Sexual Health Flashcards
1
Q
What do the Fraser Guidelines relate to?
A
Giving contraception and sexual health advice to those under 16 without parental consent
2
Q
Pneumonic to remember Fraser competence
A
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
3
Q
What is the Sexual Offences Act 2003?
A
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 it is 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
4
Q
What is the commonest STI and which age group is it most common in?
A
Chlamydia Trachomatis
Commonest in 15-25 age group (approx 5% infected)
5
Q
Why is chlamydia trachomatis difficult to culture?
A
It is an obligate intracellular bacteria (cannot replicate outside of host cell)
6
Q
What is the incubation period of chlamydia trachomatis?
A
1-3 weeks
7
Q
What % of people with chlamydia are asymptomatic?
A
50% men and 75% women
Thus often found on screening, contact tracing or when complications present
8
Q
What are the signs/symptoms of chlamydia infection in females?
A
- Increased vaginal discharge secondary to cervicitis
- Urethritis (dysuria, frequency, urgency)
- PCB and IMB
- Deep dyspareunia
- Lower abdo pain
- +/- contact bleeding
9
Q
What complications can arise from chlamydia infection in women?
A
PID (10-30% infections)
Tubal infertility
Increased risk of ectopic pregnancy
(chlamydia implicated in 75% of ectopics and tubal infertility)
Perihepatitis - Fitz-Hugh-Curtis syndrome Reiters syndrome (more common in men)
10
Q
What is Reiters syndrome?
A
Triad of:
- Arthritis
- Urethritis
- Conjunctivitis
(occurs after infection, esp of GI or urogenital tract)
11
Q
What are implications of chlamydia infection in pregnancy?
A
PROM and premature delivery
Low birth weight
Postpartum endometriosis
Infection can spread from the cervix into the uterine cavity causing chorioamnionitis
12
Q
What are the signs/symptoms of chlamydia infection in males?
A
- Dysuria
- Discharge = white, cloudy or water
- Testicular pain
- Scrotal pain / swelling
13
Q
What complications can arise from chlamydia infection in men?
A
- Acute epididymo-orchitis (usually unilateral pain)
- Proctitis
- Reiters syndrome
14
Q
How does chlamydia present in neonates?
A
- Neonatal conjunctivitis (30% within first 2 weeks)
- Neonatal pneumonia (15% within first 4 months)
- Otitis media
- Can develop vaginal infection
15
Q
What investigations are done for chlamydia?
A
Vulvovaginal swab
Urine for PCR
Screening (National screening programme for <25yr olds)
16
Q
What is the treatment for chlamydia?
A
Azithromycin 1g PO stat single dose
Doxycycline 100mg PO BD for 7 days
Abstinence until partner is treated and Ab completed
17
Q
What is the treatment for chlamydia in pregnancy?
A
Erythromycin
18
Q
What is the causative organism of Gonorrhoea infection and how common is it?
A
Neisseria gonorrhoea - intracellular gram negative diplococcus
3rd most common STI in UK
19
Q
MOVE THIS CARD
What are the initial sites of infection of chlamydia and gonorrhoea?
A
Columnar epithelium of urethra, endocervix, rectum, pharynx or conjunctiva (depending on mode of exposure)
20
Q
What is the incubation period of gonorrhoea?
A
2-5 days (in 80% men who develop urethral symptoms)
21
Q
Asymptomatic gonorrhoea is particularly common in which sites?
A
Pharynx, cervix and rectum (common in both sexes)
22
Q
What are the signs/symptoms of gonorrhoea infection in females?
A
- Greenish vaginal discharge = examination may show mucopurulent discharge from cervical os, urethra, Skene’s glands or Bartholin’s glands
- Dysuria
- Urethritis
- IMB/PCB (less common)
Usually asymptomatic (found by screening, contact tracing or when complications arise)
23
Q
What are complications of gonorrhoea infection in females?
A
- Lower abdo pain
- bartholinitis
- vulvo-vaginitis pre-pubertal girls (vs infection of endocervix in post-pubertal)
- 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)
24
Q
What are the complications of gonorrhoea infection in pregnancy?
A
Chorioamnioitis
Postpartum endometritis
PROM, premature delivery and low birth weight
25
What are the signs/symptoms of gonorrhoea infection in males?
- Discharge = yellow, green, white
- Dysuria
- Urethritis
- Foreskin swelling
- Scrotal pain / swelling
- Tender inguinal LN
26
What are complications of gonorrhoea infection in males?
- Epidymo-orchitis
- abcesses of paraurethral glands
- urethral stricture
- disseminated gonorrhoea
- secondary infertility due to damage to epididymis
27
Other than urogenital areas, where else can gonorrhoea infect?
Can cause infection of rectum, throat and eyes
28
What are the signs/symptoms of gonorrhoea infection in neonates?
```
Opthalmia neonatorum (40-50%)
Can develop vaginal infection
```
29
What investigations are done for gonorrhoea?
- VVS for NAAT testing
- ECS for culture and sensitivity (Amies charcoal transport medium)
- Urethral swabs
- Rectal / pharyngeal swabs
30
What is the treatment for gonorrhoea?
-Abx (same in pregnancy)
Ceftriaxaone 250mg IM
Cefixime 500mg Oral
Spectinomycin 2mg IM
(all single dose)
(>20% strains resistant to ciprofloxacin)
31
What is the causative organism of syphilis?
Treponemum pallidum = sprirochaete
32
How is syphilis transmitted?
Sexually or vertically
33
What is the initial site of infection of syphilis?
Site of exposure - usually genitals, perianal area or mouth
34
How many stages are there in syphilis infection?
4 = primary, secondary, latent and tertiary
35
When does the primary stage of syphilis occur?
9-90 weeks after exposure
36
What are the features of the primary stage of syphilis?
Solitary, painless, genital ulcer = chancre at inoculation site (but can be multiple, painful)
Also presence of inguinal lymphadenopathy = local
37
Describe the appearance of a chancre
Round and clean with an indurated base and defined edges, non-purulent
38
When does the second stage of syphilis occur?
4-8 weeks after appearance of primary chancre
| if primary untreated, 25% develop into secondary
39
What are the features second stage of syphilis?
MULTI-SYSTEM
- Generalised polymorphic rash affecting palms and soles that are symmetrical and non-itchy
- Disseminated rash
- Generalised lymphadenopathy
- Condyloma lata (wart-like lesions on genitals / mouth)
- anterior uveitis
- hepatitis, splenomegaly, glomerulonephritis
40
When does the latent stage of syphilis occur?
```
Early = <2yr after infection
Late = >2yr after infection
```
41
What are the features of latent stage syphilis?
People with untreated syphilis but no symptoms = latent syphilis
42
When does the tertiary stage of syphilis occur?
1-10 years after exposure
= presents in up to 40% of people infected for >2yrs
43
What are the features of the tertiary stage of syhpillis?
Benign - gummatous lesions
CV - aortitis, coronary arteritis
Neurosyphilis - tabes dorsalis (demyelination of dorsal columns and dorsal roots), paresis
44
Why is syphilis particularly worrying in pregnancy and what can it cause?
Syphilis can cross the placenta
- Preterm delivery
- stillbirth
- congenital syphilis
45
What investigations are done for syphilis?
Serology:
- Rapid plasma regain (RPR) and venereal disease reference laboratory (VDRL) most commonly used
Also NAAT testing, smear from primary lesion may show spirochaetes on dark ground microscopy
Routine screening at antenatal booking in pregnancy
46
What is the treatment for syphilis?
Primary, secondary and latent = SINGLE dose benzathine penicillins IM
Late latent, CV and gummatous - THREE doses bezathine penicillin IM weekly for 3 weeks
Penicillin allergy - doxycycline (CI in pregnancy so can use erythromycin)
47
What is the causative organism of trichomonas?
Trichomoniasis Vaginalis - Flagellate protozoan
48
What are the signs/symptoms of trichomonas?
Asymptomatic in 10-50%
- Frothy, green offensive smelling discharge
- Vulval itching and soreness
- Dysuria
- Superficial dyspareunia
- 2% 'strawberry cervix' = punctate haemorrhages
49
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. No test for males - must be tested and treated if partner is infected.
50
What are the implications of trichomonas in pregnancy?
Associated with PROM, pre-term delivery and low birth weight
May be acquired perinatally, occurring in 5% of babies born to infected mothers
51
What investigations can be done for trichomonas?
- Swab from posterior fornix at speculum exam for wet mount microscopy. Can see flagellated protozoa swimming around
- Culture = gold standard
52
What is the treatment for trichomonas?
Metronidazole 2g orally in single dose OR metronidazole 400-500mg twice daily for 5-7 days
- Avoid in 1st trimester
+contact tracing and treatment of partners / abstinence until treated
53
MOVE CARD
What does HVS look for?
What does ECS look for?
and check NAAT info
HVS = TV / candida / BV
ECS = NG / CT / NAAT
54
What is the commonest cause of abnormal discharge in women of childbearing age?
Bacterial vaginosis
55
What is the pH range of the vagina in BV?
pH >4.5-6.0 (normal is equal to/less than 4.5)
56
What type bacteria dominate the vaginal flora in BV?
Anaerobes eg Gardenerella and Mycoplasma hominis (replace the usually dominant vaginal lactobacilli)
57
Is BV sexually transmitted?
No
58
What are some risk factors for BV?
- Vaginal douching
- Receptive cunnilingus
- Black ethnicity
- Recent change of sexual partner
- Smoking
- Recent change of sexual partner
59
What are some complications of BV?
- Prevalence high in those with BID
| - Cellulitis / abscess formation following RV hysterectomy
60
What are the signs/symptoms of BV?
- Asymptomatic (50%)
- Profuse, whitish grey, offensive smelling vaginal discharge
- Characteristic 'fishy' smell = due to presence of amines released by bacterial proteolysis
61
What are the implications of BV in pregnancy?
- Late miscarriage (2nd trimester)
- Preterm birth
- PROM
- Post-partum endometriosis
62
What investigations can be done for BV?
- vaginal pH >4.5
- low vaginal swab
- 'whiff test' = characteristic fishy smell after adding 10% potassium hydroxide to discharge
- microscopic detection of 'clue cells' = squamous epithelial cells with bacteria adhered to walls
- Hay/Ison criteria for Gram Stained vaginal smear
63
What is the treatment of BV?
May resolve spontaneously and recurrence rate high even if successfully treated
- Metronidazole 400mg PO BD 5 days OR metronidazole 2g single dose
- Clindamycin 2% cream vaginally at night for 7 days
64
What is thrush?
Infection with a yeast-like fungus, most commonly Candida albicans = Candiasis
65
How common is candidiasis?
70% women experience at some point, 20-40% women are chronic carriers
66
What are risk factors for developing candidiasis?
Things which alter the vaginal microflora eg:
- Ab
- Pregnancy
- High dose COCP (oestrogen)
- DM
- Anaemia
= NOT sexually transmitted
67
What are the signs/symptoms of candidiasis?
- Vulval itching and soreness
- Thick, curd-like, white vaginal discharge
- Dysuria
- Superficial dyspareunia
- Characteristic appearance of vulval and vaginal erythema, vulval dissuading, typical white plaques adherent to the vaginal wall
- satellite lesions
- excoriations
= unlikely to cause significant complications unless woman severely immunocompromised
- may be asymptomatic
68
What are the implications of candidiasis in pregnancy?
- Very common in pregnancy with no major adverse effects
69
What investigations are done for candidiasis?
Often treated without investigations on typical symptoms
- Culture from HVS or LVS
- Microscopic detection of spores and pseudohyphae on wet slides
70
What is the treatment of candidiasis?
As so many women are chronic carriers = only treat if symptomatic
- Clotrimazole 500mg pessary +/- topical clotrimazole cream OR
- fluconazole 150mg single dose (CI in pregnancy)
Topical antifungals not systemically absorbed = safe at all gestations
General advice eg wear cotton underwear / avoid irritants
71
What is normal Vaginal Discharge?
1-4mls per 24 hours
White or clear
Non - offensive odour
Varies with menstrual cycle
72
Name some causes of Vaginal Discharge with post-coital coital bleeding
Infection
- Chlamydia
- Gonorrhoea
Cervical abnormality
- Polyp
- Ectopy
- Premalignant (CIN)
- Malignancy
73
What is lymphogranuloma venerum (LGV)?
A type of chlamydia which can cause rectal symptoms. Very invasive and required prolonged treatment (sometimes anal reconstructions required)
74
What is balantitis?
| What is posthitis?
```
Balanitis = inflammation of the glans penis
Posthitis = inflammation of the prepuce
```
= Balanoposthitis
75
Who does balantitis most commonly affect?
Boys <4yr and men who have not been circumcised
76
What is the possible aetiologies of balantitis?
- Candida (most common)
- Bacterial infection
- STI eg chlamydia, gonorrhoea, genital herpes
- Irritant / allergic
- Poor hygiene
- Psoriasis
- Lichen sclerosis
- Zoon's (plasma cell) balantitis
- Circinate balanitis
- Fixed drug eruptions
- Premalignant conditions
77
What are the signs/symptoms of balantitis?
Variable
- redness, irritation, unpleasant odour
- redness at the end of penis
- smegma = thick lumpy discharge from under the foreskin
- may have difficulty retracting foreskin
- dysuria
78
What investigations can be done for balantitis?
Urethral swab
79
What is the management of balanoposthitis?
Treat underlying cause eg Abx / antifungals
Mild steroid cream for allergies / irritants (but do not use alone in infection as it can make it worse)
If phimosis present (unretractable foreskin) may need circumcision
General advice eg clean penis everyday with water and avoid irritants
80
Name some normal anatomical variants which may be mistaken for warts (4)
- Pearly penile papules
- Fordyce spots
- Parafrenular glands
- Vestibular papillae
81
What are anogenital warts and what causes them?
Benign lesions caused by HPV
(90% types 6 or 11)
Warts may also contain oncogenic types (8 and 16) but these usually cause dysplastic lesions can cancer
82
What is condylomata acuminate?
(ano)genital warts
83
What are the signs/symptom of genital warts?
Varied appearance eg tiny flat patches on vulval skin, small papilliform (cauliflower-like) swellings, can affect cervix
May be asymptomatic = HPV infection very common and most do not result in visible genital tract lesions
84
What investigations are done for genital warts?
Clinical diagnosis
| May need biopsy to exclude neoplasia
85
What is the management of genital warts?
Skin lesion can be removed but virus is still in system (eg can come back when immunosuppressed)
No treatment option - some resolves spontaneously
Physical ablation = cryotherapy, excision, electrocautery
Topical application = podophyllotoxin (tetarogenic), imiquimod
86
What is the prevention of HPV?
Vaccination - quadrivalent vaccine since 2012 for girls (6, 8, 11, 16)
MSM not protected - but just started vaccine for boys
87
How is molluscum contagiosum spread in young adults and where on body does it affect?
Sexual transmission typically affecting young adults. Affects genitals, pubic region, lower abdo, upper thighs, buttocks
88
Describe a characteristic molluscum contagiosum lesion
Smooth surfaced, firm, dome-shaped papule with central umbilication
89
How is molluscum contagious diagnosed and treated?
Clinically
No treatment - takes approx 6 months to go away
Genital molluscum - offer routine STI screen
90
What virus causes herpes?
```
HSV-1 = oral
HSV-2 = genital
```
(HSV-1 can cause genital herpes but 70% are caused by HSV-2)
91
Which is herpes simplex virus is more common?
HSV-1 (in both? check?)
92
What is the difference between primary and secondary infection of HSV-1/HSV-2?
Check for antibodies - primary means it has been recently contracted and body has not been seroconverted ?? explain
93
How common is herpes?
2nd most common STI in the UK (after chlamydia, before genital warts and gonorrhoea)
- approx 70% population infected
94
What is the incubation period of HSV?
5-14 days
95
What are the signs/symptoms of primary HSV infection?
How long do they typically last?
Primary infection = usually more severe
Local symptoms (anogenital herpes):
- Painful ulceration
- Dysuria
- Vaginal / urethral discharge
- Vulvitis and pain (could be severe enough to cause urinary retention)
- Ulcers can coalesce to form larger superficial lesions with characteristic serpiginous edges
Systemic:
- Flu-like illness (muscle aches, malaise, headache)
3 weeks
96
Describe what happens when herpes is reactivated
HSV remains latent in dorsal root ganglion. When reactivated, it travels down the axon and into basal skin layers. Some episodes will be symptomatic whilst others are asymptomatic.
97
What can trigger a reactivation of herpes?
Stress, sex, menstruation
98
What are some complications of herpes?
- Meningitis
- Sacral radiculopathy (can cause urinary retention / constipation)
- Transverse myelitis
Disseminated infection
- Myalgia
- Auto-inoculation to distant sites
- Erythema multiforme
99
What are the implications of herpes in pregnancy?
Primary infection can lead to miscarriage or preterm labour
100
What are the implications of herpes in neonates?
- Transmission rate from vaginal delivery during primary infection can be as high as 50% but rare during recurrent attack
- Neonatal herpes appear during first 2 weeks of life = 25% confided to eyes and mouth, 75% widely disseminated (high morbidity and mortality)
101
How is herpes investigated?
Usually clinical diagnosis
Viral culture of vesicle fluid = gold standard
Acute and convalescent antibodies may be helpful
102
What is the treatment of herpes?
No cure
| Treatment with aciclovir can help to shorten duration and severity if given within 5 days of onset of symptoms
103
What is the management of herpes during pregnancy?
If labour is within 6wks of primary infection then delivery by CS recommended (provided membranes have not been ruptured for >4hrs)
With active vesicles from recurrent attack, risk vs benefit of surgery against small chance of neonatal infection
104
MOVE THIS CARD ONTO GYNAE ONCOLOGY
How does HPV cause cervical caner
HPV only oncogenic if it can enter cells and reach the nucleus for cell replication. Usually cannot enter cells.
Nicotine holds cell membranes open, allowing viral entry. Smoking increases risk of cervical cancer in a HPV +ve woman by twenty !!!
105
What are the 4 HIV presentations?
1) Primary HIV
2) Asymptomatic - screening
3) Symptomatic
4) Advanced HIV
106
What are the signs/symptoms of primary HIV (acute infection with HIV)?
- Fever
- Malaise
- Myalgia
- Lymphadenopathy
- Pharyngitis
- Rash
- Some present with an AIDs defining illness, neurological involvement or persistently low CD4 count (<200 cells/mm cubed)
Diagnosis within 6 months, recent -ve HIV test supports diagnosis
107
How long do symptoms of primary HIV infection / seroconversion last?
Begins 2-6 weeks after infection lasting 5-10 days (rarely > 14 days)
108
What are the window periods for antigen and HIV antibody detection?
p24 antigen detected 2-4wks after infection
HIV antibody detected 4-8wks after infection
- Thus a 4th generation (Ag/Ab) HIV test will detect the majority of infected patients by 4 weeks after an infection
109
What investigations are done for HIV?
Antibodies to core (p24) and surface (GP 41, 120, 160) proteins develop in 2-6wks
= repeat after 3 months in case delayed seroconversion
111
How long does the asymptomatic stage of HIV last?
Average 5-10yrs
112
List some example symptoms of symptomatic HIV:
- Non-specific
- Skin lesions
- Oral lesions
- Recurrent bacterial infections
- Abnormal blood results
- Non-specific: persistent lymphadenopopathy, fever, myalgia, diarrhoea
- Skin lesions: folliculitis, multi-site Herpes zoster, seborrhoea keratitis
- Oral lesions: candidiasis, oral hairy leukoplakia
- Recurrent bacterial infections: pneumonia, impetigo
- Abnormal blood results: lymphopenia, thrombocytopenia
113
What is a healthy CD4 count?
Greater than 500 cells/mm cubed = marker of healthy immune function
If falls lower than this, individuals at greater risk of opportunistic infections (used as a guide of when to start HAART)
114
What investigations and monitoring are done for HIV?
Routine - U&Es, FBC, lipid / bone profile, glucose
Serology - Hep A, B (surfaceAg and coreAb), Hep C, Syphilis
HIV viral load, CD4 count
115
What is the HIV test I?
Rapid point of care test
- Bedside test / in clinic
- Results in front of patient
116
What are the pros and cons of the HIV test I?
Pros:
- Quick
- Good for needle phobic pt
Cons:
- Some are 3rd generation = only pick up antibodies not antigen (12wk window period)
- Reactive tests require a laboratory venous sample for results confirmation
117
What is the HIV test II?
Venous blood sample in clotted tube, sent to the lab
118
What are the pros and cons of the HIV test II?
Pros:
- Accurate
- 4th generation test for shorted window period
Cons:
- Results not instant
119
What is PrEP?
Pre-Exposure Prophylaxis
- Given to HIV -ve people
- Taken before, during and after sex
- Can be taken daily or around sexual activity
- V effective
120
What is PEPSE?
Post Exposure Prophylaxis
- HIV medication taken after high risk sex / exposure
- Within 72hrs of risk (ideally within 24hrs)
- Take for 28 days
- Obtained from sexual health clinics of A&E
- Need for baseline HIV test and monitoring
121
How is HIV prevented MTCT (mother to child transmission)?
- Routine antenatal screening (opt-out)
- Delivery by CS
- PEP for baby for 4wks after brith
- Formula feeding (low income get milk vouchers)
- Avoid delivery before 34wks, PROM, invasive procedures during labour such as fetal blood sampling
122
What is HAART?
Highly active antiretroviral therapy = sustained inhibition of viral replication. Results in reinstitution of immune system in most pt, even those with advanced disease and low CD4 counts
123
What are NRTIs and NNRTIs?
Nucleoside/nucleotide analogues (NRTIs) and non-nucleoside agents (NNRTIs) inhibit viral reverse transcriptase enzyme
NRTIs
- Zidovudine
- Abacavir
NNRTIs:
- Nevirapine
- Etravirine
124
Name other examples of antiretroviral therapy
- Protease inhibitors (PIs) eg Indinavir
- Entry inhibitors eg Enfuviritide
- Fusion inhibitors
- CCR5 antagonists
- Integrase inhibitors eg Raltegravir
= often in pt who have failed previous ARV treatments or developed ARV resistance
125
What two features are diagnostic of AIDS?
Development of opportunistic infections of malignancy (including cervical carcinoma) or a CD4 count <200cells/mm cubed
126
List some common AIDS defining diseases in:
1) Resource rich countries
2) Resource poor countries
1) Resource rich countries:
- Pneumocystitis pneumonia
- Oesophageal candida
- Non-Hodgkin's lymphoma
- TB (pulmonary and extra pulmonary)
2) Resource poor countries
- TB (pulmonary and extra pulmonary)
- HIV wasting syndrome
- Cerebal toxoplasmosis
- Cryptococcus meningitis
127
List 3 infections specific to MSM
- Rectal LGV
- New variant syphilis
- Anal canal warts and anal intraepithelial neoplasia
128
*CHECK ON PAPER*
HIV risk assessment in sexual health clinic
- IVDU
- MSM
- CSW
??
129
List 4 dermatological conditions causing vulval pruritis
Lichen sclerosus
Lichen planus
Eczema / lichen simplex
Psoriasis
130
List 4 infections and infestations causing vulval pruritis
```
Candidiasis
Trichomonoiasis
Prodrome of recurrent herpes simplex infection
Genital warts
Scabies
Prediculosis pubis
Threadworms
```
131
List types of intercourse increasing risk of HIV transmission from most to least risk
Receptive anal intercourse > receptive vaginal intercourse > insertive anal intercourse > insertive vaginal intercourse
