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This item is 8 years and 3 months old; some content may no longer be current. Good sexual health is about achieving both physical and psychological wellbeing, free from disease, coercion or abuse. Reaching and maintaining good sexual health requires a positive and respectful approach to sex and sexual relationships, as well as the ability to have pleasurable and safe sexual experiences. Primary care plays an important role in the provision of all aspects of sexual health care, including educating about sexually transmitted infections STIs and safer sex and providing testing and treatment for STIs.
Chlamydia is the most commonly reported STI in New Zealand, with a reported incidence in of new cases per people. There are multiple cultural, behavioural and economic factors contributing to current disparities in sexual health indices in different population groups in New Zealand. Primary care is ideally situated to address these issues by improving the sexual health knowledge of patients and facilitating the diagnosis and treatment of STIs. Questions about sexual health should be routinely included as part of a general history for all patients seen in primary care. The purpose of taking a sexual health history is to assess risk of STIs, identify problems with sexual function, identify issues of past sexual abuse or risk of future abuse, and to assess overall sexual wellbeing and knowledge.
Ensure that the patient feels comfortable and able to speak openly. It is important that practitioners are also comfortable with asking questions about sexual health in order to help put patients at ease. It should be clear from the outset that the consultation is confidential, and the tone of the conversation should aim to normalise the clinical encounter, e. All questions in the sexual history should be gender neutral until the gender of sexual contacts is known. It is important to discuss confidentiality, and its limitations, in case any ificant safety issues are identified.
It may be helpful to briefly explain why each question is being asked and that the questions are routine, e. It may not be possible to take a full sexual history at the initial presentation, especially if this was not the primary reason for the visit.
The most relevant information is whether the patient is currently symptomatic, whether any test is indicated at that visit, whether they are at risk of unwanted pregnancy and whether they have risk factors for HIV, syphilis, hepatitis or other infections. Asymptomatic, young people can be referred to the Practice Nurse for a more in-depth sexual health history and testing if there is insufficient time during the consultation, or be encouraged to return for an additional consultation.
New Zealand research shows that nurse-led education and self-collection of samples is an effective strategy for increasing uptake of opportunistic chlamydia testing in people aged 16 — 24 years. The range of questions that may be included as part of a complete sexual history are: 3. Once relevant information has been gathered, ask again if the patient has any questions or if they want to add anything before assessing their risk of infection. Consistently and correctly using condoms is the most important advice for reducing the risk of pregnancy and STIs. It is recommended that a water-based lubricant is used with condoms to reduce risk of breakage during vaginal or anal sex.
This can be prescribed by a clinician or purchased from an accredited pharmacist in a community pharmacy.
Advice on condom use can be excluded in women who have sex exclusively with women, although other methods of STI protection and not sharing sex toys, should be suggested. Traditionally, advice on safer sex included abstinence. There is now a large body of evidence showing that the promotion of abstinence has no benefit in preventing unintended pregnancy and STIs. The information gained from the sexual history will guide the extent of physical examination and laboratory testing required.
Generally, routine STI testing should occur annually where appropriate, but this depends on risk factors. Testing should be repeated more frequently i. If there is a specific sexual event that the patient is concerned about and they are currently asymptomatic then it is recommended that testing be deferred until two weeks after the event. If they are unlikely to come back for testing or if they have current anogenital symptoms then testing should be done at the time of presentation.
Any patient with atypical anogenital ulceration should be referred to or discussed with a sexual health physician for further information see New Zealand Sexual Health Society genital ulcer disease summary: www. STI test availability varies throughout New Zealand, and testing should always be guided by local laboratory recommendations. Ideally, an examination should be performed as part of a sexual health check-up, and samples for testing taken during the examination. However, self-testing is a safe and effective method for opportunistic testing in asymptomatic patients or those who decline examination.
It is important to tell patients how and when they will be notified of test. For low-risk patients it is usually appropriate to tell them that they will only be contacted if there are any abnormal. For higher risk patients, e. MSM having unprotected anal sex, it is recommended that they are asked to re-attend to discuss their in person. A self-collected vaginal swab is appropriate for opportunistic testing for chlamydia in an asymptomatic female, or if a genital examination is declined.
Instruct the patient to remove the swab from its container, insert it Nurse at skin casual fuck screeing 4 cm into the vagina, rotate and then replace in the swab container. A first void urine first 30 mL of the stream is not the first-line recommendation for chlamydia testing in women as it has lower sensitivity than a vaginal swab, but is useful if the patient declines examination and does not want to self-collect a swab.
Urine samples do not have to be early morning urine. Ideally the patient should not have passed urine in the two hours, however, if the patient is unlikely to return for testing, a specimen should still be collected and tested. A study has shown Nurse at skin casual fuck screeing the voiding interval does not ificantly alter of the Cobas PCR assay when testing for chlamydia in males.
Testing as recommended for all males should be offered at least annually, depending on sexual history. Additional tests, regardless of stated sexual practices, should also be included for MSM. MSM with anorectal symptoms should be referred to, or discussed with, a sexual health physician. A positive NAAT test from an extra-genital site needs to be confirmed by supplementary testing, which is done automatically by the laboratory. Treatment should be initiated if testing reveals a positive result for an STI, or if there is a high index of suspicion, e. Patients should be advised to avoid unprotected sexual intercourse until seven days after treatment has been initiated for any STI, and at least seven days after sexual contacts have been treated, to reduce risk of re-infection.
All patients should be routinely followed up one week after treatment to check adherence, symptom resolution and whether partner notification has occurred. This role is often undertaken by the Practice Nurse.
Re-treatment is necessary if there has been unprotected sex with untreated sexual contacts during the week after treatment initiation. Patients should be advised to have a repeat sexual health check in three months, as reinfection is common. Entering a recall in the practice management system can be helpful. Partner notification, or contact tracing, is the process of identifying sexual contacts of a person with a STI and ensuring that they are aware of their possible exposure.
This helps to prevent reinfection in the index case, and allows identification of undiagnosed STIs and prevention of possible complications in their contacts. Partner notification should be discussed at the time of treatment for a STI and is recommended when the following conditions are identified: chlamydia, gonorrhoea, trichomoniasis, non-gonococcal urethritis, pelvic inflammatory disease and epididymo-orchitis.
Partner notification is not necessary for people diagnosed with genital warts or genital herpes although regular sexual partners may benefit from an assessment and a routine sexual health check. Management of partner notification for syphilis or HIV is more complex and referral to, or discussion with, a sexual health physician is recommended.
The most common method of partner notification is for the index case to notify their sexual contacts themselves. If the patient does not wish to notify their contacts due to concerns about confidentiality or safety, e. If a patient attends as a contact of someone who has been infected, the index case must not be identified to the contact.
Referral to appropriate agencies should be facilitated if there is ongoing risk of violence from a current relationship. The General Practitioner, or usually the Practice Nurse, should follow up with the patient after one week to confirm that relevant sexual contacts have been notified, as well as to check symptom resolution, adherence to medication and whether there has been any unprotected sex.
Referral to, or discussion with, a sexual health physician is recommended for patients with: Referral is also needed for patients who require specific sexual health counselling, or for follow-up of patients or contacts who fail to attend for treatment.
The first-line recommended treatment for people with chlamydia and males with non-gonococcal urethritisand their sexual partners is azithromycin 1 g, stat, or alternatively if not pregnantdoxycycline mg, twice daily, for seven days. Patients with a symptomatic rectal chlamydia infection, should be referred to, or discussed with, a sexual health physician. All patients treated for chlamydia and gonorrhoea should be advised to have a repeat sexual health check in three months, as re-infection is common.
A test of cure is unnecessary, except in women treated during pregnancy or if a non-standard treatment has been used. This should be carried out five weeks after treatment was initiated. Co-infection with chlamydia is very common, and azithromycin should Nurse at skin casual fuck screeing be co-administered, even if the chlamydia test is negative as the medicines Nurse at skin casual fuck screeing synergistically and reduce the risk of development of resistance.
If the isolate is known to be ciprofloxacin sensitive, a mg stat dose of ciprofloxacin can be used instead of ceftriaxone but not in women who are pregnant. A test of cure for gonorrhoea is not usually required unless there is a risk of re-exposure, symptoms do not resolve or a non-standard first-line medicine has been used test in five weeks.
Patients should be encouraged to return in three months for a sexual health check. Ceftriaxone injection is used for treating gonorrhoea if the antibiotic susceptibility is unknown, if the isolate is ciprofloxacin resistant, and for females who are pregnant or breast feeding ciprofloxacin is contraindicated in pregnancy.
The recommended dose of ceftriaxone for the treatment of gonorrhoea has increased from mg ceftriaxone IM, to mg IM stat. This increase in the dose for ceftriaxone has been recommended to overcome emerging cephalosporin resistance in Neisseria gonorrhoeae. The first-line recommended treatment for people with trichomoniasis, and their sexual partners is metronidazole 2 g, stat, or alternatively if not tolerated, metronidazole mg, twice daily, for seven days.
Metronidazole may be given to women who are pregnant category B2 or breast feeding, but they should be advised to avoid breast feeding for 12 — 24 hours after the dose. A test of cure for trichomoniasis is not usually required unless there is a risk of re-exposure. Culture of urethral swabs is rarely positive in males, due to low sensitivity, therefore empirical treatment of male partners is recommended without testing for trichomoniasis.
Male contacts should, however, have a routine sexual health check for other STIs. Women with bacterial vaginosis are often asymptomatic. It is not usually necessary to treat bacterial vaginosis unless symptoms are present or an invasive procedure is planned, e.
If treatment is required, first-line is metronidazole mg, twice daily, for seven days. Ornidazole mg, twice daily, for five days, or 1.
Pelvic inflammatory disease PID is usually caused by a STI, particularly in women aged under 25 years, women who have had recent change of sexual partner or women with a history of gonorrhoea or chlamydia. Diagnosis of PID is clinical, taking into the history, clinical findings and of tests.
However, STI tests will often be negative and a low threshold for treatment is appropriate, given the potential long-term consequences of infection and diagnostic uncertainty. Treatment should cover infection with gonorrhoea, chlamydia and anaerobes. First-line treatment is ceftriaxone mg, IM, stat plus doxycycline mg, twice daily, for 14 days plus metronidazole mg, twice daily, for 14 days.
Metronidazole can be discontinued in women with mild PID symptoms, if it is not tolerated.Nurse at skin casual fuck screeing
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