Prompt diagnosis and treatment is imperative to reduce onward transmission of sexually transmitted infections (STIs) by shortening the natural period of infectivity. Approximately one-third of patients attending genitourinary medicine (GUM) clinics have initially contacted primary care about their complaint.1^–3 These patients have been shown to have a longer duration of genital symptoms than patients accessing GUM directly and this might increase the risk of further STI transmission.1 4 The extent to which patients “fall out” of services between primary care and clinic is unknown and this presents additional potential for ongoing STI transmission.

There is little research into which patients contact primary care initially with STI related issues, the extent of care they receive prior to attendance at GUM and the impact this may have on both the individual patient and broader public health.

We aimed to explore engagement with primary care prior to clinic attendance in a GUM population and assess the degree of advice/care that they receive there.

METHODS

A cross-sectional survey was undertaken of 1000 new patients attending both booked and drop-in GUM clinics from three sites in Cornwall between June and December 2006. Information from the patient was recorded by the consulting GUM doctor or specialist nurse on a data collection sheet on whether they had contacted primary care about their presenting complaint and what assessment and management they had received there. This information was linked to the clinical diagnosis given on the day in the GUM clinic after microscopy and, if applicable, urinalysis, and with demographical information.

In circumstances where the GUM clinician had recorded “not applicable” or “don’t know” this information was excluded from the analysis. A χ2 test was used to calculate p values.

RESULTS

See table 1. Altogether, 368/1000 (37%) patients had contacted primary care prior to attending GUM and 348 had been seen in primary care. The initial point of contact for patients with genital warts was more likely to be primary care (94/163 (58%), p = 0.05), whereas patients with urethritis were more likely to have attended GUM directly (93/133 (70%), p<0.005). Patients aged 25 years and over were significantly more likely to have contacted primary care (203/483 (42%)) than those aged under 25 years (165/517 (32%); p<0.005). There was no difference between male and female patients.

A total of 176/290 (61%) patients were given a diagnosis in primary care of which 36/176 (20%) had not undergone genital examination, 124/156 (79%) had not been tested for chlamydia and 133/161 (83%) had not had any other investigation. In 60/164 (37%) patients, the diagnosis was different from that given by the GUM healthcare professional. Altogether 100/301 (33%) patients had been offered treatment of which 34/100 (34%) had not undergone genital examination, 52/83 (63%) had not been tested for chlamydia and 57/89 (64%) had not had any other investigation.

Ninety-two patients had attended primary care with genital warts before coming to GUM services. Of these, 80 (87%) had been examined, 68 (74%) had been correctly diagnosed and 8 (9%) offered treatment.

A total of 45/346 (13%) patients attended GUM without being advised to do so in primary care.

DISCUSSION

Over one-third of patients seen in the GUM clinic had contacted primary care before attending—a proportion similar to that seen in more urban settings.1 2 The majority of these patients, including those given a diagnosis and/or offered treatment in primary care, had not had a chlamydia test or any other investigations during the primary care consultation. With the potential “fall out” of patients between primary care and GUM, this may represent a missed opportunity to detect and appropriately manage STIs. Male patients were significantly less likely to have a chlamydia test despite this being a non-invasive test in men. The reasons for this are unclear, although similar findings have been reported elsewhere.5 6

Genital warts can be diagnosed on clinical examination without requiring further investigation to establish the diagnosis prior to treatment. The majority of patients with genital warts had been correctly diagnosed in primary care but only a small proportion offered treatment. If primary care practitioners could be encouraged to manage uncomplicated genital warts this could substantially decrease the burden on GUM services;7 however, the question of whether all patients with genital warts require a full STI screen is controversial.8

This study does not include those patients seen and treated solely in primary care. We need further studies in primary care settings on patients who present there with STI-related concerns, the care they receive and the proportion referred to GUM. This would provide a clearer understanding of present STI service provision and guide future training and service planning.