Sexual Health and STI's Flashcards
1
Q
What is the definition of bacterial vaginosis?
A
Bacterial vaginosis (BV) refers to an overgrowth of bacteria in the vagina, specifically anaerobic bacteria. It is not a sexually transmitted infection.
2
Q
How can STI’s be contracted?
A
Unprotected intercourse
Blood transfusion
Needle reuse
Pregnancy
3
Q
What are the consequences of STIs
A
herpes and syphilis can increase the risk of HIV acquisition three-fold or more.
HPV infection causes 570 000 cases of cervical cancer and over 300 000 cervical cancer deaths each year
gonorrhoea and chlamydia are major causes of pelvic inflammatory disease (PID). Adverse pregnancy outcomes and infertility in women.
4
Q
What is BV caused by?
A
gardenella vaginalis
5
Q
What are lactobacilli?
A
Lactobacilli are the main component of the healthy vaginal bacterial flora. These bacteria produce lactic acid that keeps the vaginal pH low (under 4.5). The acidic environment prevents other bacteria from overgrowing. When there are reduced numbers of lactobacilli in the vagina, the pH rises. This more alkaline environment enables anaerobic bacteria to multiply.
6
Q
What are some examples of anaerobic bacteria associated with BV?
A
Gardnerella vaginalis (most common)
Mycoplasma hominis
Prevotella species
7
Q
Bacterial vaginosis can also occur alongside what else?
A
It is worth remembering that bacterial vaginosis can occur alongside other infections, including candidiasis, chlamydia and gonorrhoea.
8
Q
What is the aetiology of Bacterial vaginosis?
A
Commonest cause of abnormal discharge in women of childbearing age.
The pH of vaginal fluid is elevated above 4.5 and up to 6.0.
Lactobacilli may be present, but the flora is dominated by many anaerobic and facultative anaerobic bacteria:
- Gardnerella vaginalis (biofilm)
- Prevotella spp
- Mycoplasma hominis
- Mobiluncus spp.
- Atopobium vaginalis (biofilm)
9
Q
What are the RFs for BV?
A
Multiple sexual partners (although it is not sexually transmitted)
Excessive vaginal cleaning (douching, use of cleaning products and vaginal washes)
Recent antibiotics
Smoking
Copper coil
Bacterial vaginosis occurs less frequently in women taking the combined pill or using condoms effectively.
Vaginal douching
Receptive cunnilingus
Black race
Recent change of sex partner
Smoking
Presence of an STI e.g. chlamydia or herpes
10
Q
What is the presentation/ S + S of BV?
A
The standard presenting feature of bacterial vaginosis is a fishy-smelling watery grey or white vaginal discharge. Half of women with BV are asymptomatic.
Itching, irritation and pain are not typically associated with BV and suggest an alternative cause or co-occurring infection.
11
Q
Signs and symptoms of BV
A
Symptoms
Offensive fishy smelling vaginal discharge
Not associated with soreness, itching, or irritation
Many women (approximately 50%) are asymptomatic
Signs
Thin, white, homogeneous discharge, coating the walls of thevagina and vestibule.
BV is not usually associated with signs of inflammation
12
Q
Investigations for BV?
A
speculum examination can be performed to confirm the typical discharge, complete a high vaginal swab and exclude other causes of symptoms.
Vaginal pH can be tested using a swab and pH paper. The normal vaginal pH is 3.5 – 4.5. BV occurs with a pH above 4.5.
A standard charcoal vaginal swab can be taken for microscopy. This can be a high vaginal swab taken during a speculum examination or a self-taken low vaginal swab.
Bacterial vaginosis gives “clue cells” on microscopy. Clue cells are epithelial cells from the cervix that have bacteria stuck inside them, usually Gardnerella vaginalis.
13
Q
What is the management of BV?
A
Asymptomatic - no tx
Metronidazole for 7 days
14
Q
What are the complications of BV?
A
Bacterial vaginosis can increase the risk of catching sexually transmitted infections, including chlamydia, gonorrhoea and HIV.
It is also associated with several complications in pregnant women:
Miscarriage
Preterm delivery
Premature rupture of membranes
Chorioamnionitis
Low birth weight
Postpartum endometritis
15
Q
Hay/ison Criteria
(BASHH recommended)
for BV
A
- grade 1 (Normal): Lactobacillus morphotypes predominate
- grade 2 (Intermediate): Mixed flora with some Lactobacilli present, butGardnerella or Mobiluncus morphotypes also present
- grade 3 (BV): Predominantly Gardnerella and/or Mobiluncusmorphotypes. Few or absent Lactobacilli.
grade 0: No bacteria present
grade 4 Gram positive coccipredomina
0
16
Q
AMSEL’s criteria for BV
A
At least three of the four criteria are present for the diagnosis to be confirmed:
(1) Thin, white, homogeneous discharge
(2) Clue cells on microscopy of wet mount
(3) pH of vaginal fluid >4.5
(4) Release of a fishy odour on adding alkali (10% KOH)
17
Q
What is BV associated with?
A
Bacterial vaginitis is associated with an increased risk of preterm birth and infective complications following gynaecological surgery (1).
18
Q
Which bacteria is the most commonly found in BV?
A
Gardnerella vaginalis is commonly found in women with BV but the presence of Gardnerella alone is insufficient to constitute a diagnosis of BV because it is a commensal organism in 30-40% of asymptomatic women (2)
19
Q
What is the epidemiology of BV
A
prevalence of bacterial vaginosis among women is 5-30% (1)
20
Q
What is the pathogenesis of BV?
A
Male partners may be colonised with Gardnerella vaginalis, and some organisms causing vaginosis have also been found in the rectum suggesting that this may provide a reservoir for vaginal infection.
The initial change in the pathogenesis is probably an increase in vaginal pH from pH 4.0 to pH 5.5. This is probably due to the production of amines by Gardnerella and and Prevotella.
It is unclear why only some women are susceptible.
21
Q
What is the general management for BV?
A
General advice
Avoid vaginal douching
Avoid use of shower gel
Avoid se of antiseptic agents or shampoo in the bath etc
Treatment indicated:
Symptomatic women
Women undergoing some surgical procedures
Women who do not volunteer symptoms may elect to take treatment if offered
22
Q
Treatment of BV?
A
400 mg twice daily oral metronidazole for 5 to 7 days,
0.75% metronidazole vaginal gel for 5 days or 2% clindamycin vaginal cream for 7 days
23
Q
Alternative treatment of BV?
A
dequalinium may be a suitable alternative treatment if:
women cannot tolerate metronidazole or clindamycin, or in other circumstances where those treatments are not suitable e.g. women with inflammatory bowel disease, or antibiotic-associated colitis where clindamycin is contraindicated
in situations where fewer treatments are available due to interactions or allergies, e.g. in pregnancy
where it would be beneficial to avoid use of an antibiotic
24
Q
BV in pregnancy treatment
A
- antibiotic treatment can eradicate bacterial vaginosis in pregnancy
- this particular review however provides little evidence that screening and treating all pregnant women with asymptomatic bacterial vaginosis will prevent preterm birth and its consequences
- standard treatment in the UK is oral metronidazole 400mg twice a day for five to seven days (1,2,4,8)
- there are no reports of an increase in birth defects with the use of metronidazole during pregnancy - however, it is better to avoid its use in the first trimester
- delaying breast-feeding until 24 hours after completing therapy
- topical clindamycin is an alternative treatment option
- Clindamycin 2% cream at night for 7 days (5)
dequalinium is another alternative to metronidazole (2)
25
What is Trichomonas vaginalis/ the definition?
Trichomonas vaginalis is a type of parasite spread through sexual intercourse. Trichomonas is classed as a protozoan, and is a single-celled organism with flagella
Trichomonas has four flagella at the front and a single flagellum at the back, giving a characteristic appearance to the organism.
26
How is trichomonas spread?
Trichomonas is spread through sexual activity and lives in the urethra of men and women and the vagina of women.
Infection can only follow intravaginal or intraurethral inoculation of the organism
27
What does trichomonas increase the risk of?
Contracting HIV by damaging the vaginal mucosa
Bacterial vaginosis
Cervical cancer
Pelvic inflammatory disease
Pregnancy-related complications such as preterm delivery.
28
What is the presentation + S/S of Trichomoniasis?
Vaginal discharge
Itching
Dysuria (painful urination)
Dyspareunia (painful sex)
Balanitis (inflammation to the glans penis)
No increased frequency or urgency
Lower abdominal discomfort
The typical description of the vaginal discharge is frothy and yellow-green, although this can vary significantly. It may have a fishy smell.
Examination of the cervix can reveal a characteristic “strawberry cervix” (also called colpitis macularis)
Testing the vaginal pH will reveal a raised ph (above 4.5), similar to bacterial vaginosis.
29
Signs of trichomonas vaginals
Up to 70% have vaginal discharge, from thin and scanty to profuse and thick.
Classical frothy yellow discharge occurs in 10-30%.
Other signs include vulvitis, vaginitis and 2% of patients have strawberry cervix.
30
What are the investigations/ diagnosis for? trichomoniasis
The diagnosis can be confirmed with a standard charcoal swab with microscopy (examination under a microscope).
Swabs should be taken from the posterior fornix of the vagina (behind the cervix) in women. A self-taken low vaginal swab may be used as an alternative.
A urethral swab or first-catch urine is used in men.
direct wet preparation for typical motile protozoa
swab in transport media / Feinberg's liquid culture medium - examine for protozoa after 2 days incubatio
TV testing should be done in women complaining of vaginal discharge or vulvitis, or found to have evidence of vulvitis, and/or vaginitis on examination
Swab taken from posterior fornix during speculum examination
Self-taken swabs are likely to give equivalent results
Nucleic acid amplification tests (NAAT) if available. - GS
31
General management of TV
General Advice
Full explanation of diagnosis with written information.
Screening for other STIs
Recommended regimes
Metronidazole 400-500mg twice daily for 5-7 days
Alternative regimens
Tinidazole 2g orally in a single dose
32
What is the management for trichomoniasis?
Patients should be referred to a genitourinary medicine (GUM) specialist service for diagnosis, treatment and contact tracing.
metronidazole 400 mg twice a day for 5-7 days or 2 g as a stat dose if compliance is a problem
Pregnant women who does not want metronidazole: clotrimazole 100mg pessary at night for 6 nights
Alcohol abstinence is advised during the course of the treatment and at least for 2 days afterwards because of the possibility of a disulfiram-like reaction (1).
Current sexual partners of women diagnosed with TV should be offered a full sexual health screen and should be treated for TV irrespective of the results of their tests
33
What are the complications of Trichomonas vaginals
Associated with preterm delivery and low birth weight in pregnancy
May predispose to maternal postpartum sepsis
May enhance HIV transmission
34
Epidemiology of T?
This is most common in females between 18 and 35 years. It is usually, but not always, sexually acquired. The incubation period is 4 days to 3 weeks.
35
What is urethral trichomoniasis?
this may be present in up to half of the cases of vaginal infestation. It may cause dysuria and frequency if the trigone of the bladder is involved.
36
What is the definition of Thrush (vaginal candidiasis)
It refers to vaginal infection with a yeast of the Candida family. The most common is Candida albicans.
Candida may colonise the vagina without causing symptoms. It then progresses to infection when the right environment occurs, for example, during pregnancy or after treatment with broad-spectrum antibiotics that alter the vaginal flora.
37
What are the RFs of vaginal thrush?
Increased oestrogen (higher in pregnancy, lower pre-puberty and post-menopause)
Poorly controlled diabetes
Immunosuppression (e.g. using corticosteroids)
Broad-spectrum antibiotics
38
What are the symptoms of vaginal thrush?
Thick, white discharge that does not typically smell
Vulval and vaginal itching, irritation or discomfort
More severe infection can lead to:
Erythema
Fissures
Oedema
Pain during sex (dyspareunia)
Dysuria
Excoriation
39
What are the investigations for vaginal thrush?
Often treatment for candidiasis is started empirically, based on the presentation.
Testing the vaginal pH using a swab and pH paper can be helpful in differentiating between bacterial vaginosis and trichomonas (pH > 4.5) and candidiasis (pH < 4.5).
A charcoal swab with microscopy can confirm the diagnosis.
40
What is the treatment for vaginal thrush?
Antifungal cream (i.e. clotrimazole) inserted into the vagina with an applicator
Antifungal pessary (i.e. clotrimazole)
Oral antifungal tablets (i.e. fluconazole)
41
According to NICE what is recommended for initial uncomplicated cases>
A single dose of intravaginal clotrimazole cream (5g of 10% cream) at night
A single dose of clotrimazole pessary (500mg) at night
Three doses of clotrimazole pessaries (200mg) over three nights
A single dose of fluconazole (150mg)
42
Other treatments for vaginal thrush?
Canesten Duo is a standard over-the-counter treatment worth knowing. It contains a single fluconazole tablet and clotrimazole cream to use externally for vulval symptoms.
They also recommend recurrent infections (more than 4 in a year) can be treated with an induction and maintenance regime over six months with oral or vaginal antifungal medications. This is an off-label use.
Warn women that antifungal creams and pessaries can damage latex condoms and prevent spermicides from working, so alternative contraceptive is required for at least five days after use.
43
Epidemiology of vaginal thrush?
common among women of reproductive age
caused by overgrowth of yeasts; C. albicans, in 70-90% of cases, with non-albicans species such as C. glabrata in the remainder
presence of candida in the vulvovaginal area does not necessarily require treatment, unless symptomatic, as between 10% and 20% of women will have vulvovaginal colonisation
44
When does vaginal thrush occur most commonly?
candidiasis occurs most commonly when the vagina is exposed to estrogen, therefore it is more common during the reproductive years and during pregnancy
an episode of vulvovaginal candidiasis (VVC) is often precipitated by use of antibiotics
immunocompromised women and women with diabetes are predisposed to candidiasis
45
What are the RFs of recurrent vaginal thrush?
antibacterial therapy, pregnancy, diabetes mellitus, or possibly oral contraceptive use
reservoirs of infection may also lead to recontamination and should be treated; these include other skin sites such as the digits, nail beds, and umbilicus as well as the gastro-intestinal tract and the bladder
the partner may also be the source of re-infection and, if symptomatic, should be treated with a topical imidazole cream at the same time.
46
What does Public Health England state as guidance for recurrent vaginal thrush?
fluconazole (induction/maintenance)
150mg every 72 hours for 3 doses THEN 150mg once a week
47
What are some self help measures that patients with recurrent vaginal thrush can be advised on?
if there is any bowel reservoir of organisms then consider treatment with oral antifungals will treat bowel infection
treatment of male sexual partner (treatment is simultaneous)
avoid precipitating factors e.g. tight fitting clothes,
the use of natural yoghurt (taken orally or given intravaginally) - the bacteria in the yoghurt apparently produce pH changes in the vagina that discourage the growth of candida
diabetes must be excluded
48
What are some alternative recommended regimens for vaginal thrush?
initially, fluconazole by mouth 150 mg every 72 hours for 3 doses, then 150 mg once every week for 6 months;
initially, intravaginal application of a topical imidazole for 10-14 days, then clotrimazole vaginally 500-mg pessary once every week for 6 months;
initially, intravaginal application of a topical imidazole for 10-14 days, then itraconazole by mouth 50-100 mg daily for 6 months.
49
What is balanitis, posthitis and balanoposthitis?
balanitis - inflammation of the glans penis
posthitis - inflammation of the foreskin
balanoposthitis - inflammation of the glans penis and foreskin
50
What is the epidemiology of balanitis?
Balanitis is common in young boys with a non-retractile foreskin and in the elderly where there may be predisposing factors such as malignancy or diabetes. The organisms most commonly involved are faecal bacteria and candida.
51
What are the signs and symptoms of balanitis / presentation?
Presentation is with irritation or pain in the penis and discharge from beneath the foreskin. Inflammation is visible. Recurrent balanitis may cause a phimosis with disturbance of micturition.
52
What is anyone with balanitis advised to do?
avoid contact with any potential skin irritants (e.g. soap)
keep area clean by bathing twice daily with a weak saline solution while symptoms persist
53
What do we do to men with acute balanitis?
refer all men with acute balanitis and suspected urethritis, ulceration, or lymphadenopathy to a genito-urinary medicine clinic (2)
with the exception of recurrent ulceration due to herpes simplex in someone with an established diagnosis
swab the sub-preputial space prior to starting empirical treatment (2)
54
What do we give for balanitis secondary to candida?
responds to topical antifungal cream or oral antifungal treatment
55
What are the treatment options for adults with balanitis?
topical imidazole e.g. econazole, ketoconazole, sulconazole,clotrimazole 1% or miconazole 2% applied twice a day till the symptoms resolve
oral fluconazole - 150mg stat if symptoms are severe
topical nystatin - in case of resistance and allergy to imidazole (3)
topical terbinafine
56
What are the treatment options for children with balanitis?
a topical imidazole e.g. clotrimazole, econazole, ketoconazole, miconazole, sulconazole
topical nystatin
recommended that treatment with a topical antifungal should be continued for 2-3 days after clinical cure
57
What is the treatment for bacterial balanitis?
may require oral antibiotic treatment (e.g. flucloxacillin or erythromycin)
sometimes a combined steroid/antibiotic cream (e.g. hydrocortisone acetate 1%, fusidic acid 1%) or combined antifungal/steroid cream (e.g. hydrocortisone 1%, clotrimazole1%) is used to reduce inflammation caused by infection
topical corticosteroid should be applied until the inflammation has cleared
twice a day for up to 2 weeks (3)
58
What is balanitis xerotica et obliterans?
Balanitis xerotica et obliterans refers to thickening and depigmentation of the foreskin which is often adherent to the glans penis. The cause is unknown
59
S + S or presentations of balanitis xerotica
May be asymptomatic. Patients could present with itching, dyspareunia, white patches on the glans often with involvement of the prepuce, meatal thickening and narrowing (1).
Elsewhere in the body, the condition may be known as lichen sclerosus.
Diagnosis is through clinical features and biopsy (1).
60
Treatment of balanitis xerotica?
topical steroid creams – used once daily until remission and then gradually tapered
treatment of secondary infection
circumcision – in phimosis and resistant cases
surgery for meatal narrowing.
61
What is balanitis plasmocellularis?
shiny, moist, erythematous, well-dermacated plaque on the glans penis in an older uncircumcised male
well-demarcated, moist, shiny, bright-red or autumn-brown multiple pinpoint patches involve the glans and prepuce - “cayenne pepper spots”
62
What is the presentation often for balanitis?
Indolent and asymptomatic
63
What are the DDs for balanitis plasmocellularis
seborrhoeic dermatitis,erosive lichen planus, psoriasis, fixed drug eruption, secondary syphilis, erythroplasia of Queyrat and Kaposi's sarcoma
64
Treatment for balanitis plasmocellularis
may improve with altered washing habits plus intermittent application of a mild or potent topical corticosteroid (with or without antibiotics and anticandidal drugs)
often persists or relapses
almost all cases occur in uncircumcised men and nearly all are cured by circumcision
alternative methods – CO2 laser (1)
65
Features of circinate balinitis
characterised by serpiginous, annular lesions with slightly raised borders on the glans penis of an uncircumcised man
in circumcised men papulosquamous plaques and papules occur on the penis
occurs in Reiter's syndrome
66
What is the definition of Chancroid?
Chancroid is a tropical sexually transmitted disease caused by Haemophillus ducreyi, a gram negative bacterium.
67
What is the epidemiology of chancroid?
It is endemic in Africa, Asia and South America, and is more common in men, particularly uncircumcised men. HIV is a very important cofactor, with a 60% association in Africa.
68
What are the pathological causes of chancroid?
Lipooligosaccharide
Pili
Isolation specimen
Media
69
What is the pathogenesis of chancroid?
Incubation - 4-10 days
Inoculation through epiderman microabrasions > attachment of bacteria to ecm in skin via pili, lipooligosaccharide > attachment to cells via specific heat shock protein (GroEL) > cytotoxin release, epithelial injury > formation of erythematous pauple > evolves into pustule > pustule ruptures, forms ulcers
70
RFs for chancroid
Uncircumcised
poverty
Hoes
71
Complications of chancroid
HIV contraction
72
S + S of chancroid
Painful genital ulcers
Prepuce
Glans penis
Dysuria, dyspareunia,
vaginal discharge
rectal bleeding
inguinal lymphadenopathy
73
Investigations for chancroid
Culture
NAAT
PCR
Histological characteristics
74
Criteria for chancroid diagnosis (other diagnostics)
- one painful genital ulcers
- no evidence of treponema pallidum infections
- no evidence of herpes
- appearance of genital ulcers, regional lymphadenopathy
- purulent exudate in superficial epidermis with perivascular, interstitial mononuclear infiltrate in dermis
75
Treatment for chancroid
Single dose therapy with azithromyocin/ ceftriaxone
Alternative - multiple - dose therapy with ciprofloxacin/ erythromycin
Fluctuant lymphadenopathy - needle aspiration, drainage to prevent spontaneous rupture
76
What is chlamydia
Chlamydia trachomatis is a gram-negative bacteria
77
How does chlamydia trachomatis work
it enters and replicates within cells before rupturing the cell and spreading to others.
78
Most common STI?
Chlamydia
79
What makes you have a higher risk of catching the infection of chlamydia?
-Being young,
-sexually active
-multiple partners increase the risk of catching the infection.
A large number of cases are asymptomatic (50% in men and 75% in woman). Asymptomatic patients can still pass the infection on.
80
What is the National Chlamydia Screening programme
Public Health England has set out a National Chlamydia Screening Programme (NCSP). This program aims to screen every sexually active person under 25 years of age for chlamydia annually or when they change their sexual partner.
81
2 types of swabs used in sexual health testing
Charcoal swabs
Nucleic acid amplification test (NAAT) swabs
82
What do Charcoal swabs allow for
microscopy (looking at the sample under the microscope),
culture (growing the organism)
sensitivities (testing which antibiotics are effective against the bacteria).
Charcoal swabs look like a long cotton bud that goes into a tube with a black transport medium at the end. The transport medium is called Amies transport medium, and contains a chemical solution for keeping microorganisms alive during transport.
83
What does microscopy involve
gram staining and examination under a microscope. A stain is used to highlight different types of bacteria with different colours. Charcoal swabs can be used for endocervical swabs and high vaginal swabs (HVS).
84
What testing is used specifically for Chlamydia and Gonorrhea
Nucleic acid amplification tests (NAAT) check directly for the DNA or RNA of the organism
85
Emerging Antimicrobial resistance (AMR) of STIs
Gonorrhoea:
Known resistance to penicillin, tetracyclines
high rates of quinolone resistance
Increasing azithromycin resistance
Emerging resistance of extended-spectrum cephalosporins,
Mycoplasma : Doxycyline and Azithromycin
Syphilis: Azithromycin
86
Presentation of Chlamydia in women
Abnormal vaginal discharge
Pelvic pain
Abnormal vaginal bleeding (intermenstrual or postcoital)
Painful sex (dyspareunia)
Painful urination (dysuria)
87
Chlamydia presentation in men
Urethral discharge or discomfort
Painful urination (dysuria)
Epididymo-orchitis
Reactive arthritis
88
First line treatment for uncomplicated chlamydia
doxycycline 100mg twice a day for 7 days.
89
Doxycycline issues + alternatives
contraindicated in pregnancy and breastfeeding.
Erythromycin 500mg four times daily for 7 days
Erythromycin 500mg twice daily for 14 days
Amoxicillin 500mg three times daily for 7 days
90
Non medical management of chylmadia
Abstain from sex for seven days of treatment of all partners to reduce the risk of re-infection
Refer all patients to genitourinary medicine (GUM) for contact tracing and notification of sexual partners
Test for and treat any other sexually transmitted infections
Provide advice about ways to prevent future infection
Consider safeguarding issues and sexual abuse in children and young people
91
Normal complications of chlamydia
Pelvic inflammatory disease
Chronic pelvic pain
Infertility
Ectopic pregnancy
Epididymo-orchitis
Conjunctivitis
Lymphogranuloma venereum
Reactive arthritis
92
Pregnancy-related complications of chlamydia
Preterm delivery
Premature rupture of membranes
Low birth weight
Postpartum endometritis
Neonatal infection (conjunctivitis and pneumonia)
93
Curable bacteria infection that are curable?
Syphilis
Gonorrhaea
Chlamydia
Trichomonas
94
Viral infection are incurable but treatable
Herpes Simples Virus (HSV)
HIV
And preventable:
Hepatitis B
Human Papilloma Virus (HPV)
95
Symptoms of STI
Common symptoms of STIs include vaginal discharge, urethral discharge in men, genital ulcers, and abdominal pain
BUT
The majority of STIs have no symptoms or only mild symptoms that may not be recognized as an STI.
96
What are the challenges arising in the health system and the biological factors which make it difficult to control the spread of STIs
Challenges arising in the health system
Health services maybe unavailable; far away; expensive; stigmatizing
Little emphasis on educational and efforts to prevent infection.
Inability to offer the most effective drugs (cost)
Biological factors
Asymptomatic infection – individuals at risk will not seek treatment
97
Social factors to control the spread of STIs
Feelings of embarrassment or guilt reluctance to seek health care
Ignorance or misinformation.
A preference for alternative health sources
A reluctance to follow safe sex practices
The social stigma so often attached to STIs
Failure to complete treatment
The difficulty of notifying sexual partners
98
Principles of STI management
Listen to the patient
Non-judgemental approach
Screen for accompanying STIs
Partner notification
Prevention
99
Venereal disease act of 1917
Ensure correct treatment by qualified professonals
Ensure confidentiality
Ensure access , self referral
Free treatment
100
What is HPV?
HPV is a DNA virus
Can infect all types of squamous epithelium
> 100 types have been described.
~ 40 types can infect the genitals.
~ 14 types classified as ‘high risk’ (ongogenic)
16 and HPV 18 cause about 70 %of all cases of cervical cancer.
‘Low risk’ types (6 and 11) cause about 90% of cases of genital warts
101
Pathogenesis of HPV?
Transmission is mainly skin to skin contact
Incubation period 3-4 month ( range 1month to 2 years)
Can clear spontaneously
Oncogenic types can progress to pre-cancerous/cancerous
102
What can high risk HPV lead to?
Oropharyngeal cancer
cervical cancer
Anal cancer
Genital warts
penile cancer
Vulvar cancer
103
Features of ano-genital HPV
The most common sexually transmitted infection
Most infections non-visible
Transmission usually through Genital contact
- Perinatal transmission can occur
- Transfer from hand to genitals reported in children (HPV2)
Mostly benign lesions
~ 90% are caused by HPV types 6 or 11
Most resolve spontaneously with a year
104
Clinical features of HPV
Single or multiple ,benign epithelial skin tumours
Lesions may broad based or pedunculated and some are pigmented.
Multifocal infection of the ano-genital skin
Asymptomatic lesions may be seen on the vagina, cervix, urethral meatus, and anal canal
Perianal lesions are common in both sexes
Extra-genital lesions caused by genital HPV types may be seen in the oral cavity, larynx, conjunctivae, and nasal cavity
105
Clinical presentation of HPV
Presence of new lumps/growths in the anogenital area.
Generally IP between 3 weeks to 8 but can be as long as 18 months
Some “new” presentations will actually be recurrent disease
local irritation
bleeding
discomfort/itching
Rarely , secondary infection and maceration
cauliflower-like growths of varying size
flat, plaque-like
pigmented.
Rarely, may grow more rapidly and infiltrate local tissue or cause local erosions
106
How do we diagnose HPV?
Mainly clinical
Rarely needs bx
107
How do we assess for HPV?
Examine the external ano-genital and surrounding skin
For females : vaginal speculum examination
For males : urethral meatus
Examine anal canal if symptomatic
Extra-genital sites (e.g. oral cavity) should be examined if clinically indicated
Recording of lesions on genital maps can aid of response to treatment.
108
DDs of HPV
Mulloscum contagious
Pearly penile papules
Condymomata accuminta
109
Treatment for HPV
Physical ablation
Excision
Cryotherapy
Electrosurgery
Laser treatment
Topical applications:
Podophyllotoxin (Warticon® and Condyline®)
Imiquimod 5% cream
Catephen® 10% ointment
TCA 80-90% (specialist clinic setting only)
5-Fluorouracil 5% cream - Not recommended for routine management
Interferons - Not recommended for routine managemen
110
Prevention of HPV
LIMITING NUMBER OF SEX PARTNERS
CONDOM USE
HPV VACCINES
Gardasil
111
Normal vaginal discharge
clear to white
Odourless
High viscosity.
112
Features of the vagina
Diverse echo systems
109 bacteria forming units/g vaginal fluid
Dominated by lactobacilli
convert glycogen to lactic acid helps maintain an acidic vaginal fluid
produce H2O2 serves as a host defense mechanism
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Causes of vaginitis:
common among women of reproductive age
characterized by
vaginal discharge
vulval itching
Vulval irritation
vaginal odour
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Non- infectious causes of vaginitis
Allergies
Mucopurulent cervicitis
Atrophic vaginitis
Vulvar vestibulitis
Lichen simplex chronicus
Lichen sclerosis
Foreign bodies
Desquamative inflammatory vaginitis
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Infection related causes of vaginitis
Sexually transmitted
Genital herpes
Chlamydia
Gonorrhea
Trichomonas
Non sti
Candida
BV
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What do we look for in the history of someone with vaginal dishcharge?
menstrual cycle
sexual history (including gender of sex partners and specific sexual practices)
vaginal hygiene practices (such as douching
PMHx
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What do we want to see in the examination for vaginitis
Vagina:
Note characteristics discharge
Colour
Viscosity
Adherence to walls
Presence of odour
Cervix:
r/o cervicitis
Collection of specimen
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Investigations for vaginal discharge
Saline Wet Mount
H2O2 and Whiff test (dry mount)
Litmus Testing for pH of Vaginal Fluid
Gram's Stain
Point-of-Care Organism Specific Tests
Culture
Nucleic Acid Amplification Tests
(Polymerase Chain Reaction)
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30 yr old
Female
RMP
3 week history of offensive “fishy” smelling discharge
No other symptoms
On IUS
No PMHx
Nil Medication
NKDA
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What is vulvovaginal candidiasis
An acute inflammatory dermatitis of the vulva and vagina caused by mucosal invasion of commensal yeast species, caused in 80-92% by Candida albicans
Non-albicans species e.g. C. glabrata, C. tropicalis, C. krusei, C.parapsilosis, and Saccharomyces cerevisiae
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Symptoms of vulvovaginal candidiasis
Vulval itch
Vulval soreness
Vaginal discharge
Superficial dyspareunia
External dysuria
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Signs of vulvovaginal candidiasis
Erythema
Fissuring
Discharge, typically curdy but may be thin. Non-offensive.
Oedema
Satellite lesions
Excoriation
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What is complicated candidiasis?
Severe symptoms (by subjective assessment)
Pregnancy
Recurrent vulvovaginal candidiasis (at least 4 episodes per year)
Non-albicans species
Abnormal host (e.g. hyperoestrogenic state, diabetes mellitus, immunosuppression)
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How do we diagnose vulvovaginal candidiasis?
Microscopy and culture is standard for symptomatic women
Vaginal swab should be taken from the anterior fornix (for the following:
Gram or wet film examination
Direct plating to solid fungal media. Speciation to albicans/non-albicans is essential if complicated disease suspected/present
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General Management of vulvovaginal candidiasis
General Advice:
Vulval moisturisers as soap substitute and regular skin conditioner (not for internal use)
Avoid tight fitting synthetic clothing
Avoid irritants e.g. perfumed products
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Vulvovaginal Candidiasis: Management Non complicated
Topical
Clotrimazole Pessary
Clotrimazole Vaginal cream (10%)
Fenticonazole Pessary
Isoconazole Vaginal tablet
Miconazole Ovule
Miconazole Pessary
Nystatin Vaginal cream
Nystatin Pessary
Oral
Fluconazole* Capsule 150mg stat
Itraconazole* Capsule 200mg bd x 1 day
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Vulvovaginal candidiasis management complicated
Severe symptoms (a subjective assessment)
Pregnancy
Recurrent vulvovaginal candidiasis (more than 4 attacks per year)
Non-albicans species
Abnormal host (e.g. hyperoestrogenic state, diabetes mellitus, immunosuppression)
Treatment :
fluconazole 150mg should be repeated after 3 days
If oral treatment is contra-indicated repeat a single dose pessary after 3 days
Low-potency corticosteroids are also thought to improve symptomatic relief in conjunction with antifungal therapy
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27 year old man
5 day history of yellow discharge from his urethra and pain passing urine
No testicular pain or swelling
Last sex- can’t quite remember, “definitely before lockdown”
Approximately 6 female partners in the past 6 months.
White discharge from glans of penis
Due to skeleton service we had no in-house microscopy
Swab taken for gonorrhoea culture
Urine sent for chlamydia and gonorrhoea NAAT
Blood sent for HIV and syphilis
Treated for presumed gonorrhoea with stat dose of 1g IM ceftriaxone
Results-4 days later due to weekend
CT/GC NAAT negative
HIV and syphilis negative
Called patient-not very happy as he feels no better!
Diagnosis?
Treated as presumed mycoplasma genitalium
1st line for non-complicated myoplasma genitalium- doxycycline 100mg BD 7 days followed by azithromycin 1g day 1, 500mg days 2 and 3.
Covered for trichomonas vaginalis with metronidazole 400mg BD 5 days
His symptoms resolved
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What is mycoplasma genitalium?
First isolated in 1981
Mollicutes class. Smallest known self-replicating bacterium
No cell wall-not visible by gram stain
Diseases associated with M. genitalium are thought largely to be due to host immune response, it has been shown to be directly toxic to cells causing cilial damage in human fallopian tubes.
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Where is mycoplasma genitalium found?
Prevalence rates in general population range from 1-2%. Amongst sexual health clinic attendees, 4-38%.
Found in genital tract and rectum. Carriage in oropharynx is rare
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Clinical presentations in people with a penis
Asymptomatic -majority
Non-chlamydial non-gonococcal urethritis.
Urethral discharge, dysuria, penile irritation, urethral discomfort, (balanoposthitis)
Epididymo-orchitis
Sexually acquired reactive arthritis (SARA)
(Possibly proctitis)
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Clinical presentations in people with a vagina
Asymptomatic-majority
Dysuria
Post-coital bleeding/inter-menstrual bleeding
Cervicitis
Pelvic inflammatory disease
SARA
Pre-term delivery
(Proctitis)
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Testing for STIs
Targeted based on symptoms and contacts, not used for screening
People with a penis: first void urine
People with a vagina: vulvovaginal swab (viral swab)
Ideally all positive specimens should be tested for macrolide resistance-mediating mutations.
Test any partners that the patient is planning to have sex with again
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treatment for mycoplasma genitalium
Non-complicated infection:
1st line: doxycycline 100mg BD 7 days followed by azithromycin 1g on day 1, 500mg on days 2 and 3.
2nd line: moxifloxacin 400mg OD 10 days
Complicated infection:
Moxifloxacin 400mg OD 14 days
Macrolide resistance globally: 30-100 % (UK approx 40%)
Moxifloxacin resistance increasing in Asia-Pacific
Test of cure at 5 weeks (and definitely no earlier than 3 weeks)
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Rates for gonorrhoea
Rates remain high
67% of gonorrhoea diagnoses are in MSM
In December 2021 UK Health Security Agency (UKHSA) confirmed ceftriaxone resistance in a N. gonorrhoea isolate from a UK resident heterosexual man in his 20s.
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Complicated GC
Proctitis
Conjunctivitis
PID
Tenosynovitis
Arthritis
SARA
Disseminated GC infection (DGI)
136
What to do when someone has suspected gonorrhoea
Ideally refer all suspected and confirmed cases to a sexual health clinic
Culture
Low threshold for pharyngeal sampling
Treatment with ceftriaxone unless known to be sensitive to ciprofloxacin
Partner notification
Test of cure
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First line medication for Gonorrhea
First Line Ceftriaxone 1g STAT
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GC arthritis
Is the most common acute septic arthritis in young adults
Is a consequence of disseminated gonococcal infection (DGI)
DGI could manifest either
as a bacteraemia form (arthritis-dermatitis syndrome) in 60% of cases
or as a localized septic arthritis in the other 40%
Arthritis-dermatitis syndrome includes the classic triad of dermatitis, tenosynovitis, and migratory polyarthritis
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What is SARA
seronegative spondyloarthropathies.
sterile inflammation of the synovial membranes, fascia and tendons triggered by an infection at a distal site.
Reiters syndrome encompasses the classic triad
Conjunctivitis
Arthritis
Urethritis
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Causes of STI
Chlamydia trachomatis: This has the strongest association with SARA and has been identified in up to two-thirds of cases.
Neisseria gonorrhoeae: This is associated in up to 16% of cases and distinct from its role in septic arthritis
Mycoplasma genitalium: This is a well-recognised cause of urethritis but has only been identified in the joints in a few cases, so its arthritogenic potential is not yet fully known.
Sexual transmission of enteric pathogens triggering SARA has been reported
Shigella outbreaks
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Shigella sonnei
Recent increase in sexually transmitted extensively drug resistant (XDR) Shigella sonnei.
>50 cases between 1/9/21 and 20/12/21 (previously 1 case per month)
Mainly MSM, mainly London
Resistance markers against macrolides, fluroquinolones, amonoglycosides, sulphonamide, trimethoprim, tetracycline. In addition most of the recent cases are associated with ESBL production-results in ceftriaxone resistance.
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What is shigella sonnei
Mostly self limiting diarrhoea
Antibiotic treatment recommended for:
Severe symptoms (fever, bloody diarrhoea, sepsis)
Those needing hospital admission
Diarrhoea beyond 7 days
Immunodeficiency
If treatment needed discuss with microbiology.
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Pre-exposure prophylaxis
Tenofovir DF/emtricitabine licensed and commissioned in UK.
Daily dosing or event based (not proven for vaginal sex).
Current evidence is that it is >99% effective at preventing HIV infection when taken correctly.
Signpost/refer eligible people to Sexual Health clinic.
