Sexual health Flashcards
What is chlamydia?
What is the incubation period?
- Most common STI in UK, 1/100 young women.
- Caused by chlamydia trochmiontas –> obligate intracellular pathogen
- Spread through sexual contact
- Incubation of 1-3 weeks
What is the presentation of chlamydia?
- Asymptomatic in 70% women, 50% women
- Women –> bleeding (IM, PC), discharge (mucopurulent), dysuria, friable inflamed cervix, dyspareunia
- Men –> discharge (mucopurulent), dysuria, urethral discomfort, epidiyoorchitis, reactive arthritis
What are the investigations for chlamydia?
Where should swabs be taken?
When should individuals be tested?
- Nucleic acid amplification tests
- Women –> vulvovaginal
- Men –> urine, first void
- Test two weeks after exposure
What is the management for chlamydia?
- 1st line –> doxycycline 100mg BD for 7 days.
- CI or not tolerated –> azithromycin 1g stat w 2 days 500mg.
-Pregnant –> 1st line azithromycin 1g stat. Alternatives erythromycin, amoxicillin
- Offer a choice of provider for initial partner notification either trained practice nurses with support from GUM, or referral to GUM
- Men w urethral symps –> Tx all contacts in last 4 weeks
- Women or asymp men –> Tx all contacts from last 6 months
- Tx before get results of tests
- Retest all <25 w/i 3-6 months to check
- Retest those >25 high risk
What is erectile dysfunction?
- Persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance.
- It is a symptom and not a disease and the causes can broadly be split into organic, psychogenic and mixed.
- RF –> similar to those for CVD –> obesity, diabetes, dyslipidaemia, metabolic syndrome, hypertension, endothelial dysfunction, lack of exercise, alcohol and smoking
- Very common. It can occur at any age but is more common in older.
What are the causes of ED? Organic and non organic?
4 organic categories
Organic causes
- Vasculogenic (CVD, HTN, high lipids, DM).
- Neurogenic (MS, PD).
- Anatomical (peyronies, hypospadia, prostate Ca).
- Hormonal (hypogonadism, hypo or hyper thyroid, cushings).
Psychogenic
-May be situational –> e.g due to psychiatric illness (depression) or general e.g lack of arousability.
Drugs
-Anti HTN, antipsy, antidepressants. SSRIs, BB.
What features help differentiate organic v non organic causes of ED?
Factors favouring an organic cause
- Gradual onset of symptoms
- Lack of tumescence (?erection at night)
- Normal libido
Factors favouring a psychogenic causes
- Sudden onset of symptoms
- Decreased libido
- Good quality spontaneous or self-stimulated erections
- Major life events
- Problems or changes in a relationship
- Previous psychological problems
- History of premature ejaculation
What are the investigations in ED?
- NICE recommend that all men have their 10-year cardiovascular risk calculated by measuring lipid and fasting glucose serum levels.
- Free testosterone should also be measured in all in the morning between 9 and 11am. If free testosterone is low or borderline, it should be repeated along with follicle-stimulating hormone, luteinizing hormone and prolactin levels. If any of these are abnormal refer to endocrinology for further assessment.
Assessment of a man with erectile dysfunction should include
- A detailed history, including present and past erection quality, lifestyle (including alcohol intake, smoking status, and illicit drug use), and previous treatments tried.
- A focused physical examination to identify any genitourinary, endocrine, vascular, or neurological causes of erectile dysfunction.
- Appropriate investigations, including glucose-lipid profile and total testosterone, to identify any reversible/modifiable risk factors.
What is the management for ED?
What is the alternative 1st line in those who main 1st line CI?
- Erectile dysfunction usually responds well to a combination of lifestyle measures (such as weight loss, smoking cessation, and reducing alcohol consumption) and drug treatment.
- People with erectile dysfunction who cycle for more than three hours per week should be advised to stop
Medical
- First line –> Phosphodiesterase-5 (PDE-5) inhibitors (sildenafil, tadalafil, vardenafil, or avanafil) –> regardless of suspected cause (provided there are no contraindications).
- PDE-5 inhibitors are not initiators of erection but require sexual stimulation in order to facilitate erection.
- A low dose should be tried initially, titrating up if ineffective. A man with erectile dysfunction should receive 6–8 doses of a PDE-5 inhibitor at a maximum dose with sexual stimulation before being classified as a non-responder.
- Sildenafil can be purchased over-the-counter without a prescription.
- Vacuum erection devices are recommended as first-line treatment in those who can’t/won’t take a PDE-5 inhibitor.
When should people be referred w ED?
- To urology — for young men who have always had erectile dysfunction and for all men with a history of trauma to genital area, pelvis or spine; abnormality of the penis or testicles; or no response to maximum dose of at least two PDE-5 inhibitors.
- To endocrinology — if hypogonadism is suspected (abnormal serum testosterone).
- To cardiology — if the man has CVD that makes sexual activity unsafe or contraindicates PDE-5 inhibitor use.
- To mental health services — if an underlying psychogenic cause is suspected or the man has severe mental distress.
What is gonorrohoea?
-STI caused by Neisseria gonorrhoeae gram –ve diplococci
-Acute infection can occur on any mucous membrane surface w coloumnar epthelium –> endocervix in women, urethra, rectum, conjunctiva and pharynx
-Most common in those age 15-24 and men of any age who have sex w men.
-Incubation period of 2-5 days.
What is the presentation of gonorrhoea?
- Urogenital asymptomatic in up to 50% women.
- Women –> When symps –> tends to develop w/i 10 days –> vaginal discharge typically odourless purulent possibly green/yellow (as cervicitis), pelvic pain, dysuria, rarely IM bleeding.
- Men –> 90% symptomatic –> genital usually symptomatic. Purulent or mucopurulent urethreal discharge possible green or yellow (80%), dysuria >50%. Possible testicular pain or swelling epididymoorchitis. Symptoms tend to start w/i 2-5 days exposure.
-Pharyngeal and rectal infection usually asymp – when symp can cause tonsilittis or pharyngitis. Rectal can cause anal discharge, rectal pain.
-Rectal infection may cause anal or rectal discomfort and discharge, but is often asymptomatic.
-Pharyngeal infection may cause a sore throat, but is often asymptomatic.
-Prostatitis causes perineal pain, urinary symptoms and prostate tenderness on examination.
-Conjunctivitis causes erythema and a purulent discharge.
What are the investigations for gonorrhoea?
- Ideally refer all w suspected gonorrhoea to GUM clinic or other local specialist sexual health service for confirmation of diagnosis.
- NAAT –> take no earlier than 3 days after sexual contact w person. –> detects RNA or DNA of gonorrhoea.
- Women –> vulvovaginal swab 1st line
- Men –> first void urine.
- In MSM –> also rectal and pharyngeal swab and those w RF e.g anal/oral sex.
What is the management for gonorrhoea?
-Treat only in primary care when specialist services can’t be access or person not wanted to attend even when have info and advice.
- 1st line –> sensitivities not known –> single dose of IM ceftriaxone 1g. If ceftriaxone refused (e.g needle phobia) then oral alternative cefixime 400mg single dose and oral azithromycin 2mg single dose.
- If sensitivities are known (and the organism is sensitive to ciprofloxacin) –> single dose of oral ciprofloxacin 500mg should be given
- For confirmed or suspected uncomplicated anogenital or pharyngeal gonorrhoea, intramuscular ceftriaxone should be prescribed first line.
- Follow up after 1 week –> check adherence treatment and symptoms resolution, ask about adverse drug reactions, confirm partner notification, ask about recent sexual history and reinforce advice safe sex.
- Test of cure –> recommended in all. Prioritise those w persistent symptoms and signs, pharyngeal infection, treated with anything other than 1st line.
- Abstain from sex for 7 days, test and treat any other STIs, consider safeguarding issues and sexual abuse in children and young people.
- Partner notification –> Tx sexual partners.
When should you refer those with gonorrhoea?
- Conjunctival gonorrhoea, complications, treatment not working.
- Women pregnant or think ascending infection.
- Hospital when, suspected disseminated, fever, malaise, joint pain and swelling, rash.
