من انا

صورتي
الرياض, Saudi Arabia
مسلم، وأناأحوج ما أكون إلى معرفة نفسي

الجمعة، 3 فبراير، 2012

Acknowledgements

DEPARTMENT O F
HEALT H A N D FA M I L I E S
NT Guidelines for the Management of
Sexually Transmitted Infections in the
Primary Health Care setting
Sexual Health and Blood Borne Virus Unit
Centre for Disease Control
Acknowledgements
The authors are grateful to the many people who have assisted in the production of this guideline, including:
- Steven Skov, Maggie Richardson & Anne Davis, Sexual Health & Blood Bourne Virus Unit NT
- Kerrie Gell & Raelin Huang, Nganampa Health Council
- Kirsty Smith, Tri State STI/HIV Project
- Annie Tangey, Ngaanyatjarra Health Service
Updated May 2008 - Guidelines are for review May 2009
Further copies of the guidelines are available at:
http://www.nt.gov.au/health/cdc/protocols.shtml
General enquiries about this publication should be directed to:
Sexual Health and Blood Borne Virus Unit (SHBBVU)
Department of Health and Community Services
PO Box 40596
Casuarina NT 0811
Phone: (08) 89228874
Facsimile: (08) 89228809
Cover painting: Better Health
Story: People are calling out for help. They have sickness caused by bacteria, and blood borne viruses. Some sickness
causes discharge. When treatment happens and information is shared, people feel better and can tell others.
Artist: Nola Jimarin of Nauiyu Community
3
Contents
Sexual history......................................................................................... 5
Sexual risk assessment.......................................................................... 8
Male examination ................................................................................. 10
Female examination ............................................................................. 11
Important points – lab tests for STIs..................................................... 13
Antibiotic Resistance of
Hepatitis B ............................................................................................ 14
Investigations – males.......................................................................... 15
Investigations – females....................................................................... 17
pH testing of vaginal secretions ........................................................... 19
Neisseria gonorrhoeae................................... 14
Syndromic presentations and management
Management of abnormal vaginal discharge.........................................................20
Flow chart – Vaginal and speculum examination not possible .........................................................23
Flow chart – Vaginal and speculum examination possible ...............................................................24
Management of Pelvic Inflammatory Disease........................................................25
Flow chart – PID............................................................................................................................... 29
Management of male urethral discharge or dysuria...............................................30
Flow chart – male urethral discharge ................................................................................................ 32
Management of epididymo-orchitis ........................................................................33
Flow chart – epididymo-orchitis......................................................................................................... 36
Management of genital ulcers................................................................................37
Flow chart – genital ulcers................................................................................................................. 40
Flow chart – genital herpes ............................................................................................................... 41
Management of genital warts.................................................................................42
Disease Specific Treatment
Gonorrhoea ...........................................................................................................45
Chlamydia..............................................................................................................47
4
Trichomonasis .......................................................................................................48
Donovanosis..........................................................................................................49
Syphilis ..................................................................................................................50
Genital Herpes.......................................................................................................51
Bacterial vaginosis.................................................................................................52
Candidiasis ............................................................................................................53
Standard treatment protocols for sexually transmitted infections ...... 54
SHBBVU Guidelines May 2008
5
Sexual history
At all times, ensure patient privacy, confidentiality and comfort. Be friendly and nonjudgemental
and ask open ended questions. The following checklist will help you cover all
the questions you should ask.
Presenting complaints
Listen to the patient’s reason for attending. Follow-up with questions about their symptoms.
SYMPTOMS - ask about onset, duration and change over time.
Urethral/vaginal/anal discharge - amount, colour, odour?
Abnormal vaginal or rectal bleeding?
Dysuria/urinary frequency?
better or worse?
Lower abdominal pain - genital/anal, pain type, site of pain, what makes the pain
Itch/discomfort in perineum, peri-anal, pubic region?
Genital lumps, sores?
Pain with defecation?
Dyspareunia?
Fever, enlarged lymph nodes?
Rashes - genital and elsewhere?
Sore throat?
Any other symptoms?
Sexual history
Do they have a current regular sexual partner (or partners)?
Is the partner male or female?
How long have they been together?
Type of sexual contact - oral/vaginal/anal?
Do they use condoms - always/sometimes/never?
likely to have had other partners recently, a man who has sex with other men, a sex
worker, an injecting drug user)?
Are they concerned about their current partner’s past or current risk (eg. is the partner
partner?
Have they had sexual intercourse with any casual partners in the past 3 months?
When was the last unprotected (without a condom) sexual intercourse with this
Type of sexual contact – oral/vaginal/anal?
Were condoms used?
Were any of these partners from outside the Top End or Central Australia (see p 14)?
Have they had more than 1 sexual partner in the past 6 months?
Have they ever accepted money/favours for sex?
Were any of these partners injecting drug users or sex workers?
6
Social history
Do they drink alcohol? How much and how often?
Do they smoke?
Any history of tattoos/piercing?
ever shared equipment?
Any history of current or past IV drug use, if so - when did they last inject, have they
Any blood transfusions - if so when (pre 1985 for HIV and pre 1990 for HCV)?
Any needle stick injuries?
Past medical history
Any previous sexually transmitted infections (STI) or similar symptoms?
Any medical or surgical conditions?
vaccinating all Aboriginal children against Hepatitis B at birth since 1988 and all
children since 1990)
Have they been vaccinated for Hepatitis B or A? (The NT has had a program of
Medications/allergies
Current medications prescribed - particularly antibiotics or creams?
Any medications they have taken without prescription?
Any known allergies?
Current contraception - any problems?
Gynaecological history
Date of last menstrual period?
Usual menstrual cycle - has this changed?
Pregnancies including terminations/miscarriages?
Complications in pregnancy?
Gynaecological procedures - past history?
Contraceptive history - any problems?
Abnormal vaginal bleeding?
Pap smears - date of most recent pap, any abnormal pap smears?
Pre-test information if testing for blood borne viruses
Explain the nature of the test, and how confidentiality of test results will be assured.
Ensure client understands the concept of a ‘window period’.
Advise client that they should return in person for test results.
what might it mean?
Discuss social and cultural implications of a positive test - who they would tell and
SHBBVU Guidelines May 2008
7
Education as part of a sexual health consultation
miscarriages in women.
Discuss how STIs are spread and the importance of treatment to prevent infertility and
Discuss safe sex and the use of condoms.
Advise that if they have an STI, recent partners will need to be checked and treated.
Contact tracing
infection and miscarriages and infertility in women).
Explain the reasons partners need a check-up and treatment (to prevent repeat
know:
1. ask them to tell their partner/s to come to the clinic for a check-up and treatment;
Explain how confidentiality will be maintained and methods of letting their partner/s
or
2. ask for the names of their partner/s and the clinic staff can follow them up, names of
contacts will never be recorded in the index case’s medical record and contacts
not
aretold who named them.
8
Sexual risk assessment
These guidelines are for all regions of the Northern Territory (NT). The prevalence of STIs
varies greatly within the NT and this will affect the likelihood that a person who has had
unprotected intercourse may have been exposed to an STI. Practitioners can seek advice
from their local Centre for Disease Control (CDC) about the prevalence of STIs in their area.
While these guidelines generally recommend a syndromic management approach, different
approaches are appropriate for people or groups with different risk status. As a result,
recommendations for treatment will vary. Some of the protocols in this publication suggest
making a risk assessment, identify criteria to do so and recommend treatment accordingly.
Remote Communities
People who live in and are sexually active in remote communities are at increased risk of
syphilis, gonorrhoea, chlamydia and trichomonas because of the very high rates of infection
in those communities. In general terms, communities in the western regions of Central
Australia have higher rates than other regions. However, there are also remote communities
where rates are lower.
People who live in urban settings but who have a sexual network connection to remote
communities are also at an increased risk of infection. That is, those people whose sexual
partners are connected to remote communities.
Age
There is international evidence that people in their mid to late teens and early adulthood
have higher rates of STIs than older people. As a generalisation, people will have a higher
STI risk if they are:
under 25 years with no sexual network connection to remote communities; or
under 35 years with a sexual network connection to remote communities.
Sexual Partners
The greater the number of sexual partners a person has, the higher their risk of contracting
an STI. People with higher numbers of sexual partners pose an increased risk of infecting
others. This is especially true if they have concurrent sexual partners: ie. they are having sex
with more than one person during the same time period.
There is evidence from international studies that for chlamydia infection in women, there is
an increased risk of infection if a woman has:
a new sexual partner in the past 3 months; or
This evidence suggests that there is a similarly increased level of risk for other STIs and for
people in the NT.
more than 1 sexual partner in the past 6 months.
SHBBVU Guidelines May 2008
9
Recent STI
Evidence tells us that people who contract an STI are at greater risk of doing so again.
Various studies have measured this over periods of 3, 6 and 12 months. A person who has
had an STI in the past 12 months may be at increased risk of re-infection.
Alcohol and other substance use
There is a perception that excessive use of alcohol and other substances increases the risk
of STIs. There is evidence from Central Australia to support this. However, it is not the
substance use on its own that increases risk, but that people who are intoxicated become
disinhibited and are more likely to have sex (especially with someone who is not their usual
partner) and less likely to have safe sex, and therefore more likely to contract an STI.
Regular partner’s behaviour
When assessing a person’s risk of an STI, their regular partner’s behaviour may be more
important than their own. This is particularly the case for women. It is relatively common for
women to be monogamous but for their husbands or boyfriends to have other sexual
partners. This would increase the woman’s risk of STI. Similarly, a sexual partner’s alcohol or
drug use may suggest an increased risk for the person.
10
Male examination
Ensure privacy and patient comfort throughout the examination.
Ensure good lighting and have underwear removed to allow adequate examination.
A sheet to cover the genital area should be used before and after examination for client
comfort. It is important the patient is informed about what the examination involves and
consents to the examination.
Start with a general examination of skin, abdomen, inguinal region then genital area.
General examination
Skin - rashes, tattoos, fungal infections in flexures, skin creases.
Hands and feet - fungal infections, rashes.
development.
Nails on hands and feet - candida or fungal infections or changes in nail
Hair and eyebrows - hair loss, lice.
Lymph nodes - cervical, axilla, inguinal.
Mouth, teeth and throat - inflammation, ulcers, plaques, oral candida.
Temperature and pulse if febrile.
Abdominal examination
(always palpate gently).
Look for tenderness, masses, guarding, rebound tenderness, scars, bowel sounds
Inguinal region
Examine for lymph nodes - enlarged, tender, bilateral or unilateral, fluctuant.
Rashes - folliculitis, fungal infections.
Genital examination
Pubic hair area - any skin lesions or signs of pubic lice.
odour and consistency.
Penis and under the foreskin - note any discharge from the meatus and its colour,
Any lumps, rashes or ulcers eg. warts, molluscum, genital herpes, candida.
(epididymitis).
Scrotum and testicles - any swelling, heat, tenderness - unilateral or bilateral
symptoms).
Examine the anal area for rashes, ulcers, lumps, discharge (+/-proctoscopy if anal
Offer prostate examination in males over 45 years.
SHBBVU Guidelines May 2008
11
Female examination
Ensure privacy and patient comfort throughout the examination.
Ensure good lighting and have underwear removed to allow adequate examination.
A sheet to cover the genital area should be used before and after examination for client
comfort. It is important the patient is informed about what the examination involves and
consents to the examination.
Start with a general examination of skin, abdomen, inguinal region then genital area.
General examination
Skin - rashes, tattoos, fungal infections in flexures/skin creases.
Hands and feet - fungal infections, rashes.
development.
Nails on hands and feet - candida or fungal infections or changes in nail
Hair and eyebrows - hair loss, lice.
Lymph nodes - cervical, axilla, inguinal.
Mouth, teeth and throat - inflammation, ulcers, plaques, oral candida.
Temperature and pulse if febrile.
Abdominal examination
(always palpate gently).
Look for tenderness, masses, guarding, rebound tenderness, scars, bowel sounds
Inguinal region
Examine for lymph nodes - enlarged, tender, bilateral or unilateral, fluctuant.
Rashes - folliculitis, fungal infections.
Breast examination - as required
External genital examination - vulva
Pubic hair area - any skin lesions, warts, molluscum, scabies, pubic lice.
redness, swelling, signs of itching, excoriation or scratch marks.
Gently open the labia and examine the labia majora and minora. Look for any vulval
Any signs of discharge - note its colour, odour and consistency.
Look for ulceration or splits in the skin - herpes, donovanosis, syphilis or trauma.
plaques.
Any lesions eg. warts, cysts, molluscum contagiosum, pigmented lesions, white
Higher rates of carcinoma of the vulva have been observed in the East Arnhem region
among Aboriginal women in recent years.
12
Internal genital examination - vaginal speculum
Insert speculum gently - usually best lubricated with warm water.
smell, colour and consistency. Any warts, cysts, ulcers or signs of trauma.
Note the vaginal walls and check for inflammation, discharge - increased quantity,
Note the cervix - shape, size, ectropion, inflammation, discharge, bleeding.
Are there any warts, ulcers, polyps or cysts on the cervix.
Bimanual examination
With one hand on the abdomen and 2 or 3 fingers of the other hand in the vagina, note any
tenderness or pain when moving the cervix, feel the size and orientation of the uterus, for
any masses in the adnexa (if any of these signs are present see PID protocol, p 25
).
Anal examination
Examine the anal area for warts, lesions, ulcers, discharge or rashes (+/- proctoscopy if anal
symptoms).

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