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what are the most common microbial causes of female genital discharge?
- overgrowth of vaginal commensals. recurrence common
- candidiasis
- bacterial vaginosis
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what are the STI causes of female genital discharge?
- Trichomonas vaginalis
- Gonorrhoea
- Chlamydia
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what kind of discharge would you see with gonorrhoea and chlamydia and if suspected what needs to be checked?
- mucopurulent discharge
- check signs of PID: deep dyspareunia, pelvic pain, abnormal bleeding
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what % of chlamydia are asymptomatic?
80%
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what % of gonorrhoea are asymptomatic?
50%
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what Qs need to be asked with female genital discharge?
- 1. duration
- 2. past episodes
- 3. colour, consistency, blood stained
- 4. genital pruritis
- 5. dysuria
- 6. dyspareunia (superficial ie on penetration or deep)
- 7. pelvic pain
- 8. abnormal bleeding: intermenstural or post-coital
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what is physiological discharge in women like at start/end of cycle?
thick white
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what is physiological discharge in women like mid cycle?
clear and stretchy - fertile mucoid. increased in volume
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what 2 factors can increase normal discharge? and why
- 1. COCP
- 2. pregnancy
- due to oestrogen effect
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what is normal pH of vaginal discharge?
< 4.5
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what is the cause of thrush? (organism full name)
candida albicans overgrowth
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name 5 pre-disposing factors to thrush
- 1. immunocompromised eg diabetes, corticosteroids
- 2. broad spectrum antibiotics - wipe out normal flora
- 3. intra-uterine devices
- 4. constrictive, non porous underwear
- 5. soaps, bubble bath
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what are 3 symptoms of thrush?
- 1. genital pruritis or burning
- 2. dyspareunia - superficial
- 3. thick white cheesy discharge with sour odour
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what would you see OE both of genitalia and on speculum of thrush?
- genitals: erythema, oedema, scratching, shallow erosions and lichenification (thick hard skin)
- speculum: cottage cheese like plaques of discharge, sometimes adherent to mucosal surface
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what Ix do you do in thrush?
vaginal swab for gram and culture
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what is the cause of bacterial vaginosis (BV)?
- alteration of vaginal flora resulting in loss of lactic acid producing lactobacilli
- so overgrowth of BV associated anaerobes
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name a BV associated anaerobe?
Gardnerella vaginalis
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what happens to vaginal pH in BV?
increases, >4.5
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what are risk factors for BV? (6)
- black ethnicity
- IUD
- lack of condom use
- genital washing - douche
- smoking?
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name 3 symptoms of BV
- 1. dishcharge: fishy smell, more after coitus, white-grey colour, thin watery
- 2. pruritis
- 3. dyspareunia
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what are tests for BV?
- pH > 4.5
- vaginal swab for gram stain
- clue cells on microscopy
- release of fishy odour on adding alkali: KOH solution
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what is Rx for BV?
- metronidazole
- clindamycin vaginal cream
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how is trichomonas acquired?
STI
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what kind of organism is trichomonas?
protozoa. trichomonas vaginalis
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what is incubation period of trichomonas?
1-2 weeks
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name 4 symptoms of trichomonas?
- 1. discharge: profuse, bubbly, white or green, offensive
- 2. vulval soreness
- 3. vulval pruritis or swelling
- 4. superficial dyspareunia
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what do you see O/E in trichomonas (think all parts of gentialia)
- 1. vulva, vagina, cervix: all inflammed
- 2. discharge: thin, frothy, purulent, offensive, pools at posterior fornix
- 3. vaginal wall and cervix: strawberry appearance with punctate bleeding erosions
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what problems can trichomonas give in pregnancy?
- 1. pre-term delivery
- 2. LBW in new borns
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what is Rx for trichomonas?
- metronidazole 2g stat
- and partners
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what sample is taken for trichomonas?
HVS - saline, cover slip, microscopy. see flagella kick out back, characteristic jerky motility. undulating membrane.
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how sensitive is microscopy?
70%
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what is the culture medium for trichomonas?
- liver digest glucose broth. brown medium
- incubate for 2 days in CO2 incubator
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what else can the trichomonas media check for?
Candida
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what is the gold standard test for trichomonas?
culture
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name 2 Rx for trichomonas?
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what is the cause of gonorrhoea? which organism and what gram and shape is it?
- neisseria gonorrhoea
- gram -ve
- intracellular diplococci
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if pts develop symptoms with gonorrhoea, when do they do so?
within 10 days of infection
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what % have co-infection with chlamydia?
37%
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name 5 symptoms of gonorrhoea?
- 1. absent or v slight so ignored in most cases
- 2. dysuria
- 3. vaginal discharge - actually not vaginal but from cervix, mucopurulent
- 4. DEEP dyspareunia
- 5. pelvic pain
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what do you see O/E with gonorrhoea
- 1. examination often normal
- 2. urethral/cervical purulent discharge
- 3. endocervical inflammation
- 4. signs of PID on bimanual examination: cervical excitation or adnexal tenderness
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what is the most common complication of gonorrhoea in men? and other comps?
- acute epididymitis
- cellulitis
- penile lymphangitis
- periuthetral abscess
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where else can gonorrhoea get to?
joints
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where are swabs taken for gonorrhoea in females?
- cervical
- urethral
- throat
- rectal (but most rectal slides in MSM)
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what is the most common complication of gonorrhoea in women?
PID
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what is the screen for asymptomatic gonorrhoea? why better than culture?
- first catch urine sample for GC NAAT test
- better as quicker!
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what is most common test for gonorrhoea?
- endocervical swab
- NAAT test
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what is Rx for gonorrhoea? give 3 and dose of first
- cefixime 400mg stat
- ceftriaxone
- spectinomycin
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what is the most common STI in the UK?
chlamydia
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what causes chlamydia?
chlamydia trachomatis
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what type of organism is CT? and what gram stain?
- obligate intracellular pathogen, so difficult to culture
- gram negative
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what are the symptoms of chlamydia
- 1. often asymptomatic
- 2. vaginal discharge
- 3. deep dyspareunia
- 4. pelvic pain
- 5. abnormal bleeding
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what can you see OE chlamydia?
- mucopurulent cervical discharge
- inflamed, friable cervix (contact bleeding)
- adnexal tenderness if PID
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what is pH like in chlamydia?
normal
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what is the diagnostic test for chlamydia?
- cervical swab (endocervical)
- NAAT
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what is Rx for chlamydia? and dose for first
- azithromycin 1g stat
- or doxycycline
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what are 2 most common infective causes of male genital discharge?
- gonorrhoea
- NGU: non gonococcal urethritis
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if man presents with genital discharge, what Qs to be asked?
- 1. duration
- 2. colour of discharge
- 3. dysuria, frequency, UTI qs
- 4. scrotal pain or swelling
- 5. if MSM - rectal discharge, pain
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name 2 physiological causes of male discharge
- 1. prostatorrhoea
- 2. sexual arousal
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what is the incubation days for gonorrhoea
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what % of men with gonorrhoea are asymptomatic?
< 10%
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what % of men are connected with chlamydia?
30%
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what are 2 main symptoms of gonorrhoea in men?
- urethral discharge
- dysuria
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what should be checked for OE GC in men?
- urethral discharge
- scrotal swelling or pain: epididymitis, orchitis
- meatitis
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what is the commonest cause for NGU?
chlamydia
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what % of NGU are asymptomatic?
50%
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what is incubation days for NGU with chlamydia?
6-14 days
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if NGU with no pathogen found, what is it called?
NSU: non specific urethritis
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what are causes of NSU?
- mycoplasma genitalium
- ureaplasma urealyticum
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what is difference between GC and NGU?
in NGU discharge is less dramatic and get peri-urethral itching or tingling
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who should you look for proctitis in?
anoreceptive MSM
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what are symptoms of proctitis?
- pruritis
- tenesmus
- anal dampness or discharge
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what is main difference between gonorrhoea and chlamydia infection in men?
gonorrhoea: profuse yellow/green discharge
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what are most common causes of rectal discharge?
gonorrhoea and chlamydia
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