Sexually Transmitted Disease (STD)

The Venereal Diseases Act of 1917 defined 3 such diseases. They were syphilis, gonorrhoea and chancroid. In the UK chancroid is unimportant and often forgotten although it is still troublesome in some parts of Africa. Syphilis ebbed but has been resurgent and the prevalence of gonorrhoea is often taken as an index of the degree of promiscuity in the community.

The generic term for the venereal diseases (VD) was changed to sexually transmitted diseases (STD) and the VD clinics became special clinics as new euphemisms were devised to hide the embarrassment of society. More recently the speciality was called genito-urinary medicine (GUM). They are also referred to as sexually transmitted infections (STI). The range of diseases that would meet that classification is now much wider.

• After a surge in sexually transmitted diseases during the First World War there was a lull between wars and another surge during the Second World War. Some young men going off to war sought comfort in a way that put them at risk of acquiring sexually transmitted diseases.
• The 1960s saw an unprecedented availability of the pill and increased promiscuity, without barrier contraception. The slogan of the young was "make love, not war" and the use of drugs became more prevalent. There was an unrealistic expectation that antibiotics could cure all sexually transmitted diseases.
• The advent of AIDS was a chilling reminder of the limitation of antibiotics and whilst promiscuity fell, as indicated by the incidence of gonorrhoea, this fall was only temporary.
• Young people representing 12% of the population account for nearly half of all STDs diagnosed in genitourinary medicine clinics in the UK in 2007.¹
• Of particular concern is the very high rate of chlamydia and genital wart infections in girls aged 16-19 years.¹

To make a meaningful analysis of the facts and figures, it is important to look at the various ways by which the diseases may be spread. Not all such diseases are always spread by sexual activity. Transmission of infection can occur, for example by intravenous drug abuse. Some diseases can be vertically transmitted from mother to child.

The pool of undiagnosed disease in a population is also an important problem. Such people can spread infection unwittingly. The number of people carrying undiagnosed infection varies according to the disease concerned. In many cases, infection remains undiagnosed as the individual is asymptomatic. The disease may be more likely to produce symptoms in one sex than the other, but it remains contagious. For example a man may readily see a primary chancre of syphilis on his glans whilst a woman is unaware of one on her cervix. Candida may cause vaginal discharge and pruritus vulvae but often in men it causes no symptoms.

The Health Protection Agency's recent reports give much cause for concern.¹ Unsafe sexual practices amongst the young are reflected in higher rates of infection. To summarise:

• HIV and AIDS:
  • A high level of new diagnosis in men having sex with men (MSM) but with a slight fall in observed cases in recent years.
  • A steady increase in the number of new HIV diagnoses in the heterosexual population. Over half of such diagnoses are made in the heterosexual population and about 95% of these are from Africa.
  • Limited but compelling evidence that heterosexual transmission of HIV within the UK is slowly rising with half of white heterosexuals now acquiring their infection in the UK.
  • There are similar rates of new HIV infection across the country but with big increases seen in the East Midlands, the East of England and Northern Ireland.
  • Later diagnosis is higher in heterosexuals (for example more patients with higher CD4 counts).
  • All groups show steady increase in the over 55 age group.
• Gonorrhoea:
  • Rates of diagnosis have fallen slightly since 2002.
  • However this masks an increase in the MSM group since 2002.
  • Rates of diagnosis have been increasing in Scotland and Northern Ireland.
• Chlamydia:
  • There continue to be high rates of chlamydia infection. It is still the most common STD.
  • In 2006 chlamydia screening revealed positivity rates of around 10% in the 16 to 24 age group for men and women.
  • Screening in 2006 also revealed rising rates of positivity in men between 25 and 34 years.
• Syphilis:
  • Cases have plateaued in all groups since 2005.
  • Most cases occur in men and most of these in the MSM group.
• Genital warts:
  • Since 1997 there has been a steady rise in the 16 to 24 year age group, particularly diagnosed in GUM clinics (along with other STIs especially chlamydia).
  • Genital warts are the second most common STD.
  • Higher rates are noted in young women particularly, with rates double those in men.
• Other observations:
  • By the end of 2004 there were an estimated 58,300 people living with HIV in the UK, of whom 34% were unaware of their infection.
  • The incidence of gonorrhoea also remained high amongst homosexuals in 2004, with 3,977 infections diagnosed. More than a quarter were resistant to ciprofloxacin. The epidemic of syphilis in this group continued to grow, and there has been a significant increase in the number of cases of lymphogranuloma venereum (LGV). The last was previously thought of as a rare disease.
  • Young people in the UK have a high prevalence of chlamydia, gonorrhoea and genital warts. Rates of diagnoses have continued to increase among young people with the highest rates of gonorrhoea diagnoses seen among men aged 20-24 and women aged 16-19. About three-quarters of chlamydia diagnoses in women were in young women, and 56% of diagnoses in men were in young men.
  • Some of the increases in gonorrhoea and chlamydia diagnoses among young people may reflect increased attendance of young people at GUM clinics, and for chlamydia, increased and more sensitive testing.
  • Diagnoses however, will underestimate the true level of infection in the UK, as many infections are asymptomatic.
  • HIV, gonorrhoea and syphilis have marked variation in geographical distribution within the British Isles and within England. For chlamydia, genital warts and genital herpes simplex virus (HSV), there was much less variation across the UK.

The risk of acquiring sexually transmitted diseases is greatest in those who are promiscuous, especially if they do not use barrier contraceptives.

Other factors associated with a higher incidence of sexually transmitted infections are:^2,3

• Young age
• Failure to use barrier contraceptives
• Non-regular sexual relationships
• Homosexuality
• Intravenous drug use
• African origin (sub-Saharan Africa)
• Social deprivation
• Prostitution
• Poor access to advice and treatment of STDs

The number of diseases that are usually transmitted by sexual intercourse or which may be transmitted by that route, is much greater than the 3 defined by the Venereal Disease Act.⁴ Some on this list may seem a little surprising to be classified as sexually transmitted diseases:

• Syphilis
• Gonorrhoea⁵
• Chancroid
• HIV infection and AIDS
• Chlamydia⁶
• Nonspecific urethritis (NSU) including Reiter's disease⁷
• Lymphogranuloma venereum⁸
• Genital herpes simplex⁹
• Genital warts¹⁰
• Carcinoma of cervix
• Vaginal candidiasis¹¹
• Hepatitis B and, to a rather lesser extent, hepatitis C¹²
• Pelvic inflammatory disease¹³
• Trichomonas Vaginalis¹⁴
• Epididymo-orchitis¹⁵

Many of these diseases are covered in more detail under the appropriate article.

Most STDs are best treated in a GUM clinic as they have expertise in diagnosis and treatment as well as the ability to perform contact tracing. However many patients with STDs present to GPs and it is essential that the initial advice and information is correct even if definitive diagnosis and treatment are not given.

History

This can present problems in general practice for many reasons. For example:

• Patients are often reluctant to talk about their condition because of the stigma associated with STDs.
• Patients may not appreciate that their symptoms are the result of a sexually transmitted disease.
• Inexperience or lack of knowledge amongst GPs.
• Colluding with patients to 'play down' symptoms.
• Lack of time to adequately assess.
• The sensitivity of the subject for doctor and patient (particularly when the doctor has known the patient and family for many years).
• Problems posed by the need for intimate examinations (use of chaperones for example).

With these issues in mind it is important to make patients feel more comfortable during the history-taking and examination. For example a demeanour which displays interest and concern is preferable to one which might convey the opposite. If the doctor appears distracted or judgemental, in the context of STDs particularly, this will impede successful diagnosis and management. It is worth remembering basics:

• Welcome your patient
• Encourage your patient to talk
• Look at your patient
• Listen to your patient

Sexual history

A sexual history is essential to guide decisions about management, or additional examinations or tests that might benefit the patient with suspected STD. In a private place where no one else can hear, the patient should be asked about:

• The reason for their visit.
• Social history, including factors that may increase STI/RTI risk.
• Past medical history, including any medications or drug allergies.
• Previous pregnancies and routine gynaecological history (including last menstrual period, menstrual pattern, contraception).
• Sexual history with particular reference to any behaviour associated with risk. This includes for example not using barrier contraceptives, multiple partners and sexual practices associated with particular infections.
• Symptoms of the presenting complaint.
• Specific symptoms of STD.
• Psychosexual history. Psychosexual difficulties can cause symptoms similar to those of STD.

Examination

• Avoid the possibility of others walking in on the examination.
• t is usually advisable to have a chaperone when examining patients of the opposite sex.
• It is appropriate to begin with a general assessment, including vital signs, inspection of the skin and detection of signs of systemic disease.
• Remember basics before examining:
  • Ensure that the examination can be conducted in privacy.
  • Wash hands well (water and soap).
  • Use a sheet or clothing to cover patient.
  • Position patient and ensure they are comfortable.
  • Explain what you are about to do.
  • Put on suitable examination glove.
  • Carry out the examination in good light.

Female patients

There are three components to the female genital examination (assuming speculum/equipment available):

• External genital examination:
  Inspect perineum and anus—using the gloved hand.
  • Look for lumps, swelling, lymphadenopathy, abnormal discharge, sores, ulcers, tears and scars around the genitals and in between the skin folds of the vulva.
• Speculum examination for:
  • Vaginal discharge and redness of the vaginal walls (vaginitis).
  • Ulcers, sores or blisters.
  • Cervical abnormalities (tumours, contact bleeding or discharge).
• Bimanual examination:
  Lower abdominal tenderness (when pressing with the outside hand).
  • Cervical motion tenderness (often evident from facial expression) when the cervix is moved from side to side with the fingers of the gloved hand in the vagina.
  • Uterine or adnexal tenderness when pressing the outside and inside hands together.
  • Any abnormal swelling (remember pregnancy, uterovaginal prolapse, ovarian cysts, tumours etc)

Male patients

• Ask the patient to stand up and lower his underpants to his knees (or examine with patient lying if preferred).
• Palpate the inguinal region for enlarged lymph nodes or buboes.
• Palpate the scrotum, feeling for the testis, epididymis, and spermatic cord on each side.
• Examine the penis, noting any rashes or sores.
• Ask the patient to pull back the foreskin if present and look at the glans penis and urethral meatus.
• If no obvious discharge, ask the patient to milk the urethra.
• Ask the patient to turn his back to you and bend over, spreading his buttocks slightly. This can also be done with the patient lying on his side with the top leg flexed up towards his chest.
• Examine the anus for ulcers, warts, rashes, or discharge.

History and examination may lead to the detection of STD which may be entirely unsuspected by the patient, particularly the asymptomatic patient (for example STDs detected at routine cervical cytology screening).

Practical guidance is available for the most appropriate tests to use in primary care to diagnose STDs from a number of sources. These are not evidence based but provide guidance for testing in a primary care setting:

• The Bacterial Special Interest Group of British Association for Sexual Health and HIV (BASHH).¹⁶
• The Sexually Transmitted Screening and Testing Guidelines for UK genitourinary medicine clinics.
• The local laboratory.

More extensive testing is available by referral to a local genitourinary medicine clinic.
All pathology laboratories have their own operating policies. It is often important to discuss tests with the local laboratory. The processing of samples varies considerably and may depend on the clinical information provided. There are other
guidelines produced from the Health Protection Agency and Association of Medical Microbiologists to inform healthcare professionals working in laboratories.

Tests vary around the country, so you should be familiar locally with:

• Which swabs to take
• Where to swab
• How to take a sample
• Transport issues
• The sensitivity and specificity of tests (as false positives and false negatives occur)

If there is a particular local need consider:

• Going on a Sexually Transmitted Infection Foundation (STIF) course (for example see the BASHH link below for local venues)
• Talking to your local GU clinic and microbiology laboratory

What to test for and when

Asymptomatic patients

Those at high risk of sexually transmitted infections are:

• Under the age of 25 and/or
• With a new sexual partner within the previous 12 months

Women

• Test for Chlamydia trachomatis.
• In areas of high prevalence of gonorrhoea (or if local outbreak) a test for Neisseria gonorrhoeae should be undertaken in high risk patients.
• Trichomonas (relatively uncommon and usually symptomatic but should be tested for).
• It is not possible to exclude herpes genitalis by ‘screening’. Only test for herpes if lesions present.⁹
• In asymptomatic patients there is no value in taking samples for bacterial vaginosis or candida¹¹ (neither of which are strictly sexually transmitted).

Men

High risk groups (above):

• Urine test for chlamydia and gonorrhoea.
• A positive test for gonorrhoea should prompt refer to GU clinic for a gonorrhoea culture to be obtained (confirms diagnosis and gives antibiotic sensitivities prior to treatment)

Symptomatic patients

Women

• Symptomatic women in high risk groups (under 25 and new sexual partner last 12 months) test for:
  • Gonorrhoea
  • Chlamydia
  • Bacterial vaginosis
  • Trichomonas
  • Candida¹¹
• Symptomatic women over 25 years:
  • A risk assessment should be undertaken.
  • Test for chlamydia and gonorrhoea whatever the genital symptoms if not previously performed.
  • The commonest cause of vaginal discharge will be either bacterial vaginosis or candida.
  • If there has been no change in sexual partner since the last test for chlamydia/gonorrhoea, then empirical treatment based on the pH paper result with further investigation if the symptoms do not resolve should suffice. For normal vaginal pH treat as if candida, for elevated pH (5.0) treat for bacterial vaginosis.
  • If urinary symptoms and/or lower abdominal pain, sexually transmitted organisms should be excluded in the high risk group and considered on the basis of a risk assessment in those over 25 with no change of partner.

Men

• Urethral discharge and/or dysuria usually indicate a STD.⁷
• Ideally a diagnosis of urethritis needs to be made for which microscopy of a Gram-stained slide is required (see gonorrhoea article).
• Tests for gonorrhoea and chlamydia are recommended.
• Men with testicular swelling or discomfort should have STD excluded.¹⁵ The commonest cause of these symptoms in men under 40 is Chlamydia trachomatis.
  An MSU is also advisable to exclude a urinary tract organism as a cause of this, especially in the over 40s.

HIV and Syphilis testing

Syphilis and HIV testing should be offered to:

• Patients from high prevalence countries or have lifestyle factors that put them at higher risk of these infections.
• Patients with symptoms that could be attributed to either of these diseases.
• Screening for these infections should be considered in high risk groups who are asymptomatic but may be presenting in primary care for other reasons.

Full guidance on HIV testing is given in the article entitled HIV Counselling.

Hepatitis B¹²

• Screen for Hepatitis B as for HIV/Syphilis risk.
• Those in a risk group should be offered and given a Hepatitis B vaccination if they are susceptible.

Gonorrhoea⁵

• The recommended test is either culture or nucleic acid amplification test (NAAT). A positive NAAT should be confirmed using culture.
• If facilities are available, a slide smeared thinly with discharge and air dried for gram staining and microscopy may give a rapid diagnosis.
• Sampling sites:
  • Men - urethra (plus pharynx and rectum if the history indicates the possibility of infection but by culture only not NAAT)
  • Women - endocervix (plus pharynx and rectum if the history indicates the possibility of infection but by culture only not NAAT)
• Transportation issues:
  • Culture - swab to be sent in transport media (e.g. Amies, Stuarts)
  • Refrigerate while awaiting transportation
  • Deliver to the laboratory within 24 hours (there is loss of viability even after 6hours so rapid transport recommended or referral to GU clinic if confirming a positive NAAT)
  • If potential exposure to infection occurred within 48 hours of test then repeat swab for culture after 2 weeks
  • NAAT - no special precautions (see manufacturer’s instructions for details on individual NAATs)

Chlamydia^6,17

• The recommended test is the nucleic acid amplification test.
• Sampling sites:
  • Men - urethra or urine. Urine testing is less traumatic for the patient and recommended.
  • Women - endocervix (urine or vulval/vaginal swabs are also acceptable with NAAT but not with other methods like the enzyme linked immunosorbent assay or EIA)
• There are no transportation issues or special precautions (see manufacturer’s instructions for details on individual NAATs).

Syphilis

• The recommended test is the enzyme linked immunosorbent assay (EIA) blood test.
• There are no transportation issues or special precautions.
• It is important to note that serology may take up to 3 months to become positive following infection.

Bacterial vaginosis

• Recommended test is a gram stain of a thin smear of vaginal discharge placed on a microscopy slide and air dried.
• If pH paper is available an elevated vaginal pH (>4.5) is consistent with bacterial vaginosis (test lacks specificity).
• Swab taken from vaginal wall (or self-taken low vaginal swabs).
• The swab to be sent in transport media (e.g. Amies, Stuarts) requesting gram stain for mixed flora suggestive of bacterial vaginosis (or air-dried smear sent to the laboratory).
• Sample should be refrigerated while awaiting transportation.

• Details can be found in the articles linked above under the heading 'Sexually transmitted diseases'.
• Management of STD in children and young people is beyond the cope of this article.¹⁸
• Anyone who is being treated for a sexually transmitted infection should abstain from sexual activity until treatment (their own and their partners) is complete.
• Single dose antibiotics are often used where possible, to improve compliance.

The HPA report for 2008 suggests:¹

• Better access for young people to sexual health services which can deliver advice, screening and treatment of STDs.
• Interventions to promote sexual health which are of proven effectiveness are needed.
• Health education to provide information and skills is needed in the area of relationship and sexual health.
• Information to enable primary care to target preventive measures is needed.

This is supported also by advice on prevention from the WHO.³
The social stigma of having a sexually transmitted disease is enormous and the GUM clinics, since their origin, have been discrete and kept anonymity for their patients. Patients are often given a number so that they do not have to present with a name. They tend to have a discrete entrance in a distant part of the hospital and, to ensure compliance, the drugs they dispense are exempt from prescription charges. It is the only part of the NHS that will not routinely inform the patient's GP of attendance.

Despite anonymity and sensitivity of diagnosis clinics will attempt to trace contacts of those with sexually transmissible diseases. This is a very important role.

A number of factors have been identified as contributing to a successful programme.¹⁹ Adverse attitudes to the wearing of condoms must also be overcome. As explained in the article on AIDS there has been disinformation about condoms.^20,21,22

There is uncertainty about the origins of syphilis. Some people claim that it was brought back from America by Columbus' sailors but others argue that it originated in the Old World. An archeological find of the bones of an Essex woman suggested that she had advanced syphilis, between 1300 and 1450. This would predate Columbus' voyage of 1492.

It is often claimed that Henry VIII died of syphilis but the evidence for or against is poor. In those days any ulceration was called pox and syphilis was the great pox. The ulcer on his leg that failed to heal may well have been from type 2 diabetes.

The legendary Giacomo Casanova (1725-1798) was said to have invented the condom, fashioned from a sheep's intestine, not as a contraceptive but as protection against syphilis. He may have used them but he was not the first. Condoms appear in some of the pictures of A Harlot's Progress by William Hogarth (1697-1764). This series of paintings was completed in 1731, when Casanova would have been 6 years old.

The term syphilis was not part of the English language until 1717, following the translation of an Italian work. The disease had been the pox and in London rhyming slang, the acquisition of any GUM infection is still referred to as "a dose of the Surrey Docks". The clap refers to gonorrhoea, from the old French word clapier, meaning a brothel. It was long thought that the two diseases were one. In 1767, John Hunter inoculated a subject with matter of gonorrhoea on the prepuce and glans but the inoculum was from a patient suffering from both diseases and syphilis developed.²³ In 1793, Benjamin Bell, an Edinburgh surgeon confirmed that the diseases were distinct as a result of experimentation on medical students. This was in the days before Local Research Ethics Committees. The eminent Guy's surgeon Sir Ashley Cooper recognised the two diseases as distinct and in 1824 he wrote in The Lancet "a man who gives mercury in gonorrhoea deserves to be flogged out of the profession because he must be quite ignorant of the principle in which the disease is cured."

The etymology of gonorrhoea is probably from the Greek for seed flow in that it was assumed that the urethral discharge was semen. Folk etymology suggests an association with the biblical town of Gomorrah. Its equally evil neighbour, Sodom, is the origin for the term for anal intercourse. In the Book of Genesis, chapters 18 and 19 outline the evils of those towns and their unpleasant end in a hail of fire and brimstone.

In 1864 Parliament passed the Contagious Diseases Act. This legislation allowed policeman to arrest prostitutes in ports and army towns and bring them in to have compulsory checks for venereal disease. If the women were suffering from sexually transmitted diseases they were placed in a locked hospital until cured. It was claimed that this was the best way to protect men from infected women. Many of the women arrested were not prostitutes but they still were forced to go to the police station to undergo a humiliating medical examination.

During the First World War, with so many servicemen abroad, it is unsurprising that sexually transmitted diseases were rife. A Royal Commission on Venereal Diseases had been set up in 1913, before the outbreak of war and it was this that led to an Act of Parliament in 1917. It identified 3 diseases that were in the original classification that were euphemistically referred to as venereal diseases (VD), after Venus, the Roman goddess of love.

The traditional treatment for syphilis was heavy metals such as bismuth and mercury. They are of dubious efficacy but highly toxic. Hence the adage "one night with venus and a lifetime with mercury." The discovery that penicillin can treat syphilis has revolutionised its management.