STD Toolkit

Guidelines for Routine Evaluations

A clinician's guide:
How to examine and test

STD Clinical Practice Guidelines for Routine Evaluation of Men

The following minimal physical and laboratory examination should be performed on all sexually active men seeking STD clinical services that are at risk for STD infections. This evaluation should be performed at each clinical visit for the assessment of a new problem. Additionally, all patients should be counseled regarding means to reduce their risk of acquiring a sexually transmitted disease.

Physical examination:

  1. Inspect the skin of the abdomen, chest, back, forearms, hands, palms, inguinal area, thighs, lower legs, feet, soles or any other area indicated by medical or epidemiologic history.
  2. Examine cervical, axillary, femoral and inguinal areas for lymphadenopathy.
  3. Perform oropharyngeal examination under good lighting. Be particularly aware to observe for lesions under the tongue and along buccal surfaces.
  4. Inspect genitalia. Retract foreskin, if present, and milk the urethra for discharge
  5. Inspect and palpate scrotal contents.
  6. Inspect the anus if patient participates in anal sex or if anorectal symptoms are present.

Laboratory Testing:

Routine screening for Chlamydia trachomatis and Neiserria gonorrhoeae should be done frequently, depending upon risk factors. In general, testing should occur every 3 months for any male who has recently changed partners or who states he has more than a single exclusive partner. (For specific information on who should be tested and when, please see individual disease descriptions and testing recommendations found in the right hand toolbar).

The following tests should be considered at every visit:

  1. Urethral Gram-stained smear if patient has signs or symptoms of urethritis or gonorrhea.
  2. Tests for urethral infection (APTIMA is a combined NAAT for Chlamydia and Gonorrhea)

    1. Chlamydia: Urethral/urine Nucleic Acid Amplification Test (NAAT) for C.trachomatis for routine screening; signs or symptoms of urethritis present or urethral discharge noted; prior chlamydia infection or patient has a sex partner with gonorrhea or chlamydia infection
    2. Gonorrhea: Urethral/urine NAAT for N.gonorrhea for routine screening, signs or symptoms of urethritis present or urethral discharge, prior gonorrhea infection or patient has a sex partner with gonorrhea or chlamydia infection.

     

  3. Rectal NAAT testing for N.gonorrhea and C.trachomatis in men who report receptive anal sex with men.
  4. Pharyngeal NAAT testing for N.gonorrhea and C.trachomatis in men who report oral sex.
  5. HIV testing and counseling.
  6. Syphilis serology as routine testing if not done within preceding year or if patient has multiple sex partners or partner with current syphilis infection.
  7. Offer Herpes Simplex (HSV) serologic type specific testing or culture of lesions if seen, unless there is prior documentation of HSV infection; HSV testing is an especially high priority for persons at high risk for HIV.
  8. Offer serologic testing for viral hepatitis (types A, B & C) to MSM population, IV drug users, and sex partners of persons with any hepatitis infection.

    1. Vaccinate for Hep A and Hep B if suspected risk factors; conduct post-vaccination testing (1 month after last immunization) to determine serologic response.
    2. Vaccinate for HPV to protect against genital warts and cervical/anal/oral cancer.

STD Clinical Practice Guidelines for Routine Evaluation of Women

The following minimal physical and laboratory examinations should be performed on all sexually active women seeking STD clinical services that are at risk for STD infections. This evaluation should be performed at each clinical visit for assessment of a new problem. Additionally, all patients should be counseled regarding means to reduce their risk of acquiring a sexually transmitted disease.

Physical examination:

  1. Inspect the skin of the abdomen, chest, back, forearms, hands, palms, inguinal area, thighs, lower legs, feet, soles or any other area indicated by medical or epidemiologic history.
  2. Examine cervical, axillary, femoral and inguinal areas for lymphadenopathy.
  3. Perform oropharyngeal examination under good lighting. Be particularly aware to observe for lesions under the tongue and along buccal surfaces.
  4. Palpate the lower abdomen.
  5. Inspect genitalia, perineum, and anus if patient participates in anal sex or if anorectal symptoms are present.
  6. Speculum examination of vagina and cervix; check Bartholin glands. Perform bimanual pelvic examination as your protocols advise.

Laboratory testing:

Routine screening for Chlamydia trachomatis and Neiserria gonorrhoeae should be done frequently, depending upon risk factors. In general, testing should occur every 3 months for any female who has recently changed partners or who states more than a single exclusive partner. (For specific information on who should be tested and when, please see individual disease descriptions and testing recommendations found in the right hand toolbar). The following tests should be considered at every visit. Vaginal secretions should be collected from vaginal wall or pooled secretions.

  1. Urine human chorionic gonadotropin (HCG) assay if undiagnosed pregnancy is suspected.
  2. Vaginal Secretion pH.
  3. Saline Wet preparation microscopy of vaginal secretions for clue cells, fungal elements and trichomonads; amine odor (KOH sniff/whiff) test.
  4. Tests for cervical/vaginal infection (APTIMA is a combined NAAT for Chlamydia and Gonorrhea)

    1. Chlamydia: Endocervical swab (preferred), vaginal swab, urine NAAT for C.trachomatis for routine screening, signs or symptoms of discharge, prior chlamydia infection or patient has a sex partner with gonorrhea or chlamydia infection.
    2. Gonorrhea: Endocervical swab (preferred), vaginal swab, urine NAAT for N.gonorrhea for routine screening, signs or symptoms of discharge, prior gonorrhea infection or patient has a sex partner with gonorrhea or chlamydia infection.
  5. Rectal NAAT testing for N.gonorrhea and C.trachomatis in women who report receptive anal sex.
  6. Pharyngeal NAAT testing for N.gonorrhea and C.trachomatis in women who report oral sex.
  7. Cervical cytology if indicated.
  8. HIV testing and counseling
  9. Syphilis serology as routine testing if not done within preceding year or if patient has multiple sex partners or partner with current syphilis infection.
  10. Offer Herpes Simplex (HSV) serologic type specific testing or culture of lesions if seen, unless there is prior documentation of HSV infection; HSV testing is an especially high priority for persons at high risk for HIV.
  11. Offer serologic testing for viral hepatitis (types A, B & C) to Sex Worker population, IV drug users, and sex partners of persons with any hepatitis infection.

    1. Vaccinate for Hep A and Hep B if suspected risk factors; conduct post-vaccination testing (1 month after last immunization) to determine serologic response.
    2. Vaccinate for HPV to protect against genital warts and cervical/anal/oral cancer.

*Routine rectal and pharyngeal cultures are not recommended for all patients presenting for routine screening as prevalence rate in heterosexual females has not supported the cost of running them.