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This article provides an overview of some infections affecting the genital area, including some non-sexually transmitted infections. The next best practice journal will finish this series, with articles about the treatment of STIs, and talking about safer sex to patients. Background: Chlamydia infection is the most frequently diagnosed sexually transmitted infection (STI) in New Zealand and is most common in sexually active adolescents and young adults.
Transmission: Chlamydia is transmitted through contact with genital secretions resulting in infection of the endocervix, urethra, rectum and occasionally pharynx and eye.
The most accurate results will be obtained at least 1-2 weeks after potential exposure due to an incubation period of approximately 7-21 days.
Symptomatic women can present with vaginal discharge (mucopurulent, milky or clear), lower abdominal pain, dyspareunia, dysuria or irregular PV bleeding.
Tip: Chlamydia testing should be considered in all patients found to have a sterile pyuria, as well as women presenting with breakthrough bleeding while taking the combined oral contraceptive pill.
Testing: The Ministry of Health recommends that Chlamydia testing is considered in all sexually active patients under 25 years of age,2 when they access healthcare whether or not they have symptoms.
Testing should be offered to all sexually active females under 25 years of age if they have never been tested. First Void Urine (FVU) tests for men are generally as sensitive in detecting Chlamydia infection as swabs and are generally better tolerated than traditional deep urethral swabs.
Taking a vaginal or endocervical swab for Chlamydia gives the best chance of detecting Chlamydia as the vagina is usually the primary site of infection.
Another presentation of Chlamydia trachomatis is lymphogranuloma venerum (LGV) which can cause small painless genital ulcers and subsequent painful chronic granulomatous inguinal lymphadenopathy. Any patient with symptomatic anorectal disease, positive for Chlamydia and not responding to normal therapy, should have LGV considered as a differential diagnosis. LGV is diagnosed by rectal swab (for NAA technique) and by excluding other causes of enlarged lymph nodes or genital ulcers.
A first void urine (FVU) is the first 25-30 ml of urine voided, preferably two hours since the man has last urinated. The women should find a comfortable position, either sitting or standing and then insert the Chlamydia swab at least 2-3 cm into the vagina (about half way along the swab). Transmission: Infection due to Neisseria gonorrhoeae is through contact with genital secretions and like Chlamydia can result in infection of the endocervix, urethra, rectum and occasionally pharynx and eye.
The incubation period is approximately 2-5 days (range 2-10 days), so swabs taken too soon after exposure may be falsely negative. Symptoms: Infection can cause dysuria, vaginal discharge or lower abdominal pain in females and urethral discharge (often mucopurulent) in men. It is important that it is transported to the laboratory as soon as possible, as there is up to a 50% loss of viable organism if there is over 24 hours before the sample gets to the laboratory.
Transmission: Treponema pallidum can enter the body by sexual contact through the skin lining the genital tract, anus or mouth.
The first stage is highly infectious and usually presents as a solitary painless ulcer (chancre) at the site of infection which persists for between 10-100 days. Third stage syphilis occurs in about one third of cases some months-years after the ulcer and rash have disappeared, and can involve damage to the brain, heart or spinal cord. Testing: At the early stages, exudate from the ulcer, transferred onto a glass slide, can be examined by darkground microscopy in some laboratories.

Symptoms: HSV genital infection may be asymptomatic or may cause painful genital lesions and sometimes a discharge. Testing: Swabs for viral typing, to differentiate between HSV-1 and HSV-2, should be obtained in all patients with newly diagnosed genital herpes, as the information can influence prognosis and counseling. Viral swabs are taken from the genital lesion (de-roof any vesicles if necessary) and broken off into viral transport medium while awaiting transportation to the laboratory.
Type specific HSV serology is rarely clinically useful, although may sometimes be useful for people with a history of genital symptoms but have never had a successful confirmatory test, or a pregnant woman presenting with her first clinical episode of herpes while she is pregnant. Symptoms: Gardnerella is found in 50% of normal healthy women without causing any symptoms. Non-specific urethritis (NSU) or non-gonococcal urethritis (NGU) is a diagnosis of exclusion. It is thought that some cases are caused by infection with organisms such as Mycoplasma genitalium, Ureaplasma urealyticum, HSV and Trichomonas vaginalis or following exposure to irritants such as detergents or chemicals. Background: Genital warts are the most common viral infection diagnosed in sexual health clinics, and are most common in sexually active adolescents and young adults.
Approximately 90% of genital warts are caused by Human Papilloma virus (HPV) subtypes 6 & 11.
Transmission: HPV infection is transmitted by direct skin-to-skin contact and condoms are considered only partially protective. Symptoms: HPV infection can range from being asymptomatic to causing multiple fleshy or flat lumps on the genitals.
Testing: At present, diagnosis is made clinically or the presence of HPV may be detected on smears. Molluscum contagiosum is usually painless, although lumps may sometimes be itchy, or become infected.
Background: Genital thrush is usually caused by the yeast Candida albicans, though sometimes it can be caused by atypical yeasts (such as C.
Transmission: is not usually sexually transmitted and is most often associated with recent antibiotic use, pregnancy, immunosuppression and diabetes. Laboratories in New Zealand can usually test for Gonorrhoea, Trichomonas vaginalis, Bacterial vaginosis and Candida on the same swab.
Specimen collection requirements may differ from region to region, check with your laboratory provider.
All sexual contacts within the previous 60 days need to be notified that they require testing and treatment for possible chlamydia infection.
If there have been no sexual contacts within the previous 60 days, then the most recent sexual contact should be notified, up to a maximum of six months. All sexual contacts within the specified timeframe should be treated for chlamydia, even if the offer of a test is declined. The 2007 annual ESR STI surveillance1 reported that the number of Chlamydia cases diagnosed had increased by 19.4% in the previous four years. These methods include polymerase chain reactions (PCR) which results in Nucleic acid amplications (NAA). Very occasionally it may be necessary to check for Chlamydia in the bladder as it can be a cause of UTIs.
If a man has recently voided urine, a deep urethral swab (5-6cm deep) may be performed instead, but most men would probably choose to wait and collect the FVU after two hours have lapsed.

Gonococcal infections rates are higher among young adults and among men who have sex with men. This tends to occur three to five days after exposure and is often more severe than other causes of ophthalmia neonatorum (eg, chlamydia). Traditionally HSV-1 was the usual cause of orolabial herpes (lips and mouth), while HSV-2 was the usual cause of genital herpes but increasingly there is cross-over occurring. Viral shedding occurs most easily when a sore is present but can occur even when a person has no symptoms.
Only 20% people with gential herpes has a typical syndrome, 20% are asymptomatic and the further 60% are atypical symptomatic. It takes several weeks for an antibody response to occur following the primary exposure to HSV. In women this can include dysuria, vaginal irritation and sometimes a yellow-green frothy vaginal discharge. It is associated with a reduction in lactobacilli and hydrogen peroxide production, a rise in the vaginal pH, and the overgrowth of BV associated organisms. Treatment is not required in asymptomatic women unless they are about to undergo an invasive procedure such as IUCD insertion and TOP. It is defined as a condition where the male urethra is inflamed (i.e there may be penile discharge, or numerous polymorphs on a urethral swab) but a diagnosis of Chlamydia or Gonorrhoea has been excluded. They are of public health concern because of their association with other subtypes of HPV (mainly 16 &18) that are linked with genital cancer (cervical, penile and anal). Many women also report thrush occurring more frequently while using oral contraceptives, or at particular stages of their menstrual cycle. However, a separate Chlamydia swab is needed for Chlamydia, and a viral medium swab is needed for Herpes Simplex Virus. Systematic review: noninvasive testing for Chlamydia trachomatis and Neiserria gonorrhoeae.
Vaginal swabs are the specimens of choice when screening for Chlamydia trachomatis and Neisseria gonorrhoeae: results from a multicenter evaluation of the APTIMA assays for both infections. Self-collection of vaginal swabs for the detection of Chlamydia, gonorrhea and trichomonas: opportunity to encourage sexually transmitted disease testing among adolescents. Women find it easy and prefer to collect their own vaginal swab to diagnose Chlamydia trachomatis or Neiserria gonorrhoeae infections.
Resurgence of Lymphogranuloma venerum in Western Europe: an outbreak of Chlamydia trachomatis serovar L(2) proctitis in the Netherlands among men who have sex with men. This process is so sensitive that Chlamydia can be detected using samples from anywhere in the vagina, leading to the advent of self-taken swabs being practical. If this is suspected and the vaginal swab comes back negative, a first void urine may be the most practical thing to do, as this has better patient acceptance than urethral swabs. First void urine tests for men and self-taken vaginal swabs for women can be ideal for offering Chlamydia testing to asymptomatic individuals as they are generally well accepted by patients.
About 10-20% of women in their reproductive years may be colonised with candida sp., but will be asymptomatic13 and not require treatment.

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