Infective causes of discharge

Question 1

What is thrush?

Answer 1

This is a yeast infection of the lower female reproductive tract.

Question 2

What is the pathogenesis of thrush?

Answer 2

85-90% of cases are due to candida albicans. Other organisms include Candida glabrata, Candida tropicalis, Candida krusei and Candida parapsilosis.

Candida is a normal commensal organism in the vagina.

Question 3

What are the risk factors for thrush?

Answer 3

Pregnancy 
DM 
Antibiotics use 
Foreign bodies 
Chemotherapy 
Contraceptives

Question 4

Symptoms and signs of thrush

Answer 4

Pruritus vulvae 
Vulval soreness 
White 'cheesy' discharge 
Dyspareunia 
Dysuria (external) 
Vulval erythema- possibly with fissuring 
Vulval oedema 
Satellite lesions 
Excoriation

Question 5

Differentials of thrush

Answer 5

BV 
Trichomonas vaginalis 
STIs 
Atrophic vaginitis 
Helminthic infection 
Lichen sclerosus 
Contact dermatitis 
Eczema 
Psoriasis 
UTIs 
Rectovesical fistula

Question 6

Investigations for thrush

Answer 6

Routine vaginal swabs are not required, in suspected bacterial/resistant or complicated infection.

Take swabs from the anterior fornix or lateral vaginal wall and send for microscopy, culture and sensitivity.

Take midstream specimen of urine (MSU) if symptoms could be due to urinary tract infection.

Question 7

Management of thrush

Answer 7

Use a soap substitute to clean the vulval area, wear loose-fitting underwear, prescribe either an intravaginal antifungal such as clotrimazole or miconazole.

Severe infections are treated with two doses of oral fluconazole (150mg).

Intravaginal clotrimazole or miconazole should be used in pregnancy.

Question 8

Complications of thrush

Answer 8

Depression

Psychosexual problems

Question 9

What is the definition of BV?

Answer 9

BV is caused by an overgrowth of predominantly anaerobic organisms in the vagina. The most common organisms include Gardnerella vaginalis, Prevotella spp.

BV is the most common cause of abnormal vaginal discharge in women of reproductive age.

Question 10

Risk factors for BV

Answer 10

Sexual activity
New sexual partner
Other STIs
Ethnicity
Presence of a IUCD
Vaginal douching
Bubble baths
Receptive oral sex
Smoking.

Question 11

Protective factors against BV

Answer 11

Condom use
COC
Circumcised partner

Question 12

Presentation of BV

Answer 12

Offensive, fishy-smelling vaginal discharge without soreness or irritation.

Half of all women infected are asymptomatic.

There is usually a thin layer of white discharge covering the vaginal wall.

Question 13

Differential diagnosis of BV

Answer 13

Other vaginal infection: candida, trichomoniasis, chlamydia, gonorrhoea, herpes simplex.

Other benign causes of vaginal discharge- physiological discharge, chemical irritants, foreign body, pregnancy, cervical ectropion.

Tumours of the vulva, vagina, cervix or endometrium

Postmenopausal vaginal discharge due to atrophic vaginitis

Vaginal discharge after gynae surgery.

Question 14

Investigations for BV

Answer 14

Amsel’s criteria require at least three of the following for diagnosis:

i. Homogeneous discharge as above.
ii. Microscopy showing vaginal epithelial cells coated with a large number of bacilli (‘clue cells’).
iii. Vaginal pH >4.5.
iv. Fishy odour on adding 10% potassium hydroxide to vaginal fluid.

Clinical diagnosis

Question 15

Management of BV

Answer 15

a. Advise avoidance of vaginal douching, advise against the use of shower gel, asymptomatic women usually do not need treatment unless they are pregnant.

b. Treatment options are:
Oral metronidazole 400-500 mg bd for 5-7 days. Treatment of choice. This may be used in pregnant women.
Oral metronidazole 2 g stat. Avoid in pregnant women.
Metronidazole vaginal gel 0.75% once daily for five days.
Clindamycin vaginal gel 2% once daily for seven days.
Oral tinidazole 2 g stat.
Oral clindamycin 300 mg bd for seven days.

Question 16

Complications of BV

Answer 16

BV can increase the risk of acquiring and transmitting HIV and other STIs.

In pregnancy, BV is associated with various complications:

i. Late miscarriage
ii. Preterm delivery
iii. Premature rupture of membranes.
iv. Low birth weight
v. Postpartum endometritis

Question 17

What is chlamydia?

Answer 17

Chlamydiae are small, obligate intracellular Gram-negative bacteria that infect human columnar and transitional epithelium.

Chlamydia trachomatis is responsible for:

i. Ocular infection (trachoma).
ii. Genitourinary infections.
iii. Proctitis.
iv. Sexually acquired reactive arthritis.
v. Lymphogranuloma venereum (a rare, sexually transmitted tropical infection causing genital ulcers and inguinal lymphadenopathy).

Question 18

Prevalence of chlamydia

Answer 18

It is the most commonly diagnosed sexually transmitted infection (STI) in the UK and the most common preventable cause of infertility worldwide.

It is asymptomatic in approximately 50% of men and at least 70% of women.

Sequelae can, however, include pelvic inflammatory disease (PID), ectopic pregnancy, tubal infertility in women and proctitis, epididymitis and epididymo-orchitis in men.

Question 19

Risk factors for chlamydia

Answer 19

Age <25 years.
Sexual partner positive for chlamydia (two thirds of partners of people testing positive for chlamydia will test positive).
Two or more sexual partners in the preceding year.
A recent change in sexual partner.
Lack of consistent use of condoms.
Non-barrier contraception.
Infection with another STI.
Poor socio-economic status.
Genetic predisposition.

Question 20

Presentation of chlamydia

Answer 20

Most cases are symptomatic.

Women present with vaginal discharge, dysuria, vague lower abdominal pain, fever, intermenstrual or postcoital bleeding, deep dyspareunia.

Men present with classical urethritis with dysuria and urethal discharge or epididymo-orchitis presenting as unilateral testicular pain and swelling.

In both sexes, young adults present with a reactive arthritis. Proctitis and pharyngeal infection.

-In women, signs can include:
A friable, inflamed cervix with contact bleeding.
Mucopurulent endocervical discharge
Abdominal tenderness
Pelvic adnexal tenderness on bimanual palpation
Cervical excitation

Question 21

Differential diagnosis of chlamydia

Answer 21

a. Gonorrhoea
b. Trichomonas vaginalis infection
c. UTI
d. BV
e. Endometriosis
f. Urethral/vaginal foreign body

Question 22

Investigations for chlamydia

Answer 22

Vulvovaginal swab for NAATs.

Question 23

Management for chlamydia

Answer 23

Antibiotic treatment of the index case- doxycycline 100mg (CI in pregnancy) or a single dose of 1g of azithromycin.
Pregnancy- erythromycin, amoxicillin or azithromycin
Screening for other STIs
Partner notification

Question 24

General advice for chlamydia

Answer 24

Chlamydia is primarily sexually transmitted.

Infection is very often asymptomatic and may have persisted for many months or even for years.

No diagnostic test is 100% sensitive.

Potential complications of not treating chlamydia.

The importance of investigating and treating sexual partners.

Agree on the method of partner notification.

The importance of complying with treatment.

Antibiotic side-effects and interactions.

Avoidance of sexual intercourse (genital, oral and anal sex) even with a condom for a week after single-dose therapy or until finishing a longer regimen.

The patient should not resume sex with their partner(s) until they too have completed treatment (or for a week following stat dose of azithromycin) or received negative test results; otherwise there is a high risk of re-infection.

It is important to test for other STIs, including human immunodeficiency virus (HIV) and hepatitis B.

Advice on safer sexual practices, contraception and condom use.

Question 25

Complications of chlamydia

Answer 25

``` PID Infertility Ectopic pregnancy Perihepatitis as part of Fitz-Hugh and Curtis syndrome Reactive arthritis ```

Question 26

What is the definition of gonorrhoea?

Answer 26

Neisseria gonorrhoeae is a Gram-negative diplococcus infecting mucous membranes of the urethra, endocervix, rectum, pharynx and conjunctiva. Transmission occurs by the direct inoculation of infected secretions from one mucous membrane to another, usually sexually and, less commonly, perinatally. The incubation period is usually taken as being between 2 and 5 days but may be up to 10 days.

Question 27

Risk factors for gonorrhoea

Answer 27

``` Young age Hx of previous STI Co-existent STIs New or multiple sexual partners Recent sexual activity abroad Certain sexual activities eg. Anal intercourse, frequent insertive oral sex Inconsistent condom use Hx of drug use or commercial sex work ```

Question 28

Presentation of gonorrhoea

Answer 28

Gonorrhoea is believed to be symptomatic in most men (90-95%) and asymptomatic in half of women. Symptoms: Men present with urethral infection (discharge and/or dysuria), rectal infection or pharyngeal infection. Women present with endocervical infection (discharge, lower abdominal pain), urethral infection, pharyngeal infection. Signs in men include purulent urethral discharge and epididymal tenderness. Signs in women include endocervical discharge, pelvic tenderness.

Question 29

Differentials of gonorrhoea

Answer 29

``` Chlamydia Endometriosis Appendicitis Pharyngitis Arthritis ```

Question 30

Investigations of gonorrhoea

Answer 30

Endocervical swab for NAATs

Question 31

Management for gonorrhoea

Answer 31

Allow time to provide a detailed explanation of the condition and its long-term implications for the patient and their partner's/partners' health, reinforced with written information. Advise on safer sexual practices for the future. Advise patients to avoid unprotected sexual intercourse until both they and their partner(s) have completed treatment. Advise routine screening for other STIs in all patients with or at risk of gonorrhoea. Co-infection with other STIs, particularly chlamydia, is common. Partner notification should preferably be performed by a trained health adviser. Drug treatment- ceftriaxone 500mg plus azithromycin (1st line) Cefixime and cefotaxime can be used.

Question 32

Complications of gonorrhoea

Answer 32

``` Gonococcal urethritis Prostatitis PID Bartholin’s abscess Peri-hepatitis (Fitz-Hugh Curtis) Premature labour and miscarriage Corneal scarring and blindness from neonatal ophthalmic infection ```

Question 33

What is trichomonas vaginalis?

Answer 33

Trichomonas vaginalis is a very common sexually transmitted infection (STI) that can cause vaginitis, cervicitis and urethritis.

Question 34

Causes of trichomonas vaginalis

Answer 34

T. vaginalis is a flagellated protozoan. In women the organism is found in the vagina, urethra and paraurethral glands. Urethral infection is present in 90% of infected women. In men infection is usually of the urethra. In adults transmission is almost exclusively through sexual intercourse.

Question 35

Presentation of trichomonas vaginalis in women

Answer 35

The symptoms of T. vaginalis can be confused with bacterial vaginosis (BV). Around 70% of women have a vaginal discharge. Although this is usually a frothy yellowish discharge, it can vary from being thin and scanty to profuse and thick. Other common symptoms include vulval itching, dysuria or offensive odour. Lower abdominal discomfort can occur in some women. There may be signs of local inflammation with vulvitis and vaginitis. Cervicitis may be present which is called a strawberry cervix.

Question 36

Presentation of trichomonas vaginalis in men

Answer 36

Men are usually asymptomatic. T. vaginalis is increasingly being recognised as a cause of non-gonococcal urethritis. The most common symptoms are dysuria and presence of a urethral discharge. The vast majority of men will have no abnormal signs on examination.

Question 37

Differential diagnosis of T. vaginalis

Answer 37

Candidiasis, BV, chlamydia, gonorrhoea, herpes simplex. Postmenopausal vaginal discharge due to atrophic vaginitis. Vaginal discharge after gynae surgery.

Question 38

Investigations of T. vaginalis

Answer 38

If T. vaginalis is suspected, a high vaginal swab can be taken from the posterior fornix but sensitivity may be low because motility reduces with transit time. Women with suspected T. vaginalis should also have contact tracing undertaken. Women with T. vaginalis need testing for other STIs. Urethral culture or culture of first-void urine will diagnose 60-80% of cases in men. Test of cure is only recommended if symptoms persist or recur.

Question 39

Management of T. vaginalis

Answer 39

Both partners should ideally be treated at the same time. Sexual intercourse should be avoided for at least one week following receiving treatment. All patients should receive clear and accurate written information about this condition. Although TV is easily treated with metronidazole in most cases, resistant strains are on the increase. Systemic treatments are far more effective than topical treatments and include: - Oral metronidazole 2 g as a single dose. - Oral metronidazole 400 mg to 500 mg bd for five to seven days. - Oral tinidazole 2 g single dose can be given as an alternative if metronidazole is not effective. - Treatment of partners is recommended, regardless of their results.

Question 40

Complications of T. vaginalis

Answer 40

Preterm delivery and low birth weight. Postpartum sepsis Enhance HIV transmission Prostatitis

Question 41

What is herpes simplex?

Answer 41

Genital herpes simplex is caused by infection with the herpes simplex virus (HSV). HSV is sub-divided into HSV type 1 (HSV-1) and HSV type 2 (HSV-2). Type 1 is the usual cause of infections of the oral region and causes cold sores (herpes labialis). In the UK it is now also the most common cause of genital herpes. Type 2 is associated with anogenital infection (penis, anus, vagina). It was the most common cause of genital infection but HSV-1 has overtaken it. HSV-2 is the most likely to cause recurrent anogenital infection. However, both can infect the mouth and/or genitals, due to oral sex or autoinoculation.

Question 42

Transmission of herpes simplex

Answer 42

-Genital herpes is acquired from contact with: Infectious secretions on oral, genital or anal mucosal surfaces. Contact with lesions from other anatomical sites - eg, eyes, skin or herpetic whitlow. -Therefore, the infection is transmitted through vaginal, anal and oral sex, close genital contact and contact with other sites such as the eyes and fingers.

Question 43

Risk factors for herpes simplex

Answer 43

Multiple sexual partners. Previous history of STIs. Early age of first sexual intercourse. Unprotected sexual encounters. Men who have sex with men (and female partners of men who have sex with men). Female gender. Human immunodeficiency virus (HIV) infection.

Question 44

Presentation of herpes simplex virus

Answer 44

In many cases there are no symptoms and the infected person does not know they have the disease and does not present to the medical profession. Where the condition is symptomatic, it usually presents as multiple painful ulcers.

Question 45

What are the symptoms of Herpes simplex virus?

Answer 45

Febrile flu-like prodrome (5-7 days). Myalgia and fever are the main systemic symptoms. Tingling neuropathic pain in the genital area/buttocks/legs. Extensive painful crops of blisters/ulcers in the genital area (including the vagina and cervix in women and the urethra in men). Lesions are usually bilateral in primary disease (usually unilateral in recurrent cases). Tender lymph nodes (inguinal). Usually bilateral in primary disease. Local oedema Dysuria. Vaginal or urethral discharge.

Question 46

Investigations for herpes simplex virus.

Answer 46

Viral culture | DNA detection using PCR of a swab from the base of an ulcer.

Question 47

Differential diagnosis of herpes simplex virus

Answer 47

``` Vulvo-vaginal candidiasis Gonorrhoea Non-gonococcal urethritis Syphilis BV Scabies Psoriasis Reactive arthritis Herpes zoster ```

Question 48

Management of HSV

Answer 48

Advice includes: Saline bathing (one teaspoon of salt in one pint of warm water). Oral painkillers. Topical lidocaine 5% gel or ointment is suitable analgesia. Vaseline® or topical lidocaine may be applied to prevent pain during micturition. Micturition whilst sitting in a bath can help prevent urinary retention. Increase fluid intake to dilute urine to reduce pain during micturition. -The British Association for Sexual Health and HIV (BASHH) guidelines advise first-line treatment should be five days of: Aciclovir 400 mg three times daily; OR Valaciclovir, 500 mg twice daily for five days. -BASHH alternative regimens (also for five days) are: Aciclovir 200 mg five times daily; OR Famciclovir 250 mg three times daily.

Question 49

Complications of HSV

Answer 49

Autonomic neuropathy, resulting in urinary retention. Aseptic meningitis. Spread to extra-genital areas. Secondary infection with candida or streptococci. Perinatal transmission if the women is pregnant. Psychological and psychosexual problems.