Management of male urethral discharge
Patient complains of urethral discharge or dysuria
If history of receptive oral or anal
sex take 2 swabs of throat or anus
1. NAAT Chlamydia
2. MC&S
Take history, examine patient
YES Visible urethral discharge present? NO
Immediate treatment for Gonorrhoea and Chlamydia
Azithromycin 1g and amoxycillin* 3g, and probenecid* 1g orally
(*use ceftriaxone 250mg IMI instead 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
Follow up test results
Review in one week to give results of tests and ensure symptoms have resolved and contact tracing done
If symptoms not better re-examine, re-test. Consult with Medical Officer at local Sexual Health Unit
SHBBVU Guidelines May 2008
33
Management of epididymo-orchitis
(swollen painful testes)
Causes
The causes of epididymo-orchitis vary with age.
Among younger sexually active men gonorrhoea and chlamydia are common (usually <35
years but can be <45 years in Indigenous men in remote communities).
Among older men, organisms associated with urinary tract infections (
E. coli, Pseudomonas,
Klebsiella
the cause.
Many references use age 35 years as a cut off point to guide treatment. However, for men
living in remote NT communities or whose sexual networks relate to remote communities
with high rates of gonorrhoea and chlamydia, 45 years may be more appropriate.
species) occur. It is not possible to tell by clinical examination which organism is
History, examination and tests
Ask about:
•
suddenly, or whether there was any trauma preceding the pain;
how long the pain and swelling have been present, whether it started slowly or
•
any nausea or vomiting;
•
recent symptoms of urethral discharge or dysuria;
•
other possible STI symptoms (eg. sores, warts or lumps, rash, sore throat);
•
sexual partners and if any of them are from outside the NT.
Examination
Look for urethral discharge and fever especially (see Male examination, p 10).
In all men with epididymo-orchitis
•
trichomonas; and
Take a first void urine for gonorrhoea culture and NAAT for chlamydia and
•
a midstream urine for MC&S.
For men in whom a urethral discharge is present regardless of age
Take 2 swabs of the discharge:
•
media); and
First swab for MC&S (roll onto glass slide and let dry in air and put swab in transport
•
pathology company instructions (dry tube for PCR, transport media tube for TMA, see
p 13).
Torsion of the testis can be very similar to epididymo-orchitis and is an emergency.
If there is any doubt about the diagnosis, the patient should be referred immediately to
hospital. Nurses and Aboriginal health workers should always consult with a doctor.
Second swab for NAAT for gonorrhoea, chlamydia and trichomonas according to
34
For all men under 35 (under 45 if remote community connection
)
•
HbcAb)
Take a blood test for syphilis serology, HIV +/- Hepatitis B (HBsAg, HBsAb, and
See hepatitis B, p 14.
Treatment
If there is any doubt about the diagnosis, consult with a specialist and consider
referring immediately to hospital to rule out torsion of the testis.
For men of any age in whom a urethral discharge is present or for men under 35 years of
age (under 45 years in remote communities) gonorrhoea or chlamydia are likely causes.
•
ceftriaxone 250mg IMI stat; and
azithromycin 1g
orally stat; and
doxycycline 100mg
bd for 14 days.
•
For men over 35 years of age (over 45 years in remote communities) in whom a urethral
discharge is not present a urinary tract infection is the likely cause.
Repeat the azithromycin on day 8 if any doubt about ability to take the doxycycline.
•
cephalexin 1g bd for 14 days, or
•
amoxycillin+clavulinate 875/125mg bd for 14 days, or
•
norfloxacin 400mg bd for 14 days, or
•
ciprofloxacin 500mg bd for 14 days.
If allergic to the medication, consult the local SHU.
For all men
•
Paracetamol for the pain and advise rest in bed.
•
Wearing firm underpants can support the scrotum and help reduce the pain.
•
infections found.
Check the results of the tests for other infections and the antibiotic sensitivity of any
•
consider sending to hospital.
See him on days 3 and 8 - if he is not improving, consult with the local SHU and
For men treated for an STI
•
given single dose treatment for gonorrhoea and chlamydia.
Ensure that all sexual partner/s from the last 3 months are checked for STIs and
•
to reduce their risk of pelvic infection and infertility.
Explain that all partner/s need to be treated as well so he doesn’t get re-infected and
•
treatment.
Advise him not to have sex until 1 week after both his treatment and his partner/s
•
Discuss condoms and safe sex.
•
give
On day 8 if there is any doubt about whether he is able to take all the doxycycline,azithromycin 1g by mouth once again.
For men treated for a urinary tract infection
•
Check the organism found on culture and its antibiotic sensitivity.
•
When the infection is resolved, arrange renal investigations (eg. ultrasound).
SHBBVU Guidelines May 2008
35
Differential diagnosis: Scrotal swelling: epididymo-orchitis
or torsion of the testis?
Scrotal swelling may be due to either epididymo-orchitis or torsion of the testis. It can be very
difficult to tell the difference between the two on clinical grounds. Torsion of the testis
requires surgery and, if there is a delay of more than several hours, can lead to loss of the
testis. Therefore a quick decision is needed.
Nurses and Aboriginal Health Workers should always consult with a doctor. Doctors should
consider consulting a specialist.
If there is any doubt about the diagnosis refer immediately to hospital.
The table below provides an outline to assist in making a diagnosis.
Torsion
Epididymo-orchitis
Age
Can be any age but more
usually under 1 year or
between 10-25 years.
Rare in boys before puberty.
Usually young sexually active
men or older men.
Onset
Usually sudden but can
be gradual. Sometimes
related to recent trauma.
Gradual.
Pain
Always present usually
moderately strong or severe.
Usually mild to moderate.
Other symptoms
May have abdominal pain,
and vomiting.
May have abdominal pain,
dysuria or urethral discharge.
Fever
Either no fever or less than
37.5
Usually more than 37.5
but may be absent.
On examination
Scrotum often swollen,
red and warm. Testicle within
the scrotum also swollen and
tender. Affected testicle may
be sitting higher than the
other and/or lying sideways.
Scrotum often swollen, red
and warm. Testicle within
the scrotum also swollen
and tender. Urethral discharge
may be present. May be nitrites
on urinalysis.
Effect of lifting the scrotum
Either no change in pain
or worsens the pain.
May relieve the pain.
oC.oC
36
Take 2 swabs of discharge if present:
MC&S and NAAT Gono/Chlamydia/Trichomonas
Take separate urines:
First-Void Urine MC&S and NAAT
Gono/Chlamydia/Trichomonas and
Mid-Stream Urine for MC&S
Take blood for HIV, syphilis serology, +/-Hep B
(if not immune and can do follow up see p 14)
Take separate urines:
First-Void Urine for MC&S and
NAAT Gono/Chlamydia/ Trichomonas and
Mid-Stream Urine for MC&S
Cephalexin 1g bd for 14 days, OR
amoxycillin+clavulinate 875/125mg
bd for 14 days, OR norfloxacin
400mg bd for 14 days, OR
ciprofloxacin 500mg bd for 14 days
Review on Days 3 and 7. Check test results.
If not improving consider sending to hospital
Management of epididymo-orchitis
Nurses and Aboriginal health workers
should always consult with a doctor
Paracetamol
Rest in bed
Scrotal support
(eg firm underpants)
Consider torsion of testis: if any doubt,
Take history, examine patient
send immediately to hospital
Visible urethral discharge present
or patient under 35 years ?
(under 45 in remote community)
YES
Probable STI
NO
Probable urinary
tract infection
Azithromycin 1g orally and ceftriaxone 250mg IMI
and doxycycline 100mg bd for 14 days
Review on Day 3: if no improvement consult with
local Sexual Health Unit and consider sending to
hospital. Check test results
Review on Day 7. If no improvement send to
hospital. If improving, give azithromycin 1g if any
doubt about compliance with doxycycline
Education and counselling
Promote / provide condoms
Arrange full check-up and treatment
for gonorrhoea and chlamydia for sex partner/s
When infection resolved, arrange renal
investigations
Patient with swollen, red, painful scrotum
SHBBVU Guidelines May 2008
37
Management of genital ulcers
Causes
The common causes will vary with the population group.
Among non-Aboriginal people the commonest cause is herpes although syphilis does occur.
Among Aboriginal people syphilis is relatively common especially in remote communities
although herpes also occurs. Donovanosis is mainly found in remote communities and while
increasingly rare, still occurs.
The possibility of malignancy as a cause of genital ulceration should not be overlooked
especially if there is poor response to treatment. Increased rates of vulval carcinoma have
been observed in the East Arnhem region in recent years.
History and examination
•
How long the ulcers have been present and have they had them before?
•
discharge, dysuria, rash, sore throat)
Ask about other possible STI symptoms (eg. warts or lumps, urethral or vaginal
•
Central Australia.
Ask about sexual partner/s and if any of them are from outside the Top End or
•
See Sexual history p 5.
Examination
It is important to look inside the vagina with a speculum in women, under the foreskin and
scrotum in men and in the peri-anal region in both sexes.
(see Male examination, p 10; Female examination, p 11).
Genital Herpes
May present as multiple, painful or itchy small blisters, which become ulcers, then scabs and
then heal. There may be tender lymph nodes in the groin. The first or primary episode is
always the most severe episode and can last 2-3 weeks. It is often associated with flu like
symptoms and headache and there can be severe localised genital swelling, pain and
retention of urine, requiring hospitalisation. Herpes can recur. If so, the ulcers are not usually
as severe and heal within a week.
Syphilis
Usually presents as a single (occasionally 2)
rolled edge and the base of the ulcer is firm (‘indurated’) although they can often be atypical
in appearance. Without treatment the sore will go away in 4-6 weeks but the person will still
have syphilis.
painless ulcer/s which are red, round with a
Donovanosis
Usually presents as a red, beefy, raised, raw, painless lesion. Can be painful if secondary
infection is present. Without treatment the ulcer will not heal, and can spread slowly outwards
and become very large, eroding normal tissue. Ulcer/s may be present for months or years. It
can be difficult to tell syphilis and donovanosis apart.
These infections can vary greatly in the way they look. It is frequently not possible to
tell by looking which organism is the cause.
38
Investigations
Do a full STI check
•
herpes, syphilis and donovanosis.
(For herpes like sores: if blisters are present gently burst with a sterile needle and
swab the fluid, for other sores just swab the sore or scab).
Using a dry swab, swab the base of the ulcer. REQUEST: genital ulcer NAAT for
•
REQUEST: MC&S and NAAT chlamydia, gonorrhoea and (in women only)
trichomonas. (If doing a speculum examination in a woman taking endocervical and
high vaginal swabs is better).
Take 2 self collected vaginal swabs or a urine test in women and a urine test in men.
•
HbcAb).
Take a blood test for syphilis serology, HIV +/- Hepatitis B (HBsAg, HBsAb, andSee hepatitis B, p14.
Treatment
Treatment should be given straight away - do not wait for test results to come back.
•
below).
If the sores are completely typical of herpes, then manage as for herpes only (see
•
p 39).
If not completely typical of herpes, then manage as for syphilis and donovanosis (see
•
Talk to your local SHU about any pregnant woman with genital ulcers.
Herpes management
Primary herpes
Primary herpes is the person’s first episode of genital herpes.
•
daily for 5 days.
Give valaciclovir 500 mg twice daily for 5 - 10 days, or famciclovir 125 mg 3 times
•
them (or any drying agent).
Keep the sores clean with salt water washes and/or put betadine on the sores to dry
•
Give paracetamol 2 tablets by mouth every 4 hours as needed for pain.
•
prior to passing urine.
Lignocaine gel may be helpful during the first few days to reduce pain particularly
•
Note: Both valaciclovir and famciclovir require authority prescriptions and are approved for
recurrent herpes. Both are effective in primary herpes but the PBS will only authorise
valaciclovir for primary episodes.
Talk to your SHU if the woman is pregnant or can’t pass urine.
Recurrent herpes
Recurrent episodes are usually less severe and heal within a week. Usually only keeping
them clean and mild pain relief is needed. If the episodes are more severe or frequent,
specific treatment may be needed. For maximum benefit, treatment should be commenced
within 24 hours of the onset of symptoms.
•
5 days
If the person is getting 6 or more recurrent episodes per year, they may benefit from taking
long term daily medication to prevent or reduce the recurrences. Seek advice from your local
SHU.
Give valaciclovir 500 mg twice daily for 3 days or famciclovir 125 mg twice daily for
SHBBVU Guidelines May 2008
39
Follow up at 1 week
•
A positive test confirms genital herpes.
•
if the sores come back).
A negative test does not exclude genital herpes (ask them to return for another swab
•
Provide herpes information and advice about safe sexual behaviour.
•
Offer sexual partners information on herpes and a full STI screen.
Any woman who has herpes or whose partner has herpes should be advised to tell
their doctor of this if they get pregnant in the future (risk of neonatal herpes).
Blood tests for antibodies to herpes are available. However, their interpretation and
application to the clinical situation is complex. Practitioners are advised to seek advice from
the local Sexual Health Unit medical officer before considering their use.
Syphilis and donovanosis management
•
Give benzathine penicillin IMI 1.8gm or 2.4 million units.
•
Azithromycin 1gm orally.
•
the same treatment.
Contact trace all sexual partners in the last 3 months and offer a full STI screen and
Syphilis and donovanosis are notifiable diseases. Contact your local SHU if treating
for syphilis or donovanosis.
Follow up at 1 week
•
Check test results.
•
If the ulcer is still present or the donovanosis test is positive keep giving
azithromycin 1g
orally once a week until the sore has healed. An alternative is
azithromycin 500mg
per day for 7 days (there is less evidence for this treatment).
•
If possible examine the ulcer each week until it is fully healed.
•
biopsy to investigate other causes.
The ulcer must be examined at 4 weeks. If no response to treatment consider a
•
for a recurrence.
Examine the person at 3 months and 6 months after treatment is completed to look
•
for RPRs on both specimens to be ‘run in parallel’.
If syphilis was diagnosed, repeat syphilis serology 6 months after treatment and ask
Safe sex advice
•
condoms do not always cover the ulcer. Advise the person not to have sex until the
sores have healed.Advise the person about safer sexual practices and condom use. Remember
