Sexual Health Flashcards
what is bacterial vaginosis?
overgrowth of anaerobic bacteria in vagina that causes unusual fishy smelling, grey-ish white thin discharge
Caused by the loss of normal lactobacilli in vagina. Increases risk of STI transmission
what percentage of women with BV have no symptoms?
50%
What symtoms are not related to BV?
Soreness or itching
What are 4 risk factors for BV?
multiple sexual partners
recent Abx
IUD - copper coil
excessive vaginal cleaning
what is the diagnostic criteria for BV?
Ansel criteria
thin, white, homogenous discharge
Clue cells
pH >4.5
Whiff test +ve on alkali added
what are 2 complications of BV?
small chance of premature birth/miscarriage
Inceased risk of STI
what is discharge like in BV?
Thin, grey/white, fishy smelling
pH >4.5
What is the first line antibiotic for BV?
1 - Metronidazole 400mg BD 5-7days
OR
2g STAT one off
OR
intravaginal gel 0.75% OD 5 days
SAFE IN PREGNANCY - 2g STAT not safe in pregnancy
2 - Clindamycin gel 2% OD 7 days
What is the healthy bacteria in the vagina?
lactobilli - produce lactic acid and reduce pH of vagina (<4.5)
What is the most common pathogenic cause of BV?
Gardnerella vaginalis
what are 3 common pathogenic causes of BV?
gardnerella vaginalis (most common)
Mycoplasma hominis
prevotella species
ALL ANAEROBIC
What is normal vaginal pH?
3.5-4.5
What is the is the gold standard investigation for BV?
high or low vaginal swab
should also swab for STIs
What cells are found under a microscope in BV?
clue cells
what are 6 complications of BV in pregnancy?
Miscarriage
Preterm delivery
PROM
Chorioamnionitis
Low birth weight
post partum endometritis
Which antibiotic should you avoid alcohol whilst on?
Metronidazole - causes nausea, vomiting, flushing and sometimes shock
what is the most common cause of vaginal thrush?
Candida albicans
What are 4 risk factors for thrush?
increased oestrogen (pregnancy)
poorly controlled diabetes
immunosuppresion
Broad spectrum ABx
what are the symptoms of vaginal thrush?
thick white discharge
vulva and vaginal itching and irritation
What are 6 complications of vaginal thrush?
erythema
fissures
oedema
pain during sex (dyspareunia)
dysuria
excoriation
what is one test that can be used to distiguish between trush and BV/trichomonas?
vaginal pH swab
>4.5 in BV and Trichomonas
<4.5 in candidiasis
what swab is used for vaginal MCS?
charcoal swab - for BV, candidiasis, gonorrhoea, trichomonas, other bacteria
What is the management for thrush?
antifungal cream - clotrimazole 5g 10% single dose
antifungal pessary - clotrimazole 500mg single dose
Oral antifungal - fluconazole 150mg single dose
what is a contraindication to oral antifungals in thrush treatment?
pregnancy
what should you tell patients using antifungal creams?
can degrade latex condoms and prevent spermacides from working => use other forms of birth control for at least 5 days
what is the management of oral thrush?
1 - Miconazole oral gel - 2.5ml QDS
2 - nystatin suspension - 1ml QDS for 7 days
3 - if severe/extensive - fluconazole 50mg OD for 14 days
how is trichomonas spread?
sexual activity
what pathogen causes trichomonas?
Trichomonas vaginalis
Protozoan
what does trichomonas infection increase risk of?
HIV contraction (due to vaginal mucosa damage)
BV
cevical cancer
PID
pregnancy complications
What does the discharge look like in trichomonasis?
frothy, yellow-green fishy smelling discharge
on pelvic examination what can be found in someone with trichomoniasis?
strawberry cervix (colpitis macularis) caused by inflammation causing tiny haemorrhages on cerviix surface
how is trichomoniasis diagnosed?
charcoal microscopy swab from posterior fornix of vagina
vaginal pH >4.5
Urethral or first catch urine in men
What is the treatment for trichomoniasis?
refer to GUM for contact tracing
metronidazole 2g single dose
OR
400-500mg TD 5-7days
2g single dose not safe in pregnancy
what are 5 complications of Trichomonas?
Prostatitis
Increased risk prostate/cervical cancer
Infertility
PID
Prinatal complications - IUGR, Prem
what are 4 causes of balantitis?
Eczema/dermatitis
Bacteria - s.aureus, gonorrhoea
Candida
Lichen Planus
Lichen sclerosis
Penile neoplasm
what are 4 risk factors for balantitis
poor hygiene
over washing
HPV
uncircumsised
what are 2 investigations for balantitis?
swab for microbiology and PCR
viral swab
What is the management of balanitis?
gentle saline washes including under foreskin and 1% hydrocortisone if severe
Treat cause
What bacteria causes chancroid?
Haemophilus Ducreyi - coccobacillus
What STI is an important cofactor in HIV transmision?
Chancroid
what are 2 symptoms of chancroid?
Painful erythematous genital papules that become pustular and erode
Inguinal lymphadenopathy
what are 4 risk factors for chancroid?
Geographical location - Africa and Asia more common
Lower socioeconomic stasis
Unprotected sex
Coinfection with other STIs
what STI causes genital ulcers?
chancroid
What is the treatment for chancroid?
IM azithromycin 1g one off dose
Ceftriaxone or erythromycin in allergy
What bacteria causes chlamydia?
Chlamydia trachomatis
gram negative
what is the most common STI in the UK?
Chlamydia
what percentage of men and women are asymptomatic with chlamydia?
men - 50%
women - 75%
what is nucleic acid amplification test swabbing used for?
chlamydia and gonorrhoea
what samples are used in nucleic acid amplification tests?
Vulvovaginal/cervical swab
First void urine sample
how long after possible exposure should chlamydia testing take place?
2 weeks
what are 5 chlamydia symptoms in women?
Abnormal vaginal discharge
pelvic pain
abnormal vaginal bleeding
painful sex
dysuria
what are 4 symptoms of chlamydia in men?
urethral discharge/discomfort
painful urination
epididymo-orchitis
reactive arthritis
what can be found o/e in chlamydia?
Pelvic/abdo tenderness
Cervical motion tenderness
Inflamed cervis - cervicitis
Purulent discharge
what is the 1st line treatment for chlamydia?
Doxycycline 100mg BD 7 days
OR
Azithromycin, 1g STAT then 500mg BD for 2 days
DOXYCYCLINE NOT SAFE IN PREGNANCY!!!
what are 8 complications of chlamydia?
PID
chronic pelvic pain
infertility
ectopic pregnancy
epididymo-orchitis
conjunctivitis
Lymphogranuloma venereum
reactive arthritis
Fitz-hugh-curtis syndrome
what are 5 complication of chlamydia in pregnancy?
preterm deliivery
premature rupture of membranes
low birthweight
post partum endometritis
neonatal infection - conjunctivitis and pneumonia
when is a test of cure recommended in chlamydia?
pregnancy
poor compliance suspected
symptoms persist
what is lymphogranuloma venereum?
a condition affecting the lymphoid tissue around chlamydia infected sites
most common in MSM and and HIV
what are the stages of lymphogranuloma venereum?
primary - painless ulcer on genitals
secondary - lymphadenitis
tertiary - inflamation of rectum leading to anal pain, change in bowel, tenesmus and discharge
what is the treatment of lymphogranuloma venereum?
Doxycycline 100mg BD 21 days
What bacteria causes syphilis?
Treponema pallidum
spirochete
what is the incubation period for syphilis?
9-90 days
average 21 days
what is the transmission for syphilis?
Sexual
Vertical transmission
IV drug use
Blood transfusions and organ transplants
what are the 5 stages of syphilis?
primary
secondary
latent
tertiary
neurosyphilis
what are 2 symptoms of primary syphilis?
painless genital ulcer (chancre)
local lymphadenopathy
tends to resolve in 3-8 weeks
what are 6 symptoms of secondary syphilis?
maculopapular rash - trunks, palms, soles
condylomata lata - grey warts around genitals and anus
low grade fever and lymphadenopathy
oral lesions - snail trail ulcers
alopecia
3-12 weeks long
what are 3 symptoms of tertiary syphilis?
gummatous lesions - granulomatous lesions on skin, organs and bone
aortic aneurysms
Neurosyphilis
Cardiovascular syphilis
what are 8 symptoms of neurosyphilis?
headache
altered behaviour
tabes dorsalis - demyelination of posterior columns of spinal cord
ocular syphilis
paralysis
sensory impairment
Argyll-robertson pupil
what are 4 featues of cardiovascular syphilis?
Aortic aneurysm
Aortic regurgitation
coronary ostia stenosis - angina and heart failure
Conduction defects
What is Argyll-Robertson pupil?
prostitutes pupil in neurosyphilis
accommodates but does not react to light
How do you diagnoses syphilis?
Asymptomatic screening - treponemal specific antibody test
Symptomatic - Syphilis serology and dark field microscopy
What is the 1st line treatment for syphilis?
Deep IM benzathine benzylpenicillin 1.8g single dose in early, 3 doses in late/latent
SAFE IN PREGGOS
ALLERGY - Doxycycline - 100mg BD 14 days early, 28 days late
PLUS PREGNANCY
Erythromycin - 500mg QDS
What can trichomoniasis in pregnancy cause?
premature birth
low birthweight
what can syphilis in pregnancy cause?
congenital syphilis
miscarriage
still birth
early death
What is the treatment for chlamydia in preggos?
Azithromycin 1g once then 500mg OD for 2 days
Erythromycin 500mg QD for 7 days
Amoxicillin 500mg TD 7 days
what are the complications of chlamydia during pregnancy?
pre-term labour
bleeding in pregnancy
PID + fertility problems
ectopic pregnancy
congenital chlamydia - eye or chest infection
what is a complication of spriocete (syphilis) infection after antibiotic treatment?
Jarisch-herxheimer reaction - fever, headache, myalgia, tahycardia after 1st dose
No wheeze or hypotension in comparison to anaphylaxis
Can also cause fetal distress and premature labour
also lymes + other spirocetes
Which ganglia is genital herpes usually latent in?
sacral nerve ganglia
what are 5 manifestations of HSV?
Cold sores
Genital herpes
aphthous ulcers (in mouth)
herpetic whitlow (painful skin lesions on fingers)
herpes keratitis - inflammation of cornea
what are 5 presentations of genital herpes?
ulcers
neuropathy
flu like symptoms
dysuria
inguinal lymphadenopathy
what is the management of genital herpes?
Aciclovir - 200mg 5x daily for 5 days for 1st infection or 800mg TDS for 2 days for recurrence
paracetamol, topical lidocaine and cleaning with warm salt water can also help
How is genital herpes managed in pregnancy?
if contracted<28 weeks - aciclovir course then prophylactic aciclovir from 36 weeks
> 28 weeks - aciclovir continually till delivery
Recurrence of pre-existing genital herpes - prophylactic aciclovir from 36 weeks
what pathogen causes genital warts ?
Human papillomavirus
HPV6 and 11 most commonly
what is the treatment for genital warts?
1 - Topical podophyllum or cryotherapy
2 - imiquimod
What bacteria causes gonorrhoea?
Neisseria gonorrhoeae
Gram -ve diplococci
what are 4 symptoms of gonorrhoea?
odourless purulent discharge (can be green/yellow)
Dysuria
pelvic pain
testicular pain
How do you diagnose gonorrhoea?
Nucleic Acid Amplification Test
endocervical swab or first catch urine sample
What is the treatment for gonorrhoea?
IM ceftriaxone 1g - safe in pregnancy
Oral Ciprofloxacin 500mg
Single dose if sensitivities are known
What are 5 complications of gonorrhoea?
PID
Infertility
Prostatitis + epididymo-orchitis
Septic arthritis
Conjunctivitis
Disseminated gonococcal infection
Fitz-hugh-curtis syndrome
when should a test of cure be done for gonorrhoea?
for everyone due to high abx resistance
72h after treatment for culture in symptomatic patients
7 days after tx RNA NAAT
14 days after Tx DNA NAAT
what are 6 presentations of disseminated gonococcal infection?
Triad - tenosynovitis, dermatitis, polyarthralgia/arthralgia
Non-specific skin lesions
Migratory
polyarthritis
Systemic symptoms - fever, fatigue
which cells does HIV affect?
CD4 T-Helper cells
what kind of virus is HIV?
RNA retrovirus
what is the most common type of HIV virus?
HIV-1
HIV-2 is found mostly in west Africa
what is the transmission of HIV like? 3
Unprotected sexual activity - vagina, anal, oral
Vertical transmission
Mucous membrane, blood or open wound exposure to infected blood or bodily fluids
What are 4 Aids defining infections occurring with a CD4 count 200-500?
HSV
Pulmonary TB
Kaposi sarcoma
Invasive cervical cancer
What are 5 Aids defining infections occurring with a CD4 count 100-200?
Pneumocystitis pneumonia
Cryptosporidiosis - most common cause of diarrhoea in aids
Histoplasmosis pneumonia
Progressive multifocal leukoencephalopathy
HIV encephalopathy
What are 2 Aids defining infections occurring with a CD4 count 50-100?
Toxoplasmosis
Oesophagitis - candida, HSV, CMV
What are 4 Aids defining infections occurring with a CD4 count <50?
CMV retinitis and colitis
Cryptococcal meningitis - fungal cysts visible on indian ink stain of CSF
Mycobacterium avium complex
CNS lymphoma
How long after exposure to HIV virus can it take for testing to become positive?
45 days
what is the normal CD4 count?
500-1200 cells
what CD4 count puts you at risk of opportunistic infections?
<200 cells/mm3
What is the treatment of HIV?
Antiretroviral therapy (ART)
what are 5 classes of antiretroviral therapy?
Protease inhibitors
Integrase inhibitors
Nucleoside reverse transcriptase inhibitors (NRTIs)
Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
Entry inhibitors
what is the usual antiretroviral starting regime?
2 nucleoside reverse transcriptase inhibitors - Tenofovir + emtricitabine
PLUS
3rd agent - Bictegravir
what medication can be given people with a very low CD4 count in HIV to prevent pneumocystis jirovecii infection?
Prophylactic co-trimoxazole
if CD4 count <200
How often do people with HIV get cervical smears?
Yearly
what are 2 vaccinations that are avoided in HIV?
BCG
Typhoid
life attenuated vaccinations
how should HIV +ve mothers with a viral load <50 give birth?
Normal vaginal delivery
how should HIV +ve mothers with a viral load 50-400 give birth?
consider pre-labour caesarean section
how should a HIV +ve mother with a viral load >400 give birth?
pre labour caesarean
what is given during labour and delivery in an HIV +ve mother with an unknown/viral load >1000?
IV zidovudine
what can be given as prophylaxis to the baby of an HIV +ve mother?
low risk - zidovudine for 2-4 weeks
High risk - zidovudine, lamivudine, nevirapine for 4 weeks
Should HIV +ve mothers breasfeed?
It is NOT recommended
what can be given as post exposure prophylaxis for HIV?
emtricitabine/tenofovir
PLUS Raltegravir
for 28 days
what is given as pre-exposure prophylaxis for HIV?
Emtrictabine/Tenofovir (Truvada)
what are 7 features of HIV seroconversion?
typically 3-12 weeks after infection
sore throat
lymphadenopathy
malaise, myalgia, arthralgia
diarrhoea
maculopapular rash
mouth ulcers
meningioencephalitis - rarely
what is the presentation of Kaposi’s sarcoma?
purple papules or plaques on skin or mucosa
caused by HHV-8
what is the investigation pathway for HIV?
ELISA - detection of HIV antibodies and p24 antigen
Sensitive 4 weeks post transmission
Repeat at 12 weeks if negative
Confirmatory testing if positive
Western blot or repeat ELISA is used for confirmatory testing
what are 4 opportunistic infections that occur in HIV but are not AIDS defining?
Oral candida
Hairly leukoplasia - white hairy patch on side of tongue
Shingles
Aspergillosis
what are 4 general side effects of nucleoside reverse transcriptase inhibitors?
Bone marrow suppression
Lipodystrophy
hepatotoxicity
myalgia
what is one general side effect of non-nucleoside reverse transcriptase inhibitors?
rashes
what are 5 general side effects of protease inhibitors?
hypercholesterolaemia
central obesity
diabetes
alopecia
P450 inhibitors
what are 3 differences on MRI head of toxoplasmosis and CNS lymphoma?
Toxoplasmosis
- multiple lesions
- ring/nodular enhancing
- thallium SPECT negative
Lymphoma
- single lesions
- solid enhancement
- thallium SPECT positive
what are 6 signs of congenital syphilis?
Blunted upper incisor teeth
Rhagades - linear scars at angle of mouth
Keratitis
Saber shins - deformation of tibia, anterior bowing
saddle nose
deafness
what virus causes anal warts (condylomata)?
HPV
what is the recommended contraceptives for trans people who are able to get pregnant?
Progesterone only contraception do not interfere with testosterone therapy
what organism causes public lice?
phthirus pubis
what is the management of pubic lice?
5% permethrin cream
OR
0.5% malthion aqueous solution
what is the management of pubic lice in the eyelashes?
inert occlusive ophthalmic ointment OR paraffin eye ointment BD for 8-10 days
what virus most often causes oral herpes?
HSV-1
what virus causes genital herpes?
HSV-1 or HSV-2
how is HSV-1 spread?
saliva and bodily secretion
where does HSV-1 lay dormant?
dorsal root ganglion
how is HSV-2 spread?
primarily sexual contact
where does HSV-2 lay dormant?
sheath of sensory nerves
what are the 3Ms of microscopic HSV infection?
Multinucleation
Margination of chromatin
Moulding of nuclei
what HPV strains cause most cervical cancers?
HPV 16 and 18
what HPV strains cause genital warts?
6 and 11
what age is the HPV vaccine given?
12-13 years - year 8
one dose
