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VERSION 2.2

GENITOURINARY
MEDICINE
 Gynae Swabs

REMEMBER THESE TWO SWABS FOR

SYMPTOMATIC WOMAN

HVS in charcoal medium

Sent for culture

Microscopy may also be done in sexual health

clinic:
● Dry mount - Thrush, BV
● Wet mount - Trichomonas

Vulvovaginal swab for NAATs

Sent for PCR for chlamydia and gonorrhoea

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 Gynae Swabs

Vulvovaginal swab for NAATs

Sent for PCR for chlamydia and gonorrhoea

If chlamydia positive, If gonorrhoea positive,

treat take an additional swab
for culture before
treating

A high vaginal swab and

an endocervical swab
separately (these two
samples are put into
charcoal medium
Why does gonorrhoea separate and sent to the
need to be cultured? lab for culture)
Because of the growing
resistance of
gonorrhoea to antibiotics

PLABABLE
 Gynae Swabs

Good tips

Most sensitive test for Vulvo-vaginal sample

chlamydia and sent for NAAT (Pick
gonorrhoea NAAT over culture)

Asymptomatic women Self-taken

vulvovaginal swab

Symptomatic women Clinician-taken swabs

PLABABLE
 Cervicitis

Cervicitis presents with vaginal discharge, that does

not ascend upwards to pelvis, hence no pelvic pain

Treatment
● N. gonorrhoeae - IM ceftriaxone 1g single dose
or oral ciprofloxacin 500mg single dose

● C. trachomatis - oral doxycycline 100 mg BD

for 7 days (contraindicated in pregnancy) or
Day 1: Oral azithromycin 1g OD +
Day 2&3: Oral azithromycin 500mg OD

PLABABLE
 Cervicitis

Chlamydia

DCBA
Doxycycline Azithromycin
comes
before

1g single dose
100mg BD for +
7 days 500mg OD x 2
days

Azithromycin
in pregnancy

→ Doxycycline (first line)

→ Azithromycin (second line)

PLABABLE
 Cervicitis

Neisseria gonorrhoeae

C or C
Ciprofloxacin
Ceftriaxone (When sensitivity is known)

1 gram IM
500mg oral
injection
single dose
single dose

PLABABLE
 Chlamydia

Presentation in males
● Urethritis
● Dysuria
● Urethral discharge
If chlamydia or gonorrhoea untreated
● Epididymo-orchitis
● Epididymitis
● Unilateral testicular pain

Presentation in females
● Vaginal discharge
● Post-coital bleeding
● Red and inflamed vulva and cervix
● Tender pelvis not tender abdomen

If chlamydia or gonorrhoea untreated

● Salpingitis

Chlamydia is the most common sexually

transmitted disease in UK

New sexual partner could be a

Hints cause of chlamydia

PLABABLE
Pelvic Inflammatory Disease (PID)

Metronidazole
400mg BD x 14 days

Ceftriaxone Doxycycline
1 gram IM Single dose 100mg BD x 14 days

PID Cervicitis
Cervicitis presents vaginal discharge,
does not ascent upwards to pelvis, hence no
pelvic pain

PID involves adnexa and other genital structure,

hence yes pelvic pain
PLABABLE
 Vaginal Infections

Trichomoniasis (Trichomonas vaginalis)

Trichomoniasis
● Frothy, offensive smelly
yellowish-greenish discharge (also
sometimes described as fishy smell)
● Vaginal itching
● Strawberry cervix
● Vaginal pH >4.5
Treatment → Oral metronidazole

Bacterial
BacterialVaginosis
vaginosis (Gardnerella vaginalis)
● Thin, grey-white discharge
● Fishy (very offensive) smell
● Clue cells
● Positive Whiff test (potassium hydroxide)
● Vaginal pH >4.5
Treatment → Oral metronidazole + oral
clindamycin

Vulvovaginal Candidiasis
Vulvovaginal candidiasis (Candida albicans)
aka vaginal thrush
● Thick white (cheese-like) discharge
● Odourless
● Vaginal itching
● Vaginal pH 4-4.5
Treatment → Topical clotrimazole or oral
fluconazole
PLABABLE
 Vaginal Infections

We are going one step further to help you remember

Trichomoniasis
>4.5
Bacterial Vaginosis

pH

Vulvovaginal
4 - 4.5 Candidiasis

The normal vaginal pH in a woman

of child-brearing age is 3.5 to 4.5

Memory tool
Coke in a CAN is acidic very
KE

much like CANdidiasis

CO

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We have coloured the boxes to help you remember:

Trichomoniasis → Yellowish green discharge
Bacterial Vaginosis → Grey-white discharge
Vulvovaginal candidiasis → White discharge
PLABABLE
 Vaginal Infections

We are going one step further to help you remember

Trichomoniasis

Strawberry cervix
Also remember
vulvovaginitis

Bacterial Vaginosis
Note:
Fishy smell Trichomoniasis
Clue cells can sometimes
be described
as fishy smell
too
Vulvovaginal
Candidiasis

Cottage cheese

PLABABLE
 Vaginal Infections

We are going one step further to help you remember

Trichomoniasis

Frothy

Bacterial Vaginosis

Thin

Vulvovaginal
Candidiasis

Thick

PLABABLE
 Vaginal Infections

When comparing trichomoniasis and bacterial

vaginosis, also look for this BIG CLUE:
→ Vulvovaginitis

Trichomoniasis

● Has an inflammatory process so vulvovaginitis

is one of the signs found in trichomoniasis.
● Vaginal itching, pain, irritation and soreness are
mostly present.

Bacterial Vaginosis
● Has an NON-inflammatory process so
vulvovaginitis is NOT one of the signs normally
found in bacterial vaginosis
● Vaginal itching, pain, irritation and soreness are
rarely present.

PLABABLE
 Vaginal Infections

Brain trainers:

A 30 year old woman present with very

strong foul smelling vaginal discharge. The
discharge is thin?
➔ Gardnerella vaginosis
(bacterial vaginosis)

❌ Chlamydia or gonorrhoea as they do not

present foul smelling discharge

A 29 year old woman present with frothy,

yellow bad smelling discharge. Mild vaginal
itching and vulva looks slightly inflamed.
Sexually active.
➔ Trichomoniasis

PLABABLE
 Vaginal Infections

Broad spectrum antibiotics

→ Kills normal vaginal flora
→ Increase risk of developing bacterial
vaginosis or vaginal candidiasis

Bacterial vaginosis vs
Trichomonas vaginalis

● Both pH > 4.5

● Bacterial vaginosis is more common
(Bacterial vaginosis is the most common
cause of abnormal vaginal discharge in
child-bearing age)
● Bacterial vaginosis is not sexually
transmitted (but incidence increases with
women who are more sexually active)
● Trichomoniasis has yellowish-greenish
offensive discharge
● Trichomoniasis can result in vulvovaginitis
but bacterial vaginosis rarely causes
vulvovaginitis because it is
non-inflammatory

PLABABLE
 Human Papillomavirus (HPV)

Features:
● Sexually transmitted
● HPV 6 and 11 → Genital warts (benign
cauliflower-like growths)
● Includes anogenital warts in both male and
female
● HPV 16 and 18 → Cervical cancers

Prevention:
● Gardasil vaccination (vaccine against HPV
6, 11,16 and 18)
● Has no benefit if genital wart has
developed

Treatment:
● Ablation (cryotherapy)
● 30% of cases have spontaneous resolution
in 6 months

PLABABLE
 Genital warts

Brain trainer:

A patient has genital warts on her vulva. What is the

most appropriate treatment ?

➔ Cryotherapy

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 Genital warts

Brain trainer:

A woman presents with painless vulval lesions of

varying sizes that appeared a few weeks ago. What
is the most likely organism?

➔ Human papillomavirus

PLABABLE
 Genital Ulcers

Genital
Haemophilus
Syphilis herpes
ducreyi
(HSV)

Multiple
painful
ulcers
Single Single
non-painful painful
ulcer ulcer

+ Dysuria

Rx:
Aciclovir

Investigation:
● Viral culture + NAAT or DNA
detection using PCR (Polymerase
chain reaction)
IF negative and ulcer are recurrent
→ Check for anti-HSV antibody
PLABABLE
 Genital herpes

Brain trainer:

You suspect a patient has genital herpes but PCR

and viral culture are negative. What is the most
appropriate investigation to make a diagnosis ?

➔ Anti-HSV antibodies

PLABABLE
 Rash in Palms & Soles

Hand , foot and Rocky mountain

mouth disease spotted fever

Coxsackie Tick
virus (Rickettsia)

Secondary syphilis

Treponema
Pallidum

PLABABLE
 Syphilis

● Sexually transmitted
● Caused by Treponema pallidum

Primary stage:
● Chancre - single painless genital ulcer at site
of sexual contact + lymphadenopathy

Secondary stage - 6 weeks after chancre

appears:
● Fever, lymphadenopathy, malaise (systemic
symptoms)
● Rash on soles, palms and face
● Condyloma lata

Tertiary stage - if remain untreated for long

time:
● Gummas (granulomatous lesions commonly
affected skin and bones)
● Cardiovascular syphilis (ascending
aorta-aneurysm / AR)
● Neurological syphilis (dementia / tabes
dorsalis)

PLABABLE
 Syphilis

Investigation

Chancre still present Chancre has healed

PCR at Syphilis
GP serology
clinic

Dark
Microscopy
at
Genitourinary
clinic

PLABABLE
 Syphilis

Brain trainer:

A man has ulcers in his mouth and you suspect

syphilis. What is the most appropriate investigation
to make a diagnosis ?

➔ Swab of mouth ulcer for PCR

PLABABLE
 Men Sleep with Men (MSM)

Bottom
Top

Has ‘insertive’ sexual Has ‘receptive’ sexual

intercourse intercourse
i.e. inserting penis i.e. receiving anus

Investigation methods

1. Rectal Swab
1. Urethral swab

Nucleic-acid
2. First void urine
amplification test
(NAAT) is needed for
First 20 ml of urine for
Chlamydia,
microscopy, culture
Gonorrhea screening

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 Men Sleep with Men (MSM)

All MSM need screening for HIV, hepatitis B,

chlamydia and N. gonorrhoeae

Receptive anal sex has a higher risk of getting HIV

compare to insertive

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 Image Attributions

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Martin Strachoň CC-BY SA 3.0

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