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Dip GUM > Urethritis and Cervicitis > Flashcards

Urethritis and Cervicitis Flashcards

1
Q

Which STI is a gram -ve diplococcus

A

Neisseria gonorrhoea

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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

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3
Q

what proportion of women with gonorrhoea are asymptomatic?

A

Up to 80%

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4
Q

what proportion of men with gonorrhoea are asymptomatic?

A

Penile urethral GC - asymptomatic in ~10%

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5
Q

Treatment of gonorrhoea

A

Monotherapy - ceftriaxone 1g intramuscularly (2019 guidelines)

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6
Q

Which STI is an obligate intracellular pathogen

A

Chlamydia

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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

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8
Q

what proportion of women with chlamydia are asymptomatic?

A

70%

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9
Q

what proportion of men with chlamydia are asymptomatic?

A

50%

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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)

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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

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12
Q

What type of bacteria is gonorrhoea

A

Gram-negative diplococcus within polymorphonuclear leukocytes

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13
Q

Primary sites of infection for gonorrhoea

A

Columnar epithelium-lined mucous membranes

  • urethra
  • endocervix
  • rectum
  • pharynx
  • conjunctiva
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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

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15
Q

Symptoms and signs of penile urethral gonorrhoea infection

A

Discharge

Dysuria

Mucopurulent urethral discharge

Rarely - testicular / epididymal pain + tenderness + swelling

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16
Q

Symptoms and signs of Female urethral gonorrhoea infection

A

dysuria

Without urinary frequency

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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

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18
Q

Symptoms and signs of rectal gonorrhoea infection

A

Most asymptomatic

Anal discharge

Perianal/ anal pain or discomfort

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19
Q

What proportion of cisgender women with urogenital gonorrhoea also have rectal gonorrhoea irrespective of history of anal sex

A

1/3

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20
Q

Symptoms and signs of pharyngeal gonorrhoea infection

A

Most asymptomatic

Occasionally - sore throat

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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

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22
Q

What is disseminated gonorrhoea?

A

Untreated gonorrhoea

Haematogenous dissemination causing skin lesions, arthralgia, arthritis and tenosynovitis

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23
Q

Sensitivity of microscopy of urethral or meatal swabs of penile urethral discharge

A

90–95%

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24
Q

Sensitivity of microscopy of urethral or meatal swabs for people without penile urethral discharge

A

50–75% not recommended

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25
Q

Window period for gonorrhoea testing

A

2 weeks Infection cannot be ruled out in individuals who test within two weeks of sexual contact

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26
Q

What is the main role of culture testing for gonorrhoea

A

Antimicrobial susceptibility testing

Take culture samples at time of NAAT sample or prior to treatment

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27
Q

Sensitivity of gonorrhoea NAATs test in asymptomatic patients

A

>95% - in both symptomatic and asymptomatic infection

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28
Q

Sensitivity of microscopy of female urethral or endocervocal swabs

A

female urethral - 20%

endocervical - 37–50%

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29
Q

Advice re abstaining after treatment of gonorrhoea

A

abstain until seven days after they and their partner(s) have completed treatment

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30
Q

Indications for gonorrea treatment

A

Microscopy identification of intracellular Gram-negative diplococci

Positive culture

Confirmed positive NAAT

Sexual partner of confirmed case of gonococcal infection

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31
Q

Treatment of gonorrhoea in pregnant patients

A

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)

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32
Q

Treatment of gonorrhoea in HIV-positive individuals

A

manage as per HIV-negative individuals

Ceftriaxone 1g IM STAT monotherapy

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33
Q

partner notification timeframes for GC

A

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

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34
Q

When is a test of cure indicated for gonorrhoea

A

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
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35
Q

reporting guideline for treatment failure for GC

A

Possible cases of ceftriaxone treatment failure in England should be reported to Public Health England

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36
Q

treatment regimen for Gonococcal conjunctivitis

A

Ceftriaxone 1g IM STAT mono-therapy

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37
Q

Treatment of Gonococcal PID

A

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

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38
Q

Treatment of uncomplicated ano-genital and pharyngeal gonorrhoea infection in adults when antimicrobial susceptibility is not known prior to treatment

A

Ceftriaxone 1g IM STAT mono-therapy

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39
Q

Treatment of gonorrhoea in breastfeeding patients

A

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)

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40
Q

When is Epidemiological treatment indicated for sexual contacts of gonorrhoea

A
  • 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)
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41
Q

Causes of a positive GC TOC

A

Treatment failure Reinfection

Residual non-viable organism

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42
Q

Treatment for Gonococcal epididymo-orchitis

A

Ceftriaxone 1g IM STAT mono-therapy

AND

the regimen chosen to treat epididymo-orchitis

Doxycycline 100mg by mouth twice daily for 10-14 days

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43
Q

Treatment of uncomplicated ano-genital and pharyngeal gonorrhoea infection in adults when antimicrobial susceptibility is known prior to treatment

A

Ciprofloxacin 500mg PO STAT

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44
Q

Prevalence of ciprofloxacin resistance in the UK

A

36.4% in 2017

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45
Q

Alternative treatment regimens for uncomplicated ano-genital and pharyngeal gonorrhoea infection in adults

A

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)
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46
Q

Why may Alternative treatment regimens for gonorrhoea be used?

A

Allergy

Needle phobia

Other absolute or relative contraindications

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47
Q

Symptoms of LGV

A

Asymptomatic infection may occur

Tenesmus

Anorectal discharge (often bloody)

Anal discomfort

Diarrhoea or altered bowel habit

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48
Q

Treatment of pharyngeal chlamydia

A

Doxycycline 100mg PO BD 7/7

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49
Q

Treatment of rectal chlamydia

A

Doxycycline 100mg PO BD 7/7

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50
Q

When is a TOC required for chlamydial infections?

A

Rectal chlamydia

Chlamydia in pregnancy

If poor compliance is suspected

Where symptoms persist

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51
Q

If a TOC is indicated after chlamydia infection how long should it be deferred after treatment?

A

at least 3 weeks

52
Q

Second line treatment for chlamydia

A

Azithromycin 1g PO STAT then 500mg OD for 2/7

53
Q

Treatment of chalmydia in Pregnancy and breast feeding

A

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
Q

What causes LGV?

A

L1, L2 and L3 serotypes of Chlamyia trachomatis

55
Q

In which patients is LGV more common?

A

MSM more common in HIV. +ve patients

56
Q

What is new variant chlamydia trachomatis

A

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
Q

Recommended management of a HIV positive patient with rectal chlamydia

A

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
Q

What is the look back period for PN for male urethral chlamydia

A

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
Q

What is the look back period for PN for females with chlamydia

A

PN for all contacts in last 6months

60
Q

What is the look back period for PN for patients with rectal or pharyngeal chlamydia

A

PN for all contacts in last 6months

61
Q

Common organisms associated with NGU

A

Chlamydia trachomatis

Mycoplasma genitalium

Ureaplasmas

Trichomonas vaginalis

Adenoviruses

Herpes simplex virus

62
Q

What are the 2 most common causative organisms of NGU And in whom are they most likely to be detected?

A

Chlamydia trachomatis

Mycoplasma genitalium

More likely to be detected in: 􏰁

  • Younger patients
  • 􏰁 patients with urethral discharge +/- dysuria
63
Q

In what % of cases with NGU is neither chlamydia nor mycoplasma detected ?

64
Q

When is pathogen negative NGU more likely?

A

Increasing patient age

Absence of discharge or clinical symptoms

65
Q

in which ethnic groups is NGU caused by trichomonas more prevalent?

A

Trichomonas vaginalis is more common in non-white ethnic groups

Uncommon in the UK

More common in men aged > 30

66
Q

What evidence is there that ureaplasmas cause NGU?

A

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
Q

What % of patients with NGU are identified as having a urinary tract infection?

A

6% ( in a single study)

68
Q

What % of patients with NGU may be caused by Adenoviruses?

A

estimated 2%–4% of symptomatic patients often associated with a conjunctivitis

69
Q

What % of patients with NGU may be caused by Herpes simplex viruses (1 and 2)?

A

uncommon cause of NGU Approx 2%–3%

70
Q

What are possible non infective causes of NGU?

A

urethral stricture

foreign bodies

friction during vigorous sex or masturbation

by getting irritants like soap into the urethra

71
Q

what are the less common organisms that have been reported as causes of NGU?

A

Epstein Barr Virus

Neisseria meningitidis

Haemophilus sp

Candida sp

Bacterial vaginosis associated bacteria

72
Q

Symptoms of NGU

A

Urethral discharge

Dysuria

Penile irritation

Urethral discomfort

Asymptomatic

73
Q

Signs of NGU

A

Urethral discharge - may or may not be noticed by the patient

Balano-posthitis

Normal examination

74
Q

Complications of NGU

A

Epididymo-orchitis

Sexually acquired reactive arthritis / Reiter’s syndrome

75
Q

Diagnostic criteria for NGU

A

5+ polymorphonuclear leukocytes per high power (􏰂1000) microscopic field

Averaged over 5 fields

on a smear obtained from the anterior urethra

76
Q

which patients should be assessed for NGU

A

Male patients with urethral discharge or balanoposthitis

77
Q

What should be used to take a penile urethral smear for microscopy?

A

5-mm plastic loop or a cotton tipped swab

(or a Dacron swab / or a Rayon swab - least preferred as more uncomfortable)

78
Q

What is a leucocyte esterase dipstick used for? When should it be carried out? 􏰁

A

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
Q

What is the recommended minimum time since passing urine to take a urethral smear in a male with suspected urethritis?

A

Optimum time is not known 2–4 hours is conventional

80
Q

Investigation of patients for NGU in settings where microscopy is not available

A

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
Q

What is the % failure rate of doxycycline to cure mycoplasma genitalium?

A

Doxycycline 100 mg BD microbiologcal failure rate up to 68%

82
Q

Which quinolones are more effective in treating mycoplasma genitalium?

A

Newer generation quinolones such as moxifloxacin have high efficacy

Early generation quinolones such as ofloxacin and ciprofloxacin are NOT highly active

83
Q

Treatment of NGU - recommended by BASHH

A

Doxycycline 100 mg BD 7 / 7

OR

Azithromycin 1 g STAT + 500mg OD 2/7

84
Q

Alternative treatment of NGU - recommended by BASHH

A

ALTERNATIVE REGIMENS - Ofloxacin 200 mg BD or 400 mg OD 7 days

85
Q

PN for NGU

A

All sexual partners at risk should be assessed and offered epidemiological treatment

Look back recommended = 4 weeks for symptomatic men

86
Q

Define persistent NGU

A

Persistent NGU = symptoms do not resolve following treatment Occurs in 15%–25% of patients after initial treatment

87
Q

Define recurrent NGU

A

Recurrent NGU = recurrence of symptomatic urethritis occurring 30–90 days following treatment of acute NGU

Occurs in 10%–20% of patients

88
Q

aetiology of persistent NGU

A

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
Q

What is recommended regarding re-treatment of female partners of men with Persistent or recurrent NGU

A

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
Q

Treatment regimen for Persistent or recurrent NGU

A

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
Q

Management before re-treatment for persistent or recurrent NGU

A

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
Q

Management of continuing symptoms of NGU after second treatment

A

Limited evidence

Moxifloxacin 400 mg PO OD 7-14/7

93
Q

Differential diagnosis of continuing symptoms of NGU after second treatment

A

Chronic abacterial prostatitis

Chronic pelvic pain syndrome

Psychosexual causes

94
Q

Is doxycycline recommended for Post Exposure Prophylaxis for STIs?

A

Not endorsed by BASHH or PHE

Any potential benefits are outweighed by the considerable potential to select resistance

95
Q

What is the smallest known self-replicating bacterium?

A

Mycoplasma genitalium

96
Q

Why is Mycoplasma genitalium not visible with gram stain?

A

It lacks a cell wall

97
Q

Why do we not use culture to detect Mycoplasma genitalium

A

The organism is fastidious typically requires weeks or months to culture.

98
Q

risk factors for mycoplasma genitalium infection

A

younger age

non-white ethnicity

smoking

increasing number of sexual partners

99
Q

What is the prevalence of mycoplasma genitalium in men with NGI?

100
Q

Mycoplasma genitalium in women may be liknked to which symptoms or conditions

A

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
Q

Does asymptomatic mycoplasma genitalium infection need treatment?

A

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
Q

symptoms of mycoplasma genitalium in males

A

None – the majority are asymptomatic

Urethral discharge

Dysuria

Penile irritation

Urethral discomfort

Urethritis (acute, persistent, recurrent)

Balanoposthitis (in one study)

103
Q

Complications of mycoplasma genitalium in males

A

Sexually acquired reactive arthritis

Epididymitis

104
Q

symptoms of mycoplasma genitalium in females

A

None – the majority are asymptomatic

Dysuria

Post-coital bleeding

Painful inter-menstrual bleeding

Cervicitis

Lower abdominal pain

105
Q

Complications of mycoplasma genitalium in females

A

Pelvic inflammatory disease

Tubal factor infertility (uncertain association)

Sexually acquired reactive arthritis

Pre-term delivery

106
Q

Recommendations for testing for mycoplasma genitalium

A

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
Q

Diagnosis of mycoplasma genitalium

A

NAATs for Mycoplasma genitalium

  • men - first void urine
  • women - VVS

And test for macrolide resistance

108
Q

Window period for mycoplasma genitalium

A

No data on the incubation period for Mycoplasma genitalium

109
Q

What proportion of mycoplasma genitalium in the UK is resistant to macrolines

A

Macrolide resistance in the UK is estimated at

40%

110
Q

What is the eradication rate of mycoplasma genitalium when treated with doxycycline

111
Q

recommended treatment regimen for uncomplicated mycoplasma genitalium

A

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
Q

when treating mycoplasma genitalium what is the advice regarding the timeframe for starting azithromycin after the doxycycline

A

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
Q

recommended treatment regimen for complicated mycoplasma genitalium e.g. PID or epididymo-orchitis

A

moxifloxacin 400mg PO OD 14-day regimen

114
Q

PN for mycoplasma genitalium

A

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
Q

Alternative regimens for mycoplasma genitalium

A
  • 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
Q

Treatment of mycoplasma genitalium in pregnancy

A

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
Q

Treatment of mycoplasma genitalium in breastfeeding women

A

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
Q

advice re Test of Cure and follow up for mycoplasma genitalium

A

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
Q

Treatment of disseminated gonorrhoea

A

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
Q

Window period for chlamydia testing

121
Q

What % of patients with positive GC tests are co-infected with chlamydia

122
Q

What is the purpose and indication of GC culture

A

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
Q

what are the considerations for GC testing in patients with genital reconstruction surgery

A

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
Q

Symptoms of adenovirus urethritis

A

Dysuria

Meatitis

Conjunctivitis

+/- constitutional symptoms ( fever, coughs, sore throats)

125
Q

what types of adenovrius exist

which types have been linked with urethritis

A

47 serotypes

types 8 / 19 / 37 have been isolated from patients with urethritis / cervicitis / genital ulcers

126
Q

risk factors for adnovirus uretheitis

A

More common in autumn / winter

Associated with receiving oral sex

Dip GUM (27 decks)

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