Sexually Transmitted Infections

STI Management

STI care involves managing both symptomatic and asymptomatic patients. Figure 2 demonstrates the essential steps of this process of medical care5. For practical reasons let us now separate the two main clinical assessment strategies and examine suggestions for incorporating these into clinical practice.

Risk Assessment

Routine screening in Canada is currently recommended for groups or asymptomatic individuals with high- risk behaviors, due to the prohibitive cost of screening the general population. The following individuals are identified frequently as core groups or transmitters with high-risk behaviors that contribute significantly to the prevalence of STIs.

1. Commercial sex workers and their clients.
2. Street youth
3. Injection drug users
4. Inner city poor

Physicians should learn to identify these individuals in their practice to ensure that appropriate screening and education are an integral part of all clinical encounters. For patients not apparently falling into these groups a strategy to include inquiries regarding sexual or drug-related risk behaviors should be a routine part of most patient encounters relevant to general health or specific issues related to reproductive health. The following clinical problems can be clues suggesting the presence of STIs.

1. Urinary and/or genital tract complaints
2. Problems with interpersonal relationships
3. Psychosocial problems
4. Depression
5. Anxiety or mood disorders

Many studies have shown that less than a third of physicians obtain an adequate sexual history from their patients. It has been proposed6 that if time during a patient-physician encounter allows for only a single question, a reasonable choice is the following:

What do you do to protect yourself from STIs / HIV?

Figure 3. Example of a Short Sexual History Assessing Risk for STIs

Are you sexually active at present? If not, how long has it been since you had sexual contact with someone? When you were/are sexually active, was/is it with men, women or both? How many lifetime sexual partners have you had? (Estimate only, if > 10) What percentage of these partners was "casual"? What kind of sexual activity do/did you engage in? Do you always practice "safer sex"? Have you ever had a sexually transmitted disease?

Source: Gabel and Pearsol Taking an Effective Sexual and Drug History Journal of Family Practice 1993; 37:185

Women are more frequently targeted for screening because the frequency of asymptomatic infection is higher and the consequences of untreated infection greater in terms of morbidity and mortality. It should be noted, however, that differences exist between Canada and the US in determining who should be screened and for which infections. As an example, the US currently suggests screening for chlamydia in all the following: sexually active women < 20 years old, women between ages 20-24 years with either

1. a history of inconsistent use of barrier methods or
2. a new sexual partner in the prior 3 months and women > 24 years of age with both of the latter risks.

In Canada however, chlamydia screening is recommended only for contacts with a known STI and sub - groups with high STI prevalence rates or "at- risk" for complications of infection i.e. pregnant women. Despite this, a number of recommendations can be made for screening based on age, risks, test effectiveness and cost and opportunities for testing. These recommendations are summarized in Table 3.

Syndrome Assessment

Most patients with symptomatic disease will present to physicians with a recognizable STI syndrome that helps to define the appropriate investigation and empiric management. It is important to note however that the presentation of a patient with an STI represents a unique opportunity to assess them for other STIs and to initiate counseling interventions to educate them on means to reduce their risk for future STIs. Remember, STIs are like wolves; they travel in packs. A patient who has developed one STI has als o placed him/herself at risk to acquire other sexually transmitted infections. The commonest clinical STI syndromes faced by physicians along with the common microbial causes and the appropriate investigations are summarized in Table 4. All patients presenting with an STI should also be offered serologic testing for syphilis, HBV and HIV. Syphilis serology is inexpensive and so worth doing despite its declining incidence. Hepatitis B serology can be precluded if there is a documented response to prior HBV vaccination. HIV serology should be only undertaken with appropriate preand post-test counseling. Hepatitis C serology should not be done routinely except for those individuals at-risk for acquiring HCV. These include blood product recipients prior to 1992 and those with a current or past history of injection drug use. Sexual transmission of HCV is infrequent.

Last Modified: September 5, 2006