Sexual health check up

NZ has high rate of STI
- high compared to other developed nations
Chlamydia most commonly reported STI
- incidence 2011: 786 new cases / 100 000 people
- 70% occur in people 15-24yo
- Females > Males 2.8:1
Gonorrhoea second
- 67 new cases / 100 000 people
genital warts, herpes, non-specific urethritis, syphillis
C & G higher in maori and pacific ≤25yo
Syphilis more common MSM (83% of cases)

routine preventative health care check-up in all sexually active people
- especially \<25yo
sexual contacts of someone with bacterial STI, PID or epidiymo-orchitis
people who have had recent partner change or multiple partners
females attending for routine smears
prior to IUD insertion
routine antenatal testing
before TOP
Specific anogenital symptoms
sexual assault victims
request sexual health checkup

“we routinely discuss sexual health with all our patients, is it ok if I ask you osme questions?”
“Chlamydia is very common in sexually active young people, so can I ask you some questions to see if you need a check-up?”

Any specific problems / symptoms
- females;
  - unusual vaginal discharge
  - lower abdominal pain
  - abnormal bleeding
  - urinary symptoms
  - dyspareunia
  - [lumps or bumps]
- males:
  - dysuria
  - penile discharge
- both:
  - genital itch
  - rashes
  - sore/blisters
  - anorectal symptoms
Sexually active at present
- ?in relationship
When was lasat time had sex
- was with regular partner/casual
sexual contact male/female?
sexual encounters:
- vaginal
- oral
- anal sex
how many sexual contacts/partners have you had in the previous 2 months?
Do you use condoms/protection:
- always,
- sometimes
- never
Females
- LMP
- smear
- hormonal contraceptive
Any previous STI
Have you had all routine vaccinations - HepB, HPV
ever had sex under influence of etoh/drugs
- injected drugs
traded sex for $ or drugs
unwanted sexual contact
every been afraid in relationship, or hurt by partner?
non-professional tattoo, genital piercing, medical/dental treatment overseas or in developming nation

misuse of eoth / other recreational drugs
early onset of sexual activity
inconsistent condom use
multiple/frequent change of sexual contacts
- >10 last 6 months
history of sexual assault or intimate partner abuse
commercial sex worker
- having unprotected sex with a commercial sex worker
risk of HIV
- MSM
- country with high prevalence
- injecting drug users
- sexual partners of above
risk of blood-borne infections - hep C
- injecting drug users
- HIV positive MSM
- people who have received medical/dental rx in developing nation
- non-professional tattoo or piercing

consistently and correctly using condoms
- water based lubricant
- thicker condoms don’t offer any more protection
use of Emergency contraceptive pill
not sharing sex toys
etoh/drug use
- may predispose them to higher-risk sexual behaviours
promotion of abstinence no benefit in preventing unintended pregnancy and STI

STI testing annually where appropriate
- may need to be more frequent
specific sexual event concerned about
- deferred until 2 weeks after event then test
atypical anogenital ulceration -> sexual health physician
Nucleic acid amplification tests (NAAT)
- chlamydia nad gonorrhoea on since PCR swab or urine spec
examination = ideal
- self testing safe and effective method for opportunistic testing in asymptomatic patients or those who decline exam
arrange how and when notified of test results
for low-risk:
- tell only if abnormal results
- higher risk
  - re-attend to discuss results

physical exam
- look at vulval and perianal skin
- inguinal nodes
- vestibule
- introitus
- cervix and vagina
- looking for:
  - skin lesions
  - rashes
  - ulceration
  - abnormal vaginal discharge
- if speculum:
  - endocervical swabs
    - chlamydia and gonorrhoea testing
      - one swab in NAAT
  - someone with gonorrhoea sustpected
    - culture and antibiotic on additional swab
  - high vaginal for:
    - bacterial vaginosis,
    - candida,
    - trichomoniasis
  instructions for high vaginal:
  
  remove from container
  
  insert approx 4cm into vagina
  
  rotate then replace in swab container
Serology for Hep B, syphilis and HIV
- Hep C serology
- Viral swab for herpes simplex virus if ulcers are present
- first void urine (first 30ML of stream) not firstline
  - lwoer sensitivity than vaginal swab

AKA contact tracing
helps prevent reinfection in index case
identification of undiagnosed STI
discussed at time of treatment of STI
- chlamydia
- gonorrhoea
- trichomoniasis
- non-gonococcal urethritis
- PID
- epididymo-orchitis
not needed for genital warts/genital herpes
syphilis / HIV more complicated
- referred to / discussion sexual health physician
most common
- index case to notify themselves
- all within last 2/12
- discuss with patient how they are goign to do
- provdie with information they will need

all sexual contacts within previous 60d
- require testing and treatment for possible (chlaymdia) infection
if no sexual contacts within 60d then most recent sexual contact should be notified up to max 6 months
all sexual contacts should be treated; even if offer of a test is declined
patients offered choice:
- patient referral
- providor referral