Contents
Page No
1.
General points & who to refer to the Sexual Health Clinic
(SHC) previously known as GUM.
2
2.
Taking a sexual history
3
3.
Which tests to take?
3
4.
4





Causes of Vaginal Discharge
Management of Specific Causes of Vaginal Discharge
Bacterial vaginosis
Trichomonas Vaginalis
Candida albicans
Chlamydia trachomatis
Neisseria gonorrhoea
12




Causes of Male Urethral Discharge & Dysuria
Management of specific causes of Male Urethral Discharge & Dysuria
Non- gonococcal urethritis
Chlamydia trachomatis
Neisseria gonorrhoea
Herpes Simplex Virus
13


Causes of Genital Ulceration
Management of specific causes of genital ulceration
Herpes Simplex
Syphilis
7.
Balanitis
16
8.
Vulval skin problems
16
9.
Causes of Genital Lumps
Management of Genital Warts
18
5.
6.
Further information:
 See www.doctors.net.uk for excellent online courses on sexual health and sexual
history taking.
 See www.bashh.org for guidelines on the management of all STIs.
Qualifying Statement
The authors have taken all possible care to ensure that these guidelines are accurate and
that the correct dosages and routes of medication have been given. However, it remains
the responsibility of the prescribing clinician to ensure the accuracy and appropriateness
of the advice given. As with all guidelines, they do change with time but it is planned to
regularly update them.
1.
General Points & Who to refer to GUM










Please refer any patients who wish an asymptomatic screen to a sexual health
clinic.
The waiting time for an appointment at any of the clinics in Tayside is around one
week at present.
Patients can also attend a walk-in clinic. These run every afternoon in the SHC at
Ninewells and on a Monday and Thursday morning at the SHC at Perth Royal
Infirmary. Please return to the home page of this website for further information
about this service.
Symptomatic patients can be referred via the GP direct- access phone line on
01382 425533, or the patient can refer themselves on 01382 425542. These
numbers are for the SHC at Ninewells Hospital which is open Monday to Friday.
If the patient wants to be seen in Perth or Arbroath please see the relevant pages
on this website for contact information. Please send a brief letter with the patient
if you want information for your records.
We do not see patients with genital warts urgently, and only need to see these
patients if they wish to have a full STI screen. We know that 20% of patients
presenting with warts will have another STI.
First line treatment for genital warts is Podophyllotoxin (Warticon) cream for
women or perianal warts in either sex and Podophyllotoxin (Warticon) paint for
men with penile warts. These treatments should not be used in pregnancy. Patients
should be advised that the treatment can take up to 12 weeks to work. Smokers
should be advised that they may take longer to clear their warts than nonsmokers.
HIV testing is routinely offered to all patients attending a SHC. Only those
patients who are felt to be at ‘high risk’ of infection are offered accelerated HIV
testing. ‘Low risk’ patients will be asked to phone for their results 2 weeks after
their appointment.
Patients who have been screened in the community and are found to have an STI
should be referred to GUM for partner notification. We are in the process of
setting up a service to provide partner notification to patients diagnosed with an
STI out with the sexual health services. Once our plans are finalised we will send
you more information on this development.
A Young Persons Clinic runs in the SHC at Ninewells on a Thursday afternoon
from 1.30pm. This clinic is aimed at 12-18 year olds, and offers screening for
STIs, together with contraception while assessing any child protection issues.
Appointments can be made on 01382 632600. However, the clinic also runs as a
walk-in and patients who arrive between 1.30 and 4.00 will be seen that day.
Genital Skin Problems
Women with genital skin problems can be referred to the Joint Vulval Skin Clinic
which is based in The Sexual Health Clinic at Ninewells. Referral should be made
by letter in the normal way. There is a significant waiting list for this clinic at
present. We are however able to triage urgent patients so if this is the case please
indicate this on the referral letter.
Male patients with genital skin problems are seen in the routine SHC, for which
there is no waiting list.
2
2.
Taking a sexual history in Primary Care
A sexual history in Primary Care does not have to be as detailed as one taken in a SHC
setting. As with any history it is good practice to observe the following:





3.
Ensure privacy at all times
Explain why you are asking such detailed questions
Remind the client that these are questions we ask everyone who may have a
problem which may be related to sex
Only ask relevant questions
It is good practice to enquire about the number of sexual partners in the previous 6
months as this will help with partner notification, should the patient be diagnosed
with an STI.
Which tests to take in Primary Care?
The following is a guide to tests which can be taken in Primary Care as part of a sexual
health screen.
Asymptomatic Female
 Endocervical swab for N. gonorrhoea (black charcoal)
 Endocervical swab or a vulvo-vaginal swab for Chlamydia trachomatis
 +/- Syphilis serology and HIV antibody screening
Symptomatic Female
As for Asymptomatic female but include:
 High Vaginal swab (charcoal) this is to look for pathogens which can cause a
vaginal discharge eg. Candida sp., Bacterial vaginosis, Trichomonas vaginalis and
Streptococci
 pH – the normal vaginal pH is 3.5-4.5. It can be useful to put a sample of the
discharge on a piece of pH paper at the time of swab taking. Bacterial vaginosis
and vaginal Trichomonas are associated with a high pH >5. However seminal
fluid and blood will also increase the vaginal pH.
A quicker diagnosis may be reached by doing microscopy and if this is required it would
be appropriate to refer the patient to a SHC.
Asymptomatic Heterosexual Male (preferably patient has not PU’d for >1 hour)



Urethral swab for N. gonorrhoea (charcoal)
First Void urine for Chlamydia trachomatis
+/- Syphilis serology and HIV antibody testing
Symptomatic Heterosexual Male
As for asymptomatic male. However, a quicker diagnosis may be reached by doing
microscopy and if this is required it would be appropriate to refer this patient to a SHC. It
is not possible to diagnose Non-gonococcal urethritis (NGU) outside the SHC setting.
3
Men who have sex with men (MSM)
The same tests should be taken as outlined for a Heterosexual male but the following tests
should be added:
 Throat swab (charcoal) for N. gonorrhoea
 Rectal swab for Chlamydia trachomatis
 Rectal swab for N. gonorrhoea (charcoal)
 Check Hepatitis B core antibody to look for evidence of previous infection. If
non-immune, vaccinate.
 Check Hepatitis A IgG and if no evidence of previous immunity or history of
prior vaccination, offer to vaccinate.
4.
Causes of vaginal discharge
Vaginal discharge is a common presenting symptom in Primary Care. A sexual history
should be taken and a sexual health screen offered if the history dictates. Those at highest
risk of having a sexually transmitted infection are all sexually active women aged under
25 and women over 25 who have had a recent change of sexual partner or who have had
more than one sexual partner in the last year. –see SIGN guidelines for further
information.
The most common cause of vaginal discharge is Bacterial vaginosis.
The list below outlines causes of Vaginal discharge and these should be considered when
a patient attends complaining of a vaginal discharge.
 Bacterial vaginosis
 Candidiasis
 Trichomonas vaginalis
 Neisseria gonorrhoea
 Chlamydia trachomatis
 HSV
 Foreign body e.g. retained tampon
 Physiological
 Cervical cancer
 Fistula
Bacterial Vaginosis
Most common cause of vaginal discharge.
Caused by overgrowth of Gardnerella vaginalis, Mobilluncus and other anaerobic
organisms. It is not an STI
Signs
Malodourous vaginal discharge, often worse after sexual intercourse
Doesn’t usually cause itching or discomfort
Investigations
4
HVS
pH - >4.5
Treatment
Metronidazole 400mg BD for 1 week or 2G stat (the stat dose should not be used in
pregnancy)
Clindamycin 300mg BD for 7 days
Points to tell the patient
 Not an STI

Partners do not need treatment

Recurrences can be brought on by menstruation and sexual intercourse due to the
fact that sperm and blood increase the vaginal pH (condoms can help reduce
recurrences), and overwashing.

Associated with the IUCD, smoking, Black ethnicity
To prevent recurrences:
 Consider removal of the IUCD
 Consider using a method of contraception which decreases the frequency of
menstruation e.g. Depo provera
 Use of condoms prevent sperm causing alkaline pH in vagina and therefore
reduces recurrences
Consider referral to a SHC for management of patients with recurrent BV.
Trichomonas vaginalis
Very uncommon diagnosis
Signs/symptoms
Malodourous, itchy vaginal discharge
Superficial dyspareunia
Vaginitis
Abdominal pain
Investigations
HVS (black charcoal swab)
pH – >4.5
Treatment
5
Metronidazole 400mg BD or 2G stat (do not use the stat dose in pregnancy)
Important points
 Must have Test of Cure (TOC) 1-2 weeks following treatment

Metronidazole resistance not uncommon, but consider reinfection also. – refer to
SHC.

Partner notification required. Male partners need treatment.

If a Cervical smear is reported as showing Trichomonas like organisms, this is not
sufficient to make a diagnosis of TV. A black charcoal HVS should be sent for
confirmation before making this diagnosis.
Candida (Thrush)
Most cases are caused by Candida albicans but need to consider other Candida sp. if
patient appears to be resistant to treatment.
Signs/symptoms
Itchy, white vaginal discharge
Superficial dyspareunia
Vulval oedema
Vulval erythema
Investigations
HVS – Black charcoal swab
pH – usually normal (3 -4)
Urinalysis – exclude diabetes
Treatment
Clotrimazole pessary 500mg stat PV
Clotrimazole 10% VC PV
Fluconazole 150mg stat (do not use in pregnancy)
Important points
 Partners do not usually need treatment
 No benefit of yeast free diets
 Use of a soap substitute and exclusion of perfumed washing products is important.
Please see the vulval skin section.
6

Recurrent candidiasis – refer to SHC after giving the patient information about
the exclusion of all perfumed washing products, fabric softners and baby wipes.
See vulval skin section for patient information leaflet on this.
Chlamydia Trachomatis
Who to test for Chlamydia?
Tayside has the highest rates of Chlamydia infection in those under 25 in Scotland, with
22% of young men and 14% of young women being infected. (2005 figures)
In Scotland as a whole, though the highest rates of infection are in the under 25
population, over half the tests for Chlamydia are performed in those over 25. Despite
young men having the highest rates of infection, the majority of tests are performed in
women. The majority of male testing occurs in SHC when men attend because they have
symptoms or are asked to attend as contacts of Chlamydia.
Targeting of Chlamydia screening to the most appropriate population groups is required .
Those who should be targeted for screening include:
 All sexually active men and women under the age of 25
 Individuals with a new sexual partner
 Individuals who have had more than one sexual partner in the last year.
Individuals who require testing for Chlamydia include:
 Those with symptoms –see below
 Infants with conjunctivitis and pneumonitis, and if found to be positive for
Chlamydia their parents.
 Sexual contacts of a Chlamydia positive individual.
Once infected with Chlamydia the infection can persist or resolve spontaneously.
Two thirds of the sexual partners of Chlamydia positive individuals are also Chlamydia
positive.
Symptoms and Signs
Women:
o 70% Asymptomatic
o Post coital or intermenstrual bleeding (always think about the possibility of
Chlamydia)
o Vaginal discharge
o New lower abdominal pain
o Deep dyspareunia
o Dysuria (sterile pyuria can be caused by Chlamydia)
o Cervicitis and contact bleeding
Men:
o 50% Asymptomatic
7
o Urethral discharge
o Dysuria
Note: Pharyngeal Chlamydia is usually asymptomatic.
Rectal Chlamydia may be asymptomatic but may cause rectal discharge and
discomfort.
Over the last few years there has been an increase in the number of cases of
Lymphogranuloma venereum (LGV) which is caused by a different serovar of Chlamydia
trachomatis.
This infection is found mainly amongst men who have sex with men (MSM), many of
whom are HIV positive.
It presents as a severe proctitis or genital ulceration with prominent inguinal
lymphadenopathy.
For this reason if a rectal sample is found to be positive for Chlamydia, the sample should
be sent to the LGV Reference Laboratory in Edinburgh, by the Microbiology Department
in Ninewells. Therefore, if your patient has significant rectal symptoms please alert the
laboratory to this by noting this on the microbiology form.
Complications of Chlamydia
 Some women who have Chlamydia will develop Pelvic Inflammatory Disease
(PID)
o Many will have no or only mild symptoms.
o The risk of developing PID increases with each recurrence of Chlamydia.
 Epididimo-orchitis
 Adult conjunctivitis
 Neonatal conjunctivitis and pneumonitis
 Sexually acquired reactive arthritis
Investigations
A nucleic acid amplification test (NAAT) is used in Tayside to test for Chlamydia.
Women:
 An endocervical swab is the preferred method for testing in women.
The test requires endocervical columnar cells so the swab should be inserted into the
cervical os and rotated firmly against the walls of the endocervix.
 A vulvo-vaginal swab can be performed by the clinician without a speculum or be
self-taken by the patient.
 A first voided urine sample.
Men:
 A first voided urine sample.
Recent research would suggest that urine does not require to be held for a fixed length
of time prior to providing a urine sample.
 A urethral swab if the patient is unable to pass urine.
What to do with a positive result?
The microbiology lab will contact you if your patient has a positive Chlamydia result.
8
There are two options:
1. You treat your patient and ask them not to have any sexual contact until their
partner has also been treated. They should wait 7 days after taking Azithromycin.
Please then refer to for partner notification and screening for other STIs.
A health advisor from SHC will contact the patient by phone (mobile number preferred)
to ensure that the patient has been treated for chlamydia and has not been reinfected.
Screening for other sexually transmitted infections in the SHC will be offered. Many
patients particularly if they are asymptomatic decline further testing and therefore do not
attend the SHC. Partner notification can be arranged over the phone. Patients must be
made aware that a health advisor will contact them, but that they do not necessarily need
to attend the clinic.
2. If you feel that your patient needs to be seen in the SHC, for whatever reason
(often if there is concern as to whether they will abstain from sexual intercourse
until after their partner is treated) then do not treat. We will see them in GUM
within 48 hours of your referral.
We will ask them to attend with their partner so that they can be treated together.
Patients can be referred direct to a health advisor at Ninewells 5 days per week on
01382 632600
Treatment
Indications for therapy:
 A positive Chlamydia PCR test
 On epidemiological grounds if a recent sexual partner has confirmed Chlamydia
infection. (But such an individual also requires to be tested for Chlamydia to
allow ongoing contact tracing.)
Uncomplicated infection of the Pharynx, Genitalia and Rectum.
 Azithromycin 1g single dose orally (preferably on a empty stomach)
OR
 Doxycycline 100mg twice daily orally for 7 days
OR

Ofloxacin 400mg once daily for 7 days.
Pregnant patients.
 Azithromycin 1G stat
OR
 Erythromycin 500 mg twice daily orally for 14 days
OR

Erythromycin 500mg qds. for 7 days
9

Azithromycin is not licensed for use in pregnancy; however there is no
indication that any adverse events have been caused by the drug when it
has been used in this situation.
 The WHO advocates the use of Azithromycin in pregnancy.
 Up to 25% of patients (non pregnant) who take Erythromycin fail to
complete the course due to side effects.
 Untreated chlamydial infection in pregnancy can result in preterm birth,
IUGR, neonatal conjunctivitis and pneumonitis.
For the above reasons a pregnant patient who has been diagnosed with Chlamydia should
be offered treatment with all of the above regimens.
She needs to be told that Azithromycin is an unlicensed treatment for Chlamydia in
pregnancy.
Ultimately it is the patient’s decision as to which drug regime she wishes to take.
Whichever treatment course is chosen, a test of cure (TOC) should be performed three
weeks or more after completing treatment.
All Chlamydia Positive Patients:


Should be advised to abstain from all sexual intercourse (oral, genital and
anal sex and even sex with a condom) for seven days after being treated
with Azithromycin, or until they have completed their treatment course
with another antibiotic.
All patients who are found to have Chlamydia should be offered a screen
for other sexually transmitted diseases and should be encouraged to have
an HIV test.
Complicated infection
Males
 Epididymo-orchitis
Treatment:
Ofloxacin 400mg twice daily orally for 14 days
Females
 Pelvic Inflammatory Disease
Treatment:
Ofloxacin 400 mg twice daily orally for 14 days AND Metronidazole 400 mg twice
daily orally for 10-14 days
OR
Doxycycline 100mg twice daily orally for 14 days AND Metronidazole 400mg
twice daily orally for 10-14 days
Chlamydial conjunctivitis
Adults
Treatment:
 As for uncomplicated chlamydia infection
10

Ofloxacin eye drops can be considered
Neonates
 Erythromycin syrup orally
Neonatal infection results in infection of the conjunctivae and nasopharynx and
therefore systemic treatment is required.
Follow up:
Contact tracing
 In asymptomatic patients the look back period is 6 months or the last sexual
partner if this time period is longer. If a man presents with symptoms of urethritis,
partner notification should include all sexual partners from the previous 4 weeks.
 Patients should be advised to have no sexual contact (oral, genital or anal) even
with a condom until both they and their partner(s) have completed treatment.
 The patient must wait 7 days after treatment with Azithromycin or until they have
completed a 7 day course of treatment with another antibiotic.
 Epidemiological treatment of partners.
 All patients should be followed up to check compliance with antibiotic therapy
and to make sure that there is no risk of re-infection from an untreated partner.
 It may be appropriate to do this by phone in the majority of patients, as they
would not otherwise be required to come back to the clinic.
 Routine test of cure (TOC) is not necessary in all patients.
 The following patients should have a test of cure (urine or endocervical swab) no
sooner that 3 weeks after completion of antibiotic therapy:
o Patients who remain symptomatic
o Pregnant women
o Patients who may be re-infected or who have not complied with antibiotic
therapy (should be re-treated as well as re-tested)
o Patients who request a TOC
o Patients not treated with optimal antibiotic therapy, such as Erythromycin
Neisseria Gonorrhoea
Who to screen:
 Men with a urethral discharge
 Women with a vaginal discharge, Bartholin’s abscess
 Heterosexual men, MSM and females who are asymptomatic but request a full
STI screen
 Male and female contacts of Gonorrhoea.
Which test:
 Heterosexual man
o Urethral swab.
 MSM
o Urethral, rectal and throat swab.
 Women
11
o Urethral and endocervical swab.
A standard black charcoal bacteriology swab should be used. The swab needs to get to
the laboratory to be plated out onto special medium and then placed in a CO2 incubator
within six hours of being taken.
If this is not possible (eg. Friday afternoon), the discharge from the urethra or endocervix
can be placed on a slide and air dried, before being placed in a slide carrier for transport
to the lab. Please write the patients details onto the slide. The slide can then be Gram
stained in the lab and viewed. A culture swab should also be sent, and if negative can be
repeated at a later date depending on the microscopy result.
Treatment:
Cefixime 400mgs stat
Partner Notification:
A full sexual history must be taken to allow appropriate contact tracing. Patients will
often not attend the sexual health clinic (SHC) if they have already been treated and
therefore it is often easier for us if you do not treat the patient but ask them to attend the
SHC. If you contact a health advisor with your patients details she will contact them
(provided the patient is aware that this will happen) which allows us to undertake partner
notification and to arrange treatment that day or the following day (depending on the time
patient is referred). Please phone 01382 632600. (direct line)
Approximately 50% of sexual partners will also be infected and therefore we will usually
treat partners epidemiologically depending on the circumstances. All partners need to be
tested for infection even if epidemiologically treated.
Between 25% and 50% of patients who have Gonorrhoea will be co-infected with
Chlamydia. If the Chlamydia result is negative the patient does not require treatment, but
if the result is not available/unknown it is worth adding Azithromycin 1G stat.
All patients who are found to have a sexually transmitted infection, such as Gonorrhoea,
should be tested for HIV and Syphilis.
5.
Male dysuria/discharge
Chlamydia trachomatis
Neisseria gonorrhoea
Non-gonococcal urethritis
HSV
UTI
Chemicals
Urethral stricture
Non-Gonococcal Urethritis (NGU)
This diagnosis is made at microscopy and therefore can only occur in the SHC setting.
Testing for NGU is now only undertaken in SYMPTOMATIC males.
A urethral swab from a male patient is smeared onto a glass slide, fixed using heat and
then Gram stained. At microscopy, if there are >5 polymorphonuclear leucocytes
12
(PMNL) per high power field, a diagnosis of Non-Gonococcal Urethritis (NGU) is made.
This diagnosis only affects men but female partners should be epidemiologically treated.
NGU is the new name for Non-Specific Urethritis (NSU). Urethitis is most commonly
caused by chlamydia and therefore treatment is with standard Chlamydia therapy.
However a number of patients with NGU will be Chlamydia negative and therefore the
urethritis may be caused by another organism such as Mycoplasma or Ureaplasma. At
present there are no routine tests available for genital strains of these organisms in our
laboratory. Therefore, often we will not know exactly what organism caused the
infection.
Treatment
Treat as for Chlamydia trachomatis infection with
 1g Azithromycin stat
OR
 Doxycycline 100mgs bd for 7 days
Partner notification - refer to HA
Avoid SI for 1 week after treatment and until partner has also been treated.
Patients with recurrent NGU should be referred to the SHC.
There we will ensure that the patient’s regular partner has been treated and offer
treatment with
 Azithromycin 500mgs stat followed by Azithromycin 250mgs daily for a further 4
days
AND
 Metronidazole 400mgs bd for 5 days
6.
Genital ulceration
The two main causes of genital ulceration in this country are Herpes Simplex and
Syphilis (mainly in men who have sex with men)
However a fuller list of causes of genital ulceration is given below. Genital herpes will be
discussed in more detail.
A high index of suspicion is needed for Syphilis. All patients who present with a genital
sore should have syphilis serology checked, ESPECIALLY if they are men who have sex
with men. If there is a possibility that a patient has syphilis they should be referred
urgently to the SHC for further investigation and management. Please do not treat with
antibiotics prior to referral.
The management of syphilis is therefore not discussed here in any further detail.
Causes of genital ulceration
Herpes Simplex Virus (Types 1 & II)
Syphilis
Bechets disease
Lympogranuloma Venereum LGV
Fixed drug eruption
Trauma
Dermatoses
Malignancy
13
Chancroid
Donovanosis
Herpes Zoster (Unilateral ulceration)
Genital Herpes Simplex Virus Infection
Genital Herpes infection is caused by Type 1 (>50% cases) and Type 2 Herpes simplex
Virus (HSV). Clinically there is no way of telling which virus has caused the genital
lesions but there are some important prognostic differences. Therefore anyone seen
complaining of genital pain should be examined and a swab taken for HSV PCR. (green
tube). This is worth doing even if you want your patient to be seen in GUM, as we will be
able to access the result of your investigation, and once the patient is commenced on
Aciclovir the test we take may be negative.
Though many patients acquire HSV infection from a long term regular partner they
should all be offered a screen for the other sexually transmitted infections. All patients
with genital ulceration should as a minimum have syphilis serology performed, because
of the increasing incidence of syphilis in the UK at present.
The majority of individuals with HSV infection are asymptomatic- they do not suffer
from oral or genital ulceration but they can intermittently shed herpes simplex virus from
these sites, and infect their sexual partners. This is called asymptomatic shedding and
occurs twice as frequently in HSV 2 than HSV 1 and occurs for longer periods in women
than in men. Men are more likely to have asymptomatic carriage of HSV 2 which
explains why women are more likely to acquire HSV 2 over time. It is uncommon for this
to happen during casual sexual encounters therefore and is seen more frequently in longer
term relationships. It is quite reasonable to reassure a patient who is in a long term
relationship that developing an acute attack of primary herpes does not necessarily mean
that their sexual partner has been unfaithful.
Management of recurrent episodes of HSV
Patients with recurrent episodes of infection should be reassured that they do not need to
take antiviral treatment with each episode of ulceration. Often patients become
unnecessarily stressed about the need to get to their GP or to the hospital to get Aciclovir,
because they believe that the infection will not get better without taking treatment.
Treatment is only effective if started during the prodrome or within 24 hours of lesions
developing, and in this situation can shorten the duration of symptoms and viral shedding
by a median of 1-2 days. However for many patients the length of each episode of
ulceration is not altered by taking anti-virals, and the benefits of taking treatment are
outweighed by the stigma of taking tablets. In a minority of cases, treatment started in the
prodrome may avert the episode of ulceration. The application of Betadine Paint has
been shown to be beneficial in the management of recurrent genital herpes. However it is
important to be sure from the history and virology results that the patient is really
suffering from HSV. It is common to see patients who believe they are getting recurrent
attacks of herpes when in fact this is not the cause of their symptoms at all. Many patients
who are seen in the SHC presenting for the management of their recurrent ‘HSV’ have
never had a herpes culture/PCR to confirm their diagnosis and often do not have HSV at
all but a genital dermatosis.
Patients with recurrent symptoms of self described genital ulceration, but nothing to see
on examination should be given a herpes swab kit (same bottle as Chlamydia) and asked
14
to take a self taken sample for herpes PCR as soon as ulcers appear. They then need to
hand their sample in to your practice as soon as possible after being taken, to be sent to
the lab. If this self taken swab is negative it makes the diagnosis of recurrent genital
HSV very unlikely.
Women with recurrent genital symptoms and a negative HSV virology swab can be
referred to the Joint Vulval Skin Clinic. This is based in the SHC at Ninewells and runs
twice per month.
Type 1 Genital herpes will only cause recurrences in around 50% patients. It is unusual to
see such patients in the SHC with troublesome recurrences.
90% of patients with Type 2 HSV will go on to have further recurrences. It is difficult to
generalise in HSV infection but patients will often have frequent (monthly) recurrences
within the first 6-12 months following infection. However if they are asked to keep a
diary they will often notice that the gap between symptoms starts to lengthen from 6
months onwards, as the patients own immune system starts to control the infection.
Modern management of recurrent HSV infection would suggest that it is better to defer
Aciclovir suppressive therapy until at least a year after diagnosis to allow the individual’s
own immune system to control the infection. Most patients are happy to do this when the
reasons for this are explained.
Herpes and Pregnancy
All pregnant women who are known to have had HSV in the past should be advised to
tell their midwife at booking.
However most women in this group will be able to have a normal delivery without risk to
the neonate. If they were to have an outbreak of HSV at the time of delivery some
Obstetricians would offer them a Caesarian Section. In this case it is important that they
are not examined vaginally and the membranes should obviously not be ruptured.
If a women has her first attack of HSV during pregnancy she should be offered treatment
with Aciclovir. There is no evidence that Aciclovir is harmful to the fetus. Depending on
the stage of the pregnancy she may be offered an elective Caesarian Section as the mode
of delivery.
Type specific antibody testing.
If a male partner suffers from recurrent HSV infection and his female partner is planning
a pregnancy or is in fact pregnant it may be worth considering type specific antibody
testing for the pregnant woman. This will give an indication as to whether the female
partner already has antibody protection to HSV and is therefore at no ongoing risk, or
infact has no antibody protection. In this situation the male partner may wish to consider
HSV prophylaxis to reduce shedding of virus plus the use of condoms and avoidance of
unprotected close genital contact once a pregnancy is achieved.
Type specific antibody testing can also be used to test patients who believe that they are
having severe recurrent attacks of HSV.
>60% of individuals will have evidence of antibody to type 1 HSV but only around 20%
of the UK population will have antibody to Type 2 HSV. If there is no evidence of
antibody to type 2 HSV in a patient who complains of severe recurrent genital problems,
herpes is probably not the cause of the symptoms.
15
This service is not offered routinely by the Microbiology department at Ninewells.
However, samples can be sent to London for testing if it will benefit patient management.
See patient information on website.
7.
Balanitis
This is inflammation of the glans penis. There are a number of different causes for this
and these are listed below. Often the cause is not related to an STI.
Causes of balanitis
Candida albicans
Streptococcal and Staphlococcal Infection
Anaerobes
Allergans/irritants
Circinate balanitis
Syphilis
Herpes simplex virus
Plasma cell (Zoon’s) balanitis
Dermatoses e.g. Lichen sclerosis
Penile intraepithelial neoplasia
Trichomonas vaginalis
Management:
Investigations:
 Sub-preputial swab for bacterial culture and yeasts (Aimes)
 Microscopy for yeasts
 Urinalysis
 Sexual health screen to exclude syphilis, TV, HSV.
 Urinalysis to exclude glycosuria
 Biopsy may be required if an underlying dermatosis is suspected and symptoms
do not settle with treatment.
Treatment:
Often simple measures such as salt-water bathing with the foreskin retracted twice a day
is all that is required. For the longer term patients should be advised to avoid scented
soaps and shower gels and to use soap substitutes instead. See genital skin washing
advice.
If the sub-preputial swab is positive for anaerobes, a course of metronidazole can be
given, if the patient is still symptomatic after following the above measures.
If the sub-preputial swab grows candida, this can be treated with 1% clotrimazole cream
applied twice a day for 7 days, again if the patient is still symptomatic. Often subpreputial swabs will grow organisms which are commensals and if the patient becomes
asymptomatic on the simple treatment measures above then no treatment is needed.
If the balanitis doesn’t respond to simple measures or the lesions look suspicious, please
refer to the SHC at Ninewells. A skin biopsy may be required.
8.
Genital Skin Problems
Genital skin problems are common and are often caused by washing with products which
irritate the skin.
16
If your patient is complaining of genital itch, discomfort, cracking or tearing and there is
no evidence of an underlying dermatosis on examination, it is worth giving them the
following skin care information leaflet (see below). However also exclude glycosuria.
If they fail to improve, after following all of the instructions on this leaflet for several
months, then they should be offered specialist referral.
Women should be referred to the combined vulval skin clinic at the Sexual Health Clinic
(SHC) at Ninewells Hospital.
Men can be referred to the SHC at Ninewells. Please mark the referral for Dr. Paterson.
If you think that your patient does have a dermatosis please refer immediately to the
appropriate clinic as mentioned above.
GENITAL SKIN WASHING ADVICE (For patients)
You have been diagnosed as having genital skin problems which are related to the use of
perfumed washing products.
This is an extremely common problem.
The products that you use at present dry the skin out and cause cracks to develop which
will cause itch and discomfort. Some creams will improve these symptoms in the short
term but the skin will not get better until perfumed washing products are avoided.
To ensure that your skin settles down we advise you to change the way you wash as
outlined below.
1. Stop using the products that you presently use to wash your skin. Even
simple soaps and products designed for babies, can irritate the skin, but
using plain water can dry the skin out too much. It is therefore important
to use a soap substitute.
2. Use a soap substitute to wash ALL of your body in the bath or shower. If
you use a soap substitute to wash the genital skin but your normal soap on
other parts of the body you will still get some of this soap product onto the
genital skin and your skin problems will not improve completely.
3. You can buy soap substitutes from the sensitive skin counter at Boots.
Look for:
o Aveeno,
o Oilatum,
o Boots Own Brand.
These brands produce products that can be used instead of soaps and shower
gels.
Alternatively the dispensary of the chemist will sell you: (these products can
also be prescribed by your GP)
o Diprobase Cream in a 500mls canister
o Dermol 500
(Both products can be used to wash your body like a shower gel.)
o Balneum Plus bath Oil is a suitable product for the bath, and is a good to
use if the skin is very itchy as it will settle symptoms down quickly. It can
make the bath very slippery so warn those who also use the bath.
17
Washing-up liquid is the best way to clean the bath after using Balneum
Plus Bath Oil.
4. Never wash your hair in the bath.
5. Never put bubble baths, other perfumed products or essential oils into the
bath water.
6. When washing hair in the shower do not stand under the shower, but put
your head under the stream of water and keep your lower body out.
7. Do not use fabric softeners, even those marked as ‘sensitive’ when
washing your clothes. Do not use 2 in 1 products such as Bold as these
contain a fabric softener. The fabric softener stays on towels and
underwear and will irritate the skin, and prevent it from settling.
8. Do not use baby wipes to clean the genital skin after going to the toilet.
The alcohol in these products (even those marketed for sensitive skin) can
harm the genital skin. It is better to use the Diprobase cream, or Dermol
500 (mentioned above) on some cotton wool for this purpose.
9. Coloured toilet tissue contains chemicals which can irritate the skin so
always use white toilet roll.
Do not use any creams on the genital area without discussing with staff in
the clinic.
10. For women: Avoid feminine hygiene products. Avoid panty liners which
are perfumed, look for low irritant sanitary and incontinence pads eg.
Natracare.
If you follow these guidelines closely for 3 to 4 months your symptoms should settle. If
you continue to have problems with the genital skin, ensure that you have excluded all
perfumed washing products and have not reintroduced any products as time has gone on.
If you continue to have problems after 3 months, and you think that you are doing
everything right, please phone the Sexual health Clinic for an appointment on 01382
425542.
9.
Causes of Genital Lumps
Genital warts
Molluscum contagiosum
Pearly Penile Papules
Sebaceous cysts
Folliculitis
Bartholin’s cysts
GENITAL WARTS

Genital warts are caused by the Human Papilloma Virus (HPV) and are very
common (80% of the adult population have evidence at some time of HPV
infection on molecular and serological studies) but visible warts only represent
1% of infected cases. Most infections are subclinical and transient. This explains
why it is very common for only one partner in a relationship to have genital warts.
Patients in this situation often worry, unnecessarily, about fidelity.
18


Warts are transmitted from one person to another during sex or close genital
contact.
Genital warts are caused by HPV 6,11,16 and 18.
CLINICAL ISSUES
 Most visible genital warts are caused by HPV types 6 and 11.
 Types 16 and 18 cause SIL - squamous intraepithelial lesions and all patients with
warts should be advised to give up smoking in order to reduce the risk of any
potential long term health issues.
 Women with genital warts need to participate in the standard cervical screening
programme.
 Patients with warts have a 20-30% chance of having another STI, and should be
offered screening to exclude these infections. Patients who do not wish to attend
GUM should as a minimum have a urine test for Chlamydia.
 Treatment options:
Patients should be told that treatment takes time to work and that 90% of
individuals will clear their warts within 12 weeks. Most people with genital warts
clear their warts without any treatment by producing antibodies to the wart virus.
The treatments help patients produce these antibodies.
o Cryotherapy
o Podophyllotoxin (Warticon) This comes as a solution-normally used for
penile warts, and a cream-female warts and perianal warts.
The product is applied bd for 3 consecutive nights followed by 4 days of no
application. This is continued for up to 12 weeks. (3 packs of Warticon paint or
solution)
The treatment can cause localised erythema and discomfort. Only if there is a
severe reaction to treatment should the podophylotoxin be stopped.
o Imiquimod (Aldara) is an immune modifier and it is applied on 3 nonconsecutive nights each week. Eg. Monday/Wednesday/Friday. The cream
is then washed off the next morning. The treatment course can continue
for up to 16 weeks.
Warts in pregnancy
 Neither of the above products should be used in pregnancy. It is very difficult to
get rid of warts in pregnancy and unless the warts are massive and at risk of
obstructing labour, when surgery can be an option, we generally do not treat.
Women should be told that any warts which are present at the end of the
pregnancy will normally resolve completely, and without treatment, in the first 6
weeks post partum. If this does not occur treatment can be arranged at this point.
HPV Vaccine
 A vaccine is now available to prevent genital wart virus infection with types 6,11,
16 and 18. The vaccination of girls will commence in schools in September 2008.
See patient information on website
19