This document discusses principles of managing sexually transmitted infections. It notes that many gynaecological infections are sexually transmitted and screening for multiple infections is important. It emphasizes treating partners to prevent reinfection. It then provides details on specific infections like chlamydia, gonorrhea, and herpes, describing symptoms, diagnosis, and treatment approaches.

1. Sexually transmittedSexually transmitted
infectionsinfections

2. Principles of management of sexuallyPrinciples of management of sexually
transmitted infections :transmitted infections :
* Many gynaecological infections are sexually* Many gynaecological infections are sexually
transmitted. Other such as candida and urinary tracttransmitted. Other such as candida and urinary tract
infections are frequently triggered by sexualinfections are frequently triggered by sexual
intercourse although the organism is colonizing theintercourse although the organism is colonizing the
women beforehand.women beforehand.
* It may be difficult to take a sexual history if the* It may be difficult to take a sexual history if the
patient's friend or relative are present, or in a wardpatient's friend or relative are present, or in a ward
In which there is inadequate privacy and sound-In which there is inadequate privacy and sound-
proofing.proofing.

3. * If one sexually transmitted infection is present, then* If one sexually transmitted infection is present, then
there may be others. Ideally therefore, a full screenthere may be others. Ideally therefore, a full screen
should be performed for chlamydia, gonorrhoea,should be performed for chlamydia, gonorrhoea,
vaginal infection and serological tests for syphilis,vaginal infection and serological tests for syphilis,
hepatitis B, HIV and hepatitis C if indicated.hepatitis B, HIV and hepatitis C if indicated.
* To break the chain of infection and prevent re* To break the chain of infection and prevent re ––
infection, it is essential that the patient avoidsinfection, it is essential that the patient avoids
intercourse until she is sure that her partner(s) hasintercourse until she is sure that her partner(s) has
been screened and received appropriate treatment.been screened and received appropriate treatment.

4. STDs are a Significant Problem
The consequences of untreated STDsThe consequences of untreated STDs
– Ectopic pregnancy (7Ectopic pregnancy (7--10 times increased risk in10 times increased risk in
women with history of PID)women with history of PID)
– Increased risk of cervical cancerIncreased risk of cervical cancer
– Chronic abdominal pain (18% of females with aChronic abdominal pain (18% of females with a
history of PID)history of PID)
 Infertility:Infertility:
– 2020--40% of males with untreated chlamydia and40% of males with untreated chlamydia and
gonorrheagonorrhea
– 5555--85% of females with untreated PID85% of females with untreated PID
(8(8--20% of females with untreated gonorrhea20% of females with untreated gonorrhea
develop PID)develop PID)
 Increased risk of HBV and HIV/AIDS transmissionIncreased risk of HBV and HIV/AIDS transmission

5. STIsSTIs –– classificationclassification
 BACTERIALBACTERIAL
 VIRALVIRAL
 PROTOZOALPROTOZOAL
 FUNGALFUNGAL
 ECTOPARASITESECTOPARASITES

6. 11 –– Chlamydia trachomatis:Chlamydia trachomatis:
Is the commonest bacterial sexually transmittedIs the commonest bacterial sexually transmitted
infection in industrialized countries, women under 25infection in industrialized countries, women under 25
years of age have the highest prevalence.years of age have the highest prevalence.
* Many infections are asymptomatic, approximately* Many infections are asymptomatic, approximately
50% in men and 80% in women. In men it is the most50% in men and 80% in women. In men it is the most
important cause of NGU. In women it causes cervisitisimportant cause of NGU. In women it causes cervisitis
and PID.and PID.
* Chlamydia trachomatis is a small bacteria that is an* Chlamydia trachomatis is a small bacteria that is an
obligate intracellular pathogen. Serovars A-C causeobligate intracellular pathogen. Serovars A-C cause
trachoma infection of the conjunctiva.trachoma infection of the conjunctiva.

7. Serovars DSerovars D –– K cause genital infection, specificK cause genital infection, specific
lymhogranuloma venereum ( LGV ) Serovars (Llymhogranuloma venereum ( LGV ) Serovars (L11 –– LL33))
cause LGV.cause LGV.
The infectious particle is the elementary body, theyThe infectious particle is the elementary body, they
gain entry to the cells by binding to specific surfacegain entry to the cells by binding to specific surface
receptors. Once inside the cells inclusion bodies form,receptors. Once inside the cells inclusion bodies form,
which contain the metabolically active reticulatewhich contain the metabolically active reticulate
bodies. These divide by binary fission. After 48 hoursbodies. These divide by binary fission. After 48 hours
life cycle reticulate bodies condense into elementarylife cycle reticulate bodies condense into elementary
bodies which are released from the cell surface.bodies which are released from the cell surface.
Heavily infected cells die but it is the inflammatoryHeavily infected cells die but it is the inflammatory
response to infection that contributes most toresponse to infection that contributes most to
damaging the epithelial surface.damaging the epithelial surface.

9. Humoral immunity may protect from reHumoral immunity may protect from re –– infection, butinfection, but
Abs are serovarsAbs are serovars –– specific and the protection is shortspecific and the protection is short
lived. Cell mediated immunity with activation oflived. Cell mediated immunity with activation of
cytotoxic Tcytotoxic T –– cell and production of interferon Y Is morecell and production of interferon Y Is more
important for controlling established infection.important for controlling established infection.
Diagnosis :Diagnosis :
It is diagnosd by specific tests :It is diagnosd by specific tests :
11 –– ELISA ( enzymeELISA ( enzyme –– linked immunosorbant assay ):linked immunosorbant assay ):
Commonly used but their sensitivity is limited .theCommonly used but their sensitivity is limited .the
sample should be collected from endocervix and areassample should be collected from endocervix and areas
of cervical ectropion so that columnar cells harvestedof cervical ectropion so that columnar cells harvested
( not used on rectal or conjunctiva swab )( not used on rectal or conjunctiva swab )

10. 22 –– PCR and the ligase chain reaction (LCR) :PCR and the ligase chain reaction (LCR) :
To detect DNA, are more sensitive, applied toTo detect DNA, are more sensitive, applied to
urine sample or vaginal swabs and have detectionurine sample or vaginal swabs and have detection
rate superior to ELISA on cervical swabs.rate superior to ELISA on cervical swabs.
But it is expensive, so not applied as aBut it is expensive, so not applied as a
screening test.screening test.
33 –– A Direct fluorescent Ab test ( DFA ):A Direct fluorescent Ab test ( DFA ):
Performed on cervical smears collected into aPerformed on cervical smears collected into a
specific collecting slide and fixed in alcohol, it isspecific collecting slide and fixed in alcohol, it is
reliable on rectal and conjunctival swabs.reliable on rectal and conjunctival swabs.
44 –– Cell culture :Cell culture :
Initially was the only wayInitially was the only way

11. 55 –– MicroMicro –– immunofluorescence :immunofluorescence :
Can be used to detect serum Abs which are notCan be used to detect serum Abs which are not
present in all infected individual.present in all infected individual.
The highest AB titer are found in women with PID orThe highest AB titer are found in women with PID or
disseminated infection. They are present in 60% ofdisseminated infection. They are present in 60% of
women with tubal factor Infertility.women with tubal factor Infertility.
Intracellular Inclusions of C. trachomatis

12. Chlamydia Female (CervixChlamydia Female (Cervix((

13. Treatment :Treatment :
These are effective for uncomplicated chlamydialThese are effective for uncomplicated chlamydial
infection :infection :
11 –– Doxycycline 100 mg twice a day for 7 days.Doxycycline 100 mg twice a day for 7 days.
22 –– Erythromycin 500 mg twice a day for 14 days usedErythromycin 500 mg twice a day for 14 days used
in pregnancy.in pregnancy.
33 –– Azithromycin 1g as a single dose.Azithromycin 1g as a single dose.
44 –– Ofloxacin 400 mg daily for 7 days.Ofloxacin 400 mg daily for 7 days.
It is essential that sexual partners are screened fully forIt is essential that sexual partners are screened fully for
STD and prescribed treatment for chlamydia beforeSTD and prescribed treatment for chlamydia before
sexual intercourse is resumed.sexual intercourse is resumed.

14. 22 –– Gonorrhea :Gonorrhea :
The incidence has declined in developed countries inThe incidence has declined in developed countries in
the last 2 decades. The prevalence is < 1% in womenthe last 2 decades. The prevalence is < 1% in women
of childbearing age. Chronic asymptomatic infection isof childbearing age. Chronic asymptomatic infection is
common. 50% of women have no symptoms or signs ofcommon. 50% of women have no symptoms or signs of
infection. Approximately 90% of men are symptomatic.infection. Approximately 90% of men are symptomatic.
* IN male gonorrhoea causes a severe urethritis, with* IN male gonorrhoea causes a severe urethritis, with
green urethral discharge and dysuria.green urethral discharge and dysuria.
* In female the spectrum of disease is similar to* In female the spectrum of disease is similar to
chlamydia.chlamydia.
* It is carried in the throat or cause an exudative* It is carried in the throat or cause an exudative
tonsillitis, it can cause conjunctivitis in adults. It causetonsillitis, it can cause conjunctivitis in adults. It cause
proctitis In women and homosexual men, who mayproctitis In women and homosexual men, who may
present with purulent discharge, bleeding and rectalpresent with purulent discharge, bleeding and rectal
pain.pain.

15. Nisseria gonorrhoea :Nisseria gonorrhoea :
It is a gramIt is a gram –– negative diplococcus , it colonizenegative diplococcus , it colonize
columnar or cuboidal epithelium.columnar or cuboidal epithelium.
Protective immunity does not appear to develop.Protective immunity does not appear to develop.
Reliable serological tests for gonorrhoea have beenReliable serological tests for gonorrhoea have been
developed. When antibiotic use is not controlleddeveloped. When antibiotic use is not controlled
adequatelyadequately –– resistant strains emerge rapidly.resistant strains emerge rapidly.
There are chromosomal mutation conferring reducedThere are chromosomal mutation conferring reduced
sensitivity to penicillin, and recently mutationsensitivity to penicillin, and recently mutation
conferring Resistance to Quinolone antibiotic haveconferring Resistance to Quinolone antibiotic have
emerged in developed countries.emerged in developed countries.
High levelHigh level –– resistance to penicillin is mediated by aresistance to penicillin is mediated by a
plasmid, penicillinase producing Neisseria gonorrhoeaplasmid, penicillinase producing Neisseria gonorrhoea
strains.strains.

16. Gonorrhea In Women
Gonorrhea

17. Diagnosis :Diagnosis :
Is made by observing typical GramIs made by observing typical Gram –– negativenegative
intracellular diploccoci on gram smears of urethral,intracellular diploccoci on gram smears of urethral,
cervical and rectal swabs.cervical and rectal swabs.
It is a fastidious organism, requiring COIt is a fastidious organism, requiring CO22
concentration of 17%, specific media such as bloodconcentration of 17%, specific media such as blood
agar and antibiotics to inhibit the growth of otheragar and antibiotics to inhibit the growth of other
micro-organisms.micro-organisms.
DNADNA –– based detection tests are available forbased detection tests are available for
screening but culture remain essential to allow ABscreening but culture remain essential to allow AB
sensitivity tests.sensitivity tests.

18. Treatment :Treatment :
11 –– Amoxycillin 3 g with probenecid 2 g as a singleAmoxycillin 3 g with probenecid 2 g as a single
dose.dose.
22 –– Ciprofluxacin 500 mg as a single dose.Ciprofluxacin 500 mg as a single dose.
33 –– Spectinomycin 2 g as a single dose (I.M ).Spectinomycin 2 g as a single dose (I.M ).
44 –– Ceftriaxone 250 mg as a single dose ( I.M ).Ceftriaxone 250 mg as a single dose ( I.M ).
The choice of AB is decided by local sensitivityThe choice of AB is decided by local sensitivity
patterns, history of recent travel and coast.patterns, history of recent travel and coast.
Sex partner should be screened fully for STD andSex partner should be screened fully for STD and
treated.treated.
> 50% of female infected with gonorhoea have a> 50% of female infected with gonorhoea have a
concomitant chlamydial infection, this meansconcomitant chlamydial infection, this means
chlamydial treatment prescribed routinely for allchlamydial treatment prescribed routinely for all
women with gonorhoea.women with gonorhoea.

19. Because possibility of AB resistance and occasionalBecause possibility of AB resistance and occasional
treatment failure women should have 2 tests of culturetreatment failure women should have 2 tests of culture
performed following treatment as tests of cure.performed following treatment as tests of cure.

20. Genital ulcer disease :Genital ulcer disease :
Classification :Classification :
1 –1 – Infective :Infective :
a – HSV b – Primary syphilisa – HSV b – Primary syphilis
c- LGV d – Chancroidc- LGV d – Chancroid
e – Donovanosis f – HIVe – Donovanosis f – HIV
2 –2 – Non – infective :Non – infective :
a – Aphthaus ulcers b – Traumaa – Aphthaus ulcers b – Trauma
c – Skin diseases ex, lichen sclerosisc – Skin diseases ex, lichen sclerosis
d – Bahcet disease e – Dermititis artefectad – Bahcet disease e – Dermititis artefecta
f – Other multisystem disorders ex, sarcoidosis.f – Other multisystem disorders ex, sarcoidosis.

21. 11 –– Herpes simplex virusHerpes simplex virus
Traditionally herpes simplex virus type I (HSV -I )Traditionally herpes simplex virus type I (HSV -I )
causes oral lesion ( cold area ) and herpes II. Herpescauses oral lesion ( cold area ) and herpes II. Herpes
II causes genital herpes, but now 50% of genitalII causes genital herpes, but now 50% of genital
lesion are caused by HSVlesion are caused by HSV –– I.I.
Individual with one type of HSV infection canIndividual with one type of HSV infection can
develop symptomatic infection from other type,develop symptomatic infection from other type,
although there is some partial immunity.although there is some partial immunity.
Diagnosis :Diagnosis :
Is made by collecting serum from a vesicle with aIs made by collecting serum from a vesicle with a
small needle and syringe or by applying a cottonsmall needle and syringe or by applying a cotton ––
tipped swab to ulcers. The virus is demonstrated bytipped swab to ulcers. The virus is demonstrated by
electron microscopy or culture in a tissue monolayer.electron microscopy or culture in a tissue monolayer.
Monoclonal Ab are used to type the virus onceMonoclonal Ab are used to type the virus once
cultured.cultured.

22. * Serology test are available, but cannot reliably* Serology test are available, but cannot reliably
Distinguish between Ab to HSV I and HSV II.Distinguish between Ab to HSV I and HSV II.
Primary herpes :Primary herpes :
Presents up to 3 weeks after acquisition, usuallyPresents up to 3 weeks after acquisition, usually
widespread involvement of the vulva and the vagina,widespread involvement of the vulva and the vagina,
and the cervix can also be affected. Primaryand the cervix can also be affected. Primary
pharyngeal or rectal infection following orogenital orpharyngeal or rectal infection following orogenital or
rectal intercourse.rectal intercourse.
Painful vesicles develop which coalesce into multiplePainful vesicles develop which coalesce into multiple
ulcers, periurethral involvement may cause severeulcers, periurethral involvement may cause severe
pain and urinary retention can result. This may also bepain and urinary retention can result. This may also be
partly due to involvement of the sacral nerves.partly due to involvement of the sacral nerves.

23. Herpes (PenisHerpes (Penis((

24. Treatment :Treatment :
Includes :Includes :
11 –– Analgesics.Analgesics.
22 –– bathing in salt water.bathing in salt water.
33 –– Lignocaine gel can be applied to sore areas.Lignocaine gel can be applied to sore areas.
44 –– Anti viral treatment to stop viral replication.Anti viral treatment to stop viral replication.
Healing occur over the following weeks, AciclovairHealing occur over the following weeks, Aciclovair
200 mg 5 times a day for 5 days is the cheapest and200 mg 5 times a day for 5 days is the cheapest and
most established treatment. Famciclovair andmost established treatment. Famciclovair and
valaciclovir have greater bioavailability but arevalaciclovir have greater bioavailability but are
considerably more expensive.considerably more expensive.

25. Recurrent herpsRecurrent herps
Following a primary infection, herpes colonize theFollowing a primary infection, herpes colonize the
neurons in the dorsal root ganglia establishing a latentneurons in the dorsal root ganglia establishing a latent
infection. Productive infection occur intermittently wheninfection. Productive infection occur intermittently when
virus particles are produced and track down the axonsvirus particles are produced and track down the axons
to the skin, vesicles and ulcers then occurs in the sameto the skin, vesicles and ulcers then occurs in the same
area, sometimes distant anatomical sites are affected ifarea, sometimes distant anatomical sites are affected if
supplied by the same dermatomal nerve root.supplied by the same dermatomal nerve root.
The spectrum of severity varies :The spectrum of severity varies :
11 –– Asymptomatic shedding of the virus.Asymptomatic shedding of the virus.
22 –– Trivial ulcers resembling small abrasion on theTrivial ulcers resembling small abrasion on the
vulva.vulva.
33 –– wide spread or chronic ulceration ca be seen inwide spread or chronic ulceration ca be seen in
pregnant women.pregnant women.
44 –– if a women is immunosuppresed large atypicalif a women is immunosuppresed large atypical
ulcer can develop.ulcer can develop.

26. Treatment :Treatment :
Anti viral agents are usually ineffective in treating anAnti viral agents are usually ineffective in treating an
established attack, which will resolve just as quicklyestablished attack, which will resolve just as quickly
without specific treatment. Usually advice the patient towithout specific treatment. Usually advice the patient to
keep the area clean by washing with salt water and tokeep the area clean by washing with salt water and to
avoid sexual intercourse until fully healed.avoid sexual intercourse until fully healed.
In small proportion of patients who develop frequentIn small proportion of patients who develop frequent
recurrence ( > 6-8 times per year ) or are considerablyrecurrence ( > 6-8 times per year ) or are considerably
incapacitated during the attacks, long termincapacitated during the attacks, long term
suppression with acyclovir 400 m twice a day reducesuppression with acyclovir 400 m twice a day reduce
the frequency of attack, it may still occur and can bethe frequency of attack, it may still occur and can be
transmitted to the partner.transmitted to the partner.
Many individuals experience a prodrome before theMany individuals experience a prodrome before the
onset of the vesicles and ulceration as tinglingonset of the vesicles and ulceration as tingling
sensation with pain in thigh and perineum, suchsensation with pain in thigh and perineum, such
patients benefited from episodic treatment ( 5 daypatients benefited from episodic treatment ( 5 day
treatment pack to keep at home ) to be initiated whentreatment pack to keep at home ) to be initiated when

27. Complications :Complications :
11 –– Psychological distress.Psychological distress.
22 –– Neurological involvement during primary herpesNeurological involvement during primary herpes
infection is uncommon, but it may present as asepticinfection is uncommon, but it may present as aseptic
meningitis or transverse myelitis or autonomicmeningitis or transverse myelitis or autonomic
neuropathy.neuropathy.
33 –– Herpes keratitis which is a serious condition thatHerpes keratitis which is a serious condition that
can produce corneal scarring and blindness especially ifcan produce corneal scarring and blindness especially if
inappropriately treated with steroid in the absence ofinappropriately treated with steroid in the absence of
antiviral agent.antiviral agent.

28. Primary herpes outbreak
in a female. Photo
courtesy of the CDC.
Primary herpes outbreak in
the same female patient 4
days later. Photo courtesy
of the CDC.