SEXUALLY TRANSMITTED DISEASES

and
PELVIC INFLAMMATORY DISEASE

DR GETAHUN K.
AMU-CMHS, 2020
 DEFENSE OF GENITAL TRACT
• Despite free anastamosis of lymphatic and blood
vessels of pelvis and communication to exterior,
pelvis infection is low due to defense system of the
genital tract.
• VULVAR DEFENSES:
– Anatomic: apposition of cleft by labia & bartholin’s
gland.
– Physiologic: fungicidal action of secretion of the
apocrine gland.
• VAGINAL DEFENSE:
– Estrogen-stimulated vaginal epithelial cells are rich in glycogen.
– lactobacilli convert it to lactic acid.
– Anatomic: apposition of anterior and posterior wall and
stratified epithelium.
– Physiologic: maintained by the hormone estrogen.
– Polymicrobial –balance (“bacterial interference”).
Physiology of the Vagina
• Cervical defense
– Glands & cervical mucus
– Bactericidal nature of mucus
– Most of the antibody-producing cells in the female genital tract are
located in the endocervix.
• Uterine defense
– Cyclic shedding of endometrium
– Closure of uterine ostium of fallopian tube.
• Tubal defense
– Integrated mucus plicae & epithelial cilia
– Peristalsis of tube and ciliary movement
 Common microorganism in Obstetrics and Gynecology
Apathogenic Facultative Pathogenic
Pathogenic
Lactobacilli Gardnerella vag. N. gonorrhoeae
Enterococci Chlamydia trach.
Streptococci B Streptococci A
Proteus species Staph. aureus
Staph. epidermidis
Kleb. pneumoniae
Bacteroides sp.
Peptostreptococci
Peptococci
Veillonella
Mobiluncus
Mycoplasma
Pseudomonas
Candida species
 SEXUALLY TRANSMITTED DISEASES
• The term denote disorders spread principally by
intimate contact:
1. Sexual intercourse
2. Close body contact, kissing, cunnilingus, and anal intercourse.
3. Transplacental spread, eg. HIV and syphilis
4. Passage through the birth canal, e.g. gonorrhea, Chlamydia, and HIV
5. Lactation during the neonatal period
 TERMINOLOGY
• WHO recommends that the term STD be replaced by the term STI.
• It better incorporates asymptomatic infections.
• Has also been adopted by a wide range of scientific societies &
publications.
 EPIDEMIOLOGY OF STIs
• STIs are major public health problems in all countries.
• Globally 340 million new cases of curable STIs occur every year
• Majority are in sub-Saharan Africa.
• In many developing countries, STIs are among the top five disease
for which adults seek health services.
• 1% prevalence (EDHS 2011), underestimation!
• Higher in unmarried & young adults.
• More frequent among females than males between the ages of
14-19.
• After the age of 19, there is slight male preponderance.
• The factors attributed for higher frequency among females aged 14–19
years may be :
– The start of sexual activity is usually earlier for girls than for boys.
– Girls tend to have sex with older male partners, who have more sexual
experience and are more likely to carry infections.
– Due to the characteristics of the genital tract of young girls, they are
especially vulnerable to infection with STIs.
– Sexually transmissible infections often produce no symptoms or only mild
symptoms in women.
– Services in general may be more accessible to men than women.
– Cultural and economic constraints might also prevent a proportion of
women from attending for treatment.
• After the age of 19, there is slight male preponderance.
– A large number of men might be infected after practicing unsafe
sex with a small number of sex workers.
– Older men may be more sexually active than women of the
same age.
– Men are more likely to change partners than women.
STI Transmission Dynamics
At Population Level

Bridging population
General population

Core
transmitters
 FIVE KEY POINTS ABOUT ALL STDS TODAY

1. STDs affect men and women of all backgrounds

and economic levels.
- They are most prevalent among teenagers and young
adults.
- Nearly two-thirds of all STDs occur in people younger than

25 years of age.
2. The incidence of STDs is rising.
- Because in the last few decades, young people
have become sexually active earlier yet are marrying later.
- In addition, divorce is more common.
- The net result is that sexually active people today are
more likely to have multiple sex partners during their
lives and are potentially at risk for developing STDs.
3. Most of the time, STDs cause no symptoms,
particularly in women.
- When and if symptoms develop, they may be confused with those
of other diseases not transmitted through sexual contact.
- Even when an STD causes no symptoms, however, a person who
is infected may be able to pass the disease on to a sex partner.
-Recommend periodic testing or screening for people who have
more than one sex partner.
4. STDs tend to be more severe and more frequent for
women than for men.
- Because the frequency of asymptomatic infection - many
women do not seek care until serious problems have developed.
- Some STDS can spread to cause PID, which in turn  infertility
& ectopic (tubal) pregnancy.
- May be associated with cervical cancer; HPV
- causes genital warts.
- Other genital cancers.
5. STDs can be passed from a mother to her baby before, during,
or immediately after birth.
- When diagnosed and treated early, many STDs can be

treated effectively.
 THE LINK BETWEEN STI & HIV
• Both share same behavior & mode of transmission.
• STIs facilitate the transmission of HIV.
– HIV acquisition increases by twofold to fivefold in the presence of other
STIs.
A person with open sores in the genital area is much more likely both
to contract and to transmit HIV.
 Chancroid and syphilis are the main bacterial causes of sores.
 Genital herpes also facilitates HIV transmission.
 Chlamydia, gonorrhea and trichomoniasis can also facilitate the
transmission of HIV.
 The link between STI & HIV
The presence of HIV can make people more susceptible
to the acquisition of STIs.
The presence of HIV increases the:
– Severity of STIs
– Atypical presentation
– Recurrence or persistence
– Their resistance to standard treatment
 Clinical presentations of HIV and STI co-infection
 Atypical presentation of Syphilis, rapid progression to neurosyphilis.
 Atypical lesions of chancroid.
 Recurrent or persistent genital ulcers from HSV2.
 Severe genital herpes may require suppression of recurrence with
acyclovir.
 Human papilloma virus with exophytic genital warts.
 Risk of treatment failure with single injection of Benzanthine
Penicillin in primary syphilis.
 Topical anti-fungals are less effective.
 STI- microorganisms
1. Transmitted by sexual route (conventional STI).
2. Transmission described but less defined evidence.
 Organisms transmitted sexually

• Bacteria • Viral
1. N. gonorrhea 1. HIV
2. C. trachomitis 2. HSV
3. T. pallidum 3. HBV
4. H. ducreyi 4. HPV
5. C. granulomatis 5. MCV
6. U. urealyticum • Others
1. T. vaginalis
 STDs-described but less defined for sexual transmission

• Bacteria • Viral
1. M.hominis 1. CMV
2. G. vaginalis 2. HCV
3. HSV type 8
4. EBV
• Others
1. C. albicans
2. S. scabiei
 Approaches to STD-Dx & Rx
Three approaches:
1. Laboratory based (etiologic)
2. Clinical without laboratory support
3. Syndromic approach
 Etiologic Management
• Advantages:
Avoids over treatment
Conforms to traditional clinical training
Satisfies patients who feel not properly attended
Can be extended as screening for the asymptomatics.
• Problems of Etiologic Approach
– Some bacteria are fastidious & difficult to culture
– Lab. results often not reliable.
– Mixed infections often overlooked.
– Miss-treated/untreated infections can lead to complications
and continued transmission.
– Expensive.
 Clinical Management
• Advantages:
Saves time for patients.
Reduces laboratory expenses.
• Disadvantages:
Requires high clinical knowledge
Most STIs cause similar symptoms
Mixed infections are common & failure to treat may lead to
serious complications.
Doesn’t identify asymptomatic STIs.
Atypical presentation - HIV
 Syndromic approach
• Definition :
– Syndromic management is a management approach that uses
clinical algorithms on an STD Syndrome, the constellation of
patient symptoms and clinical signs to determine therapy.
– Algorithms are adapted to local STD prevalence.
– Chooses antimicrobial agents to cover all the possible
pathogens responsible for the syndromes in the specific
geographic area.
 Syndromic Management
History
 In 1991 WHO developed and started advocating the
syndromic approach to address the limitation of
aetiological (lab) & presumptive(clinical) Dx & Mx.
COMPONENTS OF THE SYNDROMIC APPROACH
1. Identification and Rx of the Syndrome
2. Education and counseling on
- Rx compliance
- Risk reduction including condom use
3. Partner notification
4. Provision of condoms
5. VCT for HIV
 Clinical Problem Decision Box

Enlarged and Painful Inguinal Lymph

nodes?

Take History & Examine

Ulcer (s) Use Genital

Present? Yes Ulcer Flow Chart

No

Use inguinal bubo

Flow chart Action Box
 Advantages
• Expedited care
• Cost savings – less technically demanding
• Increased client satisfaction
• Treatment at first visit
 Decreases further transmission
 Decreases complication
 Eliminates need for return visit
• Decrease incidence of HIV (by 42% in Tanzania)
• Uses flow charts in case Mx which
 Standardizes Dx, Rx, referral and reporting
 Improves surveillance
 Improves programme Mx
• High sensitivity
• Gives emphasis to non-medical aspects of STD care.
 Disadvantages
• Inevitable over treatment (multiple antimicrobials for single infection).
• Does not address subclinical and asymptomatic STI.
• High sensitivity is at the cost of specificity.
• Works well with some syndromes (GU,UD) but not as well with others (VD).
• Rx with multiple drug might be expensive.
• The recommended drugs may not be available.
• But, cost effectiveness increases further when
 Applied to high STD prevalence areas
 Long term cost of STD is considered
 Increased HIV transmission and continued STD transmission is
considered.
 Identifying Syndromes
SYNDROME MOST COMMON CAUSE

Vaginal discharge Vaginitis (trichomniasis, candidisis)

Cervicitis (gonorrhea, chlamydia)
Urethral discharge in men Gonorrhea, chlamydia

Genital ulcer Syphilis, chancroid, herpes

Lower abdominal pain Gonorrhea, chlamydia, mixed anaerobes

Scrotal swelling Gonorrhea, chlamydia

Inguinal bubo LGV, Chancroid

Neonatal conjuctivitis Gonorrhea, chlamydia

 Genital Ulcers
a) Syphilis
b) Chancroid
c) Lymphogranuloma venereum (LGV)
d) Granuloma inguinale
e) Genital herpes
f) Behçet‘s Syndrome
– Etiology: Unknown.
– Most likely autoimmune arteriitis with subsequent tissue necrosis and
ulcer formation.
Vulvar and Vaginal Lesions and Ulcers
- Two Different Types -
Four Questions to ask while examining genital ulcers
1. Is it single or multiple?

2. What is the appearance of the lesion?

3. Is it painful or painless?

4. Are the nearby lymph nodes enlarged and/or painful?

 Syphilis
• Organism characteristics & microbiology
– By treponema pallidum
– Is tightly coiled a spirochete
– Can invade intact mucous membrane or area of abraded skin .
• Incidence and epidemiology
– The incidence is rising.
– Only 30% of patients exposed acquire the disease.
– In those infected patients not taking medication 60% do develop immune defense
sufficient to control the infection.
– The remaining(40%) will go to late and tertiary syphilis.
 Clinical diseases
1. EARLY SYPHILIS

A) Primary syphilis
• Painless , solitary and hard
chancre is the whole mark.
• It occurs at the site of inoculation.
• There is regional LAP.
• Incubation period 10-90 days.
Syphilis - Primary Stage

Single ulcer, not painful

Syphilis - Primary Stage

„edematous Vulvitis“
B) Secondary stage of Syphilis
• From the primary chancre, Treponema pallidum disseminates
systemically with the blood vessels in the patient‘s body.( Disseminated
spirochetemia).
• Maculo-papular rash and/or moist papules (condylomata lata) show up
after one to three months on the skin or mucosal membranes.
• The rash may be accompanied by fever and malaise.
• Less frequent: meningitis, hepatitis, nephritis.

• The secondary stage can be even entirely asymptomatic and it is

followed by a latent phase that can last for years before the tertiary stage
of Syphilis occurs.
• Clinical features of secondary syphilis
• Skin lesions-----------------------------75-80%
• Mucous membrane lesions----------30%
• Generalised LAP-----50-60%
• Arthritis, arthralgia, and periostitis
• Hepatitis
• Glomerulonephritis and nephritic syndrome Rare
• Iridocyclitis and choroidoretinitis
• Neurological disease (meningitis and cranial nerve
palsies)
• Alopecia
 Secondary stage of Syphilis

Moist- and painless papules/condylomata lata of secondary syphilis.

Secondary Stage of Syphilis

Maculo-papular rash
 2. Latent syphilis

– Characterized by serologic evidences but no clinical signs &

symptoms.
– Most patients are not infectious.
– Arbitrary division of this stage but has no clinical significance
with regard to treatment
– Early latency (< 4 years from initial infection )
– Late latency (>4 years )
 3. Tertiary/Late Syphilis
• Incidence :
• 30 - 50 % of untreated syphilitic patients.
• 5-30 years after initial infection.
• There are three divisions:
1. Benign disease(gummas) - lesion occur in vital organs.
– Can be life threatening if they compromise the organ.
– Usually solitary lesions showing granulomatous inflammation with
central necrosis.
– Found most often in the skin and skeletal system, mouth, upper
respiratory tract, liver, and stomach.
2. Cardiovascular disease - involvement of the heart and the aorta are
frequent dysfunction may cause serious problem.
3. Neurological diseases - three clinical syndromes of neurological
involvement:
– Asymptomatic disease: no neurological manifestations but abnormal CSF.
– Meningovascular disease: the commonest manifestation is cranial nerve
palsies. (third, sixth, seventh, and eight) and pupillary abnormalities.
– Parenchymatous disease  tabis dorsalis & dementia the commonest
manifestation.
Cardiovascular syphilis—aneurysm of the
ascending aorta and cardiomegaly Gummas on the lower limb
 Congenital Syphilis
• Untreated syphilis during pregnancy has a transmission rate Stillbirth 27 weeks of gestation
approaching 70% - 100%.
• Embryonal infection: leads to abortion.
• Fetal infection:
- one third are born with congenital syphilis.
- one third abort between 12 and 28
weeks or end as stillbirth.
- Intrauterine death in 25%.
- Perinatal mortality in 25-30% if untreated.
• Diagnosis
A. Non treponemal specific test
• RPR (rapid plasma reagin) test,
• Standard VDRL slide test,
• Toludine Red Unheated Serum Test (TRUST)
B. Treponemal specific test
• FTA-ABS; fluorescent treponemal antibody absorbed (used commonly for
adults)
• MHA-TP; microhaemagglutination assay (for neonates)
C. Dark field microscopy
 Treatment of Syphilis
a) Management of the early stage syphilis in adults:
 Benzathine Penicillin G, a single dose of 2.400.000 IU by buttock
injection, 1.200.000 IU for each buttock
or
 Procaine Penicillin G diluted into water, intramuscular injection
1.200.000 IU per day for 10 days.

 If the patient is allergic against Penicillin and is not pregnant.

 Doxycycline 100 mg, orally 2 times a day for 15 days.
 Treatment of Syphilis
b) Management of the late stage syphilis in adults:
 Benzathine Penicillin G, 2.400.000 IU by buttock injection, 1.200.000
IU for each buttock. Give three times day 1,7 and 14.
 Procaine Penicillin G diluted into water, intramuscular injection
1.200.000 IU per day for 15 days.
 Doxycycline 100 mg orally twice a day for 30 days.
 Treatment of Syphilis
c) Management of syphilis in pregnant women:
 Same as not pregnant.
 In case of Penicillin allergy: early stage
Erythromycin 500 mg orally 4 times a day for 15 days
 Late stage syphilis:
Erythromycin 500 mg orally 4 times a day for 30 days
 Chancroid
Epidemiology:
• Spread through direct sexual contact male to female.
• Incidence ranges from 3:1 to 24:1.
Pathogenesis:
• Gram-negative Hemophilus ducreyi.
Diagnosis:
• Painful, soft ulcer, demarkated with necrotic and ragged basis.
• kissing ulcers do occur.
• Unilateral LAP that may suppurate.
Incubation time: 1-2weeks.
 Chancroid

Woman with chancroid lesions ot the perineal area. Appearance

of lesion: multiple, ragged borders, painful, dirty basis of the
ulcers. One lymph node swollen in the left iliac fossa.
 Chancroid

1 an open fistulating singular lymph node/bubo which is painful.

2 shows the primary chancroid lesion at the penis with a painful soft ulcer.
 Chancroid
• Treatment:
Ceftriazone 250 mg i.m. single shot or
Azithromycin 1 g orally single application
Alternatively:
Erythromycin 4 x 500 mg 7 days
Ciprofloxazin 2 x 500 mg 3 days
Co-Trimoxazole (Trimethoprim) 80 mg and Sulphamethoxazole 400 mg 8 tablets/day
for 2 days.
 Lymphogranuloma venereum
• Etiology:
Chlamydia trachomatis serotypes L1 - L3, intracellular
multiplication.
• Incubation time: 2 - 5 days.
 Lymphogranuloma venereum
• Symptoms:
1. Transient painless primary genital or anorectal ulcer that disappears mostly
undiagnosed.
2. Confluent inguinal lymph nodes 2-3 weeks later.
3. Eventually multiple fistulae (different from chancroid).
4. Intrapelvic lymph node swelling may cause symptoms similar to PID.
5. Untreated extensive lymphatic obstruction, edema, elephantiasis of genitals.
 Lymphogranuloma venereum

Woman and man in their 30s with lymph edema of the scrotum and penis and the labia.
 Lymphogranuloma venereum
• Diagnosis:
Direct immunofluorescence of Chlamydia with antibodies against serotypes
L1 - L3 (specific).
Complement fixation tests are positive in 95 %
• Treatment:
Doxycycline 200 mg per day for 3wks.
Surgical measures for disfigured conditions.
 Granuloma inguinale
• Etiology:
Infection caused by gram-negative bacillus: Donovania granulomatis
• Incubation time: 8-80 days.
• Clinical course:
Soft, red, painless granuloma that can be covered by a thin, gray
membrane.
Lymph nodes moderately enlarged, painless, no abscess formation.

• Treatment:
Doxycycline 200 mg/day for 3 weeks
 Granuloma inguinale

Typical granulomatous ulceration of granuloma inguinale in a 32-year-old woman. A soft,

red, painless granuloma that can be covered by a thin gray membrane. The lymph
nodes are moderately enlarged and painless.
 Granuloma inguinale

Verrucous type (wart-like) of granuloma inguinale.

 Genital Herpes
Etiology:
• Caused by DNA viruses, herpes simplex viruses: type 1 or 2
• HSV 1 „oral“ type.
• HSV 2 „genital type“ as it occurs primarily there.
• Primary infection occurs in child hood.
• Latent infection resides in the sensory ganglion of trigeminal,
sacral & vagal nerves.
• Transmission = only by direct contact.
Genital Herpes:Pathogenesis
 Genital Herpes
Symptoms – Clinical Course
burning sensation

clear blisters

becoming cloudy (leukocytes)

red borders (!)

often confluent

flat epidermal ulcer

healing without scar

Signs or symptoms Primary Recurrent
Number of lesions ClinicalMultiple
differences between primary Scattered 1 to 3
and recurrent vulvovaginitis due to herpes simplex
Location of lesions virus
Tend to involve type
both 2
labia and vagina; Limited involvement of
cervix may be concomitantly involved vulva, vagina, or cervix
Mucosal involvement

Size of lesions Variable; tend to be larger than those Tend to be smaller

observed in recurrent disease

Inguinal adenopathy Present Usually absent

Viremia Occurs Absent

Systemic symptoms Present Absent

Local symptoms (dysuria, Present Present

itching, dyspareunia)

Duration 2-3 weeks 7-10 days

 Primary Genital Herpes

Partial immunity – scattered blisters and ulcers.

 Recurrent Secondary Genital Herpes

Recurring Recurring genital

genital herpes with large
herpes with efflorescence
minimal
ulcers
 Genital Herpes
• Laboratory:
1. The herpes virus is easy to grow in cell cultures.Positive culture after 24 hrs.
2. Confirmation of diagnosis and identification of HSV 1 or 2 is carried out by
type-specific immuno-sera in a fluorescence test.
3. Direct antigen test
4. Amplification with PCR.
5. Serology:
 Treatment
• To modify course of symptoms.
• 1st episode – acyclovir 200mg 5x per day /7 days (doesn’t
appear to influence natural Hx of recurrent disease)
• Famciclovir (250 mg three times daily)
• Valaciclovir (500 mg twice daily
• Recurrence – acyclovir 200mg tid continuously for frequently
recurring outbreaks(>6 X per year)
Recommended treatment for non vesicular genital ulcer
Benzathine penicillin 2.4 million units IM stat
Or (in penicillin allergy)
Doxycycline 100 mg bid for 14 days
Plus
Ciprofloxacin 500mg bid orally for 3 days.
Or
Erythromycin tablets 500 mg qid for 7 days
VAGINAL DISCHARGE
 Vaginal Discharge (VD)
• Most difficult syndrome to diagnose.
• Either vaginitis or cervicitis.
• Cervicitis - N.gonorrhea
- C.trachomatis
• Vaginitis - Trichomonas vaginalis
- Candida albicans
- Bacterial vaginosis
• Effective management of cervicitis is more important from patient point of
view b/c of serious sequale.
Questions to ask women who complain of vaginal discharge

Discharge Associated symptoms

● Onset ● Itching
● Duration ● Soreness
● Amount ● Dysuria
● Colour ● Intermenstrual/postcoital bleeding
● Blood staining ● Lower abdominal pain
● Consistency ● Pelvic pain
● Odour ● Dyspareunia superficial and deep
● Previous episodes
 Risk factors for presence of STIs

● Age under 25 years

● Symptoms developed after recent change of sexual
partner or multiple contacts
● Partner’s risk behavior
● Patient is single
● Partner has urethral discharge
● Having ever traded for sex
 Bacterial vaginosis (Gardnerella)
• Cause : anaerobes (G. Vaginalis , M. hominis, provetella
sps)..etc.
• It has been postulated that repeated alkalinization of the
vagina, which occurs with frequent sexual intercourse or use
of douches plays a role.
• Clinical finding: No fever, no lymph nodes, no inflammation, but has
fishy odor discharge, and KOH positive.

Typical whitish, creamy

discharge of bacterial
vaginosis.
Bacterial vaginosis (Gardnerella)
Amsel’s criteria for DX
1. Homogenous grayish-white discharge
2. Vaginal PH > 4.5
3. Positive whiff-amine test
4. Clue cells on saline wet mount
3 of 4 is diagnostic!

Vagina and cervix in severe

bacterial vaginosis.
 Bacterial vaginosis (Gardnerella)
• Treatment:

Metronidazole 500mg po twice daily for 7 days.

Metronidazole 2gm po stat.

Metronidazole gel 0.75% bid for 5 days.

Clindamycin 300mg po bid for 7 days.

Clindamycin cream 2%.

Vaginal wet mount with 0.1 % methylene blue stain x 400:

No partner treatment is needed!! Clue cells as leading sign for Gardnerella vaginosis,
superficial cells, no or few leukocytes only.
 Complication of B.vaginosis
• Increased risk of PID.
• Post op cuff infection after hysterectomy
• In pregnancy: Increased risk for PROM, preterm labor,
chorioamnionitis, and endometeritis.
 Vulvovaginal Candidasis
Causes:
C. Albicans, C. Glabrata, C.tropicalis

Predisposing factor:
DM, pregnancy, immunosuppression, antiobiotic use
An estimated 75% of women experience at least one episode of vulvovaginal

candidiasis (VVC) during their lifetimes.

Clinical faeture:
Vulva with signs of inflammation, vaginal discharge is thick, white with white
crumbs of epithelial cells on the vaginal surface (cottage cheese).
Candida Vulvitis and Vaginitis

Candida vaginitis with cottage cheese

like discharge and red vaginal walls.
Uncomplicated
• Sporadic or infrequent in occurrence
• Mild to moderate symptoms
• Likely to be Candida albicans
• Immunocompetent women
Complicated
• Recurrent symptoms
• Severe symptoms
• Non-albicans Candida
• Immunocompromised, e.g., diabetic women
 Candida Vulvitis and Vaginitis
• Normal PH
• Microscopy (1:400):
KOH
Leukocytes ++
Lactobacilli +++
Few yeast cells, pseudo- Candida vaginitis with sprouting cells and
hyphae inside the cell pseudomycelia. 0.1 % methylene blue.
o Fungal culture is recommended to confirm the diagnosis.
Treatment:
Clotrimazole 200 mg vaginal tablets 3 nights and cream outside of the vulva,
alternatively Miconazole
Oral anti fungal agent: fluconazole 150 mg po stat.
 Trichomonas vaginitis
• Cause: T.vaginalis is flagellated parasite.
• Diagnosis
Often asymptomatic
Vaginal itching, purulent and profuse, gray to yellowish malodorous
discharge.
It often accompanies BV, which can be diagnosed in as many as 60%
of patients with trichomonas vaginitis.
 Trichomonas Vaginitis

• Speculum: Inflammation of vagina and cervix with “red spots“ (strawberry

cervix) and frothy discharge.

Left:
Trichomonas vaginitis with red
walls and white discharge.

Right:
Trichomonas vaginitis with
granular or macular changes here
on the cervical surface.
 Trichomonas Vaginitis
Diagnostical Tools:
1. Vaginal wet mount with saline or direct
preparation  95 % sensitivity.
2. Pap smear= 60 %
3. Gram  30 %
Treatement
Metronidazole 2 gm po stat or 500 po bid for 7day
Tinidazole 2 g orally single dose
(Treat sexual partner)!
 Genital Chlamydial Infections
Predominant Serotype Syndrome .
A, B, Ba, C Trachoma
D through K Nongonococcal urethritis, Epididymitis, Reiter's
syndrome,mucopurulene Proctitis, Mucopurulent
cervicitis, Urethral syndrome, Endometritis, Salpingitis,
Perihepatitis, Inclusion conjunctivitis and Neonatal
pneumonia
L1, L2, L3 Lymphogranuloma venereum
 Genital Chlamydial Infections
Epidemiology:
• Most prevalent sexually transmitted bacterium.
• Complications of pelvic inflammatory disease:
– Ectopic pregnancies
– Tubal infertility
 Genital Chlamydial Infections
Pathogenesis:
• C.T. Is an obligate intracellular bacterium.
• Elementary bodies infect the glandular epithelium of cervix,
fallopian tubes, peritoneum and urethra.
• Elementary bodies transform into reticulate bodies which are
sensitive to antibiotic treatment.
• 48 hours later reticulate bodies retransform into elementary body
and stay in inclusions for days and weeks.
• The long growth cycle explains why prolonged courses of
treatment are necessary.
 Genital Chlamydial Infections

Anatomy of the internal genitals: Ascending infections starting of from a chlamydial or

gonorrhoic cervizitis.
 Genital Chlamydia trachomatis Infection
Symptoms in men:

• Urethral discharge.
• Epididymitis is rare.
• Conjunctivitis by direct transmission via hand from genital to eye
• Arthritis - usually monoarthritis.
 Chlamydia trachomatis Infections
Symptoms in women:
• Purulent cervicitis, urethritis.
• Ascending infections with
endometritis/salpingitis(PID)
• Perihepatitis in 10 %.
• Conjunctivitis/arthritis are rare in women.
• Asymptomatic chlamydial PID is common (70 % of tubal
infertility cases never experienced clinical PID).
 Genital Chlamydial Infections

Genital infection with chlamydia trachomatis

acute PID subacute, chronic PID

10 % 90 %

with symptoms without symptoms

40-60 % 40-60 %

up to 50 %, of the patients with tubal infertility probably caused

by a chlamydia infection, have no history of pelvic inflammatory
disease!
Diagnosis of Chlamydia is by:
• Fluorescence test, PCR, LCR (source of sample:
urine,cervix)
• NAAT
 Chlamydia trachomatis-Treatment
• Men and women are treated for 10-14 days with:
• Doxycyclin 200 mg orally twice daily (cheap)
• Erythromycin 500-750 mg qid(pregnancy)
or
• Roxythromycin 300 mg orally once daily (breastfeeding)
• Clarithromycin 250 mg orally twice daily
• Azithromycin 1 g orally single dose
• Ciprofloxacin 500 mg orally twice daily

• Note: no drug resistancy known for these drugs!

 …VD
Treatment
Cervicitis (Gonorrhea & Chlamydia): if risk assessment is positive
Recommended regimen
Ciprofloxacin 500mg po single dose or
Ceftriaxone 250mg im single dose or
Cefixime 400mg po single dose or
Spectinomycin 2gm im single dose
Plus
Doxycycline 100mg po bid/7 days or
TTC 500mg po qid / 7 days or
Erythromycin (pregnant)
 …VD
Vaginitis: if risk assessment is negative
Recommended regimen
metronidazole 2gm PO single dose or
metronidazole 500mg PO bid/7 days
plus
Nystatin 100,000 IU intra vaginally once/14 d, or
Clotrimazole 200mg once daily/3 days, or
Clotrimazole 500mg single dose
URETHRAL DISCHARGE
 Clinical Presentations
• Burning sensation on urination & urethral discharge are
common symptoms of urethritis in men.

• N.gonorrhea & C.trachomatis are common causes.

• T.vaginalis is found to be the second most common cause

exceeding C.trachomatis in Ethiopia.
 Gonorrhoea

Male gonococcal
urethritis
 Clinical Signs With Urethritis
Gonorrhoea Chlamydia
Incubation: 6days 2-3 weeks

Dysuria: 70-80% 40%

Discharge: 90% <80%

a lot a little
 Complications Caused By NG and CT
• N. gonnorhea or C.
• N. Gonorrhea trachomitis
• Disseminated gonococcal infection (1-2%)
1. Epididimitis
• C. trachomitis 2. Conjunctivitis
• 3. Urethral stricture
Reiter's syndrome
4. PID
5. Infertility
6. Ectopic pregnancy
7. Enhanced transmission of HIV
( five fold)
 Urethral discharge
complains of urethral discharge or dysuria

Take history & Examine [Milk urethra if necessary]

• Educate on RR
No Other STIs?
Discharge present? No • Offer CTP
• Promote & provide
Yes condoms
Yes

Treat for GC & CT Use appropriate flow chart

•Educate on risk reduction

•Offer HCT
•Promote & provide condoms
• Partner management
• Advise to return in 7 days if symptoms
persist
 Recommended Treatment For Urethral Discharge and
Burning on Urination

Ciprofloxacin 500 tablet mg po stat

Or
Spectinomycin 2 grams IM stat
PLUS
Doxycycline 100 mg po bid for 7 days
Or
Tetracycline 500 mg qid for 7 days
Or
Erythromycin 500mg qid for 7 days if the patient has
contraindications for tetracyclines (eg: children, pregnancy)
 Inguinal Bubo
• Inguinal adenopathy
• LGV (L1,L2,L3),
• Chancroid
• G I (donovanosis) is:
– Klebsiella granulomatis, formerly known as
Calymmatobacterium granulomatis.
 Inguinal Bubo, cont’d
• Rare systemic symptoms except LGV
• Common predisposing factor for the spread of
HIV.
• Complications:
– Abscess formation
– PID
– Lymphatic obstruction
– Stenosis
– Infertility
 …Inguinal Bubo

• Recommended regimen (LGV)

Doxycycline 100mg po bid/14 days or
TTC 500mg po qid/14 days
• Alternative regimen
Erythromycin 500mg po qid/14 days or
Sulfadiazine 1gm qid/ 14 days
• Aspirate fluctuant lymph nodes through normal skin
• Incision and drainage or excision of nodes is contraindicated .
Neonatal Conjunctivitis
 Neonatal Conjunctivitis
• Defined as purulent conjuctivitis
occurring in a baby less than one
month of age.
• Sight-threatening condition.
• The most important causes are
gonorrhoea and chlamydia.
• If caused by gonorrhoea, blindness
often follows.
• Can be prevented.

Gonococcal conjunctivitis of the newborn

• As soon as the baby is born, carefully wipe both eyes with dry,
clean cotton wool; then apply 1% silver nitrate solution or 1%
tetracycline eye ointment into the infant’s eyes.
• Other options: 0.5% Erythromycin ointment or 2.5% povidone
iodine solution.
 Neonate with eye discharge

Take history and Examine

•Reassure mother
No •Advise to return if
Bilateral or unilateral
swollen eyelids with necessary
purulent discharge

Yes
Yes
Rx child & mother for GC & Chlamydia
•For mother only:
• Educate on RR Improved
• Provide condoms
• Offer HIV testing No
Refer
• Advise to return in 3days
SCROTAL SWELLING
complains of scrotal swelling/pain

Take history and examine

•Reassure patient/educate
•Promote and provide condoms
No
Swelling/pain confirmed? •Offer HIV testing
•Analgesics
Yes
Testis rotated or No Treat GC & CT
elevated, or •Educate on RR
history of trauma?
•Promote & provide condoms
Yes •Partner management
•Offer HIV testing
Refer immediately
•Review in 7 days or earlier if
for surgical opinion necessary, if worse, refer
 HUMAN PAPILLOMA VIRUS (HPV)
• The genital virus in this double-stranded DNA family.
• HPV is the most common sexually transmitted viral infection.
• 120 different subtypes
• Low-risk subtypes 6 and 11: Condylomata acuminata.
• High-risk subtype 16, 18: associated with premalignant and malignant
lesions of cervix, vulva and vagina.
• Other high-risk HPV: 31, 33, 35, 39, 45, 56, 58, 65.
• All others belong to low-risk group of HPV.
• Transmission by sexual intercourse (exceptions!)
 Diagnosis of HPV Infection
• Clinical: Flat condyloma or condyloma acuminata.
• Pap-smear: with koilocyte.
• Biopsy: Papillomatous elongation, parakeratosis with
cytoplasmatic vacuoles (koilocytes).
 Condylomata acuminata
Soft, pink, partly pedunculated
growth, reminding
of cauliflower.
 Treatment of HPV Infection
• Podophyllotoxin locally
• Application of Trichloroacetic acid
• Cryotherapy with liquid nitrogen
• Laser vaporization
• Electric cauterization
• Imiquimod 5% cream
• Vitamin C locally can be helpful in the treatment of chronic genital
warts.
PELVIC INFLAMMATORY DISEASE
 Definition
• PID refers to acute infection of the upper genital tract
(above the internal cervical os) in women.
• A more descriptive term = UGTI
– Severity & Extent of disease
• This is differentiated from (LGTI) because response to treatment
appears to be different in these two entities.
• Community-acquired Vs Iatrogenic.
• 85% are spontaneous & 15% follow procedure.
Risk Factors
1. History of STI
2. Age
– Adolescent 1:8 Vs 1:80 for sexually active >24yrs, b/c columnar epithelium.
3. Contraceptives
– IUDs = threefold to fivefold, but only in the 1st 3weeks of insertion
– Barriers = ↓ 60%
– OCP = ↓ risk, good at prevention of fertility, 2mechanisms.
– Previous tubal ligation = 1/450
4. Instrumentation ex. 1/200 induced abortion
5. Previous acute PID = 25 %.
6. Multiple sexual partners
 Etiology
• Neisseria gonorrhoeae and Chlamydia trachomatis serovars D-K.
• Common cause of PID = 1/3rd each.
• However, most => polymicrobial infection caused by ascending
infection.
• C. trachomatis etiologic role is very different from N. gonorrhea
 N. Gonnorrhea C.Trachomatis
• Gram-negative IC diplococcus • Is a slow-growing intracellular
• Rapid cycle 20 to 40 minutes organism.
to divide. • Growth cycle 48 to 72 hours.
• Rapid and intense • Does not induce a rapid or
inflammatory response. violent inflammatory
• Less complication response.
• Early Rx • Destruction by rupture.
• Delayed Rx
 Mode of infection
 Ascending : most common route
E.g.. Gonococcus
 Lymphatic & pelvic veins
E.g. Postabortal & puerperium
 Blood steam . E.g. Tuberculosis
 From an adjacent inflammatory structure like appendix
Classification:
• Post STI
• Postmenstrual
• Post abortal
• Post Partum
• Post Instrumentation, IUD – Related
CRITERIA FOR THE DIAGNOSIS:
Major Criteria:
• Cervical motion tenderness or
• Lower abdominal / uterine tenderness or
• Adnexal tenderness
Other minor criteria:
• Oral temperature >101°F (>38.3°C)
• Abnormal cervical or vaginal mucopurulent discharge
• Presence of abundant numbers of WBC on saline microscopy of
vaginal secretions
• Elevated ESR
• Elevated C-reactive protein
• Laboratory documentation of cervical infection with N. gonorrhoeae
or C. trachomatis
 DDX:
• Acute appendicitis
• Endometriosis
• Torsion or rupture of an adnexal mass
• Ectopic pregnancy and
• LGTI
• UTI, etc…
 Investigation
• Recommended lab Ix
– Pregnancy test
– Microscopic exam of vaginal discharge in saline
– Complete blood counts & ESR
– Nucleic acid amplification tests for chlamydia and gonococcus
– Urinalysis
– Serology test for syphilis
– C-reactive protein (optional)
– Endometrial biopsy
• Imaging studies
– Ultrasound
– MRI
– Laparoscopy
 Fitz-Hugh-Curtis syndrome:
• Perihepatic inflammation and adhesions.
• Develops in 1% to 10% of acute PID.
• RUQ- pain & tenderness, pleuritic pain.
• Usually preceded by the clinical onset of acute PID.
• DDX = acute cholecystitis or pneumonia.
• Develop from vascular or transperitoneal dissemination of either N.
gonorrhoeae or C. trachomatis to produce the perihepatic inflammation.
• Other organisms may be involved, but limited data exist on their causality.
 Grading of severity
Clinical system:
Grade I: Disease limited to the adnexae.
Grade II: PID with an inflammatory mass.
Grade III: Ruptured tubo-ovarian abscess and pelvic
peritonitis.
Laparoscopic system:
Mild: Erythema and edema of the adnexae.
Moderate: Purulent exudates from fallopian tubes.
Severe: Pyosalpinx, inflammatory complex, TOA.
• COMPLICATION:
Early
• Sepsis → MOF → Death( ruptured TOA = 10 %)
• Surgical morbidity ( for TOA)
• Arthritis /myocarditis
Late
• Infertility = 20%
• Ectopic Pregnancy = 6-10X; higher= 12 %
• Chronic pelvic Pain = 20%
• Chronic PID
• Psychological consequences
• Dyspareunia
Treatment
• Based on the consensus that PID is polymicrobial in cause.
• Empirical antibiotic protocols should cover a wide range of
bacteria.
• Oral therapy can be considered for women with mild to
moderately severe acute PID.
CDC-Recommended Treatment Regimens for Oral Therapy
• Regimen A
- Levofloxacin 500 mg orally once daily for 14 days
OR
- Ofloxacin 400 mg orally once daily for 14 days
WITH OR WITHOUT
- Metronidazole 500 mg orally twice a day for 14 days

• Regimen B
- Ceftriaxone 250 mg IM in a single dose
PLUS
- Doxycycline 100 mg orally twice a day for 14 days
WITH OR WITHOUT
- Metronidazole 500 mg orally twice a day for 14 days

• PATIENT MONITORING — patient should be seen within 48 to 72 hours.

 Criteria for Hospitalization
• Surgical emergencies (such as appendicitis) cannot be excluded.
• Pregnant.
• No response clinically to oral therapy
• Unable to follow or tolerate oral regimen
• Has severe illness, nausea and vomiting, or high fever
• The patient has a tubo-ovarian abscess
• Previously failed outpatient therapy
• ?Adolescents
• ?HIV / AIDS
 CDC-Recommended Parenteral Treatment
Regimen A
- Cefotetan 2 g IV every 12 hours
OR
- Cefoxitin 2 g IV every 6 hours
PLUS
- Doxycycline 100 mg orally or IV every 12 hours
Regimen B
- Clindamycin 900 mg IV every 8 hours
PLUS
- Gentamicin
• D/C IV 24 hours after a patient improves clinically.
• Continue oral therapy
– Doxycycline 100 mg orally twice a day or
– Clindamycin 450 mg orally four times a day
• Complete a total of 14 days of therapy
• Other alternative
Augumentin + doxycycline
• Hospitalized patients can be considered for
discharge when:
their fever has lysed for more than 24 hours,
the white blood cell count has become normal,
rebound tenderness is absent, and
repeat examination shows marked amelioration of pelvic
organ tenderness.
 Surgical managemnet
• Colpotomy
• Percutaneous drainage: transgluteal drainage approach.
• Laparascopy
• Laparatomy
 Indication for surgery
• TOA not responding to antibiotics
• Ruptured TOA
• Generalized peritonitis
• Unsettled diagnosis
 Patient counseling
Should include:
• Education on route of transmission
• Importance of partner treatment: if they had sexual
contact during the preceding 60 days.
• Future safe sex practices
• Offering HIV test: All patients with any diagnosis of an
STD.
 Reading ass’t
• PELVIC ABSCESS
• CHRONIC/RECURRENT PID
• PELVIC TUBERCULOSIS
THANK YOU
!