STI diagnosis treatment Dr Jolle Turner Consultant in

STI diagnosis & treatment Dr Joëlle Turner Consultant in Sexual Health Luton Sexual Health 27 th February 2018

Overall objectives of session • Look at examples of presentations of STIs • How to assess a patient with a possible STI – history taking and examination • Testing for STIs • Consider differential diagnoses and appropriate referral • Treatment and follow up • Partner notification

Case 1 • 17 yr old female presents with intermenstrual bleeding • On COC pill – previously regular withdrawal bleed only • No discharge/dysuria/abdominal pain • No dyspareunia or postcoital bleeding • New boyfriend of 2 months, age 18

Differential diagnosis? • Breakthrough bleeding • Cervical ectopy or other pathology • STI • Examination: • Normal vulva and vagina, no discharge seen • Cervix – small area of ectopy, contact bleeding

Chlamydia/gonorrhoea NAAT swabs • Detect nucleic acid of dead or living bacteria/bacterial remains – PCR technique • Equivalent sensitivity with endocervical or selftaken vulvovaginal swabs (but not urine in women)

Chlamydia NAAT positive • Treatment options: – Doxycycline 100 mg bd x 7 days (preferred if no pregnancy risk or other contraindication) – Azithromycin 1 g stat po • Other advice: – No sex (with or without condom, inc. oral/anal) until 7 days after treatment completion • Partner notification: – Recommend test & treat all partners from last 6 months – no sex until 7 days after treatment

Case 2 • 22 yr old man • Presents with right testicular pain and swelling – noted 3 hours ago on waking, gradually worsening • Moderate pain • Intermittent dysuria for 2 weeks

History • • No urethral discharge or recent diarrhoea No recent travel No previous UTI or catheterisation No associated abdo pain/N+V No recent trauma No PMHx, no medications Sexual history – 3 casual female partners in last 3 months – all unprotected vaginal and oral sex

Differential diagnosis? • • • Torsion Epididymo-orchitis Testicular mass Hydrocele Testicular infarction or rupture Scrotal cellulitis/Fournier’s gangrene

Examination findings • Right scrotum swollen and red • Right testicular and epididymal swelling and tenderness • Normal lie of testis • No urethral discharge • Abdomen soft, non tender

Investigations and referral • Urine dipstick + MSU • Urine for chlamydia and gonorrhoea NAAT test – First void urine – Plain (white top) bottle or NAAT tube – Virology form • Tests before treatment! • Offer blood test for HIV/syphilis • If any suspicion of torsion urgent urology review. • If no suspicion of torsion/torsion ruled out start Abx

Treatment • STI most likely if age <35 and no other features – Treat with doxycycline 100 mg bd x 14 days – if GC suspected (frank pus discharge, contact of GC) needs ceftriaxone 500 mg IM stat also • If UTI/enteric pathogen suspected – e. g. dipstick +ve, recent diarrhoea, previous UTI/catheter, age >35 – Ciprofloxacin 500 mg bd for 10 -14 days – Ofloxacin 200 -400 mg bd for 10 -14 days

Other advice • Scrotal support – folded up towel, briefs>boxers • Ice and analgesia • No sex until a week after abx complete • Partner notification – treat partner if STI suspected. • Follow up at 2 -3 weeks if sx persist

Case 3 • 26 yr old woman • Presents with 10 day history of pelvic pain and vaginal bleeding • Cramping pain, constant • Intermenstrual bleeding and post coital bleeding for last month. • Now heavy constant bleeding for 3 days

History • • Yellow PV discharge with odour No dysuria/frequency No bowel changes/N+V Deep dyspareunia for last 6 weeks • No previous medical history, no medications • LMP 5/52 ago, not using any contraception, last sexual intercourse 3/52 ago • Regular partner for last 6 months

Differential diagnosis? • • • Ectopic pregnancy Early miscarriage Appendicitis Pelvic inflammatory disease (PID) Ovarian cyst rupture Endometriosis

Examination findings • • Vulva NAD Vagina – thin white/yellow discharge Cervix – inflamed, mucoid discharge Bimanual – bilateral adnexal tenderness but no masses, mild cervical motion tenderness • Abdomen soft, no rebound/guarding, mild lower abdominal tenderness L>R

Tests • • Pregnancy test – negative Urine dip – trace leucocytes only Blood test for HIV/syphilis NAAT swab for chlamydia/gonorrhoea/TV (or charcoal swab for TV) – High vaginal – Self-taken vulvovaginal

Pathogens linked to PID • • Chlamydia & gonorrhoea BV-associated bacteria Other STIs e. g. mycoplasma genitalium Other non–STIs • STI detected in <one third of cases • ‘Translocation’ of vaginal bacteria

Treatment • Standard treatment for PID is with combination Abx: • Doxycycline 100 mg bd x 2/52 (consider alternative if risk of pregnancy) plus • Metronidazole 400 mg bd x 10 -14 days • +/- Ceftriaxone IM 500 mg stat if gonorrhoea suspected • No sex during treatment

Follow up • If complicated/severe PID suspected refer to sexual health same or next day • Ensure partner notification commenced • Important to do tests before antibiotics commenced • If fever/systemically unwell consider gynae admission for iv Abx and USS ? tubo-ovarian abscess • Review at 2 -3 weeks – Check completed abx – Repeat pregnancy test, review swab results – Check if sx/signs resolved – Ensure has abstained from sex and partner screened and treated • If signs and sx persist proceed to USS

Case 3 • 52 yr old woman • Presents with 3 day history of fever, swollen glands, myalgia • Also reports dysuria, difficulty passing urine and vulval soreness • Yellowish vaginal discharge • No pelvic pain, no bleeding (post menopausal) • Last sex 4 years ago • Oral intercourse with new partner – 1 week ago

On examination • Waddling gait, difficulty sitting down • Tender inguinal lymph nodes • Vulva sore +++

Tests • Urine dip • Ensure can pass urine • Swab for HSV PCR • Blood test for HIV/syphilis • Do not attempt vaginal swabs or speculum examination – too painful

Treatment and referral • Start aciclovir 200 mg 5 x/day or 400 mg tds x 5/7 • Admission for catheterisation if urinary retention • Give topical lidocaine cream/gel (instillagel if nothing else available) for symptomatic relief • Advise analgesia, salt water bathing, pee in bath • Refer to sexual health esp. if no access to swab testing for confirmation of diagnosis, symptoms severe or not settling or if diagnosis unclear • If frequent recurrences can provide suppresiive treatment – Aciclovir 400 mg bd for 6 -12 months

Follow up • Review if not improving • Otherwise review after ulcers healed – Perform rest of STI screen (swabs/bloods) – Review swab results – Counsel about HSV – Advise about transmission to partners – Refer to Herpes Viruses Association for advice www. hva. org. uk

Luton Sexual Health opening hours • • Monday 9. 00 – 18. 30 Tuesday 9. 00 – 17. 30 Wednesday 9. 00 – 18. 30 Thursday 9. 00 – 18. 30 Friday 9. 00 – 13. 00 Saturday 9. 00 – 15. 00 Walk in clinics daily • Contact us if any advice needed • See www. lutonsexualhealth. org. uk

Resources • British Association for Sexual Health and HIV – www. bashh. org/guidelines • British HIV Association – www. bhiva. org/guidelines