Sexually transmitted diseases (STDs) remain epidemic in all societies and the range of pathogens that are known to be spread by sex continues to increase. In 1990 over 578000 new cases were seen in genitourinary medicine (GUM) clinics in the UK. In the last 50 years there has been an increase in viral conditions, particularly Herpes simplex virus (HSV) and human papillomavirus, but a decrease in cases of syphilis and gonorrhoea. The recognition of AIDS and human immunodeficiency virus (HIV) has heightened awareness of STDs. In GUM clinics up to 25% of patients attend for advice and checks on their sexual health.
Three of the commonest presenting symptoms are vaginal discharge, urethral discharge and genital ulceration. In addition to a full general medical history the following should be obtained:
SEXUAL HISTORY: number and types of sexual contact (e.g. orogenital), partner’s sex, use of condoms and other forms of contraception, previous history of STDs including dates and treatment received, HIV testing and results and hepatitis B vaccination
TRAVEL ABROAD to areas where antibiotic resistance is known or where particular pathogens are endemic
DRUG MISUSEIN WOMEN, menstrual and obstetric history
General examination must include a review of the mouth, throat, skin and lymph nodes in all patients. Signs of HIV infection are covered.The inguinal, genital and perianal areas should be examined with a good light source. The groins should be palpated for lymphadenopathy and hernias. The pubic hair must be examined for nits and lice. The external genitalia must be examined for signs of erythema, fissures, ulcers, chancres, pigmented or hypopigmented areas and condylomata. Signs of trauma may be seen. In men, the penile skin should be examined and the foreskin retracted to look for balanitis, ulceration, condylomata or tumours. The urethral meatus is located and the presence of discharge noted. Scrotal contents are palpated and the consistency of the testes and epididymis noted. A rectal examination/proctoscopy should be performed in patients with rectal symptoms, those who practise anoreceptive intercourse and patients with prostatic symptoms. A search for rectal condylomata is indicated in patients with perianal lesions. In women, Bartholin’s glands must be identified and examined. The cervix should be inspected for ulceration, discharge, bleeding and ectopy and the walls of the vagina for condylomata. A bimanual pelvic examination is performed to elicit adnexal tenderness or masses, cervical tenderness and to assess the position, size and mobility of the uterus. Rectal examination and proctoscopy are performed if the patient has symptoms or practises anoreceptive intercourse.
Although history and examination will guide investigation it must be remembered that multiple infections may coexist, some being asymptomatic.
1 In men:
(a) Urethral smears for Gram staining
(b) Urethral swabs for gonococcal culture and Chlamydia testing
(c) Two glass urine test and urinalysis
(d) Rectal swabs for Gram staining and culture
(e) Throat swab for culture
(f) Blood for syphilis serology
2 In women:
(a) Smears from the lateral vaginal wall for Gram staining
(b) Vaginal swab for culture of Candida and Trichomonas
(c) A wet preparation is made from the posterior fornix for Trichomonas and for the potassium hydroxide test for bacterial vaginosis
(d) The pH of vaginal secretions using narrow range indicator paper
(e) Endocervical smears and swabs for Gram staining, gonococcal culture and Chlamydia tests
(f) Urethral smears and swabs for Gram staining and gonococcal culture
(g) Rectal and throat swabs, if indicated
i) Cervical cytology
j) Blood syphilis serology
3 Additional investigations when appropriate include:
a) Blood for hepatitis Band C serology, HIV antibody testing (with full counselling)
b) Swabs for HSV and Haemophilus ducreyi from clinically suspicious lesions in special media
(c) Smears and swabs from subpreputial area in men with balanoposthitis (inflammation of glans penis and prepuce)
d) Scrapings from lesions suspicious of early syphilis for immediate dark-ground microscopy
e) Pregnancy testing
(f) Stools for Giardia, Shigella or Salmonella from homosexual men
TREATMENT, PREVENTION AND CONTROL
The treatment of specific conditions is considered in the appropriate section. Many GUM clinics keep basic stocks of medication and dispense directly to the patient. Tracing the sexual partners of patients is crucial in controlling spread of SIDs. The aims are to prevent the spread of infection within the community and to ensure that people with asymptomatic infection are properly treated. Interviewing people about their sexual partners requires considerable tact and sensitivity and specialist health advisors are available in GUM clinics. Prevention starts with education and information. People begin sexual activity at ever younger ages and education programmes need to include school pupils as well as young adults. Education of health professionals is also crucial. Appropriate and accessible services must be well advertised. The risks of acquiring an SID may be reduced by avoiding multiple partners, correct and consistent use of condoms and avoiding sex with people who have symptoms of infection. For those who change their sexual partners frequently regular check-ups (approximately 3- monthly) are advisable. Once people develop symptoms they should be encouraged to seek medical advice as soon as possible to reduce complications and spread to others.