8ChlamydiaCommon (3-5% sexually active females attending UK General Practice)Complications cost at least £50million annually in the UK
9CLINICAL FEATURES (chlamydia) 80% Females asymptomaticPCB/IMB, abdo pain, discharge,cervicitis50% males asymptomaticUrethral discharge, dysuriaRISK FACTORS FOR INFECTIONCOMPLICATIONS
10DIAGNOSIS (chlamydia) Women endocervical swab gives best specimenUrethral swabs will identify additional 10-20%Men urethral swab (painful!)ELISA vs PCRUrine testing
11WHAT CAN I DO IN PRACTICE? (chlamydia) 1. POSITIVE RESULT BACKTreat patientContacts need treatmentAdvised no SI until both partners treatedCan refer to clinic for full testsGuidelines say only retest if symtomatic/possibility of reinfection at 3 weeks
12TREATMENT (chlamydia) Doxycycline 100mg bd 7 daysAzithromycin 1g orally as single doseErythromycin 500mg qds 10 days (pregnancy)Ofloxacin 200mg bd 7 days
19WHAT CAN I DO IN GENERAL PRACTICE? Refer any patients with confirmed GC on swabs to GUMRefer any acute urethral dischargeRefer contacts of GC to GUM for treatment and ixRefer females with lower abdominal pain
20TREATMENT (gonorrhoea) Cefixime 400mg oral as single doseCiprofloxacin 500mg statSpectinimycin 2g IM single doseCeftriaxone 250mg IM ( pregnancy)
21FOLLOW UP 2 Weeks TOC in clinic Pregnant women, symptomatic patients Check contacts have been treated/testedBe aware of possible co-infection with chlamydia
24NSU Male urethritis in the absence of gonorrhoea Mucopurulent cervicitis equivalent condition in female30-50% due to chlamydia20% due to mycoplasma genitalium
25Clinical Features Urethral discharge, dysuria, irritation (M) Vaginal discharge (usually asymptomatic)DIAGNOSISMicroscopySwabs, check for chlamydia
26TREATMENT Doxycycline 100mg bd for 7 days Azithromycin 1g as a single doseTreat contacts
27GENITAL HERPES HSV 1/ 2 Common Incubation period 1-2 weeks Asymptomatic sheddingChronic conditionPsychological aspects
28CLINICAL FEATURESPainful ulceration, dysuria, vaginal or urethral dischargeMay be systemically unwellBlistering/ulceration external genitaliaInguinal lymphadenopathyCOMPLICATIONS: urinary retention, aseptic meningitis
29DIAGNOSIS Isolation of HSV from genital lesions Often a clinical diagnosisSerology, not routinely done
30WHAT CAN I DO IN GENERAL PRACTICE? Take a viral culture swabGeneral advice: saline bathing, analgesia, topical anaesthetic, petroleum jellyStart oral antiviral drugs (within 5 days)Aciclovir 200mg five times a day for 5 daysPsychological supportArrange F/U GUM 3-4 weeks for full tests
35GENITAL WARTS Human papillomavirus (HPV) >90 genotypes Nearly always sexually transmittedCommonDifficult and time consuming to treatCertain types associated with cervical dysplasiaBenign epithelial skin tumours
36DIAGNOSIS Most cases naked eye examination Colposcope helps May need biopsy if dx uncertain
37What can I do in General Practice? Refer GUM for full assessmentWill not need urgent assessment if no other symptoms presentYou can give warticon lotion/cream if confident of dx
38TREATMENT IN CLINICAll treatments have significant failure and relapse ratesPodophyllin, trichloroacetic acid, cryotherapyHome treatments are warticon and aldara (imiquimod)(HPV vaccine)
44Diagnosis/Management (trichomonas) HVSDirect observation wet smearMore difficult to culture in menTreat sexual partners simultaneouslyMetronidazole 400mg bd 5-7 days or 2g statRefer GUM for full tests
46Bacterial VaginosisThe commonest cause of vaginal discharge in women childbearing ageReplacement of lactobacilli and raised PhNot regarded as sexually transmitted
47SYMPTOMS/SIGNS 50% women asymptomatic ‘fishy’ vaginal discharge Thin/white dischargeIn pregnancy BV is associated with late miscarriage, preterm birth, preterm premature rupture of membranes, post partum endometritis
49What shall I do in general practice? Treatment is indicated for symptomatic and pregnant womenYou do not have to treat asymptomatic women but can offer treatmentGeneral advice re vaginal douching, use of soap etcTreatment: metronidazole 400mg bd for 5-7 days or 2g statClindamycin cream 2% daily 7 days, metronidazole gel 0.75% daily 5 days
50Vulvovaginal Candidiasis Candida. albicans approx 90%, candida.glabrata approx 10%10-20% women of childbearing age may harbour candida species in the absence of symptoms. They do not require rxSymptoms/signsBeware the woman with ‘recurrent thrush’Do a HVS
51Management Avoid local irritants/synthetic clothing Treat with topical and oral azole therapies (clotrimazole/fluconazole)Nystatin for non albicans speciesNo evidence to support treatment of asymptomatic male partnersRecurrent candidosis
55CASE 1Kylie is a 15yr old girl who complains of intermenstrual ‘spotting’ for the last 2 months. You see from her records she attended surgery 3 months ago and was prescribed mercilon. How would you manage her?( mercilon is a low strength COCP)
56Case 2Susan is a 45 year old lady married lady. She has had three prescriptions for clotrimazole and one for oral fluconazole for her ‘thrush’. She is quite upset that she is still symptomatic. What do you do?
57CASE 3Tina is a 48 year old lady who attends surgery with a 2 day history of vulval soreness. On examination you notice a crop of blisters to the vulva. How do you proceed?
58Case 4Delia is a 32 year old woman who presents with a 5 day history of abdominal pain, discharge and painful intercourse. The pain is now so severe she is unable to have intercourse. How would you manage her?
59Case 5Frank is a 28 year old man. In the last 2 weeks he has noticed some lumps on his penis. They are not sore are itchy. He was not going to bother the doctor, but his new boyfriend made him the appointment.