Episode 43: HIV & Sexual Health Part 3

Author: Eoghan Colgan  @eoghan_colgan
Special Guest: Rebecca Metcalfe @becksmetcalfe

05/02/20

Listen

Podcast Rebecca Metcalfe 3.png

Guest Bios

Rebecca Metcalfe

240x250^.jpeg

Dr Becky Metcalfe is a Consultant in Sexual Health & HIV Medicine in NHS Greater Glasgow & Clyde. Her special interests include women living with HIV and managing HIV in vulnerable groups. She is part of a team managing an ongoing outbreak of HIV amongst people who inject drugs in Glasgow.

Show Notes

Rebecca Metcalfe is a Consultant in Sexual Health with a specialist interest in HIV and sexual health. In this episode, Eoghan and Rebecca discuss a number of sexual health-related problems that can present to ED and how to manage them. Topics include sexual assault, male urethritis, herpes, and emergency contraception.

TAKE-HOME POINTS

Rape/sexual assault

  • all ED staff should know where the local sexual assault referral centre is

  • take a careful and sensitive approach (but does not need to be detailed)

    • make sure they are comfortable

    • ask what they can remember and document

    • decide if they are acutely injured and need emergency care

      • significant genital injury may require gynaecology/urology

    • If no emergency treatment required, could be left to referral centre as don’t want to do too much that could affect forensic evidence

    • ask them if they want to involve the police or not (can make that decision at any time), and would they like to atend the referral centre, which can happen with our without police involvement

  • ED Treatments are limited if referral centre is close (who can handle all); if not close then consider:

    • emergency contraception

    • PEP

    • Hep B Vaccination

  • Forensic examination should be done ASAP, buit no later than one week from incident

    • samples have a higher vield if not weashed away (seminal fluid, sperm, DNA etc)

    • patient should bring clothes/underwear worn at time of assault

Sexual Assault Referral Centre

  • The patinet will receive a holistic range of support

  • They can go with or without the police

  • They do not have to have an intimate exam

    • they decide at the centre, at different stages, how far they want to take the examination/assessment

  • Patinet should bring a friend for support

  • They will be seen by a doctor and a nurse

    • initially a comfortable room for a relaxed conversation - gathering information

    • they can have breaks and withdraw at any time

    • a forensic examination will be explained and conducted if they agree

      • this is a full examination, including genitals, with swabs/samples taken

    • everything is fully explained

  • They may receive treatments if required:

    • emergency contraception, Hep B Vaccination, PEP, Cervical smear if not had recently

  • Whole process takes about 2 hours

  • The centre, or the police, may take clothing

  • They will be offered a follow-up appt around 2 weeks later, and this includes:

    • repeat testing for STI’s (chlamydia and gonnorhea)

    • BBV/HIV testing

    • further counselling and support

male urethritis

  • Main recommendation: refer to sexual health clinic WITHOUT treatment

    • this is to avoid giving the wrong treatment and contributing to antimicrobial resistance (big issue in gonnorhea and mycoplasma)

    • Could wait over the weekend as long as not in significant pain/retention

  • Could take a brief sexual history:

    • last time had sex

    • what type of sex

    • who with

    • when symptoms began

  • Ensure they can urinate: painful ulcerating condition susch as herpes can lead to retention

  • Could examine, looking for:

    • ulcers at the tip of the penis (herpes)

    • infecvtion of the glans penis (balanitis)

    • discharge from the urethra (typically chlamydia, mycoplasma or gonnorhea)

  • Very useful to send a urine sample for chlamdyia or gonnorhea (different tube from MSSU)

  • Could do a charcoal swab of discharge (can grow gonnorhea)

  • Swab any ulcers for herpes

    • could use a viral PCR sample stick from paediatrics

  • If sexual health clinic not available, some treatment options include:

    • look at discharge under microscope

      • if lots of white cells but do not see gonococcus, then could treat with doxycycline (which cill cover chlamydia, the commonest cause of non-specific urethritis)

      • if discharge more perulent, patinet is MSM (higher gonococcus levels), or patinet knows they have had comtact with someone with gonnorhea, then treat with IM cefrtriaxone

        • but really important to send a sample

  • Young male with UTI symptoms, but no external changes and no discharge:

    • should still best be treated at sexual health clinic and have STI excluded

herpes

  • typically painful blisters/ulcers in male or female genitalia

    • if someone presents with p[ainful genitalia - it is important to look at the skin

    • if skin is normal then that is reassuring thyat herpes not present

  • Herpes simplex virus (type 1 or type 2)

    • incredibly common

    • it is a lifelong virus: no cure but can treat a flare and keep it at bay

  • Sexual history:

    • any new partners?

    • what type of sex (can be transferred by oral sex)

    • if a partner has had it a long time they may be asymptomatic

    • They shoudl be seen in a sexual health clinic (particularly if first episode)

      • for education and for other STI’s to be tested for

  • If possibe, please send a viral PCR swab (to virology)

    • a dry swab for fluid from the ulcers

    • if too painful, patinet themselves can do the swab

    • some places do a dual herpes and syphllis test

      • syphyllis typicall has painless ulcers (and less florid) but there can be overlap between the two conditions making it hard to be sure

  • Treat with high-dose acyclovir and early follow-up at sexual health clinic

  • Check they can pass ruine, because it can be too painful to do so (might be worth asking them to provide a sample in dept to check)

    • they will need admitted if they cannot

    • measures to help with urinating:

      • urinate in a shallow bath of warm water

      • or pour lukewarm water on the area when urinating

        • this decreases the acidity of the urine

  • Symptomatic treatment of skin is important:

    • don’t put anything on the skin (ointments etc)

    • bathe in a shallow bath with warm water and handful of salt

Emergency Contraception

  • less common presentation in ED as widely available from pharmacies etc

  • Assess the risk of pregnancy:

    • was a condom used?

    • did it break?

    • at what stage did they ejaculate, or not?

    • what stage of her cycle is she?

      • highest risk is mid-cycle; less risk if period just been or just starting

      • easier if regular cycle but unreliable if irregular cycle

    • have they any contraception already and do they take it?

  • Oral Contraception:

    • Levogenestrol (commonest) or Ulipristal

    • check any drug interactions

    • give early but best within 72 hours

  • Copper Coil (IUD)

    • the best option:

      • can be given up to 5 days post intercourse (or day 19 if a regular cycle)

      • is a good ongoing contraception

    • if discussing IUD and making referral, give the oral contraception also (in case they miss appt)

  • Advice on discharge:

    • make sure not pregnant:

      • check if next period late or do a pregnancy test 3 weeks after

    • ongoing contraception to be discussed with GP or sexual health clinic

links

Sandyford Clinic Glasgow: Prep information

https://www.sandyford.org/sexual-health-information/sexual-health/hiv-prevention-testing/prep/

Hannah BellSeP1, SeP2, SeP3, SeP4Comment