History and examination

The majority of patients may be asymptomatic. However, a patient may present with symptoms or for a check-up if they feel they have been at risk.

Symptoms may be:

• dysuria
• rash
• discharge
• menstrual problems
• itch
• abdominal pain
• lumps
• hair loss
• ulcers
• enlarged groin lymph nodes
• pain and swelling in the scrotum.

• Does the patient have a regular sex partner and when did they last have sex?
• Does the patient have casual sex partners and when did they last have sex?
• Does the patient have sex with men, women or both?
• What are the possible risk behaviours of sexual partners?
• What type of contraception is used? Are condoms used?
• Does the patient, or do the partners, have a history of previous STIs/BBVs?
• Does the partner have any symptoms?
• Are sexual activities vaginal; oral; anal?
• Are their sexual contacts from overseas or interstate?

Rationale: A full and relevant clinical history enables the service provider to anticipate what might be found on physical examination. In addition, it is important to determine what risk factors may be present. Information about sexual practices also determines which sites should be examined and the range of specimens to be collected.

An understanding of past medical events will provide important clues for the diagnosis and management of STIs/BBVs, e.g. injecting drug use; overseas travel?

Special considerations

• The STI/BBV consultation involves personal and sensitive issues that can cause the patient considerable fear and apprehension. Stress the point that all information will be confidential.
• Give adequate time to the interview. It is helpful to let the patient talk freely and to tell their story in their own time – a friendly non-judgemental listening ear is often the best approach. Provide opportunities for the patient to ask questions.
• Ask direct questions (e.g. "Who did you have sex with?"). Do not use ambiguous terms, (e.g. "sleep with"). Note, however, that open questioning can be offensive to some cultural groups.
• It may be necessary to jog the patient's memory by linking sexual encounters with events significant to the patient (e.g. public holidays, special events (e.g. rodeo, mardi gras), travel, visits to relatives).
• It is useful to start questioning about sexual partners with the most recent sexual encounter, slowly working backwards.
• If the patient forgets the names of contacts, a description of the contact may be useful.
• Be adaptable when obtaining a sexual history. Experienced judgement by the service provider will determine which approach is most appropriate in the light of any language or cultural factors that may apply.
• If English is not the patient's first language, use an appropriately trained interpreter or staff member, not a family member, see contacts for patients – where to go. 
• Consider whether the patient needs additional support from a carer or person of the same gender or cultural group during the consultation.
• Do not presume the gender of sexual partners as this may lead to inaccurate information.

Ask about legal drugs that may affect the disease or its diagnosis, as well as other drugs:

• current medications
• antibiotics, whether prescribed or not, taken now or in the past three months
• over-the-counter medications
• topical medications containing antibiotics, antiseptics or steroid preparations
• injecting drug use now or in the past, including anabolic steroids and recreational drugs
• alcohol and other recreational drugs
• known drug allergies.

Rationale: A patient's drug history is important information because of the potential interactions between drugs and the possibility that the patient has a drug allergy. Alcohol and recreational drug use are important risk factors to consider.

Other factors to consider:

• risks for blood-borne viruses, which include:
  • injecting drug use
  • blood transfusion before 1985
  • body piercing
  • tattoos
  • country of birth/ethnicity
• gynaecological history – cervical cancer screening, last normal menstrual period.

Obtain informed consent to the examination and the tests to be conducted before proceeding. Rationale: No medical procedures can be done without the patient's informed consent. Obtaining informed consent requires sensitive and explicit communication, so that the patient can understand what is going to happen, as well as the nature of the infection being considered and the investigations proposed. Explaining the proposed examination and getting the patient's consent are the first steps towards actively involving the patient in managing the infection. 

An interpreter may be needed if English is not the patient's first language. (See contacts for patients – where to go, for further information about interpreter services.) Consider the use of visual materials (e.g. posters) when explaining the examination to all patients.

Examination should include the genital area, and the oral and perianal areas, as indicated by the patient's history.

For women with a suspected STI, a vaginal examination using a speculum should be undertaken.

Where a woman declines to have a vaginal examination or it is culturally inappropriate, a self-obtained low vaginal swab (SOLVS) can be used to test for chlamydia or gonorrhoea in an asymptomatic woman. (See Specimen collection in women who are examined and STI self-testing card (PDF 716KB)).

It should be recognised that examination is best practice and not just for obtaining swabs.

Rationale: A thorough physical examination is necessary to accurately diagnose and treat a patient with a suspected STI/HIV. This applies to all STIs.

Special considerations

• Special care should be exercised to avoid contact with infectious materials. Wearing gloves is essential and eye protection should be worn when there is risk of material splashing.
• In all patients with anorectal pain or discharge, proctoscopy should be performed to exclude anal canal or lower rectal disease.
• For vaginal examination, always use a vaginal speculum, warmed to body temperature, to visualise the cervix. Bimanual pelvic examination should be performed in patients with lower abdominal symptoms. If there is extensive disease with donovanosis or herpes, a vaginal examination may be painful and may have to be temporarily deferred.

Forms used by the Kimberley Population Health Unit to aid in the assessment of possible STIs are provided as examples that can be adapted for various WA health regions.

Sample and/or updated forms will be loaded on to the website from time-to-time as they become available.

• STI clinical management form (PDF 169KB)
• Sexual contact interview and tracing form (PDF 41KB)