sexual health Flashcards
Commonest cause of change in genital discharge in women?
bacterial vaginosis
What are two strong indicators of STIs in women?
- post-coital bleeding (though could be dt polyp or ectropian)
- pelvic pain
What are the two commonest differentials for inter-menstrual bleeding in young women?
- infection
- new contraception
What are the window periods for the tests for:
- chlamydia?
- gonorrhoea?
- HIV?
- syphilis?
ie how long after contact before the test is reliable (ie few false negatives)
2 weeks for chlamydia and gonorrhoea
4 weeks for HIV
3 months for syphilis
What is the two step question to ask about their gender identity?
“What gender do you identify as?”
“What sex were you assigned at birth?”
What percentage of trans people are involved in sex work?
what other common things make them at higher risk of HIV? 3
46% of trans people are involved in sex work
Transactional sex, stigma, substance abuse, mental health
What can you say if a partner tries to join your patient in a consultation for sexual health?
“Do you mind if I just see you on your own first and then you can come in later”
Explain that it’s policy to see people on their own
What is ‘normal’ discharge for women like?
1-4mls per 24 hrs
white or clear
non-offensive odour
varies with menstrual cycle (except if on pill)
nb most women have abnormal discharge at some point in their lives
What are the common causes of discharge in women: - non-infective? 3 infective: - non-STI (vaginal)? 2 - STI (vaginal)? 1 - STI (endocervical / urethral)? 2
which of these are the commonest and 2nd commonest cause of abnormal discharge?
NON-INFECTIVE
- physiological
- cervical ectopy (more common if on COCP or pregnant)
- foreign body
INFECTIVE
Non-STI (vaginal)
- bacterial vaginosis (commonest)
- candida (2nd commonest)
STI (vaginal)
- trichomonas vaginalis
STI (endocervical / urethral)
- chlamydia trachomatis
- neisseria gonorrhoeae
nb getting an increase in physiological discharge dt an ectropian is normal in premenopausal women but NOT normal in post-menopausal women (suspicion of ca)
nb chlamydia and gonorrhoea less rarely present with change in discharge in women
nb discharge also can change during pregnancy
What should you always assess for risk of before managing potential abnormal discharge?
pregnancy risk!
do a PT if not sure
What is the 1) pH and 2) vaginal flora like in:
- a healthy vagina?
- a vagina with bacterial vaginosis?
HEALTHY
- lactobacilli are dominant bacteria
- low levels of other bacteria
- pH <4.5
BACTERIAL VAGINOSIS
- lactobacilli may be present (but reduced in number)
- flora dominated by anaerobic bacteria
- pH > 4.5 - 6
What is bacterial vaginosis?
Risk factors for bacterial vaginosis? 5
Bacterial vaginosis (BV) describes an overgrowth of predominately anaerobic organisms such asGardnerella vaginalis. This leads to a consequent fall in lactic acid producing aerobic lactobacilli resulting in a raised vaginal pH.
Whilst BV is not a sexually transmitted infection it is seen almost exclusively in sexually active women.
RISK FACTORS
- Vaginal douching (Commoner in black ethnicity)
- Black ethnicity (regardless of douching)
- Recent change of sexual partner
- Smoking
- Presence of STI (and vice versa - if got BV, increase change of STI)
nb receptive cunnilingus (women receiving oral sex) may also be a risk factor but don’t really ask about and never suggest changing!
What is the typical appearance of vaginal discharge in:
- bacterial vaginosis?
- candida?
- Trichomonas vaginalis?
also associated symptoms for two of them (one has 4, other has 3)
BACTERIAL VAGINOSIS
- Offensive fishy smelling vaginal discharge
- Increased volume, thin, watery (like milk with frothy bubbles)
- NOT associated with soreness, itching, or irritation (ie signs of inflammation
- Many asymptomatic (50%)
CANDIDA
- Thick vaginal ‘cottage cheese’ discharge (but not offensive smell)
- Vulval itch
- Vulval soreness
- Superficial dyspareunia
- External dysuria (dt inflammation around urethra)
- signs of inflammation and erythema
TRICHOMONAS VAGINALIS
- Offensive, yellow/green, frothy discharge (10-30%)
- Vulvovaginitis (inflammation -> vulval itch and dysuria)
- Strawberry cervix (2%)
- 10-50% asymptomatic
so basically candida is cottage cheese plus inflammation, BV is offensive discharge without inflammation and trichomonas is offensive discharge and inflammation
- “the one that is a n STI has both sets of symptoms:”
What are women at risk of following a course of antibiotics?
thrush - ie candida
makes sense
What are the criteria for diagnosing bacterial vaginosis? how many do you have to have to diagnose it?
investigations in GUM clinic? 2
investigations in GP? 2
Amsel’s criteria for diagnosis of BV - 3 of the following 4 points should be present:
- thin, white homogenous discharge
- clue cells on microscopy: stippled vaginal epithelial cells
- vaginal pH > 4.5
- positive whiff test (addition of potassium hydroxide results in fishy odour)
GUM CLINIC W MICROSCOPY
- low vaginal swab
- hay-ison criteria gram stained vaginal smear
GP
- low vaginal swab (send to lab)
- narrow-range pH strip (pH >4.5)
though in reality in GP, do swab and then treat anyway before comes back if typical symptoms
Medical management of bacterial vaginosis? 1
Cure rate?
who is treatment indicated for? 2
Other general advice for women? 2
Management
* oral metronidazole for 5-7 days
- 70-80% initial cure rate
- relapse rate > 50% within 3 months
treatment for:
- symptomatic women
- Those undergoing certain surgical obs/gynae procedures
general advice
- avoid douching
- wash vulva / vagina with water only
nb the BNF suggests topical metronidazole ortopical clindamycinas alternatives - though these are rarely used!
Risk factors for candida? 3
- immune suppression (incl diabetes + pregnancy)
- antibiotic use
- oestrogen exposure (eg COCP, HRT)
Candida:
- possible investigations? 2
- when to do investigations? 2
- microscopy of a gram stained vaginal slide in specialist GU settings
- Culture of a low vaginal swab asking for yeast sensitivities
(nb Best place to swab for candida is mid vagina)
Often treated without investigation on typical symptoms
do investigations if:
- no response to treatment
- doubt over diagnosis
nb 10-20% of women during reproductive years may be colonised with Candida sp. but have no clinical signs or symptoms = no treatment required
Management of candida:
- advice?
- medication options?
- use a soap substitute (eg emollients - as in eczema)
- avoid tight fitting clothing
- avoid soaps etc (ie local irritants)
Oral OR topical management
- Patient preference
- availability
- pregnancy (topical only!)
Clotrimazole pessary 500mg stat (single dose)
- 7 days in pregnancy
Fluconazole 150mg PO stat (not in pregnancy)
nb no need to treat asymptomatic male partners
Trichomonas vaginalis:
- is it an STI?
- signs on examination? 4
- investigations? 2
yes
- Classical frothy yellow offensive discharge (occurs in 10-30%)
- Vulvitis (ie a lot of inflammation)
- Vaginitis
- 2% strawberry cervix
- swab from posterior fornix at speculum exam for wet mount microscopy (GU specialist settings only)
- Vulvovaginal NAAT (as if have one STI then likely to have others)
Management of Trichomonas vaginalis:
- general advice? 2
- medical management options? 2
- what are three common reasons for treatment failure?
- Sexual partners should be treated simultaneously
- Avoid sex for 1/52 AND until partners have completed treatment
OPTIONS:
- Metronidzole 2g PO stat dose
- Metronidazole 400mg BD for 5-7 days
Common reasons for treatment failure:
- poor compliance
- sexual history / reinfection
- vomiting the metronidazole up (can’t have alcohol on met)
What are the differences between BV, candida and trichomonas in:
- discharge?
- odour?
- presence of itch?
- other symptoms
- signs on exam?
- vaginal pH?
BACTERIAL VAGINOSIS
- thin discharge
- fishy
- no itch
- dyspareunia, dysuria
- discharge coating vagina + vestibule (no vulval inflammation)
CANDIDIASIS
- thick white discharge
- non-offensive
- vulval itch
- soreness, superficial dyspareunia
- normal findings OR vulval erythema, oedema, fissuring, satellite lesions
TRICHOMONAS
- scanty to profuse discharge
- offensive
- vulval itch
- lower abdo pain
- frothy yellow discharge, vulvitis, vaginitis, cervicitis
so basically candida is cottage cheese plus inflammation, BV is offensive discharge without inflammation and trichomonas is offensive discharge and inflammation
- “the one that is a n STI has both sets of symptoms:”
nb trichomonas is often misdiagnosed as candida or BV
If someone presents with change in vaginal discharge:
- what features of the discharge should you ask about? 6
- what other symptoms should you always ask about? 4
DISCHARGE
- colour
- smell
- consistency
- amount
- any blood?
- any association with periods?
- dysuria
- vulval itch
- pelvic pain
- dyspareunia (superficial or deep)
If patient has one STI, which other STIs should you also test for?
Chlamydia
Gonorrhoea
Syphilis
HIV
Chlamydia:
- risk factors? 4
- what % of partners are also infected?
- <25 years (70% of infections)
- New sexual partner
- > 1 partner in last year
- Lack of consistent condom use
High frequency of transmission, 75% of partners also infected
Chlamydia in women:
- possible symptoms? 6
- possible signs on exam? 2
- possible complications? 5
MAJORITY ARE ASYMPTOMATIC
- increase in vaginal discharge
- Dysuria
- Post-coital bleeding
- intermenstrual bleeding
- Deep dyspareunia
- Lower abdo pain (sometimes RUQ)
POSSIBLE SIGNS
- mucopurulent cervicitis
- contact bleeding
COMPLICATIONS
- PID, endometritis, salpingitis
- Tubal infertility
- Ectopic pregnancy
- Sexually acquired reactive arthritis (SARA)
- Perihepatitis (Fitz-Hugh Curtis syndrome)
^ so can sometimes get RUQ pain
Main investigation for chlamydia in women?
window period?
What else should always test for if a positive result? 3
other test to consider?
VVS (vulval-vaginal swab) NAAT in women (can also do endocervical)
2 weeks – consider repeat test based on sexual history (ie if not just one UPSI)
- Don’t want to give false negatives
if positive:
- gonorrhoea
- HIV
- syphilis
Consider extra-genital sampling
(nb get more +ve results from rectal sites and can get rectal infection from just having vaginal sex)
Women with rectal symptoms should be referred to GUM services to check for lymphogranuloma venerum (LGV)
- ie rectal mucus blood discharge, itching
nb chlamydia is an obligate intracellular bacterium and so doesn’t culture
Management of chlamydia in men + women:
- general advice? 2
- 1st line management?
- other management option? when is this indicated? 4
- when should a test of cure be done?
- Avoid sex for 1/52 until they AND their partners have completed treatment
- show how to use condoms
1st line = Doxycycline 100mg BD for 7 days
alternative = Azithromycin 1g PO stat
give azithro if:
- pregnant (doxy is CI)
- breastfeeding (doxy is CI)
- allergy to doxy
- adherence concerns (as is a stat dose)
test of cure not normally needed
- only needed in pregnancy
Gonorrhoea:
- type of organism? (+ colour on gram stain)
- what are the 5 common sites of infection in women?
- mode of transmission?
Gram negative diplococcus: Neisseria gonorrhoeae
- pink/red on gram stain
Primary sites of infection are mucous membranes:
- urethra
- endocervix
- rectum
- pharynx
- conjunctiva
Transmission: Direct inoculation of infected secretions from one mucous membrane to another
gonorrhoea in women:
- % that are asymptomatic?
- potential symptoms? 6
endocervical infection asymptomatic in up to 50% of cases
- increased or altered discharge
- menorrhagia
- post-coital bleeding
- inter-menstrual bleeding
- lower abdo pain (25%)
- urethral infection may cause dysuria (not frequency)
possible clinical signs of gonorrhoea in women:
- if uncomplicated? 2
- if complicated? 1
- a rare complication and how it presents?
- Mucopurulent endocervical discharge
- Endocervical contact bleeding
Complicated: PID
Disseminated gonococcal infection (DGI) and gonococcal arthritis may also occur, with gonococcal infection being the most common cause of septic arthritis in young adults. The pathophysiology of DGI is not fully understood but is thought to be due to haematogenous spread from mucosal infection (e.g. Asymptomatic genital infection). Initially there may be a classic triad of symptoms: tenosynovitis, migratory polyarthritis and dermatitis. Later complications include septic arthritis, endocarditis and perihepatitis (Fitz-Hugh-Curtis syndrome)
Key features of disseminated gonococcal infection
tenosynovitis
migratory polyarthritis
dermatitis (lesions can be maculopapular or vesicular)
investigations for gonorrhoea? 3
what to do as a 2nd line test if a screening test comes back positive?
- what additional tests needed if confirmed gonorrhoea? 3
- VVS for NAAT (do for all discharge)
if think gonorrhoea:
- Gram stained slide for microscopy from infected site (GU specialist clinics only)
If slide and / or NAAT comes back positive, MUST do a swab and culture:
- Bacterial swab for gonorrhoea culture from infected site
TAKE THE SWAB FOR CULTURE ETC FROM ENDO CERVIX (ie VVS is just for NAAT)
ALWAYS CULTURE!!!!
- chlamydia
- syphilis
- HIV
Management of gonorrhoea (for men + women):
- general advice? 2
- medications to give to all? 2
- what additional tests needed? 1
- Avoid sex for 1/52 until they AND their partners have completed treatment
- MUST return for TOC (test of cure) for at 2/52 after therapy
single dose of IM ceftriaxone 1g
- nb used to be ciprofloxacin but increasing resistance - if know culture results and sensitive to cipro then can still use
nb if severely pen allergic then be aware ceftriaxone is a beta lactam
If good practise to treat for chlamydia at same time (unless sure don’t have)
- so give course of doxy too!
EVERYONE must have TOC after 2 weeks - counsel on importance of coming back!
- also do pregnancy test on all women having UPSIs
nb If partner has STI and pt has signs then treat before know result of test
Symptoms of urethritis in men? 3
- Urethral discharge
- Dysuria
- Urethral discomfort
urethral discharge in men is ALWAYS abnormal
UTIs in young men is v rare
- Dysuria in young men is STI until proven otherwise!!
Causes of urethritis in men:
- gonococcal?
- non-gonococcal? 3
GONOCOCCAL
- gonorrhoea
NON-GONOCOCCAL
- Chlamydia
- Non-chlamydial
- — Mycoplasma genitalium
- — Non-specific urethritis (NSU)
nb, except NSU, all of these are sexually transmitted!
If discharge is not gonorrhoea then assume (and treat for chlamydia) - only really for mycoplasma genitalium if treatment for others are unsuccessful
