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Sexual Transmitted Infections in General Practice

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Title: 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

4
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6
Uncomplicated Chlamydia NWLH 1997 to 2013
7
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Uncomplicated N. gonorrhoea at NWLH 1997 to 2013
12
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)

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. 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

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 (lt45) 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 (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

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
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

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 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

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 doesnt
    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 didnt 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 cutsor sores on the
    vulva
  • Possibly in a stable relationship

51
Herpes
52
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

53
Primary herpes
54
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

55
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

56
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

57
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

58
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

59
Warts
60
warts, meatal
61
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

62
Warts treatment
  • Podophyllotoxin
  • Cryotherapy
  • Imiquimod
  • No treatment

63
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

64
Lice
65
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

66
Scabies
67
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

68
Rash of HIV seroconversion
69
Shingles think HIV
70
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)

71
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
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