STI

Question 1

most common STI in the UK

Answer 1

chlamydia

Question 2

RFs for chlamydia infection

Answer 2

<25
new sexual partner or more than one sexual partner in a year
lack of condom use

Question 3

female symptoms of chlamydia

Answer 3

often asymptomatic 
increased vaginal discharge
PCB
IMB
Dysuria 
Lower abdo pain 
Deep dyspareunia

Question 4

male symptoms of chlamydia

Answer 4

often asymptomatic
dysuria
urethral discharge

Question 5

symptoms of rectal chlamydial infection

Answer 5

usually asymptomatic
anal discharge
anorectal discomfort

Question 6

Ix of chlamydial infection

Answer 6

Men: first-pass urine once held for >1hour, the first 20 ml of the urinary stream should be captured as the earliest portion of the urine contains the highest organism load

Women: Vulvovaginal swab (can be self sampled) This is collected by inserting a dry swab about 2–3 inches into the vagina and gently rotating for 10 to 30 s. sensitivity 96–98%

Rectal and pharyngeal sampling should be routine in all men who have sex with men (MSM),considered in women who are sexual contacts of gonorrhoea andbe guided by an assessment of risk and symptoms in everyone else

The current standard of care for all cases, including extra-genital infections, is NAAT from urine or swab (as above)

Question 7

Mx for uncomplicated chlamydia

Answer 7

Treat with abx: 1st line: Doxycycline 100mg BD for 7 days.
2nd line: Azithromycin 1g orally as a single dose, followed by 500mg OD for 2 days

Abstain from sex - Patients should be advised to avoid sex (including oral sex) until they have been treated and their partner(s) have been tested +/- completed treatment (or wait seven days if treated with azithromycin)

Partner notification (PN) – 
Male cases with urethral symptoms: all contacts since, and in the 4 weeks prior to, the onset of symptoms
All other cases (i.e. all females, asymptomatic males and males with symptoms at extragenital sites): all contacts in the 6 months prior to presentation

Test of cure (TOC)
Not routinely recommended for uncomplicated chlamydia
Should be performed no earlier than 3 weeks (but ideally at around 6 weeks) after Rx because residual, nonviable chlamydial DNA may be detected by NAAT for 3–5 weeks following Rx
TOC is recommended in
Pregnancy
Where poor compliance is suspected
If symptoms persist
For those with rectal infection
Repeat testing should be performed 3–6 months after treatment in under 25-years olds diagnosed with chlamydia (not really TOC but they are high risk of repeat infection)

Question 8

female symptoms of gonorrhoea

Answer 8

The most common symptom (in about 50%): an increased or altered vaginal discharge
Lower abdominal pain (in about 25%)
Gonorrhoea rarely causes intermenstrual bleeding and menorrhagia
On examination, a mucopurulent endocervical discharge may be seen and easily induced endocervical bleeding may be present

Question 9

male symptoms of gonorrhoea

Answer 9

Symptoms occur in over 90%
Mucopurulent discharge and/or dysuria usually appearing 2-5 days following exposure
Rarely, testicular and epididymal pain

Question 10

Ix of gonorrhoea

Answer 10

Microscopy:
Microscopy allows direct visualisation of N. gonorrhoeae as monomorphic Gram-negative diplococci within polymorphonuclear leukocytes
Microscopy of urethral or meatal swab smears has good sensitivity (90–95%) in people with penile discharge and is recommended to facilitate immediate presumptive diagnosis in these individuals
Microscopy has only 37–50% and 20% sensitivity compared with culture for detecting gonorrhoea from endocervical and female urethral smears, respectively. The sensitivity of cervical microscopy compared to NAATs is approx 16%. Female urethral and cervical microscopy is therefore not routinely recommended
Ano-rectal smears and microscopy should be offered if rectal symptoms are present
Microscopy of pharyngeal specimens is not recommended

NAAT (The current standard of care for all cases, including extra-genital infections, is NAAT)
Men: first-pass urine: once held for >1hour, the first 20 ml of the urinary stream should be captured as the earliest portion of the urine contains the highest organism load
Women: Vulvovaginal swab: (can be self sampled) collected by inserting a dry swab about 2–3 inches into the vagina and gently rotating for 10 to 30s, sensitivity of 96–98%
Rectal and pharyngeal sampling should be routine in all men who have sex with men (MSM),considered in women who are sexual contacts of gonorrhoea andbe guided by an assessment of risk and symptoms in everyone else.

Culture:
The primary role of culture is for antimicrobial susceptibility testing, which is of increasing importance as antimicrobial resistance in N. gonorrhoeae continues to evolve and spread
All individuals with gonorrhoea diagnosed by NAAT should have cultures taken prior to treatment

Question 11

Management of gonorrhoea

Answer 11

Ensure gonorrhoea culture taken from infected sites

Treat with abx: 1st line: Ceftriaxone 1g IM stat (usually reconstituted with 3.5mls 1% lidocaine)
2nd line: Cefixime 400 mg orally as a single dose plus azithromycin 2 g orally (Only advisable if IM injection is contraindicated or refused by the patient. Resistance to cefixime is currently low in the UK)
Alternative 2nd line: Gentamicin 240 mg intramuscularly as a single dose plus azithromycin 2 g orally

Abstain from sex - Patients should be advised to abstain from sex (including oral sex) until 7 days after they have completed treatment or for 7 days after the partner has been treated (if this is required)

Inform partner and discuss partner notification (PN) –
All partners within the preceding 2 weeks (or the last partner if >2 weeks ago) of male patients with symptomatic urethral infection
All partners within the preceding 3 months of patients with infection at other sites or asymptomatic infection

Test of cure (TOC)
All patients diagnosed with gonorrhoea should be advised to have a TOC
The time to a negative TOC using NAATs is variable and there are limited data to inform optimum time to TOC. However, most individuals should be negative 14 days following treatment and this is what is commonly suggested

Cases of possible ceftriaxone treatment failure in England should be reported to Public Health England

Question 12

female symptoms of trichomoniasis vaginalis

Answer 12

10-50% asymptomatic
vaginal discharge
vulval itching
dysuria 
offensive odour
low abdo discomfort
2% have strawberry cervix

Question 13

male symptoms of trichomoniasis vaginalis

Answer 13

15-50% asymptomatic 
urethral discharge
dysuria
urethral irritation
urinary frequency 
rarely purulent urethral discharge or prostatitis

Question 14

complications of TV

Answer 14

There is increasing evidence that TV infection can have a detrimental outcome on pregnancy and is associated with preterm delivery and low birth weight

Question 15

Testing for TV

Answer 15

When to consider testing for TV:
Asymptomatic testing not routinely performed
Testing for TV should be undertaken in women complaining of vaginal discharge or vulvitis
Testing in men is recommended for TV contacts, and should be considered in those with persistent urethritis

Microscopy:
Detection of motile trichomonads by microscopy can be achieved by collection of vaginal (or urethral) discharge using a swab or loop, which is then mixed with a small drop of saline on a glass slide and a coverslip placed on top. The wet preparation should be read within 10 min of collection, as the trichomonads will quickly loose motility and be more difficult to identify.
Sensitivity is reported to be as low as 45–60% in women and lower in men, so a negative result should be interpreted with caution.

NAAT: offer the highest sensitivity for the detection of TV. They should be the test of choice where resources allow and are the current ‘‘gold standard’’
Females
Swab taken from the posterior fornix at the time of speculum examination.
Self-administered vaginal swabs have been used in many recent studies, and are likely to give equivalent results
Males:
First-pass urine once held for >1hour, the first 20 ml of the urinary stream should be captured as the earliest portion of the urine contains the highest organism load. This will diagnose 60–80% cases.

Culture: not routinely performed

Question 16

Tx of TV

Answer 16

Treat with abx:
1st line: Metronidazole 400mg twice daily for 5–7 days (generally 5 days is used)
Or
Metronidazole 2 g orally in a single dose (not typically used due to significant nausea)
Alternative Rx: Tinidazole 2 g orally in a single dose. (Tinidazole has similar activity to metronidazole but is more expensive)
Note all recommended treatment from same class of abx- however significant allergy to this class is uncommon, consult specialist in this instance
Note importance to advise patients to abstain from alcohol whilst on Rx and for 48hrs after due to significant side effects (nausea/vomiting)

Abstain from sex: Patients should be advised to abstain from sex (including oral sex) until 7 days after they and their partner(s) have completed treatment

Partner notification (PN):
Current partners and any partner(s) within the 4 weeks prior to presentation should be screened for the full range of STIs and treated for TV irrespective of the results of investigations

Test of cure (TOC)
Only recommended if the patient remains symptomatic following treatment, or if symptoms recur

Question 17

bacteria responsible for syphilis

Answer 17

Treponema pallidum

Question 18

symptoms of primary syphilis

Answer 18

Painless solitary ulcer
Indurated, firm base
Painless regional lymphadenopathy
Can be multiple, painful and purulent (usually extra-genital)

Question 19

symptoms of secondary syphilis

Answer 19

Rash

• Widespread mucocutaneous
• May be itchy
• Can affect palms and soles
• Mucous patches (buccal, lingual and genital)

Condylomata lata (highly infectious, mainly affecting perineum and anus)

Alopecia
Hepatitis
Splenomegaly
Glomerulonephritis
Neurological complications
Acute meningitis
Cranial nerve palsies
Uveitis
Optic neuropathy
Interstitial keratitis and retinal involvement

Question 20

Ix for syphilis

Answer 20

A full history is important to identify between:
Stages of syphilis
Previously treated syphilis
Non-venereal T. pallidum infection (yaws, pinta, bejel), which may have identical serological results

Examination:
If early disease (primary or secondary) suspected include the following, when indicated:
Genital examination
Skin examination including eyes, mouth, scalp, palms and soles
Neurological examination if neurological symptom elicited
If symptomatic late disease suspected (including suspected late congenital disease); clinical examination should be undertaken as indicated, with attention to:
Skin
Musculoskeletal system (congenital)
Cardiovascular system (for signs of aortic regurgitation)
Nervous system (general paresis: dysarthria, hypotonia, intention tremor, and reflex abnormalities;
Tabes dorsalis: pupil abnormalities, impaired reflexes, impaired vibration and joint position sense, sensory ataxia and optic atrophy
`

Question 21

Tests for syphilis

Answer 21

If possible chancre identified:
-Microscopy:
Dark ground microscopy: should be performed by experienced observers
Swab taken of the chancre and examined for spirochetes
Is less reliable in examining rectal and non-penile genital lesions and not suitable for examining oral lesions due to the presence of commensal treponemes
-PCR swab of chancre:
Can be used on oral or other lesions where commensal treponemes may also be present

Serology (to be used if chancre present or not):
Initial screening test: An EIA/CLIA, preferably detecting both IgM and IgG is the screening test of choice (cannot differentiate between types of T pallidum infection)
Confirmatory test if initial screening reactive: A quantitative RPR or VDRL should be performed when screening tests are positive
Note Treponemal screening tests are negative before a chancre develops and may be for up to two weeks afterwards

Example of syphilis serology in primary or early late syphilis: EIA positive, RPR 1:64 (the higher the RPR the “more active” the infection is)
Example of late latent/ tertiary/ previously treated or non venereal result: EIA positive, RPR non reactive

Question 22

Tx of syphilis

Answer 22

Before treatment administered a repeat RPR blood test should be taken to ensure baseline “reactivity” is documented to enable assessment of treatment response in future

Early syphilis (primary, secondary and early latent: ie syphilis acquired within the last 2 years) 
1st line: Benzathine penicillin 2.4 MU IM single dose (note reconstituted with 6-8mls 1% lidocaine and split into 2 IM injections one into R and one into L buttock)
2nd line: Doxycycline 100mg PO BD 14 days

Late latent, cardiovascular and gummatous syphilis (ie syphilis acquired >2 years ago or there is some doubt over timing of acquisition of syphilis)
1st line: Benzathine penicillin 2.4 MU IM once a week for 3 weeks (note importance of exact timing of doses 1 week apart)
2nd line: Doxycycline 100mg PO BD for 28 days

Neurosyphilis including neurological/ophthalmicinvolvement in early syphilis
Prednisolone 40-60mg PO OD for 3 days to start 24hrs before syphilis Rx PLUS
1st line: Procaine penicillin 1.8 MU–2.4 MU IM OD for 14 days plus probenecid 500mg PO QDS for 14 days
2nd line: Doxycycline 200mg PO BD for 28 days

Warn patient re Jarisch-Herxheimer reaction (An acute febrile illness with headache, myalgia, chills and rigours which self resolves within 24 hours)

Abstain from sex:
There is very little evidence to inform advice about the time sexual abstinence is recommended, however, patients should be advised to refrain from sexual contact of any kind until the lesions of early syphilis (if they were present) are fully healed and until 2 weeks following treatment completion

Partner notification (PN):
All patients should have PN discussed at diagnosis. The look-back period isas appropriate for their stage of syphilis
Follow up testing: Recommended clinical and serological (RPR or VDRL) follow-up is at 3, 6 and 12 months,then if indicated, 6 monthly until VDRL/RPR non reactive (ie negative) or serofast

Question 23

sign and symptoms of HSV

Answer 23

Symptoms:
The patient may be asymptomatic, and the disease unrecognised
Local symptoms: painful ulceration, dysuria, vaginal or urethral discharge
Systemic symptoms: much more common in primary disease: fever and myalgia

Signs:
Blistering and ulceration of the external genitalia or perianal region (cervix/rectum)
Tender inguinal lymphadenitis, usually bilateral
In recurrent disease:
It is usual for lesions to affect favoured sites.
Lesions may alternate between sides but are usually unilateral for each episode
Lymphadenitis occurs in around 30% of patients
Recurrent outbreaks are limited to the infected dermatome

Question 24

complications of HSV

Answer 24

Superinfection of lesions with candida and streptococcal species (typically occurs in the second week of lesion progression)
Autonomic neuropathy, resulting in urinary retention
Autoinoculation to fingers and adjacent skin e.g. on thighs
Aseptic meningitis

Question 25

Ix of HSV

Answer 25

PCR: (most common investigation used)
HSV DNA detection by polymerase chain reaction (PCR)- swab taken from ulcer
The confirmation and typing of the infection and its type, by direct detection of HSV in genital lesions,are essential for diagnosis, prognosis, counselling and management

Serology: (note not used routinely- often evokes more questions than answers!)
Testing for HSV type-specific antibodies can be used to diagnose HSV infection
The detection of HSV-1 IgG or HSV-2 IgG or both in a single serum sample represents HSV infection at some time
It is difficult to say whether infection is recent as IgM detection is unreliable and avidity studies are not commonly available
Value of routine screening remains to be established
Serology may be helpful in the following situations:
Recurrent genital disease of unknown cause
Counselling patients with initial episodes ofdisease (to help identify recent or established infection in order to aid counselling), includingpregnant women
Investigating asymptomatic partners of patients with genital herpes, including women who are planning a pregnancy or are pregnant, or couples concerned about possible susceptibility to transmission in possibly discordant relationships

Question 26

Tx of HSV

Answer 26

Treatment aim is to reduce duration and severity of symptoms

HSV is not “curable” but is manageable

Oral antiviral treatment:
Antiviral drugs are indicated within 5 days of the start of the episode, while new lesions are still forming, or if systemic symptoms persist
Topical agents are less effective than oral agents, combining oral and topical treatment is of no additional benefit over oral treatment alone
Preferred regimens: aciclovir 400 mg three times daily or valaciclovir 500 mg twice daily
Alternative short course treatment: Aciclovir 800 mg three times daily for 2 days or Valaciclovir 500 mg bd for 3 days

General advice:
Saline bathing 
Analgesia 
Topical anaesthetic agents, e.g. 5% lidocaine ointment to apply especially prior to micturition
Pass urine in the bath/shower

Reassurance and support: important to provide reassurance that 1st episode HSV will always be the worst and any future recurrences will be much less symptomatic

Question 27

mx of recurrent genital herpes

Answer 27

supportive therapy only
episodic antiviral treatments
suppressive antiviral therapy

Question 28

mx of HSV outbreak

Answer 28

Identify lesions from clinical examination and hx

Take HSV PCR swab from lesions (if not had previous confirmed dx)

Offer full STI screening (bloods for HIV/syphilis, swab (or urine in men) for GC/CT)

Discuss dx with pt (dx usually clinical)

In collaboration with pt decide on management which may consist of

• General advice only
• General advice and oral antiviral treatment

Abstain from sex: Abstinence from sexual contact is recommended during lesion recurrences or prodromes

Consider informing partner and discuss partner notification (PN):
Disclosure is advised in all relationships since this is associated with lower transmission risks

Offer ongoing support: (Diagnosis often causes considerable distress)
Herpes virus association: https://herpes.org.uk/
Health Advisor follow up

Follow up testing: not required

Question 29

symptoms of genital warts

Answer 29

Asymptomatic
Single or multiple lumps
Irritation or discomfort
Bleeding
Rarely, secondary infection
Commonly warts present as soft cauliflower-like growths of varying size but can be flat, plaque-like or pigmented

Question 30

diagnosis of genital warts

Answer 30

clinical

Question 31

mx of genital warts

Answer 31

General advice
Full explanation and reassurance (Genital warts remain one of the most common conditions treated in GUM clinics)
Screening for STIs
Condoms reduce risk of acquisition of HPV (30-60% reduction)
Stop smoking: smokers may respond less well to treatment
No changes to routine National Cervical Screening Programme are recommended

Treatment: Treatment choice depends on examination findings and patient preference.
No treatment may be an option as 30% patients will clear warts spontaneously. All treatments have significant failure and relapse rates, and can cause local skin reaction
Cryotherapy - Repeat at weekly intervals, will likely need at least 4 treatments (and often more). Is the only treatment suitable in pregnancy
Podophyllotoxin (Warticon® (cream) and Condyline®(solution) - Treatment cycles consist of twice daily application for 3 days, followed by 4 days rest, for 4-5 cycles
Imiquimod 5% cream - Apply three times weekly and wash off 6-10 hours later, for up to 16 weeks
Surgical Excision - Under local anaesthetic (rarely used)

Partner notification: Notification of previous sexual partner(s) is not recommended , current sexual partner(s) may benefit from assessment as they may have undetected genital warts, other STIs, or need an explanation or advice about HPV infection

Follow up: Review is recommended at the end of a treatment course to monitor response and assess the need for further therapy (in practise advice given to pt to return if ongoing warts visible after end of treatment course which is typically 4 weeks)

Question 32

symptoms of vulvovaginal candida

Answer 32

Vulval itch 
vaginal discharge (often described as thick, white like cottage cheese)
Vulval soreness or burning
Superficial dyspareunia
Erythema
Fissuring
Vulval swelling/oedema
Vaginal discharge; typically non-offensive and curdy (but may be thin or absent)
Excoriation marks.

Question 33

Is candidiasis an STI

Answer 33

NOPE

Question 34

Ix for vulvovaginal candida

Answer 34

Clinical diagnosis based on typical features
Microscopy:
Used in level 3 GUM services
A high vaginal swab (HVS) of the discharge taken for Gram stain
Fungal culture:
Not routinely performed in acute infection
To be considered in recurrent cases

Question 35

tx for vulvovaginal candida

Answer 35

1st line: Fluconazole capsule 150 mg as a single dose, orally
2nd line: Clotrimazole pessary 500 mg as a single dose, intravaginally
Clotrimazole (canestan) cream often used in addition to oral or pessary treatment for symptomatic relief of itch

Offer STI screening
Sex: no requirement to abstain from sex but may be advisable due to current vulval symptoms
Partner Notification: Not required
Follow up: Not required

Question 36

RFs for BV

Answer 36

Vaginal douching
Use of soap/shower gel/feminine products
Receptive cunnilingus
Black ethnicity
Recent change of sexual partner
Smoking
Presence of an STI e.g. chlamydia or herpes

Question 37

signs and symptoms of BV

Answer 37

Symptoms
Offensive fishy smelling vaginal discharge
Generally not associated with soreness, itching, or irritation
Many women (approximately 50%) are asymptomatic

Signs
Thin, white, homogeneous discharge, coating the walls of the vagina and vestibule

Question 38

Ix of BV

Answer 38

Microscopy- performed at level 3 GUM services

MC+S swab- if dx in doubt and no microscopy available

Question 39

Tx of BV

Answer 39

General advice:
Wash with water externally only, no soaps/shower gels etc
Can use emollient to wash
Stop douching
Shower rather than bath

Antibiotic Rx: not necessarily required, important to discuss with patient
1st line: Metronidazole 400mg twice daily for 5-7 days
OR Intravaginal metronidazole gel (0.75%) once daily for 5 days
OR Intravaginal clindamycin cream (2%) once daily for 7 days

Sex: no requirement to abstain from sex
Partner notification: not required
Follow up: not required

Question 40

signs and symptoms of PID

Answer 40

Symptoms:
lower abdominal pain, typically bilateral
deep dyspareunia
abnormal vaginal bleeding
abnormal vaginal discharge

Signs:
lower abdominal tenderness, usually bilateral
adnexal tenderness
cervical motion tenderness
fever (>38°C)

Question 41

Ix of PID

Answer 41

PID is a clinical dx and empirical antibiotic treatment should be considered and usually offered in any woman who has recent onset, bilateral lower abdominal pain associated with adnexal or cervical motion tenderness on bimanual examination, in whom pregnancy has been excluded
Microscopy: performed in level 3 GUM services to identify potential other causes of sx
STI screening: tests should be performed routinely for GC/CT/HIV/syphilis and mycoplasma genitalium if treating for PID
Pregnancy test: ALL women with lower abdominal pain MUST have pregnancy excluded whether they are on reliable contraception or not

Question 42

Tx for PID

Answer 42

1st line :
IM ceftriaxone 1gsingle dose plus
Oral doxycycline 100mg BD for 14 days plus
Oral metronidazole 400mg BD for 14 days

2nd line:
Oral ofloxacin400mg BD for 14 days plus
Oral metronidazole 400mg BD for 14 days
or
Oral moxifloxacin 400mg OD for 14 days 
** Ofloxacin and moxifloxacin should be avoided in patients who are at high risk of gonococcal PID because of increasing quinolone resistance in the UK**

Abstain from sex - Avoid sex (including oral sex) until they have completed the treatment course and current partner had testing +/- treatment

Inform partner and discuss partner notification (PN) –
Current male partners should be contacted and offered STI screening (particularly GC/CT)
Empirical therapy should also be offered to male partners e.g. doxycycline 100mg twice daily for 1 week
Other recent sexual partners may also be offered screening - tracing of contacts within 6 months of symptom onset is recommended but this may be influenced by sexual history

Test of cure (TOC):
Review at 72 hours is recommended, particularly if moderate or severe signs
Further review 2-4 weeks after RX may be useful to ensure:
Adequate clinical response
Compliance with oral antibiotics
Screening and treatment of sexual contacts
Awareness of the significance of PID and its sequelae
Repeat pregnancy test, if indicated

Question 43

complications of PID

Answer 43

scarring of the fallopian tubes, which can cause an increased risk of ectopic pregnancy
Infertility
Abscess formation in a fallopian tube and/or ovary
Chronic pelvic pain