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February 19, 2009 Sexually Transmitted Diseases I H. Hunter Handsfield, MD

February 19, 2009 Sexually Transmitted Diseases I H. Hunter Handsfield, MD. I-TECH STD Update Series H. Hunter Handsfield, MD Devika Singh, MD. Genital syndromes in men: Urethritis and related conditions Genital syndromes in women I: Cervicitis, vaginal infections

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February 19, 2009 Sexually Transmitted Diseases I H. Hunter Handsfield, MD

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  1. February 19, 2009 Sexually Transmitted Diseases I H. Hunter Handsfield, MD

  2. I-TECH STD Update SeriesH. Hunter Handsfield, MDDevika Singh, MD • Genital syndromes in men: Urethritis and related conditions • Genital syndromes in women I: Cervicitis, vaginal infections • Genital syndromes in women II: PID, STD and pregnancy, HPV and cervical cancer • Genital ulcer disease: Herpes, syphilis, and miscellaneous STDs

  3. VD, STD, STI: What’s the Difference? • Venereal Disease:Syphilis, gonorrhea, LGV, chancroid, donovanosis • “VD” clearly became pejorative and scientifically limited • Sexually Transmitted Disease:NGU, chlamydia, cervicitis, herpes, etc • An improvement, but what about “disease”? • Sexually Transmitted Infection: Asymptomatic HSV, HPV, HIV not viewed as “disease” • However, it is now undertood that Sx and Asx infections have equal clinical and epidemiologic implications • But perhaps “infection” is less stigmatizing than “disease”

  4. STDs are Sexist • Transmission efficiency greater male to female than the reverse • More women asymptomatic or with atypical, nonspecific Sx; delayed care • Diagnosis more difficult in women • Complications more frequent in women, often severe or permanent

  5. Male Genital InfectionsCase 1 PRESENTATION • 27 year old man • History • 2 days mildly painful urination • 1 day staining of underwear, “maybe a drip from my penis” • Unprotected vaginal sex with a new female partner 5 days ago, “but I didn’t pay her” • Last void 2 hours prior to exam EXAMINATION

  6. Male Genital InfectionsCase 1 DIFFERENTIAL DIAGNOSIS OF URETHRITIS • Gonorrhea • Nongonococcal urethritis (NGU)* • Nonsexually acquired • Trauma • Schistosomiasis • Coliforms, Enterococcus, coag-neg staph, etc • Other * Same as nonspecific urethritis (NSU)

  7. Gonorrhea • Etiology: Neisseria gonorrhoeae (gonococcus) • Main manifestations: Urogenital inflammation (urethra, cervix, rectum, fallopian tubes, epididymis) • Women: Cervicitis, urethritis, pelvic inflammatory disease, infertility, tubal pregnancy • Men: Urethritis, epididymitis, reactive arthritis • Newborns: Eye infections • Treatment: Antibiotics, primarily cephalosporins; quinolones (resistance problems) • Prevention and control • Personal: Safe sex, condoms • Public: Screening, esp. women

  8. Gonococcal Isolate Surveillance Project (GISP) — Percent of Neisseria gonorrhoeae isolates with resistance or intermediate resistance to ciprofloxacin, 1990–2003 Note: Resistant isolates have ciprofloxacin MICs ≥ µg/ml. Isolates with intermediate resistance have ciprofloxacin MICs of 0.125 - 0.5 µg/ml. Susceptibility to ciprofloxacin was first measured in GISP in 1990.

  9. Treatment of Uncomplicated Gonorrhea RECOMMENDED • Ceftriaxone 125-250 mg IM • Cefixime 400 mg PO • Cefpodoxime 400 mg PO • Ciprofloxacin 500 mg PO • Ofloxacin 400 mg PO • Levofloxacin 250 mg PO PLUS • Azithromycin or • Doxycycline No longer recommended Include as syndromic management of urethritis

  10. Male Genital InfectionsCase 2 PRESENTATION • 22 year old man • History • 1 week scant urethral discharge • No pain • Unprotected vaginal sex intermittently with 2 partners in preceding 3 months, last sex “about 2 weeks ago” EXAMINATION

  11. Male Genital InfectionsETIOLOGY OF NGU INITIAL, NON-RECURRENT, DOCUMENTED URETHRITIS • Chlamydia trachomatis 20-40% • Mycoplasma genitalium 10-20% • Other and unknown 30-50% • Ureaplasma urealyticum? 10-30%? • Normal flora (oral, vaginal)? 10-20%? • U. parvum0 • Trichomonas vaginalis 0-5% • Adenovirus 0-5% • Herpes simplex virus 0-5% See Bradshaw et al, JID 2006;193:336-45

  12. Clinical Diagnosis of Urethritis • Abnormal discharge observed: purulent, mucopurulent • Preferably examine >4 hr since last urination • In absence of visible discharge • Symptoms: Discharge + dysuria • Documented urethral inflmmation • Gram stained smear (preferred) • WBC or leukcocyte esterase in first-void urine

  13. Etiologic Diagnosis of Urethritis • Gram stained smear of urethral secretions • >5 WBC per 500x microscopic field • ICGND for gonorrhea • Sensitivity 90-95% • Specificity 90-95% • Microbiology, if available and cost effective • N. gonorrhoeae (Culture or NAAT) • C. trachomatis (NAAT) • U. urealyticum NOT RECOMMENDED • M. genitalium? NAAT not readily available • Other (T. vaginalis, HSV, others: not practical) • Symptomatic; lower if asx • Dependent on experience

  14. Treatment of NGU • Azithromycin 1.0 g, single dose • Chlamydia efficacy 90-95% • Clinical efficacy ~90% • M. genitalium: Usually effective but apparent risk of inducible resistance • Doxycycline 100 mg po BID x 7 days • Chlamydia efficacy >98% • Clinical efficacy ~90% • M. genitalium Not effective • Alternatives: Other tetracyclines, erythromycin, fluoroquinolones

  15. Gonorrhea versus NGU

  16. NGU Counterparts in Female Partners • Gonorrhea • Chlamydia • Trichomoniasis • Herpes • No others are certain • M. genitalium? (active research) • Ureaplasma: probably none • Some NGU may be caused by partner’s normal flora • No female or male partner morbidity has ever been reported for nonchlamydial NGU

  17. Management of Sex Partners of Men with NGU • Goals • Treat/prevent chlamydia • Prevent reinfection • Treat with same regimen as index case • Examine for other STDs, if practical • Partner treatment of unknown benefit in recurrent or persistent NGU

  18. Recurrent and Persistent NGU • Symptoms may take 10-14 days to completely resolve • Symptoms persist or recur within 4-6 weeks in 10-15% • Evaluation • Document urethritis • Otherwise, no treatment • Treatment • Retreat with opposite drug (AZM or doxy) • Metronidazole or tinidazole • No documented need to retreat partners

  19. Male Genital InfectionsCase 3 PRESENTATION • 33 year old HIV infected married man • Outwardly healthy, CD4 500 cells/mm3, not on ART • History • 2 days severe dysuria • “Maybe a little” urethral discharge • Monogamous with wife, regular unprotected vaginal and oral sex • Wife not known to have HIV, but “we assume she has it” EXAMINATION

  20. Bacterial verus Viral NGU Concider acyclovir in patients with proiment dysuria and meatal inflammation? Bradshaw C et al. JID 2006;193:336-45

  21. Male Genital InfectionsCase 4 PRESENTATION • 34 year old HIV infected man • Intermittent ART, CD4 100 cells/mm3, chronic diarrhea, weight loss, cough • History • Scant urethral discharge, mild dysuria 2 weeks • Painful, swollen R testicle 7 days, increasing • Claims monogamous with wife (evasive) • Night sweats and “maybe a little fever” 2-3 weeks

  22. Male Genital InfectionsCase 4 EXAMINATION • Slim, thenar wasting, dishydrosis • Temperature 38.2 • Right testicle diffusely enlarged, 3+ tenderness, indurated; uncertain localization to epididymis • Testicle not obvlously elevated in scrotal sac • No visible urethral discharge

  23. Male Genital InfectionsCase 4 DIAGNOSIS AND MANAGEMENT? • Evaluate for urethritis • Urethral gram stained smear etc • Increased WBC, no ICGND • Urine culture if available • Initial therapy • Ceftriaxone or other single-dose GC regimen plus either • Ofloxacin 300 mg PO BID x 14 days or • Doxycycline 100 mg PO BID x 14 days • Evaluate for tuberculosis

  24. Acute Testicular Enlargment 1 • Epididymitis • Chlamydia, gonorrhea • Age <35 • Sexually active • Nonsexually transmitted UTI pathogens (E. coli, Enterococcus, Pseudomonas, etc) • Age >35 • Insertive anal sex • Urethral instrumentation • Anatomic anomalies, e.g. urethral stricture • Drugs • Amiodarone, e.g.

  25. Acute Testicular Enlargment 2 THE FOUR T’s • Trauma • History usually is obvious • Torsion • Age 12-20 • Sudden onset, often during sleep • Elevation of testicle • Surgical emergency to salvage testicle • Tuberculosis (and mycoses) • Local epidemiology • Individual risk, e.g. HIV • Usually gradual onset • Tumor (i.e., testicular cancer) • Usually gradual onset • Usually not tender

  26. Complications of Male Urethritis

  27. Male Genital InfectionsCase 5 PRESENTATION • 27 year old man, not known to have HIV • History • Mongamous 5 yr apart from condom-protected vaginal sex with CSW 6 weeks ago • Vague pain in groin, testicles, penile “tingling” started the next morning, worsening in past 2 weeks • Two episodes of “semen” (“cloudy, like mucus”) from penis during defecation • “STD panel” 1 week after exposure: Negative urine for GC/CT, neg blood for HIV, syphilis, HSV-2, HBV, HCV • Self treatment with amoxycillin, minocycline, ciprofloxacin • “I must have chlamydia or herpes, doctor! I can’t have sex with my wife. Please help!”

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