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Doing grand. So we're covering sexual health today and I've got another election next week now, obviously, sexual health is a specialty in itself. So we're not going to get through much of it. So I'm thinking this model is a kind of a either refresher for those of you who are have done sexual health before or kind of an introduction to sexual health. And we will cover kind of some of the main bits and pieces and that we can, there's not very many of you. So just feel free to ask questions whenever just to come at this from why, why sexual health? My I am a G P now, but one of my jobs previously was at a sexual health clinic and I just, this was area special interest for me. So I see quite a lot of it at my own practice and GP as well. So just to go through what we're doing. So today is part one, we're going to have a chat about some of the common present presentations, how we do sexual health history is one of the features of that. And then we'll have a look at some examination and what you, what we do for sort of your genital examinations. Um, next week, same time is gonna be case studies with some pictures and kind of symptoms and things like that. And then we'll go over more the individual diagnosis and management of the case is if we have time at the end of next week or this week, I'll talk a little bit about pep and prep. That's kind of the big thing in sexual health in the last year or two. Let's make one of the biggest change in sexual health that we've seen in the last decade. Um Just to go over some, the stuff that I'm not going to cover. I think that's useful to know as well. I'm normally do anything about contraceptions. I think one of the lecturers is doing that. Um emergency contraception will give a MS as well cause I did a lecture on that a couple of weeks ago. Um Sexual health also encompasses kind of things like sexual dysfunction and psycho sexual problems, but that's very super specialist and unlikely to be uh you know, I think you guys didn't deal with. We'll, we'll put that to one side as well. Um And with the, with the blood borne viruses, I won't go into too much detail about management because things like HIV need specialist care. So the vast majority of doctors, unless you go into that kind of area, you're gonna be diagnosing it and then sending it on to someone else, we can touch on it briefly and then kind of the meds that are for it, but just cause it was very much time, we won't go into too much depth. If, if we do, uh I might do some more sessions next term. If, if that's possible and I'll go into each of the conditions in a bit more depth, then just because even something like syphilis, I could spend two hours on and, and not finish. Um grant. So if we have a start, honestly, the most important thing about sexual health and taking sexual health history is do not be awkward about it. The vast majority of trouble people get into is because they come at the patient in a sort of hesitant manner. There are being in a lying around the questions, they're not sure how, what vocabulary to use. Um They come across awkward. If you are awkward, your patient will be awkward back. Your patient is more likely to get affronted and more likely to get annoyed if you are asking it in kind of a way as if you are embarrassed about the subject. Um Now generally if you're seeing someone in a sexual health clinic that's going to be easier because they're gonna be expecting at least some of the questions. But what when it can be more challenging is if you're in a general practice clinic, if you're seeing them in a different setting, such a primary care or A and E and then not expecting those questions, it can come off quite intrusive, especially if they don't understand why you're asking those questions. So someone who comes in with abdominal pain, for example, to A and E and you think they've got pelvic inflammatory disease, which is where they've got possibly SDI that they've had chronically and has led to inflammation kind of around the genital organs. Um They're going to get a lot more iffy about you starting to ask things like, have you had chlamydia before? How many sexual partners do you have? But if you explain why, if you pre face that with something like I'm asking a few questions, these are going to be quite personal, but there's a reason behind it and this is the reason I find that usually works quite well. I'm not gonna talk much about it but anyone coming into a sexual health clinic, if they could, if there's a chance they could be pregnant, just make sure you think about that job one c test partly because it's useful to know and also it will affect management for some of these conditions. So some of these conditions, the antibiotics or the drugs are gonna give them aren't safe and public pregnancy and on the flip side for things like syphilis or herpes, if they are pregnant, the management might be different, it might be kind of more important and rapid. Er, um, just think about, think about that. If we go on to kind of the beginnings of histories, often you already know this, but this will be on the top of your patient information sheet. But if we start off with the patient themselves, the things that we need to know about them is how old they are. And just because I mentioned before, it used to know why you're asking us questions, age can not always be implication of kind of the risk of stds. So if we think about it from uh kind of the kind of national guidance from the NHS point of view, generally thought it was people on the age of 25 or higher risk having said that was a massive caveat in that certain other populations have, for example, can be over 65 people who live in residential homes can also have high risk of S T I S. So it's, it's not always that take up, but it's used to know and it comes into things like if this person is under the age of 18, you're gonna be asking slightly different questions if they are above the age of 18. So you might want to know more about their partners, more about the relationships from a safeguarding point of view if if that's the case. So the other thing you need to know about them is is kind of what genitals are you dealing with. So what gender do they currently identify with? What gender were they at birth? And if that is different, then you might need to know if they've had surgery to or hormones for that purpose. There are, I'm not going to go into because it's quite niche, but there are different, um, sexual health problems you can develop if you've had kind of bottom surgery because of the types of tissue that are there and the repurposing of things. Um, generally those patients' don't tend to come to general clinics because they have a specialist kind of conduct where they are from currently will affect the incidence of certain S T I S. We know that for example, at the moment in London, syphilis in the heterosexual population is increasing, we're finding people who are testing positive for syphilis during pregnancy. It wasn't a thing that we found 5, 10 years ago. It varies with time. It varies, the country, different nations will have different incidences and also the other relevance to this is resistance. So, treatment resistance is gonna vary depending on where they've picked that bug up. So if this is a person who don't know, is a holiday in London, but they live in India, what antibiotics are going to work for them might be different to a person who's picked up chlamydia in London. Um uh there's uh the north of England has developed very resistant gonorrhea. Um So again, if, if there's someone that lives in the UK, even, but different parts of the UK the antibiotics sensitivity pattern may change depending on what's happened there. Um, and then lastly, when did they last have an esti ice cream? So, if they've had an ST ice cream pretty recently, it's gonna affect working to test and why they're here. If they've never had one, you're probably, probably more likely to do a pretty wide screen. And the questions don't matter as much thinking about sexual health histories in general. It's worth, um, it's very similar to any other medical history, but there's a lot more questions you ask and sex as in their sex is going to affect. What questions you ask. Uh, if we think about the common presentations, uh, common presentations, what, what sort of things do you think people would come into a sexual health clinic? What would they present with? Just put them in the chat or yell at me either is fine. Pain, the stream. Yes. Yep. Um, burning sensation, shin while situation like burning when they p Yep, what else? Itchiness? Itchiness. Yeah. It's a genital itchiness. But actually you get patient who did that with itchiness all over as well? What else? Redness of the skin? Yep. So rushes, lumps and bumps. Lumps and bumps. Yeah. Random mouth. Yeah. Perfect. So, I just kind of had a general list of things that you commonly see. Um, lumps and bumps is a big one. Definitely something that comes in and people get more worried about lumps and bumps often despite the fact that lumps and bumps are often less serious, it's just something that's very visible. Something that they can feel in a place they can't get a good look at generally scares people, especially if their partners noticed it and they've never noticed it before. So sometimes people come in not because they've got symptoms because they're partners gone. There's something weird down there. I don't know what it is and that's what's kind of sent them into us. Um ulcers. So someone mentioned, I think you mentioned it can be mouth as well. So you remember different kind of sex with a different kind of stds. So, ulcers on the genitals also in the mouth, genital pain, I think we mentioned as well, including pain with sex regardless of which gender abdominal pain. Isn't, isn't there necessarily a presentations? People tend not to come to ST I clinics because they've got Donal pain. But in G P I C a lot more of that. I see a lot more women coming in saying I've got lower abdominal pain. We've been, I've treated for a uti it's not gone away. Actually, we need to be ST ice cream. Um So I'd double discharge from kind of different places. So that can be penal, that can be vaginal, that can be anal, that can be um sort of ulcers in the mouth of discharging lots of different types of that urine symptoms of things like being more frequently burning when you're p uh blood in your p uh or blood from the vagina or blood from the back passage, including things like instruments, instruments, tral bleeding, and postcoital bleeding is bleeding after sex, bleeding between periods. Both need to think about S T I S as well. General rashes we mentioned and itching and itching can be quite nonspecific. So it can be, I'm itching everywhere. It can be, I'm itching in my genitals. It can be, I'm just itching at night. Um There are we, I'm not really getting into it, but I will next. So if we have time, there's quite a few things that get misdiagnosing this area, especially with itching. So for example, the big one tends to be women who have come in and say I've got itchiness in the vagina get told, oh, it's probably thrush, which it often is fair enough. But the other things to think about things like lichen simplex, lichen sclerosis, the dermatologic conditions that can also affect the same area. Also, eczema or psoriasis can affect those areas. It sometimes if someone's coming in repeatedly with thrush, just think is it still thrush? I think tooting, especially if they have truly had recurrent thrush. If they've just been itchy a lot down there, often they will itch and it becomes a little cycle. And then, then that would like in simplex, which is where the skin is hardened. Um And that action of skin hardening in response to itchiness will in itself be itchy. So you end up a little cycle that they're itching more and more and the skin is hardening and the treatment for that is very different. And you can end up in a cycle where women are getting treated for thrush repeatedly when actually that's not what it was, what was going on before, but it's not what's going on. Now, we'll go into more detail about that. I've put a little asterisk next to assault because that's, it's not a common presentation, I wouldn't say. But it's a very important presentation. So non consensual sex is a thing that tends to present sexual health clinics first rather than A and E or um uh G P practices, I think because it's easier to access or prior to COVID, it used to be easy to access and I think the thought of going to A and E can be quite scary. So people tend to tend to walk into a sexual health clinic and say I've been assaulted and how you manage that and the history take around that is very different um to the other conditions. So, I mean to the questions are the same, but you need to be a lot more diligent in how you're documenting things because if this ends up being needed to be used in Court's, if they want to get the police involved that will affect your notes, could get pulled up in cough and you need to be careful rather than short handing. What they're saying is a lot more writing exactly what they're saying. Quotation marks because if you're the first person that they have, give this information to, you will be a witness or your notes will be act as a witness. So you just have to be much more careful about how you document that. Um, and similar with the examination, at least in the UK, there are certain things you have to do around um swabs and stuff, but that doesn't really matter unless you are going to be working in sexual health in the UK, so that we'll ignore that for now. Um So the history for each of these things are slightly different. Now, if we just take um gentle pain as the first one, how do we take a pain history? What is the, what's the structure we all have in our head for pain history. Socrates, Socrates perfect. And what does it stand for? So onset character, radiation associated symptoms, concept, timing, exacerbating factors, relieving factors and then scale of 1 to 10 with 10 being the worst. So I've just put here. So Socrates is exactly what we use for pain histories. And actually in most of sexual health, Socrates works quite well for all the presentation, even if it's not pain. So these are kind of obvious for pain. But if we think, take a different presentation here, so say we take lumps and bumps, what sort of things. Do we want to know when not take if someone comes in and says I've got a genital lump. What do you want to know about that location? Yep. Where is it? When did it come on? How did it come on? Um, the pain. Yep. Does it hurt? How big is it? How many is it spreading? What else we got? Yeah. Sorry. As I want to say something, say that answer. Uh timing, timing. Yes. So is it is it is it, is it growing over time? How long has it been there? And if we just think of it as Socrates again, it's it's pretty, it applies pretty well. So site where is the lump um onset? How did it come on slowly? Does it come on quickly? How long has it been there? Character if I think of that as a description of the lump. So is it a big lump? Is it a small lump? Is it pink? Is it painful? Is it, has it got multiple heads? Has it got multiple um colors to it? Radiation? In this case, I think it was spread. So has the lump got bigger? Have more lumps appeared, have lumps appeared in other parts of your body that aren't genitals, associations think of these other symptoms. So is the lump associated with pain? Is the lump associated. General discharge is the lump associative. The fever is the lump associated with um loss of hair growth in that area, time kind of self explanatory exacerbating and alleviating features. Does the lump get bigger when you cough? Could it be a hernia? Does the lump move around? Is it a lymph node? Is it mobile? Does the lump get worse when you have a repeated kind of skin to skin contact? Or if you're shaving the area of your rubbing the area? Is it folliculitis things that are alleviating the factor. Does the lump come and go by itself? Does the lump go away entirely for a couple of days and then come back again. Does it get worse when you have sex? Does it, does it get better when you're feeling well? Does it get worse when you're down under things like herpes get worse when you're stressed? Um And then severity is kind of the same. Uh severity is slightly different in that I would uh in, in sexual health. I would also ask how much is it bothering you because for something like we're going to the HPV warts, if it's not bothering you just leave it alone, it doesn't, doesn't need anything doing with it, your body will deal with it eventually. Um And then I think if we just take another one, uh what should we take? So let's take itching. So again, itching. Where is itching? How did it come on quickly? Are you itching all the time? Um Is it the description of the itch can be a little bit different, I guess because what you're saying with description is, is it all itchy or is it one part that's itchy? Is the itching is coming with a rash? Is the issue is coming with something else? Is the issue of spreading such as symptoms? Is there, redness is the hair loss is there, can you see small insects or things moving around? Um but kind of self explanatory there. So uh and then if we go on to history of effects, this is the bit where people tend to get awkward and this is the bit you need to kind of say professional as much as possible. You want to know the history of the most recent sexual intercourse. This is like this bit of the history is a little bit different depending on whether they're coming in because they want a, just a routine screen and then that, that's nothing they're worried about or if they're coming in because there's already something symptomatically going on. If there's something already symptomatically going on, like they've already got a rash, they've already got discharged. This is still important. But what you realistically need to know is more a general sexual history since their last ST I screen, as opposed to exactly the last, last episode of intercourse, the last episode of intercourse is specifically important if they're not symptomatic because you need to make sure that you're covering for that test will come to timing windows later for tests. So just cut questions in this area. When did they last have sex? Who was it with? This question is more important like I mentioned, if they're under the age of 18, if it's still relevant otherwise, but if they're under the age of 18, you need to know how old is that partner? Is that partner in a position of responsibility? Is that partner in a control and then the controlling relationship? Do you need to be worried for safeguarding point of view? The questions will be more in depth if they're under this age of 16, because legally, technically they can't consent. Well, consent as an issue. So between ages of 13 and 16 need to be very careful about the who are they having sex with? And you want to think about safeguarding for. This is a little, it's the older they get, the easier it gets with this. Um Generally though who are they having sex with? Who is it someone that they regularly have sex with your husband or partner, wife, whatever? Or is it someone that they, are they met just that day? Is it multiple partners? Um Are they are the same or opposite gender to them? And where are the partners from? So, like I mentioned before, the incidents of stds might be different depending on the partner sort of a tourist on holiday or, or from somewhere else. Um As opposed to if the partner is local, was it consensual important to ask because it will change what you do for the rest of the appointment. What type of sex was it? And this is, people do all sorts of things. So you got to be quite specific with this, who did what to whom and kind of who in reverse as well? You need to know what type of sex was it? Was it oral vaginal or anal sex or a combination of those? Was it penetrative or was it non penetrative? The risk for different sci is going to vary depending on whether it was penetrative or non pen, pen it penetrative. And then did they use any protection? So what condoms used? Are they prepared for pregnancy? If, if that's the problem, that's a risk, um Grants the next bit is you have to then repeat those questions for every sexual encounter on sexual partner in the last three months or since the last time the SDI screen if we don't have that much time, so realistic, what you're doing is you're just checking that sort of question in general. So for example, for the, what type of sex if they said to you, the last time I had sex was three weeks ago, it was oral sex. I would then ask since your last sci screen, have you had any vaginal sex? Have you had any anal sex? Um The, what you're trying to do? What you're trying to get is a risk assessment trying to work out what test do I need to do for this person? Um And is that gonna be enough of the extra things for the most part you're going to be doing a full screen? The tests aren't that expensive. It's easy to do a full screen unless you've got resource issues. Uh The, the other ones that we can ask for this and systemic symptoms will come back to that in a bit. The specific risk assessment you then need to do and this is important because while everyone's gonna get tested for chlamydia and gonorrhea and even HIV and syphilis, at least in the UK, these are going to help you understand, what is the risk of that HIV test coming back positive? And do I need to be thinking about the hepatitis is? So the HEP A B and C are all counted now as sexual transmitted infections, who you think about uh testing for those? So the specific blood borne virus risk questions just be in the stands for is, have you ever paid or been paid for sex? Any recreational drug use? If that's the case, was this related to intercourse? There are certain drugs, at least in London and probably other parts of the world as well where they are specifically attributed to sexual activity. So there are drugs that people do because it either makes them last longer. It makes the experience pleasurable. It's a bunch of different things to talk about that later. If you're interested. Um, we need to know how they did the drug. So, were they injecting it, were they snorting it that they put them somewhere? There are lots of different kinds of mucosal absorptions. Sometimes people put it, they were wonderful things like they put on the tongue. There's weird things you put in your eyes, you can put in your, in your bottom. There's lots of different things you can do with the various drugs. What was the drug they did? Because that might affect how they've done it. How much did they use and how often are they using it? Because that's more of a kind of just general risk assessment of going to have a chat about recreational drug use and then safety around that. And you need to do even if they currently the drugs they're using aren't injected. Have they ever injected? However they ever had sex with a partner who has injected recreational drugs? Because then they definitely HEP B hep C testing. Um, any partners from abroad we've discussed already and any bisexual partners. So this is more applicable to women. So, what you're actually asking is, have you ever had sex with a man who have sex with men because that might increase the risk of blood borne viruses. Now, when we come to pep and prep, we'll see why that may not be as relevant in the coming years. But at the moment, we still ask this question, um, other bits of the history, as you would ask in any normal um history. So, past medical and surgical histories specifically have they had stds before? Someone who's had an std in the past is at increased risk of then having another ST I, it's just, it's a statistic that exists. Um, surgical history can affect uh certain other parts of your sexual health. It's not necessarily that associated with your ST high risk, but it's just useful to know, uh, if they are someone that menstruates, we need to know what their mental history was. That's kind of the standard questions of, when was your last period? How long your periods have they changed recently? Uh Any chance you can be pregnant again coming into that and then guiding history. So if have they had previous pregnancies, are they planning pregnancies? Are they currently pregnant? Will affect what test you do and will affect how you manage the result? If again, if it's relevant, are they up to date with smear tests? HPV is sexually transmitted? It's not something that we get. It's resulting that we have a routine test for in the UK is we don't test every with HPV and sexual health clinics which a lot of people don't get kind of get confused about. But the smear test is the kind of high risk HPV test which to make sure they've had that done or you can do it or you can recommend they see their GP for it. Drugs history. Just a general medication history, including allergies and immunizations and in social history can come, we'll come back to life histories. Relevant. But again, if they're under 18, it's much more relevant. Uh, basically, uh so, uh and, and get a break this down into conditions to consider and sexual transmitted infections to consider. So just we're going to go down the words, just yell at me what they mean. What is epididymitis information of the epididymis? Yeah, exactly. So information. What, what would your patient say if they came in with that? What's they're presenting complaint? Yeah. So my test is hurt is the most common one with that one. Pelvic inflammatory disease. What's that inflammation of the pelvis? Yeah. So it's information of the pelvic organs. So I think of pelvic inflammatory disease as um what's the, what's the patient going to say to you? There's pain around the abdominal area that could be discharged? They could be bleeding. Yeah. Yeah. And the big trigger one is, it hurts when I have sex. So deep dyspareunia, postcoital bleeding, having function disease. So, and what they mean by that and what we would call it medically might be surgical excitation. So, what we're saying is that when you have sex because there's trauma to the cervix, it's hurting or there's an extra tenderness because you've got information in of your pelvic organs which then leads to sort of scar formation uh and can affect fertility och itis. Well, I won't do that again. The same test is hurt is the usual presentation or sometimes I've got one massive testes, it's kind of swelling is the other big one for that conjunctive itis. You know, I can assume, you know, what contract is, is people like I mentioned before, do all sorts of things. If someone is coming in repeatedly with conjunctivitis, it's not going away and they've got green discharge. Think gonorrhea send a swab. I mean, ask first but um I've seen more cases of kind of gonococcal conjunctivitis than I ever thought I would. Um yeah, things happen. Uh proctitis. What's proctitis? Inflammation of the lining of the rectum? Yeah. And what do they present with? Are they like the types that can get either diarrhea or constipation? Because yeah, sorry. As I'm going to say something pain. Well, yes. So pain, we're going the toilet often aversion. They're going to the toilet because of pain, which is what causes the constipation because I just don't want to put because it hurts or they can because because of the information of the lining because that's needs a transit that can also need the diarrhea. The other thing they can get is they can just come in and say I've got green discharge or I've got white discharge coming on the bottom. Um And the population of patients who get proctitis often know to be honest that they've got it before they come in uh, they kind of come in and say doctor, I think I've got practice again and that there's a couple different causes for that. But often they, they've had it before and they know they know what causes it. Um, your arthritis burning when I P is the main, main, something with that badge in Itis. It's vaginitis again. Information to vaginal. Yeah. So, labial information, um, or what they come in with is either bones down there. Sometimes it could be gets mistaken as a uti because they come in and say it burns and I P. Um and also pain with sex or superficial dyspareunia comes into vaginitis. Bad tinnitus is an interesting one because it's I don't think of it as a sexual health presentation in primary care. Vaginitis has lots of different causes, some of which can be S T I S but there's a lot of dermatological conditions to consider and things in vaginismus to kind of a pain with insertion without a medically clear cause is much more common than we think. So there's lots of other things to think about vaginitis service. Itis it hurts when I have sex deeply and getting bleeding in between my periods. It's an inflamed service. Um, folliculitis is not an S T I but patient's get really confused and patient's will often come and see you because they've got ingrown hairs. Often. The cause of that is because they've been shaving or they've been waxing the area different skin types will react differently to waxing. It's not an STD, but it just, it comes into ST I claims quite a lot because people think, oh, I've got red bumps. It must be herpes or it must be, um, HPV, reactive arthritis specifically sort of committee. We're gonna real, it's worth thinking someone come with multi joint pain if they're young and they're fit and there's no family history of inflammatory arthritis. I three cities. It's worth considering. Is this a reactive arthritis? Should I be doing STD screening on them especially. They've also got conjunctivitis with it because it becomes kind of been a group and then stomatitis, uh information of the lining of the mouth comes with oral herpes comes with other things as well. And then if we just move on to infections, yell some S T I s at me just what, what, what sci is? Do we know gonorrhea? Yep, splice. Yep, chlamydia. Yep. Big three. I got like about 10 more. Keep going. Yep. So, hep, B and C and actually a now, but we'll talk about that in a minute. Go on syphilis. Yep. I think, I think that's a syphilis. What else have we got other than syphilis? What is, what goes hand in hand with uh gonorrhea normally. And then he said it. So chlamydia, um, we've got genital herpes pube nice. Is that pubic lice? Yeah. Try. Can, I can't sit on drag ammonia's, you can have HPV which leads to an STD. Yep. So that's genital wart. Um, scabies. Is that an STD or? It's? So I'll just, I'll just show you my list. This is the list and I spread them slightly artificially, but I'll explain why I spread them this way. I like to think of a sexually transmitted infections versus sex related infections. So, the sexually transmitted infections for the most part, you need fluid transfer. So you have to kind of got a reasonable way of into the sex. Need to be patriots sex for that, for you to worry about that transfer. If someone is saying that they've had kind of, they've used to call heavy petting. So they've been kind of rubbing genitals unless they've got skin boone's. I'm not really worried about HIV, transfers unless they're bleeding for some reason, it's very unlikely they're going to transfer HIV, that way. But then if we come across HPV. HPV can be transmitted through sex. Doesn't have to be kind of full on sex to transmit it. If you are heavy petting, if you're rubbing genitals together, you can transfer by mucosal contact. So that's kind of why I split these into 22 sections. There's a little bit of overlap and I'll explain it as I go through the, if we just go down the list and we'll just talk about some of them in a bit more in a bit more detail. HIV, human um, deficiency of our chairs. I'm not going to get too much into that we all know exists. It's worth testing for, for most people you find kind of it in unusual demographics that you weren't expecting. Hepatitis A B and C. So I'm going to talk about little bit about that. Hep B and C blood borne viruses gets transferred. We know that's an S T I heck A has now kind of come up as, um, and ST I because of practices. So hep A is transferred fecal orally often it's from contaminated water. And that's what we traditionally think of it as we think of as a traveler's infection. Um In, at least in the UK, we think of it as travels infection. But because of certain sexual practices, specifically rimming hepatitis A can be transmitted via sex. So think of that as well and it's worth testing for. So someone's coming into you with abdominal pain and quite a lot of diarrhea when I see them a sexual health clinic especially, I'm thinking, do you need Hepatitis A testing what sexual practices? And they're quite specific questions you have to ask, have you engaged in these, in these practices? And you kind of have to use the terminology that they're using. Coming back to club. Don't be awkward if a patient says rimming, use the word rimming. If a patient says a street name for a drug that you've never heard of, ask them what the kind of trade name for that would be or what the, what the actual name for that drug is. But then I would continue to use the language that they have used moving forward. And you will, I learned so much stuff in my patient's that I just never knew existed and it's just, it's quite a wide world with, with kind of what different people enjoying different people do. Um, syphilis, like I said, syphilis is a whole whole lecture in itself if this is really interesting. Um And on the rise in London, so I've seen it, I've seen someone walk into a and e a couple of years ago, he was pre COVID. I had a chap who walked into A and E and I was seeing him in minors and he just come in cause I had a whole body rash but had no other symptoms. And my first question to him was it wasn't itchy or anything a what's your sexual history? I think you've got syphilis and he had syphilis because there's quite a lot, there's a lot of things they can give you rashes but a full, there's something about syphilis, rash, a full body head to toe rash, which isn't really symptomatic in any other way. It's, it's just worth thinking about that because I think that's something that comes into primary care quite a lot for us. Very secondary syphilis. Second drink which pardon? Uh like stages of syphilis. Yes. So, yes, there's the, there's the primary secondary and tertiary stages of syphilis. Well, I'll go into that a bit more detail next week. But as I said, since you mentioned it, what, what is primary syphilis? What does it present with? No, no, no, the child, the person who came to a clinic, a full body rash. I think it was secondary, maybe secondary syphilis. Yeah. No, it was, it was a second secondary syphilis that he had. The primary syphilis is more, is the, is the shankar. So it's the penis ulcer. Um But he had second syphilis. He hadn't had a syphilis test in about 10 years. But I mean, I don't think he had it for 10 years but he, he um you had a few other things as well once we tested him. Um Comedia quite common, we'll go to that bit more next week. Um And then L G V. What does LG be stand for anyone? Anyone? Is that the lesbian, transgender? So I say that again, Lola, gay and transgender know. So L G V stands for lymphogranuloma venereal. Um So it's a, it's a particular strain of a chlamydia bacteria that gives you quite nasty infections. It's more common in the homosexual population in London. Um It, I just think of it as really bad chlamydia but it tends to give you things like the proctitis more commonly and you get quite aggressive um discharge with it and the treatment is much more intense. So it's think of it as kind of chlamydia plus um L G B gonorrhea, we'll talk about it more next week. The things with this problem, we've gonorrhea is resistant patterns exchanging constantly. It's quite resistant to things we used to use to treat it. So, having to change that around and at the moment, the treatment, first line for gonorrhea is a, a shot of cefTRIAXone which logistically is more challenging because a lot of GP practices don't do that. So it's kind of more logistics issue for that. Um Has anyone heard of micro plasma? What do you know about micro plasma? Oh The word don't remember it. Right. Yeah. Yeah. So, so micro plasma again is not the thing that we think about very much. I think again, the last five years, it's probably come up more. We so when we talk about your arthritis earlier in the information of the the view of 33 specifically more an issue normally in men, we think of it as two types. So we think of as your arthritis or nongonococcal, your arthritis. So what that implies is that the vast majority of cases of your arthritis used to be going to re related. So you were testing for gonorrhea and that was the most likely cause. And then we had this cohort of patient's who had nongonococcal your arthritis where we were saying we don't really know why you've got information of your urethra. We're not entirely clear what's going on with that and what we've actually discovered and up to about 30% of those patients', they have micro plasma, which is um uh it's another, another bug which can cause public founder disease. Your arthritis. It's because epididymo-orchitis and we weren't testing for it or something that we're doing a lot more testing for. I'll talk about a bit more detail next week, but it's, it's worth having a look at because it's becoming much more of a problem now that we have testing for it now that we regularly test for it. The other thing with it is that lots of patients are asymptomatic for it. So it's not worth doing it as a general screen. But in certain populations, for example, the arthritis is who are nongonococcal mycoplasma is a big, big thing to think about at the moment. I mean, the other one that's actually coming out that I haven't mentioned, I forgot to write on here is there's a ureaplasma. Um that's also kind of hitting the radar at the moment as a, as a, as an S T I trichomonas. What does trichomonas present with anyone discharge, I think is that the one that's green and really like fishy, like smell very prominent to, um that's how you can differentiate between thrush and try to promote this kind of thing. Um uh sort of not quite. So I think what you're thinking of actually back to your vaginosis in that, but that's what I think you've complained three things in one there, but we'll talk about, talk about it back to you about tonight. Just at the moment, diagnosis. Even bacterial vaginosis is an overgrown um is an overgrowth of your body's own vaginal bacteria. So it's normally, I think it's only gardella Mattarella, Gardnerella bacteria that grows and it gives you a really fishy smell, really thin, watery, um clear discharge and profuse amount of it. It's quite common. It's not necessary to treat it unless you want to. If it's bothering the woman treat it. For example, they're pregnant because the treatments, metroNIDAZOLE, which is, don't we just leave it alone? It's related to the ph imbalance. That's kind of where the thrush conversation comes in. What's happened is that you got somehow got ph imbalance and often it's from people using soap in the vagina and things like that. And subsequent to that, it's causing imbalance in the ratios of the bacteria that live in your vagina. The this specific species has overgrown and it's giving you that discharge trichomonas is different cause trichomonas is an S T I. The trichomonas gives you loads of um green discharge. It's one of those things that we didn't use to test for regularly, but we're kind of becoming more aware of it and it's more um uh it's more noticeable, noticeable as an S D I. It's caused by a very tiny, tiny parasite and the way we used to diagnose it back in the day was by dark ground microscopy. And not very many people have that skill anymore. So, it's quite read that it's done. I've only ever seen it done once when I bought one of my bosses did it when I had a woman I suspected had trichomonas. And it's quite interesting because you can see the little little parasites wiggling around on the screen on the microscope. Pardon? Prophesy toilets? Prophesies. Yeah. Um, herpes. So, hedges be one and two. Traditionally, we thought of HSV one as the thing that gave you oral herpes. And we thought HSB two as the thing that gave you vaginal or genital herpes. There's no, there's no differentiation. Now, people have oral sex. It may still be more common that way around, I think just be too. It doesn't, you don't tend to get on oral swabs, but it doesn't really matter. You can get either one, either place. So you were just talking about herpes in general. Um The thing that's interesting about herpes and patient's find is quite distressing and this is why I often herpes specifically gives people like sexual issues is once you have it, you've got it for life. It's not going anywhere. Truth is the same for HIV. And until recently Hepatitis C, but herpes is much more common, um, kind of in the heterosexual population. So we see a lot more patient's who kind of can't reconcile the fact that they've been affected by herpes. It's also ideally part notifications. So you should be telling your partners that you have herpes before you have sex with them. So it will affect future sexual relationships. Um, so there are specific, I mean, at least in the UK, in London, there are specific clinics of people with herpes who are struggling with how to break the news to partners and things. Uh, and even if you are not currently showing symptoms, if you're not having the ulcers of time, you can still transmit herpes. And that's quite a big thing for people to get their head around. So people kind of, some people end up abstaining because they're just so anxious about getting someone else. The condition, um, chancroid, I'm not gonna talk too much about, we don't really see it in the UK, you get an ulcer. It's, yeah, anyone else want to miss anything about Chancroid. Uh, I think herpes has this, uh, stigma on that. It could spread through objects. Well, but it's not possible. Yeah, that's true. Swimming pools is the common one. People think, especially you just think you can get herpes from swimming pools, which you really can't do. There's quite a few of these that people think that's the toilet seat to the other one. So public toilet seats, people think you can get chlamydia from and you can't, towels, towels as even. Yeah, towels as well. Share ink kind of swimming costumes and various other things. It's none of that is going to transmit herpes. Um, but oral sex is, and that's the one people don't really think about. Uh, because if you, even if you have the risk of transmission is higher, if you are currently having an act about rick, so if you've got loads of ulcers and blisters everywhere, you're more like a transmit herpes. But even if you don't have any, you could still be transmitting herpes. So there's not. And to build your partner might have herpes. Some people get away very lightly with herpes. Some people have no, they have had one minor outbreak where they got a couple of listeners. It hurt a couple of days and then they just never had another outbreak again. And they don't know that they've got herpes and that's kind of why it spreads. But other people get it quite badly. I've seen a chap who I had a patient who is a man in his forties and he worked abroad for business. Uh He was in the Middle East quite often which is quite challenging place for sexual health care. He had quite bad outrace of herpes when he was stressed to the point where when he came in to see me, he had wrapped sort of wet towels, wet, wet tissue paper all around his, his genitals because the skin had basically peeled off his entire genitals. It was rubbing on his underwear. It was quite an aggressive, aggressive site. Despite the fact, he was on suppression, which is, which is not, which is not pleasant for him. Unfortunately, and then if we move across the sex related infections, so these can be transmitted by sex. They are not necessarily just transmitted by what people traditionally called sex of penetrative vaginal sex. HPV. We talked about briefly but if we think of that as a massive bag of viruses, HPV is over 40 different viruses and they, some of them do different things. So people get confused, that kind of warts on your fingers can be HPV as well. That is not the same as genital warts. That is not the same as the strains of HPV that are likely to give you incidence of cervical cancer. There are high risk strains for cervical cancer. In the UK, we vaccinate against four of them. At the moment, there is a vaccine for, there's a nana Vaillant vaccine available as well. So in the US, I think at the moment they're vaccinating against the nine strains. Now, the four strain vaccine that we use in the UK, currently vaccinates against the two highest risk experience for several cancer and the two highest risk strains for um genital warts. But there's so many other ones out there, the incidents of HPV is incredibly high. Most people, if they've had sex at some point in their life will have got a string of HPV. But because the majority of people clear it by themselves within two years and I think it's something like one, between one and 10% of people will show symptoms from a genital warts point of view. It transmits a lot because we don't, most people don't know, they have it. Some people, even if they do have genital warts might have one tiny wart somewhere in a skin fold that they've never, never noticed before. Um, and, and this is another one that can transmit from kind of genital genital contact, not swimming pools, not towels. Um, but you don't have to be regularly and actively having sex with someone to get HPV for them. Um, it can also lay dormant for a long time. Some of the common things that comes into me at the moment is patient's asking, did my boyfriend and my girlfriend cheat on me because I didn't used to have HPV on my smear test because now we test for HPV initially on smear test, so four years ago to have HPV. But now I've got HPV. Not, it's very difficult to say because of how long it can be dominant someone system. And because it's asymptomatic, you don't know if they just picked it up now or where, where it's come from. Thrush. I've put a little bit of a caveat on Thrush just because so not to do with fluids, but Thrush can be transmitted via sex. And one of the big problems with that is what we think of it normally is a condition of for women, we normally think of thrush or something. Women get um balanitis being the kind of puncture to put on. The other list is the male equivalent and that's inflammation at the head of the penis. So the glands of the penis looks red, looks irritated, can be, can be quite sore. What can happen is because men can carry um yeasts without showing balanitis symptoms. If you've got a woman who's getting recurrent thrush, treat her partner as well because what might be happening is that you're treating her, the thrush is going away, but her partner is acting as a carriage because he's, they've had sex and every time she then had sex with him, it's coming back into her system. So it's a bit of a it's always getting recurrent thrush, treat the partners, one of the most common things. And then like I mentioned before, make sure it actually is thrush to do some swabs because you might be treating a skin condition as thrush rather than thrush. Not everyone who has thrush will have classical symptoms. The classical symptoms of thrush being cheesy white, discharge, itchiness sometimes kind of red and can be swollen. Some people have a variety of those symptoms are not all kind of one or not all of them. So it's um it's worth doing swabs. The challenge with that is the swabs for thrush are not that effective. You have to actively get a bit of the yeast on your swab for it to be effective. So you, it's hard because you can get false negative. So you, you just didn't get the right bit. For example, um it's often what I do is if I'm doing so, we'll treat them anyway if it comes back negative or have a bit more of a think about is this actually thrush? Because you can similarly with this and bacteria vaginosis, there's long term options, but we'll talk about it next week. Natural diagnosis. We talked about already pubic lice and scabies. Someone mentioned these already. Um this is where the social stuff comes in. So housing conditions affect these and molluscum actually as well. The scabies is a pain to treat scabies is really irritating cause you have to, you have to treat the entire household twice and you have to um wash basic. It's a bit like bed bugs. You, you're kind of doing quite, quite an intensive wash of clothing and bedding and things. The incidence of scabies is higher in London than I would have expected. I actually have seen quite a lot of it. It tends to be higher in East London than it is in other parts of London. I'm sure other countries have different incidences of it. The treatment is unpleasant. You are basically covering your head yourself head to toe in, in sort of tari things and sitting down for a couple of hours. So it's not, it's, it's quite the treatment, failure rate because of lack of compliance is quite high with it, which is challenging because it's, it's quite annoying just to, to get to deal with and whole households can get it quite quickly. If someone is living an over current situation, they're not transmitting scabies is higher. That's why housing and social history matters in this, in this aspect. Um Anyone know what molluscum is? Isn't that chicken pox? Uh No. So it's um it's an infection. It can look a little bit like chicken pox but it doesn't. Um, it, so if we think of what is, what is chickenpox, what's the virus? Yeah. So it's a herpes virus. The chicken pox is the hope is herpes zoster. Um Molluscum is a, it's an infection caused by molluscum contagiosum. It's harmless. It's completely doesn't do anything. It does look a little bit like um kind of herpes herpetic viruses. You get tiny, little blisters, they don't hurt, they're not itchy, they don't bother you the way you tell. It's molluscum is partly cause they're completely, they don't bother you and they're not, not a problem, but they have this little central dimpling. So they, they have a little hole. I got my, I'll show you pictures next week. They have a little, little hole on the top of it and they come in little clusters. We don't normally treat them because they will go away by themselves. They're actually a lot more common in Children. Um and they tend Children to get around there, around their face is so I want to hug my laptop in. Um, Children tend to get around their, their face is a bit more. They do go away but they can be there for months and months. Sometimes people find it a bit, um, embarrassing to have it because it looks like other things because it looks like herpes that because it looks like what's, if you do want to treat them, you can freeze them off. But you're interesting, a risk of infection and there's not really any point in, in, in treating them. You find molluscum can be more common. People are immune, suppressed for patients who are HIV, positive on or on. Immunosuppressives do tend to get molluscum is kind of in other areas and you can get it, um, on the genitals. So people present to you thinking they've got herpes or thinking they've got, um, uh, something else and then actually they've got molluscum monkeypox is the new one. It was kind of, it seems to kind of left the news at the moment but it was very much in vogue a couple of months ago. It's not, it's a bit like scabies in that it's not necessarily a sexually transmitted infection. It's to do with close contact. So to do with prolonged close contact, the reason it kind of got grouped in with sexual transmit infections was because it was transmitting around sort of the the gay male population in New York. And, and they thought it was through sexual intercourse. That is a form of close contact, but you wouldn't necessarily to have sex with someone to get monkey past. You could just be living with them. Um, and then shigella, which we don't traditionally think of as an S T I again, because it's transmission, it's fecal oral, depending on sexual practices. You have a risk of transmitting that. So we were running quite low in time which realized um I can't think I'll just very, very briefly go through this final exams. Depends on what genitals they've got what you're examining, cover up anything you don't need to see when you don't need to see it. So if you're doing a, just, just take your exam, you can cover up the penis, you just need the penis exam, you can cover the testicles, expose what you need when you need to do it. Um Get a sharp one if you want one. Uh don't forget abdominal exams when you're doing any high general exam, I always have a feel the tummy. And then think about things like lymphadenopathy with a generalized, if you're finding glands in their groin, just check out elsewhere because glands in your groin could be folliculitis or chlamydia, they've got glands everywhere. You're thinking HIV syphilis, you're thinking going systemic instead. Uh and then testing windows. We haven't got time for this. I'll go into more detail next week. But the, the test you do will not come back positive in a certain timeframe. So if I have had sex today, and I think I've got chlamydia, there is not that much point. Me getting a test for two weeks because I was the earliest test will come back. This is, this is only true from asymptomatic. If I had, if I had sex today and I got were discharged next week, that's fine to test that will come back positive. But, but for asymptomatic patient's, there's a certain window for which they would come back positive. So there's no point wasting a test in that time. Often people get anxious, especially they've had a one night stand, they'll come into a special health clinic the next day and say, oh, I need to, I need to committee a test and you're like, no, actually, we need to wait and do it in a couple of weeks time. I've just written the windows down here for certain tests. The things to be that want to be noticing is um syphilis, syphilis and HIV HIV has two different tests. The lab bloods that we normally send their fourth gen antigen antibody test so they can come back. So I think it's 45 days is the earliest they can come back. And we say six weeks normally. But if you're doing a point of care test, which is what a lot of community centers and kind of resource limited areas have doing a, just a finger prick. That's three months. You're only covered to say that if you do a test that's negative, all you can say is that three months ago I did not have HIV. You can't say that in that three months. You haven't then got HIV. And you can do RNA HIV testing and that is much quicker, but we don't do that unless someone is incredibly high risk. For example, they have had sex with a partner who has known untreated HIV positive and uh the condom broke or something. Uh I'll just, I'll just stop there because I realized were quite short on time. Is there any questions from that? I'll go into more depth on the actual stds next week when we do cases. Uh it was regarding uh I don't remember. I had one lecture in my university. It was so herpes, either one of them has also uh or dental complications like uh yellowing of the teeth or something. See again, which one? So that's the syphilis and babies does that? No, it was uh like one of my professors tell, told us uh story about a dental student who have a patient coming into the clinic and just by looking at the teeth which was very yellow, she concluded that this might be syphilis. She again and again, again and again, and the test came back negative. But again, like she, she insisted four times and the four times test came back negative but I don't know how she was a dentist export. She knew when she saw its syphilis something and then the fifth time it came positive. So I haven't actually mentioned it on him. Uh information and I've got to make a note. So, congenital syphilis causes teeth, dental problems. I don't know if I can't, I mean, I'm sure I can't suspect hush. I don't think if you were an adult to develop syphilis, you could, I think it would if you develop syphilis prior to your kind of adult teeth growing, you would get dental problems. Congenital syphilis is massive for dental problems. So kids who, so moms who have syphilis, one of the big problems with their Children can come up with very weird teeth including very yellow teeth. The positive negative issue is the way we do syphilis blood because I've just put syphilis blood test there specifically because there's a lot of different syphilis, blood tests and then not, none of them are 100%. The way we do syphilis testing is normally we do a non specific trip animal um syphilis test first. So we just look like an RPR VDRL other just fancy names for them. And if that is positive, we then do a specific um syphilis strep animal antibody test to confirm it is syphilis because there are certain other infections that can cross react with the syphilis test. The reason I mention that is the VDRL and, and a pr in 50% of kind of cases, if you've got late stage syphilis, it comes back negative because of what they're measuring. You will, you only really test high positive in the first two months post infection so that these are really good for some primary syphilis is um early syphilis is. But if you are, if you suspect syphilis, that test is going to keep coming back negative, it's a chronic. So if, if they have congenital syphilis, if that person, whoever it was, the tooth person got syphilis during their moms pregnancy, they are now very late stage syphilis. They are not going to test positive on the standard syphilis test. They're going to have to have the treponema specific test and, and sometimes they need things like lumber punctures because that's the only way it's gonna test positive for syphilis. It's sneaky as a independent as an infection. Does that make sense? Yes, I think I'll take your silence is. Yes. Also, if they've got an answer for syphilis, you can swab it. So if they've got a shankar, like a lovely big painless ulcer on the penis or whatever, you can just swab it and that will come back positive much earlier. And that is a much better marker, but only applicable to primary syphilis. So, again, not helpful when someone's doesn't remember that they had an ulcer and has now got weird symptoms later in life