Sexually Transmitted Infection

DAP HNE J ARI TO - ARI NTO C, MD

LE V E L 1 FAMI LY AND CO MMUNI TY ME DI CI NE RE S I DE NT
 OUTLINE

I. Definition of STI and STD

II. Ectoparasitic Infections
III. Vaginitis
IV. Mucopurulent cervicitis
V. Genital ulcers
 STI versus STD
Sexually Transmitted Infection(STI)
- refers to a pathogen that causes infection
through sexual contact

Sexually Transmitted
Disease(STD)
- refers to a recognizable disease state that
has developed from an infection.

Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and
Mortality Weekly Report,
Ectoparasitic infection
Case 1
A case of M.M. 19 yo‚ female‚ a college student who came
in complaining of intolerable itching in her perineal area for
7 days. Her symptom started after she had an unprotected
sexual intercourse with a schoolmate last Valentines Day. On
physical examination everything was unremarkable except
for the findings you had in her perineal area where you
noticed excoriation and nits on her pubic hair. What is your
diagnosis?
II. Ectoparasitic infections
A. Pediculosis pubis
- infestation by the crab louse/ pubic
louse, Phthirus pubis.
- most contagious of all STIs(90 %
infected with single exposure)
- transmitted by close contact
- confined to the hairy areas of the
vulva.
- incubation period: approximately
30 days.
Source: Guidelines for Clinicians on the Management of Vaginitides‚ 2021
II. Ectoparasitic infections
A. Pediculosis Pubis

Predominant symptom→ constant

pubic pruritus (allergic sensitization)

Definitive diagnosis: scratch the skin

papule with a needle and place the crust
under a drop of mineral oil.

Source: Guidelines for Clinicians on the Management of Vaginitides‚ 2021

 II. Ectoparasitic infections
A. Pediculosis Pubis

Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly
Report,
 II. Ectoparasitic infections
A. Pediculosis Pubis
Management Considerations:
- The treatment regimen should not be applied to
the eyes.
- Bedding and clothing should be decontaminated
or removed from body contact for at least 72
hours.
-Follow up after 1 week if symptoms persist.
-Sex partners within the previous month should
be treated.

Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly
Report,
 II. Ectoparasitic infections
B. Scabies

- Caused by Sarcoptes scabiei

- Transmitted by close and prolonged
contact
- Widespread over the body
- adult female itch mite digs a burrow just
beneath the skin→ lays eggs(1 month).

Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly
Report,
 II. Ectoparasitic infections
B. Scabies

- Clinical symptom:
severe but
intermittent itching.
- Pathognomonic
sign: burrow in the
skin

Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly
Report,
 II. Ectoparasitic infections
B. Scabies

Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly
Report,
 II. Ectoparasitic infections
B. Scabies
Management Considerations:

- Combination treatment is needed for patients who have the crusted

scabies
-Retreatment 2 weeks after the initial treatment regimen can be considered
for those persons who are still symptomatic or when live mites are
observed
--Sex partners within the previous month should be examined.

Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly
Report,
II. Ectoparasitic infections
Case 2
A case of Maria Makiling‚ 30 yo‚ single and has been constantly seeing a guy for 3
months. She had an unprotected sex with her new found friend. She recently found out
that she got pregnant. At the same time she noticed erythematous papular rash with
linear burrows in her buttocks and vulva which is very itchy especially at night time. She
consulted the clinic. What would be the best management for her?
A. Apply Lindane 1% then wash off after 8 hours
B. Permethrin 1 % cream and wash off for 10 minutes
C. Ivermectin 200 µg/kg of body weight PO then repeat after 14 days
D. Break up with her partner
III. Vaginitis
Case 3
Martina‚ a 25 year old‚ single‚ just broke up with
his boyfriend to be with her American chatmate.
When your reviewed her sexual history‚ she
confessed that she had 5 sexual partners
including her recent exboyfriend. She is worried
because she noticed a whitish discharge and a
fishy odor smell coming from her vagina. She
sought consult at your clinic so that she will be
treated before her American chatmate arrives
next month. What is your most likely diagnosis?
 III. Vaginitis
A. Bacterial Vaginosis
• most prevalent cause of symptomatic vaginitis
• shift from lactobacilli-dominant to mixed
flora(genital mycoplasmas, G. vaginalis, and
anaerobes, such as peptostreptococci, and
Prevotella and Mobiluncus spp)
• Risk factors: new or multiple sexual partners,
women who have sex with women, douching as
least monthly or within the prior 7 days, and social
stressors (e.g., homelessness, threats to personal
safety, insufficient financial resources)
Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly
Report,
 III. Vaginitis
A. Bacterial Vaginosis
Diagnosis:
Clinical(AMSEL CRITERIA)
• Homogeneous, thin discharge (milklike consistency)
that smoothly coats the vaginal walls
• Clue cells (e.g., vaginal epithelial cells studded with
adherent bacteria) on microscopic examination
• pH of vaginal fluid >4.5
• A fishy odor of vaginal discharge before or after
addition of 10% KOH (i.e., the whiff test)

Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly
Report,
 III. Vaginitis
A. Bacterial Vaginosis
Diagnosis:
• Gram staining: Gold standard
• NUGENT Scoring
System(predominant bacterial
morphotype)
• HAY ISON Criteria
• Bacterial culture: no role in the
evaluation

Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly
Report,
 III. Vaginitis
A. Bacterial Vaginosis

Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly
Report,
 III. Vaginitis
A. Bacterial Vaginosis

Management Considerations:
- Recurrent BVs are treated with the same regimen but
suppressive therapy for persistent recurrence is under
study
- Routine treatment of sex partners is not recommended.
- Pregnant women with BV is safe to undergo treatment
- Women with HIV will follow the regular treatment regimen
Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly
Report,
 III. Vaginitis
Case 4

Candice‚ 39 yo‚ married came in with complains

of perineal pruritus and odorless whitish
discharge. She is a known diabetic for 3 years.
Her sibling and mother are also known diabetic.
On examination of the perineal area you noted
excoriation and erythema in some areas. On
speculum examination you observed a cottage
cheese discharge attached to the vaginal walls.
You suspected Candidiasis. What type of
Candidiasis does Candice most likely have?

Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly
Report,
 III. Vaginitis
B. Candidiasis
Signs & Symptoms:
- Pruritus (predominant symptom)
- Vaginal discharge (white or whitish gray, highly viscous, granular or floccular, with no
odor)
-Vulvar signs: erythema, edema, and excoriation.
Speculum examination: a cottage cheese–type discharge is often visualized

Diagnosis:
1. wet smear(vaginal secretion+10% to 20% potassium hydroxide)
→ filamentous forms, mycelia, or pseudohyphae
2. culture with Nickerson or Sabouraud medium
Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly
Report,
TOPICAL ANTIFUNGAL AGENTS
x1-3 DAYS
TOPICAL AZOLES x 7 to 14 days
OR
ORAL THERAPY + 2nd DOSE OF
SINGLE ORAL DOSE OF FLUCONAZOLE
FLUCONAZOLE
 III. Vaginitis
B. Candidiasis

Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly
Report,
 III. Vaginitis
B. Candidiasis

Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly
Report,
 III. Vaginitis
B. Candidiasis

• Recurrent VVC: ≥ 3 episodes of symptomatic VVC in <1 year:

7–14 days of topical therapy or oral dose of fluconazole every third day
for a total of 3 doses plus maintenance antifungal regimen weekly for 6
months
• Severe VVC: 7–14 days of topical azole or 150 mg of fluconazole in
two sequential oral doses
• Sex partners are not treated unless complains of balanitis
• Pregnant women: Only topical azole therapies for 7 days
Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly
Report,
III. Vaginitis
Case 5
Mark‚ an 18 year old college student came
in for consult with his girlfriend. Mark had a
sexual intercourse with a stranger 1 week
ago. He noticed a malodorous yellow green
penile discharge and experienced
discomfort on urination. He is suspecting
the stranger whom he had a sexual
intercourse with infected him with an STI.
What is your most likely diagnosis?
 III. Vaginitis
C. Trichomoniasis
• caused by anaerobic flagellated protozoon, T. vaginalis
• Highly contagious: following a single sexual contact, at least 2/3 of
male & female sexual partners become infected
• Incubation period: 4 to 28 days
• Symptom: profuse vaginal discharge(feel “wet”), abnormal vaginal
odor, vulvar pruritus, dysuria; urethritis, epididymitis, or
prostatitis

Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly
Report,
 III. Vaginitis
C. Trichomoniasis

Diagnostics:
Nucleic acid amplification tests (NAATs): 3-5x
more sensitive than wet mount

Strawberry appearance

Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly
Report,
 III. Vaginitis
C. Trichomoniasis
Management Considerations:
• Treatment failure in a woman ->reexposed to an untreated partner,
a repeat course of the same regimen
If no reexposure-> Metronidazole or tinidazole 2 g OD for 7 days
• Treatment failure in a man -> reexposed to an untreated partner,
retreat with a single 2-g dose of metronidazole.
If no reexposure-> Metronidazole 500 mg 2 times/ day for 7 day
• For women with HIV-> treat with Metronidazole 500 mg BID for 7
days
• Routine treatment of sex partner is needed
Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly
Report,
 III. Vaginitis

Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly
Report,
IV. Mucopurulent Cervicitis
A. Gonorrhea
- Caused by N. gonorrheae
- 2nd most common bacterial STI
- Incubation period: 3-5 days
- Asymptomatic(80 %) but may present with:
* vaginal discharge, urethral discharge,
dysuria, abnormal uterine bleeding, pelvic
discomfort

Risk of transmission from a SINGLE SEXUAL

ENCOUNTER
Male to Female: 80-90 %
Female to Male: 20-25 %
IV. Mucopurulent Cervicitis
A. Gonorrhea
Diagnostics:
Clinical Manifestation of DGI
• Nucleic acid amplification testing (NAAT)
Early Stage Late Stage
of the urine or vaginal secretions-> most Migratory Arthritis Arthritis
sensitive and specific Tenosynovitis Perihepatitis
Dermatitis Endocarditis
* Culture(Thayer Martin)→ rectal, Pericarditis
oropharyngeal and conjunctival Osteomyelitis
Meningitis
specimen

Most Common Systemic Complication:

Disseminated Gonococcal Infection(DGI)
 IV. Mucopurulent Cervicitis
A. Gonorrhea

Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly
Report,
 IV. Mucopurulent Cervicitis
A. Gonorrhea

Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly
Report,
 IV. Mucopurulent Cervicitis
A. Gonorrhea
Management Considerations for Uncomplicated Gonorrhea and DGI
• Recent sex partners <60 days preceding onset of symptoms or
gonorrhea diagnosis should be referred for evaluation, testing, and
presumptive treatment
• Treating all pregnant women with N. gonorrhoeae infection
during pregnancy

Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly
Report,
 IV. Mucopurulent Cervicitis
A. Gonorrhea
Gonoccocal Infection among Neonates
• most severe manifestations are ophthalmia
neonatorum & sepsis
• Recommended Regimen:
Erythromycin 0.5% ophthalmic ointment in each
eye SD
Alternative: Ceftriaxone 25–50 mg/kg body weight
IV or IM, not to exceed 250 mg in a single dose

Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly
Report,
 IV. Mucopurulent Cervicitis

Case 6
Norhea Go a 23 year old housewife came in to your clinic
complaining of vaginal discharge and discomfort on
urination. She is monogamous and her last sexual activity
with her husband was 5 days ago when her husband who is a
seafarer just arrived. She is suspecting that her husband
infected her with an STI. What is your approach to managing
Rhea?
Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly
Report,
 IV. Mucopurulent Cervicitis
B. Chlamydia
❑ Most common STD
❑ Risk factor:
✓ Previous Infection
✓ Recent Change of Partner or > 1 Partner
✓ Failure to use Barrier Contraceptives
✓ History of other STI
❑ Diagnosis:
✓ (+)yellow / green mucus on a swab(swab test)
✓ > 10 PMN leukocytes per oil immersion field of gram
stain of endocervix
✓ Friability, erythema, or edema w/n a zone of cervical
ectopy
Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly
Report,
 IV. Cervicitis
B. Chlamydia
Diagnostics:
- Nucliec Acid Amplification Test(NAAT)
- Cytology
- Serology(anti chlamydial antibody)
- Antigen Detection Method (Enzyme Immunoassay)
- DNA probe(Hybridization without Amplification)
- Hybridization with amplification of detection signal
- Culture

Source: Breaking the Chain: A Sourcebook on Sexually Transmitted Infection

 IV. Mucopurulent Cervicitis
B. Chlamydia

Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly
Report,
 IV. Mucopurulent Cervicitis
B. Chlamydia

Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly
Report,
 IV. Mucopurulent Cervicitis
B. Chlamydia
Management Considerations for Uncomplicated Gonorrhea and DGI
• Recent sex partners <60 days preceding onset of symptoms or
chlamydia diagnosis should be referred for evaluation, testing, and
presumptive treatment
• Sex partners should be instructed to abstain from condomless
sexual intercourse until they and their sex partners have been
treated

Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly
Report,
 IV. Mucopurulent Cervicitis
B. Chlamydia Infection among Neonates

Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly
Report,
V. Genital Ulcers
A. Genital Herpes
-recurrent viral infection that is incurable and highly contagious,.
Two distinct types
Type 1 (HSV-1):
- most commonly acquired in women < 25 yo
- may cause lower genital tract infection (13% to 40%)
- Genital HSV-1- transmitted from orolabial lesions to the vulva during
oralgenital contact or from genital to genital to genital contact with a
partner with genital herpes

Type 2 (HSV-2)
- may have mild or unrecognized infection
Source: Comprehensive Gynecology 7th Edition
V. Genital Ulcers
A. Genital Herpes

GENITAL HERPES SYNDROMES

1. Primary Infection: Initial Infection with either Herpes Simplex Virus Type 1 or without
prior exposure(antibodies) to either

2. Recurrent Infection: reactivation of latent virus, not a reinfection

3. Nonprimary first episode: first clinical episode with herpes simplex virus type 1 or 2 in
a patient with prior exposure to the other viral serotype

Source: Breaking the Chain: A Sourcebook on Sexually Transmitted Infection, 3rd Edition
V. Genital Ulcers
A. Genital Herpes
- Primary herpes - incubation period is between 3 & 7 days (average 6 days).
- Symptoms:
• paresthesia of the vulvar skin → eruption of multiple painful vesicles → shallow,
superficial ulcers over a large area of the vulva.
• Severe vulvar pain, tenderness, and inguinal adenopathy and simultaneous
involvement of the vagina and cervix
• Systemic symptoms: general malaise and fever(70%)
• Herpes encephalitis- mortality rate ~50%.

Source: Comprehensive Gynecology 7th Edition

V. Genital Ulcers
A. Genital Herpes

Recurrent genital herpes- less severe

symptoms unilateral vulvar involvement,
duration of 7 days, and viral shedding
occurs ~ 5 days.
• probability and frequency of recurrence
related to HSV serotype
• HSV-2 infection: 80% of women will
experience a recurrence within 12 months
• HSV-1: 55% chance of a recurrence within
1 year, with the average rate of recurrence
slightly less than one episode per year
Source: Comprehensive Gynecology 7th Edition
V. Genital Ulcers
A. Genital Herpes
Clinical diagnosis: simple clinical inspection
Diagnosis: Viral cultures are useful in primary episodes(80% sensitivity)
- (PCR) assay: most accurate and sensitive technique
- The Western blot assay: most specific method for diagnosing recurrent herpes
& unrecognized or subclinical infection.
- Type-specific HSV serologic assays might be useful in the following situations:
(1) recurrent genital symptoms or atypical symptoms, with negative HSV cultures;
(2) clinical diagnosis of genital herpes without laboratory confirmation; or
(3) partner with genital herpes.

Source: Comprehensive Gynecology 7th Edition

 V. Genital Ulcers
A. Genital Herpes

Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly
Report,
 V. Genital Ulcers
A. Genital Herpes

Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly
Report,
 V. Genital Ulcers
A. Genital Herpes

Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly
Report,
V. Genital Ulcers

Case 7
Hermesia‚ a 25 yo female‚ came in with complaint of painful vulvar ulcers. She
presented the same condition 6 months ago and was managed as a case of
Genital Herpes. You are now suspecting a recurrent HSV infection. What is the
best management for her case?
A. Acyclovir 400 mg tab 1 tablet 3x a day for 7- 10 days
B. Acyclovir 800 mg tab 1 tab 2x a day for 5 days
C. Ceftriaxone 500 mg IM SD
D. Benzathine Pen G 2.4 million units IM SD
V. Genital Ulcers
B. Granuloma Inguinale (Donovanosis)
- caused by Klebsiella granulomatis
- a chronic, ulcerative, bacterial infection of the skin and
subcutaneous tissue of the vulva
- can be spread sexually and through close nonsexual contact.
- Incubation period: 1 to 12 weeks.
-nodule → a painless, slowly progressing ulcer surrounded by
highly vascular granulation tissue.
- Diagnosis: clinical(endemic areas) or by identifying Donovan
bodies in smears and specimens taken from the ulcers

Source: Comprehensive Gynecology 7th Edition

 V. Genital Ulcers
B. Granuloma Inguinale (Donovanosis)

Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly
Report,
V. Genital Ulcers
C. Lymphogranuloma venereum (LGV)

❑chronic infection of lymphatic tissue caused by Chlamydia

trachomatis(serotypes L1, L2 , L3)
❑ Incubation period: 3-30 days.
❑Three distinct phases:
Primary infection- shallow, painless ulcer typically located on the
vestibule or labia but occasionally in the periurethral or perirectal region.
Secondary Phase- painful adenopathy in inguinal and perirectal areas
Tertiary Phase - extensive tissue destruction of the external genitalia and
anorectal region.

Source: Comprehensive Gynecology 7th Edition

 V. Genital Ulcers
C. Lymphogranuloma venereum (LGV)
Diagnosis: LGV specific molecular testing (PCR-based genotyping)

Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly
Report,
 V. Genital Ulcers
C. Lymphogranuloma venereum (LGV)
Management Considerations:
• Retest for chlamydia approximately 3 months after treatment.
• Persons who have had sexual contact with a patient who has LGV
within the 60 days before onset of the patient’s symptoms should
be evaluated, examined, and tested for chlamydial infection
• Asymptomatic partners should be presumptively treated with a
chlamydia regimen

Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly
Report,
 V. Genital Ulcers
D. Chancroid
• sexually transmitted, acute, ulcerative disease of the vulva caused
by Haemophilus ducreyi.
• soft chancre: always painful and tender
• ulcers are shallow, with a characteristic ragged edge(vulvar
vestibule>vagina or cervix) with a dirty, gray, necrotic, foul-
smelling exudate and lack induration at the base
Gram stain: streptobacillary chains(extracellular school of fish)
Incubation period: 3-6 days
Source: Workowski, K. A., et al (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly
Report,
V. Genital Ulcers
D. Chancroid
❑Definitive diagnosis: H. ducreyi on special culture media
❑ Management:
❑ Azithromycin 1 g orally in a single dose or
❑ Ceftriaxone 250 mg intramuscular (IM) in a single dose or
❑ Ciprofloxacin 500 mg orally twice daily for 3 days; or
❑ Erythromycin base 500 mg orally three times daily for 7 days.

Source: Comprehensive Gynecology 7th Edition

V. Genital Ulcers
D. Chancroid
Management Considerations:
• Reexamine patient 3–7 days after therapy initiation
• Sexual partners though asymptomatic should be treated if with
sexual contact during the 10 days preceding the patient’s
symptom onset.
• Persons with HIV infection are more likely to experience chancroid
treatment failure and to have ulcers that heal slowly

Source: Comprehensive Gynecology 7th Edition

V. Genital Ulcers
E. Syphilis
Management Considerations:
• Reexamine patient 3–7 days after therapy initiation
• Sexual partners though asymptomatic should be treated if with
sexual contact during the 10 days preceding the patient’s
symptom onset.
• Persons with HIV infection are more likely to experience chancroid
treatment failure and to have ulcers that heal slowly

Source: Comprehensive Gynecology 7th Edition

V. Genital Ulcers
E. Syphilis
❑Chronic, complex systemic disease produced by Treponema pallidum
❑ Incubation period: 10- 90 days( ave. 3 weeks)→ moderately contagious
❑Definitive diagnosis: darkfield microscopy of lesion exudate or tissue
❑ Two types of serologic tests:
Nontreponemal- VDRL slide test & RPR card test; inexpensive and easy to
perform used as screening tests for the disease, become positive 4 to
6 weeks after exposure, and also are a useful index of treatment
response.
Antitreponemal antibody tests: fluorescent-labeled Treponema antibody absorption
(FTA-ABS) test & microhemagglutination assay for antibodies to T. pallidum
(MHATP).
Source: Comprehensive Gynecology 7th Edition
V. Genital Ulcers
E. Syphilis
❑false-positive results: recent febrile illness, pregnancy,
immunization, chronic active hepatitis, malaria, sarcoidosis,
intravenous (IV) drug use, HIV infection, advancing age, acute
herpes simplex, and autoimmune diseases(SLE & RA)
❑A false-negative result(1-2 %): excess of anticardiolipin antibody in the serum,
termed the prozone phenomenon.

Source: Comprehensive Gynecology 7th Edition

V. Genital Ulcers
E. Syphilis
Three Stages
❑Primary syphilis- a painless papule appears at the
site of inoculation 2 to 3 weeks after exposure
which ulcerates(1-2 cm) with raised indurated
margin and a nonexudative base
❑Secondary syphilis: systemic disease (between 6
weeks & 6 months, average of 9 weeks)

Latent stage: 2 to 20 years, w/ positive serology

without symptoms or signs of disease

Source: Comprehensive Gynecology 7th Edition

V. Genital Ulcers
E. Syphilis

❑ Three Stages Vulvar lesions: large, raised,

Latent stage: flattened, grayish white areas
❑ Early latent syphilis- infection of 1 year or less.
❑All other cases: late latent or latent syphilis of unknown duration
❑ Tertiary phase: has destructive effects on the central
nervous, cardiovascular, and musculoskeletal systems
Manifestation: optic atrophy, tabes dorsalis, generalized
paresis, aortic aneurysm, and gummas of the skin and red macules and papules over the palms
of the hands and the soles of the feet
bones

necrotic center and the

obliteration of small
Source: Comprehensive Gynecology 7th Edition vessels by endarteritis
V. Genital Ulcers
E. Syphilis
Early Syphilis: reexamination
clinically & serologically at 6 and 12 Successful therapy → titer should decline fourfold in 6 months &
months following therapy become negative within 12 months

•Latent syphilis: quantitative

nontreponemal serologic tests 6,
12, and 24 months following
therapy.
First 3 to 4 years of the latent phase → relapses of secondary
•Retreatment: three weekly syphilis
injections of benzathine penicillin Sustained fourfold increase in nontreponemal test titers → failed
G, 2.4 million units IM.. treatment or reinfection

Source: Comprehensive Gynecology 7th Edition

V. Genital Ulcers
E. Syphilis
Syphilis
Neurosyphilis: CSF examination
-neurologic or ophthalmologic
signs/symptoms, -evidence of active tertiary
syphilis
-treatment failures
-HIV infection with late latent syphilis or
syphilis of an unknown duration
Sexual partners: evaluated clinically and
serologically
Primary & Secondary syphilis: 3 months plus
duration of symptoms
Early latent syphilis:1 year

Source: Comprehensive Gynecology 7th Edition

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