An excellent presentation on sexual health from the team at Airedale

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 12-18 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