Genitourinary Medicine For GPs November 2007

Agenda Recent changes How to take the necessary swabs Brief overview STI’s What can be done in General Practice Cases

New diagnosis of selected STIs in GUM clinics, England, Wales and Northern Ireland % change 2004 1995-2004 Genital Warts 79,417 32% Chlamydia 103,680 222% Gonorrhoea 22,000 111% Genital herpes 19,010 15% Syphilus 2,200 1497%

Female Swabs HVS BV (charcoal) Candida (charcoal) Trichomonas (charcoal) Endocervical Chlamydia Gonorrhoea (charcoal) Urethral 10-20% additional chlamydia Gonorrhoea HSV Herpes simplex type I and II

Male Swabs URETHRAL ENTRANCE GONORRHOEA (charcoal) INSIDE URETHRA CHLAMYDIA

Overview of STIs

Chlamydia Common (3-5% sexually active females attending UK General Practice) Complications cost at least £50million annually in the UK

CLINICAL FEATURES (chlamydia) 80% Females asymptomatic PCB/IMB, abdo pain, discharge,cervicitis 50% males asymptomatic Urethral discharge, dysuria RISK FACTORS FOR INFECTION COMPLICATIONS

DIAGNOSIS (chlamydia) Women endocervical swab gives best specimen Urethral swabs will identify additional 10-20% Men urethral swab (painful!) ELISA vs PCR Urine testing

WHAT CAN I DO IN PRACTICE? (chlamydia) 1. POSITIVE RESULT BACK Treat patient Contacts need treatment Advised no SI until both partners treated Can refer to clinic for full tests Guidelines say only retest if symtomatic/possibility of reinfection at 3 weeks

TREATMENT (chlamydia) Doxycycline 100mg bd 7 days Azithromycin 1g orally as single dose Erythromycin 500mg qds 10 days (pregnancy) Ofloxacin 200mg bd 7 days

CHLAMYDIA CERVICITIS

EPIDIDYMITIS

GONORRHOEA ‘THE CLAP’ CLINICAL FEATURES Women 50% asymptomatic Vaginal discharge, abdo pain, dysuria Rarely causes IMB/menorrhagia Pharyngeal infection asymptomatic >90% Men 80% discharge, 50% dysuria Rectal symptoms Signs

DIAGNOSIS (gonorrhoea) Laboratory culture Microscopy NB: Specimen collection sites

WHAT CAN I DO IN GENERAL PRACTICE? Refer any patients with confirmed GC on swabs to GUM Refer any acute urethral discharge Refer contacts of GC to GUM for treatment and ix Refer females with lower abdominal pain

TREATMENT (gonorrhoea) Cefixime 400mg oral as single dose Ciprofloxacin 500mg stat Spectinimycin 2g IM single dose Ceftriaxone 250mg IM ( pregnancy)

FOLLOW UP 2 Weeks TOC in clinic Pregnant women, symptomatic patients Check contacts have been treated/tested Be aware of possible co-infection with chlamydia

CERVICITIS

NSU Male urethritis in the absence of gonorrhoea Mucopurulent cervicitis equivalent condition in female 30-50% due to chlamydia 20% due to mycoplasma genitalium

Clinical Features Urethral discharge, dysuria, irritation (M) Vaginal discharge (usually asymptomatic) DIAGNOSIS Microscopy Swabs, check for chlamydia

TREATMENT Doxycycline 100mg bd for 7 days Azithromycin 1g as a single dose Treat contacts

GENITAL HERPES HSV 1/ 2 Common Incubation period 1-2 weeks Asymptomatic shedding Chronic condition Psychological aspects

CLINICAL FEATURES Painful ulceration, dysuria, vaginal or urethral discharge May be systemically unwell Blistering/ulceration external genitalia Inguinal lymphadenopathy COMPLICATIONS: urinary retention, aseptic meningitis

DIAGNOSIS Isolation of HSV from genital lesions Often a clinical diagnosis Serology, not routinely done

WHAT CAN I DO IN GENERAL PRACTICE? Take a viral culture swab General advice: saline bathing, analgesia, topical anaesthetic, petroleum jelly Start oral antiviral drugs (within 5 days) Aciclovir 200mg five times a day for 5 days Psychological support Arrange F/U GUM 3-4 weeks for full tests

GENITAL HERPES VULVA

GENITAL HERPES PENIS

GENITAL WARTS Human papillomavirus (HPV) >90 genotypes Nearly always sexually transmitted Common Difficult and time consuming to treat Certain types associated with cervical dysplasia Benign epithelial skin tumours

DIAGNOSIS Most cases naked eye examination Colposcope helps May need biopsy if dx uncertain

What can I do in General Practice? Refer GUM for full assessment Will not need urgent assessment if no other symptoms present You can give warticon lotion/cream if confident of dx

TREATMENT IN CLINIC All treatments have significant failure and relapse rates Podophyllin, trichloroacetic acid, cryotherapy Home treatments are warticon and aldara (imiquimod) (HPV vaccine)

GENITAL WARTS VULVA

WARTS PENIS

TRICHOMONAS Flagellated protozoan Almost exclusively sexually transmitted Female symptoms: discharge, itching, odour, abdo pain. 10-50% are asymptomatic Male symptoms: urethral discharge/ dysuria. 10-50% asymptomatic

Diagnosis/Management (trichomonas) HVS Direct observation wet smear More difficult to culture in men Treat sexual partners simultaneously Metronidazole 400mg bd 5-7 days or 2g stat Refer GUM for full tests

Bacterial Vaginosis The commonest cause of vaginal discharge in women childbearing age Replacement of lactobacilli and raised Ph Not regarded as sexually transmitted

SYMPTOMS/SIGNS 50% women asymptomatic ‘fishy’ vaginal discharge Thin/white discharge In pregnancy BV is associated with late miscarriage, preterm birth, preterm premature rupture of membranes, post partum endometritis

Diagnosis HVS Gram stain

What shall I do in general practice? Treatment is indicated for symptomatic and pregnant women You do not have to treat asymptomatic women but can offer treatment General advice re vaginal douching, use of soap etc Treatment: metronidazole 400mg bd for 5-7 days or 2g stat Clindamycin cream 2% daily 7 days, metronidazole gel 0.75% daily 5 days

Vulvovaginal 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 rx Symptoms/signs Beware the woman with ‘recurrent thrush’ Do a HVS

Management Avoid local irritants/synthetic clothing Treat with topical and oral azole therapies (clotrimazole/fluconazole) Nystatin for non albicans species No evidence to support treatment of asymptomatic male partners Recurrent candidosis

CANDIDAL BALANITIS

Cases

CASE 1 Kylie 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)

Case 2 Susan 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?

CASE 3 Tina 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?

Case 4 Delia 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?

Case 5 Frank 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.