Gynaecology: Sexual health

• Approach: Sexual History and Testing | Partner Notification and Confidentiality
• Vaginal discharge: Approach to Vaginal Discharge | Bacterial Vaginosis | Vulvovaginal Candidiasis | Trichomonas
• Bacterial STIs: Chlamydia | Gonorrhoea | Mycoplasma Genitalium | Pelvic Inflammatory Disease | Epididymo-orchitis and Urethritis in Men | Syphilis
• Viral STIs: Genital Herpes | Genital Warts | HIV | HIV Prevention — PrEP and PEP | Hepatitis and Mpox
• Other: Genital Ulcers — Approach | Scabies and Pubic Lice | After Sexual Assault
• Revision: Drug Reference Table | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🧪 Sexual health — STIs are common, often have no symptoms, and can cause infertility, ectopic pregnancy, chronic pain and (with HIV and syphilis) serious illness. Gonorrhoea and syphilis rates in England are high. Most STIs are easy to test for and treat, so take a respectful, non-judgemental sexual history, test widely, treat promptly, and make sure partners are notified. Sexual health clinics (GUM) are free and confidential.
Your four questions for every patient: What are the symptoms, and when was the last sexual contact (window periods)? What tests are needed for this person's risk (sites, HIV, syphilis, hepatitis)? Is there a risk of pregnancy (emergency contraception), HIV exposure (PEP), or a safeguarding concern? Have partners been notified?

Sexual History and Testing

• Ask with privacy and explain why the questions matter; be non-judgemental; don't assume gender of partners.
• Key questions:
  • Symptoms — discharge, dysuria, ulcers, lumps, rash, pelvic or testicular pain, bleeding after sex or between periods.
  • Last sexual contact and the one before — gender of partners, regular or casual, partner's symptoms or diagnoses.
  • Type of sex (oral, vaginal, anal) — decides which sites to test.
  • Condom use; contraception; LMP (pregnancy risk).
  • Previous STIs; HIV test history; PrEP use.
  • Risk factors for blood-borne viruses — injecting drugs, chemsex, sex with partners from high-prevalence countries, sex work, men who have sex with men (MSM).
  • Hepatitis A and B and HPV vaccination status.
  • Safeguarding — age, coercion, exploitation, domestic abuse, alcohol and drugs.
• Tests:
  • Chlamydia and gonorrhoea NAAT — women: vulvovaginal swab (self-taken is fine); men: first-void urine; plus throat and rectal swabs depending on sexual practices (MSM routinely).
  • Gonorrhoea culture (before antibiotics) if NAAT positive or symptoms — for antibiotic sensitivities.
  • Blood — HIV (4th generation antigen/antibody) and syphilis serology; hepatitis B (and C) if at risk.
  • High vaginal swab / microscopy — if symptoms (BV, candida, TV).
  • Herpes PCR swab of ulcers.
• Window periods — chlamydia and gonorrhoea about 2 weeks; HIV (4th generation) 45 days; syphilis up to 12 weeks. Test now and repeat after the window period.

↑ Back to index

Partner Notification and Confidentiality

• Partner notification — tells sexual partners they may be infected so they can be tested and treated (prevents reinfection and onward spread).
  • Patient referral (patient tells partners), provider referral (clinic contacts partners anonymously), or contract referral.
  • Look-back periods — e.g. chlamydia: 4 weeks before symptoms, or 6 months if no symptoms; gonorrhoea: 2 weeks before symptoms (men with urethral symptoms) or 3 months.
  • Often done by sexual health advisers.
• Confidentiality — sexual health clinics keep separate records (not shared with GPs without consent). Information can be disclosed without consent only in exceptional circumstances (serious risk of harm).
• Abstain from sex until treatment is finished (and partners treated) — e.g. 7 days after chlamydia treatment.
• Test of cure — for gonorrhoea (all), chlamydia in pregnancy, Mycoplasma genitalium, and others per guidance.

↑ Back to index

Approach to Vaginal Discharge

• Assessment — sexual history; pH paper; speculum examination if STI risk, recurrent symptoms, pregnancy, abnormal bleeding or upper genital tract symptoms; STI NAAT for anyone at risk.
• Young, low-risk woman with typical thrush or BV symptoms — can be treated empirically.

↑ Back to index

Bacterial Vaginosis

• What it is: An overgrowth of mixed anaerobic bacteria (e.g. Gardnerella vaginalis) replacing normal lactobacilli. The commonest cause of abnormal discharge. Not a classic STI, but linked to sexual activity.
• Triggers — douching, bubble baths, new or multiple partners, copper IUD, smoking.
• Diagnosis — Amsel criteria (3 of 4): thin white-grey discharge; pH over 4.5; fishy smell when adding potassium hydroxide (whiff test); clue cells on microscopy. Or Gram stain (Hay–Ison criteria).
• Treatment:
  • Metronidazole 400 mg twice daily for 7 days (or 2 g single dose); avoid alcohol during and 48 hours after.
  • Alternatives — metronidazole gel or clindamycin cream vaginally.
  • Partners don't need treatment.
  • Recurrent — avoid douching; consider suppressive treatment; lactic acid gels.
• Complications — in pregnancy, linked to preterm birth and late miscarriage (treat if symptomatic); after gynaecological surgery — infection; increases risk of acquiring HIV and other STIs.

↑ Back to index

Vulvovaginal Candidiasis

• Cause — Candida albicans (mostly); not sexually transmitted.
• Risk factors — antibiotics, pregnancy, diabetes (poorly controlled), immunosuppression, high-oestrogen states, SGLT2 inhibitors.
• Features — vulval itch and soreness, thick white discharge, superficial dyspareunia, dysuria; red, swollen vulva with satellite lesions.
• Treatment:
  • Clotrimazole 500 mg pessary (single dose) ± topical clotrimazole cream, or
  • Fluconazole 150 mg orally (single dose) — avoid in pregnancy (use topical clotrimazole for 7 nights).
• Recurrent candidiasis (4 or more episodes a year):
  • Confirm with culture; check for diabetes (HbA1c); review triggers.
  • Induction (e.g. fluconazole 150 mg every 72 hours for 3 doses) then maintenance (fluconazole 150 mg weekly for 6 months).
  • Non-albicans species (e.g. C. glabrata) may need other treatment.
• Men — balanitis (red, itchy glans); clotrimazole cream; check glucose.

↑ Back to index

Trichomonas

• Trichomonas vaginalis — a protozoan; sexually transmitted.
• Features:
  • Women — frothy yellow-green offensive discharge, itch, soreness, dysuria; strawberry cervix (punctate haemorrhages); pH over 4.5. Many have no symptoms.
  • Men — usually no symptoms; urethritis.
• Diagnosis — NAAT (most sensitive); microscopy (motile flagellated organisms).
• Treatment — metronidazole 400 mg twice daily for 7 days (preferred over a single 2 g dose); treat partners; avoid sex until both treated; test for other STIs.
• Pregnancy — linked to preterm birth and low birth weight; treat.

↑ Back to index

Chlamydia

• Chlamydia trachomatis — the commonest bacterial STI in the UK, mostly in people under 25.
• Features:
  • Often no symptoms (about 70% of women, 50% of men).
  • Women — increased discharge, dysuria, intermenstrual or post-coital bleeding, pelvic pain, deep dyspareunia; mucopurulent cervicitis with contact bleeding.
  • Men — urethral discharge, dysuria, testicular pain (epididymitis).
  • Rectal (proctitis) and throat infection.
• Screening — the National Chlamydia Screening Programme (England) focuses on opportunistic testing of young women under 25; test annually and after a new partner.
• Diagnosis — NAAT: vulvovaginal swab (women), first-void urine (men), rectal and throat swabs as appropriate.
• Treatment (BASHH):
  • Doxycycline 100 mg twice daily for 7 days (first line).
  • Pregnancy, breastfeeding or doxycycline unsuitable — azithromycin 1 g then 500 mg daily for 2 days (or erythromycin, amoxicillin).
  • Avoid sex for 7 days after treatment and until partners are treated.
  • Test of cure in pregnancy (and if rectal infection treated with azithromycin); retest under-25s at 3 months (high reinfection).
  • Partner notification.
• Complications:
  • Women — PID, chronic pelvic pain, tubal infertility, ectopic pregnancy, perihepatitis (Fitz-Hugh–Curtis syndrome).
  • Men — epididymo-orchitis, sexually acquired reactive arthritis (arthritis, urethritis, conjunctivitis).
  • Babies — conjunctivitis and pneumonia (from mothers in labour).
  • Lymphogranuloma venereum (LGV) — invasive serovars (L1–L3), mainly MSM: proctitis, ulcers, swollen groin nodes; doxycycline for 21 days.

↑ Back to index

Gonorrhoea

• Neisseria gonorrhoeae — rates in England are very high; growing antibiotic resistance (including ceftriaxone-resistant strains).
• Features:
  • Men — purulent urethral discharge and dysuria within days (most have symptoms).
  • Women — often no symptoms; discharge, dysuria, intermenstrual bleeding, pelvic pain.
  • Rectal (discharge, pain) and throat infection — often no symptoms.
• Diagnosis — NAAT; culture before treatment (antibiotic sensitivity); Gram stain of urethral discharge in men shows Gram-negative intracellular diplococci (immediate diagnosis).
• Treatment (BASHH):
  • Ceftriaxone 1 g IM single dose.
  • Ciprofloxacin 500 mg orally only if the strain is known to be sensitive.
  • Test of cure for everyone — NAAT 2 weeks after treatment (culture if symptoms persist).
  • Partner notification; avoid sex for 7 days and until test of cure if appropriate.
• Complications:
  • PID, infertility, ectopic; epididymo-orchitis; Bartholin's abscess.
  • Disseminated gonococcal infection — fever, pustular skin lesions, tenosynovitis, migratory arthritis or septic arthritis (young sexually active adult with a hot joint).
  • Neonatal — ophthalmia neonatorum (days 1–5).
• Gonorrhoea vaccine — since August 2025, England offers the 4CMenB (meningococcal B) vaccine to people at higher risk (mainly gay, bisexual and other men who have sex with men with recent STIs or multiple partners) through sexual health clinics — it gives partial protection against gonorrhoea.

↑ Back to index

Mycoplasma Genitalium

• Mycoplasma genitalium — a cause of non-gonococcal urethritis, cervicitis and PID; high antibiotic resistance (macrolides).
• Test only if symptoms (urethritis, PID, cervicitis) or a partner is positive — not for screening.
• Treatment (BASHH):
  • Doxycycline 100 mg twice daily for 7 days, then moxifloxacin 400 mg daily for 10 days (if macrolide resistance or status unknown).
  • If macrolide-sensitive — doxycycline, then azithromycin.
  • Test of cure at least 3–5 weeks after treatment.

↑ Back to index

Pelvic Inflammatory Disease

• What it is: Infection of the upper genital tract — womb, tubes, ovaries, pelvic peritoneum — usually ascending from the cervix.
• Causes — chlamydia, gonorrhoea, Mycoplasma genitalium, anaerobes and other vaginal bacteria (many have no organism found). Risk higher after IUD insertion (first 20 days), termination, or childbirth.
• Features:
  • Lower abdominal pain (usually both sides).
  • Deep dyspareunia.
  • Abnormal discharge; intermenstrual or post-coital bleeding; dysuria.
  • Fever (more severe disease).
  • Cervical motion tenderness and adnexal tenderness on bimanual examination.
• Diagnosis — clinical (low threshold to treat — the risks of untreated PID are high); pregnancy test (exclude ectopic); NAAT for chlamydia, gonorrhoea, Mycoplasma genitalium; FBC, CRP; ultrasound if an abscess is suspected. A negative swab doesn't exclude PID.
• Treatment (BASHH — outpatient):
  • Ceftriaxone 1 g IM single dose, plus
  • Doxycycline 100 mg twice daily for 14 days, plus
  • Metronidazole 400 mg twice daily for 14 days.
  • (Alternative — ofloxacin with metronidazole for 14 days, if gonorrhoea unlikely.)
  • IUD — can usually stay in if improving within 48–72 hours (remove if not, and consider emergency contraception if recent sex).
  • Analgesia; partner notification and treatment; avoid sex until treatment is complete.
  • Review at 72 hours.
• Admit for IV antibiotics if:
  • Severe illness, high fever, vomiting, or can't take oral treatment.
  • Tubo-ovarian abscess (may need drainage).
  • Pregnancy; surgical emergency can't be excluded (appendicitis, ectopic).
  • No response to oral treatment.
• Complications:
  • Tubal infertility (risk rises with each episode).
  • Ectopic pregnancy.
  • Chronic pelvic pain.
  • Tubo-ovarian abscess.
  • Fitz-Hugh–Curtis syndrome — perihepatitis: right upper quadrant pain (liver capsule "violin string" adhesions).

↑ Back to index

Epididymo-orchitis and Urethritis in Men

• Urethritis — discharge, dysuria, urethral irritation:
  • Gonococcal — usually purulent, sudden onset.
  • Non-gonococcal (NGU) — chlamydia, Mycoplasma genitalium, trichomonas, adenovirus, herpes.
  • Diagnosis — urethral smear (polymorphs), NAAT on first-void urine.
  • Treatment — NGU: doxycycline 100 mg twice daily for 7 days; gonorrhoea: ceftriaxone; partners treated.
• Epididymo-orchitis — pain and swelling of the epididymis and testis, usually one side, coming on over hours to days:
  • Exclude testicular torsion first (sudden severe pain, young men — urgent surgical exploration).
  • Likely STI (usually under 35, or sexual risk) — chlamydia or gonorrhoea: ceftriaxone 1 g IM plus doxycycline 100 mg twice daily for 10–14 days.
  • Likely enteric organisms (older men, recent urinary procedures, urinary symptoms) — ofloxacin or levofloxacin for 14 days (or per sensitivities).
  • Analgesia, scrotal support, rest.
  • Other causes — mumps orchitis, TB, amiodarone (non-infective).
• Prostatitis — see the Lower Urinary Tract Infection section of the renal chapters.

↑ Back to index

Syphilis

• Treponema pallidum — cases in England are at the highest levels in decades, mainly in MSM, but also rising in heterosexual people.
• Stages:

• Diagnosis:
  • Treponemal test (EIA or TPPA) — positive for life after infection (screening and confirmation).
  • Non-treponemal test (RPR) — reflects disease activity; used to monitor treatment (should fall 4-fold).
  • PCR of ulcers; dark-ground microscopy.
  • Test for HIV; LP if neurological signs.
• Treatment:
  • Early syphilis — benzathine penicillin 2.4 million units IM single dose.
  • Late latent — benzathine penicillin weekly for 3 weeks.
  • Neurosyphilis — IV benzylpenicillin or procaine penicillin with probenecid.
  • Penicillin allergy — doxycycline (not in pregnancy — desensitise to penicillin if pregnant).
  • Jarisch–Herxheimer reaction — fever, rigors, headache, muscle aches within 24 hours of treatment (endotoxin release); usually mild; in pregnancy can trigger preterm labour or fetal distress.
  • Partner notification; follow-up RPR.

↑ Back to index

Genital Herpes

• Herpes simplex virus — HSV-1 (now a common cause of genital herpes, from oral sex) and HSV-2. Lifelong infection; many people never know they have it.
• First episode:
  • Multiple painful blisters and ulcers on the genitals.
  • Dysuria (can cause urinary retention), tender groin lymph nodes.
  • Fever, malaise, headache; aseptic meningitis (rare).
• Recurrences — usually milder and shorter, often with tingling first; triggers include stress, illness, periods.
• Diagnosis — PCR swab of an ulcer.
• Treatment:
  • First episode — aciclovir 400 mg three times daily for 5 days (or valaciclovir 500 mg twice daily), started within 5 days or while new lesions are forming; saline bathing, analgesia, topical lidocaine; catheter (suprapubic) for retention.
  • Recurrences — self-care; short "episodic" courses (e.g. aciclovir 800 mg three times daily for 2 days).
  • Frequent recurrences (6 or more a year) — suppressive aciclovir 400 mg twice daily (review after a year).
• Transmission — can occur without lesions (asymptomatic shedding); condoms reduce risk; avoid sex during outbreaks; suppressive treatment reduces transmission.
• Pregnancy — see the Medical Problems in Pregnancy chapter (primary infection near term — caesarean).

↑ Back to index

Genital Warts

• Cause — HPV types 6 and 11 (low-risk types — they don't cause cancer).
• Features — painless lumps on the genitals or around the anus; soft and cauliflower-like (moist areas) or flat and keratinised (dry skin); may itch or bleed.
• Treatment (no treatment is also an option — about a third clear on their own):
  • Podophyllotoxin cream or solution — soft, non-keratinised warts (not in pregnancy).
  • Imiquimod cream — keratinised warts (not in pregnancy).
  • Cryotherapy — keratinised warts and in pregnancy.
  • Excision, electrocautery, laser for resistant warts.
  • Recurrence is common; stopping smoking helps.
• Prevention — HPV vaccine (Gardasil protects against types 6, 11, 16, 18 and others) — offered to all 12–13-year-olds and to MSM up to 45; condoms reduce (don't eliminate) risk.
• Warts in young children — usually non-sexual (from the carer's hand warts or birth), but consider safeguarding.

↑ Back to index

HIV

• Who to test (opt-out testing — normalise it):
  • Everyone attending sexual health services; all pregnant women; people with indicator conditions.
  • Opt-out testing in emergency departments in areas of high HIV prevalence (England, since 2022), alongside hepatitis B and C.
  • MSM (at least yearly, every 3 months if higher risk), people from high-prevalence countries, people who inject drugs, partners of people with HIV.
• Indicator conditions (test for HIV) — examples:
  • Any STI; hepatitis B or C; TB.
  • Pneumocystis pneumonia, oral candida, oral hairy leukoplakia, recurrent shingles or shingles in a young person.
  • Seborrhoeic dermatitis (severe), unexplained weight loss, fever, diarrhoea, lymphadenopathy.
  • Lymphoma, cervical or anal cancer, Kaposi sarcoma.
  • Unexplained low blood counts (lymphopenia, thrombocytopenia).
  • Community-acquired pneumonia, recurrent bacterial infections, aseptic meningitis, peripheral neuropathy, Guillain–Barré.
• Primary HIV infection (seroconversion) — 2–6 weeks after exposure: flu or glandular-fever-like illness — fever, sore throat, rash, lymphadenopathy, mouth ulcers, aseptic meningitis. Very infectious (high viral load).
• Tests — 4th generation HIV antibody/p24 antigen test (window period 45 days); point-of-care tests; HIV viral load and CD4 count once diagnosed.
• Treatment:
  • Antiretroviral therapy (ART) for everyone with HIV, started promptly — usually a combination of 2–3 drugs (often a single daily tablet, or long-acting injections).
  • Normal life expectancy with treatment.
  • Undetectable = Untransmittable (U=U) — people with an undetectable viral load for 6 months or more don't pass HIV on through sex.
  • Opportunistic infection prophylaxis if CD4 is low (co-trimoxazole under 200).
  • Drug interactions — many (e.g. boosted regimens with statins, steroids, contraception) — check the Liverpool HIV interactions website.
• AIDS-defining illnesses — PCP, oesophageal candida, cerebral toxoplasmosis, cryptococcal meningitis, CMV retinitis, Kaposi sarcoma, lymphoma, TB, progressive multifocal leukoencephalopathy, HIV wasting.

↑ Back to index

HIV Prevention — PrEP and PEP

• Pre-exposure prophylaxis (PrEP):
  • Tenofovir disoproxil with emtricitabine — routinely available free from NHS sexual health clinics in England (since 2020).
  • For people at higher risk (e.g. MSM and trans women with condomless anal sex; partners of people with detectable HIV).
  • Daily, or event-based ("2-1-1" — for anal sex only: 2 tablets 2–24 hours before sex, then 1 at 24 and 48 hours).
  • Highly effective (over 95% when taken correctly).
  • Monitoring — HIV and STI tests every 3 months; kidney function; hepatitis B status.
  • Long-acting injectable PrEP (cabotegravir) is an emerging option.
• Post-exposure prophylaxis (PEP):
  • A 28-day course of antiretrovirals after a significant exposure.
  • Start as soon as possible — ideally within 24 hours, and no later than 72 hours.
  • Available from sexual health clinics and emergency departments.
  • Indications — e.g. condomless anal or vaginal sex with a partner known to have detectable HIV or from a high-prevalence group; sexual assault (risk-based); needlestick injury from an HIV-positive source.
  • Not recommended if the source has an undetectable viral load (U=U).
  • Baseline HIV test; follow-up test after completing the course (8–12 weeks after exposure).
• Other prevention — condoms, regular testing, treatment as prevention (U=U), hepatitis B vaccination.

↑ Back to index

Hepatitis and Mpox

• Hepatitis B — sexually transmissible; vaccinate MSM, sex workers, people who inject drugs, partners of people with hepatitis B, people with HIV. Test those at risk.
• Hepatitis A — faecal–oral (including sexual contact); outbreaks among MSM; vaccinate MSM.
• Hepatitis C — mainly blood-borne (injecting drugs); sexual transmission among MSM (especially with HIV, chemsex, traumatic sex). Test at risk groups; curable with direct-acting antivirals.
• Mpox (monkeypox virus):
  • Close skin-to-skin contact, including sex; outbreaks since 2022, mostly in GBMSM.
  • Fever, lymphadenopathy, then painful lesions (vesicles, pustules, umbilicated) — often genital or anal; proctitis.
  • PCR swab of lesions; isolate.
  • Vaccine (MVA-BN) offered routinely to eligible GBMSM through sexual health services; clade I mpox is a notifiable high-consequence infection — follow UKHSA guidance.

↑ Back to index

Genital Ulcers — Approach

• Test every genital ulcer for HSV (PCR) and syphilis (PCR and serology), and offer HIV testing.

↑ Back to index

Scabies and Pubic Lice

• Scabies (Sarcoptes scabiei mite):
  • Spread by prolonged skin contact (including sex, households, care homes).
  • Intense itch, worse at night; burrows in finger webs, wrists; papules on the genitals (nodules on the penis), buttocks, axillae.
  • Treatment — permethrin 5% cream to the whole body (including scalp in the elderly and children), left for 8–12 hours, repeated after 7 days; malathion if allergic; oral ivermectin for crusted (Norwegian) scabies or outbreaks.
  • Treat all close contacts at the same time; wash bedding and clothes at 50 °C or seal for 72 hours.
  • Itch can persist for up to 4–6 weeks after successful treatment.
• Pubic lice ("crabs" — Phthirus pubis):
  • Itch; lice and eggs (nits) on pubic hair (also body hair, eyelashes).
  • Treatment — permethrin 5% cream or malathion 0.5% to all body hair, repeated after 7 days; petroleum jelly for eyelashes.
  • Treat partners; test for other STIs.

↑ Back to index

After Sexual Assault

• Priorities:
  • Safety and treatment of injuries.
  • Believe and support; let the person keep control of decisions.
  • Sexual assault referral centre (SARC) — 24-hour specialist care: forensic examination (with or without police involvement), medical and emotional support, independent sexual violence advisers (ISVAs).
  • Forensic evidence — best collected within 7 days (some up to 10–14 days); advise not to wash or change clothes if possible, but don't delay medical care.
• Medical care:
  • Emergency contraception — copper IUD (best) or oral EC.
  • HIV PEP — within 72 hours based on risk assessment.
  • Hepatitis B vaccination (accelerated course) — ideally within 6 weeks.
  • STI testing — at presentation and after window periods (2 weeks for chlamydia and gonorrhoea; HIV and syphilis at 6 and 12 weeks); presumptive antibiotics if unlikely to return.
  • Mental health — PTSD, depression, self-harm risk; follow-up and counselling.
• Safeguarding — children and young people (mandatory child protection referral), adults at risk, domestic abuse (MARAC).
• Documentation — careful, factual notes using the person's own words.

↑ Back to index

Drug Reference Table

↑ Back to index

Spot the Diagnosis

↑ Back to index

Exam-style Scenarios

1. A 19-year-old woman has a positive chlamydia NAAT on a routine screen. She has no symptoms and one regular partner.
Answer: Uncomplicated genital chlamydia.

• Doxycycline 100 mg twice daily for 7 days (azithromycin if pregnant).
• No sex for 7 days and until partner treated; partner notification.
• Test for gonorrhoea, HIV and syphilis; retest in 3 months; discuss contraception and condoms.

2. A 24-year-old has 5 days of lower abdominal pain, deep dyspareunia and discharge. Temperature 37.9 °C; cervical motion tenderness. Pregnancy test negative.
Answer: Pelvic inflammatory disease.

• NAATs (chlamydia, gonorrhoea, Mgen); start treatment straight away.
• Ceftriaxone 1 g IM, plus doxycycline and metronidazole for 14 days.
• Review at 72 hours; admit if worsening or abscess; partner notification.

3. A 30-year-old man who has sex with men has a painless ulcer on the penis for 10 days and painless enlarged groin nodes.
Answer: Probable primary syphilis.

• Syphilis PCR of the ulcer and serology (EIA, RPR); HSV PCR; HIV test; full STI screen.
• Benzathine penicillin 2.4 MU IM; warn about Jarisch–Herxheimer reaction.
• Partner notification; RPR follow-up; discuss PrEP and vaccines (hepatitis A and B, HPV, mpox, 4CMenB).

4. A 26-year-old woman had condomless sex with a new male partner from a high HIV-prevalence country 30 hours ago. His status is unknown.
Answer: Possible HIV and pregnancy exposure.

• Risk assessment for HIV PEP (start within 72 hours if recommended).
• Emergency contraception (copper IUD or oral).
• Baseline HIV, syphilis and hepatitis B tests; STI NAAT now and at 2 weeks; follow-up HIV test after PEP.