Sexually Transmitted Diseases

1. Farah Chouhdry ST1 GP Sexually Transmitted Diseases

2. Sexually Transmitted Diseases • bacterial infections • viral infections • fungal infections • protozoal infections • parasitic infestation

3. Lumps & Ulcers

6. GENITAL WARTS • These are benign tumours of the epidermis induced by inoculation of specific human papilloma viruses • Most common viral sexually transmitted infection in the UK • Highest rates of diagnosis are seen in young women and men under 24 years • The mean incubation period is about 3 months (range from 3 weeks to 8 months.) • Caused by different strains of human papilloma virus - especially HPV types 6 and 11, which cause over 90% of the genital warts

7. ......Clinical features • Women: asymptomatic or painful, friable,lesions or pruritis • Men : generally see them • The lesions can be solitary or multiple. • Those on the warm, moist, non-hair bearing areas are usually soft and non-keratinised,filiform, larger(1-5mm) • Those on the dry hairy skin are firm and keratinised. • Warts start as small flat lesions 1-2 mm in diameter. • The larger warts become pedunculated and may resemble a cauliflower in appearance. • The growth of the warts is favoured by pregnancy, poor hygiene and vaginal discharge.

8. …..HPV and genital cancer • HPV-DNA is found in 85-100% of high-grade cervical precancer • infection with HPV type 16 or 18 has been associated with a higher rate of progression of cervical squamous intraepithelial lesions and cancer (1) • one study in 106 early carcinomas found the following serotypes: • HPV 16 -55% • HPV 18- 17% • HPV 33- 6% • HPV 35- 1% • unidentified HPV 10% • No HPV 16% (Favre et al Lancet 1990) • The link between HPV and cervical cancer is strong and epidemiologically it may be considered to be causal

9. ......Managment • Cryotherapy or topical application in clinic • Home treatment with podophyllotoxin cream or lotion (Soft non keratinized warts) • Curettage or surgical removal may be indicated (Keratinized warts). • Imiquimod 5% cream is another treatment option.imiquimod is an immune response modifier. • the partner should be seen for a check up, and the couple treated at the same time if necessary • sexual intercourse should be avoided during treatment, though condoms may protect against transmission • women should not become pregnant during treatment therefore good contraception is essential • warts grow in warm, moist areas, therefore it may be advisable to wear loose clothing and underwear • the use of condoms for three months after the disappearance of lesions is empirical • Topical photodynamic therapy

13. Genital herpes • Caused by Herpes simplex virus type 1 & 2 • HSV is spread through skin-to-skin contact or direct mucocutaneous contact • The incubation period is 3 days to 2 weeks after exposure • Complications occur more often in men, who also suffer more with symptoms. • Recurrent attacks are common

14. ...Clinical Features Local symptoms on day 0, after incubation: • itch and tingling ,redness ,vesicle formation, By day 8 or 9: • pustule developing into a wet ulcer ,dysuria - ulcers are exquisitely painful, and retention of urine may result • vaginal / urethral discharge ,inguinal lymphadenopathy • HSV pharyngitis in 10% of oral cases Systemic features: • headache ,myalgia ,general malaise ,urinary retention, constipation From day 10: • healing with crusting, complete by day 14 • may get a second crop

15. ....Diagnosis • History and examination. • The gold standard is viral culture. • Other diagnostic methods : • polymerase chain reaction testing, • Antibody-based tests,(Western blot assay –gold standard) • (type-specific glycoprotein G serologic test )

16. ...Complications • Local extension • Extragenital spread - buttocks, fingers or eye • CNS: • aseptic meningitis, much more common with HSV II, occurring in perhaps 20% of patients, 5% needing hospitalisation • autonomic dysfunction - hyperaesthesia, anaesthesia, difficulty in micturition and defaecation • Rare complications: • erythemamultiforme ,monoarthritis ,hepatitis, • thrombocytopaenia ,spread to preexisting lesions • 10% of lesions become superinfected with bacteria or candida

17. ...Managment • symptomatic: • analgesia ,saline baths • acyclovir, 200mgs, 5 times a day for 5 days – (alternatives: famciclovir and valaciclovir . • Recurrent episodes may require continous acyclovir • primary or first-episode genital herpes is managed via referral to the genitourinary medicine clinic • interventions to prevent sexual transmission of herpes simplex virus • male condom use to prevent sexual transmission from infected men to uninfected sexual partners • antiviral treatment of infected sexual partner (reduced transmission to uninfected partner) - seek genitourinary medicine specialist advice

19. Crabs or Pubic Lice • The pubic louse is Phthirius pubis, the mature form of which is transferred during close body contact for example, sexual contact. • The major symptom is pruritus in the genital region especially in pubic hair. Examination may show the crab shaped adult louse which is brownish coloured and about 2 mm in diameter, or their ova - nits - which are a shiny white and the size of a pin head. • Diagnosis is made on the basis of the history and clinical examination

20. ....Treatment • infestation needs to be confirmed by the detection of live lice/viable eggs • most common in young adults, as it is often acquired during sexual contact. It is important to establish whether pubic lice have been acquired in this way or not, as there may be a need to refer the individual to a genitourinary medicine clinic for screening for sexually transmitted infections • contact tracing over the previous 3 months is recommended • aqueous malathion 0.5% liquid or permethrin 5% dermal cream are recommended for application to the entire body and should be repeated after 7 days.

22. SCABIES • scabies is common and is pandemic • common in women than in men • common in winter than summer • risk of transfer of infestation via towels, bedding, clothing, upholstery used by patients with typical symptoms of scabies

23. ...Transmission • direct (skin-to-skin contact) - the main route of transmission • indirect (via infested clothing, bedding) - indirect transmission can be seen in crusted scabies but it rarely occurs in classic scabies • transmission in institutional settings and within family members is common • sexual transmission is possible

24. Clinical Features • Presenting lesions in scabies are papules, vesicles, pustules, and nodules. • Greyish white linear burrows may be seen on the finger webs, sides of the fingers, wrists, elbows, anterior axillary fold, periumbilical area, and areolae, • buttocks and male genitalia - firm, red papules. • severe , persistent itching, worse at night and following bathing, is frequently the initial complaint - this indicates that hypersensitivity has developed and may antedate infection by several weeks - often, there is a widespread rash with many small papules, • but there may be excoriation, dermatitis, and secondary infection with vesicles and pustules

25. Diagnosis • extraction of mite from the burrow using a sharp needle • ink test - to show a burrow • microscopic examination of skin scrapings • a skin biopsy may be done to confirm the diagnosis

26. Treatment • permethrin is the drug of choice • malathion should be used as second line • benzyl benzoate • the entire body, except head and neck, must be treated • Clothing and bed linen should be washed and all household and close contacts treated simultaneously even in the absence of symptoms

28. MOLLUSCUM CONTAGIOSUM is a viral skin disease characterised by firm, round, translucent, multiple, dome shaped, pearly white or flesh coloured, umbilicated papules of up to 5mm in diameter containing caseous matter and peculiar capsulated bodies • It is usually a benign, self limiting viral infection caused by a DNA virus of pox family • Spread of the infection is probably through direct skin-to-skin contact and lesions may occur in any part of the body • common childhood eruption specially in children who bathe together. • adults presenting to STD clinics where the disease has been transmitted during sexual contact • immunodeficient patients e.g. - AIDS • It has an incubation period that varies from 3 to 12 weeks

29. Contd Etiology • viral infection, often appearing in crops as a result of self inoculation and person to person contact • Steroid cream and chapped, damp skin encourages spread. • common in the atopic. Diagnosis • made on the clinical appearance. • Otherwise, the contents of a papule can be expressed, smeared on an slide and stained with Giemsa

30. contd • Differential Diagnosis: • warts ,sebaceous cysts • Treatment • no specific treatment is required - a self-limiting infection • may resolve spontaneously in 6-9 months (but some cases may persist up to 4 years) • prevention of spread of the disease – hygienic measures • cryotherapy – application of liquid nitrogen to the lesion • expression of the contents of the pearly core (manually or using forceps) • piercing with an orange stick , with or without the application of tincture of iodine or phenol • curettage or diathermy • itching might be a problem for the patient and may require an emollient and a mild topical corticosteroid (e.g. hydrocortisone 1%) 

31. Treatment (Other options) • topical 0.5% podophyllotoxin (applied to lesions twice a day for 3 consecutive days and repeated weekly cycles until the lesions cleared) • home-applied imiquimod 5% cream • Eczema around the lesion can be treated with emollients, 1% ichthammol paste or mild topical or mild topical steroid • consider referring adults to genitourinary medicine for infection screen • Highly active antiretroviral therapy may be necessary in HIV patients for the resolution of the disease • Criteria for referral to a secondary care facility: • diagnostic uncertainty • extensive, painful, inflamed lesions • immunosuppressed patients

33. GRANULOMA VENEREUM • This is a tropically acquired sexually transmitted disease caused by Calymmatobacterium granulomatis. • It is a painless condition • lesions in the genital and inguinal creases. • These start as red papules and develop into granulomatous ulcers. • Diagnosis : histology of biopsy for typical Donovan bodies. • Treatment: Tetracycline.

36. Sebaceous glands & Penile papules • Sebaceous glands and penile papules are often mistaken for STDs, but they are not sexually transmitted. • Sebaceous glands are usually attached to hair follicles, but can also appear on hairless areas of the body, such as the penis. The glands release a fatty substance called sebum on to the surface of the skin, which may give the appearance of a rash. • Pearly penile papules are often mistaken for genital warts but are in fact a physical variation found in many men. • Papules appear around the head of the penis as small, dome-shaped bumps, which may be skin-coloured.

41. SYPHILIS • sexually transmitted disease which is characterised by: • minor early illness • more serious late manifestations after a variable latent period • The infective agent is a spirochaete, treponemapallidum. • Clinically there are four types of syphilis: • primary • secondary • tertiary • congenital

42. Diagnosis • Diagnostic procedures include: • dark ground microscopy - detection of spirochaete in primary and secondary syphilis • serology - detection of anti-treponemal antibodies with: • non-specific antigen - cardiolipin used in the Venereal Disease Reference Laboratory (VDRL) test. This is not specific for Treponemes but is useful to assess the efficacy of treatment of proven syphilis - it will revert to negative once Treponema eliminated • specific treponemal antigens: • TPHA } remain positive life-long and • FTA-ABS } specific to Treponemapallidum • lumbar puncture may be indicated to exclude neurosyphilis

43. Treatment (Syphilis) • Treatment of choice for primary syphilis is long-acting procaine penicillin 600 mg OD, IMfor 10-12 days. • For CNS disease, secondary and tertiary syphilis, the treatment regime is for 14 days. • If compliance is in doubt then injections of benzathine penicillin 2.4 g per week for 2 weeks is an alternative. • If not penicillin sensitive, tetracycline 500 mg p.o. 6-hourly for 14 days • or doxycyline 100 mg 12-hourly for 14 days may be given. • Follow-up should occur over 2 years to ensure a satisfactory response.

46. CHANCROID (Venereal/Soft Sore) • Tropical sexually transmitted disease caused by Haemophillusducreyi, a gram negative bacterium. • It is endemic in Africa, Asia and South America • common in men, particularly uncircumcised men. • HIV is a very important cofactor, with a 60% association in Africa. • After a one week incubation period a papule develops which becomes a pustule and then an ulcer, which is characteristically very painful, more so in men. • Diagnosis is by Gram-stain of exudate, cultured on enriched media - serology is unreliable. • 50% of cases have a painful adenopathy with development of bubos - inflamed lymph nodes with pus and necrosis, fixed to the skin. There is no systemic component

47. ...Contd • In the absence of treatment, the chancroid lesion can persist for months to years. • Treatment is with cotrimoxazole or erythromycin. • Control of the infection at the community level is probably best effected by the promotion of the use of condoms.

50. LYMPHO GRANULOMA VENEREUM is a tropical sexually transmitted disease caused by Chlamydia trachomatis • Endemic in Africa, India, SE Asia, South America and the Caribbean, • Men affected more commonly than women, principally between the age 20 to 30 years. • Three stages to the disease: • an asymptomatic ulcer which resolves rapidly • an inguinal syndrome, between 1 week and 6 months later, with adenopathy (lymph nodes are painful) and bubo development. • There is often systemic illness and malaise • regional abscess or fistula, resulting in regional strictures, e.g. rectal strictures • Diagnosis is by serology and intradermal skin test with LGV antigen - Frei's test. • Treated with tetracyclines or erythromycin.