Gum

Question 1

What is the most common cause of pathological vaginal discharge in women of reproductive age?

Answer 1

Bacterial vaginosis
Polymicrobial disorder of vaginal flora. Reduced vaginal lactobacilli, more alkaline secretions.
May be symptomatic or asymptomatic.

Question 2

Risk factors for BV

Answer 2

Vaginal douching, receptive cunnilingus, recent change in sexual partner, smoker, prevalence of UTI, ?IUD use.

Symptoms may be eacerbated by sexual activity and assocaited with increased transmission of STIs especialyl HIV and chlamydia.

Question 3

Presentation of BV

Answer 3

milky homogenous vaginal discharge typically smells of fish

Question 4

Complications of BV

Answer 4

PID, post op infection, adverse pregnancy outcomes

Question 5

Diagnosing BV

Answer 5

It is polymicrobial disorder of vaginal flora, so not so easy to test for.

Can do clinical diagnosis by treating empirically based on clinical picture of malodourous discharge in absence of inflammatory symptoms and examination.

Confirmation requires lab testing of secretions, using Amsels criteria or Hay/Ison criteria.

If recurrent, refer to GUM for confirmation of diagnosis

Question 6

Management of BV

Answer 6

Offer treatment to symptomatic women, if undergoing surgical procedure or some pregnant women.

First line metronidazole 400mg BD for 7d, or 2g oral stat dose. Or intravaginal metronidazole 0.75% gel OD for 5d, or intravaginal clindamycin cream OD for 7d.

Alternative or oral tinadazole stat or oral clindamycin 7d.

Topical agents may impact efficacy of condoms.

Question 7

Non pharma advice to give for those with BV

Answer 7

Consider STI screen and pregnancy test. Avoid vaginal douching, no shower gels, avoid shampoos in the bath.

CHC and condom use may protect against BV (lactobacilli favour oesotrgenised environment).

Question 8

Mx of BV in pregnancy and breastfeeding

Answer 8

Pregnancy first line metronidazole oral 400mg BD for 7 days (as normal). Dont use stat 2g metro.
Given potential pregnancy consequences, consider treating asymptomatic pregnant women with BV.

Use intravaginal preparations if breastfeeding.

Question 9

What is the most common STI in the UK

Answer 9

Chlamydia (50% all STIs)
Gonorrhoea is the second most common.

Question 10

What is the chlamydia screening programme?

Answer 10

We should proactively offer a chlamydia tet to all sexually active women aged less than 25YO annually and also following a change of partner.

Question 11

Risk factors for chlamydia infection

Answer 11

<25YO, new sexual partner, more than 1 sexual partner last yr, lack of condoms.

High transmission rates, 75% of partners tested also had chlamydia.

Question 12

Where does chlamydia affect

Answer 12

Usually endocervix and urethra. Can also affect conjuctiva, rectum and pharynx.

Question 13

Symptoms and signs of chlamydia

Answer 13

Vaginal discharge, post coital or intermenstrual bleeding, dysuria, lower abdo or pelvic pain, dyspareunia, cervicitis, pelvic or cervical motion tenderness, anal discomfort/discharge.

But is asymptomatic in 70% women so infection may go on for years. Infection may resolve spontaneously.

In men, chlamydia usually presents with urethral discharge and dysuria.

Rarely conjuctivitis - unilateral chronic low grade irritation.

Question 14

What is opthalmia neonatorum

Answer 14

This is neonatal chlamydia infection - consider in baby who develops conjuctivitis in first 30 days of birth. Direct innoculation through mothers genital tract.

Question 15

What is lymphogranuloma venereum

Answer 15

Rare infection caused by specific serotype of chlmaydia trachomatis. Mainly in MSM. Most HIV positive. Symptoms of tenesmus, bloody anal discharge, pain, diarrhoae, CIBH. Or may be asymp.

Question 16

Complications of chlamydia infection

Answer 16

PID (16% those with untreated chlamydia), endometritis, salpingitis, tubal infertility, ectopic pregnancy, sexually acquired reactive arthritis, perihepatitis, chronic pelvic pain, epididymo-orchitis.

BASHH states early diagnosis and treatment of chlamydia is paramount to prevent subsequent infertility.

Question 17

Diagnosis of chlamydia

Answer 17

Positive NAAT needed - needs to be 2 weeks since sexual exposure.

Women - vulvovaginal swab (may be self taken). Urine testing is not as good.

Men - first catch urine. urethral swab alternative but uncomfortable.

Question 18

Management of chlamydia infection

Answer 18

First line for men and non pregnant women
- doxycycline 100mg BD for 7 days.
Second line - azithromycin 1g orally stat then 500mg daily for 2d (if allergic to doxy). Or erythro or ofloxicin.

First line pregnant women - azithromycin 1g orally stat then 500mg daily for 2d. Alternatives erythromycin or amoxicillin.

Recommend full STI screen to those diagnosed
Do not remove IUD in uncomplicated chlamydia infection.

Question 19

When to do test of cure for chlamydia

Answer 19

If women is pregnant, or poor compliance suspected, or symptoms persist. Test 3 weeks after completion of treatment as NAAT can remain positive for up to 3 weeks.

If not meeting these criteria, don’t routinely test for cure.

Less than 25 year olds should be offered repeated test at 3 months after treatment as they are at highest risk of reinfection.

Question 20

Partner notification after chlamydia diagnosis

Answer 20

Partners should be offered treatment.
Advised no sex for 7 days.
Contact trace all sexual partners over the last 6 months.

Question 21

Who is at high risk for gonorrhoea infection

Answer 21

Young people 15-24YO, MSM, black people, most deprived.
Increasingly reduced susceptibility to first line antibiotiocs.

Question 22

When to test for gonorrhoea

Answer 22

If patient has symptoms, has a positive sexual contact, or has high risk sexual history.

NO routine screening for gonorrhoea (unless in very high prevalence setting eg attendees at sexual health clinics).

Routine screening not offered in pregnancy

Question 23

Symptoms of gonorrhoea

Answer 23

In Men - urethral discharge >90%, dysuria, less commonly testicular pain.

In women - Abnormal vaginal discharge, low abdo pain in 50%, dysuria, rarely IMB or HMB. 50% asymptomatic.

Rectal infection may present with anal discharge or pain. Pharnygeal infection may present with sore throat.

Question 24

Complications of gonorrhoea infection

Answer 24

Rare but serious
PID (up to 14% women with gonorrheoa).
Epididymo-orchitis
Prostatitis
Abscesses
Arthritis or tenosynovitis
Disseminated spread
Neonatal infection
Current infection with gonorrhoea increases risk of catching HIV by 2.5%

Question 25

Diagnosis of gonorrhoea

Answer 25

Gonorrhoea is gram negative diplococcus NAAT testing (re test if contact within last 14 days) - Women - Vulvovaginal swab - Men - first pass urine or swab urethra ok. Swab pharynx and rectum if indicated. If positive result, then microscopy and bacterial culture and senstiivities BEFORE treatment. - In men - microscopy 90% sensitive if urethral discharge present. - In women, endocervical swab and urethral swab too for max sensitivity.

Question 26

Management of gonorrhoea

Answer 26

Ideally refer to GUM for this. Screen for all other STIs, confirm with C&S, no sex for 7 days after completed treatment. Sexual partner notification. Treatment failures require reporting to UKHSA. Offer review after treatment to ensure resolution of symp. Uncomplicated anogenital or pharyngeal infection = ceftriaxone 1g IM single dose. For anything more complicated need to refer to GUM too.

Question 27

When to do test of cure for gonorrhoea

Answer 27

If pharyngeal infection, pregnancy, antimicrobial sensitivity unknown, non first line antibiotics used, or persistent signs or symptoms.

Question 28

When can you use empirical treatment of sexual contacts

Answer 28

If presenting within 14 days and are one of - pregnant women, limited access to return to FU, or sex workers. For all others, no treatment but test after 2 weeks and treat if positive.

Question 29

Vaccination for gonorrhoea?

Answer 29

No licenced vaccine. But close to meisseria meningitidis so 4CMenB vaccine can be used off licence for at risk groups. - GBMSM with history of bacterial STI in last 12m. - GBMSM with more than 5 sexual partners last 3m. - sex workers. - two doses given 4 weeks apart. - Can be given at same time as gonorrhoea treatment.

Question 30

What is the treatment of candida infection

Answer 30

Azole antifungals.

Question 31

Most common infections leading to PID

Answer 31

Chlamydia and gonorrhoea.

Question 32

Over what prevelence is HIV said to be high or very high

Answer 32

More than 2 in 1000 high More than 5 in 1000 very high

Question 33

Which organisms can cause pelvic inflammatory disease

Answer 33

Chlamydia, gonorrhoea, mycoplasma.

Question 34

what is the most common presentation of pelvic inflammatory disease

Answer 34

recent onset bilateral abdominal pain and localised tenderness on bimanual examination (especially under 25YO). - Think PID - Exclude pregnancy - Offer empirical treatment. - Do swabs but negative swabs do not rule out PID. Full STI screen.

Question 35

First line treatment for pelvic inflammatory disease

Answer 35

IV ceftriaxone 1g stat AND doxycycline 100mg BD oral for 14d AND metronidazole 400mg BD oral for 14 days. (the ceftriaxone is the treatment for gonorrheoa, doxy is the treatment for chlamydia, metronidazole covers other anaerobes). If mycoplasma genitalium positive PID, treat with moxifloxacin 400mg BD for 14d.

Question 36

What is mycoplasma genitalium

Answer 36

Newly identified organism responsible for significant number of STIs in men and women. Mostly asymptomatic but can cause urethritis, cervicitis, PID, and potentially proctitis. Diagnosis from NAAT (first void urine in men, vaginal swab women) but test might not be available. Therefore, need to refer to GUM for testing (this is everyone with urethritis, everyone with symptoms/signs PID, those with cervicitis, PCB, epididymo-orchitis or proctitis if other infections have been ruled out and index of suspicion is high.

Question 37

First line mx for mycoplasma genitalium

Answer 37

Sig macrolide resistance. All positive tests should have macrolide sensitivity. First line mx doxycycline plus azithromycin, moxifloxacin for complicated infections. (remember that mycoplasma have no cell wall so penicillin will not be helpful). test current sexual partners and treat if positive.