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Case 4 - STIs Flashcards

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1
Q

how can patients go to sexual health clinics?

A

▪Patients usually self refer themselves into sexual health clinics or can be referred by other healthcare professionals and GPs.

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2
Q

who can offer STI testing, contraception and refer people to a sexual health clinic?

A

▪GP practices , School nurses and abortion services can also offer STI testing, contraception and refer patients into the clinic.

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3
Q

regarding sexual health provision, what do pharmacists do?

A

pharmacists - provide oral emergency contraception, progesterone-only pills (as a contraceptive) and signpost to screening and sexual health clinics

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4
Q

who can prescribe in (sexual health) clinic

A

Doctors
Nurses Prescribers
Pharmacists
Nurses who have a PGD for each STI

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5
Q

Young people (15 - 24 years) have the highest number of STIs and high levels of unwanted
pregnancies
Why?

A
  • Often asymptomatic and have poor partner notification/commitment/change in partners frequently
  • Unsafe sexual behaviour
  • lack of knowledge on sex education
  • change in attitude and behaviour compared to 1900s (more people have sex now than before)
  • increased awareness and increased testing for STIs
  • alcohol/ drug use (during sex)
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6
Q

define competence

A

▪Competence : A legal concept referring to the right to make an autonomous decision.

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7
Q

define decision making capacity, as well as the 4 dimensions it covers

A

(decision making) capacity is a clinical concept that refers to the individual’s ability to make
a decision. Four dimensions are considered:
1. How people understand information about their condition and the available options
2. How people compare the options (of the treatments or no treatment) by balancing risks and benefits and can discuss pros and cons
3. How people discuss the relevance of the options for their own situation
4. How people can express a choice and argue it in the light of previous discussions.

decision making capacity can change at different times and in different circumstances

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8
Q

regarding sex and minors aged between 13 and 16

A

minors aged between 13 and 16 are able to consent to sex provided they are Gillick competent and partners are of a similar age

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9
Q

legal age of consent to sexual intercourse is?

A

Legal age for consent for sexual intercourse is 16
Under 13s are unable to consent to sex. This is classed as mandatory rape and should be reported

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10
Q

regarding sex and minors aged between 16 and 18

A

In minors aged 16-18, consent (to sex) should be treated as if given by an adult. This is set in the Family Law Reform Act (1969) and is affirmed in the Mental Health Act 2005.
All patients under 18 should assessed for child sexual exploitation with CSERQ4

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11
Q

define (Gillick) competence

A

Children under 16 can consent to treatments if they have sufficient understanding and intelligence to fully understand what is involved in a proposed treatment.

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12
Q

when are Fraser guidelines used?

A

Fraser guidelines are used specifically to decide if a child under 16 can consent to receiving contraceptive treatment and advice, (extended in 2006 to include) sexual health and termination advice.
this care can be provided if 5 criteria are met

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13
Q

what are the 5 criteria that must be met under Fraser guidelines to provide care?

A

patient has sufficient maturity and intelligence to understand the nature and implications of the proposed treatment

patient can’t be persuaded to tell their parents or to allow the Dr to tell them (refuses to let parents know)

patient is very likely to begin or continue to have sex with or without the contraceptive treatment/(sexual health or contraceptive) advice

patient’s mental and physical health is likely to suffer unless they receive the advice or treatment

the advice or treatment is in the patient’s best interests

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14
Q

what are STIs?

A

STIs are infections that are transmitted through unprotected vaginal, anal or oral sex, genital skin contact or sharing sex toys.

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15
Q

PRINCIPLES OF STI MANAGEMENT

A

▪Identify risk factors for STIs
▪Appropriate examination/ investigation(s)
▪Correct diagnosis
▪Effective treatment
▪Notification & treatment of sexual partner(s)
▪Health education – future risk reduction

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16
Q

PREVENTION OF HIV THROUGH SEXUAL HEALTH CLINICS

A

PrEP - stands for pre-exposure prophylaxis, taking this before sex
PEP - post exposure prophylaxis, taking this after sex

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17
Q

Common STIs

A

Chlamydia, Gonorrhoea, Herpes, Genital Warts and Syphilis

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18
Q

less common STIs

A

Trichomonas Vaginalis (TV), Pubic lice, Scabies, Non specific Urethritis (NSU), Mycoplasma Genitalium, HIV, Hepatitis and Monkey pox

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19
Q

investigations in sexual health clinics for asymptomatic male patients

A

First pass urine - tests for chlamydia (CT) and gonorrhoea (GC)
Blood - HIV and Syphilis (also detects Hepatitis B and C)

additional tests for MSM - men who have sex with men:
throat swab (GC and CT NAAT)
self taken rectal swab (GC and CT NAAT)
blood - Hep B (Hep C and A if necessary)

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20
Q

investigations in sexual health clinics for asymptomatic female patients

A

Self taken vaginal swab (CT &GC NAAT)
Blood – HIV and Syphilis (Hep B and C)

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21
Q

investigations for STIs in symptomatic male patients

A

First pass urine(CT &GC NAAT)
Urethral swab for GC culture and microscopy
Blood – HIV and Syphilis (Hep B and C)

additional tests for MSM:
Throat swab (GC and CT NAAT)
Throat swab for GC culture
Self taken rectal swab (GC and CT NAAT)
Rectal swab for GC culture
Blood – Hep B (Hep C and A if necessary)

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22
Q

investigations for STIs in symptomatic female patients

A

Self taken vaginal swab(CT &GC NAAT)
Microscopy - detecting for TV, BV and candida
HVS (high vaginal swab) - Culture and microscopy - detecting for TV, BV, Candida
Endo cervical swab – GC culture
Blood – HIV and Syphilis (Hep B and C)

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23
Q

window period for testing

A

Hepatitis infections - repeat testing at 3 months and at 6 months

Syphilis - symptoms appear 9-90 days. Blood test may be positive 2 weeks after symptoms start. Repeat at 12 weeks to ensure negative.

Point-of-care (POC) HIV test - a 4th generation test - test should be taken 45 days after potential exposure to HIV

PCR test for syphilis should be done at the presentation of a primary ulcer

4th generation HIV test is a blood test that detects for HIV antibodies and the p24 antigen- this test should be done 45 days after potential exposure

NAAT test for Chlamydia and Gonorrhoea - this test should be done 2 weeks after potential exposure

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24
Q

where does chlamydia trachomatis infect

A

▪Infects the mucosal epithelium cells of urethra, uterus, cervix, Fallopian tubes, testicles, rectum, throat and eyes.

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25
how is chlamydia transmitted?
▪Transmission through: unprotected vaginal, oral or anal sex (or sharing sex toys) mother to her baby during vaginal delivery. from genitals to fingers to eyes, causing conjunctivitis.
26
female symptoms of chlamydia
* Asymptomatic -up to 70% of women * Increased vaginal discharge * Dysuria * Lower abdominal pain and deep dyspareunia which can be symptoms of PID (pelvic inflammatory disease) * Post-coital and intermenstrual bleeding (bleeding after sex and b/w periods)
27
Male symptoms of chlamydia
Asymptomatic - up to 50% men Discharge from the tip of the penis Dysuria/Urethral discomfort/urethritis Painful testicles with swelling which can be symptoms of Epididymo-orchitis
28
chlamydia: female signs on examination
Mucopurulent cervicitis (inflammation of the cervix that can cause a discharge from it) with or without contact bleeding Signs of PID are chlamydia signs and pelvic tenderness with cervical motion tenderness (pain or tenderness in the cervix). with or without systemic symptoms such as pyrexia (increased body temp) and tachycardia (heart rate that's faster than 10 bpm)
29
chlamydia: male signs on examination
Clear urethral discharge Signs of epididymo orchitis (inflammation of the epididymis and testicles which leads to a swollen tender testicle)
30
investigations for chlamydia positive patients
CT/GC NAAT from urine / vagina/ throat/ rectum - this test should be taken at a 2 week window period after exposure.
31
Antibiotic therapy for chlamydia positive patients
Doxycycline should be taken at 100mg twice a day every day (unless it’s contraindicated in pregnancy) OR Azithromycin should be taken 1g immediately, followed by 500mg of azithromycin for the next 2 days
32
advice for chlamydia positive patients
 No sex for 1 week and until partner/s has completed treatment  Partner notification and treatment of partners from last 4 weeks. Look back for partners over 6 months if patient is asymptomatic.  Offer other STI screening /Promote positive sexual health message/promote condoms  Recommend TOC (test of cure) if patient is pregnant, unsure of compliance or if rectal chlamydia is at 3-5 weeks. Recommend retest at 3 months in younger patients due to high reinfection rates.
33
who is Gonorrhoea diagnoses most frequent in
Gonorrhoea diagnoses were most frequent in males aged 15-24
34
what is GONORRHOEA caused by?
GONORRHOEA is caused by Neisseria gonorrhoeae, which is a Gram-negative diplococcus bacterium
35
what does GONORRHOEA infect?
Infects the; urethra, uterus, cervix, fallopian tubes, testicles, rectum, throat and sometimes eyes.
36
transmission of Gonorrhoea is by?
* Transmission through: -unprotected vaginal, oral or anal sex or sharing sex toys -mother to her baby during vaginal delivery -From genitals to fingers to eyes, causing conjunctivitis
37
is chlamydia higher in males or females
females
38
is gonorrhoea higher in males or females
gonorrhoea is higher in males than females
39
gonorrhoea symptoms in females
Asymptomatic -up to 50% of women Increased vaginal discharge - creamy / green colour Dysuria (pain when urinating), cystitis (inflammation of the bladder) symptoms Lower abdominal pain and deep dyspareunia which can be symptoms of PID (pelvic inflammatory disease) occurring in 16% of infected people Can have rectal or pharyngeal discharge Post-coital and intermenstrual bleeding
40
gonorrhoea symptoms in males
Asymptomatic - up to 10-20 % men Discharge from the tip of the penis - creamy/ green in colour Dysuria/Urethral discomfort/urethritis Painful testicles with swelling (which can be symptoms of Epididymo orchitis) Can have rectal or pharyngeal discharge
41
GONORRHOEA SIGNS ON EXAMINATION - females
vaginal discharge Mucopurulent cervicitis (inflammation of the cervix that can cause a discharge from it) with or without contact bleeding Signs of PID (pelvic inflammatory disease) are Pelvic tenderness and Cervical motion tenderness. Systemic symptoms such as pyrexia (high body temp above normal) and tachycardia (heart rate that's faster than 100bpm)
42
GONORRHOEA SIGNS ON EXAMINATION - males
Cloudy thick urethral discharge Signs of epididymo-orchitis such as swollen, tender testicles
43
Investigations: MANAGEMENT OF GONORRHOEA POSITIVE PATIENTS
CT/GC NAAT - this test should be taken at a 2 week window period swab for culture and sensitivity from all relevant sites prior to treatment for gonorrhea Direct visualization of Gram-negative diplococci within polymorphs
44
Antibiotic therapy: MANAGEMENT OF GONORRHOEA POSITIVE PATIENTS
after the swab for culture and sensitivity has been performed, 1g of ceftriaxone should be given INTRAMUSCULARLY (IM) Alternatively Ciprofloxacin 500mg stat oral – only if sensitivity known (stat - means immediately)
45
Advice: MANAGEMENT OF GONORRHOEA POSITIVE PATIENTS
 Partner notification and treatment for partner (partners from the last 2 weeks should be notified and treated if patient is a symptomatic male; partners should be treated from the last 3 months for females or asymptomatic males), offer other STI tests  No sex for 1 week and until partner has also completed treatment  Promote positive sexual health message/ condoms/ reduce risk taking / vaccine in future
46
COMPLICATIONS OF CHLAMYDIA AND GONORRHOEA
PID can occur in women who have untreated gonorrhoea or untreated chlamydia Epididymo-orchitis in males SARA - sexually acquired reactive arthritis <1% Fitz Hugh Curtis syndrome- perihepatitis (inflammation of liver capsule and surrounding peritoneum) Disseminated infection in gonorrhoea- skin , joints
47
what is PID?
▪PID is inflammation in the upper genital tract usually from an ascending infection, such as STI or anaerobic bacteria
48
How to manage PID (pelvic inflammatory disease)?
▪Admit if unwell ▪History and examination and STI tests ▪Give broad spectrum antibiotics - the following should be given: Ceftriaxone 1g stat IM (given intramuscularly immediately) Doxycycline 100mg bd and metronidazole 400mg bd 2 weeks (Doxycycline and metronidazole given twice a day for 2 weeks) ▪Partner notification and treatment ▪Review at 72 hours and 3 weeks (consider window period testing for other STI)
49
Complications of PID (pelvic inflammatory disease)
Future infertility Ectopic pregnancy in the future Chronic pelvic pain
50
what is the treatment for a younger male patient with EPIDIDYMO ORCHITIS, presenting with urethritis symptoms and discharge, urine dip: leukocytes?
STI likely history Ceftriaxone 1g IM stat and Doxycycline 100mg bd x 14 days
51
what is the treatment for an older male patient with EPIDIDYMO ORCHITIS, presenting with urinary/ prostate symptoms, urine dip-leukocytes and nitrites?
Ofloxacin 200mg bd x14 days (CIs - certain contraindications)
52
how is HERPES SIMPLEX VIRUS HSV transmitted?
Transmitted by skin to skin contact with ulcer or virus shed on the skin during sex - oral, genital or rectal. Mother to baby during vaginal delivery if there are active lesions.
53
is HERPES SIMPLEX VIRUS HSV more common in males or females?
females
54
HERPES SYMPTOMS AND SIGNS
▪Prodrome phase -Feeling generally unwell, possible flu-like symptoms especially primary episode ▪Genital ulceration and pain - Small, painful fluid filled blisters/ ulcers in the genital or anal area with dysuria. Can cause urinary retention secondary to autonomic dysfunction. ▪Swollen lymph nodes in the groin area *Secondary complications- urinary retention , bacterial skin infection, occular symptoms, eczema herpeticum, encephalitis/ meningitis
55
History and examination of Herpes
typical small often multiple ulcers / sores
56
Investigations for Herpes
Investigations -Viral PCR swab from lesions can diagnose and sub type virus, other STI screens
57
treatment for Herpes
Aciclovir 400mg tds 5-10 days (this means Aciclovir at 400 mg three times a day for 5-10 days) OR Valaciclovir 500mg bd 5-10 days primary episode (antivirals) Analgesia/ topical anaesthetic gel- instillagel
58
counselling and advice for Herpes
Advice of the re-nature of disease/ recurrence/transmission and risk to partners / asymptomatic shedding pregnancy – csection if primary episode of Herpes in last trimester
59
what are genital warts caused by
Caused by Human Papilloma Virus HPV, common types 6 and 11
60
are genital warts more common in males or females
males
61
GENITAL WARTS MANAGEMENT
 Topical treatments - best for multiple, soft, small warts – (imiquimod 5%, podophyllotoxin solution) .this aims to reduce symptoms and help resolution  Referral to genitourinary medicine (GUM) for cryotherapy or use of trichloroacetic acid to remove warts. If they persist or are atypical, can be managed by ablative therapy or referral to surgical speciality for removal  Consider other STI screens , no partner notification needed, advise condom use  Smoking seems to be linked to delayed clearance
62
what is syphilis caused by
▪Syphilis bacterium spirochaete - Treponema pallidum
63
SYPHILIS SYMPTOMS/ SIGNS
Primary syphilis ulcer/ chancre* –ulcer/s on skin, genitals, rectum, anus or in the mouth. This can be painless Secondary syphilis* -skin rash, Lymph nodes, alopecia, condylomata, hepatits, splenomegaly, glomerulonephritis, meningitis Latent asymptomatic phase- Early latent if < 2 years * Late latent if >2 years Tertiary- complex brain/ heart and soft tissue/ bone problems
64
MANAGEMENT OF SYPHILIS
MU- million units QDS- 4 times daily OD - once daily ▪Primary treatment Benzathine penicillin 2.4MU IM (single dose) or Doxycycline 100mg bd x 14/7 (doxycycline twice a day for 14 days) ▪Late latent, cardiovascular and gummatous syphilis Above weekly for 3 weeks = 3 doses ▪Neurosyphilis Procaine penicillin 1.8–2.4 MU IM OD PLUS probenecid 500 mg PO QDS for 14 days
65
Symptoms/ Signs of TRICHOMONAS VAGINALIS
Offensive smelling frothy vaginal discharge/ raised pH -Itching, irritation, dysuria, cervicitis on exam- some people get strawberry cervix -urethral discharge, balanitis Associated with pre-term delivery, post partum sepsis
66
Management of TRICHOMONAS DISCHARGE
Metronidazole 400mg bd (twice a day) for 5-7 days or Metronidazole 2g STAT Treat partners / Test of cure if symptoms persist and retreat
67
treatment of scabies
Treat permethrin 5% cream to all body and repeat in a week Treat others in household, partners, wash all clothes and bedding on high heat
68
treatment of pubic lice
Treat with permethrin 5%/ lyclear, clean all bedding clothes – repeat after a week
69
what is HIV?
HIV (human immunodeficiency virus) is a RNA virus that damages the CD4 cells in your immune system and weakens your ability to fight certain types of everyday infections and disease
70
what is AIDS?
AIDS (acquired immune deficiency syndrome) is the name used to describe these specific infections and illnesses that happen when this part of the immune system has been severely damaged usually once CD4 cells get lower than 200

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