Vaginal discharge + STI's

Question 1

What are the risk factors for STI’s? (give 4)

Answer 1

Age <25
>1 Sexual partner in the last 12 months
New sexual partner
Unprotected sexual intercourse
Previous STI’s

Question 2

What investigations would you perform for vaginal discharge?

Answer 2

Get a pregnancy test

Triple swabs:
Vulvovaginal NAAT - for Chlamydia + Gonorrhoea
High vaginal charcoal swab - Trichomonas vaginalis, Gardnerella vaginalis, Candida
Endocervical charcoal swab - think this is more for Gonorrhoea culture + sensitivity

Question 3

What STI investigations would you perform for ASYMPTOMATIC males

Answer 3

First pass urine NAAT - for Neisseria gonorrhoea + Chlamydia Trachomatis

Bloods - for HIV + Syphilis +/- Hep B/C

Rectal + Pharyngeal swabs - in MSM

Question 4

What STI investigations would you perform for SYMPTOMATIC males?

Answer 4

First pass urine NAAT - for Neisseria Gonorrhoea + Chlamydia Trachomatis

Bloods - for HIV + Syphilis +/- Hep B/C

Rectal + Pharyngeal swabs - in MSM

+

Urethral smear - GC/Non-gonococcal urethritis (microscopy)

GC culture plate

Rectal + Pharyngeal swabs + Culture in MSM

Dark ground microscopy (primary syphilis)

Herpes simplex virus PCR

Urinalysis

Question 4

Give 4 risk factors for Candidia Albicans infection

Answer 4

Immunosuppression (HIV, steroids etc…)

Diabetes mellitus

High oestrogen levels (pregnancy, luteal phase, some OCP’s)

Recent antibiotic usage (up to 3 months before)

Mucosal breakdown (sexual contact, dermatitis)

Question 5

What is the treatment for Candida Albicans infection

Answer 5

Clotrimazole 500mg pessary PV

Fluconazole 150mg PO (AVOID IN PREGNANCY + BREASTFEEDING)

Question 6

What is the treatment for recurrent candidiasis

Answer 6

Induction therapy followed by maintenance therapy:
Fluconazole 150mg every 72hours for 3 doses
Then Fluconazole 150mg once weekly for 6 months

Clotrimazole pessaries can be used if Fluconazole is contraindicated

Question 7

What is the triggers for Bacterial vaginosis (Gardnerella Vaginalis)

Answer 7

Sex
Menses
Receptive oral SI
Vaginal douching
Perfumed bath products
Change in sexual partners
Presence of STI

Question 8

What criteria are used for diagnosis of Bacterial Vaginosis?

Answer 8

Hay-Ison criteria
or
Amsel criteria

Question 9

What are the components of the Amsel criteria of Bacteria Vaginosis?

Answer 9

Characteristic discharge
Clue cells on microscopy (wet mount)
Raised pH (>4.5)
Odour with KOH (whiff test)

Question 10

What are the components of the Hay-Ison criteria of Bacterial Vaginosis?

Answer 10

0 = No bacteria
1 = Normal
2 = Reduce lactobacilli + mixed flora (intermediate)
3 = Few/absent lactobacilli + mixed flora; predominant Gardnerella morphotypes
4 = Gram-positive cocci dominate

Question 11

What is the treatment for Bacterial vaginosis?

Answer 11

Treat symptomatic patients only unless pre-surgery or patient requests

Metronidazole 400mg BD for 5 days

Question 12

What are the symptoms of Trichomonas Vaginalis

Answer 12

50% = Frothy vaginal discharge
Dysuria
Vulval soreness / itching
Strawberry cervix

Question 13

What are the complications for Trichomonas Vaginalis?

Answer 13

Pregnancy complications (pre-term, low birth weight)
Enhance HIV transmission

Question 14

How is Trichomonas Vaginalis diagnosed?

Answer 14

Female = Posterior fornix swab (NAAT = 98-100% sensitive)

Male = TV testing should be considered if persistent urethritis with urethral culture or culture first void urine

Question 15

What is the treatment for Trichomonas Vaginalis?

Answer 15

Metronidazole 400mg PO BD for 5-7 days

Treat male partners empirically

Question 16

What is non-specific urethritis?

Answer 16

Inflammation of the urethra in the absence of a diagnosis of Chlamydia or Gonorrhoea

(same as non-gonococcal urethritis?)

Question 17

What symptoms are experienced with non-specific urethritis?

Answer 17

Urethral discharge,
Dysuria,
Penile irritation

Question 18

How is non-specific urethritis diagnosed?

Answer 18

> =5 polymorphonuclear leucocytes per high power field

Question 19

What is the management for non-specific urethritis?

Answer 19

Send STI screening
1/52 of Doxycycline 100mg PO BD
Abstain during treatment and treat partners

Question 20

What are the causative organisms for non-specific urethritis (non-gonococcal urethritis)?

Answer 20

Chlamydia trachomatis (11-50%)
Mycoplasma genitalium (6-50%)
Ureaplasmas (11-26%)
Trichomonas vaginalis (1-20%)
Adenovirus (2-4%)
Herpes simplex virus (2-3%)

Question 21

What are the complications of Chlamydia Trachomatis infections? (give 3)

Answer 21

Pelvic inflammatory disease

Epididymo-orchitis (for men)

Seronegative autoimmune reactive arthritis

Tubal factor infertility

Increased risk of ectopic pregnancies

Question 22

What is the treatment for Chlamydia Trachomatis

Answer 22

1st line = Doxycycline 100mg BD for 7 days

2nd line = Azithromycin 1g PO stat followed by 500mg PO OD for 2 days

Note complicated infections (Eg PID) require longer treatment

Question 23

What is the presentation for Chlamydia Trachomatis in women?

Answer 23

Lower abdominal pain // PID
Dysuria
Post-coital bleeding + IMB
Vaginal discharge

Question 24

What is the presentation for Chlamydia Trachomatis infections in men?

Answer 24

Discharge (often clear)
Dysuria
Testicular pain (epididymitis)

Question 25

What is the gram stain appearance of Neisseria Gonorrhoea

Answer 25

Gram negative diplococci

Question 26

What are the investigations for Neisseria Gonorrhea in women?

Answer 26

Vulvovaginal NAAT testing

Endocervical charcoal swab for culture - always required prior to any treatment to check antibiotic sensitivities

Question 27

What is the treatment for Gonorrhoea trachomatis?

Answer 27

Ceftriaxone 1g STAT IM single dose
(if sensitivities known consider Ciprofloxacin 500mg PO stat - to reduce ceftriaxone resistance)

No sexual intercourse until 1 week post treatment + until sexual partner also received treatment

Question 28

What is the treatment for Mycoplasma Genitalium infections?

Answer 28

1/52 Doxycycline followed by 3/7 Azithromycin

May fail if previous exposure + resistance&raquo_space; develops resistance to macrolides (eg Azithromycin, Clarithromycin) easily