STI, PID, Genital Tb

STI, PID, Genital Tb Dawit Desalegn, MD Ob-Gyn Dept’, AAU-MF December, 2009

Sexually Transmitted Diseases • The term denote disorders spread principally by intimate contact:- • Sexual intercourse, • Close body contact, kissing, and anal intercourse. • Transplacental spread, • Passage through the birth canal, and • Lactation during the neonatal period

Terminology • WHO recommends that the term STD be replaced by the term STI. • STI has been adopted since 1999 as it better incorporates asymptomaticinfections. • Has also been adopted by a wide range of scientific societies & publications.

Introduction • the most common infectious diseases in the most parts of the world • five key points about all STDs today:

STDs affect men and women of all backgrounds and economic levels. - They are most prevalent among teenagers and young adults. - Nearly two-thirds of all STDs occur in people younger than 25 years of age.

continued 2. The incidence of STDs is rising - Because in the last few decades, young people have become sexually active earlier yet are marrying later. - In addition, divorce is more common. - The net result is that sexually active people today are more likely to have multiple sex partners during their lives and are potentially at risk for developing STDs.

continued 3 Most of the time, STDs cause no symptoms, particularly in women. - When and if symptoms develop, they may be confused with those of other diseases not transmitted through sexual contact. - Even when an STD causes no symptoms, however, a person who is infected may be able to pass the disease on to a sex partner. - recommend periodic testing or screening for people who have more than one sex partner.

continued 4, STDs tend to be more severe and more frequent for women than for men, - because the frequency of asymptomatic infection - many women do not seek care until serious problems have developed. - Some STDs can spread to cause PID, which in turn infertility & ectopic (tubal) pregnancy. - may be associated with cervical cancer; HPV - causes genital warts - other genital cancers.

continued 5. STDs can be passed from a mother to her baby before, during, or immediately after birth; - When diagnosed and treated early, many STDs can be treated effectively. - Some infections have become resistant to the drugs used to treat them and now require newer types of antibiotics.

STD; microorganisms • Long list • Transmitted by sexual route (conventional STI) • Transmission described but less defined evidence

Bacteria N. gonorrhea C. trachomitis T. pallidum H. ducreyi C. granulomatis U. urealyticum Viral HIV HSV HBV HPV Molluscom contagiosum virus Others T. vaginalis Cont’d; Organisms transmitted sexually

Bacteria M.hominis G. vaginalis Viral CMV HCV HSV type 8 EBV Others C. albicans S. scabiei STDs; described but less defined for sexual transmission

Sexually transmissible • Gonococci and Chlamydia infections • Syphilis • Genital herpes • Papilloma virus infection • LGV, Chancroid and GI • Miscellaneous causes

Approaches to STD Dx & Rx Three approaches • Laboratory based • Clinical without laboratory support • Syndromic Approach

Background • Traditional approach to STD Dx and Rx relies on laboratory diagnosis to determine etiologic agents • Expensive • Involves delay in Dx and Rx • Depends on technician and lab accuracy • Often not available in resource poor settings • Requires quality control procedures

…Background • Alternative approach – Clinical Dx • Presumptive Dx of one etiology based on clinical findings • Often inaccurate and incomplete • Similarities of Sn and Sx • Misses Co-infection • Atypical presentation - HIV

Definition • Syndromic Management is a management approach that uses clinical algorithms on an STD Syndrome, the constellation of patient symptoms and clinical signs to determine therapy. • Algorithms are adapted to local STD prevalence • Chooses antimicrobial agents to cover all the possible pathogens responsible for the syndromes in the specific geographic area.

Syndromic Management History • In 1991 WHO developed and started advocating the syndromic approach to address the limitation of aetiological (lab) & presumptive(clinical) Dx & Mx

…Syndromic Management Based On • Recognition of relatively consistent and characteristic combinations of easily elicited Sx and easily recognized Sn (Syndromes) with which STD commonly presents • Knowledge of the most common etiologies of different syndromes • Knowledge of antimicrobial susceptibility pattern • Knowledge of behavioral & demographic characteristics of people with STD

…Syndromic Management Components • Identification and Rx of the Syndrome • Education and counseling on - Rx compliance - Risk reduction including condom use • Partner notification • Provision of condoms • VCT for HIV

Advantages • Expedited care • Cost savings – less technically demanding • Increased client satisfaction • Treatment at first visit • Decreases further transmission • Decreases complication • Eliminates need for return visit • Decrease incidence of HIV (by 42% in Tanzania)

…Advantages • Uses flow charts in case Mx which • Standardizes Dx,Rx, referral and reporting • Improves surveillance • Improves programme Mx • High sensitivity • Gives emphasis to non-medical aspects of STD care

Disadvantages • Inevitable over treatment (multiple antimicrobials for single infection) • Does not address subclinical and asymptomatic STI • High sensitivity is at the cost of specificity • Doesn’t address poor health care seeking behavior for STD Sx • Works well with some syndromes (GU,UD) but not as well with others (VD)

…Disadv. • Rx with multiple drug might be expensive and • The recommended drugs may not be available • But, cost effectiveness increases further when • Applied to high STD prevalence areas • Long term cost of STD is considered • Increased HIV transmission and continued STD transmission is considered

Major STD Clinical Syndromes • Genital ulcer • Urethral discharge • Abnormal vaginal discharge • Lower abdominal pain • Bubo inguinale • Scrotal swelling • Neonatal conjuctivitis

Genital Ulcer Disease (GUD) • Algorithms for GUD try to identify presence of • Herpes, • Syphilis and/or • Chancroid • Frequency of causative agents differ in different parts • Review – syndromic treatment without lab support showed high cure rate • 100% - Cote D’ivore • 64% - Zambia

Herpes Simplex Virus • DNA virus • remain in latent form • other members of the family includes VZ, CMV ,EBV • there are different antigenic strains • but are divided in two:- • Type1 = oral • Type2 = genital • primary infection occurs in child hood • latent infection resides in the sensory ganglion of trigeminal, sacral & vagal • 50 -100% of adults have serologic evidence of HSV1 • 20-80% type2

HSV Cont… • transmission = only by direct contact • clinical disease • painful papule followed by vesicle ,ulceration crusting & healing • more sever in women • Primary Vs Recurrent • primary episode • more symptomatic • incubation range 2-14 days • there is fever & lymphadenities • viral shedding & healing prolonged

HSV Cont… • recurrent episode • frequently have prodromal period signaling active viral replication, • lesions are often localized • shedding is shorter • recurrences is not usually from re infection but are reaction of latent viruses

Diagnosis = mainly clinical • Tissue culture • best method but lengthy and costly • ELISA testing 70% • Direct immunofluoresent staining 75% sensitive = both the negative culture and smear don't exclude infection

Syphilis • organism characteristics & microbiology • By treponema pallidum • is tightly coiled a spirochete that can not be grown • can invade intact mucous membrane or area of abraded skin . • incidence and epidemiology • the incidence is rising • only 30% of patients exposed acquire the disease • in those infected patients not taking medication 60% do develop immune defense sufficient to control the infection • the remaining will go to late and tertiary syphilis

Clinical diseases 1. EARLY SYPHILIS A = primary syphilis, • painless chancre is the whole mark • it occurs at the site of inoculation • there is regional lymphadenopathy • incubation period 10-90 days B = 20 syphilis - mucocutaneous skin lesion 6-8weeks after the original inoculation - alopacia, hepatitis & nephrotic syndrome

continued 2. Latent syphilis • characterized by serologic evidences but no clinical signs &symptoms • most patients are not infectious about 25% could have recent skin lesion • arbitrary division of this stage but has no clinical significance with regard to treatment • early latency (< 4 years from initial infection ) • late latency (>4 years )

continued 3. LATE SYPHILIS • 5-30 years after initial infection • there are three divisions 1. benign disease(gummas) - lesion occur in vital organs • can be life threatening if they compromise the organ 2. cardiovascular disease - involvement of the heart and the aorta are frequent dysfunction may cause serious problem 3. neurological diseases - three clinical syndromes of neurological involvement • asymptomatic disease no neurological manifestations but abnormal CSF • meningovascular disease the commonest manifestation is paresis ,(tabis dorsalis) • parenchymatous disease dementia the commonest manifestation

Diagnosis A. Non treponemal specific test:- • RPR (rapid plasma reagin) test, • standard VDRL slide test, B. Treponemal specific test; • FTA-ABS; fluorescent treponemal antibody absorbed (used commonly for adults ), • MHA_TP micro haemagglutination assay( for neonates) C. Dark field microscopy • the higher the titer the higher the inflammatory reaction • false +ve tests in chronic illnesses • e.g. leprosy - auto immune diseases( lupus) • pregnancy - drug addiction

Chancroid • Haemophilus ducreyi :- a gram negative bacteria • is a painful soft chancre ragged with raised borders • kissing ulcers do occur • unilateral lymphadenopathy that may suppurate • incubation period is 2-5 days • the organism is fastidious

…GUD Genital ulcers Patient complains of genital sore or ulcer Examine -Educate -Counsel if needed -Promote/provide condoms No No Vesicular/recurrent lesion(s) present? Ulcer present? Yes Yes -Treat for syphilis and chancroid -Educate -Counsel if needed -Promote/provide condoms -Partner management -Advise to return in 7 days -Management of herpes -Educate -Counsel if needed -Promote/provide condoms

…GUD • Syphilis • Recommended regimen Benzantine Penicillin 2.4miu im singledose • Alternative regimen Procaine Penicillin 1.2miu im for ten days • Penicillin allergy– TTC 500mg po qid/15d or doxycycline 100mg po bid/15d

…GUD • Chancroid • Recommended regimen Erythromycin 500mg po qid/7days • Alternative regimen Ciprofloxacin 500mg single dose or Ceftriaxone 250mg im single dose or Spectinomycin 2gm im single dose

…GUD • Herpes – to modify course of symptoms • 1st episode – acyclovir 200mg 5x per day /7 days(doesn’t appear to influence natural Hx of recurrent disease) • Recurrence – acyclovir 200mg tid continuously for frequently recurring outbreaks(>6 per year)

Inguinal Bubo • Inguinal adenopathy • LGV (L1,L2,L3), • Chancroid, • G I (donovanosis) is • Klebsiella granulomatis, formerly known as Calymmatobacterium granulomatis • Common in the tropics as a cause of genital ulcer • Men affected more than females • Prostitution is reservoir • Painful adenopathy

Inguinal Bubo, cont’d • Rare systemic symptoms except LGV • Common predisposing factor for the spread of HIV • Complications: • Abscess formation • PID • Lymphatic obstruction • Stenosis • Infertility

Differential Diagnosis • Infection in the lower limbs and perineum • Malignancy • Herpes genitalis • Syphilis

Inguinal Bubo Enlarged and/or painful inguinal lymph nodes? Examine Yes Ulcer(s) present? Use genital ulcers flow chart No -Treat for lymphogranuloma venereum -Educate -Counsel if needed -Promote/provide condoms -Partner management -Advise to return in 7 days

…Inguinal Bubo • Recommended regimen (LGV) Doxycycline 100mg po bid/14 days or TTC 500mg po qid/14 days • Alternative regimen Erythromycin 500mg po qid/14 days or Sulfadiazine 1gm qid/ 14 days • Aspirate fluctuant lymph nodes through normal skin • Incision and drainage or excision of nodes is contraindicated

Vaginal Discharge (VD) • Most difficultsyndrome to diagnose • Either vaginitis or cervicitis • Cervicitis- N.gonorrhea - C.trachomatis • Vaginitis - Trichomonas vaginalis - Candida albicans - Bacterial vaginosis • Effective management of cervicitis is more important from patient point of view b/c of serious sequele

…VD • VD is not an adequate indicator of any particular STD making it a poor algorithm entry point • Use of riskassessment has shown to improve performance of syndromic management algorithms • The probability of correct Rx of STI relative to probability of overtreatment is increased

…VD • Risk scores use variables that are common risk predictors for STD • Young age less than 21 • Multiple partners • Partner has urethral discharge • New partner in the past three months • Patient is single • Need adaptation to local,social and behavioral conditions and should be periodically updated

…VD Vaginal Discharge Patient complains of vaginal discharge (vaginal itching) partner symptomatic or specific risk factors positive? No -Treat for vaginal infection -Educate -Counsel if needed -Promote/provide condoms Yes -Treat for cervical and vaginal infections -Educate -Counsel if needed -Promote/provide condoms -Partner management -Return if necessary

…VD Vaginal Discharge (with speculum) Patient complains of vaginal discharge (vaginal itching) partner symptomatic or specific risk factors positive? No Yes Treat for cervical infection plus vaginal infection according to speculum examination findings Speculum and bimanual vaginal examinations Mucopus from Cervix? Profuse VD? No discharge? Curd-like VD? Cervical motion tenderness present? -Educate -Counsel if needed -promote/provide condoms -Treat for cervical & vaginal infections -Educate -Counsel if needed -Promote/provide condoms -Partner Mx -Return if necessary -Treat for trichomonas & bacterial vagionosis -Educate -Counsel if needed -Promote/provide condoms -Partner Mx -Return if necessary -Treat for candida -Educate -Counsel if needed -Promote/provide condoms -Return if necessary Use flow- chart for lower abdominal pain

STI, PID, Genital Tb