A Discussion About
Sexually Transmitted Diseases
A.J. is a 16y/o woman who presents to
Teen Clinic w/ cc: low abdominal pain x2
days. She’s also experienced some
burning with urination x4 days, tactile
fevers x1 day. She thinks she may have
had a little more vaginal d/c than usual
recently. She can’t recall the number of
sexual partners she’s had, but has been
with a new partner for about 3 wks. She
has had occasional unprotected sex.
Speculum exam reveals…
Most common STD ~4 million cases /year in
the US alone.
Rates of Chlamydia are highest in adolescent
women, and drop off steeply in the early 20’s.
Risk factors: young age, black race, multiple sex
partners, recent new partner, h/o STD, and low
rate of barrier contraceptive usage.
Usually asymptomatic in women, symptomatic in
Clinical Findings in Chlamydia
Asymptomatic infection is common among both
women and men.
Cervicitis is the most common chlamydial
syndrome vaginal d/c, lower abdominal pain
are most common sx. Dysuria may be present.
PID can be the presenting sx.
Signs: Mucopurulent cervical d/c, cervical friability/
In men: if symptomatic, may present as
urethritis, epididymitis or prostatitis.
Signs: penile d/c, unilateral scrotal pain/edema.
Sequelae of Chlamydia
Approximately 30% of women w/
chlamydia will develop PID if left
Increased incidence of ectopic pregnancy
after chlamydia infection
PID due to CT has higher rates of
Can develop perihepatitis (Fitzhugh-Curtis
Diagnosis of Chlamydia
Historically – cell culture, DFA or ELISA
Now Ligase Chain Rxn (LCR) is standard
of care. Can be done on cervical swab or
urine (less invasive).
LCR: sensitivity = 90-95%, specificity =
CDC recommends annual chlamydia
screening of all sexually active women
<25 y/o, even if asymptomatic.
Treatment of Chlamydia
Azithromycin 1g po x1, or
Doxycycline 100mg po BID x7 days.
Erythromycin base 500mg po QID X7days
Erythromycin ethylsuccinate 800mg po QID
Ofloxacin 300mg po BID x7days
Levofloxacin 500mg po qd x7days
If recommended regimen is used for
treatment, no test-of-cure is necessary
unless sx persist or reinfxn suspected or
patient is pregnant.
Patient’s sex partners must be treated if
sexual contact within 60 days of sx.
L.T. is a 37 y/o man who presents to your
clinic with cc: right testicular pain x3 days.
He also describes some whitish penile d/c
since yesterday and mild burning w/
urination. No F/C/N/V or abdominal pain.
L.T. is concerned re: new sexual partner
who was “a little shady”, and wants to be
tested for STDs.
Physical exam reveals…
Most affected women are asymptomatic,
while most men are symptomatic.
After exposure, 20-50% of men and 60-90%
of women become infected.
Without therapy, 10-17% of women develop
pelvic inflammatory disease (PID).
Approximately 10-30% patients infected with
Gonorrhea are co-infected with Chlamydia.
Clinical Findings in Gonorrhea
Women: If symptomatic localized to lower
genitourinary tract and include:
Urinary frequency and dysuria
Itching, burning or purulent d/c from vulva,
vagina, cervix or urethera.
Men: About 90% of men are symptomatic
82% purulent penile d/c, 53% dysuria
Unilateral epididymitis, proctatitis possible.
Disseminated infection possible – usually a triad
of polyarthralgias, tenosynovitis and dermatitis.
Work Up of Gonorrhea
Culture = “gold standard”. 65-85% sensitive in
asymptomatic pts, 100% specific.
Gram stain. Only 60% sensitive in symptomatic
women, 100% sensitive in symptomatic men.
LCR (urine or swab) 50-95% sensitive, 100%
High prevalence of co-infection with other STDs
(esp. Chlamydia) important to do complete
Treatment for Gonorrhea
Cefixime 400mg po x1 or,
Ceftriaxone 125mg IM x1 or,
Ciprofloxacin 500mg po x1 or,
Ofloxacin 400mg po x1 or,
Levofloxacin 250mg po x1
PLUS…for presumed co-infxn w/ chlamydia:
Azithromycin 1g po x1 or,
Doxycycline 100mg po BID x7 days
Gonorrhea is a reportable disease.
Patient’s sex partners within 60 days of
the onset of symptoms must also be
treated, both for Gonorrhea and
According to the CDC, if uncomplicated
gonorrhea is treated w/ recommended
regimen, no test-of-cure is necessary.
M.W. is a 18 y/o man who presents to
Planned Parenthood w/ cc: “rash”. He
seems quite anxious as he tells you about
the painful lesion on his penis which
started about 5 days ago. It began w/
burning pain, then small blisters appeared.
He picked at a few of the blisters, and then
the area began to erode into an ulcer-like
lesion. It’s still quite painful and oozing
Doc, it really hurts a lot!
Genital Herpes Simplex Virus
HSV is the most prevalent cause of genital
Genital HSV is a recurrent, life-long viral
About 85% of cases of genital HSV are due to
HSV-2, however HSV-1 can also cause genital
At least 50 million people in the US have genital
Most pts infected w/ HSV-2 are asymptomatic,
but shed virus intermittently.
Clinical Findings in Genital HSV
Primary infxn – Usually more severe than
secondary, but can also be asymptomatic.
Prodromal sx of burning, itching, tingling
Vesicular eruption follows, then erodes into painful
ulcers in genital region.
Bilateral inguinal adenopathy, fever and malaise can
accompany severe infxns.
Lesions persist for 2-6 weeks
Secondary infxn – may be asymptomatic, or less
severe presentation of above w/out systemic sx.
Diagnosis of HSV
HSV cell culture of “fresh” lesion, preferably still
in the vesicular state.
Serology – type-specific serology, usually takes
~21 days to develop antibodies (sensitivity = 80-
96%, specificity >96%).
IgM suggestive of new infxn (1/2 life ~ 6wks).
IgG suggestive of chronic infxn.
PCR – Not yet widely available, but probably will
become new standard (highly sensitive and
Treatment of Genital HSV
Acyclovir 400mg po TID x7-10 days, or
Famciclovir 250mg TID x7-10 days, or
Valacyclovir 1g BID x7-10 days.
Topical lidocaine may be used for analgesia.
Recurrent Infxn: episodic therapy (w/ each outbreak)
Acyclovir 400mg po TID x5 days, or
Famciclovir 125mg BID x5 days, or
Valacyclovir 500mg BID x3-5 days.
Suppressive Therapy: (Pts w/ >6 outbreaks/yr)
Acyclovir 400mg BID (~$30/ 1 month supply)
Famcyclovir 250 mg BID (~$200/ 1 month supply)
Valacyclovir 1gm qd (~$100/ 1 month supply)
Genital HSV-2 has much higher recurrence rate than
genital HSV-1, so serologic testing may be useful in tx.
Approximately 50% of pts will have recurrence w/in 6
months of primary infxn.
Suppressive Tx prolongs interval to recurrence, modestly
reduces duration of viral shedding.
Patient counseling is critical!
Need to inform potential new partners
Risks w/ pregnancy and delivery, etc…
Development of an HSV-2 vaccine is underway.
Another painful ulcer…
Endemic in several areas in the US, but
occurs more frequently in Africa, West
Indies and SE Asia.
Usually sexually transmitted
Incubation period is short: lesion usually
appears w/in 3-5 days after exposure.
~10% of pts w/ chancroid are co-infected
w/ HSV or syphilis.
Clinical Findings in Chancroid
Lesion starts as erythematous papule, evolves
into a pustule which then erodes into a painful
ulcer. Infected pts many have more than 1
Typical ulcer is 1 to 2cm in diameter, has
erythematous base w/ clearly demarcated,
Inguinal lymphadenitis occurs ~50% of cases.
Nodes my become fluctulant and drain pus.
Diagnosis of Chancroid
Definitive Dx requires positive culture for H.
ducreyi on special cx media that is not widely
available. (Sensitivity only ~80%).
Presumptive Dx via clinical criteria:
Painful genital ulcers, +/- inguinal LAN.
Negative for T. pallidum (syphilis) w/ darkfield exam
HSV culture of lesion is negative.
PCR test in development not yet widely
Treatment of Chancroid
Successful treatment for chancroid cures the
infection, resolves clinical sx and prevents
Azithromycin 1g po x1, or
Ceftriaxone 250mg IM x1, or
Ciprofloxacin 500mg po BID x3 days, or
Erythromycin 500mg TID x 7 days.
Sex partners must be tx’d regardless of sx if
sexual contact w/in 10 days prior to sx onset.
Chancroid is a reportable disease.
What about a painless genital ulcer?
Systemic disease caused by Treponema
“Mini-epidemic” in the 1980’s to early 90’s
w/ 20.3 cases per 100,000 population.
Incidence declining w/ 2.2 cases per
100,000 population in 2000.
Highest US incidence in southeast.
Black:Caucasian incidence ~30:1.
Clinical Findings in Syphilis
Primary Infxn: painless ulcer at the site of
Secondary Infxn (relapsing episodes are
possible for up to 5 yrs after primary):
skin rash (symmetric eruption of trunk,
extremities including palms and soles)
Mucocutaneous ulcer-like lesions
Systemic rubbery/painless lymphadenopathy
Wide array of neurologic abnormalities
Clinical Findings, continued
Latent Syphilis: period during which
serology is positive, but patients lack
Tertiary Syphilis: Advanced infection
presenting w/ cardiac, ophthalmic, auditory
abnormalities, gummatous lesions,
advanced neurologic manifestations.
Diagnosis of Syphilis
The chancre of primary syphilis is best
diagnosed w/ darkfield microscopy.
Secondary or latent phase are best
diagnosed with serology:
Nontreponemal tests: VDRL and RPR
Many causes of false positive
Become non-reactive 2-3 yr after treatment.
Treponemal tests: FTA-abs and TP-pa
More specific than non-treponemal tests.
Generally remain reactive for life.
Treatment of Syphilis
Primary & Secondary:
Benzathine penicillin G 2.4 million U. IM x1
Doxycycline 100mg po BID x14 days, or
Tetracycline 500mg po QID x14 days.
Benzathine penicillin G 2.4 million U IM x1
Late Latent and Tertiary:
Benzathine penicillin G 2. million U IM x3 q
Doctor, I’ve got these bumps…
Genital Human Papilloma Virus
Condyloma acuminatum (anogenital warts)
Diagnosis is clinical
Treatment is cryothearpy w/ liquid nitrogen,
Condoylox 0.5% soln. BID x3d q 4d x4,or Aldara 5%
cream qod x<4months.
Screening via regular Pap smears. Diagnosis via Pap
smear, HPV serotyping, colposcopy w/ or s/ biopsy.
Treatment: cryotherapy, surgical excision, curretage,
Estimated that there are 300 milion HBV
carriers in the world, 1.25 million in the US
Sexual transmission is the most common
mechanism of transmission accounts
for >50% new cases in the US.
Percutaneous transmission (IVDU, tatoos,
accupuncture, sharing razors/toothbrush)
Incubation time is 6 wks to 6 mos after
Diagnosis & Treatment of HBV
Diagnosis is via serology.
Postexposure tx w/ HBIG, plus vaccination
with HBV vaccine w/in 14 days after exposure
Vaccination of all household members.
Vaccination of all high risk individuals (eg.
healthcare workers, IVD users, pts w/ hx of
STD, pts who have sex w/ IVD users, men
who have sex w/ men.
Human Immunodeficiency Virus
Risk factors include unprotected sex
multiple sexual partners, hx of other STDs,
men who have sex w/ men, pts who have
sex w/ IVD users, IVD use, perinatal
exposure to infected mom.
Progression of disease varies. From
exposure to development of AIDS – few
months to 17 yrs (median=10yrs)
Testing for HIV
Should be offered to all pts presenting for
evaluation of STD, as wellas to all pts with risk
Informed consent required prior to testing. Both
pre-test and post-test counseling is an integral
part of testing procedure.
ELISA as screening.
Western Blot or immunofluorescent assay (IFA) as
Centers for Disease Control: Morbidity & Mortality Weekly
Report. “Sexually Transmitted Diseases Treatment
Guidelines 2002”. 10 May 2002, Vol. 51, No. RR-6.
DeCherney, Pernoll. Current: Obstetric & Gynecologic
Diagnosis & Treatment. 8th Ed. (McGraw Hill, Lange: New
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Tierney, McPhee, Papadakis. Current: Medical Diagnosis
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