Sexually Transmitted Diseases

They are the Diseases that are transmitted mainly through sexual contact.

Classification according to causative organisms:

• Bacterial
• Syphilis
• Gonorrhea
• Chancroid
• LGV
• granuloma inguinal
• Viral
• HSV (Herpes simplex virus)
• HIV (Human immunodeficiency virus)
• HPV (Human papilloma virus)
• Pox virus causes Molluscum Contagiosum
• HBV
• HCV
• Protozoal Arthropodic
• Trichomoniasis
• candidiasis
• Scabies
• Pediculosis
Methods of transmission of STDs
• Direct contact
• Sexual contact
• Heterosexual – homosexual
• Asexual contact
• Direct contact with contaminated secretions
• Blood contact
• Vertical Transmission
• Transplacental
• Vaginal delivery
• Breast feeding

How to prevent STDs

• Reduce exposure:
• delay sex exposure / reduce partners
• Reduce transmission efficiency:
• Safe sex
• Reduce duration of infectiousness:
• early detection
• treatment of cases
• Sex education and contact tracing
 General role in management of STDs

 You should prescribe the appropriate medication for the correct duration to
prevent relapse or resistance of the organism.
 You have to screen for other STDs
 You must treat the sexual partner(s) to prevent the reinfection.

Presentation of STDs

Genital Ulcer Syndrome

Discharge
Other Genital Lesions
Systemic Disese

Genital Ulcers STDs

Genital ulcers can be classified either STDs and non-STDs ulcers

Non-STIs Ulcers
• Traumatic: Friction or rough intercourse or self inflected
• Infective: Tuberculosis or nonspecific folliculitis
• Neoplastic: Squamous cell carcenoma
• Fixed Drug Eruption
• Behcet Disease: Syndome of genital ulcerations, oral ulcerations, eye
manifestation and systemic manifistations.
STIs Ulcers
• Syphilis
• Chancroid
• Lymphogranuloma Venereum
• Granuloma Inguinale
• Herpes progenitalis
 Syphilis
 Causative organism:
 Treponema Pallidum:
 Spiral organism, with regular coils, moves in a “cork-screw”
fashion, Multiply every 30 hours, can not be grown on ordinary
culture media & Needs animal inoculation (rabbit & hamster).
 Acquired Syphilis:
 Early infectious phase: 1st 2 years post infection
 Primary Stage: ---- Chancre
 Secondary stage ---- Generalized bilateral symmetrical non
itchy non vesiculobullous skin rash, “Macular, Papular, Papulo-
squamous or pustular” & Mucous patches. Condyloma Lata: a
popular eruption in moisture areas ozzing highly infectious
fluid.
 Early latent phase
 Late non- infectious phase: after the 2nd year post infection
 Late latent
 Benign tertiary stage ---- “Gumma” central necrosis
surrounded by chronic inflammatory cells
 Malignant tertiary stage ---- Cardiovascular and CNS
affection
 Syphilis – “Chancre”

 It develops at the site of infection:

 Site: 95% genital area and 5% extra genital
 Lesion:
 Single, macule  papule  ulcer “Single, Painless, rounded, well
defined, indurated base, & dull red floor with grayish scab” 
heals spontaneously within 3 to 10 weeks leaving thin atrophic scar.
 Lymph nodes:
 Bilateral inlarged discrete painless and rubbery

Diagnosis of Syphilis

 Chancre
 Dark ground microscopy: material is taken from the ulcer floor or
from the lymph node puncture and examined under dark ground
microscope. Treponema pallidum is identified by its characteristic
luminescence & corkscrew motility.
 Serological tests: are of little value as they are usually become +ve
after disappearance of the 1st stage.
 Serological Tests:
 I – Non-specific:
 Antigen: Reagin antibodies / cardiolipin
 VDRL (Venereal Disease Research Laboratory) Test
 RPR (Rapid Plasma Reagin)
 II – Specific:
 Antigen: treponemal antigens
  FTA-Absorption Test (Fluorescent Treponemal
Antibody)
 TPHA Test (Treponema Pallidum Haemagglutination)
 TPI (Treponema Pallidum Immobilization)

Treatment of Syphilis
 Benzathin penicillin G: 2.4 million units IM
 Primary & secondary stage: single injection.
 Tertiary stage: three injections separated by one-week interval.
 For neuro-syphilis
 Aqueous crystalline penicillin G: 18 – 24 million unit / day
administered as 3 – 4 million units IV / 4 H or continuous infusion for
10 – 14 days.
 Procaine penicillin G: 2.4 million units IM daily + Probenecid 500
mg orally 4 times a day both for 10 - 14 day
 Chancroid

 Causative organism: Hemophilus ducreyii “Gram –ve short Bacilli”

 Incubation period: 2-5 days
 Lesion:
 Multiple small shallow painful ulcers that bleeds easily on touch.
 Regional lymph nodes: Unilateral acutely inflamed, swollen, tender,
matted and break down forming a sinus oozing pus.
 Treatment:
 Azithromycine 1 gm single oral dose
 Ceftriaxone 250 mg IM in a single dose
 Ciprofoxacin 500 mg oraly/12 h for 3 days
 Erythromcycin 500 mg/ 8 h for 7 days
 Lymphogranuloma Venereum

 Causative organism: Chlamydia trachomatis “Serotype L1,2,3”

 Incubation period: 7-15 days
 Lesion:
 Papule or vesicle that breaks into ulcer and heals rapidly.
 Regional lymph nodes: Usually bilateral, Matted forming a sausage
shaped swelling below and above inguinal ligament “Sign of groove”.
Then they breaks down and open with multiple sinuses.
 General manifestation: Fever, Headache, arthralgia etc.
 Treatment:
 Doxycycline 100 mg/12 h for 21 days
 Erythromcycin or Tetracyclin 500 mg/ 6 h for 21 days
 Granuloma Inguinale

 Causative organism: Calymmato bacterium granulomatis “Gram –ve

Bacilli”
 Incubation period: 2-6 weeks
 Lesion:
 Granulomatous genital lesions that ulcerate with velvety appearance
and raised everted edges clinically resembles malignant ulcer.
 Regional lymph nodes: not affected but subcutaneous inguinal lesions
are mistaken for enlarged LNs “psudo-bubo”
 Treatment:
 Azithromycin 1g/ week for 3 weeks
 Doxycycline 100 mg /12 h for 3 weeks
 Ciprofoxacin 750 mg oraly/12 h for 3 days
 Erythromcycin 500 mg/ 8 h for 7 days
 Trimethoprime-sulphamethoxazole one double strength tablet (160
mg/800 mg) / 12 h for 3 weeks
 Herpes progenitalis

 Causative organism: Herpes simplex virus” “Type II in 95% of cases and

Type I in 5%”
 Incubation period: 2-7 days
 Lesion:
 It starts by burning sensation followed by appearance of grouped
vesicles on erythematous base. They rupture forming erosions that
may be get 2ry infection leading to pustules.
 Heal in 1-2 weeks and recurrence is common.
 Regional lymph nodes: enlarged & tender.
 General manifestations: occur only with primary attack.
 Treatment:
 Topical and Systemic Acyclovir.
 Urethral discharge

Classification of Urethral discharge

 Physiologic:
o Prosemen: it is the secretion comes out the urethra upon sexual
excitation
o Prostatorrhea: it is the excess secretions of the prostate comes out the
urethra upon straining
 Pthologica:
o Infective:
 Gonococcal
 Non gonococcal
o Non-infective
 Traumatic: after catheterization
 Neoplastic
 Chemical irritation

Causes of infective urethral discharge

Gonorrhea
It is caused by Neisseria gonorrhea which is Gram negative kidney shaped

Non Gonococcal uretheral dischargee

1- Chlamydia trachomatis: Serovar D-K
2- Mycoplasma
3- Trichomonas vaginalis
4- Intrameatal lesions e.g. Herpes progenitalis, Chancre, Lymphogranuloma
venerum
 Gonorrhea

It is caused by Neisseria gonorrhea which is Gram negative kidney shaped Non-

motile Non-spore forming Diplococci

Clinical presentation:
 Genital presentation in males
 Genital presentation in females
 Extra-genital gonorrhea

Clinical presentation in male

Incubation period: 2-5 days
Clinical picture
 Urinary symptoms: dysuria, frequency of micturition, urgency and
hematuria
 Urethral discharge: profuse, purulent, greenish yellow
 Hyperemia and oedema of urethral orifice
Complications: “spread of infection”
 Balano-posthitis, para-urethral abscess, fistula and stricture
 Littritis, Cowperitis
 Acute prostatitis, seminal vesiculitis and epididymitis

Clinical presentation in female

Incubation period: 2-5 days
Clinical picture:
 Urinary symptoms: dysuria, frequency, urgency and hematuria
  Mild soreness of the vulve
 Urethral discharge: scanty, mucopurulent
 Low back pain or lower abdominal pain
Complications: “spread of infection”
 Cystitis, Skenitis, Bartholinitis & Bartholine abscess.
 Salpingitis, oophoritis, tubo-ovarian abscess & pelvic peritonitis
 Pelvic inflammatory disease

Extragenital manifestations
 Proctitis
 Pharyngitis
 Conjunctivitis
 Disseminated Gonococcal infection
 Dermatitis
 Arthritis
 Hepatitis
 Meningitis

Diagnosis of Gonorrhea
1 - Stained smear:
- Gram stain
2 - Culture:
Modified Thayer and Martin medium
3 - Colonies confirmatory tests:
Gram stained smear examination from colonies.
 Oxidase test: Oxidase reagent turns gonococcal colonies black.
Sugar fermentation test (gonococcus ferments glucose only).
4- Direct immunofluorescence test (most specific and most sensitive test)
5- Serological tests e.g. Complement fixation test.

Treatment of gonorrhea
None complicated cases:

Third generation Cephalosporines: Cefotriaxone 250 mg IM single dose

OR
Quinolone: single dose of ciprofloxacin, norlfloxacin, or ofloxacin.

PLUS
Doxycycline: 100mg capsules twice daily for 10 days (for possible associated
Chlamydia infection)
Disseminated and complicated gonococcal infection:
 Hospitalization.
 Treatment for 1-2 weeks with higher dose of the previously mentioned drugs.

Causes of none gonoccocal urethral discharge

1- Chlamydia trachomatis: Serotype D-K
2- Mycoplasma
3- Trichomonas vaginalis
4- Intrameatal lesions e.g. Herpes progenitalis, Chancre, Lymphogranuloma
venerum
Clinical Picture:
Incubation Period: 1 - 5 weeks
Symptoms:
 Urethral discomfort
 Scanty mucoid discharge
 Micturition symptoms
Complications:
 As gonorrhea but much more common due to mild presentations of
symptoms that may delay the onset of diagnosis and treatment

Medical Treatment:
 Of chamydia and mycoplasma:
Azythromycin 1 gram once
Doxycycline 100mg twice daily for 2 weeks
 Of Trichomonas vaginalis:
Metronidazole 500mg twice daily for 7 days or 2gm single dose
Tinidazole 2gm single dose
 Human Immunodeficiency Virus (HIV)
Acquired Immunodeficiency Syndrome (AIDS)

Human Immunodeficiency Virus (HIV)

 Type: Retrovirus (RNA virus)
 There are two types of HIV:
 HIV-1: in Western countries
 HIV-2: in West Africa
 Resulted in:
 Massive Immunosuppression
 Leads to opportunistic infections & neoplasms

Virus structure:
 Two copies of single-stranded RNA located inside a conical core which in
turn is surrounded by a lipid envelope.
 Viral enzymes:
 Reverse transcriptase which leads to formation of DNA copies
 Protease and integrase that help the DNA copies of the viral RNA to
be integrated in the host cell DNA.

Mode of transmission:
 Sexual contact is the most common route of HIV transmission (78% world
wide).
 Direct, skin penetrating blood exposure (e.g., needle-stick injuries, needle
sharing and blood transfusion).
 Pregnancy related issues (vertical transmission, peri-natal transmission and
through breast feeding).
Pathogenesis:
 The viral receptor on these cells is surface protein CD4
 T-Helper lymphocytes are the target cells for virus infection
 After Primary infection, viral replication occurs  viremia & decreased
number of CD4 cells.
 Then an immune response to HIV occurs 1-3 months after infection 
Plasma viremia drops and level of CD4 rebound .
 Later on decline in the number of CD4 cells and opportunistic infection
occurred.

WHO stages for HIV infections

 Stage 1 = CD4 count > 500 /mm3
 Stage 2 = CD4 count (350-499) /mm3
 Stage 3 = CD4 count (200-350) /mm3
 Stage 4 = CD4 count < 200 /mm3

Clinical stages for HIV infections

 Primary HIV infection: acute febrile illness - seroconversion
 Asymptomatic HIV infection
 Early symptomatic HIV infection
 Late symptomatic HIV infection (AIDS)
 Advanced HIV infection
Primary HIV infection
Clinical picture:
 It occurs in 50-90%
Symptoms:
 Acute onset of FAHM, generalized L.N. enlargement, pharyngitis,
diarrhea, maculopapular rash.
 May be oral and genital ulceration.
 May be neurological manifestations e.g. aseptic meningitis,
encephalitis
 Opportunistic infections e.g. oral & esophageal candida
Laboratory findings:
 Marked transient  CD4 count
 CD4:CD8 ratio is inverted

Asymptomatic HIV infection

Clinical picture:
 No HIV related symptoms
Lab. Finding:
 CD4 count usually >500 cells / mm3
 Rate of drop 40 – 80 cells /mm per year.
Lasts 1.5 - 15 years
Progression to symptomatic phase depends on many factors
Early symptomatic HIV infection
Clinical picture:
 Persistent Generalized Lymphadenopathy (Earlist sign)
 Constitutional manifestations.: fever, diarrhea, weight loss, headache,
chronic fatigue.
 Muco-cutaneous manifestations: candidiasis (oral & vulvovaginal), herpes
zoster, herpes simplex, oral hairy leukoplakia.
 Opportunistic infection: sinusitis, bronchitis, pneumonia
 Idiopathic thrombocytopenic purpura.
Lab. Findings:
CD4 drops 200 – 500 cells / mm
Viral load start to increase

Late symptomatic HIV infection = AIDS

Clinical picture:
Appearance of one or more of the typical opportunistic infections or
neoplasms diagnostic of AIDS by definitional criteria.
 Opportunistic infection e.g. Pneumocystits carnii pneumonia,
toxoplasmosis...elc.
 Neoplastic e.g. Lymphoma, Kaposi sarcoma
 AIDS wasting syndrome >10% weight loss / month
 Neurological e.g. Polyneuropathy, AIDS dementia complex (ADC) . CNS
lymphoma

Lab . Finding:
 CD4 fell below 200 cells / mm
 Marked increase viral load
Terminal stage CD4 < 50 cells / mm
 All AIDS defining Opportunistic infection and malignancies.
 Certain Opportunistic infection are more likely to occur e.g.: Cryptococcal
meningitis, Disseminated histoplasmosis
 Marked deterioration of general condition

Laboratory Diagnosis of HIV

 Diagnostic tests:
 Antibody detection:
 Western blot technique 42-45 days
 ELISA 20 days
 Rapid antibody tests.
 Antigen detection: 9-11 days
 P24 antigen “especially in the window phase” in acute phase of
HIV infection”
 PCR to detect viral RNA
 Prognostic tests:
 Viral load (counting viral particles)
 CD4 count
Prevention of HIV
 Sex education
 Screening of blood before donation
 Infection control measures to reduce risk of occupational infection for
examples using gloves, gowns, masks, protective eyewear.
 Vertical transmission is reduced by preventing breast-feeding and sometimes
using ICSI as a method to prevent female infection.

Management of HIV infection:

1- Antiretroviral drugs:
These drugs inhibits the different viral enzymes leading to reduction of viral
replication but not total eradication of HIV.
They include:
 Reverse transcriptase inhibitors
 Protease inhibitors
2- Prevention and treatment of opportunistic infections.
3- Treatment of associated morbidity
 Genital Warts “Condyloma Accuminata”

Causative organism: Human papilloma virus (HPV).

Clinical presentation: Genital outgrowth characterized by:
 Multiple (rarely single), skin colored or slightly hyperpigmented, dry,
cauliflower-like or flat toped mass. Variable in size from pinhead-size to a large
tumor.
 Sites:
 In males: penile shaft, pubic area, glans penis, intrameatal, perianal, groin.
 In females: cervix may lead to cancer cervix, vagina, vulva, pubic area,
perianal.
Complications:
- Cancer cervix
Treatment:
 Repeated application of 25% podophyllin resin in alcohol or in liquid
paraffin.
 Electrocautery, Cryocautery and surgical removal are less preferred.
 CO2 laser surgery
 Molluscum Contagiosum
Causative organism: Poxvirus.
Clinical presentation:
- Multiple pearly-white papules with characteristic central umbilication.
- Site: Genital skin, ansus and pubic region.
Treatment:
Curettage, cryocautery or electrocautery.