WOMEN ANDKing NEWBORN Edward Memorial HEALTH SERVICE Hospital ObstetricsKing Edward & Gynaecology Memorial Hospital CLINICAL PRACTICE GUIDELINE Sexually Transmitted Infections (STI) This document should be read in conjunction with the Disclaimer Contents Screening tests for sexually transmitted infections .......................... 2 Specimen collection ................................................................................................ 2 Screening tests ........................................................................................................ 2 Equipment ............................................................................................................... 2 Summary table for screening tests1 ......................................................................... 3 Screening tests: Asymptomatic patients (male & female) ................ 5 Procedure: Routine screening ................................................................................. 5 Screening tests: Symptomatic female ................................................ 7 Procedure ................................................................................................................ 7 Screening tests: Symptomatic male ................................................... 9 Routine screening in symptomatic men ................................................................... 9 Interpretation of treponemal serology .............................................. 10 Cryotherapy ........................................................................................ 11 Indications ............................................................................................................. 11 Procedure .............................................................................................................. 11 Post treatment management ................................................................................. 11 Vaginal discharge .............................................................................. 12 Testing of vaginal discharge .................................................................................. 12 Causes of an elevated vaginal pH (>4.5) .............................................................. 13 The value of microscopy and a gram stain smear ................................................. 13 Interpretation of a report ........................................................................................ 13 Vaginitis1 ............................................................................................................... 15 Cervicitis1 .............................................................................................................. 16 Urine collection .................................................................................. 16 Chlamydia, Condylomata acuminata (genital warts), Gonorrhoea, Herpes, Syphilis, Trichomoniasis ..................................................... 17 Children under 14 who are diagnosed with a STI ............................ 17 References and resources ................................................................ 18 Sexually Transmitted Infections (STI) Screening tests for sexually transmitted infections Specimen collection See Clinical Guidelines: Vaginal Procedures: Speculum Examination; Low Vaginal, High Vaginal, Endocervical and Rectal swabs; Papanicolaou (Pap) smear Screening tests Take a detailed sexual and drug history.1 The patient’s privacy and confidentiality are maintained according to relevant laws, policies and professional codes of ethics/conduct. Essential tests1 Women presenting for a sexually transmitted infection (STI) / HIV assessment, should be offered screening for1: Chlamydia Syphilis Hepatitis B2 Gonorrhoea HIV3 Hepatitis A: If symptomatic or other risk factors e.g. Hepatitis C infection or a history of male to male and / or oro-anal sex, and if there is an intention to vaccinate if negative.1 Hepatitis C: If clinical suspicion e.g. History of intravenous drug use (IVDU),1 incarceration, acute hepatitis4 Note: Gain informed consent and provide counselling / support as required.1-6 Additional tests Consider testing for other (non-notifiable) diseases1 such as: Genital herpes1 Trichomoniasis1 Bacterial Candidiasis. vaginosis Also consider testing for: Donovanosis – when lesions are present & other causes have been excluded e.g. herpes, syphilis1 Cervical screening test (CST)- should be performed on all new patients, unless one has been performed in the last 6 weeks. Equipment 3x Swab packs (with charcoal transport medium plus a slide) to collect: 1. A high vaginal specimen (HVS) for culture & make a smear on glass slide for microscopy 2. Cervical discharge (if present) for culture and make a smear for microscopy 3. For urethral microscopy and anal culture. Glass slide in slide container for urethral, vaginal and endocervical swab (ECS) smear Dry swab for collection of ECS for chlamydia and gonorrhoea PCR Urine container for collection of first void urine for Chlamydia and Gonorrhoea PCR Obstetrics & Gynaecology Page 2 of 20 Sexually Transmitted Infections (STI) Jumbo cotton swabs – for wiping away secretions Narrow range pH paper (range 4.0-6.0) Cervical Screening Test equipment See Clinical Guideline, O&G: Vaginal Procedures: Cervical Screening . Speculum Lubricant. Optional charcoal swab for anal gonorrhoea testing Optional charcoal and Dry swab PCR test for oropharyngeal testing for gonorrhoea and chlamydia Optional dry PCR swabs X2 for urethral and endocervical PCR testing for Mycoplasma genitalium Optional dry PCR swab X1 for high vaginal trichomoniasis PCR Summary table for screening tests1 Screening Specimen collection Additional information Test vaginal pH A HVS may exclude other pathogens.1 AND Cervical screening is taken prior to an Obtain a charcoal HVS (& slide) ECS when required.1 for culture and sensitivity.1 Ensure mucus is cleared from the cervix AND with a ‘jumbo’ cotton swab. Collect Dry swab ECS for If the cervix is inflamed or pus is present Chlamydia PCR & place swab also collect an ECS for culture and 1 back into container. sensitivity. Chlamydia / Collect Charcoal ECS for culture Consider collecting 2x throat and anal Gonorrhoea and sensitivity – apply to slide, dry swabs for PCR and culture and then place into charcoal sensitivity if sexual practices pose risk or medium.1 if patient is named contact of 1 AND gonorrhoea. Obtain a 20ml first void urine for PCR1 OR If urine is not available take a dry urethral swab for PCR.1 Collect serology (5ml red or HIV, Hepatitis gold top serum tube)1, 2 Collect serology1 Take the dry swab from the inner edges AND of the ulcer.1 Syphilis If an ulcer is present collect The ulcer can be cleaned with saline if 1 a dry swab for PCR1 required. Collect a dry swab at or near The specimen should be clearly labelled the edge of the ulcer for ‘for Donovan bodies’, or ‘Genital Ulcer Donovanosis PCR1 Disease’. AND Impression smear – gently clean the Impression smear (scrape / lesion with a gauze swab and saline. Obstetrics & Gynaecology Page 3 of 20 Sexually Transmitted Infections (STI) slide)1 Squeeze the lesion gently. Press a OR clean slide onto the lesion to collect Crush smear1 exudate, or swab the lesion vigorously OR and make a smear from the internal Punch biopsy1 lesions.1 Crush smear – if possible remove and place granulation tissue into saline and send to lab.1 Collect a vaginal pH1 Culture is not routinely performed.1 AND Diagnosed with any 3 of these criteria: Bacterial HVS (& a smear on glass Vaginal pH>4.5, “fishy” malodour, Vaginosis slide).1 characteristic discharge & presence of clue cells.1 Collect specimen as per Swab for NAAT (PCR) Genital instructions provided by the KEMH Herpes collection kit. Obtain a vaginal pH1 Vaginal pH >4.51 1 Trichomoniasis AND NAAT is useful. HVS PCR swab Note: All women having screening tests for STIs should be offered Cervical screening at the same time when meeting the criteria for the testing. Obstetrics & Gynaecology Page 4 of 20 Sexually Transmitted Infections (STI) Screening tests: Asymptomatic patients (male & female) Aim To inform staff of the STI screening for patients who present as asymptomatic. Background Although most patients present as asymptomatic, some may have a sexually transmitted infection (STI).1 Sexual health checks should be a ‘normalised’ part of routine health care.1 Patients presenting for other tests, such as cervical screening, contraception or wellness checks, provide an opportunity for healthcare practitioners to offer screening.1 Patients can also request STI screening tests.1 Procedure: Routine screening All patients 1. Brief sexual / drug history- consider relevant investigations.1 2. Consider serology: Syphilis1 HIV antibody1 HSV-2 serology Hepatitis B1: If previously unvaccinated: HBsAg / HbcAb If previously vaccinated: HBsAb Hepatitis A if: If symptomatic or a history of MSM and / or oro-anal sex, and if there is an intention to vaccinate if negative.1 Hepatitis C if: IVDU,1 MSM, or HBV carrier or sex industry worker (SIW) Abbreviations: HBV: Hepatitis B virus; HIV: Human immunodeficiency virus; HSV-2: Herpes simplex virus type 2; IVDU: Intravenous drug use; MSM: Men who have sex with men, SIW; cervical screening test (CST) 3. Anal swabs (x2) if: Receptive anal sex (1. Charcoal swab for Gonorrhoea culture & sensitivity; 2. Dry swab for Chlamydia and Gonococcal PCR). These can be self-obtained with instructions.1