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S EXUALLY T RANSMITTED D ISEASES (STD’ S ) 75% of the world’s STD’s occur in developing countries because... They have a greater proportion of young adults Urban migration Practices such as.. Polygamy High bride prices Use of traditional remedies Health resources are limited Self treatment and incomplete treatment → Drug resistance War and civil disturbances Burden of Illness WHO worldwide estimates for 1995... Syphilis Gonorrhoea 62,000 cases Chlamydia 12,000 cases 88,000 cases There are marked regional variations especially for the less common STD’s Chancroid, Lymphomagranuloma venereum & Donovanosis Symptoms of STD Vaginal discharge or irritation Dysuria and Dyspareunia Genital ulceration or other lesions Lower abdominal or testicular pain HOWEVER May be asymptomatic in carriers And early symptoms ignored in others Diagnosis of STD Requires a high index of suspicion And a knowledge of common local presentations When ONE sexually transmitted disease is diagnosed... Always consider the possibility of others In this context pregnancy and abnormal cervical cytology should be regarded as STD’s Lack of diagnostic resources may require an empiric approach to treatment Principals of Management Best dealt with by a network of detection, treatment and follow up facilities coordinated by Specialist Clinics Should operate in conjunction with resources for HIV Such centres should provide... Patient friendly resources Confidentiality Single dose treatment regimens ... Optimises compliance Reduces the risk of emerging drug resistance Offers the best prophylaxis against long term complications There is a potentially long list of STD’s Syphilis Gonorrhoea Chlamydia Lymphogranuloma venereum Chancroid Donovanosis Genital Herpes Genital warts Bacterial vaginosis S YPHILIS A sexually transmitted infection caused by the spirochetal bacterium Treponema pallidum Incubation period usually 14 – 28 days Recognised in 3 stages in adults… Primary = typically a painless genital ulcer with non tender rubbery lymphadenopathy. Will be tender if 20 infection occurs. May go unrecognised Secondary = Fever, rash, anorexia, aches & pains, and condyloma lata Occurs 2 – 8 weeks in only 1:3 individuals after primary infection and resolves spontaneously Tertiary = can affect any body organ including heart, bones and brain D IAGNOSIS OF S YPHILIS Diagnosed by a serological test for reagin – a lipid released from cells that are attacked by T. pallidum This test is sensitive and should revert to negative after treatment but… It is not positive until up to 12w after infection It is non-specific and there is a large number of conditions that cause a false positive test Tests that detect antibodies to Treponema are more specific, appear before reagin but… Usually negative with the primary chancre They are present for life even after successful treatment Yaws (and Pinta) will also be positive to these tests Rapid test used at PMGH is an antibody test Dark field microscopy of the organism possible S YPHILIS IN P REGNANCY Typically does not cross the placenta until >20 weeks Fetal effects include… Stillbirth Intrauterine growth restriction Prematurity Neonatal effects include… Hepatosplenomegaly Pneumonia Anaemia & Jaundice Skin lesions Osteochondritis T REATMENT OF S YPHILIS In the mother with a positive STS = serological test for syphilis Give 3 doses of Benzathine penicillin 2.4 mU weekly Erythromycin 500 mg 4 x daily for 15 – 30 days for true penicillin allergy For a neonate Adequate treatment >28 days before delivery should prevent neonatal syphilis But “safety net” treatment commonly practised 25,000 IU/Kg Penicillin twice daily for 10 days If the baby is clinically affected at birth the prognosis is poor – see paediatric texts diagnosis & treatment Ideally all babies born to STS-positive mothers should be followed with reagin tests until negative F OLLOW - UP AND C ONTACT T RACING For a patient with a positive STS… Contact and test/treat all partners for previous 12m Other children may require testing Follow up by a specialist clinic by reagin testing is desirable to ensure that this test returns to negative (or titre stabilises) after appropriate therapy is confirmed It is desirable to document this and give this to the patient to present at future health encounters Gonorrhoea and Chlamydial Infections Share a number of features in common Gonorrhoea is caused by... Neisseria gonorrhoea Whereas Chlamydia trachomatis... Subtypes D – K Preferentially infect columnar and transitional epithelium of the male and female genital and urinary tracts Both may spread within the peritoneal cavity But only N. gonorrhoea is blood-borne spread to joints whereas C. trachomatis can cause neonatal pneumonia Gonorrhoea and Chlamydial Symptoms 50% of females are asymptomatic So it is an important cause of chronic PID and infertility Acute symptoms include... Vaginal discharge Dysuria (males and females) RUQ in women Can cause proctitis, pharyngitis, arthritis & dermatitis Tends to flare in the post menstrual week in ♀ or after abortion/D&C etc. Diagnosis of Gonorrhoea and Chlamydia Requires gram stain for N. gonorrhoea Look for gram negative diploccoci Ideally also culture and test for antibiotic sensitivity The best test for Chlamydia is PCR (Polymerase Chain Reaction) Can be performed on the first passed urine from both females and males Where it has high sensitivity for genital tract infection And high specificity Follow up for Gonorrhoea and Chlamydia Retesting not required after adequate single dose testing But trace and test or treat all sexual contacts of the last two months after the diagnosis of acute infection Neisseria and Chlamydia in the Neonate N. gonorrhoea causes an acute conjunctivitis within 5 days Whereas C. trachomatis causes conjunctivitis at 5 – 14 days And can cause a pneumonia and otitis Untreated the conjunctivitis causes keratitis and blindness Treatment is by a single dose of IM antibiotics Check local protocols Or use universal prophylaxis with AgNO3 drops (need to be made up fresh), Tetracycline or Erythromycin ointment Lymphogranuloma venereum Caused by Chlamydia trachomatis Subtypes L1-3 Incubation period 7 – 28 days Causes a genital vesicle or papule → shallow ulcer with inguinal lymhadenopathy Can cause lower abdominal pain and PID Untreated results in fistula, stricture and lymphatic obstruction → elephantoid change in the genitals Consult your local laboratory for possible tests DD includes... Chancroid, Syphilis and Herpes when acute Donovanosis, TB, Filiarisis, Actinomycosis, Crohns and neoplasm Lymphogranuloma venereum Lymphogranuloma venereum Treatment Doxycycline or Erythromycin for not less than 21 days May require reconstructive surgery And Caesarean delivery in a few Donovanosis Caused by Calymmatobacterium granulomatis Incubation period 8 – 90 days Causes chronic slowly-growing granulomatous ulceration of the anogenital region and groin Begins as a painless indurated ulcer that grows into a beefy granuloma with a rolled edge with moderate lymphadenopathy Secondary infection and surface bleeding common It then becomes painful, foul and locally erosive or sometimes neoplastic May also cause fibrosis, stenosis and elephantoid change Donovanosis Donovanosis (cont’d) Diagnose by Leishman stain of crushed material from the lesion Look for Donovan bodies in cytoplasmic vacuoles of enlarged mononuclear cells Treat with... Trimethoprim/Sulfamethaxozale Doxycycline or Erythromycin for 3 weeks or until healed Combination therapy with Gentamicin, Chloramphenicol or Streptomycin may be required Donovanosis Diagnosis Chancroid Caused by Haemophilus ducreyi (Gram neg Bacterium) Incubation period 1 – 8 days Causes a painful genital ulcer with inguinal buboes Tender papules → Pustule → Ulcer with ragged red margin & granulomatous slough in the base Main DD is syphilis – negative to dark field illumination Mostly diagnosed in men Women are presumably carriers Contact and treat partners of the preceding 10 days Treatment Considerable regional variation in antibiotic sensitivity so check local protocols Chancroid Genital Herpes 66% is due to Type 2 Herpes simplex and 33% is due to Type 1 of this virus More or less reversed for oral Herpes Affects ≈ 5% of the population Spread by direct contact (genital, oral or other) The virus established latency in neurones from where recurrences occur The Primary Attack Incubation period 2 – 10 days Erythema, itching & burning then vesicles Severe generalised vulvovaginitis is common with the 1st attack Genital Herpes Genital Herpes (cont’d) Primary Attack (cont’d) Urinary retention common May be systemic features with fever, arthralgia etc. Secondary Attacks Occur in 50% of individuals Troublesome “cold sores” at varying intervals Causes great psychological distress Diagnosis Usually clinical aided by PCR and viral culture Genital Herpes Treatment of Genital Herpes Primary Attack Good hygiene, Sitz bathes etc Analgesia Bladder catheterisation Responds to Acyclovir (and similar antiviral agents) Secondary Attacks Counselling and maintaining good health Topical Acyclovir There is a role for oral Acyclovir in prophylaxis Genital Herpes during Pregnancy Genital herpes at the time of vaginal delivery carries a risk of neonatal Herpes – Mother to Child Transmission This is a very serious generalised infection with high mortality and risk of long term morbidity (See Herpes in Pregnancy) Risk from primary infection is 25 – 56% Risk from secondary infection is only 1 – 3% Caesarean section (provided that membranes have not ruptured >4 hrs) reduces the risk of MTC of Herpes A Word About HIV The most important STD of our time It is the Syphilis of the 21st century All STD’s (with the possible exception of gonorrhoea and Chlamydia) but particularly those with genital ulceration will greatly increase the risk of HIV transmission And concurrent HIV makes many of the STD’s much worse, especially the viral ones due to Human Papilloma virus and Herpes simplex A NY Q UESTIONS OR C OMMENTS ?
