Objectives

What happens when a patient

attends Appreciate the concerns a patient may have attending a SH
clinic
sexual health Understand the process when a patient attends a SH clinic

clinic?
Review sexual history taking
Revise female and male genital examination
Review contact tracing
Have an introduction to STIs and their treatments

Why do we have sexual

Who gets STIs?
health clinics?

Why do we have sexual health Why do we have sexual health

clinics? clinics?
Diagnose, treat and prevent STIs; prevent unwanted pregnancies;
address psychological and sexual problems.

Our principles:
Walk-in, no referral needed, free service and treatment
Minimise personal and public health impact of STIs by:
- Rapid diagnosis and treatment
- Preventing onward transmission
- Promoting safe sex
- Targeting at-risk groups
- Giving psychological support

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 What services do we offer? What are patients concerned about?

STI diagnosis asymptomatic / symptomatic

Sexual health advice
Provision of condoms and other contraception
HIV post-exposure prophylaxis (PEP)
Hep A + B vaccinations
Managing sexual disorders e.g. erectile dysfunction
Diagnosis and management of genital dermatoses
Specialist clinics targeting at-risk individuals
- Young People
- Commercial Sex Workers
- Men-who-have-sex-with-men
- Sexual assault

Some patient concerns Who works in a sexual health centre?

Confidentiality
Closed room with a sound proof door
Notes are kept separate & do not leave the building
GPs not routinely informed unless consent given
Being judged
All encounters should be non-judgemental
Neutral language
Embarrassment
Natural when talking about intimate issues
Helps if health professional does not shows signs of embarrassment
themselves!
Possible infection and its consequences
Unwanted pregnancy
Infertility
Passing on infection
Effect on relationships
Guilt, shame, infidelity

Multidisciplinary Team

Reception Health Advisers

Log patients into system,
manage patient flow
Create notes, find old notes
Field telephone calls, send texts
Nursing
Asymptomatic / symptomatic
patients
Microscopy
Dispense medications
Contact tracing
Manage patient flow
Specialist nurses E.g. sex
workers, HIV
Health promotion / prevention
Contact tracing
Counselling
Risk assessment
Child protection / vulnerable
adults
Doctors
Manage complex / difficult cases
Genital examination inc
bimanual examination
Systemic examinations
Onward referral to other
specialties e.g. gynae, urology
Communication with GPs

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 How do I take a sexual history? How do I take a sexual history?

Be aware of patients Use language they understand

anxieties and fears Mirror their terms
Make them feel safe and in Translate
control
Be self-aware
Be non-judgemental
Be empathic
Reassure
Do not be presumptive
Use open questions
Give them a chance to explain Act with sensitivity
what the problem is in their
own words Sexuality, cultural, religious
Keep it neutral
Ensure confidentiality
Exceptions e.g. Child protection
issues

Someone is going to examine my

Examination genitals!

Someone is going to examine my

genitals!
Female examination

Patient may be anxious or embarrassed

Offer female or male examiner if requested

Offer chaperone

Tailor examination to symptoms reported

Confidentiality

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 Female anatomy Female external genitalia

Prepuce

Mons
pubis Clitoris
Labia majora
Urethral
orifice
Labia
minora Hymenal
remnants
Perineum Vaginal
orifice
Anus Fossa
navicularis

How do you do a female exam?

Gonorrhoea Chlamydia Tricho- Candida Bacterial
Inspection monas Vaginosis
- Vulva and vestibule Microscopy NR NR NR
- Urethra Culture
Cervix NAAT
- Perineum
- Perianal area NAAT
NAAT Micro Micro Micro
Speculum exam - Vagina Vagina (Can self swab NAAT* Culture Culture Culture
- Cervix if no
symptoms) (PCR) pH
Bimanual exam
NAAT*
Proctoscopy - Anal canal Oropharynx Culture NAAT* NR NR NR
Micro
Systemic - Lymphadenopathy Rectum Culture NAAT* NR NR NR
- Eyes
- Mouth, abdomen NAAT*
- Joints, skin PCR (if no
other spec.
Urine NR NR NR NR
available)

Male genital examination Male external genitalia

1. Testicles
2. Epididymis
3. Corpus cavernosa
4. Foreskin
5. Frenulum
6. Urethral opening
7. Glans penis
8. Corpus spongiosum
9. Penis
10. Scrotum

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 Male genital examination Which samples to take in men?
Inspection:
Inguinal area
Penis, prepuce, glans, meatus
Scrotum
Perineum Gonorrhoea NSU Chlamydia Candida Trichomonas
Perianal Micro Micro Culture
Urethra Culture NR NR (PCR)
Palpation
Testes, epididymis
Urine NAAT NR NAAT NR NR
Proctoscopy NAAT*
Rectum Oropharynx Culture NR NAAT* NR NR
Micro
Systemic
Rectum Culture NR NAAT* NR NR
Lymphadenopathy, eyes, mouth, abdomen, joints, skin NAAT*

Investigations

Microscopy
Sexually transmitted
Gram stain and microscopy
Wet slide infections in women
Dark ground microscopy

Enables rapid diagnosis and

treatment
- Gram negative intracellular
diplococci
- Non specific urethritis
- Bacterial vaginosis
- Candida
- Syphilis
- Trichomonas vaginalis

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 Herpes simplex Genital warts

Bartholins abscess Cervix - normal!

Ectropion Nabothian follicle

6
Candida vaginitis / cervicitis Chlamydia cervicitis

Muco-purulent cervicitis Trichomonas vaginalis

STIs in men

Urethritis
- gonorrhoea
- chlamydia

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Balanitis - candida Genital warts

Molluscum contagiosum

Herpes simplex
Herpes simplex

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Syphilitic chancre
Secondary syphilis

Secondary syphilis: snail

track ulcers

Secondary syphilis:
condyloma lata

Candida: spores and hyphae

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Bacterial vaginosis: clue cell Polymorphonuclear
leukocytes (pus cells)

Gram-negative intracellular Trichomonas vaginalis

diplococci

Spirochaete: syphilis (T.

pallidum) Sperm!

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 Role play

Three scenarios:

What information do you need?

How do you collect the information?
Remember sensitive and non-judgemental approach

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