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Y4 Obstetrics and Gynaecology > 21 - STI's 1 > Flashcards

21 - STI's 1 Flashcards

1
Q

What STI screening should you do for an asymptomatic patient?

A

Woman

  • Self taken vulvo vaginal swab NAAT for C+G
  • Bloods for Syphilis, HepB/C, HIV
  • Urinalysis/Pregnancy test where appropriate

Man

  • First pass Urine for dual NAAT for C+G
  • Bloods for Syphilis, HepB/C, HIV
  • May need Triple Swabs inc rectal and pharyngeal swabs if MSM
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2
Q

What STI screening should you do for a symptomatic patient?

A

Woman

  • High Vaginal Swab for microscopy and pH. TV, BV, Candida
  • Vulvovaginal Swab for NAAT for C+G
  • Bloods
  • Urinalysis and Pregnancy test if requested

Man

  • Urethral smear GC culture
  • First Pass Urine for C+G
  • BBV Bloods
  • Triple swabs inc pharyngeal and rectal if MSM
  • Consider Candia and Herpes swabs
  • Urine dip
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3
Q

What are the three methods of partner notification?

A

ALWAYS REASSURE PATIENT IT WILL BE ANONYMOUS

  • Patient referral: e.g contact card, text, instagram
  • Provider referral: GUM clinic contact them
  • Contract referral: Pt has agreed time frame to tell partner and if they don’t then GUM will tell them
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4
Q

What are the three methods of partner notification?

A
  • Patient referral: e.g contact card, text, instagram
  • Provider referral: GUM clinic contact them
  • Contract referral: Pt has agreed time frame to tell partner and if they don’t then GUM will tell them
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5
Q

How far do you need to look back for a chlamydia infection for partner notification?

A

6 months

For gonorrhoea it is 3 months

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6
Q

How long should partner notification take at maximum for HIV?

A

3 months, ideally should be within 4 weeks

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7
Q

How do you assess for BBV?

A
  • Paid for sex?
  • IV drug user or had sex with IV drug user?
  • Had sex with somebody not in this country?
  • Sex with bisexual man or man who has sex with men?
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8
Q

What is the pathophysiology and causative organism of BV?

A

Gardnerella Vaginalis

Overgrowth of anaerobic vaginal flora due to loss of lactobacilli

Lactobacilli usually produce lactic acid to keep pH<4.5, when pH raises over>4.5 allows anaerobic bacteria to grow

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9
Q

What are some risk factors for developing BV?

A
  • Multiple sexual partners
  • Excessive vaginal cleaning (douching, vaginal washes)
  • Recent antibiotics
  • Smoking
  • Copper coil
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10
Q

How does BV present?

A
  • Asymptomatic
  • Thin grey discharge
  • Fishy odour to discharge
  • Dysuria
  • Dyspareunia
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11
Q

How is BV diagnosed?

A

Ix: Speculum, Lateral wall pH, high vaginal charcoal swab, STI screening

Amsel Criteria (3 of 4 need to be met)

  • Vaginal pH > 4.5
  • Typical discharge
  • Positive whiff-amine test: development of fishy odour with addition of 10% potassium hydroxide to vaginal discharge
  • Clue cells (on microscopy): vaginal epithelial cells studded with adherent coccobacilli
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12
Q

How is BV treated?

A

Metronidazole or Clindamycin

Only treat if symptomatic or if pregnant and having TOP!!!!

  • Reduce risk factors
  • Oral or intravaginal gel metronidazole for 5-7 days,
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13
Q

What are some of the complications with BV?

A
  • Increased risk of STIs
  • Post surgical infections
  • Pregnancy issues: Miscarriage, Preterm deliver, Premature rupture of membranes, Chorioamnionitis, Postpartum endometritis
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14
Q

What is the pathophysiology/risk factors for vulvovaginal candidiasis?

A

Candida Albicans (yeast/fungi)

  • Oestrogen exposure
  • Immunocompromised state (e.g. systemic corticosteroids)
  • Poorly controlled diabetes mellitus
  • Broad-spectrum antibiotic use: alters the vaginal flora
  • Vaginal Hygiene Products
  • Sexual activity
  • Hormone replacement therapy (HRT)
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15
Q

What are some signs and symptoms of thrush?

A

Symptoms

  • Vaginal itching and soreness
  • Thick white discharge with no odor
  • Superficial dyspareunia
  • Dysuria

Signs

  • Vulvovaginal irritation
  • Vaginal fissuring
  • Excoritation
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16
Q

How is candidiasis investigated and managed?

A

Ix

  • Diagnosis can be made on history alone
  • Can do vaginal examination
  • Can do whiff test, vaginal swab, HbA1c, STI screen, HIV screen if not sure

Mx

  • Intravaginal clotrimazole cream or pessary
  • Single dose oral Fluconazole
  • Topical Clotrimazole 2-3 times per day for vulval symptoms
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17
Q

When using anti fungal vaginal creams and pessaries, what information do you need to give a woman?

A

Can damage latex condoms so need additional contraception for at least 5 days after use

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18
Q

How is recurrent thrush treated? (4 or more episodes in one year)

A

Induction Maintenance Regime

  • Confirm treatment course and adherence
  • Reassess risk factors e.g HbA1c
  • Consider alternative diagnosis e.g BV or STI
  • Consider alternative treatment
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19
Q

What is the pathophysiology and causative organism of Trichomoniasis?

A

Trichomonas Vaginalis - Protozoa with flagella

Most common non-viral STI worldwide

Is passed by sexual contact, never MSM though

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20
Q

What are the signs and symptoms of Trichomoniasis?

A

Symptoms

  • Asymptomatic
  • Frothy green-yellow discharge
  • Vulval itching or soreness
  • Malodorous
  • Dysuria
  • Abdominal pain

Signs

  • Women:
    • Frothy green-yellow discharge
    • Vulval inflammation
    • Cervical inflammation (often described as ‘strawberry cervix’)
  • Men:
    • Usually no signs
    • Rarely balanitis
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21
Q

How is trichomoniasis investigated and diagnosed?

A

MICROSCOPY FOR DIAGNOSIS!!!!!!

  • pH test from lateral wall of vagina will show pH>4.5
  • High vaginal swab from posterior fornix for MC+S
  • First catch urine or urethral swab from men
  • STI screening for other STIs
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22
Q

How is trichomoniasis treated?

A
  • Oral metronidazole: abstain from sex for 1 week after both themselves and partner treated
  • Contact tracing: last 4 weeks needs treatment
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23
Q

What are the complications of a trichomoniasis infection?

A

Increased risk of

  • Contracting HIV by damaging the vaginal mucosa
  • Infertility
  • Bacterial vaginosis
  • Cervical and prostate cancer
  • Pelvic inflammatory disease
  • Pregnancy-related complications such as preterm delivery.
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24
Q

What is the difference between charcoal swabs and NAAT swabs?

A

Charcoal

  • Used for microscopy, culture, sensitivities and gram staining
  • Taken endocervical or high vaginal
  • Used for organisms shown on image

NAAT

  • Used to look for DNA and RNA
  • Used for gonorrhoea and chlamydia
  • Men: first catch urine or urethral swab
  • Women: endocervical, vulvovaginal or first-catch urine
  • Can also do pharyngeal and rectal if oral and anal sex
  • If test +ve for Gonorrhoea need MC+S charcoal swab to confirm
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25
Q

What organism causes Chlamydia and what are the risk factors for this?

A

Chlamydia Trachomatis (Gram Negative Bacteria)

  • Age < 25 years
  • New sexual partner
  • Unprotected sexual intercouse
  • ≥1 partner over last year
  • Concurrent STI
  • Previous STI
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26
Q

What is the National Chlamydia Screening Programme?

A

Aims to screen every sexually active person under 25 years of age for chlamydia annually or when they change their sexual partner

Everyone that tests positive should have a re-test three months after treatment to check not caught it again

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26
Q

How does chlamydia present in men and women?

A

Women

  • USUALLY ASYMPTOMATIC
  • Abnormal vaginal discharge
  • IMB or PCB
  • Deep pelvic pain
  • Dyspareunia
  • Dysuria

Men

  • Urethral discharge or discomfort
  • Dysuria
  • Epididymo-orchitis
  • Reactive arthritis
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27
Q

How is Chlamydia diagnosed and managed?

A

Ix

  • NAAT: either endocervical, vulvovaginal, urethral, first-catch urine, pharyngeal, rectal

Mx

  • Doxycycline or Azithromycin BD for 7 days
  • If pregnant then Azithromycin 1g stat then 500mg once a day for 2 days
  • Contact trace
  • Abstain from sex until treatment done or for 7 days if single dose treatment
  • Test for and treat other STIs
  • Give advice on how to avoid in the future
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28
Q

What are the complications with a chlamydia infection?

A
  • Epididymo-orchitis
  • PID
  • Chronic pelvic pain
  • Infertility
  • Ectopic pregnancy
  • Conjunctivitis
  • Lymphogranuloma venereum
  • Reactive arthritis

Pregnancy-related:

  • Preterm delivery
  • Premature rupture of membranes
  • Low birth weight
  • Postpartum endometritis
  • Neonatal infection (conjunctivitis and pneumonia)
29
Q

What is Fitz-Hugh Curtis Syndrome and how do you treat it?

A

Complication of PID, usually Chlamydia

RUQ due to Peri-Hepatitis

Treat with analgesia and antibiotics for underlying PID

30
Q

After treatment for Chlamydia do you need another test?

A
  • Test of cure not recommended if uncomplicated
  • If <25 repeat in 3 months to see if caught it again
  • If pregnant or rectal chlamydia need test of cure three weeks after treatment
31
Q

What is Lymphogranuloma Venereum?

A

Caused by Chlamydia Trachomatis

Usually occurs in MSM population

Penile papule that turn into shallow ulcers

32
Q

What are the different stages of Lymphogranuloma Venereum?

A

Chlamydia trachomatis serovars L1/L2/L3

Primary Stage: painless ulcer on penis, vagina or rectum

Secondary Stage: lymphadenitis, swelling, inflammation and pain in the inguinal and femoral lymph nodes. Groove sign!!!!

Tertiary Stage: inflammation of the rectum (proctitis) and anus. Leads to anal pain, tenesmus, change in bowel habits and anal discharge

33
Q

How is Lymphogranuloma Venereum diagnosed and managed?

A

Ix

  • NAAT: ideally from base of shallow ulcer, if not do urethral/rectal/first catch urine
  • Histology
  • Serology

Mx

  • Three week (21 days) course of doxycycline
  • Avoid sex during treatment
  • Contact trace over past 4 weeks - 3 months
34
Q

What are the complications if LGV is left untreated?

A
  • Lymphoedema
  • Fistulae
  • Strictures
  • Disfiguring fibrotic scarring
35
Q

Chlamydia can be spread from genitals to the eyes when genital fluid gets in contact with it. How does this present?

A

Chronic erythema, irritation and discharge lasting more than two weeks

36
Q

What is the pathophysiology and causative organism of Gonorrhoea?

A

Neisseria Gonorrhoeae (Gram Negative Diplococci)

Highest prevalence in MSM

Causes infection of mucous membranes, most notably the urethra, endocervix, rectum, pharynx and conjunctiva. Rarely, it can cause disseminated infection

Causes urethritis, endocervicitis, PID

37
Q

How do gonorrhoea infections present?

A

Men usually symptomatic, women usually aymptomatic

Women

  • Odourless purulent discharge, possibly green or yellow
  • Dysuria
  • Pelvic pain

Men

  • Odourless purulent discharge, possibly green or yellow
  • Dysuria
  • Testicular pain or swelling (epididymo-orchitis)
38
Q

What are some examples of disseminated gonococcal infections?

A
  • Meningitis
  • Endocarditis
  • Septic arthritis
  • Tendinitis
  • Fitz Hugh Curtis Syndrome
  • PID
  • Prostatitis
  • Conjuncitvitis
39
Q

How is gonorrhoea diagnosed?

A

NAAT: detect RNA or DNA of gonorrhoea. Endocervical, vulvovaginal or urethral swabs, or in a first-catch urine sample. Rectal and pharyngeal swab are recommended in all MSM

Charcoal endocervical swab: microscopy, culture and antibiotic sensitivities before initiating antibiotics. This is particularly important given the high rates of antibiotic resistance

STI screening: often confection with Chlamydia

40
Q

How is gonorrhoea managed?

A
  • If antimicrobial susceptibility unknown: intramuscular ceftriaxone
  • If micro-organism is sensitive to ciprofloxacin: oral ciprofloxacin
  • Contact trace in last 14 days
  • Abstain from sex for 7 days and treat partner
  • Test for chlamydia co-infection
  • TEST OF CURE IS NEEDED
  • Provide advice on how to avoid in future
41
Q

Is a test of cure needed with gonorrhoea?

A

YES!!!! Need NAAT if asymptomatic, culture if symptomatic

Has high antibiotic resistance, especially to Azithromycin so needs it after at least:

  • 72 hours after treatment for culture
  • 7 days after treatment for RNA NATT
  • 14 days after treatment for DNA NATT
42
Q

What are the complications with a gonorrhoea infection?

A

Opthalmia Neonatorum which can lead to sepsis and blindness in neonate

43
Q

What infection does mycoplasma genitalium cause?

A

Non-gonococcal urethritis

Mycoplasma genitalium infection may lead to:

  • Urethritis
  • Epididymitis
  • Cervicitis
  • Endometritis
  • Pelvic inflammatory disease
  • Reactive arthritis
  • Preterm delivery in pregnancy
  • Tubal infertility
44
Q

How is non-gonococcal urethritis by MG diagnosed and managed?

A

Urethritis takes longer to develop with chlamydia (two weeks) than gonorrhoea (days)

Ix

  • NAAT: vaginal and first catch urine. If positive need to check for macrolide resistance

Mx

  • Doxycycline 100mg twice daily for 7 days then
  • Don’t use azithromycin anymore due to resistance
  • Test of cure not needed
45
Q

What is pelvic inflammatory disease?

A

Inflammation and infection of the pelvic organs due to infection spreading up through the cervix

Cause of infertility and chronic pelvic pain

46
Q

What are the causes of PID?

A

Common:

  • Neisseria Gonorrhoeae (severe)
  • Chlamydia Trachomatis
  • Mycoplasma Genitalium

Less Common

  • Gardnerella Vaginalis
  • HiB
  • E.Coli
47
Q

What are some risk factors for PID?

A
  • Multiple sexual partners
  • Younger age
  • Not using condoms
  • STIs
  • Previous PID
  • IUD
48
Q

How may PID present and what examination findings will there be?

A

Symptoms

  • Pelvic or abdominal pain
  • Dysparaenuia
  • IMB or PCB
  • Fever
  • Dysuria
  • Abnormal discharge
  • RUQ pain

Examination

  • Pelvic and adnexal tenderness
  • Cervical motion excitation on bimanual exam
  • Cervicitis
  • Purulent discharge
49
Q

What investigations should you do if you suspect PID?

A

Always start empirical antibiotics before test results

  • NAAT for Gonorrhoea, Chlamydia and MG
  • High vaginal swab for BV, Trichomoniasis and Candida
  • Microscopy for pus cells
  • HIV test
  • Syphillis test
  • Pregnancy test to exclude ectopic
  • ESR/CRP
50
Q

How is PID managed?

A

START EMPIRICALLY BEFORE SWAB RESULTS

Doxycycline + Metronidazole for 14 days

plus

IM ceftriaxone

  • Need to contact trace
  • If signs of sepsis or tuboovarian abscess admit for IV antibiotics and surgical drainage
51
Q

What are some complications of PID left untreated?

A
  • Infertility
  • Sepsis
  • Abscess
  • Chronic pelvic pain
  • Fitz-Hugh Curtis Syndrome (Perihepatitis)
  • Ectopic Pregnancy
52
Q

What is Fitz-Hugh-Curtis Syndrome and how is it treated?

A

Complication of PID causing inflammation and infection of the liver capsule leading to adhesions between liver and peritoneum

RUQ and right shoulder tip pain

Mx: Laparoscopy and Adhesiolysis

53
Q

What drugs are usually used in Chemsex?

A

Sex under the influence to enhance pleasure. Usually increases risk of BBV as risky behaviour, also ask in BBV risk assessment

  • Methamphetamine
  • Mephedrone
  • GHB/GBL
54
Q

How is epididymo-orchitis treated?

A

Do US to rule out testicular torsion

Ceftriaxone 1g intramuscularly and Doxycycline 100mg twice daily for 14 days

Where Mycoplasma genitalium has been tested and identified, treatment should be guided to include an appropriate antibiotic (e.g. moxifloxacin)

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62
Q

What are the different methods of inducing labour?

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63
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64
Q

What are the two main causes of secondary PPH?

A
  • Endometritis
  • Retained products of conception
65
Q

What are some reasons for a small fetus?

A

Small when below the 10th percentile

Do US measurements like AC, Femur length, Head circumference, Umbilical Artery Doppler, Amniotic Fluid volume, MCA doppler

66
Q

What are the risks to the fetus with prematurity?

A
67
Q

How should PPROM be managed?

A
  • Do TVUS for cervical length (<15mm likely early labour)
  • Do fetal fibronectin test
68
Q

How is preterm labour without PPROM managed?

A

Magnesium Sulphate is only given if before 32 weeks gestation

69
Q

What is the risk of recurrence of OC with subsequent pregnancies?

A

50%

70
Q

What is the increase in risk of developing VTE in pregnancy compared to the general population?

A

5 FOLD

71
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Y4 Obstetrics and Gynaecology (23 decks)

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