Tuesday, 5 August 2008

Sexual History

Dear Bloggers

I am on my vacation this week, but it will not prevent me for writing to you all.

Today I want to mention about taking a sexual history This is an essential part of the history taking especially when considering patients with unexplained systemic symptoms and signs, genitourinary symptoms, neurological diseases, fertility problems etc.

When asking a sexual history, try to be tactful. Speak ideally in a private room off the main ward, but if not possible speak in a low voice to the patient or even write down the questions on paper and ask the patient to answer in writing so that those around do not hear the conversation. This of course depends on the literacy of the patient. Remember that such answers, verbal or written, are CONFIDENTIAL and should not be divulged to persons unrelated to the care of the patient. Written responses should be filed in the confidential patient notes.

Most patients are normallyseen in an outpatient setting and ideally, patients should be interviewed in a clinic room without others being able to overhear. A specialist STI clinic may be more preferable to the patient in some circumstances which usually have tailored facilities.

Questions to ask include:

-Are you sexually active? If so, how frequently ?

-Do you have sex with men or women or both ?

-Are you currently in a monogomous relationship? When was the last time you had sex with someone else? (Remember that being married does not preclude polygamy)

-What type of sex do you engage in? Oral, vaginal, anal etc? Any unusual sexual practises e.g. Group sex?

-Do you engage in safe sex? What do you think it means ?

-Do you use condoms / cervical cap / female condom / spermicide / contraceptive steroids / coitus interruptus (withdrawal before ejaculation) ??

-If you / your partner use a condom, is it worn strictly before insertion or just before ejaculation?

-Have you ever had a sexually transmitted infection (STI)? If so, when ? What type? Where was it diagnosed? How was it treated and for how long?

-Do you worry that you might be at risk of a current STI or HIV infection? Have you ever wanted or been tested for HIV? What was the result?

-(Female) How are your periods ? Regular? How many days between your periods? How many days do you bleed? Are they heavy or light? Do you think you might be pregnant? Have you ever been pregnant? Have you ever had a loss or pregnancy or a termination ?

-Have you had any unusual vaginal discharge e.g. yellow or fishy smell, or an itchiness? [trichomonas, gonorrhoea / chlamydia, candida]

-Does your penis itch inside during erection? Any milky discharge? [gonorrhoea / chlamydia]

-Do you get pains during sexual intercourse (female)? Painful during deep thrusting (female)? Pain on ejaculation (male)? [PID / Prostatitis-- gonorrhoea / chlamydia / mixed infection]

-Have you ever had penile / vulval /anal warts? [HPV]

-Have you ever had a rash in your groin / anal region ? Was it painful? Has it recurred from time to time? [HSV infection]

-Any recent / previous scabs on your penis / vulva / any unusual rash on the palms of your hands or the soles of your feet? Any generalised rash? Any mouth ulcers? [syphilis]

Other questions that could be asked include asking about the patient's occupation e.g. sex worker; exposure to contaminated blood or blood products e.g. tattooing, IV drug misuse, blood transfusion, haemophiliac [not a strict sexual history question]

What's the use of a sexual history at all?

The above questions are useful to determine if the patient is high risk for acquiring / transmitting STIs.

It determines the locations of the body that might be at risk from infection e.g. mouth, anus, vagina-cervix, and hence, which areas need to be tested e.g. cervical swabs.

It determines if an STI has ever been diagnosed and how it was treated and whether it was treated adequately.

Painful sex might indicate Pelvic Inflammatory Disease (PID) and painful ejaculation can signify prostatitis (as can painful defecation and bloody ejaculate).

Basically, the string of questions above can give a clue about the likely cause of an STI e.g. penile itching can be from gonorrhoea, chlamydia trachomatis etc..

Asking about 'safe sex' is important as patients ideas vs doctors ideas are sometimes different. Some people consider that STI transmission only comes from ejaculate exposure and only put on a condom just before ejaculation. This is NOT protected sex. Semen can still leak from the urethra even before ejaculation. Moreover, it does not prevent exposure to HSV, HPV, chlamydia, gonorrhoea, syphilis or HIV. Only condom use prior to insertion can decrease such exposure.

Remember that PID can also cause spontaneous abortion or reduced / loss of fertility. Hence, a pregnancy history is important.

Always consider asking about current pregnancy. Always consider doing a pregnancy test if even the patient thinks they are not pregnant. Early pregnancy can cause bleeding simulating a period. Missing a pregnancy in a person with an STI should be avoided as it changes what kinds of treatments can be provided e.g. Doxycyline should be avoided in pregnancy, and puts the foetus at increased risk e.g. HIV transmission during delivery.

Remember that odd rashes that involve the hands and feet can signify secondary syphilis. An influenza-type illness with headache, sore throat, disseminated morbilliform rash, fatigue, malaise etc may signify an acute HIV seroconversion illness. Remember too, that those patients with viral meningitis should also have a sexual history taken as HIV can present in this way. An HIV test with prior consent from the patient should be considered in such circumstances.

Please remember to ask about this important part of the history. It can sometimes give you the answer unexpectedly.

As doctors, it is your responsibility to find out the patient problems to make a competent diagnosis. Ignoring the sexual history from feeling embarrassed will only lead to further problems. If you miss an important diagnosis such as this, the embarrassment will come back on you for certain.

For a good easy reading text on STIs I would advocate the ABC of Sexually Transmitted Infections by Adler et al, fifth edition. BMJ Books.

Please consider.