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Right. So I just wanted to try just so I can make sure that I share my screen. Hi, everyone. Um Thanks for coming tonight. We have our first session of revision um on genital discharge and genital warts and ulcers. Um We have Aba here who's gonna teach tonight. Just a reminder that she has got a feedback form at the end. That'd be really great if you guys could fill in. Um It's a QR code and I'll put the link in the chat as well, but a hand over to introduce yourself. Yeah. So, hi everyone. My name's Aba at least introduced me. I'm currently in F one at Royal ST Hospital in um West Midlands North. So I've had two rotations now, one in OB Gy and I've just finished oncology this weekend. Um I was just telling Lucy that I actually did go to Birmingham last year for intercalation and clinical sciences and I did my medical degree at Queen Mary's small to campus. So, yeah, I'm a bit familiar with Birmingham, but I don't know exactly what your curriculum is like for the whole of your med school. Um So hopefully this will help you out for your finals and any exams that you've got coming up with gum. But, um, so just, you can just put in the chat, you can see the chat or you can turn your mics on if you've got any questions or at any point or if you want to ask something or just anything else that you want to add, that's fine. So, yeah, nice to meet you all. So we're just gonna start with the session now. So as you know, this is a gum revision session and on urethral discharge and ulcers. Ok. So just a bit of background. So obviously, um or genitourinary medicine is um sexual, sexually transmitted infections. That's the, that's the study that we're doing there and it's also known as venereal disease. I thought it was quite interesting as I was reading that venereal disease actually comes from venous, the God of love. So it sounds a bit more romantic than sexually trans infection. So I don't know if that makes any patients feel better if you tell them that. But I think that's a bit interesting. I think sometimes these random facts can help you remember things. But um venereal diseases or ST s are um obviously, they're very prevalent and their greatest in heterosexuals, aged 15 to 24 year olds, particularly in ba groups and um queer people as well. So gays and bisexual um other men who have sex with men. Ok. So there's obviously many different presentations and symptoms that can come with S ti si just thought we'd start off with a bit of interaction and the word map to get a bit of a broader picture of what kind of symptoms that um these ST is can present with. So if you want to scan this QR code or to go on menter and type in this code, I'll give you a couple of minutes to do that And then you can just enter some s ti symptoms and we'll just have a bit of a talk about that and we'll go from there. So I'll just give you a few minutes and then I'll change to the word web screen. Ok? I can see that some of people are logging on. I'm just gonna leave it there for a couple more seconds just to make sure you all get on before I change the screen. Ok? If you want to put in the chat that, um, if it's going, ok, if you're managing to get on, I think I can see one person at the moment. Let's see. OK, we'll just share what we have so far and then, um, anyone else can just shout out. So I'm just gonna share my screen now. Ok? All right. So I hope everyone can see that. Ok. We're getting a few more. OK? So I'm not being very savvy with this, but we can, we can see the word map here. OK? So we've got four responses so far. We've got painful urination. That's great. That's definitely a big indicator of ast I can also be a non sexual infection. In which case, it could just be an, a standard uti but also known as dys urea. I'm sure, you know, so discharge as well. That's something that's a bit more specific to sexually transmitted infections, itching as well. Pruritis. So it could be accompanied with a rash. It could just be generalized itching. You could see excoriations there from repeated itching and ulcers. Of course, we're going to talk about that later. So there's different, um we can see that there's different descriptions of the dermatological changes that can happen with certain ST S and so the type of ulcer that a person might have might differ and which can give you a bit more of a clinical indication what ST I might be going on. Ok. So I'll stop sharing them. Has anyone got any more? They can shout out or just while I share the PDF again? Ok. Well, there's a lot, there's a lot of symptoms as well. So we mentioned rash. Um This session is mainly going to focus on male ST s or presentations of sts in men or people with penises, but there's obviously also like female presentations or female sex presentations as well. So things include unusual vaginal bleeding, like postcoital bleeding, intermenstrual bleeding. Um There's also things that, you know, other lumps apart from ulcers like lumps under the skin, lymphadenopathy as well, um and other and anal symptoms as well. So all these things occurring around the anus too. So itching, ulcers, sores, those kind of things as well. But obviously, this session, we're gonna be concentrating on urethral discharge and ulcers. OK. So just to talk a bit about how we're gonna diagnose these conditions. So this is supposed to be on the slideshow. I say um animation So you can see the answers already. But I was gonna ask you if you know the difference between screening and testing for S TI S, it's quite subtle. And as you can see by the Venn diagram, there is overlap as well. But the main diff difference here is that if you're screening a patient, it's because they presented to you without, without symptoms. Whereas if you're testing, you've got a clinical indication because the patient is presenting with symptoms. Of course, there's overlap in between because you are still going to um give them a diagnostic test that's going to come back with an answer whether they have an sti so those things will be the same, your first pass urine tests, your swabs, things like that as well. Serological testing. Um So just to contextualize what screening might look like, so if a person who's sexually active just might be doing routine screening, so recommend recommendations every 3 to 6 months, you just go for an asymptomatic screen. Um If you, if you don't have symptoms. This can be done at home as well. There's a lot of um great services online where you can just order a, a, an at home testing kit. So, like I've got this little picture on the left here, there's a bundle that comes usually. Um So you would fill out a online with your, with your sex, your sexual activity. What kind of sex you've been having? And then they'll send you swabs accordingly. So if you're a female and you might get a vaginal swab, a throat swab, an anal swab, depending on what kind of sex you're having. And then you'll also get a couple of lancets and you can fill up the little blood vials as well. So a very small amount of blood that they can use for, um, for screening for syphilis and HIV. Those are the standard serological testings that come with the screening. Um, but whereas if we look at testing, you've got a patient with symptoms. So they're going to need to go to a point of contact. So that could either be a GP, it could be emergency depending on why they've come or what they have access to or a sexual health clinic obviously would be the most equipped thing. But it depends what the patient themselves think is. The problem. If you know, they think it's sexually related, they might try and book in at a sexual health clinic. So then of course, you're going to have to take a detailed history based on the symptoms and sexual history as well. So your standard things as well. Um So if it's pain, you know your standard things and then the sexual history as well to ascertain risk, who else this patient is having contact with what their sex is. High risk factors such as um you know, paying for sex, chem, sex, sex under influence of alcohol. And then it's obviously going to involve an examination as well. So of the affected area or areas because of course, um with you, you're going to assume that there's going to be a genital, an anal genital presentation. But as we're going to go through many of these sts have extragenital manifestations as well. So depending on the s the symptoms and how you're seeing the patient, you might need to examine some other systems as well. And of course, so as I mentioned, you're going to take swabs for screening and for testing as well. But if the, if you're testing a patient and they have symptoms such as urethral discharge, then you're going to want to take swabs of the discharge or of the ulcer like from the ulcer base. So it's not just like screening where if it's a female screening, then you would just screen from the vagina itself that you're going to be testing specifically what the person is presenting with. Ok. So when we want to our first condition, so this is gonorrhea. So gonorrhea is actually the mo the second most commonly diagnosed S TI in the UK. Can anyone put on the chat? What the first is? Does anyone know or shout out, turn your mic on if you can, we'll talk about it later. But does anyone know what it is? Yeah. So tias put it in the chat. Yeah, that's right. It is chlamydia. Um We often talk about chlamydia and gonorrhea together because the testing is the same process. Um, it's, as I mentioned in screening, it's the swabs or first pass urine in males. Um, and they can have similar presentations as well. And as we've both, as we've just talked about, they're both very common. But for me, I think, um, usually remembering that gonorrhea presents with symptoms more often than chlamydia does, helps a lot. So I remember I watched this video on youtube. Um, I think maybe even before I was in med school about an SGI clinic and it was like this very northern doctor and she was, and she was talking to a patient who'd come in with symptoms and she said, oh, drippy Willy, then it has to be gonorrhea and that's just always stuck in my head. I think, you know, obviously it's very silly. It's something that, you know, you might not want to say to a patient. Um, depending on, you know, how they might receive that. But it's something that you can kind of differentiate in your head. So gon as we, as we've talked about this, told us about urethral discharge. So gonorrhea, um it, it has symptoms in over 90% of cases. And in males, the most common symptom is the urethral discharge and it's, it's quite muco purulent, so kind of um like pus like. Um so that's where that comes from the, the drippy will symptoms. Um So it's a gram negative diplococcus called necessaria gonorrhea. And you can see that corner, you can see that image in the corner. So you've got your normal neutrophils there and then the intracellular gonorrhea bacteria. So diplococcal, obviously, they come in to you. So you can see the small arrows pointing to those there. Um Yeah. So there's obviously we there's different extragenital sites like I mentioned. So most commonly it will be a genital infection, but it does also infect other areas such as the rectum, such as the pharynx as well. Um We're going to talk about it in a couple of minutes as well, but gonorrhea is, is, it's often talked about in the context of resistance. It's um it's, it's one of the STIs s that is becoming more frequently diagnosed in the past 10 years. The diagnosis or positive results for gonorrhea have more than doubled in the last decade. Um And this is partly due to the increasing antibiotic resistance with the condition. So, as I mentioned, so you can get different symptoms depending on where you're infected. So if it's an oral infection, then you'll have the sore throat symptoms or if it's an eye infection, you'll have like discharge from the eyes as well. So that um purulent discharge in the eyes. Um Yeah. So if the diagnosis, as we mentioned, the urine collection in male sex is preferred and if possible a first pass urine. So the first, the first void that the male would have waking up in the morning is going to have the highest probability of returning an accurate test. So that's the ideal and throat and rectal swabs as indicated. So that's gonna be guided by your history or the person's risk factors. So there's different ways of testing for gonorrhea. The most common and most sensitive and specific is the NAT testing. So the nucleic acid amplification testing and um that's probably um overall, it's the most common testing for most ST is as well. It's I've put it on the slides for the other conditions too. But in general, the rule of thumb, it's most likely going to be a N A test for most STIs. There are other things you can do as well. So, microscopy that would be getting a direct vision of the, the gram length of diplococcal like we see in the right hand corner. So that would be using smears from the discharge you've obtained from the patient. So it would be sent to the lab and then they would put that under a microscope and give a positive diagnosis based on what they can see and there's also culturing as well. Um Culturing is not something that is really routine, but it's mainly used in the context of finding sensitivities for the infection rather than actually diagnosing. So as we mentioned, that's going to be important if you're concerned about resistance as well. So that's, it's usually more for sensitivities rather than actual diagnosis. Um And also just to mention as well, the reason why N testing is preferred is it's, it's more stable, you don't, you, other things like culture depends a lot on how long it takes for your sample to get to the lab, how well it was transported and how stable the sample is. But that is, is quite reliable in that way that you don't have as many concerns. So especially if we're talking about screening tests where the patient is sending them the, sending them in the post from home, you don't know how long it might sit around in a, in a postbox or whatever, then it's, it's the most ideal form of testing. So if we move on to treatment, so the first line treatment is a stat dose of cefTRIAXone. I am. So, um it's obviously intramuscular, you might have to consider a second line treatment if your patient is extremely needle phobic or of course, if they have a resistance to first line treatment, in which case, Ciprofloxacin 500 mgs is taken also its a stat dose. Um There's many other um 3rd, 4th line treatments as well, obviously, because this is such a resistant um such a resistant infection. Um But for many of the STIs as well, there's also a lot of different treatments as well based on, you know, other contraindications. But you shouldn't need to know too many of them for your exams, maybe just 1st and 2nd line, obviously prioritize first line, but um just just for your information. But obviously because they need that one dose, it's important to counsel the patient, tell them exactly what this s ti means. The kind of complications that can occur if they don't get it treated and, and to impress on them that they have to be abstinent until seven days after the treatment is completed. So you would tell the patient of their positive diagnosis, give them their treatment, treat their partner as well or anyone else that they've had contact with and tell them not to have sex until seven days after that treatment is completed because there's that risk of reinfection or passing it all along to another person as well. Um Yeah, so anyone who comes back positive as well should be tested for oropharyngeal. Um So you would give them a swab as well in their follow up if it did come back positive. And so also in your follow up, you have to do a confirmation for test of cure so T OC as it's abbreviated. So to make sure that the treatment did work, actually, all treatment failures for gonorrhea have to be reported to public health England as part of this problem with resistance that we've talked about. So that just shows you how big an issue it is really. And you know, the most, the biggest way to tackle it is to try and stop the spread. And so that's practicing safe sex and, you know, educating people and making sure that they're compliant with the antibiotic regime. So I've just got some, I've just got a graph just to demonstrate the resistance. Um So this is from, I've included this in the resources at the end as well. It's quite a long document, but this graph just illustrates what I was trying to say. So as you can see, it's got all these different antibiotic treatments for gonorrhea um along the X axis and on the top it has m so that's a minimum inhibitory concentration of the particular antibiotics. So what it's showing is that the lowest concentration of that specific antimicrobial that's needed to inhibit the growth of gonorrhea. So you can see as the years have gone on, you're needing more of the antimicrobial to inhibit the growth of gonorrhea. So that, so that's meaning that the gonorrhea is becoming more resistance to the particular antibiotics as well. So you can see that purple line is ciprofloxacin. So that's had the biggest increase um I mean tetracycline as well. But um the data starts at 2015 for that one. But um so you can see that resistance is increasing a lot. So that's why it's not first line anymore. And then you can see cefTRIAXone, which is now first line is quite low, quite flat against the X axis. So that's one of the more reliable ones, but of course, that could all change in the years to come as well. So that just kind of illustrates the point of the of the um increasing resistance. Ok. So moving on to the next condition, I've put this one in because it's also um quite talked about in and consents to resistance. But it's definitely not as common as in exams and things. And even in life, it's more, it's more seen in males who have sex with males, but it, it, but it's just something to be aware of. So it also infects the genitourinary tract and it can cause proctitis as well. So infection of, you know, the back passage anus and, and uh all of that. So, but many of the people who are infected do not develop the disease, you can just naturally um clear it. But um and a lot of the infection as well is asymptomatic, but it can have that similar presentation of discharge. Um also dysuria and just genital irritation as well. So as I mentioned, most of these things are diagnosed with that, um Uh and so you want that first pass urine test as well. So the management for this is going to be Doxycycline 100 MGB D for seven days and the period from no sex is longer, obviously, because it's not a stat dose, you are having seven days. So seven days after the treatment is finished, you still need to be abstinent to make sure that you're not passing on or getting reinfected. Um So this Doxycycline treatment is also common for some other STIs s we're going to talk about as well. So even if it does come up on the exams, you know, you can kind of your bet and just put Doxycycline if that's the answer as well. But let's move on. So now the most common chlamydia um OK, I also forgot to mention, of course, there's gonna be a few sensitive images on this slide as on in this presentation as well. Sorry for saying that so late, I'm sure you're expecting it. But um just to be aware. Um So this is the most common S TI in the UK in the UK like we talked about. Um So and so this is another intracellular bacterium called cho. So you can see that one in the right hand corner as well. So, so very similar to gonorrhea, like we talked about, it can have those extragenital infections too. Um But unlike gonorrhea, more commonly than not, it's asymptomatic, particularly in females as well. Um, although we are focusing on males, it's just important to note, um, especially in females, it can be asymptomatic. Um, but when it does have symptoms, it can also present with this urethral discharge. But, um, it's more likely gonna be quite watery thin and white, not like that, um, purulent discharge with gonorrhea. Um, but of course, it's still important to swab. And the thing is even if you, if there is urethral discharge as well, it's going to be the same test. So it's gonna be that and that test. So then they'll screen for both things, both for chlamydia and for gonorrhea as well. So the results will tell you but just something, you know, if you're in clinic and you see that or you're in a clinical setting, then you can have a bit of an indication of which one it might be of the chlamydia versus gonorrhea just based on the character of the discharge as well. Um So untreated, there's different complications that can occur as well. So, reactive arthritis. So if you remember from your rheumatology, there's different triggers to certain immune diseases as well. So chlamydia gonorrhea infection can also trigger these reactive arthritis. So if you see a young person, of course, sts don't just occur in young people, but um you might have a higher suspicion that that might be the trigger if you see a young male presenting to you with arthritis symptoms and then the one of the biggest complications in males is the inflammation of the epidermis and the testes as well. So, um the orchid system as well. So that could be the presentation also if, if it's been long standard and the person hasn't been screened or tested. Um So of course, as we mentioned, there's other testing modalities as well. But for chlamydia, the culturing is quite a long process. It's a very time consuming. So it, it wouldn't usually be done because we're not as concerned with resistance as we are gonorrhea. It's not as common for it to be cultured. Um But yeah, and that is the most sensitive and specific again for, for, for chlamydia. Um Yeah. So as I mentioned, Doxycycline is a common treatment. So this is another one that can be treated with doxycycline for seven days. Um So that's the first line treatment, but you might have to do the second line. So the Azithromycin um the Azithromycin treatment as well. Does anyone know what a big contraindication for doxycycline is probably one of the most common up put in a scenario. So it's actually in pregnancy, you can't give doxycycline um because it has implications for the for fetal health. Um So you'd go with Azithromycin in that case. So that would be probably one of the, you know, the biggest contraindications. Ok. So next condition. So the next condition is oh yeah, t just put it in there as well. Yeah, pregnancy is correct. That's right. Um So lymph, so lymphogranuloma venereum is, um it is technically a kind of chlamydia. So it's just uh caused by a different seroi of chlamydia. So, L2 being the most common. So typically you'll see this in endemic countries. So they're usually like South West Africa, Southern Africa, um Southeast Asia Caribbean. But if you do see them in the western world, commonly, that person is HIV positive as well. So that's a very important coinfection to consider as well. If you see this kind of chlamydia infection in a person in the western world, you would always screen for other S TI S as well, but you'd be particularly concerned about HIV. So uh the incubation period is like um 3 to 30 days. And so you'll get symptoms like the image I've got on the top, right? So in males, you can see that you've got this um ulcerative lesion here often on the coronal sulcus. So that means it's, it's right under the head of the penis. Um So that gap between the head of the penis and the shaft, you'll find ulcers around there. Um So you can see that kind of raised ulcer there. So you can also it can also be a rectal or foundry infection as you said it is, it is a chlamydia infection. So the same kind of the same kind of pattern of disease you could see. And um this is important to remember as well. For males who have sex with males because L GV is a, is a big cause of rectal infection and we'll go through it a bit later as well. But um, it can cause quite severe anal symptoms as well. Usually, um, bleeding tus, so trouble, um, um, passing stool as well, um, discharge as well. Constipation also because of the pain as well. If it's a psychological effect, then that's so LGB is a major cause of that. So if you see a male who has sex with other males presenting with anal symptoms, there, there will be a big differential in your head. So it has a few different stages of infections. So, um things like this also that I'm showing you would be a primary lesion and um so moving on to a secondary infection and that's when you start to see lymph adenopathy. So, I've got this picture on the, on the bottom here. So this is what's called the groove sign. So you have um swollen, lymph lights, swollen lymph nodes above and below the inguinal ligament. So, um so the top one would be um the femoral femoral lymph nodes and then the inguinal lymph node underneath, separated by the inguinal ligament. So that's what's the groove running in between the two. So that's why it's called the groove sign. And that's very, that's quite classical of LGV infections. Um It doesn't happen in everyone. It's about 15 to 20% of people you'll have this sign, but it's maybe it might appear in your um what they call the picture exams as well. If they show you that, then it's most commonly associated with L GV. And then moving on to tertiary infections, that's when you'll get um some chronic inflammation from a long standing infection. So, um lymph adenopathy will become more painful. Um, you can have a chance of getting obstruction of the lymph nodes and can get genital edema and swelling. And then this chronic inflammation. So if it is um a proctitis caused by LGV as well, it will give symptoms similar to IBD. So it will be similar to Crohn's disease that patchy inflammation with a lot of um change in bowel habits and as we mentioned as well, the bleeding discharge and things as well. So those are becoming chronic and worse issues. So, same with IBD. If you go on and treat it, you can get fistulous formation, abscesses and things like that. So, quite nasty complications. So as you said, it's a chlamydia, so same, same kind of thing, you're going to take a nap from the infected site and then the same treatment Doxycycline, except it's going to be a longer course for LGB because it's a more severe serovar. Um I've put drainage there as well because if you're going on to these long standard complicated issues, then things like fistulas will require surgery. If there's abscesses, they might need to go to the theater to drainage and you might need to physically remove the lymph obstruction if the treatment is not resolving it. So things like that just to consider with more severe infections. Ok. So moving on to syphilis as well. Um So I've got a picture here. Um Yeah, I think sometimes just adding in these things just helps you remember. So, um then, so this is quite prevalent, I mean, it, it is quite prevalent in medieval times and obviously long ago before we had, you know, antimicrobials to treat these things. So if you think like Queen Mary, the first reportedly had syphilis and a lot of these important historical figures who would get their portraits painted would in real life, they had a lot of syphilitic lesions that can affect the face and the skin as well and that would all be painted out and then people meet them in person and not wanna marry them or things like that because they look quite different because of all the the stigmatic disease that they have. So I just put that there as well just um and then I think it's quite interesting. But um so syphilis is um called by uh Trone and palladium. Uh So it's a bacterial infection um that has three different stages. And I think it's helpful from a revision standpoint to kind of link it to HIV as well because those things are tested for together in a screening process. So both of them, they would be tested with blood tests. So, a serological test and I think they're quite similar in the way that they have different stages of infections. So these three stages and I'll talk about it as well that you can do blood tests to monitor the effect of treatment as well. So kind of the obviously for HIV the viral load and then for syphilis, you can, it would be kind of like the bacterial load in the blood that tells you how active the disease is and how well your treatment is working. So if we look at um the natural course of syphilis, so you get your primary infection so that can appear like 21 days ish around your um exposing events so that sexual contact. But um the period ranges from nine days to 90 days. So it would be part of your history taking when they had that um sexual interaction that they think they could have got the infection and you might need to call the patient back to test again because even if the first test comes back negative, if they're not over 90 days from that um first contact, then it could still, they could still come positive at a later date. So you have to do a confirmatory test to make sure that you haven't missed the infection just because it was too early. Um So in that primary infection, you're gonna get a shanker. So that is the the ulcerative lesion that is classical syphilis. So, um I will show it to you in the next slide, but um it's, it's a painless lesion with like um just a clear base. There's usually not much redness and yet, um most notably, it's painless as well. So that's going to help you differentiate it from a lot of other ulcerative ST is, but this will spontaneously resolve over a matter of weeks as well. So it depends how concerned the patient is. You know, how much education they have. If they don't present, it can, it could be missed and they could progress to secondary syphilis. So in the secondary stages, that was going to happen 4 to 10 weeks after that primary stage and then this is where systems will start to become systemic. So you get this, this widespread, well, you can get this widespread rash that um classically affects the palms and the soles of the feet but can affect the trunk as well. Um You'll get other systemic manifestations. So, splenomegaly, you can see there's some derangement in FTS from hepatitis to increase in kidney function if they've got glomer, nephritis, neurological symptoms as well, that also are a big part of the tertiary stage two. So if you've got a young patient with a lot of systemic problems and you don't really have a specific course for it. Um screen is definitely going to be something that you have to rule out something that you're going to have to do to rule out syphilis as well. So, moving on to tertiary. So that's something that can happen years and years after that primary infection because um the secondary infection will again, it resolve spontaneously in 3 to 12 weeks and you will enter a latent stage. So that latent stage can go on for, you know, 2030 years where the disease was incubated and then you'll get a recurrence of tertiary symptoms a lot later in life. So these are split into three categories, neurological cardiovascular and gummatus. So, gummatus is um it's uh essentially granuloma. So it's um just a collection of, you know, um cell debris and um just encased in cells. So, you know, think about TB and things very similar to that and it's mainly found in the skin and bones of patients with tertiary syphilis. So, if you think about these medical historians, that's how they've diagnosed these deceased syphilitic patients from the medieval times and things that we've spoken about, you can see the changes are still there in their bones. Ok. Um So to go on to diagnosis, as we mentioned, it's a blood test. So you're going to be testing for um antibodies against the um against the talla. So if you remember from your immunology, I GM is the first antibody produced. So that would be more around a um primary syphilis. So the more about the initial infection, an IgG will be produced later. So in those secondary tertiary stages, you'll still be able to detect. But of course, if they've got um active lesions, then you can swab those and um you can do testing to identify tep palladium from those swabs. And as I mentioned, so we've got these tests so that RPR is the rapid plasma reagent test. Um so that can be tested for in the blood. And so that will indicate disease activity. So as we mentioned, we've got these latent stages with syphilis. So you can test if someone is in a latent stage or if you know, if they're known to be syphilitic, you can test someone that's in the latent stage or an active stage by their RPR level. So above 16 would be active disease where it can be passed on and they might be having symptoms and under um is um inactive and they wouldn't be able to pass it on. So that's why I say it's quite similar to HIV in that way. So if you think about the viral load and undetectable equals unts, unts mis, then it's a bit similar in that way. So I think it might just help in your head if you kind of link those things together. So the treatment for syphilis is penicillin. So this can be given as a single dose in a primary infection. So that and as an iron, um also in secondary stages as well. And the early latent period of a secondary infection. But if it's a more severe infection, deep set, um these tertiary stages, then you will need to give it repeatedly for over three weeks or possibly even longer, depending on the kind of manifestations they have. So I've got a few pictures of the presentations of syphilis. So these are the, the chakra pictures up here. So you can see these, these lesions on darker skin and as well as um lighter skin as well. So they usually come by themselves as well. So that's another giveaway for syphilitic lesions rather than things like um like herpes as well. That would usually be in clusters chan are usually by themselves um singular lesions. Um So that's something to know. And then this is the kind of rash that we mentioned as well that you can get in secondary syphilis. So you can see it classically here, it's on the soles of the feet and these two males have them on their trunk as well. And so this, I've taken from the bas guidelines. Um So these are the, the characterizations of the tertiary syphilis infections. So, the different headings that I mentioned the um neurovascular, the neurological cardiovascular and gummatous. Um So the most common neurosyphilitic condition you're going to hear about is this TBI dorsalis. So that's inflammation of the spinal cord itself. So, as you can imagine that can present with different symptoms depending on what level that is affecting. Um so it can at different levels and different um either motor weaknesses, sensation, sensation changes, just depending on what part of the spinal cord is affected. Um So, cardiovascular as well, usually it's gonna be an kind of aortic dilatation kind of presentation or aortic regurgitation, heart failure. And um so at this point as well, it might be something to consider based. Um because as we mentioned, it can be latent for several years. So depending on the age of the patient, when they contracted syphilis, it might not be unusual for them to have aortic regurgitation. So it just shows you how many different causes of these things that there are. And sometimes it involves a lot of kind of detective work to figure out what's going on. So if there's no other cardiac history, then it might be something to consider and the patient is maybe just a little bit younger than you'd expect. Usually you think aortic regurg and kind of eighties and you know, very elderly, but they're 60 they're coming with it, then it might be something that you need to consider. And then the gummatous lesion like our two people on the other side can have those. Yeah, like disruption to facial features and the bones as well. Ok. So moving on to other ulcerative um conditions, it's so viral. Now, this is herpes simplex virus. So um so this is the most common cause of ulcers specifically. So I know we said that chlamydia is the most common bacterial infection. Usually that wouldn't cause ulcers, but herpes simplex is the most common cause of ulcers. So, just remember that. Um so this is obviously a viral infection and there's this kind of um different pathogenesis that's HSV, one versus HSV two. So usually it's HSV one causing oral lesions and HSV two causing genital lesions. But um it has been shown that there is overlap in, in these different kind of um pathogenesis. So it's not necessarily binary like that, but um that's the most accepted thing. Um So, unlike our bacterial things that we've been looking at before, most of the time, it's going to be a PCR diagnosis um from your swabs. So you'll swab a lesion when it's active, when it, when the patient presents and um it will be sent for PCR. And that's, it's a faster way of getting the result. It's more sensitive and there is a lower risk of contamination with the, with the PCR. Um So as I mentioned before, when I was comparing some of the lesions, it's usually like a cluster, a cluster of vesicles on the skin with a red base. So you can see that here and um on a on a white person presentation that red base on the darker skin, obviously, you might not get that, but you can still see that it's very similar as these clusters of quite puffy vesicles on the skin. Um So as you mentioned, obviously, you can get oral genital transmission because it infects the both the lips and the genital region as well. Um So it's important to remember for herpes that it can be asymptomatic for a long time. So when you're initially infected, you might not actually get a presentation, you might not get symptoms of, of herpes. So I remember I had an osk, I think in my final year where the patient presented with herpes. And then part of the osk was the, this person was in a relationship and they asked, oh, what does this mean? My partner is cheating on me. And in that moment, I couldn't remember which one. can you can reoccur later? So I just kind of evaded the question and said, oh, well, it's fine. We'll get them tested too. We'll see whatever. But, um, so, but you guys can be confident in your answers because you, you remember from this session, hopefully that um herpes simplex can have a long period of latency. So you can be in a stable relationship, um, monogamous. Um And then suddenly get, um, get an episode of a herpes outbreak and it could be something that you've contracted years before you were in that relationship. So that's something to remember. Um So of course, you get the ulcers, but there's also like a pro to it. Um because because herpes is a lifelong infection, um There's no curing it, there's no getting rid of it, but it's not always active. So you'll have periods where the, the ulcers will come and they'll go and the symptoms will come and go. So, before those episodes, you can get a prodromal illness where you just feel general unwell, generally unwell, um you might start getting a bit of pain and then the symptoms will kick in. So the diarrhea, the ulcers, painful lymph nodes and neuropathic pain as well because it is a herpes virus. So, if you think about herpes zoster as well, how that invades nerve ganglions, it's a similar um pathogenesis and that, so you can get that nerve pain too. So you can, obviously, it's a lifelong condition with a recurrent episode throughout your lifetime. So they usually a normal episode would resolve in 3 to 4 days. Um And it's considered a prolonged episode if it's above four days. Um So it's just so during a period where you're where you're symptomatic, you're advised not to have sex and you to present for antiviral treatment as well. So, um usually that's with acyclovir. So you'll take that three times a day for five days. Um And usually you would only be treated during those active, active um um active episode. But um you can consider long term suppressive treatment in patients that have prolonged episodes and also frequent episodes, meaning over six times a year. So, suppressive treatment is long term antiviral treatment that can happen for up to a year So a year is the maximum amount of time you can have a patient on suppressive treatment um due to the side effects. Um So it's at a lower dose than what we've got here for the episodic treatment. But that would um that was, that's what you consider if your patient is really suffering with recurrent episodes and really important to remember as well to give these patients analgesia, the pain can be very severe. If you've ever seen a patient come to you in an active herpes outbreak, it can be very severe with that neuropathic pain. So to give them regular analgesia as well is important. OK, so I'm moving on to the next virus. So HPV or human papilloma virus. So um this is a cause of um of warts. Um So we've got this um the HPV type six and 11. So those are the most common benign causes. I know probably most of you are going to be familiar with 1618 because those are the most common carcinogenic types. So just remember like those two are different. So six and 11, benign, 16 and 18 is carcinogenic. Um So um I think a lot of you were familiar with this because I know the vaccination program has been rolled out since 20 22,008. So the vaccinations for all girls aged 12 to 13. So I remember getting my vaccination um in your A I and I know a lot of, you will have had it as well. Um, it's interesting to note that it's only given to girls. Um, you know, it's not something that only affects girls. It has a higher risk of being carcinogenic in girls, which is why it's given to them. But, um, boys could also be given the vaccine as well. It's just, it's only given to females because they're at higher risk and because it costs less for the, for the NHS just to give it to half the population. Um So they choose to give it to the people who are most at risk, which makes sense. But, you know, we could really stop the spread of HPV if um males were also given the vaccine as well. So that's just something to remember that it's not only females who are at risk from it, but that's just how we vaccinate in this country. Um So it's a very common infection but it's just, there's so many serotypes that a lot of them are at low risk of causing a lower risk than and 18 and causing a cancer. And it's common for it to be spontaneously cleared by the body. So you can test positive on the screen in one year if you're a female in the regular screening program and then, you know, they'll follow you up until you clear the vaccine until you clear the virus. Um So as we mentioned, it's often asymptomatic, but it classically causes these warts or lumps. Oh Lucas has put um I think the last year or so boys have got a two but I'm not aware of it. Um being policy, but that would be very good. I hope, I hope that's true. I'll have to look it up afterwards, but thank you for mentioning that. Um So it gives these kind of lumps and warts. So the classic cauliflower distribution. So, um you know, they protrude from the skin a lot, they're in big clusters. So that's what it means by cauliflower like growth and you can also get them in other places rather than just the genitals as well. So usually diagnosis is just a spot diagnosis if it's one that is causing warts, obviously, like I mentioned, there's the female screening program as well. So that is done with your smear test. Um So I'm sure we'll talk about more tomorrow. Um But if you are querying other causes as well, then the definitive thing is going to be a biopsy. So it will be a biopsy and the microscopy to see the virus and the changes that are happening to the epithelium. Um So management, you have to obviously explain to the patient what the virus is, the risks that come with it and depending on the it progressing to a cancer. Um Sometimes there's no treatment because as I mentioned, it can resolve spontaneously if they clear the virus and the warts might go. Um But there's these other chemical treatments that you can apply directly to the lesions um to help them regress. And if they're larger or they, you know, they are causing the patient distress, then you can do ablative methods as well. So, cryotherapy or um heat ablation and things. So I've got this picture here. This is a cryotherapy. This is obviously to a hand, it's not for HPV. But um so you use um um nitrous oxide, which is obviously extremely cold and then you freeze the lesion and it will fall off. OK. So just to quickly mention some rectal infections as well. So we've already mentioned, um as we've gone through that, a lot of these things can be, can infect the, the rectum as well. So, gonorrhea, um you know, can be asymptomatic like we mentioned, but can cause anal discharge as well and a lot of pain. So, as we mentioned, if you test positive for genital gonorrhea, then you should be followed up with um r lymph or sampling, obviously, depending on your history to your sexual activity. But that is usually what would be done as part of the follow up and recall and chlamydia as well. Obviously, we mentioned a lot of the time chlamydia can be asymptomatic, but the same kind of picture discharge, pain, discomfort, herpes proctitis. Big thing to consider in males who have sex with males. And as we went over before L GV is a, is a big offender of rectal infections in males who have sex with males. And it has those nasty complications that we um that we mentioned before that can mimic Crohn's disease. Ok. So the important thing to note with all of these TS is partner notification. So, um, so it's important as part of your history taking to ascertain who these people are having sex with and who else is at risk where they might have got it from themselves and to trace these people from the index case. So the index case being that person that presented to you with the symptoms and then their contacts. So their contacts are the people that you have to trace and notify. So you can, it can be either a patient referral or provider referral. So patient referral means you explain to the patient, their diagnosis, what S ti they have complications treatment and you ask them, you know, who else um could be at risk of this. Who else are you having sex with? And you ask them to tell them to tell that person to come in for testing versus a provider referral, where can you know, you can offer the patient a choice as well, obviously. But so they would just pass on the contact details and then the clinician or the establishment would contact the person who's at risk and tell them that they've had, they're at risk of certain sti and they're being called for epidemiological treatment or for testing So, epidemiological treatment means that um because your partner has tested positive that you're going to be treated automatically. Um So, regardless of testing, we're still going to treat you because it may be, even if we test, it's just too early to show that you have that sti but because you've definitely had sex with someone who was positive, we're going to give you the same um antiviral antibiotic treatment. And um, so the, the, the cases where you treat and the periods where you have to look back, the look back interval. So that's how far into the patient's sexual history, you have to look back changes depending on the kind of ST and the, the sex of the patient. So for example, for chlamydia, um between males and females, the look back interval is longer for females because um because they have that they're more likely to be asymptomatic. So you have to look further back into their sexual history and contact more people. Um Obviously, depending on how many people they've had sex with because more people could be at risk because it's hard to know when exactly they got it. Um So the bat has a guideline on the different look back intervals for different S TI s but you don't need to remember all of that, but just want to note um So partner notification should only not be done if the contact is not traceable. So if you know, maybe the person was it was a one night stand. They don't know the person who don't have any contacts or they were under the influence of drugs or sex and they don't know who the person was or it could be a nonconsensual act and the person's not traceable. So those would be the only considerations where you wouldn't notify the partner. Um And then you have to document all of this as well. So document that you've taken a history, you've asked, you've chased the person as well and just something to know about patient referrals as well that you would check that they had been done at the follow up appointments as well and that person has presented. And if they haven't, then you can as the provider contact that person because their health is at risk. So that's one of those incidents where you can great confidentiality, not in the sense that you would give the identity of the person and he put them at risk, but you would still record them for testing or treatment. And so just quickly go over some non ST causes of, of some of the presentation we talked about. So just some things to consider, it's not all STIs. So malignancy could cause like lumps and bumps that we talked about. Um So for testicular cancer, you would want to get them an ultrasound and do some um tests for some markers as well. So that be to HCG, that's another kind of classical like scenario, I remember I had a, um, a case based learning or something where, you know, it's a, a man and a woman and then the pregnancy test, they're not sure if it's working. So the man does and it's positive and it's because he's got testicular cancer. So because it's the same hormone that be to HCG trauma as well, could be the reason for ulcerations and things. Becher's disease is another one. So that is a autoimmune vasculitis that can cause mainly oral oral ulcers, but also genital as well. So I've got the signs and symptoms in this little bubble here, but you most likely have a lot of um systemic features too. Um And it's one of those that's associated with HL BF 51. Um And folliculitis is another thing to note. So that's the picture up here. So that's just just bacterial colonization of the follicles. You know, it's particularly going to be more prevalent if they have a history of hair removal around the genital region. So, shaving, waxing anything where you mess around down there, it can cause an infection and epidermitis. Of course, it's a complication of STIs as well, but it can have different, different infective causes that are not sti related. So like this EK mumps viral thing as well, important to know you have to exclude testicular torsion in these cases. So it also it would involve an ultrasound and then you'd treat accordingly, but it is also treated with doxy usually. So again, you obviously have to do your due diligence and investigations, but it's a similar treatment for most things. Ok. So that's the end of the um, end of the teaching session. It just ended right on time. Um I've just got a list of resources here for you that I've used in this presentation or just things that I think are helpful are interesting and I'll give you the slides or Lucy will send them to you. And I've got a feedback link as well if you'll be kind enough to fill that out. So I've got the QR code for it here and then Lucy has just posted it in the chat for me. But thank you for listening. Does anyone have any questions? We'll give a few seconds. So those just come through. I just looked up the um HPV vaccines while you were going through. Um And basically, it has been extended to um males aged 12 to 13 and sort of the school vaccination program. Um But also men who sleep with men under the age of 45 they're also eligible to get it on the NHS. Um Obviously, they wouldn't have got it at school, but if they wish to get it, they can get it up to the age of 45. So I thought, OK, that's very interesting to know. OK, thank you for bringing that up. That's very good. So maybe in the future we could have very low HPV transmissions rates with males being vaccinated as well. But does anyone have any questions or any comments? Anything? So, Tia's point, I didn't know HPV can be cleared from one's body system. I thought it was like HIV chronic. Um So, no, it actually can be cleared spontaneously from the body and very often is. So that's another reason why I think even the NHS website for HPV is quite good at explaining this as well. So with the HPV screening program that you might test positive and if you don't have any epithelial changes that you would just be recorder higher frequency than other people in the screening program because it might be that a year after you test positive, you will test negative because you've spontaneously cleared the virus. So the only risk really or what we're worried about is it progressing to um um to a cancer to becoming a cancerous change? So, yeah, you can spontaneously just clear the virus and Tunisia's asked the follow up question. Can a 29 year old still take the HPV vaccine? Yes, you can still take the vaccine. Um As you just check, you might just just have to check whether they'll give it to you for free, but I'm sure they will if they're giving under 45 year old males as well, but you can still take the vaccine. Um I think they just tend to give it at that age group because the risk factors for HPV. Are you having more sexual partners? So, if you're having more sexual partners it's likely that you're going to have sex earlier. So they try and get people into the program when they're younger, um, get them vaccinated before they're having sex so that, um, you're not going to contract it when you do start having sex. So, but, um, you can still take the vaccine when you're older as well. It's just more effective in a public health scheme to give it to younger people. Anyone else got any more questions? Yeah, I think that might be it for now. But so thank you so much for giving me your time tonight and running this teaching session. It's been really appreciated. Um I will send out the slides after this and this was recorded so it will get uploaded so you can watch it back. Um If anything you wanted to go over. But yeah, thank you so much. I will thank you and just to say it might be better to send the powerpoint version because there's quite a bit of information in the speaker notes as well if I'll send those out. Ok, that