STI Flashcards
(124 cards)
1
Q
What can vaginal discharge be caused by
A
Bacterial vaginiosis Candidiasis Trichomoniasis Chlamydia Gonorrhoea
2
Q
Symptoms signs for Candida
A
10-20% assymptomatic
Thick white discharge
Non offensive smell
Associated irritation - itchy/sore, vulval oedema
3
Q
Investigation for Candida
A
pH <4.5
Swabs High vaginal swab for Candida culture
4
Q
BV symptoms
A
~50% assymtomatic
Discharge thin/grey
Smell fishy
Usually none but may be burning
5
Q
Trichomoniasis infection
A
10-50% asymptomatic
Discharge thin frothy
Smell fishy
Associated symptoms itchy sore dysuria
6
Q
Physical Vaughan discharge
A
Clear/white
Odourless
None
7
Q
Investigation BV
A
pH >5
Swabs high vaginal swab
8
Q
Investigation for Trichomoniasis
A
pH >5
High vaginal swab
Wet Prep for microscopy
TV culture or NAAT
9
Q
Physical investigation results
A
pH <4.5
Swabs none
10
Q
BV causative organism
A
Characterised by a reduction in lactobacilli and an overgrowth of predominately anaerobic organism in the vagina Gardnerella vaginalis Provetella spp Mycoplasma hominids Mobiluncus spp Inc vaginal pH
11
Q
Transmission of BV
A
It can arise as remit spontaneously in women regardless of sexual activity
12
Q
Diagnosis of BV
A
Amsels criteria 3/4 +ve Thin grey white homogenous discharge \+ve amine test (release of fishy odour on adding alkali/10% KOH Clue cells on microscopy pH of vaginal fluid >4.5
Other scoring systems
Nugents and hay-ison score - this one is based on the results of the vagina gram stain alone
Lactobacilli and clue cells on grams stained vagina slide
Grade0 epithelial cells need bacteria
Grade 1 normal vaginal flora (reduced number of lactobacilli with mixed bacterial flora)
Grade 2 intermediate vaginal flora (reduced no of lactobacilli with mixed bacterial flora)
Grade 3 mixed bacterial flora only
Grade 4 gram positive cocci only
Grade 2&3 consistent with diagnosis of BV
13
Q
Who is tx indicated in BV
A
Only for symptomatic women
14
Q
Recommended tx regimens BV
A
Metronidazole 400mg 2x daily for 5 days or 2g stat dose
15
Q
Alternative regimens for BV
A
Intravaginal metronidazole geo once daly for 5 days
Intravaginal clindamycin cream for 7 days
Lactic acid vaginal gel is sometime ps considered for tx lacks devidence
16
Q
Tx for BV in pregnancy
A
Metronidazole can be used in all stages of pregnancy and during breast feeding
However manufacturers recommend that single 2g dose regimens are best avoided in these circumstances
17
Q
Complication of BV
A
Association with post termination pregnancy endometriosis and pelvic inflammatory disease
BV is associated with late miscarriage
18
Q
General advice for BV
A
Avoid vagina douching
Use of shower gel and antiseptic agents or shampoo in the bath. Patients should be informed that the condition may be recurrent and why
19
Q
Follow up of BV
A
None if symptoms resolve
Recurrence is common
Difficult to manage specialist advice may be necessary
May need to use metronidazole on days if the cycle to prevent it
Intravaginal lactic acidosis have been found beneficial
Contact tracing not required
20
Q
Causative organism in Candida
A
Most common species
Candida albicans
21
Q
How common is Candida
A
Most women will have it at least once in their lives
22
Q
Who requires tx for Candida
A
Only those symptomatic
23
Q
Symptoms and signs Candida
A
Itch
Vulva vaginal soreness
Superficial dyspareunia
Discharge
Vulvovaginitis Swelling Linear fissures \+ or - variable non offensive discharge Satellite lesions
24
Q
Diagnosis of Candida
A
Clinical features alone
Symptoms and signs are not specific
More than half may have allergic reactions
These need appropriate exclusions and management in order to control the symptoms
25
Complication Candida
None
26
Diagnosis of Candida in primary care
Clinical
pH more than 5
High vaginal swab but 10-20% asymptomatic vaginal carrier and symptoms may not be due to the Candida itself
Tests may be negative if recently self treated
27
Management Candida
No signs symp do not tx
Recommended regimen
Antifungal pessary -/+ ream for external areas
Alternative fluconazole stat avoid in pregnancy
28
Recurrent of Persisten problems with Candida
HVS to confirm and document frequency
Full screening for other infections
Other causes of Vulvo vaginitis
Other Candida albican species Candida glabrata
Important to consider precipitants - soaps , shower gels, sanitary towel, which may inc risk of inflam response
29
Risk factors for Candida
DM
Corticosteroid use
Frequent ab use
30
Are hormonal contraceptives associated
No
31
Management of persistence Candida
Seek advice
Use of oral or pessaries
Weekly or every 2 weeks for 4-6 months will prevent recurrence and symptoms relief
32
Pregnancy and breast feeding with Candida
Asymptomatic colonisation is higher in pregnancy
Symptomatic candidiasis is more prevalent in pregnancy
Tx topical azoles
CI oral therapy
33
Contact tracing in Candida
No evidence to support tx of asymptomatic male partners
34
Follow up
If resolves unnecessary
35
Candida in men sym sign
Mild balantis
| Pruritis
36
What can Candida in men be a sign of
Undiagnosed DM
37
Treatment of Candida in men
Avoid irritants and drying agents such as soap
| Advise soap substitute and emollient +/- azole cream
38
How do men get it
May be sexually acquires and female partner may be asymptomatic or have high yeast carriage
Recurrent female partner tx may be beneficial
39
Causative organism of chlamydia trachomatis
Obligate intracellular bacterium with long life cycle
40
Transmission of chlamydia trachomatis
Common sti in UK
Perinatal transmission - neonatal conjunctivitis
Income 4-12 weeks pneumonitis
41
Symptoms of chlamydia trachomatis is women
```
Asymptomatic 80%
Post coital inter menstrual bleeding
Purulent vaginal discharge
Lower abdo pain
Can cause proctitis
```
```
Signs
None
Cervicitis, mucopurulent discharge
Cervical contact bleeding
Local complication - bartholinitis, signs of pelvic inflamm
```
42
Symptoms and signs of chlamydia trachomatis in men
```
Asymptomatic 50%
Urethral discharge
Dysuria
Testicular /epididymal pain
Can cause proctitis
```
Non
Urethral discharge and or dysuria
Local complications epididymitis
43
Complications of chlamydia
Men - epididymitis
Women - PID , endometriosis , salpingitis, tubal damage, chronic pelvic pain
Inc risk of ectopic pregnancy, tubal damage and chronic pelvic pain
Perihepatitis, Reiter’s syndrome
Autoinnoculation may result in chlamydia conjunctivitis
44
Diagnosis of chlamydia
NAATs
Nucleic acid amplification tests
Test of choice - high sensitivity and specificity, tests can be done on a range of sample types, inc non-invasive and self taken samples
Used in chlamydia screening, rectal chlamydia, LGV, gonorrhoea
45
How to test for chlamydia
Men can be a first void MSU and swab
Women - enodcervial/vulvovaginal swab
Swab mouth and rectum is sex occurs there
46
Tx recommendation for chlamydia
Doxycycline 100mg bd for 7 days
Azithromycin 1g stat is an alternative but may be only 95%effective and may be less effective in treating recital infection with this dose
Alternative ofloflaxin
47
Pregnancy in chlamydia
Low birthweight
Post partum endometriosis
Neonatal conjunctivitis, pneumonitis
48
Contact tracing in chlamydia
Should be discussed with all patients
Essential that all recent last 6 months or current sexual partners should be informed
Advised to attend for evaluation and tx
49
Should epidemiological tx for c trachomatis be given if gets -ve
Yes
50
During tx what can’t patients do c
| Chlamydia
Sex even with a condom until tx over
51
Follow up chlamydia
Ensure partner notification has take place
Exclude reinfection
Ensure compliance of the medications
52
What is epididymo-orchitis
Is defined as inflammation of the epididymis and testicles triggered by an infectious agent
53
Symptoms and signs of epididymitis
Usually unilateral
Bilateral maybe
Patient may complain of scrotal swelling and pain
Examination will usually reveal unilateral testicular tenderness its ted er swollen epididymitis and erythema of the overlying skin
54
Differential diagnosis of epididymitis
Testicular torsion
Inguinal hernia
Tumour (uncommon, usually non painful)
55
Causes of epididymitis
```
N. Gonorrhoea
C. Trachomatis
E. Coil enterobacteriae
Mumps
M. Tb
```
56
Assessment of epididymitis
Sexual hx important
| STI screen and MSU
57
Mx
| Epididymitis
Patients under 35 STI likely and the rosy should cover this possibility whilst waiting for microbiological results
Patients older 35 low STI risk likely UTI
Regimen if suspect STI
Doxycyline 100mg 14days plus ceftriaxone IM
Rest, analgesia, supportive underwear
UTI suspected follow local prescribing policy for UTI
58
Follow up epididymitis
Review at 2 weeks and continue therapy for 1 month if not fully recovered
Full recovery may take some time
No response, check ab resistance, US scan is persistent
59
Contact tracing epididymitis
Current partner should be contact traced unless urinary
60
Causative organism gonorrhoea
Neisseria gonorrhoaea
| Infects musical surfaces if genital tract, rectum, oropharynx, eye
61
Transmission gonorrhoea
STI
Perinatal eye infection of neonate
Older children gonorrhoea sexual abuse
62
Symptoms of gonorrhoea
```
Depend on site of infection
ASymptomatic
Urethral infection in men - discharge +-dysuria
Rectal may get pain discharge
Phayngeal no symp
Cervical non specific pain discharge
```
63
Signs gonorrhoea
Exam may be normal
Other signs depend on site of infection
Urethra purulent discharge, Meatitis, signs of local complications
Cervix - cervicitis, purulent discharge, PID
Rectum - discharge, proctitis
Pharynx - exudate , pharyngitis, symp rare
64
Complications gonorrhoea
```
Men
Epididymitis
Infection of various penile glands
Risk of abscess formation
Women
Endometriosis
Salpingitis, peritonitis, tubal-ovarian abscesses
Bartholinitis
```
65
Diagnosis gonorrhoea
Men
Discharge gram stain and microscopic exam
Culture or NAATs on FVU
Women
Endocervical swab primary care
Vulvivaginal self test in clinic asymptomatic
Symptomatic endocervical
Should be screened for other STI
Should be managed in GuM
66
Tx gonorrhoea
Local resistance guidelines
Source of infection
Anatomical site of infection
Bham- ceftriaxone
67
Contact tracing gonorrhoea
Past 3 months contact
68
Follow up gonorrhoea
2 weeks no response check sensitivity
69
What is the causative organism of the herpes simplex virus
HSV1 and 2
| Both can infect either the mouth or genitals
70
How is HSV transmitted
By close of physical contact either sexual and or oral genital
It can only be transmitted when an already infected individual is shedding virus which happens sporadically and is not a necessarily in association with symptoms (asymptomatic shedding)
71
What is the clinical presentation of HSV
Variable
Most patients are quiet the infection asymptomatically
A minority will develop a severe primary attack or first clinical episode within 2 to 12 days of acquisition of the virus. Some develop minor lesions only and 70 to 80% of individuals have no clinical symptoms and maybe suspected because a sexual partner presents with symptoms
72
Who is primary infection more severe in
| HSV
Females
73
What are the typical symptoms that may occur in HSV
```
Febrile illness (prodrome) 5 to 7 days
Dysuria
Painful inguinal lymph adenopathy
Tingling/neuropathic pain may occur in genital area buttocks and legs
Genital blisters ulcers or fissures
```
74
If HSV last more than four weeks what should you suspect
Underlying immuno deficiency
75
Potential complications of HSV
Acute urinary retention
Constipation
Aseptic meningitis
76
What is the clinical course of HSV
Recurrent episodes are usually mild. Presenting symptoms in men and women may typically include
Neuropathic prodrome the tingling burning may occur in genital area buttocks legs
Erythema blisters fishes in ulcers
These usually resolve in 3 to 4 days
77
The risk of symptomatic recurrences is increased in which patients
HSV
```
Young below 20 years of age
Have a severe first episode
Within three months of primary episode
Who have genital Type II infection
With HIV infection or other immuno deficiency
```
78
Diagnosis of HSV
Patient should be seen as soon as possible during an acute attack if possible swabs for HSV PCR should be taken from the lesions the treatment should not be delayed if these are not readily available
Negative PCR test do not exclude herpes as it may have been taken to late in attack
if presentation is not typical other causes of genital warts need excluding especially syphilis but again anti-viral treatment should not be delayed
79
Treatment of HSV
Primary episode if within five days of lesion developing will be on five days but still forming new lesions commence acyclovir valacyclovir and Famciclovir
Regular analgesics and laxatives where appropriate
Bathing in a delete saline solution to relieve symptoms would you secondary infection and promote healing
Counselling is really important and may need to be treated subsequently give a leaflet
Recurrent episodes specific anti-viral therapy is not usually required saline washes and simple and analgesics can be recommended
Frequent prolonged episodes patients experiencing 6 episodes per annum may benefit from a period of suppressive therapy with the aim is to amend recurrences use acyclovir for a period of six months with regular reviews
80
Pregnancy and HSV
Advice should be sought in the case of a primary attack at any stage during pregnancy as this may be associated with higher risk of adverse outcomes
If no lesions are present then a vagina delivery is appropriate
In the third trimester women should be offered as oppressive therapy to reduce the risk of occurrence at the time of delivery
If a primary attack occurs in the third trimester caesarean section is recommended
If recurrent HSV then vagina delivery is fine
Pregnant partners of men with herpes should be told not to have sex at the time of any recurrences
81
Contact tracing in HSV
HSV is often passed in stable relationships but it can be useful to see the partners to explain the diagnosis and treatment options if it occurs
82
What is the cause of organism In hepatitis B infection
Hepatitis B virus
83
Transmission of hepatitis b
It is 10 to 100 times more infectious than HIV sexual transmission occurs in unvaccinated gay men correlates with multiple partners unprotected anal sex with oral anal sex transmission may occur after heterosexual contact sex workers are at a higher risk
Parenteral transmission blood products drug users sharing needles and syringes and a needle stick injury
Vertical transmission from mother to infant
Sporadic infection occurs in people without apparent risk factors in institutions for learning difficulties and also in children in countries with high endemicity but the mode of transmission is poorly understood
84
Clinical presentation of hepatitis B
Incubation period is between one and six months
Virtually all Infants and children have asymptomatic acute infection
Asymptomatic infection is also found in 10 to 50% of adults in the acute phase and especially likely in those with HIV convection women tend to have a more severe disease than men
85
Diagnosis of hepatitis B
Hepatitis B surface antigen and is positive in acute and chronic infection disappearing in result infection usually appears within three months of infection
Hepatitis B core antibody is a marker of acquired infection and remains positive and resolve infection but negative and vaccinated patients
Hepatitis B envelope antigen is a marker of height viral activity/infectivity
Hepatitis B surface antibody is a marker of successful vaccination or evidence of an old HBV infection when the hep b core antibody is also present and it’s titre determines the level of immunity
86
What happens to the liver function tests in chronic infection
HBV
In most cases the only abnormality will be mildly abnormal aminotransferase levels and in many the LFTs will be normal only in severe light stage liver disease do the LFTs become grossly abnormal
87
Acute complications of HBV
Less than 1% of patients with acute infectious hepatitis will develop fulminant hepatitis mortality is less than 1%
5 to 10% will developed chronic infection but the rate is higher in those with asymptomatic acute infection immunocompromised patients with HIV infection chronic renal failure & those receiving immunosuppressant drugs
In pregnancy there is an increased rate of miscarriage/premature labour in acute infection
90% of infants born to infectious positive mothers will become chronic carriers unless immunised 20 to 30% of this group developed chronic hepatitis cirrhosis or carcinoma of the liver liver
88
Complications of chronic infection of HBV
Carriers with the antigen have a higher risk of developing complications
Concurrent hepatitis C infection can lead to forming and hepatitis more aggressive chronic hepatitis and an increased risk of liver cancer
Current HIV infection may increase the risk of progression to cirrhosis
10 to 50% of chronic carriers will develop cirrhosis leading to premature death in approximately 50% 10% of cirrhotic patients will progress to liver cancer
89
Treatment of HBV
Patients who present acutely in primary care setting can be monitored and usually do not require hospital admission
In view of the possibility of chronic infection swallows you should be a piece of six months even if LFTs normal
Patient to develop a antibodies but remain hepatitis surface antigen positive after six month should have assessment by a hepatologist to determine if additional investigations are required
90
Pregnancy and breastfeeding in HBV
Vertical transmission Occurs in 90% of pregnancies were the mother is hepatitis E antigen positive and in about 10% of those with surface antigen positive and e antigen negative mothers
Most infected infants become chronic carriers
Infants born to infectious mothers are vaccinated from birth usually in combination with hepatitis B specific immunoglobulin it reduces transmission by 90%
Infected mothers she should continue to breastfeed as there is no additional risk of transmission
91
Contact partner tracing in hep B
Contact tracing should include any sexual contact or needle sharing partner during the period in which the index case is thought to have been infectious
infectious period from two weeks before the onset of jaundice do the patient becomes surface antigen negative
Where there is evidence of chronic carriage and especially if e antigen is positive the patient should be advised of the importance of vaccination for future sexual contacts and testing and vaccination should be made for children in the household if Not h vaccinated at birth
consideration should be given to testing and screening any other long-term household contacts e.g. parents carers or residents in the case of institutional care
92
What to do if exposed to HBV after unprotected intercourse or parental exposure or needlestick injury
Specific hepatitis B immunoglobulin
May be administered it works best within 48 hours and is of no use after more than seven days
An accelerated course of the recombinant vaccine should be offered to those given HBIG plus all sexual and household contacts at 0,1, 2 12 months it’s possible to give even more rapid corses
Avoid a sexual contact especially on protective penetrative sex until vaccination has been successful
93
Who should be screened for hep B
```
MSM
Sex workers
IVDU
HIV positive patients
Sexual assault victims
Individuals from endemic areas
Needlestick victims
Sexual partners of positive or high risk patients
```
94
Causative organism and transmission of syphilis
Treponema pallidum
A spirochaete
Syphilis is most infectious through sexual contact during the primary and secondary phases of the infection but transmission can occur during the early latent phase perinatal transmission may also occur later in the disease course
95
Symptoms and signs of syphilis
Primary syphilis presents as an ulcer a chancre and regional lymph adenopathy 9 to 90 days after exposures
The chancre is classically single painless and indurated with a clean base discharging indurated in the anogenital region. However they are often atypical multiple painful purulent destructive extra genital therefore any ulcer should have said please considered in the differential
Secondary syphilis can present as a multisystem involvement within the first two years of infection: a generalised polymorphic rash generally not itchy affecting the palms and soles of the feet, patchy alopecia, anterior uveitis, meningitis, cranial nerve palsy, hepatitis, splenomegaly, periosteitis and glomerulonephritis
Early latent syphilis is characterised by positive Serology for syphilis with no clinical evidence of infection within the first two years infection
Late latent syphilis is infection diagnosed on testing which is more than two years duration of no symptoms or signs
Symptomatic late syphilis is found in up to 40% of individuals but is extremely rare in the modern era
96
What are the main features of symptomatic late syphilis
Neurosyphilis-the most common manifestations are related to dorsal column loss and dementia it may be asymptomatic and is diagnosed when individuals have latent syphilis with abnormal CSF examination but with no associated neurological symptoms or signs
Cardiovascular syphilis is characterised by aortitis usually involving the aortic root and may result in aortic regurgitation, aortic aneurysm is and angina
Gummata are inflammatory fibrous nodules and plaques that can be locally destructive most commonly occur in skin and bone can affect any organ
97
Diagnosis of syphilis
Most made on syphilis serology
The diagnosis may be suspected on the basis of sexual history and symptoms
It may be made on the basis of finding T pallidum and dark field microscopy from material obtained from lesions or via DNA test
DNA test conveniently comes as a combined test with herpes simplex DNA allowing for simultaneous detection of both infections
98
Recommended treatment of syphilis
Long acting penicillin
| The regiment of preparation vary depending upon the disease stage, Coexisting HIV, & pregnancy
99
Contact tracing in syphilis
Current partners should be screened for syphilis and other SDIs repeats serology may be necessary after three months
look back period for the partners and children will depend on the disease stage presentation and on occasions maybe for some years
100
Follow-up for syphilis
Depends upon the stage of infection but is for a minimum of one year with repeat blood test‘s
101
Causative organism and transmission of Trichomonas vaginalis
It is a flagellated protozoon in adults it is almost exclusively sexually transmitted
102
Symptoms & signs Of Trichomonas vaginalis
Women The organism is found in the vagina and urethra, 50% are asymptomatic remainder have a vagina discharge offensive yellow thin and frothy, vulval irritation superficial dyspareunia or dysuria
Signs include vulvitis vaginitis an excessive discharge yellow commonly cervicitis with contact bleeding
Men infection is usually of the urethra although it has been isolated from the subpreputial sack and from lesions of the penis
men are usually asymptomatic and examination is normal some have symptoms and signs of urethritis and rarely balantis
103
Complications of Trichomonas vaginalis
There is an association with preterm delivery and low-birth-weight
104
Diagnosis of Trichomonas vaginalis
High vagina swab and females the pH is usually about five
The preferred test is NAAT
microscopy in sexual health clinics or culture alternatives
Diagnosis is more difficult in men and as a result my partner is a female patients should always be treated
105
Recommended treatment of Trichomonas vaginalis
Metronidazole
106
Treatment of TV in pregnancy
Metronidazole can be used in all stages of pregnancy and breastfeeding
107
Contact tracing of TV
Partner should be screened for STIs and treated for TV regardless of the results of the test sexual absence advised until treatment of all partners is completed
108
What is urethritis
Syndrome characterised by dysuria and discharge examination may reveal objective evidence of discharge
109
Causative organisms of urethritis
N. Gonorrhoea
C trachomatis
Mycoplasma genitalium
TV
110
TransMission of urethritis
Usually sexually acquired
| Females are commonly asymp need to be treated as run the risk of developing pelvic infection
111
Investigations of urethritis
Primary care maybe suspected by history and examination
Commonest causes an STI
Sterilepyuria in any man with every symptoms is suggestive of urethritis
Urethral swab for Gram stain
URine or urethral swab do you NAATS for chlamydia and Gonorrhoea
+ -urethral swab for gonorrhoea culture
112
Diagnosis of urethritis
```
Gram stain urethral smear
Exclude other localised problems which could explain urethral inflammatory exudate such
Balanitis
Penile herpes
Urethral warts
Cystitis
```
113
Complications of urethritis
Epididymitis
Reiters syndrome
Prostatitis
Sub fertility
114
Treatment of urethritis
Doxyckine
| Azithrimycin
115
Contact tracing in urethritis
Last 3 months
| Avoid any sex until completion of ab
116
Persistent or recurrent urethritis
Try alternative antibiotics
117
What causes warts
HPV
118
TransMission and incubation period of HPV
Passed through close physical contact almost always genital for genital warts
Incubation period 3 to 18 months but can be longer many people infected never develop visible warts but can still transmit the virus that though it is often not able to get the source infection
119
Symptoms and signs of warts
Genital lumps which may be hard or soft and range from 1 to multiple
Bleeding especially urethral
Occasional itchy
Sometimes hyperpigmentation
In women the sites are at the volva the perianal region the cervix the vagina and the urethra
In me. They are found on the penis +/- urethra, perianal region and scrotum
120
Diagnosis of warts
Clinical and based on the appearance of warts
121
Treatment of warts
Do you eradicate the visible warts is not possible to guarantee to eradicate the virus
Podophyllotoxin cream - avoid in pregnancy or nut allergy
Weekly cryotherapy if available
122
Pregnancy and warts
No risk to vertical transmission
| Most tx CI
123
Which HPV commonly causes warts
Six and 11
124
Which strains of HPV oncogenic
16 18 31
