Urethritis and Cervicitis Flashcards
1
Q
Which STI is a gram -ve diplococcus
A
Neisseria gonorrhoea
2
Q
Symptoms of gonorrhoea
A
Asymptomatic
Increased vaginal discharge
Abdo / pelivic pain
Dysuria
Urethral discharge
Proctitis / rectal bleeding
Cervical bleeding on contact
Cervical excitation
3
Q
what proportion of women with gonorrhoea are asymptomatic?
A
Up to 80%
4
Q
what proportion of men with gonorrhoea are asymptomatic?
A
Penile urethral GC - asymptomatic in ~10%
5
Q
Treatment of gonorrhoea
A
Monotherapy - ceftriaxone 1g intramuscularly (2019 guidelines)
6
Q
Which STI is an obligate intracellular pathogen
A
Chlamydia
7
Q
Symptoms / signs of chlamydia infection
A
Asymptomatic
Vaginal discharge
Lower abdo pain
Intermenstrual bleeding
Cervical discharge
Post-coital (contact) bleeding
Dysuria
Urethral discharge
8
Q
what proportion of women with chlamydia are asymptomatic?
A
70%
9
Q
what proportion of men with chlamydia are asymptomatic?
A
50%
10
Q
Complications of chlamydia
A
PID
endometritis /salpingitis
tubal infertility
Ectopic pregnancy
Fitz-Hugh-Curtis syndrome = peri-hepatitis
Neonatal or adult conjunctivitis
Neonatal pneumonia
Sexually acquired reactive arthritis
Epididymo-orchitis (may be associated with male sub-fertility)
11
Q
Treatment of chlamydia
A
First line = Doxycycline 100mg oral BD 7d (contraindicated in pregnancy)
Second line = Azithromycin 1g STAT PO, followed by 500mg OD PO 2/7
Alternative regimens:
Erythromycin 500mg BD 10–14 days
Ofloxacin 200mg BD or 400mg OD 7days
12
Q
What type of bacteria is gonorrhoea
A
Gram-negative diplococcus within polymorphonuclear leukocytes
13
Q
Primary sites of infection for gonorrhoea
A
Columnar epithelium-lined mucous membranes
- urethra
- endocervix
- rectum
- pharynx
- conjunctiva
14
Q
mode of transmission of gonorrhoea
A
Transmission = direct inoculation of infected secretions from one mucous membrane to another
Secondary infection to other sites via systemic or transluminal spread
15
Q
Symptoms and signs of penile urethral gonorrhoea infection
A
Discharge
Dysuria
Mucopurulent urethral discharge
Rarely - testicular / epididymal pain + tenderness + swelling
16
Q
Symptoms and signs of Female urethral gonorrhoea infection
A
dysuria
Without urinary frequency
17
Q
Symptoms and signs of endocervical gonorrhoea infection
A
increased or altered vaginal discharge
mucopurulent endocervical discharge
lower abdominal pain
intermenstrual bleeding
HMB
easily induced endocervical bleeding
18
Q
Symptoms and signs of rectal gonorrhoea infection
A
Most asymptomatic
Anal discharge
Perianal/ anal pain or discomfort
19
Q
What proportion of cisgender women with urogenital gonorrhoea also have rectal gonorrhoea irrespective of history of anal sex
A
1/3
20
Q
Symptoms and signs of pharyngeal gonorrhoea infection
A
Most asymptomatic
Occasionally - sore throat
21
Q
What complications of gonorrhoea infection may occur?
A
epididymo-orchitis
prostatitis
pelvic inflammatory disease (PID)
Haematogenous dissemination - skin lesions, arthralgia, arthritis and tenosynovitis
22
Q
What is disseminated gonorrhoea?
A
Untreated gonorrhoea
Haematogenous dissemination causing skin lesions, arthralgia, arthritis and tenosynovitis
23
Q
Sensitivity of microscopy of urethral or meatal swabs of penile urethral discharge
A
90–95%
24
Q
Sensitivity of microscopy of urethral or meatal swabs for people without penile urethral discharge
A
50–75% not recommended
25
Window period for gonorrhoea testing
2 weeks Infection cannot be ruled out in individuals who test within two weeks of sexual contact
26
What is the main role of culture testing for gonorrhoea
Antimicrobial susceptibility testing
Take culture samples at time of NAAT sample or prior to treatment
27
Sensitivity of gonorrhoea NAATs test in asymptomatic patients
\>95% - in both symptomatic and asymptomatic infection
28
Sensitivity of microscopy of female urethral or endocervocal swabs
female urethral - 20%
endocervical - 37–50%
29
Advice re abstaining after treatment of gonorrhoea
abstain until seven days after they and their partner(s) have completed treatment
30
Indications for gonorrea treatment
Microscopy identification of intracellular Gram-negative diplococci
Positive culture
Confirmed positive NAAT
Sexual partner of confirmed case of gonococcal infection
31
Treatment of gonorrhoea in pregnant patients
Avoid quinolones or tetracyclines
Pregnancy does not diminish treatment efficacy.
Ceftriaxone 1g IM STAT
OR
Spectinomycin 2g IM STAT (FDA pregnancy category B - not expected to be harmful - used if no suitable alternatives)
OR
Azithromycin 2g PO STAT (only if adequate alternatives not available and known susceptible)
32
Treatment of gonorrhoea in HIV-positive individuals
manage as per HIV-negative individuals
Ceftriaxone 1g IM STAT monotherapy
33
partner notification timeframes for GC
For male symptomatic urethral infection - All partners within 2 weeks
OR
most recent partner if \>2/52 ago
For GC at all other sites or male asymptomatic urethral infection - all partners in last 3 months
34
When is a test of cure indicated for gonorrhoea
ALL patients diagnosed with gonorrhoea should be advised to return for TOC
Extra emphasis given to patients:
- With persistent symptoms / signs
- With pharyngeal infection
- Treated with non-first line treatment
- infection acquired in Asia-Pacific region
35
reporting guideline for treatment failure for GC
Possible cases of ceftriaxone treatment failure in England should be reported to Public Health England
36
treatment regimen for Gonococcal conjunctivitis
Ceftriaxone 1g IM STAT mono-therapy
37
Treatment of Gonococcal PID
Ceftriaxone 1g IM STAT mono-therapy
PLUS
regimen chosen to treat PID
first line = Doxycycline 100mg BD 14/7
AND metronidazole 400mg BD 14/7
38
Treatment of uncomplicated ano-genital and pharyngeal gonorrhoea infection in adults when antimicrobial susceptibility is not known prior to treatment
Ceftriaxone 1g IM STAT mono-therapy
39
Treatment of gonorrhoea in breastfeeding patients
Avoid quinolones or tetracyclines if breastfeeding
Ceftriaxone 1g IM STAT
OR Spectinomycin 2g IM STAT (unknown if it is excreted in breastmilk - use with caution
OR Azithromycin 2g PO STAT (only if adequate alternatives not available and if isolate known to be susceptible)
40
When is Epidemiological treatment indicated for sexual contacts of gonorrhoea
- partners who test positive for gonorrhoea
- partner presenting within 14 days of exposure (discuss - if asymptomatic could wait and repeat testing 2/52 after exposure)
41
Causes of a positive GC TOC
Treatment failure Reinfection
Residual non-viable organism
42
Treatment for Gonococcal epididymo-orchitis
Ceftriaxone 1g IM STAT mono-therapy
AND
the regimen chosen to treat epididymo-orchitis
Doxycycline 100mg by mouth twice daily for 10-14 days
43
Treatment of uncomplicated ano-genital and pharyngeal gonorrhoea infection in adults when antimicrobial susceptibility is known prior to treatment
Ciprofloxacin 500mg PO STAT
44
Prevalence of ciprofloxacin resistance in the UK
36.4% in 2017
45
Alternative treatment regimens for uncomplicated ano-genital and pharyngeal gonorrhoea infection in adults
Alternative regimens - all have been associated with treatment failure when used as monotherapy
Especially for pharyngeal infection
Use DUAL therapy with azithromycin 2g if possible
- Cefixime 400mg PO STAT + azithromycin 2g PO ( Only if IM injection contraindicated or refused)
- Gentamicin 240mg IM STAT + azithromycin 2g PO
- Spectinomycin 2g IM STAT + azithromycin 2g PO (not for pharyngeal infection)
- Azithromycin 2g PO mono-therapy (clinical efficacy doesn't always correlate with in vitro susceptibility + azithromycin resistance is high)
46
Why may Alternative treatment regimens for gonorrhoea be used?
Allergy
Needle phobia
Other absolute or relative contraindications
47
Symptoms of LGV
Asymptomatic infection may occur
Tenesmus
Anorectal discharge (often bloody)
Anal discomfort
Diarrhoea or altered bowel habit
48
Treatment of pharyngeal chlamydia
Doxycycline 100mg PO BD 7/7
49
Treatment of rectal chlamydia
Doxycycline 100mg PO BD 7/7
50
When is a TOC required for chlamydial infections?
Rectal chlamydia
Chlamydia in pregnancy
If poor compliance is suspected
Where symptoms persist
51
If a TOC is indicated after chlamydia infection how long should it be deferred after treatment?
at least 3 weeks
52
Second line treatment for chlamydia
Azithromycin 1g PO STAT then 500mg OD for 2/7
53
Treatment of chalmydia in Pregnancy and breast feeding
AVOID doxycyline and ofloxacin
- Azithromycin 1g PO STAT then 500mg OD for 2/7
OR
- Erythromycin 500mg QDS 7/7
OR
- Erythromycin 500mg BD 14/7
OR
- Amoxicillin 500mg TDS 7/7
54
What causes LGV?
L1, L2 and L3 serotypes of Chlamyia trachomatis
55
In which patients is LGV more common?
MSM more common in HIV. +ve patients
56
What is new variant chlamydia trachomatis
A variant of chlamydia trachomatis
Reported in Sweden
Has a 377 bp deletion in the cryptic plasmid
Some commercial NAATs used this region as the amplification target resulting in false-negative results.
These commercial assays have been re-designed to detect this strain
57
Recommended management of a HIV positive patient with rectal chlamydia
HIV-positive individuals with rectal chlamydial infection should be treated with 3 weeks of doxycycline
OR should have a TOC
OR can receive 7/7 treatment if they had a negative LGV test
58
What is the look back period for PN for male urethral chlamydia
Male urethral chlamydia with symptoms = PN for all contacts since,
and the 4 weeks before the onset of symptoms
Asymptomatic male urethral chlamydia = PN for all contacts in last 6 months
59
What is the look back period for PN for females with chlamydia
PN for all contacts in last 6months
60
What is the look back period for PN for patients with rectal or pharyngeal chlamydia
PN for all contacts in last 6months
61
Common organisms associated with NGU
Chlamydia trachomatis
Mycoplasma genitalium
Ureaplasmas
Trichomonas vaginalis
Adenoviruses
Herpes simplex virus
62
What are the 2 most common causative organisms of NGU And in whom are they most likely to be detected?
Chlamydia trachomatis
Mycoplasma genitalium
More likely to be detected in:
- Younger patients
- patients with urethral discharge +/- dysuria
63
In what % of cases with NGU is neither chlamydia nor mycoplasma detected ?
30%–80%
64
When is pathogen negative NGU more likely?
Increasing patient age
Absence of discharge or clinical symptoms
65
in which ethnic groups is NGU caused by trichomonas more prevalent?
Trichomonas vaginalis is more common in non-white ethnic groups
Uncommon in the UK
More common in men aged \> 30
66
What evidence is there that ureaplasmas cause NGU?
Inconsistent associations with NGU
Earlier studies did not differentiate between ureaplasma urealyticum and Ureaplasma parvum.
Increasing evidence that ONLY Ureaplasma urealyticum is pathogenic - may account for 5%–10% of cases of acute NGU
67
What % of patients with NGU are identified as having a urinary tract infection?
6% ( in a single study)
68
What % of patients with NGU may be caused by Adenoviruses?
estimated 2%–4% of symptomatic patients often associated with a conjunctivitis
69
What % of patients with NGU may be caused by Herpes simplex viruses (1 and 2)?
uncommon cause of NGU Approx 2%–3%
70
What are possible non infective causes of NGU?
urethral stricture
foreign bodies
friction during vigorous sex or masturbation
by getting irritants like soap into the urethra
71
what are the less common organisms that have been reported as causes of NGU?
Epstein Barr Virus
Neisseria meningitidis
Haemophilus sp
Candida sp
Bacterial vaginosis associated bacteria
72
Symptoms of NGU
Urethral discharge
Dysuria
Penile irritation
Urethral discomfort
Asymptomatic
73
Signs of NGU
Urethral discharge - may or may not be noticed by the patient
Balano-posthitis
Normal examination
74
Complications of NGU
Epididymo-orchitis
Sexually acquired reactive arthritis / Reiter’s syndrome
75
Diagnostic criteria for NGU
5+ polymorphonuclear leukocytes per high power (1000) microscopic field
Averaged over 5 fields
on a smear obtained from the anterior urethra
76
which patients should be assessed for NGU
Male patients with urethral discharge or balanoposthitis
77
What should be used to take a penile urethral smear for microscopy?
5-mm plastic loop or a cotton tipped swab
(or a Dacron swab / or a Rayon swab - least preferred as more uncomfortable)
78
What is a leucocyte esterase dipstick used for? When should it be carried out?
A screening test - used to detect a substance suggestive of WBCs in the urine
Used if - UTI suspected
- A patient with symptomatic urethritis and a negative urethral smear on microscopy
79
What is the recommended minimum time since passing urine to take a urethral smear in a male with suspected urethritis?
Optimum time is not known 2–4 hours is conventional
80
Investigation of patients for NGU in settings where microscopy is not available
Ideally - refer to a centre which has microscopy available
If patient does not wish to attend another clinic then diagnose based on:
- Presence of mucopurulent / purulent urethral discharge on examination
- 1+ on a leucocyte esterase dipstick on a FPU specimen
- presence of threads in a FPU specimen
81
What is the % failure rate of doxycycline to cure mycoplasma genitalium?
Doxycycline 100 mg BD microbiologcal failure rate up to 68%
82
Which quinolones are more effective in treating mycoplasma genitalium?
Newer generation quinolones such as moxifloxacin have high efficacy
Early generation quinolones such as ofloxacin and ciprofloxacin are NOT highly active
83
Treatment of NGU - recommended by BASHH
Doxycycline 100 mg BD 7 / 7
OR
Azithromycin 1 g STAT + 500mg OD 2/7
84
Alternative treatment of NGU - recommended by BASHH
ALTERNATIVE REGIMENS - Ofloxacin 200 mg BD or 400 mg OD 7 days
85
PN for NGU
All sexual partners at risk should be assessed and offered epidemiological treatment
Look back recommended = 4 weeks for symptomatic men
86
Define persistent NGU
Persistent NGU = symptoms do not resolve following treatment Occurs in 15%–25% of patients after initial treatment
87
Define recurrent NGU
Recurrent NGU = recurrence of symptomatic urethritis occurring 30–90 days following treatment of acute NGU
Occurs in 10%–20% of patients
88
aetiology of persistent NGU
Multifactorial Infectious agent identified in \<50% of cases
Mycoplasma genitalium in 20%–40%
Chlamydia in 10%–20%
Ureaplasmas may play a role in some men
Trichomonas in up to 10%
89
What is recommended regarding re-treatment of female partners of men with Persistent or recurrent NGU
historical advice was not necessary to re-treat F partners if treated appropriately initially.
Current advice, in light of mycoplasma genitalium = re-treatment of female partners is beneficial if persistent/recurrent NGU in the index case
Re-treatment should cover MG
90
Treatment regimen for Persistent or recurrent NGU
If treated with doxy first line:
- Azithromycin 1g STAT then 500 mg OD for 2/7
AND metronidazole 400mg BD for 5 days
OR
If treated with azith first line:
- Moxifloxacin 400mg OD for 10 days
AND Metronidazole 400mg BD for 5 days
91
Management before re-treatment for persistent or recurrent NGU
Ensure complete initial course of therapy Is re-infection a possible cause
Only re-treat if patient has symptoms of urethritis and either physical signs or microscopic evidence
Reassure asymptomatic patients - no further test or treatment
92
Management of continuing symptoms of NGU after second treatment
Limited evidence
Moxifloxacin 400 mg PO OD 7-14/7
93
Differential diagnosis of continuing symptoms of NGU after second treatment
Chronic abacterial prostatitis
Chronic pelvic pain syndrome
Psychosexual causes
94
Is doxycycline recommended for Post Exposure Prophylaxis for STIs?
Not endorsed by BASHH or PHE
Any potential benefits are outweighed by the considerable potential to select resistance
95
What is the smallest known self-replicating bacterium?
Mycoplasma genitalium
96
Why is Mycoplasma genitalium not visible with gram stain?
It lacks a cell wall
97
Why do we not use culture to detect Mycoplasma genitalium
The organism is fastidious typically requires weeks or months to culture.
98
risk factors for mycoplasma genitalium infection
younger age
non-white ethnicity
smoking
increasing number of sexual partners
99
What is the prevalence of mycoplasma genitalium in men with NGI?
10-20%
100
Mycoplasma genitalium in women may be liknked to which symptoms or conditions
An association is supported with
- post coital bleeding
- cervicitis
- endometritis
- PID
possible association with
- pre-term birth
- spontaneous miscarriage
Unclear - may cause epithelial cilial damage in fallopian tube and ?link with tubal factor infertility
101
Does asymptomatic mycoplasma genitalium infection need treatment?
No
Unless they are a partner of a symptomatic patient with mycoplasma genitalium in which case offer treatment to reduce the risk of re-infection in the index case.
- use the same regimen as the index patient
102
symptoms of mycoplasma genitalium in males
None – the majority are asymptomatic
Urethral discharge
Dysuria
Penile irritation
Urethral discomfort
Urethritis (acute, persistent, recurrent)
Balanoposthitis (in one study)
103
Complications of mycoplasma genitalium in males
Sexually acquired reactive arthritis
Epididymitis
104
symptoms of mycoplasma genitalium in females
None – the majority are asymptomatic
Dysuria
Post-coital bleeding
Painful inter-menstrual bleeding
Cervicitis
Lower abdominal pain
105
Complications of mycoplasma genitalium in females
Pelvic inflammatory disease
Tubal factor infertility (uncertain association)
Sexually acquired reactive arthritis
Pre-term delivery
106
Recommendations for testing for mycoplasma genitalium
In patients with:
- non-gonococcal urethritis
- signs and symptoms of PID
- current sexual partners of persons infected with M. genitalium
Consider in patients with:
- muco- purulent cervicitis
- post-coital bleeding
- epididymitis
- sexually-acquired proctitis
107
Diagnosis of mycoplasma genitalium
NAATs for Mycoplasma genitalium
- men - first void urine
- women - VVS
And test for macrolide resistance
108
Window period for mycoplasma genitalium
No data on the incubation period for Mycoplasma genitalium
109
What proportion of mycoplasma genitalium in the UK is resistant to macrolines
Macrolide resistance in the UK is estimated at
40%
110
What is the eradication rate of mycoplasma genitalium when treated with doxycycline
30-40%
111
recommended treatment regimen for uncomplicated mycoplasma genitalium
Doxycycline 100mg BD 7/7
whilst awaiting M Gen result and resistance testing
followed by
- azithromycin 1g PO STAT then 500mg PO OD for 2/7 once known sensitive
OR
Moxifloxacin 400mg PO OD 10/7
if macrolide resistant
or if azithromycin failed
112
when treating mycoplasma genitalium what is the advice regarding the timeframe for starting azithromycin after the doxycycline
Azithromycin should be given immediately after doxycycline
ideally within 2 weeks of completing doxycycline
If this is not possible then repeat the course of doxycycline prior to azithromycin
113
recommended treatment regimen for complicated mycoplasma genitalium e.g. PID or epididymo-orchitis
moxifloxacin 400mg PO OD 14-day regimen
114
PN for mycoplasma genitalium
Current partners including non-regular partners where there may be further sexual contact
should be tested and treated if positive.
To reduce the risk of re-infection
115
Alternative regimens for mycoplasma genitalium
- Doxycycline 100mg BD 7/7 then pristinamycin 1g PO QDS 10 / 7
- Pristinamycin 1g PO QDS 10/7
- Doxycycline 100mg PO BD 14/ 7
- Minocycline 100mg PO BD 14/7
116
Treatment of mycoplasma genitalium in pregnancy
Azithromycin g PO STAT then 500mg PO OD for 2/7
Moxifloxacin is contra-indicated in pregnancy
Doxycycline considered safe in the first trimester by the FDA but the BNF advises against use in all trimesters
where possible delay treatment until after pregnancy
117
Treatment of mycoplasma genitalium in breastfeeding women
Very low levels of azithromycin are detected in breast milk - risk considered to be low.
Monitor infants for SE due to effects on the GI flora including diarrhoea and candidiasis.
Doxycycline is excreted in breast milk - contraindicated - risk tooth discolouration and affects bone growth
Moxifloxacin - contraindicated in breastfeeding.
Pristinamycin - contraindicated in breastfeeding due to SE profile
118
advice re Test of Cure and follow up for mycoplasma genitalium
TOC recommended for all patients with mycoplasma genitalium even if infection initially sensitive to macrolides
Optimal time to TOC not determined - 5 weeks (not \<3 weeks)
119
Treatment of disseminated gonorrhoea
Ceftriaxone 1g IM every 24 hours
or Cefotaxime 1g IV 8 hourly
or if sensitive - Ciprofloxacin 500mg IV 12 hourly
Continue treatment for 7/7
Switch to PO after 24-48 hours
- cefixime 400mg BD / Ciprofloxacin 500mg BD / ofloxacin 400mg BD
120
Window period for chlamydia testing
2 weeks
121
What % of patients with positive GC tests are co-infected with chlamydia
19%
122
What is the purpose and indication of GC culture
antimicrobial susceptibility testing
take at the time of NAAT if suspicion of GC
Take culture from each site If NAAT +ve
take culture before treatment
123
what are the considerations for GC testing in patients with genital reconstruction surgery
GC susceptibility is related to the nature of the reconstruction
use of mucosal tissues (bowel / vaginal) = more susceptible
skin = less susceptible
urethra - remains susceptivble
GC of the neopenis is rare
124
Symptoms of adenovirus urethritis
Dysuria
Meatitis
Conjunctivitis
+/- constitutional symptoms ( fever, coughs, sore throats)
125
what types of adenovrius exist
which types have been linked with urethritis
47 serotypes
types 8 / 19 / 37 have been isolated from patients with urethritis / cervicitis / genital ulcers
126
risk factors for adnovirus uretheitis
More common in autumn / winter
Associated with receiving oral sex
127
