Sexually Transmitted Infections

1. Sexually Transmitted Infections Update for Halifax GPs Dr John Watson Consultant in Sexual health & HIV medicine

2. Why is STI control important?

3. It has significant immediate and long term complications Human Behaviour is diverse and continues to find new infections

4. Outline • Several cases to cover main syndromes • Discharge/testicular pain in men & lower abdo pain in women • Ulcers • Lumps

5. Principles of STI Management • Listen to the patient • Non-judgemental approach • Screen for accompanying STIs (blood & swab/urine) • Partner notification • Prevention

6. 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

7. 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?

8. Case 1 : examination

9. 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.

10. 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

11. Sampling for Epididymitis • MSU • Chlamydia & GC dual NAATs • HIV and syphilis testing • Persistent or relapsed cases : semen sample (post ejaculation)

12. 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

13. Urethral Discharge STI • Chlamydia • Gonorrhoea • Mycoplasma genitalium • Trichomonas • Men- Non-specific Urethritis (NSU) Semen UTI Viruses :HSV, Adenovirus Urethral wart Unexplained

14. 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 inmost • Vaginal discharge • Abnormal bleeding • Abdominal pain • Dysuria

15. Chlamydia–Clinical Features Similar to GC But less symptoms Most women none

16. 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

17. 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

18. 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

19. 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)

20. 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

21. 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

22. 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.

23. 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

24. Genital Ulcers : common causes- • Herpes (HSV) • Syphilis • Erosions : Candida & Scabies • Non specific

25. 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

26. Genital Lumps • Genital Warts • Molluscum • Penile Papillae • Atypical lesions : biopsy PIN/VIN

27. 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

28. 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

29. Primary 9-90 days Secondary <2years Early latent <2years Late latent >2 years Tertiary/complications >2yrs-life Infectious ++ Highly Infectious +++ Infectious + Non-Infectious Non-Infectious 29

30. 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

31. 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

32. Secondary Syphilis (S2)“A generalised systemic infection” Fever Malaise Rash + esp “palms and soles++” Lymph nodes + Mucosal ulcers Condylomata lata Alopecia

33. 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