1. Common STI in Primary Care Dr Sadia Shaikh GP Registrar MBBS,DRCOG,DFSRH, Letter of Competence in IUT and Sub dermal implants Certificate of Competence in Sexual Health Clinical Skills.

2. Quiz ► When should you suspect Chlamydia ? ► What are the symptoms in women ? ► What are the symptoms in men? ► When you should start treatment & what will you give? ► What antibiotic –if pregnant or breast feeding?

3. When should you suspect and test for Chlamydia? ► Women:  Test for Chlamydia if they are sexually active with symptoms and signs suggesting Chlamydia: ► Post-coital or intermenstrual bleeding. ► Purulent vaginal discharge. ► Mucopurulent cervical discharge or/contact bleeding ► Deep dyspareunia. ► Dysuria. ► Pelvic pain and tenderness. ► Asymptomatic in approx 70%.

4. Continued…. ► Men:  Test for Chlamydia if they are sexually active with symptoms and signs suggesting Chlamydia: ► Dysuria (urinary frequency or nocturia is more suggestive of a urinary tract infection). ► Urethral discharge. ► Urethral discomfort. ► Asymptomatic in over 50%.

5. Management In people with signs or symptoms strongly suggestive of Chlamydia, start treatment without waiting for laboratory confirmation (after testing for other sexually transmitted infections as appropriate). treatmenttesting treatmenttesting ► Strongly encourage all people who test positive for Chlamydia to undergo screening for other sexually transmitted infections, including an HIV test and, where indicated, hepatitis B screening and vaccination.

6. Management ► First-line treatment:  Azithromycin 1 g single dose, or  Doxycycline 100 mg twice a day for 7 days. ► In women who are pregnant or breastfeeding:  Azithromycin 1 g single dose, or  Amoxicillin 500 mg three times a day for 7 days, or  Erythromycin 500 mg four times a day for 7 days.

7. Contact Tracing ► Tracing of all sexual contacts in the previous 6 months is recommended.

8. Quiz Gonorrhea ► How you will diagnose in Men? ► What is the incubation period? ► How will you diagnose in women? ► Which antibiotic for anogenital G? ► How to treat pharyngeal G? ► How to do follow up? ► Test of cure? ► Partner notification?& how?

9. Gonorrhea ► How will you Diagnose in men? ► Symptoms usually develop after 2–5 days incubation, although they may appear after 10 days or more. ► Genital infection is most common and causes:  Urethral discharge in 80% of men.  Dysuria in about 50% of men. Usually there is no frequency or urgency.  No symptoms in 10% of men. ► Rectal infection is asymptomatic in most men (about 75%), but may cause acute proctitis. This presents as anal pruritus, pain and spasm of the anal sphincter (tenesmus), purulent discharge, or bleeding. ► Pharyngeal infection is asymptomatic in 90% of men, but may cause overt pharyngitis.

10. How will you diagnose in women ► Asymptomatic in 50% ► Increased or altered vaginal discharge in up to 50% of women ► dysuria in 12% of women. ► dysuria in 12% of women. ► Intermenstrual bleeding, sometimes triggered by intercourse (less commonly). ► Most commonly, purulent or mucopurulent endocervical discharge, or easily induced endocervical bleeding (in <50 of women).

11. Management ► Ideally, refer all people with confirmed or suspected gonorrhea to a GUM clinic or to a general practice providing an enhanced sexual health service. refer ► For confirmed anogenital gonorrhea, prescribe:  A cephalosporin first line. ► Cefixime (400 mg, single oral dose) is usually preferred owing to convenience (off-label indication). ► Ceftriaxone (500mg, intramuscular injection) is licensed but is often not readily available in primary care.

12. Management cont… ► Ciprofloxacin (500 mg, single oral dose) if ceph is CI. ► For confirmed pharyngeal gonorrhea:  Ceftriaxone (500 mg, intramuscular injection) first line if this is available.  If Ceftriaxone is unavailable, consider a 3-day course of oral Cefixime (400 mg loading dose, followed by 200 mg twice a day for 3 days). Note this regimen is off label and is recommended on the basis of expert opinion rather than trial-based evidence.  Prescribe oral ciprofloxacin (if a cephalosporin is contraindicated) only if the infection is known to be sensitive to it. ► If gonorrhea has not been confirmed, treat empirically whilst waiting for laboratory confirmation, and consider offering an antibiotic to cover Chlamydia trachomatis (azithromycin or doxycyline).

13. Follow up ► After 1 week to verify the success of treatment.  Test of cure (swab for culture and sensitivity at least 3 days after antibiotic treatment) is required. ► Advise the person to abstain from sex until they and any partners have successfully completed treatment, and to practice safe sex in the future.

14. Partner Notification ► symptomatic anogenital gonorrhea, all partners within the preceding 2 weeks should be notified, ► asymptomatic gonorrhea, or gonorrhea at other sites, all partners within the preceding 3 months should be notified. ► Notified partners should be screened for STD’s and treated empirically for gonorrhea and chlamydia whilst waiting for results (azithromycin 1 gram as a single oral dose or doxycycline 100 mg twice a day for 7 days are suitable choices).

15. Quiz HS ► How will you diagnose? ► How to treat primary episode? ► How to manage recurrent attacks? ► When to start suppressive therapy? ► What are the triggers factors?

16. Herpes simplex - genital ► How will you diagnose? ► Ask about symptoms including painful ulcers, dysuria, vaginal or urethral discharge, malaise, and fever; their onset and duration, and whether similar symptoms have been experienced previously. ► Clinical finding & + viral culture.

17. Contin…. ► Ideally, all people with suspected genital herpes should be referred to a specialist in genito-urinary medicine for diagnosis, treatment, screening for sexually transmitted infections, counseling, and follow up.

18. Treatment in Primary care ► Prescribe oral aciclovir (200 mg five times a day) within 5 days of the start of the episode or while new lesions are forming. ► Apply vaseline or a topical anaesthetic (e.g. lidocaine 5%) to lesions to help with painful micturition, if required. ► Increase fluid intake to produce dilute urine (which is less painful to void). Urinate in a bath or with water flowing over the area to reduce stinging.

19. Managing Recurrent Genital Herpes ► Suppressive antiviral treatment (e.g. oral aciclovir 400 mg twice daily for 6–12 months) if attacks are frequent (e.g. six or more attacks per year), causing psychological distress, or affecting the person's social life: ► After 1 year, stop treatment for a minimum period of two recurrences. ► If attacks are still considered problematic, restart suppressive treatment. If attacks are not considered problematic (off treatment), future attacks can be controlled with episodic antiviral treatment (if needed). ► If the person has breakthrough attacks on suppressive treatment, seek specialist advice.

20. Advice ► Episodes usually last up to 10 days and on average people have 4– 5 attacks in the first 2 years. Thereafter, attacks reduce in frequency and severity, but there is no cure for genital herpes at present. ► Transmission can occur when there are no symptoms (asymptomatic shedding), but that the risk is higher when symptomatic. Advise the person to:  Avoid sex (including orogenital sex) if lesions are present.  Use condoms with new or uninfected partners. Explain that condoms cannot completely prevent transmission, due to close skin contact or contact with infected secretions during foreplay.  Identified personal trigger factors (e.g. sexual intercourse, sunlight, physical illness, excess alcohol, stress).

21. Quiz PID ► When will you suspect? ► What are signs & symptoms? ► What are the risk factors? ► Which antibiotics to treat empirically? ► What are the complication? ► Partner notification ► Follow up?

22. PID ► How will you diagnose? ► On clinical grounds. ► Negative swab results do not rule out a diagnosis of PID. ► Do not delay making a diagnosis and initiating treatment whilst waiting for the results of laboratory tests.

23. When will you suspect? ► Pelvic or lower abdominal pain (usually bilateral). ► Deep dyspareunia particularly of recent onset. ► Abnormal vaginal bleeding (intermenstrual, postcoital, or 'breakthrough') which may be secondary to associated cervicitis and endometritis. ► Abnormal vaginal or cervical discharge as a result of associated cervicitis, endometritis, or bacterial vaginosis. ► Right upper quadrant pain due to peri-hepatitis (Fitz– Hugh–Curtis syndrome).

24. What signs to look for? ► Lower abdominal tenderness — usually bilateral. ► Adnexal tenderness (with or without a palpable mass), cervical motion tenderness, uterine tenderness (on bimanual vaginal examination). ► Abnormal cervical or vaginal mucopurulent discharge (on speculum examination). ► A fever of greater than 38°C, although the temperature is often normal.

25. Risk Factors ► Factors related to sexual behaviour:  Young age (less than 25 years).  Early age of first coitus.  Multiple sexual partners.  Recent new partner (within the previous 3 months).  History of sexually transmitted infection in the woman or her partner.

26. Continue…… ► Recent instrumentation of the uterus or interruption of the cervical barrier:  Termination of pregnancy.  Insertion of an intrauterine device (within the past 6 weeks).  Hysterosalpingography.  In vitro fertilization and intrauterine insemination

27. Management ► Women with suspected mild or moderate (PID) may be treated in primary care if an ectopic pregnancy can be ruled out. ► Test for other STD’s and other genital infections. ► Provide pain relief with ibuprofen or paracetamol. ► Ceftriaxone 500 mg as a single intramuscular dose, plus oral doxycycline 100 mg twice daily and oral metronidazole 400 mg twice daily, both for 14 days. ► Oral cefixime 400 mg as a single dose (off-label use) can be used as an alternative to ceftriaxone 500 mg in the above regimen.

28. What advice should I give? ► The importance of completing the course of antibiotics (even if swabs are negative) in order to reduce the risk of long-term complications such as infertility, ectopic pregnancy, and chronic pelvic pain.  The exception to this is if the woman has mild or moderate pelvic inflammatory disease (PID) and is unable to tolerate metronidazole. She may stop taking the metronidazole but must continue with the other antibiotics in the regimen. ► The importance of screening for STD’s. ► The need for contact tracing, and screening and treatment of sexual partners to prevent reinfection. ► The need to avoid unprotected intercourse until both the woman and her partner's) have completed treatment. ► That fertility is usually not affected in mild PID if it is treated promptly, but repeated episodes of PID are associated with an exponential increase in the risk of infertility.

29. How will you manage sexual partners? ► Ideally, current partners and recent partners (within the last 6 months) should be seen in a genito-urinary medicine (GUM) clinic, or primary care facility with equivalent expertise for screening, treatment, and contact tracing. ► Partners may need to be managed in primary care if they refuse or are unable to attend a GUM clinic, or if there is likely to be an unacceptable delay in accessing specialist services.

30. Continue….. ► If it is not possible to adequately screen the partner for chlamydia and gonorrhea, empirical treatment for Chlamydia and gonorrhea should be given. ► Advise sexual abstinence until both the woman with pelvic inflammatory disease and her partner have completed the course of treatment. ► Advise sexual abstinence until both the woman with pelvic inflammatory disease and her partner have completed the course of treatment.

31. Follow up ► Review within 72 hours.  There should be demonstrable clinical improvement (such as a reduction in abdominal tenderness, and a reduction in uterine, adnexal, and cervical motion tenderness).  Check the antibiotic sensitivities from swab results. Even if swabs are negative, treatment should be continued.

32. Quiz Testicular discomfort ► How will you manage men who present with testicular discomfort? ► <35 yr/sexually active/multiple partners? ► >35 yr/not sexually active /regular partner ► Follow up

33. Epididymo-orchititis ► How do you further assess a man or adolescent with testicular discomfort? ► Identify the most likely causative organism based on risk factors. ► ► Any sexually transmitted infection:   Age less than 35 years.   More than one sexual partner in the past 12 months.   Any urethral discharge. ► ► In sexually active adolescents and men younger than 35 years of age, the causative organism is likely to be Chlamydia trachomatis or Neisseria gonorrhea.

34. Continue…. ► If epididymo-orchitis is thought to be due any sexually transmitted organism, including gonorrhea:  Treat without waiting for test results with oral doxycyline 100 mg twice daily for 10– 14 days, plus a single dose of either intramuscular ceftriaxone 500 mg, if available, or oral cefixime 400 mg stat as an alternative to intramuscular ceftriaxone.

35. Continued… ► Enteric organisms associated with lower urinary tract infections:  Low risk sexual history.  Age 35 years or older.  History of penetrative anal intercourse.  Recent urological instrumentation or catheterization. ► In men 35 years or older and adolescents and men younger than 35 years of age who are not sexually active, the causative organisms are typically enteric organisms found in lower urinary tract infections, such as Escherichia coli.

36. Continued…. ► If epididymo-orchitis is thought to be due to an enteric organism (for example, Escherichia coli):  Treat without waiting for test results with ciprofloxacin 500 mg by mouth twice daily for 10 days, or ofloxacin 200 mg by mouth twice daily for 14 days.

37. Advice ► Advice:  Bed rest, scrotal elevation (such as with supportive underwear), and analgesia.  If ciprofloxacin or ofloxacin is prescribed, avoid nonsteroidal anti-inflammatories, and discontinue treatment and seek immediate medical advice if joint or tendon pain occur.  If symptoms worsen, or do not begin to improve within 3 days, return for reassessment.

38. Anogenital Warts ► Diagnosis is made by examination with the naked eye in most cases. ► Lesions may be single or multiple and tend to occur in areas that are traumatized during sexual intercourse. ► Referral to a sexual health specialist is recommended for all people with anogenital warts.