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Sexually Transmitted Diseases

Sexually Transmitted Diseases. They include GENITAL ULCERS HSV, chancroid , syphilis, lymphogranuloma venereum , Granuloma Inguinale Chlamydia ( urethritis / cervicitis / epididymitis ) gonorrhea, ( urethritis / cervicitis / epididymitis ) GENITAL WARTS MOLLUSCUM CONTAGIOSUM

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Sexually Transmitted Diseases

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  1. Sexually Transmitted Diseases

  2. They include • GENITAL ULCERS • HSV, • chancroid, • syphilis, • lymphogranulomavenereum, • GranulomaInguinale • Chlamydia (urethritis/cervicitis/epididymitis) • gonorrhea, (urethritis/cervicitis/epididymitis) • GENITAL WARTS • MOLLUSCUM CONTAGIOSUM • Scabies • PEDICULOSIS PUBIS

  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 ).

  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.

  5. groups are at higher risk of contracting an STD • men • low socioeconomic class • blacks • drug users • urban • Adolescent • STDs require contact tracing and treatment of sexual partners • syphilis • gonorrhoeae • chlamydia

  6. GENITAL ULCERS • pathognomonic presentations of an ulcer • fixed drug eruption: always triggered by the ingestion of one particular medication • herpes simplex: vesicles on an erythematous base • 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 ).

  7. the DDx for genital ulcers • Premalignant • erythroplasia of Queyrat • Malignant • SCC • Non-malignant • syphilis • chancroid • herpes • lymphogranulomavenereum • granulomainguinale • fixed drug eruptions • traumatic ulcers

  8. 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 • granulomainguinale: crush prep for cytologic or histologic identification of C. granulomatis • lymphogranulomavenereum: PCR, serologic test, culture for C. trachomatis

  9. 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.

  10. 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 10-25% 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

  11. Vulvovaginal herpes simplex virus infection Herpes simplex virus infection on the penis • 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. Typical vesicular eruption of herpes simplex virus.

  12. diagnose HSV • pathognomonic vesicles on erythematous base • Pap smear: intranuclear inclusions • immunofluorescent techniques • viral isolation by culture: most sensitive • PCR for HSV • Treatment.

  13. CHANCROID • the etiologic agent in chancroid • H. ducreyi • the physical findings in chancroid. • painful lymphadenopathy in 50% • ulcer w/ deep undermined border • soft, indurated, and purulent • base of lesion friable and bleeds easily • 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

  14. Chancroid with regional adenopathy Chancre. Erosive volcano-like lesion with a hard border Chancroid. Soft, painful, erosive lesions.

  15. 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

  16. SYPHILIS • the etiologic agent for syphilis • Treponemapallidum 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

  17. Syphilis with vulvar chancre Syphilis with penile chancre Secondary syphilis affecting the soles of the feet Secondary syphilis affecting the genitalia

  18. How can syphilis be diagnosed? • 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

  19. LYMPHOGRANULOMA VENEREUM • caused by C. trachomatisserotypes L1, L2, L3 • Diagnosis • the physical findings in lymphogranulomavenereum 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.

  20. Lymphogranulomavenereum Lymphogranulomavenereum. Swollen bubo in the area of inguinal lymph nodes. Lymphogranulomavenereum with inguinal adenopathy

  21. diagnose lymphogranulomavenereum by • culture of C. trachomatis • best obtained from aspiration of fluctuant inguinal node • bloodwork • leukocytosis, anemia, elevated gamma globulins • the treatment of lymphogranulomavenereum • doxycycline 100mg PO BID x 21d

  22. GranulomaInguinale • Etiologic agent in granulomainguinale • Calymmatobacteriumgranulomatis • Gm-ve intracellular organism • Physical findings in granulomainguinale. • small papule seen first • forms as small ulcer painless above level of the skin • base of ulcer erythematous, may bleed • nontender, indurated, and firm

  23. Granulomainguinale. Irregularly shaped ulcer without inguinal adenopathy

  24. Diagnose granulomainguinale • identification of Donovan bodies on a stained smear • Blue or black staining bodies ) • crush specimen for histologic study • biopsy • no culture available • Treatment of granulomainguinale. • 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

  25. 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 • 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 • 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 mucopurulentendocervical 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

  26. 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

  27. Etiologies of NGU • C. trachomatis 30 – 50 % • U. urealyticum. 20 – 50 % • Mycoplasmahomins • HSV • T. vaginalis • Mycoplasmagenitalium • diagnose NGU • intraurethral swab • Gram stain: >4 PMN per HPF • first-void urine • spun sediment: >15 PMN per HPF • WBC on dipstick • Chlamydia cultures • performed on an endocervical swab specimen

  28. other assays • direct fluorescent antibody (DFA) • Chlamydia-specific monoclonal Ab conjugated to fluorescent stain • ELISA • 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

  29. Treatment • Azithromycin, 1 g by mouth as a single dose, or doxycycline, 100 mg twice daily for 7 days. • Alternative therapies include • 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 • 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 • resistance • usually due to tetracycline-resistant Ureaplasmaurealyticum treat w/ erythromycin x 1-2weeks

  30. the evaluation for men w/ recurrent or persistent urethritis despite adequate treatment. • urethral swabs: Neisseriagonorrhoeaeand 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 • PID • Infertility • single episode: 12% • 2 episodes: 35% • 3 epidodes: 75% • ectopic pregnancy • pain • perinatal infections

  31. GONORRHEA • caused by the gram-negative diplococcusNeisseriagonorrhoeae • 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 mucopurulentendocervical discharge may be present. • Many women are asymptomatic

  32. Differential Diagnosis of STDs in Women

  33. 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

  34. 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

  35. 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

  36. complications of acute epididymitis • abscess formation • testicular infarction • chronic pain • infertility

  37. Management of the acute scrotum.

  38. 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)

  39. Meatal wart caused by human papillomavirus Condylomaacuminatum. Exophytic warty lesion of the genital region Penile warts. Vaginal condylomata caused by human papillomavirus.

  40. 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 • 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

  41. The site-specific treatment for genital warts. • External genital, perianal, vaginal • primary: cryotherapy w/ liquid nitrogen • secondary: podophyllin 10-25% x 4 weeks, trichloroacetic acid 80-90% weekly • treatment choices for patient-applied therapy include • 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 • Cervical: r/o dysplasia • Meatal • primary: cryotherapy • secondary: podophyllin

  42. Urethral: cryotherapy, 5% 5-FU or thiotepa • do not use podophyllin • 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 • Anorectal • primary: cryotherapy • secondary: surgical removal, trichloroacetic acid • 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

  43. MOLLUSCUM CONTAGIOSUM • the etiologic agent for molluscumcontagiosum • 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 • eosinophilichyalin 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 condylomaacuminata 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.

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