Transcript Sexually Transmitted Diseases

Farah Chouhdry
ST1 GP
SEXUALLY TRANSMITTED
DISEASES
Sexually Transmitted Diseases
 bacterial infections
 viral infections
 fungal infections
 protozoal infections
 parasitic infestation
Lumps & Ulcers
BACTERIAL
VIRAL
Chancroid
Warts
Scabies
Granuloma
inguinale
Molluscum
contagiosum
Pubic Lice
Lymphogranul Herpes
oma
venereum
Syphilis
AIDS
FUNGAL
PROTOZOAL
PARASITIC
GENITAL WARTS
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These are benign tumours of the epidermis induced
by inoculation of specific human papilloma viruses
Most common viral sexually transmitted infection in
the UK
Highest rates of diagnosis are seen in young women
and men under 24 years
The mean incubation period is about 3 months (range
from 3 weeks to 8 months.)
Caused by different strains of human papilloma virus especially HPV types 6 and 11, which cause over 90%
of the genital warts
......Clinical features
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Women: asymptomatic or painful, friable,lesions or pruritis
Men : generally see them
The lesions can be solitary or multiple.
Those on the warm, moist, non-hair bearing areas are
usually soft and non-keratinised,filiform, larger(1-5mm)
Those on the dry hairy skin are firm and keratinised.
Warts start as small flat lesions 1-2 mm in diameter.
The larger warts become pedunculated and may resemble
a cauliflower in appearance.
The growth of the warts is favoured by pregnancy, poor
hygiene and vaginal discharge.
…..HPV and genital cancer
 HPV-DNA is found in 85-100% of high-grade cervical precancer
 infection with HPV type 16 or 18 has been associated with a
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higher rate of progression of cervical squamous intraepithelial
lesions and cancer (1)
one study in 106 early carcinomas found the following serotypes:
HPV 16 -55%
HPV 18- 17%
HPV 33- 6%
HPV 35- 1%
unidentified HPV 10%
No HPV 16% (Favre et al Lancet 1990)
The link between HPV and cervical cancer is strong and
epidemiologically it may be considered to be causal
......Managment
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Cryotherapy or topical application in clinic
Home treatment with podophyllotoxin cream or lotion (Soft non keratinized
warts)
Curettage or surgical removal may be indicated (Keratinized warts).
Imiquimod 5% cream is another treatment option. imiquimod is an immune
response modifier.
the partner should be seen for a check up, and the couple treated at the
same time if necessary
sexual intercourse should be avoided during treatment, though condoms
may protect against transmission
women should not become pregnant during treatment therefore good
contraception is essential
warts grow in warm, moist areas, therefore it may be advisable to wear
loose clothing and underwear
the use of condoms for three months after the disappearance of lesions is
empirical
Topical photodynamic therapy
Genital herpes
 Caused by Herpes simplex virus type 1 & 2
 HSV is spread through skin-to-skin contact or
direct mucocutaneous contact
 The incubation period is 3 days to 2 weeks
after exposure
 Complications occur more often in men, who
also suffer more with symptoms.
 Recurrent attacks are common
...Clinical Features
Local symptoms on day 0, after incubation:
 itch and tingling ,redness ,vesicle formation,
By day 8 or 9:
 pustule developing into a wet ulcer ,dysuria - ulcers are
exquisitely painful, and retention of urine may result
 vaginal / urethral discharge ,inguinal lymphadenopathy
 HSV pharyngitis in 10% of oral cases
Systemic features:
 headache ,myalgia ,general malaise ,urinary retention,
constipation
From day 10:
 healing with crusting, complete by day 14
 may get a second crop
....Diagnosis
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History and examination.
The gold standard is viral culture.
Other diagnostic methods :
polymerase chain reaction testing,
Antibody-based tests,(Western blot assay –
gold standard)
 (type-specific glycoprotein G serologic test )
...Complications
 Local extension
 Extragenital spread - buttocks, fingers or eye
 CNS:
 aseptic meningitis, much more common with HSV II,
occurring in perhaps 20% of patients, 5% needing
hospitalisation
 autonomic dysfunction - hyperaesthesia, anaesthesia,
difficulty in micturition and defaecation
 Rare complications:
 erythema multiforme ,monoarthritis ,hepatitis,
 thrombocytopaenia ,spread to preexisting lesions
 10% of lesions become superinfected with bacteria
or candida
...Managment
 symptomatic:
 analgesia ,saline baths
 acyclovir, 200mgs, 5 times a day for 5 days – (alternatives:
famciclovir and valaciclovir .
 Recurrent episodes may require continous acyclovir
 primary or first-episode genital herpes is managed via
referral to the genitourinary medicine clinic
 interventions to prevent sexual transmission of herpes
simplex virus
 male condom use to prevent sexual transmission from infected
men to uninfected sexual partners
 antiviral treatment of infected sexual partner (reduced
transmission to uninfected partner) - seek genitourinary medicine
specialist advice
Crabs or Pubic Lice
 The pubic louse is Phthirius pubis, the mature
form of which is transferred during close body
contact for example, sexual contact.
 The major symptom is pruritus in the genital
region especially in pubic hair. Examination may
show the crab shaped adult louse which is
brownish coloured and about 2 mm in diameter,
or their ova - nits - which are a shiny white and
the size of a pin head.
 Diagnosis is made on the basis of the history and
clinical examination
....Treatment
 infestation needs to be confirmed by the
detection of live lice/viable eggs
 most common in young adults, as it is often acquired
during sexual contact. It is important to establish
whether pubic lice have been acquired in this way or
not, as there may be a need to refer the individual to a
genitourinary medicine clinic for screening for sexually
transmitted infections
 contact tracing over the previous 3 months is
recommended
 aqueous malathion 0.5% liquid or permethrin 5%
dermal cream are recommended for application to the
entire body and should be repeated after 7 days.
SCABIES
 scabies is common and is pandemic
 common in women than in men
 common in winter than summer
 risk of transfer of infestation via towels, bedding,
clothing, upholstery used by patients with typical
symptoms of scabies
...Transmission
 direct (skin-to-skin contact) - the main route of
transmission
 indirect (via infested clothing, bedding) - indirect
transmission can be seen in crusted scabies but it rarely
occurs in classic scabies
 transmission in institutional settings and within family
members is common
 sexual transmission is possible
Clinical Features
 Presenting lesions in scabies are papules, vesicles, pustules, and
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nodules.
Greyish white linear burrows may be seen on the finger webs,
sides of the fingers, wrists, elbows, anterior axillary fold,
periumbilical area, and areolae,
buttocks and male genitalia - firm, red papules.
severe , persistent itching, worse at night and following bathing,
is frequently the initial complaint - this indicates that
hypersensitivity has developed and may antedate infection by
several weeks - often, there is a widespread rash with many small
papules,
but there may be excoriation, dermatitis, and secondary
infection with vesicles and pustules
Diagnosis
 extraction of mite from the burrow using a
sharp needle
 ink test - to show a burrow
 microscopic examination of skin scrapings
 a skin biopsy may be done to confirm the
diagnosis
Treatment
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permethrin is the drug of choice
malathion should be used as second line
benzyl benzoate
the entire body, except head and neck, must be
treated
 Clothing and bed linen should be washed and all
household and close contacts treated
simultaneously even in the absence of symptoms
MOLLUSCUM CONTAGIOSUM
is a viral skin disease characterised by firm, round,
translucent, multiple, dome shaped, pearly white or flesh
coloured, umbilicated papules of up to 5mm in diameter
containing caseous matter and peculiar capsulated bodies
 It is usually a benign, self limiting viral infection caused by a
DNA virus of pox family
 Spread of the infection is probably through direct skin-toskin contact and lesions may occur in any part of the body
 common childhood eruption specially in children who bathe
together.
 adults presenting to STD clinics where the disease has been
transmitted during sexual contact
 immunodeficient patients e.g. - AIDS
 It has an incubation period that varies from 3 to 12 weeks
Contd
Etiology
 viral infection, often appearing in crops as a result of
self inoculation and person to person contact
 Steroid cream and chapped, damp skin encourages
spread.
 common in the atopic.
Diagnosis
 made on the clinical appearance.
 Otherwise, the contents of a papule can be
expressed, smeared on an slide and stained with
Giemsa
contd
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Differential Diagnosis:
warts ,sebaceous cysts
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Treatment
no specific treatment is required - a self-limiting infection
may resolve spontaneously in 6-9 months (but some cases may persist up to
4 years)
prevention of spread of the disease – hygienic measures
cryotherapy – application of liquid nitrogen to the lesion
expression of the contents of the pearly core (manually or using forceps)
piercing with an orange stick , with or without the application of tincture of
iodine or phenol
curettage or diathermy
itching might be a problem for the patient and may require an emollient and
a mild topical corticosteroid (e.g. hydrocortisone 1%)
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Treatment
(Other options)
 topical 0.5% podophyllotoxin (applied to lesions twice a day for 3
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consecutive days and repeated weekly cycles until the lesions
cleared)
home-applied imiquimod 5% cream
Eczema around the lesion can be treated with emollients, 1%
ichthammol paste or mild topical or mild topical steroid
consider referring adults to genitourinary medicine for infection
screen
Highly active antiretroviral therapy may be necessary in HIV
patients for the resolution of the disease
Criteria for referral to a secondary care facility:
diagnostic uncertainty
extensive, painful, inflamed lesions
immunosuppressed patients
GRANULOMA VENEREUM
 This is a tropically acquired sexually transmitted
disease caused by Calymmatobacterium
granulomatis.
 It is a painless condition
 lesions in the genital and inguinal creases.
 These start as red papules and develop into
granulomatous ulcers.
 Diagnosis : histology of biopsy for typical
Donovan bodies.
 Treatment: Tetracycline.
Sebaceous glands & Penile
papules
 Sebaceous glands and penile papules are often mistaken
for STDs, but they are not sexually transmitted.
 Sebaceous glands are usually attached to hair follicles, but
can also appear on hairless areas of the body, such as the
penis. The glands release a fatty substance called sebum on
to the surface of the skin, which may give the appearance
of a rash.
 Pearly penile papules are often mistaken for genital warts
but are in fact a physical variation found in many men.
 Papules appear around the head of the penis as small,
dome-shaped bumps, which may be skin-coloured.
SYPHILIS
 sexually transmitted disease which is characterised by:
 minor early illness
 more serious late manifestations after a variable latent
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period
The infective agent is a spirochaete, treponema pallidum.
Clinically there are four types of syphilis:
primary
secondary
tertiary
congenital
Diagnosis
 Diagnostic procedures include:
 dark ground microscopy - detection of spirochaete in
primary and secondary syphilis
 serology - detection of anti-treponemal antibodies with:
 non-specific antigen - cardiolipin used in the Venereal Disease
Reference Laboratory (VDRL) test. This is not specific for
Treponemes but is useful to assess the efficacy of treatment of
proven syphilis - it will revert to negative once Treponema
eliminated
 specific treponemal antigens:
 TPHA } remain positive life-long and
 FTA-ABS } specific to Treponema pallidum
 lumbar puncture may be indicated to exclude neurosyphilis
Treatment (Syphilis)
 Treatment of choice for primary syphilis is long-acting
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procaine penicillin 600 mg OD, IMfor 10-12 days.
For CNS disease, secondary and tertiary syphilis, the
treatment regime is for 14 days.
If compliance is in doubt then injections of benzathine
penicillin 2.4 g per week for 2 weeks is an alternative.
If not penicillin sensitive, tetracycline 500 mg p.o. 6-hourly
for 14 days
or doxycyline 100 mg 12-hourly for 14 days may be given.
Follow-up should occur over 2 years to ensure a satisfactory
response.
CHANCROID (Venereal/Soft Sore)
 Tropical sexually transmitted disease caused by Haemophillus
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ducreyi, a gram negative bacterium.
It is endemic in Africa, Asia and South America
common in men, particularly uncircumcised men.
HIV is a very important cofactor, with a 60% association in Africa.
After a one week incubation period a papule develops which
becomes a pustule and then an ulcer, which is characteristically very
painful, more so in men.
Diagnosis is by Gram-stain of exudate, cultured on enriched media serology is unreliable.
50% of cases have a painful adenopathy with development of bubos
- inflamed lymph nodes with pus and necrosis, fixed to the skin.
There is no systemic component
...Contd
 In the absence of treatment, the chancroid
lesion can persist for months to years.
 Treatment is with cotrimoxazole or
erythromycin.
 Control of the infection at the community
level is probably best effected by the
promotion of the use of condoms.
LYMPHO GRANULOMA VENEREUM
is a tropical sexually transmitted disease caused by Chlamydia trachomatis
 Endemic in Africa, India, SE Asia, South America and the Caribbean,
 Men affected more commonly than women, principally between the age
20 to 30 years.
 Three stages to the disease:
 an asymptomatic ulcer which resolves rapidly
 an inguinal syndrome, between 1 week and 6 months later, with
adenopathy (lymph nodes are painful) and bubo development.
 There is often systemic illness and malaise
 regional abscess or fistula, resulting in regional strictures, e.g. rectal
strictures
 Diagnosis is by serology and intradermal skin test with LGV antigen Frei's test.
 Treated with tetracyclines or erythromycin.
HIV (AIDS)
 Syndrome that is based on evidence of human
immunodeficiency virus (HIV) infection and the
development of one or more of a list of opportunistic
infections or malignancies for which there is no other
explanation.
 The most common of the defined diseases accounting for
up to 80% of the defined AIDS cases are Pneumocystis
carinii pneumonia and Kaposi's sarcoma.
 The origin of HIV is unknown. The HIV-1 virus has been
found in blood samples in Africa that date from the 1960's.
 The incubation period from infection with the virus to
development of AIDS is highly variable (approximately 1
year to 9 years).
Kaposi’s sarcoma
 Multicentric, malignant neoplastic vascular proliferation
 characterised by the development of bluish-red nodules
on the skin.
 Sometimes there may be widespread visceral
involvement.
 It may metastasize to lymph nodes.
 KS may occur in immunocompromised patients (e.g. HIV
positive patients, transplant patients) and in these
patients a particulary virulent, disseminated form occurs
Clinical Features
 The lesions of Kaposi's sarcoma may at first appear like bruises,
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being coloured purple and blue.
Later become slightly raised and firmer, with the colour
darkening so that the lesions become purple and black.
painful or itchy
may develop at multiple sites over the body and cause cosmetic
distress.
gastrointestinal involvement which is usually asymptomatic,
though dysphagia or obstructive symptoms may occur.
Pulmonary manifestations include pleural, parenchymal and
airway lesions, and recurrent pleural effusions may occur.
There may also be liver and lymph node involvement
Managment
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In the Classical Jewish and Mediterranean variety and the endemic
African variety, Kaposi's sarcoma (KS) is an indolent condition with no
significant reduction in life expectancy.
local therapies :
cryotherapy, radiotherapy and topical treatments (early skin lesions)
highly active antiretroviral therapy (HAART)
unsightly lesions on the face or other exposed areas may be excised or
may respond well to short courses of radiotherapy.
 More extensive limb involvement responds well to wide-field irradiation
 when the disease is progressing rapidly in spite of HAART or when there
is visceral involvement, systemic treatment with cytotoxic
chemotherapy is indicated.
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