Gynae - Acute STIs (inc BV and Candidiassis)

Question 1

Pelvic Inflammatory Disease

Pathophysiology 
Risk Factors
Clinical Features
Differential Diagnosis
Complications

Answer 1

1. ) Pathophysiology - infection of the uterus, fallopian tubes, ovaries and peritoneum due to the upwards spread of a bacterial infection from the vagina/cervix
   - common bacteria: Neisseria gonorrhoea, Chlamydia trachomatis, and Mycoplasma genitalium
   - other bacteria: Gardnerella vaginalis (BV), E.coli (associated with UTIs), H. influenza
2. ) Risk Factors
   - age 15-24. hx of STIs, previous hx of PID
   - sex, UPSI, multiple partners, recent partner change
   - instrumentation of the cervix e.g. gynae surgery, TOP, IUS/IUD insertion
3. ) Clinical Features - can be asymptomatic OR:
   - pain: lower abdo/pelvic pain, dysuria
   - sex: deep dyspareunia, post-coital bleeding
   - menstrual: menorrhagia, dysmenorrhoea, IMB
   - abnormal vaginal discharge: purulent, odorous
   - fever (>38°C) and N+V in advanced cases
   - bimanual: uterine/adnexal tenderness, cervical excitation, palpable mass, abnormal vaginal discharge
4. ) Differential Diagnosis
   - ectopic pregnancy (must exclude pregnancy)
   - ruptured ovarian cyst, endometriosis, UTI, STI
5. ) Complications
   - ectopic: narrowing and scarring of fallopian tubes
   - infertility, tubo-ovarian abscess, chronic pelvic pain
   - Fitz-Hugh Curtis syndrome: perihepatitis causing adhesion that causes RUQ pain

Question 2

Management of Pelvic Inflammatory Disease

Infection Swabs
Other Investigations
General Management
Antibiotics

Answer 2

1. ) Infection Swabs
   - testing is via nucleic acid amplification (NAAT)
   - a negative swab does not exclude the diagnosis
   - endocervical swabs: gonorrhoea and chlamydia
   - HVS: BV, trichomoniasis, candidiasis, group B strep
   - triple swab: endocervical NAAT swab (1st) + endocervical charcoal swab + HVS charcoal swab
2. ) Other Investigations
   - full STI screen offered to all women: chlamydia, gonorrhoea, HIV, syphilis, as a minimum
   - urine dip +/- MSU (exclude UTI), pregnancy test
   - TVUS: severe disease or diagnostic uncertainty
   - laparoscopy: to observe gross inflammatory changes, and to obtain a peritoneal biopsy, it is indicated only in severe cases where there is diagnostic uncertainty
3. ) General Management
   - simple analgesics, advise rest, drink plenty of fluids
   - avoid sexual intercourse until the antibiotic course is complete and partner(s) are treated (all partners from the last 6 months should be tested and treated)
   - admission criteria: risk of ectopic, severe/septic sx, signs of pelvic peritonitis, unresponsive to oral abx
4. ) Antibiotics - triple therapy given for 14 days, before the swab results are available
   - IM ceftriaxone 1g (1 dose) to cover gonorrhoea
   - PO doxycycline for chlamydia and mycoplasma
   - PO metronidazole for anaerobes e.g. G. vaginalis
   - alternative is just ofloxacin and metronidazole

Question 3

Chlamydia trachomatis

Pathophysiology
Clinical Features in Women
Clinical Features in Men
Differential Diagnoses

Answer 3

1. ) Pathophysiology
   - an obligate intracellular gram-ve bacterium
   - transmission via unprotected vaginal, anal, oral sex and can spread by just direct skin to skin contact
   - can also cause conjunctivitis (if semen/vaginal fluid enter eye), can be spread vertically during delivery
   - incubation period is typically between 7 and 21 days
   - risk factors: age <25, UPSI, +ve sexual parter, recent change in partners, co-infection with another STI
2. ) Clinical Features in Women - 70% asymptomatic
   - sx: lower abdo pain, dysuria, deep dyspareunia, intermenstrual or post-coital bleeding
   - discharge: yellow, mucopurulent, odorous
   - signs: cervicitis +/- contact bleeding, , pelvic tenderness, cervical excitation
3. ) Clinical Features in Men - 50% asymptomatic
   - sx: urethritis causing dysuria and urethral discharge, epididymo-orchitis causing testicular pain
   - signs: epididymal tenderness, purulent discharge
   - rectal chlamydia and lymphogranuloma venereum in patients presenting w/ anorectal sx: discomfort, discharge, bleeding and change in bowel habits
4. ) Differential Diagnoses - other STIs
   - a full STI screen should be undertaken

Question 4

Management of Chlamydia

Investigations
Management
Complications

Answer 4

1. ) Investigations
   - NAAT swabs as chlamydia is too small to see on a microscope so charcoal swabs cannot be used
   - women: VVS (1°) or endocervical or first catch urine
   - men: first catch urine sample (1°) or urethral swab
   - pharyngeal or rectal swab after oral/anal sex
   - full STI screen is recommended due to co-infections
   - if +ve, contact tracing is necessary
2. ) Management
   - uncomplicated: doxycycline 100mg BD for 7 days
   - doxycycline is contraindicated in pregnancy and breastfeeding so erythromycin or azithromycin used
   - avoid sex until treatment is complete (inc partners)
   - test of cure only if the patient is pregnant, compliance was poor or when symptoms persist
3. ) Complications
   - PID (women), epididymitis/epididymo-orchitis (men)
   - sexually acquired reactive arthritis where the joints, eyes, urethra become inflamed (more common in men)
   - pregnancy: preterm delivery, PROM, low birth weight, postpartum endometritis, neonatal infection

Question 5

Neisseria Gonorrhoea

Pathophysiology
Clinical Features in Women
Clinical Features in Men
Differential Diagnoses

Answer 5

1. ) Pathophysiology - g-ve diplococcus
   - transmitted through unprotected vaginal/oral/anal sex, it can also be vertically transmitted to newborns
   - strong affinity for mucous membranes
   - incubation period is 2-5 days
   - risk factors: <25yrs, previous hx of STI, multiple partners, MSM, living in high-density urban areas
2. ) Clinical Features in Women - 50% symptomatic
   - odourless purulent (green/yellow) discharge
   - pain: lower abdo pain, dyspareunia, dysuria
   - IMB and or PCB can occur but are rare
   - examination: can be normal but may show pelvic tenderness, easily induced cervical bleeding, mucopurulent endocervical discharge
3. ) Clinical Features in Men - 90% symptomatic
   - odourless purulent urethral discharge, dysuria, testicular pain/swelling in epidydymo-orchitis
   - rectal infection: usually asymptomatic, anal discharge anal pain/discomfort
   - pharyngeal infection: usually asymptomatic
4. ) Differential Diagnoses - other STIs
   - a full STI screen should be undertaken

Question 6

Management of Gonorrhoea

Investigations
Management
Complications

Answer 6

1. ) Investigations - patients should be referred to GUM clinics if suspected of gonorrhoea
   - females: 1 NAAT swab (endocervical or VVS) and 1 or 2 charcoal (MC+S) swabs (endocervical or urethral)
   - males: 1 NAAT (urine), 1 charcoal swab (urethral)
   - rectal and pharyngeal swabs are recommended in all MSM and those partaking in anal or oral sex
   - charcoal swabs should be taken for MC+S before initiating abx due to high rates of abx resistance
2. ) Management - treat w/ empirical abx if waiting for lab results but sx are indicative of gonorrhoea
   - 1 dose of IM ceftriaxone 1g (unknown sensitivities) OR (PO cefixime + PO azithromycin)
   - 1 dose of PO ciprofloxacin 500mg (known sensitivity)
   - offer screening for other STIs
   - contact tracing to treat previous partners
   - avoid sex until treatment is complete (inc partners)
   - test of cure: 72hrs for MC+S, 7d for RNA NAAT, 14d for DNA NAAT
3. ) Complications
   - PID: should admit if signs of complicated/severe PID
   - epididymo-orchitis and prostatitis in men
   - neonatal gonococcal conjunctivitis, is a medical emergency as it can lead to sepsis and/or blindness
   - disseminated gonococcal infection (DGI) is rare but can cause systemic sx, joint pains, and skin lesions
   - DGI should be treated in hospital as it can develop into life-threatening gonococcal meningitis

Question 7

Trichomonas Vaginalis

Pathophysiology
Clinical Features
Investigations
Management

Answer 7

1. ) Pathophysiology - anaerobic flagellated protozoan
   - only transmitted via unprotected vaginal intercourse, rarely transmitted vertically
   - urethral infection is present in nearly all cases and in women, there is often infection at more than one site
   - increases the risk of contracting HIV, BV, cervical cancer, PID, pregnancy complications e.g. pre-term
   - risk factors: older women, UPSI, multiple partners, hx of STIs
2. ) Clinical Features - up to 50% asymptomatic
   - offensive vaginal odour, vulval itchiness or soreness
   - frothy yellow/green discharge, may smell fishy
   - dyspareunia, dysuria, raised vaginal pH (>4.5)
   - strawberry cervix: punctate, papilliform appearance
   - often asymptomatic in men but may cause urethral discharge, dysuria, frequency, balanitis
3. ) Investigations
   - female: charcoal HVS or self-taken vaginal swab
   - male: urethral swab or first void urine sample
   - contact tracing if a patient tests +ve
   - full STI screen for coexisting infections
4. ) Management - anti-protozoan antibiotics
   - PO metronidazole 2g (1 dose) OR metronidazole 400-500mg BD for 5-7 days
   - PO tinidazole 2g (1 dose) is an alternative
   - treat previous partners in the last 4 weeks
   - avoid sex until treatment is complete (inc partners)
   - test of cure is not necessary unless not better

Question 8

Bacterial Vaginosis

Pathophysiology
Risk Factors
Clinical Features
Differential Diagnoses

Answer 8

1. ) Pathophysiology - non-STI of the vagina
   - disturbed normal vaginal flora –> ↓lactobacilli which produce H2O2 to keep the vagina acidic (pH <4.5)
   - ↑ in pH allows the growth of other organisms:
   - Gardnerella vaginalis (main), anaerobes, mycoplasma
2. ) Risk Factors - change in normal vaginal flora
   - vaginal douching, scented soaps, vaginal deodorant
   - oral sex, active STI, IUD, recent antibiotic use
   - new/multiple partners, smoking, black women
3. ) Clinical Features - up to 50% are asymptomatic
   - most common cause of abnormal vaginal discharge:
   - watery grey/white, offensive fishy-smelling
   - soreness, itching/irritation suggests co-infection
   - examination: thin, white/grey, homogenous discharge

4.) Differential Diagnoses - abnormal vaginal discharge
- candidiasis: profuse thick white, itchy, curd-like
- trichomoniasis: thin, frothy, offensive, green/yellow
w/ associated irritation, dysuria and inflammation
- Gonorrhoea/Chlamydia: odourless, green/yellow

Question 9

Management of Bacterial Vaginosis

Investigations
Management
Prognosis and Advice

Answer 9

1. ) Investigations
   - preferred diagnosis w/ charcoal HVS for microscopy:
   - ‘clue cells’, ↓lactobacilli, absence of pus cells
   - diagnosis can also be made with a vaginal pH >4.5 and the KOH whiff test (fishy odour) but this is rare
2. ) Management
   - asymptomatic BV does not require treatment
   - Abx: PO metronidazole 400mg BD for 5-7days OR 1 dose of 2g OR as a gel applied directly to the vagina
   - can also use clindamycin or tinidazole
3. ) Prognosis and Advice
   - test of cure is not necessary as sx usually resolve
   - recurrent BV is common usually within 3 months
   - avoid vaginal douching, scented shower gels, antiseptic agents and shampoos in the bath
   - consider the removal of an IUD that is present
   - must be treated if pregnant as can cause PROM, premature birth, miscarriage, chorioamnionitis

Question 10

Vulvovaginal Candidiasis

Pathophysiology
Risk Factors
Clinical Features
Differential Diagnosis

Answer 10

1. ) Pathophysiology - a fungal infection of the lower reproductive tract, aka ‘thrush’ or yeast infection
   - opportunistic infection w/ Candida albicans which is also part of the body’s normal flora in the GI tract
   - highly common, peaks in women 20-40yrs
   - up to 20% of women may carry candida without any symptoms and do not require treatment
2. ) Risk Factors
   - pregnancy: ↑oestrogen promotes candida growth
   - immunosuppression/immunocompromised: poor DM control, HIV or cancer patients, use of corticosteroids
   - use of broad-spectrum antibiotics: alters normal vaginal microbiota, allowing candida to flourish/grow
3. ) Clinical Features - clinical diagnosis
   - vulval itchiness (most common), superficial dysuria
   - odourless, white, curd-like vaginal discharge
   - examination: erythema and swelling of the vulva, satellite lesions, red, pustular lesions with superficial white/creamy pseudomembranous plaques that can be scraped off, curd-like discharge in the vagina
4. ) Differential Diagnosis
   - bacterial vaginosis, trichomoniasis, UTI
   - contact dermatitis, eczema, psoriasis

Question 11

Management of Vulvovaginal Candidiasis

Investigations
Antifungal Therapy
General Management

Answer 11

1. ) Investigations - only for complicated cases:
   - recurrent infections, associated with risk factors such as pregnancy, diabetes, compromised immunity
   - measuring vaginal pH is always recommended
   - charcoal HVS w/ microscopy to confirm the diagnosis: spores and mycelia are indicative of the infection
   - recurrent candidiasis (4+/year): HVS to confirm, HbA1c to exclude DM, exclude lichen sclerosis
2. ) Antifungal Therapy - oral or topical
   - 1°: PO fluconazole 150mg as a single dose (contraindicated in pregnancy)
   - 2°: intravaginal clotrimazole 500mg pessary as a single dose OR 100mg for 7 days
   - clotrimazole and fluconazole can be bought OTC (Canesten Duo contains 1 tablet and 1 cream)
   - vulval symptoms: topical clotrimazole/ketoconazole can be added to oral or intravaginal therapy
   - antifungal creams and pessaries can damage latex condoms and prevent spermicides from working, so alternative contraceptive is required for 5+ days
   - consider prophylactic PO fluconazole if recurrent
3. ) General Management
   - safety net: return if sx have not subsided in 7-14d
   - referral to a specialist if Tx continues to fail or if non-albicans Candida species has been identified
   - advise using soap substitutes and avoid cleaning the vaginal area more than once a day
   - avoid potential irritants e.g. shower gels, vaginal deodorants, douches, tight-fitting underwear/tights