GDS Health Care

✍️ Body Lice

Body lice are tiny insects, about the size of a sesame seed. Body lice live in your clothing and bedding and travel to your skin several times a day to feed on blood. The most common sites for bites are around the neck, shoulders, armpits, waist and groin — places where clothing seams are most likely to touch skin.

Body lice are most common in crowded and unhygienic living conditions, such as refugee camps and shelters for the homeless. Body lice bites can spread certain types of diseases and can even cause epidemics.

Clothing and bedding that have been infested with body lice should be laundered in hot, soapy water and machine dried using the hot cycle.

Definition

Lice are blood-sucking insects and specific parasites of human beings. Lice are 1-3 mm long and have three pairs of legs that end in powerful claws.

P***c lice are slightly smaller than head lice and body lice.

The female lives for 1-3 months but dies when separated from the host. The female louse lays up to 300 eggs, called nits, during her lifetime.

The nits are less than 1 mm in diameter and, when viable, are opalescent. The nits hatch 6-10 days after they have been laid, giving rise to nymphs that become adults in 10 days.

Three species of lice have adapted to live on humans:

Head louse (Pediculus humanus capitis) - see separate Head Lice article.

Crab (or p***c) louse (Pthirus p***s).

Body louse (Pediculus humanus).

P***c lice

The p***c louse (Pthirus p***s) is 'crab'-shaped, grey-brown in colour,and about 2 mm in length. The female lays eggs (smaller than a pinhead) on the hair shaft, near to the body.

The eggs hatch after about 6-10 days. The empty nit eggshells are tightly attached to the hair. The female louse lives for 1-3 months. Eradication of p***c lice from the body is unlikely unless treated.

Signs and Symptoms

Presentation

Patients usually present after discovering lice or nits.

Many lice infestations are asymptomatic.

Pruritus is accompanied by excoriations that can become infected secondarily and papules linked to bite reactions.

Diagnosis is based on seeing eggs (nits), nymphs or mature lice. Observing lice is difficult. Nymphs and mature lice, despite being unable to hop or jump, can move rapidly through dry hair. The use of a magnifying glass assists with diagnosis.

Mature lice are 3-4 mm long. Nits are much smaller (about 1 mm). The p***c louse is about the same length as the head or body louse but has a wider body.

Body lice can be found in any area of the body, although they tend to avoid the scalp, except at the margins. Nits are laid in the host's clothing and are not usually found on the hair as with head lice and p***c lice. Body lice and eggs are found in clothing seams.

Diagnosis

Differential diagnosis

Unlike dandruff and hair root sheath casts, nits are stuck to the hair and are difficult to remove.

Nits are fluorescent under a Wood's light.

Prevention and Screening

Prevention

To prevent re-infestation, treat contacts of the patient at the same time as the patient.

Washing combs and brushes reduces re-infestation.

Treatment

Management

Treatment includes improved hygiene and laundering in hot water of all the infested clothing, bedding and linens. Drug treatment (eg, malathion or permethrin) is required in large-scale infestations.

Bed linens and clothes must be systematically decontaminated.

Hygiene and washing clothes, bedding and towels are most important and are usually sufficient but application of permethrin or malathion may be required.

Outbreaks require delousing of people with 1% permethrin dusting powder, basic sanitation and hygiene, changes of clean clothing, and sometimes shaving.

Antibiotics are needed to treat louse-borne infectious diseases.

Treating clothing with permethrin may prevent infestation.

Prevalence and Risk Factors

Epidemiology

Pediculosis is usually caused by contact with an infested person.

The body louse (Pediculus humanus) is most often seen in cold climates, in poor sanitation and with overcrowding.

Body lice also occur mainly when clothes are not changed or washed regularly. Therefore homeless populations are predominantly affected.

Pediculosis and scabies may co-exist in the same individual.

✍️Pelvic inflammatory disease

Pelvic inflammatory disease (PID) is an infection of the female reproductive organs. It usually occurs when s*xually transmitted bacteria spread from your va**na to your uterus, fallopian tubes or ovaries.

Pelvic inflammatory disease often causes no signs or symptoms. As a result, you might not realize you have the condition and get needed treatment. The condition might be detected later if you have trouble getting pregnant or if you develop chronic pelvic pain.

Symptoms
Signs and symptoms of pelvic inflammatory disease might include:

Pain in your lower abdomen and pelvis
Heavy va**nal discharge with an unpleasant odor
Abnormal uterine bleeding, especially during or after in*******se, or between menstrual cycles
Pain or bleeding during in*******se
Fever, sometimes with chills
Painful or difficult urination

Pelvic inflammatory disease (PID) is a general term for infection of the upper ge***al tract, including the uterus, Fallopian tubes, and ovaries.

PID usually results from ascending infection from the cervix. It is a common and serious complication of some s*xually transmitted diseases, especially chlamydia and gonorrhoea.

It can damage the Fallopian tubes and tissues in and near the uterus and ovaries. Untreated PID can lead to serious complications, including infertility, ectopic pregnancy, abscess formation and chronic pelvic pain.

Signs and Symptoms

Presentation

Diagnosis of acute PID made only on clinical signs and positive swab results is 65-90% as accurate when compared to laparoscopic diagnosis. Many episodes of PID go unrecognised, as women often have absent, mild, or atypical symptoms.

Symptoms

The following features are suggestive of PID:

Bilateral lower abdominal pain.

Deep dyspareunia.

Abnormal va**nal bleeding (postcoital, intermenstrual or menorrhagia).

Vaginal or cervical discharge that is purulent.

Signs

Lower abdominal tenderness (usually bilateral).

Mucopurulent cervical discharge and cervicitis seen on speculum examination.

Cervical motion tenderness and adnexal tenderness on bimanual va**nal examination.

Fever above 38°C (but may be apyrexial).

Diagnosis

Investigations

Pregnancy test (pregnant women with PID should be admitted; ectopic pregnancy may be confused with PID).

Cervical swabs for chlamydia and gonorrhoea: a positive result supports the diagnosis of PID, but a negative result does not exclude PID.

An elevated ESR or CRP also supports a diagnosis of PID.

Endometrial biopsy and ultrasound scanning may also be helpful.

Laparoscopy with direct visualisation of the Fallopian tubes is the best single diagnostic test, but is an invasive procedure and therefore not appropriate in routine clinical practice.

Urinalysis and urine culture: to exclude urinary tract infection.

Prevention and Screening

Prevention

Limited evidence suggests that screening for chlamydia and treating identified infection prior to IUCD insertion reduces the risk of PID.

Routine prophylactic antibiotics prior to IUCD insertion are not recommended.

It has been recommended that testing for chlamydia be offered to women at increased risk of s*xually transmitted infections and to all s*xually active women aged under 25 years.

Treatment

Management

Provide adequate pain relief.

The evidence for whether an IUCD should be left in situ or removed is limited. Removal of the IUCD may be associated with better short-term clinical outcomes.

The decision to remove the IUCD needs to be balanced against the risk of pregnancy in those who have had otherwise unprotected in*******se in the preceding seven days.

Consider referral to a GUM clinic, for a full s*xually transmitted infection screen (HIV, etc.), contact tracing and treatment of s*xual partners.

Antibiotic treatment

The current outpatient treatment recommendation is ceftriaxone 500 mg as a single intramuscular (IM) dose, followed by doxycycline 100 mg orally twice-daily and metronidazole 400 mg twice-daily, for 14 days.

Do not delay antibiotic treatment while waiting for the results of tests if PID is clinically suspected. It is likely that delayed treatment increases the risk of long-term complications, such as ectopic pregnancy, infertility and pelvic pain.

Negative swabs do not exclude PID and therefore should not influence the decision to treat. Emphasise the importance of completing the course of antibiotics to reduce the risk of long-term complications.

Broad-spectrum antibiotic treatment to cover C. trachomatis, N. gonorrhoeae and anaerobic infection is recommended.

Other recommended regimes include:

Outpatient regimens:

Ofloxacin 400 mg orally twice-daily plus oral metronidazole 400 mg twice-daily, for 14 days. This is not recommended if the woman is at high risk of gonococcal PID because of increasing quinolone resistance of gonorrhoea. Levofloxacin may be used as a once-daily, convenient alternative to ofloxacin.

Severely ill patients:

Intravenous (IV) therapy is recommended for patients with more severe clinical disease, eg pyrexia above 38°C, clinical signs of tubo-ovarian abscess, signs of pelvic peritonitis or pregnancy.

Initial treatment with doxycycline, single-dose IV ceftriaxone and IV metronidazole, then change to oral doxycycline and metronidazole to complete 14 days of treatment.

There is no evidence-based recommendation for treatment in pregnancy, but an empiric regimen might include IM ceftriaxone plus oral or IV erythromycin, with the possible addition of oral or IV metronidazole 500 mg three times daily in clinically severe disease. Any risk of this regimen is justified on the basis of need to provide therapy and low risk to the fetus.

IV therapy should be continued for 24 hours after signs of clinical improvement.

Management of s*xual partners

Although most infected male partners have no symptoms, infection rates of 26-36% for C. trachomatis have been reported among partners.

Patients should be advised to avoid unprotected in*******se until they, and their partner(s) have completed treatment and follow-up.

Screen for other s*xually transmitted infections, ideally at a GUM clinic. All s*xual partners within the previous six months (or the most recent s*xual partner if there have been no s*xual contacts within the previous six months) should be notified and offered screening for s*xually transmitted infections.

Sexual partners should be treated for chlamydial infection even if this is not identified on testing.

Treatment for gonorrhoea only needs to be offered if N. gonorrhoeae is identified in the woman with PID or in her partner.

Empirical treatment for chlamydial infection and gonorrhoea should be given to partners who are unwilling to be screened.

Prevalence and Risk Factors

Epidemiology

Pelvic infections are often polymicrobial. PID can be caused by ge***al mycoplasmas, endogenous va**nal flora (anaerobic and aerobic bacteria), aerobic streptococci, Mycobacterium tuberculosis, and s*xually transmitted infections such as Chlamydia trachomatis or Neisseria gonorrhoeae.

Ge***al chlamydial infection is currently the most common s*xually transmitted infection diagnosed in genitourinary medicine (GUM) clinics in the United Kingdom.

The incidence of gonorrhoea is increasing and therefore becoming a more common cause of PID.

Other organisms implicated in PID include those commonly associated with bacterial vaginosis, eg Gardnerella va**nalis, Mycoplasma hominis, Mobiluncus spp. and other anaerobes.

Actinomycetes are part of the normal va**nal flora and a rare cause of PID

Risk factors

Risk factors for acquiring s*xually transmitted infections, eg young age, new s*xual partner, multiple s*xual partners, lack of barrier contraception, lower socio-economic group.
Insertion of intrauterine contraceptive device (IUCD) - for the first 3-4 weeks after insertion.
Termination of pregnancy

✍️ P***c Lice
Definition

Lice are blood-sucking insects and specific parasites of human beings. Lice are 1-3 mm long and have three pairs of legs that end in powerful claws.

P***c lice are slightly smaller than head lice and body lice.

The female lives for 1-3 months but dies when separated from the host. The female louse lays up to 300 eggs, called nits, during her lifetime.

The nits are less than 1 mm in diameter and, when viable, are opalescent. The nits hatch 6-10 days after they have been laid, giving rise to nymphs that become adults in 10 days.

Three species of lice have adapted to live on humans:

Head louse (Pediculus humanus capitis) - see separate Head Lice article.

Crab (or p***c) louse (Pthirus p***s).

Body louse (Pediculus humanus).

P***c lice

The p***c louse (Pthirus p***s) is 'crab'-shaped, grey-brown in colour,and about 2 mm in length. The female lays eggs (smaller than a pinhead) on the hair shaft, near to the body. The eggs hatch after about 6-10 days. The empty nit eggshells are tightly attached to the hair.
The female louse lives for 1-3 months. Eradication of p***c lice from the body is unlikely unless treated.

Signs and Symptoms

Presentation

The incubation period is usually between five days and several weeks.

The diagnosis is based on finding adult lice or eggs. P***c lice live on coarse hair, especially in the p***c and peria**l areas but also on the eyelashes, abdomen, back, axillae and on the head.

Therefore, all hairy parts of the body should be examined. A fine-toothed comb may be useful for detection. Dermatoscopy has also proved a useful diagnostic technique in cases of doubt.

Itchy red papules are the most common presentation. Itching takes 1-3 weeks to develop after the first infestation but may occur immediately following re-infestation. Itching tends to be worse at night.

Blue macules may be visible at feeding sites.

Minute dark-brown specks of louse excreta are sometimes seen on the skin and underwear.

Prevention and Screening

Prevention

Shaving the infested areas does not provide protection from re-infestation because p***c lice need only a minimal length of hair on which to lay eggs.

Treatment

Management

Consider whether the p***c lice infestation has been acquired via s*xual or non-s*xual contact.

If acquired via s*xual contact, refer to a genitourinary medicine (GUM) clinic for treatment, screening for other s*xually transmitted infections and contact tracing.

Treat the individual with a topical insecticide: two applications of malathion 0.5% aqueous lotion or permethrin 5% dermal cream, seven days apart. All surfaces of the body should be treated, including the scalp, neck and face (paying particular attention to the eyebrows and other facial hair).

Advise the individual to avoid close body contact until they and any current s*xual partner have been treated.

Any close contacts over the previous three months should be examined for p***c lice.

For people with infestation of the eyelashes, treat the eyelashes with an inert occlusive ophthalmic ointment (eg, simple eye ointment BP) or a topical insecticide (a cream rinse or shampoo should be used). An inert occlusive ophthalmic ointment should be used for people under the age of 18 years and for those who are pregnant or breast-feeding.

If p***c lice infestation is unresponsive to initial insecticide treatment, repeat the previous treatment with the correct technique (rather than switching to a different treatment).

If insecticide resistance is suspected, switch to the alternative insecticide (malathion or permethrin).

When re-infestation occurs, repeat the previous treatment; assess all close contacts for p***c lice and treat all positive cases simultaneously.

Prevalence and Risk Factors

Epidemiology

They are common among young adults.

P***c lice infest 2 to over 10% of human populations.

P***c lice are transmitted by close body contact, which can be from s*xual contact or from close family contact (eg, from an infested beard or chest).

P***c lice in children may be an indication of s*xual abuse but most children with p***c lice infestation have probably acquired this innocently.

✍️ Epididymo-Orchitis
Definition

Acute epididymo-orchitis is a clinical syndrome consisting of pain, swelling and inflammation of the epididymis, with or without inflammation of the te**es. The most common route of infection is local extension and is mainly due to infections spreading from the urethra (s*xually transmitted infections (STIs)) or from the bladder.
Orchitis (infection limited to the te**is) is much less common. Chronic epididymitis refers to epididymal pain and inflammation (usually without scrotal swelling) that lasts for more than six months.

Etiology

Aetiology of epididymo-orchitis

In men under 35 years old, infection is most often due to a s*xually transmitted pathogen - eg, Chlamydia trachomatis and Neisseria gonorrhoeae.

In men over 35 years old, infection is most often due to a non-s*xually transmitted Gram-negative enteric organism causing urinary tract infections - eg, Escherichia coli, Pseudomonas spp. Specific risk factors include recent instrumentation or catheterisation.

However, there is an overlap between these groups and a thorough s*xual history is imperative for all age groups.

Mumps should be considered as an aetiology since the epidemic in 2005.

Extrapulmonary tuberculosis (TB) represents 40-45% of TB cases in the UK but tuberculous epididymo-orchitis is a rare presentation. It is likely to present in patients from high prevalence countries or with a previous history of TB and particularly in patients with immunodeficiency. It is usually a result of disseminated infection and commonly associated with renal TB but can be an isolated finding.

Ureaplasma urealyticum is found in men with epididymo-orchitis, often in association with N. gonorrhoeae or C. trachomatis infection.

12-19% of men with Behзet's disease develop epididymo-orchitis. This is non-infective and thought to be part of the disease process. It is associated with more severe disease.

Other rare infections (eg, brucellosis, coccidioidomycosis, blastomycosis, cytomegalovirus and candidiasis) usually occur in immunocompromised hosts.

Epididymo-orchitis has also been reported as an adverse effect of amiodarone. This is dose-dependent and usually occurs at doses greater than 200 mg daily.

Aetiology of acute orchitis

Viral: mumps orchitis is most common. Coxsackievirus A, varicella and echoviral infections are rare.

Bacterial and pyogenic infections: E. coli, Klebsiella, Pseudomonas, Staphylococcus and Streptococcus species are unusual.

Granulomatous: syphilis, TB, leprosy, Actinomyces spp. and fungal diseases are rare.

Trauma.

Idiopathic.

Signs and Symptoms

It usually presents with unilateral scrotal pain and swelling of relatively acute onset.

Acute epididymitis is usually unilateral but is bilateral in 5-10% of the patients.

In s*xually transmitted epididymo-orchitis there may be symptoms of urethritis or a urethral discharge.

There may be a history of symptoms suggesting a urinary tract infection or a history of bacteriuria.

Mumps usually presents with headache, fever and unilateral or bilateral parotid swelling but may present with epididymitis. Scrotal involvement can occur without systemic symptoms.

Symptoms suggestive of tuberculous infection include subacute/chronic onset of painless or painful scrotal swelling, associated with systemic symptoms of TB, a scrotal sinus or thickened scrotal skin.

Signs

Tenderness to palpation on the affected side.

Palpable swelling of the epididymis, starting with the tail at the lower pole of the te**is and spreading towards the head at the upper pole of the te**is with or without involvement of the testicle.

There may also be urethral discharge, secondary hydrocele, erythema and/or oedema of the sc***um on the affected side and pyrexia.

Differential diagnosis

Testicular torsion

Testicular torsion is the most important differential diagnosis. It is a surgical emergency, should be considered in all patients and should be excluded first (testicular salvage is essential within six hours and becomes decreasingly likely with time).

Differentiation between epididymo-orchitis and testicular torsion on clinical examination may be difficult and, if any doubt exists, then urgent surgical exploration is advocated.

Torsion is more common in men who are younger than 20 years but it can occur at any age.

A painful swollen testicle in an adolescent boy or a young man should be managed as torsion until proven otherwise.

Torsion is more likely if the onset of pain is acute (typically around four hours at presentation) and the pain is severe.

Careful evaluation for the possible causes of acute scrotal pain and swelling is essential.

Testicular torsion with ischaemia or infarction.

Trauma.

Abscess formation.

Testicular or epididymal tumour.

Hydrocele.

Diagnosis

Investigations

A s*xually transmitted cause should always be excluded. The following should be performed:

Gram-stained urethral smear (even if urethral symptoms are absent), examined microscopically for the diagnosis of urethritis, (5 or more polymorphonuclear leukocytes per high power field x 1,000) and presumptive diagnosis of gonorrhoea (Gram-negative intracellular diplococci), or Gram-stained preparation from a centrifuged sample of first passed urine (FPU) for microscopy is an alternative method of diagnosing urethritis (10 or more polymorphonuclear leukocytes per high power field x 1,000).

Urethral swab for N. gonorrhoeae culture and/or FPU or urethral swab for nucleic acid amplification test (NAAT) for N. gonorrhoeae.

FPU or urethral swab for C. trachomatis NAAT.

Microscopy and culture of midstream specimen of urine (MSU) for bacteria. Urinalysis including nitrite and/or a leukocyte esterase test is helpful but is not diagnostic.
Consider HIV testing if there are any risk factors or clinical suspicion.

If it can be arranged without delay, colour Doppler ultrasound to assess arterial blood flow, may be useful to help differentiate between epididymo-orchitis and torsion of the spermatic cord (but the sensitivity for detecting torsion may not be 100% and this should not delay surgical exploration of the sc***um).

Further Investigations

Other investigations which could be considered include:

All patients with s*xually transmitted epididymo-orchitis should be screened for other STIs.

Anatomical abnormalities of the urinary tract are common in the group infected with Gram-negative enteric organisms and further investigation of the urinary tract should be considered in all such patients, especially in those older than 50 years.

When investigating for tuberculous infection, three early morning urine samples should be obtained but these are not always positive for acid-alcohol fast bacilli (AAFB) in the setting of tuberculous epididymitis. Other investigations recommended include intravenous urography, renal tract ultrasound scan and biopsy of the site as well as CXR to exclude or confirm co-existing respiratory involvement.

When considering mumps as a possible diagnosis, mumps IgM/IgG serology should be checked.

There is no role for epididymal aspiration/fine-needle aspiration cytology in routine clinical practice. It may be useful in recurrent infection which fails to respond to therapy and if epididymo-orchitis is found at operation and in the case of suspected tuberculous epididymitis.

Treatment

Management

If there is any possibility of torsion, arrange urgent urology opinion.

If there is possible STI - eg, younger age, multiple partners or new partner:

Refer urgently to a genitourinary clinic for full STI screen, treatment and contact tracing.

Advise to avoid unprotected s*x until treatment and follow-up, including tracing and treating s*xual contacts, have been completed.

General advice

Appropriate rest, a**lgesia and scrotal support are recommended.

Non-steroidal anti-inflammatory drugs may be helpful.

Patients should be advised to abstain from s*xual in*******se until they and their partner(s) have completed treatment and follow-up in those with confirmed or suspected s*xually transmitted epididymo-orchitis.

Drugs

Empirical therapy should be given to all patients with epididymo-orchitis before culture/NAAT results are available. The antibiotic regimen chosen should be determined in the light of the immediate tests (urethral or FPU smear, urinalysis) as well as age, s*xual history including insertive a**l in*******se, any recent instrumentation or catheterisation and any known urinary tract abnormalities.

Antibiotics may need to be varied according to local knowledge of antibiotic sensitivities and changed once the results of cultures and sensitivities are known.

For epididymo-orchitis most probably due to any s*xually transmitted pathogen: ceftriaxone 250 mg intramuscularly single dose, plus doxycycline 100 mg by mouth twice daily for 10-14 days.

If it is most probably due to chlamydia or other non-gonococcal organisms (ie where gonorrhoea is considered unlikely as microscopy is negative for Gram-negative intracellular diplococci and no risk factors for gonorrhoea are identified) consider: doxycycline 100 mg by mouth twice daily for 10-14 days or ofloxacin 200 mg by mouth twice daily for 14 days. It is vital that sensitivity testing be undertaken before ofloxacin is given.

For epididymo-orchitis most probably due to enteric organisms: ofloxacin 200 mg by mouth twice daily for 14 days or ciprofloxacin 500 mg by mouth twice daily for 10 days.

Corticosteroids have been used in the treatment of acute epididymo-orchitis but have not been shown to be of benefit.

In those with severe epididymo-orchitis or features suggestive of bacteraemia, inpatient management of fluid and electrolyte balance is required.

Intravenous broad-spectrum therapy directed towards coliforms and Pseudomonas aeruginosa should be considered: cefuroxime 1.5 g three times daily with or without gentamicin for 3-5 days until fever subsides; in those with severe allergy to penicillin, use ciprofloxacin 500 mg twice daily.

For epididymo-orchitis of all causes where the patient is allergic to cephalosporins and/or tetracyclines: ofloxacin 200 mg by mouth twice daily for 14 days.

Sexual partners

Partner notification and treatment are recommended for all patients with epididymo-orchitis secondary to gonorrhoea, chlamydia and non-gonococcal urethritis (NGU) or of indeterminate aetiology and subsequent MSU negative.

Follow-up

If there is no improvement in the patient's condition after three days, the diagnosis should be reassessed and therapy re-evaluated

Further follow-up is recommended at two weeks to assess compliance with treatment, partner notification and improvement of symptoms.

The swelling and tenderness can persist after antimicrobial therapy is completed but should be significantly improved. Where there is little improvement, further investigations such as an ultrasound scan or surgical assessment should be considered.

Surgical

Scrotal exploration if a torsion or tumour cannot be ruled out and for the complications of acute epididymitis and orchitis (eg, abscess, testicular infarction).

Prevalence and Risk Factors

Epidemiology

A study of UK general practices during the years 2003-2008 reported a highest incidence of 25/10,000 in 2004-2005. The incidence declined during the latter part of the study.

Acute epididymitis most commonly occurs in patients aged 15-30 years and patients older than 60 years. In the UK GP study, the incidence declined in younger age groups throughout the study period but that of males over 45 years was stable. Prepubertal epididymitis is rare (and testicular torsion is much more common in this age group).

Mumps orchitis occurs in up to 40% of postpubertal boys with mumps; it is rare in prepubertal boys.

Risk factors

Common risk factors for gonorrhoea are previous infection with N. gonorrhoeae, known contact of gonorrhoea, presence of purulent urethral discharge, men who have s*x with men and black ethnicity.

Instrumentation and indwelling catheters are common risk factors for acute epididymitis. Urethritis or prostatitis may also co-exist.

Structural or functional abnormalities of the urinary tract are common in the group infected with Gram-negative enteric organisms. Adults usually have bladder outlet obstruction or urethral stricture; children may have an ectopic ureter, posterior urethral valves or vesicoureteral reflux.

A**l in*******se is also a risk factor for infection with enteric pathogens.
Reflux of infected urine from the prostatic urethra to the epididymis via the ejaculatory ducts and vas deferens may be induced by Valsalva manoeuvre or strenuous exertion.
Epididymitis is common in men performing strenuous exertion when there is no opportunity to void, resulting in a full bladder.

✍️ Menorrhagia
Definition

Menorrhagia is menstrual blood loss which interferes with a woman's physical, emotional, social, and material quality of life, and which can occur alone or in combination with other symptoms. Any intervention should aim to improve her quality of life. Research studies usually take menorrhagia to be a monthly menstrual blood loss in excess of 80 ml.

Normal

The average menstrual cycle has a blood loss for 7 days of a cycle of between 21 and 35 days. The usual shorthand for this is:

K = 7/21-35 in which K represents menstrual cycle, 7 is the duration of bleeding and 21-35 represents the length of the cycle.

Menstrual loss is heaviest for the first few days and becomes much lighter, tailing off towards the end.

Other definitions include:

Metrorrhagia - flow at irregular intervals.

Menometrorrhagia - frequent and excessive flow.

Polymenorrhoea - bleeding at intervals of less than 21 days.

Dysfunctional uterine bleeding (DUB) - abnormal uterine bleeding without any obvious structural or systemic pathology. It usually presents as menorrhagia. The diagnosis of DUB can only be made once all other causes for abnormal, or heavy, uterine bleeding have been excluded.

Dysmenorrhoea - pain with menstruation.

The average menstrual blood loss is about 35-40 ml. Some researchers have found that no more than 10% of women who complain of heavy menstruation have blood loss in excess of 80 ml. Menorrhagia is very subjective; a more practical definition may be that it is menstrual loss that is greater than the woman feels she can reasonably manage. The National Institute for Health and Care Excellence (NICE) defines heavy menstrual loss as excessive blood loss that interferes with a woman's physical, social, emotional and/or quality of life.

Menorrhagia is related to increased limitations in physical activities and limitations in social and leisure activities.

Etiology

40-60% of those who complain of excessive bleeding have no pathology and this is called dysfunctional uterine bleeding (DUB).

20% of cases are associated with anovulatory cycles and these are most common at the extremes of reproductive life.

Local causes include:

Fibroids.

Endometrial polyps.

Adenomyosis.

Endometritis.

Endometrial hyperplasia.

Pelvic inflammatory disease (PID).

Carcinoma, especially endometrial carcinoma in women aged over 40; this usually presents with postmenopausal bleeding, but 20-25% of cases present with abnormalities of the menstrual cycle.

Systemic disease can include hypothyroidism, liver or kidney failure, obesity and bleeding disorders - eg, von Willebrands's disease.

An intrauterine contraceptive device (IUCD) or anticoagulant treatment can increase menstrual flow.

Signs and Symptoms

Presentation

See separate article Gynaecological History and Examination.

Note the total duration of bleeding and how much of that time it is heavy. Over 90% of menstrual loss occurs in the first 3 days and there is no correlation with the duration of loss and the total volume. Pictorial blood loss assessment charts may be useful.

Note the length of the cycle, ie the duration from the start of one period to the start of the next.

If the patient has to wear tampons and towels simultaneously, flow is heavy.

The passage of clots represents heavy flow. Clots may be painful as they pass through the cervix.

Ask about other associated menstrual problems - for example, premenstrual syndrome, intermenstrual bleeding (IMB), postcoital bleeding (PCB), dyspareunia and pelvic pain.

Ask about contraception and intentions with regard to further children, as this may affect management.

Ask about any symptoms to suggest anaemia.

Ascertain the effect on personal life, including any time off work.

Ask about past medical problems, including clotting disorders, thyroid status and gynaecological history.

Ask about easy bruising or bleeding gums.

Examination

Clinical examination should be undertaken to assess for any anaemia and also to rule out potential organic causes of menorrhagia.

Note general appearance and BMI. Body fat is very important in relation to metabolism of steroid hormones.

Note any signs suggestive of endocrine abnormality (hirsutism, acne) or bruising.

Look at the tongue for pallor and the nails for koilonychia.

Examination of the abdomen always precedes pelvic examination; otherwise, large pelvic masses can be missed.

Ascertain that the cervical smear is up-to-date.

Inspect the cervix and take swabs if clinically indicated.

Perform a bimanual examination. Abnormalities may include a bulky or grossly enlarged uterus, fixation of the uterus or tenderness.

Diagnosis

Investigations

Women can be asked to complete a pictorial representation to assess the volume of blood loss.

FBC is important. Every woman presenting with heavy menstrual bleeding should have FBC taken. The most common cause of iron deficiency anaemia in women is menorrhagia.

Tests for endocrine abnormalities, including TFTs should be performed only if there is clinical suspicion.

Assessment of bleeding disorders is only indicated if there is clinical suspicion.

When to refer to secondary care

If appropriate, you should refer the patient for an endometrial biopsy to exclude endometrial cancer or atypical hyperplasia. Indications for a biopsy include:

Persistent intermenstrual bleeding.

Symptoms that have not improved with medical management.

Women aged over 45 years with heavy menstrual bleeding.

Women with a history to suggest endometrial pathology.

If an abnormality is suspected after physical examination (apart from fibroids