Despite the widespread publicity about HIV and safer sex, sexually transmissible diseases (STDs) remain common. During 1992­93, 327,000 males attended genito-urinary clinics in the UK, a 1 per cent increase on the previous year. This figure does not include the increasingly large number of men who choose to receive treatment for an STD from their doctor rather than at a special genito-urinary clinic.

It is now widely known that sexual activity without a condom while abroad is a high risk activity for catching a number of STDs, including HIV and hepatitis B. Despite this, the attitude that 'It won't happen to me' is common.

A study at a UK genito-urinary clinic found that 51 per cent of heterosexual males had sex with a local foreign contact while on holiday during the preceding year. Many did not use a condom. Study of a further 68 males returning from abroad with an STD found that only 32 per cent had used condoms. Seven per cent said the condom had burst or come off, 12 per cent had not used them consistently, and 49 per cent hadn't bothered with a condom at all.

Nearer to home, a survey of 1,000 young people aged 16 to 29 found that 600 admitted to having sex with a new partner while on holiday in Devon without using a condom.

The sexual behaviour of homosexual males in England and Wales is hardly better. Gonorrhoea, syphilis, HIV and hepatitis B are slowly increasing in incidence, as unsafe sex is just as common now as it was five years ago. In particular, research shows that some HIV-positive men continue to practise unsafe sex despite the fact that they are receiving counselling on living with the virus. This shows a bizarre lack of concern for their own health and that of others.

SAFER SEX

A man's main protection against HIV, hepatitis B and other STDs is practising safer sex. Any sexual activity, even safer sex, with at-risk partners (e.g. bisexuals, drug abusers, casual contacts abroad or with those from endemic countries) greatly increases your risk of contracting HIV or hepatitis B.

• Always use strong, reliable condoms unless in a monogamous relationship where you know your partner is not infected with hepatitis B or HIV.

• Keep your number of sexual partners to a minimum, especially when travelling abroad.

• Avoid activities in which bleeding can occur (e.g. anal sex, fisting).

• Only use water-based lubricants. Oil-based products such as baby oil or petroleum jelly can weaken rubber condoms by 95 per cent within 15 minutes.

• Use condoms and/or dental dams for oral sex.

• Avoid sharing needles, razors, toothbrushes or sex toys such as vibrators.

• If travelling to endemic areas, carry 'dedicated medical kits'

(specially put together for people travelling to risk areas) containing syringes and needles, etc. Some travellers take their own transfusion kits and substitute blood products.

• Have a dental and medical check-up before travelling, to minimize the risk of having to be treated abroad.

• Even if both you and your partner are HIV positive, still practise safer sex. Reinfection with HIV, or superinfection with herpes or hepatitis B will cause further harm to your health and may hasten the progress of your disease.

EXOTIC VENEREAL DISEASES THAT CAN BE ACQUIRED ABROAD

Several exotic STDs are occasionally seen in the UK, having been caught in the tropics. These include:

Chancroid

due to infection with the bacterium Haemophilus ducreyii. This causes painful genital ulcers within three to five days of infection. The lymph nodes in the groin swell up to cause painful, bulging swellings (nicknamed 'buboes'). In severe cases, extensive tissue ulceration and destruction occur.

Lymphogranuloma venereum

caused by Chlamydia trachomatis serotypes 1, 2 and 3, which are closely related to the Chlamydia that causes non-specific urethritis (see Chlamydia and sperm). Small, painless ulcers or lumps appear 7­15 days after infection. Fever, headache, muscle and joint aches and a rash sometimes also occur.

This first stage is short-lived and is occasionally symptomless. The disease then progresses to massive swelling and inflammation of the lymph nodes in the groin to form unilateral or bilateral buboes. Abscesses may form with ulcers on the overlying skin. These take several months to heal unless antibiotic treatment is given.

Granuloma inguinale (Donovanosis)

due to an organism called Donovania granulomatis. This causes painless nodules 1­12 weeks after infection. They are commonly sited on the penis or around the anus. The nodules gradually ulcerate to form painless, beef-red ulcers with a typical rolled edge. Bleeding often occurs as the ulcer slowly enlarges. Antibiotics (e.g. tetracycline) will cure the infection but, if left untreated, ulcers may eventually heal with massive scarring.

CHLAMYDIA AND NON-SPECIFIC URETHRITIS

Infection with Chlamydia trachomatis is the commonest male STD in the Western world. It causes up to 60 per cent of cases of non-specific urethritis (NSU) and 45 per cent of cases of epididymo-orchitis. It can also be isolated from 7 per cent of sexually active males attending genito-urinary clinics who do not have symptoms of infection.

In the UK 43,294 males were diagnosed as having NSU during 1992­93. A further 12,806 cases were definitely attributed to Chlamydia and a further 3,629 men were treated for the condition 'epidemiologically' because their partners were affected. This was despite their having no symptoms themselves.

Chlamydia is a cross between a bacterium and a virus. It is too small to be seen under a light microscope and is difficult to grow in culture. Most clinics detect it with a special antigen test performed on sloughed urethral lining cells ­ a test that can take several days to give a result.

Some men infected with Chlamydia have no symptoms but can pass on the infection to female (or male) sexual partners. Other men notice symptoms of stinging at the end of the penis, watery discharge and pain on passing water. These symptoms usually start within one to six weeks of exposure to infection.

Infected males often complain of a discharge early in the morning which clears during the day. Staining of the underclothes with a mucous or slightly pus-stained discharge is another give-away sign. Sometimes, urination produces a spray as the end of the gummed-up urethra bursts open as water is forced through.

A tentative diagnosis is made by taking a swab of the urethral discharge and examining it under the microscope. Pus cells are usually found but no causative bacteria. Diagnosis is also helped by collecting urine in three specimen jars. Haziness of the first urine passed which doesn't clear on adding 5 per cent acetic acid (vinegar) indicates there are pus cells suspended in it. Threads of pus and sloughed urethral lining cells can often be fished out too and examined under the microscope. Urethral swabs are also sent off for antigen testing. Urethral lining cells are needed, and these are obtained by passing a small plastic ringed probe 2 cm down into the urethra and gently twisting it around. This is unpleasant, especially if the urethra is inflamed.

The presence of pus cells in a urethral discharge but no causative organisms merits a diagnosis of non-specific urethritis (NSU), which is likely to be due to Chlamydia.

Treatment is started immediately with a course of antibiotics (one of the many types of tetracycline or erythromycin) while awaiting results of the antigen tests. These can take several days to arrive and do not always find traces of infection when it is there. It is better to treat a suspected but unproved Chlamydia infection, than to let a missed infection grumble on.

If left untreated, Chlamydia can progress to epididymo-orchitis (infection and swelling of a testicle) or can spread to the eye (usually by the fingers) to cause conjunctivitis. NSU also triggers an immunological reaction called Reiter's syndrome in 1 per cent of affected males.

Reiter's Syndrome

Reiter's syndrome is diagnosed by the presence of urethritis, bilateral conjunctivitis (and sometimes uveitis ­ inflammation of the lining of the eye, including the iris) plus arthritis. Most patients with Reiter's syndrome have a recent history of a new sexual contact followed by urethral inflammation and discharge.

Reiter's syndrome is the commonest cause of arthritis in young men. The arthritis usually affects one or two joints ­ commonly a knee or ankle ­ and is often accompanied by a fever and feelings of being unwell. The affected joints become hot, swollen, stiff and painful. Tendons, ligaments and the soles of the feet may become inflamed. Skin rashes are also common.

Treatment of Reiter's arthritis is with painkillers and anti-inflammatory drugs. The NSU is treated with antibiotics. Most first attacks resolve within two to six months, but re-covery can be delayed for as long as a year. Unfortunately, the arthritis flares up again in a third of cases, especially after further episodes of NSU. During 1992­93, a total of 293 males were newly diagnosed as having Reiter's syndrome in the UK.

Chlamydia and Subfertility

Other important reasons for diagnosing and treating Chlamydia infection in males is to trace and treat female contacts and prevent the disease being passed on any further. Chlamydia infection in females is often symptomless and slowly inflames and blocks the Fallopian tubes. This is a common cause of pelvic inflammatory disease (PID) and subsequent female infertility.

Low-grade infection with organisms causing NSU, including Chlamydia, can also trigger male subfertility. This is because pus cells affect the sperm. Increased numbers of superoxide free radicals, which have been linked with sperm damage, are released. This effect is reversible after antibiotic therapy.

It is important not to indulge in sexual activity until treatment has finished and all your tests are clear, otherwise infection can be passed on and can flare up again in yourself.

Other causes of NSU apart from Chlamydia include organisms that are difficult to see or culture such as Ureaplasma and Mycoplasma. These respond to the same antibiotics as Chlamydia. Mycoplasma genitalium was first isolated from two men with NSU 10 years ago but has only recently been confirmed as a causative agent. Using DNA probes, it has recently been identified in 23 per cent of men with symptoms of NSU in whom Chlamydia was not found. Mycoplasma genitalium was also found in 3 per cent of men who had no symptoms of infection.

GENITAL WARTS

Genital warts are one of the commonest STDs to affect males, with infection almost classifiable as an epidemic. During 1992­93, over 49,000 cases were treated among UK males, of which almost 27,000 were first attacks. The other 22,000 cases were recurrent infections.

Genital warts are caused by the human papilloma virus (HPV), of which at least 60 different types exist. Essentially, a wart is a benign tumour. These vary in shape and size from small, multiple, finger-like projections to single, large excrescences that resemble cauliflowers. They are often moist and can itch.

Genital warts are usually transmitted by sexual contact, although it is thought that occasionally the virus is passed on via the hands. After exposure to infection it takes between a few weeks and several years before the first wart suddenly appears. They can occur anywhere on the penis, within the tip of the urethra or around the anus.

HPV can also enter a dormant stage within human cells and, once infection is present, may reoccur periodically throughout life. Some types of HPV are also linked with an increased risk of developing genital cancers. For this reason, women who have had genital warts should have annual cervical smears. In the same way, some experts suggest that homosexual men with anogenital warts should have regular anal canal smears to pick up early cell changes that might eventually lead to anal carcinoma.

Genital warts are best treated in a specialist genito-urinary clinic where you can be screened for evidence of other STDs. Never be too embarrassed to see your doctor about genital warts.

Treatment options include:

• painting the warts with a solution of podophyllum. This is a cytotoxic substance which literally kills wart-infected cells. It is applied to the warts at the clinic and subsequently washed off after six to eight hours. Application is repeated at weekly intervals and can take weeks to remove visible signs of wart infection.

• applying podophyllotoxin, the active ingredient of podophyllum. This can be prescribed in a weak solution for self-application. The solution is painted on twice daily for three days per week over a maximum of five weeks. Again, it takes several weeks to work.

• applying trichloro-acetic acid (TCA) in the clinic on a weekly basis. This strong acid coagulates wart cells and usually works quite quickly. If not applied carefully, ulceration of surrounding skin can occur. TCA and podophyllum are sometimes used together for faster results.

• freezing the warts with a cryotherapy probe. This is best reserved for single warts and those just inside the tip of the urethra, as it is less likely than other methods to cause urethral scarring. Regular repeat sessions are usually needed before the warts disappear.

• burning off the warts using bipolar electrocautery (e.g. ValleyLab). The warts are numbed with a local anaesthetic injection (using a fine dental needle) and then literally exterminated by grasping them between a pair of forceps and passing a buzz of electricity through. Shallow burns form, which heal over the following week to produce instant and gratifying results. This is an excellent method for treating larger or multiple genital warts. Unfortunately, the equipment is expensive and not every genito-urinary clinic can afford it.

GENITAL HERPES

Genital herpes was originally thought to be caused only by the Herpes simplex virus type 2 (HSV2), while cold sores on the lip were thought more likely to be due to Herpes simplex type 1. This distinction has become blurred, however, with the increased practice of oral sex.

Blood tests show that most of us have been exposed to the Herpes simplex virus by the time we reach middle age. Many people have what is called a sub-clinical attack ­ with no visible signs of infection and no ill affects. These people are then naturally immune to further infection but do not know they have been infected.

In Europe and the US, genital Herpes simplex virus infection is the commonest cause of genital ulceration, accounting for 5 per cent of patients seen in genito-urinary clinics. The US Center for Disease Control estimates that up to 500,000 new cases of genital herpes occur in the US per year. A population survey suggested that the disease may be present in up to 25 million people.

In the UK, the number of genital herpes cases increased by 70 per cent from 1981 to 1985. Between 1992 and 1993, 11,609 males were treated for genital herpes infection, of which 54 per cent were first, or primary, attacks.

Primary Herpes

The first time you catch herpes is known as the primary attack. If infection causes symptoms they usually develop two to 14 days after exposure. Symptoms of primary herpes include:

• itching and irritation around the genitals

• a general feeling of being unwell

• low-grade fever

• headache

• muscle aches and joint pains

• abdominal pain

• shooting pains in the lower limbs (neuralgia)

• enlarged, tender lymph nodes (glands) in the groin

• difficulty passing urine.

After one or two days, the classic herpes blister appears as a red, inflamed lump. This quickly breaks down to form a blister which ruptures to leave a painful ulcer.

These lesions are highly infectious and weep fluid that is teeming with over 1,000,000 viruses per ml.

In the male, symptoms usually last for 10­13 days. There is a wide range of clinical patterns, however, and the primary attack may be mild (lasting only a few days) or severe (symptoms lasting three to four weeks). Complete healing usually occurs in under 21 days unless the immune system is compromised in any way.

Ulcers on the glans penis and foreskin of uncircumcised males tend to heal without scars. Lesions in dry areas (e.g. penile shaft, scrotum, thighs, buttocks) crust over and form a scab. These tend to leave faint marks which will fade with time.

Peri-anal and rectal lesions are usually accompanied by spasm of the anus (tenesmus) and a profuse rectal mucous discharge.

Very occasionally it proves impossible to pass water during a primary herpetic attack. The bladder fills up and acute retention of urine occurs. This may be an involuntary reflex due to the pain of hot, acid, salty urine contacting ulcers at the tip of the penis or in the urethral entrance. Relief may be gained by sitting in a warm bath and urinating directly into the bath-water. Sometimes, a local anaesthetic and catheterization is necessary.

The herpes virus can also cause acute urinary retention through temporarily interfering with nerve function as it invades nerve endings. This is known as lumbo-sacral radiculo- myelopathy. In males, it is most common where herpes infection of the rectum and anus (proctitis) is present. Symptoms usually include impotence as well as difficulty urinating and opening the bowels. Catheterization and hospitalization are usually necessary, as symptoms take a week or two to resolve.

Recurrent Genital Herpes

Herpes viruses are unusual in that they are not totally eradicated from the body by the immune system. During the primary attack, the virus enters sensory nerve endings near the site of infection and travel up the associated nerves. They remain dormant within the dorsal root ganglion of the sacral nerves at the base of the spinal cord, out of reach of antibodies or antiviral drugs, until reactivated.

Several factors are known to trigger a herpes recurrence. These include:

• physical stress

• mental stress

• excessive heat or cold

• local genital trauma (e.g. rough sexual intercourse, plucking or shaving pubic hair)

• fluctuations in pituitary and adrenal hormone levels

• general ill health, other infections (e.g. colds)

• impaired immunity (e.g. due to drugs, HIV, cancer)

• exposure to ultra-violet light (e.g. sunbathing)

• exposure to X-irradiation

Upon reactivation, herpes viruses travel down the nerve to reach the genital mucosa. It may not take the same route as the way it came up, which is why a primary attack may consist of lesions on the penis while a recurrence may affect the anal region.

Recurrences are never as bad as the primary attack. You will not get the flu-like symptoms and, often, only a tiny sore appears. This is more of a nuisance than a problem. The sores tend to heal quickly compared with those of the primary attack and are often gone within three to five days.

Frequency of Recurrences

It is impossible to predict how many herpes recurrences some-one will suffer. Around 50 per cent of sufferers never have a recurrence, 25 per cent get one once or twice per year, while a few unlucky people seem to get one every month. In general, Herpes simplex recurrences become less frequent with time ­ infections are said to 'burn themselves out'.

Fifty per cent of patients notice prodromal symptoms (early warning signs of an impending attack) before recurrent lesions occur. These include itching, tingling, pins and needles, numbness, burning and shooting pains in the buttocks, thighs, penis, scrotum or even the feet. These prodromal symptoms are due to irritation as the Herpes simplex virus travels up or down the sensory nerve axons.

To help prevent triggering a recurrence, avoid strong sunlight or sun beds. Wear loose underwear (e.g. boxer shorts) so air can circulate and keep your genitals cool. Keep a record of when you get recurrent attacks in an attempt to find a pattern. If, for example, recurrences always come when you are over-worked and stressed, try to avoid this. If they are related to rough sex, try using a lubricant such as KY Jelly.

Asymptomatic Shedding

Some people seem to shed the herpes virus without any symptoms. Infectious viral particles have been isolated from the urethra and semen of men who have never even had a primary attack. Some experts now advise people who know they have had genital herpes to use a barrier method of contraception (male condom, female condom, diaphragm) whenever they make love, even when lesions are not present, so that asymptomatic shedding of the virus does not pass infection on.

When lesions are present, sex is best avoided from the start of the prodrome until lesions are fully healed. Condoms that cover the ulcerated area will provide some protection but cannot guarantee that the virus will not be transmitted.

Similarly, oro-genital contact should be avoided whenever lip or genital sores are present. Oral herpes can be passed to the genitals and vice versa.

Treatment of Genital Herpes

During a primary attack of herpes, try to attend a genito-urinary clinic straightaway. A drug called acyclovir is available which, if taken early enough, can shorten your attack and may possibly prevent a recurrence. Unfortunately, the diagnosis is not usually made until lesions are present. By then, the herpes virus has already started to invade nerve endings.

Acyclovir is available as a cream or tablet. It must be used five times per day from the beginning of symptoms, for at least five days.

Take paracetamol or other analgesics to dampen pain, but make sure you keep within the recommended safe doses. If pain is severe, try applying an ice-pack to the sores. Wrap ice cubes in a piece of clean cotton and place on the area for a short while. Use a clean cloth each time ­ and if possible, wear rubber gloves. Hygiene is important to stop you passing the infection to other parts of your body such as your eyes.

Try bathing the affected area at least four times per day with a salt solution. Make this up by dissolving a tablespoon of salt in a pint of tepid water. Apply the solution for 5­10 minutes, then pat the area dry. A hairdryer set on a low heat can also be used. Leave the sores exposed to air as much as possible, as this avoids irritation from clothes and helps the sores to dry out. If your symptoms are very distressing, your doctor or a genito-urinary clinic can prescribe stronger painkillers.

If recurrent attacks are troublesome, suppression therapy is available. This entails taking continuous acyclovir tablets two to four times a day. Treatment is usually given for three to six months initially to assess the patient's response. On stopping, if a recurrence occurs treatment can begin again.