GUM Flashcards
(101 cards)
1
Q
Time for symptoms of chlamydia and gonorrhoea to develop in males
A
Chlamydia: About 1-2 weeks after exposure. <4 weeks.
Gonorrhoea: 2-5 days after exposure
2
Q
How does Gonorrhoea appear on microscopy?
A
Gram-negative intracellular diplococci
3
Q
What is a NAAT?
A
Nucleic acid amplification test.
Can be used e.g. to confirm the presence of gonorrhoea/chlamydia in first pass urine.
4
Q
Treatment options for chlamydia
A
Azithromycin 1g single dose
Doxycycline 100mg BD for 7 days (rectal chlamydia tends to respond better to this then azithro)
Erythromycin 500mg BD for 2 weeks
5
Q
If symptoms persist after treatment for chlamydia/gonorrhoea, what 3 things should be considered?
A
- Treatment failure
- Reinfection
- Infection by less common pathogens (e.g. Trichomonas vaginalis or Mycoplasma genitalium)
6
Q
What type of bacterium is Chlamydia trachomatis?
A
Oval-shaped, gram negative, obligate intracellular bacterium
7
Q
Main symptoms caused by Chlamydia in women
A
Dysuria, vaginal discharge, intermenstrual bleeding.
Less commonly PID, peri-hepatitis (Fitz-Hugh-Curtis syndrome), conjunctivitis, reactive arthritis.
8
Q
Chlamydial symptoms in neonates
A
Conjunctivitis and pneumonia
9
Q
Main symptoms caused by Gonorrhoea in women
A
Dysuria, vaginal discharge, abnormal bleeding.
Mucopurulent discharge from cervical os/urethra/Skene’s glands/Bartholin’s glands on examination.
Less commonly: lower abdo pain, bartholinitis, vulvo-vaginitis.
10
Q
Causes of scrotal swelling and pain in adults/adolescents
A
Infections (chlamydia, gonorrhoea, TB, mumps, G-ve bacteria) Torsion Hydrocoele, spermatocoele, varicocoele Vasculitis: HSP, Kawasaki's disease, Buerger's disease Amiodarone therapy Tumour Hernia Trauma
11
Q
Organisms causing acute epididymo-orchitis in young men?
And men over 35?
A
Young men: Chlamydia or Gonorrhoea
Over 35s: E. coli, Klebsiella, Pseudomonas, Proteus. Subsequent to urinary tract infection.
12
Q
Distinguishing features of mumps orchitis?
A
Onset over several days after parotid swelling
Severe testicular pain (unilateral or bilateral)
Marked systemic
13
Q
Causative organisms for acute prostatitis?
A
Mostly E. coli, Proteus, Streptococcus faecalis, Klebsiella, Pseudomonas.
Can also be gonorrhoea, chlamydia or trichomoniasis, but STIs are less common.
14
Q
Causes of pelvic pain in men
A
Specific and non-specific granulomatous prostatitis Pudendal neuralgia (sometimes due to tumour) BOO Bladder tumours Stones Ejaculatory duct obstruction Seminal vesicle calculi IBS
15
Q
Antibiotics for prostate infections
A
28-day course of a quinolone or tetracycline (these have better prostatic penetration than other abx)
16
Q
What are the main presentations of oral STIs?
A
Gonorrhoea/chlamydia: often asymptomatic.
Primary syphilis: can affect tongue/lips (chancre)
Secondary syphilis: can cause oral mucositis
Warts: can present in/around the mouth
HIV: many!
17
Q
Changes in vagina at puberty.
What happens at menopause?
A
Pre-puberty: Lined with simple cuboidal epithelium. Neutral pH. Colonised with skin commensals.
Puberty: Under influence of oestrogen, epithelium becomes stratified squamous. pH falls to 3.5-4.5. Lactobacilli become the predominant organism.
Menopause: atrophic changes. pH back to neutral and back to skin commensals.
18
Q
Features of vaginal candidiasis
How is it confirmed?
A
++ itchy
‘Yeasty’ smelling, thick white discharge.
pH <4.5 (normal)
Confirmed by microscopy and culture.
19
Q
Features of bacterial vaginosis.
How is it confirmed?
A
Not itchy.
Offensive, fishy smelling, thin, homogenous, white/yellow discharge.
pH 4.5-7.0 (high)
Confirmed by microscopy.
20
Q
Features of vaginal Trichomoniasis.
How is it confirmed?
A
+++ itchy.
Offensive, thin, homogenous, yellow/green discharge.
pH 4.5-7.0 (high).
Confirmed by microscopy and culture.
21
Q
Features of cervicitis.
How is it confirmed?
A
Not itchy.
Discharge doesn’t tend to smell. White/green, mucoid.
pH can be any.
Confirmed by microscopy and culture for chlamydia and gonorrhoea as these can be causative.
22
Q
Which hormone is vaginal candidiasis dependent on?
A
Oestrogen, so rarely seen pre-puberty/post-menopause.
Increased incidence in pregnancy/high-dose COCP
23
Q
Treatments for vaginal candidiasis
A
Single dose topical azole e.g. clotrimazole pessary
Oral fluconazole single dose.
Longer courses recommended in pregnancy (where oral azoles not recommended) or where there are unavoidable predisposing factors e.g. steroid therapy.
24
Q
Predisposing factors for BV
A
Afro-caribbean ethnicity
Intrauterine contraceptive device
25
Amsel criteria for BV (no longer used)
Need 3/4 to be present:
1. Vaginal pH >4.5
2. Release of fishy smell on addition of alkali
3. Characteristic discharge on examination
4. 'Clue cells' on microscopy (vaginal epithelial cells so heavily coated with bacteria that the border is obscured)
26
How is BV now diagnosed?
Gram-stained vaginal smear.
Lactobacilli are large G+ve bacilli. In BV, these are reduced and instead there are lots of G+ve and G-ve cocci (anaerobes).
27
Treatments for BV
```
Metronidazole (5 day BD course or single dose)
Metronidazole vaginal gel
Clindamycin cream (clindamycin used in pregnancy)
```
28
Complications of BV
In pregnancy: Increased risk of second trimester miscarriage + preterm delivery.
Increased incidence of endometritis/PID if not treated before a TOP.
29
Clinical features of Trichomoniasis (in women/men)
Women:
Can be asymptomatic for several months
Vulvo-vaginitis
Abnormal discharge (green/yellow, sometimes offensive)
'Strawberry cervix' with punctate haemorrhages)
BV may also develop
Men:
Usually asymptomatic. Can cause non-gonococcal urethritis.
30
What does Trichomonas look like on microscopy?
Large, tear shaped, motile, 4 moving flagellae
31
Treatment for Trichomoniasis
Metronidazole single high dose or 5 day course.
If persistent, try increasing dose/Tinidazole/referral to specialist.
32
Complications of Trichomoniasis
Can be found in the upper genital tract and bladder but not thought to cause problems.
Risk factor for preterm birth but if asymptomatic, treating doesn't improve outcomes.
33
Causes of vaginal infections in children
Streptococcal
Shigella (can cause chronic haemorrhagic vaginitis)
If recurrent, consider foreign body.
Pinworms--> itching at night.
Chlamydia or gonorrhoea will cause a generalised vaginitis + purulent discharge due to cuboidal epithelium.
34
Differential diagnosis of lower abdominal pain in a young woman
```
UTI
Appendicitis
PID
Ectopic pregnancy
Endometriosis
Ovarian cyst torsion or rupture
IBS
```
35
Indications for hospital admission for women with acute PID
```
Surgical emergency cannot be excluded
Clinically severe disease
Presence of tubo-ovarian abscess
Pregnancy
Lack of response to oral therapy
Intolerance to oral therapy
```
36
Options for outpatient treatment of PID
(needs to cover gonorrhoea, chlamydia and anaerobes)
IM ceftriaxone single dose + oral doxycyline BD + metronidazole BD for 14 days.
Ofloxacin BD + metronidazole BD for 14 days.
Moxifloxacin OD for 14 days.
37
STI screening offered to all pregnant women in the UK
Screening recommended in certain circumstances
All women: syphilis serology, hep B serology, HIV antibody test
Certain circumstances: women <25 chlamydica. anti-HCV ab in high risk groups.
38
Problems chlamydia can cause in pregnancy.
Treatment
Premature rupture of membranes, preterm delivery, low birth weight, postpartum infection
Azithromycin 1g single dose or erythromycin 500mg BD for 14 days.
39
Which STIs can cause ascending infections in pregnancy?
Chlamydia trachomatis
Neisseria gonorrhoea
Trichomonas vaginalis
BV
40
Which STIs can undergo transplacental spread?
Syphilis
| HIV
41
Which STIs can undergo perinatal transmission?
```
Chlamydia trachomatis
Neisseria gonorrhoeae
HIV
Herpes
HPV
Hep B
Hep C
```
42
Which STIs can cause postpartum infections?
Chlamydia trachomatis
Neisseria gonorrhoeae
BV
43
What problems can Chlamydia cause in a neonate?
| What is the perinatal transmission rate?
Main presentation = conjunctivitis
Can also colonise the nasopharynx--> otitis media or chlamydial pneumonitis. Can cause vaginal infection.
50-70% perinatal transmission rate.
44
Treatment of gonorrhoea in pregnancy?
Tetracycliens and quinolones contraindicated.
Give cefixime, ceftriaxone or spectinomycin single dose.
45
Gonorrhoea problems in the neonate
| Perinatal transmission rate
Mostly conjunctivitis--> may lead to corneal ulceration, perforation and blindness. Can cause vaginal infection.
Trasmission 40%
46
Features of early and late congenital syphilis
Early: rash, hepatosplenomegaly, syphilitic snuffles, periostitis
Late: interstitial keratitis, Hutchinson's incisors, Moon's mulberry molars, rhagades, Saddlenose deformity, frontal bossing, deafness
47
Treatment of syphilis in pregnancy
IM benzathien penicillin weekly for 3 weeks or IM procaine penicillin OD for up to 17 days.
48
3 categories of neonatal herpes infection
1. Localised to site of viral entry (skin, eye, mouth)
2. Encephalitis
3. Disseminated infection.
Almost always symptomatic and frequently fatal.
49
Management of first episode genital herpes in pregnancy
Oral/IV aciclovir depending on clinical severity.
Plan vaginal delivery, unless first episode at time of delivery or within 6 weeks of EDD/onset of labour. Then, if vaginal delivery unavoidable, consider aciclovir for mum and baby.
50
Testing of infants for HIV transmission
HIV DNA PCR on peripheral blood lymphocytes at 1 day, 6 weeks and 12 weeks. If all -ve and not being breastfed- no transmission!
Confirm loss of maternal HIV Abs at 18 months.
51
Effects of trichomoniasis in pregnancy
| How should it be managed?
Can cause preterm delivery and low birth weight. No direct infective complications to the neonate but can cause vaginal infection.
Treat with metronidazole 400mg BD for 5-7 days (no evidence of teratogenicity in the first trimester) Also screen for gonorrhoea and chlamydia co-infection.
52
Complications of BV in pregnancy
| Treatment
Can cause late miscarriage, preterm birth, preterm premature rupture of membranes, postpartum endometritis.
Metronidazole for 5-7 days (NOT stat as too high dose), metronidazole intravaginal gel or clindamycin cream
53
Causes of genital ulcers
STIs
Other infectious agents
Dermatological conditions
Trauma
54
Incubation period for genital HSV infection
What percentage of people get signs/symptoms on initial acquisition?
Which (1 or 2) recurs more frequently?
5-14 days
Less than half
HSV-2 recurs more frequently (~4 times in the first year) vs. HSV-1 (about once every 18 months)
55
Appearance of first episode of genital herpes
| Any systemic features?
Vesicles which then become superficial & v. painful ulcers
Ulcers may coalesce to form larger lesions with serpiginous edges.
Some get fissures, erythema, dysuria.
Local tender lymphadenopathy +- lower limb myalgia
10% get headache, malaise, photophobia
56
How long does a typical episode of genital herpes last?
| What are the most common complications
3 weeks
Superinfection of lesions and adhesion formation.
Severe dysuria can lead to urinary retention.
57
Where can HSV recurrences occur?
| What are the typical triggers and prodromal symptoms?
Anywhere in the dermatome. May involve the perianal, buttock and thigh areas.
Often no trigger. May be UV radiation or trauma.
Prodromal symptoms may be localised tingling/itch.
58
How is genital herpes diagnosed?
PCR, culture or antigen detection from swabs of lesion.
(PCR is most accurate).
Viral typing is useful as it provides some prognostic info.
Serological tests for HSV-1 or HSV-2 antibodies are available- can be used to exclude.
59
Treatment of first episode of genital herpes
| Treatment for recurrent episodes
```
Oral antivirals (e.g. aciclovir) if in early stages/new lesions still appearing/systemic symptoms.
Give for at least 5 days and 10 if still unwell.
```
Treatment for recurrence often not necessary. Short course of aciclovir can hasten recovery if given within 24-48hrs. If severe recurrent disease, daily suppressive therapy may be more helpful.
60
Which stains of Chlamydia trachomatis are the oculogenital strains and which are the LGV strains?
What is the difference in the tissues they affect?
```
Oculogenital = Serovars A-K. Cause mucosal disease.
LGV = serovars L1, L2 and L3. Invade & destroy lymphatic tissue.
```
61
Clinical course of lymphogranuloma venereum
Primary: 3-30 days after infection. Transient genital ulceration
Secondary: 2-6 weeks later. Inguinal or anorectal syndrome
Tertiary: Following chronic infection, any number of years later. Genito-anorectal syndrome.
62
Appearance of the primary stage of LGV
Transient papules or ulcers at the site of inoculation. Usually single non-indurated ulcer, sometimes painful, heals without scarring.
63
Typical presentation of the second stage of LGV
| Why does it present differently in women?
Inguinal syndrome: unilateral inguinal and/or femoral lymphadenopathy + buboes (enlarged, tender glands in the groin). Buboes may suppurate and rupture.
Classical 'groove sign' = groove-like depression caused by femoral and inguinal lymph node enlargement above and below the inguinal ligament.
This lymphadenopathy is less common in women as the vagina, cervix, posterior urethra and rectum drain to the deep iliac or perirectal lymph nodes.
64
What happens in the tertiary stage of LGV?
Fibrosis due to chronic infection leads to lymphatic obstruction and genital lymphoedema.
Women: elephantiasis of the vulva, growths, fistulae, ulceration, scarring.
Men: oedema and deformity of the penis.
65
Late complications of LGV
Rectal strictures, proctitis, colitis, perianal abscess, perineal/rectovaginal/urethral fistulae.
66
Diagnosis of LGV
| Management
PCR from lesional samples
Doxycycline or erythromycin QDS for 3 weeks. May need buboe aspiration or surgical intervention for late complications.
Avoid sex until they & partners have finished treatment.
67
Causative organism of chancroid
| Presentation
Haemophilus ducreyi
Single/multiple non-indurated painful anogenital ulcers. Have a purulent base and contact bleeding.
Also inguinal lymphadenopathy.
68
Complications of chancroid
Tissue destruction, inguinal abscess formation (bubo) and chronic suppurative sinuses.
69
Diagnosis and treatment of chancroid
Diagnosis: microscopy/culture (both poorly sensitive). PCR is good but not widely available.
Treatment: azithromycin single dose, ceftriaxone single dose, ciprofloxacin or erythromycin.
70
What causes Donovanosis (granuloma inguinale)
How does it appear?
How is it diagnosed?
How is it treated?
Caused by Klebsiella granulomatis
Long incubation period. Slow-growing, painless, fiable genital and inguinal lesions. 'Beefy-red' and haemorrhagic.
Diagnosed by demonstration if intracellular Donovan bodies (closed safety pin- like organisms)
Treament: azithromycin, ceftriaxone, co-trimox or doxycycline etc. All for min. 3 weeks.
71
What kind of bacterium is treponema palldium?
Where does it live?
How is it transmitted?
Coiled motile spirochaete bacterium
Obligate parasite, and humans are the only natural host. (no in vitro culture possible)
Sexually transmitted or from mother to child
72
Incubation period for primary syphilis
| Presentiation
9-90 days (usually 14-21)
Lesions at site of innoculation (mouth is most common extragenital site)
Red macule--> papule--> ulcerates. Normally solitary, painless ulcer. Round, clean, indurated base, defined edges.
Local painless, rubbery lymph nodes.
73
Time for secondary syphilis to develop.
| Presentation
4-8 weeks after primary lesion (which may still be present)
Symmetrical, non-itchy, macular, papular, papulosquamous and (rarely) pustular lesions.
Macular lesions tend to be on the trunk, 0.5-1cm.
Papules = same size, coppery red. Can be most places incl. palms, soles, genitalia
74
What are condylomata lata?
Large flashy masses formed when papular lesions in syphilis coalesce in warm, opposed areas of the body.
75
What kind of lesions are found on the mucous membranes in syphilis?
Shallow, painless erosions.
| Have a greyish appearance. Sometimes called 'snail-track' ulcers.
76
Systemic features of secondary syphilis
Malaise, fever, anorexia, generalised lymphadenopathy.
Any organ can show evidence of the bacteraemia, so can also get hepatitis, iritis, meningitis, optic neuritis + papilloedema.
77
Types of neurosyphillis
Asymptomatic
Meningovascular
Parenchymatous (general paresis and tabes dorsalis)
78
When does meningovasular syphilis occur?
| How does it present?
Can be in the early or late stages e.g. can be at the same time as skin lesions.
Signs of meningitis. Third, sixth and eight cranial nerve involvement, papilloedema. Sometimes homonymous hemianopia or hemiplegia.
Argyll Robertson pupils.
79
Features of tabes dorsalis
Ataxia, failing vision, sphincter disturbances, attacks of severe pain. 'Lightening pain' Incontinence, deafness, impotence.
Posterior column degeneration--> absent ankle and knee reflexes, impaired vibration and position sense, positive Romberg's sign.
80
What occurs in cardiovascular syphilis?
Can affect any vessels.
Most commonly large, esp the aorta.
Aortitis (+- coronary ostial stenosis), aneurysm of the ascending part or arch--> widened mediastinum and pressure on surrounding structures, aortic incompetence.
81
What are gummata in syphilis?
Granulomatous lesions that form 3-12 years after infection.
Can occur on the skin/mucous membranes, or in bones or viscera.
On the skin: usually occur in groups. Usually nodular, painless, can ulcerate, firm, coppery red.
82
Direct tests for syphillis
Dark ground microscopy (not used any more). 3 classic movements (watch spring, corkscrew, angular)
NAATs- being increasingly used. Much more sensitive and specific.
83
How do the RPR and VRDL tests work?
What to changing titres mean?
What happens in chronic infection?
Can you et false positives?
Depend on appearance of cardiolipin antibody (reagin) in the serum.
Titres decrease with treatment response and increase with treatment failure/re-infection.
BUT titres also slowly decay without treatment, so untreated patients can have low/negative results.
False positives with acute infections (herpes, measles, mumps etc.) or after typhoid or yellow fever immunisation. Or chronically with autoimmune diseases/RA.
84
Specific test for syphilis
| When can it otherwise be positive?
EIA (enzyme immunoassay): becomes positive early in the disease.
Can also be positive in other treponemal conditions e.g. ayws, bejel, pinta.
85
Old tests for syphilis
FTA, TPHA, TPPA.
| TPHA/TPPA can still be used to confirm a positive EIA test.
86
Treatment of syphilis
Single dose of IM benpen or 10 days of procaine penicillin
| Alternative = doxycycline
87
What is the Jarisch-Herxheimer reaction?
| How is it treated?
Common in primary and secondary syphilis- fever and flu like symptoms 3-12 hours after the first injection of penicillin. Can also get enlargement/spreading of the chancre or skin lesions.
Treatment: reassurance. Paracetamol/NSAIDs
88
Principles of HIV and syphilis co-infection/testing
HIV-positive individuals may have a more rapid progression to neurosyphilis/other forms of late syphilis
All patients with syphilis should be tested for HIV and everyone with HIV should be regularly tested for syphilis
89
Which viruses cause most genital warts?
What is the median incubation period?
Does everyone infected get warts?
HPV-6 and HPV-11 (low risk genotypes)
Median incubation period = 3 months. Can be shorter or much longer
No. Some studies suggest 99% don't.
90
When should you consider biopsy of genital warts?
When the diagnosis is uncertain.
When the warts are pigmented, inducrated or fixed
If lesions don't respond or worsen with treatment.
If there is persistent ulceration or bleeding.
91
Different appearances of genital warts
Condylomata acuminata (cauliflower-like appearance, skin-coloured/pink/hyperpigmented)
Smooth papules
Flat papules (generaly on internal strutures e.g. cervix)
Keratotic warts
92
What is the natural progression of genital warts without treatment?
5-30% disappear at 3 months
20% stay the same
50% grow larger in size or number
93
Treatments for genital warts
| Do they work?
```
Chemical applications (cytotoxic or immunestimulant) e.g. podophyllotoxin, imiquimod.
Physical ablation e.g. cryotherapy, ecision, electrosurgery, laser treatment.
```
Most will respond within 2-3 months, but lots recur.
94
Appearance of molluscum contagiosum
| What causes it?
Multiple small, smooth pearly coloured papules with central umbilication. May resemble vesicles but are actually solid.
A poxvirus
95
How is molluscum contagiosum transmitted?
| Does it need treatment?
Spread by cutaneous contact in children, or in adults it is sexually transmitted. The immunocompromised can get it at extragenital sites.
Can be given e.g. cryotherapy, but most resolve within 3 months (although can recur).
96
What causes scabies?
How is it transmitted?
How does it present?
Sarcoptes scabiei
Prolonged skin-to-skin contact (>20mins)
Symptoms = intense itching, esp at night, due to hypersensitivity as excrement is absorbed into skin capillaries. Develop after 4-6 weeks on first infection, but quicker with subsequent infections.
97
Typical rash seen in scabies
Polymorphic, symmetrica rash.
Particularly affects the interdigital spaces, wrist flexor surfaces, elbow extensor, anterior axillary folds, buttox, genitalia.
Classic rash = greyish wavy channel on the skin surface extending from an erythematous papule.
98
Treatment for scabies
General advice about close contact & partner/contact treatment.
Contaminated clothes/bed linen washed at 50 C
Topical permethrin or malthion---> left on for 12 hours, then washed off.
99
What is Pediculosis pubis and what causes it?
Which regions can they infect?
Treatment
'crabs'- Phthiris pubis
Can infect the pubic, thigh, abdominal, axillary, eyebrow and eyelash hair.
Topical malthion, permethrin, phenothrin, carbaryl. Usually needs a second application after 3-7 days.
100
Which non-hepatitis viruses can cause hepatitis?
EBV and CMV
101
Treatment for anogenital gonorrhoea
IM ceftriaxone 500mg + stat azithromycin 1g
| Must do test of cure (with culture >72hrs or NAAT >2 weeks)
