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Sexually Transmitted Diseases

Sexually Transmitted Diseases. Seema Izfar, MD 2/15/12. Sexually Transmitted Diseases. there are more than 25 diseases spread primarily by sexual means distal anoderm, perinanal skin, anoderm - can either be from anal intercourse or contiguous spread from other genitalia.

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Sexually Transmitted Diseases

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  1. Sexually Transmitted Diseases • Seema Izfar, MD • 2/15/12

  2. Sexually Transmitted Diseases • there are more than 25 diseases spread primarily by sexual means • distal anoderm, perinanal skin, anoderm - can either be from anal intercourse or contiguous spread from other genitalia

  3. Sexually Transmitted Diseases • hard to diagnose • usually symptom of an organ rather than organism • often presence of more than one organism • true pathogen vs colonizing organism • lack of rapid sensitive diagnostic tests

  4. Anorectal Immunology • anal health requires integrity of skin and mucosa • immunoglobulin A (rectal mucosa) • cell-mediated immunity: Langherhan cells, T cells • HPV invades and increases Langherhan cells • HIV destroys LCs • HPV and HSV invade cell and destroy nm surveillance • HIV, HAART, +/- HSV may increase HPV-related dysplasia

  5. Gonorrhea • gram-negative diplococci • most common bacterial STD involving anorectum • occurs in columnar, cuboidal epithelium • frequently asymptomatic - incubation 3d - 2wks • 35-50% of women with cervical gonorrhea have rectal gonorrhea (contiguous spread)

  6. Gonorrhea

  7. Gonorrhea • symptoms: pruritus, tenesmus, bloody or mucopurulent discharge, pain • can have external erythema or superficial ulceration • anoscopy/proctoscopy with thick purulent discharge or nonspecific proctitis • lube may decrease yield of cxs • treat: cephalosporin or quinolone (penicillin G resistance high)

  8. Chlamydia/Lymphogranuloma Venereum • obligate intracellular organism • simultaneous infection with gonorrhea common - treat both • LGV serovars - more aggressive infection with perianal, anal, and rectal ulceration • anoscopy/proctoscopy with friable rectal mucosa - can be difficult to distinguish from Crohn’s • rectal gram stain - PMN’s without visible diplococci

  9. Chlamydia/Lymphogranuloma Venereum • can do direct fluroescent Ab detection or ELISA • or treat empirically - azithromycin one dose 1g orally, or doxy 100mg BID x 7days • LGV - doxy for 21 days • HIV and LGV may require longer therapy

  10. Syphilis • spirochete Treponema pallidum • primary (chancre or proctitis), secondary (condyloma lata) or tertiary • anal chancre - small papule that ulcerates - painful (differs from genital chancre) • can be difficult to distinguish from anal fissure

  11. Anal Syphilis

  12. Syphilis • primary within 2-10 wks exposure, secondary 4-10wks after primary lesion • secondary - hematogenous dissemination: fever, malaise, arthralgias, wt loss • findings: maculopapular rash, condyloma lata • symptoms resolve 3-12 wks rather, 25 % relapse (early latent syphilis)

  13. Syphilis • diagnosis: visualization of spirochetes on dark-field microscopy • also may be demonstrable on Warthin-Starry silver stain • RPR, VDRL - false neg 25% • treatment: penicillin G 2.4 million units IM, pen-allergic treated w doxy 100 BID x 14d • failure treated with re-dose pen G x 3 wks • f/u serology (RPR or VDRL) at 6 mos, re-check at 3mos for HIV positive pts

  14. Syphilis

  15. Haemophilus Ducreyi • gram-neg facultative anaerobe - causes ulcerating STD • more common in developing countries (only 6million global incidence) • tender papules with erythema --> pustules --> erosions • painful LAD - more common in males • facilitates transfer of HIV (ulcerations, open sores)

  16. Haemophilus Ducreyi • diagnosis by GS - nonmotile GNRs in groups • difficult to culture • PCR more sensitive • treatment - single-dose azithromycin 1g or ceftriaxone 250mg IM

  17. Danovanosis Inguinale • ulcerating lesion of genitalia - sexual and nonsexual transmission - C. granulomatosis or Donovania granulomatosis • more common in Africa, SA, Australia • subsequent sclerotic lesions can cause anal stenosis • cannot be cxed but can see macrophage inclusions on smear (Donovan bodies) • doxy 100 BID x 7 days or 3 wks azithro, cipro, or erythro

  18. Herpes Simplex Virus • DNA virus - same family as EBV, CMV, VZV • 20% population seropositive (50% in black females) • increasing HSV-1 genital transmission (30%) • clinical: systemic (fevers, HA, malaise), pina, vesicles, coalescence, healing

  19. Herpes Simplex Virus • HSV second most common cause of proctitis in homosexual males • distal 10cm - friable • sacral radiculopathy, urinary retention, constipation, impotence • tender LAD in 1/2 of pts • latency in host cell nuclei (sensory ganglia)

  20. Herpes Simplex Virus • diagnosis by clinical picture • pap smear or Tzank prep: multi-nucleated giant cells with inclusion bodies - ground glass • cxs from swabs or biopsies • direct immunofluorescence

  21. Herpes Simplex Virus • treatment of symptoms • can have shortened course of herpes proctitis with 10d acyclovir • IV acyclovir for severe symptoms • >five recurrences/yr considered for suppressive treatment - valyclovir, acylovir • daily valcyclovir suppression has show to lower transmission rate

  22. HPV • DNA papovirus - most common STD • 80 subtypes - 16 and 18 have highest risk of anal dysplasia • anoscopy - involvement above dentate line rare • destruction and fulguration of all gross disease - recurrence 20-30% • burn superficial condyloma without intruding on deep dermis or fat

  23. HPV • topical agents like podofilox or imiquimod not approved for us inside anal canal • podofilox - BID x 3 days, off 4 days - cycle one month • clearance 35-80% with recurrence 10-20% • imiquimod - increases local interferon production - 3x/wk x 16 wks • response in 50%, recurrence in 11%

  24. HPV • Bushke-Lowenstein tumor - giant condyloma, risk for underlying squamous or in situ SCC, excise with 1cm margins • chemorads for poor surgical candidates • can do APR if involving the sphincters

  25. Molluscum Contagiosum • poxvirus - benign papular condition • 2 to 6mm umbilicated papules • excisional bx with enlarged epithelial cells with intracytoplasmic molluscum bodies • treatment with eradication, can also use podophyllin or imiquimod

  26. HIV • ~5% pt with anorectal complaints HIV pos • several studies with poor wound healing and increased morbidity after anorectal procedures in HIV pts • assoc with presence of AIDS, dec. leukocytes, dec. CD4 • Morandi et al - 50% AIDS pts p hemorrhoidectomy with nonhealing wounds at 32 wks

  27. HIV • HIV anal fissures and ulcers - need to distinguish from STD ulceration like HSV or syphilis • HIV-related ulcers more proximal in anal canal (above dentate line) - surgical debridement, bx, cx, can inject with steroids to help w pain

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