Sexually Transmitted Diseases (STDs)

1. Sexually Transmitted Diseases (STDs) Khalid A. Yarouf 4MedStudents.com

2. Outline • Introduction. • Urethritis: • Clinical Features. • Hx. • P/E. • Investigations. • Management. • 2 Cases.

3. Introduction • Communicable disease transmitted b/w humans mainly by sexual activity including genital-genital contact, anal-genital contact & oral-genital contact. • May also be transmitted by blood & during birth. • STD syndromes: urethritis, epididymitis, cervicitis, vulvovaginitis, genital ulcer disease, infertility, AIDS, intestinal infections, genital warts, neoplasia, scabies, pubic lice.

4. Urethritis • Painful urethral discharge & testicular swelling are the most common presentations of symptomatic STDs in ♂. • Complications of urethritis: epididymitis, Reiter’s synd, prostatitis, inflammatory strictures. • Non-gonococcal urethritis (NGCU) is > common than gonococcal urethritis.

5. Urethritis (Clinical Features) • Urethral discharge often worse in morning, dysuria, urethral itching.

6. Con’t (CFx) • Upper figure: Specimens of urethral pus showing PNMs ingesting N. gonorrhoeae, seen as kidney-shaped diplococci. • Lower figure: Gonococcal urethritis. Typical purulent meatal discharge with inflammation of glans.

7. Con’t (CFx) • Epididymitis: • Causes: mostly 2º to urethritis or prostatitis. • When accompanied with urethritis  probably sexually acquired. • Symptoms: • Acute onset of unilateral testicular pain & swelling. • Urethral discharge & dysuria. • P/E: • Tenderness of epididymis & vas deferens. • Erythema & edema of overlying skin. • DDx: trauma, torsion of testicles, tumor.

8. Con’t (CFx) • Hx: • Sexual activity: multiple partners, sexual orientation, use safe sex, type of sex. • UTI signs. • Recent Hx of trauma or genito-urinary (GU) tract manipulation. • Known or suspected structural or functional abnormalities of urinary tract. • P/E: • Look @ urethral discharge. • If not obvious on GU exam  ask pt to milk his urethra from base to meatus 3-4X. • If no discharge initially  ask symptomatic pt to return for reexamination @ least 4 hours after voiding.

9. Con’t (CFx) • Examine scrotal contents. • Early in epididymitis, swelling & tenderness is localized to one area of epididymis. But in time, swelling usually extends to involve whole epididymis & surrounding area such that the epididymis is not discernible in inflammatory mass. • Gentle elevation relieves pain of testicular torsion, while increases in epididymitis. • A non-tender, rock-hard scrotal mass should make you think of Ca.

10. Con’t (Ix) • Lab test  Urethral swab of discharge: • Gram stain: look for Gram (-)ve intracellular diplococci (GC) inside WBCs • ↑ Sensitivity & specificity = 97-99%. • Culture it for GC, or, Chlamydia (sensitivity 70-90% & specificity 100%). • If swab of discharge from cervix  sensitivity 30-65%.

11. Con’t (Mx) 3º Prevention = early effective intervention. • Pharmacological: • GC  Ceftriaxone 125 mg IM. • NGCU: • Doxycyline 100 mg orally twice X 7 days OR • Azithromycin 1 g orally in single dose. • If Trichomonas is suspected  consider presumptive Rx for GC & Chlamydia while awaiting cultures. • If CFx of epididymitis are present  test for GC & Chlamydia  presumptively treat for Chlamydia, use ice, NSAIDs, scrotal support, rest.

12. Con’t (Mx) • Non-pharmacological: • Sexual intercourse should be avoided for 7 days after initial Rx. • Referral of partner(s) who have symptoms within preceding 60 days to Rx. • Patient education. • REPORT to Preventive Medicine Department. • Follow-up: pt should return for evaluation if symptoms persist / recur after completion of Rx.

13. Con’t (Mx) 2º Prevention = Prevention of disease after it starts, but before symptoms appear. • Tracing & Rx of partners of cases. • Screening: • of sexually active people for infection (Chlamydia, gonorrhea, syphilis, HIV, cancer due to HPV by Pap smear). • and Rx of pregnant women to prevent transmission to fetus.

14. Con’t (Mx) 1º Prevention = Prevention of disease before it starts. • Abstinence or mutually faithful relationship. • Safer sex  correct use of condoms: • Latex condoms preferred. • Use new, in-date, good condition condom & handle carefully, leave space at the tip. • Use adequate water-based lubricant. • Vaginal spermicide increases effectiveness (before intercourse). • Counseling & Rx of cases and partners  to prevent new transmission. • Education of adolescents on prevention. • Vaccination for Hepatitis B.

15. Con’t (Mx) Recurrent / persistent NGU: • Usual time = 2-3 weeks following Rx. • Tests for Chlamydia & Ureaplasma are usually (-)ve. • Hx: • Check compliance. • Establish any possible contact with untreated sexual partners. • P/E: • Document objective evidence of urethritis. • Ix: • Wet preparation & culture of urethral smear for Trichomonas vaginalis & fungi. • Culture should be taken for HSV. • MSU should be examined & cultured. • Mx: a further two weeks’ Rx with Metronidazole AND Erythromycin.

16. Case 1 • Abdullah is a 34-year old married Emarati man who came to your PHC clinic complaining of low back pain. He says he hurt his back lifting a chair at home a week ago. The pain is felt in the lumbar area and is a moderately severe ache. There is no radiation of the pain to either leg. The pain is a bit worse with sitting. It is relieved by lying down. It’s improving slowly. There are no abnormal physical findings. During your discussion with him about the management of low back pain, he mentions that he has had a urethral discharge of several weeks. There’s no dysuria. He says he has been checked for this and describes midstream urine test which he says was normal 2 weeks ago. While you’re trying to explain to him the need for appropriate testing and management, he gets up and walks out.

17. Questions • What test is appropriate for his urethral discharge? • What might be the cause? • What would be the management? • What public health implications might there be? • What other related problems can you think of? • How should they be managed: • from an individual health? • from a public health point of view?

18. Case 2 • A 16-year old young man sees you at the PHC complaining of a URTI. He asks for a script for cough syrup and leaves. 2 days later he is back with his mother. She comes into the consultation room with him and stays with him until he tells you that he has pain with urination. The she leaves. The boy then tells you that 7 days ago he had a sexual encounter with a prostitute in Dubai! He has had dysuria for 4 days. He admits that he was too embarrassed to bring up this complaint when he was in to see you 2 days ago.

19. Questions • What other information would you like to know? • What might be the cause of this young man’s problem? • What other infections must you consider? • What test would you do? • What organisms might be involved? • What personal and public health issues arise from this example?