Stds

Sexually Transmitted Diseases •

Notes: o HPV and HBV – cause of cervical and hepatocellular CA o 6 Curable STD’s:  Gonorrhea  Chlamydial infections  Syphilis  Chancroid  Trichomoniasis  Bacterial Vaginosis ?

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Classification and Epidemiology o

Certain STD’s are most concentrated in “core populations”  Prostitutes and clients  Some homosexuals  Illicit drug users     

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Syphilis Gonorrhea HIV infections Hepatitis B Chancroid

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Other STD’s are evenly distributed even in low risk population  HPV  Genital Herpes

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3 factors in rate of spread of STD and their prevention  Rate of exposure • Change of norms  Efficiency of transmission per exposure • Contraceptives and safe sexual practices  Duration of infectivity • Early dx and tx

Management of Common STD’s o Diagnosis initially basis of presenting signs and symptoms and associated risk factors Risk assessment → Clinical Assessment → Dx testing/screening → Tx → prevention o

Four C’s of prevention and control   

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Compliance with therapy Counseling on risk reduction Contact tracing Condom promotion and provision

Urethritis in Men •

Notes:

o C. Trichomatis – most common cause of non-gonococcal urethritis o

M. genitalium – probable cause of many Chlamydia-negative cases; Some cases implicates Ureaplasma urealyticum Coliform bacteria in men who practices anal sex

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Initial Evaluation o Demonstration of urethral discharge or pyuria o Exclusion of local or systemic complications o Urethral Gram’s stain to confirm urethritis; Detect gram (-) diplococci o Test for N. gonorrhea, C. trichomatis

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Approach to patient suspected of urethritis o Establish presence of urethritis

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Gram stain will reveal ≥ 5 neutrophilsper 1000x field Gonococcal infections reveals gram (-) intracellular diplococci Centrifuged sediments of voided urine will show ≥ 10 leukocytes per high power field Or by leukocyte esterase test Patient w/o evidence of urethritis may have functional rather than organic problems

Evaluate for complications or alternative diagnosis  Exclude epididymitis and systemic complications (i.e. disseminated gonococcal infection or Reiter’s)  Digital examination seldom contributes to evaluation of urethritis; but can exclude bacterial prostatitis and cystitis

o Evaluate for gonococcal chlamydial infections   o

If there is no gram (-) diplococci; its NGU; then test for Chlamydia However, gram staining may be false (-) for diplococci; culture or dna detection may show (+) results.

Treat Urethritis  If it is NGU: • Initially treat with: o Azithromycin (1.0 g. orally in single dose), or; o Doxycyclin (100mg orally bid for 7 days) • Follow with: o Metronidazole (2 g. orally qid for 7 days), plus o Erythromycin base (500 mg orally qid for 7 days) 

If gonococcal urethritis (or if not tested for it or unsure if it is): • 3rd generation cephalosphorin cefixime, or;

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Flouroquinone: ciprofloxacin, ofloxacin, levofloxacin are also effective 1st line regimen Uncomplicated infection in penicillin-allergic who cannot tolerate quinolone may take single dose of Spectinomycin

Epididymitis •

Notes: o Almost always unilateral, and must be differentiated from:  Testicular torsion • Usually in 2nd or 3rd decade of life • Sudden onset of pain • Elevation of the testicle w/in the scrotal sac • Rotation of the epididymis from a posterior to an anterior position • Absence of blood flow on Doppler or Tc scan  Tumor  Trauma o o o

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Frequently caused by C. trichomatis; less by N. gonorrhea Enterobacteriacae in men who practice anal sex Usually associated with overt or subclinical Urethritis

Treatment:: o Ceftriaxone (250mg single dose IM) followed by doxycycline (100mg orally bid for 10 days), or; o Ofloxacin (300mg orally bid for 10 days) or levofloxacin (500mg orally once daily for 10 days)

Urethritis and Urethral Syndrome in Women •

Urethral Syndrome o Epidemiology  Young age  More than one current sexual partner  A new partner in the past month  Partner with urethritis or mucopurulent cervicitis o C. trichomatis; N. gonorrhea; Occasionally HSV o “internal” dysuria (usually w/o urgency or frequency) o Pyuria, w/o E. coli or other uropathogens at a count of ≥ 102/ml

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Vulvar Herpes or Vulvovaginal Candidiasis o “external” dysuria caused by contact of urine with inflamed or ulcerated labia or introitus

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Bacterial Cystitis o Acute onset, associated with urinary urgency or frequency, hematuria, or suprapubic tenderness

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Acute Pyelonephritis o Symptoms of acute bacterial cystitis, CVA pain/tenderness

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Bacterial UTI o Urinary pathogens at ≥ 102/ml from a dysuric patient w/ pyuria

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Acute Urethral Syndrome Due to C. trichomatis, N. gonorrhea o Dysuria w. sterile pyuria

Vulvovaginal Infections •

Notes:

o Discharge form cervical os is mucoid while disharge from vagina is non-mucoid •

since it does not have glands that produce mucus Sequelae and complications of vulvovaginal infections o Recurrent or chronic vulvovaginal candidiasis develops with increasing frequency among women with systemic illness (i.e. DM, HIV-related immunosuppression) o

Trichomoniases

Vulvovaginal Candidiasis

Bacterial Vaginitis

Increased risk of HIV infections May cause premature onset of labor Anaerobic bacterial infection of endometrium and salphinges May be signs or features of toxic shock syndrome •

Vaginal Trichomoniasis o Signs and Symptoms

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Profuse, yellow, purulent, homogenous vaginal discharge Vulvar irritation With visible inflammation of the vaginal and vular epithelium and petechial lesions on the cervix ( strawberry cervix evident by colposcopy) Ph of ≥ 5.0 Microscopy reveals leukocytes, motile trichomonads

Treatment  Metronidazole (2g orally single dose or 500mg orally bid for 7 days)  Treatment of male sexual partners

Bacterial Vaginosis o Notes:

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A.K.A. – nonspecific vaginitis, H. vaginitis, anaerobic vaginitis, Gardnerella-associated vaginal discharge. Vaginal fluid lacks hydrogen peroxidase-producing Lactobacillus spp. Which constitute normal flora and helps protect against certain cervical and vaginal infections

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AMSEL Criteria (must have 3 of 4):  Objective signs of increased white homogenous vaginal discharge  Vaginal discharge of ph >4.5  Distinct fishy odor when mixed with 10% KOH • Due to volatile amine (trimethylene)  Microscopic findings of “clue cells” • Vaginal epithelia cells coated with coccobacillary organism giving them a granular appearance and distinct borders

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Other diagnostic tests:  Card test that screen vaginal fluid for ph .4.5 and trimethylene  Dipstick test that detects proline aminopeptidase Treatment  Metronidazole (500mg PO for 7 days)  Clindamycin 2%cream (1 full applicator vaginally each night for 7days)  Metronidazole gel 0.75% (1full applicator 2x daily for 5days)  Metronidazole (2g PO single dose)  Examination for STD; no treatment if normal

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Vulvovaginal Candidiasis o Signs and Symptoms  Vular pruritus, burning, or irritation  Vulvar erythema, edema, fissures and tenderness • Lesions of genital herpes may be difficult to differentiate from the fissures of vulvovaginal candidiasis  w/o malodor  w/o increase vaginal discharge; with white scanty vaginal discharge (cottage cheese-like curds) o

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Antibiotic treatment of male partners has not reduced the rate of recurrence among affected females

Diagnosis  Microscopic findings of hyphae or pseudohyphae in 10% KOH  Gram’s staining

Other Causes of Vaginal Discharge or Vaginitis o Ulcerative vaginitis  Associated with toxic shock syndrome o Desquamative inflammatory vaginitis  Reveals neutrophils, massive vaginal epithelial cell exfoliation with increased number of parabasal cells and gram (+) cocci  Treat with 2% clindamycin cream) o Foreign bodies o Vaginal atrophy in postmenopausal women o Postpartum period during prolonged breast feeding o Allergic reaction to latex condom o Vaginal apthae  Associated with HIV infections  Behcet’s syndrome • Syndrome mostly affecting males characterized br severe uveitis and retinal vasculitis

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Vestibulitis

Mucopurulent Cervicitis •

Notes: o Inflammation of the columnar epithelium and subepithelium of the endocervix and of any contiguous columnar epithelium that are exposed in an ectopic position on the cervix o “silent partner” of urethritis in men o Commonly caused be C. trichomatis and N. gonorrhea o Harbringer of PID, can lead to obstetric complications

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Signs and Symptoms o Yellow mucopurulent discharge from the cervical os o Increase number of PMN leukocytes in gram stain or pap smear

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Treatment (same as urethritis)

Cervical Ectopy •

Notes: o Erroneously termed as “cervical erosions” o Easily confused with infectious endocervicitis o Presence of one-cell thick columnar epithelium extending from the endocervix into the ectocervix o Normally found in adolescence and early adulthood;

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Gradually resolves through 2nd and 3rd decade of life as squamous metaplasia replaces the ectopic columnar epithelium Oral contraceptive favors persistence ore recurrence of ectopy while smoking hastens squamous metaplasia

Ulcerative Genital Lesions •

Notes: o Increases risk of sexual acquisition and shedding of HIV o Chancroid was once the most common of genital ulcers; followed by primary syphilis; the genital herpes Recently genital herpes as most common in some developing countries Lymphogranuloma venereum (LGV) and Donovanosis in developing countries o Other causes  Candidiasis and traumatized genital warts  Lesions due to widespread involvement of more widespread dermatoses  Cutaneous manifestations of systemic disease (i.e. Steven-Johnson syndrome) o When genital ulcers persist – biopsy is indicated to exclude Donovanosis, Carcinoma, and other nonvenereal dermatoses

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Treatment: o Herpes – acyclovir, valacyclovir, or famiclovir o Syphilis confirmed – Benzathine penicillin (2.4mil units IM) to patient all seropositive partners o Chancroid confirmed or suspected – Ciprofloxacin (500mg PO single dose) or; Ceftriaxone (250mg IM single dose)

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Diagnosis (for T. pallidum) o Rapid Serologic test o Dark-field o Direct immunoflourescence o PCR test

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Primary Syphilis o Painless, nontender, indurated ulcers with firm, nontender inguinal adenopathy o Early primary lesion - Papule

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Genital Herpes

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Typical vesicles or pustules or a cluster of painful ulcers preceded by vesiculopustular lesions Early primary lesion - Vescicle HSV-2 causes more frequent recurrences Atypical or clinically trivial ulcers may be more common than classic vesiculopustular lesions therefore the need for specific test for HSV

Chancroid o H. Ducreyi o Early primary lesion - pustule o Painful and purulent ulcers, accompanied by inguinal lymphadenopathy with fluctuance or overlying erythema o Enlarged, fluctuant lymph nodes should be aspirated for:  PCR test to detect H. ducreyi  Gram stainig to rule out other pyogenic bacteria

Site

Proctitis

Proctocolitis

Enterocolitis

Enteritis

Limited to rectal mucosa

Rectum to colon

Small and large bowel

Small bowel alone

Ano-rectal pain and mucopurulent, bloody rectal discharge Commonly produces tenesmus and constipation; but no true diarrhea More often causes true diarrhea Anoscopy usually shows mucosal exudate and easily induced mucosal bleeding (+ wipe test)

Diarrhea and abdominal bloating or cramping pain w/o anorectal symptom; Normal findings on anoscopy and sigmoidoscopy

Results from direct Result from ingestion of typical intestinal pathogens through oral-anal exposure inoculation of typical STD pathogen Due to Campylobacter or Shigella

w/o HIV infection, often due to Giardia Lamblia

Anorectal Intercourse •

N. gonorrhea, HSV, or C. trichomatis are the most common cause of infectious proctitis

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Gonococcal or Chlamydial proctitis typically involves the most distal rectal mucosa and the anal crypt and is clinically mild, w/o systemic manifestations

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Primary and secondary syphilis can also produce anal or anorectal lesions, with or without symptoms

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Primary proctitis due to HSV and proctocolitis due to C. trichomatis that cause LGV often produce severe anorectal pain and fever

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Perianal ulcers and inguinal lymphadenopathy, mostly due to HSV, can also occur in LGV and or syphilis

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Primary Herpetic Proctitis can be complicated by: o (1) sacral nerve root radiculopathies (presenting as urinary retention), (2) laxity of anal sphincter, (3) constipation

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LGV – rectal biopsy shows crypt abscesses, granulomas, and giant cells – findings resemble Chron’s disease

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Syphilis can also produce rectal granulomas, usually in association infiltration by plasma cells or other mononuclear cells