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Sexually Transmitted Infections in Primary Care

RCGP Sex, Drugs, HIV and Viral Hepatitis Group

British Association for Sexual Health and HIV (BASHH)

Second Edition 2013

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By Dr Neil Lazaro Royal College of GPs

British Association for Sexual Health and HIV

Acknowledgments to:

Mark Bunegar of Fluke Design for typesetting this document so patiently and professionally Lyndy Pullen, Head of Professional Programmes, Royal College of GPs

Lancashire Care NHS Foundation Trust

The production of this document was supported by educational grants from Meda Pharmaceuticals and Gilead Sciences Ltd. These companies have had no editorial input or control over the content of this document.

Citation

This document should be cited as Sexually Transmitted Infections in Primary Care 2013 (RCGP/BASHH) by Lazaro N. available at www.rcgp.org and www.bashh.org/guidelines

Disclaimer

This publication is intended for the use of General Medical Practitioners and other healthcare professionals in the UK.

The author, publishers, RCGP Sex, Drugs, HIV and Viral Hepatitis Group and the British Association for Sexual Health and HIV (BASHH) have taken care to ensure that the information contained in this document is correct to the best of their knowledge, at the time of publication. Whilst every effort has been made to ensure the accuracy of the information presented, particularly that related to the prescription of drugs, no liability can be accepted for information that is subsequently shown to be wrong. It is the responsibility of the attending clinician to make his or her own clinical judgment on an individual basis. Readers are advised to check that the information contained in this document, especially that related to drug usage, complies with information contained in the most up to date British National Formulary, or manufacturer’s data sheets, and that it complies with the latest legislation and standards of practice. Every effort has been made to give accurate information and acknowledge all references. Any omissions or corrections submitted to the publishers will gladly be incorporated where possible in subsequent editions. This guidance represents the views of the RCGP Sex, Drugs, HIV and Viral Hepatitis Group and is not necessarily the policy of the RCGP Council.

Clinical advice, particularly with regard to testing and treatments, may change.

Updates are always highlighted on the BASHH Clinical Effectiveness Group guidelines

webpage and readers are advised to check this regularly: www.bashh.org/guidelines

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Contents

1. Standards for the Management of Sexually Transmitted Infections (STIs) 10

2. HIV 16

3. Male urethritis 19

4. Abnormal vaginal discharge in women of reproductive years 24

5. Bacterial vaginosis 32

6. Vulvo-vaginal candidiasis 39

7. Trichomonas vaginalis 45

8. Pelvic inflammatory disease 47

9. Epididymo-orchitis 52

10. Chlamydia 56

11. Gonorrhoea 65

12. Genital herpes 69

13. Syphilis 78

14. Genital warts 83

15. The ABC of hepatitis 89

16. Pubic lice 91

17. Genital scabies 93

18. Genital molluscum contagiosum 95

19. Balanitis 96

20. Vulval conditions 99

21. Prostatitis 107

22. Proctitis / colitis / enteric infections 112

23. Sexually acquired reactive arthritis 115

24. Sexual assault 119

25. Ophthalmia neonatorum 124

26. Haematospermia 127

27. Young people 128

28. Tropical STIs 131

Appendix 1: Partner notification 133

Appendix 2: Useful resources 141

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Development process

The British Association for Sexual Health and HIV (BASHH) is the lead professional representative body for those practicing sexual health, including the management of STIs and HIV, in the UK. The Clinical Effectiveness Group of BASHH produces national clinical guidelines for Secondary Care physicians; these guidelines are systematically developed and assessed in a robust and reproducible manner. Recent BASHH guidelines have received accreditation from NHS Evidence, which is managed by the National Institute for Health and Clinical Excellence (NICE): www.evidence.nhs.uk

This document is a collection, set out in chapters, of appropriate BASHH guidelines that have been adapted by the author for pragmatic use in a Primary Care setting.

The author trained and worked as a GP and now sits on the Clinical Effectiveness Group of BASHH. Clinical guidance from additional sources has been cited where appropriate.

Initially, specific chapters were assessed by the specialist authors of the individual BASHH guidelines. The whole document was then reviewed by members of the RCGP Sex, Drugs, HIV and Viral Hepatitis Group as well as by experienced STI specialists. Furthermore, a General Practitioner with no specialist background knowledge of STIs appraised the document for usability.

The author received no funding to produce this document.

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Preface

This publication updates and replaces the first edition of STIs in Primary Care written by me in 2006. Once again, it is based on relevant Secondary Care guidelines produced by the British Association for Sexual Health and HIV (BASHH), which have been adapted for more appropriate and practical use in a Primary Care setting. I am grateful for the feedback of each BASHH guideline author on my adaptation of their work.

The document also brings together advice from other publications that many GPs may not have time to read thoroughly. For example, the chapter on STI management standards has been written specifically to draw your attention to this important area and all readers are advised to look at this section (chapter 1).

This publication is intended to advise the busy GP on the best course of management when dealing with STIs and related conditions in a GP sugery. It has been reviewed by GPs and deals with what might reasonably be expected of the ‘average’ GP. In many cases, particularly with the increased availability of walk-in GU services, referral to GUM will often be the most appropriate course of action. In cases where referral is difficult, for whatever reason, this document should help with pragmatic advice.

It retains the informal and sometimes shorthand dialogue of its predecessor which has proved popular with busy clinicians wanting to look up guidance quickly. Certain tables and algorithms are repeated in various chapters as I acknowledge that sections are often looked at in isolation. Readers are advised to look at a chapter in its entirety rather than simply jump to a ‘treatment’ section, as STI management always involves a wider context than simply prescribing drugs. Whilst the advice in this document is correct at the time of going to press, readers are strongly advised to check the BASHH guidelines website (see foot of each page) for management updates, as tests and treatment options can rapidly change.

With sexually transmitted infections continuing to rise, there remains a need for GPs (and other non-specialist clinicians such as those working in contraceptive clinics, prisons, A&E and HM Forces etc) to be able to manage patients swiftly, pragmatically and appropriately. I hope this publication helps.

Dr Neil Lazaro

BSc (Hons) MRCGP DipGUMed DTM&H DFSRH

Member of BASHH Clinical Effectiveness Group and the Royal College of GPs Sex, Drugs, HIV and Viral Hepatitis Group March 2013

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Foreword from the Chair of the RCGP

The Royal College of General Practitioners (RCGP) is the professional membership body and guardian of standards, for family doctors in the UK. We aim to promote excellence in primary healthcare, working to improve GP education and training. We provide a comprehensive range of resources to help GPs keep their knowledge and skills up to date.

This document is such a resource. GPs frequently see people who present at risk of an STI, with or without symptoms, and this booklet will be very helpful in managing patients appropriately. It is a readable, comprehensive and very practical ‘coal-face’ guide of what to do (and how to do it) in a primary care setting.

Judging by the popularity of its 2006 predecessor, I’m sure it will continue to provide a valuable resource to all those involved in community healthcare. I am delighted to welcome it and will be keeping a copy in my Favourites folder!

The author, Dr Lazaro, is a former GP and current member of the RCGP. He has extensive knowledge of the subject and I congratulate him for his hard work in producing this.

My thanks also to the British Association for Sexual Health and HIV for their help and support in its production.

Dr Clare Gerada

MBE MOM FRCPsych FRCGP FRCP

Chair of the Royal College of General Practitioners, London

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Foreword from the President of BASHH

National specialist society guidelines are usually written from the perspective of the specialist, so they may sometimes be difficult for primary care clinicians to implement fully into their own practice. Yet many people with sexual health problems choose to consult their General Practitioner about them.

In recognition of this, the author, who has experience of working in both primary care and specialist services, set up this joint initiative between the Royal College of General Practitioners and the British Association for Sexual Health and HIV; he has produced this document by modifying the national guidelines to make them more applicable to primary care. The first edition was published in 2006 and here is the newly updated second edition.

I congratulate the author on this text, which consists of accurate and relevant information for the management of sexually transmitted infections and related conditions in primary care. Along with the condensed and compact format, this applicability to primary care will mean that this information is easily accessible and useful to all working in general practice and other non-specialist settings.

Dr Janet Wilson President

British Association for Sexual Health and HIV

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Acknowledgements

I am very grateful to the following people for their help and advice with the production of this publication:

The specialist authors of the individual BASHH guidelines which formed the basis of this document, who kindly reviewed and ratified specific chapters.

Dr Chris Bignell (Nottingham University Hospitals NHS Trust) – Gonorrhoea

Dr Fiona Boag (Chelsea and Westminster Hospital NHS Foundation Trust, London) – Chlamydia Dr Gary Brook (Central Middlesex Hospital, Northwest London Hospitals NHS Trust) – Hepatitis

Dr Elizabeth Carlin (Sherwood Forest Hospitals NHS Foundation Trust & Nottingham University Hospitals NHS Trust) – Sexually acquired reactive arthritis

Dr Beata Cybulska (Bristol University Hospital NHS Foundation Trust) – Sexual assault

Dr Sarah Edwards (West Suffolk Hospital NHS Foundation Trust, Bury St Edmunds) – Balanitis and vulval conditions Dr Mark FitzGerald (Royal Cornwall Hospital NHS Trust) – Gonorrhoea

Dr Philip Hay (St George’s Healthcare NHS Trust, London) – Bacterial vaginosis Dr Paddy Horner (University Hospitals Bristol NHS Foundation Trust, Bristol) – Chlamydia Dr Margaret Kingston (Central Manchester University Hospitals NHS Foundation Trust) – Syphilis Dr Mayura Nathan (Homerton University Hospital NHS Foundation Trust, London) – Warts Dr Raj Patel (University Hospital Southampton NHS Foundation Trust) – Herpes

Dr Claire Robertson (Heart of England NHS Foundation Trust, Birmingham) – Candidiasis Dr Karen Rogstad (Sheffield Teaching Hospitals NHS Foundation Trust) – Young people

Prof Jonathan Ross (University Hospital Birmingham NHS Foundation Trust) – Pelvic inflammatory disease Dr Gordon Scott (Edinburgh Royal Infirmary, Edinburgh) – Scabies, pubic lice and molluscum contagiosum Dr Jackie Sherrard (Oxford University Hospitals NHS Trust) – Trichomonas vaginalis

Dr Emma Street (Calderdale and Huddersfield NHS Foundation Trust) – Epididymo-orchitis and prostatitis Dr David White (Heart of England NHS Foundation Trust, Birmingham) – Candidiasis

Acknowledgements also to

The Clinical Effectiveness Group of BASHH: comments from Dr Keith Radcliffe (Chair), Dr Mark FitzGerald, Dr Margaret Kingston and Dr Ann Sullivan

The Clinical Standards Unit of BASHH: comments from Dr Immy Ahmed (Chair) Dr Hugo McClean (comments on STI standards and Partner Notification issues) My thanks also to the following for their thorough reviews of the whole document

Dr Helen Bailey, Associate Specialist, Wrexham Maelor Hospital, Wrexham

Dr Penny Goold, Consultant Physician, GU Medicine, Whittall Street Clinic, Birmingham

Dr Anne Greenwood, Clinical Director of Sexual Health, North Locality, Community Health Services Division, Blackpool Teaching Hospitals NHS Foundation Trust

Prof Catherine Ison, Director Sexually Transmitted Bacteria Reference Laboratory, Health Protection Agency, London

Dr Louise Melvin, Consultant in Sexual & Reproductive Health and Director of the Clinical Effectiveness Unit of the Faculty of Sexual

& Reproductive Healthcare, Glasgow

Dr Lisa Nayler, GP, Madeira Medical Centre, Poole, Dorset

Dr John Sweeney, Consultant Physician in GUM & HIV, Blackpool Victoria Hospital and Royal Preston Hospital, Lancashire Dr Nick Theobald, Clinical Lecturer / Associate Specialist, Chelsea and Westminster Hospital, London

The members of the Royal College of General Practitioners’ RCGP Sex, Drugs, HIV and Viral Hepatitis Group who gave particular advice from a Primary Care perspective: Dr Kate Armitage , Sarah Challinor, Dr Philippa James , Ruth Lowbury, Dr Richard Ma, Dr Philippa Matthews, Dr Ewen Stewart and Dr Gill Tonge.

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/ increase / decrease / male / female

BME black and minority ethnic groups BV bacterial vaginosis

cf confer (ie: compare) c/o complaining of

DIC disseminated intravascular coagulation d/w discuss with

FCU first-catch urine FPU first-pass urine

GC gonococcus (gonorrhoea) HPA Health Protection Agency HVS high vaginal swab HPV human papilloma virus

Hx history

m/c/s microscopy, culture and sensitivity MSM men who have sex with other men MSU mid-stream urine

NAAT Nucleic Acid Amplification Technique / Test (a very sensitive way of detecting DNA / RNA) NSAIDS non-steroidal anti-inflammatory drugs

PMHx past medical history PPT precipitate

PROM premature rupture of membranes

Pt patient

PPV positive predictive value

Rx treatment

STI sexually transmitted infection

Sx symptoms

TB tuberculosis

ToC test of cure (another test after Rx to ensure eradication) ToP termination of pregnancy

TV Trichomonas vaginalis

UPSI unprotected sexual intercourse UTI urinary tract infection

VVS vulvo-vaginal swab

Abbreviations

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■ Standards have been developed1 to support all providers of sexual health services in achieving safe, high quality services for the management of STIs. The Standards also provide specific sections to support commissioners of services

■ The Standards cover all aspects of current best practice in the management of STIs, including the diagnosis and treatment of individuals, as well as the broader public health role of infection control

■ There are nine standards covering all aspects of STI management

■ clinical issues

■ commissioning issues

■ frameworks for monitoring performance, with key performance indicators

■ The standards have been endorsed by all professional groups involved in providing sexual healthcare, including the RCGP.

■ They represent current best practice and are intended for use in all services where STIs may be managed.

■ Primarily this involves services specifically commissioned by the NHS to manage STIs (including services provided by the Third and Independent sectors) but also includes GPs who may manage STIs incidentally rather than through a formally commissioned service.

■ If you are providing a commissioned STI service, you will know about these standards. If you are a GP who might occasionally manage STIs simply as part of your day to day clinical work, then bear in mind that the standards should be adhered to as pragmatically as possible (there is advice to refer patients on if you are unable to meet certain criteria).

■ A patient information leaflet2 (see figure 1) summarises what patient can expect from all service providers

■ The standards have been produced for England, but clinical recommendations also apply to Wales and Northern Ireland. Sexual Health service standards for Scotland were published by NHS Quality Improvement Scotland in 2008.3

1. Standards for the Management of Sexually Transmitted Infections (STIs)

Figure 1: Patient information leaflet

Summary of what patients should expect from clinicians managing STIs (adapted from ref 2)

■ To be offered an appointment to be seen within 2 working days of contacting an STI service

■ To have care managed by trained and competent staff

■ To receive confidential, non-judgmental advice

■ To be offered, as a minimum, tests for Chlamydia, gonorrhoea, HIV and syphilis

■ To have the most accurate tests for infections

■ To receive all results (negative or positive) within 14 working days

■ To be given the most effective treatment free of charge* if any infections are found

■ To be offered support in helping sexual partners to access testing and treatment

■ To be offered free condoms*

■ To be able to give feedback about STI services received and have feedback acted upon

■ To receive care from high quality STI services that are safe, well-managed and accountable

■ To be referred to another service quickly and easily, if necessary

* may be difficult in non-commissioned services – consider referral

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The standards document1 is easy to read and can be downloaded for free – I recommend you take a look.

For non-specialist GPs who may simply deal with STIs on an ad-hoc basis and don’t have time to look at the main document, I have summarised it in table 1. It is not exhaustive but gives you an idea of the basic issues involved in STI management. It can be used as a reference guide when GPs see a particular condition.

Don’t be put off dealing with STIs, but do think “Am I the best person to be dealing with this?” (It may, of course be that pragmatically you ARE the best person there and then). Just be aware that if you do commence management, then there are other issues involved and be aware of them – your patients may well be (see figure 1). As with all aspects of general practice, work within your levels of competence and if unsure, ask for advice or refer.

1. Standards for the Management of Sexually Transmitted Infections (STIs)

Table 1: Standards for the management of STIs (adapted from ref 1) Standard

1. Principles of STI care STI services should be open access

■ Urgent problems should be managed the same day / next session

■ Pts should have choice of where to access services

■ Confidentiality is expected

■ Rx should be those recommended by the latest BASHH guidelines4

■ Partner notification should be instigated where appropriate

■ Surveillance data should be collected

If you can’t provide this – refer (local care pathways should be in place.

See Standard 7)

Equitable standards of care should be available in every setting. This may be difficult for non-specialist GPs to provide and you may well need to be pragmatic in some circumstances after d/w Pt Partner notification is vital in some conditions and although you might not be able to do it thoroughly, it should at least be d/w Pts. Consider referral to GUM for completion

Data collection will improve with use of the Genitourinary Medicine Clinic Activity Dataset which currently has been developed for data collection from commissioned enhanced sexual health services. Work is ongoing by the Health Protection Agency and the NHS Information Centre General Practice Extract Service to specify a routine extract from all GPs for the surveillance of STIs.

Gonorrhoea statistics are increasingly important ( ing resistance) and GUM should be involved in the management of all gonorrhoea cases.

Recommendations Pragmatically what this means

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1. Standards for the Management of Sexually Transmitted Infections (STIs)

Standard

2. Appropriately trained staff

3. The clinical assessment

4. Diagnostics

■ All professionals should be competent to deliver their service

■ Competence should be assessed and maintained

■ A comprehensive clinical governance framework should demonstrate the maintenance of national and local standards of care as well as the clinical competence of the health care workers providing this

■ The leadership role of Level 3 providers5 (mainly specialist GUM services) should be explicit and commissioned

■ Appropriate medical and sexual Hx should be taken ( sensitive, private, confidential, awareness of Child Protection issues and Mental Capacity issues)

■ Appropriate examination

■ Appropriate tests

■ Any STI test? 100% pts should be offered an HIV test as well

■ Minimum STI screen = Chlamydia, gonorrhoea, HIV and syphilis testing

■ Results procedure

■ Diagnostic tests should be the latest ‘gold standard’ tests:

validated and reliable.

■ Point-of-care tests should only be used as screening tests.

A reactive result? confirm in lab

■ Labs should be accredited

■ Results should be back < 7/7

GUM services should have a leadership role in supporting education, training and clinical governance.

As with all general practice, if you feel out of your depth – refer. The problem of course, is not knowing what you don’t know...

Training is available (see Appendix 2:

Resources)

Confidentiality issues.

A chaperone should be offered to everyone for intimate examinations, and if needed and not available, provided at another time or place The correct materials for specimen collection and transport should be used

Patient should be informed of all results, including negative results.

HIV testing can be provided quickly in General Practice and easy-to-follow guidelines are available (see HIV chapter) Although the prevalence of certain infections will vary, it is good practice to screen everyone

There must be equity across all care providers

Recommendations Pragmatically what this means

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1. Standards for the Management of Sexually Transmitted Infections (STIs)

Standard

5. Clinical management

6. Information governance

■ Syndromic management (Rx without tests) is considered sub-optimal and not

recommended unless in exceptional circumstances

■ Empirical Rx (Rx at time of consultation before test result is back) may be appropriate in some circumstances (Eg: Rx’ing the partner of someone with an STI)

■ Staff should be competent at interpreting test results

■ Rx should be in line with latest BASHH guidelines4 and be free of charge6

■ Partner notification should be instigated where appropriate

■ Health promotion: written information / advice, condoms supplied free, one-to-one interventions to promote behavioural change

■ Information (on Pts and their sexual contacts) should be held securely and in strict accordance with current guidance.

■ Data sharing should follow current national guidance

Free Rx s are difficult in routine general practice currently. If you can’t provide this (and the Pt wants free Rx) then refer (local care pathways should be in place).

Of course, some Pts may not be worried about paying for a prescription from you, but the offer of free Rx at a specialist service should be made.

Your practice should have written policies on information security and sharing and confidentiality that all staff are trained to use.

Be very careful about what you record in the notes. Identifiable data (e.g. the names of sexual contacts) should be recorded only if necessary for the purposes of partner notification and should not be documented in the patient’s primary care record in case the information is subsequently shared e.g. insurance reports

Recommendations Pragmatically what this means

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1. Standards for the Management of Sexually Transmitted Infections (STIs)

Standard

7. Links to other services

8. Clinical governance

9. Patient and public engagement

■ Clinical links to GUM

■ Care pathways should be in place, linking Levels 1, 2 and 3

■ Sexual health networks should be developed in every health economy

■ Clinical leadership should be provided by GUM services – they should also support education and training

■ Elements of clinical practice should be audited at least annually

■ Risk management procedures should be in place

■ Patients and the public should be consulted about services

■ A documented patient and public engagement (PPE) plan should be implemented

■ There should be evidence of both service user feedback and the service’s response to feedback arising from implementation of a PPE plan

■ Patient-reported outcomes should be developed

Specialist advice, support and referral should be available to you.

Most people’s sexual health needs are wider than the pharmacological management of an STI – GPs are well placed to be involved holistically.

In fact, GPs are ideally placed to manage issues such as alcohol / drug use or mental health issues, which can adversely affect sexual health.

Consider auditing your care of Pts with STIs in collaboration with your local Level 3 service.

Collaborate with your patient participation groups and consider how to reach specific groups such as MSM, BME, young patients, etc.

Agree on a written engagement plan that includes using and responding to user feedback

Pt-reported outcome measures should be pretty standard in GP.

Recommendations Pragmatically what this means

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References

1. Standards for the management of Sexually Transmitted Infections 2010

BASHH and Medical Foundation for AIDS and Sexual Health ISBN 978-1-905545-42-1 Available at www.medfash.org.uk and www.bashh.org.uk

2. Your guide to the standards for the management of sexually transmitted infections Medical Foundation for AIDS and Sexual Health 2010

Available at www.medfash.org.uk and www.bashh.org.uk 3. Sexual Health Services Standards

NHS Quality Improvement Scotland March 2008 ISBN 1-84404-497-1 Available at www.healthcareimprovementscotland.org

4. British Association for Sexual Health & HIV Clinical Effectiveness Group Guidelines.

Available at www.bashh.org/guidelines.

5. The national strategy for sexual health and HIV

Dept of Health London 2001 Gateway ref 2001 Crown copyright

Available at www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4003133 6. A statutory right to free treatment for sexually transmitted infections originates from specific legislation:

National Health Service. Prescription Charges for Hospital Outpatients. HM(68)30. London:

Ministry of Health, 1968

1. Standards for the Management of Sexually Transmitted Infections (STIs)

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■ HIV infection rates are increasing and GPs should not be afraid to offer testing in Primary Care.

■ Gone are the days of the HIV test being a secretive affair offered only after ‘counseling’ in specialist units.

HIV testing can and should be done in General Practice for...

■ anyone at risk

■ anyone with clinical indicator diseases see algorithm below

■ anyone requesting it

■ Effective treatments are now available, making HIV a manageable long-term condition

■ The earlier HIV is diagnosed, the better the outcome. Late-stage disease has a poorer prognosis

■ More detailed HIV issues are beyond the scope of this document and are addressed in the excellent publication HIV in Primary Care (2011)1 available at www.medfash.org.uk

■ Written by practicing GPs and HIV specialists with an interest in GP education, it is instructive, practical and easy to use with a comprehensive index and full colour illustrations.

■ Highly recommended!

■ See next section for advice on HIV testing in General Practice

2. HIV

}

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HIV testing in General Practice

Adapted from The 6-step guide to HIV Testing in Primary Care written by the Sex, Drugs and HIV Group of the RCGP 2010 and the UK National Guidelines for HIV Testing 2008

2. HIV

Do you practice in an area of high HIV prevalence (> 2 per 1000)?

Not sure? Ask your local specialists or find out at http://tinyurl.com/9dqabmq

■ Offer HIV test to all new patients registering.

■ Also

– Offer test to all ‘at-risk’ patients*

– Offer test to all those with clinical indicator diseases**

■ You can advertise testing in your waiting room using printed publications and leaflets

Area of low HIV prevalence (< 2 per 1000)?

■ Offer test to all ‘at-risk’ patients*

■ Offer test to all those with clinical indicator diseases**

* The ‘at-risk’ patient

■ Anyone with an STI

■ Men who have sex with other men

■ Those buying / selling sex

■ Those from countries of high HIV prevalence.

See www.unaids.org

■ IVDUs

■ Any sexual partner of the above

** Clinical indicator diseases for HIV See table 1

The HIV Test

■ Specialist in-depth ‘counselling’ is not necessary.

■ Explain the benefits of testing

– earlier diagnosis better prognosis

– effective treatments now available better prognosis

■ The patient only needs to give verbal consent to the test

■ Insurance issues? Reassure Pts that insurance companies should not ask whether an individual has ever had a negative HIV test. Applicants themselves must declare a +ve result, but that would be the case with any other medical condition. In fact some insurance companies do insure HIV+ pts

■ Take 10 mls of clotted blood and send it to virology marked ‘HIV test’

■ Agree with Pt how and when to give results (? face to face). Check correct contact details.

■ Results: If neg – talk about risk reduction (safer sex, etc). Re-test if within 3/12 window period If positive – refer (pathways should be in place). If unwell, refer more quickly.

Yes No

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2. HIV

Table 1: Clinical indicator diseases for adult HIV infection (adapted from ref 2) Clinical specialty

Dermatology

ENT

Gastroenterology

Gynaecology

Haematology

Neurology

Oncology

Respiratory medicine

Other

■ Kaposi’s sarcoma

■ Persistent cryptosporidiosis

■ Cervical cancer

■ Cerebral toxoplasmosis

■ Primary cerebral lymphoma

■ Cryptococcal meningitis

■ Non-Hodgkin’s lymphoma

■ Tuberculosis

■ Pneumocystis

■ Severe / recalcitrant seborrhoeic dermatitis or psoriasis

■ Lymphadenopathy of unknown cause

■ Chronic parotitis

■ Oral candidiasis

■ Oral hairy leukoplakia

■ Chronic diarrhoea of unknown cause

■ Weight loss of unknown cause

■ Vaginal intraepithelial neoplasia

■ Cervical intraepithelial neoplasia Grade 2 or above

■ Any unexplained blood dyscrasia, including

neutropaenia, lymphopaenia and thrombocytopaenia

■ Aseptic meningitis / encephalitis

■ Cerebral abscess

■ Space occupying lesion of unknown cause

■ Anal cancer or anal intraepithelial dysplasia

■ Lung cancer

■ Hodgkin’s lymphoma

■ Bacterial pneumonia

■ Aspergillosis

■ Mononucleosis-like syndrome (consider primary HIV infection)

■ Pyrexia of unknown origin

■ Any lymphadenopathy of unknown cause

AIDS defining condition Other conditions where HIV testing should be offered

References

1. HIV in Primary Care 2011 (2nd edition) ISBN 978-0-9549973-9-7

Medical Foundation for AIDS & Sexual Health (MedFASH) BMA House, Tavistock Square, London, WC1H 9JP www.medfash.org.uk

2. UK National Guidelines for HIV Testing 2008 British HIV Association, British Association for Sexual Health & HIV, British Infection Society Available at www.bhiva.org/files/file1031097.pdf

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Background

1, 2, 3, 4

■ Urethritis is usually due to a sexually transmitted infection although a UTI (uncommon in young ) may produce similar Sx

■ The inflammation may sometimes be due to non-infective causes, but STIs must always be excluded if the Hx (ie: sexual contact, including oral sex) is suggestive

The following symptoms may be present

■ Urethral discharge

■ usually a result of an STI

■ the type of discharge may be mucoid, purulent or muco-purulent

■ the quantity of discharge may be minimal or copious

■ Urethral discomfort or ‘itch’

■ Dysuria

■ don’t assume dysuria in a male is always a UTI !

a sexually active man c/o dysuria must have STIs excluded

■ consider screening for a UTI if Hx suggestive, or if older in whom UTI may be more likely

■ Epididymo-orchitis (see chapter 9)

■ Symptoms of sexually acquired reactive arthritis (see chapter 23)

STI causes (you cannot reliably distinguish these clinically):

1. Chlamydia

■ diagnosed on 1st pass urine ( a NAAT test)

■ common cause of urethritis

2. Gonorrhoea (also known as ‘gonococcus’ or ‘GC’ for short)

■ less common than Chlamydia

■ prevalence in certain populations ( MSM, BME groups, urban areas )

■ can also be diagnosed on 1st pass urine in ( or swab sent for culture) – check with your local lab (NB: urine is not an optimal specimen for gonorrhoea in females. See gonorrhoea chapter)

3. Non-specific urethritis (NSU)

■ this is really a diagnosis of exclusion after GC and Chlamydia have been ruled out

lots of different organisms can cause this, such as Mycoplasma genitalium, TV, yeasts, herpes, and adenoviruses (the latter is often seasonal and associated with oral sex)

■ sometimes, there isn’t an infective cause at all

■ normally diagnosed on microscopy in GUM. Not practical in GP – thus this diagnosis will be presumed on the basis of negative GC and Chlamydia tests

■ partner notification should still be carried out (see below)

3. Male urethritis

See national STI Management

Standards:

Chapter 1

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Management

(see also STI Management Standards chapter)

■ Take a Hx (including a sexual Hx)

■ Examine

■ If you suspect an STI...

■ Refer to GU (local care management pathways should be in place) or

■ If an urgent (< 48 hours) appt is not possible then consider:

■ taking tests for STIs

■ and then treating empirically (see below)

Note:

■ This is not ideal, but is simply pragmatic especially if it is a Friday evening when urgent GU access may be difficult

■ Treating an STI promptly, not only alleviates symptoms but also halts the subsequent spread of infection

■ If you decide to treat a presumed STI, you must attend to the process of notifying recent sexual partners, who may be unaware they might be carrying an asymptomatic infection.

■ At the very least, this involves telling the index patient they should abstain from sex until recent sexual partners have been checked / treated, and that those partners should seek medical advice.

■ Water-tight partner notification is difficult to achieve in General Practice and is probably best left to GU clinics

■ Rx’ing an STI involves other principles – see the chapter on STI Standards

Tests

You should talk to your local lab / GUM about which swabs and samples to take. Consider...

■ Obtain a first pass urine specimen ( ideally when Pt hasn’t passed urine for at least 1 hour – but you may need to be pragmatic)

■ send the 1st pass urine for Chlamydia NAAT and Gonorrhoea NAAT (both can be done on the same urine sample, if available in your local lab) (NB: urine is not an optimal specimen for gonorrhoea detection in females.

See gonorrhoea chapter)

■ look for ‘threads’ (these are strands of mucus / pus suspended in urine. They can be a useful clue for inflammation in the anterior urethra , but this is neither sensitive nor specific and should not be relied upon as a sole diagnostic criteria for urethritis)

■ If gonorrhoea NAAT unavailable, take a urethral swab for gonorrhoea culture, but this needs to reach the lab promptly (within 24 to 48 hours. d/w your local lab)

■ Test for other STIs (minimum: Chlamydia, gonorrhoea, as well as syphilis and HIV blood tests)

3. Male urethritis

(21)

3. Male urethritis

Treatment

Syndromic management (Rx without tests) is considered sub-optimal and not recommended unless there are exceptional circumstances. If you plan to Rx, then take tests first!

■ Empirical Rx (Rx at time of consultation before test result is back) may be appropriate in some circumstances (Eg: pragmatic Friday evening consultation). Don’t forget partners may need Rx as well.

The Rx for Chlamydia and NSU is:

AZITHROMYCIN 1 g po stat or

DOXYCYCLINE 100 mg po bd 7/7

The Rx for uncomplicated urethral gonorrhoea (see also the Gonorrhoea chapter) is currently 1st line: CEFTRIAXONE 500 mg im injection stat + AZITHROMYCIN 1 g po stat

2nd line: CEFIXIME 400 mg po stat + AZITHROMYCIN 1 g po stat

NB:

■ Increasing resistance to gonorrhoea – the Rx given in this publication is correct at the time of going to press but it may change. See BASHH website for latest Rx guidance. www.bashh.org/guidelines

■ If you intend to treat for gonorrhoea, take a swab for culture first if possible (resistance needs to be monitored)

■ If oral Cefixime regimen is used, beware Rx failure

Pts must be followed up

■ All gonorrhoea cases should have a test of cure taken (see gonorrhoea chapter)

■ All Rx failures must be reported to the HPA

■ Partner(s) must be Rx’d

■ Tests of cure are not generally required for urethral Chlamydia / NSU cases in males.

The complexities of gonorrhoea management make it difficult for most GPs to deal with and cases should be referred promptly to GUM for management5

■ The difficulty, of course, is initially differentiating Chlamydia / NSU (easier to Rx in GP) from gonorrhoea

■ this is difficult clinically – you cannot tell just from Sx / signs

■ Friday evening consultations are difficult. Pragmatic Rx needed

■ Pragmatically, therefore

■ if you are likely to come across gonorrhoea ( Eg: high local prevalence) have a plan agreed in advance with local GUM services about out-of-hours / non-GU management

■ if you strongly suspect gonorrhoea, Rx according to guidance as best as you can but follow-up the Pt closely

■ make sure you have the Pt’s contact details for follow-up

(22)

Note:

■ Advise pt to tell their sexual partner(s) to attend GU clinic for Rx.

■ A generic Contact Slip for use in Primary Care can be found in Appendix 1 – you may wish to print it off to use

■ Consider FU (? GU / ? GP) in 1 to 2 weeks ( Rx compliance, partner notification, symptoms resolved? etc)

■ Advise pt NO sexual encounters at all, until given the all clear

■ not even with a condom because sexual contact can occur before a condom is put on

■ condoms can also split

‘No sex’ includes all genital-mucous membrane contact (so no oral sex either)

■ They may not attend for follow up, so when you Rx them initially, advise no sex until 7 days after Rx finishes and symptoms resolved and partner (s) have been successfully treated. Partners must wait >7 days after their Rx before commencing sex again.

All gonorrhoea cases need a test of cure. Gonorrhoea is best managed in GUM.

■ Give Pt written advice (Pt information leaflets)

■ Document all of this.

Partner notification

How far back you trace depends on what the diagnosis is and when the Pt developed urethral symptoms

Gonorrhoea2

symptoms? – all sexual partners in previous 2 weeks no symptoms? – all sexual partners in previous 3 months

Chlamydia3

symptoms? – all sexual partners in previous 4 weeks no symptoms? – all sexual partners in previous 6 months

NSU4

symptoms? – all sexual partners in previous 4 weeks

These figures are arbitrary as it is not known for sure how long asymptomatic carriage can be. Common sense should be used in assessing which sexual partners may have been at risk, and sometimes longer time periods may be involved.

d/w GUM for advice (or refer Pt).

Partner notification should be pursued in all patients, preferably by a trained Health Advisor in GU medicine, who can also document action and outcomes. This applies, to a greater or lesser degree, to most STIs. For the time being, water- tight partner notification remains difficult to achieve in Primary Care. You must be aware of the need for it and document that you have discussed this with the patient. See STI Standards chapter.

3. Male urethritis

(23)

References

1. Sexually Transmitted Infections (4th Ed) Holmes et al.

Published by McGraw-Hill 2008 ISBN 978-0-07-141748-8

2. UK national guideline for the management of gonorrhoea in adults 2011 C. Bignell and M. FitzGerald

International Journal of STD & AIDS 2011; 22: 541–547

3. 2006 UK National Guideline for the management of genital tract infection with Chlamydia trachomatis British Association for Sexual Health and HIV Clinical Effectiveness Group

Available at www.bashh/guidelines

4. 2007 UK National Guideline for the management of non-gonococcal urethritis (updated 2008) British Association for Sexual Health and HIV Clinical Effectiveness Group

Available at www.bashh/guidelines

5. Guidance for gonorrhoea testing in England and Wales 2010

Health Protection Agency / British Association for Sexual Health and HIV Available at www.bashh/guidelines and www.hpa.org

3. Male urethritis

(24)

Background

1

Causes

■ Infective

■ Bacterial vaginosis (commonest cause of abnormal vaginal discharge)

■ Candida

■ Non-infective

■ Physiological (common) – a diagnosis of exclusion

■ Others (cervical ectopy, polyps, foreign bodies, genital dermatoses, malignancies, allergies, fistulae)

■ Sexually transmitted

■ Chlamydia (common)

■ Gonorrhoea (less common)

Trichomonas vaginalis (less common) History – essential!

■‘Candida’ is often over-diagnosed (by patients as well as clinicians) and over-Rx’d2

■ BV is often under-diagnosed (despite being more common than Candida)

■ STIs may be missed if a sensitive sexual history is not taken

■ Ask...

■ What has been noticed? For how long?

■ Any itch? Any malodour?

■ Consistency of discharge? Eg: lumpy ( ? Candida), homogeneous ( ? BV), frothy ( ? TV)

■ Anything make it better or worse?

■ Any Rx tried? (Prescription as well as any over-the-counter preparations). Any vaginal douching?

■ Cyclical symptoms?

■ Any Sx / signs of PID? (have a low threshold to examine to examine if so)

■ Any risk of STIs? Does their partner have any Sx of STIs (Eg: urethral discharge? Epididymitis?)

■ Contraceptive use?

■ Past medical Hx

NB: Note that I have not listed ‘colour’ here as my personal view is that it is very subjective and not always helpful (unless, of course, blood stained). As the commonest causes of abnormal vaginal discharge are BV and Candida, the questions I ask early on in the consultation are about associated malodour and itch.

4. Abnormal vaginal discharge in women of reproductive years

(25)

4. Abnormal vaginal discharge in women of reproductive years

Table 1: Vaginal discharge – diagnosis clues (see also individual chapters)

Notes

Discharge

Odour

Associated symptoms (not all may be present)

Typical signs

Vaginal pH ( take from lateral wall) Normal

= 3.5 to 4.5

Commonest cause of abnormal vaginal discharge.

Not sexually transmitted.

Homogeneous (ie: same consistency ) – thin and watery)

Malodour

Usually none (unless accompanied by Candida)

Discharge coats the vagina and vestibule No vaginal or vulval inflammation (unless accompanied by Candida)

> 4.5

Bacterial vaginosis Vulvo-Vaginal Candidiasis Trichomoniasis

Perceived by women to be more common than it actually is.

Not sexually transmitted.

Variable but often thick, lumpy and white

No malodour

Itch / soreness External dysuria External dyspareunia

May look normal or

Vaginal inflammation and / or

Vulval inflammation +/- fissures +/- oedema +/- satellite lesions

≤4.5 (ie: normal)

An STI ! Diagnosis should be made with a reliable method as there will be implications for partner(s)

Variable – may be frothy

Malodour

Itch / soreness Dysuria

Lower abdominal pain

May look normal or

Frothy discharge +/- vulvitis +/- vaginitis +/- cervicitis*

( *the so-called ‘Strawberry cervix’ : often quoted but actually rare: < 2%)

> 4.5

(26)

Examination

■ Not always needed (see algorithm below). It is pragmatic not to have to examine every woman c/o vaginal discharge providing it sounds uncomplicated. But...

■ You should take a thorough history and not simply rely on a patient’s self-diagnosis

■ Patients with recurrent Sx or those that fail to improve should be examined and investigated

■ Certain conditions should prompt an appropriate examination and investigations first-line If you do examine, then…

■ Note appearance of discharge and any associated signs

■ Check vaginal pH (see below)

■ Evidence of cervicitis? Consider STIs – take endocervical swabs for Chlamydia and gonorrhoea.

■ TV suspected? TV is difficult to diagnose in GP (see chapter 7) – consider referral. d/w GUM / lab

■ Retained foreign body? Remove and consider antibiotics (however, this isn’t always needed once the foreign body is removed). If toxic shock (rare) then Rx appropriately.

■ PID suspected? – see PID chapter

■ Sounds physiological (cyclical, no itch, no malodour, no other Sx)?

■ reassure, but examine and investigate if necessary, if only to exclude other causes

Investigations

pH

■ Normal vaginal pH is up to 4.5 ( kept acidic by normal lactobacilli)

■ It’s an indicator of vaginal ecology

■ It is sensitive (for pH) but

■ It is not very specific

■ It can be normal (acidic) with

■ Normality

■ Candida

■ It can be raised with

■ local blood, semen, cervical secretions, lubrication used on the speculum

■ BV and TV (cannot distinguish between these two on pH alone)

■ Sometimes cervical gonorrhoea and Chlamydia infections ( alter the local vaginal ecology and often occur with BV)

■ How to measure vaginal pH

■ take a swab or plastic loop, rub it along the lateral wall collecting some discharge, then rub it onto pH paper

■ avoid the cervix which has alkaline secretions; these can collect in the posterior fornix, so avoid this area as well

■ specific narrow-range pH paper must be used, urine dipsticks are not suitable (GUM can advise you of pH paper suppliers)

4. Abnormal vaginal discharge in women of reproductive years

(27)

4. Abnormal vaginal discharge in women of reproductive years

Figure 1: Vaginal discharge in Primary Care algorithm (adapted from ref 1)

Manage as appropriate

TV suspected? d/w GUM / refer

Uncertain diagnosis? Refer Rx for BV

Eg:

METRONIDAZOLE 400 mg po b.d 5 to 7 days

or 2 g po stat

Rx for Candida Eg:

FLUCONAZOLE 150 mg po stat

or CLOTRIMAZOLE

500 mg PV stat

History

See above

Not sexually active or

Low risk of STIs or

None of the conditions listed on the right

Examination declined Examination accepted

High risk of STIs < age 25 previous STIs recent new partner or

> 1 partner in past year

Upper reproductive tract Sx

Bloody discharge

Uncertain Sx

Pregnant, post partum, post ToP, post instrumentation

Recurrent Sx or failed Rx

Examine and investigate (see table 1)

Vaginal pH

Endocervical swabs for Chlamydia and Gonorrhoea plus bloods for HIV and syphilis

Consider a high vaginal swab

? urine dipstick

? pregnancy test

Bimanual examination if PID suspected

Foreign body?

Other Consider examination

and investigations based on clinical findings Syndromic Rx based on Hx

Pt to return if Sx do not improve or if they recur

pH ≤ 4.5

Malodour, no itch Itch, no malodour pH > 4.5

(28)

Tests for STIs

(see also appropriate chapters) Gonorrhoea

■ endocervical swab (charcoal transport swab) for culture (but correct storage and/or prompt transport to lab is needed)

■ alternatively, a NAAT test may be used (fewer transport issues compared with culture)

■ as a speculum is in, you might as well take an endocervical swab

■ but be aware this will not give antibiotic sensitivities so consider a culture swab as well if gonorrhoea is strongly suspected

■ make sure the NAAT result will be a valid one (is the PPV > 90% ? – d/w lab / GUM)

■ NB: female urines are sub-optimal for gonorrhoea NAAT tests

■ A vulvo-vaginal swab (which can be self-taken) may also be used to detect gonorrhoea (and Chlamydia)

Chlamydia

■ a NAAT should be used

■ urines are OK but as a speculum is in, you might as well take an endocervical swab

■ It can be the same swab as the gonorrhoea NAAT

■ A vulvo-vaginal swab (which can be self-taken) may also be used to detect Chlamydia (and gonorrhoea)

TV

■ Currently difficult to diagnose in GP

■ The easiest test in GP is a high vaginal swab (HVS)

– Ideally should reach the lab within a few hours to find organisms alive (difficult++ in most GP settings) – Staining may be undertaken on the HVS in the lab to look for dead organisms

■ But! Whist a +ve report on a high vaginal swab can probably be relied upon, a negative report does not exclude TV. This makes HVSs of limited value in diagnosing TV

■ Specific TV culture media is available but not widely used

■ Newer NAAT tests are in development but not yet widely available

■ Thus, it’s probably easier at the moment to refer suspected cases to GUM

HIV and syphilis

■ These blood tests should be taken as well if gonorrhoea and Chlamydia are tested for3

■ When testing for HIV4

■ In general

– any doctor / nurse / midwife should be able to take an HIV test

– lengthy pre-test ‘counseling’ is not required for HIV tests unless the Pt requests or needs it – many Pts with HIV do not know they are infected

4. Abnormal vaginal discharge in women of reproductive years

See national STI Management

Standards:

Chapter 1

(29)

■ The patient should

– be aware of the test and give consent (formal written consent is not necessary) – be aware of the 3 month window period and re-test again as necessary

– be aware that simply having a test (with a subsequent negative result) should not have implications for insurance / mortgage issues. See ref 4 for more details

■ You should

– explain the benefits of testing (Rx saves lives, safer sex advice for future, etc) – agree details of how the results will be given to the patient (check contact details) – discuss future safer sex issues

– have a process in place for fast-track referral of +ve results

■ See also the HIV chapter

High Vaginal Swabs (HVS)

■ Much used by GPs – but poor evidence of them being useful!

■ Think of the last time you had a HVS report. What was the yield? Did it change you practice?

Or did you just get a report back saying ‘Mixed anaerobes’ and wondered what to do?!!

■ The lab will simply report what is cultured, but reporting of commensals may lead to over-Rx and cause undue anxiety. For example, do not diagnose BV just because Gardnerella vaginalis is found on HVS – it is found in 30 to 40% ‘normal’ women

■ Results should be interpreted with the whole clinical picture in mind

■ HVSs are not always used in GU clinics – partly because their usefulness is questionable, and partly because GU clinics are able to do near-pt tests like microscopy (which can give ‘instant’ results for BV, TV and Candida)

■ HVSs may be useful to find micro-organisms that can cause cervicitis / endometritis / salpingitis, so consider taking an HVS in these circumstances, although the most important tests will be endocervical swabs for Chlamydia and gonorrhoea

■ Why is the usefulness questionable?

■ some evidence that the information provided by the lab from an HVS isn’t exactly what the GP thought it would provide5

■ labs may differ in what tests they do and what organisms they report, and also what advice on Rx they may give

■ some labs will run more tests than others, some will run more tests when detailed clinical information is given You should discuss these points with your lab

■ Some evidence that

– diagnostic yield of an HVS is poor except for finding Candida6, which produces characteristic symptoms anyway (and if it’s not producing symptoms, you wouldn’t need to treat!)

– limited value of HVS in diagnosing BV (and may lead to under diagnosis if no other diagnostic criteria are used)7

4. Abnormal vaginal discharge in women of reproductive years

(30)

So, should GPs take high vaginal swabs?

■ Not sure! Probably not routinely

■ They should not be a knee-jerk response to any vaginal discharge – an undisciplined fishing expedition!

■ Whilst ‘fishing expeditions’ have their place in general practice (at least to exclude certain things) the yield of HVSs may be poor when not used appropriately

■ Probably useful to confirm organisms that can cause or complicate cervicitis / endometritis / salpingitis, so take an HVS if you suspect these conditions

■ Useful in persistent vaginitis, for group B strep screening and in pregnancy, post-partum and post-instrumentation infections.

■ Useful to prove a diagnosis of recurrent candidiasis.

■ Not useful for gonorrhoea and Chlamydia (these are cervical organisms – take endocervical swabs instead)

■ If you do send a high vaginal swab, give the lab as much clinical information as possible. Do not assume that a full range of tests will be run on your sample; most labs tailor the tests done on a sample depending on the clinical information supplied. The more information you supply on the form, the better the yield. Don’t just write

‘discharge’!

■ Site sampled

■ Associated Sx

■ Infection suspected

■ Past / proposed Rx

Bottom line: useful in some circumstances, but think about what might be going on, what you hope to confirm and ensure you take into account the whole clinical picture.

Management

■ Candida

■ If suspected / proven (with Sx) : Rx (see Candida chapter)

■ If recurrent: see Candida chapter

■ BV

■ If suspected on Sx: Rx (see BV chapter)

■ If recurrent: see BV chapter

■ TV

■ If suspected: refer to GUM

■ If proven: see TV chapter

■ If Rx’ing in GP – do not forget the national STI management standards

■ Chlamydia / gonorrhoea

■ If suspected: test

■ If proven: see appropriate chapters

■ If Rx’ing in GP – do not forget the national STI management standards

■ Others

■ As appropriate

■ Refer difficult cases

4. Abnormal vaginal discharge in women of reproductive years

(31)

References

1. The management of vaginal discharge in non genito-urinary medicine settings 2012 Faculty of Sexual and Reproductive Healthcare, Clinical Effectiveness Unit ISSN 1755-103X Available at www.fsrh.org and www.bashh.org/guidelines

2. Ferris D.G, Myirjesy P, Sobel J.D, Soper D, Pavletic A, Litaker M.S.

Over-the-counter antifungal drug misuse associated with patient-diagnosed vulvovaginal candidiasis.

Obstet Gynecol. 2002; 99(3): 419–425.

3. Standards for the management of Sexually Transmitted Infections 2010 Medical Foundation for AIDS and Sexual Health ISBN 978-1-905545-42-1 Available at www.medfash.org.uk and www.bashh.org.uk

4. UK national guidelines for HIV Testing 2008

British HIV Association / British Association for Sexual Health and HIV / British Infection Society Available at www.bhiva.org

5. How is the high vaginal swab used to investigate vaginal discharge in primary care and how do GPs expectations of the test match the tests performed by their microbiological services?

Noble et al.

Sex Transm Infect 2004; 80: 204–206

6. How useful are high vaginal swabs in general practice? Results of a multicentre study Jungmann et al.

Int J STD&AIDS 2004;15:238–239

7. Can a laboratory diagnosis of bacterial vaginosis be made from a transported high vaginal swab using anaerobic culture and microscopy of a wet preparation?

Crowley et al.

Sex Transm Infect 1998;74: 228

Further reading

The management of vaginal discharge in non genito-urinary medicine settings 2012 Faculty of Sexual and Reproductive Healthcare, Clinical Effectiveness Unit ISSN 1755-103X Available at www.fsrh.org and www.bashh.org/guidelines

4. Abnormal vaginal discharge in women of reproductive years

(32)

Background

1,2,3

■ Commonest cause of abnormal vaginal discharge in women of childbearing age

■ BV can arise and remit spontaneously in sexually active and inactive women

■ ? Trigger* overgrowth of mixed (mostly anaerobic) bacteria ‘normal’ vaginal lactobacilli replaced

* Recent studies have identified some bacterial species, hitherto unidentified, which seem to be specific for BV.These may have a principle role in the aetiology of BV. Further research is ongoing.

■ An acidic pH (3.5 to 4.5) is associated with Lactobacilli (they produce lactic acid) = normal

■ An alkaline pH (> 4.5) favours the growth of the mixed anaerobes which produce the Sx of BV

■ Thus, there is an interplay between vaginal pH and the growth of normal or abnormal bacteria

■ Associations

■ not specifically sexually transmitted but more likely to occur in the sexually active

■ hence the term ‘sexually associated’

– risk if recent new sexual partner

■ linked with concurrent STIs

■ more common in black / smokers / vaginal douching / bubble baths / receptive cunnilingus

■ risk if copper IUD (unclear if this is also the case with IUS)

■ linked with alkaline vaginal pH ( menstruation, semen)

■ What protects against BV?

■ Combined oral contraceptive pill (oestrogen favours lactobacilli)

■ Condoms

■ Circumcised partner

■ BV may co-exist with other causes of vaginal discharge (TV, candida, cervicitis)

5. Bacterial vaginosis (BV)

Figure 1

/ VAGINAL pH / MIXED ANAEROBES

/ LACTOBACILLI

(33)

Symptoms

■ Offensive fishy-smelling watery discharge (malodour often noticed after UPSI alkaline semen)

Not usually associated with soreness or itching (it is an ‘-osis’ not an ‘-itis’)

■ May be asymptomatic (although if Rx’d, women may notice a difference)

Signs

■ Thin grey / white homogeneous discharge

■ Raised vaginal pH: > 4.5 (normal is 3.5 to 4.5)

Complications

■ Pregnancy

■ BV is associated with late miscarriage, PROM, preterm birth, post-partum endometritis

■ PID

■ uncertain if BV causes PID. Whilst the prevalence of BV is high in women with PID, there are no data on whether Rx’ing asymptomatic women for BV reduced their subsequent risk of developing PID

■ TOP

■ BV is associated with post-op endometritis and PID (thus screen pre-TOP)

■ IUCD insertion

■ BV more likely (but no studies of whether BV PID after IUCD insertion)

■ STIs

■ Linked with risk of to HIV transmission and increased acquisition of STIs in women

■ One study observed that BV was associated with non-gonococcal urethritis in partners4

■ Some surgical procedures

■ incidence of infection following trans-vaginal hysterectomy

5. Bacterial vaginosis (BV)

(34)

Diagnosis

(this is difficult in General Practice!) There are two ways to diagnose BV

1. Most GU depts use a diagnosis based on the microscopic appearance of a Gram-stained smear of vaginal discharge, the Ison / Hay criteria:

Grade 1: lactobacilli predominate (this is normal)

Grade 2: some lactobacilli but other organisms present (intermediate) Grade 3: few / absent lactobacilli – lots of other organisms (this is BV)

2. Another diagnostic method uses Amsel’s criteria: 3 out of 4 make the diagnosis...

1. Thin white homogenous discharge

2. pH of vaginal fluid > 4.5 (normal is 3.5 to 4.5 )

3. Release of fishy odour on adding alkali (10% KOH) to drop of discharge on a microscope slide 4. ‘Clue cells’ (vaginal epithelial cells covered in bacteria) seen on microscopy

Both of these diagnostic criteria rely on microscopy and, in the case of Amsel’s criteria, the use of 10% KOH which is very caustic and potentially dangerous outside of a laboratory setting.

Clearly, these are difficult to do in a GP setting, and the diagnosis of BV in primary care may, for the time being, have to be a pragmatic one based simply on the presence of a malodorous discharge with a raised pH and no soreness / irritation (see figure 2)

Some pathology labs diagnose BV on a microscope slide

■ prepared in the lab from a high vaginal swab, or

■ taken directly in GP and sent to the lab in a protective box ( similar to the old Cx smear boxes)

Talk to your lab / GU service about the locally preferred method for diagnosing BV outside of GU settings

NB:

■ The isolation of Gardnerella vaginalis on HVS culture should not be used to diagnose BV because it is found in 30 to 40% ‘normal’ women.

■ New point-of-care tests exist and perform adequately, but are not yet widely available

■ NAAT tests detecting BV-associated bacteria are under development

5. Bacterial vaginosis (BV)

(35)

5. Bacterial vaginosis (BV)

Figure 2: Vaginal discharge in Primary Care algorithm (adapted from ref 2)

Manage as appropriate

TV suspected? d/w GUM / refer

Uncertain diagnosis? Refer Rx for BV

Eg:

METRONIDAZOLE 400 mg po b.d 5 to 7 days

or 2 g po stat

Rx for Candida Eg:

FLUCONAZOLE 150 mg po stat

or CLOTRIMAZOLE

500 mg PV stat

History

See above

Not sexually active or

Low risk of STIs or

None of the conditions listed on the right

Examination declined Examination accepted

High risk of STIs < age 25 previous STIs recent new partner or

> 1 partner in past year

Upper reproductive tract Sx

Bloody discharge

Uncertain Sx

Pregnant, post partum, post ToP, post instrumentation

Recurrent Sx or failed Rx

Examine and investigate

Vaginal pH

Endocervical swabs for Chlamydia and Gonorrhoea plus bloods for HIV and syphilis

Consider a high vaginal swab

? urine dipstick

? pregnancy test

Bimanual examination if PID suspected

Foreign body?

Other Consider examination

and investigations based on clinical findings Syndromic Rx based on Hx

Pt to return if Sx do not improve or if they recur

pH ≤ 4.5

Malodour, no itch Itch, no malodour pH > 4.5

參考文獻

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