Sexual Health Flashcards
What is important in terms of Consent and confidentiality for sexual health histories?
Confidentiality - If young person does not want parents or guardians involved, doctor should explain the possible benefits of having parents informed, but respect the young person’s wishes, views and confidentiality if they do not wish for parental involvement.
Consent - Young people <16 involved in sexual activity should be questioned to elicit whether sexual activity is voluntary, to ensure there is no coercion (particularly when there is a disparity of age), sexual exploitation, rape, or other sexual abuse.
Where sexual abuse is suspected or disclosed the clinician must work with the young person to support them and address the possible sequelae of STIs, pregnancy, psychological, and psychosexual issues.
The clinician has a duty to disclose the information to child protection services but should seek the young person’s agreement wherever possible.
The law permits the disclosure of confidential information necessary to safeguard a young person. Legal advice should be taken in doubtful cases.
Disclosure against the young person’s wishes is dealt with in the General Medical Council (GMC) guidelines Confidentiality: Protecting and Providing Information, in the British Medical Association (BMA) publication Consent, Rights and Choices in Health Care for Young People, the Children Act, and the Department of Health (DOH) document Medical Responsibilities.
In practice, the clinician must take into account both the need of the young person for a confidential sexual health service and the need to protect that young person from sexual abuse and sexual exploitation. The clinician also has a duty to consider the possibility that other young people may be at risk of abuse.
What are key questions to ask when taking a Sexual health history?
- https://www.bashhguidelines.org/media/1078/sexual-history-taking-guideline-2013-2.pdf
Identify high-risk groups, types of swabs to take, at risk contacts
- Presenting complaint
- History of presenting complaint –leave until last
- Previous medical history (to include surgical, obstetric, gynaecology (smear), sexually transmitted diseases, vaccinations e.g. HEP B)
- Drugs/allergies
- Systems review
- Family history
- Social history
Presenting complaint
Symptoms - duration, associated features
Male • Urinary – dysuria • Urethral discharge • Testes – pain, swelling • Rectal samples – blood, mucus, rectal pain (MSM)
Women • Urinary - dysuria • Vaginal discharge – colour, smell, amount • Bleeding – intermenstrual / postcoital • Lower abdominal pain • Dyspareunia – superficial, deep • Menstruation • Pregnancy?
Both
• Skin changes i.e. rash, spots, sores, blisters, lumps
‘These are questions we ask everyone who presents with a vaginal discharge. Do you mind if I ask them?’
‘I need to ask you these sensitive questions so that I know where I need to take swabs from’
‘I need to ask questions about your partners so we can decide who else may need treatment
PMH
• Pregnancy/terminations/miscarriages
• Smears
• STIs
DHX
• Contraception
• Allergies
Last sexual contact
• When
• With whom – male/female, regular (duration of relationship) or casual
– Type of sex – oral (oropenile, orovaginal, oroanal), anal (insertive and/or receptive), vaginal, digital contact
– Condom use with each type of sex, ?every time ?any condom accidents
– Sex toys/rimming etc.
Similar details of all sexual partners over previous 3 months – ‘when did you last have sex with some one who was not the person you have just told me about?’
Risk assessment
Have you/has anyone you have had sex with
• Known HIV / positive partner
• IVDU
• MSM
• Sex with someone who was born outside of the UK (Africa, Asia, Eastern Europe due to IVDUs)
• Commercial sex worker (CSW) (have you ever paid for or been paid for sex)
What questions do you ask as part of a HIV risk assessment?
- Introduce yourself, say you’re a medical student, ask consent
- Explain why you’re talking to them
- Name, age, occupation, relationship status
- Explain confidentiality
- Why have they come today?
- Do they have any symptoms?
- Why do they think they need a test? - First would like to assess risk factors
- Have they ever had a partner they know/think is HIV positive? Were condoms used
- Have they ever had sex with a man or a bisexual man
- Have they ever had sex with anyone born outside the UK (Caribbean, Africa, south east Asia, Indian subcontinent, Russia) or who has lived in a high risk area
- Have they had sex outside the UK
- Have they ever injected drugs or slept with someone who has?
- Have they ever paid for sex or been paid for sex?
- Ever had a blood transfusion or medical treatment abroad - How much do they know about HIV/AIDS
- Difference between the two
- Incurable but important to detect early - Is it a good idea to get tested?
- Gives peace of mind if negative
- If positive can help prolong good health, support, advise about safe sex
- May be anxious when waiting
- If you are positive may be anxious and worried about telling people
- May limit insurance (negative tests don’t affect anything) - What does the test involve?
- Blood test
- Result should take 48-72 hours
- May then ask you to come back in to get the results
- If they’re high risk get them to come in anyway - Window period
- May take 3 months before antibodies can be detected
- If the specific contact worried about was over 3 months ago then only need one test
- Otherwise will need another test in 3 months time. - Confidentiality; doesn’t go in GP notes
- Would they like to have the test?
- Offer them a full screen
- May also be at risk for other infections
- Blood test to also look for syphilis and Hep B+C
- Swabs for Chlamydia and Gonorrhoea - Will arrange for it to be done
- Give them a leaflet and a follow-up appointment
- Thank you
What should you do about Partner notification?
- Arrangements should be in place for the management and treatment of all sexual partners of clients found to have an STI.
- Clients and partners should abstain from sexual intercourse until treatment has been completed. Contact tracing of perpetrators is a complex issue which should be addressed if possible with the help of a Health Advisor who can arrange provider referral if appropriate.
- This will require discussion with the client about our duty of care towards the client, the assailant and respective partners/sexual contacts.
- Contact tracing can be arranged via the investigating police officer bearing in mind that positive STI may have evidential potential and will require demonstrating a chain of evidence.
What should you do when you are made aware of Sexual assault?
Follow up after sexual assault –
- Offer first HIV PEPSE follow-up appointment before starter pack finishes (usually 3-5 days) and carry out baseline bloods if not already done, review the wish to continue, side effects and compliance followed by weekly (if problems) or two weekly (if no problems) follow up appointments until completion of the course (41, 52)
- Offer STI screening at baseline and/or 2 weeks after the alleged assault.
- Do baseline bloods for syphilis, hepatitis B and C depending on risk assessment at first follow up appointment
- Offer hepatitis B vaccination within 6 weeks of assault (45, 57, 58, 59) and complete within the timeframe dictated by chosen schedule
- Carry out risk identification (child protection, self-harm, domestic violence)
- Carry out pregnancy testing where and when applicable Review psychosocial needs and coping 22
- Use of 4th generation HIV tests (for both HIV antibodies and p24 antigen) is recommended
- Offer HIV test at 3 months post assault (or 3 months post completion of HIV PEPSE if given)
- Consider HIV test 1 months post high-risk exposure if 4th generation HIV tests are used (60) Offer serological tests for hepatitis B, C and syphilis at 3 months post assault.
- Consider repeating tests at 6 months for Hepatitis B and HIV as late seroconversion has been documented
Pregnancy prevention –
- Copper intrauterine contraceptive device (CuIUD)
- Hormonal emergency contraception
Pregnancy following sexual assault -
If a pregnancy test is positive, discuss options which include:
- Continuing with the pregnancy
- Termination of pregnancy
- Paternity testing
- Using products of conception as evidence
What is Genital discharge?
Excessive vaginal discharge can be physiological or pathological
Defined as any one of the three presentations-
• Excessive vaginal discharge not associated with menstruation; pre, mid and post period.
• Offensive or malodorous discharge
• Yellowish or mucopurulent discharge
What are the causes of Genital discharge?
CAUSES- • Physiological – 1-4mls per 24hrs, white/clear, non-offensive odour, varies with menstrual cycle o Age dependent Neonate and infant Pre puberty Child bearing Post-menopausal o Excessive secretion Pregnancy or sexual arousal • Pathological - o Non infective: Chemical irritation • Antiseptics, bath additives, perfume soaps Foreign bodies • Retained tampons Cervical ectopy o Infective: causes cervicitis Non-STI (vaginal): bacterial vaginosis, candida STI: • Trichomonas vaginalis (vaginal)
What question do you needs to ask when taking a Hx of Genital discharge?
HISTORY -
• Source of discharge must be determined- Perineal discharge could originate from vagina, cervix, urinary tract and rectum
• Ascertain the following attributes of the discharge: quantity, duration, colour, consistency and odour
• Symptoms include
o itching or burning . External Dysuria, Dyspareunia
• Prior similar episodes
o Sexually transmitted infection
o Sexual activities
o Birth control method
o Last menstrual period (ALWAYS assess pregnancy risk before treating)
o Douching practice and other RFs
o Antibiotic use
o General medical history
Systemic symptoms such as lower abdominal pain, fever, chills, nausea, and vomiting
What is the treatment for Genital discharge?
Treatment of individual causes: (REST are below)
• Eczema / psoriasis- moderately potent topical steroid e.g. Betnovate cream
• Lichen planus- usually self-limiting
• Lichen sclerosis- potent topical steroid. Requires long term follow up as small risk of malignant transformation.
• Scabies/pubic lice- Topical Permethrin and treat all household/sexual contacts
*Arrange urgent admission for women with pelvic inflammatory disease (PID) who are pregnant, pyrexial and unwell, or unable to take oral fluids or medications.
What are the causes of Bacterial vaginosis?
o Commonest cause of abnormal discharge in women of child-bearing age
o In healthy vagina, lactobacilli dominant + low levels of other bacteria = pH <4.5
o In Bacterial vaginosis, pH >4.5-6.0 as flora dominated by anaerobic bacteria (lactobacilli may be present)
What are the Risk Factors of Bacterial vaginosis?
vaginal douching, black, smoker, receptive cunnilingus, recent change of sexual partner, presence of STI
What are the clinical features of Bacterial vaginosis?
- 50% asymptomatic):
o Offensive fishy smelling vaginal discharge
o Increased volume, thin, watery, white
o Not assoc. with soreness, itching, irritation or signs of inflammation
What are the investigations for Bacterial vaginosis?
- Outpatient/GP: typical Sx, pH >4.5, low vaginal swab to lab
- GU: low vaginal swab, Hay/Ison criteria Gram stained vaginal smear
What is the treatment for Bacterial vaginosis?
- General advice: avoid vaginal douching and antiseptic agents/bath products
- Treatment: PO/topical metronidazole – Sx women, undergoing certain surgeries, pt. choice (if lactating = topical); no Rx of sexual partner needed
o Oral = metronidazole 500mg BD 7 days OR clindamycin 300mg BD 7 days
o Topical = 0.75% metronidazole gel 5 days OR clindamycin cream 2% 7 days
What are the complications of Bacterial vaginosis?
↑incidence in PID, cellulitis/abscess following TV hysetercomy, late miscarriage, preterm birth, PRoM and post-partum endometritis
What are the causes of Candida?
- Candida albicans 90-92%
- Non-albicans species – e.g. C. glabrata/topicalis/krusei etc (poor Rx response )
What are the Risk Factors of Candida?
immunosuppression (inc. pregnancy, diabetes), Abx use, elevated oestrogen
What are the clinical features of Candida?
o Vulval itch, soreness
o Erythema, oedema, fissuring and excoriations
o Satellite lesions
o Thick vaginal discharge
o Superficial dyspareunia and external dysuria
o 10-20% of women in reproductive years colonized but asymptomatic = no Rx required
What are the investigations for Candida?
- NOT usually done – Rx based on Sx
o If no response to Rx/doubt over diagnosis = microscopy of gram-stained vaginal slide and culture of low vaginal swab asking for yeast sensitivities
What is the treatment for Candida?
- General advice: routine use of soap substitute + regular emollient, avoid tight fitting synthetic clothes + local irritiants
- Treatment: clotrimazole pessary 500mg stat OR fluconazole 150mg PO stat (oral C/I in pregnancy = 7 days of topical azole) – depends on preference/availability; no need to Rx asymptomatic male partners (consider asking re/ contraception)
What is Dysuria?
Painful or difficult urination, due to irritation to bladder or urethra
What are the causes of Dysuria?
Stones, infection, indwelling catheter
May suggest a UTI
What are the clinical features of Dysuria?
Burning sensation when urinating
What is the treatment for Dysuria?
Treatment of dysuria depends on its cause:
o Cystitis and pyelonephritis — These infections, usually caused by bacteria, can be cured with antibiotics taken by mouth. Antibiotics may be given into a vein (intravenously) for severe pyelonephritis with high fever, shaking chills and vomiting.
o Urethritis — Urethritis is treated with antibiotics. The type of antibiotic used depends on which infection causes the urethritis.
o Vaginitis — Trichomoniasis and bacterial vaginosis are treated with antibiotics. Yeast infections are treated with antifungal drugs, either as a pill by mouth or as a suppository or cream inserted into the vagina.
If you are sexually active and are being treated for dysuria caused by a sexually transmitted disease, your sex partners must be treated, too.
What are the causes of Trichomoniasis Vaginalis?
Ulcers usually caused by sexually transmitted diseases such as genital herpes, syphilis, chancroid, or Chlamydia trachomatis. Non sexual causes – • Fungal – vulvovaginal candidiasis o burning during sex and urination o itching o increased vaginal discharge • Viral, bacterial infections • Inflammatory disease - Crohns disease
What are the clinical features of Trichomoniasis Vaginalis?
• Sometimes with enlarged groin lymph nodes • Painful o Chancroid o Genital herpes simplex • Painless o Syphilis o Lymphogranuloma venereurm o Granuloma inguinale
What is the treatment for Trichomoniasis Vaginalis?
• STIs are typically treated with antibiotic and antivirals – acyclovir
• Non infection caused –
o corticosteroids
o antihistamines
o immunomodulatory drugs, such as methotrexate
What are the causes of Trichomoniasis Vaginalis?
• Infection found in vagina, urethra and paraurethral glands of female
• Trichomonas vaginalis – flagellated, anaerobic protozoan
o Motile flagellate protozoa seen.
• WBC often present
What are the clinical features of Trichomoniasis Vaginalis?
• 10-15% asymptomatic – especially in men
• Profuse, offensive, greenish/grey, frothy discharge
• Vaginal and vulval irritation/itch
• Superficial dyspareunia
• Dysuria
EXAMINATION:
• Pelvic:
• Inspection:
• Vaginal discharge and vulval erythema (vulvitis and vaginitis)
• 2% strawberry cervix
• Cusco speculum:
• Cervicitis
• Erythematous, punctuate appearance of a cervix (strawberry cervix/colpitis macularis)
What are the investigations for Trichomoniasis Vaginalis?
- Diagnostic:
- Vaginal pH >5.0
- HVS for direct microscopy and culture in a Trichomonas medium = vulvovaginal NAAT
- Swab from posterior fornix at speculum exam for wet mount microscopy = trichomonads seen (pathognomonic)
- STI screen:
- HVS (BV, Candida albicans)
- Endocervical swab (Neisseria gonorrhoea, Chlamydia trachomatis)
- Blood tests for HIV, syphillis and hepatitis B (abundance of leukocytes)
What is the treatment for Trichomoniasis Vaginalis?
- Advice:
- Contact tracing, treat contacts at same time, contraception advice: avoid sex for 1wk and until partners completed Rx
- Medical:
- Metronidazole (2g PO stat dose OR 400mg BD 5-7 days – option for male contacts) OR Tinidazole 2g orally single dose Met usually cures 90% of ppl after first dose
- Repeat swab 7 days after completing treatment
- Follow-up examination after 2 m.
- Rx failure consider compliance, exclude vomiting of metronidazole, sexual Hx ?reinfection, resistance
What are the Risk Factors of Trichomoniasis Vaginalis?
Sexual contact (almost exclusively)
