sexual transmitted diseases, what you need to know if you are working in the emergency room

1. Rashid A. M. Abuelhassan
MBBS,MRCEM
R4 Emergency Medicine Resident
SEXUALLY
TRANSMITTED DISEASES
AND THE EMERGENCY ROOM

2. 500,000,000
New infection Per year
http://www.who.int/mediacentre/factsheets/fs110/en/

3. • syphilis in pregnancy leads to 305 000 fetal and
neonatal deaths, and leaves 215 000 infants at
increased risk of dying from prematurity, low birth
weight or congenital disease each year.
• HPV infection causes an estimated 530 000 cases of
cervical cancer and 275 000 cervical cancer deaths
each year
• STIs in sub-Saharan Africa, is the cause of up to 85%
of infertility among women seeking infertility care
• STI such as syphilis or HSV-2 infection increases the
chances of acquiring HIV infection by three-fold or
more.

5. CDC FACT SHEET | Incidence, Prevalence, and Cost of Sexually Transmitted Infections in the United States 2013

10. 40 years sailor came
to ER with this mass .
• What is it ?

12. Why we need to know about it?
• First/only medical contact for some pt.
• Complications are Disguised presentations.
• Complications are preventable.

13. PRESENTATIONS OF STDS?
• Flu
• Sore throat
• Headach
• Red eye
• Joint pain
• abdominal pain
• Abnormal menses
• Anal pain
• rash

15. • individual future health (Infertility, Cancer, urogenital
complications).
• protection others
• preventive education .
• Instructions for future screening.
The ED role & Why?

16. Approach in ER
• Privacy & Confidentiality
• Proper clinical assessment
• Pregnant or not?
• PEP
• GUM clinic
• Tracing & prophylaxis

17. What is the Most Common Cause Of
1- Ulcerative STD ?
2- Nonviral STD ?
3- Viral STDs?
4- Bacterial STDs
5- Second most common cause of Bacterial STD ?

19. DD

20. Syphilis

21. SYPHILIS
Treponema Pallidum
Primary
 Chancre
Painless with indurated border any where
 May not be there
 No constitutional symptoms
IP (9-90d) 1ry (2-6wk) 2ry (5-8wk) Latent 3ry ( >3yrs)

22. Secondary (5-8 Wk After Resolution Of 1ry Syphilis).
• Rash ( popular red pink) + lymphadenopathy
• Non specific symptoms ( sore throat etc )
• Condyloma Lata
• resolve spontaneously
IP (9-90d) 1ry (2-6wk) 2ry (5-8wk) Latent 3ry ( >3yrs)

23. LATENT:
• Asymptomatic but lab +ve
• Subcategorized into:
• early latent syphilis, (the preceding year)
• late latent syphilis of unknown duration.
IP (9-90d) 1ry (2-6wk) 2ry (5-8wk) Latent 3ry ( >3yrs)

24. TERTIARY
 3 to 20 years or more after a latent period.
 Gummatous.
 Thoracic Aortic Aneurysms
 Meningitis, Peripheral Neuropathy (Tabes
Dorsalis)
IP (9-90d) 1ry (2-6wk) 2ry (5-8wk) Latent 3ry ( >3yrs)
http://www.nejm.org/doi/full/10.1056/NEJMicm1008124

26. SHOULD WE EXPECT AORTIC ANEURYSM IN
YOUNG ?

28.  Darkfield Microscopy (sen 80%) :
Not Routinely Available, diagnostic even if serology -ve
 Serology (Require Both For Definitive Diagnosis):
 Nontreponemal (sensitive Not specific):
 VDRL, RPR , + ve In 2-4 Wk After Chancre, need confirmation
by Immunoassay
 In 2ry 100% sen
 Treponemal (sensitive and specific):
 MHA-TP, FTA-ABS
 Culture: Difficult To Culture
IP (9-90d) 1ry (2-6wk) 2ry (5-8wk) Latent 3ry ( >3yrs)

29. Treatment ( including pregnant)
1ry & 2ry :
Benzathine Penicillin G 2.4 M Units IM × 1
Doxacycline 100mg BID for 2wks
3ry :
Benzathine Penicillin G 2.4 M Units IM x3, 1 Week Apart
IP (9-90d) 1ry (2-6wk) 2ry (5-8wk) Latent 3ry ( >3yrs)
Jarisch-Herxheimer reaction occurs frequently in treatment of early syphilis
( febrile reaction +headache + myalgias within the first 24 h)

30. Contacts :
 Within The Last 90 Days  Tested But
Treated Presumptively.
 > 90 Days  Tested But Treated If Indicated
 F/U @ 6 And 12 Months (nonreactive or a
fourfold decrease in titers in 6/12)
Pregnancy + Penicillin Allergy + Syphilis At Any Stage
 Penicillin Is Still Recommended After Desensitization
IP (9-90d) 1ry (2-6wk) 2ry (5-8wk) Latent 3ry ( >3yrs)

31.  Most Common Cause Of Ulcerative STDs.
 1:5 Sexually Active Adults Is Infected.
 Most commonly HSV-2
 Major Role In Transmission Of HIV.
 IP 2 To 7 Days.
 It Is Either Primary Infection Or Recurrence.
GENITAL HERPES SIMPLEX
Herpes simplex virus (HSV) type 1 or type 2

32.  Symptoms: May Include Low-Grade
Fever, Myalgias, Headache, Fatigue
And Adenopathy.
 2 To 4 Weeks to Heal.
 Viral Shedding Can Last Up To 3
Weeks.
 The Degree Of illness Depends On The
Presence Or Absence Of Abs.

33.  DIAGNOSIS IS USUALLY CLINICAL.
 TZANCK SMEAR:
Is Not Recommended Because Of Its Lack of
Sensitivity.
 PCR:
New Acquisition Of The Virus May Take Up To 6
Weeks To Show Positive Antibodies.
 CULTURE:
Gold Standard.
Takes 3 To 10 Days.

34.  FIRST EPISODE
 Acyclovir 400 mg PO tid for 7–10 Days (
including pregnant).
 Valacyclovir 1 g PO bid for 7–10 Days.
 RECURRENT
 Valacyclovir 1 g PO qd For 5 Days. (
including pregnant).
 Sever
 Acyclovir 5+10mg/kg IV q8h for 2-d then
oral 400mg PO bid till completiong 10 days
.
Decreases The Duration Of Symptoms, And Shedding Of
The Virus, So Infectivity.

35. Chancroid
Haemophilus ducreyi
• 10% of infected also have HSV or T.
pallidum
• painful erythematous papule of 4 to 10
days.
• Eroded ulcerated, and often pustular (not
vesicular). 1 -2 cm , sharp, undermined
margins very painful with friable base
covered with yellow-gray necrotic
exudates.
• Multiple lesions 50%
• Painful inguinal lymphadenopathy 1 - 2
wks after primary infection
• A bubo will develop
• Constitutional symptoms are rare, and
ulcerations are rarely recurrent.

36. • Diagnoses
• C/S  sen=<80%
• No approved PCR test
• All patients should be tested for HSV,
syphilis, and HIV also at 3 months
• Treatment
• Azithromycin 1g PO in a single dose
• ceftriaxone 250mg IM single dose
• ID / Aspiration of Buboes
• Partners in the last 10 days included
• Pregnant
• Same .

37. LYMPHOGRANULOMA VENEREUM
struma, tropical bubo or Durand-Nicolas-Favre disease
painless primary chancre
1 to 3 wk  unilateral inguinal
lymphadenopathy (60% of cases)
suppurative lymphadenopathy,
Scarring (cause linear depressions parallel
to the inguinal ligament)  groove sign
fever, chills, arthralgias,
erythema nodosum
meningoencephalitis.
 LV proctitis Confused withUC

38. • Diagnose
• Culture, direct
immunofluorescence testing, and
nucleic acid detection
• clinically
• Treatment
• Doxycycline 100mg BID for 21d OR
• Azithromycin 1g PO weekly x3
• pregnant or lactating 
erythromycin or Azithromycin
• partners within 60 d

39. GRANULOMA INGUINALE
DONOVANOSIS
• Klebsiella Granulomatis
 IP: 2 wk - 6 m
 Subcutaneous nodule with No Lymphadenopathy
 painless, beefy, ulcerative bleeds easily
• Diagnose
• difficult to culture, and diagnosis often requires
visualization of characteristic Donovan bodies on
tissue biopsy
• Traetament
• Doxycycline PO at least 3 wk until lesion heals
• Azithromycin, ciprofloxacin, erythromycin base, and
trimethoprim-sulfamethoxazole are alternatives for at
least
• pregnant or lactating Azithromycin 1g Po weekly x3
• Partners : within 60 days of appearance if
symptomatic

40. GENITAL WARTS
HPV
• Oncogenic  geno. 16 & 18
• Warts  geno. 6 & 11
• IP : 1 to 8 m
• cauliflower-like coalesce to
form condylomata acuminate
• Often enlarge during pregnancy

41. • Diagnosis : clinical.
• Treatment : not by ER
• Vaccination
• geno. 6 & 11 -> bivalent vaccine
(CervarixR)
• geno. 16 & 18  quadrivalent vaccine
(GardasilR)
• @ 11-12 for females can start at 9
catch up at 13-26
• @ 9-27 for Males

42.  IP:Of 1 to 3 Weeks.
 Symptoms:
Male:urethritis, Epididymitis, Proctitis, Prostatitis
Reiter’s syndrome (urethritis, conjunctivitis, and
rash).
Female: Cervicitis, bleeding, Perihepatitis( Fitz-Hugh–
Curtis Syn).
Complications : PID, Ectopic pregnancy , BARTHOLIN
CYST AND ABSCESS, Infertility
 75% Of Women & 50% Of Men Are Asymptomatic.
Chlamydia
Chlamydia Trachomatis
40% Of Women With Untreated Chlamydia Develop PID

43. Diagnoses :
 NAAT (sen>90%, spe 99%) :Do Not Require Viable Organisms
 Males: Urine Screening For Symptomatic ( swab not
necessary
 In Females: Swabs For NAATs From Cervix, Urethra And
UrineTest Of Choice In Females Is Endocervical Swabs
 PCR, NAHT, ELIS
 CULTURE (sensitivity 60-80%) : Difficult
The CDC Recommends Chlamydia Testing For All Women With
Cervical Infections And All Pregnant.

44. Treatment
In uncomplicated
 Azithromycin 1 g PO Once, (Cure Rates 97%) OR
 Doxycycline 100 mg PO bid x 7 (Cure Rate 98%)
Complicated
Doxycycline is recommended first instead of azithromycin
 Pregnant ; Azithromycin 1 g PO Once
 Abstain From Sexual Intercourse For 7 Days After
Completion Of Treatment.
 Sexual Partners in 60 d need To Be Tested
 Retest after 3 months

45.  2nd most comon STI WW.
 Women Are Often Asymptomatic.
 20% Of Untreated Women Develop PID.
 Symptoms: IP 7-10d
 In Women: Discharge (Mucopurulant) Abdominal
Pain Dyspareunia Or Dysuria.
 In Men: Dysuria, purulent urethral discharge,
epidydmitis , prostitis
 Rash , asymmetrical arthralgia, tenosynovitis,
septic arthritis are common presentations.
 Complications : PID, chronic pelvic pain, Ectopic
pregnancy , bartholin cyst / abscess, Infertility
GONORRHEA

46.  Gonococcal Bacteremia, Frequent in Women
 Symptoms: Fever, Arthritis/Arthralgia And Rash
(Pustular, Acral, Tender)
 Rarely: Hepatitis, Myocarditis, Endocarditis And
Meningitis.
Diagnosis :
By Isolating From Blood, Synovial Fluid, Or Infected Skin.
Disseminated Gonococcal Infection (DGI)
Arthritis-Dermatitis Syndrome.

47. Diagnosis
GRAM STAIN:
In Symptomatic Patients (Less Useful In Asymptomatic).
NAATs (sensitivity 95-99%):
Endocervical / Urethral Swabs
Urine From Both Men And Women
CULTURE (Gold Standard):
endocervical / urethral
In DGI Blood C/S is only +ve in 20%-50% so take swab

48. TREATMENTS:
Dual therapy is now recommended
 Cefixime 400 mg PO ONCE OR Ceftriaxone 250mg IM
ONCE Plus
 Azithromycin1g PO once OR doxycycline 100mg PO Bid
for 7d
 Fluroquinalones NOT 1ST LINE
 Pregnant : Cephalosporin OR 2g Azithromycin OR 2g
spectinomycin IM once.
 DGI: 1g ceftriaxone IM/IV q 24h followed by cefixime
400mg PO BID for minmum 1 wk + evaluation of
possible Enocarditis and Meningitis
 GA: rarely need drainage & irrigation
 Abstain From Sexual Intercourse For 7 Days After
Completion Of Treatment.
 Sexual Partners in 60 d need To Be Tested

49. NONGONOCOCCAL URETHRITIS
C. trachomatis, U. urealyticum, M. genitalium, T. vaginalis, HSV and adenovirus.
Diagnose:
urethral specimen or first-void urine specimen >= 5 WBCs HPF
Treatment :
• empirically as chlamydial urethritis
• Symptomatic, noncompliant, ,new partner, or previous
not treated  repeat treatment
• still, culture for T. vaginalis and use :
• metronidazole 2 g Od once OR
• tinidazole 2 grams PO plus azithromycin 1 g PO Once

50. TRICHOMONIASIS
T. Vaginalis
 Symptoms: IP: 3-28d
• Female: Dysuria, Vulvar Itching, Vaginal
Discharge, Lower Abdominal Pain And
Dyspareunia
Thin & Scanty Vaginal Discharge In 70%,
Strawberry Cervix ( 2%-10% ).
Vaginal pH Above 4.5.
• Males: Urethral Discharge, Prostatitis Or
Epididymitis. Represent (20 %) of NGU.

51. DIAGNOSIS:
 Males, Only Culture Of Urethral Swab, Urine, Or
Semen Is Approved For Use ± NAAT
 Females ( CDC recommend screening)
• Wet-Mount (Sen60% -70%) >20 min not motile
• PCR (Sen 88%–97% And Spec 99%):
• Culture: Gold Stander take 7 d

52. TREATMENT
 Metronidazole 2 g PO Once OR 500 mg PO bid For 7 Days
(Cure Rates 90% – 95%)
OR
 Tinidazole 2 g PO Once (Cure Rates 86% – 100%).
 Partners Should Be Treated
 In Pregnancy 2 g Metronidazole once At Any Stage Of
Pregnancy Showed No Teratogenic Or Mutagenic Effects In
Meta-Analyses
 Avoid contact for 7d & avoid alchohol
IF 2 g regimen Failed  7 Days Regimen OR 2 g / Day For 5 Days.

53.  PID Is An Infection Of The Female UGT, Can
Be (Endometritis, Salpingitis, Peritonitis,
Or Tubo-Ovarian Abscess)
 PID Is An Ascending Infection.
 Can Be STD Or Non STD (Usually Flora)
 Caused By C.Trachomatis and N. Gonorrhea
Often Polymicrobial.
PELVIC INFLAMMATORY DISEASE
(PID)

54.  Risk Factors: Young, Multiple
Partners, Smoking And Menses.
 Serious Complications In 25%
 30% Of Infertility, 50% Of Ectopic.
 Symptoms: abdominal pain.
Dyspareunia, PVB, vaginal discharge,
fever.
 10% of patients with PID develop
Perihepatitis
PELVIC INFLAMMATORY DISEASE (PID)

55.  Diagnosis
 Clinical
 Laparoscopy With Biopsy .
 Treatment: CDC Recommends Empirical ttt If :
 Minimum Criteria:
 Uterine Tenderness, Adnexal Tenderness, Or Both.
 Cervical Motion Tenderness.
 Other Supportive Criteria:
 Oral Temperature Greater Than 38° C.
 Abnormal Cervical Or Vaginal Discharge.
 WBCs On Wet Mount Of Vaginal Secretions.
 Elevated ESR or CRP.
 Documented Infection With Gonorrhea or Chlamydia.

56. Treat all partners during 60 days prior to symptom onset
Outpatient Options
• Ceftriaxone 250mg IM x1 + doxycycline 100mg PO BID x14d +/-
metronidazole 500mg PO BID x14d (if risk for anaerobes); consider in:
• Pelvic abscess
• Proven or suspected infection with Trichomonas or Bacterial
Vaginosis
• History of gynecological instrumentation in the preceding 2-3wks
• Ceftriaxone 250mg IM x1 + 1 g of azithromycin per week, x 2 weeks +/- flagyl
*
Inpatient
• Cefoxitin 2gm IV q6hr OR cefotetan 2gm IV q12hr + doxycycline PO or IV 100
mg q12hr OR
Clindamycin 900mg IV q8h + gentamicin 2mg/kg QD OR
Ampicillin-sulbactam 3gm IV q6hr + doxycycline 100mg IV/PO q12hr
FOR IUD: No change in treatment if IUD in place
A single RCT shows that azithromycin is superior to doxycycline even when compliance in taking
doxycycline is excellent (98.2% vs 87.5%)

57. Disposition :
Admit
• Tubo-ovarian abscess
• Fitz-Hugh-Curtis
• Pregnancy
• Sepsis/Peritonitis
• Unable to tolerate PO
• Failed outpatient treatment
• HIV+
Discharge
• 72hr follow up
• abstain from contact or adhere strictly to barriers until symptoms
abated
PELVIC INFLAMMATORY DISEASE (PID)

58. Are we treating it the right way ?

59. • HIV/AIDS
• Hepatitis
• Molluscum Contagiosum
• Nongonococcal urethritis
• Pubic Lice
• CANDIDIASIS
• BACTERIAL VAGINOSIS
Other STI

60. PROPHYLAXIS AFTER SEXUAL
ASSAULT
• Ceftriaxone 250 mg IM+
metronidazole 2 g PO +
(azithromycin 1 g PO OR
Doxycycline 100 mg PO BID for 7
days )
• Hepatitis B vaccine
• HIV prophylaxis decision is a case-
by-case
• Repeat evaluation for STIs .
• Don’t forget the contraceptives

61. Patients Qs’

62. Contraceptives anti-STD≠

63. Barrier methods effectiveness

65. TAKE HOME MESSAGE
• Multiple STIs frequently occur together.
• Perform a pregnancy test in all females of
childbearing potential then give contraceptives
• adnexal or cervical motion tenderness =PID.
• A single dose of azithromycin is inadequate to treat
upper female genital tract infection; patients
require a 2-week course of antibiotics.
• A follow up is a must for confirmation for negativity

66. Questions