Female Genital Infections

Female Genital Infections Sexual history Most recent exposure – when, regular/casual partner, if regular how long for, contraception/protection, condom breakages/slips, has partner got symptoms Previous sexual partner – how long ago (if past few months get all details above), how many partners over past few months Related to HIV – ever injected drugs? Are any male partners bisexual, injecting or from high risk areas (asia/sub Saharan Africa) Symptoms Asymptomatic 80% chlamydia, 50% gonorrhoea, 65% PID, 30% genital warts, 50% genital herpes Vaginal Discharge Ask about odour, vulval itching, soreness, dysuria, IMB, PCB, abdo pain Vaginal infections – bacterial vaginosis, candida, trichomonas Cervical infections – chlamydia, neisseia gonorrhoea Physiological discharge – cervical ectopy Other causes – retained tampon, retained products of conception Dysuria Usually acute bacterial cystitis, urethritis and vulvitis Is it external (as urine touches vulva), frequency, urgency, nocturia, haematuria, vaginal discharge, PCB, abdo pain, vulval sores, itching Acute bacterial cystitis – coliforms, staph saphrophyticus Urethritis – chlamydia, neisseria gonorrhoea Vulvitis – genital herpes, candida, trichomonas, vulval dermatological conditions Vulval Lumps Due to infection, anatomical variants etc Are the lumps painful, how many, how long for, any other symptoms Viral infections – genital warts, molluscum contagiosum, VIN & vulval cancer Bacterial infections – syphylitic condylomata lata, skene’s or bartholins abscesses (chamydia/gonorrhoea) Others – anatomic variants, vulval papillae, sebaceous cysts Vulval Ulcers Most commonly infection (genital herpes most common) Are they painful, how many, how long for, any other symptoms Infective – genital herpes, syphilis Non infective – aphthous ulcers, behcets syndrome Lower Abdominal Pain Many causes, most common group for infective is under 25’s Any discharge, PCB, ICB, deep dyspareunia, last LMP, contraception, ?pregnant, any other symptoms Uterus – endometritis (chlamydia, gonorrhoea, bacterial vaginosis), endometriosis Tubes – salpingitis (chlamydia, gonorrhoea), ectopic Ovary – torsion, haemorrhage into a cyst Other – cystitis, acute appendicitis, IBS Chlamydia trachomatis Most common STI (3-5% of sexually active women, 14% of under 20’s,). Usually cervix, + 50% urethreal Importance - Can cause vaginal discharge, increased/irregular bleeding, PID, infertility (tubal damage) & ectopics, ovarian, skenes & bartholins abscess, endometritis, salpingitis, perihepatits. In pregnancy – can cause miscarriage, preterm birth, postpartum & neonatal infection. Can cause reactive arthritis, increase HIV risk, some links to cervical cancer In men – epididymo-orchitis, discharge & dysuria Symptoms - 80% asymptomatic, increased discharge, dysuria, If extensive - lower abdo pain, IMB O/E – can cause mucopurulent cervicitis, contact bleeding, may look normal Testing offered to – anyone symptomatic, @ GUM, wanting TOP, under 25s, new partner or > 2 partners in last yr Diagnosis – swab is best (look for organism), or urine (for antigen) Management – If male/not preg – 1g azithromycin (stat) – (not if preg/breast feeding, allergic, liver disease, renal impairment) Otherwise – 100mg doxycycline b.d for 7 days - (not if photosensitivity, avoid Fe & indigestion remedy, risk of candida) Neisseria Gonorrhoea Sexually aquired in adults - Cervix & urethral infections (70%) Importance – can à abscesses, endometritis, salpingitis (10-20%), perihepatitis, ectopics, infertility, acute arthritis, dermatitis, increased HIV risk In pregnancy – can cause miscarriage, preterm birth, postpartum & neonatal infection Symptoms – 50% asymptomatic. Increased discharge, dysuria, PCB, If extensive – lower abdo pain & IMB O/E – purulent or mucopurulent cervicitis, contact bleeds, may look normal. Management – ciprofloxacin / ofloxacin / ampicillin / ceftriaxone Pelvic Inflammatory Disease Due to infections ascending into upper genital tract (endometritis, salpingitis, tubo-ovarian abscess, pelvic peritonitis) Importance – major problem is tubal damage. Each episode increases damage & therefore ectopic risk Causes – mainly chlamydia (mild) & gonorrhoea(more severe), mycoplasma hominis & anaerobes also found. Symptoms – onset in 1st part of cycle. Lower abdominal pain (most common), increased vaginal discharge, irregular bleeds, deep dyspareunia, dysuria O/E – mucopurulent discharge with contact bleeding (indicative of cervicitis), adnexal & cervical ternderness, pyrexia, palpable adnexal mass Diagnosis – no specific test available. May be raised ESR, CRP, WCC. Microbiology samples are gold standard. Diagnosis usually made based on clinical findings & LGT swabs. ALWAYS exclude ectopic pregnancy Management – admit if diagnostic uncertainty, severe case or failure to respond to oral therapy. Empirical treatment until organism known (minimises tube damage) IV if severe. Give appropriate analgesia Bacterial Vaginosis Overgrowth of anaerobic bacteria, genital mycoplasmas and gardnerella vaginalis NOT sexually transmitted so partners do not need to be treated Most common cause of vaginal discharge in women of reproductive age Importance – increases vaginal cell cuff following procedures, increases HIV risk In pregnancy – increases risk of late miscarriage and preterm birth Symptoms – 50% asymptomatic. Mainly increased discharge and fishy odour (worse with sex & period) O/E – milky white discharge, may be frothy, adheres to vaginal wall Diagnosis – Amsels criteria (at least 3 of the following): typical discharge, vaginal pH > 4.5, amine odour with 10% KOH, clue cells on microscopy. Can use gram stain vaginal smear. Culture is not used (due to high colonisation rate of normal women). Management – in all women with symptoms, undergoing TOP & pregnant with previous preterm birth. Metronidazole or clindamycin Candida infections Very common – 75% lifetime risk, increased if pregnant, immunosupression or uncontrolled DM NOT sexually transmitted – partners do not need treatment. No long term complications Symptoms – vulval itching (nearly all symptomatic cases). Thick white discharge, vulval burning, external dysuria, superficial dyspareunia O/E –vulval erythema, fissuring, oedema, white plaques on vaginal walls Diagnosis – by culture Management – topical clotrimazole / econazole / miconazole, oral fluconazole / itraconazole Trichomonas Vaginalis (TV) Relatively rare in UK (common in Africa & Asia). Sexually transmitted. Only in urogenital tract Importance – Increased risk HIV, low birth weight & preterm delivery Symptoms – asymptomatic (10-50%). Vaginal discharge, odour, pruritus, external dysuria, dyspareunia Diagnosis – culture Management – metronidazole, check for other STIs Genital Warts Painless, benign, epithelial tumours causes by HPV 6 & 11 Highly infectious, incubation average 3 months (up to yrs). Commonest viral STI in UK Importance – Cervical cancer. vertical transmission can occur Symptoms – painless so many asymptomatic. Vulval lumps, flesh coloured papules Diagnosis – by clinical appearance, biopsy if in doubt Management – topical cytotoxics, imiquimod, ablative therapy Genital Herpes Due to HSV 1 or 2 Initially acute vesicular / ulcerating eruption à recurring lesions (gets into DRG) Importance – life long infection. Risk of vertical transmission in 3rd trimester, increased HIV risk, psychological fear, rejection by sexual partners, meningitis, neuropathy Symptoms 1o infection – vulval soreness, external dysuria, multiple painful superficial ulcers + tender lymphadenopathy Symptoms 2o infection / recurrence – may be asymptomatic but still infectious, a few ulcers in limited area Diagnosis – by viral culture Management 1o – antivirals (acyclovir, famcyclovir, valacylovir), analgesia, saline bathing, PU in bath to lessen pain, explain recurrence risk Management 2o – self limiting so support, antivirals may hasten recovery Syphilis (Treponema Pallidum) Is sexually transmitted in adults Importance – miscarriage, still birth, congenital syphilis Symptoms – asymptomatic, primary – chancre (single painless ulcer with rolled indurated edges) which often goes unnoticed, secondary – generalised illness, fever, malaise, skin, mucosal rashes (trunk, limbs, palms & soles), warty papules on vulva, Late – neurosyphilis, cardiovascular or gummata Diagnosis – serology Management – long course of antibiotics required with intense follow up HIV Spread by contact with body fluids, now routine in antenatal testing Importance – lifelong illness. Treatment in pregnant mothers reduces vertical transmission Symptoms – asymptomatic for several years, mild systemic illness (fever, malaise, rash) at seroconversion, increase in other infections, opportunistic infections become serious Diagnosis – serology – patient must consent to test Management – monitor viral load and CD4, antiretrovirals when CD4 < 350 x 109/l, prophylaxis for pneumocystis if CD4 < 200 x 109/l