GUM

Question 1

Name infectious causes of urethral discharge and the aetiological agent

Answer 1

• Gonococcal urethritis (Neisseria Gonorhea)
• Non-gonococcal urethritis (no aetiology, Chlamydia trachomatis, Mycoplasma genitalium, Trichomonas vaginalis, Candida albicans)
• Intra-urethral ulcers (HSV)
• Intra-urethral warts (HPV)

Question 2

Name a non-infectious cause of urethral causes

Answer 2

Physiological trauma

Question 3

Infectious causes (+ causative organism) of vaginal discharge

Answer 3

Vaginal infections:
* Candida albicans
* Gardnerella vaginalis
* Trichomonas vaginalis

Cervical infections:
* Chlamydia trachomatis
* Neisseria gonorrhoeae
* Herpes simplex virus (HSV)
* Human Papilloma virus (HPV)
* Treponema pallidum

All except candida and gardnerella are sexually transmitted

Question 4

Non-infectious causes of vaginal discharge

Answer 4

Vaginal:
* Physiological trauma
* FB (retained tampons)
* Retained products

Cervical:
* Carcinoma of the cervix (linked with HPV infection)

Question 5

Infectious causes of genital ulcers (and causative organism)

Answer 5

Multiple and painful:
* Herpetic (HSV)
* Chancroid (Haemophilus ducreyi)
* Scabies (Sarcopetes scabiei)

Single and painful:
* TB (M. tuberculosis)
* Bacterial infection (Staphylococcus aureus)

Multiple and painless (Treponema pallidum)

Single and painless:
* Primary syphilis (Treponema pallidum)
* Lmphgranuloma venerium (LGV) (Chlamydia trachomatis (LGV serovar))
* Granuloma inguinale (Klebsiella granulomatis (Donovanosis)

Question 6

Non-infectious diseases of genital ucers

Answer 6

• Behcet’s disease
• Steven Johnson syndrome
• Carcinomas

Question 7

Causative organism of chlamydia and transmission

Answer 7

Chlamydia Trachomatis (obligate intracellular bacteria)

Transmission = sex + vertical

Question 8

Risk factors for chlamydia

Answer 8

• Under 25
• New sexual partner
• > 1 sexual partner/year
• No condoms

Question 9

Clinical features of chlamydia in women and men

Answer 9

Women
* Symptoms: asymptomatic (70%), dysuria, pelvic pain
* Signs: Increased vaginal discharge, post coital/intermenstrual bleeding

Men:
* Symptoms: asymptomatic (50%), dysuria, testicular pain
* Signs: Urethral discharge

Question 10

Ix and management for chlamydia

Answer 10

Ix:
* Nucleic acid amplification technique (NAAT)
* Test for LGV in MSM with rectal chlamydia

Management:
* Doxycycline 100mg BD for 7 days (NB Doxycycline = contraindicated in pregnancy)
* Alternative: Azithromycin 1G OD day 1, 500mg OD day 2+3

Question 11

Advice + test of cure in chlamydia

Answer 11

Advice:
* No sexual contact for 1 week
* PIL leaflet on condition
* Health advisor on contact tracing

Test of cure (TOC):
* Retest in 3 months if under 25
* TOC in 6 weeks if pregnant or rectal infection

Question 12

Complications of chlamydia

Answer 12

Males:
* Epididymo-orchitis (red, swollen, tender hemiscrotum)
* Prostatitis (dysuria, haematuria, haematospermia, urgency)
* Urethral structure (inflammation in the urethra can lead to fibrosis of the lumen)

Females:
* Pelvic inflammatory disease (PID) = infection of the uterus, fallopian tubes, ovaries and inside the pelvis due to bacterial spread
* Peritoneal spread (Fitz-High-Curtis syndrome; inflammation of the liver capsule without parenchymal involvement - presents with RUQ pain)
* Problems in pregnancy (miscarriage, ectopic pregnancies, preterm delivery, congenital infections, vertical transmission - causing chlamydial conjunctivitis + pneumonia in newborn)
* Infertility

General complications:
* Reactive arthritis - an autoimmune arthritis (triad of conjuctivitis, urethritis, arthritis - ‘can’t see, can’t pee, can’t climb a tree’)
* Trachoma (granular conjunctivitis of the inner eyelids resulting in eye discharge, swollen eyelids and trichiasis (misdirected eyelashes))
* Lymphogranuloma venereum (LGV) = infection of the lymphatic vessels + nodes

Question 13

Causative organism of gonorrhoea and transmission

Answer 13

Neisseria Gonorrhoea (gram-negative diplococcus)

Transmission: Sexual contact, vertical

Question 14

A 23 y/o male presents to the GP with dysuria and ‘pus coming out of the penis’. His history includes 9 sexual partners in the last 3 months, none of whoch he used a condom with. O/E there is yellow discharge from the urethral meatus. Underlying diagnosis?

Answer 14

Gonorrhoea

Question 15

Clinical features of gonorrhoea

Answer 15

Women:
* Symptoms: Asymptomatic (50%), pelvic pain (25%), dysuria (12%)
* Signs: Mucopurulent discharge (50%)

Males:
* Symptoms: Asymptomatic (<10%), dysuria (50%)
* Signs: Mucopurulent discharge (80%)

Question 16

Ix and management for gonorrhoea

Answer 16

Ix:
* Microscopy (sensitivity 90-95% if discharge present, 50% if not)
* NAAT (sensitivity >96%)
* Culture (important due to increasing antibiotic resistance with GC)

Treatment:
* Ceftriaxone 1g IM (mixed with 3.5msl 1% lidocaine)
* Ciprofloxacin 500mg PO stat FIRST-LINE (where sensitivities available prior to treatment)

Question 17

Advice and TOC for gonorrhoea

Answer 17

Advice:
* No sexual contact for 1 week after patient and their partner are treated
* PIL leaflet on condition
* Health advisor for contact tracing

TOC: 2 weeks after treatment

Question 18

Complications of gonorrhoea

Answer 18

Men → epididymo-orchitis; Women → PID

Males:
* Urethral stricture (chronic inflammation leads to fibrosis)
* Infertility (chronic epididymitis can lead to infertility)

Females:
* PID (increases the risk of tubal infertility)
* Fitz-Hugh-Curtis syndrome (peritoneal spread can lead to perihepatitis (inflammation of the liver capsule without parenchymal involvement) which presents with RUQ pain
* Pregnancy issues (risk of miscarriage, congenital malformations, vertical transmission)

Disseminated infection:
* Septic arthritis
* Temosynovitis
* Meningitis
* Infective endocarditis
* Dermatitis (Vesicular, pustular or maculopapular lesions)
* Polyarthalgia

Question 19

Causative organisms of non-specific urethritis (NSU)/ non-gonococcal urethritis

Answer 19

• No cause found in 50%, chlamydia trachomatis up to 45%
• Mycoplasma genitalium 10-25%
• Trichomonas vaginalis 1-20%
• Ureaplasma urealyticum 5-10%
• UTI <6%, adenoviruses 2-4%
• Herpes Simplex Virus 2-3%
• Candida, trauma, irritation, urethral stricture, lichen sclerosis, urinary calculi

Question 20

Risk factors and transmission of Non-Specific Urethritis (NSU) / non-gonococcal urethritis

Answer 20

Risk factors:
* Sexually active
* Unprotected sex
* Homo/bisexual
* Aged <35
* Multiple partners

Transmission:
* Sexual

Question 21

Clinical features and complications of Non-Specific Urethritis (NSU) / non-gonococcal urethritis

Answer 21

Clinical features:
* Asymptomatic
* Urethral discharge
* Dysuria

Complications:
* Epididymo-orchitis
* Sexually acquired reactive arthritis

Question 22

Ix and management for Non-Specific Urethritis (NSU) / non-gonococcal urethritis

Answer 22

Ix:
* Microscopy: gram stained urethral smear (diagnose if >5 pus cells per film)
* Culture
* First pass urine (FPU) to test for gonorrhoea/chlamydia and mycoplasma
* Urinalysis
* MSU

Management:
Doxycycline 100mg BD 7 days

Question 23

What is the causative organisma and transmission of Trichomonas vaginalis

Answer 23

Flagellated protozoon
Transmission: sexual contact

Question 24

A 19-year-old female presents to the GUM clinic with a three-day history of foul-smelling, green, frothy discharge from her vagina. She has had 9 sexual partners in the last 3 months. Underlying diagnosis?

Answer 24

Trichomoniasis

Question 25

Clinical features of trichomoniasis in men and women

Answer 25

Men: * Symptoms: Asymptomatic (15-50%), **thin white urethral discharge**, **dysuria**, **frequency** Women: * Symptoms: Asymptomatic (15-50%), **yellow frothy discharge**, **vulval itching, dysuria, pelvic pain, dyspareunia** * Signs: **Yellow-green discharge** coating the vaginal walls, particularly the **posterior fornix**, '**strawberry cervix**' | “Strawberry” cervix : pathognomonic but only seen in 2% of cases

Question 26

Which STI involves yellow-green frothy discharge from the vagina and a 'strawberry cervix'?

Answer 26

Trichomoniasis (Trichomonas vaginalis)

Question 27

Ix and management for trichomonas vaginalis

Answer 27

Ix Women: * **Wet slide** from posterior fornix * **High vaginal swab** → bacterial culture, PCR Males: * **Urethral/ first pass urine culture** in males Treatment: * **Metronidazole** 400mg PO BID x 7 days

Question 28

Microbiology of bacterial vaginosis and transmission

Answer 28

Microbiology: * Vaginal **pH>4.5 (alkaline)** * Normal vaginal flora (**lactobacilli**) = dominated by **anaerobes** e.g. gardnerella vaginalis → causing symptoms of BV Transmission: **Not sexually transmitted**

Question 29

A 23-year-old female sex worker presents to the GUM clinic with a 5-day history of fishy-smelling vaginal discharge. She uses vaginal douches regularly. Vaginal examination reveals a thin, white discharge on the vaginal walls. Diagnosis?

Answer 29

Bacterial vaginosis

Question 30

Clinical features and complicatiosn of bacterial vaginosis

Answer 30

Clinical features: * 50% asymptomatic * **Foul-smelling 'fishy' vaginal odour** * **Greyish-white discharge** * Sign: Vagina will NOT appear inflamed or irritated Complications: * Increased risk of other STIs (2x HIV) * In pregnancy → associated with miscarriage, preterm birth/PROM, postpartum endometritis

Question 31

Ix and management for bacterial vaginosis

Answer 31

Ix: * Vaginal pH test: >4.5 * **High vaginal swab** (from prosterior fornix) → cultured and gram-stained Management: * Metronidazole 2g STAT * **Metronidazole** 400mg PO BID for 7 days Advice: * **Written and verbal information on prevention** e.g. washing only with water, avoiding soaps/shower gels/bubble bath, avoiding washing hair in bath

Question 32

Microbiology and transmission of thrush

Answer 32

Microbiology: **Candida albicans** (80-92%) + some other non-albican species Transmission: Not sexually transmitted

Question 33

Risk factors for thrush

Answer 33

* Uncontrolled diabtes mellitus * Immunosuppression * Hyperoestrogenaemia (including HRT and the COCP) * Broad-spectrum antibiotics

Question 34

Clinical features of thrush in men and women

Answer 34

Women: * **Vulval itch + soreness** * **Vaginal discharge (curdy, non-offensive)** * Superficial dyspareunia * External dysuria, erythema, fissurig, excoriation Men: * **Red skin, swelling, irritation** * Soreness + itchness * **Phimosis** * Dysuria * Dyspareunia Complications: Chronic/recurrent infection in men → leads to phimosis | Phimosis = inability to retract foreskin

Question 35

Ix and treatment of thrush

Answer 35

Ix: * Routine microscopy * **MCS (black charcoal swab)** Treatment: * **Clotrimazole** pessary 500mg stat * **Clotrimazole** 10% vaginal swab Advice: * Washing only with water, avoid soaps/shower gels/bubble bath, wearing cotton underwear, avoid thongs

Question 36

What virus causes genital herpes?

Answer 36

**Herpes simplex virus (HSV)** * HSV type 1- the usual cause of oral herpes (cold sores) * HSV type 2- historically associated with sexual transmission * (note either type can cause both oral and genital herpes)

Question 37

What is the natural history of herpes simplex virus?

Answer 37

Primary infection → **virus = becomes latent in sensory ganglia** → **periodically reactivating** to cause symptomatic lesions or asymptomatic viral shedding

Question 38

Clinical features of genital herpes

Answer 38

* Asymptomatic (80%) * **Painful blisters + ulcers, dysuria, tender inguinal lymphadentitis, discharge, fever myalgia**

Question 39

Complications of genital herpes

Answer 39

* Urinary retention * Aseptic meningitis * Adhesions

Question 40

Ix for genital herpes

Answer 40

**HSV** DNA detection by **PCR** - from **base of ulcer**

Question 41

Treatment of genital herpes

Answer 41

**ACICLOVIR** * Primary herpes → **Aciclovir 400mg** TDS (5 days); topical **anaesthetic agents** * Recurrences of herpes → **Aciclovir 800mg** TDS (2 days) Advice: * Saline bathing, regular analgesia, advice try urinating in the bath * PIL on condition * Does not need partner notification

Question 42

What is the causative organism and transmission route for genital warts

Answer 42

* Genital warts → Human papillomavirus (HPV) * Transmission → skin-to-skin contact

Question 43

Clinical features of genital warts

Answer 43

* Most asymptomatic * Can appear from 3 weeks to years after exposure to the virus * More common in pregnancy due to immune suppression * **Fleshy lumps, itching**, distorted flow of urine if present in urethra

Question 44

Management for genital warts

Answer 44

**First line: Creams (stimulate local immune response) ** * **Warticon** (podophyllotoxin) topical on 3 consecutive days * S/Es skin irritation and ulceration **Cryotherapy**: 3 freeze thaw cycles weekly * S/Es: Painful, hypooigmentation/scarring ## Footnote Advice: PIL, explain very common infection, not harmful, not the same as cervical cancer strains , treated for cosmetic reasons

Question 45

A 21-year-old woman presents to her GP with a 2-day history of bilateral lower abdominal pain, deep discomfort during intercourse and thick yellow vaginal discharge. She has recently started a new relationship and has been having unprotected sexual intercourse. Possible diagnosis?

Answer 45

Pelvic inflammatory disease (PID)

Question 46

Define pelvic inflammatory disease?

Answer 46

**PID** = infection + inflammation of the organs of the **pelvis** → caused by **infection** spreading up **through the cervix**

Question 47

What are the two main complications of PID?

Answer 47

* Tubular infertility * Chronic pelvic pain

Question 48

Definitions (of affected organs of PID)

Answer 48

* **Endometritis** = inflammation of the **endometrium** * **Salpingitis** = inflammation of the **fallopian tubes** * **Oophoritis** = inflammation of the **ovaries** * **Parametritis** = inflammation of the **parametrium**, which is the connective tissue around the uterus * **Peritonitis** = inflammation of the **peritoneal membrane**

Question 49

Causes of pelvic inflammatory disease

Answer 49

Most PID is caused by an **STI**: * **Neisseria gonorrhoeae** (more severe PID) * **Chlamydia trachomatis** * **Mycoplasma genitalium** Less commonly, not a STI: * **Gardnerella vaginalis** (associated with **BV**) * **Haemophilus influenzae** (a bacteria often associated with **respiratory infections**) * **Escherichia coli** (an enteric bacteria commonly associated with **UTIs**)

Question 50

Risk factors for pelvic inflammatory disease

Answer 50

Risk factors for PID = same as STIs * Not using barrier contraception * Multiple sexual partners * Younger age * Existing sexually transmitted infections * Previous pelvic inflammatory disease * Intrauterine device (e.g. copper coil)

Question 51

Signs and symptoms for PID

Answer 51

Symptoms: * **Lower abdominal pain** (typically **bilateral**) * **Deep dyspareunia** * **Abnormal vaginal discharge** (may be purulent) * **Abnormal vaginal bleeding** (intermenstrual, postcoital bleeding, menorrhagia) Signs on Examination: * **Pelvic tenderness** * **Adnexal tenderness** or **cervical motion tenderness** (on bimanual examination) * **Inflamed cervix (cervicitis)** * **Mucopurulent vaginal** or **cervical discharge** * **Fever > 38C (may be normal)** + other signs of **sepsis**

Question 52

Ix for Pelvic Inflammatory Disease (PID)

Answer 52

Causative organisms: * **NAAT swabs** (gonorrhoea, chlamydia, Mycoplasma) * **HIV, Syphilis test** * **High vaginal swab**: BV, candidiasis, trichomoniasis Microscope: Look for **pus cells** on microscope (absence excludes PID) * **Inflammatory markers (CRP, ESR)** (raised in PID) * **Pregnancy test** (exclude ectopic)

Question 53

Management for pelvic inflammatory disease

Answer 53

* A single dose of **intramuscular ceftriaxone 1g** → **gonorrhoea** * **Doxycycline 100mg** **BD** for **14 days** → **chlamydia + Mycoplasma genitalium** * **Metronidazole 400mg BD** for **14 days** → **anaerobes** such as **Gardnerella vaginalis** **Ceftriaxone + doxycycline** = will cover other bacterias e.g. **H. influenze + E. coli **# If patient presenting **septic** → Admission + **IV antibiotics** If **pelvic absecess** develops → may need interventional radiology or **surgery**

Question 54

Complications of pelvic inflammatory disease (PID)

Answer 54

* Sepsis * Abscess * Infertility * Chronic pelvic pain * Ectopic pregnancy * Fitz-Hugh-Curtis syndrome

Question 55

What is Fitz-Hugh-Curtiz syndrome?

Answer 55

* Fitz-Hugh-Curtiz syndrome = **complication** of **PID** * Caused by **infection + inflammation** of the **liver capsule** (Glisson's capsule) → leading to **adhesions** between the **liver + peritoneum** * **Bacteria** may spread from the **pelvis** via **peritoneal cavity, lympathic system** or **blood**

Question 56

How does Fitz-Hugh-Curtiz syndrome present and treated?

Answer 56

Presentations: * **RUQ pain** * + **Right shoulder tip pain** (if diaphragm is irritated) Mx: **Laproscopic adhesiolysis **

Question 57

A 22 year old female patient presents with pain in her right upper quadrant, she also has abnormal vaginal discharge, postcoital bleeding and pain in her pelvis. Possible diagnosis?

Answer 57

Fitz-Hugh-Curtiz syndrome

Question 58

What is syphilis caused by?

Answer 58

**Treponema pallidum** (spiral-shaped bacteria (spirochete) The bacteria gets in through skin or mucous membranes → replicates + disseminates throughout the body * **Incubation period** between the initial infection and symptoms = **21 days** on average.

Question 59

Transmission routes for syphilis

Answer 59

* **Oral, vaginal** or **anal** **sex** involving direct contact with an infected area * **Vertical transmission**: from mother to baby during pregnancy * **Intravenous drug use** * **Blood transfusions and other transplants** (although this is rare due to screening of blood products)

Question 60

What are stages of syphilis?

Answer 60

* **Primary syphilis: Painless ulcer (chancre)** at the orignal site of infection (usually genitals) * **Secondary syphilis: systemic symptoms (particulary skin + mucous membranes)**: These symptoms can resolve after 3 – 12 weeks and the patient can enter the latent stage. * **Latent stage:** symptoms disappear and the patient becomes asymptomatic despite still being infected * **Early latent syphilis** = occurs within 2 years of initial infection * **Late latent syphilis** = occurs from 2 years after the infection onwards * **Tertiary syphilis** (years after infection): Affects **many organs**, development of **gummas**, **cardiovascular + neurological complications** * **Neurosyphilis**: infection reaches the **central nervous system** - presenting with **neurological symptoms** ## Footnote A gumma is caused by the bacteria that cause syphilis. It appears during late-stage tertiary syphilis. It most often contains a mass of dead and swollen fiber-like tissue. It is most often seen in the liver.

Question 61

How does **primary syphilis** present?

Answer 61

* **Painless genital ulcer (chancre)** (tends to resolve over 3-8 weeks) * **Local lymphadenopathy**

Question 62

How does **secondary syphilis** present?

Answer 62

**Secondary syphilis** = typically starts after the **chancre has healed**, with symptoms of: * Maculopapular rash * **Condylomata lata** (grey wart-like lesions around the genitals and anus) * Low-grade fever * Lymphadenopathy * Alopecia (localised hair loss) * Oral lesions

Question 63

How does **tertiary syphilis** present?

Answer 63

Tertiary syphilis = can present with several symptoms (depending on the affected organs). Key features: * **Gummatous lesions** (**gummas** = granulomatous lesions that can affect the **skin**, **organs** and **bones**) * Aortic aneurysms * Neurosyphilis

Question 64

How can **neurosyphilis** present?

Answer 64

Neurosyphilis = can present at any stage if the infection reaches the CNS. Neurosyphilis presents with symptoms of: * **Headache** * **Altered behaviour** * Dementia * **Tabes dorsalis** (demyelination affecting the spinal cord posterior columns) * **Ocular syphilis** (affecting the eyes) * Paralysis * Sensory impairment

Question 65

What is **Argyll-Robertson pupil / 'Prostitutes pupil'**

Answer 65

**Argyll-Robertson pupil** = specific finding in **neurosyphilis** * Its a **constricted pupil that accommodates** when focusing on a **near object** - but **does not react to light** → they're often **irregulary shaped** Argyll-Robertson pupil = **'prostitute pupil'** → because it '**it accommodates but does not react**'

Question 66

A patient with tertiary syphilis presents with irregularly shaped pupils, what is this key neurological finding called?

Answer 66

Argyll-Robertson pupil ('Prostitute pupil')

Question 67

What are the investigations for syphilis?

Answer 67

**Screening for syphilis = T. pallidum antibody testing** If suspected syphilis or positive antibodies: **Swab samples** from sites of infection can be tested to confirm T. pallidum with: * **Dark field microscopy ** (characteristic **spiral-shaped rods**) * **Polymerase chain reaction (PCR)** Other investigations: * **HIV test**: as syphilis enhances the transmission of HIV * **Screening for other STIs** * **MRI/CT brain and lumbar puncture**: if neurosyphilis is suspected * **ECG and echocardiogram**: if cardiovascular syphilis is suspected

Question 68

Management of syphilis

Answer 68

**Single deep IM dose** of **benzathine benzylpenicillin** (penicillin) (Second line/alternative: **doxycycline**) * Partner notification * Contact tracing ## Footnote (Unless late latent and gummatous syphilis : 3 doses of IM benzathine penicillin)

Question 69

What is lymphogranuloma venereum (LGV)?

Answer 69

**Lymphogranuloma venereum** = a curable STI - **affecting** the **lymphatic vessels** + **nodes** - caused by **chlamydia trachomatis**

Question 70

How can lymphogranuloma venereum (LGV) be transmitted?

Answer 70

Unprotected sex: * Anal * Vaginal * Oral The risk of catching LVG is increased by having high-risk sex, such as group sex and fisting, as well as using recreational drugs. The risk may further be increased if HIV positive

Question 71

What is lymphogranuloma venereum (LGV) caused by?

Answer 71

**LGV** = caused by one of the 3 serovars of **Chlamydia trachomatis** (L2 = most common; L1 and L3 less common)

Question 72

What are the clinical features of lymphogranuloma venereum?

Answer 72

**Small painless pustule/papile + acute onset of tender, enlarged lymph nodes (?in groin)** * Stage 1 : **small painless pustule which later forms an ulcer** (on **penis**, vulva, vagina, cervix) * Stage 2 : **painful inguinal lymphadenopathy**; usually 10-30 days after the primary lesion * Stage 3 : **proctocolitis** (most commonly seen in men who have sex with men); may mimic Crohn’s disease (Pharyngeal symptoms = rare) ## Footnote The first symptom is usually a painless papule, pustule or ulcer on the penis, vulva, vagina or cervix

Question 73

A 22-year-old sexually active homosexual male presents with a small painless penile papule. A swab of the lesion suggests Chlamydia trachomatis and he is treated with 100mg oral doxycycline bd for 7 days. Diagnosis?

Answer 73

Lymphogranuloma venereum (LGV)

Question 74

Ix for lymphogranuloma venereum

Answer 74

* **Swab** taken (from rectum, vagina, throat, or an ulcer (if present)) * **NAATs**: high sensitivity and specificity and, if **positive for C.trachomatis**, **DNA** may be tested for **LGV-specific DNA**

Question 75

Management for lymphogranuloma venereum (LGV)?

Answer 75

100mg oral **doxycycline** BD for **21 days**

Question 77

A 28-year-old man presents with a painful ulcer on his penis which started as a small tender papule. He also reports painful swelling in his groin. His sexual history reveals recent unprotected intercourse with a new partner. Possible diagnosis?

Answer 77

Chancroid

Question 78

What is chancroid caused by?

Answer 78

**Chancroid** = an **STI** caused by the bacterium **Haemophilus ducreyi** **Haemophilis ducreyi** = **invade the epithelium** of the **genital region** → resulting in **inflammation, necrosis, ulceration**

Question 79

Where is chancroid most common?

Answer 79

Chancroid is rare in the UK and is more common in **Africa** and **Southeast Asia** Risk factors: * Unprotected sexual intercourse * Multiple sexual partners * Men are affected more often than women

Question 80

Signs and symptoms of chancroid

Answer 80

Signs: * **Painful solitary ulcers** on the penis or vulva * **Tender unilateral inguinal lymphadenopathy**: fluctuant lymphadenitis (bubo formation) * **Painful groin swelling** Symptoms: * **Genital pain** | Basically, **unilateral painful groin swelling + soiltary ulcers**

Question 81

Ix for chancroid

Answer 81

* **Swab of ulcer base**: to collect material for **culture** + **PCR** testing for **H. ducreyi** * HIV serology : co-infection is common Ix to consider: * Bubo aspirates: fluid may be collected from fluctuant buboes

Question 82

Management for chancroid

Answer 82

First-line: * Antibiotics: Single dose **PO azithromycin** (alternatives: ceftriaxone, erythromycin) * Partner notification + treatment Second-line: * **Abscess drainage**: If buboes (swollen lymph nodes) are fluctuant, needle aspiration can provide symptomatic relief

Question 83

Complications of chancroid

Answer 83

* **Genital scarring + stricture** * **Abscess formation in inguinal lymph node (buboes)** * Spread of the infection to other area of the body (rare)

Question 84

What is balanitis?

Answer 84

**Balanitis** = **inflammation** of the **glans penis** (Sometimes extends to the **underside** of the foreskin = **balanoposthitis**)

Question 85

What are the causes of balanitis?

Answer 85

Categories: Inflammatory, infective (bacterial + fungi), precancerous: * Candidiasis * Dermatitis (contact or allergic) * Dermatitis (eczema or psoriasis) * Bacterial * Anaerobic * Lichen planus * Lichen sclerosus

Question 86

Ix for balanitis

Answer 86

* Swab for microbiology (**gram stain + culture**) and Nucleic acid amplification test (**NAAT**) * Swab for virology (**PCR**) * **Dark-field microscopy** (for **syphilis**)

Question 87

How can balanitis present?

Answer 87

* Red scaly patches * Pruritus * Erosion * Post-inflammatory hypo- or hyper-inflammation Patient may present: * Multiple sexual partners or high-risk sexual behaviours * Uncircumcised

Question 88

Risk factors for balanitis

Answer 88

* Congenital or acquried dysfunctional foreskin * Uncircumcised state * Poor hygiene; urinary dribbling or leakage * Over-washing * Human papillomavirus (HPV) infection

Question 89

Management for balanitis

Answer 89

* **Atopic eczema** → **hydrocortisone topical** (topical corticosteroid) * **Irritant contact dermitis** → irritant avoidance + **topical corticosteroid** * **Lichen scleroisus** → **topical corticosteroid ± antifungal** (clobetasol topical) * **Gonorrhoea** → **antibiotic** * **Psoriasis** → **topical corticosteroid** * **Candidiasis** → **ketaconazole** topical (anti-fungal)

Question 90

What is sexual dysfunction in women?

Answer 90

Women's sexual dysfunctions include a spectrum of disorders that are typically multi-factorial in aetiology and include: * Sexual interest/arousal disorder (SIAD) * Female orgasmic disorder (FOD) * Genito-pelvic penetration pain disorder (GPPPD) - which combines the frequently overlapping diagnoses of vaginismus + dyspareunia

Question 91

What is the 3 criteria for diagnosing a sexual disorder in women?

Answer 91

Symptoms need to: * Persisted for **min 6 months** * Have to be** experienced in all or almost all** (75% to 100%) sexual encounters * Caused **clinically significant distress**

Question 92

What are the strong correlations (causes) with sexual dysfunction in women?

Answer 92

* Poor mental health * Stress * Low levels of emotional intimacy between partners SERUM LEVELS OF SEX HORMONES = DO NOT

Question 93

Risk factors of sexual dysfunction in women

Answer 93

* Depression * Antidepressant use * Comorbid anxiety disorder * Psychological aspects of cancer * Endometriosis * Neurological disease (can interrupt sexual response)

Question 94

Ix for sexual dysfunction in women

Answer 94

All expected to be normal, only do these if suspect underlying diseases: * FBC * Serum glucose level * Renal function * Thyroid function tests * Serum prolactin level | Basically ignore

Question 95

Management of sexual dysfunction in women

Answer 95

* Psycohological therapy * Oestrogen (for vaginal atrophy) * Vibrostimulation * Review antidepressant therapy

Question 96

What are the complications of chlamydia in pregnancy?

Answer 96

Increased risk of: * Premature delivery with low birth weight * Miscarriage * Still birth

Question 97

What antibiotics are contraindicated in pregnancy?

Answer 97

Doxycycline + ofloxacin

Question 98

What is the treatment for the mother if infected with chlamydia?

Answer 98

**Azithromycin + erythromycin** (Doxycycline = contraindicated in pregnancy)

Question 99

How may a baby present if they contract chlamydia from the mother?

Answer 99

* **Neonatal chlamydial conjunctivitis** (5-12 days after birth): inflammation + discharge in eyes * **Pneumonia** (1-3 months after birth)

Question 100

What are the Ix and management for chlamydia in neonates?

Answer 100

* Ix: Swabs from eyelid or nasopharynx * Management: Oral erythromycin

Question 101

Complications of gonorrhoea in pregnancy

Answer 101

* Perinatal mortality * Spontaneous abortion * Preamature labour * Early fetal membrane rupture

Question 102

If there vertical transmission of gonorrhoea in a neonate, what is the major clinical feature?

Answer 102

**Gonococcal conjunctivitis** Neonate will experience: * Eye pain * Redness * Discharge If untreated - can lead to long term damage + **blindness**

Question 103

Is the treatment for gonorrhoea in pregnancy the same as uncomplicated gonorrhoea?

Answer 103

Yes! Single dose of **IM ceftriaxone 1g**

Question 104

Can syphilis (T. pallidum) cross the placenta to a fetus?

Answer 104

Yes! (Pregnant women are screened for syphilis, HIV and Hepatitis B)

Question 105

If syphilis is left untreated in pregnancy, what can it lead to?

Answer 105

* Miscarriage * Stillbirth * Pre-term labour * Congenital syphilis

Question 106

How might congenital syphilis present?

Answer 106

Congenital syphilis = severe + debilitating * Saddle nose * Rashes * Fever * Failure to gain weight

Question 107

What are the complications of trichomonas vaginalis in pregnancy?

Answer 107

* **Premature labour** * **Low birth weight** * TV infection = may also predispose to **maternal postpartum sepsis**

Question 108

How is trichomonas vaginalis treatment in pregnancy?

Answer 108

Same as uncomplicated (**Metronidazole** 400-500mg twice daily for 5-7 days) High dose regimes = not tolerated Metronidazole = may affect the taste of the breast milk (so don't breastfeed for 12-24 if a single dose is used)