Dr.MOHAMED NASR Lecturer Of Dermatology & Venereology Zagazig University

1. Dr.MOHAMED NASRLecturer Of Dermatology & VenereologyZagazig University Sexually Transmitted Diseases (STDs)

2. Introduction • Communicable disease transmitted mainly by sexual activity including genital-genital contact, anal-genital contact & oral-genital contact. • May also be transmitted by blood & during birth.

3. Spectrum of STDs: Bacterial: Syphilis Gonorrhoea Non-gonococcal urethritis Chancroid Lymphogranuloma venereum Donovanosis (Granuloma inguinale) Viral: HIV infection Genital wart Herpes genitalis Hepatitis B Cytomegalovirus

4. Fungal: . Candidiasis (Moniliasis) Protozoa: . Trichomonasvaginalis Parasitic: Pediculosis pubis Scabies

5. Urethritis Painful urethral discharge & testicular swelling are the most common presentations of symptomatic STDs in ♂.

7. Classification of urethritis • Gonococcal urethritis. • Non gonococcal urethritis. Non-gonococcal urethritis (NGCU) is > common than gonococcal urethritis.

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

9. Gonorrhoea • About 62 million cases of gonorrhoea are diagnosed each year worldwide. • The causative organism, Neisseriagonorrhoeae, is a Gram negative diplococci. • Infects non-cornified epithelium • Cervix • Urethra • Rectum • Pharynx • Conjunctiva

10. Transmission • Gonorrhoea is always sexually transmitted in adults. • Transmission is more efficient from males to females. • The risk of acquisition from a single act of sexual intercourse with an infected partner is estimated at 30 - 70%. • Vertical transmission also occurs. About 30% of babies born to infected mothers develop ophthalmia neonatorum, typically presenting in the first week after birth.

11. Gonococcal Infections in Women • Cervicitis • Urethritis • Proctitis • Accessory gland infection (Skene, Bartholin) • Pelvic inflammatory disease (PID) • Peri-hepatitis (Fitz-Hugh-Curtis) • Pregnancy morbidity • Conjunctivitis Many infections asymptomatic • Pharyngitis • DGI

14. Gonococcal Cervicitis • Incubation 3-7 days • Symptoms: • Vaginal discharge • Dysuria • Vaginal bleeding • Cervical signs : • Erythema • Friability • Purulent exudate

15. Pelvic Inflammatory Disease • Symp.: bilateral lower abdominal pain. • Signs: uterine/ adnexal tenderness, +/- fever. • Laparoscopy may show hydrosalpinx, inflammation, abscess, adhesions. Adhesions Tube PID often silent

16. Bartholin’s Abscess • Tender swelling in the lower 3rd of the labia with difficulty in walking & sitting. • Treatment: antibiotic, analgesic, drainage followed by marsupialization.

17. Gonococcal Infections in Men • Urethritis • Epididymitis • Proctitis • Conjunctivitis • Abscess of Cowper’s/Tyson’s glands • Seminal vesiculitis • Prostatitis Many infections asymptomatic • Pharyngitis • DGI • Urethral stricture • Penile edema

18. Gonococcal Urethritis • Incubation 2-5 days. • Abrupt onset of severe dysuria. • Yellowish-green purulent urethral discharge.

19. Epididymitis • Swollen painful epididymis usually unilateral. • Epididymal tenderness or mass on exam.

20. Extra-genital gonococcal infection 1. Ano-rectal gonorhoea: * It results from rectal sex with an infected partner. * It is often asymptomatic but there may be a burning pain, tenesmus, pain on defaecation & bloody or mucopurulent stools.

21. 2. Gonococcal pharyngitis * It always results from oro-genital coitus. * There is sore throat & pain on swallowing.

22. 3. Gonorrhoea in children a. Ophthalmia neonatorum: * gonococcal eye infection of the newborn during passage through the birth canal. * it develops within 7 days of birth, always bilateral. * Lid edema, erythema and marked purulent discharge.

23. b. Gonococcal vulvo-vaginitis * before puberty, the vulval and vaginal epithelium is immature stratified squamous epithelium, this allows gonococcal infection to occur. * discharge on child’s underclothing. * vulva is red & oedematous.

24. 4. Disseminated gonorrhoea (DGI) • “Dermatitis-arthritis syndrome” • Arthritis: 90% • Characterized by fever, chills, skin lesions, arthralgia, tenosynovitis • Less commonly, hepatitis, myocarditis, endocarditis, meningitis • Rash characterized as macular or papular, pustular, hemorrhagic or necrotic, mostly on distal extremities.

25. Complications of gonorrhoea

26. Local complications in men • Para-urethral duct infection • Tysonitis (infection of sebaceous glands) • Periurethral abscess • Epididymitis • Penile oedema • Prostatitis. • Seminal vesiculitis.

27. Local complications in women • Bartholinitis • Skenitis (para-urethral gland infection) • Endometritis • Salpingitis, which may lead to peritonitis and tubo-ovarian abscesses • Perihepatitis

28. Less commonly, disseminated infection occurs by haematogenous spread: • Septicaemia • Arthritis • Dermatitis • Endocarditis • Meningitis

29. GC Diagnostic Methods • Gram stain smear • Culture: - Enriched media e.g. Mcleod’s chocolate agar. - Selective media e.g. Thayer-Martin media. • Antigen Detection Tests: EIA & DFA • Nucleic Acid Detection Tests: • Probe Hybridization • Nucleic Acid Amplification Tests (NAATs) • Hybrid Capture

30. Gonorrhea TreatmentGenital & Rectal Infections in Adults Recommended regimens: • Cefixime 400 mg PO x 1 or • Ceftriaxone 125 mg IM x 1 or • Ciprofloxicin 500 mg PO x 1 or • Ofloxacin 400 mg PO x 1 or • Levofloxacin 250 mg PO x 1 PLUS if chlamydia is not ruled out: • Azithromycin 1 g PO x 1 or • Doxycycline 100 mg PO BID x 7 d All sex partners within past 60 days need evaluation and treatment

31. Gonorrhea TreatmentGenital & Rectal Infections in Adults Alternative regimens: • Ceftizoxime 500 mg IM x 1 • Cefotaxime 500 mg IM x 1 • Cefoxitin 2 g IM x 1 plus probenecid 1 g PO x 1 • Gatifloxacin 400 mg PO x 1 • Lomefloxacin 400 mg PO x 1 • Norfloxacin 800 mg PO x 1 • Spectinomycin 2 g IM x 1

32. Gonorrhea TreatmentPregnancy Must avoid quinolones & tetracycline Recommended regimens: • Cefixime 400 mg PO x 1 • Ceftriaxone 125 mg IM x 1 PLUSif chlamydia is not ruled out: • Azithromycin 1 g PO x 1 • Other appropriate chlamydial regimen Test of cure in 3-4 weeks

33. Gonorrhea TreatmentNeonates Ophthalmia neonatorum prophylaxis: • Silver nitrate 1% aqueous solution topical x 1 • Erythromycin 0.5% ointment topical x 1 • Tetracycline 1% ointment topical x 1 Ophthalmia neonatorum treatment: • Ceftriaxone 25-50 mg/kg IV or IM x 1 NTE 125 mg NTE = not to exceed

34. Gonococcal conjunctivitis: • Ceftriaxone 1 gm single IM once

35. Disseminated Gonococcal Infection (DGI) • Ceftriaxone 1 g IM or IV every 24 hours • Alternative RegimensCefotaxime 1 g IV every 8 hours ORCeftizoxime 1 g IV every 8 hours ORCiprofloxacin 400 mg IV every 12 hours OROfloxacin 400 mg IV every 12 hours ORLevofloxacin 250 mg IV daily ORSpectinomycin 2 g IM every 12 hours • All of the preceding regimens should be continued for 24–48 hours after improvement begins.

36. Gonorrhea TreatmentChildren Uncomplicated genital infection: • > 45 kg: same as adults • < 45 kg: ceftriaxone 125 mg IM x 1 (alternative spectinomycin 40 mg/kg IM x 1) Disseminated Gonococcal Infection: • Ceftriaxone 25-50 mg/kg/d x 7 d • Treat for 10-14d if child weights > 45 kg

37. Thank You