Sexual health Flashcards
Infection of the urogenital tract with chlamydia typically causes what?
inflam of urethra in men
inflam of cervix and/or urethra in women
Chlamydia can aslo afffect where? (outside of the urogenital tract)
conjunctiva, rectum, nasopharynx
What % of pts with chlamydia are asymptomatic?
70% women
50% men
When is chlamydial infection considered to be uncomplicated?
when infection has not ascended to the upper genital tract
Ascending chlamydia infection in women can cause what?
PID
National Chlamydia Screening Programme recommends annual screening for who?
all sexually active women <25yrs of age or more frequently if they change their partner
Test for chlamydia are recommended in sexually active women with what symptoms?
post-coital or intermenstrual bleeding, increased or purulent vaginal discharge, mucopurulent cervical discharge, deep dyspareunia, dysuria, pelvic pain and tenderness, inflamed or friable cervix
Test for chlamydia are recommended in sexually active men with what symptoms?
dysuria, urethral discharge, urethral discomfort, epididymo-orchitis or reactive arthritis
How can samples for chlamydia be taken in women?
vulvo-vaginal swab (insert 5cm into vagina and retate 10-30secs)
alternative= endocervical swab (with speculum inside cervical os swab rotated 360°) or 1st void urine
How can samples for chlamydia be taken in men?
first void urine
alternative= urethral swab
Where is pt managed if they test positive for chlamydia?
refer to GUM clinic for Tx, screening for other STIs, info on STIs and partner notification
if pt declines then Mx in primary care
Tx for chlamydia?
doxycycline 100mg twice a day for 7d
contraindicated= azithromycin 1 g orally as a single dose for 1 day, followed by 500 mg orally once daily for 2 days.
(contraindicated in pregnancy or breastfeeding)
Tx for chlamydia if pregnant or breastfeeding?
azithromycin, amoxicillin or erythromycin
Advice on sexual intercourse after pt has tested positive for chlamydia?
avoidance (incl genital, oral and anal, even with condom) until pt and partner(s) have completed course of Tx (or waited 7d after Tx with azithromycin)
Test of cure in chlamydia?
not necessary unless: pregnant, poor compliance suspected or symptoms persist
Repeat testing after pt has been diagnosed with chalmydia?
Offered to all people under the age of 25 years diagnosed with chlamydia 3–6 months after completion of treatment to check for re-infection.
Considered for people over the age of 25 years who are at high risk of re-infection.
How long after intercourse can chlamydia be positive?
test within 2w of exposure and then if negative repeat 2w after exposure
Symptoms of lymphogranuloma venereum (LGV) in chlamydia?
tenesmus
anorectal discharge (often bloody) and discomfort
diarrhoea or altered bowel habit
Symptoms of rectal chlamydia?
usually asymptomatic
anal discharge and anorectal discomfort
Symptoms of adult chlamydial conjunctivitis?
unilateral chronic low grade conjunctival irritation (may be bilateral)
symptoms of oropharyngeal infection with chlamydia?
usually asymptomatic
pharyngitis and sore throat
How to collect first-catch urine (FCU) sample for chlamydia testing?
urine should have been helf in bladder for at least 1hr before testing
first 20ml of urinary stream should be captured
kits for self-taken are available
Extra-genital samples in chlamydia testing?
All people with proctitis should have rectal swabs taken to test for lymphogranuloma venereum (LGV).
All HIV-positive men who have sex with men (with or without symptoms) with Chlamydia trachomatis at any site should have rectal swabs taken to test for LGV.
Samples for LGV testing should be sent to the Public Health England
Differential diagnosis for chlamydia?
- STIs:
gonorrhoea
bacterial vaginosis
vaginal candidiasis
trichomonas vaginitis - PID
- UTI
When to refer to GUM if test positive for chlamydia?
urgent if no response to Tx
if PID suspected
What causes chlamydia?
Chlamydia trachomatis (an obligate intracellular pathogen)
most prevalent STI in UK?
chlamydia
incubation period for chlamydia?
7-21d
most are asymptomatic
Main features of chlamydia?
asymptomatic (70% w & 50% m)
women: cervicitis (discharge, bleeding), dysuria
men: urethral discharge, dysuria
Potential Cx of chlamydia?
epididymitis
PID
endometritis
increased incidence of ectopic pregnancies
infertility
reactive arthritis
perihepatitis (Fitz-Hugh-Curtis syndrome)
Ix for chlamydia?
nuclear acid amplification tests (NAATs)
vulvovaginal swab in women and first void urine in men
National Chlamydia Screening Programme open to who?
all men & women aged 15-24yrs
relies heavily on opportunistic testing
What contacts should be notified for pts tested positive for chlamydia?
men with urethral symptoms= all contacts since and in 4w prior to the onset of symptoms
women and asymptomatic men= all partners from last 6m or most recent sexual partner
Contacts with confirmed chlamydia should be offered what?
Tx before the results of their Ix (treat then test)
What causes gonorrhoea?
Neisseria gonorrhoeae bacterium
Uncomplicated gonorrhoea primarily affects where?
mucous membranes of urethra, endocervix, rectum, pharynx and conjunctiva
Cx of untreated gonorrhoea?
men= ipididymitis, infertility, prostatitis
women= PID and Cx of pregnancy
Gonnorrhoea is primarily associated with uncomplicated infection of genital tract, which is symptomatic in what % of pts?
over 90% of men and 50% of womend
Symptoms of gonorrhoea in men?
urethral infection= mucopurulent or purulent urethral discharge; dysuria; 2-8 days after exposure.
frequency and urgency usually absent
rare= testicular and epididymal pain
Symptoms of gonorrhoea in women?
urethral infection= dysuria without frequency
endocervical infection= increased or altered vaginal discharge, lower abdo pain and/or intermenstrual bleeding
Symptoms of rectal and pharyngeal infections with gonorrhoea in men and women?
usually asymptomatic
Diagnosis of gonorrhoea?
NAAT or by culture
Where is pt with suspected gonorrhoea Ix & Mx?
same as chlamydia
In gonorrhoea, when is hospital admission required?
pt with suspected disseminated gonorrhoea
women with severe or complicated PID
Symptoms of disseminated gonorrhoea?
fever
malaise
joint pain and swelling
rash
When is referral required for pts with gonorrhoea?
conjunctival gonorrhoea
other gonorrhoea Cx
don’t respond/allergic to Abx
women suspected of having ascending infection
Mx for gonorrhoea?
- Abx (ideally culture before prescribing to test for susceptibility and identify resistant strains)
- screening for other STIs and HIV
- encourage pt led partner notification
- info and advice
Follow up for pt with gonorrhoea?
follow up 1w after Tx to confirm adherence to Tx and resolution of symptoms, ?adverse effects, confirm partner notification, ask recent sexual history, advise safe sex
Test of cure for gonorrhoea?
recommended in all who have been treated, but priority given to:
- persistent signs or symptoms
- pharyngeal infection
- been treated with anything other than 1st line Tx
- acquired infection in Asia-Pacific region when antimicrobial susceptibility was unknown
Exam in women with gonorrhoea to assess possible ascending infection which may result in PID?
bimanual pelvic exam for cervical motion tenderness, uterine tenderness and adnexal tenderness
Extra-genital infection with gonorrhoea symptoms?
- rectal= mucopurulent discharge from anus
- pharyngeal= erythema and exudate, anterior cervical lymphadenopathy, sore throat, asymptomatic
- conjunctivitis= thick white/yellow discharge (examine eyes with slit lamp to exclude corneal infection)
Children and young people who present with gonorrhoea?
consider possibility of sexual abuse unless clear evidence of mother-to-child transmission during birth, or of blood contamination
Testing for gonorrhoea?
women= vulvovaginal swab (can be self-taken); if had hysterectomy then urine and vulvovaginal swab
men= first pass urine
specimens for culture (urethral, endocervical, neovaginal, anorectal, and pharyngeal swabs) should be taken alongside NAATs from people suspected clinically of having gonorrhoea (and from their sexual contacts).
When testing for gonorrhoea, who should have rectal and pharyngeal sampling?
Routine in all men who have sex with men (MSM).
Considered in women who are sexual contacts of gonorrhoea.
Guided by an assessment of risk and symptoms in everyone else.
Differential diagnosis for gonorrhoea in men?
Non-gonococcal urethritis caused by Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma genitalium, or Trichomonas vaginalis.
Acute prostatitis.
Genital herpes simplex infection
Candida infection.
Differential diagnosis for gonorrhoea in women?
chlamydia (can’t distinguish between C and G by clinical features alone)
candida
bacterial vaginosis
trichomoniasis
PID
genital herpes simplex infection
Pt with gonorrhoea, when to refer to appropriate speciality?
- women with suspected ascending infection
- pt with Cx
- conjunctival gonorrhoea
- don’t respond to Tx
Tx for gonorrhoea?
Antimicrobial susceptibility unknown= ceftriaxone 1g IM injection single dose
Antimicrobial susceptibility known= ciprofloxacin 500mg single dose
contraindicated/needle phobia= gentamicin 240 mg IM as a single dose plus azithromycin 2 g orally OR cefixime 400 mg orally as a single dose plus azithromycin 2 g orally (if IM refused)
Penicillin allergy= ceftriaxone and cefixime
Pregnant or breastfeeding= ceftriaxone 1 g IM injection as a single dose. Alternative=
Azithromycin 2 g as a single oral dose
Tx for gonorrhoea if antimicrobial susceptibility unknown?
ceftriaxone 1g IM injection single dose
Tx for gonorrhoea if 1st line contraindicated or pt has needle phobia?
gentamicin 240 mg IM as a single dose plus azithromycin 2 g orally
OR cefixime 400 mg orally as a single dose plus azithromycin 2 g orally (if IM refused)
Tx for gonorrhoea if pregnant or breastfeeding?
ceftriaxone 1 g IM injection as a single dose.
Alternative=
Azithromycin 2 g as a single oral dose
What partners should be notified if pt tests positive for gonorrhoea?
men with symptomatic urethral infection= all sexual partners within the preceding 2 weeks, or their most recent partner if this was longer than 2 weeks ago.
For all other people (that is, women and men with asymptomatic gonorrhoea or gonorrhoea at other sites), all partners within the preceding 3 months.
Tx for partners/contacts of pt with gonorrhoea?
empirical Tx not needed for all
those presenting >14d of exposure, empirical treatment is recommended only following a positive test for gonorrhoea.
Within 14 days of exposure, empirical treatment should be considered based on a clinical risk assessment and following a discussion with the person. In asymptomatic individuals, it may be appropriate to not give epidemiological treatment, and to repeat testing 2 weeks after exposure.
What type of bacteria is Neisseria gonorrhoeae?
gram negative diplococcus
Transmission of gonorrhoea?
acute infection can occur on any mucous membrane surface, typically gentiourinary but also rectum and pharynx
Incubation period for gonorrhoea?
2-5d
Main features of gonorrhoea?
males: urethral discharge, dysuria
females: cervicitis e.g. leading to vaginal discharge
rectal and pharyngeal infection is usually asymptomatic
Why is immunisation not possible and reinfection common for gonorrhoea?
due to antigen variation of type IV pili (proteins which adhere to surfaces) and Opa proteins (surface proteins which bind to receptors on immune cells)
Local Cx what may develop with gonorrhoea?
urethral strictures, epididymitis and salpingitis (hence may lead to infertility).
Disseminated gonococcal infection (DGI) and gonococcal arthritis may occur
Most common cause of septic arthritis in young adults?
gonococcal infection
Pathophysiology of DGI?
thought to be due to haematogenous spread from mucosal infection (eg. asymptomatic gential infection)
Presentation of disseminated gonococcal infection (DGI)?
initial triad= tenosynovitis, migratory polyarthritis and dermatitis
Later Cx= septic arthritis, endocarditis and perihepatitis (Fitz-High-Curtis syndrome)
Triad= tenosynovitis, migratory polyarthritis and dermatitis (lesions can be maculopapular or vesicular)?
Disseminated gonococcal infection
What causes syphilis?
Treponema pallidum (a spirochete bacterium)
How is syphilis mostly sexually transmitted?
during direct contact with an infectious lesion
Untreated syphilis?
can persist for yrs and progress through several stages
Stages of syphilis?
- early syphilis (within 2yrs of infection) includes 3 stages= primary, secondary and early latent
- late syphilis (>2yrs after infection) includes 2 stages= late latent and tertiary
Can syphilis be cured?
yes if Tx early with appropriate Abx
untreated= around 1/3 progress to later stages of disease which can lead to severe, sometimes irreversible Cx
Cx of syphilis?
- neurosyphilis
- cardiovascular syphilis
- gummatous syphilis
- adverse outcomes in pregnancy
- facilitation of HIV transmission
Cx of syphilis: neurosyphilis?
neuro invl. can occur at any stage
affects meninges, arteries, cranial nerves, eyes, brain and spinal cord
Meningitis.
Cranial nerve palsies (in particular II and VIII).
Hearing loss.
Ocular disease including optic neuropathy, uveitis and retinitis.
Infectious arteritis (ischaemia, thrombosis, infarction).
Tabes dorsalis (inflam spinal dorsal column/nerve roots)= paraesthesia, absent reflexes, lightening pains
General paresis (cortical neuronal loss)- dementia, personality change, seizures, hemiparesis.
Cx of syphilis: cardiovascular syphilis?
aortic aneurysm, aortic regurg, HF
Cx of syphilis: gummatous syphilis?
granulomatous lesions with a necrotic centre most often affecting the skin and bones
When to suspect syphilis?
- genital lesion(s)= solitary, painless, indurated, genital ulcer (chancre) (may be atypical- painful, multiple, extra-genital)
- associated regional lymphadenopathy common
- non-pruritic maculopapular rash= typically palms and soles
- moist wart-like lesions (condylomata lata)= sites of skin friction eg. perianal, vuval, under breasts and axillae
- patchy lesions on oral mucosa (‘snail tract’ lesions)
- generalised lymphadenopathy
- unexplained neuro or opthalmological symptoms
- RFs
RFs for syphilis?
unprotected sex, multiple or anonymous sexual partners or transactional sex
Painless, solidatary, indurated, genital ulcer (chancre), with non-pruritic maculopapular rash on palms and soles and generalised lymphadenopathy?
syphilis
What to do if you suspect a pt has syphilis?
- refer to GUM clinic/local specialist sexual health service
- if have HIV and refuses GUM clinic refer to infectious diseases or HIV centre
- if refuse referral discuss with GUM specialist= may suggest testing in primary care
Advise to pt with suspected syphilis before diagnosis?
avoid any kind of sexual contact or exposure to other people to active lesions until either diagnosis excluded or successful Tx been confirmed
Ix for syphilis in primary care?
swabs from active lesions (incl. virology swab) and serology
interpretation of results difficult and repeat testing normally needed- specialist input required
If +ve refer to GUM clinic for Mx and partner notification, if refuse then advice from GUM specialist
- screen for other STIs too
People with suspected syphilis who decline testing, and people diagnosed with syphilis who decline treatment, should be advised what?
if they are found to have infected other people with syphilis via unprotected sexual contact or non-sexual contact with active lesions, despite knowing that this could occur, they may be subject to prosecution.
Why can diagnosis of syphilis be delayed or missed?
can present with wide range of nonspecific symptoms and sometimes may be asymptomatic
Primary syphilis timing?
Onset: 9–90 days after exposure (mean 21 days)
Resolution: usually resolves spontaneously over 3–10 weeks
Primary syphilis features?
CHANCRE, usually genital (can be extra-genital: anal, rectal, oral, hands)
May be associated with local lymphadenopathy
What features may be present in syphilis if there is HIV co-infection?
atypical features eg. multiple, painful and/or purulent chancre or multiple lesions
Secondary syphilis timing?
Onset: 4–12 weeks after appearance of initial chancre
Resolution: untreated symptoms slowly resolve over 3–12 weeks but may recur (approximately 25% of cases)
Secondary syphilis clinical features?
systemic= fever, headache, generalised lymphadenopathy, hepatitis, splenomegaly, glomerulonephritis
skin= non-pruritic maculopapular rash (generalised or only palms & soles), condylomata lata (grey/white moist warty lesions on oral/genital mucosa or perianal)
alopecia= patchy hair loss of scalp, beard and eyebrows
mucous patches= oval, shallow, ulcerative patches with raised silver boreders on oral or genital mucosa
Early neurosyphilis= (1-2%) meningitis, CN II and VIII palsies, hearing loss, infectious arteritis (ischaemia, infarction, thrombosis), ocular disease (optic neuropathy, uveitis, retinitis)
maculopapular rash, condylomata lata, oral lesions, generalized lymphadenopathy, unexplained neurological or ophthalmological symptoms
Latent syphilis timing?
Early latent syphilis – less than 2 years duration from initial infection.
Late latent syphilis – more than 2 years duration from initial infection.
Latent syphilis clinical features?
Asymptomatic: Serological evidence of infection in the absence of clinical features.
Around 25% of people have a recurrence of secondary disease during the early latent stage.
Tertiary syphilis timing?
15 to 40 years after initial infection
Tertiary syphilis clinical features?
Gummatous syphilis= Gumma — granulomatous lesions with a necrotic centre. Can develop anywhere but most often affect skin and bone.
Cardiovascular syphilis= CVD — often due to vasculitis and chronic inflammation of the aortic vasa vasorum. Aortic regurgitation. Aortic aneurysm. HF. Angina.
Neurosyphilis= Tabes dorsalis (inflammation of spinal dorsal column/nerve roots) — may present with ‘lightening pains’, paraesthesia, Charcot’s joints, pupillary change, absent reflexes, joint position and vibration sense.
General paresis (cortical neuronal loss) — may present with forgetfulness and personality change which develop into severe dementia. Seizures and hemiparesis may occur.
Differential diagnosis for primary syphilis?
Chancre:
- genital= genital herpes, balanitis, chancroid, ca, Behcets syndrome, LGV
- peri-anal= herpes simplex, anal fissure, Crohns, anal ca
- cervix= cervical herpes, erosions, ca
- oral mucosa= herpes simplex, apthous stomatitis, Behcets syndrome, trauma, drug reactions, ca
Regional lymphadenopathy:
- malignany
- infection
- systemic disease
Differential diagnosis for secondary syphilis?
Maculopapular rash:
- HIV, rubella, scabies, measles
- guttate psoriasis, pityriasis rosea, eczema
- drug reactions
Condylomata lata:
- HPV, molluscum contagiosum, haemorrhoids
Patchy lesions on oral mucosa:
- oral ca
- apthous lesions
Regional or generalised lymphadenopathy:
- infectious
- malignancy
- systemic disease
Differential diagnosis for tertiary syphilis?
- dementia
- psychiatric conditions
- chronic granulomatous lesions of TB
- sarcoidosis
- leprosy
Can pt get syphilis Tx in primary care?
not readily available for use
Preventative measures for syphilis?
- condoms
- avoidance of drugs and alcohol when having sex
- regular screening
- early recognition, Tx and prophylactic Tx of exposed contacts
What else could you screen for if you suspect syphilis in a pt?
other STIs: chlamydia, gonorrhoea, Hep B, Hep C and HIV
Why take a virology swab from any active lesions (genital, extragenital, oral) in suspected syphilis?
exclude herpes simplex
First line Tx for syphilis?
IM benxathine penicillin
alternative= doxycycline
Specific tests for syphilis?
1) Direct tests= demonstrate T.pallidum from swabs taken from primary lesions. Include Dark-field microscopy (not oral lesions) and PCR (oral)
2) Serological tests
False negative serology in syphilis testing?
Treponemal screening tests are negative before a chancre develops and remain negative for up to two weeks afterwards.
A false-negative RPR/VDRL test may occur in secondary or early latent syphilis — this may be more likely to occur in people co-infected with HIV.
The RPR/VDRL and IgM may be negative in late syphilis.
False positive serology in syphilis testing?
False-positive results occur occasionally with any of the serological tests for syphilis.
Some conditions and other factors such as viral infections, malignancy, autoimmune disorders, older age, injecting drug use and pregnancy are associated with increased likelihood of a false positive non-treponemal test.
Repeat testing in syphilis?
All positive screening tests must be confirmed with a different serological test.
Negative serology tests should be repeated at 6 and 12 weeks after an isolated high risk exposure or 2 weeks after possible chancres that are dark-field microscopy and/or PCR negative.
How is ocular or neurosyphilis diagnosed?
CSF examination in addition to serology
How is syphilis diagnosed?
clinical features, serology and microscopic exam of infected tissue.
Treponema pallidum is very sensitive organism and can’t be grown on artifical media.
Serological tests for syphilis?
- Non-treponemal tests= not specific so can get false +ve. Based on reactivity of serum from infected pts to cardiolipin-cholesterol-lecithin antigen. Assess quantity of antibodies being produced. -ve after Tx.
- Treponemal-specific tests= more complex and expensive but specific. Qualitative only: reactive or non-reactive.
Examples of non-treponemal tests for syphilis?
rapid plasma reagin (RPR) and Venereal Disease Research Laboratory (VDRL)
Examples of treponemal-specific tests for syphilis?
TP-EIA (T. pallidum enzyme immunoassay), TPHA (T. pallidum HaemAgglutination test)
the TP-EIA test has become increasingly popular in recent years
Testing algorithms for syphilis are complicated but typically involve what?
combination of non-treponemal test with a treponemal-specific test
Serological tests and direct test.
Causes of false positive non-treponemal (cardiolipin) tests in syphilis?
pregnancy
SLE, anti-phospholipid syndrome
tuberculosis
leprosy
malaria
HIV
Syphilis testing: positive non-treponemal test + positive treponemal test?
consistent with active syphilis infection
Syphilis testing: Positive non-treponemal test + negative treponemal test?
consistent with a false-positive syphilis result e.g. due to pregnancy or SLE
Syphilis testing: Negative non-treponemal test + positive treponemal test?
consistent with successfully treated syphilis
Incubation period of syphilis?
9-90days
Primary syphilis main features?
chancre - painless ulcer at the site of sexual contact
local non-tender lymphadenopathy
often not seen in women (the lesion may be on the cervix)
Chancre?
painless ulcer at the site of sexual contact in syphilis
Secondary syphilis main features?
occurs 6-10 weeks after primary infection
systemic symptoms: fevers, lymphadenopathy
rash on trunk, palms and soles
buccal ‘snail track’ ulcers (30%)
condylomata lata (painless, warty lesions on the genitalia )
Tertiary syphilis main features?
gummas (granulomatous lesions of the skin and bones)
ascending aortic aneurysms
general paralysis of the insane
tabes dorsalis
Argyll-Robertson pupil
Features of congenital syphilis?
blunted upper incisor teeth (Hutchinson’s teeth), ‘mulberry’ molars
rhagades (linear scars at the angle of the mouth)
keratitis
saber shins
saddle nose
deafness
What should be monitored after syphilis Tx to assess the response?
nontreponemal (rapid plasma reagin [RPR] or Venereal Disease Research Laboratory [VDRL]) titres
a fourfold decline in titres (e.g. 1:16 → 1:4 or 1:32 → 1:8)is often considered an adequate response to treatment
What is sometimes seen after syphilis Tx?
Jarisch-Herxheimer reaction
Jarisch-Herxheimer reaction features?
sometimes seen after syphilis Tx
fever, rash, tachycardia after first dose of Abx
NO wheeze or hypotension in contrast to anaphylaxis
Jarisch-Herxheimer reaction Tx?
no Tx needed other than antipyretics if required
What is Jarisch-Herxheimer reaction though to be due to?
release of endotoxins following bacterial death and typically occurs within a few hrs of Tx
Atrophic vaginitis?
occurs in post-menopausal women
vaginal dryness, dyspareunia and occassional spotting
pale and dry vagina
Tx for atrophic vaginitis?
vaginal lubricants and moisturisers
2nd line= topical oestrogen cream
Pelvic inflammatory disease (PID)?
infection of upper genital tract affecting typically sexually active young women
PID: infection spreads where?
up from vagina and endocervix, causing possible endometritis, salpingitis, parametritis, oophoritis, tubo-ovarian abscess and/or pelvic peritonitis (severe cases)
What groups is PID incidence decreasing?
age groups eligible for chlamydia screening
Causes of PID?
STIs: Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium
Mixed infections common= normal vaginal microbiome, resp and/or enteric pathogens may be involved
RFs for developing PID?
- <25yrs
- not using barrier methods
- previous PID or STI
- multiple or recent new sexual partners
- recent intrumentation of uterus or interruption of cervical barrier
Risk of Cx with PID is increased with what?
severe or repeated infection
Non-infective Cx of PID?
ectopic pregnancy
tubal factor infertility
chronic pelvic pain
Symptoms of PID?
recent onset pelvic or lower abdo pain; deep dyspareunia; secondary dysmenorrhoea; abnormal vaginal bleeding or mucopurulent discharge; systemic symptoms
What should you ask in the history if you suspect PID?
symptoms
recent and current contraception; risk of pregnancy; sexual history; risk factors for PID; smear history
Examination for PID?
general, abdo and pelvic exam to assess for:
lower abdo, adnexal, cervical motion and/or uterine tenderness
Ix for PID?
- pregnancy test
- vaginal swabs for STI testing= PUS CELLS
- bloods= inflam markers (CRP, ESR, leucocytes); HIV and syphilis serology
Urgent admission for PID if?
- pregnancy
- suspected ectopic pregnancy
- severe Cx
- systemically unwell
- primary care Mx not possible
PID- signpost to local sexual health service for what?
STI screening, Tx, contact tracing of current and recent sexual partners
Advise for pt with PID?
abstain from all sexual activity until both women and any sexual partner(s) have completed Abx, symptom free and have had a test of cure if needed
info and support
Review for pt with PID?
within 72hrs in primary care depending on judgement to assess:
- response to Tx
- vaginal swab results
- amend Tx if needed
- advise barrier methods
consider further review 2-4w after completion of Abx Tx
Mx for PID?
- ensure sexual partners screened and Tx
- paracetamol/ibuprofen for symptom relief
- start empirical Abx soon as diagnosis made, don’t wait on results of Ix
- if results -ve still complete Abx course to reduce risk Cx
Differential diagnosis for PID?
- ectopic preg
- threatened miscarriage
- acute appendicitis
- endometriosis
- GI disorders
- ovarian cyst Cx (torsion, rupture, haemorrhage)
- UTI, pyelonephritis
- Mittelschmerz pain
- ruptured corpus luteal cyst
- functional pelvic pain
What is suspect PID and pt has copper or IUD in situ?
- mild-moderate symptoms= can remain in situ as long as improving within 48-72hrs after Abx started
- severe or not improving= remove
- if remove consider hormonal contraception
Contact tracing of partners within how long for PID?
6m
Abx choice for suspected PID?
risk of gonococcal infection high= ceftriaxone 1 g single IM dose, followed by oral doxycycline 100 mg twice daily plus oral metronidazole 400 mg twice daily for 14d
second line= oral ofloxacin 400 mg twice daily plus oral metronidazole 400 mg twice daily for 14d
if +ve for Mycoplasma= oral moxifloxacin 400mg once daily for 14d
PID test of cure?
done if:
-+ve initial test result for gonorrhoea=
Repeat testing should be routinely arranged 2–4w after completion of Tx.
+ve initial test result for chlamydia= 3–5 weeks after completion of treatment if there are persisting symptoms or if compliance with oral antibiotics and/or tracing of sexual contacts indicates the possibility of persisting or recurrent infection.
+ve initial test result for Mycoplasma genitalium=
4 weeks after
Persistent symptoms after completing antibiotic treatment.
An initial test result showing unknown antibiotic sensitivity or antibiotic resistance (in cases of gonorrhoea or Mycoplasma genitalium).
Suspected poor compliance with antibiotic treatment or treatment has not been tolerated.
Possible persisting or recurrent infection, for example, due to repeated sexual contact with untreated partners.
Mx for sexual partners of PID?
any current and recent within last 6m
- chlamydia and gonorrhoea screening= if male start Abx imediately, if women wait for results: doxycycline 100 mg twice daily for one week.
- test for Mycoplasma= if +ve then treat
- abstain from sexual activity and use barrier methods
PID is used to describe what?
infection and inflam of female pelvic organs incl. uterus, fallopian tubes, ovaries and surrounding peritoneum
usually the result of ascending infection from the endocervix
Causative organisms of PID?
Chlamydia trachomatis
Neisseria gonorrhoeae
Mycoplasma genitalium
Mycoplasma hominis
Most common cause of PID?
Chlamydia trachomatis
Main features of PID?
lower abdominal pain
fever
deep dyspareunia
dysuria and menstrual irregularities may occur
vaginal or cervical discharge
cervical excitation
PID: high vaginal swabs are often…
negative
Why does PID have such a low threshold for Tx?
difficult making an accurate diagnosis and potential Cx of untreated PID
Cx of PID?
perihepatitis (Fitz-Hugh Curtis Syndrome)
infertility - the risk may be as high as 10-20% after a single episode
chronic pelvic pain
ectopic pregnancy
Cx of PID: perihepatitis (Fitz-Hugh Curtis Syndrome)?
occurs in around 10% of cases
it is characterised by right upper quadrant pain and may be confused with cholecystitis
Another name for vulvovaginal candidiasis (candida)?
genital thrush
Vaginal candidiasis?
symptomatic inflam of vagina and/or vulva caused by a superficial fungal infection
What normal causes vaginal candidiasis?
Candida albicans
Vaginal candidiasis symptoms?
vulval or vaginal itch and irritation
non-offensive vaginal discharge (white, ‘cheese like’, non malodorous)
superficial dyspareunia and dysuria
Acute infection of vaginal candidiasis?
First or single isolated presentation of vulvovaginal candidasis
Recurrent infection of vaginal candidiasis?
four or more symptomatic episodes in 1 yr
Is vaginal candidiasis common?
very
up to 20% women may be colonised by asymptomatic Candida which does not require Tx
RFs for vaginal candidiasis?
- recent Abx use
- local irritants
- steroid use
- uncontrolled diabetes or other causes of immunosupression (HIV)
- increase in endogenous and exogenous oestrogen eg. pregnancy and COCP
Possible Cx of vaginal candidiasis?
- recurrent infection
- reduced QOL
- psychosexual difficulties
Examination for vaginal candidiasis?
examine external genitalia for vulvovaginal inflam, erythema, fissuring or excoriations
Ix for vaginal candidiasis?
- exam: usually clinical
- HSV for culture if uncertain, persistent or recurrent
- HSV for culture with full speciation and sensitivity testing if poor or partial response for maintenance Tx for recurrent infection
- ?tests to exclude other diagnosis if needed: eg. MSU if ?UTI; HbA1c exclude DM, STI screening
Mx for vaginal candidiasis?
- self-Mx for symptom relief
- Antifungal Tx= oral fluconazole 150mg single dose.
AND clotrimazole 1% or 2% cream 2-3x a day if vulval symptoms
If oral contraindicated then clotrimazole 500 mg intravaginal pessary as a single dose.
- If severe infection then repeat fluconazole dose after 72hrs (so on day 1 and 4)
- Follow up in 7-14d if Tx failure or recurrent infection
Mx for vaginal candidiasis recurrent infection?
induction and maintenance regimen
Specialist referral or advice for vaginal candidiasis?
- uncertain
- persistent
- young pt
- non-albicans Candida species
- azole resistant Candida
What symptoms may indicate an alternative/additional diagnosis in suspected vaginal candidiasis?
- foul smelling/purulent discharge, itch not usually prominent= ?bacterial vaginosis
- Urinary freq/urgency= ?UTI
- abnormal vaginal bleeding= ?STI or gynae ca
- other recurrent infections= ?immunosupression
Normal physiological discharge?
cyclical
no itch, pain or malodour
may increase during puberty and pregnancy
Differential diagnosis for vaginal candidiasis?
- Bacterial vaginosis
- Trichomoniasis (discharge profuse, frothy, grey-green, malodorous)
- Chlamydia (no itch)
- Gonorrhoea (pain, rare for itch, purulent cervical discharge)
- Genital herpes (ulceration, discharge uncommon)
- Normal physiological discharge
- Vulval skin conditions
- Atrophic vaginitis
- Vulvodynia
- Foreign body (retained tampon)
- Gynae malignancy
Self-Mx advice for vaginal candidiasis?
- use simple emollients and soap subsitute to wash vulval area
- avoid irritant soap, shampoo, wipes
- avoid vaginal douching
- avoid tight fitting, non-absorbent clothing which may irritate
Mx for vaginal candidiasis if breastfeeding or aged 12-15yrs?
topical clotrimazole 1% or 2%
Mx for vaginal candidiasis if pregnant?
clotrimazole pessary 500 mg intravaginally at night for up to 7 consecutive nights first-line (if aged 16 years and older)
Mx for recurrent vaginal candidiasis in pregnancy?
Induction= clotrimazole pessary 500 mg intravaginally at night, if aged 16 years and older) for 10–14 days.
Maintenance= one clotrimazole pessary 500 mg intravaginally at night once a week for six months (if aged 16 years and older).
If vulval symptoms= topical clotrimazole 1% or 2% cream applied 2–3 times a day (routine use not recommended)
Mx for recurrent vaginal candidiasis?
Induction= 3 doses oral fluconazole 150 mg (to be taken every 72 hours)
Maintenance= oral fluconazole 150 mg once a week for six months.
routine use of a topical imidazole in addition to an oral or intravaginal antifungal for vulval symptoms is not recommended
Mx for recurrent vaginal candidiasis if there are symptoms between maintenance Tx doses?
Oral fluconazole 150 mg twice-weekly instead of once a week, or
consider the use of cetirizine 10 mg once daily for six months (off-label indication).
Is high vaginal swab routinely indicated for vaginal candidiasis?
not routine, mainly clinical
Main features of vaginal candidiasis?
‘cottage cheese’, non-offensive discharge
vulvitis: superficial dyspareunia, dysuria
itch
vulval erythema, fissuring, satellite lesions may be seen
Vaginal candidiasis in pregnancy, what Tx is contraindicated?
oral Tx
What to think if pt has recurrent vaginal candidiasis?
- ?compliance
- HbA1c for DM
- different diagnosis eg. lichen sclerosus
- confirm diagnosis with HVS for microscopy and culture
Chancroid?
tropical disease caused by Haemophilus ducreyi
causes painful genital ulcers associated with unilateral painful inguinal lymph node enlargement
ulcers have a sharp defined, ragged, undermined border
What causes chancroid?
Haemophilus ducreyi
Painful genital ulcers with unilateral painful inguinal lymph node enlargement
chancroid
2 strains of HSV and what they cause?
HSV1= oral lesions (cold sores)
HSV2= genital herpes
but considerable OVERLAP
Genital herpes?
infection caused by herpes simplex virus (HSV)
Most common cause of oro-labial and genital herpes in UK?
HSV-1
What is more likely to cause recurrent genital herpes?
HSV-2
How is HSV acquired?
at mucosal surfaces or skin breaks by direct sexual contact, or more rarely contact with lesions at other sites eg. eyes or fingers
Primary infection with HSV-2?
Mainly asymptomatic
following primary infection, the virus becomes latent in local sensory ganglia
Recurrent genital herpes?
clinical symptoms due to reactivation of pre-existing HSV infection after a latent period
CP of recurrent genital herpes (reactivation of HSV after latent asymptomatic period)?
symptomatic lesions or asymptomatic lesions
infectious viral shredding from external genitalia, anorectum, cervix or urethra; risk of onward transmission
Cx of genital herpes?
- psychosocial impact
- secondary infection of lesions
- autoinoculation to fingers or other sites
- herpes proctitis
- urinary retention
- systemic infection
- neonatal transmission
Average recurrences a yr following the first symptomatic episode after HSV-2 infection?
4-5 per yr
symptoms typically reduce in frequency and severity over time
When to suspect genital herpes simplex (CP)?
Multiple painful vesicles, blisters, or ulcers on the external genitalia, perineum, and/or perianal region.
Dysuria, vaginal or urethral discharge, systemic symptoms, and tender bilateral inguinal lymphadenopathy.
Prodromal tingling or pain in the genital area, back, buttocks, or thighs up to 48 hours before lesions appear in recurrent episodes.
Typically milder, unilateral, and localized lesions in recurrent episodes.
What to consider doing for a pt with suspected genital herpes and is unable or unwilling to attend specialist sexual health service for confirmation of diagnosis, Tx and follow up?
viral swab from anogenital lesion for PCR testing and screen for other STIs
may do rectal swab
Mx for genital herpes?
- advice on self-care and minimising risk of transmission
- Oral antiviral Tx
- Recurrent= episodic oral antivirals for acute episodes and suppressive Tx to prevent future episodes
In a pt with genital herpes, when should referral to hospital or specialist be arranged?
- severely systemically unwell
- suspect severe Cx
- uncertain
- not responded to Tx
- pregnant (urgent referral to specialist sexual health needed for 1st episode)
- immunocompromised
- breakthrough recurrent episodes despite being on suppressive Tx
Multiple painful crops of genital blisters which quickly burst to leave erosions and ulcers on the external genitalia, perineum, and/or perianal region.
Genital herpes
Lesions for genital herpes typically develop when?
4-7d after exposure to HSV
What may occur up to 48hrs before lesions appear in recurrent episodes of genital herpes?
prodromal tingling or buring pain in genital area, lower back, buttocks, upper thighs
How long can primary and recurrent episodes of genital herpes last?
Primary episode= up to 3w
Recurrent episode= 6-12d
Examination of external genitalia, perineum and perianal region may show what in pt with genital herpes?
First episode: genital lesions are usually bilateral with signs of redness, vesicles, blisters, and ulcers.
Lesions can also affect the vagina and cervix in women.
Men who have sex with men (MSM) may present with herpes proctitis due to involvement of the rectum.
There may be lesions on the upper thighs, buttocks, and associated tender bilateral inguinal lymphadenopathy.
Atypical herpes lesions can present with fissures, mild erythema, linear lesions, erosions, or excoriations.
Recurrent episodes: genital lesions are usually less severe, unilateral, and localized to the same area (dermatome) during each episode.
Self-care advise for genital herpes?
saline bathing= wash affected area using saline (1tsp salt in 560ml warm water). Promotes lesion healing, ease symptoms and prevent secondary infection
Over the counter analgesia
Consider topical petroleum jelly or anaesthetic (lidocaine 5% gel) to lesions eg. before passing urine if dysuria
Increase fluid intake to dilute urine.
Try urinate in bath or with water flowing over the area to reduce stinging.
Advise to minimise transmission of genital herpes?
- abstain from sexual activity until lesions cleared or if lesions present
Transmission of genital herpes?
Advise that transmission can occur when there are no symptoms (‘asymptomatic shedding’), but the risk is higher when a person is symptomatic.
Male condoms may reduce the risk of future transmission, but cannot prevent it completely. Transmission is still possible with close skin contact, or contact with infected secretions during foreplay.
(HSV-1) infection may have spread from elsewhere on the body, such as the lips or fingers.
Reassure that a first episode may not necessarily indicate recent infection, and transmission can occur from an asymptomatic partner years into a monogamous relationship.
Is there a risk of neonatal transmission in genital herpes?
Yes
If pregnant women has 1st episode of genital herpes, esp in 3rd trimester
Antivirals for genital herpes?
Start within 5d of the start of a 1st episode or while new lesions are forming
Prescribe aciclovir 400 mg three times a day for 5 days, or valaciclovir 500 mg twice a day for 5 days
Consider extending duration to 10d if new lesions appear during Tx or healing incomplete
Antivirals in genital herpes if pt is immunocompromised or has untreated HIV (and is mild and uncomplicated)?
aciclovir 400 mg five times a day for 7–10 days, or valaciclovir 500–1000 mg twice a day for 10 days, or famciclovir 250–500 mg three times a day for 10 days.
If new lesions appear after 3–5 days of treatment, or if there is any uncertainty about management, seek specialist advice from the person’s infectious diseases team
Follow up in genital herpes?
if Mx in primary care, review in 5-7d
When to offer episodic oral antiviral Tx in genital herpes?
If episodes are infrequent (<6 per yr)
Episodic oral antivirals for recurrent genital herpes?
aciclovir 800 mg three times a day for 2 days (or aciclovir 400mg 3x d for 5d
Immunocompromsied/untreated HIV= aciclovir 400 mg three times a day for 5–10 days
When to offer suppressive oral antiviral Tx in genital herpes?
if episodes are frequent (6 or more per yr)
Suppressive oral antiviral Tx for recurrent genital herpes?
Prescribe aciclovir 400 mg twice a day (or 200 mg four times a day
full suppressive effect is seen from 5 days after treatment is started
breakthrough recurrences occur on treatment, consider increasing the antiviral dose to aciclovir 400 mg three times a day
Immunocompromised/untreated HIV= oral aciclovir 400 mg twice to three times a day
When to stop suppressive Tx for recurrent genital herpes?
after a maximum of one year, to reassess the frequency of recurrences. The minimum assessment period should include at least 2 further recurrent episodes. Consider restarting suppressive treatment if a person has a high rate of recurrence off treatment.
Main features of genital herpes?
painful genital ulceration
may be associated with dysuria and pruritus
the primary infection is often more severe than recurrent episodes
systemic features such as headache, fever and malaise are more common in primary episodes
tender inguinal lymphadenopathy
urinary retention may occur
Ix for genital herpes?
NAAT
HSV serology may be useful eg. in recurrent genital ulceration of unknown cause
Pregnancy and genital herpes?
elective c-section at term is advised if a primary attack of herpes occurs during pregnancy at greater than 28 weeks gestation
women with recurrent herpes who are pregnant should be treated with suppressive therapy and be advised that the risk of transmission to their baby is low
Condylomata acuminata?
Anogenital warts
Anogenital warts?
benign, proliferative growths occurring in the genital, perineal, anal and perianal areas
What causes anogenital warts?
HPV, most commonly low risk genotypes 6 & 11
Peak age of prevalence of anogenital warts?
20-24yrs
Most common mode of transmission of anogenital warts?
sexual contact
rarely peri-natally or from hand warts
Diagnosis of anogenital warts?
clinical exam
CP of anogenital warts?
lesions may be single or multiple
tend to occur on areas of friction
warts on dry, hairy skin tend to be firm and keratinised (horny)
warts on moist, warm, non-hairy skin tend to be soft and non-keratinised
lesions may be broad-based or pedunculated (attached by a stalk) and some are pigmented
When to perform biopsy on anogenital warts?
if the lesions are atypical
What lesions may be misdiagnosed as anogenital warts?
Pearly penile papules.
Benign molluscum
contagiosum, skin tags, and seborrhoeic keratoses.
Vulval, penile, or anal intraepithelial neoplasia, and frank malignancy.
Anogenital condylomata lata of secondary syphilis.
Mx of anogenital warts?
refer to sexual health specialist, esp if: pregnant; children (?sexual abuse); immunocompromised.
can offer Tx in primary care if certain of diagnosis
Options:
- No Tx
- Self-applied Tx
- Ablative methods
Tx options for anogenital warts?
1) No Tx= 1/3 will disappear spontaneously within 6m
2) Self-applied Tx= podophyllotoxin 0.5% solution or cream; imiquimod cream
3) Ablative methods= cryotherapy, excision or electrocautery
Advice for pt with anogenital warts?
- no changes are recommended in cervical screening
- use of condoms
- smoking cession advised to improve response to Tx
Sexual partner of a pt with anogenital warts?
assess for undetected genital warts and other STIs
explain and advice about disease in partner
Main features of anogenital warts?
small (2 - 5 mm) fleshy protuberances which are slightly pigmented
may bleed or itch
Recurrence of anogenital warts?
often resistant to treatment and recurrence is common although the majority of anogenital infections with HPV clear without intervention within 1-2 years
Primary attack vs recurrent attacks in genital herpes?
Primary= severe, fever, multiple painful ulcers
Recurrent= less severe, localised to one site
What causes lymphogranuloma venereum (LGV)?
Chlamydia trachomatis
Stages of lymphogranuloma venereum (LGV) infection?
stage 1: small painless pustule which later forms an ulcer
stage 2: painful inguinal lymphadenopathy
stage 3: proctocolitis
Differentials for genital ulcers?
- Genital herpes= painful
- Syphilis= painless
- Chancroid= painful
- LGV
- Behcet’s disease
- carcinoma
- granuloma inguinale: Klebsiella granulomatis (Calymmatobacterium granulomatis)
Bacterial vaginosis (BV)?
overgrowth of predominantly anaerobic organisms and loss of lactobacilli
Vagina loses its normal acidity and the pH increases to greater than 4.5
Vagina pH in bacterial vaginosis?
> 4.5
Factors that increase risk of developing bacterial vaginosis?
- sexually active (but it is NOT an STI)
- douches, deodorant and vaginal washes
- factors linked to an alkaline vaginal pH (menstruation, semen)
- copper IUD
- smoking
Is bacterial vaginosis an STI?
no
Factors that reduce risk of developing bacterial vaginosis?
- hormonal contraception
- consistent condom use
- circumcised partner
Most common cause of abnormal vaginal discharge in women of childbearing age?
bacterial vaginosis (can happen in peri or postmenopausal women too)
What is bacterial vaginosis associated with?
- increased risk of STIs and HIV
- obstetric complications
- increased risk of infections following gynae procedures
Obstetric Cx associated with bacterial vaginosis?
late miscarriage, pre-term labour, pre-term birth, pre-term premature rupture of membranes, low birth weight, and postpartum endometritis
CP of bacterial vaginosis?
- 50% asymptomatic
- fishy-smelling vaginal discharge
- thin white/grey homogenous discharge coating walls of vagina and vestibule
- not usually associated with soreness, itching or irritation
Fishy-smelling vaginal discharge not associated with itching or soreness?
bacterial vaginosis
Exam findings in bacterial vaginosis?
thin white homogenous discharge coating the walls of vagina and vestibule
Ix for bacterial vaginosis?
- exam: bimanual and speculum (except in preg women with low lying placenta)
- check pH of vaginal discharge
- send sample of discharge to lab for gram-stain and microscopy
In women with characteristic symptoms of bacterial vaginosis, examination and further Ix may be omitted and empirical Tx started if all of the following apply…
- low risk of STI
- no symptoms of other conditions
- symptoms not developed pre or post a gynae procedure
- not postnatal or post miscarriage
- not pre or post termination of preg
- 1st episode, or if recurrent, previous episode of similar symptoms diagnosed previously to be BV following exam
- not pregnant
Non-pregnant women with asymptomatic bacterial vaginosis?
do not usually need Tx
Mx for bacterial vaginosis?
- oral metronidazole 400 mg twice a day for 5 to 7 day 1st line
- if adherence an issue= 2g single oral dose met
- alternative= intravaginal metronidazole or topical clindamycin
Do pregnant women get routine screening for BV?
no
What is pregnant women is incidentally found to have asymptomatic BV?
consult women’s obstetrician
if symptomatic= oral metronidazole (don’t use intravaginal clindamycin- an alternative in the 1st trimester; less preferred anyway)
Do you get recurrence of bacterial vaginosis?
yes it is common
Symptoms of bacterial vaginosis persist or recur after inital Tx?
- check adherence
- reconsider diagnosis
- check not having continued exposure to contributing factors
Raised vaginal pH?
bacterial vaginosis
trichomoniasis
Normal vaginal pH in women of childbearing age?
3.5-4.5
Bacterial vaginosis describes an overgrowth of predominatley anaerobic organisms such as…
Gardnerella vaginalis
Why do you get a raised vaginal pH in BV?
overgrowth of predominately anaerobic organisms eg. Gardnerella vaginalis leads to a consequent fall in lactic acid producing aerobic lactobacilli resulting in a raised vaginal pH.
Criteria for diagnosing BV?
Amsel’s criteria - 3 of the following 4 points should be present:
thin, white homogenous discharge
clue cells on microscopy: stippled vaginal epithelial cells
vaginal pH > 4.5
positive whiff test (addition of potassium hydroxide results in fishy odour)
Clue cells on microscopy?
Bacterial vaginosis!
stippled vaginal epithelial cells
Bacterial vaginosis vs trichomonas?
BV= thin white discharge; clue cells on microscopy
T= frothy yellow-green discharge; vulvovaginitis; strawberry cervix; wet mount: motile trophozoites
Both= offensive vaginal discharge; vaginal pH >4.5; treat with metronidazole
Type of cells in cervix?
On the ectocervix there is a transformation zone where the stratified squamous epithelium meets the columnar epithelium of the cervical canal.
What changes does elevated oestrogen levels (ovulatory phase, preg, COCP use) result in the ectocervix?
Elevated oestrogen levels (ovulatory phase, pregnancy, combined oral contraceptive pill use) result in larger area of columnar epithelium being present on the ectocervix
Another term for cervical ectropion?
cervical erosion
Features of cervical ectropion?
vaginal discharge
post-coital bleeding
What is used to manage cervical ectropion?
Ablative treatment (for example ‘cold coagulation’) is only used for troublesome symptoms
Cervical ectropion?
benign condition where the glandular cells (columnar epithelium) that are normally found inside the cervical canal spread to the outer surface of the cervix.
This part of the cervix is usually covered by squamous epithelial cells, and when the glandular cells come into contact with the acidic environment of the vagina, it can cause symptoms or changes in appearance during a pelvic exam.
Is cervical ectropion linked to ca or precancerous changes?
no it is benign condition
cervical screening important however as symptoms overlap with more serious conditions
Trichomoniasis?
STI caused by flagellated protozoan Trichomonas vaginalis.
Most common non-viral STI worldwide
Cx of trichomoniasis?
- perinatal Cx (preterm delivery and/or low birthweight)
- infertility
- enhanced HIV transmission
CP of trichomoniasis?
up to 50% women asymptomatic
women= vaginal discharge, vulval itching, dysuria and offensive odour
15-50% men asymptomatic
men= usually present as sexual partners of infected women; urethral discharge and/or dysuria
Diagnosis of trichomoniasis?
ideally confirmed by sexual health specialist, if can’t refer then test in primary care.
- women= HVS (from posterior fornix)
- men= urethral swab and/or urine sample
- Test for other STIs (chlamydia, gonorrhoea, HIV, syphilis)
Mx for trichomoniasis?
oral metronidazole 400-500mg twice a day for 5-7d, or single 2g dose
(don’t use single dose in pregnant or breastfeeding)
Asymptomatic pregnant women= specialist advice
Symptomatic pregnant= oral metronidazole
HIV= 500mg twice a day for 7d
Current partner(s) and any partner(s) within what period should be treated and screened for STIs if pt presents with trichomoniasis?
within last 4w
Follow up after Tx for trichomoniasis?
follow up to review symptoms, check contact tracing, disscuss STI screen results
sexual abstinence for 1 w and until completed Tx
tests to confirm cure not routine
What if pt has trichomoniasis and symptoms persist or recur after Tx?
- refer sexual health
- compliance
- reinfection?
- reconsider diagnosis
- repeat 7-day metronidazole Tx (400-500mg twice a day); if pregnant refer before more Tx
When should specialist advice be sought from a GUM specialist for a pt with trichomoniasis?
- if 2nd line Tx course fails
- failed first line single dose Tx
Ix for trichomoniasis?
- speculum exam
- test vaginal pH (>4.5= trichomoniasis)
- HVS for gram staining
- STI screen
What may be seen on examination in pt with trichomoniasis?
- yellow-green, frothy discharge with fishy odour
- inflam of vulva and vagina or STRAWBERRY CERVIX (cervicitis) on pelvic exam
- 5-15% normal
Cause of trichomoniasis?
Trichomonas vaginalis is a highly motile, flagellated protozoan parasite
Main features of trichomoniasis?
vaginal discharge: offensive, yellow/green, frothy
vulvovaginitis
strawberry cervix
pH > 4.5
in men is usually asymptomatic but may cause urethritis
What does microscopy on wet mount for trichomoniasis show?
motile trophozoites
Vaginal discharge may be…?
physiological (normal) or pathological (abnormal)
Features of physiological vaginal discharge?
white or clear, mucus-like, non-offensive discharge that varies with the menstrual cycle and in the different reproductive stages.
Features of pathological vaginal discharge?
change in colour, consistency, volume, and/or
odour.
It may be associated with symptoms such as itch, soreness, dysuria, pelvic pain, or intermenstrual or post-coital bleeding.
Abnormal vaginal discharge can be due to what 3 types of causes?
infective (non-sexually transmitted)
infective (sexually-transmitted)
non-infective
Infective non-sexually transmitted causes of vaginal discharge?
bacterial vaginosis and vulvovaginal candidiasis
Infective sexually transmitted causes of vaginal discharge?
chlamydia, gonorrhoea, trichomoniasis, PID
Non-infective causes of vaginal discharge?
retained foreign body, dermatitis, gynaecological ca
When may pt not need a pelvic exam if they present with vaginal discharge?
history indicates bacterial vaginosis or vulvovaginal candidiasis, the risk of STI is low, and there are no symptoms indicative of upper genital tract infection (such as abnormal bleeding, deep dyspareunia, pelvic or abdominal pain, or fever).
Women presents with vaginal discharge and increased risk of STI, should be offered what?
testing for chlamydia, gonorrhoea, trichomoniasis, HIV and syphilis
ideally in GUM clinic to facilitate Tx and partner notification, but can be done in primary care
Women presents with abnormal vaginal discharge, when should a diagnosis of PID be considered?
any woman aged under 25 years who has recent onset bilateral lower abdominal pain associated with local tenderness on bimanual examination, in whom pregnancy has been excluded.
Should be a low threshold for empirical treatment of PID, as delaying Tx may increase the risk of long-term Cx, such as ectopic pregnancy, infertility, and pelvic pain.
Mx of vaginal discharge?
TUC
Reassuring women with features suggestive of physiological discharge and giving general healthcare advice (such as personal hygiene).
When to consider admission of referral for women presenting with vaginal discharge?
- urgent admission- PID and pregnant or severe CP eg. N, V & fever >38
- suspected ca pathway if ?gynae ca
- referral GUM clinic should be strongly recommended for women with confirmed STI, if unwilling or unable then Tx in primary care
- Referral to a GUM clinic should be arranged if symptoms are persistent or recurrent or there is doubt about the cause of vaginal discharge.
How to assess a womens risk of STI?
Have condomless sex with new or casual partners or
Are younger than 25 years of age, or
Have had a new sexual partner or more than one sexual partner in the last 12 months or
Have had a previous STI, or
Are of Black ethnicity.
If pelvic exam is indicated in a women eg. presenting with vaginal discharge, what do you do?
- inspect vulva
- speculum exam
- test pH of vaginal discharge
- consider bimanual exam if ?upper genital tract infection= adnexal tenderness, cervical motion tenderness or uterine tenderness
- high vaginal swab
woman aged under 25 years who has recent onset bilateral lower abdominal pain associated with local tenderness on bimanual examination, in whom pregnancy has been excluded.
?PID
When may high vaginal swabs be used?
o aid the diagnosis of bacterial vaginosis, vulvovaginal candidiasis, Trichomonas vaginalis, or other genital tract infections (such as streptococcal organisms), but their use should generally be reserved for when:
- Symptoms, signs, or pH are inconsistent with a specific diagnosis.
- The woman is pregnant, postpartum, post-abortion, post-miscarriage, post-instrumentation, or pre-or post-gynaecological surgery.
- It is within 3 weeks of intrauterine contraceptive insertion.
- Symptoms are recurrent (four or more cases a year).
There is no, partial, or poor response to treatment.
Other tests could do if women presents with abnormal discharge: already done speculum +/- bimanual exam; pH of vagina; STI screen and maybe a high vaginal swab?
consider:
- urine preg test
- urine dip to exclude UTI
What if pt has cervicitis?
treat for chlamydia whilst awaiting swab results
Common causes of vaginal discharge?
physiological
Candida
Trichomonas vaginalis
bacterial vaginosis
Less common causes of vaginal discharge?
Gonorrhoea
Chlamydia can cause a vaginal discharge although this is rarely the presenting symptoms
ectropion
foreign body
cervical cancer
Lichen sclerosus?
inflam condition usually affecting genitalia and more common in elderly females
Lichen sclerosus more common in who?
elderly females
Lichen sclerosus leads to what?
atrophy of epidermis with white plaques forming
Features of lichen sclerosus?
- white patches/plaques that may scar
- itch prominent
- may result in pain during intercourse or urination
Diagnosis of lichen sclerosus?
usually always clinical
biopsy is atypical features present
Mx for lichen sclerosus?
topical steroids and emollients
Why do pts with lichen sclerosus get follow up?
increased risk of vulval ca
When may biopsy be performed for lichen sclerosus?
if atypical features, uncertain or is suspicious of neoplastic change.
Pts under routine follow up will need a biopsy if:
(i) there is a suspicion of neoplastic change, i.e. a persistent area of hyperkeratosis, erosion or erythema, or new warty or papular lesions;
(ii) the disease fails to respond to adequate treatment;
(iii) there is extragenital LS, with features suggesting an overlap with morphoea;
(iv) there are pigmented areas, in order to exclude an abnormal melanocytic proliferation;
and
(v) second-line therapy is to be used.
Vulval intraepithelial neoplasia (VIN)?
pre-cancerous skin lesion of vulva and may result in SCC if untreated
Average age of women affected with vulval intraepithelial neoplasia?
50
RFs for vulval intraepithelial neoplasia?
- HPV 16 & 18
- smoking
- HSV
- lichen sclerosus
Features of vulval intraepithelial neoplasia?
- itching, burning
- raised, well-defined skin lesions
Ix for vulval intraepithelial neoplasia?
- biopsy= punch or excisional for histology
- HPV testing= PCR or in situ hybridisation for high risk HPV DNA
Mx for vulval intraepithelial neoplasia?
- topical therapies= imiquimod; 5-Fluorouracil
- surgical interventions= complete removal of dysplastic areas whilst preserving normal anatomy as possible; wide local excision, laser ablation or partial vulvectomy in extensive disease
Follow up and surveillance for vulval intraepithelial neoplasia?
regular monitoring with repeat colposcopy and biopsy if recurrence or progression is suspected
Imiquimod?
immune response modifer
5-Fluorouracil?
topical chemotherapeutic agent
Bartholin’s abscess?
when Bartholin’s glands become infected and enlarge
Bartholin’s glands?
pair of glands located next to entrance to vagina
normally the size of a pea
Tx for Bartholin’s abscess?
Abx or
insertion of a word catheter or surgery- marsupialization
Bartholin’s cyst?
develops when entrance to Bartholin duct becomes blocked
How does Bartholin’s cyst develop?
when entrance to Bartholin duct becomes blocked, gland continues to produce mucus which builds up behind the blockage, eventually leading to formation of mass
Bartholin’s cyst: the initial blockage of Bartholin duct is most commonly caused by what?
vulvar oedema
Bartholin’s cyst are usually…
sterile
Features of Bartholin’s cyst?
usually painless and asymptomatic- often detected routine pelvic exam or women herself
large cyst: superficial dyspareunia and uncomfortable sitting
Bartholin’s cyst vs abscess?
abscess= extremely painful, erythema and often gross deformity of affected side of vulva
cyst= usually asymptomatic, painless. If large can cause superficial dyspareunia and uncomfortable sitting
abscess 3x more common than cyst in terms of presentation (maybe as cyst asymptomatic)
Size of Bartholin’s cysts?
usually unilateral and 1-3cm diameter
glands should not be palpable in health
Exam of Bartholin’s cyst?
soft, painless lump in the labium. It is best felt between a finger at the posterior vaginal introitus and a thumb lateral to the labium.
RFs for development of Bartholin’s cyst?
increasing age up to menopause before decreasing, only 10% in women >40yrs
having one cyst RF for developing a second
RFs poorly understood
Mx for Bartholin’s cyst?
asymptomatic= no intervention; in older women (>40) may have incision and drainage with biopsy in order to exclude carcinoma
symptomatic and/or disfiguring= incision and drainage (with/without placement of word catheter to allow continuing drainage) or marsupialisation procedure (creation of new orifice through glandular secretions may drain; more effective at preventing recurrence but longer op and more invasive).
No evidence of Abx use if no abscess.
80% of vulval ca are?
SCC
Most cases of vulval ca occur in women aged?
> 65yrs
Is vulval ca common?
rare
RFs for vulval ca?
- age
- HPV infection
- VIN
- immunosuppression
- lichen sclerosus
Features of vulval ca?
- lump or ulcer on labia majora
- inguinal lymphadenopathy
- may be associated with itching, irritation
Oral herpes simplex virus (HSV)?
mild, self-limiting infection of lips, cheeks or nose (herpes labialis or ‘cold sores’) or oropharyngeal mucosa (gingivostomatitis)
Most common cause of oral herpes?
HSV1
HSV1 infections?
most are subclinical and asymptomatic
Symptomatic primary infection of oral herpes (HSV1) usually presents as what in children?
gingivostomatitis
How is HSV1 transmitted?
direct contact with infected secretions entering via skin or mucous membranes, from a person who is actively shedding the virus
Cx of oral HSV?
can be life-threatening or severe esp in immunocompromised
- eczema herpeticum
- eye disease eg. corneal ulceration
- erythema multiforme
- pneumonia
- encephalitis
Oral herpes: primary herpes labialis lesions usually resolve when?
within 10-14d
gingivostomatitis usually within 2-3w
Features of oral herpes?
Herpes labialis= prodrome of fever, sore throat, and lymphadenopathy, particularly in primary infections.
Initial symptoms= pain, burning, tingling, and itching may precede visible lesions and typically last 6–48 hours.
Herpes labialis lesions are typically crops of vesicles that rupture, ulcer, crust, and heal (usually without scarring).
Herpes gingivostomatitis lesions are typically crops of painful vesicles that rupture and form ulcers on the pharyngeal and oral mucosa.
People who are immunocompromised may have severe, atypical lesions anywhere in the oral cavity.
Assessment of pt with suspect oral herpes should include what?
any known trigger factors eg. UV light, stress, fever or trauma to area
any red flags for oral ca
Ix for oral herpes?
not usually needed in primary care
Hospital admission in pt with suspected oral herpes?
if unable to swallow or is dehydrated, immunocompromised with severe infection or serious Cx is suspected
Referral or specialist advice in pt with suspected oral herpes when?
- immunocompromised with troublesome infection
- pregnant
- severe, frequent or persistent infections
- associated recurrent erythema multiforme
- lesions are refractory to primary care Tx
- lesions are atypical
Mx for oral herpes?
- analgesia for pain and fever
- consider oral antiviral (aciclovir, min 5 days, from prodome symptoms before vesicles appear and until healed): if primary infection, recurrent lesions are severe frequent or persistent or for recurrent gingivostomatitis (rare). Also if immunocompromised and primary or recurrent infection.
- Advise that topical antiviral preparations, topical analgesics, mouthwash, and lip barrier preparations are not routinely recommended, but some people may find them helpful, and they are available over-the-counter.
- self-care advice to avoid trigger factors and to reduce risk of autoinoculation and transmission to others
- sunscreen or sunblock lip balm for recurrent infections triggered by sunlight
Ocular herpes simplex virus infections?
can cause inflam of retina (retinitis), iris and associated uveal tract (iritis or uveitis), cornea (keratitis), conjunctiva (conjunctivitis), eyelids (blepharitis) and surrounding skin (periocular dermatitis)
What usually causes ocular herpes?
HSV1
Features of ocular herpes?
most asymptomatic
if symptomatic, usually presents with blepharoconjunctivitis
Recurrent HSV ocular infection
more common clinically, and lesions typically cause keratitis which may affect one or more of the three corneal layers:
Epithelial — the most common ocular manifestation of HSV infection, accounting for 50–80% of cases.
Stromal — which may be non-necrotizing or necrotizing.
Metaherpetic ulcer (trophic keratitis).
Ocular HSV transmission?
direct contact with active orofacial lesions or infected secretions such as saliva or tears, from a person who is actively shedding the virus.
HSV persists in a latent state in the trigeminal nerve ganglion, where it can remain latent indefinitely or can reactivate, leading to viral shedding at the corneal surface.
Cx of ocular herpes?
Corneal scarring and visual impairment.
Corneal perforation.
Secondary infection with bacteria or fungi.
Systemic infection, such as aseptic meningitis, encephalitis, or hepatitis.
Prognosis of ocular HSV?
Blepharoconjunctivitis tends to resolve within 2 weeks, and epithelial keratitis tends to resolve in 1–2 weeks.
About 25% of people with epithelial keratitis will develop stromal keratitis or iritis.
Recurrent ocular HSV is common, with the risk increasing after each subsequent episode.
Symptoms and signs of ocular herpes?
Eye pain, eye irritation or watering, and photophobia.
Blurred vision.
An acute red eye.
Crops of vesicles, ulcers, or pustules along the lid margin or periocular skin.
A hazy cornea or creamy opacity (suggests stromal keratitis).
A fixed irregular pupil or limbal injection (suggests iritis or uveitis).
Reduced corneal sensation.
Reduced visual acuity.
Diagnosis of ocular herpes?
clinical examination to check for systemic infection, such as pyrexia, lymphadenopathy, and hepatosplenomegaly.
Fluorescein staining of the cornea to check for a dendritic or amoeboid ulcer, suggesting epithelial involvement.
Checking visual acuity.
Mx of ocular herpes?
Referral of all cases to eye casualty or an emergency eye service for same-day assessment and specialist management.
If same-day assessment is not possible or practical, specialist ophthalmological advice should be sought regarding initiating drug treatment in primary care.
Note: some optometrists can initiate topical antiviral treatment for suspected epithelial keratitis in specific clinical circumstances.
