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
Gonorrhoea in men:
- primary sites of infection? 4
- what % are symptomatic?
- symptoms? 3
- Urethra
- Rectum
- Pharynx
- Conjunctive
80% of men are symptomatic
- Urethral discharge (norm yellow in gonorrhoea)
- Dysuria
- Urethral discomfort
nb can get anal discharge if that is the site of infection
potential complications of gonorrhoea in men?
- Epididymo-orchitis
- Proctitis
- disseminated gonorrhoea
former two can lead to sub fertility
latter can cause arthritis etc
investigations for gonorrhoea in men?
what to do as a 2nd line test if a screening test comes back positive?
- what other thing to do in MSM?
- what additional tests needed if confirmed gonorrhoea? 3
- NAAT from site of infection (urethra / anus)(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
ALWAYS CULTURE!!!!
If MSM, do 3-site culture (pharynx, anus, urethra)
- chlamydia
- syphilis
- HIV
nb management is same as for female
Chlamydia in men:
- symptoms of urethral infection? 3
- what other symptoms must you always ask about?
- Urethral discharge (norm white / clear in chlamydia)
- Dysuria
- Urethral discomfort
always ask about rectal symptoms (can present like IBS)
Investigations for chlamydia in men:
- always?
- if have microscopy?
- if MSM?
- If any rectal symptoms?
- NAAT from infected site for ALL
If microscopy, Gram stained urethral or rectal smear meeting criteria for NGU – offer treatment on the day
3 site testing in MSM (pharynx, urethra, rectum)
test for LGV if any rectal symptoms
nb management is as per women (doxy) - though epididymo-orchitis requires extensive treatment
Basically if got non-gonococcal urethritis then give doxycycline (ie assume chlamydia)
non-specific urethritis (NSU)
- what is it?
- when / how to diagnose?
- management?
basically a diagnosis of exclusion once gonorrhoea and chlamydia have been ruled out in men with urethral discharge
do gram stain urethral smear and NAAT test
- if both negative then refer to GUM
manage as per chlamydia, refer to GUM if symptoms not resolved
Mycoplasm genetalium:
- proportion of men + women who are asymptomatic?
- possible male symptoms? 3
- possible female presentations?
- when is it tested for? 1
- investigations? 2
- management?
majority of men + women are asymptomatic
men
- urethral discharge
- dysuria
- urethral discomfort
women
- cervicitis (change in discharge, contact bleeding etc)
- PID
currently only tested for after treatment failure for chlamydia and gonorrhoea
swab and resistance testing (also NAAT to confirm not chlamydia or gonorrhoea)
depends on culture results - a lot of abx resistance so can be hard!
Rectal presentations of STIs
- common symptoms? 4
- what questions should always ask in sexual hx? 3
- possible STI causes of rectal symptoms? 4
- altered bowel habit
- presence of blood
- presence of mucus / discharge
- feeling of tenesmus
- gender of partners?
- what type of sex having?
- any change in bowels?
- chlamydia (esp LGV)
- gonorrhoea
- herpes
- sexually transmitted enteric infection (eg shigella - from anal-oral sex, ie rimming)
nb these can often present to GP or GI clinic, always think STI if see young person with altered bowel habit - especially MSM
What are four normal anatomical variants that are often mistaken for genital warts?
describe them
(nb these are all small lesions - larger lumps are on a different flashcard)
PEARLY PENILE PAPULES
- Small white papules on the ring around end of penis
FORDYCE SPOTS
- Yellow macules / papules - are small sebacious cysts on labia or penis / scrotum
VESTIBULAR PAPILLAE
- small, shiny, skin-colored growths on a woman’s vulva. The papillae occur in a line or as symmetrical patches on the labia minora on both sides of the vulva
PARAFRENULAR GLANDS
- normal glands that appear on either side of the frenulum (‘banjo string’). Occasionally, just three or four glands are lined up symmetrically. More often, however, the glands are scattered
nb these are all NORMAL!
**see photos on ‘genital skin’ ppt from intro weeks
non-STI causes of larger lumps on the:
- vulva? 1
- testicles? 2
- both? 1
what to do about each
VULVA
bartholin’s cysts
- fine if small and non-infected
- if infected, may need drainage and marsupialisation
- if suspciois for bartholin’s cancer (rare) can do biopsy
TESTICLES
varicocele
- varicose veins of the testicles
- often not treated but are if causeing infertility or pain
cystocele
- often harmless, blocked lymph duct
- will norm resolve spontaneously
obvs sudden pain and swelling in testes - think torsion!
BOTH
sebaceous cysts
- norm fine
- common
Common STI causes of genital lumps? 3
- characteristics of each AND
how they spread?
nb this doesn’t include ulcers!
ANOGENITAL WARTS
- 90% caused by HPV 6+11
- very common, most don’t result in visible genital tract lesions (smoker or immune-deficient increases likelihood)
- clinical diagnosis
- see photos online*
- sexual and skin to skin contact (condoms don’t completely prevent against)
MOLLOSCUM CONTAGIOSUM
- Sexual transmission usually affecting young adults. Affects genitals, pubic region, lower abdomen, upper thighs, and/or buttocks (also affects kids as skin to skin)
- Lesions are usually characteristic, presenting as smooth-surfaced, firm, dome-shaped papules with central umbilication
- clinical diagnosis
SCABIES
- Is REALLY itchy
- Skin to skin contact
- Can have nodular appearance
- Look at webs of hands
- clinical diagnosis
nb HPV 6 + 11 give warts, 16 + 18 give cancer
ANOGENITAL WARTS:
- what to tell patient?
- management options? (2 groups, give examples of each)
- Who offer HPV vaccine to in GUM clinic (if not already had)?
- what other tests to offer someone with anogenital warts? 4
- When to biopsy warts? 1
very common, most don’t result in visible genital tract lesions (smoker or immune-deficient increases likelihood)
- warts will resolve by themselves (body will clear virus within a year)
- can use condoms but doesn’t completely prevent against
- no treatment is an option
- different strains of HPV which cause cervical cancer
MANAGEMENT OPTIONS:
- nb no treatment is an option!
1) Physical ablation
- Cryotherapy
- Excision (rare, if don’t go)
- Electrocautery
2) Topical applications (can’t use in pregnancy)
- podophyllotoxin (for non-keratinised warts)
- imiquimod (for keratinised warts)
nb see clinic-specific guidelines on warts management
Offer HPV vaccine to MSM if not had before
if have warts, test for:
- chlamydia
- gonorrhoea
- HIV
- syphilis
IF WART ON CERVIX - BIOPSY IN CASE IS CANCER!
Management of molluscum contagiosum? 2
MOLLOSCUM CONTAGIOSUM
- if genital molluscum, offer a routine STI screen (NAAT, HIV, syphilis)
- no treatment often recommended, but can do cryotherapy
Management of scabies? 2
SCABIES
- treat everyone in house with topical insecticide (permethrin or malathion)
- thoroughly clean bedding and clothes
Two commonest causes of genital ulcers?
- what are the two main differences between them?
- other rarer cause of vulval ulcer?
GENITAL HERPES
- painful (esp if first infection)
- often multiple lesions
SPYHILIS CHANCRE
- painless
- norm single lesion
vulval cancer can present as an ulcer - so especially think of in older women
HERPES
- two viruses? which norm causes which?
- symptoms? 3
- additional symptoms in primary infection? 3
- which gender / sexuality most common in?
HSV1 - mainly oral (cold sores)
HSV2 - mainly genital
- painful ulceration
- dysuria
- vaginal or urethral discharge
systemic symptoms (really only in primary infection):
- fever
- myalgia
- inguinal lymphadenopathy
generally recurrent infections are a lot more mild than initial infection
Herpes is much more common in heterosexual women (than heterosexual men)
- Low in MSM and very low in WSW
HERPES:
- incubation period?
- pathophysiology after primary infection?
- when is herpes infectious?
- triggers for recurrence? 3
- symptoms people often get before recurrence?
Incubation period is 2days to 2 weeks (ie get symptoms soon after contact)
Following primary infection, the virus becomes latent in local sensory ganglia, periodically reactivating to cause symptomatic lesions or asymptomatic, but infectious, viral shedding.
Can transmit oral herpes to genital if NO active lesion
- But rare
- Much more common to transmit when active lesion
common triggers:
- stress
- sex
- menstruation
often get ‘tingling’ before recurrence
- tell people to abstain from when get tingling!)
HERPES:
- investigation?
- medical management?
- additional management if primary infection?
- how long to avoid sexual contact for after flare?
- management if frequent recurrences? (incl def of frequent recurrence)
swab for viral PCR
acyclovir
if primary:
- saline baths
- lignocaine gel
Avoid sexual contact for 4 weeks from flare.
Recurrences are very variable
- If >6 recurrences a year then give daily acyclovir as prophylaxis
nb if you’re suspecting herpes at all (ie not sure if syphilis or herpes) thencover with acyclovir until know for sure!
HERPES
- who’s most at risk from primary infection?
- additional management if this group get it? 1
Pregnant woman who get PRIMARY herpes infection in THIRD trimester is very dangerous
- Need c-section (in addition to acyclovir)
nb much lower risk if just a recurrence
nb acyclovir is safe to give in pregnancy
SYPHILIS:
- causative organism?
- most common gender / sexuality to get it?
- what other STI are people commonly co-infected with?
- incubation period?
spirochete
Treponema pallidum
predominates among white MSM aged 25–34, many of whom (40%) are HIV-1 co-infected.
10-90 days incubation (usually about 21 days)
SYPHILIS:
- presentation of primary? 2
- if untreated, % who will go on to get secondary syphilis?
- how long after primary syphilis does secondary syphilis normally occur?
- Chancre (develops from a single papule)
- Anogenital, single, painless and indurated with clean base, non-purulent
- nb can be multiple, painful
- localised, non-tender lymph nodes
- Resolve over 3-8 weeks
If primary syphilis is untreated 25% will develop secondary syphilis
secondary syphilis occurs 4-10 weeks after initial chancre
SECONDARY SYPHILIS:
- Commonest presentation? 5
- other possible presentations? 8
Maculopapular rash all over body (esp palms, soles and trunk)
- May be itchy
- fevers
- lymphadenopathy
- buccal ‘snail track’ ulcers (30%)
- condylomata lata (painless, warty lesions on the genitalia)
OTHER POSSIBLE PRESENTATIONS:
- Hepatitis
- Splenomegaly
- Glomerulonephritis
- Acute meningitis
- Cranial nerve palsies
- Uveitis
- Optic neuropathy
- Interstitial keratitis and retinal involvement
nb following secondary can have latent syphilis:
- early latent <2 years
- late latent >2 years
TERTIARY SYPHILIS:
- three types?
- who more common in?
about 40% still infected after 2 years
NEUROSYPHILIS
- Tabes dorsalis (syphilitic myelopathy) = slow demyelination of neural tracts in dorsal columns + Dementia
CARDIOVASCULAR
- Damage to aortic route -> aortic route dilitation
- incredibly rare
GUMMATOUS
- incredibly rare
- nodules on skin and intenral organs
- areas of necrotic tissue
tertiary syphilis more common in people who are HIV+
SYPHILIS:
- two blood tests?
- what to be aware with for blood tests?
- two tests to do if chancre present?
- other tests to do if positive for syphilis? 3
Blood test (*think both in the same test?) - VDRL carbon antigen test (venereal disease research laboratory test) + RPR test (rapid plasma reagin test)
blood tests look for antibodies against syphilis so, once been infected before, will always be positive (*check this!)
IF CHANCRE:
- PCR for herpes (to exclude)
- Smear from primary lesion –> dark field microscopy showing spirochetes (spiral bacteria)
- HIV
- chlamydia
- gonorrhoea
Risks of syphilis in pregnancy? 3
- pre-term delivery
- still birth
- congenital syphilis
SYPHILIS
- management for primary, secondary and early latent? 1
- management for late latent, cardiovascular + gummatous? 1
- alternatives, if allergy? 1
- other management for all? (and timescale for this)
primary, secondary and early latent
= Benzathine penicillin 2.4MU IM single dose
Late latent, cardiovascular and gummatous
= Benzathine penicillin 2.4 MU IM weekly for three weeks (three doses)
Alternatives (penicillin allergy) include doxycycline PO (not quite as good)
nb longer treatment courses for neurosyphilis / ophthalmic syphilis
CONTACT TRACING
- may go back years!
What is:
- balanitis?
- posthitis?
- balanoposthitis?
Balanitis - Balanitis describes inflammation of the glans penis (ie head of penis)
Posthitis - inflammation of the prepuce (foreskin)
balanoposthitis
= inflammation of both
Balanoposthitis
- symptoms? 6
- commonest cause?
- other causes? 8
- Local rash
- Soreness
- Itch
- Odour
- Inability to retract the foreskin
- Discharge from the glans / behind the foreskin
CANDIDA is commonest cause
- common in diabetic
- may get white plaques
OTHER CAUSES:
- Anaerobic balanitis
- Lichen sclerosus
(treat w potent steroid (dermovate) as can give very small chance of SCC if left untreated) - Zoon’s (plasma cell) balanitis (typically men in 50s/60s)
- Psoriasis
- Circinate balanitis (associated with SARA, looking like psoriasis - do STI screen if suspect!)
- Irritant / allergic
- Fixed drug eruptions
- Premalignant conditions (esp hyperpigmented etc, biopsy if suspicious + follow up)
nb Candida is NOT sexually transmitted, sex may cause irritation to the skin but not actually passing infection
What to always ask about if anyone presents with genital skin changes? 2
1) Always ask if any ezcema, atopy, psoriasis
As these look different on genital skin than normal skin
2) What are patients washing vulva / penis with?n (femwash is very irritant)
What does SARA stand for in sexual health?
previously known as?
sexually acquired reactive arthritis (SARA)
previously known as reiter’s syndrome
conditions which affect the vulva:
- possible symptoms? 4
- common conditions? 7
- Itch/irritation
- Soreness/redness
- Dyspareunia
(superficial) - Urinary symptoms (esp dysuria)
- candida (v common)
- lichen sclerosus (see other flashcard)
- lichen planus (see other flashcard)
- lichen simplex (see other flashcard)
- vulval eczema
- vulval psoriasis
- vulval intra-epithelial neoplasia (see gynae onc)
- also pagets disease of vulva? - look up *
Difference between lichen sclerosus, lichen planus and lichen simplex?
describe each (don’t need test or management though)
nb these are all of the vulva
LICHEN SCLEROSUS
- more common in over 50s
- patches on skin that are white, itchy, smooth or crinkled
- atrophic skin, can get telengiectasia
- can lead to formation of scar tissue - labia majora or minora may disappear, ie loss of architecture)
- 4% risk of SSC
- chronic lifelong condition
LICHEN PLANUS
- sore red patches on vulva (also get in mouth)
- or could be flat topped papules, white lacy papules, plaques or erosions
- itching is main symptom
- can go away with time
nb both sclerosis and planus are autoimmune
LICHEN SIMPLEX
- a response to basically any other vulval condition and skin being rubbed / itched over time (though norm ezcema or psoriasis)
- get itching -> thickening + scar tissue -> more itching etc
- skin appears leathery and thickened
General investigations / management for vulval conditions / balanitis:
- investigations which may be helpful? 4
- general management advice to patient? 3
(specific management for conditions is on another flashcard)
- Swab for candida /bacterial culture
- HSV /syphilis PCR
- STI screen
- Biopsy may be indicated if cause remains uncertain (or if suspect lichen sclerosis or cancer)
- Avoid soaps / irritants
- Emollients can be used as soap substitutes
- Avoid tight fitting underwear (skinny jeans, thongs)
Management of balanitis / vulvitis:
- options if caused by candida? 2
- medical management of most things? 1
- medical management if lichen sclerosis? 2
CANDIDA
- Clotrimazole cream or oral fluconazole
- topical steroids for pretty much everything (if not infective)
lichen sclerosis
- potent steroids (dermavate)
- oestrogen pessary
nb need biopsy for lichen sclerosis
DON’T FORGET GENERAL ADVICE ABOUT WASHING WITH EMOLLIENTS, AVOIDING SOAP ETC!!
Lesson common causes of genital ulcers (ie once ruled out herpes + syphilis):
- other STIs? 2
- other infections? 2
- inflammatory / autoimmune? 5
- other? 3
OTHER STIs (aside from herpes + syphilis)
- LGV (type of chlamydia)
- Chancroid, Donovanosis (these are tropical STIs - very rare in UK)
OTHER INFECTIONS
(these can break down skin + cause ulcers)
- candida
- bacterial infections
INFLAMM + AUTOIMMUNE
- Crohn’s disease
- Behcet’s disease
- Stevens-Johnson syndrome (typically have anal and oral lesions too)
- erosive lichen planus
- pyoderma gangrenosum (ulcerative disease of older people, generally on the leg but occasionally on the genitals)
OTHER CAUSES
- trauma
- drug reactions
- malignancy (vulvar or penile ca)
don’t get too bogged down in these - just remember the general categories
If genital skin symptoms, what other (more systemic) symptoms should you ask about? 4
- Joint problems
- Skin problems
- Oral or anal symptoms
- Lymph nodes (esp around genitals)
What to tell patients about genital herpes? 7
- Herpes virus, also known as cold sore virus [Type 1 and Type 2 may behave differently in different sites]
- Sexually transmitted [check for other STIs]
- Common, not dangerous- unless first episode in last stage of pregnancy (can reduce risk if treat mum- GUIDELINES available)
- Treat first episodes with aciclovir (BASHH guidelines for doses)
- Recurrences are mild and short lived
saline baths and topical anaesthetic gels/creams may help self management - Approx 5% get frequent episodes that bother them- can offer episodic treatment with aciclovir to self-initiate, or suppressive daily dosing
- not curable
Genital warts - what to tell patient? 9
- Common
- STI (should check for other STI)
- Caused by a skin virus (HPV), passed with skin to skin contact
- Not dangerous (HPV types 6 and 11 commonly implicated)
- Virus is usually cleared from the skin
(factors such as smoking/HIV/pregnancy may affect clearance (ie make it harder)) - Range of treatments available
including some for use at home (podophyllotoxin and imiquimod) - no treatment is an option (most infections resolve spontaneously within a year)
- Partner notification not necessary:
partner can attend if they have noticed any lesions (most HPV infections do not result in visible genital tract lesions) - Partner may also want to come in for general STI test - Incubation period is variable, but generally between 3 weeks to 8 months
What should you always give a patient after they are diagnosed with a condition? 1
LEAFLET!!!!! about said condition
eg a really good PIL for genital warts: https://www.bashhguidelines.org/media/1179/wart-pil-screen-v-2018.pdf
balanitis - what to tell patients? 7
- Inflammation of the head of penis and foreskin
- Many causes, in this case most likely yeasts
- STI screen – based on risk assessment
- Avoid irritants
- Use water / emollient rather than soap
- Treatment – usually topical antifungal eg. clotrimazole 1% twice daily until resolved
- don’t need partner notification
What are the three broad differentials in a women presents with dysuria? how do you differentiate between?
- what is the main differential if a man presents with dysuria?
WOMAN
- STI
- UTI
- vulval condition (inflam or candida)
^ ask about LUTS and other symptoms (discharge, dyspareunia, itching)
- also sexual hx
MAN
- STI (until proven otherwise)
- may also be balanitis / candida
Main differential diagnoses for post-coital bleeding:
- infective? 2
- non-infective? 3
What is mneumonic for abnormal uterine bleeding? 9
INFECTIVE
- cervicitis (chlamydia or gonorrhoea - ie STIs that affect cervix)
- other infections (bacterial vaginosis, candida etc)
NON-INFECTIVE
- ectropian (esp if on COCP or pregnant)
- cervical polyp
- cervical cancer
PALM COEIN for abnormal uterine bleeding (any change in amount, timing etc of bleeding)
- it doesn’t include infections though so be aware
- but if ever stuck on any type of AUB, ask about these
Main differential diagnoses for inter-menstrual bleeding:
- infective? 2
- non-infective? 3
What is mneumonic for abnormal uterine bleeding? 9
INFECTIVE
- STI (chlamydia, gonorrhoea, trichomonas)
- bacterial vaginosis
NON-INFECTIVE
- some contraceptives (esp if recently started)
- polyp (nb may also cause menorrhagia)
- cancer
nb things like fibroids, endometriosis etc cause menorrhagia, but don’t norm cause IMB
PALM COEIN for abnormal uterine bleeding (any change in amount, timing etc of bleeding)
- it doesn’t include infections though so be aware
- but if ever stuck on any type of AUB, ask about these
Main differential diagnoses for acute pelvic pain in women:
- in all (incl gynae and other)? 7
- only if pregnancy test is positive? 3
(nb this is not pain in later pregnancy - eg placental abruption etc)
what groups of symptoms should you always ask about if any pelvic / lower abdo pain in woman? 3
IN ALL (ie if PT +ve or -ve)
- PID
- Dysmenorrhoea (incl endometriosis)
- mittelschmertz
- ruptured ovarian cyst
- ovarian torsion
- UTI
- appendicitis
ONLY IF PT IS POSITIVE
- ectopic pregnancy
- miscarriage
- threatened miscarriage
nb other things like IBD, fibroid degeneration, porphyria, sickle cell etc but focus on common things!
- alway ask if had before!
if pelvic pain, always ask about:
- vaginal / uterine symptoms (eg AUB, change in discharge, LMP)
- bowel symptoms
- urinary symptoms
Dyspareunia:
- differential diagnosis for deep? 7
- differential diagnosis for superficial / entry? 4
- differential diagnoses for both? 3
- what common cause if pain comes on AFTER sex?
DEEP DYSPAREUNIA:
- PID (ie cervical STI - also endometritis, eg RPOC)
- endometriosis
- pelvic adhesions
- adenomyosis or fibroids
- adnexal pathology (eg ovarian cyst)
- painful bladder syndrome (interstitial cystitis)
- retroverted uterus
SUPERFICIAL DYSPAREUNIA
- herpes infection
- derm diseases (lichen planus, sclerosus, psoriasis)
- vaginismus
- vulvodynia
BOTH
- vaginal atrophy (esp in older women)
- inadequate lubrication (always ask!!)
- vaginal infection (candida, trichomonas, BV)
if pain starts AFTER sex - more likely to be bowel irritation - eg IBS - ask about bowel symptoms!
Causes of chronic pelvic pain:
- Gynae? 9
- Urological? 1
- GI? 3
- Neuro? 3
GYNAE
- Adhesions
- Endometriosis
- Ovarian remnant syndrome
- PID
- Vulvodynia
- Adenomyosis
- Fibroids
- Dysmenorrhoea
- Ovarian cysts
UROLOGICAL
- painful bladder syndrome (aka interstitial cystitis)
GI
- small bowel obstruction
- hernia
- IBS
Neuro
- Nerve damage
- Pudendal neuralgia
- Ilio-inguinal / genitofemoral / pudendal nerve damage
HIV
- what term is now used instead of AIDS?
- what is time period between exposure and when gets into cells?
- what % of infected people in UK don’t know they have it?
- what are the three main modes of transmission?
say advanced or late-stage HIV (ie instead of AIDS)
Process of HIV binding and integrating in human DNA can take 3-5 days after exposure
- this is therefore the period in which PEP can work!
8% (1 in 12) of people living with HIV in UK don’t know they have it
main modes of transmission:
- sexually
- vertically (mother to child - MTCT)
- blood
What is the ‘UN AIDS Target’?
90% diagnosed
90% of diagnosed on treatment
90% of those on treatment virally suppressed
nb UK doing better than this atm!
Apart from not using condoms, what other factors increase your risk of HIV transmission during sex? 4
1) TYPE OF SEX
- Receptive anal intercourse > insertive anal intercourse > receptive vaginal intercourse > insertive vaginal intercourse
2) TRAUMA
- sexual assault
- fisting
3) PRESENCE OF OTHER STIs + GENITAL INFECTIONS
- herpes (highest risk)
- gonorrhoea
- syphilis
- BV
this is due to area already being inflamed
4) NOT BEING CIRCUMCISED
- if man if circumcised, much LESS likely to both transmit or receive virus
- Underneath foreskin are langerhan cells (so easy place to root CD4 cells etc)
Mother to child transmission (MTCT) of HIV:
- what done to prevent this? 4
- type of delivery recommended?
- what is the likelihood of transmission if woman is aware of her HIV status and is compliant with her ARVs in pregnancy?
1) opt-out antenatal HIV screening in the UK
- done with booking bloods
2) ensure HIV+ women are treated with ARVs throughout pregnancy (ideally want undetectable)
3) have a pregnancy
MDT meeting for all HIV+ mothers
4) give baby PEP for 4 weeks after birth
if undetectable, can have vaginal delivery
if detectable viral load, have c-section
If a woman is aware of her HIV status and is compliant with her HIV treatment in pregnancy the risk of MTCT is < 0.014% (UK and Ireland)
nb see other flashcard for breastfeeding advice in HIV+ mother
What is the advice give to HIV+ mums who want to breastfeed?
STRONGLY advise women NOT to breastfeed
- Can get milk vouchers if can’t afford
Women who really wish to breastfeed can be supported to do so (but is quite onerous)
If you want to breast feed you have to EXCLUSIVELY do so - can’t do a bit of both as it affects babies microbiome and makes them more susceptible
Also have to be regularly monitored for viral load etc
What are the three main methods that HIV can be transmitted through the blood?
- IVDU
- needlestick injury
- blood transfusion from infected person
OCCUPATIONAL EXPOSURE TO HIV
- two methods of transmission?
- what should you do following an occupational exposure to reduce risk of transmission? 3
- what shouldn’t you do?
- what should you do to assess risk? 1
- where should you go / who should you contact? 2
- what is time period for PEP to be taken in?
- needle stick injury
- mucosal injury (eg in eye)
- squeeze and bleed wound
- run under running water
- dry wound and cover with waterproof plaster
- don’t suck wound
- don’t scrub wound while washing it
Risk assessment of the donor & recipient by uninvolved clinician:
Obtain consent to screen blood for HIV (and other BBV) (they can say no!)
Assess recipient’s eligibility to commence PEP for HIV
- If high risk, start PEP until results come back
- If low risk, norm professionals choice whether they wait or not
Time is critical – do not delay assessment
Contact occupational health (if in ours) or go A+E if out of hours!
PEP needs to be taken within 72 hours (but sooner you take it the better)
- PEP doesn’t really have many side effects
Blood transmission of HIV
- how to reduce risk in IVDU?
- what to ask to understand if someone got HIV from a blood transfusion?
needle exchange programmes for IVDU!
In UK – blood and organ donors have been screened for blood borne viruses (BBV) since 1985
- Later dates in other countries
- ASK if patient had transfusion or surgery abroad
nb small cohort of patients living with HIV infected through transfusion prior to screening eg older patients with haemophilia
