Repro 4

Question 1

Outline the types, diagnosis, treatment, screening and vaccines when discussing the Human Papilloma viruses (HPV)

Answer 1

Types

• HPV 6&11
  
  • benign & painless - outgrowths on the penis, vagina, perianal skin
  • cause anogenital warts
• HPV 16&18
  
  • high risk - implicated in >70% of cervical cancer
    - can cause anogenital Cancer
    - cervical cancer is most common cancer 15-34 age range

Diagnosis
- biopsy, hybrid capture and genome analysis

Treatment

• can be None - 70% resolve in 1year with 90% in 2 years
• topical podophyllin, imiquimod, surgery

Screening

• cervical papsmear - identifies precancerous cells - NOT cancer
• colposcopy, cervical swab.

Vaccines

• gardasil - protection vs HPV 6,11,16&18
• Cervarix - protection vs 16&18

Question 2

Describe the Herpes Simplex Virus (HSV), diagnosis and treatment

Answer 2

PC: extensive, painful genital ulceration +/- dysuria (painful urination)
- can present with painful inguinal lymphadenopathy

Types

• HSV1 - cold sores
• HSV2- genital herpes

Recurrent infections are possible as the virus can remain latent in the dorsal root ganglion

Diagnosis
- take a swab of the lesions/ulcers/blisters and do PCR

Treatment

• aciclovir in first episode or severe disease
  - also given prophylactically in recurrent episodes
• barrier contraception is a must

Question 3

Describe the specimen collection from males, females and neonates in regards to Chlamydia trochamatis

Answer 3

Males

• urethral swab
• first catch urine

Females
- endocervical swab (not too acceptable by the patient)

Neonates
- eye swab - invert eyelid and take swab

Question 4

Why is Chlamydia trochamatis harder to diagnose than other STIs ?

Answer 4

It is an obligate intracellular bacteria and it doesn’t grow in labs as well. Therefore it is harder to diagnose.

Question 5

What is peri-hepatitis? Name two infections that can cause peri-hepatitis. Name one presenting symptom of peri-hepatitis

Answer 5

This is the inflammation of the liver capsule.
Chlamydia trochamatis and neisseria gonorrhoea can cause this.
Often presents with shoulder tip pain, referred pain.

Question 6

Describe the infection of Chlamydia trochamatis is females and neonates.

Answer 6

Females

• infection of the epithelium of the urethra or cervix
• often can be asymptomatic
• ascending infection involving the urinary genital tract can present as salpingitis or endometritis but is often PID
• most common PID agent and routinely causes infertility or ectopic pregnancy due to the tubule damage.

Neonates

• can lead to neonatal conjunctivitis
• presents as conjunctivitis but it is a systemic infection not local
• can cause neonatal pneumonia if untreated or only treated locally

Question 7

Describe Chlamydia trochamatis infection in men

Answer 7

Presents as urethritis, prostatitis, epididymitis.

Question 8

What triad of symptoms constitutes ‘acute epididymitis’

Answer 8

Arthritis, urethritis and conjunctivitis.

Question 9

Outline the diagnosis of Chlamydia trochamatis

Answer 9

• tissue culture but it is expensive as this is an obligate intrwllular bacteria and doesn’t grow easily in labs.
• Nucleic Acid Amplification Test (NAATs)
  
  • high sensitivity
  • can dual test with Neisseria gonorrhoea.

Question 10

Outline the treatment, and reason for dual treatment, of neisseria gonorrhoea

Answer 10

IM ceftriaxone with azithromycin

- azithromycin given to prevent the emergence of resistance to the cephs.

Question 11

Outline the diagnosis of neisseria gonorrhoea infection

Answer 11

females
- endocervical, urethral and pharyngeal

Males
- urethral and laryngeal swabs

NAAT testing dual with chlamydia.

Question 12

Outline the problems neisseria gonorrhoea infection can cause in males and females

Answer 12

Men
- gonacoccal urethritis.

Female

• acute cervicitis
• PID - tubo-ovarian abscess
• Bartholin gland abscess - glands located near the base of vagina
  
  • can grow into the size of an egg.

Question 13

What type of bacteria is neisseria gonorrhoea and how is it grown?

Answer 13

Gram negative diplococci

Grown on enriched agar, such as chocolate agar.

Question 14

How is BV diagnosed and treated?

Answer 14

Vaginal pH > 5
KOH whiff test

Treated with metronidazole.

Question 15

Describe the abnormality in vulvovaginal candidiasis

Answer 15

• infection via Candida albicans, which is part of normal flora.
• can occur in diabetes, treatment with other Abx, obesity, steroids,OC
• profuse white, itchy, curd like discharge
• treated with topical or oral Azoles or nystatin.

Question 16

Which are the ‘at risk’ groups of getting STIs ?

Answer 16

• Young people
• lower socioeconomic groups
• ethnic groups
• specific sexual behaviours
  
  • age of first intercourse
  • number of sexual partners
  • sexual orientation
    
    • especially homosexuals

Question 17

What is pelvic inflammatory disease?

Answer 17

The result of ascending inflammation from the endocervix, which can cause salpingitis, oophoritis, tubule-ovarian abscess, endometritis, parametritis and/or pelvic peritonitis.

Question 18

How does inflammation occur, in regards to PID? How are adhesions formed?

Answer 18

Inflammation occurs as a result of infection.

Adhesions occur when the tubular epithelium gets damaged, forming adhesions.

Question 19

Define the following:

1. Endometritis
2. Salpingitis
3. Tubo-ovarian abscess

Answer 19

1. Inflammation of the endometrium - the lining of the uterus
2. Inflammation of the Fallopian tubes
3. A pocket of pus that forms during an infection of Fallopian tubes and ovaries.

Question 20

What are the complications of PID?

Answer 20

Fitz-Hugh-Curtis Syndrome
    - RUQ pain and Peri hepatitis - chlamydia infections
Ectopic pregnancy
Infertility
Chronic pelvic pain

Question 21

What are the two most common causative agents of PID? Besides these, name some others.

Answer 21

• Chlamydia and gonorrhoea
  
  • most common
  • get get dual testing kits
• others include:
  
  • gardenerella vaginalis
  • anaerobes
  • mycoplasma

Question 22

Name some risk factors for PID

Answer 22

• sexual partners and behaviour
• IUCD
  
  • increases risk in first week, but then eventually settles down
• OCP is considered protective against symptomatic PID
• alcohol, drug and cigarette use.
• similar to STIs
  
  • low socioeconomic class
  • age of first sexual intercourse
  • lack of barrier contraception

Question 23

Pain is a clinical feature of PID. Explain this in slightly more depth.

Answer 23

• bilateral lower abdo pain
• Adnexal tenderness
  
  • Adnexal structures are those that are accessory
    
    • eg Fallopian tubes, ligaments and ovaries
• deep dyspareunia
  
  • pain after coitus
• cervical excitation

Question 24

Besides pain, what other 3 symptoms would you expect in a woman who you suspect is suffering from PID?

Answer 24

• pyrexia
• abnormal vaginal bleeding
• abnormal vaginal discharges or cervical discharge.

Question 25

What is cervical excitation?

Answer 25

Pain on moving the uterus around

Question 26

Chandeliers sign is the colloquial name for which symptom of PID?

Answer 26

Cervical excitation.

Question 27

What are investigations you would like to conduct in a case of suspected PID

Answer 27

- pregnancy test - rule this out asap - blood test - WBC / CrP - endocervical and high vaginal swabs - presence of NG or CT supports the PID diagnosis - absence of NG or CT does not exclude diagnosis of PID

Question 28

What is the treatment regimen for an inpatient PID patient?

Answer 28

IV ceftriaxone 500mg stat IV/PO doxycycline 100mg BD IV metronidazole 400mg BD

Question 29

What is the treatment for PID for an outpatient

Answer 29

IV ceftriaxone 500mg stat | PO Doxy 100mg BD + PO metronidazole 400mg BD.

Question 30

In what situation would a laparoscopy or laparotomy be indicated?

Answer 30

Presence of tubo-ovarian abscess No luck with pharmacological treatment Clinically severe disease.

Question 31

Why is contact tracing vital?

Answer 31

To treat sexual partners.