Normal environment of the vagina


The vagina provides a barrier to infection. It is well adapted to this function as it has:

  • Squamous epithelial lining colonized by bacterial flora, mainly lactobacillus.
  • Acidic pH (<4.5)


However during the pre-pubertal and post-menopausal periods, the lack of oestrogens means this environment is different:

  • The epithelium becomes atrophic
  • The pH is higher (6.5 – 7.5)


This causes a decreased ability to fight infection. Despite this, the highest incidence of STD's is in women aged 16-19 and men aged 20-24.



Clinical features


  • Asymptomatic (50% of men, 80% of women)
  • Urethritis and proctitis in men
  • Vaginal discharge, dysuria, dyspareunia, lower abdominal pain, IMB or PCB in women.




    Diagnosis is by urethral swabs in men and endocervical swabs in women for microscopy, culture and sensitivity. A first catch urine sample can also now be used and is widely used in screening campaigns such as RU Clear.




    Pelvic Inflammatory Disease

    Ectopic Pregnancy

    Tubal Infertility


    Reiters Syndrome



    Clinical Features


    • Asymptomatic
    • Urethritis (dysuria)
    • Discharge (purulent)
    • In men only: fever, sweating, proctitis, pharyngitis.




    Urethral or cervical swabs for microscopy, culture and sensitivity.






      Clinical Features


      • Vulval itching, soreness and erythema
      • Dyspareunia
      • Dysuria
      • Vaginal Discharge - thick, white curdy discharge "cottage cheese"




      Urethral or cervical swabs for microscopy, culture and sensitivity.


      Bacterial Vaginosis (BV)

      These two organisms are able to proliferate (e.g. due to antibiotic therapy) and replace the natural vaginal microflora leading to the following symptoms:


      • Vaginal Discharge (grey/white)
      • Fishy vaginal odour
      • ‘Clue’ cells on microscopy




      High vaginal swab and microscopy and culture of discharge






      Clinical Features


      Primary Syphilis - painless chancre, lymphadenopathy


      Secondary Syphilis - flu-like symptoms, lymphadenopathy, maculopapular rash, condylomata lata (flat plaques in the anogenital region)


      Latent Phase - symptom free, but positive serology.


      Tertiary Syphilis - the symptoms of tertiary syphilis will depend on what part of the body the infection spreads to. For example, it may affect the nervous system, visual system, cardiovascular system, musculoskeletal system or vasculature, potentially causing any of the following symptoms:


      • Stroke
      • Dementia
      • Ataxia
      • Numbness
      • Paralysis
      • Blindness
      • Deafness
      • Heart disease
      • Skin rashes


      Tertiary syphilis can cause death.


        Image taken from



        There is increased susceptibility to HIV infection. This could be due to risky sexual behaviour being more likely in those who have contracted syphilis previously, or the fact there may be bleeding sores in the anogenital region.



        Clinical Features


        •  In men - urethritis (dysuria)
        •  In women - vaginitis, superficial dyspareunia, vulval irritation.




          • Wet film microscopy of discharge
          • Culture of discharge


            Genital Warts

            Warts may be located in:


            • Men: Urethra, Shaft, Urethral meatus
            • Women: External genitalia, cervix (associated with cervical neoplasia) and perineal region.


              Warts are usually more prominent during pregnancy and in the immunosupressed.




              Diagnosis is mainly clinical, however biopsy for culture can be performed if there are doubts about the diagnosis




                Cervical carcinoma

                Anal tract cancer (if anal sex)


                  Genital Herpes

                  Clinical features


                  • Shallow, painful ulcers – 'genital cold sores'
                  • Tingling sensation before ulcers develop
                  • Painful lymphadenopathy
                  • Urinary Retention (mainly seen in women)




                    Culture or PCR of vesicular fluid or ulcer swabs



                        The main problems come when infection is present during pregnancy. 


                        A) Infection of the neonate may lead to:

                        • Encephalitis
                        • Meningoencephalitis
                        • Conjunctivitis
                        • Widespread visceral disease


                        B) Genital herpes is generally a contra-indication to vaginal delivery. It usually requires a Caesarean section (usually a lower segment caesarean)


                        Sexual History Taking


                        Sexual history-taking requires not only clinical knowledge and general history-taking skills but also the ability to talk about very sensitive topics and put the patient at ease to volunteer such information freely. Among the most common reasons why doctors and medical students experience difficulty talking to patients about sex are embarrassment and personal unease with the subject.

                        There are three important aspects to sexual history-taking:


                        1. Introduction and Making the patient feel comfortable
                        2. Taking the history
                        3. Conclusion and Sexual Education


                        Introduction and Making the patient feel at ease


                        Ensure you are in a quiet room with privacy and that you will not be disturbed for the duration of the consultation


                        Be aware of the patient's body language: Are they fidgiting with their hands or defensively crossing their arms? What is the posture adopted by the patient in the chair? Are they slouched, sitting upright or relaxed and at ease? Analysing this information will allow you to guide your speed and gauge the patient's feelings, comfort and state of mind. Acknowledging their status could be useful for the consultation.


                        Introduction: Introduce yourself, ask the patients name and date of birth and check how they prefer to be adressed as. For example: "I would like to ask you a few personal questions about your sex life. I understand they are very personal but it is important for me to know so I can help you with [your problem]"


                        Ensure confidentiality; especially important due to the nature of the information being exchanged


                        Start with open questions, such as "What brings you in today?" or "How can I help?"


                          The Sexual History

                          For each of the patient's complaints explore: time of onset, features and associated symptoms. A good way of thinking about a sexual history is in 5 P's: 


                          1. Partners
                          2. Prevention of Pregnancy
                          3. Protection from STD's
                          4. Past STD's
                          5. Practices



                            • Do you have a sexual partner at the moment? or When did you last have sex?
                            • Is/was that a casual partner or a regular partner?
                            • Was that partner a woman or a man?
                            • In the past 6 months how many partners have you had sex with? Elicit gender, type of sexual activity (oral, vaginal, anal), condom use and country of origin of all the partners in that timeline.
                            • Ask if any of the partners experienced or is experiencing similiar symptoms


                              Prevention of Pregnancy

                              • Are you trying to get pregnant?(women); Is your partner trying to get pregnant?(men)
                              • Are you concerned about getting pregnant/ causing a pregnancy?
                              • What steps are you taking to prevent a pregnancy from ocurring?


                                Protection from STD's

                                • What do you do to protect yourself from STD's?
                                • Explore patient's beliefs about contraception and protection from STD's. This will allow you to gauge the level of education you will have to give at the end.


                                  Past STD's

                                  • Have you had any STD in the past? Was it succesfully treated?
                                  • Has your partner/any of your partners had an STD? Was it succesfully treated?
                                  • Have you or your partner(s) ever had an HIV test?



                                  Try and gague what other behaviour the person may be involved in which may put them at risk of blood-bourne infections such as HIV and Hepatitis

                                  • IVDU
                                  • Tatoos
                                  • Blood transfusion

                                  Some other questions which are important to ask:

                                  • Have you ever paid, or been paid for sex?
                                  • Have you had sex with someone abroad? If so, where? (High risk areas are places such as Africa and Thailand)


                                  Associated history

                                   Ask about other symptoms:

                                  • Discharge: colour, duration, where it is noticed, smell.
                                  • Urinary symptoms: dysuria, frequency, nocturia, urgency 
                                  • Pain: location, character, duration, dyspareunia,


                                    Menstrual History: LMP, duration of cycle, regularity, dysmenorrhoea, menorrhagia, 


                                    Past Medical History: enquire about any illness, especially diabetes, depression, heart disease


                                    Obstetric History: number of pregnancies, number of children (TOP or Miscarriages), type of delivery, complications during pregnancy and labour, health of the children currently


                                    Gynaecological History: cervical smear status, previous results, any gynaecological surgery?


                                    Drug History: COCP, any other medications, recreational drugs.


                                      Social History: smoking, alcohol, recreational drugs (if not asked previously), occupation, accomodation etc.


                                      Conclusion and Sexual Education


                                      • Suggest the need to do a relevant examination
                                      • Suggest the need to do some follow-up tests (such as a HVS, Cervical Smear or other swabs)
                                      • Education: Having gauged the patient's knowledge, offer advice as to the dangers of their current practices, such as unprotected sex, or dispel the (many) myths that people have about sex, pregnancy and contraception/protection from STD's



                                          Table - Summary of Sexually Transmitted Infections



                                          1. Akunjee, M. Jalali, S. & Siddiqui, S. The Easy Guide to OSCEs for Specialities. Oxford: Radcliffe Publishing; 2009
                                          2. Tomlinson, J. ABC of sexual health: Taking a Sexual History. British Medical Journal [internet]. 1998 December [cited 18/05/2011]; 1573-1576. Available here
                                          3. Horn, K. & Fernandes A. Taking a Sexual History in Genitourinary Medicine [internet]. Bath: Royal United Hospital Bath NHS Trust. 2007 [cited 18/05/2011]. Available here.
                                          4. California Chlamydia Action Coalition [internet]. A Guide To Sexual History Taking [cited 18/05/2011] Available here



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