Genitourinary Medicine

Question 1

What are the STD triple swabs?

Answer 1

In a setting outside a sexual health clinic, three swabs (“triple swabs”) are usually taken to screen for infection in symptomatic women

Question 2

What are the different swabs for the STD triple swab?

Answer 2

Swab 1

1. Stuarts Medium
2. Posterior Fornix
3. “HVS”
4. TV, BV (“heavy growth of anaerobes”), Candida (& grp B strep)

Swab 2

1. Endocervix
2. Stuart’s Medium
3. “ECS”
4. GC

Swab 3

1. Endocervix (cells)
2. Chlam swab
3. “Chlamydia”
4. Chlamydia

Question 3

What is thrush?

Answer 3

A vaginal yeast infection is a fungal infection that causes irritation, discharge and intense itchiness of the vagina and the vulva — the tissues at the vaginal opening.

Also called vaginal candidiasis

Question 4

What is the cause of thrush?

Answer 4

Overgrowth of Candida albicans

Overgrowth of yeast can result from:

1. Antibiotic use, which causes an imbalance in natural vaginal flora
2. Pregnancy
3. Uncontrolled diabetes
4. An impaired immune system
5. Taking oral contraceptives or hormone therapy that increase estrogen levels

Question 5

What are the symptoms of thursh?

Answer 5

‘Cottage cheese’, non-offensive discharge

Vulvitis: dyspareunia, dysuria

Itch

Vulval erythema, fissuring, satellite lesions may be seen

Watery vaginal discharge

Question 6

How do you diagnose thrush?

Answer 6

1. A high vaginal swab is not routinely indicated if the clinical features are consistent with candidiasis
2. HbA1c for recurrent infections should be done

Question 7

What is the treatment for thrush?

Answer 7

Local treatments include

1. Clotrimazole pessary (e.g. clotrimazole 500mg PV stat)

Oral treatments include

1. Itraconazole 200mg PO bd for 1 day or fluconazole 150mg PO stat

if pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated

Question 8

What is chlamdyia?

Answer 8

Chlamydia trachomatis is a common sexually transmitted infection (STI) caused by bacteria

Question 9

What is the cause of chlamydia?

Answer 9

Chlamydia trachomatis

Most commonly spread through vaginal, oral and anal sex

It’s also possible for pregnant women to spread chlamydia to their children during delivery, causing pneumonia or a serious eye infection in the newborns

Question 10

What are the complications of chlamydia?

Answer 10

1. Pelvic inflammatory disease
2. Epididymitis
3. Prostate gland infection
4. Ecotopic pregnancy

Question 11

What are the symptoms of chlamydia?

Answer 11

1. Asymptomatic in around 70% of women and 50% of men
2. Women
   
   • Cervicitis (discharge, bleeding)
   • Dysuria

Question 12

Who is screened regularly for chlamydia?

Answer 12

1. Sexually active women age 25 or younger
2. Pregnant women
3. Women and men at high risk

Question 13

How is chlamydia diagnosed?

Answer 13

1. Urine test - first line for men
2. Vulvovaginal swab - pap test - first line for women

Investigation of choice - NAAT is done on these swabs

Question 14

What is the treatment for chlamydia?

Answer 14

First line

1. Doxycycline (7 day course)

In women who are breastfeeding or pregnant

1. Azithromycin
2. Amoxicillin
3. Erythromycin

Question 15

What is bacterial vaginosis?

Answer 15

Bacterial vaginosis is a type of vaginal inflammation caused by the overgrowth of bacteria naturally found in the vagina, which upsets the natural balance.

Question 16

What is the cause of bacterial vaginosis?

Answer 16

Bacterial vaginosis results from overgrowth of one of several bacteria naturally found in your vagina.

Usually, “good” bacteria (lactobacilli) outnumber “bad” bacteria (anaerobes)

Question 17

What are the symptoms of bacterial vaginosis?

Answer 17

1. Thin, gray, white or green vaginal discharge
2. Foul-smelling “fishy” vaginal odor
3. Vaginal itching
4. Burning during urination
5. Many women with bacterial vaginosis have no signs or symptoms.

Question 18

How do you diagnose bacterial vaginosis?

Answer 18

1. Thin, white homogenous discharge
2. Clue cells on microscopy: stippled vaginal epithelial cells
3. Vaginal pH > 4.5
4. Positive whiff/amine test (addition of potassium hydroxide results in fishy odour)

Question 19

What is the treatment for bacterial vaginosis?

Answer 19

1st line - Metranidazole

2nd Line - Clindamycin

Question 20

What is Trichomoniasis?

Answer 20

Trichomoniasis is a common sexually transmitted infection caused by a parasite

Question 21

What is the cause of Trichomoniasis?

Answer 21

Trichomoniasis is caused by a one-celled protozoan, a type of tiny parasite that travels between people during sexual intercourse.

The incubation period between exposure and infection is unknown, but it’s thought to range from four to 28 days.

Question 22

What are the symptoms of trichomoniasis?

Answer 22

In Women

1. Vaginal discharge: offensive, yellow/green, frothy
2. Vulvovaginitis
3. Strawberry cervix
4. pH > 4.5

In men

1. Usually asymptomatic but may cause urethritis

Question 23

How do you diagnose Trichomoniasis?

Answer 23

1. Sample of vaginal fluid for women
2. Urine for men under a microscope
3. Shows Trophozoites

Question 24

What is the treatment for trichomoniasis?

Answer 24

Metronidazole 5-7 days OR 2g single dose

Question 25

What is the difference between bacterial vaginosis and trichomonas?

Answer 25

Question 26

What is gonorrhea?

Answer 26

Gonorrhea is an infection caused by a sexually transmitted bacterium that infects both males and females. Gonorrhea most often affects the urethra, rectum or throat. In females, gonorrhea can also infect the cervix.

Question 27

What is the cause of gonorrhea?

Answer 27

Gonorrhea is caused by the bacterium Neisseria gonorrhoeae

Question 28

What are the complications of gonorrhea?

Answer 28

1. PID in women 2. Epididymitis in men

Question 29

What are the symptoms for gonorrhea?

Answer 29

**Males:** Urethral discharge, dysuria **Females:** Cervicitis e.g. leading to vaginal discharge Rectal and pharyngeal infection is usually asymptomatic

Question 30

How do you diagnose gonorrhea?

Answer 30

1. **Microscopic examination of Gram stained smears** * ​​Genital secretions looking for gram negative diplococci within cytoplasm of polymorphs * Male urethra * Female endocervix 2. **Nucleic acid amplification tests (NAAT)** * ​​Men - First pass utine * Women - vaginal or endocervical swab 3. **Culture on selective medium to confirm diagnosis**

Question 31

What is the treatment for gonorrhea?

Answer 31

1. IM Cefriaxone 1g - single doese 2. If **needlephobic -** oral ceftriaxone with azithromycin 3. If **allergic** - gentamycin

Question 32

What is Herpes?

Answer 32

Genital herpes is a common sexually transmitted infection caused by the herpes simplex virus (HSV)

Question 33

What is the cause of herpes?

Answer 33

**HSV-1** This is the type that usually causes cold sores or fever blisters around your mouth. HSV-1 is often spread through skin-to-skin contact, though it can be spread to your genital area during oral sex. Recurrences are much less frequent than they are with HSV-2 infection. **HSV-2** This is the type that commonly causes genital herpes. The virus spreads through sexual contact and skin-to-skin contact. HSV-2 is very common and highly contagious, whether or not you have an open sore.

Question 34

What are the symptoms of herpes?

Answer 34

**Pain or itching** You may experience pain and tenderness in your genital area until the infection clears. **Small red bumps or tiny white blisters** These may appear a few days to a few weeks after infection. **Ulcers** These may form when blisters rupture and ooze or bleed. Ulcers may make it painful to urinate. **Scabs** Skin will crust over and form scabs as ulcers heal.

Question 35

How do you diagnose herpes?

Answer 35

1. **Nucleic acid amplification tests (NAAT)** 2. **HSV serology** may be useful in certain situations such as recurrent genital ulceration of unknown cause

Question 36

What is the treatment for herpes?

Answer 36

Acyclovir Valacyclovir SAME AS SHINGLES

Question 37

What is syphilis?

Answer 37

Syphilis is a bacterial infection usually spread by sexual contact

Question 38

What is the causative orghanism of syphilis?

Answer 38

Treponema pallidum

Question 39

What are the symptoms of syphilis?

Answer 39

**Primary syphilis** The first sign of syphilis is a small sore, called a chancre **Secondary syphilis** Within a few weeks of the original chancre healing, you may experience a rash that begins on your trunk but eventually covers your entire body — even the palms of your hands and the soles of your feet. This rash is usually not itchy and may be accompanied by wartlike sores in your mouth or genital area **Latent syphilis** If you aren't treated for syphilis, the disease moves from the secondary stage to the hidden (latent) stage, when you have no symptoms **Tertiary syphillis** ​Gummas (granulomatous lesions of the skin and bones) Ascending aortic aneurysms General paralysis of the insane Tabes dorsalis Argyll-Robertson pupil

Question 40

How do you diagnose syphilis?

Answer 40

1. **Dark ground microscopy** * Detection of spirochaete in primary and secondary syphilis 2. **Serology** * **​Treponema pallidum Haemagglutination test (TPHA)** - Always positive even after treatment * **​Venereal Disease Research Laboratory (VDRL Test)** - Negative after treatment

Question 41

What are the results of the VDRL and TPHA after treatment of syphilis?

Answer 41

VDRL (Venereal Disease Research Laboratory) becomes **negative** TPHA (Treponema pallidum HaemAgglutination test) remains **positive**

Question 42

What is the treatment for syphilis?

Answer 42

1. IM **benzathine penicillin** is the first-line management * Alternatives: doxycycline 1. The **Jarisch-Herxheimer** reaction is sometimes seen following treatment * Fever, rash, tachycardia after the first dose of antibiotic * In contrast to anaphylaxis, there is no wheeze or hypotension * It is thought to be due to the release of endotoxins following bacterial death and typically occurs within a few hours of treatment * ​No treatment is needed other than antipyretics if required

Question 43

What is the Jarisch-Herxheimer reaction?

Answer 43

Reaction after taking treatment for syphilis for the first time Fever, chills, nausea, achy pain and a headache

Question 44

What is genital warts?

Answer 44

Genital warts are one of the most common types of sexually transmitted infections.

Question 45

What is the cause of genital warts?

Answer 45

The human papillomavirus (HPV) 6 + 11

Question 46

What are the symptoms of genital warts?

Answer 46

Small, flesh-colored, brown or pink swellings in your genital area A cauliflower-like shape caused by several warts close together Itching or discomfort in your genital area Bleeding with intercourse

Question 47

How do you diagnose genital warts?

Answer 47

Pap tests HPV test

Question 48

What is the treatment for genital warts?

Answer 48

**FIRST LINE** Topical podophyllin - better for non-keratinised warts Cryotherapy (freezing) - better for keratinised warts **SECOND LINE** Topical Imiquimod

Question 49

What is HIV?

Answer 49

Acquired immunodeficiency syndrome (AIDS) is a chronic, potentially life-threatening condition caused by the human immunodeficiency virus (HIV)

Question 50

What is the cause of HIV?

Answer 50

HIV is caused by a virus. It can spread through sexual contact or blood, or from mother to child during pregnancy, childbirth or breast-feeding.

Question 51

What are the symptoms of HIV?

Answer 51

1. Fever 2. Headache 3. Muscle aches and joint pain 4. Rash 5. Sore throat and painful mouth sores 6. Swollen lymph glands, mainly on the neck 7. Diarrhea 8. Weight loss 9. Cough 10. Night sweats

Question 52

How do you diagnose HIV?

Answer 52

**Antigen/antibody tests** These tests look for antibodies to HIV in blood or saliva. Most rapid HIV tests, including self-tests done at home, are antibody tests **Nucleic acid tests (NATs)** These tests look for the actual virus in your blood (viral load). They also involve blood drawn from a vein. If you might have been exposed to HIV within the past few weeks

Question 53

What is the treatment for HIV?

Answer 53

1. **Antiretroviral therapy** * **​​**Typically two nucleoside reverse transcriptase inhibitors (NRTI) and either a protease inhibitor (PI) 2. **Mode of delivery** * Vaginal delivery is recommended if viral load is less than 50 copies/ml at 36 weeks, otherwise caesarian section is recommended * A zidovudine infusion should be started four hours before beginning the caesarean section 3. **Neonatal antiretroviral therapy** 4. **Infant feeding** * In the UK all women should be advised not to breast feed