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Stage 3 > GUM/Sexual Health > Flashcards

GUM/Sexual Health Flashcards

1
Q

How does pelvic inflammatory disease (PID) occur?

A

When infection spreads from vagina, through into cervix and then into upper genital tract

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2
Q

What is the most common cause of PID?

A

Chlamydia trachomatis

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3
Q

What is the second most common cause of PID?

A

Neisseria gonorrhoea

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4
Q

Which pathogens can cause PID?

A

1) Chlamydia
2) Gonorrhoea
3) Anaerobic bacteria
Sometimes no pathogen can be isolated

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5
Q

How is PID spread?

A

Sexually

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6
Q

How is PID diagnosed?

A

Clinical diagnosis

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7
Q

What are the symptoms of PID?

A

1) Severe bilateral abdominal pain (like a band across front of lower abdomen)
2) Discharge
3) Post-coital bleeding (inter-menstrual bleeding)
4) Dyspareunia

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8
Q

What are the signs of PID?

A

1) Adnexal tenderness
2) Cervical motion tenderness on bimanual examination - unable to tolerate bimanual or speculum
3) Fever
4) Abdominal tenderness
5) Recent STI

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9
Q

What condition does cervical motion tenderness on bimanual examination indicate?

A

PID

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10
Q

What is Fitz Hugh Curtis syndrome?

A

When adhesions form between the anterior liver capsule to the anterior abdominal wall or diaphragm, on a background of PID (10% of PID patients present like this)

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11
Q

How does Fitz Hugh Curtis syndrome present?

A

RUQ pain (secondary to inflammation of liver capsule) on background of PID symptoms

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12
Q

How are liver function tests in Fitz Hugh Curtis syndrome?

A

Normal

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13
Q

What investigations are done in PID?

A

1) Pelvic examination
2) Pregnancy test
3) Swabs for gonorrhoea and chlamydia
4) Bloods
5) Transvaginal ultrasound

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14
Q

Which combination of antibiotics are given for PID?

A

1) IM ceftriaxone
2) Doxycycline
3) Metronidazole
OR ofloxacin + metronidazole

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15
Q

How is PID managed?

A

1) Outpatient antibiotic treatment
2) Analgesia
3) Review patient in 4 weeks

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16
Q

Which patients are given empirical treatment for PID and why?

A

All young sexually active women with bilateral lower abdominal pain with adnexal tenderness - due to significant number of women not diagnosed

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17
Q

What are three complications of PID?

A

1) Chronic pelvic pain (40%)
2) Infertility (15%)
3) Ectopic pregnancy (1%)

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18
Q

How is Fitz Hugh Curtis syndrome investigated?

A

1) Abdominal ultrasound - to exclude stones
2) Laparoscopy - for definitive diagnosis

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19
Q

How is Fitz Hugh Curtis syndrome treated?

A

Antibiotics

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20
Q

Which blood marker can be high in PID?

A

Ca-125

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21
Q

What increases your risk of developing PID?

A

STIs in the past

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22
Q

What are the two possible causes of genital herpes?

A

1) HSV- 1 - most common
2) HSV-2 - more likely to cause recurrent anogenital symptoms

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23
Q

What is the most common cause of oral herpes?

A

HSV-1 (HSV2 rarely affects the mouth and lips)

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24
Q

What is the most common cause of genital herpes?

A

HSV-1

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25
Q

How do you differentiate between HSV-1 and HSV-2 herpes infection?

A

They are clinically indistinguishable

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26
Q

How does genital herpes present?

A

Asymptomatic OR
1) Multiple painful genital ulcers/lesions on vulva
2) Dysuria ± urinary retention
3) Vaginal/urethral discharge
4) Lesions typically crust and heal - at this point the virus ceases to be shed from the lesions
5) May have fever, malaise, headache
6) Palpable inguinal lymphadenopathy

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27
Q

What are the features of recurrent episodes of genital herpes?

A

1) Recurrent episodes are usually less severe than a primary episode
2) There may not be a clearly identifiable trigger
3) The recurrent episode may have a prodromal phase e.g. tingling

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28
Q

How is genital herpes diagnosed?

A

1) Clinical - history & examination
2) NAAT

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29
Q

What is the most effective method of diagnosing genital herpes?

A

Obtain a swab from the base of the ulcer + analyse using nucleic acid amplification tests (NAAT)

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30
Q

How is HSV transmitted?

A

1) Skin-to-skin
2) The virus can be shed in the prodromal phase + during phases of recurrence or when displaying clinical symptoms for the first time
3) The virus can also be shed when the patient is asymptomatic

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31
Q

What is the current guidance with abstinence in genital herpes?

A

The current guidance advises patients to abstain from sex during clinical recurrence or when they are experiencing prodromal symptoms

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32
Q

What is the primary treatment for genital herpes simplex infection?

A

Oral antivirals

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33
Q

When should genital herpes be treated?

A

1) Treatment should commence within 5 days of the start of the episode OR
2) While new lesions are forming for people with a first clinical episode of genital herpes

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34
Q

What is first line treatment for genital herpes?

A

Aciclovir 400mg TDS for 5 days ± topical lidocaine 2% gel for symptomatic analgesic relief

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35
Q

What common treatment regimes used for genital herpes?

A

1) Aciclovir 400mg TDS for 5 days
2) Aciclovir 200mg five times daily for 5 days
3) Valaciclovir 500mg BD for 5 days
4) Famciclovir 250mg TDS for 5 days

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36
Q

How do you manage a first time episode of HSV (genital herpes) in pregnancy?

A

1) Refer to GUM clinic
2) Do not delay treatment - 400mg aciclovir TDS for 5 days
3) Acquisition of primary genital herpes simplex in the first or second trimester does not preclude vaginal delivery, however suppressive therapy with oral Aciclovir may be given from week 36 to reduce the risk of HSV lesions at term

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37
Q

How do you manage recurrent HSV (genital herpes) in pregnancy?

A

1) Women with recurrent genital herpes should be informed that the risk of neonatal herpes is low, even if lesions are present at the time of delivery (0–3% for vaginal delivery) - if a woman has HSV lesions at term, delivery via caesarean section is recommended to reduce the risk of vertical transmission to the newborn
2) Although there is no evidence that aciclovir is unsafe in early pregnancy, the majority of recurrent episodes of genital herpes are short-lasting and resolve within 7–10 days without antiviral treatment
3) Supportive treatment measures using saline bathing and analgesia with standard doses of paracetamol alone will usually suffice

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38
Q

Which virus is associated with the development of cervical cancer in women and vulval, anal and throat cancers?

A

HPV16 or HPV18

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39
Q

Which virus is associated with the development of Kaposi’s sarcoma in patients with HIV?

A

Human herpesvirus 8 (HHV8)

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40
Q

What are two normal variant/self-limiting skin conditions affecting the glans and prepuce of the penis?

A

1) Pearly penile papules (multiple uniform smooth flesh coloured lesions around the coronal margin of the glans) - reassure that they are not sexually transmitted + discharge
2) Angiokeratomas

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41
Q

Which inflammatory skin conditions can affect the penis?

A

1) Eczema
2) Psoriasis
3) Lichen planus
4) Lichen sclerosus
5) Zoon’s balanitis

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42
Q

What is Erythroplasia of Queyrat?

A

1) A squamous cell carcinoma in situ that affects the penis
2) Should be referred immediately in the primary care setting
3) More likely to affect older patients
4) Presents with a red, well circumscribed and painless lesion on the prepuce or the glans

43
Q

How do you treat keratinised genital warts?

A

Cryotherapy

44
Q

How do you treat non-keratinised genital warts?

A

Podophyllotoxin or imiquimod

45
Q

What would you see on urinalysis in PID?

A

Negative

46
Q

What is the most common bacterial STI in the UK?

A

Chlamydia (highest in sexually active young adults 15-24)

47
Q

What type of bacteria is chlamydia trachomatis?

A

Obligate intracellular bacterium - appears as small, round, elementary bodies within infected cells

48
Q

How does chlamydia present?

A

Asymptomatic (esp. in women) OR
1) Men - urethral discharge + dysuria
2) Women - dysuria, intermenstrual bleeding + vaginal discharge
3) If anal infection - discharge or anorectal discomfort
4) History of unprotected sex

49
Q

How can neonates become infected with chlamydia?

A

From exposure to the infected mother’s genital tract during delivery

50
Q

How does neonatal chlamydia present?

A

Pneumonia and conjunctivitis

51
Q

How do you diagnose vaginal chlamydia?

A

Vulvovaginal swab (self or clinician taken) or endocervical swab or first catch urine sample - analysed using NAAT

52
Q

How do you diagnose penile chlamydia?

A

Urine or urethral swab - analysed using NAAT

53
Q

How do you diagnose anal chlamydia?

A

Anal swab - analysed using NAAT

54
Q

In which GUM conditions is a test of cure normally recommended?

A

1) Rectal chlamydia
2) Gonorrhoea - to monitor disease clearance and decide on whether the antibiotic regimen used was effective or needs altering

55
Q

What is the treatment for chlamydia?

A

Oral doxycycline BD for 7 days

56
Q

What does nucleic acid amplification tests (NAAT) look for?

A

DNA or RNA of chlamydia trachomatis (or other bacterial infections incl. gonorrhoea

57
Q

What investigations are done in bacterial vaginosis (BV)?

A

1) Microscopy and culture - clue cells (epithelial cells from the cervix that have bacteria stuck inside them, usually Gardnerella vaginalis) present on wet mount
2) Vaginal pH testing - vaginal pH > 4.5 suggests BV
3) Whiff test

58
Q

What is a cervical smear used for?

A

To screen for HPV infection and cervical cancer

59
Q

Microscopy and culture can be used to diagnose which GUM conditions?

A

1) Bacterial vaginosis
2) Candidiasis
3) Gonorrhoea
4) Trichomonas vaginalis

60
Q

What type of bacteria is neisseria gonorrhoeae?

A

Gram negative intracellular diplococcus

61
Q

In which patient groups is gonorrhoea most common?

A

1) Young adults (15-24)
2) MSM

62
Q

How does gonorrhoea present?

A

1) Men - asymptomatic OR discharge (odourless, purulent, green/yellow), dysuria, tender inguinal nodes, testicular pain/swelling
2) Women - discharge (odourless, purulent, green/yellow), dysuria, abnormal bleeding, pelvic/abdominal pain ± cervical motion tenderness
3) Extra-genital complications - pharyngitis, rectal pain and discharge and disseminated infection

63
Q

What might you see on examination of a women with gonorrhoea?

A

Discharge from the os, Skene’s gland or Bartholin’s gland

64
Q

What are extra-genital complications of gonorrhoea?

A

1) Pharyngitis
2) Rectal pain + discharge
3) Disseminated infection

65
Q

Which types of swabs can be used to diagnose gonorrhoea?

A

1) Self taken vulvovaginal swab in women
2) Self-obtained first pass urine in men
3) Self-obtained rectal swab
4) Clinician-obtained endocervical or penile swab

66
Q

How do you diagnose gonorrhoea?

A

1) Microscopy - presence of monomorphic gram-negative diplococci within polymorphonuclear cells
2) Culture
3) ± NAAT

67
Q

What would you see on microscopy of gonorrhoea?

A

Presence of monomorphic Gram-negative diplococci within polymorphonuclear leukocytes

68
Q

How do you treat gonorrhoea?

A

Ceftriaxone 1g IM (if sensitivities are known then single dose of PO ciprofloxacin)

69
Q

What are major complications of untreated gonorrhoea?

A

1) Infertility in women
2) Infertility in men
3) Infection that spreads to the joints and other areas of the body
4) Increased risk of HIV/AIDs

70
Q

How can gonorrhoea lead to infertility in women?

A

1) Gonorrhoea can spread into the uterus and fallopian tubes, causing PID
2) PID can result in scarring of the tubes, greater risk of pregnancy complications and infertility

71
Q

How can gonorrhoea lead to infertility in men?

A

1) Gonorrhoea can cause a small, coiled tube in the rear portion of the testicles where the sperm ducts are located (epididymis) to become inflamed (epididymitis)
2) Untreated epididymitis can lead to infertility

72
Q

What are the features of disseminated gonorrhoea infection?

A

1) The bacterium that causes gonorrhoea can spread through the bloodstream and infect other parts of your body, including your joints
2) Fever, rash, skin sores, joint pain, swelling and stiffness are possible results

73
Q

What is the link between gonorrhoea and HIV/AIDS?

A

1) Having gonorrhoea makes you more susceptible to infection with HIV, the virus that leads to AIDS
2) People who have both gonorrhoea and HIV are able to pass both diseases more readily to their partners

74
Q

What is candida albicans?

A

A fungal infection caused by yeast

75
Q

What does candida albicans look like on microscopy?

A

Round, budding years with pseudohyphae

76
Q

How does trichomonas appear on microscopy?

A

Small, pear shaped parasites with a single nucleus and flagella

77
Q

What is bacterial vaginosis?

A

A bacterial imbalance of the vagina caused by an overgrowth of anaerobic bacteria and a loss of lactobacilli - bacterial overgrowth leading to vaginal discharge with an associated fishy odour

78
Q

What are the clinical features of BV?

A

1) Increased vaginal discharge - uncomfortable, may increase around menses/worse after bleeds
2) Grey-white watery discharge
3) Characteristic fishy smelling discharge esp. after intercourse (maybe just on bimanual/speculum examination)
NOT itching or pain

79
Q

What is the most common cause of abnormal vaginal discharge in women of childbearing age?

A

Bacterial vaginosis - prevalence as high as 50% in some communities

80
Q

Which criteria are used to diagnose BV?

A

Amstel criteria

81
Q

How do you diagnose BV?

A

Clinical - 3 out of 4 Amstel criteria need to be present:
1) Vaginal pH > 4.5
2) Homogenous grey or milky discharge
3) Positive whiff test - addition of 10% potassium hydroxide produces fishy odour
4) Clue cells present on wet mount

82
Q

How do you treat BV (if asymptomatic don’t need treatment)?

A

1) First line = metronidazole (PO or vaginal pessary) - ?avoid in first trimester
2) Second line = clindamycin (PO or vaginal pessary)

83
Q

What are the features of BV and pregnancy?

A

1) Pregnant women are at increased risk of bacterial vaginosis due to changes in hormone
2) If you have BV during pregnancy, your baby is at increased risk for premature birth and low birthweight, however bacterial vaginosis causes no problems in the majority of pregnancies

84
Q

What is the first line treatment for candida albicans infection (thrush)?

A

Clotrimazole pessary

85
Q

What is the treatment of choice in women with recurrent candida infection?

A

Nystatin pessary

86
Q

What treatment is used for treating resistant strains of candida infection e.g. candida glabrata?

A

Oral fluconazole

87
Q

Which bacteria is associated with BV?

A

Gardnerella vaginalis

88
Q

What is the most common cause of thrush?

A

Candida albicans (85-90%)

89
Q

How does thrush (candidiasis) present in women?

A

1) Cottage-cheese like discharge - white curdy discharge with sour milk odour
2) Dysuria
3) Superficial dyspareunia
4) Itching
5) Examination - swelling, fissuring, erythema, intertrigo, thick white discharge

90
Q

How does trichomonas vaginalis present?

A

Asymptomatic OR
1) Profuse, frothy, yellow vaginal discharge
2) Vulval irritation
3) Dyspareunia
4) Strawberry cervix (rare)
5) Men - non-gonococcal urethritis

91
Q

What are the lesions like in female genital herpes?

A

Multiple wet ulcer-like vesicles on vulva and perineum which are painful to touch, with surrounding erythema

92
Q

When would IV aciclovir be used to treat herpes simplex?

A

Patients with evidence of disseminated herpes simplex disease e.g. involving more than one mucosal site, fever or evidence of meningitis

93
Q

Why is a higher dose of aciclovir recommended for genital herpes in pregnancy?

A

Bc pregnancy results in a higher circulating blood volume and therefore a higher volume of distribution for any drug

94
Q

Would you remove an IUD in uncomplicated chlamydia infection?

A

No

95
Q

What are risk factors for candida infection?

A

1) Pregnancy
2) Antibiotic use
3) Immunosuppression

96
Q

What is the method of transmission for candida?

A

Non-sexual

97
Q

How does thrush present in men?

A

1) Soreness
2) Pruritis
3) Erythema
4) Examination - dry, dull, red glazed plaques and papules

98
Q

What are risk factors for BV?

A

1) Unprotected sexual intercourse/multiple sexual partners
2) Excessive vaginal cleaning
3) Recent abx
4) Smoking
5) Copper coil

99
Q

What is trichomoniasis caused by?

A

Sexual transmission of trichomonas vaginalis (flagellated protozoan) - incubation period ~ 7 days

100
Q

How do you diagnose trichomonas?

A

Microscopy and culture (small, pear shaped parasites with a single nucleus and flagella)

101
Q

How do you treat trichomonas?

A

1) Metronidazole PO BD for 7 days
2) Follow up in one week
3) Screen sexual contacts

102
Q

Which three GUM conditions are treated with metronidazole?

A

BV, trichomonas and PID (PID also with ceftriaxone and doxycycline)

103
Q

Which virus causes genital warts?

A

HPV

Stage 3 (61 decks)

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