STI Clinical Hints

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Male urethritis

Treat empirically. Don’t wait for results.
Use azithromycin 1 g stat. Add ceftriaxone 500 mg stat, dissolved in 2 ml 1% lignocaine, only if gonorrhoea (TG) is suspected ie thick, purulent discharge in a gay man or returned traveller.
Consider herpes (TG) or adenoviral urethritis (TG) when dysuria is severe.

Candidiasis and Trichomoniasis (TG) are almost always associated with vulvar itching and/or irritation.
Exclude a retained tampon or other foreign body in cases of malodorous discharge.
Think of herpes in cases of vulvitis with inguinal lymphadenitis. Candidiasis is unlikely to be associated with regional lymph node inflammation.

A syphilis epidemic is occurring in men in Victoria
Blood tests alone are inadequate.
A first-void urine sample (men and women) or high vaginal swab (women) should always be sent for chlamydial testing.
A first-void urine sample does not have to be the first urine of the day.
Never order an HIV test without accompanying syphilis serology
Gay men should have a throat swab for gonococci and anal swabs for gonococci and chlamydia.
Hepatitis C serology is unnecessary, except in injecting drug users and HIV positive gay men.
Genital cultures for Ureaplasma urealyticum and Mycoplasma (TG) hominis are not helpful.
When ordering Hepatitis B serology, there is no point ordering just HBsAg unless the patient is jaundiced or acute viral hepatitis is suspected.
If ordering Hepatitis B serology to determine immunity, order anti-HBc and anti-HBs. If anti-HBc is reactive and Anti-HBs is negative, then ask the lab to do HBsAg
In interpreting syphilis serology, the TPPA is a reliable indicator of exposure to syphilis.
Any person with a reactive TPPA and no convincing history of treatment should be treated for syphilis.
Avoid herpes serology as a screening test, and be careful when interpreting results. HSV EIA serology is prone to frequent false positives and negatives.

In any painful breach of the genital skin, consider genital herpes.
Most first presentations of herpes are recurrences of prior asymptomatic infection, rather than being recently acquired.
A negative swab for PCR does not exclude a diagnosis of herpes, especially if the lesions are more than a few days old.
Herpes does not prevent normal vaginal delivery.
Kenacomb ointment is best avoided on the genitals. It may prolong herpes ulceration.

Do not confuse normal anatomical variants for genital warts.Such normal findings include pearly penile papules, Tyson's glands, vestibular papillae and sebaceous glands (Fordyce spots).
Warts typically have a verrucous surface, and tend to be centrally distributed in the anogenital region.
Molluscum contagiosum lesions are smooth, round and centrally umbilicated. They tend to be distributed more peripherally than warts, on buttocks, thighs and pubic area.
Warts (TG) do not cause cancer. Topical treatments work best on non-keratinized warts.