Sexual Health Flashcards
What do the Fraser Guidelines relate to?
Giving contraception and sexual health advice to those under 16 without parental consent
Pneumonic to remember Fraser competence
UPSIS = unprotected sex is silly
young person Understands the advice given
Parental involvement encouraged by clinician
young person likely to continue having Sexual intercourse
it is in the young persons best Interest to supply them with contraception
Young persons physical and mental health is likely to Suffer without contraception
What is the Sexual Offences Act 2003?
Sexual intercourse and all forms of sexual touching of minors (under 16yrs) are illegal in England and Wales
Children under 13 years are deemed incapable of consent. It is therefore classified as rape or sexual assault and must be reported.
There is no legal obligation to report sex between 13-16 yr olds unless exploitation is suspected
What is the commonest STI and which age group is it most common in?
Chlamydia Trachomatis
Commonest in 15-25 age group (approx 5% infected)
Why is chlamydia trachomatis difficult to culture?
It is an obligate intracellular bacteria (cannot replicate outside of host cell)
What is the incubation period of chlamydia trachomatis?
1-3 weeks
What % of people with chlamydia are asymptomatic?
50% men and 75% women
Thus often found on screening, contact tracing or when complications present
What are the signs/symptoms of chlamydia infection in females?
- Increased vaginal discharge secondary to cervicitis
- Urethritis (dysuria, frequency, urgency)
- PCB and IMB
- Deep dyspareunia
- Lower abdo pain
- +/- contact bleeding
What complications can arise from chlamydia infection in women?
PID (10-30% infections) Tubal infertility Increased risk of ectopic pregnancy Perihepatitis - Fitz-Hugh-Curtis syndrome Reactive arthritis (more common in men)
What is Reiters disease (Reactive Arthritis)?
Triad of:
- Arthritis
- Urethritis
- Conjunctivitis
(occurs after infection, esp of GI or urogenital tract)
Can’t pee, see or climb up a tree
What are implications of chlamydia infection in pregnancy?
PROM and premature delivery
Low birth weight
Postpartum endometriosis
Infection can spread from the cervix into the uterine cavity causing chorioamnionitis
What are the signs/symptoms of chlamydia infection in males?
- Dysuria
- Urethral discharge = white, cloudy or watery
- Testicular pain due to epididymo-orchitis
- Scrotal pain / swelling
What complications can arise from chlamydia infection in men?
- Acute epididymo-orchitis (usually unilateral pain)
- Proctitis
- Infertility
- Reactive arthritis
How does chlamydia present in neonates?
- Neonatal conjunctivitis (30% within first 2 weeks)
- Neonatal pneumonia (15% within first 4 months)
- Otitis media
- Can develop vaginal infection
What investigations are done for chlamydia? What is the window period?
Women:
- Vulvovaginal swab + NAAT
- First catch urine sample
Men:
- Urethral swab + NAAT
- First catch urine sample
Window period = 2 weeks
What is the treatment for chlamydia?
Doxycycline 100mg PO BD for 7 days
If doxycycline contraindicated :
Azithromycin 1g PO STAT
If doxycycline and azithromycin contraindicated:
Erythromycin 500mg BD for 10-14 days
Oflaxacin 200mg BD or 400mg OD for 7 days
Abstinence until partner is treated and Abx completed
What is the treatment for chlamydia in pregnancy?
Azithromycin 1g PO STAT
Test of cure
If azithromycin contraindicated:
Erythromycin 500mg BD for 10-14 days
Test of cure
What is the causative organism of Gonorrhoea infection? Describe it
Neisseria gonorrhoea - intracellular gram negative diplococcus
What are the initial sites of infection of chlamydia and gonorrhoea?
Columnar epithelium of urethra, endocervix, rectum, pharynx or conjunctiva (depending on mode of exposure)
What is the incubation period of gonorrhoea?
2-5 days (in 80% men who develop urethral symptoms)
Asymptomatic gonorrhoea is particularly common in which sites?
Pharynx, cervix and rectum (common in both sexes)
What are the signs/symptoms of gonorrhoea infection in females?
Symptoms • Altered/increased vaginal discharge - thin, watery, green/yellow • Dysuria • Dyspareunia • Lower abdominal pain • IMB or PCB - rarely
Signs
• Mucopurulent endocervical discharge from cervical os, urethra, Skene’s glands or Bartholin’s glands
• Easily induced cervical bleeding
• Pelvic tenderness
What are complications of gonorrhoea infection in females?
- PID (approx 15% infections)
- Bartholin’s or Skene’s abscess
- Tubal infertility
- Increase risk of ectopic pregnancy
- Disseminated gonorrhoea = fever, pustular rash, migratory polyarthralgia, septic arthritis
- Rarely gonococcal endocarditis (M&F)
What are the complications of gonorrhoea infection in pregnancy?
Chorioamnioitis
Postpartum endometritis
PROM, premature delivery and low birth weight
What are the signs/symptoms of gonorrhoea infection in males?
- Urethral discharge = yellow, green, white
- Dysuria
- Urethritis
- Foreskin swelling
- Scrotal pain / swelling
- Tender inguinal LN
What are complications of gonorrhoea infection in males?
- Epididymo-orchitis
- Abcesses of paraurethral glands
- Urethral stricture
- Disseminated gonorrhoea
- Secondary infertility due to damage to epididymis
What are the signs/symptoms of gonorrhoea infection in neonates?
Opthalmia neonatorum (gonococcal conjunctivitis) Can develop vaginal infection
What investigations are done for gonorrhoea in males and females?
Females
• Endocervical/vaginal swab - NAAT
• Endocervical/urethral swab - microscopy + culture (Amies charcoal transport medium)
Males
• First pass urine - NAAT
• Urethral/meatal swab - microscopy + culture
Pharyngeal and rectal swabs if indicated
What is the treatment for gonorrhoea?
Abx (same in pregnancy)
Single dose IM ceftriaxone 1g
AND
PO azithromycin 1g/ciprofloxacin 500mg
Do test of cure for all at 2 weeks after therapy
Avoid sex for 7 days or/and until they + their partners have completed treatment
What is the causative organism of syphilis? What is its shape and gram stain?
Treponema pallidum Sprirochaete (spiral shaped)
Gram-negative
How is syphilis transmitted?
Sexual transmission - break in skin or intact mucous membranes
Via placenta from mother to foetus - congenital syphilis
Infected blood products
What is the initial site of infection of syphilis?
Site of contact - usually genitals, perianal area or mouth
How many stages are there in syphilis infection?
4
1) Primary
2) Secondary
3) Latent
4) Late/Tertiary
When does the primary stage of syphilis occur?
9-90 weeks after exposure
What are the features of the primary stage of syphilis?
After inoculation, a papule (slightly raised lesion with no fluid) appears before ulcerating into a chancre (singular painless, hard, non-itchy ulcer)
It resolves after 3-8 weeks
Describe the appearance of a chancre
Round and clean with an indurated base and defined edges, non-purulent
When does the second stage of syphilis occur?
4-8 weeks after appearance of primary chancre
if primary untreated, 25% develop into secondary
What are the features second stage of syphilis?
MULTI-SYSTEM
- Maculopapular symmetrical skin rash - hands and soles of feet - not painful or itchy
- Fever, malaise, arthralgia, weight loss, headaches
- Condylomata lata - elevated plaques like warts on moist areas of skin - inner thighs, anogenital region, axillae - highly infectious
- Painless lymphadenopathy
- Silvery-grey mucous membrane lesions/ulcers - oral, pharyngeal, genital
When does the latent stage of syphilis occur?
Early = <2yr after infection Late = >2yr after infection
What are the features of latent stage syphilis?
People with untreated syphilis but no symptoms = latent syphilis
When does the tertiary stage of syphilis occur?
1-10 years after exposure
it is now rare due to advent of penicillin
What are the features of the tertiary stage of syhpillis?
Gummatous syphilis…
• Granulomas form in bone, skin, URT, mouth
Neurosyphilis…
• Tabes dorsalis - ataxia, numb legs, absence of deep tendon reflexes, lightning pains, loss of pain + temperature sensation, skin + joint damage
• Dementia - cognitive impairment, mood alterations, psychosis
• Meningovascular complications - CN palsies, stroke
• Argyll Robertson pupil - constricted and unreactive to light but reacts to accommodation
Cardiovascular…
• Aortic regurgitation (diastolic murmur) - aortic valvulitis
• Angina
• Dilation and calcification of ascending aorta - syphilitic aortitis (atherosclerotic-type change in the ascending aorta)
Why is syphilis particularly worrying in pregnancy and what can it cause?
Syphilis can cross the placenta
- Preterm delivery
- stillbirth
- congenital syphilis
What investigations are done for syphilis?
Serology:
- Rapid plasma regain (RPR) and venereal disease reference laboratory (VDRL) most commonly used
Dark ground microscopy of chancre fluid to detect spirochaete
PCR testing of swabs from lesions
What is the treatment for syphilis?
Benzylpenicillin 2.4MU IM single dose in primary + secondary syphilis
Benzylpenicillin 2.4MU IM weekly for 3 weeks in tertiary syphilis
Dose = 2.4 million units
Penicillin allergy - doxycycline (CI in pregnancy so can use erythromycin)
What is the causative organism of trichomonas? Describe it
How does it replicate?
Trichomoniasis Vaginalis
Anaerobic flagellated protozoan
Replication: binary fission whilst destroying epithelial cells through direct contact + release of cytotoxins
What are the symptoms and the signs of trichomonas?
Asymptomatic in 10-50%
Symptoms
• Profuse, foul-smelling, greenish/yellow, frothy discharge
• Vaginal and vulval irritation/soreness/itchiness
• Dysuria
• Superficial dyspareunia
Signs
• Abnormal vaginal discharge - frothy yellow/green
• Vulvitis + vaginitis
• Strawberry cervix - erythematous, punctuate appearance
What does trichomonas vaginalis infect and how is it spread?
Infects the vagina, urethra and paraurethral glands in women.
Almost exclusively transmitted via sexual intercourse
What are the implications of trichomonas in pregnancy and post-partum period?
Associated with PROM, pre-term delivery and low birth weight
TV infection at delivery can predispose to maternal postpartum sepsis
Metronidazole can affect taste of breast milk
What investigations can be done for trichomonas?
High vaginal swab from posterior fornix for saline wet-mount microscopy - can see flagellated protozoa swimming around
Culture in a Trichomonas medium = gold standard
NB There is no test for males so they must be treated if their partner is infected
What is the treatment for trichomonas?
Metronidazole 2g PO single dose
OR
Metronidazole 400mg BD for 5-7 days
Treat sexual partners of preceding four weeks simultaneously - metronidazole 400mg BD for 7 days
What does high vaginal swab look for?
What does endocervical swab look for?
HVS = TV / candida / BV
ECS = NG / CT
