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Terminal patient can't get to see same GP



Genital herpes may present as dysuria. Likewise, chlamydia can also present in this way. Therefore beware of presuming women have UTIs and ensure you have a very low threshold for examination.


Sexual history-taking is paramount. Taking a sexual history from a patient with genital ulcers may prevent someone with Behcet's syndrome from being misunderstood and mis-referred ­ this is especially important for children and young adults who have not had sex.


A single ulcer just might be syphilis ­ painless or painful ­ so do bear this in mind.


It is possible for genital herpes to be transmitted from someone who has no symptoms, and from someone who was originally infected years before. Many more of us have had herpes than know it. Condoms are protective if used correctly, but it is important no genital contact occurs without them.


The diagnosis can often be made clinically, but a positive viral culture represents concrete information for the patient who had just one or two ulcers.

Never take a test for an STI in primary care without a risk assessment ­ this process will ensure you have gained informed consent.


Viral culture is more successful if you dip the swab tip into the viral culture medium before rubbing it on the base of the ulcer. You should also take two separate swabs and store them together in one pot of culture medium. Check with your lab so that you know how to recognise if your culture medium is out of date: sometimes the medium changes colour. Dry swabs are not suitable for culture.


Do not insist on testing for chlamydia, gonorrhoea and trichomonas vaginalis if the patient is in pain. Instead, arrange to do this later. An HIV test should also be discussed.


It is important to be encouraging with patients with recurrent herpes. Explain that attacks usually lessen greatly in severity or stop. Patient-initiated therapy for repeat attacks should be considered. Alternatively, patients may benefit from regular oral antivirals such as aciclovir 400mg bd for a year (and then see if recurrences recommence). Instillagel and salty baths may give symptomatic relief.


Genital herpes can cause overwhelming infection in neonates. Alert the obstetric team if a pregnant woman has a first episode of genital herpes at >28/40. Antivirals may be given from week 36 if the woman has a history of recurrent herpes. Caesarean sections are done if there are active lesions when labour commences.


And finally: partner notification is not conducted for genital herpes as there is no benefit in this.

Dr Philippa Matthews, a GP in Birmingham and programme director in sexual health and HIV in the West Midlands deanery GP unit, passes on her top tips

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