NHS Borders

STI Management Protocol Version 5

www.borderssexualhealth.org.uk

July 2011

Contents

Page No.

What’s new in Version 5 4

1. Borders Sexual Health Clinics – sites and times 5 STI Screening – Flowchart 1 9

2. Patient Assessment 10

3. Testing for Sexually Transmitted Infections 11 How to take samples 14

4. Investigation and Management of Common Presenting Complaints 15

4.1: - assessment 15 Vulvovaginal 16 Recurrent Vulvovaginal Candidiasis 17 Bacterial Vaginosis 18 Management of Discharge in Female Patients - Flowchart 2 19 Recurrent Bacterial Vaginosis 20 Infection 20 Gonococcal /Urethritis (see section 4) 21 Chlamydial Cervicitis (see section 4) 21 Non-infective Causes of Vaginal Discharge 21

4.2: Urethral Discharge (Males) - assessment 22 Non Gonococcal Urethritis 23 Chlamydial Urethritis 24 Gonococcal Urethritis 24 Recurrent and Persistent NSU 25

4.3: Genital Ulceration- assessment 26 Initial Episode Infection 27 Recurrence of Genital Herpes 29 Frequent Recurrences of Genital Herpes 29 Genital Ulceration of Unknown cause 29

4.4: Genital warts and Other Lumps or Spots: 30 Genital Warts 31 Molluscum Contagiosum 33 Folliculitis 33

4.5: 34 Common Diagnoses 34 Phthiriasis Pubis (pubic lice) 34 Scabies 34 Pruritus Ani 35

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4.6: 36 Females: Pelvic Inflammatory PID) 36

Males : Acute Bacterial Prostatitis 39

Chronic Bacterial Prostatitis 39

Chronic Pelvic Pain Syndrome 40

4.7: Epididymitis/Epididymo-orchitis 41

5. Sexually Transmitted Infections 42

5.1: Chlamydia 42

5.2: Gonorrhoea 44

6. Hepatitis 46

Hepatitis A 46 Hepatitis B 46 Hepatitis C 48

6. Post-exposure prophylaxis for sexual exposure to BBV (PEPSE) 50

7. Pelvic Pain : Patient Information Leaflet 52

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What’s new in Version 5?

Version 4 was released in January 2009. Since then:

Nucleic testing for gonorrhoea was introduced in the Borders. Tests for gonorrhoea can be performed on urine (men) and self-taken vulvovaginal swabs (women) .A GP STI Testing Kit is available and specimens should be sent along with the form accompanying the kit.

Routine STI screening in asymptomatic women no longer requires a . (this was intended to test for Trichomonas vaginalis, which is very rare in asymptomatic women in Scotland).

Performing an STI screen in general practice is now much simpler. In line with national and local moves to increase HIV testing to reduced the 30% of HIV infections that remain undiagnosed, we now recommend that all STI screens include tests for chlamydia, gonorrhoea, syphilis and HIV. See notes on Diagnostic HIV Testing page 53

Gonorrhoea treatment has changed in line with national guidance to Ceftriaxone 500mg single dose by intramuscular injection, because of evidence of reduced sensitivity to Cefixime. This reinforces our recommendation that cases of gonorrhoea should be referred to sexual health services for treatment.

For treatment of occasional recurrences of genital herpes, the preferred dose and schedule recommended is Aciclovir 800mg three times daily for 2 days. This option uses 12 x 400mg tablets per course and patients can be supplied with 56 tablets at an NHS cost of around £7.00. This provides enough treatment for 4 recurrences.

A new flowchart and guidance on the use of PEPSE (post exposure prophylaxis for sexual exposure for HIV), has been developed n line with national guidance.

The Borders Chlamydia Protocol, incorporated in this document has been abbreviated pending a forthcoming report on Chlamydia testing by an Expert Group convened by the Chief Medical Officer. A full revised protocol will be produced separately.

4 Frequency and staffing of BSHS clinics at March 2011

Location Description Frequency Staffing

Galashiels Family Planning Mon 6-7.30pm FP Nurse Health Centre Clinic Receptionist Family Planning Alt Thursday 11am- Assoc Specialist Clinic 1pm 1 FP nurse 1 Receptionist Thurs 6-7.30pm Staff Grade

1 FP Nurses

Receptionist Referral Clinic Wed 9.30 -12.00 Assoc Spec (alternate weeks Receptionist/ Auxiliary with Hawick) Implant Clinic Tues 9-12.30am Nurse Specialist Thursday 6-7.30pm Nurse Specialist

Drop-in Thurs 11am-1pm CNS

Fri 2.30-4.30pm Receptionist/Auxiliary GUM Clinic Tues 9am-1pm Consultant (+HIV Clinic Fri 9am-1pm C NS monthly) Health Adviser

Receptionist/Auxiliary Hawick Family Planning Mon 6-7.30pm Staff Grade/AS alt

Community Clinic weeks

Hospital FP Nurse Receptionist Implant Clinic Mon 6-7.30 (Alt Nurse Specialist Weeks) Joint Community Weds 9.30-12.00am Consultant Gynae/Sexual (ALT)Gynaecologist Health Drop-in CNS

Auxiliary

Referral Clinic Wed 9.30 -12.00 Assoc Spec (alternate weeks Receptionist/ Auxiliary with Galashiels) Duns Family Planning Alt Thurs 4-5.30 Staff Grade - Knoll Health Clinic FP Nurse Centre Receptionist Drop-in Alt Fri 2.30-4.30 CNS

Peebles Family Planning 2nd and 4th Wed of Staff Grade

- Hay Lodge Health Clinic the month 6.00-7.30 2 FP Nurses Centre Receptionist Drop-in Alt Mon 2.45- CNS 4.45pm Eyemouth Drop-in Alt Fri 2.30-4.30pm CNS – Health Centre

CNS – Community Nurse Specialist

For full details on opening times and to make appointments phone 01896 663700. Our website www.borderssexualhealth.org.uk contains a range of information including a Service Directory, detailing what is available at each clinic.

5 Services : All clinics welcome men and women of all ages. All clinics offer emergency contraception (the ‘morning after’ pill), male and female condoms, oral contraception, Implant insertion, injectable contraception, testing and treatment for STIs and advice on sexual health for men and women. All clinics provide tests, advice on termination (abortion) and if required, referral for termination of pregnancy. You can come to any of our clinics for these things. All clinics provide services for women, Gay and bisexual men and transgender men and women Most clinics offer additional services:

Drop-in Clinics All the above services plus testing and treatment for a range of STIs, advice on contraception, HIV and syphilis blood tests. You don’t need an appointment for drop-in clinics.

Family Planning Clinics Advice on contraception, prescriptions for the oral contraceptive pill, injectable contraception (the Depo), the diaphragm (cap) and natural methods. Male and female condoms, testing for STIs and advice on sexual health for men and women. Most clinics also offer the IUCD (coil) and Implantable contraception (Implanon) by appointment.

HIV Clinic HIV Clinics are held on the first Tuesday of every month, although patients are seen in other GUM clinics as required.

Borders Sexual Health GUM Clinic

Where is it? The specialist GUM Clinic is at Galashiels Health Centre, Currie Road, Galashiels. All other sexual health clinics and drop-ins offer STI testing and treatment, but for GP referrals requiring medical review, please refer to the Galashiels clinic.

How do you contact the clinic?

 Phone 01896 663700 for patient appointments and to contact consultant or sexual health adviser for advice.

Advice for GPs The GUM consultant (Dan Clutterbuck) can be contacted on 01896 663700, or through RIE switchboard on 0131 536 1000. Consultant advice is available by phone 5 days per week. In case of difficulty advice is also available from the GUM consultant on-call in Edinburgh through RIE switchboard 0131 536 1000. Email for advice on: [email protected]

6 Out of hours advice is available from the Registrar on call for ID/GUM in Edinburgh through LUHT switchboard on 0131 536 1000.

Community Nurse Specialists in Sexual Health can give advice or help with specific cases, such as contacts of infection in the community. They are also able to supply chlamydia postal testing kits (PTKs), STI testing kits and training on STI and sexual health management.

Borders South & East: Gillian Forbes - [email protected]

Borders Central/Western : Suzanne Balfour – [email protected]

Borders General Hospital & Borders: Gillian Elliot – [email protected]

Postal Testing Kits & Borders: Lou Graham – [email protected]

Telephone advice for patients

Phone 01896 663700 for appointments or other enquiries. Advice calls are directed to the doctor or health adviser.

To make an appointment

 By letter: Referrals by letter from a GP will be offered an outpatient appointment: the waiting time is 2 weeks or less. Urgent cases can be seen in the next clinic if necessary - please phone if required.  By phone: Phone 01896 663700.  GPs can phone on a patient’s behalf, but anyone can phone and arrange an appointment for themselves

How do you get seen?

 By appointment: see above

 The walk-in clinic. Patients with symptoms or who feel that the problem is urgent and can’t wait may attend the clinic between 9.00 and 10.00 on Tuesdays and Fridays. We guarantee to see all attendees at this clinic. Patients with appointments will be given priority, so those attending the urgent problem clinic may have to wait and the consultation may be brief if the clinic is busy.

 HIV care. We currently care for 28 people with HIV infection. New referrals can be made by letter or by telephone. The first Tuesday of each month is a dedicated HIV clinic. We also provide HIV support through drop-in clinics and home visits by arrangement.

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 Family planning clinics. All family planning clinics offer testing and treatment for chlamydia and advice on other STIs. This may be an option for patients unwilling to attend the GUM clinic.

 Drop-in Clinics. Drop-in clinics are aimed at (but not restricted to) young people under 25. The clinics are nurse led and deal with common STIs and contraceptive prescriptions. Treatments are dispensed through PGD.

All Drop Ins provide: o Chlamydia testing o Syphilis testing o HIV testing o Contact tracing o Treatment for Chlamydia o Treatment for Gonorrhoea o Treatment for Herpes o Treatment for Genital warts o Pregnancy testing o Condom distribution o Family planning advice

Communication

Letters to GPs

 We routinely send letters on patients referred by their GP. We also send letters (with the patients consent) on patients diagnosed with conditions with long term implications, genital skin conditions or those requiring long term treatment. We no longer send letters on patients attending for STI testing, or who are diagnosed with and treated for an uncomplicated STI.  Occasionally patients who have been referred by letter do not want us to write back to their GP.  We take between two weeks and a month to produce letters. If you need information on a patient’s visit before then, please phone.  Due to the increasing workload, we use standard letters in some cases. If you require further information, please get in touch.

Results for patients

 Patients are asked to phone for results two weeks after attending clinic.  Results are available from an automated telephone line, accessed using the patient’s unique number  Patients who request it receive a copy of the letter to their GP

Information for patients Supplies of patient information leaflets are available by telephoning 01896 663700 or email request to [email protected]

8 Flowchart 1: STI Screening

See common presenting Concern regarding STIs complaints

No symptoms Patient assessment Symptoms: Sexual contacts, Diagnose /treat or symptoms refer GUM

Sexual contact with new partner less Refer to GUM clinic/for GUM opinion than Symptomatic patients 10 days ago? Walk-in clinic Tues & Fri 9.00-10.00am Yes or by appointment 01896 663700 Drop-in clinics (see page 4 and website) Urgent problem Rape or sexual Phone GUM consultant 9-4.30, Mon-Fri assault? 01896 663700 Edinburgh GUM triage 0131 536 2105

Out of hours Infectious disease registrar/SHO on-call, No ARU, Western General Hospital: No 0131 537 1000

Defer testing/ Give first dose of Hepatitis B attendance at GUM vaccination course. to day 14 Consider HIV risk: PEPSE? Arrange appointment at GUM clinic

Refer to GUM , send to drop-in clinic or do STI screen in the community Do the tests in general practice using the GP STI Testing Kit (see Page 10) Swab or first-voided urine for chlamydia PCR Swab or first-voided urine for gonorrhoea PCR* Syphilis, HIV serology Refer to GUM clinic and Asymptomatic patients: Phone for appointment on 01896 663700. Hepatitis B testing if sexual contact abroad, Patient phones for appointment on 01896 men who have sex with men, or other risk 663700 factors Give patient clinic leaflet Refer by letter

9 2 Patient Assessment

What to consider: Whether the patient is symptomatic What is the risk of STI (whether symptomatic or not) Whether testing in general practice is appropriate If so, what tests you are able to do in general practice

Background:  Asymptomatic STIs are now so common that lack of symptoms is not a reliable indicator of the likelihood of an STI. A sexual history is important – particularly in the assessment of risk factors.  All the tests we routinely use in the clinic can be used in the community.  A routine STI screen should include tests for chlamydia, gonorrhoea, syphilis and HIV  In low risk individuals it may be appropriate not to test, or if under 20 to test for chlamydia alone  Tests for Hepatitis B and Hepatitis C may be indicated in those with risk factors.

New patients:  History:  Assess symptoms: Red flag symptoms: Refer to GUM Yellow flag symptoms: Consider referral to GUM  Recurrent vaginal discharge in women  Painless anogenital ulcers  Bloody discharge in men or women  Recurrent urethral discharge in  Pelvic pain in men or women men  Testicular pain  Rectal symptoms in MSM  Deep in women

 Symptom algorithms for the commoner presentations follow in later sections  Take a full sexual history including date of last sexual intercourse, geographical location of contact, casual or regular partner, partner’s gender, nationality and details of condom use and nature of sexual activity.  Ask about other partners in the last 3 months as well as sex outside the UK.  Check previous STIs including hepatitis and hepatitis B status in those at risk

Red flag risk factors: Refer to GUM if: Yellow flag risk factors: Consider referral to  Physical examination: GUM if: Pay particular attention to:  Multiple recent partners  Men who-have-sex-with men

 Sex with partners in Africa, Asia  Sex with non-UK partners

or the former Soviet Union  Previous STI

 Contact of syphilis, HIV or  Contact of chlamydia

gonorrhoea 

 Men: external genitalia including inspection under the foreskin and of the urethral meatus  Women: presence of genital ulceration, appearance of any discharge, cervical inflammation or discharge, pain on bimanual examination

Red flag signs: Refer to GUM if: Yellow flag signs: Consider referral to  Single genital ulcer GUM if:  Multiple painless ulcers  Multiple painful genital ulcers  Urethral discharge in men 10  Adnexal tenderness on bimanual examination in women

3 Testing for Sexually Transmitted Infections

Options – see flowchart 1:  Refer to GUM clinic  By appointment if asymptomatic: 01896 663700 or send a referral letter  By appointment or to the Walk-in urgent problem clinic if symptomatic: Tues & Fri 09.00-10.00am

 Do an STI screen in the community  Send to a Drop-in

Routine testing for STIs in men*:

General practice, FPC, Drop-in What we do in GUM

All men All men Full history and genital examination Full history and genital examination Urine for chlamydia PCR Urine for Chlamydia PCR Urine for gonorrhoea PCR Urethral swab for gonorrhoea culture Syphilis and HIV serology Syphilis and HIV serology

Plus - in MSM If symptomatic:

Throat swab for gonorrhoea PCR Urethral swab for Gram-stain

Rectal swab for gonorrhoea PCR

Syphilis serology Plus - in MSM

Hepatitis B serology Throat swab for gonorrhoea PCR

Hepatitis A+B vaccination Rectal swab for gonorrhoea PCR

Offer HIV testing Rectal swab for chlamydia Hepatitis B serology Hepatitis A+B vaccination

Routine testing for STIs in women*:

What we do in GUM- General practice, FPC All women All women Full history and examination Full history and genital examination Urethral and endocervical swabs for Endocervical swab (or self-taken gonorrhoea ( culture) vulval swab) for Chlamydia and Endocervical swab for Chlamydia PCR Gonorrhoea PCR HVS for wet-mount microscopy for Syphilis and HIV serology Trichomonas vaginalis

HVS for Gram-stain microscopy for

candida and bacterial vaginosis

Syphilis serology

Offer all patients HIV testing

11 Borders STI Testing Kit – User Information

Contents:  Self Obtained Lower Vaginal Swab (SOLVS) kit (for women). (The self taken swab can also be used by a clinician for cervical/vaginal samples if wished).  SOLVS patient instruction leaflet  Urine sample bottle (for men - urine samples should NOT be used for gonorrhoea testing in women)  STI request form  Notes on HIV testing  Patient information: o STI testing Leaflet o Chlamydia leaflet o Borders Sexual Health leaflet

Indications and limitations This kit is intended for testing for STIs in general practice or peripheral sexual health/drop in clinics. It may be used for routine STI screening in asymptomatic or symptomatic patients, or for diagnostic testing in those with symptoms. It will provide exactly the same results using the same tests as a routine STI screen in the GUM clinic, following the recommendations of the British Association of Sexual Health and HIV (BASHH). A routine STI test in an asymptomatic patient should take no more than 15 minutes and can be done in 10. This guidance should be used in conjunction with the Borders STI Management Protocol in the professionals section of the BSH website. http://www.borderssexualhealth.org.uk/STIManagementGuidelines.htm

This kit won’t identify:  Bacterial vaginosis or vulvovaginal candidiasis in women with vaginal discharge  Trichomonas vaginalis infection (very rare in Scotland) (for these tests an additional Amies swab from the vaginal fornices (HVS) will be required). A routine STI screen doesn’t include a test for TV.  Non specific urethritis in men with discharge (unless caused by chlamydial infection) (an air dried microscopy slide of urethral material can be used for this purpose)

Which tests to perform Patients requesting STI screening may wish to have a full set of tests performed regardless of risk. It is quite appropriate to do this. In patients unsure of which tests they require, or who present with symptoms, the decision on testing may be based on risk assessment. Two basic levels of testing are recommended for simplicity:

 For patients at low-moderate risk of infection: no tests or a Chlamydia test alone  For patients at moderate or high risk of infection: a full STI screen – Chlamydia and gonorrhoea tests, syphilis and HIV serology.

Tests for Hepatitis B and C do not usually form part of a routine STI screen in Scotland. Tests may be added for those with specific risk factors – see below and Borders STI management guidelines or the Borders Blood Borne Virus resource pack for Health professionals.

Basic risk assessment

High risk factors: sex abroad, multiple partners, sex with partners from abroad, MSM (men who have sex with men), previous STI.

Moderate risk factors: new partner in last year, more than one partner in last year, under 25, high risk but consistent condom use, partners elsewhere in UK.

Low risk factors: same partner>1 year, over 25, no partner, WSW, moderate risk but all partners from Borders.

12 When not to test in general practice: Red flag symptoms: Refer to G.U.M.  Painless anogenital ulcers Procedure  Recurrent urethral discharge in men  Take a sexual history  Rectal symptoms in MSM.  Assess level of risk  Explain the tests involved Red flag risk factors: Refer to GUM if  Informed consent for testing  Contact of syphilis, HIV or gonorrhoea  Complete testing form  Explain consent for partner notification Red flag signs: Refer to GUM if:  Perform tests  Single genital ulcer  Make arrangements for receiving result  Multiple painless ulcers

Completing the testing form Please complete the risk factor section if performing HIV testing. Explain to the patient that by signing the form they are consenting to contact by a sexual health adviser in the event of a positive result. The adviser will discuss with them the need to ensure that sexual partner(s) are tested and treated. All discussions will be completely confidential and the health advisor will not disclose the patients name or other details to any partners. If the consent section of the form is not completed, the tester is responsible for completing partner notification.

Tests in men First voided urine (does not need to be early morning) in universal container for chlamydia and gonorrhoea PCR. Serum (brown tube) for syphilis and HIV (+/- Hepatitis B and C serology)

Tests in women Self taken lower vaginal swab (see instructions) or physician taken endocervical or vaginal swab (if performing examination) for chlamydia and gonorrhoea PCR. Urine samples should NOT be used for gonorrhoea testing in women) – the sensitivity of PCR for gonorrhoea on female urine is questionable. Serum (brown tube) for syphilis and HIV (+/- Hepatitis B and C serology)

Tests in men-who-have –sex-with-men In most cases gay and bisexual men should be encouraged to attend the sexual health clinic. Where this is not possible or desirable, a swab (using the same sample tube and swab supplied for vulvovaginal tests) should be taken from the pharynx and another from the rectum, in addition to tests in men as above. See Borders STI protocol for details of swab taking. Swabs should be clearly labelled ‘throat’ and ‘rectal’. Screening for Hepatitis B infection (but not Hepatitis C) is routine in MSM.

Testing for HIV, Hepatitis B and Hepatitis C HIV testing is increasingly regarded as part of routine screening for STIs. See the HIV testing guidance with this pack. Tests for Hepatitis B are indicated in men-who-have-sex-with-men, those from endemic areas (including but not exclusively Asia, Southern Africa), sex workers and those using or partners of those using intravenous drugs. Request HepBcAb (Hepatitis B core antibody) and HepBsAg (Hepatitis B surface antigen). If a client reports previously having been vaccinated, request HepBsAb (Hepatitis B surface antibody). See Borders Sexual health STI management protocol for more detail. Hepatitis C is only rarely transmitted through sexual contact. Regular partners of those with Hepatitis C infection should be tested. See Borders Sexual Health STI Management protocol or Borders Blood borne virus resource pack for more details.

For advice and support on any aspect of the use of this kit, contact us on 01896 663700, or [email protected] or [email protected]

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Detail on how to take the samples

For gonorrhoea and chlamydia PCR:

Genital samples

 A single sample (urine in men, endocervical, vulval or vaginal swab in women) can be used for gonorrhoea and chlamydia.  Urine or swab samples for PCR for chlamydia are satisfactory in both men and women. Swabs are easier for the lab to process, but the choice can be based on what is most convenient at the time.  Urine or swab samples for PCR for gonorrhoea are satisfactory in men. In women, urine samples for gonorrhoea are not sufficiently sensitive and will not be tested for gonorrhoea by PCR. Urine samples are less uncomfortable for men and may be preferred to swabs.  For women who are asymptomatic or decline speculum examination, self-taken vulvo-vaginal swabs (using the same swab and transport bottle used for endocervical swabs) are at least as sensitive as physician taken endocervical swabs. They may be more sensitive than first voided urine in women, although the difference is likely to be small and the choice of sample can be based on convenience and patient preference. Swabs are preferred to urine samples by a majority of young women in many studies.  Urine PCR testing for chlamydia. First 20ml of voided urine in a sterile universal container. (If dipstick testing is undertaken (e.g. for suspected UTI, test a separate sample to avoid contamination.)

Throat swab Using the same swab and transport bottle supplied for endocervical swabs, sweep over from the tonsillar fossae and soft palate. Label the sample including the site: ‘Throat’.

Urethral swab Sample the terminal 1cm of the in men or the opening only in women. In most cases this should not be necessary – a urine sample will be used.

Endocervical swab Use water to lubricate the speculum if possible- to avoid contaminating samples with lubricant. Remove any excess discharge or mucus first with a separate swab, or a small ‘mop’ made by twisting an extra bit of cotton wool around a standard swab.

Anorectal swab Using the same swab and transport bottle supplied for endocervical swabs, insert the swab 2-3m into the anal canal and rotate 2 or 3 times in an arc (to ensure contact with the mucosa). Label the sample including the site: ‘rectal’

For , candidiasis and bacterial vaginosis (symptomatic women only)

 Take a cotton swab from the lateral and posterior fornices and place in Amies transport medium and send to the laboratory for microscopy. In asymptomatic patients it is enough to request microscopy for Trichomonas vaginalis, so the lab won’t have to perform additional irrelevant tests for yeasts and other . For syphilis, HIV and hepatitis serology

 Blood sample for syphilis and HIV serology (brown serum tube)  Hepatitis B surface antigen (HBsAg) and Core antibody (Anti-HBc) (serum tube)

14 4 Investigation and Management of Common Presenting Complaints

4.1 Vaginal Discharge

What to consider:

Do symptoms indicate a particular diagnosis? What is the risk of STI? Is it safe to give empirical treatment alone? Which, if any tests are indicated?

Background:  Vaginal discharge is a common presenting symptom in general practice. It is not possible to reliably distinguish between sexually transmitted and non- sexually transmitted causes on history alone.  The commonest infective causes are thrush and bacterial vaginosis (BV) – these are not sexually transmitted. A HVS is not always necessary for the diagnosis of thrush and BV.  The use of narrow range pH paper can be helpful in assessing discharge. A pH of <4.9 is unlikely if the diagnosis is BV or Trichomoniasis. pH > 5.0 is unlikely in thrush. (Contact the GUM clinic if you have trouble sourcing narrow-range pH paper).  Trichomonas vaginalis, gonorrhoea and Chlamydia trachomatis are sexually transmitted causes of vaginal discharge. Asymptomatic infection with these organisms may coexist with BV or thrush.  In all cases, a consultation about a discharge is a good opportunity to discuss screening for STIs.

History (see also Page 7)

Sexual history: Long-term regular partner, or no recent sexual partner, over 25 = lower risk of STI Everyone else = at risk of STI

Symptom profile: Clinical diagnosis is possible with a combination of symptoms and signs, but each individual feature has a low sensitivity for particular causes: e.g. Itching with thick, white curdy discharge, and fissuring of : likely to be candida (thin milky fishy-smelling discharge, worse after sex: likely to be bacterial vaginosis)

Clinical review is needed for other symptoms such as: abdominal pain, deep dyspareunia, menstrual disturbance, post-coital or (PID), urinary symptoms (UTI), and lesions such as warts/ herpes.

Examination

 A diagnosis of first episode genital herpes is sometimes missed in women diagnosed on symptoms alone – examination is advisable in all cases, especially if severe or regional pain.  Character of discharge (see flowchart) - may allow presumptive diagnosis.  Presence of cervicitis/ mucopurulent cervical discharge – indicates discharge is cervical rather than vaginal - testing for STIs is indicated. 15

Red Flags: refer to GUM Yellow flags: consider referral to

Contact of gonorrhoea GUM:

Pelvic pain/tenderness

Contact of chlamydia

Recurrent problem unresponsive to

treatment

Tests – vaginal discharge

Low risk of STI Risk of STI  Treat blind if confident See testing for STIs in women page 9 patient would return if still symptomatic

 HVS if doubt about diagnosis, no response

to first-line treatment

 Opportunistic chlamydia testing if under 25 years and not previously tested

Vaginal Discharge - Common Diagnoses

1. Vulvovaginal Candidiasis (“Thrush”)

Characteristics: Vulval itch +/- burning with erythema, fissures Curdy white non-odorous discharge

Symptoms can be similar to those of herpes simplex, so examine at least externally if patient is very sore.

Diagnosis: Typical symptoms and external appearance HVS: Yeasts present on culture

.Treatment: Only if symptomatic First choices: Fluconazole 150mg p.o. single dose (not in pregnancy, think interactions) Second Choice Itraconazole 200mg p.o. twice daily for one day (more expensive, more interactions) Third choice Vaginal clotrimazole 500mg for 1 night or 200mg for 3 nights or or Econazole pessaries 150mg for 3 nights or long-acting pessaries 150mg for 1 night

16 Useful Patient Information  Not a sexually transmitted infection  Caused by an overgrowth of Candida spp. which are a bowel commensal  Treating partner does not improve outcome  May recur  Bubble baths, douching, tight clothing, nylon underwear, , premenstrual week and pregnancy may predispose  No evidence that low oestrogen combined pill or diet have any effect

 Organism not able be “eradicated” by systemic treatment

Leaflet: Thrush: A self-help guide. Health Education Board for Scotland. 0131 536 5500

Vaginal Discharge: http://www.borderssexualhealth.org.uk/Trichomoniasis

Recurrent Vulvovaginal Candidiasis

Diagnosis: Defined as four episodes of mycologically proven candidiasis in 12 months. Confirm by microscopy or culture. Non-albicans candida spp may account for significant proportion.

Management:

 Eliminate/ reduce predisposing factors (see above)

 Cyclical symptoms: Fluconazole 150mg orally once or Clotrimazole 500mg

or Itraconazole 200mg p.o. twice daily for 1 day just prior to usual onset of

symptoms, or during second week of the cycle, increased to twice monthly or

weekly if not successful.

 Persistent symptoms: Fluconazole 50mg p.o. daily for up to two weeks

or Fluconazole 150mg once weekly or clotrimazole pessary 500mg weekly for three

or six months.

 Troublesome but relatively infrequent recurrences: give supply of treatment to

keep at home.

 Consider referral or advice from GUM

All these regimes are empirical and can be adapted for the individual patient. For patients with really troublesome symptoms, it may be helpful to start with a high frequency of treatment (e.g. weekly) and reduce frequency over time.

Itraconazole 200mg p.o. twice daily for one day has a broader spectrum of activity than Fluconazole 150mg single dose. However this is unlikely to have any clinical significance and it is no longer cheaper than Fluconazole. It is contraindicated in women with liver disease.

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Bacterial Vaginosis

Characteristics: Thin, milky, fishy-smelling discharge Sometimes the smell is the only symptom Worse after intercourse Little or no

Diagnosis: Based on Amsel’s criteria: at least 3 of the following:  Homogenous white vaginal discharge  Clue cells in wet and gram-stained films (often also mixed organisms and depleted numbers of lactobacilli)  Vaginal pH>4.9  Amine odour from vaginal discharge before or after addition of 10% (not done routinely)

Note: Up to 50% of women will have on culture, i.e. presence of G. vaginalis on culture is not diagnostic of bacterial vaginosis.

18 Flowchart 2: Management of Discharge in Female

Consider AGE, SEXUAL HISTORY and CLINICAL FEATURES to decide on the need for HVS, chlamydia testing or full screening for sexually transmitted infections

Urine, endocervical swab or self-taken vulvovaginal swab Patient Patient under 20 years for PCR for Chlamydia Age

Consider a full screen for other sexually transmitted infections (Page 7)

2 or more partners in Sexual Urine, endocervical swab or the last year. History self-taken vulvovaginal swab for PCR for Chlamydia Bloody discharge Deep dyspareunia Post coital bleeding Consider pelvic Intermenstrual bleeding inflammatory disease Clinical Purulent cervicitis features

Smell, especially after White, curdy Atypical features Purulent, green or sex discharge Recurrence frothy discharge No itch Itch No response to Bloodstained

Thin, homogenous Vulval irritation, treatment discharge discharge erythema, fissuring Pre/post termination Known/suspected Vaginal pH>4.9 Vaginal pH<4.5 of pregnancy contact of STI Postnatal Contact abroad Previous STI

No HVS necessary No HVS necessary HVS for bacteriology Full screening for STIs Treat for bacterial Treat for candidiasis (Page 10) vaginosis Treat on clinical suspicion

Follow-up with results

19

Bacterial Vaginosis: Treatment:  only if symptomatic*

First choices: 400mg twice daily for 7 days (slightly more effective in clearing BV at 1 month after treatment than the single 2g dose) or Metronidazole 0.75% vaginal gel 5g applicatorful nightly for 5 nights

Second choice: 5% vaginal cream 5g applicatorful nightly for 5-7 nights

Notes: * Consider treatment in pregnancy in asymptomatic women – d/w consultant 1st Trimester pregnancy or breast-feeding use clindamycin

Patient Information:  Not sexually transmitted  No need to, or proof of benefit of treating partner  Avoid soaps, bubble baths, douching  May recur Leaflet: What do you know about…vaginal discharge? Health Education Board for Scotland. 0131 536 5500 Download at: A http://www.borderssexualhealth.org.uk/Trichomoniasis.

Recurrent Bacterial Vaginosis

Diagnosis:

3 or more confirmed episodes in 12 months.

Management:  Metronidazole 0.75% gel 5g PV nocte for 5 days  Discuss with GUM consultant or refer GUM  Lactic acid gel (eg Relactagel) may be helpful in controlling symptoms

Trichomonas Vaginalis Infection

Characteristics:

Thin, greenish, foamy discharge

Vulvitis and : can be severe

Vaginal pH tends to be very high (>6.0) in trichomoniasis

20

Treatment: 1Diagnosis:st Line: Metronidazole 2g single dose  Trichomoronas vaginalis reported on HVS ( a wet film of material obtained from posterior vaginal fornix onMetronidazole direct microscopy 400mg or afte twicer incubation daily offor Amies’ 7 days sw ab from HVS)

2nd Line: Intravaginal metronidazole gel. 0.75% once daily for 5 days

Single dose metronidazole is contraindicated in pregnancy

Notes: Trichomoniasis may co-exist with other STIs – especially gonorrhoea: routine STI testing in all cases Treat male contacts empirically as above Follow-up: Test-of-cure at 2 weeks Consider referral to GUM for all of the above

Patient Information:

 TV is a sexually transmitted infection

 Males are usually asymptomatic

 Male partners should receive empirical treatment to reduce reinfection rates and

further transmission

Leaflet: What do you know about vaginal discharge? Health Education Board for Scotland. 0131 536 5500 Download at: http://www.borderssexualhealth.org.uk/Trichomoniasis

Recurrent or treatment-resistant Trichomonas vaginalis infection  May be due to non-adherence to treatment or reinfection.  Metronidazole resistance does occur.  Discuss all cases with GUM consultant.

Gonococcal cervicitis – see section 4 Chlamydial cervicitis – see section 4

Non-infective causes of vaginal discharge 1. Cervical ectropion: May be more pronounced with prolonged COC use. If the patient is concerned by it, consider:  Stopping COC (with alternative contraception)  Referral to for cold coagulation

2. High pH with no evidence of abnormal flora - may be worth trying Aci-Jel 1 applicator full nocte for a month.

21 4.2 Urethral Discharge (Males)

What to consider:

Men with discharge need testing for STIs This can be done in general practice, but referral to GUM is welcomed Contact tracing (partner notification) will be required in every case –Community Nurse Specialist if you require assistance with this. If the patient is to be treated prior to referral, please do tests as below

Background:  Mucopurulent discharge in men is usually pathological  The main causes are non-gonococcal urethritis (NGU), also called non-specific urethritis (NSU). Gonorrhoea is a less common cause of discharge in men in Scotland.  The discharge of gonorrhoea can’t be distinguished from NGU on clinical grounds.  About 50% of men with NGU have chlamydia  Men occasionally present with concern regarding a physiological discharge (they ‘squeeze to check’). These men usually have underlying concerns re STI or a sexual contact.  Partners MUST be seen and treated. If the patient is to be treated prior to referral, please do tests as below.

History:  Duration  Discomfort or dysuria  If there is buttock or leg pain consider (rare) urethral HSV infection.

Examination:  As for routine STI screen. Purulent green discharge may raise suspicion of gonorrhoea, clear mucoid or white may indicate NGU.  Examine the urethral meatus for ulceration.

Testing:  Same as for a routine STI screen (See below and Page 9).

Investigation of men with urethral discharge  Urine for PCR testing for chlamydia and gonorrhoea. First 20ml of voided urine in a sterile universal container. (If dipstick testing is undertaken (e.g. for suspected UTI, test a separate sample to avoid contamination.)  Complete GP STI testing kit request form  Negative leukocyte esterase on urine sticks testing has good negative predictive value for the presence of NSU.

PLUS, in men who have sex with men:

 Throat swab for gonorrhoea PCR: Using the same swab and transport bottle supplied for endocervical swabs, sweep over from the tonsillar fossae and soft palate. Label the sample including the site: ‘Throat’.  Anorectal swab for gonorrhoea and chlamydia PCR: Using the same swab and transport bottle supplied for endocervical swabs, insert the swab 2-3m into the anal canal and rotate 2 or 3 times in an arc (to ensure contact with the mucosa). Label the sample including the site: ‘rectal’.

22 Urethral Discharge - Common Diagnoses

Non Gonococcal Urethritis (NGU) or Non Specific Urethritis (NSU)

Diagnosis:  Can only be diagnosed on microscopy – hence the need to send an air-dried slide to the lab/clinic  Men with urethral discharge can be treated for suspected NGU pending results of gonorrhoea/chlamydia tests

Treatment: st 1 Line: Azithromycin 1g stat nd 2 line: Doxycycline 100mg bd for 7 days rd 3 line: Erythromycin 500mg twice daily for 7 days

Patient Information:  Approximately 50% caused by chlamydia, which is sexually transmitted  Not always sexually transmitted:  Also caused by: o Urethral irritants o Foreign bodies o Alcohol (?)  Whether a sexually transmitted organism is identified or not, partner(s) should be screened for STIs and given epidemiological treatment. Around 30% of female partners of men with non-chlamydial, non-gonococcal urethritis are found to have chlamydia.  No sex until both partners complete treatment

Leaflet: “What do you know about chlamydia & NSU? “ Health Education Board for Scotland. 0131 536 5500. Download at: http://www.borderssexualhealth.org.uk/Chlamydia

Follow up:  Review at three weeks to check symptom resolution, adherence, contact tracing.  If patient is asymptomatic and partner(s) known to have been treated there is no indication for follow up unless patient wishes.

23

Chlamydial Urethritis (Chlamydial NGU or Chlamydial NSU)

Diagnosis:  Positive PCR chlamydia on urine or urethral sample.  Diagnosis is often made after the patient has been treated for NSU – treatment, contact tracing and follow-up are unchanged by a positive chlamydia result.  DO NOT DO A TEST OF CURE FOR CHLAMYDIA WITHIN FIVE WEEKS OF TREATMENT!

Treatment: As for NSU. The majority of cases will have been treated as NSU on microscopy findings at presentation, but cases of urethral chlamydial infection without pus cells on microscopy are seen.

Patient Information:  See chlamydial infection (section 4)

Follow up:  Retest for Chlamydia within 6 months (see section 4)

Gonococcal Urethritis

REFERRAL TO GUM RECOMMENDED

Diagnosis:  Presence of gram-negative intracellular diplococci on gram stained slide of discharge from terminal urethra (if air dried slide sent to the lab)  Positive PCR (with a second NAAT confirmation) for N. gonorrhoea  Positive culture for gonorrhoea from an Amies’ swab of urethral discharge  Culture confirmation is required for sensitivity testing. For this reason if possible send to BSHS for treatment. Throat (and rectal cultures in men who have sex with men) must be taken before treatment if urethral slides or PCR positive.  Diagnosis may be made after a man has been presumptively diagnosed and treated for NSU.

Treatment  Ceftriaxone 500mg intramuscular single dose o PLUS Azithromycin 1g single dose  NOTE: Ciprofloxacin no longer recommended due to resistance

 See gonorrhoea (section 4)

24 Recurrent and Persistent NSU

Referral to GUM recommended for most cases

What to consider:

NSU may persist after treatment because of reinfection Symptoms may persist even if inflammation does not Repeated courses of antibiotics may reinforce the idea that ‘something is wrong’ Immediate microscopy, available in GUM, is useful

Background:

 Symptoms may persist for 2 or 3 weeks after the effective treatment of NSU  Reinfection or treatment failure does occur, but some men are hypervigilant after an episode of NSU and squeeze to check for discharge  Retreatment of the latter group of men can exacerbate the problem  In a few cases, persistent symptoms are due to undiagnosed herpes or infection with Trichomonas vaginalis. Both are uncommon causes of urethritis.  Some men are subject to recurrent bouts of non-chlamydial NSU, occurring weeks or months after an initial episode, even if with the same partner. In these cases repeated retreatment of the partner is not necessary.

Diagnosis:  Persistence of symptoms and finding of >5 pus cells/HPF on a slide at least 2 weeks after treatment.  An air-dried slide of urethral material for Gram-staining is mandatory

 Confirm adherence

 Confirm partner(s) treated  Exclude reinfection (retest for chlamydia/gonorrhoea if initially positive)  If only persistent symptom is discharge, check whether this is true discharge or during self examination and milking of urethra

Treatment:

Persistent NSU (within 30 days of the original episode) ONLY if there is microscopic evidence of persisting urethritis:

 Azithromycin 500mg single dose then 250mg daily for 6 days plus  Metronidazole 2g stat

If there is no evidence of persisting urethritis the appropriate management is strong reassurance and discouragement from self-examination.

Recurrent NSU ( >30 days after initial episode, same partner)

Treatment: 1st Line: As for NSU, plus advise to reduce alcohol intake, increase fluid intake 2nd Line: Azithromycin 500mg single dose then 250mg daily for 6 days plus Metronidazole 2g stat

 Avoid repeated examination or treatment of a regular partner  Discourage self-examination  Do not treat symptoms without microscopic evidence of urethritis 25 4.3 Genital Ulceration

What to consider: Multiple, painful genital ulcers are usually caused by herpes simplex infection. In patients with no history of sex abroad, these can be managed safely in general practice. Single, painless or atypical ulcers are of concern and should be referred.

Background:  Other infective causes of genital ulcers are syphilis, chancroid, donovanosis and lymphogranuloma venereum. All are uncommon or rare.  There have been outbreaks of syphilis in the UK since 2000, including 200 cases per year in Scotland. 87% of cases are in men-who-have-sex-with-men. There have been a handful of cases per year in the Borders.

Referral to GUM is mandatory in cases with:  Solitary ulcer  Painless ulcers  A history of sex outside western Europe

Ideally, viral isolation (using the same swab as the chlamydia/gonorrhoea PCR swab) should be taken prior to initiating treatment, although it is possible to isolate HSV from lesions up to 24 hours after initiation of treatment.

History:  Duration, development of ulcers. Pain and tenderness. Lymphadenopathy. Regional neuralgia – buttocks and legs. Systemic symptoms – flu-like, myalgia, headache.  Especially detailed sexual history is appropriate: should include orogenital sex (HSV), details of all partners in the last 3 months (syphilis), history of orolabial cold- sore in a partner, travel, drugs, trauma.

Examination:  Genital herpes: visual examination of the external genitalia only to minimise discomfort. If not a typical clinical picture of HSV infection, a full general examination is appropriate, paying particular attention to the skin and oral mucosae.

Specimens:  As for generic STI screen (defer these if patient in severe discomfort). Plus:  Swab for HSV PCR (the same swab as used for Chlamydia – must be VERY CLEARLY labelled as an HSV swab, to avoid it going into the Chlamydia PCR run!). For PCR identification of HSV 1 or 2.  If primary syphilis suspected, or appearance not consistent with herpes, refer to GUM (Send to walk-in or referral by phone). Send blood for syphilis serology if delay expected (indicate “query primary syphilis”) G

26

Genital Ulceration - Common Diagnoses

There are currently around 200 cases of syphilis diagnosed each year in Scotland.

Initial Episode Herpes Simplex Virus Infection Diagnosis:  Often clinical. Can usually be confirmed by a positive HSV culture result (but never excluded by a negative). PCR is very sensitive – so it IS worth testing very small or  healing lesions.

Features suggesting HSV infection:  Symptoms develop within 9 (usually 3) days of sexual contact. (Delayed symptomatic presentation beyond 4 weeks of initial herpes infection is uncommon, but does occur)  Systemic flu-like symptoms (usually only in primary infection)  Localised lymphadenopathy  Regional neuralgia – buttocks and legs.  Severe external dysuria  A severe episode with systemic symptoms is likely to be newly-acquired infection

Management:  Aciclovir 200mg x5/day (or 400mg tds) for 5 days or Valaciclovir 500mg bd. for 5 days unless symptoms are very mild or are healing at presentation. If symptoms are very severe or ulceration is extensive, consider a 10 day course of therapy.  Antivirals are of less use if lesions present for >5days, but treatment is indicated if new lesions are appearing at any stage.  Saline bathing (no proof of efficacy)  Oral analgesia  Local anaesthetics may be useful in severe cases in women, as a last resort to avoid the need for suprapubic catheterisation. EMLA (Lidocaine/Prilocaine) is useful. Instillagel (Lidocaine/Chlorhexidine) is also antibacterial and is inexpensive.  Hospital admission: If signs of urinary retention, intractable pain, meningitis or pregnancy (1st or 3rd trimester)

Advice to patients: the acute episode  Adequate rest, take time off work  Drink plenty of fluids (dilute urine rather than avoid drinking to reduce need for urination)  A warm bath containing sodium bicarbonate or salt is soothing  Pass urine in the bath, or with the shower spray directed at the affected area  Patients can be referred on to the GUM clinic for further information and counselling re HSV

27

Patient Information:  The first attack is usually the worst.  Stress that although lifelong infection, recurrences can be treated if severe.  In most cases, recurrences are an inconvenience but do not require treatment with antivirals.  HSV1: 50% chance of recurrence, HSV2: 89% chance of recurrence in the first year after a symptomatic initial episode.  Recurrence rate variable. 2/3 have fewer recurrences in year 2 than year one, but 1/3 have more. Average decrease in recurrence rate is about 1 (0.8) per year.  Median recurrence rate is 4-5 episodes per year for HSV 2, 1 episode per year for HSV1. Draw parallels with cold sores in childhood.  Asymptomatic carriage common. About ¾ of new infections are from asymptomatic partners. Only 10% of people with HSV 2 antibodies give a history of genital herpes. No indication of infidelity in long-term partner.  No effect on fertility. Not a problem in pregnancy unless the primary infection occurs at the time of delivery. Many obstetricians would now allow vaginal delivery during a recurrence.  Chance of an asymptomatic female passing HSV to a male partner with whom she has regular unprotected sex is about 1% per year. Transmission rates in other circumstances are unknown but likely to be similar.  Virus more commonly excreted in the first three months after infection than subsequently.

Leaflet: “What do you know about…genital herpes?” Health Education Board for Scotland. 0131 536 5500. Download at: http://www.borderssexualhealth.org.uk/GenitalHerpes.htm

Herpes simplex – A guide. Herpes virus association 020 7607 9661 (Excellent leaflet 50p each) The Herpes Virus Association (www.herpes.org.uk) offers excellent information, leaflets, telephone helplines and newsletters for those affected by HSV

Follow Up:  In a severe primary attack review at 5 days to confirm no new lesions appearing. If new lesions are appearing- further 5 days of aciclovir.  Otherwise review at 3 weeks with HSV isolation results:  Full STI screen if deferred at first visit  Advice according to HSV type isolated  Advise patient to return in the event of further attack with severe symptoms.  No need to reattend, or for further treatment, if recurrences are infrequent and/or mild.

Treatment:  If symptoms are distressing or severe- as for primary herpes simplex virus infection.  In many cases self-management of minor symptomatic episodes with salt baths and analgesia is adequate.  Treatment with aciclovir will shorten an attack by about 1 day on average but needs to be initiated within 24hrs of symptoms starting (so is rarely useful for the current attack).  Aciclovir 200mg x5/day for 5 days, or Aciclovir 800mg three times daily for 2 days are effective and supplies can be given for future episodes. The latter option uses 12 x 400mg tablets per course and patients can be supplied with 56 tablets at an NHS cost of around £7.00. This provides enough treatment for 4 recurrences. 28

Recurrence of Genital Herpes

Most cases of recurrent genital herpes do not require antiviral treatment. Topical antivirals (e.g. Zovirax cream) are of little or no use in genital herpes.

Diagnosis:  If the patient gives a history suggestive of previous attacks but there is no virological evidence, it is worth attempting viral isolation if ulcers present.  Type-specific HSV serology is not routinely used but is available and may be helpful in a minority of cases. Refer to GUM if required.

Frequent Recurrences of Genital Herpes

An indication for referral to GUM, or phone for advice

Diagnosis:  Virological culture confirmation is required before giving suppressive therapy. Discuss with GUM if this is not the case.  If no response to suppressive aciclovir consider co-existing diagnoses (?dermatitis, candida)

Treatment:  If less than 6 episodes per year, sufficiently severe to warrant treatment, patient experiences prodrome: give supply of aciclovir 200mg x 25 to self-initiate treatment.  If >6 episodes per year (or less than 6 if severe physical symptoms or psychological sequelae), consider suppressive therapy

1st Line: Aciclovir 400mg bd. Give three months supply then review. Usual duration of therapy 12 months, then trial of withdrawal. Efficacy in prevention of recurrences is around 75%. 2nd Line: Aciclovir 200mg qid. More efficacious than above, but difficult to adhere to. 3rd Line: Valaciclovir 500mg od ONLY if aciclovir ineffective as it is much more expensive 4th Line: Famciclovir 250mg bd – ONLY after GUM review as even more expensive

Genital Ulceration of unknown cause Refer to GUM in every case

There are currently around 200 cases of syphilis diagnosed each year in Scotland. The majority are in men-who-have-sex-with-men. Perform syphilis serology if in any doubt about ulceration, and don’t hesitate to phone for advice.

29 4.4 Genital Warts and Other Lumps and Spots

What to consider: Confident of a diagnosis of warts? If so, these can be managed in general practice Should the patient be tested for other STIs? – yes, usually Is there any doubt about diagnosis? - then please refer Contact tracing is not routinely indicated for genital warts

Background:  The vast majority of genital lumps are genital warts.  Genital wart viruses (Human papilloma viruses) are very common. Between 10% and 45% of sexually active young women have evidence of infection. Men are probably similar- there are few data.  Asymptomatic and subclinical infection is common.  Some types of genital wart virus are associated with genital tract cancers. The majority of those causing warts are NOT associated with oncogenesis.  Treatment is for cosmetic reasons only. There is no evidence that treatment affects the rate of transmission.  Wart viruses are highly transmissible. In one study 64% of sexual partners developed warts between 3 weeks and 8 months after contact (mean 2.8 months).  Anatomical features sometimes confused with warts include coronal papillae (tiny papules around the corona of the glans ), sebaceous glands, vestibular papillomata and hymenal remnants.

History:  Routine sexual history (page 10).  Warts may appear months or occasionally years into a regular relationship.  Discomfort from warts is unusual unless there is co-existing candidal infection.  Warts often co-exist with bacterial STIs so ask about discharge etc.  Confirm a cervical smear history in women.

Examination:

 Warts are usually obvious. If in doubt – refer rather than treat.

 The use of a hand lens may distinguish the rough, keratinised surface of even very

small warts from the umbilicated lesions of molluscum contagiosum.

 Note whether any erythematous lesions are perifollicular (folliculitis)

 Examine the urethral meatus and perianal area in all cases.

Samples:  Routine STI testing is indicated (Page 10)  Consider referral for biopsy if single, pigmented ulcerated or bleeding lesion  If molluscum contagiosum suspected, remove ‘pearly’ core from lesions with the tip of a needle, placing in a dry universal container and sending to virology for electron microscopy for pox virus. G

30 Genital Lumps or Spots: Common Diagnoses

Genital Warts: Condylomata Acuminata

Treatment:

1) Fleshy External Genital Warts, less than 10 in number or 5cm2 in total area

1st Line: Podophyllotoxin 0.5% solution or 0.15% cream (men) or 0.15% cream (women) twice daily, 3 days weekly for 5 weeks or Cryotherapy with liquid nitrogen - repeated at two weekly intervals for 5 cycles.

* Podophyllin and podophyllotoxin contraindicated in pregnancy or if risk of pregnancy*

Note: Podophyllotoxin 0.5% solution is sold as Warticon Solution or Condyline. Podophyllotoxin 0.15% cream is sold as Warticon cream. Podophyllin in methylated spirits or paraffin is of variable strength, lower effectiveness and higher toxicity and is no longer recommended.

If partial response -

Further cycle of the same therapy

If non-response -

Change to alternative treatment (i.e. from cryo-pod or pod-cryo) or refer to GUM.

Treatment: 2) Keratinised External Genital Warts

Cryotherapy with liquid nitrogen or Cryotherapy with liquid nitrogen plus Podophyllotoxin solution or cream

(patient attends clinic for cryotherapy, self treats with Podophyllotoxin on alternate weeks)

3) External genital warts: extensive, >10 in number or >5cm in area, perianal warts

As 1), but refer unless good response by 5 cycles of therapy

4) Vaginal warts

Only if patient is aware of them and wishes them treated – refer to gynaecology

31

What if nothing happens? – Treatment-resistant warts

Warts persisting after 2 or more 5-week cycles of podophyllotoxin treatment or 10 cycles of cryotherapy, or very extensive perianal warts may respond to the immune response modifier Imiquimod. This can be prescribed through GUM- please refer.

Patient Information:  Caused by human papillomavirus  Latent period is months or years  Asymptomatic carriage is common  No implication of infidelity in regular relationship  Spread almost always sexual  New warts may appear even during treatment  About 70% of people are clear of warts after 5 weeks of therapy  Recurrence is very common  The vast majority of genital warts (>85%) are caused by viruses having no connection with cervical carcinoma.  Women with genital warts require routine 3 yearly cervical smears only and no additional intervention or screening

Condom Use:  With any new partner, or a partner with whom sex has previously been protected, use condoms while warts are being treated and for six months after clearance  With a partner with whom sex regularly took place without a condom before warts appeared, there is little evidence of benefit in starting to use condoms. There is some evidence that the rate of clearance of warts is improved in those using condoms.  Condom use cannot be guaranteed to prevent transmission. Condoms do protect against the acquisition of HPV – young people without warts can be advised that condoms will provide some protection

Leaflets: What do you know about…genital wart? Health Education Board for Scotland. 0131 536 5500 Download at: http://www.borderssexualhealth.org.uk/GenitalWarts.htm

Genital warts (looking after your sexual health), fpa UK. Order on 0845 310 1334 or

www.fpa.org.uk

32 Molluscum Contagiosum

Diagnosis:  Umbilicated pearly or waxy lesions confirmed if necessary by electron microscopy showing poxvirus.  Always screen for other STIs.

Treatment: 1st line: Cryotherapy 2nd line: Condyline liquid (as for genital warts) 3rd line: Removal of the small ‘pearls’ of white matter from the centre of each individual lesions (if few in no.)

Patient Information:  Viral infection spread by bodily contact (and possibly other routes such as shared towels)  Common in young children - spread by social contact  Spread in adults often sexual  Resolve spontaneously in 6-9 months  No need for contact tracing

Folliculitis

Diagnosis:  Perifollicular erythema occasionally with discharge of pus. If more severe may be open, impetiginous rash. May be precipitated by shaving of pubic hair.

Treatment:

 Single episode, moderate to severe: Flucloxacillin 250mg qds for 5 days

 Recurrent episodes, mild: Use Dermol 500 as a soap substitute.

Patient information:  May be precipitated by shaving of pubic hair  Other methods of depilation may reduce problem

33

4.5 Itch

What to consider: Is a sexually transmitted cause likely? If so, test for other sexually transmitted infections Is empirical treatment for crab lice or scabies indicated?

 History: Localised (where) or generalised. Duration. Contacts. Travel. Presence or absence of rash.. Previous history of skin disease/allergy/atopy. Pets. Recent .

 Examination: Full exposure of skin surface (not necessarily all at the same time). Careful examination of finger folds, skin creases (scabies), flexor and extensor surfaces of joints (psoriasis). Pubic, axillary and other body hair (pubic lice). Groin skin folds and natal cleft (fungal infections).

 Specimens: Routine STI screen is indicated. Skin scrapings from suspected fungal infection (onto sellotape on a glass slide or a black paper envelope) can be sent to mycology for culture.

Itch - Common Diagnoses

Phthiriasis Pubis (Crab Lice or Pubic Lice)

Diagnosis:  Visual or microscopic identification of adult lice, eggs or faeces. The adults are usually seen as bluish marks at the base of pubic hairs

Treatment: 1st Line: Malathion 0.5% liquid emulsion. Topically to all surfaces below neckline, concentrating on hairy areas. Wash off after 12 hours. Repeat application 7 days later. (One bottle is sufficient for 2 applications). Change bed linen, wash most recently used clothes. (Normal washing only- no need for boiling).

2nd Line: Permethrin 5% Cream.

Patient Information:

 Spread by close body contact including, but not exclusively, sexual intercourse.

 Spread from clothing or bedding requires use soon (<<24hrs) after the infected

individual

 Discourage shaving of pubic hair

 Regular partners should be treated

 Itch may persist for up to 4 weeks after treatment- discourage repeated

retreatment

34 Scabies

Diagnosis:  Severe itch may prevent sleep. Silvery lines and excoriation on finger web spaces, wrists, elbows and axillary folds. Lesions on genitals may be nodular.

Treatment:  Permethrin 5% cream applied to the whole body including the scalp, face and ears and washed off after 12h.

Patient Information:  Spread by close body contact including, but not exclusively, sexual intercourse.

 Wash clothing and bedding (hot wash>50C) after treatment. Tumble drying or

sealing clothes in a plastic bag for 72hrs will also kill mites.  Discourage shaving of pubic hair  Regular partners and household contacts should be treated.  Itch may persist for up to 4 weeks after treatment- discourage repeated retreatment. This can be relieved with Crotamiton (Eurax) cream or lotion available OTC.

Pruritus Ani

Diagnosis:  Common causes are systemic dermatoses (often with no evidence elsewhere), particularly eczema and psoriasis  Consider Tinea cruris, genital warts and threadworm (Enterobius vermicularis)

On examination:  A rash may be obvious.  Threadworm may be seen as small white 1-2cm worms, or detected by applying sellotape sticky side down to the perianal area, preferably first thing in the morning. The tape can be stuck to a glass slide and sent in a slide carrier for microscopy.

Treatment: 1st Line: Clotrimazole 1% HC is effective for tinea and candida infection

2nd Line: Piperazine 4g sachet stat, or mebendazole 100mg stat repeated in 14 days for threadworm.

35

4.6 Pelvic Pain

Females: Pelvic Inflammatory Disease (P.I.D.)

What to consider: The likelihood of pelvic inflammatory disease The possibility of competing diagnoses The implications of untreated disease for the individual (parity, age) Whether treatment can be carried out in general practice (symptom severity, need to exclude other diagnoses)

Acute/ severe disease including women with systemic symptoms and signs such as fever should be referred to the GUM clinic, or the gynaecology SHO on-call. In chronic or mild to moderate disease, referral carries less advantage, as the diagnosis is clinical and oral treatment is given. Testing for STIs must be carried out in all cases. Contact tracing and treatment of regular partners should be done regardless of the results of test for STIs

Background:  Definition: Inflammation and infection of the upper genital tract involving the fallopian tubes, ovaries and surrounding structures.  High morbidity: 8% risk of subsequent tubal after 1 episode, 10% risk of ectopic pregnancy.  Early treatment improves outcome - women who delay more than 3 days after the onset of symptoms are 3 x more likely to develop long term sequelae  More common in women under 25  Often associated with a new sexual partner  Chlamydia is the commonest cause. Both Chlamydia trachomatis and Neisseria gonorrhoea cause the initial epithelial damage allowing opportunistic upward infection with other microorganisms ie E.coli, H. influenzae and Anaerobes.  Negative tests for STI do not exclude the diagnosis.  Clinical diagnosis has very low sensitivity and specificity, but definitive diagnosis requires laparoscopy or MRI, so suspected mild to moderate cases are treated empirically  A low threshold for empirical treatment is appropriate

Diagnosis:

Symptoms and signs Pelvic inflammatory disease represents a spectrum of severity from asymptomatic 'silent' disease, through minimally symptomatic infection (which may be chronic), to severe disease which often presents acutely. There are no definitive diagnostic tests routinely available. A high index of clinical suspicion with a low threshold for empirical treatment is a common pragmatic approach.

Minimal criteria for clinical diagnosis:  Lower abdominal pain  Bilateral adnexal tenderness  Pain on cervical excitation  No evidence of a competing diagnosis- always exclude pregnancy: consider the possibility of ectopic pregnancy

36

Samples: Full microbiological tests for Chlamydia trachomatis and Neisseria gonorrhoeae must be carried out (see page 7)

Treatment:

Ofloxacin 400mg orally twice daily for 14 days plus Metronidazole 400mg orally twice daily for 7 days

and if contact/ high risk of gonorrhoea

Ceftriaxone 500mg single intramuscular dose Partners should be seen and treated regardless of the microbiological findings

 Encourage bed rest  No sexual intercourse until partner seen and treated, including chlamydia- negative PID.  Patient information as for chlamydial infection.

Delay in treatment of PID has been shown to increase the risk of infertility and ectopic pregnancy, particularly in chlamydial PID. therapy should be initiated without waiting for the results of investigations. Most women with PID are treated as outpatients, and there is little evidence that inpatient treatment with IV antibiotics is more effective than oral treatment. However, admission should be considered in certain circumstances: CDC recommendations for hospital admission with PID, from which UK Guidelines are derived:

 Severe illness  Diagnosis uncertain  Surgical emergency cannot be excluded  Pelvic abscess suspected  Patient pregnant  Patient adolescent  Patient has HIV infection  Unable to tolerate oral therapy  No response to oral therapy  Follow up within 72 hours not possible

Outpatient management:  Antibiotic therapy  Review after 72 hours in moderate/severe cases. Reconsider referral for further investigation including laparoscopy if no improvement.  All women should be seen for partner notification and information giving.

37

Follow up:  Women with severe acute disease should be reviewed at 72 hours  All women should be seen on completion of therapy (2 to 3 weeks) to confirm adherence, resolution of symptoms and partner notification.

Partner notification

Male partners of women with PID should be treated whether or not C. trachomatis (or N. gonorrhoeae) is isolated. If N. gonorrhoeae are not seen on gram stained slides from the female urethra and endocervix, or the male urethra, at first attendance, it is reasonable to treat a male partner solely for suspected C. trachomatis infection. i.e. treat as for NGU.

Standard advice is to avoid intercourse until follow up appointment. Women may be counselled regarding the risk of infertility following PID.

38

Males: Prostatitis

It is important to differentiate between acute bacterial prostatitis and chronic abacterial prostatitis/prostatodynia.

Classification: Acute Bacterial Prostatitis – evidence of acute bacterial infection Chronic bacterial prostatitis – evidence of recurrent bacterial infection Chronic pelvic pain syndrome – no demonstrable infection CPPS Inflammatory (formerly chronic abacterial prostatitis) CPPS Non-inflammatory (formerly prostatodynia)

Acute bacterial prostatitis

Aetiology: Coliform organisms and other urinary tract pathogens.

Symptoms: An acute, often severe systemic illness:  Fever  Chills  Symptoms of urinary tract infection such as dysuria and frequency.  Low back pain and perineal pain. Sometimes penile or rectal pain.

Signs:  Of systemic bacteraemia  Of local inflammation: smooth warm, extremely tense and tender prostate (avoid rigorous examination)  Secondary retention occasionally occurs

Diagnosis: MSSU Blood cultures

Treatment: Ofloxacin 200mg twice daily for 28days

Follow-up: Renal tract ultrasound and cystoscopy are indicated in to exclude obstruction as a predisposing cause of infection

Chronic Bacterial Prostatitis Recurrent bacterial UTIs due to coliforms, usually in middle-aged men. The diagnosis is made on a combination of symptoms and repeated isolation of the same organism. Treat according to antibiotic sensitivity of this organism.

39 Chronic Pelvic Pain Syndrome

Pain, as for acute bacterial prostatitis, persisting for more than 3 months. An indication for referral to GUM or Urology

The aetiology is obscure. It is not caused by infection, either with coliform organisms or sexually transmitted pathogens such as chlamydia. Reflux of urine into the prostatic ducts has been postulated as a mechanism for inflammation.

Chronic prostatitis is divided into chronic bacterial prostatitis, chronic abacterial prostatitis-inflammatory and chronic abacterial prostatitis-non-inflammatory. The distinction between the conditions is not fully defined and subject to controversy. Management is based on clinical assessment and empirical therapy.

Symptoms: Persistent or recurrent pain in the genital area lasting more than 3 months is the cardinal feature. This may be either spasmodic/acutely recurrent or chronic/persistent. Characteristically pain radiates to either  one or both testicles  the tip of the penis  the groins  across the lower abdomen

Pain may be worse during ejaculation or after intercourse. Urinary frequency or feeling of inadequate bladder emptying is occasionally present.

Signs: There may be few or no clinical signs.

Management: Sexually transmitted disease, non-gonococcal urethritis and urinary tract infection should be excluded. Localisation procedures (e.g. Stamey’s procedure) are no longer recommended, even in the specialist clinic. Men over 40 yrs should be referred to urology.

Treatment: A prolonged course of ciprofloxacin 500mg mg twice daily is usually offered. An initial course of 28days may be continued for several months, depending upon the response. Smooth muscle relaxants may be helpful e.g. alfluzosin 2.5mg tds. NSAIDS have also been shown to be of benefit.

40

4.7 Epididymitis/Epididymo-orchitis

Refer to GUM/Surgeon on call if doubt about diagnosis

What to consider: Is an STI cause likely- sexual history, age, contacts? Is there any possibility of testicular torsion?

Background:  In men under 35 yrs commonly caused by chlamydial infection or gonorrhoea.  In men over 35 by Gram-negative enteric organisms.  There is considerable overlap between the two so full sexual history is helpful.  STI testing should be done in all sexually active cases

Diagnosis: Tender, enlarged epididymis or testis (epididymo-orchitis) with or without systemic symptoms. Usually unilateral. Can occur without accompanying urethritis. The main differential is testicular torsion - more likely in younger men. If there is any doubt about the diagnosis refer for urgent surgical review and ultrasound scan of testis. STI screen should be performed (Page 10) prior to empirical treatment and referral to GUM.

Treatment:

1st Line: Doxycycline 100mg orally twice daily for 14 days

2nd Line: Erythromycin 500mg orally twice daily for 14 days

plus Ceftriaxone 500mg single dose if contact/suspicion of gonorrhoea

No suggestion sexual transmission or men over 35, cause unknown:

1st Line: Ofloxacin 400mg by mouth twice daily for 14 days 2nd Line: Ciprofloxacin 500mg orally twice daily for 10 days

Analgesia with Non-steroidal anti-inflammatory drugs may be helpful.

Patient Information:  Partner(s) must be seen and treated  No sex until patient and partner have completed treatment  Scrotal support/supportive underwear may be helpful  Symptoms may take a month to resolve

Follow up: Review at 14 days - if symptoms persist, further 14 days antibiotics. If proven UTI refer Urologist.

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5 Sexually Transmitted Infections

5.1 Chlamydia Management of patients with chlamydial infection can be undertaken in any setting, provided contact tracing can be completed. Referral to GUM is welcomed but is not mandatory.

Sexually active patients with symptoms or signs of chlamydia:

Women Men Vaginal discharge Dysuria Post coital or intermenstrual Urethral discharge/ discomfort bleeding Dysuria Epididymo-orchitis Pelvic pain Reactive arthritis Deep dyspareunia Cervicitis (friable or bleeding on contact)

Samples:

Men: First voided urine. (not necessary to use early morning urine, or to hold urine for two hours beforehand)

Women: Sample choice can be based on patient preference and convenience. Self-obtained lower vaginal swab (SOLVS) or clinician-taken lower vaginal or endocervical swab are equally sensitive and acceptable. All are as sensitive as (or possibly slightly more sensitive than) first voided urine. Urine: 15-20ml sample in universal container with a standard microbiology lab form.

Self-obtained lower vaginal swab: the standard test kit for endocervical swab can be used by the patient if preferred to examination

Options:

a) Treat in Primary Care: appropriate in most cases and likely to be preferred by the patient. b) Treat in Community Pharmacy under PGD. c) If at high risk of other STIs, consider referral to Borders Sexual Health – without treatment if possible. Note that patients referred to sexual health services after being treated DON’T COME, so this is not a satisfactory means of partner notification.

Testing for other sexually transmitted infections is not routinely required except in:

 Symptomatic men  Men who have sex with men  Sexual contact overseas, or with a partner from overseas

Treatment: uncomplicated Chlamydial infection in all patients *: Azithromycin 1g single dose

42 * Azithromycin 1g single dose is not licensed for use in pregnancy but is widely used and recommended by SIGN, BASHH and other bodies.

Advise No sex (including vaginal or anal sex with a condom, or oral sex) for 7 days after treatment, or 7 days after partner treated, whichever is latest.

Notify all partners in the last six months or the last regular partner (one month for symptomatic males)

Partner notification options:

i. Refer cases to Borders Sexual Health (any clinic: GUM/Family Planning/Drop-in: see www.borderssexualhealth.org.uk). Best to give us details by phone or email as well in case they don’t come!

ii. ‘Shared care’: Get partner details and patient details including mobile phone number(s) and pass to Community Nurse Specialists (Phone: 01896 663700 / email: [email protected])

iii. Refer all cases to the Practice Chlamydia Co-ordinator:

Name…………………………………………………………..

iv. Give a ‘Contact of Chlamydia’ card to index patient (the minimum). Partners can take this card to a GP, clinic or Borders Community Pharmacy for treatment.

1. Follow up

Test of cure is not required. If patient wishes test of cure, wait at least 5 weeks before retesting

Patient Information:  Spread is through sexual contact  Asymptomatic infection may precede symptoms in men and women by months or years.  Not necessarily an implication of infidelity in long-term partner.  Potential for complications if untreated: PID, epididymitis.  Patient and partner must complete course of treatment before having sex.

Leaflets:

(charge for leaflets)

What do you know about...chlamydia & NSU? www.hebs.scot.nhs.uk

http://www.borderssexualhealth.org.uk/Chlamydia

43 5.2 Gonorrhoea

REFERRAL TO GUM RECOMMENDED

What to consider: Will the patient attend GUM? – if so, this is preferred option If not, can GUM give support in management – please phone for advice Can contact tracing be carried out? GUM health advisers can undertake contact tracing if details of patient contacts are passed on.

Background

 Gonorrhoea presents with urethritis in men, vaginal discharge and pelvic inflammatory disease in women, proctitis in women and homosexual men.

 Disseminated gonococcal infection is very uncommon.

 Asymptomatic infection of the pharynx, urethra, and rectum occurs.

 Antibiotic resistance is common. Resistance to Ciprofloxacin, and Tetracyclines is widespread. The concentration of Cefixime required to kill gonorrhoea in sensitivity tests has been gradually rising and there are isolated reports of resistance. In early 2011, the recommended treatment for gonorrhoea in the UK was changed to Ceftriaxone 500mg single IM dose.

 On finding gonorrhoea at one site, we check other potentially infected sites for infection. We also routinely do test of cure after treatment. Although treatment failure is rare if the treatments below are used, reinfection is common.

Diagnosis: Neisseria gonorrhoeae cultured or identified by confirmed PCR from the endocervix, pharynx, urethra or rectum

Presence of gram-negative intracellular diplococci on a gram stained smear from the urethra in males and the urethra or cervix in females. (If an air-dried slide sent to the lab for staining)

Treatment: Uncomplicated gonorrhoea Ceftriaxone 500mg single intramuscular dose Second line: Cefixime 400mg single oral dose

PLUS

Azithromycin 1g stat for possible chlamydial co-infection (there is also some evidence that eradication of gonorrhoea from the throat is better with the addition of azithromycin)

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Treatment: Complicated Gonorrhoea

 Epididymitis: Ceftriaxone 500mg intramuscularly plus Doxycycline 100mg b.d. for 14 days or Erythromycin 500mg qds for 14 days

(PID) Ceftriaxone 500mg intramuscularly plus Ofloxacin 400mg orally twice daily for 14 days plus Metronidazole 400mg orally twice daily for 7 days

Patient Information:

 All sexual partners must be seen and treated

 No sexual intercourse until test-of cure result negative

 Asymptomatic infection may precede symptoms in women by months

 50% of men have symptoms by day 6

Leaflets: “What do you know about…gonorrhoea?”

http://www.borderssexualhealth.org.uk/Gonorrhoea.htm

Follow Up: Review at 7 -14 days for test of cure (if culture positive diagnosis) Advise patient to return sooner if no improvement in symptoms in 4 days.

 Gonorrhoea Contacts Epidemiological treatment is indicated if the risks of unnecessary treatment are thought to be less than the risk of complications or further transmission. In practical terms, this means that if patients are unwilling or unable to attend GUM, they should be treated. Take PCR tests from ALL potentially exposed sites:

Females:  Endocervical or vulvovaginal, throat and rectal culture or PCR (separate, labelled swab from each site)

Males:  Urethral smear and throat PCR in all males (separate, labelled swab from each site)  Rectal PCR in all men who have sex with men

Patient Information: Gonorrhoea contacts No sexual contact (including oral sex) until partner has test of cure.

45 6: Hepatitis

Diagnosis and management of hepatitis is not covered here: serological testing and vaccination for sexual risk is considered.

Hepatitis A

Men who have sex with men, those with hepatitis C and HIV are at risk.

Test: Hepatitis A IgG is the test for prior exposure. Hepatitis A IgM indicates acute Infection, so only indicated in the investigation of symptomatic patients.

Vaccination: Usually given with Hepatitis B as Twinrix 1ml IM at 0,7 and 21 days with a booster at 1 year.

There is no test for vaccine induced immunity

Hepatitis B Screening: Screen members of at risk groups before first vaccination. In those who may not attend for follow up and are at significant risk it is acceptable to test and vaccinate at the same time. At risk: Homosexual men Male and female sex industry workers IVDUs and their sexual partners Partners of known carriers Patients from tropical Africa, Far East and other endemic areas.

Test: Hepatitis B core antibody (HepBcAb) is the screening test. If negative, offer vaccination . If positive, test for Hepatitis B surface antigen (HepBsAg) and Hepatitis B surface antibody (HepBsAb). See below for interpretation of serology.

Vaccination: Engerix B 1ml im at 0, 7 and 21 days, with a booster at 1 year

if Hepatitis A vaccination also indicated:

Twinrix 1ml im at 0, 7 and 21 days, with a booster at 1 year

Alternative regimes for both vaccines:

0, 2 and 6 weeks, with a booster at 1 year 0, 1 month and 6 months

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Follow up:

Hepatitis B surface antibody ( HepBsAb) level checked at 6-8 weeks after last vaccination.

Level Action >100mIU/ml No further boosters or blood tests

10-100mIU/ml Give further dose of vaccine, repeat HepBsAb level at 4-6 weeks. If still partial response, give 1 further booster and test again. If levels are still non protective then give no further vaccination.

<10mIU/ml Give a further dose of vaccine 6 months after the last, repeat anti-HBs six weeks later. If still a partial response, give a further booster and retests again 6 weeks later. If still <10mIU, give no further vaccine but advise as non-responder.

Non responders should be informed that they can receive HBIG ( Hep B Immunoglobulin) if they have a (definite) hepatitis exposure in the future.

Interpretation of Hepatitis Serology HepBsA HepBsAb HepBeA HepBeA HepBcA HepBcIg g g b b M Acute Hep B + - + - + + Infection Previous - + - +/- + - exposure: immune Carrier of + - - + + - low infectivity Carrier of + - - - + - Intermediat e infectivity Carrier of + - + - + - high infectivity Vaccine - + - - - - induced immunity Previous - - - +/- + - exposure*

47 Hepatitis B surface antigen (HepBsAg): Active infection with hepatitis B Hepatitis B surface antibody (HepBsAb): Immunity to hep B, naturally or vaccine induced Hepatitis B e antigen (HepBeAg): Acute HepB infection or chronic carrier of high infectivity. Hepatitis B e antibody (HepBeAb); Resolving acute Hep B infection or chronic carrier, low infectivity Hepatitis B core antibody (HepBcAb): Natural infection with Hep B at some time in the past. Hepatitis B core IgM (HepBcIgM): Acute infection with Hep B

*If there is evidence of previous exposure but HepBsAb is negative there is no indication for vaccination.

Hepatitis C

Screening Screening may be offered to those in risk groups and anyone concerned about the virus. Clarify what is the perceived risk factor- many people have misconceptions. Risk groups:

Intravenous drug users

HIV+ve (all groups) Ex users (even just once!) Needlestick from Hep C +ve index High risk

Regular sexual partners of IVDUs Transfusion outside western Europe, N.America, Australia and NZ. Transfusion in UK before 1991 Tattoos Some risk

The rate amongst regular female partners of male drug users (seroprevalence 85%) is 8%. Casual sexual partners of those with, or at risk of, Hepatitis C can therefore probably be assumed to be low risk.

A diagnosis of Hepatitis C has significant implications for the patient and should be discussed in full. Points to consider.

80% of patients eventually (15-20yrs) develop chronic hepatitis 20-30% develop cirrhosis 50% of cirrhotic patients develop life threatening complications but Investigation will involve liver biopsy Treatment involves once weekly subcutaneous injections over several months and is effective in less than 50%

48 The main benefit of testing is to allow the patient to stop using alcohol which appears to slow progression of the disease.

Test

Screening test: Hepatitis C antibody

If positive: Hepatitis C viral RNA and repeat Hep C antibody

Acute exposure: Incubation period 6 - 8weeks Acute illness in only 10% Test for Hepatitis C antibody at 3 and 6 months. Interferon may be used for acute, asymptomatic Hepatitis C infection: refer to GI liver service if acute infection.

Patient Information

 Approx 20% develop cirrhosis after 20years  Interferon +/- ribavirin is effective in around 50%  Risk of sexual transmission <10% in lifetime partner  Barrier contraception will protect  Low risk of vertical transmission  Risk from needlestick approx 3% (much higher than HIV)

49 7. Post-exposure prophylaxis for Sexual Exposure to Blood-Borne Viruses (PEPSE)

Principles for the management of patients exposed, or potentially exposed to blood-borne viruses through sex are similar to those for occupational exposure (see Borders Needlestick Good Practice Guidelines). Cases of sexual exposure should be discussed with the GUM/ID consultant on call. The following notes may be helpful.

For needlestick exposure the risk of acquiring infection is approximately 0.3% for HIV, 3% for Hepatitis C and 30% for Hepatitis B (if HepB eAg +ve)

Sexual exposure may occur through consensual or non-consensual sex. Patients who are HIV+ve and under care should be aware of the availability of PEPSE. Many of those with regular partners who are HIV negative will have packs of PEP drugs at home for self-initiation of treatment in the event of condom burst or other exposure.

Hepatitis B: All cases of suspected exposure to BBV should receive the first dose of a course of vaccination against Hepatitis B unless known to be Hepatitis B immune. Post-exposure vaccination is effective if the first dose is given up to 10 days after exposure. See section 6.

HIV Drugs for post exposure prophylaxis for HIV are available at the A+E Dept, Borders General Hospital, BGH Pharmacy and the Borders Sexual Health Clinic, Currie Road, Galashiels. Advice should usually be sought from a GUM/ID consultant before giving PEPSE.

Assessing risk: The risk of HIV transmission in sexual exposure is the risk of transmission per exposure x the risk of the index case being HIV positive.

Risk of transmission per exposure for sexual contact is

Receptive anal sex 0.1-3.0% Receptive vaginal sex 0.1-0.2% Insertive anal sex 0.06% Insertive vaginal sex 0.03-0.09% Receptive oral sex 0 - 0.04%

To calculate the risk to the individual, multiply the risk activity by the known or estimated seroprevalance in the index case:

Known HIV positive: 1.0 Homosexual man, Scotland, unknown status 4.4% Injecting drug user, Scotland, unknown status 0.5% Heterosexual by region of birth, unknown status: Scotland 0.01- 0.1% UK 0.1-0.5% 50 Other Europe 0.2-2% Sub Saharan Africa 6-12%

In most cases of exposure in Scotland prophylaxis is only recommended if the source ‘donor’ case is known to be HIV positive.

Recommendations, source known HIV positive

Receptive anal sex Recommended Receptive vaginal sex Recommended Insertive anal sex Recommended Insertive vaginal sex Recommended Receptive oral sex Consider Fellatio with ejaculation Consider Splash of semen in eye Not recommended Fellatio, no ejaculation Not recommended

If the source is of unknown status, PEPSE would be recommended only in the highest risk situation (receptive anal or vaginal sex) if the source came from a high risk group or an area of HIV high prevalence. It is recommended that all cases in which the source is of unknown status are discussed with a consultant.

Giving PEPSE  The aim is to give PEP within 1 hour of exposure. Benefit reduces after 12 hours but there may be some benefit in the highest risk cases of giving the first dose up to 72 hours after exposure.

 If the source is known to be HIV positive, get details of name, DOB, consultant and treatment centre if possible. Details of treatment history, CD4 and viral load are required.

 If the source is high risk but status unknown, consider HIV testing source (liaise with GUM consultant/health adviser if required).

 PEP is thought to reduce the risk of seroconversion by 80%

 The PEP pack contains Truvada (Tenofovir/emtricitabine) and Kaletra (lopinavir/r). The pack contains 3 days supply and a leaflet outlining side effects. The drugs must be taken for 4 weeks. Patients should be reviewed in the GUM clinic within 3 days of starting PEP. In cases where the index case is on antiretroviral treatment, the PEP treatment may be modified to suit.

 Take baseline FBC, U+Es, liver function tests and serum to store. If the patient has significant prior HIV or Hepatitis risk, consider baseline testing.

 Side effects are listed in the BNF. Kaletra often causes diarrhoea – give a regular supply of Loperamide if required.

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8. Pelvic Pain

Patient Information Leaflet

Pelvic pain (lower abdominal pain) in women has many causes. One cause is infection of the (womb) and fallopian tubes. This is called Pelvic Inflammatory Disease or PID. PID can be triggered by a variety of infections. The commonest is chlamydia.

If PID is not treated it can cause damage to the fallopian tubes. The fallopian tubes carry the egg (ovum) from the ovary to the womb. Damage to the tubes can cause problems:

 the woman may become infertile – that is where she is unable to become pregnant.  if she does become pregnant, the fertilised egg sometimes grows outside the womb, because the tube is partly blocked or damaged – this is an ectopic pregnancy and can be dangerous.  damage can cause pain that continues after the infection has gone– called chronic pelvic pain.

All of these problems are quite UNCOMMON after PID, but because they CAN happen, we think of PID as a potentially serious problem.

It is not always possible to make a definite diagnosis of PID by a medical examination. It is possible to test for chlamydial and gonococcal infections but these tests are negative in many cases of PID. Many women with pelvic pain suspected to be PID turn out NOT to have PID after all.

Because of the serious problems that can result from untreated PID, we offer treatment to anyone who is suspected may have PID:

 We know that the sooner treatment is started, the lower the chance of problems.  We usually start the treatment before any test results are available.  The treatment is usually a 2-week course of antibiotics.  The aim of treatment is to cure any infection as quickly as possible.

As a result, we sometimes give a course of treatment to women who do not actually have PID. We also advise that any regular sexual partner is treated in case an infection is passed back and forth between partners. Again, this results in some men taking treatment they may not require. All of these people are taking treatment to make sure that those who do have an infection have it cured.

What does the antibiotic treatment do? If a woman has PID, treatment with antibiotics will cure the infection, although it might not undo any damage that has already occurred.

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I have finished the treatment but I still have pain? It may take several weeks for the pain and discomfort to settle down – the infection will clear with the antibiotics but the inflammation takes longer to get better.

The pain is worse than when I started the treatment? If you have been treated for PID and the pain is getting worse, this may be because there is another cause of the pain and you may need further tests. If this is the case, come back to let us know.

53 9. Notes on Diagnostic HIV testing

From Joint BHIVA/RCP/RCGP UK Guidance on HIV testing http://www.bhiva.org/HIVTesting2008.aspx, Borders Sexual Health leaflets on HIV testing.

Who should be tested for HIV Infection?

Universal HIV testing is recommended in all of the following settings:

1. GUM or sexual health clinics 2. antenatal services 3. termination of pregnancy services 4. drug dependency programmes 5. healthcare services for those diagnosed with tuberculosis, hepatitis B, hepatitis C and lymphoma.

HIV testing should be also routinely offered and recommended to the following patients:

1. all patients presenting for healthcare where HIV, including primary HIV infection, enters the (see table of indicator and section on primary HIV infection) 2. all patients diagnosed with a sexually transmitted infection 3. all sexual partners of men and women known to be HIV positive 4. all men who have disclosed sexual contact with other men 5. all female sexual contacts of men who have sex with men 6. all patients reporting a history of injecting drug use 7. all men and women known to be from a country of high HIV prevalence (>1%*) 8. all men and women who report sexual contact abroad or in the UK with individuals from countries of high HIV prevalence.* * for an up to date list see http://www.unaids.org/en/KnowledgeCentre/HIVData/Epidemiology/latestEpiData.asp

Clinical indicator diseases for adult HIV infection

AIDS-defining conditions Other conditions where HIV testing should be offered

Respiratory Tuberculosis (Bacterial pneumonia): Pneumocystis Proven bacterial pneumonia; any episode with risk factor(s) for infection Proven bacterial pneumonia (2 episodes in one year), regardless of risk factors Aspergillosis

Neurology Cerebral toxoplasmosis Aseptic meningitis /encephalitis Primary cerebral lymphoma Cerebral abscess Cryptococcal meningitis Space occupying lesion of unknown cause Progressive multifocal Guillain–Barré syndrome leucoencephalopathy Transverse myelitis Peripheral neuropathy Dementia Leucoencephalopathy

Dermatology Kaposi’s sarcoma Severe or recalcitrant seborrhoeic dermatitis Severe or recalcitrant psoriasis Multidermatomal or recurrent herpes zoster Gastroenterology 54 Persistent cryptosporidiosis Oral candidiasis Oral hairy Chronic diarrhoea of unknown cause Weight loss of unknown cause Salmonella, shigella or campylobacter Hepatitis B infection Hepatitis C infection Oncology Non-Hodgkin’s lymphoma Anal cancer or anal intraepithelial dysplasia Lung cancer Seminoma Head and neck cancer Hodgkin’s lymphoma Castleman’s disease Gynaecology Cervical cancer Vaginal intraepithelial neoplasia Cervical intraepithelial neoplasia Grade 2 or above Haematology Any unexplained blood dyscrasia including: •thrombocytopenia • neutropenia • lymphopenia Ophthalmology Cytomegalovirus retinitis Infective retinal diseases including herpesviruses and toxoplasma Any unexplained retinopathy

ENT Lymphadenopathy of unknown cause Chronic parotitis Lymphoepithelial parotid cysts Other Mononucleosis-like syndrome (primary HIV infection) Pyrexia of unknown origin Any lymphadenopathy of unknown cause

Any sexually transmitted infection

How to test for HIV Infection.

It is NOT necessary to perform full pre-test counselling on all patients undergoing HIV testing. A two tier approach is recommended: most patients are at low risk of HIV and require testing with informed consent only.

The essential elements that the pre-test discussion should cover are: • the benefits of testing to the individual • details of how the result will be given.

Where testing is offered in an individual presenting with an HIV indicator condition, it is appropriate to introduce testing along with discussion of other routine tests. This is best done at the time of the initial tests – to normalise the procedure and avoid the HIV test being presented as unusual or exceptional. For example:

‘We will need to do some routine blood tests to find out what is going on. We usually do an HIV test as part of this – is that OK with you?’

‘We need to do some tests to make a diagnosis. One of these tests is a test for HIV – do you have any concerns about this?’

The response to this question leads naturally into a risk assessment for HIV infection. Risk assessment in not essential, but may help in indicating the likelihood of a positive HIV result and the need for any further discussion about the test and its implications.

55 The ‘Edinburgh’ Risk Assessment Table:

 Have you ever been tested for HIV?  Ever thought that you might be at risk of HIV (if yes, why)?  Have you had unprotected sex (vaginal or anal) with: o a partner from Africa, Asia or W. Indies o a male partner (men) or bisexual partner (women) o an HIV positive partner o a partner who has injected drugs o a sex worker (or been paid for sex).

 Have you ever: o injected drugs o had a needlestick injury o been raped.

Sensitivity of this assessment in Lothian GUM Clinic: Missed only 1 of 29 positive cases in 3000 HIV tests (2003/4).

Only 2 of 113 positives in 26,000 tests had no risk factors and no STI/HIV symptoms (2005-2007).

No risk factors: If no risk factors are identified and the patient is asymptomatic an unexpected positive result is unlikely. Remember that the background prevalence of HIV in the UK is around 2/1000, so the majority, even of those with HIV indicator conditions, will be HIV negative.

 Test with informed consent  Give a leaflet explaining the test  Address any issues raised re confidentiality, insurance, treatment  Explain the window period for infection if relevant  Arrange to give result

Risk factors identified: If the clinical history and or examination reveals more than one HIV indicator condition (eg a past history of shingles), or risk factors for HIV acquisition are identified, a more detailed pre-test discussion may be indicated.

Full pre and post test discussion for HIV testing might include:

 Information on the test and its implications  Informed consent  Discussion on extent and limits of confidentiality  Preparation for test outcome: effect on health, life expectancy, sexual and emotional relationships, existing children and future procreation, treatment, psychological impact, sources of support, visas, travel and residency.  Insurance and occupational health  Onward referral and care  Post test counselling, giving support and follow up to those with positive results.

Remember that these issues can be dealt with in the event of a positive result – in the same way that the implications of any other significant diagnosis is dealt with. It is not necessary to discuss all of the above with every patient, and the discussion should be tailored to the patients concerns.

56 Remember that even the highest risk test is much more likely to be negative than positive.

HIV window period: HIV antibody may not be present in the blood for up to three months after acquisition of the virus. Patients who have had a high risk exposure within the preceding three months should be advised to retest. This advice remains valid, although currently available tests are very unlikely to remain negative for more than one month after acquiring the virus. If a patient is at high risk, do not defer the test – test now and test again. Around 50% of onward HIV transmissions occur within weeks of infection.

For advice on testing, dealing with a positive result, additional support or training, contact Borders Sexual Health

Appointments and advice: 01896 663700 Nurse Specialists: 01896 663705

Dr Dan Clutterbuck email: [email protected] For consultant advice by phone, use the numbers above to be directed appropriately, or contact NHS Lothian switchboard on 0131 536 1000

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01896 663700

www.borderssexualhealth.org.uk

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