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Year 4 GOSH > Sexual Health > Flashcards

Sexual Health Flashcards

1
Q

Organisms causing PID?

A
  • Chlamydia trachomatis (20-30%)
  • Neisseria gonorrhoeae (10-15%)
  • Mycoplasma genitalium (15%)
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2
Q

Presentation of PID?

A
  1. PAIN: lower abdo pain b/L, deep dyspareunia, constant.
  2. BLEEDING: any irregular (PCB, IMB etc)
  3. OTHER: change in vaginal discharge (often purulent), recent change in partner?
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3
Q

Signs suggestive of PID on bimanual vaginal examination?

A
  • Adnexal tenderness (sometimes a tender mass)

- Cervical motion tenderness

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4
Q

Investigations for PID?

A
  1. PREGNANCY TEST
  2. VVS for NAAT: chlamydia, gonorrhoea + trichomonas
  3. Endocervical swab for gonorrhoea culture
  4. Urine dip + MSU
  5. Bloods for HIV + Syphilis
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5
Q

Complications of PID?

A
  1. Tubal factor infertility
  2. Chronic dyspareunia + pelvic pain
  3. Ectopic pregnancy
  4. Peri-hepatitis (Fitz Hugh Curtis syndrome)
  5. Tubo-ovarian abscess
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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)

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7
Q

Management of PID? (3-step treatment)

A
  1. Ceftriaxone 500mg IM (w/ azithromycin if gonorrhoea implicated)
  2. Doxycycline 100mg BD PO 14days
  3. Metronidazole 400mg BD PO 7-14days
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8
Q

What does PID caused by mycoplasma genitalium require?

A

Moxifloxacin

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9
Q

Counselling a woman with PID?

A
  1. Inflammation of woman’s reproductive organs.
  2. 25% caused by an STI
  3. Easy to treat but untreated causes serious problems
  4. NO SEX until they + their partner have completed treatment
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10
Q

What is the commonest cause of abnormal discharge in WOCA?

A

Bacterial Vaginosis (non-STI)

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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
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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.

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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

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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.

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15
Q

What would you suspect in someone with recurrent Candida?

A

HIV or diabetes

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16
Q

Risk factors for Candida?

A

Immune suppression including pregnancy, diabetes.
Antibiotic use.
Elevated oestrogen.

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17
Q

Symptoms of Candida?

A

Vulval ITCH + soreness
Thick vaginal discharge
Superficial dyspareunia/dysuria

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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)
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19
Q

How do you manage Candida in pregnancy?

A

Intravaginal Clotrimazole/ Miconazole 7days.

do NOT give ORAL -azoles in pregnancy!!

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20
Q

Presentation of Trichomonas vaginalis?

A
  • 10-50% asymptomatic
  • ^vaginal discharge (frothy yellow discharge)
  • Vilval itch
  • Dysuria
  • 2% strawberry cervix
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21
Q

How do you investigate Trichomonas vaginalis?

A
  • Swab from posterior fornix (at spec exam) for wet mount microscopy.
  • Vulvovaginal NAAT
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22
Q

Management for Trichomonas vaginalis?

A

-Metronidazole 2g PO stat
OR
-Metronidazole 400mg BD 5-7days

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23
Q

Management for the male partner in Trichomonas vaginalis?

A

Metronidazole 400mg BD 7days

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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)

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25
Q

Where does Chlamydia thrachomatis inhabit?

A

Endocervix!
Rectum, pharynx, eye, urethra.
(not vagina)

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26
Q

Symptoms of Chlamydia thrachomatis?

A
  • ^vaginal discharge
  • Dysuria (if in urethra)
  • PCB/IMB
  • Deep dyspareunia
  • Lower abdo pain

-Mucopurulent cervicitis +/- contact bleeding.

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27
Q

Complications of Chlamydia?

A
  • PID, endometritis, salpingitis
  • Tubal infertility
  • Ectopic pregnancy
  • Reactive arthritis
  • Perihepatitis (Fitz-High Curtis syndrome)
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28
Q

Complications of chlamydia in pregnancy?

A
  • 2nd trimester miscarriage
  • Growth retardation
  • Chlamydia conjunctivitis
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29
Q

What is the window period for investigating chlamydia?

A 
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.
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30
Q

Investigations for Chlamydia ?

A
  • Standard VVS NAAT test
  • Can swab different sites if indicated by sx/risk group
  • Women w/ rectal sx > refer to GUM!
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31
Q

What is the general advice for managing Chlamydia?

A
  • 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.
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32
Q

Treatment for Chlamydia?

A
  • Doxycycline 100mg BD for 7/7 (C/I in pregnancy!!)

- If doxy not tolerated/pregnant = Azithromycin 1g PO stat

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33
Q

What is the regime for Chlamydia treatment in pregnancy?

A

Azithromycin 1g PO stat + 500mg OD for 2 days.

Or can consider giving Erythromycin 500mg BD 10-14days.

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34
Q

What are the primary sites of infection for Gonorrhoea?

A

Mucous membranes:

Urethra, endocervix, rectum, pharynx, conjunctiva

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35
Q

Transmission of Gonorrhoea?

A

Direct from one mucous membrane to another.

unlike chlamydia, quite fragile + so more focused on sexual Hx of last 2 wks

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36
Q

Symptoms of Gonorrhoea?

A
  • 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)
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37
Q

Signs of Gonorrhoea?

A
  • Mucopurulent endocervical discharge

- Endocervical contact bleeding

38
Q

Investigations in Gonorrhoea?

A
  • VVS for NAAT
  • Gram stained slide for microscopy from infected site
  • Bacterial swab for gonorrhoea culture from infected site.
39
Q

General advice for management of Gonorrhoea?

A
  • Avoid sex for 1/52 until they + their partner have completed treatment.
  • ALWAYS culture
  • ALWAYS TOC for ALL at 2/52 after therapy
40
Q

How do you manage uncomplicated anogenital gonorrhoea?

A
  • Ceftriaxone 1g IM stat

- If also have chlamydia: give doxy for 1 week (best practice)

41
Q

How do you investigate for Gonococcal urethritis in Males?

A
  • 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
Q

What are some complications for Gonococcal urethritis in men?

A

Epididymo-orchitis
Proctitis
Disseminated gonorrhoea

43
Q

What does urethral discharge look like in:

a) Gonoccocal urethritis
b) Chlamydia urethritis

A

a) Yellow discharge

b) Clear/white discharge

44
Q

What is LGV (lymphogranuloma venereum)

A

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
Q

What is the main cause of urogenital infection + lymphogranuloma venereum in men?

A

Chlamydia urethritis

46
Q

Prevalence of different organisms in non-specific urethral discharge?

A
  • C. trachomatis (11-50%)
  • M. genitalium (6-50%)
  • Ureaplasmas (11-26%)
  • T. vaginalis
  • Adenoviruses
  • HSV
47
Q

How do you manage non-specific urethral discharge?

A

(gram stained urethral smear, NAAT)

-7/7 doxycycline 100mg PO (as per chlamydia for initial presentation)

48
Q

What are some STI causes of rectal discharge?

A
  • Chlamydia/ LGV (most common)
  • Gonorrhoea
  • Herpes
  • Sexually transmitted enteric infections
49
Q

What are anogenital warts caused by?

A

90% HPV 6 or 11

50
Q

What is the incubation time of anogenital warts?

A

Between 3 weeks to 8 months !! (so hard to determine which partner it came from)

51
Q

Management of anogenital warts: Physical Ablation?

A
  • Cyrotherapy
  • Excision
  • Electrocautery
52
Q

Management of anogenital warts: topical applications?

A
  • Podophyllotoxin (CONTRAINDICATED IN PREGNANCY)

- ALDARA- Imiquimod

53
Q

What are the types of HSV that cause anogenital herpes?

A

HSV-1 / HSV-2

cant tell clinically- generally HSV1 more common oral, + HSV2 more common genital - but can get oral-genital transfer

54
Q

What happens to the virus following primary infection?

A

The virus becomes latent in local sensory ganglia.

Periodically reactivates to cause symptomatic lesions or asymptomatic (but infectious) viral shedding.

55
Q

What can episodes of Herpes be triggered by?

A

Mental + physical stress.
Too much sunlight.
Pregnancy.

56
Q

Symptoms of anogenital herpes?

A

Local sx: painful ulceration, dysuria, vaginal or urethral discharge.
Systemic: fever + myalgia.

57
Q

Investigations for anogenital herpes?

58
Q

Treatment for anogenital herpes?

A
  • 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
Q

What is syphilis caused by?

A

Spirochete Treponema Pallidum

60
Q

What is the highest risk group for syphilis?

A

White MSM 25-34yrs.

Most of whom are co-infected with HIV.

61
Q

What are the symptoms + incubation period for primary syphillis?

A

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
Q

How do you investigate primary syphilis?

A

Lab diagnosis: PCR, serology, dark ground microscopy (after taking from chancre)

63
Q

How many primary syphilis pts go on to secondary syphilis?

A

If primary untreated, 25% will go on to develop secondary.

This occurs 4-10wks after appearance of initial chancre.

64
Q

Symptoms of secondary syphilis?

A
  • 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
Q

How may tertiary syphilis present (these are also conditions in their own right)?

A
  • Neurosyphilis: wide-stepping gait, delusions of grandeur, loss of vibration sense.
  • CV: dilation of aortic root.
  • Gummatous: ulceration of the limbs.
66
Q

Treatment of Primary/Secondary/Early Latent Syphilis?

A

Benzathine penicillin 2.4MU IM single dose.

67
Q

Treatment of late latent/CV/Gummatous Syphilis?

A

Benzathine penicillin 2.4MU IM for 3 weeks (3 doses)

68
Q

How can you determine between types of latent syphilis?

A
  • Early latent (<2yrs)

- Late latent (>2yrs)

69
Q

What about if you are treating someone with syphilis + they have a penicillin allergy?

A

Doxycycline!

70
Q

What is Balanitis?

A

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
Q

What causes Balanitis?

A
  • Candida (common)

- Anaerobic balanitis (when difficult to retract foreskin)

72
Q

Symptoms of Balanitis?

A 
Local rash
Soreness
Itch
Odour
Inability to retract foreskin
-Discharge from the glans/ behind the foreskin
73
Q

How do you manage Balanitis/ Vulval conditions?

A

Investigations:

  • Swab for candida/bacteria culture
  • HSV/syphilis PCR
  • STI screen

Management:
Avoid soaps/ irritants
Avoid tight fitting underwear

74
Q

Pathophysiology of HIV?

A
  • 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
Q

HIV life cycle?

A
  • 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
Q

Management of HIV in pregnancy to reduce MTCT?

A

C-section can reduce the risk, + other HIV meds.

  • Controlled maternal HIV!
  • No breastfeeding (especially if uncontrolled)
77
Q

What occurs during the Primary HIV Stage? (seroconversion)

A
  • Diagnosis within 6 months
  • DDx: Viral illness/ Glandular Fever/ Meningitis/ other STI
  • Very HIGH viral load > very infectious!
78
Q

Common sx of acute HIV infection?

A
  • Fever
  • Pharyngitis
  • Lymphadenopathy
  • Rash
79
Q

What occurs during the Asymptomatic Stage of HIV? (screening stage)

A
  • After seroconversion stage, illness passes + person remains asymptomatic for 5-10yrs.
  • Ongoing viral replication causes immune system damage (chronic inflammatory state)
80
Q

What are the most common sx of HIV?

A
  • 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
Q

Features of Advanced HIV?

A
  • 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
Q

Investigations/monitoring for HIV?

A
  • 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
Q

Treatment for HIV?

A
  • 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
Q

What are some important drug interactions with HAART?

A
  • Steroids
  • Statins
  • Anti-anxiety/sedatives
  • Anticoags
  • Chemo drugs
  • Anti-TB
  • Recreational drugs
  • Antacids
85
Q

What are the window periods for HIV testing?

A
  • P24 antigen detected 2-4wks after infection (dont test <2wks as may be false -ve)
  • HIV antibody 4-8wks
86
Q

What is the guidance for testing with the 4th generation HIV test?

A

Tests for antigen + antibody.
Detects majority by 4wks after an exposure.
Consider repeat at 8wks if high risk.

87
Q

What is the 3rd generation HIV test?

A
  • JUST tests for antibody

- Window period is 12 weeks

88
Q

What is the Rapid Point of Care test?

A
  • 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
Q

What is the Venous Blood Sample test for HIV?

A
  • 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
Q

What is PrEP? (pre-exposure prophylactics)

A

Given to HIV negative people: taken before, during + after sex.
V effective.
Still need for regular testing.
Doesn’t protect against other STIs.

91
Q

What is PEPSE? (post-exposure prophylactics)

A

Taken after high risk sex/ exposure.
Within 72hrs of risk, take for 28days.

For MTCT: PEP for baby for 4 weeks after birth.

Year 4 GOSH (3 decks)

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