Tasty Morsels of EM 095 – #FRCEM Sexually transmitted infections

31 Jul

I’m entering a few months prep for the UK and Ireland exit exam in Emergency Medicine: the FRCEM. I’ll be adding lots of little notes on pearls I’ve learned along the way. A lot of my revision is based around the Handbook of EM as a curriculum guide and review of contemporary, mainly UK guidelines. I also focus on the areas that I’m a bit sketchy on. With that in mind I hope they’re useful.

You can find more things on the FRCEM on this site here

This is a big one, both in terms of scope of the diseases included and their relative testability in an exam. In addition I find I rarely have to deal with them that much as other clinics are available to patients. Hence the need for revision

Tell me about PID?

(BASHH 2011 Guideline)

  • Aetiology
    • ascending infection from cervix
    • causing a broad spectrum of ‘itis’ from endometritis to abscess to peritonitis
    • Chlamydia and Gonorrhoea are implicated but still only a quarter of all cases. Gardenerella vaginalis and other local vaginal anaerobes are other microbes involved.
  • Symptoms
    • lower abdo pain
    • dyspareunia
    • abnormal vaginal bleeding
    • discharge
  • Signs
    • lower abdo tenderness
    • cervical motion tenderness
    • adnexal tenderness
    • T>38

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When and how should it be treated?

  • When to treat
    • “A diagnosis of PID, and empirical antibiotic treatment, should be considered and usually offered in any young (under 25) sexually active woman who has recent onset, bilateral lower abdominal pain associated with local tenderness on bimanual vaginal examination, in whom pregnancy has been excluded.”
    • note that covers a quite huge number of people
  • Formal diagnosis
    • lots here about testing but mainly about how the tests aren’t very good.
  • Indications for admission
    • surgical emergency cannot be excluded
    • lack of response to oral therapy
    • clinically severe disease – though no definition
    • presence of a tuboovarian abcess
    • intolerance to oral therapy
    • pregnancy
  • Outpatient Treatment (both are similar efficacy)
    • ONE
      • ceftriaxone 500mg IM single dose
      • doxycycline 100mg BD 14 days
      • metronidazole 400mg BD 14 days
    • TWO
      • ofloxacin PO 400mg BD 14 days
      • metronidazole 400mg BD 14 days
    • Of note they include a bunch of other reigimes and some for IV use but they’re all kind of similar and would be information overload for me
    • also note recommended screening for partners and single dose azithromycin 1g for male partners

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Outline gonnorrhoea and treatment?

(from BASHH 2011)

  • Symptoms/Signs
    • Men
      • discharge
      • dysuria
      • early (2-5 days of exposure)
      • of note pharyngeal and rectal disease is often asymptomatic
    • Women
      • often asymptomatic cervicitis
      • vaginal discharge reasonably common
      • dysuria not so much
  • Testing
    • again there’s a lot on this but too much detail i think for me
  • Treatment (of interest gonnorrhoea might win the race to be the first totally resistant bacteria…)
    • Ceftriaxone 500mg IM
    • and azithromycin 1g PO single dose

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Outline Chlamydia and its treatment

(From BASHH 2015)

  • Symptoms/Signs
    • often asymptomatic
    • if present similar to gonorrhoea
  • Complications
    • again cross over with gonorrhoea
    • PID
    • tubal infertility
    • ectopic
    • reactive arthritis (rare)
    • perihepatits (rare – the Fitz-Hugh-Curtis thingy)
  • Treatment
    • doxycycline 100mg BD 7 days
    • OR azithromycin 1g PO single dose

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What is and how do we treat NGU?

(from BASHH 2015)

  • this of course requires testing to know it’s non-gonococcal so it’s less in our remit
  • of note most of it is
    • Chlamydia
    • Mycoplasma genitalium
  • Treatment is similar to chlamydia unsurprisingly
    • doxycycline 100mg BD 7 days
    • OR azithromycin 1g PO single dose

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What about epidydimoorchitis?

(from BASHH 2010)

  • age 35 is key cut off – below this chlamydia and gonorrhoea are common.
  • the older group are more likely to have the usual urinary tract pathogens. Of note BASHH recommends urinary tract investigation in all of those with these organisms cultured. Presumably this means ultrasound or cystoscopy looking for obstruction but they don’t state specifically
  • remember mumps
  • Treatment if suspected to be sexually transmitted (eg <35)
    • ceftriaxone 500mg IM single dose (the gonorrhoea)
    • AND doxycycline 100mg BD 14 days (the chlamydia)
  • Treatment if suspected to be enteric (eg >35)
    • ciprofloxacin 500mg BD 10 days

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When should we prescribe PEPSE?

(from BASHH 2015)

  • recommended if risk is >1/1000
  • ultimately it’s a risk assessment process and the guideline provides useful tables to help guide you
  • higher risk features (based on HIV +ve source on no treatment)
    • receptive or insertive anal sex
    • receptive vaginal sex
    • shared injecting equipment
    • MSM population
    • needlestick
  • treatment
    • ASAP but within 72 hrs (do not give beyond this)
    • 28 days the usual length of course
    • Truvada AND raltegravir the regime of choice

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What about genital HSV?

(From BASSH 2014)

  • HSV 1 (classically the lip version) now the commonest genital cause. I’m not sure how it got there but I imagine it has something to do with this tweet

  • HSV 2 more likely to cause recurrent symptoms
  • incubation 2 days to 2 weeks
  • just like varicella it remains latent in sensory ganglia
  • can be asymptomatic
  • systemic symptoms are fever and arthralgia and much more common in primary disease than in recurrence
  • remember inguinal lymphadenitis (cutaneous regional nodes, unlike testicles which are abdominal)
  • superinfection is candida or strep
  • can cause auonomic neuropathy causing urinary retention (i always thought this was just due to painful ulceration but i suppose this makes sense)
  • can have autoinoculation elsewhere
  • management
    • saline baths
    • topical local anaesthetic
    • antivirals if
      • within 5 days
      • systemic symptoms
    • they mention a few but aciclovir 400mg TID seems to be the one i’d go for (note the TID dosing not the crazy 5 a day thing that we normally write)
    • of note antivirals do not reduce recurrences
  • differentials of genital ulceration include
    • syphillis
    • LGV (a form of chlamydia)
    • Bechet’s

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