Genito-Urinary Medicine for Finals OSCEs

1. Genito-Urinary Medicine for Finals OSCEs Dr Laura Smith Dr Clare Andrews F1s, MRI

2. Sexual history taking • Presenting complaint • Other presenting symptoms to cover: Discharge, skin problems, abdom pain, dysuria, irreg bleeding/post-coital bleeding, peri-anal symptoms • Parteners in last 3 months • Patient risks • Prev hx STI/GU clinic appts • Contraception • Menstrual hx

3. Sexually transmitted diseases

5. Anogenital warts Cause Human Papilloma Virus – most commonly types 6 and 11 Transmission Passed by close skin to skin contact Symptoms Very small no. Of cases (1%) are symptomatic. Also in those that are symptomatic there can be a latency period weeks-years before symptoms occur.

6. Diagnosis Only in symptomatic pts – with warts Treatment Pts own immune system will clear it eventually No cure for the virus but can treat the symptoms Therapeutic treatments Podophyllotoxin – cycles 3 days use then 4 days off Imiquimod cream Liquid nitrogen cryotherapy Electrocautery Surgical excision

8. Gonorrhoea Cause Neisseria Gonorrhoea – Gram negative diplococci that targets coloumnar epithelium Transmission Oral, anal, vaginal sex Symptoms MALE – Urethral discharge (yellow/green), dysuria, fever, testicular pain, prostatitis, epididymitis, urethritis FEMALE – vaginal discharge, dysuria, postcoital bleeding, irregular menstrual cycle, cervicitis Complications Septic arthritis, PID, Reiters, urethral strictures and infertility, pericarditis, endocarditis, dermatitis, meningitis

9. Diagnosis Urethral swab, endocervical/high vaginal swab, Treatment (increasing resistance to ciprofloxacin – so less frequently used a first line treatment) Cefixime 400mg STAT Cefotaxime 250mg/Ceftriaxone 500mg IM NB: If treating concurrently against Chlamydia use Azithromycin 1g STAT or doxycycline 7/7

11. Chlamydia Cause Chlamydia trachomatis is a Gram-negative intracellular organism. It is the commonest sexually transmitted bacterial infection in the UK Transmission Oral, anal, vaginal Symptoms In 70% of women and in roughly 50% men it is asymptomatic Men: urethritis, epididymitis, proctitis, Arthritis Women: cervicitis, urethritis, pelvic inflammatory disease, arthritis

12. Diagnosis Urine testing, high vaginal/endocervical swabs, urethral swabs Treatment Azithromycin 1g STAT Doxycycline 7/7 course PID treatment Doxycycline + Metronidazole + IM Ceftriaxone 14/7 course

14. Syphillis Cause A spirochaete, treponema pallidum Incubation period of 9-90 days Transmission Enters via broken mucous membranes during sex Symptoms Clinically there are four types of syphilis: primary secondary tertiary congenital

15. Primary: Chancre -Painless ulcers at the site of contact Secondary: 4-8 weeks after primary Rash affecting face, palms, soles and trunk Signs of systemic infection – malaise, lymphadenopathy, pyrexia, hyperkeratosis (palms and soles), condylomata lata Tertiary: Tertiarysyphilis usually occurs 1–10 years after the initial infection, however in some cases it can take up to 50 years. This is characterised by gummas which are grannulomas that grow in the skin, bones, viscera and mucosa

16. Quarternery: Aortitis and aortic aneurysms Neurosyphilis: Neurosyphilis may occur at any stage of syphilis Asymptomatic neurosyphilis Meningovascular syphilis General Paresis Tabes Dorsalis

17. Diagnosis dark ground microscopy - detection of spirochaete in primary and secondary syphilis serology - detection of anti-treponemal antibodies with lumbar puncture may be indicated to exclude neurosyphilis Treatment Primary syphilis - long-acting procaine penicillin 600 mg daily IM 10/7 CNS disease, secondary and tertiary syphilis - treatment is for 14/7 OR - benzathine penicillin 2.4 g per week for 2 weeks (if poor compliance)

19. Herpes Cause Predominantly Herpes simplex virus 2 altough some cases caused by 1 Transmission Both types of herpes simplex, can be spread skin to skin contact Symtoms Painful vesicles, which then burst leading to ulcer formation, which can also cause urine retention. Also maliase, myalgia, headache

20. Diagnosis PCR, Clinical diagnosis, Smear culture Treatment Genital Herpes cannot be cured. Viral shedding can occur even when asymptomatic. Treatment shortens course of symptomatic outbreak. oral anti-viral medications include: acyclovir 400mg TDS 5/7 (have to increase the dose in immunosuppressed pts), famciclovir 250mg TDS 5/7, valacyclovir

21. Contraception • Common comm skills station • Type • How it works • Pros • Cons

22. The combined oral contraceptive pill • Suppresses FSH and LH • So, preventing ovulation, thickening cervical mucus and reducing endometrial receptivity • Pros: • Highly effective, easy to reverse and convenient to use; • Relief from menstrual problems • Protect against PID • Reduces incidence of benign breast disease, ovarian cysts, ovarian cancer and endometrial cancer • Cons: • Side effects (breakthough bleeding, breast tenderness) • Risk of VTE, MI, stroke, breast ca

23. The progesterone only pill • Inhibition of ovulation, transport of the ovum is delayed, the cervical mucus becomes more viscous and impenetrable to sperm and the endometrium is unsuitable for implantation • Pros: • Reliable if taken correctly, easily reversible and convenient to use • Avoids cardiovascular risks of oestrogen • Can often be used by women with contraindications to COCP • Can be used during breast feeding • Cons: • Side effects: amenorrhoea and breakthrough bleeding • Needs to taken at the same time daily • Increase risk of functional ovarian cysts (30% increased risk) and possibility of breast cancer (similar to COCP)

24. Progestogen injectables • IM injections containing long acting progestogen • Pros: • Very effective and convenient • Can be used during breast feeding • Cons: • Cannot be stopped • Menstrual irregularities are common • Weight gain • Delayed returned of fertility; can be >1 year • ?Risk of depression • ?Increased risk of breast cancer • Reduced bone mineral density

25. The implant (Implannon) • Long acting reversible contraceptive • Subdermal etonogestrel (a progesterone) contained in a rod in the upper arm is released slowly into the systemic circulation • Pros • Highly effective with very few pregnancies reported • Long duration of action • Reversible • Very convenient • Cons • Irregular bleeding • Weight gain, headache, acne

26. IUS Levonorgestrel-releasing intrauterine system; Mirena Reduces endometrial growth and prevents implantation Pros: very effective, convenient and reversible Reduces blood loss and dysmenorrhoea ?reduce risk of PID compared with normal IUDs Does not significantly interact with other drugs as action is principally local Cons: Menstrual irregularities are common in first few months Typical progestogenic side effects Dysfunctional ovarian cyst, but usually resolves spontaneously Need for fitting IUD and IUS • IUD • induce an inflammatory response in the uterus which affects the viability of sperm and ova; prevent fertilisation and implantation • Last 5-10yrs • Pros: • Highly effective, reversible and convenient • Effective directly following fitting • Cons: • Intermenstrual bleeding, mennorhagia, dsymennorhoea • Displacement or expulsion • Increased risk of PID (screened before insertion) • Uterine perforation • Ectopic pregnancy

27. Female Barrier method: soft pliable polyurethane, pre-lubricated and has 2 flexible rings Pros: No known side effects Helps prevent STD Reduces risk of cervical carcinoma Can be inserted prior to intercourse Cons: Needs careful insertion Can be pushed into vagina or bypassed May be uncomfortable Condoms • Male • Barrier method • Pros: • Ready availability • Protects against STD • Protects women against cervical cancer • Cons: • ?Expensive if purchased • Needs prior planning • Requires cooperation of both partners • May reduce sensitivity • Can break or slip off

28. Natural family planning • calendar, temperature, cervical mucus and palpating the cervix • Pros: • No side effects • Complies with religious practices of some patients • Cons: • Requires considerable commitment from both partners • Unreliable with unpredictable cycle