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PHAM02 > GUM > Flashcards

GUM Flashcards

1
Q

STI vs STD

A

STI refers to a pathogen that causes infection through sexual contact,
whereas the term STD refers to a recognisable disease state that has developed from an infection

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2
Q

STIs trasmitted non-sexually

A
  • mother to infant during pregnancy or childbirth (Gonnorhoea, HIV, syphilis and chlamydia)
  • blood transfusions
  • shared needles
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3
Q

cause of gonorrhoea

A

Neisseria gonorrhoea (bacteria)

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4
Q

cause of chlamydia

A

chlamydia trachomatis (bacteria)

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5
Q

cause of syphilis

A

treponema pallidum (bacteria)

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6
Q

cause of genital warts, cervical cancer

A

human papilloma virus HPV (virus)

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7
Q

LT complications of STIs

A

– PID
- ectopic pregnancy
- postpartum endometriosis
- infertility
- chronic abdominal pain
– adverse pregnancy outcomes (including abortion, intrauterine death, and premature delivery)
– neonatal and infant infections and blindness
– urethral strictures and epididymitis in men
– CV and neurological damage
– cancers - HPV cervical and rectal cancer
– arthritis

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8
Q

what STI has highest risk of resistance

A

gonorrhoea

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9
Q

SHS - sexual health services

A

level 1 = asymptomatic
level 2 = symptomatic
level 3 = complex/specialist

level 1&2
– GP’s
– Some pharmacies
– SRH services
– Young people’s services
– online sexual health services

level 3
- GUM and SRH (sexual and
reproductive health) services

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10
Q

general services SHS provide

A

– sexual Hx taking & risk assessment
– STI screening and Tx
– advice and supply of regular and EC
– condom distribution
– signposting to appropriate sexual health services
– sexual assault services/referral
– Hepatitis A and B vaccines & screening
– HIV screening
– cervical screening
– post-exposure prophylaxis (PEP) –specialist

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11
Q

services pharmacies can offer (level 1 SHS)

A
  • sexual health advice, signposting & campaigns
  • EHC
  • ongoing contraception via PGD or OTC
  • chlamydia screening and Tx from age 15-24
  • condom distribution via sale or C-Card
  • STI kit “click and collect” service
  • pregnancy testing
  • preconception care
  • Supply of ED Tx
  • HPV vaccine
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12
Q

highest risk groups

A
  • 15-24 years
  • people from, or who have visited countries with high
    rates of HIV +- other STIs
  • MSM
  • multiple/concurrent partners
  • early onset sexual activity previous bacterial STI
  • contact of STI
  • people with sexual partners from groups mentioned
    above
  • alcohol or substance abuse
  • IV drug use
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13
Q

principles of safe sex

A

education
- on transmission of STI’s
partner reduction
- spread of STI’s depends on the rate of change of sexual partners, esp concurrent partners
Condom
Repeat testing
- screening for asymptomatic STIs should be recommended at least annually & 3 monthly if high risk of HIV
Vaccination
- HPV, hepatitis
HIV Pre-exposure Prophylaxis (PrEP)

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14
Q

Condom distribution services (CDS)

A

C-card is the most common CDS
- targets up to age of 19yrs (24 yrs in some areas)

also involves:
* discussion around condoms (& how to use)
* safe sex
* contraception
* STIs

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15
Q

Under 13’s

A

– Not legally able to consent to sexual activity
– Document circumstances
– Discuss with Child Protection lead, and record conversation

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16
Q

13-16years

A
  • Consider potential harm to child
  • Consider informing Child protection lead
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17
Q

U6yrs

A

always assess Fraser guidance

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18
Q

16- 17 year-old

A

– Over 16’s have the right to independence
– However, the law defines a child as <18 years old
– Even though over age of consent they should be treated as children and offer children safeguarding support if needed

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19
Q

18 year-old and over

A

assumed to be competent with capacity to consent unless otherwise suggested

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20
Q

signs of vulnerability and alerting features

A
  • Learning disability;
  • Older “boyfriend”
  • Young person not permitted to be seen without partner
  • Use of drugs and/or alcohol
  • Homelessness
  • Association with other young people believed to be in exploitative relationships
  • Young people in care
  • Young person presented with gift/cash by partner after accessing pharmacy
  • Multiple presentations for EHC/STD Tx or pregnancy tests
  • Any features of abuse within relationship
  • Migrant children (trafficking)
  • Any evidence that sexual activity was not consensual
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21
Q

when taking Hx for STI screening

A
  • reason for attendance
  • Hx of presenting problem (if symptomatic)
  • full sexual Hx
  • relevant PMHx, incl previous STIs
  • vaccine Hx - Hep B
  • drug Hx (incl recreational)
  • allergies
  • menstrual, contraceptive & obstetric history
  • date & outcome of last cervical cytology
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22
Q

sexual Hx - asymptomatic

A
  • confirm lack of Sx
  • establish competency, safeguarding children/vulnerable adults
  • date of last sexual contact (LSC) and number of partners in the last 3mths
  • gender of partner, anatomic sites of exposure, condom use, suspected infection, infection risk or symptoms in partners
  • previous STIs
  • women: Last menstrual period, contraceptive and cervical cytology Hx
  • blood borne virus risk assessment and vaccination Hx if at risk
  • alcohol and recreational drug Hx
  • agree the method of giving results
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23
Q

Sexual history - Symptomatic, additional Qs

A
  • Symptoms/reason for attendance
  • Pregnancy and gynaecological history if indicated
  • PMHx, surgical Hx
  • Medication Hx and Hx of drug allergies
  • Agree the method of giving results
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24
Q

transmission of chlamydia

A

– Primarily through penetrative sex
– Contact with infected genital secretions
– Autoinoculation of infected secretions onto mucous membranes
– Splash from genital fluids
– From mother to baby at delivery

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25
Q

complications of chlamydia

A

– PID (women)
– Epididymo-orchitis (swelling of testicles and/or epididymis) (men)
– Conjunctivitis
– Lymphogranuloma venereum (LGV) (men)
– Sexually acquired reactive arthritis (SARA)
– Adverse outcomes in pregnancy - premature delivery, low birth weight, infections in neonates
– Anxiety and psychological distress

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26
Q

% asymptomatic with chlamydia

A

70% female

50% male

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27
Q

Chlamydia risk factors

A
  • Age under 25 years
  • A new sexual partner
  • More than 1 sexual partner in the last year
  • Lack of consistent condom use
28
Q

Chlamydia - symptoms female

A
  • Vaginal discharge
  • Dysuria
  • Vague lower abdominal pain
  • Fever
  • Intermenstrual or postcoital bleeding
  • Deep dyspareunia
  • Pelvic pain/tenderness
  • Cervical motion tenderness
  • Inflamed or friable cervix
29
Q

Chlamydia - symptoms male

A
  • Men tend to have either classical urethritis with
    dysuria and urethral discharge
    or
  • Epididymo-orchitis presenting as unilateral testicular pain ± swelling
  • Fever may also be a feature in men.
  • Reactive arthritis
30
Q

Chlamydia Screening

A

Nucleic acid amplification tests (NAATs)
– Highly specific and sensitive
– Women: vulvovaginal swab (1st line)
- Alternatives: 1st void urine sample or endocervical swab
– Men: 1st void urine sample (1st line)

31
Q

chlamydia Tx

A

FIRST LINE: Doxycycline 100 mg BD for 7 days
– c/i in pregnancy & bf
– GI side effects common
– photosensitivity

ALTERNATIVES:
– Azithromycin 1 g orally as a single dose for 1 day, followed by 500 mg orally OD for 2 days
– Erythromycin 500 mg BD for 10–14 days
– Ofloxacin 200 mg BD for 7 days

32
Q

AMR and chlamydia

A

used 1g single dose azithromycin (SDA) or 7 days doxycycline

Mycoplasma genitalium (MGen) - emerging, significant sexually transmitted pathogen, can get co-infection with chlamydia

inc prevalence of macrolide resistance in MGen, because of use of SDA to treat STIs

SDA less effective than doxycycline

SDA no longer recommended

33
Q

Tx for chmalydia in pregnancy

A
  • Azithromycin 1g stat followed by 500mg for 2 days
  • Erythromycin 500mg twice daily for 14 days
  • Amoxicillin 500 mg three times a day for 7 days

** doxycycline and ofloxacin are c/i

34
Q

Chlamydia – follow up

A
  • Avoid sexual intercourse (incl oral sex) until the person & partner completed treatment (or waited 7
    days after Tx with azithromycin)
  • Failure of Tx can be due to re-infection
  • Screen for other STIs
  • Refer to a GUM clinic for partner notification.
    – Symptomatic males – all partners within 2 weeks
    – Asymptomatic - preceding three months should be
    notified
35
Q

test for cure with chlamydia

A

A test of cure not routinely recommended

36
Q

transmission of gonorrhoea

A

– Sexual contact where infected secretions are passed from one mucous membrane to another
– During childbirth

37
Q

Sx of disseminated gonorrhoea

A

skin lesions
arthralgia
tenosynovitis
arthritis

38
Q

complications of gonorrhoea

A

– Men – Epididymitis, prostatitis, infertility
– Women – PID + dangers in pregnancy
– Babies – blindness

39
Q

gonorrhoea Sx - female

A
40
Q

gonorrhoea Sx - female

A

Genital gonorrhoea infection is
usually symptomatic in men
* Urethral discharge
* Dysuria
Rectal and pharyngeal –
asymptomatic

41
Q

gonorrhoea screening

A
  • A NAAT for the presence of N. Gonorrhoea
    Women: vulvovaginal swab

Men - 1st pass urine sample

  • Culture required if patient is NAAT positive for gonorrhoea - to test for susceptibility and ID resistant strains
42
Q

AMR and Gonorrhoea

A
  • No class of antimicrobials where resistance hasn’t developed
  • Strains of MDR are evident
  • ‘Super gonorrhoea’ - resistant to the most common antibacterials
  • change 1st line Tx: Tx was dual therapy of ceftriaxone with azithromycin
  • Ceftriaxone resistance remains rare in the UK
43
Q

Gonorrhoea - treatment

A

** Tx ideally based on susceptibility

susceptibility is not known:
- Ceftriaxone 1 g IM injection as a single dose
- safe when pregnant/bf

susceptibility is known:
- Ciprofloxacin 500mg orally as a single dose
- pregnancy/bf: Azithromycin 2g orally as a single dose

44
Q

disseminated Gonorrhoea - treatment

A
  • Ceftriaxone 1g IM or IV every 24hrs
  • Cefotaxime 1g IV every 8hrs

24-48 hours after Sx begin to improve switch to
* Cefixime 400 mg twice daily
or
* Ciprofloxacin 500 mg twice daily

(switch should be made guided by sensitivities)

45
Q

Gonorrhoea - follow up

A
  • Avoid sexual intercourse (including oral sex) until Tx completed (or waited 7
    days after Tx with azithromycin)
  • Follow up about 1 week after Tx to:
  • confirm adherence to Tx and Sx resolution
  • ask about adverse reactions
  • confirm that partner notification has been carried out
  • ask about recent sexual Hx (and the possibility of reinfection)
  • reinforce advice about safe sexual practice

TEST FOR CURE recommended for all people treated for gonorrhoea
- asymptomatic - test with NAAT at least 2 weeks after completion of Tx
- Sx - test with culture, at least 3 days after completion of Tx
- consider additional testing with NAAT after one week if culture is -ve
- GUM clinic notification - as for chlamydia
- notified partners - test and treat empirically whilst awaiting results
- advice on safer sexual practices, contraception and condom use

46
Q

What is HPV?

A

DOUBLE STRANDED dna VIRUS

47
Q

high risk types of HPV that cause cancer

A

HPV16

HPV18

48
Q

HPV vaccination

A

Cevarix - used until 2012
- Bivalent - protects against 2 strains HPV16 & HPV18

Gardasil
- quadrivalent vaccine - protects against 4 strains HPV16, HPV18, HPV6 & HPV11

Gardasil 9
- 2021-22 vaccine programme
- same as Gardasil + also HPV31, HPV33, HPV45, HPV52

49
Q

Immunisation schedule for HPV vaccine

A
  • best effectiveness, vaccine must be given before the patient becomes sexually active
  • usually 2 doses of the vaccine given 6 mths apart
  • U15yrs 15:
  • 1st dose of 0.5ml of HPV vaccine
  • 2nd dose of 0.5 ml 6mths (up to 24mths) after 1st dose
  • O15yrs
  • 3-dose schedule given at 0, 1, and 4–6mths
50
Q

cause of genital warts

A

viral cause: HPV

ondylomata acuminata

51
Q

transmission of genital warts

A
  • direct skin to skin contact with a person who has clinical/subclinical HPV, or contact with genital secretions
  • most common - sexual contact, but also peri-natally and from hand warts
  • oro-genital transmission is also possible
  • can also occur from contact with contaminated surfaces/objects
  • auto-inoculation from one site to another common
52
Q

Genital warts - symptoms

A
  • Often asymptomatic
  • Can be single, or multiple, and tend to occur in areas of high friction
  • Lesions may be disfiguring or embarrassing
  • Possible itching, bleeding or dyspareunia
  • Present as soft cauliflower-like growths of varying size
  • Less commonly - flat, plaque-like or pigmented
  • Colour can vary from whitish to flesh-coloured to hyperpigmented to erythematous
  • Usually less than 10 mm in diameter
53
Q

Genital warts - Treatment options

A
  1. No Tx
    - 30% warts disappear spontaneously within 6mths, not always indicated
  2. Self applied Tx
    - Podophyllotoxin 0.5% solution or 0.15% cream (Warticon)
    - Imiquimod 5% cream (Aldara)
    - Sinecatechins 10% ointment (Catephen)
  3. Abrasive methods
    - cryotherapy
    - excision
    - electrocautery
  4. Specialist application
    - trichloroacetic acid (TCA) 80-90% solution
54
Q

Genital warts – Treatment choice

A
  • All Tx have significant failure and relapse rates
  • Choice of Tx is dependent upon the:
  • type of warts - non-keratinised or keratinised
  • no. & volume of warts
  • response to previous Tx
  • site of lesions
55
Q

Genital warts - advice

A
  • conflicting info on condom use
  • HPV persists after clinical clearance of warts for very variable lengths of time
  • Psychological distress is common - referral for counselling
  • 20% have concurrent STIs
  • Current partners and partners in the previous 6mths should be assessed
  • Advice about smoking cessation should be given - better Tx response
56
Q

Genital warts – follow up

A
  • Review after completion of Tx
  • Change treatment if:
  • intolerant of the current Tx
  • < 50% response to it by 4–5 weeks (8-12 weeks for imiquimod)
  • Follow up 3mths after Tx if concern re recurrences (timeframe recurrence is likely)
  • More frequent follow up if immunocompromised
57
Q

Viral cause or herpes simplex

A

herpes simplex virus (HSV) 1 or HSV-2

58
Q

Transmission of herpes simplex

A
  • Infectious secretions on oral (HSV-1) , genital or anal mucosal surfaces (HSV-2)
  • Contact with lesions from other anatomical sites
  • Most HSV infections (80%) are transmitted by people who are unaware they’re infected
59
Q

HSV - symptoms 1st episode

A
  • Multiple painful blisters
  • Lesions are usually bilateral & develop 4–7 days after exposure to HSV infection
  • If symptomatic with lesions - report
    headache, fever, malaise, dysuria, or
    tender inguinal lymphadenopathy
  • Other symptoms include - vaginal/urethral discharge, local oedema
  • Tingling/neuropathic pain in the
    genital area, lower back, buttocks or
    legs
  • Lasts up to 20 days
60
Q

HSV - symptoms recurrent genital herpes

A
  • Usually occurs in the same area and may be preceded by localized prodromal tingling and burning Sx 48hrs before the
    appearance of lesions
  • Often less severe and last from 6-48hrs
  • Systemic symptoms, fever & malaise are less common
  • Lesions crust and heal in around 10
    days
61
Q

triggers for HSVreactivation

A
  • Local trauma (sexual intercourse or surgery)
  • UV light
  • Physical illness, immunosuppression
  • Smoking
  • Drinking alcohol
  • Tight clothing, nylon or Lycra underwear
  • Stress
62
Q

HSV – Tx 1st episode

A

ORAL ANTIVIRALS:
* start within 5 days of the start of the episode/while new lesions are forming for people with a first episode
* BASHH guidelines - first-line treatment should be five days of:
- Aciclovir 400 mg TDS
or
- Valaciclovir 500 mg BD

  • Self care measures
    ** only helps with the episode
63
Q

HSV – Tx recurrent episodes

A
  • Supportive measures alone
  • Antiviral therapy as required
  • Suppressive therapy

Episodic Tx:
* BASHH advises short courses as options for 1st line therapy:
- Aciclovir 800 mg TDS for 2 days
- Famciclovir 1 g BD for 1 day
- Valaciclovir 500 mg BD for 3 days

64
Q

Suppressive Tx for HSV

A
  • Often indicated if >6 attacks per year.
  • Usual treatment:
  • Aciclovir 400 mg BD (or 200 mg QDS)
  • Famciclovir 250 mg BD
  • Valaciclovir 500 mg OD
  • The suppressive effect takes 5 days of therapy to establish
  • Discontinue after 12mths to reassess attack frequency (duration = 6-12mths)
  • Suppressive Tx also reduces the risk of asymptomatic shedding
65
Q

Supportive management of HSV Tx

A
  • Saline bathing
  • Oral painkillers
  • Topical anaesthetics
  • abstain until lesions cleared
  • Pain on micturition (urination)
  • vaseline
  • micturition in a bath can help prevent urinary retention
  • inc fluid intake to dilute urine
66
Q

Supportive management of HSV Tx

A
  • Saline bathing (prevent 2 infection)
  • Oral painkillers
  • Topical anaesthetics
  • abstain until lesions cleared
  • Pain on micturition (urination)
  • vaseline
  • micturition in a bath can help prevent urinary retention
  • inc fluid intake to dilute urine
67
Q

HSV – follow up

A
  • Advise to refrain from intercourse when have active lesions
  • Disclosure in relationships should be advised
  • No cure for genital herpes

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