Common STI’s in General

Practice
⮚Chlamydia
⮚Gonorrhea
⮚Trichomonas
⮚Other Non- STI’s but genital infections are :
⮚Candida
⮚Bacterial Vaginoses.
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• Genital Chlamydia most common STI : 2012. 206,912

people tested positive
• 64% were under 25
• Highest in men aged 20-24, women 16-19
• Highest rates in women 20-24 & 16-19
• Rates of STI’s highest in residents of Urban Areas : In
London
 Chlamydia

❖Chlamydia stems from a bacterium chlamydia trachomatis

❖Women with chlamydia can infect their newborn infant
during delivery
❖Symptoms appear 7-21 days after infection, different for
men, women and children.
❖Can test 14 days after exposure
 Chlamydia – the facts
Caused by
Bacteria Chlamydia trachomatis

Incidence
The most commonly diagnosed STI in the UK

Symptoms Chlamydia trachomatis

In many cases Chlamydia is asymptomatic however
• Women – vaginal discharge, abdominal pain,
pain on passing urine
• Men – discharge from the penis, testicular
inflammation, irritation of the penis
• Babies – eye infection, pneumonia

Transmission
• Via vaginal, anal and oral sex
• Can be transmitted from mother to unborn baby Swollen testicles due to a
Chlamydia infection
Symptoms in Men

✔Inflammation of the urethra

✔Stinging feeling when passing urine

✔Pain or tenderness in the testicles.

✔Asymptomatic in over 50%

✔Rectal discomfort/proctitis
Signs in Men

• Urethral discharge and/or dysuria

• Local complications such as epididymitis

Symptoms in Women

• Purulent vaginal discharge

• Pain caused by pelvic inflammation

• Dysuria

• Post coital or inter-menstrual bleeding.

• Asymptomatic in 80%
Signs in women

• Cervicitis, muco-purulent discharge

• Cervical contact bleeding

• Local complications e.g. bartholinitis, signs of pelvic

infection
Chlamydia in men and women

43. Mucopurulent cervicitis

 Diagnosis

• Nucleic acid amplification tests (NAATS)

• Urine tests or swabs

• High sensitivity and specificity

• Chlamydia can not be diagnosed on genital swabs sent for

• MC&S e.g. HVS in charcoal swabs
Treatment

• Doxycycline 100mg x 7 days

• Azithromycin 1g stat if compliance is an issue

• A l t e r n a ti v e R E G I M E N S
• Erythromycin 500 mg bd x14 days( if pregnancy possible or
breast feeding)

• Erythromycin 500 mg qds x 7

• Ofloxacin 200mg bd/400mg od x 7days

complications

⮚ PID/ epididymitis

⮚ Low birth weight

⮚ Post-partum endometritis
⮚ Neonatal conjunctivitis and pneumonia

In women, ascending infection leads to pelvic

inflammatory disease: endometritis, salpingitis, tubal
damage, and chronic pelvic pain.
PID the risks of ectopic pregnancy and infertility.

Autoinoculation may result in chlamydial conjunctivitis

Contact tracing/partner notification

• Partner notification should be discussed with all patients

identified with genital chlamydial infection. All recent
(last 6 months or last previous partner whatever is
longer) and current sexual partner

• Invited to attend for evaluation.

• Treatment should be given even if tests are negative

Patient Advice

• If Chlamydia Trachomatis is left untreated it could lead to

serious complications

• Need to treat sexual partners

• Abstain from sexual intercourse (even with a condom)

including oral sex until completion of therapy ( wait 7 days if
treatment with Azithromycin)

• Side effects of treatment

• Advice on safer sexual practices and how to avoid infection

in the future
Gonorrhoea

• Caused by Neisseria gonorrhoea loves moist, warm areas

• In women the cervix is the most common site of infection.

The disease can also spread to the uterus and fallopian
tubes

• Pelvic inflammatory disease can be caused if untreated

leading to infertility

• Pregnant women can pass it on to the newborn infant when

normal delivery leading to severe conjunctivitis
 Gonorrhoea
Caused by
Bacterium Neisseria gonorrhoeae
Incidence
Increased by 46% between 1997 and 2006 in
the UK
Symptoms
• About half of all women infected with
gonorrhoea, and over 90% of men
experience symptoms
• Can affect the genitals, anus, rectum and
throat with symptoms including Neisseria gonorrhoeae

– a thin, watery discharge from the vagina

or tip of the penis that can appear yellow
or green, and pain when urinating
Transmission
• Sexual intercourse
Signs and Symptoms

• Early symptoms are often mild, and many women who are
infected have no visible symptoms of the disease

• Painful burning sensation while urinating Yellowish or

bloody discharge from the vagina

• Bleeding between periods

• Abdominal pain
Symptoms in Men

• Burning micturition

• Yellowish-white discharge from the penis: also called

mucoid from the urethra

• Local complications in men

Epididymitis
Infection of various penile glands
Symptoms in women

•Cervicitis •Local complications in women

•Discharge mucoid purulent •Bartholinitis

•Cervical excitation •endometritis

•Signs of upper genital tract

infection
Other signs and symptoms

• General S/S if affected in other areas include:

• Rectal itching

• Pharyngeal infection is usually asymptomatic ( If infection has

occurred via oro-genital route)

• Complications include septicaemia, arthritis, and skin lesions

Diagnosis

• Gonorrhoea and Chlamydia can be isolated from an

endocervical swab taken in primary care
Diagnosis

• Isolated from an endocervical swab taken

• NAATs testing for both gonorrhoea and chlamydia

Treatment

• Gonorrhoea Treatment

• In view of increasing antibiotic resistance to gonorrhoea, the

British Association now recommend that all gonorrhoea be
treated with
• Ceftriaxone 500 mg im stat  + azithromycin 1 g stat po
Updated treatment

• However if there is ANY DOUBT that the client will

attend DOSH, or if for any reason an im injection is
inappropriate, these second line regimens are also
indicated and should be given by the GP

• Cefixime 400 mg po + azithromycin 1 g stat po

• OR
• Azithromycin 2g po stat
Contact tracing/partner notification

• All recent (last 3 months or previous partner if longer) and

current sexual partners
Bacterial Vaginosis

Causative Organism :
reduction in lactobacilli and an
overgrowth of predominantly anaerobic organisms
(Gardnerella vaginalis, Prevotella spp, Mycoplasma hominis,
Mobiluncus spp) in the vagina with an increase in vaginal pH.
Transmission
• Can arise and remit spontaneously in women
regardless of sexual activity.

• Therefore no contact tracing and partner notification is

required.
Signs and Symptoms

• Asymptomatic

• Offensive fishy-smelling vaginal discharge

• Less commonly vaginal irritation or mild low

abdominal discomfort

• Examination may reveal a thin, greyish/white

homogenous discharge
Diagnosis

• Thin, grey/white homogenous discharge

• pH of vaginal fluid > 4.5 ( usually not done in general

practice)

• Positive amine test ( release of fishy odour on adding an

alkali-10%KOH)

• Clue cells on microscopy, available on most HVS

Treatment

• Symptomatic women, pregnant women with a history of

recurrent miscarriage and women undergoing some surgical
procedures

• Metronidazole 400-500 mg twice daily for 5-7 days or 2g stat

• Intravaginal clindamycin cream (2%) once daily for 7 days.

• Clindamycin 300mg bd x 7 days.

Non-drug treatments
General Advice

• Patients should avoid vaginal douching

• Use of shower gel

• Use of antiseptic agents or shampoo in the bath

• No F/U is needed. Recurrence is very common (up

to 50% by 3 months) and can be difficult to manage;
if so specialist advice may be beneficial
What is this?
Thrush
Commonest species is
Candida albicans.
Symptoms
Pruritis
Vulval/vaginal soreness
Superficial dyspareunia
discharge
Signs

Vulvo-vaginitis

Swelling

Linear fissures

Variable +/- (non-offensive)

discharge

Satellite lesions
Diagnosis in primary care

• Clinical pH< 5

• High Vaginal swab ( HVS) but 10-20% women are

asymptomatic vaginal carriers

• Tests may be negative if treated recently.

Management

• If s/s strongly suggest treat as candida

• Recommended regimen

• Anti fungal pessary +/- cream for external area

• Fluconazole 150 mg stat

The image above shows a severe case of vaginal thrush with
Candida albicans fungal growth at the mouth and around
the sides of the cervix.
Associated Factors

• Avoid precipitating factors such as soaps, shower gels,

sanitary towels which may increase the risk of local
response.

• Wet wipes- used to clean vulval areas

Genital herpes
Herpes Simplex Virus

• HSV 1 and 2

• Can infect either mouth or genitals

• Cross infect due to autoinoculation

• Transmitted by close physical contact when virus is shredded by

infected individual

• Sporadic shredding can occur even if no active lesions

• Lifelong infection with episodic symptoms
Herpes signs and symptoms

• Multiple painful blisters

• Malaise – febrile flu like illness

• Tingling pain in infected area

• Tender lymphadenitis

• Local odeama
Complications

• Secondary infection of lesions

• Auto inoculation to fingers and adjacent skin

• Urinary retention

• Aseptic meningitis
Management/treatment
• Consider referral to DOSH if same day available , if not
• Swab base of blister using viral swab (help to know which
type HSV)
• NATT testing most areas now as better detection rates –
check with your local labs

What helps?
• Saline bathing
• Topical anaesthesia eg lidocaine ointment
• Oral analgesia
• Oral antivirals – more effective than topical ones and no
benefit on combining treatments- aciclovir first choice most
prescribers
• Follow up with DOSH review of recurrent or frequent attacks
Trichomonas Vaginalis

• Causative organism Trichomonas vaginalis (TV) is a

flagellated protozoon

• Exclusively sexually transmitted

• 50% of women are asymptomatic

• Discharge if present is thin, watery, yellow, offensive, frothy

• Can be reported on cervical cytology
 WHAT CAUSES IT?
• Caused by the single-celled protozoan
parasite
• Women:
SYMPTOMS
– Some symptoms may include:
• a frothy, yellow-green vaginal discharge with a strong
odor
• discomfort during intercourse and urination,
• irritation and itching of genitals area
• Men:
– Most no signs or symptoms
– Some symptoms may include:
• penis irritation
• mild discharge
• slight burning after urination or ejaculation.
 HOW TRICHOMONIASIS IS
DIAGNOSED
• Doctor
• Physical exam & lab test

• The parasite is harder to detect in men than

in women
Thin, watery discharge from cervix due to TV and strawberry
discolouration on the cervix due to TV
 HOW IS IT TRANSMITTED?
• Sex with infected partner
 HOW IS IT TREATED?
• Prescription drugs
• Given by mouth in a single dose.
TERIMA KASIH……