The sex clinic

1. The sex clinic Mark Gilhooly ST2 O&G

2. Sexual Health • Key health issues include unintended pregnancy and STI • STI diagnosis – rise by 2% since 2011 with 427,000 cases in 2011 • Young heterosexuals (15-25 yrs) and MSM remain at highest risk • Higher teenage pregnancy rates in UK compared to other European countries

3. Question: • An asymptomatic 23 year old sees her GP following UPSI 3 days ago. She is concerned about having caught an STI. She has no other medical problems and does not use contraception. What will you do?

4. Discussion: • History, history, history • Offer STI testing 2 and 12 weeks post UPSI • Treat if high risk – consider referral to GUM • Use the event as a chance to discuss barrier contraception and LARC

5. Question: • An asymptomatic male is treated for Chlamydia at the GUM clinic. Contact tracing is discussed– who should be contacted and by whom?

6. Discussion: • Aim to break the chain of transmission, reduce complication rates, opportunity for health promotion • Self referral versus provider referral versus anonymity (via contact slips) • Asymptomatic male – screen all partners in past 6 months or the most recent sexual partner • Symptomatic male or female – all partners in the past 4 weeks

7. Chlamydia Trachomatis • Most common STI in developed countries • Women aged 16-19 and men aged 20-24 are most affected • Asymptomatic in 70 % of women and 50% men • Symptoms include: Urethral/vaginal discharge, dysuria, dyspareunia, IMB, lower abdominal pain in women • Testing: Swab versus Urine • Lower vaginal swabs are shown to be 90-95% sensitive

8. Urine sampling sensitivity of 65-100% • Women should hold their urine for 1 hour prior to providing specimen • Men should give a first catch specimen (as sensitive as swab in men) • Treatment: Doxycycline 100 mg 7/7 or Azithromycin 1g as single dose or Erythromycin (if pregnant/breastfeeding)

9. Neisseria Gonorrhoea • Infects mucosal surfaces of the genital tract, rectum, oropharynx and eye • Always sexually transmitted in adults • Less than 10% men will be asymptomatic • Cervical infection in women is asymptomatic in 50% • Diagnosis: endo-cervical swabs in women and urethral swabs in men

10. Neisseria Gonorrhoea • At high risk of having concominant STI and/or extra genital involvement • Advisable to manage patients with gonorrhoea in GUM clinics • On the spot gram stains can give quick provisional diagnosis • Treatment: IM Ceftriaxone 500 mg or quinolone in some areas

11. Question: • An 22 year old male sees his GP. He was recently treated for chlamydia 2 weeks ago. He has abstained from sex. He sees you because he has on-going dysuria and urethral discharge. What would you do?

12. Discussion: • Consider compliance to chlamydia treatment • Consider co-infection with another STI – Gonorrhoea co-infection is common with chlamydia particularly in at-risk groups • Men with urethral discharge, complicated STI, STI in pregnancy, genital ulceration and MSM should always be seen in GUM clinic

13. Question : • Routine tests of cure are only recommended in which group of patients?

14. Discussion: • Routine tests of cure are not indicated except in pregnant patients or those treated with erythromycin • Tests of cure should be performed 5 weeks after completion of treatment (6 weeks if azithromycin)

15. PID • Results from ascending infection from the endo-cervix • Negative microbiological tests do not exclude the diagnosis as in 50 % no organism is found • Long term complications: chronic pelvic pain, ectopic, infertility, tubo-ovarian abscess • Infective agents: • Chlamydia - 10-40 % untreated will have PID • Gonorrhoea – Up to 30 % will also have chlamydia • Anaerobes – usually secondary to above

16. PID • Diagnosis: Bimanual is required to make the diagnosis (cervical excitation) • Have a low diagnostic threshold – be prepared to over diagnose and over treat • Treatment: Ceftriaxone 500 mg IM, doxycycline 100mg bd and metronidazole 400 mg bd for 14/7 or ofloxacin 400 mg bd and metronidazole 400 mg bd 14/7

17. Question: • You have just inserted a IUD for a 20 year old. Is she at increased risk of PID/STI?

18. Discussion: • Increased risk of infection for the first 20 days then risk reduces to the same as background population

19. Question: • A patient was diagnosed with PID during a recent hospital admission for pelvic pain. She is taking antibiotics according to local policy. She also takes the COCP. Despite advice she continues to have unprotected sex. Should she be offered emergency contraception?

20. Discussion: • Advice to avoid intercourse even with barrier contraception until fully treated • No barrier contraception is required when taking antibiotics (COPC/POP) • You would have thought she may have learn’t her lesson

21. Herpes Simplex Virus • HSV 1 & 2 – both can affect either mouth or genital • Transmission by close physical contact – sexual or oro-genital • Only transmitted when the virus is shedding, which can be when asymptomatic • Primary infection and recurrent episodes • Complications – retention, constipation, meningitis

22. Herpes Simplex Virus • Primary infection - Febrile illness, Dysuria, painful inguinal LN’s, Genital blistering, ulceration and fissures • Treatment: Aciclovir, valaciclovir, famciclovir 5/7 duration • Saline washes, increased fluid intake • Complications in pregnancy – need discussion with GUM

23. Question: • A 22 year old female student attends with painful micturition and genital ulceration, she has recently changed partners. You suspect a diagnosis of Herpes. How will you manage her?

24. Discussion: • CKS advises referring all first presentations to secondary care for full work up • Do GP’s stock viral swabs? • Remember analgesia – lidocaine gels/instillagel can be used and advise about increasing fluid intake to reduce concentration of urine thus reducing irritation

25. www.fsrh.org.uk • www.cks.nice.org.uk • BASHH (www.bashh.org.uk)