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Guidance on specific conditions

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


  • 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



  • 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


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



  • 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 


Retained tampon

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


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


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)


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)



  • 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



  • 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


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


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


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


  • 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


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


  • 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


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%


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



  • 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


Last modified: 25-09-08