1. Case presentation Carley firm

2. Patient XX  26 Year old female bank worker  HPC - 36 hour history - painful vulvar lesions - dysuria for 18 hours – unable to pass urine - thick, white vaginal discharge  Sexual history - 6 months: monogamous relationship with a male partner - 50+ male sexual partners in the past, 3 in the last 12 months. Occasionally protected - genital warts, gonorrhoea and chlamydia infections

3. Examination  Abdo soft, non tender  20+ 5mm blister-like, angry, red lesions filled with clear fluid around vaginal entrance  White vaginal discharge  External swabs taken  Too tender to examine internally

4. Differential Diagnoses 1. Herpes simplex virus infection 2. Folliculitis 3. Chancroid 4. Herpes zoster infection 5. Syphilis

5. Investigations  Initially treated empirically  Vulvular lesions swabbed for virology  HSV PCR of swab from lesion base: DNA detection.

6. What is genital herpes?  A viral infection of the genital region  There are two types of herpes simplex virus:  Epidemiology Type 2: Usually only causes genital herpes. It can sometimes cause cold sores Type 1: The usual cause of cold sores around the mouth. It also causes up to half of cases of genital herpes.

7. Transmission  skin-to-skin contact - Kissing - Sexual contact - Vertical transmission

8. Signs & Symptoms o Mostly asymptomatic! o General malaise, mild fever, aches & pains o Groups of small, painful blisters then appear around the genitals and/or anus o Dysuria and vaginal discharge is common in women o Bilateral inguinal o lymphadenopathy 1 2

9. Recurrence  Tend to be less severe and shorter than the first episode.  Most people do not develop a fever  A tingling or itch in the genital area for 12-24 hours may indicate a recurrence is starting.

10. Treatment  Analgaesia & Antivirals  Tips for symptoms - Pass urine whilst sitting in a warm bath or with water flowing over the area. - Apply barrier cream before passing urine - Place an ice pack or cold teabags over sores - Have lots to drink

11. Public Health  Avoid sharing towels or any sponges or face cloths  E.g. sex during active illness….  Offer screening for other STIs

12. Complications  Urinary retention  Infection may spread to other areas  Super-infection of blisters by bacteria

13. Taking a Sexual History Age & sex Presenting Complaint  Symptoms (SOCRATES) - Duration - Associated features e.g. dyspareunia in women or testicular pain in men  Last Sexual Contact - When - Who (gender of partner, regular/casual/known) - Type of sex (oral/vaginal/anal) - Condoms (always/ sometimes/ never? Any condom accidents?)  Previous Sexual Contacts in the last 12 months (as for Last sexual contact)

14.  Past History - Of STIs and treatment of the client and partner  Medical history Medications Allergies  HIV Risk assessment - Previous test - Risk factors-Men that have sex with men/HIV positive partner/ partner from high prevalence area/ injecting drug use/ sex work - Window period - Expectation of result - Support

15. Female Hx  LMP, Menstrual cycle and any IMP/PCB  Contraception: method & correct usage  Cervical Cytology  Obstetric history

16. STI quizzzz!!!!

17. Case 1  A 20-year-old male student attends a walk-in centre 7 days after a having unprotected vaginal intercourse with a stranger at a friend’s party.  “I got up this morning and went for a pee; it really hurt – sort of burning and stinging. Then I noticed there was yellow stuff coming out. It’s really gross”  On examination, the patient is clearly uncomfortable, and you note a purulent urethral discharge with crusting at the meatus.

18. Questions  What are your top 2 differentials?  What is your next investigation?  Microscopy is positive for Neisseria gonorrhoeae. How will you manage this patient?  What else should you do? 3 3

19. Case 2  Amy Fletcher, a 34-year-old mechanical engineer, arrives at her GP looking anxious and upset. On gentle questioning, she reports the appearance of painless “bumpy growths on [her] vagina”  She has looked up her symptoms on the internet, and is now frightened that she will develop cancer.  Examination reveals scattered, pink, papular lesions on the inner aspect of the labia minora.

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21. Questions  What are these lesions?  What is the causative organism?  How will you treat them?  How will you counsel this patient re malignancy?

22. Case 3  Bradley Thomas is a 29-year-old nightclub bouncer, who presents to this GP with a sore-throat, non- pruritic rash on his hands and a 7 day history of malaise, arthralgia and night-time headaches.  He remembers that he had an unusual mouth ulcer a few weeks ago, which took a while to get better. He ignored it because it didn’t hurt, and by the time he thought he should get it checked out it was beginning to heal.  He has been having unprotected oral sex with several male partners over the past few months.  Examination reveals a generalised polymorphic rash on his palms and soles of his feet.

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24. Questions  Which STI best fits with Bradley’s clinical picture?  What investigations would you conduct?  How will you treat it?  What other management would you instigate?

25. Take home points  HSV is very prevalent but usually asymptomatic  Symptom relief is a crucial part of treatment  Take advantage of the opportunity to offer sexual health advice from an individual and public health perspective  Always offer screening for other STIs  Contact tracing is indicated in STIs only when treatment is required

26. Resources  Pictures taken from 1. http://en.wikipedia.org/wiki/Herpes_genitalis 2. http://www.pharmacy-and- drugs.com/Skin_diseases/Herpes_simplex.html 3. http://www.genitaldischarge.com/p/gonorrhoea.html 4. http://www.pelauts.com/genital/genital-warts-18-jpg.html 5. https://www.healthtap.com/#topics/how-do-you-get-tested-for- genital-warts 6. http://hardinmd.lib.uiowa.edu/cdc/syphilis15.html 7. http://www.cmaj.ca/content/176/1/33/F3.expansion.html  Information 1. Kumar and Clarke 2. Patient.co.uk (patient plus articles) 3. NICE guidance