Sexually transmitted diseases have increased in variety and complexity due to changes in sexual behavior. There are now over 25 viral, bacterial, protozoal and fungal agents that can be transmitted sexually. Screening and treatment of STDs is challenging due to the diversity of pathogens and rising antibiotic resistance. Prevention through abstinence, monogamy, barrier methods and vaccination remains the most effective strategy to control the spread of sexually transmitted infections.

1. Sexually Transmissible
Diseases Update
Almataria Teaching Hospital, Nasser Institute
Cairo, Egypt
Dr. Mamdouh Sabry
MD. Ain Shams, Ph.D. France
Consultant Ob. & Gyn.

2.  The sexual freedom, the earlier onset of
sexual activity and the evolution in
contraceptive pattern during the last 4
decades generated the virtual revolution
of sexually transmitted diseases (STDs).
 The more effort we try to do to prevent or
manage, the more the diseases we find
the more difficult the treatment is !? it is
linked to the most intimate human
behavior.

3.  From the classic five venereal disease
(gonorrhea, syphilis, chancroid,
lymphogranuloma venereum and granuloma
inguinale) the number of STD agents has
grown to over 25.
 The risk of transmission is growing from
couples to contacts, newborn and health
care workers.

4. Sexually transmissible pathogens
Bacterial agents:
N. gonorrhoeae
C. trachomatis
T. pallidum
H. ducreyi
Shigella spp.
Compylobacter
Group B streptococcus
G. vaginalis
Genital mycoplasmas
M. hominis
U. urealyticum
Fungal agents
C. albicans
Other fungi
Viral agents
Herpes simplex virus
Human papilloma virus
HIV& ZIKA viruses
Hepatitis A, B, C, D, G ±
Molluscum contagiosum V
Epstein – Barr virus
Human herpes V. type E
Human lymphotropic Vs.
Protozoan agents
T. vaginalis
E. histolytica
G. lambia
Ectoparasites
P. pubis
P. scabiei

5. Major Sexually transmitted diseases
Syndrome/ complication STD Agent (s)
AIDS HIV
Pelvic inflammatory disease N.G., C.T., M.hom.,….
Female lower genital tract infection
Vulvitis C. albicans, herpes simplex V.
Vaginitis C. albicans, T. vaginalis
Cervicitis N.G., C.T., H.S. V.
Urethritis N.G., C.T.
Bacterial vaginosis G.V., Bact. spp., Peptos. spp., M.hom.
Genital warts HPV
Male genital tract
Urethritis sp. & non sp. N.G., C.T., U.U.,T.V
Epididymitis C.T., N.G.,T.V
Proctitis N.G., HSV, C.T.
Genital ulceration HSV, T.P., H.D., C.T (LGV)
Hepatitis HAV, HBV, HCV, CMV
Acute arthritis N.G., C.T.
Enterocolitis G.L., E.H., Shigella, Compylobacter

6. PREVENTION

7. Resistance To Infection
• Digestive system. (pH, enzymes, …)
• Respiratory system. (Temp., cilia, …)
• Urinary system. (pH, others …)
• Genital system:
- Vagina… - Cervix… - Uterus…
- Fallopian tube - Peritoneum…
• Innate immune response.
• Microbiome.

8. • The innate immune system recognizes
microbes directly through pattern
recognition receptors (PRRs), which are
receptors specific for molecular
components of micro-organisms that are
not made by the host.
• It is the first line barrier and the rapid
mechanism to prevent microbial invasion
• It starts sooner before cellular response,( T
cells and humoral response )

9. • The microbiome — the collection of bacteria,
fungi, and viruses that live in and on the body, may
also be considered a component of the innate
immune system, as it profoundly impacts
mechanisms of host defense . Couple share!?
• The body's microbial composition directly influences
the maturation of the immune response and its
continued effectiveness, protects against pathogen
overgrowth, and modulates the balance between
inflammation and immune homeostasis .
For example, skin microbes interact with the
immune system to promote wound healing .
• Lactobacilli…Fecal microbiota transplantation is an
effective method of ulcerative colitis TTT.

10. The primary prevention is directed to;
prevent disease in future patient, contact
and treat infected individuals.
 Abstain from sexual intercourse (contact
and infected )
 Monogamous relationship (marriage)
 Prevention by ; drugs, vaccines and
barriers as ♂ Condom, ♀ Condom and
vaginal spermicides + cervical barriers.

11. The probability of transmission per act of sexual
intercourse is different regarding each virus, not bacteria
Couple:
 Male condom:
 HIV :  risk 0.55 / 100 person / year
 HSV :  no protection !!!
 HPV :  controversial
 Hep. B. :  no controlled studies ?!
 Hep. C. :  lack of protection!!!
 Female condom: highly protective
 Bacterial, others, ♂- ♀ transmission, plus other factors.

12. Vaccination
-Vaccinations are available for the prevention of
several infections that are sexually transmitted or
associated with sexual activity; these include
hepatitis A, hepatitis B, human papilloma virus
(HPV), and N. meningitidis.
-Individuals with advanced immunodeficiency may
have an impaired response to vaccination, and
multiple doses may be required to achieve an
adequate antibody response.
-N. gonorrhea vaccine in progress?, but infection
does not mean future immunity.

13. BCG vaccination and COVID-19 (October 2020)
The innate immune system is the first line of defense
against many novel pathogens for which humans have little
or no pre-existing immunity. Recent large-scale studies
suggest that countries in which (BCG) vaccination is
widespread have lower mortality rates from COVID-19.
This finding may be explained by the ability of some
vaccines to enhance innate immune responses to infections
other than that caused by the target pathogen.
This phenomenon, called "trained immunity," results from
epigenetic changes in macrophages and neutrophils.
Although these cells are short-lived, recent work has
revealed that similar changes occur in long-lived
hematopoietic stem cells, revealing a mechanism of lasting
"memory" within the innate immune system

14. Epigenetics
- All body cells have the same DNA sequence, which
carries the organism's entire genome.
- Despite having the same genetic code, cells from
different tissues behave very differently.
- It is not explained by differences in genome
sequence, but rather are created by additional
layers of regulation that determine which genes are
expressed to create a cell-specific phenotype.
Epigenetic regulation,(Heritable changes) which can
increase or decrease the expression of genes
without altering genomic sequence(DNA sequence),
contributes to this cell-type-specific variation.

15. AFTER EXPOSURE
• SCREENING
• PROPHYLAXIS
• HCWs
• TREATMENT

16.  Screening for STDs
 All individual attending STI clinics.
 All patients with another STI. e.g. genital warts.
 Patients with recurrent vaginal discharge or vulval
symptoms.
 Patients complaining of lower abdominal pain.
 Patients with recurrent urethral discharge, dysuria.
 Patients complaining of genital sore or ulcer.
 Patients complaining of scrotal swelling or pain.
 Mothers of infants with Chlamydia conjunctivitis
 Before IVF

17.  Prophylaxis
Post-exposure (sexual assault)
• NG, Ch.T, TV, S. ;
• Ceftriaxone 125 mg x1 im
Plus
• Azithromycin 1 gm x1 or
doxycycline 100 mg x 2
x7 Plus
• Metronidazole 2 gm x1
• Penicillin
• HIV
• Zidovudine and
• Lamuvudine or
• Didanosine and
• Stavudine + ?
• Nelfinavir or
• Indinavir
• All for 28 days.
• HBV, HPV, HSV, HCV
and ZIKA viruses.

18. Viral Infection
Specific Test
Negative, so
Protect
Positive, so
Immune or infected
Re-test 3-12 months
if risk continues
Confirm
If +ve
If Immune
No ttt TTT OF
infection

19. Management
The care of HIV positive women or other viral
diseases requires a team consisting of
experts in virology , an obstetrician and
pediatrician.
Target groups:
I. Mother & fetus.
II. Husband.
III.Health care workers (HCW).

20. Mother + Fetus
Risk of vertical transmission: HIV example
 Untreated 15 - 45% (70% at delivery - 30% in utero)
 Treated  according to timing of delivery. ±1.6%
During pregnancy Labour Lactation
ART.:
• Zidovudine
• Nevirapine
• Zidov. + lamivudine
• Nevirapine + Zidov.
• Avoid 1st trimester ttt
• C.S 38 wks./if viral load
> 1000 copies/ml
• Avoid PROM
• If NVD; no intervention
• Antiseptic bath to baby
• Bl. Trans. (CMV. -ve
blood)
• Risk > 14%
• No lactation
• 6 wks. ART.
after delivery
• contraception

21. Measures to reduce the risk of vertical
transmission
 Cesarean section to women with viral loads of 1000 or
more at 38 weeks of gestation
 Maximize the chance of a term delivery
 Avoid invasive fetal procedures
 Avoid scalp electrodes, fetal scalp sampling, artificial
rupture of membranes, operative vaginal deliveries
 Avoid episiotomies
 Wash the infant in an antimicrobial bath as soon as
possible and immediately before administrating
parenteral medication or obtaining blood
 Avoid breastfeeding
Keep mother’s viral load at 50 copies or less (undetectable)

22. HIV is not a highly infectious virus when compared to
others, Intact skin forms an effective barrier even if
exposed to blood with high virus titre.
Health care workers:
 HIV :  needle stick  0.3%;  mucous memb. 0.09%
 HBV: 30 % - HSV: most prevalent STD, shedding
 HCV: 3 % increases transmission
 HPV : HCW eye, larynx affection during TTT , vaccine is
given, even after age 26 years, (Grade 2B) .
keeping in mind other factors

23. Universal precaution
necessary
Universal precaution not
necessary unless
contaminated with blood
Body fluids and universal precautions
Blood
Semen
Vaginal secretions
Tissue
Fluids
Amniotic
Peritoneal
Pericardial
Pleural
Synovial
Cerebrospinal
Breast milk
Urine
Sputum
Sweat
Vomitus
Feces
Nasal secretion
Tears
saliva

24.  At least one blood exposure can be
documented in over 30% of surgical
procedures  75% of which may have
been preventable.
 Guide lines to reduce exposure with
needles or sharp instruments must be
followed.

25. To reduce exposure with sharp instruments
 Observe universal precautions.
 Do not recap needles.
 Wear double gloves.
 Place sharps box where sharps are used.
 Announce sharp instruments at passing.
 Pass sharp instruments in a basin.
 Use instruments to load needles.
 “One wound, one surgeon”.
 Check hourly for disruptions of protective
barriers.

26.  Treatment
Drug selected for treating STIs should fulfill the
following criteria:
 High efficacy at least 95%
 Low cost
 Acceptable toxicity and tolerance
 Single dose as much as possible
 Oral administration as possible
 No contraindication
 Organism resistance is unlikely to develop

27. Azithromycin and clarithromycin have a broader
spectrum of activity that includes many gram-
negative, atypical, and mycobacterial organisms as
well as many gram-positive organisms beside
several atypical organisms.
Azithromycin is active against Mycoplasma
genitalium, Haemophilus ducreyi
(Chancroid), Klebsiella granulomatis (granuloma
inguinale), Chlamydia trachomatis, and Neisseria
gonorrhoeae, so It is used in treatment of (STIs)
Azithromycin is used in syphilis according to
geographic area due to resistance development.

28. Syphilis
- Penicillin G benzathin 2,4 million unit IM
once.
- Doxycycline 100 mg orally twice per day
for 14 days.
- Tetracycline 500 mg x 4/day, 14 days.
- Ceftriaxone 1-2 gm IM daily for 14 days.
- Amoxicillin 3 gm + probenesid 500 mg oral
twice daily for 2 weeks.

29. PID
• Antibiotic regimens for outpatients: –
For patients with mild or moderate PID who are
treated as outpatients. ceftriaxone as a single
intramuscular dose (500 mg, or 1 g for
individuals ≥100 kg) plus doxycycline (100 mg
orally twice daily for 14 days) to
cover C.trachomatis and N. gonorrhoeae rather
than other regimens (Grade 2C). In addition,
mtronidazole is added (500 mg twice daily for
14 days) to the regimen for anaerobic coverage
(Grade 2C)

30. Conclusion

31. Sexually Transmitted Diseases ( STD) Update :
- Vaccination against HPV does not prevent infection
with other strains of the virus, and it doesn't mean full
protection against Cancer cervix.
- Many factors expose to cancer cervix , as other
genital sexual infections and multiple sexual partners
- Male condom doesn't prevent many sexually
transmitted diseases and not a suitable method for
contraception if used alone, as it has a high failure
rate.
- Exposure to one STD means risk of infection with
more than 20 viral, bacterial and protozoal diseases. .

32. - Once a STD is discovered or a case of accidental
intercourse outside marital life is declared, more than 5
drugs has to be ingested at once, with screening for
HIV and many other infections regularly for more than
3 months, plus getting some anti retroviral drugs, other
antiviral drugs and immunoglobulins.
- Zica virus and its virus family are sexually transmitted
diseases and can be excreted in semen for 3 months
or more after exposure.
- Oral and Orogenital Sex can transmit many sexual
infections.
- Many STD are asymptomatic, but more serious pelvic
and peritoneal diseases may appear later.

33. - Women are more susceptible to STD than men.
- Rate of transmission from men to women and
vice versa is 3 to one.
- Women share same strains of organisms with
their single partner that gives them a kind of
resistance against many infections and genital
cancer.
- Many Sexually Transmitted Diseases are now
resistant to various conventional drugs.
- What to do?
- How to prevent ?
- What about vaccination?
- How To Treat?

34.  Certain STIs as gonorrhea , syphilis, HBV and HPV are
more readily transmitted than others e.g. HIV; while
others are affecting body silently e.g. Ch.T.
 Sexual practice plays an important roll in enhancing or
reducing the chance of infection
 In simple words, prevention is better than cure, no safe
sex is available outside marriage, no barriers can
protect, enough vaccines are not available
 Tell your pts. (To go home, sleep in your bedrooms,
thank God for your wives and husbands, love them
tenderly because safe sex is unavailable outside).

35. Thank You
Best Wishes