8. Sexually transmitted Diseases Flashcards
Who gets STIs?
young age (<20 years) - low age at 1st intercourse - coitarche
frequent partner change, high no. lifetime partners, concurrency (simultaneous partners)
sexual orientation
ethnicity for some STIs
use of non barrier contraception
residence in inner city/ deprivation
history of previous STI
Age at first intercourse
Initiation of sex at earlier ages throughout W. Europe
UK showed continuing decline
Median age now 16ys (~30% <16ys)
Higher rate teenage pregnancy in UK (2x Germany, 3x France, 6x Holland)
Young people
Early age associated with poor subsequent sexual health status
Behaviourally more vulnerable to STI acquisition
- higher numbers of sexual partners / partners change
- greater numbers of concurrent partners
- yet to develop skills and confidence to use condoms, negotiate safe sex,
- more risk-taking behaviour/ experimentation
- poor contraception awareness
Physiology
Early intercourse
The earlier intercourse occurs, the higher the proportion express regret & report being more or less willing than their partner
20% men; 42% women express regret they had not waited longer
Vulnerabilities associated with early intercourse
Associated with vulnerabilities:
leaving home / not living with parents before 16 years
leaving school early
family disruption & disadvantage
lack of nurturing relationships
those whose main source of information on sex was not school / parents
Where do young people get information from?
25% daily searches access porn sites
Most common Google search term: “sex”
40 billion hits/month for popular sites
Unintended exposure – reported by 70% of 15-17yo while searching or checking e-mails
Intended viewing
58% teenagers view porn regularly; 1:10 every day
Free, unrestricted, uncensored
Boy’s use and attitudes to porn
Average age first seen 10 ys1
Main reasons: learn about sex / how to give pleasure, gain status in peer group
Younger age, more impressionable; less likely to have received sex education
Young men consuming a lot of porn
more likely to have earlier sex, certain sexual activities, less condom use
6x more likely to access then women
Girls use and attitude to porn
Average age 14 ys
Use also increasing but many women mixed feelings
More likely to see as degrading
Many afraid to show concerns
Both have mixed feelings about their partners using it
negative aspects of porn
Unrealistic nature & expectations
Self-image / performance anxiety
Lack of censorship / boundaries – hardcore material becomes addictive / normalised
Ethical issues e.g. exploitation of women
Sexual consent blurred
Lack of condom use = reduced risk perception / perceived need to practice safe sex
main messages to get across to young people
Don’t rush into it – avoid peer pressure
Use a condom with all new partners - continue until both screened
Sort out contraception
Avoid overlapping sexual relationships
Get screened for chlamydia/gonorrhoea when you have a new partner
MSM should have regular sexual health screens, including HIV, get vaccinated for hepatitis A/B and HPV & consider PrEP for HIV prevention
Concurrent (simultaenous) partners
Individuals engaged in >1 sexual partnership at once
Important in STI epidemiology opportunity for transmission
NATSAL 14.6 % men & 9% women had concurrent partnerships within last 5 years
Higher rates concurrence in the younger age range
Whats a core group?
sub-group of the population – high turnover not a static entity highly sexually active individuals high prevalence of infection reservoirs of infection high frequency of transmission
Effective control at the population level based on targeting core groups
GMC guidance on sexual examinations
Offer a chaperone
Explain to patient why examination is necessary & what it will involve
Give patient privacy to undress & dress
Obtain patient’s permission before the examination - discontinue if patient asks you to
Keep discussion relevant - avoid unnecessary comments
GMC guidance on examinations
Offer a chaperone
Explain to patient why examination is necessary & what it will involve
Give patient privacy to undress & dress
Obtain patient’s permission before the examination - discontinue if patient asks you to
Keep discussion relevant - avoid unnecessary comments
Female genital examination
Inspect pubic area, labia majora & minora & perianal area
Inspect & palpate inguinal region
Leg rests - allow better visualisation
Speculum examination (use water as lubricant - gels can interfere with tests)
Bimanual examination (if indicated)
Male genital examination
Inspect pubic area, inguinal region
Inspect scrotum & perianal area
Palpate scrotal contents – note presence of testes, any lumps/ tenderness
Inspect penis - record whether circumcised - if not inspect under foreskin
Particular attention to coronal sulcus, frenulum & meatus
Note presence of urethral discharge
Normal appearance mistaken for abnormalities by patient
pearly penile papules - coronal papillae
Fordyce spots - visible sebaceous glands present in most individuals
vaginal papules/papillomatosis
Genital enlarged sebaceous glands
Other conditions presenting with genital signs
Malignant melanoma
Psoriasis
Tinea cruris - dermatophyte (fungal) infection
pruritic papules - Lesions and burrows in finger webs and wrist due to scabies
Bacterial/protozoal STIs
Chlamydia, gonorrhoea, syphilis, trichomonas more often florid symptoms early presentation rapid diagnosis effective treatment available curative reservoirs can be controlled
Viral STIs
Herpes, warts, HIV, hepatitis many unaware of infection delayed presentation diagnostic tests may be unreliable symptomatic treatment only often life-long expanding reservoirs
Gonorrhoea and chlamydia commonly cause
Dysuria and discharge
The incubation period is 2 to 30 days with most symptoms occurring between 4-6 days after being infected
primary syphilis
1-3 weeks after contact (9-90 days), red mark -> raised spot -> ulcer at the site of contact
Enlarged lymph nodes in the groin/neck, heals within 1-3 weeks (with or without treatment)
Lesions aren’t painful
Secondary syphilis
2-6 weeks after 10 stage - lasts for 2-4 weeks
Systemic dissemination - millions spirochaetes spread through-out the body
Flu-like illness, headache, lymphadenopathy
Mouth ulcers - “snail track” painless
Condylomata lata - white/grey lumps in moist areas
Arthritis
Rapid resolution with effective treatment
Particularly suspect if rash involves palms & soles
Trichomonas vaginalis
Single cell protozoan parasite
Infects vagina & urethra
Dysuria, discharge
Causes frothy discharge, “strawberry cervix”
Diagnosed by seeing motile organisms on microscopy
Responds well to metronidazole
Genital warts
Extremely common, human papilloma virus (HPV)
Type 6 & 11 in 90%
Vs types 16 & 18, 31, 33 etc. (cervical cancer)
The number of diagnoses of anogenital warts has declined since 2009, most notably among women. The decline can partly be attributed to the moderately protective effect of HPV 16/18 vaccination against anogenital warts in young women.
Herpes simplex virus
Symptoms
painful ulceration, dysuria, vaginal discharge
systemic symptoms e.g. fever and myalgia (more common in 10)
Signs
blistering & ulceration (+/- cervix/rectum)
inguinal lymphadenopathy
Only 20% of people are aware that they have genital warts
Non-sexually transmitted infections
Candida/thrush
Bacterial vaginosis
Candida/thrush
fungal
itching, discharge, swelling
papular rash in males
topical antifungals
Bacterial vaginosis
discharge / “fishy” odour imbalance of vaginal flora overgrowth of anaerobes often result of over-washing / bubble baths etc. responds to metronidazole
complications of chlamydia/gonorrhoea
PID, epididymitis, infertility, chronic pain, Reiter’s syndrome (urethritis, arthritis, conjunctivitis)
HPV/warts complications
cervical cancer, AIN, VIN, PIN
Bacterial vaginosis
miscarriage, early labour, low-birth wt
Trichomonas vaginalis complications
miscarriage, early labour, low-birth wt
Syphilis complications
dementia, cardiac abnormalities etc etc
Hep B, Hep C complications
cirrhosis, liver cancer
HIV complications
long term morbidity & mortality opportunistic infections, tumours, non-AIDS malignancies
