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Gynaecology > Sexual Health And Sexual Dysfunction > Flashcards

Sexual Health And Sexual Dysfunction Flashcards

1
Q

What is hypoactive sexual desire disorder (HSDD)?

A

It presents with loss of libido and decline in sexual desire.
It affects personal relationships and causes distress.

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2
Q

What are the causes of HSDD?

A 
Psychosexual (majority)
Menopause
Depression
Chemotherapy
Radiotherapy
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3
Q

What are important questions to ask in patients with possible HSDD?

A

When it started, normal sexual function, realistic and at odds with sexual partner? Relationship problems?

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4
Q

What is the treatment for HSDD?

A

Psychosexual counselling

Testosterone supplementation may help (especially if symptoms followed oophorectomy)

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5
Q

What are they causes of superficial dyspareunia?

A

Infections

Skin conditions like lichen sclerosis

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6
Q

How can superficial dyspareunia be treated?

A

Treat the underlying cause
But pain can start a cycle of fear, anticipation and avoidance
Lubricants and local anaesthetics can help to break the cycle

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7
Q

What is vaginismus?

A

Difficulty of the woman to allow vaginal penetration despite wanting to
It involves involuntary contraction of the pelvic floor muscles an adductors
It is a symptom/sign, but not a diagnosis
Usually precipitated by another cause - physical/psychological

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8
Q

When suspecting vaginismus what should first be excluded?

A

Anatomical problems like vaginal septae

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9
Q

What is the management for vaginismus?

A

Vaginal dilators may alleviate the pubococcygeal reflex

Encourage the woman to use her own fingers in combination with some relaxation exercises

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10
Q

What is vulvodynia?

A

A burning pain occurring in the absence of visible findings/a clinically identifiable neurological disorder

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11
Q

What is the treatment for vulvodynia?

A

MDT approach with physio, psychosexual medicine and pain management
First line treatment: pelvic floor exercises, internal and external perineal massage, topical anaesthetic
Tricyclic antidepressants and gabapentin may also work

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12
Q

What is the general management for sexual dysfunction?

A

Lifestyle: diet, exercise, stress reduction, exploration of relationship problems/body image issues
Education: body function, encourage exploration, sexual education material, lubricants
Hormonal: oestrogen replacement in menopausal women, testosterone if oophorectomy and HSDD
Behavioural therapy
Devices: e.g. for anorgasmia or vaginismus such as dilators or clitoral stimulators

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13
Q

What are the key symptoms to ask about in the sexual history for a woman?

A 
Genital skin changes
Vulval itching or soreness
Dysuria
Abnormal vaginal discharge
Abnormal vaginal bleeding
Dyspareunia
Abdominal/pelvic pain
Systemic symptoms
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14
Q

What are important questions to ask about vaginal discharge?

A

Volume
Colour - including if it was blood-stained
Consistency - thickened or watery
Smell

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15
Q

Which STIs cause abnormal vaginal discharge and what are the characteristics of each?

A 
Gonorrhoea
Chlamydia
Bacterial vaginosis 
- offensive, fishy-smelling discharge
- no soreness or irritation
Trichomonas vaginalis
- yellow, frothy discharge
- associated with vaginal itching and irritation
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16
Q

What are the different types of vaginal bleeding and what are the causes of each?

A

Post-coital bleeding
- infection, cervical ectropion, cervical cancer
Intermenstrual bleeding
- infection, cervical/endometrial cancer, uterine fibroids, endometriosis, hormonal contraception, pregnancy

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17
Q

What are the causes of dyspareunia?

A

STIs, endometriosis, vaginal atrophy, malignancy

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18
Q

What are the different types of dyspareunia?

A

Superficial - e.g. genital herpes

Deep - e.g. gonorrhoea, chlamydia

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19
Q

What are important questions to ask about dyspareunia?

A

Do you experience pain around the time of having sex?
How long does it last?
When does it occur? (Before, during or after)
Is the aim on the surface and in the vagina or more deep?
Nature of the pain

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20
Q

What are the risk factors for STIs?

A 
Unprotected sexual intercourse
Multiple sexual partners
15-24 year olds
Illicit drug and alcohol use
MSM
Sex workers
Urba areas
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21
Q

What is the causative organism for chlamydia?

A

Chlamydia trachomatis

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22
Q

How is chlamydia transmitted?

A

Obligate intracellular bacteria - predominantly transmitted via sexual contact
Also perinatal transmission from mother to baby during vaginal deliver - can lead to neonatal conjunctivitis and pneumonia

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23
Q

What is the presentation of chlamydia?

A

Asymptomatic in over 80% of cases
Males - mucupurulent discharge, dysuria, scrotal pain, proctitis
Females - mucupurulent vaginal discharge, cervicitis, cervical bleeding upon contact, proctitis, point-coital bleeding, IMB

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24
Q

What are the diagnostic investigations for chalmydia?

A

NAAT - first pass urine in males; vulvovaginal swabs in females
Oropharyngeal and rectal sites can also be swabbed

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25
Q

What is the management for chlamydia?

A

Azithromycin 1g oral single dose/
Doxycycline 100mg oral BD for 1 week (favoured if proctitis present)/
Erythromycin 500mg oral BD for 2 weeks

Contact tracing and partner notification need to be offered
All forms of sex should be avoided until both parties tested and treated

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26
Q

What are the complications of chlamydia?

A

PID - increases risk of ectopic pregnancy and infertility
Epididymitis
Prostatitis
Reactive arthritis

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27
Q

What is lymphogranuloma venerum?

A

Caused by a more invasive stereotype of chlamydia trachomatis
Causes a triad of inguinal lymphadenopathy, proctocolitis and fever

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28
Q

What is the causative organism of gonorrhoea?

A

Neisseria gonorrhoeae

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29
Q

How is gonorrhoea transmitted?

A

Predominantly via sexual contact
Mucosal epithelium lining the genital tract, orophraynx and rectum are commonly affected
Transmission during childbirth can cause gonococcal conjunctivitis which has an earlier onset than chalmydial conjunctivitis

30
Q

How does gonorrhoea present?

A

Males - mucopurulent urethral discharge, dysuria, orchitis
Females - mucopurulent cervical discharge with cervicitis, cervical bleeding upon contact, dyspareunia, pelvic pain
Rectal infection - rectal bleeding, rectal discharge, tenesmus, proctitis
Oropharyngeal infection - pharyngitis, anterior cervical lymphadenopathy

31
Q

What are the investigations for gonorrhoea?

A

NAAT - first pass urine in males/vulvovaginal swabs in females
Oropharyngeal and rectal sites can also be swabbed
Cultures taken prior to administering antibiotics to assess antibiotic susceptibility

32
Q

What is the management of gonorrhoea?

A

Ceftriaxone 500mg IM single dose +
Azithromycin 1g oral single dose

Contact tracing and partner notification
Avoid intercourse until tested and treated

Test of cure 2 weeks after treatment using NAAT

33
Q

What are the complications of gonorrhoea?

A

PID - increased ectopic pregnancy and infertility risk
Fitz-Hugh-Curtis syndrome - secondary to PID there is inflammation of the hepatic capsule leading to perihepatic adhesions
Chronic pelvic pain in females
Infertility in males secondary to epididymitis
Prostatitis
Bartholinitis

34
Q

What is the causative organism for syphilis?

A

Treponema pallidum (sphirochete bacterium)

35
Q

How is syphilis transmitted?

A

Sexual contact with an infected person who has a lesion on the skin/mucosa
Congenital syphilis occurs as a result of trans-placental transmission which increases the risk of stillbirth/miscarriage

36
Q

Describe the 1st stage of syphilis.

A 
Primary syphilis
Development of an induration painless ulcer (chancre)
Forms most often on the genitals 
Can form from 9-90 days
Most infectious
37
Q

Describe the 2nd stage of syphilis.

A

Secondary syphilis
6 weeks to 6 months following primary infection
Widespread non-pruritic maculopapular rash involving palms and soles
Accompanied by Alopecia, condylomata lata, generalised lymphadenopathy, oral snail-track lesions and systemic symptoms
Most infectious

38
Q

Describe the 3rd stage of syphilis.

A

Early latent

Asymptomatic infection + positive diagnostic serology obtained within 2 years of infection

39
Q

Describe the 4th stage of syphilis.

A

Late latent

Asymptomatic infection + positive diagnostic serology after 2 years of infection

40
Q

Describe the 5th stage of syphilis.

A

Tertiary syphilis
Untreated syphilis over many years
Can develop into neurosyphilis/cardiovascular syphilis/gummatous syphilis

41
Q

What are the diagnostic investigations for syphilis?

A

Dark ground microscopy of chancre fluid (motile, spring-shaped bacteria in primary)
Syphilis PCR - swab taken from ulcerated lesion
Treponemal-specific serology remains positive throughout life (EIA, TPHA, TPPA)
Cardiolipin serology tests to measure disease activity, disease staging and treatment efficacy (RPR, VDRL)

42
Q

What is the management for syphilis?

A

Benzathine benzylpenicillin IM single dose
+
Prednisolone PO for 3 days (Comice 24hrs before penicillin given)

Contact tracing and partner notification

43
Q

What are the complications of syphilis?

A

Jarisch-Herxheimer reaction (antibiotic treatment of syphilis causes a sepsis-like picture due to release of toxins from treponemal bacterial breakdown which is why steroids are administered before to prevent this)
HIV co-infection

44
Q

What are the causative organisms of herpes?

A

HSV-1 and 2

45
Q

How is herpes transmitted?

A

Transmitted through mucosal surfaces or broken skin
HSV-1 (oral herpes) - spread via oral-oral route, but can also affect the genital
HSV-2 (genital herpes) - sexually transmitted and affects the genital and anal areas

It is a lifelong infection as it stays dormant within the sensory ganglia causing intermittent reactivation

The virus is transmitted even if asymptomatic (asymptomatic shedding)

46
Q

How does herpes primary infection present?

A

Multiple painful blisters erupt around genitals/mouth
Burst to leave ulcers/fissures
Accompanying dysuria, pyrexia, painful inguinal lymphadenopathy, neuropathic pain around external genitalia
Can last up to 3 weeks
Recurrent infections only last around 3 days and tend to have milder symptoms

47
Q

What are the diagnostic investigations for herpes?

A

HSV PCR/culture from swabs taken from lesions (burst the lesion and swab the base)

48
Q

What is the management of herpes?

A

Primary episode - aciclovir 400mg PO TDS for 7-10 days (should be commenced within 3 days of symptom onset)

Recurrent episodes -800mg PO TDS for 2 days

Salt water baths, oral analgesia, topical lidocaine

49
Q

What are the complications of herpes?

A

Urinary retention
HSV keratitis - dendritic lesion on the cornea
Aseptic meningitis
Neonatal HSV (increased risk if the mother becomes infected in the third trimester)
Herpetic whitlow

50
Q

What are the causative organisms of genital warts?

A

HPV 6 and 11

51
Q

How are genital warts transmitted?

A

Direct skin to skin contact

Many carry the virus, but not all develop genital warts

52
Q

How does genital warts present?

A

Warts can vary in size, colour and texture
Mostly appear around the vaginal opening and penis (these areas are most exposed to friction)
The anus, cervix and urethral meatus can also be affected
Predominantly genital warts are asymptomatic, but itching, bleeding and pain can occur

53
Q

What are the diagnostic investigations for genital warts?

A

Diagnosis is clinical

Biopsies should be obtained if the lesion bleeds/is ulcerated/indurated

54
Q

What is the management for genital warts?

A

First line

  • topical podophyllotoxin (non-keratinised)
  • topical imiquimod (keratinised)

Second line
- cryotherapy/surgical excision

55
Q

What are the complications of genital warts?

A

Anogenital cancer

Scarring following treatment

56
Q

What is the causative organism of trichomoniasis?

A

Trichomonas vaginalis (flagellated Protozoa)

57
Q

How is trichomoniasis transmitted?

A

Via sexual intercourse

58
Q

How does trichomoniasis present?

A

Asymptomatic in >50%
Females: vaginal discharge (thin, frothy yellow-coloured discharge with a ‘fishy’ smell), vulval pruritis, vulvovaginitis, dysuria, dyspareunia
Males: urethral discharge, dysuria, balanitis

59
Q

What are the diagnostic investigations for trichomoniasis?

A

Vaginal pH - alkaline (>5)
High vaginal swab for wet mount microscopy
Culture of vaginal discharge
Men - culture of urethral swab/first pass urine

60
Q

What is the management for trichomoniasis?

A

Metronidazole 2g PO single dose
Contact tracing and partner notification
All forms of sex should be avoided until both parties are tested and treated

61
Q

What are the complications of trichomoniasis?

A

PID - ectopic pregnancy and infertility
Altered vaginal fora
Prostatitis
Increased risk of premature rupture of membranes and preterm birth in pregnancy

62
Q

What is HIV and how does it affect cells in the body?

A

It is a single-stranded RNA retrovirus that infects and replicates within the human immune system using host CD4 cells

63
Q

What is AIDS?

A

Acquired immune deficiency syndrome
When HIV is not treated - there is destruction of the immune system
Characterised by the development of certain (AIDS-defining) infections and malignancies e.g. pneumocystis jiroveci, pneumonia, non-Hodgkins lymphoma, TB.

64
Q

Describe how HIV infects the CD4 cell.

A

Penetrates the CD4 cell and empties its contents.
SsRNA converted to dsDNA by reverse transcriptase.
Combined with the host DNA using integrase.
When the infected cell divides, the viral DNA is read, creating viral protein chains and the immature virus pushes out of the cell, retaining some cell membrane.
The virus matures when protease cuts the viral protein chains and they assemble to create a working virus.
The host cell is destroyed during this process.

65
Q

Describe the stages in an HIV infection.

A

Upon seroconversion (the process of producing anti-HIV Abs during primary infection), the patient may experience flu-like symptoms. CD4 levels fall in response to the initial, rapid replication of HIV. The patient is extremely infectious at this stage.

Latent phase - over the next few months/years. Initially asymptomatic, but then more susceptible to infections with CD4 levels falling and viral load increasing. The HIV infection can then later be symptomatic.

Over an average of 10 years, can develop into AIDS.

66
Q

How is HIV transmitted?

A

Unprotected sexual contact - vaginal/oral/anal
Sharing of injecting equipment
Medical procedures (blood products, skin grafts, organ donation)
Vertical transmission (during childbirth/breast feeding)

67
Q

What factors make a person more likely to catch HIV?

A

Exposure to a higher viral level
STI causing anogenital inflammation
Breaks in the skin/mucosa

68
Q

Who are the at risk groups for HIV?

A

MSM
IV drug users
In high prevalence areas
Unprotected sex with someone who has lived or travelled to Africa

69
Q

The clinical features of HIV can be split into initial seroconversion illness and symptomatic HIV. What are the features of the initial seroconversion illness?

A 
2-6 weeks after exposure
Non-specific, flu-like illness (fever, muscle aches, malaise)
Lymphadenopathy
Maculopapular rash
Pharyngitis
70
Q

What are the features of symptomatic HIV and how does it develop?

A

Months to years after the seroconversion illness, the infection can enter a latent, asymptomatic phase. After this the infection will become symptomatic.
Weight loss, high temperature, diarrhoea
Frequent motor opportunistic infections e.g. herpes zoster, candidiasis

71
Q

What are the investigations that are done for HIV?

A

Fourth generation tests are 1st line (ELISAs test for serum/salivary HIV Abs and p24 antigen) - give reliable results 4-6 weeks after exposure

Other rapid test kits and at home kits give results in 30 mins but are not as accurate and still need confirming with ELISA if positive.

Gynaecology (12 decks)

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