investigated
- HIV antibody: ELISA (enzyme linked immune-sorbent assay) and confirmatory western blot assay
- combined tests: HIV antibody and HIV p24 antigen
- if a combined HIV test is +ve, repeat to confirm diagnosis
- Serum HIV rapid test - point of care test
How should HIV be tested for in asymptomatic patients
- testing should be done at 4 weeks after possible exposure
- after an initial negative result, offer a repeat test at 12 weeks
How is HIV monitored
- CD4 count (normal= 500-1200 cells/mm3)
- testing for HIV RNA per ml of blood indicates viral load - aim for undetectable
How is HIV managed
highly active anti-retroviral therapy (HAART) at diagnosis
* Nucleoside reverse transcriptase inhibitors (NRTI)
* Non-nucleoside reverse transcriptase inhibitors (NNRTI)
* Protease inhibitors (ritonavir)
* Integrase inhibitors (raltegravir)
* entry inhibitors (e.g. fuzeon)
Give 3 examples of Nucleoside analogue reverse transcriptase inhibitors (NRTI)
- zidovudine
- tenofovir
- emtricitabine
- didanosine
Give 4 AIDS defining illnesses
- Kaposi’s sarcoma
- Pneumocystis jirovecii pneumonia (PCP)
- Cytomegalovirus infection
- Candidiasis (oesophageal or bronchial)
- Hodgkin’s Lymphomas
- Tuberculosis
What is the prophylaxis for HIV
- post exposure prophylaxis (PEP): used within 72hrs of exposure to reduce risk of transmission - emtricitabine/tenofovir (Truvada) and raltegravir for 28 days
- Pre-exposure prophylaxis (PrEP): ART for those at high risk of transmission - co-formulation of emtricitabine/tenofovir
