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Christopher Sonnex - Sexual Health and Genital Medicine in Clinical Practice

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Sexual Health and Genital Medicine in Clinical Practice
Author:
Christopher Sonnex
Publisher:
Springer
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Books / Home and family
Year:
2015
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This fully revised and updated second edition of Sexual Health and Genital Medicine in Clinical Practice covers the range of conditions seen in genitourinary medicine, sexual health and sexually transmitted infection clinics, making it a useful and practical guide to all health practitioners in this area. This book is aimed at medical practitioners who require a quick reference guide to help with diagnosis and management of genital problems. In addition, it provides essential guidance on what to do next when faced with a patient presenting with a genital complaint, whether the patient can be successfully treated with a drug regimen or needs to be referred up to the Sexual Health and Genital Medicine specialist. Sexual Health and Genital Medicine in Clinical Practice will be of particular interest to residents on their rotations through this field of medicine, doctors in training, specialist nurses, and primary care practitioners.

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Springer International Publishing Switzerland 2015

Christopher Sonnex Sexual Health and Genital Medicine in Clinical Practice In Clinical Practice 10.1007/978-3-319-21638-6_1

1. Which Patients to Refer to Genitourinary Medicine or Sexual Health

Christopher Sonnex 1

(1)

Cambridgeshire Community Services, Cambridge, UK

There is an appreciable overlap between genitourinary (GU) medicine and gynecology, urology and dermatology, which sometimes leads to difficulties when deciding to whom to turn for further advice or a specialist opinion. The following should be considered as general guidelines: if in doubt to whom to refer, give your local GU medicine/sexual health clinic a call.

Many consultants in GU medicine have specific interests and the services available from individual clinics may vary accordingly. A large number of clinics provide expertise in vulval disease, genital dermatology, psychosexual medicine, colposcopy, and sexual assault assessment and management. Getting to know your local department of GU medicine or sexual health is to be strongly recommended: GU medicine clinicians are usually very approachable and are delighted to have general practitioners (GPs) and practice nurses attend clinical sessions and learn more about the specialty.

Consider Urgent Referral

Men with
- Urethral discharge or dysuria
- Acute epididymitis.
Men and women with
- Primary genital herpes
- Genital ulceration: Previously unconfirmed diagnosis.

Referral Strongly Recommended

Men and women with:
- Concern (patient or doctor) regarding sexually transmitted infection
- Concern regarding human immunodeficiency virus (HIV) infection
- Any of the following infections (proven or suspected):
  chlamydial infection
  non-gonococcal, non-chlamydial urethritis (i.e. non-specific urethritis NSU)
  gonorrhoea
  genital warts
  trichomoniasis
  syphilis
- Sexual partners of patients with:
  chlamydial infection
  non-gonococcal, non-chlamydial urethritis (i.e. non-specific urethritis NSU)
  gonorrhoea
  genital warts
  trichomoniasis.
- Positive syphilis serology.

Referral Recommended

Women with
- Persistent/recurrent vaginal discharge
- Persistent/recurrent vulval irritation/soreness/burning
- Chronic pelvic pain
- Dysuria/frequency with sterile urine culture.
- Young women with post-coital bleeding (possibly prior to referral to gynecology)
- Painful sexual intercourse (superficial or deep).
Men with
- Testicular/intrascrotal discomfort
- Symptoms suggestive of prostatitis/chronic pelvic pain syndrome
- Balanoposthitis.
Men and women with
- Genital warts
- Genital molluscum contagiosum
- Genital lumps of uncertain etiology
- Pubic lice
- Genital rashes (diagnosis uncertain or unresponsive to treatment).

Consider Referral

Women with recurrent candidiasis or recurrent bacterial vaginosis.

Springer International Publishing Switzerland 2015

Christopher Sonnex Sexual Health and Genital Medicine in Clinical Practice In Clinical Practice 10.1007/978-3-319-21638-6_2

2. Routine Investigations Performed in Genitourinary Medicine

Christopher Sonnex 1

(1)

Cambridgeshire Community Services, Cambridge, UK

Patients attending a GU medicine department for the first time and those presenting with new problems will usually undergo a variety of investigations to check for evidence of infection, both sexually and non-sexually acquired. Many GPs are uncertain which tests are routinely performed and a standard letter from the clinic stating that the screen for genital infection proved negative is not particularly instructive. All clinics should be screening for the same infections; however, the specific tests used may vary from clinic to clinic.

Tests routinely performed are as follows.

Men with Symptoms (e.g. Dysuria, Urethral Discharge)

Urethral Swab

Gram stain microscopy

Four polymorphs per high power field (HPF) = urethritis
Gram-negative diplococci within polymorphs presumptive diagnosis of gonococcal urethritis

Culture for Neisseria gonorrhoeae (provides definitive diagnosis of gonorrhoea).

Urethral Swab

Chlamydia trachomatis detection by nucleic acid amplification test (NAAT) e.g. polymerase chain reaction (PCR) or ligase chain reaction (LCR).

Neisseria gonorrhoeae detection by nucleic acid amplification test (NAAT) e.g. PCR or LCR.

These are usually performed on the same sample.

Many clinics have now moved from urethral swab to urine testing for chlamydia detection, which is likely to become the favoured method (certainly by patients) for diagnosing urethral infection in men.

Many clinics also rely on the NAAT for diagnosing gonococcal infection (either by urethral swab or urine) and perform culture only if gonorrhoea is considered a possible diagnosis. Its important to remember that a patient diagnosed with gonorrhoea by a NAAT will require a further swab for Neisseria gonorrhoeae culture, as this will provide antibiotic sensitivities.

Two Glass Urine Test

This is a time honoured test still performed in some UK GU Medicine clinics, although now considered to be of debatable value for diagnosing urethritis. It has a place in helping to differentiate a pure urethritis (usually sexually acquired) from a urethritis present in association with a cystitis (i.e. a UTI, and not sexually acquired).

First glass = a first catch urine (50 ml)
Second glass = second part of urinary stream (50 ml)

Any remaining urine is passed into the urinal.

Interpretation of urine results:

First: clear

Second: clear

= normal

First: pus (seen as threads, flakes, general haze)

Second: clear

= anterior urethritis (e.g. chlamydia, gonorrhoea, non-specific urethritis (i.e. non-chlamydial, non-gonococcal urethritis))

First: pus

Second: pus

= posterior urethritis or cystitis (e.g. E. coli , etc.)

Send the first glass urine or a mid-stream urine (MSU) for culture.

The urine may also be checked by dipstix. This may show the presence of white blood cells in cases of urethritis and WBC, protein, nitrate and possibly blood in cases of cystitis.

Phosphaturia is a common cause of cloudy urine. The addition of acetic acid will clear the urine when excess phosphates are present whereas the haze remains in cases of pyuria.

Men Without Symptoms

As the clinical significance of asymptomatic urethritis is currently uncertain, most U.K. clinics no longer look for urethritis in asymptomatic men. A urine NAAT is usually performed, looking for both chlamydial and gonococcal infection.

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