Sexual health Flashcards by Joe Sullivan

What are some non-infective causes of changes in discharge?

Cervical ectropion
Foreign body
Physiological (some discharge for women is normal)

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What are some infective causes for changes in discharge?

NOT STI (bacterial vaginosis, candida)
STI (Trichomonas vaginalis, chlamydia trachomatis, Neisseria gonorrhoeae)

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What is physiological vaginal discharge like?

It is clear, has a non-offensive odour, is approx 1-4mls every 24 hours and varies with the menstrual cycle

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What is the commonest cause of vaginal discharge in women of CBA?

Bacterial vaginosis

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What is the pathophysiology of bacterial vaginosis? What does the discharge look like and what symptoms are commonly experienced?

There is bacterial overgrowth causing lack of lactobacilli meaning the pH of the vagina increases (normal=4.5m BV=4.5-6)
Discharge is thin, watery, white
There is no soreness, itchiness or irritation

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What are some possible complications of BV?

PID
Obstetric complications
- Late miscarriage 
- Pre-term birth
- Post-Delivery endometritis 
- PROM

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If you suspect BV what tests should you do?

Low vaginal swab
pH of vagina
Gray-Ison gram stained vaginal smear

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What management should be recommended for BV?

Avoid douching - just wash with water
Only treat if symptomatic or undergoing gynaecological surgery
MEDICATION: metronidazole

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What organism causes thrush?

Candida albicans

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Who is most likely to get candida?

immunosuppressed (e.g. HIV)
Abx use
Elevated oestrogen

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What are the symptoms of candida?

Thick, creamy, lumpy discharge (cottage cheese)
Vulval itch and soreness, excoriations
Redness/rash on the vulva - satellite lesions, fissuring, oedema
Superficial dyspareunia and dysuria

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How should we investigate a patient with suspected candida?

Candida is so common that it often doesn’t require investigation before treatment
- Ca do microscopy in GUM if clinically picture is slightly more confusing

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How should we manage a case of candida?

Soap substitute, emollient for skin irritation, loose cotton underwear and avoid local irritants

MEDICAL: Oral fluconazole 150mg PO (cannot give if pregnant)
OR
500mg CLOTRIMAZOLE PESSARY

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Is trichomonas vaginalis an STI?

YES - it is commonly mistaken for BV or candida

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What are some symptoms of trichomonas vaginalis?

Vulval itch and soreness 
Frothy, yellow discharge 
Dysuria 
Vulvitis 
Vaginitis 
STRAWBERRY CERVIX (highly suggestive but only present in 10%)

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If you suspect a woman might have TV how should you investigate?

Swabs from posterior fornix then mount on wet mount slide for microscopy

Also do VVS NAAT swabs

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How should we manage a woman with TV?

Treat partners and avoid sex for 1/52

2g Metronidazole stat dose
OR
400mg metronidazole BD for 5-7 days (this is the more effective regime and this should be given to males always)

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What is the most common STI in the UK?

Chlamydia Trachomatis

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What are the chances you will pass on chlamydia if you have it?

75%

Majority of people are asymptomatic

What are some symptoms of chlamydia?

Increased discharge (women)
Dysuria 
PCB
IMB 
Dyspareunia (deep)
Lower abdominal pain

What might you find on examination in a women with chlamydia?

Mucopurulent cervicitis

Contact bleeding of the cervix

What are some complications of chlamydia?

PID, endometriosis, salpingitis 
Tubal infertility 
Ectopic pregnancy 
Sexually acquire reactive arthritis 
Fitz-Hugh Curtis Syndrome

What investigations should you do in someone you suspect to have chlamydia?

NAAT VVS or urine

Consider swabbing in different sites (throat and rectum in MSM)

How long do you have to wait for chlamydia to show as positive on test?

2 weeks

How should we manage chlamydia?

Abstain for 1/52 and treat partners (CONTACT TRACING) DOXYCYCLINE 7/7 100mg BD (CI'd in pregnancy) AZITHROMYCIN 1g PO STAT (if pregnant give 500mg OD for 2 days after) ***if woman is pregnant then re-test her to make sure the infection has been cleared

What sort of bacteria is neisseria gonorrhoeae?

Gram negative diplococcus

What are some symptoms of people who have gonorrhoea?

``` Pain Purulent discharge PCB, IMB or menorrhagia Lower abdomen pain Dysuria if urethral infection ***might be endocervical bleeding, can lead to PID ```

What investigations should be done in someone who has suspected gonorrhoea?

VVS NAAT and urine for men Consider multi site testing in MSM (rectum and throat) Can do microscopy and analyse if in GUM

How should we manage cases of gonorrhoea ?

Avoid sex for 1/52 and contact trace partners 1g PO AZITHROMYCIN and 500mg IM injection of CEFTRIAXONE Do swabs 2/52 later to check it has been cleared

Name some physiological skin changes on the penis?

Fordyce spots (around the base of the glans) Pearly, penile, papules Parafrenular glands

What causes genital warts?

HUMAN PAPILLOMA VIRUS 90% are caused by strains 6-11 - remaining are caused by 16 and 18 (more concerning because oncogenic)

Is HPV sexually transmitted and what is the incubation period?

Yes it is | Incubation period can be any time between 3 weeks and 8 months meaning it can be very hard to contact trace

What managements can be offered for HPV warts?

``` Cryotherapy Immiquimod cream - ALDARA Cautery Excision SMOKING makes warts act much longer ```

What other lumps on the penis are commonly mistaken for HPV warts?

Molloscum contagiosum (think this if they are umbilicate) Lymphoceles can cause lumps on the penis Sebaceous cysts are also not uncommon on the penis Scabies can also occur on the penis

What causes genital ulcers?

Herpes virus (usually HSV-2)

How will herpes ulcers present?

There might be multiple | They are usually quite small, very shallow and very painful, can be sloughy and produce discharge

How do we investigate possible cases of herpes?

Take a viral PCR swab of the ulcers (might be difficult given how painful they are)

How do we manage herpes ulcers and can we cure then?

Aciclovir 400mg BD PO when symptomatic It is a lifelong infection that we can't clear - should not have sex when symptomatic but can normally when not - chances of passing on v low ***always contact trace

How does syphilis often present?

Large, painless lesions/ulcers on the genitals known as CHANCRES Rashes on hands and feet

If you think a chancre might be syphilitic what is the best way to investigate?

Viral PCR of chancre | Blood test for syphilis

What organism causes syphilis? Who is highest risk?

Treponema Pallidum | Highest risk is MSM between 25-34

What are the stages of syphilis?

Primary Secondary Latent (early and late) Late

What are the symptoms of primary syphilis?

Incubation period of 9-90 days (average 21) Simple papule that turns into a chancre (usually anogenital) May be multiple and develop over 3-8 weeks Then resolve

What are some symptoms of secondary syphilis?

25% of patients with primary will go on to develop secondary Occurs 4-10 weeks after initial chancre Most noticeable symptoms is SYPHILIS RASH (hands and feet, widspread and very itchy) Can also get hepatosplenomegaly, glomerulonephritis and neurological complications (acute uveitis, cranial nerve palsies and meningitis)

How long do the early and late latent phases of syphilis last for?

``` Early latent (2 years) Late latent - anything longer than 2 years ```

What symptoms can we expect in the late (tertiary) phase of syphilis?

NEURO - wide-stepping gait, delusions of grandeur, loss of vibration sense CARDIO - Dilation of aortic root GUMMATOUS - Ulceration of limbs

How can we manage syphilis ?

Depends on stage... If primary, secondary or early latent...Benzathine Penicillin 2.4MU IM single dose Late latent or tertiary...Benzathine penicillin 2.4MU IM three doses (one a week for three weeks)