Sexual Health

Question 1

What is the proper name for genital warts?
relatively how common are they?
What are they caused by?

Answer 1

The proper name is Condylomata accuminata.
They are the most commonly diagnosed viral sexually transmitted infection in the UK. (Second most common STI of any type after Chlamydia).
They are caused by HPV infection.

Question 2

How many subtypes of HPV can cause oncogenic affects?

What type of cancer(s) are they associated with?

Answer 2

About 15 genotypes are oncogenic, especially there the cause of multiple infections or specific infections.
They’re associated mainly with cerviacal cancer but can also cause cancer of the anus, the external genitalia, the oropharynx and the oral cavity.

Question 3

What are the worst genotypes of HPV to have? What are these genotypes?

Answer 3

HPV 16 and 18 are responsible for 70% of cancers.

Question 4

How is HPV transmitted?

Answer 4

The main mode transmission is by sexual contacts including oral sex and anal sex with people have clinical of subclinical HPV infection.
However can occur perinatally, and through contact with contaminated surfaces or objects
There is also some evidence that children with warts on their hands may transmit the infection to their genitals.

Question 5

Notification used when dealing with HPV infection?

Answer 5

No. The reason for this is that reinfection is not necessarily due to sexual contact with the partner.

Question 6

What is the chance of getting an HPV infection when in sexual contact with a partner who has HPV?

Answer 6

Risk is 20% over 6 months of sexual contact.

Question 7

What are the two methods of preventing HPV infection? How about ways of reducing the risk of infection and transmission HPV infection?

Answer 7

1) vaccination.
2) abstinence.
The risk of transmitting the infection can be reduced by having safe sex in terms of using condoms, and by reducing, or ideally having just one, sexual partner.

Question 8

Does condom use complete stop the chance of HPV transmission?

Answer 8

No it doesn’t. It helps prevent transmission, but HPV can affect a wider skin area than that covered by the condom.

Question 9

What skin cells does HPV target?
Why is it that the skin cells can not usually be affected here?
What is the incubation period for HPV infection?
Where is it the clinical lesions eventually appear?

Answer 9

Primary target of HPV is the basal keratinosites of the skin.
Normally the virus cannot enter these cells because of the overlying cell which act as a mechanical barrier. However abrasions and so on the skin is thought to the damage this barrier which then allows the virus to gain entry.
The incubation period is usually 3 to 4 months, although lesions can develop after as little as six weeks or as long as two years.
Clinical lesions eventually appear when the virus causes basal cell proliferation.

Question 10

What branch of the immune system is responsible for clearing HPV infection?

Answer 10

Cell mediated new responses, i.e. not humeral immune responses.
In immunocompetent individuals the hosts immunity spontaneously clears the majority of genital HPV infections and 10-30% of genital warts are estimated to resolve within three months of onset without Rx.

Question 11

How many women of reproductive age will be affected by vulvovaginal candidiasis?
What might make infection (including serious and recurrent infection) be more likely? (8)

Answer 11

75%!
Made more likely by:
1) use/overuse of antibiotics
2) pregnancy
3) diabetes 
4) immunosuppression.
5) HRT
6) Oral contraceptive pill.
7) sexual behaviour - increased frequency of intercourse and/or receptive oral sex.
8) Imidazole-resistant strains.

Question 12

What are the signs and symptoms of vulvovaginal thrush?

What age group is most affected?

Answer 12

Symptoms:
1) Itching
2) soreness
3) dysparaunea
4) dysurea
5) odourless vaginal discharge (usually thick and white, sometimes described as "curd-like")
Signs:
1) erythema 
2) excoriation
3) (in severe cases) fissuring and vulval oedema.

It is most common in women aged 20-40, though can affect any age. (Less frequent in post menopausal women).

Question 13

What is occasionally mistaken for candidiasis and why?

Answer 13

Immediately prior to menstruation, there is an overgrowth of Lactobacillus bacteria –> pH is lowered further than usual –> this can result in an overly acidic environment which can cause local vaginal irritation (cytolytic vaginosis) which can be mistaken for candidiasis.

Question 14

How can vulvovaginal thrush be divided and why is this important?

Answer 14

1) uncomplicated (episodic)
2) complicated
Important distinction, as the Rx varies.

Question 15

What is the difference in presentation of complicated and uncomplicated vulvovaginal thrush?

Answer 15

Uncomplicated - mild or moderate symptoms; not recurrent.
Complicated - occurring in pregnancy; recurrent (at least 4 episodes in a year); severe symptoms; underlying abnormality (e.g., diabetes, immunosuppression); non-albicans species.

Question 16

Why is it important to be sure that a woman presenting with symptoms that you think represent thrush actually has this?

Answer 16

Because it might be something else! Just as equally, it might be they have BOTH thrush and another condition.

Question 17

What are three common causes of vaginal discharge?

Answer 17

1) thrush
2) bacterial vaginosis
3) trichomoniasis

Question 18

How does the vaginal discharge and the symptoms vary in the three common causes of vaginal discharge?

Answer 18

Candidiasis: thick and white; non-offensive odour; vulval itch; soreness, superficial dysparaunea, and dysurea.
Trichomoniasis: scanty to profuse discharge; offensive odour; vulval itch; dysurea; lower abdominal pain.
Bacterial vaginosis: thin discharge; offensive/fishy smell; no itch; no other symptoms.

Question 19

What visible signs might be seen among the three main infective causes of vaginal discharge?
What point of care testing can be done?

Answer 19

The point of care testing is vaginal pH.
Bacterial vaginosis - discharge coats the vagina and vestibule. NO vulval inflammation. Vaginal pH more than 4.5
Candida - normal or vulval erythema; oedema; fissuring; satellite lesions. Vaginal pH less than or equal to 4.5
Trichomoniasis: Frothy yellow discharge; vulvulitis; vaginitis; carve citric; ‘strawberry cervix’. Vaginal pH more than 4.5.

Question 20

As discussed, common differentials for vulvovaginal candida are bacterial vaginosis and trichomoniasis. But these and other differentials should be considered, both infective and non-infective. Name them (6,5)

Answer 20

Infective:
1) Candida.
2) Bacterial vaginosis.
3) Chlamydia.
4) Gonorrhoea.
5) Trichomoniasis.
6) Herpes.
Non-infective:
1) Foreign bodies (e.g., retained tampons and even condoms!)
2) Cervical polyps.
3) Genital tract malignancy.
4) Fistula.
5) Allergic reactions.

Question 21

What are the most common causes of vaginal discharge that prompt women to present?

Answer 21

Vaginovulval candidiasis and physiological bacterial vaginosis, but also physiological discharge!

Question 22

Are women good at self diagnosis and treatment of candidiasis?

Answer 22

In general, no! A recent study showed that over the counter sales of antifungals to treat ‘thrush’ only actually worked on about 35% of women! The rest had bacterial vaginosis, mixed vaginitis, and small percentage having trichomoniasis.
A women seeking antifungals for thrush may be advised to see her GP, especially if the diagnosis is unclear, it is her first episode, or if she has had two or more infections of ‘candidiasis’ in the last 6 months.

Question 23

What assessment should be made of a woman presenting with vaginal discharge and/or concerns that they have candidiasis?

Answer 23

1) Take a detailed Hx, in lauding sexual history (especially if patient less than 25).
2) Explore the patient’s thoughts, concerns, fears.
3) Remember that recurrent or severe candidiasis may represent a more serious underlying pathology, e.g. Diabetes or immunocompromis. This might be worth mentioning if relevant.
4) The FSRH recommend that all women presenting with genital symptoms should be offered a vaginal examination…
5) …BUT it is acceptable to give Rx for candidiasis without examining the patient if the risk of STI is low and there are no symptoms of PID.
6) Women should be counselled to return for examination is symptoms persist.

Question 24

If when taking a Hx from a woman presenting with vaginal discharge, they are deemed at high risk of STI, what should be done?

Answer 24

Should either be referred to GUM or send vaginal, endocervical swab or urine for chlamydia or gonorrhoea.
Then perform a vaginal pH test, which can help the diagnosis.

Question 25

If a patient presents with a frothy yellow vaginal discharge, they have a vaginal pH more then 4.5, and they have an offensive odour to the discharge +- pruritus, vaginitis, dysurea…what have they likely got, and what should be done?

Answer 25

They likely have trichomoniasis.
Refer to GUM.
Send high vaginal swab to lab for trichomoniasis and other STI’s.

Question 26

Is microscopy and culture required if bacterial vaginosis is suspected? What vaginal pH and discharge would be expected in this case? What treatment?

Answer 26

A pH of more than 4.5 would be expected.
The vaginal discharge will typically by thin, grey-white, with a fishy/offensive odour, the area is not generally sore.
Microscopy and culture is NOT required.
Empirical therapy should be given.

Question 27

If candida is suspected, what should be given? Is microscopy and culture needed?

Answer 27

Give empirical treatment.

Culture not needed unless recurrent.

Question 28

If a vaginal discharge does not have the characteristics usually associated with another cause, what should you be considering and how should you act?

Answer 28

Other causes:
1) Physiological.
2) Foreign body.
3) STI.
4) Strep/staph infection.
In this case, send high vaginal swab for culture; also endocervical swab or urine for chlamydia or gonorrhoea.
Note that the vaginal pH will likely be more than 4.5 - which means the only case where it is often lower, is candidiasis!

Question 29

Isolated candidiasis does not usually require a high vaginal swab (which would be pointless anyway because a lot of women have candida species as a normal commensal).
But if a HSV was performed and showed candida, under what circumstance should treatment be given?

Answer 29

If they are symptomatic.

Question 30

In which women should an endocervical swab be taken to test for chlamydia and gonorrhoea?

Answer 30

1) anyone below the age of 25.

2) those at high risk of having an STI.

Question 31

What should a vaginal examination in the context of vaginal discharge involve?

Answer 31

1) Inspection of the vulva.
2) Speculum examination of the internal vaginal walls, the discharge itself, and the cervix.
3) To look for signs of ulceration, inflammation, or other lesion can suggest conditions other than candidiasis.

Question 32

When is it recommended to send off a high vaginal swab in cases of suspected candidiasis?

Answer 32

Certainly not all the time!

1) if the symptoms are not typical of candidiasis.
2) recurrent (over 4 episodes in a year)
3) resistant to Rx.

Question 33

Do tampons increase the risk of developing candidiasis?

What might?

Answer 33

No, tampons don’t.
But…
1) High oestrogen contraceptives, especially in cases of recurrent candidiasis. The recommendation is to use Depo-provera or POP instead.
2) In place of soap, vaginal moisturisers should be used.
3 Avoid tight fitting synthetic clothes and sanitary towls.

Question 34

What treatments are used for uncomplicated vulvovaginal candidiasis?

Answer 34

Loads! But basically…
1) clotrimazole 1% or 2% cream bd-tds to affected areas.
2) clotrimazole pessary - insert one pessary at night as a single dose. (Note: can gave 100mg pessary every night for 6 nights or 200mg pessary every night for 3 nights instead).
3) intravaginal clotrimazole 19% cream 5g at night as a single dose.
4) micronazole 2% in 5g applicator - once a day for 14 days or twice a day for 7 days.
5) miconazole vaginal capsule 1.2g inserted at night as a single dose.
6) econazole 1% cream - 5g applicator at might for 14 nights.
7) fluconazole - 150mg ORAL TABLET AS A SINGLE DOSE.
8) itraconazols - 200mg ORAL TABLET bd for one day.
Why doesn’t everyone just use the oral tablet?!?

Question 35

What is the best formulation used to treat uncomplicated candidiasis?

Answer 35

None! They are all as good as each other, with the possible note that the oral versions have more scope for systemic side effects.
Note this is true for preparations that are taken as a one off dose vs preparations taken for several days!!

Question 36

What is the problem with using vaginal creams and pessaries to Rx candidiasis?

Answer 36

They can damage and compromise condoms.

Question 37

What are the cure rates for simple candidiasis?

Answer 37

80%!

Question 38

Candidiasis in pregnancy is considered complicated candidiasis. What is the risk to the baby?
How should these women be treated?

Answer 38

No risk to the baby! No risk of low birth weight or premature delivery.
If the woman is asymptomatic DONT TREAT!
But…this is a case where oral treatments are NOT used.
Instead give topical Imidazole (any-none is better than another) - 4 days will cure about 50%, 7 days will cure just over 90%, but there is no benefit in longer Rx. Therefore prescribe 7 days of topical Rx in this case.

Question 39

Why are oral Rx for vulvovaginal thrush NOT used in pregnancy.

Answer 39

At higher doses (e.g., 400mg/day) there have been rooted cases of foetal malformation.

Question 40

What is defined as recurrent vulvovaginal thrush?
What to wonder about/Ix for?
What else will Ix inform?
How to Rx?

Answer 40

4 or more cases in a year.
Send HSV for microscopy and sensitivity - this is to confirm the diagnosis, but also to identify any associated infections,e.g., BV; or the small amount of cases caused by non-albicans species.
In this case, one should wonder about underlying causes e.g., diabetes or immune compromise.
Rx involves an initial induction regime then a maintenance regime lasting 6/12. NOTE THAT THIS IS UNLICENSED CURRENTLY.

Question 41

Describe the initial and maintenance Rx of recurrent vulvovaginal candidiasis?

Answer 41

Inductions: either:
1) oral fluconazole 150mg every 72 hrs for 3 doses, or…
2) oral itraconazole 200mg once a day for 7 days,or…
3) topical imidazole therapy for 10-14/7 depending on response.
Then maintainance (6 months): either:
1) topical clotrimazole pessary 500mg once a week
2) oral fluconazole 150mg once a week OR itraconazole 200mg twice a day, one day every month for 6/12.
Note that in induction regime, oral fluconazole and oral itraconazole should be avoided in pregnancy or breast feeding.

Question 42

With correctly Rx recurrent vulvovaginal thrush, what is the cure rate?

Answer 42

90% after 6 months!

Question 43

What is the risk of long term (I.e., six month) courses of anti-fungals for thrush Rx? What Ix is recommended before starting?

Answer 43

Small risk of hepatotoxicity, especially with itraconazole.
LFT’s should be monitored when patients are on longer term oral imidazoles.
Ketaconazole is especially risky, and shouldn’t be used except by someone with lots of relevant experience.

Question 44

How is severe vulvovaginal candidiasis treated?

Answer 44

1) take vaginal swab to identify any resistant species and to confirm the diagnosis.
2) EITHER two doses of oral fluconazole 150mg 3 days apart (should be avoided in pregnancy or breastfeeding) OR…
3) two intravaginal clotrimazole pessaries 500mg 3 days apart.
4) if symptoms do not resolve on 10-14 days, the woman should be asked to return.

Question 45

Why does diabetes complicate vulvovaginal candidiasis?

Answer 45

Increased glucose levels in vaginal secretions increase the yeast’s adhesion and growth on the vaginal skin.

Question 46

What about the occurrence of Candidiasis in HIV +ive women?

Answer 46

Candida is more common in women with HIV, and this may have impact on quality of life.
Note though, that treatment for the well controlled diabetic or for then on-immunocompromised HIV patients is the same as for healthy women.

Question 47

How to Rx women with candidiasis and HIV or diabetes?

Answer 47

As discussed, if immunocompetent or well controlled diabetes –> same as for any other women.
Otherwise, a longer course of oral antifungals can be used e.g., 7 days of fluconazole, or a longer topical course, e.g., 6-14 days clotrimazole.
General advice on washing, clothing and contraception should also be offered,

Question 48

What is the most common gynaecological symptom in pre-pubertal girls?

Answer 48

Vaginal discharge. In the majority of cases it is due to a non-specific bacterial vulvovaginitis caused by organisms including skin and gut commensals. It can be associated with poor anal hygiene.

Question 49

How should a pre-pubertal girl with vaginal discharge be assessed?

Answer 49

Sensitively!
If possible on the mother’s lap and avoiding instrumentation.
If there is a discharge, it usually pools in the posterior fourchette, and swabs can be taken from here.

Question 50

What is the appearance of non-specific vulvovaginitis?

Answer 50

Usually a generalised inflammation of the vulva and vagina with associated discharge, which may be offensive.
Antibiotics are only needed if it is a single organism identified on the culture from the swab, I.e., not ‘mixed growth’
Otherwise, Rx involves improving vulval hygiene and general measures such as avoiding perfumed soap and wearing cotton underwear.

Question 51

How common a cause of vulvovaginitis is candida in prepubertal girls?
Why might they have it?
How is it treated?

Answer 51

Very uncommon in prepubertal girls.
Usually a precipitating factor, e.g., diabetes, recent antibiotic course. Always consider the possibility of sexual abuse, especially if there are associated emotional or behavioural changes.
Treatment is with TOPICAL antifungals.

Question 52

How common is vulvovaginal candidiasis in post-menopausal women?
What may provoke it?
What is it often mistaken for, and how can that be treated?

Answer 52

It is uncommon in post-menopausal women, thought to be die to lower levels of oestrogen.
If affected, the woman in question may have a pre-dissing factor such as diabetes or take HRT or tamoxifen.
Much more common after menopause to have atrophic vaginitis (presents with vaginal dryness, itching, burning, and sometimes offensive discharge).
In this case, Rx is with topical HRT or vaginal moisturiser.