STIs
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2. Non- ulcer forming
1. Ulcer forming
- Bacterial vaginosis
- Herpes simplex I & II - Trichomonal vaginalis
- Candidiasis
- Condylomata acuminata
- Gonorrhoea
- Chancroid - Chlamydial infections
- Pediculosis pubis
- Granuloma inguinale
- Scabies (sarcoptes scabiei)
- Syphilis - Hepatitis
- Molluscum contagiosum virus
- Lymphogranuloma
- Cytomegalovirus
venereum - Group B streptococcus
HIV -
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Routes of spread
- Sexual intercourse (principal)
- Close body contact
- Kissing
- Mouth-breast contact
- Anal intercourse
- Oral sex
- Transplacental
- Birth canal (genital tract)
- Lactation
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Clinician’s role in preventing and
treating STIs
- Understand microbiology of STIs for appropriate diagnosis & treatment
- Alleviate symptoms & prevent future sequelae.
- Prevent transmission to others
- Patient education & counseling.
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HERPES SIMPLEX
By HSV 1&2, ( Approx 85% due to HSV type 2)
Occurs through direct contact with secretions or mucosal surfaces
contaminated with virus.
o Can enter skin with or without cracks
o Initially replicates in dermis or epidermis-along peripheral sensory nerves-
dorsal root ganglion-latent infection established.
Incubation period 2-7 days.
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Signs & symptoms
o Prodromal -tingling, burning or itching sensation
o Vesicular eruptions – painful ulcers in small parts but can be wider.
o Urinary symptoms including dysuria or retention.
o Severe infections – fever, malaise& bilateral inguinal adenopathy.
o Herpetic cervicitis – profuse watery discharge
o Rarely disseminated infection or could be asymptomatic.
• May persist 2-6 weeks with no subsequent scarring
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Primary herpes, male
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Recurrent herpes, male
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Herpes, female
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Primary herpes, female
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Same patient, four days later
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Herpes cervicitis
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Diagnosis
- Clinical presentation
- Laboratory
Culture organisms from vesicular fluid in acute phase.
Pap smear ulcer scraping – giant cells indicative of viral infection.
serology – 85%& of patients develop IgM antibodies to type 2 virus within 4 days of
exposure.
Recurrence- occurs despite adequate humoral & cell-mediated immunity.
- Type2 more likely to recur than type 1.
- Ulcers smaller, fewer and confined to one area in vulva, vagina or cervix.
- Healing in 1-3 weeks
- Generally no inguinal adenopathy and systemic symptoms.
- Extragenital sites such as fingers, buttocks & trunk (eczema herpeticum) have been described.
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Treatment
Lesions self-limiting
Symptomatic treatment
- good genital hygiene
- Loose-fitting undergarments
- Cold compress or sitz baths
- Oral analgesics
• Antivirals
- acyclovir 400mg tds 7 – 10 days
- Famciclovir 250mg bd 7 – 10 days
- Valacyclovir 100mg bd x 10/7
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Prevention
- No precautious in absence of active lesions
- Small lesions away from oral or vaginal orifices to be covered with adhesive or paper tape during
coitus
- A non immune partner usually will be infected.
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CONDYLOMATA ACUMINATA (VENEREAL WARTS)
Caused by human papillomavirus(HPV)
Papillary growths tend to coalesce and form large cauliflower-like masses
Incubation- 3 months or longer
During treatment – keep area clean ,avoid sex or use condom with partner
Has oncogenic potential – pap smear ± biopsy.
Treatment modes
- Cover with bichloroacetic or trichloroacetic acid weekly till warts are gone.
- Cryosurgery
- Electrosurgical destruction (cauterization)
- Excision
- Self-administered e.g. podofilex 0.5% solution or gel.
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Condyloma acuminata, penile
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Condyloma acuminata, anal
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Condyloma acuminata, meatal
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Condyloma acuminata, vulva
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Condyloma acuminata, vaginal wall
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CHANCROID (SOFT CHANCRE)
Painful, tender genital ulcer with inguinal adenitis, with erythema or fluctuance.
Causative organism Haemophilus ducreyi
Exposure usually through coitus but accidentally acquired on hands have occurred.
Incubation period less than 5 days
Cofactor for HIV transmission.
10% of patients may have coinfection with herpes or syphilis.
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Signs and Symptoms
Vesicopustule lesion generating to saucer-shaped ragged
ulcer circumscribed by an inflammatory wheel
Very tender with heavy ,contagious foul discharge
Inguinal adenitis may become necrotic and drain
spontaneously.
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Chancroid ulcers
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Chancroid Male - regional adenopathy
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Chancroid - ruptured node
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Chancroid - gram stain of H. ducreyi
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Lab
Less reliable than clinical diagnosis
Isolation of H. ducreyi in less than 1/3 of cases
Polymerase chain reaction (PCR) becoming widely available.
Differential diagnosis
Syphilis, granuloma inguinale ,herpes simplex and
lymphogranuloma venereum.
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Management
Good personal hygiene
Antimicrobial agents vary by locality (regimens)
- Azithromycin 1gm start oral
- Cefriaxone 250mg 1m start
- Erythromycin 500mg tds× 1/52
- Ciprofloxacin 500mg bd × 3/7
Fluctuant lymph nodes may need aspiration through adjacent normal skin
NB: I/D not recommended as will delay healing,
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Prognosis
Untreated or poorly managed – may persist and develop secondary
infection – deep scarring
Improvement within 7-10 days, if not – co infection, HIV, resistant strains
or non-compliance.
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GRANULOMA INGUINALE ( DONOVANOSIS)
Chronic ulcerative granulomatous disease
Usually develops in vulva , perineum , or inguinal regions
May occur in cervical, uterine, oral and ovarian
Causative organism – calymmatobacterium granulomatis
• ( Donovan body- ie bacteria encapsulated in mononuclear leukocyte)
Transmission through coitus.
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Signs and symptoms
Malodorous discharge
Papule – ulceration with development of a beefy-red granular zone with clean sharp
edges.
Ulcer shows little tendency to heal
Usually no local or systemic symptoms.
Inguinal swelling common with late formation of abscesses (buboes)
Chronic cervical lesions rare – redness , ulceration or granulation tissue with fibrosis
Healing with fibrosis
Co-existence of another venereal disease often
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Granuloma inguinale, male
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Granuloma inguinale, female
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Granuloma inguinale, chronic destructive
lesion
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Granuloma inguinale with
both active and healed lesions
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Granuloma inguinale, Donovan bodies
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• Lab
Biopsy or smear material stained with Wright’s , Giemsa’s or silver stain –
large mononuclear cells with one or more cystic inclusions ( Donovan
bodies – small round or rod-shaped particles that stain purple in H/E
(haematoxylin & eosin preparations)
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• Prevention
Personal hygiene
Therapy immediately after exposure
• Treatment modes
Trimethoprim –sulphamethoxazole 1 double- strength tab bd for 3 weeks
Doxycycline 100mg bd for 3 weeks
Ciprofloxacin 750mg bd for 3 weeks
Erythromycin 500mg qid for 2-3 weeks
Azithromycin 1gm weekly for 3 weeks
• Treat partner with whom she had sexual contact 60 days prior to onset of symptoms
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LYMPHOGRANULOMA VENEREUM
Caused by one of the aggressive L serotypes (L1,L2 or L3) of
Chlamydia trachomatis
Sexual transmission, men more frequently affected than
women.
Incubation period 7-21 days
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Signs and symptoms
Early vesicopustular eruption may go unnoticed.
Inguinal and vulval ulceration, lymphoedema and secondary bilateral invasion –
growth very tender and has a hard red to purplish- blue cutaneous induration 10-
30 days after exposure.
Anorectal lymphoedema (defaecation painful and stool may be blood streaked)
Later as lymphoedema and ulceration undergo cicatrization – rectal stricture and
vaginal narrowing and distortion – difficult defaecation and severe dyspareunia.
Late phase systemic symptoms –fever, headache, athralgia, chills and abdominal
cramps.
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LGV primary lesion
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Chronic lymphogranuloma venereum in
female. Genital elephantiasis
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LGV lymphadenopathy
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Lab
Complement fixation using a heat-stable antigen – group specific for all
Chlamydia species,
Test positive at titres ≥ 1:16 in more than 80% cases of LGV.
Possible isolation of C. trachomatis from appropriate specimens
confirming immunotype (seldom available).
Microimmunofluorescent test .
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Differential Diagnosis
As disseminated disease – meningitis, arthritis, pleurisy or peritonitis.
As cutaneous lesion – granuloma inguinale, tuberculosis, early syphilis and chancroid.
As colonic lesion ( proctoscopy and mucosal biopsy ) – carcinoma, schistosomiasis and
granuloma inguinale.
Complication
Perianal scarring and rectal strictures –can involve entire sigmoid colon.
Vulvar elephantiasis – marked distortion of external genitalia.
Prevention
Condom
Refrain from coitus
Treat exposure with sulphonamides or tetracyclines.
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Treatment
a)Chemotherapy
Doxycycline 100mg bd ×3/52 ( repeat if disease persists)
Erythromycin 500mg qid×3/52
b) Local surgical treatment.
Dilate anal strictures manually at weekly interval
Severe stricture may require diversionary colostomy
Aspirate abscesses
If disease arrested – complete vulvectomy for cosmetic reasons
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SYPHILIS
1) By Treponema pallidum by direct contact with an infectious moist lesion.
2) T. pallidum pass through intact mucous membrane or abraded skin.
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Signs and symptoms
1. Primary syphilis
Painless genital sore (chancre ) on labia, vulva, vagina, cervix,
anus, lips or nipples.
Painless, rubbery, regional lymphadenopathy followed by
generalized lymphadenopathy in 3rd - 6th week.
Darkfield microscopic findings – [Link]
Positive serological tests in 70% of cases.
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2. Secondary syphilis
Bilateral symmetrical extragenital papulosquamous eruption
Condyloma lata in perineal area
Mucous patches
Systemic manifestation including patchy alopecia, hepatitis and
nephritis.
Darkfield microscopy findings in moist areas.
Positive serological test for syphilis.
Lymphadenopathy
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3. Latent syphilis
Absence of lesions
Serologic test usually reactive; titre may be low.
4. Tertiary syphilis
• Cardiac – aortic aneurysms or insufficiency.
• Neurologic – mostly during latent phase.
•Ophthalmic and auditory systems involvement
•Cranial nerve palsy and meningitis.
• Skin or bone (gummas )
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Syphilis - Treponema pallidum
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Primary syphilis-chancre
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Primary syphilis - chancre
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Primary syphilis - chancre
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Primary syphilis - chancre of anus
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Primary syphilis - chancre
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Secondary syphilis - papulosquamous rash
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Secondary syphilis - papulo-pustular rash
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Secondary syphilis
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Secondary syphilis
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Secondary syphilis
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Secondary syphilis - alopecia
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Late syphilis - serpiginous gummata of
forearm
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Late syphilis - ulcerating gumma
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Cardiovascular syphilis - narrowing of
coronary ostia in aorta
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Neurosyphilis - spirochetes in neural tissue
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Congenital syphilis - mucous patches
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Congenital syphilis - - Hutchinson’s teeth
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Congenital syphilis - perforation of palate
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Lab
Serological Tests (for syphilis) - Positive several weeks after primary lesion appears
a) Non-treponemal tests
Flocculation tests including VDRL, rapid reagin test, and automated reagin test.
False positives:- collagen diseases, malaria, infections mononucleosis, febrile diseases, leprosy,
vaccination, drug addiction
b) Treponemal antibody tests
Fluorescent treponemal antibody absorption (FTA – ABS) test
Microhaemagglutination assay for T. pallidum (MHA – TP)
Both more sensitive and specific than non-treponemal tests (except for MHA – TP in primary
disease)
• Remain positive despite therapy so no use as titres or therapy follow up
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Differential diagnoses
[Link] syphilis
• – chancroid, granuloma inguinale, lymphogranuloma
• venereum, herpes genitalis, carcinoma, scabies, trauma, lichen planus,
psoriasis, drug eruption, mycotic infections & Reiter’s syndrome.
2. Secondary syphilis
– psoriasis, lichen planus, tinea versicolor, drug eruption, iritis, neurorerinitis,
condyloma acuminata, infectious mononucleosis, alopecia etc
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Treatment
Primary, secondary and early latent (less than 1 year duration)
- Benzathine penicillin G 2.4 million 1m start
- Tetracycline chloride 500mg qid X 2/52
- Doxycycline 100mg bd X 2/52
- Avoid erythromycin estolate in pregnancy (potential drug – related hepatotoxicity)
Late syphilis (except neurosyphilis)
Benzathine penicillin G 2.4 million units 1m weekly X 3/52
Tetracychrine and doxycycline as above.
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VAGINITIS
Clinical syndrome characterized by
- Vaginal discharge
- Vulvar irritation or
- Malodorous discharge
Divided into two
- Infectious vaginitis
- Atrophic vaginitis
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•Infectious vaginitis
1. Bacterial vaginosis
o Most frequent but 50% of women asymptomatic
Loss of lactobacilli
Increase in vaginal pH (>4.5)
Increase in multiple aerobic and anaerobic bacteria
o Causes
Gardnerella vaginalis (formerly corynebacterium vaginale and haemophilus
vaginalis)
Anaerobic bacteria (fishy oduor) such as Bacteroids and peptostreptococus spp;
and genital mycoplasmas
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o Clinical criteria for diagnosis
Homogeneous white, non-inflammatory discharge
Microscopic pressure of >20%
Vaginal discharge with Ph > 4.5 (vaginal cells with G.
vaginalis)
Fishy odour with or without addition of potassium
hydroxide (KOH)
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o Diagnosis
Wet preparation (unstained exfoliated vaginal cells with many small dark particles
– set up referred to as “clue cells)
Culture
Gram’s stain
o Treatment -oral
Metronidazole 400mg, bd for 7 days
Metronidazole 2g stat
Clindamycin 300mg bd for 7 days
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2. Trichomonas vaginitis
o By Trichomonas vaginalis
o Persistent profuse, extremely frothy, greenish at times foul – smelling vaginal
discharge
• Generalized vaginal erythma with multiple petechiae (strawberry spots)
• Urinary symptoms
• Tests
• Wet mount with normal saline (motile flagellates)
• Pap smear (may get false positives
• Culture (gold standard – 95% specificity and 100% specificity)
• Treatment
• Metronidazole 2g stat
• Associations
• Perinatal complications
• Increased transmission of HIV
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Candidiasis
o C. albicans (commonest of candida species)
o Frequently inhabits mouth, throat, large intestine and vagina normally.
o Clinical infection may be associated with:-
- Systematic disorder (mellitus, HIV, Obesity)
- Pregnancy
- Medication (antibiotics, corticosteroids, oral contraceptives)
- Chronic debilitation
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S/S
- Intense vulvar pruritis
- A white curd-like, cheesy vaginal discharge
- Vulvar erythma
- Burning sensation on micturation
Tests
- Vaginal secretions mixed with 10% KOH show
pseudohyphae
- Vaginal culture (gold standard)
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Treatment options
Chemical and dyes
1% gentian violet (aniline dye) painted over vaginal surfaces weekly.
Boric acid pessary (600mg)
Imidazole
Clotrimazole
Oral preparations e.g ketaconazole, fluconazole
• Creams may be combined with steroids to reduce inflammation if patient
remains symptomatic
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GONORRHOEA
o By Neisseria gonorrheae
o Columnar and transitional epithelium of genitourinary
tract principal site of invasion
o Patients at risk of incubating syphilis
o 20 – 40% also have Chlamydia
o Incubation period 3 -5 days
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•Clinical findings
o Vaginal/ urethral discharge with possible inflammation of vulva, vagina, cervix and urethra
o Dysuria
o Lower abdominal pain
o Fever, chills, nausea, and vomiting
o Bartholinitis
o Anorectal inflammation more often by perineal spread of vaginal secretions rather than anal
intercourse
o Disseminated infections
Commonly polyarthralgia, tendosynovitis and dermatitis
May be purulent arthritis without dermatitis
Endocarditis and meningitis have been described
o Conjunctivitis
In adults usually autoinculation
Olphthalmia neonatorum
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Gonococcal urethritis
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Gonococcal cervicitis
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Gonorrhea - gram stain of urethral discharge
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Bartholin’s abscess
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Bartholin’s abscess
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Gonococcal ophthalmia
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Disseminated gonorrhea - skin lesion
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Disseminated gonorrhea - skin lesion
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Lab findings
o Thayer – martin or Transgrow media show oxidase –
positive gram – negative diplococci
o Enzyme immunoassay from cervical swab or urine
specimens
o Gram stain
Complications
Salpingitis
Tubal scarring
Infertility
Ectopic pregnancy
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Treatment
o Suspect other STIs,
o Cover for N. gonorhoeae, C. trachomatis and incubating syphilis
Regimens for non-complicated
• Ceftriazone 125mg 1M once then Doxycycline 100mg orally bd X
7 days (for non-pregnant patients)
• Azithromycin 1g orally as single dose
• Cefixime 0.4g orally stat then Docycycline or Azithromycin
• Ofloxacin 0.4g, levoflaxin 0.25g or ciproflozacin 0.5g orally once
for non-pregnant women. Once then Doxycycline or azithromycin
• Can use β - Lactamase inhibitors
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Regimens for complicated
•Acute salpingitis – peritonitis
•Disseminated infections
Ceftriaxone 1g (1m or IV)
Ceftizoxime 1g IV 8 hourly
If B – Lactamase allergy, spectinomycin 2g 1m 12 hourly.
Oral medications include Ceftizoxime 0.4g 12 hourly, Ciprofloxacin
0.5g 12hrly, Ofloxacin 0.4g 12 hrly or Levofloxacin 0.5g OD in non-
pregnant or lactating women.
•Neonates and children with untreated gonorrheae
• Ceftriaxome 25 – 50mg/kg IV or 1m maximum 125mg. give with
caution with prematurity or hyperbilirubinaemia infants
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The End
Thank You
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