Zero To Finals - GU

Question 1

Causes of abnormal vaginal discharge

Answer 1

⚫ Vulvovaginal candidadis (thrush)
⚫ Chlamydia
⚫ Gonnorhoea
⚫ Trichomonas vaginalis
⚫ Bacterial vaginosis
⚫ Cervical ectropion
⚫ Foreign bodies
⚫ Rectovaginal fistula
Don’t forget physiological and hormonal changes can cause the
vaginal discharge to change, so it may be not normal for the woman
in question, but not necessarily entirely abnormal.

Question 2

Chlamydia trachomatis

Answer 2

Chlamydia trachomatis is a gram-negative bacteria. It is an intracellular organism, meaning it enters and replicates within cells before rupturing the cell and spreading to others. Chlamydia is the most common sexually transmitted infection in the UK and a significant cause of infertility.
Being young, sexually active and having multiple partners increase the risk of catching the infection. A large number of cases are asymptomatic (50% in men and 75% in woman). Asymptomatic patients can still pass the infection on.

Question 3

Presentation of chlamydia

Answer 3

Presentation
The majority of cases of chlamydia in women are asymptomatic. Consider chlamydia in women that are sexually active and present with:
• Abnormal vaginal discharge
• Pelvic pain
• Abnormal vaginal bleeding (intermenstrual or postcoital)
• Painful sex (dyspareunia)
• Painful urination (dysuria)

Consider chlamydia in men that are sexually active and present with:
	○ Urethral discharge or discomfort
	○ Painful urination (dysuria)
	○ Epididymo-orchitis
	○ Reactive arthritis

It is worth considering rectal chlamydia and lymphogranuloma venereum in patients presenting with anorectal symptoms, such as discomfort, discharge, bleeding and change in bowel habits.

Question 4

How is chlamydia diagnosed?

Answer 4

Diagnosis
Nucleic acid amplification tests (NAAT) are used to diagnose chlamydia. This can involve a:
○ Vulvovaginal swab
○ Endocervical swab
○ First-catch urine sample (in women or men)
○ Urethral swab in men
○ Rectal swab (after anal sex)
○ Pharyngeal swab (after oral sex)

Question 5

Management of chlamydia

Answer 5

First-line for uncomplicated chlamydia infection is doxycycline 100mg twice a day for 7 days.

Doxycycline is contraindicated in pregnancy and breastfeeding. Alternatives options listed in the BASHH guidelines (always check guidelines) for treatment in pregnant or breastfeeding women are:
• Azithromycin 1g stat then 500mg once a day for 2 days
• Erythromycin 500mg four times daily for 7 days
• Erythromycin 500mg twice daily for 14 days
• Amoxicillin 500mg three times daily for 7 days

A test of cure is not routinely recommended. However, a test of cure should be used for rectal cases of chlamydia, in pregnancy and where symptoms persist.

Other factors to consider are:
	○ Abstain from sex for seven days of treatment of all partners to reduce the risk of re-infection
	○ Refer all patients to genitourinary medicine (GUM) for contact tracing and notification of sexual partners
	○ Test for and treat any other sexually transmitted infections
	○ Provide advice about ways to prevent future infection
	○ Consider safeguarding issues and sexual abuse in children and young people

Question 6

Complications of chlamydia

Answer 6

Complications
There are a large number of complications from infection with chlamydia:
• Pelvic inflammatory disease
• Chronic pelvic pain
• Infertility
• Ectopic pregnancy
• Epididymo-orchitis
• Conjunctivitis
• Lymphogranuloma venereum
• Reactive arthritis

Pregnancy-related complications include:
	○ Preterm delivery
	○ Premature rupture of membranes
	○ Low birth weight
	○ Postpartum endometritis
	○ Neonatal infection (conjunctivitis and pneumonia)

Question 7

Chlamydial Conjunctivitis

Answer 7

Chlamydial Conjunctivitis
Chlamydia can infect the conjunctiva of the eye. Conjunctival infection is usually as a result of sexual activity, when genital fluid comes in contact with the eye, for example, through hand-to-eye spread. It presents with chronic erythema, irritation and discharge lasting more than two weeks. Most cases are unilateral.
Chlamydial conjunctivitis occurs more frequently in young adults. It can also affect neonates with mothers infected with chlamydia. Gonococcal conjunctivitis is a crucial differential diagnosis and should be tested.

Question 8

Gonorrhoea

Answer 8

Neisseria gonorrhoea is a gram-negative diplococcus bacteria. It infects mucous membranes with a columnar epithelium, such as the endocervix in women, urethra, rectum, conjunctiva and pharynx. It spreads via contact with mucous secretions from infected areas.
Gonorrhoea is a sexually transmitted infection. Being young, sexually active and having multiple partners increases the risk of infection with gonorrhoea. Having other sexually transmitted infections, such as chlamydia or HIV, also increases the risk.
There is a high level of antibiotic resistance to gonorrhoea. Traditionally ciprofloxacin or azithromycin was used to treat gonorrhoea. However, there are now high levels of resistance to these antibiotics.

Question 9

Presentation of gonorrhoea

Answer 9

Presentation
Infection with gonorrhoea is more likely to be symptomatic than infection with chlamydia. 90% of men and 50% of women are symptomatic. The presentation will vary depending on the site. Female genital infections can present with:
• Odourless purulent discharge, possibly green or yellow
• Dysuria
• Pelvic pain

Male genital infections can present with:
	○ Odourless purulent discharge, possibly green or yellow
	○ Dysuria
	○ Testicular pain or swelling (epididymo-orchitis)
	 
	Rectal infection may cause anal or rectal discomfort and discharge, but is often asymptomatic. Pharyngeal infection may cause a sore throat, but is often asymptomatic. Prostatitis causes perineal pain, urinary symptoms and prostate tenderness on examination. Conjunctivitis causes erythema and a purulent discharge.

Question 10

How is gonorrhoea diagnosed?

Answer 10

Diagnosis
Nucleic acid amplification testing (NAAT) is used to detect the RNA or DNA of gonorrhoea. Genital infection can be diagnosed with endocervical, vulvovaginal or urethral swabs, or in a first-catch urine sample. Rectal and pharyngeal swab are recommended in all men who have sex with men (MSM), and in those with risk factors (e.g. anal and oral sex) or symptoms of infection in these areas.
A standard charcoal endocervical swab should be taken for microscopy, culture and antibiotic sensitivities before initiating antibiotics. This is particularly important given the high rates of antibiotic resistance.

TOM TIP: It is worth remembering that NAAT tests are used to check if a gonococcal infection is present or not by looking for gonococcal RNA or DNA. They do not provide any information about the specific bacteria and their antibiotic sensitivities and resistance. This is why a standard charcoal swab for microscopy, culture and sensitivities is so essential, to guide the choice of antibiotics to use in treatment.

Question 11

Management for gonorrhoea

Answer 11

Patients should be referred to GUM clinics (or local equivalent) to coordinate testing, treatment and contact tracing. Management depends on whether antibiotic sensitivities are known. For uncomplicated gonococcal infections:
• A single dose of intramuscular ceftriaxone 1g if the sensitivities are NOT known
• A single dose of oral ciprofloxacin 500mg if the sensitivities ARE known
Different regimes are recommended for complicated infections, infections in other sites and pregnant women. Most regimes involve a single dose of intramuscular ceftriaxone.

All patients should have a follow-up “test of cure” given the high antibiotic resistance. This is with NAAT testing if they are asymptomatic, or cultures where they are symptomatic. BASHH recommend a test of cure at least:
	○ 72 hours after treatment for culture
	○ 7 days after treatment for RNA NAAT
	○ 14 days after treatment for DNA NAAT
	 
	Other factors to consider are:
		§ Abstain from sex for seven days of treatment of all partners to reduce the risk of re-infection
		§ Test for and treat any other sexually transmitted infections
		§ Provide advice about ways to prevent future infection
		§ Consider safeguarding issues and sexual abuse in children and young people

Question 12

Presentation of gonorrhoea

Answer 12

Presentation
Infection with gonorrhoea is more likely to be symptomatic than infection with chlamydia. 90% of men and 50% of women are symptomatic. The presentation will vary depending on the site. Female genital infections can present with:
• Odourless purulent discharge, possibly green or yellow
• Dysuria
• Pelvic pain

Male genital infections can present with:
	○ Odourless purulent discharge, possibly green or yellow
	○ Dysuria
	○ Testicular pain or swelling (epididymo-orchitis)
	 
	Rectal infection may cause anal or rectal discomfort and discharge, but is often asymptomatic. Pharyngeal infection may cause a sore throat, but is often asymptomatic. Prostatitis causes perineal pain, urinary symptoms and prostate tenderness on examination. Conjunctivitis causes erythema and a purulent discharge.

Question 13

Complications of gonorrhoea

Answer 13

Complications
• Pelvic inflammatory disease
• Chronic pelvic pain
• Infertility
• Epididymo-orchitis (men)
• Prostatitis (men)
• Conjunctivitis
• Urethral strictures
• Disseminated gonococcal infection
• Skin lesions
• Fitz-Hugh-Curtis syndrome
• Septic arthritis
• Endocarditis

A key complication to remember is gonococcal conjunctivitis in a neonate. Gonococcal infection is contracted from the mother during birth. Neonatal conjunctivitis is called ophthalmia neonatorum. This is a medical emergency and is associated with sepsis, perforation of the eye and blindness.

Question 14

Disseminated Gonococcal Infection

Answer 14

Disseminated Gonococcal Infection
Disseminated gonococcal infection (GDI) is a complication of untreated gonococcal infection, where the bacteria spreads to the skin and joints. It causes:
• Various non-specific skin lesions
• Polyarthralgia (joint aches and pains)
• Migratory polyarthritis (arthritis that moves between joints)
• Tenosynovitis
• Systemic symptoms such as fever and fatigue

Question 15

Trichomonas vaginalis

Answer 15

Trichomonas vaginalis (strawberry cervix) is a type of parasite spread through sexual intercourse. Trichomonas is classed as a protozoan, and is a single-celled organism with flagella. Flagella are appendages stretching from the body, similar to limbs. Trichomonas has four flagella at the front and a single flagellum at the back, giving a characteristic appearance to the organism. The flagella are used for movement, attaching to tissues and causing damage.
Trichomonas is spread through sexual activity and lives in the urethra of men and women and the vagina of women.
Trichomonas can increase the risk of:
• Contracting HIV by damaging the vaginal mucosa
• Bacterial vaginosis
• Cervical cancer
• Pelvic inflammatory disease
• Pregnancy-related complications such as preterm delivery.

Question 16

Presentation of trichomoniasis

Answer 16

Presentation
Up to 50% of cases of trichomoniasis are asymptomatic. When symptoms occur, they are non-specific:
• Vaginal discharge
• Itching
• Dysuria (painful urination)
• Dyspareunia (painful sex)
• Balanitis (inflammation to the glans penis)
The typical description of the vaginal discharge is frothy and yellow-green, although this can vary significantly. It may have a fishy smell.
Examination of the cervix can reveal a characteristic “strawberry cervix” (also called colpitis macularis). A strawberry cervix is caused by inflammation (cervicitis) relating to the trichomonas infection. There are tiny haemorrhages across the surface of the cervix, giving the appearance of a strawberry.
Testing the vaginal pH will reveal a raised ph (above 4.5), similar to bacterial vaginosis.

Question 17

How is trichomonas vaginalis diagnosed?

Answer 17

Diagnosis
The diagnosis can be confirmed with a standard charcoal swab with microscopy (examination under a microscope).
Swabs should be taken from the posterior fornix of the vagina (behind the cervix) in women. A self-taken low vaginal swab may be used as an alternative.
A urethral swab or first-catch urine is used in men.

Question 18

Trichomonas vaginalis management

Answer 18

Management
Patients should be referred to a genitourinary medicine (GUM) specialist service for diagnosis, treatment and contact tracing.
Treatment is with metronidazole.
2g stat dose, or 500mg BD
for seven days
Don’t drink alcohol

Question 19

Bacterial vaginosis

Answer 19

Bacterial vaginosis (BV) refers to an overgrowth of bacteria in the vagina, specifically anaerobic bacteria. It is not a sexually transmitted infection. It is caused by a loss of the lactobacilli “friendly bacteria” in the vagina. Bacterial vaginosis can increase the risk of women developing sexually transmitted infections.
Lactobacilli are the main component of the healthy vaginal bacterial flora. These bacteria produce lactic acid that keeps the vaginal pH low (under 4.5). The acidic environment prevents other bacteria from overgrowing. When there are reduced numbers of lactobacilli in the vagina, the pH rises. This more alkaline environment enables anaerobic bacteria to multiply.
Examples of anaerobic bacteria associated with bacterial vaginosis are:
• Gardnerella vaginalis (most common)
• Mycoplasma hominis
• Prevotella species
It is worth remembering that bacterial vaginosis can occur alongside other infections, including candidiasis, chlamydia and gonorrhoea.

Question 20

Risk factors for BV

Answer 20

Risk Factors
There are a number of factors that increase the risk of developing bacterial vaginosis:
• Multiple sexual partners (although it is not sexually transmitted)
• Excessive vaginal cleaning (douching, use of cleaning products and vaginal washes)
• Recent antibiotics
• Smoking
• Copper coil
Bacterial vaginosis occurs less frequently in women taking the combined pill or using condoms effectively.
TOM TIP: When taking a history from someone with typical symptoms of bacterial vaginosis, the diagnosis can be quite obvious based on the fishy-smelling discharge. The thing that scores you points in your exams and is critical in practice is to assess for causes and give advice. For example, sensitively ask about the use of soaps to clean the vagina and vaginal douching and provide information about how these can increase the risk.

Question 21

Presentation of bacterial vaginosis

Answer 21

Presentation
The standard presenting feature of bacterial vaginosis is a fishy-smelling watery grey or white vaginal discharge. Half of women with BV are asymptomatic.
Itching, irritation and pain are not typically associated with BV and suggest an alternative cause or co-occurring infection.
A speculum examination can be performed to confirm the typical discharge, complete a high vaginal swab and exclude other causes of symptoms. Examination is not always required where the symptoms are typical, and the women is low risk of sexually transmitted infections.

Question 22

Investigations for bacterial vaginosis

Answer 22

Investigations
Vaginal pH can be tested using a swab and pH paper. The normal vaginal pH is 3.5 – 4.5. BV occurs with a pH above 4.5.
A standard charcoal vaginal swab can be taken for microscopy. This can be a high vaginal swab taken during a speculum examination or a self-taken low vaginal swab.
Bacterial vaginosis gives “clue cells” on microscopy. Clue cells are epithelial cells from the cervix that have bacteria stuck inside them, usually Gardnerella vaginalis.

TOM TIP: Remember that clue cells on microscopy mean bacterial vaginosis. This is a common association tested in MCQ exams.

Question 23

Management of BV

Answer 23

Management
Asymptomatic BV does not usually require treatment. Additionally, it may resolve without treatment.
Metronidazole is the antibiotic of choice for treating bacterial vaginosis. Metronidazole specifically targets anaerobic bacteria. This is given orally, or by vaginal gel. Clindamycin is an alternative but less optimal antibiotic choice.

Always assess the risk of additional pelvic infections, with swabs for chlamydia and gonorrhoea where appropriate.
Provide advice and information about measures that can reduce the risk of further episodes of bacterial vaginosis, such as avoiding vaginal irrigation or cleaning with soaps that may disrupt the natural flora.

TOM TIP: Whenever prescribing metronidazole advise patients to avoid alcohol for the duration of treatment. This is a crucial association you should remember, and something examiners will look out for when you are explaining the treatment to a patient. Alcohol and metronidazole can cause a “disulfiram-like reaction”, with nausea and vomiting, flushing and sometimes severe symptoms of shock and angioedema.

Question 24

Complications of BV

Answer 24

Complications
Bacterial vaginosis can increase the risk of catching sexually transmitted infections, including chlamydia, gonorrhoea and HIV.
It is also associated with several complications in pregnant women:
• Miscarriage
• Preterm delivery
• Premature rupture of membranes
• Chorioamnionitis
• Low birth weight
• Postpartum endometritis

Question 25

Vaginal candidiasis

Answer 25

Vaginal candidiasis is commonly referred to as “thrush”. It refers to vaginal infection with a yeast of the Candida family. The most common is Candida albicans.
Candida may colonise the vagina without causing symptoms. It then progresses to infection when the right environment occurs, for example, during pregnancy or after treatment with broad-spectrum antibiotics that alter the vaginal flora.

Question 26

Risk factors for vaginal candidiasis

Answer 26

Risk Factors
• Increased oestrogen (higher in pregnancy, lower pre-puberty and post-menopause)
• Poorly controlled diabetes
• Immunosuppression (e.g. using corticosteroids)
• Broad-spectrum antibiotics

Question 27

Presentation of vaginal candidiasis

Answer 27

Presentation
The symptoms of vaginal candidiasis are:
• Thick, white discharge that does not typically smell
• Vulval and vaginal itching, irritation or discomfort

More severe infection can lead to:
	○ Erythema
	○ Fissures
	○ Oedema
	○ Pain during sex (dyspareunia)
	○ Dysuria
	○ Excoriation

Question 28

Investigations for vaginal candidiasis

Answer 28

Investigations
Often treatment for candidiasis is started empirically, based on the presentation.
Testing the vaginal pH using a swab and pH paper can be helpful in differentiating between bacterial vaginosis and trichomonas (pH > 4.5) and candidiasis (pH < 4.5).
A charcoal swab with microscopy can confirm the diagnosis.

Question 29

Management for vaginal candidiasis

Answer 29

Treatment of candidiasis is with antifungal medications. These can be delivered in several ways:
• Antifungal cream (i.e. clotrimazole) inserted into the vagina with an applicator
• Antifungal pessary (i.e. clotrimazole)
• Oral antifungal tablets (i.e. fluconazole)

Question 30

Mycoplasma genitalium

Answer 30

Mycoplasma genitalium (MG) is a bacteria that causes non-gonococcal urethritis. It is a sexually transmitted infection. There are developing problems with antibiotic resistance, particularly with azithromycin.
Most cases of MG do not cause symptoms. The presentation is very similar to chlamydia, and patients may be infected with both organisms. Urethritis is a key feature.
Mycoplasma genitalium infection may lead to:
• Urethritis
• Epididymitis
• Cervicitis
• Endometritis
• Pelvic inflammatory disease
• Reactive arthritis
• Preterm delivery in pregnancy
• Tubal infertility

Question 31

Management of Mycoplasma Genitalium

Answer 31

Management
The BASHH guidelines (2018) recommend a course of doxycycline followed by azithromycin for uncomplicated genital infections:
• Doxycycline 100mg twice daily for 7 days then;
• Azithromycin 1g stat then 500mg once a day for 2 days (unless it is known to be resistant to macrolides)

Moxifloxacin is used as an alternative or in complicated infections. Azithromycin alone is used in pregnancy and breastfeeding (remember doxycycline is contraindicated).

Question 32

Endometritis

Answer 32

• Endometritis is inflammation of the endometrium

Question 33

Salpingitis

Answer 33

• Salpingitis is inflammation of the fallopian tubes

Question 34

Oophoritis

Answer 34

Oophoritis is inflammation of the ovaries

Question 35

Parametritis

Answer 35

• Parametritis is inflammation of the parametrium, which is the connective tissue around the uterus

Question 36

Peritonitis

Answer 36

• Peritonitis is inflammation of the peritoneal membrane

Question 37

Pelvic inflammatory disease

Answer 37

Pelvic inflammatory disease (PID) is inflammation and infection of the organs of the pelvis, caused by infection spreading up through the cervix. It is a significant cause of tubular infertility and chronic pelvic pain.

Question 38

Causes of pelvic inflammatory disease

Answer 38

Causes
Most cases of pelvic inflammatory disease are caused by one of the sexually transmitted pelvic infections:
• Neisseria gonorrhoeae tends to produce more severe PID
• Chlamydia trachomatis
• Mycoplasma genitalium

Pelvic inflammatory disease can less commonly be caused by non-sexually transmitted infections, such as:
	○ Gardnerella vaginalis (associated with bacterial vaginosis)
	○ Haemophilus influenzae (a bacteria often associated with respiratory infections)
	○ Escherichia coli (an enteric bacteria commonly associated with urinary tract infections)

Question 39

Risk factors for pelvic inflammatory disease

Answer 39

Risk Factors
There risk factors for pelvic inflammatory disease are the same as any other sexually transmitted infection:
• Not using barrier contraception
• Multiple sexual partners
• Younger age
• Existing sexually transmitted infections
• Previous pelvic inflammatory disease
• Intrauterine device (e.g. copper coil)

Question 40

Symptoms and examination findings of pelvic inflammatory disease

Answer 40

Presentation
Women may present with symptoms of:
• Pelvic or lower abdominal pain
• Abnormal vaginal discharge
• Abnormal bleeding (intermenstrual or postcoital)
• Pain during sex (dyspareunia)
• Fever
• Dysuria

Examination findings may reveal:
	○ Pelvic tenderness
	○ Cervical motion tenderness (cervical excitation)
	○ Inflamed cervix (cervicitis)
	○ Purulent discharge
	Patients may have a fever and other signs of sepsis.

Question 41

Investigations for suspected pelvic inflammatory disease

Answer 41

Investigations

Patients with pelvic inflammatory disease should have testing for causative organisms and other sexually transmitted infections:
• NAAT swabs for gonorrhoea and chlamydia
• NAAT swabs for Mycoplasma genitalium if available
• HIV test
• Syphilis test

A high vaginal swab can be used to look for bacterial vaginosis, candidiasis and trichomoniasis.

A microscope can be used to look for pus cells on swabs from the vagina or endocervix. The absence of pus cells is useful for excluding PID.

A pregnancy test should be performed on sexually active women presenting with lower abdominal pain to exclude an ectopic pregnancy.

Inflammatory markers (CRP and ESR) are raised in PID and can help support the diagnosis.

Question 42

Management for pelvic inflammatory disease

Answer 42

Management
Where appropriate patients should be referred to a genitourinary medicine (GUM) specialist service for management and contact tracing. Antibiotics are started empirically, before swab results are obtained, to avoid a delay and complications.

Antibiotics will depend on local and national guidelines. The BASSH guidelines (published 2018, updated 2019) suggest various inpatient and outpatient regimes to cover possible causative organisms. One suggested outpatient regime (listed here to help your understanding and not as a guide to treatment) is:
• A single dose of intramuscular ceftriaxone 1g (to cover gonorrhoea)
• Doxycycline 100mg twice daily for 14 days (to cover chlamydia and Mycoplasma genitalium)
• Metronidazole 400mg twice daily for 14 days (to cover anaerobes such as Gardnerella vaginalis)
Ceftriaxone and doxycycline will cover many other bacteria, including H. influenzae and E. coli.

Question 43

Fitz-Hugh-Curtis Syndrome

Answer 43

Fitz-Hugh-Curtis Syndrome

Fitz-Hugh-Curtis syndrome is a complication of pelvic inflammatory disease. It is caused by inflammation and infection of the liver capsule (Glisson’s capsule), leading to adhesions between the liver and peritoneum. Bacteria may spread from the pelvis via the peritoneal cavity, lymphatic system or blood.
Fitz-Hugh-Curtis syndrome results in right upper quadrant pain that can be referred to the right shoulder tip if there is diaphragmatic irritation. Laparoscopy can be used to visualise and also treat the adhesions by adhesiolysis.

Question 44

Complications of pelvic inflammatory disease

Answer 44

Complications
• Sepsis
• Abscess
• Infertility
• Chronic pelvic pain
• Ectopic pregnancy
• Fitz-Hugh-Curtis syndrome