The exhaustive list of questions to ask during a full sexual health history is shown in Box 61.1. Such a history is really only suitable for sexual health clinics and special circumstances such as symptomatic or otherwise high-risk patients. There is growing appreciation that a full sexual history for all patients in all scenarios is unnecessary and intrusive, and yields false responses from a significant proportion of patients—an observation that would probably not surprise most experienced GPs.

BOX 61.1 Sexual health history ^*

• Presenting condition

• Targeted symptom search: dysuria, frequency, discharge, lumps, rashes, ulcers

• Past medical and surgical history

• Medication

• Allergy

• Recreational drug use: cigarettes, alcohol, illicit drugs (especially in relation to sex)

• History of injecting drug use, shared injecting equipment, tattooing, body piercing, medical procedures

• History of incarceration

• Menstrual history

• Obstetric history

• Pap smear history

• Contraceptive history

• Previous STIs, treatments and outcomes

• Previous sexual health testing

• Vaccination for hepatitis B (and hepatitis A, for men who have sex with men)

• Last sexual activity

• Number of partners in the previous 3 and 6 months

• Are partners male/female/both?

• Are partners symptomatic, from overseas, sex workers?

• Type of sex: oral, vaginal, anal

• Condom use

• Sexual assault

^* Not all these questions are appropriate to ask asymptomatic patients in low-risk settings.

A recent Australian study illustrates this point well.¹ The authors examined the attitudes of women to chlamydia testing in general practice. Acceptance of age-based chlamydia testing was high, but women did not want to be asked to provide a sexual history as part of being asked to have a chlamydia test. Some reported that they would lie if asked how many partners they had had. The authors conclude that chlamydia screening in general practice needs to be normalised and destigmatised.

That having been said, there is still a place for more detailed sexual histories. In some settings, such as sexual health clinics, patients expect to be asked about their sexual histories and are not surprised or unwilling to offer a response. Similarly, patients who present with genital symptoms or have previously had an STI might reasonably expect to be asked about their sexual history.

The aims of sexual history taking depend on the clinical scenario. For patients presenting for sexual health testing, the history should focus on the presence of symptoms and the risk of STI acquisition. The history will help to determine which tests to take, and tailor the extent of pre-test counselling. A history for sexual problems is often more wide-ranging and includes assessment of relationships, stressors, mood, sexuality, physical problems, medications and so on.

An asymptomatic patient attending a general practice setting, or one whose symptoms are not obviously related to sexual health, might be more surprised by a line of questioning directed at their sexual history. A patient who presents to the GP with a maculopapular rash, for example, might not suspect syphilis as the cause.

It falls to the person taking a sexual history to employ non-intrusive strategies that distinguish low-risk from high-risk settings, and then alter the direction of the history accordingly. This is a complex task, and it is reasonable to initially find the process daunting. The task, however, gets easier with experience and practice. In turn most patients will read the comfort level of the interviewer and respond in kind: the interviewer who can respectfully and confidently collect an intimate history provides an obvious cue for the patient to respond with similar openness and confidence (see Box 61.2, for example).

Doctor–patient power dynamics can lead to the patient feeling it necessary to please their healthcare provider. Sensitivity in history-taking, and listening to cues from the patient, will avoid the assumption of heterosexuality. Simple clarification of partners as male, female or both will facilitate disclosure.

Patients might expect that unsafe sex will be displeasing or disappointing to healthcare professionals and minimise the risks they report. Providing a non-threatening space for the patient to honestly disclose an accurate sexual history is better than an authoritarian, judgmental response. Similarly, focusing on finding tailored solutions is more effective than focusing on the problems.

Patients who are diagnosed with an STI should be counselled on the route of transmission, strategies for prevention and (where applicable) partner management.

SAFER SEX AND STI PREVENTION

The World Health Organization ranks unsafe sex as the world’s fifth most prevalent cause of mortality.^2,³ This includes mortality from HIV infection, consequences of pregnancy (predominantly lack of access to safe abortion and contraception), cervical and anal cancers and bacterial STI. Disease acquired through sexual activity accounts for 0.5% of the burden of disease in Australia.⁴ Lower rates in developed countries are attributable to education, access to contraception (particularly condoms) and safe abortion, cervical screening and better healthcare for those who acquire STIs.

Condoms have become an integral part of safer sex strategies. Used consistently, they provide excellent protection against HIV transmission, as well as other STIs spread through infected secretions, such as gonorrhoea, chlamydia and trichomoniasis. Protection against those infections transmitted via skin and mucous membrane contact, including herpes virus infection and human papillomavirus, appears to be less. Condoms are also reasonably effective as a contraceptive method. Compared with most other contraceptives, they are readily available, inexpensive and safe.

Between 16% and 20% of Australian couples reported using condoms with their regular partner in the previous 3 months, and condom use was higher with casual partners than with regular partners. Gay men reported higher rates of condom use than heterosexuals. Condom use has increased significantly among people having sex for the first time.⁵

Common problems with condoms include slippage, breakage, loss of erection and reduced spontaneity. The most common problem, however, is simply not using them. Problems of slippage and breakage are usually related to lubricant: either using an oil-based lubricant, or not using any lubricant. Storing condoms in hot places, using expired condoms or not applying condoms correctly can also contribute. Ill-fitting condoms, either too tight or too loose, might break or slip more readily. For those with latex allergy, polyurethane condoms are available. Not only are these condoms as effective as latex, they transmit heat and sensation better than latex, and are less likely to degrade with heat.

Abstinence, like condoms, is effective only if used consistently. While celibacy is a valid personal choice for some people, there is incontrovertible evidence that it is ineffective as a public health strategy to reduce STIs or unintended pregnancies.⁶

Primary care presents many opportunities for introducing safer sex messages. Consultations about contraception, Pap smears, sexual health checks, STIs, genital dermatology and so on can lead to a discussion about safer sex. In the safety of a confidential consultation, patients respond well to being presented with an opportunity to ask questions about safer sex, and this can segue into assessing their understanding of safe sex. A combination of verbal and printed information gives patients the opportunity to review information later.

Identifying problems with consistent condom (or other contraceptive) use represents a golden opportunity to engage in preventive activities. The topic can be introduced with non-threatening questions that give patients permission to report problems. For example: ‘Have you had any problems with condoms?’ can lead to identification of specific problems.

The urges that humans experience to engage in sex (including unsafe sex) are powerful, and not always amenable to rational thinking strategies. Sometimes, however, unsafe sex can be a symptom of other underlying problems—mental health problems such as depression or mood elevation, low self-esteem and issues of dependence, alcohol or recreational drug use or sexual abuse are worth considering when patterns of unsafe sexual behaviour are identified.

SEXUALLY TRANSMISSIBLE INFECTIONS

Sexually transmissible infections are caused by a diverse group of organisms. They range in size from viruses, usually measured in micrometres, to ectoparasites such as pubic lice, which are visible to the human eye. Their life cycles differ enormously, and may include stages of latency, asymptomatic carriage, systemic spread, immune evasion or neural invasion. Some are extraordinarily well adapted to coexist with humans and cause their host such little damage that they are spread widely from person to person. Some cause disease so severe that they damage their own chances of onward transmission by causing disabling symptoms, or even remove their host from the population altogether.

What these organisms share is the exploitation of normal human behaviour: sex. For STIs, sex represents a way to breach the gap from host to host without having to deal with the extremes of temperature, desiccation, ultraviolet radiation and sheer distances that usually separate one host from another. For some pathogens, this is further facilitated by transport directly to target sites of the new host within warm, buffered, nutrient-rich media such as semen and other genital secretions.

Current treatments for STIs are, wherever possible, single high-dose treatments in order to ensure adherence and minimise the induction of resistance in other flora.

Below is a brief description of the sexually transmissible organisms that are more commonly encountered in most affluent countries.

CHLAMYDIA

Chlamydia trachomatis is a common bacterial pathogen that infects the epithelial cells of the genital tract and can lead to urethritis or cervicitis and facilitates the polymicrobial infection of pelvic inflammatory disease. It can also cause proctitis and conjunctivitis. Despite such a wide range of disease in which chlamydia is implicated, most infections (about 85%) are asymptomatic. Many countries are experiencing an epidemic of chlamydia infection, and risk groups include younger age groups, Indigenous populations and men who have sex with men (MSM). Globally, chlamydia infections have a worldwide distribution and are prevalent in almost all human populations. The treatment of choice for chlamydia is the macrolide-like antibiotic azithromycin. Fortunately, resistance to azithromycin is rare.

GONORRHOEA

Neisseria gonorrhoeae is a bacterial pathogen that can cause urethritis or cervicitis and facilitate the polymicrobial infection of pelvic inflammatory disease. It can also cause proctitis, pharyngitis and conjunctivitis. Gonorrhoea is frequently asymptomatic in the cervix, throat and rectum, but is usually symptomatic in the male urethra. Gonorrhoea has been epidemic for many years, although rates are only about one-tenth of that of chlamydia. Risk groups include MSM and Indigenous populations. Internationally, gonorrhoea has remained endemic in most of the world’s populations. Gonorrhoea is infamous for its ability to acquire resistance to antimicrobial agents, and (with the exception of some rural Indigenous populations) there is no oral first-line agent available in Australia. The treatment of choice for gonorrhoea is ceftriaxone.

SYPHILIS

Treponema pallidum infections have made a spectacular resurgence in urban communities in recent years. Globally, syphilis remains endemic in most of the world’s population. Primary syphilis presents at the site(s) of inoculation with an ulcer. Secondary syphilis presents weeks to months later with truncal rash, rash on palms and soles, malaise and occasional involvement of the eye, meninges, liver and other organs. Tertiary syphilis occurs after many years (sometimes sooner, in immunosuppressed patients) and represents an immunological reaction against organisms in the brain, spinal cord, blood vessels and heart, skin, bones, joints and many other soft tissues. The recent urban epidemic of syphilis has centred on MSM. Syphilis is epidemic among many rural Indigenous communities, and the few cases of congenital syphilis in recent times have arisen from here. It is diagnosed by serological tests and by polymerase chain reaction (PCR) (where available). Syphilis is treated with injections of penicillin G, to which it remains sensitive.

FIGURE 61.1 Secondary syphilis on the sole of the foot

TRICHOMONAS

Trichomonas vaginalis is a protozoan parasite that infects the vagina and male urethra. It causes vaginitis, or sometimes cervicitis, in women, but is usually asymptomatic in men. Trichomoniasis is rarely seen in urban Australia, but is highly prevalent in some rural Indigenous communities. Internationally, trichomonas can be found at high prevalence wherever a sexually active population has poor access to healthcare. Trichomoniasis can be seen as a marker of health service equity: it requires no eradication program, but disappears from communities upon the instigation of good-quality, accessible general health services. It is diagnosed by microscopy of vaginal swabs or PCR, and can be visualised in Pap smears (although only in about 60% of cases). Treatment is with metronidazole or tinidazole.

HERPES SIMPLEX VIRUSES

Genital herpes is caused by the two herpes simplex viruses: type 1 (HSV-1) and type 2 (HSV-2). The prevalence of HSV-2 in the general Australian population is 12%, but the prevalence in women is double that of men. The prevalence of HSV-1 is 76%, but it is not possible to determine how much of this infection represents genital infection, and how much is oro-labial. Globally, herpes simplex viruses are the most common cause of genital ulceration. In the past, HSV-1 was observed to be restricted to the face, where it caused herpes labialis or cold sores; HSV-2 was thought to be restricted to the genitals, where it caused genital herpes. This situation has changed in recent years, and HSV-1 has become a much more common cause of genital herpes in younger generations.

MOLLICUTES

Mycoplasma genitalium is a sexually transmissible organism of emerging significance. It has been associated with male urethritis, cervicitis and pelvic inflammatory disease. Testing, treatments and contact management are yet to be standardised, although the regimens used to treat non-specific urethritis will effectively treat most infections. Liaison with a sexual health physician is recommended advice.

FIGURE 61.2 Primary herpes

Ureaplasma urealyticum is a sexually transmissible organism that is associated with male urethritis. It is usually managed successfully by the agents used to treat non-specific urethritis.

HUMAN IMMUNODEFICIENCY VIRUS

HIV is covered in Chapter 60.

ASYMPTOMATIC SEXUAL HEALTH CHECKS

Chlamydia, gonorrhoea, syphilis, HIV and hepatitis B are frequently asymptomatic, but nevertheless can be transmitted to others. These particular infections also carry significant public health implications.

Screening strategies are justifiable when a condition is common, has serious consequence, can be readily tested for or can be managed effectively. STIs share these features to varying degrees.

STIs are not evenly distributed throughout the population. Several groups in the community experience higher than average rates of STI. Focusing screening strategies on those at highest risk makes testing more cost-effective and lessens the chance of yielding excessive false-positive tests in low-risk populations.

The sexual health history is the tool by which primary care providers can determine whether an asymptomatic individual is suitable for screening, and helps to determine which tests to perform.

Urogenital:

• women:

• endocervical swab for chlamydia and gonorrhoea

• first-catch urine for PCR for chlamydia and gonorrhoea

• men:

• first-catch urine for PCR for chlamydia and gonorrhoea.

Serology:

• HIV antibody

• hepatitis B surface antigen and core antibody

• hepatitis A total antibody

• hepatitis C antibody (if at risk, e.g. intravenous drug user)

• syphilis serology—most laboratories use enzyme immunoassay (EIA) for screening.

‘Window periods’ exist for serological tests, and tests may need to be repeated once the window period has elapsed, to completely exclude infection after a particular exposure:

• HIV—12 weeks

• hepatitis B—24 weeks

• hepatitis A—4 weeks

• hepatitis C—24 weeks

• syphilis—12 weeks.

GENITAL SYNDROMES

Several sexually transmissible agents can affect one anatomical site and induce similar pathological processes, or syndromes. Rather than discuss organisms separately, it seems sensible to group them together by the nature of the syndromes they cause. This approach has the added advantage of better matching the way patients present.

URETHRITIS

Urethritis is characterised by urethral discharge, meatal erythema, dysuria or urethral irritation. Chlamydia and gonorrhoea represent the most important causes of urethritis; they carry significant public health implications, including consequences for partners such as pelvic inflammatory disease, chronic pelvic pain and tubal factor infertility. Complications such as epididymo-orchitis and dissemination of gonococci may arise from these infections.

Chlamydia urethritis typically presents as a mucoid discharge, urinary frequency or urethral irritation. It is important to again note, however, that most urethral infections in men will be asymptomatic. Chlamydia urethritis is treated with azithromycin 1 g orally statim. Other regimens include doxycycline 10 mg b.i.d for 7 days, or roxithromycin 150 mg b.i.d. for 10 days.

Gonococcal urethritis typical presents as a profuse purulent discharge. Less than 10% of men with urethral gonorrhoea are asymptomatic, but there is an over-representation of dissemination and epididymo-orchitis among these cases. Coexistent pharyngeal and rectal infections are common among MSM, but are usually asymptomatic. Chlamydia coinfection is very commonly seen among men with gonorrhoea. Gonococcal urethritis is best treated with 500 mg ceftriaxone IMI as a single dose dissolved in 2 mL of 1% lignocaine. Treatment for chlamydia coinfection is recommended.

Non-specific urethritis (NSU) represents the syndrome of urethritis caused by agents other than chlamydia or gonorrhoea. Its clinical features are very similar to chlamydial urethritis, and unless a specific cause can be found, the treatment for NSU is (fortuitously) the same as for chlamydia.

Patients who present with urethritis should be treated clinically, rather than withholding treatment until test results are available. For urban heterosexual men with a scant, clear discharge, empiric treatment with azithromycin will cover chlamydia and non-specific urethritis; gonorrhoea treatment can be withheld until tests are received. In settings where gonorrhoea is more likely—for example, purulent urethral discharge in a returned traveller—empiric treatment for both gonorrhoea and chlamydia should be given.

For around half the cases of urethritis, no easily identifiable cause is found. For most men with NSU, empiric treatment is sufficient to alleviate symptoms; those who do not respond may require further assessment to exclude important pathology.

Sexually transmissible agents implicated in NSU include herpes simplex viruses and Trichomonas vaginalis. The role of Mycoplasma genitalium as a sexually transmissible agent of public health significance is currently being investigated. While this organism is responsible for a substantial proportion of NSU, testing is not widely available and optimal treatment regimens are yet to be determined. Specialist liaison is recommended for treatment options. Viral agents such as adenovirus and herpes simplex viruses are sometimes distinguished by intense perimeatal erythema, inguinal adenopathy, but scant mucoid discharge. Adenovirus urethritis may be accompanied by conjunctivitis and coryzal symptoms.

Other organisms include Ureaplasma urealyticum, anaerobes and various organisms which, when inoculated into the male urethra, may cause localised mucosal irritation. However, these same organisms can be found in asymptomatic men. Specific diagnostic tests for these organisms are not routinely recommended, as their detection is difficult and would not alter the management of uncomplicated urethritis.

Non-infective causes of urethritis include trauma from, for example, vigorous sexual activity, urethral stricture (fortunately rare these days), foreign body and Reiter syndrome. The anxious patient who ‘milks’ his urethra in search of discharge will, if he is diligent enough, cause a traumatic urethritis.

FIGURE 61.3 Viral urethritis

VAGINAL DISCHARGE

The most common causes of vaginal discharge are candidiasis and bacterial vaginosis. Although these are not sexually transmissible, concomitant STI should be excluded by collecting an endocervical nucleic acid amplification test (NAAT) (e.g. PCR) for chlamydia and gonorrhoea. Bacterial vaginosis and candidiasis can be diagnosed on microscopy of the high vaginal swab.

Bacterial vaginosis is an overgrowth of the anaerobic species that usually make up a minority of the bacterial populations in the healthy vagina. It can arise spontaneously, or be induced by altering the physicochemical environment of the vagina (e.g. with frequent sexual intercourse, or douching). Bacterial vaginosis is not an invasive process and seldom leads to an inflammatory response. Asymptomatic women who present with bacterial vaginosis reported on a high vaginal swab do not require treatment (unless they are in a high-risk pregnancy or about to undergo cervical instrumentation). Bacterial vaginosis typically presents with a thin, malodorous, homogenous, greyish discharge. Symptoms are often worse after sex or during menstruation. Treatment with metronidazole or clindamycin is effective, but relapse is common. Recurrences might be reduced by stopping douching, or avoiding semen in the vagina. Probiotic therapy has not been successful in treating bacterial vaginosis or preventing recurrence.

Candida species are normal vaginal flora, and do not require treatment unless symptomatic. Candidiasis represents overgrowth of the endemic Candida albicans population, either through an increase in their trophic factors (e.g. oestrogen-containing oral contraceptives or HRT), reduction in their inhibitory factors (e.g. removal of bacterial flora through antibiotics or douching) or immunosuppression (e.g. diabetes or HIV). Candidiasis typically presents with a clumping, thick, white or yellowish discharge, often accompanied by vulval erythema. Topical and oral azoles are equally effective at eradicating Candida albicans. Topical preparations work faster, but oral fluconazole is less messy and more convenient. Longer courses of topical azoles are more effective than shorter courses. Women with disordered glucose metabolism will often notice candidiasis symptoms promptly after ingesting a sugar load; they certainly benefit from good glycaemic control. The role of sugar in the diets of women with normal glucose metabolism, however, is less clear. Similarly, yeast-free diets are an evidence-free zone. Yoghurt and other probiotics are lacking in evidence of efficacy, but topical yoghurt on a tampon may provide symptomatic relief through its emollient properties. Less messy is the insertion of a probiotic (Lactobacillus) capsule per vagina daily for one week. It can also be done several days premenstrually if candida exacerbations occur with periods.

Recurrent candidiasis (four or more microbiologically confirmed episodes per year) is more difficult to treat. Weekly oral fluconazole for up to 6 months may help to reduce the bowel carriage of Candida from which recurrences are thought to arise. Alternatively, doubling the duration of standard doses may help. Attention to predisposing factors is recommended. Care should be taken to ensure that the Candida species recovered by the laboratory are albicans, as non-albicans species such as C. glabrata and C. krusei are often resistant to azoles. Liaison with a sexual health physician, gynaecologist or microbiologist is recommended. The available evidence for use of probiotics for prevention of recurrent vulvovaginal candidiasis is limited. There are some small clinical trials supporting the effectiveness of oral or intravaginal administration of lactobacilli, particularly the strains acidophilus, rhamnosus GR-1 and fermentum RC-14. In vitro studies have shown that lactobacilli inhibit the growth of C. albicans and its adherence to the vaginal epithelium. A recent review of probiotics for recurrent vulvovaginal candidiasis concluded that there is limited beneficial evidence, but as adverse effects are rare, it may be recommended.⁷

Garlic has antifungal properties, and wrapping a single clove in unbleached gauze may be effective in treating candidiasis. Side effects, however, include local irritant and allergic reactions, as well as odour.⁸ Tea tree oil is ineffective for vulvovaginal candidiasis, and can lead to severe contact reactions.⁸ Gentian violet has antifungal properties, but there are no randomised controlled trials of its efficacy, and side effects include vulval irritation and staining of clothes.⁸

Douching is not a recommended treatment of candidiasis. Douching can in fact be quite harmful and has no place in women’s hygiene practices. It may remove the normal vaginal bacteria, leading to an overgrowth of pathogenic species and a predisposition to STIs, such as Neisseria gonorrhoeae or Chlamydia trachomatis. The pressurised fluid can force pathogens upwards from the lower genital tract into the cervix, uterus, uterine tubes and abdominal cavity, potentially causing pelvic inflammatory disease. Douching is also linked to vulval dermatitis and chemical burns, ectopic pregnancy and bacterial vaginosis.⁹

Cervicitis is most frequently caused by chlamydia, but gonorrhoea and trichomoniasis are less common causes. Cervicitis may present with vaginal discharge, dyspareunia, abnormal menstrual bleeding, postcoital bleeding or intermenstrual bleeding. Chlamydia cervicitis is treated with azithromycin 1 g orally statim. Alternatively, doxycycline (100 mg b.i.d. for 7 days) can be used in women with macrolide allergy.

Involvement of the normally sterile upper genital tract can result from chlamydial or gonorrhoeal cervicitis facilitating polymicrobial infection to ascend from the vagina. The result is pelvic inflammatory disease (PID). Treatment of PID involves a longer course of antibiotic therapy: doxycycline 100 mg b.i.d. and metronidazole 400 mg b.i.d., both for 14 days. Ceftriaxone 500 mg IMI should be added where gonorrhoea is suspected or proven, particularly in areas where gonorrhoea is prevalent in women (e.g. remote Indigenous communities). The role of azithromycin as a replacement for doxycycline is evolving an evidence base, and most would agree that adding a stat dose of azithromycin at the beginning of the course is good practice. For more severe PID, refer to a gynaecologist.

Trichomoniasis causes a vaginal discharge that resembles bacterial vaginosis, but may show inflammatory features (e.g. vaginitis, vulvitis or cervicitis). Trichomoniasis is treated with tinidazole or metronidazole 2 g orally statim. As it is an STI, partner treatment is recommended.

Other causes of vaginal discharge include foreign body, physiological discharge, pregnancy, ectopic pregnancy and malignancy of the cervix or vagina. Some dermatological conditions (e.g. lichen planus) can also affect the vaginal mucosa and present with discharge.

PROCTITIS

Anal problems are common, but the history and examination is often non-specific. STIs are often forgotten causes of anorectal symptoms, and it is not unusual for sexual health clinics to ‘inherit’ patients who have delayed and arrived by circuitous routes to the correct diagnosis.

Proctitis can present with anal discharge, or irritation of the perianal skin from constant exposure to discharge. Painful spasm (tenesmus) and a feeling of incomplete emptying with defecation may be reported. Bowel habit may be altered and vary, from diarrhoea, to constipation, to alternating diarrhoea and constipation. Systemic symptoms are sometimes seen in more severe cases, and the patient may be quite unwell.

Examination may show inguinal adenopathy, discharge at the anal verge. Proctoscopy must be performed very gently and carefully, and sometimes requires the instillation of lignocaine jelly to relieve the pain and spasm enough to allow examination. Discharge, oedema, ulceration, fissures or haemorrhoids should be noted. NAAT (e.g. PCR) swabs for chlamydia and herpes should be collected, as should cultures for gonorrhoea. Syphilis can cause proctitis, and serology should be collected, as might a syphilis PCR where it is available.

Proctitis is caused by chlamydia, gonorrhoea, herpes and, less frequently, syphilis. As patients can be quite ill, and deteriorate quickly, it is recommended that treatment be commenced immediately, rather than waiting for tests to come back. Treatment is recommended to cover chlamydia, gonorrhoea and herpes. Empiric treatment with doxycycline 100 mg b.i.d. for 10 days, ceftriaxone 500 mg IMI and valaciclovir 500 mg b.i.d. for 5 days is recommended.

Asymptomatic carriage of chlamydia and gonorrhoea is common among MSM who have anal sex, but should be considered in anyone who has anal sexual practices. It should be noted that penile–anal intercourse is not the only way to transmit STIs to the anus: digital play has been implicated with infection too.

Lymphogranuloma venereum (LGV), caused by invasive strains of chlamydia, has been reported in MSM from many cities. Presentation is usually with severe proctitis or proctocolitis. Chlamydia PCR tests will be reactive for LGV, and further testing should be discussed with a local sexual health physician or microbiologist. LGV is usually treated with prolonged courses of doxycycline, but azithromycin will probably have a role here in the future.

GENITAL LUMPS

Warts are overwhelmingly the most common cause of genital lump. The causative agent, human papillomavirus (HPV) is acquired by up to 80% of sexually active adults, yet only about 5% of those exposed will develop warts. Most warts are caused by the non-oncogenic strains of HPV, primarily HPV6 and HPV11, although there are approximately thirty other genotypes that show a tropism for genital skin.

Treatments for genital warts are not very well studied; this is perhaps surprising for such a common condition. There are few well-designed, randomised trials, and those that exist vary greatly in their duration of follow-up and methodology. Unfortunately, this makes intelligent comment comparing various treatments impossible. The situation is complicated further by the high rate of response to placebo, a feature that has led to erroneous conclusions being drawn from substandard trials. The H₂ blocker, cimetidine, is probably the best example of this: non-comparative studies using cimetidine reported encouragingly high rates of wart resolution. In placebo-controlled trials, however, cimetidine performed no better than placebo. The use of cimetidine for wart treatment is an ideal study in medical quackery.

Medical treatments for warts include imiquimod and podophyllotoxin, both of which can be applied by the patient at home. Practitioner-applied medical therapy includes podophyllin resin and trichloroacetic acid, but training is required for the use of these. Commercially available over-the-counter preparations for warts are not suitable for genital warts as the concentrations of salicylic acid, podophyllin derivatives and other ingredients are too high. Care should be taken to avoid using imiquimod or podophyllin/toxin in pregnant women.

Ablative therapies include liquid nitrogen or nitrous oxide cryotherapy. These are easy to use, widely available and can be used as adjunctive therapy with medical treatments when they fail to resolve warts.

More invasive ablative therapy such as electrocautery, scissor excision or laser ablation requires local, or even general, anaesthaesia and is probably no more effective than other modalities. It should, ideally, be reserved for warts that have failed to respond to more sensible treatments.

Zinc supplementation has been examined in one double-blind randomised controlled trial ¹⁰ and showed a significantly greater response to zinc than to placebo. The dose of zinc studies was reasonable high, and side effects included gastrointestinal symptoms such as nausea, vomiting and abdominal pain.

Lifestyle modification may be useful in managing warts, particularly those that are difficult to treat. Smoking and stress are likely contributors to ongoing genital warts. Hypnosis was found to be an effective treatment for warts in one trial.¹¹ In this study, hypnosis resulted in greater wart regression than placebo or salicylic acid.

MOLLUSCUM CONTAGIOSUM

Normal anatomical features are commonly misdiagnosed as warts. Clinicians should be aware of the appearance of features such as pearly penile papules, vestibular papillae, Fordyce spots and Tyson glands.

Other causes of genital bumps include skin tags (acrochordon), seborrhoeic keratoses and tumours.

GENITAL ULCERS

Ulcers on genital skin and mucosal membranes are a common presentation in primary care. The causes of genital herpes are listed in Box 61.4. Almost all genital ulcers in developed communities are caused by the herpes simplex viruses. Other causes of genital ulcers are important because of their public health implications, and the seriousness of their complications if left untreated.

Herpes is the most common cause of genital ulceration worldwide.

Herpes infection can present either as an initial infection or as a recurrence. An initial infection may be more severe in its manifestation, with bilateral ulceration, larger and deeper lesions, adenopathy and extragenital manifestations such as fever, headache, radiculopathy and meningism. Primary infection, in which the newly infected person has not been previously infected by either HSV-1 or HSV-2, is associated with the most severe presentations. Previous exposure to HSV-1 does not protect people from acquiring HSV-2 (or vice versa), but does tend to reduce the severity of the clinical manifestations if the other virus is acquired later.

Recurrences are the hallmark of herpes simplex viruses. HSV rapidly establishes latency in the lumbosacral dorsal root ganglia during initial infection. After latency is established, virions are continuously transported to the skin or mucosal surface via sensory neurons. Sub-epithelial lymphocytes destroy viruses, leaving the neuron, and limit viral replication. When neuronal production of virus increases or the function of these lymphocytes is disturbed, recurrences occur. In this way, recurrences can be seen as having virological and/or immunological triggers.

Triggers for recurrence are poorly understood, and may vary widely among individuals. Commonly described triggers include sunburn or windburn, concomitant infections such as URTIs, sleep deprivation, changes in nutrition (e.g. skipping meals) and physical or psychological stress. Recurrences are more frequent early in the course of infection, and tend to become less frequent and less severe as time goes on. This is particularly true of HSV-1 genital infections, where it is uncommon to see clinical recurrences after the first 6–12 months. Recurrences are seen with greater frequency and severity in the immunosuppressed.

Virtually all patients who have herpes infections will experience virological recurrence, whereby there is viral replication and shedding of virus from the skin. The ‘classic’ clinical appearance of a recurrence is of grouped vesicles on an erythematous base that burst to form painful ulcers. These recurrences are very easy to recognise clinically, but only about one-fifth of people with genital herpes will experience these classic recurrences. Another fifth will periodically shed virus, but remain completely asymptomatic. The other 60% will have ‘atypical’ recurrences and have a wide variety of clinical manifestations. Atypical lesions include fissures, painless ulcers, erythema or altered sensation without any visible changes. Unsurprisingly, most people with herpes simplex infections on their genitals remain unaware of the infection.

Transmission of herpes is predominantly through asymptomatic or subclinical shedding of virus—that is, production of virus from skin or mucosa that has few, if any, signs or symptoms.

Transmission can be reduced by consistent condom use, avoiding sexual contact when symptoms are present, and suppressive use of valaciclovir (the efficacy of other antivirals in interrupting transmission remains to be determined).

Although initial infections can be severe, the psychosocial consequences are by far the most significant source of morbidity from herpes, and the GP will need to provide advice on coping with the emotional and social impact of the virus.

Treatment approaches

SYPHILIS

Syphilis has made something of a comeback in recent years, with an epidemic among MSM. Other risk factors include HIV seropositivity, and attendance at sex clubs, sex parties and other venues where high rates of partner change can be facilitated. Finding partners over the internet has also been linked with syphilis acquisition.

Early diagnosis, prompt treatment, contact tracing and opportunistic screening for those at risk are the main public health strategies for controlling the current syphilis epidemic.

Unfortunately, clinicians’ unfamiliarity with syphilis has led to delays in treatment and the risk of ongoing transmission in many cases. While a detailed description of the clinical spectrum of syphilis is beyond the scope of this book, the key clinical features of early syphilis are listed in Box 61.5.

BOX 61.5 Key clinical features of syphilis

Primary syphilis:

• Incubation period is 9–90 days.

• Painless ulcer is common, although ulcers are occasionally painful.

• Ulcer may be missed if hidden, e.g. anal, pharyngeal.

• Ulcer is often indurated: like a button under the skin.

• If ignored, the lesion slowly disappears.

• Primary lesions are teeming with organisms and are highly infectious.

Secondary syphilis:

• Appears a few weeks after the primary lesion has gone.

• Sometimes primary lesion is still present.

• Wide spectrum of clinical manifestations.

• Non-itchy maculopapular rash involving the trunk, palms and soles.

• Systemic symptoms often present: fatigue, malaise.

• Adenopathy, hepatomegaly and splenomegaly are common.

• Sometimes neurological and eye involvement: stroke-like signs, uveitis.

• Patients with secondary syphilis are highly infectious.

Tertiary syphilis:

• Rarely seen nowadays.

• Inflammatory lesions of bone, brain, heart, skin, eye, viscera.

• Very wide spectrum of clinical manifestations.

• Patient is no longer infectious.

Treatment of syphilis is best done in conjunction with a sexual health physician, or other specialist with training in syphilis management.

Contact management of syphilis is a crucial part of management. Contacts should be treated on presentation, rather than awaiting tests that may still be negative in the incubation period.

SPECIAL POPULATIONS

YOUTH

Young people have a number of factors that predispose them to acquiring STIs. The comparatively high rate of partner change experienced by young people still learning about relationships, sex and themselves provides an epidemiological opportunity for disease acquisition. Biological factors such as cervical ectropion may predispose younger women, and those using oestrogen-containing contraceptives may be at increased risk of chlamydia acquisition. Young people have a greater chance of encountering new pathogens to which they have not mounted immunological defences, further predisposing them to new infections.

Opportunistic screening is recommended for people aged between 15 and 29 years.

ABORIGINALS AND TORRES STRAIT ISLANDERS

Some Aboriginals and Torres Strait Islanders (ATSI), particularly in rural and remote areas, have higher rates of bacterial infections such as gonorrhoea, chlamydia and syphilis. There are also higher rates of herpes and hepatitis B infections. HIV infection rates are comparable to those of the general population. ATSI in the remote northern parts of Australia are among the few populations in which donovanosis is still seen. Trichomonas vaginalis remains common in rural and remote ATSI, despite being rarely seen in the general population. Vaccination for hepatitis B is recommended.

MEN WHO HAVE SEX WITH MEN

Some MSM, particularly in large urban centres, have higher rates of bacterial infections such as gonorrhoea, chlamydia and syphilis. There are also higher rates of herpes, hepatitis A, hepatitis B and HIV infection. STIs are associated with higher rates of HIV transmission. Vaccination for hepatitis A and B is recommended.

In addition to the testing listed for asymptomatic men above, rectal swabs for chlamydia (NAAT) and gonorrhoea (NAAT or culture) and throat swabs for gonorrhoea (NAAT or culture) are strongly encouraged as a routine part of screening MSM.

WOMEN WHO HAVE SEX WITH WOMEN

STIs can be transmitted between women through the sharing of cervical, vaginal and anal secretions. Reported rates of most STIs among women who have sex with women (WSW) are probably no less than rates among heterosexual women. Rates of HIV, hepatitis B, hepatitis C and syphilis, however, are reported at very low rates. Bacterial vaginosis is more commonly found among WSW and, unlike heterosexual contact, it appears that bacterial vaginosis can be sexually transmitted. Cervical abnormalities are reported as frequently as in women in general, but uptake of screening among younger women is suboptimal. Healthcare practitioners play an important role in encouraging WSW to participate in cervical screening. Lesbians need Pap smears even if they have never had sex with a man.¹²

Safer sex between women:¹³

• Acknowledge risk of STI transmission via body fluids and skin-to-skin contact

• Hepatitis B vaccination

• Regular STI testing when changing partners

• Latex dams are not popular, but other helpful strategies include:

• ensuring adequate lubrication

• keeping fingernails short

• using condoms on sex toys and changing between partners, or washing toys between partners

• using latex gloves for penetrative sex and avoiding oral sex during menstruation if BBV status is unknown or if there is risk of BBV transmission.

COMMERCIAL SEX WORKERS

In the early days of the HIV epidemic, commercial sex workers (CSW) in Australia were pivotal in preventing the spread of HIV into the general community. Sex worker organisations vigorously promoted safer sex practices, and CSW incorporated condoms for all penetrative services with an outstanding level of uniformity and consistency. Consequently, STIs are infrequently seen in CSW, and when they do occur they have often been acquired from private, rather than professional, life.

RETURNED TRAVELLERS

Those who have sex in countries with high rates of endemicity are at high risk of acquiring STIs. The risk is particularly high after unprotected sex with sex workers. Clinicians should be aware of the higher risk of unusual conditions, including HIV, syphilis, LGV and chancroid.

MANAGING PARTNERS

Contact tracing is a necessary part of managing STIs of public health significance. Responsibility for contact tracing is considered an intrinsic part of testing for, diagnosing and managing patients with an STI. As many people with STI are asymptomatic, infected partners are usually unaware of the infection. Ensuring they are diagnosed and treated is important from ethical, public health and personal health aspects. It also prevents reinfection of the index case.

Partners can be notified in two main ways: provider referral, in which the clinician contacts the partner; and patient referral, in which the patient notifies the partner. Provider referral is the preferred strategy for uncommon or serious conditions such as syphilis or HIV, and many state or local authorities will have contact tracers to assist in these cases. Sexual health clinics can assist in these cases too, and can further assist in the counselling, treatment and follow-up of these patients. Partners can be contacted by telephone, letter or, in some instances, personal visit.

Patient referral is much less labour-intensive, and is more appropriate for common conditions, such as chlamydia.

Email and text messages are another way for partners to be contacted. The website of the STI in Gay Men Action Group (see Resources list) was created to assist gay men to notify their contacts via a text message or an ePostcard.

A common pitfall in the management of contacts is not treating them on presentation. Where there is an established risk of contact with a treatable STI, treatment should be offered immediately, rather than waiting for test results. Testing should still occur, but should not delay treatment. Box 61.6 summarises the management of partners.

BOX 61.6 Management of contacts of patients with STI

• Chlamydia—priority of contact tracing is high. Contacts from the previous 6 months (or as determined by symptoms or testing history) should be offered presumptive therapy with azithromycin 1 g orally statim.

• Gonorrhoea—priority of contact tracing is high. Contacts from the previous 6 months (or as determined by symptoms or testing history) should be offered presumptive therapy with ceftriaxone 500 mg IMI statim, dissolved in 2 mL of 1% lignocaine. Ciprofloxacin 500 mg orally statim may be used only if the isolate is known to be sensitive.

• Syphilis—priority of contact tracing is high. Consultation with a sexual health physician is recommended in all cases.

• Trichomoniasis—priority of contact tracing is medium (easily contactable partners only). Contacts from the previous 3 months (or as determined by symptoms or testing history) should be offered presumptive therapy with metronidazole or tinidazole 2 g orally statim.

• HIV—priority of contact tracing is high, and referral to a sexual health clinic or other HIV specialist is recommended. Contacts who may have been exposed in the previous 3 days may be eligible for post-exposure prophylaxis.

• Genital herpes—priority of contact tracing is low. Contacts should present if they become symptomatic, or require information or counselling. Post-exposure prophylaxis or other presumptive therapy is not recommended.

• Genital warts—contact tracing is not recommended, but partners may be seen for information.

• Candidiasis—contact tracing is generally not recommended, but regular partners might be considered for treatment if they are symptomatic, or in recurrent candidiasis.

• Bacterial vaginosis—is not sexually transmissible (except perhaps in women who have sex with women).

Adapted from the Australasian Contact Tracing Manual¹⁴

The Australasian Contact Tracing Manual¹⁴ contains more information about contact tracing and such useful additions as patient handouts, case studies, privacy legislation considerations and sample contact tracing letters.

GENITAL DERMATOLOGY

A complete discussion of genital dermatology is beyond the scope of this chapter. Genital skin differs from other skin. It is thin skin that is usually under conditions approaching those of occlusion. The microbiology includes colonisation with yeasts, coliform and various organisms that thrive in dark, moist environments. Genital skin is often sweaty and moist, and might be exposed to urine, genital secretions or faecal matter. Perhaps most importantly, the range of irritants that this delicate skin is exposed to is mind-boggling.

Soaps, detergents and over-washing are the most frequent irritants. Increasing one’s washing habits is, unfortunately, a common reaction to irritation or rash on genital skin. Over-the-counter preparations, such as antifungals, tea tree oil, paw-paw ointment and antiseptics can all be potent irritants, especially when applied to non-intact skin. Often, by the time patients present, the clinical picture has become complicated.

Skin conditions affecting the genitals may appear different from extragenital skin. Psoriasis, for instance, is often less well demarcated and has less scale. A careful history and extragenital skin examination will often give the clinician the diagnosis before the genitals are even visualised.

Treatment of dermatological conditions is described in Chapter 42, Skin. Similar treatment strategies can be employed in the genitals, but care should be taken to account for the occluded conditions and thinness of genital skin. Tar solutions and salicylic acid concentrations should not exceed 3%, and care should be taken with the use of calcipotriol. Ointments are better tolerated than creams on genital surfaces, and provoke less irritation.

FIGURE 61.4 Psoriasis of the glans penis

FIGURE 61.5 Severe balanoposthitis (see Ch 46)

Both vulvitis and balanitis are more commonly associated with irritant exposure than most clinicians appreciate. Other causes, such as candida infection and bacterial superinfection, may complicate the picture, but care should be taken to address any underlying irritant dermatitis. Combination preparations that include corticosteroid, antifungal and antibacterial in an ointment base are useful.

SEXUAL DIFFICULTIES

It is not possible to give a detailed account of sexual difficulties here, but some of the common themes and problems are introduced. Erectile dysfunction is covered separately in Chapter 49, reflecting the recent increase in research and availability of newer treatments in recent times.

Delayed ejaculation

In delayed ejaculation, there is a very prolonged time from arousal to ejaculation despite appropriate stimuli. This may be caused by medication (SSRIs are the most common), pathological causes (diabetes, prostatectomy, neurological disorders) and psychological causes (depression and anxiety). Exploring patient expectations is worthwhile, as some (usually males) have unrealistic expectations of their ability to perform sexually. Organic causes are usually associated with delayed ejaculation all the time, whereas psychogenic causes are associated with a fluctuating course.

Anorgasmia

Anorgasmia is failure to reach orgasm during sexual activity. Anorgasmia is more common in women, and can be an extension of the same processes that cause delayed ejaculation. Individuals vary greatly in the time it takes to reach orgasm and, for many women, orgasm is not routinely experienced during ‘missionary position’ penetrative sex. It is worth exploring the perceptions of ‘failure’ in anorgasmia and perhaps redefining success for both partners. For many, orgasm is not the sole goal of every act of intercourse. Helping partners appreciate each other’s turn-ons and turn-offs through counselling and sensate focus can help.

Dyspareunia

Pain during sex is known as dyspareunia. It is much more common in women, and seldom seen in men. It can arise from multiple causes including vaginismus (see below), pelvic pathology, postmenopausal vaginal dryness, dermatological problems and penetration when the woman is not aroused. See also Ch 52.

Vaginismus

Vaginismus is caused by involuntary spasm of the muscles that encircle the vagina, leading to pain on penetration or attempted penetration. While most cases are attributed to psychological causes, painful pathology of the vulva, vagina or pelvis may contribute. Sometimes vaginismus persists after the original physical cause has resolved. Sensate focus and counselling can help once physical causes have been excluded or managed.

Low libido

Low libido was recently noted to be the most commonly reported sexual difficulty, but it remains difficult to define. Exploring patients’ expectations can be useful. Depression, anxiety, hypothyroidism, hypogonadism and almost any chronic medical condition can be associated with loss of libido. Relationship problems, sexuality issues and a wide variety of inter- and intra-personal issues can be involved. External stressors, such as work pressures, family pressures, financial problems and many others, can be implicated. Often the problem is not low libido per se, but a desire mismatch between partners. Education about desire discrepancy can help, as can counselling.

Premature ejaculation

In premature ejaculation there is a very short time from arousal to ejaculation. Exploring what the client means by ‘too early’ and identifying unrealistic expectations can be useful. Premature ejaculation is most frequently reported by young men who are becoming sexually active, or entering their first relationship. Many men find that the problem decreases as they settle into a new relationship, and become more sexually experienced and more confident. For some men, the biological threshold for ejaculation is set very low, and does not settle with time. Strategies for treating premature ejaculation that is problematic include: using a condom; numbing creams (e.g. EMLA); SSRIs in low doses, e.g. sertraline 25 mg daily, titrated up if necessary. Exercises aimed at ‘desensitising’ the premature ejaculator, such as Seman’s exercises and stop-start and squeeze techniques, are options for those who don’t want SSRI therapy, but the acceptability and efficacy of these techniques in clinical practice is doubtful.

It does not take much time in general practice to gain an awareness of how common sexual difficulties are. The prevalence of sexual difficulties was illustrated in the landmark Study of Health and Relationships ⁵ and confirms that sexual difficulties are common, perhaps surprisingly so. Table 61.1 describes the frequency of various sexual difficulties.

TABLE 61.1 Sexual difficulties for at least one month in the previous year

Sexual difficulties	Men (%)	Women (%)
Lacked interest in having sex	25	55
Came to orgasm too quickly	24	12
Worried during sex that body looked unattractive	14	36
Unable to orgasm	6	29
Felt anxious about ability to perform	16	17
Did not find sex pleasurable	6	27
Physical pain during intercourse	2	20
Vaginal dryness	–	24
Trouble keeping erection	10	–
Used treatment to aid erections	2	–