The document discusses sexually transmitted infections (STIs) focusing on their transmission, presenting problems in men and women, and approaches to diagnosis and treatment. It covers various STIs including syphilis, gonorrhea, and chlamydia, detailing clinical features, risk factors, prevention, and complications. Diagnostic methods and treatment guidelines are also outlined, emphasizing the importance of early detection and management.

1. Sexually Transmitted
Infections (STI)
Dr. Zaid Mohammed Saeed

2. Group of contagious conditions whose principal mode
of transmission is by intimate sexual activity involving
the moist mucous membranes of the penis, vulva,
vagina, cervix, anus, rectum, mouth and pharynx, along
with their adjacent skin surfaces.

3. Presenting problems in men
1. Urethral discharge
•Gonorrhoea and chlamydia.
•Non-specific urethritis (NSU): Trichomonas vaginalis,
herpes simplex virus (HSV), mycoplasmas, ureaplasma or
adenoviruses.
2. Genital itch and/or rash
May be caused by subclinical urethritis, candidiasis,
anaerobic balanitis (inflammation of the glans), phthirus
pubis, genital herpes.

4. 3. Genital ulceration
• Painful like genital herpes (the most common cause of
genital ulceration) and chancroid,
lymphogranuloma venereum or
• Painless like syphilis,
granuloma inguinale.
4. Genital lumps
cause is
Most common cause are warts. Less common
molluscum contagiosum. .viral infection ‫ﻮ‬ ‫ﻟﻲھ‬ ‫ا‬
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5. Proctitis in men having sex with men
gonorrhoea, chlamydia, herpes and syphilis.

5. Presenting problems in women
1. Vaginal discharge
•Not sexually transmitted, being due to either candidal
infection or bacterial vaginosis (BV).
•Trichomoniasis, gonorrhoea and chlamydia.But here due STD
2. Lower abdominal pain A feature of pelvic inflammatory
disease (PID)
3. Genital ulceration
4. Genital lumps
5. Chronic vulval pain and or itch

6. Who is at particular risk for STI?
• Sex workers, male and female
• Clients of sex workers
• Men who have sex with men
• Injecting drug users (sex for money or drugs) and their
partners
• Frequent travellers

7. Approach to patients with STI
1. History
•Genital symptoms: ulceration, rash, irritation, pain, swelling
•Urinary symptoms, especially dysuria.
•Urethral discharge (men) and vaginal discharge, pelvic pain
or dyspareunia (women)
•General health: menstrual and obstetric history
•Recent medication
•Immunization status
•Alcohol intake and recreational drug use.

8. 2. Examination
General: Mouth, eyes, joints, skin
Inguinal LAP, skin of genital area (warts, tinea cruris, ulcer),
pubic area (pediculosis), urethral meatus (discharge),
proctoscopy (features of proctitis)
In women: Abdomen (masses, tenderness), vagina and cervix
(abnormal discharge, ulcers, inflammation, bimanual
examination for adnexial tenderness)
As in pelvic inflammatory disease.
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Pain in pelvic region.

9. 3. Investigations:
•Nucleic acid amplification test (NAAT) for chlamydia and
gonorrhea
•Culture for gonorrhea
•Serological test for syphilis (STS)
• Human immunodeficiency virus (HIV) test
•Serological tests for hepatitis A/B
Note//Clymydia can not be cultured.
Gonorrhea is fastidious organism

10. Prevention of STI
1. Case-finding
Early diagnosis and treatment
2. Changing behavior
• Delay the onset of sexual activity and limit the number of
sexual partners.
• Encouraging the use of barrier methods of contraception

11. Syphilis
The Causative organism is the spirochete Treponema pallidum.
Transmission
• Sexual relationships, Main route
• Kissing,
• Blood transfusion
• Percutaneous injury
• Transplacental infection of the fetus can occur.
IP can range from 9 – 90 days, but usually it is 2 – 4 weeks.

12. Clinical classification:
•Early syphilis includes primary, secondary and early latent
(within 2 years of infection).
•Late syphilis includes late latent (after 2 years of infection),
benign tertiary, cardiovascular and neurosyphilis.

13. •Primary syphilis
•Chancre develops at the site of infection, usually in the genital
area in the form of an indurated ulcer (chancre).
•The draining inguinal lymph nodes may become enlarged.
• Painless and non-tender
•Without treatment, the chancre will resolve within 2–6 weeks to
leave a thin atrophic scar.
•Extragenital chancres are found in about 10% of patients.
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Painless ulcer

15. Secondary syphilis
Occurs 6–8 weeks after the development of the chancre
∙ Constitutional features
∙ Skin rash (over 75% of patients) on the trunk and limbs that
may later involve the palms and soles
∙ Without treatment, the rash may last for up to 12 weeks.
∙ Condylomata lata (papules coalescing to plaques)
(50% of
∙ Generalised non-tender lymphadenopathy
patients)
∙ Mucosal lesions, known as mucous patches
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Any rash involve palms & soles we should put in mind it
may be secondary syphilis.

17. Secondary syphilis,maculopapullar
rash.

18. Condylomata lata

19. • Other features, such as meningitis, cranial nerve palsies,
anterior or posterior uveitis, hepatitis, gastritis,
glomerulonephritis or periostitis
The clinical manifestations of secondary syphilis will resolve
without treatment, but relapse may occur.

20. Latent syphilis
Positive syphilis serology or the diagnostic cerebrospinal fluid
(CSF) abnormalities of neurosyphilis in an untreated patient
with no evidence of clinical disease.
• Early latency (within 2 years of infection), when syphilis
may be transmitted sexually,
• Late latency, when the patient is no longer sexually
infectious.
Without treatment, over 60% of patients might be expected to
suffer little or no ill health.
But may be transmitted by other routes.
40 percent may develop
benign tertiary—-
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Should be untreated

21. Benign tertiary syphilis
This may develop between 3 and 10 years after infection
• Gumma: chronic granulomatous lesion, which may be
single or multiple. Healing with scar formation may impair
the function of the structure affected. (skin, mucous
membranes, bone, brain, spinal cord, liver or the testes)
• Paroxysmal cold haemoglobinuria may be seen.
Attack of hemolytic anaemia at cold
temperature((autoantibodies active at lower temperature)).

23. Cardiovascular syphilis
Aortitis, which may involve the aortic valve and/or the
coronary ostia, is the key feature. Clinical features include
aortic incompetence, angina and aortic aneurysm
Neurosyphilis
May be asymptomatic or present with meningovascular
disease, tabes dorsalis and general paralysis of the insane. paralytic
dementia
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Comes as meningitis
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Involvement of dorsal column with peripheral
neuropathy.

24. Investigations
1. Direct identification of Treponema pallidum using a dark-field
microscope, a direct fluorescent antibody test or PCR.
A. Non-treponemal (non-specific) tests (positive after 4 weeks)
•Venereal Diseases Research Laboratory (VDRL) test
•Rapid plasma reagin (RPR) test
B. Treponemal (specific) antibody tests (positive after 2 weeks)
•Treponemal antigen-based enzyme immunoassay (EIA) for IgG and IgM
•Treponema pallidum haemagglutination assay (TPHA)
•T. pallidum particle agglutination assay (TPPA)
•Fluorescent treponemal antibody-absorbed (FTA-ABS) test
2. Serological tests for syphilis (STS):Most commonly used
Non specific because may be positive
with other as borrelia,leptospira
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And become negative after treatment.
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Positive earlier and still positive after treatment but
after many years may become negative,

26. 3. CSF: In benign tertiary and cardiovascular syphilis, patients
with clinical signs of neurosyphilis and in both early and late
latent syphilis.
4. Chest X-ray, electrocardiogram (ECG) and
echocardiogram are useful in the investigation of
cardiovascular syphilis.
5. ​Biopsy may be required to diagnose gumma.
Patient with primary
and secondary or
without neurological
sign no need for CSF

27. Enzyme immunoassay
Specific test//EIA
Non specific if
positive syphilis is
considered. Also specific
Fluorescent treponema—-
Here is mean we need at
least to positive test
to said there is
syphilis.

28. Treatment
Penicillin is the drug of choice. Doxycycline if allergic
∙ Early syphilis: single dose of 2.4 megaunits of intramuscular
benzathine benzylpenicillin.
∙ Late syphilis (except neurosyphilis): three doses at weekly
intervals.
∙ Neurosyphilis: 14-day
supplemented by a
course
3-day
of procaine penicillin
course of prednisolone.
(doxycycline is not effective for neurosyphilis)
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Primary secondary and early latent.

29. ∙ Pregnancy: with penicillin hypersensitivity
∙ Erythromycin
∙ Ceftriaxone
∙ Penicillin desensitization
Jarisch–Herxheimer reaction is an acute febrile reaction that
follows treatment that is common in early syphilis and rare in
late syphilis.
Prednisolone for 3 days can be used to prevent the reaction
Doxycycline is
contraindicated in
pregnancy
For short period not permanent
desensitisation occurs,we use
it in pregnancy because we can
not use doxycycline

30. Gonorrhea (Neisseria gonorrhoeae)
Clinical features
∙ IP is usually 2–10 days.
∙ Urethritis (asymptomatic in about 10% of cases in male and
80% in female).
∙ Proctitis (MSM)
∙ Cervicitis
∙ PID.
∙ Pharyngitis
∙ Conjunctivitis.
∙ Disseminated gonococcal infection (DGI)
Gram negative
dipplococci
Pelvic infl
Arthritis,tenosynovitis,skin
rash.
Tenosynovitis=Inflammation of
tissue around joint.

31. Investigations
∙ Gram-negative diplococci may be seen on microscopy of
smears from infected sites
∙ culture
∙ NAAT
Treatment
∙ Ceftriaxone IM plus azithromycin orally or
∙ Cefixime orally or
∙ Ciprofloxacin orally
The partner(s) of patients with gonorrhoea should be sought
and treated as soon as possible.
Nucleic avid
amplification test
For clamydia but any
person with gonnerhea
give it azythro

33. Complications of untreated GC Important assay

34. 1. In men
Presentation and complications:
Urethritis: usually milder than gonorrhea and may be
asymptomatic in over 50% of cases.
Conjunctivitis: is also milder than in gonorrhoea;
Epididymo-orchitis and sexually acquired reactive arthritis
(SARA) are rare. Without treatment, symptoms may resolve
but the patient remains infectious for several months.
The partner(s) of men with chlamydia should be treated, even
if laboratory tests for chlamydia are negative
Chlamydial: IP varies from 1 week to a few months.Mostly asymptomatic
But not cause
pharyngitis
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No organism in fluid of joint,only reactive

35. Chlamydial infection in women
of patients
• The cervix and urethra are commonly involved.
• Infection is asymptomatic in about 80%
discharge.
• PID
Investigations
∙ NAAT: the test of choice
∙ Serology: microimmunofluorescence test (less sensitivity
and specificity)
And subsequent
infertility

36. Treatment
Azithromycin orally as a single dose or Doxycycline orally
for 7 days
Genital herpes simplex
Painful genital ulcers (usually multiple),
Diagnosed best by PCR,
Treated with acyclovir
Other STIs
Human papilloma virus, molluscum contagiosum, viral
hepatitis, phthirus pubis (pediculosis)
Herpes-2
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Pox virus
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‫ل‬ ‫م‬ ‫ق‬ ‫ل‬ ‫ا‬

37. See You
Next Year