NHS Borders. STI Management Protocol Version 5.

Transcription

1 NHS Borders STI Management Protocol Version 5 July 2011

2 Contents Page No. What s new in Version Borders Sexual Health Clinics sites and times 5 STI Screening Flowchart Patient Assessment Testing for Sexually Transmitted Infections 11 How to take samples Investigation and Management of Common Presenting Complaints : Vaginal Discharge- assessment 15 Vulvovaginal Candidiasis 16 Recurrent Vulvovaginal Candidiasis 17 Bacterial Vaginosis 18 Management of Discharge in Female Patients - Flowchart 2 19 Recurrent Bacterial Vaginosis 20 Trichomonas Vaginalis Infection 20 Gonococcal Cervicitis/Urethritis (see section 4) 21 Chlamydial Cervicitis (see section 4) 21 Non-infective Causes of Vaginal Discharge : Urethral Discharge (Males) - assessment 22 Non Gonococcal Urethritis 23 Chlamydial Urethritis 24 Gonococcal Urethritis 24 Recurrent and Persistent NSU : Genital Ulceration- assessment 26 Initial Episode Herpes Simplex Virus Infection 27 Recurrence of Genital Herpes 29 Frequent Recurrences of Genital Herpes 29 Genital Ulceration of Unknown cause : Genital warts and Other Lumps or Spots: 30 Genital Warts 31 Molluscum Contagiosum 33 Folliculitis : Itch 34 Common Diagnoses 34 Phthiriasis Pubis (pubic lice) 34 Scabies 34 Pruritus Ani 35 2

3 4.6: Pelvic Pain 36 Females: Pelvic Inflammatory Disease PID) 36 Males : Acute Bacterial Prostatitis 39 Chronic Bacterial Prostatitis 39 Chronic Pelvic Pain Syndrome : Epididymitis/Epididymo-orchitis Sexually Transmitted Infections : Chlamydia : Gonorrhoea Hepatitis 46 Hepatitis A 46 Hepatitis B 46 Hepatitis C Post-exposure prophylaxis for sexual exposure to BBV (PEPSE) Pelvic Pain : Patient Information Leaflet 52 3

4 What s new in Version 5? Version 4 was released in January Since then: Nucleic acid testing for gonorrhoea was introduced in the Borders. Tests for gonorrhoea can be performed on urine (men) and self-taken vulvovaginal swabs (women).a GP STI Testing Kit is available and specimens should be sent along with the form accompanying the kit. Routine STI screening in asymptomatic women no longer requires a high vaginal swab. (this was intended to test for Trichomonas vaginalis, which is very rare in asymptomatic women in Scotland). Performing an STI screen in general practice is now much simpler. In line with national and local moves to increase HIV testing to reduced the 30% of HIV infections that remain undiagnosed, we now recommend that all STI screens include tests for chlamydia, gonorrhoea, syphilis and HIV. See notes on Diagnostic HIV Testing page 53 Gonorrhoea treatment has changed in line with national guidance to Ceftriaxone 500mg single dose by intramuscular injection, because of evidence of reduced sensitivity to Cefixime. This reinforces our recommendation that cases of gonorrhoea should be referred to sexual health services for treatment. For treatment of occasional recurrences of genital herpes, the preferred dose and schedule recommended is Aciclovir 800mg three times daily for 2 days. This option uses 12 x 400mg tablets per course and patients can be supplied with 56 tablets at an NHS cost of around This provides enough treatment for 4 recurrences. A new flowchart and guidance on the use of PEPSE (post exposure prophylaxis for sexual exposure for HIV), has been developed n line with national guidance. The Borders Chlamydia Protocol, incorporated in this document has been abbreviated pending a forthcoming report on Chlamydia testing by an Expert Group convened by the Chief Medical Officer. A full revised protocol will be produced separately. 4

5 Frequency and staffing of BSHS clinics at March 2011 Location Description Frequency Staffing Galashiels Health Centre Family Planning Clinic Mon pm FP Nurse Receptionist Family Planning Clinic Alt Thursday 11am- 1pm Assoc Specialist 1 FP nurse 1 Receptionist Thurs pm Staff Grade 1 FP Nurses Referral Clinic Wed (alternate weeks with Hawick) Implant Clinic Tues am Thursday pm Drop-in Thurs 11am-1pm Fri pm GUM Clinic (+HIV Clinic monthly) Tues 9am-1pm Fri 9am-1pm Receptionist Assoc Spec Receptionist/ Auxiliary Nurse Specialist Nurse Specialist CNS Receptionist/Auxiliary Consultant C NS Health Adviser Hawick Community Hospital Duns - Knoll Health Centre Peebles - Hay Lodge Health Centre Eyemouth Health Centre Family Planning Clinic Implant Clinic Joint Community Gynae/Sexual Health Drop-in Mon pm Mon (Alt Weeks) Weds am Referral Clinic Wed (alternate weeks with Galashiels) Family Planning Alt Thurs Clinic Receptionist/Auxiliary Staff Grade/AS alt weeks FP Nurse Receptionist Nurse Specialist Consultant (ALT)Gynaecologist CNS Auxiliary Assoc Spec Receptionist/ Auxiliary Staff Grade FP Nurse Receptionist Drop-in Alt Fri CNS Family Planning Clinic 2 nd and 4 th Wed of the month Staff Grade 2 FP Nurses Receptionist Drop-in Alt Mon CNS 4.45pm Drop-in Alt Fri pm CNS CNS Community Nurse Specialist For full details on opening times and to make appointments phone Our website contains a range of information including a Service Directory, detailing what is available at each clinic. 5

6 Services : All clinics welcome men and women of all ages. All clinics offer emergency contraception (the morning after pill), male and female condoms, oral contraception, Implant insertion, injectable contraception, testing and treatment for STIs and advice on sexual health for men and women. All clinics provide pregnancy tests, advice on termination (abortion) and if required, referral for termination of pregnancy. You can come to any of our clinics for these things. All clinics provide services for Lesbian women, Gay and bisexual men and transgender men and women Most clinics offer additional services: Drop-in Clinics All the above services plus testing and treatment for a range of STIs, advice on contraception, HIV and syphilis blood tests. You don t need an appointment for drop-in clinics. Family Planning Clinics Advice on contraception, prescriptions for the oral contraceptive pill, injectable contraception (the Depo), the diaphragm (cap) and natural methods. Male and female condoms, testing for STIs and advice on sexual health for men and women. Most clinics also offer the IUCD (coil) and Implantable contraception (Implanon) by appointment. HIV Clinic HIV Clinics are held on the first Tuesday of every month, although patients are seen in other GUM clinics as required. Borders Sexual Health GUM Clinic Where is it? The specialist GUM Clinic is at Galashiels Health Centre, Currie Road, Galashiels. All other sexual health clinics and drop-ins offer STI testing and treatment, but for GP referrals requiring medical review, please refer to the Galashiels clinic. How do you contact the clinic? Phone for patient appointments and to contact consultant or sexual health adviser for advice. Advice for GPs The GUM consultant (Dan Clutterbuck) can be contacted on , or through RIE switchboard on Consultant advice is available by phone 5 days per week. In case of difficulty advice is also available from the GUM consultant on-call in Edinburgh through RIE switchboard for advice on: dan.clutterbuck@borders.scot.nhs.uk 6

7 Out of hours advice is available from the Registrar on call for ID/GUM in Edinburgh through LUHT switchboard on Community Nurse Specialists in Sexual Health can give advice or help with specific cases, such as contacts of infection in the community. They are also able to supply chlamydia postal testing kits (PTKs), STI testing kits and training on STI and sexual health management. Borders South & East: Gillian Forbes - Gillian.Forbes@borders.scot.nhs.uk Borders Central/Western : Suzanne Balfour Suzanne.Balfour@borders.scot.nhs.uk Borders General Hospital & Borders: Gillian Elliot Gillian.Elliot@borders.scot.nhs.uk Postal Testing Kits & Borders: Lou Graham Louise.Graham@borders.scot.nhs.uk Telephone advice for patients Phone for appointments or other enquiries. Advice calls are directed to the doctor or health adviser. To make an appointment By letter: Referrals by letter from a GP will be offered an outpatient appointment: the waiting time is 2 weeks or less. Urgent cases can be seen in the next clinic if necessary - please phone if required. By phone: Phone GPs can phone on a patient s behalf, but anyone can phone and arrange an appointment for themselves How do you get seen? By appointment: see above The walk-in clinic. Patients with symptoms or who feel that the problem is urgent and can t wait may attend the clinic between 9.00 and on Tuesdays and Fridays. We guarantee to see all attendees at this clinic. Patients with appointments will be given priority, so those attending the urgent problem clinic may have to wait and the consultation may be brief if the clinic is busy. HIV care. We currently care for 28 people with HIV infection. New referrals can be made by letter or by telephone. The first Tuesday of each month is a dedicated HIV clinic. We also provide HIV support through drop-in clinics and home visits by arrangement. 7

8 Family planning clinics. All family planning clinics offer testing and treatment for chlamydia and advice on other STIs. This may be an option for patients unwilling to attend the GUM clinic. Drop-in Clinics. Drop-in clinics are aimed at (but not restricted to) young people under 25. The clinics are nurse led and deal with common STIs and contraceptive prescriptions. Treatments are dispensed through PGD. All Drop Ins provide: o Chlamydia testing o Syphilis testing o HIV testing o Contact tracing o Treatment for Chlamydia o Treatment for Gonorrhoea o Treatment for Herpes o Treatment for Genital warts o Pregnancy testing o Condom distribution o Family planning advice Communication Letters to GPs We routinely send letters on patients referred by their GP. We also send letters (with the patients consent) on patients diagnosed with conditions with long term implications, genital skin conditions or those requiring long term treatment. We no longer send letters on patients attending for STI testing, or who are diagnosed with and treated for an uncomplicated STI. Occasionally patients who have been referred by letter do not want us to write back to their GP. We take between two weeks and a month to produce letters. If you need information on a patient s visit before then, please phone. Due to the increasing workload, we use standard letters in some cases. If you require further information, please get in touch. Results for patients Patients are asked to phone for results two weeks after attending clinic. Results are available from an automated telephone line, accessed using the patient s unique number Patients who request it receive a copy of the letter to their GP Information for patients Supplies of patient information leaflets are available by telephoning or request to hazel.mitchell@borders.scot.nhs.uk 8

9 Flowchart 1: STI Screening Concern regarding STIs See common presenting complaints No symptoms Patient assessment Sexual contacts, symptoms Symptoms: Diagnose /treat or refer GUM Sexual contact with new partner less than 10 days ago? Rape or sexual assault? Yes Refer to GUM clinic/for GUM opinion Symptomatic patients Walk-in clinic Tues & Fri am or by appointment Drop-in clinics (see page 4 and website) Urgent problem Phone GUM consultant , Mon-Fri Edinburgh GUM triage No No Out of hours Infectious disease registrar/sho on-call, ARU, Western General Hospital: Defer testing/ attendance at GUM to day 14 Give first dose of Hepatitis B vaccination course. Consider HIV risk: PEPSE? Arrange appointment at GUM clinic Refer to GUM, send to drop-in clinic or do STI screen in the community Refer to GUM clinic Asymptomatic patients: Phone for appointment on Patient phones for appointment on Give patient clinic leaflet Refer by letter Do the tests in general practice using the GP STI Testing Kit (see Page 10) Swab or first-voided urine for chlamydia PCR Swab or first-voided urine for gonorrhoea PCR* Syphilis, HIV serology and Hepatitis B testing if sexual contact abroad, men who have sex with men, or other risk factors 9

10 2 Patient Assessment What to consider: Whether the patient is symptomatic What is the risk of STI (whether symptomatic or not) Whether testing in general practice is appropriate If so, what tests you are able to do in general practice Background: Asymptomatic STIs are now so common that lack of symptoms is not a reliable indicator of the likelihood of an STI. A sexual history is important particularly in the assessment of risk factors. All the tests we routinely use in the clinic can be used in the community. A routine STI screen should include tests for chlamydia, gonorrhoea, syphilis and HIV In low risk individuals it may be appropriate not to test, or if under 20 to test for chlamydia alone Tests for Hepatitis B and Hepatitis C may be indicated in those with risk factors. New patients: History: Assess symptoms: Red flag symptoms: Refer to GUM Painless anogenital ulcers Recurrent urethral discharge in men Rectal symptoms in MSM Yellow flag symptoms: Consider referral to GUM Recurrent vaginal discharge in women Bloody discharge in men or women Pelvic pain in men or women Testicular pain Deep dyspareunia in women Symptom algorithms for the commoner presentations follow in later sections Take a full sexual history including date of last sexual intercourse, geographical location of contact, casual or regular partner, partner s gender, nationality and details of condom use and nature of sexual activity. Ask about other partners in the last 3 months as well as sex outside the UK. Check previous STIs including hepatitis and hepatitis B status in those at risk Red flag risk factors: Refer to GUM if: Physical examination: Pay particular attention to: Multiple recent partners Sex with partners in Africa, Asia or the former Soviet Union Contact of syphilis, HIV or gonorrhoea Yellow flag risk factors: Consider referral to GUM if: Men who-have-sex-with men Sex with non-uk partners Previous STI Contact of chlamydia Sexual assault Men: external genitalia including inspection under the foreskin and of the urethral meatus Women: presence of genital ulceration, appearance of any discharge, cervical inflammation or discharge, pain on bimanual examination Red flag signs: Refer to GUM if: Single genital ulcer Multiple painless ulcers 10 Yellow flag signs: Consider referral to GUM if: Multiple painful genital ulcers Urethral discharge in men Adnexal tenderness on bimanual examination in women

11 3 Testing for Sexually Transmitted Infections Options see flowchart 1: Refer to GUM clinic By appointment if asymptomatic: or send a referral letter By appointment or to the Walk-in urgent problem clinic if symptomatic: Tues & Fri am Do an STI screen in the community Send to a Drop-in Routine testing for STIs in men*: General practice, FPC, Drop-in All men Full history and genital examination Urine for chlamydia PCR Urine for gonorrhoea PCR Syphilis and HIV serology Plus - in MSM Throat swab for gonorrhoea PCR Rectal swab for gonorrhoea PCR Syphilis serology Hepatitis B serology Hepatitis A+B vaccination Offer HIV testing What we do in GUM All men Full history and genital examination Urine for Chlamydia PCR Urethral swab for gonorrhoea culture Syphilis and HIV serology If symptomatic: Urethral swab for Gram-stain microscopy Plus - in MSM Throat swab for gonorrhoea PCR Rectal swab for gonorrhoea PCR Rectal swab for chlamydia Hepatitis B serology Hepatitis A+B vaccination Routine testing for STIs in women*: General practice, FPC All women Full history and genital examination Endocervical swab (or self-taken vulval swab) for Chlamydia and Gonorrhoea PCR Syphilis and HIV serology What we do in GUM- All women Full history and examination Urethral and endocervical swabs for gonorrhoea ( culture) Endocervical swab for Chlamydia PCR HVS for wet-mount microscopy for Trichomonas vaginalis HVS for Gram-stain microscopy for candida and bacterial vaginosis Syphilis serology Offer all patients HIV testing 11

12 Borders STI Testing Kit User Information Contents: Self Obtained Lower Vaginal Swab (SOLVS) kit (for women). (The self taken swab can also be used by a clinician for cervical/vaginal samples if wished). SOLVS patient instruction leaflet Urine sample bottle (for men - urine samples should NOT be used for gonorrhoea testing in women) STI request form Notes on HIV testing Patient information: o STI testing Leaflet o Chlamydia leaflet o Borders Sexual Health leaflet Indications and limitations This kit is intended for testing for STIs in general practice or peripheral sexual health/drop in clinics. It may be used for routine STI screening in asymptomatic or symptomatic patients, or for diagnostic testing in those with symptoms. It will provide exactly the same results using the same tests as a routine STI screen in the GUM clinic, following the recommendations of the British Association of Sexual Health and HIV (BASHH). A routine STI test in an asymptomatic patient should take no more than 15 minutes and can be done in 10. This guidance should be used in conjunction with the Borders STI Management Protocol in the professionals section of the BSH website. This kit won t identify: Bacterial vaginosis or vulvovaginal candidiasis in women with vaginal discharge Trichomonas vaginalis infection (very rare in Scotland) (for these tests an additional Amies swab from the vaginal fornices (HVS) will be required). A routine STI screen doesn t include a test for TV. Non specific urethritis in men with discharge (unless caused by chlamydial infection) (an air dried microscopy slide of urethral material can be used for this purpose) Which tests to perform Patients requesting STI screening may wish to have a full set of tests performed regardless of risk. It is quite appropriate to do this. In patients unsure of which tests they require, or who present with symptoms, the decision on testing may be based on risk assessment. Two basic levels of testing are recommended for simplicity: For patients at low-moderate risk of infection: no tests or a Chlamydia test alone For patients at moderate or high risk of infection: a full STI screen Chlamydia and gonorrhoea tests, syphilis and HIV serology. Tests for Hepatitis B and C do not usually form part of a routine STI screen in Scotland. Tests may be added for those with specific risk factors see below and Borders STI management guidelines or the Borders Blood Borne Virus resource pack for Health professionals. Basic risk assessment High risk factors: sex abroad, multiple partners, sex with partners from abroad, MSM (men who have sex with men), previous STI. Moderate risk factors: new partner in last year, more than one partner in last year, under 25, high risk but consistent condom use, partners elsewhere in UK. Low risk factors: same partner>1 year, over 25, no partner, WSW, moderate risk but all partners from Borders. 12

13 Procedure Take a sexual history Assess level of risk Explain the tests involved Informed consent for testing Complete testing form Explain consent for partner notification Perform tests Make arrangements for receiving result When not to test in general practice: Red flag symptoms: Refer to G.U.M. Painless anogenital ulcers Recurrent urethral discharge in men Rectal symptoms in MSM. Red flag risk factors: Refer to GUM if Contact of syphilis, HIV or gonorrhoea Red flag signs: Refer to GUM if: Single genital ulcer Multiple painless ulcers Completing the testing form Please complete the risk factor section if performing HIV testing. Explain to the patient that by signing the form they are consenting to contact by a sexual health adviser in the event of a positive result. The adviser will discuss with them the need to ensure that sexual partner(s) are tested and treated. All discussions will be completely confidential and the health advisor will not disclose the patients name or other details to any partners. If the consent section of the form is not completed, the tester is responsible for completing partner notification. Tests in men First voided urine (does not need to be early morning) in universal container for chlamydia and gonorrhoea PCR. Serum (brown tube) for syphilis and HIV (+/- Hepatitis B and C serology) Tests in women Self taken lower vaginal swab (see instructions) or physician taken endocervical or vaginal swab (if performing examination) for chlamydia and gonorrhoea PCR. Urine samples should NOT be used for gonorrhoea testing in women) the sensitivity of PCR for gonorrhoea on female urine is questionable. Serum (brown tube) for syphilis and HIV (+/- Hepatitis B and C serology) Tests in men-who-have sex-with-men In most cases gay and bisexual men should be encouraged to attend the sexual health clinic. Where this is not possible or desirable, a swab (using the same sample tube and swab supplied for vulvovaginal tests) should be taken from the pharynx and another from the rectum, in addition to tests in men as above. See Borders STI protocol for details of swab taking. Swabs should be clearly labelled throat and rectal. Screening for Hepatitis B infection (but not Hepatitis C) is routine in MSM. Testing for HIV, Hepatitis B and Hepatitis C HIV testing is increasingly regarded as part of routine screening for STIs. See the HIV testing guidance with this pack. Tests for Hepatitis B are indicated in men-who-have-sex-with-men, those from endemic areas (including but not exclusively Asia, Southern Africa), sex workers and those using or partners of those using intravenous drugs. Request HepBcAb (Hepatitis B core antibody) and HepBsAg (Hepatitis B surface antigen). If a client reports previously having been vaccinated, request HepBsAb (Hepatitis B surface antibody). See Borders Sexual health STI management protocol for more detail. Hepatitis C is only rarely transmitted through sexual contact. Regular partners of those with Hepatitis C infection should be tested. See Borders Sexual Health STI Management protocol or Borders Blood borne virus resource pack for more details. For advice and support on any aspect of the use of this kit, contact us on , or Dan.Clutterbuck@borders.scot.nhs.uk or Gillian.Forbes@borders.scot.nhs.uk 13

14 Detail on how to take the samples For gonorrhoea and chlamydia PCR: Genital samples A single sample (urine in men, endocervical, vulval or vaginal swab in women) can be used for gonorrhoea and chlamydia. Urine or swab samples for PCR for chlamydia are satisfactory in both men and women. Swabs are easier for the lab to process, but the choice can be based on what is most convenient at the time. Urine or swab samples for PCR for gonorrhoea are satisfactory in men. In women, urine samples for gonorrhoea are not sufficiently sensitive and will not be tested for gonorrhoea by PCR. Urine samples are less uncomfortable for men and may be preferred to swabs. For women who are asymptomatic or decline speculum examination, self-taken vulvo-vaginal swabs (using the same swab and transport bottle used for endocervical swabs) are at least as sensitive as physician taken endocervical swabs. They may be more sensitive than first voided urine in women, although the difference is likely to be small and the choice of sample can be based on convenience and patient preference. Swabs are preferred to urine samples by a majority of young women in many studies. Urine PCR testing for chlamydia. First 20ml of voided urine in a sterile universal container. (If dipstick testing is undertaken (e.g. for suspected UTI, test a separate sample to avoid contamination.) Throat swab Using the same swab and transport bottle supplied for endocervical swabs, sweep over from the tonsillar fossae and soft palate. Label the sample including the site: Throat. Urethral swab Sample the terminal 1cm of the urethra in men or the opening only in women. In most cases this should not be necessary a urine sample will be used. Endocervical swab Use water to lubricate the speculum if possible- to avoid contaminating samples with lubricant. Remove any excess discharge or mucus first with a separate swab, or a small mop made by twisting an extra bit of cotton wool around a standard swab. Anorectal swab Using the same swab and transport bottle supplied for endocervical swabs, insert the swab 2-3m into the anal canal and rotate 2 or 3 times in an arc (to ensure contact with the mucosa). Label the sample including the site: rectal For trichomoniasis, candidiasis and bacterial vaginosis (symptomatic women only) Take a cotton swab from the lateral and posterior fornices and place in Amies transport medium and send to the laboratory for microscopy. In asymptomatic patients it is enough to request microscopy for Trichomonas vaginalis, so the lab won t have to perform additional irrelevant tests for yeasts and other bacteria. For syphilis, HIV and hepatitis serology Blood sample for syphilis and HIV serology (brown serum tube) Hepatitis B surface antigen (HBsAg) and Core antibody (Anti-HBc) (serum tube) 14

15 4 Investigation and Management of Common Presenting Complaints 4.1 Vaginal Discharge What to consider: Do symptoms indicate a particular diagnosis? What is the risk of STI? Is it safe to give empirical treatment alone? Which, if any tests are indicated? Background: Vaginal discharge is a common presenting symptom in general practice. It is not possible to reliably distinguish between sexually transmitted and nonsexually transmitted causes on history alone. The commonest infective causes are thrush and bacterial vaginosis (BV) these are not sexually transmitted. A HVS is not always necessary for the diagnosis of thrush and BV. The use of narrow range ph paper can be helpful in assessing discharge. A ph of <4.9 is unlikely if the diagnosis is BV or Trichomoniasis. ph > 5.0 is unlikely in thrush. (Contact the GUM clinic if you have trouble sourcing narrow-range ph paper). Trichomonas vaginalis, gonorrhoea and Chlamydia trachomatis are sexually transmitted causes of vaginal discharge. Asymptomatic infection with these organisms may coexist with BV or thrush. In all cases, a consultation about a discharge is a good opportunity to discuss screening for STIs. History (see also Page 7) Sexual history: Long-term regular partner, or no recent sexual partner, over 25 = lower risk of STI Everyone else = at risk of STI Symptom profile: Clinical diagnosis is possible with a combination of symptoms and signs, but each individual feature has a low sensitivity for particular causes: e.g. Itching with thick, white curdy discharge, erythema and fissuring of vulva: likely to be candida (thin milky fishy-smelling discharge, worse after sex: likely to be bacterial vaginosis) Clinical review is needed for other symptoms such as: abdominal pain, deep dyspareunia, menstrual disturbance, post-coital or intermenstrual bleeding (PID), urinary symptoms (UTI), and lesions such as warts/ herpes. Examination A diagnosis of first episode genital herpes is sometimes missed in women diagnosed on symptoms alone examination is advisable in all cases, especially if severe dysuria or regional pain. Character of discharge (see flowchart) - may allow presumptive diagnosis. Presence of cervicitis/ mucopurulent cervical discharge indicates discharge is cervical rather than vaginal - testing for STIs is indicated. 15

16 Red Flags: refer to GUM Contact of gonorrhoea Yellow flags: consider referral to GUM: Pelvic pain/tenderness Contact of chlamydia Recurrent problem unresponsive to treatment Tests vaginal discharge Low risk of STI Treat blind if confident patient would return if still symptomatic HVS if doubt about diagnosis, no response to first-line treatment Opportunistic chlamydia testing if under 25 years and not previously tested Risk of STI See testing for STIs in women page 9 Vaginal Discharge - Common Diagnoses 1. Vulvovaginal Candidiasis ( Thrush ) Characteristics: Vulval itch +/- burning with erythema, fissures Curdy white non-odorous discharge Symptoms can be similar to those of herpes simplex, so examine at least externally if patient is very sore. Diagnosis: Typical symptoms and external appearance HVS: Yeasts present on culture. Treatment: Only if symptomatic First choices: Fluconazole 150mg p.o. single dose (not in pregnancy, think interactions) Second Choice Itraconazole 200mg p.o. twice daily for one day (more expensive, more interactions) Third choice Vaginal clotrimazole pessaries 500mg for 1 night or 200mg for 3 nights or or Econazole pessaries 150mg for 3 nights or long-acting pessaries 150mg for 1 night 16

17 Useful Patient Information Not a sexually transmitted infection Caused by an overgrowth of Candida spp. which are a bowel commensal Treating partner does not improve outcome May recur Bubble baths, douching, tight clothing, nylon underwear, antibiotics, premenstrual week and pregnancy may predispose No evidence that low oestrogen combined pill or diet have any effect Organism not able be eradicated by systemic treatment Leaflet: Thrush: A self-help guide. Health Education Board for Scotland Vaginal Discharge: Recurrent Vulvovaginal Candidiasis Diagnosis: Defined as four episodes of mycologically proven candidiasis in 12 months. Confirm by microscopy or culture. Non-albicans candida spp may account for significant proportion. Management: Eliminate/ reduce predisposing factors (see above) Cyclical symptoms: Fluconazole 150mg orally once or Clotrimazole 500mg pessary or Itraconazole 200mg p.o. twice daily for 1 day just prior to usual onset of symptoms, or during second week of the cycle, increased to twice monthly or weekly if not successful. Persistent symptoms: Fluconazole 50mg p.o. daily for up to two weeks or Fluconazole 150mg once weekly or clotrimazole pessary 500mg weekly for three or six months. Troublesome but relatively infrequent recurrences: give supply of treatment to keep at home. Consider referral or advice from GUM All these regimes are empirical and can be adapted for the individual patient. For patients with really troublesome symptoms, it may be helpful to start with a high frequency of treatment (e.g. weekly) and reduce frequency over time. Itraconazole 200mg p.o. twice daily for one day has a broader spectrum of activity than Fluconazole 150mg single dose. However this is unlikely to have any clinical significance and it is no longer cheaper than Fluconazole. It is contraindicated in women with liver disease. 17

18 Bacterial Vaginosis Characteristics: Thin, milky, fishy-smelling discharge Sometimes the smell is the only symptom Worse after intercourse Little or no vulvitis Diagnosis: Based on Amsel s criteria: at least 3 of the following: Homogenous white vaginal discharge Clue cells in wet and gram-stained films (often also mixed organisms and depleted numbers of lactobacilli) Vaginal ph>4.9 Amine odour from vaginal discharge before or after addition of 10% potassium hydroxide (not done routinely) Note: Up to 50% of women will have Gardnerella vaginalis on culture, i.e. presence of G. vaginalis on culture is not diagnostic of bacterial vaginosis. 18

19 Flowchart 2: Management of Discharge in Female Consider AGE, SEXUAL HISTORY and CLINICAL FEATURES to decide on the need for HVS, chlamydia testing or full screening for sexually transmitted infections Patient Age Patient under 20 years Urine, endocervical swab or self-taken vulvovaginal swab for PCR for Chlamydia Consider a full screen for other sexually transmitted infections (Page 7) Sexual History Clinical features 2 or more partners in the last year. Bloody discharge Deep dyspareunia Post coital bleeding Intermenstrual bleeding Purulent cervicitis Urine, endocervical swab or self-taken vulvovaginal swab for PCR for Chlamydia Consider pelvic inflammatory disease Smell, especially after sex No itch Thin, homogenous discharge Vaginal ph>4.9 White, curdy discharge Itch Vulval irritation, erythema, fissuring Vaginal ph<4.5 Atypical features Recurrence No response to treatment Pre/post termination of pregnancy Postnatal Purulent, green or frothy discharge Bloodstained discharge Known/suspected contact of STI Contact abroad Previous STI No HVS necessary Treat for bacterial vaginosis No HVS necessary Treat for candidiasis HVS for bacteriology Full screening for STIs (Page 10) Treat on clinical suspicion Follow-up with results 19

20 Bacterial Vaginosis: Treatment: only if symptomatic* First choices: Metronidazole 400mg twice daily for 7 days (slightly more effective in clearing BV at 1 month after treatment than the single 2g dose) or Metronidazole 0.75% vaginal gel 5g applicatorful nightly for 5 nights Second choice: Clindamycin 5% vaginal cream 5g applicatorful nightly for 5-7 nights Notes: * Consider treatment in pregnancy in asymptomatic women d/w consultant 1 st Trimester pregnancy or breast-feeding use clindamycin Patient Information: Not sexually transmitted No need to, or proof of benefit of treating partner Avoid soaps, bubble baths, douching May recur Leaflet: What do you know about vaginal discharge? Health Education Board for Scotland Download at: A Recurrent Bacterial Vaginosis Diagnosis: 3 or more confirmed episodes in 12 months. Management: Metronidazole 0.75% gel 5g PV nocte for 5 days Discuss with GUM consultant or refer GUM Lactic acid gel (eg Relactagel) may be helpful in controlling symptoms Trichomonas Vaginalis Infection Characteristics: Thin, greenish, foamy discharge Vulvitis and vaginitis: can be severe Vaginal ph tends to be very high (>6.0) in trichomoniasis 20

21 Treatment: Diagnosis: 1 st Line: Metronidazole 2g single dose Tricho monas or vaginalis reported on HVS ( a wet film of material obtained from posterior vaginal fornix on Metronidazole direct microscopy 400mg or after twice incubation daily of for Amies 7 days swab from HVS) 2 nd Line: Intravaginal metronidazole gel. 0.75% once daily for 5 days Single dose metronidazole is contraindicated in pregnancy Notes: Trichomoniasis may co-exist with other STIs especially gonorrhoea: routine STI testing in all cases Treat male contacts empirically as above Follow-up: Test-of-cure at 2 weeks Consider referral to GUM for all of the above Patient Information: TV is a sexually transmitted infection Males are usually asymptomatic Male partners should receive empirical treatment to reduce reinfection rates and further transmission Leaflet: What do you know about vaginal discharge? Health Education Board for Scotland Download at: Recurrent or treatment-resistant Trichomonas vaginalis infection May be due to non-adherence to treatment or reinfection. Metronidazole resistance does occur. Discuss all cases with GUM consultant. Gonococcal cervicitis see section 4 Chlamydial cervicitis see section 4 Non-infective causes of vaginal discharge 1. Cervical ectropion: May be more pronounced with prolonged COC use. If the patient is concerned by it, consider: Stopping COC (with alternative contraception) Referral to gynaecology for cold coagulation 2. High ph with no evidence of abnormal flora - may be worth trying Aci-Jel 1 applicator full nocte for a month. 21

22 4.2 Urethral Discharge (Males) What to consider: Men with discharge need testing for STIs This can be done in general practice, but referral to GUM is welcomed Contact tracing (partner notification) will be required in every case Community Nurse Specialist if you require assistance with this. If the patient is to be treated prior to referral, please do tests as below Background: Mucopurulent discharge in men is usually pathological The main causes are non-gonococcal urethritis (NGU), also called non-specific urethritis (NSU). Gonorrhoea is a less common cause of discharge in men in Scotland. The discharge of gonorrhoea can t be distinguished from NGU on clinical grounds. About 50% of men with NGU have chlamydia Men occasionally present with concern regarding a physiological discharge (they squeeze to check ). These men usually have underlying concerns re STI or a sexual contact. Partners MUST be seen and treated. If the patient is to be treated prior to referral, please do tests as below. History: Duration Discomfort or dysuria If there is buttock or leg pain consider (rare) urethral HSV infection. Examination: As for routine STI screen. Purulent green discharge may raise suspicion of gonorrhoea, clear mucoid or white may indicate NGU. Examine the urethral meatus for ulceration. Testing: Same as for a routine STI screen (See below and Page 9). Investigation of men with urethral discharge Urine for PCR testing for chlamydia and gonorrhoea. First 20ml of voided urine in a sterile universal container. (If dipstick testing is undertaken (e.g. for suspected UTI, test a separate sample to avoid contamination.) Complete GP STI testing kit request form Negative leukocyte esterase on urine sticks testing has good negative predictive value for the presence of NSU. PLUS, in men who have sex with men: Throat swab for gonorrhoea PCR: Using the same swab and transport bottle supplied for endocervical swabs, sweep over from the tonsillar fossae and soft palate. Label the sample including the site: Throat. Anorectal swab for gonorrhoea and chlamydia PCR: Using the same swab and transport bottle supplied for endocervical swabs, insert the swab 2-3m into the anal canal and rotate 2 or 3 times in an arc (to ensure contact with the mucosa). Label the sample including the site: rectal. 22

23 Urethral Discharge - Common Diagnoses Non Gonococcal Urethritis (NGU) or Non Specific Urethritis (NSU) Diagnosis: Can only be diagnosed on microscopy hence the need to send an air-dried slide to the lab/clinic Men with urethral discharge can be treated for suspected NGU pending results of gonorrhoea/chlamydia tests Treatment: 1 st Line: Azithromycin 1g stat 2 nd line: Doxycycline 100mg bd for 7 days 3 rd line: Erythromycin 500mg twice daily for 7 days Patient Information: Approximately 50% caused by chlamydia, which is sexually transmitted Not always sexually transmitted: Also caused by: o Urethral irritants o Foreign bodies o Alcohol (?) Whether a sexually transmitted organism is identified or not, partner(s) should be screened for STIs and given epidemiological treatment. Around 30% of female partners of men with non-chlamydial, non-gonococcal urethritis are found to have chlamydia. No sex until both partners complete treatment Leaflet: What do you know about chlamydia & NSU? Health Education Board for Scotland Download at: Follow up: Review at three weeks to check symptom resolution, adherence, contact tracing. If patient is asymptomatic and partner(s) known to have been treated there is no indication for follow up unless patient wishes. 23

24 Chlamydial Urethritis (Chlamydial NGU or Chlamydial NSU) Diagnosis: Positive PCR chlamydia on urine or urethral sample. Diagnosis is often made after the patient has been treated for NSU treatment, contact tracing and follow-up are unchanged by a positive chlamydia result. DO NOT DO A TEST OF CURE FOR CHLAMYDIA WITHIN FIVE WEEKS OF TREATMENT! Treatment: As for NSU. The majority of cases will have been treated as NSU on microscopy findings at presentation, but cases of urethral chlamydial infection without pus cells on microscopy are seen. Patient Information: See chlamydial infection (section 4) Follow up: Retest for Chlamydia within 6 months (see section 4) Gonococcal Urethritis REFERRAL TO GUM RECOMMENDED Diagnosis: Presence of gram-negative intracellular diplococci on gram stained slide of discharge from terminal urethra (if air dried slide sent to the lab) Positive PCR (with a second NAAT confirmation) for N. gonorrhoea Positive culture for gonorrhoea from an Amies swab of urethral discharge Culture confirmation is required for sensitivity testing. For this reason if possible send to BSHS for treatment. Throat (and rectal cultures in men who have sex with men) must be taken before treatment if urethral slides or PCR positive. Diagnosis may be made after a man has been presumptively diagnosed and treated for NSU. Treatment Ceftriaxone 500mg intramuscular single dose o PLUS Azithromycin 1g single dose NOTE: Ciprofloxacin no longer recommended due to resistance See gonorrhoea (section 4) 24

25 Recurrent and Persistent NSU Referral to GUM recommended for most cases What to consider: NSU may persist after treatment because of reinfection Symptoms may persist even if inflammation does not Repeated courses of antibiotics may reinforce the idea that something is wrong Immediate microscopy, available in GUM, is useful Background: Symptoms may persist for 2 or 3 weeks after the effective treatment of NSU Reinfection or treatment failure does occur, but some men are hypervigilant after an episode of NSU and squeeze to check for discharge Retreatment of the latter group of men can exacerbate the problem In a few cases, persistent symptoms are due to undiagnosed herpes or infection with Trichomonas vaginalis. Both are uncommon causes of urethritis. Some men are subject to recurrent bouts of non-chlamydial NSU, occurring weeks or months after an initial episode, even if with the same partner. In these cases repeated retreatment of the partner is not necessary. Diagnosis: Persistence of symptoms and finding of >5 pus cells/hpf on a slide at least 2 weeks after treatment. An air-dried slide of urethral material for Gram-staining is mandatory Confirm adherence Confirm partner(s) treated Exclude reinfection (retest for chlamydia/gonorrhoea if initially positive) If only persistent symptom is discharge, check whether this is true discharge or during self examination and milking of urethra Treatment: Persistent NSU (within 30 days of the original episode) ONLY if there is microscopic evidence of persisting urethritis: Azithromycin 500mg single dose then 250mg daily for 6 days plus Metronidazole 2g stat If there is no evidence of persisting urethritis the appropriate management is strong reassurance and discouragement from self-examination. Recurrent NSU ( >30 days after initial episode, same partner) Treatment: 1 st Line: As for NSU, plus advise to reduce alcohol intake, increase fluid intake 2 nd Line: Azithromycin 500mg single dose then 250mg daily for 6 days plus Metronidazole 2g stat Avoid repeated examination or treatment of a regular partner Discourage self-examination Do not treat symptoms without microscopic evidence of urethritis 25

26 4.3 Genital Ulceration What to consider: Multiple, painful genital ulcers are usually caused by herpes simplex infection. In patients with no history of sex abroad, these can be managed safely in general practice. Single, painless or atypical ulcers are of concern and should be referred. Background: Other infective causes of genital ulcers are syphilis, chancroid, donovanosis and lymphogranuloma venereum. All are uncommon or rare. There have been outbreaks of syphilis in the UK since 2000, including 200 cases per year in Scotland. 87% of cases are in men-who-have-sex-with-men. There have been a handful of cases per year in the Borders. Referral to GUM is mandatory in cases with: Solitary ulcer Painless ulcers A history of sex outside western Europe Ideally, viral isolation (using the same swab as the chlamydia/gonorrhoea PCR swab) should be taken prior to initiating treatment, although it is possible to isolate HSV from lesions up to 24 hours after initiation of treatment. History: Duration, development of ulcers. Pain and tenderness. Lymphadenopathy. Regional neuralgia buttocks and legs. Systemic symptoms flu-like, myalgia, headache. Especially detailed sexual history is appropriate: should include orogenital sex (HSV), details of all partners in the last 3 months (syphilis), history of orolabial coldsore in a partner, travel, drugs, trauma. Examination: Genital herpes: visual examination of the external genitalia only to minimise discomfort. If not a typical clinical picture of HSV infection, a full general examination is appropriate, paying particular attention to the skin and oral mucosae. G Specimens: As for generic STI screen (defer these if patient in severe discomfort). Plus: Swab for HSV PCR (the same swab as used for Chlamydia must be VERY CLEARLY labelled as an HSV swab, to avoid it going into the Chlamydia PCR run!). For PCR identification of HSV 1 or 2. If primary syphilis suspected, or appearance not consistent with herpes, refer to GUM (Send to walk-in or referral by phone). Send blood for syphilis serology if delay expected (indicate query primary syphilis ) 26

27 Genital Ulceration - Common Diagnoses There are currently around 200 cases of syphilis diagnosed each year in Scotland. Initial Episode Herpes Simplex Virus Infection Diagnosis: Often clinical. Can usually be confirmed by a positive HSV culture result (but never excluded by a negative). PCR is very sensitive so it IS worth testing very small or healing lesions. Features suggesting HSV infection: Symptoms develop within 9 (usually 3) days of sexual contact. (Delayed symptomatic presentation beyond 4 weeks of initial herpes infection is uncommon, but does occur) Systemic flu-like symptoms (usually only in primary infection) Localised lymphadenopathy Regional neuralgia buttocks and legs. Severe external dysuria A severe episode with systemic symptoms is likely to be newly-acquired infection Management: Aciclovir 200mg x5/day (or 400mg tds) for 5 days or Valaciclovir 500mg bd. for 5 days unless symptoms are very mild or are healing at presentation. If symptoms are very severe or ulceration is extensive, consider a 10 day course of therapy. Antivirals are of less use if lesions present for >5days, but treatment is indicated if new lesions are appearing at any stage. Saline bathing (no proof of efficacy) Oral analgesia Local anaesthetics may be useful in severe cases in women, as a last resort to avoid the need for suprapubic catheterisation. EMLA (Lidocaine/Prilocaine) is useful. Instillagel (Lidocaine/Chlorhexidine) is also antibacterial and is inexpensive. Hospital admission: If signs of urinary retention, intractable pain, meningitis or pregnancy (1 st or 3 rd trimester) Advice to patients: the acute episode Adequate rest, take time off work Drink plenty of fluids (dilute urine rather than avoid drinking to reduce need for urination) A warm bath containing sodium bicarbonate or salt is soothing Pass urine in the bath, or with the shower spray directed at the affected area Patients can be referred on to the GUM clinic for further information and counselling re HSV 27

28 Patient Information: The first attack is usually the worst. Stress that although lifelong infection, recurrences can be treated if severe. In most cases, recurrences are an inconvenience but do not require treatment with antivirals. HSV1: 50% chance of recurrence, HSV2: 89% chance of recurrence in the first year after a symptomatic initial episode. Recurrence rate variable. 2/3 have fewer recurrences in year 2 than year one, but 1/3 have more. Average decrease in recurrence rate is about 1 (0.8) per year. Median recurrence rate is 4-5 episodes per year for HSV 2, 1 episode per year for HSV1. Draw parallels with cold sores in childhood. Asymptomatic carriage common. About ¾ of new infections are from asymptomatic partners. Only 10% of people with HSV 2 antibodies give a history of genital herpes. No indication of infidelity in long-term partner. No effect on fertility. Not a problem in pregnancy unless the primary infection occurs at the time of delivery. Many obstetricians would now allow vaginal delivery during a recurrence. Chance of an asymptomatic female passing HSV to a male partner with whom she has regular unprotected sex is about 1% per year. Transmission rates in other circumstances are unknown but likely to be similar. Virus more commonly excreted in the first three months after infection than subsequently. Leaflet: What do you know about genital herpes? Health Education Board for Scotland Download at: Herpes simplex A guide. Herpes virus association (Excellent leaflet 50p each) The Herpes Virus Association ( offers excellent information, leaflets, telephone helplines and newsletters for those affected by HSV Follow Up: In a severe primary attack review at 5 days to confirm no new lesions appearing. If new lesions are appearing- further 5 days of aciclovir. Otherwise review at 3 weeks with HSV isolation results: Full STI screen if deferred at first visit Advice according to HSV type isolated Advise patient to return in the event of further attack with severe symptoms. No need to reattend, or for further treatment, if recurrences are infrequent and/or mild. Treatment: If symptoms are distressing or severe- as for primary herpes simplex virus infection. In many cases self-management of minor symptomatic episodes with salt baths and analgesia is adequate. Treatment with aciclovir will shorten an attack by about 1 day on average but needs to be initiated within 24hrs of symptoms starting (so is rarely useful for the current attack). Aciclovir 200mg x5/day for 5 days, or Aciclovir 800mg three times daily for 2 days are effective and supplies can be given for future episodes. The latter option uses 12 x 400mg tablets per course and patients can be supplied with 56 tablets at an NHS cost of around This provides enough treatment for 4 recurrences. 28