LPCG SH

... your local sexual health service

Guidance on specific conditions

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Vaginal Discharge Candidiasis Bacterial Vaginosis Trichomonas Retained Tampon
Vulval itching Vulval problems Abnormal Bleeding Dyspareunia Female dysuria
Urethral discharge Male dysuria Penile skin Testicular pain HIV

Vaginal Discharge – causes

  • Physiological
  • Candidiasis
  • Bacterial vaginosis
  • Trichomonas
  • Chlamydia
  • Gonorrhoea
  • Streptococcal infection - not important unless in final trimester (see midwife)
  • Other (retained tampon)

Vaginal Discharge – examination

  • Appearance of vulva (red, swollen in thrush)
  • Is there any visible discharge? Many women wash thoroughly prior to being examined
  • What does the discharge look like?
  • Does it look clear/white (normal) or does it resemble other common infections?
  • Is there any smell?
  • Take samples for chlamydia & gonorrhoea
  • Take HVS if you suspect thrush, BV or trich or want confirmation that there is no infection
  • Use of pH paper optional
  • Chlamydia and gonorrhoea can occur with a normal looking cervix
  • They can also produce cervicitis, with purulent discharge and contact bleeding

Physiological

  • Clear or white, may be heavy
  • Alters during menstrual cycle (if ovulation not suppressed)
  • Irritation and soreness uncommon
  • Normal sour odour
  • May be related to presence of ectropion
  • Diagnose when vagina healthy and tests negative

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Candidiasis

  • White discharge (curdy, cottage cheese)
  • Musty, yeasty odour
  • Intensely itchy, irritating, burning, painful
  • Swollen labia, inflamed, possible satellite lesions
  • Excoriation, shallow ulceration
  • External dysuria and superficial dyspareunia
  • May be provoked by antibiotics, diabetes, change in vaginal environment
  • Can affect male if not using condoms, uncircumcised, no postcoital washing
  • Diagnosis made clinically but can be confirmed with HVS Stuarts media
  • Treatment clotrimazole pessaries, cream (+hydrocortisone if very sore)
  • Oral treatment – fluconazole 50mg daily 7 days or 150mg stat

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Bacterial Vaginosis

  • Grey or white discharge, sometimes sticks to vaginal walls
  • Fishy odour especially after sex, can vary throughout cycle
  • Minimal itching or soreness
  • pH >4.5 if using test paper (don’t let speculum lubricant touch paper!)
  • Clinical diagnosis, treat with metronidazole 400mg bd 5d
  • Alternatives - clindamycin cream (may weaken condoms)
  • Or metronidazole gel pv 5 d
  • Advise against excessive genital washing/douching
  • Not sexually transmitted, partner does not need treating

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Trichomonas

  • Rarely seen in primary care in Leicester
  • Green frothy discharge with distinctive nasty odour (rotting flesh)
  • Itch may be intense because of inflammation
  • Vulva & vagina red, with “strawberry cervix”
  • Can get a “tide mark” of inflammation extending to inner thighs
  • Often a marker for other infections such as gonorrhoea, chlamydia
  • Clinical diagnosis, confirmed by HVS Stuarts media
  • Treatment with metronidazole 400mg bd 5 days (may need repeating)
  • Sexually transmitted, so arrange for partner to be tested and treated 

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Retained tampon

  • Foul odour, sometimes with bloodstained discharge
  • Removing tampon is curative, no other treatment needed
  • Check posterior fornix to ensure all removed

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Vulval Itching

  • Infections
    • Thrush, TV, scabies, crab lice, threadworms
  • Dermatological conditions
    • Eczema, psoriasis, lichen simplex/sclerosus/planus
  • Skin sensitivity
    • Detergents, perfumes, deodorants
  • Miscellaneous
    • Diabetes, post menopausal, pregnancy, urinary incontinence, itch elsewhere, psychological, idiopathic

Examination - Vulval Itching

  • Look at vulva
    • Excoriation
    • Swollen, red labia (with discharge of thrush/TV?)
    • Burrows
    • Crabs
    • Rash eg eczema, psoriasis, lichen sclerosus
  • Routine swabs
  • Check urine for sugar

Management – Vulval Itching

  • Treat infection or other cause
  • Advise emollient as soap substitute
  • Do not scratch!
  • Loose cotton underwear, allow air to circulate
  • Avoid chemicals, don’t wash excessively
  • Refer for second opinion if unsure of dermatological diagnosis

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Vulval Skin Problems

  • Lumps
    • Normal – Fordyce glands, skin tags
    • Warts, molluscum, boils, sebaceous cysts, nodes
  • Ulcers
    • Herpes, syphilis, Behcet’s, cancer
  • Rash
    • Eczema, psoriasis, lichen simplex, sclerosus, planus, VIN
    • Candidiasis, TV

Management of vulval problems

  • Examination of genitalia & STI screening
  • Warts
    • Podophyllotoxin (Warticon Cream) good for new warts, apply bd for 3 consecutive days each week
    • Liquid nitrogen if available
    • Imiquimod (Aldara) good for keratinised warts, apply Mon Wed Fri, warn about reaction
    • Refer for Hyfrecation under LA or scissoring
  • Molluscum
    • Not HPV but pox virus
    • Characteristic dimple in surface
    • Reasonable not to treat
    • Liquid N2 or gentle hyfrecation if patient insists
  • Boils/seb cysts
    • Treat as per usual
  • Herpes
    • Confirm by culture using viral media
    • Treat with aciclovir 200mg x5 for 5 days while waiting for result
    • Symptomatic advice, barrier cream, pain relief, local anaesthetic, teabags
    • Discuss natural history of infection once diagnosis has been confirmed
    • Patient held treatment/prophylactic treatment
  • Ulceration which is not typical of herpes
    • Refer for second opinion ?syphilis ?sq cell Ca
  • Rashes
    • Eczema and psoriasis often occur on genitals
    • Beware “recurrent thrush itching” could be lichen sclerosus
    • Refer for second opinion (Dr Dhar at GUM or vulval dermatology clinic)

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Abnormal Bleeding

  • Intermenstrual or post-coital bleeding
    • Pregnancy related
    • Hormonal contraception related
    • Dysfunctional uterine bleeding
    • Infections
    • Trauma
    • Ovulatory spotting
    • Gynaecological Neoplasia
    • Bleeding diathesis, medication (SSRIs, warfarin)

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Dyspareunia

  • Intermenstrual or post-coital bleeding
    • Superficial dyspareunia - examination
    • Vaginissmus (?psychological)
    • Trauma, fissuring, cuts to vulva and hymen
    • Vulvitis from thrush, TV or dermatitis
    • Ulceration from herpes
    • Bartholin’s or other infections
    • Painful episiotomy scar
    • Lichen sclerosus
    • Atrophic changes
    • Vestibulitis/vulvodynia
  • Deep dyspareunia – needs pelvic exam
    • Uterine fibroids or fixed retroverted uterus
    • Endometriosis
    • Pelvic inflammatory disease (acute or chronic)
    • Ovarian cyst or other pelvic masses
    • Bowel problems (IBD, constipation)
  • Usual STI screening tests and refer for scan or gynae opinion

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Dysuria

  • Causes of pain passing urine
    • Cystitis/urethritis
      • Bacterial UTI
      • Trauma
      • Stone
    • Genital infections (thrush, TV, gonorrhoea, chlamydia, herpes)
    • Atrophic vaginitis in older women
    • External dermatological problems

Management of Dysuria

  • Decide whether genital examination is needed
  • Urine sample, dipstick, and send MSU as appropriate
  • Treat with fluids, Cranberry juice, and consider antibiotics +/- agents to make urine alkaline
  • Offer screening for STIs in high risk groups

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Urethral discharge or irritation

  • This is an STI until proven otherwise
    • Examine penis for discharge
    • Profuse yellow/green pus likely to be gonorrhoea
    • Clear or milky discharge likely to be chlamydia or non-specific urethritis
    • Swab urethral meatus for gonorrhoea testing
    • First pass urine sample for chlamydia testing
    • Consider treatment based on clinical findings before results available
    • Arrange follow up and partner notification
  • Treatment before results
    • Azithromycin 1g stat po for NSU & chlamydia
    • If you suspect gonorrhoea (purulent profuse discharge), treat with cefixime 400mg stat po AND give azithromycin 1g stat to cover chlamydia too
    • Partner notification
    • NO sex (oral, genital or anal) even with condoms for at least a week after partner has been treated
    • Follow up proven gonorrhoea with test of cure 2wk later

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Dysuria - Men

  • In sexually active men, this is an STI until proven otherwise
    • Examine penis for discharge, ulceration
    • Gently swab (Stuarts) urethral meatus for GC
    • First catch urine specimen for chlamydia
    • Look for “threads” by swirling urine in bottle
    • Treat as non-specific urethritis (Azithro 1g stat)
    • Dipstick and MSU if you think it is UTI
    • Arrange follow up

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Penile skin problems

  • Examine penis
    • Normal markings pearly papules, coronal papillae, melanosis, sebaceous cysts, Tyson’s glands
    • Lumps & bumps: warts, scabies, molluscum
    • Ulcers: herpes, syphilis, carcinoma, Behcet’s
    • Changes to glans and foreskin: balanitis/posthitis

Balano-posthitis

  • Posthitis – foreskin inflammation
  • Balanitis – glans inflammation
    • Candida gives red blotches on glans, sometimes with white colonies visible. Foreskin may be tight and fissured. Treat with Daktacort cream bd.
    • Circinate balanitis – annular rash, associated with chlamydia. Confirm diagnosis & treat.
    • Red velvety patches – balanitis of Zoon or Queyrat. Refer for biopsy then steroid cream
    • White scarring – lichen sclerosus (used to be BXO) treat with potent topical steroids +/- circumcision

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Testicular Pain

  • Causes
    • Epididymo-orchitis
    • Torsion
    • Referred pain
    • Cryptogenic (chronic pelvic pain syndrome)
  • Torsion – immediate surgical referral
  • Referred pain from kidney stones, neuralgia with shingles or MS
  • Chronic pelvic pain syndrome – difficult, leave diagnosis to GUM clinic

Epididymo-orchitis

  • Don’t forget mumps
  • In sexually active men under 45, likely to be chlamydia or gonorrhoea
  • In older men, can be related to urinary tract infection
  • Possible blood borne spread (streptococcal, tuberculous)
  • Rarely caused by drugs (amiodarone)
  • Painful swollen testicles and tubes, usually bilateral, with red, warm scrotum
  • Perform usual STI screening tests and send an MSU if indicated
  • If clinically chlamydia / GC treat appropriately
  • Otherwise, give azithromycin 1g stat and pain relief (paracetamol, ibuprofen)
  • Scrotal support and rest
  • Be sure you have not missed a torsion

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Role of GP with HIV+ patients

  • Alphabet soup therapy
  • Drug Interactions
  • “Is my cough something to worry about?”
  • Be an advocate for your patient
  • Interpret complicated medical information
  • Pastoral care

HIV shared care

  • HIV infection is a chronic disorder
  • GPs need to be aware their patient has HIV and what treatment they are taking
  • Patients may feel that arrangements for confidentiality are less robust in primary care than in GUM clinics
  • Drug interactions – a minefield
    • PPIs & statins

Why increase HIV testing?

  • 30% of all HIV +ve people in UK are unaware of their infection
  • This group usually presents late with more advanced disease
  • Often have been seen several times in primary & secondary care without being tested for HIV
  • They continue to transmit HIV

HIV testing already routine

  • Antenatal testing
  • Testing in GU clinic setting
  • “Opt out” testing
  • SE London prevalence of HIV = 0.6%
    • Women from Sub Saharan African = 2.4%

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High risk groups - for targetted testing (more cost-effective)

  • Men who have sex with men
  • Women with bisexual partners
  • Those having had sex with people from high prevalence areas of the world
  • IVDUs and their partners
  • Blood transfusions overseas
  • Sex workers & their clients

High risk conditions - for targetted testing

  • Any unusual bacterial, fungal or viral disease:
    • infection with tuberculosis
    • suspected Pneumocystis carinii pneumonia
    • suspected cerebral toxoplasmosis
    • oral/oesophageal candidiasis
    • hairy leucoplakia
    • persistent genital ulceration
    • presence of another blood-borne or STI, eg syphilis, hepatitis B
    • suspected seroconversion illness (eg flu-like illness, glandular fever with negative EBV serology)
  • Odd tumours
    • Cerebral lymphoma
    • Non Hodgkins lymphoma
    • Kaposi
  • Unusual skin diseases
    • Extensive seborrhoeic dermatitis
    • Shingles
    • Giant molluscum especially on face
  • Persistent generalised lymphadenopathy
  • PUO, persistent diarrhoea, night sweats, weight loss
  • Unexplained low lymphocyte or platelet count
  • Any strange clinical situation, think ?HIV

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Counselling

  • Lengthy pre-test HIV counselling is not a requirement
  • Provide an opportunity for pre-test discussion to ensure informed consent
  • Information leaflets improve take-up
  • Negative tests need not be declared on insurance applications

Practical considerations

  • HIV antibody testing best on blood
  • Saliva will work but needs confirmation
  • All positive tests must be repeated
  • “Window period”
  • Testing & needlestick injuries
  • Communicating the results
  • Recording the results

Broaching the subject

  • Relatively easy when the patient asks for STI screening, or in a “sexy setting”
  • Difficult when you suspect HIV and feel a test is needed
  • Use “breaking bad news” techniques
    • SPIKES (setting up, patient perception, invitation to go there, knowledge, empathy, strategy)
    • Be honest, competent and attentive

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Last modified: 25-09-08