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STI
Site
Test
Sample
Chlamydia
Urethra
PCR (or other NAAT)
First catch urine (FCU) - 10 to
20ml, at least 1 hour after last
passing urine
• Endo cervical dry swab
(clinician collected)
Cervix
PCR (or other NAAT)
• Vaginal dry swab - self or
clinician collected
• FCU (as above)
Gonorrhoea
Rectum
PCR (or other NAAT)
Rectal dry swab - self or clinician
collected
Urethra
1. Microscopy (Gram stain), culture and sensitivity
1. Dry swab* - smear on slide
for microscopy, then place in
Amies +/- charcoal medium
2. Dry swab* or FCU (as above)
2. PCR (or other NAAT)
* NB - only if discharge present
Throat & Rectum
Culture and sensitivity
Dry swab from pharyngeal or
rectal mucosa placed in Amies
+/- charcoal medium
STI
Site
Test
Sample
Herpes
Lesion or ulcer
PCR (or other NAAT)
Dry swab usually, but check with
local lab.
Serum
HSV serology - EIA. Western blot
also available in a few centres
Clotted blood tube & store at 4 oC
after clotting
Genital warts
Clinical diagnosis
Human Papilloma virus
1. Cytological Pap smear
Cervicalr
2. liquid based cytology
(plastic instruments required)
3. *Digene ® Hybrid Capture
4. *PCR
*As per pap guidelines
1. Microscopy, culture
Trichomoniasis
Vagina
2. Wet prep
3. *PCR
* Check availability with lab
1. Pap smear - smear from ecto
and endo cervix, fixed within
five seconds
2. smear from ecto and endo
cervix swished in liquid
medium (e.g. cytec)
3. cervical swab in Digene ®
transport medium
4. dry swab
1. Dry swab from posterior fornix
in Amies medium (or specific
broth supplied by local lab)
2. Dry swab onto drop of normal
saline on glass slide; examine
under cover slip – (only if
microscope on site)
3. Dry swab from posterior fornix’
STI
Site
Test
Sample
Bacterial
Vagi nosis
Vagina
Microscopy- Gram stain
Dry swab from posterior fornix
and lateral wall of vagina and
smeared onto glass slide
Candidiasis (Thrush)
Vagina or vulva
Microscopy (Gram stain), culture
and sensitivity
Cotton swab from posterior fornix
and lateral wall of vagina or from
vulva smeared onto glass slide.
Place swab in Amies medium
HIV
Serum
HIV 1& 2 antibodies
Clotted blood tube & store at 4 oC
after clotting
Hepatitis A
Serum
Hep A antibodies - total (& IgM for
recent infection)
Clotted blood tube & store at 4oC
after clotting
Hepatitis B
Serum
1. HepB sAg - acute or chronic
infection
2. HepB sAb - marker of immunity
3. HepB cAb - marker of recent or
past infection
Clotted blood tube & store at 4oC
after clotting
Hepatitis C
Serum
HCV Antibodies - for screening
Clotted blood tube & store at 4o C
after clotting
STI
Site
Test
Sample
Syphilis
Serum
RPR & a specific test (e.g. EIA or
TPPA).
Clotted blood tube & store at 4o C
after clotting
Chancre or ulcer
NSU (Non-specific
urethritis)
NB Diagnosis is one
of exclusion of spcific
infections, in the
presence of urethral
symptoms and evidence
of urethral inflammation
on microscopy
Urethra
*NB - only if discharge
present
1. PCR
2. Darkground microscopy
1. Microscopy for Gram stain
(looking for polymorphs)
2. Microscopy (Gram stain),
culture and sensitivity for
Neisseria gonorrhoeae
3. PCR (or other NAAT) for
Chlamydia trachomatis and
Neisseria gonorrhoeae
4. PCR (or other NAAT) for other
vaginalis, Mycoplasma genitalium, Herpes simplex virus)
only if other specific tests are
negative
1. Dry swab of ulcer
2. wet prep- must have dark field
microscope and trained microscopist on site to read slide
1. *Dry swab moistened with
normal saline from terminal
urethra, or centrifuged deposit
of FCU
2. *Dry swab - smear on slide
for microscopy, then place in
Amies +/- charcoal medium
3. FCU
4. Dry swab moistened with
normal saline or FCU
– check with local laboratory
Treatment Table
These are first line treatments as a quick guide - for further information or alternatives please consult text
Infection
Drug
Strength, Dose & Frequency
Chlamydia
Azithromycin (B1)
500 mg x 2 (=1gram) po Stat
Gonorrhoea
Ceftriaxone (B1)
500mg IM Stat
Azithromycin (B1)
500mg x 2 (=1gram) po Stat
Doxycycline (D)
100mg BD po for 14 days
Metronidazole (B2)
400mgBD po for 14 days
Epididymo-orchitis
Azithromycin (B1),
followed by
Doxycycline (D)
1g as a single dose, po Stat
Syphilis early <2years
Benzathine Penicillin (A) 1.8grams IM
Syphilis late >2 years
Benzathine Penicillin (A) 1.8grams IM weekly for 3 doses
Bacterial Vaginosis (BV)
Metronidazole (B2)
PID
100mg BD po for 21 days
400mg BD po for 7 days
Comment
Mix with 2mls of 1%
Lignocaine
Plus Ceftriaxone
500mg IM If gono
suspected (chap 4)
Severe cases may
need IV antibiotics
Clotrimazole (A)
100mg PV pessary or cream (A) for 6 nights,
OR 200mg PV pessary (A) for 3 nights, OR
500mg PV pessary single dose (A)
Metronidazole (B2)
2g po Stat
Valaciclovir OR
500mg BD po 7-10 days
Aciclovir
400mg TDS po 7-10 days
Herpes recurrent :
Aciclovir OR
800mg TDS po 2 days
Episodic
Famciclovir OR
500m stat ; then 250mg BD po for 3 doses
Valaciclovir
500mg BD po 3 days
Valaciclovir OR
500mg daily po
Famciclovir
250mg BD po
Levonorgestrel (B3)
1.5mg po Stat
Acute vulvovaginal
candidiasis/ Thrush
Trichomoniasis
Herpes initial
Herpes recurrent :
Suppressive
Emergency
Contraception
Plus paracetamol
&/or lignocaine gel
PRN
Commence therapy
within 24 hours of
onset of symptoms
Contents
Preface����������������������������������������������������������������������������3
1. ASYMPTOMATIC SEXUAL HEALTH SCREEN�����������6
2. VULVOVAGINAL SYMPTOMS������������������������������������� 15
3. Urethritis in Males������������������������������������������������ 28
4. Pelvic Pain in Females������������������������������������������� 35
5. PELVIC PAIN IN Males������������������������������������������������ 45
6. ANORECTAL SYMPTOMS������������������������������������������� 52
7. SEXUALLY acquired ULCERS�������������������������������� 65
8. LUMPS AND BUMPS����������������������������������������������������� 73
9. VIRAL HEPATITIS����������������������������������������������������������� 85
10. ITCHES, RASHES & JOINTS (including DGI)������ 98
11. HIV & AIDS���������������������������������������������������������������������108
12. EMERGENCY PRESENTATIONS����������������������������� 116
13. SEXUAL HISTORY TAKING &
PUBLIC HEALTH ISSUES�������������������������������������������126
14. Young people, confidentiality & access to medical advice / treatment ���������������������138
15. RESOURCES, web LINKS & CONTACTS������������142
Disclaimer
These guidelines are an updated version of the 2002 guidelines.
The publisher accepts no responsibility for errors, omissions
or inaccuracies contained herein or the consequences of
any action taken as a result of information in this publication.
These guidelines are no substitute for consultation with
medical practitioner experience in the management of
considerations described herein.
Not all recommended drug dosages in this guideline are
PBS entitled. It is up to the medical practitioner to know this
required information and treat as they see fit. The dosages
recommended are in common use by experts in the field
today and are therefore recommended on this basis.
© Sexual Health Society Of Victoria 2008
Photo supplied by Jacki Mein and Lewis Marshall
Illustration by Mark Chung p.62
ISBN: 978-0-9805925-0-4
This booklet has been produced on recycled paper with the
highest regard for the environment.
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Preface
It is with great pleasure that The Sexual Health Society
of Victoria presents to you the National STI Management Guidelines 7th edition. It has been a long
journey since the previous edition in 2002 but we
have worked on making this edition easier to use,
re-formatting the layout and using a syndromic or
presenting symptoms approach. We hope this format
combined with the new flow charts, diagrams and
photos will enable easier diagnosis and treatment
and you find this edition as useful as the last.
I wish to acknowledge the help and support of the
SHSOV committee and guidelines working group.
I want to earnestly thank Dr David Bradford for the
enormous amount of work, who as Medical Editor
was professional, tireless and patient until completion.
His attention to detail and wealth of knowledge is
terrific and helped shape the guidelines into what
they have become.
I also wish to thank Mark Chung for his preparation
of the guidelines and Nyree Chung for project
management. Without this team I would still be
looking at drafts.
Lastly I would like to thanks all the contributors
whose marvelous combined knowledge have brought
together this wonderful set of guidelines to help
medical and nursing practitioners around Australia
care for patients with sexual health issues.
Dr Siobhan Bourke
Coordinating editor and President SHSOV
Contributions by:
Dr Stuart Aitken Sexual Health Physician, Senior
Medical Officer Gold Coast Sexual Health Clinic,
Queensland
Dr Katrina Allen General Practitioner and Sexual
Health Physician, SHINE South Australia
Dr Karen Berzins Sexual Health Physician,
Melbourne Sexual Health Centre, Mercy Hospital for
Women, Victoria
Dr Siobhan Bourke Sexual Health Physician
Melbourne Sexual Health Centre and Victorian
Cytology Service, Victoria
Dr Chris Bourne Head, NSW Sexually Transmitted
Infections Programs Unit; Senior Staff Specialist at
Sydney Sexual Health Centre, Sydney Hospital; and
a Conjoint Senior Lecturer, School of Public Health
and Community Medicine, University of New South
Wales
Dr David Bradford FRCS & Sexual Health Physician, a foundation fellow of the Australasian Chapter of Sexual Health Medicine (FAChSHM) & Former
Director of the Sexual Health Service at Cairns Base
Hospital. Currently works part time at Cairns Sexual
Health Clinic, Queensland
Dr Kathy Cook Obstetrician Gynaecologist & Sexual
Health Physician, Melbourne Sexual Health Centre
and Mercy Hospital for Women, Victoria
Dr Benjamin Cowie Infectious Diseases Physician,
Victorian Infectious Diseases Service, Royal Melbourne Hospital and Victorian Infectious Diseases
Reference Laboratory, Victoria
Ms Alison Duffin Sexual and Reproductive Health
Nurse, Family Planning Victoria, Melbourne, Victoria
Dr Lewis Marshall Sexual Health & Public Health
Physician, Head of Fremantle Sexual Health Service.
Co-lead of the Infections and immunology Health
Network for the WA Department of Health, Western
Australia
Dr Jacki Mein Sexual Health & Public Health
Physician, Wu Chopperen Aboriginal Health Service
and Family Planning in Cairns, Queensland
Dr Maree O’Sullivan Director Sexual Health Service
Hobart Tasmania
Dr Vanita Parekh Senior Specialist Deputy Director,
Canberra Sexual Health Centre & Medical Director
Forensic and Medical Sexual Assault Care, Clinical
Forensics ACT, Australian Capital Territory
Dr Darren Russell Clinical Associate Professor The
University of Melbourne, Sexual Health Physician,
Director of Cairns Sexual Health Service,
Queensland.
Endorsments
Australasian Chapter of
Sexual Health Medicine
Royal Australian College of
General Practitioners
Department of Human
Services
Australasian Society for
HIV Medicine
Australasian Sexual Health
& HIV Nurses Association
ASYMPTOMATIC SEXUAL HEALTH SCREEN
Overview:
Screening is justified if the condition is common, has
serious consequences and there are mechanisms
available for testing and management. More often
than not, most of the major sexually transmissible
infections (STIs) of public health significance are
entirely asymptomatic in the early stages of infection.
This justifies screening on request but just as
importantly, opportunistically.
Who is at risk and should be screened?
The commonly recognised risk factors in the
general population are:
People aged 15 -29 years
People with a past history of STIs
Men who have sex with men (MSM)
Known contacts of a person with an STI
People who have had sex overseas
Indigenous clients
People who don’t use barrier forms of protection
consistently with casual contacts
People with multiple sexual partners
People who have recently changed sexual partner
Neonates born to infected mothers
Medical Issues:
Up to 85 - 90% of infections with Chlamydia
trachomatis in men and women are asymptomatic.
Presence of symptoms may also vary depending on
site of infection. 10 % of urethral infections in men
with gonorrhoea may be asymptomatic whilst
pharyngeal and rectal infections are nearly always
asymptomatic. Symptoms of other STIs such as
HIV, hepatitis B and syphilis may go unnoticed or be
attributed to other causes such as glandular fever.
6
Maree O’Sullivan
In the absence of symptoms an adequate sexual
health history is the most important aspect of the
clinical interaction.
For all consultations:
Establish good rapport
Determine the presenting reason- let the client tell
their story
Address their issue
Start with non-threatening ‘safe’ questions
Proceed to the specific
Take the opportunity to raise the issue of an STI
screen with any clients in the list above, no matter
what their presentation might be
1
General aspects of the history should include:
Past medical history
Medication and allergy history
Menstrual and obstetric history
Social history – smoking, alcohol, recreational use
of drugs (especially in relation to sex)
Sexual history – past STIs
A travel history of the client and their partners will
help to alert to the possibility of resistant infections as
well as STIs which are uncommon in Australia
(e.g. LGV, Donovanosis, Chancroid etc). As in most
of medicine more is missed by not asking rather than
not knowing.
If sexually active you want to know
When
With whom – male/female/both; person(s) in or
recently arrived from another country
Type – oral/anal/vaginal
Safer sexual practices (and what clients
understand by the term)
How many partners – especially in last 3 months
Past sexual health screening – if, where and when
Maree O’Sullivan
7
Asymptomatic screen
History:
Examination:
The history will guide the clinicians as to what sites
need to be examined (not always required).
Clinical genital examination is essential for
infections such as genital warts, and molluscum
contagiosum rely on visual diagnosis. It is also
important to exclude the presence of specific genital
dermatoses as well as genital signs of systemic
conditions.
Investigations:
The purpose of the screening process is to:
limit the sequelae of the infection
minimise ongoing transmission
treat infected people
limit the number of false negative tests.
The method of screening test used is dependent on
the setting, and needs to take into consideration:
Specimen type and availability in local laboratory
Cost
Sensitivity and specificity of the test
Specimen transportation requirement
All testing should be undertaken only with informed
consent and appropriate counselling on the medical
and social consequences of the possible results.
Women:
Genitourinary:
Endocervical swab for PCR for Chlamydia and
gonorrhoea
Or
First void urine for PCR for Chlamydia and gonorrhoea, collected at least >1 hour after last void
8
Maree O’Sullivan
Rectal and pharyngeal – if indicated on history:
Pharyngeal and ano-rectal (blind) swab for culture
for N. gonorrhoeae
Ano-rectal (blind) swab for PCR for Chlamydia
NB Patient-collected or clinician-collected salinemoistened anal (blind) swabs are an acceptable and
appropriate approach to asymptomatic testing of the
anus
Men:
Urogenital:
First void urine, collected at least >1 hour after last
void, for PCR for Chlamydia and gonorrhoea
Or
Urethral swab for PCR for Chlamydia and gonorrhoea (but ONLY if some discharge is present –
the test is too uncomfortable and invasive in a dry
urethra- see chapter on urethritis)
Maree O’Sullivan
9
1
Asymptomatic screen
NB: The combined Chlamydia and gonorrhoea PCR
assay is validated for use in endocervical, urethral
and first void urine specimens. Specimens for PCR
for Chlamydia from the ano-rectum, though not
formally validated, are now widely used for screening
and appear to be reliable in clinical practice. Due to
the wide range of antibiotic resistance to
gonorrhoea, where possible, a positive gonococcal
PCR result should be followed up by culture to keep
track of resistant strains in the local community.
Swabs for culture (rather than PCR) for gonorrhoea
should be taken from pharynx and ano-rectum where
the history indicates the need to check these sites.
Endocervical swab for smear and culture for
N. gonorrhoeae (if required as in above note)
High vaginal swab for specific culture or PCR (if
available) if trichomoniasis is clinically suspected
Pap smear - if not done within the national cervical
cytology guideline framework
NB: The combined Chlamydia and gonorrhoea PCR
assay is validated for use in urethral and first void
urine specimens. Specimens for PCR for Chlamydia
from the ano-rectum, though not formally validated,
are now widely used for screening and appear to be
reliable in clinical practice. Due to the wide range of
antibiotic resistance to gonorrhoea, where possible,
a positive gonococcal PCR result should be followed
up by culture to keep track of resistant strains in the
local community. Swabs for culture (rather than PCR)
for gonorrhoea should be taken from pharynx and
ano-rectum where the history indicates the need to
check these sites.
Urethral swab for smear and culture for
N. gonorrhoeae is not generally recommended in
an asymptomatic screen because of the absence
of any discharge
Rectal and pharyngeal –in ALL MSM at annual
intervals as recommended in the STIGMA
guidelines:
Pharyngeal and ano-rectal (blind) swab for culture
for N. gonorrhoeae
Ano-rectal (blind) swab for PCR for Chlamydia
NB Patient-collected or clinician-collected salinemoistened anal (blind) swabs are an acceptable and
appropriate approach to asymptomatic testing of the
anus
Women and Men:
Serological testing is not required for every STI
checkup, assess risk of blood born viruses and
syphilis before ordering tests. Some low risk persons
request blood tests and in some circumstances it is
worth carrying out to avoid multiple medical
appointments.
Serology:
HIV antibody
Hepatitis B surface antibody and core antibody with
a view to vaccination in those without immunity.
10
Maree O’Sullivan
For diagnosis of clinically inapparent infection,
hepatis B surface antigen.
Hepatitis C antibody – only if history of exposure
risk eg IDU
Syphilis serology – RPR and a specific treponemal
test (eg TPPA or EIA or TPHA or FTA-ABS)
Serological tests may need to be repeated after
recognized window periods post exposure:
HIV – at 12 weeks (Check with your lab shorter window period testing)
Hepatitis B – at 4, 12 and 24 weeks
Hepatitis C – at 12 and 24 weeks
Syphilis
– at 6 weeks
1
Other Tests:
Other tests as determined by the examination e.g.
swabs for PCR or culture (depending on local
availability) – for viral and/or bacterial testing of
genital ulcers (see sexually acquired ulcers chapter).
If syphilis is suspected, syphilis serology (as above)
is mandatory. In some centres a PCR test for
Treponema pallidum is available on a swab from a
suspicious lesion. Dark field microscopy is only very
rarely available now.
Medical Management:
Treatment is specific to the infection that is identified.
Treatment of Chlamydia- Azithromycin (B1) 1g po
stat OR Doxycycline 100mg BD po for 7 days
[PID see pelvic pain chapter]
Treatment of gonorrhoea- Ceftriaxone (B1) 500mg IM
stat dissolved in 2mL of 1% lignocaine plus treatment
for possible Chlamydia co-infection
Maree O’Sullivan
11
Asymptomatic screen
Hepatitis A antibody in men who have sex with men
with a view to vaccination in those without immunity.
This is not part of routine screening, consider for
faecal / oral contact.
Early Syphilis (Primary or Secondary)
Benzathine penicillin (A) 1.8g IM single dose
OR
Procaine penicillin (A) 1g IM daily for 10 days
(preferred therapy if patient is HIV positive)
If allergic to penicillin
Doxycycline (D) 100mg BD po for 14 days (NOT in
pregnancy or breast feeding)
[Hepatitis ABC- see chapter on Viral Hepatitis]
[HIV- see chapter on HIV/AIDS]
All sex partners should be evaluated, tested, and
treated. People who have been diagnosed with an
STI should abstain from sexual intercourse until they
and their sex partners have completed treatment,
otherwise re-infection is possible.
Test of cure is not recommended for people who
have been treated for Chlamydia as the PCR tests
may stay positive for up to 6 weeks. Reinfection with
Chlamydia is common and repeat testing 3 months
after a positive diagnosis should be considered.
Follow–up approximately one week after treatment
to check that symptoms and signs have settled and
that contacts have been treated is recommended for
gonorrhoea.
Other Considerations:
An asymptomatic screen is an ideal time to reinforce
safer sex and safer injecting and to provide basic
education on sexual health and STIs and HIV/AIDS.
Special Considerations:
Asymptomatic screens provide the means to detect
unrecognized infection and to reduce individual
morbidity as well as the reduction of the risk of
partner and vertical transmission.
12
Maree O’Sullivan
Sex Workers:
Maree O’Sullivan
13
1
Asymptomatic screen
Depending on the State or Territory, Sex Workers
may require or may request a screen for STIs on a
monthly basis. Chlamydia, gonorrhoea and
trichomoniasis should be swabbed for monthly. A
speculum examination is recommended every three
to six months; testing in between times can be taken
on blind vaginal swabs. Throat swabs for gonorrhoea
should be done for both females and males and anal
swabs for gonorrhoea and chlamydia for all male
SWs and only for female SWs who give a history of
receptive anal sex. HIV and syphilis should be tested
for serologically on a three monthly basis. Hepatitis
B vaccination should be completed and serological
confirmation of immunity should be recorded.
Consider Hepatitis A vaccination in male SWs. Pap
tests should also be taken as per national cervical
cytology guideline framework.
Vaginal discharge
(For more details see text for full description & assess for pregnancy)
Examination should include: • Vulva
• Vagina
• Cervix
If pain or temperature is present also do a PV Bimanual and consider PID
If discharge present take
the following samples:
Cervix – Chlamydia
Cervix – M/C/S (for gono)
Vagina – M/C/S
Possible causes of discharge
Vaginal discharge
Bacterial Vaginosis
• Smelly odour
• White colour
• D/C intermittent
• Associated with sexual activity
Thrush
• Red vulva and vaginal walls
• Itchy
• D/C is thick white / cottage cheese
Trichomoniasis
• Green colour
• D/C Frothy
Foreign Body
• Odour present
• F/B visualised
Physiological
• Changes with menstrual cycle
• If no apparent pathogen, may see
mucus at cervix
14
If no discharge take
the following sample
Cervix –Chlamydia
Cervical discharge
Chlamydia
• Minimal discharge
• Abnormal bleeding
• Post coital bleeding
• Inter-menstrual
bleeding
Gonorrhoea
• Yellow green colour
• Purulent D/C
Physiological
• No apparent
pathogen, often
mucus seen at cervix
Karen Berzins & Siobhan Bourke
VULVOVAGINAL SYMPTOMS
Overview:
Vaginal symptoms are common and are often
distressing. Vulval symptoms often coexist with
vaginal symptoms, and need specific attention. The
clinical scenarios range from mild and localised, to
associated pelvic inflammatory disease.
The commonest causes are not necessarily sexually
transmissible infections (STIs), rather candidiasis,
bacterial vaginosis (BV) and UTIs. However, STIs
can coexist. Identification of groups at increased risk
of STI guides tests. There is emerging evidence that
BV may also be sexually transmitted, or at the least
is associated with sexual activity. It may be a marker
of risk for other STIs. Symptomatic physiological
discharge is relatively common, and is a diagnosis of
exclusion. Preovulatory fertile cervical mucus can be
experienced as abnormal discharge.
Medical Issues:
Most common:
Vulval dermatitis, Eczema and irritants (often
associated with candidiasis)
Trauma (secondary to scratching, including sexual
friction, especially associated with infections and
dermatitis)
Karen Berzins & Siobhan Bourke
15
2
vulvoVaginal symptoms
Infections
• Candidiasis (75% of women will have at least one
episode, and in 5%, candidiasis is recurrent)
• BV (occasionally coexists with candidiasis and
may be a risk factor for STI)
• Herpes simplex virus (HSV) types 1 and 2 vulvovaginal infection (most recurrences are type 2)
• Urinary Tract Infection
• Warts
Common:
• Chlamydia (asymptomatic Chlamydia is very
common- see Chapter on asymptomatic
screening). Women at risk: Age under 30, past
history of Chlamydia, partner change in past 1 - 3
months, recent lower abdominal pain,
intermenstrual or post coital bleeding
Uncommon:
• Gonorrhoea and Trichomoniasis (consider risks,
clinical setting – gonorrhoea is more frequent in
partners of bisexual men, and both gonorrhoea &
trichomoniasis are more frequent in women who
have had unprotected sex overseas and
Indigenous women)
• Mycoplasma genitalium infection of endocervix or
urethra
• Vulval pain syndrome (localised introital, or
generalized)
• Vulval Lichen Sclerosus (often misdiagnosed as
Candida)
• Pubic lice and Scabies
• Retained foreign body (tampon, sponge, condom)
Rare:
• Malignancies of the cervix or vulva.
• Aphthous ulceration ( exclude HSV)
• Erosive dermatitis that includes the vagina
(purulent discharge, can be blood-stained).
Not to be missed:
• Pregnancy and associated complications
• Pelvic inflammatory disease
• Retained foreign body
• Malignancy
History:
History of the presenting problem: describe the vulval
or vaginal symptom and its chronicity and associated
features
16
Karen Berzins & Siobhan Bourke
Discharge: type/colour/amount/blood stained or
abnormal bleeding/ odour
Pain: location: vulval, introital (entrance to the
vagina), deep inside/ severity/ associated with sex or
tampon use/chronicity
Itch or burning sensation: vulval or vaginal scratching
especially at night
Rashes, lumps or bumps
Urinary symptoms
Recent antibiotics/antifungals
Take a full sexual history
Examination:
Discharge is commonest, but usually there are
combinations of itch, discharge, odour and pain.
Discharge
Mostly of vaginal origin (BV, candidiasis, also
trichomoniasis in some settings), less often cervical
(Chlamydia, gonorrhoea or rarely herpetic infection)
with mucopurulent cervicitis. Exclude foreign body.
Infection with bacterial vaginosis, clinically there is a
homogenous gray-white discharge and pH > 4.5
Infection with Trichomonas vaginalis classically is
inflammatory, with a frothy yellow/green discharge
and pH > 4.5 (this can be tested at time of
examination using appropriate pH litmus paper
- also used in the diagnosis of BV). There may be the
appearance of a “strawberry cervix” associated with
the inflammation.
Karen Berzins & Siobhan Bourke
17
vulvoVaginal symptoms
Infection with Candida albicans classically has a
“cottage cheese” discharge and vulvovaginal
erythema, and sometimes fissuring. Immunosuppression, diabetes and antibiotics are risk factors for
recurrent candidiasis in a minority of cases.
2
Mucopurulent cervicitis can produce vaginal discharge,
which is usually caused by Chlamydia and
Gonorrhoea.
Rarely, a purulent or blood stained discharge may be
due to desquamative inflammatory vaginitis or
erosive lichen planus. These are rare conditions,
often associated with vulval burning and vaginal
petechiae. Specialist advice is recommended.
Treatment is often difficult and protracted.
Malignancy of the cervix may produce a blood
stained discharge or postcoital bleeding.
Exclude pregnancy in cases of abnormal vaginal
bleeding.
Odour
Mostly due to BV, but consider retained foreign
body. Bacterial vaginosis is an overgrowth of various
endogenous bacteria (including Gardnerella vaginalis
and mobiluncus species). The odour is worse in the
presence of blood or semen as pH rises. Treatment
may predispose to candidiasis.
Itch and burn
Vaginal (or only vulval) itch and/or burning can occur
with acute candidiasis, trichomoniasis or any
dermatitis. Severe candidiasis can be erosive.
Vulval Lichen Sclerosus is associated with
anatomical abnomalities and scarring. Early disease
is very subtle. There is a 3 to 5 % malignancy risk.
BV alone is noninflammatory, but excessive
discharge itself may cause vulval irritation (ask about
the use of pads as a potential irritant).
HSV lesions may itch locally.
Warts associated with dry skin can itch.
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Karen Berzins & Siobhan Bourke
Pubic lice and scabies are intensely itchy. Examine
carefully, check partner symptoms and test for STIs.
Pain
Vulvovaginal pain is not uncommon. It is usually a
pain on penetration (sexual or tampons) and
burning afterwards may persist minutes to days. If
pain is associated with an infective cause PID should
be excluded; treat for PID if unsure. See chapter on
pelvic pain.
Generalised unprovoked pain or discomfort can also
occur from a group of causes. One such cause is
neuropathic pain.
These are diagnoses of exclusion and one should
especially exclude subtle candidiasis, dermatitis and
HSV lesions. The skin and its structures may appear
normal. There is intense pain on cotton tip
pressure around the introitus in localised pain, and
often altered sensation (prickling, scratchy, itchy or
sharp) in generalised pain.
Multidisciplinary specialist advice (including pelvic
floor physiotherapists and sexual counsellors) is
recommended.
2
Examination in summary
By gently applying a cotton tip swab at various sites
around the introitus, the examiner may elicit evidence
of very localised or more generalised pain.
The clinician should note any signs of systemic
involvement (raised pulse rate or temperature) and
should always palpate the abdomen looking for
localised pelvic tenderness.
Karen Berzins & Siobhan Bourke
19
vulvoVaginal symptoms
Careful visual examination of the vulva and introitus
with a good light source is important looking for the
features discussed above e.g. rash, atypical skin
lesions (fissures, tiny ulcers etc), signs of scratching,
discharge (and its character). The clinician should
consciously note any odour.
Speculum examination is highly recommended. (If
patient declines, some testing can still be performed.)
Exclude foreign body, sample lateral vaginal wall and
vaginal fluid. Bimanual examination for cervical
motion tenderness, uterine size and tenderness,
and adnexal tenderness or mass should always be
attempted.
pH testing of vaginal (not cervical) discharge provides
valuable clinical information. eg BV pH > 4.5
Remember clinical signs alone often have poor diagnostic value, and tests are always recommended.
Investigations:
From any lesion(s), whether inflamed, scaly, fissured,
split skin or ulcerated, take a dry swab for HSV PCR
and a swab for Candida sp, which can first be rolled
onto a slide, air-dried and sent for microscopy and
then placed in Stuart’s or Amies transport medium for
culture.
Specimens for microscopy can also be obtained from
the vulva, vaginal lateral wall (roll dry swab down lateral wall of vagina starting in the posterior fossa) and
endocervical canal. Roll swabs onto a slide, allow to
air-dry and send for microscopy. The swabs can then
be placed into Stuart’s or Amies transport medium for
culture for Neisseria gonorrhoeae and Trichomonas
vaginalis. (NB Charcoal transport medium is best for
gonorrhoea but only critical if there are long delays
in transport to the laboratory). A dry swab from the
endocervix is taken for PCR for Chlamydia. If
speculum examination is refused or too painful, blind
vaginal swabs can be sent in transport medium for
gonorrhoea and dry for Chlamydia. If the patient
declines high vaginal swabs, first void urine for PCR
for Chlamydia and gonorrhoea gives excellent
sensitivity and specificity. Microscopy is reasonably
sensitive for candidiasis and BV using blind swabs
and these allow pH testing as well.
20
Karen Berzins & Siobhan Bourke
Wet prep is another useful test in some situations
(e.g. if near laboratory) –using a cotton swab take
a sample from the vaginal lateral wall and place on
a slide in a drop of normal saline and cover with a
cover slip and get to lab quickly - these specimens
are good for identifying candidiasis and
trichomoniasis.
Stuart’s, Amies or charcoal transport media should
be kept at room temperature if there is any delay in
transport to the laboratory. First void urine specimens
that have been held > 1 hour (no vulval or perineal
cleansing) ideally should be kept at < 40C or frozen.
Storing them at room temperature for > 24 hours will
reduce sensitivity, as may the presence of blood.
MSU for M/C/S and urine pregnancy test should be
taken as indicated.
Take a Pap smear if due or if there has been recent
abnormal bleeding (consider Thinprep ® if there
is significant discharge). Remember the Pap is a
screening test only, and abnormal cervical
bleeding requires specific tests, i.e. colposcopy,
if no other cause is diagnosed.
Investigations: Interpreting results
Candida sp. observed only on culture may represent
the commensal state (point prevalence up to 20% of
women). Many colonies are needed for it to be visible on microscopy, and the pseudohyphae represent a more active form. Candidiasis is often atypical. Microscopy will show pseudohyphae which are
the commonest forms of the symptomatic Candida
Karen Berzins & Siobhan Bourke
21
2
vulvoVaginal symptoms
Microscopy is sufficient to diagnose candidiasis and
BV, and also identify motile trichomonads in the wet
prep if examined promptly. Laboratories mostly
perform routine vaginal cultures also but delay in
transport will limit the sensitivity of Trichomonas
vaginalis culture. Not all laboratories perform
Trichomonas vaginalis culture but some do a PCR
test.
albicans species. Nonalbicans species (C glabrata
and C krusei) are seen only in the budding form and
occasionally cause symptoms. They are typically
less responsive to standard treatments. Laboratories
should culture and speciate yeast varieties if budding
yeasts are seen and symptoms are persisting after
standard treatments. It is possible to obtain
antifungal sensitivity testing for unresponsive cases.
Nucleic acid amplification tests (NAAT- an example
is a PCR test) are used to detect Chlamydia and in
certain settings gonorrhoea. Culture is preferred for
gonorrhoea for reasons of specificity and antibiotic
sensitivity testing. If PCR is used for gonorrhoea
testing, laboratories will usually perform a supplementary NAAT to confirm gonorrhoea (occasionally
non pathogenic species of Neisseria cause false
positives).
When BV is present, microscopy shows clue cells
(gram variable endogenous cocco- bacilli that are
densely adherent to epithelial cells), with a varying
loss of lactobacilli and a characteristic absence of
polymorphs.
Medical Management:
Treatment of Bacterial Vaginosis (BV)
Metronidazole (B2) 400mg BD po for 7 days
(NB.Less likely to fail than a stat 2 g dose)
Offer candida prophylaxis
OR
Clindamycin cream (A) 2% 5g daily intravaginally for
7 days
BV Male partners occasionally have symptoms of
urethritis or balanitis associated with Gardnerella
vaginalis, but routine treatment of asymptomatic
22
Karen Berzins & Siobhan Bourke
partners is not necessary. BV can be distressingly
recurrent, and partner treatment does not reduce
recurrences. Guidelines are yet to be established on
prevention of recurrences of BV.
Treatment of acute vulvovaginal candidiasis (VVC)
NB: All topical and oral azole therapies give cure
rates of 80-95% in non-pregnant women.
Nystatin preparations give cure rates of 70 to 90%.
Treatments are fungistatic, not fungicidal, and
relapses occur.
Clotrimazole 100mg pessary or cream (A)
intravaginally for 6 nights, OR 200mg pessary (A)
intravaginally for 3 nights, OR 500mg pessary (A)
intravaginally stat
OR
Miconazole 100mg pessary (A) intravaginally for 6
nights
OR
Nystatin vaginal cream 100,000IU (A) intravaginally
for 14 nights (or pessary BD)
OR
Pregnancy - oral azoles are contraindicated. Use
topical therapy in longer durations ie 12 to 14 days
as response rates are lower and recurrences are
more frequent.
Oral antifungal treatment may be preferred especially if
there is introital pain or contact irritation from creams
or pessaries. PV treatments may work faster than
oral alone where vulval irritation is involved. If very
itchy or inflamed add 1% hydrocortisone cream BD
and always cease soap usage.
Karen Berzins & Siobhan Bourke
23
vulvoVaginal symptoms
Fluconazole (D) 150mg po stat - only to be used in
acute VVC if unable to use topical therapy (say in the
case of dermatitis). The cure rate is not higher.
2
Treatment of Chlamydia
Azithromycin (B1)1g po stat
OR
Doxycycline (D) 100mg BD po for 7 days
Treatment of PID - see pelvic pain in females chapter
Treatment of Gonorrhoea
Ceftriaxone (B1) 500mg IM stat dissolved in 2mL of
1% lignocaine plus treatment for possible Chlamydia
co-infection
Treatment of Trichomoniasis
Metronidazole (B2) 2g po stat
OR
Tinidazole (B3) 2g po stat
OR
Metronidazole (B2) 400mg BD po for 5 days
Treatment of Genital herpes - see sexually acquired
ulcer chapter.
The role of Mycoplasma genitalium as a sexually
transmissible agent of public health significance is
currently being investigated. While this organism is
responsible for a substantial proportion of nonspecific urethritis (NSU) in men and has been
implicated in endocervical infection and the aetiology
of PID, testing is not widely available and optimal
treatment regimens are yet to be determined.
Specialist liaison is recommended for testing and
treatment options.
24
Karen Berzins & Siobhan Bourke
Asymptomatic STIs require treatment (only treating
asymptomatic Trichomonas vaginalis in pregnancy is
controversial).
Asymptomatic Bacterial Vaginosis should be
treated prior to gynaecological instrumentation
(including IUD insertion and removal) or surgery.
Pregnancy is a special case and requires
consultation. There is increasing evidence that BV in
pregnancy is associated with premature labour,
chorioamnionitis and post partum endometritis.
Asymptomatic Candida and positive cultures alone
usually do not require treatment.
Nonalbicans Species may be more difficult to
eradicate, and no clear guidelines exist. Double
dose and double duration of the topical azoles should
be tried first. Boric acid 600mg vaginal pessaries
can be used nocte for 10-14 days. These can only be
obtained from certain chemists – discuss with your
local pharmacy.
Karen Berzins & Siobhan Bourke
25
2
vulvoVaginal symptoms
Recurrent Vulvovaginal Candidiasis (4 or more
times per year) requires long term suppression (6
months), which achieves around 90% remission, but
relapses within a further 6 months are frequent.
Various regimens may be used, but fluconazole (D)
150 mg po per week after 2 - 3 initial doses 3 days
apart, is the most studied. Topical treatments may
cause irritation with long term use. Episodic double
duration of standard treatments is an alternative.
Vulval dermatitis often coexists, and a moisturiser
(sorbolene) and 1% hydrocortisone cream or ointment
BD should be used according to symptoms. Chronic
pain symptoms may also develop. See advice from
specialists: both medical and physiotherapy. Referral
may be appropriate at initial consultation.
Other Considerations:
A neonate with Chlamydia and/or gonorrhoea (or at
high risk from untreated maternal infection) always
requires systemic antibiotics. Eye infection due to
gonorrhoea presents within days of birth and is a
neonatal emergency. Blindness can occur by 24
hours. Chlamydia can cause neonatal conjunctivitis
or a pneumonitis typically about 3 weeks after birth.
Refer to a Paediatric infectious disease physician
and treat both the mother and her partner.
26
Karen Berzins & Siobhan Bourke
3
Urethritis in males
Urethral Discharge
(See text for full description)
Need to examine •
•
•
•
•
Meatus, glans
Shaft of penis
Foreskin
Testes
Inguinal nodes
If discharge present:
Take urethral swab – M/C/S
(for gono)
Collect 1st pass urine Chlamydia (Ideally client not
urinated in the last hour)
If no discharge present:
Collect 1st pass urine Chlamydia
Chlamydia
Possible causes
Non Specific Urethritis
• See text for details
• Clear colour
• Intermittent,
mild dysuria
Gonorrhoea
•
•
•
•
Thick
Yellowy
Purulent d/c
Dysuria +++
Stuart Aitken
27
Urethritis in Males
Overview:
Urethritis is characterised by urethral discharge or
meatal erythema. Patients may experience dysuria,
urinary frequency or urethral irritation such as itch
or formication. Symptoms and signs vary, and many
patients with urethral pathogens are asymptomatic
(see chapter on asymptomatic screening). Laboratory
testing is always required to confirm the diagnosis
and identify pathogens.
Chlamydia (Chlamydia trachomatis) and gonorrhoea
(Neisseria gonorrhoeae) represent the most important
causes of urethritis: they carry significant public
health implications, including consequences for
partners such as pelvic inflammatory disease,chronic
pelvic pain and tubal factor infertility. Although
infrequent, complications such as epididymoorchitis
and dissemination of gonococci may arise from these
infections.
Who is at risk and should be screened?
See chapter on asymptomatic screening.
Medical Issues:
Chlamydia urethritis is often indistinguishable from
other causes of urethritis on clinical examination. It
typically presents as a mucoid, watery or mucopurulent discharge within 1-3 weeks of exposure.
Chlamydia is now the commonest identified cause of
urethritis in Australia. While Chlamydia may present
with urethritis, it is important to note that most
urethral chlamydial infections in men are
asymptomatic.
Gonococcal urethritis is often clinically indistinguishable from other causes of urethritis. It typically
presents as a purulent discharge within one to eleven
days of exposure. Occasional cases are asymptomatic.
Coexistent pharyngeal and anorectal infections are
common in men who have sex with men, and are
28
Stuart Aitken
3
Gonococcal strains resistant to penicillin, tetracyclines
and fluoroquinolones have become common in most
Australian communities. Because of the high
prevalence of resistance, extra-genital involvement
and Chlamydia co-infection, penicillin-based
regimens are no longer recommended (except in
some areas of Central Australia). Ideally, treatment
should be effective against all antibiotic-resistant
strains, eradicate infection from extragenital sites,
and cover co-infection with Chlamydia.
Non-specific Urethritis (NSU) represents the syndrome
of urethritis caused by agents other than Chlamydia
or gonorrhoea. Its clinical features are very similar to
chlamydial urethritis. For around half the cases of
urethritis in Australia, no easily identifiable cause of
urethritis is found. For most men with NSU, empiric
treatment is sufficient to alleviate symptoms; those
who do not respond may require further assessment
to exclude important pathology.
Sexually transmissible agents implicated in NSU
include Herpes simplex viruses and Trichomonas
vaginalis. Urethritis caused by these agents can be
managed by the regimens described elsewhere in
this publication.
The role of Mycoplasma genitalium as a sexually
transmissible agent of public health significance is
currently being investigated. While this organism is
responsible for a substantial proportion of NSU,
testing is not widely available and optimal treatment
regimens are yet to be determined. Specialist liaison
is recommended for treatment options.
Viral agents such as adenovirus and Herpes
simplex viruses are sometimes distinguished by
intense perimeatal erythema, inguinal adenopathy,
but scant mucoid discharge. Adenovirus urethritis
may be accompanied by conjunctivitis and coryzal
symptoms.
Stuart Aitken
29
Urethritis in males
usually asymptomatic. Men who present with
gonorrhoea are frequently co-infected with Chlamydia.
Other organisms include Ureaplasma urealyticum,
anaerobes and various organisms which, when
inoculated into the male urethra, may cause localised
mucosal irritation. However, these same organisms
can be found in asymptomatic men. Specific diagnostic tests for these organisms are not routinely
recommended as their detection is difficult and would
not alter the management of uncomplicated urethritis.
Non-infective causes of urethritis include trauma, for
example from vigorous sexual activity; urethral
stricture (fortunately rare these days); foreign body
and Reiter’s syndrome. The anxious patient who
‘milks’ his urethra in search for discharge will, if he’s
diligent enough, cause a traumatic urethritis.
History:
A sexual history is a fundamental element in the
assessment of urethritis.
Salient points include:
• Duration of symptoms
• Amount and nature of discharge
• Gender of partners
• Numbers of recent partners
• Sexual contact with sex workers overseas
• Use of condoms for insertive intercourse
• Symptoms suggestive of deep or complicated
infection
Examination:
Examination is fundamental to the assessment of
urethritis.
Findings typically include:
• Urethral discharge, which may be purulent,
watery, mucoid or mucopurulent and vary in
amounts from profuse to scant
• Inguinal adenopathy
• Perimeatal erythema
30
Stuart Aitken
3
Investigations:
The development of nucleic acid amplification tests
(NAATs), such as PCR, has dramatically improved
the diagnosis of Chlamydia and gonorrhoea from
urethral sites. These tests are now widely available
and offer a robust method of testing for these
infections. Suitable specimens include swabs from
the urethra and first-void urine. Testing for both
Chlamydia and gonorrhoea can be performed on a
single specimen.
NAATs do not provide information about antimicrobial
sensitivities. For Chlamydia, this does not matter: its
sensitivity to the recommended regimens is reliable.
Gonorrhoea, however, has a long history of
developing resistance to antimicrobials, and
resistance data from cultured isolates provides
crucial epidemiological information. For this reason,
men who have symptoms of urethritis, particularly
discharge, should have a urethral swab collected for
culture and sensitivity testing.
Urethral swabs for gonococcal culture should be
sent to the laboratory at room temperature in Amies
or charcoal-containing Stuart’s medium. Results are
usually available within 36 hours. Gram staining
and microscopic examination of swabs should reveal
polymorphs in urethritis of any cause; the typical
intracellular Gram-negative diplococci of the
gonococcus are found in most cases of gonococcal
urethritis.
Medical Management:
Men who present with urethritis should be offered
treatment immediately. Ideally, treatment for urethritis
should cover both Chlamydia and gonorrhoea.Where
this is not practical or where local epidemiology
indicates that one infection is substantially more
Stuart Aitken
31
Urethritis in males
Examination should assess for complication such
as epididymoorchitis and disseminated gonococcal
infection.
common, it is reasonable to treat for the prevalent
organism as long as testing for both organisms is
performed and follow-up is guaranteed. In most
urban settings, this would mean treating for
Chlamydia with azithromycin, but also providing a
prescription for ceftriaxone. If tests for gonorrhoea
are reactive, the patient would fill the prescription and
return for administration of the ceftriaxone. Similarly,
in settings in which gonorrhoea seems very likely,
such as recent overseas travel, purulent discharge or
other epidemiological risks for gonorrhoea, the
clinician might choose to treat for gonorrhoea at
presentation, and withhold Chlamydia treatment until
testing is complete.
Gonococcal urethritis
Ceftriaxone (B1) 500mg IMI as a single dose dissolved in 2mL of 1% lignocaine
PLUS treatment for Chlamydia co-infection
As ceftriaxone is quite painful to inject intramuscularly, it is recommended that the powder be
dissolved in lignocaine.
It should be noted that ciprofloxacin is no longer recommended as a first line agent. Quinolone resistance
is particularly common among those who acquired
their infection overseas (particularly in South East
Asia), but domestic transmission has become
sustained. Men who have sex with men continue to
have high rates of quinolone resistance. Where sensitivity to ciprofloxacin has already been established,
or where first line therapy is not available, consider
using
Ciprofloxacin 500mg (B3) po as a single dose
PLUS treatment for Chlamydial co-infection
It is worthwhile noting that the sensitivities provided
by laboratories are best used as epidemiological
markers, rather than treatment options. Development
of resistance in vivo, despite the results of in vitro
32
Stuart Aitken
3
In some remote areas of Central Australia, penicillinbased regimens are still used as resistance has not
yet become established. These are not
recommended for other parts of Australia and local
guidelines should be consulted.
Chlamydial and Non-Specific Urethritis
Azithromycin (B1) 1g po as a single dose
Other regimens for Chlamydia and NSU include
Doxycyline (D) 100mg BD po for 7 days Or
Roxithromycin (B1) 300mg po once daily (or 150mg
po BD) for 10 days
For symptoms which recur, re-infection should be
excluded and treatment may be repeated. For
infections that are not responding to standard
therapies, have atypical features or are complicated
or disseminated, specialist consultation is
recommended.
Other Considerations:
As with other sexually transmissible infections, the
diagnosis of urethritis is an opportunity to test for
other sexually transmissible infections and review
safer sex practices. Information, preferably printed as
well as verbal, about transmission and prevention of
their infection should ideally be provided.
Contact tracing is recommended for partners of those
diagnosed with chlamydial or gonococcal
urethritis. For both of these infections, contacts
should be traced as determined by symptoms and
sexual history, usually back to a period of six months.
Contacts of Chlamydia should be counselled,
examined, tested appropriately and presumptively
treated with 1g of azithromycin po as a stat dose.
Stuart Aitken
33
Urethritis in males
antibiotic sensitivities is a well-documented
phenomenon.
Contacts of gonorrhoea should be counselled,
examined, tested appropriately and presumptively
treated with ceftriaxone 500mg IMI as described
above.
Contact tracing for Mycoplasma genitalium is not as
well validated as for Chlamydia or gonorrhoea, and
should probably be limited to regular partners. One
suggested regimen is azithromycin 500mg po daily
for three days. Specialist liaison is recommended.
Contact tracing for other sexually transmissible
pathogens is described in other sections. Contact
tracing of urethritis where there is no identifiable
pathogen is not routinely recommended.
34
Stuart Aitken
Pelvic Pain in Females
Overview:
Pelvic pain in women is a very common presentation.
It may be acute or chronic. It may be gynaecological
or non gynaecological in nature.
Pelvic pain may be due to many processes involving
many body systems.
A systematic approach will help you in your diagnosis
and management.
In a women of child bearing years exclude pregnancy
and potential complications including ectopic pregnancy.
Have a high index of suspicion for PID and if in doubt,
TREAT for same.
In all women include gynaecological causes.
2. Examine your patients
Mistakes are made by not looking!!
If concerned get a chaperone to assist in a proper
pelvic examination.
Explain what you are about to do.
Note any discharges and take swabs.
3. Investigate
Exclude infection with appropriate swabs and urine
specimens.
Refer for imaging techniques, serology when indicated
4. Seek specialist help when a surgical or
obstetric cause is likely
Kathryn Cook
35
Pelvic pain in Females
1. Always take a good history.
4
5. Remember atypical presentations of common causes.
6. Not to be missed
Pregnancy including ectopic
PID
Appendicitis
Medical Issues:
Gynaecological causes
Cyclical pain mid cycle = Mittleschmertz is due to
ovulation. It is acute onset followed by a dull ache for
several hours. It is due to a prostaglandin effect on
the ovaries.
Management includes anti-prostaglandins and
consider cessation of ovulation eg OCP. If
problematic refer to a gynaecologist.
Cyclical pain at the time of a period = Dysmenorrhoea. Initial management as outlined above. This
can be very severe in approximately 5 % of women.
In this case consider endometriosis.
Endometriosis is a disease where tissues with
characteristics of endometrium occur outside the
uterus. Overall 5-10% of women are affected; this
increases in infertile women and those with gynaecological symptoms. Clinical presentation includes
dysmenorrhoea, dyspareunia, infertility, complication
of an endometriotic cyst and bowel or urinary pain.
Diagnosis is by laparoscopy and biopsy. Refer for
gynaecological opinion.
PID may be acute or chronic, presentation is often
subtle and a high index of suspicion is necessary to
diagnose this. Consider PID in all cases of
abdominal tenderness and pelvic pain, note that the
patient doesn’t have to be febrile.
36
Kathryn Cook
Remember Chlamydia is often asymptomatic. See
below section on PID.
Investigations start with a pregnancy test, ideally a
serum BhCG as this helps with interpreting
ultrasound findings. It is rare to have a false negative
result. At levels of BhCG of > 1000 a transvaginal
scan (TVS) can usually detect an intrauterine
pregnancy. Intrauterine pregnancy can usually be
seen at 5 weeks (from LNMP) by TVS and 7 weeks
by abdominal scan. BhCG in normal pregnancy
approximately doubles every 48 hours, if the pattern
is less than this consider an abnormal pregnancy,
including ectopic. Remember recurrence rate, advise
early BhCG and TVS in subsequent pregnancies.
Other early pregnancy causes of pelvic pain include
corpus luteal cyst and threatened or evolving
spontaneous abortion.
Remember that in all cases of early pregnancy
bleeding, check blood group and antibody screen, and
administer anti-D Rhesus prophylaxis if appropriate.
Ovarian cysts and neoplasm may cause pain due
to torsion, bleeding or rupture. Gynaecological
referral to hospital is recommended
Kathryn Cook
37
4
Pelvic pain in Females
Ectopic pregnancy rates are increasing, probably
reflecting PID. Aetiology includes inflammatory tubal
damage, prior tubal surgery including reanastomosis
and ligation, prior ectopic pregnancy (recurrence rate
10-15%), assisted reproduction (eg IVF and GIFT),
endometriosis and type of contraception, note IUDs
and progestagenic forms including emergency post
coital contraception. The majority of ectopics are
tubal, less frequent sites are cornual, ovarian,
cervical and rarely abdominal. Diagnosis is made
with a high index of suspicion of the classic
symptoms of pain, bleeding and an adnexal
mass. The latter is the least important feature,
particularly with early ultrasounds.
History:
LNMP and cycle
Onset and nature of pain
Contraception / condoms
Examination:
When examining a patient with pelvic pain first
establish vital signs and stability. Remember that a
young, healthy woman may mask shock.
Examine the whole abdomen, noting tenderness,
guarding or rebound. Do a speculum examination,
note the cervix, discharge, or bleeding. Take
appropriate swabs and Pap test if indicated. Perform
a bimanual vaginal examination and note tenderness
on rocking the cervix (Cx excitation) and any pelvic
masses. Remember that most pelvic masses are not
detected on abdominal examination alone. Consider
a PR examination if you suspect a GIT cause of the
pain, eg. retrocaecal appendicitis.
Vital signs
Tenderness, guarding or rebound
Speculum examination, swabs and +/- Pap smear.
Bimanual examination, Cx excitation or mass.
Investigations:
BhCG
FBE, CRP
MSU
Cervical and vaginal swabs
Pelvic ultrasound
If BhCG positive:
Check blood group and antibody screen
Remember anti D Rhesus isoimmunization
prophylaxis.
38
Kathryn Cook
PELVIC INFLAMMATORY DISEASE (PID)
The clinical features of pelvic infection are
variable and may be minimal, especially in the case
of chlamydial disease. In women aged under 25
years 60–80% is caused by sexually transmitted
chlamydia or gonococci mixed with other commensals and anaerobic genital flora. Otherwise PID often
occurs by ascending spread of genital commensals
following surgical trauma, pregnancy, IUD insertion
or removal.
The following signs may be present on
examination:
abdominal tenderness, guarding or rebound.
tenderness or a mass in the adnexa, may be
unilateral or bilateral.
cervical excitation - pain on moving the cervix laterally.
temperature and pulse may be raised.
Investigations
In cases of suspected PID, the following
investigations should be performed:
Wet preparation. A drop of vaginal secretion is
mixed with a drop of saline on a microscope slide,
and the preparation examined under 400x
magnification.The presence of polymorphs (3+)
supports a diagnosis of cervical infection.
Endocervical swab for gram-stained smear. This is
for detection of gonococci and other bacteria.
Endocervical swab for bacterial culture.This should
be sent to the laboratory at room temperature in
Amies or charcoal-containing Stuart’s transport
medium. This specimen is suitable for culture
of gonococci, anaerobes, Mycoplasma spp and
other endogenous flora.
Kathryn Cook
39
4
Pelvic pain in Females
A high index of suspicion is necessary if the diagnosis is not to be missed. Symptoms may include lower
abdominal pain or discomfort, vaginal discharge,
abnormal vaginal bleeding or pain with intercourse.
Endocervical swab for Chlamydia trachomatis.
Chlamydial tests are now almost always NAAT.
Others include cultures and antigen. Each test
method has stringent criteria for specimen
collection and transport, and the laboratory’s
requirements should be followed exactly.
Urine sample for nucleic acid testing (NAAT) for
chlamydia and gonorrhoea maybe helpful in the
presence of PV bleeding.
Hospital admission is recommended for patients
other than those with mild disease and is
mandatory if tubo-ovarian abscess is suspected.
Treatment of PID should be reviewed after 48 to
72 hrs results and clinical response. Duration of
treatment depends on the severity of disease and
the response to therapy.
It should continue until symptoms and cervical
tenderness have resolved, and for a minimum of 14
days. The clinical diagnosis of PID is unreliable.
Specialist referral is indicated if the diagnosis is
doubtful or if rapid resolution of symptoms does not
occur.
Management
Acute PID can be divided into two broad categories
on the basis of clinical history.
1. Acute PID in young sexually active women with
no predisposing factors.
In these patients, the likely primary aetiological
agents are Chlamydia trachomatis and Neisseria
gonorrhoeae.
In mild cases these pathogens predominate, but in
severe disease and in repeated episodes of PID the
aetiology is often polymicrobial, the primary
pathogens being mixed with endogenous flora and
Mycoplasma hominis. Sexual contacts of patients
with STI-related PID should be treated after appropriate tests have been taken.
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Kathryn Cook
Outpatient treatment STI-related PID
Azithromycin (B1) 1g po stat,
plus Doxycycline (D)100mg BD po for 14 days,
plus Metronidazole (B2) 400mg BD po for 14 days.* Offer Candida prophylaxis*
plus, if gonorrhoea is suspected or proven,
ceftriaxone (B1) 500mg IM once
NB: There is some evidence that the use of ceftriaxone
improves clinical outcome in non gonococcal infection presumably due to its broad antimicrobial effect.
Inpatient treatment for severe STI-related PID
Cefotaxime (B1) 1g 8 hourly IV, or
Cefoxitin (B1) 2g 6 hourly IV, or
Ceftriaxone (B1)1g dailyIV ,
together with
Metronidazole (B2) po 500mg IV 8 hourly,
plus Doxycycline (D)100mg BD po12 hourly po,
or Roxithromycin (B1) 150mg BD po
or 300mg daily po as a single dose, until the patient
is afebrile and improved,
then Doxycycline (D)100mg BD po for 2 to 4 weeks,
or Roxithromycin (B1) 150mg BD po or 300mg
daily po as a single dose for 2 to 4 weeks.
NB: if IUD already in situ treat as above for 24 - 48
hrs and review clinically prior to removal of IUD.
Kathryn Cook
41
Pelvic pain in Females
NB: Suspected gonorrhoea cases will be for high risk
persons eg. the women who has had sex with a
person from overseas where the gono rates are
much higher than in the heterosexual community
in Australia (eg. UK, Asia), Indigenous women and
women whose male partners are or suspected to be
bisexual
4
2. Patients who develop PID after a recent pregnancy,
abortion or gynaecological procedure, and those
with a prior history of PID, or IUD insertion or
removal.
In these patients, Chlamydia trachomatis,
Neisseria gonorrhoeae and Mycoplasma hominis
may be implicated, together with BV organisms,
mixed anaerobic and aerobic bacteria such as
Bacteroides spp, anaerobic cocci, Streptococcus spp
and enteric bacteria.
Outpatient treatment of mild-moderate procedure
-related PID
Doxycycline (D)100mg po BD for 2 to 4 weeks,
or
Amoxycillin (A) 500mg TDS po PLUS Metronidazole (B2) 400mg TDS po for 2 to 4 weeks.
Inpatient treatment of severe procedure-related
PID
Clindamycin (A) 600mg 6 hourly IV plus Gentamicin
(D) 1.5mg/kg IV 8 hourly IV until afebrile, then
Clindamycin (A)150-300mg QID po for 2 weeks,
or
Cefotetan (B1) 2g 12 hourly IV (availability) or
Cefoxitin (B1) 2g 6 hourly IV plus Doxycycline
(D)100mg BD po until afebrile, then Doxycycline
(D)100mg BD po for 2 weeks.
Inpatient treatment of severe septicaemic,
procedure-related PID
Amoxycillin (A) 2g IV 4 hourly plus Gentamicin
(D)1.5 mg/kg IV 8 hourly plus Metronidazole (B2)
po 500mg IV 8 hourly until afebrile, then Doxycycline (D)100mg BD po for 2 weeks.
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Kathryn Cook
SPECIAL CONSIDERATIONS:
GIT causes: appendicitis, constipation, diverticular
disease, inflammatory or irritable bowel and
malignancy. All may present atypically.
Appendicitis typically has central abdominal pain that
then radiates to the right iliac fossa. This pain may be
associated with anorexia, fever and elevation of the
white cell count.
Any bowel or viscus may perforate resulting in
peritonitis with signs of a rigid acute abdomen. In
this case the patient is usually lying very still with
rebound and guarding noted on palpation.
4
Urinary tract causes: infection, retention, calculi and
malignancy.
Classically UTIs have frequency, urgency and
dysuria. Lower abdominal/pelvic pain may be the
only symptom. Sometimes loin pain may indicate
renal involvement.
A mid-stream specimen of urine should be sent for
microscopy and culture and as urethritis, especially
in women, may be difficult to distinguish from a UTI,
remember to send a first void urine for PCR for
Chlamydia and gonorrhoea, if indicated by the sexual
history.
In pregnancy, asymptomatic bacteruria is more
common and may result in pyelonephritis,
chorioamnionitis and, threatened premature labour.
Remember a completely negative dip stick virtually
excludes bacterial UTI (negative predictive value of
>95%)
Muscular skeletal causes: referred pain from the
back, hips or muscle spasm.
In pregnancy extra joint mobility under the influence
of pregnancy hormones results in sometimes severe
pelvic pain. This is often movement-associated and
Kathryn Cook
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Pelvic pain in Females
Prompt surgical review is required
involves the symphysis pubis. For any concerns of
pain in pregnancy always enquire regarding bleeding
and foetal movements.
Get an obstetric review.
Suspected ectopic – If established pregnancy and
suspicious of ectopic, get an obstetric review and/or
try to determine location of pregnancy via ultrasound.
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Kathryn Cook
PELVIC PAIN IN Males
Overview
Pelvic pain in men usually comes from the gastrointestinal tract (GIT). Pelvic pain may also arise from
the urinary tract (bladder and urethra) and from the
prostate and associated structures (seminal vesicles,
Cowper’s glands etc). In addition, pain from a testicular condition may be referred and felt predominantly
in the pelvis or lower abdomen.
Not to be missed:
Testicular torsion
Complicated inguinal hernia
Other considerations
Epididymoorchitis
UTI
Acute prostatitis
Testicular malignancy
Medical Issues:
Genital Causes
Because the genital and urinary tracts in men are
inseparable and because the male urethra is lengthy,
it is often difficult to sort out precisely where pelvic
pain originating in any of these structures is coming
from. Urethral pain, prostatic pain and bladder neck
pain can all feel very similar to the patient and associated symptoms like urethral discomfort, frequency
of micturition, dysuria and urgency are characteristic
of several quite separate conditions.
Kathy Cook & David Bradford
45
5
PELVIC PAIN IN Males
GIT Causes – these are discussed below under
Special Considerations
Urinary tract Causes – these are discussed below
under Special Considerations
Sexually transmissible infections (STIs) like
Chlamydia, trichomoniasis and gonorrhoea target the
anterior male urethra. Although in pre-penicillin days
gonorrhoea was known to cause infections in the
posterior urethra, the prostate and the
seminal vesicles, it is extremely rare for STIs ever to
affect these structures nowadays except perhaps in
very resource-poor parts of the world. However the
epididymis remains susceptible to infection by both
Neisseria gonorrhoeae and Chlamydia
trachomatis and infection here readily spreads
to involve the adjoining testis with resultant
epididymoorchitis. Epididymoorchitis is always
preceded by the colonisation of the anterior urethra
by a sexually transmissible pathogen but more often
than not this is asymptomatic; the first the patient
knows about the infection is gradual onset of pain
and swelling in the affected testis. STIs usually occur
in younger adult age groups and testicular torsion
is a condition usually only found in adolescents and
young adults. Therefore correctly differentiating
testicular torsion from epididymoorchitis in young
men is obviously vitally important.
A group of patients who have placed themselves at
risk of urethritis due to a perceived sexual indiscretion,
or who have actually acquired and been effectively
treated for urethritis continue to have ongoing
urethral symptoms and often accompanying vague
pelvic, perineal or testicular pain. Careful examination
of such patients (including PR examination of the
prostate) reveals no abnormalities and repeat testing
for urethritis due to all known sexually transmissible
pathogens is usually negative. Typically this group of
patients exhibits varying degrees of anxiety, shame
and guilt about their past behaviour. Clinicians should
refer such patients to a sexual health clinic or an
experienced sexual health physician. Their management is difficult and generally requires a team
approach involving sexual counselling. A chronic pain
multi-disciplinary approach is often effective. To label
such a patient as suffering from ‘chronic prostatitis’
because his symptoms include perineal or deep
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Kathy Cook & David Bradford
pelvic pain, to prescribe long term antibiotic therapy,
or to subject him to repeated investigations including
prostatic massage are all totally inappropriate and
potentially harmful measures.
Prostatitis (acute or chronic) and prostatodynia are
distressing conditions but fortunately they are
relatively uncommon. Symptoms may include sexual
dysfunction, voiding problems and perineal or pelvic
pain. In general, patients at risk of STIs or with a past
history of STIs are not at greater risk of
prostatitis than the rest of the male community.
Prostatitis occurring as a complication of gonorrhoea,
Chlamydia, trichomoniasis or any other known sexually
transmissible pathogen, if it does occur at all, is
exceptionally rare in Australia today. Further discussion
of prostatitis and prostatodynia is beyond the scope
of these Guidelines.
TESTICULAR TORSION
History:
This most important condition of young men presents
with acute unilateral scrotal pain and swelling; it may
also feature lower abdominal pain. This episode may
occur after several less severe bouts, reflecting subacute spontaneously resolved torsions.
Epididymoorchitis
Testicular tumour
Examination:
The scrotum is red, swollen and painful. The affected
testis may be palpated high in the scrotum. Remember
that pain may limit your examination. Unlike
epididymoorchitis, pyuria and raised temperature are
uncommon.
Kathy Cook & David Bradford
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PELVIC PAIN IN Males
Differential diagnosis:
5
Investigations:
A Doppler ultrasound may be useful in determining
torsion
BEWARE - there are pitfalls in interpreting the
ultrasound, do not delay surgical review if you
have any concerns. Surgery within six hours usually
preserves the testicle.
Management:
REMEMBER testicular torsion in a young man who
has scrotal pain +/- lower abdominal pain
ARRANGE prompt surgical review, as immediate
surgery may save a testis.
EPIDIDYMOORCHITIS
History:
Epididymoorchitis also presents with unilateral scrotal
pain and swelling. Bilateral epididymoorchitis is very
uncommon. In younger men this condition is almost
always the result of an infection acquired sexually,
mostly due to a sexually transmissible pathogen,
but in men who perform insertive anal intercourse
without condoms, occasionally a coliform organism
may be the cause of the epididymoorchitis. In men
over fifty, epididymoorchitis is more commonly due to
infection with a urinary tract pathogen such as E coli
and there may be accompanying symptoms suggestive of urinary tract infection and preceding prostatomegaly. The onset of epididymoorchitis is usually
gradual rather than sudden. It may be accompanied
by urethral symptoms (discharge, dysuria or urethral
discomfort) but often there are no urethral symptoms
or signs. There may be accompanying systemic
symptoms of fever and malaise especially if the
infection is gonococcal rather than chlamydial.
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Kathy Cook & David Bradford
Differential diagnosis:
Torsion of the testis
Testicular tumour
Examination:
A normal testis is usually palpable in the early stages
with a separate enlarged, indurated and tender
epididymis. After a few days, differentiation of testis
and epididymis becomes more difficult, the whole
mass feeling enlarged, tender and knobbly.
Sometimes there is a reactive hydrocoele surrounding
the infective process.
The clinician should always examine the urethral
meatus looking for signs of discharge and/or meatal
inflammation
Investigations:
Doppler Ultrasound Scan (as above) – will help to
differentiate torsion or tumour
First-void urine specimen for microscopy and culture
- the presence of pyuria is suggestive of infection
First-void urine specimen for PCR for Chlamydia and
gonorrhoea
MSU for microscopy, culture and sensitivity
Medical Management:
Faced with a swollen painful testis clinicians should
first exclude torsion and testicular tumour, then
prescribe immediate treatment for epididymoorchitis.
The specific treatment in younger men should cover
Chlamydia. It should also cover gonorrhoea in the
presence of a purulent urethral discharge, in
Indigenous men, if the patient is a known contact of a
Kathy Cook & David Bradford
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PELVIC PAIN IN Males
If any urethral discharge is present - swabs of the
discharge can be sent for microscopy, culture &
sensitivity and PCR for Chlamydia
5
partner with gonorrhoea, if there is a history of
male-to-male sex, or sex overseas in a country
where gonorrhoea is prevalent. In men over fifty
where there is no relevant sexual history initial
treatment should be with antibiotics appropriate for a
urinary tract infection. In both situations the clinician
can change treatment in a few days when the results
of investigations become available.
Treatment of epididymoorchitis due to an STI:
Azithromycin 1g po as a single dose, followed by
Doxycycline 100mg BD po for 21 days
PLUS, (if gonorrhoea suspected – see above)
Ceftriaxone (BI) 500mg IM daily for 3 days
Almost all cases of epididymoorchitis in young men
are acquired sexually, so management must be as
for an STI with education about safer sex, contact
tracing, and advice to avoid sex until symptoms
abate and partners have been treated. Patients
should rest up and avoid strenuous activities until
pain and swelling begin to settle. Screening for other
STIs (especially syphilis and HIV) is important.
Clinicians should review patients in 3 days to check
progress, compliance with medications, contact
tracing, and results of laboratory tests. Further
follow-up after 21 days of therapy is a sensible
measure. It is important to note that the epididymis
does not return to its normal soft consistency for
several months after successful treatment.
There are many other conditions that may
manifest as pelvic pain in both men and women.
The following list is far from exhaustive but
provides other systems to consider in your
diagnosis.
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Kathy Cook & David Bradford
SPECIAL CONSIDERATIONS:
GIT causes: appendicitis, constipation, diverticular
disease, inflammatory or irritable bowel and
malignancy. All may present atypically.
Appendicitis typically has central abdominal pain
that then radiates to the right iliac fossa. It may have
anorexia associated, temperature and typically an
elevation of the white cell count.
Any bowel or viscus may perforate resulting in
peritonitis with signs of a rigid acute abdomen. In this
case the patient is usually lying very still with rebound
and guarding noted on palpation.
Prompt surgical review is required
Urinary tract causes: infection, retention, calculi and
malignancy.
Classically UTIs have frequency, urgency and dysuria.
Lower abdominal/pelvic pain may be the only symptom. Sometimes loin pain may indicate renal involvement.
Remember a completely negative dip stick virtually
excludes a symptomatic bacterial UTI (negative
predictive value of >95%)
Muscular skeletal causes: referred pain from the back,
hips or muscle spasm.
Kathy Cook & David Bradford
51
5
PELVIC PAIN IN Males
A mid-stream specimen of urine should be sent for
microscopy and culture and as urethritis, especially
in women, may be difficult to distinguish from a UTI,
remember to send a first void urine for PCR for
Chlamydia and gonorrhoea, if indicated by the sexual
history.
ANORECTAL SYMPTOMS
Overview:
Anal problems are common and can manifest as
lumps, ulcers, rashes, discharge, bleeding, itching or
altered defaecation. Often there is little congruence
between anorectal symptoms and signs because
patients are neither able to visualise their own
anorectal region nor describe their symptoms well.
For example, an ulcer may feel like a lump,
‘diarrhoea’ may be discharge and ‘constipation’ may
be tenesmus. Also, STIs affecting the anus or rectum
often have no symptoms or poorly defined symptoms
that can mimic other common conditions. Common
conditions of the anorectum and perianal skin are
haemorrhoids, anal fissures and conditions causing
itching such as dermatitis, fungal and parasitic
infections, skin disorders, allergic reactions and poor
anal hygiene (see table on pages 58-61 for care and
treatment of common non-STI anorectal conditions).
Specific STI tests including anal swabs should be
undertaken whenever there is a history of receptive anal sexual practices (not just intercourse) and
especially if there are any anal symptoms or signs.
Patient-collected or clinician-collected salinemoistened anal swabs are an acceptable and appropriate approach to asymptomatic testing of the anus
but, where there are symptoms, inspection and
proctoscopy are essential additional tools. Punch
biopsy should be considered for lesions that are
atypical or unresponsive to treatment, especially in
people with HIV.
Homosexually active men who perform anal sexual
practices are particularly at risk of anorectal STI and
common anorectal problems. Gonorrhoea, syphilis, chlamydia, anogenital herpes, anogenital warts,
enteric pathogens (eg. giardiasis, shigellosis) and
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6
Women who perform receptive anal sexual practices
are also at risk of similar problems.
STIs may be spread through anal sex when blood,
semen or other body fluid is shared even if there is
no anal penetration. Oral-anal contact, kissing or oral
contact with fingers that have been touching the anus
or genitals can transmit infection. The sharing of sex
toys may also transmit certain infections.
The following steps ensure a thorough assessment
of anorectal symptoms.
History:
• Clarify meaning of symptoms
• Elicit any local or systemic associated symptoms
• Ask about specific anal sexual behaviour
including use of condoms, sex toys
• Ask about self applied treatments
(e.g. haemorrhoid creams)
Examination:
After the genital examination where the patient is
exposed from the knees to umbilicus while lying flat
on an examination bed, ask the patient to then turn
into the left lateral position with knees together and
bent. Ask the patient to retract their upper buttock
with their right hand to allow free inspection of the
perineum and perianal area using an examination
light.
• Inspect anus and perineum for rashes, ulcers,
discharge or lumps
• Insert lubricated proctoscope gently directed
towards the umbilicus slowing to allow relaxation
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Anorectal symptoms
HIV are currently common among homosexually
active men in large cities of the world. Lymphogranuloma venereum (LGV) has also recently
emerged among some HIV+ gay men mostly
presenting as proctitis.
of the internal anal sphincter. Remove trocar and
inspect rectal mucosa
• Remove proctoscope slowly, observing the anal
wall for haemorrhoids and fistulae. Continue to
apply inward pressure as you withdraw to prevent
painful clamping by the internal anal sphincter
around the end of the proctosope.
Investigations:
• Rectal mucosa swabs via proctoscope for
gonorrhoea [PCR or microscopy & culture],
chlamydia [PCR](LGV serotype if positive [also
PCR]) and Herpes simplex virus (HSV) [PCR]
• Venepuncture (syphilis and HIV serology)
• Stool sample [microscopy and culture] if
diarrhoea is present
• Ulcer swab (HSV [PCR])
Medical Management:
If anoscopy reveals proctitis (pus, friable mucosa,
contact bleeding), presumptive treatment should be
initiated for chlamydia and gonorrhoea:
• Doxycycline (D) 100mg BD po for 10 days (21
days if LGV confirmed)
• Ceftriaxone (B1) 500mg IM stat in 2ml 1%
lignocaine
Azithromycin has not been evaluated but is likely to
be a suitable substitute for doxycycline in the
management of anal LGV.
Proctitis associated with painful ulceration also
suggests Herpes Simplex Virus infection, so presumptive anti-viral treatment should also be given:
• Valaciclovir (B3) 500mg BD po for 5 days or
• Aciclovir (B3)200mg five times per day po for 5
days
Review the patient within 4 days to assess resolution
of symptoms.
Repeat testing for Syphilis and HIV within 6 weeks is
recommended to cover the window periods.
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6
Anal Health Care:
Simple preventive health care for the anus and
perianal skin can prevent many common anorectal
problems. Although it is generally quite tough, the
perianal skin can be traumatized by faecal soiling,
persistent moisture, abrasion from toilet tissue,
excessive washing, unlubricated (or forced) anal
penetration and application of treatments. Over-thecounter steroid, antibiotic or haemorrhoid
preparations may alleviate the symptoms of anal
conditions but may also alter or mask clinical signs.
Perianal cleansing
Washing the anal region before and after anal sex
reduces the amount of bacteria that could be spread.
The use of water only, without soap or detergent, can
reduce the loss of perianal skin oils and anal mucus
which protect against infections.
Lubrication
The anus does not produce its own lubrication so
lubricant needs to be applied during any anal
penetrative sex to prevent mucosal tearing. Lubricant
use, cleanliness and condoms reduce the chance of
tearing and minimise the risk of transmitting disease
during anal sex. Lubricant should be water-based, as
oil-based lubricants increase the risk of latex condom
breakage. Lubricants and condoms containing
nonoxynol-9 spermicide should also be avoided as
they increase the risk of HIV transmission by
damaging the lining of the rectum.
Condoms and other barriers
Condoms help prevent the spread of STIs when worn
prior to and during any anal contact. Oral–anal contact
is safest when using a dental dam, a flat sheet of
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55
Anorectal symptoms
The management, advice, follow up and partner
notification of anorectal STIs is generally the same
as for genital STIs see chapter 13
latex that acts as a barrier between the mouth or
fingers and the anus. Female condoms may suit
some MSM and transgender people.
Douching
Overuse of enemas can destroy the normal healthy
balance of bacteria in the lower intestine. Routine
use of enemas is not recommended. Some men
douche with warm water before receptive anal sex to
clean the rectum and anus.
Symptom/Sign
Differential diagnosis
Lump
Haemorrhoids
Anogenital warts
Anorectal abscess
Syphilis
Anogenital Herpes
Neoplasm
Ulcer
Anal fissure
Anorectal fistula
Syphilis
Pilonidal sinus
Neoplasm
Itching and rashes
See chapter 8, itches
and rashes
Anal discharge
Proctitis – gonorrhoea,
Chlamydia, HSV, LGV
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Differential diagnosis
Bleeding per rectum
Anal fissure-usually
after defaecation, on
toilet tissue
Anorectal symptoms
Symptom/Sign
Neoplasm
Proctitis - gonorrhoea,
Chlamydia, HSV, LGV
Altered defaecation:
- Tenesmus, pain
Proctitis - gonorrhoea,
Chlamydia, HSV, LGV
- Diarrhoea
Proctitis - gonorrhoea,
Chlamydia, HSV, LGV
- +/- bloating, nausea,
fever
Enterocolitis- Amoeba,
Giardia, Shigella,
Campylobacter
Picture of anorectum/perineum anatomy
and conditions page 62.
Page 58-61 The management of common
(non-infectious) anorectal conditions
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57
Care and Treatment of anorectal conditions
Condition
Symptoms & diagnosis
Anal
fissure
Pain, bleeding during or shortly after
defaecation and receptive anal sex.
Pain subsides in minutes-hours.
Itching with healing. Anal inspection
reveals a single, painful triangular
ulcer.
Small amount of bleeding as blood
on toilet paper or on stool after bowel
movement. Swollen anal lump felt in
anal canal (“Internal haemorrhoids”)
Haemorrhoids
or protruding from anus (“External
haemorrhoids”). May be tender if a
blood clot has formed or if the
surface has been rubbed raw.
Anorectal
abscesses
Swollen, red, tender, painful lump
under the skin around or in the anus.
May have a small point discharging
pus.
Anorectal
fistula
May be painful, or discharge pus
from one or more openings. A probe
inserted into an opening helps
determine depth and direction.
Looking through an anoscope into
the rectum may help locate an
internal opening.
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Anorectal symptoms
Treatment
•
•
•
•
Stool softener
Lubricant suppositories
Warm salt bath after bowel movement
Nitroglycerin ointment
•
•
•
•
•
No treatment for small haemorrhoids.
Stool softeners for constipation.
Salt water bath
‘Injection sclerotherapy’
‘Rubber band ligation’, surgery
•
Inject local anaesthetic, cut the abscess
and drain the pus. Send sample for culture
& sensitivity – NB gonococcal anorectal
abscesses can occur sometimes and will
require antibiotic treatment- Ceftriaxone
(B1) 500mg IM Stat followed by daily
Ceftriaxone or alternative oral antibiotic if
sensitive for 10 to 14 days
Antibiotic use helpful if fever, diabetes, or
infection in rectum or elsewhere in the body.
May become an anorectal fistula
•
•
•
•
Surgery (fistulotomy)
Anal sphincter damage can cause difficulty
controlling bowel movements
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Care and Treatment of anorectal conditions
Condition
Symptoms & diagnosis
Anal
itching
Skin disorders, allergic reactions,
certain foods, micro-organisms (eg,
fungi, bacteria), parasite infestations
(eg, pinworms), antibiotics, diabetes,
liver disease, skin tags, poor hygiene,
excessive sweating
Pilonidal
disease
Tiny holes (pits) at the top of the cleft
between the buttocks. There may
be an abscess or sinus which can
be painful and swollen
Foreign
objects
Swallowed or inserted objects lodged
in the rectum or junction of the anus
and rectum. Sudden, excruciating pain
suggests the object is penetrating the
anal or rectal wall. Locate object by
probing gently with a gloved finger.
Sigmoidoscopy and x-rays may be
required
Anal
neoplasm
May have no symptoms until there is
bleeding, change of bowel motions or
weight loss. An indurated ulcer may
be felt PR and a bleeding raised anal
ulcer may be seen on inspection or
anoscope examination.
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Anorectal symptoms
Treatment
•
•
•
After bowel movements, gentle cleaning of
the anal area with water.
Treat pinworms (if suspected)
Corticosteroid (if skin disease) or anti-fungal
(if fungus) creams or suppositories.
Avoid irritating foods (if food irritant)
Loose clothing and light bed linen
•
•
Pilonidal abscess-cut and drain
Surgery may be needed
•
If the object is small, local anaesthetic
injected into the anal skin or wall. This
allows for retraction of the anus and
removal of the object. If the object is large,
refer for exploratory surgery.
•
Refer for biopsy and, if confirmed as
cancer, surgery.
•
•
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61
Reference:
Adapted from ‘Clinical guidelines for sexual health
care of men who have sex with men’, Asia Pacific
Branch-International Union against Sexually Transmitted Infections 2006.
The web host has changed for the guidelines to
HYPERLINK “http://www.iusti.org/sti-information/pdf/
IUSTI_AP_MSM_Nov_2006.pdf”
Picture
of common anorectal conditions
http://www.iusti.org/sti-information/pdf/IUSTI_AP_
Illustration: Mark Chung
MSM_Nov_2006.pdf.
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Anorectal symptoms
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Ulcers.
See text for full description. Note: A history of travel or MSM
important - see chapter for more details
Need to examine
•
•
•
•
Affected area
Inguinal and regional nodes
Full genital inspection
Mouth and throat
Testing • Swab – PCR for Herpes
• Note: consider testing for Syphilis in
certain populations -see text for more
details
Herpes (majority)
Possible causes
•
•
•
•
•
•
Painful
Shallow depth
Recurrent
Blisters
Oedema
+ / - regional nodes
Syphilis
Tropical causes
• See text
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David Bradford
•
•
•
•
Painless
Solitary
Sloughing
Indurated edges
SEXUALLY acquired ULCERS
Overview:
Medical Issues:
Sexually acquired genital ulcers can be single
or multiple, painless or painful, soft or indurated,
chronic or short-lived, and recurrent or once-only.
They can be mild (easily overlooked) or severe.
Even if ulcers are severe and painful, associated
shame may be a barrier to the patient seeking help.
Ulcers may be accompanied by enlarged inguinal
nodes which may or may not be tender.
The causes of sexually acquired genital ulcers are
listed below:
• Genital Herpes - Herpes simplex virus types 1 or 2
• Syphilis - Treponema pallidum
• Chancroid – Haemophilus ducreyi
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7
Sexually acquired ulcers
Breaches in the skin or mucous membrane are
called ulcers and they can occur anywhere in the
anogenital region. Although not as common as
urethral or vaginal discharge, anogenital ulceration
is a quite frequent presentation at Sexual Health
Clinics. However not all ulcers in the anogenital
region are sexually acquired. Causes other than
sexual are:
• Physical – trauma (admittedly often sexually
related, but not always e.g. zip fasteners)
• Allergic – fixed drug eruption, Stevens-Johnson
syndrome, severe reaction to local topical
allergen
• Neoplastic – Squamous cell carcinoma and its
predecessors, vulval intraepithelial neoplasia
(VIN), penile intraepithelial neoplasia (PIN) and
Bowen’s Disease.
• Rare causes – tropical (cutaneous amoebiasis,
cutaneous tuberculosis, leishmaniasis) and other
rarities (aphthosis including Behçet’s Disease,
Crohn’s Disease)
• Lymphogranuloma venereum (LGV) – Chlamydia
trachomatis serovars L1-L3
• Donovanosis (Granuloma inguinale) – Klebsiella
granulomatis
• Primary HIV infection (PHI) – painful aphthous
ulcers may occur on genital mucous membrane
as part of PHI; usually accompanied by oral
ulceration and systemic symptoms
Anogenital ulcer(s) due to STIs are mostly likely to
be herpetic, but sometimes might be syphilitic and
this is always a diagnosis NOT to miss. Very rarely
in Australasia ulcers may be due to chancroid (but
only with a history of recent overseas travel). Travel
and sexual exposure in endemic tropical areas was
historically the only way an Australian resident would
ever contract LGV but since 2003 a handful of MSM
in Australian cities have developed LGV. This has
mostly presented as an LGV proctitis rather than as
genital ulceration however. Donovanosis occurs only
in Indigenous Australians in central and northern
Australia, or in visitors from endemic areas
(especially PNG).
History:
Initially the clinician should seek to establish whether
the anogenital ulceration is sexually acquired, or
whether there is another likely cause. Questions
about recent medications, applications of topical
agents, overuse of soap, possible trauma and exposure to allergens are relevant here. A sexual history
is vitally important and should cover:
• sex overseas recently? (syphilis, chancroid, LGV)
• sex with a partner recently arrived from overseas? (as above)
• same sex partners? (if male, herpes & syphilis
both likely, with LGV a fairly uncommon possibility)
The nature of the ulceration is also helpful information, as follows:
• Ulceration painful? (herpes, chancroid)
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David Bradford
• Ulceration recurrent? (herpes)
• Ulceration chronic (longer than 6 weeks)? (neoplasia, donovanosis or herpes in an immunosuppressed client)
• Accompanying oral ulcers? (possible PHI)
Examination:
Investigations:
Either the clinician or the client (after instruction) can
take a cotton tipped swab from an ulcerated area.
The local laboratory will provide appropriate transport tubes and/or media for NAAT tests or culture.
Definitive diagnosis is dependent on appropriate
laboratory tests:
• Swab for herpes (preferably nucleic acid amplification test - NAAT eg polymerase chain reaction
[PCR]; culture if a NAAT is not available)
• Swab for treponemal NAAT (usually PCR) if
available. It is rare to find a laboratory that can
reliably perform dark field microscopy nowadays
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7
Sexually acquired ulcers
The clinician should always try to examine a client
who presents with anogenital ulceration. If the client
is embarrassed and unwilling, the clinician should
postpone the examination until next visit but still
arrange appropriate tests (see below) by asking the
client to self collect swabs from lesions. Examination
should include:
• Inspection of the ano-genital area (including
nooks, crevices and especially under the foreskin). You don’t see if you don’t look!
• Palpation of ulceration with a gloved hand
to determine induration and pain (indurated
=syphilis/neoplasia; painful= trauma, herpes,
chancroid).
• Palpation of the inguinal lymph nodes (painful
lymphadenitis = herpes, chancroid, LGV; painless lymphadenopathy = syphilis, neoplasia).
• Inspection of the mouth and throat, looking for
accompanying ulceration (PHI, aphthosis)
• Syphilis serology (RPR and treponemal EIA or
RPR and TPPA) – these are mandatory tests
whenever there is anogenital ulceration
• HIV serology, if primary HIV infection with
apthous ulceration is suspected
• If chancroid or LGV or donovanosis is probable, consult your laboratory for advice. Multiplex PCR tests (single swab for syphilis, herpes,
chancroid, and sometimes donovanosis) are
becoming available. Some laboratories can
perform a chlamydial NAAT specific for L1-L3
serovars
• Biopsy if lesion is chronic (>6 weeks)
What do test results mean?
Positive results tend to correlate well with the true
diagnosis (i.e. false positives are uncommon).
Negative results may not eliminate a true diagnosis
(especially herpes culture; also serology in very
early syphilis):
• negative herpes test – tell patient herpes may
still be likely - reattend early for repeat test if
there is recurrence
• negative syphilis serology and clinical suspicion;
repeat in 2 weeks
• positive RPR alone – confirm with TPPA or
treponemal EIA (laboratory may not automatically do this; it is always best to ask for both a
specific test as well as the RPR in the presence
of anogenital ulceration)
• positive treponemal EIA, or RPR/TPPA – check
if previously treated for syphilis – if RPR titre is
low positive serology may be explained by earlier
treated infection
• negative HIV test in the presence of symptoms
consistent with PHI – repeat in 1 to 2 weeks
Medical Management:
Immediate treatment (but always after tests have
been taken) based on the clinician’s presumptive
diagnosis is often in the patient’s best interests and
in the interests of the public health. Discussion with
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David Bradford
the patient about how best to contact and follow
up her or his sexual partners (contact tracing) is an
essential part of treatment.
If the patient is in discomfort:
• commence antiviral therapy for herpes immediately
If there is clinical suspicion of syphilis (indurated,
painless, single ulcer, exposure in an endemic area
or highly sexually active MSM)
• add treatment for syphilis immediately
Definitive treatment
Initial herpes (if in discomfort)
• Aciclovir (B3) 400 mg TDS po 7-10 days
OR
• Valaciclovir (B3) 500 mg BD po 7-10 days
Together with:
• Lignocaine 2% jelly topically if needed. Exercise
caution as it may cause sensitization with prolonged use.
• Paracetamol/codeine for pain relief
• Antifungal medication (preferably oral) for thrush
if present; antibiotics if secondarily infected
• Topical antivirals and antibiotics are ineffective
• Education and counseling for psychosocial
effects of reactivation and reoccurrences
Recurrent genital herpes
Episodic therapy MUST be commenced within 24
hours of symptom onset. The following short courses
have been shown to be at least as effective as 5-day
courses.
David Bradford
69
7
Sexually acquired ulcers
If exposure overseas (SE Asia, India, China, Africa,
Sth & Central America)
• add treatment for syphilis immediately and give
1g Azithromycin (B1) po to cover for chancroid
and LGV
• Aciclovir (B3) 800mg TDS po 2 days
OR
• Famciclovir (B1) 500mg stat followed by 250mg
BD po 3 doses
OR
• Valaciclovir (B3) 500mg BD po 3 days
NB even shorter course therapies are used in the
USA see http://www.ahmf.com.au for details
Suppressive therapy
• Aciclovir (B3) 400 mg BD po or 200mg TDS po
OR
• Famciclovir (B1) 250 mg BD po
OR
• Valaciclovir (B3) 500 mg daily* po
*In patients who have frequent recurrences (10 or
more per year) once daily therapy may be insufficient. These patients may require twice daily therapy
as 500mg bd.
Clinicians should reassess patients after 6 months
of suppressive therapy and continue if recurrences
continue to be a problem.
Early Syphilis (Primary or Secondary)
• Benzathine penicillin (A) 1.8g IM single dose OR
• Procaine penicillin (A) 1g IM daily for 10 days
(preferred therapy if patient is HIV positive)
If allergic to penicillin
• Doxycycline (D) 100mg BD po for 14 days (NOT
in pregnancy or breast feeding; see page 72)
Chancroid
• Azithromycin (B1) 1g po as a single dose OR
• Ciprofloxacin ( B3) 500mg BD po for 3 days OR
• Ceftriaxone (B1) 500mg IM as a single dose
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David Bradford
Donovanosis
• Azithromycin (B1) 1g weekly po for 4 weeks as
directly observed therapy
• Re-examine at 4 weeks – if not healed continue
1g weekly to 6 weeks
• Re-examine at 6 weeks – if not healed, biopsy
Lymphogranuloma venereum (LGV)
• Azithromycin (B1)1g po as a single dose on
suspicion
• If diagnosis confirmed then continue with
Doxycycline (D) 100mg BD po for 21 days
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71
Sexually acquired ulcers
What advice to give the patient about STIs and
follow-up
• Advice about sexually transmitted infections and
HIV, tailored to that patient’s needs, on how best
to reduce risks of acquiring STIs and how not to
transmit more chronic viral STIs like herpes (i.e.
safer sex discussion)
• Encourage to be screened for other STIs (especially HIV and hepatitis B)
• Full information about contact tracing sexual
partners (i.e. with herpes - any recent regular
partner; with syphilis and donovanosis - all
partners in the past 3 months; with LGV and
chancroid - any traceable partner)
• Recommend vaccination for hepatitis B (and
hepatitis A for MSM) if patient is not immune
• Arrange follow up in one to two weeks to ensure
symptoms have settled for all cases of anogenital ulceration and to assess need for ongoing
counselling and support. In the case of syphilis,
follow-up serology every 3 months over the next
12 months to ensure RPR titre is falling
Special Considerations:
Obstetric Patients
Herpes
• Perinatal transmission to the infant is most likely
in vaginal delivery in women who have acquired
genital herpes for the first time in the second half
of pregnancy. Such women require management
by an experienced team. Transmission is rare in
women with a past history of genital herpes.
Aciclovir is now frequently used in pregnancy if
indicated.
Syphilis
• Management of penicillin allergic pregnant
women with syphilis is problematic. Penicillin
desensitisation before penicillin treatment is the
recommended ideal. Infants born to mothers
treated with drugs other than penicillin must be
treated at birth as for congenital syphilis.
Chancroid – recommended treatment in pregnancy:
• Ceftriaxone (B1) 500mg IM single dose
Donovanosis – recommended treatment in pregnancy:
• Azithromycin (B1) (as above) is the most
appropriate treatment for pregnant women
LGV – recommended treatment in pregnancy:
• Erythromycin (A) 500mg QID po 21 days – this
is very difficult to adhere to, so Azithromycin (B1)
1g po every 3 or 4 days covering a 3 week period
may be easier – no evidence base as yet however
Neonatal Patients
Herpes – the treatment of neonatal herpes is beyond
the scope of this monograph
Congenital syphilis
• Benzathine penicillin (A) 50mg/kg IM as a single
dose if CSF is negative for neurosyphilis
• Benzyl penicillin (A) 50mg/kg IM or IV daily in 2
divided doses for 10 days OR
• Procaine penicillin (A) 50mg/kg IM daily for 10
days
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David Bradford
LUMPS AND BUMPS
Overview:
A genital lump or bump is a very common STI
presentation. In the sexually active patient, new
lumps will mostly be warts, but normal skin variants
and benign skin conditions need to be kept in mind
too. Most causes are treatable or benign.
The Gardasil ® HPV vaccine covers two of the HPV
strains most likely to cause clinical warts and is
therefore likely to decrease clinical wart presentations
in the coming years, as coverage increases in the
younger Australian population. Gardasil ® is on the
National Immunisation Program and covers infections
with HPV types 6, 11, 16 & 18. Types 6 & 11 cause
90% of genital warts. Another vaccine has come on
the market, Cervarix ® covering types 16 & 18. So
both the vaccines protects the types that cause 70%
of cervical cancer but only Gardasil ® covers against
warts.
Medical Issues:
Causative conditions
8
Possible presentations
Usually the patient feels or sees the lump.
Occasionally they can be tender, or itchy.
After people examine themselves for the first time
(eg after first sex, or gynaecologic procedures) they
may find normal variations, and become anxious
about possible causes.
Causes
Most of the time this will be genital warts, caused
by human papillomavirus, or HPV. These are usually
Jacki Mein & Lewis Marshall
73
LUMPS AND BUMPS
Infections, normal skin structures, and benign skin
conditions. Very rarely lumps can be cancer.
firm and painless with a whitish cauliflower-like surface, but can be flat, fimbriate, or pedunculated.
Sometimes the bumps will be normal anatomical
variations, e.g. Tyson’s glands - either side of the
frenulum, usually paired, or pearly penile papules many one to two mm regular bilateral bumps lined up
around the edge of the corona (penile head), or foreskin remnants in circumcised men. Occasionally
sebaceous glands or epidermoid cysts,
Fordyce’s spots, and angiokeratomas cause
concern if they have not been noted before. A lump
in the groin may be a lymph node. This may be
due to STIs commonly causing ulcers (see sexually
acquired ulcers chapter), systemic pathology, e.g.
HIV or other infections, or distal infection,
e.g. cellulitis.
Uncommonly lumps might be due to molluscum
contagiosum, smooth two to three mm pale bumps
with a central dimple; an abscess, or Bartholinitis
in women - a one to three cm painful mass in the
lower third of either labia minora. In travellers from
high prevalence countries, men who have sex with
men, or in Indigenous Australians, condylomata lata
– (infectious secondary syphilis) cause wet soft
painless lumps clustered in skin folds.
Very rarely a hard, non tender lump in an elderly
patient – usually over 60 years- may be a genital
cancer.
History:
What to ask to help diagnosis
How long have the lump(s) been present?
Warts usually grow to noticeable size over weeks
to months.
Is this the first time you have checked yourself?
Keep in mind normal variants if self examination
is new to the patient!
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Jacki Mein & Lewis Marshall
Are the lumps growing/more appearing?
More likely to be warts or other infection if yes.
Are they sore?
Abscess, Bartholinitis, lymph nodes, folliculitis
can all be painful. Warts are usually not.
Examination:
What to look for - genital and associated systems
Examine abdomen to thighs.
Warts: firm, painless irregular cauliflower surface
(common sites are undersurface of foreskin, base of
penis and vulval fourchette). Can be keratinised on
skin, often multiple.
Tyson’s glands: 1-2 mm regular paired, on either
side of the penile frenulum.
Pearly penile papules: 1-2mm regular smooth
bilateral, edging the penile corona.
Sebaceous cysts/Fordyce’s spots: 2-5mm pale
smooth soft, attached to skin.
Epidermoid cysts: 2-10mm pale smooth soft
attached to skin (often scrotum)
Angiokeratomas: pink/red smooth well demarcated,
painless.
8
Lymph node: 1-3cm, in groin, may be tender, deep
to skin. Check for distal infection.
LUMPS AND BUMPS
Molluscum: 2-4mm smooth pale, central dimple,
often multiple, only on skin, especially suprapubic
region and inner thighs.
Abscess: tender red warm lump attached to skin.
Bartholinitis: tender lump lower third labia minora.
Condylomata lata: soft wet smooth clustering in skin
creases.
Cancer: hard nontender irregular may bleed easily,
in older patient.
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75
Investigations:
What to test for
Diagnosis is usually clinical, see above.
If patient sexually active:
Patients having unprotected sex outside a monogamous relationship should be offered a basic STI
screen including blood for HIV, HBV, and syphilis,
and first void urine (males and females) or endocervical swab for PCR for Chlamydia and gonorrhoea.
Ensure Pap smears are up to date in women, and
female partners of men with warts, as some HPV
strains increase cervical cancer risk.
How to test/Interpreting results
Suspected condylomata lata should be dry swabbed
for syphilis PCR and serology taken for syphilis.
Suspected cancer should be biopsied for histology.
Medical Management:
(Treatment, follow up, information, advice, contact
tracing)
Warts
Treatment. Patients usually want treatment for cosmetic
reasons. Larger warts need more treatment. Consider
method availability, cost, and convenience (doctor or
patient administered). Current options include:
• Ablation: doctor-applied freezing with liquid
nitrogen or N2O, or diathermy if available in the
practice – good for big warts, cheap, may require
repeat patient visits.
• Immune modulation: imiquimod (B1) cream-apply
alternate days for several weeks, good for recurrent warts, home applied, but costly
• Chemical destruction: podophyllotoxin cream
(0.02%), or paint (0.1%), apply nightly for 3 days
then leave for 4 days. It can be home applied, is
cheap, and usually effective
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Jacki Mein & Lewis Marshall
• Less common clinic-only treatments: podophyllin,
trichloroacetic acid, laser ablation, surgical
excision and/or diathermy, 5FU (D) cream.
NB: Imiquimod, Podophyllin and Podophyllotoxin
preparations are anti-mitotic so should NOT be used
in pregnancy.
Follow-up. May be required if warts are not gone with
initial therapy.
Information and advice. Good local pamphlets are
available at (http://www.hpv.org.nz/info/info.html).
Written patient information is useful as wart virus
infection is complex.
Genital wart virus infection is really common -75 -80%
of sexually active adults will be infected but less than
a quarter will ever develop warts. There are lots of
strains which are almost always sexually transmitted.
They rarely arise from contact with hand warts, toilet
seats etc.
Wart virus infection may remain dormant for days to
years before warts develop. If someone has had more
than one partner it is impossible to say from whom
they acquired the virus.
This means that condoms are not necessary for HPV
protection of a long-term monogamous partner.
Condoms do not offer good protection but can reduce
exposure against wart virus infection. Condoms do
protect against other STIs.
Treatment does not get rid of the virus infection, just
the warts and therefore they can recur.
Contact tracing. As wart virus is very common, and
usually asymptomatic, formal contact tracing is
not usually necessary. However it is useful to sugJacki Mein & Lewis Marshall
77
8
LUMPS AND BUMPS
Once infected, a person carries and can transmit
the virus sexually until they clear it from their body
(weeks to years). On clearing the virus they are
probably immune to that strain but not to other wart
virus strains.
gest regular partners get checked, as a number will
have warts and may want treatment. Ensure female
patients and partners are up to date with PAP smear
testing.
Management of non-wart causes
Tyson’s glands, pearly penile papules, sebaceous
and epidermoid cysts, Fordyce’s spots: benign,
reassure.
Lymph node: Check for cause (early genital HSV,
HIV or other systemic infection, drainage of distal
infection).
Molluscum: Often disappear if pricked and squeezed.
Can treat as for warts. Do not usually recur. Occasionally seen on face and chests of young children
(not sexually transmitted in this group) and in immune
suppressed adults (e.g. late HIV infection) where
reactivation of latent molluscum virus infection has
occurred. Contact tracing not usually necessary.
Abscess: drain/observe depending on size and
symptoms.
Bartholinitis: observe/refer for marsupialization
depending on size, symptoms and recurrence.
In settings of high STI prevalence, gonorrhoea is a
common cause.
Condylomata lata: treat as for early syphilis, see
sexually acquired ulcers chapter. An RPR and a
specific serological test (TPPA, EIA etc) for syphilis
will always be reactive (the RPR at high titre - usually
>1:16) in the presence of condylomata lata.
Cancer: refer oncologist.
Other Considerations:
Process of exclusion: Condylomata lata are a
sign of early syphilis. Consider in people at risk, e.g.
homosexually active men, individuals having recent
unprotected sex in high prevalence countries, or
indigenous Australians in areas of high prevalence.
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Jacki Mein & Lewis Marshall
An RPR and a specific serological test (TPPA, EIA
etc) for syphilis will always be reactive (the RPR at
high titre - usually >1:16) in the presence of
condylomata lata. Syphilis can cause serious illness
and early syphilis is highly infectious. Particularly in
antenates, prompt treatment and follow-up is vital as
syphilis can cause serious pregnancy and neonatal
complications. If in doubt check with a specialist and
ask patient to return.
Penile/vulval cancer may present as a very firm
painless lump, usually in older people, growing
slowly over time. If in doubt biopsy or refer for biopsy
as this is important not to miss.
Special Considerations:
Warts in pregnancy and HIV or the immunocompromised
Warts can often grow fast in pregnant and/or HIV
positive women and need prompt aggressive treatment (not chemical in pregnancy) cryotherapy or
diathermy. Chemical treatments can be used with
care in HIV or the immunocompromised. Warts often
resolve after (delivery) pregnancy.
Warts in neonates - sexual abuse?
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8
LUMPS AND BUMPS
Neonates can be infected genitally at birth and if a
baby develops genital warts, vertical transmission
needs to be considered. Check for a maternal history
of genital warts. However investigation by appropriate
child protective services is important to exclude sexual
abuse, as the diagnosis of vertical transmission is one
of exclusion.
LUMPS AND BUMPS – VISUAL DIAGRAM
Normal variants:
Pearly papules of the penis - bilateral
regular smooth surface1-2mm lumps arranged
around the coronal head
Vulval papillae - bilateral regular soft smooth
1-3mm lumps arranged around the vulva esp in
labial folds
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Fordyce’s spots - sebaceous glands in the skin
of the shaft of the penis or vulva
Tyson’s glands - paired smooth small bumps
around the penile frenulum adjacent to the penile
meatus
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LUMPS AND BUMPS
Circumcisional remnants are exactly that- bits of
the foreskin left after most of it has been surgically
cut away. They appear as small soft skin tag(s)  or
flap(s), usually occurring in a belt-like distribution
around midshaft of the penis and may be associated
with faint circumcisional skin scarring, depending on
the age at which circumcision occurred. They are
painless, retain normal skin colour and texture and
remain the same size and shape over time.
Benign skin conditions:
Folliculitis Red, raised, +/- pus around hair
follicle, may be tender
Bartholinitis in women
-tender 1-3cm lump in lower third labia minora
Sebaceous and epidermoid cysts
-smooth pale lumps 2-5mm attached to skin
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Angiokeratomas - red/pink well demarcated
irregular lesions on keratinised skin
Infection:
8
Most common scenario: In the sexually active
population, new lumps are usually warts
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LUMPS AND BUMPS
Human Papilloma Virus – clinical warts
-cauliflower surface, raised, firm, often multiple and
different sizes 2mm – several cm, non-tender, may
be itchy
Molluscum Contagiosum Virus – molluscum
- ovoid, dome shaped, central umbilication, smooth,
2-5mm and often multiple, non-tender
Cancer:
Very rare usually in older age groups
Hard, tethered, irregular in size/shape, distort normal
structures, may bleed easily, usually non-tender
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9
Overview:
Viral hepatitis is an important health problem worldwide. It is estimated that over 300,000 Australians
are chronically infected with viral hepatitis B (HBV)
or C (HCV) or both. The sexual route of transmission
is important for hepatitis A (HAV), HBV and hepatitis
D (HDV); sexual transmission of HCV is much less
common. For people living with chronic viral hepatitis,
approximately 25% will develop advanced liver disease
such as cirrhosis or hepatocellular carcinoma (HCC).
People living with HIV/AIDS are at increased risk
of also having chronic viral hepatitis B or C or both,
and the rate of progression to severe liver disease is
higher. As safe and effective vaccines are available
for both HAV and HBV (including in a combined
formulation) immunisation should be encouraged for
all patients at risk of infection.
Medical Issues:
Although symptoms and signs of acute or chronic
hepatitis are important to recognise, in many cases
patients are asymptomatic or exhibit mild or nonspecific symptoms. Therefore a thorough exploration
of potential risks of transmission with patients is
critical to enable diagnosis. Knowledge of the risk
factors for infection, and of particular groups in the
community at higher risk, should also be the
foundation for a comprehensive and pro-active
vaccination policy. Some risk factors for infection and
related information appear in the tables below.
Benjamin Cowie
85
VIRAL HEPATITIS
VIRAL HEPATITIS
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Benjamin Cowie
Risk factors for
infection and groups
at higher risk of
infection
Modes of
transmission
Sexual / household contact with
acute case
MSM* (esp. with multiple
partners)
Travel to endemic areas
Day care attendance/ work
Sewerage workers
Injecting drug users
Other recreational drug users
Point source outbreaks due
to contaminated food occur
uncommonly
•
•
•
•
•
•
•
•
Faeco-oral
Contaminated food / drink
•
•
HAV
•
•
•
•
•
•
•
•
Sexual / household contact with
infected person
MSM*
People with multiple sex
partners
Perinatal (~80% transmission
risk)
People born in high prevalence
regions and their sexual
partners
Indigenous Australians
Unsafe injecting drug use
Unsterile percutaneous
exposure**
Prisoners
•
HBV
Parenteral and mucosal (esp.
sexual) exposure to infected
blood or bodily fluids
•
•
•
•
•
•
•
HCV
Unsafe injecting
drug use is
responsible for
>80% of infections
Unsterile
percutaneous
exposure**
Prisoners
Perinatal (~5%
transmission risk)
Sexual transmission
is documented, but
rare
Primarily parenteral
exposure to
infected blood
Benjamin Cowie
87
Other information
•
•
Vaccine available?
HEV is a differential diagnosis
in returned travellers with acute
hepatitis; high mortality in
pregnant women
Yes
HAV does not cause chronic
infections
2 weeks - 2 months; typically
~1 month
•
•
Rare in children
Common in adults
•
•
Risk of progression
to chronicity?
Incubation period
Acute illness?
•
HDV only occurs in conjunction
with HBV infection; modes of
transmission are similar
Yes
90% of neonates,
20-50% of children,
5% of adults
•
•
•
•
1 - 6 months; typically ~2 - 3
months
Rare in children
More common in adults
•
•
•
HBV
•
•
•
•
•
•
* MSM men who
have sex with men
**including
medical and
dental procedures,
transfusions,
tattooing, piercing
No
Approximately 75%
2 weeks - 6 months;
typically ~2 months
Uncommon, and
typically nonspecific
HCV
VIRAL HEPATITIS
HAV
9
History:
It is generally not possible to distinguish between
acute viral hepatitis infections on clinical features
alone. It is also important to remember that subclinical
infection or non-specific clinical features are very
common. These facts reinforce the importance of
eliciting relevant epidemiological clues and having
a low threshold for testing. Symptoms and signs of
chronic viral hepatitis do not reliably reflect disease
activity - their absence does not preclude significant
pathology.
Symptoms of viral hepatitis can include malaise,
lethargy, anorexia, nausea and vomiting, fever,
jaundice, headache and myalgia, abdominal pain
particularly in the right upper quadrant, pruritis,
and intolerance of alcohol or fatty foods. Signs can
include tender hepatomegaly, fever, and icterus,
and with cirrhosis, spider naevi, palmar erythema,
and gynaecomastia. Features of portal hypertension
such as ascites, splenomegaly, and haematemesis
and melaena may be present. With the onset of liver
failure (acute or chronic), symptoms can include
intractable nausea, excessive bruising and bleeding,
and with hepatic encephalopathy, reversal of the
diurnal sleep pattern, increasing lethargy and
behavioural changes. Signs include bruising and
bleeding, peripheral oedema, jaundice, hepatic flap,
foetor hepaticus, and alterations in conscious state.
The extrahepatic manifestations of viral hepatitis are
protean; common clinical features include vasculitic
rashes and other skin conditions, arthritis, abdominal
pain, peripheral neuropathy, and dry eyes and
mouth. People living with chronic HCV in particular
have a high prevalence of depression.
Investigations:
The diagnosis of viral hepatitis is established by
blood tests. The cornerstone of first-line testing
remains serology, although newer molecular (e.g.
PCR-based) tests are assuming an increasing role.
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9
HAV
Acute: anti-HAV IgM positive
Past infection: anti-HAV total Ab positive and
anti-HAV IgM negative
HBV
Consideration should be given to ordering a panel of
HBV serology including HBsAg, anti-HBc and antiHBs for any patient with risk factors for HBV infection.
This avoids both missing chronic HBV infections
and unnecessary vaccination. The recent addition of
HBV DNA viral load testing to the Medicare Benefits
Schedule means that this test is now accessible
in the primary care setting up to once per year for
patients not receiving antiviral therapy, and four times
per year for patients on antiviral medication.
Serologic
test
Results
Typical interpretation
HBsAg
anti-HBc
anti-HBs
negative
negative
negative
Susceptible
HBsAg
anti-HBc
anti-HBs
negative
negative
positive
Vaccinated; if titre >10
mIU/mL and has had
complete course of
vaccination, no further
immunisation required.
HBsAg
anti-HBc
anti-HBs
positive
negative
negative
Early acute infection
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VIRAL HEPATITIS
Some find these tests confusing (particularly those
for HBV), but a systematic approach to testing makes
interpreting the results more straightforward.
Serologic
test
Results
Typical interpretation
HBsAg
anti-HBc
IgM anti-HBc*
anti-HBs
positive
positive
positive
negative
Acute infection*
HBsAg
anti-HBc
IgM anti-HBc*
anti-HBs
positive
positive
negative
negative
Chronic HBV infection*
HBsAg
anti-HBc
anti-HBs
negative
positive
positive
Resolved infection
negative
positive
negative
Either distant resolved
infection; recovering
from acute infection;
false positive; or ‘occult’
chronic infection (HBV
DNA PCR positive)
HBsAg
anti-HBc
anti-HBs
Above table from Mast E.E. et al., MMWR Recomm
Rep, 2006; 55(RR-16): p. 4.
*IgM anti-HBc can be positive during a flare of
chronic HBV infection.
HCV
Anti-HCV is a marker of ever having been infected
with HCV; up to 25% of anti-HCV positive patients
will have cleared the infection. Due to the availability
of a Medicare rebate for HCV RNA PCR, this test
to establish the replicative status (i.e. whether the
infection persists or has been cleared) of an antiHCV positive patient is possible in the primary care
setting. Repeatedly negative PCR and persistently
normal ALT suggests cleared infection.
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9
Current or past infection: anti-HDV positive
Medical Management:
The management of acute viral hepatitis is supportive and can usually be undertaken without hospitalisation. Monitoring for features of fulminant hepatitis
(occurring in <1% of patients) such as intractable
vomiting, altered conscious state, coagulopathy, or
persistently rising or very high bilirubin is important;
such patients must be hospitalised and may require
liver transplantation. Patients should be counselled
to avoid alcohol, minimise paracetamol usage, and
avoid aspirin and narcotics or sedatives. No specific
therapies are routinely used to treat acute viral
hepatitis. Although there is mounting evidence that
antiviral treatment of acute HCV is associated with
high rates of viral clearance, this is still under evaluation and is currently available only through clinical
trials.
Test
Test
results
Alternative
Interinterpretation
pretations
anti-HCV
negative no
HCV RNA PCR negative infection
anti-HCV
negative
HCV RNA PCR positive
previous
infection with
clearance and
seroreversion;
during
incubation
period
acute
infection
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VIRAL HEPATITIS
HDV
Test
Test
results
Alternative
Interinterpretation
pretations
anti-HCV
positive
HCV RNA PCR negative
past
resolved
infection
anti-HCV
positive
HCV RNA PCR positive
acute or
chronic
infection
chronic
infection with
transiently
undetectable
RNA PCR;
false positive
antibody result
Effective therapies exist to treat both chronic HBV
and HCV. For patients with chronic HBV with persistently elevated ALT and biopsy evidence of chronic
hepatitis, possible treatments include nucleoside
analogues (lamivudine, entecavir, adefovir) or pegylated interferon. The aim of therapy is to suppress
viral replication, induce HBeAg seroconversion, and
prevent progressive fibrosis and HCC. In the case
of HCV, combined therapy with pegylated interferon
and ribavirin elicits a sustained virologic response
(SVR, defined as remaining HCV RNA PCR negative
6 months after cessation of therapy) in 45 – 80% of
patients depending on HCV genotype. Achievement
of an SVR is associated with improvement in liver
histology, reduction in incidence of HCC and reduced
mortality, and SVR appears durable in >95% of
patients. The former requirements for a liver biopsy
and raised ALT to access treatment no longer apply
to chronic HCV infection.
An important aspect of the management of viral
hepatitis is counselling of the patient and ideally their
partners and/or family members on all aspects of the
illness. This should include natural history,
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9
Other Considerations:
Notification:
Any newly diagnosed viral hepatitis must be notified
by the treating doctor and the testing laboratory to
enable an appropriate public health response.
Screening of contacts:
Discussion with the newly diagnosed patient
regarding relevant contact tracing and screening is
advisable. Contacts to consider include sexual,
blood-to-blood (e.g. IDU), and household contacts
(in the case of HAV and HBV). Occupational contact
tracing may be relevant (e.g. food preparation for
HAV, health care workers involved in exposure prone
procedures for HBV and HCV). Commonwealth and
State/Territory guidelines should be followed and
assistance can be sought from State or Territory
public health authorities.
Serological follow-up for people exposed to HBV or
HCV should extend to 6 months following exposure
(typically performed at 1, 3 and 6 months).
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VIRAL HEPATITIS
how the virus is transmitted and how to prevent this
from occurring, the availability of treatment, the need
for ongoing monitoring, and providing adequate time
to answer all questions. Discussion of alcohol intake
and if necessary, minimisation is also important, as
is a harm minimisation approach in the setting of
ongoing IDU.
Immunisation:
Vaccination against HAV or HBV or both (combined
formulation) should be pro-actively offered to all
people with risk factors for infection.
People with chronic viral hepatitis should be
protected against further liver injury. A person with
chronic HBV requires vaccination against HAV;
a person with chronic HCV should be vaccinated
against both HAV and HBV.
Sexual and household contacts of a person infected
with either HAV or HBV should be immunised:
HAV: sexual and household contacts (during the 2
weeks prior to and for 1 week after the onset of
jaundice in the index case) should receive normal
human immunoglobulin (NHIG) and non-immune
individuals at ongoing risk of HAV infection can
commence active vaccination against HAV simultaneously. NHIG should be administered as soon as
possible, certainly within 2 weeks. A recently
published clinical trial has suggested hepatitis A
vaccine is as effective as NHIG at preventing HAV
in healthy contacts following exposure; Australian
guidelines do not currently recommend this approach
but this may change in the future.
HBV: following significant exposure to an HBsAg
positive source, a non-immune individual should
receive hepatitis B immune globulin (HBIG) as soon
as possible and commence hepatitis B vaccination
simultaneously. HBIG can only be obtained from the
Australian Red Cross Blood Service.
Sexual exposure: HBIG and commence vaccination
within 14 days
Percutaneous exposure: HBIG within 72 hours,
commence vaccination within 7 days
Perinatal exposure: HBIG within 12 hours,
commence vaccination within 24 hours, repeat
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9
Exposures with lesser risk (e.g. susceptible
household contacts of people with chronic HBV,
susceptible long-term partners of patients with
latent HBV infection) usually do not warrant HBIG
but hepatitis B vaccination should still be strongly
encouraged.
People presenting following unprotected sexual or
needle-sharing contact with a person of unknown
HBsAg status should be offered vaccination against
HBV (consider vaccination against HAV also), as
should patients presenting for STI screening or
treatment.
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VIRAL HEPATITIS
vaccine doses at 2, 4 and 6 or 12 months. This
regimen reduces the risk of infection by 90%.
The child should be screened for HBV infection with
HBsAg and anti-HBs 3 months after completing the
vaccine series.
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HBIG (hepatitis B)
NHIG (hepatitis A)
Immunoglobulins
Combined hepatitis A/B
Hepatitis B vaccine
Hepatitis A vaccine
Vaccines
Product (all given IM)
Sexual: 400IU
Percutaneous: 400 IU
Perinatal: 100 IU
<25kg – 0.5mL
25-50kg – 1.0mL
>50kg – 2.0 mL
1.0mL (0.5mL in children
– age cut-off variable for
different products)
Dose
Both immunoglobulin preparations are
given as a single dose IM. Both can be
given simultaneously with the relevant
vaccine, but must be administered in a
different site.
3 doses at 0, 1 and 6 months
(infant: 0, 2, 4, and 6 or 12 months)
3 doses at 0, 1 and 6 months
2 doses 6 - 12 months apart
Usual schedule
9
References and further reading
National Health and Medical Research Council. The
Australian Immunisation Handbook. 9th edn. 2008,
Commonwealth of Australia: Canberra.
Bradford D, et al., eds. HIV/Viral hepatitis and STIs: a
guide for primary care. Revised edn. 2008, Australasian Society for HIV Medicine Inc: Darlinghurst.
Mast, E.E., et al., A comprehensive immunization
strategy to eliminate transmission of hepatitis B virus
infection in the United States: recommendations of
the Advisory Committee on Immunization Practices
(ACIP) Part II: immunization of adults. MMWR
Recomm Rep, 2006; 55(RR-16): p. 1-33.
Chin, J., ed. Control of Communicable Diseases
Manual. 17th edn. 2000, American Public Health
Association: Washington.
Owen, R., et al., Australia’s notifiable diseases
status, 2005: annual report of the National Notifiable
Diseases Surveillance System. Commun Dis Intell,
2007; 31(1): p. 1-70.
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VIRAL HEPATITIS
For more detailed discussion see the Australian
Immunisation Handbook 8th edn.
ITCHES, RASHES & JOINTS (including DGI)
Overview:
Genital itches and rashes commonly present in
general practice and can usually be well differentiated
by a good history and examination. Many patients
will present after they have attempted to treat the
condition themselves and a medication history is
important.
Joints:
Arthralgias are a common presenting problem of
prodromal viral illness including Hepatitis B, Hepatitis
C, HIV.
Urethritis associated with arthritis and conjunctivitis
is, a rare complication due to Chlamydia & Gonorrhoea or sometimes a gastroenteritis (ie can be nonSTI). Mucocutaneous manifestations are also possible. The condition is associated with HLA type B27.
Medical Issues:
Initial identification: location of itch/rash, duration,
association with applications, sex, other genital or
general symptoms
Common causes:
• Itch: pubic lice, scabies, thrush, allergy/dermatitis,
pruritis ani, vulvodynia
• Rash: scabies, thrush, herpes, allergy/dermatitis,
psoriasis
Causes define the treatments or advice
Persistent problems or lack of response may warrant
biopsy and/or referral.
There are three generalised rashes of considerable
importance in sexual health medicine, which should
not be overlooked – the rash of primary HIV infection
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the rash of disseminated gonococcal infection (DGI)
and the rash of secondary syphilis (see discussion
later in this Chapter).
History:
Genital Rashes
10
Significant history: other skin diseases – dermatitis,
psoriasis, intertrigo
• Past STI history
• Medical conditions: diabetes
• Medication
Scabies: itch usually worse at night or when getting warm, spares only the face and scalp, typically
infects all body especially finger and toe webs with a
thin red ‘trail’ on skin (burrow). History of itch and
visible rash all over, not just on genitals.
Pubic lice: severe itch primarily on genitals though
can spread through body hair on males. No rash but
may have excoriation marks on skin under pubic hair.
Thrush: Moderate to severe local vulval or vaginal
itch in women, often worsens in the week before the
period. Associated with whitish, moderate to thick
vaginal discharge which is either without odour or
smells yeasty. Thrush can be precipitated by medication (the Pill, antibiotics) applications (creams, soaps
etc.) and is a sex-associated condition so can occur
with a new sexual partner but it is rarely necessary to
treat a male partner unless he has symptoms (spotty
rash under foreskin or head of penis, persistent itch).
Allergy: can occur as response to soaps/secretions/
sweat and topical applications.
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itches and Rashes
Basic information sieve: location, duration, associations, other symptoms, intensity, variation in itch in
response to scratching – does scratching temporarily
relieve itch or make it worse? (see vulvodynia paragraph below)
Contact dermatitis: has frequent association with
medication or local application history.
Herpes: occasionally can present atypically as a
rash but many histories will uncover preceding pain
without rash or the rash itself may show some
characteristic vesicles which can be sampled for viral
culture.
Dermatitis: can occur anywhere on the body and the
genitals are no exception. Suspect particularly with a
history of self diagnosed thrush infections and
frequent treatment with creams, do a swab for
microscopy, culture and sensitivity and cease all
treatment until the results are available. May need
Hydrocortisone 1% cream or ointment to settle.
Pruritis ani: is a moderate to severe persistent itch
around anus. Can be extensively self-treated as an
itch or present with ‘rash’ inflammation from
persistent scratching.
Intertrigo: itch (+/- rash in skin creases of groin)
spares the genitals but affects all the areas where
skin overlaps. The itch is mild to moderate but very
persistent and longstanding.
Psoriasis: is usually mildly itchy and is associated
with a well demarcated erythematous patch.
Lichen sclerosus: is characterised by long
duration, mild to moderate itch with characteristic
pale vulva.
Vulvodynia: in women, severe persistent painful
vulval itch which becomes more painful when
scratched can indicate vulvodynia. It is usually
present for many years and associated with marked
dyspareunia.
Generalised rashes
It is not uncommon for viral infections to present with
generalised rashes as well as considering conditions
outlined below- HIV, DGI & syphilis- consider viral
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exanthems including glandular fever, Hepatitis B, and
Hepatitis C and perform the relevant serology.
Disseminated gonococcal infection (DGI): The
skin manifestations of DGI are multiple pustular,
petechial or necrotic macules or papules on the trunk
or extremities associated with gonococcal bacteraemia and often accompanied by polyarthalgia and
tenosynovitis.
Secondary syphilis: The rash of secondary syphilis is a maculo-papular erythematous non-itchy rash
involving the trunk and the inner aspects of arms and
legs extending to the palms and soles with onset
about 6 weeks after acquiring syphilis and usually
after the primary chancre has disappeared. The rash
is usually accompanied by generalised lymphadenopathy and systemic symptoms. Condylomata
lata (moist, wart-like lumps in perineal and perianal
skin groves and creases) may also occur in
secondary syphilis.
Examination:
Need to examine: body part(s) affected; see if general involvement eg scabies
• groin, pubic hair
• full genital examination for rash, discharge, excoriation
• can include speculum examination to swab for
thrush
Body examination: check finger and toe webs and
other parts of body for scabies burrows, check
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itches and Rashes
Primary HIV Infection (PHI): PHI is a glandular
fever-like illness accompanied by a macular
erythematous non-itchy rash involving the trunk,
inner aspects of arms and legs and occasionally the
palms and soles with onset 2 – 6 weeks after a risky
sexual exposure. The rash may be accompanied by
both oral and genital apthous ulcers and generalised
lymphadenopathy.
antecubital fossae and popliteal fossae for patches of
dermatitis
Check for other rashes eg psoriasis, intertrigo (frequently also occurring under the breasts in women)
Genital examination
Pubic hair: inspect for adult lice (crabs) and nits
(pubic lice eggs) which are small (1mm) stuck to
base of the hair and can be dislodged by combing
pubic hair
Rash: excoriation indicates severe persistent itch
(lice, scabies, dermatitis, chronic inflammation)
Red confluent rash usually in the creases (groin,
natal cleft) with spots on the edge of the rash
‘satellite lesions’ (thrush)
Erythematous inflammatory response around blisters
– herpes until proved otherwise
Erythematous inflamed skin with clearly defined
margins – psoriasis possibly dermatitis
Vulvodynia - Normal looking vagina but a history of
severe persistent itch. Local severe pain (usually
introital) can be elicited on testing by gently touching
around the introitus with a cotton bud
Generalised rash: always check palms and soles;
look for aphthous ulceration on buccal mucosa,
under foreskin, inside introitus and on vaginal wall;
check perineum and perianal area for condylomata
lata; check for signs of tenosynovitis & arthritis;
check for generalised lymphadenopathy and
enlarged spleen
Investigations:
Most commonly diagnosis of genital rashes is made
on history and examination but this can be clarified
by a swab in some situations.
Swab: Either swab the lesion or take a blind low or
high vaginal swab which will detect thrush. If the
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history warrants it a full STI screen can be offered at
the same time. Send swabs for microscopy, culture
and sensitivity, including swabs from lesions in viral
culture medium or a PCR test for HSV if there is any
suspicion of herpes.
Unusual rashes/lesions can be biopsied for a clear
diagnosis. Unless the sexual partner has symptoms it
is rarely of any value to also test them.
Generalised Rash:
• HIV testing now routinely combines an antibody
and antigen test, if primary HIV infection is suspected
• Swabs for culture and sensitivity for Neisseria gonorrhoeae from all possible mucosal sites
(pharynx, endocervix, urethra, conjunctiva, rectum) as per history; blood cultures; aspirate of
joint effusion, if DGI suspected
• RPR plus a specific treponemal test (EIA or TPPA
or FTA ABS) if secondary syphilis is suspected
Medical Management:
Generally treat according to the diagnosis but be
aware of need to maintain genital health and avoid
the 4 Ss:
Secretions – sweat & non breathing underwear can
worsen thrush (loose cotton clothing)
Soaps – bath oils, vaginal deodorants can all cause
local irritation
Steroids – can cause decreased resistance
(especially to HSV)
Scratching – can cause further skin break down
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itches and Rashes
Results generally can be acted on if positive, though
if the itch/discharge has gone and thrush is identified
it is reasonable to notify the woman but refrain from
treatment until the itch returns.
Thrush: all treatment is available over the counter
at the pharmacists. Start with the azole creams
(clotrimazole, econazole, miconazole) preparations
of variable strength and quantity, all ADEC category
A. Most are successful and affordable but repeated
applications with little break between can induce a
contact dermatitis to the cream. Oral azoles (fluconazole (D), itraconazole (B3)) are alternative treatments but have the disadvantage of being more
expensive and not providing immediate local relief.
This is not a notifiable infection. In the case of genital
dermatoses and vulvo-vaginal candidiasis, unless the
partner has symptoms, it is rarely worth treating the
male sexual partner.
Lice: Apply permethrin 1% cream or lotion (B2) to all
body hair (not scalp) after first dampening hair. Leave
on for 30 minutes. Rinse off thoroughly. Comb out
dead lice and nits. Repeat in 1 week or as directed
by the manufacturer’s instructions.
Scabies: Apply permethrin 5% cream (B2) from chin
to toes at bed time. Allow to dry before retiring. Wash
off thoroughly in the morning. Itch will persist for
about two weeks and can be relieved with antipruritic soothing lotions or 1% hydrocortisone cream.
A second application of permethrin may be needed in
a week or as directed by the manufacturer’s
instructions.
Herpes: persistent disabling attacks may need oral
medication (aciclovir, valaciclovir or famciclovir) but
local relief using lignocaine gel, salt baths, betadine
can often be adequate for infrequent attacks.
Dermatitis, and vulval or penile psoriasis can be
effectively treated with steroids usually with rapid
effect. If treatment does not have some effect within
a week consider biopsy to check the diagnosis.
Lichen sclerosus is a serious condition with the
potential to lead to extensive fibrosis and distortion
of the introitus in women and phimosis and meatal
stenosis in men. Suspicious lesions should be
biopsied initially to prove the diagnosis. It requires
104 Katrina Allen
long term treatment with high potency steroid
cream or ointment. Yearly review of area should be
organised and repeat biopsies of suspicious areas
due to a small but significant risk of malignancy.
If concerned refer for specialist advice.
Vulvodynia: treatment needs to include careful
counselling usually including sex therapy but the
symptoms can often respond to a low dose (10
–15mg) of amitriptyline po (ADEC category C).
Primary HIV Infection: see HIV Chapter
DGI: Admit and treat with Ceftriaxone (B1) 25 – 50
mg/ kgm IV or IM daily for 7 days (see below)
Secondary syphilis: treat with penicillin exactly as
for primary syphilis (see Sexually acquired ulcers
Chapter)
Special Considerations:
Occasionally persistent severe thrush can indicate
systemic disease such as the onset of NID diabetes
mellitus or HIV.
DISSEMINATED GONOCOCCAL INFECTION (DGI)
Overview
Rarely (in 0.5 – 3% of all cases) gonorrhoea becomes
a disseminated infection with bacteraemia and skin
and joint involvement. Dissemination can occur from
a gonococcal infection on any mucosal site (urethral,
rectal, endocervical, pharyngeal or conjunctival).
Frequently the mucosal infection is asymptomatic
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itches and Rashes
Intertrigo is ideally treated by separating the involved
surfaces, but as it is often seen in the genitocrural
surfaces in obesity this is rarely an immediately
practical measure. As it can be a mixed infection of
both C. albicans and S. aureus, sometimes mixed
antibiotic and fungicide creams can be most helpful
though hygiene advice is also important.
in the presence of a disseminated infection. DGI is
more common in women than in men.
Medical Issues
DGI presents in two ways:
1.as a bacteraemia (mild fevers, malaise, chills
and rigors) with the arthralgia/dermatitis syndrome (tenosynovitis and/or migratory polyarthralgia affecting usually more peripheral joints and/
or multiple painless macular, pustular or necrotic
skin lesions near affected joints and on the trunk
2.as a septic arthritis affecting no more than one or
two major joints (knee, elbow, ankle etc)
Because of the non-specific nature of the presentation
and the lack of genital symptoms, the diagnosis is
difficult and frequently missed (at least initially).
Investigations
Swabs for microscopy, culture and sensitivity for
Neisseria gonorrhoeae from all possible mucosal
sites depending on recent sexual history have the
best yield in confirming the diagnosis. In the absence
of discharge, first void urine and high vaginal swabs
for PCR for gonorrhoea are an acceptable alternative
Blood cultures for Neisseria gonorrhoeae should be
done but have only a poor yield
Joint aspirates sent for microscopy, culture and
sensitivity have a good yield when large joints are
involved with palpable effusions. If septic joint is
suspected argent orthopedic referral is necessary.
Swabs from skin lesions for microscopy, culture &
sensitivity have only a poor yield
Medical Management
Where DGI is suspected, the clinician should arrange
hospital admission because rarely gonococcal
meningitis, endocarditis or osteomyelitis can occur as
serious complications of DGI.
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After tests have been taken, as above, treatment
consists of:
Ceftriaxone (B1) 25 – 50 mg/ kgm IM or IV daily for
7 days
PLUS Azithromycin (B1) 1g po as a single dose for
possible chlamydial coinfection
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itches and Rashes
Patients should be managed as for an STI with
education about safer sex, contact tracing, and
advice to avoid sex until symptoms abate and
partners have been treated. Screening for other STIs
(especially syphilis and HIV) is important.
HIV & AIDS
Overview:
The Human Immunodeficiency Virus is a retrovirus
which was discovered by French and American
researchers in 1983, and an antibody test for HIV-1
was available the following year. A less common and
less virulent virus, HIV-2, is found mainly in West
Africa, and only isolated cases have been detected
in Australia.
HIV-1 has been the cause of millions of deaths, and
the United Nations estimates that as at the end of
2007, 33.2 million people are currently living with
HIV/AIDS. Some 2.5 million people contracted it in
2007, while 2.1 million died that year. It is likely that
this virus is responsible for more deaths than any
other pandemic in recorded history. Increasingly,
children and adolescents are being affected by this
epidemic.
The virus brings about its damage to individuals in
a variety of ways, the most obvious by causing CD4
lymphocytes (also known as T4, or T-helper, cells) to
be depleted. This leaves the immune system open to
opportunistic infections and tumours such as
Pneumocystis jiroveci (also known as Pneumocystis
carinii) pneumonia, oesophageal candidiasis,
cerebral toxoplasmosis, diarrhoeal diseases,
Kaposi’s sarcoma, and lymphomas. These, and
many other such conditions, are known as AIDS
– Acquired Immune Deficiency Syndrome.
The Situation in Australia
In Australia, most (>85%) incident cases occur in
homosexually active men, and the virus has not yet
broadly infiltrated injecting drug users and the more
general heterosexual community. It is estimated that
16,400 Australians were living with HIV/AIDS by the
end of 2006, including over 1,200 adult/adolescent
women. Seventy per cent of all those with HIV/AIDS
were receiving antiviral treatments for their
108 Darren Russell
infection.For the last few years, incident cases of
HIV have been rising in many parts of Australia and
this remains a cause for great concern. The number
of HIV infections diagnosed in Australia in 2006 was
998, an increase of 31% since 2000. Some commentators consider it possible that a generalised
epidemic, similar to that seen in the USA and some
European countries, may occur in the near future if
the incidence of HIV infection cannot be reduced.
The Asia Pacific region is an area of burgeoning
growth for HIV. In particular, Papua New Guinea,
Cambodia, Thailand, and Myanmar are all
experiencing high – and rising - rates of HIV.
Transmission from PNG, in particular, to the
Australian Indigenous communities of the Torres
Strait and Cape York is likely.
Transmission:
Medical Issues:
Clinical features and diagnostic considerations
Diagnosis of HIV infection depends on taking a careful history that seeks evidence of risk behaviour for
HIV, and physical examination, that looks for clinical
manifestations of immune dysfunction or neuropsychiatric conditions. A high index of suspicion should
be maintained because of the varied clinical picture
in HIV disease.
Diagnosis
Antibody testing has been the mainstay of testing for
HIV. People may be tested for many reasons, including:
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HIV AIDS
HIV can be transmitted in 3 ways:
1.Sexual intercourse (vaginal or anal)
2.Injection of blood, or through mucous membranes
contaminated with blood or body fluids
3.From infected mother to infant - in utero, perinatally, or through breastfeeding.
• As part of a sexual health check-up (including an
occupational screen for sex workers)
• Due to symptoms or signs of HIV/AIDS
• Antenatal screening (HIV testing should be
offered to all pregnant women)
• As part of an immigration screen
• Insurance medical testing
• Blood bank and tissue donation screening
• After occupational or non-occupational exposure
to HIV
• Prior to some forms of employment
Over the last 3 years, new generation, combined
antigen/antibody tests have become more widely
available, and these are now the tests that are performed when an HIV test is requested. Formerly it
could take up to 3 months for an antibody test to
become reactive after infection, but these new tests
can generally rule out HIV infection after a matter of
weeks from the date of infection. The new ‘window
period’ from acquiring HIV to testing becoming
positive is now less than 6 weeks.
Pre-test discussion is always a wise step to take
when ordering an HIV test on a patient. The consequences of a positive result for the individual, their
sexual partner(s), future relationships, as well as
future work and travel plans, are many. If an HIV test
comes back positive, enough time should be allowed
to give the result – face-to-face – in an unhurried
and supportive manner. Ongoing support and
counselling is likely to be required.
If a positive result occurs, a repeat specimen is
tested to be certain that the original result was correct.
In addition, baseline testing for a range of other
infections, including sexually transmitted infections
(STIs), is performed. A CD4 count and HIV quantitative RNA test (‘viral load’) are also done, and a baseline genotypic resistance assay is now also considered routine – the latter looks for any evidence of
resistant virus that may have been transmitted from
the HIV ‘donor’. Currently in Australia, it is
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estimated that 10-15% of transmissions involve a
resistant virus – this percentage does differ significantly around various parts of Australia, however.
The diagnosis of Primary HIV infection (PHI) can be
difficult, but the most important aspect is to suspect
the diagnosis in the first instance. A sexual history
and targeted physical examination can provide
clues, and such laboratory indicators as a lowered
(or raised) white cell count, atypical lymphocytes
in the blood film, and a liver transaminitis can point
to the diagnosis. Early in the course of PHI the HIV
antibody screening test may be negative, but the
combined antigen/antibody test has a much briefer
window period. Special tests such as detection of
the p24 antigen, and proviral DNA, should best be
ordered after consultation with the laboratory, and/
or an experienced HIV clinician. If clinical suspicion
remains, repeat HIV Ag/Ab testing is necessary.
Regular monitoring
Medical Management:
General principles of good management are as follows:
1.Promote preventive messages, as prevention is
the most effective public health measure.
Clinicians should pay particular attention to preventive education and counselling on HIV/AIDS
issues. Encourage testing for HIV in any patient
at risk because of their own, or a partner's, sexual
or needle-using behaviour. Antenatal testing is
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HIV AIDS
HIV infected patients should attend regular followups every 3 to 6 months, or more frequently if their
clinical or immunological condition warrants it. At
each visit, assess the patient psychologically and
reinforce the prevention of transmission messages.
Physical examination should look for evidence of
immune dysfunction, and haematological, biochemical, viral load, and immune function testing should
be arranged. If the patient is on antiretroviral therapy
discuss any difficulties with compliance.
particularly important in this context, as vertical
transmission can nearly always be averted
2.Provide regular follow-up for clinical assessment,
monitor CD4 counts and viral load, and arrange
psychological support as required – depression is
a common sequelae of HIV infection
3.Arrange access to combination antiretroviral
drugs when required (see below)
4.Arrange prophylaxis for some common
opportunistic infections as appropriate
5.Keep a high index of suspicion for opportunistic
infections in immunosuppressed patients and
treat with appropriate antimicrobial agents on
diagnosis
6.Look for secondary cancers and other AIDS
related conditions and treat as appropriate
The decision to commence treatment with the newer
antiretroviral agents can be a difficult one. We are
now moving towards a model of care for HIV/AIDS
similar to that for diabetes – we cannot cure these
conditions, but current treatments, if adhered to
carefully, can prevent most of the illnesses
associated with these conditions. In other words,
HIV infection can now be conceptualised as a
chronic, manageable illness for many of those living with the virus. A normal, or near-normal lifespan,
may be possible.
The treatment of PHI remains controversial. Apart
from symptomatic treatment of the viral infection,
the place of antiretroviral therapy is still being
researched. There are no strong data to support
routine treatment of people with PHI, though some
clinicians will offer treatment. Moreover, if treatment
is offered, there are no data regarding the length of
such treatment. It is currently recommended that
antiretroviral treatment be offered in the context of a
clinical trial, and not done routinely.
Treatment is usually commenced when the CD4
count drops to 350-500 cells/µl (a usual level for a
healthy adult is 450-1200 cells/µl). Sometimes treatment will commence at a higher CD4 count, usually
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if the person is symptomatic with HIV, or pregnant.
Antiretroviral treatment during pregnancy is now
routine, and can reduce the mother-to-child
transmission rate to <1% - without antiretroviral
treatments or caesarean section the rate is
approximately 25%.
The classes of drugs that are currently available in
Australia include:
• Nucleoside (and nucleotide) analogue reverse
transcriptase inhibitors (NRTIs)
• Non-nucleoside analogue reverse transcriptase
inhibitors (NNRTIs)
• Protease inhibitors (PIs)
• A fusion inhibitor
• An entry inhibitor
• An integrase inhibitor
Excellent compliance is required with these
therapies. If doses are missed, resistance by the
virus to the various medications occurs, rendering
the treatments much less effective. In addition,
people with HIV are more likely to have other health
issues that impact on their health. Some of these
include: a higher rate of tobacco and alcohol misuse,
higher rates of mental illnesses, and higher rates of
unemployment and poverty.
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HIV AIDS
The treatments often produce side-effects which
limit the ability of patients to take them effectively,
Some side-effects include:
• Nausea and diarrhoea
• Skin rash
• Lipoatrophy (loss of fat from the limbs and face)
• Hyperlipidaemia
• Raised liver transaminases and bilirubin
• Impaired glucose tolerance and diabetes
HIV Prevention:
Current:
• Condoms and community health education,
focussed on at-risk individuals and communities
have consistently been shown to be effective in
the prevention of HIV
• Needle and syringe programs, along with methadone and buprenorphine substitution programs,
are arguably some of the most cost-effective
public health technologies ever introduced
• Post-exposure prophylaxis (PEP) is a combination
of 2 or 3 antiretroviral agents given within 72
hours of a significant exposure to HIV (usually
sexual or occupational). The medications are
taken for 1 month and greatly reduce the risk of
acquiring HIV
• Mother to child transmission can be prevented by
using antiretrovirals for the mother throughout
pregnancy, and for the baby for a short period
after birth. Avoidance of breastfeeding is also
advised in resource-rich settings such as Australia
• Male circumcision – uncircumcised men practising vaginal intercourse and insertive anal intercourse are several-fold more likely to contract
HIV than those who are circumcised. Trials in
high-prevalence parts of Africa have shown that
circumcision reduces the rate of HIV infection
in males by 60 to 70%, and circumcision is now
advocated in high-prevalence populations
• Early recognition and diagnosis of primary HIV
infection combined with counselling the index
patient and contact tracing of partners. It is
estimated that about half of all HIV infections
are due to infection by someone who has been
recently infected. Counselling the index patient in
this setting could have great benefits in reducing
onwards transmission.
Future:
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• Vaginal and anal microbicidal agents that can
be introduced by the person having sex (without
requiring their sexual partner’s permission) are
undergoing trials
• Pre-Exposure Prophylaxis (PREP) – HIV medications taken prior to intercourse may reduce the
risk of HIV infection for those at high risk. Trials
are ongoing
• Increased emphasis on testing for, and treating,
other STIs such as Chlamydia trachomatis,
gonorrhoea, syphilis, and genital herpes - all of
which increase the risk of HIV acquisition and
transmission. Trials looking at suppressing HSV-2
in order to prevent HIV transmission are underway, but early results appear to be disappointing.
References and further reading
www.unaids.org/en/ accessed 18 June 2007
www.ashm.org.au
1
• The Australasian Society for HIV Medicine is an
excellent source of educational materials and
information for health professionals
www.afao.org.au
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HIV AIDS
• The Australian Federation of AIDS Organisations
has resources for people living with HIV/AIDS,
and for those at risk, including links to other
reputable websites around the world
11
EMERGENCY PRESENTATIONS
Overview:
The following presentations will be dealt with in
this chapter:
1.
UNPROTECTED SEX
2.
ADULT SEXUAL ASSAULT
3.
COMMUNITY NEEDLE STICK INJURY
Unprotected sex
Anal, vaginal and oral sex performed or received
without a condom or in the event of condom failure
(eg slippage or breakage) may generate anxiety.
The possibility of sexual assault should be considered
with all presentations of unprotected sex. In the case
of sexual assault involving a child, urgent referral
to a doctor with experience in child abuse cases is
warranted. You may also need to make a mandatory
report that is required by the legislation in your jurisdiction.
Common concerns revolve around:
The acquisition of a sexually transmitted infection,
especially HIV infection.The type of sexual contact
(e.g. non-penetrative or penetrative - anal,
vaginal or oral sex) is important, as both receptive
unprotected anal and vaginal intercourse are
many times more risky for HIV acquisition than
other sexual activities
Post exposure prophylaxis for HIV (PEP) should be
offered up to 72 hours after unprotected sex where
the risk is assessed to be sufficiently significant for
the benefit gained by taking PEP to out-weigh the
potential harm or side effects of the medications (for
example unprotected receptive anal intercourse for
men who have sex with men). Consult local state or
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territory guidelines for PEP through specialist sexual
health centres or infectious disease medical units of
tertiary hospitals.
Enquire if the partner has any signs or symptoms of
a STI and test and treat appropriately. E.g. Azithromycin if a male partner has a urethral discharge
The risk of pregnancy and emergency contraception. Emergency contraception may be offered up
to 120 hours following a sexual assault or
unprotected sex, in situations where pregnancy is
a risk. A single dose of 1.5mg of Levonorgestrel
(B3) po should be given.
Any woman who is not on regular contraception,
does not wish to become pregnant and has had
genital exposure to semen should be offered
progesterone-only emergency contraception.
There are no known medical contra-indications to
progesterone-only emergency contraception except
that it is not indicated in confirmed pregnancy or
breast cancer.
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EMERGENCY PRESENTATIONS
Emergency contraception works best when given
immediately after unprotected sex. Studies show
that it is effective when given up to 120 hours after
unprotected sex. In Australia this medication is
available as pharmacist prescribed medication.
A single dose of 1.5mg of Levonorgestrel (B3) po
should be given. The patient should be aware of the
following:
The efficacy of emergency contraception decreases
with time.
Should their next menstrual period be more than 3
weeks late following emergency contraception,
they need to undergo a pregnancy test. A safeguard is to recommend a pregnancy test in all
women 3 weeks after emergency contraception.
There is a failure rate with emergency contraception.
Emergency contraception does not protect against
STIs.
Ongoing contraception may be required.
Adult Sexual Assault
People who have been sexually assaulted may
present to a variety of services. 1 in 5 women and
1 in 20 men have experienced sexual coercion; this
is often a helpful piece of information to people who
have been sexually assaulted. Medical practitioners
are often consulted following sexual assault; a nonjudgemental and non-blaming attitude on the part of
the health care professional is essential.
There are urgent medical and forensic issues that
may need to be addressed in cases of recent sexual
assault (less than 1 week).
An explanation of all of the issues is useful as well as
details of appropriate referral.
Details of a full range of sexual assault services in
Australia that provide comprehensive care can be
accessed online at: http://www.famsacaustralia.org.
au/
Medical Issues:
It is imperative that management of life threatening
injuries take precedence over forensic evidence
collection.
The pertinent issues related to sexual assault are:
Injury assessment: particularly exclusion of serious injury.
The risk of pregnancy
The risk of bacterial sexually transmitted infections
The risk of blood-borne virus transmission
Patient safety issues
Psychological issues
Forensic issues
Legal issues.
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History:
The important factors to elicit from the history are:
Has the victim suffered any life threatening
injuries? This will dictate the need for medical care
in an appropriate setting.
When did the assault occur? This will have a
bearing on any STI prophylaxis that may be offered,
as well as the value of collection of forensic
evidence.
Will this person be returning to a safe environment? The patient must not be sent back to a
dangerous environment and an appropriate referral
must be made to ensure their safety.
Does this person have adequate support?
Previous trauma increases the chance of ongoing
psychological stress.
Examination:
Head to toe screening for the presence of any
injuries with appropriate documentation should occur.
This can be done in sections and prevents the need
to fully expose the patient during the examination.
Documentation of the injury should include: type, site
(from a fixed body landmark), size, shape and the
involvement of anatomical structures
Injuries may not become obvious for a few days after
the examination, it is important to explain this to the
patient; if they are reporting to the police they should
report any new injuries to them for documentation.
Investigations:
Screening for bacterial sexually transmitted infections.
Penetration of an orifice requires screening for
bacterial STIs from that site e.g. oro-pharynx, vagina,
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EMERGENCY PRESENTATIONS
Note: Non-genital injury is often more suggestive of
non-consent than genital injury in adults.
12
anus and urethra. The time interval between the
exposure and testing should be noted and retesting
should occur if initial collection is within the window
perod. (Assumed to be approximately 1 week for
PCR based testing)
Screening for blood borne viruses and syphilis. A
blood test should be taken for HIV, Hepatitis B
serology, Hepatitis C and Syphilis. These are
baseline tests and if positive, in most cases, will
indicate pre-existing infection.
If prophylaxis is given, baseline testing should be
performed as most positive results are from preexisting infection.
Contact tracing should be sensitively initiated in the
event of a positive result.
Medical management:
Injury assessment: Particularly exclusion of serious
injury. Check that there is no history of head injury,
strangulation or other serious injury. If this is the
case referral to the nearest emergency department is
warranted.
Tetanus prophylaxis should be considered in cases
where the skin has been broken. It may be required
if the person has not been previously vaccinated
(also consider the need for conjunct tetanus immunoglobulin) or has not had a booster in the past 10
years.
The risk of pregnancy: Assessment and prophylaxis.
Emergency contraception may be offered up to 120
hours following a sexual assault or unprotected sex,
in situations where pregnancy is a risk. A single dose
of 1.5mg of Levonorgestrel (B3) po should be given.
The risk of bacterial sexually transmitted infection:
Assessment and prophylaxis. This includes
Chlamydia, gonorrhoea, trichomoniasis, and syphilis.
Local prevalence data and the ability to follow up the
patient will guide the use of prophylaxis.
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The following prophylaxis may be used:
Chlamydia: Azithromycin (B1) 1g po stat
Gonorrhoea: Ceftriaxone (B1) 500mg IM stat
Syphilis: Benzathine penicillin (A) 1.8gIM stat
Trichomoniasis: Metronidazole (B2) 2g po stat
The risk of blood borne virus and syphilis transmission: Assessment and prophylaxis. This includes
HIV, Hepatitis B, Hepatitis C and syphilis. Baseline
testing may be performed; it should be noted that this
will demonstrate the presence of pre-existing infection
in most cases of recent sexual assault.
HIV
The healthcare practitioner should consider HIV
post exposure prophylaxis. It may not be required
or indicated. Further advice may be sought from
a specialist Sexual Health Physicians or Infectious
Diseases Physician.
Factors that should be considered are:
The risk of the assailant being HIV positive e.g.
known HIV positive, from a high-risk country, from a
high-risk group
In cases of male to male sexual assault
In cases where multiple assailants are involved
At the patient’s specific request (after appropriate
information-giving about pros and cons in that
patient’s situation)
The choice of HIV post exposure prophylaxis should
be discussed with a local HIV medication prescriber
and tailored according to the situation.
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EMERGENCY PRESENTATIONS
The type of sexual contact (e.g. non-penetrative or
penetrative - anal, vaginal or oral sex) as receptive
unprotected anal and vaginal intercourse are many
times more risky for HIV acquisition than other sexual
activities
Hepatitis B
In people who are not immune to Hepatitis B:
Hepatitis B vaccine and hepatitis B immunoglobulin
should be offered. This should be given as soon as
possible and in an appropriate medical environment
with resuscitation facilities.
Hepatitis C
At present there is no available prophylaxis for
Hepatitis C.
The person’s immediate safety should be
assessed.
Useful questions to ask patients are:
Do you feel safe returning to your home at the
moment?
Do you have people around you who you could talk
to about this and who would offer support?
If the person does not feel safe a sexual assault
agency will be able to help with this issue. Other
services for emergency accommodation may be
available in your jurisdiction.
Psychological issues
Rape Trauma Syndrome and Post Traumatic Stress
Disorder are psychological sequale that may be
associated with sexual assault and in these cases
referral is important. Specific sexual assault
counselling services are available around Australia
and are listed on the website above.
Forensic issues: Forensic examination may only be
carried out with the permission of the person.
Referral to an appropriately trained medical
practitioner for this examination is preferable and
should be offered.
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A list of the agencies with access to forensic medical
officers can be found on the FAMSAC Australia
website above. A forensic medical examination may
be performed up to the following time limits:
Oral penetration Anal penetration
Vaginal penetration 48 hours
48 hours
1 week
Other legal issues. A full set of contemporaneous
clinical notes must be made by the healthcare
professional. These include:
Documentation of referral to other staff or agencies.
Documentation of consent for any forensic procedure
to be carried out.
Specific protocols are available in each jurisdiction to
direct the forensic management of victims.
Follow Up
All of these issues should be readdressed at follow
up consultations. Retesting should be undertaken if
the person was initially tested in the window period
for any infections.
Needle stick injuries in the community and the workplace generate much anxiety and media concern.
The anxiety generated in the patient, their friends
and family can be profound and prolonged due to the
necessity for retesting. (This may be up to six months
following the injury). Safer sex is also recommended
during this period, which can also add to the anxiety.
Appropriate support and counselling is an adjunct to
any medical treatment.
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EMERGENCY PRESENTATIONS
Community AND WORKPLACE
Needle stick injury
12
Immediate action:
Immediate care of the wound, washing with clean
water is recommended.
Tetanus prophylaxis as above.
Baseline testing for HIV, Hepatitis B and Hepatitis C
should be taken. This sample must be taken with the
consent of the patient. Testing for syphilis may be
warranted in some high prevalence populations
(e.g. remote Aboriginal communities).
Source person testing (if known), may be carried out.
Ideally a separate health care practitioner should be
involved and this testing should occur with the full
consent of the source person. Consent to release
the source person’s results must be obtained if these
results are to be given to the injured person’s practitioner. A decision about offering prophylaxis in these
situations must be made with full awareness about
the limitations of the tests and window periods.
Prophylaxis for HIV and Hepatitis B. Immense
anxiety about contracting these infections often
occurs. Advice should be sought from local specialist
services with regard to local prophylaxis policies.
Reassurance, where clearly any risk is exceedingly
small (e.g. as in a needle stick injury from a discarded needle left lying about in the environment).
It is helpful for the patient (or parent or guardian) to
know that there has been no case of HIV transmission EVER documented from such a needle stick
and only a very small number of cases of hepatitis
C worldwide. While there is a risk from hepatitis B in
such a situation, prophylaxis against hepatitis B is
readily available. (see above).
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History:
The following information is required to determine
decisions about ongoing management:
Details of the injury: time, type of implement and extent of contamination, any first aid measures that have been undertaken and details of thesource
person if they are known,
Patient concerns: Addressing concerns aids in the
subsequent management of the patient
Examination:
Examination of the injury site in order to assess and
document the following:
Nature of the injury: type, site (from a fixed body
landmark), size, shape and the involvement of
anatomical structures
Any evidence of secondary infection. Appropriate
medical management should then be initiated.
Investigations:
Screening for blood borne viruses (HIV, Hepatitis B,
Hepatitis C serology ). These are baseline tests and
if positive, in most cases will indicate pre-existing
infection.
Follow up testing: testing for HIV may be carried out
at 6 weeks, 12 weeks and it should be repeated at
24 weeks if HIV post exposure prophylaxis is given.
Hepatitis B and Hepatitis C testing may be carried
out at 4, 12 and 24 weeks.
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EMERGENCY PRESENTATIONS
Baseline testing and prophylaxis may be offered on
a case-by-case basis as is the case in sexual assault
(see above). Referral for counselling may be warranted in cases of anxiety to discuss safer sex practices.
SEXUAL HISTORY TAKING & PUBLIC
HEALTH ISSUES
Overview:
Sexual history taking:
A risk assessment of sexually transmissible
infections (STIs) and blood borne viruses (BBVs)
is not solely for the sexual health physician, sexual
health nurse, or sexual health counsellor. In any
aspect of medicine, health care providers may see
patients who have diseases or psychological
conditions directly linked to their recent or past
sexual or risk behaviour.
At the beginning of the consultation it is important
to introduce the topic of taking a full sexual and risk
assessment history to the client with a simple
explanation of risk assessment needs:
E.g. “I am going to ask you about your medical
history including questions about your sexual history
to assess whether you have been at risk of sexually
transmissible infections (infections that are passed
on from one person to another, via some form of
sexual activity) or blood borne viruses (viruses that
can be passed from one person to another via blood,
like Hepatitis and HIV, for example). Is that OK? If
you don’t understand something I say, please let me
know so I can explain it better for you. Similarly, if
you say something that I don’t understand, I’ll ask
you to explain what you mean too.”
Something else you, as a health practitioner, may
need to consider in relation to discussing sex with
clients is to recognise your own feelings and attitudes
that may influence the interaction. E.g. consider your
own values and belief systems regarding particular
sexual health issues or activities.
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13
Taking a standard medical history from a patient who
may have acquired an STI is no different from historytaking in other fields of medicine, and only a few
points need to be made here.
Non-technical language:
For any client who may have acquired an STI/BBV,
visiting a health care provider may be daunting. The
client may be unfamiliar with technical or medical
jargon such as ‘vulva’ and ‘urethra’. Try to keep
language simple, avoiding medical jargon and
explain terminology used if necessary. Similarly, as
a health care provider you may be unaware of
colloquial terminology - if you do not understand a
term the client is using make sure you ask them for a
definition. You may need to adapt to the client’s level
of understanding and use language that is
appropriate and that you feel comfortable with.
Specific questioning
about symptoms:
It is important not to presume that a presenting
genital symptom is the only problem as more than
one problem may be present. Ask directly about each
symptom in turn.
Direct questioning about genital symptoms should
include nature of the present problem, timing, natural
history, any other associated symptoms, severity and
any treatments they may have tried so far. If the
person states they have no symptoms ensure that
you have covered the following:
Dysuria
Vaginal/urethral/rectal discharge/symptoms
Pelvic pain
Dyspareunia
Abnormal bleeding (female)
Testicular symptoms (males)
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SEXUAL HISTORY TAKING & PUBLIC HEALTH
The Medical history in Patients at Risk of
STIs/BBVs
Itches/lumps/bumps/rashes
Sores or ulcers
Anything else noted or unusual - headache, fever,
lymphadenopathy etc
General history:
1.Drug allergies and recent/current oral or topical
medications:
In STI management all the above are particularly
relevant as they could mask symptoms or
treatment options. Make sure you ask about self
-medication as well as clinician directed therapy.
2.Past medical history
3.Vaccination history (particularly Hepatitis A and B,
Rubella and HPV for young females)
4.Previous history of STI/BBV:
It is important not to miss information regarding
previous STIs/BBVs and treatment. Ask about
previous history of STI where a sexual partner
was not treated, and there is the possibility of
re-infection
5.Risk BBV
Also enquire about risks not necessarily sexual:
- Piercings, tattoo, surgery, blood transfusion or vaccination (especially in an environment or country where equipment may not have been sterile. E.g. a tattoo gained in prison)
- Blood transfusion in Australia before 1990
- IVDU
- Partners that may be at high risk E.g. partner who is IVDU, from high prevalence countries
Asking about previous risks, testing and treatment
of STIs/BBVs, as well as any current symptoms, is
an easy and relatively painless way to lead into the
patients’ sexual history ….”now as I mentioned
earlier I am going to ask you more personal
questions about your sex life..”
Health care providers proficient at taking a standard
medical history may feel a lack of confidence in
dealing with sexual health matters. This is especially
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13
Every practitioner has an individual style of taking
a sexual history, and there are no hard and fast rules.
The health care provider who is able to create a
comfortable atmosphere with a relaxed and friendly
approach at the start of the consultation is at a
greater advantage. However, for those to whom this
style does not come naturally, an adequate sexual
history can still be taken, provided they have the
will to tackle the task and have a non judgmental
approach to their patient.
There are just a few tips that may help:
Do not presume a patient’s sexual orientation
Do not presume the gender of a patient’s sexual
contact
An easy question to open with is to ask a patient
“when did you last have sex?” This is a relatively innocuous question and can then lead on
for you to ask, “Who was it with? Was it a regular
partner, someone you know or someone you had
just met? Male or female? What country are they
from?”
Do not use expressions or ask direct questions that
may label patients. For example, some men who
have had sex with other men do not classify
themselves as gay or bisexual. So to establish
any same sex activity a better approach is to ask
whether the patient has “…ever had sexual
contact with a man?” “…ever had sexual contact
with a woman?”. If they say “yes”, ask “when was
the last time?” and again establish type of sexual
activity and whether any barriers such as
condoms or dams were used.
Remember that a patient may be at risk of STIs
through the activities of a regular or current
sexual partner, not because of his or her own
sexual behaviour. Some patients may find this
difficult to articulate, so gentle questioning about
the current partner’s sexual health is always
necessary.
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SEXUAL HISTORY TAKING & PUBLIC HEALTH
so when there are age, gender, race, sexuality or
cultural differences between patient and provider.
Ask patients about their knowledge of STI/BBV
transmission and safer sex practices, including
the use of condoms or other prophylactic measures. This is an excellent opportunity during the
consultation to take a little time to provide some
preventive education. It may be useful to make
patients aware that condoms come in different
shapes and sizes, as well as the non latex male
condom and the female condom.
So that correct tests can be taken from the appropriate sites, it is important to ask about any
insertive or receptive oral and anal sex, as well
as vaginal intercourse (and if appropriate, mutual
masturbation), and to ask whether patients used
condoms or other barrier methods for specific
forms of sexual activity.
For females it is pertinent to ask about last normal
menstrual period. If at risk of pregnancy (ie hetero
sexual sex) whether they have been pregnant in
the past, possible pregnancy now – any relevant
symptoms? It may be relevant to discuss doing
a pregnancy test. It is best to go by the edict that
all females of reproductive age are pregnant until
proven otherwise - then a pregnancy will not be
missed!
Evidence clearly demonstrates that patients do not
mind being questioned about their sexual health, as
long as they do not feel ridiculed and they understand why they are being asked personal questions.
If however you do find it difficult in obtaining the information from the patient, stop and assess why the
client is reluctant to divulge any of this information. It
could be due to cultural or gender issues or previous
negative experience during a sexual health
consultation. It is their choice to divulge or not to
divulge and pressuring the patient will not make this
better. You may have enough information to start the
examination. During the examination you may be
able to explain more what you see and ask a few
relevant questions related to this.
The impression to convey to patients is that it is safe
to talk about sexual behaviour and sexuality because
it is a normal part of any professional consultation
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13
An accurate medical and sexual history is
an essential prerequisite to an appropriate
physical examination and to subsequent
investigations for STIs/BBVs.
Examination:
Once again it is important to ensure privacy and
comfort to clients when examining them. When
asked to get undress – specify lower half or upper
half - it is best to not have them fully unclothed all at
once. Also avail them of a covering sheet so they feel
modestly covered before the examination begins.
Symptomatic patients often delay attending out of
fear or embarrassment. Young people may delay
seeking help for fear of parents or carers being
informed.
The following are guidelines to best examination
practices:
Privacy: It is important to ensure privacy for the
patient, and to carry out the history, examination and
testing in as gentle and sensitive a manner as
possible, and free from interruptions.
Alleviating fears: An STI examination may be
uncomfortable or embarrassing for many patients,
so the health care provider must make every effort
to reassure patients by making sure they understand
Alison Duffin & Siobhan Bourke
131
SEXUAL HISTORY TAKING & PUBLIC HEALTH
and important in their overall management. Whatever
way a sexual history is obtained, the patient must
feel assured that details given to health care providers
are regarded as being in strict confidence and will not
be released without permission to any third parties.
Maintenance of confidentiality is the cornerstone of
sexual history taking. There is one caveat to this and
not just with consultations around sexual health
- if the client tells you about issues endangering their
lives or the lives of others there may be justification
to break confidentiality and report to the appropriate
authorities- e.g. ongoing child sexual abuse or
suicidal ideation.
what is going to be done, and are as relaxed as
possible before starting the examination. This is not
only consistent with basic human rights and dignity,
but also an important public health measure, as
present and future patients will only cooperate and
attend if they are treated in a non-judgmental and
considerate manner.
Good light: A good light source is mandatory. It is
best if the light is moveable; head lamps are often a
good substitute for a movable wall or floor lamp.
Good preparation: Ensure that an assistant has the
necessary equipment (slides, swabs and spatulas)
ready or, in the case of a single-handed practitioner
that they are within easy reach. Good genital
examination and testing is as much a matter of forethought and planning as is sensitivity to the patient’s
feelings and needs. Metal instruments should be
warmed in warm water before insertion and, in the
case of
vaginal speculae, this will also provide enough
lubrication to minimise discomfort. Artificial lubricants
may interfere with Pap smear interpretation, and may
inhibit the growth of some STI pathogens so use
sparingly when needed.
A careful examination is an essential part of the
assessment of patients concerned about STIs.
The genital examination is an essential prerequisite
to interpreting results of many laboratory tests for
genital infections.
Examination is the only method available for
detecting some STIs such as genital warts.
The specifics will be covered in individual chapters.
General management:
The general principles of management of patients
with STIs are as important as prescribing correct
antimicrobials. Follow these guidelines:
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13
Sexual activity: Patients must be advised on sexual
intercourse in the future. Some conditions require
restraint from sexual intercourse until a medication is
finished and some require protection of all partners in
the future- see specific chapters.
Partner notification: (see later section for more
detail): Patients are often their own best contact tracers
and they should always be made aware of their
responsibility to ensure that recent sexual partners
are checked and treated. Similarly, the practitioner’s
responsibility does not end with deciding the correct
treatment for the patient. In difficult cases or where
time, experience or cross-cultural issues make
contact tracing by patient or healthcare provider
impossible, the practitioner should seek the help of
Indigenous health workers or trained local Health
Department contact tracers/counsellors. The nearest
public sexual health centre or STI clinic will be able
and willing to assist. A
Follow-up: In principle, patients should always be
followed-up after completion of a course of treatment
for repeat tests to ensure cure, though this may
not always be possible in practice. When a course
of treatment rather than a single dose has been
prescribed, follow-up is important to check
compliance. For viral infections such as herpes, HIV,
and hepatitis B, follow-up appointments allow
patients to ask further questions and to access
counselling and support.
Alison Duffin & Siobhan Bourke
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SEXUAL HISTORY TAKING & PUBLIC HEALTH
Information: The patient should be told the specific
diagnosis. A brief description of the natural history of
the disease, treated and untreated, should always
be given. Particular fears regarding future fertility,
the possibility of recurrence, transmissibility and HIV
infection should be addressed.
Prevention: Every STI case or inquiry offers an
opportunity for preventive education. The principles
of prevention do not include taking a judgmental or
moralistic stance. They do require an assessment
of patients’ lifestyles, beliefs, cultures, past sexual
practices and difficulties they may encounter in
trying to reduce their risks. The issues discussed
in counselling a young urban heterosexual woman
will vary from those covered when dealing with an
older homosexual man or a young aboriginal from a
remote community. However, the object of all counselling sessions is the same, namely to encourage
patients to eliminate or at least decrease their risk of
future infection.
Basic points:
1.Abstaining from penetrative sexual intercourse
will substantially reduce the risk of contracting or
passing on STIs. If penetrative intercourse does
occur, condoms and water-soluble lubricant will
reduce the STI risk. Patients should be instructed
in condom use, and told where affordable condoms
and lubricant can be obtained, and how to negotiate with partners to ensure that condoms are
used. Men can practice using condoms during
masturbation, and men and women should carry
condoms or at least have them within easy access.
2.Mutual fidelity of uninfected partners is one of the
best methods of preventing STIs. Health workers
should encourage sexual partners to communicate their sexual needs to each other, and assist
them in establishing a relationship where honesty
about sex prevails. This may be more conducive
to reducing risks of STIs than merely advocating
a monogamous relationship, which may be so in
name only.
3.While reducing the number of sexual partners
may appear, logically, to reduce the risk of
contracting or passing on STIs, there is obviously
a difference between a gay man who continues to
have a large number of casual sexual partners
but who scrupulously maintains safe sex
practices with all of them, and a young woman
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13
In counselling for prevention of STIs, health care providers must be always conscious of the link between
sexually transmissible and blood borne infections.
Advice about protected sexual intercourse must be
accompanied by advice about the risks of sharing
equipment during occasional, recreational, or wellestablished injecting drug use. Patients at potential
or actual risk must be advised where clean injecting
equipment can be obtained, and instructed about
local operation and siting of needle availability
programs.
Future prevention is as important as current
treatment. Follow-up is essential for promoting
preventive practices. The risk of acquiring STIs is
related to unprotected sexual intercourse, as well
as number of partners.
Partner Notification:
As well as the index patient, at least one other person
is involved. Partner notification (contact tracing) is a
necessary but sensitive part of management.
Alison Duffin & Siobhan Bourke
135
SEXUAL HISTORY TAKING & PUBLIC HEALTH
who has a series of monogamous relationships
of six months duration each (serial monogamy),
but who is never able to get any of her partners
to use condoms. Over a given time, the young
woman is at considerably more risk of contracting
an STI, even though she has fewer partners than
the gay man.
4.Avoiding sexual contact if prospective partners
suspect they may have contracted an STI is a
sensible measure. Encouraging people who have
had unprotected sex to attend for checkups
before undertaking any new sexual relationship
will substantially reduce risk of transmission. This
places a responsibility on health authorities to
ensure that facilities for performing STI checks
and dealing with STIs are easily accessible to
those who need these services. The World Health
Organisation has recognised that provision of
better and more easily accessible facilities for
dealing with the traditional STIs will do much to
prevent more people becoming infected with HIV.
An assurance of confidentiality and explanation of
the reasons for contact tracing are necessary for
patient cooperation. In some cases when contact
tracing is going to put the index case at risk of harm
a clinician needs to weigh up the risks. A discussion
with the Health Department contact tracers will assist
in how to go about these difficult situations. It is
important to “do no harm”.
Some hints follow:
An attitude of trust will facilitate discussion of the
infection and the need to contact partners, and
make the patient more likely to give out sensitive
information.
Basic information, such as the frequency of
asymptomatic carriage, will encourage patients to
contact partners. Have literature on hand. Multilingual pamphlets are available from major sexual
health/STI centres.
‘Contact’ letters stating diagnosis and management, which the patient can hand to his/her
partner (in turn to pass on to his/her health care
provider), are useful.
The index patient is the ideal person to contact
partners, but this is sometimes not practical or
culturally possible, and local health workers or
Health Department contact tracers may need to
be involved. Useful information to hand on to
contact tracers includes: name, age, address,
phone numbers, hair colour, accent, race, distinguishing marks and whether he or she was a
sex worker in the sex industry. For sex workers,
information should be obtained about the escort
agency or place of work, when the patient used
the agency’s services and the worker’s ‘working’
name.
If the patient cannot remember details, enquire
whether any of the patient’s friends could give
more details or whether the patient could go back
to the meeting place and make enquiries.
Psychological issues such as guilt, relationship
problems or sexual identity may inhibit the patient
in giving information. Recognise your own
prejudices and take into account any negative
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13
Alison Duffin & Siobhan Bourke
137
SEXUAL HISTORY TAKING & PUBLIC HEALTH
feelings you may have towards certain groups
such as sex workers, gay men and injecting drug
users. Contact the nearest sexual health or STI
centre if you feel uneasy dealing with the situation
or would like help or advice.
If making a referral to the contact tracers in your
local Health Department it is often best that the
index person is not known to them so they can
very simply maintain confidentiality. This is often
not possible with HIV as they will need to get the
cooperation from the Index person to assist in
thorough contact tracing. Ask advice from them
about this, they will instruct you well.
Young people, confidentiality &
access to medical advice / treatment
in Australia
Overview:
Young people need to feel comfortable at their first
point of contact with a health service, and this is from
the front line person (receptionist) right through to
the doctor. Particularly important issues pertinent to
young people accessing health services are privacy
and confidentiality, as well as other access issues
such as: Bulk Billing, cost of medications, timing of
clinics, waiting times and appointment booking
procedures versus drop in clinics.
The above issues should be considered when
offering services for young people.
In Australian Law:
Each State and Territory has different legal age of
sexual consent laws, and medical practitioners
should be aware of these in the State or Territory
in which they are practising
Anyone under the age of 18 is considered a minor.
Once a person reaches the age of 18, they are
considered an adult, and this is when parental
guardianship stops. If the person is 18 years or
older, it is assumed that they have the intellectual
capacity or “competence” to understand and consent to their own medical treatment without a
parent or guardian’s consent/permission. A medical
practitioner may decide that, due to certain factors,
a person may not have the intellectual capacity to
consent e.g. in the case of a severe intellectual
disability.
A person under the age of 18 years, may be able
to consent to their own medical treatment if the
medical practitioner decides that they have the
level of maturity and understanding to consent
without a parents’ or guardians’ consent or
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Siobhan Bourke & Alison Duffin
However, confidentiality can be broken if the
medical practitioner knows or believes that the
person is at ongoing risk of harm. If confidentiality
is to be broken then this should be explained to
the young person before doing so (although this
may not always be possible, and in this instance,
the reason for not informing the young person
should be clearly documented). This is known as
mandatory notification and the process in each
State and Territory is different and it is therefore
Siobhan Bourke & Alison Duffin 139
14
Young people
permission. This is known as “the mature minor
principle.”
A medical practitioner must ask certain questions
of young people who are seeking sexual health/
contraceptive advice and treatment to ascertain
whether the young person is “competent to
consent to medical advice and treatment without
parents’ or guardians’ consent. These questions
are based on guidelines known as the “Fraser
guidelines” from the UK and have been endorsed
by the Australian High court, and are known as
“the mature minor principle”. This principle is
based on the young person’s cognitive ability
to consent, and is not based on the age of the
young person. An assessment of understanding
of the details of the treatment, the risks, benefits
and side effects and also the consequences of
not having the treatment must be explained by
the medical practitioner and they must be satisfied that the minor has full understanding of
these consequences. It is only once the medical
practitioner is satisfied, that the practitioner can
provide the treatment to the competent minor.
Good assessment tools include a HEADSS
assessment (see below) to give understanding
of the young person and organizational aspects
of their life. Asking the young person to explain
what it is they understand of the treatment once
the health care provider has explained the treatment allows the health care provider not only to
know that the treatment will be taken correctly
but that the young person has a full understanding. It is essential to document this competency.
Young people have the same right to confidentiality as adults do
important that every medical practitioner be
aware of their mandated requirements in the State
or Territory under which they are practising.
HEADSS assessment (Adapted from J.M. Goldenring and E. Cohen (1998) Getting into adolescent heads Community Paediatrics, July: 75-80)
HEADSS assessment is a tool to assess the young
person as a whole – it is recommended to do in all
consultations with young people including sexual histories. It can often give a better understanding of the
young person and enable the health practitioner to
assess their competency.
HEADSS is a mnemonic for
Home, Education/Employment, Activities, Drugs,
Sexuality and Suicidality/self harm or depression.
It is a reminder system to ask about:
Home: who are you living with, are you happy there,
are you safe there? etc
Education or employment: are you in school/
working or both, how are you grades going, are you
enjoying it, full time work, part time, looking for work?
etc
Activities: what do you do at other times? Hobbies,
sports? Friends? etc
Drugs: do you use alcohol, other drugs, how often?
With whom? Alone? etc
Sexuality: the health care provider will have gleaned
some of this from the sexual history taken but is the
young person comfortable with their sexuality, have
they been attracted to the opposite sex, the same
sex and are they feeling ok about this?
Suicidality and Depression: this too may have been
broached in the medical history, but if not, have they
had history of depression, low moods, any self
harming? Any suicidal thoughts? etc
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Siobhan Bourke & Alison Duffin
There are long lists of the types of questions that can
be asked and these guidelines have not attempted to
reproduce these. It is best to ask questions that the
health care professional is comfortable with, that are
not prying in nature but that allow a good assessment of the person as a whole.
There is not always time for an extensive history but
it is recommended, when giving a new treatment to
a minor, that a full sexual history, medical history,
HEADSS assessment and treatment discussion is
had to ensure that the competency can be obtained
and clearly documented.
Siobhan Bourke & Alison Duffin
141
14
Young people
If the practitioner is unsure about competence then a
discussion or consultation with a colleague is
warranted. This should be done with the permission
of the young person.
RESOURCES, web LINKS & CONTACTS
Overview:
• Australian Contact Tracing Manual (2006). Copies available at http://www.ashm.org.au/contacttracing/
• STI testing guidelines for MSM: http://www.racp.
edu.au/public/SH_MSMguidelines.pdf
• PEP INFO: http://www.hivhepsti.info/
documents/2005NPEPbrochure.pdf and http://
www.ashm.org.au/uploads/File/npep-bbv.pdf
• HEADSS assessment: http://www.csdgp.com.
au/Youth%20REACH/4.%20Adolescent%20
HEADSS%20Assessment.pdf
• Working with young people: http://www.caah.chw.
edu.au/resources/flashcard-section2.pdf and
• For further info on HIV and Hepatitis go to
Australasian Society for HIV Medicine:
http://ashm.org.au
• http://www.stirc.med.usyd.edu.au
• Australasian Chapter of Sexual Health Medicine
http://www.racp.edu.au/page/about-the-racp/
structure/australasian-chapter-of-sexual-healthmedicine
AUSTRALIAN PUBLIC SEXUAL HEALTH CLINICS
& FAMILY PLANNING CLINICS
Australian Capital Territory
Sexual Health and Family Planning ACT Inc.
(SHFPATC)
(02) 6247 3077 www.shfpact.org.au
Canberra Sexual Health Centre
(02) 6244 2184 www.health.act.gov.au/sexualhealth
142
Resources, Web Links & Contacts
New South Wales
Albury Sexual Health Service
Albury Community Health Service
Sexual Health Service
596 Smollett Street
Albury NSW 2640
(02) 6058 1800
Armidale Community Health Centre
Clair House
cnr Butler and Rusden Streets
Armidale NSW 2350
(02) 6776 9600
Family Planning NSW
FPA Health
(02) 8752 4300 www.fpnsw.org.au
Bourke Sexual Health Service
Community Health Centre
12 Darling Street
Bourke NSW 2840
(02) 6872 2145
15
Campbelltown Community Health Centre
Suite 11, 261 Queens Street
Campbelltown NSW 2560
(02) 4628 5878
Resources, Web Links & Contacts
143
RESOURCES, web LINKS & CONTACTS
Broken Hill Sexual Health
Primary Health Centre
Broken Hill Base Hospital
Thomas Street
Broken Hill NSW 2880
(08) 8080 1556
Royal Prince Alfred Hospital:
Women and Babies/Sexual Health
Executive Unit. Building 89
Level 5, Missenden Road
Camperdown NSW 2050
(02) 9515 8984
Sutherland Sexual Health Clinic
Sutherland Hospital
430 Kingsway
Caringbah 2229
(02) 9350 2742
Coffs Harbour Sexual Health Clinic (Clinic 916)
Coffs Harbour Health Campus
345 Pacific Highway
Coffs Harbour NSW 2450
(02) 6656 7865
Hunter Area Outreach Clinic
Family Planning NSW- Newcastle
15-19 Queen Street
Cooks Hill NSW 2300
(02) 49294485
Wentworth/Balranald Sexual Health Service
Dareton Health Centre
44–46 Tapio Street
Dareton NSW 2717
(03) 5021 7200
Kirketon Road Centre
Above the Darlinghurst Fire Station
Victoria Street (entrance)
Darlinghurst NSW 2010
(02) 9360 2766 D
Dubbo Sexual Health Service
203 Brisbane Street
Dubbo NSW 2830
(02) 6841 2480
144
Resources, Web Links & Contacts
The Lakes Clinic
Forster/Tuncurry Community Health Centre
16 Breese Parade
Forster NSW 2428
(02) 6555 1800
Holden Street Clinic
69 Holden Street
Gosford NSW 2250
(02) 4320 2114
Goulburn Community Health Centre
Goldsmith Street
Goulburn NSW 2580
(02) 4827 3913
Griffith Community Health Centre
39 Yambil Street
Griffith NSW 2680
(02) 6966 9900
Blue Mountains Sexual Health/HIV Clinic
Blue Mountains Hospital
Great Western Highway
Katoomba NSW 2780
(02) 4784 6560
15
Short Street Centre Sexual Health Clinic
St George Hospital
Ground Floor, Prichard Wing
Short Street
Kogarah NSW 2217
(02) 9350 2742
Resources, Web Links & Contacts
145
RESOURCES, web LINKS & CONTACTS
Nepean Sexual Health & HIV Clinic
The Court Building, Nepean Hospital
Derby Street Entrance
Kingswood NSW 2747
(02) 4734 2507
Lightning Ridge Sexual Health Service
cnr Opal and Pandora Streets
Lightning Ridge NSW 2834
(02) 6829 9900
Lismore Sexual Health Service
Lismore Base Hospital
4 Shepherd Lane
Lismore NSW 2480
(02) 6620 2980
Liverpool Sexual Health Clinic
Bigge Park Centre
Elizabeth & Bigge Streets
Liverpool NSW 2170
(02) 9827 8022
Manly Sexual Health Service
8/18 Whistler Street (entrance in Market Lane )
Manly NSW 2095
(02) 9977 3288
Livingstone Road Sexual Health Centre
(Currently re-locating to Royal Prince Alfred Hospital. Ring RPA for more details on:
(02) 9560 3057 I A N D F P C L I N I C S N S W
Luxford Road Sexual Health Clinic
Mt Druitt Hospital Grounds
Luxford Road
Mt Druitt NSW 2770
(02) 9881 1733
Narooma Community Health Centre,
Sexual Health Services
cnr Graham and Field Streets
Narooma NSW 2546
(02) 4476 2344
146
Resources, Web Links & Contacts
Hunter Sexual Health Service
The Pacific Clinic, Newcastle SHS Level 2, 670
Hunter Street, Newcastle NSW 2300
(02)40164536.
www.sesiahs.health.nsw.gov.au/sydhosp/Services/
sshc.asp
The Sanctuary Men’s Sexual Health Clinic
6 Mary Street
Newtown NSW 2042
(02) 9650 3057
Shoalhaven Sexual Health Clinic
Shoalhaven District Hospital
Shoalhaven Street
Nowra NSW 2541
(02) 4423 9353
Orange Sexual Health Clinic
Community Health Centre
96 Kite Street
Orange NSW 2800
(02) 6392 8600
15
Parramatta Health Service
162 Marsden Street
Parramatta NSW 2150
(02) 9843 3124
Port Macquarie – Clinic 33 Sexual Health
Service
Port Macquarie Community Health Centre
Morton Street
Port Macquarie NSW 2444
(02) 6588 2750
Resources, Web Links & Contacts
147
RESOURCES, web LINKS & CONTACTS
Parramatta Sexual Health Clinic
Queanbeyan Community Health Centre,
Sexual health Service
26 Antill Street
Queanbeyan NSW 2620
(02) 6298 9233
Northern Sydney Sexual Health,
HIV & Hepatitis Service (Clinic 16)
Royal North Shore Hospital
Block 3, Herbert Street
St Leonards NSW 2065
(02) 9926 7414
Albion Street Centre
Surry Hills NSW 2010
(02) 9332 9600 and
www.sesahs.nsw.gov.au/albionstcentre
Sydney Sexual Health Centre
Nightingale Wing
Sydney Hospital Macquarie St
Sydney 2000
(02) 9382 7440
www.sesahs.nsw.gov.au/sydhosp/SSHC.asp
Bligh Street Clinic
5 Bligh Street
Tamworth NSW 2430
(02) 6766 3095
Manning Clinic
Taree Community Health Centre
64 Pulteney Street
Taree 2430
(02) 6592 9315
148
Resources, Web Links & Contacts
Tweed Valley Sexual Health Service (Clinic 145)
Level 1, 145 Wharf Street
Tweed Heads NSW 2485
(07) 5506 6850
Wagga Wagga Sexual Health Service
79 Brookong Avenue
Wagga Wagga NSW 2650
(02) 6938 6492
Illawarra Sexual Health Service
Port Kembla Hospital
Fairfax Road
Warrawong NSW 2502
(02) 4223 8457
Northern Territory
Alice Springs (Clinic 34)
Centre for Disease Control
Alice Springs Hospital, Gap Road
Alice Springs NT 0871
(08) 8951 7549
15
Ground Floor, Health House
87 Mitchell Street
Darwin NT 0800
(08) 8999 2678
Family Planning Northern Territory
(08) 8948 0144
Katherine (Clinic 34)
O’Keefe House, Katherine Hospital
Gorge Road
Resources, Web Links & Contacts
149
RESOURCES, web LINKS & CONTACTS
Darwin (Clinic 34)
Katherine NT 0851
(08) 8973 9049
Nhulunbuy (Clinic 34)
Centre for Disease Control
Cnr Chesterfield &
Matthew Flinders Way
Nhulunbuy NT 0881
(08) 8987 0356
Tennant Creek (Clinic 34)
Health Development Unit
cnr Schmidt and Windley Streets
Tennant Creek NT 0860
(08) 8962 4250
Queensland
Men’s and Women’s Health,
Bamaga Hospital
Sagaukaz Street
Bamaga QLD 4876
(07) 4090 4219
AIDS Medical Unit (Brisbane)
(07) 3837 5622
and Brisbane Sexual Health Clinic
Roma St
Brisbane QLD 4000
(07) 3837 5611
www.health.qld.gov.au/sexhealth/help/Brisbane.
shtml
Q Clinic
Bundaberg Base Hospital
PO Box 34
Bundaberg QLD 4670
(07) 4150 2754
150
Resources, Web Links & Contacts
Doll’s House Sexual Health Clinic
Cairns Base Hospital
Cairns QLD 4870
(07) 4050 6205
http://www.health.qld.gov.au/sexhealth
Family Planning Queensland
(07) 3250 0240 www.fpq.com.au
Ipswich Sexual Health Service
Health Plaza
Bell Street
Ipswich QLD 4305
(07) 3817 2428
Redcliffe Sexual Health Service
Redcliffe Community Centre
181 Anzac Avenue
Kippa Ring QLD 4021
(07) 3897 6300
15
Sexual Health & Sexual Assault Services
Gold Coast Sexual Health Clinic
15-17 Maud Street
Miami QLD 4220
(07) 5576 9033
Mount Isa District Sexual Health Services
Doreen Street Clinic
Mount Isa Base Hospital
Doreen Street
Mount Isa QLD 4825
(07) 4744 4805
Resources, Web Links & Contacts
151
RESOURCES, web LINKS & CONTACTS
Mackay Community Health Centre
12-14 Nelson Street
Mackay QLD 4740
(07) 4968 3919
HIV and Sexual Health Service (Clinic 87)
87 Blackall Terrace
Nambour QLD 4560
(07) 5470 5244
Palm Island, Men’s and Women’s’ Business
Joyce Palmer Health Service
Palm Island QLD 4816
(07) 4752 5165
Rockhampton Sexual Health, HIV and Hepatitis C Services
8 Canning Street
Rockhampton QLD 4700
(07) 4920 5555
Thursday Island Men’s and Women’s Health
Douglas Street
Thursday Island QLD 4875
(07) 4069 0413
Toowomba Sexual Health Service
Toowomba Base Hospital
Kobi House
Pechey Street
Toowoomba QLD 4350
(07) 4616 6446
Townsville Sexual Health Service
35 Gregory Street
North Ward QLD 4810
(07) 4778 9600
Weipa Sexual Health Program
Cape York Health Service
Weipa QLD 4874
(07) 4090 6207
152
Resources, Web Links & Contacts
Princes Alexandra Sexual Health (PASH)
Princes Alexandra Hospital
Wooloongabba QLD 4102
(07) 3240 5881
South Australia
Clinic 275
275 North Terrace
Adelaide 5000
(08) 8222 5075 www.stdservices.on.net
SHine SA (previously Family Planning SA)
www.shinesa.org.au
Tasmania
Family Planning Tasmania Inc.
Sexual Health Service Devonport
23 Steele Street
Devonport TAS 7310
(03) 6421 7759
Sexual Health Service Hobart
60 Collins Street
Hobart TAS 7000
(03) 6233 3557
Sexual Health Service Launceston
42 Canning Street
Launceston TAS 7250
(03) 6336 2216
Resources, Web Links & Contacts
153
15
RESOURCES, web LINKS & CONTACTS
(03) 6228 5422 and Sexual Health Service Burnie
11 Jones Street
Burnie TAS 7310
(03) 6434 6315
Victoria
Ballarat Community Health Centre
BCHC – Sexual Health Clinic
710 Sturt Street
Ballarat VIC 3350
(03) 5338 4540
Family Planning Victoria
Box Hill (03) 9257 0100
Action Centre City (young people’s clinic) (03) 9654
4766 and www.fpv.org.au
Royal Women’s Hospital,
Communicable Diseases Clinic
132 Grattan Street
Carlton VIC 3053
(03) 9344 2002
Melbourne Sexual Health Centre
580 Swanston Street
Carlton VIC 3053
(03) 9341 6200 and www.mshc.org.au
Community Health Bendigo,
STI/BBV Service
Seymour Street
Eaglehawk VIC 3556
(03) 5434 4300
Frankston Hospital, Sexual Health Clinic
Hastings Road
Frankston VIC 3199
(03) 9784 7650
154
Resources, Web Links & Contacts
Sexual Health Clinic, Geelong
Geelong Hospital
Geelong VIC 3220
(03) 5226 7802 (Tuesdays only)
Alfred Hospital HIV Service and I.D. Clinic
Commercial Road
Prahran VIC 3181
(03) 9076 6081
Latrobe Regional Hospital, AIDS/STD Clinic
Princes Highway
Traralgon VIC 3844
(03) 5173 8111
Vermont Street Health Clinic
79 Vermont Street
Wodonga VIC 3690
(02) 6051 7535 www.wrhs.org.au
Western Australia
15
Fremantle Hospital, Sexual Health Clinic B2
Department of Infectious Diseases
Alma Street
Fremantle WA 6160
(08) 9431 2149
www.fhhs.health.wa.gov.au
Mainly Men Clinic
Quarry Health Centre
7 Quarry Street
Fremantle WA 6160
(08) 9430 4544
Resources, Web Links & Contacts
155
RESOURCES, web LINKS & CONTACTS
Family Planning Western Australia
Ph: (09) 9227 6177 www.fpwa.org.au
Kalgoorlie Sexual Health Clinic
36 Ware Street
Kalgoorlie WA 6432
(08) 9080 8200
Haven Clinic,
Billy Dower Youth Centre
Dower Street
Mandurah WA 6210
(08) 9534 8943
Royal Perth Hospital, Sexual Health Clinic
Wellington Street
Perth WA 6000
(08) 9224 2178
Rockingham Clinic
Youth Health Service, Rockingham, WA
(08) 9528 8680
www.rockingham.wa.gov.au
King Edward Memorial Hospital, Sexual
Health Clinic
Bagot Road
Subiaco WA 6008
(08) 9340 1014
www.wchs.health.wa.gov.au
156
Resources, Web Links & Contacts
Notes
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