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Genitourinary Medicine Flashcards

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1
Q

Which bacteria are essential to controlling the vaginal pH?

A

Lactobacilli

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2
Q

What is the pathophysiology of bacterial vaginosis?

A

Reduced lactobacilli = reduced lactic acid = increased pH = anaerobic bacteria multiply e.g. G vaginalis / M hominids/ Prevotella sp.

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3
Q

Give the risk factors for bacterial vaginosis.

A 
Multiple sexual partners
Excessive vaginal cleaning 
Recent ABX
Smoking 
Copper coil
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4
Q

What are the clinical features of bacterial vaginosis?

A

Asymptomatic

Vaginal odour: fishy (due to amines)
White/grey vaginal discharge

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5
Q

Clue cells are pathognomonic of?

A

Bacterial vaginosis

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6
Q

Which criteria can be used to make a diagnosis of Bacterial Vaginosis?

A 
Amsel Criteria (3/4):
pH > 4.5 
White/grey discharge 
Fishy odour 
Clue cells
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7
Q

What is the management for Bacterial vaginosis?

A

Metronidazole PO 400mg BDS 5-7 days

Can use throughout pregnancy

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8
Q

What is the most common cause of Bacterial vaginosis?

A

Gardnerella vaginalis

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9
Q

What is the gold standard investigation in Bacterial vaginosis?

A

Vaginal swab and microscopy + gram-stain

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10
Q

What pathogen is the cause for vaginal candidiasis?

A

C albicans

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11
Q

How may genital thrush be classified?

A

Uncomplicated: simple, single cause and no other comorbidities

Complicated: recurrent (≥4 episodes); severe infection; major co-morbidity

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12
Q

Give 3 RFs for Vulvovaginal candidiasis

A

Poorly controlled diabetes

Immunocompromised

Local irritants

Broad-spectrum ABX

Sexual activity

HRT

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13
Q

What are the clinical features of vulvovaginal candidiasis?

A

Non-malodorous, thick and white vaginal discharge
Vaginal itching
Vaginal soreness

Vulvovaginal irritation
Vaginal fissuring
Excoriation

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14
Q

How is VV Candidiasis managed?

A

Uncomplicated
Intra-vaginal Clotrimazole 10% single dose

Complicated
Fluconazole PO 150mg BDS for 2/7 (3 days apart)

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15
Q

If a patient has VV Candidiasis refractory to treatment within 7-14 days, what is your next steps?

A 
Confirm Tx course and adherence
\+ 
Reassess RF
\+ 
Consider alternative diagnosis 
\+
Consider treatment
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16
Q

A patient is on their 4th episode of thrush this year. How would you manage them?

A

Supportive: RF modification
+
Medical: Oral Fluconazole 14/7 (induction) + Oral Fluconazole for 6/12 (maintenance)

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17
Q

Which pathogen causes Trichomonas?

A

Trichomonas vaginalis - a protozoa

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18
Q

What are the clinical features of Trichomonas?

A

Malodorous, frothy green-yellow discharge
Vulval itchiness

Inflammation of the vulva/glans

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19
Q

What investigations should be conducted in a patient with potential Trichomonas infection?

A

Cervical inspection

Vaginal swab

Microscopy

NAAT

Culture

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20
Q

What is the management for Trichomonas?

A

Metronidazole PO 400mg BDS for 5/7

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21
Q

what pathogen causes Chlamydia?

A

Chlamydia trachomatis

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22
Q

What is the gold-standard test for Chlamydia?

A

NAAT

VVS (F)

FCU (M)

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23
Q

Which serovars of Chlamydia cause Trachoma?

A

A-C

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24
Q

Which serovars of Chlamydia cause LGV?

A

L1-L3

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25
Which serovars of Chlamydia cause Urogenital infection?
D-K
26
What are the clinical features of Chlamydia?
Majority (75% F cf 50% M) are asymptomatic ``` If symptoms: Vaginal/ Urethral discharge Post-coital bleeding Intermenstrual bleeding Dysuria Lower abdominal pain Deep dyspareunia ```
27
What are the complications of Chlamydia?
Tubo-ovarian abscess Fitz-Hugh-Curtis Syndrome Infertility Ectopic pregnancy Chronic pelvic pain
28
What are the clinical features of Fitz-Hugh-Curtis Syndrome?
Complication of PID due to Chlamydia/Gonorrhoeal infection featuring RUQ due to pelvic adhesions
29
What is the management of Chlamydia?
Doxycycline 200mg STAT then 100mg PO OD 7/7 + Ceftriaxone IM 1g STAT + Test of cure 4 weeks later
30
Which conditions cause genital ulcers?
``` Syphilis HSV HPV Granuloma inguinale LGV Chancroid ```
31
Which patient group is Lymphgranuloma venereum more prevalent amongst?
MSM
32
What are the 3 stages of infection of LGV?
Primary: Painless papule/pustule or ulcer Secondary: Regional lymphadenopathy (femoral/inguinal) days to weeks after primary lesion with lymphadenitis become confluent to form a buboe Tertiary: Recover OR chronic anogenital infection which causes proctocolitis, fistulae, strictures or fibrotic areas
33
What are the clinical features of LGV?
Two areas affected - the genitals + the anus Painless pustule/papule/ulcer Rectal pain Rectal bleeding Rectal discharge Tenesmus ``` Lymphadenopathy Lymphadenitis Buboes Groove sign (inguinal and femoral lymphadenopathy separated by inguinal ligament) Systemic upset ``` Proctitis Fistulae Strictures
34
What conditions is Groove sign seen in and how is it caused?
LGV due to lymphadenopathy of femoral and inguinal regions which is separated by the inguinal ligament
35
How is LGV diagnosed?
Swab + NAAT
36
How is LGV managed?
Supportive: Avoid sexual contact + trace testing (4 weeks of symptoms or 3 months of asymptomatic carriage) + Medical: Doxycycline 100mg PO 3/52
37
What are the complications of LGV?
Lymphoedema Fistulae formation Strictures Disfiguring fibrotic scarring
38
Which organism causes Gonorrhoea?
Neisseria gonorrhoea
39
What is the morphology of N gonorrhoea?
Gram negative diplococci
40
What proportion of gonorrhoea infections cause disseminated infection?
1%
41
What are the complications of Gonorrhoea?
``` Septic arthritis Meningitis Reiter's Syndrome Conjunctivitis Endocarditis ``` ``` PID Tubal infertility Ectopic pregnancy Chronic pelvic pain Fitz-Hugh-Curtis Syndrome ``` Prostatitis Epididymo-orchitis PID
42
What are the clinical features of Gonorrhoea infection?
Urethral discharge (M > F) - mucopurulent discharge Cervicitis - and vaginal discharge Lower abdominal pain Dysuria Testicular pain
43
What is the gold-standard test for Gonorrhoea?
NAAT - urethral swabs (M) and VVS (F)
44
What is the management of Gonorrhoea?
Supportive: Contact tracing 3/12; Stop sexual contact until 7 days post-treatment; Test of cure 1/12 + Medical: Ceftriaxone IM 1g
45
Which pathogen causes Syphilis?
T pallidum
46
What are the clinical features of Syphilis?
Primary features: - Chancre (painless ulcer) - Local, non-tender lymphadenopathy Secondary features: - Fever - Lymphadenopathy - Rash on trunk and volar surfaces - Buccal snail track ulcers - Condylomata lata (painless, warty lesions on genitalia) Tertiary features: - Gummas (granulomatous lesions of skin and bone) - Ascending aortic aneurysms - Tabes dorsalis - Argyll-Robertson pupil
47
What are the clinical features of congenital syphilis?
Deafness Saddle nose Rhagades (linear scars at angle of mouth) Keratitis Blunted upper incisor teeth (Hutchinson's teeth) Mulberry molars Clutton's joints (symmetrical joint swelling - e.g. knees) Saber shins (tibial bowing from chronic inflammation)
48
What is Latent Syphilis?
An asymptomatic period in which there is serological evidence of infection but no symptoms 1) Early latent syphilis = <2 years from infection 2) Late latent syphilis =>2 years from infection
49
In which condition is an Argyll-Robertson pupil seen? Outline what is seen.
Neurosyphilis - constricted pupil accommodates when focusing to nearby object but does not react to light
50
How is Syphilis diagnosed?
Ab test - Serology
51
How is Syphilis managed?
IM Benzathine benzylpenicillin
52
What is a Jarisch-Herxheimer reaction?
Acute febrile illness presenting in first 24 hours of Syphilis treatment with headache, myalgia, chills and rigors. Reaction occurs following initial dose of anti-treponemal treatment. Occurs in 10-35% patients.
53
How do you manage a Jarisch-Herxheimer reaction?
NSAIDs + Prednisolone PO 40-60mg 3/7 (after first dose of anti-treponemal ABx)
54
Which bacterium causes Granuloma inguinale?
Klebsiella granulomatis
55
What are the clinical features of Granuloma inguinale?
Painless papule/nodule with beefy red appearance (high vascularity) in the genital or inguinal region Papule/Nodule develop an ulcerated appearance - ulcerate from the middle with friable, raised and rolled margin
56
How is Granuloma inguinale diagnosed?
Clinically, due to lack of resources in endemic regions PCR with Donovan bodies seen
57
How is Granuloma inguinale managed?
Azithromycin 1g PO weekly
58
What are the complications of Granuloma Inguinale?
``` Malignant change - e.g. Squamous Cell Carcinoma Lymphoedema Haematogenous spread Polyarthritis Osteomyelitis Stenosis (anus/vagina) Mental Health Disease ```
59
Which pathogen causes Chancroid?
Haemophilus ducreyi
60
What is the clinical presentation of Chancroid?
Multiple painful papules which become ulcers Lymphadenopathy Buboe (infected, painful lymphadenitis, ulcerating and becoming supportive
61
How is Chancroid diagnosed?
Swab + NAAT Microscopy - gram negative coccobacili
62
What is the management for Chancroid?
Azithromycin PO 1mg STAT
63
Which pathogen causes Pediculosis pubis?
Phthirus pubis (crab louse) Pediculosis humanus capitis Pediculosis humanus corporis
64
What are the clinical features of Pediculosis pubis?
Pruritus Visible lice Small blue macules - prolonged infestation and injection of natural anticoagulant from live saliva
65
How is diagnosis of Pediculosis pubis made?
Direct visualisation with naked eye or microscopic examination to identify lice/nits
66
How is Pediculosis pubis managed?
Supportive: wash bedding at high temperature setting + Medical: Topical permethrin 1% Apply to site, wash after 10 minutes, remove nits with comb and put clean clothes on
67
Which pathogen causes Anogenital herpes?
HSV-1 HSV-2
68
What is the most common cause of Anogenital herpes?
HSV-1
69
What is the typical location of HSV in recurrent oro-labial herpes?
Trigeminal ganglia
70
What is the typical location of HSV in recurrent anogenital herpes?
Sacral nerve root ganglia
71
What are the clinical features of anogenital herpes?
Painful vesicle/pustule/ulceration present on genitals (F+M) or anus (M) Discharge Systemic symptoms: fever, headache, malaise, myalgia Proctitis: bleeding, tenesmus, pain, discharge Lymphadenopathy/lymphadenitis
72
How is anogenital herpes diagnosed?
Swab + NAAT Serology (if recurrent genital ulcers)
73
How is anogenital herpes managed?
Aciclovir PO 400mg TDS 5/7
74
What are the complications of Anogenital herpes?
``` Aseptic meningitis Encephalitis Pneumonia Oesophagitis Hepatitis Urinary retention ```
75
Which pathogen causes anogenital warts?
HPV-6 and HPV-11
76
What are the clinical features of anogenital warts?
Anal wart (condylomata): cauliflower appearance Irritation Bleeding
77
How are Anogenital warts diagnosed?
Clinical diagnosis
78
How are anogenital warts managed?
Supportive: use condoms; GUM referral + Medical: Podophyllotoxin cream 0.15%; Imiquimod 5% ± Surgery: Cryotherapy; Electrocautery; Excision
79
What genotypes of HPV is protected against by the vaccine given at 12-13 years old in the UK?
HPV-6, -11, -16, -18 (Gardasil)
80
Explain how the Cervical Screening Programme in the UK works?
Aged 25-64 invited 25-49 = every 3 years 49-65 = every 5 years Test for hrHPV - positive? If positive, then cytology of cells conducted Any dyskaryosis (low-grade or high-grade) = Colposcopy within 2 weeks
81
What type of epithelium lines the endocervix?
Simple columnar epithelium
82
What epithelium lines the ectocervix?
Non-keratinised stratified squamous epithelia
83
What is the most common type of cervical cancer?
Invasive squamous cell carcinoma
84
What does Colposcopy comprise of?
Visualisation of the cervix with additional tests. Lugol's iodine test: add iodine-based solution with normal tissue containing glycogen going brown/black. CIN/Invasive cancer does not contain much glycogen thus does not stain. Acetic acid can be applied which causes abnormal cells to become white - acetowhite Biopsy - tissue sample to allow further analysis to be performed See and treat policy may be offered to those with high-grade CIN
85
What reasons are there to delay cervical screening?
Menstruating Pregnancy Less than 3/12 after a pregnancy (post-natal/ miscarriage/ ToP) Abnormal vaginal discharge
86
If cytology is normal but hrHPV positive, what is your next action?
Repeat cervical screening at 12 months
87
If the hrHPV is positive but cytology is negative, you have recalled 12-months later and hrHPV +ve at 24 months, what is your next course of action?
Colposcopy
88
How is CIN treated?
LLETZ
89
What are the grades of CIN?
CIN 1 = mild dysphasia CIN 2 = moderate dysplasia CIN 3 = severe dysplasia
90
A patient enquires about contraception. She asks which types are available.
Abstinence Natural family planning Barrier - condoms COCP POP Copper coil Progesterone coil Progesterone injection Progesterone implant Surgery
91
Which form of IUD would you use in a patient with Wilson's Disease?
Progesterone-secreting coil - avoid Copper coil
92
In a patient with previous cervical cancer, which form of contraception should be avoided?
IUD
93
A patient is worried about the risk factors for the combined oral contraceptive pill. What risks factors would you check in her?
``` Migraine with aura Uncontrolled hypertension (>160/ >100) VTE Hx Aged 35+ and smoker Major surgery with prolonged immobility Arteriopath (vascular disease; IHD; CM; AF) Liver disease SLE Antiphospholipid syndrome ```
94
Why should the progesterone injection be stopped before 50 years old?
Risk of OP
95
How long should contraception be used following menopause?
>50 = 1 year <50 = 2 years
96
When can an IUD be inserted for postpartum contraception?
within 48 hours of birth and 4 weeks of birth
97
When can the COCP be started after childbirth?
6 weeks after childbirth if breastfeeding
98
What is the MOA of the COCP?
Contains both oestrogen and progesterone. 1) Prevent ovulation 2) Progesterone thickens cervical mucous 3) Progesterone inhibits proliferation of endometrium, reducing chance of successful implantation Both oestrogen and progesterone have negative feedback on Hypothalamus and Anterior pituitary to suppress GnRH, LH and FSH thus ovulation does not occur
99
What are the two types of COCP?
Monophasic (same amount) Multiphasic (varying amounts)
100
What does Microgynon contain?
Ethinylestradiol + Levornogestrel
101
What does Loestrin pill contain?
Ethinylestradiol and Norethisterone
102
What are the different pill regimes?
21 days on, 7 days off 63 days on, 7 days off Continuous use without pill-free period
103
What are the side effects of the pill?
``` Breakthrough bleeding Mastalgia Mood changes/depression Headaches Hypertension VTE Small increased risk of breast and cervical cancer (returns to normal 10 years after stopping) Small increased risk of MI/Stroke ```
104
What are the benefits of the COCP?
Contraception Rapid return to fertility after stopping Improvement in premenstrual symptoms, menorrhagia, dysmenorrhoea Reduced risk of benign ovarian cysts Reduced risk of endometrial, ovarian and colon cancer
105
What are the contraindications to starting the COCP?
``` Uncontrolled hypertension (>160; >100) VTE Hx Immobility Migraine with aura (risk of stroke) Vascular disease Ischaemic Heart Disease AF Liver cirrhosis and liver tumours SLE Antiphospholipid syndrome ```
106
What level of protection does starting the pill have depending on where you are in your menstrual cycle?
Before day 5 = immediately After day 5 = condoms for first 7 days
107
How should you swap from a POP to a COCP?
7 days of extra contraception required
108
How may you screen for contraindications in a consultation regarding the contraceptive pill?
``` Age PMHx -VTE/ Migraine/Cancer/ CVD/ SLE FHx - VTE/ Breast Cancer Weight and height Blood pressure ```
109
When missing the pill and it is <72 hours since the last pill was taken, what is the advice?
Take missed pill ASAP - can take 2 in one day No extra contraception is required
110
If a woman misses her pill in Day 2 and Day 6 of her cycle, what is the advice?
Emergency contraception - Days 1-7 and 2 missed pills = emergency contraception
111
What rule can we use when deciding if a woman requires emergency contraception when missing the pill?
Use the "Rule of 7" when a woman has missed her pill 2 times (>72 hours since last pill was taken) Days 1-7 = emergency contraception Days 8-14 = none needed Days 15-21 = none needed, take next pack back-to-back
112
Prior to a major operation, when should you stop the COCP?
4 weeks before
113
How do you take the POP?
Continuously
114
Which type of pill cannot be delayed by more than 3 hours?
Traditional POP - Norgeston
115
How late can the Desogestrel-only pill be taken for and still be effective?
12 hours
116
What is the MOA of the POP?
Only progesterone Inhibit ovulation (Desogestrel) Thicken cervical mucous Altering endometrium to make implantation less likely Reduce ciliary action of fallopian tubes
117
How long does it take for the POP to have full effect as a contraceptive?
48 hours
118
When switching from a COCP to a POP, what precautions should be taken?
Week of hormone-free period after COCP pack is best time to swap, no additional contraception required If sexual intercourse since completing last pack of COCP, take Days 1-7 then switch, then use 48 hours of additional contraception
119
What are the side effects of POP?
Bleeding changes: 1/3 less; 1/3 normal; 1/3 unscheduled Breast tenderness Headaches Acne Small risk of ovarian cysts; ectopic pregnancy (reduced ciliary action); increased risk of breast cancer
120
When is a pill considered missed if a POP?
3 hours if traditional POP 12 hours if desogestrel POP
121
What should you do if you miss a POP?
Take normal pill, take missed pill, use extra contraception for 48 hours Emergency contraception if sex since missed pill or within 48 hours of restarting regular pills
122
How is the Progesterone injection administered?
Depot medroxyprogesterone acetate (DMPA) given IM or SC in 3/12 interns
123
How long may it take for fertility to resume following the Depot Medroxyprogesterone acetate injection?
12 months
124
What are the contraindications for the Depot Medroxyprogesterone Acetate injection?
``` Breast cancer Ischaemic Heart Disease and Stroke Unexplained vaginal bleeding Severe liver cirrhosis Liver cancer ```
125
What are the side effects of the Progesterone Injection?
Weight gain Osteoporosis ``` Acne Reduced libido Mood changes Headaches Flushes Alopecia Skin irritation at injection sites ``` Osteoporosis
126
What are the potential benefits of the Progesterone injection?
Improve dysmenorrhoea Improves endometriosis Reduces risk of ovarian and endometrial cancer Reduces the severity of sickle cell crisis in patients with sickle cell anaemia
127
How long does the progesterone implant last?
3 years
128
Which form of progesterone is used in the Nexplanon implant?
Etonogestrel
129
How may the progesterone implant affect the bleeding pattern?
1/3 = infrequent bleeding 1/4 = prolonged bleeding 1/5 = no bleeding Remainder have normal, regular bleeding
130
Which two types of IUD exist?
Copper coil IUD Levornogestrel
131
What is the difference between a IUD and IUS?
the two types of coils are referred to as IUD and IUS. The intrauterine device (IUD) refers to the copper coil, and the intrauterine system (IUS) refers to the levonorgestrel (e.g. Mirena) coil. The copper coil is just a “device”, whereas the hormones in the Mirena make it a “system”.
132
When are IUDs contraindicated?
``` PID Immunosuppression Pregnancy Unexplained bleeding Pelvic cancer Uterine cavity distortion e.g. fibroids ```
133
Which genetic condition is the Copper coil contraindicated?
Wilson's disease
134
When the Copper IUD is inserted, how long does it take to be effective?
Instantly
135
How long is the Mirena coil licensed for in contraception?
5 years for contraception
136
How long is the Mirena coil licensed for in HRT?
4 years
137
When is irregular bleeding considered normal following insertion of an IUD?
6 months, after this, exclude other causes such as sexually transmitted infections, pregnancy, cervical screening etc.
138
Which organisms may be found on the cervical smears of women with the coil?
Actinomyces-Like Organisms (ALO) on smears
139
Which forms of emergency contraception exist? When would you use each?
Levornogestrel (within 72 hours of UPSI) Ulipristal (within 120 hours of UPSI) Copper coil (within 5 days of UPSI)
140
A woman presents following an UPSI. She is in day 11 of her cycle, she had the UPSI on day 5. Her cycle is usually 30 days long. What form of emergency contraception would you use and why?
Copper coil as it is within 5 days of her estimated date of ovulation. Cycle is 30 days thus 30 - 14 = 16
141
A woman presents following an UPSI. She is in day 11 of her cycle, she had the UPSI on day 10. Her cycle is usually 30 days long. What form of emergency contraception would you use and why?
Levornogestrel as she is within 72 hours
142
A woman presents following an UPSI. She is in day 11 of her cycle, she had the UPSI on day 7. Her cycle is usually 30 days long. What form of emergency contraception would you use and why?
Ulipristal - as within 120 hours of UPSI
143
What is the dose of Levornogestrel given as emergency contraception?
1.5mg STAT or 3mg STAT (if >70kg or BMI >26)
144
What are the side effects of Ulipristal?
N/V ``` Spotting Abdominopelvic pain Back pain Mood changes Headache Dizziness Breast tenderness ```
145
What are the main cautions when using Ulipristal?
Breastfeeding avoided for 1 week Avoid in severe asthma
146
Which forms of sterilisation exist?
Female: Tubal occlusion Male: Vasectomy
147
What is Gillick Competence?
Judgement surrounding a child able to consent to treatment - decision by decision basis
148
What are the Frazer Guidelines?
Guidelines specific to provision of contraception to patients under 16 years old without parental input and consent Child must be mature and intelligent enough to understand treatment Cannot be persuaded to discuss with parents Likely to have intercourse regardless of treatment Physical/Mental health likely to suffer without treatment Treatment is in their best interest
149
Strawberry cervix is present in which infection?
Trichomonas

Medicine (18 decks)

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