Module 203 STIs 2023.pptx

Sexually transmitted infections What’s next after the sexual history… Dr Gillian Dean Consultant in HIV & Sexual Health Learning outcomes • Who gets STIs & why – risk groups • What next after the sexual history • how to examine the genitals • what to look for • Classification of STIs • Why are ST...

Sexually transmitted infections What’s next after the sexual history… Dr Gillian Dean Consultant in HIV & Sexual Health Learning outcomes • Who gets STIs & why – risk groups • What next after the sexual history • how to examine the genitals • what to look for • Classification of STIs • Why are STIs important - long-term consequences Who gets STIs? ANYONE having sex… BUT the risk groups are: • Frequent partner change, high no. lifetime partners, concurrency (simultaneous partners) • Young age (<20 years) - lower age at 1st intercourse, ‘coitarche’ • Ethnicity for some STIs • Sexual orientation • Residence in inner city/ deprivation • Use of non barrier contraception • History of previous STI Who gets STIs? ANYONE having sex BUT the risk groups are: • Frequent partner change, high no. lifetime partners, concurrency (simultaneous partners) • Young age (<20 years) - lower age at 1st intercourse, ‘coitarche’ • Ethnicity for some STIs • Sexual orientation • Residence in inner city/ deprivation • Use of non barrier contraception • History of previous STI Who gets STIs? ANYONE having sex BUT the risk groups are: • Frequent partner change, high no. lifetime partners, concurrency (simultaneous partners) • Young age (<20 years) - lower age at 1st intercourse, ‘coitarche’ • Ethnicity for some STIs • Sexual orientation • Residence in inner city/ deprivation • Use of non barrier contraception • History of previous STI Percentage of all STIs occurring in young adults (16-24), UK 80% Men P e rc e n ta g e a g e d 1 6 -2 4 Women 60% 40% 20% 0% O verall Population 2 Chlamydia W ar ts (1st attack) Gono rrhoea Genital he rpes (1st Attack) Syphilis HIV Total Median age first sex is now 16ys Behaviourally more vulnerable to STI acquisition Early age associated with poor subsequent sexual health Yet to develop skills and confidence to negotiate safe sex Poor awareness contraception Higher numbers of sexual partners / partners change Greater numbers of concurrent partners More risk-taking behaviour Physiology? What is this? NATSAL-3 The earlier intercourse occurs, the higher the proportion: • Express regret they had not waited longer • Report being more or less willing than their partner • 20% men and 42% women express regret they had not waited longer Early intercourse Associated with vulnerabilities: • leaving home / not living with parents before 16 years • leaving school early • family disruption & disadvantage, lack of nurturing relationships • those whose main source of information on sex was not school or parents Where do young people get information? Main messages to get across to young people • Don’t rush into it – avoid peer pressure • Use condoms with all new partners • Get a STI screen when you have a new partner • Sort out contraception • Avoid overlapping sexual relationships • GBM* should also get vaccinated for hepatitis A/B and HPV & consider HIV PrEP *Gay and bisexual Who gets STIs? ANYONE having sex BUT the risk groups are: • Frequent partner change, high no. lifetime partners, concurrency (simultaneous partners) • Young age (<20 years) - lower age at 1st intercourse, ‘coitarche’ • Ethnicity for some STIs • Sexual orientation • Residence in inner city/ deprivation • Use of non barrier contraception • History of previous STI Rates of STI diagnoses by ethnic group among men: England, 2021 Chlamydia Gonorrhoea Infectious syphilis ‡ Genital warts* Genital herpes* Trichomoniasis Rate per 100,000 population 1,400 1,200 1,000 800 600 400 200 0 Asian Black African Black Black Other Caribbean Mixed Ethnicity 30 UK Health Security Agency: 2021 STI Slide Set (version 1.0, published 4 October 2022) Other White Who gets STIs? ANYONE having sex BUT the risk groups are: • Frequent partner change, high no. lifetime partners, concurrency (simultaneous partners) • Young age (<20 years) - lower age at 1st intercourse, ‘coitarche’ • Ethnicity for some STIs • Sexual orientation • Use of non barrier contraception • Residence in inner city/ deprivation • History of previous STI Rates of gonorrhoea diagnoses by gender and age: England, 2021 500 Rate per 100,000 population 450 400 350 Men 300 Women 250 200 150 100 50 0 15 23 20 25 30 35 Age 40 45 UK Health Security Agency: 2021 STI Slide Set (version 1.0, published 4 October 2022) 50 55 60 Rates of infectious syphilis (primary, secondary and early latent) diagnoses by gender and age: England, 2021 80 Rate per 100,000 population 70 Men Women 60 50 40 30 20 10 0 15 20 25 30 35 40 45 Age 24 UK Health Security Agency: 2021 STI Slide Set (version 1.0, published 4 October 2022) 50 55 60 Why? Sexual networks & core groups (definition) • sub-group of the population – high turnover • not a static entity • highly sexually active individuals • high prevalence of infection • reservoirs of infection • high frequency of transmission Effective control at the population level based on targeting core groups Who gets STIs? ANYONE having sex BUT the risk groups are: • Frequent partner change, high no. lifetime partners, concurrency (simultaneous partners) • Young age (<20 years) - lower age at 1st intercourse, ‘coitarche’ • Ethnicity for some STIs • Sexual orientation • Residence in inner city/ deprivation • Use of non barrier contraception • History of previous STI Rates of STI diagnoses by index of multiple deprivation quintile: England, 2021 Chlamydia Genital warts* Genital herpes* Gonorrhoea Infectious syphilis** New STIs 350 300 700 600 250 500 200 400 150 300 100 200 50 100 0 0 1 (Most deprived) 2 3 4 5 (Least deprived) IMD quintile 42 800 UK Health Security Agency: 2021 STI Slide Set (version 1.0, published 4 October 2022) New STI rate per 100,000 population Rate per 100,000 population 400 Who gets STIs? ANYONE having sex BUT the risk groups are: • Frequent partner change, high no. lifetime partners, concurrency (simultaneous partners) • Young age (<20 years) - lower age at 1st intercourse, ‘coitarche’ • Ethnicity for some STIs • Sexual orientation • Residence in inner city/ deprivation • Use of non barrier contraception • History of previous STI The examination GMC guidance • Offer a chaperone • Explain to patient why examination is necessary & what it will involve • Give patient privacy to undress & dress • Obtain patient’s permission before the examination • Discontinue if patient asks you to • Keep discussion relevant - avoid unnecessary comments Female genital examination • Leg rests - allow better visualisation • Inspect & palpate inguinal region • Inspect perianal area • Look between skin folds • Speculum examination with visualisation cervix • Bimanual examination (if indicated) Female genital examination – can you name AM? A F B G C H D I L J E K M Male genital examination – can you name the anatomy Male genital examination • Inspect pubic area, inguinal region • Inspect scrotum & perianal area • Palpate scrotal contents – note presence of testes, any lumps/ tenderness • Inspect penis - record whether circumcised if not inspect under foreskin • Particular attention to coronal sulcus, frenulum & meatus • Note presence of urethral discharge Normal appearances may be mistaken for abnormality by patient Pearly penile papules Normal appearances may be mistaken for abnormality by patient Fordyce spots Normal appearances may be mistaken for abnormality by patient Vulval papules / papillomatosis ‘Normal’ appearances may be mistaken for infection by patient Enlarged sebaceous glands Epidermoid cysts Other conditions presenting with genital signs Malignant melanoma Other conditions presenting with genital signs Psoriasis Diagnosis? Tinea cruris – dermatophyte (fungal) infection Pruritic papules… Pruritic papules… Lesions & burrows in finger webs & wrist Scabies Bacterial/protozoal vs. viral STIs Bacterial / protozoal * Viral Chlamydia, gonorrhoea, syphilis, TV* Herpes, warts, HIV, hepatitis • many unaware of infection • more often florid symptoms • delayed presentation • early presentation • diagnostic tests may be unreliable • rapid diagnosis • symptomatic treatment only • effective treatment available • often life-long • curative • expanding reservoirs • reservoirs can be controlled *TV: trichomonas vaginalis Discharge 2o to gonorrhoea / chlamydia Gonorrhoea: intracellular gram negative diplo-cocci Primary syphilis • 1-3 weeks after contact (9-90 days), red mark raised spot ulcer at the site of contact • Enlarged lymph nodes in the groin/neck • Heals within 1-3 weeks (with or without treatment) Secondary syphilis • 2-6 weeks after 10 stage - lasts for 2-4 weeks • Systemic dissemination - millions spirochaetes • Flu-like illness, headache, lymphadenopathy • Mouth ulcers - “snail track” painless • Condylomata lata - white/grey lumps in moist areas • Arthritis • Rapid resolution with effective treatment • Particularly suspect if rash involves palms & soles Trichomonas vaginalis • Single cell protozoan parasite • Infects vagina & urethra • Dysuria, discharge • Causes frothy discharge, “strawberry cervix” • Diagnosed by seeing motile organisms on microscopy • Responds well to metronidazole Viral STIs Genital warts • Extremely common, human papilloma virus (HPV) • Type 6 & 11 in 90% • Vs types 16 & 18, 31, 33 etc. (cervical cancer) Number of genital warts (first episode) diagnoses by gender: England, 2012 to 2021 45,000 Men Number of diagnoses 40,000 Women 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0 2012 2013 2014 2015 2016 2017 2018 2019 2020 ‡ 2021 ‡ Year ‡ Data reported in 2020 and 2021 are notably lower than previous years due to the reconfiguration of SHSs during the national response to the COVID-19 pandemic 15 UK Health Security Agency: 2021 STI Slide Set (version 1.0, published 4 October 2022) Molluscum contagiosum Herpes simplex type 1 & 2 Symptoms • painful ulceration, dysuria, vaginal discharge • systemic symptoms e.g. fever and myalgia (more common in first occurrence) • recurrences generally less severe Signs • blistering & ulceration (+/- cervix/rectum) • painful inguinal lymphadenopathy • heals after 5-14 days Non-sexually transmitted infections Candida / thrush • • • • fungal itching, discharge, swelling papular rash in males topical antifungals Bacterial vaginosis • • • • discharge / “fishy” odour imbalance of vaginal flora overgrowth of anaerobes responds to metronidazole Complications of STIs Chlamydia / gonorrhoeaPID,  epididymitis, infertility, chronic pain, seronegative arthritis +/- urethritis and conjunctivitis HPV / warts  Bacterial vaginosis cervical cancer, anal/vulval/penile intraepithelial neoplasia  (AIN/VIN/PIN) early labour, low-birth weight Trichomonas vaginalis miscarriage,  Syphilis  miscarriage, early labour, low-birth weight cardiac abnormalities etc etc Hepatitis B, hepatitis C dementia,  HIV  cirrhosis, liver cancer opportunistic infections, lymphoma, non-AIDS malignancies Most STIs increase the risk of HIV acquisition / transmission Summary • Rates of STIs are increasing because of changing behaviour, communication, globalisation • Certain groups are more vulnerable to STIs due to links with core groups through sexual networks • Patients may present with ‘normal anatomy’ or non-STI pathology • Differences between bacterial vs viral infections • Serious complications therefore correct diagnosis & prompt treatment essential