Sexual health history and clinical examination

There are no hard and fast rules about taking a sexual, or any other medical history. See Notes on sexual history taking for an outline of the model used in this clinic.

When using the NaSH system, it is sometimes helpful to have two distinct phases to the consultation – the first for an open, patient centred discussion using a series of open questions to establish the patient’s needs. The second, for the completion of the NaSH minimal dataset, can often be addressed in a series of closed questions to fill in detail. The NaSH minimum dataset: Flow Chart 2, includes the mandatory data fields for any patient attending for STI testing or treatment.

Plates for the culture of N.gonorrhoeae (MNYC medium) are not available in all peripheral clinics. The optimal management of gonorrhoea includes culture to determine antibiotic sensitivity so referral of all cases and contacts of gonorrhoea to Galashiels Health Centre Borders Sexual Health clinic is ideal. However pragmatic decisions should be made based on risk, symptoms and the likelihood of attendance.

Other documents in this folder:

NaSH Minimum Dataset
Notes on sexual history taking
HIV risk assessment
Hepatitis B risk assessment
Instructions for self taken swabs – MSM
Instructions for Roche 4800 urine samples
Instructions for Roche 4800 vaginal swab samples

Men who have sex with women

All men

• First voided specimen of urine for detection of Chlamydia trachomatis and Neisseria gonorrhoeae
• Serological tests (IgG EIA only) for syphilis
• HIV antibody testing

Men who are contacts of a female partner with gonorrhoea, or are known to have urethral gonorrhoea

• Pharyngeal sample for dual NAAT testing for N.gonorrhoeae and C.trachomatis
• Pharyngeal culture for N.gonorrhoeae (where available)
• Urethral culture for N. gonorrhoeae (where available) (it is usually more efficient to take this sample at the same time, rather than repeating examination if the urethral slide is positive for GNID)

Men with signs of discharge or urethral inflammation

• Urethral smear for Gram-smear microscopy if urethral discharge noted
• Urethral culture for N.gonorrhoeae (where available) (it is usually more efficient to take this sample at the same time, rather than repeating examination if the urethral slide is positive for GNID)

Men who have sex with men (MSM)

All MSM

• Pharyngeal sample for dual NAAT testing for N.gonorrhoeae and C.trachomatis
• First voided specimen of urine for detection of C.trachomatis and N.gonorrhoeae
• Rectal sample for dual NAAT testing for N.gonorrhoeae and C.trachomatis
• Serological tests (IgG EIA only) for syphilis
• HIV antibody testing
• Hepatitis B antigen and core antibody tests (if not previously tested or vaccinated)

Men who are contacts of a male partner with gonorrhoea, or are known to have urethral gonorrhoea

• Pharyngeal culture for N.gonorrhoeae (where available)
• Rectal culture for N.gonorrhoeae (where available)
• Urethral culture for N. gonorrhoeae (where available) (it is usually more efficient to take this sample at the same time, rather than repeating examination if the urethral slide is positive for GNID)

All women

• Vulvovaginal swab for dual NAAT testing for N. gonorrhoeae and C. trachomatis. This can be a self-taken swab
• Serological tests (IgG EIA only) for syphilis
• HIV antibody testing

Women who have reported a change in vaginal discharge, or where the discharge appears abnormal

• Measure the pH using narrow-range pH paper
• Take sample of material from the posterior vaginal fornix to prepare a smear on a microscope slide for Gram-staining, and then suspend some of the material in a drop of isotonic saline on another slide

Women at elevated risk of gonorrhoea because they:

• work in the sex industry 
• report sexual assault 
• are contacts of gonococcal infection, or 
• have been diagnosed with gonorrhoea at an anogenital site (positive cervical, urethral, vulvovaginal or rectal GC NAAT test) 
• have been presumptively diagnosed with gonorrhoea (GNID seen on microscopy of a Gram-stained smear of urethral or endocervical material)

Also require:

• Pharyngeal sample for dual NAAT testing for N.gonorrhoeae and C.trachomatis
• Rectal sample for dual NAAT testing for N.gonorrhoeae and C.trachomatis

Women who are to be treated for a presumptive diagnosis of gonorrhoea because of:

• having been diagnosed with gonorrhoea at an anogenital site (positive cervical, urethral, vulvovaginal or rectal GC NAAT test) 
• having been presumptively diagnosed with gonorrhoea (GNID seen on microscopy of a Gram-stained smear of urethral or endocervical material)

Also require:

• Pharyngeal culture for N.gonorrhoeae (where available)
• Urethral culture for N. gonorrhoeae (where available) 
• Endocervical culture for N. gonorrhoeae (where available) unlike NAAT testing, this specimen must be taken from the endocervix and not vulvo-vagina
• Rectal culture for N. gonorrhoeae (where available)

All male and female patients

Take a blood sample for serological tests for syphilis and HIV infection in all attendees regardless of risk factors, unless the patient declines.

Men and women from populations with higher prevalence of Hepatitis B infection

Perform Hepatitis B surface antigen and core antibody (sAg and cAb) tests, if there is a history of:

• injecting drug use (by the patient or a sexual partner
• sexual contact with an individual from a geographical area where HBV infection is endemic (intermediate or high on map) 
• blood transfusion/ invasive medical procedures in the same areas 
• tattoos or piercings performed in unlicensed settings (low risk except in gaol)
• work in the sex industry

Men and women from populations with higher prevalence of Hepatitis C infection

Perform Hepatitis C antibody test in:

• All MSM who are HIV infected 
• MSM who give a history of sex with increased risk of Hepatitis C infection (including fisting, sex with multiple partners in conjunction with drug use (‘Chemsex’)

and men and women who give a history of:

• injecting drug use by the patient or a sexual partner, (although the risk of transmission of HCV through sexual contact is less than that of HIV and hepatitis B)
• sexual contact with an individual from a geographical area where HCV infection is endemic (prevalence >2.0% on the map below) 
• blood transfusion/ invasive medical procedures in the same areas 
• tattoos or piercings performed in unlicensed settings (low risk except in gaol)

In asymptomatic men at low risk of syphilis or BBV who are attending for routine screening for STIs, examination is not necessary. In asymptomatic MSM (men-who-have–sex-with–men) who are regular attendees for screening, offer the option of self-taken samples for NAAT testing from the pharynx and rectum.  Don’t assume that men will prefer not to be examined.

See instructions for self-taken swabs - MSM

In all symptomatic men, contacts of STI or those at high risk of infection, an examination is indicated. See Box 1 for a summary. This may include:

Oral examination and sampling

• Inspect the oral cavity and pharynx for lesions such as warts or ulcers, for example, those seen in secondary syphilis.
• Take an oropharyngeal sample for dual NAAT testing for gonorrhoeae and C.trachomatis in all MSM and in heterosexual men who are contacts of gonococcal infection, or have been diagnosed with urethral gonorrhoea (this can be self taken if the patient prefers).
• Take an oropharyngeal sample for culture for gonorrhoeae men who are contacts of gonococcal infection, or have been diagnosed with urethral gonorrhoea (see Gonorrhoea chapter for details of how to do this). It is NOT necessary to routinely perform culture on all MSM.

Note:

• NaSH requests: Chlamydia: pharynx, GC NAAT: pharynx, GC culture: pharynx
• Culture samples should not be self-taken and the sensitivity of culture is highly dependent on sampling technique.
• Pharyngeal testing for trachomatis is of unproven benefit. It is not possible to suppress the chlamydia result on the dual NAAT in use in our laboratory, so NAAT testing for N.gonorrhoeae inevitably involves testing for chlamydia too. There is no indication for routinely testing for pharyngeal chlamydial infection.

Genital examination and urethral samples

• Inspect the pubic area for Phthirus pubis, warts, and molluscum contagiosum, or other lesions.
• Examine the genitocrural folds for tinea cruris or warts.
• Palpate the inguinal lymph nodes. Note enlargement: unilateral, for example, in lymphogranuloma venereum, or bilateral.  Note whether or not the enlarged nodes are tender, such as in primary genital herpes.
• Palpate the testes and epidididymes. Epididymitis may complicate untreated chlamydial and gonococcal infections of the urethra.
• Examine the shaft of the penis. Identify lesions such as warts, molluscum contagiosum, and scabetic papules.
• Retract the prepuce (foreskin), if present, and look for balanoposthitis, warts or ulcers (see below).
• Examine the urethral meatus for urethral discharge. Evert the lips of the meatus to identify warts in the distal urethra.
• In men with symptoms or signs of urethral inflammation, take a urethral sample for Gram-stain microscopy. Insert a plastic disposable (blue) inoculating loop (10L) into the urethra to a distance of about 2 cm, apply gentle lateral pressure against the wall of the urethra and withdraw the loop. Prepare a smear on a microscope slide.

Notes:

• Men unable to provide a urine sample: If he is unable to provide a urine sample for NAAT testing , use a cotton wool-tipped plastic swab (provided by the manufacturer of the test collection kit) about 3-5 cm into the urethra, withdrawing, and breaking off the end into a buffer solution. Remember to delete the urine sample requests from NaSH and request Chlamydia: urethral and GC NAAT: urethral.
• In men with candidal balanitis, and in those with symptoms suggestive of a urinary tract infection, always test the urine for protein, blood and glucose. Candidal balanitis may be the presenting feature of diabetes mellitus.

Perianal examination and anorectal sampling

In MSM, inspect the perineum, perianal region and anus for lesions such as warts, herpetic ulceration, syphilitic chancre or anal fissure (note that a chancre can occasionally mimic anal fissure).

In MSM take a rectal sample for dual NAAT testing for gonorrhoeae and C. trachomatis using the cotton wool-tipped plastic swab in the test collection kit, inserted about 3 cm into the anal canal while pressing laterally against the rectal mucosa and rotating gently for a minimum of 10 seconds. Withdrawing and break off the end into the buffer solution provided (this can be self taken if the patient prefers – see self taken swab instructions)

In MSM who are contacts of a male partner with gonorrhoea, who have a positive NAAT test for gonorrhoea at any site, or have a urethral slide positive for GNID, take a rectal culture for gonorrhoea. Use a cotton wool tipped swab inserted about 3 cm into the anal canal while pressing laterally against the rectal mucosa and rotating gently for a minimum of 10 seconds.

If there are anorectal symptoms, pass a proctoscope, examine the distal rectum and anal canal, and obtain the appropriate specimens for microbiological examination as described above.

In asymptomatic women at low risk of syphilis or BBV who are attending for routine screening for STIs, examination is not necessary. Women can be given instructions for the self-taking of vulvo-vaginal swabs. Don’t assume that women will prefer not to be examined. Be aware that many women will want the reassurance of an examination, so unless she is in a drop-in clinic with no facilities for examination, she should be offered the option of an examination.

See instructions for self-taken vulvo-vaginal swabs

In all symptomatic women, contacts of STI or those at high risk of infection, an examination is indicated. Examination of the anogenital area should be performed with the woman in the semi-lithotomy position on a couch in a warm and well-lit room. See Box 3 for a summary. Examination may include:

Oral examination and sampling

Inspect the oral cavity and pharynx for lesions such as warts or ulcers, for example, those seen in secondary syphilis.

Take an oropharyngeal sample for dual NAAT testing for gonorrhoeae and C.trachomatis (this can be self taken if the patient prefers) in women who

• work in the sex industry
• report sexual assault
• are contacts of gonococcal infection, or
• have been diagnosed with gonorrhoea at an anogenital site (positive cervical, urethral, vulvovaginal or rectal GC NAAT test)
• have been presumptively diagnosed with gonorrhoea (GNID seen on microscopy of a Gram-stained smear of urethral or endocervical material)

Take an oropharyngeal sample for culture (in addition to the NAAT test) for gonorrhoea in women who are contacts of gonococcal infection, or have been diagnosed with urethral gonorrhoea at an anogenital site (see Gonorrhoea chapter for details of how to do this).

Notes

• It is only necessary to take samples for gonococcal culture in addition to NAAT tests in those who are being treated for possible gonorrhoea.
• NaSH requests: Chlamydia: pharynx, GC NAAT: pharynx, GC culture: pharynx
• Culture samples should not be self-taken and the sensitivity of culture is highly dependent on sampling technique.
• Pharyngeal testing for trachomatis is of unproven benefit. It is not possible to suppress the chlamydia result on the dual NAAT in use in our laboratory, so NAAT testing for N.gonorrhoeae inevitably involves testing for chlamydia too. There is no indication for routinely testing for pharyngeal chlamydial infection.

Genital examination and samples

• Inspect the abdomen, and palpate for tenderness, guarding and masses.
• Inspect the pubic area for pubis, warts and molluscum contagiosum.
• Palpate the inguinal lymph nodes, and note enlargement and tenderness such as in primary genital herpes.
• Inspect the labia majora for lesions such as warts or ulcers.
• Gently separate the labia minora from the labia majora. Examine the labia minora and, after wiping with a cotton wool ball (anterior to posterior or ‘front-to-back’ direction, inspect the introitus.  Look particularly for warts and lesions of herpes (HSV).
  
  Take a vulvovaginal swab for dual NAAT testing for N. gonorrhoea and C. trachomatis using the cotton wool-tipped plastic swab in the test collection kit, inserted about 5 cm into the vagina while pressing laterally against the vaginal wall and rotating gently with a swirling motion for a minimum of 10 seconds. Withdraw and break off the end into the buffer solution provided (this can be self taken if the patient prefers – see self taken swab instructions)

In women who are contacts of a partner with gonorrhoea:

• Obtain urethral material for Gram-smear microscopy by gently inserting a disposable plastic inoculating loop (10L) into the distal 2cm of the urethra, applying gentle lateral pressure and withdrawing.
• Culture urethral material obtained in the same way for gonorrhoeae (MNYC medium)

Pass a plastic vaginal speculum and examine the character of any vaginal discharge. A homogeneous milky-white discharge that coats the vaginal walls suggests bacterial vaginosis.  Note inflammation of the vaginal walls, as may occur in trichomoniasis. See chapter on vaginal discharge.

In women who have reported a change in discharge, or where the discharge appears abnormal:

• Measure the pH using narrow-range pH paper, avoiding the alkaline cervical secretions. The paper can be applied directly to discharge at the introitus or a cotton wool tipped applicator stick can be used to sample discharge from the lateral or posterior fornix for application to the pH paper. In bacterial vaginosis, the pH of the discharge is >5.0
• Collect a sample of material from the posterior vaginal fornix, using a cotton wool-tipped applicator stick. Prepare a smear on a microscope slide for subsequent Gram-staining, and then suspend some of the material in a drop of isotonic saline on another slide. 
• Examine (x40 objective lens: magnification x400:) the saline mount preparation for the motile trophozoites of Trichomonas vaginalis, fungal hyphae and “clue cells”.
• Examine (x100 oil-immersion lens, magnification x1,000) the Gram-stained smear for the spores and/or hyphae of candidal infection, the presence or absence of lactobacilli (in bacterial vaginosis, lactobacilli are reduced in number or absent, their place being taken by a mixture of Gram-negative and Gram-variable cocco-bacilli), and “clue cells”.

Note the appearance of the ectocervix and the character of any discharge from the endocervical canal; in chlamydial and gonococcal infections there may be a mucopurulent discharge.

In women who are contacts of a partner with gonorrhoea:

• Use a cotton wool-tipped applicator stick to collect material for microscopy for gonorrhoeae from the endocervical canal, smearing the sample on a plain microscopy slide.
• Culture cervical material obtained in the same way for gonorrhoeae (MNYC medium)

If there is pelvic pain, or other features suggestive of PID, perform a bimanual vaginal examination.

In women with symptoms suggestive of a urinary tract infection, haematuria or proteinuria. obtain a mid-stream specimen of urine for microscopy and culture

If there is risk of pregnancy, perform a pregnancy test on urine.

Perianal examination and anorectal sampling

Inspect the perineum, perianal region and anus for lesions such as warts.

Take a rectal sample for dual NAAT testing for gonorrhoea and C. trachomatis in women who:

• work in the sex industry
• report sexual assault
• are contacts of gonococcal infection, or
• have been diagnosed with gonorrhoea at an anogenital site (positive cervical, urethral, vulvovaginal or rectal GC NAAT test,
• have been presumptively diagnosed with gonorrhoea (GNID seen on microscopy of a Gram-stained smear of urethral or endocervical material)

Using the cotton wool-tipped plastic swab in the test collection kit, insert about 3 cm into the anal canal while pressing laterally against the rectal mucosa and rotating gently for a minimum of 10 seconds. Withdraw and break off the end into the buffer solution provided (this can be self taken if the patient prefers – see self taken swab instructions for MSM)

In women who are contacts of a male partner with gonorrhoea, who have a positive NAAT test for gonorrhoea at any site, or have a urethral or cervical slide positive for GNID, take a rectal culture for gonorrhoea. Use a cotton wool tipped swab inserted about 3 cm into the anal canal while pressing laterally against the rectal mucosa and rotating gently for a minimum of 10 seconds.

If there are anorectal symptoms, pass a proctoscope, examine the distal rectum and anal canal, and obtain the appropriate specimens for microbiological examination as described above.

Take a blood sample for serological tests for syphilis and HIV infection in all attendees regardless of risk factors, unless the patient declines.

Hepatitis B testing

Offer serological tests for hepatitis B virus (HBV) infection (HepBsAg and HepB core Ab) in:

• All men reporting same sex sexual contact (MSM)

Male and female patient with a history of:

• injecting drug use (by the patient or a sexual partner)
• sexual contact with an individual from a geographical area where HBV infection is endemic (intermediate or high on map below)
• blood transfusion/ invasive medical procedures in the same areas
• tattoos or piercings performed in unlicensed settings (low risk except in gaol)
• work in the sex industry

See test requests on NaSH and map of hepatitis worldwide prevalence below.

Tick ‘hepatitis B screen’ on request form.

The window period before antibodies to hepatitis B become detectable may be up to three months. In cases where there has been a known or suspected contact with hepatitis B infection, discuss testing with a GUM consultant.

Offer serological tests for hepatitis C virus (HCV) infection in:

• All MSM who are HIV infected 
• MSM who give a history of sex with increased risk of Hepatitis C infection (including fisting, sex with multiple partners in conjunction with drug use or ‘Chemsex’) 

Male and female patients who give a history of: 

• injecting drug use by the patient or a sexual partner, (although the risk of transmission of HCV through sexual contact is less than that of HIV and hepatitis B). 
• sexual contact with an individual from a geographical area where HCV infection is endemic (prevalence >2.0% on the map below)
• blood transfusion/ invasive medical procedures in the same areas
• tattoos or piercings performed in unlicensed settings (low risk except in gaol) 

The window period before antibodies to Hepatitis C become detectable may be up to six months. In cases where there has been a known or suspected contact with Hepatitis C infection, discuss testing with a GUM consultant.

The table below indicates the minimum fields to be completed on all attendees at all General Clinics (includes FP general, GUM general, Combined, Emergency, Youth, Outreach, Walk-in) and GUM Complex (GUM Complex, Forensic, Chlam Clinic, SHA/HIVT and Gay Men) in Borders Sexual Health Services. It may not be necessary to complete all fields at every attendance, but updates to medical history, partner status etc should be recorded.