Case presentation Carley firm
Patient XX • 26 Year old female bank worker • HPC • 36 hour history • painful vulvar lesions • dysuria for 18 hours – unable to pass urine • thick, white vaginal discharge • Sexual history • 6 months: monogamous relationship with a male partner • 50+ male sexual partners in the past, 3 in the last 12 months. Occasionally protected • genital warts, gonorrhoea and chlamydia infections
Examination • Abdo soft, non tender • 20+ 5mm blister-like, angry, red lesions filled with clear fluid around vaginal entrance • White vaginal discharge • External swabs taken • Too tender to examine internally
Differential Diagnoses Herpes simplex virus infection Folliculitis Chancroid Herpes zoster infection Syphilis
Investigations Initially treated empirically Vulvular lesions swabbed for virology HSV PCR of swab from lesion base: DNA detection.
What is genital herpes? A viral infection of the genital region There are two types of herpes simplex virus: Epidemiology Type 1: The usual cause of cold sores around the mouth. It also causes up to half of cases of genital herpes. Type 2: Usually only causes genital herpes. It can sometimes cause cold sores
Transmission skin-to-skin contact Kissing Sexual contact Vertical transmission
Signs & Symptoms Mostly asymptomatic! General malaise, mild fever, aches & pains Groups of small, painful blisters then appear around the genitals and/or anus Dysuria and vaginal discharge is common in women Bilateral inguinal lymphadenopathy 2 1
Recurrence Tend to be less severe and shorter than the first episode. Most people do not develop a fever A tingling or itch in the genital area for 12-24 hours may indicate a recurrence is starting.
Treatment Analgaesia & Antivirals Tips for symptoms Pass urine whilst sitting in a warm bath or with water flowing over the area. Apply barrier cream before passing urine Place an ice pack or cold teabags over sores Have lots to drink
Public Health Avoid sharing towels or any sponges or face cloths E.g. sex during active illness…. Offer screening for other STIs
Complications Urinary retention Infection may spread to other areas Super-infection of blisters by bacteria
Taking a Sexual History • Age & sex • Presenting Complaint • Symptoms (SOCRATES)- Duration- Associated features e.g. dyspareunia in women or testicular pain in men • Last Sexual Contact- When- Who (gender of partner, regular/casual/known)- Type of sex (oral/vaginal/anal)- Condoms (always/ sometimes/ never? Any condom accidents?) • Previous Sexual Contacts in the last 12 months(as for Last sexual contact)
Past History- Of STIs and treatment of the client and partner • Medical historyMedicationsAllergies • HIV Risk assessment- Previous test- Risk factors-Men that have sex with men/HIV positive partner/ partner from high prevalence area/ injecting drug use/ sex work- Window period- Expectation of result- Support
Female Hx • LMP, Menstrual cycle and any IMP/PCB • Contraception: method & correct usage • Cervical Cytology • Obstetric history
Case 1 • A 20-year-old male student attends a walk-in centre 7 days after a having unprotected vaginal intercourse with a stranger at a friend’s party. • “I got up this morning and went for a pee; it really hurt – sort of burning and stinging. Then I noticed there was yellow stuff coming out. It’s really gross” • On examination, the patient is clearly uncomfortable, and you note a purulent urethral discharge with crusting at the meatus.
Questions • What are your top 2 differentials? • What is your next investigation? • Microscopy is positive for Neisseria gonorrhoeae. How will you manage this patient? • What else should you do? 3 3
Case 2 • Amy Fletcher, a 34-year-old mechanical engineer, arrives at her GP looking anxious and upset. On gentle questioning, she reports the appearance of painless “bumpy growths on [her] vagina” • She has looked up her symptoms on the internet, and is now frightened that she will develop cancer. • Examination reveals scattered, pink, papular lesions on the inner aspect of the labia minora.
4 4 5
Questions • What are these lesions? • What is the causative organism? • How will you treat them? • How will you counsel this patient re malignancy?
Case 3 • Bradley Thomas is a 29-year-old nightclub bouncer, who presents to this GP with a sore-throat, non-pruritic rash on his hands and a 7 day history of malaise, arthralgia and night-time headaches. • He remembers that he had an unusual mouth ulcer a few weeks ago, which took a while to get better. He ignored it because it didn’t hurt, and by the time he thought he should get it checked out it was beginning to heal. • He has been having unprotected oral sex with several male partners over the past few months. • Examination reveals a generalised polymorphic rash on his palms and soles of his feet.
Questions • Which STI best fits with Bradley’s clinical picture? • What investigations would you conduct? • How will you treat it? • What other management would you instigate?
Take home points • HSV is very prevalent but usually asymptomatic • Symptom relief is a crucial part of treatment • Take advantage of the opportunity to offer sexual health advice from an individual and public health perspective • Always offer screening for other STIs • Contact tracing is indicated in STIs only when treatment is required
Resources • Pictures taken from 1. http://en.wikipedia.org/wiki/Herpes_genitalis 2. http://www.pharmacy-and-drugs.com/Skin_diseases/Herpes_simplex.html 3. http://www.genitaldischarge.com/p/gonorrhoea.html 4. http://www.pelauts.com/genital/genital-warts-18-jpg.html 5. https://www.healthtap.com/#topics/how-do-you-get-tested-for-genital-warts 6. http://hardinmd.lib.uiowa.edu/cdc/syphilis15.html 7. http://www.cmaj.ca/content/176/1/33/F3.expansion.html • Information 1. Kumar and Clarke 2. Patient.co.uk (patient plus articles) 3. NICE guidance