1. Sexual Health for Practice Nurses

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

3. 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

5. 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

6. 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

7. 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

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

10. 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

12. Screening/Testing for Sexual Infections in your setting
When?

13. 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

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

16. 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

17. 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

18. 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

19. 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

20. 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

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

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

25. 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

26. 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

28. 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

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

32. 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 Most of this is explained by a reduction in genital warts diagnoses in 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.

33. 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.

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

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

36. Bacterial vaginosis

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

39. 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

40. 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.

41. Vulvovaginal Candidiasis
Thrush

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

44. 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.

45. Chlamydia

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

48. 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

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

50. Notes: Total number of chlamydia diagnoses among women: England, 2006-2015
The number of chlamydia diagnoses in GUM services increased steadily between 2006 & This was followed by a decline between 2008 & 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 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.