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Chapter 1: The Clinical Approach to the Patient with Possible STD

Persons seeking evaluation and care for sexually transmitted diseases (STDs) may attend public health clinics specializing in the care of these infections, but most are seen by primary care providers (PCPs), obstetrician/gynecologists, urologists, pediatricians and emergency room providers. Many patients with STDs also make appointments for other reasons, for example, a Papanicolaou (Pap) smear or a pregnancy test, and thus it is important to take a sexual history from all sexually active patients to determine their risk of STD. The diagnosis of STD has become increasingly complex as a greater number of pathogens and syndromes have been described and some treatment regimens have changed due to drug resistance.

Patients at highest risk of STD acquisition include: 1) sexually active adolescents; 2) men or women with multiple sex partners, a sexual partner who has other partners, or a new sexual partner in the last two months; 3) men or women with genital signs or symptoms outlined in the routine STD history section below; 4) men who have sex with men; 5) men or women with a sexual partner who has an STD; and 6) men and women not using barrier contraceptive methods.

A number of factors make the identification and treatment of STDs challenging. First, many patients with an STD have few or no symptoms, and their infections will remain undetected if routine screening is not performed. Second, many patients have simultaneous infections involving more than one site (e.g., cervix plus urethra, cervix plus vagina, urethra plus rectum, or urethra plus pharynx), and the symptoms resulting from these infections may overlap, such that they cannot be clearly distinguished on the basis of symptoms alone. Third, patients may be infected with more than one pathogen (e.g., simultaneous urethral infection with chlamydia and gonorrhea). Fourth, laboratory facilities may lack the technology to readily identify all sexually transmitted pathogens. Therefore, many patients may present with symptoms that cannot be readily or reliably attributed to a specific pathogen, while others with asymptomatic infections are not diagnosed because the appropriate laboratory test is unavailable. Finally, in addition to diagnosis and treatment of individual patients, the clinician has the responsibility for STD case detection by screening at-risk, asymptomatic individuals and their sexual contacts. Early education and interventions in these high-risk persons aids in the prevention and transmission of STDs.

For these reasons, it is advisable that clinicians adopt a consistent approach to persons with risk of STD. These patients should undergo a standardized examination that includes:

  1. specific relevant history,
  2. physical examination, and
  3. appropriate laboratory tests.

THE ROUTINE STD HISTORY

It is critical to ensure that a patient is at ease when engaging in STD risk assessment and counseling. The preferred approach emphasizes respect, compassion and a nonjudgmental attitude. Optimal counseling takes into consideration a patient's age, culture, language, gender, sexual orientation, education and developmental level. Providers should utilize open-ended questions (for example, "tell me about any new sex partners you have had since your last visit"). Providers should utilize non-technical terms when asking about symptoms of STD ("have you ever had a sore or scab on your penis?"). It is also helpful to use language that normalizes potentially uncomfortable topics ("some of my patients have difficulty using a condom with every sex act. Is this an issue for you?"). One approach to eliciting information about five key areas of interest is summarized in five "Ps": Partners, Prevention of Pregnancy, Protection from STDs, Practices and Past STDs. The 2010 CDC STD Treatment Guidelines list specific questions within these topic areas. Below we provide a series of questions that address these areas as well as others that are important considerations when managing patients (for example, history of allergy to medication). Moreover, it may be worthwhile for providers to consider client-centered interactive counseling, a counseling approach designed to individually tailor risk reduction. More information is available at: www.nnptc.org

Suggested History - Women

  1. What brings you in today?
  2. Do you have specific symptoms, and, if so, tell me about your main symptom.
  3. Are you experiencing an increase in vaginal discharge or odor and, if so, for how long?
  4. Do you have vulvar itching or irritation and, if so, for how long?
  5. Do you have burning with urination, urgency, or frequency and, if so, for how long?
  6. Have you noticed any genital lesions or sores and, if so, how long have they been present?
  7. Have you had any recent lower abdominal pain or rectal symptoms and, if so, for how long?
  8. Have you noted any skin rash in your genital area or anywhere else on your body?
  9. Have you had sex with more than one partner in the last 2 months and, if so, how many? Have you had sex with any new partners in the last 2 months? How many partners have you had in the last year? As far as you know, do any of your sex part­ners have other sex partners? Do any of your sex partners have signs of infection? Are any of your partners infected with HIV?
  10. Do you have sex with men, women, or both?
  11. When was your last sexual encounter?
  12. In the last 2 months, have you given or received oral sex? Anal sex? Vaginal sex? If so, did you use protection (condoms) for any or all of these episodes?
  13. When was your last menstrual period? Was it normal?
  14. (If with a male partner) Are you and your partner trying to get pregnant? If not, what are you doing to prevent pregnancy? If you use condoms, do you use them with all of your partners? Which partners do you use condoms with and how often do you forget to use them?
  15. Tell me how often you use drugs or alcohol?
  16. Have you taken any antibiotics in the last month?
  17. Have you had any allergic reactions to any medications that you know of?
  18. Have you had any sexually transmitted diseases diagnosed previously and, if so, when and which one(s)? Have you had a diagnosis of chlamydial infection in the last year? 6 months? Have you had a test for HIV? If so, what was the date and result of your last HIV test? Are you concerned that you might have been exposed to a partner with HIV or at risk from HIV?
  19. Do you regularly use alcohol or drugs? If you use injection drugs, do you share needles? How do you feel that drugs or alcohol impact your sex life?
  20. If you have had male partners, to your knowledge, have any of them been bisexual?
  21. Do you douche? If so, how often? What do usually use?
  22. Have you been vaccinated against hepatitis B? HPV?

Suggested History - Men

  1. What brings you in today?
  2. Do you have specific symptoms and, if so, which is your main symptom?
  3. Do you have a urethral discharge and, if so, for how long? How would you describe it, for example, clear and thin? White and thick? Yellow and thick?
  4. Do you have any burning when you pass urine and, if so, for how long have you noticed it?
  5. Have you noticed any skin lesions on your penis, scrotum, or groin and, if so, for how long?
  6. Have you noted any skin rash in your genital area or anywhere else on your body?
  7. Have you had any rectal symptoms, diarrhea, or constipation?
  8. Have you had sex with more than one partner in the last 2 months and, if so, how many? Have you had sex with any new partners in the last 2 months? How many partners have you had in the last year? As far as you know, do any of your sex partners have signs of infection? Are any of your partners infected with HIV?
  9. Do you have sex with men, women, or both?
  10. When was your last sexual encounter?
  11. In the last 2 months have you had vaginal sex? Given or received oral sex? Given or received anal sex?
  12. Have you taken any antibiotics in the last month?
  13. Have you had allergic reactions to any medications?
  14. Have you had any sexually transmitted disease diagnosed previously and, if so, which one(s) and when? Have you had an HIV test? If so, what was the date and result of your last HIV test? Are you concerned that you may have been exposed to a partner with HIV or at risk for HIV?
  15. Do you regularly use alcohol or drugs, injection or other? If you use injection drugs, do you share needles? Have you used or are you using methamphetamine?
  16. (If with a female partner) Is your partner trying to get pregnant? If not, what are you doing to prevent pregnancy? What has your experience with using condoms been? Are there any partners you tend to use condoms with more often?
  17. (If with a male partner) What has your experience been using condoms with men? Have you been vaccinated against hepatitis A and hepatitis B?
  18. Do you regularly use alcohol or drugs? If you use injection drugs, do you share needles? How do you feel that drugs or alcohol impact your sex life?
  19. Have you been vaccinated against hepatitis B? HPV?

THE PHYSICAL EXAMINATION

As with the history, a routine approach toward examining patients with STDs should be adopted.

Physical Exam - Women

The minimal routine physical examination for women with a suspected STD includes the following:

  1. Temperature, pulse and blood pressure
  2. Skin inspection of lower abdomen, trunk, inguinal areas, thighs, hands, palms, soles and forearms
  3. Inspection of the pubic hair for lice and nits
  4. Inspection and palpation of the external genitalia and inspection of the perineum and anus
  5. Speculum examination of the vaginal and cervix
  6. Bimanual pelvic examination
  7. Palpation for inguinal and femoral adenopathy
  8. For women reporting anal sex, inspection of the anus. For complaints of rectal symptoms, anoscopy

Physical Exam - Men

The minimal routine physical examination for men with a suspected STD includes the following:

  1. Inspection of the skin of the genitals, inguinal areas, thighs, lower abdomen, hands, palms, soles and forearms.
  2. Inspection of the pubic hair for lice and nits.
  3. Inspection of the penis, including urethral meatus, with retraction of the foreskin, if present, and milking of the urethra
  4. Palpation of the scrotal contents
  5. Palpation for inguinal and femoral lymphadenopathy
  6. For men who report sex with other men (MSM), inspection of the mouth, throat/pharynx, perineum, and anus. Palpation for cervical, supraclavicular, and axillary lymphadenopathy. For MSM complaining of rectal symptoms, anoscopy

After completion of the routine screening history and physical examination, it should be possible to tentatively classify patients into one of several clinical syndromes. Some patients will be asymptomatic and have no signs on physical exam and should receive no therapy until their laboratory test results are received. Identifying a tentative clinical syndrome helps narrow the field of possible pathogens that could cause the infection. Table 1-1 summarizes the most common pathogens associated with different syndromes. Algorithmic approaches to specific etiologic diagnoses for each of the syndromes are presented in the relevant chapters. These recommendations should be followed while waiting for laboratory confirmation of the diagnosis, and they may suggest that additional historic data or laboratory tests are necessary.

Table 1-1

Selected Syndromes And Complications With Corresponding Sexually Transmitted Etiological Agentsa
SYNDROME AGENT
Men
Urethritis N. gonorrhoeae, C. trachomatis, herpes simplex virus (HSV), T. vaginalis, M. genitalium
Epididymitis C. trachomatis, N. gonorrhoeae
Intestinal infections:  
Proctitis N. gonorrhoeae, HSV, C. trachomatis, T. pallidum
Proctocolitis Campylobacter sp. Shigella sp. E. histolytica, Salmonella sp.
Enteritis G. lamblia, cryptosporidiosis
Women
Lower genitourinary tract infections:  
Vulvitus C. albicans, HSV
Vaginitis T. vaginalis, C. albicans, and anaerobes associated with bacterial vaginosis (BV)
Cervicitis N. gonorrhoeae, C. trachomatis, HSV (ectocervicitis), M. genitalium
Urethritis N. gonorrhoeae, C. trachomatis, HSV
Upper genitourinary tract infections:  
Pelvic inflammatory disease N. gonorrhoeae, C. trachomatis, M. genitalium, aerobes (E. coli) anaerobes (e.g. peptostreptococci)
Infertility:  
Postsalpingitis, postobstetric, postabortion N. gonorrhoeae, C. trachomatis
Pregnancy morbidity:  
Chorioamnionitis, amniotic fluid of these conditions, including BV infection, prematurity, premature rupture of membranes, postpartum endometritis, ectopic pregnancy Several STD agents have been implicated in one or more of these conditions, including BV
Men & Women
Genital ulceration HSV, T. pallidum, H. ducreyi, Klebsiella granulomatis, C. trachomatis (LGV strains)
Nonulcerative genital skin lesions T. pallidum, C. albicans, HSV
Genital warts Human papillomavirus (HPV) types 6 and 11
Molluscum contagiosum Pox virus
Ectoparasite infestations Sarcoptes scabiei, Phthirus pubis
Neoplasia:  
Cervical intraepithelial neoplasia, carcinoma HPV types 16 and 18, and other oncogenic HPV types
Anal carcinoma HPV types 16, 18 and other oncogenic types
Hepatocellular carcinoma Hepatitis B
Kaposi's sarcoma HIV, HHV-8
Hepatitis Hepatitis A, B and C viruses, cytomegalovirus, T. pallidum
Acquired immune deficiency Syndrome (AIDS) HIV-1, HIV-2
Acute arthritis with urogenital or intestinal infection N. gonorrhoeae, C. trachomatis, Shigella sp., Campylobacter sp.
Neonates & Infants
TORCHES syndromeb Cytomegalovirus, HSV, T. pallidum
Conjunctivitis C. trachomatis, N. gonorrhoeae
Pneumonia C. trachomatis
Sepsis, meningitis Group B streptococcus
Cognitive impairment, deafness Cytomegalovirus, HSV, T. pallidum
aFor each of the above syndromes, some cases cannot yet be ascribed to any cause and must be considered idiopathic.
bTORCHES is an acronym for toxoplasmosis, rubella, cytomegalovirus, herpes, and syphilis. The syndrome consists of various combinations of encephalitis, hepatitis, dermatitis, and disseminated intravascular coagulation.

 

SCREENING LABORATORY TESTS

Routine screening laboratory data should be obtained from all patients at risk of an STD. The following list of procedures is recommended:

STD Screening Tests: Heterosexual WOMEN

  1. Diagnostic test for trichomoniasis* (including rapid antigen test, nucleic acid probe, culture, or nucleic acid amplification test)
  2. Nucleic acid amplification test* (NAAT) forN. gonorrhoeae from the following sites:
    1. Self-collected vaginal swab (alternatively, endocervical swab or first-catch urine)
    2. Pharynx (if report of oral sex, and if assay validated by performing laboratory)
    3. Rectum (if report of receptive anal sex, and if validated by performing laboratory)
  3. NAAT for C. trachomatis from the following sites:
    1. Self-collected vaginal swab (alternatively, endocervical swab or first-catch urine)
    2. Rectum (if report of receptive anal sex, and if assay validated by performing laboratory)
  4. Pap smear as directed by standard guidelines
  5. Syphilis serology
  6. HIV antibody assay

STD Screening Tests: Heterosexual MEN

  1. Urethral gram stain is recommended if:
    1. patient has symptoms of urethritis
    2. patient has mucopurulent or purulent urethral discharge on examination
    3. patient is a contact to a partner with PID, cervicitis, or known case of N. gonorrhoeae or C. trachomatis
  2. First-void urine for leukocyte esterase testing or microscopic examination of first-void urine sediment
  3. Urine for NAAT for N. gonorrhoeae and C. trachomatis
  4. Syphilis serology
  5. HIV antibody assay

STD Screening Tests: Men who have sex with Men

  1. Urethral gram stain is recommended if:
    1. patient has symptoms of urethritis
    2. patient has mucopurulent or purulent discharge on examination
    3. patient is a contact to a partner with N. gonorrhoeae or C. trachomatis
  2. First-void urine for leukocyte esterase testing or microscopic examination of first-void urine sediment
  3. NAAT for N. gonorrhoeae from the following sites:
    1. Urine
    2. Pharynx (if report of oral sex, and if assay validated by performing laboratory)
    3. Rectum (if report of anal sex, and if assay validated by performing laboratory)
  4. NAAT for C. trachomatis from the following sites:
    1. Urine
    2. Rectum (if report of receptive anal sex, and if assay validated by performing laboratory)
  5. Syphilis serology
  6. HIV antibody assay
  7. Hepatitis B screening test (HBsAg and HBsAb), if not previously vaccinated

STD Screening Tests: Women who have sex with Women

  1. KOH preparation (assess for yeast forms), amine odor assessment (whiff test) pH, saline wet prep (assess Amsel criteria for bacterial vaginosis)
  2. Diagnostic test for trichomoniasis (including rapid antigen test, nucleic acid probe, culture, or nucleic acid amplification test)
  3. Nucleic acid amplification test* (NAAT) for N. gonorrhoeae from the following sites:
    1. Self-collected vaginal swab (alternatively, endocervical swab or first-catch urine)
    2. Pharynx (if report of oral sex, and if assay validated by performing laboratory)
    3. Rectum (if report of receptive anal sex, and if validated by performing laboratory)
  4. NAAT for C. trachomatis from the following sites:
    1. Self-collected vaginal swab (alternatively, endocervical swab or first-catch urine)
    2. Rectum (if report of receptive anal sex, and if assay validated by performing laboratory)
  5. Pap smear as directed by standard guidelines
  6. Syphilis serology
  7. HIV antibody assay

*NAAT offers high sensitivity and is FDA approved for urine testing of C. trachomatis and N. gonorrhoeae. Some NAATs are cleared for use with vaginal swab specimens, which can be self-collected by the patient. If NAAT is unavailable, cell culture, direct immunofluorescence, EIA, and nucleic acid hybridization tests are available for the detection of C. trachomatis on endocervical specimens in women and urethral swabs from men, but are inferior in ability to reliably detect infection and are not preferred diagnostic methods. Culture and nucleic acid hybridization tests for N. gonorrhoeae can be done on these same specimens.

In summary, each time a patient comes to you with a possible STD, make a clear and comprehensive clinical assessment based on:

  • the history of sex of partners, number of partners, specific sexual activities and symptoms
  • a physical examination with a clear description of any noted abnormalities
  • a plan, including all diagnostics requested and therapies initiated

The management plan should clearly state which drugs and exact doses have been prescribed, the need, when applicable, for notification of sex partners, and when the patient should plan to return for follow-up. A specific management plan for the patient's sexual partners should also be listed. Confirmed cases should be reported to the state/local health department.

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