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Sexual Health in the Surgery

Sexual Health in the Surgery. Dr. Simon Benson ST2. Main topics. Discharge Dysuria Dyspareunia Erectile Dysfunction Genital Dermatology Anal Symptoms. The Sexual History. Current sexual partner Recent (6/12) sexual partners Nature of relationship Gender of partner

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Sexual Health in the Surgery

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  1. Sexual Health in the Surgery Dr. Simon Benson ST2

  2. Main topics • Discharge • Dysuria • Dyspareunia • Erectile Dysfunction • Genital Dermatology • Anal Symptoms

  3. The Sexual History • Current sexual partner • Recent (6/12) sexual partners • Nature of relationship • Gender of partner • Nature of intercourse • Contraception? • Partner symptoms • Date of LMP, length, regularity

  4. Vaginal Discharge • 95% caused by 5 causes: • Excessive normal secretions • BV • Candida • Cervicitis (Gonorrhoeal, Chlamydial, Herpetic) • TV

  5. Vaginal Discharge • BV • Vaginal flora change • Not sexually transmitted • Affects up to 40% of women • Associated with complications post partem • White offensive discharge • 50% remit by self • Can treat with metronidazole po / clindamycin topically

  6. Vaginal Discharge • Candida • Fungal infection • Predisposing factors: Cushings / Addisons, DM, pregnancy, steroids, Antibiotics • Pruritis • Thick, creamy, non offensive • Treat if symptomatic – clotrimazole.

  7. Vaginal Discharge • Chlamydia • Screening – urine testing, self test • Men usually asymptomatic (may have urethritis) • Women (>70% asymptomatic) – discharge (mucopurulent), PCB / IMB / PID, dysuria • Examination – Discharge, tender, bleeding cervix, tender adnexae, cervical excitation • Doxycycline 100mg bd for 7/7, azithromycin 1g po once

  8. Vaginal Discharge • Gonorrhoea • Men (50% acute infections asymtpomatic) – urethritis, prostatitis, urethral stricture, arthritis • Women: PID, miscarriage, preterm labour. • Ceftriaxone 250mg IM • Ciprofloxacin 500mg PO

  9. Vaginal Discharge • Trichomonas Vaginalis • Men: 15-50% asymptomatic – dysuria / urethral discharge. • Women: 10-50% are asymtpomatic – copious mucopurulent yellow smelly (fishy) discharge, itchy • Metronidazole (patient and partner)

  10. Herpes • Direct contact with lesions • Appear anywhere on skin or mucosa • Painful red genital ulcers which crust over and heal. • Last 3-4 weeks • Major complication is urinary retention • URGENT referral to gynae, never catheterise

  11. Herpes • Contact tracing • Aciclovir treatment if <5days • Analgesia • Reactivation is less severe • Neonatal herpes is a paediatric emergency

  12. Genital Warts • Caused by HPV • Can be asymptomatic • Warts caused by HPV 6 or 11 (90%) • Females – vulval or introitus • Males – Penis or Anus • Treat with podophyllotoxin or imiquimod • Barrier contraception for 3/12 after warts gone. • Alternatives – cryo, electocautery, excision

  13. HPV Vaccination • Prevent infection from strains causing cervical cancer (HPV 16, 18) • Some cover HPV 6 and 11 • Needed before sexual activity (12-14yo) • Still need cervical smears as not protective against all strains causing cervical cancer

  14. Syphilis • Up 3000% on three years ago • Refer all cases to specialist care • Primary – Chancre at site of contact • Secondary – Systemic symptoms 4-8/52 later (fever, malaise, lymph, anal papules) • Tertiary - Granulomas in connective tissue occur 2-20years after initial infection • Quaternary – Cardio / Neuro complications

  15. Hepatitis B • Common globally • Spread via sex, blood, mother to baby • High risk groups • 85% recover fully, 10% carriers, 5% chronic hepatitis • Treatment is initially supportive but chronic hepatitis uses interferon and lamivudine

  16. Hepatitis C • Also common • Less likely to spread via sexual intercourse but possible • Antibody detectable at 4months, PCR sooner • Needs specialist referral • 50% recover, 15% develop hepatoma, 5% develop cirrhosis

  17. HIV • Retrovirus affecting Th cells • 1 in 3 patients affected in UK are unaware • Risk of transmission is low (1:1000 exposures) • 70% is sexual transmission • Antibodies take 3 months to develop • Prophylaxis available if accidental exposure

  18. When to test? • Signs of HIV • Routine screen • Patient request • Identified risk • Infected sexual partner • IVDU as partner • Patient from high risk area • MSM • Multiple partners • Surgical procedure in high risk country

  19. Arranging the test • Is primary care appropriate? • Pre-test counselling • Need for repeats (<3/12) • Other tests needed? • Consent • Make follow up appt for results • Discuss barrier contraception to prevent new risk

  20. Contraception • Lots of methods • Sterilisation • Implant • IUS • COCP • POP • IUCD • Barriers • Natural methods • Emergency

  21. Emergency Contraception • <72hrs after unprotected intercourse • Levonorgesterel 1.5mg • If vomits within 3hrs, give another dose with antiemetic • If on enzyme inducing drugs consider coil or higher dose • Efficacy • 0-24hr – 95% • 24-48hr – 85% • 48-72hr – 58%

  22. Emergency Contraception • < 5days after unprotected intercourse • Insert copper IUCD • Efficacy is >99% • Return if abdo pain, late period, further contraceptive advice needed

  23. COCP • Contain oestrogen and progestogen • Associated with risks • Coronary artery disease 15 per 1000 (higher in smokers) • Stroke 1 in 1000 (higher in smokers) • VTE 0.05 in 1000 • Breast cancer 20 per 1000 • Cervical cancer 0.1 per 1000 (higher with longer term use)

  24. COCP • Risk outweighs benefit if: • Smoker >35 or Non smoker >50 • BMI >30 • BP >140/90 • PMHx of cardiovascular disease • PMHx of VTE • Focal migraine • Vascular complications of DM • Female malignancy • Liver disease

  25. Initiation of COCP • History (medical and sexual) • Check BP • Discuss risks and side effects • Consider smoking cessation advice • Consider thrombophilia screen if FHx of VTE (<45yo) or cholesterol if FHx of MI (<450yo)

  26. COCP • Effective immediately if: • Taken on days 1-3 of cycle • End of 3rd week post partem • < 7days after miscarriage/TOP • Follow up • 3/12 – Check side effects and BP, risk factors • 6/12 thereafter

  27. Missed pills • If < 2 pills missed, no additional contraception needed • If > 3, need to use condoms or abstain for 7 days • If pills missed in week 1 consider emergency contraception • If pills missed in week 3 omit pill free break • Nb if POP, need extra contraception for 2days

  28. Reasons to stop immediately • Severe sudden CP • Sudden SOB • Calf pain • Acute abdominal pain • Severe headache • Hepatitis • BP >160/100 • Prolonged immobility after surgery

  29. Use with antibiotics • If <3 week course • Use additional contraceptive methods • Continue for 7 days after • Omit next pill free interval • If enzyme inducer • Use additional contraceptive methods • Continue for 4 weeks after

  30. Contraception to Under 16s • Can give without parental consent if: • In best interest • Sufficient maturity to understand moral, social and emotional implications • Cannot be persuaded to inform parents • Likely to begin sexual intercourse without • Likely to suffer if no advice given

  31. Choices for under 16s • Condoms (higher failure rate) • COCP (needs compliance) • Implants (2nd line) • IUCD (Can be hard to insert) • Morning after pill (not suitable as regular)

  32. Erectile Dysfunction • 50% men aged 40-70 experience problems • Organic causes account for 80% • CVS • DM • Neurological • Smoking • Side effects of drugs (BP, SSRIs)

  33. Treatment options • Viagra • Apomorphine • Intraurethral preparations • Vacuum devices • Penile prosthesis • Androgen supplements • Psychotherapy

  34. Viagra • The little blue pill • Prescribable on NHS if • Prostate cancer • Kidney failure • Spinal cord lesion • DM • MD • PD • Polio • Already receiving on 14/09/1998 • Severe psychological distress

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