Sexual & Genitourinary medicine Flashcards
(171 cards)
1
Q
What swabs are involved in sexual health testing?
A
- Charcoal swabs
- Nucleic acid amplification test (NAAT) swabs
2
Q
What are charcoal swabs used for?
A
- Allow for microscopy (w/ gram staining), culture & sensitivities
- Swab with Amies transport medium at the end: contains chemical solution to keep microorganisms alive during transport
- Can be used for endocervical swabs and high vaginal swabs
3
Q
What are NAAT swabs used for?
A
- Check directly for DNA or RNA of the organism
- Specifically for chlamydia & Gonorrhoea
- When gonorrhoea is suspected on NAAT test –> endocervical charcoal swab required for MC+S
4
Q
How can NAAT swabs be taken for both men and women? (in order of preference)
A
- Women: endocervical, vulvovaginal, then first-catch urine
- Men: first-catch urine then urethral swab
Rectal & pharyngeal NAAT swabs - diagnose chlamydia in rectum & throat where anal or oral sex has occured
5
Q
What are the ‘triple swabs’?
A
- Endocervical - “ECS”
- High Vaginal - “HVS”
- Endocervical NAAT - “Chlamydia”
6
Q
What does each swab test for in the triple swab?
A
- ECS (charcoal): Gonorrhoea
- HVS (charcoal): TB & BV, group B strep, candida
- NAAT: Chlamydia & Gonorrhoea
7
Q
What is the difference between double and triple swabs?
A
Double swabs:
* NAAT & HVS in charcoal
Triple swabs:
* NAAT & HVS in charcoal & ECS in charcoal
8
Q
What is thrush?
(vaginal candidiasis)
A
Vaginal infection with a yeast of the candida family - MC is candida albicans
9
Q
How does thrush come about?
A
- Candida may colonise the vagina without causing symptoms
- It then progresses to infection when the right environment occurs
- e.g. during pregnancy, after Tx with broad-spectrum ABx that alter vaginal flora
10
Q
What are 4 risk factors for developing thrush?
A
- Increased oestrogen - e.g. in pregnancy (lower pre-puberty & post-menopause)
- Poorly controlled diabetes
- Immunosuppression - e.g. using corticosteroids
- Broad-spectrum ABx
11
Q
What are the symptoms of vaginal candidiasis (thrush)? (2)
A
- Thick white discharge that does not typically smell
- Vulval & vaginal itching, irritation or discomfort
12
Q
What can more severe vaginal candidiasis infection lead to? (6)
A
- Erythema
- Fissures
- Oedema
- Dyspareunia (pain during sex)
- Dysuria
- Excoriation
13
Q
What investigations can be done for vaginal candidiasis?
A
- Testing vaginal pH using a swab and pH paper - to differentiate between BV/TV and candidiasis
- Charcoal swab with microscopy can confirm Dx
14
Q
What is the difference in pH between bacterial vaginosis/trichomonas and candidiasis?
A
- BV/TV = pH > 4.5
- Candidiasis = pH < 4.5
15
Q
What are the treatment options for vaginal candidiasis (thrush)?
A
- Antifungal cream: clotrimazole inserted into vagina
- Antifungal pessary: clotrimazole
- Oral antifungal tablets: fluconazole
AKA antifungal medications!!
16
Q
What is the standard over-the-counter treatment for thrush?
A
Canesten Duo
* contains single fluconazole tablet & clotrimazole cream to use externally for vulval Sx
17
Q
What is the most common STI in the UK?
A
Chlamydia
18
Q
What kind of organism is Chlamydia trachomatis?
A
Gram negative bacteria
* Intracellular organism: enters & replicates within cells before rupturing the cell and spreading to others
19
Q
What increases your risk of catching chlamydia?
A
- Young
- Sexually active
- Multiple partners
20
Q
What is the National Chlamydia Screening programme (NCSP)?
A
- Aims to screen every sexually active person under 25 years for chlamydia
- Annually or when they change their sexual partner
- Everyone that tests positive should have a re-test 3 months after Tx (to make sure they have not contracted chlamydia again)
21
Q
When a patient attends GUM clinic for STI screening, what is the minimum they are tested for?
A
- Chlamydia
- Gonorrhoea
- Syphilis (blood test)
- HIV (blood test)
22
Q
What is the presentation of chlamydia in sexually active women?
A
75% cases asymptomatic
* Abnormal vaginal discharge
* Abnormal vaginal bleeding (intermenstrual/postcoital)
* Pelvic pain
* Dyspareunia
* Dysuria
23
Q
What is the presentation of chlamydia in sexually active men?
A
50% asymptomatic
* Urethral discharge or discomfort
* Dysuria
* Epididymo-orchitis
* Reactive arthritis
24
Q
What are the examination findings for chlamydia?
A
- Pelvic/abdominal tenderness
- Cervical motion tenderness (cervical excitation)
- Inflamed cervix (cervitis)
- Purulent discharge
25
What is the first line treatment of uncomplicated chlamydia?
**100mg doxycycline BD for 7 days**
## Footnote
Abstain from sex for 7 days, notify sexual partners for contact tracing, consider safeguarding issues & sexual abuse
26
When is doxycycline contraindicated?
**Pregnancy** & **breastfeeding**
* Alternative options: **azithromycin**, **erythromycin**, **amoxicillin**
27
What are some complications of chlamydia?
* Pelvic infalmmatory disease
* Chronic pelvic pain
* Infertility
* Ectopic pregnancy
* Epididymo-orchitis
* Conjunctivitis
* Lymphogranuloma venereum
* Reactive arthritis
28
What are 5 pregnancy related complications of chlamydia?
* **Preterm** delivery
* **PRoM**
* **Low birthweight**
* Postpartum endometritis
* Neonatal infection (**conjunctivitis** / **Pneumonia**)
29
What is lymphogranuloma venereum (LGV)?
* Condition affecting **lymphoid tissue** around sit of infection with **chlamydia**
* Most common in men who have sex with men (MSM)
* Occurs in 3 stages: primary, secondary, tertiary
30
What happens in the 3 stages of LGV?
Primary
* **Painless ulcer** - on penis, vaginal wall or rectum
Secondary
* **Lymphadenitis** - swelling, inflammation, pain in lymph nodes infected with bacteria
* Inguinal or femoral lymoh nodes may be affected
Tertiary
* Inflammation of rectum (**Proctitis**) and anus
* **Proctocolitis** leads to anal pain, change in bowel habits, tenesmus and discharge
31
What is the treatment of lymphogranuloma venereum?
**100mg doxycycline BD for 21 days**
32
What is chlamydial conjunctivitis?
Usually result of sexual activity when genital fluid comes in contact with conjunctiva of eye (e.g. hand-to-eye spread)
33
How does chlamydial conjunctivitis present?
* **Chronic erythema**
* **Irritation**
* **Discharge**
* Unilateral
* Lasting more than **2 weeks**
34
What is bacterial vaginosis? (BV)
Overgrowth of **anaerobic bacteria** in the vagina
* It is **NOT** an STI
35
What causes bacterial vaginosis?
* **Lactobacilli** = healthy vaginal **bacterial flora**
* These produce **lactic acid** which keeps the **vaginal pH** low (< 4.5)
* Acidic environment prevents other bacteria from overgrowing
* **Loss** of lactobacilli = **pH rises**
* This **more alkaline** environment enables **anaerobic bacteria** to multiply
36
What bacteria are associated with BV?
* **Gardnerella vaginalis** (MC)
* **Mycoplasma hominis**
* **Prevotella** species
37
What are some risk factors for BV? (5)
* **Multiple sexual partners** (although not sexually transmitted)
* **Excessive vaginal cleaning** (douching, use of cleaning products & vaginal washes)
* Recent **ABx**
* **Smoking**
* **Copper coil**
38
What is the presentation of BV?
50% ASx
* **Fishy-smelling** watery grey/white discharge
39
What investigations are done for BV?
* **Vaginal pH** - swab and pH paper (normal 3.5-4.5, BV occurs > 4.5)
* Charcoal vaginal swab - **microscopy** (can be HVS or self-taken low vaginal swab)
40
How does BV present on microscopy?
**Clue cells**
* epithelial cells from cervix that have bacteria stuck inside them, usually **gardnerella vaginalis**
41
What is the management of BV?
**Metronidazole**: ABx that targets anaerobic bacteria (given orally or vaginal gel)
* Alternative: **clindamycin**
* Advise about measures to **reduce risk** e.g. avoid vaginal irrigation/cleaning with soaps that disrupt natural flora
* Assess risk of other pelvic infections - Chlam & Gon swabs
* ASx doesn't usually require Tx
42
What are the complications of BV?
* Increases risk of catching STIs (Chl,Gon,HIV)
In pregnant women:
* Miscarriage
* Preterm delivery
* PRoM
* Chorioamnionitis
* Low birth weight
* Postpartum endometritis
43
What is trichomonas vaginalis?
* Parasite spread through sexual intercourse & lives in **urethra** of men, and **vagina** & **urethra** of women
* Classed as a **protozoan**: single-celled organism w/ **flagella**
44
What can trichomonas increase the risk of? (5)
* **Contracting HIV** by damaging vaginal mucosa
* **BV**
* **Cervical cancer**
* **PID**
* Pregnancy-related Cx e.g. preterm delivery
45
How does trichomonas present?
Up to 50% ASx
* Typically **frothy yellow-green** vaginal discharge - may have **fishy smell**
* **Itching**
* **Dysuria**
* **Dyspareunia**
* **Balanitis** (inflammation to the glans penis)
46
What does examination of the cervix reveal in trichomonas?
**"Strawberry cervix"** (colpitis macularis)
* Caused by inflammation (cervicitis)
* Tiny haemorrhages across surface of cervix
Vaginal pH will be raised (> 4.5) like BV
47
How is a diagnosis of trichomonas made in women?
**Charcoal swab** with **microscopy**
* Swab taken from **posterior fornix** of vagina (alt. self-taken lower vag swab)
48
How is a diagnosis of trichomonas made in men?
**Urethral swab** or **first-catch urine**
49
What is the management of trichomonas?
**Metronidazole**
* Refer to GUM for contact tracing
50
What is Neisseria Gonorrhoea?
* **Gram negative diplococcus** bacteria
* Infects **mucous membranes** with a **columnar epithelium**
* e.g. **endocervix**, **urethra**, **rectum**, **conjunctiva** and **pharynx**
* Spreads via contact w/ mucous secretions from infected areas
51
What increases the risk of infection with gonorrhoea?
* Young
* Sexually active
* Multiple partners
* Having other STIs
52
What is the genital presentation of gonorrhoea in women?
50% symptomatic
* **Odourless purulent discharge**, possible green/yellow
* **Dysuria**
* **Pelvic pain**
53
What is the genital presentation of gonorrhoea in men?
90% symptomatic
* **Odourless purulent discharge**, possibly green/yellow
* **Dysuria**
* **Epididymo-orchitis** (testicular pain/swelling)
54
What are the other presentations of gonorhhoea - rectal, pharyngeal, prostatitis, conjunctivitis?
Rectal
* anal/rectal **discomfort** & **discharge**
* often **ASx**
Pharyngeal
* **sore throat**
* often **ASx**
Prostatitis
* **perineal pain**
* urinary Sx
* prostate tenderness on examination
Conjunctivitis
* **erythema**
* **purulent discharge**
55
How is a diagnosis of gonorrhoea made?
* **NAAT** - detects RNA/DNA
* Genital infection - swabs (**EC**, **VV**, **urethral**) or first-catch urine sample
* **Charcoal endocervical swab** - Microscopy, Culture + ABx sensitivities (due to high rates of ABx resistance)
56
What is the management of uncomplicated gonorrhoea?
* **Single dose IM ceftriaxone** (if sensitivities NOT known)
* **Single dose oral ciprofloxacin** (if sensitivities ARE known)
* Follow up **"test of cure"** with NAAT testing if ASx, or cultures if symptomatic
57
What is Disseminated gonococcal infection? (DGI)
Complication of untreated gonococcal infection, where bacteria spreads to **skin & joints**, causing:
* non-specific **skin lesions**
* **polyarthralgia**
* **migratory polyarthritis**
* **tenosynovitis**
* systemic Sx e.g. fever, fatigue
58
What are some complications of gonorrhoea?
* PID
* Chronic pelvic pain
* Infertility
* Epididymo-orchitis
* Prostatitis
* Gonococcal conjunctivitis (neonate) - medical emergency
* Urethral strictures
* Disseminated gonococcal infection
* Skin lesions
* Fitz-Hugh-Curtis syndrome
* Septic arthritis
* Endocarditis
59
What organism is responsible for cold sores and genital herpes?
**Herpes simplex virus** (HSV)
* Two strains: HSV-1 & HSV-2
60
What happens after the initial infection of HSV?
Virus becomes **latent** in the associated **sensory nerve ganglia**
* Cold sores: trigeminal nerve ganglion
* Genital herpes: sacral nerve ganglia
61
How is HSV spread?
Through direct contact with affected **mucous membranes** or **viral shedding** in **mucous secretions**
* Virus can be shed even when no Sx are present (i.e. can be contracted from asymptomatic individuals)
62
What are the 2 strains of HSV and what does each strain cause?
* HSV-1: **cold sores**, often contracted in childhood & remains dormant in **trigeminal nerve ganglion**, reactivates as cold sores#
* HSV-2: **genital herpes**, STI, can also cause lesions in mouth
## Footnote
HSV-1 can cause genital herpes usually contracted through oro-genital sex
63
What is the presentation of genital herpes?
* **Ulcers**/ **blistering lesions** affecting genital area
* **Neuropathic pain** (tingling/burning/shooting)
* **Flu-like Sx** (e.g. fatigue, headache)
* **Dysuria**
* **Inguinal lymphadenopathy**
64
What other ways can HSV present (not genital)?
* **Aphthous ulcers** (painful oral sores)
* **Herpes keratitis** (cornea inflammation)
* **Herpetic whitlow** (painful skin lesion on finger/thumb)
65
How is a diagnosis of genital herpes made?
* Clinically made
* Ask about sexual contacts inc. those w/ cold sores
* **Viral PCR** swab from lesion can confirm Dx & causative organism
66
What is the management of genital herpes?
* **Aciclovir**
* Manage Sx: paracetamol, topical lidocaine (instillagel), avoid intercorse etc.
* Refer to GUM
67
What issues can arise from having genital herpes when pregnant?
* Risk of **neonatal herpes simplex infection** contracted during labour/delivery
* Has high **morbidity** & **mortality**
68
What is the management of genital herpes in pregnancy?
Depends whether it is the first episode or recurrent
* Primary genital herpes: (contracted before 28 weeks) --> **Aciclovir** followed by **prophylactic aciclovir**
* Recurrent genital herpes: regular **prophylactic aciclovir** from 36 weeks gestation
69
What bacteria causes syphilis?
**Treponema pallidum**
* **Spirochete** - spiral-shaped bacteria
70
How is syphilis transmitted?
Bacteria gets in through skin/mucous membranes, **replicates** then **disseminates** throughout body
* Mainly **STI**: oral, vaginal, anal sex
* **Vertical transmission**: mother-->baby
* **IVDU**
* **Blood transfusions**/transplants (rare)
71
What are the stages of syphilis?
Primary
* **Painless ulcer** = "chancre" at original site of infection (usually genitals)
Secondary
* **Systemic Sx** (particularly skin & mucous membranes)
Latent
* Occurs after secondary stage where Sx disappear & Pt becomes ASx despite still being infected
* **Early latent syphilis** occurs within 2 years
* **Late latent syphilis** occurs from 2 years onwards
Tertiary
* Occurs many years after inital infection
* Can affect many organs
* Development of **gummas**, CVS & neuro Cx
72
What is neurosyphilis?
* occurs in infection involves **CNS**
* presents w/ neurological Sx
73
How does **primary syphilis** present?
* **Chancre**: tends to resolve over 3-8 weeks
* Local lymphadenopathy
74
How does **secondary syphilis** present?
* Maculopapular rash
* **Condylomata lata** (grey wart-like lesions around genitals & anus)
* Low-grade **fever**
* Lymphadenopathy
* Alopecia
* Oral lesions
75
How does **tertiary syphilis** present?
* **Gummatous lesions** (gummas): granulomatous lesions that affect skin, organs, bones
* Aortic aneurysms
* Neurosyphilis
76
How does **neurosyphilis** present?
* Headache
* Altered behavious
* Dementia
* **Tabes dorsalis** (demyelination affecting spinal cord posterior columns)
* **Ocular syphilis** (affecting eyes)
* Paralysis
* Sensory impairment
* **Argyll-Robertson pupil**: constricted pupil that accomodates when focusing on a near object but doesn't react to light
77
How is a diagnosis of syphilis made?
* **Antibody testing** for antibodies to the **T. pallidum** bacteria
* Presence of T. Pallidum can be confirmed with: **dark field microscopy** & **PCR**
* **Rapid plasma reagin** (RPR) & **Venereal disease research lab** (VDRL) both test quantity of antibodies produced to syphilis - non-specific but sensitive tests (often produce false positives)
77
What is the management of syphilis?
* **Single deep IM dose of benzathine benzylpenicillin**
* Alt: ceftriaxone, amoxilcillin, doxycycline
* Full screening for other STIs
* Contact tracing
* Prevention of future infections
78
What kind of virus is HPV?
Non-enveloped double-stranded circular **DNA virus** in the Papillomaviridae family
79
How many types of HPV are there?
**Over 150**
* 40 affect anogenital area
* 15 are oncogenic
80
What types of HPV cause genital warts?
**HPV-6** and **HPV-11**
## Footnote
(low risk)
81
How prevalent is HPV?
* **Extremely** - nearly all men & women acquire HPV infection during their lifetime
* almost 40% of women are infected with HPV during the first 2 years of sexual activity
* High-risk HPV causes around **5% of cancers** worldwide
82
What cancers can HPV cause?
* Cervical
* Vulval
* Vaginal
* Anal
* Penile
* Head
* Neck
83
What are 2 important high risk HPV types?
**HPV-16** and **HPV-18** which can contribute to over **70%** of cervical cancer
84
What is the lifecyle of HPV?
- **HPV Entry**: Microtrauma allows HPV to access **basal keratinocytes** via **L1 & L2** capsid proteins and enter cells by endocytosis.
- **Infection Site**: Virus establishes in **basal layer** for persistent infection, proliferating with basal cells.
- **Replication**: Infected basal cells differentiate, triggering early gene expression and viral replication, releasing new virions.
- **Immune Response**: Most infections clear in **12-14 months** via **Th1** pro-inflammatory, cell-mediated response.
- **Outcome**: Immune system may clear or suppress virus, but **70-80%** of cases don't generate lasting antibodies, risking reinfection.
85
How does HPV cause warts?
**Hyperproliferation** of infected epithelia
86
How is HPV spread?
* **Skin-skin contact** during **sexual intercourse**
* Contact with **contaminated** surfaces
* **Oro-genital** transmission
* Perinatal vertical transmission
* Autoinoculation
87
What are some factors that increase the risk of HPV?
* Early age of first sexual intercourse
* High number of sexual partners
* Condomless sexs
* Immunosuppression (inc. HIV)
88
How do HPV infections present?
70-90% **asymptomatic**: cleared within **12-14** months
* **Warts**: 2-5mm cauliflower-like growths (non-hairy skin = soft/non-keratinised, hairy skin = firm/keratinised)
* **Pruritus** / irritation around wart
* **Pain**/**bleeding** (due to local trauma)
* **Haematuria** & distortion of urinary flow (due to intra-meatal warts)
89
What clinical examinations are done for HPV infections?
* Examine **anogenital area**: ext genitalia, perineum, anus
* Vaginal **speculum** exam
* **Meatoscopy**: intrameatal warts
* **Proctoscopy**: anal margin warts
* **Anoscopy**: recurrent perianal warts
90
What are some differentials for anogenital lesions?
* **Condyloma latum**: moist whiteish papules w/ systemic Sx (fever, malaise, wt loss)
* **Molluscum contagiosum**: flesh/pearly-coloured lesions w/ central dells
* **Pearly penile papules**: 1-2mm flesh-coloured papules around corona/sulcus of penis glans
* **Skin tags**: soft, skin-coloured, round pedunculated papilloma
* **Carcinoma in situ**: multifocal/erythematous/pigmented lesions w/ smooth velvety surface
91
What investigations should be done for genital warts?
Dx following clinical exam, swabs & blood tests **not routinely performed**, however offer **full sexual health screen**
* Urine sample
* Swabs of vagina, cervix, rectum, oropharynx for NAAT
* FBC, CRP, serology (HIV, syphilis, HBV, HCV)
* Biopsy: if wart is indurated, fixed, bleeding, ulcerated, pigmented
92
What is the management of HPV infection?
**No specific Tx**
Aim = **destroy/remove warts**
* Self-administered Tx: **topical treatment** (podophyllotoxin, imiquimod & sinecathins)
* Specialist Tx: trichloroacetic acid / **ablative methods** (cryotherapy, excision, electrocautery)
93
What are some side effects of podophyllotoxin, imiquimod & sinecathins?
* Potential **skin irritation**
* Imiquimod & sinecathins can **weaken condoms**
94
How can HPV be prevented?
* **Condoms**
* Male **circumcision**
* **Vaccination**: Gardasil (protects against strains 6,11,16,18)
* Limiting number of sexual partners
95
Who is eligible for the HPV vaccine?
* Girls & boys aged **11-14**
* **MSM** 15-45 years
* **High risk** individuals: transgender, sex workers
* People living w/ **HIV**
96
What kind of virus is HIV?
**RNA retrovirus**
2 types:
* **HIV-1** (MC)
* **HIV-2** (west africa)
97
What is AIDS?
**Acquired immunodeficiency syndrome**
* Occurs when HIV is not treated, the disease progresses, person becomes immunocompromised
* Immunodeficiency leads to **opportunistic infections** & **AIDS-defining illnesses**
98
How does HIV work?
* Virus enters and destroys **CD4 T-helper cells** of immune system
* An initial **seroconversion** flu-like illness occurs within a few weeks of infection
* Infection is then ASx until condition progresses to immunodeficiency
* Disease progression may occur years after initial infection
99
How is HIV transmitted?
* **Unprotected sex** (vaginal, anal, oral)
* **Vertical transmission** (mother-->child)
* Mucous memb/blood/open wound exposure to **infected blood/bodily fluids** (e.g. sharing needles, needle-stick injury)
100
When do AIDS-defining illnesses occur?
* Associated with **end-stage HIV** infection
* Occur when **CD4 count** has dropped to a level that allows for **unusual opportunistic infections** & **malignancies** to appear
101
Name some examples of AIDS-defining illnesses? (6)
* Kaposi's sarcoma
* Pneumocystis jirovecii pneumonia (PCP)
* Cytomegalovirus infection
* Candidiasis (oesophageal/bronchial)
* Lymphomas
* Tuberculosis
102
What are the 2 screening tests for HIV?
* Fourth-generation lab test: **HIV antibodies** & **p24 antigen** (45 day window period)
* Point-of-care tests: **HIV antibodies** (90 day window period)
103
What is the normal range for CD4 count? And what is the range for someone with HIV?
* Normal: **500-1200** cells/mm3
* **Under 200** cells/mm3: puts patient at high risk of opportunistic infections
104
How else can you test for HIV? (to do with the blood)
Testing for **HIV RNA** per ml of blood indicates **viral load**
* An **undetectable** viral load means level is below recordable range (usually 20 copies/ml)
* Viral load can be in the hundreds of thousands in untreated HIV
105
What is the management of HIV?
Combination of **antiretroviral therapy** (ART) medications
Aims to achieve normal CD4 count & undetectable viral load
* Usual starting regime is **2 NRTIs** (e.g. tenofovir + emtricitabine) plus a **third agent** (e.g. bictegravir)
106
Name 5 classes of antiretroviral therapy medications
* Protease inhibitors (**PI**)
* Integrase inhibitors (**II**)
* Nucleoside reverse transcriptase inhibitors(**NRTI**)
* Non-nucleoside reverse transcriptase inhibitors (**NNRTI**)
* Entry inhibitors (**EI**)
107
What is given to HIV positive patients with a CD4 count under 200/mm3 to protect against pneumocystis jirovecii pneumonia?
**Prophylactic co-trimoxazole**
108
What can HIV increase the risk of? And how can this be monitored?
* **CVD**: monitor RF, blood lipids
* **HPV & cervical cancer**: yearly cervical smears
109
What vaccines should be avoided in patients with HIV?
**Live vaccines**: BCG and typhoid
110
How can HIV transmission during birth be reduced?
* If mother's viral load**< 50 copies/ml**: **normal vaginal delivery**
* If mother's viral load**> 50 copies/ml**: **consider pre-labour C section**
* If mother's viral load**> 400 copies/ml**: **pre-labour C section**
* If mother's viral load **unknown or > 1000 copies/ml**: **IV zidovudine** given
111
What prophylaxis is given to babies when mother has HIV?
* Low-risk babies: **zidovudine** for 2-4 weeks
* High-risk babies: **zidovudine**, **lamivudine** & **nevirapine** for 4 weeks
112
What is PEP?
**Post-exposure prophylaxis**
* Must be commenced within **72 hours** to reduce risk of HIV transmission
* Involves a combination of **ART therapy**: emtricitabine/tenofovir & raltegravir for **28 days**
113
What is PrEP?
**Pre-exposure prophylaxis**
* Taken before exposure to reduce risk of HIV transmission
* Usually emitricitabine/tenofovir
114
What is contact tracing?
Process of telling your sexual partners that they may have been exposed to an STI to help them
115
What is a paraphilia?
Experiencing recurring/intense **sexual arousal** to **atypical objects**, places, situations, fantasies, behaviours
116
Name some examples of paraphilias
* Voyeurism
* Exhibitionism
* Frotteurism: touching unconsenting person
* Sexual masochism: being humiliated etc
* Sexual sadism: suffering of another person
* Paedophilia: sexual activity w/ prepubescent child
* Fetishism e.g. somnophilia (unconscious), urophilia (urine)
* Autogynaephilia (men aroused by visualising themselves as women)
* Necrophilia
117
What is the treatment for paraphilias?
Psychotherapy: **CBT**
118
What is sexual aversion disorder?
* Sexual disorder characterised by **extreme avoidance** of genital sexual contact with a sexual partner
* More common in females
* Accompanied by **fear**, **revulsion**, **disgust**, **anxiety** when faced with sexual situations
* People with SAD may use **strategies to avoid sexual contact**: e.g falling asleep early, neglecting appearance, burying themselves in work
* Can be helped with **CBT**
119
What is hypoactive sexual desire disorder?
* Sexual dysfunction that causes **lack of sexual desire/interest** and **distress** in relationships
* Can be helped with **hormone therapy** (oestrogen), lifestyle changes & meds to boost libido
120
What is female sexual arousal disorder?
* Type of sexual dysfunction that makes it **hard to get aroused** and can affect a woman's ability to reach orgasm
* Can cause **distress**, **low self-esteem**, **relationship problems**
* Can be helped with **counselling** & **SSRIs**
121
What is erectile dysfunction?
An inability to **obtain** or **maintain** an erection sufficient for penetration and for the satisfaction of both sexual partners
122
What are some causes of erectile dysfunction?
* **Vascular**: HTN, atherosclerosis, hyperlipidemia, smoking
* **Neuro**: Parkinson's, MS, stroke, peripheral neuropathy, spinal cord injury
* **Hormonal**: hypogonadism, hyperprolactinaemia, thyroid disease, Cushing's
* **Drug induced**: antihypertensives, BB, diuretics, antidepressants, antipsychotics, anticonvulsants, recreational drugs
* **Structural**: pelvic/penile trauma, Peyronie's disease
* **Systemic disease**: DM, renal failure
* **Psychogenic**: depression, anxiety, schizophrenia, performance anxiety
123
What questions should you ask in an ED history?
* **Onset** of sexual dysfunction (short vs gradual)
* **Duration** of sexual dysfunction (lifetime vs acquired)
* Difficulties with **arousal**
* **Rigidity** of erections
* Duration of **sexual stimulation**
* Difficulties with **ejaculation**
* Difficulties with **orgasm**
* Presence/absence of **morning erections**
124
What investigations are done for ED?
Based on the suspected cause of the ED e.g. vascular cause suspected --> tests to evaluate CVD risk
* FBC
* LFTs
* U&Es
* TFTs
* Lipid profile
* Fasting glucose and/or HbA1C
* Serum total testosterone
125
In cases of **complex** or **refractory** ED, what specialised tests can be done?
* **Nocturnal penile tumescence testing** (NPT): used to distinguish between organic vs psychogenic ED. Pt wears device overnight - measures number, tumescence & rigidity of erections
* **Duplex doppler imaging/angiography**: if vascular cause suspected
126
What is the management of ED?
* **Modify RF**: stop smoking/drinking, wt loss
* **Phosphodiesterase-5 inhibitors** (PDE-5 inhibitors): sildenafil, vardenafil, avanafil
* **Psychosexual councelling**
* Hormone therapy: e.g. low testosterone
* Penile prosthesis: inflatable implants vs semirigid rods
127
What can untreated ED lead to an increased risk of?
**CVD**
128
What is female orgasmic disorder?
Difficulty/inability for a woman to **reach orgasm** during sexual stimulation
129
What are the 4 types of orgasmic dysfunction?
* **Primary anorgasmia**: never had an orgasm
* **Secondary anorgasmia**: difficulty reaching orgasm, even tho had one before
* **Situational anorgasmia**: MC, can only orgasm during specific situations e.g. oral sex, masturbation
* **General anorgasmia**: inability to achieve orgasm under any circumstance, even when highly aroused
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What is the treatment for orgasmic dysfunction?
* Treat underlying medical conditions
* Switch antidepressant meds
* CBT/ sex therapy
* Oestrogen hormone therapy
131
What is delayed ejaculation?
Condition where it takes a long period of sexual arousal to reach climax and release ejaculate.
Some people with DE can't ejaculate at all
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How is delayed ejaculation classified?
* **Lifelong vs acquired**: lifelong means present from time of sexual maturity, acquired means after a period of typical sexual functioning
* **Generalised vs situational**: generalised isn't limited to certain partners/kinds of arousal, situational happens only under certain conditions
133
What are some psychological and medical causes of delayed ejaculation?
* Depression/anxiety
* Some antidepressants/antipsychotics
* Other substances: antiHTN, diuretics, alcohol
* Relationship problems
* Performance anxiety/Poor body image
* Cultural/religious taboos
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What are some physical causes of delayed ejaculation?
* Birth defects that affect reproductive system
* Injury to pelvic nerves that control orgasm
* UTI
* Prostate surgery
* Diabetic neuropathy, stroke, spinal cord nerve damage
* Hypothyroidism, hypogonadism (low testosterone)
* Retrograde ejaculation
135
What are some medications used to treat delayed ejaculation?
* Amantadine (Parkinson's)
* Buspirone (anxiety)
* Cyproheptadine (allergies)
136
What is premature ejaculation?
Occurs when men ejaculate sooner than wanted during sex
* Always/nearly always ejaculate within 1-3 minutes of penetration
* Are not able to delay ejaculation all/nearly all the time
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What is the treatment for premature ejaculation?
* Behavioural techniques: e.g. masturbate 1-2 hours before intercourse
* Medications: e.g. topical lidocaine 10 mins before sex to reduce sensation and help delay ejaculation, SSRIs
* Counselling
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What is retrograde ejaculation?
When semen enters **bladder** instead of emerging through penis during orgasm
* Still reach climax but ejaculate little/no semen = **dry orgasm**
* RE isn't harmful but can cause male infertility
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What causes retrograde ejaculation?
**Bladder neck muscle** doesn't tighten properly --> ejaculate enters bladder
140
What increases your risk of having retrograde ejaculation?
* DM, MS
* Prostate/bladder surgery
* Certain antiHTN drugs, antidepressants
* Spinal cord injury
141
What are some medications to treat retrograde ejaculation?
* Imipramine (antidepressant)
* Midodrine (constricts blood vessels)
* Chlorpheniramine (antihistamine)
## Footnote
These help keep bladder neck muscle closed during ejaculation
142
What is dyspareunia?
Pain during intercourse
143
What are some possible causes of dyspareunia?
* Vaginal **dryness**: from menopause, childbirth, breastfeeding, meds etc.
* Skin disorders that cause **ulcers**, **itching**, burning etc.
* **UTIs**
* **Vaginismus**
* **Endometriosis**
* **Pelvic Inflammatory Disease**
* **Uterine fibroids**
* Stress
* Self-image/body issues
* Cancer, arthritis, diabetes, thyroid disease
144
Who is at increased risk of dyspareunia?
* More common in women
* Take meds that cause vaginal dryness
* Have viral/bacterial infection
* Postmenopausal
145
How is dyspareunia treated?
Treat underlying cause:
* ABs
* Antifungal meds
* Topical corticosteroids
* Oestrogen
146
What is vaginismus?
**Involuntary tensing** of the vagina/pelvic floor muscles
147
What causes are linked to vaginismus?
* Past sexual abuse/ trauma
* Past painful intercourse
* Emotional factors
148
What is the treatment of vaginismus?
* Education & counselling
* Pelvic floor exercises
* Vaginal dilators
149
What is vulvodynia?
Long-term pain in the vulva
* burning, irritation, stinging, rawness, soreness, sharp/knife-like
150
What factors can contribute to vulvodynia?
* Injury/irritation of nerves of the vulva
* Past vaginal infections
* Inflammation that affects vulva
* Some genetic conditions
* Allergies
* Hormonal changes
151
What investigations are done for vulvodynia?
* Pelvic exam
* Swabs
* Biopsy
* Bloods: hormone levels
152
What medications are used to treat vulvodynia?
* **Antidepressants/anticonvulsants**: ease long-term pain
* **Local anaesthetic**: lidocaine before sex (short term pain relief)
* **Nerve blocks**: given near to nerves that are sensitive to pain (long-standing pain that doesn't respond to other Tx)
* **Hormone creams**: oestrogen
* **Antihistamines**: reduce itching
153
What therapy is available to treat vulvodynia?
* **Pelvic floor therapy**
* **CBT**
* Couples therapy
154
What is Peyronie disease?
Condition that causes **fibrous scar tissue** to form in penis causing **curved**, **painful erections**
155
What are the symptoms of Peyronie's disease?
* **Swelling** that later causes a hard lump to develop on shaft of penis
* **Curve** in penis when **erect**
* **Painful erections**: make sex difficult
* Problems getting/keeping an erection
156
What increases your risk of developing Peyronie's disease?
* Injury
* DM
* HTN
* High cholesterol
* CHD
* Arteriosclerosis
* Meds: BBs / antidepressants
157
What are the treatment options for Peyronie's disease?
* **Meds** to slow down growth of hard area on penis / treat ED - verapamil and xiaflex
* **Sound waves** to break down hard area
* **Surgery** to straighten penis
158
What is azoospermia?
**No sperm** found in ejaculate: can be **obstructive** or **non-obstructive**
159
What are the types of azoospermia?
**Pre-testicular**
* imparied production of **hormones** responsible for creating sperm
**Testicular**
* abnormalities in **structure**/**function** of testicles
**Post-testicular**
* problems with ejaculation due to **obstruction** in reproductive tract
160
What are some causes of **non-obstructive** azoospermia?
* **Genetic** disorders/damage to hypothalamus & pituitary gland: hormone related azoospermia
* **Absence of testicles**
* **Cryptorchidism** (testicles haven't dropped)
* **Sertoli cell-only syndrome** (don't produce sperm)
* Tumours
* Radiation
* Diabetes
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What are some causes of **obstructive** azoospermia?
* **Missing connection** somewhere: e.g epididymis / vas deferens tubes
* **Congenital**: e.g. congenital bilateral absence of vas deferens (CBAVD)
* Previous/current **infection**
* Cysts, injury, vasectomy
162
What is the treatment of azoospermia?
* Obstructive: **Surgery** (reconnecting/reconstructing tubes that aren't allowing sperm to flow)
* Pre-testicular: **hormonal Tx**
* Testicular: may not respond to medical Tx*
## Footnote
*Can still have biological children with IVF
163
What is hypospadias?
* Male **birth defect** where opening of penis is on **underside** rather than tip
* Causes **downward curve** of penis & **abnormal spraying** during urination
164
What are some risk factors for hypospadias?
* **FHx**
* **Genetics**
* Maternal age **> 35**
165
What is the treatment of hypospadias?
**Surgery** to reposition urethral opening (usually done between 6 -12 months)
166
What is anejaculation?
Orgasm occurs but semen isn't released from penis
167
What are some causes of anejaculation?
* **Diabetes**
* **Infections**
* **Meds**: antidepressants/alpha blockers to treat HTN/enlarged prostate
* Nerve damage from **bladder**/**prostate surgery**
* **Parkinson's**/ **MS**
* **Spinal cord injury**
* Testicular cancer Tx
* **Anxiety**/**depression**
168
What is the treatment for anejaculation?
* Psychotherapy
* Sex therapy
* Anxiety meds
169
What is sexuality?
How you **identify**, how you experience **sexual** & **romantic attraction**, your interest in/preferences around sexual & romantic **relationships** & **behaviour**
170
What is paraphimosis
Retraction of the foreskin but cant push it back - can lead to ischemia
