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Genitourinary Medicine HANNAH MCPHEE HMCPHEE01@QUB.AC.UK(C) MLA Content Map, General Medical Council Not Covered • HIV Topics • Loss of libido • Vulval itching/lumps SEXUAL HEALTH HISTORY • Pelvic inflammatory disease CONTRACEPTION (BRIEFLY) • Painful intercourse SEXUALLY TRANSMITTED INFECTIONS • HPV VAGINAL DISCHARGE EPIDIYMO-ORCHITIS & ERECTILE DYSFUNCTION MCQ CLUES + OSCE TIPSSexual Health History • Good rapport • May delve into psychosexual history • Who/What/Where/Why? • The 5Ps: ⚬ Partners ⚬ Practices ⚬ Protection from STIs ⚬ Past History of STIs ⚬ Pregnancy IntentionPartners (Who) • Are you currently having sex of any kind with anyone ? • In recent months, how many sexual partners have you had? • What is/are the gender(s) of your sexual partners? • Do you or your partner have any other sexual partners? Practices (What/Where/Why) • Type of sexual contact • Online dating • Drugs/Chemsex • Exchange (housing, finances, drugs etc.) • Previous/risk of SAProtection from STIs • Have you discussed this with your partner? • What methods are used? • Frequencies? • HPV, HIV and Hepatitis prevention • PrEP use? Past History of STIs • Last sexual health screen/test • Any previous diagnoses of STIs? If yes - treatment? • Any recurring symptoms? • Partners’ historyPregnancy Intention • Any children? • Do you want [more] children? ⚬ When? ⚬ Importance of pregnancy prevention now? • Contraception ⚬ Yes/no? ⚬ Type ⚬ Compliance ⚬ ICE/offer to provide more informationContraception - Need to Know Options UKMEC Contraindications Risks OSCESTOP Side Effect Profiles PassMed Emergency Contraception Options Textbook Missed Pills Rules regarding young people *PRACTICE THIS*Contraceptive Effectiveness Sterilisation Intrauterine Devices, Progresterone Injectables & Implant COCP and Progesterone Pills Rings, Condoms, Caps with Spermacide Fertility Awareness Methods (C) Faculty of Reproductive and Sexual Healthcare COCP UKMEC Category 3: UKMEC Category 4: • >35 y/o + smoking <15 cigarettes a • >35 y/o + smoking >15 cigarettes a day day • BMI >35 kg/m^2 • Migraine with aura • FMH VTE in 1st Degree Relative • PMH VTE, thromboembolic mut., • Immobility stroke, IHD • HTN • Postpartum <6/52 + breastfeeding • Known BRCA1/2 MUT • Current breast cancer (C) Faculty of Reproductive and Sexual Healthcare Progesterone-based Contraception UKMEC Category 3: UKMEC Category 4: • Unexplained vaginal bleeding • Current breast cancer • IHD/Stroke • Past breast cancer • Liver disease (cirrhosis) or liver cancer GI Headaches Nausea Upset OESTROGEN Vaginal bleeding VTE SIDE or spotting Risk EFFECTS Breast Tenderness Mood changes Breast & Cervical Ca. Risk GI Headaches Tiredness Upset Changes to period inclu. PROGESTERONE Acne SIDE EFFECTS spotting, intermenstrual bleeding Mood changes Breast Tenderness(C) OSCEstop©Faculty of Sexual and Reproductive Healthcare Emergency Contraction Guidelines©Faculty of Sexual and Reproductive Healthcare Emergency Contraction GuidelinesSexually Transmitted Infections Gonorrhoea Trichomoniasis Chlamydia Syphilis Genital Herpes Mycoplasma genitaliumRisk Factors for STIs SEXUALLY ACTIVE MULTIPLE SEXUAL PARTNERS MULTIPLE INFECTIONS Diagnosis Nucleic Acid Amplification Test (NAAT) • Chlamydia • Gonorrhoea • Herpes Antibody Testing +/- PCR • +PCR: HIV • -PCR: Syphilis MC&S - Charcoal, N Swab or First-catch Urine (M) • Trichomoniasis • Gonorrohea - must have charcoal + (C) https://www.centurymedicaldentaNAATm/std-testing-nyc-std-doctor/ Gonorrhoea Increasingly common STI in the UK Caused by Neisseria gonorrhoeae Infects mucus membranes with columnar epithelium - endocervix, urethra, rectum, conjunctive & pharynx Symptomatic >90% men and 50% womenClinical Presentation Mucopurulent/purulent discharge Dysuria w/o urinary frequency ↑ or altered vaginal discharge Lower abdominal pain Intermenstrual bleeding (rare) Treatment UNCOMPLICATED ANO-RECTAL & PHARYNGEAL Single dose IM Ceftriazone 1g if sensitivies UNKNOWN Single dose ORAL Ciprofloxacin 500 mg if sensitivities known ALTERNATIVE REGIMES Single dose ORAL Cefixime 400 mg + ORAL 2 g Azithromycin Single dose IM Gentamicin 240 g + ORAL 2 g AzithromycinTest of Cure ASYMPTOMATIC: NAAT Testing SYMPTOMATIC: cultures • 72 hrs after treatment (culture) • 7 days after treatment (RNA NAAT) • 14 days after treatment (DNA NAAT) Not routine for chlamydia unless rectal case, in pregnancy or when symptoms persistComplications Pelvic inflammatory Conjunctivitis disease Chronic pelvic pain Urethral strictures Disseminated Infertility gonococcal infection Epididymo-orchitis Fitz-Hugh-Curtis Syndrome Prostatitis Septic Arthritis Chlamydia Most common STI in UK Caused by Chlamydia trachnomatis Genital, conjunctival or nasopharyngeal infection Asymptomatic 50% men and 75% womenClinical Presentation Female Male ABNORMAL VAGINAL DISCHARGE URETHRAL DISCHARGE POST-COITAL & INTERMENSTRUAL BLEEDING URETHRAL DISCOMFORT DYSURIA PELVIC +/- ABDOMINAL PAIN EPIDIYMO-ORCHITIS DYSPAREUNIA REACTIVE ARTHRITIS (RARE) Treatment UNCOMPLICATED UROGENITAL & PHARYNGEAL PO Doxycycline 100 mg BD for 7/7 ALTERNATIVE REGIMES PO Erythromycin 500 mg BD for 10-14/7 OR PO Ofloxacin 200 mg BD/400 mg OD for 7/7 Treatment PREGNANCY OR BREASTFEEDING PO Azithromycin 1 g single dose, followed by 500 mg OD for 2/7 OR PO Erythromycin 500 mg QDS for 7/7 OR PO Erythromycin 500 mg BD for 14/7 OR PO Amoxicillin 500 mg TDS for 7/7Complications Pelvic inflammatory Conjunctivitis disease Chronic pelvic pain Lymphagranuloma venereum Infertility Reactive arthritis Ectopic pregnancy Epididymo-orchitisPregnancy-related Complications Preterm delivery Neonatal conjunctivitis Premature rupture Neonatal of membranes pneumonia Low birth weight Postpartum endometritis Genital Herpes Caused by Herpes Simplex Virus, HSV-1 most common in UK Asymptomatic initial infection Latent in associated sensory nerve ganglia (sacral nerve ganglia) Primary infection symptoms for up to 3 weeksClinical Presentation Ulcers affecting genital region Neuropathic pain Flu-like symptoms Inguinal lymphadenopathy Dysuria Treatment PREFERRED REGIME PO Aciclovir 400mg TDS OR PO Valaciclovir 500 mg BD ADDITIONAL MEASURES • Paracetamol/Instillagel • Adequate oral intake • Saline baths • Loose clothing • Topical Vasaline • Abstain from sexComplications Superinfection of lesions (Candida, streptococcal) Autonomic neuropathy → urinary retention Autoinoculation to fingers and adjacent skin Aseptic meningitis Trichomoniasis Caused by trichomonas vaginalis Parasitic protozoal infection Urethral and vaginal colonisation Increased risk of contracting HIV, vaginal infections, PID, cervical cancer and pregnancy- related complicationsClinical Presentation Vaginal Discharge: yellow-green, frothy, fishy Itching Dysuria Dyspaeunia Balanitis Treatment PREFERRED PO Metronidazole 500 mg BD 5- 7/7 OR Single dose PO Metronidazole 2 g High-dose metronidazole is not recommended in pregnancy, breastfeeding or patients with HIV Syphilis Caused by Treponema pallidum, a spirochete Enters through skin or mucous membranes, replicates & disseminates 21 day incubation period Contracted sexually, via vertical transmission, IVDU, blood transfusions & other transplantsStages Primary syphilis: painless ulcer (chancre) at site of infection Secondary syphilis: systemic symptoms for 3- 12 weeks Latent syphilis: asymptomatic stage Tertiary syphilis: development of gummas NeurosyphilisClinical Presentation Primary: Painless genital ulcer +/- local lymphadenopathy Secondary: Maculopapular rash, condylomata lata, fever, lymphadenopathy, alopecia, oral lesions Tertiary: Gummatous lesions, aortic aneurysms, neurosyphilis Neurosyphilis: Tabes dorsalis, ocular syphilis, sensory and motor impairment(C) BASHH Guidelines: SyphilisDiagnosis • Antibody testing • Dark field microscopy • PCR • Rapid plasma reagin (RPR) • Venereal Disease Research Laboratory (VDRL) Various regimes for late and neurosyphillis including Ceftriaxone, amoxicillin and doxyclycline Treatment PRIMARY INFECTION Single deep IM Benzathine benzylpenicillin Penicillin allergic: Doxycycline PREGNANCY Trimester 1+2: single dose IM Benzathine benzylpenicillin Trimester 3: IM Benzathine benzylpenicillin on Day 1 and 8A 25 y/o female complains of a painful swollen L knee for the past two weeks. She was recently treated for a sexually transmitted infection. A large effusion is noted on examination. Synovial fluid analysis reveals elevated WCC but negative cultures. Which is the most likely causative organism? 1.Trichomonas vaginalis 2.Chlamydia trachomatis 3.Trepomena pallidum 4.Herpes simplex virus 5.Human papilloma virusA 25 y/o female complains of a painful swollen L knee for the past two weeks. She was recently treated for a sexually transmitted infection. A large effusion is noted on examination. Synovial fluid analysis reveals elevated WCC but negative cultures. Which is the most likely causative organism? 1.Trichomonas vaginalis 2.Chlamydia trachomatis 3.Trepomena pallidum 4.Herpes simplex virus 5.Human papilloma virusA 24-year-old woman presents to her GP with a two-week history of dysuria and vaginal discharge. She describes the discharge as thin and white-yellow, with a slight smell. She had unprotected sex with a new sexual partner two weeks ago. Which of the following is the most appropriate management? 1.Oral aciclovir 2.Oral azithromycin 3.IM benzylpenicillin 4.Oral doxycycline 5.IM ceftriaxoneA 24-year-old woman presents to her GP with a two-week history of dysuria and vaginal discharge. She describes the discharge as thin and white-yellow, with a slight smell. She had unprotected sex with a new sexual partner two weeks ago. Which of the following is the most appropriate management? 1.Oral aciclovir 2.Oral azithromycin 3.IM benzylpenicillin 4.Oral doxycycline 5.IM ceftriaxoneA 21-year-old woman presents to the GP with abnormal vaginal discharge and unexpected vaginal bleeding. She denies any rashes or genital lesions, and her last menstrual period was three weeks ago. She recently had unprotected sex with a new partner. Swabs are taken, and microscopy shows Gram-negative diplococci. Which of the following is the most likely diagnosis? 1.Trichomonas vaginalis 2.Chlamydia trachomatis 3.Trepomena pallidum 4.Bacterial vaginosis 5.Neisseria gonorrhoeaeA 21-year-old woman presents to the GP with abnormal vaginal discharge and unexpected vaginal bleeding. She denies any rashes or genital lesions, and her last menstrual period was three weeks ago. She recently had unprotected sex with a new partner. Swabs are taken, and microscopy shows Gram-negative diplococci. Which of the following is the most likely diagnosis? 1.Trichomonas vaginalis 2.Chlamydia trachomatis 3.Trepomena pallidum 4.Bacterial vaginosis 5.Neisseria gonorrhoeaeA 24-year-old woman presents to her GP with a two-week history of dysuria and vaginal discharge. She describes the discharge as thin and white-yellow, with a slight smell. Her last menstrual period was three weeks ago, and a pregnancy test is negative. There is no itching or vaginal pain. Urinalysis is negative. She had unprotected sex with a new sexual partner two weeks ago. Which of the following is the most appropriate management? 1.Oral aciclovir 2.Oral azithromycin 3.IM benzylpenicillin 4.Oral doxycycline 5.IM ceftriaxoneA 24-year-old woman presents to her GP with a two-week history of dysuria and vaginal discharge. She describes the discharge as thin and white-yellow, with a slight smell. Her last menstrual period was three weeks ago, and a pregnancy test is negative. There is no itching or vaginal pain. Urinalysis is negative. She had unprotected sex with a new sexual partner two weeks ago. Which of the following is the most appropriate management? 1.Oral aciclovir 2.Oral azithromycin 3.IM benzylpenicillin 4.Oral doxycycline 5.IM ceftriaxoneBacterial Vaginosis Disruption to vaginal microbiome e.g. antibiotics ALKALINE VAGINAL ENVIRONMENT Overgrowth of Loss of anaerobic bacteria Gardnerella vaginosis lactobacilli species Mycoplasma hominis Prevotella spp.Risk Factors Multiple sexual partners Smoking Excessive vaginal Copper coil cleaning Recent antibiotics Presence of STI Black ethnicityClinical Presentation Offensive (fish-smelling) discharge White/grey discharge Asymptomatic (50%) O/e: Thin, white homonogeous dischargeComplications Can increase the risk of contracting a sexually transmitted disease Pregnancy-related Complications Miscarriage Chorioamniotis Preterm delivery Low brith weight Premature rupture of membranes Postpartum endometritisCandidiasis • Vaginal infection with candida • Candida albicans commonly • Colonisation vs infection • Risk Factors: ⚬ Pregnancy ⚬ Poorly controlled diabetes ⚬ Immunosuppression ⚬ Broad-spectrum antibioticsClinical Presentation Thick white discharge Vulval +/- vaginal itching, irritation, discomfort [s] Erythema and oedema [s] Fissure [s] Dysparaenuria & dysuriaDiagnosis • Clinical diagnosis • Vaginal swab for microscopy ⚬ Charcoal swab Treatment RECOMMENDED ANTIFUNGALS Single dose PO Fluconazole 150 mg OR Topical/Intravaginal 1-2% clotrimazole BD/TDS OR Single dose intravaginal 5g of 10% clotrimazole cream nocte OR Single dose clotrimazole 500 mg pessary nocte OR Three doses clotrimazole 200 mg pessaries over three nightsA 22-year-old type 1 diabetic woman presents to the GUM clinic complaining of a thick, white vaginal discharge. On questioning, she reports no history of sexually transmitted infection. What is the next most appropriate step in management? 1.Intravaginal clotrimazole cream 2.Clotrimazole pessary 3.PO fluconazole 4.PO clindamycin 5.PO nystatinA 22-year-old type 1 diabetic woman presents to the GUM clinic complaining of a thick, white vaginal discharge. On questioning, she reports no history of sexually transmitted infection. What is the next most appropriate step in management? 1.Intravaginal clotrimazole cream 2.Clotrimazole pessary 3.PO fluconazole 4.PO clindamycin 5.PO nystatinA 32-year-old woman presents to clinic with a 4-day history of vaginal pruritus and reports a white, curd-like vaginal discharge. She is currently at 32 weeks gestation of her third pregnancy. Given the likely diagnosis, which of the following is the most appropriate course of management? 1.Ketaconazole 2% cream 2.No treatment 3.PO Itraconazole 4.PO fluconazole 5.Intravaginal clotrimazoleA 32-year-old woman presents to clinic with a 4-day history of vaginal pruritus and reports a white, curd-like vaginal discharge. She is currently at 32 weeks gestation of her third pregnancy. Given the likely diagnosis, which of the following is the most appropriate course of management? 1.Ketaconazole 2% cream 2.No treatment 3.PO Itraconazole 4.PO fluconazole 5.Intravaginal clotrimazoleA 21-year-old woman presents to clinic with vaginal discharge that increases around her menses. Upon bimanual and speculum examination, an ectropion is observed and there is noted to be a fishy odour. What is the most likely causative organism for this presentation? 1.Gardnerella vaginalis 2.Candida albicans 3.Trichomoniasis vaginalis 4.Candida glabrata 5.Escherichia coliA 21-year-old woman presents to clinic with vaginal discharge that increases around her menses. Upon bimanual and speculum examination, an ectropion is observed and there is noted to be a fishy odour. What is the most likely causative organism for this presentation? 1.Gardnerella vaginalis 2.Candida albicans 3.Trichomoniasis vaginalis 4.Candida glabrata 5.Escherichia coliEpididymo-orchitis • Epididymitis: inflammation of the epididymis • Orchitis: inflammation of testicles • Epididymo-orchitis: result of infection in the epididymis and testicle on one side • Causes: ⚬ E. coli ⚬ Chlamydia trachomatis ⚬ Neisseria gonorrhoea ⚬ MumpsClinical Presentation TESTICULAR PAIN SWELLING OF TESTICLE AND EPIDYMIS TENDERNESS ON PALPATION URETHRAL DISCHARGE SYSTEMIC FEATURESDiagnosis Treat as testicular torsion until proven otherwise • Urine MC&S • Chlamydia & gonorrhoea NAAT testing (first-pass urine) • Charcoal swab for gonorrhoea C&S • Salvia swap for PCR mumps • Serum antibodies for mumps • UltrasoundManagement • Empirical antibiotics: ⚬ PO Ofloxacin 200 mg BD 14/7 OR PO Levofloxacin 500 mg OD 10/7 ⚬ Alternatives: doxycycline, ciprofloxacin, Co-amoxiclav • Analgesia: ⚬ Paracetamol +/- NSAIDs • Supportive underwear • Reduced physical activity • Abstienence from intercourseComplications Chronic pain Sub-fertility & infertility Chronic Reactive hydrocele epididymitis Testicular Scrotal abscess atrophyErectile Dysfunction Symptom not a disease Organic vs psychogenic causes Not a normal part of aging Red flags: priaprism, young, suspicious DRE +/- ↑PSARisk Factors Vascular Disease Other CVD Risk Factors Autonomic Neuropathy Alcohol Drugs: SSRIs, beta-blockers Endocrine disorders Anatomical abnomalities, trauma or surgeryInvestigations Q-RISK score + Sexual + psych Hx metabolic profile FBC, U&E, TFTs, DRE prolactin PSA Free Testosterone Can be managed in primary care or may require endocrine or urology referralManagement • Address modifiable risk factors • Psychosexual therapy • Oral phosphodiesterase inhibitors (Sildenafil) ⚬ S/E: headache, flushing, hypotension, blue tinge to vision ⚬ C/I: anterior ischaemic optic neuropathy, recent MI/stroke/ unstable angina, hypotension, use of organic nitrates • Vacuum erection devices • Intra-cavernosal injectionsA 25-year-old man presents to the emergency department with a 24-hour history of a moderately painful, swollen right testicle. He has recently returned from a holiday in Thailand where he had unprotected sexual intercourse with multiple women. He also reports some mild urethral discharge. The right testicle is tender to palpation. What is the most likely cause of his testicular pain? 1.Testicular Torsion 2.Hydrocoele 3.E. coli urinary tract infection 4.Chlamydia trachomatis 5.VaricocoeleA 25-year-old man presents to the emergency department with a 24-hour history of a moderately painful, swollen right testicle. He has recently returned from a holiday in Thailand where he had unprotected sexual intercourse with multiple women. He also reports some mild urethral discharge. The right testicle is tender to palpation. What is the most likely cause of his testicular pain? 1.Testicular Torsion 2.Hydrocoele 3.E. coli urinary tract infection 4.Chlamydia trachomatis 5.VaricocoeleA 62-year-old male presents to the GP with erectile dysfunction but is advised that he can not start phosphodiesterase-5 (PDE5) inhibitors due to a contraindication. Which of the following is a contraindication of PDE5 inhibitors? 1.Use of organic nitrates 2.SBP 140 mmHg 3.Myocardial infarction 3 years ago 4.Stable angina 5.DiabetesA 62-year-old male presents to the GP with erectile dysfunction but is advised that he can not start phosphodiesterase-5 (PDE5) inhibitors due to a contraindication. Which of the following is a contraindication of PDE5 inhibitors? 1.Use of organic nitrates 2.SBP 140 mmHg 3.Myocardial infarction 3 years ago 4.Stable angina 5.DiabetesAn 18-year-old man presents to the emergency department with right-sided testicular pain. Which of the following would favour a diagnosis of epididymo- orchitis over testicular torsion? 1.Worsening of pain on elevation 2.Blue-dot sign 3.Sudden onset 4.Relief of pain on elevation 5.Absent cremasteric reflexAn 18-year-old man presents to the emergency department with right-sided testicular pain. Which of the following would favour a diagnosis of epididymo- orchitis over testicular torsion? 1.Worsening of pain on elevation 2.Blue-dot sign 3.Sudden onset 4.Relief of pain on elevation 5.Absent cremasteric reflexMCQ Clues Gram-negative diplococcus = Neisseria gonorrhoeae (2 ss/2rs) 1 Sore joint (knee) = chlamydia Sore tendon/multiple sore joints = disseminated gonorrhoea Strawberry cervix = trichomoniasis ↑Ca-125 - ?pelvic inflammatory diseaseMCQ Clues Clue cells = bacterial vaginosis Vasculopath in erectile dysfunction Common STIs are common Right upper quadrant pain in person of childbearing age - Fitz-Hugh-Curtis Syndrome? GUM OSCEs COUNSELLING INFECTIONS OR DISCHARGE SOCIAL HISTORY - SEXUAL HISTORY TESTICULAR PAIN GYNAE - CONTRACEPTION, SMEARSContraception Counselling Very brief sexual + obstetric history Ideas, Concerns and Expectations Consent, Sexual History, Safeguarding, Intention Answer patient Contraindications Mechanism of Action/Delivery System Risk v BenefitsSTI Management Advice • Check for penicillin allergy • Refer to GUM for contact tracing • Abstain from sex for 7/7 after treatment of all partners • Test for and treat any other STIs • Provide advice about preventing future infection • Consider safeguarding issues and sexual abuse in young people • Leaflets, NHS Website, FSRH and BASSH • Notifiable Disease/Organisms: Monkeypox, Hep A/B/C/D/E, MumpsOSCE Advice • Ideas, Concerns, Expectations • Build rapport and reassure patient that this is normal and this is a safe environment • Don’t assume sexual orientation or pregnancy risk ⚬ LGBTQIA+ inclusivity • Leaflets or other sources of information • If you feel awkward, the patient will • Communication skills >>> Clinical KnowledgeAny questions? hmcphee01@qub.ac.uk