Complications in sexual health

Question 1

What investigations should you do if someone has pain passing faeces and a sexual history indicating risk of STI?

Answer 1

Proctoscope

Microscopy of any discharge/ulcerated/inflamed areas

Viral swabs for HSV and syphilis

Chlamydia and gonorrhoea NAATs testing - first pass urine, rectal, pharynx

Culture for gonorrhoea from sexually exposed sites

Bloods: HIC
Syphilis
Hep B and C

Stool samples (if diarrhoea - ?shigella)

Question 2

What are some sexually–acquired causes of proctitis?

Answer 2

Lymphomagrnauloma venerum (LGV)

Gonorrhoea

Non-LGV chlamydia

Herpes

Shigella

Hepatitis

Question 3

What are some NON sexually-acquired causes of proctitis?

Answer 3

inflammatory bowel disease

haemorrhoids/polyps

malignancy

Question 4

What is lymphogranuloma venerum (LGV)?

Answer 4

Caused by 1 of 3 serovars of chalmydia

More common in dense sexual networks eg. sex parties, chem sex, Hep C outbreaks

Question 5

How might LGV present: 1) in MSM

2) ‘classically’?

Answer 5

1) haemorrhage proctitis (direct mucosal spread)

2) less common. Ulceration, inguinal lymphadenopathy, buboes

Question 6

How is LGV diagnosed?

Answer 6

If chlamydia NAAT comes back positive, send sample off to central lab for testing

Question 7

How is LGV managed?

Answer 7

Abstain
Partner notification
Safer sex advice
WP blood testing

3 week course of doxycycline 100mg

Question 8

What should you include in a follow up of LGV?

Answer 8

Ensure symptoms resolved

Assess whether there is any permanent damage (fibrosis, strictures, fistulae) - may require surgical involvement

Question 9

What are some of the permanent damages that can be caused by LGV?

Answer 9

Fibrosis
Strictures
Fistulae

More common in those who haven’t been treated

Question 10

What can cause testicular pain?

Answer 10

infections
trauma
torsion
tumours

Question 11

What investigation should you do for someone presents with rectal symptoms and the main one of these is diarrhoea?

Answer 11

Stool samples - shigella

common in MSM

Question 12

What is one of the most important questions to ask someone who presents with testicular pain?

Answer 12

Onset

If it was quick onset, think about torsion

Question 13

How might acute epididymo-orchitis present?

Answer 13

Pain
Sweeping
Inflammation
of epididymis +/- testes
(must exclude torsion)

O/E: tenderness on affected side (may billet)
Palpable swelling of epididymis
Urethral discharge
secondary hydrocele
erythema and/or oedema of affected scrotum
pyrexia

Question 14

What investigations should you do for someone in whom you suspect acute epidymo-orchitis?

Answer 14

Microscopy/urethral or FPU (looking for urethritis)
Gonorrhoea and chlamydia

Urethral culture (gonorrhoea)

NAATs (FPU) (chlamydia and gonorrhoea)

Dipstick and MSU +/- culture (nitrites and leucocyte positive = UTI)

Doppler US (assess flow)
IgM/IgG serology (mumps)
AAFB: x3 early morning samples (TB)
Urinary pathogen (structural abnormalities)

Question 15

How would you treat acute epididymo-orchitis?

Answer 15

Abstain from sexual intercourse until patient and partner fully treated

Ceftriaxone, prolonged course of doxycycline 10-14 days

STI unlikely: oxaflocin/ciprofloxacin

Question 16

What are some complications associated with acute epididymo-orchitis?

Answer 16

Hydrocele

Abscess

Question 17

What are some local complications of STI?

Answer 17

PID
Endometriosis
Salpingitis

Tubal infertility
Ectopic pregnancy

Fitz-Hugh Curtis syndrome (peri hepatitis)

Bartholin’s abscess

Epididymo-orchitis
Prostatitis
Proctitis

Question 18

What are some skin and mucus manifestations of STIs?

Answer 18

Conjunctivitis - direct inoculation

• chlamydia (unilateral, low grade irritation, normal chlamydia treatment)
• Gonorrhoea (purulent discharge, 3 days treatment)

SARA: sexually acquired reactive arthritis

Disseminated gonococci infection

Question 19

What is SARA?

Answer 19

Sexually acquired reactive arthritis associated with HLA-B27

Sterile inflammation of synovial membranes, tendons, fascia

Triad: urethritis, arthritis, conjunctivitis +/- cutaneous signs eg. keratoderma blenorrhagica, circinate balanitis. Oral ulceration, uveitis, cardio/neuro involvement.

Question 20

How does disseminated gonococcal infection spread? What symptoms does this cause?

Answer 20

Haematogenous

Skin lesions
Artralgia
Arthritis
Tenosynovitis

Question 21

What are some complications of chlamydia in pregnancy?

Answer 21

IUGR
Premature rupture of membranes
Pre-term delivery
Low birth weight

Question 22

What are some complications of gonorrhoea in pregnancy?

Answer 22

Low birth weight

Preterm birth

Question 23

Which STIs can cause complications in pregnancy?

Answer 23

Chlamydia
Gonorrhoea
TV
BV

Question 24

How does ophatlmia neonatorum present?

Answer 24

Conjunctivitis
Chemises (oedema of conjunctiva)
Purulent exudate

Question 25

How soon does ophatlmia neonatorum present?

Answer 25

1-2 weeks of life (if caused by chlamydia) Within 5 days (if, less commonly, due to gonorrhoea)

Question 26

How would you investigate/diagnose ophthalmia neonatorum?

Answer 26

NAATs: chlamydia and gonorrhoea from everted eyelid (NOT just discharge) Gram stain and culture (gonorrhoea) STI screen in parents

Question 27

How would you treat ophthalmia neonatorum?

Answer 27

systemic erythromycin cephalosporin (eg. ceftriaxone) for gonorrhoea

Question 28

What are some complications of chlamydia in the neonatal period?

Answer 28

Ophthalmia neonatorum Neonatal pneumonitis

Question 29

When, after birth, does neonatal pneumonitis develop?

Answer 29

1-3 months of age

Question 30

What are some features of neonatal pneumonitis?

Answer 30

Staccato cough (dry, high-pitched) Tachypnoea

Question 31

How would you diagnose neonatal pneumonitis?

Answer 31

CXR: hyperinflation/ bilateral diffuse infiltrates Nasopharyngeal swabs/tracheal aspirate - NAAT chlamydia testing

Question 32

How would you treat a baby with neonatal pneumonitis?

Answer 32

Systemic antibiotics: erythromycin Screen and treat parents