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Uh, hi, everyone. Thanks for logging in so far. So we're just gonna give it five more minutes just to let a few others join in and then we'll start off. Thanks. Hi, everyone. So we'll make a start now. First of all, as I said, thanks to everyone that's logged in. My name is Owen and I'm one of the members of the peer share committee this year. And first of all, a big thanks to Hannah for, um, logging in tonight and she's going to take us through, uh, genito urinary medicine and sexual health. And just before I hand over to Hannah, just two wee things I'd like to say. So for all our speakers throughout this lecture series is we're going to try and give them as much feedback as we can. So I'm going to post a link into the chat towards the end of the talk. And we would really appreciate just if you could fill that out and that helps both us in future years improve peer share. But then also to give the speakers some feedback for the portfolio and different things as well. And I'm also gonna post a link to the fourth year whatsapp chat that we've made for the peer share lectures. It's and here for us just to um post any updates, changes in times and things even like lecture slides as well can go in there. So if you can join that, if you already have done. So, thanks very much. And if you'd like to pass it on to anyone that hasn't joined and just encourage them to use that link as well. But as I say, I'll post those towards the end and for now I'll just hand you over to Hannah. Alright, so hi, everyone. Um my name's Hannah. I'm gonna give you kind of like a very quick snapshot of gum essentially tonight. My aim with this is it might be a wee bit intensive. I've got some difficult M TQ snapped in but I wanna try and give you guys the opportunities to get some very quick, easy marks when you guys are sitting in your A KT in a couple of months. So there's understandably a lot of overlap between sexual health gum with obstetrics and gynecology, which I know a lot of you guys have already gone over with cer through the patient. Um, sexual health entails a few things. There's a few things that relate to men and women um differently. So we're gonna go through quite a lot of these tonight. So the main things I wanna run through is taking a good sexual health history going through dis your two really common vaginal infections, epididymo, orchitis, and erectile dysfunction. And at the end, I've got lots of M CQ clues to look out for in questions, some tips for them and the Aussies. I've also included a little bit at the end about contraception. Whether or not we get time to go through that tonight. I'm not sure. But when you get the slides, you can always go through it and it's just a few kind of key things to remember, particularly about emergency contraception not covered today are the things that really overlap with gynecology like pelvic inflammatory disease. I haven't gone into too much detail. Things like loss of libido and HIV. Don't worry too much about knowing HIV. They don't expect you to be experts and it might only be like one question if you ever did get asked about HIV and an M CQ. So taking a good sexual health history, it does seem a little bit scary, especially if it's not something you've practiced before. But the main things like anything relating to sexual health, good report and communication is the best way to approach this. You know, if you seem nervous, your pretend patient in an ay is gonna seem really, really nervous as well. They're gonna pick up on that. And it's important just to remember as much for yourself as it is any patient in an AK that, you know, if it's an SDI counseling station, for example, like these things happen. It's really common. Um It's very treatable and it's not a problem for anyone at all. So that's just a really key thing to remember. It's down to how you act with your patient and how you communicate when it comes to sexual health. The ways that I teach how to give, how to take a good sexual health history is either doing who, what, where, why questions essentially or the CDC splits this into the five P. So asking questions about partners practices protection from ST is past history of ST is or anything that might be relevant. Um And pregnancy intention starting with partners is really straightforward. These are like your really broad opening questions that you would do in any history, you know, is the patient when you having sex of any kind with anyone at the moment and if you are having sexual activity at the minute, you know, how many sexual partners do you have? What are the genders of your sexual partners? Um Do you or your partner have any other sexual partners keeping these really broad and open and just practicing these? So it sounds like there's a bit of a flow coming out of your mouth and you're not, you're not stumbling and you're not trying to assume someone's sexuality and or getting into full light into holes. Like I think most of us in practices have done the question like, oh have you any intention of getting pregnant and the patient in front of you is someone that is not in a heterosexual relationship. When it comes to practices, it can be a little bit awkward asking this but trying to define the type of sexual contact and the type of sexual activity that someone's going into. You know, if someone's having oral sex or penetrative sex, it might be pointing you towards other conditions. If it is, for example, an SDI station asking about online dating because there could be some safety risks. Understandably if someone is meeting up with people um that they've met online for sexual activity asking about chem sex. If you're not really sure on chem sex, don't worry, just ask open questions about, you know, have you ever had sexual activity under the influence of drugs? Have you ever had sexual activity in exchange for drugs? Um and that goes down on to the next point of exchange, it might not be drugs or alcohol that someone might be engaging in sexual activity for. It could be housing, it could be finances, it could be other things. Um and this just kind of helps gay. Whether do you have someone that is of particular risk of harm or assault? Have they previously been at risk or previously? Unfortunately been the victim of a form of assault? Um And again, they seem really quite awkward and quite difficult to ask, but just practice these when you're practicing for your Aussies, you don't have to go into too much detail for an Akie, but just be aware that you're looking at this broad holistic approach to a sexual health history, protection from dis kind of falls under. What again? Um, have you discussed contraception with your partner? What methods are they using? Checking somebody's compliance if they're on like an oral contraceptive pill or if they use condoms, asking people have they had HPV and hepatitis vaccinations? Do they use any prep? Are they aware of HIV? Risks? Things like that? Their past history of ST is ask a person, have you ever had a sexual health screen or test? When was the last one you had previously been diagnosed with an ST I if so, what was the treatment? Um, if they have previously had an S ti this is quite important, especially if it was something like chlamydia that has a really, really high reinfected concordance rate. Are they experiencing any symptoms if they got treated for an S ST I did their partner currently at the time also get tested. Um, because you could be presented with someone that's repres because their partner had not been treated for the D I. Um, and then asking you, do you know of your current partner's um, sexual health history, pregnancy intention? Ask a person? Do they want any Children? If so, do they want more Children? Is it important that they conceive soon or is it something they're thinking about the future and seeing, you know, how important is it for you to be on contraception to prevent pregnancy at the minute. And this doesn't even just fall into sexual health history. You know, this is something you ask all the time and like postnatal um appointments with mums that um are six weeks, postpartum, talking about contraception, just running through really quick things. Do you know much about contraception? Ice is so important in any kind of station like this? Ice the hell out of everyone in ay is the best advice I could give anyone. Um But are you currently on it? Do you wanna, do you wanna try contraception? What types would you be considered? You know, do you anticipate any issues with compliance? You know, someone slightly more suitable to a pill or a coil? Um and always just offer to provide more information. Queens are quite good. We had an ST counseling station when we were fourth years and they literally as you went in the door on the store was all the chlamydia leaflets that they give out in gum clinic and GP settings. So you literally could be like before you did anything else? This is a lot of information I'm gonna give you today. Um But here's a leaflet that you can take home with you. So, Queens, like if it's anything information wise, whether it's sex health related or any other kind of counseling station, it will be somewhere in the room and they will try to make it kind of obvious that you can go. Ok. Leaflet here. Bam, two marks done. So going on to S TI S. Um, the, these are the main ones, I'm kind of going over gonorrhea, chlamydia, herpes syphilis. I've also got a little bit on triggers and then something I'm not going over today, but that would be good to know in future practice. Um, is about mycoplasma, um, genitalium. So risk factors for SDI is pretty self explanatory. If you've got people that are sexually active, if they've got multiple sexual partners or if they currently have an infection, you know, if they've got BV or they currently have an SDI, they're gonna be at a high risk of getting another infection. Dis can be diagnosed a myriad of ways. Um Chlamydia and gonorrhea are in a combination test which is your nucleic acid amplification test. You can also use nap testing to diagnose the herpes. Um HIV is a combination of antibody testing from serum sample. Um plus PCR, whereas syphilis, it's just the blood test for antibody testing. You can also do microscopy cultures and sensitivity whether this is, you know, a charcoal swab for chlamydia. Um It is a vulval vaginal swab that a patient has taken themselves. It's an endocervical swab that you've done as part of the speculum exam. Men first catch urine, which some people don't come across the different types of um urine samples. This is quite important in lab. So a first catch urine if you haven't come across, this is where you instruct someone to just pee in a cup. Um And it is that first bit of urine that you get. Um this is not the one that you want for UTI S. You want um a midstream urine sample for UTI S one, you say, oh can you pee a little bit and then get your collection just so that, that isn't contaminated with any skin flora. Just on. Az aside, if you haven't come across that before, um for microscopy culture and sensitivities, you need to do this for trichomoniasis and gonorrhea, go go, gonorrhea needs two tests done to confirm the diagnosis. So you must have a charcoal swab and you must do not. Um as you can see on there is there's lots of different ways that you can test them. Um And it's very good to be aware. Um What tests can be done um For S TRS gonorrhea is increasingly becoming the most common in the UK. I don't imagine the question banks have changed. They'd probably say that it is still chlamydia. Uh but gonorrhea levels are rising. It is caused by Neisseria, gonorrhea. A way to remember if you get at a question on the bacteria. Neisseria has two ss and gonorrhea has two R's. So it's, there's a diplococci bacterium. Um That's a big M CQ hint I have for you on it infects the mucous membranes that have corona epithelium. So you can get an endocervic infection. A urethral infection. The rectum, the conjunctiva or the pharynx can all be infected. Gonorrhea is pretty much always symptomatic in men. Uh only about symptomatic, 50% of the time in women presenting complaint. Um This one is really associated with um having like mucopurulent purulent discharge, um especially in men, they'll complain that, you know, that they have discharge about 80% of the time plus or minus dysuria. Um Gonorrhea tends to appear about 2 to 8 days after exposure, which is quite rapid. Um although these patients, if they have a urethral infection, um they're complaining of pain when they urinate, they don't typically have frequency or urgency like you would expect with a uti um women could present with a urethral infection or it could be endo um so they may or may not have discharge down below. Um Regardless of whether it's, you know, urethral or it's end of the vital, they might say, oh, my discharge has increased or it's a bit different to normal. Uh I can get lower abdominal pain. Um And it's quite rare for gonorrhea compared to chlamydia to get intramenstrual bleeding. Um A lot of the time rectal and pharyngeal infections can be asymptomatic, but it also could be someone's come in with a sore throat. Um That could be a gonorrheal infection. Um Men, sometimes if they are participating in anal sex, they can get prostatitis. So they'll come in complaining of uh perineal pain, they might have urinary symptoms that prostate is probably gonna be tender on examination. Uh And when it comes to a conjunctival infection, conjunctivitis, it is a very, very red eye and very um purulent discharge. And uh treatment of gonorrhea is pretty straightforward. You probably say a lot about azithromycin. We don't like using azithromycin when we can avoid it because for most ST is there are insane rates of antibiotic resistance to azithromycin. So the current treatment of uncomplicated gonorrheal infection is just a single im um CF dose. Um If sent activities are known if you have done for MC NS for gonorrhea, sometimes oral ciprofloxacin is done, but often people come in. Ok, you've got a positive gonorrhea test. You're in gum clinic. We're just gonna give you your injection now, contra indications. So there's a really patient preference based on allergy. You know, if someone is penicillin allergic, they're needle phobic other patients like, yeah, I really, really don't wanna get um an injection today. You can go oral um you can use other cephalosporins as well. And you know, if you just have this super strain that is really resistant but is sensitive to azithro, you can still use Azithro test of cure. You need to know this gonorrhea is the only one that absolutely does need a test of cure. If you've had someone come in, they don't have symptoms and their gonorrhea is um diagnosed on that testing. Um You, you, depending on kind of test they got, you treat them, you test them, sorry, seven or 14 days after treatment. If someone has been symptomatic, you have to repeat the culture. Um and that's three days after the treatment. Um That's something you just need to have aware in your head. Complications of gonorrhea, like a lot, a lot of str S they are gonna be relatively similar pelvic inflammatory disease and chronic pelvic pain is, is a huge issue for um people that have endocervical infections. It can be a cause of infant infertility. It can be a cause of epididymal orchitis, prostatitis, conjunctivitis. You can get urethral strictures, um disseminate gonococcal infection is basically when the bacteria spreads to the skin. So these patients might, you know, and they're prompt, they'll have a previous diagnosis of gonorrhea, but they've come in, they've got nonspecific skin lesions. They've got polyarthralgia, they've got migratory polyarthritis, tender synovitis, plus or minus systemic symptoms. So you're thinking and they're quite systemically unwell and they've got lots of muscle and joint pain. You're wondering is this a disseminated infection? You've all probably come across in the MC QS about Fit You Curtis Syndrome where there's infection in the liver. Um and gonorrhea can also be a cause of septic, arthritis, chlamydia. It is the most common in the UK and it is caused by an intracellular obligate organism, chlamydia. Um Trachomatis we love we love na bacteria. Um It can cause in genital conjunctival, nasopharyngeal infection. The highest prevalence rates in the UK are quoted as being between 15 and 24 year olds. So if they put the age in an M CQ prompt, remember that if they are particularly young, there might be a higher chance of it being chlamydia infection over gonorrhea, it has a very high frequency of transmission. Concordance rates are up to 75% of partners being reported. So you need to make sure that if someone's getting treated for chlamydia, you need to encourage them for their partners to come up, get tested and treated as well. Chlamydia can be quite tricky because it's asymptomatic in about 50% of men and in about two thirds of women, um the symptoms of chlamydia, um men can have urethral discharge. Women can have vaginal discharge, postcoital intermenstrual bleeding is more common in people with vaginas than not. Um People can complain of urethral discomfort, epididymal orchitis, pelvic or abdominal pain, pain during sex. Um And both sexes could complain of dysuria and reactive arthritis. On examination. If you're doing like a speculum exam, you're probably gonna see very mucopurulent cervicitis with or without contact bleeding. They'll probably complain of pelvic or abdominal tenderness, cervical motion tenderness. Um And you would, you would see the pu very purulent discharge there treatment. If you are going to remember two things that Doxycycline treats. Uh One is Lyme disease and one is chlamydia. Um We like we like doxy for this and it's just a weak course of doxy. Like I was saying earlier, we're not using Azithromycin much anymore, but we still use it in pregnancy or breastfeeding. Um or if that cannot be used for whatever reason. Um Erythromycin can be used but more important that you guys remember doxycycline for chlamydia for a week, complications, very similar to gonorrhea, pelvic inflammatory disease, chronic pelvic pain, infertility, ectopic pregnancies, epididymal orchitis, conjunctivitis, lympho granulum verum. This is basically, this affects lymphoid tissue around the site of chlamydia infection. And it's basically that bacteria gets inside the lymphoid tissue. Um and you can see it in um men who have sex with men, it might start off as like a painless ulcer, usually like on the penis. It's on the vaginal wall or in the rectum. They'll have lymph adenitis. So they'll have swelling, inflammation, pain in the lymph nodes, either inguinal lymph nodes or femoral. Um and they then might present with prostatitis later on. You know, if they end up with procto colitis, they'll have anal pain change in bowel habit, tenesmus discharge from the back passage treatment again, for this is Doxycycline. Um But you're treating them for three weeks instead of one week. Um if they get LGB and then um in chlamydia infections, they can get a reactive arthritis, pregnancy related complications related to chlamydia infection. Um just think it's o it's everything that's early. So your preterm delivery, your premature rupture of membranes baby might have a low birth weight. Um, mum might get postpartum endometritis. So just an infection of endometrium. Um and if it has been a vaginal delivery, baby could end up with conjunctivitis or pneumonia, genital herpes. Um This is caused by herpes simplex virus. HSV, one is actually now the most common cause of genital herpes um rather than HSV two. It, I'm not sure if your MC QS will have updated to reflect this. It might still say that HSV one is cold sores and HSV twos is genital, but um both can cause both. It has an asymptomatic initial infection. Um and it lays dormant in the associated sensory nerve ganglia. So in the face, it's trigeminal um and then it's sacral nerve ganglia. Um and genitalia, the primary infection symptoms may lay may last for up to three weeks. Um So, you know, they may be asymptomatic and when they do finally develop symptoms, it might be months or years later when the latent virus has been reactivated. Those initial infection symptoms usually appear for about two week period. Um They might have really localized symptoms. First of painful clusters of ulcers in the genital region, dysuria, vaginal urethral discharge, neuropathic type, kind of shooting hot, sharp stabby pain. Um rather than like a dull ache, um systemic symptoms. It's just your typical flu like ones you feel a bit rubbish, you've got malaise, you might have a fever, um you have might have myalgia, like just generally not feeling in yourself. Um And this is much more common in someone that this is their primary first presentation of herpes rather than recurrent disease. Um The person may also have, you know, inguinal lymphadenopathy signs. Um You're looking for these blistering ulcers on the external genitalia in the perianal region. They tend to be in clusters rather than like a single ulcer. Um lesions and lymphadenitis in the first episodes of herpes are usually bilateral. Um but then it kind of migrates to like an infected dermato or like a it's unilateral in recurrent disease. Um So that's, yeah. And just as a side note, if you ever come across someone with genital herpes in practice, there's still a lot of stigma about it. I'd really, I think this would more be real life than ever in a osk. I think it'd be quite tough to give you herpes for counseling in an ay. But um having a diagnosis of genital herpes will not ruin your life. So please, if you ever come across patients that do have genital herpes be very nice and reassure them that it's not, it's not gonna be as bad as they think. Cos there's still a lot of social stigma around herpes. So you want to treat someone with herpes with usually aciclovir. Um And there's other ones that you can use as well. Herpes is very painful. It's neuropathic pain that people are getting in their genitalia, which I'm sure you can imagine is just awful. So there's lots of additional measures that you wanna give like regular paracetamol, even giving people in still a gel, um, to put in there, urethra that can be really helpful. Um, saline baths, topical Vaseline, making sure, especially if they have systemic symptoms that they are drinking enough fluids, they're wearing loose clothing and they absolutely must abstain from sex if they currently have active herpes, that's getting treated because it is just very, very contagious. Some of the complications associated with herpes is super infection of these lesions. It could be fungal, which is typically candida infection or it could just be streptococcal infection, which is kind of hard to avoid because streptococcal species just live on the skin. Um because of this and how, how contagious herpes is, you know, autoinoculation to skin and fingers is really, really common. So like really good hygiene measures need to be advised while someone is getting treated for the herpes. So that uh it doesn't inoculate anywhere else because the herpes virus is living in the sacral ganglia. It can lead to autonomic neuropathy and that's probably gonna present with urinary retention, um which is really horrible and may even lead to mean hospitalization the same as if they end up getting an aseptic meningitis, it probably have to be hospitalized um to manage um these or again, if they just have really severe constitutional symptoms may need to be hospitalized. Um, sometimes suprapubic catheterization um is a better option for the patient. It's quite, it's proven to give a really good symptom control. Trichomoniasis is a parasitic protozoal infection. Um It colonizes the urethra and the vagina. Um Some people just have it, you know, it's not really an SDI in the same sense that gonorrhea and chlamydia is an SDI if you get any kind of questions on like what these organisms look like. Trichomonas, it trichomonas has like a really characteristic appearance. It's got full flagella at the front and a single flagellum at the back. And if you get anything, an M CQ prompt about, you can see this organism waving at you. Um because that's what it looks like under a microscope, you know, it's trigonias if somebody has monus and there is an increased risk of contracting HIV other vaginal infections, pelvic inflammatory disease, potentially cervical cancer risk goes up. Um And there is a risk of pregnancy related complications. So I have an image of the strawberry here because this will be your big giggle giveaway on examination if someone has trigonias and that's strawberry cervix. So um this is a specific cervicitis relating to infection where there are these tiny hemorrhages um on the surface of the cervix. So, if you ever see strawberry cervix in an M TQ, you know, it's trigonias. Uh people, if they have symptoms of this, they're probably mostly gonna say, you know, there's been a change in my vaginal discharge. You know, it might be yellow, it might be green, it might not have a color change at all. It might be frothy. They'll say it might be a bit fishy or a bit smelly. Um There's a wee bit of overlap in the clinical presentation of this with bacterial vaginitis which we'll get onto later. Uh There is um a rate is in the vaginal ph when people have this infection. So, because the microbiome has been thrown off and they're producing potentially more vaginal discharge that they usually do, they might feel uncomfortable and itchy. Um sometimes it can cause dysuria and dysuria and um people with penises that get it, this can actually really cause a balanitis, which has a million different causes. So, don't worry about that. Treatment is metroNIDAZOLE. There's a few ways you can do it. It kind of depends on trust guidelines. But you're thinking, ok, this is a protozoal infection. So it's gonna be metroNIDAZOLE. Um If you've got loads of drug options in your MC QS, um this is very specific for the protozoal infection as well as metroNIDAZOLE. Just been very good for her. In general syphilis uh caused by um try pallidum, which is a spherocyte. Again, if you get anything in the problem about what these bugs look like. Aery is syphilis. S for s um it enters through skin or mucous membranes replicates and then disseminates. Um, it has a 21 day incubation period, then keep an eye out in your M CQ prompt about incubation periods. And when they actually start presenting with symptoms, after having unprotected sex syphilis can be contracted sexually, obviously. Um also via that transmission from IV drug use blood transfusion and other transplants. But those latter two, thankfully, quite rare. Now, there's lots of stages of syphilis though, you don't need to know everything about the stages. Just know that you have primary secondary latency, tertiary and neurosyphilis or uh pary syphilis. So, primary syphilis, you get this chan chance. However, you say it, which is basically just a painless ulcer at the site of the infection. Secondary is where people get these systemic symptoms for 3 to 12 weeks. Latent syphilis is their asymptomatic phase after these two phases. So you might see early latent, which is within the first two years of infection or late latent, which is two years after the initial infection onward. And someone could be latent for decades. Um Tertiary syphilis is where you get the, the development of gas, which is like your um your granuloma tissue that develops and that's when people start to get their neurological and cardiovascular syphilis symptoms. And then the last stage is your neurosyphilis. So, presentation varies depending on the stages. Primary tends to just be this painless ulcer unlike herpes, which is painful. Um and local lymphadenopathy that might be for 3 to 8 weeks. Um If it's extra genital, it might be a little bit painful. Um, but you'll see in the stem if there's lots and lots of pain, you're thinking herpes. If there's little or no pain, you're thinking something else like syphilis, your secondary symptoms tend to be more systemic. You get your lymphadenopathy, your maculopapular rash, your fever, you might have alopecia, oral symptoms and that's about 4 to 10 weeks after the initial chanter tertiary is where you get these gass. So, hematosis, lesions of the skin organ bones can affect the palms and the soles and neurosyphilis symptoms might even crop up in the tertiary stage. Um And then neurosyphilis has very specific things like here, you've got your Argyle Robertson pupil, which is your constricted pupil that accommodates when focusing on a near object that doesn't react to light. And as you can see here, it is pretty circular, but it's kind of a of an irregular shape. Again, if you are really, really interested in this, this is you know how long um some of these symptoms can appear, but you don't need to learn this if you wanna go more fash is the place to go diagnosis um is predominantly antibody testing. So you're looking at um EI A I GG and I GM. If you think this is someone's first presentation, it's a primary in primary stage syphilis, you want to get your antre I GM anti antibody testing done. Um your rapid plasma region, your RPR or your venereal disease research, lab VD LR, you'll see those abbreviated when you're requesting tests and these are very nonspecific but sensitive test to assess active syphilis infection. So you're basically just looking at the quantities of antibodies produced by the body to infection with syphilis. So the higher the number, the greater the chance that there is active disease. But because it's quite nonspecific, there is a really high um false positive risk primary infection um is just benzylpenicillin. You don't need to know doses. But whether like a primary infection or in pregnancy, you can still use benzyl penicillin. Um If someone is allergic to penicillin, you can use doxy. So I have a couple of NC QS. These are like the hardest ones I could pick out. Most sex health questions will be easier. Um But I just wanna point out a few clues in these stems. So if you guys wanna answer in the poll, like absolutely no judgment if you do or you don't. Um But if you have a 25 year old female complaining of a pain, swollen, left knee for the past two weeks, she was recently treated for an sti she's a very large effusion on examination, but the synovial fluid analysis has negative cultures, but a raised white cell count. What do you think the most likely organism is? Do they have trichomoniasis? Do they have chlamydia? Do they have syphilis? Do they have herpes or do they have HPV? If anyone wants to have a go, it's grand some of these. Yeah. Two. Uh, I know you're not confident this is gonna be hard for a reason. But, yeah, this would be chlamydia because, um, it's been in the last two weeks, um, you know, that she's had this, um, it hasn't really given you the last time that she had unprotected sex but I think in two weeks is greater than gonorrhea, which is about 2 to 8 days. Um She has raised white cell counts but negative cultures. Um So this might be like referred to as being like an aseptic um arthritis, but that's a very tricky one and, and that was the point of these like the ones you get in your A KT will probably be a lot easier than these. A 24 year old woman presents to a GP with a two week history of Dyer and vaginal discharge. She describes the discharge as thin and white or yellow color with a slight smell. She had unprotected sex with a new sexual partner two weeks ago. What is the most appropriate management? Do you wanna give her a Ciclovia? Do you wanna give her Azithromycin? Do you wanna give her Im Benzyl penicillin? Do you wanna give her oral doxy or do you wanna give her Im cefTRIAXone? The these ones are hard but I just say like, do go over a couple of them we've had quite a few, um, sexual health questions in our finals because they kind of overlap with infection, um, as well as like the minimum two sex health ones. Um, and they do like asking the two parties. Yeah, someone here has put four, which is the correct answer it would be or doxycycline because, um, this is a 24 year old. So if you remember that when I was talking about chlamydia, it's really common between the ages of 15 and 24. Um So if someone has an sti i that it would be chlamydia, um and it's this kind of thin white yellow discharge rather than like a very like mucopurulent discharge that you would expect with gonorrhea. And then again, if you're thinking about two weeks ago, it's a bit, a little bit longer than when typically gonorrhea will rear its head. A 21 year old woman presents the GP with abnormal vaginal discharge and unexplained vaginal bleeding. She doesn't have any rashes or genital lesions. Her last period three weeks ago, she's recently had unprotected sex with a new partner. Swabs are taken, a microscopy shows gram negative diplo which of the following is the most likely diagnosis? Trichomonas, chlamydia. Um Traminda, does she have bacterial vaginosis or is it nice gonorrhea? Yeah. So a few people put in five. and it is indeed nice gonorrhea. Just the best way I think to remember is diplo coca means like you have two balls together. Um And nicer has two Ss and two Rs in it. Grand going off now, um off of S TI S into kind of like vaginal infections. So, bacterial vaginosis really quite common and it's kind of this whole cycle of things. Someone's had some kind of disruption to their vaginal microbiome. Really common. One that you'll get in your stems is someone's recently been on broad spectrum antibiotics. Other things might be they have a new sexual partner that has a very different skin flora to them. And they obviously you don't know that cos no one knows what their own microbiome is. Like, let alone anybody else's because there's been this disruption, you can get this loss of lactobacilli species. And that is like the, it, that's the predominant theory, the species in the vaginal microbiome. And that's what's responsible for the acidic environment. But because you've had this disruption, for whatever reason, your, you've lost some of these species. And because you've had this disruption, there's kind of been, there's a void now to fill in that microbiome. And it encourages anaerobic bacteria to overgrow the more anaerobic bacteria that you get, the more loss of normal lact bil I species you're gonna get. And it's just this continuous cycle where you're starting to get very alkaline vaginal environment. The, the most common reason behind this and the one to know that gives the help of MC Qs is Gardnerella vaginosis, but also other ones can be prevotella or mycoplasma risk factors that are a couple for BV, multiple sexual partners. Again, introduction of new bacteria fungi, whatever a, a new person that they've had sex with has a different microbiome to them. Excessive vaginal cleaning like douching. Please tell your patients not to do that. The vagina is self cleaning any recent antibiotics. Um It is higher in black ethnic groups um than other ethnicities. If you're a smoker, there's an increased risk. Copper coil in the presence of an sti I, they'll complain of an offensive discharge in the stem. It'll probably say fish smelling. Um, it tends to be this white gray discharge. Some people are asymptomatic with BV. Um, but it would be unlikely to give you in a stem or like it probably, they probably will say, ok, there's something gone off with my discharge, not really sure what it is. Um, on examination, they probably have this thin white homogenous discharge as well. Um, and they might come in feeling like, quite embarrassed because of the smell or they're worried that other people can smell it or because there has been this change in this discharge. They just feel really uncomfortable. Sorry, assure them that that's ok. Um Treatment is very easy. You give them um intravaginal cream, either metroNIDAZOLE or Clindamycin for five days to a week. Um They don't even have to go to their GP for that. They can get it over the counter complications. Really can kind of increase the risk of contracting a sexually transmitted disease just because the microbiome is off. There are certain pregnancy related complications suggested increased risk of miscarriage, preterm labor, premature rupture membranes, chitti I can't speak tonight. Apologies. A low birth weight or postpartum endometritis. Again, a lot of that kind of related because the microbiome in the vagina is completely off. Candidiasis is also known as thrush. Uh it is a vaginal infection with Candida. It's most commonly candida albicans. Um Candida is quite normal in the vaginal microbiome. So it's this kind of colonization versus infection thing. You need the right environment for it to cause infection. So that could be things like pregnancy when everything's gone off, poorly controlled diabetes, immunosuppression or recent broad spectrum antibiotic use might complain of this in the M ZQ like cottage cheese describing discharge, it's thick, it's white, it's uncomfortable. They might have horrendous vulval or vaginal itch, it's irritated, they're uncomfortable. Some people get systemic symptoms, they might have erythema and edema down below, they could develop AFA fissure. Um and they might even get, you know, pain in sex and pain urinating diagnosis tends to be clinical, but you can send off a charcoal swab for microscopy. Recommended antifungals is a lot. Um A lot of it kind of depends on the symptom and what's in the guidelines or like, you know, if it's like a GP or a pharmacy environment, they can just get canister duo, which is a single, a single fluconazole tablet plus the clotrimazole cream, which will either be intravaginal or topical. Um, people can get them individually. Um, I kinda really recommend, you know, if they've got risk factors, you know, if they're a diabetic or if they've got really severe symptoms or, you know, this might be their second or third episode of thrush in the last year. You really kind of wanna target them with oral antifungals. Um an exception to this would be pregnancy as the azoles are teratogenic and toxic to the fetus. Um If they seem pretty well, you know, it's their first episode of thrush, you would probably be going for like your intravaginal, topical pessary options. So if you're just kind of aware that you can use fluconazole if they're really quite unwell. Um but not if they're pregnant or if they're diabetic and then you go on top of all clotrimazole really as a pessary other management considerations, you might get a question on this recurrent candidiasis is only diagnosed. Um if someone's had more than four infections in a year that is treated with combination oral vaginal agents for at least six months. So they get an induction period and a maintenance regime manage their risk factors. Like if they're an uncontrolled diabetic, get their diabetes under control and that will reduce the risk of them getting any kind of infection. Um an important thing to know antifungal creams and pessaries can damage latex compounds and inhibit sperm side use. Um, so if someone's sexually active during this time, they need to have alternative contraception for at least a week. The 22 year old type one diabetic presents to the gum clinic complaining of a thick white vaginal discharge, she's got no history of an S ti what do you think is the most appropriate management? Again, I'd hope that you would get a little bit more information in the stem than like in this one. But sometimes they give you the very, very little information in the stem. So if you got a really nasty question like this, you would be thinking this is a type one diabetic. So you know that she is gonna be a high risk of getting thrush. So you'd wanna offer her systemic treatment with fluconazole. A 32 year old woman presents to clinic four day history of itchiness and has a white curd like vaginal discharge. She's currently pregnant based on this diagnosis. What do you think is the most appropriate cause of management? Do you wanna give her ketoconazole cream? Do you wanna leave it? Do you wanna give her an oral agent or do you wanna give her an intravaginal ping? Yeah, someone has sent five which would be right. Uh And that's the important thing here. All of these are azole drugs which you don't wanna give to someone that is in their pregnancy because they're TriC. Um So just if you say azole, nope, not for you. A 21 year old woman presents to clinic with vaginal discharge that increases around her menses upon by manual spectrum examination. She does have an ectropium but there is a fish odor uh to her discharge. What do you think is the most likely causative organism for this presentation being it's Gardena Candida, trichomoniasis, uh a different type of candida or Ecom. Yeah. A few people have said one which is right. This is quite hard cos like they never really talk about it. And then you get all these MC QS that are all about bacteria and you're like, oh my God, what caused this? But yes, golla is probably the most typical cause of BD. Good moving on now. Um epididymal orchitis. So this these can be kinda like separate conditions or they can be come together. So, epididymitis, you've got inflammation of um the epididymis, you know, which is like the first part of the testicle that sperm goes through. Um That's where they're matured and stored before the end of the vas deferens. Um orchitis is general inflammation of the testicles and a combination too is usually the result of infection um of the epididymis and the testicle on one side. So, common causes of this are a lot, but the ones to be aware of would be eco like chlamydia, gonorrhea and lumps. So this will be a gradual onset, you know, minutes to hours of this unilateral pain in the testicle. They might complain of like a dragging or a heavy sensation. The testicle might look visibly swollen. It'll be very, very tender on palpation. They might complain of urethral discharge or they might be systemically unwell diagnosis. Treat this as a testicular torsion until proven. Otherwise, you can kind of come back from someone having an epididymal orchitis that has been diagnosed a bit later on in the day, but you can't come back if you've completely missed that someone has a testicular torsion and their symptoms in real life might be very, very similar. Um So whilst you're doing your work up for a testicular torsion, try and get urine microscopy culture sensitivity sent off, get this first pass urine sent off for chlamydia and gonorrhea testing. Um If you have time, you can send off a charcoal swab as well. Um You can do serum or saliva um antibodies, PCR for mumps and you can do an ultrasound. Um And just for mumps, you don't really know, need to know the ins and out of the test. It's just if they've got a high IG M they have an acute infection. Um but if they've got higher I GG, they have a, they've either previously had mumps or they've been vaccinated against it management. Um So treat them if you think that this could be an SDI. So that's your combination of the chlamydia and gonorrhea testing. So you give them their their IM CF plus their doxycycline. Um If you don't think it's an SDI and you wanna treat them, um empirically, you're giving them quinolone just because these have like really, really good empirical cover, they'll get rid of a lot of gram negative bacteria um that can cause epididymal oritis. Uh Important things to remember about the quinolones though. A big side effect is tendon damage and rupture and it's most notably the achilles. So you might come in when someone's come in, they're complaining like of severe severe pain in their ankle, they think their achilles is ruptured, they were treated um for an infection recently like something like that in the stem. Um and it's because they've been on like ofloxacin. Um It can also lower the seizure threshold. So be very careful in epileptics, give them painkillers, usually paracetamol plus minus NSAID, uh encourage supportive underwear, reduce physical activity and abstinence from intercourse whilst they're getting over this infection complications. Um Chronic pain, you can get chronic epidermitis, testicular atrophy, sub or infertility, a reactive hydrocele or scrotal abscess, erectile dysfunction. Um Most of you will know what that is, persistent inability to attain, maintain an erection. Um for sexual performance, this is a symptom. It is never a disease. Um It can be split into organic psychogenic or mixed courses. Increasing age is linked with an increased prevalence of erectile dysfunction, but it is not part of the aging process to someone if they're complaining of new erectile dysfunction, checking their history to see what, what else might be going on. Red flags that need urgent referral to urology is someone that presents with pre op. So they have an incredibly painful erection and that can be associated things with like sickle cell disease. It's often like a hematological problem if they are young and have always had erectile dysfunction that needs to be seen by urology. And if you've examined someone saying GP they've put a suspicious dre exam and their psa might be up. Um but their only symptom is erectile dysfunction. It still could be an issue with the prostate. So get them referred two weeks to urology, risk factors. The biggest one is vascular disease if you have a vascular path, um they unfortunately are more likely to develop erectile dysfunction, other cardiovascular disease, risk factors. You know, if they have ischemic heart disease have previously had a stroke, that's also a risk factor, autonomic neuropathy, particularly diabetics or increased risk of developing erectile dysfunction. Alcohol can be a temporary risk of developing erectile dysfunction, certain drugs, you know, SSRI S beta blockers, MDMA, other illicit substances, endocrine disorders like a prolactinoma, um can cause it anatomical abnormalities, trauma or surgery. There are things like um hirons disease where there's fibrous scar tissue built up inside the tissue. Um and that can cause an erectile dysfunction and that might be in your younger person. Um, that needs a urology referral because they've always had it but they're still pretty young investigations. Full sexual and psych history. See, is this organic or is it psychogenic, perform a GRE get a PSA level if they're in an appropriate age group, AQ risk score and a metabolic profile. So that's your lipids, fasting glucose. HBA A1C, things like that. See if they are a vascular path, um, bloods FB C uni T FT S prolactinomas. Is this an endocrine cause potentially and free testosterone. If you're getting a testosterone measurement for anything that needs to be between nine and 11 a.m. And if you've got someone coming in with a and you've done this free testosterone, it's low or borderline um that gets repeated with your FSH LH and prolactin levels. And if that panel is abnormal, that goes to endocrine, whereas if some of the others, you know, suspicious dre high psa that goes to urology, otherwise you can manage it in GP, you know, address any modifiable risk factors. You know, if you think this might be psychosexual, you can send them to psychosexual therapy. Specifically, main management they all know of is Viagra sildenafil, which is an oral phosphodiesterase inhibitor. Common side effects of this because it can impact the BP. It can say like headache, flushing, hypertension and the M CQ, the one to look out for is a blue tinge to the vision. And you can remember that because Viagra is a little blue pill. Absolutely contraindicated in use of organic nitrates because you're running the risk of absolutely tanking someone's BP and killing them that way. Um, relative, um, contraindications, some anti ischemic optic neuropathy, if they've had a recent mi or stroke or they have unstable angina. Um, I think it's for like 3 to 6 months you want to hold off. Um, but if it's past the six month mark that they've had their M I, um, you can probably restart the Viagra if they desperately need it. Um And then there are other devices, but I highly doubt you'd be asked on them. So, a few more wee questions if anyone is feeling up to it. Um A 25 year old man presents to Ed as a 24 hour of a moderately painful swollen right testicle. He's recently retired from holiday in Thailand when he had unprotected sex, multiple women. He's also reports some mild discharge from his urethra. His right testicle is tender to palpation. What do he thinks caused this? Do we think it's a torsion Hydrocele? He's got a uti I caused by E coli. He's got chlamydia or he's got a Varicocele. One is feeling brave. Yeah, four. So the really big clue. This is a young fella. Um It's quite like sudden onset a day I would say is like, oh, ok. Yeah. Um And then he's had unprotected sex with people. Um So a young man is more likely to have an sti than he is a uti hydroceles. Um, not painful. Tho Seles might be a bit uncomfortable but it wouldn't be like moderately to severely painful and testiculus torsion. He'd be in absolute agony. A 62 year old man turns to the GP has erectile dysfunction, but he's been advised that he can't stop um, phosphodiesterase inhibitors due to a contraindication. Which of these is a contraindication to PD five inhibitors. Use of organic nitrate, a systolic BP of 140. He had a heart attack three years ago. He's got stable on diet. He's a diabetic. Yeah. So a few people have wrote in that be one. Yeah. Um All of these are fine that BP is grand for a 62 year old without any other information. M I was greater than six months ago. So it's a case stable. Angina is not a contra in detection and nor is diabetes and this will be, it will potentially tank someone's BP, um which is potentially fatal as you all know. So that's me rambling on with all the content. I know that was a lot that I wanted to give you quick overview and some of the more difficult questions that you could get in sex health because most of them are really, really straightforward. Um They do really try hard to give you clues in the MC Qs and like I really like gum, hence why I'm doing this. But a lot of my friends who aren't that interested in? Go like we come out of our A KT and they were like, those questions were ab absolutely grand. Like, um I don't have any issue or any worries about how I did in those questions. So some of the clues, um, a grand neighbor, the cock eye is always, is like gonorrhea saying it's nicer has two ss, gonorrhea has two Rs. If there is one sore joint, it's usually the knee, it might be disseminated chlamydia. But if there are multiple sore tendons, sore joints, um it's a migrated polyarthritic picture. That's your disseminated gonorrhea. So you're thinking again, are like two Rs. So more than two sites affected and chlamydia is just one. if they say strawberry cervix, then there's always gonna be trichomoniasis. Um One thing I learned that I actually saw in some MC Qs recently, um was that ac A 125 marker can be increased in pelvic inflammatory disease. So, the more you know, um if you see anything to do with clue cells, it will be bacterial vaginosis. Um It is just how gardella the kind of the microscope. So anytime you see clue cells automatically that is b um look out for your vascular, ask if you get a question on erectile dysfunction, common S TI S are common. So if you're not like 100% sure on a presentation, look to see, could this just be an S TI and they just have some funky symptoms. Um any right upper quadrant pain in a person or childbearing a age. Could this be fit you kind of syndrome? Um Clues. So, um this is kind of like about Ph and microscopy excuses by the mistakes. But if you've got an increase to the ph, you're thinking BV or trichomoniasis, but if it's very acidic, it's candidiasis. Anything to do with clue cells, that's your BV. Anything to do with yeast or pseudohypha, that's gonna be candidiasis. Anything to do with the waving flagella or microscopy is gonna be trichomoniasis. Another thing in M CQ is friend sign. So pain on elevation will persist in testicular torsion but not an epi epididymal oritis. Um So friends positive means that the pain subsides. It's probably epididymal oritis. Hep B is the most likely type of hepatitis to be sexually transmitted. If you have AQ on that A and C can be sexually transmitted, but it's probably gonna be B a very, very quick run through of sys. There's lots of things you could do it, it comes under s and running through a counseling is quite an easy one for them to do. It's cheap and easy to reproduce. You get something or infections or discharge whether it's a history or a speculum exam. Um If you get a sex history, either as part of the social one just at the station, it'd be a bit mean, but they could give you just stick the pain in an ob per except me. Like I said, at the very start, anything to do with counseling, um Ice, Ice is your best friend and being nice and being reassuring that this is normal and like they can ask you any question that they want, you know, being a very nice person that I assure you are uh contraception and you really, really want a brief history. You want to ask some very important sexual Seric questions. Don't get too bogged down on this because all your marks are gonna come from listening to the patient answering their questions, going through contraindications, going through the devices and the risks and the benefits. If you get S ti management, um they could reproduce it cos we got it as 1/4 year. Um So it might be one to just practice. Always check for a penicillin allergy, always refer to gum even if you're not sure what to do. It's like, would you be happy for me to make you an appointment with the Gum Clinic? Um Contract tracing can be anonymous and tell them like we would, we would like you to contact your sexual partners and suggest that they get tested. But we can also do this as part of the Gum Clinic. Um and they will get anonymous message being like, please come to Guam and get screening tests done. Um Really, really simple advice will get you lots of marks as well if you're like Oh my God. I can't remember what antibiotic to use in this chlamydia one. You'll get loads and loads of marks which saying please avoid having sex for a week after you and everyone you're having sex with has been treated test for all other ST is offer them advice about any fu future infection and give them that lovely little leaflet that will probably be sat right next to you. Um Do you consider safeguarding stuff and sexual abuse in young people? Like be aware of like Frasier guidelines, ga it competency um leaflets, it would probably be right next to you in Aussie Station if you're not sure, like always at the NHS website, not even in this kind of thing, but if you're like, you can find more information about condition ABC whatever it is in your ay refer them to the NHS website. Um And then like, like for you, like your guidelines is like f faculty, sexual reproductive health and bash. Um your only notifiable diseases and organisms are monkeypox, hepatitis and mumps. Um You don't need to notify about anything else. Ask your advice just for everything. Ice, ice everybody. You'll get so many marks and your patient will be like, you're so lovely. Um And they really cared about me. Um build a good rapport, reassure them that it's normal that it's a safe environment. Don't assume sexual orientation or pregnancy risk just be a bit inclusive. They don't do this as like the main state of the, of the ay station, but they will put in protective characteristics into the station. So like we had a station in our finals where it was in pediatrics and the baby had two mums and some people incorrectly assumed that one of the mums was a grandmother because the actor was slightly older. Um So just be inclusive and don't assume anything. Um always give out leaflets um and practice it if you're like, if I got anything to do with sex health in an Ay, I'd feel really awkward, practice it with your friends because on the day, if you look and feel awkward, your patient will um and you won't get a good patient mark and your communication skills. How you are with a patient, how you offer information is always going to give you more marks than any clinical knowledge ever will. You might get two marks if you're like, oh, you've got chlamydia. So we're gonna give you Doxycycline for a week. Like if you're nice and you reassure them and you answer their questions, you're gonna get bucket loads more marks than just know an antibiotic. So I hope that wasn't too um awful. I know those were quite hard ones, but I hopefully think that will mean that any other dumb sex health questions you'll get will be a lot nicer than what I've asked you today. And please don't hesitate to send me an email. Um If you have any questions? Thanks very much, Hannah. Um, definitely a brilliant talk there and I learned certainly lots of things as well. Um, before everyone heads off, can I just very quickly, um, remind you all just if you wouldn't mind to fill out the feedback for Hannah there and also just to join the whatsapp if the, if you haven't already done, so I'll put the link to both in the chat there. And if you have any issues with any of that, give you just get in touch with your one of your committee members that's in the trust that you're in at the moment. Um And I'd certainly need a test to what Hannah said there, this sort of stuff does come up and is assessed regularly. So by all means, feel free to go back and have a look at this again. This is recorded and it's gonna be put up on, on med all by next week. Hopefully. So, um, thanks again for coming everyone and enjoy the rest of your night. Thank you. Thanks, Hanna. Thanks for doing that. No bother. I hope that wasn't too arduous for people. No, not at all. I was sitting there, there was, there was a few things that would have saved me a bit of time studying there a couple of weeks ago. But, um, no, thank you. It was brilliant. Thank you very much for doing this and I think the numbers are only up a wee bit. So it was good to get a few extra people in there. I haven't been to any of them yet. But yeah. No, like they're all off. So, absolutely fair play to who did come tonight. Like I told my share ones to take the week off because they need it. That's true. I think people will aye, the numbers will definitely pick up after Easter. But no, as you say, for a play, like, and no fair play to you for doing that was a great few slices that, so I appreciate it. No bother. All right. Right. I will see you later. Yes. Uh-huh. See us talking to you shortly, I'm sure. All right, bye. All right.