Session 9

Question 1

Factors effecting STI transmission

Answer 1

Question 2

Burden of STI/problems with having STIs

Answer 2

Question 3

How can STIs present?

Answer 3

Question 4

Give examples of bacteria, viruses, parasites, fungi & Protozoa causing STIs

Answer 4

Question 5

What investigations can you perform for STI in men?

Answer 5

first pass urine (men only) – urethral GC/CT (can be sent in white universal pot)

vulvo-vaginal swab – vaginal/cervical GC/CT (use chlamydia swab pack and break pink swab tip into NAAT medium)

pharyngeal swab – GC/CT of the throat (use plain purple swab and break tip into NAAT medium)

rectal swab – GC/CT of the rectum (send as for pharyngeal swab)

Question 6

What investigations would you perform in women?

Answer 6

All of these samples can be self-taken. Rectal swabs should be introduced approx. 2cm into the rectum, rotated against the rectal wall, and removed. Vulvo-vaginal swabs should be inserted as far into the vagina as possible, and swept along the vaginal walls and vulva as they are removed to maximise sample volume.

Additional tests for symptomatic patientsmay include the following:

urethral discharge – charcoal swab to microbiology requesting Gonococcal culture

vaginal discharge – charcoal swab from cervical os for Gonococcal culture; additional charcoal swab from posterior fornix for Trichomonas vaginalis and Candida culture

oral/genital ulceration – green viral swab for herpes simplex virus (HSV) 1 and 2 PCR

anal discharge – charcoal swab for Gonococcal culture, HSV swab if significant anorectal discomfort

conjunctivitis – GC/CT NAAT from conjunctiva; charcoal swab for Gonococcal culture if significant purulent discharge.

Question 7

Chylamydia trachomatis

Answer 7

Question 8

Niesseria gonorrhoea

Answer 8

Question 9

Symphilis

Answer 9

Question 10

HSV presentation

Answer 10

Ulcer base specific type serology

Question 11

Trichomonas vaginalis

Answer 11

Question 12

How to treat scabies and pubic lice

1. Features of scabies
2. Management
3. The BNF advises to apply the insecticide to all areas, including the face and scalp, contrary to the manufacturer’s recommendation. Patients should be given the following instructions:

Image below is Norwegian scabies

Answer 12

skin contact

scabies mite lays its eggs in the stratum corneum. The intense pruritus associated with scabies is due to a delayed type IV hypersensitivity reaction to mites/eggs which occurs about 30 days after the initial infection.

1.

• widespread pruritus
• linear burrows on the side of fingers, interdigital webs and flexor aspects of the wrist
• in infants the face and scalp may also be affected
• secondary features due to scratching: excoriation, infection

2.

permethrin 5% is first-line

malathion 0.5% is second-line

pruritus persists for up to 4-6 weeks post eradication

3.

• apply the insecticide cream or liquid to cool, dry skin
• between fingers and toes, under nails, armpit area, creases of the skin such as at the wrist and elbow
• allow to dry and leave on the skin for 8-12 hours for permethrin, or for 24 hours for malathion, before washing off
• reapply if insecticide is removed during the treatment period, e.g. If wash hands, change nappy, etc
• repeat treatment 7 days later

Question 13

What is this image showing

Answer 13

HPV - anogential warts

6 11 non harmful

16 18 harmful - cervical cancer

Question 14

Bacterial vaginosis

Answer 14

Question 15

Vulvovaginal candidiasis

Answer 15

Question 16

State some less complicated UTIS

Answer 16

Question 17

Systemic complications of STIs

Answer 17

The result of infection ascending
from the endocervix, causing
endometritis, salpingitis,
parametritis, oophoritis, tubo-
ovarian abscess and/or pelvic
peritonitis”

Question 18

1. What is PID?
2. Pathophysiology?

Answer 18

1. The result of infection ascending from the endocervix, causing endometritis, salpingitis,
   parametritis, oophoritis, tubo- ovarian abscess and/or pelvic peritonitis

ESPOAP

parametritis inflammation of CT of uterus/parametrium

oophoritis - ovary

2.  Ascending infection from the endocervix and vagina

 Infection causes inflammation

 Inflammation causes damage:

Thus damaged tubal epithelium

Thus adhesions form

 Some recovery of tubal epithelium does occur

Question 19

1. Aetiology
2. Risk factors

Answer 19

1. Sexually transmitted infections:
   - Chlamydia trachomatis D-K
   - Neiserria gonorrhoea

Others

• **Gardnerella vaginalis
• Mycoplasma hominis**
• Anaerobes
• Actinomycosis

Often polymicrobial

2. As for STIs:
   - Young age
   - Lack of use of barrier contraception
   - Multiple sexual partners
   - Low socioeconomic class

IUCD

Question 20

Clinical features to check for PID

Answer 20

Question 21

Answer 21

Question 22

1. Investigations
2. Clinical findings for PID

Answer 22

Urinary and/or serum pregnancy test

Endocervical and High vaginal swabs

• Presence of NG/CT supports diagnosis
• Absence of NG/CT does not exclude diagnosis

Blood tests

• WBC and CRP

Screening for other STIs including HIV

Diagnostic laparoscopy is gold standard

- Can also perform adhesiolysis and drain abscesses

Question 23

1. Findings at laparoscopy in women with suspected PID
2. Management

Answer 23

1. IMAGE

fibre-optic instrument is inserted through the abdominal wall to view the organs in the abdomen or permit small-scale surgery

2.  Low threshold for empirical treatment
   - Delayed treatment increases longterm sequelae

 Symptomatic management with analgesia and rest

 Management of sepsis

 Severe disease requires IV antibiotics and admission for observation and possible surgical intervention

• Pyrexia >38, signs of tubo-ovarian abscess, signs of pelvic peritonitis
• No response to oral therapy
• Increased risk of longterm sequelae

 Contact tracing essential for partners, and full screen for woman

• GUM best able to do this

Question 24

Antiobiotics treatment regime for PID

When might laparoscopy be considered?

Answer 24

Surgical management - Laparoscopy/laparotomy may be considered if:

• no response to therapy
• Clinically severe disease
• Presence of a tubo-ovarian abscess

Question 25

Complications of laparoscopy?

Answer 25

**Ectopic pregnancy** **Infertility** **Chronic pelvic pain** **Fitz-Hugh-Curtis Syndrome** -\> RUQ pain and peri-hepatitis following Chlamydial PID (10- 15%) **Reiter syndrome** -\> Disseminated Chlamydial infection add on note: describe the causation and consequences of pelvic inflammatory disease in women

Question 26

Answer 26

Question 27

1. Syphilis Primary features: 2. Secondary features - occurs 6-10 weeks after primary infection 3. Tertiary features 4. Features of congenital syphilis

Answer 27

1. * chancre - **painless** ulcer at the site of sexual contact * local non-tender lymphadenopathy * often not seen in women (the lesion may be on the cervix) 2. * systemic symptoms: fevers, lymphadenopathy * rash on trunk, palms and soles * buccal 'snail track' ulcers (30%) * condylomata lata (**painless**, warty lesions on the genitalia ) 3. * gummas (granulomatous lesions of the skin and bones) * ascending aortic aneurysms * general paralysis of the insane * tabes dorsalis * Argyll-Robertson pupil 4. blunted upper incisor teeth (Hutchinson's teeth), 'mulberry' molars rhagades (linear scars at the angle of the mouth) keratitis saber shins saddle nose deafness