Genito-urinary conditions

The UK has high rates of sexual ill health, and many of the genito-urinary conditions seen in primary care - although not all - may be sexually transmitted. Recognition of the characteristics of STIs is therefore essential

Gonorrhoea

The infection develops from direct contact between mucous membranes and is caused by infection with Neisseria Gonorrhoeae. Incubation is usually 2-5 days. The condition is more common in men who have sex with men. In male urethral infection, 80% will have urethral discharge and 50% will have dysuria. Endocervical infection may be asymptomatic in 50% but it may cause an altered vaginal discharge. Complications in men include prostatitis and epididymo-orchitis while in women pelvic inflammatory disease may develop. Treatment of uncomplicated infection should be with ceftriaxone and azithromycin. This combination is used as there is increasing multidrug resistant infection.

Herpes simplex

Herpes simplex infection is a painful condition whether it occurs around the mouth or in the genital region. The pain may be so severe that a woman may be unable to pass urine and may go into retention. In this situation it may be necessary to pass a catheter. The cause is commonly HSV-2 although in some cases it is HSV-1 which may be transmitted though oral-genital contact. The incubation period for the primary event is around 3-7 days and may be

associated with generalised symptoms such as muscle aches, headache and fever. The vesicular eruption may occur on the labia and extend into the vaginal introitus and there may be a cervicitis too. In men the vesicles may affect any part of the penis and extend onto the scrotum. Treatment is symptomatic and with an anti-viral medication such as aciclovir.

Vaginal candidiasis

Fungus enjoys growing in dark moist environments and so the vagina is an ideal place for the infection to develop. The commonest symptoms are an increased vaginal discharge which will be described as white or pale yellow. Irritation and itch may be present and discomfort may occur during sexual intercourse. The vulva may appear red and swollen and parting the labia may reveal a discharge. Passing a speculum will show a white vaginal discharge with possible 'plaques' adherent to the vaginal walls. Predisposing factors include antibiotic therapy, diabetes. Treatment includes the use of local intravaginal antifungal medication such as clotrimazole, econazole or oral treatment with fluconazole.

Pelvic Inflammatory Disease

Pelvic inflammatory disease (PID) is thought to result in subfertility in 20% cases. Most cases are as a result of infection with either chlamydia or gonorrhoea. The former may cause silent infection while gonorrhoea may cause acute symptoms. Bilateral lower abdominal pain accompanied by discharge should make the clinician suspicious. Extension of the pain to the right side of the upper abdomen may suggest the development of Fitz-Hugh-Curtis syndrome where fine adhesions attached to the liver have developed (as in this picture). Treatment in the community is with ofloxacin 400mg bd and metronidazole 400mg bd for 14 days.

Genital warts

Genital warts develop as a result of infection with human papillomavirus (HPV). The majority are caused by HPV 6 and 11. Types 16 and 18 are associated with the development of neoplasia. Between 20-30% sufferers may have another sexually transmitted infection at diagnosis. The lesions may not be visible until several months after the infection has been acquired. They may develop on the thighs, vulva, vagina, cervix, penis, perianal area and inside the anus. The lesions commonly do not cause symptoms but they may be associated with itching. The warts themselves may be flat lesions but can grow to be exophytic. Various treatments are available, including podophyllotoxin cream 0.5%, imiquimod, cryotherapy, electrotherapy.