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Madeleine, I think you've probably been to one of my talks before um It is a different talk because I think your presenter dropped out, so I've only had a few days to make a new one, so but I think going through s. T. I. S and infections that are not sexually transmitted would be quite useful. Um I think it's something I definitely didn't know much about when I was in. I guess you guys probably pee, final year at this point, um so it would be good to go through so what we'll do is, we'll do, we'll go through a case quickly um just to start it off and then we'll go through all of the sexually transmitted infections that could be relevant and then the two non sexually transmitted infections and I have a quick quiz at the end, I'm hoping to keep it less than an hour. Um I don't want to kind of keep you all stuck here because I don't want to get boring. If you have got any questions like Anna said, just um you put them in the chat, whatever do it while you remember what the question was about before you forget it um okay, so case one is stephanie rockwood. She's 26 presents to her gp, feeling generally unwell with muscle aches, fatigue, and just feeling a bit hot. Um She doesn't really want to give you anything else you ask her you know open questions and she says no no I'm okay what else would you want to ask her, so it's a very vague presentation isn't it and it doesn't, it's not even related yet to s. T. I. S. Or anything gynie at all. She just feels generally unwell, muscle aches, just rubbish um and you will often get in Aussies and in real life people who come in with really vague symptoms um and the best thing to do is to just go through a quick review of every system, especially if they're very, they're not being cooperative with the open question you say, oh you know could you tell me more about that and they're just gonna go, yeah, I told you or they don't want to give you more information usually, there's lots of different reasons why they might be embarrassed. They might have you know personal issues with it and I think that's quite typical of what uh Noski, station might be with somebody who comes in with a potential s. T. I. They don't really want to talk about it. It's an uncomfortable thing to discuss. Um So these kind of things, if you're considering something guy, any s. T. I. Non st, I like any pain when urinating, dysuria, pain in the abdomen, pain, and genitals, any abnormal discharge how long has it been going on for you think anything's triggered it you can always go through your socrates questions, it doesn't have to just be for pain you can use. Socrates is quite a nice reminder of pretty much everything for every presenting complaint. Um So she's had pain on urination for the last week and she's noticed some small red bumps on her vulva, but she thought they were just ingrown heads um and she's had some mucus like discharge what else would you like to know or do you feel like you can make a diagnosis or potential diagnosis already at this point. If she's told you this, you probably already gained rapport with her, uh which is important in these in any any consultant, but absent guy any, specifically when you're talking about things like s. T. I. S. And sexual health is important to get them on your side before you start asking them these deep and personal questions. Um So she's already told you these things, so she's likely to be receptive to you asking things about her sexual history, whether she's had stds in the past. If she has multiple partners, things like that that you really will need some sexual history, anyone want to give it a go with the diagnosis. They're feeling generally unwell, run down, muscle aches, fevers, some small red bumps and dis, area, and a little bit of discharge. Yeah, so it's quite typical of genital herpes, which is an s. T. I. Caused by herpes simplex virus. You probably I'm sure throughout medical school heard of this lots of times, there's two different types there's hsv one and hsv two, both of them can cause genital herpes, so hsv one is the one that affects the mouth and the nose area and basically causes cold sores, but that can be spread spread to the genitals via oral sex, so it is not just about the mouth on the nose. HSv is the one that affects the genital and anal area primarily, and that skin to skin to skin contact, so after it enters the body through mucous membrane, small cracks in the skin it goes up to the nearest nerve and it stays under the ganglion and it stays there and it's dormant and then it can be reactivated at a later time. Um And I just wrote that bottom, a symptomatic shredding is shedding is an important cause of transmission as well. Um just to say that most of these notes are from teach me jobs and go. I need to teach me serious, which is really good. I've put all the links to it across here, cause some of it I've quoted um So make sure you go and have a look at their website for that some of this stuff, so herpes you have primary infection. You have secondary infection because it lays dormant in the nerve root and then it comes back out so primary infection you get quite thick, clear white mucus um and obviously these things affect men and women. This is a gynie talks. I'm going to focus mainly on the way that it affects women, but there are things in here about men as well. Um you will get small and painful red blisters and then they will become open sores. Eventually, there is a picture there um and after about 20 days they start to cross over and heel and go away, they'll have flu like symptoms. They might have some itching. They might have some dysuria. It really depends on patient um so that's the primary infection, The secondary infection then is when you get a reactivation of the virus from the nerve root. It comes back out um and it basically causes the exact same thing all over again, but they tend to be shorter and less severe and as it goes on, it just gets better and better in religious stops. Um Seems like it's a similar presentation, burning itching, red blisters that hurt things like that and the cold sores are the ones that mainly caused by hsv one, which are quite painful lesion's around the mouth and the nose, don't really tend to last more than 7 to 10 days, but again that can be dormant and that can be reactivated as well. So the risk factors and these risk factors are pretty much always the same through all of these s. T. I. S. Is multiple sexual partners oral sex with a partner suffering with cold sores um and not using barrier protection by when we say unprotected sex. In this topic, what I mean is not using barrier protections. You could think of protective sex as having somebody taking the oral contraceptive pill because it's protective against pregnancy, but that's not protective against stds and I think a lot of patient's need education around that because they have the wrong idea and you say you know are you having protective sex and they say yes, but they don't mean condoms or barrier protection. They mean a contraceptive pill. So, investigations you need a swab from an open source, and that off a pcr to differentiate between type one and type two, it can be negative that swab but it can you can still diagnose genital herpes. If there are recurrent infections that persist with the same symptoms. Examination of history is almost always the most important part of it, make sure you're looking at the risk factors and you're looking at what the blisters look like um when somebody comes in with such a vague history and you're not entirely sure that it is genital herpes and you think that a systemic infection is equally likely you'll need to go down that route as well. So, if you want blood tests, you want to do an fbc, you want to check the white cells, want to take check hemoglobin anything like that then go ahead. If you're thinking, it's just genital herpes that's not really necessary, but if you think somebody is systemically unwell, then go down that route, so the management primary infection and pretty much all of it is around a cycle of it, an antiviral, which reduces the size of the lesions and how many there are for a current outbreaks. If you have a lot of outbreaks, then you can just have acyclovir from symptom onset until the symptoms go away, but otherwise it's just symptom management, so pain relief, ice packs apparently, vaseline people have also said have been really helpful. Um Any site give you if it gets bad, education is important, they need to avoid all sexual content during an outbreak, and they need to be told that the cold sores can also transmit genital herpes and they should tell all of their current partners and maybe do some contact tracing with things like this. It's difficult, you can't really enforce contact tracing uh with things like hiv. It's a little more urgent because it's a blood born sexually transmitted infection. There's different ways that you can do contact tracing, but for this, it's just kind of strongly encouraging them um a regular full sexual health screen, which everybody should have and a lot of people don't I don't know why maybe it's a fear of kind of the stigma of going and getting one or going to a gum clinic. I don't know, um but really everybody should be having one every couple of years or every time you get a new sexual partner. The earlier you catch these things, the easier it is to treat the less complications you have. Um So you know, education around that is really important. I think it's probably something that's coming up a lot more now than it did even a few years ago um in pregnancy. Herpes in pregnancy. If they are already, if they already have herpes before they get pregnant, the baby should be protected by the antibodies, so it doesn't really matter not to 3% transmission via vaginal birth. Is it's not a big problem, but if they contact herpes during the last trimester, then there is an issue, so two out of five contract the virus via vaginal birth, so we recommend to have a cesarean for the neonate. Sometimes it can affect the skin. It can affect the eyes and the mouth, um or you can have slightly more serious consequences, so it can become disseminated affecting the internal organs or you can have it affecting the nervous system and the brain and that can cause encephalitis. So you know it goes from if they've already had herpes really not being an issue too, if they contract it in the last trimester being a big complication, um so antiviral treatment is used and they do carry a high risk of mortality, so it's important to make sure that you're diagnosing these people early um okay, so gonorrhea is a gram negative diplococcus. It's the second most common bacterial st, i bonus points, does anybody know what the most common one is. It will come up in the quest later. No well come on to it um so it's unprotected sex, vaginal anal, oral sex, and it can also be transmitted vertically, which means from mother to child and again but I mean unprotected, I mean not using barrier protection um and once that's attached to the mucous mucous membrane, it goes into the host cell and it causes inflammation whilst preventing an immune response because it binds to the surface proteins to the receptors on immune cells, so it's quite good at hiding, um So the symptoms in men and women are pretty much the same. Um dis iria for women, painful intercourse for men that doesn't isn't less it's less of an issue. Um For women, thin, watery kind of a yellowy green discharge can have some lower abdominal pain and if it's severe, it's quite uncommon, if it's severe, they can have some post coital bleeding, intermenstrual bleeding, and on examination, if you take a swab, the cervix might start bleeding. When you touch it, there's more common with other stds, but it can happen with gonorrhea as well. Um Men urethral discharge dis, area sorry, that's felt wrong and epidermal tenderness, you can get a pharyngeal infection, but that's usually a symptomatic, 90% are asymptomatic. Rectal infections can also be asymptomatic, but you can also get some pain and some discharge investigations for women. An endo endo cervical and vaginal swab sent off for n. A. Eight e. N. A. 80 which is nuclear acid amplification test, anjel, want a urethral swab for microscopy in culture as well. men, you can either do a urethral swab or you can do a first pass urine important that it's first pass and not midstream, so when you're sending it off like a UTI, it's a mid stream because when you the first bit of urine that you avoid will contain cells from the urethra and kind of, from that surrounding areas, and you don't want that when you're testing for a UTI because your natural skin your skin naturally has lots of bacteria on it and you may have something in the urethra that flushes out when you go to the toilet, but with this, you want to collect all of that, so it's a first pass urine. Um um you can also take swabs, you can take swabs from anywhere that you think is effective throat rectum, I, wherever you see it and it needs treating management, you don't need to wait for the swabs to come back before giving them the dose of antibiotics, so it's a one time dose of, I am care, try Axon a 1 g, you don't really need to remember the dosage, Just remember that it is a one time dose of kept try Axon and that will serve you well again education, a full sexual health screen that should be regular complications and this is a pelvic inflammatory disease. I'll say it now is a complication of all the stds. If you leave it untreated, I talked about it at length. In one of my other talks, I've got a slide on it later, but if you want the more in depth um information that I had in the last one, I think these guys should have it, but I'm happy to send it to. If you want, I put my email on the front, um In men, prostatitis, epididymo, orchitis can also be a problem and disseminated gonococcal infections, which can cause things like joint pain, skin lesion's they need to go to hospital if they have systemic symptoms, so fever, joint pain, muscle aches, rash, but that is different from the kind of systemic symptoms you'd see with the herpes presentation so that would be like somebody presenting feeling like they have a cold. This is somebody presenting seeming like they have sepsis so different um because it can become meningitis, which can then become life threatening. Um Also send female patient's who have severe pelvic pelvic inflammatory disease or complicated factors. They need to go talk to as well um and in pregnancy, it can cause premature labor, early membrane rupture still births, and gonococcal conjunctive itIS um and there's all the conjunctive itIS will come up from a lot of the s. T. I. S. And that happens a lot during birth um So they'll need an urgent referral and the treatment to prevent blindness, but that kind of happens more with pediatrics and ophthalmology, and it's less it's less a guy any topic, so chlamydia then is the most common bacterial st i, about 46% of the cases in the UK, in the last few years. At least there are different types, it's an intracellular gram negative bacteria. There are different serotypes, so a to see cause is ocular infections, d two, k, s, g, u, and L1 to L3 is something you might have heard of lymphogranuloma veneer e. Um It's not something that comes up very often, sometimes on pass med, It's one of those like odd questions that comes up um It's incidences increasing with men who have sex with men, so it's not really got anything. It's more of a male problem and it can lead to things like proctitis, give it a google. It's very rare, it's not something that comes up a lot um transmission again like I said, unprotected any kind of unprotected sex, and it can also be skin to skin contact of genital, so it doesn't actually have to be penetrative sex for this to happen um And it can also mean that the barrier methods of contraception don't necessarily completely protect you because they don't cover all of the skin, so if somebody has a lesion or part of it say on, like their thigh or part of that like another part of their genitals and that touches you that's enough um and like I said you can get committed a chlamydia conjunctive itis, if it gets in the eye and that's the same for um women who give birth while they have conjunctivitis, they can the neonate can then get chlamydia conjunctivitis incubation period 7 to 21 days. It goes into the host cell as an elementary body, which is infectious, but it can't replicate and it becomes a reticular body, which is the opposite, so it's not infectious, but it can replicate after it's replicated enough that the host cell is basically about to burst. It goes back to elementary bodies, so when the cell does burst, it can infect other cells causing inflammation and tissue damage and continuing on that cycle male this is female. Most of them are a symptomatic, more so in women than men. Dis, iria, discharge, painful intercourse, lower abdominal pain, pelvic tenderness. Again some kind like postcoital or inter menstrual bleeding can be this and on examination, you might get cycle excitation so that's when you kind of push over the cervix and it just becomes really painful. They kind of jump that is not the kind of reaction. You'd expect usually, if you were to take a swab from a cervix, some people might find it mildly uncomfortable, but really it shouldn't be painful at all and if it is, you might need to start thinking about something else um and in men, it's very similar but they might get testicular pain or epididymo, orchitis and things like that um similar as it was with gonorrhea to taking swabs vulvovaginal, though in women as well as an under cervical or you can do first catch urine sample, so you can test for this. Um Quite simply if you were to give um urine sample to the g. P. Sometimes they offer you say say you're giving a urine sample for a potential uti. They often offer it to you if you'd like to have it tested for stds as well and then the same thing, first catch urine sample or your youthful swab, it's too small to be seen via microscopy, so it's sent for any 80 again and again swabs from anywhere that's affected. I rectum throat wherever you think it is take a swab and the same thing education contact tracing make sure they have a thought screen because it might even if they have chlamydia, they might have other issues as well or you think it's chlamydia and it might not be so just go through the whole lot uh. Management, there's a couple of different ways you can do it the most way, the most common way of doing it is a doctor cycling for seven days or you can do the azithromycin 1 g, just one single dose, um but if they're allergic to that or it's contraindicated, then you've got a erythromycin or ofloxacin um no sexual contact until either the treatment is completed or seven days post azithromycin does, because that's just a single dose like I said earlier pelvic inflammatory disease. If it's left untreated in women, um other things like it can it can go up, it can become an ascending infection and it can cause infections that endometrium, the fallopian tubes, and up men similar um so it can kind of spread to epididymitis and orchitis and that can affect fertility. If it's left untreated, you will have heard of this, I'm sure sexually acquired reactive arthritis um I I think it's remembered by the kind of saying, can't see can't p, can't climb a tree, so you have joint pain um issues with the eyes you might get you the itis, and then you'll have dysuria and the classic issues of s. T. I. S. A. Reactive arthritis is often a station that you might get when somebody just comes in with achy joints um in pregnancy increases the risk of premature delivery with low birth weights and miscarriage and stillbirth. As most of them do, they do carry these risks and you can get neonatal medial conjunctive itIS, you can, even they can even get pneumonias from it, which can happen months after they're born, um which is also treated with oral arrest. From icing These things about nominates, you don't really need to know about the treatment, you just need to know that there is a risk um and knowing about the conjunctive itis. It's important when you do your optimal placement, you should be going through that in lectures, but that will that can come up in your Pete's questions um okay, then so warts are benign epithelial mucosal growths and it's pretty much always caused by HPV which is the most common viral st. I. Um there is now a vaccination that has been for a while now um for HPV, so the numbers are expected to decrease they have been going down. It should be going down a lot more in the next couple of years, so six and 11 are responsible for the majority of anna, genital warts. There's I think 100 different types of hpV six and 11 other one for warts. It's skin to skin contact, so you don't doesn't actually have to be penetrative sex to pass this on. Um So condoms don't fully protect you the virus. It penetrates epithelial barrier and then infect basil keratinocyte and within that the virus replicates, which means the multiplication of the current keratinocyte and that grows and it grows lesion's mostly they're very symptomatic. They just kind of have this lesion this, this growth here and it doesn't really cause many issues um and it might just be one that's really little that goes away quite quickly, so people might not even know, um so they can last. They can last a really long time, weeks, two years after the initial infection, or they can be gone within a few days. They're painless kind of, they're just skin like growth just like kind of like a skin tag almost um and it can be just one or there can be lots of them. It really does vary person to person, and some of them can become irritated or inflamed, especially the ones that kind of sit around areas that will get irritated, like on like where your underwear with sits that's tip that's going to get irritated because it's being hit a lot, you can also get it, larynx, eyes, nose, or all cavity pretty much anywhere um Can get most of these stds now risk factors earlier age at first sexual encounter and that's mainly because we give the vaccine at 12 to 13 years old because that's typically that's what was decided was a good age that is likely to be before their first sexual encounter, but obviously, if it's not that vaccination, isn't gonna help them if they've already got hpV before they're 12 or 13, that's not gonna do anything multiple partners, which is a risk factor for pretty much every sdi out there, immuno suppression, smoking, and diabetes, diabetes associated more with the persistence of what rather than actually getting them in the first place. Investigations So pretty much you examine them you, pretty you probably already know what it is. It's good to do a speculum exam in women just to see if there's anything else on the inside um and if there are any kind of around the anal margin or that you can see in the rectum, you will know to look improperly um you could take a biopsy. If you are even slightly concerned that it doesn't that it might be something other than a wart. It is atypical, then you should do a biopsy obviously as a student in a noski, even as an f one, you refer it to your senior. It's not a decision you would be making, might not need treatment. Um Most of them do self resolved, but there's a lot of different topical treatments out there um I've just put them on here, They're creams um you don't need to know the names of them. They do weaken latex condoms, though what they might say to you in a station is oh the gp has given them this cream. What do you think we need to say to them and that would be one um or you can physically take them off, so you can cut them off cryotherapy, laser surgery, so electro, or just normal laser surgery ups the patient really um so vaccination it started quite a long time ago. Now 2008. I remember having it. Um when I was 12 or 13 and it was at the time just offered two girls aged 12 to 13 and it only protected against the types that are most commonly associated with cervical cancer and that's 16 and 18 in 2012 that changed so now it also protects against six and 11, which are the ones that cause warts um And it's also now offer two boys as well because it was only offered to girls because we were protecting against cervical cancer, so it didn't make sense to give it to the boys, but now it's being given to everyone because well firstly, it's now changed, so we have type six and type 11 preventing warts, but also if we prevent it in boys in men, it stops them from passing it on to women and it's also worth if your at georgia's for any of your surgical rotations going to one of the Urology clinics um because with the, I went to a penal cancer clinic once and they were talking about how oh I've done it, again how have I done that again my screen is gone Anyway, they were talking about how hpV can also cause penile cancer, so there's multiple reasons why it's a good idea now to include boys aged 12 to 13 and the vaccination schedule, which is what has been happening now for a while, can you still see my slides, then, I'm guessing you probably can, but I don't know what this is, it's like I know how to fix it. It's just really strange, so every time I try and move like the the bit where I can see myself, it's just disappears or maybe if I open that no see I can't see it okay. I'll just do it again, sorry, I really need a new laptop. I think this one is struggling mhm, okay, okay, can you see that not yet, it's up ok, great let me just go back to whatever page we were on. I need to stop touching the screen okay, we were here anything won't we uh yeah so it's now offered to girls and boys at that age um In pregnancy, it's not really associated with many complications in pregnancy. You can get warts that grow and in pregnancy, everything grows so if you have of God's sake, I've done it. Again, I don't know what can you still see it. Yeah. Um I can see your google slides okay and now it's got, I don't know what that is, I'll have to figure that out later about what's going on with that, um but yeah everything in pregnancy grows um So if you have a wart anywhere, even if it's if it's a genital or literally anything it will grow because of the hormones in pregnancy and it's harmless it doesn't matter, um If there's lots of lesion's then you can try and treat to reduce them, you can try and you can get rid of them just to stop the baby from being exposed during birth um do in pregnancy, It's better to do a physical ablation to actually just cut it off or laser it off than it is to use medications because a lot of those creams aren't safe transmission risk in incredibly low. Um If the neona is infected, their immune system should clear it very quickly. Um Very rarely they can get it as a respiratory illness, so they can get water in the throat, but that's incredibly rare usually, it's a very low risk thing. Um So just quickly, I think you probably already had a talk on this, but just talking about HPV and cervical cancers. Almost all cases of cervical cancer associated with HPV and 70% of those that are hpV related are related to 16 and 18. Important to remember these numbers um persistent infection can also lead to cancer of the other parts of all the vaginal vagina anus, but cervical is the most common um so we can that's why we have screening, so cervical screening it starts at 25 ends at age 64. Um You just have an endo cervical swab. It's sent to test for HPV if that's positive, they send it for cytology to look for c. I. N, stages 12, and three. You probably will have gone this before. I don't spend too much time on it here um and then I've got this pathway and I've put the link to the page that is quite useful for. So. If there is no HPV, you just go back to the normal screening and it used to be three years now it's every five years. Um If there is hpV then it goes to cytology. If there's no normal cells, then you have another HPV test in one year. If that's normal, you go back to the five year schedule. If there are cell changes, then you'll be invited for a colposcopy um which is a really quick fast procedure um and you can have a um you can have it taken out at the same time, you can have a loop excision. This is we're getting on to something different. It's useful to have a look at it um but just for now remember that hpV 16 and 18 are the ones that are most likely linked to the cancers. Ok hiv is a very complicated virus in the way that it works. I I'm not an expert on how it works, but you also don't need to be um most of the content on these slides is not something you need to memorize what you do need to know is what I will say now, so it's a single stranded RNA a retrovirus which uses the cd four cells as hosts to infect and to replicate, and it can lead to aids, which I'm sure you probably all heard of this nice diagram here gives you the kind of outline of how it does this and why unless you're in like a 2nd 1st or second year maybe two year and they want you to know a lot about the, the pathophysiology, you're very unlikely to need this. As long as you know the basics, it's fine but what I've done is in the presenter notes on this, I've copied and pasted all of it from teaching jobs and janie that is there, um transmission is any unprotected sexual contact or share ing of equipment like injecting if you're an eye IV drug user medical procedures Now, this doesn't happen anymore, but pre, I think 1980 something like that blood was not screened for HIV because it just wasn't really a thing and so people donated blood, not knowing they had hiv, and then it was given to people and then they got hiv same with organ donation. It just wasn't tested for um and that's why it was given. Obviously, it's tested for everything now uh and vertical transmission, so mother to child, so 2 to 6 weeks after exposure. These are kind of symptoms you could expect so fever, fatigue, lymphadenopathy, muscle aches, farengitis, and a rash, a maculopapular rash um and then when you get your symptomatic hiv, so after a latent phase, it will then become symptomatic, so the 2 to 6 weeks they might start to feel unwell, then for a certain amount of time depends on the person, they will feel okay a latent phase and then they will start getting these weight and it, it really depends on the person um and you could say there's about anything in medicine, um but weight loss, diarrhea are quite common and opportunistic infections. These are kind of, classed as minor and severe, minor ones are things like herpes zoster, so shingles, or if they're quite young then then they haven't had chickenpox and that um candid, eyes, this as well, and they might have fevers. Aids though so the immuno deficiency is typically characterized by the development of severe opportunistic infections, which are things like Pneumocystis jiroveci, so that's an ammonia that is just pretty much. The only people that get it are people with hiv. That's led to AIDS tuberculosis. Now that it happens in lots of different people, but it's an opportunity infection here and things like non Hodgkin's lymphoma as well. Um Investigations are things called fourth generation tests Now. If I move this, do, you think, it's gonna okay, no so I was just trying to move the window. Again, I was worried it would ruin the slides. Um So the fourth generation test, though the Alyssa's testing for serum or saliva re hiV antibodies and the p 24 anti GIN. Now, again, this stuff is probably not going to come up in your clinical year exams. It's not going to come up in your off skis and the the written questions your m. C. A. S are very unlikely to be testing you on this stuff because it's not important about making you a safe doctor. What makes you a safe doctor is being able to ask the right questions, initiate the right treatment, so it's rare that this kind of stuff comes up useful to know, but I'd start. I'd memorize management, symptom, symptoms, and management more than anything else, it does give reliable results um 4 to 6 weeks post exposure, so it takes a long time you can't be tested for it straight away. Um There are rapid kits, kind of, I guess similar to the Covid rapid kits give you a result in 30 minutes you can do it at home, but if that's positive you have to come in for this test anyway, so because they are less accurate and contact tracing here is really important, um you could do a whole talk and contact tracing and hiv um have a look. It's it's quite complicated because HiV is a blood borne st, i, and it's a really severe illness. There are different rules around who can be contacted and who can't it is complicated, have a look because other s. T. I s, you can't really force somebody to tell someone else that they might have it. Hiv is slightly different have a look, um it can come up in like communication skills stations where you have somebody with an s. T. I. You need to counsel them on contact tracing management, so the main part of it is the highly active antiretroviral therapy, doesn't cure it, but it does reduce the viral load and you can reduce it to be undetectable, which it's not a cure, but that person can you know go on and live a good in a long life, has a really good prognosis and a very low risk of transmission. Now, these are loads of other medications that I don't know the names of you, don't really need to know the names of, but just be aware that there are other ones that can be used in combination to help. Um So monitoring monitoring is important. I'm not sure how often it is, but I would imagine at least a few times a year, cd four count HIV viral load, and then kind of what you'd expect fbc, younis, LFTS, and your analysis in pregnancy. It can be transmitted in utero at delivery and through breastfeeding, so it's a really high chance of this being transmitted so to reduce that you can use antenatal antiretroviral therapy, but they need to avoid breastfeeding and neonatal post exposure prophylaxis, which is when somebody thinks they have been in contact or knows they have been in contact with it within the last 72 hours. You can give them this post exposure prophylaxis, which is the Truvada um the raltegravir. Again, I don't really know how exactly what they work and you don't need to either you just need to know that post exposure prophylaxis is a thing um and if that happens, if you manage to reduce the risk in pregnancy, the transmission is less than 1% without it. It's one in four, so it's really important that that gets sorted out. There is pre exposure prophylaxis as well prep. Um I haven't really gone into this and this talk but well worth looking at okay. So syphilis then um is a spy. I actually still don't know how to say it a spirochete. I think gram negative bacteria, which is the subspecies of pallidum. There are lots of different sub species and most of them don't cause s. T. I s, they cause different things with the skin and with the bone. Um These are the names here of the different types of diseases that causes don't need to know those. Um Just need to know that this type is an s. T. I, so it enters through a break through the skin, all through mucus membranes as pretty much all of them do it divides, and then in this case an ulcer forms after an incubation period of 2 to 3 weeks and that is primary syphilis. When you get the ulcer. If it's left untreated, it can persist and it can go on to secondary and tertiary um and it can cause things like obliterating arteritis, so that's when the endothelial cells and vessels proliferate madly because of syphilis, which causes alumin of the vessel to narrow, which can cause a scheme. Um These are the more common effects that probably gonna hear about so following exposure you'll get this pap, your this ulcer that appears it's usually painless. It might be there for a while and then it will it should um excuse me it should heal. It's typically just one quite hard, not itchy, not particularly painful, um Sometimes they can be in the mouth very rarely and that with those are quite painful, but the, the genital ones shouldn't be and it should heal within 33 to 10 weeks with treatment, secondary develops. If you haven't done anything to treat it and it's quite severe so that'll be about three months post the first infection, so the skin rash I've put up here and I have put the link to it, cause I have stolen it. Um This is the kind of rash that you might get on the hands and the soles of your feet. They might also have things like fever, joint pain, weight loss, feeling really fatigued, getting other plaques and warts, lymphadenopathy, and another thing that comes up. I think probably another passed very specific question is a great enj, to the mucous membranes. It can also affect the internal organs. We'll talk more about that with tertiary syphilis, so following secondary syphilis, it then becomes latent again and then a symptomatic until it becomes reactivated and then you get tertiary, which is when you get really life threatening severe complications, so there's there's a couple of different ones. There's these are the three ones that you need to know about. Um The first one is one that can form in the bone, skin, mucous membranes of the upper respiratory tract, mouth and viscera. All the connective tissues typically long, liver, and test is um so that's that's the one that we kind of we know about, but the other two are the ones that are more important for exams. Cardiovascular and neuro syphilis. A cardiovascular aortic regurgitation can often happen due to valvulitis, so you'll have a diastolic moment with that and you'll get aortic root dilation. You can get eye joe, angina due to stenosis of the coronary arteries and dilation and calcification of the ascending aorta, so there's quite a few different issues with the cardiovascular system there and then neurosyphilis is even more dangerous so you can get this condition. Tabes dorsalis, a taxi, a numb legs, hyperreflexia, skin and joint damage, reduce temperature and pain sensation. There's quite a lot of different things associated with that. Specifically it can contribute to dementia, so, according to impairment, mood alterations, psychosis, meningitis, and the ninja vascular complications so you can get cranial nerve palsy, stroke, um and I still don't know how to say this one either. I think our goal, robertson people is when you have a constrictive people that's unreactive to light, but it reacts to accommodation, so the investigations that you want to do a dark ground microscopy of the fluid in the ulcer, which will hopefully detect it in primary syphilis and then a pcr testing of a swab from an active lesion, so whenever you have active lesions you want to swab from it. Um There's also lots of other tests that you can do on the serum to have a look things. Um Really you just wanna remember that you've got the swabs um and you if you're suspecting neuro syphilis, then you need to do a lumbar puncture to look for antibodies in the csf management. Early syphilis bends, bends athene penicillin just one dose late syphilis. You have the same thing but three doses at weekly intervals in neuro syphilis, there's a lot more so you have procaine penicillin um pro, benefit or benzoyl penicillin, which usually needs to be iv as an inpatient, is quite a serious complication. They need to avoid any sexual contact until all the active lesions have been successfully treated and again full sexual health screening, education contact tracing all really important um There is a reaction called a jaros her excimer reaction which is when you get an inflammatory response to the death of the syphilis bacteria, the troponins causing a flu like illness within 24 hours of the treatment starting. Really it's just supportive management for that unless there are neuro, cardiovascular syphilis patient's and then they need oral steroids before they get more antibiotics to just reduce that inflammation and in pregnancy everyone who is pregnant will be offered at their first antenatal screening. I think I said this earlier testing for all of these things. Syphilis hiv, hep b, I think there's some others just to find it early, so it can be treated early and it won't hopefully affect pregnancy later on, Syphilis can cross the placenta and it can infect the baby during delivery, so it really is important to treat it early or it will become a problem quickly. If it's untreated, it can cause miscarriage, stillbirth, preterm labor, and congenital syphilis, so imagine a baby getting all of these secondary and tertiary problems, so trichomonas is transmitted again through unprotected vaginal sexual intercourse, but it's not transmitted through oral or anal sex. It's just unprotected vaginal, It's rare for it to be transmitted vertically mother to child, but it isn't impossible it can happen it can happen it can be passed on during delivery. It's an anaerobic um oh these long words, I hate them fledge elated protozoan that can affect the female urethra, vaginal, vagina, and paraurethral glands. It can also affect men, the urethra, and just underneath the foreskin, as it's a virus, it goes through binary fission, destroying the epithelial cells through direct sale contact, and release a cytotox in's um it prevents recognition and activation of the complement pathway because it binds to host plasma proteins. Okay so male and female um sorry made them feel the symptoms symptoms are again quite similar in women. A thick kind of frothy yellowy green discharge is seen frothy is quite a trigger word. In questions, they like it a lot, itching, quite sore, dysuria, painful intercourse, um it could be quite smelly and another thing that's really important to remember is the strawberry cervix. Um When you look it's quite, I was meant to put a picture sorry, I didn't get around to it, but it's quite distinct you should you should be able to recognize it and then it's very similar, rarely you can get inflammation of the glands, penis, but that doesn't happen very often um thorough history and exam always important and again swabs, so a hive, vaginal swabs in the posterior fornix send it for culture and sensitivities. Sometimes a specialist clinics, they can just put it straight onto a microscope and see if it's there. Um for men, urethra swab or first void urine as it pretty much has been for all of them, contact tracing, full sexual health screen, and education, so no sexual contact until one week post the single dose antibiotic or until the antibiotic is complete and that is usually metronidazol of um 2 g already for a single dose or metronidazole 400 to 500 mg twice daily for 500 that's not what I meant to say not for 507 days for 5 to 7 days. Um I will change that before the slides get sent out, don't give people antibiotics for that long. Um Alternatively, there is a 10 year Deshaun 2 g orally, just for one one dose um and obviously as is for all s. T. I. As the patient's current partners or partners in the last few weeks should also be tested. Treatment is the same with people when they're pregnant, the risk there is a risk of premature labor and low birth weight, but it's not as concerning as the other stds. We've discussed um and treatment is the same, so pelvic inflammatory disease, like I said earlier, I did a talk that went into this on a, in a lot of detail previously, so I don't want to go too much into it now, um but it presents it basically untreated, untreated s. T. I. S. Is what causes this presentation most of the time, so you get really severe abdominal pain pain during sex, pain, on urination pain, really painful periods, just pain. You can also get abnormal vaginal discharge and you can have spotting like I said earlier when the cervix is inflamed and infected, you can touch it and it might start bleeding which is why that happens. Um laproscopy you can diagnose it through that or a positive st, i so I've associated with severe pelvic pain can be enough. Pain management's really important antibiotics to treat the underlying st, i. That's not been treated yet, so it can either be a 14 day course or it can be an injection. It depends on your trust guidelines in a noski, if they ask you about management, you'd say antibiotics as per trust guidelines because it changes regardless, like wherever you are, it'll probably be quite different, so just keep it at that. Um These are some of the doxycycline, levofloxacin kept tracks and they are all used for different different places for different things, but just say trust the trust um guidelines aim to find the partner and regular follow up. There is like I said there's more information and the other one's feel free to ask if you haven't got the slides, I'm happy to send them, then there's two that are non sexually transmitted and then we're done and going to the quiz so non sexually transmitted infections like bacterial vaginosis. Both of these, there's bacterial vaginosis and then there's candidiasis as well, which is thrush and they are both the lower genital tract. Um This one occurs because there is a disturbance in the normal flora, so there's normally a lot of lactobacilli bacteria which produce hydrogen peroxide, which helps maintain the acidic ph of the vagina and it should be less than 4.5 the ph, but when there's a disturbance in this and there's not enough of that than the ph goes up, and as the ph goes up, a lot of other bacteria can grow. Usually, it's this one Gardnerella vaginalis, it doesn't have to be that there are others, but that's the one that's the most common um. It is the most common cause of abnormal vaginal discharge in women of childbearing age um So in real life practice, if you're a gp, you work in a gum clinic and somebody comes in worried about vaginal discharge, this is probably the most likely cause. Um Risk factors are basically about the over cleaning of the vagina. The vagina is essentially self cleaning. You don't need to put products inside to clean it um so people who um you do shing so putting water and things into vagina to clean it. That's a big risk factor same as using scented soaps um but also things like antibiotic use because that kills bacteria, so that would probably would also do this smoking. Having an s. T. I. Will also increase the ph of the vagina sector activity with a new partner, especially also having an IUD because you have something physically there, 50% are asymptomatic and a lot of people don't notice, um but if they do notice, the main symptom is a fishy smelling white gray vaginal discharge which is quite nasty. Um There are differentials like I said candidiasis, so thrush is probably a common one, but other stds as well. Um History examination important um Really you can probably just diagnose this. On history examination, but we like to send um a smear, a swab for microscopy, and it's gram stain for clue cells and they like this comes up a lot. I remember on past med it might, I don't know if it came up on actual exams, but clue cells they really like to you to know that that's what you find in bacterial vaginosis and reviews not a reduced number of the lactobacilli that we talked about earlier and an absence of past cells. You can also just make a diagnosis based on the vaginal ph of less than 4.5 with these symptoms. Um If they're asymptomatic, they don't need the treatment, if they say no they don't have to have it. Otherwise, it's treated with antibiotics usually metronidazole as a tablet or you can have it as a gel that's applied directly to the vagina. Clindamycin or tinidazole can also be used. Um Sometimes symptoms return would be within three months usually and you can just treat it at the same um for sexual health screen because it could be something else they could have something else at the same time and education so not too overly clean the vagina um in pregnancy can cause premature birth and miscarriage and chorioamnionitis um The treatment is the same for pregnant women, are not pregnant women. um So then the last one then is um candidiasis, which is thrust or a yeast infection. It's incredibly common most people will experience it. Women will experience it at least once in their lifetime. It's a fungal infection of the lower female tracked. About 90 cases are called by Candida albicans uh which also causes oral thrush. Um It's found as part of the body's normal flora in the GI tract um and so oral candidiasis can be found in men or women. It's an opportunistic infection, so in people with hiv, they can get it a lot more often than people who don't, but it does happen in most people, but it does exploit weakened immune systems. About 20% of women have it asymptomatically in, so they don't need treatment. Risk factors are pregnancy, diabetes, antibiotic use, steroid use and just any kind of immuno suppression, so the steroid use is linked to the immune suppression. Um It pretend presents with itching kind of white, thick discharge, dysuria. There can be erythema or swelling and sometimes satellite lesion, so there's red postural that have superficial white plaques that you can actually scrape off um You don't really need to do anything else. If the history in the exam is clear, you can measure the vaginal ph, if you want, um but you don't really need to go thoroughly into investigations. It's quite easy to diagnose you can just go straight to management, but if there is repeated infection and vaginal smear with microscopic investigation can be done um so you would see spores um. If it was vulva, vaginal candid, I assis, initially, it's intra vaginal antifungal kind of creams and gels, um but you can use orals if the patient would rather like fluconazole as an alternative, um topical imidazole can be given, so that's not what that does is it kind of helps with the symptoms around the vulvar rather than going into the vagina and fixing the issue itself, so you can give that at the same time alongside oral or intra vaginal treatments, just to manage those symptoms. If they don't subside within a week or two, consider something else um you know you need to go back and revisit your diagnosis and maybe do some more tests measuring the vaginal ph, or doing sending a smear for microscopy also address predisposing factors, so diabetes is a big one uncontrolled diabetes. You will struggle to get vulva, vaginal candidiasis or even oral thrush under control because the diabetes is pushing it along. So you need to make sure that they're diabetic control is fixed before this will go away and make sure the patient is administering the medication correctly, so with these, um get an applicator that you can use to push it in, um but a lot of people might not know how to use it, they might be putting it in the wrong place. They might be finding it uncomfortable to do and they might not actually be doing it, so always important to check when somebody's condition it's anything is not progressing is not improving as you would have expected it to then. It's important to check that they are taking the medication and taking it correctly. Um In pregnancy, It is quite common because the higher estrogen levels can predispose you to developing candida, so it's more likely the management you can't give them oral antifungals because that can cause issues with the pregnancy, but they can have the the vaginal creams and gels. You just need to tell them to be very careful when they apply it, so they don't cause any damage to the surrounding structures. Great okay, so those are all of my references, but I've also been putting references throughout the slides as well, um so hopefully you can see that now okay we've just got to an hour. Hopefully, the quiz won't take long, it's quite um it's quite easy, so I don't know if any of you have used cahoot before, um but if you go to kohut dot com just on your phones and then I can give you a cove to put into your phones and then it's just an interactive quiz a quick one um to finish off with, has anyone got any questions while we wait for this stuff to get sorted sorry I just had a real quick question um about how you decide whether to use like single doses for chlamydia over um like a five day long course. I think I think it depends on the severity of the infection and also what the patient wants. I think a lot of people would prefer to just have one then they would to have multiple um but also thinking about things like renal function and liver function depends on how that medication is excreted. If you're gonna give somebody a large dose, if the renal function is not great and it's renally excreted, then you might have an issue with that. I think there's a lot of different factors. I don't know the immediate answer. Um I can have a look and I can let you know, but I think that's probably the main reasons, no that makes sense. Thank you, also, sorry, um why don't you swab um like hpv genital wart um whereas everything else you tend to swab, I mean, I guess you can swab them. I think it's mainly because it's you look at it and you just know what has caused that because with genital warts, it's hpV um and there's if you swabbed it, there's not really anything. I guess it's not an open sore, so you're swabbing basically just skin um I'll let me I'm going to give it a google because I'm interested, now stop no, I think it's because it's not an open sore, so you wouldn't actually get anything from it. Yeah that makes sense, thank you. Ok, I'm I'm interested in what I wrote now because I'm already can't remember are the recommended medications. Yeah, So, if you really wanted to be sure, then the biopsy, but yeah the swabs there's not anything open cool all right, So let's do the quiz, I don't know how many people there are. There's a maximum of 10 for this game, uh but I don't think we have that many so the game pin will come up in a second, just go onto your phones onto cahoot um and you can join. If you like mm. I always like using cahoot because it measures how it measures if you've got the question right but also how quickly you got it right. Um So it's quite fun well there's a qr code er there as well, actually, if you wanted to use it like that hmm well how many people are in the meeting, just so I can wait and see how many people before I start the quiz 77 is that 12345 okay, cool let's start then okay, so what's the most common bacterial st. I. In the uk, All of these statistics will be related to the uk okay yeah amazing Chlamydia gonorrhea is the second most common great cool right, so here as I said it measures how quickly you want to correct you as well as how you want to correctly, um which is what gives you those scores so what's the first line management chlamydia. The I think I've been a bit mean with this. One yeah exactly doctor slightly more erythromycin, so one dose of kept try Axon is for gonorrhea. Great flow in the lead, so oh I just told you what is the management of gonorrhea. Yeah, one dose of petra accent, and I did just tell you that sorry and what's the most common viral st, i exactly hpv um so I can see why people would put hsv one and hsv two um but hpV so the human papilloma virus is the most common cool, so which types of hate hpv caused the walks yeah exactly six and 11 you're all on it and then which of the hpV types are the most strongly associated with the cervical cancers. Cool you guys are good at this um So how often as meares done in patient with no abnormalities. Founder This has changed recently every five years, yeah every three years is what it used to be, so it's only just changed to every five years. It's every year if they're abnormalities found, so if you're found to be HPV positive, but there's no changes in the cells you will be re tested for HPV in one year and if that's negative, then you just go back to normal five years. It was just found that it was more expensive, but there was no patient benefit to do it more often than that, so what's the most common cause of abnormal vaginal discharge in women of childbearing age. Yeah bacterial vaginosis yeah is the most common cause of that discharge. Candid I assis is probably the most common infection, but it's not the most common cause of a discharge. The discharge you might get in that, but more it's kind of that itching, uncomfortable sensation or a symptomatic, so why is for the vaginal candidiasis, is more likely to occur with women. Yeah exactly high levels of estrogen, so which of these is it severe opportunistic infection that can indicate AIDS and I'll tell you now two of these are correct. Yeah exactly so pneumonia caused by pneumocystis jiroveci, and non Hodgkin's lymphoma. Both of those are correct, so what's the name of the syphilis complication that affects the skin, bone, mucous membranes, viscera, and connective tissue. This one's a bit harder yep exactly well done cool nearly there, so what's the management for early syphilis yeah exactly so it is the same in late um syphilis. It's just more um in neuro syphilis, it's a completely different thing that we talked about earlier, which is more more management, which is likely needed to be iv as an inpatient, so what st i causes a strawberry service. Mhm, yeah exactly Trichomonas perfect well done. Um It's one of those ones that is really useful to just know um actually what I might do is just google, strawberry cervix, and hope that it comes up so just because I didn't put a picture in it oh that google picture how stupid of me not picture so eggs mhm, okay. So hopefully, if I open this, you can all see it, um So this is what a strawberry service would look like and so I think earlier I said it's a virus, it's not a virus, it's like a parasite trichomonas which is cool what causes this. Um So yeah when you see this. If they show you a picture of this in an oscar, you just see this. Generally, you should automatically just know what it is cool okay. The last few questions what's the management of trichomonas vaginalis, yeah metronidazol nice, so the antifungal gel is for the volvo vaginal candid night candidiasis. Benzylpenicillin didn't really come up much. I think you can use it in the neuro syphilis section, but other than that not really okay. Last questions, so who so flow is still winning let's see so what infection presents with a gray fish smelling discharge, fishy smelling nice bacterial vaginosis. Yeah so candidiasis is usually kind of a, if there is a discharge, it's gonna be like a white, sticky, quite thick discharge, Bacterial vaginosis is gray, very foul smelling great, so that was the last question so let's see who won nice flow well done. I don't have a prize for you. If it was in person you might get a chocolate uh sorry no luck um I hope that was useful for you and I will make that stop making that annoying noise. I hope that was useful. I will um happily send you the slides once I've changed it from 507 days to 5 to 7 days um And if you have any questions, let me know my email is at the front. Um If you have any questions about medicine in general, starting f one anything I'm happy to answer sorry uh it was really good I realized the little advertise, but they they added because it's really cute sorry, have the advertisers for coup you know, Yeah, it's cool, isn't it, mhm