1. An excellent presentation on sexual health from the team at Airedale

2. Sexual Health Topics
VTS February 2011

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

4. 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

5. 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

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

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

8. 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

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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

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

17. 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

18. 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

19. 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)

20. 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

21. 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

22. 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

23. 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)

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

25. 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

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

27. HPV Vaccination National programme for 12 yr old girls
Catch up campaign for 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

28. 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

29. 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

30. 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