Sexual History Flashcards
What is the structure of a sexual history?
- Confirm patients name, date of birth, occupation.
- “What can I help you with”
- Characterize complaint, ask patient if there’s anything they’re worried about and ask specifically about other sexual symptoms:
- Discharge different from normal
- Pain passing urine? Change in urinary frequency or nocturia
- Any unusual bleeding: between periods, after sex?
- Pain during or after sex
- Lumps / bumps / ulcers / sores
- Stomach pain
- History of Sexual partners. “I’m going to ask you some questions now about your sexual relationships now.
- Previous gynae history: Menstrual / Contraception use / Brief Obs history / Smears
- Have you ever been to the GUM clinic before?
- PMHx / FHx / DHx including allergies and recent Abx / SHx
- Risk assessment. “These questions are routine, and we ask them to everyone - they help us assess your risk for certain viruses such as HIV and Hepatitis.”
What are the key symptoms to elicit in a female sexual history?
- Discharge that is different from usual
- Skin changes around the vagina / itching
- Pain when you pass water / frequency / urinating at night
- Any unusual bleeding - after sex / between periods
- Pain during sex (superficial / deep), or general lower abdominal pain
- Lumps, bumps or sores
What are the key symptoms to elicit in a male sexual history?
- Discharge
- Pain passing water / urge / frequency / passing water at night
- Testicular problems - sore or swollen
- Abdominal pain
- Lumps / bumps / ulcers / sores
What questions should be asked regarding last sexual intercourse, and previous sexual partners?
This section of the history must be introduced.
“I’m going to ask you a few questions about your sexual health and sexual practices. I understand these questions are very personal, but they are important for your overall health”
- Are you sexually active?
- When was the last time you had sex?
- Oral / Anal / Vaginal?
- Was it with a man or a woman?
- Was it a one off, or a regular partner?
- Are they from the UK?
- Did you use condoms? Every time?
- Did your partner have any symptoms you were aware of.
Repeat for all recent sexual contacts. Phrase as “When did you last have sex with anybody else?”
What questions should be included in the risk assessment?
“Just so you know, I ask these questions to all of my adult patients, regardless or age, gender or marital status. It is important to help us assess your risk for viruses such as hepatitis and HIV.
- Have you ever had sex with another man, or been with a man who you know has had sex with other men?
- Have you or any of your partners ever injected drugs
- Have you or any of your partners ever paid for sex?
- Have you ever had sex with anybody from Afria or Asia?
- Have you ever had medical treatment abroad?
- Have you ever had an HIV test?
- Have you been vaccinated against hepatitis?
What is the test for chlamydia? What is the management?
Test
- First catch urine, for NAAT.
- If in doubt of diagnosis for discharge, may also swab and perform cultures, microscopy and NAAT for gonorrhoea.
Management
- Doxycycline or azithromycin. Azithromycin provided in a single dose therefore better if compliance may be an issue.
- Partner notification - partners within 6 months.
How are warts diagnosed? What is the management?
Diagnosis
Diagnosed on clinical grounds by inspection. If there is any doubt, they may be biopsied.
Management
- No treatment - most regress spontaneously, but take time
- Chemical agents: tricholoroacetic acid or topical podophyllin frequently used to physically destroy wart tissue.
- Interferon alpha: can achieve complete resolution, but is associated with side effects and recurrence.
- Surgery: excisional or ablative may be considered if medical therapy fails, or warts are ameenable. Cryotherapy can be performed in the office, laser or excisional therapy requires an operating room
- Patients should be informed that they may be infectious despite the absence of visible warts.
How is the diagnosis of herpes made? What is the management?
Diagnosis
- Swabs taken for PCR testing, although a negative result does not exclude herpes, as it may be too late in the attack.
- If any doubt, exclude syphillis (dark field microscopy)
- May be able to do direct fluorescence antibody, or specific serologic testing. PCR is useful for finding asymptomatic viral shedding.
Treatment
- Aciclovir 200mg x 5 /day for 5 days
- NSAID / laxative
- Sitz bath. Can urinate into bath if too painful.
- Counselling that HSV may recur, but secondary attacks are usually not as severe as primaries.
How is HIV diagnosed? What is the management?
Diagnosis
Based on detection of antibodies to HIV; 95% diagnosed by detection of p24 serum antigen by 6 weeks from time of infection. Antibodies are detectable in almost all infected patients if measured > 3 months from time of exposure.
Management
- Advice regarding contraception and safe sex practices.
- Refer to specialist, and commence HAART
- Advise PEPSE is available should be freely available in GUM clinics and A&E departments
- Contact tracing is difficult, but ideally all traceable at risk partners should be seen and counselled with a view to testing.
What diagnostic tests are performed in urethritis? What is the management?
Investigations
- First catch urine. A positive leukocyte esterase, or > 10 leukocytes per high powered field is consistent with urethritis. The sample is used for NAAT (nucleic acid amplification test), which is the most sensitive choice for identification of micro-organism
- Urethral gram stain: useful for identifying non-gonococcal urethritis; a gram-negative intracellular or extracellular diplococcus in urethral exudate suggests gonorrhoea.
Management
Ceftriaxone for gonorrhoea, doxycycline / azithromycin for chlamydia.
