Sexually transmitted infections

Local help resources Your local Genito - Urinary Medicine Department is called the Harrison and is located in the Churchill Hospital. Oxford. Tel 01865 246036 for all appointments.

Students frequently ask questions about the clinic including what is it like to go there? is it a confidential service? and what happens? so here is a simple guide to help you find your way around their system which aims to offer you a streamlined sexual health service supporting student health.

Where is it? The Clinic is located on the second floor of a building just to the left side of the Radcliffe Infirmary, and is sign posted on the wall outside as The Harrison Department.

When you enter follow the stair case up and you will arrive at a narrow door, keep going and follow the signs for reception. If you require a lift pass the entrance to the Harrison and instead take the second door on the right, go inside, turn right again, and second on the left knock or ring and someone will open the door and help with the lift.

Inside the Clinic
Reception The receptionist will greet you and ask you to complete a registration sheet. You may provide any name you like as long you are consistent and remember it through the system. Your details are not given to anyone else and remain confidential so many students do choose to give their real name.

Waiting Room Take a seat in the waiting room: there are two waiting rooms, one opposite reception and a bigger one a few feet away. Clients are called via an intercom system (hence the need to remember your name). There is a drinks machine in the larger waiting room. Do not go to the toilet for at least three hours before being seen as you are most likely going to have to provide a specimen of urine and three hours is needed to provide an accurate assessment.

The Consultation The Doctor will call you via the tannoy system to a numbered room so make your way along the corridor. He or she will take a full sexual history and discuss with you any screening that they advise. You can make an informed decision about undergoing any testing so ask all the questions you need to. If testing is indicated you will be asked to change rooms for any physical examination to take place.

Back to the Waiting Room to await results You will then be asked to take a seat in the waiting room again. All samples taken as slides, will be read microscopically during your wait in the department.

The wait at this time is about 20 minutes so bring something to do.

Non Specific Urethritis and Gonorrhea can be detected on slide. If it is present you will be treated on the day with antibiotics.

Thrush and bacterial vaginosis can also be detected on the slide.

When the slide has been read you will be called back to the doctor to be given your results. In between this time if you have consented to blood tests you will see the nurse to have you blood taken.

Health Advisors Some patients may see a health adviser although all patients can request to see a health adviser if they wish. Health advisers routinely see patients with Chlamydia, Gonorrhea syphilis, hepatitis C and anyone having an HIV test.

Research suggests that patients diagnosed with Herpes derive great benefit from seeing a health adviser at time of diagnosis.

The rest of the results of your tests are normally ready in one week and you will either be asked to return or phone for these results.

In some circumstances a doctor may want you to return for a follow up examination. This is normally to ensure that symptoms have resolved (especially with PID, epididymo-orchitis and Gonorrhea)

Confidentiality and the VD Act (1974) GUM clinics in the UK are bound by the National Health Service (VD) regulations of 1974, which assures patient confidentiality over and above that which is provided in other health care establishments. In addition GU services are also bound by more general laws around confidentiality such as the Data Protection Act which governs the information stored on computer.

Some of the first things you may notice are the practical measures in place in the Harrison department to allow compliance with the above regulations:

Common Sexually Transmitted Infections

Gonorrhoea (GC)
(see table below)
Gonorrhoea is a bacterial infection caused by the gram negative diplococcus Neisseria gonorrhoea.

About 19,000 new cases of GC per year in this country although this has been rising rapidly over the last year especially amongst 16-25 heterosexual males & females.

Local stats: Figures for the Harrison for October - December 2000: Male = 34 Female = 15. Up on the previous quarter ( Male = 20. Female = 8 (almost doubled). Undoubtedly the quarter from January - March will see a significant rise because of seasonal variations / school / university term times.

Galen, a Greek physician (130-210 A.D) gave gonorrhoea it's name (gonos, seed: rhoia, flow) thinking in error, that the pus discharge was the loss of waste semen.
Hippocrates described the manner of catching gonorrhoea as "excesses of the pleasures of Venus" so even as far back as 500BC it was known that GC was sexually transmitted. The treatments given were however, directed towards men since it is usually only men who develop obvious recognisable symptoms.

It was thought that the disease could be stopped through cold baths, wrapping the sex organs in wool and abstinence. In Persia the treatment included placing a live louse inside the patients penis and in Egypt cold seawater mixed with vinegar was forced under great pressure into the penis to treat the disease.

Today the treatment is a little more humane! And involves taking oral antibiotics

Chlamydia
(see table below)
Infections due to chlamydia are the most common sexually transmitted infection in the UK today with an estimated 90,000 new cases per year and an estimated prevalence of 800/100,000 in the UK population. This is sustained by unrecognised and thus untreated symptomless infection in men and women. Complications cost at least £50 million annually in the UK.

Local stats: The Harrison department figures for October to December 2000 for actual chlamydia positive diagnoses excluding Non specific urethritis (male) and Pelvic inflammatory disease (PID) (women) = Females 97 cases & Males 77 cases using the chlamydia elisa test which is 60 -70 % accurate.

Men with NSU, regardless of whether they have a positive chlamydia diagnosis are treated for chlamydia. Women presenting with PID are also treated for chlamydia regardless of their test result.

Chlamydia infections are caused by the bacterium Chlamydia Trachomatis.

Genital Warts
(see table below)
Genital warts (condylomata Acuminata) are caused by a group of viruses called the human papilloma viruses (HPVs). They are spread by sexual contact with an infected partner and are very contagious. Genital warts affect an estimated 77,000 people in the UK annually. Approximately two thirds of persons who have sexual contact with an infected partner will develop this common STI.

Local stats: Harrsion Department figures for genital warts from October - December 2000 = Male 88 Female 90

Genital Herpes
(see table below)
Genital herpes is a contagious infection that affects an estimated 20,000 people every year in the UK. The infection is caused by the herpes simplex virus of which there are two types HSV 1 and HSV 2. HSV 1 more commonly causes oral herpes (cold sores). Over the last 5 years the incidence of HSV 1 on the genitals has been increasing more rapidly than HSV 2. The WHO estimates that over 100 million people are infected with herpes worldwide.

Syphilis
(see table below)
Syphilis, which swept through Europe in a devastating epidemic during the late 15th century, is now readily treated with antibiotics. Prior to discovery of antibiotics for almost 400 years, mercury was the most widely used treatment for syphilis. Salves made out of animal fat and mercury were rubbed on the sores and rashes caused by the disease. Alternatively mercury was heated in special ovens while patients breathed the fumes for hours at a time. The effect of mercury treatment was to cause a heavy flow of saliva (as well as poisoning the individual!). Its use was based on an old idea first taught by Hippocrates that illness resulted from one body fluid being out of balance with the rest. Places set up for this treatment were called spittle houses. Much later in the early 1900s and indeed through the first war patients were treated with an equally poisonous compound of bismuth and arsenic.

Syphilis is caused by a corkscrew shaped bacterium called treponema palledum and is acquired by direct contact with someone in the first two stages of the disease which can last up to two years.

Chlamydia
TRANSMISSION	Vaginal sex, anal sex, oral sex, close genital contact, mother to child at birth
SYMPTOMS (clinical features)	In women: Asymptomatic (80%) Post-coital bleeding Lower abdo pain Purulent vaginal discharge Mucopurulent cervicitis and/or cervical bleeding. In men: Aspmtomatic in up to 50% Urethral discharge Dysuria The severity of these is variable and may be so mild as to be unnoticed by the patient. Rectal infection is usually asymptomatic but may cause anal discharge and anorectal discomfort. Pharyngeal infections are asymptomatic
COMPLICATIONS	Pelvic inflammatory disease Peri-hepatitis (fitz-hugh-curtis syndrome) Tubal damage (infertility, ectopic pregnancy) Chronic pelvic pain Transmission to neonate (conjunctivitis, pneumonia) Epididymo-orchitis Sexually acquired reactive arthritis/reiters syndrome (commoner in men)
TESTS	Women: Cervical swab and a urethral swab Men: Urine sample for men together with a urethral swab. If anal sex has taken place then a rectal swab should also be taken. If oral sex then a pharyngeal swab should be taken.
TREATMENT	Recommended: Doxycycline 100mgs twice a day for 7 days or Azithromycin 1g orally in a single dose. Alternatives: Erythromycin 500mgs twice a day for 14 days or Deteclo 300mgs twice a day for 7 days. or Ofloxacin 200mgs twice a day for 7 days
FOLLOW UP	Partner notification: Sexual contact should be traced back for 6 months or to the last sexual partner whichever is the longer. It is routinely acknowledged that it is perfectly reasonable to contact partners as far back as a year. Assessment of treatment efficacy/exclusion of reinfection and health education is an important part of follow up. Test of cures are usually recommended for pregnant women.
Gonorrhoea
TRANSMISSION	Vaginal sex Anal sex Oral sex Close genital contact Mother to child at birth
SYMPTOMS (clinical features)	In women: frequently asymptomatic (50%). Increased vaginal discharge May present with abdo pain due to genital tract involvement Urethral infection may cause dysuria (but not frequency) Is a rare cause of intrarmenstrual bleeding or menorrhagia Pharyngeal infection is usually asymptomatic.
COMPLICATIONS	Infections generally remain localised to the anogenital and pharyngeal mucosae, but may spread to the upper genital infection to cause epididymitis in men (1%) or pelvic inflammatory disease (PID) in women (approx. 3%) Much less common are disseminated infections (DGI) These include: septicaemia, arthritis, dermatitis, endocarditis and meningitis.
TESTS	Up to 80% of symptomatic urethral infection in men will be diagnosed on a gram-stained smear, but only 50-70% of asymptomatic urethral infection. Microscopy of the cervix and rectum is considered less reliable (40-50%) In most women the diagnosis will be made on culture from the cervix although in GC contacts the urethra and rectum should also be sampled. In GC contacts samples should be taken on two separate occasions before GC is excluded.
TREATMENT	If the infection was acquired in the UK the first line treatment is: Amoxycillin 3g + probenicid 1g orally as a single dose. Imported infection should be assumed to be Penicillin resistant when treated before antimicrobial sensitivity is known: Ciprofloxacin 500mg orally as a single dose. Alternative regimens not usually used in the UK but valuable against imported infections from SE Asia are: Ceftriaxone 250mg im as a single dose, Spectinomycin 2g i/m as a single dose.
FOLLOW UP	Symptomatic improvement with treatment does not guarantee eradication of GC. There should be at least one test of cure (which in women should include the rectum). And, the final test of cure should take place 48-72 hours after the last antibiotic therapy. Patients with uncomplicated infection should be seen at 24-48hrs for a TOC which will pick up treatment failures. All patients should see the health adviser and contacts should be traced for 3 months or to the last sexual partner (whichever is longer) In some situations epidemiological treatment may be given to named contacts where there is a likelihood of poor compliance, risk of complication or infection of others.
Warts	More than 80 different types of human papilloma virus. Some strains have a particular prediliction for the genital area. Those most commonly referred to are 6, 11, 16, 18, 31, 33. But approximately 30 different types are associated with genital infection.
TRANSMISSION	HPV is passed through close physical contact (skin to skin), almost always genital for genital warts. Autoinoculation from other sites is unusual.
SYMPTOMS(clinical features)	Symptoms in both sexes include: Genital growths, which may be hard or soft and range from solitary to multiple. Bleeding especially urethral. Occasional itching. Sometimes pigmentation is present. In men: warts are found frequently on the penis, urethra,in the perianal area and rarely on the scrotum. In women: the vulva, perianal, the cervix and vagina (less frequently) and, infrequently the urethra are sites for warts in women.
COMPLICATIONS	Genital warts may be associated with abnormal cervical smears. HPV 16, 18, 31, 33 and several other genital strains are oncogenic. There is an increased risk of cervical cancer and other genital tract neoplasias in infected patients however extra genital warts are most commonly caused by HPV 6 and 11 which are rarely associated with dysplasia and do not cause genital or anal cancers.
TESTS	The diagnosis for genital warts is usually clinical and based on the very characteristic appearance of warts. If there is any doubt about the diagnosis for example pigmentation, ulceration other atypical appearance then a biopsy should be taken.
TREATMENT	The aim of the treatment is to eradicate visible warts. It is not possible to eradicate the virus. The patient will remain infectious even in the absence of visible warts. Treatment for simple external warts is: Podophyllin (avoid in pregnancy), TCA (external keratinized warts), Cryotherapy (for few solitary warts), Hyfrecater (for few recalcitrant solitary warts. Treatment may be used alone or in combination, once or twice weekly. If not responding to treatment after a maximum of 6 weeks review by doctor and consider changing therapy or referral to a senior doctor. Cervical warts may be treated via colposcopy and oral warts with cryotherapy.
FOLLOW UP	Patients should be monitored during treamtnet to check efficacy and the need to change if not responding. A cervical smear should be taken at presentation and repeated at 12 months. If this is normal the woman can revert to standard screening. Approximately 60% of the contacts will also have genital warts. All contacts should be traced and offered STI screening and advice. Female contacts are normally offered a cervical smear and repeated in 12 months.
Herpes
TRANSMISSION	Causative organism is the herpes simplex virus types 1 and 2.
SYMPTOMS (clinical features)	Herpes can only be transmitted when an already infected individual is shedding the virus which happens sporadically and not necessarily in association with symptoms. It is transmitted through close physical contact, genital-genital and oro-genital. Infection is acquired through intact mucous membrane or when the virus comes in contact with damaged keratinised epithelium.
COMPLICATIONS	A minority of people will develop a severe primary attack or first clinical episode within 2-12 weeks of acquisition of the virus. It may not be possible to distinguish between a so-called primary attack, which implies new infection or first clinical episode where the patient has acquired genital herpes at some time in the past, but only recently developed symptoms. Some develop minor lesions (blisters) only and 70-80% of people have no symptoms at all. Primary infection usually more severe in women. Febrile illness (prodrome) lasting 5-7 days Dysuria, urinary frequency, painful inguinal, lymphadenopathy, tingling neuropathic pain, genital blisters, ulcers, fissures. An untreated episode may last 3 weeks or more. Recurrent episodes are usually mild and symptoms may include neuropathic prodrome with tingling and burning, erythema, blisters, ulcers.
TESTS	Usually only on the first episode and risk reduced with antiviral therapy. Include acute urinary retention, which occurs predominantly in women Constipation which may be a risk with first episode of perianal infection. Aseptic meningitis. Herpes in pregnancy is usually only significant if the patient is experiencing a primary attack. In early pregnancy the usual outcome is either an unaffected foetus or a miscarriage. At term there is a 50% risk of neonatal transmission. In women with a history of genital herpes, the risk of transmission is in the range of 0-4%. However most neonatal herpes occurs in infants whose mothers have no history of genital herpes.
TREATMENT	Patients should be seen as soon as possible during an acute attack. Swabs are taken from the lesion for HSV culture. A negative culture does not exclude HSV. Other causes of genital ulceration should be excluded especially syphilis.
FOLLOW UP	Treatment for a primary or first episode if within 5 days of lesions developing or beyond 5 days if new lesions are developing commence treatment immediately. Valaciclovir 500mg bd for 5 days. Analgesics, laxatives, advice about urinating, lignocaine gel. A dilute saline solution (eg 1 tsp salt in a tumbler of warm water/1teacup of salt to medium bath) to relieve symptoms, reduce secondary infection and promote healing. Counselling is of the utmost importance, may need to be repeated subsequently
Syphilis
TRANSMISSION	Causative organism spirochaete Treponema Pallidum
SYMPTOMS (clinical features)	Almost exclusively sexual although can be passed from mother to child. Sexual transmission occurs in the first two years of untreated infection, although transmission to the foetus may occur up to 10 years after primary infection.
COMPLICATIONS	Primary 9-90 days Macule-palule painless ulcer. Heals spontaneously in 2-6 weeks. Indurated with clear exudate. Up to 50% may be atypical in some way e.g. multiple, painful, purulent, extragenital. Secondary 2-6 months Transient variable skin rash which can affect the soles and palms. Generalised lymphadenopathy. Condylomata lata-warty type lesions on the genitals. Mucosal ulceration. Latent Serological diagnosis. Late syphilis Cardiovascular, neurological, gummatous syphilis.
TESTS	Neurological manifestations may occur at any time in the course of the disease. The late manifestations can arise at anytime from 5 years after the primary infection in an individual who has received no treatment or inadequate treatment. For diagnosis of primary syphilis the exudate from lesions should be examined by dark field microscopy for spirochaetes. Repeat dark field daily for 3 days if the clinical suspicion is high. Serological tests do not become positive for at least 10-14 days after appearance of the primary lesion. If strong suspicion repeat FTA in 2 weeks. Repeat serology after 3 months in any case of undiagnosed genital ulcerationIn secondary syphilis the serology tests are always strongly positive. Latent and late syphilis diagnosis is based on a combination of positive TPHA and FTA. With or without positive VDRL and RPR.
TREATMENT	Treatment for early syphilis, (primary, secondary and early latent): First line therapy: bicillin 800000 units (=procaine penicillin G600,000 units) IM daily for 10 days. If unable to give Bicillin over the WE then give double dose on Monday morning. Penicillin allergy: Doxycycline 200mg daily for 14 days Or Tetracycline 500mgs QDS X 14days
FOLLOW UP	Review at 3 months for repeat syphilis serology and continue 6 monthly follow up for 2 years for patients with primary or secondary syphilis or yaws. Partner notification should take place for all partners for up to two years prior to diagnosis (discuss with senior doctor).
Hepatitis B
TRANSMISSION	Causative organism hepatitis B virus (small DNA virus). Endemic worldwide with high carriage rates up to 20% particularly in South and South east Asia, but also in Southern Europe, central and South America, Africa and Eastern Europe. In the UK carriage varies from 0.01-0.04% in blood donors to > 1% in IVDU and gay men. About 10-100 times more infectious than HIVSexual transmission occurs in unvaccinated gay men and correlates with multiple partners, unprotected anal sex and also or anal sex (rimming). Transmission also occurs after heterosexual contact e.g. 18% infection rate for regular partners of patients with acute hepatitis B. Sex workers are also considered high risk. Other routes of transmission areVertical transmission (mother to child) Blood, blood products, drug users sharing needles and equipment and occupational needlestick injuries. Infected mothers can continue to breastfeed.
SYMPTOMS (clinical features)	Incubation period of 40-160 days. Virtually all infants and children have asymptomatic acute infection. Asymptomatic infection is also found in 10-50% of adults in the acute phase and is especially likely In those who are co infected with HIV. Women tend to have more severe disease than men. Less than 1% of patients will get fulminant hepatitis 5-10% will develop chronic infection but the rate is higher in those with asymptomatic acute infection and those with HIV co infection. Almost all of infants born to Hep B positive mothers will become chronic carriers unless immunised. 20-30% of this group will go on to develop chronic hepatitis, cirrhosis or carcinoma of the liver. Carriers with the e antigen have a higher risk of developing complications.
COMPLICATIONS	Mortality is less than 1% for acute cases. Between 10-50% of chronic carriers will develop cirrhosis leading to premature death in approximately 50%. About 10% of cirrhotic patients will progress to develop liver cancer.
TESTS	Diagnosis is made by serology.
TREATMENT	Patients who present acutely in the primary care setting can be monitored and usually do not require hospital admission. In view of the possibility of chronic infection serology should be repeated after 6 months even if the LFT s are normal. Patients who develop e antibodies but remain HbsAg positive should have annual liver function tests and referral considered of abnormality develops. Persistent HBeAg Carriers should be referred.
FOLLOW UP	Hepatitis B testing should be considered in: Gay men CSWsIVDU. HIV positive patients. Sexual assault victims. People from countries where Hep B is common. Needlestick injuries. Sexual partners of positive or high risk patients. If non immune vaccinations should be offered to non immune patients in most of the above groups. The main exceptions are those who have been sexually assaulted and those born in countries of high endemicity but not at continuing risk. Vaccination schedule is 0 mths, 1 mnth and 6 mths Accelerated vaccination is 0 mths, 1 mth and 3 mths. Test for antibody response at 8-12.

Hepatitis C	Causative organism Hep C virus, genus hepacicvirus of the family flaviviridae.
TRANSMISSION	Parenteral spread accounts for the majority of cases through shared needles, syringes and other drug using equipment in IVDUs. Can also be transmitted via infected blood products and needlestick injuries. Sexual transmission occurs at a low rate (approximately 0.2-2% per year of relationship) but this rate increases if the index patient is also HIV infected. Vertical mother to child transmission also occurs at a low rate (5% or less) but transmission rates for women co-infected with HIV are higher at up to 40%.
SYMPTOMS (clinical features)	Usually infection is acquired asymptomatically. Approximately 5% will develop a hepatic illness which is usually mild.
COMPLICATIONS	Acute fulminant hepatitis is rare (< 1%). Approximately 50-85% of infected patients become chronic carriers-a state which is normally asymptomatic. Symptoms/signs are worse if there is a high intake of alcohol or other liver disease. Mortality in acute hepatitis is very low. But 20% of carriers will progress to severe liver disease after 20 years infection, with an increased risk of liver cancer. Pregnancy.There is at present no way of reducing the risk of vertical transmission. Women should be informed of the potential risk of transmission in pregnancy. Breast feeding should continue as there appears to be no additional risk of transmission.
TESTS	Diagnosis is based on the detection of Antibodies Anti HCV. There are no easy tests for the carrier state. PCR is sometimes done to detect active virus although this is not necessary before referral to the liver specialist at the JR.
TREATMENT	Anti HCV positive patients should be offered a referral to the JR for further investigation and possible treatment. Patients referred must be prepared to undergo a liver biopsy.
FOLLOW UP	There is currently no vaccine available to contacts of Hep C. It seems likely that if condoms are used consistently then sexual transmission will be avoided although given the low transmission rate monogamous partners may choose not to use them.

Molloscum Contagiosum	Causative agent the Pox Virus
TRANSMISSION	Transmission is through direct skin to skin contact and may affect any part of the body. It is a common childhood infection but in adults is usually sexually acquired.
SYMPTOMS (clinical features)	After an incubation period of 3-12 weeks, discreet pearly, papular, smooth umbilicated lesions appear. The size of the lesions rarely exceeds 5mm and if untreated there is usually spontaneous regression after several months.
COMPLICATIONS	Lesions can become large and unsightly in immunocompromised patients.
TESTS	Diagnosis is based on clinical appearance.
TREATMENT	Treatment is for cosmetic reasons only as most lesions will resolve spontaneously without treament.Treatment is usually by piercing with an orange stick with the application of phenol.
FOLLOW UP	No need for treatment or screening of sexual partners unless another infection is present.