Sexual History

“I'm going to ask you a few questions about your sexual health & practices. I understand that these questions are personal but they are important for your overall health. I ask these questions to all my adult patients. Confidential. Questions?”

1. Name/age/occupation
2. PC
3. HPC: dysuria, discharge, abdo pain, scroatl pain, bleeding
4. PMH: had this before, last menstrual period
5. DH: OCP (good at taking it?), abx

6. Then:

   Partners

   “Are you currently sexually active?” Timing of last intercourse, How many, gender, partners, duration of relationship, RFs (eg. drug use, partners), ppl other than partner

   Practices

   “What kind of sexual contact do you have or have you had?”

   Protection from STDs

   Condoms etc. “Do you & your partner(s) use any protection against STDs? If not, could you tell me the reason? If so, what kind of protection do you use? How often do you use this protection? If sometimes, in what situations or with whom do you use protection?”

   Past history

   STDs, HIV, syphilis

   Pregnancy prevention

   Trying? Condom/OCP.

7. “What other concerns or questions regarding your sexual health or sexual practices would you like to discuss?”

Risk Factors for sexually transmitted diseases

• Unprotected sex
• Multiple partners
• Sex during menstruation
• Sexual secretions
• Blood contagion
• IV drug use
• Shared needles
• Needleprick injury
• Vertical

Investigations

1. Urine dipstick and MSU for MC+S. Chlamydia can be detected in urine.
2. Ulcers: swabs for HSV culture, microscopy for syphilis
3. Urethral smear for gram stain/culture for gonorrhoeae in men endocervix in women, chlamydia swab
4. High vaginal swab for microscopy/culture for candida, gardnerella, trichomonas
5. Blood tests: syphilis, hepatitis, HIV serology
6. Nuclear amplification assays for chlamydia

Common Diseases

Gonnorrhoea

Signs: men

Urethral pus±dysuria, tenesmus, paroctitis±discharge

Signs: women

Often asx. May have vagina discharge, dysuria, proctitis

Complications

Local : Prostatitis, cystitis, salpingitis (pain, fever, infertility), epidimytis, arthritis, Bartholinitis. Systemic : Septicaemia, Reiters. Obstetric : Ophthalmia neonatorum. Long-term : Urethral stricture, infertility

Management

Cefixime. Treat for chlamydia too. No alcohol/intercourse until clear. Treat contacts.

Chlamydia trachomatis

Commoner. Harder to diagnose. Sx/Si similar to ↑.

Complications

Similar to ↑. Rectum/pharynx not affected.Esp Reiters, neonatal conjunctivitis

Management

1 week doxycycline 100mg/12h PO. Single dose of azithromycin 1g PO. No alcohol/intercourse until clear. Treat contacts

Other causes of discharge

Thrush (Candida albicans)

White curds. Vulva/vagina may be red, sore, fissured. Ix: Strings of mycelium/oval spores on microscopy. Management: Imidazole vaginal pessary e.g. clotrimazole. Or one dose of fluconazole 150mg PO

Trichomonas Vaginalis

Vaginitis & bubbly fishy-smelling discharge. Exclude gonorrhoea. Ix: Motile flagellate on microscopy or culture. Management: Metronidazole 400mg/12h PO.

Bacterial vaginosis

Fishy smelling dischage. Itch is rare, no inflammation. Ix: “Clue cells” on microscopy. Management: Metronidazole 400mg/12 PO for 5d, or clindamycin cream.

Other

Hep B

Spread through IV route (Infected blood products, IV drug use, tattooists), sex, vertical

HIV

Sex (esp homosexual), IV drug use, contaminated blood products, organ donations, vertical