STI Flashcards
What causes urethritis [6]
Chlamydia Trachomatis = most common
Neisseria gonorrhoea
Trichomoniasis vaginalis
HSV
Mycoplasma genitalium
Ureaplasma
What are the symptoms of urethritis [3]
How do you know its not UTI?
Urethral discharge
Dysuria
Meatitis (erythema of urethral meatus)
Don’t get discharge
Discharge can be physiological
Chlamydia Ax Incubation period Symptoms - male [4], female [4] Incidence of asymptomatics between genders Signs [3]
Ax: chlamydia trachomatis serovars D to K
Incubation period is 7-14 days
Symptoms:
- Male: asymptomatic 20%, slight penile discharge, dysuria, scrotal pain, proctitis
- Female: asymptomatic 80%, vaginal discharge, dysuria, IMB, PCB
- Conjunctivitis
Signs:
- Mucopurulent vaginal or penile discharge
- Cervicitis
- Cervical bleeding on contact
Chlamydia
Investigation: screening [2], diagnostic [3]
Management [2]
Investigations: nucleic acid amplification test of…
- Screening: 1st void urine (M), self-taken vaginal swab (F)
- Diagnosis: cervical (F), urethral (M) or rectal (MSM) swab
Mx: DOXYCYCLINE oral
• Follow-up: test for reinfection at 3-12 months
-
Chlamydia Complication Female [3] Male [2] Both [2]
- F: PID, Fitz Hugh Curtis syndrome, infertility
- M: epididymitis (can cause infertility), prostatitis
- B: reactive arthritis or Reiter’s syndrome
Gonorrhoea More common in... Ax Incubation period Symptoms: M [1] F [4] Asymptomaticity between genders Signs
Ep: less common than chlamydia, MSM
Ax: Neisseria gonorrhoea (gram negative diplococcus)
Incubation period is 5-6 days on average
Symptoms: - M: asymptomatic 10%, dysuria - F: asymptomatic 50%, dysuria, vaginal discharge, IMB, PCB Signs: - Thick yellow profuse discharge
Reiter’s syndrome [3]
urethritis/cervicitis, conjunctivitis, arthritis
Gonorrhea
Ix [3]
Mx [3]
Complications [3]
NAAT of first void urine (M)
NAAT - exposed site swab (B)
Culture for antibiotic sensitivities
Mx: intramuscular ceftriaxone
Follow-up: test of cure at 2 weeks and test of reinfection at 3 months
Local complications that may develop include urethral strictures, epididymitis and salpingitis (hence may lead to infertility).
Systemic complications (disseminated):
tenosynovitis
migratory polyarthritis
dermatitis (lesions can be maculopapular or vesicular)
How is culture for antibiotic sensitivities done in gonorrhea investigation?
Gram stained smear from urethra, vagina or rectum
Trichomoniasis Ep Ax Incubation Symptoms: M, F [2] Asymptomaticity between genders Signs: discharge [5]
Ep: middle aged women Ax: trichomoniasis vaginalis Incubation period 5-28d Symptoms: - Male: asymptomatic - Female: asymptomatic 20%, vaginal discharge, vulvitis Signs: - Profuse thin, greenish, foul, frothy vaginal discharge
Trichomoniasis
Ix [3]
Mx - 2 options
Cx [2]
Ix:
- microscopy of wet preparation of HIGH vaginal swab
- Leishman’s or acridine orange stained specimen of discharge
- culture
Mx:
- Metronidazole 400mg oral BD for 5d or 2g single dose
Cx:
- Miscarriage, preterm labour
Syphilis Ep Ax, can be transmitted with... Incubation Differentials of ulcer presentation [6]
Ep: MSM
Ax: treponema pallidum (anaerobic gram-negative spirochete), can be transmitted with HIV
Incubation period is 9-90
days until chancre appears
Differentials of ulcer presentation:
- Herpes: painful
- Lymphogranuloma venereum: painless pustule > ulcer > painful lymphadenopathy
- Chancroid
- Behcet’s disease
- Carcinoma
- Granuloma inguinale: Klebsiella granulomatis
What is chancroid? [3]
What is a chancre? [2]
Stages [5]
Chancroid: Painful genital ulcer, unilateral inguinal LN swelling, Haemophilus ducreyi
Chancre is a painless indurated ulcer seen in primary stage of syphilis
Four stages:
- Primary
- Secondary
- Early latent
- Late latent
- Tertiary
Syphilis presentation
Primary
Secondary [7]
• Primary: CHANCRE
• Secondary (6 weeks-6 months following primary infection):
- non-pruritic maculopapular rash of palms and soles
- alopecia
- condylomata lata
- generalised lymphadenopathy
- oral snail track lesions
- systemic symptoms (pyrexia, fatigue, malaise)
Syphilis
Early latent [3]
Late latent [3]
Tertiary [3]
- Early latent: asymptomatic infection and positive diagnostic serology within 2 years of infection
- Late latent: asymptomatic infection and positive diagnostic serology after 2 years of infection
Tertiary
o Neurosyphilis: tabes dorsalis, general paresis, stroke
o Cardiovascular syphilis: aortitis, aortic aneurysms
o Gummatous syphilis: granulomas of skin, bone and mucosa
Syphilis
Investigation: diagnostic [3], disease activity monitoring
Dx:
- Serology of treponema pallidum
- PCR: ulcer swab
- Dark ground microscopy of ulcer base: motile spring shaped bacteria
Disease activity:
- cardiolipin serology tests (rapid plasma regain (RPR))
Describe serology of treponema palladium [3]
IgG/IgM, enzyme immunoassay (EIA)
Tremponaemea hemagglutination test (TPHA)
Particle agglutination test (TPPA)
Syphilis Mx
Early [3]
Late [4]
Neurosyphilis [2]
Early mx
- <2y with no neurological involvement:
- Benzathine benzylpenicillin 2.4MU IM once
- OR Doxycycline 100mg oral BD for 2w
Late mx
- > 2y with no neuro involvement
- Benzathine benzylpenicillin 2.4MU IM
- Weekly for 3w
- Doxycycline 100mg oral BD for 28d
• Neurosyphilis:
- IM PROCAINE PENICILLIN 2.4U IM for 14d
- with PROBENECID
Syphilis Mx
Pregnant
Adverse reaction to benzathine penicillin + doxy combo
Pregnant:
- one off benzathine penicillin if 1st or 2nd trimester
- 2 doses 1 week apart in third trimester
o Jarisch-Herxheimer reaction: seen after initiating therapy (fever, rash and tachycardia after 1st dose of abx)
Syphilis complications [7]
Cx:
- tertiary syphilis
- congenital syphilis (extremely rare; thrombocytopenia
- condylata mata
- haemorrhagic rhinitis
- Hutchison’s incisors
- frontal bossing, saddle nose deformity)
- miscarriage, stillbirth
Herpes Ep gender Ax Route of transmission Incubation Asymptomaticity Presentation [6]
Ep: equal Ax: herpes simplex virus type 1 and type 2 Type 1: oral sex Type 2: genital skin contact Incubation: 5d to months
Presentation:
- Asymptomatic 80%
- Recurring monthly, annually
- Burning, itching, tender ulceration
- Tender inguinal lymphadenopathy
- Flu-like sx
- Dysuria
- Neuralgic back pain, legs, pelvis
Herpes Investigation Mx of: 1. Primary outbreak - give 3 options 2. Infrequent recurrences [2] 3. Frequent recurrences
Ix: PCR of swab from lesion (although usually clinical dx)
Mx:
• Primary outbreak: ACICLOVIR 200mg 5 times daily or 400mg 3 times daily for 5 days
• Infrequent recurrences:
- LIDOCAINE ointment
- ACICLOVIR 1.2g once daily until symptoms gone after 1-3 days
• Frequent recurrences: ACICLOVIR 400mg twice daily as suppression
Anogenital warts or Genital HPV Ep [2] Ax [2] Incubation Presentation [2] Ix Mx [4]
Ep: >80% of population gets genital HPV at some point but only 20% of them get warts
Ax: HPV types 6 and 11
Incubation period is 2 weeks to 8 months
Sy/Si: lumps, anogenital itching or bleeding (perianal or intraurethral), cauliflower texture
Ix: biopsy if unusual but usually clinical dx
Mx:
- Topical podophyllum or cryotherapy
Multiple, non-keratinised warts are generally best treated with topical agents whereas solitary, keratinised warts respond better to cryotherapy
- IMIQUMOD 2nd line
- diathermy or scissor removal if bulky
Pelvic inflammatory disease
Causative organisms [4]
Chlamydia trachomatis*
Neisseria gonorrhoeae
Mycoplasma genitalium
Mycoplasma hominis
Pelvic inflammatory disease Investigation [3]
a pregnancy test should be done to exclude an ectopic pregnancy
high vaginal swab: these are often negative
screen for Chlamydia and Gonorrhoea
Management of PID [4]
Have a low threshold for management
oral ofloxacin + oral metronidazole
OR intramuscular ceftriaxone + oral doxycycline + oral metronidazole
? Remove IUDs
Complications PID [3]
perihepatitis (Fitz-Hugh Curtis Syndrome)
chronic pelvic pain
ectopic pregnancy
What is Fitz Hugh Curtis syndrome [3]
- occurs in around 10% of cases
- it is characterised by right upper quadrant pain and may be confused with cholecystitis
- infertility - the risk may be as high as 10-20% after a single episode
