Sexual Health Flashcards
What are the 4 parts of a sexual history?
- With whom - male/female, regular/casual
- Type of sex - oral, vaginal, anal
- Condoms and contraception
- Risk assessment
What are the 5 parts of a risk assessment?
- Known HIV +ve partner
- MSM
- IVDU
- Sex with someone born outside UK
- Paid or been paid for sex
What makes up an STI screen for an asymptomatic female?
Own VVS for chlamydia and gonorrhoea
Bloods for HIV, syphilis and hep B
What makes up an STI screen for a SYMPTOMATIC female?
VVS for C+G - NAAT 2nd VVS for microscopy Speculum - cervical smear if needed HVS for BV, candida and Trichomonas - slide and plate Endocervical swab for G culture Bloods for HIV, S, Hep B
What colours are the NAAT and HVS/ECS tubes?
NAAT = red HVS/ECS = black
What makes up an STI screen for asymptomatic males?
1st void urine test for C+G
Bloods for HIV, S, Hep B
What makes up an STI screen for SYMPTOMATIC males?
Urine
Bloods
Urethral opening swab - slide and plate
Examine pelvis and penis
What makes up an STI screen for an asymptomatic MSM?
Throat, rectum, penis swab
Urine
Bloods
What makes up an STI screen for a SYMPTOMATIC MSM?
2x triple swab
Urine
Bloods
Examination
What type of test is a VVS?
NAAT test for C+G
2 week window
What type of test is first void urine?
NAAT test for C+G
2 week window
What type of test is a HVS?
Microscopy for BV, Candida and trichomonas
What type of test is an endocervical swab?
Culture for gonorrhoea sensitivities
What are the blood tests done in an STI screen?
HIV antibody and p-24 antigen - 3 month window
Syphilis treponemal antibody - 5 week window
Hep A IgM
Hep B surface antigen (HBsAh)
Anti-HCV
What type of test is a viral swab?
Viral PCR for herpes
What is chlamydia?
Intracellular bacteria
Affects columnar epithelium of GU tract
What are the symptoms of Chlamydia?
Vaginal discharge - mucopurulent
Lower abdominal pain
PCB, IMB
Dysuria and urethral discharge in men
How is Chlamydia diagnosed?
NAAT
VVS in women (red tube)
First void urine or urethral swab in men
What is the treatment of chlamydia?
1g Azithromycin STAT then 500mg next day, 250mg day after
OR 100mg Doxycycline BD 7 days
What advice should you give people with Chlamydia?
Abstain during treatment of both partners completed
Future condom use
Test for cure not necessary unless pregnant
What are some complications of chlamydia?
PID Reactive arthritis Reiter's syndrome Fitz-Hugh-Curtis syndrome Conjunctivitis
What are the features of PID?
Abdo pain
Tubal infertility possibly
What is Reiter’s syndrome?
Triad of:
- Urethritis
- Arthritis
- Conjunctivits
Associated with HLA-B27
What is Fitz-Hugh-Curtis syndrome?
Perihepatitis - characterised by pyrexia, RUQ pain, guarding, abnormal LFTs
What are the complication of chlamydia in pregnancy?
IUGR
Chorioamnionitis
Preterm delivery/PROM
Miscarriage
What is the treatment of chlamydia in pregnancy?
Erythromycin
Doxycycline = contraindicated in pregnancy
What are two neonatal complications of chlamydia?
Ophthalmia neonatorum
Neonatal pneumonitis
What is ophthalmia neonatorum?
Presents 1-2 weeks
Conjuctivitis, conjunctival oedema, purulent exudate
Tx = erythromycin
What is neonatal pneumonitis?
Presents 1-3 months
Staccato cough, tachypnoea
Tx = erythromycin
What type of bacteria is gonorrhoea?
Gram-negative diplococcus
What are the symptoms of gonorrhoea?
Vaginal discharge - endocervical Lower abdominal pain Dysuria Proctitis with rectal bleeding Urethral discharge in men
How is gonorrhoea diagnosed?
Endocervical swab - culture
VVS - NAAT
Urethral, rectal, throat swabs
What is the treatment of gonorrhoea?
Ceftriaxome 500mg IM
Azithromycin 1g PO etc
TEST FOR CURE
What are some complications of gonorrhoea?
PID
Subfertility
Bartholin’s abscess
Similar to chlamydia
What is the treatment of gonococcal PID?
Ceftriaxone STAT plus doxycycline AND metronidazole for 14 days
What is Thrichomonas vaginalis?
Flagellate protozoan
How does TV present?
Vulval soreness and itching Foul smelling frothy green discharge Dysuria Dyspareunia Strawberry cervix
How is TV diagnosed?
Vaginal pH >5.0
Seen on saline wet-mount (pathognomonic)
What is the treatment of TV?
Metronidazole 2g STAT or 400mg BD 7 days
Both partners and contact tracing
Test for cure
What is bacterial vaginosis?
Increased anaerobes and decreased lactobacilli -> alkaline pH
Eg. Gardenella vaginalis, Mycoplasma hominis etc
What are the features of BV?
Fishy discharge
Grey/white discharge adherent to vaginal walls
More prominent during and following menstruation
What is the Amsel criteria for diagnosing BV?
- Presence of clue cells on microscopy
- Creamy grey/white discharge seen
- Vaginal pH >4.5
- Release of fishy odour upon alkali addition
Need 3+ for diagnosis
What is the Hay criteria for BV?
Grade 1 = normal, lactobacillus predominates
Grade 2 = intermediate, Gardenerella +/- Mobiluncus seen with lactobacillus
Grade 3 = BV, lactobacillus absent, mostly Gardenerella
What is the treatment for BV?
Metronidazole 400mg BD 5 days or 2g STAT
Why is BV an issue in pregnancy?
If in 1st trimester, can cause late 2nd trimester miscarriages
What should women with a history of 2nd trimester miscarriages have?
Early pregnancy vaginal swab and treatment
What is vulvovaginal candidiasis?
90% = candida albicans
What are some risk factors for candidiasis? (5)
Pregnancy Immunocompromised High dose COCP Broad spectrum Abx HRT
What are the features of candidiasis?
Vulval itching and soreness Thick cottage cheese discharge Dyspareunia Dysuria Erythema
What is the vaginal pH of candidiasis?
Normal
How is candidiasis diagnosed?
HVS microscopy - see budding yeasts and pseudohyphae
Cultured on Sabutaud’s medium
What is the treatment of candidiasis?
Only if symptomatic
500mg Clotrimazole pessary
OR topical 10% clotrimazole cream
OR oral fluconazole 150mg
What is the treatment of a complicated candida infection?
Same but for 2 weeks
Eg. severe, pregnancy, DM
What is recurrent candida infection?
4+ episodes per year with positive microscopy
Tx = Fluconazole 150mg PO 3 doses every 72hrs then 150mg weekly for 6 months
What is lichen simplex?
Chronic rubbing causes eczema and itching causes lichenification
What are the features of lichen simplex?
Poorly demarcated plaques with scaling, excoriations and lichenification
What is the management of lichen simplex?
Emollients mainly
Possibly mild topical steroids
What causes lichen planus?
Unknown
What are the features of lichen planus?
Itchy, papular eruption with a fine scale
Can also be oral - white stripes on tongue = Wickham’s stricture
What is the treatment of lichen planus?
Conservative - usually self-limiting
Same as lichen simplex
What is lichen sclerosis?
Destructive inflammatory skin condition
Affects anogenital area
Often have another AUTOIMMUNE condition
What causes lichen sclerosis?
Autoimmune
Hyalinization of skin -> fragility and loss of anatomy
What are the features of lichen sclerosis?
Fragile skin
Loss of anatomy
Stricturing and narrowing of vaginal opening
Vulval itching
What investigation may be useful for lichen simplex?
Biopsy - can confirm diagnosis
What is the treatment of leeching sclerosis?
Potent topical steroids
What is a complication of lichen sclerosis?
Squamous cell carcinoma
What is vulvodynia?
Vulval discomfort, often BURNING
In absence of skin disease
What are the features balanitis?
Sore, inflamed glans penis
Can’t retract foreskin
Dysuria
Possibly discharge
What can cause candida balanitis?
Diabetes - do BM and urine dip
Oral Abx
Poor hygiene
Immunosuppression
What are some skin changes that may be present with candida balanitis?
Red papules with superficial erosions
White plaques
What is the treatment of balanitis?
Candida = Clotrimazole 1% cream
Bacterial = Flucloxacillin
Anaerobe = Metronidazole
Hygiene measures
What are Pthyris pubis?
Pubic lice/crabs
What are the features of Pthyris pubis?
Genital itch
Blue spots
Perifolliculitis
What would indicate a diagnosis of Pthyris pubis?
Egg is pubic hair
What is the treatment of Pthyris pubis?
Permethrin 1%
Treat all sexual contacts
What are Hirsuties coronae glandis or coronal papules?
Pearly penile papules on ridge of glans penis
Normal
What are epidermoid cysts?
Small hard lumps which grow under the skin
What are Fordyce spots?
White/yellow bumps due to enlarged oils glands
Generally on face, can be on genitalia
What are the types of Herpes?
HSV1 = oral infection HSV2 = anogenital infection
What happens once infected with herpes?
Can remain latent in sensory ganglia
Lytic lesions at times of stress
What are the features of primary HSV infection?
Irritation or parasthesia at lesion site -> painful papule -> ulcer
Whole episode completed within a week
Some systemic flu-like symptoms also
What are the features of HSV reactivation?
Times of stress/menstruation
Shorter and less severe than primary infection
50% patients
How is HSV diagnosed?
Clinical
Can do viral PCR swab (black tube)
What is the treatment of HSV infection?
Aciclovir 400mg TDS oral 5 days
What is the treatment of recurrent HSV?
None needing, self-limiting
Saline baths and analgesia
Frequent attacks = acyclovir in first 24hrs of attack
What are the complications of HSV infection?
Autonomic neuropathy -> urinary retention
Aseptic meningitis
Secondary bacterial infection
What do you do if a women gets primary herpes in the 1st or 2nd trimester?
Give Aciclovir 400mg TDS from 36 weeks
Reduces reactivation risk and need for LSCS
What do you do if a women gets primary herpes in the 3rd trimester?
Takes 6 weeks for antibody response to develop against HSV to protect neonate
Greatest risk
LSCS recommended
Same as 1st/2nd trimester Mx otherwise
What is the management if a women has active HSV in labour?
LSCS
If vaginal delivery occurs = IV acyclovir for mother and neonate and avoid invasion procedures
What causes genital warts?
HPV 6 and 11
How are genital warts transmitted?
Gains entry via basal epithelial layer through microabrasions during sexual contact
How are genital warts prevented?
Gardasil vaccination at 12yrs includes 6 and 11 subtypes
What is the incubation period for genital warts?
3 months
Anywhere from 3wks to 2yrs
Can you contract genital warts from an asymptomatic partner?
Yes
What therapies are available for genital warts?
Ablation
Immune modulation
Surgery
What are the ablative therapies for genital warts?
Cryotherapy - if <6 warts
Podophyllotoxin cream - it >6 warts
What are the immune modulation therapies for genital warts?
Imiquimod 5% cream = keratinised, persistent or recurrent warts
Lower recurrence rate (30%)
What organism causes syphilis?
Treponema pallidum
How is syphilis transmitted?
Abrasion in skin or intact mucous membrane
3 week incubation
How does primary syphilis present?
9-90 days post-expose
Painless ulcer = chancre
Resolves in 2-6 weeks
How does secondary syphilis present?
6 weeks to 6 months post-exposure
Generalised infection and lymphadenopathy
Maculopapular rash on palms and soles
Systemic symptoms
How does tertiary syphilis present?
10-40 years post-exposure
With severe organ effects
What is neurosyphilis?
Dorsal column loss, dementia, meningeal involvement
What is cardiovascular syphilis?
Aortic regurg, AAA, angioma
What are gumma?
Locally destructive fibrous nodules
Affect bones and skin generally
What is early latent syphilis?
Positive serology but no clinical evidence in first 2yrs of infection
What is late latent syphilis?
Positive serology after >2yrs of infection
What investigations should be performed for suspected syphilis?
Serology
Dark group microscopy from ulcer
PCR from ulcer
How accurate is serology?
Primary = 70-80%
Secondary = 100%
Repeat in 3 months if negative with genital ulcer
What is the advantage of microscopy and PCR?
Can give immediate treatment
What is the treatment for syphilis?
Benzathine Penicillin 2.4MU IM STAT
What is the 2nd line treatment for syphilis?
Oral azithromycin
What is the treatment of neurosyphilis?
Procaine benzylpenicillin 750mg IM for 10 days
OR
Doxycycline 100mg BD 14 days
What is Jarisch-Herxheimer reaction?
Reaction to syphilis treatment
Acute febrile illness with headache, myalgia, chills
Usually resolves within 24 hours
What is the major complication of syphilis infection in pregnancy?
1/4 have 2nd trimester miscarriage or stillbirth
10% chance of neonatal death
What measures are taken to avoid syphilis in pregnancy?
All women screened at booking
