During a consultation with a sexual health focus, advanced clinical practitioners (ACPs) will consider the next steps to follow as part of their line of inquiry: this includes appropriate and required investigations, advice or education required for the patient and/or referral to other services. It is especially the case that, within a sexual health context, the consultation and subsequent steps can be challenging and distressing for the patient, so the ACP must consider their knowledge and experience when caring for a patient in this area.
This article is the second in a series on the subject and seeks to provide an overview of some key areas to consider following the sexual health history take. The first covered the consultation and clinical assessment process (McPhillips and Wood, 2022). This article is particularly aimed at those ACPs working outside this field of practice, who may not often encounter consultations of a sexual health nature as a first presentation. The article does not aim to offer comprehensive guidance and ACPs should always work within their own scope of competence (Nursing and Midwifery Council, 2018, Health and Care Professions Council, 2018).
Consent and capacity
As highlighted in the previous article (McPhillips and Wood, 2022) consent is critical when pursuing any sexual health examination and/or investigation. It may be given either orally, in writing or implied. However, when considering investigations in this context, consent should be clearly sought and clearly documented, with evidence that the patient or client was fully informed and counselled in advance (Brook et al, 2020). For an ACP who is consulting a patient aged under 16 years, and so of legal age in the UK for sexual activity, it is vital to be aware of and understand the law and legislation within the country to ensure compliance with the specific legislation. Although 16 years is the legal age of consent, for the purposes of safeguarding a minor is considered to be a person under the age of 18 years, and it is also important to consider the age of the patient's sexual partner.
When obtaining consent for medical treatment from children (in England), it may be beneficial to consider use of the Gillick competence and Fraser guidelines. While often discussed in tandem the nature and purpose of these tools are very different (Wheeler, 2006). The Gillick competence seeks to establish whether a child aged under 16 years has the competence to consent to medical treatment or intervention and, if so, they are deemed to be ‘Gillick competent’ (Care Quality Commission (CQC), 2019). Those failing to be ‘Gillick competent’ require an individual with parental responsibility or the courts to consent on their behalf; the health professional is obliged to raise a safeguarding concern, and the young person should be informed of this. The Fraser guidelines are also aimed at determining the competence of children aged under 16 years: these guidelines are predominantly centred on the consent to contraceptive advice and treatment, but they also include termination of pregnancy and the treatment of sexually transmitted infections (STIs) (CQC, 2019). As the ACP, you should seek help and guidance from your local sexual health experts and local services if you are concerned or need direction.
Differentials
Pulling together a differential diagnosis can be difficult in sexual health consultations for those working outside the specialty. It is therefore important to recognise any red flags and emergency conditions (Table 1) and to refer to appropriate services when indicated. It is worth noting that these red flags must be used in the context of the patient history because they are common in many other conditions and illnesses.
Table 1. Red flags in a sexual health consultation
| Abnormal bleeding | 1,2,3,4,5 | Lumps/growths | |
| Discharge | 1,2,3 | Weight loss | 3 |
| Ulcers | Fatigue | 3 | |
| Lymphadenopathy | 3 | Sore throat | 3 |
| Vulval itch | Abdominal pain | 1,2,3,4,5,6 | |
| Flu-like symptoms | 1,3 | Pelvic pain | 1,2,3,4,6 |
| Myalgia | 3 | Sores/lesions | 3 |
| Diarrhoea | 3 | Rashes | |
| Change in menstruation | 1,2 | Swelling | 3,5 |
| New incontinence | 3 | Nausea and/or vomiting | 1,2,3,4,5 |
| Warts | Headache | ||
| Recurrent infection | 6 | Fevers | 1,3,4,5 |
Emergency conditions: 1=pelvic inflammatory disease; 2=ectopic pregnancy; 3=malignancy; 4=ovarian torsion; 5=testicular torsion;6=sexual assault; 7=abuse; 8=other safeguarding concerns
It is also essential that the practitioner ensures they are aware of signs of sexual abuse or trauma, and are familiar with the local guidance and pathway for safeguarding and referral for patients presenting with such. Some of the red flags that may indicate abuse or trauma are noted in Table 2. A key consideration is discussion of concerns with colleagues and consideration of input from other services.
Table 2. Red flags that may be indicative of abuse or trauma
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Sexual health investigations
Investigations within sexual health can provide accurate diagnosis when history and exam alone have not provided a clear differential or have generated several differentials. The choice of tests will be influenced by the history and examination, as well as by the setting in which the patient is seen. It may be necessary to have investigations undertaken by a specialist service or clinic, and the ACP should be aware of the services available and the pathways for referral. Having this knowledge and understanding can allow the ACP to prepare the patient for the referral process and what it may potentially involve, ensuring that informed consent is gained and helping to reduce patient anxiety by removing some of the unknowns.
In this context, consideration of whether a detailed clinical examination of the genital area is necessary is part of the critical thinking aspect for the ACP. Clinical examination is generally required only in symptomatic patients. Examination of the genitals requires the ACP to be mindful of the sensitivity of this examination, as well as to be aware of patient groups that may require special consideration, such as transgender patients, children and young people, individuals without good spoken English, and patients with learning or physical disabilities.
Pelvic exam
A pelvic exam for women should be carried out only by a professional who is competent in this procedure, however knowledge of this process can be useful when referring a patient to have this undertaken. The patient may have questions before consenting to the referral so being able to explain the steps that will take place can benefit both the patient and the ACP.
The exam is carried out in two parts: the speculum exam and the bi-manual exam (Pattman et al, 2010). The bi-manual exam involves the insertion of two lubricated, gloved fingers into the vagina while the other hand is placed on the lower abdomen, pressing down gently. This exam is to check the pelvic organs (uterus, ovaries and fallopian tubes). To ensure an accurate exam the patient should have an empty bladder and be positioned on their back, with knees bent and apart. Prior to the bi-manual exam it is essential to undertake an external abdominal exam and an inspection of the external genitalia. The speculum exam consists of the insertion of a speculum into the vagina and this is then gently opened. A visual examination of the vagina and cervix will take place, and swabs will usually be taken, noting discharge, blisters, excoriation and inflammation. A cervical (Pap) smear can be completed at the same time, if appropriate, as well as other swabs taken. A cervical smear is taken to detect the presence of high-risk human papillomavirus (HPV) strains and/or abnormal precancerous cells.
Male genital exam
A genital exam should be carried out, if indicated from the clinical history, to ascertain that a patient has symptoms, and the anogenital area inspected, noting the presence of discharge and lesions. Further palpation of inguinal regions, as well as scrotal contents and an examination of the urethral meatus for discharge and lesions, would also be included. Investigations may be potentially embarrassing or uncomfortable for the patient and so should not be undertaken unnecessarily or without a clear rationale. Allowing the patient to take their own swabs and provide urine samples may reduce any potential discomfort, but there is an obvious risk of contamination or mis-sampling associated with this approach, which should therefore be considered on an individual basis.
The investigation overview (Table 3) (British Association for Sexual Health and HIV (BASHH), 2019a) provides a clear summary of recommended tests, investigations and examinations within sexual health, dependent on the considered diagnosis. The ACP should use the information gained during the consultation process to determine which tests, if any, are indicated. When considering HIV testing, particular attention should be given to not only the risk factors indicated by patient choices but also where the patient has presented (in clinics such as tuberculosis (TB), antenatal, addiction and substance misuse, hepatitis and lymphoma, termination or pregnancy services, and sexual health services), along with the area in which patients are accessing healthcare (high and extremely high HIV seroprevalence is regarded as an indicator for testing) (Palfreeman et al, 2020).
Table 3. Investigation overview
| Patient group | Blood | Urine | Swabs | Examination | Vaccination |
|---|---|---|---|---|---|
| Asymptomatic female | Syphilis, HIV, hep B, hep C if indicated | Vaginal: gonorrhoea and chlamydia | Hep B if appropriate | ||
| Asymptomatic male (heterosexual) | Syphilis, HIV, hep B, hep C if indicated | First void (held for >1 hour) for gonorrhoea and chlamydia | Hep B if appropriate | ||
| Asymptomatic male (men who have sex with men (MSM)) | Syphilis, HIV, hep B, hep C if indicated | First void (held for >1 hour) for gonorrhoea and chlamydia | Throat (gonococcal) rectal (gonorrhoea and chlamydia), if history of receptive anal sex | Hep B if appropriate | |
| Symptomatic female | Syphilis, HIV, hep B, hep C if indicated | Mid-stream urine, pregnancy test | Vaginal (gonorrhoea, chlamydia, trichomonas, candida, bacterial vaginosis), ulcer/fissures (herpes simplex), cervical (gonococcus). If high risk or known gonorrhoea contact, rectal/urethral/throat swabs | External genitalia, oral cavity | Hep B if appropriate |
| Symptomatic male (heterosexual) | Syphilis, HIV, hep B, hep C if indicated | First void (held for >1 hour) for gonorrhoea and chlamydia Mid-stream urine is symptomatic of urinary tract infection | Urethra (gonococcal), ulcer/fissures (herpes simplex), throat (gonococcal) | External genitalia, perianal area, rectum, oral cavity | Hep B if appropriate |
| Symptomatic male (MSM) | Syphilis, HIV, hep B, hep C if indicated | First void (held for >1 hour) for gonorrhoea and chlamydia | Urethra (gonococcal), ulcer/fissures (herpes simplex), throat (gonococcal) rectal (gonorrhoeal and chlamydia) rectal mucosal (gonococcal) | External genitalia, peri-anal area, rectum, oral cavity | Hep B if appropriate |
Swabs
Swabs may be of benefit in diagnosing STIs and informing the correct course of treatment. Vulvovaginal and/or endocervical swabs, as well as a high vaginal swab may be appropriate for patients with a cervix. Patients may be able to take their own vaginal swabs, but in such cases time should be taken to explain the procedure and technique to avoid contamination. Rectal swabs should not come in contact with the perianal skin prior to collection (due to risk of contamination), and care should be taken not to touch the swab. Home swabs or self-swabs may be offered in some areas of care; this can increase uptake of testing and reduce stress or embarrassment for the patient as an exam will not then not required, in cases where the patient is asymptomatic.
Urine
Urine tests can check for some STIs (but the risk of contamination can be high. Results from urine tests are more accurate if the bladder has not been emptied for upwards of an hour (ideally two or more). If home testing is being undertaken then clear guidance should be given to the patient to avoid contamination.
Blood tests
Blood tests can check for viral infections (and, with some viruses, also for previous exposure), as well as infections such as HIV, syphilis, hepatitis B and hepatitis C. In addition, blood tests can check for impact of infection throughout the body and other systems, such as renal and hepatic function. As in the case of swabs and urine tests, blood tests to detect bloodborne viruses are available not only through NHS facilities, but also through private clinics.
Informed consent must be gained for testing for bloodborne viruses: this involves informing the patient of the procedure, the benefits of testing and how the results will be reported; the patient should also be offered the opportunity to ask any questions. If the patient does not consent for testing, this may be due to concerns over privacy and stigma. This is when it may be appropriate to inform a patient that there are other pathways for testing, that having the tests will not have an impact on their care and that their confidentiality will not be broken wherever they choose to have testing.
Some blood tests can detect infection only three to six months after exposure, and a thorough history will therefore aid testing requirements. Some areas of care can offer point-of-care testing for HIV. A small amount of blood is taken from a finger prick and it takes about one minute to get the result; if the result indicates positivity for HIV, a formal blood test will then be required to be obtained and sent to the laboratories for confirmation.
Window periods
When diagnosing an STI, there is a ‘window period’ between the potential contact and the time when a test is able to detect the infection. This requires careful explanation to the patient, and an invitation for re-screening may be necessary, dependent on the STI considered. This can be 2 weeks for gonorrhoea and chlamydia, 45 days or 90 days (test dependent) for HIV, 12 weeks in the case of syphilis, and 3-4 months for hepatitis B/hepatitis C. There can be a delay in the incubation period for an infection to show, but tests also can become positive before the maximum incubation period has been reached. For example, incubation for HIV can be up to 45 days, and for hepatitis C between 40 and 160 days.
Regular screening should be encouraged for patients who are considered high risk (Raffe and Soni, 2018). Asymptomatic individuals who belong to these high risk groups are recommended for regular STI testing (at least annually) (BASHH, 2014; 2015; Palfreeman et al, 2020), namely:
- All men who have sex with men (MSM) and female sexual partners
- Persons born in, or who have had a sexual partner born in, a country with a high prevalence of hepatitis B
- Commercial sex workers (CSM)
- People who inject drugs (PWID).
In addition, in the case of HIV, testing should be done with the above groups, plus (Palfreeman et al, 2020):
- Black Africans
- Prisoners
- Trans women
- People from countries with high HIV seroprevalence and their sexual partners
- People attending health services whose users have an associated risk of HIV
- All people presenting with symptoms and/or signs consistent with an HIV indicator condition
- People accessing health care in areas with high/extremely high HIV seroprevalence
- Sexual partners of an individual diagnosed with HIV.
Partner notification
Partner notification is an essential part of STI treatment as part of managing the infection because this can break the ‘chain’ of transmission and reduce re-infections. It can also ensure that sexual partners are tested and, if necessary, offered treatment as soon as possible to prevent further infections and health complications. This is a challenging area associated with stigma: the ACP may need to support the patient with approaching their partner, or previous partners, or with informing current or previous partners. This will help reduce the risk of other individuals contracting infection and may also reduce the risk of re-infection. This may be an uncomfortable or upsetting conversation to have with the patient and the ACP should be mindful of any potential for any presentation that is potentially secondary to assault. Mental health services and support may be an appropriate pathway for referral.
If the ACP is unfamiliar or unsure about the process of partner notification and local referral processes, they should consider calling a health adviser or another healthcare colleague based within sexual health services for support and advice around this sensitive topic. Sexual health services will be able to assist with the process or inform the practitioner of any steps required and appropriate considerations for the ACP.
Treatment options
All management and treatment for STIs are outlined on the BASHH website (https://www.bashh.org/guidelines), which also provides comprehensive guidelines for ACPs in this field for each STI.
Antibiotics
Antibiotics can be the appropriate course of treatment for many STIs (Table 4). Chlamydia (Nwokolo et al, 2016) and gonorrhoea (Fifer et al, 2020) are both treated with antibiotics as is syphilis (Kingston et al, 2016), and the BASHH guidelines on each STI can guide the correct prescribing decision for these conditions. Presentations such as urethritis may be treated with antibiotics, with swabs sent for culture and sensitivities to identify underlying causes of the symptoms. Antivirals may be more appropriate in some presentations, such as herpes and, again, prescribing guidance may vary between localities. Treatment options may vary across health boards and locations and, although ACPs are encouraged to review their local protocols and formularies when prescribing in this area, the BASHH website (https://www.bashh.org/guidelines) may recommend the most up-to-date and appropriate treatment, keeping in mind the rise in antimicrobial-resistant STIs.
Table 4. Sexually transmitted infection treatments. Quick reference guide
| STI | Management/treatment |
|---|---|
| Chlamydia | Uncomplicated urogenital infection (and pharyngeal infection)
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| Gonorrhoea | Treatment of uncomplicated anogenital and pharyngeal infection in adults When antimicrobial susceptibility is not known prior to treatment:
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| Pelvic inflammatory disease (PID) | Outpatient regimens: Intramuscular ceftriaxone 1000 mg single dose, plusOral doxycycline 100 mg BD for 14 days, plusOral metronidazole 400 mg BD for 14 days orOral ofloxacin 400 mg BD for 14 daysOral metronidazole* 400 mg BD for 14 days orOral moxifloxacin 400 mg OD for 14 days |
| Genital herpes | First episode: recommended regimens (all for 5 days):Preferred regimens:
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| Syphilis | Early syphilis (primary, secondary and early latent)
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Topical treatments
Some presentations such as anal fissures and haemorrhoids may be treated with topical preparations. Emollients and topical steroids can be of use in conditions such as lichen simplex. Topical treatments may be used in combination with antibiotics to treat internal and external symptoms and infection, this is commonly seen in candida infection and bacterial vaginosis. It should be noted that neither of these presentations are STIs.
Other treatments
Other treatments may include lifestyle and diet changes (to soften faeces and reduce strain in patients presenting with anal fissures), as well as other simple interventions such as positioning during defecation and encouraging good hygiene. Avoidance of highly perfumed soaps or similar products may be useful advice for patients suffering irritation of the external genitalia, as may the recommendation that they wear loose-fitting, natural fabrics to help reduce discomfort.
Vaccine
Immunisation against hepatitis B is recommended for MSM, for individuals who work in the sex industry (or who frequently change sexual partners), and for the sexual partners and close family and household contacts of parenteral drug misusers, along with those non-parenteral drug misusers and those at risk of progressing into this group (UK Health Security Agency, 2020).
Hepatitis A infection numbers have risen in the UK (in the main part in the London area) and Europe, in MSM. It is therefore recommended that MSM, along with close contacts of those with hepatitis A, undertake a vaccination programme (Vaccination Knowledge Project, 2019). Patients at risk of both hepatitis A and hepatitis B may be able to access a combined vaccination.
HPV vaccination for MSM (up to and including those aged 45 years) has become available in the past few years across the UK. At present, this vaccination is available through sexual health clinics and HIV clinics. This was initiated because MSM are at higher risk of anal cancer than heterosexual men, and those living with HIV are at an even higher risk (NHS Inform, 2022).
Emergency contraception
Oral emergency contraception may be required and is within the ACP's remit for prescription, depending on clinical situation. Table 5 presents the three methods of emergency contraception used in the UK (Faculty of Sexual and Reproductive Healthcare (FSRH), 2020). It is recommended that it is considered for any woman who does not wish to conceive if there is a potential risk of pregnancy after unprotected sexual intercourse.
Table 5. Emergency contraception in the UK
| Method | Class | Recommended dose/use | Indications |
|---|---|---|---|
| Copper intrauterine (IUD) device (Cu-IUD) | Intrauterine contraceptive method | IUD retained until pregnancy excluded (eg onset of next menstrual period) or can be kept for ongoing contraception | Within 5 days (120 hours) after the first unprotected sexual intercourse in a cycle or within 5 days after the earliest estimated date of ovulation |
| Levonorgestrel EC (LNG-EC) | Progestogen | Single oral dose 1.5 mg | Licensed for use within 72 hours after unprotected sexual intercourse or contraceptive failure |
| Ulipristal acetate EC (UPA-EC) | Progesterone receptor modulator | Single oral dose 30 mg | Licensed for use within 5 days (120 hours) after unprotected sexual intercourse or contraceptive failure |
When prescribing levonorgestrel, the patient's body habitus should be taken into consideration. Studies have found that patients with a high body mass index (BMI) experience both lower and total bioavailability of levonorgestrel than women with a normal BMI (Kapp et al, 2015; Natavio et al, 2019). The Joint Formulary Committee (https://bnf.nice.org.uk) recommends that higher doses be considered in patients weighing over 70 kg or with a BMI of >26 kg/m2.
For patients prescribed emergency contraception the ACP should consider the risk of drug interaction between the patient's regular and the emergency contraception, potentially reducing efficacy of one or both. A thorough medication and drug history should be obtained; consulting specialty guidance such as the Faculty of Sexual and Reproductive Healthcare's FSRH Guideline Emergency Contraception (2020) will support the ACP's decision making to ensure no increased risks of failure of either method of contraception due to drug interaction. This guidance will also provide the ACP with direction on other risks when prescribing emergency contraception, such as interactions with other groups of medications, timing of emergency contraception, contraindications, as well as the provision of emergency contraception.
Further care from ACPs
The ACP may be required to consider other elements of treatment and care as well as STIs. Considering education, support and referral to other services or follow up is crucial for patients and consultations of this nature.
Patient education
Patient education serves a vital role in the management and maintenance of sexual health. This starts within the school system, but attendance and delivery can be variable, and it should not be assumed that the patient is adequately informed and educated. Outside the state education system there is wide variation in the availability and access to sexual health services and education.
Patients may feel uncomfortable receiving sexual health education during the consultation and, even if appropriate and the patient is comfortable, time constraints may not allow this.
There is a multitude of resources online to which patients can be signposted: this includes both local and national groups who provide education, information, and even support on the issues. Printed leaflets may be useful and allow the patient time to re-read and digest information. When providing access to links for online information (previously written materials) it should not always be assumed that the patient has internet access or the appropriate literacy skills required for these to be of benefit. The practitioner should always be aware that access or literacy may be a barrier to education, and appropriate steps should be taken to overcome this and facilitate education.
Safety netting
Although referral to specialist services or clinics may be required, care should be taken to inform the patient of average waiting times and to ensure that they are aware that they can re-present should symptoms worsen, or new symptoms or conditions arise prior to the referral appointment. Listing any signs or symptoms that the patient should watch out for can ensure that urgent treatment or investigations are not delayed.
Safety netting with regards to a patient's safety and situation is also a consideration when dealing with a sexual health-related consultation. If there are any concerns surrounding abuse or safety of the patient—including sexual assault, trauma and gender-based violence—the ACP should take appropriate steps to safeguard the patient. Follow local policy and guidelines to inform the process. This is a specialist area and ACPs should seek support if this is an area they are not comfortable with. Signposting support sites to patients is a key element of the consultation. Various services are available dependent on location, however, there are also UK-wide services that anyone is able to access. Voluntary organisations such as Women's Aid, Victim Support, The Survivors Trust or Survivors UK, as well as the Rape Crisis Helpline or National Domestic Abuse Helpline, may be useful for the patient, depending on the situation.
If there is any doubt about whether to share information regarding a patient's safety or situation, seek advice from an experienced colleague, the safeguarding lead or a Caldicott Guardian. (This is a senior person responsible for protecting the confidentiality of people's health and care information and making sure it is used properly. All NHS organisations and local authorities which provide social services must have a Caldicott Guardian.) Decisions should be made in conjunction with appropriate others where possible.
Education for the ACP within sexual health
For ACPs working in sexual health, a bespoke curriculum has been devised by the BASHH (2019b). The curriculum provides clear areas for ACPs who work in this area, and can support ACPs to develop knowledge and skills within this area of practice. ACPs who do not work in the area, but have an interest in sexual health or would like to increase their knowledge about the subject, can access a variety of online courses through BASHH and NHS Health Education England's e-learning for health at www.e-lfh.org.uk.
Conclusion
This article has presented some key areas for ACPs to consider when presented with a patient with sexual health concerns and considering investigations. An ACP who is not experienced in this area should seek help and support due to the sensitive nature of the examinations and investigations. Particular consideration requires to be taken both in relation to window periods as well as education to support the patient.
KEY POINTS
- Patient education is essential to preventing sexual ill health and infection/reinfection
- Sexual health discussions can be a daunting process for patients and ensuring their comfort and privacy is fundamental to their care experience
- Having an understanding of investigations/procedures that you are referring the patient for can be of benefit to both patient and ACP
- An awareness of red flags will inform appropriate investigations and safety for the patient
CPD reflective questions
- What techniques and skills would you use in a sexual health-focused consultation?
- Consider the challenges you would face if a patient is disengaged with your diagnosis and reasoning
- Consider what services, expertise and education are available to you within your practice area in regard to sexual health