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Okie dokey. Um Can people hear me? Are you all right to just pop a a quick message in the chat? Perfect. Ok. Um Thank you all so much for coming and my name is G, I'm a doctor. I'm working based out of Cumbria at the moment. Um And yeah, I'd like to welcome you all to the session. We're gonna have a brief chat about STIs and bacterial vaginosis today. Um So yeah, I'd just like to thank Doctor Baster and Doctor Emma Winter for helping me um verify all the content on the slides and hopefully you'll enjoy the session. Um If we could just pop to the next slide. Perfect. So we've got a couple of learning outcomes that we're gonna cover today. So we're gonna recognize diagnose and formulate management plans for STIs and bacterial vaginosis. Hopefully you'll be able to understand the process of partner notification and to be able to explain this using patient friendly language, which is really important, especially for practical exams. Like ask. Um we want you to be able to use appropriate guidelines when managing presentations of STIs and bacterial vaginosis and to be able to competently take a sexual health history, including risk assessment and safeguarding. And that's kind of a common thread that I'm gonna be covering throughout all of my sessions because it's such an important part of all medicine but especially things like sexual health. Okie dokey. Next slide, please. Ok. So just a bit of housekeeping before we start. So um all my sources and my references and links for all of the images that I use will be in the presenter notes of the slide. So after the session, I'll upload them all to meal and you'll be able to access all of those resources. And I've also got together some patient information leaflets and extra resources in those notes as well. Um Great examples of patient friendly language, um at least at Newcastle, which is where I trained, they really liked inos if we brought up the concept of offering a patient an information leaflet for any condition really that you discuss that just really good basic information, even just for revision. Um And then obviously with us talking about sexual health, there will be images of genitals within the session. There will be images with discharge, bleeding, swelling. You know, if, if that's something that you might not feel comfortable with, maybe just step away for this session. I think there's no way that we can avoid it unfortunately, and then just in terms of language, um I might use the words men and women throughout the session. Um I will try my best not to, you know, I want to use inclusive language. But if that does happen, it's on the understanding that of course, any condition, regardless of your gender identity, you can be affected by any of these conditions. And it's something to be really aware of in all aspects of our clinical practice. We should be using correct pronouns for all patients. If you're unsure, just ask, ask people and try and be as respectful as possible to all patients. And then if I use these two in any of the slides, am a or am a means assigned male at birth and a fab means assigned female at birth. So I hope that all makes sense, right? I'm gonna just put my camera off and we'll get on with the teaching. Okey dokey. So, um the way that this session is going to run is we're going to have a few different cases. Um I'd really appreciate if you could all just pop um answers in the chat. Um I'm really gonna be the only person that sees your responses. So, um don't be afraid to, to guess if you're not sure. Um So case one is a 22 year old female patient presents to her local sexual health clinic with a two week history of postcoital bleeding and increased vaginal discharge. She denies a change in smell or color of her discharge, fever, abdominal pain, rash and dyspareunia, which just means pain during sex she's otherwise fit and well, she takes the combined pill and she's got no known allergies. She's had three sexual partners in the last six months who are all male. She had unprotected vaginal and oral sex with all of these partners and she doesn't know if any of them have had symptoms based on the information that we've got so far. Um, if you just pop in the chat, what your top differential diagnosis might be for this patient? That could be about 20 or 30 seconds. Okie Dokes. So, um thank you all for popping your answers in the chat. So we've had a couple of different options. Um So we've had P ID and chlamydia both really good um options for this patient. So if we just pop onto the next slide, wonderful. So this patient has chlamydia. Um So the kind of differences between this and Pid, sometimes it's a little bit difficult because Pid does have a range of symptoms. Usually patients with PID are a little bit more generally unwell. Um And really the only thing she's noticed is a change in her discharge. Um Pelvic inflammatory disease, inflammation in the title. Usually patients are a little bit more unwell and usually in quite a bit of pain with it as well, at least from my clinical experience, but definitely something to consider. Um So chlamydia, one of the most common STIs that you'll see in clinical practice. So it may be asymptomatic. Um in a lot of patients. Um if it's not asymptomatic symptoms, can incl include mcop perent, which just means it looks a bit mucusy and has pus in it. Um cervical discharge, a friable cervix which means that when you touch it with um for example, like a cotton swab, it will bleed, um post coital bleeding and intermenstrual bleeding. So, basically bleeding after sex and bleeding in between periods. Um and in male patients, you can have uh mucus from the urethra or mucopurulent discharge from the urethra as well. And some female patients may have odorous mucoid vaginal discharge. So, no pus there, it's just a change in texture. Um Less common symptoms can include dysuria. So, pain when uh passing water and deep dyspareunia, um pelvic pain, fever, and scrotal pain. So deep dyspareunia, pelvic pain and fever would be more suggestive of something like pid rather than just a simple chlamydia. But definitely, you know, every patient is different. You can get different presentations within that next slide, please. So, um investigations that we want to do for a patient presenting with chlamydia, our gold standard test. So, the test that we really want to be doing if it's available to us is in that. Um So either you'll do a vulvovaginal swab or a rectal swab or a pharyngeal swab. If um you're suspecting a patient has chlamydia in their throat. Um in a patient who's assigned male at birth, if you're suspecting uh urethral chlamydia. A first catch urine is your gold standard test for that. Um And in any patient presenting with symptoms, suggestive of an sti we need to do a full sti screen including HIV and syphilis testing that point. I will bang on about throughout this whole session. But it's really important because if you're suspecting any sti you might have several at once and not know about it. And especially with things like HIV, which is a long term health condition. It's really important to pick that up early and get people on appropriate treatment. Um So treatment for chlamydia, uh first line is doxycycline, um or you can do an extended course of azithromycin and then um a stat dose and then a uh an extended course of that safety netting for patients with chlamydia. You need to avoid any sexual contact until both you and your partners have completed the course of antibiotics. It's really important to let them know that because for example, patients with multiple recent partners, if those partners haven't got tested at the same time as they have, it might take a little while for them to get on treatment and complete their course. Um So very, very important for them to abstain until everyone has finished their course of treatment. Next slide, please. Ok. So um we don't normally do a test of cure for chlamydia, but it's important to do in pregnancy. Um just with extra risk factors for um babies in parents who have chlamydia, um, if they're not compliant with their treatment, because obviously, if they've not taken their full course of antibiotics, they may not have, um, eradicated their chlamydia in persistent symptoms. So, again, you might suspect that either they've taken the full course and it hasn't quite worked or they might not have taken it properly. And in rectal chlamydia, risk factors for chlamydia age under 25 sexually active, obviously, um, new or multiple sexual partners. Um, sexual contact with someone who has chlamydia having a previous ST I, I'm not using condoms and then complications of chlamydia, epididymitis in um, patients assigned male at birth reactive arthritis, ophthalmia, neonatorum, which we'll talk about, um, a little bit later on. I've got a picture of it, but essentially it's um, vertical transmission from, uh, pregnant parents to babies and it causes eye problems in small babies and then you can get chlamydia pneumonia, which is very rare. II wouldn't worry too much about that one for, um, medical school exams increases your risk of ectopic pregnancy, infertility. And then PID is sort of a complication of, of having an sti for a long time or not, uh, being treated on time, cervical cancer and perihepatitis again, not very common. Next slide, please. Ok. So, um, we're going to move on to our next case. Um, by the way, if you feel that I'm going too fast or too slow, just let me know if there's anything that any of you aren't understanding, just pop a message in the chat and I'll be happy to try and explain things more or in a different way. So, um, a 17 year old male patient presents to his local sexual health clinic with a one week history of painful urination and perent urethral discharge. That's just, um, like pus in the discharge. He's finding it very painful to pass urine and is worried about what could be causing this. He doesn't have a fever, rash, abdominal pain or testicular pain. He recently got into a new relationship and hasn't been tested for STIs in every year and he doesn't know when his last um, partner's sti test was based on the information that we've got about this patient. Um What would your top differential diagnosis for him be? Again? I'll give you about 20 or 30 seconds and then we'll have a chat about it. Ok. Lovely. So we've had a few people saying gonorrhea and that is the correct answer. So, if we pop on to the next slide, could we pop to the next slide if that's? Ok. Oh, perfect. Thank you. Um, so yeah, this patient is presenting with gonorrhea. So the um scientific name for the er strain of it is Neisseria gonorrhea. So this can be urethral endocervical. So, within the cervix rectal or pharyngeal and it can be also passed to babies during birth. That's vertical transmission. So your classic signs and symptoms are mucopurulent urethral discharge, um epididymis, tenderness or swelling, dysuria or pain on passing water. Lower abdominal pain, increased or altered vaginal discharge, anal discharge, anal or perianal pain, a sore throat. If it's pharyngeal and cervical motion tenderness, which basically just means when you're doing a um PV examination if you're doing a bimanual. So where you've got two fingers inside, if you move the cervix around, patients will find that very uncomfortable or painful. Um And if we just look at the image on the left, that's a really good example of classical discharge and gonorrhea. Um And it's a really classical presentation to have male patients who really, really are struggling to pass urine because of the amount of pain they're in. Um it's really, really uncomfortable for people, unfortunately. So investigations that we can do for suspecting someone has gonorrhea. So again, our gold standard is a NT. So you can do a vulvovaginal swab, a urethral uh swab, a urine sample, a rectal swab or a pharyngeal swab as well. If you're suspecting that it's in their throat. Um in symptomatic male patients, microscopy is just as good as that and it provides an immediate diagnosis. So, depending on all of your experiences and sexual health, I don't know if you've had placements there, but basically every sexual health center will have a room for microscopy. It's a really, really good skill to learn if you do get the chance and I find it very interesting personally. But essentially, if you can get a sample of that discharge, pop it onto a side, ground, stain it and look at it under the microscope. If you will have a look at the photo on the right, what we're looking for is little groups of uh diplococci intracellular diplococci and that's characteristic for gonorrhea. Um you can do a chocolate agar culture to test for sensitivities. Um It's kind of been in the news a little bit recently in the past few years. Um Super gonorrhea is what the media seems to be calling it, but essentially it's um antibiotic resistance. Um And unfortunately, because people are either not getting tested, don't realize that they have it or are delaying treatment or not taking treatment properly. Um It means that sometimes it's a little bit harder to treat. So that might be necessary for some patients and again, a full sti screen including bloods for syphilis and HIV is always recommended. We could pop to the next slide. OK. So um you want to take culture swabs before starting treatment just in case you run into issues again, like I said, with treating gonorrhea um in uncomplicated uh presentations of gonorrhea, it's just a single im dose of cefTRIAXone. Um It's a bit nippy for patients. They might not enjoy it. It's usually an injection into their uh backside. Um But it's only 11 shot and then they're sorted, which is quite nice rather than having to remember to take a long course of antibiotics. Um If they have a complicated presentation, for example, if they have pid from having gonorrhea and as long as they're not pregnant, you can give a 1 g. I am single dose of cefTRIAXone and a two week course of doxycycline and two week course of metroNIDAZOLE. If they have a complicated presentation, for example, like something like pid and they're pregnant, they need admission and specialist treatment that wouldn't be managed in the community just because of uh increased risk. Obviously in pregnant patients um in uncomplicated anal dental or pharyngeal infection. Um it's the same as an uncomplicated infection anywhere else. It's that single dose of iron cefTRIAXone next side, please. Ok. So safety netting for these patients, they need to avoid any sexual contact until seven days after they've completed treatment and their partners have completed treatment. So if they've got that one shot of im ceftrixone a week from then or obviously, if they're on a longer treatment plan, then it's a week from finishing that um test of cure. So if they're still symptomatic, you need to do a culture at least 72 hours after completion of treatment. And we also do do a test of cure in basically everyone with gonorrhea and we use a nat to check for um cure of the infection there. Um risk factors for gonorrhea, age 1524 black ancestry. I'm not actually quite sure why that one's um a risk factor. I'm sure there's some interesting background to that. Um current or prior history of sti multiple recent sexual partners, inconsistent condom use. MSM, which just means men who have sex with men. Um risk factors of partners. So for example, if you've got a partner who has any of these risk factors, even if you don't, if you're um sleeping with them, then you sort of increase your risk as well. Um And a history of sexual or physical abuse complications of gonorrhea include epididymal orchitis, prostatitis P. I, like we mentioned before, infertility and ophthalmia neonatorum. So again, like we were chatting about with chlamydia. If you just have a look at the picture on the right hand side, this is what it might look like in uh babies. Um And it's just an infection in their eyes from uh vaginal birth and passing on either chlamydia or gonorrhea through that route. Ok. Next slide, please. F so case three, we've got a 57 year old female who presents to her local sexual health clinic with a one month history of lumps on her vulva. She noticed one at first and now there are several scattered around the same area. She describes the lumps to you as pink, raised and squishy with some of flatter to the rest of her skin. They're not painful, but she reports occasional itchiness and she denies a rash, fever change in discharge dysuria malaise and weight loss. She's only ever had one sexual partner who's her husband and they've been together for 17 years based on the information you've got so far. Um, what would your top differential for this patient be? Ok. So we've had a couple of different options for this one. so we've had, 03 different options. Ok. Um, so we've had genital warts, syphilis and lichen planus. Ok. So all really interesting options. Um, We will be covering syphilis later. This presentation was of genital warts. And hopefully, I'll be able to explain the um the differences in presentation between the two if we just pop to the next slide. OK. So genital warts, they're caused by HPV or human papilloma virus. Um And we'll be going into more detail about the vaccination program and other presentations to do with HPV in the OBS and Gynae section of the revision sessions. So I think off the top of my head, it's on the 31st of March. Um So if you want a little bit more information about HPV, we'll be talking about it there. Um But in this session, I'll just be covering the gentle wart side of it. So they can affect anogenital skin, lips, oral mucosis. So inside the mouth oropharynx. So down further towards the throat, larynx, conjunctiva and nasal cavity. And like I said, they're caused by HPV and usually it's type six and 11 for genital warts. So if we look at the pictures on the right hand side, I try to find pictures with different skin tones because they do look very different depending on, uh, the color of patient's skin. Um, but they can kind of look anything from pink to light brown to really dark brown. They can be flat to the skin. They can be raised. They're usually kind of squishy but they can look a bit scabby as well. Usually they won't bleed or look raw. And that's kind of one of the ways of differentiating them from syphilis if you're thinking, oh, I don't know whether it's, it's gentle warts or syphilis. Um I would say the two key things is usually with syphilis. So if you're looking for a shanker, usually it'll be one lesion compared to gentle warts, which will usually be several. Um, and syphilis, it, it's more of an ulcer rather than a lump. So it will look raw and red and a bit um irritated. So these are benign growths. Um So noncancerous um investigations wise, it's usually a clinical diagnosis by a specialist. So you can have these diagnosed in a sexual health clinic by a consultant or a specialist nurse. You can biopsy them if you're concerned that say, for example, you're seeing some lesions that definitely look characteristic of genital warts and some um that are looking like something different if you're concerned that it might be malignancy. Um And of course, the ice cream needed next slide, please So, um, you've got a bunch of different options for treatment of genital warts. So you can, um, if patients are happy to self apply, you can use Aldara, which is imiquimod and it's three times a week for up to eight weeks or poil toxin, which is commonly known as water con. So it's twice a day for three consecutive days and you do that for four weeks, you can also get treatment in clinic. So, cryotherapy, it's just really, really cold therapy and it, um, it kills the warts. Um, that's safe to use in pregnancy, which is um, obviously an advantage, you can laser them and you can use TCA. So essentially, it's almost like a, a dilute similar to vinegar, I suppose is, is a way to think about it. So it's, it's like a weak acid that's also safe in pregnancy and you can use a nitro zinc complex. So that's known commonly as, er, you can refrain from treating, um, like I said, they're benign, they're not cancerous, they don't cause any health problems. Their biggest problem for patients is usually cosmetic and patients don't like the look of them. And I can understand that, you know, it's, it's a big change for people to go through. Um, they can self resolve in six months in up to 30% of people. So some patients prefer just to see how they go, um, and they self resolve and you can also do surgical excision which is safe in pregnancy. And also um you know, it's, it's quite a quick treatment. You don't have to do several things in one, in the several treatments spaced out. You can just have one excision and it's gone. Obviously though that comes with other complications, infection, bleeding, scarring afterwards. So, you know, it's risk benefit for every patient next slide, please. Ok, so safety netting for these patients. Um patient information, leaflet is really helpful um gives them information on transmission and treatment so they can weigh up what, what treatment they might like to do if anything. Um And they should avoid having sex while being treated with genital warts and use condoms. I mean, that's universal advice for anyone uh risk factors. So, intercourse at an early age, the reason for that uh at least partially is because now we've got a vaccination uh scheme in the UK that's given between the ages of like sort of 12 and 13. So if patients are having sex for the first time at a very early age before that, they've had that vaccination, um they're not going to be protected against HPV at all. Increased number of sexual partners, females aged 19 to 22 and males aged 22 to 26. If you have a partner with lots of sexual partners or if you're immunocompromised, complications of this include incomplete resolution. So still having some or all of your warts following treatment and scarring after treatment as well. Next slide, please. Ok. How's everyone doing? Does anyone need a break? Where halfway through? At least now, how are people feeling if anyone needs a break or anything? Just pop a message in the chat. I'm happy to do five or 10 minutes. Um If no one says anything, I'll just carry on if that's all right. Ok. Um So case four, a 60 year old male presents to his local sexual health clinic with a three week history of an ulcer on his penis. He describes it as red, raw, looking, well defined painless and non pruritic. So not itchy, he only has one ulcer and has never had anything like this before. He doesn't have dysuria, testicular or abdominal pain, urethral discharge fever or any other symptoms. His last sexual encounter was with an on off casual male partner about six weeks ago. He doesn't think this partner has any symptoms. So, based on the information we have so far, what would your top differential diagnosis for this patient be? Ok. Yeah. So we've had a few through already saying syphilis and that's exactly right. Next slide, please. Ok. So this patient has presented with syphilis. So this is caused by treponema, pallidum signs and symptoms depend on the stage of syphilis that a patient presents with. So primary syphilis is what this patient has presented with a painless genital ulcer. This is um another really important thing um when you're differentiating syphilis from other STIs s the chakra or Singulair ulcer will be painless. It'll have a clean base and a sharp border. So if we look to the pa uh picture on the left hand side, that's a picture of a shanker. So this patient example, he might have presented with something of hum. You can also have raised lymph nodes in primary syphilis. Then if we move on to secondary syphilis, you'll get a non pruritic. So not itchy maculopapular rash. So that's the picture in the middle. Um classically, it'll involve palms and soles. So if you're doing a single best answer exam and you see rash on the palms and the soles, you can almost guarantee that they'll be talking about syphilis. You can also have these snail track lesions in the mouth. So if you look at the picture on the right hand side, it does literally look like a snail track um inside the mouth. And you can also have unexplained neurological or ocular symptoms. Then if we move on to early latent syphilis. So this can be asymptomatic. Normally. Um latent syphilis just means that the virus is lying latent. Um and early latent is within two years of first infection, late latent is exactly the same. So the patient will be asymptomatic, but it's been over two years since they were infected with syphilis. And then if we're getting to tertiary syphilis, which is very rare nowadays because thankfully, we pick up most cases um pretty early, but you can have all different presentations of tertiary syphilis in all different body systems, neurological ocular cardiovascular guts, basically. Any, any sort of involvement. All right. Next slide, please. So, investigations for syphilis. So it's screened for during pregnancy in your booking bloods. Um If you're just seeing a patient though, in clinic, you can do dark field microscopy of a swab from uh a shanker lesion if they've got one, you can also do a PCR from a lesion. And if you get a negative result from this, it rules out syphilis. So it's quite uh sensitive. Uh you can also do a serum enzyme immunoassay. So from a blood test, you also need to do a full sti screen, of course. Um once you have diagnosed syphilis, you use RPR. So rapid plasma reagin to measure disease activity and to monitor their response to treatment. So, treatment wise for syphilis. Oh and I forgot to say sorry, that picture is um what troponins look like on dark field microscopy. So um this isn't generally done in clinics because it requires more specialized equipment. Um But essentially they just look like little corkscrews or spirals. Um and they will move as well on microscopy, you have to do the microscopy pretty quickly um because they are living things traps. But um yeah, if you see these under the microscope, that's characteristic for syphilis. So, treatment wise, um if you're suspecting early infection or if you've got someone who's a contact of someone with confirmed syphilis, you give them benzathine benzylpenicillin. So, it's an im single dose. Um, or if patients are allergic to penicillin or would prefer not to have an injection, you can also use doxycycline for two weeks as a second line. Um In late latent syphilis, you need to do the same benzathine benzylpenicillin injection, but you do once a week for three weeks, um which can be uh difficult for patients. These injections are a little bit uncomfortable from my experience. Um and usually it'll be split in half the dose. So it'll be one in each side of the backside. Um and it can be a little bit nippy for people. And again, you can use uh doxycycline as an alternative and it would be a 28 day course this time for neurosyphilis including ocular syphilis. Um I wouldn't worry about remembering this treatment necessarily. Um It's more uh just for interest. I don't think it would come up in medical school exams necessarily, but it's procaine penicillin um and oral probe, probenecid uh for two weeks or you can use Kear and IM or IV for two weeks plus steroids. Ok. Next slide please. Um ok. So safety net in these patients, um we need them to seek medical attention and take paracetamol if they get a fever, a headache or muscle aches after antibiotic treatment. So this is called garish Herx heimer reaction. And it's um it's not super common, but it's definitely a known reaction for people to have after syphilis treatment. And it's essentially just this fevery reaction pretty soon after getting the, uh, benzathine benzylpenicillin injections. Uh, in my experience in actual sexual health clinics, we'll often ask the patients to just sit in the waiting room for 1520 minutes, half an hour after they've had their treatment just to make sure that they're fine in the absolute immediate time after they've had their uh antibiotics. And then they're welcome to go home. And of course, we give them the safety nursing advice. Um So patients need to avoid sex until two weeks after the, sorry, that's a typo until after the symptoms have resolved in primary symptom in primary syphilis. And two weeks after the antibiotic course has been completed and we need to make them aware that future ST screens will reveal that they've had syphilis in the past. Um So that's very important for them to know just for future health care and for um that privacy as well. So risk factors, sexual contact with a person with syphilis and men who have sex with men. Again, recreational drug use, sex work and multiple sexual partners and current HIV or another ST and complications of syphilis. So you can get congenital syphilis from mother to baby. So that's vertical transmission. Um Syphilis can also cause miscarriage, stillbirth or neonatal death in this circumstance. Um which is why we screen for it in anyone who presents with early pregnancy. Uh and then like we mentioned before, her arm reaction. So this is acute febrile illness within 24 hours of the antibiotic treatment for syphilis. Um So you can consider giving them steroids to prevent this. I've never seen that actually being done in practice though. OK. Next slide, please. So this is just a really good uh little infographic. Um I won't hover over it for too long. But if you're looking for a really nice summary of the stages of syphilis, I thought this one was lovely. All right. Next slide, please. Oh, so case five is a 40 year old non-binary patient who is assigned female at birth. They present to their local sexual health clinic with a two week history of frothy yellow malodorous discharge. They have no other symptoms at all. They've had two sexual partners in the last six months, one male and one female. They don't know whether either pa partner has any symptoms as they were casual. One time partners on speculum examination, you notice some red spots on the patient's cervix based on that information. What do you think your top differential would be for this patient? Ok. Yeah, perfect. So we've had a couple of people say trichomonas if we just pop to the next slide, please. So yeah, this is trichomonas, vaginalis. Um So your classic single best answer question will say either red spots on the cervix or strawberry cervix that's one of those little buzzwords to keep in mind. That's classic for trichomonas in exams. Not so classic in real life. I read a study that said it's only present in about 2% of patients. So that really interested me because definitely in medical school they bang on about it like it's seen in everyone. Um If you look at the picture at the top, that's what a strawberry cervix looks like. So again, if you see that image in a single best answer, it's more than likely going to be a question about trichomonas. So, signs and symptoms include abnormal vaginal discharge. So your classic presentation is it smells odd or unpleasant. Uh It's frothy and it's yellow in color vulvitis. So, inflammation of the vulva vaginitis, inflammation or irritation of the vagina, vulval itching and dysuria. So male patients can present with urethral discharge or dysuria, but they can be asymptomatic as well. Investigations wise, it'll be a vaginal swab. So either a nat or microscopy and a urethral or meatal swab for a nat. And if you look at the bottom picture, what that shows is a uh a trach is what I've heard them called as a sign. Basically, this is um what causes trichomonas, vaginalis. Um You'll see that on microscopy and similar to troponins, they are alive. So they have these little flagella. If you have a little look, um the little sort of strings sticking out of the bottom, those will wiggle and they will be moving around the slide. It's quite cool if you get to see them in person because again, you'll only see them for a short while after the swab has been taken because they're living things. Um Treatment wise, it's metroNIDAZOLE for a week. Um ideally it's 500 mg tablets, but those aren't as available as 400 mg. So if those are all, we have, those are fine too And safety netting for these patients to avoid sex for at least one week and until you and your partners have had treatment and follow up for this next slide, please. Ok. So test of cure is only recommended if patients are still symptomatic after treatment or symptoms recur following treatment. And it's done four weeks after they've started treatment, risk factors, female, um increasing number of sexual partners, low socioeconomic status and previous sti and complications can be um preterm delivery, low birth weight and you also have an increased risk of HIV transmission if you've got trachinus next slide, please. Ok. So case six, a 22 year old female presents to her local sexual health clinic with four days of severe dysuria. She's noticed some red spots on her vulva this morning, which were not there before they're very painful and she's now finding it difficult to pass urine at all due to the pain. When you talk to her more. She's telling you she's had a bad chest around two weeks ago, which has now resolved. Um, she went to a GP two days ago with the dysuria and they've given her antibiotics for a uti, but her symptoms haven't improved at all. In fact, they seem to have got worse. So, based on this presentation, what would your top differential diagnosis for this patient be? Ok. So, yeah, we've had a couple of people say gentle herpes and that's absolutely correct. Next slide, please. Ok. So herpes or herpes simplex. So it can affect skin around the genitals and the mouth. So those are more commonly known as cold sores. Um If we look at the picture just there, that's an example of what genital herpes might look like. So um sort of red um ulcerated, very, very painful lesions on the genitals. Common signs and symptoms are dysuria, lymphadenopathy. So, raised lymph nodes, genital or oral ulcers like we've seen in the picture fever, that's rare and it's usually only with the first episode, they might have a prodrome and it's usually a tingling sensation before they get the ulcers. And um often you'll see patients who know they have genital herpes who will come in and say that they've had this sort of prodrome, this tingling sensation and they'll come to access antivirals because they know that they're about to get an episode. Um primary and reactivation episodes. So first and subsequent episodes often happen after a viral illness or being under the weather or being under stress is another common one. you know, you commonly see people who have moved house recently or been through exams or some sort of other stress. Um, and either they didn't know that they had herpes before and they've had a first episode or they've had a reoccurrence of it. Investigations wise, it's often a clinical diagnosis based on history and exam. If you get a presentation, like in the case example, that's a very, very classic presentation. And, um, just to make you all aware more for clinical practice than for exams, it's quite common that people will get misdiagnosed with a uti before they get the ulcers. Um, and I've seen a couple of, uh, female patients and unfortunately, they were in a lot of discomfort and I've even had a patient who had to be catheterized because of the amount of discomfort she was in and she couldn't pass urine at all because of the amount of pain. Um, and she had unfortunately been misdiagnosed with a UTI and had she been diagnosed correctly the first time, uh, we might have prevented it getting as bad as it got for her. So it's just something to keep in the back of your mind when you're seeing patients who have symptoms like dysuria. Just have a think. Could it be a first presentation or a reactivation of genital herpes? It's just something that's useful to think about. Um, you can also do an HSV PCR. So just a swab of the lesions to know whether they have type one or type two HSV or if you're not sure about the diagnosis. Um If you are taking a swab from a patient with herpes, it needs to be from the lesions and if you can de roof them, so take the top off them. So you get the um sort of fluid inside. That's the best option. This is very, very painful for patients though. Um even to just touch some patients, lesions can be very, very uncomfortable. So if you're going to take a swab, I would cancel them appropriately that it might be uncomfortable or painful. And if they don't want to do it, that's absolutely fine. That's completely their choice. So just something to make them aware of rather than just going in and, and taking the swab. Ok. Next slide, please. So, treatment of herpes is acyclovir. So an antiviral um five day course, you need to start it within five days of symptom onset. So, um again, with the patient that I mentioned before, who had been misdiagnosed, unfortunately, by the time she was diagnosed with genital herpes, it was past that five day period. So she couldn't access antivirals, um which was a real shame because they can shorten the course of symptoms. Um You can also do symptomatic management. So commonly, if patients are finding it painful to pass urine, if they either run water. So if they stand in the shower and run water over when they're trying to pass urine or they, uh, pass urine in a bath. Um, that can be very helpful. We can also give them instill a gel. So it's um, commonly used for popping catheters in. So it's just a lubricating gel with a bit of local anesthetic in that can be very, very helpful. And, uh, paracetamol, you can use a topical antiviral if you've got oral herpes as well. And you can use suppressive acyclovir if you get multiple episodes in one year. Um, and that can just either uh prevent you from getting more reoccurrences or if you do it can make them shorter and less severe safety netting wise for these patients, they need to seek urgent medical attention if they get dysuria badly enough that they can't pass urine, that's an emergency and they will likely need a catheter. They need to drink plenty of fluids because the more concentrated your urine is, the more it's going to burn when it's coming out. And that's not gonna help you. When you're trying to pass urine. They need to avoid sex while symptoms or blisters are present and they need to tell their doctor their GP or their um midwife if they become pregnant and they have genital herpes because there's a potential that they could transmit it during birth. Another thing to make patients aware of is that treatment is not gonna cure their herpes, but it can help manage their symptoms. And another thing that a lot of patients experience is they'll have one really awful first episode of genital herpes and they might never get another one again or they might only get one more and it might be 10 years down the line. It's really unpredictable. Um, and usually the first episode is the worst. So patients will often be in a lot of pain, unfortunately, with the first episode and then they might get no symptoms at all for the rest of their life. It's really hard to predict. Ok. Next slide. So risk factors for herpes um HIV infection, any sort of immunosuppression, not using condoms, um high risk behavior. So this can include things like a history of ST is increased number of sexual partners and early age of first intercourse. And then complications are need for hospitalization and for a catheter due to severe dysuria and being unable to pass urine. This is rare, but I have seen it. Um Acyclovir resistance, esophagitis and erythema multiforme. Ok. Next slide, please. All right. So just a quick note on partner notification. So this is a really important part of sexual health because we want to um prevent more spread of STIs s and make sure that anyone who might be at risk of having one is informed of this and can access treatment and testing. So, in chlamydia, um if you have, if you diagnose a patient with chlamydia, um ideally, you want to notify all partners that they've had within the past 60 days or if they're asymptomatic, it's the past six months in gonorrhea. If you have a male symptomatic patient with urethral infection, it's all partners in the last two weeks or the last partner that they've had, if it's more than two weeks ago and in male asymptomatic patients, or if they've got a non urethral infection or in all female patients, it's all partners within the last three months. And then in genital warts, if you can advise them to inform their current partners, that's great. But there's no specific times scale because HPV can lie latent for a really long time before people experience warts. Next slide, please. Ok. So in syphilis, if it's primary syphilis, so they've presented like our patient example with a shanker and it's all all partners in the last three months in secondary or early latent syphilis, all partners in the last two years. So, again, early latent syphilis is uh asymptomatic syphilis where they've uh been, had a a infection within the last two years and then late syphilis. So that is uh tertiary and late latent syphilis. It's lifetime partners and possibly their Children as well in trichomonas, vaginalis or partners within the last four weeks. And then for genital herpes, it's similar to genital warts. So we need to encourage patients to inform their partners if they're happy to do so. But it can lay latent for a really long time. So sometimes it's hard to, there's no specific times scale. Um The other thing to note with partner notification is if patients feel uncomfortable or unhappy to disclose to their partners themselves, that's completely understandable. Um We can organize in sexual health clinics for partners to be notified by the clinic without revealing any information about who has tested positive or anything about the person that we're actually treating everything is kept completely confidential. So that's something that a lot of people find beneficial if they just give us a phone number or an address for partners, if, if they have that information and we can organize all of the notification. Ok. Next slide, please. Ok. So, um this is our last case of the evening. Um So you're working in a GP surgery and your next patient is a 25 year old female. She explains that for the last week, she's had very strong smelling discharge and she's worried she might have an sti i her discharge has not had any change in color or consistency. And she's been in a long term monogamous relationship with her girlfriend for three years. She denies abdominal pain, rashes, itch, dyspareunia and urinary symptoms. So, based on that limited information, what would your top differential for this patient be? Ok. Lovely. Yeah, we only had uh one more condition to cover and that's absolutely right. So this patient has bacterial vaginosis and more commonly known as BV. Next slide, please. So, um bacterial vaginosis is an overgrowth of anaerobic organisms and a loss of lactobacilli. So, lactobacilli are present in normal vaginal flora, um losing them and having an overgrowth of these anaerobic organisms can cause your ph to increase uh really important to note that this is not an ST um it's in this session because it fit best with um the sort of group of other uh conditions that this is not a sexually transmitted infection. So, presentation again for your single breast answer exams, the classic will be a fishy smelling discharge. Um It will classically be thin, white colored. Um, but it's important to note that 50% of patients that you see with BV are completely asymptomatic and they won't know that they have it risk factors wise for this uh, vaginal douching being sexually active menstruation. Um It, I didn't realize why this was but menstruation uh increases the ph of your vagina. So, um, anything that causes that to happen increases your risk of B uh if you've got uh an intrauterine copper device. So this is a type of contraception that doesn't use hormones. It's just copper, um, smoking and having an active ST protective factors. So things that reduce your likelihood of getting BV are hormonal contraception consistent. Condom. Use a circumcised partner if uh, you are sleeping with someone who is a side male at birth. Ok. Next slide, please. Oh, ok. So investigations wise, um, you can do what's called the whiff test. So if you combine a sample of the discharge with potassium hydroxide, it will give off a classical fishy smell. But from my experience, you often don't need to combine the discharge with anything. It will often have quite a strong smell in itself. Um You can also test the ph of the discharge. And if it's above 4.5 it's indicative that they might have BB and you can also do a gram stain in microscopy. So again, looking at it under the microscope, um classical findings on microscopy are clue cells. So basically these look kind of fluffy and it's visible in the little cartoon on the uh on the bottom of the screen. So they're kind of fluffy looking and it's basically just skin cells that are covered in bacteria. Um And you won't be seeing lactobacill e either fab. All right. Next slide, please. So you can diagnose and treat BV based on clinical presentation alone in certain circumstances. So, those are listed on the right hand side. So, um if the person is low risk of an sti if they don't have any symptoms of other conditions including STIs, if symptoms have not developed pre or post a gynae procedure. So for example, if a patient has had a uh sterilization or a coal insertion and may develop symptoms of BV, uh it's not enough just to treat them based on presentation. So it's really important to take a thorough history like we do with every patient just to make sure that you're not missing any of those. Um If the uh patient is not postnatal or post miscarriage, um they shouldn't be pre or post termination of pregnancy. Um if this is the first episode of suspected BV, or if recurrent a previous episode of recognizably similar symptoms. So basically, if this is a classic presentation of BV for that patient, then it's fine to diagnose based on clinical presentation or if it's their first episode of suspected B. Um and that they're not pregnant. So treatment wise, it's metroNIDAZOLE 400 oral twice a day for 5 to 7 days. That's your first line. You don't need to treat BV. If it's asymptomatic, if it's not bothering the patient, that's absolutely fine safety netting wise. Um to avoid douching scented shower gel, any antiseptic shampoo in the bath. Basically, anything that can change the ph of the vagina, it's self cleaning really, you only need water if you really need to use soap, ideally not inside. Um And it should be unscented and suitable for sensitive skin, but ideally, if they could just use water, that is the ideal next slide, please. Oh, so that is us done for the evening. Um I hope the session has been helpful and I hope that um, all the content made sense to everyone. Thank you for getting involved on the chat. It makes um, the session a lot more interactive and um makes it nice having a bit of interaction from all of you. So I really appreciate it. Um The QR code on the screen is just a link to a feedback form. I really appreciate it. Um I'm really keen to kind of tailor these sessions around what you all might find useful. Um So if you've got any suggestions about things that you might like to see covered to do with sexual health or I also am the infectious diseases lead. So I'll be doing two sessions on infectious diseases as well. So if there's anything you think might be helpful or if you'd like any advice on foundation or um if you're thinking about a career in sexual health and you want some advice on things you might want to do in med school or in foundation, I'd love to help with that as well. Um So if there's anything I can help with, just pocket on feedback form, um If you are interested in learning a bit more about microscopy, I've got an article coming out in about a week's time. So that will cover microscopy in more detail. It'll teach you how to do a gram stain, what you're looking for underneath the microscope, how to take a sample and keep it clean. Um and lots of pictures and hopefully a lot of good information as well. So that will be out mind the bleep.com and yeah, thank you all again for listening. And I hope you have a lovely rest of your evening.