Sexually Transmitted Infections

Question 1

When should you consider preforming a sexual health screen?

Answer 1

Anyone presenting with symptoms of:
- Vaginitis (change in discharge, dysuria, change in MB)
- Urethritis (Penile discharge, dysuria, meatal discomfort)
- Epididymo-orchitis (painful, swollen testies)
- PID (pelvic pain, fever, change in discharge, dyspareunia)
- Proctitis (rectal discharge/pain/bleeding)
- Ulcers/lumps
- Possible syphilis (rash on torso, palms and soles of feet)
- Possible HIV seroconversion

Question 2

What is included in a standard sexual health screen and how is it taken?

Answer 2

NAAT testing for chlamydia and gonorrhoea. Blood tests for syphillus and HIV.
Women - Self taken vulvovaginal swab.
Men - Urine sample
Men who have sex with men (MSM) - Urine sample, throat swab and a self taken rectal swab.

Question 3

Who are the high risks for gonorrhoea and what are its features.

Answer 3

High risk - MSM, afro-Caribbean, urban areas with deprivation and women < 25.
It is a gram negative diplococci which infects the mucous membrane of urethra, endocervix, rectum, pharynx and conjunctiva. Incubation is 2-5 days

Question 4

What are the signs and symptoms of Gonorrhoea?

Answer 4

Penile urethra - 90% get symptoms of urethral discharge (profuse and yellowy) and dysuria 2-5 days from exposure.
Vaginal/endocervix/urethra - 50% asymptomatic, change in discharge, abdo/pelvic pain, dysuria, may have altered bleeding
Pharynx - asymptomatic
Rectum - usually asymptomatic but can get anal discharge, pain or discomfort.

Question 5

Explain the diagnosis and treatment of Gonorrhoea

Answer 5

NAAT testing (can take up to 1 week) or urethral sample microscopy and a culture plate to assess drug resistance.
Treated with 1g ceftriaxone**(first line) IM or ciprofloxacin if sensitive. Repeat tests after 2 weeks

Question 6

What are the complications which can arise from gonorrhoea?

Answer 6

Epididymo-orchitis
Prostatitis,
PID
Disseminated gonococcal infection (affecting skin and joints)
Resistance (50% are resistant to at least 1 abx)

Question 7

What are the symptoms of disseminated gonococcal infection?

Answer 7

• Tenosynovitis,
• Migratory polyarthritis,
• Dermatitis
• Later complications can be septic arthritis, endocarditis and perihepatitis (fits-hugh-curtis syndrome)

Question 8

What are is the epidemiology of chlamydia?

Answer 8

Most common bacterial STI in UK.
Risk factors include being under 25 years, having a new sexual partner, inconsistent condom use.
Some people can clear the infection

Question 9

What are the signs and symptoms of chlamydia?

Answer 9

A
Penile urethra - 50% asymptomatic but can get clear urethral discharge, dysuria or meatal discomfort.
Vaginal - 70% asymptomatic but can get IMB/PC bleeding, cervicitis or contact bleeding, change in discharge and pelvic pain.
Pharynx - Asymptomatic
Rectal - Usually asymptomatic but can get proctitis or lymphogranuloma venereum which can cause lymphadenopathy/ulcer disease

Question 10

What is the diagnosis and treatment of chlamydia?

Answer 10

NAAT testing (too small for microscopy) from vulvovaginal in women and urine in men. Carry out 2 weeks from exposure
Doxycycline 100mg BD for 1 week. If pregnant then can use azithromycin* (first line), or amoxicillin/erythromycin.

Question 11

What are the complications of chlamydia?

Answer 11

• Epididymitis,
• PID,
• Endometriosis
• Increased risk of ectopic pregnancy
• Infertility
• Reactive arthritis
• Perihepatitis

Question 12

Describe features of Mycoplasma Genitalium

Answer 12

Bacteria which can exist asymptomatically on 1-2% of people. Some people can have an inflammatory response eg, urethritis/PID.
Treatment is not indicated unless symptomatic/partner is symptomatic
Investigations - NAAT
Treatment - Depends on antibiotic resistance.

Question 13

Describe the symptoms of Trichomonas Vaginalis, the investigations and treatment.

Answer 13

Vaginal symptoms - Frothy, yellow discharge with an INTESE ITCH. Strawberry cervix in 2%.
Penile - Usually asymptomatic but can have urethritis
Diagnosis - Microscopy/culture.
Treatment - Metronidazole

Question 14

Describe features of syphilis and the clinical presentation of primary syphilis

Answer 14

Caused by treponema pallidum which is a gram negative spirochete.
More common in MSM
Primary syphilis presents with a chancre which is usually single and painless with clear fluid.

Question 15

Describe the clinical presentation of secondary syphilis

Answer 15

Can occur from 3 months -2 years after exposure
Generalised rash affecting palms and soles but can appear on trunk.
Can present very non-specific with muco-cutaneous lesion, condylomata lata, lymphadenopathy and fever.
Less commonly anterior uveitis and hearing loss.

Question 16

Describe the tertiary presentation of syphilis

Answer 16

Neurosyphilis which can present with neurological symptoms including cognitive.
Cardiovascular syphilis which can cause aortic valve disease, aortic aneurysm.
Gummatous syphilis - presents with punched out lesions

Question 17

What are features of congenital syphillis?

Answer 17

• Blunted upper incisor teeth
• Rhagades (linear scars at angle of mouth)
• Keratitis,
• Saber shins (deformity of the tibia)
• Saddle node
• Deafness

Question 18

Explain the diagnosis and treatment of syphilis

Answer 18

If chancre present then do dark ground microscopy/viral PCR swab.
Blood tests for antibodies,
Rapid plasma reagin - quantitative marker
Treated with Benzathine penicillin.

Question 19

Describe features of ano-genital warts

Answer 19

Caused by HPV 6 and 11
Incidence reduced dramatically with quadrivalent vaccine.
Diagnosis based of clinical appearance,
Treatment via cyrotherapy, topical treatments (podophyllum or imiquimod), surgical excision.
Give reassurance that there is high prevalence and benign.

Question 20

Which HPV strains are linked to cervical cancer?

Answer 20

HPV - 16, 18 and 33

Question 21

What are the complications and treatment of HSV?

Answer 21

Complications - CNS involvement, balanitis, proctitis, urinary retention, risk of neonatal infection if first episode while mother is pregnant.
- Treatment: give advice about high prevalence, possible future recurrence. Treat flare ups with aciclovir.

Question 22

Describe features of scabies

Answer 22

Itch especially at night cause by mite excrement. Burrows classically appear in web spaces, wrists, elbows and nipples.
Diagnosis made on clinical appearence and treated with malathion 0.5% or permethrin 5%

Question 23

describe features of phthirus pubis

Answer 23

Public lice transmitted by close bodily contact.
Incidence decreasing but treated by malathion 0.5% or permethrin 1%