www.bashhguidelines.org/current-guidelines/hiv/post-exposure-prophylaxis-following-sexual-exposure/)Genitourinary medicine: overview
Genitourinary medicine: in clinic
Genitourinary medicine (GUM) involves the diagnosis and care of patients with sexually transmitted infections (STIs) and HIV. Related areas include contraceptive care, genital dermatoses, young people's clinics, sexual dysfunction and psychosexual medicine, and outreach services for sex workers and drug users. Most patients are seen as outpatients but some HIV-related cases require inpatient care. Relatively little undergraduate time is dedicated to GUM and the clinics can therefore seem like mysterious places that medical students have little understanding of. However, a huge variety of care is provided through GUM and you should aim to get as involved as possible to make the most of your very short time in this speciality.
Patients presenting without symptoms - find out what tests and vaccinations are routinely offered.
These are very common presentations to GUM clinics and you should be able to see several cases, learn the most common causes, and how to diagnose and manage them.
You should have a basic knowledge of pelvic anatomy and be able to list the most common causes of pelvic pain and how to manage them, including referral to gynaecology for ectopic pregnancies and surgeons for appendicitis. Pelvic inflammatory disease (PID) is an important and common cause of pelvic pain in GUM clinics.
The most important cause of this is acute testicular torsion which is a urological emergency requiring immediate referral. Epididymo-orchitis is an important and common cause of testicular pain in SH clinics.
Consideration of contraception should form part of the consultation for all female presentations to SH clinics to identify those at risk of unwanted pregnancy, provide emergency contraception, and also information on local termination of pregnancy (TOP) services. Gain basic knowledge of the options available including mechanism of action, failure rate, and pros and cons to consider when counselling patients.
Cases of sexual assault may initially present to SH clinic, or be referred from specialist services. They require specialist, experienced care. As a student it is unlikely that you will these see cases, but you should be aware of how to manage them and the referral pathways to health advisors, counsellors, and specialized sexual assault divisions of the police (e.g. The Havens in London).
HIV risk assessment is an important skill. Antiretrovirals can be used to reduce the risk of transmission after potential sexual exposure (PEPSE) or occupational exposure, and now also before sex (PrEP), if the risk is high enough. Occupational exposure following needle-stick injury or blood splashes is more commonly managed by occupational health. Ask someone to take you through the risk assessment table in the British Association for Sexual Health and HIV PEPSE guideline. (See British Association for Sexual Health and HIV, www.bashhguidelines.org/current-guidelines/hiv/post-exposure-prophylaxis-following-sexual-exposure/)
This is an enormous topic and can seem daunting, but there are a few points you should focus on covering during your attachment:
• Screening programmes and opportunities for early diagnosis.
• HIV pretest discussion and how to give the results: spend time with the health advisors in the SH clinic who often have pretest discussions and recall those patients who test positive to give the diagnosis.
• Partner notification: again the health advisors do vital work in this area, and difficult cases are discussed at MDTs—you should definitely attend one of these to gain an understanding of the complex medical, social, and psychological aspects to some HIV cases.
• Medical presentations: of primary or established HIV infection, including the most common opportunistic infections. Spend time in HIV clinic and ask if/how HIV inpatient care is provided in your area to see if you can also spend time on the wards.
• Basic principles of antiretroviral therapy: Sitting in on new patient appointments in HIV clinic will be useful for this.
• Screening programmes and opportunities for early diagnosis.
GUM is a fun, friendly, non-judgemental speciality so get as involved as you can. Sit in on clinics, observe the history taking, examinations, swab-taking, microscopy, and treatments such as cryotherapy. Try to follow a patient on their journey through the SH clinic to start understanding how it all works. Then aim to practise some elements yourself, in particular taking a history, examining, and taking swabs.
Demonstration of correct condom technique. Sit in with the health advisors when they do a ’safe sex’ session with a patient.
Very simple once someone has shown you how to do it.
Performed on symptomatic patients to take samples for microscopy and testing.
Performed in the ‘GUM lab’ by trained nurses; ask them to take you through the preparation of the slides and what they are looking for. Most labs will also have teaching slides they can use to show you examples.
Treatment for warts, often booked in advance for 6-week courses of weekly cryotherapy so ask if there are any patients booked in for this.
HIV-positive patients requiring inpatient care often require procedures as part of their diagnostic workup. These can include bronchoscopy, LP, pleural aspiration/drain insertion, skin biopsy, and OGD, to name but a few. Infectious diseases wards, for example, will be more likely to have procedures such as these to see, and more regularly.
• An accurate sexual history is essential in order to properly assess the risk of infection (and all potential sites) and pregnancy, and identify sexual contacts who may be at risk of infection.
• Partner notification is the process by which sexual contacts who may have been at risk of infection from an index case are traced in order to enable access to healthcare. It has huge public health implications as a core component of STI prevention— 
STI diagnosis and reduced transmission, re-infection, and complications.
• In all cases of suspected/proven STI, patients should be counselled to abstain from sex until fully treated to break the re-infection cycle.
• For HIV-positive patients, partner notification is particularly important; patients often require support from specialists to disclose their status to partners.
• Confidentiality is a core value in GUM and should be emphasized to patients to relieve any anxiety. Contacts can be traced anonymously if patients wish. In the case of HIV, patients are fully supported in the partner notification of partners at previous or ongoing risk, and any children.
Honours
In the UK, persons can now be prosecuted for reckless HIV transmission. In cases where disclosure is not forthcoming and identifiable partners are felt to be at ongoing risk, patients need to be aware of the legal implications of failing to disclose and failing to prevent transmission through consistent condom use and adherence to antiretrovirals.
There is currently an aim to move away from traditional ‘male’ and ‘female’ descriptive terminology and towards ‘penile’ and ‘vaginal’, in line with increasing fluidity of gender and sexuality. See 
pp. 118–120.
Involves sampling genital material (i.e. vaginal, cervical, urethral, and rectal swabs), placing it on slides, and viewing under the microscope in the GUM lab, allowing some diagnoses to be made in clinic. A simple Gram stain is performed and examined to identify, for example, candida, bacterial vaginosis, and gonorrhoea. ‘Wet mount’ is where vaginal discharge is placed onto a slide with saline on, covered with a cover slip, and examined to identify motile trichomonads in trichomoniasis. Dark-field/dark-ground microscopy is used to identify motile spirochetes in cases of syphilis.
Either first-pass urine (penile) or swabs are taken and sent for testing; highly sensitive in both asymptomatic and symptomatic patients.
This is commonly used for herpes simplex virus, and sometimes for syphilis, on swabs taken from the ulcer.
Swabbed material is either transported in an appropriate culture medium or directly plated onto culture plates and sent to pathology; allows pathogen identification and antimicrobial sensitivities to be determined. This is important in cases of gonorrhoea as there are increasing rates of antibiotic resistance.
Blood is taken and tested for syphilis and HIV, as well as hepatitis B and C if needed.
This is the commonest cause of abnormal discharge. The vaginal pH rises above the normal 4.5 with overgrowth of anaerobic species and too few lactobacilli.
• Presentation: With a thin fishy-smelling discharge, but may be asymptomatic (up to 50%). Inflammation and itch are uncommon. It is not sexually transmitted; vaginal douching, use of shower gels, and antiseptic agents can precipitate the pH change. Clue cells can be seen on microscopy.
• Treatment: Options include metronidazole PO/gel or clindamycin gel.
Honours
Using Amsel’s criteria, at least three of the four criteria need to be present to confirm the diagnosis:
• Thin, white, homogeneous discharge.
• Clue cells on microscopy of wet mount.
• Release of fishy odour on adding alkali (rarely done now, patient report of malodour is usually seen as sufficient).
Hay/Ison’s criteria refer to Gram-stained vaginal smear appearances:
• Grade 1: lactobacilli predominate.
• Grade 2: mixed flora with some lactobacilli.
• Grade 3: mostly Gardnerella ± Mobiluncus, with few/absent lactobacilli.
This is a flagellated protozoan. In women it is found in the vagina, urethra, and paraurethral glands; transmission is almost exclusively through sexual intercourse.
• Symptoms: 10–50% women are asymptomatic, but symptoms include vaginal discharge (classically frothy), vulval itching, dysuria, and offensive odour. Up to 2% have the classical ‘strawberry cervix’ visible to the naked eye.
• Diagnosis: This is by detecting the motile trichomonads on light-field wet-mount microscopy, culture, or NAAT (most sensitive and specific).
• Treatment: This is with PO metronidazole, and PN.
This is a fungal infection caused by Candida albicans in 90% of cases.
• Symptoms: Include vulval itch and soreness, vaginal discharge (typically heterogenous, but can be thin), superficial dyspareunia, and dysuria.
• Diagnosis: This is on microscopy and culture.
• Treatment: Options include topical azoles in cream or pessary form, (hydrocortisone combination if vulvitis is marked), or in PO tablet form. General measures such as use of soap substitutes and avoidance of tight-fitting synthetic clothing and perfumed substances can help prevent recurrence.
This is infection of the mucous membranes by Gram-negative diplococcus Neisseria gonorrhoeae.
• Symptoms: These depend on the site of infection and include penile urethral discharge, dysuria, anal discharge and perianal pain, vaginal discharge, and lower abdominal pain. Discharge is mucopurulent. Complications include epididymo-orchitis, prostatitis, PID, and disseminated gonococcal infection.
• Diagnosis: Gram-negative intracellular diplococci are seen within polymorphonuclear leucocytes (PMNLs) on microscopy. Specimens taken: penile—first-pass urine for NAATs and urethral swab for MC&S; vaginal—vaginal and endocervical swabs for NAATs and culture. Rectal/pharyngeal swabs are also taken if history dictates.
• Treatment: This is increasingly difficult due to rising antibiotic resistance. Current treatment is 500 mg ceftriaxone IM + 1g azithromycin PO but new national guidance is imminent. Visit the British Association for Sexual Health and HIV website www.bashh.org for up to date guidance.
This is the most common curable STI in the UK. It is often asymptomatic (70% women, 50% men) which leads to ongoing transmission.
• Screening: In 2003, the National Chlamydia Screening Programme (NCSP) was established in an effort to prevent and control chlamydia through early detection and treatment, reduce onward transmission, and prevent the consequences of untreated infection. People aged 16–25 can access free and confidential chlamydia tests as part of the NCSP at multiple sites across the UK.
• Symptoms: Female symptoms include postcoital or intermenstrual bleeding, lower abdominal pain, purulent vaginal discharge, cervicitis, and dysuria. In men, the main symptoms are urethral discharge and dysuria.
• Complications: Up to 30% of untreated women develop PID which can result in infertility, ectopic pregnancy, and chronic pelvic pain.
• Diagnosis: It is diagnosed on NAAT testing. All potentially exposed sites should be sampled: penile (first pass urine), vaginal (endocervical or vulvovaginal), pharynx, rectal, and conjunctival.
• Treatment: This is with doxycycline 100 mg twice daily for 7 days.
This refers to urethritis where GC is not identified on microscopy. It may or may not be secondary to a STI. Commonest causative organisms isolated are CT and Mycoplasma genitalium.
• Symptoms: These include urethral discharge, dysuria, and penile irritation.
• Diagnosis: This is made by demonstrating an excess of PMNLs in the anterior urethra on microscopy of a Gram-stained urethral smear or first pass urine in symptomatic patients.
• Treatment: This is doxycycline 100 mg twice daily for 7 days. All partners at risk should be identified and treated.
This is caused by HSV types 1 and 2 and is transmitted through direct contact. After primary infection, the virus lays dormant in local sensory ganglia and then periodically reactivates to cause either lesions or asymptomatic virus shedding.
• Symptoms: These include painful ulcers, dysuria, vaginal or urethral discharge, and systemic symptoms of fever and myalgia (see Fig. 17.1).
• Complications: These include autonomic neuropathy causing urinary retention, and aseptic meningitis.
• Diagnosis: This is made clinically from the typical appearance, and detecting HSV on swabs taken from the base of the ulcer.
• Treatment: This includes saline baths, analgesia, topical anaesthetics (e.g. lidocaine), and oral antivirals (e.g. 400mg TDS for 5 days). Patients should abstain from sex during episodes; condom use reduces transmission but cannot completely prevent it. This condition often causes significant distress and health advisors and counsellors can be very helpful in supporting the patient.
Fig. 17.1 Herpes simplex virus genital infection. (a) Female genital infection. (b) Male genital infection. Reproduced with permission from Temesgen, Zelalem, Mayo Clinic Infectious Diseases Board Review, 2012, Oxford University Press.
This is caused by the spirochete bacterium Treponema pallidum. It is transmitted through direct contact (usually sexual), mother-to-child transmission, or via infected blood products. It is classified as acquired or congenital and early or late.
• Primary syphilis: Presents with the ‘primary chancre’, a classically painless, non-healing, anogenital ulcer, and regional lymphadenopathy.
• Secondary syphilis: Multisystem involvement with rash (often affecting palms and soles), generalized lymphadenopathy, condylomata lata (wart-like lesions), and mucocutaneous lesions.
• Latent syphilis: Asymptomatic infection diagnosed on serological testing, either early or late.
• Symptomatic late syphilis: This is very rare, but there are three types:
1. Cardiovascular: results in ascending aortic aneurysms and aortic regurgitation.
• Meningovascular (cranial nerve palsies, stroke).
• General paresis (dementia, psychoses).
• Tabes dorsalis (dorsal column/nerve root inflammation causing sensory ataxia, paraesthesia, lightning pains, areflexia, Charcot’s joints, optic atrophy, and Aryl–Robertson pupils).
3. Gummatous: granulomas form in the skin, mucosa, bone, joints, and rarely viscera.
• Diagnosis: This is made with a combination of history, examination, and investigations including dark-ground microscopy in primary syphilis, and serology.
• Serological testing: This can be confusing and is usually managed by senior members of the team; Table 17.1 should hopefully make interpretation easier.
• Treatment: This is with either benzathine or procaine penicillin IM (or doxycycline PO if penicillin-allergic), the dosage and course length of which varies depending on whether infection is early, late-latent or late-symptomatic.
• Follow-up: This is necessary to monitor response to treatment and detect re-infection or treatment failure.
Table 17.1 Serology testing in syphilis
| Test | Examples | Notes |
| Treponema-specific antibody | TPHA (T. pallidum haemagglutination assay) | Positive in any stage of syphilis infection. |
| EIA (enzyme immunoassay) | Used as a screening test. Also positive in non-syphilis treponemal infection (yaws, pinta). | |
| FTA (fluorescent treponemal antibody) | Remains positive even after effective treatment. | |
| Cardiolipin antibody | VDRL (Venereal Disease Research Laboratory) | A high or rising titre indicates active or recent infection. Titres fall with effective treatment and become negative or serofast at a low titre (1:2) |
| RPR (rapid plasma regain) | False positives seen in several other conditions (pregnancy, TB, SLE, advanced HIV). |
A rare group of infections causing inguinal lymphadenopathy and genital ulceration from endemic areas (African-Caribbean):
1. Lymphogranuloma venereum (LGV) caused by CT serovars L1–L3.
2. Chancroid caused by Haemophilus ducreyi.
3. Donovanosis (granuloma inguinale) caused by Klebsiella granulomatis.
These are caused by human papilloma virus (HPV) most commonly types 6 and 11. They are mostly sexually transmitted, occur at any site, and are generally asymptomatic but can cause irritation and soreness.
• Treatment: Depends on distribution, type, number, and patient preference and this is a point for discussion. Find out the mechanism of some topical treatment options (e.g. podophyllotoxin and imiquimod) and observe cryotherapy treatment in SH clinic.
Lower abdominal pain is a common presentation in young women. It is very important to exclude ectopic pregnancy and appendicitis. Other common causes include PID, UTI, and constipation. PID is inflammation of the upper female genital tract and supporting structures, usually caused by infection. A full STI screen is needed and pelvic examination including bimanual examination. The choice of antibiotic treatment regimen for PID depends on local antimicrobial resistance, patient preference and disease severity—consult your local guidelines.
The most important causes of this are testicular torsion (emergency referral to urology (see p. 806), 6 hours to salvage the testis), strangulated hernia (emergency referral to general surgeons), epididymo-orchitis, tumour (but rarely causes pain) and trauma. Epididymo-orchitis is acute pain, swelling, and inflammation of the epididymis and/or testes. It has several causes, including GC, CT, UTI, TB (think if from an area of high prevalence or immunocompromised), and mumps. A full STI screen should be performed. To cover all potential STIs including GC, treatment is with a stat dose of ceftriaxone IM and doxycycline PO; if cover for enteric organisms is required (unprotected insertive anal sex), ofloxacin/ciprofloxacin is recommended.
PEP is the use of emergency antiretroviral treatment to prevent transmission following exposure to HIV, either occupational or following sexual exposure (PEPSE). The decision to use PEP involves balancing the risk of transmission (which varies according to type of exposure) against the side effects. It should be given within 72 hrs the exposure to gain maximum effectiveness (<72 hours).
PrEP is an oral tablet of antiretrovirals taken before sex by HIV negative individuals at high risk of acquiring HIV (inconsistent condom use, recent STI, recent PEP course, drug use with sex, or HIV-positive partner not taking medication appropriately) as it has been shown to significantly reduce the risk of HIV transmission (PROUD and IPERGAY studies). It is currently available from GUM clinics on the NHS in Scotland and Wales, and through the IMPACT trial in England.
A contraceptive and reproductive history forms part of the full sexual history in order to assess the risk of pregnancy and discuss emergency contraception. A basic knowledge of contraceptive methods, mechanism of action, and failure rate is required to enable patients to make informed choices. See table 17.2. All contraceptive methods are only effective if used consistently and correctly. A full medical history should be taken prior to commencing hormonal methods; the UK Medical Eligibility Criteria for Contraceptive Use provides guidance.1
This provides women with a method of preventing unwanted pregnancy following an episode of unprotected sexual intercourse (UPSI). There are three methods:
• Copper coil inserted up to 5 days (120 hours) after UPSI, or within 5 days from earliest estimated date of ovulation. Failure rate is <1%.
• Ulipristal (ellaOne®) also inhibits or delays ovulation and is licensed for up to 120 days after UPSI.
• Levonorgestrel (Levonelle®) primarily inhibits ovulation and is licensed for use within 72 hours after UPSI/contraceptive failure.
HIV is fairly unique in terms of the scope of conditions, infections, and malignancies that can occur as a consequence, affecting every system. It is now a treatable, manageable condition allowing HIV-positive patients to lead normal lives with normal life expectancy, including having relationships and children without transmitting the virus. However, around 1 in 4 of those infected with HIV are unaware of their infection; therefore it is important to know who to test. Testing should be offered in the presence of risk factors, HIV-associated conditions (Primary HIV infection, indicator conditions and opportunistic infections, see pp. 364–365), and to all new GP registrants and medical admissions in areas of high prevalence.
Trivia
Acquired immune deficiency syndrome (AIDS) began as an epidemic in 1981 with cases being reported all over the US. A retrovirus was later identified as the cause, and labelled as human immunodeficiency virus (HIV) in 1986. A similar virus was discovered that year in West Africa (HIV-2). It is believed to have originated in apes, as simian immunodeficiency virus shares many similarities with HIV, and crossed species (early 1900s).
Those for HIV include originating from a country of high prevalence, STI diagnosis, sexual intercourse with a known HIV-positive partner or partner from high prevalence area, men who have sex with men (MSM), IV drug use, and sex within the commercial sex trade. See Fig. 17.2 for global HIV rates.
Honours
• Septicaemia, pyrexia of unknown origin, recurrent pneumonia.
• Abnormal neurology/peripheral neuropathy/dementia/space-occupying lesions.
• Cancer—especially non-Hodgkin lymphoma and anal/cervical cancers.
• Abnormal haematology—thrombocytopenia, anaemia, lymphopenia
Table 17.2 Methods of contraception
| Method | Examples | Mode of action | Failure rate |
| Barrier | Male condom | Physical barrier preventing sperm meeting ova | 2% |
| Female condom | 5% | ||
| Diaphragms | 5–8% | ||
| Combined hormonal | Pill, transdermal patch, vaginal ring | Inhibit ovulation May also affect cervical/endometrial mucus | 0.3% |
| Progestogen only | Pill | Alter cervical mucus | <1% |
| Injection | Prevent ovulation Thicken cervical mucus Thin endometrium | <4/1000 over 2 years | |
| Implant | <1/1000 over 3 years | ||
| Intrauterine | Copper coil | Inhibits fertilization Affects implantation Thickens cervical mucus | 1–2% over 5 years |
| Levonorgestrel releasing | Inhibits implantation |
This is made using serum to test for HIV-1 and HIV-2 antibodies and p24 antigen. 4th generation tests can now detect HIV 2-6 weeks after exposure. A positive diagnostic test should be confirmed a second time before a formal diagnosis is made. The diagnostic ‘window period’ refers to the period after exposure to HIV and before seroconversion where markers of infection are absent/too low for detection and false negatives may occur (variable but roughly 4 weeks); hence, a negative test should always be followed by a confirmatory test at 3 months. A positive diagnostic test should be confirmed a second time before a formal diagnosis is made.
Point of care tests (POCT) are available in GUM clinics, antenatal units and community settings. They are finger-prick tests that take 15 minutes to give a result and are therefore useful when a result is needed urgently. They have higher false positive rates and therefore require a confirmatory serum test.
This is a glycoprotein expressed on the surface of T-helper lymphocytes and is used as a staging marker of HIV infection, together with the HIV viral load in the blood. As time goes on post infection, the CD4 count falls and the HIV viral load increases; once the CD4 count falls <350, patients become at risk of opportunistic infections and diagnosis after this point is classified as a late diagnosis.
Honours
In the UK, verbal consent is required prior to testing for HIV. In some areas of high prevalence, screening programmes exist where all medical patients are tested routinely on admission and patients can ‘opt out’ of having an HIV test if they wish. Routine antenatal screening was also introduced in about 2000.
However, in cases where consent cannot be gained, e.g. the unconscious patient, and there is a clinical need to test for HIV, the test can be performed in the patient’s best interest.
Patients get sick if they do not know they have the disease and present late with opportunistic infections or AIDs-defining conditions, or if they do not take their medication. Late diagnosis is the most important factor in morbidity and mortality from HIV. AIDS is defined as CD4 count <200, or the presence of certain AIDS-defining conditions e.g. TB and Pneumocystis pneumonia.
The introduction of antiretroviral therapy in the 1990s revolutionized the care of patients with HIV/AIDS. There are several classes from which drugs are selected to create a combination therapy, including reverse transcriptase inhibitors (RTIs), protease inhibitors (PIs), and integrase inhibitors (IIs). Each class works differently and when used in combination forms a highly active antiretroviral therapy (HAART) which reduces the viral load and allows immune recovery. Resistance can develop if not taken at the same time every day.
Patients diagnosed at CD4 <100 are at higher risk of IRIS after commencing HAART. As the CD4 count recovers, any infection can worsen and subclinical infections can be unmasked, the symptoms and timing of which depend on the underlying infection. Examples include hepatitis C IRIS with ALT rise, herpes simplex IRIS with often very severe ulceration, and TB IRIS with fever and lymphadenopathy.
This can be difficult and requires specialist input; high-dose steroids may be required to manage symptoms.
Patients who are diagnosed and adherent to antiretroviral treatment usually remain well, but remain at irisk of certain infections (encapsulated organisms), adverse effects of medications, and malignancies. They are therefore monitored closely, every 6–12 months, with both HIV and systemic monitoring bloods (renal, liver and bone) and thorough systems review. Co-morbidities are also carefully considered, and blood pressure and lipid profile are monitored due to increased risk of cardiovascular disease and diabetes.
It is important to perform baseline serology for infective causes of hepatitis at HIV diagnosis to identify those who are co-infected and measure their baseline hepatitis viral loads. These patients should be referred to specialist clinics for assessment of fibrosis, careful choice of HAART, initiation of hepatitis C treatment, and regular surveillance for hepatocellular carcinoma.
1. Faculty of Sexual and Reproductive Healthcare (2016). UK Medical Eligibility Criteria for Contraceptive Use. London: Faculty of Sexual and Reproductive Healthcare. www.fsrh.org/documents/ukmec-2016/fsrh-ukmec-full-book-2017.pdf
These are less common than other specialities but there are a few presentations you should be familiar with:
PID See p. 51
Epididymo-orchitis See p. 806
This can develop due to autonomic neuropathy as a direct effect of the HSV on neurons, or secondary to severe pain preventing micturition. Patients may require catheterization; suprapubic is preferred to avoid ascending herpes infection in the urinary tract.
Patients present with symptoms and signs of meningeal involvement with headache, fever, meningism, and photophobia. It is different from bacterial presentations as they are less unwell, fully conscious, and CSF analysis is different (clear CSF, lymphocytosis, normal protein and glucose). Treat with aciclovir if suspected as CSF viral cultures take weeks.
Presents differently with confusion, altered behaviour, and possibly drowsiness. CT/MRI, LP, and treatment with aciclovir is required, as with meningitis.
ED have a supply of PEPSE and are familiar with assessing risk and counselling patients.
Emergency contraception See p. 360
This is rare but patients can present systemically unwell secondary to disseminated GC which spreads via haematogenous route causing skin lesions, arthralgia, arthritis, tenosynovitis, and sepsis.
In general, the patients that present unwell to ED fall into one of three groups: those who do not know they have HIV, those who do not take their medication appropriately, or those who know of their status but default care completely. As mentioned before, patients with undiagnosed HIV tend to present late and sick, with either opportunistic infections or malignancies. When seeing any patients in ED with any of the indicator conditions you must test for HIV, particularly in areas of the UK with high prevalence and if the patient originates from a high-prevalence country.
Primary HIV infection and acute seroconversion illness symptoms happen in 80% of newly infected patients, at around 4–6 weeks post infection, with non-specific symptoms of fever, rash, pharyngitis, and myalgia. It is a golden time to test as it may be the only time that patient presents to healthcare services until their disease is much more advanced as HIV infection is so often asymptomatic.
HIV-related disease is an important cause of this and must be tested for. It mostly occurs when CD4 count falls to <100 and is less common in patients established on HAART. Infectious causes are by far the most common, followed by neoplasia and drug reactions.
Oral/pharyngeal/oesophageal candidiasis is associated with advanced HIV infection. It presents as white plaques and dysphagia/odynophagia. Easily spotted but also easily missed if you do not look. It usually responds well to azoles, e.g. fluconazole.
This is caused by the fungus Pneumocystis jirovecii. Most cases occur in patients with CD4 counts <200. It typically presents with progressive exertional dyspnoea over weeks with dry cough. The CXR is deceptively normal but CT thorax classically reveals perihilar ground-glass opacification. It is diagnosed on silver staining or immunofluorescence of bronchoalveolar lavage (BAL) samples. First-line treatments are co-trimoxazole and HAART.
HIV/TB co-infection can be very difficult to manage due to diagnostic challenges in immunosuppression, drug toxicities/interactions, and IRIS with HAART—flare of TB symptoms with fever and malaise as the immune system recovers and directs action at the mycobacteria. TB can occur at any CD4 count and can be pulmonary or extrapulmonary. Pulmonary disease is suspected in the presence of fevers, night sweats, weight loss, respiratory symptoms, and abnormal CXR findings with lymphadenopathy. Send sputum for acid-fast bacilli staining, BAL if sputum is smear negative and tissue cultures if extrapulmonary disease is suspected. Anti-TB treatment should be commenced before HIV treatment due to the effects of immune recovery in the context of untreated TB.
This is infection with Toxoplasma gondii, an obligate intracellular pathogen transmitted from cats, which most commonly causes cerebral abscess mass lesions. It presents with focal neurological signs and symptoms, raised intracranial pressure (headache and vomiting), and sometimes seizures. It is diagnosed by finding multiple ring-enhancing lesions on CT brain and treated with sulfadiazine and pyrimethamine. Primary CNS lymphoma is the main differential.
This is the commonest systemic fungal infection associated with HIV, caused by the encapsulated yeast Cryptococcus, but is now very rare since the advent of HAART. It can present as cryptococcal meningitis (headache, fever, and meningism), with serum/CSF positive for cryptococcal antigen. Treatment is with amphotericin B.
Taking a sexual history is less likely to come up in exams but is something that every medical student should be able to do; you will at some point in your career (especially in gynaecology, urology, and general practice) come across a case where knowing the sexual history is crucial to treat the patient correctly. It involves eliciting details which enable accurate assessment of the risk of STI, site, type, risk of pregnancy, and dictates all further investigations:
Discharge, soreness, bleeding, pain.
• Date of last sexual intercourse.
• Type of relationship (casual or regular) and duration.
• Condom use (always, occasional, mostly, never).
• Oral—giving/receiving and condom use.
• Anal—insertive/receptive and condom use.
• Country of origin of partner.
• Present/past medical history
• Contraceptive/obstetrics and gynaecology (O&G) history
Start by introducing yourself, be aware of body language and consider acknowledging any distress the patient may be feeling. A good way to begin is with an open question such as ‘How can I help you today?’ This enables the patient to say why they have come and perhaps what they are worried about. You can then move on to ask about any symptoms they might have at the moment. To lead on to obtaining details of their recent sexual activity, you could ask the question, ‘When did you last have sex?’ and proceed to ask all the above-listed questions regarding this sexual encounter, and then ask about any previous encounters moving chronologically back through the last 3 months. When it comes to asking details about route of sex, this will be awkward if you are feeling awkward and embarrassed—a way to dispel this is by practising with a fellow student, working out what phrases feel natural to you to use when asking about whether sex was vaginal, oral or anal, receptive/insertive, active/passive, etc. Explaining to patients that the information is needed in order to direct investigations can help if they are feeling the questions are too intrusive.
Scenarios that could come up in communication stations include pretest discussion for HIV, delivering a positive result, or issues regarding confidentiality.
This should begin with the rationale for testing. Patients are often anxious for many possible reasons including lack of understanding, stigma, and perceived effects on employment, immigration status, and relationships. The positive message as outlined earlier regarding diagnosis and treatments and the advantages of testing should be made clear. Details should be given of how the patient will get the results and when, and the patient’s contact details should be checked for accuracy. Treatment for HIV-positive patients is free on the NHS regardless of immigration status.
Patients should understand the significance of the window period in the context of a negative result, and that a repeat confirmatory test may be required.
The result is best given by the person who performed the test, in a private environment. Beware the pitfall of patients misunderstanding the word ‘positive’ and believing this to mean good news. It may be better to say something like ‘the blood test shows you have HIV’ rather than ‘you are HIV-positive’ to avoid misinterpretation. Consider avoiding phrases like ‘I’m afraid to say …’ or ‘I’m very sorry but …’ as this re-enforces the negative connotations of an HIV diagnosis. Emphasize the positive message, and that the patient is far better off knowing they have it than not knowing. Explain that their care will be managed by a specialist HIV team and make arrangements for the patient to see them. Stress the importance of confidentiality, but that it is standard practice to inform the GP for managing future care.
As with history taking, you will at some point in your career have to examine genitalia; misdiagnoses are frequently made because doctors do not examine ‘down below’. Therefore, use your placement to improve these skills and overcome any reluctance to perform the examinations. Practise asking questions about sexual practices so you can do this without getting embarrassed and in a non-judgemental way.
Good lighting is required, the patient should be comfortable, and a chaperone present.
1. General inspection: skin lesions, rashes, generalized lymphadenopathy, oral lesions, hair loss, joints (extragenital manifestations of STIs/systemic diseases).
2. Inspect the pubic area and palpate for inguinal lymphadenopathy.
3. Penis: examine the prepuce, glans, urethral meatus, and foreskin, looking for ulcers, lumps, rashes, and urethral discharge. Swabs depend on symptoms:
• Symptomatic 
urethral swab (microscopy) & GC culture.
4. Scrotum: inspect scrotal skin then palpate the testes which should be equal in size, non-tender, and smooth. Look for any swelling and if present, evaluate further:
• Can you get above it? If not, it may be an inguinal hernia so proceed to examine for this.
• Is it solid or cystic? Use a torch to differentiate; cystic swellings will transilluminate.
• Is it attached to the testis or separate?
5. Urine for CT/GC NAATs, and urinalysis if symptomatic of UTI.
Preparation is key: with the help of a chaperone, position the patient on the couch, supine, with feet together/in stirrups, knees bent and legs relaxed out to the sides, and buttocks in line with the edge of the couch. Place a sheet over the abdomen and ensure illuminating light is available. Then with disposable gloves on, proceed, explaining to the patient what you are doing:
1. General inspection as for males.
2. Inspect the pubic area and palpate the inguinal nodes.
3. Examine the vulva: labia majora, labia minora, introitus, urethra, clitoris; examine for any ulceration, lumps, lesions, rashes, swelling, irritation, etc. A methodical approach means you will not miss important yet potentially subtle changes such as those caused by female genital mutilation and vulval dermatoses.
4. Insert the speculum, lubricated with gel/water:
• Vagina: look for irritation, ulcers/lesions, atypical discharge.
• Cervix: again looking for atypical discharge, pain, and any abnormality of the cervical epithelium.
• Swabs: vaginal wall for microscopy for BV/candida, posterior fornix wet mount for microscopy for TV, and endocervical swabs for CT/GC NAATs, Gram stain microscopy, and GC culture.
5. Bimanual: perform if any history of pelvic/abdominal pain. Insert two fingers into the vagina to reach the cervix while palpating per abdomen with the other hand to assess for cervical excitation and adnexal tenderness (e.g. infection), and any adnexal or pelvic masses (do not forget possible pregnancy!).