UKMLA: Sexual Health

Bacterial Vaginosis: What is BV?

Not an STI→ due to loss of lactobacilli friendly bacteria in vagina and overgrowth of anaerobic bacteria

Bacterial Vaginosis: Which bacteria is associated with BV?

• Gardnerella vaginalis (most common)

• Mycoplasma hominis

• Prevotella species

Bacterial Vaginosis: What are the risk factors for BV?

• 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

Bacterial Vaginosis: What are the symptoms of BV?

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

Bacterial Vaginosis: What are the 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→ CLUE CELLS VSIBLE = BACTERIAL VAGINOSIS

Bacterial Vaginosis: What is the management?

Metronidazole orally or gel → do not take with alcohol!

(Clindamycin alternatively)

Bacterial Vaginosis: What are the 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

 

Candidiasis: What are the risk factors?

• Increased oestrogen (higher in pregnancy, lower pre-puberty and post-menopause)

• Poorly controlled diabetes

• Immunosuppression (e.g. using corticosteroids)

• Broad-spectrum antibiotics

Candidiasis: What are the symptoms ?

• 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

Candidiasis: What are the investigations?

• Charcoal swab

• Vaginal PH less than 4.5

Candidiasis: What is the management?

Any of the following:

• A single dose of intravaginal clotrimazole cream (5g of 10% cream) at night

• A single dose of clotrimazole pessary (500mg) at night

• Three doses of clotrimazole pessaries (200mg) over three nights

• A single dose of fluconazole (150mg)

Candidiasis: What is the risk of using pessaries and anti-fungals?

Warn women that antifungal creams and pessaries can damage latex condoms and prevent spermicides from working, so alternative contraceptive is required for at least five days after use

Candidiasis: What is canisten duo?

It contains a single fluconazole tablet and clotrimazole cream to use externally for vulval symptoms.

Chlamydia: What is chlamydia?

• Chlamydia trachomatis is a gram-negative bacteria

• Most common STI

• Can cause infertility

• Young and sexually active people are at most risk

• Usually asymptomatic

Which STI’s are tested during an STI screening?

In general, when a patient attends a GUM clinic for STI screening, as a minimum, they are tested for:

• Chlamydia

• Gonorrhoea

• Syphilis (blood test)

• HIV (blood test)

Chlamydia: What are the investigations?

• Charcoal swab

• NAAT swab→ first catch urine

• Rectal and pharyngeal NAAT swab

Chlamydia: What are the symptoms in women?

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)

Chlamydia: What are the symptoms in men?

Consider chlamydia in men that are sexually active and present with:

• Urethral discharge or discomfort

• Painful urination (dysuria)

• Epididymo-orchitis

• Reactive arthritis

Chlamydia: What is the management?

No sex for 7 days plus:

Doxycycline 100mg twice a day, for 7 days

UNLESS PREGNANT OR BREASTFEEDING: 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

Chlamydia: What are the complications in pregnant women?

• Preterm delivery

• Premature rupture of membranes

• Low birth weight

• Postpartum endometritis

• Neonatal infection (conjunctivitis and pneumonia)

Chlamydia: What is Lymphogranuloma Vereum?

A condition affecting the lymphoid tissue around the site of infection with chlamydia. It most commonly occurs in men who have sex with men (MSM).

Chlamydia: What are the stages of Lymphogranuloma Vereum?

1. Painless ulcer on penis, vagina or rectum

2. Lymphadenitis

3. Proctitis of anus→ leads to tenesmus which is the feeling of needing to empty bowels even when done

Chlamydia: What is the management of Lymphaogranuloma Venereum?

Doxycycline 100mg twice daily for 21 days

Chlamydia: What is chlamydial conjuctivitis?

Chronic erythema, irritation and discharge lasting more than two weeks. Most cases are unilateral.

Herpes: What is HSV-1?

• Cold sores

• Contracted initially in childhood (before 5 years old)

• Latent in trigeminal nerve ganglion

Herpes: What are the symptoms of Of genital herpes?

• Painful ulcers or blistering lesions affecting the genital area

• Neuropathic type pain (tingling, burning or shooting)

• Flu-like symptoms (e.g. fatigue and headaches)

• Dysuria (painful urination)

• Inguinal lymphadenopathy

Herpes: What is the investigation?

The diagnosis can be made clinically based on the history and examination findings.

A viral PCR swab from a lesion can confirm the diagnosis and causative organism.

Herpes: What is HSV-2?

• Genital herpes

• Latent in sacral nerve ganglia

Herpes: How is it transmitted?

The herpes simplex virus is spread through direct contact with affected mucous membranes or viral shedding in mucous secretions. The virus can be shed even when no symptoms are present, meaning it can be contracted from asymptomatic individuals

Herpes: How is it managed?

• Aciclovir

• Lidocaine

• Paracetamol

• Loose clothes

Herpes: What are the complications in pregnant women?

Neonatal herpes simplex infection may be contracted during labour and delivery. Neonatal herpes simplex infection has high morbidity and mortality

Herpes: What is the management in pregnant women?

• From 36 weeks→ Aciclovir

• No symptoms→ vaginal delivery

• Symptomatic→ C section

Gonorrhoea: What is gonorrhoea?

• Neisseria gonorrhoea

• Gram negative diplococcus

• STI

Gonorrhoea: What are the symptoms?

• Odourless purulent discharge, possibly green or yellow

• Dysuria

• Pelvic pain/testicular pain (epididymo-orchitis)

Gonorrhoea: What are the signs?

• Rectal infection→ usually asymptomatic

• Pharyngeal infection→ sore throat

• Prostatitis→ perineal pain, tender

• Conjuctivitis→ erythema and purulent discharge

Gonorrhoea: What is the investigation?

• NAAT to test for gonococcal RNA/DNA

• Charcoal endocervical swab to determine which antibiotic to use

Gonorrhoea: What is the management?

• 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

Gonorrhoea: What is the test of cure?

All patients should have a follow-up “test of cure” given the high antibiotic resistance:

• 72 hours after treatment for culture

• 7 days after treatment for RNA NAAT

• 14 days after treatment for DNA NAAT

What is neonatal conjuctivitis?

“Opthalmia neonatorum”→ medical emergency associated with sepsis, perforation of the eye and blindness

Gonorrhoea: What is 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

HIV: What is HIV?

• RNA retrovirus

• HIV-1 most common

• HIV-2 most common in west Africa

• Destroys CD4 T-helper cells

HIV: How is it transmitted?

• Unprotected anal, vaginal or oral sexual activity

• Mother to child at any stage of pregnancy, birth or breastfeeding (called vertical transmission)

• Mucous membrane, blood or open wound exposure to infected blood or bodily fluids

HIV: When does AIDS-defining illness occur?

If CD4 count is less than 200. Examples of AIDS-defining illnesses include:

• Kaposi’s sarcoma

• Pneumocystis jirovecii pneumonia (PCP)

• Cytomegalovirus infection

• Candidiasis (oesophageal or bronchial)

• Lymphomas

• Tuberculosis

HIV: What are the investigations?

Combined antibody and P24 antigen test → 45 day window period for reliability

HIV: What is a normal CD4 count?

500-1200 cells/mm3

HIV: Which drugs are used in triple therapy to manage HIV?

Antiretroviral therapy:

Tenofovir + emtricitabine + bictegravir

HIV: What drug is used as prophylaxis for pneumocystis jirovecci pneumonia In HIV patients?

Co-trimoxazole

HIV: What are the additional steps to manage HIV?

• Avoid live vaccines

• Annual cervical smear tests

HIV: What is PEP?

PEP involves a combination of ART therapy. The current regime is emtricitabine/tenofovir (Truvada) and raltegravir for 28 days.

HIV: What is prep?

Tenofovir + emtricitabine

HIV: How can vertical transmission be prevented during birth?

• Viral load under 50→ vaginal

• Viral load over 50→ pre-labour c section

HIV: What drugs are given to a baby after child-birth induced transmission?

• Viral load under 50→ zidovudine for 2-4 weeks

• Viral load over 50→ zidovudine, lamivudine and nevirapine for 4 weeks

HIV: What is the guidance in testing children of HIV positive parents?

Babies to HIV positive parents are tested twice for HIV:

• HIV viral load test at 3 months. If this is negative, the child has not contracted HIV during birth and will not develop HIV unless they have further exposure.

• HIV antibody test at 24 months. This is to assess whether they have contracted HIV since their 3 month viral load, for example through breast feeding. If the 3 month test is negative and they are not breastfed, this should be negative.

Note that the antibody test can be positive in infants who do not have HIV for up to 18 months of age. This is due to maternal antibodies that have crossed the placenta during pregnancy.

Mycoplasma Genitalium: What is it?

• Non-gonococcal urethritis

• STI

• Urethritis is a key feature

Mycoplasma Genitalium: What is the management?

• Doxycycline 100mg twice daily for 7 days AND

• Azithromycin 1g stat then 500mg once a day for 2 days (unless it is known to be resistant to macrolides)

• Test of cure after treatment

 

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

Which drug can be given to pregnant ± breastfeeding women instead of doxycycline?

Azithromycin

Mycoplasma Genitalium: What is the investigation?

• First urine sample in the morning for men

• Vaginal swabs (can be self-taken) for womeN

Pelvic Inflammatory Disease: What are the complications?

• Tubular infertility

• Chronic pelvic pain

What is salphingits?

Inflammation of ovaries

What is oophoritis?

Inflammation of the ovaries

What is parametris?

Inflammation of parametrium (connective tissue around the uterus)

Pelvic Inflammatory Disease: What are the causes?

• Neisseria gonorrhoeae tends to produce more severe PID

• Chlamydia trachomatis

• Mycoplasma genitalium

• Gardnerella vaginalis

• Haemophilus influenzae

• E. coli

Pelvic Inflammatory Disease: What are the risk factors?

• Not using barrier contraception

• Multiple sexual partners

• Younger age

• Existing sexually transmitted infections

• Previous pelvic inflammatory disease

• Intrauterine device (e.g. copper coil)

Pelvic Inflammatory Disease: What is the presentation?

• Pelvic or lower abdominal pain

• Abnormal vaginal discharge

• Abnormal bleeding (intermenstrual or postcoital)

• Pain during sex (dyspareunia)

• Fever

• Dysuria

Pelvic Inflammatory Disease: What are the investigations?

• 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.

Pelvic Inflammatory Disease: What is the management?

• Contact tracing

• 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)

Pelvic Inflammatory Disease: What are the complications?

• Sepsis

• Abscess

• Infertility

• Chronic pelvic pain

• Ectopic pregnancy

• Fitz-Hugh-Curtis syndrome

Pelvic Inflammatory Disease: What is Fitz-Hugh-Curtis Syndrome?

• Complication of pelvic inflammatory disease

• Causes inflammation and infection of liver = right upper quadrant pain that can refer to right shoulder tip

• Manage via adhesiolysis

Syphillis: What is it?

• Treponema pallium

• Spiral bacteria

• STI

• IV drug user, transfusions, baby, sex

Syphillis: What is primary Syphillis?

Painless chancre ulcer at original site of infection

Syphillis: What is secondary Syphillis?

Systemic symptoms, particularly of the skin and mucous membranes. These symptoms can resolve after 3 – 12 weeks:

• Maculopapular rash

• Condylomata lata (grey wart-like lesions around the genitals and anus)

• Low-grade fever

• Lymphadenopathy

• Alopecia (localised hair loss)

• Oral lesions

Syphillis: What is latent Syphillis?

• Early latent→ within 2 years

• Late latent→ after 2 years

• Presents with:

• Gummatous lesions (gummas are granulomatous lesions that can affect the skin, organs and bones)

• Aortic aneurysms

• Neurosyphilis

Syphillis: What are the symptoms of neurosyphillis?

• Headache

• Altered behaviour

• Dementia

• Tabes dorsalis (demyelination affecting the spinal cord posterior columns)

• Ocular syphilis (affecting the eyes)

• Paralysis

• Sensory impairment

Syphillis: What is the ‘Argyll-Robertson pupil’ sign?

Argyll-Robertson pupil is a specific finding in neurosyphilis. It is a constricted pupil that accommodates when focusing on a near object but does not react to light. They are often irregularly shaped

Syphillis: What are the investigations?

• Dark field microscopy

• PCR testing

Syphillis: What is the management?

A single deep IM injection of bezathine benzylpenicillin

Trichomonas Vaginalis: What is it?

• Parasite spread via sex

• Protozoan

• Single-celled organism with flagella

• Lives in urethra of men

• Lives in vagina of women

Trichomonas Vaginalis: What are the complications?

• HIV

• BV

• Cervical cancer

• Pelvic inflammatory disease

• Pregnancy-related complications e.g. preterm delivery

Trichomoniasis Vaginalis: What are the symptoms?

• Often asymptomatic

• Vaginal discharge→ frothy, yellow-green, maybe fishy smell

• Itching

• Dysuria (painful urination)

• Dyspareunia (painful sex)

• Balanitis (inflammation to the glans penis)

• Vaginal PH >4.5

Trichomonas Vaginalis: What is the ‘Colitis Macularis’ sign?

Strawberry cervix presentation due to Trichomonas infection

Trichomonas Vaginalis: What are the investigations?

• Charcoal swab with mircroscopy via posterior fornix of vagina

• Urethral swab or first-catch urine is used in men

Trichomonas Vaginalis: What is the management?

• Metronidazole

• Refer to GUM

• Contact tracing