Ch13: GU/GYN Flashcards
(103 cards)
1
Q
% of yeast infections caused by candida albicans species
A
80-90%
2
Q
STI most likely to cause penile discharge
A
gonorrhea
3
Q
first line treatment for chlamydia
A
azithromycin 1g PO 1x
4
Q
first line treatment for gonorrhea
A
ceftriaxone 250mg IM 1x plus azithromycin 1g PO 1x
5
Q
first line treatment for trichomoniasis
A
metronidazole 2g PO 1x
or tinidazole 2g PO 1x
6
Q
first line treatment for genital HSV
A
oral acyclovir, famiciclovir, or valacyclovir
dose and length depends on whether first time infection, recurrence, or prophylaxis
7
Q
first line treatment for syphilis
A
benzathine penicillin G 2.4 million units IM 1x
8
Q
firm, round, painless genital and/or anal lesion with clean base and indurated margins accompanied by localized lymphadenopathy that resolves on its own ~3 weeks
suspect….
A
primary syphilis
9
Q
pt presents with nonpuritic skin rash involving the trunk, palms of the hands, and soles of the feet. systemic symptoms are flu-like, including fever, diffuse lymphadenopathy, sore throat, patchy hair loss, headache, weight loss, muscle aches, fatigue. resolves without treatment
suspect….
A
secondary syphilis
10
Q
genital warts are most commonly caused by….
A
HPV 6 or 11
11
Q
HPV-related GU malignancies are most commonly caused by….
A
HPV 16, 18, 31, 33
12
Q
options for the treatment of genital warts
A
- topical imiquimod [Aldara] (patient-applied; external only)
- topical podofilox
- cryotherapy with liquid nitrogen
- TCA (provider-applied) or bichloracetic acid
- surgical removal
13
Q
outpatient treatment of PID
A
ceftriaxone 250mg IM 1x plus doxycycline 100mg PO BID x 14 days with or without metronidazole 500mg PO BID x 14 days
14
Q
what is balanitis
A
inflammation/erythema of the glans of the penis
15
Q
presentation of yeast infection in males
A
balanitis, groin-fold involvement, scrotal excoriation
16
Q
genital yeast infection is fairly uncommon in males unless there is this underlying comorbidity….
A
diabetes
17
Q
first line treatment options for acute uncomplicated UTI
A
- TMP/SMX (Bactrim)
- nitrofurantoin (Macrobid)
- fosomycin (Monurol - new)
- fluoroquinolone (ciprofloxacin, levofloxacin, moxifloxacin)
18
Q
(3) most common causative agents of UTIs
A
- ** e. coli (almost always)
- klebsiella
- staph saprophyticus
19
Q
what medication can be added to UTI abx therapy for reduction in dysuria symptoms
A
phenazopyridine (Pyridium)
available OTC, a urinary tract analgesic. turns the urine a crazy bright red orange color that stains everything
^^ has been removed from the Canadian market?
20
Q
warn patients about this possible side effect before recommending phenazopyridine (Pyridium)
A
turns the urine a bright red orange color that stains everything
21
Q
PID equivalent in men
A
epididymoorchitis (upper reproductive tract infection with inflammation of the epididymis and testis)
22
Q
Prehn’s sign
A
relief of discomfort with scrotal elevation
23
Q
epididymoorchitis in males is commonly caused by (2) if folks <35yo, vs. by (1) in folks >35yo or insertive partner in anal intercourse
A
<35yo =
- gonorrhea
- chlamydia
> 35yo =
enterobacteriaceae (coliforms)
24
Q
priority sequelae to prevent in epididymoorchitis
A
infertility
25
acute bacterial prostatitis in males <35yo is commonly caused by (2), versus (1) in males >35yo or otherwise low risk for STI
<35yo =
1. gonorrhea
2. chlamydia
>35yo or low STI risk =
1. enterobacteriaceae (coliforms)
26
male patient presents with irritative voiding symptoms, fever, and painful swelling of the epididymis and scrotum. on physical exam, pain is relieved by scrotal elevation
you suspect....
epididymoorchitis (s/t gonorrhea, chlamydia, or enterobacteriaceae coliforms)
27
male patient presents with irritative voiding symptoms, suprapubic and perineal pain, fever. cc: "it hurts when I sit"
on physical exam, there is a tender, boggy prostate and leukocytosis on labs
you suspect....
acute bacterial prostatitis (s/t gonorrhea, chlamydia, or enterobacteriaceae coliforms)
28
first line treatment for epididymoorchitis
if suspected cause chlamydia/gonorrhea:
- ceftriaxone 250mg IM 1x plus doxycycline 100mg PO BID x 10 days
if suspect enterobacteriaceae coliforms:
- levofloxacin 500mg PO QD x 10 days (fluoroquinolones)
29
first line treatment for acute bacterial prostatitis
if suspect chlamydia/gonorrhea:
- ceftriaxone 250mg IM 1x plus doxycycline 100mg PO BID x 10 days
if suspect enterobacteriaceae coliforms:
- ciprofloxacin 500mg PO BID x 14 days (fluoroquinolnones)
30
worst vs. best tolerated OAB medication
worst tolerated = oxybutynin (Ditropan), causes lots of dry mouth, constipation, anticholinergic effects
best tolerated mirabegron (Myrbetriq)
31
(2) first line BPH medications
- tamsulosin (Flomax) --> relaxes the bladder neck
| - finasteride (Proscar) --> shrinks the prostate
32
DIAPPERS mnemonic for treatable underlying causes of urinary incontinence
```
D - delirium
I - infection (UTI usually)
A - atrophic vaginitis
P - pharmaceuticals (e.g., diuretics)
P - psych (e.g., depression)
E - excess urine output (e.g., heart failure, poorly controlled DM)
R - restricted mobility
S - stool impaction
```
33
if you suspect testicular torsion in primary care, next steps...
refer to specialist immediately!
needs intervention within 6 hours to save blood supply to the testicle
often confirmed with US
34
TWIST scores for evaluation of testicular torsion (signs and symptoms, not a mnemonic)
- testicular swelling
- hard testicle
- absent cremasteric reflex
- nausea or vomiting
- high riding testicle
35
(3) most potent risk factors for HIV
- receptive anal intercourse
- needle-sharing during injection drug use
- needlestick
36
duration of ART therapy for someone using PEP
post-exposure prophylaxis
28 day course
37
duration of ART therapy for someone using PrEP
daily treatment should continue until risk of HIV infection is low
38
management options for urge incontinence or OAB (4)
- behavioral therapy e.g., bladder training, avoiding bladder irritants
- anticholinergics/antimuscarinics (e.g., oxybutynin)
- beta 3 agonist (e.g., mirabegron)
- botulinum toxin injections
39
medication class: oxybutynin (Ditropan)
anticholinergic/antimuscarinic
40
medication class: tolterodine (Detrol)
anticholinergic/antimuscarinic
41
medication class: mirabegron (Myrbetriq)
beta 3 agonist
42
management options for stress incontinence (4)
- kegel exercises
- pelvic floor PT e.g., biofeedback, electrical stim
- pessary for pelvic flood support
- surgery e.g., urethral stents, sling
43
management options for functional incontinence (1)
typically in someone with limited mobility issues or altered cognition, so typically ameliorated by having an assistant who is aware of voiding cue and available to help with toileting and self-care activities
44
high risk patients for whom more frequent cervical cancer screening should be performed (3)
- HIV
- DES exposure in utero
- immunosuppressed
45
recommendations regarding anal pap test
- not recommended universally
- recommended for those who are high risk, which includes HIV-positive, receptive anal sex, history of anal warts, h/o cervical or vulvar cancer
- there is no consensus on frequency of screening -- consider every year for HIV-positive, and every 2-3 years for others
46
how long after a possible exposure can you use PEP
as soon as possible, must be within 72 hours of possible exposure
47
monitoring considerations for someone taking PrEP
- exclude acute or chronic HIV infection prior to initiation (underlying HIV infection while on PrEP can engender resistance to the drugs)
- assess hepatitis B infection and immunity status
- reassess for HIV infection Q3 months while on PrEP (more often PRN)
- pregnancy test Q3 months
- assess kidney function at baseline and Q6 months; must d/c PrEP at first indication of developing CKD
- STI tests Q6 months (consider including oral/rectal STI testing PRN)
48
what is the only FDA-approved regimen for PrEP at this time
tenofovir (tenofovir disoproxil fumarate; TDF) 300mg + truvada (emtricitabine; FTC) 200mg QD
49
monitoring considerations for someone taking PEP
- initiate within 72 hours of possible exposure
- 28 day course of 3-drug ART regimen
- HIV testing at baseline (time of exposure)
- HIV follow-up testing at 6 weeks, 12 weeks, and 6-months post-exposure
50
goals of HIV ART therapy (4)
- suppress plasma viral RNA (viral load)
- restore and preserve immunologic function (CD4 count)
- reduce morbidity and mortality (e.g., AIDs)
- prevent HIV transmission
51
% of pregnancies that are unintended in the USA
~50%
depends on age (lowest rate of unintended 30-39yo)
52
(4) birth control methods with less than 1 pregnancies per 100 folks in 1 year (failure rate <1%)
LARCs = arm implant, IUDs
sterilization = female, male
53
(5) birth control methods with 6-12 pregnancies per 100 folks in 1 year (TYPICAL USE)
- OCPs
- depo-provera injection
- patch
- ring
- diaphragm
54
condoms, withdrawal, and sponge, fertility awareness, and spermicide contraceptive methods all have a failure rate higher than....?
>18 pregnancies per 100 folks in 1 year (>20%)
55
MEC Category 1
no restriction on use
56
MEC Category 2
benefits generally outweigh risks
57
MEC Category 3
risks usually outweigh risks
58
MEC Category 4
contraindicated - unacceptable risk
59
MEC Category:<35yo, smoker, wants to use COCs
category 2 (ok)
60
MEC Category: 35yo or older, smokes cigarette, wants to use COCs
category 3 (risks outweigh benefits) if <15 cigs/day
category 4 (contraindicated) if >15 cigs/day
d/t estrogen and tobacco which both increase blood clot risk
61
MEC Category: smoking, any amount, any age, wants to use POPs
category 1 - totally ok :)
62
MEC Category: smoking, any amount, any age, wants to use DMPA
category 1 - totally ok :)
63
MEC Category: smoking, any amount, any age, wants to use Nexplanon arm implant
category 1 - totally ok :)
64
MEC Category: smoking, any amount, any age, wants to use IUD arm implant
copper and LNG-IUDs both category 1 - totally ok :)
65
"low dose" combined hormonal contraceptives refers to an estrogen level less than....
< or = 35 mcg
66
(4) MOAs of combined hormonal contraception
- ovarian and pituitary inhibition (reduces LH surge s/t constant low dose)
- thickens cervical mucus (progesterone)
- endometrial atrophy (progestin) and stabilization (estrogen)
- cycle control (regulates; can choose more predictable schedule to having a period)
MOST OF THE MOA COMES FROM THE PROGESTERONE, THE ESTROGEN IS USEFUL FOR REDUCED SPOTTING AND ALLOWING A WITHDRAWAL BLEED (because with estrogen, lining is not entirely atrophic)
67
recommended not to use depo provera for longer than _____ d/t risk for bone loss
2 years
68
MEC: <18yo pt who wants DMPA
category 2
ok, but risk for bone loss limit use to <2 years
69
what is the most important part of the physical exam for a new patient coming in to start COCs
blood pressure, only strongly recommended item
70
what are the only (2) birth controls where bimanual exam and cervical inspection is strongly recommended
- IUD
- diaphragm/ cervical cap
r/o cervicitis, abnormality of the uterus
71
how to be reasonably certain that someone is not pregnant
- no symptoms of pregnancy, AND
+ <7 days after the start of normal menses
+ no intercourse since the start of last menses
+ correctly and consistently using a reliable method of contraception
+ < 7 days after a SAB or elective abortion
+ within 4 weeks postpartum
+ fully or nearly fully breastfeeding (>85% of all feeds), amenorrhoeic, and <6 months postpartum
taken together, negative predictive value of 99-100%
72
For contraceptive methods other than _____, the benefits of starting to use a method likely exceed any risk, even in situations in which the healthcare provider is uncertain whether the patient is pregnant
IUDs
this is because these hormones are already naturally in the body already, not overtly harmful to the pregnancy
73
Sunday start method for COCs
- start on the Sunday after menses begins
- that means monthly menses will occur during the week, never over the weekend
- use back-up protection for 7 days after starting
74
First day of menses start method for COCs
- start on the first day of menses
- thus, no back-up method is needed (by the time ovulation naturally would occur, there is enough hormone on board that ovulation is suppressed)
75
Quick start method for COCs
- be reasonably certain that the patient is not pregnant
- start the method that day
- use back-up method for 7 days
76
Jump start method for COCs (well-suited if unprotected intercourse since LMP)
- prescribe oral emergency contraception
- start OCPs same day
- use back-up method for 7 days
77
MEC: 45yo or older with recurrent tension-type headaches, wants COCs
category 2 - benefits outweigh risks
78
MEC: <45yo with recurrent tension-type headaches, wants COCs
category 1 - totally ok :)
79
MEC: >35yo with HTN (controlled or adequately controlled), wants COCs
category 3 (adequately controlled HTN) or category 4 (not controlled)
in either case, COCs are a poor choice
80
which antibiotic is most likely to reduce effectiveness of COCs?
rifampin (TB medication)
81
true or false: available scientific data does not support the hypothesis that antibiotics (with the exception of rifampin) lowers the efficacy of oral contraceptives
true!!!!!!
all antibiotics alter gut flora. there is some recirculation of estrogen as a result of some of the flora of the gut.... when gut flora is reduced, they will end up spotting more. but does not make the OCP less effective
82
common side effect of taking antibiotics while on COCs
spotting (does not indicate reduced efficacy) -- > continue taking then COCs even if spotting
83
the reduction in free androgens noted in the patient taking COCs can cause improvement in ......
acne vulgaris
84
MEC: factor V leiden mutation and COCs
category 4 - contraindicated
85
MEC: h/o gastric bypass surgery and COCs
category 3 - risks outweigh the benefits
duodenum is bypassed in gastric bypass, and this is where most medications are absorbed. so less benefit to taking OCPs after gastric bypass
86
MEC: postpartum <21 days and COCs
category 4 - contraindicated
really high risk of blood clots this early postpartum, and estrogen postpartum can reduce milk supply
87
MOA: IUDs
foreign body effect induced by presence of the device in the intrauterine cavity results in a sterile-inflammatory response that impairs implantation
copper: additionally toxic to sperm
LNG: additional thickening of cervical mucus as physical barrier, atrophic endometrium further prevents implantation
88
how long is Nexplanon effective for
3 years
89
most common side effect of Nexplanon
spotting/irregular bleeding, particularly early on
can manage by putting on COCs for up to 3 months, timed NSAIDs x 2 weeks (naproxen 500mg PO BID) --> prostaglandin effect can shut down the bleeding, or d/c the Nexplanon
90
after a single coital act, folks who do not use contraception have a _____ chance of becoming pregnant
7.2%
91
(3) prescription methods for emergency contraception
- copper IUD
- ulipristal acetate (Ella) 30mg PO single dose
- levonorgestrel in 1-2 doses (Plan B)
92
what is the single most effective emergency contraception option
copper IUD
0.09% pregnancy rate after placement within 5 days
93
will emergency contraception disrupt an established pregnancy?
no
94
side effects of emergency contraceptive pills
nausea (14%), vomiting (1%) - if vomiting occurs within 2 hours of taking, repeat the dose
95
when should menses return with emergency contraceptive pills
in >95% of folks, next menstrual period will occur within 3 weeks
obtain another pregnancy test if menses are delayed beyond 1 week of anticipated date of onset
aka, should have gotten period as usual/was expected. if late, take a test
96
when does emergency contraception need to be taken
Copper IUD and Ulipristal Acetate (Ella) effective up to 120 hours (5 days) after intercourse, but most effective within 72 hours (3 days)
LNG recommended up to 3 days (72 hours) after intercourse
97
MOA of levonorgestrel (Plan B) pills for emergency contraception
prevents LH surge, inhibiting ovulation
inhibits tubal transport to keep sperm and egg from meeting one another
98
MOA of ulipristal acetate (Ella) emergency contraception
progesterone agonist/antagonist with a direct inhibitory effect on follicular development and ovum release and causes changes in the endometrium that can reduce likelihood of implantation
99
most important difference in efficacy between levonorgestrel (Plan B) and ulipristal acetate (Ella) for emergency contraception
levonorgestrel (Plan B) only effective at inhibiting ovulation if given at least 2 days before LH surge begins
In contrast, ulipristal acetate (Ella) remains effective when administered up to immediately before LH surge begins. When given prior to LH surge, inhibits 100% of follicle rupture. However, even if Ella is given after LH begins to surge, it still reduces change of follicular rupture by ~50%. Finally, when given AT the time of LH peak, delays ovulation by 24-48 hours (which can still help as sperm die off)
thus, closer to time of ovulation ulipristal acetate (Ella) is likely more effective
100
what to do if vomiting occurs within 2-3 hours of emergency contraceptive dose is taken
repeat the dose
101
what is the only contraindication to emergency contraception
active uterine infection for Copper IUD only
102
growing body of evidence to suggest that the oral emergency contraception methods are less effective for patients who are _______, though this is not true for copper IUD
obese
103
is there a higher rate of birth defects if pregnancy does occur after taking emergency contraception?
no
