Introduction

There are two main principles in the management of sexually transmitted infections. First, an infected patient implies that at least one other person is also infected. Thus, treating a patient in isolation will not control the spread of these diseases. Second, a patient may harbour more than one sexually transmitted infection (Box 21.1). Many infections are asymptomatic, acquired months or even years previously. Patients are often uncomfortable or embarrassed to give their sexual history or a history of genitourinary symptoms as stigma and shame are often attached to sexually transmitted infections. Remember that babies, monogamous partners and victims of rape and sexual abuse can also be infected.

The interview and examination must be carried out in private, in strict confidence and avoiding any disapproving, judgemental or moralistic attitude. As with other clinical problems, diagnosis is achieved by history (Box 21.2), examination and relevant laboratory tests. Following diagnosis, effective treatment and partner notification/contact tracing should be instituted promptly. In children under 16 years of age, ensure they are able to comprehend (follow the Fraser’s guidelines in the UK) and it is essential to exclude any child protection issues and sexual abuse.

History

Sexual history

Enquiry into the less embarrassing aspects of the medical history fosters the patient’s confidence, so start with this before moving on to more intimate matters, such as (in the case of women) contraception and the menstrual history. Details of the sexual history should be obtained by simple questions. Ascertain the date of exposure: ‘When did you last have intercourse/sex?’ and particulars of sexual contacts over recent months. Heterosexual, homosexual or bisexual contact should be ascertained: ‘Do you have intercourse/sex with men, women or both?’ If married: ‘When did you last have intercourse/sex with your wife/husband?’ followed by ‘When did you last have intercourse/sex with someone else?’ and whether with regular partners, casual contacts or commercial sex workers (Did you pay for sex?). Are sexual partners traceable, for example place of intercourse: ‘which town?’ and ‘whether abroad?’ If there are several contacts, it is useful to identify them by first names.

The incubation period of infection may be assessed from the date of exposure to the onset of symptoms, and hence the probable cause. Tropical sexually transmitted infections should also be considered in patients presenting with genital problems acquired in the tropics. A history of intercourse with homosexual or bisexual men, injecting drug users or persons in or from an area of high HIV endemicity suggest AIDS as the cause of multisystemic symptoms and signs.

The type of sexual practice will dictate the sites from which to take tests (see below). It is also helpful to understand some of the common or unfamiliar terms that may be used in relation to sexual practices. ‘Straight sex’ indicates heterosexual (penovaginal) intercourse. Ask whether the person also practises insertive or receptive oropenile intercourse: ‘Do you receive or give ‘oral sex’?’ Certain practices in homosexual or bisexual men (‘gay sex’) may predispose to particular infections; for example, if there is oroanal contact, the possibility of intestinal pathogens should be considered. Hepatitis B and HIV infections are more common in those practising receptive penoanal intercourse. Ask whether the patient practises insertive (‘active’, ‘give anal sex’) or receptive (‘passive’, ‘receive anal sex’) penoanal intercourse: ‘When did you last have anal sex?’, ‘Do you give or receive anal sex?’ or simply ‘Are you ‘active’, ‘passive’ or both?’ Some patients practise oroanal intercourse (‘rimming’), insertive or receptive brachioanal intercourse (‘fisting’) and, rarely, urinating onto each other (‘watersports’) or using faeces during intercourse (’scat’). ‘Bare backing’ is unprotected anal intercourse; ‘cottaging’ is sexual intercourse in public places.

Heterosexual couples may also practise penoanal intercourse. This should be enquired for if rectal infection is found in women, although this commonly occurs in association with infection at other genital sites without having anal sex. Sex ‘toys’ or ‘dildoes’ (artificial penises) are objects inserted into the rectum or vagina. ‘Fisting’ and ‘toys’ may cause injury presenting as an acute abdomen. ‘Bondage’, in which the person is tied up during sex, may be associated with masochism (sexual gratification through the infliction of pain on another). This should be considered if superficial injuries are present without an obvious cause.

Enquire about the use of condoms whether or not the patient is using other methods of contraception. Condom use should be advised if the person is at risk of acquiring or transmitting sexually transmitted infections, or if the efficacy of an oral contraceptive is affected by the concomitant use of other drugs. Many infections that may initially be acquired through non-sexual means, for example hepatitis B and HIV infection among injecting drug users and haemophiliacs, may be secondarily transmitted through sexual intercourse. Advice on non-penetrative ‘safer sex’ practices, such as body rubbing, dry kissing and masturbating each other, can be given to infected individuals who do not wish to have penetrative intercourse.

Sexual dysfunction, including erectile problems, premature and retarded ejaculation, often presents to a sexually transmitted disease clinic. Impotence is likely to be psychogenic if it is sudden in onset, related to life events, situational or intermittent, or if nocturnal or early morning erections are unaffected, and organic causes often have a psychogenic component. Curvature of the penis on erection may result from Peyronie’s penile fibrosis.

Genital examination

The patient should be examined in a well-lit room and gloves should always be worn. Chaperoning should be offered; female patients must be chaperoned when examined by male clinicians.

Male genitalia

The penis

Note the appearance and size of the penis, the presence or absence of the prepuce and the position of the external urethral orifice. Examine the penile shaft for warts, molluscum, ulcers, burrows and excoriated papules of scabies and rashes. In Peyronie’s disease, there may be induration or a fibrotic lump inside the penile shaft. In the uncircumcised, establish that the prepuce can be readily retracted by gently withdrawing it over the glans penis. This allows inspection of the undersurface of the prepuce, the glans, the coronal sulcus and the external urethral orifice (meatus) for warts (Fig. 21.1), inflammation, ulcers and other rashes. Always carefully draw the prepuce forwards after examination; otherwise paraphimosis – painful oedema of the foreskin due to constriction by a retracted prepuce – may ensue.

Figure 21.1 Genital wart on the frenum of the penis.

Phimosis is narrowing of the preputial orifice, thereby preventing retraction of the foreskin; it may be due to lichen sclerosus. This predisposes to recurrent episodes of infection of the glans (balanitis), the prepuce (posthitis) or both (balanoposthitis). Circinate balanitis in Reiter’s disease appears as erythematous eroded lesions which coalesce with a slightly raised and polycyclic edge. Multiple small yellow or white submucous deposits (Fordyce’s spots) may be seen on the inner prepuce. These are ectopic sebaceous glands and do not require treatment. Smegma, which is greyish–white cheesy material arising from Tyson’s glands, may accumulate under the prepuce if unwashed.

Hypospadias is a congenital abnormality in which the external urethral orifice is not at the tip of the glans penis but opens at its ventral surface in the midline, anywhere from the glans to the shaft, or even in the perineum. Epispadias, a similar opening situated on the dorsal surface of the penis, is rare.

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