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Sexual Health Flashcards

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1
Q

What is the normal vaginal pH.

How is this beneficial?

A

<4.5

inhibits growth of other bacteria

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2
Q

What maintains the normal vaginal pH

A

lactobacilli produce hydrogen peroxide - maintains acidic pH

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3
Q

What is the pathophysiology of bacterial vaginosis

A

disturbance of normal vaginal flora
decrease in lactobacilli
increase in Gardnerella vaginalis, anaerobes and mycoplasma
increase in vaginal pH >4.5

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4
Q

What are the risk factors for BV?

A 
new or multiple sexual partners
scented soaps/douching
STIs
recent abx
IUD
receptive oral sex
smoking
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5
Q

What are the symptoms of BV

A

50% asymptomatic
fishy odour
white/grey homogenous thin vaginal discharge
no soreness/irritation

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6
Q

What is the differential diagnosis for BV

A

vaginal candidiasis
STI
trichomonas vaginalis

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7
Q

What investogations are done for BV

A

high vaginal smear of discharge, gram stained

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8
Q

What are Amsel’s criteria

A

help to diagnose BV - need >=3

homogenous white/grey thin discharge
bacilli on microscopy of smear - clue cells
pH >4.5
positive KOH whiff test

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9
Q

What are clue cells

A

vaginal epithelium studded with gram variable coccobacilli - indicate presence BV

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10
Q

What are the Ison/Hay criteria?

A

Way of classifying BV depending on gram stained smear of vaginal discharge

Grade 1 - mainly lactobacilli = normal
grade 2 - some lactobacilli, others present = intermediate
grade 3 - few lactobacilli, others predominate = BV

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11
Q

What is the management of BV

A

metronidazole 400mg BD 5 days
avoid scented shower gels, douching
?removal IUD

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12
Q

What are the risks of BV in pregnancy

A

premature birth
miscarriage
chorioamnionitis

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13
Q

What microorganism is involved in Vaginal candidiasis

A

Candida albicans - 90%

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14
Q

Describe the pathophysiology of vaginal candidiasis

A

opportunistic - immunocompromised leads to infection

hypersensitivity - changes in oestrogen etc leads to hypersensitivity reaction

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15
Q

What are the risk factors for candida

A 
pregnancy
DM
immunocompromised
recent course of broad spectrum Abx
corticosteroids
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16
Q

What are the symptoms of candida

A

vulval itch
superficial dysruria
vaginal discharge -white, curd like, non-offensive

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17
Q

What can be seen in examination in candida

A

white curd like vaginal discharge
satellite lesions
erythema and swelling of vulva

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18
Q

Differential diagnosis of candidiasis

A 
BV
TV
UTI
contact dermatitis
eczema/psoraisis
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19
Q

What investigations are needed to diagnose candidiasis

A

if uncomplicated - none! do on history + examination

if complicated eg. DM, pregnancy, recurrent
- do vaginal smear and microscopy (see spores adn mycelia)

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20
Q

What is the management of candidiasis

A

topical clotrimazole for vagina

oral fluconazole

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21
Q

What is the management of recurrent candidiasis

A

3 x 150mg oral fluconazole over 10 days

500mg clotrimazole once a week for 6 months

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22
Q

What is the management of candidiasis in pregnancy

A

NOT oral
pessary of clotrimazole - avoid damaging cervix with applicator for vaginal cream

check for otehr STIs which could be dangerous in pregnancy

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23
Q

How quickly should candidiasis clear up with treatment

What should be done if the infection does not clear?

A

within 7-10 days

consider alternative diagnosis
modify predisposing factors eg. diabetic control
consider concordance

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24
Q

When is emergency contraception used?

A

after sexual intercourse if:

unprotected sex
failed method of contraception

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25
What are the options for emergency contraception
levonorgestrel ullipristal acetate copper IUD
26
Which method of emergency contraception is most effective?
copper IUD
27
How does levonorgestrel work?
synthetic progesterone prevents ovulation for 5-7days no effect on implantation
28
How does ullipristal acetate work?
progesterone receptor modulator delay ovulation for 5-7days prevents development of follicles/rupture of follicles at time of LH surge but not after
29
How does the copper IUD work as emergency contraception?
toxic to sperm | makes implantation impossible due to inflammation of endometrium
30
What time frame can each form of emergency contraception be used within?
levonorgestrel - 72 hours ullipristal acetate - 72-120 hours copper IUD - 5 days/ 5 days ovulation
31
What are the contraindications to levonorgestrel
malabsorption eg crohn's | enzyme inducing drugs
32
What are the contraindications to ullipristal acetate
malabsorption eg crohn's enzyme inducing drugs breast feeding hepatic dysfucntion
33
What are the contraindications to copper IUD
uterine fibroids suspected/documented PID suspected/documented STI
34
What needs to be done before inserting a copper IUD
test for STI - chlamydia at least | can give dose of prophylactic abx to cover
35
What are the side effects of hormonal emergency contraception
``` nausea - should take second dose if vomit within 2/3 hours diarrhoea menstrual disturbance breast tenderness abdo pain ```
36
What are the complications of copper IUD emergency contraception
``` increased risk of ectopic pregnancy pelvic infections expulsion IUD bleeding pelvic pain ```
37
What causes chlamaydia and what kind of organism is it?
Chlamydia trachomatis obligate intracellular gram -ve bacteria
38
What do the different serotypes of chlamydia cause?
``` A-C = conjuntivitis D-K = urogenital L1-L3 = lymphogranuloma venereum causing proctitis ```
39
How is chlamydia transmitted
skin to skin contact | oral, anal, vaginal sex
40
What is the incubation period for chlamydia
7-21 days
41
What are the risk factors for chlamydia
``` <25y sexual partner who is chlamydia +ve change in sexual partner unprotected sex co-infection with another STI ```
42
What are the symptoms of chlamydia in a male?
none -50% testicular pain urethral discharge dysuria
43
What are the symptoms of chlamydia in a female?
``` none- 70% change in discharge dysuria IMB/PCB deep dyspareunia lower abdo pain ```
44
What are the signs of chlamydia in a male?
epididymal tenderness | mucopurulent discharge
45
What are the signs of chlamydia in a female?
mucopurulent endocervical discharge cervicitis/contact bleeding cervical motion tenderness pelvic tenderness
46
How is chlamydia investigated
NAAT - male: first catch urine, urethral swab - female: vulvo/vaginal swab, endocervical swab, first catch urine full STI screen
47
How is chlamydia managed
uncomplicated: - doxycycline 100mg BD 7days OR - single dose 1g azityhromycin avoid sex until treatment finished contact tracing
48
When should a test of cure be sought following for chlamydia treatment
if pregnant poor compliance symptoms persist
49
What are the complications of chlamydia for women
salpingitis or endometritis leading to PID leading to: perihepatitis increased risk ectopic pregnancy infertility
50
What are the complications of chlamydia for men
epididymitis epididymo-orchitis could lead to infertility
51
What are the risks of chlamydia in pregnancy
premature birth low birth weight neonatal chlamydial conjunctivitis in first 2 weeks pneumonia at 1-3months
52
What is the treatment of chlamydia during pregnancy
azithromycin and erythromycin
53
Which STI can lead to reactive arthritis?
Chlamydia
54
What organism causes gonorrhoea?
Neisseria gonorrhoeae | Gram-negative diplococcus
55
How is gonorrhoea transmitted?
unprotected sex - vaginal, oral, anal | vertical
56
What is the incubation period for gonorrhoea?
2-5days
57
What are the risk factors for gonorrhoea
<25y new sexual partner MSM prev infection
58
What are the symptoms of gonorrhoea in a man?
mucopurulent urethral discharge | dysuria
59
What are the symptoms of gonorrhoea in a woman?
``` 50% asymptomatic change in discharge - watery, thin, green/yellow dyspareunia dysuria lower abdo pain ```
60
What are the signs of gonorrhoea in a man?
``` mucopurulent urethral discharge epididymal tenderness (rare!) ```
61
What are the signs of gonorrhoea in a woman?
normal examination mucopurulent endocervical discharge cervix bleeds easily pelvic tenderness
62
What investigations should be done to investigate gonorrhoea
males: first pass urine NAAT, urethral swab microscopy and culture females: endocervical/vaginal swab - NAAT and microscopy and culture full STI screen - G+C, HIV, syphilis
63
What is the management of gonorrheoa
ceftriaxone 500mg IM STAT azithromycin 1g PO STAT abstain until finished treatment contact tracing advice on safe sex test of cure after 2 weeks
64
What are the complications of gonorrheoa?
females: PID males: epididymo-orchitis, prostatitis both: disseminated gonococcal infection
65
What are the some of the problems caused by disseminated gonococcal infection?
arthritis skin lesions meningitis endocarditis
66
What problems can gonorrhoea cause in pregnancy>
premature labour spontaneous abortion early fetal membrane rupture vertical transmission
67
What problems are associated with vertical transmission of gonorrhoea
gonococcal conjunctivitis in neonate - can lead to blindness
68
What organism causes genital warts
HPV6 or HPV11 - double-stranded-DNA papovaviruses | causes 90% genital warts
69
How are genital warts transmitted?
skint o skin contact
70
Can you still catch genital warts if you use a condom?
yes! condom does not completely cover all skin in genital area
71
Which strains of HPV cause cervical cancer
HPV16 | HPV18
72
What are genital warts
benign proliferative epithelial growths
73
What are the risk factors for genital warts
``` early age at first sexual intercourse multiple sexual partners immunosupression smoking DM ```
74
What are the symptoms of HPV
no symptoms at all - infection occurs with no warts and then resolves warts! - painless, fleshy. can be soft/hard, singular/multiple
75
What is the differential diagnosis for HPV
``` molluscum contagiosum vestibular papillomatosis Epidermoid cysts. Hair follicles. Sebaceous glands. Skin tags. Pearly penile papules ```
76
What investigations should be done in someone with genital warts?
full STI screen vaginal speculum/rectal proctoscopy biopsy if atypical ?cancer
77
What is the management of genital warts?
reassurance - they are benign and do resolvev spontaneously! multiple warts: 1. podophyllotoxin BD 3d/week. 2. review after 4 weeks, continue if >50% improvement, change to imiguimod OD alternate days 3d/week for 16 weeks 3. excision One or few warts 1. podophyllotoxin BD 3d/week. OR cryo once per week 2. review after 4 weeks, continue if >50% improvement, change to imiguimod OD alternate days 3d/week for 16 weeks/podo regime 3. excision
78
What treatments for genital warts are able to be used in pregnancy
NOT podophylllotoxin or imiquimod give cryo once weekly consider excision or defer untila fter pregnanvy
79
Do genital warts cause any problems during pregnancy
no risks to mother or fetus | warts can multiply or enlarge
80
What has been done to reduce the incidence of genital warts?
HPV vaccine to 12-13 year old girls 2008 HPV 16 and 18 only 2012 also HPV 6 and 11
81
What causes syphilis?
Treponema pallidum | gram negative spirochete
82
How is syphilis transmitted?
break in skin or via mucous membrane in sexual contact | vertical transmission to fetus
83
Describe the stages of syphilis
primary = 9-90 days after infection. chancre formation. resolves spontaneously secondary = 6-12 weeks after infection. generalised symptoms, lymphadenopathy, rash on soles and palms resolves in 2/3 months latent phase - no sx early = less than 2 years since infection late = more than two years since infection teartiaty type IV hypersensitivity reaction neurosyphilis, cardiovascular syphilis or gummatous syphilis
84
Describe the chancre seen in primary syphilis
raised border, hard base, painless, non-itchy | found on genitals
85
What are the risk factors for syphilis
UPSI multiple sexual partners HIV MSM
86
What are the signs and symptoms of secondary syphilis?
``` fever headaches malaise arthralgia skin rash on palms and soles weight loss painless lymphadenopathy ```
87
What are the signs and symptoms of gummatous syphilis?
Inflammatory fibrous nodules or plaques (granulomas) in bone, skin, mucous membranes, connective tissue, organs
88
What are the signs and symptoms of neurosyphilis?
tabes dorsalis = (loss of dorsal column) ataxia, numb legs, absence of deep tendon reflexes, lightning pains, loss of pain and temperature sensation, skin and joint damage. dementia meningovascular Argyle-robertson pupils = loss of light reflex, accomodation remains
89
What are the signs and symptoms of cardiovascular yphilis?
aortitis -usually involves the aortic root but may affect other parts of the aorta aortic regurgitation, aortic aneurysm angina.
90
What investigations are done for syphilis?
swab and dark field microscopy blood serology - EIA for treponemal IgG and IgM = exposure to treponemes - TPHA/TPPA selective for T pallidum RPR is used to stage syphilis and show response to treatment
91
What is the management of syphilis
early: benzathine penicillin 2.4 megaunits IM STAT late: benzathine penicillin 2.4 megaunits IM 3 doses at weekly intervals ``` avoid sexual contact screen for other STIs contact tracing follow up serology repeat screening to find re-infection ```
92
What are the risks of having syphilis during pregnancy
stillbirth miscarriage pre-term labour congenital syphilis
93
What STIs are pregant women screened for
syphilis HIV hepatitis B
94
Describe congenital syphilis
early = <2y old rash on palms and soles, hemorrhagic rhinitis, lymphadenopathy, hepatosplenomegaly late = >2y arthritis of the knees, Hutchininson's incisors, saddle nose deformity
95
What reaction can occur after treating syphilis? Descibe this
Jarisch Herxheimer reaction Flu like symptoms 24 hours after treatment due to inflammation secondary to death of treponemes can be dangerous in pregnancy - can cause contractions, fetal heart rate abnormalities and even stillbirth
96
What causes trichomoniasis
Trichonomas vaginalis | anaerobic flagellated protozoan
97
How is trichomoniasis transmitted
only through unprotected vaginal sex | not anal or oral!
98
What are the risk factors for TV
multiple sexual partners UPSI other STIs older age!
99
What are the symptoms of TV in males?
urethral discharge dysuria frequency painful/ithching foreskin
100
What are the symptoms of TV in females?
offensive frothy green/yellow discharge dysuria dyspareunia itchy/sore vuvla
101
What are the signs of TV in males?
urethral discharge
102
What are the signs of TV in females?
offensive frothy green/yellow discharge strawberry cervix vulvitis vaginitis
103
What investigations should be done in suspected TV
males: urethral swab/first pass urine for NAAT and MC+S females: high vaginal swab from posterior fornix/vaginal swab - NAAT and MC+S
104
What is the management of TV
metronidazole 2g PO STAT contact tracing full STI screen abstain for 1 week after treatment
105
what are the risks of TV during pregnancy
premature labour low birth weight maternal post partum sepsis
106
What causes genital herpes
HSV1 or HSV2
107
How is herpes transmitted
skin to skin contact during sexual intercourse can be transmitted via oral sex - coldsores NB: asymptomatic shedding - pt does not need to have symptoms to transmit virus
108
Describe the relationship between primary and recurrent herpes
primary = initial infection virus travels to local sensory ganglion reactivation = moves back down to skin to cause recurrent infections
109
What are the risk factors for herpes
``` multiple sexual partners UPSI other STIs oral sex MSM HIV ```
110
What are the symptoms of primary herpes
``` bilateral red painful blisters around genitals urethral/vaginal discharge fever muscles aches itchy genitals ``` resolves after 20 days
111
What are the symptoms of recurrent herpes
burning/itching around the genitals painful red blisters - often unilateral shorter duration - 10 days less severe lesions decrease in severity over time
112
What investigations can be done in suspected herpes?
swab from open sore - PCR can do serology - can identify those with asymptomatic infection but may take up to 12 weeks to become positive after primary infection
113
What is the management of herpes
counselling - this is a life long infection full STI screen antivirals can decrease the size and number of lesions, but cannot cure it abstain during outbreaks contact tracing primary: aciclovir 400mg TDS for 5 days recurrent: 800mg TDS 2 days
114
When can suppresive therapy for herpes be considered?
>6 episodes a year | take 400mg BD every day
115
What problems can herpes cause during pregancy
risk of transmission to baby at birth causing neonatl herpes
116
Which trimester is a new primary infection of herpes most likely to cause neonatal herpes in?
third trimester
117
How is herpes managed during pregnancy
primary infection first/second trimester: aciclovir initially, aciclovir from 36 weeks (400mg TDS), normal vaginal delivery third trimester: first/second trimester: aciclovir initially, aciclovir from 36 weeks. C SECTION to reduce risk transmission recurrent infection aciclovir at 36 weeks, vaginal delivery
118
Describe neonatal herpes
occurs 2 days - 6 weeks after delivery localised infection - vesciles on skin, eyes or moith CNS infection can cause lethargy, feeding difficulties and seizures disseminated infection can cause jaundice, hepatosplenomegaly and DIC
119
What causes HIV
human immunodeficiency virus | single stranded RNA retrovirus
120
Describe the pathophysiology og HIV
HIV virus infects CD4 T Helper cells | repilicates inside them using reverse transcriptase and integrase enzymes
121
How is HIV transmitted
unprotected sex - vaginal, oral, anal contaminated needles pregnancy - in utero, at delivery and via breast feeding
122
What are the risk factors for HIV
UPSI with someone who has lived in/travelled to Africa MSM IVDU from a high prevalence area
123
Describe the presentation and time course of HIV
1. seroconversion illness occurs 2-6 weeks after infection flu like - fever, muscle aches, malaise, lymphadenopathy, maculopapular rash, pharyngitis 2. latent - asymptomatic 3. symptomatic = AIDS related complex weight loss, fever, diarrhoea, night sweats, freq opportunistic infections eg. candida, herpes simplex, HZV 4. AIDS presence of defining illness eg. Hodgkin's lymphoma, pneumocystis jiroveci
124
How is HIV tested for?
serum ELISA - for HIV Ab and p24 antigen Ab show up 4-6 weeks after infection p24 antigen shows in active infection even if no Ab yet
125
How is HIV monitored
CD4 count | viral load
126
How is HIV treated
highly active antiretroviral therapy (HAART) is begun as soon as HIV diagnosis is given eg. atripla, stribild, triumeq contact tracing counselling
127
What other investigations should be done at time of HIV diagnosis
Assessment for other infections: eg, tuberculosis, hepatitis B, cytomegalovirus (CMV), toxoplasma, syphilis, varicella. Screening for co-existing sexually transmitted infections (STIs). Baseline CXR and cervical smear
128
What are the risks of HIV during pregnancy and how is this reduced?
risk of tranmission to fetus in utero, at birth or during breast feeding HAART during pregnancy and delivery avoid breastfeeding neonatal PEP C section not recommended if viral load is undetectable
129
Explain what PEP is
post exposure prophylaxis given within 72 hours of exposure to HIV one month course
130
Describe the pathophysiology of PID
ascending infective inflammation of upper female genital tract caused by Chlamydia, gonnorhoea, normal vaginal flora, mycoplasma etc
131
What are the risk factors for PID
``` 15-24 UPSI sexually active recent change in sexual partner history of STI prev hx of PID IUD TOP gynae surgery ```
132
What are the symptoms of PID
``` sometimes none bilateral pelvic pain PCB, IMB, heavy bleeding purulent vaginal or cervical discharge deep dyspareunia ```
133
What are the signs of PID
bilateral lower abdominal tenderness speculum: purulent endocervical discharge, cervicitis bimanual: cervical motion tenderness, adnexal tenderness fever N+V
134
What is the differential diagnosis for PID
``` ectopic pregnancy appendicitis tubo-ovarian abscess ruptured ivarian cyst endometriosis UTI ```
135
What investigations should be done in suspected PID
pregnancy test urine dip and MSU endocervical and vaginal swab - G+C, TV, BV full STI screen TV US scan laparoscopy - severe cases if diagnostic uncertainty
136
What is the management of mild/moderate PID
Abx at home for 14 days ceftriaxone - 500mg IM STAT doxycycline 100mg BD PO metronidazole 400mg BD PO analgesia abstain from sexual intercourse until treatment finished contact tracing
137
What suggests that hospital admission is needed in severe cases of suspected PID
If pregnant and especially if there is a risk of ectopic pregnancy. Severe symptoms: nausea, vomiting, high fever. Signs of pelvic peritonitis. Unresponsive to oral antibiotics, need for IV therapy. Need for emergency surgery or suspicion of alternative diagnosis.
138
What is the treatment for severe PID
IV abx in hospital stop IV when improved for 24 hours and swithv to oral for 14 day course
139
what are the long term consequences of PID
``` infertility ectopic pregnancy - due to narrowing and scarring of the fallopian tubes chronic pelvic pain Fitz-High-Curtis tubo ovarian abscess ```
140
What is androgen insensitivity syndrome
X-linked recessive condition due to end-organ resistance to testosterone causing genotypically male children (46XY) to have a female phenotype.
141
What are the features of androgen insensitivity syndrome
primary amenorrhoea undescended testes - leading to bilateral groin swellings no pubic hair can have small breasts (testosterone converted to oestrogen peripherally)

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