This document discusses sexually transmitted diseases (STDs) and their epidemiological determinants and clinical presentations. It notes that over 20 pathogens can be spread through intimate sexual contact, causing diseases like gonorrhea, syphilis, chlamydia, herpes, HIV/AIDS, and trichomoniasis. The highest incidence rates are in those aged 20-29, and determinants include age, sex, marital status, socioeconomic status, population factors, social behaviors, and alcohol use. Common symptoms and signs are discussed for each disease, as well as their treatment and potential complications. Syndromic management approaches are also outlined.

1. Sexually Transmitted Diseases
Mrs. Namita Batra Guin
Associate Professor
Dept. of Community Health Nursing

2. Introduction
• Transmitted by wide range of bacteria, viral,
protozoal and fungal agents and ectoparasites.
• STI’s are infections that are spread from person
to person through intimate sexual contact.
• STI’s are dangerous because they are easily
spread and it is hard to tell just by looking who
has an STI.

3. Epidemiological determinants
• Agent factor: over 20 pathogens are found to be
spread by sexual contact.
▫ Neisseria gonorrhoeae – gonorrhoea
▫ Treponema pallidum- syphilis
▫ Chlamydia trachomatis- urethritis, cervicitis.
▫ Herpes simplex virus- genital herpes
▫ HIV- AIDS
▫ Trichomonas vaginalis – vaginitis.

4. Epidemiological determinants
• Host factor:
▫ Age: highest incidence in 20-24 years followed by
25-29 and 15-19 years
▫ Sex: morbidity is higher in men but is much more
severe in women.
▫ Marital status: higher among singles, divorced and
separated persons.
▫ Socio-economic status: low socio-economic have
high morbidity rates.

5. Epidemiological determinants
• Demographic factors:
▫ Population explosion
▫ Marked increase in young people
▫ Rural to urban migration
▫ Increasing educational opportunities for women
for delaying their marriage and increasing STD
risks.

6. Epidemiological determinants
• Social factors:
▫ Prostitution: major factor in the spread of STD.
Acts as reservoir of infection.
▫ Broken homes: promiscuous women are
withdrawn . Home is unhappy and children reared
in such an atmosphere are likely to go astray in
search of other avenues of happiness.
▫ Sexual disharmony: married people with strained
relation, divorced and separated persons.
▫ Easy money: prostitution is a reflection of poverty.
It provides an occupation for earning easy money

7. Epidemiological determinants
• Social factors:
▫ Emotional immaturity: often stressed as a social
factor in acquiring STDs
▫ Urbanization and industrialization: conductive
type of lifestyles leads to high levels of infections
since long working hours, relative isolation from
the family and social mobility causes causal sexual
relationships.
▫ Social disruption: caused by disasters, wars and
civil unrest
▫ International travel: travellers import and export
the infection

8. Epidemiological determinants
• Social factors:
▫ Changing behaviour patterns: more relaxation to
moral and cultural values in present day society
provides the young people opportunity to break
away from the traditional ways of life
▫ Social stigma: stigma attached to STD accounts for
non- detection of the cases, not disclosing the
source of contact etc.
▫ Alcoholism: effects of alcohol seems to be more
indirect than direct.

9. Common STD’s are:
• Chlamydia
• Gonorrhea
• Genital Herpes (HSV-2)
• Genital Warts (HPV)
• Hepatitis B
• HIV and AIDS
• Pubic Lice
• Syphilis
• Trichomoniasis

10. Clinical spectrum
• Gonococcal infection:
▫ Causes inflammation of genital tract, cervix and
rectum in women
▫ Pharyngitis
▫ Possible complication – PID in women,
epididymis in men
▫ Can cause sub-fertility and urethral strictures
▫ ‘serious consequences in infants- eye infection
leading to blindness if not treated
▫ Antibiotics of choices are: - Ciprofloxacin,
ceftriaxone, cefixime or spectinomycin

11. Clinical spectrum
• Syphilis:
▫ Causes ulceration of the uro-genital tract, mouth
or rectum
▫ Other signs occur in later stages ranges from skin
eruption to cardiovascular and nervous system
complications
▫ Congenital syphilis is important to cause
stillbirths
▫ Antibiotics – penicillin, doxycycline and
erthromycin.

12. Clinical spectrum
• Chlamydial infection:
▫ A high % of people doesn’t have any clinical
manifestations
▫ If they occur they are similar to gonorrhoea.
▫ Complications can result in sterility in women and
vertical transmission during childbirth leading to
conjuctivitis or eye inflammation
▫ In men – epididymis and urethritis
▫ Antibiotics – doxycycline or azithromycin,
alternative can be – amoxycilin, ofloxacin,
erthromycin or tetracycline

13. Clinical spectrum
• Trichomoniasis:
▫ Parasitic infection leading to vaginitis and vaginal
discharge in women
▫ Usually there are no symptoms
▫ In men- urethritis
▫ T. vaginalis can cause adverse outcomes in
pregnancy- low birth weight PROM
▫ Treatment- metronidazole or tinidazole

14. Clinical spectrum
• Chancroid:
▫ After infection, small papule develops at the site of
inoculation, within 2-3 days
▫ Lesion erodes into deep ulcer that is extremely
painful
▫ Painful swelling in inguinal lymph nodes
▫ Antibiotics: - ciprofloxacin, erythromycin,
ceftriaxone and azithromycin

15. Clinical spectrum
• Lymphogranuloma venereum:
▫ Present with swelling of lymph nodes in the groin
▫ 3-30 days after exposure it may pass unrecognised
and resolve spontaeneously
▫ Untreated may cause lymphatic damage resulting
in elephantiasis of genitalia
▫ Antibiotics used are: doxycycline, erythromycin
and tetracycline

16. Clinical spectrum
• Donovanosis:
▫ First manifestation is small papule which ruptures
to form granulomatous lesion that is pain free and
bleeds readily on contact.
▫ Antibiotics used- doxycycline, azithromycin.
Alternatives- erythromycin, tetracycline,
trimethoprim –sulphamethoxale.

17. Clinical spectrum
• Genital herpes:
▫ HSV-2 causes genital herpes
▫ Typical papular lesions that progress to multiple
blisters and ulcers
▫ First episode is frequently associated with
prolonged course of ulceration lasting up to 3-4
weeks.
▫ HSV infection is life long. Subclinical infections
also occur.
▫ There is no cure for HSV-2 infection
▫ Antivirals reduce the severity and duration of
lesions

18. Clinical spectrum
• Human papilloma:
▫ HPV causes genital warts which vary from
common soft, flesh coloured protuberances which
may become cauliflower like to papular flat warts
on drier areas
▫ Seen in any part of genitalia including perianal
region
▫ Manifestation- cervical cancer caused by sub-
types.
▫ Treatment generally reserved for large lesions

19. Syndromic approach to STD
• Common syndromes and sequelae:
▫ Male urethritis
▫ Lower genital syndrome in women
▫ Genital ulceration
▫ Prostitis/colitis
▫ Salphingitis
▫ Epididymis/orchitis
▫ Infertility/ ectopic pregnancy
▫ Postnatal and perinatal morbidity
▫ Hepatitis/hepatic carcinoma
▫ Genital carcinoma
▫ AIDS

20. Syndromic management of urethral discharge
Treatment for gonorrhea and
chlamydial infection.
Health education and
counseling
Examine and treat partners
Follow up, 7- 14 days after
treatment
Discharge persists
Assess: treatment compliance
good and reinfection unlikely
Urethral discharge confirmed
by clinician
Clinical cure
Assess: treatment compliance
bad and/or reinfection likely
Start protocol again
Refer
Laboratory investigations: Gram
stain exam of urethral smear-
shows Gram –ve intracellular
diplococci in case of gnorrhoea
In non- gonococcal urethritis more
than 5 neutrophils/ oil immersion
field are observed

21. Syndromic management of genital ulcer
Vesicular lesion present or
history of vesicular lesions
often recurrent ?
Follow up, after 7 days
Improving?
Refer
Genital ulcer
Herpes management
Clinical cure

22. Control of STDs
• Initial planning
• Intervention strategies
• Support component
• Monitoring and evaluation

23. Initial planning
• Problem definition: define disease problem in
terms of prevalence, psychosocial consequences and
other health effects by geographic areas and
population groups with aid of surveys.
• Establishing priorities: rational planning
requires establishment of priorities. Depends on
magnitude, feasibility of control.
• Setting objectives: priorities must be converted to
discrete, achievable and measurable objectives.
• Considering strategies: variety of strategies
must be planned.

24. Intervention strategies
• Case detection:
• Screening: testing for apparently healthy persons from general
population. High priority is given to special groups i.e. pregnant women,
blood donors industrial workers etc.
• Contact tracing: sexual partners of diagnosed patients are identified,
located, investigated and treated.
• Cluster testing: partners are asked the name of other persons of either
sex who move in same socio-sexual environment. They are screened.
• Case holding and treatment: tendency of drop out is very
common. Therefore every effort should be made to ensure complete
and adequate treatment.
• Epidemiological treatment: also known as contact treatment.
Consists of full therapeutic dose of treatment to persons recently
exposed to STD while awaiting the results of laboratory tests.
Should be combined with venereal examination and tracing of
contacts revealed by the examination

25. Intervention strategies
• Personal prophylaxis: contraceptives,
maintenance of hygiene of the private parts,
vaccines like hepatitis B.
• Health education: principle aim to avoid
STDs, to minimize disease acquisition and
transmission.

26. Support components
• STD clinic: for consultation, investigations and
treatment, contact tracing and other relevant
services. STD clinics should maintain the
anonymity. Center should be housed adjacent to
other medical facilities and training centers
• Laboratory services: for correct diagnosis and
treatment decisions, for contact tracing, surveillance
and detection of resistance
• Primary health care: integrate STD control
activities with primary health care system.

27. Support components
• Information system: data required for STD control activities are:
clinical notification, laboratory notification and sentinel and adhoc
surveillance.
• Legislation: to encourage to seek early treatment and name their
sexual contacts, to screen high risk groups, to improve notification
by general practitioners, health education of public.
• Social welfare measures: STDs are social problems, so there is
need of social therapy.
• Measures include: rehab of prostitutes, provision of recreation
facilities in the community, provision of decent living conditions,
marriage counseling, prohibiting the sale of sexually stimulating
literature, pornographic books or photographs.

28. Monitoring and evaluation
• Ongoing evaluation of disease trends provides
more direct measure of program effectiveness
• It may be used to determine the appropriateness
of the selected intervention.

29. Primary syphilis

30. Secondary syphilis

31. Genital herpes

32. Gonorrhoea

33. Chlamydia

34. Perianal warts