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STIs Flashcards

1
Q

What are the vaginal defences to STIs?

A

Stratified squamous epithelium
Ph< 4.5
lactobacilli

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2
Q

What is PID?

A

A spectrum of disorders of the upper genital tract
including
-endometritis
-salpingitis
-oophoritis
-parametritis
-tubo-ovarian abscess
-pelvic peritonitis
(peri-hepatitis)

Traditionally salpingitis due to STIs

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3
Q

What is the incidence of PID?

A

Incidence increasing: 2% will be affected

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4
Q

Who is the incidence of PID higher in?

A

Younger (15-24)
Lower SEC
Nulliparous

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5
Q

What are the microbiology causes of PID?

A

Chlamydia (up to 35%) & gonorrhoea account for majority of cases.

Less commonly:
STIS: Mycoplasma genitalium
Gut Flora: E Coli, clostridium, bacteroides
Vaginal flora: G. Vaginalis, Actinomyces israelii
Skin flora: strep pyogenes, Staph aureus

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6
Q

What is the pathology of PID? (As in where did this infection come from)

A

Ascending infection:
- from vagina/cervix
-Direct inoculation (ERPC, TOP, lap + dye, IUD)

Descending:
-transperitoneal (appendix, diverticulitis)
-haematogenous (classically TB)

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7
Q

What are the risk factors for PID?

A

Sexual behaviour

Recent instrumentation

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8
Q

What are the protective factors against PID? (4)

A

Pregnancy

Sterilisation

OCP

Barrier contraception

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9
Q

What are the clinical features of PID on history?

A

Often asymptomatic
-late presentation with subfertility or menstrual problems

Symptoms include
-Bilateral lower abdo pain
-Deep Dyspareunia
-Secondary dysmenorrhoea

-fever (> 38)
-vaginal bleeding (menstrual irreg, post coital)
-vaginal/cervix discharge
-nausea and vomiting

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10
Q

What are the clinical features on exam in PID?

A

NEWs chart: HR, BP, Temp

Abdominal: bilat lower abdo tenderness

Pelvic:
bimanual: bilat adnexal tenderness (or mass)
cervical excitation
speculum: purulent vaginal discharge

Very frequently less clear and confused with appendix, ovarian cysts and ectopic pregnancy (all unilateral)

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11
Q

What are the DDx for PID? (7)

A

● ectopic pregnancy

● complications of an ovarian cyst, such as rupture or torsion
● endometriosis

● Appendicitis
● irritable bowel syndrome (and less commonly, other gastrointestinal disorders)

● urinary tract infection/stones

● functional pain (pain of unknown physical origin)

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12
Q

What are the DDx or any acute pain in OBGYN?

A
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13
Q

What investigations would you do for PID? (5)

A

Endocervical/Urethral swabs (chlamydia and gonorrhoea):
-negative does not exclude
-note absence of endocervical or vaginal pus cells o/r
PID (95% predictive value)

Urine: Pregnancy test/Urinalysis

Bloods: FBC, ESR, CRP (can assess severity, but can be normal in mild-mod disease), blood cultures, LFTs

Pelvic Ultrasound: ? Abscess/hydrospalpinx ? Other cause

Laparoscopy + BX (fimbrial)

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14
Q

where are the different swabs taken from?

A
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15
Q

What is the management of PID? (4)

A

‘Pelvic rest’

Analgesics

Antibiotics
IV->if severe disease: fever, peritonitis,
abscess
Remove IUCD if severe disease (Abx first)

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16
Q

What are the BASHH guidelines 2019 for PID?

A

Mild to moderate PID no difference in outcomes between inpatient or outpatient management.

Outpatient antibiotic treatment should be commenced as soon as the diagnosis is suspected.

Outpatient regimens:
First line:
IM ceftriaxone stat 1gr
+ doxycycline 100mg bd
+ metronidazole 400mg bd
x 14/7

Other regimens
Ofloxacin + metronidazole
Moxifloxacin

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17
Q

How should more complex cases of PID be managed?

A

Admit febrile patients and treat them with IV antibiotics
ceftriaxone 2g daily, doxycycline 100mg twice daily.
->Then oral doxycycline 100mg twice daily + oral
metronidazole 400mg twice daily x 14/7

Review diagnosis if no improvement in 24 hours and perform a laparoscopy
Pelvic abscess may require drainage (under USS guidance or laparoscopically)

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18
Q

What are the short term complications of PID? (3)

A

Abscess
(Pyosalpinx, ovarian, pelvic)

Peritonitis

Fritz-Hugh-Curtis syndrome (RUQ pain, perihepatitis, 10-20%)

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19
Q

What are the long term complications of PID? (5)

A

Recurrent disease

Chronic pelvic pain

Ectopic pregnancy (x8)

Infertility (x1: 13%, x3: 75%)

Adhesions

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20
Q

How should someone with PID be followed up?

A

Review at 72 hours and Further review 2-4 weeks after therapy may be useful to ensure:
● compliance with oral antibiotics

●adequate clinical response to treatment

● awareness of the significance of PID and its complications

● screening and treatment of sexual contacts

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21
Q

What causes chronic PID?

A

No or inadequate abx

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22
Q

What are the clincial features of chronic PID? (4)

A
  • Dense adhesions
  • Hydro or pyosalpinx
  • Chronic pain, infertility, abnormal menstruation/discharge (see acute)
  • Exam: fixed retroverted uterus (see acute)
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23
Q

What investigations should be done for chronic PID? (2)

A

TVUS

Laparoscopy

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24
Q

What treatments are done for chronic PID? (3)

A

abx/analgesics if acute infection

adhesionolysis

salpingectomy

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25
The following are known causes of pelvic inflammatory disease Strep pyogenes Mycoplasma Chlamydia Clostridium Welchii Trichomonas
Strep pyogenes – T ->post abortion or delivery Mycoplasma- T Chlamydia –T (often super-infection) Clostridium Welchii- T Tichomonas-F
26
Which of the following is not a late complication of PID Chronic pelvic pain Ectopic pregnancy Pelvic adhesions Abscess formation Infertility
Answer: abscess formation – short-term
27
What is tested for on asymptomatic STI screening?
Bloods HIV Syphilis Hep B & C Swabs or Urine Chlamydia and gonorrhoea ?HVS for trichomonas
28
What is NB to note when screening for STIs?
Patient: -Screen for concurrent disease Screen partners: -regular -contact trace Statutory Notification
29
What are some facts about chlamydia? The most common cause of STIs Caused by a gram negative intracellular organism Silent in over half the cases Sensitive to metronidazole Possible cause of pneumonia in infants
The most common cause of STDs - T Caused by a gram negative intracellular organism -T Silent in over half the cases - T Sensitive to metronidazole -F Possible cause of pneumonia in infants -T
30
What organism causes chlamydia?
Gram negative bacteria, Chlamydia trachomatis
31
What is the epidemiology of chlamydia?
3% of 18-24 y/o in UK. (most common STI)
32
What is the natural history of chlamydia?
Symptoms usually 7-21 days post exposure
33
What are the symptoms of chlamydia? (3)
Usually asymptomatic (70%) Cervicitis: Discharge, PCB, IMB, dyspareunia urethritis: dysuria lower abdo pain
34
What are the complications of chlamydia? (4)
PID and its complications (see above) bartholonitis Reiter’s syndrome/SARA (arthritis, conjunctivitis, urethritis) Pregnancy: miscarriage, preterm labour, neonatal conjunctivitis (5-14d) & pneumonia
35
How is chlamydia diagnosed?
1) Vulvovaginal> Endocervical swabs (+/- urethral) & NAAT 2) Urine for NAAT: EMU (1st void: less sensitive)
36
What is the treatment of **chlamydia**?
**Doxycycline 100mg bd po for 7/7** or azithromycin (1g, then 500mg od po x 2/7) or erythromycin
37
what is the cervical appearance with chlamydia?
38
What are some facts about gonorrhea? Infects the vaginal epithelium May cause arthritis May be symptomless Is diagnosed by a serological test Crosses the placenta
Infects the vaginal epithelium - F glandular epithelium in cervix and urethra May cause arthritis -T blood borne spread (septic arthritis) May be symptomless - T 50% Is diagnosed by a serological test - F unreliable-> swabs or urine Crosses the placenta - F but can cause neonatal opthalmia
39
What is the causative organism in gonorrhoea?
Neisseria gonorrhoea, Gram neg diplococcus
40
What is the epidemiology of gonorrhoea?
Increased incidence. Higher prevalence MSM.
41
What is the natural history of gonorrhoea?
Symptoms: Usually 2-7 days post-exposure
42
What are the signs and symptoms of gonorrhoea? (5)
Commonly asymptomatic (50%). Fever Cervicitis: Discharge, IMB, PCB, deep dyspareunia. urethritis: dysuria Lower abdo pain
43
What are the complications of gonorrhoea?
PID, Bartholinitis, Reiters/SARA More aggressive: urethral stricture, bacteraemia, septic arthritis, polyarthralgia, rash, inflammation anus (d/c + pain), oropharynx(usually asymptomatic) pregnancy: miscarriage, preterm labour, neonatal opthalmia (2-7 days PN)
44
How is gonorrhoea diagnosed?
1) vulvovaginal swabs +NAAT> endocervical swab & NAAT (+urethral swab), 2) Urine: NAAT on EMU (less sensitive) 3) gram stain (accurate in men but less accurate in women)
45
What is the treatment for **gonorrhoea**?
**Ceftriaxone 1g stat** Test of cure recommended (2 weeks after treatment)
46
what is the cervical appearance of gonorrhoea?
47
Case
48
What is this?
Genital warts
49
What is the medical term for gential warts?
Condyloma acuminata
50
What organism causes genital warts?
Human papilloma virus (6,11 -90% of genital warts. 16/18? )
51
What is the epidemiology of genital warts?
Effect approx 1%
52
What are the signs and symptoms of genital warts?
3 month incubation 90% disappear spontaneously within 2yrs Warts (flat – papilliform), itch, irritation 25% have another STD.
53
What are the complications of genital warts?
(of HPV infection) : Cervical cancer Vaccine
54
What is the treatment for genital warts?
Topical podophyllin, imiquimod, Tricholoracetic acid Cryotherapy, Diathermy/laser/excision (resist/keratinised) condoms for 3/12 post treatment.
55
Case
56
Case
57
What organism causes genital herpes?
Double stranded DNA virus. Herpes Simplex V Type 2>1
58
What are the clinical presentations of genital herpes? (5)
can be asymptomatic * Primary: (incubation 3days to 2 weeks) vesicles and ulcers at introitus. (secondary bacterial infection) * Lymphadenopathy, dysuria (retention) * systemic symptoms, aseptic meningitis * Recurrent: 75%. Less severe – tingling prior and < pain . * Neonatal: encephalitis (C-section)
59
What are the ways to diagnose gential herpes?
Swab-NAAT (or cell culture). serology (distinguish primary from recurrent)
60
How is genital herpes treated?
Oral acyclovir (400mg tds x 5/7)/valciclovir (severe infections, decrease duration of symptoms-within 5 days). Analgesia. Tx secondary infections.
61
NEONATAL INFECTION & DISEASE RARE BUT FATAL DISEASE. MAY ARISE FROM VERTICAL OR HORIZONTAL CONTACT. TRANSMISSION AT DELIVERY 85%; IN UTERO 5%; EARLY POST-NATAL 10% MANIFESTATIONS OF NEONATAL DISEASE SEM – SKIN, EYES AND MOUTH VESICULAR LESIONS 83% PRESENT AT ABOUT 10 DAYS. CNS – CNS LESIONS WITH OR WITHOUT SEM 63% PRESENT WITH CNS MANIFESTATIONS ABOUT 17-19DAYS. DISEMINATED DISEASE – MULTIPLE ORGAN INFECTION 58%
62
What is this?
Genital herpes
63
Case
64
What is the organism causing trichomonas vaginalis?
A flagellate protozoan
65
What is the natural history of trich?
Symptoms 5-28 days post exposure
66
What are the signs and symptoms of Trich? (4)
10-50% asymptomatic Vagina: Discharge: smelly, Green/Grey, watery, frothy cervix: ‘strawberry’ red cervix Vulval irritation: sore and itch. Sup dyspareunia Dysuria, +/- increased frequency.
67
How is trich diagnosed?
Wet film microscopy. Swab and culture or swab and NAAT (later highest sensitivity)
68
How is trich treated?
Metronidazole 500 b.d 7 days
69
What is this?
Trich
70
What is the causative organism of HIV/AIDS?
Human Immunodeficiency V
71
What are the signs and symptoms of HIV?
seroconversion: flu like illness, rash, adenopathy
72
What are the signs and symptoms of AIDS?
opportunistic infections (PCP, candida, kaposi’s sarcoma) or CD4< 200. yearly smears.
73
How are pregnant women with HIV/AIDS managed?
ART (antenatal, intra-partum, post-partum) Delivery: vaginal possible with low viral load<400 copies/ml and on adequate ART Avoid breast feeding
74
How is HIV/AIDS monitored?
CD4 count Viral load
75
What is the treatment of HIV/AIDS?
HAART
76
HIV CAN BE TRANSMITTED IN UTERO (30%), OR IN THE PERIPARTUM PERIOD (DURING LABOUR AND DELIVERY, OR THROUGH BREASTFEEDING) (70%). THE OVERALL RISK OF TRANSMISSION IN UNTREATED WOMAN VARIES FROM 20-40% WITH IMPROVEMNTS IN MEDICATION THE RISK OF TRANSMISSION IN TREATMENT-COMPLIANT WOMEN IS <0.1% INCREASED RISK OF TRANSMISSION ASSOCIATED WITH HIGH MATERNAL VIRAL LOAD (SEROCONVERSION DURING PREGNANCY OR ADVANCED DISEASE); LOW MATERNAL CD4; CO-EXISTING OTHER STIs; PROLONGED RUPTURE OF MEMBRANES; INVASIVE MONITORING DURING LABOUR; BREASTFEEDING AND PREMATURITY.
GENERAL PRINCIPLES OF MANAGEMENT WHERE CD4 COUNTS <350 X 106/L START ANTI RETROVIRAL (ARV) THERAPY. USUALLY A COMBINATION OF 2 NEUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTIs) AND A BOOSTED PROTEASE INHIBITOR. ZIDOUVIDINE (ZDV/AZT) A NRTI IS MAINSTAY AS IT CROSSES PLACENTA. MULTIPLE PROTOCOLS IN PLACE FOR MATERNAL ANTENATAL, PERIPARTUM AND NEONATAL TREATMENT DEPENDING ON DISEASE STATUS e.g. “ELITE CPNTROLLERS” AS WELL AS WOMEN WITH CO-EXISTING HIV AND HEPATITIS B OR C. ELECTIVE LSCS WHERE MOTHER HAS HIGH VIRAL LOAD (i.e. > 400 copies/ml) , IS ON NO ARV THERAPY OR ZDV MONOTHERAPY. BATH INFANT AFTER DELIVERY. CLEAN EYES WITH SALINE. NO BREASTFEEDING ( ARVs will reduce but not eliminate transmission). WHERE SAFE ALTERNATIVES AVAILABLE AVOID BF. MOTHER WHO TAKES ARV TO STOP PERIPARTUM TRANSMISSION MAY STOP POST DELIVERY. FOUR WEEK ZDV OR ZDV TRIPLE THERAPY FOR INFANTS DEPENDING ON MATERNAL STATUS.
77
What is the causative organism of syphilis?
Treponema pallidum (spirochete)
78
What are the clinical features of syphilis?
Primary: painless ulcer (chancre): 10-90 days post-exposure (av: 21d) Secondary: Rash, influenza like sx, condyloma: lata. (possible vasculitis) Latent phase Tertiary syphilis: Aortic regurg, dementia, tabes dorsalis, gummata. in pregnancy: IUGR/IUD/pre-term labour/hutchinsons triad
79
How is syphilis diagnosed?
1) Dark ground microscopy (primary and secondary) (NAAT can also be used) 2) Serology: VDRL (-ve when treated), TPHA, FTA tests
80
What is the treatment of syphilis?
early **IM Benzathine penicillin** single dose latent/tertiary: variable regimens
81
** CONGENITAL SYPHILIS (Treponema pallidum)** NOTIFIABLE DISEASE IN OWN RIGHT PREVENTABLE. DURING FIRST YEAR OF MATERNAL INFECTION THERE IS 80-90% CHANCE OF TRANSMISSION TO FETUS. 50% RISK IN 2* SYPHILIS, 40% RISK WITH LATENT SYPHILIS, 10% RISK WITH TERTIARY. 25-30% AFFECTED FETUSES DIE IN UTERO: IUGR, NON-IMMUNE HYDROPS. 25-30% AFFECTED NEONATES DIE EARLY CONGENITAL SYPHILIS <2 YEARS. HEPATOSPLENOMEGALY, LYMPHADENOPATHY, SYPHILIS RASH, PERSISTENT RHINITIS, OSTEOCHONDRITIS, PNEUMONIA, PAROT PSEUDOPARALYSIS, BULGING FONTANELLE, SEIZURES. LATE CONGENITAL SYPHILIS MANIFESTS >2 YEARS. USUALLY NEAR PUBERTY: HUTCHINSONS TRIAD – PEG-SHAPED INCISOR TEETH, EIGHTH NERVE DEAFNESS, INTERSTITIAL KERATITIS. SADDLE NOSE, TIBIAL BOWING. STERILE JOINT EFFUSIONS.
82
What is this?
Syphilis
83
What are causes of vaginal discharge?
* physiological * foreign body * malignancy * infection: Candida Bacterial Vaginosis STI – chlamydia/gonorrhoea/trichomonas Other – beta haemolytic strep
84
What is seen in primary syphilis?
Painless ulcer (chancre)
85
What is seen in secondary syphilis? (4)
* rash * influenza like Sx * condyloma lata * possible vasculitis
86
What is seen in tertiary syphilis? (4)
* aortic regurgitation * dementia * tabes dorsalis * gummata
87
What can syphilis cause in pregnancy? (4)
* IUGR * IUD * preterm delivery * hutchinsons triad
88
What STIs can cause PID? (3)
* chlamydia (35%) * gonorrhea * mycoplasma genitalium
89
What gut flora can cause PID? (3)
* E. coli * clostridium * bacteroids
90
What vaginal flora can cause PID? (2)
* G. Vaginalis * actinomyces israelii
91
What skin flora can cause PID? (2
* strep pyogenes * staph aureus
92
What is hutchinsons triad?
Presentation of congenital syphilis = * keratitis * malformed teeth * eighth nerve deafness
93
What is hutchinsons triad?
Presentation of congenital syphilis = * keratitis * malformed teeth * eighth nerve deafness

OBGYN (25 decks)

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