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Could um contact if you guys could let me know who was here just in the chat and that'd be really useful for me. Um So this is the second lecture in sexual health series that I'm giving. Like I mentioned last time, sexual health is a massive topic and we're not going to get through anywhere near all of it. But last week, we come with some of the fundamentals on the basics and this week we're gonna do some cases. So it's very much more interactive this week. Just feel like yell at me or put something to chat if you've got any questions or answers, I'm going to be asking you guys a lot of questions. So if you respond with silence, it's gonna be very awkward for me. Um But we'll just, we'll just go into it and then you can, we can see how far we get. So first case got a 22 year old man who's presenting with lumps on his penis. Tell me some things you're gonna want to ask him. When did the minister? I feel sorry guys, I'd say that again. Uh We're asking, when did it first appear? Yeah. So when did it first appear? Is it itchy or painful? Yeah. And, uh, I mean, directly jumping into what is a sexual history? You know? I don't know, but it should be a good question. I don't jump in one of the sexual history. Yeah. So, so we're doing a sexual cases that saying we're definitely against sexual histories, the thing that really want you guys to get into the habit of doing and this is something that I think you very much develop kind of the first couple of years practicing as well as in the funding of medical school is thinking about why you ask a question that you asked. So when you said Assad, is it painful, what are the differentials in your head that you're thinking about when you ask that question or anyone? Bye. That's what it could be brought. Uh It could be cancerous but it's, it's too early to say yes. Yeah. Yeah. So cancerous or infection rock. It's on the test. We do. Uh Yeah. So there's, there's a specific things you're thinking about. So, for example, is it painful? Is it herpes? Is it painless? That could be something malignant? That could be genital warts. I'll give you a bit more of the history for him. So he says that these are painless and he didn't notice them. His partner noticed them when they were having sex. There's no associate symptoms with it. So he's feeling well himself. He's not got any problems passing urine and there's no discharge from anywhere kind of in the general area. Um, he has a regular female sexual partner for the last year and he's had previous partners but they've always been female. His last ST I screen was a year ago. That's, that's a bit more brief history. And if I show you some pictures, I warn you all, there's quite a lot of pictures of things in this one that might be a bit startling, but we'll, we'll go with it because this is what the topic is. So just someone describe to me what they see, see it's uh it's at the based on the glance penis and of these, it was the same person. Those, those are the same, they're pictures bits of down nets, but let's assume they are the same person. So one of the, you know, rectal opening and I'm gonna, yeah. And what when you're examining these, what kind of things are you looking for? We look at the texture, we look at the color you look at the size as well. Mhm And with the texture, what, what do you specifically looking forward, texture, texture as it's, it's moist or whether it's uh fleshy or it's dry? Yeah, fleshy, fleshy, fleshy is a very good word there. So it'll help you differentiate between a couple things we'll talk about in a minute. The classic, if we're saying this is HPV Warts, the classic description of them is they have a cauliflower like surface, so they feel quite rough to touch on top and then you feel like it would be if you're rubbing the top of a very small cauliflower. So, and then the flesh he comes inside a later. So, yeah. So, so we're thinking, what we're saying is we're thinking HPV was from this. So a couple of questions based on the history that we've got given and the fact that he's got HPV warts. So if we look at the thing again, he's had regular female sexual partner for the past year. Last STD screen was a year ago. Um And he's only just noticed these, these are, these are relatively new. The most common question patient's ask you when this happens is, has my girlfriend cheated on me? So what do we think? How can we answer this question for our patient's question? Pardon? This was the question I had in my mind. But uh it would be like doing, let's just say serious to emotionally painful to ask the patient as well. But uh checking the fidelity of the partners because patient himself has been a Yeah, it would be much more awkward if the partner would be along with him as well. Yeah. No, absolutely. Definitely, definitely makes him more awkward. But what do we think? Can we say one way or the other? Whether the partner's been unfaithful if without asking the partner, can we tell them what we think I could say uh how many sexual partner is your partner had before you were together uh in that manner. Yeah. So that, that could be an issue. But actually, realistically speaking with this case, if we look at the fact that he has had this partner for one year and he said he himself has had previous partners. There is no way to say that this is a new infection. So HPV, the warts usually appear within 3 to 6 months after infection. But in some people can be latent and can remain dormant without showing warts for years. So he himself may have been infected by a previous partner and then only just shown warts similarly because a lot of people who get HPV, the wart type don't have, don't develop warts, they never get the actual symptoms of it. His partner could have had it previously and infected him at any point during their sexual relationship and he's only just showed up the symptoms. So realistically, with this kind of question, which is really common. The answer is we can't tell you there is no uh generally numb on the side of not causing relationship issues, but you have to tell them that they could have had this for years. They could have been the one who came into the relationship with HPV and given it to their partner. It's just because not everyone is symptomatic and because it can take a long time before you saw symptoms. We have no way of telling who, who gave it to who or when they gave it to who, um, the next question you get is if it's a male patient, they've got a female partner. Most people are aware in their heads in the UK, that HPV means several cancer. That's kind of like the thing that's drummed into you. So, what, what's the answer to? Does his girlfriend need a smear test answer as in whether we should ask him or whether we should ask this, uh did his partner? So if he comes in and says, oh, well, you've told this man, he's got HPV warts and he's saying, does my partner need to go get a smear test? They should so realistically, yes. I mean, if they are due for a smear test, we have a national screening program. It's every three years. If they are up to date with their smear test, if they do not need an additional smear, the there are 100 and 50 different strains of HPV, of which 40 ish strains are thought to infect the genitals. Now, the strains that are high risk for infections for HPV warts are not the same strains that are high risk for um cervical cancer or anal cancer or penile cancer, which are much less lower incidents. The strains that are most commonly giving genital warts are strange six and 11. Now it's becoming less of an issue now because a lot of people are vaccinated against it. So, specifically, sort of people who are now in their thirties or younger in the UK are mostly vaccinated against HPV. So we're not seeing as much genital warts in H and civil cancer as we previously were the answer to this question. Does his girlfriend, your smear test is, yes, she should have it routinely as expected, but she does not need any extra precautions, um, than, than she normally would take. The smear test. Does not, it looks for certain types of HPV. It does not pick up every kind of HPV. They look when you're doing a smear test in the UK. Now they look for HPV first. So, what they're looking for is they're looking for high risk cancer strains so they could, she could have a completely normal, huh, smear test previously and still be carrying a strain. That's wart type. Uh, does he need to abstain from sex? Can they keep having sex while he's got what's, uh, they need to? Absolutely no sex treating, uh, no sex until treatment is there. So, not actually not necessarily. So the kind of tell me what treatment options, what, what, what treatment options do we have? And he thought, uh, medication, medication. Yes. So there's, there's a couple different treatment options for, for warts. The main treatment option for warts is you can just do nothing. HPV is cleared by most people systems within two years and it is not something that gives you, it's annoying so that what the strength to give you warts are annoying. And if you get excessive outbreaks of warts around the vaginal opening, they can cause problems in pregnancy for delivery. Other than that, there's not really a lot of complications of side effects of HPV. And because it is incredibly common in the UK, the statistics suggest that 75% of sexually active adults will get a strain of genital HPB at some point in their sexual life, it's really common and most people don't show symptoms so that people don't know they have it. There is no reason to abstain from sex when you've got warts because the chances are you've already given it to your other half, the, if you're having new partners and things, it might be worthwhile, but realistically, they may already have HPV strains themselves. So there is high HPV is one of those unusual ones where actually if you have it, there's the advice is you can continue having sex. There's no specific reason. Now, the risk of transmission for H B B warts is slightly higher while the warts are present. But because the treatment options actually treat the warts themselves, they do not treat the underlying virus, which your body has to clear itself. Even if you have the treatment options, which we talked about. In a second, you, the virus remains within your system and you can still transmit it from um genital contact or sexual contact following treatment. So it, the reason we treat it tends to be more for an aesthetic reason. So, because people don't like the look of them more so than a transmission reason. Now, the treatment options, there's two fold. So we've got do nothing. But if we want to do something about them because the patient's embarrassed about them or they're in a really awkward position or there's lots of them then you can do at home treatments. So those would be things like, um, uh podophyllotoxin or Imiquimod, which are topical treatments. The patient can apply themselves or get a partner to apply because these can be in really awkward positions. So not everyone can reach or quite get a good look at where they're trying to put them on. So there's an option to do topical treatments or the one that actually probably works a bit better, but requires regular attendance is cryotherapy. So a couple of cycles of cryotherapy will generally get rid of most, most warts. But again, you're only treating the watch, you're not treating the virus, the virus is still within them. Their own immune system has to basically clear that virus over time, which is why there's not that much of a point of abstaining from sex unless you're gonna have stayed for two years. There's no specific test that we do for what's types of HPV strains in the US. There are certain tests they do where they do full HPV panels. We don't do that in the UK just because it's so common. Everyone's going to come up with some and it's not really gonna inform what you do following that. Um, I'm gonna move on from HPV there. Does anyone have any specific, what's type questions you can ask later if you, if you think of something later, I just want to talk a little bit about things that can look like HPV warts that are not HPV warts because this is another common one that comes in and people freak out and think I've got genital warts and they don't. So just going from the top down, we'll show you some pictures of some of these so pearly penile papules, little lumps on the tip of the penis that are completely innocuous. There is nothing to do about them. Some people get, some men get really worried about them because they don't know everyone has them. Some people have lots of them. Some people have a couple, you don't do anything with them, you just leave them alone. Similarly, skin tags, especially around the anus. So because people can get skin tags, secondary hemorrhoids or other reasons in that area, they can sometimes look and that's the what I had mentioned, the freshness come in them. So what's tend to be much more solid and consistency, you can kind of kind of, you can rub in that quite hard and rough to touch where skin tags tend to be quite, uh, flimsy and, and fleshy in nature. Molluscum. We'll look at some pictures of that. Herpes. People come in and think what they've got is if someone comes in and says I've got genital warts, but it's really painful. It's not genital warts, genital warts can occasionally itch but they are not painful unless for some reason you've got a secondary bacterial infection on them. Um, the stimulus papillomatosis is a not a condition. It's just a thing. Some people get, it's a women around the opening of the vagina can get a papillomatous area. So they've got a little bumpy area around there and that can be quite extensive for some women. It can be quite small for some women. It can be itchy in some cases. And because of the way they look because they have that papillomatous look, they can get mistaken for warts. Now, the complication here is the way to really differentiate them is the VESIcare papillomatosis tends to be symmetrical but you can get kissing warts. So because what's or to inoculate, so you can get what's from one bit of your skin to another bit of your skin, which is why people should never try and cut them off themselves because they just make it spread. You can get kissing warts which are two bits of skin that are touching, then transmit the virus between themselves or then transmit the wart between themselves. It's a bit more of a niche look as to how you tell between the two. But it's similar problems tend to be more like a widespread area rather than an individual lump. So it looks like a very, very widespread water and it's more, it's more skin colored. It's, um, it's not as raised off the surface. It's just a thing to think about as differentials forward. I spot similar similarly are sebaceous glands in the vaginal tissue, not what seborrheic keratosis, you can get them around your bottom. Um So age related what treatment for which is pretty similar. So, cryotherapy, um but you need to do anything with them at all. And I think people just be wary of elderly patient who are coming in and saying I've suddenly got genital awards around the back passage. Is this a differential for that? And then we talked about before they give a malignant genital regions as well. You can get a lot of weird and wonderful kind of appearances for genital cancers. Um Just some pictures. So this is pearly penile papules. Um Some, they don't all look like this for some minutes, just one or two spots around, around the area and for others, they get quite a lot more. It doesn't, it doesn't give you symptoms, it doesn't bother you, it doesn't go away or get better, which is just there. Um So anyway, anyway, so those are skin tags. Bit more fleshy less of the sort of cauliflower texture that we talked about before and quite a numerous with different sizes can be anywhere on your body. Some people are more prone to them. If you cut them off, you might just get more uh the, the treatment of the skin tag is same as uh you said about the cryo. Yeah, the skin tag treatment is exactly the same. The only difference being you can just cut these off with a scalpel. So skin tags don't because they're not viral in nature, they do not all to inoculate, they do not spread. So if you cut it off, they're not going to come back somewhere else, which, so it's a little bit easier to take them off for the vast majority people. Skin tags are not a problem. You don't have to treat them. But again, for aesthetic reasons, we sometimes treat them and cryotherapy works very well. And actually cryotherapy on a skin tag tends to work faster than cryotherapy on award. But you, you start to get them in kind of every week or every other week to have a couple of rounds of it. So just timing that can be an issue depending on kind of, you got to make sure they're not going on holiday somewhere in the middle of the treatment. Um, what's this? It looks like a blister. Yeah, you can't be blistered. I think if I just point out to this, this has got a little extra round bit in the middle. So you've got the out around bit and then, then it'll around it on all of them. And if I say that they're painless and they're usually on Children thoughts. So this is molluscum, this is molluscum contagiosum, um which is a viral skin infection can spread quite quickly and incredibly common in Children or in, in immunocompromised adults of patients who have HIV or on long term immune suppressants, rheumatological conditions can get this. Um, they can be quite widespread or they can be localized. You can get them the genitals. Sometimes people come in and think, think it's a wart. I think it's herpes, they're not painful, they're completely asymptomatic. Um they transferred by skin to skin contact. Um and they're generally similar to HPV, that your body clears the virus within about two years. Something in Children, something like 50% will be cleared within 12 months and about 75% within 18 months. Some people, it takes longer, you can cryotherapy them if you want. It tends to be more the only times I've had to do cryotherapy on them have been when I'm working in um sort of specialist sexual health clinics there. So that our, for a sex worker population because it, because it's visible because it looks not pleasant. They, people can be embarrassed about them. If it's affecting their income, they might want it cryotherapy. But for the vast majority, it just goes away by themselves. They also ought to, ought to inoculate. So don't cut them off with things they will just spread. Uh, so this is the, the last comparative picture I've got and this is per peas. So it's not, they're not the clearest pictures I'm afraid. But if we think of them as little blisters on this area here and here we can see it's kind of following a bit of a dermatomal distribution on the bottom. This is, this is herpes. The difference being it's painful, it's blisters. Um You see what's coming next. So if you move onto pain as a symptom, I've got 35 year old man with a new recent new sexual partner presenting with an ulcer on the shaft of his penis, a single ulcer on the shaft of the penis. Uh kind of give the game away there. What is the single most important question to ask a man presenting with a single ulcer? Um sexual partner? They're, they're using the picture. Sure. Yes. There's, there's one very specific question though. There's one kind of, it's kind of on the title of the page. So, is it painful? So the pain is the most important question here because ulcers can be lots of different things, but painful versus painless is one of the most common ways of differentiating between them. So if you look at these here, these are the things that we got to. This is a picture of syphilis. This is a picture of primary syphilis and he's got to hopefully painless ulcers in the tip of his penis. Now, when these are early, when these are small, it can be incredibly hard to differentiate this from herpes. Now, obviously, we'll do all the swabs and all the same tests, but treatment you might want to start it sooner. So it's worth um thinking about, is it painful anymore time anyone comes to also? Because if they say it's not painful, you need to be thinking syphilis and you might want to start treatment early and thinking about precautions, especially if they've got female partners who could be pregnant or there's a risk of pregnancy. Um I'm not gonna go into syphilis cause it's a whole lecture in itself. If we have time some other day, I'll do that. But let's talk about her piece of it. Um It's incredibly common. It depends on country as to the incidence rates of it. So we split into HSV one and HSV two. So herpes simplex, one versus two. Traditionally HSV, one is thought of as the oral type of herpes gives you cold sores. HSV two is thought of as um genital herpes because people engage in oral sex, you can get either one, either place. So it doesn't really matter. You're treating the same. The incidents in the UK is thought about 70% about seven and 10 people have HSV one or kind of what we thought was oral herpes or cold. So's about 10% of people. Just one in 10 people have HSV, two. Not everyone knows they have herpes. So, for lots of people, when they first get infected with herpes, all they get is they get a bit of a cold type symptoms. They feel a bit down and out. They have a bit of body aches and things and that's it. They, they're never going to suspect that that was a herpes infection. Now, for some people, it's not that pleasant and they get pretty nasty, gentle lesion's so small blisters in crops. Um If they do get symptoms, this tends to be worst on your first initial infection than it is on flares following that. The once you have herpes you have it for life, there is, it remains dormant in your nerves in your skin and mucosa, there's nothing we can do to make it go away, but we can help manage it, things that cause flares stress, um injury, other thing, other, other stresses in your body such as pregnancy, all of these be having a cold is the common one. That's why it's called cold sores and they get transmitted by skin to skin transmission. So it doesn't have to necessarily be um penetrative sex that transmits them. Now, the skin to skin transmission is um higher risk when someone has active flare. So if someone has got blisters, the risk of transmitting is highest at that point. So generally we have advised abstaining from sex during those windows. But you can still transmit even when you're not having a flare, which is why it's so common and why it spreads, um, so much it does not spread through bed sheets or towels or anything like that. The virus dies very quickly when it's not on, um, skin because it doesn't like room temperature doesn't like being cold, it just dies. So there's not a risk of transmitting it from sitting on toilets or anything like that. Or my. Pardon? For my, sorry, I can't actually, you then uh for my, for Mike's like any non living things like uh when you stand by this cancer way, there's no four mix for right now. Just uh okay. Sure. Um The management of it is there's two different tactics for it. So if someone is having recurrent flares, if someone is having lots of flares frequently over time, then you're thinking about giving them some kind of suppression treatment. Long term. The treat the, what you're using is the same. So you're using an antiviral psoriasis cyclopia, you can also use ganciclovir, valacyclovir. But using that, you're using a, an antiviral if they are just having infrequent flares and they know what triggers it. So they know every time I have an exam for medical school, I get a flare of per peas, you can just give them a short course is that they take, you need to start taking the tablets within five days of the flare presenting and often the flare presents before the lesion's do. So you, people just start feeling under the weather a bit, run down, they feel like tingly in their mouth or genitals. Um The sooner you start the treatment, the more likely it is to have a significant impact on a flare. So people tend to have pill in pocket strategies for this. If they know they have specific triggers or people who get really bad, really common flares, just take a tablet or two tablets daily. Kind of lifelong complications of um HSV. There's quite a few but the once think about specifically an initial infection is your arthritis more common in women. They come in and they tell you that they've got really painful vagina. You have a look, you see blisters, you, the question you need to ask them is when did you last pass urine? Because people, people can go into urine retention because of how bad the arthritis is. So people just avoid peeing and then end up in hospital needing a catheter. The thing that you can do to help with that is if they have got lesions that look like they're coming around the urethral opening, give them local anesthetic jails take home. So even if I'm saying it's not, it's not that painful right now because the lesion's get worse for the first five days, give them local aesthetics that if it does get worse, they have a pain killer that works locally that will allow them to peak because your arthritis is the most annoying complication to deal with proctitis. So you can get herpes flares um uh in uh in around the anus or in the rectum, you can be left with residual neuralgia. So after a flare, sometimes people get shooting pains down their inner thighs or kind of around the genital areas, you have to think about treatment for that, but that's thinking about things like amitriptyline and if patient's are immunocompromised, so patients who either have HIV again or are on long term steroid treatments can get systemic infection or meningitis. It's incredibly let very rare, but you end up kind of hospitalized with it because you need and you need IV antivirals in that case. Okay. So that was a quick run through of HSV. I'm very conscious of the fact that we're quite short on time. Any questions about HSV or we'll we'll skip through. Mm. Okay. We'll do pain was to say saying on the pain theme 27 year old man with painful lumps in his groin. What else do we want to know to ask? What, what sexual history questions do we need to know? Let's let's talk about that specifically regarding the sexual history with us girls. How actively actively women is? Yeah. What does, what does that mean? So if you, if I was the patient, how would you actually phrase that question? Because you can't say how active are you doesn't really mean anything to patient. What, what are you specifically asking the patient? Well, it was the last time you had sex. Uh how many times you have sex in between the periods of instants? I mean, you know, the period is the wrong right way to ask it because between the mention nations. Yeah, that's fine. I think period is fine. What do you use? I think the other thing to think about, who are you having sex with is a really important question in this, in this situation. So are you and I would, I would be very specific in my questioning because sexual health, people do all sorts of things and you need to and the risks depend on what they're doing. So who are you having sex with? They might respond to that with my regular partner? Great. And are they male or female? So I need to know the gender of their partner. Have you had any other sexual contacts other than with your partner in the last 36, whatever months do you um, what sort of sexual activities do you engage in? So, are you having oral sex? Are you having anal sex? Are you having just um P IV or peace and vagina sex? So very specific questions around sexual health history there, lumps in groin. What sort of things are going through your head? You can put in the chat if you want to do that, people can't speak out loud. I'll give you some more history and you can have a reader the next bit of history and see what, what is going through your head at the moment. So, sexually active, he's a man who sleeps with men. He's had six partners in the last three months. He's got no penal symptoms, but he gets blood and discharge from the back passage after he opens his bowels, he's getting some diarrhea on and off recently and it's hurting when he opens his Bell's, he gets a feeling that he needs to go to the toilet again as soon as he's been, but nothing's then coming out what sort of things are going through your head? A prolapse or prolapse or hemorrhoids, maybe hemorrhoids, hemorrhoids. Well, I mean, anal prolapse actually is a thing. I've got a patient with a massive one at the moment, but less common and very, very uncommon and 27 year old man, even kind of sexual activity and type of sexuality can make it more likely, but he's very young to be having a product. But hemorrhoids is a really good thought. Someone's put a hernia maybe. So the painful lump in the groin. Yes. And I guess that could give you bowel symptoms as well. It's unlikely to be giving you discharge in the stool and, and if it's giving you blood, I'm rushing this medication and, and injury would be an injury within the rectum degree possible. So, say that again, injuring an injury, injury. Yeah. Yeah. So has there been trauma recently is not an unreasonable question to ask? Um, I think it depends on how long the history is. Therefore. So if it's been a trauma, traumatic experience in the area, it's probably been a couple of days and again, discharge is slightly less likely if it's been going on for a couple of weeks. I'm not thinking trauma as much. That's a good thought. Yeah. What examination are we going to do? We would do endoscopy as well. If there is a blood, if the blood discharge is like, would ask if the blood is fresh as it completely red or change in the color of the blood, it completely red, then we would do an endoscopy and see what the needing is. It's definitely should be by the secret buy the descending colon. Yeah. So we're thinking, is this melena or is this fresh blood? And oscopy is a good thought. It's probably not something you're gonna do in the room. So what, what can you do in the room with this sort of presentation? We might also ask to cough, patient to conflict 2000 pants and bend over and try to cough. So if something like as someone said, prolapse as possible possible, yeah. So a cough, a cough test will be useful especially for the hernia possibility with the lump in the groin. And that will help you understand if that if there's a hernia from a cough impulse test, uh, cough with the back passage. I think you're more better of doing a pr exam, if I'm honest, because a cough test again with the age he's at, it's likely he's got pretty good anal tone and it's unlikely he's gonna suddenly get lots of kind of blood coming up when he coughs. A pr is gonna tell you what's in the rectum. So you're going to see what's on your glove. Is the discharge in your glove? Is there blood in your glove? Yes. So someone said Dre Exactly. So a digital rectal exam or a per rectum exam. Um The other thing you're doing is something called proctoscopy. So I don't know if many people have come across before. So it's a little bit like a speculum, but it doesn't do the deduct thing. So, a proctoscope is a little plastic tube which is got an inner tube and altitude on it. It's the inner tube is the inserter. You cover the end of it with, with lubrication or jelly and then you put it in someone's bottom, you take out the inner tube and then the what you're left with is a plastic tube. And as you gradually retract that you can see the inside of the rectum and the rectal tissue in that area. So in your clinic room, a proctoscopy is very helpful because you can see a is there specific bleeding points in the rectum are there lesions in the rectum. Now, the caveat to this is, it's going to hurt. So, if there's a lot of pain, I often don't do a proctoscope just because it's, it's not the most comfortable thing in the world. Um, but it does give you a very good uh direct view of, of what's going on there. So, I think in my head, so this came into me, I'd be thinking absolutely hemorrhoids as, as a differential because of the symptoms he's presenting with. But just because of the background, the fact he had six sexual partners in the last three months. The fact that we're in London and the fact that he's a man who sleeps with men and the painful groin lumps, the thing I have to think about is an infection. It can never pronounce this live for granuloma venereal. Um This is not very common. This is quite a rare thing in lots of parts of the world. It's becoming more common. It's worth just thinking about it so that we have it in the back of our heads. Lymph. I'm going to call it L G V because I can't pronounce the whole word L G B is a specific strain of chlamydia, which can be quite give quite a nasty infection. It's much more common in, in the the gay population. It's much more common in sort of bigger cities. Um And it doesn't always give everyone symptoms, but when it does give symptoms. It gives quite nasty symptoms. So, for some people, all they present with is painful lumps in the groin as I do ask the question, you know, just, yes, I, I just remember while, uh, discussing that, uh, the sexual history, you forgot to ask one motive. The patient is the patient using any objects as early while, uh, sexual acts as well, sex stories or something maybe or better and while using it. But uh he's uh keeping, keeping it hygienic because sometimes they don't keep it high. Yeah. So keep not just giving it hygienic but are they share ing? So some people will share sex toys. So one of the things that can increase your risk of transmission of something like L G B is if you are share ing things like anal beads or uh other sex toys. So it is a really good question. Think about sex toys when, when, when you're asking very specific questions about social history and that would increase your risks for this condition specifically. Um I think of L G V as nasty chlamydia is just chlamydia, but it's a type of, it's a specific strain of it that causes worse infection. The most common symptoms people come in with, with L G V and honestly, every time I've seen L G V, the patient sort of knows they already have it because they've had it before is that they've got anal discharge. It's kind of yellowy green they see it in their underwear. It hurts when they open their bowels as with kind of general practitioner symptoms back and swing you both ways. So some people get constipated with that because they are registered to open their bells and some people get diarrhea with that because of the localized information causing a gut to move faster. You get quite big palpable lymphadenopathy and it's painful. So it's just, just as you would, you have a sore throat and you get a big glands in your neck. Same same concept here. They can, you can get L G V on the kind of in the front side station in the penal symptoms. You can get really, really spirit of discharge, lots and lots of discharge in the penis more than you would see normally with chlamydia and it can be uncomfortable as well. It tends to, it's more common sort of in the in the rectal area. For some reason much the two of the population that gets it. The treatment for it is doctor cycling and treatments three week for doctor side limb as opposed to chlamydia with the treatment only for one week or two weeks, depending on kind of area that you're in the, when in the UK. At least I'm not sure how it works in other countries in the UK. Whenever someone gets a positive chlamydia test, that swab is automatically then tested for L G V because we do have incidence of it. The problem with that is that the L G V result doesn't come back for another three weeks, which is why if you suspect it clinically and that chlamydia comes back positive, we just treat them with three weeks of it. If and that's where kind of the sexual health specific questions come in because your understanding risk factors who's more likely to have it if this is the um heterosexual woman who's living in the middle of the countryside somewhere who's had one new sexual partner who has been a man who's never slept with a man. The chances of this being L G V are much lower and you're much more like his. Treat them as a general committee and then wait for the swabs to come back and then treat them as L G B. If necessary, committee has complications, committee can lead to things like scarring and P I D and infertility secondary to that. But L G B has more side effects. So if you don't treat it properly, you can get quite nasty scarring um around the area which can then lead to sort of long term bowel complications and kind of got complications and you can end up with permanent swollen genitals if it's not treated appropriately and quickly enough. So it's nasty and it's committee, two things to remember. So just, it's just a good thing to be aware of I think. Um let me just make sure that if they want to say about that. Yes. Uh, just going on to kind of slightly associated topic with all of this. Just talking about partner notification. There is no in the UK exchanges. Part nation America has different rules. I'm sure Europe and I'm sure India has different rules. Um, there isn't in the UK, there's no legal requirement to notify partners if you test positive for an S T I. And that includes things like herpes. The only exception to that rule is if you can be shown to be to have done reckless transmission of HIV, you can be prosecuted for that. And a reckless transmission of HIV is quite specific. They have to prove that you knew that you had, um HIV. At the time of sexual intercourse, you didn't tell the partners, the partner was not aware of your stages, you were not on sufficient treatments, you were not completely suppressed. Um, there's a couple other criteria in there. So, but for the most part, I'm going to strongly advise any patient who comes back positive for an STD to tell the other half you get some resistance, especially when there's been an infidelity involved. People don't want to kind of tell on themselves. We do anonymous part notification in the UK. So you, they, we can tell partners for them. It doesn't really help though. If your partner's only set with you, it's still, you're still kind of giving the game away in a sense. Um, but there are, it is really important, especially if you've got female partners in the risk of pregnancy. So, for syphilis, if you get congenital syphilis, it can because a lot of lot of fetal defects, herpes, if you get herpes in the trimester, nearest delivery and cause a lot of problems, got a rear it, if you are symptomatic near time of delivery, you can get conjunctival infections and things like that. So it's generally trying to advise as strongly as possible. But if they say no, there's not a lot we can do about it. We can't, we can't kind of go behind their back and tell people. Um, there are specific time windows for how far you're going back with these and they are in some cases related to how the infection progresses. So in some cases, it's due with what the infection is. Um And now it's natural history goes and in other cases to do with how quickly the tests can come back positive, I'll just go through them quickly. But I'm sure you need some of your time. If you've got a man who's got urethral discharge, that's, that is gonna rear, he needs to tell the partners in the last two weeks because if you're symptomatic, the chances of infection from the national course, mean that you probably got them in the last two weeks of infection if you're asymptomatic, however, it's, or if you're a woman, it's last three months or the most recent partner you've had, even if that was more than three months ago. So, if your most recent partner was eight months ago, you still need to tell that person. It's probably that person that's, that's given it to you. Now, it doesn't catch all of these. You're obviously gonna miss some because it might be the person 10 months ago, gave it to you, but you've had sex eight months ago, it's not going to catch them all. But these are kind of the rules of thumb. Um, just a few other ones, chlamydia, slightly different to gonorrhea. Um, last four weeks for symptomatic, it's three, last three months. If you've got L G V and for all women in asymptomatic men, it's last six months. I spell that wrong syphilis if it's primary syphilis. So if you've got a painless ulcer that you can see if you notify for the last three months, any other kind of syphilis test that comes back positive. So, if your secondary or tertiary, you've got rashes, you've got your logical symptoms or something. We had a wonderful, uh, you need to find partners in the last two years. So usually it's quite a lot of sitting down and thinking about writing down everyone you've had sex within two years. So some people can be quite difficult, especially if they've had kind of a more varied sexual history. Uh, and then hepatitis is just slightly different because hepatitis is transmitted via sex or via blood bond transmissions. Your, it you notify for two weeks worth of sex contacts or needle sharing prior to developing jaundice or prior to the surface antigen becoming negative on testing just to be aware that they're all kind of different and it's worth looking them up. Um Each time, what time are we on? Well, not got long left. Okay. I'm going to whip through this so I will really don't. He'll work through this quick, quickly. 27 year old woman, discolored vaginal discharge. I'm not gonna ask you any questions. Questions are all the same as we talked about before. Throw me some differentials for vaginal discharge in a woman or type them in the chat. So my dog is attacking me. Uh First thing we should like a commonly both uh vaginosis. So simple vaginal infection. Yeah. Advance with the sexual. What is the name anemia condition? What's the simple vaginal infection? Single? Yes. A thrush thrush is one. Yep. What else? Bacterial? Yes. A bacteria vaginosis. Anything else we could advance with these sexual history as well after? Yeah, say, say she's uh there are, I think the thing I'm trying to point out here is the sexual history is really important in sexual health. But to a certain extent, you're going to be doing a full screen on everyone because we have access to those tests and it's worth just doing it because you never know when you're gonna find something you weren't expecting so differentials we've got kind of non ST I infections, things like thrush and BV. And then from, from ST I point of view, what ST I give you discovered the general discharge. Uh Yeah, less so the more common one century we'll just, we'll just go through the battery of time. The more common sense, things like chlamydia, gonorrhea, trichomoniasis, trichomoniasis, they, for textbook answers, they will tell you colors. So they will say chlamydia is yellow discharge and they will say gonorrhea is greenish and Trackman isis is green, none of that matter. They will get weird discharge and that discharge can be of any color and sometimes it's clear. So I just need you thinking about abnormal discharge, whether it's smellier or or more colorful if there is a sexual history to think about do str screens, um The herpes can also give you a bit of an abnormal discharge because if it's localized information can cause increased amounts of discharge tend to be thin testing. What is an STD screen? What does it consist of? I'm just gonna go through it cause it's the most time and we'll talk with the swabs. So for comedian gonorrhea, you're doing a swab for a nat if it's a woman that's a nuclear Gasset amplification test trying to get a bit of the bug and amplify, it's um kind of DNA. RNA. Uh you can in a man do that as a urine sample when a woman you're doing either a high vaginal swab or you are giving the woman herself a swab and coming to swirl it around 10 times about sending media inside the vagina for a man. You want first catch urine in the morning in the beginning of the sample. So unlike with UTIs, when we say midstream, this is beginning of the stream first sample in the morning. It's the highest um kind of infection load with Kaneria and chlamydia depending on risk factors. Think about where your swabbing. So the classic ones obviously are the genitals, you're gonna do penis or vagina depending on the kind of gender and genital organs. But some people need swabs of the back passage. If there's any history of anal sex, swab the back passage. If there's history of oral sex, you can get chlamydia and gonorrhea in your throat. So swab the pharynx, they do, they are often asymptomatic, but they can transmit if they are symptomatic, they can be something as simple as a sore throat. So you don't always know that they've got infection their throat unless you're stopping through it. So kind of anyone who's high risk, any sort of sex work history, um kind of multiple partners, different partners of uh multiple genders, swab everything. Um The trichomonas is a swab that was just genital syphilis is a blood test as, as HIV these all have different testing windows. And what I mean by that is if you get a chlamydia test if someone is asymptomatic and you get a chlamydia test that is negative, all you can confirm is that they did not have chlamydia two weeks ago. If they have got chlamydia within the past week, it may just be the infection is not kind of sustained enough. The infection has not grown enough to come back positive. They need to have a test two weeks, post them, post their most recent high risk sexual encounter. So what I mean is the last time that they had um unprotected sex, they need to have a test two weeks after that to be completely clear. The facilities three months for HIV. It depends on the test. You're doing some of them. It, it quits some, it's three months. The I won't go into more detail about that last case. We'll just whip through this 1, 40 year old woman or 40 year old man or woman presents with generalized each, including her genitals and they're worried that they have got crabs. What do you want to know? This one is slightly different? So we'll just, just very quickly whip through it. What is crabs? What's the non colloquial name for it? So, do they worry? They've got pubic lice if we give you, I was going to say stand associated rash or discharge or anything done yet. Good question. So, with the itching, what else can they see anything else? Uh huh. Of the rashes scaling the scaling as availability dry or just your tree blister. The light. Yep. So associated, associated skin lesions. Have they got striations? Have they got blisters? Have they got ulcers anywhere else? Um If I say that they are really just sexual history when you make sure that it's not utilized, if I say that they're not sexually active, but their last partner was four months ago. Um And that the itch is worse at night, then they, there's a bit of social history here. They live and shared accommodation with six other people. What is there something that jumps to your mind is what this could be. Escapees. Yep. Scabies. So helpfully, you look at their hands and they have got lovely title. Um, yeah, little blisters here and they've got points in between their fingers with scaling and scabbing. So this is scabies. Now, the thing to not confuse this with is Pompholyx or decide Roddick Eczema. So this, if this was just, if we're looking at just this hand and the history was, I've got really itchy hands. It's every time I use hand sanitizer or it's every time I have cold weather I've had it for years, it comes and goes a bit steroid premix to go away. That is Pompholyx or decide Roddick Eczema if it is, I'm itchy all over. That is scabies. So they can look slightly similar, but they come with different histories. So just a whip through of scabies. Um, it's, it's a might it's uh only affects humans. You can't give it to your dog, you can't give it to your cat. You can't get it off them. Different, different mammals have different mites that affect them as humans. We are unlucky and that we have quite a few that only affect us, things like crabs, um, and scabies. Um, it is highly contagious. It is especially contagious if you're living in a cramped cry housing situation. So anything that affects kind of quality of living will affect it. So people who are, you know, in war torn regions, people who are living in poverty, people who have um uh trans in the long term transport to migrants all like to be affected by this. It causes a generalized it and it takes about 4 to 6 weeks after your first infection before you start really getting the all over body itch. If you are reinfected, the itch starts immediately. So the first infection takes 4 to 6 weeks. But for some reason because your body is already aware of this and it's created an immune response previously on secondary infection. The itch is much quicker, intensely worse at night, but that is true of pretty much all forms of itching. So most things does that make you itchy, including eczema tend to be worse at night. Um Even if you treat them and it the treatment works, they can continue to be itchy afterwards. So sometimes people feel like you failed to treat them. We haven't. It's just that they remain itchy for a good couple of months afterwards. The caveat to that is because the treatment is so annoying. It treats treatment, failure can be quite common. You have to treat everyone in the same house at the same time cause otherwise they'll just re infect it to other. So you have to think about planning ahead for a day when everyone in that household is available because everything, all clothing and bedding needs to be washed. So ideally all clothing on things and you wash the high temperatures. If there's things you can't wash or it's difficult to wash like um curtains or do these, put them in a black bin bag and leave them alone for 40 hours, then stick them outside and air them if you can for 72 hours, just really trying to get everything as free of uh might as possible. Treatment is 5% permethrin from the jaw downs. You're literally covering everything from here, down to your toes and you got to go under your nails. You've got to go between your fingers and toes and you've got to sit like that for 12 hours. It's really annoying. It's not that it's quite an aggressive treatment. So people can get kind of skin reactions to it and you got to repeat it 7 to 10 days after your first initial course. They're all there alternatives available because they were permethrin shortages. A couple of years ago. So you can use Malathion on, um, and if that's not working, you can use all I ever met him, which is quite strong drug. And if you're using or Aleve, you can repeat the dose in two weeks time. So that is a very quick run through of scabies. Um, it's becoming more common in London. We're seeing a lot more of it and I'm sure other parts of the world are seeing, seeing it to. Um I think it's my last slide and I think I'm in time, I've worked through a lot of that very quickly and I've missed quite a lot of sexual infections. We will do that next time. If I have time, things like syphilis can, can take a good two hours themselves. Any questions I have one uh since it's not necessary to conduct patient in the educate. But uh is it uh contact tracing is an important thing to do? Yeah, it's gonna outbreak of perfumes or sickness like you said, the exceptionally actually. But if there is a big piece of sickness shouldn't be contact tracing. So yeah, I mean, concentrating, we should be doing it all the time anyway. So regardless of whether there's an outbreak or not, we should realistically being contact notification, but a patient can refuse to tell you. So the patient, there's no legal responsibility for them to tell you and we do not, they are not notifiable illnesses at the moment. So, if you get a positive case with herpes, you don't have, there's no higher agency reporting this to. There is not if there is an outbreak of herpes because herpes is so common, there is nothing we really do specifically about it. Apart from maybe more kind of campaigning around for awareness syphilis is slightly different. A syphilis is an interesting one because at the moment, the numbers of syphilis cases in London in the heterosexual population is increasing. Um And actually, I was looking at earlier and it's, if it's one of the most common stds in Ukraine, not your wife. Um, syphilis is what is interesting because of the implications for pregnancy and foetus. We're seeing a lot more cases of when you get pregnant for the first time in the UK, one of the second or whatever one of the screening tests you have is syphilis testing. Um And usually that was just a kind of a heart back to the olden times when we used to have an issue with it. But we're seeing a lot more positive cases now. Um, there is not, it's, there's still no legal requirement for you to partner defi it's kind of a moral requirement still. But I guess that could change because if there was kind of big outbreaks and things, maybe the government would say actually, no, we have to have to change the law slightly. But at the moment as it stands, contact tracing really important. But if a patient says no, I'm not gonna tell you, it's a, it's a dilemma kind of as to what you're gonna do about that. There were, there was like there's society caveats this rule. So there's things like if you have a duty of care to both patient's, which basically means if, if you find out your patient has a condition and their partner is not your patient, you cannot disclose if you find out your patient has a specific condition like syphilis and your, and the partner is also your patient. You technically have a duty of care to your, to the partner as well. And for example, say, you know that um you say you, you've got a male patient who test positive for syphilis and you know that they're female partner has come and told you that we're trying to get pregnant now. So you know that they're having operated sex with the goal of becoming pregnant, then you've got a lot more of an ethical conundrum there because you have a duty of care to both patient's and you view of care to the child because they would probably registered with your practice as well. And to be honest, that's really when you get legal teams involved, that's when you start pulling your um things like uh the legal representatives for doctors to, to run through cases because that is your first line is trying to convince the patient is a terrible idea not to tell their other house, but if they are adamant, they don't want to review it, you got to get legal teams involved and kind of management gets involved in that, in that sort of situation. It's a nightmare if that happens because that makes sense, sort of rambled on left. It does make sense. Anything else? Any other questions? Okay. I think we're good um good luck for whatever your next lecture is in that case. Uh and I will leave you there. Hannah, am I alright to stop sharing and you can stop recording?