CAROLYN GARVEN NICOLA GRANT Sexual Health Nurse Practitioners GUM SERVICE GATESHEAD CAROLYN GARVEN NICOLA GRANT Sexual Health Nurse Practitioners

What are sexual health services? Genitourinary Clinic (GUM) Contraception and Sexual Health (CASH) Sexual Health Promotion (including- LAC, education, LGBT, Stag, YM&B, C-Card) Teenage Pregnancy Options Nurse School Based Services Chlamydia Screening

VISION Sexual health services in Gateshead are based on a framework of evidence based and needs led services. To provide value for money Support the delivery of national targets Build a patient centred service Contribute to a reduction in health inequalities

Access to Gum clinics 100 % of patients attending GUM clinics must be offered an appointment within 48 hours of contacting the clinic. The percentage of patients attending GUM clinics who are seen within 48 hours of contacting the service is monitored by the DoH.

Sexually transmitted infections In 2006, there were 376,508 new sexually transmitted infection diagnoses at GUM clinics in the UK, an increase of 63 per cent on 1997. Between 2005 and 2006 the number of new diagnoses increased by 2 per cent.

Between 1997 and 2006 the largest increases were seen in diagnoses of genital chlamydia which rose by 166 per cent, gonorrhoea by 46 per cent and syphilis by 1,607 per cent. Genital chlamydia infection was the most commonly diagnosed STI at GUM clinics in the UK, with 113,585 diagnoses of uncomplicated infection made in 2006.

Between 2003 and 2006, around one in ten of those screened for chlamydia were found to be positive. Chlamydia is implicated in more than 50 per cent of cases of pelvic inflammatory disease which can lead to ectopic pregnancy and infertility in women and fertility problems in men.

Gonorrhoea was the second most common bacterial STI in the UK, with 19,007 diagnoses of uncomplicated infection in 2006.

Genital warts are the most common viral STI diagnosed in GUM clinics in the UK.

HIV An estimated 73,000 adults are now living with HIV in the UK, according to the Health Protection Agency's latest report on the UK 's sexual health. This figure includes both those who have been diagnosed and also around a third (21,600) who remain unaware of their HIV status. In 2006, 48 per cent of HIV infections were acquired through heterosexual intercourse. The majority of these were acquired outside the UK

Who is at risk? Sexually active population Groups with increased risk are: Young adults - account for half of all STI’s diagnosed Men having sex with men People living with a disadvantage, race, social status, education, LAC

GUM Gateshead 2 Sexual Health Nurse Practitioners 2 Sexual Health Nurses 2 Health Advisors 4 Health Care Assistants Newly appointed consultant starting in September

WHAT ROUTINE SCREENING CONSISTS OF HISTORY TAKING ASSESS WHETHER PATIENT IS SYMPTOMATIC OR ASYMPTOMATIC HIGH RISK OR LOW RISK? DEPENDS ON SEXUALITY, LIFESTYLE, i.e. IV DRUG USE, LARGE NUMBERS OF CASUAL SEXUAL PARTNERS

ASYMPTOMATIC SCREENING SWABS FOR CHLAMYDIA AND GONORRHOEA BLOODS FOR HIV AND SYPHILIS TEXT RESULTS 7-10 DAYS LEAFLET GIVEN

SYMPTOMATIC SCREENING SWABS FOR CHLAMYDIA AND GONORRHOEA FEMALE SWABS FOR BV/CANDIDA/TV BLOODS FOR HIV AND SYPHILIS MICROSCOPY CARRIED OUT IN THE UNIT, WET/DRY SLIDES/ POSSIBLE BLOOD TESTING FOR HEPATITIS B AND C

SEXUALLY TRANSMITTED INFECTIONS Chlamydia Gonorrhoea Trichomonas Genital warts Herpes

Chlamydia

Chlamydia SITES Cervix Urethra Rectum Pharynx Eye Incubation period up to 14 days

Other Sites Rectal infections Usually asymptomatic, but may cause anal discharge and anorectal discomfort (proctitis) Pharyngeal infections These are asymptomatic and are uncommon

Signs and Symptoms Women Asymptomatic in approximately 70% Post coital or intermenstrual bleeding Lower abdominal pain Purulent vaginal discharge Mucopurulent cervicitis and/or contact bleeding Dysuria

Signs and Symptoms Men Asymptomatic in over 50% in a community setting Urethral discharge Dysuria The severity of these two symptoms is variable and may be so mild as to be unnoticed by the patient.

Treatment of genital, rectal and pharyngeal uncomplicated infection see appropriate and epidemiological treatment Recommended regimens: (Grade of recommendation A) • Doxycycline 100mg bd for 7 days (contraindicated in pregnancy) or • Azithromycin 1gm orally in a single dose

Partner notification Symptomatic 4 weeks Asymptomatic 6 months Advised to abstain from sexual intercourse until they and their partner(s) have completed therapy (and waited 7 days if treated with Azithromycin).

Trichomonas Sites High Vaginal secretions Difficult to isolate in men urethral infection is present in 90% of episodes Diagnosis is made by wet mount microscopy or HVS

Trichomonas Trichomonas

Signs and symptoms Females • 10 - 50% are asymptomatic. • The commonest symptoms include vaginal discharge, vulval itching, dysuria, or offensive odour. • Occasionally the presenting complaint is of low abdominal discomfort

Male 15 to 50% of men with T. vaginalis are asymptomatic and usually present as sexual partners of infected women. The commonest presentation is with urethral discharge and/or dysuria. Other symptoms include urethral irritation and frequency

Treatment Metronidazole 2g orally in a single dose or Metronidazole 400 – 500mg twice daily for 5 - 7 days

Partners Sexual partner(s) should be treated simultaneously. Patients should be advised to avoid sexual intercourse (including oral sex) until they and their partner(s) have completed treatment and follow-up.

GONORRHOEA Sites Cervix Urethra Rectum Pharynx Eye Incubation period 3-7 days

Signs and Symptoms Female • infection at the endocervix is frequently asymptomatic (up to 50%). • increased or altered vaginal discharge is the most common symptom (up to 50%). • lower abdominal pain may be present (up to 25%). • urethral infection may cause dysuria (12%) but not frequency.

Female Symptoms gonorrhea is a rare cause of intermenstrual bleeding or menorrhagia. rectal infection more frequently develops by transmucosal spread of infected genital secretions than from anal intercourse and is usually asymptomatic. pharyngeal infection is usually asymptomatic (>90%).

Signs Women: • mucopurulent endocervical discharge and endocervical bleeding (<50%). • pelvic/lower abdominal tenderness (<5%). • commonly, no abnormal findings are present on examination.

Male Symptoms urethral infection commonly causes urethral discharge (>80%) and/or dysuria (>50%). urethral infection can be asymptomatic (<10%). rectal infection in homosexual men is usually asymptomatic pharyngeal infection is usually asymptomatic (>90%).

Signs Men • a mucopurulent or purulent urethral discharge is commonly evident. • rarely, epididymal tenderness/swelling or balanitis may be present.

Gonorrhoea Gonorrhoea

Treatment Cefixime 400mg oral as a single dose

Partner notification 2 weeks for symptomatic men 12 weeks for Asymptomatic males and all females All patients with gonorrhoea should be screened for genital infection with Chlamydia trachomatis and receive presumptive treatment for this infection.

Genital Warts In 2005 just over 80,000 new diagnoses of Ano-genital warts were made in genitourinary (GU) medicine clinics in the United Kingdom. Although the large majority of these result in little physical discomfort, they may be disfiguring and psychologically distressing.

Genital warts may be associated with irritation and soreness especially around the anus Symptoms of distortion of urine flow or bleeding from the urethra or anus, may indicate internal lesions

Treatment options Cryotherapy Warticon Aldara No treatment No PN required

Differential diagnosis; Molluscum

Herpes

Genital Herpes Signs The patient may be asymptomatic Local symptoms consist of painful ulceration, dysuria, vaginal or urethral discharge. Systemic symptoms such as fever are much more common in primary than in initial or recurrent disease.

Signs Blistering and ulceration of the external genitalia (+/- cervix/rectum) Tender inguinal lymphadenitis, usually bilateral

Management First Episode Genital Herpes General advice Saline bathing Analgesia Aciclovir 200mgs five times daily for 5 days Instillagel

Recurrent Herpes Recurrences are self-limiting and generally cause minor symptoms. Strategies include: supportive therapy only episodic antiviral treatments suppressive antiviral therapy.

Syphilis Primary syphilis is characterized by an ulcer (the chancre) and regional lymphadenopathy. The chancre is classically in the anogenital region, is single, painless and indurated with a clean base discharging clear serum.

Chancre Chancre

Secondary syphilis is characterized by multisystem involvement within the first two years of infection. There is often a rash typically generalized macular, papular or macular–papular often affecting the palms and soles

Partner Notification Required for most sexually transmitted infections Process of informing sexual contacts of infected individuals Usually initiated by Health Advisors Voluntary, requires consent of individual Essential to reduce the amount of infection in the community Various methods, patient, health advisor, mixed

Promoting safer sex Addressed at each clinic attendance Degree depends on existing knowledge and current sexual risk taking Health advisor can work with individuals motivated to address sexual risk taking

Vaginal Infections Candida Bacterial vaginosis

Normal female dry slide

Candida- Hyphae on a wet slide Wet slide- Candida

Candida spores on dry slide Candida spores on a dry slide Candida spores on dry slide

Bacterial Vaginosis Bacterial Vaginosis

Treatment BV- Metronidazole 400mgs bd for 5 days Candida- Local Clotrimazole or Fluconazole All treatment is free of charge Dispensed in the unit by qualified nurses Written information given about treatment and infection Health advisor appointments are available for discussion

Consent The legal age for all young people to consent to have sex is still 16, regardless of sexual orientation. The aim of the law is to protect the rights and interests of young people, and make it easier to prosecute people who pressure or force others into having sex they don’t want.

Young People between 13 and 16 The Sexual Offences Act 2003 reinforces that, whilst mutually agreed, non-exploitative sexual activity between teenagers does take place and that often no harm comes from it, the age of consent should still remain at 16. This acknowledges that this group of young people are still vulnerable, even when they do not view themselves as such.

Young People under the Age of 13 Young people under the age of 13 are deemed unable to give consent to sexual activity. ‘Working Together’ makes it clear that cases involving under 13 year olds who are either having penetrative sex, or are engaged in other intimate sexual activity are likely to involve significant harm to the child or children.

Consent to Treatment The Sexual Offences Act Amended (2003) does not prevent the provision of confidential contraceptive/sexual health advice or treatment to under 13’s. Young people under 13 continue to be able to consent to treatment if they are considered competent to understand the treatment proposed. The judgement of competence rests with the professional on a case-by-case basis using the Fraser Guidelines as a framework.

Confidentiality The duty of confidentiality owed to a person under 16, in any setting, is the same as that owed to any other person. This is enshrined in professional codes.

Confidentiality can only be breached in exceptional circumstances where the health, safety and welfare of the young person or others would be at grave risk and depends on the degree of likely harm, not solely on the age of the young person.

Gateshead Sexual Health Services Confidentiality Notice You have the right not to have any information about you passed on to anyone outside the service (like parents, family, friends, Doctors, teachers, social workers, etc.) without you knowing about it and agreeing to it.

The only time this may be different is if you tell us that you or someone else is in a dangerous situation and by us telling someone else this may prevent you or them from being harmed. If a worker felt they had to pass on information without your permission, they would still inform you of what they were going to do.

Any Questions?