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Systemic presentations of STIs Flashcards

1
Q

What is PID

A

Inflammation and infection arising from endocervix
Leading to endometritis, salpingitis, oophoritis and pelvic peritonitis.
Often due to chalmydia, gonorrhoea or BV

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2
Q

Symptoms of PID

A 
Lower abdo / pelvic pain
Abnormal PV discharge 
Deep dyspareunia
Pyrexia >38
Altered bleeding - HMB, PCB, IMB He
Secondary dysmenorrhoea
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3
Q

Outpatient treatment of PID

A

Ceftriaxone 1g IM STAT
and doxycycline 100mg BD 14/7
and metronidazole 400mg BD 14/7

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4
Q

When is hospitalisation indicated for PID

A 
Severe infection
Adnexal mass ? Abscess
Sepsis
Poor response to treatment
Severe pain requiring strong analgesics
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5
Q

Cause of PID

A

usually ascending infection from endocervix
causing endometritis / salpingitis / parametritis / oophoriti / tubo-ovarian abcess / pelvic peritonitis

Common causative agents = gonorrhoea and chlamydia
Mycoplasma genitalium

Other organisms commonly found which may be implicated
Gardnerella vaginalis
anaerobes (including Prevotella, Atopobium, Leptotrichia)

Pathogen negative PID is common

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6
Q

Commonest cause of PID

A

Chlamydia = commonest identified cause

Other organisms commonly found which may be implicated
Gardnerella vaginalis
anaerobes (including Prevotella, Atopobium, Leptotrichia) Mycoplasma genitalium

Pathogen negative PID is common

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7
Q

What effect does insertion of an IUCD have on PID risk

A

increases the risk of developing PID

only for 4-6 weeks after insertion

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8
Q

Signs of PID

A

Lower abdominal tenderness - usually bilateral
Adnexal tenderness on bimanual
+/- tender mass
cervical motion tenderness
fever (>38°C) in moderate to severe disease

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9
Q

In which patients is the risk of PID highest?

A

women under 25
not using barrier contraception
new sexual partner

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10
Q

diagnosis of PID

A

Clinical

based on examination findings

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11
Q

Complications of PID

A

Fitz-Hugh Curtis syndrome

tubo-ovarian abscess

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12
Q

Impact of HIV on PID

A

May have more severe symptoms associated with PID
Respond well to standard antibiotic therapy
No change in treatment indicated

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13
Q

what is Fitz-Hugh Curtis syndrome

A

right upper quadrant pain
associated with perihepatitis
hepatic adhesions

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14
Q

Which patients with PID should be suspected of having a tubo-ovarian abscess

A

Systemically unwell
Palpation of an adnexal mass
Lack of response to therapy

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15
Q

Should an IUCD be removed in a patient with PID?

A

For mild to moderate PID - leave the IUCD in situ
review after 48-72 hours
Remove if no significant clinical improvement

decision to remove IUD balanced against the risk of pregnancy

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16
Q

what tests are indicated for a patient with a clincal diagnosis of PID

A 
Pregnancy test
Chlamydia
Gonorrhoea
Mycoplasma Genitalium 
If moderate / severe - CRP, WCC
USS if abscess / hydrosalpinx suspected
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17
Q

Differential diagnosis of PID

A
  • ectopic pregnancy
  • acute appendicitis
  • endometriosis
  • complications of an ovarian cyst e.g. torsion or rupture
  • urinary tract infection
  • irritable bowel syndrome
  • Acute bowel infection or diverticular disease
  • functional pain - longstanding symptoms
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18
Q

what proportion of women with acute appendicitis have cervical motion tenderness

A

1 / 4

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19
Q

Advice for women treated for PID regarding future fertility

A

Following treatment fertility is usually maintained
There remains a risk of future infertility / chronic pelvic pain / ectopic pregnancy
More severe disease = greater risk
Repeat episodes of PID = an exponential increase in the risk
The earlier treatment is given the lower the risk

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20
Q

Alternative treatment options for PID

A

Ofloxacin 400mg PO BD
AND metronidazole 400mg PO BD for 14 days

or

Moxifloxacin 400mg PO OD 14 days

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21
Q

treatment of M genitalium associated PID

A

Moxifloxacin 400mg PO OD 14 days

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22
Q

Inpatient treatment of PID

A 
IV ceftriaxone 2g daily 
AND IV doxycycline 100mg BD daily 
followed by 
PO doxycycline 100mg BD 
AND PO oral metronidazole 400mg BD 
total of 14 days
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23
Q

Alternative inpatient treatment of PID

A 
IV clindamycin 900mg TDS 
AND IV gentamicin (2mg/kg loading dose)
then 1.5mg/kg TDS\
followed by 
PO clindamycin 450mg QDS 
OR PO doxycycline 100mg BD
AND  PO metronidazole 400mg BD 
total of 14 days

or IV ofloxacin 400mg BD plus IV metronidazole 500mg TDS 14 days
or IV ciprofloxacin 200mg BD plus IV doxycycline 100mg BD plus IV metronidazole 500mg TDS 14 days

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24
Q

When treating severe PID with IV therapy when can the switch to oral treatment be made

A

IV therapy continued until 24 hours after clinical improvement
then switched to oral

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25
Risks associated with PID in pregnancy
uncommon | increase in maternal and fetal morbidity
26
Surgical Management of PID
Laparoscopy - dividing adhesions / draining pelvic abscesses | Ultrasound guided aspiration of pelvic fluid collections = less invasive
27
Follow up for patients treated for PID
``` Review at 72 hours iif moderate or severe symptoms o Review at 2-4 weeks to ensure: • response to treatment • compliance with antibiotics • PN complete • repeat pregnancy test ```
28
Timeframe for repeating mycoplasma genitalium test after treating M. gen PID
4 weeks | to ensure microbiological clearance
29
What empirical treatment should be offered to male sexual partners of women with PID
doxycycline 100mg BD for 1 week
30
What is the look back period for PN for women with PID
6 months before symptom onset
31
Possible causes of epidiymo-orchitis
STIs Urinary infection Mumps Consider tuberculous epididymo-orchitis (high prevalence countries /previous TB / immunodeficiency) Behcet’s disease amiodarone treatment Rare infective causes - brucella and fungi incl candida
32
Treatment of epididymo-orchitis | Suspected STI related
If epididymo-orchitis most likely due to any STI: - Ceftriaxone 1g IM STAT AND - Doxycycline 100mg PO BD 10-14 days If most probably non-gonococcal cause could consider: - Doxycycline 100mg PO BD 10-14 days or Ofloxacin 200mg PO BD 14 days
33
What is epididymo-orchitis
clinical syndrome | Pain, swelling and inflammation of the epididymis +/- testes
34
Commonest aetiology of epididymo-orchitis in under 35s
most often a sexually transmitted pathogen | such as Chlamydia or gonorrhoea
35
Commonest aetiology of epididymo-orchitis in over 35s
most often non-sexually transmitted Gram negative enteric organisms causing urinary tract infections Risks include recent instrumentation / catheterisation
36
What additional investigations are recommended for men with epididymo-orchitis caused by gram negative enteric organisms
Further investigations of the urinary tract | anatomical or functional abnormalities are common in this group
37
What % of men with mumps develop epididymo-orchitis
up to 40% of post-pubertal males Mumps epidemic in 2005
38
risk factors for tuberculous epididymo-orchitis
rare presentation - patients from high prevalence countries - previous history of TB - immunodeficiency usually as a result of disseminated infection commonly associated with renal TB TB epididymitis - noted as a complication of BCG instillation for treatment of bladder carcinoma
39
Does mycoplasma genitalium cause epididymo-orchitis?
Yes | Test men with epididymo-orchitis for mycoplasma genitalium
40
What % of UK TB cases are extra-pulmonary
40-45% of TB cases in the UK
41
Does Ureaplasma urealyticum cause epididymo-orchitis?
Often found in men with epididymo-orchitis | BUT Evidence lacking to support causation
42
Symptoms of epididymo-orchitis
characteristically = unilateral scrotal pain and swelling relatively acute onset +/- urethritis or urethral discharge
43
What is the most important differential diagnosis of epididymo-orchitis
Torsion of the spermatic cord (testicular torsion) surgical emergency
44
What is the timeframe for surgery for testicular torsion
testicular salvage surgery IS REQUIRED WITHIN 6 HOURS becomes decreasingly likely with time
45
Symptoms of mumps
headache fever characteristic unilateral / bilateral parotid swelling 7-10 days later - unilateral testicular swelling +/- epididymitis
46
Symptoms suggestive of tuberculous epididymo-orchitis
``` subacute / chronic onset painless or painful scrotal swelling +/- associated systemic symptoms of tuberculosis +/- scrotal sinus +/-thickened scrotal skin ```
47
Signs of epididymo-orchitis
Tenderness to palpation Palpable swelling of epididymis - starting with tail at the lower pole - spreading towards the head +/- involvement of the testicle ``` Possibly o urethral discharge o secondary hydrocoele o erythema / oedema of the scrotum o pyrexia ```
48
Complications of epididymo-orchitis
More common in uropathogen related epididymo-orchitis than STI causes • Reactive hydrocoele • Abscess formation • Infarction of the testicle • Infertility - poorly understood relationship Mumps epididymo-orchitis can lead to testicular atrophy.
49
Of those with bilateral orchitis what % will have reduced fertility
13%
50
Diagnosis of epididymo-orchitis and cause
STI testing • Gram stained urethral smear • Urethral swab for gonorrhoea culture • FPU or urethral swab for NAATs - gonorrhoea / chlamydia • MCS of MSU for bacteria • urine dipstick - nitrite and leucocyte KUB USS + urologist RV - if confirmed UTI cause
51
Test for confirming diagnosis of mumps epididymo-orchitis
mumps IgM / IgG serology
52
Investigation for tuberculous epididymo-orchitis
3x early morning urines for AAFB - not always positive in TB epididymitis IV urography renal tract USS biopsy of the site CXR to exclude / confirm co- existing respiratory involvement
53
General advice for management of epididymo-orchitis
Rest Analgesia Scrotal support NSAIDs Abstain from sexual intercourse until they and partner(s) completed treatment and follow-up - if STI cause
54
Treatment of epididymo-orchitis most probably due to enteric organisms
- Ofloxacin 200mg PO BD 14 days or - Ciprofloxacin 500mg PO BD 10 days
55
Are corticosteroids beneficial in the treatment of acute epididymo-orchitis
no
56
Treatment of severe epididymo-orchitis or epididymo-orchitis with features of sepsis
in-patient management fluid and electrolytes IV antibiotics - cefuroxime 1.5g TDS +/- Gentamicin for 3-5 days
57
Treatment of epididymo-orchitis of all causes where the patient is allergic to cephalosporins and/or tetracyclines
Ofloxacin 200mg PO BD 14 days
58
PN for epididymo-orchitis
Partner notification and empirical treatment for all patients with epididymo-orchitis due to gonorrhoea / chlamydia / NGU or / indeterminate aetiology and MSU negative
59
Follow-up of epididymo-orchitis
Review at 3 days If no improvement - review diagnosis and therapy re-evaluated Further follow-up at 2 weeks - assess compliance, PN and improvement of symptoms. TOC if GC +ve If minimal improvement in swelling - arrange USS or surgical assessment
60
Differential diagnosis in suspected epididymo-orchitis which does not improve with antibiotics
``` testicular ischaemia / infarction testicular / epididymal tumour alternative infectious aetiologies - TB, mumps or rarer infective cause non-infective causes progression to an abscess ```
61
Aetiology of reactive arthritis
sterile inflammation of synovial membrane / tendons / fascia triggered by an infection at a distant site usually GI or STI
62
What is the name of reactive arthritis caused by and STI
sexually acquired reactive arthritis = SARA Includes sexually acquired Reiter’s syndrome
63
What is Reiter’s syndrome
the triad of urethritis, arthritis and conjunctivitis +/- other cutaneous / mucous membrane lesions - keratoderma blennorrhagic / circinate balanitis/vulvitis, uveitis / oral ulceration / cardiac or neurological involvement
64
Most common causes of SARA
urethritis or cervicitis Most common = Chlamydia - 35-69% of cases Gonorrhoeae - up to 16% Ureaplasma urealyticum - a few cases
65
Mechanism of SARA
not fully known Immune response to uro­genital micro­-organisms Synovial fluid cultures are negative for organisms An intrasynovial immune response to the organisms occurs Intra-articular bacterial antigen has been found in the joints Synovitis is mediated by proinflammatory cytokine
66
What is the implication of possession of the HLA­B27 gene in relation to SARA
HLA­B27 gene increases susceptibility to SARA | up to 50x
67
What history may be associated with a patient with SARA
past or family history of spondyloarthritis or iritis | Sexual intercourse - usually with a new partner - within 3 months prior to the onset of arthritis
68
Symptoms of SARA
Arthritis within 30 days of sexual contact Recent urethral discharge +/- dysuria Pain +/- swelling and stiffness, at one or more joints Esp knees, ankles and feet Pain and stiffness at entheses - esp posterior / plantar aspect of the heels Enthesitis / fasciitis Painful movements - tenosynovitis Low back pain / stiffness Irritable eyes +/- redness / photophobia / reduced visual acuity Conjunctivitis Iritis is less common Systemic symptoms - malaise / fatigue / fever
69
Signs of SARA
``` Genital infection Arthritis Enthesopathy Tenosynovitis. Acute sacro­-iliitis Conjunctivitis Psoriasiform rash nail dystrophy Heart lesions usually asymptomatic - tachycardia, LV dilatation, pericarditis, aortic valve disease Renal pathology - proteinuria / microhaematuria / aseptic pyuria ```
70
Complications of SARA
Majority = self­ limiting complications of SARA are principally due to aggressive arthritis - more likely with a HLA­B27 gene - chronic symptoms - Erosive joint damage - Persistent locomotor disability - cataract formation - from nadequately treated / recurrent uveitis
71
What is the mean duration of first episode of SARA
4­ - 6 months followed by full recovery 50% have recurrent episodes at variable intervals
72
Diagnosis of SARA
3 components. · Typical clinical features of spondyloarthropathy. · Evidence of genito­urinary infection · Investigation of specificity and activity of arthritis
73
General advice for the management of SARA
self­-limiting disease Avoid sexual intercourse - including oral sex - until treatment completed and follow­up for any STI Rest NSAIDS
74
Essential investigations for SARA
``` - STI screening HIV test ESR or CRP FBC Urinalysis ```
75
Additional investigations which are often useful in SARA
``` LFTS U+Es HLA­B27. X­rays - affected joints + sacro­iliac joints. ECG. Echo ``` Ophthalmic evaluation including slit lamp sometimes useful - Blood cultures. - Stool culture (if enteritic ReA is suspected). - USS of affected joints / entheses. - MRI of sacro­iliac joints - Synovial fluid analysis - cell count / Gram stain / crystals / culture. - Synovial biopsy - Exclusion tests - rheumatoid factor / autoantibodies (SLE) / plasma urate (gout), CXR + serum ACE level (sarcoidosis)
76
Management of SARA
``` Treat STI Rest NSAIDS Physiotherapy Ice packs Intra-a­rticular corticosteroid injections ```
77
Management of moderate / severe SARA | or failure of first line treatment
- Systemic corticosteroids +/- osteoporosis prophylaxis. - Sulphasalazine / Methotrexate / Azathioprine - If disabling symptoms persist 3+ months or erosive joint damage - Gold salts and ­D-penicillamine - occasionally used for persistent polyarthritis - Biological agents - TNF alpha blockers - use for treating ReA is anecdotal - possible they may re­activate the infective trigger

Dip GUM (27 decks)

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