Management of under-16-year olds in UK genitourinary medicine clinics: British Co-operative Clinical Group.

In 2004, the management of under-16-year olds in UK genitourinary (GU) medicine clinics was surveyed. Questionnaires were sent to 185 lead GU medicine consultants. A total of 111 questionnaires were returned (60%). Ninety-eight percent of respondents managed young people aged 13-16. Fifty percent managed under 13-year-olds. Twenty-nine percent of respondents ran dedicated young people's clinics. Ninety-eight percent were aware of the National Guidelines, and 74% had adopted them. Fifty-seven percent had a named departmental child protection lead. Thirty-seven percent of consultants had received training specific to child protection issues in GU medicine. Improvements had been made since a similar survey published in 2001, but the need for further training was still apparent.

A review of policy change regarding how patients access their HIV test results at two genitourinary medicine services in Central London.

A retrospective note audit was carried out across two genitourinary (GU) medicine services in Central London to review a radical change in policy one year after its implementation that allows patients assessed as low risk for HIV infection to receive their HIV result by post. Sixteen patients tested positive across the two clinics but had arranged to receive their results by post. Their recall management and outcomes are discussed.

Investigation of cavernosal smooth muscle dysfunction in low flow priapism using an in vitro model.

The effects of hypoxia (pO2: 50 mmHg), acidosis (pH: 6.9) or glucopenia (absence of glucose) in vitro on the tone of the rabbit corpus cavernosum were investigated. The recovery of smooth muscle contractility following exposure to these conditions was also assessed. Hypoxia, acidosis or glucopenia alone or in combination showed a sustained reduction in the tone. Reperfusion of tissue strips showed complete recovery of smooth muscle tone for all conditions except when hypoxia and glucopenia were combined or when hypoxia, glucopenia and acidosis were used in combination. Incomplete recovery of tone was associated with a significant reduction in tissue ATP concentrations and an increase in the number of TUNEL (terminal deoxynucleotidyl transferase-mediated dUTP nick-end labelling)-positive nuclei. This indicates that following reversal of hypoxia, acidosis and glucopenia, failure of conventional alpha-adrenergic agonists to produce tumescence in low flow priapism is associated with irreversible smooth muscle cell dysfunction, which is linked to ATP reduction and smooth muscle cell death.

Update on oral treatments for male erectile dysfunction.

Impairment of erectile function compromises quality of life in millions of men and their partners, many of whom prefer to suffer in silence. It is important to maintain an elevated index of clinical suspicion in patients with erectile dysfunction (ED) risk factors (e.g. hypertension, diabetes, coronary heart disease). There remains a high rate of voluntary discontinuation of therapy associated with most treatment modalities. Since the introduction of sildenafil, a greater awareness and openness regarding the epidemiology and treatment of male erectile dysfunction has emerged. The development of newer and potentially more efficacious phosphodiesterase type 5 (PDE5) inhibitors will serve to treat an even greater number of patients, allowing once daily and more convenient dosing. An increased understanding of the physiological principles of penile erection has allowed the development of novel oral pharmacological therapies. The new agents offer a potential benefit in a broader range of patients and clinical situations. They may provide a more acceptable alternative than other more invasive options (intracavernosal/urethral injection, implant surgery). The dopamine agonist apomorphine acts on the central control of penile erection to allow a sublingual preparation to produce a prompt response. It is not contraindicated in patients on nitrate medication for coronary artery disease, or in patients with depression or on antidepressants. As with any other treatment, the clinician's responsibility in the care of ED patients does not end with the writing of a prescription. Adequate education and follow-up are needed to optimize the efficacy and safety of oral ED therapy. Furthermore, patients and their partners need to be advised that the agents are not effective in the absence of sexual stimulation. Communicating with both the patient and his partner in a discreet, non-judgmental manner that fosters the physician-patient alliance can facilitate the recognition and treatment of ED.

NCX-911, a novel nitric oxide-releasing PDE5 inhibitor relaxes rabbit corpus cavernosum in the absence of endogenous nitric oxide.

Phosphodiesterase type 5 (PDE5) inhibitors have reduced efficacy in treating erectile dysfunction (ED) in conditions where there is a lack of endogenous nitric oxide (NO). Therefore, NO-releasing PDE5 inhibitors have been developed. Here we report the effect of such a compound, NCX-911, on the tone and nitrergic relaxations of rabbit corpus cavernosum in the absence or presence of a NO synthase inhibitor, N(G)-nitro-L-arginine methyl ester (L-NAME; 500 microM). NCX-911 was found to be as potent as sildenafil at inducing relaxation of rabbit cavernosum (EC(50) values 997.8+/-195.7 and 1000.5+/-140.8 nM, respectively). The potency of NCX-911 was not altered, but that of sildenafil decreased five-fold in the presence of L-NAME (EC(50) values 1281.2+/-268.3 and 4959.1+/-882.1, nM respectively, P<0.001 for sildenafil). Both compounds potentiated nitrergic relaxations with similar potencies. These results suggest that NO-releasing PDE5 inhibitors could potentially be more useful than PDE5 inhibitors in the treatment of ED in conditions where there is a lack of endogenous NO.

Oral agents for erectile dysfunction.

Erectile dysfunction is a common disease affecting the lives of millions of men worldwide. Sildenafil was the first oral treatment licensed for male erectile dysfunction. However, there are now a number of other options available. In this article the currently available oral treatments are reviewed.

Predictors of seropositivity to herpes simplex virus type 2 in women.

Five hundred and twenty consecutive women newly attending a genitourinary medicine clinic who participated in a study of sexual behaviour were also tested for type-specific antibody to herpes simplex virus type 2; 135 (26%) were seropositive, of whom only 29 (21.5%) had had clinical evidence of genital herpes. Seropositive women were much more likely to have a past history of genital herpes (odds ratio [OR] 173). They were also more likely to be black non-UK born (OR 14), aged 30 years or over (OR 6), to have had 6-20 sexual partners (OR 3-4), especially from abroad (OR 12), to be unemployed (OR 6) or blue collar workers (OR 4), to have smoked cigarettes (OR 2) and to have practised peno-anal penetration (OR 5). Disease predictors included a past history of pelvic inflammatory disease (OR 63) and bacterial vaginosis (OR 3). Unexpected predictors were only one sexual partner (OR 5) and no non-regular partners (OR 5). Commencing intercourse before 16 years of age showed a protective effect (OR 0.2) and so did use of oral contraception (OR 0.5). Our findings show that infection with HSV-2 is associated with a wider range of morbidity and also emphasize the role of male sexual partner selection in the transmission of infection.

Current oral treatments for erectile dysfunction.

Erectile dysfunction (ED) is defined as the inability to achieve and maintain a penile erection adequate for satisfactory sexual intercourse. It is a significant male health problem of global dimensions affecting approximately 150 million men worldwide. A broad range of options are currently available for the management of ED. They include oral agents (phosphodiesterase 5 inhibitors, dopamine agonists and alpha-receptor blocking drugs), intracavernosal injection (papaverine, phentolamine, prostaglandin E1, vasoactive intestinal peptide), transurethral vasoactive agents (prostaglandin E1), vacuum erection devices, vascular surgery and penile prostheses. Here we review the physiology of penile erection and the currently available oral preparations. In addition, novel therapeutic strategies to improve erectile function are discussed.

Racial origin, sexual lifestyle, and genital infection among women attending a genitourinary medicine clinic in London (1992).

OBJECTIVES: To compare variables of sexual behaviour and incidence of genital infections among women of different racial origins and lifestyles. DESIGN: A prospective cross sectional study of sexual behaviour reported by a standardised self administered questionnaire in new patients who presented for screening and diagnosis. SETTING: A genitourinary medicine clinic in west London. SUBJECTS: 1084 consecutive women newly attending in 1992. MAIN OUTCOME MEASURES: Variables relating to sociodemographic status, sexual lifestyle, condom use, sexually transmitted diseases, and other genital infections stratified by racial origin. RESULTS: There were 948 evaluable women, of whom 932 (98.3%) were heterosexual and 16 (1.7%) were lesbian. Previous heterosexual intercourse was reported by 69% of lesbian women and their most frequent diagnosis was bacterial vaginosis (38%). The majority of heterosexual women were white (78%) and 16% were black. The black women were more likely to be teenagers (18% cf 8%; p = 0.0004) or students (28% cf 15%; p = 0.0008), and to have had an earlier coitarche (48% cf 38% before aged 17; p < 0.004). They also had a higher proportion of pregnancies (58% cf 38%; p < 0.00001) and births (38% cf 20%; p < 0.00001). The white women showed significantly more sexual partners during the preceding year (p = 0.004) and in total (p < 0.00001) and more reported non-regular partners (48% cf 35%; p = 0.004) with whom they were more likely to use condoms (p = 0.009). However, the black women were more likely to have gonorrhoea (7% cf 2% p < 0.0003), chlamydial infection (12% cf 5% p < 0.002), trichomoniasis (10% cf 2% p < 0.00001), or to sexual contacts of men with non-gonococcal urethritis (19% cf 12% p < 0.02). They were less likely to have genital warts (3% cf 12% p = 0.002). Logistic regression showed that all these variables were independently associated with the black women. The Asian women (2%), none of whom had a sexually transmitted disease, had commenced intercourse later (mean 19.7 years) than both black women (mean 16.8 years) and white women (mean 17.6 years). CONCLUSIONS: Sexual intercourse commenced approximately 1 year earlier in the black women, who were more likely to have become pregnant, had children, and to have acquired a bacterial sexually transmitted infection than were the white women.

Trends in female sexual behaviour and sexually transmitted diseases in London, 1982-1992.

OBJECTIVE: To measure changes in female sexual behaviour, including condom use, and their relationship with the incidence of sexually transmitted and other genital diseases in women during the decade 1982-92. DESIGN: A prospective series of cross-sectional surveys of sexual behaviour reported by a standardised self-administered questionnaire in new patients who presented for screening and diagnosis. SETTING: A genitourinary medicine clinic in West London. SUBJECTS: 4089 consecutive newly attending patients who completed sexual behaviour questionnaires during 1982, 1987, 1989 and 1992. MAIN OUTCOME MEASURES: Trends in socio-demographic status, sexual behaviour, condom-use, sexually transmitted diseases and other genital infections diagnosed by routine clinical and laboratory methods. RESULTS: Women reported significantly increasing condom use (from 3.6% to 20.7%) and decreasing oral contraception (from 51.2% to 40.1%), but the proportion who used no contraception (23.6% to 24.7%) and the proportion who had never been pregnant (58.3% to 59.9%) remained similar. Numbers of sexual partners in the preceding year decreased (p < 0.001) and an increasing proportion of women practised oral intercourse (p < 0.001). During the same period, there was a progressive decline (p < 0.001) in the incidence of gonorrhoea, chlamydial infection and trichomoniasis by approximately two-thirds. However, the incidence of vaginal candidosis (p < 0.001), bacterial vaginosis (p < 0.001) and genital warts (p < 0.01) increased. CONCLUSIONS: Increasing use of condoms for vaginal intercourse with both regular and non-regular partners has been associated with a decrease in the incidence of gonorrhoea, chlamydial infection and trichomoniasis. There was also an increase in the practice of fellatio and a change in the spectrum of STD and other genital infections with little net reduction in morbidity. HIV infection showed no evidence of heterosexual spread.

Heterosexual relationships and condom-use in the spread of sexually transmitted diseases to women.

OBJECTIVES: To examine the effect of patient-defined non-regular heterosexual relationships on the incidence of sexually transmitted diseases and other genital infections in women and the role of condom use in the prevention of their spread. DESIGN: A cross-sectional study of sexual behaviour reported by a standardised self-administered questionnaire in new patients who presented for screening and diagnosis. SETTING: A genitourinary medicine clinic in West London. SUBJECTS: 938 consecutive newly attending women who completed a sexual behaviour questionnaire in 1992. MAIN OUTCOME MEASURES: Variables relating to socio-demographic status, sexual behaviour, condom use, sexually transmitted diseases and other genital infections stratified by the reporting of non-regular partners. RESULTS: We found that women who reported non-regular sexual partners were more likely to be single (p = 0.0001), white (p < 0.0001), have had coitarche before 17 years of age (p = 0.003) and many more sexual partners both in the last year and in their life-time (p < 0.0001) and were more likely to practise fellatio (p < 0.0001), anal penetration (p = 0.004) and to be smokers (p < 0.0001). Paradoxically, the incidence of sexually transmitted diseases and other genital infections was no higher in this group than in the group of women who did not have non-regular partners. Increasing condom use with regular partners correlated with decreasing incidence of gonorrhoea (p < 0.001), chlamydial infection (p < 0.01) and trichomoniasis (p < 0.02), but increasing condom use with non-regular partners did not show this trend. CONCLUSIONS: Regular heterosexual partners play the major role in transmission of bacterial sexually transmitted diseases to women. This is significantly influenced by use of condoms.

PIP: The authors investigated the effect of patient-defined non-regular heterosexual relationships upon the incidence of sexually transmitted diseases (STD) and other genital infections in women and the role of condom use in preventing their spread. Findings are based upon responses to a 1992 sexual behavior questionnaire among 938 consecutive newly attending women presenting at a genitourinary medicine clinic in West London for screening and diagnosis. It was found that women who reported non-regular sex partners were more likely to be single, White, have had coitarche before age 17 years and many more sex partners both during the last year and in their lifetime, and were more likely to practice fellatio, anal sex, and smoke cigarettes. The incidence of STDs and other genital infections was no higher in this group than among women who did not have non-regular partners. Increasing condom use with regular partners correlated with decreasing incidence of gonorrhea, chlamydial infection, and trichomoniasis, but increasing condom use with non-regular partners did not show a similar trend. The authors conclude that regular heterosexual partners play the major role in transmitting bacterial STDs to women.

The potential effect on Neisseria gonorrhoeae of the use of clindamycin vaginal cream in the empirical treatment of vaginal discharge.

The minimum inhibitory concentrations (MIC) of clindamycin for 62 consecutive isolates of Neisseria gonorrhoeae were found to be 0.03-4 mg/L; the MIC50 and MIC90 were 0.125 and 2.0 mg/L respectively. Seven women treated with clindamycin vaginal cream had cervical mucus samples taken after seven days treatment. The concentrations of clindamycin achieved in the cervical mucus were 30-150 times higher (141-337 mg/L) than the highest MIC of the 62 N. gonorrhoeae isolates. Clindamycin vaginal cream is being used increasingly in Genitourinary Medicine clinics and General Practice for the treatment of bacterial vaginosis. This study shows that clindamycin vaginal cream achieves intra cervical concentrations that are high enough to inhibit N. gonorrhoeae. Empirical use of this therapy should be preceded by urethral and cervical swabs for N. gonorrhoeae in any woman at risk of gonorrhoeae.

A case cluster of possible tissue invasive gonorrhoea.

OBJECTIVE: To describe a cluster of patients presenting with severe symptoms and infected with an unusual strain of Neisseria gonorrhoeae. SETTING: A north London Department of Sexual Health. PATIENTS: Five patients were linked by reported sexual contact or other epidemiological evidence as part of a cluster of gonococcal infection. Cultured N gonorrhoea were subtyped by serological (serovar) and cultural (auxotype) methods and antibiotic sensitivities measured by minimum inhibitory concentration (MIC). RESULTS: Four of the patients had severe gonorrhoea-related systemic or extragenital symptoms: disseminated gonococcal infection with oligoarthritis (1 patient), acute pelvic inflammatory disease (1 patient, who was also chlamydia positive) and tender inguinal adenopathy (2 patients). The fifth patient was asymptomatic. N gonorrhoeae was isolated in four of the patients. All four organisms had identical MICs. Three of the organisms were subtyped and found to be the same rare strain (serovar 1A1, auxotype NR). CONCLUSION: This case cluster provides evidence for strain-related virulence in an uncommon gonococcal subtype.

Gynaecological disorders and human immunodeficiency virus infection.

It is increasingly apparent that the differences in the prevalence and severity of various gynaecological conditions are a function of immunosuppression and differences in behavioural factors, rather than a direct effect of HIV itself. Women infected with HIV will present with their gynaecological disorders initially to their carers in both primary care and genitourinary medicine clinic settings. It is therefore essential that all those involved in the management of these women are aware of the interactions between HIV infection, immunosuppression and various gynaecological conditions so that they may be appropriately managed.

A women-only clinic for HIV, genitourinary medicine and substance misuse.

OBJECTIVE: To evaluate a multidisciplinary women-only clinic (WOC) providing HIV testing, HIV follow-up, genitourinary screening and a substance misuse service. The clinic is designed to attract women who are at risk of acquiring sexually transmitted infections, including HIV, yet are not using existing medical services. DESIGN: A questionnaire survey and review of the case notes of women attending the WOC during the first seven months (April to October 1991) and comparison with a mixed-sex, daytime genitourinary clinic (John Hunter Clinic), and a HIV out-patients clinic (Kobler Centre) all within St Stephen's Clinic. RESULTS: One hundred and twenty-nine women attended the WOC over the seven month period and 113 completed a questionnaire. The main reasons for attendance included a preference to be seen by a female doctor and staff, the presence of female patients in the waiting area, and the greater convenience of an evening clinic. In the absence of the WOC over half the patients (56%) indicated that they would not have attended a genitourinary medicine (GUM) clinic. The WOC attracted significantly more new patients than in the JHC (31.5% vs 15% p < 0.001). One hundred and four women (81%) were screened for genitourinary infection. Compared with the JHC there were significantly more cases of genital warts (33.9% vs 16.1% p < 0.001) and candidosis (41.5% vs 22.3% p < 0.001). A greater number of HIV tests were also performed (19% vs 9% p < 0.01). Sixteen (12.4%) women were HIV positive. Their attendance record at both first appointment (88% vs 64% p < 0.05) and subsequent follow-up appointments (81% vs 43% p < 0.05) was significantly higher than a comparable group of women seen by the same doctor (FB) in the Kobler Centre. The women also saw the health adviser more frequently. Although the number of injecting drug users was small (eight), all women currently injecting drugs entered a detoxification programme. CONCLUSION: The WOC has become an established and popular service at St Stephen's. Women not previously using medical services are attending. The multidisciplinary nature of the clinic encourages a wider use of medical and paramedical services. Attendance record for HIV positive women has improved significantly. Whether these factors will lead to improved standards of sexual health will require a longer period of audit. Seventy-nine per cent of women indicated they would use a family planning service if available. An integrated family planning clinic was introduced after the audit period.