Women's Health: urogenital conditions

Question 1

What is cystitis

Answer 1

Umbrella term encompassing lower urinary tract inflammation (abacterial cystitis) and infection (bacterial cystitis) affecting the bladder and sometimes the urethra.

Cystitis will often resolve spontaneously. Bacterial cystitis is considered an uncomplicated UTI; however it may progress to an upper UTI or pyelonephritis (kidney infection)

Question 2

Cystitis Symptoms

Answer 2

• Frequency
  
  • Urgency
  • Dysuria
  • Strangury
  • Haematuria
  • Suprapubic pain or discomfort
    Change in the appearance and/or smell of urine

Question 3

Acute pyelonephritis symptoms

Answer 3

• Fever
  
  • Rigors
  • Loin pain
  • Dysuria
    Nausea and vomiting

Question 4

Cystitis triggering factors

Answer 4

• Dehydration
  
  • Perfumed toiletries
  • Spicy foods
  • Sexual intercourse
  • Synthetic underwear
  • Smoking
    Stress

Question 5

cystitis risk factors

Answer 5

• Recent/frequent sexual activity
  
  • History of cystitis
  • Maternal history of cystitis
  • Diabetes
  • Postmenopausal
    Pregnancy

Question 6

cystitis referral

Answer 6

• Under 16 yrs
  
  • Males
  • Frequent episodes either due to relapse or recurrence or women with known functional or anatomical abnormalities
  • Flank pain
  • Fever
  • Nausea and vomiting
  • Pregnant women
  • Diabetes
  • 70 +
  • Immunocompromised
  • Haematuria
  • Associated vaginal discharge
  • Medicine induced
  • Symptoms of STI
    Duration longer than 5-7 days

Question 7

cystitis treatment

Answer 7

Alkalizing agents e.g. sodium citrate or potassium citrate
Infection makes the urine more acidic and these products try and counteract the effect.
Little evidence for these products
Cautioned in renal impairment, diabetes, heart disease, hypertension, low salt diet, pregnancy and lactation

Cranberry
Lack of evidence
Interaction with warfarin

Probiotics
lack of evidence

Acute uncomplicated lower UTIs can be self limiting and delay of antibiotic treatment with provision of a back up prescription may lead to symptom resolution without antibiotic treatment. This can be used if symptoms do not improve within 48 hrs or if they worsen at any time. In practice, if patient has 3 symptoms GP will prescribe empiric therapy

Question 8

Treatment of lower UTI in non pregnant women under 65 yrs

Answer 8

Often resolves after a couple of days

1st choice
Nitro 100mg m/r bd for 3 days
Or if resistant trimethoprim 200mg bd for 3 days

If both unsuitable

Pivmecilllinam 400mg stat then 200mg tds for 3 days
(contraindicated in penicillin allergy)

Question 9

UTI practical advice

Answer 9

• Drinking increased quantities of water
  
  • Use of OTC preparations and analgesics, such as paracetamol and aspirin
  • Avoiding feminine hygiene sprays and deodrants, which may irritate the urethra
  • Avoiding delaying micturition
  • Treating constipation promptly as can increase the risk of UTIs
  • Avoiding tea, coffee and other drinks that appear to precipitate an attack
  • Avoiding tight fitting clothes and synthetic hoisery or underwear
  • Avoiding the use of perfumed soaps, shower gels and bubble baths
  • Washing after sexual intercourse
  • Emptying the bladder after sexual intercourse
  • Cessation of using a diaphragm for contraception as this can press on the bladder, thus preventing it from emptying completely on urination and increasing the risk of UTI s
    Using condoms without spermicidal lubricant thus reducing the risk of irritation and UTI

Question 10

UTI cautions

Answer 10

• Pregnancy
  
  • Common in pregnancy
  • Nitrofurantoin should be avoided close to term
  • Trimethoprim should be avoided in first trimester
  • Diabetes
  • More common as sugar in the urine provides an ideal environment for bacterial growth
  • At risk of renal complications- refer
  • Post menopause
  • Particularly prone to cystitis
    If frequent may benefit from vaginal oestrogen- refer to GP

Question 11

Physiological discharge

Answer 11

Normally white in appearance but oxidises in contact with air to become more yellow. Consists of epithelial cells from the vagina and cervix and the mucus arises mainly from the cervical glands, bacteria and fluid. The amount of discharge varies with the individual woman and changes throughout the menstrual period. It is also altered when using an IUD or hormonal contraception. Pregnant women show an increase in mucus production due to an increased vascularity of tissues. Normal discharge is non irritant and does not have strong odour

Question 12

Bacterial vaginosis symptoms

Answer 12

• Fishy odour, which may be worse following sexual intercourse
  
  • Thin, white discharge
  • Not associated with soreness, itching or irritation
    pH >4.5

Question 13

BV risk factors

Answer 13

• Multiple sexual partners
  
  • Early age of first sexual intercourse
  • Presence of an STI
  • Vaginal douching
  • Use of an IUD
  • Smoking
    “sexually associated” not transmitted

Question 14

BV treatment

Answer 14

Oral metronidazole 400mg bd for 5-7 days
Maybe relapsing and remitting
Balance activ Rx (lactic acid and glycogen) may be used prophylactically

Question 15

chlamydia symptoms

Answer 15

• Purulent vaginal discharge
  
  • Mucopurulent cervical discharge
  • Intermenstrual bleeding
  • Postcoital bleeding
  • Dysuria
  • Lower abdominal pain and tenderness in the pelvic region
    Deep dyspareunia

Question 16

chlamydia transmission

Answer 16

Sexual contact

Question 17

chlamydia treatment

Answer 17

Antibiotics
Doxycycline 100mg BD for 7 days

Question 18

Trichomoniasis symptoms

Answer 18

• Vaginal or urethral discharge
  
  • Discharge varies from thin and scanty to frothy purulent and yellow in colour
  • Offensive odour
  • Vulval and vaginal soreness/irritation and itching
  • Inflamed cervix, which may be coloured red “strawberry cervix”
  • Dysuria
  • Lower abdominal pain
  • pH >4.5
    Up to 50% can be asymptomatic

Question 19

Trichomoniasis treatment

Answer 19

Oral metronidazole
Sexual partners should be treated aswell and screened for other STIs

Question 20

Gonorrhea symptoms

Answer 20

Similar to those of chlamydia, except the vaginal or urethral discharge when present is thick and green or yellow in colour
* Pelvic or lower abdominal pain
* Dysuria, if urethra infected
Intermenstrual bleeding or heavy bleeding

Question 21

Gonorrhoea treatment

Answer 21

Referred to gum clinic
* Ciprofloxacin 500mg orally as a single dose
Ciprofloxacin contraindicated in pregnancy
Ceftriaxone 1g IM injection is recommended as a single dose first line

Question 22

Thrush

Answer 22

Thrush occurs frequently during fertile years. Much less common in prepubertal girls and postmenopausal women
Candida albicans is responsible for between 80-90% of cases. Fungus is opportunistic and carried in the bowel, under the nails, on the skin and in the vagina. Does not result in complications but can be irritating and cause considerable distress. It grows under favourable conditions to produce symptoms
Common in pregnancy. Condition improves following delivery of the baby

Question 23

Thrush symptoms

Answer 23

• Itching and soreness of the vulva and vagina
  
  • Dysuria and dyspareunia
  • Curdy, white discharge
  • Usually odourless but may be “yeasty”
  • Vagina and vulva may be inflamed
    pH <4.5

Question 24

thrush risk factors- antibiotics

Answer 24

• Occurs in around 30% of women taking a course of antibiotics
  
  • Broad spectrum antibiotics in particular may cause an attack of thrush due to a reduction in the normal commensal flora enabling candida to multiply
  • Only women who are already colonized with candida are at risk of vulvo vaginal candidiasis following treatment with antibiotics
    Occurs more frequently when either higher doses of antibiotics have been taken or the patient has had a repeated course

Question 25

thrush risk factors- contraceptives

Answer 25

* Contraceptives, especially COC increase the risk of VVC Results from studies have been inconsistent, therefore definitive conclusions cannot be made

Question 26

thrush risk factors- diabetes

Answer 26

* Poorly controlled diabetes predisposes a woman to symptomatic VVC and warrants reassessment of her condition. * Higher blood glucose levels may favour the growth of candida Thrush occurring in post menopausal women should be checked out as it may be the first indication of diabetes

Question 27

thrush risk factors- sexual behaviour

Answer 27

* Incidence of VCC increases during the years of sexual activity * Does not appear to be any benefit in treating asymptomatic sexual partners * Sexual partner may be the source of infection and re infection and in certain cases treatment of a male partner is advocated Women receiving oral sex may be at greater risk of VVC

Question 28

thrush risk factors- immunosuppression

Answer 28

* The use of oral steroids and other immunosuppressive agents lower the body's immune system, permitting candida overgrowth VCC is more common in women with HIV and AIDS, with the risk increasing as time since diagnosis increases

Question 29

thrush risk factors- pregnancy

Answer 29

* Occurs in around 30-40% of pregnant patients * Thought that the high concentrations of reproductive hormones in pregnancy increase the glycogen content in the vaginal tissue and provide a carbon source for candida Oestrogen enhances the adherence of candida to vaginal epithelial cells

Question 30

thrush risk factors- tamoxifen

Answer 30

Women on long term treatment with tamoxifen have been shown to present with recurrent VVC

Question 31

thrush risk factors- topical vaginal preparations

Answer 31

* Suggested that using highly perfumed vaginal preparations may cause irritation or allergy and may potentially predispose towards infection with candida. NICE has found no evidence of local irritants such as soaps and shower gels increasing the risk of VVC

Question 32

thrush treatment

Answer 32

* Imidazoles intravaginally- clotrimazole, econazole or miconazole * Triazoles orally- fluconazole or itraconazole * topical imidazoles are most commonly used in the treatment of acute VVC. To be effective, intravaginal application is required, although women should apply cream to the vulva aswell since this area is commonly affected * A single high dose is as effective as a lower dose over several days * Topical preparations may damage condoms * Oral triazoles are contraindicated in pregnancy and breastfeeding

Question 33

thrush referral

Answer 33

* More than 2 previous attacks of candidiasis in the last 6 months * STI risk * Pregnancy/suspected pregnancy * Aged under 16 or over 60 * Diabetes * Immunocompromised * Abnormal or irregular vaginal bleeding * Vulval/vaginal sores, ulcers or blisters * Lower abdominal pain or dysuria * No improvement in 7 days, despite treatment Adverse effects from the treatment

Question 34

HPV

Answer 34

* HPV infection is very common, it lives on the skin in and around the whole genital area, so the use of condoms cant provide complete protection from it * Doesnt cause symptoms in many people * Can cause painless growths or lumps around the vagina, penis or anus * Gardasil vaccine available- given to both boys and girls aged 12-13 years

Question 35

abnormal discharge practical advice

Answer 35

Dos * Use water and emollient to wash the affected area * Dry properly after washing * Wear cotton underwear * Avoid sex until thrush cleared if uncomfortable Don’t * Do not use soap or shower gels * Do not use douches or deodrants on your vagina or penis Do not wear tight underwear or tight fitting clothes