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SECTION THREE
Osmolality (mOsmol/kg)
Specific gravity (mOsmol/kg)
Serum creatinine (µmol/l)
Urine osmolality (mOsmol/kg)
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Renal and urology system
379
known renal or urinary tract disease. The urine
specimen should be passed into a clean container
without additives, by placing a sterile container
in the path of the urine stream once voiding has
commenced (i.e. a mid- stream specimen). Normally,
sample should be tested as soon as possible, or
refrigerated (not frozen) and returned to room
temperature before testing.
Quantity
Normal adults in temperate climates usually pass
between 750 and 2500 ml of urine every 24 hours.
The minimum daily urine output compatible with
normal renal excretory function varies from person
to person and also with other factors, such as diet.
Colour
The colour of urine is heavily influenced by the
urinary flow rate, with high flow leading to dilute
urine and hence a pale colour. Darkening occurs
on standing as a result of oxidation of urobilinogen
to coloured urobilin. Table 17.10 describes some
common causes of discoloured urine.
Specific gravity and osmolality
Specific gravity and osmolality measurements are
functions of the urinary concentrations of sodium,
chloride and urea in the absence of significant
glycosuria. The range of specific gravity is 1.001 to
1.035, which is equivalent to 50–1350 mOsmol/kg
water (Fig. 17.4). In advanced renal disease, the
osmolality becomes relatively fixed at about 300
mOsmol/kg water, close to that of the glomerular
filtrate (Fig. 17.5). This is termed isosthenuria, and
because the urine concentration cannot be varied,
causes increased sensitivity to changes in sodium and
water balance.
pH
The pH varies from 4 to 8 and can be measured
using paper strips impregnated with an indicator.
Table 17.10 Causes of discoloured urine
Colour Cause
Brown Bile pigments
Red Large volume of blood
Cloudy Leucocytes (infection)
Orange Rifampicin
Grey Methyldopa
Pale yellow Dilution: polyuria/excess water intake
Blood
Myoglobin (brown/red)
Nitrofurantoin
Intravascular haemolysis (free haemoglobin)
Large volume of red blood cells
Phosphates
Senna
If more accurate measurements are needed, as in
suspected renal tubular acidosis, a pH electrode
is used. Most people pass acid urine most of the
time, exceptions being in some vegetarians, certain
types of renal tubular acidosis, rapid water diuresis,
metabolic alkalosis and urine infection with ureasplitting organisms.
1.04
1.03
1.02
1.01
1.00
0
Figure 17.4 Relationship between specific gravity and osmolality.
800
End-stage
600
renal
failure
400
200
0
0
Figure 17.5 Relationship between renal concentration and
diluting capacity, and serum creatinine concentration. The
serum creatinine is plotted on a logarithmic scale. This therefore
represents linear changes in glomerular filtration rate (GFR), such
as might occur in progressive renal failure. End- stage renal failure
is shown on the left, and normal renal function on the right. Curve
(a) represents maximum concentrating capacity (e.g. in water
deprivation, when the normal kidney can maintain the serum
creatinine in the normal range by increasing urine osmolality).
In renal failure, the urine cannot be concentrated and the serum
creatinine rises. Curve (b) represents the maximum diluting
capacity (e.g. after the ingestion of large volumes of water). The
normal kidney excretes urine of low osmolality. In end- stage renal
failure, urine osmolality cannot be reduced and the water load is
not adequately handled. There is also isosthenuria (i.e. the urine
tends towards an iso-osmolar state (specific gravity 1.010)).
1000
200
1503005001000
2000
a
Normal
renal
function
b
100120
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Renal and urology system
Glucose
Glucose oxidase- impregnated dipsticks provide a
quick and semi- quantitative test for glucose in urine.
By far the most common causes of glycosuria are
diabetes and during pregnancy, in which glycosuria
occurs with normal plasma glucose concentrations.
Very rarely, tubular transport defects may be
associated with glycosuria at normal plasma glucose
concentrations, and more frequently, patients with
CKD may exhibit glycosuria at normal plasma
glucose concentrations.
Protein
The normal daily urine protein output is <150 mg
and albumin <30 mg/day. Dipsticks reactive to
urine albumin provide a simple semi- quantitative
test and are sensitive to 200–300 mg protein/l.
Albumin excretion in the range of 30 to 200 mg/day
is termed microalbuminuria. Although this range is
frequently too low to be detectable by stick testing,
it is an important finding, particularly in people
with diabetes in whom it predicts the later onset
of overt diabetic nephropathy. The urinary protein
excretion rate generally rises in the upright posture;
with activity and, in some normal individuals,
this may lead to apparently abnormal proteinuria
(orthostatic proteinuria). Measurement of protein in
an early- morning urine specimen, however, reveals
no protein.
The albumin- to- creatinine (ACR) and protein- tocreatinine (PCR) ratios are useful surrogate markers
for proteinuria. They are increasingly used instead
of the 24- hour urine collection for quantification
of protein excretion (Table 17.11). The diagnostic
implications of proteinuria depend on its magnitude
(Table 17.12). Heavy proteinuria (>1.5 g/day) is
nearly always glomerular in origin, and albumin
predominates over larger proteins, such as globulins.
Other proteins, rarely measured, arise from the
renal tubules; they include Tamm- Horsfall protein,
retinol- binding protein and nephrocalcin, the latter
helping to prevent the formation of urinary stones.
It is worth noting that urine light chains (found in
plasma cell dyscrasias, such as myeloma) may not be
detected by some routine laboratory urine protein
assays and have to be sought separately.
Microscopy
Microscopy (Figs 17.6–17.9) is performed after slow
spinning of a fresh urine specimen for approximately
2 minutes. The pellet is resuspended in 0.5 ml of
urine and examined unstained on a microscope
slide under a coverslip. Important findings include
leucocytes (suggestive of infection), red blood cells
and tubular casts. The presence of tubular casts is
indicative of parenchymal renal disease. They may
be red cell casts or white cell casts in which TammHorsfall protein matrix has solidified and is studded
with red or white blood cells. Granular casts probably
represent degenerate cellular casts and have a grainy
appearance. Hyaline casts contain no elements or
debris and may be seen in small numbers in normal
urine. The presence of red cell casts should alert
one to the possibility of an aggressive GN. Red cell
morphology may be a useful indicator of the source
of bleeding. Red cells with a normal outline usually,
but not always, arise from the renal collecting system
or from a point downstream of that, whereas red
cells arising from the glomeruli are often distorted.
Table 17.11 Relationship between ACR, PCR and 24- hour urine protein excretion
Microalbuminuria 3–30
Proteinuria >30 >50 >0.5
ACR, albumin- to- creatinine; PCR, protein- to- creatinine.
Table 17.12 Proteinuria
Mild (<500 mg/day) Moderate (up to 3 g/day) Heavy (>3 g/day)
Benign hypertensive nephrosclerosis
Obstructive nephropathy
Prerenal uraemia
Renal tumour
Fever
Tubulointerstitial nephropathy
Chronic pyelonephritis
Early diabetic nephropathy
Orthostatic proteinuria
Urinary tract infection
ACR (mg/mmol) PCR (mg/mmol) 24- hour urine protein (g/day)
Chronic pyelonephritis
Acute tubular necrosis
Acute glomerulonephritis
Chronic glomerulonephritis
Obstructive nephropathy
Accelerated phase hypertension
Orthostatic proteinuria
Urinary tract infection
Acute glomerulonephritis
Chronic glomerulonephritis
Diabetic nephropathy
Pre- eclampsia
Myeloma
All causes of nephrotic syndrome
Figure 17.6 Erythrocytes in urinary sediment.
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SECTION THREE
Renal and urology system
Figure 17.9 Granular casts in urinary sediment.
during passage to the exterior. Extensive studies have
shown that the finding of more than 105 bacteria
per millilitre in a mid- stream specimen is usually
associated with active urinary infection, especially
when accompanied by leucocytes.
381
Figure 17.7 Leukocytes in urinary sediment.
Figure 17.8 Hyaline casts, leukocytes and bacteria in urinary
sediment. (Reproduced with permission from Spencer ES, Petersen I
1971 Hand Atlas of Urinary Sediment. Munksgaard, Copenhagen.)
Microbiological examination of the urine
Mid- stream urine specimens are normally satisfactory,
but they are always contaminated to a certain extent
Measurement of the glomerular filtration rate
Accurate assessment of the GFR requires
measurement in blood alone or blood and urine
of a compound that is filtered freely at the
glomerulus and neither reabsorbed nor secreted
by the tubules. Inulin is the best agent but it is a
laborious investigation that is generally confined to
research and is not routinely available. A number
of surrogates for the inulin clearance method exist
and details of these are given in Table 17.13. The
most frequently used surrogates, and also the crudest
ones, are the plasma urea and plasma creatinine
concentrations. Both compounds are produced
endogenously (at an inconstant rate in the case of
urea) and excreted by glomerular filtration. Neither
is particularly accurate when used to establish the
absolute level of glomerular filtration, although the
plasma creatinine concentration is very useful when
used to follow changes in an individual patient’s
renal function (Fig. 17.10). Creatinine clearance
is more precise but it requires a 24- hour urine
collection with measurements of plasma creatinine
concentration and urine creatinine excretion. Only
those compounds that are freely filtered at the
glomerulus and neither secreted nor reabsorbed by
the renal tubules are suitable for GFR measurement.
Several mathematical formulae are used to estimate
GFR (Table 17.14), validated internationally and
used by most laboratories. GFR estimation using
some of these formulae has traditionally included a
correction factor to account for differences in muscle
mass in black patients; this is increasingly being
phased out in recognition of the genetic diversity
within black patients and lack of a scientific evidence
to underpin clinical decision making based on race.
382
Creatinine clearance (ml/min)
Serum creatinine (µmol/l)
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Renal and urology system
Table 17.13 Measurement of the glomerular filtration rate
Method Comments
Plasma urea Poor surrogate:
– variable production rate
– variable excretion rate
– dependant on uptake
Plasma
creatinine
Better than urea
Poor discrimination at near- normal
glomerular filtration rate (GFR)
Calculated GFR Useful surrogate of creatinine clearance
(MDRD or CKD- EPI formulae)
Creatinine
clearance
Reasonable surrogate but depends on
accurate timed urine collection (usually
24 hours)
UV/P where U equals the urinary
concentration of creatinine, V the urinary
flow rate (usually expressed in ml/min)
and P equals the plasma creatinine
concentration.
51
Cr- EDTA The best surrogate in clinical practice
Expensive
Inulin clearance Near- perfect measurement of GFR but:
– needs continuous infusion
– difficult urine and plasma assays
– research studies only: not suited to
clinical practice
1000
800
600
400
200
0
0
Figure 17.10 Relationship between creatinine clearance and
plasma creatinine concentrations. The normal range of serum
creatinine concentration can be maintained only when the renal
creatinine clearance is greater than about 60 ml/min. The red area
represents the normal range of creatinine concentration.
20
40 60 80
100
GFR peaks at 20 to 25 years of age and declines
steadily thereafter at a rate of approximately 1 ml/
min/year.
Other biochemical tests important in renal
disease
The GFR is usually measured along with urea and
electrolytes (sodium, potassium, chloride), expressed
Table 17.14 Estimation of GFR formulae
Cockcroft and Gault Male GFR = [1.23 × weight (kg) ×
(140 − age)]/creatinine
Female GFR = [1.03 × weight (kg) ×
(140 − age)]/creatinine
Modification of diet
in renal disease
GFR = 186 × PCR − 1.154 × age −
0.203 × 1.212 (if black) × 0.742 (if
female)
PCR = plasma creatinine in mg/dl
CKD- EPI CKD- EPI equation expressed as a
single equation:
GFR = 141 × min (Scr /κ, 1)α ×
max(Scr /κ, 1)
- 1.209
× 0.993
Age
×
1.018 [if female] × 1.159 [if black]
where:
Scr is serum creatinine in mg/dl,
κ is 0.7 for females and 0.9 for males,
α is −0.329 for females and −0.411
for males,
min indicates the minimum of Scr /κ
or 1, and
max indicates the maximum of Scr /κ
or 1
in mmol/l. Sodium balance can be an indicator of
volume status, or may reflect an underlying tubular
or endocrine disorder. An elevated potassium, owing
to the failure of the K/H co- transporter in the distal
tubule, is a common finding in renal insufficiency;
high levels (>6 mmol/l) can result in arrhythmia
and even sudden cardiac death, and require urgent
assessment and treatment. A low potassium level
can be an indicator of an underlying tubular disorder.
Urea frequently rises in parallel with creatinine and
is responsible for many of the symptoms associated
with chronic kidney disease. Exceptions are in upper
GI bleeding, when the passage of blood through the
bowel results in reabsorption of urea into the circulation, and dehydration. In both these situations the
urea can be elevated disproportionately to the rise in
creatinine level.
In CKD 3 and above, measurement of bone
parameters (calcium, phosphate, vitamin D,
parathyroid hormone) should be undertaken to
monitor the effects of CKD in bone mineralization.
These tests are also useful when evaluating the
patient with renal stones for underlying causes.
Anaemia is frequently seen in the patient with
CKD, and in those with bleeding in the urinary
tract from any cause. An elevated white cell
count with associated neutrophilia may be seen in
infection.
Immunological and serological tests for infection,
viruses and auto- immune disease may be indicated
in the investigation of renal syndromes, including
nephrotic syndrome, nephritic syndrome, acute
kidney injury and CKD.
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Renal and urology system
383
Measurement of renal tubular function
The two tests most frequently utilized to measure
renal tubular function are:
1. Tests of renal concentrating ability when
investigating possible causes of polyuria
2. Tests of renal acidification in patients with
metabolic acidosis and possible underlying renal
tubular acidosis
Renal concentrating ability involves treating the
patient in a way that should lead to the production
of a concentrated urine. Water deprivation is the
most common provocation: after 12 hours, the
urine osmolality should be at least 750 mmol/kg
(specific gravity 1.020). Failure to concentrate the
urine indicates either impairment of vasopressin
output (pituitary diabetes insipidus) or resistance
of the renal tubules to the action of vasopressin
(nephrogenic diabetes insipidus). These two
possibilities may be distinguished by measuring the
urine osmolality after an injection of vasopressin
(or an analogue) when the urine osmolality should
increase to at least 750 mmol/kg.
Renal tubular acidification can be assumed to be
adequate if the pH of a random specimen of urine
is below 5.5. Urine pH > 5.5 in the presence of
metabolic acidosis usually indicates renal tubular
acidosis. If the patient is only minimally acidotic and
the urine pH is >5.5, a provocative test, in which
ammonium chloride is given at a dose of 0.1 g/kg
body weight to provide an acid load and an acute
mild metabolic acidosis, can be performed. The pH
should fall to <5.4 if acidification is normal.
Assessment of the urine in the stone- forming
patient
involves measurement of the important constituents
of stone whose outputs may be abnormally increased
and also measurement of at least one of the natural
inhibitors of stone formation, combined with analysis
of the stone itself.
The identification of increased excretion rates
of calcium, uric acid, oxalate or cystine indicates a
strong predisposition to recurrent stone formation.
Conversely, citrate is a natural inhibitor of stone
formation, and a low urine citrate is associated
with increased stone risk. All patients who make
radiopaque stones should be screened for cystinuria
using the nitroprusside test. If hypercalciuria or
hypercalcaemia are noted, then the parathyroid and
serum angiotensin- converting enzyme should also
be measured.
Kidney biopsy
Kidney biopsy, in which one or two small cores of
renal cortex are removed using a needle- biopsy, is
performed in patients in whom renal parenchymal
disease is suspected. However, not everyone with
renal parenchymal disease requires a biopsy. The
procedure is invasive and carries a small but definite
risk of serious complications. It is therefore important
to define the indications and contraindications
carefully.
Kidney biopsy is often the only way to distinguish
the various forms of GN, both from one another and
from tubulo- interstitial diseases of the kidney.
Imaging of the urinary tract
Plain radiographs
In many people, one or both of the kidneys can be
seen outlined by perirenal fat on plain abdominal
films. The information gleaned is limited, although
certain types of renal stone and renal calcification
may be identified.
Ultrasound
Ultrasound provides good images of the renal
parenchyma and collecting system, and gives a reliable
estimate of renal size as well as identifying discrete
lesions within the parenchyma, hydronephrosis and
stones. Doppler studies often permit assessment of
blood flow in the main renal arteries. The resistive
index, measured by Doppler ultrasound, indicates
the degree of chronic intrarenal ischaemic injury,
but is very operator dependent. Although the upper
ureter can be seen quite well in most patients, the
lower ureter is not visualized adequately. Ultrasound
allows calculation of the bladder capacity when full
and after micturition (emptying should be virtually
complete), as well as visualization of the bladder
wall and lesions projecting into the bladder itself (e.g.
tumours). It can be combined with a measurement
of urinary flow rate along with post- micturition
residual to assess the efficiency of micturition and
bladder emptying in patients with lower urinary
tract symptoms (LUTS) or incontinence. The
volume of the prostate gland can be derived at an
ultrasound examination, and can be compared with
normal values.
Intravenous urography
Intravenous urography involves the intravenous
injection of organic iodine compounds that are
excreted and concentrated radiographically. It is an
extremely good technique for examining the renal
collecting system, the ureters and the bladder (Fig.
17.11). Imaging by IVU depends on renal function.
This is useful in that it gives a crude measure of the
symmetry, or otherwise, of excretory capacity, but it
also means that the image quality is poor in patients
with renal insufficiency in whom the GFR is low
(Fig. 17.12).
Antegrade and retrograde urography
In antegrade and retrograde urography X- ray contrast
material is instilled directly into the urinary tract
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Renal and urology system
Figure 17.11 Normal excretion urogram. In this film, taken 15
minutes after intravenous injection of the iodine- based contrast
medium, the calyces of both kidneys, the ureters and the bladder
can be seen.
via a percutaneous needle (antegrade) or a ureteric
catheter inserted via a cystoscope (retrograde).
These tests are invasive and are most often used in
the evaluation of patients with clear obstruction of
the urinary tract.
Cystography
In cystography, the bladder is filled with contrast
medium via a urethral catheter and X- rays are taken
before, during and after micturition. The test assesses
reflux and the completeness of bladder emptying.
This also is an invasive test, the principal risk being
the introduction of infection. Urodynamics (the
measurement of pressure and urine flow) may
be included in more detailed studies of bladder
function.
Radionuclide studies
Diethylenetriamine penta- acetic acid (99Tc- DTPA)
is used to investigate the excretory function of
each kidney selectively (Fig. 17.13). The test is very
useful for the assessment of symmetry of function,
delayed onset of excretion (as may happen in renal
artery stenosis) and retention of excreted isotope (as
seen in the presence of obstruction).99Tc- DMSA
(dimercaptosuccinic acid) is a similar technique
used to show the gross renal morphology. An
Figure 17.12 Excretion urogram. In this film, made 30 minutes
after injection of contrast, the left kidney fails to excrete a
detectable concentration of contrast (non- functioning left kidney)
and the right kidney shows dilated, hydronephrotic calyces. The
right ureter is partially obstructed at the level of the body of the
fifth lumbar vertebra. The circular lucency in the bladder is the
dilated balloon of a Foley catheter.
Left kidney
Right kidney
Background
0
Figure 17.13 Radioisotope excretion (ordinate) during the 30
minutes after intravenous injection in a patient with right renal
artery stenosis and hypertension. The left kidney achieves more
rapid excretion of isotope. The malfunctioning right kidney caused
the patient’s hypertension.
15
30
A
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Liver
Kidney
Hilum
B
Figure 17.14 (A) CT scan with (B) drawing showing normal
kidneys.
Intestine
Aorta
Spleen
Pelvis of
kidney
Kidney
MAG3 (mercaptoacetyltriglycine) renogram can
assess comparative function and demonstrate upper
urinary tract obstruction.
SECTION THREE
Renal and urology system
Computed tomography and magnetic
resonance imaging
Computed tomography scanning of the kidneys
yields important information about the kidneys
and surrounding structures in the retroperitoneum
(Fig. 17.14). It is useful in patients with ureteric
obstruction from, for example, retroperitoneal
malignancy or retroperitoneal fibrosis. Triplephase CT is used to discriminate malignant renal
tumours from benign ones. Standard intravenous
contrast used for CT scanning can result in an AKI
if the baseline GFR is reduced. In some cases, more
information is obtained using magnetic resonance
imaging (MRI). Caution has to be exercised,
however, if gadolinium is required, because
its use has been associated with nephrogenic
systemic fibrosis in patients with advanced renal
disease. Current data suggest an increased risk
of this condition in patients with a GFR below
30 ml/min.
Arteriography and venography
Arteriography and venography, which are both
invasive, are used rarely in selected patients. The
most common indication is the patient with
hypertension and/or renal insufficiency in whom
renal artery stenosis is suspected. In the context of
renal insufficiency, contrast- induced deterioration of
function can occasionally occur, mitigated by ensuring
the patient is well hydrated. MRI can be used to
generate images of the major renal vasculature and
has the advantage of avoiding contrast nephropathy
and of being non- invasive.
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BASIC SYSTEMS
Sexually transmitted infections
Laurence Dufaur and Liat Sarner
18
Introduction
The following chapter covers the history, examination
and investigation of the patient who presents with
genital symptoms and outlines the common sexually
transmitted infections (STI) and non- infective
conditions encountered in the sexual health clinic.
A fundamental principle in the treatment of the
patient with genital symptoms is recognition of
the stigma associated with the condition and the
shame he may feel in presenting himself to you.
To overcome these barriers and to facilitate an
accurate assessment, carry out the consultation in
total privacy with assurances of confidentially reenforced. It is the responsibility of health services
to ensure that protected characteristic groups (as
defined by the Equality Act 2010) are free from
discrimination. You should demonstrate a nonjudgmental and relaxed approach by using both
verbal and non- verbal cues and in doing so create
a space where people feel able to discuss their
sexual health issues without prejudice of their age,
sexual orientation, gender/gender identity, race,
disability, marital status or beliefs. Gay, bisexual and
other men who have sex with men (MSM), trans
peoplea and those from Black and Asian minority
ethnic (BAME) groups are particularly vulnerable
to systemic discrimination and are at higher risk of
sexual ill health.
STI are frequently asymptomatic yet have
significant long- term complications for patients
and their sexual contacts. Routine sexual health
screening and partner notification are therefore
required to break the chain of infection, but also to
provide an excellent opportunity to educate service
users around ‘safe- sex’, STI prevention (including
prophylaxis and vaccination) and effective
contraception to prevent unplanned pregnancies.
Finally, many patients who present with genital
symptoms will have no disease at all. It is your
a
Trans is an umbrella term used to describe people
whose gender identity differs from the sex they
were assigned at birth in contrast to cisgender whose
gender identity is congruent with the sex they were
assigned at birth.
duty to reassure them and to explore the factors
that have led them to question their sexual health,
which may involve discussions around health
anxiety.
Preparation
Following your own introduction, ask the patient
how he would like to be addressed and what
pronoun to use. Avoid making assumptions about
any sexual orientation or level of understanding
about sexual health. It is accepted practice to see
all patients alone even if they request a friend
or partner to be present in the consulting room.
A partner who insists on being present can be a
warning sign for intimate partner violence (IPV).
IPV can be screened for in private by asking simple
questions about fear and threats to the patient’s
safety and wellbeing. If a language barrier exists,
always use a dedicated telephone translation
service.
History
Begin with an open question that enables the patient
ample time and space to state and describe in his own
words the issue that has brought him into the clinic.
Prompt the patient to expand but do not interrupt
at this stage or you may inadvertently miss the most
important features. This introductory phase allows
the clinician to demonstrate interest and empathy
and provides an opportunity to develop rapport
before embarking on the more sensitive subject of
the sexual history.
Presenting complaint
Urethral discharge
Urethral discharge is usually observed by the patient
as an abnormal liquid draining from the penile
urethra or as a stain on underwear. Clarify the colour
and duration. Discharge may be associated with
urethral irritation or itch, dysuria and, occasionally,
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Sexually transmitted infections
urinary frequency (if the trigone of the bladder is
involved).
A clear stringy secretion noticed following sexual
arousal or on waking is likely to be physiological
prostatic secretions and would not be associated
with inflammatory symptoms. Men who have had
little if any prior sexual education may not be aware
that this is normal.
Vaginal discharge
Vaginal discharge is usually observed by the patient
as a change in the appearance, smell or quantity of
fluid that is normally produced by the vagina and
cervix.
Clarify the duration, relationship to the menstrual
cycle, colour, consistency, odour as well as associated
soreness, itching and pain. A history of vaginal
douching, pregnancy, diabetes mellitus as well as oral
contraceptive, antibiotic and immunosuppressive
drug use are important considerations.
Dysuria
The patient may present with dysuria in isolation,
in association with a vaginal or urethral discharge,
ulcers or with symptoms of a urinary tract
infection.
Scrotal pain and swelling
Often a unilateral aching of the scrotal contents
with or without enlargement may be a symptom of
epididymo- orchitis.
Clarify the onset, duration and severity and make
note of associated urethritis, lower urinary tract
symptoms, lower abdominal and flank pain, fever
and any history of trauma or surgery.
requires urgent referral to exclude an endometrial
malignancy.
Dyspareunia
Dyspareunia is pain experienced during sexual
intercourse. Clarify first if it is superficial (felt in the
vulvo- vagina on penetration) or deep (felt in the
lower abdomen and pelvis).
If superficial dyspareunia is caused by vulvitis (e.g.
owing to candida, herpes simplex or dermatitis),
then it may be associated with an abnormal vaginal
discharge or vulval skin changes.
Deep dyspareunia is often associated with
lower abdominal pain (LAP) and is a symptom
of PID. Clarify the site, onset, character, radiation,
timing (including positional pain) severity and
any associated abnormal vaginal discharge and
bleeding, urinary symptoms, change in bowel habit
and fever. Because deep dyspareunia and LAP can
be caused by any abdominal or pelvic pathology
(e.g. endometritis, ovarian cysts and adhesions), a
detailed menstrual, obstetric, gynaecological and
surgical history, including previous instrumentation,
is relevant. Pregnancy risk should be assessed and an
ectopic pregnancy must be excluded.
Anorectal symptoms
The patient may describe pain, soreness, itching,
rectal discharge or bleeding or tenesmus, all of which
are symptoms of proctitis.
Clarify the onset and duration and note a change in
bowel habit. Non- infective proctitis may be an early
presentation of Crohn’s disease or ulcerative colitis
so enquire about weight loss, fever and systemic
complications.
Skin complaints
Abnormal vaginal bleeding
A change in the character of the menstrual period
as being heavier (menorrhagia) or more painful
(dysmenorrhea) is abnormal. Inter- menstrual
bleeding (IMB) and post- coital bleeding (PCB) is
typically spotting of blood between periods or in the
hours or days following sexual intercourse. It may
be a symptom of mucopurulent cervicitis and pelvic
inflammatory disease (PID).
Clarify the relationship of the bleeding to the
normal and last menstrual cycle (note the usual length
and regularity), current and previous contraceptive
use, obstetric and gynecological history, cervical
smear tests history (including previous diagnoses,
treatment and follow up) as well as human papilloma
virus (HPV) vaccination history.
Abnormal vaginal bleeding requires exclusion of
endometrial and cervical pathology and STI. In postmenopausal women, new onset vaginal bleeding
The patient may describe lumps or growths, a
spot, a cut, a sore or a rash in the ano- genital area
which can be painful, itchy or uncomfortable but
otherwise may be symptom free. Generalized rashes
are also seen and may be associated with ano- genital
symptoms, fever and systemic illness.
Clarify the location, onset and duration, paying
particular attention to the relationship with recent
sexual intercourse, washing, the use of perfumed
products and practices such as waxing and shaving
pubic hair. The evolution of the symptoms over
time is also important, including any previous
similar episodes. Urethral and vaginal discharge,
dysuria and anorectal symptoms may co- exist
with skin complaints. Make note of a past history
of genital herpes, syphilis and genital warts as well
as dermatological conditions and atopy. A travel,
medication and smoking history may be relevant.
Document the HPV vaccination history (bivalent
versus quadrivalent).
SECTION THREE
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Sexually transmitted infections
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Sexual wellbeing
A difficulty in achieving or maintaining an erect penis
may be associated with arteriopathy, polypharmacy or
prostate surgery in older men. In younger men, along
with premature and delayed ejaculation, it is mostly
likely learned and psychogenic in nature. Vaginismus
is the unconscious tightening of the vaginal walls
following penetration. Vulvodynia is localized vulval
tenderness or pain (not always associated with
sexual intercourse) and is multifactorial in origin.
Management of these conditions often involves
input from the multidisciplinary team, including
specialist psychology and physiotherapy.
The sexual history
It is important to sign- post this part of the history.
‘I’m now going to ask you some important questions
about your sexual relationships and the type of sex
you have’. Enquire as to the most recent sexual
encounter, when it occurred and the type of partner
(e.g. steady established, new relationship, occasional,
one- off or commercial sex). Ask ‘what gender are
they?’ then clarify the type of sex (e.g. oral, vaginal
or anal), whether they were insertive (active/top/
giving) or receptive (passive/bottom/receiving)
and if barrier protection was used. Work backwards
sequentially, detailing previous sexual encounters
and finally clarify the total number of different sexual
partners in the preceding 3 months. If an index case
is diagnosed with an STI, then it may be necessary
to gather information on his sexual contacts to
provide those at risk of infection with screening and
epidemiological treatment. This process is known as
partner notification (PN).
The sexual health screen (SHS) and STI
history
Establish if the patient has ever had an SHS, when
this occurred and the results. The last negative result
for bacterial STI and blood borne viruses (BBV) will
act as a baseline from which to assess sexual risk and
provide PN. A past history of STI is a good predictor
of risk. Include the date of diagnosis, treatment
given and response (if applicable). This is also useful
information when considering a presenting issue that
is recurrent (e.g. in genital herpes) or when ordering
serological tests (e.g. in syphilis and hepatitis).
Risk assessment for BBV
Human immunodeficiency virus (HIV), hepatitis
B virus (HBV) and hepatitis C virus (HCV) are
typically spread sexually or through intravenous
drug use (IVDU), but may be passed from mother
to child to varying degrees. Historically, infection
through contaminated blood products, tattoos and
piercings was an identifiable risk, but this has been
ameliorated through widespread screening, singleuse instruments and disinfection practices. The
patient and their partner’s country of birth is useful
in assessing endemic risk (sub- Saharan African,
South- East Asia and South America carrying the
greatest risk for BBV acquisition). MSM, sex workers,
intravenous drug users and prisoners are also all at
increased risk.
Special groups
MSM
Men having sex with men are at increased risk of
STI exposure owing to a high frequency of sexual
partners built around dense geosocial sexual
networking apps (e.g. Grindr, Scruff). Specific drugs,
such as gamma hydroxybutyrate (GHB, G), crystal
methamphetamine (tina) and mephedrone (meph),
are taken to enhance the sexual experience (chemsex) by increasing sexual appetite and reducing
inhibitions. As the rectal mucosa is more fragile and
susceptible to infection, condomless receptive anal
intercourse, fisting and the use and sharing of sex
toys significantly increase the risk of STI acquisition.
A surge in IVDU amongst MSM has driven a rise in
cases of HCV infection.
Sensitively enquire about group sex, toys and
chem- sex, including the route of administration of
any drugs taken.
Hepatitis A virus (HAV) is spread via the faeco- oral
route and usually causes a self- limiting gastrointestinal
illness but may, rarely, lead to fulminant hepatic
failure. Sexually transmitted outbreaks in MSM
occur periodically with oro- anal sex (rimming) being
an important risk factor. Giardiasis, amoebiasis and
bacterial dysentery (e.g. shigella and salmonella) are
additional causes of diarrhoea in MSM, so examine
stools for the presence of such organisms in addition
to serological testing for acute HAV (IgM).
You should note previous infection and/or
vaccination for HAV and HBV as all unexposed MSM
should be vaccinated against these viruses. In addition,
all MSM under the age of 45 should be offered
vaccination with the quadrivalent HPV vaccine.
Trans people
There is a spectrum of trans identities, including but
not limited to trans woman, trans man, transgender,
genderqueer, non- binary and agender. Sensitivity
and special care must be employed when assessing
sexual health and wellbeing. If you inadvertently
misgender someone, acknowledge and apologize for
your error and move on. Clarify how patients refer
to their body and genitals and echo this during your
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