PRESENTATIONS AND PRINCIPLES OF MANAGEMENT

STIs in men:
symptoms and examination

generally all that is needed; if the patient is at high risk or has

concerns, however, a longer consultation might be appropriate.
The notion that pre-test counselling requires complex skills is no
longer the case.

Colm OMahony

History and examination

The patients presenting symptoms largely dictate the initial examination. The medical history is important and should cover any
previous STIs, current medication, and whether the patient has
taken any antibiotics recently, prescribed or not (some men raid
the drug cupboard and take a few old penicillin tablets on the day
before attending the clinic). Current and recent sexual relationships
can be explored when a rapport has been achieved.

History-taking in the context of STIs is little different from that in

other situations, except that the questions can be extremely personal and embarrassing for both doctor and patient. Experience
makes the task easier, but the patients embarrassment may be
increased if he feels that the doctor or nurse is also embarrassed.
As STIs become more common, and with regular campaigns urging
the public to be checked for STIs, many such consultations are
now just routine screening.

Symptoms
Ive got stuff coming out, and it stings when I urinate: this
common symptom is likely to be gonorrhoea, chlamydial infection or nonspecific urethritis. There may be testicular symptoms
if the infection has caused epididymo-orchitis. Examination may
reveal urethral discharge (Figure 1). A loop is used to make a
smear on a slide and to inoculate a gonorrhoea plate. A urethral
swab for Chlamydia is also taken, unless a first-void urine sample
is sent. If there is significant discharge, this swab does not have
to be inserted deep into the urethra; 1 cm is sufficient, provided
there is plenty of material for it to soak up. When the urethra is
dry and no discharge can be seen, taking of a urethral swab can
be extremely painful, and urine testing for Chlamydia is more
appropriate in these cases.
Thick, green discharge developing within 1 week of sexual contact usually indicates gonorrhoea, and Gram-negative intracellular
diplococci are readily seen on microscopy (Figure 2). Gram-staining
in non-gonococcal urethritis gives a result similar to that seen
in Figure 2, except that no diplococci are seen. If gonorrhoea
is suspected, a throat swab is also taken. If the patient reports
having had anal intercourse with a man, a rectal swab is taken
for gonococcal culture. Proctoscopy is recommended, particularly
if there are rectal signs or symptoms.
The value of Chlamydia swabs taken from the throat and rectum
is uncertain, because false-positive results may occur.

Why does the patient want a check-up?

A recent high-risk event may have precipitated the consultation.
If appropriate, it is worth asking about such events, and why the
patient thinks that he might be at risk of STI. A young man returning from an exotic, risk-laden holiday in the red-light district of
Bangkok requires more in-depth discussion and follow-up testing
than a man in a long-term relationship who wants a check-up for
his peace of mind.
Recent advances mean that non-invasive tests can now be used
reliably for detection of Chlamydia and gonorrhoea. Nucleic acid
amplification tests (NAATs) can be performed on first-catch urine
samples; they are highly specific and sensitive for Chlamydia, and
are therefore useful in asymptomatic patients requiring a checkup. This technology also enables check-ups to be undertaken at
locations other than GUM clinics; in the UK, some high-street
pharmacies sell Chlamydia testing kits, for which the individual
simply returns the urine sample. Use of first-catch urine samples
also facilitates screening in general practice, because no physical examination is required and the process is quick and simple.
However, NAATs for Chlamydia are not yet universally available
to clinics and GPs in the UK, and NAATs for gonorrhoea are not
widely available.
Even asymptomatic patients attending for a check-up should
be offered blood tests for syphilis, hepatitis B and HIV. A short
discussion explaining the window period for these infections is

1 Urethral discharge
in a typical case of
gonorrhoea.

Colm OMahony is Consultant Physician in Sexual Health at the Countess

of Chester Hospital NHS Foundation Trust, Chester, UK. Conflicts of
interest: none.

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2 Gram-stained smear of discharge, showing several pockets of

Gram-negative, intracellular diplococci.

3 Obvious genital warts.

Urine testing traditionally, first-catch and second-catch urine

samples were obtained as a routine screen, particularly in patients
with symptoms of urethritis. Threads would be seen in the first
sample if true urethritis were present, and the second sample
would be clear. This procedure is no longer routine, but can be
useful in atypical cases when the symptoms do not correlate with
the findings (e.g. the patient has a clear history of discharge and
dysuria, but there is nothing to see on examination). Any threads
seen can be Gram-stained. A high concentration of pus cells is
supportive evidence of urethritis.

STI clinic attendance and blood donations (a syphilis blood test

would have been undertaken). It is important to ask about orofacial cold sores in either the patient or his partner. Sexual contact
overseas or with a recently returned traveller increases the possibilities, to include, for example, chancroid and lymphogranuloma
venereum.
Examination usually reveals a blister or an ulcer. A herpes
swab is taken from this into virus transport media. The wooden,
cotton-tipped swab should be rotated firmly in the base of the
ulcer, because live virus from live cells is required for a positive
result. Any antiseptic ointment or cream that has been applied by
the patient should be wiped away first. Where appropriate facilities and an experienced microscopist are available, dark-ground
microscopy for treponemes should be undertaken. Routine blood
samples should be taken; if syphilis is suspected, a full profile
for syphilis should be requested, not simply the enzyme-linked
immunosorbent assay. Inguinal adenopathy should be sought. In
herpes, this is usually painful and very marked; in syphilis, it is
painless. The perianal area should be examined carefully in men
who have sex with men, because early syphilis sometimes presents
as a perianal fissure. The rash of secondary syphilis should be
sought, because primary lesions are sometimes present as the rash
is developing.

Ive got lumpy bits growing down there: most patients can readily diagnose their own genital warts (Figure 3), though many teenagers simply have coronal sulcus glands (pearly penile papules)
that they have never noticed before (Figure 4). When warts are
found on the penis, it is worth checking the urethra and asking
about perianal warts, because the virus can track around to the
perianal area, even in exclusively heterosexual men.
Ive got an ulcer: in the UK, ulcers usually indicate herpes
(Figure 5), though the incidence of syphilis is increasing again.
Painful ulcers are usually herpes, but detailed tests and examination are required. When taking the history, ask about previous

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Investigations in men with suspected STI

Blood tests
Serological tests for syphilis are usually performed using an
enzyme-linked immunosorbent assay; screening is usually
IgG, but IgM can be requested if early syphilis suspected;
the laboratory usually undertakes further tests on any
positive results (treponemal agglutination test and VDRL or
RPR)
HIV (pre-test discussion tailored to the individuals risk)
Hepatitis B surface antigen (men who have sex with
men, patients with a history of injecting drug use or sex
overseas)
Hepatitis B core antibody (as above, to determine any history
of hepatitis B; if negative, these individuals should be
vaccinated)
Hepatitis C (patients with a history of intravenous drug use,
but becoming more common in men who have sex with men,
particularly those who are HIV positive)

4 Coronal sulcus glands (pearly penile papules).

Genital skin
Herpes simplex (sample taken vigorously from base of
lesion for virus culture or antigen test)
Urethra
Urethral loop or swab for Gram-stain and culture for
gonorrhoea; Chlamydia swab for NAAT, though some centres
still undertake immunoassay
Pharynx
Culture for gonorrhoea (when indicated by the sexual
history or gonorrhoea suspected following examination of
other sites)

5 Herpetic ulcers on the glans and prepuce.

Rectum
Culture for gonorrhoea in men who have anal sex with men
Urine
First-catch urine sample can be used for NAAT for Chlamydia,
and in some situations for gonorrhoea also; useful in
screening asymptomatic patients, who can then be re-called
for urethral gonococcal culture if positive
Urinalysis for glucose and protein when appropriate (patients
with chronic candidiasis); mid-stream culture for patients with
symptoms of urinary tract infection
NAAT, nucleic acid amplification test

6 Extensive preputial Candida balanitis.

The typical symptoms and classic appearance (Figure 6) of

candidal infection are generally sufficient for diagnosis in a
busy clinic, but a Gram-stain of a subpreputial sample can be
prepared, looking for typical spores and hyphae. A swab can be
sent for culture and confirmation, but this is seldom necessary
except in chronic, recurrent or difficult-to-treat cases; culture is
then important, because the species of Candida present may be a
more resistant type (e.g. C. glabrata) and therefore require more
intensive therapy.

Its red and itchy, and Ive tried various things but nothing
works: this situation usually indicates candidiasis and may be
recurrent. The infection generally responds to antifungal agents,
which can be bought over the counter; other conditions should
be considered only when the patient has consistently used an
antifungal drug with no improvement.

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Eczema, psoriasis, balanitis xerotica obliterans and Zoons

plasma cell balanitis (see MEDICINE 33:10) are usually diagnosed
on the history and the typical appearance, but biopsy is occasionally required.

FURTHER READING
Adler M W. ABC of sexually transmitted infections. 5th ed. London:
BMJ Books, 2004.
Barton S E, Hay P E. Handbook of genitourinary medicine. London:
Arnold, 1999.
www.bashh.org
(National guidelines for the management of STIs.)

Practice points
Many men with chlamydial infection are asymptomatic,
so screening of young men is particularly important;
use of first-catch urine samples makes this feasible in many
settings
Most young men are uneasy about undergoing a genital
examination, and particularly the taking of a swab; the fact
that testing can be undertaken on urine samples should be
more widely disseminated
Young men who request an STI screen or have symptoms
suggesting an STI need to be seen urgently; symptoms often
diminish, so making an appointment for 2 weeks later will
simply lead to a did not attend

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