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Flashcards in STIs Deck (156):

Name 10 risk factors for STIs. (DFCM)

  • Lifestyle factors
    • Age <25 and sexually active
    • More than 2 partners in the last year
    • Serial monogamists
  • Sexual factors
    • Unprotected sex or non-barrier contraception
    • Risky sexual behaviours – anal, S&M, swingers, sex workers, homelessness
  • Past medical history
    • Previous STI
    • Known partner with STI
    • Victim of sexual assault or abuse
    • IVDU or other substance use


What are 6 components of a sexual history? (Mnemonic DFCM)

    • Sexually active? Male, female or both?
    • EXes – how many partners in the last 3 months
    • Activities – types of sexual encounters, anal, S&M
    • STIs
      • Any symptoms that make you worried about having an STI now
      • Have you had any previous STIs?
      • What are you doing to avoid STIs?
    • Abuse
      • Sexual abuse
      • Drug use? IVDU?
    • Pregnancies
      • What are you doing to avoid pregnancy? Barrier methods?
      • Have you had any pregnancies before?
      • When was your LMP?


In individuals at increased risk of STIs, what should be screened for? (TN)

  • Chlamydia
  • Gonorrhea
  • Hepatitis B
  • HIV
  • Syphilis


Which of chlamydia, gonorrhea, genital herpes, genital HPV, trichomonasvaginalis, syphilis and Hepatitis B are reportable? (DFCM)

  • Reportable: Chlamydia, Gonorrhea, Syphilis, Hepatitis ABC, HIV, Trichomonasvaginalis (some places)
  • Not Reportable: Genital herpes, Genital HPV


Which sexual partners should be tested and empirically treated for patients with an STI? (DFCM)

  • All partners within 60 days prior to symptom onset or specimen collection


What are the two most common bacterial STIs? (DFCM)

  1. Chlamydia
  2. Gonorrhea


What are two non-sexually transmitted genital tract infections? (TN)

  • Vulvovaginal candidiasis (VVC)
  • Bacterial vaginosis (BV)


What are the 3 most common infections associated with vaginal discharge in adult women? (TN)

  • BV
  • VVC
  • Trichomoniasis


In what instances are culture preferred over NAAT to screen for STIs? (PBSG)

  • Sexual abuse or assault
  • Evaluation of PID
  • Treatment failure
  • Infection acquired overseas
  • Areas with recognized antimicrobial resistance


When used correctly and consistently, how much can latex condoms reduce the risk of STI transmission? (PBSG)

  • 70%


What does the USPSTF recommend regarding screening for chlamydia and gonorrhea? (AFP)

  • Chlamydia and Gonorrhea screening for sexually active women aged 24 years or younger and in older women at increased risk
  • Insufficient evidence for men


When does the CDC recommend for retesting patients treated for chlamydia and gonorrhea? (AFP)

  • 3 months after treatment
  • 3 weeks after treatment in pregnant women (test of cure)
  • 3 months after treatment in pregnant women diagnosed in 1st trimester


What proportion of gonorrhea cases occur in males? (DFCM)

  • 2/3
  • Increased in MSM


What age groups are most commonly affected by gonorrhea? (DFCM)

  • Women 15-24
  • Men 20-29


Is HIV transmission enhanced in people with concomitant gonococcal infections? (DFCM)

  • Yes


What type of organism is gonorrhea? (TN)

  • Gram-negative intracellular diplococci


Name 6 possible symptoms for gonorrhea in women. (DFCM)

  • Vaginal discharge
  • Dysuria
  • Abnormal vaginal bleeding
  • Lower abdominal pain
  • Rectal pain and discharge if proctitis
  • Deep dyspareunia


Name 7 possible symptoms for gonorrhea in men. (DFCM)

  • Urethral discharge
  • Dysuria
  • Pyuria
  • Urethral itch
  • Testicular pain
  • Testicular swelling
  • Rectal pain and discharge if proctitis


What are 6 potential major sequelae of gonorrhea in women? (DFCM)

  • PID
  • Infertility
  • Ectopic pregnancy
  • Chronic pelvic pain
  • Reiter syndrome
  • Disseminated gonococcal infection


What are 4 potential major sequelae of gonorrhea in men? (DFCM)

  • Epididymo-orchitis
  • Infertility (rare)
  • Reiter syndrome
  • Disseminated gonococcal infection


What is first-line treatment for gonococcal disease urethritis in adults and children 9 years of age? (MUMS 2013)

  • Cefixime 400-800 mg single dose OR Ceftriaxone IM 250 mg single dose
  • AND
  • Azithromycin 1 g single dose OR Doxycycline 100 mg BID for 7 days


What is second-line treatment for gonococcal urethritis in adults and children 9 years of age? (MUMS 2013)

  • Ofloxacin 400 mg single dose (NOT approved for children) OR Ciprofloxacin 500 mg single dose (Not approved for children <18 years) OR Spectinomycin IM 2 g single dose
  • AND
  • Azithromycin 1 g single dose OR Doxycycline 100 mg BID for 7 days OR Erythromycin 2 g/day divided QID for 7 days (if not tolerated then 1 g/day divided QID for 14 days)


When is repeat testing recommended after treatment for gonococcal urethritis? (MUMS 2013)

  • 6 months


How does treatment differ for suspected gonococcal urethritis if there is or is not urethral discharge? (MUMS 2013)

  • Urethral Discharge à Treat for both even if no test results
  • No Urethral Discharge à Test and defer treatment until results available


What is the treatment of choice for gonococcal urethritis in pregnant and nursing mothers? (MUMS 2013)

  • Cefixime, Ceftriaxone or Spectinomycin


What should be used to treat concomitant chlamydial infection in pregnant and nursing women? (MUMS 2013)

  • Azithromycin 1 g single dose or Erythromycin
  • Doxycycline and erythromycin estolate contraindicated in pregnancy


In pregnant women treatment for gonococcal urethritis, how long after treatment should you retest? (MUMS 2013)

  • Culture 4-5 days post treatment


What age groups are most commonly affected by chlamydia? (DFCM)

  • Women 15-24
    • 15-19 > 20-24
  • Men 20-29


What is the rate of co-infection of chlamydia in patients with gonorrhea? (DFCM)

  • 20-42%


What type of organism is chlamydia? (AFP)

  • Gram-negative bacterium
  • Infects columnar epithelium of the cervix, urethra, and rectum


In women aged 18-26, are chlamydia or gonorrhea infections more common? (AFP)

  • Chlamydia 10x more prevalent


Name 7 possible symptoms for chlamydia in women. (DFCM)

  • Cervicitis
  • Vaginal discharge
  • Dysuria
  • Lower abdominal pain
  • Abnormal vaginal bleeding (after intercourse)
  • Dyspareunia
  • Conjunctivitis


Name 6 possible symptoms for chlamydia in men. (DFCM)

  • Urethral discharge
  • Urethritis
  • Urethral itch
  • Dysuria
  • Testicular pain
  • Conjunctivitis


What are 6 potential major sequelae of chlamydia in women? (DFCM)

  • PID
  • Infertility
  • Ectopic pregnancy
  • Chronic pelvic pain
  • Perihepatitis (Fitz-Hugh-Curtis syndrome
  • Reiter syndrome (Reactive Arthritis – aseptic arthritis, nongonococcal urethritis, and conjunctivitis)


What is Fitz-Hugh-Curtis syndrome? (AFP)

  • Rare complication of PID
  • Liver capsule (Glisson’s capsule) inflammation leading to the creation of adhesions
  • Major symptom is acute RUQ pain aggravated by breathing, coughing or laughing, may be referred to the right shoulder
  • Abdominal ultrasound and LFTs typically normal
  • CT abdomen with IV contrast may show subtle enhancement of the liver capsule
  • Diagnosed by testing for gonorrhea and chlamydia (cervical samples more sensitive than testing the urine)


What are potential complications of chlamydia infection during pregnancy? (AFP)

  • Miscarriage
  • Premature rupture of membranes
  • Preterm labor
  • Low birth weight
  • Infant death


What is another STI caused by C. trachomatis? How does it present, how is it diagnosed and how is it treated? (AFP)

  • Lymphogranuloma venerum (LGV)
    • Unilateral, tender inguinal or femoral node (may include genital ulcer or papule)
    • Anal exposure can result in proctocolitis, rectal discharge, pain, constipation, or tenesmus
    • May lead to chronic symptoms (fistulas and strictures) if left untreated
    • Diagnosis based on clinical symptoms and a genital lesion swab or lymph node sample
    • Doxycycline 100 mg PO BID for 21 days


How does C. trachomatis pneumonia present and how is it diagnosed and treated? (AFP)

  • 1-3 months following birth
  • Should be suspected in a child with tachypnea and a staccato cough (short bursts of cough) without a fever
  • CXR may reveal hyperinflation and bilateral diffuse infiltrates
  • Bloodwork can reveal eosinophilia
  • Specimens should be collected from the nasopharynx
  • Erythromycin treatment of choice


What is the leading cause of infectious blindness in the world? (AFP)

  • Chlamydia (Trachoma)
  • Chronic or recurrent ocular infection that leads to scarring of the eyelids
  • Affecting primarily rural poor in Asia and Africa


What % of PID cases result in complications of infertility? (PBSG)

  • 25%


What are 2 potential major sequelae of gonorrhea in men? (DFCM)

  • Epididymo-orchitis
  • Reiter syndrome


How can a diagnosis of chlamydia be made in men and women? (DFCM)

  • Urine NAAT (first-catch or first void) – preferably have not voided for at least 2h
  • Females: swab cervix, vagina or rectum
  • Men: urethral


What are three pathogens that can cause nongonococcal urethritis? (MUMS 2013)

  • C. trachomatis
  • U. urealyticum
  • M. genitalium


What is first-line treatment for nongonococcal disease urethritis in adults and children 9 years of age? (MUMS 2013)

  • Azithromycin 1 g single dose OR Doxycycline 100 mg BID for 7 days


What is second-line treatment for nongonococcal disease urethritis in adults and children 9 years of age? (MUMS 2013)

  • Erythromycin 2 g/day divided QID for 7 days (if not tolerated then 1 g/day divided QID for 14 days) OR Ofloxacin 300 mg BID for 7 days (not approved for children <18 years)


What is the procedure for sexual contacts of patients treatment for nongonococcal urethritis? (MUMS 2013)

  • All sexual contacts with the patient during the 60 days preceding the onset of symptoms should be tested and empirically treated regardless of clinical findings and without waiting for test results


How long after treatment until symptoms typically resolve in nongonococcal urethritis? (MUMS 2013)

  • 7 days after therapy completed
  • Abstain from sexual intercourse until 7 days after treatment completed


When is test of cure recommended after treatment for nongonococcal urethritis? (MUMS 2013)

  • Alternate regimen used
  • Children < 14 years
  • Pregnancy
    • 3-4 weeks after completion of treatment
    • 3-6 months after treatment, or in 3rd trimester
  • Non-genital site (e.g. eye)


When should men and non-pregnant women recently infected with chlamydia undergo repeat testing (not test of cure)? (AFP)

  • 3 months or within first year following treatment


What are options for treatment of nongonoccal urethritis in pregnant women? (MUMS 2013)

  • Azithromycin 1 g single dose or Erythromycin or Amoxicillin 500 mg TID for 7 days
  • Erythromycin estolate contraindicated in pregnancy


In what % can recurrent or persistent cases occur in men treated for acute nongonococcal urethritis and what other causes should be considered? (MUMS 2013)

  • 20-60%
  • Consider:
    • T. vaginalis

Tetracycline-resistant U. urealyticum or N. gonorrhea


In men with recurrent or persistent cases of acute nongonococcal urethritis that noncompliance or re-infection are ruled out, what is another treatment option? (MUMS 2013)

  • Metronidazole 2 g in a single dose
  • PLUS
  • Erythromycin 500 mg QID for 7 days OR Azithromycin 1 g single dose (if not used initially)


What is the female equivalent to gonococcal urethritis? (MUMS 2013)

  • Cervicitis


What is the treatment for cervicitis? (MUMS 2013)

  • Same as for gonococcal urethritis


How is cervicitis characterized? (MUMS 2013)

  • Inflammation of the cervix with a mucopurulent or purulent cervical discharge and an increased number of polymorphonuclear leucocytes


Can cervicitis occur in prepubertal girls? (MUMS 2013)

  • No – this is prepubertal vaginitis


What is the most common gynecologic reason for admission to the hospital in the U.S.? (AFP)

  • Pelvic inflammatory disease (PID)


Define PID. (AFP)

  • Inflammation and infection of the upper genital tract in women, typically involving the uterus and adnexa


Differentiate between mild to moderate PID and severe PID. (AFP)

  • Mild to Moderate: absence of a tubo-ovarian abscess
  • Severe: severe systemic symptoms or the presence of a tubo-ovarian abscess


What are potential symptoms of PID? (MUMS 2013)

  • Lower abdominal pain of recent onset
  • Heavy menstrual, inter-menstrual or post-coital vaginal bleeding
  • Deep dyspareunia
  • Vaginal discharge that is not explained


What are potential signs of PID? (MUMS 2013)

  • Cervical motion tenderness
  • Adnexal tenderness on bimanual exam (with or without a mass)
  • Cervicitis (purulent cervical exudate present in 30% of cases
  • Fever (present in >40% of PID cases)


How is PID diagnoses? (TN)

MOST have:

  • Lower abdominal pain

PLUS one of:

  • Cervical motion tenderness
  • Adnexal tenderness

PLUS one or more of:

  • High risk partner
  • Temperature > 38 C
  • Mucopurulent cervical discharge
  • Positive culture for N. gonorrhea, C. trachomatis, E. coli, or other vaginal flora
  • Cul-de-sac fluid, pelvic abscess or inflammatory mass on U/S or bimanual
  • Leukocytosis
  • Elevated ESR or CRP (not commonly used)


What are 8 potential complications of PID? (TN)


  • Infertility
  • Fitz-Hugh-Curtis syndrome
  • Abscesses
  • Chronic pelvic pain
  • Ectopic pregnancy
  • Peritonitis
  • Intestinal obstruction
  • Disseminated infection (sepsis, endocarditis, arthritis, meningitis)


What % of women with PID become infertile, develop chronic pain, or have an ectopic pregnancy? (AFP)

  • 20% Infertile
  • 40% Chronic Pain
  • 1% of those who conceive have an ectopic pregnancy


When should treatment be start when the diagnosis of PID is suspected? (AFP)

  • Empiric treatment should start immediately
  • Minimize risk of sequelae such as tubal obstruction and infertility


What is the single best diagnostic test for PID? What are its drawbacks? (AFP)

  • Direct visualization of the fallopian tubes by laparoscopy
    • Invasive
    • Lacks sensitivity
    • Not used routinely in clinical practice


What is the PPV of clinical diagnosis for PID compared to laparoscopy? (AFP)

  • 65-90%


What does the risks of tubal occlusion and infertility depend on in PID? (AFP)

  • Severity of infection BEFORE treatment


Name 5 risk factors for PID. (AFP)

  1. Prior infection with Chlamydia or Gonorrhea
  2. Young age at onset of sexual activity
  3. Unprotected sexual intercourse with multiple partners
  4. History of PID
  5. Instrumentation of cervix
  6. Vaginal douching
  7. IUD (within first 10 d after insertion
  8. Invasive gynecologic procedures (D&C, endometrial biopsy)


What is first line treatment for PID with mild to moderate presentation? (MUMS 2013)

  • Cefixime 800 mg single dose OR Ceftriaxone IM 250 mg single dose
  • AND
  • Doxycycline 100 mg PO BID for 14 days +/- Metronidazole 500 mg PO BID for 14 days


When should patients with suspected mild to moderate PID be reevaluated? (MUMS 2013)

  • 48 to 72 hours later


When should metronidazole be considered for treatment of mild to moderate PID? (MUMS 2013)

  • Adnexal mass formation
  • Tubo-ovarian abscess
  • Peritonitis
  • Will also effectively treat bacterial vaginosis that is commonly associated with PID


When should you consider removing an IUD in a patient with PID? (TN)

  • After a minimum 24h of treatment


Differentiate between acute, subacute and chronic epididymitis. (AFP)

  • Acute: <6 weeks
  • Chronic: >3 months


What are risk factors for epididymitis? (AFP)

  • All Men
    • Sexual activity
    • Strenuous physical activity
    • Bicycle or motorcycle riding
    • Prolonged periods of sitting (e.g. during travel, sedentary job)
  • Men >35 years
    • Recent urinary tract surgery or instrumentation
    • Anatomic abnormalities (e.g. prostatic obstruction)
  • Prepubertal boys
    • Recent urinary tract surgery or instrumentation
    • Anatomic abnormalities (e.g. PUVs, meatal stenosis)


What is the most common cause of viral orchitis? (AFP)

  • Mumps
    • Orchitis in 20-30% of men with mumps infection
    • 4-7 days after development of parotitis


What are possible signs and symptoms of epididymitis? (AFP)

  • Gradual onset of pain localized posterior to the testis
  • Occasionally radiates to the lower abdomen
  • Normal cremasteric reflex
  • Pain relief with testicular elevation (Prehn sign)
  • Tender spermatic cord (suggestive of epididymitis)
  • LUTS (frequency, urgency, hematuria, dysuria)
  • Fever


What investigations should be done for epididymitis? (AFP)

  • Gram stain and culture of swabbed urethral discharge
  • Urinalysis and urine culture (first void)
  • Scrotal ultrasound (if concerns regarding testicular torsion)


What blood test may be useful in differentiating epididymitis from testicular torsion in patients with an acute scrotum? (AFP)

  • CRP and ESR
    • CRP sensitivity 96.2% and specificity 94.2%


What pathogens are commonly responsible for epididymitis? (MUMS 2013)

  • >35 years
    • KEEPS
      • Klebsiella
      • E. coli
      • Enterococcus
      • Proteus mirabilis
      • S. saprophyticus
  • ≤35 years or multiple sex partners
    • Gonorrhea and Chlamydia


What is first line therapy for men >35 years with epididymitis? (MUMS 2013)

  • Ofloxacin 300 mg PO BID for 10 days OR Ciprofloxacin 500 mg BID for 10 days OR Levofloxacin 500 mg daily for 10 days


What is first line therapy for men ≤35 years with epididymitis? (MUMS 2013)

  • Cefixime 800 mg PO single dose OR Ceftriaxone 250 mg IM single dose
  • AND
  • Doxycycline 100 mg PO BID for 10 days


What else can be recommended for men with epididymitis in addition to antibiotics? (AFP)

  • Analgesics
  • Scrotal elevation
  • Limitation of activity
  • Use of cold packs


What are possible complications of epididymitis? (AFP)

  • Sepsis
  • Abscess
  • Infertility
  • Extension of the infection


After treatment for epididymitis, when should symptoms typically resolve? (AFP)

  • Pain in 1-3 days
  • Induration 2-4 weeks


What is this?

Q image thumb

Genital Herpes


What is a differential diagnosis for a genital ulcer?

  • Infectious
    • Chancroid
    • Fungal infection
    • Genital herpes simplex
    • Granuloma inguinale
    • Lymphogranuloma venereum
    • Secondary bacterial infection
    • Syphilis
  • Noninfectious
    • Aphthous ulcers
    • Behcet syndrome
    • Fixed drug eruption
    • Neoplasms
    • Psoriasis
    • Sexual trauma


What is the common difference between HSV-1 and HSV-2? (AFP)

  • HSV-1 à Oral
    • In the U.S., incidence of primary genital infection with HSV-1 now as common more common than HSV-2
    • HSV-1 represents as least ½ of new cases of genital cases
  • HSV-2 à Genital


What is the prevalence of HSV-2 infection in the U.S.? (AFP)

  • 1 in 5 adults


Why does HSV-1 now represent at least ½ of new cases of genital herpes? (AFP)

  • Changing adolescent sexual practices involving more oral-genital contact (oral sex)


How much does genital herpes increase the risk of acquisition of HIV? (DFCM/AFP)

  • 2x (DFCM)
  • 3x (AFP)


How can genital herpes be diagnosed? (DFCM)

  • Cluster of vesicles on an erythematous background
  • Can be seen on the genitalia, perineum, buttocks, upper thighs, or perianal areas


How can a primary infection of genital herpes present? (DFCM)

  • Prodrome of hours to days with pain, tingling, itching, or burning at site of expoure
  • Extensive painful vesiculoulcerative genital lesions
  • Last ~2 weeks
  • Systemic symptoms (fever, myalgia, malaise)
  • Tender lymphadenopathy
  • Longer course


How do secondary infections of genital herpes present? (AFP)

  • Milder
  • Heal within 6 to 12 days
  • Reactivation of latent virus


Which are typically milder, primary and secondary genital infection with HSV-1 or HSV-2? (AFP)

  • HSV-1


How does recurrence differ between genital HSV-1 and HSV-2? (AFP)

  • HSV-1 = 0-1 per year
  • HSV-2 = 4-5 per year


What % of patients with genital HSV infection are unaware of its presence?

  • 65 to 90%


How common is asymptomatic viral shedding with genital herpes? (AFP)

  • 10-20% of all days
  • More often during first year of infection


Is NAAT or culture better for swabbing genital herpes? (PBSG)

  • NAAT > Culture (More Sensitive and More Specific)


What does the USPSTF recommend regarding serologic screening for genital herpes? (AFP)

  • Against


What are scenarios in which to consider herpes simplex virus type-specific serologic testing? (AFP)

  • Patients with recurrent genital symptoms or atypical symptoms and negative herpes simplex virus PCR assay or culture
  • Patients with a clinical diagnosis of genital herpes but no laboratory confirmation
  • Patients who report having a partner with genital herpes
  • Patients presenting for a sexually transmitted disease evaluation (especially with multiple sex partners)
  • Patients with HIV
  • Men who have sex with men who are at increased risk of HIV acquisition


What % of the U.S. population have the HSV-1 antibody? (AFP)

  • 54% (asymptomatic, primarily acquired in childhood)


What is the window after HSV exposure to formation of detectable antibody? (AFP)

  • 2 weeks to 6 months


Name 8 potential complications of genital herpes. (AFP)

  1. Acute urinary retention (particularly in women)
  2. Aseptic meningitis (including a recurrent form)
  3. Disseminated herpes
  4. Encephalitis
  5. Hepatitis
  6. Neonatal infection
  7. Pelvic inflammatory disease
  8. Pneumonitis


What should patients with genital herpes be counselled about?

  • Abstain from sexual activity when lesions or prodromal symptoms are present
  • Inform sex partners that they have genital herpes
  • Sexual transmission may occur during asymptomatic periods where there is no evidence of lesions
  • Use of condoms during all sexual exposures with new sex partners should be encouraged (may not be effective depending on location of lesions or asymptomatic shedding)


When should therapy be initiated for genital herpes? (MUMS 2013)

  • Within 72 hours of onset of signs and symptoms
  • Initiation of therapy within one day of lesion onset or during prodrome that precedes outbreaks, is encouraged to ensure effective treatment of recurrent herpes
  • Patients can be provided with a supply of medication or a prescription so that self-initiation of treatment can occur immediately when symptoms begin


What is the role for topical antivirals in genital herpes? (MUMS 2013)

  • Minimal evidence, no clear benefit or role


What is first-line treatment for HSV for the first symptomatic episode? (MUMS 2013)

  • Acyclovir 400 mg TID for 5-7 days
  • OR
  • Famciclovir 250 mg TID for 5-7 days
  • OR
  • Valacyclovir 500-1000 mg BID for 5-7 days


For patients with acute recurrent (≤6 episodes per year) of genital herpes, what is first-line treatment? (MUMS 2013)

  • Acyclovir 400 mg TID for 5 days or 800 mg BID for 5 days or 800 mg TID for 2 days
  • OR
  • Famciclovir 125 mg BID for 5 days
  • OR
  • Valacyclovir 500 mg BID for 3 days or 1000 mg once daily for 3 days


When would patients need chronic suppressive treatment for genital herpes? (MUMS 2013)

  • >6 episodes per year


How much is the frequency of recurrent genital herpes reduced by with suppressive therapy? (MUMS 2013)

  • 70-80%


What would first-line chronic suppressive treatment be for genital herpes? (MUMS 2013)

  • Acyclovir 400 mg BID
  • OR
  • Famciclovir 250 mg BID
  • OR
  • Valacyclovir 250 mg BID or 500 mg daily (if >9 episodes per year then 1000 mg daily)


What is the usual duration of therapy for chronic suppressive treatment for genital herpes? (MUMS 2013)

  • 3-6 months


What is first line treatment for genital herpes for the first symptomatic episode in pregnant women? (MUMS 2013)

  • Acyclovir 200 mg 5 times daily for 5-10 days


When and why would you consider prophylaxis for genital herpes for pregnant women? (MUMS 2013)

  • Pregnant woman with prior infection within the previous year
  • Start prophylaxis at 36 weeks gestation
  • Acyclovir 200 mg QID or 400 mg TID
  • OR
  • Valacyclovir 500 mg BID


What would you recommend for laboring patients with active lesions to decrease the risk of HSV transmission? (AFP)

  • Elective Cesarean delivery


What is the risk of vertical transmission when a primary outbreak occurs at the time of delivery? (MUMS 2013/AFP)

  • 30-60% (MUMS)
  • 60% (AFP)


What is this?

Q image thumb

Genital Warts


How can genital warts appear? (AFP)

  • Small, flat-topped papules
  • Large, cauliflower-like lesions on the anogenital mucosa and surrounding skin


What on the coronal sulcus can be confused with genital warts? (AFP)

  • Pearly penile papules


What typically causes genital warts and what are the most common strains? (DFCM)

  • HPV (types 6 & 11) – 90% of genital warts


What % of the sexually active U.S. population have genital warts, and what is the estimated lifetime risk? (AFP)

  • 1% of sexually active U.S. population
  • 10% lifetime risk


What age has the highest prevalence of genital warts? (AFP)

  • Sexually active women 20 to 24 years of age
  • Sexually active men 25 to 29 years of age


In Ontario, at what grade is the HPV vaccine given to girls? (DFCM)

  • Grade 7 (starting in 2016-17, previously grade 8)


What are the 3 types of HPV vaccines and what % of cervical cancers do they help prevent? (CDC 2015)

  1. Cervarix (bivalent) – HPV 16 and 18 (65% cervical cancers)
  2. Gardasil 4 (quadrivalent) – HPV 6 and 11, 16 and 18
  3. Gardasil 9 (9-valent) – HPV 6, 11, 16, 18, 31, 33, 45, 52, 58 (additional 15% cervical cancers)


What % of cervical cancers would not be prevented by HPV vaccines?

  • 20-30%


How are the HPV vaccines given? (CDC 2015)

  • 2 doses in Ontario (Cervarix and Gardasil – time 0, 6-12 months)
    • Gardasil 9 CANNOT be given in 2 doses
  • 3 doses (Gardasil 9 – time 0, 1-2 months, 6 months)
    • Also 3 doses if:
      • No dose of HPV vaccine by 15 years of age
      • Immunocompromised or HIV
      • Gardasil 9


How do the recommendations for the HPV vaccines differ between girls and boys? (CDC 2015)

  • Girls 11-12 years of age (any vaccine)
  • Boys 11-12 years of age (only quadrivalent or 9-valent)


How early can the HPV vaccine be given in boys and girls? (CDC 2015)

  • Age 9


In females and males in whom the HPV vaccine series was not provided or not completed, what ages can receive the vaccine? (CDC 2015)

  • Females 13 to 26 years
  • Males 13 to 21 years


At what age is the HPV vaccine not licensed or recommended? (CDC 2015)

  • Older than 26 years


What are potential side effects of the HPV vaccine?

  • Soreness (pain)
  • Swelling
  • Itching
  • Redness at the injection site
  • Headache and fatigue rarely


What % of genital warts resolve spontaneously? (AFP)

  • 20% within 6 months
  • 1/3 of cases (AFP)


What is the recurrence rate for genital warts? (AFP)

  • 25-67%
  • Depends on type of treatment modality


What patient-applied immunomodulating treatment can be used to treat genital warts? (MUMS 2013)

  • Imiquimod 5% cream (Zyclara)
    • Apply at bedtime three times per week (every other night) for up to 16 weeks
    • MWF or TuThSa
    • Wash off 6-10 hours after application with soap and water


What % of patients showed clearance (NNT) and what is the recurrence rate following Imiquimod cream for genital warts? (AFP)

  • 50% clearance (NNT = 2.6)
  • 13% recurrence


What are potential adverse effects of Imiquimod cream for genital warts? (AFP)

  • Itching
  • Erythema
  • Burning
  • Irritation
  • Tenderness
  • Ulceration, erosion and pain less common


What patient-applied caustic treatment can be used to treat genital warts? (MUMS 2013)

  • Podofilox (Podophyllotoxin) 0.5% solution
    • 1 treatment cycle: apply BID in morning and at bedtime (or q12h) for 3 days, followed by no therapy for 4 days
    • Repeat if necessary up to a maximum of 4 cycles


What are potential side effects of Podofilox for genital warts? (AFP)

  • Burning
  • Pain
  • Erosion
  • Itching
  • Inflammation


What are 5 physician-administered treatment options for genital warts? (MUMS 2013)

  1. Cryotherapy
    1. Repeat every 1-2 weeks for maximum of 8 weeks
  2. Podophyllin resin 10-25% in compound tincture of benzoin
    1. Apply small amount to warts, allow to dry (can wash off after 1-4 hours)
    2. Can repeat weekly
  3. Trichloroacetic acid (TCA) 80-90% in 70% ethyl alcohol
    1. Apply small amount to warts, allow to dry and form a white frosting
    2. Can be repeat weekly
    3. Apply 5% EMLA cream around warts to be treated 10-20% minutes prior
  4. Laser therapy
  5. Surgical removal


When should you consider referral for genital warts?

  • Extensive requiring specialist consult for surgery
  • No response seen within 4-6 weeks of treatment (except imiquimod)


What is the recommendation for treatment of genital warts in pregnancy? (AFP)

  • Podophyllin is CONTRAINDICATED
  • Safety of imiquimod and podofilox unclear
  • CDC does NOT recommend prophylactic cesarean delivery or routine treatment of external genital warts in pregnant women unless lesions will cause obstructed labor or significant bleeding during delivery


What is the evidence for circumcision for prevention of genital warts? (AFP)

  • 3 RCTs in sub-Saharan Africa demonstrate that circumcision reduces heterosexual transmission of:
    • HIV
    • High-risk types of HPV
    • Herpes simplex virus


Name 5 symptoms of trichomonasvaginalis. (DFCM)

  • Vaginal discharge
  • Itch
  • Dysuria
  • Off-white/yellow frothy discharge
  • Erythema of vulva and cervix


Is trichomonasvaginalis associated with HIV? (DFCM)

  • Yes – associated with increased risk of HIV acquisition and transmission in women


How should patients with suspected trichomonasvaginalis be investigated? (DFCM)

  • Speculum exam and vaginal culture


How does trichomonasvaginalis appear on microscopy? (DFCM)

  • Motile trichomonads on wet mount


How should trichomonasvaginalis be treated? (DFCM)

  • Metronidazole 2g PO x1 dose or 500 mg PO BID x7 days
  • Treat partner with same therapy


What causes syphilis? (TN)

  • Treponema pallidum


Who is commonly affected by syphilis? (DFCM)

  • MSM aged 30-39
  • Sex workers and clients


What are the main modes of transmission of syphilis? (DFCM)

  • Vaginal
  • Anal
  • Oral


When after exposure would primary and secondary syphilis present? (TN)

  • Primary: 3-4 weeks after exposure
  • Secondary: 2-6 months after initial infection


What are the main symptoms and signs of the different states of syphilis? (DFCM)

  1. Primary:
    1. Painless chancre
    2. Lymphadenopathy
  2. Secondary:
    1. Rash (maculopapular rash on palms, soles, trunk, limbs)
    2. Fever
    3. Malaise
    4. Lymphadenopathy
    5. Mucus lesions
    6. Condylomalata
    7. Alopecia
    8. Meningitis
    9. Headaches
    10. Uveitis
  3. Latent:
    1. Asymptomatic
  4. Tertiary:
    1. CV (aortic aneurysm / regurgitation)
    2. Neurosyphilis (asymptomatic, headaches, vertigo, personality changes, dementia, ataxia, Argyll Robertson pupil)


How is syphilis diagnosed? (DFCM)

  • VDRL
  • Treponemal specific enzyme immunoassay (EIA) à MORE SENSITIVE
  • Dark-field microscopy of material from primary or secondary lesions


What is the treatment for primary/secondary/early latent syphilis? (DFCM)

  • Benzathine penicillin G 2.4 million units IM x 1 dose


Which contacts should be notified of patients with syphilis? (PBSG)

  • 3-12 months prior to development of symptoms, depending on disease stage (primary, secondary, early latent)