Transcript STIs - Pennine GP Training

Update for Halifax GPs
Dr John Watson
Consultant in Sexual health & HIV
medicine
Why is STI control important?
It has significant immediate and
long term complications
Human Behaviour is diverse and
continues to find new infections
Outline
 Several cases to cover main syndromes
 Discharge/testicular pain in men & lower abdo pain
in women
 Ulcers
 Lumps
Principles of STI Management
 Listen to the patient
 Non-judgemental approach
 Screen for accompanying STIs (blood &
swab/urine)
 Partner notification
 Prevention
The art of medicine
 What is the patients agenda?
 Are their symptoms significant or are they more
worried about an exposure
 Sexual histories : often inaccurate
 If things dont fit could it be psychosexual
Or a mental health issue
Case 1
 22y man previously well painful left testicle gradual
onset over 4 days, no trauma.
What history is needed?
 Dysuria, freq or discharge?
 History of renal infections or stones
 Sexual history : symptoms in partner?
 Angle jaw pain, recent mumps contacts?
Case 1 : examination
Epididymo-orchitis: differential
 Non specific pain ; normal exam +/- ultrasound
 Sexually transmitted : GC and chlamydia
 Enteric eg E coli : UTIs, stones, congenital renal
disease or Anal sex (UP)
 Mumps : even if had MMR x2 doses as child
 If acute <12hr think torsion
 If chronic TB possible.
Differentiating from non specific
testicular pain
Exam standing up
 Pain radiates to groin in epididimyitis usually
 Mild cases focal tenderness most marked adjacent to
vas deferens (lower pole)
 Retrograde passage of bacteria from prostatic urethra
Sampling for Epididymitis
 MSU
 Chlamydia & GC dual NAATs
 HIV and syphilis testing
 Persistent or relapsed cases : semen sample (post
ejaculation)
Case 1 : slightly different
 22y male 4 days dysuria no testicular pain
 Does he have a UTI? Shall I give trimethoprim?
 Or is it urethritis?
Sexual history , PMH renal disease and examine penis
Urethral Discharge
STI
 Chlamydia
 Gonorrhoea
 Mycoplasma genitalium
 Trichomonas
 Men-
Non-specific
Urethritis (NSU)
Semen
UTI
Viruses :HSV,
Adenovirus
Urethral wart
Unexplained
Gonorrhoea – Clinical
Features
MEN
 Incubation period 2-5
days
 Asymptomatic in some
 Dysuria
 Urethral discharge
 Epididymitis
 Tender lymph glands in
groin
 Proctitis
WOMEN
 Incubation period up to
10 days
 Asymptomatic in most
 Vaginal discharge
 Abnormal bleeding
 Abdominal pain
 Dysuria
Chlamydia
–Clinical Features
Similar to GC
But less symptoms
Most women none
Diagnosing Chlamydia/GC
MEN
 Urine
DNA TEST
For GC always culture
pre treatment pre
treatment
WOMEN
 Swab
- vulvovaginal
All should have blood
for HIV and syphilis
Treatment of Gonorrhoea
 Follow local protocol : generally refer
 Ceftriaxone 500mg IM stat
 Azithromycin 1g stat
 Doxycyline 100mg bd (cover Chlamydia)
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 Always culture pre treatment
 Increasing rates of cephalosporin resistanc Japan
Partner screening and treatment
Treatment of Chlamydia
 Follow local protocol
 Uncomplicated Chlamydia
 Doxycycline 100 mg bd 7/7
 Epididymitis : doxycyline 100mg bd 2wk plus
ceftriaxone 500mg IM
 PID
- combination of antibiotics for 14/7
 Partner screening and treatment
Complications of GC/Chlamydia
 Pelvic Inflammatory Disease
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- Infertility, ectopics, salpingitis, spontaneous
abortions
Epididmytis
Bartholins abscess
Reactive Arthritis
Conjunctivitis
Babies - Prematurity, stillbirth, low birth weight,
conjunctivitis and blindness, pneumonia
GC – Disseminated : tenosynovitis/arthrtis/pustular
skin lesions)
SARA :
 1% of chlamydial infections
 Common cause assymetrical lower limb arthropathy
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(knee/feet)
Urethral discharge often asymptomatic
Enthesopathy in most
Skin rash and uveitis in some
HLA B27 associated
Most self limiting with treatment
Rx Doxycyline 100mg bd
Opthalmology review even if no symptoms
Consider Pelvic infection
 SYMPTOM : Any female with lower abdominal pain :
acute/subacute ; gradual worsening over days is usual
 Persistant pain esp needing pain relief
 EXPOSURE : Sexual exposure/post TOP/post
partum/post gynae procedure including coil insertion
 SIGNS : Abnormal pelvic exam
 Think alternative causes : appendix, ovarian cyst,
pregnancy, urinary stone/infection
Key features Ulcers history
and exam
 First episode or recurrent?
 Herpes most common (type 1 & 2)
 Syphilis : more in at risk groups eg Men who sex with
men or CSexWorkers.
 Inguinal nodes may be tender so groin pain
 Herpes often dysuria with reduced freq.
 Primary syphilis : multiple and painful often.
Herpes Simplex
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Painful oral or genital
Primary infection can be severe
Diagnosis : swab for DNA
No cure (therefore associated anxiety in some)
Treatment: aciclovir
Increase dose if immunocompromised
 VERY GOOD ONLINE INFO VIA HERPES
ASSOCIATION
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Genital Ulcers : common
causes
 Herpes (HSV)
 Syphilis
 Erosions : Candida
& Scabies
 Non specific
Genital Warts
 Human Papilloma Virus
 > 100 different types , vaccine available for
some
 Asymptomatic infection common
 Oncogenic strains (tend NOT to be same
strain that causes external warts)
 Clinical Dx
 First line Topical treatments
Genital Lumps
 Genital Warts
 Molluscum
 Penile Papillae
 Atypical lesions : biopsy PIN/VIN
TOP 10 STI POINTERS
 1. Urethral discharge: think STI = gonorrhoea/chlamydia
 2. Acute vulval pain: think herpes
 3. Vaginal discharge
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Odour BV,, Itch/irritation Candida TV either
Chlamydia, gonorrhoea
 4. Swollen painful testes, exclude torsion then think STI
 5. Lower abdominal pain
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Exclude Ectopic/ Appendicitis
Consider upper genital tract infection
 6. Genital ulcers: think HSV, Syphilis
 7. ‘Viral illness with rash’: think primary HIV and secondary
Syphilis
 8. Arthritis think chlamydia and GC
 9. rectal pain in MSM think LGV
 10. Remember STIs travel in packs
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Differential of ulcer
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HSV and VZV
Bacterial : Syphilis, LGV, Staph including PVL strains
Fungal: candida
Protozoal/Helminth : tropical infections
Drug reaction : doxycycline
Derm : lichen planus
Rheumatoloigcal : crohns
Malignancy : SCC
 Primary
9-90 days Infectious ++
 Secondary
<2years
Highly Infectious +++
 Early latent
<2years
Infectious +
 Late latent
>2 years
 Tertiary/complications >2yrs-life
Non-Infectious
Non-Infectious
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Stages: Primary (S1)
 Incubation period: 9-90 days (ave 3 wks)
 Chancre – painful or painless ulcer at site of
spirochete entry often multiple
 Heals in a few (3-8) weeks +/-scar
 25 % of S2 pts give no history of S1
 Limitation of Antibody test need DNA swab test
Secondary syphilis
 25 % of untreated patients will develop S2
 6 - 8 weeks after beginning of S1 (sometimes sooner
or later)
 S2 can be recurrent
 over 3 - 9 months (up to 2 years)
 All will be antibody +ve
Secondary Syphilis (S2)
“A generalised systemic infection”
 Fever
 Malaise
 Rash + esp “palms and soles++”
 Lymph nodes +
 Mucosal ulcers
 Condylomata lata
 Alopecia
Take home message
genital ulcers
 Think imptcauses ; herpes, syphilis
 Test for syphilis/HIV
 Limitations of syphilis blood testing in ulcer
stage
 Dont use Antibiotics on genital ulcers without
syphilis testing