من انا

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

الجمعة، 3 فبراير، 2012

Sexual history

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).
SHBBVU Guidelines May 2008
13
Important points - laboratory tests for STIs
Nucleic Acid Amplification Tests: PCR and TMA
The principle diagnostic test for several different STIs in recent years has been the
Polymerase Chain Reaction (PCR) test. PCR tests are just one type of Nucleic Acid
Amplification Test (NAAT). There are now other types on the market.
Transcription Mediated Amplification (TMA) tests are now also widely used in the NT for the
diagnosis of Chlamydia, gonorrhoea and trichomonas.
The type of test available in a clinic will depend on the pathology company used.
It is now recommended that the abbreviation used when ordering these tests is NAAT as this
will cover all types of nucleic acid tests available.
The PCR and TMA tests have different collection and transport systems and you will need to
find out which one your clinic uses and what the systems are.
Currently all laboratories use PCR tests for herpes. Some laboratories have access to PCR
tests for syphilis and donovanosis.
Tests for chlamydia, gonorrhoea and trichomonas may be either PCR or TMA according to
the laboratory.
Swabs for PCR tests: a dry swab in a dry tube.
Swabs for TMA tests: need special TMA swab and transport medium container.
Urine for both PCR and TMA tests: ordinary urine collection jar.
The best place to keep all NAAT specimens awaiting transport is the fridge.
Culture specimens for gonorrhoea should be collected wherever possible so antibiotic
sensitivities can be determined. These specimens should be stored at room
temperature.
14
Antibiotic resistance of
gonorrhoeae
Neisseria
In most places in the world,
the Top End of the NT and parts of the Goldfields and Kimberley regions of Western
Australia are amongst the few places where
be treated with penicillin (eg. with oral amoxicillin and probenecid).
In determining the medication to treat someone who either has confirmed gonorrhoea or who
may have gonorrhoea, it is important to determine where the infection may have come from.
This means always asking about where the person’s sexual partner/s are from. If a partner
comes from or usually lives in the regions above, gonorrhoea can be safely treated with oral
amoxicillin and probenecid. If the person is from outside these regions an injection of
ceftriaxone is needed. The important point is where the partner is from and not where the sex
took place. If a person had sex with an overseas visitor in Alice Springs, then ceftriaxone
would be needed. If in doubt, it will be better to use ceftriaxone as this will always be
effective.
For these reasons, these guidelines frequently prompt the practitioner to ask whether the
person’s sexual partners come from either the Top End or Central Australia.
Neisseria gonorrhoeae is resistant to penicillin. Central Australia,Neisseria gonorrhoeae infections can routinely
Hepatitis B
This protocol refers generally to taking blood for syphilis, HIV and +/- Hep B.
evidence of previous hepatitis B infection or vaccination.
A test for hepatitis B (HbsAg, HbsAb and HbcAb) can be considered if there is no
his/her contacts and you will need to ensure that you and your health service
have the capacity to do so.
If testing is done, there is an obligation to do full follow up for the patient and
positive can be offered immunisation. Adult hepatitis B vaccine is not Government
funded so these vaccines must be costed to your health centre.
Patients who are not immune, not vaccinated and not hepatitis B surface antigen
hepatitis B and could be considered for anti-viral treatment.
Patients who are chronic carriers will need investigation and follow up for chronic
hepatitis B and offered vaccination +/- immune globulin if indicated. The Centre for
Disease Control (CDC) will cover the cost of vaccines and immune globulin in these
cases.
Sexual partners and close household contacts of chronic carriers should be tested for
Management Guidelines and The Australian Immunisation Handbook 9
further information.
Refer to the CDC Northern Territory Hepatitis B Vaccination Policy and Public Healthth Edition for
SHBBVU Guidelines May 2008
15
Investigations - males
Always take swabs before passing urine as this washes away any discharge.
First void urine is the first 20-30mls of urine a person passes and is preferred for STI tests.
It is not a mid stream specimen
.
Any person who has symptoms of an STI or a confirmed STI must be offered a full STI check
including bloods for syphilis and HIV. A person may refuse to have any test but if they do,
you need to write this in their notes. If you don’t, it could become a medico legal issue.
Asymptomatic male
Take a first void urine specimen:
LABEL specimen: FIRST VOID URINE.
chlamydia, gonorrhoea.
REQUEST: Nucleic Acid Amplification Test (Abbreviated to NAAT, see p 13) for
Symptoms of urethritis
If there is discharge
Take 2 swabs from the discharge:
LABEL specimens: URETHRA.
into culture medium. REQUEST: Microscopy, Culture, and Sensitivity (MC&S).
First Swab: Sample discharge and roll onto glass slide and let air dry and put swab
company instructions (dry tube for PCR, transport media tube for TMA, see p 13).
REQUEST: NAAT chlamydia and gonorrhoea and trichomonas.
Second swab: Sample discharge and put back into tube according to pathology
If discharge is not present
Take a first void urine specimen:
LABEL specimen: FIRST VOID URINE.
(MC&S).
REQUEST: NAAT chlamydia, gonorrhoea, trichomonas and gonorrhoea culture
Male with genital ulcer
If there are ulcers present - refer to genital ulcer protocol, p 37.
Additional tests if needed
If a history of receptive anal sex
Take 2 anal swabs
:
LABEL specimens: ANAL SWABS.
swab into culture medium. REQUEST: MC&S.
First Swab (do not do glass slide): Take a swab from about 1 - 2cm within anus, put
pathology company instructions (dry tube for PCR, transport media tube for TMA
(see p 13) REQUEST: NAAT Chlamydia (NB: site not validated for NAAT
gonorrhoea).
Second swab: Take a swab inside the anus and put back into tube according to
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If had receptive oral sex
Take 2 throat swabs:
LABEL specimens: THROAT SWAB.
a glass slide, leave slide to air dry, put swab into culture medium. REQUEST: MC&S.
First Swab: Take specimen from the oropharynx (back of throat) and roll this swab on
according to pathology company instructions (dry tube for PCR, transport media tube
for TMA (see p 13) REQUEST: NAAT Chlamydia (NB: site not validated for NAAT
gonorrhoea).
Second swab: Take a swab from the back of the throat and put back into tube
If dysuria present and client over 40 years of age:
Urine dipstick for protein, blood, leucocytes and nitrites.
MC&S.
Take a mid stream specimen. LABEL Specimen: MID STREAM URINE. REQUEST:
Blood Tests
client is symptomatic, at high risk for STI, or a contact of a person with an STI.
Collect blood for syphilis, HIV and possibly hepatitis B (HbsAg, HbsAb and HbcAb) if
according to local health service protocols.
These tests may also be done as part of an adult health check or well men’s check
evidence of previous hepatitis B infection or vaccination. If testing is done, there is an
obligation to do full follow up for the patient and his contacts and you will need to
ensure that your health service has the capacity to do so.
A test for hepatitis B (HbsAg, HbsAb and HbcAb) can be considered if there is noSee hepatitis B, p 14.
Storage of specimens
bacteria will die if refrigerated or if heated above 37
Culture specimens for gonorrhoea should be stored at room temperature. The°C.
NAAT specimens are best stored in the fridge.
temperature for culture and the other to go in the fridge for NAAT. If this is not
possible, store the urine in the fridge.
Ideally, urine specimens for STI tests should be split: 1 to remain at room
SHBBVU Guidelines May 2008
17
Investigations - females
Always take swabs before passing urine as this washes away any discharge.
First void urine is the first 20-30mls of urine a person passes and is preferred for STI tests. It
is not a mid stream specimen.
Any person who has symptoms of an STI or a confirmed STI must be offered a full STI check
including bloods for syphilis and HIV. A person may refuse to have any test but if they do,
you need to write this in their notes. If you don’t, it could become a medico-legal issue.
Speculum examination
Take 2 endocervical swabs
LABEL specimens: ENDOCERVICAL or CERVICAL.
dry, put swab into culture medium. REQUEST: MC&S.
First Swab: Sample discharge with swab and roll onto a glass slide, leave slide to air
company instructions (dry tube for PCR, transport media tube for TMA, see p 13).
REQUEST: NAAT chlamydia and gonorrhoea and trichomonas.
Second swab: Sample discharge and put back into tube according to pathology
Take 1 high vaginal swab
LABEL specimen: HIGH VAGINAL or HVS.
put swab into culture medium. REQUEST: MC&S.
Take a swab from upper vaginal wall and roll onto a glass slide, leave slide to air dry,
paper with swab from vagina before putting into culture medium:(if pH >4.5 treat with
2g metronidazole - see vaginal discharge protocol, p 21).
If abnormal vaginal discharge is present and if available do a pH test - touch pH
Take PAP smear
after a previous abnormal smear.
if required ie. 2 years or more since last normal pap smear, or as directed
If a history of receptive anal sex
Take 2 anal swabs
:
LABEL specimens: ANAL SWABS.
swab into culture medium. REQUEST: MC&S.
First Swab (do not do glass slide): Take a swab from about 1- 2cm within anus, put
pathology company instructions (dry tube for PCR, transport media tube for TMA, see
p 13). REQUEST: NAAT Chlamydia (NB: site not validated for NAAT gonorrhoea).
Second swab: Take a swab inside the anus and put back into tube according to
If had receptive oral sex
Take 2 throat swabs
:
LABEL specimens: THROAT SWAB.
a glass slide, leave slide to air dry, put swab into culture medium. REQUEST: MC&S.
First Swab: Take specimen from the oropharynx (back of throat) and roll this swab on
according to pathology company instructions (dry tube for PCR, transport media tube
for TMA, see p 13). REQUEST: NAAT Chlamydia (NB: site not validated for NAAT
gonorrhoea).
Second swab: Take a swab from the back of the throat and put back into tube
18
Consider urine specimen
Urine dipstick for protein, blood, leucocytes and nitrites.
REQUEST: MC&S.
Take a mid stream specimen (MSU) if concerned about urinary tract infection.
Perform a pregnancy test if period late or pregnancy possible.
Self-collected genital specimen
patient asymptomatic)
(if speculum not possible or
Ask the woman to self-collect 2 vaginal swabs.
VAGINAL SWABS.
Open the packs and label the tubes. LABEL specimen: SELF COLLECTED LOW
Send the woman to the toilet or private area to take 2 self collected swabs.
(see p 19) and then smear onto glass slide and place swab into tube of media.
REQUEST: MC&S (if pH is >4.5 consider treatment with metronidazole 2g for
trichomoniasis or bacterial vaginosis).
First swab: If abnormal vaginal discharge present and if available do pH test
instructions (dry tube for PCR, transport media tube for TMA, see p 13). REQUEST:
NAAT chlamydia and gonorrhoea and trichomonas.
Second swab: Take swab and put back into tube according to pathology company
Consider urine specimen
REQUEST: NAAT chlamydia, gonorrhoea and trichomonas.
If not possible to do self collected swabs obtain a first void urine (FVU) specimen.
Do an immediate dipstick analysis for nitrites and leucocytes.
infection REQUEST: MC&S.
Take a mid stream specimen (MSU) if concerned about possible urinary tract
Perform a pregnancy test if period late or pregnancy possible.
Blood Tests
HbcAb) if client is symptomatic, at high risk for STI, or a contact of a person with an
STI.
Collect blood for syphilis and HIV and possibly hepatitis B (HbsAg, HbsAb and
according to local health service protocols.
These tests may also be done as part of an adult health check or well women’s check
no evidence of previous hepatitis B infection or vaccination. If testing is done, there is
an obligation to do full follow up for the patient and her contacts and you will need to
ensure that your health service has the capacity to do so.
A test for hepatitis B (HbsAg, HbsAb and HbcAb) can also be considered if there isSee hepatitis B, p 14.
Storage of specimens
bacteria will die if refrigerated or if heated above 37
Culture specimens for gonorrhoea should be stored at room temperature. The°C.
NAAT specimens are best stored in the fridge.
SHBBVU Guidelines May 2008
19
pH testing of vaginal secretions
Testing of the acidity of vaginal secretions may be performed for women who have abnormal
vaginal discharge. This may be done by touching a swab of the secretions onto pH paper.
The pH is abnormal if it is >4.5.
pH testing has been widespread in Central Australian remote communities in recent years
following a study which demonstrated an association between increased pH and trichomonas
infection and bacterial vaginosis. Practical use of the test in recent years has led to a revision
of its use.
The test is only useful and is only recommended in women with abnormal vaginal discharge
and not in well women. It is not reliable and should not be used in post-menopausal women
(whose vaginal pH is higher) or in women who are menstruating, as blood will raise the pH.
The test should be used to exclude the need for treatment of trichomonas in those women
who receive syndromic treatment for abnormal vaginal discharge. In these women if the pH
is <=4.5, they do not need treatment for trichomonas (ie. single oral doses of metronidazole
or tinidazole) as part of their syndromic management.
If laboratory results indicate either trichomonas infection or bacterial vaginosis, the woman
should be followed up and treated appropriately.
20
Management of abnormal vaginal
discharge
Causes
Vaginal discharge may come from the vagina, cervix or upper genital tract. All women have
some vaginal discharge normally from cervical and vaginal secretions. This can vary
throughout the menstrual cycle and at different times of a woman’s life.
It is abnormal when it increases in amount, or is accompanied by soreness, itching or odour.
There are many conditions that can cause abnormal discharge: candidiasis, bacterial
vaginosis, trichomoniasis, gonorrhoea, and chlamydia.
Generally, it is not possible to tell by clinical examination which organism is the cause
.
History
Ask the woman about:
The amount, colour, duration and smell of the discharge.
Any itching, soreness, pain on passing urine or frequency.
pelvic inflammatory disease.
Any lower abdominal pain or pain deep inside with sex - if yes to either, assess for
throat).
Also ask about other possible STI symptoms (eg. sores, warts or lumps, rash, sore
Central Australia (see p 14).
Ask about her sexual partners and ask if any of them are from outside the Top End or
sexual partners related to remote communities carries an increased risk. Age under
25 or under 35 if remote community related, an STI in the past 12 months, more than
1 partner in past 6 months or a new partner in past 3 months indicate a higher risk of
an STI.
Assess her personal risk of STI (see p 8) - residence in a remote community or
Examination
(see Female examination, p 11)
Investigation - speculum examination
(see Investigations-females, p 17)
Take 2 endocervical swabs:
1 for MC&S (roll onto glass slide and let dry in air and put swab in transport media).
instructions (dry tube for PCR, transport media tube for TMA, see p 13).
1 for NAAT chlamydia, gonorrhoea and trichomonas according to pathology company
Take 1 high vaginal swab (HVS):
then place in transport media and label HVS: MC&S.
Touch swab onto pH paper (if available) and roll onto a glass slide and let dry in air
Do a PAP smear if one is due.
when moving the cervix, or any masses (if any of these signs are present see PID
protocol, p 25
Do a bimanual examination and feel for tenderness in the uterus or adnexae, pain).
SHBBVU Guidelines May 2008
21
Investigation - speculum examination not possible
Ask the woman to self-collect 2 low vaginal swabs:
slide and let dry in air and put swab in transport media.
1 for pH test and MC&S (touch onto pH paper if available) and then roll onto glass
instructions (dry tube for PCR, transport media tube for TMA, see p 13).
1 for NAAT chlamydia, gonorrhoea and trichomonas according to pathology company
Consider urine specimen:
Do an immediate dipstick analysis for nitrites and leucocytes.
infection REQUEST: MC&S.
Take a mid stream specimen (MSU) if concerned about possible urinary tract
Blood tests
STI is a possible cause.
Blood test for syphilis serology, HIV +/- hepatitis B (HBsAg, HBsAb, and HBcAb) if anSee hepatitis B, p 14.
Treatment
factors for STI and examination findings.
Treatment given will depend on the woman’s population group, her personal risk
inflamed or bleeds easily, treatment for gonorrhoea and chlamydia (amoxycillin,
probenecid, azithromycin) should be given regardless of the population group or
personal STI risk.
If, on speculum examination, there is discharge from the cervix or the cervix is
High risk of STI
High risk if the woman:
is from a remote community or her sexual network relates to remote communities; or
is aged <25 years (or <35 years if sexual network relates to a remote community); or
has >1 partner in the past 6 months; or
has a new partner in the past 3 months; or
Excess drug and alcohol use in either the patient or her partners is associated with
behaviours such as having multiple sexual partners or unsafe sex.
has visible discharge from the cervix or inflamed cervix on examination.
Treatment should be given immediately: do not wait for test results.
Give oral amoxycillin 3g and probenecid 1g and azithromycin 1g once only.
Central Australia (see p 14) then give
If the woman has had a recent sexual partner who is from outside the Top End orceftriaxone 250mg IMI and azithromycin 1g
orally instead.
pregnant) as a single dose on the next day. (If a pH test of vaginal fluid was
performed and was <=4.5,
Also give either oral metronidazole 2g or oral tinidazole 2g (not tinidazole ifdo not give metronidazole or tinidazole).
for nitrites or leucocytes.
Treat for urinary tract infection (UTI) if she has dysuria and urine dipstick is positive
for candida with topical
If she has vulval itch, vulval soreness or swelling, or the discharge is curd like, treatclotrimazole 500mg vaginal tablet inserted once only.
22
Low risk of STI
Low risk if the woman:
is from a population with low prevalence of gonorrhoea or chlamydia; and
new partner in last 3 months); and
has low personal risk of STI (ie. >25 years, only 1 partner in last 6 months and no
has no visible discharge from the cervix or inflamed cervix on speculum examination.
Treatment
a single dose. (If a pH test of vaginal fluid was done and was
metronidazole or tinidazole).
Give either oral metronidazole 2g or oral tinidazole 2g (not tinidazole if pregnant) as4.5, do not give
leucocytes.
Also treat for a UTI if she has dysuria and urine dipstick is positive for nitrites or
for candida with topical
If she has vulval itch, vulval soreness or swelling, or the discharge is curd like, treatclotrimazole 500mg vaginal tablet inserted once only.
If she is allergic to any of the medicines, is pregnant, or there are other symptoms,
talk to the local Sexual Health Unit (SHU).
If an STI is suspected:
again.
Explain that her partner/s need to be treated as well so that she doesn’t get infected
given the same treatment.
Make sure that sexual partner/s from the last 3 months are checked for STIs and
treated.
Advise her not to have sex until 1 week after both her treatment and her partner/s are
Discuss condoms and safe sex.
Follow up
test results for other infections and discuss safe sex and condom use again.
If resources permit, ask her to come back in 1 week to be sure he is better, check the
If no improvement, discuss with the local SHU.
SHBBVU Guidelines May 2008
23
Management of vaginal discharge
(vaginal and speculum examination not possible)
Higher risk if: Sexual network
Woman complains of vaginal discharge
relates to remote community,
or age <25 yrs, or > 1 partner
in past 6 months, or new
partner in past 3 months
Lower abdominal pain or deep pain
with sex YES
Take history, assess risk of STI*, examine patient
High risk of STI
Low risk of STI
NO
Assess for pelvic inflammatory
disease (see p 25)
Ask woman to take self-collect 2 vaginal swabs: MC&S, NAAT Gono/Chlamydia/Trichomonas
and pH test (if available)
If dysuria or urinary frequency present take a mid-stream urine for MC&S and dipstick analysis
Metronidazole 2g
or tinidazole 2g
(not if pH < = 4.5)
Take blood for HIV, syphilis serology,
+/-Hep B (if not immune and can do
follow up see p 14)
Azithromycin 1g
and amoxicillin 3g, and
probenecid 1g
pH >4.5
and if pH not done ormetronidazole 2g or tinidazole 2g
Use ceftriaxone 250mg IM instead of amoxycillin
and probenecid if partner from outside Top End
or Central Australia
Education and counselling. Promote / provide condoms
Arrange full check-up and same treatment for sex
partner/s
Review at 7 days, check test results,
if not improving consult local SHU
If vulval itch, soreness or
swelling, or discharge is curd
like
500mg vaginal tablet inserted
once only
also give clotrimazole
Review at 7 days, check test results,
if not improving consult local SHU
*
24
Management of vaginal discharge
(vaginal and speculum examination possible)
Woman complains of vaginal discharge
Higher risk if: Sexual network
relates to remote community,
or age <25 yrs, or > 1 partner
in past 6 months, or new
partner in past 3 months
Take history, assess risk of STI*, examine patient
Lower abdominal pain or deep pain
with sex or tender uterus or adnexae
or when moving cervix?
YES
High risk of STI or
inflamed or
discharging cervix
Low risk of STI and
not inflamed or
discharging cervix
NO
Assess for pelvic inflammatory
disease (see p 25)
Take 2 endocervical swabs: MC&S, NAAT Gono/Chlamydia/Trichomonas
Take 1 high vaginal swab: MC&S, pH test (if available)
If dysuria or urinary frequency present take a mid-stream urine for
MC&S and dipstick analysis
Metronidazole 2g
or tinidazole 2g
(not if pH < = 4.5)
Take blood for HIV, syphilis serology,
+/-Hep B (if not immune and can do
follow up see p 14)
Azithromycin 1g
and amoxicillin 3g, and
probenecid 1g
pH >4.5
and if pH not done ormetronidazole 2g or tinidazole 2g
Use ceftriaxone 250mg IM instead of amoxycillin
and probenecid if partner from outside Top End
or Central Australia
Education and counselling. Promote / provide condoms
Arrange full check-up and treatment for gonorrhoea,
chlamydia and trichomonas for sex partner/s.
Review at 7 days, check test results,
if not improving consult local SHU
Review at 7 days, check test results,
if not improving consult local SHU
If vulval itch, soreness or
swelling, or discharge is curd
like
500mg vaginal tablet inserted
once only
also give clotrimazole
*
SHBBVU Guidelines May 2008
25
Management of lower abdominal pain and
pelvic inflammatory disease
Causes
The causes of lower abdominal pain in a woman can vary from minor but uncomfortable
problems such as constipation or period pain, to life threatening problems such as ruptured
ectopic pregnancy or appendicitis.
Pelvic inflammatory disease (PID) is a common and often unrecognised cause of lower
abdominal pain in women in the NT, particularly in remote communities where there are high
rates of gonorrhoea and chlamydia infection.
PID is inflammation of the upper genital tract - uterus, fallopian tubes, ovaries or pelvic
cavity. It is often caused by gonorrhoea or chlamydia. Many other organisms, which usually
live in the vagina without causing harm, can also cause PID. This can occur if there has been
damage to the upper genital tract by a previous infection with gonorrhoea or chlamydia or
following a termination of pregnancy, dilatation and curettage (D&C) or insertion of an
intrauterine contraceptive device (IUCD).
A woman can still have PID even if the tests for gonorrhoea and chlamydia are negative.
It is common in remote communities for women with PID to be misdiagnosed as having a
urinary tract infection and given incorrect treatment.
Making a diagnosis can be complicated; nurses and Aboriginal Health Workers should
consult with a doctor if there is any uncertainty.
Always consider PID in a woman with lower abdominal pain.
History
Ask the woman about:
better?
the pain - how long she has had it, is it there all the time, what makes it worse or
any pain deep inside when having sex?
been present for?
vaginal discharge - amount, colour and smell of the discharge and how long it has
any fever or feeling generally unwell?
between?
any change in her periods - more bleeding than usual, more pain, any bleeding in
any itching, soreness, pain on passing urine or passing urine more often than usual?
when was her last period?
other possible STI symptoms (eg. sores, warts or lumps, rash, sore throat)?
Australia?
her sexual partners and if any of them are from outside the Top End or Central
26
Examination
(see Female examination, p 11)
Ideally, examination should include:
abdominal examination for tenderness;
vaginal examination with a speculum to look for discharge from the cervix; and
when moving the cervix, or any masses.
bimanual examination to feel for tenderness of the uterus or in the fornices; pain
Investigation - If vaginal and speculum examination is done
Take 2 endocervical swabs:
media).
First swab for MC&S (roll onto glass slide and let dry in air and put swab in transport
instructions (dry tube for PCR, transport media tube for TMA, see p 13).
1 for NAAT chlamydia, gonorrhoea and trichomonas according to pathology company
Take 1 high vaginal swab:
media).
Swab for MC&S (roll onto glass slide and let dry in air and put swab in transport
Take a PAP smear if one is due.
Investigation - If it is not possible to do a vaginal and
speculum examination
Ask the woman to take 2 self-collected low vaginal swabs:
media).
First swab for MC&S (roll onto glass slide and let dry in air and put swab in transport
instructions (dry tube for PCR, transport media tube for TMA, see p 13).
1 for NAAT chlamydia, gonorrhoea and trichomonas according to pathology company
Other tests for all women
Urine pregnancy test.
Blood test for syphilis serology, HIV +/- hepatitis B (HBsAg, HBsAb, and HBcAb).
Midstream urine test for MC&S if dysuria or urinary frequency.
See hepatitis B, p 14.
When to refer to hospital
The situation should be discussed with a doctor or specialist and she should be
referred immediately to hospital when any of the following are present:
missed, overdue or delayed period
recent delivery, miscarriage or abortion
abdominal guarding, rigidity or rebound tenderness
abdominal mass or swelling
active vaginal bleeding
patient is pregnant (NB ectopic pregnancy)
patient is very unwell or temp >38°C
surgical problem eg. appendicitis cannot be excluded
diagnosis is uncertain.
SHBBVU Guidelines May 2008
27
While arranging transfer:
take blood culture (send in to hospital with the woman); and
set up IV line: 1000ml normal saline at 125 ml/hr or as directed by a doctor; and
give ceftriaxone 1g IV; and
give azithromycin 1g orally; and
give metronidazole 500mg orally or IV.
Diagnosis and Treatment of PID in the community
If the criteria for referral to hospital (as above) are not present a diagnosis of PID can be
made and managed in the community if a woman has:
lower abdominal pain and cervical discharge; or
lower abdominal pain and vaginal discharge if a vaginal examination is not done; or
tenderness when the cervix is moved on bimanual examination; or
If there is no history of vaginal discharge, treatment for PID may be considered in women
under 25 (or 35 if sexual network relates to remote communities) with other indicators such
as deep or internal pain with sex, intermenstrual bleeding, or an STI or PID in the past year.
tenderness of the uterus or in the fornices on bimanual examination.
Talk with a doctor in these cases.
It is very important to see the woman often during treatment for PID. If it is unlikely that the
woman will be able to complete treatment, consider sending her to hospital.
Important note on doxycycline treatment
For many years daily doxycycline has been a mainstay component of PID treatment
protocols. However, for many women, this is difficult to take, particularly when
combined with daily metronidazole as recommended in the NT. This is why recent NT
protocols have recommended doses of azithromycin on days 1 and 8 in addition to the
doxycycline as a ‘back-up’ in case the woman did not take all the daily medications.
A recent study suggests that a PID treatment regimen with azithromycin on days 1 and
8 is as good as one with daily doxycycline. However, caution needs to be exercised in
using single doses of azithromycin instead of daily doxycycline. Firstly, although there
is a good theoretical basis for azithromycin being effective, it is only 1 study. Secondly,
if the dose on day 8 is not received, and the woman had not been given daily
doxycycline to take home, then she will not have received adequate treatment.
Practitioners will need to be very sure that a woman will receive the second dose of
azithromycin on day 8, if they are not going to offer daily doxycycline. If there is any
doubt then offer both.
28
DAY 1

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