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Sexually transmitted disease
- 1. Sexually Transmitted Disease DR ADITI KOTHARI
- 2. Overview ANATOMY OF GENITAL TRACT NORMAL COMMENSALS OF GENITAL REGION INTRODUCTION CLASSIFICATION OF STI DISEASES WITH THEIR CAUSATIVE AGENTS LAB DIAGNOSIS SYNDROMIC APPROACH REFERENCES
- 3. Anatomy of the genital urinary tract External genitalia Internal genitalia Penis Labia Testis ,epididymis, seminal vesical, urethra Ovaries ,fallopian tube ,uterus, vagina
- 4. Commensals of genital tract
- 5. Introduction Sexually transmitted diseases (STDs) refers to a group of clinical conditions and infections caused by pathogens that can be acquired and transmitted through sexual activity sexual contact with an infected partner through nonsexual contact IV drug abusers Incidences are mainly due to multiple sexual partners Or in homosexual practicing individuals
- 6. STI/RTI ULCERATIVE NON ULCERATIVE PAINFUL PAINLESS No lymph-adenopathy DONOVANOSIS b/l lymph-adenopathy HERPES U/L CHANCROID URETHRITIS – N gonorrhoea non gonococcal urethritis C trachomatis U urealyticum Mycoplasma hominis , HSV T vaginalis ,Mycoplasma genitalium VAGINAL DISCHARGE – Candidia spp ,G.Vaginalis ,T vaginalis GENITAL ULCERS- T pallidum ,HSV ,H ducrey C.Trachomatis , K granulomatIS GENITAL WATRS HPV SYSTEMIC MANIFESTATIONS N gonorrhoea , C trachomatis HIV,Hep B & C lymphadenopathy SYPHILIS LGV
- 7. Clinical manifestation of STI Asymptomatic –most cases of STI go un noticed as of presence of no clinical symptoms –N gonorrhoea ,C trachomatis Trichomoniasis also goes unnoticed in males Primary lesions of syphilis Dysuria Urethritis –gonococcal and non gonococcal Vaginal discharge Genital warts Genital ulcers
- 8. Urethritis and Cervicitis Inflammation of the urethra Mainly due to N. gonorrhoeae and Chlamydia trachomatis Asymptomatic cases more in men Males usually complain of dysuria and urethral discharge Where as Females complain of mucopurulent cervicitis with serious complications like ectopic pregnancy and infertility Mycoplasma hominis and Ureaplasma urealyticum are two causes of nongonococcal urethritis.
- 9. Urethritis Inflammation of urethra accompanied with discharge Dysuria may or may not be present Males are commonly affected with profuse ,mucopurulent yellow-green discharge 15% of males are asymptomatic Females • 50% are asymptomatic • Primary site –endocervical canal • C/o-discharge ,pruritis ,dysuria
- 10. Cont…urethritis Reiter’s syndrome – urethritis conjunctivitis arthritis characteristic mucocutaneous lesions Reactive arthritis is usually RF seronegative ,HLA-B27 prelidicton often precipitated by genitourinary or gastro intestinal infection usually after 2-3 weeks of infection
- 11. Causes of urethritis Gonococcal –Neisseria gonorrhoea(50%) Non gonococcal –Chlamydia trachomatis Ureaplasma urealyticum Mycoplasma genialium Trichomonas vaginalis Yeast Herpes simplex virus
- 12. organism General feature Clinical feature Complications N gonorrhoea GONORRHEA Gram neg intracellular diplococci ,Ip -2-5 days Affects both sexes Males –discharge ,dysuria Females –discharge, pruritis ,dysuria Complication Males –epididymitis, posterior urethritis, watercan perineum Females –PID,PAIN, INFERTILITY Fitz-hugh-Curtis syndrome Dissemination to other organs C trachomatis LYMPHOGRANULOMA VENERUM Gram neg intracellular Ip-1-3 weeks Urethritis with scanty or moderate whitish urethral discharge and dysuria Small lesions heal spontaneously Leaving painful lymph nodes 2-6 weeks later
- 13. U urealyticum Non specific urethritis Males- urethritis ,proctitis ,reiters syndrome Females- acute salpingitis ,PID,cervicitis and vaginitis Complications- infertility, abortions ,low birth weight babies , M genitalium RECURRENT URETHRITIS T vaginalis M hominis BACTERIAL VAGINOSIS Herpes HSV2 Genital herper Ip-5-14 days Painful lesions / vesicles ---pustule—ulcer Tender to touch systemic symptoms Tzanck’s smear
- 14. GENITAL ULCERS Single ,multiple vesicular ,ulcerative or erosive lesion of the genital area with or without inguinal lymphadenopathy Genital ulcers which are caused by sexual transmission Primary syphilis –Treponema palladium Genital herpes –Herpes simplex virus Chancroid –Haemophilus ducrey Lymphogranuloma venereum –Chlamydia trachomatis Granuloma inguinale (donovanosis) – Klebsiella granulomatis
- 15. Spontaneous healing 3-8 weeks 14-21 days No healing 2-5 days Self limiting may persist for years
- 16. donovanosis chancer on the shaft of penisBUBO Geimsa staining showing intracellular Donovan bodies Safety pin appearance Granuloma inguinale –beefy red ulcer On shaft of penis and on groin area of a female
- 18. Vaginitis or vaginal discharge Inflammation or irritation of vagina by pathogen causes discharge Normal vaginal discharge is clear to white ,odourless and viscous Vagina having lactobacillus as the dominating flora producing H₂O₂ As microbicide Common symptoms Vaginal discharge Vulvar itching Irritation Odour Organism causing vaginal discharge are Trichomonas vaginalis Gardenella vaginalis Candidia spp
- 19. Vaginal discharge Vaginal ph- Clinical finding Diagnosis Bacterial vaginosis Gardenella vaginalis And anaerobic organisms >4.5 Amsel’s criteria Grey ,homogeneous discharge Acidic ph Fishy odour Clue cells of wet film Whiff test – fishy odour due to increase in anaerobic organisms activity and addition of KOH will increase this activity Trichomoniasis Trichomonas vaginalis >4.5 Vulvar erythema Edema Profuse ,malodorous frothy yellow- green discharge Strawberry cervix Wet film-motile trophozoite Candidiasis Candida albicans Candia tropicalis Candida glabrata <4.5 Vulvovaginitis Itching ,burning ,curdy to cheese vaginal discharge Koh- pseudo hyphae seen GTT- POSITIVE For candida albicans
- 20. Genital warts Genital warts are Flat ,papular or pedunculated growth on genital mucosa Caused by - Human Papilloma Virus Usually asymptomatic but can be pruritic or painful Site: 1. Introitus in women 2. Under foreskin of uncircumcised penis 3. Shaft of penis 4. Anogenital epithelium : cervix ,vagina ,perineal ,urethra ,perianal skin ,urethra
- 21. Characteristics of warts Known as Condyloma acuminate (anogenital wart ) Cauliflower-like-appearance Skin coloured or pink ,hyperpigmented Keratotic on skin and non keratinized on mucosal surface(oral) Multiple , painless ,pruritis ,discharge are chief complains Causes urethral bleeding ,obstruction, coital bleeding, vaginal bleeding in pregnancy Lesion may regress, remain static or may progress Condyloma acuminate should be differentiated from condyloma lata
- 22. Warts by Human papilloma virus Type of warts Condyloma acuminate Genotype 6 ,11 Genital wart Cauliflower like Multiple lesions ,flat, or elevated Condyloma planum Genotype 16 ,18 ,31 & 33 Flat genital warts Seen by help of magnifying lens after application of acetic acid
- 23. Rectal lesions Increasing homosexual and heterosexual practices involving anogenital region Common organisms causing proctitis N gonorrhoea C tachomatis Common symptom –itching ,mucopurulent discharge Pain ,bleeding and tenesmus HSV-Simillar complains along with systemic symptoms
- 24. Bartholinitis Infection of Bartholin gland along with the obstruction of Bartholin duct N gonorrhoea and C trachomatis is commonly involved Anaerobic organism from the genital flora
- 25. Pelvic inflammatory disease Infection that ascends from lower genital tract to upper genital organs These infections may lead to sever complications for eg salpingitis Can lead to obstruction of fallopian tube leading to miscarriages or ectopic pregnancy, infertility Common complains Weight loss, discharge ,fever ,abdominal pain ,tenderness
- 26. Laboratory diagnosis of STI Collection and transport of specimen a) Swabs- urethral, cervical, vaginal, anogenital, oropharyngeal ulcers b) Aspirates -e.g. sores or buboes Specimen should be packed and transported to protect the safety of handler in a triple packaging system with a biohazard symbol Right patient, right test and right sample!
- 27. Urethral swab After one hour of voiding urine. Expressed discharge - collect with a sterile swab. No discharge- insert a thin, water-moistened swab (calcium alginate or Dacron) with flexible wire slowly (3 cm to 4 cm in males or 1 cm to 2 cm in females), rotate slowly and withdraw gently. Do not use calcium alginate swabs for viral cultures. Cervical swab Insert a swab 1 cm to 3 cm into the endocervical canal and rotate , for 10 s - 30 s to allow absorption of exudates In cases of suspected coinfections of N. gonorrhoeae and Chlamydia trachomatis, the cervical specimen for N gonorrhoeae detection should be taken before the specimen for C. trachomatis, because N. gonorrhoeae is present in the mucus from the endo-cervix and C. trachomatis present in the cervical epithelial cells. A small brush on a wire (cytobrush) is used to collect specimens in females in cases of C .trachomatis infections.
- 29. Vaginal swab rub a sterile cotton swab against the posterior vaginal wall and allow the swab to absorb the specimen. Vaginal washing preferred in young girls Rectal swab Specimen to be taken by the help of anoscope Insert a swab 2 cm to 3 cm into the anal canal. Avoiding fecal material, rotate to sample crypts just inside the anal ring; allow the swab to absorb specimen for 10 sec Ulcer Collect exudate for microscopy T pallidium –dark ground microscopy K granulomatis and H ducreyi –grams staining C trachomatis –DFA CULTURE –H ducreyi ,C trachomatis
- 31. Transport Specimen for chlamydia should be transported on ice If transported at room temperature then should be inoculated immediately Organisms Transport media Swabs Gonococci Modified Stuart’s or Amie’s charcoal transport media Swabs chlamydia and mycoplasmas 2SP (0.2M sucrose-phosphate transport media) SP-4 trypticase soy broth with bovine serum albumin Specimen Culture of Chlamydia spp Ice If at Room temp should be inoculated within 15 mins Specimen Delay >24 hrs expected Frozen in dry ice and 95%ethanol bath and stoed at -70ᵒC
- 32. DIRECT MICROSCOPY For presumptive diagnosis Grams staining – pink coloured gram negative intracellular diplococci --N gonorrhoea Violet coloured Gram positive oval budding yeast cell –Candida spp In females false interpretation can be done in case of gonorrhea Chlamydia Iodine stained intracellular inclusion bodies Wet mount – motile trophozoites of trichomonas vaginalis Dark ground microscopy – treponema pallidium
- 33. Gram negative intracellular diplococci under 100x Dark ground microscopy –T pallidium Trichomonas viginalis In wet mount prepration under 40x
- 34. Cont …microscopy Clue cells are seen as squamous epithelial cells with a large number of coccobacillary organisms densely attached in clusters to their surfaces, giving them a granular appearance. The edges of squamous epithelial cells, which normally have a sharply defined cell border seen in wet film under 40x magnification Clinical diagnosis –AMSEL CRITERIA Gram’s stained –gram variable coccobacillary forms Wet film under 40x
- 35. Nugent score for bacteria vaginosis
- 36. Herpes simplex virus Wright & Giemsa H & E STAIN intranuclear inclusion bodies Pap stain DONOVANOSIS Wright & Giemsa H & E STAIN DONOVAN bodies Pap stain RAPID GIEMSA STAIN
- 37. CULTURE Sample is inoculated in a suitable medium as per the isolation of suspected organism Blood agar –for candida spp Creamy pasty colony after 24 hrs of incubation at 37degrees Blood agar /chocolate agar –H ducreyi Transparent to grey coloured colony on chocolate agar Modified Thayer-Martin /New York city agar -N gonorrhoea
- 38. Modified Thayer-Martin- N GONORRHEACHOCOLATE AGAR – H ducreyi
- 39. JEMBEC media –self contained incubation system for gonococci Specimen are swabbed by rolling the swab 360 degree on the floor of agar to expose the swab to all the part of the agar It generates its onw atmosphere by generating its own Co2 because of sodium bicarbonate tablets in media
- 40. Culture Trichomonas vaginalis –diamonds media with antifungals and antibacterial Culture is examined for 5 days for growth Inpouch –TV test –for direct microscopy K. granulomatis – can be grown on embryonated eggs and cell lines HPV- Can not be grown HSV-easy to cultivated and cytopathic effect occurs in 2-3 days Identified by neutralization test or IFT Inpouch –tv test
- 41. CULTURE Mycoplasma spp- biphasic genital mycoplasma culture system Chlamydia – Mc Coy ,Hela , monkey kidney cells
- 42. Serology Serological test are the mainstay for diagnosis of syphilis
- 44. Syndromic approach Approach or treating STI /RTI on the basis of sign and symptoms most commonly responsible for each syndrome For this adequate medical history Sexual history Complete STI clinical examination Management guidelines
- 46. References