Sexual Transmitted Infections in General Practice

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Sexual Transmitted Infections in General Practice

• Dr John McSorley

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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?

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Sexually transmitted infections

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

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Uncomplicated Chlamydia NWLH 1997 to 2013
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Uncomplicated N. gonorrhoea at NWLH 1997 to 2013
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Incidence

• Chlamydia commonest (75 under 25s)
• Warts
• Herpes (Ratio FM 0.31 to 1.51)
• Gonorrhoea greatly decreased but
• Syphilis (since 2000, 7 fold increase in men and
  doubling in women)
• HIV levelling off (or not)

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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

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Why are STIs important?

• Aversely affect Pregnancy Ectopic Pregnancy
  x6-10 more likely if prev PID, c50 EP
  attributable to prev STI. lt35 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

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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

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High index of suspicion

• Young people
• 5 of under 25yr old each year every year
• Emergency contraception
• Pre termination
• Men (lt45) with urinary syndromes STI, STI, STI,
  STI, STI not UTI
• Epididymo-orchitis CT x10 more likley
• GUM

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STI screening in MSM NWLH 1997 to 2013
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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

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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?

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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?

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History, management

• At risk of chlamydia (gt5)
• 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

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Result of swab

• Chlamydia test positive
• What do you do next?

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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

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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)

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Clinical features in Chlamydial infection
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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

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Special considerations in GUM clinics

• Focus on young people
• Normalisation and early HIV testing (POCT
  testing)
• Frequent STI screens for gay men

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Patients journey in GUM clinic

• 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

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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?

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Case 2

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

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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?

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Case 2 assessment

• Examine his genitalia
• Findings are
• Superficial ulcer sub preputial area and shotty
  nodes in the groin

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Case 2 management

• Is this a drug reaction?
• Is this an STI?
• What would you recommend?

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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

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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

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Syphilis
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Syphilis

• Infectious syphilis more common in past 10 years.
• Secondary syphilis may present with a rash
• There have been gt10 local scattered epidemics
  amongst heterosexuals in UK
• Endemic again in gay men
• Foreign travel history is important
• Always consider the possibility of associated HIV

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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 doesnt
  seem to have helped

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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 didnt see why she needed to go to a clinic
  and decided to come to you her GP

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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

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Trichomoniasis
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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

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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

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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?

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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

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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!!!!

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Gonorrhoea
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Gonorrhoea Disseminated
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Gonorrhoea

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

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Herpes

• First episode genital herpes
• Recurrent genital herpes
• Common presentation
• Young woman presents with cutsor sores on the
  vulva
• Possibly in a stable relationship

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Herpes
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Patients with Herpes

• Primary genital herpes can frequently be
  diagnosed as patient enters the room
• Severe discomfort walking, sitting down
  uncomfortable, may have severe dysuria, may
  complain of discharge, may be crying
• May be febrile

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Primary herpes
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Genital herpes

• Primary herpes blisters ulcers, may be confluent,
  may be associated vulval oedema and tender
  lymphadenopathy.
• Easy to diagnose clinically
• Confirmed by a swab for herpes virus PCR

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Genital herpes

• Treatment
• Acyclovir 200mgs po 5/day for 5 days or 400mgs
  tds for 5 days
• Advice re PU in bath, handwashing
• Pain relief, lignocaine gel
• In depth discussion re infectivity, recurrences,
  partner, childbirth
• Reassurance that first attack always the worst

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Genital herpes

• 1/3 will get no more attacks
• 1/3 will get 2-3 attacks per year
• 1/3 will get frequent/severe attacks and may
  require suppressive therapy for a year or more

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Genital herpes in pregnancy

• Main problem is primary herpes.
• May cause miscarriage due to febrile illness in
  first trimester
• Primary herpes in last trimester may be
  associated with neonatal herpes
• Indication for Caesarian section if Primary or
  first episode herpes occurs within 6 weeks of
  delivery

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Warts

• Warts are often discovered incidentally during
  examinations
• They are sexually transmitted ,- human papilloma
  virus (HPV)
• The HPV types which cause warts are not
  oncogenic.
• Oncogenic HIV subtypes 16/18.
• The subtypes commonly causing warts are 6/11

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Warts
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warts, meatal
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Warts and abnormal smears

• We are commonly asked whether warts have caused
  an abnormal cervical smear
• Reassure that the HPV subtype that causes warts
  does not cause pre cancerous changes on a smear.
• Also oncogenic HPV causes anogenital cancer but
  is much rarer that cervical cancer except in MSM
  / HIV ve

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Warts treatment

• Podophyllotoxin
• Cryotherapy
• Imiquimod
• No treatment

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Lice and Scabies

• Pubic itch
• Visible crabs in pubic hair.
• Visible nits in pubic hair
• Sexually transmitted (close body contact)
• Treat with Malathion 0.5 apply to hair and leave
  overnight
• Repeat after 3-5 days
• Full STI screen

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Lice
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Scabies

• Generalised itch
• Worse at night
• Specifically finger toe webs, wrists, skin
  creases, pubic area. May cause papules on penis
• Treatment Permethrin cream. Malathion 0.5
  aqueous lotion
• Apply and leave overnight for 12 hours
• Wash clothes and bedding in gt50 degrees
• Sexual and household contacts tretaed

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Scabies
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HIV diagnoses in general practice

• Majority asymptomatic
• Late diagnosis a problem
• In GP consider testing
• All new registrations at your practice
• Flu like illness
• Skin conditions eg shingles, recurrent
  folliculitis, molluscum contagiosum on the face,
  KS
• Haematological conditions, neutropaenia,
  thrombocytopaenia

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Rash of HIV seroconversion
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Shingles think HIV
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HIV

• Normalise the HIV test
• Important clinical investigation
• In depth counselling not necessary
• If positive contact the GUM clinic (if we dont
  contact you first)

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Conclusions

• STIs are common
• High index suspicion especially amongst young
  people, gay men
• Screening with self taken swabs/urines very easy
  with DNA tests
• Normalise HIV testing
• Doing more screening will drive down the
  incidence of new disease