Sexual Transmitted Infections in General Practice

1. Sexual Transmitted Infections in General Practice Dr John McSorley

2. STIs in general practice • What are the sexually transmitted infections? • What is the epidemiology? • Why are STIs important? • What to look out for in general practice? • What is the patient experience in the GUM clinic • What is new?

3. Sexually transmitted infections • Bacterial Chlamydia / Gonorrhoea / Syphilis / Others • Viral HPV / Herpes /HIV / Hepatitis B/C ?A • Protozoa TV • Ectoparasites Lice/scabies

6. Uncomplicated Chlamydia NWLH 1997 to 2013

11. Uncomplicated N. gonorrhoea at NWLH 1997 to 2013

12. Incidence • Chlamydia commonest (75% under 25s) • Warts • Herpes (Ratio F:M 0.3:1 to 1.5:1) • Gonorrhoea greatly decreased but… • Syphilis (since 2000, 7 fold increase in men and doubling in women) • HIV levelling off (or not)

13. Why are STIs important? • ½ billion new curable STIs each year worldwide • STIs (not HIV) 2nd most common cause of healthy life lost in women (15-49) worldwide • US: 8 million cases/yr direct cost $8.7 billion/yr • Costs of the complications (PID, ectopic pregnancy,infertility) £100s millions • Physical and psychological morbidity e.g. herpes • 10-40% untreated CT develop PID • Post infection tubal damage c40% infertility • Preventable: STI care Vaccinations

14. Why are STIs important? • Aversely affect Pregnancy: Ectopic Pregnancy x6-10 more likely if prev PID, c50% EP attributable to prev STI. <35% pregnancy with untreated GC results in abortion, prem delivery • ASYMPTOMATIC c70% in UK • GP/PN will see several cases of people with STIs in a week • Failure to suspect & diagnose is a disservice • Best way to reduce STIs is by population screening

15. What/who should you be looking out for in general practice? • Very frequently asymptomatic • Symptoms dysuria, vaginal or urethral discharge, pelvic pain, genital lumps, bumps • Index of suspicion • Sexually active, change of partners, multiple partners, unfaithful partner

16. High index of suspicion • Young people • 5% of under 25yr old each year every year • Emergency contraception • Pre termination • Men (<45) with urinary syndromes STI, STI, STI, STI, STI not UTI • Epididymo-orchitis CT x10 more likley • GUM

17. STI screening in MSM: NWLH 1997 to 2013

18. Some principles to remember about STIs • More than one infection • More than one person and partner -the index and the contact - hence partner notification • Education and prevention both primary and secondary • Avoid sex until both (or all) parties are treated

19. Some common examplesCase 1 • A 19 year old girl requests an IUD for emergency contraception • She had unprotected sex 4 days ago • What questions would you like to ask?

20. Case 1 contd. • How many partners has she had in last 3-6 mths • Any previous STIs? • Does her partner have any symptoms? • Has she had other unprotected sex? • She has had 2 partners in past 3 months • What would be your next step?

21. History, management • At risk of chlamydia (>5%) • At risk of PID with IUD insertion • Consider (referral for) STI screen • Perform chlamydia test (swab or urine) • Consider prophylaxis with Azithromycin 1 gram • Advise no sex until result available

22. Result of swab • Chlamydia test positive • What do you do next?

23. Chlamydia test is positive (case 1) • Refer her and her partner to GUM clinic Full STI screen Treatment Partner notification • Or Treat yourself • If GUM attendance not possible • Doxycycline 100mgs po bd for 7 /7, or azithromycin 1 gram PO, or erythromycin 500mgs po bd for 10/7 • No sex until she and partner are treated

24. Chlamydial infection • Rarely symptomatic • 50-90% women no symptoms • 70% men no symptoms • Vaginal discharge, cervicitis uncommon • Rarely presents with PID, Reiters syndrome or reactive arthritis • Diagnosed using DNA test on swab (endocervical, vulval,vaginal, urine)

25. Clinical features in Chlamydial infection

26. Know your local GUM clinicRoutine tests • All patients tested for chlamydia, gonorrhoea, syphilis and HIV (Brent Hep B core) • ‘Pee and go’ NAAT testing (DNA testing for chlamydia/gonorrhoea) • Additional tests for Hepatitis B, trichomonas, herpes , other conditions eg hepatitis C,LGV

27. Special considerations in GUM clinics • Focus on young people • Normalisation and early HIV testing (POCT testing) • Frequent STI screens for gay men

28. Asymptomatic Nurse Rapid history Urine NAAT,blood syphilis, HIV +/-Hepatitis B Not examined No news good news Symptomatic Doctor Full history +/- examined Dr/nurse Tests swabs/other relevant tests Herpes,other sites Treatment Follow up Patients journey in GUM clinic

29. Case 2 • 34 year old married man returns from business trip to India • Noticed a sore on his penis 2 weeks ago • It is not painful but it is not getting better • What further information would you like?

30. Case 2 • Sexual history • Any sex with men? • Past history of STIs • Drug/allergy history • General medical history

31. Case 2 History • Unprotected sex with 2 sex workers in Delhi 6 weeks ago • Sex with his wife on number of occasions since his return • He took antibiotics from his dentist for 5 days 3 weeks ago • What action would you take at this stage?

32. Case 2 assessment • Examine his genitalia • Findings are: • Superficial ulcer sub preputial area and shotty nodes in the groin

33. Case 2 management • Is this a drug reaction? • Is this an STI? • What would you recommend?

34. Case 2 management • Refer to GUM clinic for full STI screen • Tests for syphilis serology, swab for PCR, full STI screen including HIV and Hepatitis B • Results show Syphilis EIA positive, raised RPR 1/64 consistent with primary syphilis

35. Case 2 management • Treated with 1 injection of benzathine penicillin I/M 2.4 mega units • Wife also needs testing and ?epidemiological treatment • Advise repeat HIV test after 3 months • Consider hepatitis B vaccination

36. Syphilis

37. Syphilis • Infectious syphilis more common in past 10 years. • Secondary syphilis may present with a rash • There have been >10 local scattered epidemics amongst heterosexuals in UK • Endemic again in gay men • Foreign travel history is important • Always consider the possibility of associated HIV

38. Case 3 • 26 year old 20 weeks pregnant , first pregnancy • Married for 2 years • Vulval discharge and itching for weeks, ?smelly • Slight external dysuria • Thrush treatment from the pharmacy but it doesn’t seem to have helped

39. Case 3 • She is very worried this will affect her baby • Sex only with her husband who is a travelling salesman • He has been avoiding sex with her lately and keeps telling her she needs to have a check up in the local clinic • She didn’t see why she needed to go to a clinic and decided to come to you her GP

40. Case 3 contd • Is this thrush? • Is this something else? • Refer to GUM • Triaged • Vaginal slides Trichomonas Vaginalis • She is very embarrassed (and angry) to hear that this is an STI but relieved it will not affect her baby • Treated Metronidazole 2 grams PO Stat

41. Trichomoniasis

42. Trichomonas vaginalis • Rarely causes symptoms in men • Typically a frothy fishy smelling discharge. • Similar to Bacterial vaginosis discharge • Diagnosed on wet mount microscopy • Not a serious infection • Marker for other STIs • Single dose treatment Metronidazole 2 grams • Treat partner

43. Case 4 • Your practice nurse has been doing a study with the local GUM clinic screening under 25s routinely for chlamydia and gonorrhoea using urine testing. • A 21 year old Afrocaribean male was found to have gonorrhoea and was recalled you are asked to see him. • What do you do

44. Case 4 • Sexual history 3 partners in past 6 weeks all unprotected. No regular girlfriend • He has no discharge or dysuria • No previous STIs • Otherwise well and not taking any medication • What do you do?

45. Case 4 • Refer to GUM clinic for full STI screen treatment and partner notification In GUM clinic Urethral swab for microscopy, GC culture and sensitivity • Treatment • Ceftriaxone 500mgs IM stat with treatment for chlamydia • Cefixime 400mgs po stat if refuses injection

46. Gonorrhoea • 40% women and 10% men are asymptomatic • Vaginal discharge and cervicitis are not common presenting symptoms in women. • Urethral discharge and dysuria are common in men • Multi drug resistant GC coming!!!!

47. Gonorrhoea

48. Gonorrhoea Disseminated

49. Gonorrhoea • Commoner in black population locally (x 10) although most cases in UK in caucasians • x5-6 in MSM

50. Herpes • First episode genital herpes • Recurrent genital herpes • Common presentation • Young woman presents with ‘cuts’or sores on the vulva • Possibly in a stable relationship