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Sexually Transmitted Infections

Sexually transmitted infections (STIs) such as chlamydia, gonorrhoea and syphilis continue to pose a significant health burden in NSW. If left undiagnosed or untreated, STIs can be transmitted unknowingly to sexual partners, facilitate the sexual transmission of HIV, and increase the risk of infertility, ectopic pregnancy, cancer and other health problems.

The priorities in the ED setting are to recognise symptoms, and test, treat and refer in a timely manner.

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Clinical Assessment

General principles of the sexual health consultation include ensuring privacy and maintaining comfort and confidentiality between the health care provider and patient. Never make assumptions about the patient, and always maintain a non-judgmental attitude.

The practitioner needs to be sensitive to cohorts where information may not be forthcoming or masquerades as other complaints e.g. culturally and linguistically diverse backgrounds, adolescents and the elderly.

In the context of potential sexual assault seek advice before further action as the forensic examination is usually done by trained personnel in specialised units. However, if the patient presents with serious and life threatening conditions manage as per usual practice.

Conducting a full sexual history may be difficult in the ED setting. Obtaining a full sexual history is not essential before conducting tests for STIs if symptoms are present.

History

General
  • past medical and STI history; HIV history
  • medications, allergies (particularly antibiotics) and contraception
  • last menstrual period
  • vaccination history
  • recreational drug use
  • joint pains
  • atypical occular symptoms
Genital symptoms
  • onset, character, periodicity, duration and relation to sexual intercourse and urination
  • anogenital discharge: amount and character
  • abnormal vaginal or rectal bleeding
  • genital rashes, ulcers, lumps and sores
  • itching and/or discomfort in the perineum, perianal and pubic region
  • lower abdominal and/or pelvic pain
  • dyspareunia
  • difficulties with micturition or defaecation
Sexual behaviours
  • any sexual partner(s) and date of last sexual exposure and others in the last three months
  • sex of partner(s) including any history of male to male contact
  • type of intercourse – oral, vaginal, anal (insertive or receptive)
  • sex overseas or in high-risk regions
  • any history of injecting drug use: what drug, how often
  • any tattoo history or blood product exposure.

Examination

A chaperone of the same gender as the patient should always be present.

Inspect for rashes, lumps, ulcers, discharge, smell, pubic hair for lice and nits and in most cases the skin of the face, trunk, forearms, palms and the oral mucosa. Inspect oropharynx as clinically indicated. An abdominal examination should be part of your overall assessment.

Men: Inspection of the penis, including meatus, retracted foreskin and perianal area +/- proctoscopy. Palpation of scrotum and expression of any discharge from the urethra.

Women: Inspection of external genitalia, perineum and speculum examination of vagina and cervix. Bimanual pelvic examination. (Refer to the ECI Pelvic Inflammatory Disease page for further information).


Testing and Following up

Testing

Testing varies with patient symptoms and clinical situation. See this STI Testing Tool - used to guide STI testing and discussions.

An STI screen typically tests for chlamydia and gonorrhea, with samples collected being based on anatomical sites at risk. Self-collected swabs / urine samples are sensitive and adequate for asymptomatic patients. Serology for HIV, syphilis and hepatitis B should also be considered.

There are typically two swabs available for use. The blue swab is used for bacterial infections and the green swab for viral infections and chlamydia.

Specific guidelines exist for STI testing for men who have sex with men available here developed by the STIs in Gay Men Action (STIGMA) Group.

Follow Up

Patients should be made aware of follow-up arrangements to review test results and discuss ongoing management and prevention. Where possible, this should occur at local Sexual Health or Community Health Services. Contact details of the closest appropriate Sexual Health Service are available here. For further sexual health information/advice, patients can also contact the NSW Sexual Health Infolink on 1800 451 624.

Prevention

Patients must be advised to avoid sexual intercourse until they attend for follow-up. In situations where patients are unlikely to comply with abstinence, they must be encouraged to use condoms to prevent/reduce the risk of STI transmission.

Further References and Resources


Other Diseases and Syndromes

See the Australian STI Management Guidelines for information to support prevention, testing, diagnosis, management and treatment of STIs (targeted at primary health care professionals). The most common STIs seen in Emergency Departments are Epididymo-orchitis and Pelvic Inflammatory Disease (PID) .

Further References and Resources


Notification and Contact Tracing

Patients are often their own best contact tracers and they should be made aware of their responsibility to ensure that recent sexual partners are checked and treated. In difficult cases or where time, experience or cross-cultural issues make contact tracing by patient or healthcare provider impossible, the local Sexual Health clinic will be able and willing to assist. When identified, contacts should be linked to appropriate care through the local Sexual Health clinic, and further assistance obtained through Sexual Health Infolink.

As diagnosis is generally yet to be confirmed during an ED encounter, the ED clinician's role may be to initiate discussion with a patient about contact tracing. The NSW STI Programs Unit has developed this tool to assist clinicians in this process. For further information, the Australasian Contact Tracing Manual contains guidelines for conditions as to whether tracing should be recommended or considered, how best to undertake this and over what time period.

See NSW Health for list of notifiable diseases. Medical practitioners and Hospitals are required to report notifiable conditions to the Public Health Units on the basis of reasonable clinical suspicion. With respect to STIs, syphilis features on the current list. See below for respective forms.

Further References and Resources


Further References and Resources

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