Genito-urinary medical cases for discussion

1. Hot Topics in
Sexual Health
Mazin

2. Common Triggers
• Males & Females
– Vaginal / Penile soreness, itching, discharge
– Spots / sores in genitals, pubes
– Lumps / bumps / warts
– Infestations
– Partner has symptoms / contact slip
– Enquiries about HIV / syphilis / hepatitis

3. Gender specific
• Male specific
– Aching sore testicles
– Cracked foreskin
– Rash on glans penis
– Dysuria
– Testicular lumps /
changes
• Female specific
– Cystitis
– Late period
– Breakthrough bleeding
– Post-coital bleeding
– Pregnancy test request
– Dyspareunia
– Emergency
contraception

4. Barriers to effective history taking
• Time
• Environment
• Attitude
• Embarrassment
• Prejudice
• Language &
understanding
• Lack of experience
• Lack of confidentiality
• Inappropriate
questions
• Gender issues
between doctor /
patient
• Stereotypical
assumptions
• Lack of support from
colleagues
• Presence of partner /
friends / parents
‘It’s not my concern to ask’

5. Ways to overcome this
• General invitation to express concerns
• National recommendations
• Published research findings
• Established screening programmes
• National campaigns
• Direct approach
• Indirect approach

6. Last Sexual Contact?
• If the last contact <3 months ago, ask how
many in the last 6 months – this allows for
collection of details for partner notification
• It takes 3 months for serological markers to
become evident for syphilis, and 1 month for
HIV..

7. Underage.. Rationale?
• How old is your partner
• Did you agree to have sex/Were you happy to
have sex
• Is your regular partner aware of this other person
• Were you paid / did you pay for this sex
• Where did you have sex
• Do you feel that you could talk to your parents
about sex

8. Fraser Guidelines
• Health professionals may give contraceptive
and sexual health advice to young people
under 16 without parental consent, as long as
the young person is competent to understand
fully the implications of any treatment, and
therefore be able to make a choice regarding
the treatment proposed.
• The health professional must establish that all
of the following criteria are met:

9. Criteria
1. The young person understands the healthcare
professional’s advice
2. The healthcare professional cannot persuade the young
person to inform his or her parents or allow the
healthcare professional to inform the parents that he or
she is seeking advice
3. The young person is very likely to begin or to continue
having sexual intercourse with or without treatment
4. Unless he or she receives advice or treatment, the young
person’s physical or mental health or body are likely to
suffer
5. The young person’s best interest require the healthcare
professional to give the advice, treatment or both without
parental consent

10. Principles Of STI Management
It is important to appreciate the public health
issues in relation to STI care and management.
• Treatment of index patient
• Contact tracing and partner notification
• Investigation and treatment of partner
• Role of Health Adviser in a Genitourinary
Medicine (GU Med) clinic
• Safer sex and risk reduction advice

11. Legal and Confidentiality Issues
You should be have a knowledge of the following:
• ‘Fraser Guideline’competence
• Issues of confidentiality in relation to STI
diagnosis and care and GU Medicine clinics
• Definitions of rape and sexual assault and legal
age of consent to sexual intercourse
– (Sexual Offences Act, 2004-available at
http://www.homeoffice.gov.uk/)
• Area ‘Child Protection Team’

12. Case 1
• 22 F
• New onset PCB
• Unprotected sex multiple partners
• Worried about future pregnancies

14. Chlamydia
• Chlamydia trachomatis (types D – K)
– Lymphogranuloma venereum (LGV)
• Most common sexually transmitted disease,
affecting 5% of sexually active women aged
15-25 years old
• Multiple sexual partners, age <25 years,
history of STIs, low socioeconomic status
• Chlamydia is a major cause for infertility and
increases the possibility of ectopic pregnancy

16. Chlamydia
• Infections tend to be asymptomatic (75%),
although there can be increased vaginal
discharge (30%), dyspareunia, IMB
(intermenstrual bleeding), PCB (postcoital
bleeding), abdominal pain, dysuria
• In males, symptoms include mucopurulent
discharge and dysuria (asymptomatic in 25%)
• Epididymo-orchitis is a complication

17. Examination
• Abdomen: Lower abdominal tenderness
• Speculum: Cervicitis, cervical / urethral discharge
• Vaginal: May have tenderness / cervical
excitation
• A 'cobblestone' appearance of the cervix may be
noted. Ascending infection can cause salpingitis
(inflammation of fallopian tubes) and, if it enters
the abdominal cavity, peri-hepatitis
– (Fitz-Hugh-Curtis syndrome; fibrotic hepatic capsule),
which leads to right upper quadrant pain and
tenderness

18. Management
• Medical: Single dose Azithromycin 1 g, or
Doxycycline 100 mg 2x daily for 1 week
• In pregnancy: Erythromycin / Amoxicillin
(Tetracyclines contraindicated)
• Other: Requires full STI screen and contact
tracing, abstinence before results

19. Pregnancy
• Chlamydia infection causes pre-
term labour and pelvic
inflammatory disease.
• In exposed neonates it increases
susceptibility to: HIV infection, tubal
pregnancies, eye infections, and
pneumonia.
• All women who are sexually active
under the age of 25 years and those
women who are pregnant who are
at high risk should be offered
screening; particularly in the setting
of termination of pregnancy, it is
important to screen.

20. LGV
• Systemic disease
• Caused by serovars L1, 2 & 3 of chlamydia
• Endemic in tropics
• Outbreaks in mainly HIV +ve MSM
UK
• 77% London, Brighton, Manchester
• Now hyper-endemic among MSM

21. Case 2
• 35M
• 3/12 hx rectal pain bloody discharge
• No recent travel
• Non-specific abo tenderness
• Referred OP gastroenterology

22. Proctoscope

23. • IV fluids
• Analgaesia
• Feels better
• Keep gastro follow up
• Continues to get unwell..

24. Risk factors for LGV
• Unprotected AI
• Sex parties, saunas
• Poly drug use
• HIV seropositivity
• Presentation with anal pain, tenesmus, pain
on defecation, bloody diarrhoea
• Often mistaken for inflammatory bowel
disease

25. LGV
• Primary stage
– Genital ulcer
– LGV proctitis
• Secondary stage
– Lymphotrophic infection
– Regional dissemination with inflammation and swelling of LNs in
surrounding tissue
– Periadentitis and bubo formation
– Buboes ulcerate, discharge, fistulae
• Tertiary
– Genito-ano-rectal syndrome (chronic inflammation)

26. Colonoscopy

28. Diagnosis & Management
• Clinical and laboratory
• NAATs for chlamydia
and further testing for
LGV specific DNA
• Doxycycline 100mg bd
21/7
• Symptoms resolve in 1-
2 weeks
• Contact tracing of
partners up to 3/12
• Follow up HIV testing

29. Case 3
• 50M
• Purulent urethral discharge / dysuria
• Recent travel to SE Asia (Thailand)
• High risk
• MDR Gonorrhoea
• HIV / Hep B Risk

30. Gonorrhoea
• Infected males present with
– Dysuria, frequency and/or a mucopurulent discharge
after 3-5 days, coupled with urethritis and meatal
oedema.
• Majority of females are asymptomatic (50-70%)
– PV discharge, IMB, PCB, dysuria, dyspareunia, lower
abdominal pain
• Disseminated gonococcal infection occurs in <1%
cases and causes pyrexia, a vasculitis rash and
polyarthritis
• Gram -ve diplococcus

31. SUPER Gonorrhoea

32. • Outbreak of high level Azithromycin resistant
N. gonorrhoea
• NG progressively exhibited reduced sensitivity
and resistance to many classes of
antimicrobials
• Azithromycin resistance is rare

33. Management
• Antibiotics: Cephalosporin, Penicillin, Tetracycline or
Quinolone (usually single stat dose)
• Culture sensitive antibiotics are used for treatment
• Other: Contact tracing and treatment of partner(s)
• Current guidelines from the British Association for
Sexual Health and HIV (BASHH) suggest Ceftriaxone
500 mg stat followed by Doxycycline 100mg BD for a
10-14 days, in the absence of sepsis

34. Case 4
• 23M
• Severe dysuria
• No discharge
• No LUTS
• Examination normal…?

35. Meatal HSV

36. Herpes simplex
• Disease resulting from HSV1 or HSV2 infection
• HSV is an alpha-herpes dsDNA
• Transmitted via close contact with an
individual shedding the virus
(eg. Kissing, sexual intercourse)

37. • 90% adults seropositive for HSV1 by 30 years
• 35% adults >60 years seropositive for HSV2
• >1/3rd world population has recurrent HSV
infections
• Infection is lifelong
• Inter-individual variation in frequency of
reactivation

38. • HSV1: Primary infection often asymptomatic, usual
symptoms:
– Pharyngitis
– Gingivostomatis, may make eating very painful; and
– Herpetic whitlow, inoculation of virus into a finger
– Recurrent infection / reactivation (herpes labialis / 'cold sore'):
Prodrome (6 hours) peri-oral tingling and burning. Vesicles
appear (48 hour duration), ulcerate and crust over. Complete
healing in 8-10 days
• HSV2: Very painful blisters and rash in genital, peri-genital
and anal area. Dysuria. Fever and malaise
• HSV encephalitis & keratoconjunctivitis: Headache,
photophobia, meningism, seizures; epiphoria (watering
eyes), photophobia, crusting

39. • Following primary viral infection the virus
becomes dormant (classically in trigeminal or
sacral root ganglia). Reactivation may occur in
response to physical or emotional stresses or
immunosuppression.
• The virus causes
cytolysis of infected
epithelial cells and
vesicle formation

40. • Topical, oral or IV Aciclovir (a nucleoside
analogue phosphorylated by viral thymidine
kinase to a monophosphate that, when
converted to triphosphate, causes chain
termination of viral DNA synthesis).
• Valaciclovir is a prodrug of Aciclovir with
better bioavailability.

41. • Neonatal HSV: Acquired during delivery. Skin
vesicles, scarring eye disease, encephalitis. May
be fatal
• Treatment: Caesarean section for mothers with
active HSV infection. IV Aciclovir to neonate
• HSV in the immunocompromised: Severe local
disease may disseminate involving the respiratory
and GI tracts
• Increased transmission of HIV in the presence of
HSV2 genital lesions

42. Case 5
• 21F
• Feeling unwell
• Severe headache
• Shooting pain down left leg
• C/O weakness of leg
• Developed painful
genital ulcers..

43. • Admitted as ?viral meningitis
• CT head reported normal
• LP – 6 WCC
• 3 mmol/L glucose
• 1.2 g/L protein
• Clear / colourless
• New partner 1/12
• Herpes virus Type 2 PCR positive in CSF

45. Aseptic meningitis
• Acute aseptic meningitis may occur as a
complication of primary anogenital HSV-2 with
headache, photophobia, meningism
• Genital lesions in 85% of primary HSV 2
meningitis – CNS symptoms 7 days later
• Normal CSF glucose
• CSF PCR for HSV diagnosis
• Recurrent benign aseptic meningitis may be
caused by HSV-2 – Mollaret’s meningitis

46. Case 6
• 49 year old HIV + man
• Attends with history of diarrhoea – frequent,
now incontinent episodes, foul smelling
• Malaise
• Good CD4 >50 cells/mm3
• VL <40 copies/ml
• Stable on Stribild

47. • AKI
• Raised inflammatory markers
• Non specific abdo tenderness
• AXR normal
• No recent travel
• ?Medication related
• Stool cultures; OCP (ova, cyst, parasite) x3

48. DDx
• C. diff, Giardia, Campylobacter
• Cryptosporidium, Microsporidium, Isospora
belli
• Mycobacterium Avium Intracellulare
• CMV, HSV, adenovirus
• HIV related ‘AIDS enteropathy’
• Small bowel over growth
• Bowel malignancy, lymphoma

49. • Sexual history
• Multiple partners
• UPAI
• Frequently visits saunas
• ‘Sero sorts’
• Occasional mephadrone and GHB
• Stool culture + positive Shigella flexneri

50. • 61% rise since 2010
• 2016 >550 cases
• High numbers of sexual
partners & condomless
sex
• Sex parties, ‘Chemsex’
• High levels of HIV
positivity

51. Shigella
• Gram negative bacterium
• 4 different species
• Can cause severe bacillary dysentery in humans
• Complications intestinal and systemic – rare
• Treatment ciprofloxacin
• Campaigns to alert MSM, hygiene advice
• Alerts to GU; notifiable disease

53. • STI transmission
• Mental health
effects
• ‘Slamming’
• GHB, Mephedrone /
Crystal meth –
powerful
psychological
dependence

55. Useful websites
• British Association for Sexual Health and HIV
http://www.bashh.org/
• Health Protection Agency
http://www.hpa.org.uk/infections/topics_az/hiv_and_sti/default.htm
• British HIV Association
http://www.bhiva.org/
• Faculty of Family Planning and Reproductive Health Care
http://www.ffprhc.org.uk/
• Society of Sexual Health Advisers
http://www.ssha.info/index.asp
• World Health Organization
http://www.who.int/topics/sexually_transmitted_infections/en/
• http://www.ssha.info/index.asp

56. References
• Competencies for providing more specialised sexually transmitted
infection services within primary care, 2005, www.bashh.org
• National Guideline for consultations requiring sexual history taking, 2005,
www.bashh.org
• Silverman S.D., 2000. Getting comfortable with sexual history taking,
Family Practice Recertification, 2000 Sep, vol.22, no. 11, p. 33 – 34, 37 –
40, 46.
• AIDS Alert, 2001. Doctors overlook sexual histories too often: its time to
make screening a priority, Sep, vol.16, no.9, p 113 –4
• Rosenthal S.L., Lewis L.M., Succop P.A., Burklow K.A., Nelson P.R., Shedd
K.D., Heyman R.B., Biro F.M., 1999. Adolescent’s views regarding sexual
history taking, Clinical Peadiatrics, 1999, April, Vol. 38, n0.4, p 227 – 33
• Peck S.A., 2001. The importance of the sexual history in a primary care
setting. Journal of Obstetric Gyneacologic and Neonatal Nursing, May –
Jun, Vol. 30, no.3, p 269 – 74.