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STIs Flashcards

1
Q

Which common STIs are caused by bacterial infection?

A

Chlamydia
Gonorrhoea
LGV
Syphillis

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2
Q

Which common STIs are caused by viral infection?

A

HSV, HPV, HIV, Molluscum Contagiosum

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3
Q

Which common STIs are caused by parasites?

A

Trichomonas vaginalis

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4
Q

What are common complications of STIs?

A

PID
Non-specific urethritis
Epididymitis/Orchitis
Prostatitis

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5
Q

What common non-STIs are seen in GU setting?

A

Candida/thrush
Bacterial vaginosis
Skin conditions

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6
Q

Post-coital contraception/Emergency Contraception

A

Morning after pill
IUCD
Counselling

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7
Q

What is the morning after pill?

A

can be used up to 72hrs post UPSI
1. Progesterone Only - 1.5mg Levonorgestrel stat dose
more effective if taken within 36 hours
Failure rate 1-3%

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8
Q

What other morning after pill could be offered?

A

Uliprastal Acetate (ellaOne) - 30mg stat dose
Selective Progesterone Recepetor Modulator
can be used up to 120 hours after UPSI

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9
Q

IUCD?

A

Copper coil can last up to 10 years
fitted up to 5 days post UPSI
failure rate < 0.5%
risk of ascending infection

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10
Q

What counselling is offered Pre-PCC?

A 
careful assessment of coital and menstrual Hx
exclude possibility of pregnancy
medical risks/CI
how to take
failure rates
ongoing contraception
risk of STI - offer GU screening
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11
Q

What is the causative organism of Chlamydia Trachomatis?

A

obligate intracellular bacterium with a long life cycle

affects mucosal membranes: genital tract, rectum, eye and rarely pharynx

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12
Q

What is the most common bacterial STI in the UK?

A

Chlamydia Trachomatis

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13
Q

What are the complications of congenital transmission of CT?

A

Neonatal conjunctivis in 30-50%, usually presenting in 2nd week of life
Less commonly, pneumonitis, presents between 4-12 weeks of age

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14
Q

What are the symptoms of CT in females?

A 
Asymptomatic in 80%
Post coital or inter-menstrual bleeding
Purulent vaginal discharge
Lower abdo pain
Dyspareunia
can cause proctitis
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15
Q

What are the signs of CT in females?

A

normal
cervicitis, mucopurulent discharge
cervical contact bleeding
Local complications - bartholinitis, signs of pelvic infection
Adenexal tenderness and cervical motion tenderness

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16
Q

What are the symptoms of CT in males?

A 
asymptomatic in 50%
urethral discharge
dysuria
testicular/epididymal pain
can cause proctitis
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17
Q

What are the signs of CT in males?

A

normal
urethral discharge +/- dysuria
local complications - epididymitis

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18
Q

What are the extra-genital features of CT?

A

Opthalmic infections - conjunctivitud

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19
Q

What are the complications of CT?

A

Men - epididymitis
Women - Pelvic inflammatory disease: Endometriosis, Salpingitis, Tubule damage and chronic pelvic pain.

Increased risk of ectopic pregnancy and infertility
Peri-hepatitis (Fitz-Hugh-Curtis syndrome) and Reiter’s syndrome

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20
Q

How is CT diagnosied?

A

NAAT - GOLD STANDARD

2 weeks after USI

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21
Q

When should you test for CT?

A

Any time

If they had UPSI within the last 2 weeks then they should be advised to test after 2 weeks window period

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22
Q

How do you treat CT?

A
  1. Azithromycin 1g stat (WHO recommend use in pregnancy; BNF - use if no other alternatives)
  2. Doxycycline 100mg bd for 7 days (CI in pregnancy and breastfeeding)

Alternative: Erithromycin 500mg bd for 10-14 days (if pregnancy or breastfeeding)

Oflaxacin for 7 days is not recommended

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23
Q

What should pts be advised about?

A

advised to avoid SI for 1/52, until partner notification and treatment

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24
Q

What are the associations of CT and pregnancy?

A

Low birth weight
Post-partum endometriosis
Neonatal conjunctivitis
Pneumonitis

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25
Q

Who else should be informed about CT diagnosis?

A

All partners in last 3 months or previous partner if longer

Current partner

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26
Q

At which sites can NAAT be performed?

A 
First pass Urine
Cervix
Vulvovagina (self-swab)
Urethral
Rectal
Pharyngeal
Opthalmic
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27
Q

When is test of cure offered/?

A

pregnant women

if 1st line Rx was not used or if Sx persist

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28
Q

What is the causative organism of Gonorrhoea?

A

Neisseria gonorrhoae

infects mucosal surfaces: genital tract, rectum, oropharynx and eye

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29
Q

How is gonorrhoea transmitted?

A

sexual transmission

Peri-natal transmission

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30
Q

What are the complications of peri-natal transmission of gonorrhoea?

A

eye infection, in the 1st week of life

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31
Q

What are the symptoms of gonorrhoea?

A

depends on site of infection

Urethral infection in men (develop Sx within 10d): discharge, dysuria, but some remain asymptomatic

Rectal infection: usually asymptomatic (80%), can cause rectal/anal pain or discharge. In women, rectal infection can occur in abscence of anal intercourse

Pharyngeal infection - asymptomatic

Cervical infection: asymptomatic (70%), symptoms include vaginal discharge and low abdo/pelvic pain - non-specific

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32
Q

What are the signs of gonorrhoea?

A

Urethra: meatitis, discharge mucoid -> purulent, signs of local complication

Cervix: cervicitis, discharge mucoid -> purulent, cervical excitation (cf. PID), signs of upper genital tract infection

Rectum: proctitis, discharge

Pharynx: pharyngitis, exudate

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33
Q

What are the complications of gonorrhoea?

A

Men: epididymitis, infection of penile glands, risk of abscess infection

Women: Barthonilitis, Endometriosis, Salpingits, Peritonitis, Tubo-ovarian abscesses

Less common: disseminated infection via haem spread resulting in septicaemia, arthritis, tenosynovitis and skin lesions

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34
Q

How is gonorrhoea diagnosed

A
  1. NAAT
    • Uses: genital and extra-genital sites
    • >95% sensitivity for endocervical / urethral, 30-60% female urine samples
    •Urine sample: Tests GC &CT on same test
  2. Culture: sensitivity
    • Important to culture – sensitivity
    • Gram stain (gm neg diplococci), oxidase positive, uses glucose NOT maltose or fructose, commercial antibody tests
    • Antibiotic susceptibility – specific test for penicillinase activity & antibiotic discs on pure culture
  3. Microscopy
    • For cervical & male urethral samples
    • If GRAM -VE DIPLOCOCCI + SYMPTOMATIC = same day diagnosis & treatment in GUM
    • Low sensitivity & specificity = so NAAT & culture

Smear test: swab urethra, cervix, throat, rectum. Symptomatic patients / contacts: full STI screen

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35
Q

What is the treatment for GC?

A

Depends on local guidelines

Current UK guidelines
Non complicated: CEFTRIAXONE stat & AZITHROMYCIN stat (same in pregnancy)

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36
Q

What advice is given to patients with GC?

A

Abstain from SI for 1 week after Rx and until their sexual partner has been treated

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37
Q

What is the follow up for GC?

A

followed up at GUM as symptomatic improvement with Rx does not guarantee eradiaction
to exclude resistant infection or re-infection specific culture media is necessary

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38
Q

Which HPV types cause external genitalia warts?

A

HPV 6 and 11

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39
Q

Which HPV type cause cervical cancer?

A

HPV 16 and 18

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40
Q

How is HPV transmitted and how long is the incubation period?

A

Close physical contact (skin-skin)

Incubation period: 3-18m

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41
Q

What are the signs and symptoms of EGW?

A

genital lumps: hard or soft/ solitary - multiple
bleeding, usually urethral
itchy
hyperpigmentation (sometimes)

Sites for females: vulva, peri-anal region, cervix, vagina (less freq), urethra (infreq)

Sites for males: penis =/- urethra in perianal region (not gay/bi)

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42
Q

National cervical screening programme

A

All woman 25 years and over should be encouraged to have cervical screening every 3 months

43
Q

What is the diagnosis for EGW?

A

Clinical Dx: appearance of genital warts, itch

Biopsy if pigmentation, ulceration, atypical appearance, failure to respond to Rx

44
Q

What is the treatment for EGW?

A

eradicate visible warts, but it can still remain infectious in absence of visible warts

Simple external warts:
podophyllotoxin cream (or soln)
•	Avoid in pregnancy
•	Reduce adverse reactions by carefully explaining
•	weekly cryotherapy – used in pregnancy

Cervix = colposcopy
Oral warts = cryotherapy

45
Q

Differential Dx for genital lumps:

A 
o	Molluscum contagiosum
o	Coronal/vulval palpillae
o	Sebaceous cysts
o	Scabies (if chronic)
o	Normal anatomical variance
46
Q

What are the useful indicators for PID?

A
  1. Young <25 yo
  2. Sexual activity : Recent partner change, Non-barrier contraceptive
  3. Cervical instrumentation:
    • TOP
    • Recent IUD change (within 3 weeks)
    • Recent miscarriage
47
Q

What causes PID:

A

Ascending infection from endocervix

1) Chlamydia : specific tests often negative
2) Gonorrhoea : 30% also have Chlamydia
3) Anaerobes: usually secondary to damage following above
4) Mycoplasma/ureaplasma
5) Streptococci = post-surgical, but must exclude G/C

48
Q

What are the signs and symptoms of PID?

A

Symptoms:

  1. Pelvic pain: constant / intermittent
  2. Deep dyspareunia
  3. Irregular menses
  4. Intermenstrual/post-coital bleeding
  5. Vaginal discharge

Signs:

  1. Cervical excitation: cervical motion tenderness
  2. Adnexal discomfort
  3. Pyrexia (unusual in chronic infection)
49
Q

What are the complications of PID?

A
  • Chronic pelvic pain
  • Ectopic pregnancy
  • Infertility
  • Abscess form
  • Peri hepatitis

Lower risk of Cx if NO TREATMENT DELAY - treat within 3 days of presenting, less when infection is mild

50
Q

How is PID diagnosed?

A

Syndrome based on clinical diagnosis
1. bi-manual exam = MUST
• have a low diagnostic threshold
• over diagnose & over treat

  1. endocervical NAAT
    • identifies GC & CT
    • chlamydia is IC, so samples must contain cellular material
    • swabs must be inserted inside the cervical os & rotated against endocervix
  2. endocervical swab for microscopy
    • look for pus cells on gram stain = cervicitis
  3. Urinalysis, pregnancy test, MSU specimen – exc DDx
  4. pelvic US/laproscopy
    • fail to respond to Tx
51
Q

What is the treatment for PID

A

Low threshold for empiric Tx of PID

Out-patient treatment for mild PID
DOXYCYCLINE 100MG BD (14 d) + METRONIDAZOLE 400mg BD (5-7d)

Or

OFLOXACIN (14 d) + METRONIDAZOLE
(14 d)

Alternative : Erythromycin (14d) + metronidazole (5-7 d)

PREGNANCY: AZITHROMYCIN stat & for 10 days, metronidazole for 7 days

if nauseous, attempt to treat orally, stop metronidazole & give anti-emetics

if IUD present, only remove if not responding to treatment, and other causes of pain have been excluded

52
Q

What treatment is offered to sexual contacts?

A

Empirical Rx for CT
AZITHROMYCIN 1g PO

due to the variable sensitivity of current diagnostic tests

53
Q

Differential diagnosis for PID:

A
  • ectopic = must exclude 1st
  • endometriosis, ovarian cysts
  • IBS, Appendicitis
  • Uterine cramps related to insertion of an IUD
54
Q

What organism causes genital herpes?

A

HSV 1 and 2

55
Q

How is HSV transmitted?

A

Both types transmitted by mouth & genitals

HSV 1 – usually causes oral lesions, but can cause genital lesions

HSV 2 –usually sexually transmitted

ONLY can be transmitted when an already infected individual is shedding the virus, can be asymptomatic 0 ASYMPTOMATIC SHEDDING

56
Q

What is the clinical presentation of herpes simplex virus?

A

Severe 1ary attack( new infection) or 1st clinical episode (acquired herpes in the past, recent Sx)
• Within 2-12 days for max 3 weeks
• 70-80% asymptomatic

Febrile illness lasting 5-7 days (prodrome)
MOST COMMON CAUSE OF UCLERS -painful
May also get tingling/soreness at the site of a subseq ulcer
Dysuria, urinary frequency
Painful inguinal lymphadenopathy
Neuropathic pain = tingling, burning in genital area, buttocks, legs
Genital blisters and fissures

Untreated 1st episode may last 3wks or more

57
Q

What are the complications of herpes simplex virus?

A

Usually occurs in 1st episode, and decreased risk if antiviral Tx given:
• Acute urinary retention (mostly women)
• Constipation: may be a risk with 1st episode peri-anal disease
• Aseptic meningitis

58
Q

What is the clinical course of herpes simplex virus?

A

Neuropathic prodrome: tingling, burning in genital area, buttocks, legs
Erythema, blisters, fissures,
resolves in 3-4 days

59
Q

How is HSV diagnosed?

A
  • Asap in acute episode
  • Swabs for HSV PCR: Tx should not be delayed if these are not available. Negative test = does not exclude herpes (may be too late)
  • HSV serology = only in pregnancy
60
Q

How is HSV treated?

A 
Primary 1st episode
If within 5 days of lesion developing:
•	Aciclovir for 5 days
•	Valaciclovir
•	Famciclovir
Bathing in dilute saline soln: reduces symptoms, secondary infection, inc healing
Counselling

Recurrent episode: saline washes, vaseline to lesions, simple analgesia

Frequent/prolonged episode: 6+/yr or prolonged (>4d) may benefit from suppressive therapy (discuss with local GUM)

61
Q

What are the guidelines for HSV and pregnancy?

A

prior Dx - no affect
primary attack during pregnancy at any stage = adverse outcomes

Symptomatic recurrences of genital herpes during 3rd trimester, but no lesion present at delivery = vaginal delivery is appropriate
If lesion present at onset of labour = ceasarian section

62
Q

What are the other causes of genital ulceration:

A 
Syphillis
LGV
Donavanosis
Chancroid
Behcets syndrome
63
Q

What are the common causes of urethritis?

A

N. gonorrhoea
C. trachomatis
Mycoplamsa/ureaplasmas
Trichomonas vaginalis

64
Q

What is the commonest cause of urinary symptoms in men < 35 years?

A

ASCENDING INFECTION i.e STI

65
Q

What does sterile pyuria in man suggest?

A

(presence of elevated numbers of white cells (>10 white cells/mm3) in urine which appears sterile using standard culture techniques)

Non-specific urethritis (NSU)

66
Q

What are the tests for urethritis?

A

Urethral smear for Gram stain
Urethral culture for N. gonorrhoea (Gram -ve diplococci)
NAAT for GC and CT
Urinalysis

67
Q

How is urethritis diagnosed?

A

Diagnosis of exclusion.

Gram stained urethral smear, taken at least 2 hours after the last voiding, of more than 5 leucocytes per high-powered field

68
Q

What the other causes of urethral inflammatory exudate?

A

Balanitis
Penile herpes
Urethral warts
Cystitis

69
Q

What are the complications of urethritis?

A

Epididymo–orchitis
sub-fertility
Reiter’s syndrome
Prostatitis

70
Q

What are the symptoms of urethritis?

A

dysuria/discharge

urinary frequency

71
Q

What is the treatment for urethritis?

A

Uncomplicated - first presentation
DOXYCYCLINE 100mg bd for 7 days
Azithromycin 1g stat if compliance is an issue

Alternative: erythromycin or ofloxacin

72
Q

How should recurrent/persistent NSU be treated?

A

Azithromycin for 4 days + metronidazole for 5 days

73
Q

What is epididymitis?

A

epydidimes +/- testicular inflammation
triggered by an infection agent:

  1. Chlamydia = most common cause under 35 yo
  2. Gonorrhoeae = up to 50% also have Chlamydia
  3. E.coli = enterobacetriacae = >35 yo +/- structural urinary tract abnormality
  4. M.tuberculosis (rare) = chronic epididymitis

UNDER 35 - more likely to have STI
OVER 35 - more likely to have UTI

74
Q

What are the symptoms and signs of epididymitis?

A
  • Usually unilateral but may be bilateral
  • Scrotal swelling, erythema, pain
  • O/E = unilateral testicular discomfort with tender swollen epididymis
75
Q

What are the assessments for epididymitis?

A

Sexual history, STI screen, urine dip, MSU

76
Q

What is the management for epididymitis?

A

If <35yo, more likely to have an STI, give therapy whilst waiting for results.
• If urine dip –ve & <35 yo = most likely due to chlamydia/non-gonococcal, non enteric org.
If high suspicion of GC, contact GUM

Recommended regimen
• DOXYCYCLINE for 14d
• Alternative Tx = OFLOXACIN for 14 d
+rest, analgesics and supportive undwear

If urine dip positive, over 35 yo, low suspicion of STI = treat as a complicated UTI infection
Review at 2 weeks and continue therapy for 1 month if not fully recovered. Should contact trace

77
Q

What causes molloscum contagiosum?

A

DNA pox virus etc. MCV1 most common cause

78
Q

What are the RF for MC and how is it transmitted?

A
  • Children
  • Immunocompromised
  • Atopic eczema
  • Direct skin contact
  • Sharing baths, towels, gym equip
79
Q

What are the signs/symptoms of MC?

A

• Firm, smooth umbilicated papules, usually 2-5 cm in diameter
o Lesions >15mm – AIDs
o Colour: colour of skin, white, translucent or yellow
o Typically clusters of up to 20

Children = usually on trunk/extremities

Adults = lower abdomen, inner thighs, genital region

80
Q

How is MC treated?

A
  • Usually self-limiting, clears up in 18 mo
  • Avoid scratching, sharing towels etc.
  • Other options: simple trauma(squeezing with fingernails/piercing) or Cryotherapy
81
Q

What causes syphillis?

A

Treponema pallidum entering abraded skin/intact mucuous membrane

transmitted via sexual or congenital

82
Q

Clinical presentation of PRIMARY syphillis:

A

All genital ulcers are syphilis until proven otherwise!

Primary syphillis:
incubation period - 9-90 days: INFECTIOUS

Painless hard MACULE -> painless solitary ULCER -> hard lump (CHANCRE)
•Ulcer at site of original infection (penis, vagina, rectum)
•Lymphadenopathy, but otherwise asymptomatic

83
Q

Clinical presentation of SECONDARY syphillis:

A
  • RASH affecting trunk, face, palms, soles
  • rash & papules are very infectious – most infectious
  • SNAIL TRACK ULCERS: mouth & genitalia
  • malaise, sore throat, arthralgia
84
Q

Clinical presentation of TERTIARY Syphillis:

A
  • GUMMA nodule (non-cancerous granuloma in any tissue of the body, skin testes, mucosa, bones), result due to inability of immune system to clear the infection
  • NEUROLOGICAL SYPHILLIS: either presents as abnormal CSF but no assos S+S or dorsal column loss, dementia & meningovascular inv
  • CV SYPHILLIS: aortitis, aortic regurge etc.
85
Q

DDx for primary syphillis:

A

herpes, LGV, chancroid, donovanosis

86
Q

DDx for secondary syphillis:

A

pityriasis rosea, viral exanthema

87
Q

How is syphillis diagnosed?

A

TREPONEMAL SEROLOGY TEST
ELISA: IgM if after 2 weeks (primary), IgG for late infectin after 4/5th week (both)

TPHA (T. pallidum haemagluttination test) - luorescent treponemal antivody absorbed test (FTA-abs) and T.pallidum recombinant antigen line aimmunoassay. Positive in 2ary and early latent syphillis

CARDIOLIPIN Ab (unspecific (preg, HIV, liver disease, EBV)
oeasiest way to detect 1ary syphilis, levels dec as disease progress. Venerea disease reference lab/rapid plasmin regain
88
Q

How is syphillis treated?

A

1ary/2ary/early latent:
1st line: IM BENZIATHINE BENZYLPENICILLIN
2nd line: oral azithromycin

  • Late latent: Benzathine penicillin
  • Neurosyphilis: procaine penicillin

• For all stages- pregnancy
o 1st & 2nd trimester:
o Benzathine penicillin

89
Q

What is trichomonas vaginallis?

A

Parasitic protozoan infection due to infection with flagellated anaerobic TV

90
Q

What are the symptoms of TV?

A

Asymptomatic in men
VAGINAL DISCHARGE: green/yellow, frothy, watery/maldorous fish smell (foul smell)
DYSURIA
STRAWBERRY CERVIX (cervicitis) - small petechial haemorrhages

91
Q

What are the complications of TV?

A

Fetus: pre-term delivery, low birth weight, increased mortality
Mother = increased susceptibility to HIV

92
Q

How is TV diagnosed?

A

Diagnosis – swab posterior fornix?

  1. Triple swab: chlamydia, gonorrhoea, other infection (often co-exists with G)
  2. Microscopy: motile protozoon & flagellae seen, vaginal pH >4.5
  3. Culture: GOLD STANDARD
93
Q

What is the treatment for TV?

A
  • Metronidazole for 5 days or stat dose.
  • In preg / breast feeding – use 5 day regimen
  • HIV: metronidazole 7 days
94
Q

What are the RF and transmission of candida/thrush?

A
  • Pregnancy
  • Steroids
  • Ax
  • Immunodeficiency
  • Diabetes

Sexually transmitted - unusual
Fungal overgrowth

95
Q

What are the S+S of thrush?

A
  • Vaginal discharge: Curd-like white, Clotted cream / cottage cheese, Usually doesn’t smell
  • Itchy & sore vulva – may appear red
  • Ballinits = inflammation of the glans
96
Q

How is candida diagnosed?

A

Triple swab & smear:

Microscopy
• Budding yeast spores & pseudohyphae
• pH <4.5
• Gram stained vaginal smear

Culture
• Direct inoculation onto Sabroud’s medium or into transport media, is also a commensal so results interpreted alongside clinical details

97
Q

How is candida/thrush treated?

A 
•	Clotrimazole: cream/pessary (topical) 
•	Fluconazole (oral)
Pregnancy – only use topical treatments only.
CG: nystatin, oreal imidazole
Recurrent infection: maintenance dose
98
Q

What are the causes for bacterial vaginosis?

A

Caused by overgrowth of many types of bacteria.
Usually anaerobes.
Decrease in number of lactobacilli.

NOT SEXUALLY TRANSMITTED

99
Q

What are the risk factors for BV?

A
  • IUCD
  • Vagina douching
  • Bubble baths
  • smoking
100
Q

What are the symptoms of BV?

A
  • Discharge: Offensive fishy smell, White/grey discharge (waste products of colonising anaerobes) coating the lateral walls of the vagina, Watery/malodorous discharge
  • Vaginal itch
101
Q

How is BV diagnosed?

A
  1. Whiff test
    • Add potassium hydroxide to a sample of vaginal discharge
    • +ve result = strong fishy odour produced
2.	Microscopy:
•	pH >4.5
•	cells:
o	reduced levels of lactobacilli
o	absent leucocytes
o	inc levels of other bacterial agents
o	clue cells present
•	Gram stained vaginal smear examined
  1. Culture: predom causatory
102
Q

What is the Hay/Ison criteria?

A
  • Grade 1 (normal): lactobacillus morphotypes predominates
  • Grade 2 : mixed flora, some lactobacilli present, but Gardneerella or Mobiluncus morphotypes also present
  • Grade 3 : mainly gardnerella +/- mobiluncus morphotypes
103
Q

How is BV treated?

A
  • Metronidazole for 5- 7 days (if adherence probs 2g stat)
  • Intravaginal clindamycin / metronidazole gel
  • Then oral clindamycin/tinidazole

Pregnancy: oral metronidazole, 2nd line-IV metronidazole, oral clindamycin

Sexual Health (3 decks)

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