Genitourinary diseases

What are 'genitourinary' diseases?
These are conditions usually caused by infections that can affect the genital area and urinary system.

Some infections are caught from another person, usually during sex.

Other cases are caused when organisms (bacteria or yeast), which are usually present in small numbers, overgrow and cause symptoms.

Some genitourinary (GU) diseases are caused by bacteria that do not cause problems in their usual home in the body, but do if they get into another place.

These diseases are often managed best at a genitourinary medicine (GUM) or sexual health clinic.

Who is at risk of sexually transmitted infections?
Young people are at greatest risk of sexually transmitted infections.

They are very unlikely to have been exposed to any sexually transmitted infections before they start having sex, so they have no chance to build up immunity (when the body can fight off an infection by itself).

In young women, the cervix (neck of the womb) is immature and is easier to infect. In general, women are more likely to be infected by a man than vice versa.

Younger people may have more partners or change partners more frequently than older generations. Sexual behaviour is the most important influence on whether you get a sexually transmitted infection. If you have sex with someone who is infected then you are likely to get the infection yourself. The more partners you have the more likely you are to have sex with someone who is infected.

How do I know if I've got an infection?
Some infections, particularly those that are sexually transmitted, can produce no symptoms at all. But they might lead to complications that cause symptoms that prompt you to seek help. Even if sexually transmitted infections do not cause symptoms, they can still be transmitted to sexual partners.

Some infections cause very similar symptoms. For example, vaginal discharge in a woman can be due to non-sexually transmitted infections such as thrush, but can also be due to sexually transmitted infections. Non-specific symptoms of change in vaginal discharge and pain on passing urine cannot tell you the type of infection. To make a diagnosis, tests usually need to be taken. Similarly in men, urethral discharge (from the tube in the penis) can be caused by more than one infection.

Sometimes symptoms occur but disappear rapidly. This does not necessarily mean that the infection has gone away. Often the infection remains hidden in the body and, if it is sexually transmitted, the infection can be passed on to a sexual partner.

What are the commonest GU diseases?
Below is a list of the commonest diseases encountered in the United Kingdom:

chlamydia trachomatis

gonorrhoea

genital herpes

non-gonococcal (or non-specific) urethritis

pubic lice ('crabs')

pelvic inflammatory disease (PID)

trichomoniasis

genital warts

bacterial vaginosis *

cystitis *

scabies (passed on through close contact, not necessarily sexual) *

thrush (candida). *

* Note: These diseases are not usually sexually transmitted, but sex can make the symptoms worse, or sometimes even initiate symptoms.

Less common GU diseases
The conditions listed below are sexually transmitted and can be very common in some parts of the world. Therefore, if you have sex without a condom abroad you are at risk of getting infected. Some of these diseases are increasing in the UK, particularly HIV and syphilis.

Chancroid.

HIV.

Syphilis.

Other causes of genital ulcers: donovanosis, lymphogranuloma venereum.

Common genitourinary diseases

Bacterial vaginosis (BV)

BV is caused by an overgrowth of bacteria that normally live in the vagina in small numbers. Although this condition is not strictly speaking sexually transmitted, BV is uncommon in virgins. The more sexual partners you have had, the more likely you are to get it. Sexual intercourse may produce symptoms or worsen the symptoms. Products that affect bacteria in the vagina can cause the condition or encourage recurrences, including products added to baths (bubble baths, antiseptics), douches, or forgetting to remove tampons.

What are the symptoms?

Sometimes women do not have any symptoms, and the condition is found only when they have a check for sexually transmitted diseases or a smear test. If symptoms are present they are usually:

a greyish white discharge with an offensive fishy smell.

a burning sensation or soreness is more common than itching although this can also occur.

there is usually no redness of the genital skin.

Often the diagnosis is missed by a GP, either because thrush is presumed to be the cause and the woman is not examined, or because the correct tests are not taken. Make sure you tell the doctor all your symptoms when you attend surgery and don't presume that you have a condition such as thrush. At least you can then discuss with your doctor the likely causes of your symptoms.

How is it treated?
The condition can resolve by itself but often antibiotics from a doctor are generally needed. Washing the genital area in mild salt water (1 teaspoon per ˝ litre of water) can reduce the soreness and amount of bacteria present on the vulva (external female genital area) and in the vagina. Unfortunately even with antibiotic treatment the condition can recur. Treating the sexual partner makes no difference. Occasionally male partners of women get infection under the foreskin that gives a strong smell and excess smegma, which may need treatment.

Chlamydia trachomatis

Infection with bacteria called Chlamydia trachomatis can cause different GU conditions, including pelvic inflammatory disease in women and non-gonococcal urethritis in men. The infection is often called 'chlamydia', although there are other types of chlamydia that affect other parts of the body (eg, lung and heart).

Chlamydia trachomatis is sexually transmitted and is the second most common sexually transmitted infection in the UK.

In women, the bacterium can infect the cervix and/or the urethra (urine tube). It can also spread up into the uterus (womb) and Fallopian tubes (which conduct eggs from the ovaries to the womb), where it causes complications of pelvic infection (pelvic inflammatory disease - see PID).

Pelvic infection with Chlamydia trachomatis can lead to infertility (see PID).

Sometimes doctors do not have the facilities to test for this infection, and if they do, some of the tests are unreliable. Get checked out at a GUM clinic if you suspect you have this infection.

What are the symptoms?
In women:

often women have no symptoms.

there may be a change in the quality and quantity of vaginal discharge.

there is sometimes stinging on passing urine.

lower abdominal pain is often the first symptom of pelvic infection (see PID).

In men:

Urethral discharge and/or stinging on passing urine or mild irritation at the end of the penis (see non-gonococcal urethritis). Most often, no symptoms are present.

Occasionally, chlamydia can cause inflamed joints - this is more common in men.

How is it treated?
Antibiotics from a doctor are essential. These can be either single-dose treatment (azithromycin) or a course, usually a tetracycline antibiotic (eg doxycycline for a week).

If one partner in a sexual relationship is infected, it is very important that the other partner is seen and treated to prevent complications and avoid re-infection.

Cystitis

This is a term that means inflammation of the bladder, and is another name for lower urinary tract infection. It occurs more in women than men and the usual cause is infection with bacteria that are normally found in the rectum (back passage). When these bacteria get into the urethra and then the bladder they cause symptoms.

What are the symptoms?

There is pain, stinging and burning when passing urine, sometimes only at the beginning or end.

There may be a desire to pass urine but only a small dribble comes out. Afterwards there can still be the feeling that you need to pass urine.

Sometimes the urine has blood in it which gives it a red colour (you should always consult your doctor if this happens).

Remember that there are other causes of these symptoms apart from a bladder infection (eg chlamydia) and the only way to make a definite diagnosis is to have some tests taken.

Men rarely get bladder infections. Often, cystitis in men can indicate some abnormality within the lower urinary tract that needs further investigation.

How is it treated?
Products are available over the counter from the pharmacist that alter the acidity of the urine. An attack of cystitis can be stopped by using this medication and drinking plenty of fluid (3L a day) to keep the bladder flushed out.

If the symptoms do not settle within a few hours then go to your doctor. A urine sample might be sent off for further tests and a course of antibiotics is usually prescribed.

During a severe episode, it is often more comfortable to pass urine while in the bath. This tends to avoid the severe stinging.

Some women are prone to get repeated attacks of cystitis. To avoid these:

try to drink plenty of fluid (not tea, coffee, or diet drinks).

do not put off going to the toilet.

make sure that you completely empty your bladder when you pass urine.

some women find drinking cranberry juice helps. A severe attack can be stopped by taking an over-the-counter preparation to change urine acidity as soon as there is any symptom.

Gonorrhoea

This is a sexually transmitted bacterial infection caused by Neisseria gonorrhoeae. It is less common than chlamydia, the incidence of gonorrhoea increased by about 30 per cent between 1998 and 1999, particularly in teenage males.

What are the symptoms?
Often women have no symptoms but the following may indicate infection:

a change in vaginal discharge, particularly a change in the colour from the normal colour of 'off-white' to yellow.

pain on passing urine.

abdominal pain.

like chlamydia, gonorrhoea can get into the uterus and Fallopian tubes and cause pelvic infection, with longer-term consequences of infertility.

Men may have urethral discharge and pain on passing urine. Sometimes no symptoms are present but gonorrhoea tends to cause urethral discharge more frequently than chlamydia.

How is it treated?
A single dose of antibiotics prescribed by a doctor. Commonly, ciprofloxacin or a penicillin called amoxicillin are prescribed by GUM clinics. It is important to have a repeat test after you have taken the course to make sure that you have been cured of gonorrhoea.

As gonorrhoea is sexually transmitted, it is vital that your present sexual partners get treated to avoid re-infection and subsequent complications. To avoid spread of infection, other recent sexual partners should also be contacted and treated.

Genital herpes

Herpes simplex virus is the cause of genital herpes and of cold sores. There are two types of virus, type one and type two; both can affect the genital area.

Genital herpes is sexually transmitted but full penetration is not required to transmit infection. Close contact is all that is necessary when ulcers are present (though occasionally the infection is transmitted when ulcers have not occurred). The virus can be transmitted through oral sex, especially men to women. Your partner does not necessarily need to have an attack of oral herpes (cold sore) to transmit the infection to your genitals but this makes it more likely.

What are the symptoms?
The first sign can be a tingling in the skin followed by small blisters that burst quickly to form ulcers which then scab over. The ulcers are usually extremely painful and lumps in the groin (swollen lymph nodes) are noticeable in most patients. In a first attack, there are often several ulcers and you can feel unwell. An attack can also begin with pain on passing urine and a change in vaginal discharge, sometimes with back and leg pain.

In a first attack passing urine can sometimes be extremely painful. By doing this in bath water it can be more comfortable. Very occasionally you might find it difficult or impossible to pass urine. Attend a doctor immediately if this is the case.

Once you have had an attack of genital herpes, the virus stays within the body and can cause recurrences. The symptoms in a recurrent attack are usually much less than the first attack, with one or two small ulcers and splits in the skin. Occasionally, you can get a more severe recurrence if you are very run down.

How is it treated?
A first attack of genital herpes is not a condition that you should self-treat. You should go straight to a doctor, preferably within a GUM clinic, as soon as you notice any ulcers. The earlier in an attack you start a course of antiviral medicine (usually aciclovir), the quicker the current ulcers will heal and the more new ulcers will be prevented.

In recurrent attacks, there is usually no point in giving treatment because the five-day treatment course usually reduces the symptoms by only 12 to 24 hours. Keep the genital skin clean by washing in mild salt water (a teaspoon full of salt to a pint of water). This will avoid 'superinfection' of the ulcers with skin bacteria.

If there are multiple episodes of recurrence, antiviral medication can be taken regularly (twice a day) to prevent further attacks. This is usually given for six months in the first instance.

Genital herpes cannot be cured, which unfortunately means that it can be transmitted to sexual partners at any time. Avoid sex if you have any symptoms that suggest a recurrence. Condoms can cut down the risk of transmission but do not eliminate it. Herpes simplex virus can less commonly shed from the skin surface without ulcers being present (asymptomatic shedding) so you cannot rely on symptoms to avoid transmitting the infection.

Non-gonoccocal (non-specific) urethritis (NGU or NSU)

NGU is an inflammation of the urethra (urine tube) in men that is NOT caused by gonorrhoea. The commonest cause is Chlamydia trachomatis. However, in about half of affected men no specific infection is found - hence the term 'non-specific urethritis' (NSU).

The infections that cause NSU are usually transmitted by vaginal or anal sex although oral sex can sometimes transmit infection.

What are the symptoms?
Men can have NGU without knowing - if symptoms are present they are tingling or burning during urination, and urethral discharge.

Men can also suffer complications such as swelling of the testicles (epididymitis). Occasionally, joints can also become inflamed.

How it is it treated?
A course of antibiotics - usually doxycycline for one week to cover chlamydial infection - can cure the problem.

If a man has this condition, his female partner should be checked and treated. It is often not possible to detect a specific infection in women. But women need treatment because some bacteria that cause NGU in men can lead to pelvic infection in women. Also, if the woman is not treated then the man can get re-infected.

Pubic lice ('crabs')

Lice are small insects that are particularly adapted to living on pubic (genital) hair because the width of their gripping 'legs' are the same width as the pubic hair. This means that pubic lice cannot infect head hair but can be found on other body hair such as chest and armpit hair. You need close contact to transmit pubic lice, not necessarily full penetrative sex.

What are the symptoms?

Lice cause itching of the hair in the pubic region, especially at night. Sometimes you can see the lice moving and when the eggs are laid you can see specks that look like dandruff stuck onto the hairs. Lice live by sucking blood so sometimes you can see blood spots on your underwear.

How is it treated?
You need specific insecticide treatment in the form of shampoo or lotion applied to the pubic area and other hairy areas. The shampoo or lotion kills the lice and eggs. You can buy this treatment at the chemist but follow the instructions carefully. Normal washing in soap and water does not work. Shaving the hair can also get rid of the lice provided all the affected areas are shaved.

Other information
Although lice can be self-treated, sexually transmitted infections are often transmitted together. If you catch pubic lice you should be checked for other infections.

Pelvic inflammatory disease (PID)

This condition that affects women is usually a result of a sexually transmitted infection that is present in the vagina or the cervix but goes up into the uterus and Fallopian tubes causing inflammation. It is often a complication of untreated infection, particularly chlamydia and more rarely gonorrhoea, which can be present for months before resulting in this complication.

What are the symptoms?
The symptoms can vary from mild to severe. Pain in the lower abdomen that is often crampy and like period pains, especially if made worse by sex, can indicate PID. The pain can come and go and the tummy may be tender to the touch. Sometimes you can feel tired and unwell and have a temperature. You may have noticed a change in your vaginal discharge and/or abnormal bleeding over the preceding weeks. This bleeding can be between periods (spotting) or your periods can be heavier, longer or more irregular than normal.

Pelvic infection can be confused with other emergency problems, such as appendicitis, so make sure you get help if you have any of the symptoms. There are many different causes of abdominal pain and PID can be difficult to diagnose. A doctor should examine you to try to find out the cause of the abdominal pain, but they might still have to make a 'best guess' at the diagnosis. If you are quite unwell, you might need further investigations such as a laparoscopy (a small telescope examination through the tummy wall that allows the doctor to look at the uterus and tubes). This investigation is usually done only if the diagnosis is in doubt or if you have not responded to standard therapy. If symptoms are severe, some women with PID need to stay in hospital.

How is it treated?
If PID is likely, a course of antibiotics should be taken to treat the most common cause of PID, Chlamydia trachomatis. Rest and take painkillers to control the pain and cut down inflammation. You must finish the course of antibiotics and avoid sexual contact until your partner has been seen and treated.

After a single episode of pelvic infection, you have a small chance of becoming infertile from blocked Fallopian tubes (about 1 in 10 women have trouble getting pregnant). After a second episode, the risk of infertility is much higher. Also there is a greater chance of being left with continuing discomfort in the abdomen. So, you must ensure your partner gets treated to avoid re-infection.

Scabies

This infection, also known as 'The itch', can be transmitted by close contact and therefore is not necessarily sexually transmitted. However, sharing a bed is a very efficient way of transmitting this infection!

Scabies presents itself as a skin problem caused by scabies mites that burrow into the skin to lay eggs under the skin surface. The eggs hatch into larvae and grow into adults that then lay eggs again. The itching is due to an allergic reaction to the mites. Mites prefer particular areas of skin such as wrists, finger webs or genitals but can burrow anywhere.

What are the symptoms?

The main symptom is intense itching, worse at night and especially after a hot bath. Small lumps appear, which are due to the mites' burrows. Scratching can cause damage that allows bacterial infections to develop. This can alter the appearance of scabies and make the diagnosis more difficult.

How is it treated?
An insecticide lotion (such as malathion) should be applied from the neck downwards over the whole skin surface and kept on for 12 to 24 hours before washing. A repeat application may be necessary, depending on the product used.

The itch may continue for up to a month after satisfactory treatment. This is due to continuing allergy rather than continuing infestation. There is no need to use more treatment but a course of antihistamines can dampen down the itch until it eventually goes away.

There are often outbreaks in families. If one person within the house has scabies, other members should also be treated. Sexual partners must be treated.

Thrush (candida)

Thrush is a very common infection. It is not normally sexually transmitted; you can get it without ever having sex. It is caused by yeast called candida that are normally found in the vagina. Yeast grow well in warm and moist places. Most women have a small amount of these yeast in the vagina but do not get symptoms. When the yeast overgrow, symptoms can develop.

What are the symptoms?
The most usual symptom is itching that can be very intense and can affect the anus as well as the vulva. A lot of women notice an increase in vaginal discharge. This can vary from thin and watery with white flecks in it to thick 'cottage-cheese-like' discharge. You may notice a smell that is different to normal although not unpleasant. The vulva can become red and swollen in a bad attack. As you urinate the urine may sting as it touches the lips of the vulva.

How is it treated?
Simple measures like washing in slightly saltly warm water can reduce the itchiness and soreness until you can get to see a doctor. For women, treatment is a choice of antifungal pessaries or cream, both of which are inserted into the vagina (eg clotrimazole), or antifungal medicine taken by mouth (eg itraconazole).

Some of the treatments are now available over the counter. However, the first time you have vaginal discharge that you think is thrush, it is important that you get a correct diagnosis by having an examination and preferably some tests.

Some women get thrush recurrently. For these women, it may be more convenient to buy over-the-counter medication. However, if you have recently changed sexual partner or think you may be at risk of sexually transmitted infections, you should have a check-up.

Women can transmit the yeast to their male partners, especially if the man has a foreskin. It has not been proven that such men can infect women - women are much more likely to get a recurrence of their own thrush. Some women are particularly prone to thrush when taking antibiotics - if this is the case, ask for an anti-thrush treatment alongside the antibiotics.

Trichomoniasis

This infection is caused by a small parasite called Trichomonas vaginalis (TV) that infects the vagina and urethra. It is almost always transmitted by sexual contact.

What are the symptoms?
In women, the usual symptoms are a yellow or greeny discharge that smells unpleasant. There is often a lot of discharge, which can be frothy. Itching and irritation of the skin of the vulva are very common with TV. Symptoms can start within a few days of catching the infection or can take a few weeks to develop.

How do you treat it?
Antibiotics are required - you should get these from your doctor.

As TV is sexually transmitted, partners must take treatment. Men usually have no symptoms, although occasionally they get stinging on passing urine. If your partner is not treated, you are at risk of getting re-infected.

Genital warts

What are genital warts? Genital warts are a condition of the genital skin caused by a virus called human papillomavirus (HPV). There are many different types of HPV, some of which prefer particular areas of skin (eg hands and feet). Other wart virus types prefer the genitals.

Genital warts are transmitted by close contact between the genitals of an infected person and those of a non-infected person, usually during sex. The wart virus can be caught and then lie dormant in the skin without causing any problems. Later, the wart virus may start to divide and produce a wart. This can take from six weeks to many months, or even years. Because the time from catching the virus to getting warts is very variable, a previous partner could have infected you a long time before warts appear.

What are the symptoms?
Warts often go unnoticed because they do not produce many symptoms and are difficult to see. Occasionally they itch or bleed. Sometimes you can feel them as lumps that are gritty to the touch. Some warts are flat and others are more fleshy. Warts can be found on any part of the genital skin including around the anus even if you have never had anal sex.

How are they treated?
Many different treatments are available, which include applying solutions directly onto the wart, freezing, burning or surgically removing the warts. It is important to consult your doctor before applying any solutions. Sometimes the solutions can cause the skin to become sore. Keep the area clean by washing in very dilute salt water (1 teaspoon to a pint of water).

Unfortunately, warts come back after treatment in about 30 per cent of patients. It is not because you have re-caught the infection but because the wart virus remains in the skin. Eventually your body should develop immunity to the wart virus and the warts will go away.

Warts commonly co-exist with other sexually transmitted infections, so you must have a check-up to exclude other infections.

While you have warts you are infectious. Condoms offer some protection but obviously they cover only the penis and there are other areas of the skin that come into contact during sex.

Less common genitourinary diseases

Chancroid

Chancroid is a sexually transmitted infection common in the tropics but rarely, if ever, caught in the UK. It is caused by bacteria.

What are the symptoms?
Symptoms usually appear about two weeks after you have had sex with an infected person. You get painful ulcers, usually several at a time. You may also notice lumps in the groin, which are swollen glands (lymph nodes).

What is the treatment?
You need to take a one to two week course of antibiotics. It is very important to attend a GUM clinic so that proper tests can be taken to make sure that you get the right treatment.

Syphilis

This infection, caused by Treponema pallidum, is uncommon in the UK but becoming more common. It is much more common in developing countries, the USA and also Eastern Europe. This sexually transmitted infection is easily treated if detected but can be serious if left untreated.

If not treated when first caught, the infection goes through three stages. In all stages, the infected person may not have any symptoms. Therefore, blood tests are taken routinely for syphilis screening in antenatal clinics and GUM clinics.

What are the symptoms?
First stage: often a single small sore or ulcer is present on the vulva, although the anus can also be affected. There are usually swollen glands in the groin. The sore appears up to 12 weeks after contact with an infected person and lasts approximately six weeks. It can heal without any treatment.

Second stage: as the sore is healing, the second stage of syphilis occurs, two to six months after contact with an infected person. The symptoms are 'flu-like' with headache, fever, sore throat and swollen glands. Usually a rash appears on the body that can affect the hands and feet.

Later stages: Treponema pallidum organisms are present in the bloodstream and can get into the brain and spinal cord. For several years, the infection may not cause symptoms (latent infection, or 'third stage'). In late stages, the organism can affect the heart and brain leading to permanent damage. This does not occur if the infection is treated adequately and early enough.

What is the treatment?
A prolonged course of antibiotics, usually by injection, is required for 10 to 21 days depending on the stage of infection. After treatment, regular check-ups at yearly intervals are advised.

Previous and present partners should have a blood test for syphilis. The organism can be transmitted up to two years after contracting the infection. After two years of having the infection, you are unlikely to transmit it to a sexual partner.

Human immunodeficiency virus (HIV)

HIV is the virus that without treatment usually causes AIDS (acquired immune deficiency syndrome). Infection is uncommon among heterosexuals in the UK, unless they engage in specific risk behaviours, such as having sex with someone who has the infection already. More women are becoming infected in the UK.

HIV is present in body fluids including blood, semen, and vaginal and cervical secretions so it can be transmitted by sharing body fluids: through sexual intercourse, sharing needles, blood transfusion, etc. The virus is not just an infection of gay men but can be transmitted through vaginal sex. Anal sex is particularly risky, and transmits the infection more easily than vaginal sex. The virus is less likely to be transmitted through oral sex than penetrative sex but transmission can occur, especially if there is bleeding from the gums, or mouth ulcers are present. Although the virus is found in saliva, kissing has not been found to transmit infection. HIV is not passed on through everyday social contact such as sharing plates, cutlery, towels, etc.

What are the symptoms?

When HIV infection is first caught, most people notice no symptoms although many can later recall a mild flu-like illness. A few people will feel feverish and unwell with swollen glands and often a skin rash. These symptoms last a short time and then the infected person returns to full health. People with HIV often look and feel well for many years but remain infectious to others.

Eventually, most people with HIV will develop AIDS if left untreated. AIDS consists of numerous infections and other illnesses that involve many different body organs.

How it is it treated?
There is no cure or vaccine available for HIV infection. Some treatments are available that can slow down the production of new virus and delay the development of AIDS.

There are many different medicine combinations, all of which have some side effects. Further information is available from helplines and websites. HIV is a life-threatening infection and the only way to protect yourself is by using a condom. You will also reduce the risk by knowing whether your partner has HIV. Tests are readily available from GUM clinics.

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