Genital Tract Infection Flashcards
(46 cards)
1
Q
What is the asymptomatic STI screening for a male?
A
- First void urine (must have held their urine for at least 1hr): chlamydia + gonorrhoea NAAT (nucleic acid test)
- Serology: HIV + syphilis (+hep B and C if indicated by risk)
2
Q
What is the asymptomatic STI screening for a female?
A
- Vulvo-vaginal swab (self-taken/nurse) (can be endo-cervical if having an examination for another reason): chlamydia + gonorrhoea NAAT
- Serology: HIV + syphilis (+Hep B and C if indicated by risk)
3
Q
What are the 3 main/common causes of urethral discharge?
A
- chlamydia
- gonorrhoea
- non-gonococcal urethritis (NGU)
4
Q
Nongonococcal urethritis (NGU) is an inflammation of the urethra that is not caused by gonorrheal infection. For treatment purposes, doctors usually classify infectious urethritis in two categories: gonococcal urethritis, caused by gonorrhea, and nongonococcal urethritis (NGU).
What are the causes of NGU?
A
- chlamydia
- mycoplasma genitalium
- ureaplasma
- UTI
- trichomonas vaginalis
- candida
- herpes simplex virus
- human papilloma virus (warts)
- syphilis
- neisseria meningitides
- chemical irritation - alcohol, drug reactions
- urinary strones
- urethral foreign body or stricture
- phimosis
- trauma
5
Q
How is urethral discharge investigated?
A
-
URETHRAL SWAB:
- microscopy → NSU (>5 polymorphonuclear leucocytes (PMN)/high power field (x1000) averaged over 5 fields) + gonorrhoea (gram negative intracellular diplococci (seen within PMN cells))
- culture (chocolate agar) → gonorrhoea - confirm diagnosis + obtain antibiotic sensitivities
-
FIRST VOID URINE - chlamydia + gonorrhoea NAAT
- mycloplasma genitalium only if PMN on urethral slide confirming NGU
6
Q
What is the treatment for NSU/NGU and also persistent NSU?
A
- NSU/NGU → doxycycline 100mg BD 1 week + any specific treatment if specific cause found eg. TV
-
Persistent NSU:
- 1st line → azithromycin 1g STAT then 500mg OD for 2 days (to cover mycoplasma genitalium) + metronidazole 400mg BD 5 days
- 2nd line → moxiflocacin 400mg OD for 10 days
- if MG positive → needs MG test-of-care in 4wks
7
Q
What are the causes of vaginal discharge?
A
- chlamydia - thin, altered
- gonorrhoea - green/yellow
- trichomonas vaginalis - frothy green/grey, offensive
- mycoplasma genitalium
- candida - thick white, yeasty
- bacterial vaginosis - offensive fishy grey/colourless thin
- herpes simplex virus
- ureaplasma
- cervical ectopy
- physiological
- pregnancy
- group B beta haemolytic streptococcus
- actinomyces
- tuberculosis
- foreign body eg. tampon
- cervical/vaginal malignancy
8
Q
What investigations should be done for vaginal discharge?
A
-
High vaginal swab (lateral vaginal walls)
- microscopy → candida (spores/hyphae), BV (clue cells)
- TV culture / NAAT
- other cultures if pregnant/symptoms persist/freq recur
- group B beta haemolytic strep
- actinomyces
- High vaginal swab (posterior fornix) → wet slide – dark ground microscopy – TV
-
Endocervical / vulvo-vaginal swabs:
- chlamydia + gonorrhoea NAAT
- mycoplasma genitalium if PID suspected
-
Endocervical swabs:
- gonorrhoea microscopy + culture if high risk/contact
- HSV swab → if clinical suspicion of genital herpes
9
Q
What are differentials for vaginal discharge with a ‘fishy’ smell?
A
- bacterial vaginosis
- retained tampon
- trichomonas
10
Q
What is the treatment for candida?
A
- clotrimazole cream topical BD to vulva 1 week
- AND clotrimazole pessary 500mg PV stat or 200mg pv 3 days
11
Q
What are features and management of trichomonas vaginalis?
A
- common sexually transmitted infection
- flagellated protozoon
- incubation 1-3 weeks
- frothy green or grey discharge
- strawberry cervix
- Rx → metronidazole 400mg po bd for 5-7 days
12
Q
What are the features and management of bacterial vaginosis?
A
- imbalance of vaginal flora rather than sexually transmitted infection
- no symptoms in male partner of affected woman
- may be triggered by vaginal douching or by sexual intercourse
- causes fishy smelling discharge w/ minimal or no itch
- replacement of normal acid-forming lactobacilli by large numbers of other organisms especially gardnerella vaginalis
- increases vaginal pH to >4.5
- “clue cells” on microscopy: vaginal epithelial cell coated w/ numerous bacteria
- typical swab report: “heavy growth of anaerobes”
- Rx → oral metronidazole or topical clindamycin cream
13
Q
What are features + management of chlamydia?
A
- chlamydia trachomatis: obligate intracellular gram negative bacterium
- 1 in 10 young women
- incubation period 7-21 days
- 60% of cases = asymptomatic
- women → cervicitis (thin discharge, bleeding), dysuria
- men → urethral discharge, dysuria
- Ix → NAAT: first void urine, vulvovaginal swab or cervical swab
- Rx → doxycycline 100mg 7days OR (if preg/allergic) azithromycin 1g stat; test of cure at 6/52 if pregnant or rectal chlamydia
14
Q
What are the complications of chlamydia?
A
- pelvic inflammatory disease
- ectopic pregnancy
- subfertility in men + women
- sexually acquired reactive arthritis / Reiter’s disease
- Fitz Hugh Curtis syndrome - perihepatitis, RUQ pain
- adult conjunctivits
- vertical transmission - neonatal conjunctivitis / pneumonitis
- epididymo-orchitis
- prostatitis
15
Q
What needs to be done in regards to contact tracing, for chlamydia?
A
- pts diagnosed w/ chlamydia should be offered a choice of provider for initial partner notification - either trained practice nurses w/ support from GUM, or referral to GUM
- for men w/ urethral symptoms: all contacts since, and in the 4 weeks prior to, the onset of symptms
- for women + asymptomatic men all partners from last 6 months or the most recent sexual partner should be contacted
- contacts of confirmed chlamydia cases should be offered treatment prior to the results of their investigations being known (treat then test!)
16
Q
What are the features of gonorrhoea?
A
- gram negative diplococcus neisseria gonorrhoeae
- acute infection can occur on any membrane surface (typically genitourinary, rectum + pharynx)
- incubation = 2-5days
- males → urethral discharge, dysuria
- females → cervicitis, discharge (green/yellow)
- rectal + pharyngeal infection usually asymptomatic
- immunisation not possible + reinfection common due to antigen variation of type IV pili and Opa proteins
- local complications → urethral strictures, epididymitis + salpingitis
17
Q
What is the treatment for gonorrhoea?
A
- empirical treatment if diagnosed prior to culture → ceftriaxone 1mg IM stat
- if antimicrobial susceptibility results available prior to treatment + isolate sensitive to ciprofloxacin → give ciprofloxacin 500mg PO stat
- only consider epidemiological treatment if presenting within 14 days of exposure
- for those presenting after 14 days of exposure give treatment based on the results of testing
18
Q
What are causes of testicular/scrotal pain?
A
- testicular torsion
- epididymo-orchidits/epididymitis
- hernia
- tense hydrocele
- testicular ischaemia/infarction
- abscess formation
- testicular or epididymal tumour
- mumps epididymo-orchitis
19
Q
What symptoms might be elicited in someone with testicular/scrotal pain? What makes torsion more likely?
A
- unilateral testicular pain
- urethral discharge; however the urethritis if often asymptomatic
- torsion more likely if:
- onset of pain is sudden + severe
- no associated urethritis or UTI
- more common below age of 20 (adolescent)
20
Q
What signs may be elicted in a patient with testicular/scrotal pain?
A
- tenderness to palpation on affected side
- palpable swelling of epididmyitis
- swelling of testis
- urethral discharge
- hydrocele
- erythema and/or oedema of scrotum on affected side
- pyrexia
21
Q
What investigations are done for testicular/scrotal pain?
A
- testicular torsion suspected → urgent referral to urology (no investigations)
- full STI screen as for urethral discharge
- urinanalysis (<35yrs: STI>UTI, >35yrs: UTI>STI)
- MSU to lab
22
Q
Pelvic inflammatory disease (PID) (AKA salpingitis) is a term used to describe infection and inflammation of the female pelvic organs including the uterus, fallopian tubes, ovaries and the surrounding peritoneum. It is usually the result of ascending infection from the endocervix.
What are the common causative organisms?
A
- chalmydia trachomitis (most common)
- neisseria gonorrhoea
- mycoplasma genitalium
- mycoplasma hominis
These are the STIs that cause PID. There are also other organisms: facultative anaerobes and nongenital pathogens.
23
Q
What are the clinical features of PID?
A
- recent onset lower abdominal pain (bilateral)
- abnormal vaginal or cervical discharge
- deep dyspareunia
- fever, N+V
- dysuria + abnormal bleeding (intermenstrual/post-coital)
- lower back pain
- perihepatitis (Fitz-Hugh Curtis syndrome) (in 10%)
O/E → lower abdo tenderness; adnexal tenderness on bimanual VE; cervical excitation; fever >38 C; cervical discharge
24
Q
What investigations need to be done for suspected PID?
A
- high vaginal + endocervical swabs as for vaginal discharge + mycoplasma genitalium
- pregnancy test → exclude ectopic
- urinanalysis (+/- MSU)
- acute appendicitis / ectopic pregnancy suspected → refer urgently to surgeon / gynae
- test of care for M. Genitalium required after 4 weeks if positive
25
What is the **treatment** for PID?
* _low threshold for treatment_
* *(low risk of gonorrhoea)* → oral ofloxacin + oral metronidazole
* OR **IM ceftriaxone +** oral **doxycycline +** oral **metronidazole** (14 days)
* if pregnant/allergic (to doxy) *→* ceftriaxone + azithromycin + metronidazole
* if mycoplasma genitalium positive *→* moxifloxacin
_Complications_ of PID: **infertility, chronic pelvic pain + ectopic pregnancy**
26
What are **causes** of **genital lumps**?
* **STI:**
* Genital warts
* Molluscum contagiosum
* Condylomata lata (secondary syphilis)
* Scabetic papules
* **Non-STI:**
* Folliculitis
* Coronal papillae
* Sebaceous glands
27
What is the **investigation** of genital lumps?
* **clinical diagnosis**
* _consider_:
* syphilis serology
* skin swab
* isolate scabies mite
28
**Genital warts** (also known as *condylomata accuminata*) are a common cause of attendance at genitourinary clinics.
What are **features** of genital warts?
* caused by **HPV** - mainly **types 6 + 11** (some eg. 16/18 oncogenic)
* incubation **3-8 months**
* often asymptomatic, may be _pruritic_ and/or bleed
* solitary/multiple
* small (2-5mm) fleshy protuberances; slightly pigmented
* keratinised/non-keratinised
* transmitted by **close contact**; auto-inoculation rare
29
What is the **treatment** of genital warts?
* **Home Rx** (multple; non-keratinised) →
* topical **podophyllotoxin** (warticon/condylline) bd 3/7 then 4/7 off + repeat cycle for 4wks
* topical imiquimod second-line
* **Hosp Rx** (solitary; keratinised) →
* **cryotherapy**
* trichlorocetic acid, hyfrecation, laser / surgery
## Footnote
*Genital warts often resistant to treatment + recurrence common although majority of anogenital infections w/ HPV clear without intervention within 1-2 years*
30
What are the **_common_** **causes** of **genital ulceration**?
* Herpes Simplex virus
* Trauma
* Syphillis
* HIV related
31
What are the causes of **genital ulceration** due to **associated scratching or irritation**?
* Folliculitis
* Scabies
* Severe candida
32
What are the **rarer causes** of genital ucleration, in GUM clinics?
* **Topical** → chancroid, lymphogranuloma venereum, granuloma inguinale
* **Premalignant/malignant** → erythoplasia of queyrat, squamous cell carcinoma
* **Drugs** → fixed drug eruption, stevens johnson syndrome
* **Rheumatological** → reiter's, behcet's, IBD
* **Dermatological** → pemphigus, erosive lichen planus
33
There are two strains of the herpes simplex virus (HSV) in humans: **HSV-1** and **HSV-2**. Whilst it was previously thought HSV-1 accounted for oral lesions (cold sores) and HSV-2 for **genital herpes** it is now known there is considerable overlap.
What are the **features** of genital herpes?
* primary infection: may present w/ severe **ulceration** + **pain**
* **urinary retention** may occur
* _painful genital ulceration_
34
What is the **management** of genital herpes?
* Oral **Aciclovir** 400mg TDS 5 days
* Ligonocaine gel for _symptomatic_ relief
* Freq exacerbations → longer term aciclovir
In **pregnancy**, elective C-section at term is advised if a primary attack of herpes occurs during pregnancy after 28/40. Women w/ recurrent herpes who are pregnant should be treated w/ suppressive therapy (aciclovir) and be advised risk of transmission to baby is low
35
**Syphilis** is a sexually transmitted infection caused by the spirochaete *Treponema pallidum.*
Why is *treponema pallidum* **hard to isolate**?
* particularly difficult to isolate after **primary** stage
* word pallidum = "_pale_" - hard to see on conventional microscopy
* special microscopy (dark-field) used to inc contrast, but also easily _missed_
* **serology** is mainstay of diagnosis in secondary + tertiary stages
* serology alone cannot differentiate between syphilis + other diseases caused by treponemes (eg yaws + pinta), but used in combo with **clinical findings**
36
Before antibiotics were developed, syphilis infected many people and evidence shows that if untreated, two-thirds of patients will s**pontaneously clear** the infection. However, in the remainder it may progress.
What are the **stages + clinical features** of syphilis?
* **Primary features** → chancre (painless ulcer); local non-tender lymphadenopathy; often not seen in women
* **Secondary features** → 6-10wks after primary infection; systemic symptoms (fever, lymphadenopathy); rash on trunk/palms/soles; buccal 'snail track' ulcers; condylomata lata (painless, warty lesions on genitalia)
* **Tertiary features** → gummas; AAAs; paralytic dementia; tabes dorsalis; Argyll-Robertson pupil
* **Congenital syphilis** → blunted upper incisors; mulberry molars; rhagades; keratitis; saber shins; saddle nose; deafness
37
What are the **serological tests** for syphilis?
* **Cardiolipin tests**
* syphilis infection leads to production of non-specific antibodies that react to cardiolipin
* eg. VDRL + RPR
* insensitive in late syphilis
* becomes _negative_ after treatment
* false positive causes → SLE, HIV, malaria, TB
* **Treponemal specific antibody tests**
* eg. TPHA
* remains _positive_ after treatment
Hence, following Rx → CDRL becomes **negative**, TPHA remains **positive**
38
What is the **treatment** for syphilis?
* **IM benzathine penicillin**
* alternatives: doxycycline
39
What **features** of genital ulcers **differentiate** between HSV1, primary syphilis and secondary syphilis?
* **Single** → syphilis, drug eruption, chancroid, premalignant/malignant
* **Multiple** → primary/recurrent HSV, secondary syphilis
* **Superficial** → HSV, secondary syphilis (oral\>genital), circinate balantis (Reiter's)
* **Deep** → primary syphilis, chacnroid
40
**Genital/groin lymphadenopathy** may be normal, size is abnormal if \>2cm.
What are **causes** of lymphadenopathy?
* HIV
* Retier's syndrome
* Herpes Simplex
* Behcet's
* Secondary syphilis
* Inflammatory Bowel Disease
* Drugs, Steven Johnson syndrome
41
What **investigations** need to be done for lymphadenopathy?
* **HIV**
* **HSV culture** / PCR NAAT → ulcer + cervix; atypical lesions (fissures, spots)
* **dark ground microscopy** → syphilis
* **syphilis serology** (positive in 70% of primary syphilis)
* specific tests - syphilis IgG, TPPA
* nonspecific - RPR (VDRL)
Consider: candida swab, MC+S, scabies search, biopsy if long-standing/atypical/elderly. If tropical contact, seek expert advice.
42
How long should sex be **avoided** if a bacterial STI is diagnosed?
* **1 week**
* 2 weeks if PID/epididymo-orchitis/on erythromycin
* and until any partners have completed treatment
* _complete_ the course of antibiotics
43
What advice should be given RE: **contact tracing**?
* contact any contacts in **last 6 months** if _asymptomatic/warts/herpes_
* **last 4 weeks** if _symptomatic_ bacterial STI
* contact tracing for syphillis depends on stage of syphillis
* for HIV will depend on estimation of duration of infection
* offer **empirical** treatment to contacts of bacterial STIs unless M.Genitalium in which case test first
Consider female/male hygeine + skin care advice if BV/candida/HSV/warts/derm condition
44
Who should attend for **test of cure**?
* **chlamydia** in pregnancy/rectal chlamydia (NAAT at 6/52 post treatment)
* **gonorrhoea** (NAAT at 2/52 post treatment)
* **TV** if still _symptomatic_ (microscopy + culture at 1/52 post treatment)
* **mycoplasma genitalium** positive (NAAT at 4/52 post treatment)
Test for chlamydia reinfection at 3/12 post-treatment if \<25yrs old
45
What advice should be given to someone who has experienced **sexual assault**?
* wanting to report to police + \<7 dats since event? → need **forensic tests** prior to STI screen
* consider **emergency contraception**
* consider **HIV** post exposure prophylaxis / **Hep B** immunoglobulin / Hep B vax - depends on assailant
* if **\<2/52** since incident → offer antibiotic prophylaxis / STI screen + repeat at 2/52
* **\>2/52** since incident → STI screen
* **\<6/52** since incident → syphilis + HIV serology
* **6-11/52** → HIV, syphilis, Hep B/C + repeat at 12/52
* **\>12/52** → HIV, syphilis, Hep B/C + repeat Hep C at 6/12
* offer support, rape info leaflets, refer to rape centre - **_ensure safety_**
46
What is important to mention in the **HIV** **pre-test discussion**?
* risk assessment
* window period - **3 months** (reliable result by _4 weeks_ post-exposure)
* HIV vs AIDS
* confidentiality
* no impact on insurance/mortgages unless HIV positive
* management
* consent
