Sexual health Flashcards
What are some INFECTIVE causes for changes in discharge?
NON STI
- BV
- Candida (thrush)
STI
Vaginal
-Trichomonas vaginalis
Endocervical/urethral
- Clamydia trachoma’s
- Neisseria gonorrhoea
What are some non-infective causes of changes in discharge?
Cervical ectropion
Foreign body
Physiological (some discharge for women is normal)
What is the commonest cause of vaginal discharge in women of CBA?
Bacterial vaginosis
What is the pathophysiology of BV?
- There is overgrowth of anaerobic bacteria (gardnerella vaginalis bacteria)
- Causing lack of lactobacilli meaning the pH of the vagina increases (normal=4.5m BV=4.5-6)
BV
What does the discharge look like and what symptoms are commonly experienced?
How many are symptomatic?
Discharge
- increased volume
- thin and watery
- fishy odor
symptoms
-may have dyspareunia/ dysuria
NO SORENESS, NO ITCHINESS
50% patients with BV are asymptomatic
What is a complication of BV?
What are some obstetric complications of PID?
Complications of BV
- PID
- Cellulitis/abcess formation following TV hysterectomy
PID in pregnancy Obstetric complications - Late miscarriage - Pre-term birth - PROM - Post-Delivery endometritis
If you suspect BV what tests should you do?
-low vaginal swab (for MC+S)>CLUE CELLS
-pH of vagina (will be >4.5)
-+ve WHIFF TEST (K+)
(at lab: Hay-Ison gram stained vaginal smear)
What management should be recommended for BV?
LIFESTYLE (no douching or tight clothing, wash with water)
MEDICATION (treat if symptomatic/having surgery)
- metronidazole (5-7 days) (oral or topical-advise if breast feeding)
- if allergic: clindamycin
(same treatment in pregnancy)
What organism causes thrush?
Candida (vast majority is albicans)
Who is most likely to get candida?
- Immunosuppressed (e.g. HIV/pregnancy/diabetes)
- Abx use
- Elevated oestrogen (COCP)
Presentation of candida? (symptoms and signs)
Symptoms of candida
- thick creamy lumpy discharge (cottage cheese)
- vulval itchiness and soreness
- dyspareunia (superficial)
- dysuria (external)
Signs -excoriations and fissures -redness/rash on vulva (satellite lesions) -odema
How should we investigate a patient with suspected candida?
- Candida is so common that it often doesn’t require investigation before treatment
- Can do microscopy of vaginal swab if in doubt/unresponsive to treatment
How should we manage a case of candida?
LIFESTYLE:
- Soap substitute
- Emollient for external skin
- Lose clothes
MEDICAL:
- Topical or oral anti fungal
- Based on choice (if pregnant>topical)
E.g. oral fluconazole or clotrimazole pessary/cream (if preg)
Is trichomonas vaginalis an STI?
YES - it is commonly mistaken for BV or candida
What are some symptoms/signs of trichomonas vaginalis?
How many are asymptomatic
Symptoms of trichomonas vaginalis
- INCREASED offensive discharge
- Vulval itch and soreness
- Dysuria
- Lower abdo pain
Signs
- Classical frothy yellow discharge (30% of patients)
- Inflamtaion (vulvitis and vaginitis)
- pH>4.5
- STRAWBERRY CERVIX (highly suggestive but only present in 10%)
Up to 50% can be asymptomatic
If you suspect a woman might have TV how should you investigate?
Trichomonas vaginalis investigations
- speculum and posterior fornix swab
- send for wet mount microscopy
- vulvovaginal NAAT swab
How should we treat a woman with TV?
Do you treat sexual partners for TV?
How long should you avoid sex?
2g Metronidazole stat dose
OR
400mg metronidazole BD for 5-7 days (this is the more effective regime and this should ALWAYS BE GIVEN TO MALES and if in 1st trimester)
-Treat partners and avoid sex for 1 week and until partners have completed treatment
What is the most common STI in the UK?
Chlamydia Trachomatis (obligate intracellular organism) (gram negative)
What are the chances you will pass on chlamydia if you have it?
- 75% (very high transmission rate)
- Majority of people are asymptomatic
What are some symptoms of chlamydia?
Symptoms
- increased vaginal discharge
- PCB and IMB (endocervical)
- Pain: lower abdo pain, dysuria and deep dyspareunia
What might you find on speculum examination in a women with chlamydia or gonorrhoea?
Clamydia
- Mucopurulent cervicitis
- Contact bleeding of the cervix
What are some complications of chlamydia? (gynae and systemic and neonatal)
Complications of chlamydia Gynae problems: -PID -endometriosis -salpingitis -Tubal infertility -Ectopic pregnancy
Systemic problems:
- Sexually acquired reactive arthritis
- Fitz-Hugh Curtis Syndrome (perihepatitis)
- Problems if pregnant-baby gets conjunctivitis/pneumonia
What investigations should you do in someone you suspect to have chlamydia?
Chlamydia testing
- NAAT VVS or urine (both after 2 weeks)
- Consider swabbing in different sites for microscopy (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?
What about if they are pregnant?
What should they do about sex?
- DOXYCYCLINE 7 days (not in pregnancy)
- If PREGNANT give AZITHROMYCIN (and re-test in 3-5 weeks later weeks her to make sure the infection has been cleared)
- Abstain for 1 week and treat partners (CONTACT TRACING)
What sort of bacteria is neisseria gonorrhoeae?
Where is primary site of infection and how is it spread?
Gram negative diplococcus (neisseria gonorrhoea)
-Primary site of infection is mucous membranes and spread by secretions from one mucous membrane to another
(urethra, endocervix, rectum, conjunctiva, pharynx)
What are some symptoms of people who have gonorrhoea?
Gonorrhoea
- Pain
- Purulent discharge (more purulent/ green than chlamydia)
- PCB, IMB or menorrhagia** (less common than chlamydia)
- Lower abdomen pain
- Dysuria if urethral infection (uthritis)
***might be endocervical bleeding, can lead to PID
What investigations should be done in someone who has suspected gonorrhoea?
- VVS NAAT AND endocervical swab (M+C-resistance) and urine for men
- Consider multi site testing in MSM (rectum and throat)
How should we manage cases of gonorrhoea ?(think about follow up)
What about sex?
IM injection of CEFTRIAXONE
-Do swabs 3 weeks later FOR ALL to check it has been cleared (resistance)
Avoid sex for 1/52 and contact trace partners
Name some physiological skin changes on the penis?
- Pearly, penile, papules
- Fordyce spots (bumps around the base of the glans)
- Parafrenular glands
- Vestibular papillae (women’s vulva)
What causes genital warts?
Are warts painful?
HUMAN PAPILLOMA VIRUS
- 90% are caused by strains 6-11
- remaining are caused by 16 and 18 (more concerning because oncogenic)
WARTS ARE PAINLESS
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?
- Some may resolve spontaneously (within 1 year)
- DO speculum/proctoscopy to see if they are present other places
Physical ablation
- cryotherapy (liquid nitrogen)
- excision
- electrocautery
Topical
- podophyllotoxin cream if soft
- imiquimod cream if keratinised (aldara)
What other lumps on the penis are commonly mistaken for HPV warts?
- Molloscum contagiosum can be sexually transmitted (umbilicate)
- Lymphoceles (swelling caused by vigorous sex)
- Sebaceous cysts are also not uncommon on the penis
- Scabies can also occur on the penis
What causes genital ulcers?
What is pathogenisis of reactivation?
Herpes virus (HSV1/2 but usually HSV-2)
- After primary infection the virus is latent in the local sensory ganglion
- Periodically reactivates (symptomatic or asymptomatic) but INFECTIOUS
How will herpes ulcers look?
What are the symptoms?
-Multiple or single shallow ulcers
- PAINFUL ulcers
- Pain on urination (urine goes on ulcers)
- Vaginal/urethral discharge
Systemic: fever and aches
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?
Any advice to patient about sex?
-Aciclovir PO 5 days when first infection or symptomatic
(recurrences are normally short lived-can be treated with saline baths and topical anaesthetic agents)
- It is a lifelong infection that we can’t clear
- Should not have sex when symptomatic
- Can spread even if no lesion (although v low chance)
- **always contact trace
How does syphilis often present?
Primary syphilis infection
-SINGLE, LARGE, PAINLESS lesion>CHANCRES
(although can be multiple and painful)
Secondary syphilis infection (2 to 8 weeks after)
- MacPap rashes on soles of hands and palms of feet
- Ulceration of skin
If you think a chancre might be syphilitic what is the best way to investigate?
- Viral PCR of chancre
- Blood test (serology) for syphilis
Cardiolipin (negetive with treatment)
TPPA (remains +ve after treatment)
What organism causes syphilis? Who is highest risk?
- Treponema Pallidum (gram neg)
- Highest risk is MSM between 25-34 (40% of which are also infected with HIV)
What are the stages of syphilis?
- Primary
- Secondary (2 to 8 weeks after)
- Latent (early lasts <2 years and late lasts >2 years)
- Late (tertiary)
- neuro-syphilis (loss of proprioception and vibration)
- cardiovascular (aortic aneurysms)
- gummatous
Primary syphilis
- incubation period
- when does it ressolve?
PRIMARY SYPHILIS
-Incubation period of 9-90 days (average 21)
-Should resolve around 3-8 weeks
How often do primary syphilis progress to secondary?
How long after chancre does it happen?
What symptoms do you get with secondary syphilis?
- 25% of patients with primary will go on to develop secondary (if untreated)
- Occurs 4-10 weeks after initial chancre
- Multisystem symptoms*
- Most noticeable symptoms is SYPHILIS RASH condylomata lata (hands and feet, and genitals). NOT ITCHY
-Can also get systemic vasculitis
How long do the early and late LATENT PHASE 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/proprioception
CARDIO - Dilation of aortic root
GUMMATOUS - Ulceration of limbs
How can we manage syphilis ?
Primary, secondary and early latent
vs
Late latent, cardiovascular, gummatous:
- Refer to sexual health
- For primary, secondary and early latent: IM Benzathine penicillin (pen G) 2.4MU single dose
Late latent, cardiovascular, gummatous: IM Benzathine penicillin (pen G) 2.4MU weekly, for 3 weeks (3 doses)
**longer treatment courses for neuro/opthalmic syphilis
Pen allergy: doxycycline
What questions do you ask males vs females in Presenting complaint?
Males
- Pain passing urine?
- Discharge?
- Testicular pain or swelling
Females 3 pains -pain urinating -pain sex -abdo pain
3 other things
- discharge changes
- bleeding (IMB and PCB)
- urine problems
SKIN: lumps/ bumps/blisters anywhere?
ANAL: pain or discharge
Ask about partners
What is balanoposthitis?
Symptoms?
Whats the most common cause?
Balanitis- inflammation of the glans penis
Prosthitis- inflammation of the glans and foreskin
Local rash, soreness, itch, odour, can’t retract foreskin, sometimes discharge
Poor hygiene- however CANDIDA is common cause when found (swab for this)
(can be premalignant)
What are some symptoms of lichen sclerosis?
Lichen sclerosis
- itch/irritation
- soreness
- dyspareunia
- urinary symptoms
What investigations would you do for a woman presenting with genital blisters?
SWABS
- vaginal swab (chlamydia and gonorrhoea NAAT test)
- blister swab (HSV and syphilis PCR)
BLOODS
-HIV and syphilis serology
What patient factors affect clearance of genital warts?
Smoking/HIV/pregnancy affect clearance of genital warts
If a patient has HIV but WONT tell partner what can you do?
INSERT answer
How do you treat BV in pregnancy?
How do you treat Candida in pregnancy?
How do you treat chlamydia in pregnancy
BV in pregnancy
-metronidazol (5-7 days)
Candida in pregnancy
-7 days TOPICAL antifuncal therapy e.g. clotrimoxasol (not oral as CI)
Chlamydia in pregnancy
- azithromycin (usually doxycycline)
- retest after 3-5 weeks to confirm cleared infection
What causes trichomonas vaginalis?
What is the pathophysiology?
How is it spread?
- trichomonas vaginalis is caused by a flagellated protozoon
- it infects the vagina, urethra and paraurethral glands
- almost exclusively sexually transmitted
What is Fitz-Hugh Curtis Syndrom?
Common causes?
Symptoms?
Perihepatitis (complication of chronic PID)
- clamydia and gonnorhea most common causes
- Right upper quadrant pain and plural effusion
What is urethritis?
- dysuria
- urethral discharge
- urethral discomfort
What causes urethritis?
Either gonococcal or non gonococcal (chlamydia, mycoplasma genitalium)
What colour is urethral discharge in gonorrhoea vs chlamydia?
gonorrhoea: yellow urethral discharge
chlamydia: clear/white
Complications of gonorrhoea?
Complications of gonorrhoea
- epididymo-orchititis (men)
- proctitis
- disseminated gonorrhoea
What is Lymphogranuloma venereum (and cause)
What are the symptoms?
What population does this effect?
Lymphogranuloma venereum
- ulcerative disease in genital area
- caused by chlamyida
Symptoms
- small painless blister (can be multiple) (then turns more painful)
- proctitis (rectal pain/discharge)
- swollen lymph nodes
- swollen genitals
Affects gay men predominantly
What screening tests are done for STIs
STI SCREENING
- Chlamydia, gonorrhoea NAAT (urine or vaginal swab)
- HIV, syphilis (serology)
What tests are tailored based on population risk?
Standard screening plus:
-3 site screen for chlamydia and gonorrhoea for MSM (urine, rectum, pharynx)
-Hepatitis B and C serology screening (sexual or endemic risk)
What do you do if patient reducesIM ceftriaxone for gonorrhoea?
For patients with gonorrhoea, a combination of oral CEFIXIME + oral AZITHROMYCIN is used if the patient refuses IM ceftriaxone
Effects of chlamidya for neonates?
- Opthalmia neonatorum (conjuctivitis of newborn)
- Pneumonia
Effects of gonorrhea for neonates?
Opthalmia neonatorum (conjuctivitis of newborn) (40-50%) Can develop vaginal infection
Whats the most common cause of Uthritis?
Gonorroea most common
How far back should you contact trace for chlamidia? (men and women)
MEN
- go back 6 months if asymptomatic
- go back 4 weeks if symptomatic
WOMEN
-go back 6 months
Most common cause of Reiter’s syndrome?
Chlamidia
cant see cant pee cant climb tree
