Sexual Health Exam 2 PDF

Clinical presentation Bugs Symptoms complications URETHRITIS Discharge clear, mucopurulent, or very purulent Neisseria gonorrhoeae Chlamydia trachomatis Trichomonas vaginalis Mycoplasma genitalium herpes simplex virus Dysuria, hematuria (blood in urine) Feeling of genital heaviness Epididymitis o...

Clinical presentation Bugs Symptoms complications URETHRITIS Discharge clear, mucopurulent, or very purulent Neisseria gonorrhoeae Chlamydia trachomatis Trichomonas vaginalis Mycoplasma genitalium herpes simplex virus Dysuria, hematuria (blood in urine) Feeling of genital heaviness Epididymitis or prostatitis if untreated CEVICITIS VULVOVAGINITIS Dysuria Abnormal uterine bleeding Lower abdominal pain Dyspareunia (pain in sex) Postcoital (after sex) bleeding Dysuria, Dyspareunia Purulent vaginal discharge (may contain blood) Abnormal “musty” odor Mucopurulent secretions from endocervical canal N. gonorrhoeae Chlamydia trachomatis Herpes simplex virus Skin and mucous membrane lesions Chancres Primary syphilis Usually painless Highly infectious Site of transmission Solitary 3-6 weeks post transmission • • • • • • Condyloma latum Secondary Syphilis Anogenital Raised nodules or plaques Highly infectious Lymphadenopathy Patchy hair loss Fever Malaise Palmar-plantar rash Secondary Syphilis Palms and soles of feet Pigmented, macular lesions Lymphadenopathy Patchy hair loss Fever Malaise Inflammation of internal and external female genitals Trichomonas vaginalis Candida albicans Herpetic Vesicles Herpes simplex virus Multiple lesions Usually in clusters May be more painful in women (ulcers, papules, vesicles) Condyloma acuminata Human papillomavirus Anogenital Cauliflower-like masses May be oncogenic Internal/External EPT Also called patient-delivered partner therapy (PDPT) Only one partner is assessed by prescriber Therapy provided to patient to deliver to partner No prescriber-patient relationship established for non-patient partner In Texas, EPT is permissible by law EPT encouraged for gonorrhea and chlamydia by Texas DSHS Etiology Chlamydia Chlamydia trachomatis Intracellular Sexual or vertical transmission Equivalent transmission Epidemiology Most commonly reported STD in the US At risk populations Female <25, MSM, low socioeconomic status Clinical Presentation Men often asymptomatic Urethritis Cervicitis Conjunctivitis Oropharyngeal and anorectal lesions Symptoms less noticeable than gonorrhea Diagnosis Urethral swab Endocervical or vaginal swab Urine culture Gonorrhea N. gonorrhoeae Gram negative diplococci Intracellular Sexual or vertical transmission ↑ male to female transmission Common in SOUTHERN U.S At risk populations Male Age<25 MSM High risk of drug resistance: C.Diff, CRE, N. Gonorrhoeae Women often asymptomatic Urethritis Cervicitis Conjunctivitis Oropharyngeal and anorectal lesions Symptoms more noticeable than Chlamydia Urethral swab Endocervical or vaginal swab Urine sample Syphilis Treponema pallidum Spirochete bacterium (xoắn khuẩn) Sexual, blood, and vertical transmission ↑ MALE TO MALE Uncommon but increasing Congenital syphilis incidence increasing rapidly (TX is 3rd) At risk populations Male MSM Low socioeconomic status Primary and secondary syphilis (see above) Latent Syphilis: Typically asymptomatic Non-transmissible May last for years Early latent < 12 months post transmission Late latent ≥ 12 months post transmission Tertiary syphilis: 10-30 years post transmission Rare Organ damage: Mostly CV and CNS affected, may result in death Darkfield microscopy : need 3 (-) to rule out. Definitive diagnosis if positive Can use for primary and secondary syphilis Non-treponemal tests Rapid plasma regain (RPR) Venereal disease research laboratory (VDRL) Treponemal tests Fluorescent treponemal antibody absorbed (FTA-ABS) Treponema passive particle agglutination (TP-PA) Enzyme immunoassays (EIA) Chemiluminescence immunoassays (CIA) Treatment Goal: Cure C. trachomatis Regimen of choice: Doxycycline 100mg POBID7D Alternate drugs: Azithromycin 1g OTD Levofloxacin 500mgQD7D EPT Goal: cure of N. gonorrhoeae infection Regimen of choice <150kg: ceftriaxone 500mg IM x 1 ≥150kg: ceftriaxone 1g IM x 1 Chlamydia coinfection Ceftriaxone + Doxycycline EPT: cefixime 800mg x 1 High light Doxycycline: NDV- take with food Erosive esophagitis- take full class of water Photosensitivity DDI: Ca2+ salts, carbamazepine, phenytoin Ceftriaxone: Allergy to PCN Injection site reactions Diarrhea Follow up Adherence Symptom persistence No condomless sex for 7 days No routine test of cure Test all partners in last 60 days Retest women in 3 months after treatment Test of cure for pregnant women 4 weeks Adherence Symptom persistence Test partners No condomless sex for 7 days No routine test of cure Test all partners in last 60 days Test of cure for higher risk patients in 7-14 days Oropharyngeal Repeat infection Alternate: Penicillin allergy: Primary/secondary (14 days) and latent (28 days) Doxycycline 100mg POBID Tetracycline 500mg POQID Ceftriaxone 1-2g IM/IV daily 10-14 days (pri/2nd only) Desensitization: Verified IgE-Mediated allergy: Exception: SJS,TEN, interstial nephritis, and hemolytic anemia Neurosyphilis, pregnancy, and congenital syphilis Questionable ability to follow up Testing: CDC 1st prenatal visit only High risk (ONLY) patients require additional testing after 28w and delivery TEXAS: ALL pregnant must be tested at 1st prenatal visit, after 28w, and at delivery Drug Therapy: Allergy possible Seizures Injection site reactions Nausea and Diarrhea Jarishch-Herxheimer reaction (early syphilis)pretreat with antipyretics Adherence Symptom persistence Partner treatment regardless of serology Primary, secondary, and early latent - all partners in last 90 days Partner treatment if serologically positive Primary – 3 months + duration of symptoms Secondary – 6 months + duration of symptoms Early latent – 1 year Late latent – long term partners Abstinence until asymptomatic (> 7 days) Routine test of cure in 6 and 12 months (and 24 if latent) . Etiology Epidemiology Clinical presentation Diagnosis Screening Treatment Follow up Trichomoniasis Trichomonas vaginalis Flagellated protozoa Sex, vertical, or surface transmission ↑ female to male transmission MOST common curable STD in U.S MOST common non-viral STD in the US/globally At risk populations: Female < 25 years old WSW Douching (thụt rửa) Incarcerated person (in jail) MOST asymptomatic Most men have spontaneous resolution Vulvovaginitis Urethritis (rare) No routine screening for HIV (-) w Suboptimal diagnosis Vaginal/urethral culture Wet-mount slide Urine culture POC testing OSOM rapid trichomonas test Vaginal swab antigen test W: high prevalence clinical settings (jail, adolescent clinics,etc) If increased risk Pt with HIV: sexually active women at entry to care and annually thereafter W: flagyl 500mg bid7d M: flagyl 2 g OTD Alternative regiment Tinidazole 2g OTD Some research show 7 days more effective than single dose AE: Metronidazole: NV, metallic taste, Disulfiramlike (no alcohol 3 days after last dose) Tinidazole: similar, GI effects less common, more expensive Treat current partners Abstinence until asymptomatic and partner finish therapy (usually 7days) Routine test of cure in 3 months (women) Test patient for HIV, syphilis, gonorrhea, and chlamydia Genital Herpes HSV-2 Sex, vertical transmitted Occurs in stages Herpetic vesicles are most common genital ulcer At risk populations Women < 25 years old MSM Primary infection: Mostly asymptomatic or minimally symptomatic urethritis vulvovaginitis herpetic symptoms flu-like symptoms Recurrent infection: prodrome Herpetic vesicles Tissue culture Serologic testing Virologic testing Initial: reduce duration and severity Suppressive: reduce frequency and severity Episodic: reduce duration and severity Adherence Psychotherapy No test of cure Etiology Epidemiology Clinical presentation Diagnosis Treatment Important info Cervical cancer Vaccine Anogenital Warts HPV Non-enveloped capsid Sex transmission HPV most common sexually transmitted infection in the US and globally Risk factor: < 25 years old MSM HIV §Usually asymptomatic §Condyloma acuminatum §Postcoital bleeding §Itching §Burning sensation §Pain §Physical exam §Lesion biopsy §Acetic acid test §Goal: Removal or remission of warts §Drug regimens of choice (external) Imiquimod 3.75% cream daily HS Imiquimod 5% cream three times daily HS Podofilox 0.5% sol BID x 3days, off x4 days. Repeat < 4x Sinecatechins 15% thin layer three times daily max 16 weeks §Cryotherapy or Surgical removal Urethral meatus, vaginal, cervical, or intra-anal warts §Imiquimod § Leave on 8 hours then rinse §Wash hands § Photosensitivity § Inflammation §Xeroderma §Sinecatechins §Minor skin reactions §Vascular eruption §Podofilox §Minor skin reactions §Flammable 3rd most common cancer dx 9th largest cause of cancer mortality Directly linked to HPV (reduce by vaccine) Gardasil 9: 3 dose 0,1-2,6m FDA approve 9-45y CDC/ACIP recommendations: Routine for all at age 11 or 12 Catch up through age 26 Now, recommended up to 45 Pelvic inflammatory disease (PID) §Vaginal/cervical infection untreated §Gonorrhea and/or chlamydia (~50%) §Trichomoniasis §Vaginal candidiasis §Bacterial vaginosis Risk factor: Sex active Low socioeconomic status Gonorrheal or chlamydial infection Previous PID Recent IUD placement §Possibly asymptomatic §Lower abdominal pain §Abnormal bleeding §Dyspareunia/postcoital bleeding §Cervical/uterine tenderness § Fever § ↑ WBCs in vaginal fluid § ↑ ESR and CRP Goal: cure infection to prevent further damage. Cover for polymicrobial infections Empiric therapy §Cefotetan and cefoxitin § GI effects § Cefotetan has disulfiram-like reaction See notes §Symptom persistence §Abstain from vaginal intercourse until treatment complete & partner treated §Routine test of cure in 3 months if gonorrheal or chlamydial §Treat all partners < 60 days