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SEXUALLY TRANSMITTED INFECTIONS Dr B S Kumari Associate Specialist September 2015 OVERVIEW Definition of Sexual Health 2. Epidemiology of STI’s 1. - Worldwide UK Sexually transmitted Infections 4. Physiological findings and Non STI’s in the Genital Area 3. Definition of Sexual Health (WHO) Sexual health is a state of physical, emotional, mental and social well-being related to sexuality; Not merely the absence of disease, dysfunction or infirmity. Requires a positive and non judgemental approach to sexuality and sexual relationships Sexual rights of all persons must be respected, protected and fulfilled What is the burden of STI’s? Worldwide &UK World wide More than 1 miilion people acquire STI’s every day > 498 million new cases of curable STIs every year(Chlamydia,Gonorrhoea,Trichomonas,Syphilis) Most common is Trichomonal Vaginalis 276 million Chlamydia 106 million 530 million have HSV2 genital herpes 290 million have Human papilloma virus UK 450,000 new STI diagnosis in 2013 in UK Most common Chlamydia(208,755 out of which 139,000 were in the 1524 yrs age group) Global prevalence of STI Rates of new STI diagnoses by LA of residence: England, 2013 England London • Data from routine GUM service returns & chlamydia data from community services • Data type: residence data 24 Public Health England: 2013 STI Slide Set Whats the trend in STI’s in UK? CASE 75 yr old women Husband died 15 yrs ago No SI since last 15 yrs c/o feeling sore down below since 2 weeks No h/o similar symptoms in the past On examination multiple tender ulcers on the labia Herpes antibody negative STIs Common bacterial infections Chlamydia trachomatis Neisseria gonorrhoea Treponema pallidum (causes syphilis) Lymphogranuloma venereum ( caused by chlamydia) Haemophilus ducreyi (causes chancroid) Klebsiella granulomatis (previously known as Calymmatobacterium granulomatis) causes granuloma inguinale or donovanosis. Common viral infections Human immunodeficiency virus (1&2) Herpes simplex virus type 1 & 2 Human papillomavirus Hepatitis B virus Protozoal infection Trichomonas vaginalis (causes vaginal trichomoniasis) Classification on the Basis of Presentation STD Urethritis Ulcerative Chlamydia Gonorrhoea Non-specific urethritis Genital Herpes Syphilis Chancroid LGV Donovanosis Behcet`s Disease Vaginal Discharge Systemic Miscellaneous Chlamydia Gonorrhoea Trichomonal infection Candidiasis Bacterial vaginosis HIV Hepatitis A Hepatitis B Hepatitis C SARA PID Epididymo-orchitis Genital warts Molluscum Contagiosum Scabies Pubic lice *Not Transmitted sexually Chlamydia Trachomatis Most common sexually transmitted infection 5 -10% of sexually active women under 24 yrs and men between 20-24 yrs may be currently infected Incubation period up to 2 weeks Caused by serovars D-K Risk Factors Age under 25yrs New sexual partner/ >1 sexual partner in the past year New sexual partner being more important than number of partners Lack of consistent use of condoms Symptoms of chlamydial infection Men - 50% asymptomatic - Discharge and dysuria Women - 70-80% asymptomatic - Discharge and dysuria - Intermenstrual/ postcoital - bleeding(cervicitis/endometritis) - Abdominal pain – 70% asymptomatic Complications associated with Chlamydia • • • • • • • • Endometritis/ Salpingitis/ PID Ectopic pregnancy Infertility Chronic pelvic pain Pregnancy complications Reiter’s syndrome Epididimo-Orchitis Fitz-Hugh Curtis syndrome Chlamydia Diagnosis Nucleic Acid Amplification Technique (NAAT) Specimen: urine (males), endocervical swab/self taken vulvovaginal swab (females) Sensitive 90-95% Specificity 99% ( 93 – 100%) Treatment Azithromycin 1gm stat (or) Doxycycline 100mg bd 7 days Gonorrhoea Second commonest bacterial STI in UK Neisseria gonorrhoea – intracellular, gram negative diplococci Incubation period 2-5 days but can be up to 2 weeks Men symptomatic >80%, women asymptomatic 50% Symptoms include dysuria, discharge, lower abdominal pain Extra-genital infection possible (pharyngeal) Disseminated - skin lesions, arthralgia, arthritis and tenosynovitis. Gonorrhoea Diagnosis Test: NAAT , Culture and microscopy Specimens : urine/urethral swab(males),endocervical ,throat rectal swabs Treatment First Line – Ceftriaxone with Azithromycin Increased resistance to Penicillins, Ciprofloxacin, Tetracyclines. Non-specific urethritis Present in males Diagnosis depends on symptoms ie discharge and dysuria and microscopy showing pus cells May be STI – usually chlamydia, less frequently mycoplasma, ureaplasma sps. May be trauma, allergic reaction, dermatitis Treatment – similar to chlamydia treatment (Azithromycin/Doxycycline) SYPHILIS •Classification •Congenital •Acquired •Early •(<2 years) •Primary •Late •(> 2 years) •Late latent •Early •<2years •Tertiary •Secondary •Early latent •<2years Infectious Stage •Late •Stigmata Primary Syphilis Spirochaete – Treponema Pallidum Primary chancre Appears 10 – 90 days post-infection at site of inoculation Classically – solitary and painless BUT can be multiple and painful and atypical Often ignored when atypical Resolves spontaneously within weeks Primary Syphilis Treponema pallidum Primary Chancre Secondary Syphilis Around 6 weeks later Alopecia, lymphadenopathy, snail track ulcers, condylomata lata, maculopaular rash (palms and soles), hepatitis…… Snail track Ulcers Secondary Syphilis Syphilis Diagnosis Direct: demonstration of Treponema pallidum Dark field microscopy PCR Serology: Non Specific VDRL RPR Specific TPPA EIA Treatment: Penicillin Genital Herpes Caused by herpes simplex virus Same virus that causes cold sores HSV-1 vs HSV-2 Spread by skin to skin contact – condoms do reduce risk of transmission Transmission occurs with or without lesions Clinical features of Herpes 60% of primary genital HSV infections asymptomatic Multiple, painful ulcers Flu–like symptoms Can lead to urinary retention, especially in women First outbreak almost always worst Recurrences decrease in frequency with time Pathway of Herpes Infection Genital Herpes Diagnosis: Clinical HSV PCR, culture infrequently used Treatment Recommended regimens (all for five days): Aciclovir 200 mg five times daily Famciclovir 250 mg three times daily Valaciclovir 500 mg twice daily Reduces severity and duration of outbreak No effect on recurrence rates Low doses can be used prophylactically Trichomonas vaginalis A flagellated protozoan. Found in the vagina, urethra and paraurethral glands. Vulval itching, dysuria, offensive odour, strawberry cervix Associated with preterm delivery and low birth weight. Trichomonas vaginalis Diagnosis Clinical (strawberry cervix and discharge) Posterior fornix vaginal wet film TV culture TV PCR based tests Treatment Metronidazole 2g orally in a single dose Metronidazole 400 – 500mg bd 5/7 Partners need treatment Genital Warts Caused by human papilloma virus Over 100 strains Low risk types 6 and 11 causes visible lesions High risk types 16 and 18 – vaccine preventable types in UK. HPV-16 and 18 contribute to over 70% of all cervical cancer cases HPV prevalence in normal cytology – 8.9% Can be carried without symptoms HPV Genital Warts Treatment usually topical – creams, cryotherapy, TCA, curettage Molluscum Contagiosum Could be sexually transmitted Look like warts Caused by pox-virus Spread by skin to skin contact Common in children In adults, not commonly seen on face Physiological findings Pearly white papules Fordyce Spots Vulval Pappilomatosis Epidermoid cyst Non STI’s in genital area Lichen planus Lichen Sclerosis Vulval Cancer Fixed drug eruption Systemic manifestations of STI’s Disseminated Gonococcal infection Rash in secondary syphilis Kaposi’s Sarcoma Oral Candidiasis in HIV CASE On further questioning pt said she had sex with a casual male 2 weeks prior to presenting with symptoms Herpes type 2 positive Myth- older woman don’t have casual sex Thank You