SEXUALLY TRANSMITTED GASTROINTESTINAL DISORDERS – CLINICAL FEATURES AND MANAGEMENT

The symptoms of proctitis will vary depending on the cause and may

include anorectal pain, pruritis, mucopurulent or bloody discharge, tenesmus and, in severe cases, constipation. Many anorectal infections are asymptomatic. Erythema, oedema, exudate or tenderness on palpation may be noted on examination. N gonorrhoeae, С trachomatis and HSV are common causes of proctitis. Proctitis may be due to chemicals in lubricants, enemas, and shampoos resulting from direct or allergic contact reactions.

Primary rectal lesions may occur in syphilis, HPV, donovanosis or lymphogranuloma venereum. G lamblia is the predominant sexually transmitted cause of enteritis. Shigella and Campylobacter species and E histolytica may cause colitis or entercolitis.

It is important to be alert to the possibility of sexually transmitted gastrointestinal disease. Clinical assessment should include inquiry about anal coitus and other sexual practices and examination of the anorectal area.

Investigation of proctitis should include swabbing of inflamed areas for microscopy and culture with selective media . Biopsy may be necessary to establish the diagnosis and to exclude malignancy.

Treatment will depend on the cause. Treatment of asymptomatic E histolytica is usually not indicated.

Amoebiasis may involve the cervix, vagina, penis, perineum or anus. Anogenital amoebiasis may be transmitted by sexual intercourse. In tropical areas, amoebiasis should be included in the differential diagnosis of genital ulcer, balanitis and genital and perianal neoplasms. Investigations should include smears or biopsy of the lesion. In third world countries, trial of therapy may be appropriate.

Amoebiasis can be treated with metronidazole (e.g. 2 g orally in one dose daily for 3 days followed by diloxanide furoate 500 mg 3 times a day for 10 days.)

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GENITAL HERPES – MANAGEMENT

At present, no cure is available. Treatment is largely symptomatic and consists of sedatives and analgaesics. Acyclovir (Zovirax), an antiviral agent, can shorten the clinical course of the primary lesion and may benefit patients with frequent severe recurrences. Indications for acyclovir are:

treatment of moderate or severe first episodes of genital herpes (200 mg 5 times daily — each 4 hours while awake — for 10 days);

suppressive treatment for patients with moderate to severe recurrent genital herpes (more than 10 attacks per year with microbiological confirmation) (200 mg 2 to 4 times per day);

treatment of acute lesions in immunosuppressed patients (5 mg/kg by slow IV infusion every 8 hours for 5 days);

suppressive treatment an in immunosuppressed patient with recurrent HSV;

treatment of neonatal infection; and

treatment of ophthalmic infections where idoxuridine proved ineffective (ophthalmic ointment).

Because genital herpes is recurrent and untreatable, patients with HSV are likely to be depressed. Patients and their partners can be assisted by counselling and support. Sexual abstinence should be practised while lesions are active. Patients can be taught to recognise the prodrome and minor symptoms which may indicate recurrence of infectivity. Condoms offer some protection.

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SYPHILIS – LATENT SYPHILIS; LATE SYPHILIS

Positive serology in a patient without symptoms or signs of disease is referred to as latent syphilis and is the commonest presentation of syphilis in Australia today. Possibly because of the widespread use of antibiotics, the infection often proceeds to the latent stage without a recognised primary or secondary stage. An attempt should be made to determine the duration of latency (by asking about previous syphilis serology at the time of blood transfusion, STD or pregnancy, by identifying the occurrence of a primary lesion etc.) because specific treatments for early and late latent syphilis are different

Tertiary manifestations of syphilis may be ‘benign’ with development of gummas (granulomatous lesions) in almost any organ, or more serious with cardiovascular or central nervous system involvement. Benign gummatous disease is rare but cardiovascular disease and neurosyphilis occasionally occur. Careful management and follow up of patients with early or latent disease is essential to prevent late sequelae.

Late syphilis should be excluded in any patient with aortic incompetence or dilatation of the ascending arch of the aorta. Syphilis should be excluded as the cause of dementia, personality change, multifocal neurological disorders, nerve deafness, pupillary abnormalities, retinal disease or uveitis.

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PELVIC INFLAMMATORY DISEASE – MANAGEMENT

Hospitalisation will be necessary if the patient is severely ill or if an

abdominal emergency such as acute appendicitis or ectopic pregnancy has not been excluded. Other indications for hospital treatment include pregnancy, inability to tolerate oral medication, expected poor compliance with oral therapy, failed outpatient management or suspected pelvic abscess. Patients who are prepubertal or adolescent are at risk of severe complications and should be admitted.

Various antibiotic regimens are used depending on the clinical situation.

Therapy should be commenced as soon as possible and not delayed until investigations are complete. Treatment should be selected according to the most probable infecting organism and the severity of symptoms. Hospitalised patients may require intravenous chemotherapy which can be replaced by oral treatment following clinical improvement. Antimicrobial therapy should be continued for at least ten days. Bed rest and sexual abstinence are of benefit during therapy. If an IUCD is present it should be removed following commencement of antibiotics.

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GENERAL STD CONTROL

The major elements of STD control, in addition to effective management of

individual patients, are:

expertise; education; expeditious contact tracing; and, evaluation of epidemiological data.

Expertise

Health authorities in each State and Territory conduct STD centres and clinics to provide an expert service. The centres and clinics generally offer free treatment for patients and provide health workers for contact tracing. They should have access to specialist services such as a gynaecologist, colposcopist, dermatologist and clinical psychologist.

Education

Education concerning STDs should be targeted at:

health care workers (medical students, medical practitioners, nurses, Aboriginal health workers);

high risk individuals (homosexual and bisexual men, prostitutes, intravenous drug users);

school students particularly at secondary level; parents; the general public; and patients and their contacts. Health authorities in States and Territories provide publications on aspects of AIDS and other STDs which may be useful to supplement or reinforce counselling.

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HUMAN SEXUALITY & HUMAN REPRODUCTION

Human sexuality is more than human reproduction – it involves all the senses and the emotions, but most parents are unable to handle their sexuality and are uncomfortable, or unwilling, to talk about sexuality with their children.

You will be a better lover if you have been brought up to be honest about sexuality, and to enjoy your body. If you have been punished for ‘playing with your privates’, you will associate them with naughtiness, and you will associate sex with guilt.

You may have escaped your upbringing to some extent, or you may be rigid in your ‘sex is dirty’ attitudes. But you can help your children to have a more appropriate, sharing attitude to sexuality if you go about it the right way.

This is what education in human sexuality is all about. It is to give children an understanding of the nature of sexuality. In today’s world, we need more sexual understanding and better, more explicit, sex education. You can start helping, by doing as many of the following as you are able to do comfortably. Don’t be ashamed of your body or your partner’s. Let your children see that neither of you is ashamed, by walking about your house naked.

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ANATOMY AND PHYSIOLOGY OF SEX

The books agree that both partners must understand the anatomy and physiology of sex (which is reasonable) and they imply that, guided by the man, a woman will learn to develop specific sexual techniques, which will eventually enable her to have a voluptuous orgasm, and to give her man an earth-shattering climax.

To achieve this desired state demands not only mental but physical training in sex. You need to learn sex exercises. The more recent manuals extend these exercises from the pelvic muscles to the fingers and the tongue, as digital and oral sex are now accepted as normal. The pelvic muscle training, as outlined, is that a woman should learn to tighten muscles around her vagina so that she can ‘squeeze the man’s penis’ as he thrusts. Men have an equivalent exercise which is to ‘snap’ the muscles at the base of the penis whenever he has a spare moment, so that he can thrust more powerfully.

With the information from the reading and with the appropriate physical training, you should be able to pleasure your partner, provided you have developed the proper techniques. The techniques include the positions for intercourse, duration and length of foreplay, methods of increasing, prolonging, heightening, and sharpening sexual desire, and additional pieces of equipment which may give greater pleasure to sex. The emotional aspects of sex get only a passing mention.

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THE HUMAN SEXUAL RESPONSE – PHISICAL REACTIONS

As the degree of sexual stimulation increases, the diameter of the shaft of the penis increases and, more particularly, the lower edge of the glans of the penis gets bigger and becomes dusky-red in colour. At this stage a man can still voluntarily suppress the urge to ejaculate, although this is becoming much more insistent with the passing moments.

It is at this time of high sexual arousal that a man who suffers from premature ejaculation often knows he is unable to prevent himself from coming. The knowledge that he has reached this stage is of particular importance to a man who is being treated for premature ejaculation. At this precise time he must withdraw his penis from his partner’s vagina – or more accurately, since she is sitting over him, she lifts herself off his penis, and squeezes it in a special way. This retraining process, with the loving help of his partner, is usually effective in curing the disorder.

ERECTION AND SEXUAL INTERCOURSE

Both types of nerve fibres reach most organs of the body. They control the rate at which your heart beats and the strength of each beat; they control your digestive processes; they control your breathing; and they control your ability to have an erection. Stimulation of the parasympathetic nerves which reach your penis leads to an inflow of blood into your penis and it becomes erect, which is why these parasympathetic nerves are called the ‘erection nerves’. But stimulation of the sympathetic nerves supplying your penis, for example by anxiety, or a sudden frightening noise, or fear, can inhibit an erection, or reduce one.

Because erections are necessary to permit sexual intercourse and perpetuate the race, man has evolved, through evolutionary processes, a second system, should the first fail or be damaged, perhaps following a spinal injury.

In this second system, nerve fibres which travel outside the spinal cord in the thoracolumbar trunk connect the higher centres of the brain with the penis, missing out the spinal parasympathetic nerves. Erotic stimuli perceived by the brain excite the thoracolumbar trunk and an erection follows.

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SEXUAL BEHAVIOUR

If you do something well (as you perceive it, or as others tell you), or if you have a good meal, or if you achieve something you have long desired, your ‘pleasure centre’ is stimulated, and messages which make you feel happy, or satiated, or triumphant pass to other parts of your body. You feel good!

Our sexual behaviour is no exception to the ‘pleasure-pain principle’, but it is unique among the drives, as it is dominated by pleasure, almost to the total exclusion of the ‘pain principle’. So when you are sexually aroused, and this leads to a warm sexual contact, and perhaps to sexual intercourse, you feel warm, relaxed, pleasured, and ‘great’.

Scientists who study brain structure and function have found that the areas of the brain which appear to control sexual arousal are closely related anatomically to areas of the brain which relay sensations of pleasure. For convenience the areas controlling sexual arousal are called the ‘sex centre’, although in reality they are systems of interconnected areas in the brain. The ‘sex centre’ and the ‘pleasure centre’ lie close to each other in the oldest part of the brain and probably have nerve fibres connecting them. In an experiment which supports this concept, Dr Heath, a scientist, has discovered that in animals orgasm is associated with strong electrical impulses in the pleasure area of the brain. Many men and women, after a particularly arousing sexual experience, feel warm and loving to their partner; they lose hostility and aggression to others, and the pleasurable mood can last for hours.

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