PROVISION OF STI SERVICES IN PRACTICE ICGP SUMMER SCHOOL 2007 DR GERALDINE HOLLAND

Transcription

1 PROVISION OF STI SERVICES IN PRACTICE ICGP SUMMER SCHOOL 2007 DR GERALDINE HOLLAND

2 WHY GENERAL PRACTICE? INCREASING DEMAND FROM PATIENTS FOR GP TO PROVIDE TESTING/SCREENING CHANGING TRENDS IN STIs OPPORTUNITY TO INCORPORATE SEXUAL HEALTH INTO ROUTINE CONSULTATIONS eg teen health/contraception/well man checks

3 ISSHR October st ever Irish Knowledge, Attitudes and Behaviours study into sexual health Telephone interview 7,300 participants, M/F, yrs Increasingly liberal attitudes Age at 1 st s. intercourse 19yrs women, 18 yrs men 25% men, 6% women - > 10 sex. Partners 9% men, 8% women sought info re STI GPs commonest source of advice on STI 60% men, 51% women prefer to seek advice from GP

4 Annual Trends , Ireland : Breakdown by Year and Disease type Sexually Transmitted Infection Total Ano-Genital Warts Chancroid Chlamydia Trachomatis Genital Herpes Simplex Gonorrhoea Granuloma Inguinale Infectious Hepatitis B Lymphogranuloma Venereum Non-Specific Urethritis Syphilis Trichomoniasis Total

5 Annual Trends , Ireland : Chlamydia trachomatis 3000 Chlamydia Trachomatis 2500 Number of Cases Year of Notification

6 Sexual Health Strategy HSE 2005 Important role of GPs in preventative and treatment services Move STI services out of hospitals Improve existing services Need for specialised education and training Publicly funded services in satellite locations Should be available on GMS Drop-in services / out-of of-hours services Improved GP links to other service providers

7 Headline Recommendations for Services - BASHH Widened role for primary care Closer working between primary and secondary care Increased community role for sexual health advisers Targeted chlamydia screening Improved access to GUM services Managed clinical networks for HIV and other services

8 Potential barriers to treatment Patient: Those at high risk of STI often don t perceive themselves to be at high risk Denial of symptom, concern Incomplete / inaccurate story Lack of education can impair risk perception Accessibility of services Location Timing cost

9 Potential Barriers to treatment? Doctor/Nurse: Time constraints Cost issues Confidentiality issues Avoidance Fear of negative reaction? Inhibitions & shyness? Fear of missing something / training issues Adequate equipment?

10 Barriers to treatment. STI Awareness on general level Asymptomatic nature of most STIs (incl HIV) Contact tracing Symptoms & Signs Dysuria (M & F) Urethral / vaginal discharge Intermenstrual / post-coital bleeding Pelvic Pain Epididymo-orchitis orchitis

11 Principles of STI Management Accessibility Confidentiality Diagnosis before treatment (where possible) Screen for accompanying STIs Simple treatment regimes Follow-up after treatment Partner notification Non-judgemental patient support, counselling and education

12 STI Service Provision in GP Common things are common chlamydia! Risk assessment: if you don t ask the question you won t hear the t answer! Adoption of practical approach: Good Hx Examination: Genital and other examination Diagnostic tests and screening: simple, inexpensive, accessible tools can make huge difference Urinalysis beta-hcg Speculum & good light ph paper swabs

13 Notifiable STI s HPSC 2004 Ano-genital warts Chlamydia trachomatis Genital herpes Non-specific urethritis Hepatitis B, C Gonorrhoea Trichomoniasis Chancroid Pediculosis Pubis, Candidiasis, Molluscum contagiosum ALL denotified 2003 HIV not statutorily notifiable in Ireland currently under review

14 Additional/linked Services Contraception/Family Planning Cervical Screening Out-reach Services Vulval/Genital Dermatology Psychosexual Adolescent health care

15 Linked Sexual Health Pathologies Mental Health Unwanted pregnancies STIs HIV Anogenital Cancers Neonatal Infections Subfertility

16 STI Service Provision in GP Know your limitations AND those of your supports (eg( labs) Partner notification Liaisons with GUM clinics, family planning centres etc.

17 Sexual Health Assessment Comprised of Sexual history taking illness orientated. Follows easily if presenting with symptoms Risk assessment important in preventing spread of asymptomatic infection/ health promotion Sexual health assessment holistic approach sees the person to whom the issues belong.

18 What s different about a sexual history? Emotional issues Emotive issues Embarrassment Involves other people Attendance as a contact Moral/legal issues

19 Managing the consultation Emphasis confidentiality & significance of information. Summarize assessment of risk Discuss safer sex in context Informed consent for tests & examination Inform when & how to obtain results Arrange treatment, referrals/follow-up

20 Five keys to good communication Permission Explanation Assumptions Conversation Timing

21 Permission Core Questions Do you mind if I ask you a few questions about Your relationships? Your sexual activity? Your risks of sexual health problems? Explanation I need ask these questions to decide your risks for certain infections and also to help choose which tests and possible treatment you might need.

22 Core Questions Avoid assumptions Are you in a relationship? / Have you a partner at present? Is that with a male or female partner? Have all of your partners been male/female? Other than your wife/husband, when was your last other sexual partner? Have you ever bought or been paid for sex?

23 CHLAMYDIA

24 CHLAMYDIA TRACHOMATIS INTRA CELLULAR BACTERIA SEXUAL/PERI-NATAL TRANSMISSION

25 Life Cycle

26 WOMEN 80% ASSYMPTOMATIC PURULENT DISCHARGE DYSURIA PCB/IMB CERVICITIS PID FITZ-HUGH HUGH-CURTIS SYN/REITERS SYN

27 Cervical Ectropion (White Arrow) with Mucopurulent Cervicitis (Black Arrow) Peipert, J. F. N Engl J Med 2003;349:

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29 MEN 50% ASSYMPTOMATIC URETHRAL DISCHARGE DYSURIA PROCTITIS EPIDIDYMO-ORCHITIS ORCHITIS

30 DIAGNOSIS ENDO-CERVICAL SWAB FIRST VOID URINE

31 TREATMENT ZITHROMAX 1G STAT PATIENT AND PARTNER ABSTAIN FOR 10/7 OR DOXYCYCLINE 100MG BD X 1/52 PREGNANT ERYTHROMYCIN 500MG BD X 2/52 OFLOXACIN 200MG BD X 1/52

32 TEST OF CURE NOT ROUTINELY INDICATED WAIT 3/52?? REPEAT SCREENING INTERVAL ROLE OF CONTACT TRACING AND CONTINUING EDUCATION IN SAFE SEXUAL PRACTICES

33 CASE 1 A 22 Y/O WOMAN PRESENTS FOR A PILL CHECK. SHE HAS BEEN ON 30ug PILL FOR 3 YEARS. SHE COMPLAINS OF SOME IRREG BLEEDING OVER THE PAST 2/12. SHE DENIES ANY MISSED PILLS. HOW DO YOU PROCEED?

34 CASE 2 30 year old man attends clinic complaining of painful testicle. What will you cover in the history? What would you examine for? What is the differential diagnosis? What investigations? What initial treatment?

35 Some answers History: how long, full sexual history, Examine: evidence of infection, mass part of the testes, discharge from penis D/D: Trauma, epididymo-orchitis orchitis,, torsion, varicocele,, hernia, tumour Inx: Gram stain, test for Chlamydia and NG, Urine. Ultrasound if D/D not clear or swelling persists after treatment Treatment: Analgesia, suspected sexually acquired doxycycline 100mg bd 2/52 (stat ceftriaxone if NG suspected). Or ofloxacin. Review

36 Epididymitis/orchitis Inflammation of the epididymis and/or testicle. Aetiology <35year old STI >35years old UTI Genital infection - Chlamydia and N.gonorrhoeae - Is the cause in 70% in under 35yrs - coliform enteric bacteria UTI. (coliform( bacteria) Other causes (eg( TB, vasculitis,, drugs)

37 CASE 3 A 30 year old woman presents with lower abdominal pain and a dark discharge. What history will you take? What examinations? What investigations?

38 Some answers Ectopic pregnancy Full hx,, exam including BM Wide differential of abdominal pain PT +ve+ Suspected ectopic so referred to early pregnancy unit for urgent further investigations. The link with chlamydia One of the sequelae of PID is increased risk of ectopic pregnancy. Chlamydia can persist in tubes, increased tubal damage (salpingitis( salpingitis), egg more likely to be fertilised in tube

39 Complications of Chlamydia In Women Bartholinitis +/- abscess Endometritis Pelvic Inflammatory Disease and sequlae chronic infection leading to subfertility,, increased risk of tubal pregnancy, chronic pelvic pain Peri-hepatitis (Fitz-Hugh Curtis syndrome) Rarely SARA - In men Epididymitis Prostatitis (not well established link) SARA Rarely peri-hepatitis

40 Causes of Vaginal Discharge Physiological Infective Foreign body Malignancy Other

41 Infections causing discharge: Vaginitis Candida Trichomonas Vaginosis Bacterial vaginosis Cervicitis Chlamydia Gonorrhoea Herpes simplex Other ß haemolytic strep

42 I I have a discharge.... what next? How long have you had it? Is there any itching, soreness or smell? Are there any other symptoms, such as lower abdominal pain, deep dyspareunia or intermenstrual bleeding? Have you had this before, if so what was it? Take a sexual history to make a risk assessment for STIs and pregnancy

43 Diagnosis of vaginal discharge Presumptive diagnosis on the basis of history and clinical findings ph of vaginal discharge High vaginal swab for MC&S (charcoal) Bimanual examination not indicated unless other pelvic pathology suspected If at risk of STIs consider also Endocervical swab

44 BV IN PREGNANCY Assoc. with late miscarriage Pre-term labour PROM Low birth wt. Endometritis post partum Rx in pregnancy even if asymptomatic Metronidazole after first trimester

45 FFPRHC 2003 Comparison of Vaginal Infections Candida BV TV Discharge White (curdy) White/grey homogenous Yellow green frothy Smell Nil (yeasty) Fishy Malodorous Pruritis Yes No Yes Vulvitis Yes/no No Yes/no Vaginitis Yes No Yes Cervicitis Occasionally No Yes PH < 4.5 >5 >5 Microscopy (HVS) White cells + Candida Clue cells + abnormal flora White cells + TV Culture (HVS) Yes No No

46 Trichomonas Vaginalis

47 Comparison of Management of Vaginal Infections Candida BV TV Systemic treatment Diflucan Metronidazole Metronidazole Topical treatment Clotrimazole Metronidazole or clindamycin cream - Partner notification Not an STI Not an STI Yes Test of cure No No Sometimes Predisposing factors Rarely Yes STI

48 Summary Take an appropriate history, including a sexual history Examine when necessary, e.g. at risk of an STI, persistent/recurrent or suspicious symptoms, treatment failures Know which tests to use, including ph of vaginal discharge Test for STIs when appropriate