Sexual Health and STI's Flashcards
What is the definition of bacterial vaginosis?
Bacterial vaginosis (BV) refers to an overgrowth of bacteria in the vagina, specifically anaerobic bacteria. It is not a sexually transmitted infection.
How can STI’s be contracted?
Unprotected intercourse
Blood transfusion
Needle reuse
Pregnancy
What are the consequences of STIs
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.
What is BV caused by?
gardenella vaginalis
What are lactobacilli?
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.
What are some examples of anaerobic bacteria associated with BV?
Gardnerella vaginalis (most common)
Mycoplasma hominis
Prevotella species
Bacterial vaginosis can also occur alongside what else?
It is worth remembering that bacterial vaginosis can occur alongside other infections, including candidiasis, chlamydia and gonorrhoea.
What is the aetiology of Bacterial vaginosis?
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)
What are the RFs for BV?
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
What is the presentation/ S + S of BV?
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.
Signs and symptoms of BV
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
Investigations for BV?
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.
What is the management of BV?
Asymptomatic - no tx
Metronidazole for 7 days
What are the complications of BV?
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
Hay/ison Criteria
(BASHH recommended)
for BV
- 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
AMSEL’s criteria for BV
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)
What is BV associated with?
Bacterial vaginitis is associated with an increased risk of preterm birth and infective complications following gynaecological surgery (1).
Which bacteria is the most commonly found in BV?
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)
What is the epidemiology of BV
prevalence of bacterial vaginosis among women is 5-30% (1)
What is the pathogenesis of BV?
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.
What is the general management for BV?
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
Treatment of BV?
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
Alternative treatment of BV?
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
BV in pregnancy treatment
- 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)
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.
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
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.
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.
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.
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
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
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
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
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.
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.
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.
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
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
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.
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)
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)
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.
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
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
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.
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
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
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.
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
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.
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.
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
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)
What do we give for balanitis secondary to candida?
responds to topical antifungal cream or oral antifungal treatment
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
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
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)
