Sexual Health

Question 1

A 23yo woman presents to a GUM clinic due to a 3/7 Hx of greyish watery vaginal discharge. There is a strong smell associated but no itching/soreness.

What is the likely diagnosis + causative agent? How will you investigate + manage her?

Answer 1

BACTERIAL VAGINOSIS caused by imbalance in vaginal flora… loss of lactobacilli… overgrowth of anaerobic organisms e.g. Gardnerella vaginalis + pH increase >4.5.

Ix: not required if typical history.

Mx:

1. advice e.g. no douching
2. METRONIDAZOLE 400mg BD PO for 5-7/7 (or 2g PO single dose)

Question 2

A 25yo woman presents to a GUM clinic due to a 2/7 Hx of a frothy yellowish discharge + dysuria + vulval itching. O/E you notice a ‘strawberry cervix’.

What is the likely diagnosis + causative agent? How will you investigate + manage her?

Answer 2

TRICHOMONIASIS caused by sexual transmission of protozoa Trichomonas vaginalis.

Ix:
- high vaginal swab for wet mount, culture (charocal swab) and/or NAAT if available

Mx:

• METRONIDAZOLE 400mg BD 5-7/7 (or 2g PO single dose)
• empirically treat partners

Question 3

A 30yo woman presents to a GUM clinic due to a 3/7 Hx of thick white discharge + severe itching.

What is the likely diagnosis + causative agent? How will you investigate + manage her?

Answer 3

CANDIDIASIS caused by C. albicans overgrowth which can be due to increased oestrogen e.g. pregnancy, immunosuppression e.g. DM or recent Abx.

Ix: not required if typical hx (but microscopy would show spores + pseudohyphae)

Mx:

• CLOTRIMAZOLE 1% cream BD for 14/7 and/or
• CLOTRIMAZOLE 500mg pessary stat. and/or
• FLUCONAZOLE 150mg PO stat.

Question 4

An 18yo woman presents to a GUM clinic due to a 3/7 Hx of vaginal discharge + dysuria. You suspect chlamydia.

How would you investigate + manage her?

Answer 4

Ix:
- endocervical or vulvovaginal swab or FCU for NAAT

Mx:

• DOXYCYCLINE 100mg BD PO for 7/7 OR
• AZITHROMYCIN 1g PO single dose.
• partner notification (last 4/52)

Question 5

An 18yo woman presents to a GUM clinic due to a 3/7 Hx of purulent vaginal discharge + PCB. You suspect gonorrhoea.

How would you investigate + manage her?

Answer 5

Ix:
- endocervical/vulvovaginal swab or FCU for NAAT + MC+S

Mx:

• CEFTRIAXONE 1g IM single dose
• partner notification
• abstinence for 7/7 post-Tx
• NAAT test of cure after 7-14/7

Question 6

A 25yo woman presents to ED with acute abdominal pain + fever + purulent vaginal discharge. O/E there is adnexal tenderness + cervical motion tenderness.

What diagnosis do you suspect and what Ix will you request?

Answer 6

PID

Ix:

1. pregnancy test: exclude ectopic
2. FBC + CRP: raised WCC
3. endocervical/vulvovaginal swab for NAAT + culture: it ID CT, NG or MG
4. swab for wet mount microscopy: presence of vaginal polymorphonuclear cells confirms infection
5. if uncertain diagnosis, consider: pelvic USS or CT

Question 7

How would you manage a woman diagnosed with mild to moderate PID?

Answer 7

1. Abx e.g.
   - CEFTRIAXONE 500mg IM +
   - DOXYCYCLINE 100mg BD PO for 14/7 +
   - METRONIDAZOLE 400mg BD PO for 14/7
2. rest + analgesia
3. partner notification (last 2/12) + treamtnent
4. abstinence until Tx completed