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Update for Halifax GPs Dr John Watson Consultant in Sexual health & HIV medicine Why is STI control important? It has significant immediate and long term complications Human Behaviour is diverse and continues to find new infections Outline Several cases to cover main syndromes Discharge/testicular pain in men & lower abdo pain in women Ulcers Lumps Principles of STI Management Listen to the patient Non-judgemental approach Screen for accompanying STIs (blood & swab/urine) Partner notification Prevention The art of medicine What is the patients agenda? Are their symptoms significant or are they more worried about an exposure Sexual histories : often inaccurate If things dont fit could it be psychosexual Or a mental health issue Case 1 22y man previously well painful left testicle gradual onset over 4 days, no trauma. What history is needed? Dysuria, freq or discharge? History of renal infections or stones Sexual history : symptoms in partner? Angle jaw pain, recent mumps contacts? Case 1 : examination Epididymo-orchitis: differential Non specific pain ; normal exam +/- ultrasound Sexually transmitted : GC and chlamydia Enteric eg E coli : UTIs, stones, congenital renal disease or Anal sex (UP) Mumps : even if had MMR x2 doses as child If acute <12hr think torsion If chronic TB possible. Differentiating from non specific testicular pain Exam standing up Pain radiates to groin in epididimyitis usually Mild cases focal tenderness most marked adjacent to vas deferens (lower pole) Retrograde passage of bacteria from prostatic urethra Sampling for Epididymitis MSU Chlamydia & GC dual NAATs HIV and syphilis testing Persistent or relapsed cases : semen sample (post ejaculation) Case 1 : slightly different 22y male 4 days dysuria no testicular pain Does he have a UTI? Shall I give trimethoprim? Or is it urethritis? Sexual history , PMH renal disease and examine penis Urethral Discharge STI Chlamydia Gonorrhoea Mycoplasma genitalium Trichomonas Men- Non-specific Urethritis (NSU) Semen UTI Viruses :HSV, Adenovirus Urethral wart Unexplained Gonorrhoea – Clinical Features MEN Incubation period 2-5 days Asymptomatic in some Dysuria Urethral discharge Epididymitis Tender lymph glands in groin Proctitis WOMEN Incubation period up to 10 days Asymptomatic in most Vaginal discharge Abnormal bleeding Abdominal pain Dysuria Chlamydia –Clinical Features Similar to GC But less symptoms Most women none Diagnosing Chlamydia/GC MEN Urine DNA TEST For GC always culture pre treatment pre treatment WOMEN Swab - vulvovaginal All should have blood for HIV and syphilis Treatment of Gonorrhoea Follow local protocol : generally refer Ceftriaxone 500mg IM stat Azithromycin 1g stat Doxycyline 100mg bd (cover Chlamydia) Always culture pre treatment Increasing rates of cephalosporin resistanc Japan Partner screening and treatment Treatment of Chlamydia Follow local protocol Uncomplicated Chlamydia Doxycycline 100 mg bd 7/7 Epididymitis : doxycyline 100mg bd 2wk plus ceftriaxone 500mg IM PID - combination of antibiotics for 14/7 Partner screening and treatment Complications of GC/Chlamydia Pelvic Inflammatory Disease • - Infertility, ectopics, salpingitis, spontaneous abortions Epididmytis Bartholins abscess Reactive Arthritis Conjunctivitis Babies - Prematurity, stillbirth, low birth weight, conjunctivitis and blindness, pneumonia GC – Disseminated : tenosynovitis/arthrtis/pustular skin lesions) SARA : 1% of chlamydial infections Common cause assymetrical lower limb arthropathy (knee/feet) Urethral discharge often asymptomatic Enthesopathy in most Skin rash and uveitis in some HLA B27 associated Most self limiting with treatment Rx Doxycyline 100mg bd Opthalmology review even if no symptoms Consider Pelvic infection SYMPTOM : Any female with lower abdominal pain : acute/subacute ; gradual worsening over days is usual Persistant pain esp needing pain relief EXPOSURE : Sexual exposure/post TOP/post partum/post gynae procedure including coil insertion SIGNS : Abnormal pelvic exam Think alternative causes : appendix, ovarian cyst, pregnancy, urinary stone/infection Key features Ulcers history and exam First episode or recurrent? Herpes most common (type 1 & 2) Syphilis : more in at risk groups eg Men who sex with men or CSexWorkers. Inguinal nodes may be tender so groin pain Herpes often dysuria with reduced freq. Primary syphilis : multiple and painful often. Herpes Simplex • • • • • • Painful oral or genital Primary infection can be severe Diagnosis : swab for DNA No cure (therefore associated anxiety in some) Treatment: aciclovir Increase dose if immunocompromised VERY GOOD ONLINE INFO VIA HERPES ASSOCIATION 23 Genital Ulcers : common causes Herpes (HSV) Syphilis Erosions : Candida & Scabies Non specific Genital Warts Human Papilloma Virus > 100 different types , vaccine available for some Asymptomatic infection common Oncogenic strains (tend NOT to be same strain that causes external warts) Clinical Dx First line Topical treatments Genital Lumps Genital Warts Molluscum Penile Papillae Atypical lesions : biopsy PIN/VIN TOP 10 STI POINTERS 1. Urethral discharge: think STI = gonorrhoea/chlamydia 2. Acute vulval pain: think herpes 3. Vaginal discharge Odour BV,, Itch/irritation Candida TV either Chlamydia, gonorrhoea 4. Swollen painful testes, exclude torsion then think STI 5. Lower abdominal pain Exclude Ectopic/ Appendicitis Consider upper genital tract infection 6. Genital ulcers: think HSV, Syphilis 7. ‘Viral illness with rash’: think primary HIV and secondary Syphilis 8. Arthritis think chlamydia and GC 9. rectal pain in MSM think LGV 10. Remember STIs travel in packs 27 Differential of ulcer HSV and VZV Bacterial : Syphilis, LGV, Staph including PVL strains Fungal: candida Protozoal/Helminth : tropical infections Drug reaction : doxycycline Derm : lichen planus Rheumatoloigcal : crohns Malignancy : SCC Primary 9-90 days Infectious ++ Secondary <2years Highly Infectious +++ Early latent <2years Infectious + Late latent >2 years Tertiary/complications >2yrs-life Non-Infectious Non-Infectious 29 Stages: Primary (S1) Incubation period: 9-90 days (ave 3 wks) Chancre – painful or painless ulcer at site of spirochete entry often multiple Heals in a few (3-8) weeks +/-scar 25 % of S2 pts give no history of S1 Limitation of Antibody test need DNA swab test Secondary syphilis 25 % of untreated patients will develop S2 6 - 8 weeks after beginning of S1 (sometimes sooner or later) S2 can be recurrent over 3 - 9 months (up to 2 years) All will be antibody +ve Secondary Syphilis (S2) “A generalised systemic infection” Fever Malaise Rash + esp “palms and soles++” Lymph nodes + Mucosal ulcers Condylomata lata Alopecia Take home message genital ulcers Think imptcauses ; herpes, syphilis Test for syphilis/HIV Limitations of syphilis blood testing in ulcer stage Dont use Antibiotics on genital ulcers without syphilis testing