Women's Health: urogenital conditions Flashcards
What is cystitis
Umbrella term encompassing lower urinary tract inflammation (abacterial cystitis) and infection (bacterial cystitis) affecting the bladder and sometimes the urethra.
Cystitis will often resolve spontaneously. Bacterial cystitis is considered an uncomplicated UTI; however it may progress to an upper UTI or pyelonephritis (kidney infection)
Cystitis Symptoms
- Frequency
- Urgency
- Dysuria
- Strangury
- Haematuria
- Suprapubic pain or discomfort
Change in the appearance and/or smell of urine
Acute pyelonephritis symptoms
- Fever
- Rigors
- Loin pain
- Dysuria
Nausea and vomiting
Cystitis triggering factors
- Dehydration
- Perfumed toiletries
- Spicy foods
- Sexual intercourse
- Synthetic underwear
- Smoking
Stress
cystitis risk factors
- Recent/frequent sexual activity
- History of cystitis
- Maternal history of cystitis
- Diabetes
- Postmenopausal
Pregnancy
cystitis referral
- Under 16 yrs
- Males
- Frequent episodes either due to relapse or recurrence or women with known functional or anatomical abnormalities
- Flank pain
- Fever
- Nausea and vomiting
- Pregnant women
- Diabetes
- 70 +
- Immunocompromised
- Haematuria
- Associated vaginal discharge
- Medicine induced
- Symptoms of STI
Duration longer than 5-7 days
cystitis treatment
Alkalizing agents e.g. sodium citrate or potassium citrate
Infection makes the urine more acidic and these products try and counteract the effect.
Little evidence for these products
Cautioned in renal impairment, diabetes, heart disease, hypertension, low salt diet, pregnancy and lactation
Cranberry
Lack of evidence
Interaction with warfarin
Probiotics
lack of evidence
Acute uncomplicated lower UTIs can be self limiting and delay of antibiotic treatment with provision of a back up prescription may lead to symptom resolution without antibiotic treatment. This can be used if symptoms do not improve within 48 hrs or if they worsen at any time. In practice, if patient has 3 symptoms GP will prescribe empiric therapy
Treatment of lower UTI in non pregnant women under 65 yrs
Often resolves after a couple of days
1st choice
Nitro 100mg m/r bd for 3 days
Or if resistant trimethoprim 200mg bd for 3 days
If both unsuitable
Pivmecilllinam 400mg stat then 200mg tds for 3 days
(contraindicated in penicillin allergy)
UTI practical advice
- Drinking increased quantities of water
- Use of OTC preparations and analgesics, such as paracetamol and aspirin
- Avoiding feminine hygiene sprays and deodrants, which may irritate the urethra
- Avoiding delaying micturition
- Treating constipation promptly as can increase the risk of UTIs
- Avoiding tea, coffee and other drinks that appear to precipitate an attack
- Avoiding tight fitting clothes and synthetic hoisery or underwear
- Avoiding the use of perfumed soaps, shower gels and bubble baths
- Washing after sexual intercourse
- Emptying the bladder after sexual intercourse
- Cessation of using a diaphragm for contraception as this can press on the bladder, thus preventing it from emptying completely on urination and increasing the risk of UTI s
Using condoms without spermicidal lubricant thus reducing the risk of irritation and UTI
UTI cautions
- Pregnancy
- Common in pregnancy
- Nitrofurantoin should be avoided close to term
- Trimethoprim should be avoided in first trimester
- Diabetes
- More common as sugar in the urine provides an ideal environment for bacterial growth
- At risk of renal complications- refer
- Post menopause
- Particularly prone to cystitis
If frequent may benefit from vaginal oestrogen- refer to GP
Physiological discharge
Normally white in appearance but oxidises in contact with air to become more yellow. Consists of epithelial cells from the vagina and cervix and the mucus arises mainly from the cervical glands, bacteria and fluid. The amount of discharge varies with the individual woman and changes throughout the menstrual period. It is also altered when using an IUD or hormonal contraception. Pregnant women show an increase in mucus production due to an increased vascularity of tissues. Normal discharge is non irritant and does not have strong odour
Bacterial vaginosis symptoms
- Fishy odour, which may be worse following sexual intercourse
- Thin, white discharge
- Not associated with soreness, itching or irritation
pH >4.5
BV risk factors
- Multiple sexual partners
- Early age of first sexual intercourse
- Presence of an STI
- Vaginal douching
- Use of an IUD
- Smoking
“sexually associated” not transmitted
BV treatment
Oral metronidazole 400mg bd for 5-7 days
Maybe relapsing and remitting
Balance activ Rx (lactic acid and glycogen) may be used prophylactically
chlamydia symptoms
- Purulent vaginal discharge
- Mucopurulent cervical discharge
- Intermenstrual bleeding
- Postcoital bleeding
- Dysuria
- Lower abdominal pain and tenderness in the pelvic region
Deep dyspareunia
chlamydia transmission
Sexual contact
chlamydia treatment
Antibiotics
Doxycycline 100mg BD for 7 days
Trichomoniasis symptoms
- Vaginal or urethral discharge
- Discharge varies from thin and scanty to frothy purulent and yellow in colour
- Offensive odour
- Vulval and vaginal soreness/irritation and itching
- Inflamed cervix, which may be coloured red “strawberry cervix”
- Dysuria
- Lower abdominal pain
- pH >4.5
Up to 50% can be asymptomatic
Trichomoniasis treatment
Oral metronidazole
Sexual partners should be treated aswell and screened for other STIs
Gonorrhea symptoms
Similar to those of chlamydia, except the vaginal or urethral discharge when present is thick and green or yellow in colour
* Pelvic or lower abdominal pain
* Dysuria, if urethra infected
Intermenstrual bleeding or heavy bleeding
Gonorrhoea treatment
Referred to gum clinic
* Ciprofloxacin 500mg orally as a single dose
Ciprofloxacin contraindicated in pregnancy
Ceftriaxone 1g IM injection is recommended as a single dose first line
Thrush
Thrush occurs frequently during fertile years. Much less common in prepubertal girls and postmenopausal women
Candida albicans is responsible for between 80-90% of cases. Fungus is opportunistic and carried in the bowel, under the nails, on the skin and in the vagina. Does not result in complications but can be irritating and cause considerable distress. It grows under favourable conditions to produce symptoms
Common in pregnancy. Condition improves following delivery of the baby
Thrush symptoms
- Itching and soreness of the vulva and vagina
- Dysuria and dyspareunia
- Curdy, white discharge
- Usually odourless but may be “yeasty”
- Vagina and vulva may be inflamed
pH <4.5
thrush risk factors- antibiotics
- Occurs in around 30% of women taking a course of antibiotics
- Broad spectrum antibiotics in particular may cause an attack of thrush due to a reduction in the normal commensal flora enabling candida to multiply
- Only women who are already colonized with candida are at risk of vulvo vaginal candidiasis following treatment with antibiotics
Occurs more frequently when either higher doses of antibiotics have been taken or the patient has had a repeated course
thrush risk factors- contraceptives
- Contraceptives, especially COC increase the risk of VVC
Results from studies have been inconsistent, therefore definitive conclusions cannot be made
thrush risk factors- diabetes
- Poorly controlled diabetes predisposes a woman to symptomatic VVC and warrants reassessment of her condition.
- Higher blood glucose levels may favour the growth of candida
Thrush occurring in post menopausal women should be checked out as it may be the first indication of diabetes
- Higher blood glucose levels may favour the growth of candida
thrush risk factors- sexual behaviour
- Incidence of VCC increases during the years of sexual activity
- Does not appear to be any benefit in treating asymptomatic sexual partners
- Sexual partner may be the source of infection and re infection and in certain cases treatment of a male partner is advocated
Women receiving oral sex may be at greater risk of VVC
thrush risk factors- immunosuppression
- The use of oral steroids and other immunosuppressive agents lower the body’s immune system, permitting candida overgrowth
VCC is more common in women with HIV and AIDS, with the risk increasing as time since diagnosis increases
thrush risk factors- pregnancy
- Occurs in around 30-40% of pregnant patients
- Thought that the high concentrations of reproductive hormones in pregnancy increase the glycogen content in the vaginal tissue and provide a carbon source for candida
Oestrogen enhances the adherence of candida to vaginal epithelial cells
- Thought that the high concentrations of reproductive hormones in pregnancy increase the glycogen content in the vaginal tissue and provide a carbon source for candida
thrush risk factors- tamoxifen
Women on long term treatment with tamoxifen have been shown to present with recurrent VVC
thrush risk factors- topical vaginal preparations
- Suggested that using highly perfumed vaginal preparations may cause irritation or allergy and may potentially predispose towards infection with candida.
NICE has found no evidence of local irritants such as soaps and shower gels increasing the risk of VVC
thrush treatment
- Imidazoles intravaginally- clotrimazole, econazole or miconazole
- Triazoles orally- fluconazole or itraconazole
- topical imidazoles are most commonly used in the treatment of acute VVC. To be effective, intravaginal application is required, although women should apply cream to the vulva aswell since this area is commonly affected
- A single high dose is as effective as a lower dose over several days
- Topical preparations may damage condoms
- Oral triazoles are contraindicated in pregnancy and breastfeeding
thrush referral
- More than 2 previous attacks of candidiasis in the last 6 months
- STI risk
- Pregnancy/suspected pregnancy
- Aged under 16 or over 60
- Diabetes
- Immunocompromised
- Abnormal or irregular vaginal bleeding
- Vulval/vaginal sores, ulcers or blisters
- Lower abdominal pain or dysuria
- No improvement in 7 days, despite treatment
Adverse effects from the treatment
HPV
- HPV infection is very common, it lives on the skin in and around the whole genital area, so the use of condoms cant provide complete protection from it
- Doesnt cause symptoms in many people
- Can cause painless growths or lumps around the vagina, penis or anus
- Gardasil vaccine available- given to both boys and girls aged 12-13 years
abnormal discharge practical advice
Dos
* Use water and emollient to wash the affected area
* Dry properly after washing
* Wear cotton underwear
* Avoid sex until thrush cleared if uncomfortable
Don’t
* Do not use soap or shower gels
* Do not use douches or deodrants on your vagina or penis
Do not wear tight underwear or tight fitting clothes
