Need to know - GU medicine
Sexual health specialist Dr Olwen Williams takes on Dr Linden Ruckert’s questions on HPV vaccination, recurrent bacterial vaginosis and diagnosing ‘real’ pelvic inflammatory disease
Sexual health specialist Dr Olwen Williams takes on Dr Linden Ruckert's questions on HPV vaccination, recurrent bacterial vaginosis and diagnosing ‘real' pelvic inflammatory disease
1 When and how do you think HPV vaccination will have an impact on the work of GUM clinics when only certain serotypes will be covered? And I'd be interested to hear your clinical opinion on whether boys should be vaccinated.
Sadly, the added benefit from using a quadrivalent vaccine, which would have also provided protection against genital warts, will not be seen. So I don't anticipate any decrease in cases of genital warts in the foreseeable future and little impact on our workload in this area.
A quadrivalent vaccine would not only have reduced the incidence of HPV-related malignancies but also reduced the enormous burden of genital warts.
There is a possibility that some parents and adolescents receiving the vaccine will not grasp the concept that it doesn't protect against warts. Oddly, the literature promoting the HPV vaccine fails to say it doesn't protect against genital warts, although it does point out the vaccine doesn't protect against chlamydia.
I believe boys should be vaccinated too, for a variety of reasons. Firstly, HPV is associated with both penile and anal carcinomas. These may not be as common as cervical cancer but are still an issue.
We also need to eradicate HPV, and one way of doing this is by herd immunisation.
2 Recurrent bacterial vaginosis is a big problem for some women. Are we any closer to understanding why and are there any effective strategies for preventing or treating it?
The recent discovery of as yet unnamed organisms in women with bacterial vaginosis (BV) may give us some answers about its aetiology and management.
There is mounting evidence that women with BV – who also develop problems such as pelvic inflammatory disease (PID) – have a poor innate and adaptive immune response in the genital tract.
Recent work looking at the role of probiotics have shown some comparable outcomes to metronidazole therapy. The probiotics used contained two strains of Lactobacilli in a capsule and were inserted into the vagina for five consecutive nights.
Other studies have looked at intravaginal yoghurt and oral consumption of yoghurt – both have some impact on recurrence of BV.
None of these treatments has reached a point where it is recommended by any UK guidelines.
Speculation that external factors such as smoking, drinking coffee, douching and presence of an IUS/IUD contribute to the development of BV remain unsubstantiated, but as these are factors that can be altered it is prudent to suggest that the woman does so.
Treatment of the male sexual partner seems to have no impact on recurrences.
3 Vaginal candida is also a problem for some women and there seems to be a variety of drug regimes. Are there any tips that we might not have considered? Do you find one regime works better than another?
It's a perennial question. What works is what keeps the woman symptom-free. Some guidelines advocate an induction regime of three doses of fluconazole 150mg every 72 hours, followed by a maintenance regime of fluconazole once weekly for six months.
Topical imidazole therapy (clotrimazole vaginal cream 10% or pessary 500mg) can also be used for 10 to 14 days followed by maintenance therapy topically in pessary form once a week – providing a microbiological diagnosis has been made.
Very occasionally, it may be necessary to do sensitivity tests to ensure one is not dealing with a resistant strain of Candida albicans but only if there have been four proven recurrences in a year.
Checking for diabetes and possibly for iron deficiency and zinc deficiency may highlight an underlying cause.
The role of exogenous oestrogens is debatable – some individuals will benefit from a change in their oral combined pill or use of a progesterone-only method.
Some clinicians have used the leukotriene receptor antagonist zafirlukast 20mg bd for six months in women with a history of atopy.
A guideline on candidiasis is available from the British Association for Sexual Health and HIV.
5 Chlamydia screening is being performed in general practice – using self-testing swabs for the under 25s and urine tests for men. It would be much easier if we could offer universal urine testing kits. What is the cost of urine testing and is cervical testing preferred for any other reason?
In England, the national chlamydia screening programme now covers 100% of the country. Now in its fifth year, it carried out 359,858 tests in 2007/8, 29% of which were in men. The aim is to reduce the prevalence of the disease in the population most at risk and as a consequence reduce the sequelae of pelvic infection and infertility.
The screening method has been designed to offer the most acceptable test to the individual without losing any sensitivity or specificity when it comes to making a microbiological diagnosis.
Unfortunately, urine testing in women does not give as good results as either self-taken vulval swabs or cervical swabs, hence the decision not to use this method of testing. Urine testing in men has proven to be acceptable and an effective way of testing a group of patients that still worry about potentially uncomfortable tests.
The cost of an individual test will depend on the kit that your laboratory uses – ranging from about £6-8. Age shouldn't be a barrier to be tested for STIs, so chlamydia testing should be available to everyone.
You can read more about the management of chlamydia in a Ten Top Tips article I wrote earlier this year.
Pelvic inflammatory disease tends to be a bit of a ‘dustbin diagnosis' in primary care. What symptoms should alert GPs to genuine cases, how should they be treated and should such cases be referred to GUM clinics?'
At a recent international meeting, experts in the field admitted that even in 2008 we were still very poor in making the diagnosis of pelvic infection. A clinical condition that ranges from mild to severe in its symptomatology can challenge the clinician.
• lower abdominal pain
• pain on intercourse
• abnormal vaginal bleeding
• abnormal vaginal discharge.
The problem is that symptoms may be absent – so-called ‘silent PID', usually attributed to chlamydia – adding to the complexity of predicting who has PID and who will have tubal damage. The differential diagnosis is vast.
Cervical motion tenderness, adnexal tenderness and the presence of pus cell at gram stain of an endocervical swab all support the diagnosis. However only 65-90% of patients will have PID even with these criteria. Laparoscopy gives a definitive diagnosis.
Early treatment is essential to reduce the risk of subsequent tubal damage. A variety of antimicrobial regimes are suggested and can be found in the Royal College of Obstetricians and Gynaecologists guideline on acute PID. The British Association for Sexual Health and HIV also has a PID guideline.
Severe cases may require hospitalisation. It is essential that all women with suspected PID are tested for chlamydia, gonorrhoea and bacterial vaginosis and the antimicrobial regime covers these organisms. Ideally all sexual partners should be screened and treated as well.
6 Do we understand, or can we predict in any way, which women with chlamydia infection are most likely to get tubal damage – aside from those with repeated episodes? Often a woman says: ‘I don't know how long I have had this – what are my chances of tubal damage?'
Are we talking here about tubal damage or infertility? I'm sure it's the latter that our patients are worried about.
The pathology behind chlamydia-related tubal damage is interesting. Pelvic infection is of polymicrobial aetiology, with chlamydia, gonorrhoea and mixed anaerobic-aerobic organisms all playing a part in the process, which leads to salpingitis and the risk of tubal damage, resulting in ectopic pregnancy or sub-fertility.
Recent work suggests that the presence of bacterial vaginosis with a high bacterial load, in a woman with chlamydia and or gonorrhoea, may facilitate the development of pelvic infection in comparison with women with either chlamydia or gonorrhoea alone.
Chlamydia serological testing has had a bad press in the past as it detected C. pneumoniae and C. psittaci as well as C. trachomatis.
The MIF test (microimmunofluoresence) is now being used as a research tool to see if there is correlation between antibody levels and disease activity. Rising chlamydia antibody levels may indicate tubal damage.
Teenage women, by nature of their genital tract immunological immaturity, are more susceptible to chlamydia PID, as are women who are HIV-positive.
Interestingly, the oral contraceptive confers some protection against ascending infection, leading to a milder disease.
Antimicrobial therapy early in an episode of PID – within 48 hours – may reduce the risk of tubal damage.
Population studies have recently suggested that the risk of PID associated with chlamydia has been overestimated. So the debate over the cost-effectiveness of chlamydia screening programmes is hotting up.
7 Have you seen any changes in the pattern of gonorrhoea and syphilis? I don't see much in my urban practice.
The past decade has seen a huge rise in both gonorrhoea and syphilis across the UK in individuals attending genitourinary medicine clinics.
The rates for gonorrhoea went up across all age groups between 1997 and 2002 then dropped to 50-20 per 100,000 male-female population in 2007. There have been some changes in the epidemiology of the disease, with an increasing number of cases occurring in young men of black Caribbean origin and men who have sex with men.
Gonorrhoea has a short incubation time and men tend to get symptoms that prompt immediate attention. With the majority of GUM clinics in the UK able to offer care within 48 hours, these services become the first port of call.
If you don't feel that you are seeing the disease, check that your genital specimens are been tested for gonorrhoea.
Syphilis – ‘the great mimicker' – is back with a vengeance. In 1998 there were 139 cases in the UK but by last year that figure had rocketed to 2,680 – a rise of 1,828%. The outbreak emerged in Manchester among men who have sex with men, and progressively moved across all of UK cities. Added to this, some cases have been seen in patients from Eastern Europe and people who have travelled to that area.
The age group with the highest rates are slightly older than those with other bacterial STIs, usually aged between 25 and 35 years of age.
If you don't keep syphilis in mind as you do a differential diagnosis in someone with genital ulcers or generalised maculo-papular rashes, it's easy to miss. I predict that in the next 10 to 20 years we will see start seeing cases of tertiary syphilis again.
8 Are there any patterns to HIV presentation that we should remember that might be outside the standard textbook presentation?
My paediatric colleagues in London remind me that we should be offering HIV testing to all children of newly diagnosed mothers, regardless of the child's age. HIV can remain asymptomatic into mid-adolescence. A tragedy to miss, but more children are presenting in adolescence – it may be vertically transmitted or acquired through sexual activity. Presentation may be failure to thrive, delayed growth, thrombocytopenia or another sexually transmitted infection.
In autumn 2007, the chief medical officer wrote to all doctors highlighting the need for more proactive HIV testing. They listed a range of clinical conditions where HIV testing should be offered.
Having enquired widely, clinicians seem to have not seen this letter. I quote from that letter:
‘It pointed out that this is especially important when the patient may have an unacknowledged but identifiable risk, or have symptoms or signs of HIV infection. As well as non-specific symptoms such as malaise and weight loss, patients with HIV may present across a range of clinical areas, such as:
• thoracic medicine – for example, tuberculosis, pneumonia
• gastroenterology – for example, oral candidiasis, severe gastroenteritis
• oncology – for example, lymphoma
• dermatology – for example, shingles, severe fungal dermatoses
• haematology – for example, idiopathic thrombocytopenic purpura
• emergency medicine – for example, coma, meningitis.'
In my own practice, I've learned you can carry out a risk assessment for HIV during a consultation that may highlight some behaviour or lifestyle associated with risk of acquiring HIV, but the absence of those risks doesn't mean you shouldn't offer the test – especially if they have a condition listed above.
Dr Olwen Williams is clinical director of the integrated sexual health service at North Wales NHS Trust. She has a special interest in STDs in adolescents and children. She was awarded an OBE in 2006 for services to medicine in Wales
Competing interests: None declared
Dr Linden Ruckert responds to the answers to her questions
• I will remember to raise the issue of HPV vaccination not preventing genital warts with teenagers – it is easy to see how that assumption might be made
• I find that my patients with recurrent bacterial vaginosis are often keen to help themselves and probiotics might be a suggestion we could try
• I will check patients with more than four proven episodes of thrush for resistant strains
• I do swabs for gonorrhoea but being aware of the pattern of disease – and alert to secondary syphilis – is a useful reminder
• I will remind teenagers of their particular vulnerability to PID due to immunological immaturity in the genital tract...
• ... but it is interesting to read that chlamydia tubal damage, in general, may be less likely than was thought
Dr Linden Ruckert is a GP in north London