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109 Cards in this Set

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  • Back
What is the normal colour of physiological discharge?

What is the normal colour, consistency and volume (increased or decreased) of it at ovulation?

At ovulation, it becomes thinner, clearer and increased in volume.
What does OCP/HRT do to physiological discharge?
Increases it.
Does physiological discharge increase or decrease with pregnancy?
What routine investigations are done for a PV discharge?
- High vaginal swab (posterior fornix) for Group B streptococcus, candida, trichomonas, and BV.
- Endocervical swab for GC and chlamydia PCR.
- Endocervical MCS swab for MCS if GC/endometritis suspected.
When investigating using a high vaginal swab (posterior fornix), what organisms would you be looking for?
- Group B streptococcus.
- Candida albicans.
- Trichomonas vaginalis.
- BV.
When doing an endocervical swab, what would you be looking for with PV discharge?
- GC.
- Chlamydia.
- MCS if GC/endometritis suspected (in this case, an endocervical MCS swab is required).
What investigations would you do for dysuria?
- Urethral swab or first swab urine for chlamydia & GC PCR.
- Mid-stream urine for MCS.
What investigations would you do for oral/rectal symptoms?
Oropharyngeal/rectal swab for MCS.
If a female patient has vesicals/genital ulcers, what should you perform investigation-wise?
- Swab for herpes culture or HSV antigen detection (HSV1, 2, zoster).
- Serology - for syphilis, lymphgranuloma, venereum, Hep B, HIV.
If a female patient has vesicals/genital ulcers, what organisms are looked for in the serology?
- Syphilis.
- Lymphgranuloma.
- Venereum.
- Hepatitis B.
- HIV.
What is monilia vulvitis?
Oedema and inflammation of the external genitalia (due to candida).
Is candida (monilia) infection an STI?
No, it's not considered an STI. Candida is endogenous.
What are the main organisms responsible for candidiasis?
- Candida albicans (90%).
- Candida glabrata (5-10%).
- Other yeasts.
What percentage of infective vaginitis comprise of candida?
What are the main symptoms of candidiasis?
- Mild to intense vulvovaginal itch - worse at night, warmth.
- Vulval soreness.
- Discomfort with sex.
What are the signs you look for during examination with candidiasis?
- Vulvovaginal erythema/excoriation/oedema.
- White curd-like discharge (may be thin).
- Adherent plaques.
What are the predisposing features of candida overgrowth?
- Immunosuppression (AIDS, pregnancy, debilitating illness, immunosuppressants).
- Diabetes.
- OCP.
- Antibiotics.
- Humidity/bathing suit/nylon or tight underwear.
- (Male resevoir - Balanitis).
What can you use to treat candida?
Topical imidazoles - works in the majority of cases. (Clotrimazole, miconazole, econazole, nystatin).

If resistant:
- Fluconazole OR
- Ketoconazole.
- Candida glabrata Boric acid.
What are the different types of 1st-line topical imidazoles (used for candida)?
- Clotrimazole (cream or pessary).
- Miconazole cream/pessary.
- Econazole pessary.
- Nysatin pessary.
Do you need to treat the male partner of a female patient diagnosed with candidiasis?
No, unless symptomatic.
Is bacterial vaginosis considered an STI?
What are the main organisms responsible for bacterial vaginosis?
- Gardnerella vaginalis.
- Mobiluncus spp.
- Anaerobes.
- Mycoplasma hominis.
What percentage of infective vaginitis is due to bacterial vaginosis?
In bacterial vaginosis, around what pH value is the vaginal discharge?
The pH would be above >4.5
What are clue cells and which infective vaginitis is it most likely to be indicative of?
Clue cells are a result of small coccobacilli attaching to vaginal squamous cells. It is indicative of bacterial vaginosis.
What are the signs and symptoms of bacterial vaginosis?
- Grey, watery profuse discharge (non-adherent).
- Malodorous (fishy) smell, especially after sex or menses.
- Usually no/minimal irritation or dyspareunia.
- No obvious vulvovaginitis.
The malodorous smell of bacterial vaginosis is particularly bad at what times?
After sex and menses.
What is the treatment for bacterial vaginosis?
50% are asymptomatic and require no treatment.

The symptomatic cases can be treated by 1 of the following:
- Metronidazole 400mg with food for 7 days.
- Clindamycin 2% vaginal cream PV daily or 300mg tablets bd - for 7 days (preferred treatment if pregnant).
- A single dose of 2g of tinidazole or metronidazole may be used but lower cure rate and Re-Rx may be needed.
Strawberry spots are indicative of what cause of infective vaginitis?
Trichomonas vaginalis.
What kind of infection is trichomonas?
Trichomonas commonly coexists with what other problem?
Bacterial vaginosis.
Is trichomonas an STI?
What are the signs and symptoms of trichomonas infection?
- Irritating, yellow-green profuse thin discharge (bubbly in 20-30%).
- Pruritis and dyspareunia.
- Malodorous (fishy) discharge.
- 50% asymptomatic.
- Vulvovaginitis.
- Characteristic punctate appearance of colpitus macularis - erythematous.
What percentage of trichomonas infection is asymptomatic?
What is the treatment of trichomonas?
- Check for other STIs.
- Treat the partner as well!

Choose one of the following:
- Tinidazole 2g single dose with food.
- Metronidazole 2g single with food.
- If relapse, metronidazole 400mg bd for 5 days.
If a pregnant patient has trichomonas, what could be used to treat her?
Metronidazole 2g single dose with food.
What is the most notified of all STIs in QLD?
Chlamydia trachomatis.
The majority of Chlamydia notifications occur in what age group?
15-24 years old (60% of notifications).
What are the signs and symptoms of chlamydia trachomatis infection?
50% asymptomatic.

Early symptoms may include:
- Mucopurulent discharge (from endocervical canal).
- Dysuria (co-existing urethral infection).

10-15% are complicated by PID.

Inflamed, oedematous and friable ectropion with contact bleeding.
Chlamydia infection is asymptomatic in what percentage of the infected?
What percentage of cases of chlamydial infection results in a PID complication?
What patients should be tested for chlamydia?
- Known sexual contact with somebody with STI/chlamydia.
- Symptomatic.
- Where there has been unprotected intercourse and one or more of the following:
= Change of sexual partner in 2 months.
= >1 sexual partner.
= Patient's partner has had other sexual partners.
- Patient < 25 years old and has had unprotected intercourse.
- Patient has an IUCD in situ, and any of the above factors exist.
How do you treat chlamydial infection?
- Azithromycin 1g orally once.
- Doxycycline 100mg bd for 7 days.

Treat the partner as well.
Gonococcal infection can result where and what reaction?
- Gonococcal urethral discharge.
- Gonococcal pharyngitis.
- Gonococcal rectal inflammation.
- Gonococcal epididymitis and sympathetic hydrocoele.
- Ophthalmia neonatorum.
Describe the structure of the gonorrhoea organism.
Gram negative intracellular diplococcus.
What cells does gonorrhoea infect?
Columnar and transitional epithelium.
What are the primary sites of infection of gonorrhoea?
Mucous membranes of the:
- Urethra.
- Endocervix.
- Rectum.
- Pharynx.
How is gonorrhoea transmitted?
- Direct sexual contact and mutual masturbation.
- Conjunctival infection via perinatal transmission and sometimes via adults with poor hygiene who auto-inoculate their eyes unwittingly after handling their genitals when going to the toilet.
What is the infection rate of gonorrhoea from a single exposure?
What is the usual incubation period of gonorrhoea?
2-7 days - may be longer.
Gonorrhoea is potentially communicable for _____ if untreated. (Days, Weeks, Months or Years?)
Months. However, once treated, communicability ends within hours.
What percentage of cases of Gonorrhoea complicated with PID?
What are the signs and symptoms for gonorrhoea infection in a woman?
Few symptoms and signs in women. For those who do have symptoms:
- Majority have endocervicitis - inflamed cervix with mucopurulent discharge.
- 70-90% urethritis.
- Ascending infection --> PID
Gonorrhoea infection commonly occurs with a coexistent...
Infection with chlamydial trachomatis.
What complications can occur with PID?
- Ectopic pregnancy.
- Infertility.
- Chronic pelvic pain.
What is the treatment for gonorrhoea?
- Ceftriaxone 250mg IMI once
- Followed immediately by anti-chlamydial treatment azithromycin 1g orally or doxycyline 100mg bd orally for 7 days.

Treat partners.

Perform follow-up cultures.
What pathological features occur with cervicitis?
- Mucopurulent discharge from endocervical canal.
- Inflamed oedematous friable ectropion with easy contact bleeding.
What are the most likely causes of cervicitis?
Gonorrhoea or chlamydia.
In cases of endocervicitis, what should you do in terms of investigations?
Take endocervical swabs for chlamydia, gonorrhoea and gram staining.
What is the treatment for a NON-STI related, mild-to-moderate case of pelvic inflammatory disease?
Mild to moderate:
- Doxycycline 100mg bd for 2-4 weeks.
- Amoxycillin 500mg tds PO PLUS metronidazole 400mg tds PO for 2-4 weeks.
What is the treatment for a NON-STI related, SEVERE case of pelvic inflammatory disease?
Amoxycillin IV plus gentamicin IV plus metronidazole IV...

Doxycycline PO for 2 weeks.
What is the treatment for a STI-related mild-to-moderate case of pelvic inflammatory disease?
- Azithromycin PLUS
- Ceftriaxone IM OR ciprofloxacin PLUS
- Doxycycline PLUS
- Metronidazole.
What is the treatment for a STI related SEVERE case of pelvic inflammatory disease?
- Cefotaxime OR ceftriaxone OR cefoxitin IV
- Metronidazole IV
- Doxycycline or roxithromycin PO
until afebrile

THEN continue oral doxycycline or roxithromycin for 2-4 weeks.
Who are at special risk for STIs?
- Homeless people.
- Young people.
- Sex workers.
- Prisoners.
- People returning from overseas.
Who may have poorer access to treatment for STIs?
- People with a disability.
- Victims of sexual violence.
- People from low SES background or from marginalised communities.
- People from NESB.
- People living in rural or remote communities.
What are the main vaginal causes for PV discharge?
- Candida.
- Trichomonas.
- Gardnerella (bacterial vaginosis).
- Atrophic vaginitis.
- Other e.g. retained foreign body, tumour.
Explain the pathology underlying atrophic vaginitis.
Reduced vaginal acidity and thin bacterial walls allowing bacterial attack.
What are the signs and symptoms of atrophic vaginitis?
- Yellowish, non-offensive discharge.
- +/- post-coital bleeding or spotting.
- Reddened vagina.
- Tenderness and dyspareunia.
What is the mainstay of treatment of atrophic vaginitis?
HRT (oral or topical).
What are the cervical causes of PV discharge?
- Gonorrhoea.
- Chlamydia.
- Non-specific genital infection.
- Herpes.
- Cervical atrophy.
- Cervical neoplasm - polyp.
What is the probability diagnosis of vaginal discharge?
Normal physiological discharge.

- Bacterial vaginosis 40-50%.
- Candidiasis 20-30%.
- Trichomonas 10-20%.
What are the serious disorders not to be missed with vaginal discharge?
- Neoplasia (carcinoma, fistulae).
- STIs/PID - chlamydia, gonorrhoea.
- Sexual abuse, especially in children.
- Tampon toxic shock syndrome (staph infection).
What are the pitfalls for vaginal discharge?
- Chemical vaginitis e.g. perfume.
- Retained foreign object e.g. tampons.
- Endometriosis (brownish discharge).
- Ectopic pregnancy ('prune juice' discharge).
- Poor toilet hygiene.
- Genital herpes (possible).
- Atrophic vaginitis.
Which of the 7 masquerades may cause vaginal discharge?
- Diabetes.
- Drugs.
- UTI.
Vaginal the patient trying to tell us something?
- Possible sexual dysfunction.
- Possible sexual abuse.
- Possible anxiety/stress.
- Possible relationship problems.
- Other concerns: cancer.
What percentage of cervical cancer can be prevented with cervical screening of asymptomatic individuals?
Hwo frequently should women have cervical screening?
Every 2 years.
Who should have cervical screening?
All women ever sexually active - to commence between 18-20 years of age.
2 years after 1st intercourse.

(Whichever is later).

Women over 70 should also be screened if they request a smear or if they have never had a smear.
At what age can a woman stop cervical screening?
70 years.
What are the risk factors for cervical cancer?
- Any woman who has been sexually active and who has not had a hysterectomy.
- First sexual intercourse at an early age.
- A number of sexual partners, or a sexual partner who has a number of other partners.
- Cigarette smoking.
- Certain strains of HPV - especially genotypes 16 & 18.
- Daughters of women who took diethylstilboestrol (DES).
- Low SES.
- Indigenous race.
On a PAP smear test, the PAP result is 'Unsatisfactory PAP'. What course of action should be taken?
Repeat the test in 6-12 weeks.
What does LSIL stand for?
Low grade squamous epithelial lesion.
The PAP smear result:
Index PAP = LSIL (possible or definite).

What course of action should be taken?
Repeat PAP smear in 12 months.

Further action after this second smear:
- Normal - repeat PAP 12 months.
- LSIL - colposcopy.
- HSIL - colposcopy.

If 2 LSIL results within 3 years (even if also a normal Pap), do a colposcopy.
The PAP smear result:
Index PAP = LSIL (possible or definite).

The repeated test done 12 months later was normal.

What course of action should be taken?
Repeat PAP smear in 12 months.
The PAP smear result:
Index PAP = LSIL (possible or definite).

The repeated PAP smear 12 months later resulted in LSIL.

What course of action should be taken?
The PAP smear result:
Index PAP = LSIL (possible or definite).

The repeated PAP smear 12 months later resulted in HSIL.

What course of action should be taken?
If the PAP smear showed 2 LSIL results within 3 years, what course of action should be taken?
If a colposcopy for LSIL results in an 'Unsatisfactory Result', what action should be taken?
Repeat PAP in 6-12 months.
If a colposcopy for LSIL results in a 'Normal Result', what action should be taken?
Yearly PAPs until 2 normal smears, then routine screening.
If a colposcopy for LSIL results in an ' LSIL Result', what action should be taken?
Biopsy --> Confirmed LSIL --> Repeat PAP @ 12 and 24 months.

If both PAPs are normal, then routine screening.

If either PAP LSIL --> Annual smears until at least 2 negative, then routine screening.
If an Index PAP smear results in a HSIL (possible or definite), what action should be taken?
Refer for colposcopy and biopsy.

If histology = CIN2 or CIN3, then it needs treatment.
What HSIL CIN levels indicate a need for treatment?
CIN2 or CIN3.
If the PAP result indicates 'HSIL with invasive features' what course of action needs to be taken?
Refer to gynae with malignancy expertise, within 2 weeks.

After treatment for HSIL:
- Colposcopy + PAP at 4-6 months.
- PAP and HPV typing at 12 months.
- Then annual PAPs until 2 consecutive negative Paps, then routine screening.
What Pap smear results require immediate referral to gynaecologist with expertise in malignancy?
- Adenocarcinoma.
- Endocervical adenocarcinoma in situ (AIS).
- Possible high-grade glandular lesions.
Screening for HPV involves what process?
HPV DNA testing.
What significance does the HPV vaccine have for women's health?
Prevention of HPV diseases including:
- Cervical cancers.
- Precancerous lesions.
- Genital warts.
Gardasil is a quadrivalent HPV recombinant vaccine protective against which HPV types?
6, 11, 16, 18.
How is Gardasil vaccination done?
3 doses IM over 6 months.
Cervarix is a HPV bivalent recombinant vaccine protective against which HPV types?
What groups are recommended to have Gardasil vaccination?
Females 9-26 years.
Males 9-15 years.
The Australian government is giving free HPV vaccines to what population?
Females 12-26 years of age.
Suggested open ended
questions for taking a sexual history.
• Why do you think you have been at risk of STIs or HIV?
• Which STIs are you particularly concerned about?
• What do you think I need to know about your sexual practises to ensure that I order the best tests?
• What do you do to protect yourself against HIV infection and other STIs?
• In what situations would you be less likely to use condoms?
• Tell me about your use of condoms, for anal sex, vaginal sex, oral sex?
STI Screening asymptomatic individuals at risk through noncommercial sexual
activity. What populations and patients would you screen?
• Anyone who asks for a test.
• Contact of anyone with an STI.
• Young sexually active people under 25 years of age (chlamydia especially).
• Unprotected sex (especially overseas country of higher HIV risk).
• Multipartnered individuals.
• Recent change in sexual partner.
What STIs can be checked with a routine blood test?
- HIV.
- Hep B.
- Syphilis.
- Hep C (not usually sexually transmitted - but if blood to blood transmission possible).
What STIs can you check for in the urine?
- Chlamydia.
- Gonorrhoea.
What is the risk of HCV transmission through sexual contact?
Risk of HCV transmission via sexual contact is low, estimated at up to 0.6% per year in monogamous relationships and up to 1.8% per year in those with multiple partners.
What is the most common notifiable bacterial infection in Australia?
What percentage of sexually active adults have been infected with HPV?
What is the prevalence of HSV1 and HSV2?
HSV-2 is common (15–30%) and HSV-1 infection, usually acquired orally before the age of 15 years, is very common (75–80%).