Sexual Health Flashcards
How long is the incubation period with syphilis?
Three weeks
What bacteria causes syphilis?
Treponema pallidum
What are the categories of acquired syphilis?
Primary:
- incubation period 2-3 weeks
- local infection
Secondary:
- incubation period 6-12 wk
- generalised infection
Latent syphilis:
- asymptomatic syphilis of around 2 years duration
Late symptomatic syphilis:
- ‘tertiary syphilis’ - cardiovascular, neurosyphilis
How does primary syphilis present?
Primary lesion develops at the site of infection
Small painless papule, which forms an ulcer (chancre) with a red margin, discharging clear serum
Usually around coronal sulcus, glans and prepuce, vulva, labia, occasionally mouth and genitalia
May have enlarged regional lymph nodes
How does secondary syphilis present?
Secondary syphilis appears 6 weeks after primary lesion
Systemic presentation - nighttime headaches, malaise, fever, aches, generalised polymorphic rash on palms, soles, or face
What is neurological syphilis?
Presentation of tertiary syphilis
May be asymptomatic but with abnormal CSF
May be symptomatic:
Tabes dorsalis - dorsal column loss
Dementia
Meningovascular involvement
What is cardiovascular syphilis?
Presentation of tertiary syphilis
Characterised by aortitis, spreading dismally from aortic root
Clinical manifestations include aortic regurgitation, aortic aneurysm, angina
How should suspected syphilis be investigated?
Screen for all STIs
Request treponemal enzyme immunoassay for IgM for early infection (primary syphilis)
How should primary syphilis be treated?
Benzathine penicillin IM single dose
Oral azithromycin single dose - second line
How common is gonorrhoea?
Accounts for 7% of newly diagnosed STIs
How long is the incubation period for gonorrhoea?
Between 2-5 days, but may be up to 10 days
How often is gonorrhoea asymptomatic in men and women?
Men - 90-95%
Women - 50%
How does gonorrhoea present in men?
Usually asymptomatic
Urethral infections:
Mucopurulent discharge, dysuria
Epidydymal tenderness/swelling
Rectal infection - anal discharge, perianal pain, pruritis, bleeding
Pharyngeal infection
How does gonorrhoea present in women?
Urethral infection: Dysuria without frequency Mucopurulent endocervical discharge Contact bleeding of cervix Pelvic/abdominal tenderness
Rectal infection
Pharyngeal infection
What bacteria causes gonorrhoea?
Neisseria gonorrhoea
Gram negative diplococci
How is gonorrhoea managed?
Ceftriaxone 500mg IM stat plus azithromycin 1g orally stat
Partner notification
No sexual intercourse until both partners have completed their abx
What are the complications of gonococcal urethritis in men?
Urethral scarring and structure Acute epididymitis Prostatitis Seminal vesiculitis Penile lymphangitis Peri-urethral abscess
What are he complications if gonorrhoea in women?
Barthholins abscess
Pelvic inflammatory disease, resulting in infertility, chronic pelvic pain and perihepatitis
What bacteria causes chlamydia?
Chlamydia trachomatis
Small obligate intracellular gram negative bacteria
How does chlamydia present in women?
Often asymptomatic Vaginal discharge Dysuria Lower abdominal pain Fever Intermenstrual or postcoital bleeding Dyspareunia Cervical excitation
How does chlamydia present in men?
Often asymptomatic Dysuria Urethral discharge Epididymo-orchitis Unilateral testicular pain and swelling Fever
What are other presentations of chlamydia infections?
Reactive arthritis
Perihepatitis (fitz-Hugh Curtis syndrome)
Proctitis with mucopurulent discharge
Pharyngeal infection
What is the triad of Reiters syndrome?
Urethritis
Arthritis
Conjunctivitis
Can be triggered with chlamydial infection
What is the treatment of chlamydia?
1g azithromycin
Or
7 days doxycycline
Alternatives include erythromycin and
Ofloxacin
Partner notification
No sexual inter course until both partners have completed their abx
What is a differential for vaginal discharge in a young woman?
Bacterial vaginosis
Candida albicans
Trichomonas vaginalis
Chlamydia trachomatis
Neisseria gonorrhoea
Cervical ectopy
Pregnancy
Retained tampons
Foreign body
How should female genital infections been investigated?
Look at appearance of vaginal discharge and perform vaginal pH (BV)
High vaginal swab - BV, candida and TV
Vulvovaginal swab - chlamydia and gonorrhoea NAAT
Endocervical swab for GC culture
Syphilis serology and HIV
What are causes of post coital bleeding?
Infection:
Chlamydia
Gonorrhoea
Cervical abnormality: Polyp CIN Cervical malignancy Ectopy
What investigations should be done to investigate post coital bleeding?
Speculum
Vulvovaginal swab - chlamydia and gonorrhoea NAAT
Endocervical swab - gonorrhoea culture
Cervical assessment - smear and colposcopy
What is a differential for dysuria in young women?
UTI Chlamydia trachomatis Gonorrhoea Genital herpes Genital candidiasis Trichomonas vaginalis Vulval dermatoses
How might dysuria be investigated?
Examine vulva - signs if excoriation, fissuring, erythema, oedema
Take herpes/syphilis swab from vulval
ulcer
MSU
Perform vulvovaginal swab for chlamydia and gonorrhoea NAAT
Perform high vulvovaginal swabs for candida, TV and BV
Endocervical swab for gonorrhoea culture
How should a suspected STI/UTI be investigated in a male?
Urethral swab - grab stained smear and culture for gonorrhoea
FSU - chlamydia and gonorrhoea NAAT
MSU to exclude UTI
Syphilis and HIV serology
If MSM- rectal and pharyngeal swabs for chlamydia and gonorrhoea - NAAT is culture
What is a differential for genital rash?
Candida Strep/staph Anaerobes Trichomonas Gardnerella Syphilis Heroes simplex Circinate balanitis Lichen sclerosis Lichen planus Psoriasis Eczema
What is a differential for genital itch?
Thrush
Trichomoniasis in females
Scabies
Pthyris pubis
Dermatitis
Lichen sclerosis
Lichen planus
Lichen simplex
How should genital rash be investigated?
Supreputial swab for candida and bacterial culture
Urinalysis for glucose if candida suspected
Viral swab for HSV
Syphilis serology if genital ulcer
STI screen if appropriate
Biopsy if necessary
What is general advice to give to patients with genital rash?
Salt water bathing
Avoid soaps while inflammation persists
Use aqueous cream/E45 wash as soap substitute
What is the treatment for candida infection?
Topical antifungals -
e.g canesten cream BD until symptoms resolve (clotrimaxole)
What is the treatment for lichen planus?
Usually self limiting
What is the treatment for lichen sclerosis?
Potent topical steroid
Requires long term follow up due to small risk if malignant transformation
How does candida balanitis present?
Common condition
Red papules, superficial erosion, or white plaques
How is candida balanitis managed?
Exclude diabetes, lichen planus and candidal balanitis
Topical therapy- clotrimaxole cream or fluconazole
How does circinate balanitis present?
Painless, mucocutaneous lesions
Associated with sexually acquired reactive arthritis
Skin lesions are similar to psoriasis
How does scabies present?
Widespread pruritic dermatitis, genital nodules, burrows in fingerspaces
How is scabies diagnosed?
Clinical
Skin scrapings may help
What is the management of scabies
Permethrin 5% cream
Treat household and close contacts
What is pthyris pubis and how does it present?
Pubic lice
Genital itch
Blue spots
Perifolliculitis
What is the treatment of pthyris pubis?
Permethrin 1% or malathion 0.5%
Treat sexual partners
How does lichen simplex present?
Due to chronic rubbing or scratching?
Poorly demarcated plaques of thickened skin
Usually affects scrotum in men and labia majors in women
How is lichen simplex treated?
Avoid irritants
Emollients/moisturiser
Mild topical steroid
How does lichen sclerosis present?
Itching or soreness
Pale, Atrophic skin, erosions, telangiectasia, loss of architecture
May develop into SCC (4%)
How is lichen sclerosis treated?
General skin advice
Potent topical steroids
How does lichen planus present?
Lichen planus is an inflammatory condition of unknown aetiology
Different morphological appearances:
Violaceous, flat-topped papules
White lacy papules
Plaques or erosions
Itching is main symptom
Self limiting
How many people under 25 are colonised with HSV-1?
60%
Majority acquired subclinically - 80% unaware they are infected
How many men and women are affects by genital herpes!
Female - 1 in 8
Male - 1 in 25
How often do recurrences occur in herpes?
Males have more recurrences
These are usually self limiting, and last 7-12 days
HSV1 - 1-2 recurrences a year
HSV2 - 4-6 recurrences a year
Recurrences usually decrease over time
20% have no recurrences
How should a herpes outbreak be treated?
Saltwater bathing
Topical anaesthetic/oral analgesia
Acyclovir 400mg 3x a day for 5 days
How can herpes be passed on, and how can this be prevented?
Direct contact with mucous membranes or skin
Most infectious during recurrence, although viral shedding occurs when asymptomatic
Avoid sex during recurrences, use condoms otherwise
What causes molluscum contagiosum?
Molluscum virus - DNA pox virus
How is molluscum contagiosum treated?
Cryotherapy
Currette
Enucleation
Podophyllotoxin
How do genital warts tend to appear?
Smooth polypoidal lesions
What virus causes genital warts?
Human papilloma virus (HPV)
What types if HPV are responsible for genital warts?
HPV subtypes 6 and 11 responsible for 90% of genital warts
HPV subtypes 16-18 tend not to cause genital warts, instead cause cervical cancer
How are genital warts transmitted?
HPV gains access to basal epithelial layer through micro abrasions in genital skin during sexual contact
May be transmitted by oral-genital contact- rarely transmitted by digital genital contact
What is the incubation period for genital warts?
Usually 3 months
Can be as short as 3 weeks, can be as long as 2 years
How are genital warts treated?
Ablative therapies:
Cryotherapy - if few warts
Podophyllotoxin cream - if many warts
Electrocautery - for intrameatal warts
Immune modulation:
Imiquimod 5% cream - persistent warts - low recurrence rates
Surgical:
Curettage
Excision
Debulking
How long do genital warts take to resolve?
Most resolve by 3 months with treatment
Detectable in genital skin for 1 year
May recur, and a small minority may have persistent warts
May be re-infected with a different HPV strain
How long is a patient with genital warts infectious for?
3 months after the warts have resolved
Can genital warts be transmitted when asymptomatic?
Yes
Condoms do not eliminate transmission, they just reduce it
Can anal genital warts occur without anal sex?
Yes
HPV is a multicentric infection, and not limited to initial site of infection
What is lymphogranuloma venereum?
STI caused by chlamydia trachomatis
Presents with painless papule which ulcerates and heals
Then develop lymphadenopathy and inguinal abscesses
What causes strawberry cervix?
Trichomonas
Punctate erythematous appearance of cervix in trichomoniasis
What is chancroid?
Ulcerative condition if the genitalia which develops to cause: Single /multiple ulcers Phimosis Enlargement of inguinal lymph nodes Abscess Discharging sinus
Caused by haemophilus ducreyi
