Sexual Health Flashcards
1
Q
Organisms causing PID?
A
- Chlamydia trachomatis (20-30%)
- Neisseria gonorrhoeae (10-15%)
- Mycoplasma genitalium (15%)
2
Q
Presentation of PID?
A
- PAIN: lower abdo pain b/L, deep dyspareunia, constant.
- BLEEDING: any irregular (PCB, IMB etc)
- OTHER: change in vaginal discharge (often purulent), recent change in partner?
3
Q
Signs suggestive of PID on bimanual vaginal examination?
A
- Adnexal tenderness (sometimes a tender mass)
- Cervical motion tenderness
4
Q
Investigations for PID?
A
- PREGNANCY TEST
- VVS for NAAT: chlamydia, gonorrhoea + trichomonas
- Endocervical swab for gonorrhoea culture
- Urine dip + MSU
- Bloods for HIV + Syphilis
5
Q
Complications of PID?
A
- Tubal factor infertility
- Chronic dyspareunia + pelvic pain
- Ectopic pregnancy
- Peri-hepatitis (Fitz Hugh Curtis syndrome)
- Tubo-ovarian abscess
6
Q
What is classic presentation of peri-hepatitis/Fitz Hugh Curtis syndrome?
A
Women <30yrs, RUQ is highly suggestive of perihepatitis rather than cholecystitis.
(especially related to chlamydia)
7
Q
Management of PID? (3-step treatment)
A
- Ceftriaxone 500mg IM (w/ azithromycin if gonorrhoea implicated)
- Doxycycline 100mg BD PO 14days
- Metronidazole 400mg BD PO 7-14days
8
Q
What does PID caused by mycoplasma genitalium require?
A
Moxifloxacin
9
Q
Counselling a woman with PID?
A
- Inflammation of woman’s reproductive organs.
- 25% caused by an STI
- Easy to treat but untreated causes serious problems
- NO SEX until they + their partner have completed treatment
10
Q
What is the commonest cause of abnormal discharge in WOCA?
A
Bacterial Vaginosis (non-STI)
11
Q
Symptoms/signs of Bacterial Vaginosis?
A
- Offensive fishy smelling vaginal discharge
- ^vol, thin, watery
- Not assoc w/ soreness, itching, irritation
- Many asymptomatic (50%)
- pH>4.5
12
Q
What is the Hay/Ison criteria for investigating Bacterial Vaginosis?
A
Gram stained vaginal smear: mixture of gram +ve/-ve bacteria, as the lactobacilli die off + there is overgrowth of other vaginal flora which is what changes pH.
13
Q
Treatment for Bacterial Vaginosis?
A
Conservative: avoid vaginal douching, use of antiseptic agents/ bath products.
Treatment: (indicated for symptomatic women/pts choice) Metronidazole PO/TOP
14
Q
What different species of Candida are there?
A
a) Candida albicans 80-92%
b) Non-albicans species e.g. C glabrata, C tropicales, C krusei.
15
Q
What would you suspect in someone with recurrent Candida?
A
HIV or diabetes
16
Q
Risk factors for Candida?
A
Immune suppression including pregnancy, diabetes.
Antibiotic use.
Elevated oestrogen.
17
Q
Symptoms of Candida?
A
Vulval ITCH + soreness
Thick vaginal discharge
Superficial dyspareunia/dysuria
18
Q
How do you manage uncomplicated Candida?
A
(oral vs topical- pt preference)
- Clotrimazole pessary 500mg stat
- Fluconazole 150mg PO stat (not in pregnancy)
19
Q
How do you manage Candida in pregnancy?
A
Intravaginal Clotrimazole/ Miconazole 7days.
do NOT give ORAL -azoles in pregnancy!!
20
Q
Presentation of Trichomonas vaginalis?
A
- 10-50% asymptomatic
- ^vaginal discharge (frothy yellow discharge)
- Vilval itch
- Dysuria
- 2% strawberry cervix
21
Q
How do you investigate Trichomonas vaginalis?
A
- Swab from posterior fornix (at spec exam) for wet mount microscopy.
- Vulvovaginal NAAT
22
Q
Management for Trichomonas vaginalis?
A
-Metronidazole 2g PO stat
OR
-Metronidazole 400mg BD 5-7days
23
Q
Management for the male partner in Trichomonas vaginalis?
A
Metronidazole 400mg BD 7days
24
Q
What are the classical presentations for the discharge of Gonorrhoea/ Chlamydia?
A
Gonorrhoea: yellow/green
Chlamydia: profuse+different (+clear/cloudy in men)
(classic but cant generalise)
25
Where does Chlamydia thrachomatis inhabit?
Endocervix!
Rectum, pharynx, eye, urethra.
(not vagina)
26
Symptoms of Chlamydia thrachomatis?
- ^vaginal discharge
- Dysuria (if in urethra)
- PCB/IMB
- Deep dyspareunia
- Lower abdo pain
-Mucopurulent cervicitis +/- contact bleeding.
27
Complications of Chlamydia?
- PID, endometritis, salpingitis
- Tubal infertility
- Ectopic pregnancy
- Reactive arthritis
- Perihepatitis (Fitz-High Curtis syndrome)
28
Complications of chlamydia in pregnancy?
- 2nd trimester miscarriage
- Growth retardation
- Chlamydia conjunctivitis
29
What is the window period for investigating chlamydia?
```
2 weeks (so if the sexual contact was <2wks ago then consider that the infection may not be visible yet)
Nb. if they have sx, then test them anyway.
```
30
Investigations for Chlamydia ?
- Standard VVS NAAT test
- Can swab different sites if indicated by sx/risk group
- Women w/ rectal sx > refer to GUM!
31
What is the general advice for managing Chlamydia?
- Avoid sex for 1/52 until they/their partners have completed treatment.
- Test of cure not routine but recommended in pregnancy.
- Non-viable DNA can still be picked up 3-5wks following treatment.
32
Treatment for Chlamydia?
- Doxycycline 100mg BD for 7/7 (C/I in pregnancy!!)
| - If doxy not tolerated/pregnant = Azithromycin 1g PO stat
33
What is the regime for Chlamydia treatment in pregnancy?
Azithromycin 1g PO stat + 500mg OD for 2 days.
Or can consider giving Erythromycin 500mg BD 10-14days.
34
What are the primary sites of infection for Gonorrhoea?
Mucous membranes:
| Urethra, endocervix, rectum, pharynx, conjunctiva
35
Transmission of Gonorrhoea?
Direct from one mucous membrane to another.
| unlike chlamydia, quite fragile + so more focused on sexual Hx of last 2 wks
36
Symptoms of Gonorrhoea?
- Endocervical, asymptomatic in up to 50%.
- ^ or altered vaginal discharge
- PCB/IMB or menorrhagia
- Lower abdo pain (25%)
- Urethral infection may cause dysuria (not frequency)
37
Signs of Gonorrhoea?
- Mucopurulent endocervical discharge
| - Endocervical contact bleeding
38
Investigations in Gonorrhoea?
- VVS for NAAT
- Gram stained slide for microscopy from infected site
- Bacterial swab for gonorrhoea culture from infected site.
39
General advice for management of Gonorrhoea?
- Avoid sex for 1/52 until they + their partner have completed treatment.
- ALWAYS culture
- ALWAYS TOC for ALL at 2/52 after therapy
40
How do you manage uncomplicated anogenital gonorrhoea?
- Ceftriaxone 1g IM stat
| - If also have chlamydia: give doxy for 1 week (best practice)
41
How do you investigate for Gonococcal urethritis in Males?
- Gram stained urethral or rectal smear demonstrating gram -ve intracellular diplococci ('kissing kidney beans')
- NAAT from site of infection
- Need for 3 site screening in MSM !!!
42
What are some complications for Gonococcal urethritis in men?
Epididymo-orchitis
Proctitis
Disseminated gonorrhoea
43
What does urethral discharge look like in:
a) Gonoccocal urethritis
b) Chlamydia urethritis
a) Yellow discharge
| b) Clear/white discharge
44
What is LGV (lymphogranuloma venereum)
A disease caused by 3 strains of chlamydia trachomatis, + characterised by a small skin lesion followed by regional lymphadenopathy in groin/pelvis.
If acquired by anal sex, may manifest as severe proctitis.
45
What is the main cause of urogenital infection + lymphogranuloma venereum in men?
Chlamydia urethritis
46
Prevalence of different organisms in non-specific urethral discharge?
- C. trachomatis (11-50%)
- M. genitalium (6-50%)
- Ureaplasmas (11-26%)
- T. vaginalis
- Adenoviruses
- HSV
47
How do you manage non-specific urethral discharge?
(gram stained urethral smear, NAAT)
| -7/7 doxycycline 100mg PO (as per chlamydia for initial presentation)
48
What are some STI causes of rectal discharge?
- Chlamydia/ LGV (most common)
- Gonorrhoea
- Herpes
- Sexually transmitted enteric infections
49
What are anogenital warts caused by?
90% HPV 6 or 11
50
What is the incubation time of anogenital warts?
Between 3 weeks to 8 months !! (so hard to determine which partner it came from)
51
Management of anogenital warts: Physical Ablation?
- Cyrotherapy
- Excision
- Electrocautery
52
Management of anogenital warts: topical applications?
- Podophyllotoxin (CONTRAINDICATED IN PREGNANCY)
| - ALDARA- Imiquimod
53
What are the types of HSV that cause anogenital herpes?
HSV-1 / HSV-2
| cant tell clinically- generally HSV1 more common oral, + HSV2 more common genital - but can get oral-genital transfer
54
What happens to the virus following primary infection?
The virus becomes latent in local sensory ganglia.
| Periodically reactivates to cause symptomatic lesions or asymptomatic (but infectious) viral shedding.
55
What can episodes of Herpes be triggered by?
Mental + physical stress.
Too much sunlight.
Pregnancy.
56
Symptoms of anogenital herpes?
Local sx: painful ulceration, dysuria, vaginal or urethral discharge.
Systemic: fever + myalgia.
57
Investigations for anogenital herpes?
Viral PCR
58
Treatment for anogenital herpes?
- For 1st clinical episode: tx should commence within 5days of start of episode, or while new lesions are forming.
- Aciclovir 400mg 3x day PO for 5-10days
59
What is syphilis caused by?
Spirochete Treponema Pallidum
60
What is the highest risk group for syphilis?
White MSM 25-34yrs.
| Most of whom are co-infected with HIV.
61
What are the symptoms + incubation period for primary syphillis?
Incubation: ~21days
Sx: CHANCRE (penile/vulval)- developing from a simple papule. Single lesion, well-defined edge, usually painless + non-purulent.
There may be multiple + develop over 3-8wks.
They will then resolve.
62
How do you investigate primary syphilis?
Lab diagnosis: PCR, serology, dark ground microscopy (after taking from chancre)
63
How many primary syphilis pts go on to secondary syphilis?
If primary untreated, 25% will go on to develop secondary.
| This occurs 4-10wks after appearance of initial chancre.
64
Symptoms of secondary syphilis?
- Secondary syphilis rash: condylomata lata (highly infectious, mainly affecting perineum + anus)
- Other Rash: widespread mucocutaneous, can affect pals+soles (any rash here- think syphilis)
- Hepatitis
- Splenomegaly
- Glomerulonephritis
- Neurological complications (acute meningitis, cranial nerve palsies, optic neuropathy).
65
How may tertiary syphilis present (these are also conditions in their own right)?
- Neurosyphilis: wide-stepping gait, delusions of grandeur, loss of vibration sense.
- CV: dilation of aortic root.
- Gummatous: ulceration of the limbs.
66
Treatment of Primary/Secondary/Early Latent Syphilis?
Benzathine penicillin 2.4MU IM single dose.
67
Treatment of late latent/CV/Gummatous Syphilis?
Benzathine penicillin 2.4MU IM for 3 weeks (3 doses)
68
How can you determine between types of latent syphilis?
- Early latent (<2yrs)
| - Late latent (>2yrs)
69
What about if you are treating someone with syphilis + they have a penicillin allergy?
Doxycycline!
70
What is Balanitis?
Describes inflammation of glans penis + foreskin.
(mostly not caused by STI (although sometimes Syphilis), because gonorrhoea + chlamydia are the ones that cause the urethritis.
71
What causes Balanitis?
- Candida (common)
| - Anaerobic balanitis (when difficult to retract foreskin)
72
Symptoms of Balanitis?
```
Local rash
Soreness
Itch
Odour
Inability to retract foreskin
-Discharge from the glans/ behind the foreskin
```
73
How do you manage Balanitis/ Vulval conditions?
Investigations:
- Swab for candida/bacteria culture
- HSV/syphilis PCR
- STI screen
Management:
Avoid soaps/ irritants
Avoid tight fitting underwear
74
Pathophysiology of HIV?
- HIV attacks the CD4 T lymphocytes
- Penetrates them, uses its retroviral properties to hijack their processes of transcription/translation- producing more viruses + killing more T lymphocytes.
- HIV has a measurable antigen: p24 !!! (can be detected in blood before the HIV antibody is produced)
75
HIV life cycle?
- Process of HIV binding + intergrating in human DNA (within CD4 cells)- can take 3-5days after exposure.
- HIV virions budding out destroys the host CD4 cell.
- So as it is replicated, the CD4 count will go down.
76
Management of HIV in pregnancy to reduce MTCT?
C-section can reduce the risk, + other HIV meds.
- Controlled maternal HIV!
- No breastfeeding (especially if uncontrolled)
77
What occurs during the Primary HIV Stage? (seroconversion)
- Diagnosis within 6 months
- DDx: Viral illness/ Glandular Fever/ Meningitis/ other STI
- Very HIGH viral load > very infectious!
78
Common sx of acute HIV infection?
- Fever
- Pharyngitis
- Lymphadenopathy
- Rash
79
What occurs during the Asymptomatic Stage of HIV? (screening stage)
- After seroconversion stage, illness passes + person remains asymptomatic for 5-10yrs.
- Ongoing viral replication causes immune system damage (chronic inflammatory state)
80
What are the most common sx of HIV?
- Nonspecific: persistent lymphadenopathy, fever, myalgia, diarrhoea.
- Skin lesions: folliculitis, multi-site HZV, sebarrhoeic dermatitis.
- Oral lesions: candidiasis, oral hairy leukoplakia.
- Recurrent bacterial infections: pneumonia, impetigo.
- Abnormal bloods: lymphopenia, thrombocytopenia.
81
Features of Advanced HIV?
- Linked to low CD4 count (T lymphocyte)... predisposes pts to opportunistic infections + cancers (B cell lymphoma)
- Diagnoses at late stage: Lower CD4 (<350)= greater damage to immune system + worse prognosis
82
Investigations/monitoring for HIV?
- Routine: U&E, LFT, FBC, lipid/bone profile, glucose.
- Serology: Hep A, B, C, Syphilis.
- HIV viral load: informs of disease progression rate + monitors treatment response.
- CD4 cell count: main indicator of risk of opportunistic infections (advanced HIV).
83
Treatment for HIV?
- Highly active antiretroviral therapy (HAART)
- Usual regime is 3 dif drugs in combo
- Poor compliance= drug resistance + failure.
- Aim of treatment= undetectable viral load.
84
What are some important drug interactions with HAART?
- Steroids
- Statins
- Anti-anxiety/sedatives
- Anticoags
- Chemo drugs
- Anti-TB
- Recreational drugs
- Antacids
85
What are the window periods for HIV testing?
- P24 antigen detected 2-4wks after infection (dont test <2wks as may be false -ve)
- HIV antibody 4-8wks
86
What is the guidance for testing with the 4th generation HIV test?
Tests for antigen + antibody.
Detects majority by 4wks after an exposure.
Consider repeat at 8wks if high risk.
87
What is the 3rd generation HIV test?
- JUST tests for antibody
| - Window period is 12 weeks
88
What is the Rapid Point of Care test?
- Either 3rd or 4th gen, or combo.
- Bedside test, results infront of pts.
- If test is positive, it is called 'reactive' as high rate of flase +ves (so require lab venous sample for confirmation).
89
What is the Venous Blood Sample test for HIV?
- Accurate, 4th gen test for short window period.
- Results not instant.
- Need to send a confirmatory sample to check sample, but still act on first result!!!
90
What is PrEP? (pre-exposure prophylactics)
Given to HIV negative people: taken before, during + after sex.
V effective.
Still need for regular testing.
Doesn't protect against other STIs.
91
What is PEPSE? (post-exposure prophylactics)
Taken after high risk sex/ exposure.
Within 72hrs of risk, take for 28days.
For MTCT: PEP for baby for 4 weeks after birth.
