Sexual Health Flashcards
What is bacterial vaginosis?
overgrowth of predominately anaerobic organisms such as :
GARDNERELLA VAGINALIS..
leads to fall in lactic acid producing aerobic lactobacilli (friendly bacteria in vagina) = raised vaginal ph.
not STI
features of bacterial vaginosis
vaginal discharge: fishy offensive
asx in 50%
no itching irritation or pain.
what is the criteria for bacterial vaginosis?
amsels criteria
3 of 4 needed
thwin white homogenous discharge
clue cells on microscopy: stippled vaginal epithelial cells
vaginal ph over 4.5
positive whiff test (addition of potassium hydroxide = fishy odour)
how would you manage bacterial vaginosis?
if asx: no tx unless if women undergoing termination of pregnancy
if sx:
oral metronidazole 5-7 days.
70-80% initial cure but relapse over 50% within 3 months
if adherence issue: single oral dose metronidazole 2g
topical metronidazole or topical clindamycin alternative
in pregnancy how can bacterial vaginosis affect it?
increased risk of preterm labour,
low birth weight
chorioamnionitis,
late miscarriage
postpartum endometritis
premature rupture of membranes
how to tx bacterial vaginosis in pregnancy?
oral metronidazole
if asx: discuss if needed
if sx: oral metro 5-7 or topical metro/clinda
NOT STAT DOSE OF METRO
examples of anaerobic bacteria associated with BV
gardnerella vaginalis -= mc
mycoplasma hominis
prevotella
risk factors of bv
multiple sex partners but not sti
smoking
recent abx
copper coil
excessive vaginal cleaning - douching - cleaning products, vaginal washes
what examination could be done to confirm bv
normal vaginal ph
speculum exam
confirm typical discharge.
high vaginal swab - exclude others.
vaginal ph : swab and ph paper.
normal vaginal ph - 3.5-4.5
what to avoid whilst bv tx and why?
alcohol.
alcoholl + metro = disulfiram like raction = nausea and vomiting, flushing
sometimes severe sx of shock and angioedema
comps of bv
increase the risk of catching sti like chlamydia gonorrhoea and hiv
what is trichomonas vaginalis?
trichomoniasis
highly motile flagellated protozoan parasite.
trichomoniasis - STI
features of trichomoniasis?
vaginal discharge: offensive, yellow/green, frothy
itching
dysuria
dyspareunia
balanitis - men
vulvovaginitis
strawberry cervix
ph over 4.5
men asx but could be urethritis
how would you investigate trichmoniasis?
miscropy of wet mount: motile trophozoites
how would you manage trichomoniasis?
oral metro 5-7 days
or one off dose of 2g metron
how would you diagnose trichomoniasis?
take swab from where?
and for men ?
standard charcoal swab with microscopy
swab taken from posterior fornix of vagina (behind cervix)
self taken low vaginal swab alternative
urethral swab/first catch urine : men
trichomonas can increase the risk of?
contracting hiv - because it damages vaginal mucosa
bv
cervical cancer
pelvic inflammatory idsease
pregnancy related comps: preterm delivery
how is trichomonas spread?
lives in urethra of men and women
vagina of women
sexual activity
what is vaginal candidasis? - thrush ?
mc yeast.
when can it happen?
vaginal infection with yeast from candida family.
mc : candida albicans
can colonise without sx.
can progress to infection during like pregnancy or after tx with broad spec abx that alter vaginal flora
risk factors of vaginal candidiasis?
increase oestrogen - pregnancy m lower prepuberty, post menopause
poorly controlled diabetes
immunosupression - using corticosteroids
broad spec abx - alter vaginal flora
features of vaginal candidiasis/
cottage cheese - non offensive discharge
vulvitis; superficial dysparenia, dysuria
itch
vulval eryhthema, fissuring, satellite lesions
excoriation
how would you investigate for vaginal candidiasis?
test vaginal ph : swab and ph paper. - ph under 4.5
charcoal swab with microscopy - to confirm
how would you manage vaginal candidiasis?
oral fluconazole 150 mg - single dose - 1st line
clotrimazole 500mg intravaginal pessary- single dose - if oral ci;d
if vulval sx: add topical imidazole as adjunct
if pregnant: only local tx cream or pessary used.
what would be considered reucrrent vaginal candidiasis?
tx
4 or more a yr
check compliance
high vaginal swab for microscopy and culture
do bg test exclude dm
exclude diff like lichen sclerosus
consider induction-maintenance regime:
induction - oral fluconazole - every 3 days for 3 doses
maintenance: oral fluconazole weekly for 6 weeks
what is chancroid?
causative organism
tx
tropical disease
STI
haemophilus ducreyi.
painful genital ulcers
unilateral painful inguinal lymph node enlargement.
ulcerS:
sharply defined, ragged, undermined border
Azithromycin: A single oral dose of 1 gram
Ciprofloxacin: An alternative is 500 mg orally twice daily for 3 days.
Ceftriaxone: IM single 250 mg
what is lymphogranuloma venerum?
STI
caused by chlamydia trachomatis serovars L1,L2 and L3
affect lymphoid tissue around site of infection with chlamydia.
risk factors of lymphogranuloma venereum
men sex men
most have hiv (if HIV+ PROCTITIS THINK THIS)
3 STAGES of infection of lymphogranuloma venererum
1: small painless pustule later forms ulcer. penis men. vaginal wall women or rectum after anal.
2: painful inguinal lymphadenopathy - poss form fistulating buboes. lymphadenitis.
3: proctocolitis - anal pain, change in bowel habit, tenesmus, discharge.
how would you treat lymphogranuloma venereum?
doxycycline
chlamydia resulting in urethritis and pelvic inflammatory disease is caused by which serovars
chlamydia trachomatris serovars d-k.
What is balanitis?
most common causes
inflammation of glans penis
can extend to underside of foreskin: balanoposthitis.
infective - bacterial and candidal
how would you investigate for balanitis
clinically
swab for microscopy and culture: bacteria or candida albicans
if doubt: biopsy
how would you treat balanitis?
non specific
specific
bacterial
anaerobic
dermatitis/circinate
lichen schlerosus
gentle saline wash, wash under foreskin, 1% hydrocortisone for short period.
specific:
- topical clotrimazole - 2 weeks.
bacterial balanitis: due to staphylococcus or group b strept - oral flucloxacillin or clarithromycin if penicillin allergic.
anaerobic balanitis: saline wash and topical/oral metro if not settle
dermatitis and circinate balanitis: mild potency topic corticosteroids - eg hydrocortisone
lichen sclerosus and plasma cell balanitis of zoon : high potency topical steroid - clobetasol.
circumcision: lichen sclerosus
explain candidiasis as a cause of balanitis
very common
acute
after intercourse
itching
white non urethral discharge
both children and adults
explain dermatitis - contact or allergic as a cause of balanitis
very common
acute
itchy , poss painful
occasionally associated with clear non-urethral ldischarge.
no other body area affected
both children and adults
explain bacterial cause of balanitis
common
acute
painful
itchy
yellow non-urethral discharge
most often due to staphylococcus spp
both kids and adult
explain anaerobic cause of balanitis
common
acute
itchy
very offensive yellow non urethral discharge
both kids and adults
explain lichen planus as a cause of balanitis
uncommon
acute and chronic
itchy
diagnostic feature: wickhams striae and violaceous papules
more commonly adults
explain lichen sclerosus as a cause of balanitis - balanitis xerotica obliterans
rare
chronic
itchy
white plaques
scarring
both kids and adults
explain plasma cell balanitis of zoon as a cause of balanitis
rare
chronic
itchy with clearly circumscribed areas of inflammation
both kids and adults
explain circinate balanitis as a cause of balanitis
uncommon
both acute and chronic
not itchy
no discharge
painless erosions
associated with reactive arthritis
adults
What is chlamydia?
incubation period
most prevalent sti in uk
caused by chlamydia trachomatis.
obligate intracellular pathogen.
incubation period: 7-21 days.
features of chlamydia
asx in around 70% of women and 50% of men
women: cervicitis (discharge, bleeding), dysuria
men: urethral discharge, dysuria, epididymo-orchitis
dyspareunia
vaginal bleeding can be intermenstrual or postcoital
potential complications of chlamydia
epididymitis
pelvic inflammatory disease
endometritis
increased incidence of ectopic pregnancy
infertility
reactive arthritis
perihepatitis - fitz hugh curtis syndrome
how would you investigate chlamydia
nuclear acid amplification test- NAATs
urine - first void urine sample , vulvovaginal swab, cervical swab - test these using NAAT technique
for women : vulvovaginal swab - 1st line
for men : urine test - 1st line
chlamydia testing - carry out 2 weeks after possible exposure
screening for chlamydia
men and women 15-24
how to manage chlamydia
doxycycline - 7 days - 1st line
if ci’d
either azithromycin - 1g od for 1 day then 500mg od for 2 days.
why in chlamydia should you use doxycycline and not azithromycin ?
concerns about mycoplasma genitalium.
how to treat chlamydia if pregnant?
azithromycin 1g stat then 500mg once day for 2 days erythromycin 500mg 4 time day for 7 days or 500mg twice day for 14 days
or amoxicillin 500mg 3 times day for 7 days
azithro 1g stat.
how to let know about chlamydia - contact tracing
men with urethral sx: all contacts since and 4 weeks prior
for women and asx men : last 6 months or most recent sexual partner
contacts of confirmed chlamydia should be offered tx before results of ix being known.
sti screening at a minimum is for which conditions
chlamydia
gonorrhoea
syphilis - blood test
hiv - blood test
what is a charcoal swab?
allow for microscopy , culture and sensitivies.
long cotton bud into tube with black transport medium at end.
amies transport medium.
keeps microorganisms alive during transport.
what can charcoal swabs confirm?
bv
candidiasis
gonorrhoea - endocervical swab
trichonmonas - posterior fornix swab
group b strept
pt with anal or oral sex suspected chlamydia what to do
rectal and pharyngeal NAAT swab
i examined someone with chlamydia. what are my findings?
pelvic/abdo tenderness
cervical motion tenderness
inflamed cervix
purulent discharge
pregnancy related comps of chlamydia
preterm delivery
premature rupture of membranes
low birth weight
postpartum endometritis
neonatal infection - conjunctivitis and pneumonia
general comps of chlamydia
pelvic inflammatory disease
chronic pelvic pain
infertility
ectopic
epididymo-orchitis
conjuncitivitis
lymphogranuloma venererum
reactive arthritis
What is Syphilis?
caused by?
STI caused by spirochete Treponema Pallidum.
3 stages:
primary
secondary
tertiary
9-90 days - incubation period
Different Stages of Disease - Syphillis
Primary - painless genital ulcer (Chancre). resolves over 3-8 weeks. local non-tender lymphadenopathy. (not seen in women mostly bc lesion could be on cervix)
Secondary - 6-10 weeks after primary infection.
- systemic sx: fevers, lymphadenopathy
- rash on trunk,palms and soles
- buccal “snail track” ulcers (30%)
condylomata late (painless, warty lesions on genitalia)
- alopecia
- maculopapular rash
Tertiary -
- gummatous lesions (granulomatous lesions that affect skin,organs and bones)
-aortic aneurysms
-neursyphillis
- general paralysis of the insane
-tabes dorsalis
-argyll-robertson pupil
Neurosyphillis - occur at any stage if infection reaches cns :
Headache
Altered behaviour
Dementia
Tabes dorsalis (demyelination affecting the spinal cord posterior columns)
Ocular syphilis (affecting the eyes)
Paralysis
Sensory impairment
explain argyll robertson pupil to me
neurosyphillis
constricted pupil accomodates when focusing on a near object but doesnt react to light.
irregular shaped.
features of congenital syphillis
blunted upper incisor teeth (hutchinson teeth) - “mulberry” molars
rhagades - linear scars at angle of mouth
keratitis
saber shins
saddle nose
deafness
how would you investigate for syphillis?
non-treponemal tests: not specific, can have false positives.
assess quantity of antibodies being produced
rapid plasma reagin(RPR) and venereal disease research laboratory (VDRL)
treponemal- specific tests
- generally more complex and expensive but specific for syphilis
- qualititive
eg: TP-EIA, TPHA
take samples from site of infection to confirm presence of t pallidum with :
dark field microscopy
PCR
causes of false positive non-treponemal (cardiolipin) tests
pregnancy
sle , anti-phospholipid syndrome
tb
leprosy
malaria
hiv
example of test results for syphilis and what they might mean?
positive non treponemal test+ positive treponemal test : active syphilis
positive non-treponemal test + negative treponemal tesT: false-positive syphilis : due to pregnancy or sle
negative non-treponemal test+ positive treponemal test: sucessfully treated syphilis
How to manage for syphilis?
im benzathine penicciline - 1st line
alternative: doxycycline
monitor nontreponemal rpr/vdrl titres.
complication of syphilis treatment.
symptoms.
tx?
jarisch-herxheimer reaction.
fever, rash tachy after 1st dose of abx
release endotoxins following bactrial death- within few hours of treatment.
no tx - antipyretics if required.
What is Genital Herpes?
hsv1 and hsv 2
after initial infection virus becomes latent in sensory nerve ganglia (trigeminal nerve ganglion with cold sores and sacral nerve ganglia with
genital herpes)
hsc 1 - cold sores - childhood before 5.- dormant in trigeminal nerve ganglion. genital herpes caused by hsv1 contracted via oro-genital sex- virus spreads from persion with oral infection to the person that gets genital infection.
hsv 2 - genital herpes. - sti - lesions in mouth
how is herpes simplex virus spread?
direct contact with affected mucous membrane or viral shredding in mucous secretions.
can be contracted from asx pts. - more common in 1st 12 mnths of infection.
features of genital herpes
how long do they last.
painful genital ulceration - poss dysuria and pruritis
primary infection more severe than recurrent episodes: systemic features:
headache
fever
malaise
tender inguinal lymphadenopathy
urinary retention poss
neuropathic type pain - tingling burning shooting
sx can last 3 weeks in primary infection. recurrent milder and resolve quicker
how to investigate for genital herpes?
nucleic acid amplification test (NAAT) - ix of choice.
hsv serology - if recurrent genital ulceration of unknown cause
viral pcr swab from a lesion - confirm causative organism
how would you manage genital herpes
general:
saline bathing
analgesia
topic anaesthetic agent: lidocaine
oral acyclovir
topical lidocaine - 2% gel
wear loose clothing
main issue with genital herpes during pregnancy
neonatal herpes simplex infection contracted during labour and delivery.
high morbidity and mortality.
pregnancy and baby immune to genital herpes?
woman develops antibodies to virus.
cross placenta into fetus.
passive immunity.
aiclovir not harmful in pregnancy
how to treat genital herpes during pregnancy?
primary genital herpes - before 28 weeks gestation - aciclovir. - then give regular prophylactic aciclovir from 36 weeks gestation onwards.
if sx present : csection
normal delivery if no sx and more than 6 weeks from initial infection.
primary genital herpes contracted after 28 weeks gestation: aciclovir follow immediately by regular prophylactic aciclovir. - c section recommended.
recurrent genital herpes : low risk of neonatal infection even if lesions are present during delivery. - give prophylactic aciclovir from 36 weeks gestation.
What are genital warts?
condylomata accuminata
caused by human papillomavirus hpv - types 6 and 11.
which types of hpv predispose to cervical cancer
16 18 33
features of genital warts
small - 2-5 mm - fleshy protuberances slightly pigmented
may bleed or itch
how would you manage genital warts?
topical podophyllum or cryotherapy - 1st line
depending on location/type of lesion:
- multiple, non-keratinised waters: topical agent
solitary keratinised warts: cyrotherapy
imiquimod - topic cream - 2nd line
genital warts - resistant to tx and recurrence is common - most anogenital infection with hpv clear without intervention within 1-2 years.
What is gonorrhoea?
causative bacteria?
what does it infect?
how does it spread?
neisseria gonorrhoea - gram negative diplococcus bacteria.
sti.
infects mucous membrane with columnar epithelium like endocervix in women, urethra, rectum, conjunctiva, pharynx.
spreads via contact with mucous secretions from infected areas.
risk factors for gonorrhorea
young sexually active
multiple partners
other stis like chlamydia hiv
abx resistance for gonorhea - tell me?
usualy ciprofloxacin and azithromycin were used to treat it but now theres high levels of resistance for these
how would you diagnose gonnorrhoea?
naat - detect rna/dna of gonorrhoea.
do endocervical,vulvovaginal or urethral swab - or first catch urine swab.
rectal and pharyngeal swab recommend in men sex men.
standard charcoal endocervical swab take for microscopy, culture and abx sensitivities before initiating abx.
feautures of gonorrhoea
local comps:
males: urethral discharge, dysuria
females: cervicitis : leading to vaginal discharge
rectal and pharyngeal infection : asx
local comps:
- urethral strcitures
epididymitis
salpingitis - poss lead to infertility
is immunisation possible for gonorrhoea?
why?
no
reinfection common: antigenic variation of type 4 pili (proteins which adhere to surfaces)
and opa proteins (surface proteins that bind to receptors on immune cells)
how would you manage gonorrhoea?
cephalosporins.
1st line : single dose of im ceftriaxone 1g.
if sensitivities known : single dose of oral ciprofloxacin 500mg
if ceftriaxone refused: oral cefixime 400 mg - single dose + oral azithromycin 2g single dose used
what is the test of cure for gonorrhoea?
recommendations to pt
follow up.
naat testing if pt asx.
72 hrs after tx for culture
7 days after tx for RNA NAAT
14 days after tx for DNA NAAT
no sex for 7 days of tx
advice about ways to prevent future infection.
complications of gonorhoea
pelvic inflammatory disease
infertility
chronic pelvic pain
conjunctivitis
urethral strictures
skin lesions
septic arthritis
endocarditis
disseminated gonococcal infection
prostatitis - in men
epididymo-orchitis (men)
firz hugh curis syndrome
key complication of gonorrhoea in a neonate?
gonococcal conjunctivitis.
when contracted from mother during birth.
opthalmia neonatorum
med emergency:
associated with sepsis perforation of eye and blindness
what is disseminated gonococcal infection
comp of untx gonococcal infection where bacteria spread to skin and joints.
poss due to haematogenous spread from mucosal infection.
causes pt to have:
dermatitis: non specific skin lesiosn
tenosynovitis
systemic: fever fatigue
migratory polyarthritis: arthritis that moves between joints
polyarthralgia: joint aches and pains
later comps:
endocarditis, perihepatitis(fitz-hugh curtis), septic arthritis
mc cause of septic arthritis in young adults
gonococcal infection
what is hiv?
what happens?
rna retrovirus.
hiv-1 mc
hiv-2 west africa.
virus enters and destroys the cd4 T-helper cells of immune system.
initial seroconversion flu like illness within few weeks of infection. then asx until conditions leads to immunodeficiency.
can be years after
transmission of hiv
not through day to day activities like kissing
its through:
unprotected anal, vaginal or oral sex
mother to child at any stage of pregnancy, birth or breastfeeding (vertical transmission)
mucous membrane, blood or open wound exposure to infected blood or bodily fluids (sharing needles, needle-stick injuries or blood splashed in an eye)
what is aids?
if hiv not treated
and the person becomes immunodeficient.
leads to opportunistic infections and aids defining illness
aids defining illnesses
where cd4 count dropped to a level that allows for unusual opportunistic infections and malignnacies.
kaposi sarcoma
pneumocystic jiroveci pneumonia
cytomegalovirus infection
candidiasis (oesophageal or bronchial)
lymphomas
tb
cd4 count is between 200-500 cells/mm3
what can happen in hiv pts
oral thrush - secondary to candida albicans
shingles - secondary to herpes zoster
hairy leukoplakia - secondary to ebv
kaposi sarcoma - secondary to hhv-8
cd4 count 50-100 cells/mm3 - what can happen in hiv pts
aspergillosis - secondary to aspergillus fumigatus
oesophageal candidiasis - secondary to candida albicans
cryptococcal meningitis
primary CNS lymphoma - secondary to EBV
cd4 count is 100-200 cells/mm3 - what can happen in hiv pts
cryptosporidiosis - self-limiting
cerebral toxoplsmosis
progressive multifocal leukoencephalopathy - secondary to JC virus
pneumocystic jirovecii pneumonia
hiv dementia
cd4 count under 50 cells/mm3
cytomegalovirus retinitis - affects 30-40% of pts with cd4 under 50 cells/mm3
mycobacterium avium-intracellulare infection
possible causes of diarrhoea in hiv patients
most common
incubation
staining
tx
cryptosporidium + other protozoa
cytomegalovirus
mycobacterium avium intracellulare
giardia
crypto- mc
intracellular protozoa
incubation: 7 days.
mild-severe diarhoea.
modified ziehl-neelsen stain - red cysts of cryptosporidium.
tx: supportive
tell me about mycobacterium avium intracellulare
- hiv
cd4 count
sx
ix
tx
atypical mycobactria
cd4 below 50
fever sweats abdo pain and diarhoea.
hepatomegaly poss and deranged lfts.
blood cultures
bm examination.
mx:
rifabutin
ethambutol
clarithromycin
screening for hiv
can take bloods for hiv in emergency department.
4th gen lab test for hiv checks for antibodies and p24 antigen. window period of 45 days - can take upto 45 days after exposure to the virus for test to turn positive. - negative result within 45 days of exposure is unrealiable. over 45 days after exposure, negative reuslt is reliable.
point of care tests for hiv antibodies: result within minutes. 90 day window period.
home testing kit:
self-sampling - poste dto lab - fourth gen test for antibodies and p24 antigen
point of care test - antibodies only
how to monitor for hiv
test cd4 count- number of cd4 cells in blood. cells destroyed by the virus.
lower the count higher the risk of opportunistic infection:
500-1200 cells/mm3 is normal
under 200 cells/mm3 - pt at high risk of opportunistic infections
test for hiv rna per ml of blood: tells you viral load.
undetectable viral load means level below recordable range (usually 20 copies/ml). viral load can be in hundreds of thousands in untreated hiv
Investigations for HIV
1st - HIV antibody test - false negative for 3 months post exposure
if negative - repeat in 3 months
confirmatory: repeat p24 or use western blot (p24, gp120, gp41)
How does HIV present?
acute (cd4>500)
- flu like symptoms
chronic/latent (cd4 500-200)
-fever
-persistent lymphadenoapthy
-opportunistic infections like ebv causing hairy leukoplakia or oral candidiasis
- tb can reactivate
aids defining
-persistent fever,fatigue, weight loss, diarrhoea, visual loss
How would you manage HIV
Antiretrovirals, aim to increase cd4 count and reduce viral load
-2 nucleoside reverse transcriptase inhibitors (nrti) + protease inhibitor or on nucleoside reverse transcriptse inhibitor
eg: tenofovir, emtricitabine and bictegravir
How would birth be managed in a women with hiv?
viral load
<50 copies/ml - normal delivery
>50 copies - consider c section
over 400 - pre-labour c section
IV zidovudine if viral load high/unknown during labour. (4 hrs before starting c section)
factors in hiv which reduce vertical transmission (from 25-30% to 2 %)
maternal antiretroviral therapy
mode of delivery - c section
neonatal antiretroviral therapy
infant feeding - bottle feeding
what neonatal antiretroviral therapy is given in hiv?
zidovudine - orally to neonate if maternal viral load is under 50 copies/ml.
otherwise triple ART.
4-6 weeks
What is mycoplasma genitalium?
non-gonoccocal urethritis sti
presents similar to chlamydia, often co infected.
urethritis key feature
increasing abx resistance, especially to azithromycin
how is mycoplasma investigated?
naat
-first urine sample in men
-vaginal swab for women
macrolide resistance and test of cure needed
mx of mycoplasma genitalum
doxycycline 100mg 2*day/7 days
2nd:
-azithromycin 1g stat then 500mg 1*day/2days
possible complications of mycoplasma
urethritis
epididymitis
cervicitis
PID
reactive arthritis
preterm delivery in pregnancy
What is erectile dysfunction?
2 main causes
persistent inability to attain/maintain an erection sufficient to permit satisfactory sexual performance.
organic - gradual onset sx, lack of tumescence, normal libido
psychogenic cause: sudden onset of sx, decreased libido, good quality spontaneous/self-stimulated erections, major life events, problems/changes in relationship, previous psychological problems, hx of premature ejaculation
risk factors of ed
cv disease: obesity, dm, dyslipidemia, met syndrome, htn, smoking
alcohol
drugs: ssri beta blockers
ix for ed
10 yr cv risk - measure lipid and fasting glucose serum levels
free testosterone - between 9 and 11am. - if low/borderline repeat with fsh,lh,prolactin.
how to manage ed
pde-5 inhibitor: sildenafil
vacuum erection: 1st line if wont take pde-5 inhibitor
stop cycling if cycline for more than 3 hrs per week
