sexually transmitted diseases

1. Sexual Health and Sexually Transmitted
Infections(STIs)
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2. At the end of this session you will be able to:-
 Classify Sexually transmitted infections
 Assess STI risk
 Explain the syndromic management and counselling of STIs
 Discuss the prevention and control of STIs
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3.  STIs are major public health problems in all countries
 Globally 340 million new cases of curable STIs occur every
year (69 million are in sub-Saharan Africa)
 In many developing countries STIs are among the top five
disease for which adults seek health services
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4.  STIs are a public health concern for adolescents and young
people in both high- and low-income countries.
 In Ethiopia, 3% and 1% of female and male teenagers aged
15–24 years, respectively, reported having a STI.
 The prevalence of STI ranges from 41.7% to 66.1% among
primary studies performed in Ethiopia
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5.  Prevalence higher in urban than rural
 Higher in unmarried & young adults (15-44 yrs.)
 More frequent among females than males between the ages of
14-19
 After the age of 19, there is slight male preponderance
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6. Reasons for underestimation:
 People with symptom-free STIs do not seek treatment
 Health facilities offering treatment for STIs may be too far
away for many people
 People seeking other health care such as antenatal services
may not be routinely screened for STIs
 Many patients perceive a stigma in attending traditional STI
referral clinics, where anyone might be perceived to be at risk
of infection by STIs
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7.  Many people may choose to go to alternative providers, both
in the formal and informal sectors, who do not report case
numbers.
 Use of an excessively long list of notifiable diseases
 Lack of uniformity of reporting
 Cost of services
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8.  The most common mode of transmission is unprotected sex
Other forms of transmission are:-
Mother to child
-During pregnancy (HIV & syphillis)
-At delivery (gonorrhea ,chlamydia &HIV)
-Through breast feeding
 Unsafe (unsterile ) use of needles or injections
 Contact with blood or blood products (syphilis , HIV &hepatitis )
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9. Biological factors
 Age, young age more susceptible
 Gender, women more easily infected than males
 Immune status
Behavioural factors
 Changing sexual partners frequently
 Having more than one sexual partner
 Having sex with ‘casual’ partners, sex-workers or their clients
 Having unprotected penetrative sexual intercourse in a situation
where either partner has an infection
 Use of alcohol or other drugs before or during sex
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10. Socio-cultural factors
 In most cultures women have very little decision making power
over sexual practices and choices, including use of condoms
 Women tend to be economically dependent on their male partners
and are therefore more likely to tolerate men’s risky behavior
 Sexual violence tends to be directed more towards women by
men, making it difficult for women to discuss STI with their male
counterparts
 In some societies the girl-child tends to be married off to an adult
male at a very young age, thus exposing the girl to infections
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11.  In some societies a permissive attitude is taken towards men
allowing them to have more than one sexual partner.
 Harmful traditional practices
-skin-piercing
-the use of unsterile needles to give injections or tattoos
-scarification or body piercing
-circumcision using shared knives
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12. Bacterial:- Bacterial STIs are caused by bacteria
passed from person-to-person during sexual activity.
There are three infections in this category:
 Chlamydia
 Gonorrhoea
 Syphilis
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13.  Among the most common bacterial STIs in the world
 Passed by having unprotected oral, anal or vaginal sex
 Condoms can help prevent the spread of chlamydia during
vaginal/anal sex
 Condoms or dental dams can be used for protection during oral sex
 Most people have no symptoms
 The infection can be cured with a single dose of antibiotics
 A person can get the infection again, so their partners should also be
tested
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14. Male
 itching of the penis
 pain while urinating
 discharge from the penis
 in some cases, there may also be pain or swelling of the
testicles
 about half of men will have no symptoms and many will
have only mild symptoms
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15. Female
 burning while urinating
 vaginal discharge or a change in normal discharge
 bleeding between menstrual cycles, or during/after intercourse
 increase in pain during menstruation or during intercourse
 abdominal or lower back pain
 occasionally causes fever and chills
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16.  Sexually transmitted bacterial infection
 Passed along by having unprotected oral, anal or vaginal sex
 Condoms can help prevent the spread of gonorrhoea during
vaginal or anal sex
 Condoms or dental dams can be used for protection during
oral sex
 Gonorrhoea can spread from an infected mother to her baby
during child birth
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17.  Most people have no symptoms
 The infection can be cured with antibiotics
 A person can get the infection again, so their partners should also be tested
 Infected people who have no symptoms can still pass along the infection
 Many women do not have symptoms. Those who do have symptoms may
experience:
- Burning during urination
- Rectal pain, itching, bleeding discharge
- Vaginal bleeding or pain
- Yellowish-white vaginal discharge
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18.  Some men may have very mild symptoms or no symptoms at all.
Those who do may experience:
 Discharge from the penis
 Burning when urinating
 Painful/swollen testicles
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19.  Rare sexually transmitted bacterial infection
 Can cause serious damage to the body if not cured, including death
 Passed along by having unprotected oral, anal or vaginal sex
 Condoms can help prevent the spread of syphilis during vaginal or
anal sex
 Condoms or dental dams can be used for protection during oral sex
 Syphilis Can spread from an infected mother to her unborn child
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20.  Syphilis produces a wide range of symptoms that are often
confused with other illnesses
 Some people have no symptoms at all
 The infection can be cured with antibiotics
 A person can get the infection again, so their partners should
also be tested
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21. Symptoms vary depending on the stage of the infection:
Primary Syphilis (1st Stage)
 3 days to 3 months after contact
 A painless open sore develops around the genitals, rectum and/or mouth
 The sore will heal on its own, but the infection remains
Secondary Syphilis (2nd Stage)
 2 to 24 weeks after exposure
 A rash can develop anywhere on the body, including on the palms of the
hands and soles of the feet.
 Flu-like symptoms develop, including headache, slight fever, fatigue, loss of
appetite, weight loss, and sore throat
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22. Latent Syphilis (3rd Stage)
 Latent syphilis occurs after secondary syphilis
 Typically, there are no symptoms
 How can I be tested for syphilis?
 A blood test is done
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23. Signs and symptoms
• Rhinitis and serosanguinous discharge from nostrils
• Bullous skin lesions
• Periostitis with pseudo paralysis
• Hepatosplenomegally
• Nephrotic syndrome
• Chorioretinitis
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24.  Confirmed diagnosis
◦ Demonstration of the spirochete on dark field
microscopy from placenta or lesions from infant
 Presumptive
◦ Any infant whose mother had untreated syphilis
◦ Reactive specific treponemal tests with or without
manifestation of congenital syphilis.
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25.  Aqueous crystalline penicillin G 50,000 units/kg IV tid for 10
days Or
 Procaine Penicillin G 50,000 units/kg IM daily for 10 days.
 Note: CSF should be examined with RPR to exclude
involvement of the CNS
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26.  Deformity of long bones or nasal bridge
 Hutchinson’s triad consisting of deafness, keratitis
and peg shaped incisor teeth.
 Hydrocephalus with evidence of mental retardation.
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27.  Aqueous crystalline penicillin G 50,000 units/kg IV or IM
QID for 10 days
 Alternative regimen for penicillin-allergic patients, after the
first month of life
◦ Erythromycin 7.5-12.5 mg/kg orally, QID for 30 days
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28. • In Ethiopia, recent syphilis prevalence among ANC attendees was 2.53% and
1.9% for treponemal and non treponemal diagnostic tests respectively
• Adverse pregnancy outcomes include
– miscarriage or stillbirth
– congenital syphilis in the newborn
– progression of latent syphilis in the mother
• RPR test should be routinely done on pregnant mothers in their first trimester
and treatment should be instituted if the RPR test shows strong reactivity
• Weak reactivity should warrant specific serologic tests before decision to treat
is made.
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29.  If primary syphilis, secondary syphilis, or history of non-
reactive RPR test within the past 2 years:
◦ Benzathine penicillin G 2.4 million units IM
OR
◦ If allergic to penicillin, ceftriaxone 1 gm IM daily x 8 – 10
days
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30.  If infected more than two years OR no prior history of
non-reactive RPR test:
◦ Benzathine penicillin G 2.4 million units IM x weekly for 3 weeks
OR
◦ If allergic to penicillin, erythromycin 500 mg PO QID x 30 days
Note:
◦ Repeat RPR in the 3rd trimester or delivery
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31.  Aqueous bezylpenicillin 10-12 million IU IV, administered
daily in doses of 2-4 million IU, every 4 hours for 14 days.
 Alternative regimen:
◦ Procaine bezylpenicillin, 1.2 million IU IM, once daily,
and probenecid, 500 mg orally, 4 times daily, both for 10-
14 days.
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32.  A parasite is an organism that lives on or in a host and gets its food
from or at the expense of its host (CDC)
Pubic lice:- The lice attach their eggs to the pubic hair and feed on
human blood, Spread by sexual contact.
 Not the same as head lice. Pubic lice do not live on the head and
head lice do not live in the pubic area
Scabies:- Caused by the itch mite. It burrows just under the skin and
lays eggs.
 The scabies mite can live for 2-4 days away from the human body;
it can be transmitted without sexual contact.
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33.  Caused by a parasite that is usually sexually transmitted, but it
can survive 24 hours on wet towels and bathing suits
 Condoms will help prevent the spread
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34.  Intense itchiness
 Reddish rash
 Pain during sex or urination
 Vaginal discharge
Treatment
o Shampoo – special shampoo to kill lice or scabies
o Lotion - special shampoo to kill lice or scabies
o Ointment- special shampoo to kill lice or scabies
o Antibiotic – used to treat Trichomoniasis`
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35.  Human Papilloma Virus (HPV)
 Herpes
 Hepatitis
 HIV / AIDS
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36.  Very contagious virus
 Some people never get symptoms
 HPV is spread through skin to skin contact , oral, anal and
vaginal sex with an infected partner
 Some types cause genital warts and other types can cause
cancer of the cervix
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37. Treatment options for genital warts:
 Special medication can be used
 Freezing with liquid nitrogen
 Laser therapy to destroy the warts
 Other types of cancer that can be caused by HPV: Vulvar, Vaginal, Penile,
Anal, Back of the throat
Treatments
 Remove the warts but does not remove he virus from the blood
 Most warts will clear over time
 There is no cure for HPV
 There is a vaccine to prevent HPV
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38.  Caused by the Herpes Simplex Virus (HSV)
 Spread through skin to skin contact and oral, anal and vaginal sex
 Some people with herpes never develop sores, but are still
contagious and may spread it to others without knowing
 People who have an initial outbreak can have more outbreaks
throughout the rest of their life
 Remember herpes is not curable.
 It is treatable!
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39.  Hepatitis is a virus that affects your liver
 It can cause permanent liver disease and cancer of the liver
 Hepatitis A & B can be prevented by vaccines
 There is no vaccine for Hepatitis C
 3 most common types of hepatitis – A, B and C
 Hepatitis A is transmitted through fecal oral route
 Hep B is transmitted through blood and bodily fluids
 Hep C is transmitted mostly through blood but also through bodily
fluids
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40.  Get vaccinated against Hepatitis
 Practice safer sex
 Do not share instruments used in body-piercing, tattooing or
hair removal
 Do not share personal items such as toothbrushes, razors and
needles
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41.  HIV is the initial infection
 AIDS is the advanced stage of the disease
 Over a period of time, the virus attacks and damages the
body’s immune and nervous system
How is HIV/AIDS spread?
 The virus is spread through bodily fluids
 Decreased risk with condom use
 There is no cure for HIV infection
 Once infected, you have HIV for life long
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42. Chlamydia and Gonorrhoea
 Urine test for males and females
 If symptoms present, swabs may be done
Trichomoniasis
 Diagnosed by taking a sample of vaginal discharge
Genital warts (HPV)
 Diagnosed by visual examination
Herpes
 Usually diagnosed by sight, and by history
 A swab of the lesion can be taken to confirm virus
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43. Hepatitis B, C, Syphilis and HIV
 Diagnosed by blood tests
Preventing STIs and pregnancy
 Delay sexual activity until you are older
 If you choose to be sexually active, use protective barriers
(condoms, dental dams) and birth control
 Risks of STIS increase with number of partners
 If you are sexually active, get tested for STIs regularly (with
each new partner) and ensure your partner is tested
 The Best Protection (from STIs and pregnancy) is Abstinence
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44.  Religious beliefs
 Family and personal values
 Knowing yourself – what makes you feel good/comfortable
 Concern about pregnancy and STIs
 Physically readiness
 Emotional readiness
 Sexual Orientation
 Gender Identity
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45.  Need for more time to think
 Personal decision-making skills
 Ability to communicate with others
 Desire
 Curiosity
 Pressure or expectations of partner
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46. CAUSE COMPLICATIONS
Gonococcal and chlamydial Infertility in men & women,
Epididymitis, ectopic pregnancy, chronic
pain, pelvic pain urethral stricture, perihepatitis
Gonorrhea Blindness in infants,
Disseminated gonococcal infection
Chlamydia Chlamydial pneumonitis in infants
Gonococcal, chlamydial & anae Pelvic and generalized peritonitis
robic infection
Acquired syphilis Permanent brain and heart disease
Congenital syphilis Extensive organ and tissue damage
Human papilloma virus Genital cancer, obstructed labour
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47.  Health problems (cervical cancer, PID, infertility, chronic
abdominal pain, ectopic pregnancy, preterm labor, maternal
mortality, etc.
 Divorce &family disruption as a result of infertility
 Cost of STI drugs may place heavy financial burden on
families , communities, & the country at large
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48.  Etiologic diagnosis – using lab to identify the causative agent
 Clinical diagnosis –using clinical experience to identify
causative agent
 Syndromic Approach
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49.  This is done by identifying the causative agent(s) using
laboratory tests and giving treatment targeting to the pathogen
identified.
Advantages:-
 Avoids over treatment
 Conforms to traditional clinical training
 Satisfies patients who feel not properly attended to
 Can be extended as screening for the asymptomatic
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50.  Requires skilled personnel & consistent supplies
 Treatment does not begin until results are available
 It is time consuming & expensive
 Testing facilities are not available at primary level
 Some bacteria fastidious &difficult to culture (H.ducrey,
C.trachomatis)
 Lab. results often not reliable
 Mixed infections often overlooked
 Miss-treated/untreated infections can lead to complications and
continued transmission
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51.  Uses clinical experience to identify symptoms which are typical for a
specific STI, then giving treatment targeted, to the suspected pathogen(s)
Advantages:-
 Saves time for patients
 Reduces laboratory expenses
Disadvantages:-
 Requires high clinical acumen
 Most STIs cause similar symptoms
 Mixed infections are common &failure to treat may lead to serious
complications
 Doesn’t identify Asymptomatic STIs
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52.  Syndrome – is group of symptoms patient complains &
clinical signs you observe during examination
 Identification of clinical syndrome and giving treatment
targeting all the locally known pathogens which can cause the
syndrome
 There are seven syndromes (aim is to identify &manage
accordingly)
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54.  STI sign and symptoms are rarely specific to a particular
causative agent
 Laboratories are either non-existent or non functional due to
lack of resources
 Dual infections are quite common and both clinician and
laboratory may miss one of them
 Waiting time for lab. results may discourage some patients
 Failure of cure at first contact
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55.  Problem oriented (responds to patient’s symptoms )
 Highly sensitive & does not miss mixed infections
 Treats the patient at first visit
 Can be implemented at primary health care level
 Use flow charts with logical steps
 Provides opportunity & time for education &counseling
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56.  History taking and examination
 Syndromic diagnosis and treatment, using flow charts
 Education and counseling on HIV testing and safer sex,
including condom promotion and provision
 Management of sexual partners
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57.  Misses sub-clinical infection
 Needs validation study: Require prior research to determine
the common causes of particular syndromes
 Needs training
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58.  A flow chart is a diagram (map) representing steps to be taken
through a process of decision making
 Can be used at any health facility
-prompt treatment is provided at initial visit
-many people with STI have access to treatment
-provides opportunity for preventive & promotive measures
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59.  The clinical problem (patient’s presenting symptom)
-Problem box
 A decision to make usually by answering yes or no to a
question
-Decision box
 An action to take (what you need to do)
-Action box
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61. Guide for History-Taking
1. General details
Age
Marital status
Locality or address
Employment
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62. Present illness
-Presenting complaints and duration
Men:
– If an inguinal bubo – is it painful? Associated with genital
ulcer? Swellings elsewhere in the body?
– If a urethral discharge – pain while passing urine?
Frequency?
– If scrotal swelling – Onset? Presence of pain? History of
trauma and concomitant urethral discharge?
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63. Women:
– If a vaginal discharge-amount, color, odor, associated pruritus,
pain while passing urine? Frequency? Risk assessment positive?*
– Lower abdominal pain-vaginal bleeding or discharge? The onset,
type of pain radiation, severity, presence of vaginal discharge, last
menstrual period, and systemic symptoms like fever, nausea and
vomiting
– Painful or difficult pregnancy or childbirth?
– Painful or difficult or irregular menstruation?
– Missed or overdue period
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64. Men and women:
– If a genital ulcer-is it painful? Recurrent? Appearance?
Spontaneous onset?
– Other symptoms, such as itching or discomfort
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65. 3. Medical history
 Any past STI – type? Dates? Any treatment and response? Results of
tests?
 Other illness – type? Dates? Any treatment and response? Results of
tests?
 Medications being taken currently
 Drug allergies.
4. Sexual history
 Currently active sexually?
 New partner in the last three months?
 Risk assessment
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66. Examining male patients for STI syndromes
 Examination of a male patient can easily be done in a standing
position, but the lying position can as well be used
 The patient should be asked to expose the area from the chest to
knees for physical examination
 Palpate the inguinal region in order to detect the presence or
absence of enlarged lymph nodes and buboes
 Palpate the scrotum, feeling for individual parts of the anatomy:
– testes, spermatic cord, epididymis
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67.  Examine the penis, noting any rashes or sores. Then retract the
foreskin if present, and look at the:
– glans penis
– urethral meatus
 If you cannot see an obvious urethral discharge, milk the
urethra or ask the patient to milk the urethra gently in order to
express any discharge
 Record your findings
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68.  Ask for patients to lie down comfortably on a couch for genital
examination.
 Ask patients to expose the area from the chest to knees for
examination
 The patient should be covered with a sheet to maintain dignity and
respect
 Palpate the abdomen for pelvic masses and tenderness, taking great
care not to hurt the patient
 Palpate the inguinal region in order to detect the presence or absence
of enlarged lymph nodes and buboes
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69.  Ask the patient to bend her knees and separate her legs, then
examine the vulva, anus and perineum
 The physical examination may include, where possible, an
internal pelvic examination involving
 bimanual examination to check for active PID; shape, size and
position of uterus for uterine masses, for example, pregnancy
 Speculum examination to check for the nature of the vaginal
discharge, purulent cervicitis and/or erosions
 Record your findings
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70.  Factors that increase vulnerability of adolescents to STIs and HIV
infection
Biological factors
• Mucosal tear during sexual act
• Underdeveloped vaginal epithelium, which could be easily
infected by aetiologies of STI.
• Cervical ectropion
Social factors
• Multiple sexual partnerships
• Commercial sex
• Poor health seeking behavior
• Poor self-esteem
• Lack of youth friendly services
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71.  Adolescents may have limited access to health care and may
not seek care adequately. Arrangements should be made to
ensure compliance and future follow up.
 Partner notification and management is often difficult, thus
risk of re-infection exists.
 Pregnancy should be considered and screening is pertinent in
adolescent females.
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72. Syndrome Infectious agent Regimen
Urethritis in male
(dysuria and urethral
discharge)
Vaginitis/cervicitis
(vaginal discharge)
N. Gonorrhoeae
C. Trachomatis
T. vaginalis
Adolescents: ceftriaxone
125 mg IM stat Plus
doxycycline 100 mg bid for
seven days.
Children: ceftriaxone 50 mg
IM stat Plus Erythromycin
10 mg/kg qid for seven
days.
Note: Use metronidazole
10mg/kg bid for seven days
for persistent symptoms
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73. Syndrome Infectious agent Regimen
Genital ulcer HSV type 2
T. Pallidum
H.ducreyi
Adolescents: acyclovir 400 mg
TID x 10 days Plus benzathine
penicillin 2.4 million units IM x
1 Pluserythromycin 500 mg
QID x 7 days
Children: Acyclovir 10 mg/kg
TID x 7 days Plus B. penicillin
G 100,000 units/kg IM single
dose Plus Erythromycin 10
mg/kg qid for seven days.
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74. Syndrome Infectious agent Regimen
PID N. Gonorrhoeae
C. Trachomatis
Anaerobes
Adolescents: Ceftriaxone
125mg stat
PlusDoxycycline 100 mg
bid x 14d
OR
Erythromycin 500 mg
QID x 14d Plus
Metronidazole 500 mg
BID x 14 days
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75.  Effective medical treatment
 Education on risk reduction
 Counseling including testing for HIV antibodies
 Contact tracing and management
 Promotion and provision of condoms
 Ensure follow up management
 Legal and emotional support
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76. • Baseline assessment including taking specimen for gram stain
and/or culture for identification of N. gonorrhea whenever
feasible,
• Reassess after 7 days for incubating infections that could cause
discharge syndrome,
• testing and counseling at baseline and 12 weeks to exclude HIV
and syphilis,
• Refer immediately for HIV post exposure prophylaxis if the
assailant is suspected to have HIV infection.
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