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Sexually Transmitted Diseases _STDs_


  • pg 1
									      Sexually Transmitted Diseases

                       Khalid A. Yarouf


       Introduction.
       Urethritis:
        –   Clinical Features.
        –   Hx.
        –   P/E.
        –   Investigations.
        –   Management.
       2 Cases.


       Communicable disease transmitted b/w humans
        mainly by sexual activity including genital-genital
        contact, anal-genital contact & oral-genital contact.
       May also be transmitted by blood & during birth.
       STD syndromes: urethritis, epididymitis, cervicitis,
        vulvovaginitis, genital ulcer disease, infertility, AIDS,
        intestinal infections, genital warts, neoplasia,
        scabies, pubic lice.


       Painful urethral discharge & testicular
        swelling are the most common
        presentations of symptomatic STDs in ♂.
       Complications of urethritis: epididymitis,
        Reiter’s synd, prostatitis, inflammatory
       Non-gonococcal urethritis (NGCU) is >
        common than gonococcal urethritis.

    Urethritis (Clinical Features)

       Urethral discharge often worse in morning,
        dysuria, urethral itching.
                            GC urethritis              NGCU

        Organism(s)         Gram (-)ve intracellular   Chlamydia trachomatis.
                            diplococci.                Ureaplasma urealyticum.
                                                       Trichomonas vaginalis.
                                                       HSV: rare.
        Incubation period   < 1 week                   2-3 weeks
           Amount           +++                        Often slight
           Color            Yellow (purulent)          Gray, white, mucoid

    Con’t (CFx)

       Upper figure: Specimens of
        urethral pus showing PNMs
        ingesting N. gonorrhoeae, seen
        as kidney-shaped diplococci.

                                     Lower figure: Gonococcal
                                      urethritis. Typical purulent
                                      meatal discharge with
                                      inflammation of glans.
    Con’t (CFx)

       Epididymitis:
        –   Causes: mostly 2º to urethritis or prostatitis.
        –   When accompanied with urethritis  probably sexually
        –   Symptoms:
                Acute onset of unilateral testicular pain & swelling.
                Urethral discharge & dysuria.
        –   P/E:
                Tenderness of epididymis & vas deferens.
                Erythema & edema of overlying skin.
        –   DDx: trauma, torsion of testicles, tumor.

    Con’t (CFx)

       Hx:
        –   Sexual activity: multiple partners, sexual orientation, use
            safe sex, type of sex.
        –   UTI signs.
        –   Recent Hx of trauma or genito-urinary (GU) tract
        –   Known or suspected structural or functional abnormalities of
            urinary tract.
       P/E:
        –   Look @ urethral discharge.
        –   If not obvious on GU exam  ask pt to milk his urethra from
            base to meatus 3-4X.
                 If no discharge initially  ask symptomatic pt to return for
                  reexamination @ least 4 hours after voiding.
    Con’t (CFx)

      –   Examine scrotal contents.
      –   Early in epididymitis, swelling & tenderness is localized to
          one area of epididymis. But in time, swelling usually extends
          to involve whole epididymis & surrounding area such that
          the epididymis is not discernible in inflammatory mass.
      –   Gentle elevation relieves pain of testicular torsion, while
          increases in epididymitis.
      –   A non-tender, rock-hard scrotal mass should make you
          think of Ca.

     Con’t (Ix)

        Lab test  Urethral swab of discharge:
         –   Gram stain: look for Gram (-)ve intracellular
             diplococci (GC) inside WBCs
                 ↑ Sensitivity & specificity = 97-99%.
         –   Culture it for GC, or, Chlamydia (sensitivity 70-
             90% & specificity 100%).
                 If swab of discharge from cervix  sensitivity 30-65%.

     Con’t (Mx)

     3º Prevention = early effective intervention.
     A. Pharmacological:
      GC  Ceftriaxone 125 mg IM.
      NGCU:
         –   Doxycyline 100 mg orally twice X 7 days       OR
         –   Azithromycin 1 g orally in single dose.
         –   If Trichomonas is suspected  consider presumptive Rx for
             GC & Chlamydia while awaiting cultures.
        If CFx of epididymitis are present  test for GC &
         Chlamydia  presumptively treat for Chlamydia, use
         ice, NSAIDs, scrotal support, rest.

     Con’t (Mx)

     B. Non-pharmacological:
      Sexual intercourse should be avoided for 7 days
        after initial Rx.
      Referral of partner(s) who have symptoms within
        preceding 60 days to Rx.
      Patient education.
      REPORT to Preventive Medicine Department.
      Follow-up: pt should return for evaluation if
        symptoms persist / recur after completion of Rx.

     Con’t (Mx)

     2º Prevention = Prevention of disease after it
       starts, but before symptoms appear.
      Tracing & Rx of partners of cases.
      Screening:
       –   of sexually active people for infection (Chlamydia,
           gonorrhea, syphilis, HIV, cancer due to HPV by
           Pap smear).
       –   and Rx of pregnant women to prevent
           transmission to fetus.

     Con’t (Mx)

     1º Prevention = Prevention of disease before it starts.
      Abstinence or mutually faithful relationship.
      Safer sex  correct use of condoms:
         –   Latex condoms preferred.
         –   Use new, in-date, good condition condom & handle carefully, leave space
             at the tip.
         –   Use adequate water-based lubricant.
         –   Vaginal spermicide increases effectiveness (before intercourse).
        Counseling & Rx of cases and partners  to prevent
         new transmission.
        Education of adolescents on prevention.
        Vaccination for Hepatitis B.

     Con’t (Mx)
     Recurrent / persistent NGU:
      Usual time = 2-3 weeks following Rx.
      Tests for Chlamydia & Ureaplasma are usually (-)ve.
      Hx:
          –    Check compliance.
          –    Establish any possible contact with untreated sexual partners.
        P/E:
          –    Document objective evidence of urethritis.
        Ix:
          –    Wet preparation & culture of urethral smear for Trichomonas vaginalis &
          –    Culture should be taken for HSV.
          –    MSU should be examined & cultured.
        Mx: a further two weeks’ Rx with Metronidazole AND Erythromycin.

     Case 1

        Abdullah is a 34-year old married Emarati man who came
         to your PHC clinic complaining of low back pain. He says
         he hurt his back lifting a chair at home a week ago. The
         pain is felt in the lumbar area and is a moderately severe
         ache. There is no radiation of the pain to either leg. The
         pain is a bit worse with sitting. It is relieved by lying
         down. It’s improving slowly. There are no abnormal
         physical findings. During your discussion with him about
         the management of low back pain, he mentions that he
         has had a urethral discharge of several weeks. There’s
         no dysuria. He says he has been checked for this and
         describes midstream urine test which he says was normal
         2 weeks ago. While you’re trying to explain to him the
         need for appropriate testing and management, he gets up
         and walks out.

     1.   What test is appropriate for his urethral discharge?
     2.   What might be the cause?
     3.   What would be the management?
     4.   What public health implications might there be?
     5.   What other related problems can you think of?
     6.   How should they be managed:
          –   from an individual health?
          –   from a public health point of view?

     Case 2

        A 16-year old young man sees you at the PHC
         complaining of a URTI. He asks for a script for
         cough syrup and leaves. 2 days later he is back with
         his mother. She comes into the consultation room
         with him and stays with him until he tells you that he
         has pain with urination. The she leaves. The boy
         then tells you that 7 days ago he had a sexual
         encounter with a prostitute in Dubai! He has had
         dysuria for 4 days. He admits that he was too
         embarrassed to bring up this complaint when he was
         in to see you 2 days ago.


     1. What other information would you like to know?
     2. What might be the cause of this young man’s
     3. What other infections must you consider?
     4. What test would you do?
     5. What organisms might be involved?
     6. What personal and public health issues arise from
        this example?


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