Sexual Health Flashcards
What is subfertility?
Diminished ability for a couple to conceive a child
What is the difference between primary and secondary infertility?
Primary) Never had children
Secondary) Struggling for subsequent children
How can a couple increase the chance of conception?
- Regular sex (3-4 times/week)
- No use of contraception
- Trying for 1+ years
What are the risk factors for subfertility?
- Increased Age
- Obesity
- Smoking and Alcohol
- Tight Underwear (Men)
- Anabolic Steroids
- Illicit Drug use
What are the phsyiological causes of infertility?
Genetics (Turner’s and Kleinfelter’s)
Ovulation/Endocrine Disorder
Tubal Abnormalities
Uterine Abnormalities
Cervical Abnormalities
Testicular Disorders
Ejaculatory Disorders
What are the genetic causes of infertiltiy?
Turner’s Syndrome (XO)
Kleinfelter’s Syndrome (XXY)
What are the Ovulation/ Endocrine causes of Infertility?
PCOS
Sheehan’s (Post Partrum Pituitary Necrosis)
Premature Ovarian Fail
Pituitary Adenoma/ Cushing’s
Hyperprolactinaemia
What Tubal Abnormalities can cause infertility?
Congenital
Pelvic Inflammatory Adhesions (Chlamydia/ Gonorrhea)
What are the Uterine abnormalities affecting infertility?
Bicornate Uterus
Fibroids
Asherman’s (Adhesions)
Endometriosis
What are the Cervical causes of Infertility?
Post Biopsy Damage
Post LLETZ Procedure damage
What testicular disorders affect Infertility?
Cryptorchidism
Varcicole
Testicular Cancer
Congenital Defects
What Ejaculatory Disorders affect Infertility?
Obstruction
Retrograde Ejaculation
Premature Ejaculation
How would you investigate infertility in women?
Bedside
History
Speculum and Bimanual
STI Screen
Bloods
Serum Progesterone (7 Days before end of cycle)
Prolactin
LH and FSH and TFT
Anti Mullerian Hormone
Imaging
TV USS
Hystersosalpingography (Tubal Patency)
Laproscopy w/ Dye (Tubal Patency w/ Co-morbidities)
How would you investigate male infertiltiy?
Bedside
History w/ Past Pregnancies
Testicular Exam
Semen Analysis
Bloods
Serum Testosterone
LH/FSH and TFT
When and why is serum progesterone tested in infertiltiy?
- 7 Days before end of cycle
- A rise suggests corpus luteum has formed and ovulation is initiated
What does a semen analysis evaluate?
Sperm Count
Motility
Morphology
What should happen if a semen analysis is abnormal?
Repeat in 3 months
How is Infertility managed?
Conservative
- Weight loss
- Smoking cessation
- Alcohol Reduction
- Stress reduction
- Manage Underlying Causes
Medical
- 1st) Clomiphene
- LH/ FSH Injections
- GnRH and Dopamine Agonists
Surgical
- IVF w/ BhCG
- Intracytoplasmic sperm injection
What is Clomiphene and its side effects?
Oestrogen Modulator
- Inhibit HPG = Negative Feedback
- Increases GnRH, FSH/LH and Ovulation
Side Effects
- Flushing
- Mittelzhmer’s (Ovulatory Pain)
- Blurred Vision
What are the complications of IVF?
Twin Pregnancy
Ectopic Pregnancy
Ovarian Hyperstimulation Syndrome
What is Ovarian Hyperstimulation Syndrome?
Raised BhCG = Raised VGEF
Causes Ascites, Oliguria, Diarrhoea and Vomiting due to >10cm Ovaries
Management
- ABCDE
- IV Colloid w/ LMWH and Urine Output
What are the Risk factors for STI?
<25 years
Unprotected Sex
Sexually Active
IV Drug Use
Partner w/ STI
Multiple Partners
Partner w/ Multiple Partners
Immunosuppresion
Low Socioeconomic Status
MSM/Anal Sex
How do you Investigate STI?
Male
- First Catch Urine MC+S
Female
- Triple Swab (High Vag NAAT, Endocervical NAAT and Charcoal)
Sexual Health Screen
Chlamydia? 6 month Contact Trace
Gonorrhea? 2 month Contract Trace
What is Chlamydia?
Negative Cocci
Obligate Intracellular Bacterium
What is the epidemiology of Chalmydia?
Most Common STI in UK
15-24 Prevalence
Presentation of Chlamydia
Asymptomatic
Men? Urethral Discharge, Proctitis and Dysuria
Women? Vaginal discharge, Cervicitis, Dysuria and Intermenstrual Bleeding
MSM? Anal Discharge/ Anorectal Discomfort
Neonate? Pneumonia/ Conjunctivitis
Why may a neonate present with Pneumonia/ Conjunctivitis from Chlamydia?
Exposed to bacterium during delivery form infected mother
How do you investigate Chlamydia infection?
Men
- Urine/ Urethral Swab w/ NAAT
Women
- Vulvovaginal/Endocervical Swab w/ NAAT
MSM/Anal
- Anal swab w/ NAAT
How do you manage Chlamydia infection?
Twice daily Oral Doxycylcine (7 Days)
Pregnant? 1g Azithromycin
When is Doxycycline contraindicated?
Breast Feeding - Causes Fetal Teeth Discolouration
What is Gonorrhea
Gram Negative Diplococcus
What is the presentation of Gonorrhea?
Men
- Discharge
- Dysuria
- Tender Inguinal Nodes
Women
- Discharge (Cervical OS/ Bartholin’s or Skene’s Gland)
- Dysuria
- Abnormal Bleeding
Extragenital
- Pharyngitis
- Conjunctivitis
- Rectal Pain/Discharge
- Septic Arthritis
- Disseminated Infection
What are the extragenital manifestations of Gonorrhea?
- Pharyngitis
- Conjunctivitis
- Rectal Pain/Discharge
- Septic Arthritis
- Disseminated Infection
How do you investigate Gonorrhea?
Men
First pass urine/ Penile Swab w/ MCUS and NAAT
Women
Vulvovaginal/ Endocervical Swab w/ MCUS and NAAT
What might you see on microscopy of Gonorrhea?
Gram Negative Diplococci
Polymorphonuclear Leukocytes
How do you manage Gonorrhea Infection?
All patients = Referral, Partner notification and Screening
Unwell = Admission
1st = IM Ceftriaxone
Other = IM Gentamycin/ Oral Cefixime w/ Oral Azithromycin
After Treatment = Test of Cure
What are the complications of Gonorrhea?
Infertility
Men - Epididymitis
Women - Pelvic Inflammatory Disease
Reactive Arthritis
Disseminated Infection
Skin and Joint (Rash/Pain)
HIV
Opthalmia Neonatorum
- Requires Emergency Eye care <48hrs
What is Trichomonas Vaginalis?
Flagellated Protazoan Parasite
Most common Non Viral STI
Presentations of Trichomonas Vaginalis
Women
- Profuse, Frothy Yellow Discharge
- Vulval Irritation
- Dyspaerunia
- “Strawberry Cervix”
Men
- Non Gonococcal urethritis
Investigating Trichomonas Vaginalis
Triple Swab (Wet Mount) and
Direct Microscopy w/ Culture
Vaginal pH can be raised
Management for Trichomonas Vaginalis
1) Oral Metronidazole 400mg BD 7 days
2) Abstain from sex >7 days and Alcohol
3) Contact Tracing and Screening
What is genital herpes?
Painful sores and ulcers on the genitals caused by HSV 1/2
Describe the symptom disribution between HSV-1 and HSV-2
HSV-1 = Traditionally oral but now the most common genital
HSV-2 = Recurrent anogenital symptoms
Presentations of Genital Herpes
Asymptomatic
Multiple painful ulcers
Dysuria and Discharge
Crusting/ Lesion Healing
Fever, Malaise, Headcahe and Urine Retention
Investigating Genital Herpes
1) History and Exam
2) Ulcer Base Swab w/ NAAT
Managing Genital herpes
Oral Antivirals <5 days for 5 days
- Aciclovir 400mg TD
- Aciclovir 200mg PD
- Valaciclovir 500mg BD
- Famciclovir 250mg TD
Other
- Analgesia
- Topical Lidocaine
How is Genital Herpes Manged in Pregnancy
1) GUM Referral w/ Aciclovir 400mg TD
Neonatal Herpes risk is low even w/ lesions at delivery
What are some differentials for genital ulcers?
Genital Herpes
- Painful w/ Dysuria and Discharge
Syphillis
- Painless w/ rash and systemic signs
Chancroid
- Painful w/ Inguinal Lymphadenopathy
Lymphogranuloma Venereum
- Painless w/ Painful Inguinal Lymphadenopathy
What can cause Painless genital/anogenital warts?
Low risk HPV 6/11
Presentations of Genital warts
Painless Lumps
Keratinised or Non Keratinised
Investigating Genital Warts
Clinical and History
Unsure? Biopsy
Managing Genital Warts
Podophyllotoxin
- Plant based antiviral destorys wart tissue
Imiquimod
- Immune response modifier (Enhances immune system)
Cryotherapy
- Liquid Nitrogen freezing
Tricloroacetic Acid
- Chemical Burning
What is Syphillis?
STI caused by Spirochet bacterium Treponema Pallidum
How is Syphillis transmission different?
It is transmitted by direct contact with syphillis sores during sex or during baby delivery
Describe the stages of Syphillis
Primary
Single painless lesion (Chancre) It is self limiiting <8 weeks and can present w/ Painless Lymphadenopathy
Secondary
Symmetrical maculopapaular rash <10 weeks of Primary. Can present with mucosal ulcers, lymphadenopathy and general systemic symptoms
Tertiary
Gummatous disease, CV Complications and neurological complications <40 years after Primary
Congenital
Transmission of Treponema Pallidum from infected mother during pregnancy
What are the presentations of Syphillis?
Primary
- Single Painless Chancre(Lesion)
- Painless regional lymphadenopathy
- Spontatenous healing <8 weeks
Secondary
- Symmetrical Maculopapular rash
- Mucosal Ulcers and Lymohadenopathy
- Glomerulonephritis and Systemic Signs
- Develops <10 weeks of Primary
Tertiary
- Gummatous Disease
- Cardiovascular (Aortitis/Arteritis)
- Neurovascular (Argyll-Robinson, Dementia, Meningovacular Syphillis)
- Develops <40 years after Primary
Congenital
- Rash (Palms, Soles, Mouth and Genitals)
- Hepatosplenomegaly and Anaemia
- Saber Shins and Neurological Sequalae
Presentations of Primary Syphillis
- Single Painless Chancre(Lesion)
- Painless regional lymphadenopathy
- Spontatenous healing <8 weeks
Presentations of Secondary Syphillis
- Symmetrical Maculopapular rash
- Mucosal Ulcers and Lymohadenopathy
- Glomerulonephritis and Systemic Signs
- Develops <10 weeks of Primary
Presentations of Tetiary Syphillis
- Gummatous Disease
- Cardiovascular (Aortitis/Arteritis)
- Neurovascular (Argyll-Robinson, Dementia, Meningovacular Syphillis)
- Develops <40 years after Primary
Presentations of Congenital Syphillis
- Rash (Palms, Soles, Mouth and Genitals)
- Hepatosplenomegaly and Anaemia
- Saber Shins and Neurological Sequalae
Investigating Syphillis
Primary
Dark Field MIcroscopy
- Lesion sample (Genital)
PCR Testing
- Oral Lesion sample
Secondary/ Tertiary
Tropenemal Test
- Enzyme Immunoassays
- Chemiluminescent Assay
Other
- Virology and STI Screen
- CSF Examination (Tertiary)
Monitoring Treatment
Non Tropenemal test
- Veneral Diseas Research Lab
How would you monitor treatment efficacy in Syphillis?
Venereal Disease Research Lab
Why may False Negatives occur in Syphillis?
- Early Presentation
- HIV infection
Why may False positives occur in Syphillis?
With Non Tropenemal Test
- Viral Infection
- Malignancy
- Autoimmunity
- Older Age
- Pregnancy
Managing Syphillis
GUM referral and Partner screening
1st) One dose IM Penicillin G (Benzathine benzylpenicillin)
Late Syphillis) <3 weeks IM Penicilin G
Neurosyphillis) IV Penicillin G
Jarisch Herxheimer Reaction
- Acute fever <24hrs after treatment
- Rx w/ Antipyretics
What is Bacterial Vaginosis?
Imbalance of the vaginal microbiome due to anaerobic bacterial overgrowth and loss of lactobacilli
Causes of Bacterial Vaginosis?
Overgrowth of Gardenerella Vaginalis
Multiple Sexual Partners
Douching (Direct Cleaning)
Lack of Conistent Condom use
Hormonal Changes
Presentations of Bacterial Vaginosis
Vaginal Discharge (Grey/White)
Fishy Smelling Discharge
Vaginal Irritation
Investigating Bacterial Vaginosis
Amsel Criteria (3+ features)
- Vaginal pH >4.5
- Grey Milky Discharge
- Positive Whiff test
- Clue Cells on Wet mount
What is a positive Whiff test?
Adding 10% Potassium Hydroxide = Fishy Smell
Managing Bacterial Vaginosis
1st ) Oral/ Vaginal Metronidazole/ Clindamycin
Prevention
- Avoid Smoking
- Avoid Vaginal Douching
- Avoid Bubble baths
Pregnancy and Vaginosis
Pregnancy increases risk of BV
BV Increases risk of premature babies and low birth weight
Rx = Metronidazole and Antenatal Care
What is Vulvovaginal Candidiasis?
“Yeast Infection” caused by Candida Albicans overgrowth
Risk Factors for Vaginal Candidiasis
Pregnancy
Antibiotics
Immunosuppresion
Presentations of Candidiasis
Women
- Itching and Burning
- White Lumpy Discharge
- Sour Milk Odour
- Dysuria and Dyspaerunia
Men
- Soreness, Pruritis and Redness
Investigating Candidiasis
1) Clinical Exam
Women
- Redness, Fissures, Thick White Discharge
Men
- Dry, Dull, Red glazed plaques and papules
2) High Vaginal Swab for MCS
M = Blastophores, Pseudohypae and Neutrophils
Managing Candidiasis
1s) Single Dose “Azole”
- Oral Fluconazole/Itraconazole
- Vaginal /Topical Clotrimazole
Recurrent?
Induction = PO Fluconazole 150 every 3 days
Maintenanance = PO Fluconazole 150mg weekly
Considerations for treatment of Candidiasis
Avoid Oral
- Pregnancy/ Breastfeeding
Avoid IV/Topical
- Integrity of Condom
- Integrity of Diaphragms
What is Pelvic Inflammatory Disease?
Infection spreads from the vagina to the cervix, and subsequently to the upper genital tract
Causes of Pelvic infallamtory disease
Sexual Contact
Non Sexual
Gonorrhea and chlamydia
Presentations of Pelvic Inflammatory Disease
- Bilateral Abdominal Pain
- Vaginal Discharge
- Post coital bleeding
- Adnexal/ Cervical Motion Tenderness
- Fever
- Fitz-Hugh-Curtis Syndrome
What is Fitz Hugh Curtis Syndrome?
Adhesions form between anteriot liver capsule and anterior abdominal wall
Can form Perihepatic Abscess
Px = RUQ pain w/ PID Px
Dx = Abdominal USS then Laporoscopy
Rx = Antibiotics and Laparosocpic Adhesion Lysis
How is Pelvic Inflammatory Disease Investigated?
Bedside
Bimanual - Cervical Motion tenderness
Pregnancy Test
High Vag Swab (STI or urinary NAAT)
Bloods
FBC and CRP
Imaging
Transvaginal USS
Mangaing Pelvic Inflammatory Disease
1st) IM Ceftriaxone + PO Doxycycline + PO Metronidazole
Severe? All are IV
Avoid Unprotected sex
What is Lymphogranuloma Venereum
Lymphogranuloma venereum is an STI caused by the L1, L2, or L3 serovars of Chlamydia trachomatis
Main Risk Factor of Lymphogranuloma venereum
MSM
Presentations of Lymphogranuloma venereum
Painless Genital Ulcer
- 3-12 Days after infection
Inguinal Lumphadenopathy
Proctitis (MSM)
Systemic Symptoms
Investigating Lymphogranuloma venereum
PCR from Swab
- Especially for Chlamydia
Managing Lymphogranuloma venereum
Oral Doxycycline (100mg BD 21 Days)
Oral Tetracycline (2g OD 21 days)
Oral Erithromycin (500mg QD 21 Days)
What is Balanitis?
Inflammation of the Glans Penis by Candida or Lichen Schlerosus
Presentation of Balanitis
Candida
- White Itchy lesions
Lichen Schlerosus
- White shiny plaques
- Koebener Phenomenon
- BXO
Balanitis Xerotic Obliterans
- White Plaque @ urethral meatus +/- Phimosis
Managing Balanitis
Candida?
Topical Clotrimazole
BXO/Lichen?
High Potency Steroid
- Clobetasol Propionate
What is Chancroid?
Sexually transmitted infection of the genital skin caused by the gram-negative bacillus Haemophilus ducreyi
Aetiology of Chancroid
Haemophilius Ducreyi
Tropical Travel
Poor Hygiene/ living Situation
Presentation of Chancroid
Painful Genital Lesion +/- bleeding
Painful Lymphadenopathy (Bubo)
Symptom onset <10 days post contact
Investigating Chancroid
1st) Clincial Exam
Culture/PCR) Haemophillius Ducreyi
Managing Chancroid
Antibiotics and Analgesia
- Ceftriaxone
- Azithromycin
- Ciprofloxacin
Buboes?
Incision and drainage
What is hypoactive sexual desire disorder?
6+ months of…
- Low libido
- Low sex cue response
- Low Initiation of sex
What are some risk factors of HSDD
Mood (Depression/ Anxiety)
Endocrine (Diabetes)
Meds (Opioids/SSRI)
Relationship Problems
Abuse and Trauma
What are two sex stimulants
Dopamine Agonists
Melanocortin
What are two sex inhibitants
5-HT (Seretonin)
Opiods
Investigating HSDD
Bloods and History
Managing HSDD
Flibanserin (Rebalance Neurotransmitters)
Bremelanotide (Sexual Desire)
Others
- Sex Therapy
- Stress Management
- Kegel Exercises
What is Anorgasmia?
Falure to orgasm depsite adequate stimulation for 6+ months
Causes of Anorgasmia
Mood
Diabetes
Postmenopause
Post Hysterectomy
Stress
Dyspaerunia
SSRI
Abuse
Investigating Anorgasmia
Bloods
Managing Anorgasmia
Clitoral Vacuum
COCP/ HRT
Sex Education
- Clitoral Stimulation
Couple’s Therapy
Direct Orgasm Treatment
- ThermiVa Radio Freqency
What is Vaginismus
Involuntary contractions of vaginal muscle during penetration causing pain
Risk factors for Vaginismus
Anxiety
Trauma/ FGM
Surgeries
Presentations of Vaginismus
Problematic sex
Pap Smears avoided
Can’t Insert IUS/IUS
Managing Vaginismus
Sex Education
Kegel Exercises
Vaginal Dilation Therapy
Sex Psychology
What is Vulvodynia?
3+ months of chronic vuoval pain with and without provoking
Managing Vulvodynia
Prevent Friction
Kegel Exercises
Analgesia
Vestibulodynia? Vestibulectomy
What is Erectile dysfuntion?
Consistent or recurrent inability to attain or maintain penile erection for a sufficient sexual performance
Causes of Erectile Dysfunction
Cardiovascular Risk Factors
Vascular disease
- Poor blood flow to penis
Medications
- Antihypertensives
- SSRI’s
- Beta Blockers
Autonomic Neuropathy
- Diabetes and Alcohol
- Spinal Cord Compression
Psychological
- Anxiety and Depression
Endocrinological
- Hyperprolactinaemia
- Prolactinoma and Hypogonadism
Pelvic Surgery
- Bladder or Prostatectomy
Anatomical
- Peyrione’s (Scar tissue in penis causing bend in erection)
Presentation of Erectile Dysfunction
- Reduced sexual desire
- Difficult Ejaculating
- Performance Anxiety
- Sudden onset = Psychogenic
- Gradual onset = Organic Cause
What are the features of an organic cause for erectile dysfunction?
Gradual Onset
Lack of Tumescence
Normal Libido
Investigating Erectile Dysfunction
1) Sexual and Psychologial History
2) Blood Tests (FBC, TFT, Prolactin and Testosterone)
3) Cardiovascular QRISK3
Managing Erectile Dysfunction
Psychosexual Therapy
Oral Phosphodiesterase Inhibitor
- Sildenafil (Increase NO = Blood flow)
Vacuum Erection device
Intra Cavernosal Injection
Penile Prostheses/ Ring
Sildenafil Action/side effects and interactions
“Little Blue Pill”
Action
Oral Phosphodiesterase Inhibitor to increase nitric oxide
Side Effects
Headache/ Flushing/ Hypotension/ Blue Vision
Contraindications
Nitrate use
Hypertension/Hypotension
Arrythmia AND Angina
Stroke/MI
What is Pyrionie
T2 Collagen deposition in Tunica Albuginda causing a deformed penis shape w/ abnormal fixed erection
What are the genetic associations of Peyrionie’s
HLA DR5
Dupuytren
Investigating Peyrionie’s
Penile USS
- Hyperechogenic Fibrotic Plaques
Managing Peyrionie’s
Plication( Sraightening surgery)
Intrapenile Injection (Collagenase)
What is premature ejaculation?
6+ months of Ejaculation <1min of sex with or without penetration before the patient wants it
What are the causes of premature ejaculation?
Performance Anxiety
Pornography
Hyperthyroid
Sex Abuse
Investigating Premature Ejaculation
Sex Bloods
Managing premature ejaculation
Stop Start Squeeze technique
54321 Breathing technique
Keigel Exercises
Lidocaine Cream
Dapoxetine SSRI
