Genitourinary medicine in pictures 7th Oct 2011 Dr K N Sankar 1 Number of new diagnoses of selected STIs, GUM clinics, United Kingdom: 2009-10 Conditions diagnosed in GUM clinics 2009 2010 % change 2009-10 Chlamydial infection 96,869 91,075 -6% Non-specific genital infection (urethritis in men or cervicitis 85,188 79,983 -6% Genital warts 77,900 75,615 -3% Genital herpes simplex 27,564 29,703 8% Gonorrhoea 15,978 16,531 3% Syphilis (early) 2,846 2,624 -8% in women without chlamydia and gonorrhoea) • Under 25 are responsible for over 50% of STI diagnoses • Under 25 represent less than 15% of the population Routine GUM clinic returns Risk factors for STIs STI ---- Complications and Sequelae • younger age (especially <25 years) • • sexual orientation ethnicity (for some STIs) • • living in inner city >2 partners in preceding 6 months • • use of non barrier contraception partner with symptoms • ANOGENITAL CANCERS • • having current STI history of STI in the past • AIDS • • • • PID ECTOPIC PREGNANCY INFERTILITY PERINATAL INFECTION • HEPATITIS / HEPATOMAS / LIVER FAILURE • DEATH Chlamydia - Symptoms • 90% women asymptomatic • 50% men asymptomatic • Rectal Infection • Pharyngeal Infection • Symptoms in women – – – – Intermenstrual bleeding, Post coital bleeding, Dyspaerunia, Discharge, • Symptoms in men – Discharge – Dysuria Extragenital infections Diagnosis by NAATs testing (e.g. PCR – polymerase chain reaction) • Conjunctival Infection 1 Treatment for non complicated Chlamydia infection Complications of Chlamydia Epididymitis / Prostatitis Proctitis Conjunctivitis PID Perihepatitis SARA (sexually acquired reactive arthiritis) • Azithromycin 1g PO stat • Doxycycline 100mg bd 7 days • Screen for other STIs • Partner notification • Test of cure not necessary Gonorrhoea - Symptoms • 70% women are asymptomatic • 10% men asymptomatic • Symptoms in women – – – – Intermenstrual bleeding Postcoital bleeding Dyspaerunia Discharge • Symptoms in men Clinical syndromes caused by GC • • • • • • • • Urethritis Cervicitis Proctatitis Prostatitis Epididymitis Pelvic inflammatory disease(5-20% unteated GC) Disseminated GC (<1%) Conjunctivitis – Discharge – Dysuria Diagnosis and Management • Refer to Sexual Health Services • Culture • NAATs – Aptima Combo® detects both N gonorrhoeae and C trachomatis Treatment • Ceftriaxone 500mg im with Azithromycin 1g Po stat • Spectinomycin 2g im • Ofloxacin 400mg PO stat • Screen for other STIs • Partner notification • Test of cure at 6 weeks • Can be used for either or both 2 Candida Bacterial Vaginosis • Complain of – – – – Vaginal itching Vulval itching Thick white discharge Superficial dyspaerunia • On examination – – – – Thick white curd like discharge Vulvitis Satellite lesions Excoriations Bacterial Vaginosis • Complain of – Thin white/grey discharge – Dampness – Offensive odour (fish like) • Overgrowth of anaerobic organisms that replace normal vaginal lactobacilli • Can occur and remit spontaneously • Not sexually transmitted • Metronidazole 400mg bd 7 days • Clindamycin 2% cream od 7 days Trichomoniasis (TV) • Complain of – – – – Thin yellow discharge Offensive Dysuria Vulval irritation • On examination • On examination – Thin white homogenous discharge, coating vagina and vestibule – – – – Thin, frothy, yellow discharge Vaginitis Vulvitis Strawberry cervix • Gram Stain of Vaginal discharge – If no on-site microscopy the laboratory can do this and report on the findings. TV • Can be asymptomatic (20 – 50%) • Flagellated protozoan • Sexually transmitted Human Papilloma Virus (Warts) • 80+ types HPV • External genital warts most commonly caused by HPV 6 and 11 • Passed on by close skin to skin contact • Rx Metronidazole 400mg bd 7days • Partner notification • Incubation period 3-18 months • May be infected but never develop a wart, but can still transmit the virus 3 Treatment of Warts Herpes Simplex • Cryotherapy weekly • HSV type I and HSV type 2 • Podophyllotoxin cream 0.15% (Warticon cream) – Use bd for 3 days every 7 days for 4 weeks – Do not use in pregnancy • Both can affect mouth and genitals • Imiquimod cream (Aldara) – Immunomodulator – Do not use in pregnancy • Transmitted by direct contact during sex or orogential contact • Can be shed asymptomatically (70% who present with HSV have caught it from an asymptomatic contact) Signs Diagnosis • 70 – 80% have no clinical signs • History • • • • • Clinical appearance Febrile illness Dysuria/ frequency Painful inguinal lymph nodes Genital blisters/ ulcers/ fissures • HSV swab PCR – Culture rarely done now Management Treatment herpes • Primary attack • Consider referal to GUM for assessment • Swab PCR • Treatment – If clinically typical and symptoms significant offer treatment before swab results • Full STI screening • Discussion and written information • Offer to see partner to discuss – Aciclovir PO 200mg 5 x day for 5 days – Famciclovir 250mg tds 5 days – Valacicilovir 500mg bd 5 days • Analgesia • Salt baths • Do not often need to treat subsequent attacks • Topical aciclovir no use • Prophylactic treatment can be considered for – patients suffering greater 6 attacks a year – last 4 weeks of pregnancy 4 Standard treatment of an individual episode Aciclovir 200 mg five times daily Aciclovir 400 mg three times daily Valaciclovir 500 mg twice daily The majority of recurrent episodes of genital herpes are short lasting and resolve within 7–10 days without Famciclovir 125 mg twice daily antiviral treatment. All courses usually for 5 days Supportive treatment measures using saline bathing and analgesia alone will suffice. 26 27 Suppressive therapy in pregnancy Recurrent herpes - vaginal delivery Daily suppressive treatment from 36 weeks A meta-analysis involving 799 women, found that aciclovir suppression reduced: The risk of neonatal herpes is much smaller. The risk of clinical HSV recurrence If recurrent herpetic lesions are present at delivery the risk Asymptomatic HSV shedding is 1–3% of developing neonatal herpes. Delivery by caesarean section 1583 caesarean sections would have to be performed to Aciclovir did not prevent HSV shedding in all women. prevent one case of herpes-related mortality or morbidity 28 29 Vaginal delivery in primary herpes episode Caesarean section If the primary episode occurred within 6 weeks of delivery women may have a vaginal birth. Caesarean section is recommended for all women with a primary episode genital herpes lesions at the time of delivery, During labour rupture of membranes and invasive procedures should be avoided or within 6 weeks of delivery. IV aciclovir may be given intrapartum to the mother and subsequently to the neonate The paediatrician should be informed. 30 31 5 Syphilis • Early Syphilis – first 2 years of infection – Infectious) Secondary Syphilis • Rash – Macular / Papular • pink • 1cm diam • can be pruritic – Primary • 9 -90 days, average 3 weeks • • • • • – Secondary • 1-6 months, average 6 – 12 weeks (resolving primary lesion present in 30%) often on trunk and overlooked dull red, ham coloured shiny or scaly typically flexor surfaces palms and soles condylomata lata - hypertrophied wart like lesions • Alopecia – Early latent – asymptomatic • Mucous membrane lesions – Mucous patches (grey) and snail track ulcers Secondary Syphilis Rash Secondary Syphilis • Differential diagnosis – Guttae psoriasis – Pityriasis rosea (herald patch) – Tinea versicolor – Measles – Rubella – Infectious mononucleosis – Drug reaction Late Syphilis • after 2 years of infection – – – – Late latent Neurological Cardiovascular Gummatous • historically around a third of patients with untreated early syphilis developed clinically overt late syphilis. • • • • • Musculoskeletal Hepatitis Glomerulonephritis Anterior uveitis/ iritis/ choridoretinitis Meningiitis, peripheral neuritis Management of Suspected Syphilis • Refer GUM if suspect syphilis • Dark ground microscopy • Serology (12 week window) • Full STS screening (HIV status important may affect treatment) • Treatment • Partner notification • Follow up 6