INTRODUCTION
A GP genitourinary medicine (GUM) post offers a valuable opportunity to develop skills in an area often poorly covered at medical school and elsewhere in the GP training programme. Within your GUM placement you can hope to develop your communication skills, improve your examination and diagnostic abilities, and learn how to recognise, screen, prevent, and treat sexually transmitted infections (STIs). You will also become comfortable in recognising and treating benign genital lumps, non-STI genital infections, and gain some valuable exposure to HIV diagnosis and management.
The most common presenting symptoms in GUM are vaginal discharge, male dysuria, genital lumps, and genital sores, and you are likely to see cases of these on a daily basis. Be reassured, however, that no two cases are alike given the often complex emotional elements that accompany physical symptoms, and make the GUM consultation a sensitive event requiring good communication skills. A non-judgmental approach is essential to ensure the best outcome for the patient.
If a GUM post is not offered as part of your GP training, strongly consider dedicating a week's study leave to attend GUM clinics, complimented by attending the British Association of Sexual Health and HIV (BASHH) Sexually Transmitted Infections Foundation (STIF) course.1 These two activities will provide a solid grounding in GUM, sufficient to deal with the most common presenting symptoms.
Below you will find some useful tips to get you started in GUM and maximise the learning opportunities of your placement.
PREPARATION
1. Review how to take a sexual history and familiarise yourself with the external genital anatomy to accurately describe your examination findings.
2. Read the information leaflets provided for patients on the common STIs. They are an invaluable source of information, and particularly cover the questions patients are most likely to ask using appropriate vocabulary.
3. Learn the appropriate language to discuss sexual behaviour. It can be embarrassing for the patient and doctor if words such as passive/active/ insertive/receptive are used incorrectly. The e-learning for general practice sessions on sexual health will give you a good head start.2
4. Befriend your GUM department's health advisor and spend a few clinic sessions observing them. They are likely to have many pearls of wisdom, particularly in communication skills.
5. Be sure to obtain a copy of your department's antimicrobial policy, as antibiotic resistance varies across the UK.
6. For a good initial source of information on STI management, consult the BASHH guidelines.3
7. Be aware of the varied presentations of HIV and the risk factors to look for when conducting a risk assessment.
GENITAL EXAMINATIONS
8. Where possible, be sensitive to patients' requests for a male or female doctor.
9. Always offer patients a chaperone (regardless of patient and doctor gender). It is an essential habit to get into and one that puts both the doctor and patient at greater ease. Document the outcome of the discussion, including the name of the chaperone.
10. Most patients are young adults who have never had a genital examination. Take time to describe, in detail, what will happen: when, by whom, and for what reason. A bad first experience is very likely to deter future inclusion in smear and sexual health screening programmes, while an acceptable one will encourage participation of the patient and his/her confidents.
11. Top tips for a speculum examination are: describe what you will do and why; encourage the patient to resist tensing their pelvic floor and to keep their bottom relaxed on the bed; advise the patient to let you know if their examination is painful; warm the speculum in water but avoid KY-Jelly® or other lubricant (these may interfere with sample collection); and if you are having difficulty visualising the cervix, ask the patient to place their clenched fists beneath their bottom to tilt the pelvis and bring the cervix into view.
12. It is not unheard of for a male patient to have an acutely embarrassing involuntary erection during a genital examination. It can be appropriate to complete the examination without acknowledging the erection, but if required, reassure the patient, offer to leave the room for a few minutes then return, or continue the examination without interruption if the patient wishes. Document the incident.
13. Look out for systemic symptoms such as joint, oral, or skin symptoms, as patients may not volunteer these routinely.
14. Remember to examine the testicles with a patient both lying down and standing.
GUM CLINICS
15. Try not to look shocked, whatever a patient tells you! A reassuring, non-judgmental approach will encourage patients to reveal their true sexual history, rather than the version they think you want to hear.
16. A good prompting question is ‘is there anything else you think I should know?’.
17. Encourage patients to have serological tests for HIV, syphilis +/- hepatitis, even if low risk.
18. It is unlikely that you will single handedly review HIV-positive patients, but you will be expected to learn how to conduct a HIV risk assessment, pre-test counselling, and deliver a positive HIV diagnosis.
19. Learn who and how to contact trace.
20. GUM offers a rare captive audience with the teenage population. Use this opportunity to promote safer sex, contraception, and lifestyle issues.
21. Be on the look out for sexual abuse and relay any concerns to your supervisor.
22. When breaking bad news, try to present the positives as well as the negatives, be sympathetic, and enlist the help of your very experienced health advisor.
23. You will quickly learn to recognise bacterial vaginosis, thrush, normal physiological discharge, and cervicitis, largely from the history and examination alone — useful skills for a GP where access to real-time microscopy is limited.
24. Fordyce spots, hirsuties papillaris genitalis (pearly penile papules), and sebaceous cysts are commonly seen in GUM. Be prepared to reassure many anxious teenagers that these lumps are normal! Sexually transmitted molluscum contagiosum is also commonly seen on the genitalia but should raise suspicion of abuse if seen there in children.
25. Samples collected during a GUM consultation may differ to those used in the general practice setting. Familiarise yourself with the ‘triple swabs’ used in general practice and how these differ to GUM clinic samples.
26. A useful way to encourage abstinence during STI treatment is to suggest that, like any other injured body part (a cut on the hand), the area ‘needs to be kept clean, dry, and rested.’
27. A bacterial STI screen is only accurate after an incubation period of up to 7–14 days from time of unprotected sexual intercourse. Serological tests have much longer ‘window periods’ of up to 3–6 months.
28. Encourage condom use!
29. Don't underestimate the benefit of lifestyle changes, such as avoiding shower gels and wearing cotton underwear in recurrent bacterial vaginosis and thrush.
PROFESSIONAL DEVELOPMENT
30. Where possible, compliment your GUM experience with the DFSRH (Diploma of the Faculty of Sexual and Reproductive Health).
31. The Diploma of Genitourinary Medicine is also available to trainees who have completed >3 months of GUM. The exam is set at the standard of a Year 2 SpR/ST4 in GUM and, therefore, may or may not be appropriate for general practice. Alternatively, BASHH have recently produced ‘STIFCompetency’, a competency-based training and assessment package for non-specialists requiring more specialist skills to manage STIs. It is easy to complete during a GUM post, but much harder outside of one.4
Notes
Provenance
Freely submitted; externally peer reviewed.
- Received October 26, 2010.
- Accepted November 9, 2010.
- © British Journal of General Practice, January 2011