Diagnosis & Management:

• Introduction

• Contents

• Disclaimer
  Please read before using the guidelines

• Clinical assessment guidelines

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Checklist: the sexual health interview

Checklist: HIV testing and counselling

The male reproductive system

The female reproductive system

Clinical assessment

 The STD consultation aims to: 

1. Define the presenting complaint.

2. Assess sexual and social behaviours for risk factors and  risk markers.

3. Screen the patient for sexually transmitted infections and associated
   conditions.

4. Diagnose and treat infection.

5. Educate the patient on risk modification and offer vaccination.

6. Promote safe sex practices

7. Limit the spread of STDs in the population and conduct contact tracing.

 General principles of the sexual consultation include ensuring privacy and maintaining confidentiality between the doctor and patient.  It is always best never to make assumptions about the patient or their behaviour and to maintain a non judgemental attitude to patient behaviours.  If there is doctor or patient discomfort this can be acknowledged.  Maintaining a relaxed body language and using terms that the patient understands and is comfortable with helps rapport development. 

History 

• General history
• Contact of an STD
• Past medical and STD history
• Medications, allergies (emphasise antibiotics) and contraception
• Last menstrual period
• Vaccination history
• Recreational drug use
  
• Symptoms and signs
• Onset, character, periodicity, duration and relation to sexual intercourse and urination
• Similarity to previous problems
• Any STD in sexual partner(s)
• Anogenital discharge and/or dysuria
• Dyspareunia and/or pelvic pain
• Ulcers, lumps, rashes or itching
  
• Sexual behaviours/risk markers
• Any sexual partner(s) and date of last sexual exposure and others in the last 3 months
• Sex of partner(s) including and history of male to male contact
• Type of intercourse – oral, vaginal, anal
• Sex overseas or in high risk areas like beats and saunas
• Any history of injecting drug use, what drug, how often
• Any tattoo history or blood product exposure
  

Examination

 This is conducted to assess genital symptoms and as part of asymptomatic assessment.

 Exposure of abdomen, genitals and thighs is required.

 Inspect for: rashes, lumps, ulcers, discharge, smell, pubic hair for lice and nits and in most cases the skin of the face, trunk, forearms, palms and the oral mucosa.

Palpate: inguinal nodes

Men:  Inspection of the penis, including meatus, retracted foreskin and perianal area +/- proctoscopy. Palpation of scrotum and expression of any discharge from the urethra.                        

Women:  Inspection of external genitalia, perineum and speculum examination of vagina and cervix.  Bimanual pelvic examination.

Specimen collection and tests

Men 

• Urethral swab (1-2 cm inside meatus or of pus)

• Gram stain

• culture and sensitivity on gonorrhoea specific medium

• Wet prep if trichomonas suspected

• Chlamydia PCR taken 3-4 cm down urethra not routinely performed unless symptomatic

• Ulcer swab

• HSV PCR

• First catch urine

• Chlamydia PCR

• Gonorrhoea PCR if urethral swab not possible in

• Men who have sex with men

• Heterosexuals who have had sex outside South Australia or define themselves as Aboriginal

• If test is positive result must be confirmed by a urethral culture
  

Men who have sex with men (in addition to the above)

• Throat swab
• Culture and sensitivity on gonorrhoea specific medium
• Rectal swab
• Best obtained through direct inspection with proctoscope
• If proctoscopy unavailable blind swabs are possible
• Culture and sensitivity on gonorrhoea specific medium
• Chlamydia PCR
  

Women

• Vaginal wall swab 

• Gram stain for candida and bacterial vaginosis

• culture and sensitivity including candida specific medium

• Vagina posterior fornix

• pH

• wet prep for trichomonas

• Endocervical swab

• culture and sensitivity on gonorrhoea specific medium

• Chlamydia PCR

• Pap smear if abnormal cervix or screening PAP due

• Ulcer swab

• HSV I, II type specific PCR

• Rectal swab (if anal sex on history)

• best obtained through direct inspection with proctoscope

• if proctoscopy unavailable blind swabs are possible

• culture and sensitivity on gonorrhoea specific medium

• Chlamydia PCR

• First void urine

• can be tested for Chlamydia by PCR if endocervical swabs not possible

Female sex workers (in addition to the above)

• Throat swab
• Culture and sensitivity on gonorrhoea specific medium

Blood tests

• Hepatitis B serology
• At first visit
• Subsequently as determined by risk markers
• Aboriginal
• Asian born
• Men who have sex with men
• Injecting drug users
• Sex workers
• Overseas sex contact
• Sexual contacts of the above
• Hepatitis C serology
• At first visit
• Subsequently as determined by risk markers
• Injecting drug users
• Tattooing
• Blood product exposure out of Australia
• Syphilis serology
• At first visit
• When syphilis is suspected on clinical grounds
• Subsequently as determined by risk markers
• Aboriginal
• Men who have sex with men
• Sex workers
• Sexual contacts of the above
• If HIV infection has been diagnosed
• HIV serology
• At first visit
• Subsequently as determined by risk markers
• Men who have sex with men
• Injecting drug users
• Overseas sex contact
• Sexual contact with a person from overseas
• Sexual contacts of the above

Diagnosis

History, examination and testing should enable a diagnosis. 

Algorithms for urethral discharge, vaginal discharge and penile or vulval lesions are included in checklist section.

If unsure contact a sexual health physician.

Management

Comprehensive management of sexually transmitted infections has four components.

1.       Treatment

Antibiotic therapy or other treatment is provided in accordance with recommendations.

 2.       Patient education

Patient education should cover the following:

·         Natural history of the disease

·         Sequelae and method of transmission

·         The treatment and side effects

·         Necessity of follow up and investigation and treatment of sexual partners

·         Public health law specific to notifiable diseases

·         Use of condoms and abstinence if required following treatment

3.       Contact tracing

 Notifiable sexually transmitted infections should be contact traced to allow for timely and appropriate treatment of sexual partners. 

4.       Follow-up

At least one follow up visit is essential in order to:      

·         Assess response and compliance to treatment

·         Assess for side effects of treatment

·         Determine whether sexual intercourse has occurred since treatment

·         Perform investigations to demonstrate cure where appropriate

·         Confirm contact tracing and treatment of sexual partners

Notification

 There is a legal requirement for the attending clinician to notify all cases of gonorrhoea, early syphilis, chlamydia, hepatitis B, hepatitis C, HIV and donovanosis to the Department of Health (see Appendix 2 for details).

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