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STIs (SYSTEMIC PRESENTATION OF STIs (widespread trunkal rash from…

- - - - 50% women asymptomatic
      - inc vag discharge, fishy odour, usually without any itch or irritation - odour often worse after sexual intercourse and during menstruation
    - - Gram stained vaginal smear showing depletion of normal lactobacilli and the presence of mixed organisms is the preferred method of diagnosis
      - amsel's criteria = 3 of the following = thin homogeneous discharge on exam, vag pH>4.5, amine odour after adding 10% potassium hydroxide to vag fluid, clue cells on microscopy
        
        menses, semen and infection with T. vaginalis can also give raised pH and pos amine test
        culture of vag secretion is not done
    - - No need if asymptomatic
      - metronidazole/clindamycin/vag gel/cream
    - - BV inc vaginal vault infection following hysterectomy, postpartum endometritis follow CS and post-abortal pelvic inflammatory disease after surgical termination of pregnancy
      - womans risk of HIV inc 2/3 fold and may inc transmission of HIV to male partner
  - - - vulval itching, thick white vaginal discharge, vulval burning, external dysuria and superficial dyspareunia
      - examination - vulval erythema, satelite lesions, fissuring, excoriation, oedema, whtie plaques on vaginal walls, discharge may be minimal
    - - microscopy and culture
    - - TOPICAL - clotrimazole/econazole/miconazole pessaries
      - ORAL - fluconazole/itraconazole
  - - - 70% asymptomatic
      - non specific: inc vag discharge, dysuria, post coital bleedong
      - lower abdo pain, dysapreunia, IMB (if spread beyond cervix)
    - - nucleic acid amplification test eg PCR (cervical or vulvovaginal swab samples)
      - enzyme immuno assay is outdated
    - - uncomplicated = azithromycin/doxycycline
      - preg and lactating = erythromycin
      - abstain from sex until completed treatment
      - test of cure unnecessary unless except after treatment in preg
      - reinfection 10-30% so retest after 6-12mths is indicated
    - - can spread beyond lower genital tract = cause skene and bartholin gland abscesses, endometritis, salpingitis, perihepatitis
      - many develop PID = lead to tubal damage, predisposing to tubal pregnancies and tubal infertility as well as causing chronic pain
      - asymptomatic upper genital tract nfection may also cause tubule damage but is so unlikely to cause infertility
      - during preg may cause miscarriage, pre-term birth, PPI, neonatal infeciton,
      - 3-4 x more likely to get HIV
      - SARA sexually acquired RA (genetic)
  - - - cervix primary site of infection but urethra also infected in 70-90%
      - 50% have no symptoms
      - lower abdo pain and IMB if infection spread beyond cervix
      - on examination may be purulent or mucopurulent cervicitis and/or contact bleeding but cervix may look normal
    - - NAAT - has lower specificty than culture but inc sensitivity - NAAT also allows abx sensitivity testing
      - also check non genital sites
    - - in preg, lactating (All women) give ceftriaxone im (oral not recommended) plus azithromycin
      - abstain until complete treatment
    - - can spread beyond lower genital tract => skene and bartholin gland abscesses, endometritis, salpingitis, perihepatitis => tubule preg/tubule infertility
  - - - ONSET OF SYMPTOMS OFTEN OCCUR IN FIRST PART OF MENSTRUAL CYCLE
      - women with chlamydia PID is less severe than gonorrhoea PID
      - lower abdo pain usually bilateral, inc vag discharge
      - adnexal and cervical motion tenderness on bimanual examination is the most common sign, but pyrexia and a palapable adnexal mass may also be present
    - - OFTEN CLINICAL
      - ESR, WCC, CRP raised (non specific)
      - DDX = Appendicitis, ectopic, preg
      - gold standard = laparoscopy
    - - Dont delay while waiting for bacteriological test results
      - if mild - oral abx as outpatient
      - iv and hospitalised if severe
    - - tubule damage, ectopic, repeated infecitons
  - - - microscopy, NAAT
    - - vag discharge with malodour
      - may also be vulval pruritus, external dysuriaand dyspareunia
      - on examination, there may be vulval erythema and excoriation
    - - METRONIDAZOLE also test for STIs
    - - Inc risk of HIV and in preg its assoc with low birth rate and preterm delivery
  - - - if symptomatic it is usual that the woman has felt the vulval lumps
      - painless so may be asymptomatic
    - - by clinical appearances
      - atypical lesions should be biopsied esp in older women
    - - warts may resolve spontaneously
      - kerative or <5 can ablate - cryotherapy, trichloroacetic acid, curettage or electro-cautery - all can be used in preg
      - dont use imiquimob cream in pregnancy
      - offer testing for STIs
      - condoms prevent spread of HPV
  - - - range from mild irritation and soreness
      - genital lesions classically pass through erythematous, vesicular and ulcerative stages before resolution
      - PRIMARY INFECTION
        
        Can cause vulval soreness and external and external dysuria but can also be asymptomatic
        
        as symptoms are non specific may be misdiagnosed with UTI or candida
        
        on examination there are multiple painful superficial ulcers
        
        tender inguinal lymphadenopathy is also usually present
      - NON PRIMARY FIRST EPISODE
        
        have previous hsv1 exposure and now hsv2
        
        some cross protection so is milder = more likely to be asymptomatic
      - COMPLICATIONS
        
        if during preg, particularly third trimester, may transmit infection to baby at time of delivery
        
        risk of perinatal transmission with recurrent HSV is low
        
        inc risk of HIV
        
        meningitis and autonomic neuropathy can occassionally occur in primary infection even lead to urinary retention
      - RECURRENT HERPES
        
        may be preceded by a prodrome of tingling, itching or pain in area
    - - NAAT OF SWABS FROM LESIONS
    - - primary and first episode = aciclovir/famiciclovir/valaciclovir
      - aciclovir can be used in preg and breast feeding
      - analgesia and saline bathing recommended
      - lidocaine gel - topical analgesia
      - test for other STIs
      - recurrent = episodic antiviral therapy may also have suppressive regimen taking -ciclovir daily
  - - - primary syphilis
        
        about 3 wks after exposure, a chancre appears. usually a single painless ulcer with rolled indurated edges which usually goes unnoticed in women - even without treatment heals spontaneously - syph serology may still be neg
      - secondary syphilis
        
        after several wks a generalised illness develops, with fever, malaise and skin and mucosal rashes - present on trunl, limbs, palms and soles - even if untreated resolves after 3-12 wks - syph serology strongly pos
      - late syphilis
        
        up to 40% of untreated pts will develop symptomatic late syphilis with neurosyphilis, CV syphilis or gummata
    - - serological testing - ENZYME IMMUNOASSAY - if positive then should do VDRL or RPR and TPHA and FTA-abs test
    - - LONG courses of abx and long-term follow up.
      - penicillins remain the treatment of choice
    - - if not treated = complications of late syphilis occur
      - can cause miscarriage and stillbirth and can be transmitted ti the infant causing congenital syphilis
- - - - vulval intraepithelial neoplasia and vulval cancer
      - molluscum contagiosum
      - genital warts
- - - - clinical indicator conditions: cervical cancer, cervical intraepithelial neiplasia (grade 2 and above) and vulval and vaginal intraepithelial neoplasia