SCE Sexual Health: Mastering Common STI Management Guidelines

As an aspiring specialist, navigating the nuances of sexual health in exams like the Specialty Certificate Examination (SCE) is crucial. Sexual health presentations are common in diverse clinical settings, from general medicine to infectious diseases and GUM clinics, making robust knowledge of diagnostic and management guidelines indispensable. This blog post, drawing on my experience as both a clinician and medical examiner, will equip you with the essential guidelines for managing common Sexually Transmitted Infections (STIs) – a frequent high-yield topic in the SCE.

The Bedrock of STI Management: Core Principles

Before diving into specific infections, remember the fundamental principles that underpin all sexual health encounters:

1. Confidentiality & Sensitivity: Patients often present with embarrassment or anxiety. A non-judgmental, confidential approach is paramount.

2. Thorough History Taking: Elicit detailed sexual history, including partners, practices, and symptoms. This guides investigations.

3. Comprehensive Screening: Many STIs are asymptomatic. Opportunistic screening is vital, especially in high-risk groups.

4. Partner Notification & Treatment: Preventing onward transmission is a public health priority. Effective partner management is key.

5. Patient Education: Discuss risk reduction, safe sex practices, and the importance of adherence to treatment and follow-up.

High-Yield STIs for Your SCE

Let's delve into the diagnostic and management guidelines for some of the most frequently tested STIs in the SCE.

1. Chlamydia Trachomatis

Chlamydia is the most commonly reported bacterial STI in the UK and is a significant cause of pelvic inflammatory disease (PID) in women and epididymo-orchitis in men if untreated.

• Diagnosis: Nucleic Acid Amplification Tests (NAATs) are the gold standard, typically performed on first-pass urine in men or self-collected/clinician-collected vulvovaginal swabs in women. Rectal and pharyngeal swabs should be considered based on sexual history.

• Treatment:

  • First-line: Doxycycline 100mg twice daily for 7 days.

  • Alternative (e.g., pregnancy, poor adherence concern): Azithromycin 1g single oral dose.

• Partner Management: All partners from the last 6 months should be contacted, tested, and empirically treated (if within 4 weeks of contact) or treated after positive test results. Expedited Partner Therapy (EPT) may be considered in some settings.

• Follow-up: Test of cure (TOC) is generally not recommended unless symptomatic, pregnant, poor adherence suspected, or rectal infection (due to lower treatment efficacy). Retesting for reinfection is recommended 3-6 months post-treatment, especially in those under 25 years.

2. Neisseria Gonorrhoeae

Gonorrhoea is a significant public health concern due to rising antimicrobial resistance, requiring vigilant management.

• Diagnosis: NAATs are highly sensitive, but culture (with antimicrobial susceptibility testing) is crucial, especially from suspected pharyngeal or rectal sites, and for all treatment failures, given resistance concerns. Gram stain of urethral discharge in symptomatic men can provide a rapid presumptive diagnosis.

• Treatment: Due to increasing resistance, dual therapy is standard:

  • First-line (uncomplicated anogenital/pharyngeal): Ceftriaxone 1g intramuscular single dose PLUS Azithromycin 1g oral single dose (though Azithromycin's role is debated due to emerging macrolide resistance, some guidelines now favour higher Ceftriaxone doses alone or with Doxycycline if no pharyngeal infection).

  • Consult local/national guidelines (e.g., BASHH) for the most up-to-date recommendations.

• Partner Management: All partners from the last 3 months should be contacted, tested, and treated.

• Follow-up: Test of cure (TOC) is essential for all treated gonorrhoea infections, 7-14 days post-treatment, particularly from pharyngeal and rectal sites, to confirm eradication and detect treatment failure/resistance.

3. Syphilis

Syphilis, caused by Treponema pallidum, is a multi-stage disease that can have severe long-term complications if left untreated.

• Diagnosis: Primarily serological testing:

  • Screening: Treponemal-specific tests (e.g., TPPA, TPHA, EIA). These remain positive for life.

  • Monitoring disease activity/treatment response: Non-treponemal tests (e.g., VDRL, RPR). Titres fall with successful treatment.

  • Clinical Presentation: Be aware of characteristic lesions (e.g., primary chancre, secondary rash, condylomata lata).

• Staging & Treatment (simplified):

  • Early Syphilis (primary, secondary, early latent <2 years): Benzathine Penicillin G 2.4 million units IM single dose.

  • Late Syphilis (late latent >2 years, cardiovascular, gummatous): Benzathine Penicillin G 2.4 million units IM weekly for 3 weeks.

  • Neurosyphilis: Requires intravenous Penicillin G regimens.

• Jarisch-Herxheimer Reaction: A self-limiting febrile reaction occurring within hours of treatment, especially for early syphilis. Manage symptomatically (antipyretics).

• Partner Management: Varies with the stage of syphilis; potentially partners from the last year or more.

• Follow-up: Regular serological monitoring (VDRL/RPR) to confirm response to treatment and rule out reinfection.

4. Genital Herpes Simplex Virus (HSV)

Caused by HSV-1 or HSV-2, genital herpes is a chronic, recurrent viral infection.

• Diagnosis: Primarily by viral swab (PCR) of vesicular fluid or ulcers. Serology can determine past exposure but doesn't distinguish between genital and oral infection.

• Management: Aimed at symptom relief, reducing duration, and preventing recurrences. HSV is not curable.

  • Primary Episode: Aciclovir 400mg three times daily for 5 days (or Valaciclovir/Famciclovir equivalents). Oral analgesics and topical anaesthetics are helpful.

  • Recurrent Episodes: Start antiviral treatment at the prodrome or within 24 hours of lesion onset (e.g., Aciclovir 200mg 5 times daily for 5 days). Shorter courses or higher doses are available.

  • Suppressive Therapy: For frequent or severe recurrences (e.g., Aciclovir 400mg twice daily for 6-12 months), reducing recurrence rates.

• Patient Counseling: Essential regarding recurrence, transmission risk, and impact on relationships.

Public Health and Prevention in the SCE Context

Remember that the SCE will often test your understanding of broader public health implications:

• Screening Programs: e.g., National Chlamydia Screening Programme.

• Vaccination: HPV vaccination is a major public health success in preventing certain cancers caused by HPV.

• Safer Sex Advice: Consistent condom use, reducing multiple partners.

Approaching Sexual Health Questions in the SCE

When faced with an SCE question on sexual health:

1. Read the Vignette Carefully: Identify key symptoms, risk factors, and patient demographics.

2. Formulate a Differential Diagnosis: Consider bacterial, viral, and parasitic STIs, and non-STI causes.

3. Outline Investigations: What tests would you order and why? (e.g., NAAT, culture, serology, microscopy).

4. Detail Management: This is where guidelines shine. Specify drug, dose, duration, and route. Don't forget non-pharmacological advice.

5. Address Public Health Aspects: Partner notification, follow-up, retesting, prevention.

Mastering these guidelines not only ensures success in your SCE but also prepares you for competent, compassionate patient care in this sensitive area of medicine.

Further Reading

• British Association for Sexual Health and HIV (BASHH) Guidelines

• Public Health England (PHE) / UK Health Security Agency (UKHSA) Guidance

Stay vigilant, keep learning, and good luck with your SCE preparations!