STI diagnosis & treatment

1. STI diagnosis & treatment Dr Joëlle Turner Consultant in Sexual Health Luton Sexual Health 27th February 2018

2. Overall objectives of session • Look at examples of presentations of STIs • How to assess a patient with a possible STI – history taking and examination • Testing for STIs • Consider differential diagnoses and appropriate referral • Treatment and follow up • Partner notification

3. Case 1 • 17 yr old female presents with intermenstrual bleeding • On COC pill – previously regular withdrawal bleed only • No discharge/dysuria/abdominal pain • No dyspareunia or postcoital bleeding • New boyfriend of 2 months, age 18

4. Differential diagnosis? • Breakthrough bleeding • Cervical ectopy or other pathology • STI • Examination: • Normal vulva and vagina, no discharge seen • Cervix – small area of ectopy, contact bleeding

5. Chlamydia/gonorrhoea NAAT swabs • Detect nucleic acid of dead or living bacteria/bacterial remains – PCR technique • Equivalent sensitivity with endocervical or self-taken vulvovaginal swabs (but not urine in women)

6. Chlamydia NAAT positive • Treatment options: • Doxycycline 100mg bd x 7 days (preferred if no pregnancy risk or other contraindication) • Azithromycin 1g stat po • Other advice: • No sex (with or without condom, inc. oral/anal) until 7 days after treatment completion • Partner notification: • Recommend test & treat all partners from last 6 months – no sex until 7 days after treatment

7. Case 2 • 22yr old man • Presents with right testicular pain and swelling – noted 3 hours ago on waking, gradually worsening • Moderate pain • Intermittent dysuria for 2 weeks

8. History • No urethral discharge or recent diarrhoea • No recent travel • No previous UTI or catheterisation • No associated abdo pain/N+V • No recent trauma • No PMHx, no medications • Sexual history – 3 casual female partners in last 3 months – all unprotected vaginal and oral sex

9. Differential diagnosis? • Torsion • Epididymo-orchitis • Testicular mass • Hydrocele • Testicular infarction or rupture • Scrotal cellulitis/Fournier’s gangrene

10. Examination findings • Right scrotum swollen and red • Right testicular and epididymal swelling and tenderness • Normal lie of testis • No urethral discharge • Abdomen soft, non tender

11. Investigations and referral • Urine dipstick + MSU • Urine for chlamydia and gonorrhoea NAAT test • First void urine • Plain (white top) bottle or NAAT tube • Virology form • Tests before treatment! • Offer blood test for HIV/syphilis • If any suspicion of torsion  urgent urology review. • If no suspicion of torsion/torsion ruled out  start Abx

12. Treatment • STI most likely if age <35 and no other features • Treat with doxycycline 100mg bd x 14 days • if GC suspected (frank pus discharge, contact of GC) needs ceftriaxone 500mg IM stat also • If UTI/enteric pathogen suspected • e.g. dipstick +ve, recent diarrhoea, previous UTI/catheter, age >35 • Ciprofloxacin 500mg bd for 10-14 days • Ofloxacin 200-400mg bd for 10-14 days

13. Other advice • Scrotal support – folded up towel, briefs>boxers • Ice and analgesia • No sex until a week after abx complete • Partner notification – treat partner if STI suspected. • Follow up at 2-3 weeks if sx persist

14. Case 3 • 26 yr old woman • Presents with 10 day history of pelvic pain and vaginal bleeding • Cramping pain, constant • Intermenstrual bleeding and post coital bleeding for last month. • Now heavy constant bleeding for 3 days

15. History • Yellow PV discharge with odour • No dysuria/frequency • No bowel changes/N+V • Deep dyspareunia for last 6 weeks • No previous medical history, no medications • LMP 5/52 ago, not using any contraception, last sexual intercourse 3/52 ago • Regular partner for last 6 months

16. Differential diagnosis? • Ectopic pregnancy • Early miscarriage • Appendicitis • Pelvic inflammatory disease (PID) • Ovarian cyst rupture • Endometriosis

17. Examination findings • Vulva NAD • Vagina – thin white/yellow discharge • Cervix – inflamed, mucoid discharge • Bimanual – bilateral adnexal tenderness but no masses, mild cervical motion tenderness • Abdomen soft, no rebound/guarding, mild lower abdominal tenderness L>R

18. Tests • Pregnancy test – negative • Urine dip – trace leucocytes only • Blood test for HIV/syphilis • NAAT swab for chlamydia/gonorrhoea/TV (or charcoal swab for TV) • High vaginal • Self-taken vulvovaginal

19. Pathogens linked to PID • Chlamydia & gonorrhoea • BV-associated bacteria • Other STIs e.g. mycoplasma genitalium • Other non–STIs • STI detected in <one third of cases • ‘Translocation’ of vaginal bacteria

20. Treatment • Standard treatment for PID is with combination Abx: • Doxycycline 100mg bd x 2/52 (consider alternative if risk of pregnancy) plus • Metronidazole 400mg bd x 10-14 days • +/- Ceftriaxone IM 500mg stat if gonorrhoea suspected • No sex during treatment

21. Follow up • If complicated/severe PID suspected refer to sexual health same or next day • Ensure partner notification commenced • Important to do tests before antibiotics commenced • If fever/systemically unwell consider gynae admission for iv Abx and USS ?tubo-ovarian abscess • Review at 2-3 weeks • Check completed abx • Repeat pregnancy test, review swab results • Check if sx/signs resolved • Ensure has abstained from sex and partner screened and treated • If signs and sx persist proceed to USS

22. Case 3 • 52 yr old woman • Presents with 3 day history of fever, swollen glands, myalgia • Also reports dysuria, difficulty passing urine and vulval soreness • Yellowish vaginal discharge • No pelvic pain, no bleeding (post menopausal) • Last sex 4 years ago • Oral intercourse with new partner – 1 week ago

23. On examination • Waddling gait, difficulty sitting down • Tender inguinal lymph nodes • Vulva sore +++

24. Tests • Urine dip • Ensure can pass urine • Swab for HSV PCR • Blood test for HIV/syphilis • Do not attempt vaginal swabs or speculum examination – too painful

25. Treatment and referral • Start aciclovir 200mg 5x/day or 400mg tds x 5/7 • Admission for catheterisation if urinary retention • Give topical lidocaine cream/gel (instillagel if nothing else available) for symptomatic relief • Advise analgesia, salt water bathing, pee in bath • Refer to sexual health esp. if no access to swab testing for confirmation of diagnosis, symptoms severe or not settling or if diagnosis unclear • If frequent recurrences can provide suppresiive treatment – Aciclovir 400mg bd for 6-12 months

26. Follow up • Review if not improving • Otherwise review after ulcers healed • Perform rest of STI screen (swabs/bloods) • Review swab results • Counsel about HSV • Advise about transmission to partners • Refer to Herpes Viruses Association for advice www.hva.org.uk

27. Luton Sexual Health opening hours • Monday 9.00 – 18.30 • Tuesday 9.00 – 17.30 • Wednesday 9.00 – 18.30 • Thursday 9.00 – 18.30 • Friday 9.00 – 13.00 • Saturday 9.00 – 15.00 • Walk in clinics daily • Contact us if any advice needed • See www.lutonsexualhealth.org.uk

28. Resources • British Association for Sexual Health and HIV – www.bashh.org/guidelines • British HIV Association – www.bhiva.org/guidelines