STD (Sexually transmitted infections)

Lumps in the genital skin / mucosa:

• Genital warts
• Molluscum contagiosum
• syphilis
• Other conditions
  • Bartholin cyst
  • Vulval intraepithelial neoplasia (VIN)
  • Squamous cell carcinoma
  • Milium 
  • Angiomyofibroblastoma 
  • Dermatofibroma

Genital Ulceration (where the skin is broken or inflamed):

• Herpes
• Syphilis

uncommonly :

• lymphogranuloma venereum (LGV)
• Donovanosis
• chancroid

Other conditions: 

• fixed drug eruptions
• aphthous ulcers
• trauma
• squamous intra-epithelial lesions
• carcinoma
• Behçet disease
• crohn’s disease.

Urethritis (male)/ Non-gonoccocal urethritis (NGU):

• Neisseria gonorrhoeae
• Chlamydia trachomatis
• Mycoplasma genitalium
• Herpes simplex virus
• Trichomonas vaginalis
• Ureaplasma urealyticum
• Adenovirus

Epididymo-orchitis 

• Chlamydia trachomatis
• Neisseria gonorrhoeae

Ano-rectal syndromes (proctitis)

• Chlamydia trachomatis (including Lymphogranuloma venereum /LVG )
• Neisseria gonorrhoeae
• Mycoplasma genitalium – can cause asymptomatic anorectal infection. Asymptomatic screening is not recommended
• Herpes simplex virus
• Treponema pallidum (syphilis) 

Vaginal discharge and cervicitis

• Chlamydia trachomatis
• Neisseria gonorrhoeae
• Mycoplasma genitalium
• Herpes simplex virus
• Trichomonas vaginalis

PID 

• Polymicrobial, unidentified cause 70%
• Neisseria gonorrhoeae
• Chlamydia trachomatis
• Mycoplasma genitalium

Ano-genital ulcers 

• Herpes simplex virus
• Treponema pallidum (chancre)
• Klebsiella granulomatis (donovanosis)
• Haemophilus ducreyi (chancroid)

Ano-genital lumps 

• Pox virus (molluscum contagiosum)
• Human papillomavirus (genital warts)
• Treponema pallidum (condylomata lata)

Genital itch

• Phthirus pubis (pubic lice)
• Sarcoptes scabei (scabies)

Systemic illness 

• Human immunodeficiency virus (HIV)
• Hepatitis B
• Hepatitis A and C (rare sexual transmission)
• Treponema pallidum (syphilis)

Key facts and guidelines

1. Not all STIs manifest on the genitals.
2. Not all genital lesions are STIs.
3. Chlamydia trachomatis is the commonest cause of urethritis.
   1. Up to 50% of men and 75% of women with chlamydia may be asymptomatic
4. Gonorrhoea may cause no symptoms, especially in women.
5. STIs such as donovanosis, lymphogranuloma venereum and chancroid occur mainly in tropical countries.
6. The presentation of STIs in children, especially vaginitis, should alert practitioners to consider sexual abuse.
7. HIV infection, which is predominantly sexually transmitted, should be considered in any person at risk of STIs as well as IV drug users. It must be appreciated that it can present as an acute febrile illness (similar to Epstein–Barr mononucleosis) before going into a long asymptomatic ‘carrier’ phase.
8. All sexually active young people aged 15–29 years should be tested annually for chlamydia with a first-pass urine or genital swab

At risk of STIs?

1. Young people aged 15–29 years
2. Men who have sex with men (MSM), especially:
   • unprotected anal sex
   • >10 partners in past 6 months
   • participate in group sex
   • use recreational dr
   • \ugs during sex
   • are HIV-positive
3. Aboriginal and Torres Strait Islander people
4. Sex workers
   • No evidence of higher STI rates among sex workers in Australia compared to the general population.
   • Priority groups: street-based sex workers, those who inject drugs, culturally and linguistically diverse sex workers, Aboriginal and Torres Strait Islander sex workers, men who have sex with men, and transgender sex workers.
5. People who
   • inject drugs
   • past history of STIs
   • have unprotected sex with casual partners
   • have unprotected sex overseas
6. Sexual partners of a person with an STI
7. Pregnant women
8. Neonates born to infected mothers

How to do an STI check

1. Take a patient history
2. Note: History and examination are often not necessary for an asymptomatic screen e.g. annual Health Check
3. Normalise the psychosocial history:
   1. ‘part of a thorough health check includes asking about behaviours that could affect your health, such as using drugs or alcohol, or sexual activity’
4. Seek consent:
   1. ‘Would it be okay if I ask you some personal questions? I ask these questions routinely with all my young patients. This will include questions about any sexual feelings and experiences you may have. You don’t have to answer any if you don’t wish to’
5. Repeat the confidentiality statement you made at the outset (or during a previous consultation):
   1. ‘I just want to remind you that anything you tell me will be kept confidential, unless your or someone else’s immediate safety is under threat. I will not repeat any personal information you share with me with anyone else, including your parents, without your permission’
6. Ask about symptoms
   1. urethral (penile) / vaginal discharge – onset, colour, odour
   2. pain or burning on passing urine (dysuria)
   3. abnormal vaginal or rectal bleeding
   4. genital rashes, lumps and sores
   5. itching / discomfort in the perineum, perianal and pubic region
   6. low abdominal pain in women
   7. pain with sex (dyspareunia)
   8. if an STI is not treated it may cause symptoms such as fever, muscle / joint
7. pains, rashes, enlarged lymph nodes
8. For each symptom ask about
   1. site – where is the pain / lesion / discharge located?
   2. onset – when did the symptom start?
   3. character – size, appearance, distribution, description of discharge, odour
   4. radiation – does it go anywhere else / are there other associated symptoms
   5. alleviating factors – does anything help to relieve the symptom(s)?
   6. timing – have you had it before? Does it come and go or is it consistent?
   7. exacerbating factors – does anything make it worse?
   8. severity – of pain / symptom
9. Take a reproductive history including
   1. menstrual
   2. obstetric
   3. contraceptive
   4. Pap smear history
10. Take a sexual history and assess STI risk including
    1. new partner, multiple partners (or partner has multiple partners), regular /
    2. casual partners
    3. same sex partners
    4. condom use
    5. recent history of STI
    6. nature of sexual intercourse – do they have oral, vaginal, anal intercourse
11. Assess Blood Born Virus (BBV) risk
    1. Injecting drug use (IDU), tattoos, body piercing, prison term, cultural penile
    2. Incisions
12. Under age/young adults
    1. HEADSS schema (home, education/employment, activities, drugs, sex and suicidality)
    2. Explore family and cultural issues as these will influence attitudes and understandings of  emerging sexuality
       1. ‘People’s attitudes and beliefs about sex are usually influenced by things such as their family, religion, or cultural background. Can you tell me a bit about your own family’s background?”
    3. Legal issues to consider are:
       1. age of consent to have sex / consensual sexual activity
       2. unwanted sexual contact “I would also like to ask about whether you have had any unwanted sexual contact. Have you ever been touched sexually without wanting to be, or been pressured or forced into doing anything sexually, without giving consent”
       3. child protection – ?abuse 
       4. consent to medical treatment

Perform examination

1. If a patient has no symptoms and is not a ‘contact’, examination is often not necessary
2. The extent and nature of the examination depends on the history and may include:
3. the mouth, the skin (rash), lymph nodes for swelling or tenderness
4. the abdomen for tenderness See Acute abdominal pain and Low abdominal pain in female – adult
5. the external genitalia including the perianal area for rashes, lumps, sores or skin splits
6. in men – urethra for discharge and inflammation. Testes and epididymis for tenderness or swelling
7. women – vulva / vagina / cervix for inflammation, discharge, bleeding
8. bi-manual examination for tenderness and masses (if practitioner experienced)

How to perform contact tracing

9. The aims of contact tracing are:
   1. to prevent reinfection
   2. to identify individuals who may be infected and would benefit from treatment
   3. to interrupt on-going transmission of disease
10. Confidentiality of all parties must be maintained
11. names of all “contacts” from the previous 6 months or as relevant to STI
12. the name of the index case must never be disclosed to the “contacts”
13. document in the “contact’s” medical record that they need immediate
14. treatment for the diagnosed STI and testing for the other common STI
15. do not write the name of the index case in the “contact’s” medical record, do not write the name of the “contact” in the medical record of the index case
16. the patient may choose to inform their “contacts” themselves or may want the clinic staff to do this
17. if clinic staff are initiating contact tracing, three attempts (telephone or home visits) should be made and documented

Education and prevention and condoms

18. Assure the patient his / her confidentiality will be protected
19. If treatment is required explain the need to abstain from sex for ___  days after they
20. and their partner have been treated
21. Give information about the transmission, symptoms and complications of STI
22. Discuss safe sex practises, contact tracing / partner notification – explain why and

Prevention

1. Know your sexual partners—The more partners you or your partners have, the higher your risk of getting an STI.
2. Use a latex or polyurethane condom—Using a latex or polyurethane condom every time you have vaginal, oral, or anal sex reduces the risk of infection.
   1. When entering a new relationship it is best to use condoms for a period of time before negotiating unprotected sex with a partner
   2. How to use a condom:
      1. Condoms should be checked for their ‘use by’ date.
      2. When opened hold the tip between the fingers and roll down over the penis. 
      3. A water based lubricant can be used inside and outside the condom for lubrication and increased pleasure. 
      4. If uncircumcised, roll the foreskin back before putting the condom on
3. Know that some sex practices increase the risk
   1. Sexual acts that tear or break the skin carry a higher risk of STIs. 
   2. Oral sex: Very low risk of STI or HIV transmission. Occasionally oral herpes can be passed on through oral sex 
   3. Masturbation and mutual masturbation: There is no risk for STIs or HIV, if there is no exchange of body fluids 
   4. Anal sex poses a high risk because tissues in the rectum break easily. 
   5. Body fluids also can carry STIs. 
   6. Having any unprotected sexual contact with an infected person poses a high risk of getting an STI.
4. Get vaccines—Vaccines are available to help protect against hepatitis B and human papillomavirus (HPV).

STI testing in asymptomatic patients

Young people (15–29 years)
	CHLAMYDIA	Annually
	HEPATITIS B	Once. First confirm HBV immune status (history of prior vaccination or serology) and vaccinate if not immune
	SYPHILIS HIV	Consider according to sexual history and local STI and HIV prevalence
Asymptomatic people requesting STI/HIV testing
	CHLAMYDIA	Annually or more often according to sexual history
	HEPATITIS B	Confirm HBV immune status (history of prior vaccination or serology) and vaccinate if not immune
	HIV	Offer to everyone requesting testing for HIV
Aboriginal and/or Torres Strait Islander people
	CHLAMYDIA GONORRHOEA SYPHILIS	Annually or more often according to sexual history or local STI prevalence. Regular testing for chlamydia, syphilis and HIV is recommended, as per the Standard Asymptomatic Check-up guideline
	HEPATITIS C HIV* TRICHOMONIASIS**	A sexual history can be difficult to obtain in certain settings so consider offering BBV/STI testing liberally to this population. * Especially in the presence of other STIs ** For those from rural/regional/remote areas
	HEPATITIS B	Confirm HBV immune status (history of prior vaccination or serology) and vaccinate if not immune
Men who have sex with men (MSM)
	CHLAMYDIA GONORRHOEA SYPHILIS HIV	At least annually, up to 4 times per year for MSM who Have any unprotected anal sex Have ≥10 sexual partners in the last 6 months Participate in group sexUse recreational drugs during sexAre HIV positive
	HEPATITIS A	Serological testing is not recommended before routine administration of hepatitis vaccine. Vaccinate as per recommendations in the Australian Immunisation Handbook.
	HEPATITIS B	Confirm HBV immune status (history of prior vaccination or serology) and vaccinate if not immune3
	HEPATITIS C	If HIV positive or have history of injecting drug use. If antibody positive, test for hepatitis C NAAT to determine if patient has chronic hepatitis C.
Sex workers (see ‘MSM’ for male sex workers)
	CHLAMYDIA GONORRHOEA SYPHILIS HIV	Testing should be based on local STI prevalence, symptoms, diagnosed or suspected STI in contact and clinical findings. Frequency based on sexual history (private and professional life), if condom use is <100%
	HEPATITIS A	Serological testing is not recommended before routine administration of hepatitis vaccine. Vaccinate as per recommendations in the Australian Immunisation Handbook.
	HEPATITIS B	Confirm HBV immune status (history of prior vaccination or serology) and vaccinate if not immune3
	HEPATITIS C	If HIV positive or have history of injecting drug use. If antibody positive, test for hepatitis C NAAT to determine if patient has chronic hepatitis C.
People who inject drugs
	CHLAMYDIA GONORRHOEA SYPHILIS	Annually or more often according to sexual history.
	HEPATITIS A	Serological testing is not recommended before routine administration of hepatitis vaccine. Vaccinate as per recommendations in the Australian Immunisation Handbook.
	HEPATITIS B	Confirm HBV immune status (history of prior vaccination or serology) and vaccinate if not immune3
	HEPATITIS C	If HIV positive or have history of injecting drug use. If antibody positive, test for hepatitis C NAAT to determine if patient has chronic hepatitis C.
	HIV HEPATITIS C	According to sexual history and annually with an ongoing history of injecting drugs. If antibody positive, test for hepatitis C NAAT to determine if patient has chronic hepatitis C.
Pregnant women
	CHLAMYDIA	Consider in pregnant women aged 15–29 years and those at higher risk
	HEPATITIS B	All pregnant women should be screened using the HBsAg test.
	HIV	Every pregnancy
	SYPHILIS	All women should have a syphilis test in the first 12 weeks of pregnancy or at the first antenatal visitAdditional testing is recommended up to five times during pregnancy for certain at-risk populations and in areas affected by a syphilis outbreak

Tests for sexually transmitted infections
	Test	Specimen	Window period	Indication	Comments
Chlamydia	PCR/LCR	Urine, swab (urethra/ cervix)	2-7 days	Screening and diagnosis	PCR at high vaginal and rectal sites not validated Retesting at one month post-treatment if indicated
	Culture	Swab – any site			Highly specific, use in legal situations
Herpes	PCR	Lesion	Lesion	Diagnosis	Negative PCR or viral culture does not exclude infection
	Viral cultures	Lesion	Lesion	Diagnosis
	EIA/ELISA	Blood	3-12 weeks	Screening	Type-specific or herpes simplex virus type 2 serology most useful. Beware false results
	Western blot	Blood	3-12 weeks	Screening
Gonorrhoea	PCR/LCR	Urine, swab (urethra/cervix)	24 hours	Screening and diagnosis	PCR at high vaginal, throat and rectal sites not validated
	Culture	Swab (urethra/cervix/throat/rectum)		Screening/diagnosis Confirmation of PCR	Culture allows antibiotic sensitivity and specificity testing
Syphilis	Dark ground microscopy	Lesion	3-30 days, if chancre	Diagnosis early syphilis	Only with symptoms
	PCR/LCR	Lesion, tissue, CSF, blood	3-30 days, if chancre	Diagnosis early syphilis	Not widely available
	EIA	Blood	2-12 weeks	Screening	Repeat serology for those with suspected exposure
	RPR/VDRL	Blood VDRL-CSF	3-12 weeks	Screening, diagnosis/staging, treatment response, reinfection
	FTA-abs TPPA/TPHA	Blood	3-12 weeks	Confirmation of diagnosis
HIV	HIV antibody: – EIA – Western blot	Blood	6-12 weeks	Screening/diagnosis	Gold standard test
	p24 antigen		earliest 2 weeks		Transient, may be absent after 2 weeks
	Qualitative PCR HIV DNA (proviral DNA)				Useful for early diagnosis
	Quantitative HIV RNA (viral load)				Beware false positives
PCRpolymerase chain reactionRPRrapid plasma reaginTPPAtreponema pallidum particle agglutinationLCRligase chain reactionVDRLvenereal disease research laboratoryTPHAtreponema pallidum haemagglutination testEIAenzyme immunoassayCSFcerebrospinal fluid ELISAenzyme-linked immunosorbent assayFTA-absfluorescent treponemal antibody absorption

Potential Barriers for Patients with Symptoms of an STI Seeing a GP or Notifying Partners of a Positive STI Result

1. Stigma and Shame:
   • Fear of judgment or discrimination from healthcare providers or community.
   • Embarrassment about discussing sexual health issues.
2. Confidentiality Concerns:
   • Worry about privacy and confidentiality, especially in small communities.
   • Fear that their health information may be disclosed to others.
3. Lack of Awareness:
   • Lack of knowledge about STI symptoms and the importance of seeking medical attention.
   • Misunderstanding the seriousness of STIs and potential complications.
4. Fear of Positive Result:
   • Anxiety about receiving a positive diagnosis and the associated implications.
   • Fear of the impact on relationships and social standing.
5. Access to Healthcare:
   • Limited availability of sexual health clinics or GPs with expertise in STIs.
   • Long waiting times for appointments.
6. Financial Constraints:
   • Cost of consultations, tests, and treatments.
   • Lack of insurance coverage for sexual health services.
7. Cultural and Religious Beliefs:
   • Cultural norms and religious beliefs that discourage discussion of sexual health.
   • Pressure to conform to community standards.
8. Communication Issues:
   • Difficulty in communicating symptoms or concerns to healthcare providers.
   • Language barriers for non-native speakers.

Additional Barriers in Rural and Remote Areas

1. Limited Healthcare Facilities:
   • Fewer healthcare providers and clinics.
   • Limited availability of specialized sexual health services.
2. Distance and Transportation:
   • Long distances to the nearest healthcare facility.
   • Lack of public transportation options.
3. Resource Constraints:
   • Limited access to diagnostic tests and treatment options.
   • Shortage of trained healthcare professionals in sexual health.
4. Increased Confidentiality Concerns:
   • Higher risk of being recognized when visiting local healthcare providers.
   • Greater fear of privacy breaches in small, close-knit communities.
5. Reduced Health Literacy:
   • Lower levels of awareness and education about STIs and sexual health.
   • Limited access to health promotion and education programs.
6. Social Isolation:
   • Greater impact of stigma and social isolation in smaller communities.
   • Fear of community gossip and judgment.

Strategies to Overcome Barriers

• Education and Awareness Campaigns:
  • Increase public knowledge about STIs, symptoms, and the importance of early treatment.
  • Reduce stigma through targeted health promotion efforts.
• Confidential Services:
  • Ensure confidentiality in sexual health services.
  • Provide anonymous testing and treatment options.
• Improving Access:
  • Enhance availability of sexual health services in rural and remote areas.
  • Implement telehealth services to provide remote consultations and support.
• Cultural Sensitivity:
  • Provide culturally appropriate education and services.
  • Engage community leaders and influencers to promote sexual health.
• Financial Support:
  • Offer subsidized or free STI testing and treatment.
  • Increase insurance coverage for sexual health services.
• Support Networks:
  • Establish support groups and counseling services.
  • Provide resources and guidance for partner notification.