STI Flashcards

Question

Ix of HSV

Answer 1

PCR: (most common investigation used) HSV DNA detection by polymerase chain reaction (PCR)- swab taken from ulcer The confirmation and typing of the infection and its type, by direct detection of HSV in genital lesions, are essential for diagnosis, prognosis, counselling and management Serology: (note not used routinely- often evokes more questions than answers!) Testing for HSV type-specific antibodies can be used to diagnose HSV infection The detection of HSV-1 IgG or HSV-2 IgG or both in a single serum sample represents HSV infection at some time It is difficult to say whether infection is recent as IgM detection is unreliable and avidity studies are not commonly available Value of routine screening remains to be established Serology may be helpful in the following situations: Recurrent genital disease of unknown cause Counselling patients with initial episodes of disease (to help identify recent or established infection in order to aid counselling), including pregnant women Investigating asymptomatic partners of patients with genital herpes, including women who are planning a pregnancy or are pregnant, or couples concerned about possible susceptibility to transmission in possibly discordant relationships

Answer 2

Treatment aim is to reduce duration and severity of symptoms HSV is not “curable” but is manageable Oral antiviral treatment: Antiviral drugs are indicated within 5 days of the start of the episode, while new lesions are still forming, or if systemic symptoms persist Topical agents are less effective than oral agents, combining oral and topical treatment is of no additional benefit over oral treatment alone Preferred regimens: aciclovir 400 mg three times daily or valaciclovir 500 mg twice daily Alternative short course treatment: Aciclovir 800 mg three times daily for 2 days or Valaciclovir 500 mg bd for 3 days ``` General advice: Saline bathing Analgesia Topical anaesthetic agents, e.g. 5% lidocaine ointment to apply especially prior to micturition Pass urine in the bath/shower ``` Reassurance and support: important to provide reassurance that 1st episode HSV will always be the worst and any future recurrences will be much less symptomatic

Answer 3

supportive therapy only episodic antiviral treatments suppressive antiviral therapy

Answer 4

Identify lesions from clinical examination and hx Take HSV PCR swab from lesions (if not had previous confirmed dx) Offer full STI screening (bloods for HIV/syphilis, swab (or urine in men) for GC/CT) Discuss dx with pt (dx usually clinical) In collaboration with pt decide on management which may consist of - General advice only - General advice and oral antiviral treatment Abstain from sex: Abstinence from sexual contact is recommended during lesion recurrences or prodromes Consider informing partner and discuss partner notification (PN): Disclosure is advised in all relationships since this is associated with lower transmission risks Offer ongoing support: (Diagnosis often causes considerable distress) Herpes virus association: https://herpes.org.uk/ Health Advisor follow up Follow up testing: not required

Answer 5

``` Asymptomatic Single or multiple lumps Irritation or discomfort Bleeding Rarely, secondary infection Commonly warts present as soft cauliflower-like growths of varying size but can be flat, plaque-like or pigmented ```

Answer 6

General advice Full explanation and reassurance (Genital warts remain one of the most common conditions treated in GUM clinics) Screening for STIs Condoms reduce risk of acquisition of HPV (30-60% reduction) Stop smoking: smokers may respond less well to treatment No changes to routine National Cervical Screening Programme are recommended Treatment: Treatment choice depends on examination findings and patient preference. No treatment may be an option as 30% patients will clear warts spontaneously. All treatments have significant failure and relapse rates, and can cause local skin reaction Cryotherapy - Repeat at weekly intervals, will likely need at least 4 treatments (and often more). Is the only treatment suitable in pregnancy Podophyllotoxin (Warticon® (cream) and Condyline®(solution) - Treatment cycles consist of twice daily application for 3 days, followed by 4 days rest, for 4-5 cycles Imiquimod 5% cream - Apply three times weekly and wash off 6-10 hours later, for up to 16 weeks Surgical Excision - Under local anaesthetic (rarely used) Partner notification: Notification of previous sexual partner(s) is not recommended , current sexual partner(s) may benefit from assessment as they may have undetected genital warts, other STIs, or need an explanation or advice about HPV infection Follow up: Review is recommended at the end of a treatment course to monitor response and assess the need for further therapy (in practise advice given to pt to return if ongoing warts visible after end of treatment course which is typically 4 weeks)

Answer 7

``` Vulval itch vaginal discharge (often described as thick, white like cottage cheese) Vulval soreness or burning Superficial dyspareunia Erythema Fissuring Vulval swelling/oedema Vaginal discharge; typically non-offensive and curdy (but may be thin or absent) Excoriation marks. ```

Answer 8

Clinical diagnosis based on typical features Microscopy: Used in level 3 GUM services A high vaginal swab (HVS) of the discharge taken for Gram stain Fungal culture: Not routinely performed in acute infection To be considered in recurrent cases

Answer 9

1st line: Fluconazole capsule 150 mg as a single dose, orally 2nd line: Clotrimazole pessary 500 mg as a single dose, intravaginally Clotrimazole (canestan) cream often used in addition to oral or pessary treatment for symptomatic relief of itch Offer STI screening Sex: no requirement to abstain from sex but may be advisable due to current vulval symptoms Partner Notification: Not required Follow up: Not required

Answer 10

``` Vaginal douching Use of soap/shower gel/feminine products Receptive cunnilingus Black ethnicity Recent change of sexual partner Smoking Presence of an STI e.g. chlamydia or herpes ```

Answer 11

Symptoms Offensive fishy smelling vaginal discharge Generally not associated with soreness, itching, or irritation Many women (approximately 50%) are asymptomatic Signs Thin, white, homogeneous discharge, coating the walls of the vagina and vestibule

Answer 12

Microscopy- performed at level 3 GUM services | MC+S swab- if dx in doubt and no microscopy available

Answer 13

``` General advice: Wash with water externally only, no soaps/shower gels etc Can use emollient to wash Stop douching Shower rather than bath ``` Antibiotic Rx: not necessarily required, important to discuss with patient 1st line: Metronidazole 400mg twice daily for 5-7 days OR Intravaginal metronidazole gel (0.75%) once daily for 5 days OR Intravaginal clindamycin cream (2%) once daily for 7 days Sex: no requirement to abstain from sex Partner notification: not required Follow up: not required

Answer 14

``` Symptoms: lower abdominal pain, typically bilateral deep dyspareunia abnormal vaginal bleeding abnormal vaginal discharge ``` ``` Signs: lower abdominal tenderness, usually bilateral adnexal tenderness cervical motion tenderness fever (>38°C) ```

Answer 15

PID is a clinical dx and empirical antibiotic treatment should be considered and usually offered in any woman who has recent onset, bilateral lower abdominal pain associated with adnexal or cervical motion tenderness on bimanual examination, in whom pregnancy has been excluded Microscopy: performed in level 3 GUM services to identify potential other causes of sx STI screening: tests should be performed routinely for GC/CT/HIV/syphilis and mycoplasma genitalium if treating for PID Pregnancy test: ALL women with lower abdominal pain MUST have pregnancy excluded whether they are on reliable contraception or not

Answer 16

1st line : IM ceftriaxone 1g single dose plus Oral doxycycline 100mg BD for 14 days plus Oral metronidazole 400mg BD for 14 days ``` 2nd line: Oral ofloxacin 400mg BD for 14 days plus Oral metronidazole 400mg BD for 14 days or Oral moxifloxacin 400mg OD for 14 days ** Ofloxacin and moxifloxacin should be avoided in patients who are at high risk of gonococcal PID because of increasing quinolone resistance in the UK** ``` Abstain from sex - Avoid sex (including oral sex) until they have completed the treatment course and current partner had testing +/- treatment Inform partner and discuss partner notification (PN) – Current male partners should be contacted and offered STI screening (particularly GC/CT) Empirical therapy should also be offered to male partners e.g. doxycycline 100mg twice daily for 1 week Other recent sexual partners may also be offered screening - tracing of contacts within 6 months of symptom onset is recommended but this may be influenced by sexual history Test of cure (TOC): Review at 72 hours is recommended, particularly if moderate or severe signs Further review 2-4 weeks after RX may be useful to ensure: Adequate clinical response Compliance with oral antibiotics Screening and treatment of sexual contacts Awareness of the significance of PID and its sequelae Repeat pregnancy test, if indicated

Answer 17

scarring of the fallopian tubes, which can cause an increased risk of ectopic pregnancy Infertility Abscess formation in a fallopian tube and/or ovary Chronic pelvic pain