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Update in Genitourinary Medicine

Update in Genitourinary Medicine. Mayur Chauhan. What ’ s New. Changes in the provision of Sexual Health Services Epidemiology of STI Microbiological and Virological Genital Sampling HIV and BBV infection. Changes to Sexual Health Services.

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Update in Genitourinary Medicine

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  1. Update in Genitourinary Medicine Mayur Chauhan

  2. What’s New • Changes in the provision of Sexual Health Services • Epidemiology of STI • Microbiological and Virological Genital Sampling • HIV and BBV infection

  3. Changes to Sexual Health Services • Responsibility of commissioning of GUM and contraceptive services to Local authority • Move towards integration of GUM and Contraceptive Services • Tendering of GUM and Contraceptive services to wide range of bidders including private • Specialized commissioning of HIV services • CCG responsible for community gynaecology

  4. Integrated Model of GUM Services

  5. National Standards

  6. Epidemiology of STI

  7. Risk factors for STIs • Younger age (especially <25 years) • Sexual orientation • Ethnicity (for some STIs) • Living in inner city • >2 partners in preceding 6 months • Use of non barrier contraception • Partner with symptoms • History of STI in the past

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  9. Chlamydia • Epidemiology • Chlamydia Screening Programme • Dual Testing • Swabbing for chlamydia

  10. Rate per 100,000 population of chlamydia cases by local authority of residence

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  12. Risk of re-infection following a positive chlamydia test • Systematic reviews show: • median of 14% of women re-infected at repeat test[7] • median of 11% of men infected at repeat test[8] [4] Woodhall STI 2012; [5] Turner STI 2012; [6] Rietmeijer STD 2002; [7] Hosenfeld STD 2009; [8] Fung STI 2007

  13. Re-testing for Chlamydia Infection • National Chlamydia Screening Programme (NSCP) for England recommends that persons under the age of 25 years treated for chlamydia should be offered a repeat test for chlamydia three months after the completion of treatment. • BASHH also supports re-testing policy

  14. Chlamydia Screening Programme • Dual Testing (chlamydia and gonorrhoea NAAT) in Newcastle and Northumberland. • Six month pilot in other areas of NE looking at the benefit of dual testing

  15. What is the Optimal Swab Sample for Diagnosing Chlamydia? • Self taken vulvo-vaginal swab • or • Clinician taken endocervical swab

  16. Two Studies from Leeds • Published in BMJ 2012:345; 2013 • Study population ---- 3973 women • Each had self taken V-V swab and endocervical swab. • Results analyzed into asymptomatic and symptomatic women for detection of chlamydia and gonorrhoea.

  17. Results • In asymptomatic women:- • Self taken vulvovaginal swabs were significantly better at detecting chlamydia infection than clinician taken endocervical swabs (P < 0.00001)

  18. Results • In symptomatic women:- • A self taken vulvovaginal swab before examination or a clinician taken vulvo-vaginal swab before speculum insertion is more sensitive in detecting chlamydia then clinician taken endocervical swab (p < 0.0008)

  19. Results for Gonorrhoea testing • In symptomatic and asymptomatic women:- • Self taken Vulvovaginal swabs tested by NAAT were significantly more sensitive at detecting gonorrhoea than culture of urethral and endocervical samples taken by clinicians—culture missed almost one in five cases of gonorrhoea (p < 0.001). • Therefore best swab sample for detection of chlamydia and GC is a self taken vulvo-vaginal swab.

  20. Take Home Message 1) Highest rates of chlamydia are in under 25 year old (M + F) 2) CSP having some impact in screening and diagnosing chlamydia infection 3) Best screening test in women is self taken or clinician taken vulvo-vaginal swab. 4) Recommend re-screening 3 months after treatment in under 25 year old men and women.

  21. LGV – Lymphogranuloma Venerum

  22. LGV in MSM • Outbreak of LGV in N Europe since Dec 03 • Chlamydia trachomatis serovariants L1–L3 are responsible. • Clinical signs of anorectal syndrome or inguinal syndrome • Proctitis with inguinal lymphadenopathy • +/- fever • Treat with 3 weeks of doxycycline

  23. Gonorrhoea • Epidemiology • Dual Testing • Antibiotic Resistance

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  25. Rate per 100,000 population of gonorrhoea cases

  26. GC Treatment • Ceftriaxone + Azithromycin • Spectinomycin • Other antibiotics guided by sensitivities

  27. Take Home Message • GC rates rising in both males and females • Screen multiple sites depending on sexual history • Refer to GUM for treatment and PN issues. • Need dual antibiotic treatments. • All patients should have TOC regardless of site of infection

  28. Pubic Lice • Prevalence decreasing • Related to shaving • Treatments --- Permatherin lotion

  29. HPV infection • Epidemiology • Treatments • HPV vaccination

  30. Warts per 100 000 population

  31. Treatments and Management • Warticon now available • Aldara (imiquimod) • Ablative therapy (cryocautery, TCA (75% - 90%), hyfrecation, excision) • Combination of all above • Vaccination with HPV vaccine (under trial) • HIV positive ---- anal smears (In London)

  32. HPV vaccination --- change from Cervarix to Gardasil In Australia --- immunization is provided to both boys and girls

  33. Herpes • Epidemiology • Management • Vaccine • Recurrent Herpes

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  35. Herpes rates per 100 000 population in the North East

  36. Herpes Management • Diagnosis ---- PCR testing • Treatments --- Acyclovir • Vaccine ----- Nil as yet

  37. Syphilis • Epidemiology • In UK the infection is endemic

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  39. Rates of Syphilis per 100 000 population

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  41. Background • 61.5% rise in the number of heterosexual patients diagnosed with syphilis in the North East of England between 2011 and 2012

  42. Heterosexual Syphilis --- NCC • Year 2012: 14 females and 14 males • Year 2013: 4 females and 7 males • Total : 39 patients

  43. Mean age • 2012 • Female 23.5 years • Male 29.7 years • 2013 • Female 21.6 years • Male 26.2 years

  44. Stage of syphilis : 23 primary, 8 secondary, 8 early latent • 10 had documented positive microscopy findings • 5 diagnosed with co-infection (4 cases of Chlamydia and 1 HSV) • 30 patient treated with Benzathine penicillin, 7 treated with doxycycline, one not known

  45. Mean Partners 6 months • Females: 1.7 partners (30% casual, 70% regular) • Males: 2.7 partners (56% casual, 44% regular)

  46. Contact tracing for males 142 contacts (Nb. One contact reports having 100 contacts in previous 2 years) • 22 traced • 22 screened • 120 untraceable (84.5%) • 15/22 screened were positive for syphilis (68.1%)

  47. Contact tracing for females 61 male contacts • 25 traced • 23 screened • 36 untraced (59%) • 16/23 screened were positive (69.5%)

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