Sexually Transmitted Infections

A review
 Contents
Introduction

Epidemiology

Some facts about STIs

History

Examination

Investigations

Differential diagnosis and Management

 Introduction
Sexually transmitted infections are any disease that is transmitted by direct sexual contact, examples include:

Gonorrhea

Chlamydia

Trichomoniasis

Syphilis

HPV

Genital herpes (HSV)

HIV

Hepatitis B

Additionally there are some sexually transmitted disease which have presented in outbreaks such as n.meningitidis, Monkeypox, Shigella
sonnei, Ebola & Zika virus
 Epidemiology
More than 1 million sexually transmitted infections are acquired per day worldwide.
The majority are asymptomatic

Currently there is no reliable epidemiological data for sexually transmitted infections

in Oman

Despite a notification system; publicly available data isn’t easily accessible

Cultural norms and taboos play a significant role in concealing the burden of STIs
in the population

Significant impacts on sexual and reproductive health due to a lack of data

transparency
 Some facts!

More than 500 million people ages 15-49 are estimated to have a genital infection with herpes simplex virus

300,000 fetal and neonatal deaths occur each year due to syphillis with an additional 215,000 infants at increased
risk of early death

Cervical cancer - Human Papilloma Virus is responsible for an estimated 530,000 cases of cervical cancer and
264,000 cervical cancer deaths each year

Chlamydia and gonorrhea (often asymptomatic) are a significant cause of infertility worldwide, as well as being
major causes for pelvic inflammatory disease. These infections also increase the risk of contracting HIV

Hepatitis B leads to over 219,000 deaths worldwide due mainly to cirrhosis and hepatocellular carcinoma
 History
Asymptomatic (majority)

Dysuria
5 P’s
Hematuria Partners
Practices
Urethral/Vaginal Discharge or bleeding Protection from STIs
Past STIs
Urethral/Vaginal erythema, inflammation Pregnancy Intention
Dyspareunia

Intermenstrual Bleeding

Testicular/Pelvic pain

Rash (vesicular rash, ulcers, erythema multiforme, sores)

Infertility

Rarely; may present with systemic symptoms: Fever, abdominal

pain, fatigue, malaise opportunistic infections,
 Examination
Abdominal examination;

Abdominal distension

Hepatomegaly (Hepatitis B)

Genital examination

Look for a rash, ulcers, erythema

Identify any malodorous discharge (trichomoniasis)

Palpate for inguinal lymphadenopathy

Palpate scrotum for an evidence of epididymitis (often secondary to gonorrhea or chlamydia)

Pelvic examination
 Investigations
Laboratory blood analysis including;

CBC, RFT, LFT, CRP

VDRL, HIV I & II, HbsAg, HCV-Ab

Additionally, testing for chlamydia and gonorrhea with urethral/vaginal swab

Urine routine and culture utilizing the “first catch” method

 Gonorrhea
Caused by Neisseria gonorrhea, common and preventable sexually transmitted infection

It can be transmitted either through direct sexual contact or through childbirth passing from mother to
child and potentially causing ophthalmia neonatorum

Presentation:

Dysuria, Vaginal/Penile Discharge, IMB, Systemic signs (disseminated disease)

In woman the most common site is the cervix causing endocervicitis and urethritis which may be
complicated by pelvic inflammatory disease. Other complications include tube-ovarian abscess and
sequelae of PID such as infertility

In men gonorrhea often presents with symptoms of urethritis such as dysuria, hematuria, penile
discharge this can predispose men to epididymitis and epididymo-orchitis.
Gonorrhea
 Gonorrhea
Investigations: CBC, Urethral/Vaginal Swab, Urine Microscopy and Culture

Gonorrhea predisposes to a higher risk to HIV and concomitant infection with

chlamydia trachomatis and this makes mandatory screening for both conditions
necessary

Treatment: Single 500mg IM dose of Ceftriaxone (1g for pts >136kg)

Co- treatment of gonorrhea with azithromycin or doxycycline is no longer

recommended and retesting is no longer required
 Chlamydia

Chlamydia trachomatis; Gram negative bacteria that can infect many organ
systems. It is the most common sexually transmitted infection in many countries

Chlamydia serotypes A, B, Ba, C can trachoma a condition endemic to Africa and

Asia that is characterized by chronic conjunctivitis, serotypes D-K cause genital
tract infection, and L1-L3 cause lymphogranuloma venerum, genital ulcer disease
associated with tropical countries
 Chlamydia

Presentation: Often asymptomatic, patients often present with dysuria, yellow

mucopurulent urethral discharge, rectal pain/bleeding, proctatitis

Females: Vaginal discharge, dyspareunia intermenstrual/postcoital bleeding,

signs and symptoms of PID and its sequelae

Men: Unilateral pain and swelling of the scrotum, epididymitis

Women are more commonly asymptomatic (80%) compared to men (50%)

Chlamydia
 Chlamydia
Investigations: Urethral/Vaginal Swab, Urine Microscopy and Culture, Concomittant
HIV testing, PAP smear (high risk of cervical cancer), testing of sexual partners

Pregnancy testing is mandatory in the case of positive chlamydia infection; drugs used
to treat chlamydia like doxycycline and ofloxacin are contraindicated in pregnancy

Treatment;

1st line: Azithromycin (1g STAT) and Doxycyline (100mg BID x 7 days)

2nd line: Levofloxacin, Ofloxacin, or erythromycin

 Trichomoniasis
Trichomoniasis caused by Trichomonas Vaginalis, found in sexually active individuals and usually presents with vaginal secretions in women or urethral
secretions in men

Symptoms in Women:

Malodorous vagina (musty)

Vulvovaginal itching

Post coital or IMB

Dyspareunia

Dysuria

Symptoms in Men:

Urethral discharge (purulent to mucoid)

Dysuria

Lower abdominal or Testicular pain (less common)

 Trichomoniasis

Investigations:

Traditionally wet mount microscopy, his has a very low sensitivity (<25%), but
it is quick, easy and low cost

Culture; previous standard technique before molecular techniques

Molecular techniques: DNA multiplication, antibodies, and hybridization

techniques
 Trichomoniasis

Treatment:

A single 2g dose of metronidazole

Metronidazole 500mg BID x 7 days

Consider concomitant treatment of chlamydia and gonorrhea

Syphilis
 Syphilis

Syphilis is a solely human pathogen caused by the spirochete bacterium

Treponema pallidum.

Mainly occur through direct sexual contact, although it may also be transmitted by
infected blood borne products or in utero. Unprotected sex is the major risk factor
for transmission.

Syphilis manifests in it’s primary, secondary, and tertiary stages. It is important to

have an appropriate timeline for staging the disease.
 Primary Syphilis
Primary:

Appearance of a chancre; it occurs 10-90 days after contact with an infected

individuals. This primary occurs on the glans penis in males and on the vulva or
cervix in females.
 Primary Syphilis

Lesions are described as solitary, raised, firm and red papules that erode to reveal an
ulcerated base with raised edges around the central ulcer

Most common presentation are solitary lesions however multiple lesions can appear
simultaneously, such as in the example above which shows “kissing lesions”
 Secondary Syphilis

Secondary syphilis presents in

various ways. It generally begins
2-10 weeks after the onset of a
chancre with diffuse bilaterally
symmetric non pruritic
mucocutaneous rash which may
be subtle in a minority of patients
 Secondary Syphilis
Constitutional symptoms are generally mild
and include malaise, fatigue, anorexia,
nausea, myalgia and arthralgia

Patient can present with more severe

symptoms such as severe headache, facial
numbness or weakness, and neck stiffness in
cases of acute syphilitic meningitis

Secondary syphilis can also cause optic

neuritis, hepatitis, proctitis, arthritis, and
nephropathy
 Secondary Syphilis
When a patient presents with a rash limited
to his palms and soles always suspect
syphilis unless you have a clearer
diagnosis

Causes of rashes to the hands and feet

include:

Coxsackie A virus (HFMD)

Dishydrotic eczema

Kawasaki disease

Janeway lesions (bacterial endocarditis)

 Syphilis

Latent: Asymptomatic, only detectable by serological testing. May last from a few
years and up to 25 years before tertiary syphilis begins. Early latent is during the
first year after resolution of primary/secondary disease or within 1 year of a
positive serologic test. Non infectious (except in utero)

Tertiary: Slowly progressive disease that can affect any organs presenting with
CNS findings, hearing loss, symptoms relating to aortic aneurysms such as chest
pain and stridor
 Syphilis
Congenital:

Early (< 2 yo),

Late (> 2), manifestations include

rhinitis and cutaneous lesions (<
2 ), and impairments of hearing and
visions, dental and facial
abnormalities
 Syphilis

Long list of possible ddx for syphilis. Always consider syphillis in any patient
presenting with a rash and constitutional symptoms

Laboratory investigations; detection use an RPR (rapid plasma reagin), for

confirmation a TPHA (treponema palladium hybridization assay)

Imaging studies; depending on organ system involved for example chest CT in

aortic disease

LP: Cases of suspected syphilitic meningitis

 Syphilis
Treatment:

Benzathine penicillin is the drug of choice!

Primary, secondary syphilis and early latent syphilis: Single dose of 2.4M units (IM)

Late latent or latent syphilis of unknown duration; Three doses of 2.4M units IM at 1 week
interval totaling 7.2 M units

Pregnancy: Treatment appropriate to the stage of syphilis

In case of allergy to penicillin in case of tertiary, pregnancy, neurosyphilis desensitisation may

have to be achieved

Doxycyline for the treatment of early and latent syphilis for 28 days
 HPV
Human Papilloma Virus, sexually transmitted disease characterized by either anogenital/mucosal involvement,
non-genital cutaneous, and epidermodysplasia verruciformis (papillomas and verrucas)

Serotypes; Over 70 different serotypes, 16 and 18 being the most commonly implicated in cancers of the
cervix, vagina, vulva, and penis

Presentation;

Anogenital warts

Cervical disease (asymptomatic, detect by pap spear and lesions appear acetowhite after examination with
acetic acid and colposcopy)

Anal cancer; rectal bleeding and sensation of a mass (?haemorrhoid)

Oral wars, flat warts, plantar warts

HPV
 HPV
Investigations;

Cervical pap smear

DNA chip, linear array

Acetic acid test: apply 2-5% acetic acid moistened gauzed pas for 5-10 minutes suspected lesions the cervix,labia, penis, or perianal area
Difficult lesions that are difficult to asses become visible, dysplastic and neoplastic tissue turns white

Tissue biopsy: For an inconclusive diagnosis

Treatment;

Immune response modifiers: Imiquimod and interferon-alpha which mainly treat anogenital warts or condyloma acuminata

Cytotoxic agents: podophilox, pdophyllin and 5FU.

Ketolytic agents for treatment of nongenital cutaneous warts: Salicylic acid, trichloroacetic acid (TCA), bicolor-acetic acid (BCA)

Surgical; Cryosurgery, electrosurgery, surgical excision, laser surgery

 HSV
Herpes Simplex Virus I & II:

HSV I: Orofacial dz

HSV II: Genital dz

In some subpopulation this may be reversed

Presentation;

Asymptomatic (80%)

Acute herpetic gingivostomatitis

Trasmitted by saliva affecting both children aged 6 months to 5 years as well as adults

Acute herpetitc pharyngotonsillitis

Herpes labials

Herpetic whitlow

Herpes Gladiatorum

Eczema herpeticum

Genital herpes
 HSV
Investigations;

Tzank smear: Rapid testing, doesn’t differentiate between HSV I & II

PCR: Higher sensitivity than culture. Detects both types of HSV and has shown strong associations between HSV-1 and
Bell’s Palsy and HSV-2 and recurrent meningitis

Immunofluorescence: Distinguishes HSV I & II. Rapid results in 2-3 hrs.

Brain imaging: CT in HSV encephalitis shows focal localization in the temporal area that is associated with edema and
contrast enhancement

Treatment;

Antivirals: Acyclovir, Valacyclovir, famciclovir

Intravenous therapy for patients with conditions that necessitate hospitalization (hsv encephalitis, hepatitis, pneumonitis
Thank you for listening!