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Y5 O&G > Gynae Infection > Flashcards

Gynae Infection Flashcards

1
Q

What are the investigations for suspected gynae infections?

A
  • pH
    • Normal pH = 3-5-4.5
    • Low pH = candida
    • Normal pH = physiological, candida
    • Raised pH = contamination (blood, semen, lubrication), BV, TV
  • Swabs
    • Double swabs
      • Endocervical swab - gonorrhoea, chlamydia
      • High vaginal - (fungal and bacterial) BV, TV, candida, GBS
    • Triple swabs:
      • Endocervical - chlamydia
      • Endocervical – charcoal swab - gonorrhoea
      • High vaginal - fungal and bacterial (BV, TV, candida, GBS)
  • Bloods: HIV, syphilis
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2
Q

What are the general signs and symptoms of gynae infections?

A
  • Discharge – smell, consistency, colour, amount
  • Itch
  • Blood
  • FLAWS – infection, immunosuppression, cancer
  • Pain
  • Pregnant
  • Urinary symptoms – frequency, urgency, pain
  • Sexual history – partners, barrier, STIs
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3
Q

What is the diagnosis?

A

Physiological

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4
Q

What is the diagnosis?

A

Polyp

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5
Q

What is the diagnosis?

A

Ectropion

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6
Q

What is the diagnosis?

A

Candida

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7
Q

What is the diagnosis?

A

Trichomoniasis

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8
Q

What is the diagnosis?

A

Gonorrhoea

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9
Q

What is the most common cause of vaginal discharge?

A

Bacterial vaginosis

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10
Q

What are the risk factors for bacterial vaginosis?

A
  • Smoking
  • Vaginal Douching
  • Bubble Bathing
  • Sexual activity
  • New sexual partner
  • Other STIs - vaginosis isn’t a STI
  • Copper IUD
  • Vaginal pH increase
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11
Q

What are the protective factors for bacterial vaginosis?

A
  • Condoms
  • Circumcised partner
  • COCP
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12
Q

What are the signs and symptoms of bacterial vaginosis?

A
  • Asymptomatic (50%)
  • Offensive, fishy-smelling discharge
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13
Q

What are the appropriate investigations for suspected bacterial vaginosis?

A
  • Diagnosis = clinical + microscopy
  • Hay-Ison criteria or Amsel’s criteria
    • Amsel’s criteria = 3 out of 4:
      • Thin, white, homogenous discharge
      • Clue cells on microscopy
      • Vaginal pH >4.5
      • Fishy odour on adding 10% KOH
    • Hay-Ison criteria applied to gram stain
      • Grade 3 = BV
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14
Q

What is the management of bacterial vaginosis?

A
  • No treatment is needed if asymptomatic
  • 1st line – metronidazole
  • 2nd line – intravaginal clindamycin PV cream
  • Avoid vaginal douching, shower gel, use of shampoo in bath
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15
Q

What is the complication of bacterial vaginosis?

A
  • Associated with:
    • Late miscarriage
    • Preterm birth
    • PROM
    • Postpartum endometritis
  • Increases risk of acquiring and transmitting STIs
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16
Q

What is the route of transmission of trichomonas vaginalis?

A

STI - more common in developing countries

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17
Q

What are the signs and symptoms of trichomonas vaginalis?

A
  • Asymptomatic in 50%
  • Symptomatic:
    • Green/yellow “frothy” vaginal discharge
    • Vulval itch or vaginal soreness
    • Offensive odour
    • Lower abdominal pain and dysuria
    • Dyspareunia
  • O/E = strawberry cervix
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18
Q

What are the appropriate investigations for suspected trichomonas vaginalis?

A
  • High vaginal swab
  • Endocervical swabs for other STIs
  • Culture and gram stain
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19
Q

What is the management of trichomonas vaginalis?

A
  • 1st line = Metronidazole
  • 2nd line = Metronidazole
  • Contact tracing, abstinence for 7 days, follow-up
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20
Q

What are the complications of trichomonas vaginalis?

A
  • Pregnancy = PTL, LBW, PPROM
  • Enhance HIV/STI transmission
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21
Q

What are the risk factors for candidiasis?

A
  • Oestrogen exposure
  • Pregnancy
  • Reproductive years
  • Immunocompromise (HIV)
  • Diabetes (poorly controlled)
  • Recent ABx (i.e. for a UTI)
  • Intercourse
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22
Q

What are the signs and symptoms of candidiasis?

A
  • Vulva itching
  • Soreness
  • Irritation
  • ‘Cottage-cheese’-type discharge
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23
Q

What are the appropriate investigations for suspected candidiasis?

A
  • No investigations usually required
  • Diagnostic = HVS – microscopy, culture and gram stain
    • Speckled gram +ve spores, pseudohyphae
  • Other = MSU (UTIs), HbA1c (diabetes)
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24
Q

What is the management of candidiasis?

A
  • 1st line – clotrimazole pessary + 1% clotrimazole cream
  • 2nd line/Severe – fluconazole
  • General advice:
    • Avoid tight fitting synthetic clothing
    • Avoid local irritants
    • Do not wash female genitalia with soap/shower gels
    • Do not douche
  • If pregnant, only use topical treatment
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25
Q

What are the complications of candidiasis?

A
  • Hepatotoxicity associated with systemic azole antifungal therapy – monitor LFT
  • Oesophageal candidiasis or disseminated candidiasis in immunocompromised
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26
Q

What are the causes of cutaneous warts?

A

HPV infection – HPV 6 and 11

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27
Q

What subtypes of HPV cause cutaneous warts and cervical cancers?

A
  • 6, 11 → 90% of cutaneous warts
  • 16, 18 → over 70% of cervical cancers
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28
Q

What strategy can be used to prevent cutaneous warts?

A

HPV vaccine - Gardasil

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29
Q

What are the signs and symptoms of cutaneous warts?

A
  • Often asymptomatic
  • Vaginal discharge, PCB or IMB (local trauma), pain
  • Genital warts on vulva, vagina, cervix, anus
    • Generally painless but may itch or bleed or become inflamed
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30
Q

What are the appropriate investigations for cutaneous warts?

A
  • STI screen → triple swab, HIV, syphilis, HBV
31
Q

What is the management of cutaneous warts?

A
  • No treatment required in most cases - might refer to GUM if STI risk factors
  • Medical (contraindicated in pregnancy):
    • Keratinised warts → imiquimod cream
    • Non-keratinised warts → podophyllin/tri-chloro-acetic acid
  • Surgical:
    • Cryotherapy, laser, electrocautery
32
Q

What are the complications of cutaneous warts?

A
  • High-risk HPV leading to increased risk of anogenital cancers
  • Disfiguring – distress or psychosexual dysfunction
33
Q

What are the risk factors for chlamydia?

A
  • Most common bacterial STI in UK
  • Sexual history
    • Multiple sexual partners
    • No barrier use
    • History of STIs
    • Low socioeconomic status
34
Q

What are the signs and symptoms of chlamydia?

A
  • Asymptomatic in at least 70-80% of women
  • Symptomatic
    • Purulent PV discharge
    • Dyspareunia
    • IMB
    • PCB
    • Abdominal pain
    • Dysuria
  • Affects the endocervix ± urethra
35
Q

What are the appropriate investigations for suspected chlamydia?

A
  • Can treat on suspicion alone → unlike gonorrhoea
  • Direct microscopy
    • 1st (NAAT) - Urethral/Vulvovaginal swab or first catch urine
    • 2nd - Culture and sensitivities
36
Q

What is the management of of chlamydia?

A
  • Can treat on suspicion before lab results
    • 1st line – doxycycline (contra-indicated in pregnancy and breastfeeding)
    • 2nd line/Pregnant/Breastfeeding – azithromycin
  • Contact tracing (6 months)
  • Avoid sex until treatment has been completed
  • Recommend STI screen
  • Follow-up appointment by 5-weeks
37
Q

What are the complications of chlamydia?

A
  • PID - infertility, ectopic
  • Reactive arthritis
  • Fitz-Hugh-Curtis
  • Pregnancy - PTL, PPROM, post-partum endometritis
38
Q

What are the risk factors for gonorrhoea?

A
  • Unprotected sex
  • Multiple partners
  • Presence of other STI
  • HIV
  • Age<25
  • MSM
39
Q

What are the symptoms of gonorrhoea?

A
  • Asymptomatic in up to 50% patients
  • Symptomatic
    • PV discharge
    • IMB
    • PCB
    • Dysuria
    • Dyspareunia
    • Lower abdominal pain
40
Q

What are the signs of chlamydia on examination?

A
  • Speculum
    • Mucopurulent endocervical discharge
    • Easily induced endocervical bleeding
  • Bimanual Exam (assess for PID)
    • Cervical motion / adnexal tenderness
    • Uterine tenderness
41
Q

What are the appropriate investigations of gonorrhoea?

A
  • Direct microscopy - neutrophils, gram -ve diplococci → prescribe antibiotics
  • 1st (NAAT)
    • Men: first catch urine sample
    • Women: vulvovaginal swab
  • 2nd: Culture and sensitivities → prescribe antibiotics
42
Q

What is the management of gonorrhoea?

A
  • 1st line – ceftriaxone 1g
  • Empirical treatment only if recent sexual contact with confirmed gonococcal infection
  • Screening for other STIs/HIV
  • Contact tracing
  • Avoid sex for 1-week
  • Follow-up appointment 1-week later
  • Cure rate = 95% with treatment
43
Q

What are the complications of gonorrhoea?

A
  • PID - infertility, ectopic
  • Fitz-Hugh-Curtiz syndrome
  • Conjunctivitis
  • Increased HIV susceptibility
  • Disseminated disease - fever, rash, arthralgia, septic arthritis, meningitis, endocarditis
  • Vertical transmission - ophthalmia neonatorum – bilateral conjunctivitis
44
Q

What is syphilis?

A
  • A systemic infection caused by the gram -ve spirochete (Treponema pallidum)
  • Aetiology – sexual contact, blood-borne, or vertical
45
Q

What are the risk factors for syphillis?

A
  • Young (age <29 years)
  • African American
  • Use of illicit drugs
  • Infection with other STIs
  • Sex worker
46
Q

What are the signs and symptoms of primary syphilis?

A
  • Painless chancres ± local lymphadenopathy
  • Resolves in 3-8w
47
Q

What are the signs and symptoms of secondary syphilis?

A
  • 4-10w after chancre – only 25% get symptoms
    • Rough papulonodular rash (hands, feet, trunk)
    • Uveitis
    • Condylomata Lata
    • Lymphadenopathy + systemic symptoms
    • “Snail track oral ulcer”
    • Resolves in 2-12w
48
Q

What are the signs and symptoms of tertiary syphilis?

A
  • 1 to 20 years – affects 1/3rd of untreated illness
  • Gummatous syphilis - erosive skin and bone lesions
  • Cardiovascular syphilis - aortitis, aortic regurgitation (early diastolic decrescendo), heart failure
  • Neurosyphilis
    • Meningovascular (5-10 years) → ischaemia, insomnia, emotionally labile
    • General paresis (10-25 years) → dementia
    • Tabes dorsalis (15-20 years) → sensory problems, lightning pains, absent reflexes
49
Q

What are the appropriate investigations for suspected syphilis?

A
  • Microbiology
    • Dark-ground with dark-field illuminations
    • PCR
  • Serology – routine antenatal screening → detects treponemal antibodies
    • Takes 3 months for syphilis serology
    • Non-treponemal tests – high false positive rate
    • Treponemal tests - EIA, TPPA, FTA-ABS
  • Neurosyphilis
    • CT/MRI head
    • LP (raised WCC, raised protein)
    • TPPA >1: 320
50
Q

What is the management of 1st, 2nd and early latent syphilis?

A
  • Benzathine-Pen (IM, STAT)

OR

  • Doxycycline (BD, 14/7)
  • Follow-up - partner notification, repeat bloods at 3/12 (4-fold drop in RPR)
51
Q

What is the management of late latent or non-neuro 3rd stage syphilis?

A
  • Benzathine-Pen (IM, OW, 3/52)

OR

  • Doxycycline (BD, 28/7)
  • Follow-up - partner notification, repeat bloods at 3/12 (4-fold drop in RPR)
52
Q

What is the management of neurosyphilis?

A
  • Penicillin (IV, 4-hourly, 14/7)

OR

  • Doxycycline (BD, 28/7)
  • Prednisolone 24 hours before treatment to avoid Jarish-Herxheimer reaction
    • Release of proinflammatory cytokines in response to dying organisms
  • Admit mothers >22w when treating
  • Follow-up - partner notification, repeat bloods at 3/12 (4-fold drop in RPR)
53
Q

What are the complications of syphilis?

A
  • Risks in Pregnancy - benzathine penicillin greatly improves foetus outcomes
    • FGR
    • Foetal hydrops
    • Congenital syphilis
    • Stillbirth
    • Preterm birth
    • Neonatal death
54
Q

Define Pelvic Inflammatory Disease.

A

The result of ascending infection of the genital tract (endometritis, salpingitis, tubo-ovarian abscess)

55
Q

What are the most common organisms that cause of PID?

A
  • Chlamydia trachomatis
  • N. gonorrhoea
  • M. genitalium
  • M. hominis
56
Q

What are the risk factors for PID?

A
  • <25yo
  • Early age of first coitus
  • Multiple sexual partners
  • Recent new partner
  • History of STI (partner/woman)
57
Q

What are the signs and symptoms of PID?

A
  • Asymptomatic - with infertility ± chronic pelvic pain
  • Acutely
    • Bilateral lower abdominal pain
    • PV discharge
    • Fever
    • Irregular PVB
    • Dyspareunia
58
Q

What are the appropriate investigations for suspected PID?

A
  • Triple swabs - 2x endocervical, 1x HVS
  • Speculum - looks for signs of inflammation/discharge
  • Bimanual - cervical excitation, adnexal masses
    • If tubo-ovarian abscess possible, confirm with TVUSS
  • If febrile = Blood cultures, FBC, CRP
59
Q

What is the management of PID?

A
  • Assess patient for admission
    • If pyrexial (>38C) or septic
  • If managed as OP
    • 2-3 days to assess response to Abx → further follow-up in 2-4 weeks
      • Ceftriaxone 500 mg IM (single dose)
      • Doxycycline 100 mg BD (oral) for 14 days
      • Metronidazole 400 mg BD (oral) for 14 days
  • Inpatient Antibiotics
    • IV cefoxitin
    • IV doxycycline
    • IV clindamycin
    • IV gentamycin
  • Other = STI screening, contact tracing, discuss contraception, removal of any IUD, avoid sex
60
Q

What are the complications of PID?

A
  • Infertility
  • Ectopic pregnancy (paralyse cilia in Fallopian tubes)
  • Chronic pelvic pain
  • Up to 30% require hospital admissions
61
Q

What is a Bartholin’s cyst?

A
  • A Cyst or abscess of Bartholin’s gland (greater vestibular glands)
    • Overlying superinfection by Staphylococcus or GBS
    • Blockage of a duct to a gland in vagina has become infected
62
Q

What are the risk factors for Bartholin’s cysts?

A
  • Nulliparous
  • Previous Bartholin’s cyst
  • Sexually active
63
Q

What is the difference between a Bartholin’s and labial cysts?

A
  • Bartholin’s cysts may extend into the vaginal canal
  • Labial cysts will remain in the labia
64
Q

What are the signs and symptoms of a Bartholin’s cysts?

A
  • Unilateral labial swelling
  • Often asymptomatic/painless
  • Infected:
    • Abscess with cardinal signs of infection
    • Dyspareunia
    • Pain on sitting or walking
65
Q

What are the appropriate investigations for a suspected Bartholin’s cyst?

A
  • ≥40yo, consider a vulval biopsy but is a clinical diagnosis
  • If infected → MC&S from abscess – most are sterile but may help organism differentiation
66
Q

What is the management of a Bartholin’s cysts?

A
  • Conservative (if draining and patient well)
  • Incision and drainage ± Flucloxacillin (OD)
  • Marsupialisation (forming an open pouch to stop the cyst from reforming)
67
Q

What are the complications of a Bartholin’s cyst?

A
  • Rupture
  • Recurrence
68
Q

What are the high-risk HPV sub-types?

A

16 and 18 → CIN, VIN, VAIN → implicated in 70% of cervical cancers

69
Q

What are the low-risk HPV sub-types?

A

6 and 11 → benign genital warts

70
Q

What are the risk factors for HPV?

A
  • Smoking
  • Multiple sexual partners - 50% of sexually active adults have HPV
  • Unprotected intercourse
  • Immunosuppression
71
Q

What are the signs and symptoms of HPV?

A
  • Asymptomatic
  • Genital warts on vulva, vagina, cervix and anus
    • Painless - may itch/bleed ± become inflamed
    • Pink/red/brown warty papules
    • Four types – small popular, cauliflower, keratotic, flat papules/plaques
72
Q

What are the appropriate investigations for suspected HPV?

A
  • Clinical diagnosis - dermatoscope
  • Histology (biopsy) and cytology (smear)
73
Q

What is the management of HPV?

A
  • Medical
    • Imiquimod cream
    • Podophyllin/trichloroacetic acid
    • Both contraindicated in pregnancy
  • Surgical
    • Cryotherapy
    • Laser
    • Electrocautery
  • Prevention = HPV vaccine
    • Sub-types in vaccine = 6, 11, 16, 18

Y5 O&G (69 decks)

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