An excellent presentation on sexual health from the team at Airedale

Sexual Health Topics VTS February 2011

Topic Areas Sexual History taking Testing Screening Sexually transmitted diseases Vaginal Discharge Contact Tracing

Risk assessment & awareness Consider STI risk when providing contraceptive advice (& smear test) Consider STI risk if aware of lifestyle risk factors - alcohol etc Travel advice Assume nothing

Sexual History Taking 1 Reason for need for testing Timing of last SI (may be too early for some tests) Number of partners over last 6 months Sex of partners Type of sex Use of barrier methods

Sexual History taking 2 Geography - where had sex (prevalence varies) recent PMH STI Symptoms

Testing for STI Any intimate examination needs a chaperone Swabs - female - endocervical x2 + HVS Swabs - male - urethral, rectal if appropriate & first void urine

Screening Note Wilsons criteria Chlamydia screening for under 25s via NCSP Urine after 1hr abstinence (male & female) 1st pass not MSSU Good screening tool but pick up in females not as good as endocervical

Blood tests Needs appropriate counselling (not in 10min appt) Syphilis Hepatitis B Hepatitis C HIV

NICE Guidance February 2007 One to one interventions to reduce the transmission of sexually transmitted infections (STIs) including HIV and to reduce the rate of under 18 conceptions, especially in vulnerable and at risk groups

Contents of NICE Guidance Advises identification of high risk individuals opportunistically Structured 1 to 1 discussion with high risk individuals aimed at change behaviour Help patients with STI get partners tested and treated Refer to specialist if necessary

Choosing Health- 2004 Government white paper More rapid roll out NCSP PCTs encouraged to increase 48hr access to GUM Aim to increase chlamydia screening & reduce gonorrhoea prevalence

Chlamydia 80% of women & 50% men asymptomatic Vaginal discharge PCB or IMB lower abdominal pain, deep dyspareunia Cervicitis Men - dysuria, discharge, discomfort Epididymo-orchitis Incubation period 2-6 weeks

Chlamydia treatment Doxycycline 100mg bd for 7 days OR Stat 1g Azithromycin If pregnant - erythromycin 500mg bd for 14 days (or amox 500mg tds 7 days - not as good) No SI until partner treated or for 7 days after azithro (even with condom) PID - 14 days rx with doxycycline

Gonorrhoea Need sample at even temp & to lab in 48hrs Women - 50% asymptomatic, 50% discharge. Men - urethral infection usually discharge Men - 10% asymptomatic Pharyngeal infection usually asymptomatic Increasing resistance - check with local GUM

Urethritis Urethral discharge Dysuria Urethral itch or discomfort Infective causes - chlamydia, gonococcus or NSU NSU - ureaplasma, mycoplasma, TV, yeasts, HSV, anaerobic balanitis

Vaginal Discharge 1 FFPRHC & BASHH Guidance January 2006 Can be physiological Non - sexual infections :BV - commonest cause, Candida Sexually transmitted causes - trichomonas, chlamydia, gonorrhoea Other - FB, fistula, malignancy

Vaginal discharge2 Assess risk of STI Low risk + itch + non-offensive white discharge = treat for candida Low risk -no itch, offensive thin white discharge = treat for BV If high risk, symptoms of upper repro tract infection or post partum then test

Bacterial Vaginosis Amsel’s criteria (3/4 present) White discharge pH>4.5 Clue cells Fishy odour (with addition of 10% KOH!) Treat with oral metronidazole 400mg bd for 5-7 days, or 2g stat oral dose (alternative = topical metro or clindamycin)

Candida Itchy thick white discharge Vaginal - clotrimazole, econazole or feticonazole pessaries or miconazole intravaginal cream Oral - fluconazole 150mg stat dose Recurrent infection - oral fluconazole 100mg weekly for 6 months or clotrimazole 500mg pessary weekly for 6 months

Trichomonas Offensive scant to profuse or frothy yellow discharge Dysuria, vulval itch, low abdominal pain Vulvitis & vaginitis Needs wet microscopy to diagnose - GUM clinic Treats with metronidazole 400mg bd for 5-7 days or 2g stat dose

Group B Streptococcus Not usually symptomatic but may be found on HVS 30% of women carry it Commonest cause of early onset severe infection in newborn - 10% mortatlity USA screen for it Current guidance only treat in labour if GBS bacteriuria, previous baby with GBS disease or other risk factors

PID Ascending infection Can spread to peritoneum (includes peri-hepatitis) Mostly chlamydia or gonorrhoea Exclude pregnancy, do MSSU, swabs If severe symptoms admit, less severe refer GUM +/- treat (ofloxacin 400mg bd 14/7 + metronidazole 400mg bd 14/7)

Syphilis On the increase in some areas Primary = painless ulcer Secondary = lymphadenopathy, rash, mucosal lesions latent Tertiary = CVS, CNS Treatment = injectable penicillin

Herpes Simplex Painful genital ulcers Primary or recurrent HSV 1 &2 2/3 of carriers are totally asymptomatic Primary attack - aciclovir 200mg 5x daily for 5/7 or valciclovir 500mg bd for 5/7

Genital Warts HPV Treatment is cosmetic rather than curative GUM = cryotherapy or podophyllin, occasionally laser or surgery Home treatment - podophyllotoxin or imiquimod

HPV Vaccination National programme for 12 yr old girls Catch up campaign for 12-18 in GP surgery Cervarix – vaccinates against 2 of the 3 strains implicated in cervical cancer Other countries use Gardasil – vaccinates against all 3 strains of HPV + one of genital warts

Cervical Screening National programme – women aged 25-64 (Scotland may be different) Liquid based cytology Borderline smears are checked for HPV and processed as “high risk” if present (this may be regional) Results or referral details direct to patient

HIV Testing Discuss confidentiality, window period, treatment, transmission Risk factors What if is positive Expectation of results Safer sex Is blood needed for Hep B&C? Consent form

Contact tracing Can be by patient or health professional Systematic review - BMJ Feb 2007 looked at partner notification - with partner delivered therapy, home sampling kit for partners or additional information for patient to give to partners - all better than just patient notification of partner Can refer to GUM, have system for anonymous contacting