1. Sexually Transmitted Infections, A social issue
Sexually transmitted infections (STI) have been present since ancient time as described
by Egyptians long ago. Greek and Romans in the field of medicine have reported on
these diseases.
World Health Organization estimated, 340 million new cases in 1999 among men and
women aged 15 to 49 years. We are living in the region of South and Southeast Asia in
which the largest number of new infections occurred. Next in line are the sub Saharan
Africa , Latin America and the Caribbean.
As the main mode of transmission is through an unprotected sexual contact these
infections are called STI. However diseases of the genital area are not necessarily
transmitted through sexual contact.
In addition to the main way of transmission, some STIs can be transmitted through blood
( HIV, Syphilis etc) or through an infected pregnant mother to inborn child.(HIV,
Syphilis, Gonorrhoea, Non Gonococcal cervicitis etc).
A large number of sexually transmitted infections, are caused by bacteria, viruses and
parasites. The common diseases vary from country to country.
In Sri Lanka Genital herpes, Genital warts, Syphilis, Gonorrhoea, Non Gonococcal
urethritis / cervicitis and Tricomoniasis commonly occur.
Genital Herpes and Genital warts are caused by viruses, Syphils, Gonorrhoea and Non
Gonococcal Urethritis/ cervicitis are caused by bacteria and Trichomoniasis is caused by
a parasite. Most of these diseases, namely, Syphilis, Gonorrhoea, Non Gonococcal
Urethritis/ cervicitis and Trichomoniasis can be completely cured when the patient gets
proper treatment at correct time.
Even those curable diseases can cause problems and complications if there is delay in
receiving treatment.
Out of the STIs in Sri Lanka, Genital Herpes and Genital warts are reported
predominantly. It has become a family and social issue as those infections which are viral
in origin, have the ability to reappear in time to time during the life.
In generally three main symptoms , occurring in STIs are genital ulcers , genital
discharge and genital lumps.

2. The genital ulcers are seen in Syphilis and Genital Herpes .
The genital discharge is seen in,Gonorrhoea, Non Gonococcal urethritis/cervicitis and
Trichomonisis .
The genital lumps are seen in Genital Warts.
Commonly there is a psychological disturbance of the people on developing disease
manifestations in genital region. Genital ulcers, genital discharge and genital lumps could
be seen even in diseases, other than STIs.
Genital ulcers could be seen in , drug reactions and in the fungal infections such as
candidiasis. Genital discharge occurs in, bacteral vaginosis and candidiasis. Genital
lumps could be seen in, benign penile papille and sebaceous cysts etc. These are not
STIs and it is vital to get necessary medical advice and treatment on appearing these
symptoms. If it is a STI both the patient and the partner should be treated at the same
time even if the partner is free of clinical manifestations as the infection has been
exchanged among them.
STIs causing genital ulcers;
Syphilis; The infective organism is a bacteria, called treponema pallidum. When
infected the patient may develop the stage of primary syphilis, in about 9 to 90 days. The
main clinical manifestation is a painless and deep ulcer usually single. It is completely
curable but if not treated the patient may proceed to secondary syphilis in about 3 to 6
months .The clinical manifestations of this stage comprised of generalized rash, lymph
node enlargement or lesions involving the mucous surfaces of the mouth.
Most of the patients are diagnosed at the stage of latent syphilis as they undergo relevant
blood testing for some other reason, such as in the screening in the case of foreign
employment , antenatal clinics in pregnancy etc. There are no clinical manifestations in
this stage. Within about 15-20 years A small percentage of untreated patients may
proceed to the stage of cardiovascular syphilis involving the heart and neurosyphilis
involving central nervous system.
It can be transmitted from an infected pregnant mother to child if the mother had not
been treated before or during pregnancy. Currently it is rare to see the children with
congenital syphilis, as pregnant mothers are screened serologically for syphilis and
provided with necessary treatment.
Genital Herpes; The infective organism is a virus , called Herpes Simplex type 2 or
rarely type 1. When infected the patient may develop vesicles or blisters in the genital
region within about few days or weeks. It is often preceded with fever, burning sensation
in passing urine or pain or numbness at the sites in which vesicles are appearing. The
vesicles turn into multiple superficial painful ulcers.
These ulcers can be healed by proper treatment with relevant drugs . Delay in treatment
may lead to secondary infection of the ulcers with another bacteria or adhesions of the

3. adjoining superficial epithelial tissues in the genital region. It is important to keep the
ulcerated area dry and clean for timely healing. The patients with genital ulcers are
advised to clean the affected area with salt solution. In preparing this solution one
teaspoon of salt powder to be added to one pint of boiled water after cooling. It is
necessary to clean the affected area at least three times daily , using the salt solution.
There is a possibility of getting recurrences of the disease later, resulting appearance of
few ulcers time to time.
The possible risk to the child in Genital Herpes during pregnancy can be easily avoided if
the obstetrician is made aware prior to delivery. Therefore it is important to inform the
doctor if Genital Herpes has been developed in the past.
STIs causing genital discharge;
Gonorrhoea; The infective organism is a bacteria, called Neisseria gonorrhoeae . When
infected a male patient may develop continuous yellowish urethral discharge within about
2 to 7 days with burning sensation in passing urine and increased frequency in urination.
Only small proportion of female patients show clinical manifestations as most of them
are asymptomatic and found to be infected when investigated. This is a completely
curable disease with proper treatment.
Non Gonococcal Urethitis in male and Non Gonococcal Cervicitis in female;
The common infective organism is a bacteria, called Chlamydia trachomatis. Other
organisms such as Mycoplasma, Ureaplasma too can be implicated in this infection. The
male patient may develop urethral discharge at times specially in the morning , with
itching or tingling sensation in the urethra, burning sensation while passing urine and
increased frequency in urination or pain in the genital area and scrotal swelling in about
one to three weeks.
The female patient may develop genital discharge with burning sensation in passing
urine.
This is also a completely curable disease with proper treatment.
There is a possibility in transmitting the infection from pregnant mother infected with
Gonorrhoea or Non Gonococcal Cervicitis, to the child in delivery if the mother was not
treated early. Then child develops infection of surface epithelium of the eye causing
swelling, redness and purulent discharge. This is referred to as Opthalmia Neonatarum
and it can be cured completely. Identifying this condition lead to avoidance of
complications of the child.
Trichomoniasis; The infective organism is a parasite, called Trichomonas vaginalis.
This infection commonly affects females. When infected they may develop profuse,
frothy , offensive genital discharge with itching and burning sensation in passing urine in
about 3 to 30 days.
Most of the male patients infected with this organism do not manifest these clinical
features.
It is a completely curable disease with proper treatment.

4. STIs causing Genital Lumps;
Genital Warts; The infective organism is a virus, called Human papilloma. When
infected the patients may develop lumps in varying sizes and shapes
in genital area usually in about 1 to 6 months but sometimes later than this time period.
The lumps can be removed with correct treatment, applying according to clinical stage.
There is a possibility in reappearing the disease later. The female patients who were
infected with Human papilloma virus should undergo cervical cytology screening , called
pap smear test annually to detect early cytological changes as they is a higher risk of
getting cervical cancer, compared to normal population.
Other common diseases of the genital region
The following common diseases do not need to be transmitted through sexual contacts.
Candidiasis; This is a common infection caused by a fungus, called Candida albicans.
As the spores of the fungi are present in the environment, one can be infected provided
their hygiene is poor.
When infected, male patient may develop fissures or cleft like lesions, whitish patches ,
itching and inflammation in the genital region. Female patients may present with thick
whitish vaginal discharge, itching and inflammation in the genital region.
Baterial Vaginosis; This condition is due to an imbalance of the normal flora in the
vagina. A type of a bacteria called Lactobacilli are predominantly needed as the normal
flora of the area. When the number of Lactobacilli are decreased , it is replaced with a
mixed, predominantly anaerobic flora. Patient may develop unpleasant malodorous
vaginal discharge with itching and irritation.
Drug eruption; Some people may exhibit adverse reaction to some drugs when taken
during an illness. This is called as a Allergy, which may manifest as superficial ulcers in
the genital region.
Benign Penile Pappilae; This condition manifests as tiny , flesh coloured, smooth
papules typically located on the sulcus of the glance penis. Commonly, they are arranged
circumferentially around this area. There is no need to treat as they may gradually
become less noticeable with increased age.

5. Sebaceous cysts; Sebaceous cyst is a closed sac or sac under the surface of the skin.
They are usually painless, slow growing, small lumps that may develop in any part of the
skin bearing hair follicles, including genital region.
Prevention of the STIs;
• Adolescents; To prevent STIs in adolescents it is advisable to delay the sexual
relationships until marriage. It should be discussed openly with the parents or
teachers if there are sex related issues arising to avoid further problems. There
should be adequate awareness about the probable danger of STI and the hazards
of drugs and alcohol among them as all of these problems may be implicated
together.
• Youth ; The youth who may be on employment or higher education , should be
aware about the limitations when there is relationship with the partners of the
opposite sex.
• Adults; In prevention of STIs , it is important to limit the sexual relationships to
the marital partner. Faithfulness is a key factor in maintaining a happy life to
avoid many stresses and problems , complicated with unmatched relationships,
today.
There is a difficulty in identifying a person ,infected with STIs as the manifestations may
not be prominent externally. Some people are asymptomatic and do not show any clinical
manifestations but they can spread the disease to others through sexual contacts.
Therefore it is easier to spread the STIs within the society, but prevention from STIs is
more easier if awareness is improved.
Dr.Shantha Hettiarachchi

6. Sebaceous cysts; Sebaceous cyst is a closed sac or sac under the surface of the skin.
They are usually painless, slow growing, small lumps that may develop in any part of the
skin bearing hair follicles, including genital region.
Prevention of the STIs;
• Adolescents; To prevent STIs in adolescents it is advisable to delay the sexual
relationships until marriage. It should be discussed openly with the parents or
teachers if there are sex related issues arising to avoid further problems. There
should be adequate awareness about the probable danger of STI and the hazards
of drugs and alcohol among them as all of these problems may be implicated
together.
• Youth ; The youth who may be on employment or higher education , should be
aware about the limitations when there is relationship with the partners of the
opposite sex.
• Adults; In prevention of STIs , it is important to limit the sexual relationships to
the marital partner. Faithfulness is a key factor in maintaining a happy life to
avoid many stresses and problems , complicated with unmatched relationships,
today.
There is a difficulty in identifying a person ,infected with STIs as the manifestations may
not be prominent externally. Some people are asymptomatic and do not show any clinical
manifestations but they can spread the disease to others through sexual contacts.
Therefore it is easier to spread the STIs within the society, but prevention from STIs is
more easier if awareness is improved.
Dr.Shantha Hettiarachchi