2. Sexually Transmitted Diseases
â˘
1.
2.
3.
4.
5.
The term denote disorders spread
principally by intimate contact:Sexual intercourse,
Close body contact, kissing, and anal
intercourse.
Transplacental spread,
Passage through the birth canal, and
Lactation during the neonatal period
3. Terminology
⢠WHO recommends that the term STD be
replaced by the term STI.
⢠STI has been adopted since 1999 as it
better incorporates asymptomatic
infections.
⢠Has also been adopted by a wide range of
scientific societies & publications.
4. Introduction
⢠the most common infectious diseases in the
most parts of the world
⢠five key points about all STDs today:
5. 1. STDs affect men and women of all
backgrounds and economic levels.
- They are most prevalent among
teenagers and young adults.
- Nearly two-thirds of all STDs occur in
people younger than 25 years of age.
6. continued
2. The incidence of STDs is rising
- Because in the last few decades, young people have become
sexually active earlier yet are marrying later.
- In addition, divorce is more common.
- The net result is that sexually active people today are more likely
to have multiple sex partners during their lives and are
potentially at risk for developing STDs.
7. continued
3 Most of the time, STDs cause no symptoms,
particularly in women.
- When and if symptoms develop, they may be confused
with those of other diseases not transmitted through
sexual contact.
- Even when an STD causes no symptoms, however, a
person who is infected may be able to pass the
disease on to a sex partner.
- recommend periodic testing or screening for people
who have more than one sex partner.
8. continued
4,
STDs tend to be more severe and more frequent
for women than for men,
- because the frequency of asymptomatic infection many women do not seek care until serious problems
have developed.
- Some STDs can spread to cause PID, which in turn
â infertility & ectopic (tubal) pregnancy.
- may be associated with cervical cancer; HPV
- causes genital warts
- other genital cancers.
9. continued
5. STDs can be passed from a mother to her baby
before, during, or immediately after birth;
- When diagnosed and treated early, many STDs can be
treated effectively.
- Some infections have become resistant to the drugs
used to treat them and now require newer types of
antibiotics.
11. Contâd; Organisms transmitted sexually
â˘
1.
2.
3.
4.
5.
6.
Bacteria
N. gonorrhea
C. trachomitis
T. pallidum
H. ducreyi
C. granulomatis
U. urealyticum
â˘
1.
2.
3.
4.
5.
Viral
HIV
HSV
HBV
HPV
Molluscom
contagiosum virus
⢠Others
1. T. vaginalis
12. STDs; described but less defined for sexual transmission
â˘
Bacteria
1. M . hominis
2. G . vaginalis
â˘
1.
2.
3.
4.
â˘
1.
2.
Viral
CMV
HCV
HSV type 8
EBV
Others
C. albicans
S. scabiei
14. Approaches to STD Dx & Rx
Three approaches
1. Laboratory based
2. Clinical without laboratory support
3. Syndromic Approach
15. Background
⢠Traditional approach to STD Dx and Rx
relies on laboratory diagnosis to determine
etiologic agents
ďźExpensive
ďźInvolves delay in Dx and Rx
ďźDepends on technician and lab accuracy
ďźOften not available in resource poor settings
ďźRequires quality control procedures
16. âŚBackground
⢠Alternative approach â Clinical Dx
ďźPresumptive Dx of one etiology based on
clinical findings
ďźOften inaccurate and incomplete
⢠Similarities of Sn and Sx
⢠Misses Co-infection
⢠Atypical presentation - HIV
17. Definition
⢠Syndromic Management is a management approach
that uses clinical algorithms on an STD Syndrome, the
constellation of patient symptoms and clinical signs to
determine therapy.
⢠Algorithms are adapted to local STD prevalence
⢠Chooses antimicrobial agents to cover all the possible
pathogens responsible for the syndromes in the specific
geographic area.
18. Syndromic Management
History
ď§ In 1991 WHO developed and started
advocating the syndromic approach to
address the limitation of aetiological (lab)
& presumptive(clinical) Dx & Mx
19. âŚSyndromic Management
Based On
ď§ Recognition of relatively consistent and characteristic
combinations of easily elicited Sx and easily recognized
Sn (Syndromes) with which STD commonly presents
ď§ Knowledge of the most common etiologies of different
syndromes
ď§ Knowledge of antimicrobial susceptibility pattern
ď§ Knowledge of behavioral & demographic characteristics
of people with STD
20. âŚSyndromic Management
Components
1. Identification and Rx of the Syndrome
2. Education and counseling on
- Rx compliance
- Risk reduction including condom use
1. Partner notification
2. Provision of condoms
3. VCT for HIV
21. Advantages
⢠Expedited care
⢠Cost savings â less technically demanding
⢠Increased client satisfaction
⢠Treatment at first visit
ďDecreases further transmission
ďDecreases complication
ďEliminates need for return visit
⢠Decrease incidence of HIV (by 42% in Tanzania)
22. âŚAdvantages
⢠Uses flow charts in case Mx which
ďStandardizes Dx,Rx, referral and reporting
ďImproves surveillance
ďImproves programme Mx
⢠High sensitivity
⢠Gives emphasis to non-medical aspects of
STD care
23. Disadvantages
⢠Inevitable over treatment (multiple antimicrobials
for single infection)
⢠Does not address subclinical and asymptomatic
STI
⢠High sensitivity is at the cost of specificity
⢠Doesnât address poor health care seeking
behavior for STD Sx
⢠Works well with some syndromes (GU,UD) but
not as well with others (VD)
24. âŚDisadv.
⢠Rx with multiple drug might be expensive and
⢠The recommended drugs may not be available
⢠But, cost effectiveness increases further when
ď§ Applied to high STD prevalence areas
ď§ Long term cost of STD is considered
ď§ Increased HIV transmission and continued
STD transmission is considered
26. Genital Ulcer Disease (GUD)
â˘
Algorithms for GUD try to identify presence of
1. Herpes,
2. Syphilis and/or
3. Chancroid
⢠Frequency of causative agents differ in different
parts
⢠Review â syndromic treatment without lab
support showed high cure rate
ď 100% - Cote Dâivore
ď 64% - Zambia
27. Herpes Simplex Virus
â DNA virus
⢠remain in latent form
⢠other members of the family includes VZ, CMV ,EBV
⢠there are different antigenic strains
⢠but are divided in two:⢠Type1 = oral
⢠Type2 = genital
â primary infection occurs in child hood
â latent infection resides in the sensory ganglion of trigeminal,
sacral & vagal
â 50 -100% of adults have serologic evidence of HSV1
â 20-80% type2
28. HSV ContâŚ
⢠transmission = only by direct contact
⢠clinical disease
⢠painful papule followed by vesicle ,ulceration crusting
& healing
⢠more sever in women
⢠Primary Vs Recurrent
⢠primary episode
â
â
â
â
more symptomatic
incubation range 2-14 days
there is fever & lymphadenities
viral shedding & healing prolonged
29. HSV ContâŚ
⢠recurrent episode
â frequently have prodromal period signaling active viral
replication,
â lesions are often localized
â shedding is shorter
â recurrences is not usually from re infection but are
reaction of latent viruses
30. ⢠Diagnosis
= mainly clinical
â Tissue culture
⢠best method but lengthy and costly
â ELISA testing 70%
â Direct immunofluoresent staining 75%
sensitive
= both the negative culture and smear
don't exclude infection
31. Syphilis
⢠organism characteristics & microbiology
â By treponema pallidum
â is tightly coiled a spirochete that can not be grown
â can invade intact mucous membrane or area of abraded skin .
⢠incidence and epidemiology
â the incidence is rising
â only 30% of patients exposed acquire the disease
â in those infected patients not taking medication 60% do develop
immune defense sufficient to control the infection
â the remaining will go to late and tertiary syphilis
32. ⢠Clinical diseases
1. EARLY SYPHILIS
A = primary syphilis,
â˘
â˘
â˘
â˘
painless chancre is the whole mark
it occurs at the site of inoculation
there is regional lymphadenopathy
incubation period 10-90 days
B = 20 syphilis
- mucocutaneous skin lesion 6-8weeks after the
original inoculation
- alopacia, hepatitis & nephrotic syndrome
33. continued
2. Latent syphilis
â characterized by serologic evidences but no clinical signs
&symptoms
â most patients are not infectious about 25% could have recent
skin lesion
â arbitrary division of this stage but has no clinical significance
with regard to treatment
â early latency (< 4 years from initial infection )
â late latency (>4 years )
34. continued
3. LATE SYPHILIS
⢠5-30 years after initial infection
â there are three divisions
1. benign disease(gummas) - lesion occur in vital organs
â can be life threatening if they compromise the organ
2. cardiovascular disease - involvement of the heart and the aorta are
frequent dysfunction may cause serious problem
3. neurological diseases - three clinical syndromes of neurological
involvement
â asymptomatic disease no neurological manifestations but abnormal
CSF
â meningovascular disease the commonest manifestation is paresis ,
(tabis dorsalis)
â parenchymatous disease âdementia the commonest manifestation
35. ⢠Diagnosis
A. Non treponemal specific test:⢠RPR (rapid plasma reagin) test,
⢠standard VDRL slide test,
B. Treponemal specific test;
⢠FTA-ABS; fluorescent treponemal antibody absorbed (used
commonly for adults ),
⢠MHA_TP micro haemagglutination assay( for neonates)
C. Dark field microscopy
â˘
the higher the titer the higher the inflammatory reaction
â˘
false +ve tests in chronic illnesses
â e.g. leprosy
- auto immune diseases( lupus)
â pregnancy
- drug addiction
36. Chancroid
⢠Haemophilus ducreyi :- a gram negative
bacteria
⢠is a painful soft chancre ragged with raised
borders
⢠kissing ulcers do occur
⢠unilateral lymphadenopathy that may
suppurate
⢠incubation period is 2-5 days
⢠the organism is fastidious
37. âŚGUD
Genital ulcers
Patient complains of genital sore or ulcer
Examine
Ulcer present?
Yes
- Treat for syphilis and
chancroid
-Educate
-Counsel if needed
-Promote/provide condoms
-Partner management
-Advise to return in 7 days
-Educate
No
Vesicular/recurrent
lesion(s) present?
Yes
-Management of
herpes
-Educate
-Counsel if needed
-Promote/provide
condoms
No
-Counsel if
needed
-Promote/provide
condoms
38. âŚGUD
⢠Syphilis
ďź Recommended regimen
Benzantine Penicillin 2.4miu im singledose
ďźAlternative regimen
Procaine Penicillin 1.2miu im for ten days
ďźPenicillin allergyâ TTC 500mg po qid/15d
or doxycycline 100mg po bid/15d
40. âŚGUD
⢠Herpes â to modify course of symptoms
⢠1st episode â acyclovir 200mg 5x per day /7
days(doesnât appear to influence natural Hx of
recurrent disease)
⢠Recurrence â acyclovir 200mg tid continuously
for frequently recurring outbreaks(>6 per year)
41. Inguinal Bubo
⢠Inguinal adenopathy
⢠LGV (L1,L2,L3),
⢠Chancroid,
⢠G I (donovanosis) is
â Klebsiella granulomatis, formerly known as
Calymmatobacterium granulomatis
⢠Common in the tropics as a cause of genital ulcer
⢠Men affected more than females
⢠Prostitution is reservoir
⢠Painful adenopathy
42. Inguinal Bubo, contâd
⢠Rare systemic symptoms except LGV
⢠Common predisposing factor for the
spread of HIV
⢠Complications:
â
â
â
â
â
Abscess formation
PID
Lymphatic obstruction
Stenosis
Infertility
44. Inguinal Bubo
Enlarged and/or painful inguinal lymph nodes?
Examine
Ulcer(s) present?
Yes
No
- Treat for lymphogranuloma
venereum
-Educate
-Counsel if needed
-Promote/provide condoms
-Partner management
-Advise to return in 7 days
Use genital ulcers flow chart
45. âŚInguinal Bubo
⢠Recommended regimen (LGV)
Doxycycline 100mg po bid/14 days or
TTC 500mg po qid/14 days
⢠Alternative regimen
Erythromycin 500mg po qid/14 days or
Sulfadiazine 1gm qid/ 14 days
⢠Aspirate fluctuant lymph nodes through normal
skin
⢠Incision and drainage or excision of nodes is
contraindicated
46. Vaginal Discharge (VD)
⢠Most difficult syndrome to diagnose
⢠Either vaginitis or cervicitis
⢠Cervicitis- N.gonorrhea
- C.trachomatis
⢠Vaginitis - Trichomonas vaginalis
- Candida albicans
- Bacterial vaginosis
⢠Effective management of cervicitis is more important from
patient point of view b/c of serious sequele
47. âŚVD
⢠VD is not an adequate indicator of any particular
STD making it a poor algorithm entry point
⢠Use of risk assessment has shown to improve
performance of syndromic management
algorithms
⢠The probability of correct Rx of STI relative to
probability of overtreatment is increased
48. âŚVD
⢠Risk scores use variables that are common risk
predictors for STD
ďYoung age less than 21
ďMultiple partners
ďPartner has urethral discharge
ďNew partner in the past three months
ďPatient is single
⢠Need adaptation to local,social and behavioral
conditions and should be periodically updated
49. âŚVD
Vaginal Discharge
Patient complains of vaginal discharge
(vaginal itching)
partner symptomatic or
specific risk factors positive?
No
Yes
-Treat for cervical and vaginal infections
-Educate
-Counsel if needed
-Promote/provide
condoms
-Partner
management
-Return if
necessary
-Treat for vaginal infection
-Educate
-Counsel if needed
-Promote/provide
condoms
50. âŚVD
Vaginal Discharge (with speculum)
Patient complains of vaginal discharge
(vaginal itching)
partner symptomatic or specific
risk factors positive?
No
Yes
Treat for cervical infection plus vaginal infection
according to speculum examination findings
Mucopus from
Cervix?
Profuse
VD?
Curd-like
VD?
- Treat for cervical & - Treat for trichomonas - Treat for
vaginal infections
& bacterial vagionosis
Speculum and bimanual
vaginal examinations
No
discharge?
-Educate
candida
-Counsel if
needed
-Educate
needed
-Educate
-Educate
-Counsel if
-Counsel if
-Counsel if
needed
-promote/prov-
needed
Cervical
motion
tenderness
present?
Use flowchart for
lower
abdominal
pain
51. âŚVD
Treatment
Cervicitis (Gonorrhea & Chlamydia)
Recommended regimen
Ciprofloxacin 500mg po single dose or
Ceftriaxone 250mg im single dose or
Cefixime 400mg po single dose or
Spectinomycin 2gm im single dose
Plus
Doxycycline 100mg po bid/7 days or
TTC 500mg po qid / 7 days or
Erythromycin (pregnant)
52. âŚVD
Vaginitis
Recommended regimen
metronidazole 2gm PO single dose or
metronidazole 500mg PO bid/7 days
plus
Nystatin 100,000 IU intra vaginally once/14 d, or
Clotrimazole 200mg once daily/3 days, or
Clotrimazole 500mg single dose
53. Lower Abdominal Pain (LAP)
Patient complains of lower abdominal pain
Take history and examine
(abdominal and vaginal)
No
Temp 38°C or Pain during
examination (on moving cervix)
No
Missed/overdue
or Vaginal discharge
period or
Yes
Recent delivery
- Treat for PID
/abortion or
-Educate
Rebound
-Counsel if
tenderness or
needed
Guarding or
-Promote/provide condoms
Vaginal bleeding
-Partner
Follow up after 3 days or
management
Yes
sooner if pain persists
Refer
No
Refer
Yes
Continue Rx
Improved?
Follow
up if
pain
persists
54. PID
⢠PID refers to acute infection of the upper
genital tract (above the internal cervical os)
⢠community-acquired Vs Iatrogenic
⢠USA - annually 2.5 million outpatient visits,
⢠200,000 hospitalizations, and
⢠100,000 surgical procedures
⢠incurs an annual total expense of more than
$5 billion
55. ⢠Acute PID= attributed to an ascending
spread of microorganisms from the
vagina and endocervix.
⢠Acute PID Vs Acute salpingitis
â are often used interchangeably,
â but PID is not limited to tubal infection only.
⢠A more descriptive term = (UGTI).
â Severity & Extent of disease
⢠This is differentiated from (LGTI) because
response to treatment appears to be
different in these two entities.
56. â˘
â˘
â˘
â˘
â˘
Etiology
Neisseria gonorrhoeae and Chlamydia
trachomatis serovars D-K
common cause of PID = 1/3rd each;
However, most = polymicrobial infection
caused by ascending infection
15% of infections occur after procedures
that break the cervical mucous barrier
C. trachomatis etiologic role is very
different from N. gonorrhea
57. â˘
â˘
â˘
â˘
â˘
N. Gonnorrhea
Gram-negative IC
diplococcus
rapid cycle 20 to 40
minutes to divide
rapid and intense
inflammatory
response
Less complication
Early Rx
â˘
â˘
â˘
â˘
â˘
â˘
C.Trachomatis
is a slow-growing
intracellular organism.
lack of mitochondria
growth cycle 48 to 72
hours
does not induce a
rapid or violent
inflammatory
response
destruction by rupture
Delayed Rx
58. Initial PID â
⢠tissue damage provides fertile ground for
the growth of secondarily infecting aerobic
and anaerobic bacteria.
⢠This necrotic tissue is an excellent growth
medium, and
⢠the epithelial damage enhances the
breakdown of the surface defense
mechanisms
60. ⢠Risk Factors
1. STI
2. Age
â Adolescent 1:8 Vs 1:80 for a sexually active >24, b/c
columnar epithelium
3. Contraceptives
â
â
â
â
IUDs = threefold to fivefold
Barriers = â 60%
OCP = â risk, good Px fertility
previous tubal ligation = 1/450;
4. Instrumentation ex. 1/200 induced abortion
5. Previous acute PID = 25 %,
- partner treatment
61. Diagnosis:I. A minimal set of clinical criteria has been
recommended by the CDC for empirical treatment of
PID, including
ď Cervical motion tenderness or uterine or adnexal
tenderness in the presence of lower abdominal or pelvic
pain. The following additional criteria can also be used to
support a clinical diagnosis of PID:
1. Oral temperature >101° F (>38.3° C)
2. Abnormal cervical or vaginal mucopurulent discharge
3. Presence of abundant numbers of white blood cells
(WBCs) on saline microscopy of vaginal secretions
4. Elevated erythrocyte sedimentation rate
5. Elevated C-reactive protein
62. Diagnosis:II. Considered "confirmed" cases:
ď Patients with pelvic pain and tenderness and any one or
more of the following are:
1. Acute or chronic (plasma cell) endometritis or acute
salpingitis on histologic evaluation of a biopsy
2. Demonstration of N. gonorrhoeae or C. trachomatis in
the genital tract
3. Gross salpingitis visualized at laparoscopy or laparotomy
4. Isolation of pathogenic bacteria from a clean specimen
from the upper genital tract
5. Inflammatory/purulent pelvic peritoneal fluid without
another source
63. Diagnosis:III. The "definitive" diagnosis of PID in symptomatic
patients:
ď One or more of the following three findings are required:
1. Histologic evidence of endometritis in a biopsy
2. An imaging technique revealing thickened fluid-filled
tubes/oviducts with or without free pelvic fluid or
tuboovarian complex
3. Laparoscopic abnormalities consistent with PID (eg,
tubal erythema, edema, adhesions; purulent exudate or
cul-de-sac fluid; abnormal fibriae)
65. Laboratory tests â
â˘
â˘
â˘
â˘
Pregnancy test
Microscopic exam of vaginal discharge in saline
Complete blood counts
Nucleic acid amplification tests for chlamydia and
gonococcus
⢠Urinalysis
⢠Fecal occult blood test
⢠C-reactive protein (optional)
66. Investigations cont....
⢠Laparoscopy is limited as a method of diagnosing the
early stages of PID, but it is important to rule out nonPID surgical emergencies, such as appendicitis, and
other entities requiring different treatment modalities,
such as endometriosis.
⢠Endometrial biopsy is one alternative to laparoscopy.
However, results may be delayed up to 2 to 3 days,
making its clinical applicability limited.
⢠Ultrasonography is of limited value for patients with
mild or moderate pelvic PID.
⢠Culdocentesis, with evidence of purulent peritoneal
fluid, is helpful in the diagnosis of acute PID.
68. Complications:ď Early
⢠Sepsis â MOF â Death( ruptured TOA = 10 %)
⢠Surgical morbidity (TOA)
ď Late
⢠Infertility = 20% ,if no Rx 50% to 70%
⢠Ectopic Pregnancy = 6-10X higher; 12 %;                    Â
( due to interference of ovum transport through the tube or entrapment ofÂ
the ovum secondary to microscopic tubal damage).
⢠Chronic pelvic Pain = 4x increases  (20% vs. 5%)
⢠Chronic PID
⢠Psychological consequences