Transcript Sexually Transmitted Diseases
Slide 1
Sexually
Transmitted
Diseases
Slide 2
They include
1. GENITAL ULCERS
2. HSV,
3. chancroid,
4. syphilis,
5. lymphogranuloma venereum,
6. Granuloma Inguinale
7. Chlamydia (urethritis/cervicitis/epididymitis)
8. gonorrhea, (urethritis/cervicitis/epididymitis)
9. GENITAL WARTS
10. MOLLUSCUM CONTAGIOSUM
11. Scabies
12. PEDICULOSIS PUBIS
Slide 3
EPIDEMIOLOGY AND TRENDS
People at high risk of contracting STDs are young
adults between the ages of 18 and 28.
It is also important to bear in mind that STDs rank
among the top five risks of international travelers,
along with diarrhea, hepatitis, and motor vehicle
accidents ( Mawhorter, 1997 ).
Slide 4
It is estimated that over 15 million new cases of
STDs are reported each year and over 65 million
people are infected with incurable viral STDs (
American Social Health Association, 1998 ).
Approximately two thirds occur in adolescents and
young adults.
The most common STDs are HPV and HSV. Of the
top ten nationally notifiable infectious diseases in
the United States in 2002, five were STDs ( CDC,
2003 ). This does not include HPV and HSV, because
they are not reportable diseases.
Slide 5
groups are at higher risk of contracting an STD
1.
2.
3.
4.
5.
6.
men
low socioeconomic class
blacks
drug users
urban
Adolescent
STDs require contact tracing and treatment of
sexual partners
1. syphilis
2. gonorrhoeae
3. chlamydia
Slide 6
GENITAL ULCERS
pathognomonic presentations of an ulcer
1. fixed drug eruption: always triggered by the ingestion of one
particular medication
2. herpes simplex: vesicles on an erythematous base
3. trauma: genital ulcer that develops acutely during sexual
activity
Several sexually transmitted infections are clinically
characterized by genital ulcers, most commonly HSV,
syphilis, and chancroid.
In 2002, it was estimated that over 45 million people
had HSV whereas only 6862 cases of syphilis and 67
cases of chancroid were reported ( CDC, 2003 ).
Slide 7
the DDx for genital ulcers
◦ Premalignant
erythroplasia of Queyrat
◦ Malignant
SCC
◦ Non-malignant
syphilis
chancroid
herpes
lymphogranuloma venereum
granuloma inguinale
fixed drug eruptions
traumatic ulcers
Slide 8
Disease Lesions
Lymphaden Systemic
opathy
Symptoms
Primary
syphilis
Painless,
indurated, with a
clean base,
usually singular
Nontender,
rubbery,
nonsuppurative
bilateral
lymphadenopathy
None
Genital
herpes
Painful vesicles,
shallow, usually
multiple
Tender, bilateral
inguinal
adenopathy
Present during
primary infection
Tender papule,
then painful,
undermined
purulent ulcer,
single or multiple
Tender, regional,
painful,
suppurative
nodes
None
Small, painless
vesicle or papule
progresses to an
ulcer
Painful, matted,
large nodes
develop, with
fistula tracts
Present after
genital lesion
heals
Chancroid
Lympho
granuloma
Slide 9
Slide 10
test is most valuable for each of the following
lesions
◦
◦
◦
◦
◦
malignant lesion: biopsy
genital herpes: viral culture
syphilis: serology and darkfield exam
chancroid: selective medium culture for H. ducreyi
granuloma inguinale: crush prep for cytologic or
histologic identification of C. granulomatis
◦ lymphogranuloma venereum: PCR, serologic test, culture
for C. trachomatis
Slide 11
One should bear in mind that patients may be
coinfected with more than one STD. Approximately
10% of patients with chancroid are coinfected with
HSV or syphilis.
Empirical treatment for the most likely cause based
on history and physical examination should be
initiated as laboratory test results are pending.
Slide 12
HERPES SIMPLEX VIRUS INFECTION
the etiologic agent for genital herpes
◦ HSV type 2 in majority 85% to 90%
◦ HSV type 1 usually for oral infections, but reported in 1025% of cases
the sx of genital herpes
◦ dysuria
◦ neurologic complications
meningitis
urinary retention: sacral or autonomic nervous system
dysfunction vs. local pain
constipation, weakness, ED, sensory loss
◦ proctitis
◦ sx usually more severe in women
Slide 13
Vulvovaginal herpes simplex virus
infection
Herpes simplex virus.
Umbilicated vesicle of
the shaft,
characteristic of early
tissue infection. These
lesions are often
pustular and ulcerate
during the course of
the infection .
Herpes simplex
virus infection on
the penis
Typical vesicular eruption of herpes
simplex virus.
Slide 14
diagnose HSV
1.
2.
3.
4.
5.
pathognomonic vesicles on erythematous base
Pap smear: intranuclear inclusions
immunofluorescent techniques
viral isolation by culture: most sensitive
PCR for HSV
Treatment.
Slide 15
Agent
Acyclovir
Famciclovir
Valacyclovir
First Clinical Episode Episodic Therapy
400 mg tid for 7-10
days
Or
200 mg five times a
day for 7-10 days
400 mg tid for 5
days
Or
200 mg five times a
day for 5 days
Or
800 mg bid for 5
days
250 mg bid for 7-10 125 mg bid for 5
days
days
1 g bid for 7-10 days
500 mg bid for 3-5
days
Or
1 g/day for 5 days
Suppressive Therapy
400 mg bid
250 mg bid
500 mg/day
Or
1 g/day
Slide 16
CHANCROID
the etiologic agent in chancroid
◦ H. ducreyi
the physical findings in chancroid.
1. painful lymphadenopathy in 50%
2. ulcer w/ deep undermined border
soft, indurated, and purulent
base of lesion friable and bleeds easily
3. It can spread laterally by apposition to inner thighs and
buttocks, especially in women. It is associated with
inguinal adenopathy that is typically unilateral and
tender with tendency to become suppurative and
fistulize
Slide 17
Chancroid with regional
adenopathy
Chancre. Erosive volcanolike lesion with a hard
border
Chancroid. Soft, painful,
erosive lesions.
Slide 18
diagnosis
◦ Gram stain smear: take from base of lesion
gram-negative coccobacilli in chains w/ "school of fish"
appearance
◦ culture of H. ducreyi
treatment of chancroid
◦ difficult due to antibiotic resistance – any of:
azithromycin 1g PO x 1
ceftriaxone 250mg IM x 1
cipro 500mg PO BID x 3d
◦ treat sexual partners
Slide 19
SYPHILIS
the etiologic agent for syphilis
◦ Treponema pallidum spirochete
Diagnosis.
syphilis presents 2-4 weeks post-exposure, male pt
presents w/ painless penile sore called chancre
the different stages of syphilis
◦ primary: 1st symptomatic episode
◦ secondary: refers to recurrences
◦ latent: periods after infection where pts are seroreactive but
have no other signs or sx of the disease
◦ tertiary: formation of gummas and cardiovascular syphilis
◦ neurosyphilis: auditory or ophthalmic sx, meningitis, CN
palsies, eye disease
Slide 20
Syphilis with vulvar chancre
Syphilis with penile chancre
Secondary syphilis affecting the genitalia
Secondary syphilis affecting the
soles of the feet
Slide 21
How can syphilis be diagnosed?
1.
2.
3.
4.
5.
scrapings from base of chancre examined by darkfield or fluorescent Ab
FTA-ABS: fluorescent treponemal antibody absorption test
MHATP: microhemagglutination assay for Ab to T. pallidum
VDRL:Venereal Disease Research Laboratory non-treponemal test
RPR: rapid plasma reagin
Treatment
◦ Primary / Secondary / Early latent syphilis
benzathine penicillin G 2.4Million units IM x 1 (50000U/kg in children)
◦ Late latent syphilis / tertiary syphilis
2.4M units IM qwk x 3
◦ Patients should be followed with nontreponemal antibody titers
at 6 and 12 month.
◦ Neurosyphilis
aqueous crystalline pen G 3-4million U IV q4h x 10-14d
Patients with neurosyphilis require repeat examination of cerebrospinal fluid 3 to 6 months
after therapy and every 6 months afterward until normal results are achieved.
◦ counselling for HIV
Patients with HIV should be followed at 3, 6, 9, 12, and 24 months
Slide 22
Slide 23
LYMPHOGRANULOMA VENEREUM
caused by C. trachomatis serotypes L1, L2, L3
Diagnosis
the physical findings in lymphogranuloma venereum is
firm, painless lesion w/ low elevated borders
painful unilateral suppurative inguinal LN 2 to 6 weeks
later
◦ associated w/ F/C, N/V, arthralgia
◦ skin rashes
◦ Women and homosexual men may present with proctocolitis
and perirectal or deep iliac lymph node enlargement if the
primary lesion arises from the rectum or cervix. Significant
tissue injury and scarring may occur, leading to labial
fenestration, urethral destruction, anorectal fistulas, and
elephantiasis of the penis, scrotum, or labia.
Slide 24
Lymphogranuloma venereum. Swollen
bubo in the area of inguinal lymph nodes.
Lymphogranuloma venereum
Lymphogranuloma venereum with
inguinal adenopathy
Slide 25
diagnose lymphogranuloma venereum by
1. culture of C. trachomatis
1. best obtained from aspiration of fluctuant inguinal node
2. bloodwork
1. leukocytosis, anemia, elevated gamma globulins
the treatment of lymphogranuloma venereum
◦ doxycycline 100mg PO BID x 21d
Slide 26
Granuloma Inguinale
Etiologic
agent in granuloma inguinale
◦ Calymmatobacterium granulomatis
Gm-ve intracellular organism
Physical
findings in granuloma inguinale.
◦ small papule seen first
forms as small ulcer painless above level of the
skin
◦ base of ulcer erythematous, may bleed
◦ nontender, indurated, and firm
Slide 27
Granuloma inguinale. Irregularly shaped ulcer
without inguinal adenopathy
Slide 28
Diagnose granuloma inguinale
◦ identification of Donovan bodies on a stained smear
Blue or black staining bodies )
crush specimen for histologic study
◦ biopsy
◦ no culture available
Treatment of granuloma inguinale.
◦
◦
◦
◦
doxycycline 100mg PO BID x 3 weeks
Septra DS 1 tab PO BID x 3 weeks
cipro 750mg PO BID x 3 weeks
Erythromycin 500mg PO QID x 3 weeks
Slide 29
CHLAMYDIA TRACHOMATIS INFECTION
Diagnosis
◦
◦
◦
◦
◦
it is most prevalent in sexually active adolescents and young adults.
Virulent serotypes include D, E, F, G, H, I, J, and K.
The incubation period ranges from 3 to 14 days
majority of both of men and women are asymptomatic
In male
1.
◦
2.
50% of men experience lower urinary tract symptoms attributed to
urethritis, epididymitis, or prostatitis and may notice clear or white urethral
discharge
C. trachomatis is the most common cause of epididymitis in young men
In female
1.
2.
3.
4.
75% of women are asymptomatic and 40% with untreated infection will
develop pelvic inflammatory disease
The squamous cells of vaginal epithelium are relatively resistant to infection
with C. trachomatis, but the columnar cells of the cervix are not.
A mucopurulent endocervical discharge may be present
Scarring of the fallopian tubes from chlamydial infection puts patients at risk
for recurrent pelvic inflammatory disease with vaginal flora, ectopic
pregnancy, pelvic pain, and infertility
Slide 30
Chlamydia may also be transmitted to newborns
during vaginal birth through exposure of the
mother's infected cervix.
◦ chances of perinatal infection during vaginal delivery
15% develop chlamydial pneumonia
50% develop chlamydial conjunctivitis
Women should be screened annually until age 25 or
if risk factors such as a new sexual partner are
present
Slide 31
Etiologies of NGU
1.
2.
3.
4.
5.
6.
C. trachomatis 30 – 50 %
U. urealyticum. 20 – 50 %
Mycoplasma homins
HSV
T. vaginalis
Mycoplasma genitalium
diagnose NGU
1. intraurethral swab
Gram stain: >4 PMN per HPF
2. first-void urine
1. spun sediment: >15 PMN per HPF
2. WBC on dipstick
3. Chlamydia cultures
performed on an endocervical swab specimen
Slide 32
4.
other assays
1. direct fluorescent antibody (DFA)
Chlamydia-specific monoclonal Ab conjugated to fluorescent stain
2. ELISA
3. nucleic acid probes
a nucleic acid amplification test (NAAT) performed on an endocervical
swab specimen, if a pelvic examination is acceptable; otherwise, an NAAT
performed on urine.
NAAT to test for cure should not be performed less than 3 weeks after
treatment has been completed because dead organisms that may still be
present will yield a false-positive test.
NAATs are available that test for both infection with Chlamydia and N.
gonorrhoeae from one sample.
However, a positive result is nondiscriminatory between the two diseases
and therefore further testing would be needed to determine which disease
is present
NAATs utilizing PCR assays for urine are a highly sensitive and noninvasive
means of screening men and women for chlamydial infection.
This method should not replace pelvic examination or endocervical culture in
symptomatic women because antibiotic sensitivity cannot be determined.
Specimens for culture can be obtained from urethral or cervical swabs, urine,
or prostatic fluid
Slide 33
Treatment
1. Azithromycin, 1 g by mouth as a single dose, or doxycycline, 100
mg twice daily for 7 days.
2. Alternative therapies include
1.
2.
3.
4.
erythromycin base, 500 mg four times daily,
erythromycin ethylsuccinate, 800 mg four times daily,
ofloxacin, 300 mg twice daily,
or levofloxacin, 500 mg daily for 7 days.
causes for recurrent NGU
1. reinfection w/ original organism should be rescreened 3 to 4
months after treatment
(from non-treated sexual partner) All sexual partners who came in contact
with the patient within 60 days of diagnosis or symptom onset should be
evaluated, tested, and treated for both N. gonorrhoeae and C. trachomatis
2. resistance
usually due to tetracycline-resistant Ureaplasma urealyticum treat w/
erythromycin x 1-2weeks
Slide 34
the evaluation for men w/ recurrent or persistent urethritis
despite adequate treatment.
1.
2.
3.
4.
urethral swabs: Neisseria gonorrhoeae and Chlamydia trachomatis
cultures for fungus
examine sexual partner
uroflow and cysto: detect possible intraurethral lesions
complications of NGU in men
◦ usually none
complications of NGU in women
1. PID
2. Infertility
1.
2.
3.
single episode: 12%
2 episodes: 35%
3 epidodes: 75%
3. ectopic pregnancy
4. pain
5. perinatal infections
Slide 35
GONORRHEA
caused by the gram-negative diplococcus Neisseria
gonorrhoeae
incubation period ranges from 3 to 14 days
Risk of infection after one exposure is 10% in men and 40% in
women.
Men
◦ lower urinary tract symptoms attributed to urethritis, epididymitis,
proctitis, or prostatitis,
◦ with associated mucopurulent urethral discharge.
Women
◦ may have symptoms of vaginal and pelvic discomfort or dysuria.
◦ As with C. trachomatis, the vaginal epithelium is resistant to
infection with N. gonorrhoeae but the cervix is not.
◦ A mucopurulent endocervical discharge may be present.
◦ Many women are asymptomatic
Slide 36
Differential Diagnosis of STDs in Women
Vaginal
Discharge
pH
WBC
Microscopy
Symptoms
Normal
White, thick,
smooth
<=4.5
Absent
Lactobacilli
None
Candidiasis
White, thick,
curdy
<=4.5
Absent
Mycelia
Vulvar pruritus,
external or
superificial dysuria
Trichomoniasi
s
Frothy or
purulent
>=4.5
Present Mobile
trichomonads
present
Vulvar erythema
and edema,
punctate strawberry
lesions on cervix
Neisseria
gonorrhoeae
None or
mucopurulent
discharge
from
cervicitis
>=4.5
Present Gram-negative
diplococci within or
adjacent to
polymorphonuclear
leukocytes on
Gram stain
Vaginal and pelvic
discomfort, dysuria,
most often
asymptomatic
Chlamydia
trachomatis
None or
mucopurulent
discharge
from
cervicitis
>=4.5
Present Organisms not
visualized
Vaginal and pelvic
discomfort, dysuria,
most often
asymptomatic
Bacterial
Vaginosis
Thin, white
homogeneous
>=4.5
Absent
Fishy odor and
increased vaginal
Paucity of
lactobacilli (75% of
Slide 37
in women
◦ The CDC recommends screening by culture on an
endocervical swab specimen
in men
◦ culture on an intraurethral swab . Culture may be performed
on urethra exudates if present.
If transport and storage are not conducive, an NAAT
or nucleic acid hybridization test can be performed.
If it is not possible to obtain an intraurethral or
endocervical specimen, NAAT may be performed on
urine.
◦ Urine NAATs for N. gonorrhoeae have been shown to be less
sensitive than endocervical and intraurethral swabs in
asymptomatic men
Slide 38
Treatment
drug of choice: ceftriaxone 125mg IM x 1
plus either (azithromycin 1g PO x 1 or doxycycline 100mg
PO BID for 7 days) (NGU) 30% of men w/ GU also have
chlamydia
alternates
◦
◦
◦
◦
◦
cefixime 400mg PO / once.
cipro 500mg PO / once.
ofloxacin 500mg PO once.
levofloxacin, 250 mg po once.
plus either (azithromycin 1g PO x 1 or doxycycline 100mg PO BID
for 7 days) (NGU)
Spectinomycin, 2 g intramuscularly, can be used during pregnancy or in
patients allergic to quinolones and cephalosporins.
All sexual partners who came in contact with the patient within 60
days of diagnosis or symptom onset should be evaluated, tested, and
treated for both N. gonorrhoeae and C. trachomatis
Slide 39
Slide 40
Epididymitis
Acute Epididymitis : is clinical syn. (pain , swelling ,
&inflammation of epid. <6wk
Chronic Epidid. : ( long standing pain in epid &
testicle ,no swelling > 6wk)
The etiologies of epididymitis
Infectious
GC or chlamydia in 2/3 sexually active men < 35yrs
E. Coli if > 35yrs or in children
TB
Cryptococcus
Brucella
Non-infectious
amiodarone: concentrated in the epididymis
Slide 41
Slide 42
complications
of acute epididymitis
◦ abscess formation
◦ testicular infarction
◦ chronic pain
◦ infertility
Slide 43
Slide 44
Management of the acute scrotum.
Slide 45
GENITAL WARTS
Etiologic agent in genital warts
◦ DNA-containing virus of human papilloma species (HPV)
◦ types 6 and 11 most often cause visible external warts
◦ prevalence of HPV infection 60% of college women
◦ median duration of HPV infection was 8 months
Diagnosis
◦ Most infections are subclinical and asymptomatic
◦ anywhere on the external genitalia(cervix, vagina, urethra, anus)
◦ on mucous membranes such as the conjunctiva, mouth, and nasal
passages
◦ Because HPV progresses rapidly in HIV-infected women, cervical
cancer is considered one of the illnesses that defines the acquired
immunodeficiency syndrome (AIDS)
Slide 46
Condyloma acuminatum. Exophytic
warty lesion of the genital region
Meatal wart caused by
human papillomavirus
Vaginal condylomata caused by human papillomavirus.
Penile warts.
Slide 47
Treatment
The choice of therapy for genital warts depends on
several factors, including wart size, number, and location,
and patient and physician preference. Because genital
warts spontaneously resolve with time, observation
remains an option
the goal of treatment in HPV infection
1.
2.
3.
4.
remove exophytic warts
decrease signs or sx pt may have from wart infection
no therapy available to eradicate HPV
biopsy all atypical pigmented or persistent warts
Slide 48
The site-specific treatment for genital warts.
1. External genital, perianal, vaginal
1.
2.
primary: cryotherapy w/ liquid nitrogen
secondary: podophyllin 10-25% x 4 weeks, trichloroacetic acid 80-90%
weekly
treatment choices for patient-applied therapy include
3.
podofilox 0.5% solution or gel and imiquimod 5% cream. Podofilox solution should be
applied every 12 hours for 3 days, then off for 4 days with the option to repeat the
treatment cycle four times
Imiquimod cream should be applied three times per week at bedtime for up to 16
weeks. The area should be thoroughly washed 6 to 10 hours after application.
Imiquimod should not be used on vaginal lesions because it has been reported to
cause chronic ulceration
Surgical excision may be accomplished by electrocautery or sharply
with a tangential incision. Bleeding can generally be controlled with
electrocautery or silver nitrate application
2. Cervical: r/o dysplasia
3. Meatal
1.
2.
primary: cryotherapy
secondary: podophyllin
Slide 49
4. Urethral: cryotherapy, 5% 5-FU or thiotepa
do not use podophyllin
5. Large or extensive lesions surrounding the meatus may herald
the presence of urethral or bladder condylomata, warranting
cystourethroscopy. Urethral or bladder lesions should be
cystoscopically excised
6. Anorectal
1.
2.
primary: cryotherapy
secondary: surgical removal, trichloroacetic acid
7. Oral: surgical removal
Preliminary studies of prophylactic HPV-like particle vaccine
have been performed with encouraging results ( Evans et al,
2001 ; Ault et al, 2004 ).
A vaccine containing eight of the most common HPV types
associated with cancer could potentially prevent 95% of
cervical cancer
Slide 50
MOLLUSCUM CONTAGIOSUM
the etiologic agent for molluscum contagiosum
◦ DNA Poxviridae virus
◦ associated w/ HIV infection
the incubation period for molluscum 14 to 50 days
appear in the genital and inguinal regions, the inner thighs, and
perineum
diagnosis of molluscum
◦ small firm umbilicated papules on skin
smooth, pearly, or flesh coloured
◦ In immunocompetent persons the lesions usually spontaneously resolve
within a few months and usually by 1 year but may take up to 5 years
◦ biopsy: molluscum bodies seen
eosinophilic hyalin spherical masses seen on biopsy of mollusc
◦ the patients be tested for other STDs such as gonorrhea, chlamydia, and syphilis
and carefully examined for coexistent condyloma acuminata and pediculosis
pubis
◦ HIV testing in patients with extensive multisite lesions, especially those involving
the head and neck, and in lesions with a poor response to treatment.
Slide 51
Molluscum contagiosum affecting penis
Molluscum contagiosum on abdomen
Molluscum contagiosum.
Persistent umbilicated papules of the penile shaft.
Slide 52
Treatment
1. curettage
2. liquid nitrogen
3. chemical eradication: cantharadin, phenol, iodine, silver
nitrate, trichloroacetic acid
4. treat sexual contacts
Slide 53
SCABIES
the etiologic agent in scabies is mite: Sarcoptes
scabiei
The incubation period ranges from 2 to 6 weeks
the penile shaft and glands, areolae, finger webs, and
auxiliary folds
the diagnosis may require microscopic evidence of
the mite or eggs, which is retrieved by scraping the
burrow with a scalpel blade coated with mineral oil.
It can also usually be demonstrated if a thin shaving
of skin from a papule is removed and placed on a
glass slide and digested with heat and 10%
potassium hydroxide
Slide 54
Scabies affecting shaft of penis.
Slide 55
the sx of scabies
◦ severe urticaria worse at night, in bed
◦ severe excoriation
Treatment
1. permethrin cream (5%) to entire body – wash off
after 8 hrs
2. lindane 1% to entire body x 8-14hrs –
◦
3.
4.
cannot use if pregnant or lactating or children younger
than 2 years and patients with extensive dermatitis.
treat sexual partners
wash clothing and bed linen on hot cycle to kill
mites
Slide 56
PEDICULOSIS PUBIS
is the etiologic agent for pediculosis pubis (phthiriasis)
is crab louse
diagnose crabs
◦ Hx: itching of haired portion of pubis, thighs, or scrotum
◦ Px: nits seen attached to hair shaft near skin surface – can be
seen in axilla, eyelashes, or scalp
the treatment for crabs
1. permethrin cream to affected areas x 10min
2. lindane shampoo x 4min
should not be used after a bath and is contraindicated in children
younger than 2 years of age and in pregnant or lactating women
3. trimethoprim-sulfamethoxazole
4. treat sexual partners
5. wash bed linens and clothing
Slide 57
Sexually
Transmitted
Diseases
Slide 2
They include
1. GENITAL ULCERS
2. HSV,
3. chancroid,
4. syphilis,
5. lymphogranuloma venereum,
6. Granuloma Inguinale
7. Chlamydia (urethritis/cervicitis/epididymitis)
8. gonorrhea, (urethritis/cervicitis/epididymitis)
9. GENITAL WARTS
10. MOLLUSCUM CONTAGIOSUM
11. Scabies
12. PEDICULOSIS PUBIS
Slide 3
EPIDEMIOLOGY AND TRENDS
People at high risk of contracting STDs are young
adults between the ages of 18 and 28.
It is also important to bear in mind that STDs rank
among the top five risks of international travelers,
along with diarrhea, hepatitis, and motor vehicle
accidents ( Mawhorter, 1997 ).
Slide 4
It is estimated that over 15 million new cases of
STDs are reported each year and over 65 million
people are infected with incurable viral STDs (
American Social Health Association, 1998 ).
Approximately two thirds occur in adolescents and
young adults.
The most common STDs are HPV and HSV. Of the
top ten nationally notifiable infectious diseases in
the United States in 2002, five were STDs ( CDC,
2003 ). This does not include HPV and HSV, because
they are not reportable diseases.
Slide 5
groups are at higher risk of contracting an STD
1.
2.
3.
4.
5.
6.
men
low socioeconomic class
blacks
drug users
urban
Adolescent
STDs require contact tracing and treatment of
sexual partners
1. syphilis
2. gonorrhoeae
3. chlamydia
Slide 6
GENITAL ULCERS
pathognomonic presentations of an ulcer
1. fixed drug eruption: always triggered by the ingestion of one
particular medication
2. herpes simplex: vesicles on an erythematous base
3. trauma: genital ulcer that develops acutely during sexual
activity
Several sexually transmitted infections are clinically
characterized by genital ulcers, most commonly HSV,
syphilis, and chancroid.
In 2002, it was estimated that over 45 million people
had HSV whereas only 6862 cases of syphilis and 67
cases of chancroid were reported ( CDC, 2003 ).
Slide 7
the DDx for genital ulcers
◦ Premalignant
erythroplasia of Queyrat
◦ Malignant
SCC
◦ Non-malignant
syphilis
chancroid
herpes
lymphogranuloma venereum
granuloma inguinale
fixed drug eruptions
traumatic ulcers
Slide 8
Disease Lesions
Lymphaden Systemic
opathy
Symptoms
Primary
syphilis
Painless,
indurated, with a
clean base,
usually singular
Nontender,
rubbery,
nonsuppurative
bilateral
lymphadenopathy
None
Genital
herpes
Painful vesicles,
shallow, usually
multiple
Tender, bilateral
inguinal
adenopathy
Present during
primary infection
Tender papule,
then painful,
undermined
purulent ulcer,
single or multiple
Tender, regional,
painful,
suppurative
nodes
None
Small, painless
vesicle or papule
progresses to an
ulcer
Painful, matted,
large nodes
develop, with
fistula tracts
Present after
genital lesion
heals
Chancroid
Lympho
granuloma
Slide 9
Slide 10
test is most valuable for each of the following
lesions
◦
◦
◦
◦
◦
malignant lesion: biopsy
genital herpes: viral culture
syphilis: serology and darkfield exam
chancroid: selective medium culture for H. ducreyi
granuloma inguinale: crush prep for cytologic or
histologic identification of C. granulomatis
◦ lymphogranuloma venereum: PCR, serologic test, culture
for C. trachomatis
Slide 11
One should bear in mind that patients may be
coinfected with more than one STD. Approximately
10% of patients with chancroid are coinfected with
HSV or syphilis.
Empirical treatment for the most likely cause based
on history and physical examination should be
initiated as laboratory test results are pending.
Slide 12
HERPES SIMPLEX VIRUS INFECTION
the etiologic agent for genital herpes
◦ HSV type 2 in majority 85% to 90%
◦ HSV type 1 usually for oral infections, but reported in 1025% of cases
the sx of genital herpes
◦ dysuria
◦ neurologic complications
meningitis
urinary retention: sacral or autonomic nervous system
dysfunction vs. local pain
constipation, weakness, ED, sensory loss
◦ proctitis
◦ sx usually more severe in women
Slide 13
Vulvovaginal herpes simplex virus
infection
Herpes simplex virus.
Umbilicated vesicle of
the shaft,
characteristic of early
tissue infection. These
lesions are often
pustular and ulcerate
during the course of
the infection .
Herpes simplex
virus infection on
the penis
Typical vesicular eruption of herpes
simplex virus.
Slide 14
diagnose HSV
1.
2.
3.
4.
5.
pathognomonic vesicles on erythematous base
Pap smear: intranuclear inclusions
immunofluorescent techniques
viral isolation by culture: most sensitive
PCR for HSV
Treatment.
Slide 15
Agent
Acyclovir
Famciclovir
Valacyclovir
First Clinical Episode Episodic Therapy
400 mg tid for 7-10
days
Or
200 mg five times a
day for 7-10 days
400 mg tid for 5
days
Or
200 mg five times a
day for 5 days
Or
800 mg bid for 5
days
250 mg bid for 7-10 125 mg bid for 5
days
days
1 g bid for 7-10 days
500 mg bid for 3-5
days
Or
1 g/day for 5 days
Suppressive Therapy
400 mg bid
250 mg bid
500 mg/day
Or
1 g/day
Slide 16
CHANCROID
the etiologic agent in chancroid
◦ H. ducreyi
the physical findings in chancroid.
1. painful lymphadenopathy in 50%
2. ulcer w/ deep undermined border
soft, indurated, and purulent
base of lesion friable and bleeds easily
3. It can spread laterally by apposition to inner thighs and
buttocks, especially in women. It is associated with
inguinal adenopathy that is typically unilateral and
tender with tendency to become suppurative and
fistulize
Slide 17
Chancroid with regional
adenopathy
Chancre. Erosive volcanolike lesion with a hard
border
Chancroid. Soft, painful,
erosive lesions.
Slide 18
diagnosis
◦ Gram stain smear: take from base of lesion
gram-negative coccobacilli in chains w/ "school of fish"
appearance
◦ culture of H. ducreyi
treatment of chancroid
◦ difficult due to antibiotic resistance – any of:
azithromycin 1g PO x 1
ceftriaxone 250mg IM x 1
cipro 500mg PO BID x 3d
◦ treat sexual partners
Slide 19
SYPHILIS
the etiologic agent for syphilis
◦ Treponema pallidum spirochete
Diagnosis.
syphilis presents 2-4 weeks post-exposure, male pt
presents w/ painless penile sore called chancre
the different stages of syphilis
◦ primary: 1st symptomatic episode
◦ secondary: refers to recurrences
◦ latent: periods after infection where pts are seroreactive but
have no other signs or sx of the disease
◦ tertiary: formation of gummas and cardiovascular syphilis
◦ neurosyphilis: auditory or ophthalmic sx, meningitis, CN
palsies, eye disease
Slide 20
Syphilis with vulvar chancre
Syphilis with penile chancre
Secondary syphilis affecting the genitalia
Secondary syphilis affecting the
soles of the feet
Slide 21
How can syphilis be diagnosed?
1.
2.
3.
4.
5.
scrapings from base of chancre examined by darkfield or fluorescent Ab
FTA-ABS: fluorescent treponemal antibody absorption test
MHATP: microhemagglutination assay for Ab to T. pallidum
VDRL:Venereal Disease Research Laboratory non-treponemal test
RPR: rapid plasma reagin
Treatment
◦ Primary / Secondary / Early latent syphilis
benzathine penicillin G 2.4Million units IM x 1 (50000U/kg in children)
◦ Late latent syphilis / tertiary syphilis
2.4M units IM qwk x 3
◦ Patients should be followed with nontreponemal antibody titers
at 6 and 12 month.
◦ Neurosyphilis
aqueous crystalline pen G 3-4million U IV q4h x 10-14d
Patients with neurosyphilis require repeat examination of cerebrospinal fluid 3 to 6 months
after therapy and every 6 months afterward until normal results are achieved.
◦ counselling for HIV
Patients with HIV should be followed at 3, 6, 9, 12, and 24 months
Slide 22
Slide 23
LYMPHOGRANULOMA VENEREUM
caused by C. trachomatis serotypes L1, L2, L3
Diagnosis
the physical findings in lymphogranuloma venereum is
firm, painless lesion w/ low elevated borders
painful unilateral suppurative inguinal LN 2 to 6 weeks
later
◦ associated w/ F/C, N/V, arthralgia
◦ skin rashes
◦ Women and homosexual men may present with proctocolitis
and perirectal or deep iliac lymph node enlargement if the
primary lesion arises from the rectum or cervix. Significant
tissue injury and scarring may occur, leading to labial
fenestration, urethral destruction, anorectal fistulas, and
elephantiasis of the penis, scrotum, or labia.
Slide 24
Lymphogranuloma venereum. Swollen
bubo in the area of inguinal lymph nodes.
Lymphogranuloma venereum
Lymphogranuloma venereum with
inguinal adenopathy
Slide 25
diagnose lymphogranuloma venereum by
1. culture of C. trachomatis
1. best obtained from aspiration of fluctuant inguinal node
2. bloodwork
1. leukocytosis, anemia, elevated gamma globulins
the treatment of lymphogranuloma venereum
◦ doxycycline 100mg PO BID x 21d
Slide 26
Granuloma Inguinale
Etiologic
agent in granuloma inguinale
◦ Calymmatobacterium granulomatis
Gm-ve intracellular organism
Physical
findings in granuloma inguinale.
◦ small papule seen first
forms as small ulcer painless above level of the
skin
◦ base of ulcer erythematous, may bleed
◦ nontender, indurated, and firm
Slide 27
Granuloma inguinale. Irregularly shaped ulcer
without inguinal adenopathy
Slide 28
Diagnose granuloma inguinale
◦ identification of Donovan bodies on a stained smear
Blue or black staining bodies )
crush specimen for histologic study
◦ biopsy
◦ no culture available
Treatment of granuloma inguinale.
◦
◦
◦
◦
doxycycline 100mg PO BID x 3 weeks
Septra DS 1 tab PO BID x 3 weeks
cipro 750mg PO BID x 3 weeks
Erythromycin 500mg PO QID x 3 weeks
Slide 29
CHLAMYDIA TRACHOMATIS INFECTION
Diagnosis
◦
◦
◦
◦
◦
it is most prevalent in sexually active adolescents and young adults.
Virulent serotypes include D, E, F, G, H, I, J, and K.
The incubation period ranges from 3 to 14 days
majority of both of men and women are asymptomatic
In male
1.
◦
2.
50% of men experience lower urinary tract symptoms attributed to
urethritis, epididymitis, or prostatitis and may notice clear or white urethral
discharge
C. trachomatis is the most common cause of epididymitis in young men
In female
1.
2.
3.
4.
75% of women are asymptomatic and 40% with untreated infection will
develop pelvic inflammatory disease
The squamous cells of vaginal epithelium are relatively resistant to infection
with C. trachomatis, but the columnar cells of the cervix are not.
A mucopurulent endocervical discharge may be present
Scarring of the fallopian tubes from chlamydial infection puts patients at risk
for recurrent pelvic inflammatory disease with vaginal flora, ectopic
pregnancy, pelvic pain, and infertility
Slide 30
Chlamydia may also be transmitted to newborns
during vaginal birth through exposure of the
mother's infected cervix.
◦ chances of perinatal infection during vaginal delivery
15% develop chlamydial pneumonia
50% develop chlamydial conjunctivitis
Women should be screened annually until age 25 or
if risk factors such as a new sexual partner are
present
Slide 31
Etiologies of NGU
1.
2.
3.
4.
5.
6.
C. trachomatis 30 – 50 %
U. urealyticum. 20 – 50 %
Mycoplasma homins
HSV
T. vaginalis
Mycoplasma genitalium
diagnose NGU
1. intraurethral swab
Gram stain: >4 PMN per HPF
2. first-void urine
1. spun sediment: >15 PMN per HPF
2. WBC on dipstick
3. Chlamydia cultures
performed on an endocervical swab specimen
Slide 32
4.
other assays
1. direct fluorescent antibody (DFA)
Chlamydia-specific monoclonal Ab conjugated to fluorescent stain
2. ELISA
3. nucleic acid probes
a nucleic acid amplification test (NAAT) performed on an endocervical
swab specimen, if a pelvic examination is acceptable; otherwise, an NAAT
performed on urine.
NAAT to test for cure should not be performed less than 3 weeks after
treatment has been completed because dead organisms that may still be
present will yield a false-positive test.
NAATs are available that test for both infection with Chlamydia and N.
gonorrhoeae from one sample.
However, a positive result is nondiscriminatory between the two diseases
and therefore further testing would be needed to determine which disease
is present
NAATs utilizing PCR assays for urine are a highly sensitive and noninvasive
means of screening men and women for chlamydial infection.
This method should not replace pelvic examination or endocervical culture in
symptomatic women because antibiotic sensitivity cannot be determined.
Specimens for culture can be obtained from urethral or cervical swabs, urine,
or prostatic fluid
Slide 33
Treatment
1. Azithromycin, 1 g by mouth as a single dose, or doxycycline, 100
mg twice daily for 7 days.
2. Alternative therapies include
1.
2.
3.
4.
erythromycin base, 500 mg four times daily,
erythromycin ethylsuccinate, 800 mg four times daily,
ofloxacin, 300 mg twice daily,
or levofloxacin, 500 mg daily for 7 days.
causes for recurrent NGU
1. reinfection w/ original organism should be rescreened 3 to 4
months after treatment
(from non-treated sexual partner) All sexual partners who came in contact
with the patient within 60 days of diagnosis or symptom onset should be
evaluated, tested, and treated for both N. gonorrhoeae and C. trachomatis
2. resistance
usually due to tetracycline-resistant Ureaplasma urealyticum treat w/
erythromycin x 1-2weeks
Slide 34
the evaluation for men w/ recurrent or persistent urethritis
despite adequate treatment.
1.
2.
3.
4.
urethral swabs: Neisseria gonorrhoeae and Chlamydia trachomatis
cultures for fungus
examine sexual partner
uroflow and cysto: detect possible intraurethral lesions
complications of NGU in men
◦ usually none
complications of NGU in women
1. PID
2. Infertility
1.
2.
3.
single episode: 12%
2 episodes: 35%
3 epidodes: 75%
3. ectopic pregnancy
4. pain
5. perinatal infections
Slide 35
GONORRHEA
caused by the gram-negative diplococcus Neisseria
gonorrhoeae
incubation period ranges from 3 to 14 days
Risk of infection after one exposure is 10% in men and 40% in
women.
Men
◦ lower urinary tract symptoms attributed to urethritis, epididymitis,
proctitis, or prostatitis,
◦ with associated mucopurulent urethral discharge.
Women
◦ may have symptoms of vaginal and pelvic discomfort or dysuria.
◦ As with C. trachomatis, the vaginal epithelium is resistant to
infection with N. gonorrhoeae but the cervix is not.
◦ A mucopurulent endocervical discharge may be present.
◦ Many women are asymptomatic
Slide 36
Differential Diagnosis of STDs in Women
Vaginal
Discharge
pH
WBC
Microscopy
Symptoms
Normal
White, thick,
smooth
<=4.5
Absent
Lactobacilli
None
Candidiasis
White, thick,
curdy
<=4.5
Absent
Mycelia
Vulvar pruritus,
external or
superificial dysuria
Trichomoniasi
s
Frothy or
purulent
>=4.5
Present Mobile
trichomonads
present
Vulvar erythema
and edema,
punctate strawberry
lesions on cervix
Neisseria
gonorrhoeae
None or
mucopurulent
discharge
from
cervicitis
>=4.5
Present Gram-negative
diplococci within or
adjacent to
polymorphonuclear
leukocytes on
Gram stain
Vaginal and pelvic
discomfort, dysuria,
most often
asymptomatic
Chlamydia
trachomatis
None or
mucopurulent
discharge
from
cervicitis
>=4.5
Present Organisms not
visualized
Vaginal and pelvic
discomfort, dysuria,
most often
asymptomatic
Bacterial
Vaginosis
Thin, white
homogeneous
>=4.5
Absent
Fishy odor and
increased vaginal
Paucity of
lactobacilli (75% of
Slide 37
in women
◦ The CDC recommends screening by culture on an
endocervical swab specimen
in men
◦ culture on an intraurethral swab . Culture may be performed
on urethra exudates if present.
If transport and storage are not conducive, an NAAT
or nucleic acid hybridization test can be performed.
If it is not possible to obtain an intraurethral or
endocervical specimen, NAAT may be performed on
urine.
◦ Urine NAATs for N. gonorrhoeae have been shown to be less
sensitive than endocervical and intraurethral swabs in
asymptomatic men
Slide 38
Treatment
drug of choice: ceftriaxone 125mg IM x 1
plus either (azithromycin 1g PO x 1 or doxycycline 100mg
PO BID for 7 days) (NGU) 30% of men w/ GU also have
chlamydia
alternates
◦
◦
◦
◦
◦
cefixime 400mg PO / once.
cipro 500mg PO / once.
ofloxacin 500mg PO once.
levofloxacin, 250 mg po once.
plus either (azithromycin 1g PO x 1 or doxycycline 100mg PO BID
for 7 days) (NGU)
Spectinomycin, 2 g intramuscularly, can be used during pregnancy or in
patients allergic to quinolones and cephalosporins.
All sexual partners who came in contact with the patient within 60
days of diagnosis or symptom onset should be evaluated, tested, and
treated for both N. gonorrhoeae and C. trachomatis
Slide 39
Slide 40
Epididymitis
Acute Epididymitis : is clinical syn. (pain , swelling ,
&inflammation of epid. <6wk
Chronic Epidid. : ( long standing pain in epid &
testicle ,no swelling > 6wk)
The etiologies of epididymitis
Infectious
GC or chlamydia in 2/3 sexually active men < 35yrs
E. Coli if > 35yrs or in children
TB
Cryptococcus
Brucella
Non-infectious
amiodarone: concentrated in the epididymis
Slide 41
Slide 42
complications
of acute epididymitis
◦ abscess formation
◦ testicular infarction
◦ chronic pain
◦ infertility
Slide 43
Slide 44
Management of the acute scrotum.
Slide 45
GENITAL WARTS
Etiologic agent in genital warts
◦ DNA-containing virus of human papilloma species (HPV)
◦ types 6 and 11 most often cause visible external warts
◦ prevalence of HPV infection 60% of college women
◦ median duration of HPV infection was 8 months
Diagnosis
◦ Most infections are subclinical and asymptomatic
◦ anywhere on the external genitalia(cervix, vagina, urethra, anus)
◦ on mucous membranes such as the conjunctiva, mouth, and nasal
passages
◦ Because HPV progresses rapidly in HIV-infected women, cervical
cancer is considered one of the illnesses that defines the acquired
immunodeficiency syndrome (AIDS)
Slide 46
Condyloma acuminatum. Exophytic
warty lesion of the genital region
Meatal wart caused by
human papillomavirus
Vaginal condylomata caused by human papillomavirus.
Penile warts.
Slide 47
Treatment
The choice of therapy for genital warts depends on
several factors, including wart size, number, and location,
and patient and physician preference. Because genital
warts spontaneously resolve with time, observation
remains an option
the goal of treatment in HPV infection
1.
2.
3.
4.
remove exophytic warts
decrease signs or sx pt may have from wart infection
no therapy available to eradicate HPV
biopsy all atypical pigmented or persistent warts
Slide 48
The site-specific treatment for genital warts.
1. External genital, perianal, vaginal
1.
2.
primary: cryotherapy w/ liquid nitrogen
secondary: podophyllin 10-25% x 4 weeks, trichloroacetic acid 80-90%
weekly
treatment choices for patient-applied therapy include
3.
podofilox 0.5% solution or gel and imiquimod 5% cream. Podofilox solution should be
applied every 12 hours for 3 days, then off for 4 days with the option to repeat the
treatment cycle four times
Imiquimod cream should be applied three times per week at bedtime for up to 16
weeks. The area should be thoroughly washed 6 to 10 hours after application.
Imiquimod should not be used on vaginal lesions because it has been reported to
cause chronic ulceration
Surgical excision may be accomplished by electrocautery or sharply
with a tangential incision. Bleeding can generally be controlled with
electrocautery or silver nitrate application
2. Cervical: r/o dysplasia
3. Meatal
1.
2.
primary: cryotherapy
secondary: podophyllin
Slide 49
4. Urethral: cryotherapy, 5% 5-FU or thiotepa
do not use podophyllin
5. Large or extensive lesions surrounding the meatus may herald
the presence of urethral or bladder condylomata, warranting
cystourethroscopy. Urethral or bladder lesions should be
cystoscopically excised
6. Anorectal
1.
2.
primary: cryotherapy
secondary: surgical removal, trichloroacetic acid
7. Oral: surgical removal
Preliminary studies of prophylactic HPV-like particle vaccine
have been performed with encouraging results ( Evans et al,
2001 ; Ault et al, 2004 ).
A vaccine containing eight of the most common HPV types
associated with cancer could potentially prevent 95% of
cervical cancer
Slide 50
MOLLUSCUM CONTAGIOSUM
the etiologic agent for molluscum contagiosum
◦ DNA Poxviridae virus
◦ associated w/ HIV infection
the incubation period for molluscum 14 to 50 days
appear in the genital and inguinal regions, the inner thighs, and
perineum
diagnosis of molluscum
◦ small firm umbilicated papules on skin
smooth, pearly, or flesh coloured
◦ In immunocompetent persons the lesions usually spontaneously resolve
within a few months and usually by 1 year but may take up to 5 years
◦ biopsy: molluscum bodies seen
eosinophilic hyalin spherical masses seen on biopsy of mollusc
◦ the patients be tested for other STDs such as gonorrhea, chlamydia, and syphilis
and carefully examined for coexistent condyloma acuminata and pediculosis
pubis
◦ HIV testing in patients with extensive multisite lesions, especially those involving
the head and neck, and in lesions with a poor response to treatment.
Slide 51
Molluscum contagiosum affecting penis
Molluscum contagiosum on abdomen
Molluscum contagiosum.
Persistent umbilicated papules of the penile shaft.
Slide 52
Treatment
1. curettage
2. liquid nitrogen
3. chemical eradication: cantharadin, phenol, iodine, silver
nitrate, trichloroacetic acid
4. treat sexual contacts
Slide 53
SCABIES
the etiologic agent in scabies is mite: Sarcoptes
scabiei
The incubation period ranges from 2 to 6 weeks
the penile shaft and glands, areolae, finger webs, and
auxiliary folds
the diagnosis may require microscopic evidence of
the mite or eggs, which is retrieved by scraping the
burrow with a scalpel blade coated with mineral oil.
It can also usually be demonstrated if a thin shaving
of skin from a papule is removed and placed on a
glass slide and digested with heat and 10%
potassium hydroxide
Slide 54
Scabies affecting shaft of penis.
Slide 55
the sx of scabies
◦ severe urticaria worse at night, in bed
◦ severe excoriation
Treatment
1. permethrin cream (5%) to entire body – wash off
after 8 hrs
2. lindane 1% to entire body x 8-14hrs –
◦
3.
4.
cannot use if pregnant or lactating or children younger
than 2 years and patients with extensive dermatitis.
treat sexual partners
wash clothing and bed linen on hot cycle to kill
mites
Slide 56
PEDICULOSIS PUBIS
is the etiologic agent for pediculosis pubis (phthiriasis)
is crab louse
diagnose crabs
◦ Hx: itching of haired portion of pubis, thighs, or scrotum
◦ Px: nits seen attached to hair shaft near skin surface – can be
seen in axilla, eyelashes, or scalp
the treatment for crabs
1. permethrin cream to affected areas x 10min
2. lindane shampoo x 4min
should not be used after a bath and is contraindicated in children
younger than 2 years of age and in pregnant or lactating women
3. trimethoprim-sulfamethoxazole
4. treat sexual partners
5. wash bed linens and clothing
Slide 57