Flashcards in Session 4 - STI's and PID Deck (58):
What is the difference between a sexually transmitted disease and a sexually transmitted infection?
A STD includes symptomatic cases only whereas STI's include asymptomatic and symptomatic cases.
Which groups of people are at risk of STI's?
Specific ethnic groups
Low socio-economic status
Specific aspects of sexual behaviour - age at first sexual intercourse, no. of partners, sexual orientation, unsafe sexual activity.
Give some reasons why there has been an increased incidence of STI's:
Increased transmission - changing sexual and social behaviour, increasing density and mobility of populations.
Increased GUM attendance
Greater public, medical and national awareness e.g. with campaigns.
Improved diagnostic methods including screening programmes.
Describe the generic management of STI's
Needs to be single/very short course to ensure adherence is high. Preferably given at the GUM clinic.
Co-infections are common so other STI'd should be tested for.
Contact tracing - contact sexual partners
Sexual health education - advice on contraception and need for safe sex.
What are the main types of HPV and what do they cause?
HPV 6 and 11
Cause cutaneous, mucous and anogenital warts.
HPV 16 and 18
Most common type of STI in UK
What are the symptoms of HPV infection?
Benign painless verrucous epithelial or mucosal outgrowths on the penis, viva, vagina, urethra, cervix or on perianal skin.
However they can burn, itch, bleed or produce discharge.
If they are urethral they may alter the urine stream.
What is the main concern with HPV infection?
If infected with HPV 16 or 18 it can cause cervical or anogential cancer.
What investigations can be used to diagnose HPV infection?
Clinical - warts are usually papular and pink, red or brown. May be single but often multiple.
Can biopsy/viral typing but not often necessary.
What is the treatment for HPV infection?
None - usually spontaneous resolution 70% at 1 year and 90% at 2 years. Avoid sexual contact with new partners until warts have cleared. But HPV will persist after warts have cleared.
Check for con-current STI
Ablative surgical therapy/cryotherapy
Topical treatments - podophyllotoxin and imiquimod
Explain the vaccination given for HPV:
Gardasil - protection against HPV 6,11,16,18
Vaccine offered in girls 12-13 in 2 doses - need to give vaccine before first sexual contact.
99% effective in preventing HPV 16 and 18
What is the name of the organism that causes chlamydia and what type of micro-organism is it?
Obligate intracellular bacterium.
What are the symptoms of Chlamydia in males?
Males - White/cloudy discharge from the penis.
Burning or painful sensation on urination
Tip of penis irritated and sore.
Frequent need to urinate.
Females - dysuria, frequent/urgent need to urinate, difficulty starting urination. Itching pain discomfort when not urinating.
Testicle pain and tenderness usually only affecting one side
Blood in semen
Pain when urinating/ejaculating
Problems with urinating
Discomfort in pelvis, genitals, lower back and buttocks.
Inflammation of the anus
Tenderness/pain and irritation of rectum and anal region.
Bleeding/passing mucus from rectum
What are the symptoms of Chlamydia in females?
Can be asymptomatic
Grayish or yellow discharge
Abnormal vaginal bleeding
Pain during sex
Infection/inflammation of the fallopian tubes
Symptoms usually appear after a menstrual period
Abnormal smell/colour of vagina discharge.
Pain during ovulation/sex or coming and going during periods.
Abdominal/lower back pain
Inflammation of the serous or peritoneal covering of the liver.
Describe the investigations for Chlamydia:
Female - Endocervical and urethral swabs - Nucleic acid amplification testing (NAAT)
First void urine sample
Male - First void urine sample
What is the treatment for Chlamydia?
Azithromycin - single dose
Doxycycline - Twice daily, 7 day course.
Erythromycin in children
What are the symptoms of genital herpes?
Extensive painful genital ulceration
What microorganism is responsible for genital herpes?
Herpes Simplex Virus - HSV2
HSV1 associated with cold sores
What does recurrent genital herpes suggest?
That there is a latent infection of the dorsal root ganglia. Although cases are asymptomatic - moderate after the primary infection and are usually shorter.
What tests can be used to diagnose genital herpes?
PCR of vesicle fluid and/or of ulcer base.
What is the treatment for genital herpes?
For primary infection (and severe diseases) - aciclovir
If patient has frequent recurrences then aciclovir can be used prophylactically.
What micro-organism causes gonorrhoea?
Neisseria gonorrhoeae - Gram negative diplococcus
What symptoms does gonorrhoea cause?
Males - urethritis, prostatitis, proctitis, pharyngitis
Females - asymptomatic, endocervicitis can lead to PID if untreated and then infertility.
If infection disseminates can cause bacteraemia and skin and joint lesions.
What tests are used to diagnose gonorrhoea?
NAAT on swab from urethra, cervix, throat/rectum or urine sample.
If positive result need to culture to identify resistant strains.
What is the treatment for gonorrhoea?
Ceftriaxone 500mg one dose IM
Patients are also treated with azithromycin to prevent emergence of resistance to ceftriaxone and to treat co-infection with chlamydia.
What microorganism causes syphilis?
Treponema pallidum - spirochaete bacteria
Doesn't stain easily
What population is syphilis most prevalent in?
Describe the course of syphilis:
Primary - hardened painless ulcers clears in 2-6 weeks
Secondary - 6-8 weeks after beginning of primary ulcer, fever, rash - palms, soles and face, lymphadenopathy mucosal lesions, nighttime headaches, aches.
Latent syphilis - positive serological tests but no clinical evidence of infection - can occur for several years
Tertiary syphilis can present in three different ways:
Neurosyphilis - dorsal column loss - loss of fine touch, proprioception and dementia
Cardiovascular syphilis - Aortitis - presents with aortic regard/aneurysm and angina.
Gummata - Inflammatory fibrous nodules or plaques which may be locally destructive. Can occur in any organ but mainly affect bone or skin.
What is the test to diagnose syphilis?
The organism cannot be easily grown. Testing is via serology with an EIA antibody test. If this is positive then other tests are needed to confirm.
What is the treatment for syphilis?
What are the symptoms of trichomonas vaginalis?
Thin, frothy and offensive vaginal discharge.
Discharge from penis.
Irritation, dysuria and vaginal inflammation.
What type of organism causes trichomonas vaginalis?
How is trichomonas diagnosed?
Sample of discharge or urine sample in men.
What is the treatment for trichomonas?
What is the microorganism that causes vulvovaginal candidiasis?
Candida albicans - can be part of the normal GI/genital tract flora. Fungus.
What are the risk factors for developing candidiasis?
What are the symptoms of candidiasis?
Profuse white-itchy curd-like discharge.
Itchiness of vulva
Symptoms exacerbated premenstrually and remit during menstruation.
What is the treatment for candidiasis?
Topical azole or nystatin
What is the microorganism that causes Bacterial Vaginosis?
No particular organism, it happens when their is a disturbance of the natural flora and there is an overgrowth of some of the following organisms. Gardenella, anaerobes and mycoplasm. They replace lactobacillus and pH rises.
What is the most common cause of abnormal vagina discharge?
What are the risk factors for bacterial vaginosis?
Sexual activity - not sexually transmitted though
New sexual partner
Presence of a copper IUD
Receptive oral sex
What are the symptoms of bacterial vaginosis?
Offensive fishy smelling discharge with soreness and irritation.
On examination there is usually a thin layer of white discharge covering the vaginal wall.
What tests are used to diagnose bacterial vaginosis?
Vaginal pH >5
Fishy smell on KOH whiff test
Microscopic analysis of vaginal fluid - presence of clue cells.
What is the treatment for bacterial vaginosis?
What is the cause of Pelvic Inflammatory disease?
Result of an infection - usually sexually transmitted - ascending from the endocervix. It is usually caused by untreated chlamydia and gonorrhoea.
Termination of a pregnancy
Insertion of IUCD in last 20 days.
What are the complications of PID?
Chronic pelvic pain
What are the symptoms and signs of PID?
Bilateral lower abdominal tenderness
Adnexal tenderness on bimanual examination.
Deep dyspareunia (pain after or during sex)
Abnormal vaginal/cervical discharge
Abnormal vaginal bleeding.
Speculum examination - purulent cervical discharge, cervicitis.
What are the investigations for PID?
Triple swab - endocervical swabs for chlamydia and gonorrhoea, high vaginal swab for BV, trichomonas vaginalis and candida.
USS can help exclude other conditions.
Laparoscopy - invasive test not used routinely in clinical practice.
How would you differentiate between mild to moderate disease and severe disease? And why is this necessary?
If the patients has signs of pelvic peritonitis, tuba-ovarian abscess or pyrexia is >38 degrees it is classed as severe. It is important to differentiate as treatment is different.
What is the treatment for mild PID?
Oral Doxycycline and metronidazole
What is the treatment for severe PID?
If there is no response to treatment laparoscopy/laparotomy may be considered to drain abscess.