Transcript Evaluation & Treatment of Sexually Transmitted Diseases

Evaluation & Treatment of
Sexually Transmitted Diseases
Anthony Dekker, D.O., Associate Director
Phoenix Indian Medical Center
Director of Ambulatory Care and Community Health
Phoenix, Arizona
I. Introduction
A. STDs are the most common reported infectious
disease in adolescents.
B. STDs can have serious medical consequences for
the adolescent male/female.
C. By age 19 years, > 75% of adolescents report sexual
debut.
D. 50% of sexually active youth will experience an STD
by the end of their 18th year.
E. PID is the second most common hospital admission
diagnosis for youth.
II. Risk Factors
A. Host dependent (sexual behavior, race, gender,
ethnicity, contraceptive method, substance use,
therapeutic compliance)
B. STD pathogen (cervical biological factors,
resistant organisms)
HEADSSS History
Home environment
 Education or Occupational Issues
 Activities and Associates
 Drugs, Tobacco and Alcohol; Diet
 Sexuality Issues
 Suicide and Depression Issues
 Savagery and Victimization

Osteopathic Issues
Holistic Diagnosis and Care
 The Body’s Ability to Heal Itself
 Viscero-somatic Reflex
 Somato-visceral Response
 Concomitant Issues

III. Clinical Syndromes
A. Vaginitis
1. Symptoms: Abnormal vaginal discharge, perineal
pruritus, genital rash (or ulcer, wart, skin lesion),
dysuria, urgency, frequency, dyspareunia.
2. Trichomonas vaginalis
a. Flagellate protozoan
b. Malodorous greenish/yellow/gray
vaginal discharge.
c. May be asymptomatic
III. Clinical Syndromes cont...
d. Syndromes: Vaginitis, cervicitis
e. Vaginal pH>4.5
f. (+) trichomonads wet mount, pap smear or
culture.
G. Resistance to metronidazole has been reported
TREATMENT: Metronidazole 2 gm po X 1 dose
(non-pregnant women) or 250 mg po TID X one
week or 375 or 500 mg. po BID X 7 days.
III. Clinical Syndromes cont...
3.
Bacterial vaginosis (Gardnerella vaginalis, nonspecific
vaginitis)
a.
Pathogenic bacteria in vaginal flora
(Gardnerella, Lactobacilli)
b.
Malodorous vaginal discharge
c.
“Vaginosis”
d.
Criteria (3/4): Vaginal discharge, pH>4.5 (+)
whiff test, Clue cells
e.
Risk of Premature Rupture of the Amnionic Sac
Treatment: Metronidazole 500 mg po bid x 7 days,
Metronidazole Gel 0.5\75% bid per vagina x 5 days, or
Clindamycin cream 2% 5 gm intravaginally x 7 days
III. Clinical Syndromes cont...
4.
Vulvovaginal candidiasis (Candida albicans or other
Candida spp.)
a.
Symptoms: Pruritus, vaginal discharge (white,
“cottage cheese”); also vaginal soreness, vulvar
burning, dysuria, dyspareunia.
b.
Diagnosis: Clinical (vulvar and/or vaginal
erythema with classic discharge); wet
preparation (KOH 20%) of vaginal discharge
with hyphae and buds; positive culture for
yeast
III. Clinical Syndromes cont...
c.
d.
Usually not sexually transmitted; may be
concurrent with other STDs
Recurrent VVC (>=3 episodes annually):
affects <5% women; partner therapy is not
routinely prescribed.
Treatment:
Butoconazole 2% cream (Femstat) 5 gm intravaginally x 3 days.
Clotrimazole 1% cream (Gyne-lotrimin) 5 gm x 7 days.
Miconazole 200 mg vaginal supp. (Monistat) 1 supp. x 3 days.
Terconazole 0.8% cream (Terazol) 5 gm x 3 days.
Fluconazole 150 mg tablet (Diflucan) 1 tab po x 1 dose.
III. Clinical Syndromes cont...
B. Cervicitis
1. Symptoms: Vaginitis symptoms, abdominal or pelvic
pain, irregular or painful vaginal bleeding,
dysmenorrhea.
2. Diagnostic criteria
a.
Endocervicitis, cervical friability, erythema,
mucopurulent discharge.
b.
Positive cervical culture, antigen detection test
or gram stain (less accurate).
c.
Greater than or equal to 10 PMN/hpf.
III. Clinical Syndromes cont...
3.
Chlamydia trachomatis
a.
Bacterium
b.
Syndromes: cervicitis, PID
c.
Cervicitis or PID symptoms; may be
asymptomatic
d.
Endocervicitis, mucopus, friability/erythema, >
10 - 30 PMN/hpf
e.
(+) culture or antigen detection test
Treatment:
Azithromycin 1.0 gm po x 1 dose
Doxycycline 100 mg po BID x 7 days OR
III. Clinical Syndromes cont...
4.
Neisseria gonorrhoeae
a.
Bacterium (gram-negative diplococci in pairs)
b.
Syndromes: Same as C. trachomatis
c.
Cervicitis or PID symptoms; mucopurulent
vaginal d/c; asymptomatic
d.
Diagnosis: Same as C. trachomatis
Treatment:
Ceftriaxone 125 mg IM x 1 dose or Cefixime 400 mg po x
1 dose of Ofloxacin 400 mg po x 1 dose or Ciprofloxin 500
mg X one dose
III. Clinical Syndromes cont...
5. New diagnostic tests: Ligase Chain Reaction (LCR);
Test of cure
6.
Partner evaluation and treatment
7.
Condom education
III. Clinical Syndromes cont...
C. Pelvic Inflammatory Disease (PID)
1. Introduction
a.
Increased risk for adolescent females (biology,
contraceptive method)
b.
Ascending infection involving uterus, fallopian
tubes, ovaries, peritoneal tissues.
c.
Polymicrobial syndrome (N. gonorrhoeae, C.
trachomatis, and nonchlamydial
aerobes and anaerobes) nongonococcal
III. Clinical Syndromes cont...
2.
Diagnostic criteria
a.
All three of the following:
1.
Lower abdominal tenderness
2.
Cervical motion tenderness
3.
Adnexal tenderness
b.
One of the following should be present:
1.
Temperature > 38.3 C
2.
Elevate WBC (>=10,500/MM3)
3.
Elevated ESR
4.
Inflammatory mass by bimanual exam or
sonogram
III. Clinical Syndromes cont...
5.
3.
Evidence of N. gonorrhoeae and/or C.
trachomatis in the endocervix.
6.
Laparoscopic abnormalities consistent
with PID.
Treatment: Inpatient managment recommended for all
adolescents.
a.
Regimen A:
1.
Cefoxitin 2 g IV q 6 h or Cefotetan 2 g IV
q 12 h PLUS Doxycycline 100 mg PO or
V q 12h
2.
Follow with Doxycycline 100 mg PO bid
to complete 14 days of therapy.
III. Clinical Syndromes cont...
b.
Regimen b:
1.
Clindamycin 900 mg IV q 8h PLUS
Gentamicin 2 mg/kg loading dose IV or
IM followed by a maintenance does of
1.5 mg/ks q 8h (normal renal function)
2.
Follow with Doxycycline 100 mg PO bid
or Clindamycin 450 mg PO QID to
complete 14 days of therapy.
3.
For Tubo-Ovarian abscess, Clindamycin
offers better anaerobic coverage than
Doxycycline regimen.
III. Clinical Syndromes cont...
4.
Sequelae
a.
Perihepatitis, tubo-ovarian abscess, Fitz-HughCurtis Syndrome.
b.
Chronic pelvic pain, tubal scarring, ectopic
pregnancy, and infertility.
D. Urethritis
1. Symptoms: Dysuria, urinary frequency or urgency,
urethral discharge, meatal edema or erythema,
asymptomatic
2. Gonococcal and nongonococcal (C. trachomatis,
Ureaplasma urealyticum, T. vaginalis)
III. Clinical Syndromes cont...
3.
4.
5.
Diagnosis
Treatment
Sequelae
a.
Epididymitis (approx. 3% NGU cases)
b.
Consequences for female partner
E. Epididymitis
1. Etiology:
a.
Age < 35 years: N. gonorrhoeae and C.
trachomatis
b.
Non-sexually transmitted, associated with UTIs,
age > 35 years: Gram-negative enteric bacteria
(E. coli spp.)
III. Clinical Syndromes cont...
2.
3.
Symptoms: Unilateral testicular pain and tenderness,
epididymal swelling. Must rule out testicular torsion
diagnosis.
Diagnosis: Urethral exudate and and intraurethral
cultures for N. gonorrhoeae and C. trachomatis.
Treatment:
Ceftriaxone 250 mg IM x 1 dose, AND Doxycycline 100 mg
po BID x 10 days.
Alternative regimen: Ofloxacin 300 mg po BID x 10 days (in
patients > 17 years old) or Azithromycin 2 grams po X 1.
III. Clinical Syndromes cont...
4.
5.
6.
Bed rest, scrotal elevation
Follow up:
a.
Failure to improve within three days of therapy
requires re-evaluation.
b.
Swelling and tenderness post treatment
mandates evalution to rule out testicular cancer,
fungal or tuberculous epididymitis.
Partner evaluation and treatment
III. Clinical Syndromes cont...
F.
Genital Ulcers
1.
Diagnosis: Careful genital exam.
2.
Etiologies: Herpes Simplex Virus, T. pallidum
(syphilis); less common: chancroid (H. ducrey),
lymphogranuloma venereum (C. trachomatis)
G. Herpes Simplex Virus (HSV-1, HSV-2)
1.
Etiology: Most genital herpes cases by HSV-2
2.
Symptoms: Dysuria, dysparenunia, vulvar
irritation, vesicles, or asymptomatic.
3.
Diagnosis: Clinical presentation (grouped
vesicles, tender to palpation, inguinal
adenopathy); viral culture for ulcer base.
4.
Counseling; partner evaluation
5.
Viral shedding
Treatment: Institute within 72 hours of outbreak
or prodrome.
 First episode of Genital Herpes:

• Acyclovir 200 mg po 5 times daily for 7-10 days or
until clinical resolution.
Recurrent episodes:
Acyclovir 200 mg po 5 times a day for 5 days,
OR
Acyclovir 400 mg po 3 times a day for 5 days,
OR
Acyclovir 800 mg po 2 times a day for 5 days.
Valcyclovir, two 500 mg q 8 hours for seven days for
Herpes Zoster. For recurrent HSV infection, 500 mg.
b.i.d. for five days. For long term suppressive therapy
500 mg daily.
Famciclovir, 500 mg. t.i.d. x 7 days for Herpes Zoster.
For recurrent HSV infections, 500 mg. t.i.d. x 5 days.
For acute HSV infection (investigational for HSV)
This is not to be used in immunocompromised
patients.
Frequent Episodes
Daily suppressive therapy: Acyclovir 400 mp po 2
times a day; reassess rate of recurrences after on
year of therapy.
III. Clinical Syndromes cont...
H. Syphilis (treponema pallidum, motile spirochete)
1. Clinical: acquired infection
a.
Three stages
1.
Primary: Chancre (painless, indurated
ulcer) at inoculation site.
2.
Secondary: Polymorphic maculopapular
rash, involved palms and soles. System
symptoms and condyloma lata lesions
around vulva or anus, can occur.
3.
Tertiary: Commonly > 15 years after
primary infection; aortitis, neurosyphilis,
gummatous lesions.
III. Clinical Syndromes cont...
2.
3.
Epidemiology
a.
Worldwide; most frequent in urban areas
b.
Incidence: Dramatic increase past 10 years
(adolescents, HIV infected adults)
c.
Sexual contact
d.
Incubation period: 10-90 days post exposure (3
weeks typical)
Diagnostic testing
a.
Nontreponemal tests (VDRL, RPR)
1.
Confirmation with treponemal test
2.
Four-fold decrease titer with antibiotics =
> adequate therapy.
3.
Usually non-reactive 1 year after therapy
(primary syphilis)
III. Clinical Syndromes cont...
b.
4.
5.
6.
Treponemal tests (fluorescent treponemal ab
absorption, FTA-ABS, microhemagglutination test for
T. pallidum, MHA-TP
Therapy: Primary and secondary syphilis
a.
Benzathin penicillin G 2.4 million units 1M x 1 dose
b.
PCN allergic patients:
Doxycycline 100 mg po BID x 2 weeks, OR
Tetracycline 500 mg po QID x 2 weeks
Therapy: Late latent syphilis (or of unknown duration)
a.
Benzathine PCN G 2.4 million units IM weekly
x 3 doses total total
Follow-up
a.
Quantitative nontreponemal serology at 6 &12 mos
III. Clinical Syndromes cont...
I. Genital Warts/Human Papillomavirus (HPV)
1. Diagnosis: Careful genital exam (may need to apply
3% acetic acid to enhance SCL), abnormal Pap smear.
2. Pruritus, pain, dyspareunia, palpation of papule,
asymptomatic.
3. Clinical manifestations: Condyloma acuminatum, low
and high grade SIL
4. Association with anogenital cancers (male & female)
a.
HPV types 16, 18, 31, 33, 35
5. Management
HPV Therapies
Chemical Cauterization with BCA, TCA,
Podophyllin applied by Provider
 Self administered Podophylox
 Cryotherapy
 Surgical excision or desication
 Laser vaporization
 Interfuron Injection
 Immune Response Modification
 Observation

Immune Response Modifier
Imiquimod cream 5%
 Aldara from 3M
 physician applied for first therapy
 only for external warts
 apply three times per week
 wash hand, no sex and leave on for 6 to
10 hours
 revisits monthly

Imiquimod Therapy
Inflammatory Issues
 Cost Factors
 Patient Selection
 Partner Evaluation
 Pre-treatment of Keritinized Warts
 Off Label Uses
 Future Research, Cervical Dysplasia,
HSV

III. Clinical Syndromes cont...
J. Other
1. HIV/AIDS
2. Proctitis
3. Pharyngitis
V. STD Assessment
A. Legal Issues: Confidentiality of care
B. Evaluation
1.
Skilled interview
2.
Physical examination
3.
Laboratory tests
III. Clinical Syndromes cont...
a.
Culture, serology, direct fluorescent
antibody (DFA) test, enzyme,
immunoassay (EIA), gene probe,
polymerase and ligase chain reaction.
b.
Asymptomatic males: First-void urine
specimen (leukocyte esterase or pyuria)
C. Treatment: CDC Guidelines
D. Prevention:
1. Primary: Prior to sexual debut; focuses on delay of
initiation of sexual activity.
2. Secondary: Vulnerable adolescent; goal is to prevent
the adolescent from acquiring at STD (condom
education, periodic STD screening, partner
evaluation/treatment)
III. Clinical Syndromes cont...
3.
Tertiary: Focuses on the adolescent who has
experienced an STD; includes risk assessment
(substance use, sexual practices, contraceptive
method)
4.
Participation by clinicians, teachers, communities, and
adolescents to promote safe sexual behavior.