Hot Topics in Sexual Health

Mazin

Common Triggers

• Males & Females

– Vaginal / Penile soreness, itching, discharge

– Spots / sores in genitals, pubes

– Lumps / bumps / warts

– Infestations

– Partner has symptoms / contact slip

– Enquiries about HIV / syphilis / hepatitis

Gender specific

• Male specific

– Aching sore testicles

– Cracked foreskin

– Rash on glans penis

– Dysuria

– Testicular lumps / changes

• Female specific

– Cystitis

– Late period

– Breakthrough bleeding

– Post-coital bleeding

– Pregnancy test request

– Dyspareunia

– Emergency contraception

Barriers to effective history taking

• Time

• Environment

• Attitude

• Embarrassment

• Prejudice

• Language & understanding

• Lack of experience

• Lack of confidentiality

• Inappropriate questions

• Gender issues between doctor / patient

• Stereotypical assumptions

• Lack of support from colleagues

• Presence of partner / friends / parents

‘It’s not my concern to ask’

Ways to overcome this

• General invitation to express concerns

• National recommendations

• Published research findings

• Established screening programmes

• National campaigns

• Direct approach

• Indirect approach

Last Sexual Contact?

• If the last contact <3 months ago, ask how many in the last 6 months – this allows for collection of details for partner notification

• It takes 3 months for serological markers to become evident for syphilis, and 1 month for HIV..

Underage.. Rationale?

• How old is your partner

• Did you agree to have sex/Were you happy to have sex

• Is your regular partner aware of this other person

• Were you paid / did you pay for this sex

• Where did you have sex

• Do you feel that you could talk to your parents about sex

Fraser Guidelines

• Health professionals may give contraceptive and sexual health advice to young people under 16 without parental consent, as long as the young person is competent to understand fully the implications of any treatment, and therefore be able to make a choice regarding the treatment proposed.

• The health professional must establish that all of the following criteria are met:

Criteria

1. The young person understands the healthcare professional’s advice

2. The healthcare professional cannot persuade the young person to inform his or her parents or allow the healthcare professional to inform the parents that he or she is seeking advice

3. The young person is very likely to begin or to continue having sexual intercourse with or without treatment

4. Unless he or she receives advice or treatment, the young person’s physical or mental health or body are likely to suffer

5. The young person’s best interest require the healthcare professional to give the advice, treatment or both without parental consent

Principles Of STI Management

It is important to appreciate the public health

issues in relation to STI care and management.

• Treatment of index patient

• Contact tracing and partner notification

• Investigation and treatment of partner

• Role of Health Adviser in a Genitourinary Medicine (GU Med) clinic

• Safer sex and risk reduction advice

Legal and Confidentiality Issues

You should be have a knowledge of the following:

• ‘Fraser Guideline’competence

• Issues of confidentiality in relation to STI diagnosis and care and GU Medicine clinics

• Definitions of rape and sexual assault and legal age of consent to sexual intercourse – (Sexual Offences Act, 2004-available at

http://www.homeoffice.gov.uk/)

• Area ‘Child Protection Team’

Case 1

• 22 F

• New onset PCB

• Unprotected sex multiple partners

• Worried about future pregnancies

Chlamydia

• Chlamydia trachomatis (types D – K)– Lymphogranuloma venereum (LGV)

• Most common sexually transmitted disease, affecting 5% of sexually active women aged 15-25 years old

• Multiple sexual partners, age <25 years, history of STIs, low socioeconomic status

• Chlamydia is a major cause for infertility and increases the possibility of ectopic pregnancy

Chlamydia

• Infections tend to be asymptomatic (75%), although there can be increased vaginal discharge (30%), dyspareunia, IMB (intermenstrual bleeding), PCB (postcoital bleeding), abdominal pain, dysuria

• In males, symptoms include mucopurulentdischarge and dysuria (asymptomatic in 25%)

• Epididymo-orchitis is a complication

Examination

• Abdomen: Lower abdominal tenderness• Speculum: Cervicitis, cervical / urethral discharge• Vaginal: May have tenderness / cervical

excitation• A 'cobblestone' appearance of the cervix may be

noted. Ascending infection can cause salpingitis(inflammation of fallopian tubes) and, if it enters the abdominal cavity, peri-hepatitis – (Fitz-Hugh-Curtis syndrome; fibrotic hepatic capsule),

which leads to right upper quadrant pain and tenderness

Management

• Medical: Single dose Azithromycin 1 g, or Doxycycline 100 mg 2x daily for 1 week

• In pregnancy: Erythromycin / Amoxicillin(Tetracyclines contraindicated)

• Other: Requires full STI screen and contact tracing, abstinence before results

Pregnancy

• Chlamydia infection causes pre-term labour and pelvic inflammatory disease.

• In exposed neonates it increases susceptibility to: HIV infection, tubal pregnancies, eye infections, and pneumonia.

• All women who are sexually active under the age of 25 years and those women who are pregnant who are at high risk should be offered screening; particularly in the setting of termination of pregnancy, it is important to screen.

LGV

• Systemic disease

• Caused by serovars L1, 2 & 3 of chlamydia

• Endemic in tropics

• Outbreaks in mainly HIV +ve MSM

UK

• 77% London, Brighton, Manchester

• Now hyper-endemic among MSM

Case 2

• 35M

• 3/12 hx rectal pain bloody discharge

• No recent travel

• Non-specific abo tenderness

• Referred OP gastroenterology

Proctoscope

• IV fluids

• Analgaesia

• Feels better

• Keep gastro follow up

• Continues to get unwell..

Risk factors for LGV

• Unprotected AI

• Sex parties, saunas

• Poly drug use

• HIV seropositivity

• Presentation with anal pain, tenesmus, pain on defecation, bloody diarrhoea

• Often mistaken for inflammatory bowel disease

LGV

• Primary stage– Genital ulcer– LGV proctitis

• Secondary stage– Lymphotrophic infection– Regional dissemination with inflammation and swelling of LNs in

surrounding tissue– Periadentitis and bubo formation– Buboes ulcerate, discharge, fistulae

• Tertiary– Genito-ano-rectal syndrome (chronic inflammation)

Colonoscopy

Diagnosis & Management

• Clinical and laboratory• NAATs for chlamydia

and further testing for LGV specific DNA

• Doxycycline 100mg bd21/7

• Symptoms resolve in 1-2 weeks

• Contact tracing of partners up to 3/12

• Follow up HIV testing

Case 3

• 50M

• Purulent urethral discharge / dysuria

• Recent travel to SE Asia (Thailand)

• High risk

• MDR Gonorrhoea

• HIV / Hep B Risk

Gonorrhoea

• Infected males present with – Dysuria, frequency and/or a mucopurulent discharge

after 3-5 days, coupled with urethritis and meatal oedema.

• Majority of females are asymptomatic (50-70%)– PV discharge, IMB, PCB, dysuria, dyspareunia, lower

abdominal pain

• Disseminated gonococcal infection occurs in <1% cases and causes pyrexia, a vasculitis rash and polyarthritis

• Gram -ve diplococcus

SUPER Gonorrhoea

• Outbreak of high level Azithromycin resistant N. gonorrhoea

• NG progressively exhibited reduced sensitivity and resistance to many classes of antimicrobials

• Azithromycin resistance is rare

Management

• Antibiotics: Cephalosporin, Penicillin, Tetracycline orQuinolone (usually single stat dose)

• Culture sensitive antibiotics are used for treatment

• Other: Contact tracing and treatment of partner(s)

• Current guidelines from the British Association for Sexual Health and HIV (BASHH) suggest Ceftriaxone500 mg stat followed by Doxycycline 100mg BD for a 10-14 days, in the absence of sepsis

Case 4

• 23M

• Severe dysuria

• No discharge

• No LUTS

• Examination normal…?

Meatal HSV

Herpes simplex

• Disease resulting from HSV1 or HSV2 infection

• HSV is an alpha-herpes dsDNA

• Transmitted via close contact with an individual shedding the virus (eg. Kissing, sexual intercourse)

• 90% adults seropositive for HSV1 by 30 years

• 35% adults >60 years seropositive for HSV2

• >1/3rd world population has recurrent HSV infections

• Infection is lifelong

• Inter-individual variation in frequency of reactivation

• HSV1: Primary infection often asymptomatic, usual symptoms:– Pharyngitis– Gingivostomatis, may make eating very painful; and– Herpetic whitlow, inoculation of virus into a finger– Recurrent infection / reactivation (herpes labialis / 'cold sore'):

Prodrome (6 hours) peri-oral tingling and burning. Vesicles appear (48 hour duration), ulcerate and crust over. Complete healing in 8-10 days

• HSV2: Very painful blisters and rash in genital, peri-genital and anal area. Dysuria. Fever and malaise

• HSV encephalitis & keratoconjunctivitis: Headache, photophobia, meningism, seizures; epiphoria (watering eyes), photophobia, crusting

• Following primary viral infection the virus becomes dormant (classically in trigeminal or sacral root ganglia). Reactivation may occur in response to physical or emotional stresses or immunosuppression.

• The virus causes cytolysis of infected epithelial cells and vesicle formation

• Topical, oral or IV Aciclovir (a nucleoside analogue phosphorylated by viral thymidine kinase to a monophosphate that, when converted to triphosphate, causes chain termination of viral DNA synthesis).

• Valaciclovir is a prodrug of Aciclovir with better bioavailability.

• Neonatal HSV: Acquired during delivery. Skin vesicles, scarring eye disease, encephalitis. May be fatal

• Treatment: Caesarean section for mothers with active HSV infection. IV Aciclovir to neonate

• HSV in the immunocompromised: Severe local disease may disseminate involving the respiratory and GI tracts

• Increased transmission of HIV in the presence of HSV2 genital lesions

Case 5

• 21F

• Feeling unwell

• Severe headache

• Shooting pain down left leg

• C/O weakness of leg

• Developed painful genital ulcers..

• Admitted as ?viral meningitis

• CT head reported normal

• LP – 6 WCC• 3 mmol/L glucose• 1.2 g/L protein• Clear / colourless

• New partner 1/12• Herpes virus Type 2 PCR positive in CSF

Aseptic meningitis

• Acute aseptic meningitis may occur as a complication of primary anogenital HSV-2 with headache, photophobia, meningism

• Genital lesions in 85% of primary HSV 2 meningitis – CNS symptoms 7 days later

• Normal CSF glucose

• CSF PCR for HSV diagnosis

• Recurrent benign aseptic meningitis may be caused by HSV-2 – Mollaret’s meningitis

Case 6

• 49 year old HIV + man

• Attends with history of diarrhoea – frequent, now incontinent episodes, foul smelling

• Malaise

• Good CD4 >50 cells/mm3

• VL <40 copies/ml

• Stable on Stribild

• AKI

• Raised inflammatory markers

• Non specific abdo tenderness

• AXR normal

• No recent travel

• ?Medication related

• Stool cultures; OCP (ova, cyst, parasite) x3

DDx

• C. diff, Giardia, Campylobacter

• Cryptosporidium, Microsporidium, Isosporabelli

• Mycobacterium Avium Intracellulare

• CMV, HSV, adenovirus

• HIV related ‘AIDS enteropathy’

• Small bowel over growth

• Bowel malignancy, lymphoma

• Sexual history

• Multiple partners

• UPAI

• Frequently visits saunas

• ‘Sero sorts’

• Occasional mephadrone and GHB

• Stool culture + positive Shigella flexneri

• 61% rise since 2010

• 2016 >550 cases

• High numbers of sexual partners & condomlesssex

• Sex parties, ‘Chemsex’

• High levels of HIV positivity

Shigella

• Gram negative bacterium

• 4 different species

• Can cause severe bacillary dysentery in humans

• Complications intestinal and systemic – rare

• Treatment ciprofloxacin

• Campaigns to alert MSM, hygiene advice

• Alerts to GU; notifiable disease

• STI transmission

• Mental health effects

• ‘Slamming’

• GHB, Mephedrone / Crystal meth –powerful psychological dependence

Useful websites

• British Association for Sexual Health and HIVhttp://www.bashh.org/

• Health Protection Agencyhttp://www.hpa.org.uk/infections/topics_az/hiv_and_sti/default.htm

• British HIV Associationhttp://www.bhiva.org/

• Faculty of Family Planning and Reproductive Health Carehttp://www.ffprhc.org.uk/

• Society of Sexual Health Advisershttp://www.ssha.info/index.asp

• World Health Organizationhttp://www.who.int/topics/sexually_transmitted_infections/en/

• http://www.ssha.info/index.asp

References

• Competencies for providing more specialised sexually transmitted infection services within primary care, 2005, www.bashh.org

• National Guideline for consultations requiring sexual history taking, 2005, www.bashh.org

• Silverman S.D., 2000. Getting comfortable with sexual history taking, Family Practice Recertification, 2000 Sep, vol.22, no. 11, p. 33 – 34, 37 –40, 46.

• AIDS Alert, 2001. Doctors overlook sexual histories too often: its time to make screening a priority, Sep, vol.16, no.9, p 113 –4

• Rosenthal S.L., Lewis L.M., Succop P.A., Burklow K.A., Nelson P.R., SheddK.D., Heyman R.B., Biro F.M., 1999. Adolescent’s views regarding sexual history taking, Clinical Peadiatrics, 1999, April, Vol. 38, n0.4, p 227 – 33

• Peck S.A., 2001. The importance of the sexual history in a primary care setting. Journal of Obstetric Gyneacologic and Neonatal Nursing, May –Jun, Vol. 30, no.3, p 269 – 74.