STI

Question 1

What causes urethritis [6]

Answer 1

Chlamydia Trachomatis = most common
Neisseria gonorrhoea
Trichomoniasis vaginalis
HSV

Mycoplasma genitalium
Ureaplasma

Question 2

What are the symptoms of urethritis [3]

How do you know its not UTI?

Answer 2

Urethral discharge
Dysuria
Meatitis (erythema of urethral meatus)

Don’t get discharge
Discharge can be physiological

Question 3

Chlamydia
Ax 
Incubation period
Symptoms - male [4], female [4]
Incidence of asymptomatics between genders
Signs [3]

Answer 3

Ax: chlamydia trachomatis serovars D to K
Incubation period is 7-14 days
Symptoms:
- Male: asymptomatic 20%, slight penile discharge, dysuria, scrotal pain, proctitis
- Female: asymptomatic 80%, vaginal discharge, dysuria, IMB, PCB
- Conjunctivitis
Signs:
- Mucopurulent vaginal or penile discharge
- Cervicitis
- Cervical bleeding on contact

Question 4

Chlamydia
Investigation: screening [2], diagnostic [3]
Management [2]

Answer 4

Investigations: nucleic acid amplification test of…

• Screening: 1st void urine (M), self-taken vaginal swab (F)
• Diagnosis: cervical (F), urethral (M) or rectal (MSM) swab

Mx: DOXYCYCLINE oral
• Follow-up: test for reinfection at 3-12 months
-

Question 5

Chlamydia
Complication
Female [3]
Male [2]
Both [2]

Answer 5

• F: PID, Fitz Hugh Curtis syndrome, infertility
• M: epididymitis (can cause infertility), prostatitis
• B: reactive arthritis or Reiter’s syndrome

Question 6

Gonorrhoea 
More common in...
Ax 
Incubation period
Symptoms: M [1] F [4]
Asymptomaticity between genders
Signs

Answer 6

Ep: less common than chlamydia, MSM
Ax: Neisseria gonorrhoea (gram negative diplococcus)
Incubation period is 5-6 days on average

Symptoms:
- M: asymptomatic 10%, dysuria 
- F: asymptomatic 50%, dysuria, vaginal discharge, IMB, PCB
Signs:
- Thick yellow profuse discharge

Question 7

Reiter’s syndrome [3]

Answer 7

urethritis/cervicitis, conjunctivitis, arthritis

Question 8

Gonorrhea
Ix [3]
Mx [3]
Complications [3]

Answer 8

NAAT of first void urine (M)
NAAT - exposed site swab (B)
Culture for antibiotic sensitivities

Mx: intramuscular ceftriaxone
Follow-up: test of cure at 2 weeks and test of reinfection at 3 months

Local complications that may develop include urethral strictures, epididymitis and salpingitis (hence may lead to infertility).
Systemic complications (disseminated):
tenosynovitis
migratory polyarthritis
dermatitis (lesions can be maculopapular or vesicular)

Question 9

How is culture for antibiotic sensitivities done in gonorrhea investigation?

Answer 9

Gram stained smear from urethra, vagina or rectum

Question 10

Trichomoniasis
Ep 
Ax
Incubation
Symptoms: M, F [2]
Asymptomaticity between genders
Signs: discharge [5]

Answer 10

Ep: middle aged women
Ax: trichomoniasis vaginalis
Incubation period 5-28d
Symptoms:
- Male: asymptomatic
- Female: asymptomatic 20%, vaginal discharge, vulvitis
Signs:
- Profuse thin, greenish, foul, frothy vaginal discharge

Question 11

Trichomoniasis
Ix [3]
Mx - 2 options
Cx [2]

Answer 11

Ix:

• microscopy of wet preparation of HIGH vaginal swab
• Leishman’s or acridine orange stained specimen of discharge
• culture

Mx:
- Metronidazole 400mg oral BD for 5d or 2g single dose

Cx:
- Miscarriage, preterm labour

Question 12

Syphilis
Ep
Ax, can be transmitted with...
Incubation
Differentials of ulcer presentation [6]

Answer 12

Ep: MSM
Ax: treponema pallidum (anaerobic gram-negative spirochete), can be transmitted with HIV

Incubation period is 9-90
days until chancre appears

Differentials of ulcer presentation:

• Herpes: painful
• Lymphogranuloma venereum: painless pustule > ulcer > painful lymphadenopathy
• Chancroid
• Behcet’s disease
• Carcinoma
• Granuloma inguinale: Klebsiella granulomatis

Question 13

What is chancroid? [3]
What is a chancre? [2]
Stages [5]

Answer 13

Chancroid: Painful genital ulcer, unilateral inguinal LN swelling, Haemophilus ducreyi

Chancre is a painless indurated ulcer seen in primary stage of syphilis

Four stages:

• Primary
• Secondary
• Early latent
• Late latent
• Tertiary

Question 14

Syphilis presentation
Primary
Secondary [7]

Answer 14

• Primary: CHANCRE
• Secondary (6 weeks-6 months following primary infection):
- non-pruritic maculopapular rash of palms and soles
- alopecia
- condylomata lata
- generalised lymphadenopathy
- oral snail track lesions
- systemic symptoms (pyrexia, fatigue, malaise)

Question 15

Syphilis
Early latent [3]
Late latent [3]
Tertiary [3]

Answer 15

• Early latent: asymptomatic infection and positive diagnostic serology within 2 years of infection
• Late latent: asymptomatic infection and positive diagnostic serology after 2 years of infection

Tertiary
o Neurosyphilis: tabes dorsalis, general paresis, stroke
o Cardiovascular syphilis: aortitis, aortic aneurysms
o Gummatous syphilis: granulomas of skin, bone and mucosa

Question 16

Syphilis

Investigation: diagnostic [3], disease activity monitoring

Answer 16

Dx:

• Serology of treponema pallidum
• PCR: ulcer swab
• Dark ground microscopy of ulcer base: motile spring shaped bacteria

Disease activity:
- cardiolipin serology tests (rapid plasma regain (RPR))

Question 17

Describe serology of treponema palladium [3]

Answer 17

IgG/IgM, enzyme immunoassay (EIA)
Tremponaemea hemagglutination test (TPHA)
Particle agglutination test (TPPA)

Question 18

Syphilis Mx
Early [3]
Late [4]
Neurosyphilis [2]

Answer 18

Early mx

• <2y with no neurological involvement:
• Benzathine benzylpenicillin 2.4MU IM once
• OR Doxycycline 100mg oral BD for 2w

Late mx

• > 2y with no neuro involvement
• Benzathine benzylpenicillin 2.4MU IM
• Weekly for 3w
• Doxycycline 100mg oral BD for 28d

• Neurosyphilis:

• IM PROCAINE PENICILLIN 2.4U IM for 14d
• with PROBENECID

Question 19

Syphilis Mx
Pregnant
Adverse reaction to benzathine penicillin + doxy combo

Answer 19

Pregnant:

• one off benzathine penicillin if 1st or 2nd trimester
• 2 doses 1 week apart in third trimester

o Jarisch-Herxheimer reaction: seen after initiating therapy (fever, rash and tachycardia after 1st dose of abx)

Question 20

Syphilis complications [7]

Answer 20

Cx:

• tertiary syphilis
• congenital syphilis (extremely rare; thrombocytopenia
• condylata mata
• haemorrhagic rhinitis
• Hutchison’s incisors
• frontal bossing, saddle nose deformity)
• miscarriage, stillbirth

Question 21

Herpes
Ep gender
Ax
Route of transmission
Incubation
Asymptomaticity
Presentation [6]

Answer 21

Ep: equal
Ax: herpes simplex virus type 1 and type 2
Type 1: oral sex
Type 2: genital skin contact
Incubation: 5d to months

Presentation:

• Asymptomatic 80%
• Recurring monthly, annually
• Burning, itching, tender ulceration
• Tender inguinal lymphadenopathy
• Flu-like sx
• Dysuria
• Neuralgic back pain, legs, pelvis

Question 22

Herpes
Investigation 
Mx of:
1. Primary outbreak - give 3 options
2. Infrequent recurrences [2]
3. Frequent recurrences

Answer 22

Ix: PCR of swab from lesion (although usually clinical dx)

Mx:
• Primary outbreak: ACICLOVIR 200mg 5 times daily or 400mg 3 times daily for 5 days
• Infrequent recurrences:
- LIDOCAINE ointment
- ACICLOVIR 1.2g once daily until symptoms gone after 1-3 days
• Frequent recurrences: ACICLOVIR 400mg twice daily as suppression

Question 23

Anogenital warts or Genital HPV
Ep [2]
Ax [2]
Incubation
Presentation [2]
Ix 
Mx [4]

Answer 23

Ep: >80% of population gets genital HPV at some point but only 20% of them get warts
Ax: HPV types 6 and 11
Incubation period is 2 weeks to 8 months

Sy/Si: lumps, anogenital itching or bleeding (perianal or intraurethral), cauliflower texture
Ix: biopsy if unusual but usually clinical dx
Mx:
- Topical podophyllum or cryotherapy
Multiple, non-keratinised warts are generally best treated with topical agents whereas solitary, keratinised warts respond better to cryotherapy
- IMIQUMOD 2nd line
- diathermy or scissor removal if bulky

Question 24

Pelvic inflammatory disease

Causative organisms [4]

Answer 24

Chlamydia trachomatis*
Neisseria gonorrhoeae
Mycoplasma genitalium
Mycoplasma hominis

Question 25

Pelvic inflammatory disease Investigation [3]

Answer 25

a pregnancy test should be done to exclude an ectopic pregnancy high vaginal swab: these are often negative screen for Chlamydia and Gonorrhoea

Question 26

Management of PID [4]

Answer 26

Have a low threshold for management oral ofloxacin + oral metronidazole OR intramuscular ceftriaxone + oral doxycycline + oral metronidazole ? Remove IUDs

Question 27

Complications PID [3]

Answer 27

perihepatitis (Fitz-Hugh Curtis Syndrome) chronic pelvic pain ectopic pregnancy

Question 28

What is Fitz Hugh Curtis syndrome [3]

Answer 28

- occurs in around 10% of cases - it is characterised by right upper quadrant pain and may be confused with cholecystitis - infertility - the risk may be as high as 10-20% after a single episode