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Clinical history, examination, specimen collection and tests guidelines for sexually transmitted infections

General principles of the sexual consultation include ensuring privacy and maintaining confidentiality between the doctor and patient. It is always best never to make assumptions about the patient or their behaviour and to maintain a non judgemental attitude to patient behaviours. If there is doctor or patient discomfort this can be acknowledged. Maintaining a relaxed body language and using terms that the patient understands and is comfortable with helps rapport development.

Consultation aims

The sexually transmitted infection (STI) consultation aims to

  • Define the presenting complaint.
  • Assess sexual and social behaviours for risk factors and risk markers.
  • Screen the patient for sexually transmitted infections and associated conditions.
  • Diagnose and treat infection.
  • Educate the patient on risk modification and offer vaccination.
  • Promote safe sex practices.
  • Limit the spread of STIs in the population and conduct contact tracing.

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History

General history

  • Contact of an STI
  • past medical and STI history
  • medications, allergies (emphasise antibiotics) and contraception
  • last menstrual period
  • vaccination history
  • recreational drug use.

Symptoms and signs

  • Onset, character, periodicity, duration and relation to sexual intercourse and urination
  • similarity to previous problems
  • any STI in sexual partner(s)
  • anogenital discharge and/or dysuria
  • dyspareunia and/or pelvic pain
  • ulcers, lumps, rashes or itching.

Sexual behaviours/risk markers

  • Any sexual partner(s) and date of last sexual exposure and others in the last three months
  • sex of partner(s) including and history of male to male contact
  • type of intercourse – oral, vaginal, anal
  • sex overseas or in high risk areas like beats and saunas
  • any history of injecting drug use, what drug, how often
  • any tattoo history or blood product exposure.

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Examination

This is conducted to assess genital symptoms and as part of asymptomatic assessment.

Exposure of abdomen, genitals and thighs is required.

Inspect

Inspect for rashes, lumps, ulcers, discharge, smell, pubic hair for lice and nits and in most cases the skin of the face, trunk, forearms, palms and the oral mucosa.

Men: Inspection of the penis, including meatus, retracted foreskin and perianal area +/- proctoscopy. Palpation of scrotum and expression of any discharge from the urethra.

Women: Inspection of external genitalia, perineum and speculum examination of vagina and cervix. Bimanual pelvic examination.

Palpate

Palpate the inguinal nodes.

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Specimen collection and tests

Note: NAAT refers to Nucleic Acid Amplification Test, such as PCR

Men

Urethral swab

Urethral swab (1 to 2 cm inside meatus or of pus) performed in symptomatic men for:

  • gram stain
  • culture and sensitivity on gonorrhoea specific medium
  • wet prep if trichomonas suspected (low yield)
  • chlamydia NAAT taken 3 to 4 cm down urethra not routinely performed.

Ulcer swab

  • Herpes simplex virus (HSV) NAAT
  • Syphilis NAAT if clinical suspicion.

Urine sample

First catch urine for:

  • chlamydia and gonorrhoea NAAT in symptomatic or asymptomatic men
  • mycoplasma genitalium NAAT in symptomatic men
  • trichomonas NAAT if history suggests exposure.

Men who have sex with men

The following need to be conducted in addition to the above specimen collection and tests recommended for men.

Throat swab

Chlamydia and gonorrhoea NAAT in symptomatic and asymptomatic men

Rectal swab

  • Best obtained through direct inspection with proctoscope
  • if proctoscopy unavailable blind swabs are possible
  • Chlamydia and Gonorrhoea NAAT in symptomatic and asymptomatic men
  • if proctitis clinically diagnosedperform culture and sensitivity on gonorrhoea specific medium.

Women

Vaginal wall swab

  • Gram stain for candida and bacterial vaginosis
  • culture and sensitivity including candida specific medium.

Vagina posterior fornix

  • pH
  • wet prep for trichomonas
  • trichomonas vaginalis NAAT if history suggests exposure.

Endocervical swab

  • Chlamydia and gonorrhoea NAAT in symptomatic and asymptomatic women
  • culture and sensitivity on gonorrhoea specific medium in symptomatic women
  • mycoplasma genitalium NAAT if history suggests exposure.

Pap smear

Pap smear if abnormal cervix or screening PAP due.

Ulcer swab

  • HSV NAAT
  • Syphilis NAAT if history suggests exposure

Rectal swab

If anal sex on history:

  • best obtained through direct inspection with proctoscope
  • if proctoscopy unavailable blind swabs are possible
  • chlamydia and gonorrhoea NAAT in symptomatic or asymptomatic women
  • if proctitis clinically diagnosed perform culture and sensitivity on gonorrhoea specific medium.

Urine sample

First void urine can be tested for chlamydia by NAAT if endocervical swabs not possible.

Vaginal swab

Self collected vaginal swab:

  • suitable for asymptomatic screening
  • chlamydia and gonorrhoea NAAT.

Female sex workers

The following need to be conducted in addition to the above specimen collection and tests recommended for women.

Throat swab

Chlamydia and gonorrhoea NAAT.

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Blood tests

Hepatitis B serology

  • At first visit
  • subsequently as determined by risk markers:
    • Aboriginal
    • Asian born
    • men who have sex with men
    • injecting drug users
    • sex workers
    • overseas sex contact
    • sexual contacts of the above.

Hepatitis C serology

  • At first visit
  • subsequently as determined by risk markers:
    • injecting drug users
    • tattooing
    • receptive anal intercourse
    • blood product exposure out of Australia.

Syphilis serology

  • At each visit
  • when syphilis is suspected on clinical grounds
  • if Human immunodeficiency virus (HIV) infection has been diagnosed.

HIV serology

At each visit

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Diagnosis

History, examination and testing should enable a diagnosis.

If unsure contact a sexual health physician.

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Management

Comprehensive management of sexually transmitted infections has four components.

  1. treatment
  2. patient education
  3. contact tracing
  4. follow up

Treatment

Antibiotic therapy or other treatment is provided in accordance with recommendations.

Patient education

Patient education should cover the following:

  • natural history of the disease
  • sequelae and method of transmission
  • the treatment and side effects
  • necessity of follow up and investigation and treatment of sexual partners
  • public health law specific to notifiable diseases
  • use of condoms and abstinence if required following treatment.

Contact tracing

Notifiable sexually transmitted infections should be contact traced to allow for timely and appropriate treatment of sexual partners.

Follow up

At least one follow up visit is essential in order to:

  • assess response and compliance to treatment
  • assess for side effects of treatment
  • determine whether sexual intercourse has occurred since treatment
  • perform investigations to demonstrate cure where appropriate
  • confirm contact tracing and treatment of sexual partners.

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Notification

There is a legal requirement for the attending clinician to notify all cases of gonorrhoea, early syphilis, chlamydia, hepatitis B, hepatitis C, human immunodeficiency virus (HIV) and donovanosis to the Department for Health and Ageing.

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