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Gynae > Infections and asher/atrophic > Flashcards

Infections and asher/atrophic Flashcards

1
Q

What is Asherman’s syndrome?

A

Presence of intrauterine adhesions that may partially/ completely occlude the uterine cavity

Trauma, infection causing damage to the basal layer of endometrium.

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2
Q

Recall 3 risk factors for Asherman’s syndrome

A

Endometrial resection
Dilation and curettage (for miscarriage)
Endometriosis
Myomectomy / C-section

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3
Q

Recall 3 symptoms of Asherman’s syndrome

A

Amenorrhoea, subfertility, cyclical abdo pain

No external signs

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4
Q

Recall what investigations should be done in suspected Asherman’s

A

Saline hysterosonography (HSG), TVUSS
Hysteroscopy

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5
Q

What would be seen on TVUSS in Asherman’s syndrome?

A

Sub-endothelial linear striations + ‘boggy’ uterus

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6
Q

How is Asherman’s syndrome managed?

A

Initially: Hysteroscopic adhesionolysis + post-op copper IUD
Next: PO oestrogens (2-3m) and reasses cavity

PO oestrogens induce endometrial proliferation

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7
Q

Recall some complications of Asherman’s

A

Infertility, miscarriage, oligomenorrhoea
Abnormal placentation
Operation comps

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8
Q

What is atrophic vaginitis?

A

Vaginal irritation caused by thinning of the vaginal epithelium

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9
Q

What is the cause of atrophic vaginitis?

A

Reduction in circulating oestrogen ie. Post-menopause

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10
Q

Risk factors for atrophic vaginitis

A

Menopause
Prolonged lactation

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11
Q

Give 3 signs of atrophic vaginitis

A

Irritation, superficial dysuria, dyspareunia, discharge (may be bloody)

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12
Q

How does atrophic vaginitis appear O/E?

A

Pale, thin vaginal walls with loss of rugal folds, cracks or fissures

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13
Q

What investigations would you order in suspected atrophic vaginitis?

A
  1. Clinical examination
  2. Swabs for potential infection
  3. Biopsy for potential malignancy/ ulcers
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14
Q

How is atrophic vaginitis managed?

A
  1. Systemic HRT
  2. If bleeding on intercourse –> water based moisturisers and lubricants
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15
Q

Atrophic vaginitis complication

A

Increased incidence of superinfection as increased vag PH

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16
Q

What 8 things should be checked for when doing a history for gynaecological infections?

A

Discharge (smell, consistency, colour, volume), Blood
Pain
Urinary symptoms
Itch
FLAWS
Pregnancy status
Sexual history

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17
Q

What investigations should be done in a suspected gynaecological infection?

A

pH, swabs (double or triple) and blood tests (for HIV/ syphilis)

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18
Q

What is the normal pH for the lateral wall of the vagina?

A

3.5-4.5 (due to lactobacilii in vagina)

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19
Q

What is a low vaginal pH indicative of?

A

Candida

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20
Q

What is a raised vaginal pH indicative of?

A

Contamination, BV or TV

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21
Q

Describe the method of ‘double swab’?

A
  1. Endocervical swab - tests for gonorrhoea and chlamydia
  2. High vaginal swab, “charcoal swab” - fungal and bacterial (BV, TV, candida, GBS)
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22
Q

Describe the method of ‘triple swab’?

A
  1. Endocervical (for chlamydia)
  2. Endocervical charcoal swab (for gonorrhoea)
  3. High vaginal charcoal swab (for fungal/ bacterial infection)
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23
Q

What type of testing is done on the endocervical swab?

A

NAAT (nucleic acid amplification testing) for chlamydia/ gonorrhoea

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24
Q

What type of testing is done on the high vaginal swab?

A

MCandS

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25
Q

How does gonorrhoea appear under the microscope?

A

Gram neg diplococci

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26
Q

STI blood workup

A

HIV
Syphilis

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27
Q

What is the most common cause of abnormal discharge?

A

BV

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28
Q

Is BV sexually transmitted

A

No, sexually assoaciated but not transmitted

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29
Q

BV risk factors

A

Smoking
New sexual partner
STIs
Vaginal douching
IUD
Vaginal pH increase
Sexual activity

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30
Q

BV protective factors

A

Condoms
Circumcised partner
COCP

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31
Q

How does discharge appear in BV?

A

Thin and watery, grey/ white - FISHY SMELLING ODOUR

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32
Q

What are the symptoms of BV?

A

Just the discharge

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33
Q

What is the cause of BV?

A

Overgrowth of anaerobic bacteria

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34
Q

What is the most commonly implicated microbe in BV?

A

Gardrenella vaginalis

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35
Q

What is required for BV diagnosis?

A

Clinical diagnosis + microscopy, can show high pH

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36
Q

What would be shown on microscopy in BV?

A

Clue cells - vaginal epithelium cells coated with lots of bacilli

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37
Q

What are the criteria for BV diagnosis confirmation?

A

Amsel’s criteria: need 3 out of 4 out of:
1. Thin, white, homogeneous discharge
2. Clue cells on microscopy
3. Vaginal pH > 4.5
4. Fishy odour on adding 10% KOH

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38
Q

How is BV managed?

A
  1. If asymptomatic, no treatment
  2. Metronidazole, PO, 400mg, BD, 7 days
    Second line: Intravaginal clindamycin PV cream, 5g 2% 7 days
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39
Q

Recall some complications of BV

A

Late miscarriage, preterm birth, PROM and postpartum endometritis

40
Q

Recall the symptoms of trichomonas vaginalis

A

Asymptomatic in 50%
Discharge: green/ yellow, “frothy”, offensive odour
Dyspareunia
Vulval itch/ soreness
Lower abdo pain and dysuria

41
Q

What is seen OE in trichomonas vaginalis?

A

Strawberry cervix

42
Q

Recall some key investigations and results in trichomonas vaginalis?

A

High vaginal swab + direct microscopy shows flagellated organism
pH > 4.5 - it is only high in BV and TV
Whiff test
Culture and gram stain
HIV test, NAAT, VDRL
Swabs for other STIs

43
Q

What is the treatment of trichomonas vaginalis?

A

First line: Metronidazole 400mg BD PO, 7 days
Second line: Metronidazole, 2g, PO stat not in pregnancy

44
Q

Trichomonas vaginalis complications

A

Pregnancy - PTL, LBW, PPROM
Enhance STI transmission

45
Q

What are the causative organisms that can cause thrush?

A

Candida albicans (in 90%)
Candida glabrata (in 5%)

gram +ve spores

46
Q

What are the causes of candidiasis?

A

Can be spontaneous
Can be secondary to a disruption of normal vaginal flora

47
Q

Recall some risk factors for vaginal candidiasis

A

Oestrogen exposure (eg pregnancy, intercourse, poorly-controlled diabetes, HIV, recent Abx (eg for a UTI)), immunocompromise

48
Q

What is the most tell-tale examination finding in vaginal candidiasis?

A

‘Cottage-cheese’ type discharge

49
Q

Thrush SxS

A

vulva itching, soreness, irritation

50
Q

What is the expected pH in thrush?

A

Low/ normal

51
Q

What investigations would you do in suspected thrush?

A

Wouldn’t usually do any, but diagnostic is HVS MCandS showing speckled gram pos spores and pseudohyphae

Can do MSU(UTI) and HbA1c

52
Q

What are pseudohyphae indicative of?

A

C. albicans infection specifically

53
Q

How should thrush be managed?

A

1st line: clotrimazole pessary 500mg Pv stat+ 1% clotrimazole cream (BD)
2nd line/ severe: fluconazole PO STAT 15mg
If pregnant, use topical treatment only

54
Q

thrush complications

A

Hepatotoxicity with systemic azole therapy - LFTs
Oesphageal candidiasis/ disseminated candidiasis in immunocomp

55
Q

What is the latin name for cutaneous warts?

A

Condylomata acuminate

56
Q

What is the causative organism in cutaneous warts?

A

HPV 6 and 11

57
Q

What is the name of the HPV vaccine?

A

Gardasil

58
Q

Which seroforms of HPV cause cervical cancer vs cutaneous warts?

A

6 + 11 = cutaneous warts; 16 + 18 = cervical cancer

59
Q

Recall the symptoms of cutaneous warts?

A

Generally painless warts but may itch/ bleed/ become inflamed

Vaginal discharge,PCB,IMB,pain

60
Q

How do you investigate for cutaneous warts?

A

Usually a clinical diagnosis, but should also do an STI screen (triple swab: HIV, syphillis, HBV)

Biopsy

61
Q

Cutaneous warts Rx

A

Keratinised warts - imiquimod cream
non-keratinised - podophylin/tri-chloro-acetic acid

cryotherapy
laser
electrocautery

62
Q

Cutaneous warts complications

A

HPV –> anogenital cancer

63
Q

What sort of organism is chlamydia trachomatis?

A

Gram neg parasite - cannot be seen under microscope

64
Q

What are the symptoms of chlamydia?

A

Asymptomatic in 75% of women - when sympatomatic –> purulent PV discharge, dyspareunia, IMB, PCB, abdo pain + dysuria

65
Q

What investigations should be done in suspected chlamydia?

A

Unlike gonorrhoea, if there are signs and symptoms of chlamydia you can treat on suspicion alone
If not sure:
1. NAAT - vulvovaginal swab or first catch urine
2. Culture and sensitivities
Direct microscopy will show neutrophils but no organisms

66
Q

How should chlamydia be managed?

A

1st line: doxycyline - but contraindicated in pregnancy and breastfeeding
2nd line/ pregnant/ breast-feeding: azithromycin (STAT)

67
Q

Recall the signs and symptoms of gonorrhoea

A

Asymptomatic in 50%
If symptomatic, symptoms similar to chlamydia: PV discharge, IMB, PCB, dysuria, dyspareunia, lower abdo pain

68
Q

Recall the findings on speculum examination in gonorrhoea

A

Mucopurulent endocervical discharge
Easily induced endocervical bleeding

69
Q

Recall the findings on bimanual examination in gonorrhoea

A

Cervical motion/ adnexal tenderness
Uterine tenderness

70
Q

When can empirical treatment be given in suspected gonorrhoea?

A

ONLY if recent sexual contact with confirmed gonorrhoeal infection

71
Q

What would be seen on direct microscopy in gonorrhoea?

A

Neutrophils and gram neg diplococci

72
Q

What other investigations can confirm gonorrhoea infection?

A

NAAT / culture and sensitivities

73
Q

How should gonorrhoea be managed?

A

AFTER confirmation by NAAT/ MCandS/ direct microscopy (any will do)
Ceftriaxone 1g IM (NEW for 2019)
Then:
Screening for other STIs, abstain for 1 week, contact tracing - cure rate = 95% with treatment

74
Q

Recall some of the complications of gonorrhoea

A

PID, or a version of PID with liver-abdo wall adhesions called Fitz-Hugh-Curtis syndrome
Disseminated disease in 1% (fever rash arthralgia septic arthritis meningitis endocarditis
Increased HIV susceptibility
Vertical transmission ophthalmia neonatorum

75
Q

What is the causative organism in syhillis?

A

Treponema pallidum (gram neg spirochete)

76
Q

What are the symptoms of primary syphillis?

A

Painless chancre and local lymphadenopathy

77
Q

How long does primary syphillis last?

A

3-8 weeks

78
Q

What are the symptoms of secondary syphillis?

A

ONLY 25% GET SYMPTOMS
Rough papulonodular rash, “snail track oral ulcer”, condylomata lata (really gross)
Uveitis
Lymphadenopathy + system symptoms

79
Q

How long does secondary syphillis last, and after how long will it resolve?

A

It appears 4-10 weeks after the chancre, and resolves in 2 - 12 weeks before the infection becomes latent

80
Q

How is latent syphilis categorised?

A

Early and late - which guides management
Early = exposure/ symtoms <2 years after infection, latent = >2 years

81
Q

How long does tertiary syphillis last?

A

1-20 years

82
Q

What % of untreated syphillis progresses to tertiary?

A

30%

83
Q

Recall the subtypes of tertiary syphillis

A
  1. Gummatous: erosive skin and bone lesions
  2. Cardiovascular: early diastolic decrescendo from aortic regurgitation
  3. Neurosyphillis - might be meningovascular, general paresis or tabes dorsalis (lightening pains)
84
Q

How can suspected syphillis be investigated for?

A
  1. Microbiology = if chancre/ chondylomata are present, the most sensitive one is the ‘dark ground’ method, if not, PCR
  2. Serology
    - Routine screening in pregnant women to detect treponemal antibodies
    - Can use a ‘treponomal test’ - eg. EIA, TPHA
85
Q

Recall how syphillis is managed in adults

A

In primary/ secondary/ early latent:
Benzathine-Pen IM STAT OR doxycycline BD 14/7
If late latent/ non-neuro tertiary;
Benzathine-Pen IM OW 3/52, or doxycycline BD 28/7
If neurosyphillis, penicillin IV, 4-hourly, 14/7 or doxycycline BD 28/7

Prednisolone

86
Q

What is the Jarish-Herxheimer reaction?

A

Release of proinflammatory cytokines in response to dying organisms
Signs and symptoms = 24 hours of febrile myalgia
May follow syphillis treatment

87
Q

How does congenital syphillis appear?

A

Rash on soles of feet and hands +/- bone lesions

88
Q

What is the cause of PID?

A

Ascending infection from the genital tract

89
Q

What is the most common organism implicated in PID?

A

Chlamydia trachomatis

90
Q

What are the symptoms of PID?

A

Often asymptomatic - but causes infertility and chronic pelvic pain
Acutely: BL lower abdo pain, PV discharge, fever, irregular PCB, dyspareunia

91
Q

How should PID be investigated for?

A

Must start Abx before swabs
- Triple swabs
- Speculum (to look for signs of inflammation + discharge)
- Bimanual (cervical excitation, adnexal masses (eg tuboovarian abscess)
- If febrile do blood cultures fbc crp

92
Q

How should PID be managed?

A

First assess patient for admission - admit if pyrexial or septic
Otherwise
- Outpatient Abx, all 3 of ceftriaxone, doxycycline + metronidazole
- If inpatient, do IV cefoxitin + doxycycline
Remove any IUD, + other obvious stuff like STI screen, contact

93
Q

What is the mechanism by which PID can cause ectopic pregnancy?

A

Paralysed cilia in fallopian tubes

94
Q

What is Bartholin’s cyst?

A

A cyst/ abscess of bartholin’s gland (greater vestibular gland)
Likely to have overlying streptococcal/ GBS infection
= blockage of a duct to a gland in vagina which has become infected

95
Q

What is the difference between Bartholin’s cyst and labial cysts?

A

Bartholin’s cysts may extend into the vaginal canal, but labial cysts will remain in labia

96
Q

Recall the appropriate investigations in suspected Bartholin’s cyst

A

If person is >40, consider a vulval biopsy
If infected, MCandS from abscess - most are sterile but may help organism differentiation

97
Q

How should Bartholin’s cysts be managed?

A

Conservatively if draining and the patient is well
If not, Incision and drainage + ‘word’ catheter + flucloxacillin OD
If not - marsupialisation (forming an open pouch to stop the cyst from reforming)

Gynae (4 decks)

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