Sexual health

Effective control requires timely and appropriate antibiotic treatment of patients with confirmed infection as well as their sexual partners, but only a minority of partners currently receive treatment.

Sarah E Huffam FAChSHM, MPH · Katherine M Brown MB BS, MSc, FAChSHM · Marcus Y Chen FRCP, FAChSHM, PhD · Christopher K Fairley FRACP, PhD

A study of help-seeking behaviours, reproductive disorders and rates of testing for prostate problems in Aboriginal and Torres Strait Islander men from urban, rural and remote communities in the Northern Territory and Queensland.

Michael J Adams BSW, MA, PhD · Veronica R Collins BSc, MSc(Epidemiol), PhD · Michael P Dunne BA(Hons), PhD · David M de Kretser MB BS, MD, FRACP · Carol A Holden BSc(Hons), PhD, MPH

Extreme rates of gonorrhoea in remote areas must be reducedIn this issue of the Journal, there are two important articles highlighting the disadvantages experienced by Indigenous Australians, and offering important practical suggestions for improving health care.1,2 The article by Graham and colleagues analyses the notification rates for chlamydia and gonorrhoea in Australia by Indigenous status.1 Their findings are stunning. Compared with non-Indigenous Australians, Indigenous Australians have ...

Christopher K Fairley FRACP, PhD, FACSHP · Jane S Hocking MPH, MHlthSc, PhD

To the Editor: We congratulate Kwan and colleagues on their evaluation of an online chlamydia testing program (OLC) in Western Australia. However, their study does not demonstrate OLC to be a “highly effective means of increasing access to testing among young people at risk of STIs [sexually transmitted infections]”.1 Adolescents account for 30% of chlamydia notifications in WA,2 yet only 37 of the 377 people (10%) who were ...

Peter S Azzopardi · Elissa C Kennedy · Alex D Brown

In reply: Azzopardi and colleagues seem to equate “young” with “adolescent”. We defined “young” as less than 30 years of age; 84% of chlamydia notifications in Western Australia occur in this age group,1 and they comprised 71% of online chlamydia testing program (OLC) users.2 This group accesses the internet frequently, with about 90% of Australians under 35 years of age using the internet at least once a ...

Lewis J Marshall · Edwina A Jachimowicz · Lisa Bastian · Donna B Mak

Objectives: To assess notification trends for chlamydia and gonorrhoea infections in Indigenous Australians compared with non-Indigenous Australians in 2000–2009.Design and setting: We assessed trends in national notification rates using univariate Poisson regression and summary rate ratios.Main outcome measures: Crude notification rates and summary rate ratios, by Indigenous status, sex, age and area of residence.Results: Over the 10-year ...

Simon Graham BIS, MAppEpi · Rebecca J Guy BAppSc, MAppEpi, PhD · Basil Donovan MB BS, MD · Hamish McManus BEcon, BAcTS, MBIOS · Jiunn-Yih Su MB, MPH · Carol El-Hayek BSc, MEpi · Kellie S H Kwan BA(Hons), GradCertAppEpi · Amalie Dyda BHSc(Hons), MAppEpi · Handan C Wand MA, MSc, PhD · James S Ward BA

A retrospective study of the extent and management of pelvic inflammatory disease in remote-living Aboriginal women reveals that it occurs frequently, but is underdiagnosed and poorly treated.

Bronwyn J Silver BNurs, GradDipMID, MPH · Janet Knox MMed(STD/HIV), DTM · Kirsty S Smith GDipCommNurs, GDipEd, MPH · James S Ward BA · Jacqueline Boyle FRANZCOG, MPH, PhD · Rebecca J Guy BAppSc, MAppEpid, PhD · John Kaldor PhD · Alice R Rumbold BSc(Hons), MPH, PhD

To the Editor: The closet is a common lesbian response to prejudice, discrimination and stigma. Many rural lesbians choose to “pass” as heterosexual and keep their sexuality secret.1,2 Research shows that this secrecy is fuelled by the fear of violence, including harassment, ostracism and rejection,2 and it is unlikely that a lesbian will disclose her sexuality to a doctor unless she feels safe. Without full ...

Cathy Wheel

To the Editor: In June 2007 we highlighted the inconsistent application of community-accepted harm minimisation strategies, when offered to prisoners, among the various Australian jurisdictions.1 We sought information from the eight prisoner health services to assess how harm minimisation strategies were being implemented in each jurisdiction (Box). Progress has been slow, particularly in Queensland and the Northern Territory. The positive progress, however, has been the trial of condom ...

Michael H Levy · Carla Treloar

To the Editor: Australian gonorrhoea infection rates are rising.1 Infection spreads through various sexual practices, and extragenital infections are commonly asymptomatic.2 Nucleic acid amplification tests (NAATs) provide rapid, sensitive testing, regardless of the site involved or presence or absence of symptoms.3,4 There have therefore been calls for a change to NAAT-based screening for high-risk groups, including men who have sex with men (MSM).5 Limitations include ...

Miranda Sherley · Karina J Kennedy · Sarah J Martin

Chlamydia, caused by the bacteria Chlamydia trachomatis, is a sexually transmitted infection (STI) and the most commonly notified disease in Australia and in Western Australia ...

Kellie S H Kwan BA(Hons), GradCertAppEpi · Edwina A Jachimowicz BNsng, MNsgSt(Midwifery), GradDipNseEd · Lisa Bastian BAppSc(Nursing), MPH · Lewis Marshall MPH, FAFPHM, FACSHM · Donna B Mak MPH, FAFPHM, FACRRM

Objectives: To document the prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae in the refugee population settling in Western Australia from 1 January 2006 to 31 December 2009 and make recommendations for future screening for chlamydia and gonorrhoea in the refugee population.Design and participants: A prevalence and quality assurance study of 2610 refugees aged 15 years and older who attended the Humanitarian Entrant Health Service in Western Australia ...

Veronica C Hoad MB BS, MPH · Aesen Thambiran MB BS, FRACGP

Reproductive and sexual health: an Australian clinical practice handbook, 2nd ed. Sydney: Family Planning NSW, 2011 (197 pp, $65.00). ISBN 9781877026218. THIS HANDBOOK is an excellent resource for all primary care providers and medical students. The first edition was published in 2006. Since then, there have been a number of developments within the practice of reproductive and sexual health. The book is divided into 13 easily digestible chapters. There are organ-specific chapters as well as chapters on individual topics, covering pregnancy, menopause, fertility, sexually transmitted infections, pelvic inflammatory disease and sexual assault. Male sexual health issues are discussed as well. History-taking, examination, investigation and management of each area are covered in a comprehensive manner. Key points are boxed and highlighted. As many practitioners feel uncomfortable taking a sexual history and have limited experience in this area, the first chapter deals with consultation skills. The challenges involved when working with people from culturally and linguistically diverse backgrounds are discussed. The book also provides a detailed and clear guide to the management of sexual assault. This is particularly useful for providers (most, I suspect) who deal with this difficult problem very infrequently. Particularly useful, given our ageing population, is an expanded chapter covering urogynaecological issues, including urinary incontinence and pelvic organ prolapse. This book is more manual than textbook. For those requiring further information, a reference section at the end of each chapter includes useful books, articles and websites. Perhaps the book could benefit from photographs, but it does have useful diagrams, lists and flow charts. This book is up to date, succinct, well written and easily accessible. It is bound to be of everyday practical use to primary care providers working in the area.

Janice G Newton

Sexually transmitted infections. 3rd ed. David Barlow. New York: Oxford University Press, 2011 (134 pp, $29.95). ISBN 9780199595655. This slim book was first published in 1979 and this is its third edition. It is squarely aimed at the consumer who has an interest in sexually transmitted infections (STIs) — including HIV infection — and attempts to give “the facts” about these infections while dispelling myths and giving practical advice about diagnoses and treatments. The information presented is succinct and generally up to date, although the section on HIV and its treatments is already a little dated given the incredibly rapid changes that occur in this dynamic field of medicine. The 13 chapters deal with common and less common STIs such as gonorrhoea, non-specific urethritis (including Chlamydia trachomatis and Mycoplasma genitalium), genital herpes, genital warts, syphilis, “tropical” infections, viral hepatitis and HIV/AIDS. In addition, there is a chapter on “Understanding your results”, which grapples with the complexities of epidemiology, ascertainment bias and sensitivity and specificity. The author’s writings on these topics are generally quite comprehensible, although it is unlikely that many lay readers will grasp the subtleties involved in interpreting all test results after reading this chapter — lord knows, many physicians have difficulties grasping these complexities! The tone of the book is generally witty, though the avuncular style can grate somewhat at times. Moreover, the book is aimed at people living in the United Kingdom and may not be of much relevance to those outside the UK. References to general practitioners referring on for most STI problems (when the majority of Australian GPs will diagnose and treat the common conditions very competently without needing to refer to specialists), “GUM” clinics and “lavatory seats” mark the book as very British indeed. Oddly, the humorous cartoons scattered throughout the chapters feature men with a surfeit of hair (including some very retro sideburns) and a predilection for flared trousers, firmly placing the decade of their drawing as the 1970s — they look very dated in 2011. Lastly, the first line of chapter 1 didn’t enamour me to the book, either, claiming that “The UK is one of three countries, with Ireland and Malta, which recognise management of sexually transmitted infections (STIs) as a separate medical specialty”. I suspect the author has overlooked Australia and New Zealand and our longstanding Chapter of Sexual Health Medicine in this claim.

Darren B Russell

Patricia Brennan was born in Hurstville, Sydney, on 15 April 1944. She attended St George Girls High School and graduated in medicine from the University of Sydney in 1968. After residency at Sydney Hospital, she worked at the Sudan Interior Mission hospitals in Jos, Nigeria, and Galmi, Niger. Patricia became aware of the poverty and powerlessness of many African women and the vulnerability of the powerless to hidden sexual and domestic abuse. Patricia returned to Australia in 1973 to become Haematology Registrar at Prince of Wales Hospital, Randwick, while also holding the position of general practice consultant for the Sudan Interior Mission. In 1977, she established a solo general practice at Summer Hill, which she maintained until 1986. During this time, Patricia also became Assistant Medical Director of the Sydney Square Breast Clinic. Throughout her life, Patricia accepted and sought opportunities to work against oppression and injustice. Each phase of her life was characterised by questioning, passion and intellectual rigour. In the 1980s and early 1990s, her defining work was a voluntary commitment outside of medicine to reform the position of women in the church, especially in her own Anglican church. As founding President of the Movement for the Ordination of Women from 1985 to 1989, she was a charismatic and inspirational leader with a ready wit and great presence, who galvanised support and sometimes opposition to the cause. She believed ordination would achieve a transformational change in the role of all women in the church and have a symbolic power in the wider fight against abuse and coercion. In 1995, she worked with World Vision, assessing funded health programs, including programs to combat sexual assault and to manage post-traumatic stress in children in refugee camps in Gaza and the West Bank, Israel. In 1996, while undertaking her doctorate in medical anthropology, Patricia commenced as a medical officer with the Liverpool/Fairfield Sexual Assault Service and, in 2001, she became its Medical Director. This resulted in the next stage of her vocation: calling on the medical and wider community to recognise the widespread and long-lasting trauma caused by sexual assault and family violence. She completed a Masters in Forensic Medicine from Monash University, developed specialist pathways for training and, at the Royal Prince Alfred Hospital, became the first Staff Specialist in Clinical Forensic Medicine specialising in sexual assault appointed to an emergency department in New South Wales. She was a Fellow of the Australasian College of Legal Medicine, a member of the Forensic and Medical Sexual Assault Clinicians Australia, and a founding committee member of the Australasian Association of Forensic Physicians. In 2009, she became acting Medical Director of the Clinical Forensic Medical Unit of the NSW Police Force, and was appointed a Visiting Fellow in Law at the University of NSW in 2010. She pushed for medical rigour in a field of medicine where there was a history of ill founded medical opinion contributing to grave injustices: the return of children to situations of abuse, failed prosecutions due to inadequate medical evidence and, occasionally, false convictions. Patricia’s achievements were recognised with a Bicentennial Woman of Achievement Award in 1988 and, in 1993, she was made a Member of the Order of Australia for services to the community, particularly as founding President of the Movement for the Ordination of Women. Patricia was a doctor of ready wit and apt speech who exercised leadership on big picture issues with passionate intelligence. She could be discouraged by frustration at the slowness of change, but she always returned with energy and creativity to the cause. All her struggles were motivated by a bold vision and a sense of calling. She died on 6 March 2011, 4 months after being diagnosed with pancreatic cancer. She is survived by her husband Robert, children Kate, Peter and James, and grandson Gabriel.

Rosemary A Isaacs

Emergency contraception and medical abortion are options, but education about them is vital Prevention is better than cure — especially in the field of sexual and reproductive health. Australia’s teenage pregnancy rates (17.3 per 1000 women in 2003)1 and abortion rates (19.7 per 1000 women in 2008)2 are high compared with other Western countries. Such rates are not inevitable, and recent contraceptive strategies were developed to help in reducing them. One such strategy was the rescheduling in Australia of the emergency contraceptive pill (ECP) containing levonorgestrel to Schedule 3 (over-the-counter) status, making it available from pharmacists without a prescription. Improved access to the ECP is a crucial issue, given that the sooner it is taken after unprotected intercourse, the more effective it is. By rescheduling the ECP, it was hoped that women would be able to obtain it more easily within the narrow time frame recommended, especially after hours and on weekends, when it is more difficult to access a general practitioner. A second-generation antiprogestin ECP, ulipristal acetate (30 mg), has now been released and is thought to be a more effective option up to 120 hours after unprotected intercourse.3 Our recently published Australian population study of over 600 women aged 16 to 35 years found that although 95% had heard of the ECP and 26% had used it, just under half (48%) were aware that the ECP was available over the counter.4 In addition, under half (45%) thought it was safe for the health of women, most (61%) erroneously believed that it would damage a pre-existing pregnancy, and 32% that it was an abortifacient, similar to mifepristone — all findings consistent with overseas studies.5,6 Women’s attitudes towards the ECP revealed various views and beliefs influencing their use, including moral and religious reasons, fear of side effects, and unrealistically low perceptions of pregnancy risk.4 Unsurprisingly, women with good knowledge of the ECP were more likely to report having used it. Some women (12%) thought they were unlikely to become pregnant, even when having unprotected intercourse at the most fertile time of the menstrual cycle.4 Although our linked study found that pharmacists believe further information provision following ECP dispensing is their responsibility,7 most women (84%) prefer to receive information from a doctor rather than a pharmacist.4 This offers an important opportunity for GPs to help patients prevent unintended pregnancy and abortion. GPs could include discussion of the ECP in all general consultations with women of reproductive age regarding contraception or reproductive issues, such as cervical cancer screening. Ideally, GPs should seek opportunities to discuss the ECP within an overall contraceptive strategy and with all female adolescents during routine health care visits. GPs can play a critical role in informing and educating women about their risks of becoming pregnant, the use of contraceptives generally and how to use them correctly and consistently. They can also counsel about risky sexual behaviour and the higher risk of an unplanned pregnancy resulting from such behaviour. They could encourage women to keep an advance supply of the ECP at home, if appropriate. Access to such ECP options would be more widely available if it were to be subsidised or free for women who are socioeconomically disadvantaged (eg, health care card holders). As well as the prevention of unplanned pregnancy, assistance with pregnancy termination may be necessary and should always be available if women are unable to continue with a pregnancy. There are parts of Australia where sex education is inadequate, access to contraceptive advice or support is lacking, and hospitals do not provide pregnancy termination services. This can lead to problematically late presentations for abortion.8 In Australia, the removal of the requirement for ministerial approval for the importation and supply of mifepristone means that doctors can now apply to the Therapeutic Goods Administration for approval to provide this drug to their patients for medical termination of pregnancy. Mifepristone is widely used in many countries, including the United Kingdom, the United States, France, New Zealand, Sweden and China and has been shown to be a safe, effective and highly successful treatment for the termination of early pregnancy.9,10 Already, women are being offered greater options when making the decision about an unintended pregnancy — they can choose to continue with the pregnancy, to place the baby for adoption, or if they opt for termination, a limited number of clinics, such as Marie Stopes International Australia,11 are now able to provide medical termination with mifepristone as an alternative to referral for surgical abortion. This option could, and probably should, be more widely available, but a greater emphasis on prevention is clearly needed. At the very least, a sustained public information campaign should address the misconceptions we have uncovered, and publicise the availability of effective contraceptive options. At most, a more comprehensive national sexual and reproductive health strategy should be implemented.

Angela J Taft MPH, PhD · Melissa K Hobbs MPH, PhD · Safeera Y Hussainy BPharmSci, PhD · Lisa H Amir MB BS, PhD · Kay Stewart BPharmSci, PhD · Anthony M A Smith BA(Hons), PhD · Julia M Shelley MPH, PhD · Colin B Chapman BPharmSci, BVSci, PhD

To the Editor: In their article on the decline of infectious syphilis in the Australian Indigenous population from 2005 to 2009,1 Ward and colleagues conclude that it “might be the right time to move toward the elimination of infectious syphilis from remote Indigenous communities”. They note that another previously endemic sexually transmitted infection, donovanosis, has almost completely disappeared from Australia as a result of an elimination program.2 I strongly support their call to action and believe that syphilis can, and should, be next. It is likely that, outside of the small number of communities who have been able to implement a coordinated screening program, the decrease in syphilis in remote areas is an unintended benefit of the use of azithromycin for genital chlamydia and trachoma, and amoxicillin for gonorrhoea. Syphilis is only transmissible to sexual partners for a few weeks during the primary phase (when a chancre is present) and during the secondary phase (when mucocutaneous lesions may be present). Although syphilis is highly infectious during these stages, the relatively short duration of infectiousness partly explains why it is less common than other bacterial sexually transmitted infections. Because the painless ulceration of syphilis is easily ignored by men, or may go unnoticed by women with genital lesions, the diagnosis and treatment of latent (ie, subclinical) disease has been the main focus of syphilis control in remote areas. This approach has had only a limited effect on reducing the incidence of infectious syphilis. Indeed, as latent disease detection and treatment improves, there may be a paradoxical increase in the incidence of infectious cases because latently infected individuals become susceptible to new infection again after treatment.3 Therefore, detection and treatment of all cases of early, infectious syphilis must be the aim of an elimination program, but it will be extremely difficult to achieve this in a remote or rural setting using current diagnostic strategies that almost exclusively rely on serological testing. Serology is still the mainstay of syphilis diagnosis, despite the development of sensitive and specific polymerase chain reaction (PCR) tests for Treponema pallidum. Multiplex PCR tests that can also detect herpes simplex and donovanosis have been used to diagnose genital ulcerative disease in remote areas of Australia,4 but not to screen asymptomatic individuals. The validation of a syphilis PCR test that can be used to identify early, infectious syphilis should be a research priority — one that could be carried out as part of an Australian Government-funded, centrally coordinated but locally implemented, targeted syphilis elimination program.

Francis J Bowden

New data from the Health in Men Study raise questions about the role of testosterone supplementation in ageing men Ageing of the “baby boomer” generation foreshadows a future shaped by demographic change, with increasing numbers of older Australians. The large, longitudinal Western Australian Health in Men Study (HIMS) is therefore timely, as it examines the endocrinology of male ageing and predictors of health in community-dwelling older men.1,2 As part of HIMS, my colleagues and I surveyed 3274 men aged 75–95 years in 2008–2009 using a questionnaire that included items on sexual activity.3 Of 2930 men who reported on the importance they attached to sex, 48.8% considered it important, and of the 2783 men who provided data on sexual activity, 30.8% had at least one sexual encounter (defined as any mutually voluntary activity with another person that involves sexual contact, whether or not intercourse or orgasm occurs4) in the previous 12 months.3 Of these older sexually active men, 56.5% were satisfied with the frequency of sex, while 43.0% would have preferred sex more frequently.3 These findings indicate that many older Australian men consider sexual activity important and desirable. In HIMS, factors that predicted reduced sexual activity were increasing age, osteoporosis, prostate cancer, diabetes, antidepressant use, β-blocker use, and partner’s lack of interest or physical limitations.3 Living with a partner and having a non-English-speaking background were associated with increased sexual activity. Interestingly, a 1 SD increase in testosterone level, measured in blood samples collected in 2001–2004, was associated with a 20% increased likelihood of being sexually active in 2008–2009. Therefore, while older men with lower testosterone levels are likely to report symptoms such as reduced frequency of sexual thoughts and erectile difficulties,5 higher testosterone levels predict sexual activity several years into the future. This raises the question of whether giving exogenous testosterone to induce a comparable increase in circulating total testosterone levels (+ 5.6 nmol/L) would increase the frequency of sexual activity for older men. Epidemiological studies such as HIMS show that men with testosterone levels in the low-normal range have poorer health outcomes; for example, those with testosterone levels in the lowest quartile (< 11.7 nmol/L) have increased risk of stroke or transient ischaemic attack.6 Lower testosterone levels are associated with mortality in older men.7 Studies of testosterone therapy in older men show favourable effects on body composition, with increased lean mass and bone mineral density and, to an extent, improved muscle strength.8 However, there is no evidence as yet that testosterone therapy reduces cardiovascular events or mortality, or that it increases sexual activity in older men. In fact, administering higher doses of testosterone to older men with limited mobility might result in an excess of adverse cardiovascular events.9 More data are needed to help design optimal studies to clarify the role of testosterone supplementation in ageing men. In HIMS, the mean serum total testosterone level in 3638 men aged 70–89 years was 15.4 nmol/L (reference range, 8–35 nmol/L), and only a minority would have been classified as having unequivocally low testosterone levels.1 Uncertainty remains around the extent to which lower testosterone levels reflect underlying comorbidity; appropriate testosterone thresholds for the diagnosis of androgen deficiency in older men; and effects of testosterone therapy on cardiovascular risk.8 The current Testosterone Trial (ClinicalTrials.gov identifier NCT00799617) in the United States, due for completion in 2015, is recruiting older men with lower testosterone levels and will examine the effect of transdermal testosterone gel on end points of walking speed, sexual activity, vitality, memory and anaemia correction. So while the question of whether testosterone therapy might protect against cardiovascular events remains unresolved, its impact on sexual activity in the setting of a randomised controlled trial might not be known for another 4 years. Under these circumstances, the clinical approach to ageing men with symptoms of testosterone deficiency must be prudent, taking both known risks and potential benefits into account.8 Testosterone supplementation could be considered in men who are clearly hypogonadal. Symptoms of androgen deficiency should be assessed, and the diagnosis based on at least two unequivocally low early-morning testosterone levels, preferably assayed using a mass spectrometry-based methodology.10 Men should be counselled as to the risks and benefits of testosterone therapy, and treatment should be accompanied by safety monitoring, including prostate evaluation and monitoring of prostate-specific antigen levels and haematocrit. The anticipated effect of testosterone therapy would be to increase libido, and this should be included in the discussion of benefit and risk. While higher testosterone levels are associated with sexual activity in older men, non-hormonal factors are also important. HIMS found that increasing age predicted declining sexual activity; after adjusting for this and other covariates, men were four times more likely to be sexually active if they were living with a partner.3 Conversely, they were much less likely to be sexually active if their partner lacked interest in sex or had physical limitations. Medical comorbidities including diabetes and use of antidepressants were also associated with reduced likelihood of being sexually active. Therefore, social and medical factors are key determinants of whether ageing men remain sexually active. The increasing numbers of men transitioning from middle to older age should be encouraged to maintain their personal health and the health of their relationships to maximise their chances of having sex in future years.

Bu B Yeap MB BS, FRACP, PhD

In recent years, lymphogranuloma venereum, which is caused by C. trachomatis serotypes L1–L3, has emerged as a problem among men who have sex with men (MSM). Cases of LGV have been reported among MSM in the United States, United Kingdom, Europe and Australia, and have been overrepresented among HIV-positive MSM.1,2 In contrast to infections seen in developing areas where LGV remains endemic, the more recent reports among MSM in Western countries have been characterised by a predominance of proctitis cases, with fewer genital or inguinal presentations.1-3 Furthermore, nearly all recent cases have involved a clonal strain of the C. trachomatis L2b serovar.4 Genital LGV infections are commonly heralded by transient genital ulceration, followed by lymphatic spread and the development of local lymphadenopathy. A transient genital ulcer reported by Patient 2 had resolved before the development of the bubo. LGV infections causing ulceration and proctitis are readily detected using commercially available C. trachomatis nucleic acid amplification assays such as PCR or SDA. However, for LGV to be confirmed microbiologically, further genotyping is required to identify C. trachomatis serovars L1–L3, as distinct from the more common non-LGV-associated serovars D–K. This requires awareness on the part of the clinician, as LGV genotyping is only available from reference laboratories in most countries. In a symptomatic patient with a positive C. trachomatis nucleic acid amplification assay result, the clinician must specifically request referral of the original specimen or DNA extract for further testing, potentially delaying the final diagnosis. Newer amplification assays that can directly detect C. trachomatis serovars from clinical specimens are under development, but none are commercially available and they may not be cost-effective for routine diagnostic use in most settings.5 C. trachomatis serological testing can sometimes be useful for diagnosing LGV when there is no obvious lesion for sampling by PCR. However, a positive serological result does not discriminate between LGV and non-LGV chlamydial infections.6 In a recent study among MSM in Melbourne, 7% (21/292) of chlamydial rectal infections were associated with the L2 or L2b serovar.7 The distinction between LGV and non-LGV chlamydial infection of the rectum is potentially important, as a single 1 g dose of azithromycin is commonly used for non-LGV chlamydial infection, while more prolonged treatment — usually a 3-week course of doxycycline — is recommended for LGV.8-10 The extent to which inadequate treatment might be contributing to further transmission of LGV between men is not known. The diagnosis of LGV should be considered in MSM with proctitis, anogenital ulcers or inguinal buboes, particularly in HIV-positive men. If LGV genotyping is not readily available, an alternative approach would be to treat such men with a 3-week course of doxycycline or to perform a test-of-cure to ensure that the treatment has cured the patient of LGV. Clinical records An HIV-positive man (Patient 1) presented with a 4-day history of a painful anal ulcer (Figure, A), which was associated with a small, tender left-sided inguinal lymph node. He was not taking antiretroviral therapy and had a CD4 cell count of 648 cells/μL and an HIV viral load of 25 500 copies/mL. The man’s male sexual partner (Patient 2), also HIV-positive, presented on the same day with a lump in the left inguinal region (Figure, B). He was taking antiretroviral treatment and had a CD4 cell count of 494 cells/μL, with an undetectable HIV viral load (< 50 copies/mL). The lump had been present for 4 weeks and had enlarged despite treatment with amoxycillin followed by flucloxacillin given at a hospital emergency department. Two weeks before the lump appeared, the patient reported that there had been a sore on the penis but this had resolved before the lump developed. The inguinal lump had overlying erythema and was slightly fluctuant. Given these men were sexual partners, the diagnosis most likely to explain the presence of an inguinal bubo in one partner and anal ulceration in the other was lymphogranuloma venereum (LGV). Both men were treated with oral doxycycline 100 mg twice daily for 3 weeks. Patient 1 was reviewed 1 week later, by which time the anal ulcer had begun to resolve and a swab taken from the ulcer at the previous visit had tested positive for Chlamydia trachomatis by strand displacement amplification (SDA) assay and negative for herpes simplex virus and Treponema pallidum by polymerase chain reaction (PCR) assay. In both men, serological tests for syphilis returned negative results, and white cell counts were normal. Despite the doxycycline therapy, Patient 2’s bubo had enlarged further when examined 3 weeks later, with increased swelling, erythema and fluctuance. A hollow-bore needle was used to aspirate 5 mL of milky pus from the bubo. Light microscopy of the Gram-stained aspirate showed few polymorphs, and no bacteria, parasites or fungi. No acid-fast bacilli were seen on Ziehl–Neelsen staining, and bacterial culture showed no growth. The aspirate tested positive for C. trachomatis and negative for T. pallidum and Neisseria gonorrhoeae by PCR assay. Cytological examination of the aspirate showed acute inflammation, with no organisms identified. Despite the initial aspiration and continued therapy with doxycycline, the bubo reformed and then spontaneously discharged 2 days later, leaving a sinus (Figure, C). Genotyping of the chlamydia isolates from the anal ulcer and the bubo aspirate confirmed the presence of C. trachomatis serovar L2b in each patient. Both men also tested positive for C. trachomatis IgG and IgA by enzyme immunoassay.

Marcus Y Chen FRCP, PhD, MRACP · Timothy R H Read MB ChB, FACHSM · David E Leslie MB BS, FRACP · Melanie Bissessor MB ChB