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3ayeeeee > Sexual Health > Flashcards

Sexual Health Flashcards

1
Q

What does normal physiological discharge look like ?

A
  • Clear to white, nonadherent to the vaginal wall and pooled in the posterior fornix
  • Nonhomogeneous with clumps of desquamated epithelial cells
  • pH of less than 4.5, no offensive odor and an abundance of epithelial cells on saline microscopy
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2
Q

What is atrophic vaginitis ?

A
  • Dryness and atrophy of the vaginal mucosa due to a lack of oestrogen
  • Occurs in women entering the menopause
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3
Q

How does atrophic vaginitis present ?

A
  • Itching, dryness, dyspareunia and bleeding
  • Discharge can be watery and irritating or can be mixed with blood
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4
Q

How is atrophic vaginitis managed ?

A
  • Vaginal lubricants and moisturisers
  • Oestrogen cream is 2nd line
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5
Q

What is cervical ectropion ?

A
  • When the columnar epithelium of the endocervix has extended out to the ectocervix (outer area of the cervix)
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6
Q

How does cervical ectropion present ?

A
  • Vaginal bleeding or dyspareunia
  • Post-coital bleeding
  • Increased vaginal discharge
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7
Q

What are cervical polyps and how could they present ?

A
  • Benign growths, usually protruding from the surface of the cervical canal
  • Intermenstrual bleeding
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8
Q

What is Thrush ?

A
  • Also known as vaginal candidiasis
  • Common condition caused by candida albicans
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9
Q

RFs for Thrush

A
  • Increased oestrogen
  • Poorly controlled DM
  • Immunosuppression e.g. corticosteroids
  • Broad-spectrum ABs
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10
Q

Features of Thrush

A
  • Cottage cheese non-offensive discharge
  • Vulvitis: superficial dyspareunia, dysuria
  • Itch
  • Vulval erythema, fissuring, satellite lesions may be seen
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11
Q

How is Thrush managed ?

A
  • Oral fluconazole 150mg as a single dose
  • Clotrimazole 500mg intravaginal pessary as a single dose if the oral therapy is contraindicated (e.g. pregnant)
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12
Q

What counts as recurrent vaginal candidiasis and how would you manage it ?

A
  • 4 or more episodes per year
  • Compliance with previous treatments should be checked
  • Confirm diagnosis, high vaginal swab for microscopy and culture
  • Consider BM to exclude diabetes
  • Consider alternative diagnosis of lichen sclerosus
  • Induction and maintenance oral fluconazole
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13
Q

What is induction and maintenance oral fluconazole

A
  • Oral fluconazole every 3 days for 3 doses
  • Maintenance: oral fluconazole weekly for every 6 months
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14
Q

What is bacterial vaginosis ?

A
  • Loss of the lactobacilli (friendly bacteria) and colonisation of an anerobic bacteria
  • Not an STI but does increase the chance of infection
  • (Fishy/offensive smelling vaginal discharge)
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15
Q

What is amsel’s criteria ?

A
  • Thin, white homogenous discharge
  • Clue cells on microscopy
  • Vaginal pH > 4.5
  • Positive whiff test (potassium hydroxide gives fishy odour)
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16
Q
  1. What is the classic term for bacterial vaginosis ?
A
  • Foul fishy smelling thin white discharge
  • Positive whiff test – addition of potassium hydroxide
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17
Q

Bacterial vaginosis pathology

A
  • Friendly lactobacilli produce lactic acid that keeps the vaginal pH acidic < 4.5
  • When lactobacilli numbers are reduced pH increases and anaerobic bacteria are able to colonies
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18
Q

Bacterial vaginosis anaerobic bacteria

A
  • MCC - Gardnerella vaginalis
  • Mycoplasma hominis
  • Prevotella species
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18
Q

Bacterial vaginosis investigations

A
  • pH paper and a high vaginal swab during speculum examination
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19
Q

How is bacterial vaginosis managed ?

A
  • Can spontaneously resolve
  • Oral metronidazole 500mg 7 days
  • Alternative single dose of 2g stat dose
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20
Q

Bacterial vaginosis RFs

A
  • Multiple sexual partners
  • Excessive vaginal cleaning
  • Recent ABs
  • Smoko
  • Copper coil
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21
Q

What is trichomoniasis ?

A
  • A protozoan single celled organism with a flagella (four at the front and one at the back)
  • Trichomonas vaginalis
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22
Q

Complications of Trichomonas vaginalis

A
  • Contracting HIV
  • Bacterial vaginosis
  • Cervical cancer
  • PID
  • Pregnancy related complications e.g. preterm
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23
Q

How does trichomoniasis present ?

A
  • Itching and frothy yellow-green discharge (may be fishy)
  • Dysuria and dyspareunia
  • Balanitis
  • Strawberry cervix
  • Raised vaginal pH
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24
Q

What are investigations for trichomoniasis ?

A
  • Urethral and first catch urine in men
  • Charcoal swab of the posterior fornix (of the vagina) and microscopy of a wet mount shows motile trophozoites
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25
Q

What is the management for trichomoniasis ?

A
  • oral metronidazole for 5-7 days, although the BNF also supports the use of a one-off dose of 2g metronidazole
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26
Q

What is Chlamydia ?

A
  • The most prevalent STI in the UK
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27
Q

What causes Chlamydia ?

A
  • Chlamydia trachomatis
  • A gram-negative intracellular bacteria
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28
Q

What are RFs of Chlamydia

A
  • Young age
  • Sexually active with multiple partners
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29
Q

What % of Chlamydia is asymptomatic

A
  • 50% in men
  • 75% in women
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30
Q

How does Chlamydia present ?

A
  • Men: urethral discharge, dysuria, Epididymo-orchitis and reactive arthritis
  • Women: discharge, bleeding, dysuria and dyspareunia
  • Discharge is white, yellow or gray discharge and smelly
  • Cervical motion tenderness
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31
Q

Examination findings in Chlamydia ?

A
  • Pelvic or abdominal tenderness
  • Cervical motion tenderness
  • Inflamed cervix
  • Purulent discharge
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32
Q

How is Chlamydia investigated ?

A
  • Nucleic acid amplification test (NAAT)
  • Men – First catch urine sample is 1st line
  • Women – vulvovaginal swab is 1st line
  • Test should be carried out 2 weeks after possible exposure
  • Rectal swab if indicated
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33
Q

How is Chlamydia managed ?

A
  • Doxycycline 100mg twice d day for 7 days
  • In pregnancy azithromycin, erythromycin or amoxicillin e.g. azithromycin 1g stat dose
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34
Q
  1. What are complications of Chlamydia ?
A
  • Epididymitis
  • PID
  • Endometritis
  • Increased incidence of ectopic pregnancies
  • Infertility
  • Reactive arthritis
  • Perihepatitis (Fitz-Hugh-Curtis syndrome)
35
Q

What STIs are screened in a patient who attends a GUM clinic for an STI screen at a minimum

A
  • Chlamydia
  • Gonorrhoea
  • Syphilis
  • HIV
36
Q

When is Chlamydia screened for ?

A
  • Open to all men and women aged 15-24 years
37
Q

What is Gonorrhoea ?

A
  • A condition caused by Neisseria gonorrhoeae
  • Acute infections can occur on any mucous membrane surface typically the genitourinary tract but also the rectum and pharynx
38
Q

What causes Gonorrhoea ?

A
  • Neisseria gonorrhoeae
  • A gram-negative diplococcus
39
Q

What % of gonorrhoea cases are asymptomatic ?

A
  • 90% of male
  • 50% of female
40
Q

How does Gonorrhoea present ?

A
  • Males: urethral discharge, dysuria
  • Women: Odourless purulent discharge, possibly green or yellow, dysuria and pelvic pain
  • Rectal infection may cause discomfort or discharge but often symptomatic
41
Q

How is Gonorrhoea investigated ?

A
  • Nucleic acid amplification testing (NATT)
  • Rectal and pharyngeal swabs are recommended in all men who have sex with men
  • Endocervical, vulvovaginal or urethral swabs as well as first catch urine.
  • Charcoal swab endocervical should be taken for microscopy, culture and AB sensitivities before imitating ABs
42
Q

How is Gonorrhoea managed ?

A
  • A single dose of intramuscular ceftriaxone 1g if the sensitivities are NOT known
  • A single dose of oral ciprofloxacin 500mg if the sensitivities ARE known
  • All patients should be followed-up for a test of cure (NAAT testing if asymptomatic or cultures if still symptomatic)
43
Q

When do BASHH recommend a test of cure for Gonorrhoea ?

A
  • 72 hours after treatment for culture
  • 7 days after treatment for RNA NAAT
  • 14 days after treatment for DNA NAAT
44
Q

Gonorrhoea complication ?

A
  • PID
  • Chronic pelvic pain
  • Infertility
  • Epididymo-orchitis (men)
  • Prostatitis (men)
  • Conjunctivitis – if passed onto neonate then this is a medical emergency associated with sepsis, perforation of the eye and blindness
  • Urethral strictures
  • Disseminated gonococcal infection
  • Skin lesions
  • Fitz-Hugh-Curtis syndrome
  • Septic arthritis
  • Endocarditis
45
Q

What is disseminated gonococcal infection ?

A
  • A complication of untreated gonococcal infection, where the bacteria spreads to the skin and joints.
  • Various non-specific skin lesions
  • Polyarthralgia (joint aches and pains)
  • Migratory polyarthritis (arthritis that moves between joints)
  • Tenosynovitis
  • Systemic symptoms such as fever and fatigue
46
Q

What is PID ?

A
  • Infection of the female pelvic organs including the uterus, fallopian tubes, ovaries and surrounding peritoneum
  • Usually the result of ascending infection from the endocervix
47
Q

What causes PID ?

A
  • Chlamydia trachomatis
  • Neisseria gonorrhoeae tends to produce more severe PID
  • Mycoplasma genitalium
48
Q

What are RFs for PID

A
  • Not using barrier contraception
  • Multiple sexual partners
  • Younger age
  • Existing sexually transmitted infections
  • Previous pelvic inflammatory disease
  • Intrauterine device (e.g. copper coil)
49
Q

How does PID present ?

A
  • Pelvic or lower abdominal pain
  • Abnormal vaginal discharge
  • Abnormal bleeding (intermenstrual or postcoital)
  • Pain during sex (dyspareunia)
  • Fever
  • Dysuria
  • Cervical excitation
50
Q

What would you find on examination of PID ?

A
  • Pelvic tenderness
  • Cervical motion tenderness (cervical excitation)
  • Inflamed cervix (cervicitis)
  • Purulent discharge
  • Patients may have a fever and other signs of sepsis
51
Q

How is PID investigated ?

A
  • A pregnancy test should be done to exclude an ectopic pregnancy
  • High vaginal swab - these are often negative
  • Screen for Chlamydia, Gonorrhoea and mycoplasma genitalium (NAAT), HIV and syphilis, bacterial vaginosis, candidiasis and trichomoniasis
  • Pus cells from vagina or endocervix swab
  • Inflammatory markers (CSP and ESR) are both raised in PID and can help support diagnosis
52
Q

How is PID managed ?

A
  • Genitourinary medicine (GUM) referral
  • Contact tracing
  • oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole
53
Q

How could PID be managed ?

A
  • Single dose of IM ceftriaxone (to cover gonorrhea)
  • Doxycycline 100mg BD for 14 days (chlamydia and mycoplasma)
  • Metronidazole 400mg BD for 14 days (to cover anaerobes such as Gardnerella vaginalis)
54
Q

What are complications of PID ?

A
  • Sepsis
  • Abscess
  • Infertility
  • Chronic pelvic pain
  • Ectopic pregnancy
  • Fitz-Hugh-Curtis syndrome
55
Q

What is Fritz-Huge-Curtis syndrome ?

A
  • A complication of PID where there is inflammation and infection of the liver capsule leading to adhesions between the liver and peritoneum
  • Bacteria may spread from the pelvis to the peritoneal cavity, lymphatic system or blood
  • Presents as right upper quadrant pain that can be referred to the right shoulder tip if there is diaphragmatic irritation
  • Laparoscopy can be used to visualise and also treat the adhesions by adhesiolysis .
56
Q

What is Syphilis

A
  • Caused by bacteria called Treponema pallidum.
  • This bacteria is a spirochete, a type of spiral-shaped bacteria.
  • The bacteria gets in through skin or mucous membranes, replicates and then disseminates throughout the body
  • 21 day incubation period
57
Q

What causes Syphilis ?

A
  • Treponema pallidum
58
Q

How is Syphilis transmitted ?

A
  • Oral, vaginal or anal sex
  • Vertical transmission
  • IV drug use
  • Blood transfusions
59
Q

How does primary Syphilis present ?

A
  • A painless genital ulcer – chancre which tends to resolve 3-8 weeks
  • Local lymphadenopathy
60
Q
  1. How does secondary syphilis present ?
A
  • Typical starts after chancre have healed
  • Maculopapular rash
  • Grey-wart lie lesions around genitals and auns
  • Low grade fever, lymphadenopathy, alopecia and oral lesions
61
Q

How does tertiary syphilis present ?

A
  • Gummatous lesions (granulomatous lesions that can affect the skin organs and bones)
  • Aortic aneurysms
  • Neurosyphilis
62
Q

How does neurosyphilis present ?

A
  • Part of tertiary syphilis
  • Headache
  • Altered behaviour
  • Dementia
  • Tabes dorsalis (demyelination affecting the spinal cord posterior columns)
  • Ocular syphilis (affecting the eyes)
  • Paralysis
  • Sensory impairment
63
Q

What is an Argyll-Robertson Pupil ?

A
  • A specific finding of neurosyphilis
  • Argyll-Robertson pupil is a specific finding in neurosyphilis.
  • It is a constricted pupil that accommodates when focusing on a near object but does not react to light.
  • They are often irregularly shaped. It is commonly called a “prostitutes pupil” due to the relation to neurosyphilis and because “it accommodates but does not react“.
64
Q

How is syphilis investigated ?

A
  • Antibody testing for antibodies to the T. pallidum bacteria can be used as a screening test for syphilis.
  • Samples from sites of infection can be tested to confirm the presence of T. pallidum with:
  • Dark field microscopy
  • Polymerase chain reaction (PCR)
65
Q

What are specific markers for syphilis infection

A
  • VDRL – active infection
  • TPHA – specific AB test
66
Q

How is syphilis managed ?

A
  • IM benzathine penicillin 1st line
  • Doxycycline 2nd line
67
Q

HIV

A
  • Being infected with human immunodeficiency virus is referred to as being HIV positive
  • Acquired immunodeficiency syndrome (AIDS) occurs when HIV is not treated, the disease progresses, and the person becomes immunocompromised. Immunodeficiency leads to opportunistic infections and AIDS-defining illnesses.
68
Q

What causes HIV

A
  • HIV is an RNA retrovirus. HIV-1 is the most common type. HIV-2 is mainly found in West Africa. The virus enters and destroys the CD4 T-helper cells of the immune system.
69
Q

How does HIV present ?

A
  • An initial seroconversion flu-like illness occurs within a few weeks of infection. The infection is then asymptomatic until the condition progresses to immunodeficiency. Disease progression may occur years after the initial infection.
70
Q

How is HIV transmitted ?

A
  • Unprotected sex (all types)
  • Vertical transmission
  • Mucous membrane, blood or open wound exposure to infected blood or bodily fluids e.g. need sharing, needle-stick injuries or blood splashed in an eye
71
Q

When do AIDS-defining illnesses occur ?

A
  • Where the CD4 count has dropped to a level that allows for unusual opportunistic infections and malignancies to appear.
72
Q

What are AIDS-defining illnesses ?

A
  • Kaposi’s sarcoma
  • Pneumocystis jirovecii pneumonia (PCP)
  • Cytomegalovirus infection
  • Candidiasis (oesophageal or bronchial)
  • Lymphomas
  • Tuberculosis
73
Q

What is a normal CD4 count and what is considered pathological ?

A
  • 500-1200 cells/mm3 is the normal range
  • Under 200 cells/mm3 puts the patient at high risk of opportunistic infections
74
Q

How is HIV treated ?

A
  • Treatment involves a combination of antiretroviral therapy (ART) medications. ART is offered to everyone diagnosed with HIV, irrespective of viral load or CD4 count.
75
Q

What classes of antiretroviral therapy medications are used in HIV treatment ?

A
  • Protease inhibitors (PI)
  • Integrase inhibitors (II)
  • Nucleoside reverse transcriptase inhibitors (NRTI)
  • Non-nucleoside reverse transcriptase inhibitors (NNRTI)
  • Entry inhibitors (EI)
76
Q

What are the usual starting regimes used in HIV ?

A
  • Tenofovir (NRTI)
  • Emtricitabine (NRTI)
  • Bictegravir
77
Q

Additional Management of HIV

A
  • Prophylactic co-trimoxazole (against pneumocystis jirovecii pneumonia (PCP))
  • Cardiovascular monitoring
  • Yearly smears – increased risk of cervical cancer
  • Vaccinations (avoid live vaccines e.g. BCG or typhoid)
78
Q

How vertical transmission of HIV managed during birth ?

A
  • Under 50 copies/ml = normal vaginal delivery
  • Over 50 copies/ml = consider a pre-labour CS
  • Over 400 copies/ml = pre-labour CS is recommended
  • IV zidovudine is given as an infusion during labour and delivery if the viral load is unknown or above 1000 copies/ml.
  • Breast feeding is contraindicated
79
Q

Prophylaxis HIV

A
  • PEP involves a combination of ART therapy. The current regime is emtricitabine/tenofovir (Truvada) and raltegravir for 28 days.
80
Q

What is Mycoplasma Genitalium ?

A
  • A bacteria that causes non-gonococcal urethritis
81
Q

How does Mycoplasma Genitalium present ?

A
  • Most cases of MG do not cause symptoms. The presentation is very similar to chlamydia, and patients may be infected with both organisms. Urethritis is a key feature.
82
Q

Complications of mycoplasma genitalium

A
  • Urethritis
  • Epididymitis
  • Cervicitis
  • Endometritis
  • Pelvic inflammatory disease
  • Reactive arthritis
  • Preterm delivery in pregnancy
  • Tubal infertility
83
Q

How is Mycoplasma Genitalium investigated ?

A
  • First urine sample in the morning for men
  • Vaginal swabs (can be self-taken) for women
  • Nucleic acid amplification test
84
Q

How is Mycoplasma Genitalium managed ?

A
  • Both Doxycycline 100mg twice daily for 7 days then;
  • Azithromycin 1g stat then 500mg once a day for 2 days (unless it is known to be resistant to macrolides)

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