Sexual Health Flashcards
What is the epidemiology of STIs?
Infection with more than one STI is common - if have Chlamydia, may very well have gonorrhoea - so check for all
Why is it important to ask about whether STI patients have had Abx in the past few months?
(depending on the Abx) May have partly treated the STI and give a false result on swab culture for example - need to wait a couple of weeks then repeat again
Why is it important to ask men about their last voiding?
Bacteria like Chlamydia are urethral colonising - if recently voided, will give poor swab - need to be about 1.5hrs to allow good colony growth
What might you find in examination of inguinal lymph nodes?
Painful lymph nodes - herpes
Non painful lymoh nodes - syphilis (also single ulcers on penis - Shankar? or kissing lesions)
What are the baseline tests for an asymptomatic sexually active woman?
Self taken vulvo-vaginal swab:
Gonorrhoea/chalmydia nucleic acid amplification test (NAAT; type of PCR)
Bloods:
HIV + Syphilis
What are the baseline tests for an asymptomatic sexually active men?
First catch urine:
Important to be first catch as will be flushing of urethral bacteria
Chlamydia + Gonorrhoea NAAT
Bloods:
HIV + Syphilis
Additional tests in men who have sex with men (MSMs):
Pharyngeal + rectal swabs for Chlamydia/Gonorrhoea
Hep B (+/- C) bloods
What are the baseline tests for a symptomatic sexually active women?
Vulvo-vaginal swab for Gonorrhoea + Chlamydia NAAT
High vaginal swab (wet & dry slides) for Bacterial Vaginosis (BV); Trichomonas Vaginalis (TV); Candida
Cervical swab for slide + Gonorrhoea culture
Dipstick urinalysis (If has dysuria)
Blood:
HIV + Syphilis
What are the baseline tests for a symptomatic sexually active men?
Urethral swab for slide + Gonorrhoea culture ad sensitivity
First void urine for Gonorrhoea + Chlamydia NAAT
Dipstick urinalysis (If has dysuria)
Blood:
HIV + Syphilis
MSMs:
Test as for asymptomatic MSM
+ urethral and rectal slides
+ urethral, rectal, pharyngeal culture plates
What do different discharges indicate?
Gonorrhoea - thick gloopy, yellow
Chlamydia - thinner, white
Candidiasis - cottage cheese curds - not smelly
Trichomonas - green/yellow frothy - offensive
BV - thin, white/grey - fishy on whiff test (KOH drop added to discharge)
What are the characteristics of some genital lesions?
Molluscum - round, pale swellings with small dot/pore in the middle
Genital warts - HPV - fleshy, soft, possible cauliflower appearance bumps
Syphilis - single, painless ulcer (chancre)
Herpes - multiple, white raised bumps that burst to leave open red sores
What does Gonorhoea look like under the microscope
G-ve diplococci
Who is offered Hep B screening?
MSM
Commercial sex workers (CSW) +
IVDUs (including past) and their sexual partners
People from high risk areas and their sexual partners - Africa, Asia, Eastern Europe
Aim to vaccinate if non-immune
What are double and triple swabs?
Double swabs include a NAAT swab to test for both chlamydia and gonorrhoea and a high vaginal charcoal swab to test for fungal and bacterial infections such as candida albicans and bacterial vaginosis
Triple swabs include an endocervical chlamydia swab (usually in a pink wrapper), an endocervical sample using a charcoal swab to pick up gonorrhoea and a third sample, using a charcoal high vaginal swab to test for fungal and bacterial infections.
How does confidentiality work in GUM?
Can’t tell anyone outside clinic, GUM stuff kept within clinic, not told GP (unless other professional involvement required e.g. in HIV?)
Can’t tell sexual partners what is going on, done formally though contact tracing - left for partner to tell
How does contact tracing work?
Contact identification: Once someone is confirmed as infected with a virus, contacts are identified by asking about the person’s activities and the activities and roles of the people around them since onset of illness. Contacts can be anyone who has been in contact with an infected person: family members, work colleagues, friends, or health care providers.
Contact listing: All persons considered to have contact with the infected person should be listed as contacts. Efforts should be made to identify every listed contact and to inform them of their contact status, what it means, the actions that will follow, and the importance of receiving early care if they develop symptoms. Contacts should also be provided with information about prevention of the disease. In some cases, quarantine or isolation is required for high risk contacts, either at home, or in hospital.
Contact follow-up: Regular follow-up should be conducted with all contacts to monitor for symptoms and test for signs of infection.
How does Chlamydia present?
Usually between 1-3 weeks post infection, symptoms may be persistent or self resolve - if resolves doesn’t mean is cured, may still be an infection risk
Men: Dysuria Red, itchy urethral meatus Thin white non smelling discharge Dysparunia Painful testicles - epididymoorchitis
Women:
Most are asymptomatic
If they do present - as above + bleeding with sex or between periods
May end up with pelvic inflammatory disease, risk of infertility and ectopic pregnancies if untreated - why contact tracing is especially important
How do you treat Chlamydia?
1st line:
Doxycycline - 100mg PO BD for 7days
- contraindicated in pregnancy
2nd line:
Azithromycin - 1g PO on day one then 500mg OD for 2days
What are some complications of Chlamydia infection?
Reactive arthritis - cant see/wee/climb tree - TREATMENT?
Can cause infertility in women if left undiagnosed and untreated
How does Gonorrhoea present?
Asymptomatic - in 1/10 men and 50% of women
Thick yellow discharge from penis or vagina
Dysuria
Intermenstrual bleeding
If congenital - eye signs e.g. conjunctivitis, eye discharge
How is Gonorrhoea treated?
Should do MC+S before prescribing to check for resistance
Some options are:
Ceftriaxone 1g IM as a single dose
Ciprofloxacin 500mg PO as a single dose
Pharyngeal gonorrhoea is harder to get rid of than genital/anal
How does Syphilis present?
Bacterial infection= Treponema pallidum
4 stages:
Primary- lesion an the site of sexual contact = syphilitic chancre (painless, firm skin ulceration 1-2cm), solitary raised painless lymph node
Secondary- palmar-plantar erythematous rash (also whole body), systemic features of illness (fever, malaise, headache, weight loss)
Latent - split into early and late, late not as contagious, neither are symptomatic but still seropositive, may relapse
Tertiary- 1-46yrs later depending on manifestation, 3x main types: gummatous = soft tumour-like balls of inflammation in bones, skin, liver etc; neruosyphilis = dementia mimic (memory loss, personality change..), apathy seizures; cardiovascular = aortitis and aortic aneurysms
Also a congenital form - dental defects; 1-3yrs after birth = splenomegaly, fever, rash, neurosyphilis
How is Syphilis treated?
Benzypenicilin - IM
Contact tracing, sex abstinence and condoms
What is vaginal candidiasis? How does it present and how is it manged?
Caused by Candida albicans
Presentation:
Itching + reddening around the vulva
‘Curdy’ white discharge with a pH <4.5; no odour
Dysparunia
Management:
Topical clotrimazole cream
What is Bacterial vaginosis? How does it present and how is it managed?
Caused by: an imbalance in natural national flora - reduction of lactobacilli and increased in e.g. gardinerella vaginalis
Presentation:
Offensive, thin, white/grey, ‘fishy’ smelling discharge
Clue cells on microscopy
Associated with premature birth so still needs managing if discovered
Management: metronidazole PO; avoid shower gels, douching etc that would upset the flora
What is Trichomonas vaginalis? How does it present and how is it manged?
Caused by: trichomonas - flagellated Protozoa
Presentation:
Offensive, yellow/green, frothy discharge - copious
Vulvovaginitis
Strawberry cervix
Management: metronidazole PO
What are some conditions that might present with lack or loss of sexual desire?
All disorders = cause distress
Male hypoactive sexual desire disorder:
- Loss of sexual desire is the principle problem
- Not secondary to other sexual difficulties
- Does not preclude sexual enjoyment or arousal but makes the initiation of sex less likely
Female sexual interest/arousal disorder:
- Low interest in initiating sex, low arousal
- Vaginal dryness or failure of lubrication
Orgasmic disorder:
- Orgasm either does not occur or is markedly delayed - persistent and recurrent
- Can occur in men and women, more common in women
Sexual aversion disorder:
- Persistent or recurrent extreme aversion to and avoidance of all or almost all genital sexual contact with sexual partner which causes distress or interpersonal difficulty
What are some chronic medical conditions that cause sexual desire disorders?
Obesity
CVD
DM
Anaemia
What are some hormonal disorders that cause sexual desire disorders?
Men:
(a) Androgen deficiency
(b) Hypogonadism – various aetiolgoies
(c) Hyperprolactinaemia
Women:
(a) Androgen deficiency
(b) Hypothyroidism
(c) Hyperprolactinaemia
(d) Post pregnancy
(e) Addison’s disease
(f) Menopause (Vaginal or pelvic pain, Vaginal atrophy/dryness, Change in self image, mood, memory, cognition, Change in desire)
What are some iatrogenic causes of sexual desire disorders?
Prescribed meds:
(a) Both: Antidepressants, antipsychotics; Beta blockers
(b) Male: Finasteride etc
(c) Female: Oral contraceptive; Tamoxifen
Surgery:
(a) (bilateral) orchidectomy
(b) (“) oophorectomy
(c) Pelvic floor weakness or damage
Also self-inflicted:
(a) Vaginal dryness through local irritants and douching
What are some psychological causes of sexual desire disorders?
Psych conditions – depression, anxiety, substance misuse
Psych experiences – environmental, life events, trauma/abuse
Body image disorder
Couples sex script problems
Erotic dissatisfaction (a) Women have more ‘erotic plasticity’ than men – men’s sexual patterns laid down earlier than women and remain fixed, women may need a change
Couple relationship problems
How do you manage sexual desire disorders?
Both:
- Sensate focus – identify the couples sexual likes/dislikes etc
- New sexual routines, lubricant, vibrators
Males:
- Testosterone replacement
Females:
- Eros device – clitoral pump for increased arousal and enhanced ability to achieve orgasm
- HRT
- ?testosterone in some post menopausal
What is erectile disorder?
Marked difficulty in developing or maintaining an erection suitable for satisfactory intercourse
What are some aetiologies of erectile disorder?
i) Chronic medical: CVD, DM, neurological
ii) Hormonal disorders
iii) Iatrogenic - Post prostate surgery, prescribed meds – antihypertensives/antidepressants (SSRI)
iv) Age related changes – normalising
v) Ineffective sexual stimuli
vi) Pain
vii) Veno-occlusive disorder – mechanism for trapping blood in the penis isn’t effective = difficulty sustaining erections
viii) Psychological - Psych conditions; Performance anxiety including problems related to unhelpful use of pornography, ‘spectatoring’ (hyper aware of your own actions during sex); Couples script problems; Relationship problems or issues from previous relationships; Educational, cultural or religions matters
What are some pharmacological treatments for erectile disorder?
Oral:
(a) Sildenafil
(b) Tadalafil etc
Injectable (intracavernous):
(a) Alprostadil
Intraurethral:
(a) Alprostadil MUSE (medical urethral system for erection) pellet
(b) Alprostadil cream
Patient education:
(a) Need sexual stimulation to work
(b) Work best on an empty stomach
(c) Need to wait 45-60 mins
(d) Efficacy improves from the first-eighth dose
What are some non-pharmacological treatments for erectile disorder?
Vacuum device
Penile/scrotal rings
New stimulating routines ie enhancing lubricants, vibrators
Kegel exercises
What financial implications for the treatment of erectile disorder?
Can patients afford?
Some are exempt – DM, MS, PD, prostate Ca, pelvic/spinal cord injuries, dialysis, post prostate/pelvis/kidney surgery
Frustrations – can only be prescribed 4 doses/month for some tablets
What is rapid ejaculation?
The inability to control ejaculation sufficiently for both partners to enjoy sexual interaction
What are some causes of rapid ejaculation?
Biological: Genetic susceptibility Penile hypersensitivity Hyperthyroidism Prostatitis Comorbid sexual problems Sympathomimetic medications
Psych: Anxiety states Early learned sexual experiences Lack of experience, infrequent sexual activities Relationship issues Partner issues ie pain
How do you treat rapid ejaculation?
Topical anaesthetic
Dapoxetine - SSRI
Couple psychosexual therapy: Normalising/Managing partner expectations
Behavioural interventions:
Stop/start technique and sensate focus
Practice point of inevitability
Kegels; buttock relaxations during intercourse
What is delayed ejaculation?
On almost all sexual occasions either generalised or situational without the individual desiring delay there is a marked delay/infrequency/absence of ejaculation
If doesn’t happen at all = inhibited ejaculation disorder ie never ejaculated
IMPORTANT TO EXCLUDE RETROGRADE EJACULATION
What are some aetiologies of delayed ejaculation?
Similar to erectile disorder:
Physiological e.g. trauma, surgery, age etc.
Psychological e.g. depression, masturbation technique, relationship or vulnerability factors
What is retrograde ejaculation?
Sensation of ejaculation without the obvious passing of semen – passes into bladder instead
If voiding urine shortly afterwards – any milky substance? - Urine sample = spermatozoa + fructose
Damage to nerves/muscles surrounding neck of the bladder – failure to constrict upon ejaculation – prostate surgery/DM/MS/alpha blockers
Only an issue if wanting to conceive – possible need for IVF
How do you treat delayed ejaculation?
PSGP (personal sexual growth programme?)
Individual or couple therapy
Kegels
Vibration/superstimualtion
What is vaginismus?
Spasm of the pelvic floor muscles that surround the vagina causing occlusion of the vaginal opening; penetration is either impossible or painful
What are some causes of vaginismus?
Physiological
Sore vulva ie thrush
Vulvodynia – chronic pain syndrome (burning/irritation) of vulva – upon touching (including tampon insertion) or constant, often without identifiable cause (autoimmune disorders, infection, neuropathy) and poor treatment prospects (do the usual things though)
Pain conditions or anticipation of pain
FGM
Congenital abnormality
Misinformation/mistaken beliefs:
Vagina too small/no opening
First intercourse will be painful
Fears of pregnancy
Religious or cultural issues
Previous abuse/trauma/negative experiences
Fear/dislike of partner/ Relationship dissatisfaction
What is dysparenuia?
Pain during intercourse
Both men and women
Often attributed to local pathology – if possible then categorise under that
Only use this term if there is no primary nonorganic sexual dysfunction ie vaginismus, vaginal dryness
What are some different causes for different locations of genital/sex pain?
Pain on manipulation:
Infection, injury, irritation, lesions, hypersensitivity
Introitus (on entry) pain:
Episiotomy/circumcision, recurrent infection, herpes, allergies, interstitial cystitis, urethritis, vaginal atrophy, menopause, poor lubrication, insufficient arousal, substance, penis size
Mid-deep vaginal pain:
Endometriosis, shortened vagina, retroverted uterus, pelvic tumour, adhesions, IBS, constipation
Also psychological and relational aetiologies
How do you investigate and manage dyspareunia?
Investigate and treat any underlying cause - detailed Hx, physical examination, bloods etc
Vaginsmus - vaginal trainers (sequential dilatation of opening)
Therapy/PSGP
What is Peyronie’s disease and how is it managed?
Connective tissue disease – growth of fibrous plaques in tunica albuginea
Pain + pain on sex, abnormal curvature, ED, loss of girth and shortening
Increasingly common with age, affecting about 10% of people, Dupuytren’s association
Management:
Some spontaneously improve, majority get worse and some are sable
Some drugs such as vitamin E and collagen elastase drugs – though variable efficacies
Penile traction (again variable efficacy)
Surgery – last resort; loss of length to occur; penile prosthesis may be appropriate
What is hypospadias and how is it manage?
Urethral opening not at the usual location on head of penis – lower in the midline to varying degrees – embryological failure; urine can spray when passing
Usually detected in newborns on the NIPE
Treatment:
Surgery – to restore normal appearance and function, usually around 3 months of age
What is aspermia? How does it differ from azoospermia?
Lack of semen with ejaculation - not azoospermia = no sperm cells
Associated with infertility; caused by retrograde ejaculation, androgen deficiency, ejaculatory duct obstruction
What is a paraphilia and some examples?
Sexual attraction to a non-sexual thing or situation:
Urophilia/Coprophilia - sexual gratification involving urine and faeces
Masochism/sadism/sadomachism - sexual gratification from receiving pain or humiliation/inflicting pain or humiliation/both
Exhibitionism - sexual gratification of exposing oneself in public
Only count as disorders if it brings someone distress; also some are illegal e.g. exhibitionism, zoophilia, paedophilia
