Sexually Transmitted Infections

- the Hidden Epidemic

Jocelyn C. De Ocampo-De Vera,MD,DPCP

Internal Medicine-Infectious Diseases
GLOBAL BURDEN
448 million new cases of curable STIs are estimated to occur annually
throughout the world in adults aged 15-49 years (WHO,2005)
Factors Contributing to the Hidden Epidemic
Many STDs are asymptomatic
85% of women with chlamydia infection are asymptomatic
Responsible for spread of viral STDs like HSV, Hepatitis B, HIV, HPV
Lack of awareness that STDs as asymptomatic
STDs have non specific signs and symptoms

Long lag time between infection and complication

HPV cervical cancer
Hepatitis B liver cancer
Basic Transmission Cycle for STDs

Sexual
exposure to Acquisition
infected of Infection
patient

Transmission of
Infection to
Susceptible partner
Transmission dynamics of STI
The rate of spread of STI in a population is determined by three
factors:

the rate of exposure of susceptible persons to infected individuals;

the probability that an exposed, susceptible person will acquire the
infection (i.e., the "efficiency of transmission"); and
the length of time that newly infected persons remain infected and
are able to spread the infection to others.
Sexually Transmissible Microbes
Transmitted in Adults Predominantly by Sexual Intercourse

Neisseria gonorrhoeae HIV (types 1 and 2) Trichomonas vaginalis

Chlamydia trachomatis
Treponema pallidum
Haemophilus ducreyi
Klebsiella granulomatis
Ureaplasma urealyticum
Mycoplasma genitalium
Human T-cell lymphotropic Phthirus pubis
virus type I
Herpes simplex virus type 2
Human papillomavirus
Hepatitis B virus
Molluscum contagiosum virus
Clinical Presentation of Sexually Transmitted
Diseases
GENITAL SKIN and Mucous Membrane Lesions

URETHRITIS and EPIDIDYMITIS

VULVOVAGINITIS and CERVICITIS

PELVIC INFLAMMATORY DISEASE

Proctitis, Proctocolitis, Enterocolitis, and Enteritis

Infectious Causes of Genital Lesions
Sexually Transmitted Non Sexually Transmitted
Syphillis Folliculitis
HSV Tuberculosis
Chancroid Tularemia
Lymphogranuloma venereum Histoplasmosis
Donovanosis (Granuloma Candida
inguinale) Amoebiasis
HPV
Scabies
Molluscum contagiosum
infection
24 y/o MSM
Last sexual contact:
10 days PTC

>Soft tender induration

Which started as a solitary
pustule

>unilateral inguinal
lymphadenopathy
 Syphilis Herpes Chancroid Lymphogranuloma Donovanosis
Venereum
Incubation period
Genital or Perianal Ulcerations
990 days 27 days 114 days 3 days6 weeks 14 weeks (up to 6
months)
Early primary lesions Papule Vesicle Pustule Papule, pustule, or vesicle Papule

No. of lesions Usually one Multiple Usually multiple, may Usually one; often not Variable
coalesce detected, despite
lymphadenopathy
Diameter 515 mm 12 mm Variable 210 mm Variable
Edges Sharply demarcated, Erythematous Undermined, ragged, Elevated, round, or oval Elevated, irregular
elevated, round, or irregular
oval

Depth Superficial or deep Superficial Excavated Superficial or deep Elevated

Base Smooth, nonpurulent, Serous, Purulent, bleeds easily Variable, nonvascular Red and velvety,
relatively nonvascular erythematous, bleeds readily
nonvascular

Induration Firm None Soft Occasionally firm Firm

Pain Uncommon Frequently tender Usually very tender Variable Uncommon

Lymphadenopathy Firm, nontender, Firm, tender, often Tender, may suppurate, Tender, may suppurate, None; pseudobuboes
bilateral bilateral with initial loculated, usually loculated, usually
Syphillis
Chancroid
Genital Herpes
LGV
Donovanosis
 Laboratory Testing and Therapy
Syphilis Herpes Chancroid Lymphogranuloma Venereum Donovanosis

Treponema pallidum HSV type 2 Haemophilus ducreyi Klebsiella granulomatis Chlamydia trachomatis

Darkfield microscopy Tzanck smear Gram stain Gram stain PCR,serology

Penicillin G Aciclovir Azithromycin Tetracycline Doxycycline

Ceftriaxone Azithromycin Cotrimoxazole
Fluoroquinolone Erythromycin
Fluoroquinolone
Sexually Transmitted Diseases
GENITAL SKIN and Mucous Membrane Lesions

URETHRITIS and EPIDIDYMITIS

VULVOVAGINITIS and CERVICITIS

PELVIC INFLAMMATORY DISEASE

Proctitis, Proctocolitis, Enterocolitis, and Enteritis

URETHRITIS IN MEN
Dysuria
Discomfort between micturations (pain ,itching, urgency,
feeling of heaviness in the genitalia)
Urethral discharge
= may be apparent at all times- scanty at times
* Micturation immediately preceding urethral
examination may completely eliminate signs of infection
Discomfort only during ejaculation, deep pelvic pain or pain radiating
to the back
>>>>PROSTATITIS OR INFLAMMATION OF OTHER PORTIONS OF THE
UROGENITAL TRACT
URETHRITIS IN MEN
GONOCOCCAL Urethritis NON GONOCOCCAL Urethritis
( NGU )

Incubation Period: 4 days to 2 weeks Incubation Period: 4 days to 35 days

Frankly purulent discharge =Mucopurulent discharge ( thin cloudy fluid

or mucoid fluid with purulent flecks )
=may be clear and moderately viscid

Abrupt onset of symptoms Less acute onset, with symptoms increasing

over several days
 URETHRITIS IN MEN
Usual Causes Usual Initial Evaluation
Chlamydia trachomatis Demonstration of urethral discharge or pyuria
Neisseria gonorrhoeae
Mycoplasma genitalium Exclusion of local or systemic complications
Ureaplasma urealyticum
Trichomonas vaginalis Urethral Gram's stain to confirm urethritis, detect gram-negative
Herpes simplex virus diplococci

Test for N. gonorrhoeae, C. trachomatis

Visibly abnormal discharge (purulent,

mucopurulent)
Urethral Gram stain containing >4
leukocytes per oil-immersion field
First-void urine sample containing >10-
15 leukocytes per high dry field
EMPIRIC TREATMENT :
Treat Gonorrhea(unless excluded)
= Ceftriaxone or Cefpodoxime or
Cefixime
Treat Chlamydial Infection
=Azithromycin or Doxycycline
URETHRITIS IN WOMEN
BACTERIAL CYSTITIS
Associated with
urgency,frequency,hematu
ria or suprapubic
tenderness
Isolation of a single urinary
pathogen ( Escherichia coli
or Staphylococcus
saprophyticus) at counts
of >10 /ml of urine
ACUTE URETHRAL SYNDROME
INTERNAL dysuria
= with pyuria but w/o
Uropathogens
= etiologic agents: C.trachomatis,
N. gonorrhea, HSV(occasionally)
EXTERNAL dysuria
= painful contact with inflamed
or ulcerated labia or introitus
= associated w/ Vulvar HSV or
Vulvovaginal Candidiasis ( at times
w/ Trichomoniasis)
Epididymitis
Painful swelling of the scrotum,
generally unilateral, primarily
in the posterior aspect
Acute in onset
Dysuria or irritative lower
urinary tract symptoms
With or without symptoms of
urethritis
In young men(usually
associated with overt or
subclinical urethritis)
C.trachomatis
N.gonorrhea
In older men(especially post-
instrumentation)
Urinary pathogens
In men who practice insertive
rectal intercourse
Enterobacteriaceae- Coliforms
Sexually Transmitted Diseases
GENITAL SKIN and Mucous Membrane Lesions

URETHRITIS and EPIDIDYMITIS

VULVOVAGINITIS and CERVICITIS

PELVIC INFLAMMATORY DISEASE

Proctitis, Proctocolitis, Enterocolitis, and Enteritis

 VULVOVAGINITIS

NORMAL Vaginal Secretions

>Heterogenous suspension of
desquamated vaginal epithelial cells in
water
>Lactobacilli dominate the microbial flora
>pH of 3.5 to 4.6
>Odorless
>Do not cause itching or irritation
>Usually do not soil underclothing
 Vulvovaginitis
Symptomatic Patients with Normal
Vaginal Secretions Symptoms of vulvovaginitis
Differential
Chronicity Diagnosis of Abnormal
Vaginal Discharge: Discharge
Many prior visits to health care Odor
practitioners
>Vaginal infections
Vulvar discomfort
Trichomoniasis
Multiple ineffective treatments
Vulvovaginal candidiasis
with vaginal and oral Dyspareunia
Bacterial vaginosis
antimicrobial agents
>Desquamative
Absence ofinflammatory
odor vaginitis
Cervicitis
Absence of itching and irritation
Infectious
Noninfectious
Minimal, if any, staining of
clothing
Estrogen deficiency
 Normal Vaginal Vulvovaginal Candidiasis Trichomonal Vaginitis Bacterial Vaginosis
Examination

Etiology Uninfected; lactobacilli Candida albicans Trichomonas vaginalis Gardnerella vaginalis,

predominant various anaerobes and
mycoplasmas
Typical symptoms None Vulvar itching and/or Profuse purulent discharge; Malodorous, slightly
irritation vulvar itching increased discharge
Amount Variable; usually scant Scant Often profuse Moderate
Colora Clear or translucent White White or yellow White or gray
Consistency Nonhomogeneous, floccular Clumped; adherent plaques Homogeneous Homogeneous, low
viscosity; uniformly coats
vaginal walls
Inflammation of vulvar or None Erythema of vaginal Erythema of vaginal and None
vaginal epithelium epithelium, introitus; vulvar vulvar epithelium; colpitis
dermatitis, fissures common macularis
pH of vaginal fluidb Usually 4.5 Usually 4.5 Usually 5 Usually >4.5
Amine ("fishy") odor with None None May be present Present
10% KOH
Microscopyc Normal epithelial cells; Leukocytes, epithelial cells; Leukocytes; motile Clue cells; few leukocytes;
lactobacilli predominant mycelia or pseudomycelia in trichomonads seen in 80 nearly always including G.
up to 80% of C. 90% of symptomatic vaginalis plus anaerobes on
albicansculture-positive Gram's stain
 Examine the vaginal
mucosa
Cervicitis
=Erythema
=Lesions
=Secretions
Examine the cervix
=Ectropion
=Lesions
Adequate illumination
=Erythema
=Magnification, if possible Endocervical secretions
Give the patient a mirror
Inspect the external genitalia =Collect vaginal and
=Lesions
=Mucosal erythema
cervical specimens
=Bimanual examination
Mucopurulent Cervicitis
Cardinal Symptoms
Purulent vaginal discharge
Dysuria
Abnormal uterine
Cardinal signs:
bleeding yellow mucopurulent
Lower abdominal pain discharge from the cervical
os
Pelvic dyspareunia
endocervical bleeding upon
gentle swabbing
edematous cervical ectopy
Sexually Transmitted Diseases
GENITAL SKIN and Mucous Membrane Lesions

URETHRITIS and EPIDIDYMITIS

VULVOVAGINITIS and CERVICITIS

PELVIC INFLAMMATORY DISEASE

Proctitis, Proctocolitis, Enterocolitis, and Enteritis

Pelvic Inflammatory Disease
infection that ascends
from the cervix or vagina
to involve the
endometrium and/or
fallopian tubes
can extend beyond the
reproductive tract to cause
pelvic peritonitis,
generalized peritonitis,
perihepatitis, perisplenitis,
or pelvic abscess
Pelvic Inflammatory Disease
PERIHEPATITIS
Clinical diagnosis has 65%positive
predictive value
Red Flag (90% w/
Diagnosis: = Fitz-Hugh-Curtis Syndrome
laparoscopy) since many episodes =edema and ertyhma of liver capsule
are very subtle or exudate with fibrinous adhesions
Acute Appendicitis
Ectopic pregnancy between visceral and parietal
peritoneum
Dull abdominal
Tuboovarian pain,abscess
or Pelvic Abnormal
bleeding, dyspareunia =Presence of MPC,Pelvic tenderness,
subacute pleuritic RUQ pain, w/
normal liver fxn tests and normal utz
Yellow endocervical discharge
Cervical Motion tenderness
PERIAPPENDICITIS
Uterine fundal tenderness
=appendiceal serositis w/o
Adnexal tenderness involvement of intestinal mucosa
Fever =occurs as complication Gonococcal
Elevated ESR, Elevated peripheral or Chlamydial salphingitis
WBC
Pelvic Inflammatory Disease
2010 CDC STD guidelines

empirical treatment for sexually active women and other women at risk of STI with the
following minimum criteria:
= pelvic organ tenderness noted on bimanual examination
= microscopy showing WBC in vaginal secretions
= presence of MPC

*Definitive Criteria:
= histologic evidence of endometritis
= Transvaginal UTZ or other imaging : fluid filled tubes w/ or w/o free pelvic fluid or
tubo-ovarian complex
= laparoscopic findings: tubal purulent exudate, erythema and edema
Sexually Transmitted Diseases
GENITAL SKIN and Mucous Membrane Lesions

URETHRITIS and EPIDIDYMITIS

VULVOVAGINITIS and CERVICITIS

PELVIC INFLAMMATORY DISEASE

Proctitis, Proctocolitis, Enterocolitis, and Enteritis

PROCTITIS PROCTOCOLITIS ENTEROCOLITIS ENTERITIS

= inflammation limited = inflammation = inflammation = inflammation

to the rectal mucosa extending rectum to involving the small and involving the small
(distal 10-12cm) colon large bowel bowels only

=results from direct = results from ingestion of typical intestinal pathogens through oral-anal
rectal inoculation of exposure during sexual contact
typical STD pathogens

=anorectal pain and mucopurulent,bloody rectal

discharge

=tenesmus = true diarrhea

and constipation
PREVENTION and CONTROL
Thank you and Good Day