1. Genitourinary Medicine
For GPs
November 2007

2. Agenda Recent changes How to take the necessary swabs
Brief overview STI’s
What can be done in General Practice
Cases

3. New diagnosis of selected STIs in GUM clinics, England, Wales and Northern Ireland
% change
2004
Genital Warts
79,417
32%
Chlamydia
103,680
222%
Gonorrhoea
22,000
111%
Genital herpes
19,010
15%
Syphilus
2,200
1497%

5. Female Swabs HVS BV (charcoal) Candida (charcoal)
Trichomonas (charcoal)
Endocervical
Chlamydia
Gonorrhoea (charcoal)
Urethral
10-20% additional chlamydia
Gonorrhoea
HSV
Herpes simplex type I and II

6. Male Swabs URETHRAL ENTRANCE GONORRHOEA (charcoal) INSIDE URETHRA
CHLAMYDIA

7. Overview of STIs

8. Chlamydia
Common (3-5% sexually active females attending UK General Practice)
Complications cost at least £50million annually in the UK

9. CLINICAL FEATURES (chlamydia)
80% Females asymptomatic
PCB/IMB, abdo pain, discharge,cervicitis
50% males asymptomatic
Urethral discharge, dysuria
RISK FACTORS FOR INFECTION
COMPLICATIONS

10. DIAGNOSIS (chlamydia)
Women endocervical swab gives best specimen
Urethral swabs will identify additional 10-20%
Men urethral swab (painful!)
ELISA vs PCR
Urine testing

11. WHAT CAN I DO IN PRACTICE? (chlamydia)
1. POSITIVE RESULT BACK
Treat patient
Contacts need treatment
Advised no SI until both partners treated
Can refer to clinic for full tests
Guidelines say only retest if symtomatic/possibility of reinfection at 3 weeks

12. TREATMENT (chlamydia)
Doxycycline 100mg bd 7 days
Azithromycin 1g orally as single dose
Erythromycin 500mg qds 10 days (pregnancy)
Ofloxacin 200mg bd 7 days

15. CHLAMYDIA CERVICITIS

16. EPIDIDYMITIS

17. GONORRHOEA ‘THE CLAP’ CLINICAL FEATURES Women 50% asymptomatic
Vaginal discharge, abdo pain, dysuria
Rarely causes IMB/menorrhagia
Pharyngeal infection asymptomatic >90%
Men 80% discharge, 50% dysuria
Rectal symptoms
Signs

18. DIAGNOSIS (gonorrhoea)
Laboratory culture
Microscopy
NB: Specimen collection sites

19. WHAT CAN I DO IN GENERAL PRACTICE?
Refer any patients with confirmed GC on swabs to GUM
Refer any acute urethral discharge
Refer contacts of GC to GUM for treatment and ix
Refer females with lower abdominal pain

20. TREATMENT (gonorrhoea)
Cefixime 400mg oral as single dose
Ciprofloxacin 500mg stat
Spectinimycin 2g IM single dose
Ceftriaxone 250mg IM ( pregnancy)

21. FOLLOW UP 2 Weeks TOC in clinic Pregnant women, symptomatic patients
Check contacts have been treated/tested
Be aware of possible co-infection with chlamydia

23. CERVICITIS

24. NSU Male urethritis in the absence of gonorrhoea
Mucopurulent cervicitis equivalent condition in female
30-50% due to chlamydia
20% due to mycoplasma genitalium

25. Clinical Features Urethral discharge, dysuria, irritation (M)
Vaginal discharge (usually asymptomatic)
DIAGNOSIS
Microscopy
Swabs, check for chlamydia

26. TREATMENT Doxycycline 100mg bd for 7 days
Azithromycin 1g as a single dose
Treat contacts

27. GENITAL HERPES HSV 1/ 2 Common Incubation period 1-2 weeks
Asymptomatic shedding
Chronic condition
Psychological aspects

28. CLINICAL FEATURES
Painful ulceration, dysuria, vaginal or urethral discharge
May be systemically unwell
Blistering/ulceration external genitalia
Inguinal lymphadenopathy
COMPLICATIONS: urinary retention, aseptic meningitis

29. DIAGNOSIS Isolation of HSV from genital lesions
Often a clinical diagnosis
Serology, not routinely done

30. WHAT CAN I DO IN GENERAL PRACTICE?
Take a viral culture swab
General advice: saline bathing, analgesia, topical anaesthetic, petroleum jelly
Start oral antiviral drugs (within 5 days)
Aciclovir 200mg five times a day for 5 days
Psychological support
Arrange F/U GUM 3-4 weeks for full tests

33. GENITAL HERPES VULVA

34. GENITAL HERPES PENIS

35. GENITAL WARTS Human papillomavirus (HPV) >90 genotypes
Nearly always sexually transmitted
Common
Difficult and time consuming to treat
Certain types associated with cervical dysplasia
Benign epithelial skin tumours

36. DIAGNOSIS Most cases naked eye examination Colposcope helps
May need biopsy if dx uncertain

37. What can I do in General Practice?
Refer GUM for full assessment
Will not need urgent assessment if no other symptoms present
You can give warticon lotion/cream if confident of dx

38. TREATMENT IN CLINIC
All treatments have significant failure and relapse rates
Podophyllin, trichloroacetic acid, cryotherapy
Home treatments are warticon and aldara (imiquimod)
(HPV vaccine)

41. GENITAL WARTS VULVA

42. WARTS PENIS

43. TRICHOMONAS Flagellated protozoan
Almost exclusively sexually transmitted
Female symptoms: discharge, itching, odour, abdo pain % are asymptomatic
Male symptoms: urethral discharge/ dysuria % asymptomatic

44. Diagnosis/Management (trichomonas)
HVS
Direct observation wet smear
More difficult to culture in men
Treat sexual partners simultaneously
Metronidazole 400mg bd 5-7 days or 2g stat
Refer GUM for full tests

46. Bacterial Vaginosis
The commonest cause of vaginal discharge in women childbearing age
Replacement of lactobacilli and raised Ph
Not regarded as sexually transmitted

47. SYMPTOMS/SIGNS 50% women asymptomatic ‘fishy’ vaginal discharge
Thin/white discharge
In pregnancy BV is associated with late miscarriage, preterm birth, preterm premature rupture of membranes, post partum endometritis

48. Diagnosis
HVS
Gram stain

49. What shall I do in general practice?
Treatment is indicated for symptomatic and pregnant women
You do not have to treat asymptomatic women but can offer treatment
General advice re vaginal douching, use of soap etc
Treatment: metronidazole 400mg bd for 5-7 days or 2g stat
Clindamycin cream 2% daily 7 days, metronidazole gel 0.75% daily 5 days

50. Vulvovaginal Candidiasis
Candida. albicans approx 90%, candida.glabrata approx 10%
10-20% women of childbearing age may harbour candida species in the absence of symptoms. They do not require rx
Symptoms/signs
Beware the woman with ‘recurrent thrush’
Do a HVS

51. Management Avoid local irritants/synthetic clothing
Treat with topical and oral azole therapies (clotrimazole/fluconazole)
Nystatin for non albicans species
No evidence to support treatment of asymptomatic male partners
Recurrent candidosis

53. CANDIDAL BALANITIS

54. Cases

55. CASE 1
Kylie is a 15yr old girl who complains of intermenstrual ‘spotting’ for the last 2 months. You see from her records she attended surgery 3 months ago and was prescribed mercilon. How would you manage her?
( mercilon is a low strength COCP)

56. Case 2
Susan is a 45 year old lady married lady. She has had three prescriptions for clotrimazole and one for oral fluconazole for her ‘thrush’. She is quite upset that she is still symptomatic. What do you do?

57. CASE 3
Tina is a 48 year old lady who attends surgery with a 2 day history of vulval soreness. On examination you notice a crop of blisters to the vulva. How do you proceed?

58. Case 4
Delia is a 32 year old woman who presents with a 5 day history of abdominal pain, discharge and painful intercourse. The pain is now so severe she is unable to have intercourse. How would you manage her?

59. Case 5
Frank is a 28 year old man. In the last 2 weeks he has noticed some lumps on his penis. They are not sore are itchy. He was not going to bother the doctor, but his new boyfriend made him the appointment.