1. STI diagnosis & treatment
Dr Joëlle Turner
Consultant in Sexual Health
Luton Sexual Health
27th February 2018

2. Overall objectives of session
Look at examples of presentations of STIs
How to assess a patient with a possible STI – history taking and examination
Testing for STIs
Consider differential diagnoses and appropriate referral
Treatment and follow up
Partner notification

3. Case 1 17 yr old female presents with intermenstrual bleeding
On COC pill – previously regular withdrawal bleed only
No discharge/dysuria/abdominal pain
No dyspareunia or postcoital bleeding
New boyfriend of 2 months, age 18

4. Differential diagnosis?
Breakthrough bleeding
Cervical ectopy or other pathology
STI
Examination:
Normal vulva and vagina, no discharge seen
Cervix – small area of ectopy, contact bleeding

5. Chlamydia/gonorrhoea NAAT swabs
Detect nucleic acid of dead or living bacteria/bacterial remains – PCR technique
Equivalent sensitivity with endocervical or self-taken vulvovaginal swabs (but not urine in women)

6. Chlamydia NAAT positive
Treatment options:
Doxycycline 100mg bd x 7 days (preferred if no pregnancy risk or other contraindication)
Azithromycin 1g stat po
Other advice:
No sex (with or without condom, inc. oral/anal) until 7 days after treatment completion
Partner notification:
Recommend test & treat all partners from last 6 months – no sex until 7 days after treatment

7. Case 2
22yr old man
Presents with right testicular pain and swelling – noted 3 hours ago on waking, gradually worsening
Moderate pain
Intermittent dysuria for 2 weeks

8. History No urethral discharge or recent diarrhoea No recent travel
No previous UTI or catheterisation
No associated abdo pain/N+V
No recent trauma
No PMHx, no medications
Sexual history – 3 casual female partners in last 3 months – all unprotected vaginal and oral sex

9. Differential diagnosis?
Torsion
Epididymo-orchitis
Testicular mass
Hydrocele
Testicular infarction or rupture
Scrotal cellulitis/Fournier’s gangrene

10. Examination findings Right scrotum swollen and red
Right testicular and epididymal swelling and tenderness
Normal lie of testis
No urethral discharge
Abdomen soft, non tender

11. Investigations and referral
Urine dipstick + MSU
Urine for chlamydia and gonorrhoea NAAT test
First void urine
Plain (white top) bottle or NAAT tube
Virology form
Tests before treatment!
Offer blood test for HIV/syphilis
If any suspicion of torsion  urgent urology review.
If no suspicion of torsion/torsion ruled out  start Abx

12. Treatment STI most likely if age <35 and no other features
Treat with doxycycline 100mg bd x 14 days
if GC suspected (frank pus discharge, contact of GC) needs ceftriaxone 500mg IM stat also
If UTI/enteric pathogen suspected
e.g. dipstick +ve, recent diarrhoea, previous UTI/catheter, age >35
Ciprofloxacin 500mg bd for days
Ofloxacin mg bd for days

13. Other advice Scrotal support – folded up towel, briefs>boxers
Ice and analgesia
No sex until a week after abx complete
Partner notification – treat partner if STI suspected.
Follow up at 2-3 weeks if sx persist

14. Case 3
26 yr old woman
Presents with 10 day history of pelvic pain and vaginal bleeding
Cramping pain, constant
Intermenstrual bleeding and post coital bleeding for last month.
Now heavy constant bleeding for 3 days

15. History Yellow PV discharge with odour No dysuria/frequency
No bowel changes/N+V
Deep dyspareunia for last 6 weeks
No previous medical history, no medications
LMP 5/52 ago, not using any contraception, last sexual intercourse 3/52 ago
Regular partner for last 6 months

16. Differential diagnosis?
Ectopic pregnancy
Early miscarriage
Appendicitis
Pelvic inflammatory disease (PID)
Ovarian cyst rupture
Endometriosis

17. Examination findings Vulva NAD Vagina – thin white/yellow discharge
Cervix – inflamed, mucoid discharge
Bimanual – bilateral adnexal tenderness but no masses, mild cervical motion tenderness
Abdomen soft, no rebound/guarding, mild lower abdominal tenderness L>R

18. Tests Pregnancy test – negative Urine dip – trace leucocytes only
Blood test for HIV/syphilis
NAAT swab for chlamydia/gonorrhoea/TV (or charcoal swab for TV)
High vaginal
Self-taken vulvovaginal

19. Pathogens linked to PID
Chlamydia & gonorrhoea
BV-associated bacteria
Other STIs e.g. mycoplasma genitalium
Other non–STIs
STI detected in <one third of cases
‘Translocation’ of vaginal bacteria

20. Treatment Standard treatment for PID is with combination Abx:
Doxycycline 100mg bd x 2/52 (consider alternative if risk of pregnancy)
plus
Metronidazole 400mg bd x days
+/- Ceftriaxone IM 500mg stat if gonorrhoea suspected
No sex during treatment

21. Follow up
If complicated/severe PID suspected refer to sexual health same or next day
Ensure partner notification commenced
Important to do tests before antibiotics commenced
If fever/systemically unwell consider gynae admission for iv Abx and USS ?tubo-ovarian abscess
Review at 2-3 weeks
Check completed abx
Repeat pregnancy test, review swab results
Check if sx/signs resolved
Ensure has abstained from sex and partner screened and treated
If signs and sx persist proceed to USS

22. Case 3
52 yr old woman
Presents with 3 day history of fever, swollen glands, myalgia
Also reports dysuria, difficulty passing urine and vulval soreness
Yellowish vaginal discharge
No pelvic pain, no bleeding (post menopausal)
Last sex 4 years ago
Oral intercourse with new partner – 1 week ago

23. On examination Waddling gait, difficulty sitting down
Tender inguinal lymph nodes
Vulva sore +++

24. Tests Urine dip Ensure can pass urine Swab for HSV PCR
Blood test for HIV/syphilis
Do not attempt vaginal swabs or speculum examination – too painful

25. Treatment and referral
Start aciclovir 200mg 5x/day or 400mg tds x 5/7
Admission for catheterisation if urinary retention
Give topical lidocaine cream/gel (instillagel if nothing else available) for symptomatic relief
Advise analgesia, salt water bathing, pee in bath
Refer to sexual health esp. if no access to swab testing for confirmation of diagnosis, symptoms severe or not settling or if diagnosis unclear
If frequent recurrences can provide suppresiive treatment – Aciclovir 400mg bd for 6-12 months

26. Follow up Review if not improving Otherwise review after ulcers healed
Perform rest of STI screen (swabs/bloods)
Review swab results
Counsel about HSV
Advise about transmission to partners
Refer to Herpes Viruses Association for advice

27. Luton Sexual Health opening hours
Monday – 18.30
Tuesday – 17.30
Wednesday – 18.30
Thursday – 18.30
Friday – 13.00
Saturday – 15.00
Walk in clinics daily
Contact us if any advice needed
See

28. Resources
British Association for Sexual Health and HIV –
British HIV Association –