What spirochete causes syphilis
Treponema Pallidum
Transmission routes of syphillis
- Sexual
- Accidental infection
- Blood bourne
- Transplacental
Describe the three types of stages that occur with syphilis
- Regional lymphadenopathy - resolves in 3-8 weeks
- If untreated, virus spreads
LATENT:
1. Asymptomatic
LATE:
1. Spreads to MSK, mucosa, CV and neurosyphilis
Presentation of early syphilis (primary)
- Painless papule at inoculation site
- Spreads and ulcerates (painful chancre with clear margins, moist base and serous exudate on pressure
- Bilateral painless regional lymphadenopathy
- Oral sex =oropharyngeal ulceration
- Balanitis
Where else are chancre sites found
- Lips
- Tongue
- Tonsils
- Pharynx
- Anal margin
- Rectum
What is secondary syphilis
- Heamatogenous dissemination of infection
Clinical features of secondary syphilis
1, Macular, papular and hypo-pigmented lesions
- Lymphadenopathy
- Mucous membrane lesions (white/grey border may coalesce oral cavity, larynx, nasal mucosa, genitalia, anus and rectum)
- Alopecia (telogen effluvium)
- Periostitis, bursitis (bone pain)
- Hepatitis
- Glomurulonephirits/nephrotic syndrome
- Meningism
- Iritis/ anterior uveitis/ optic atrophy
Differentials of secondary syphilis
- Measles
- Rubella (cervical lymphadenopathy)
- Psoriasis (papular rash)
What is gummatous syphilis
- Gumata is syphilitic granulation tissue, nodules with central scarring
Where are gummatous syphilis found
- Skin
- Bones
- Mouth and throat
- Liver, testis
Clinical features of late syphilis
- Gummata
- CV: Aortic aneurysm, regurgitation
- Neurosyphilis: Meningovascular, general paralysis, rabes dorsals
Tabes Dorsalis: degenration of posterior columns and posterior root(difficulty walking etc)
Clinical features of babies with suyphilis
- Failure to thrive
- Skin lesions around mouth and body orifices
- Sparse hair and brittle, atrophic nails
- Hepatosplenomegaly
- Oesteochondritis and later periostitis
How is syphilis diagnosed
- Serum from chancres
- Cardiolipin antigen test
- Treponema pallidum PCR
- CSF test if neurosyphilis
- X-ray
- CT angio
- Ophthalmic slit lamp examination
NEUROIMAGING
What is seen on a syphilis serological test
- EIA positive, TPPA positive, VDRL positive, IgM positive
How i early syphilis treated
- Benzathine benzylpenecillin
treatment of late, latent, CV or gummatous syphilis
- Banzethine benzyl penicillin
Treatment of neurosyphilis
- Procaine benzylpenecilin
Histology of neisseria gonorrhoea
- Grame negative
2. Diplococci
Clinical features of n.gonnorheoa in males
Incubation: 2-5 days
- Urtehral discharge
- Dysuria
- Yellow/green discharge
- Erythema of the urethral meatus + oedema
- Anterior uveitis
Clinical features of n.gonnorheoa in females
- Asymptomatic
- Vaginal discharge
- Syduria without frequency
- lower abdo pain
Complications of n/gonnorhea
Male:
- Urethral stricture/fistula
- Prostatitis
- Epididymitis
Inflammation of scene’s glands in women
Pelvic inflammatory disease
Clinical features of disseminated gonococcal infection (systemic spread of infection)
- Gonococcal dermatitis
- Tenosynovitis
- Endocarditis
- Hepatitis
- Meningitis
Diagnosis of n.gonorrhoea
VUlvovaginalr, urethral smear for NAAT
Endocervical smear microscopy
Mid-stream microscopy: urethrl sample
Swab from area that seems infected basically
Blood culture
Treatment of n.gonnorheoa
- Ceftriaxone 1g IM single dose
Clinical Features of c.trachomatis
ONLY 60% have signs
- INCREASED vaginal discharge
- Dysuria without frequency
MALE:
- Urethral discharge
- Dysuria
Complications of c.trachomatis in males
- Reiter’s syndrome
- Prostatitis/urethritis
Pelvic inflammatory disease
Diagnostics of c.tracheomatis
- NAAT
- Light microscopy
- Sterile pyuria in MSM
Treatment of c.tracheomatis
- Doxycycline
What can cause orgasmic dysfunction and low arousal
- Partner conflict
- Ignorance
- Anxiety/depression
Management of orgasmic dysfunction
- Sensate focus
2. Testosterone gel when both ovaries removed
What is dyspareunia
1, Genital pain just before or after sexual intercourse
What is vaginismus
- Learned response secondary to dyspareunia - involuntary contraction of muscular of OUTER THIRD of vagina cueing distress
Factors that contribute to vaginismus
- Pregnancy
- Loss of control
- Sexual abuse
Management of vaginismus
- Encourage inserting finger in vagina
- Proceed to more fingers and use librication
- Kegel escercise
- Suggest partner involvement
What score system is used for erectile dysfunction
- IIEF-5
How does the IIEF-5 work
Confidence in getting and keeping an erection (1->5)
Erections on sexual stimulation hard enough for
penetration (1->5)
Maintaining erection after penetration
Maintaining erection to completion of intercourse
Satisfactory intercourse
Main causes of ED
- Lifestyle factors
- Trauma and Iatrogenic
- Drugs
- Vascular
- Endocrine
- Neuro: MS, Parkinson’s
- Psychogenic (depression/anziety
First line management for ED
- Psychosexual therapy
- Sildenafil (PDE 5 inhibitor)
- Tadalafil
- Prostaglandin E1 agent: Alprostadil
- Implants and vacuum devices
What can cause premature ejaculation
- Anxiety, deep sexual concerns, sexual assault
Primary vs secondary premature ejacultation
- Primary: ALWAYS been problem
SECONDARY: Performance anxiety, previous control
How is Premature EJ work
- Ejaculation 1-2 hours before
- Deep breath before ejacultaion (reduce stimulation)
3/ Distraction techniques - Reduce sensation
What is delayed ejaculation
- Difficulty having an orgasm
- What can cause delayed ejaculation
- Decreased sensitivity
- Prostatectomy
- MS
- Alcohol
- DM
Management of delayed ejaculation
- Reduce masturbation
- Resolve underlying anxiety
3.
What is retrograde ejaculation
- Semen enter the bladder instead of through the penis during orgasm (dry orgasm)
What can cause retrograde ejaculation
- Dysautonomia
2. Operation on prostate - transurethral resection of the prostate
How is retrograde ejaculation diagnosed
- Urinalysis
What is vulvodynia
- Affects vulvar area, chronic pain syndrome (burning)
How is vulvodynia diagnosed
Symptoms must last 3 months
Clinical features of vulvodynia
- Burning at entrance to vagina that happens when touched (tampons etc)
Causes of vulvodynia
- Sjogren syndrome
- Neuropathy
- SLE
How is vulvodynia treated
- Lubricant during sex
- Cotton underwear
- Counselling
What is peyronie’s disease
- disease causes plaques to form after chronic inflammation of tunica albuginea
- Causes abnormal curvature of penis
Diagnosis of peyronie’s disease
- penile ultrasonography
Clinical features of peyrnoie’s disease
Sexual intercourse is painful
What causes aspermia
Retrograde ejaculation Alpha blockers (tamsulosin)
What is hypospadias
- Congenital where urethra does no open in its usual location
Clinical feature of hypospadias
- Foreskin less developed (hooded)
- Chordee (downward bending of penis)
- Undescended testicles
- Pain on ejculation or weak ejaculation
Treatment of hypospadias
- Urethroplasty
What can cause anejaculation
- Spinal cord injury
What is female sexual arousal disorder
- Inability to attain sexual arousal
Diagnosis of female sexual arousal disorder
- Inadequate lubrication swelling response normally present during arousal
Diagnosis of female sexual arousal disorder
- Little interest in sex
- Few thought related to sex
- Decreased start and rejecting of sex
- Little genital sensations during sex MOST OF THE TIME
Treatment of female sexual arousal disorder
- Flibanserin
What is hypoactive sexual desire disorder
- Lack of sexual fantasies and desire for sexual activity in MALES
How is hypoactive sexual desire disorder treated
COUNSELLING FLIBANSERIN (this increases libido
What is sexual aversion disorder
IN FEMALES
What is a paraphilia
- INTENSE sexual arousal to atypical objects, situations fantasies or individuals
What causes pelvic inflammatory disease
- C.trachomatis
- N.gonnroheoa
- M.genitalium
What factors can facilitate ascending infection of PID
- Uterine contractions
- Loss of cervical mucus plug
- Carriage of bacteria by spermatozoa
Risk factors for PID
- YOUNG
- NEW PARTER within 3 months
3 .Past history of PID - Vaginal douching
- SMOKING
Symptoms of Acute PID
- Lower abdo pain
- Deep dyspareunia
- Menstrual regularity
- Vaginal discharge
- Nausea
Signs of Acute PID
- Lower abdo tenderness with guarding
- Fever
- Adnexal mass
- Abdo distention
Complications of chronic PID
- Peri-Appendicitis
- Infertility
- Ectopic pregnancy
- Perihepatitis
What is Fitz-Hugh-Curtis syndrome
- Violin string adhesions between anterior surface of liver and abdo wall
Investigations of PID
- SWABS
- FBC, CRP, ESR, chlamydial antibody
- MSSU
- Pelvic Imaging
- Lapsoscopy GOLD STANDARD
Differentials of PID
- Ectopic pregnancy
- Appendicitis
- Ovarian cyst
- IBS
Management of PID
- AVOID sexual intercourse and give CEFTRIOXONE + doxycycline
Symptoms of Acute prostatitis
- Prostatic pain
- LUTS
- Pyrexia, arthralgia
Diagnosis of prostatitis
- MSSU
- DRE
- BLOOD TESTS
- Prostatic specific antigen
- MRI of pelvis and lumbar spine
- STI screening
Management of prostatitis
- ORAL CIPROFLOXCIN or TRIMETHOPRIM
2. Paracteromal and ibuprofen
three causes of haematospermia
- Trauma
- Inflammation
- Hypertension
- Warfarin
- Haematological disorders - laekaemia
What classifies a UTI
10^5 in Urinalysis
Management of Prostatitis
- Ciprofloxacin
- Tamsulosin
- NSAIDs
- Finasteride
What class of drug is finasteride
5-alpha reductase inhibitor
What causes epipidymo-orchitis
- c tract or n.gonnorheoa
Where does infection spread from in epididymoorchitis
- urethra or bladder
2. Lymphatics or blood vessels
Causes of UTIs
- Sex
2. Catheters
What causes UTIs
- E coli
- Klebsiella
- Pseudomonas
- Shigella
- Salmonella
Clinical features of epididymo-orchitis
- Pyrexia
- arthritis
- Scrotal erythema
- Swelling of epididymis
- UNILATERAL scrotal pain and swelling
Complications of epididymo-orchitis
- Hydrocele
- Abscess
- Infertility
- Chronic prostatitis
Investigation for epididymo-orhcitis
- MSSU
- Microscopu
- FBC, CRP
- NAAT swab
- Doppler ultrasonography to exclude differentials
- Epididymal aspiration
Differentials for epididymo-orchitis
- Torsion
- Epididymitis
- Testicular cancer
Management of epididymo-orchitis
- NSAID
2. Doxycycline + ceftriaxone
What can cause reactive arthritis
- C trachematis
- Ureaplasma urealyticum
- N.gonnorheoa
- Shigella
- Salmonella
Clinical features of reactive arthritis
- Urethritis/iritis/episcleritis
- Dysuria
- Arthritis (asymmetrical polyarthritis)/enthesistis
- keratodemra blennorhagica
- Erythema nodosum
- Balantis/oral lesions
Where is arthritis seen in reactive arthritis
- Lower limbs
2. Sacroilitis
Diagnosis for reactive arthritis
- Stool culture
- ESR.CRP
- Urinalysis
- Radiology for periostitis/sacrolilitis
- ECG
- Syonivial tipsy
- HLA-B27 test
RF negative
ANA test negative
How is arthritis and enthesistis in reactive arthritis
- NCOX-2 NSAID, pred, STI antibiotics
What organism causes bacterial vaginosis
g.vaginalis
histology of g.vaginalis
Gram negative bacillus
Clinical features of g.vaginalis
- Vaginal discharge
- Moderate volume, grey->white->yellow
Frothy
Irritation
Complication of g.vaginalis
- PID
2. Pots-Hysterectomy vaginal cuff cellulitis
Treatment of g.vaginalis
- Metronidazol e
2. Clindamycin
How is trichomoniasis infection treated
ORAL metronidazole
Histology of trichomoniasis
- Flagella, hydrogenosomes, axostyle
Most common organism that causes genitalcandidiasis
- Candid albicans
Pre-disposing factors to genital candidiasis
- DM
- CHild-bearing years: luteal phase of menstruation, 3rd trimester
- HIV and drugs that impair immunity
- Contraceptives
Clinical features of genital candidiasis
- Vulval pruritus
- Burning
- External dysuria
- Dyspareunia
- Vulval erythema
What can cause recurrent vulvovaginal candidiasis
- Hypersensitivity
2. Sex
Clinical features of men wit genital candidiasis
- Balantis
2. Balanoposthitis
Diagnosis of genital candidiasis
- SWABS and microscopy
- Latex agglutination test
- PCR
- Vaginal pH should be normal
- Urinalysis
Management of genital candidiasis
- Bathing in saline or Nabicarbonate
2. Clotrimazole or oral Fluconazole
Causes of UTI (organisms)
- Staphylococcus saprophysticus
- Ecoli
- Proteus mirabilis
- Enterococci
Klebsiella and enterobacter
Diagnostics of UTi
- CLOUDY urine
- leucocyte esterase
- Nitrate reductase
- Protein and haematuria
- MSSU (10^5)
How are UTIs treated
- Fluids
2. Nitrofurantoin or trimethoprim
Complicated vs uncomplicated UTI
1.Uncomplciated are caused by a predictable group of organisms, complicated are not
Course of progression of HSV
- Primary infection
- Latency in dorsal root ganglion
- Reactivation upon nerve stimulation
- Recurrence (peripheral lesions)
- Viral shedding
Clinical features of HSV
- Pain
- Irritation
- Regional node lymphadenopathy
- Vaginal/urethral discharge
- crusting
- Urinary retention, micturition
Complications of HSV
- aSeptic meningiti s
- Sacral radiluopathy
- PHARYNGITIS
Diagnosis of HSV
- PCR swabs from lesions
- Viral cell culture
- IgM and western blot serology
- Cervical cytology
Treatment of HSV
- Saline washes to reduce risk of superinfection
- Drink plenty of flud
- Codeine phosphate
- Acyclovir (5 days)
How to prevent HSV
- Circumcision
- Condom
- Antiviral drugs
Clinical features of HPV
- Genital warts found in areas likely to be traumatised udirng sex (prepuce, urethral meatus, scrotum)
Treatment of HPV
- Podophyllotoxin
- Cryotherapy
- Trichloroacetic acid
- Electrosurgery
Machoism of action of combined pill, vaginal ring and patch
Inhabit ovulation
2. Alter cervical mucus to stop spermatozoa penetration
ADVANTAGES of combined hormonal contraceptives
- Improve acne
- Protects against PID
- Reduces risk of ovarian cancer
- Reduce large bowel cancer
DISADVANTAGES of combined hormonal contrraceptive
- Needs constant use
2. No protection against STI
IF Combine spill is missed what should the patient do
Take forgotten and take next pill when due
2. If missed two,do the same but abstain for 7 days/codnoms
First choice of COC
- Levonorgestrel
Side effects of COC/oestrogen
- Headaches
- Nausea
- Breast tenderness
- Leg Cramps
Side effects of COC/progesterone
- Mood change
- Bloating
- Greasy skin
What should be given to women postpartum contraception
POP
Prior to surgery what should be done to the oral contraceptive pill
Stop IMMEDIATELY and switch to POP
How doe the UKMEC system work for COC
- More than 35 and smoking less than 15 cigs
- BMI >35
- Fmaily history of thromboembolic disease
- Controlled HTN
- Immobility
- Gallbladder disease
UKMEC 3
UKMEC 4:
- Migraine with aura
- Uncontrolled HTn
- Current breast cancer
What is the time frame of using a copper inauterine device
- Inserted for emergency contraception within 5 days after unprotected sex
Clinical features of PID
INFLAMMATION OF UTERUS, FALLOPIAN TUBES< OVARUES AND CERVIX
1. Lower sbdo pain
2. Post coital bleeding
Intermenstrual bleeding
Chornic:
Low grade fever
Weight Loss
ABdo pain
Extra genital symptoms of Chlamidya and Gonnorheoa
- Contact with eyes - conjunctivitis
- Contact with anal or rectal mucosa - Proctitis (tenesmus, anorectal pain and bleeding, constipation)
- Pharyngitis
Treatment of PID
- IV Cefoxitin -> doxycycline for 14 days
Name three cancers caused by HPV
- Penile, anorectal, oropharyngeal
2. Carvical, vulvar, vaginal
What serotypes of HPV cause anogenital warts
6 and 11
How is HPv diagnosed
Appearance of warts or biopsy
Treatment of anogenital warts
1, Cryotherapy or TOPICAL IMIQUIMOD
CF of trichomona vaginalis
- Bad smelling prurulent discharge
- Burning
- Pruritus
LRTI symptoms and lower abod pain
DIagnosis of trichomona vaginalis
- NAAT or microsocpy of vaginal secretion
Symptoms of Crabs (pediculosis pubis) and SCabies (sarcoptes scabiei)
- BOTH PRURITIS
Lice and nits in crabs can be seen
Scbaies show erythematous papules
Microsocpic examination of hair shafts or skin
Treatment of Crabs
- Topical Permethrin
2. Nits should be removed with tweezers
Treatment of Scabies
Oral Ivermectin
Primary infection of HSV what does this mean
No previous anti HSV virus antibodies 1. Painful vesicles Pruritus Dysuria Ignuinal lymphadenopathy Fever, headahces myaglgia
Diagnosis of HSV
- Viral culture
- HSV PCR
- Serology - anti HSV antibodies
Treatment of HSV
1, Oral acyclovir
How does haemophilus decreyi cause infection
Micraabrasions in the askin -> ulcers (chancres - bleed when scraped)
Diagnosis of haemophilus decreyi
PCR
Culture
Gram Stain
Treatment of haemophilus decreyi
Ceftriaxone IM
Primary vs Secondary syphilis (both early syphilis)
Primary: Chancres
Resolves and cause systemic infection
Secondary: Comes back but no chancre Systemic infection: lymphadenopathy in inguinal and femoral regions and cervical Symmetrical maculapapular rash Heptatitis Oliguria Arterial Hypertension
What defines AIDS
CD4 cell count less than 200 mol /ml
Or presence of aids defining illness: pneuomocystic jiroveci
Diagnosis of HIV
- Enzyme-linked immunoassays
- Western Blot
- HIV viral load test (RNA)
If 1 is negative and 3 is positive - early infection
If both are positive - early or established infection
Symptoms of acute hepatitis
Nausea
Vomtiing
Upper RQ pain
Jaundice, puritis, dark urine
SYmptpoms of chronic hepatiti s
- Extrahepatic symptoms:
Arthlagia
Skin rashes
Blood test results in Hep B
HBs antigen Pos
Blood test results in Hep C
Anti-HCV Igg - positive
Treatment of Hep B
Pegylated INF
Tenofovor
Treatment of Hep C
- Velpatisvir
After what time can sexual disorders be diagnsoed
6 months
Three characteristics of played ejactulation
- Marked DELAY
- MARKED infrequency
- ABSENCE
What is Male hypoactive sexual desire disorder
- Few or no sexual thoughts
2. Low or absent desire for sexua activity
What diagnosis premature ejaculation
- Within 1 min of penetration
2. BEFORE they wish to
Three features of female orgasmic disorder
- Delay
- Infrequency
- Absence of orgasm
When is sildenafil taken before sex
30 mins to 1 hour BEFORE
How is alprostadil delivered
Intracacvernous injection
How is vaginismus treated
Botox injection A
- Vulvar vestibulectomy
- Lidocaine
Gender identity vs expression
- Own sense of gender vs how they present themselves to the world
Define transgender
GI is discordant from sex assigned at birth
What Hep B serology is seen if positive
- HepBsAg
HepBcAb
AntiHBs - vaccination
What Microbe causes warts
HPV 6 and 11
Symptoms of anogenital warts
- Single or multiple lumps
- irritation or discomfort
- Bleeding
- Rarely, secondary infection or maceration
Appearance of genital warts
Soft cauliflower-like growths of varying size but can be flat, plaque-like or pigmented.
Lesions can be BOTH moist and non-keratinised and also firm and keratinised
Anogenital warts diagnosis
Just the appearance
Management of genital warts
- Podophyllotoxin twice daily
Or cryotherapy
Management of a pregnant mown with Hep B
Only give immunoglobulins and vaccinations
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