Obstetrics / Women’s Health KFP 1.2 – Emma has PV discharge

Emma, 22, presents with PV discharge for the last 2 weeks and discomfort with sexual intercourse.  She reports lower abdominal pain and intermittent fevers.  She reports a sexual history with at least 2-3 male partners over the preceding 4-5 months.  She has no past medical history, allergies and is on the COCP.  She is compliant with it.

What are the likely causative organisms? List 3

  1. Chlamydia trachomatis
  2. Neisseria gonorrhoeae
  3. Trichomonas vaginalis – less likely

What are the diagnostic methods? List 3

  1. Endocervical swab Nucleic Acid Amplification Test (NAAT) (+/- culture for gonorrhoea)
  2. Self collected vaginal swab NAAT (+/- culture for gonorrhoea)
  3. First pass urine – NAAT –  Not as sensitive as self-collected vaginal swab.
  4. If anorectal sex – anorectal swab NAAT (+/- culture for gonorrhoea)
  5. Gonorrhoea only – pharyngeal swab NAAT +/- culture

If possible, culture samples should be obtained from genital and non-genital sites to determine antibiotic susceptibility

What medication do you want to prescribe for treatment? List 2

  1. Chlamydia and gonorrhoea are frequently asymptomatic and both should be treated immediately if high index of suspicion before results are obtained with:
  2. Chlamydia – azithromycin PO 1g stat OR Doxycycline 100mg po BD for 7 days

PLUS

Gonorrhoea – Ceftriaxone 500mg IMI, stat in 2mL 1% lignocaine

Some additional oral regimes on eTG as well

What advice is important when prescribing the treatment in the previous answers? List 1

  1. Advise no sexual contact for 7 days after treatment is administered.

What other management considerations are there? List 5

  1. Notification to State/Territory public health
  2. Contact tracing  – Male and female partners should be traced back for 6 months
  3. Start treatment for patient and sexual partner(s) without waiting for lab results.
  4. No sex with previous partners until they have been tested/treated
  5. Screen for other STIs – Hep B/C/HIV/Syphillis etc

Is test of cure required?

No.  Not routinely recommended, unless in the following groups 4  weeks after treatment:

  1. Pregnant women
  2. Rectal chlamydia

Should the patient be retested later?

  1. Yes. Re-infection is common.  Re-testing at 3 months is recommended, to detect re-infection.

What are the potential complications chlamydia and gonorrhoea infections? List 6

  • Short/medium term
    • Pelvic inflammatory disease
    • Conjuncvitits (gonorrhoea)
    • Reactive arthritis (chlamydia)
    • Anorectal symptoms
    • Septic arthritis (gonorrhoea)
    • Meningitis (rare) (gonorrhoea)
  • Long term (chlamydia)
    • Subfertility
    • Chronic pevlic pain
    • Ectopic pregnancy

Further reading:

https://www.racgp.org.au/your-practice/guidelines/redbook/6-communicable-diseases/62-sexually-transmissible-infections/

http://www.sti.guidelines.org.au/ – really good