Sexual Health for Practice Nurses

Aim For you to have the knowledge to assess, test and manage vaginal discharge and simple STIs in your patients

You will Be aware of opportunities for STI testing Consider why you should, and how you will incorporate sexual history taking into your consultations Have some knowledge of Sexual/vaginal infections and how to screen/test for common infections Understand the implications of manging your results correctly Be aware of local sexual health service provision

Sexual Health Sexual health is a state of physical, mental and social well-being in relation to sexuality. It requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence

Sexual health is a UK government priority HIV continues to be one of the most important communicable diseases in the UK. The number of people living with HIV in the UK continues to rise and Around 1 in 4 of those infected are unaware of their infection. General practice has a role in caring for patients with HIV and assessing the risk of having undiagnosed HIV The scale and impact of the under-diagnosis of Hepatitis B and C is apparent

STI testing has moved towards self-taken swabs and home sampling Rates of sexually transmitted infections (STIs) continue to rise, in some cases dramatically There are serious implications for health

General practice is the largest provider of sexual and reproductive health care (SRH) in the UK RCGP 2017

General Practice is uniquely accessible General Practice is uniquely accessible. You need to discern people at high risk of having a sexual health problem from those with zero risk GPs and practice nurses may be unaware of the extent of their lack of knowledge in what is a very rapidly changing field Many lack confidence in discussing sexual health with their patients and lack time-efficient strategies

Screening/Testing for Sexual Infections in your setting When?

New patient registration Referred by GP Vaccinations Screening for STIs New patient registration Post natal checks Any consultation! Cervical screening Repeat contraception Chronic disease/medication reviews Health education and prevention advice

Young/Vulnerable people Confidentiality Consent Fraser competent Capacity to consent to SI Adult/child safeguarding CSE Domestic violence Honour based violence Trafficking The law

Consent Children under the age of 16 can consent to medical treatment if they have sufficient maturity and judgement to enable them fully to understand what is proposed. This was clarified in England and Wales by the House of Lords in the case of Gillick vs West Norfolk and Wisbech AHA & DHSS in 1985

Fraser Guidance the young person will understand the professional's advice the young person cannot be persuaded to inform their parents the young person is likely to begin, or to continue having, sexual intercourse with or without contraceptive treatment unless the young person receives contraceptive treatment, their physical or mental health, or both, are likely to suffer the young person's best interests require them to receive contraceptive advice or treatment with or without parental consent

Take a sexual history from a male or female patient in a way that is Private and confidential Non-judgemental Responsive to the reactions of the patient Avoid assumptions about Sexual orientation Gender/age of the partner(s) Disability Ethnic origin

The initial greeting to the patient Maintain eye contact (if culturally acceptable) Use appropriate body language Initiate consultation with open questions followed by exploration of initial concerns and more closed questions as the consultation continue Explain the rationale for some of the questions asked Sexually explicit language Use language that is clear and understandable Both clinician and patient are comfortable Possibility of anxiety and distress from the patient Recognise non-verbal cues

Sanjit who is 44 is referred by the GP for triple swabs She has had a horrible smelling discharge for the past 2 months She is feeling very itchy and sore. She believes that this is due to her IUD She has been treated with a canestan pessary twice It helped for a short while, but comes back

What should you ask? Medical history Medicines Allergies Menstrual history Contraception LMP Other symptoms

Other symptoms? Consistency of discharge Nature of odour Urinary problems Pain Bleeding Lumps,rashes,ulcers

Blood Born Virus risks Number of Partners last 3/6/12 months Hepatitis B vaccianation Previous HIV test MSM or contact with MSM IVDU or contact with IVDU Snorting drug use Chemsex

SI with people from high risk countries Paid for sex Been paid for sex Sex with HIV+ person History of coercive or non-consensual SI Non-professional tattoos or piercings Blood transfusion / medical procedures abroad

Recognise sexual health emergencies CSE Emergency contraception Post-exposure prophylaxis (PEP) in HIV prevention, Hepatitis B vaccinations Responding to early presentation of rape and sexual assault

Notes: Rates of new STI diagnoses by gender & age group: England, 2015 Young adults aged 15-24 years have the highest rates of new STIs. Young women experience higher rates than young men aged 15-24 years. For older age groups (aged 25-59 years), men have higher rates than women.

Notes: Number of STI diagnoses among women: England, 2006–2015 The number of anogenital herpes (first episode) diagnoses in women increased steadily between 2006 & 2013, but has shown signs of levelling off in recent years. Gonorrhoea diagnoses have slowly increased since 2011, although there was a 2% (8,638 in 2014 to 8,488 in 2015) decrease in the most recent year. There has been a general decline in the number of anogenital warts diagnoses since 2008. Most of this is explained by a reduction in genital warts diagnoses in 15-19 year olds associated with Human Papillomavirus vaccination. Syphilis diagnoses have steadily decreased over the last decade although there has been an increase in the most recent year.

Notes: Number of STI diagnoses among men: England, 2006–2015 Following a decline in the number of gonorrhoea diagnoses among men between 2006 & 2008, diagnoses have increased sharply over the past 5 years. There was a slow but steady increase in the number of anogenital herpes (first episode) diagnoses from 2006 to 2013, followed by a slight decline. There has been an increase in syphilis diagnoses particularly in the last 2 years. There has been a marked decline in anogenital warts diagnoses in recent years, with a 6% decrease between 2014 & 2015.

Window periods Chlamydia/Gonorrhoea: 2 weeks HIV: 4 weeks Syphilis: 12 weeks Hepatitis B/C: 3-6 months

Change in Vaginal Discharge Candida or thrush Bacterial vaginosis (BV) Trichomonas vaginalis (TV) Herpes Gonorrhoea Chlamydia Physiological Retained condom, tampon or foreign body

Bacterial vaginosis

Signs & Symptoms Offensive “fishy” smelling vaginal discharge. More noticeable following sex. Not associated with soreness or irritation.

Bacterial Vaginosis Commonest cause of abnormal discharge in women of child bearing age. Caused by an imbalance in vaginal ecology. Risk factors include: Vaginal douching Using highly perfumed washing products Recent change of sexual partner Smoking

Treatment Metronidazole 400mg orally bd for 5 days. Intravaginal Metronidazole gel - once daily for 5 days. Intravaginal Clindamycin 2% cream – once daily for 7 days. Balance Activ gel (various regimes) Avoidance of highly perfumed washing products.

Vulvovaginal Candidiasis Thrush

Signs & Symptoms Vulvitis Vulval itching Superficial dyspareunia Dysuria “Curdy” white, non offensive vaginal discharge. Fissuring

Treatment Clotrimazole 500mg pv stat pessary. Clotrimazole 1% cream, topically. Daktacort cream, topically (if severe erythema). Oral fluconazole or itraconazole. Avoidance of highly perfumed washing products.

Chlamydia

Signs & Symptoms Dysuria Vaginal or urethral discharge Abdominal pain PCB/IMB Up to 80 % Asymptomatic

Chlamydia Trachomatis Epidemiology 3-5% of all women attending GP surgery 10% Under 25s Risk Factors Under 25 New partner > 1 partner in previous year Contraception TOP

Complications Pelvic Inflammatory Disease (PID) Adult or neonatal conjunctivitis Sexually Acquired Reactive Arthritis (SARA) Epididimytis Orchitis

Notes: Total number of chlamydia diagnoses among women: England, 2006-2015 The number of chlamydia diagnoses in GUM services increased steadily between 2006 & 2010. This was followed by a decline between 2008 & 2010. Between 2012 & 2014, the number of diagnoses in GUM services increased slightly, although there was a 3% decrease in the most recent year. Generally, there were more chlamydia diagnoses made in community services compared to GUM services. Between 2008 & 2010, there was a steady increase in the number of diagnoses from community services, but a decrease was observed in 2011. These changes in diagnoses between 2008 & 2011 likely reflect, in part, the effects induced by the implementation of the National Chlamydia Screening Programme (NCSP) in community-based settings. Since 2012, there has been a decline in the number of diagnoses of chlamydia made through community services. There was an 8% decrease in diagnoses of chlamydia among women made in community services in the most recent year. Chlamydia is the most commonly diagnosed STI in England with 200,288 diagnoses made in 2015, of which 114,509 (57%) were in women. Overall, there was a 6% decrease in diagnoses of chlamydia in women between 2014 & 2015.