Systemic presentations of STIs Flashcards
What is PID
Inflammation and infection arising from endocervix
Leading to endometritis, salpingitis, oophoritis and pelvic peritonitis.
Often due to chalmydia, gonorrhoea or BV
Symptoms of PID
Lower abdo / pelvic pain Abnormal PV discharge Deep dyspareunia Pyrexia >38 Altered bleeding - HMB, PCB, IMB He Secondary dysmenorrhoea
Outpatient treatment of PID
Ceftriaxone 1g IM STAT
and doxycycline 100mg BD 14/7
and metronidazole 400mg BD 14/7
When is hospitalisation indicated for PID
Severe infection Adnexal mass ? Abscess Sepsis Poor response to treatment Severe pain requiring strong analgesics
Cause of PID
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
Commonest cause of PID
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
What effect does insertion of an IUCD have on PID risk
increases the risk of developing PID
only for 4-6 weeks after insertion
Signs of PID
Lower abdominal tenderness - usually bilateral
Adnexal tenderness on bimanual
+/- tender mass
cervical motion tenderness
fever (>38°C) in moderate to severe disease
In which patients is the risk of PID highest?
women under 25
not using barrier contraception
new sexual partner
diagnosis of PID
Clinical
based on examination findings
Complications of PID
Fitz-Hugh Curtis syndrome
tubo-ovarian abscess
Impact of HIV on PID
May have more severe symptoms associated with PID
Respond well to standard antibiotic therapy
No change in treatment indicated
what is Fitz-Hugh Curtis syndrome
right upper quadrant pain
associated with perihepatitis
hepatic adhesions
Which patients with PID should be suspected of having a tubo-ovarian abscess
Systemically unwell
Palpation of an adnexal mass
Lack of response to therapy
Should an IUCD be removed in a patient with PID?
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
what tests are indicated for a patient with a clincal diagnosis of PID
Pregnancy test Chlamydia Gonorrhoea Mycoplasma Genitalium If moderate / severe - CRP, WCC USS if abscess / hydrosalpinx suspected
Differential diagnosis of PID
- 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
what proportion of women with acute appendicitis have cervical motion tenderness
1 / 4
Advice for women treated for PID regarding future fertility
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
Alternative treatment options for PID
Ofloxacin 400mg PO BD
AND metronidazole 400mg PO BD for 14 days
or
Moxifloxacin 400mg PO OD 14 days
treatment of M genitalium associated PID
Moxifloxacin 400mg PO OD 14 days
Inpatient treatment of PID
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
Alternative inpatient treatment of PID
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
When treating severe PID with IV therapy when can the switch to oral treatment be made
IV therapy continued until 24 hours after clinical improvement
then switched to oral
Risks associated with PID in pregnancy
uncommon
increase in maternal and fetal morbidity
Surgical Management of PID
Laparoscopy - dividing adhesions / draining pelvic abscesses
Ultrasound guided aspiration of pelvic fluid collections = less invasive
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
Timeframe for repeating mycoplasma genitalium test after treating M. gen PID
4 weeks
to ensure microbiological clearance
What empirical treatment should be offered to male sexual partners of women with PID
doxycycline 100mg BD for 1 week
What is the look back period for PN for women with PID
6 months before symptom onset
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
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
What is epididymo-orchitis
clinical syndrome
Pain, swelling and inflammation of the epididymis +/- testes
Commonest aetiology of epididymo-orchitis in under 35s
most often a sexually transmitted pathogen
such as Chlamydia or gonorrhoea
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
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
What % of men with mumps develop epididymo-orchitis
up to 40% of post-pubertal males
Mumps epidemic in 2005
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
Does mycoplasma genitalium cause epididymo-orchitis?
Yes
Test men with epididymo-orchitis for mycoplasma genitalium
What % of UK TB cases are extra-pulmonary
40-45% of TB cases in the UK
Does Ureaplasma urealyticum cause epididymo-orchitis?
Often found in men with epididymo-orchitis
BUT Evidence lacking to support causation
Symptoms of epididymo-orchitis
characteristically = unilateral scrotal pain and swelling
relatively acute onset
+/- urethritis or urethral discharge
What is the most important differential diagnosis of epididymo-orchitis
Torsion of the spermatic cord (testicular torsion)
surgical emergency
What is the timeframe for surgery for testicular torsion
testicular salvage surgery IS REQUIRED WITHIN 6 HOURS becomes decreasingly likely with time
Symptoms of mumps
headache
fever
characteristic unilateral / bilateral parotid swelling
7-10 days later - unilateral testicular swelling
+/- epididymitis
Symptoms suggestive of tuberculous epididymo-orchitis
subacute / chronic onset painless or painful scrotal swelling \+/- associated systemic symptoms of tuberculosis \+/- scrotal sinus \+/-thickened scrotal skin
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
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.
Of those with bilateral orchitis what % will have reduced fertility
13%
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
Test for confirming diagnosis of mumps epididymo-orchitis
mumps IgM / IgG serology
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
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
Treatment of epididymo-orchitis most probably due to enteric organisms
- Ofloxacin 200mg PO BD 14 days
or - Ciprofloxacin 500mg PO BD 10 days
Are corticosteroids beneficial in the treatment of acute epididymo-orchitis
no
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
Treatment of epididymo-orchitis of all causes where the patient is allergic to cephalosporins and/or tetracyclines
Ofloxacin 200mg PO BD 14 days
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
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
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
Aetiology of reactive arthritis
sterile inflammation
of synovial membrane / tendons / fascia
triggered by an infection at a distant site
usually GI or STI
What is the name of reactive arthritis caused by and STI
sexually acquired reactive arthritis
= SARA
Includes sexually acquired Reiter’s syndrome
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
Most common causes of SARA
urethritis or cervicitis
Most common = Chlamydia - 35-69% of cases
Gonorrhoeae - up to 16%
Ureaplasma urealyticum - a few cases
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
What is the implication of possession of the HLAB27 gene in relation to SARA
HLAB27 gene increases susceptibility to SARA
up to 50x
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
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
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
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
What is the mean duration of first episode of SARA
4 - 6 months
followed by full recovery
50% have recurrent episodes at variable intervals
Diagnosis of SARA
3 components.
· Typical clinical features of spondyloarthropathy.
· Evidence of genitourinary infection
· Investigation of specificity and activity of arthritis
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
Essential investigations for SARA
- STI screening HIV test ESR or CRP FBC Urinalysis
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)
Management of SARA
Treat STI Rest NSAIDS Physiotherapy Ice packs Intra-articular corticosteroid injections
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
