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11.sexually Transmitted Infections

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11.sexually Transmitted Infections

Gynaecology pdf
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© © All Rights Reserved
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SEXUALLY

TRANSMITTED
INFECTIONS

DR AMIT KUMAR
ASSISTANT PROFESSOR (OBG)
MADHAV HOMOEOPATHIC MEDICAL
COLLEGE,PINDWARA,SIROHI.
SEXUALLY TRANSMITTED
INFECTIONS

INTRODUCTION

• Sexually transmitted infections (STIs) include


those infections, which are predominantly
transmitted through sexual contact from an
infected partner.
• Although the transmission of the infections is
mostly due to sexual contact, other modes of
transmission include placental (HIV, syphilis),
by blood transfusion or infected needles (HIV,
hepatitis B or syphilis),

• By inoculation into the infant’s mucosa when


it passes through the birth canal (gonococcal,
chlamydial, or herpes).
The reasons for increasing incidence are:
• Rising prevalence of viral infections like HIV,
hepatitis B and C.
• Increased use of ‘Pill’ and IUCD which cannot
prevent STI and there is an increased
promiscuity and permissiveness.
• Lack of sex education and inadequate practice
of safer sex.
• Increased rate of overseas travel.
• Increased detection due to heightened
awareness
CLASSIFICATION OF STI’S
DISEASE AGENT PREVENTION
Bacterial - Safe sex as
Gonorrhoea Neisseria gonorrheae STIs are entirely
preventable.
Non-gonococcal urethritis Chlamydia trachomatis (d-k
serotypes)
Syphilis Treponema pallidum
„
Lymphogranuloma venereum Chlamydia trachomatis (l
serotypes) -Use of barrier
Chancroid Hemophilus ducreyi contraception:
Condom,
Granuloma inguinale Donovania granulomatis diaphragm,
Spermicides.
Non-specifi c vaginitis Hemophilus vaginalis

Mycoplasma infection Mycoplasma hominis


Disease Agent Prevention
™ Viral
Aids Human immunodefciency -Reducing the number of
virus(HIV1 or HIV 2) sexual partners

Genital herpes Herpes simplex virus (HSV


2) *monogamous relationship
reduces the risk of STI’S
Condyloma acuminata Human papilloma virus and RTI’S
(HPV)

Molluscum contagiosum HPV – 16, 18 or 31 „-Contact tracing and eff


ective treatment.
Viral hepatitis Pox virus

CIN(cervical intraepithilial Hepatitis B and C virus


neoplasia)
Disease Agent Prevention
Protozoal „Screening in
Bacterial vaginosis (bv) Gardnerella vaginalis asymptomatic or
symptomatic cases for
Trichomonas vaginitis Trichomonas vaginalis STI’S & RTI’S.
Monilial vaginitis ™ Fungal
Candida albicans
™ Ectoparasites Aseptic procedures
Scabies Sarcoptes scabiei In delivery, MTP
procedures and
Pediculosis pubis Crab louse (phthirus pubis) IUCD insertion.
GONORRHEA
CAUSATIVE ORGANISM-
Neisseria gonorrheae, a Gram-negative diplococcus.

INCUBATION PERIOD- The incubation period is 3–


7 days.
SITE:-The principal site of invasion is the columnar
and transitional epithelium of the genitourinary tract.
As such, the primary sites of infection are
endocervix, urethra, Skene’s gland, and Bartholin’s
gland.
Clinical Features in Adult
• About 50 percent of patients with Gonorrhea
are asymptomatic and even when the
symptoms are present, they are non-specific.
• The clinical features of acute gonococcal
infection are described as follows:
Local.
Distant or metastatic.
PID
Local
Symptoms
• Urinary symptoms such as dysuria (25%)
• Excessive irritant vaginal discharge (50%)
• Acute unilateral pain and swelling over the
labia due to involvement of Bartholin’s gland
• There may be rectal discomfort due to
associated proctitis from genital contamination
• Others: Pharyngeal infection
intermenstrual bleeding.
Signs

• Labia may be swollen and look inflamed.


• The vaginal discharge is mucopurulent.
• The external urethral meatus and the openings
of the Bartholin’s ducts look congested. On
squeezing the urethra and giving pressure on
the Bartholin’s glands, purulent exudate
escapes out through the openings.
• Bartholin’s gland may be palpably enlarged,
tender with fluctuation, suggestive of
formation of abscess.

• Speculum examination reveals congested


ectocervix with increased mucopurulent
cervical secretions escaping out through the
external os.
Distant or Metastatic
• There may be features of perihepatitis and
septicemia. Perihepatitis results from spread of
infection to the liver capsule.
• There is formation of adhesions with the
abdominal wall. This is not infrequently (5–
10%) associated with acute PID.
• Septicemia is characterized by low grade
fever, polyarthralgia, tenosynovitis, septic
arthritis, perihepatitis, meningitis,
endocarditis, and skin rash.
COMPLICATIONS —
• Acute pelvic inflammation leads to chronic
pelvic inflammatory disease, unless adequately
treated.
• Infertility,
• Ectopic pregnancy (due to tubal damage)
• Dyspareunia,
• Chronic pelvic pain,
• Tubo-ovarian mass, and
• Bartholin’s gland abscess are commonly seen.
DIAGNOSIS
• Nucleic acid amplication testing (NAAT) of
urine or endocervical discharge is done.
• First void morning urine sample (preferred) or
at least one hour since the last void sample
should be tested.
• NAAT is very sensitive and specific (95%).
• A presumptive diagnosis is made following
detection of Gram-negative intracellular
diplococci on staining
TREATMENT

Preventive
• ™Adequate therapy for Gonococcal infection
and meticulous follow up are to be done till the
patient is declared cured.
• ™To treat adequately the male sexual partner
simultaneously.
• ™To avoid multiple sex partners.
• ™To use condom till both the sexual partners
are free from disease.
SYPHILIS
• Syphilis is caused by the anaerobic spirocheta
treponema pallidum.
• Syphilitic lesion of the genital tract is acquired
by direct contact with another person who has
open primary or secondary syphilitic lesion.
• Transmission occurs through the abraded skin
or mucosal surface.
• The incubation period ranges between 9 and 90
days.
Clinical features
• The primary lesion (chancre) may be single
or multiple and is usually located in the labia.
• Fourchette, anus, cervix, and nipples are the
other sites of lesion.
• A small papule is formed, which is quickly
eroded to form an ulcer.
• The margins are raised with smooth shiny floor.
The ulcer is painless without any surrounding
inflammatory reaction.
• The inguinal glands are enlarged, discrete, and
painless.
• The primary chancre heals spontaneously in 1–
8 weeks leaving behind a scar.
• The tubes are not affected and infertility does not
occur unless associated with gonococcal infection.
• Secondary syphilis—
• Within 6 weeks to 6 months from the onset of
primary chancre, the secondary syphilis may
be evidenced in the vulva in the form of
condyloma lata.
• These are coarse, flat-topped, moist, necrotic
lesions and teeming with treponemes.
• Patient may present with systemic symptoms
like fever, headache, and sore throat.
• Maculopapular skin rashes are seen on the
palms and soles. Other features include
generalized lymphadenopathy, mucosal ulcers,
and alopecia.

• The primary and secondary stage can last upto


two years and during this period, the woman is
a source of infection.
Latent syphilis — It is the quiescence phase
after the stage of secondary syphilis has
resolved.
• It varies in duration from 2 to 20 years.
Tertiary syphilis — About one-third of
untreated patients progress from late latent
stage to tertiary syphilis.
It damages the central nervous, cardiovascular,
and musculoskeletal systems.
• Patient may present with cranial nerve palsies
(III, VI, VII, and VIII), hemiplegia, tabes
dorsalis, aortic aneurysm, and gummas of skin
and bones.
• The important pathology is endarteritis and
periarteritis of small and medium sized
vessels.
• Tertiary syphilis is characterized by
gumma. A gummatous ulcer is a deep
punched ulcer with rolled out margins.
• It is painless with a moist leather base.
Diagnosis
1. History of exposure to an infected person.
2. Identification of the organism—Treponema
pallidum, an anaerobe.
3. Serological tests:
(a) VDRL
(b)Treponema pallidum hemagglutination
(TPHA) test,Treponema pallidum enzyme
immunoassay(EIA),fluorescent treponemal
antibody absorption (FTA-abs) testand
Treponema pallidum immobilization (TPI)
test.
(c) Currently immunoblotting and PCR tests are
evaluated as more sensitive and confirmatory
tests.
TREATMENT-
Early syphilis (primary, secondary, and early
latent syphilis of less than 1 year duration)
• Benzathine penicillin G 2.4 million units is given
intramuscularly in a single dose, half to each
buttock.
• Late syphilis: Benzathine penicillin G 2.4
million units is given IM weekly for 3 weeks
(7.2 million units total).
Follow up:
• Serological test is to be performed 1, 3, 6, and
12 months after treatment of early syphilis.
• In late symptomatic cases, surveillance is for
life; the serological test is to be done annually.
• All women with simultaneous syphilis and
HIV infection may have high rate of treatment
failure.
CHLAMYDIAL INFECTIONS
• The causative organism is Chlamydia
trachomatis (of D-K serotypes), an
obligatory intracellular Gram-negative
bacteria.
• Its prevalence is more than N. gonorrhoeae as
a causative agent for STI or STD in developed
countries.
• Chlamydia has longer incubation period (6-
14 days) compared to gonorrhea (3–7 days).
• The organisms affect the columnar and
transitional epithelium of the genitourinary
tract.
• The lesion is limited superficially. As there is
no deeper penetration.
• The infection is mostly localized in the
urethra, Bartholin’s gland, and cervix.
• It can ascend upwards like gonococcal infection
to produce acute PID.
CLINICAL FEATURES are non-specific
and asymptomatic in most cases (75%).
• Dysuria, dyspareunia, postcoital bleeding, and
intermenstrual bleeding are the presenting
symptoms.
• Findings include mucopurulent cervical
discharge, cervical edema, cervical ectopy, and
cervical friability.
COMPLICATIONS:
• Urethritis and bartholinitis are manifested
by dysuria and purulent vaginal discharge.
• Chlamydial cervicitis spreads upwards to
produce endometritis and salpingitis.
• Chlamydial salpingitis is asymptomatic in
majority of the cases.
• It causes tubal scarring resulting in infertility
and ectopic pregnancy.
• It is the more common cause of perihepatitis
(Fitz-Hugh-Curtis syndrome) than
gonococcus.
DIAGNOSIS
• Chlamydial nucleic acid amplification testing
and detection by polymerase chain reaction
(PCR) is a very sensitive and specific test
(95%).
• First void urine specimen is most effective and
specific.
• Chlamydia antigen (lipopolysaccharide) can be
detected by ELISA technique.
TREATMENT
• Azithromycin — 1 g orally single dose or
• Doxycycline — 100 mg orally bid × 7 days or
• ™Ofloxacin — 200 mg orally bid × 7 days or
• ™Erythromycin — 500 mg orally bid × 7 days.
• The sexual partner should also be treated with
the same drug regimen.
CHANCROID (SOFT SORE)
• The causative organism is a Gram-negative
streptobacillus— Hemophilus ducreyi.
• The incubation period is very short 3–5 days
or less.
• The lesion starts as multiple vesicopustules
over the vulva, vagina or cervix.
• It then sloughs to form shallow ulcers
circumscribed by inflammatory zone.
• The lesion is very tender with foul purulent
and hemorrhagic discharge.
• There may be cluster of ulcers.
• Unilateral inguinal lymphadenitis may occur
which may suppurate to form abscess
(buboes).
DIAGNOSIS:
• Syphilis must be ruled out first.
• Demonstration of Ducreyi bacillus in
specialized culture media is confirmatory
TREATMENT:-
• Ceftriaxone 250 mg IM single dose is
effective.
•  Azithromycin 1 gm by mouth single dose.
•  Erythromycin 500 mg by month every 6
hours for 7 days can also be given.
• Sexual partner should also be treated.
LYMPHOGRANULOMA
VENEREUM (LGV)
• Lymphogranuloma venereum (LGV) is caused
by one of the aggressive L serotypes of
Chlamydia trachomatis usually acquired
sexually.
• The incubation period is 3–30 days. It is more
commonly found in the sea ports of the Far
East, Malaysia, Africa, and South America.
• Initial lesion is a painless papule, pustule or
ulcer in the vulva, urethra, rectum or the
cervix.
• The inguinal nodes are involved and feel
rubbery. There is acute lymphangitis and
lymphadenitis.
• The glands become necrosed and abscess
(bubo) forms. Within 7–15 days, the bubo
ruptures and results in multiple draining
sinuses and fistulas.
• The healing occurs with intense fibrosis with
lymphatic obstruction. The secondary phase is
noted by painful adenopathy.
• The classical clinical sign of LGV is the “groove
sign”, a depression between the groups of inflamed
nodes.
• The lymphatic obstruction leads to vulval swelling
where as lymphatic extension to the vulva, vagina,
or rectum leads to ulceration, fibrosis, and stricture
of the vagina or rectum.
COMPLICATIONS :
(i) Vulval elephantiasis,
(ii) Perineal scarring and dyspareunia,
(iii) Rectal stricture, and
(iv) Sinus and fistula formation.
TREATMENT:
• Prevention—Use of condom or to avoid
intercourse with a suspected infected partner.
• Definitive treatment—CDC recommends
Doxycycline 100 mg BID for at least 21 days.
• Surgical—
(i) Abscess should be aspirated but not be
excised.
(ii) Manual dilatation of the stricture weekly.
(iii)It is essential to use antibiotics during the
perioperative period.
GRANULOMA INGUINALE
(DONOVANOSIS)
• This is a chronic progressive granulomatous
diseases of the vulva, vagina, or cervix.
• It is commonly found in some tropics and
subtropics like South China, South India,
Papua New Guinea, and South America.
• The causative organism is a Gram-negative
intracellular bacillus—Calymmatobacterium
granulomatis
Clinical Features:
The disease usually manifests itself 10–80
days after coitus with an infected partner.
• The lesion starts as pustules, which breakdown
and erode the adjacent tissues through
continuity and contiguity.
• The ulcer looks hypertrophic (beefy red) due
to indurated granulation tissue.
• The margins are rolled and elevated. Biopsy
may be needed to exclude neoplasia.
• The lymph nodes do not undergo suppuration
and abscess formation (cf. Lymphogranuloma
venereum).
• Diagnosis is confirmed by demonstrating the
Donovan bodies within the mononuclear cells
in material (scrapings) from the ulcer when
stained by the Giemsa method. Donovan
bodies are clusters of dark-staining bacteria
with a bipolar (safety pin) appearance found
within the mononuclear cells.
• Treatment: Usually, it does respond well to
a broad spectrum antibiotic. However, CDC
recommends
• Doxycycline 100 mg BID for at least 3 weeks.
• Alternatively, ciprofloxacin 750 mg BID for at
least 2 weeks is given.
• The residual destructive lesion in the vulva
may require plastic surgery or vulvectomy.
BACTERIAL VAGINOSIS (BV)
(Bacterial Vaginitis)
• The causative organism was previously thought to
• be Gardnerella vaginalis (Haemophilus vaginalis).
• The present concept is that along with G vaginalis,
• anaerobic organisms such as Bacteroides species,
• Peptococcus species, mobiluncus, and Mycoplasma
• hominis act synergistically to cause vaginal infection.
• There is marked decrease in lactobacilli.
• Clinically, it is characterized by creamy vaginal
• discharge with fishy smell without extensive evidence
• of inflammation.

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