SEXUALLY TRANSMITTED INFECTIONS IN MALES Flashcards
What is dysuria?
Burning pain sensation during urination
What are the two most common causes of urethritis in men?
Gonorrhoea infection
Chlamydia infection
What are the less common causes of urethritis in men?
Mycoplasma genitalium infection
Trichomoniasis
Herpes simplex virus infection
Adenovirus infection
E. coli infection
Urinary tract infection
Trauma
Foreign body
Autoimmune - associated with reactive arthritis and allied conditions
How long does symptomatic gonorrhoea take to develop after exposure (incubation period)
2-5 days
How long do symptoms of chlamydia take to develop after exposure (incubation period)?
Normally 1-2 weeks, but pretty much always less than 4 weeks
What is the bacteria that causes gonorrhoea and what class of bacteria is it?
Neisseria gonorrhoea
Gram negative intracellular diplococci
What is the bacteria that causes chlamydia and what class of bacteria is it?
Chlamydia trachomatis
Gram negative obligate intracellular bacterium
What are the type of chlamydia that cause STIs?
Types D-K
What are the initial sites of infection of chlamydia?
Epithelial cells of urethra, cervix, rectum, pharynx, and conjunctiva.
What are the two main symptoms of chlamydia in males?
Urethral discharge
Dysuria
As well as the urethra, what other sites may be symptomatic in a chlamydia infection?
Proctitis
Conjunctivitis
Epididymo-orchitis
Reactive arthritis
What are the initial sites of infection of gonorrhoea?
Columnar epithelium of urethra, endocervix, rectum, pharynx, or conjunctiva
What are the main symptoms of gonorrhoea in men?
Urethral discharge
Dysruria
Tender inguinal lymph nodes
As well as the urethra, what other sites may be symptomatic in a gonorrhoea infection?
Epididymo-orchitis Abscesses of paraurethral glands Pharyngitis Rectum Conjunctivitis
Disseminated infection involving skin, joints and heart valves
What is the main method of diagnosis of chlamydia?
Nucleic Acid Amplification Test (NAAT)
What is the main method of diagnosis of gonorrhoea?
Detection of gram negative intracellular diplococci in smears and culture
What is the method used for screening of asymptomatic gonorrhoea?
PCR testing of urine sample
When performing a urethral smear for microscopy, what must you advise the patient to do for optimal results?
Optimal results for gram stain and culture are obtained from patients who have held their urine for 4 hours or more.
What would confirm urethritis on microscopy of a urethral smear?
Five or more polymorphs per high power yield.
If the smear shows gram negative intracellular diploccoci, what infection would you treat the patient for?
This is suggestive of gonorrhoea, however, often patients are treated for both gonorrhoea and chlamydia to cover the possibility of mixed infection. Meanwhile confirmatory tests will be carried out to confirm the presence of chlamydia.
Other than urethral smear, what investigations would be carried out on someone who presents with urethral discharge to confirm the aetiology of infection?
Nucleic Acid Amplification Test (NAAT) on first pass urine
How do we treat patients with urethritis where there is no evidence of gonorrhoea? Include doses and course duration.
Azithromycin - 1 g stat
OR
Doxycycline - 100mg BD for 1 week
OR
Erythromycin - 500mg BD for 2 weeks
These are all active against chlamydia and other pathogens associated with non-gonococcal urethritis.
What is the main side effect that patients who are started on doxycycline must be warned about?
Photosensitivity
Contraindicated in pregnancy
What is the main side effect of erythromycin?
GI upset
Also must warn of p450 inhibiting factors
What is the main side effect of azithromycin?
GI upset
A patient with urethritis where there is no evidence of gonorrhoea is given a stat dose of azithromycin. 1 week later he is still experiencing symptoms. What other pathogens might be causing his infection?
Gonorrhoea that was not picked up
Trichomonas vaginalis
Mycoplasma genitalium
How do we treat patients with urethritis caused by gonorrhoea? Include doses and duration of course
Ceftriaxone 500 mg IM stat
OR
Cefixime 400 mg PO stat (if IM is refused)
AND
Azithromycin 1 g PO stat (this is to cover mixed infection)
Traditional use of ciprofloxacin is decreasing as there is evidence of increased resistance.
What are the local complications of gonorrhoea?
Urethral stricture
Epididymitis
Salpingitis
Infertility (due to salpingitis)
What are the disseminated complications of gonorrhoea?
Classic triad of disseminated gonorrhoea infection are:
Tenosynovitis
Migratory polyarthritis
Dermatitis - maculopapular or vesicular
Later complications include:
Septic arthritis
Endocarditis
Perihepatitis (Fitz-Hugh-Curtis syndrome)
What is epididymo-orchitis?
Inflammation of the epididymis and/or testes, most commonly due to infection.
What are the main symptoms of epididymo-orchitis?
Scrotal pain and swelling
What is the differential diagnosis of scrotal pain and swelling?
Infection
Torsion of testis
Hydrocoele, spermatocoele, varicocoele
Vasculitis: HSP, Kawasaki’s disease and Buerger’s disease
Amiodarone therapy
Tumour
Hernia
Trauma
What are the organisms that commonly cause epididymo-orchitis?
Gonorrhoea
Chlamydia
Tuberculosis
Mumps virus
Gram-negative bacteria: E. coli, Klebsiella, Pseudomonas, Proteus
What is the first thing to exclude when someone presents with scrotal pain and swelling?
Acute torsion
Which age group is most affected by torsion?
Teenagers
What symptoms often accompany scrotal pain in acute torsion?
Vomiting
What investigations should be done for someone with acute onset scrotal pain to exclude torsion?
Doppler scan to demonstrate blood flow
What are the distinguishing features of mumps in someone who presents with scrotal pain?
Parotid swelling
Severe testicular pain a few days after onset of parotid swelling
Systemic symptoms (fever)
Don’t forget that parotitis may be absent
What tests should be done with suspected infective epididymo-orchitis?
Urethral smear
MSU
Investigations for gonorrhoea and chlamydia
When should you start treatment for gonorrhoea and chlamydia in young male that presents with scrotal pain and swelling?
If history and examination indicate that it is likely. Should not wait for results in a young male.
What is a varicocoele?
An abnormal enlargement of the pampiniform venous plexus in the scrotum.
What are the causative organisms for most cases of prostate infection?
Gram negative bacteria: E. coli, Klebsiella, Pseudomonas, Proteus
Streptococcus faecalis
What is the most common cause of pelvic or prostatic pain in men?
Chronic pelvic pain syndrome (also called chronic non-bacterial prostatitis
What is the NIH (national institutes of health) classification of prostatitis syndromes?
I - Acute bacterial prostatitis
II - Chronic bacterial prostatitis
III - Chronic prostatitis (CPPS)
IIIa - inflammatory (presence of leucocytes)
IIIb - non-inflammatory (absence of leucocytes)
IV - Asymptomatic inflammatory prostatitis
What are the causes of pelvic pain or prostatic symptoms in men?
Infection
CPPS
Specific or non-specific granulomatous prostatitis
Pudendal neuralgia
Bladder outlet obstruction (BPH)
Bladder tumours
Urinary stone disease
Ejaculatory duct obstruction
Seminal vesicle calculi
Irritable bowel syndrome
What are the STIs that can, but don’t commonly, affect the prostate?
Gonorrhoea
Chlamydia
Trichomoniasis
What investigations may be helpful in a patient with prostatic symptoms?
Transrectal USS
Urodynamic studies
Biopsy
What is the first choice antibiotic for prostate infection of unknown cause? Include course duration.
A quinolone or a tetracycline for 28 days. Good prostate penetrance.
What are the common symptoms associated with anorectal STIs?
Pain
Tenesmus
Bleeding
Discharge
Diarrhoea (rare)
What examination should be done in anyone presenting with signs and symptoms of anorectal infection?
PR
Proctoscopy
How might you readily diagnose herpes proctitis from examination?
Perianal vesicles or erosions
Pain is often too severe to allow proctoscopy or even PR
Which drug should be given for rectal chlamydia infections? Include course length
Rectal chlamydia infections have been shown to respond better to doxycycline than azithromycin.
Normally given for 3 weeks
What are the non-infectious anal conditions that men often present to STI services with?
Anal fissures
Haemorrhoids
Perianal haematomas
Pruritus ani
What are the orally transmitted infections in sex that cause symptoms?
Primary syphilis may present on the tongue or lips
Secondary syphilis can cause oral mucositis
HIV - oral candidiasis, angular cheilitis, gingivitis, oral hairy leucoplakia, Kaposi’s sarcoma
Perioral warts
