Download STI

Sexually
Transmitted
Infections
Tory Davis, PA-C
STD? STI? VD?

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
a.k.a. Venereal Diseases
Increasingly, the term sexually transmitted
infection (STI) is used: a person may be
infected, and may potentially infect others,
without showing signs of disease.
An STI is an illness that is spread through
sexual contact:
Vagina/penis, vulva/vulva, oral sex, and
anal sex.
Other routes: kissing, IV drug administration,
sharing of sex toys, childbirth or
breastfeeding.
Facts
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65 million of people living in the US with STI
15 million of new STI cases each year
2/3 of all STIs occurs in people 25 yrs of
age or younger
one in four new STI cases occur in
teenagers
one in four Americans have genital herpes,
and 80% of those with herpes are unaware
they have it
at least one in four Americans will get STI
at some point in their lives
One in Four

CDC study released last year shows
that 26% of teen girls has at least
one of the most common STIs
– HPV
– Chlamydia
– Trich
– HSV
Taking the History:
The 5 Ps
 Partners
 Prevention
of Pregnancy
 Protection from STDs
 Practices
 Past History of STDs
Partners

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“Do you have sex with men, women, or
both?”
“In the past 2 months, how many partners
have you had sex with?”
“In the past 12 months, how many partners
have you had sex with?”
Prevention of
pregnancy

Are you or your partner trying to get
pregnant?
– If no, what are you doing to prevent
pregnancy?

Do you use condoms?
Protection from STIs


“What do you do to protect yourself
from STIs and HIV?”
Do you use condoms?
– How often? Always, sometimes, or
rarely?
–
–
If “never:” “Why don’t you use condoms?”
If “sometimes”: “In what situations or with
whom do you not use condoms?”
Practices
“To understand your risks for STDs, I need to
understand the kind(s) of sex you have had
recently.”
“Have you had vaginal sex, meaning ‘penis in
vagina sex’”?


–
If yes, “Do you use condoms: never, sometimes, or
always?”
“Have you had anal sex, meaning ‘penis in
rectum/anus sex’”?

–
If yes, “Do you use condoms: never, sometimes, or
always?”
“Have you had oral sex, meaning ‘mouth on
penis/vagina/anus’”?

–
If yes, “Do you use a dental dam?”
Past History of STIs
“Have you ever had an STI?”
“Have any of your partners had an STI?”
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–
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Additional questions to identify HIV and hepatitis risk
“Have you or any of your partners ever injected
drugs?
“Have any of your partners exchanged money or
drugs for sex?”
“Is there anything else about your sexual
practices that you think I might need to know
about?”
STIs Characterized by…
Genital Ulcers: HSV, Syphilis, Chancroid
Urethritis/Cervicitis: Gonorrhea, Chlamydia
Vaginal Discharge: Bacterial vaginosis,
Trichomoniasis, candidiasis
Other: PID, Epididymitis/prostatitis,
HPV/genital warts,
proctitis/proctocolitis/enteritis
Ectoparasites: Pediculosis pubis, scabies
(covered in derm)
Diseases Characterized
by Genital Ulcers
Herpes (*MC)
 Syphilis
 Chancroid
 Associated with increase risk of HIV
 Diagnosis based on history and
physical is often inaccurate.

Chancroid
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Cause: gram-negative bacillus—Haemophilus
ducreyi
Incubation: 3-5 days
Initial lesion is a vesicopustule that breaks down to
form a painful, soft ulcer with a necrotic base,
surrounded by erythema
Multiple lesions develop by autoinoculation
Frequent inguinal adenitis often develops
Well established cofactor for HIV transmission (10%
may be infected).
Chancroid Epi
Transmission of H. ducreyi is almost
exclusively by sexual contact
Hygiene and cleanliness are important
determinants of contagiousness
The incidence in the U.S. has declined;
<1,500 cases/year
Prostitution is a major cause of spread (seen a
lot during Korean and Vietnam wars)
Chancroid Dx
Hx
 PE
 Bacterial culture for H. ducreyi

Chancroid Treatment
Azithromycin 1 g orally once
OR
Ceftriaxone 250 mg intramuscularly (IM)
OR
Ciprofloxacin 500 mg orally BID for 3 days
OR
Erythromycin base 500 mg po TID for 7
days
Syphilis
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Cause: spirochete (gram neg bac-t)
Treponema pallidum
Capable of infecting any organ or tissue in
the body.
Risk of transmission 30-50% in partner with
primary syphilis.
Three stages: primary, secondary, and late
(tertiary) syphilis
Also congenital and neurosyphilis
Syphilis Epidemiology
-Humans are only known host
-Transmission by direct contact with infectious
lesions, generally through sexual contact
-The incidence is highest in sexually active 2029 year olds
-Incidence: 70,000 case/year or about 7 per
hour in the US
-Higher risk for men, esp MSM
Primary Syphilis

2-6 weeks after exposure
Chancre- genital ulcer, painless
with clean base and firm, indurated
borders
 Regional lymphadenopathy
 10-30 days post exposure, heals in 3-6
weeks

Secondary Syphilis
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2-8 weeks after chancre onset
“The Great Imitator”- nonspecific sx:
malaise, fatigue, HA, fever, sore throat
Generalized lymphadenopathy
Papulosquamous dermatosis- Pale, red
discrete round lesions with scaling over
surface on palms, soles, trunk
Condyloma lata-papules coalesce and
become large, flat highly contagious
lesions
Highly infectious mucous membrane
lesions
Secondary Syphilis

Condyloma latamoist, flat, confluent
plaques
Latent syphilis
Period of time between P/S and
tertiary syphilis where lab tests will be
positive, pt is infected, but no clinical
signs
 Only infectious in pregnancy and
transfusion

Tertiary Syphilis
1-30 years after initial infection
 Late benign tertiary syphilis (gumma)
 Cardiovascular syphilis
 Neurosyphilis

Gumma
May form 1 to 10 years after initial
infection
Destructive granulomatous lesions affect
any area
Responds rapidly to treatment
Cardiovascular Syphilis
Begins 5 to 10 years after initial infection
Clinically seen 20-30 years after
infection
Obliterative endarteritis of vasa vasorum
Ascending aorta develops aortic
insufficiency and aneurysm
Neurosyphilis
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Occurs in 10% of untreated pts
HA, mental deterioration, personality
change plus
1.
2.
3.
4.
5.
6.
7.
Tremor of lips, tongue or hands
Argyll-Robertson pupil – look up
Seizures
Ataxia
Aphasia
Hyperreflexia
Cognitive changes, can evolve into psychosis
Screening
for Syphilis
Non-treponemal tests
 VDRL (Venereal Disease Research
Laboratory) test. Screen for
antibodies, not specific to T. pallidum
 RPR- rapid plasma reagin- antibody
 EIA- enzyme immunoassay test

Diagnosing SyphilisTreponemal tests
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Fluorescent treponemal antibody absorption
(FTA-ABS) test. Detects antibodies to T
pallidum. Use after 3 weeks post-exposure.
Blood or spinal fluid.
Treponema pallidum particle agglutination
assay (TPPA). Same as above, but blood
only.
Darkfield microscopy. Uses special
microscope to examine fluid or tissue from a
chancre. Mainly to diagnose syphilis in an
early stage.
Treatment
-Benzathine penicillin G 2.4 million units
IM once (if infected < 1 year)
If PCN allergic
-Doxycycline, ceftriaxone, azithromycin
Alternate tx for pregnancy, congenital,
latent, neurosyphilis, and postexposure prophylaxis (look-ups)
Response to Treatment
No definitive test of cure, reassess
clinically and serologically in 6-12
months
 Consider treatment failure if symptoms
persist or titer remains 4x normal
 If treatment failure; CSF testing, HIV
testing, and benzathine penicillin G
weekly x 3 weeks

Tuskegee Syphilis
Study 1932-1972

"The United States government did
something that was wrong—deeply,
profoundly, morally wrong. It was an
outrage to our commitment to
integrity and equality for all our
citizens... clearly racist."
—President Clinton's apology for the
Tuskegee Syphilis Experiment to the
eight remaining survivors, May 16,
1997
Genital Herpes
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Chronic, life-long viral infection caused by
human herpesviruses
Subclinical primary infections more common
than clinically manifestations
HSV persists in a latent state for the
remainder of the host’s life in the sensory
ganglia, then reactivation lesions appear in
the distal sensory nerve distribution
HSV 1 and 2
Etiology
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HSV-1 primarily transmitted by nonsexual
routes, (ie infected saliva)
– Causes cold sores and oropharynx stomatitis

HSV-2 is usually transmitted sexually or
maternally
– causing genital herpes and neonatal
infections
– also it has been linked epidemiologically
with carcinoma of the cervix
Etiology

This rough rule of HSV-1 above the
waist and HSV-2 below the waist is no
longer strictly true:
– approximately 20% of genital herpes
cases are due to HSV-1
– HSV-2 may induce oropharyngeal
infections
Epidemiology
Risk of infection is approximately 75%
following contact with a symptomatic
case.
 At least 50 million persons in the
United States have genital HSV
infection.

Genital Herpes (cont)
HSV type 2 usually involves the genital
tract, latent virus is in presacral ganglia
 Typical lesions are grouped, painful,
small, and vesicular
 Asymptomatic shedding is possible
and establishing a first episode of
HSV-2 is difficult.
 Incubation is 2-7 days

Diagnosis
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Usually done clinically however the classical
painful multiple vesicular or ulcerative
lesions are absent in many infected
persons.
May be detected by viral cultures of
vesicular fluid or direct fluorescent antibody
staining of scraped lesions may confirm
diagnosis
Presence of intranuclear inclusions
and multinucleated giant cells on a
Tzank preparation is supportive of a
diagnosis of herpes viral infections.
Who Gave it to Me?
Often difficult to tell
 Latent period
 Difficult counseling
 Emphasize prevention of spread

Treatment

Antivirals
– Acyclovir
– Famcyclovir
– Valacyclovir

Dose and duration depends:
– First episode
– Recurrent episodes
– Suppression
Diseases Characterized
by Urethritis and
Cervicitis
Gonoccocal infections
 Chlamydial infections
 Non-gonococcal infections

Gonorrhea
Caused by Neisseria gonorrhoeae
 a.k.a. “the clap”
 Can affect urethra, cervix, rectum,
conjunctiva (ophthalmia neonatorum),
oropharynx

Gonococcal Epi

700,000 cases in US/year
– But since a number of GC infections are
asymptomatic or not reported it is
estimated that there are 1-2 million total
cases/year in the U.S
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
Humans=only host
Transmitted sexually
Gonorrhea Symptoms
Often asymptomatic – contributes
spread
 Male: dysuria, purulent or
mucopurulent urethral discharge

– (word of the day: gleet)
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Female: vaginal discharge (actually
from cervix), dysuria, post-coital
bleeding, inter-menstrual bleeding
Complications
Men: epididymitis, prostatitis, proctitis
 Women: vaginitis, salpingitis, pelvic
inflammatory disease
 Both: disseminated GC-systemic
complication following the
dissemination of gonococci from the
primary site via the bloodstream.
(arthralgias, fever, rash)

Diagnosis
1.
2.
3.
Evaluation of the presenting
symptoms and sexual history
Gram stain of urethral exudates and
Culturing for N. gonorrhoeae
Dual Therapy
Patients with GC should be treated
routinely with a regimen effective
against C. trachomatis.—10-30% coinfection rates
 Once you dx GC, you don’t even have
to test for chlamydia because it is
more cost effective to treat for it.

Gonorrhea Treatment

Ceftriaxone 125 mg IM in a single dose
OR
Cefixime 400 mg orally in a single dose or 400 mg
by suspension (200 mg/5ml)
PLUS
TREATMENT FOR CHLAMYDIA IF CHLAMYDIAL
INFECTION IS NOT RULED OUT

NB- fluoroquinolones no longer
recommended due to resistance
Gonorrhea-infant
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During childbirth,
gonococci infect the
conjunctivitis, pharynx,
respiratory tract and
gastrointestinal tract of
the body.
Routine prophylaxis
with 1% AgNO4 or
0.5% erythromycin or
1% tetracycline applied
directly to the eye
following birth prevents
opthalmia neonatorium
Chlamydia
Chlamydia
 Very
common STI caused by
Chlamydia trachomatis
 1,030,911 reported cases in 2006 in
US- likely very underreported
 “The Silent Disease” asymptomatic in
75% of women and 50% of men
Chlamydia Symptoms
Female: dysuria, vaginal discharge,
lower abdominal pain, low back pain,
nausea, fever, dysparunia, bleeding
between menstrual periods
 Male: dysuria, urethral irritation, penile
discharge
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Both- commonly- NO SYMPTOMS
Complications
Chlamydia is one of most common
causes of infertility in women
 Unless screened for, infections can
easily be missed until after significant
damage done to reproductive tract- ie:
tubal scarring

Diagnosis
Urine “dirty-catch”
 Cervical swab
 Urethral swab
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Culture, PCR, nucleic acid
amplification, DNA probe, ELISA, EIA
Treatment
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Azithromycin or doxycycline
Coinfection with gonococcal infection is
common; therefore, dual therapy is
recommended.
Reinfection is common because partner is
not treated! Abstinence should be
continued until 7 days after single-dose
regimen or after completion of a 7-day
regimen.
“Non-gonoccocal
urethritis”
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Diagnosed if Gram-negative intracellular
diplococci cannot be identified on urethral
smear.
C. trachomatis is a frequent cause (15-55%)
Confirmation of chlamydial infection is
important because of partner referral.
Complications: epididymitis, prostatitis and
Reiter’s syndrome
Etiology
Most cases are unknown
 Ureaplasma urealyticum, Mycoplasma
genitalium, T. vaginalis and HSV

Diagnostic criteria
Mucopurulent or purulent discharge
 Gram stain demonstrating > 5 WBCs (or
intracellular Gram-positive diplococci)
 Positive leukocyte esterase test on first void
urine or microscopic examination of firstvoid urine demonstrating >10 WBCs/HPF
*All patients should be tested for gonococcal
and chlamydial infections

Non-GC Urethritis
Treatment
 Same
as chlamydia
Azithromycin
 Doxycycline

Diseases Characterized
by Vaginal Discharges
Bacterial vaginosis
 Trichomoniasis
 Vulvovaginal candidiasis

*NB: vulvovaginal candidiasis and
bacterial vaginosis are not usually
STD—often diagnosed in women
being evaluated for STDs
Bacterial Vaginosis
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Clinical syndrome resulting in the
replacement of Lactobacillus with high
concentrations of anaerobic bacteria
(Gardenerella, Mycoplasma)
Most common cause of vaginal discharge
and malodor. Pt c/o FISHY ODOR, worse
after intercourse.
Associated with multiple sex partners, new
sex partner, douching; not thought to be
sexually transmitted but women who have
never been sexually active rarely affected
NB-treating sexual partner not beneficial
BV Diagnostic Criteria
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1.
2.
3.
4.
Requires 3 of the following:
Homogenous, white discharge that
smoothly coats vaginal wall
The presence of clue cells of
microscopic exam (pic next slide)
pH >4.5
Fishy odor of discharge before or
after KOH
Clue cells

Bacteria cover cell wall of epithelial
cells
Treatment
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Metronidazole 500 mg orally twice/day for 7
days
or
Metronidazole gel 0.75% one applicator
intravaginally once/day x 5 days
or
Clindamycin cream 2%, one full applicator
intravaginally at bedtime
Trichomoniasis
Caused by anaerobic protozoan T.
vaginalis
 Most men are asymptomatic, while
women have symptoms characterized
by a diffuse, malodorous musty
smelling, yellow-green discharge with
vulvar irritation
 Increases risk of HIV infection

Trich Diagnosis
History, Physical exam
 Microscopy
 Culture

Treatment

Recommended Regimens
Metronidazole 2 g orally in a single
dose
OR
Tinidazole 2 g orally in a single dose
FYI

Vaginal trichomoniasis in pregnancy
has been associated with adverse
pregnancy outcome, premature
rupture of the membranes, preterm
delivery, and low birth weight
Vulvovaginal
Candidiasis

Usually caused by C. albicans but
occasionally by other species of Candida

Sx included pruritus and vaginal
discharge, vaginal soreness, vulvar
burning, dyspareunia and dysuria.
75% of all women will have 1 episode of
VVC, 45% will have more than 1 episode

Diagnosis

Clinically by pruritus and erythema in the
vaginal area; white thick discharge is
common.
– Typically described as cottage cheese discharge
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Also yeast/pseudohyphae on wet mount or
culture positive for Candida.
Usually pH <4.5
10-20% of women may harbor Candida
Normal—if asymptomatic do not treat
Treatment
Several of the –azole drugs to choose
from (Butoconazole, clotrimazole,
Miconazole, etc.) 1, 3, 7 day tx pv qhs
 Available OTC and by rx
 Oral agent available Fluconazole 150
mg orally, single dose- by rx only,
hepatic metabolism

PID
Pelvic Inflammatory Disease
PID
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
Spectrum of inflammatory disorders of the
upper female genital tract, including
endometritis, salpingitis, tubo-ovarian
abscess, and pelvic peritonitis—typically
polymicrobial.
STDs such as N. gonorrhoeae and C.
trachomatis are often guilty; however
microorganism that comprise the vaginal
flora (anaerobes, Gardenerella, H flu,
enteric Gram-negative rods) have also been
associated with PID
PID Epidemiology

High morbidity in US
– Annually: 850 k cases, 212 k admissions,
115 k surgeries

Risk factors:
– Multiple sex partners
– History of previous PID
– Menstruation (why?)
– IUD use (but OCPs decrease risk)
– Marital status (single women are at higher
risk)
– Asymptomatic gonococcal infection in
either sexual partner.
Presentation
Can be subtle and therefore lead to
inflammatory sequelae in the upper
reproductive tract.
 In all settings, no single historical,
physical, or laboratory finding is both
sensitive and specific.

PID Criteria

Minimum criteria:
– Uterine/adenexal tenderness
– Cervical motion tenderness (CMT)

Additional criteria:
–
–
–
–
–
–
Oral temp > 101 F
Abnormal cervical discharge
Presence of WBC on vaginal secretions
Elevated sed rate
Elevated c-reactive protein
Laboratory documentation of cervical infection
with GC or chlamydia
PID Criteria

Most specific criteria
– Endometrial biopsy with histopathologic
evidence of endometritis
– Transvaginal sonography or MRI showing
thickened, fluid filled tubes with or without
free fluid
– Laparoscopic abnormalities consistent
with PID
Sequelae
PID = most common cause of involuntary infertility
in women.
Dissemination to liver resulting in a perihepatitis
Fitz-Hugh-Curtis syndrome; "Violin Strings" form
between the abdominal wall and liver capsule
(may occur in both gonococcal and
nongonococcal types of PID) – can be diagnostic.
Unilateral or bilateral ovarian abscesses (with
mortality from rupture)
Tubal occlusion, scarring, and adhesions (can cause
chronic abd pain)
Who gets admitted?
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Surgical emergencies can’t be excluded (ie:
appendicitis)
Pregnant
Patient does not respond to oral
antimicrobial therapy
Patient unable to follow or tolerate
outpatient regimen
Patient has severe illness, nausea and
vomiting, or high fever
Patient has tubo-ovarian abscess
Treatment (parenteral)

Regimen A
– Cefotetan 2 g IV every 12 hours
OR
Cefoxitin 2 g IV every 6 hours
PLUS
Doxycycline 100 mg orally or IV every 12 hours

Regimen B
– Clindamycin 900 mg IV every 8 hours
PLUS
Gentamicin loading dose IV or IM (2 mg/kg of body
weight), followed by a maintenance dose (1.5 mg/kg)
every 8 hours. Single daily dosing may be substituted.
Treatment (Oral)

Ceftriaxone 250 mg IM in a single
dose
PLUS
Doxycycline 100 mg orally twice a
day for 14 days
WITH OR WITHOUT
Metronidazole 500 mg orally twice a
day for 14 days
HPV

Human Papillomavirus
– Genital warts (Condylomata Acuminata)
– Also cause cervical cancer- will be
covered in greater depth in WH section in
spring
HPV
More than 30 types of HPV can infect
the genital tract
 Most are asymptomatic, unrecognized,
or subclinical
 Visible warts are HPV types 6 or 11
 Other types strongly associated with
cervical neoplasms (16, 18, 31, 33,
and 35)

Genital Warts


Flat, papular, or pedunculated growths on
the genital mucosa
Incidence ~ 1,000,000/year in US
– That’s a lot of warts


Most frequently affected are the penis,
vulva, vagina, cervix, perineum, and
perianal area
Perfect use of condoms  risk of HPV
infection by 70%
Pathophys


HPV invades cells of the basal layer of the
epidermis, penetrating skin and mucosal
microabrasions in the genital area
Following latent period (months-years), viral
DNA, capsids, and particles are produced.
Host cells become infected and develop the
morphologic atypical koilocytosis of genital
warts
Genital Wart Diagnosis
The application of 3%–5% acetic acid
(vinegar) usually turns HPV-infected
genital mucosal tissue to a whitish
color (Clinical test)
 Biopsy

Treatment
Goal: removal of symptomatic lesions,
may or may not eradicate or eliminate
infectivity
 Options:

– Podofilox 0.5% solution or gel or
Imiquimod 5% cream (patient applied)
– Cryotherapy or Podophyllin resin 10-25%
or surgical removal (provider
administered)
Prevention
Gardasil- HPV vaccine against HPV 6,
11, 16, and 18
 Could prevent 90% of genital warts
 Licensed for use in girls 9-26
 Now approved for males age 9-26 for
prevention of HPV infection and genital
warts

– Being studies for penile/rectal cancer
prevention