This document provides an overview of sexually transmitted infections (STIs), including common types, symptoms, risk factors, transmission, complications, and treatment. It discusses how STIs like gonorrhea, chlamydia, trichomoniasis, herpes and HIV can increase susceptibility to other infections. The document emphasizes that while some STIs have no symptoms, all increase health risks if untreated. Proper education and treatment of STIs are important for preventing spread and reducing long-term impacts on individual and public health.

1. SEXUALLY TRANSMITTED
INFECTIONS 101
Peter Nugraha Soekmadji
Department of Dermatovenereology
Faculty of Medicine
Maranatha Christian University
Bandung

2. Sexually Transmitted Infections
(STIs)
• Most common infectious disease, esp. in
South & Southeast Asia
• Often asymptomatic, esp. in women

3. Why are STIs special?

4. They are different from each other
biologically & clinically, but…
They share common modes of transmission

5. Low or No Risk!!!
• Abstaining
• Hugging
• Kissing
• Holding hands
• Dancing
• Sitting on toilets
• Sharing lip balm
• Mutual monogamy
• Massage
• Sharing forks, knives,
etc.

6. High Risk
• Sexual Intercourse: vaginal, anal, oral
• Blood-to-blood contact
• Sharing needles or other drug-use equipment
• Tattoo or body piercing
• Infected mother to her baby

7. What is the
current problems with STIs?

8. • Increasing antimicrobial resistance
• Increasing transmission (global travel)
• Synergistic with HIV infection

9. STIs increase HIV susceptibility
• STD → infection & desquamation of
squamous/columnar cells → inflammatory
response
• HIV target cells (lymphocytes) on mucous
membrane ↑ → portal of entry for HIV

10. STIs facilitate HIV transmission
For a person with HIV, having an STI:
• Brings inflammatory cells loaded with HIV to
the genital tract
• Increases HIV viral shedding from mucous
membranes
• HIV alters natural history of some STIs

11. What is the
risk factors of STIs?

12. RISK FACTORS
• < 21/25 yo
• Single
• > 1 sexual partners in the last 3 months
• New sexual partners in the last 3 months
• STIs in sexual partner
• Inexperienced in condom use

15. CASE 1

16. 35 yo man with:

17. • 1 week history of yellow penile discharge &
mild dysuria
• No testicular pain, frequency, rash, lesion
• No Gram stain available
• Treated empirically with single dose of
azithromycin 1 g po

18. URETHRAL/VAGINAL
DISCHARGE
• Physiologic leukorrhea in women
• Gonococcal urethritis/cervicitis
• Nongonococcal urethritis/cervicitis
• Trichomonas vaginitis/urethritis
• Bacterial vaginosis (not STI)
• Vulvovaginal candidiasis (not STI)

19. MALE GONORRHEA
• Urethritis
– Incubation: 1-14 d (usually 2-5 d)
– Sx: Dysuria & urethral discharge (5%
asymptomatic)
– Complications

20. Gonococcal Urethritis

21. Gram Stain

22. NONGONOCOCCAL URETHRITIS
• Etiology:
– 20-40% C. trachomatis
– 20-30% genital mycoplasmas (Mycoplasma
genitalium, Ureaplasma urealyticum)
– Occasional Trichomonas vaginalis, HSV
– Unknown in ~50% cases
• Sx: Mild dysuria, mucoid discharge
• Dx: Urethral smear ≥ 5 PMNs/OI field
Urine microscopic ≥ 10 PMNs/HPF
Leukocyte esterase (+)

23. Nongonococcal Urethritis

24. TRICHOMONIASIS
• Sexually transmitted parasite: T. vaginalis
• Prevalence increases with age
• Symptoms not predictive
– Mostly asymptomatic!!!

25. Trichomoniasis

26. What is the management of CASE 1???

28. TREATMENT OF URETHRITIS

29. The patient came back 1 week later,
still with urethral discharge
What is the the most likely cause???

30. PERSISTENT URETHRITIS
• Antimicrobial resistance
• Bad compliance
• Reinfection
• Trichomoniasis

31. TREATMENT OF
PERSISTENT URETHRITIS

32. The patient came back 1 month later
with scrotal swelling
What should you do???

34. TREATMENT OF
SCROTAL SWELLING

35. The patient confessed that
he is having anal sex
What is your next step???

37. TREATMENT OF PROCTITIS

38. What should you do if the patient was female with
vaginal discharge???

39. FEMALE GONORRHEA
• Urogenital infection
– Primary site: endocervical canal
– 70-90% also colonize urethra
– Incubation: unclear; sx usually in l0 d
– Sx: majority asymptomatic; may have vaginal
discharge, dysuria, urination, labial pain/swelling,
abdominal pain
– Complications

40. Normal Cervix

41. Chlamydial Cervicitis

42. Trichomoniasis

43. BACTERIAL VAGINOSIS
• Polymicrobial clinical syndrome characterized
by loss of H2O2-producing Lactobacillus sp.
• Most common cause of vaginitis
• Complications:
– Premature rupture of membranes, premature
delivery, low birth-weight delivery, acquisition of
HIV, development of PID, post-operative infections
after gynecological procedures

44. Bacterial Vaginosis
• 50% asymptomatic
• Sx when present:
– malodorous (fishy smelling) vaginal discharge
• Diagnosis:
– Amsel Criteria
– Gram stain

45. Amsel Criteria
3 of 4:
• Homogeneous discharge
• Vaginal pH > 4.5
• Amine test positive
• Clue cell > 20%

46. Laboratory Examination of
Bacterial Vaginosis
Amine Test
“Fishy odor”
Gram stain : “Clue Cells”
Sensitivity 81%
Specificity 94%
pH >4.5

47. Clue Cells vs Normal Epithelia

48. What is the management of
female with vaginal discharge???

50. TREATMENT OF CERVICITIS

51. TREATMENT OF VAGINITIS

52. What is the complication of
female with vaginal discharge???

53. PELVIC INFLAMMATORY DISEASE
• 10%-20% women with gonorrhea develop PID
– C. trachomatis > N. gonorrhoeae in women with symptoms of
PID
• Minimal criteria:
– Uterine tenderness, adnexal tenderness +/- cervical motion
tenderness
• Other symptoms include: endocervical discharge, fever,
lower abdominal pain
• Complications:
– Infertility: 15%-24% with 1 episode PID secondary to gonorrhea
or chlamydia
– 7X risk of ectopic pregnancy with 1 episode PID
– Chronic pelvic pain in 18%

55. TREATMENT OF PID

56. CASE 2

57. 30 yo male with:

58. What is the most likely diagnosis?
A. Herpes simplex virus
B. Syphilis
C. Zipper cut
D. Granuloma inguinale
E. Additional testing is necessary*

59. Does it hurt?!?
• Painful
– Chancroid
– Genital herpes simplex
• Painless
– Syphilis
– Lymphogranuloma venereum
– Granuloma inguinale

60. Primary
(Chancre)
Secondary
(Rash)
Latent Syphilis
(No signs of disease)
Tertiary
Benign gummatous
Cardio-vascular syphilis
Neurosyphilis
1-2 years
Early Syphilis
Many years
to a lifetime
Late Syphilis
6 weeks
to
6 months
Many years
to a lifetime
Approx.
18 months
Incubation period
9 – 90 days
Course of Untreated Syphilis

61. PRIMARY SYPHILIS
• Incubation: 10-90 d (average 3 w)
• Chancre
– Early: macule/papule erodes
– Late: clean based, painless, indurated ulcer with
smooth firm borders
• Unnoticed in 15-30% of patients
• Resolves in 1-5 w
• Highly infectious!!!

62. 1st Syphilis

63. 1st Syphilis

64. SECONDARY SYPHILIS
• Hematogenous dissemination of spirochetes
• Usually 2-8 w after chancre appears
• Findings:
– rash - whole body (includes palms/soles)
– mucous patches
– condylomata lata – highly infectious!!!
– constitutional symptoms
• Sx resolve in 2-10 w

65. 2nd Syphilis

66. 2nd Syphilis

67. Reactivity of
Non-treponemal Tests

68. Reactivity of
Treponemal Tests

69. GENITAL HERPES
• Transmission: direct contact (asymptomatic
shedding)
• Primary infection commonly asymptomatic;
symptomatic cases sometimes severe,
prolonged, systemic manifestations
• Vesicles → painful ulcerations → crusting
• Potential recurrence

70. Genital Herpes

71. Genital Herpes

72. What is the management of CASE 2???

74. TREATMENT
OF
GENITAL
ULCERS

75. What is the management of
other STI syndromes???

77. TREATMENT OF
GENITAL WARTS

79. TREATMENT OF
INGUINAL BUBOES

81. TREATMENT OF
NEONATAL CONJUNCTIVITIS

82. FOLLOW UP
Discharge
•7 d after
th/
Syphilis
•1, 2, 3, 6,
12, 18-24
m
Warts
•Up to 3 m
after
clearance

83. What is the most important issues in educating &
counseling STIs patients???

84. ABCDs of STI Education
Abstinence Be faithful
Condom no Drugs

85. • Which STIs cause cancer? (HIV, HPV, Hep B, Hep C)
• Which are vaccine preventable? (4 strains of HPV, Hep B.
HSV vaccine is not very good.)
• Which STIs can be prevented by a condom?
• Which STIs can be prevented by abstinence?
• What is most common STD? (Chlamydia has highest
reported incidence, HSV prevalance is highest. Most
common curable STI in young women is trichomonaisis)
• What about lifetime occurrence of HPV? (Nobody knows)
• If you get a needlestick, which is most infectious: HIV, Hep
B, Hep C, Syphilis? And who do you call when stuck?