GUM Flashcards
STI vs STD
STI refers to a pathogen that causes infection through sexual contact,
whereas the term STD refers to a recognisable disease state that has developed from an infection
STIs trasmitted non-sexually
- mother to infant during pregnancy or childbirth (Gonnorhoea, HIV, syphilis and chlamydia)
- blood transfusions
- shared needles
cause of gonorrhoea
Neisseria gonorrhoea (bacteria)
cause of chlamydia
chlamydia trachomatis (bacteria)
cause of syphilis
treponema pallidum (bacteria)
cause of genital warts, cervical cancer
human papilloma virus HPV (virus)
LT complications of STIs
– PID
- ectopic pregnancy
- postpartum endometriosis
- infertility
- chronic abdominal pain
– adverse pregnancy outcomes (including abortion, intrauterine death, and premature delivery)
– neonatal and infant infections and blindness
– urethral strictures and epididymitis in men
– CV and neurological damage
– cancers - HPV cervical and rectal cancer
– arthritis
what STI has highest risk of resistance
gonorrhoea
SHS - sexual health services
level 1 = asymptomatic
level 2 = symptomatic
level 3 = complex/specialist
level 1&2
– GP’s
– Some pharmacies
– SRH services
– Young people’s services
– online sexual health services
level 3
- GUM and SRH (sexual and
reproductive health) services
general services SHS provide
– sexual Hx taking & risk assessment
– STI screening and Tx
– advice and supply of regular and EC
– condom distribution
– signposting to appropriate sexual health services
– sexual assault services/referral
– Hepatitis A and B vaccines & screening
– HIV screening
– cervical screening
– post-exposure prophylaxis (PEP) –specialist
services pharmacies can offer (level 1 SHS)
- sexual health advice, signposting & campaigns
- EHC
- ongoing contraception via PGD or OTC
- chlamydia screening and Tx from age 15-24
- condom distribution via sale or C-Card
- STI kit “click and collect” service
- pregnancy testing
- preconception care
- Supply of ED Tx
- HPV vaccine
highest risk groups
- 15-24 years
- people from, or who have visited countries with high
rates of HIV +- other STIs - MSM
- multiple/concurrent partners
- early onset sexual activity previous bacterial STI
- contact of STI
- people with sexual partners from groups mentioned
above - alcohol or substance abuse
- IV drug use
principles of safe sex
education
- on transmission of STI’s
partner reduction
- spread of STI’s depends on the rate of change of sexual partners, esp concurrent partners
Condom
Repeat testing
- screening for asymptomatic STIs should be recommended at least annually & 3 monthly if high risk of HIV
Vaccination
- HPV, hepatitis
HIV Pre-exposure Prophylaxis (PrEP)
Condom distribution services (CDS)
C-card is the most common CDS
- targets up to age of 19yrs (24 yrs in some areas)
also involves:
* discussion around condoms (& how to use)
* safe sex
* contraception
* STIs
Under 13’s
– Not legally able to consent to sexual activity
– Document circumstances
– Discuss with Child Protection lead, and record conversation
13-16years
- Consider potential harm to child
- Consider informing Child protection lead
U6yrs
always assess Fraser guidance
16- 17 year-old
– Over 16’s have the right to independence
– However, the law defines a child as <18 years old
– Even though over age of consent they should be treated as children and offer children safeguarding support if needed
18 year-old and over
assumed to be competent with capacity to consent unless otherwise suggested
signs of vulnerability and alerting features
- Learning disability;
- Older “boyfriend”
- Young person not permitted to be seen without partner
- Use of drugs and/or alcohol
- Homelessness
- Association with other young people believed to be in exploitative relationships
- Young people in care
- Young person presented with gift/cash by partner after accessing pharmacy
- Multiple presentations for EHC/STD Tx or pregnancy tests
- Any features of abuse within relationship
- Migrant children (trafficking)
- Any evidence that sexual activity was not consensual
when taking Hx for STI screening
- reason for attendance
- Hx of presenting problem (if symptomatic)
- full sexual Hx
- relevant PMHx, incl previous STIs
- vaccine Hx - Hep B
- drug Hx (incl recreational)
- allergies
- menstrual, contraceptive & obstetric history
- date & outcome of last cervical cytology
sexual Hx - asymptomatic
- confirm lack of Sx
- establish competency, safeguarding children/vulnerable adults
- date of last sexual contact (LSC) and number of partners in the last 3mths
- gender of partner, anatomic sites of exposure, condom use, suspected infection, infection risk or symptoms in partners
- previous STIs
- women: Last menstrual period, contraceptive and cervical cytology Hx
- blood borne virus risk assessment and vaccination Hx if at risk
- alcohol and recreational drug Hx
- agree the method of giving results
Sexual history - Symptomatic, additional Qs
- Symptoms/reason for attendance
- Pregnancy and gynaecological history if indicated
- PMHx, surgical Hx
- Medication Hx and Hx of drug allergies
- Agree the method of giving results
transmission of chlamydia
– Primarily through penetrative sex
– Contact with infected genital secretions
– Autoinoculation of infected secretions onto mucous membranes
– Splash from genital fluids
– From mother to baby at delivery
complications of chlamydia
– PID (women)
– Epididymo-orchitis (swelling of testicles and/or epididymis) (men)
– Conjunctivitis
– Lymphogranuloma venereum (LGV) (men)
– Sexually acquired reactive arthritis (SARA)
– Adverse outcomes in pregnancy - premature delivery, low birth weight, infections in neonates
– Anxiety and psychological distress
% asymptomatic with chlamydia
70% female
50% male
Chlamydia risk factors
- Age under 25 years
- A new sexual partner
- More than 1 sexual partner in the last year
- Lack of consistent condom use
Chlamydia - symptoms female
- Vaginal discharge
- Dysuria
- Vague lower abdominal pain
- Fever
- Intermenstrual or postcoital bleeding
- Deep dyspareunia
- Pelvic pain/tenderness
- Cervical motion tenderness
- Inflamed or friable cervix
Chlamydia - symptoms male
- Men tend to have either classical urethritis with
dysuria and urethral discharge
or - Epididymo-orchitis presenting as unilateral testicular pain ± swelling
- Fever may also be a feature in men.
- Reactive arthritis
Chlamydia Screening
Nucleic acid amplification tests (NAATs)
– Highly specific and sensitive
– Women: vulvovaginal swab (1st line)
- Alternatives: 1st void urine sample or endocervical swab
– Men: 1st void urine sample (1st line)
chlamydia Tx
FIRST LINE: Doxycycline 100 mg BD for 7 days
– c/i in pregnancy & bf
– GI side effects common
– photosensitivity
ALTERNATIVES:
– Azithromycin 1 g orally as a single dose for 1 day, followed by 500 mg orally OD for 2 days
– Erythromycin 500 mg BD for 10–14 days
– Ofloxacin 200 mg BD for 7 days
AMR and chlamydia
used 1g single dose azithromycin (SDA) or 7 days doxycycline
Mycoplasma genitalium (MGen) - emerging, significant sexually transmitted pathogen, can get co-infection with chlamydia
inc prevalence of macrolide resistance in MGen, because of use of SDA to treat STIs
SDA less effective than doxycycline
SDA no longer recommended
Tx for chmalydia in pregnancy
- Azithromycin 1g stat followed by 500mg for 2 days
- Erythromycin 500mg twice daily for 14 days
- Amoxicillin 500 mg three times a day for 7 days
** doxycycline and ofloxacin are c/i
Chlamydia – follow up
- Avoid sexual intercourse (incl oral sex) until the person & partner completed treatment (or waited 7
days after Tx with azithromycin) - Failure of Tx can be due to re-infection
- Screen for other STIs
- Refer to a GUM clinic for partner notification.
– Symptomatic males – all partners within 2 weeks
– Asymptomatic - preceding three months should be
notified
test for cure with chlamydia
A test of cure not routinely recommended
transmission of gonorrhoea
– Sexual contact where infected secretions are passed from one mucous membrane to another
– During childbirth
Sx of disseminated gonorrhoea
skin lesions
arthralgia
tenosynovitis
arthritis
complications of gonorrhoea
– Men – Epididymitis, prostatitis, infertility
– Women – PID + dangers in pregnancy
– Babies – blindness
gonorrhoea Sx - female
gonorrhoea Sx - female
Genital gonorrhoea infection is
usually symptomatic in men
* Urethral discharge
* Dysuria
Rectal and pharyngeal –
asymptomatic
gonorrhoea screening
- A NAAT for the presence of N. Gonorrhoea
Women: vulvovaginal swab
Men - 1st pass urine sample
- Culture required if patient is NAAT positive for gonorrhoea - to test for susceptibility and ID resistant strains
AMR and Gonorrhoea
- No class of antimicrobials where resistance hasn’t developed
- Strains of MDR are evident
- ‘Super gonorrhoea’ - resistant to the most common antibacterials
- change 1st line Tx: Tx was dual therapy of ceftriaxone with azithromycin
- Ceftriaxone resistance remains rare in the UK
Gonorrhoea - treatment
** Tx ideally based on susceptibility
susceptibility is not known:
- Ceftriaxone 1 g IM injection as a single dose
- safe when pregnant/bf
susceptibility is known:
- Ciprofloxacin 500mg orally as a single dose
- pregnancy/bf: Azithromycin 2g orally as a single dose
disseminated Gonorrhoea - treatment
- Ceftriaxone 1g IM or IV every 24hrs
- Cefotaxime 1g IV every 8hrs
24-48 hours after Sx begin to improve switch to
* Cefixime 400 mg twice daily
or
* Ciprofloxacin 500 mg twice daily
(switch should be made guided by sensitivities)
Gonorrhoea - follow up
- Avoid sexual intercourse (including oral sex) until Tx completed (or waited 7
days after Tx with azithromycin) - Follow up about 1 week after Tx to:
- confirm adherence to Tx and Sx resolution
- ask about adverse reactions
- confirm that partner notification has been carried out
- ask about recent sexual Hx (and the possibility of reinfection)
- reinforce advice about safe sexual practice
TEST FOR CURE recommended for all people treated for gonorrhoea
- asymptomatic - test with NAAT at least 2 weeks after completion of Tx
- Sx - test with culture, at least 3 days after completion of Tx
- consider additional testing with NAAT after one week if culture is -ve
- GUM clinic notification - as for chlamydia
- notified partners - test and treat empirically whilst awaiting results
- advice on safer sexual practices, contraception and condom use
What is HPV?
DOUBLE STRANDED dna VIRUS
high risk types of HPV that cause cancer
HPV16
HPV18
HPV vaccination
Cevarix - used until 2012
- Bivalent - protects against 2 strains HPV16 & HPV18
Gardasil
- quadrivalent vaccine - protects against 4 strains HPV16, HPV18, HPV6 & HPV11
Gardasil 9
- 2021-22 vaccine programme
- same as Gardasil + also HPV31, HPV33, HPV45, HPV52
Immunisation schedule for HPV vaccine
- best effectiveness, vaccine must be given before the patient becomes sexually active
- usually 2 doses of the vaccine given 6 mths apart
- U15yrs 15:
- 1st dose of 0.5ml of HPV vaccine
- 2nd dose of 0.5 ml 6mths (up to 24mths) after 1st dose
- O15yrs
- 3-dose schedule given at 0, 1, and 4–6mths
cause of genital warts
viral cause: HPV
ondylomata acuminata
transmission of genital warts
- direct skin to skin contact with a person who has clinical/subclinical HPV, or contact with genital secretions
- most common - sexual contact, but also peri-natally and from hand warts
- oro-genital transmission is also possible
- can also occur from contact with contaminated surfaces/objects
- auto-inoculation from one site to another common
Genital warts - symptoms
- Often asymptomatic
- Can be single, or multiple, and tend to occur in areas of high friction
- Lesions may be disfiguring or embarrassing
- Possible itching, bleeding or dyspareunia
- Present as soft cauliflower-like growths of varying size
- Less commonly - flat, plaque-like or pigmented
- Colour can vary from whitish to flesh-coloured to hyperpigmented to erythematous
- Usually less than 10 mm in diameter
Genital warts - Treatment options
- No Tx
- 30% warts disappear spontaneously within 6mths, not always indicated - Self applied Tx
- Podophyllotoxin 0.5% solution or 0.15% cream (Warticon)
- Imiquimod 5% cream (Aldara)
- Sinecatechins 10% ointment (Catephen) - Abrasive methods
- cryotherapy
- excision
- electrocautery - Specialist application
- trichloroacetic acid (TCA) 80-90% solution
Genital warts – Treatment choice
- All Tx have significant failure and relapse rates
- Choice of Tx is dependent upon the:
- type of warts - non-keratinised or keratinised
- no. & volume of warts
- response to previous Tx
- site of lesions
Genital warts - advice
- conflicting info on condom use
- HPV persists after clinical clearance of warts for very variable lengths of time
- Psychological distress is common - referral for counselling
- 20% have concurrent STIs
- Current partners and partners in the previous 6mths should be assessed
- Advice about smoking cessation should be given - better Tx response
Genital warts – follow up
- Review after completion of Tx
- Change treatment if:
- intolerant of the current Tx
- < 50% response to it by 4–5 weeks (8-12 weeks for imiquimod)
- Follow up 3mths after Tx if concern re recurrences (timeframe recurrence is likely)
- More frequent follow up if immunocompromised
Viral cause or herpes simplex
herpes simplex virus (HSV) 1 or HSV-2
Transmission of herpes simplex
- Infectious secretions on oral (HSV-1) , genital or anal mucosal surfaces (HSV-2)
- Contact with lesions from other anatomical sites
- Most HSV infections (80%) are transmitted by people who are unaware they’re infected
HSV - symptoms 1st episode
- Multiple painful blisters
- Lesions are usually bilateral & develop 4–7 days after exposure to HSV infection
- If symptomatic with lesions - report
headache, fever, malaise, dysuria, or
tender inguinal lymphadenopathy - Other symptoms include - vaginal/urethral discharge, local oedema
- Tingling/neuropathic pain in the
genital area, lower back, buttocks or
legs - Lasts up to 20 days
HSV - symptoms recurrent genital herpes
- Usually occurs in the same area and may be preceded by localized prodromal tingling and burning Sx 48hrs before the
appearance of lesions - Often less severe and last from 6-48hrs
- Systemic symptoms, fever & malaise are less common
- Lesions crust and heal in around 10
days
triggers for HSVreactivation
- Local trauma (sexual intercourse or surgery)
- UV light
- Physical illness, immunosuppression
- Smoking
- Drinking alcohol
- Tight clothing, nylon or Lycra underwear
- Stress
HSV – Tx 1st episode
ORAL ANTIVIRALS:
* start within 5 days of the start of the episode/while new lesions are forming for people with a first episode
* BASHH guidelines - first-line treatment should be five days of:
- Aciclovir 400 mg TDS
or
- Valaciclovir 500 mg BD
- Self care measures
** only helps with the episode
HSV – Tx recurrent episodes
- Supportive measures alone
- Antiviral therapy as required
- Suppressive therapy
Episodic Tx:
* BASHH advises short courses as options for 1st line therapy:
- Aciclovir 800 mg TDS for 2 days
- Famciclovir 1 g BD for 1 day
- Valaciclovir 500 mg BD for 3 days
Suppressive Tx for HSV
- Often indicated if >6 attacks per year.
- Usual treatment:
- Aciclovir 400 mg BD (or 200 mg QDS)
- Famciclovir 250 mg BD
- Valaciclovir 500 mg OD
- The suppressive effect takes 5 days of therapy to establish
- Discontinue after 12mths to reassess attack frequency (duration = 6-12mths)
- Suppressive Tx also reduces the risk of asymptomatic shedding
Supportive management of HSV Tx
- Saline bathing
- Oral painkillers
- Topical anaesthetics
- abstain until lesions cleared
- Pain on micturition (urination)
- vaseline
- micturition in a bath can help prevent urinary retention
- inc fluid intake to dilute urine
Supportive management of HSV Tx
- Saline bathing (prevent 2 infection)
- Oral painkillers
- Topical anaesthetics
- abstain until lesions cleared
- Pain on micturition (urination)
- vaseline
- micturition in a bath can help prevent urinary retention
- inc fluid intake to dilute urine
HSV – follow up
- Advise to refrain from intercourse when have active lesions
- Disclosure in relationships should be advised
- No cure for genital herpes
