Common Sexually Transmitted Diseases:

STD 101 for Clinicians

Something for Everyone!
Prepared by
John F. Toney, M.D., Associate Professor of Medicine,
Univ. of South Florida College of Medicine
and
Laura H. Bachmann, MD, MPH, Associate Professor of Medicine
Wake Forest Baptist Health, Winston-Salem, NC,
WG (Bill) Hefner Medical Center, Salisbury, NC
Co-Director, AL/NC STD/HIV PTC
for STD101

National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

Division of STD Prevention
 Topics

• Background Information
• “Sores”
• “Drips”

2
Background Information

3
 Background

Burden of STD in U.S.

STD Cases Reported Rate (per 100K)
Chlamydia 1.3 million (2010) 426
Gonorrhea 309,341 (2010) 100.8
Syphilis (P & S) 13,774 (2010) 4.5
STD Estimated New Cases Prevalent Cases/%
HSV 1.6 million (2000) 16.2% (2005-8)
HPV 6.2 million (2000) 26.8% F (2003-4)/
1.3-72.9% M
Trichomoniasis 7.4 million (2000) 2.3 million (2001-4)
HIV 48,100 (2009) >600,000 (2008)
Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2010. Atlanta: U.S.
Department of Health and Human Services; 2011; www.cdc.gov/hiv/topics/surveillance/resources/slides/incidence/index.htm;
Weinstock et al. Perspectives on Sexual and Reproductive Health. 2004; Sutton et al CID 2007; 45:1319-26.; Dunne et al JAMA
2007; 297(8): 813-19; Dunne et al JID 2006; 194(8): 1044-57; Xu et al. MMWR 2010 ; 59(15): 456-59 4
 STIs Facilitate HIV Transmission
• Disruption of
epithelial/mucosal
barriers
• Increase the number of
HIV target cells in the
genital tract
• Increase expression of
HIV co-receptors
• Induce secretion of
cytokines (increase HIV
shedding)
• HIV alters natural history
of some STIs
Fleming DT and Wasserheit JN. From Epidemiological Synergy to public health policy and practice: the contribution
of other sexually transmitted diseases to sexual transmission of HIV infection. Sex Transm Inf 1999;75:3-17.
Slide courtesy of AL/NC STD/HIV Prevention Training Center 5
 Background

Where Do People Go for STD

Treatment?
• Population-based estimates from National
Health and Social Life Survey
Private provider 59%
Other clinic 15%
Emergency room 10%
STD clinic 9%
Family planning clinic 7%

Source: Brackbill et al. Where do people go for treatment of sexually transmitted diseases?
Family Planning Perspectives. 31(1):10-5, 1999 6
 Chlamydia—Percentage of Reported Cases by Sex and
Selected Reporting Sources, United States, 2010

Percentage
40
Private Physician/HMO*
35 STD Clinic
Other HD* Clinic
30 Family Planning Clinic
25 Emergency Room

20

15

10

0
Men Women

*HMO = health maintenance organization; HD = health department.

NOTE: These categories represent 72.5% of cases with a known reporting source. Of all cases, 11.6% had a
missing or unknown reporting source.
 Background

Percent* of Women Who Said Topic Was Discussed

During First Visit With New Gynecological or
Obstetrical Doctor/Health Care Professional

Breast Self Exam 69% 4%

Pap Smear 60% 12%
Birth Control 33% 20%
Mammograms 34% 7%
Sexual History and/or Current… 36% 3%
Alcohol Use 24% 1%
HCP asked
HIV/AIDS 19% 2% Pt. asked
STDs other than HIV/AIDS 12% 3%

0% 10% 20% 30% 40% 50% 60% 70% 80%

*Percentages may not total to 100% because of rounding or respondents answering “Don’t know”
to the question “Who initiated this conversation?”
Source: Kaiser Family Foundation/Glamour National Survey on STDs, 1997 8
 Background

“...the scope and impact of the STD epidemic

are under-appreciated and the STD epidemic is
largely hidden from public discourse.”

IOM Report 1997

9
 Background

STDs of Concern

• “Sores” (ulcers)
– Syphilis
– Genital herpes (HSV-2, HSV-1)
– Others uncommon in the U.S.
• Lymphogranuloma venereum
• Chancroid
• Granuloma inguinale

10
 Background

STDs of Concern (continued)

• “Drips” (discharges)
– Gonorrhea
– Chlamydia
– Nongonococcal urethritis / mucopurulent
cervicitis
– Trichomonas vaginitis / urethritis
– Candidiasis
– Bacterial vaginosis
• Other major concerns
– Genital HPV (especially type 16, 18) and
Cervical/Anal/Oral Cancer 11
 “Sores”

Syphilis
Genital Herpes (HSV-2, HSV-1)

12
 Sores

Genital Ulcer Diseases –

Does It Hurt?
• Painful
– Chancroid
– Genital herpes simplex
• Painless
– Syphilis
– Lymphogranuloma venereum
– Granuloma inguinale
13
 Sores

Primary Syphilis – Clinical

Manifestations
• Incubation: 10-90 days (average 3 weeks)
• Chancre
– Early: macule/papule → erodes
– Late: clean based, painless, indurated ulcer with
smooth firm borders
– Unnoticed in 15-30% of patients
– Resolves in 1-5 weeks
– HIGHLY INFECTIOUS
14
 Sores

Primary Syphilis Chancre

15
Source: Florida STD/HIV Prevention Training Center
 Sores

Primary Syphilis

Source: Centers for Disease Control and Prevention 16

 Sores

Secondary Syphilis - Clinical

Manifestations
• Represents hematogenous dissemination of
spirochetes
• Usually 2-8 weeks after chancre appears
• Findings:
– rash - whole body (includes palms/soles)
– mucous patches
– condylomata lata - HIGHLY INFECTIOUS
– constitutional symptoms
• Sn/Sx resolve in 2-10 weeks
17
 Sores

Secondary Syphilis Rash

Source: Florida STD/HIV Prevention Training Center 18

 Sores

Secondary Syphilis:
Generalized Body Rash

Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides 19

 Sores

Secondary Syphilis Rash

Source: Florida STD/HIV Prevention Training Center 20

 Sores

Secondary Syphilis Rash

Source: Cincinnati STD/HIV Prevention Training Center 21

 Sores

Secondary Syphilis

Source: Diepgen TL, Yihune G et al. Dermatology Online Atlas 22

 Sores

Secondary Syphilis –
Condylomata Lata

Source: Florida STD/HIV Prevention Training Center 23

 Early Syphilis – Diagnosis and
Treatment
 Diagnosis:
 Clinical presentation
 Darkfield
 Serology

 Treatment:
 Benzathine PCN G 2.4 million units x 1
 Sores

Genital Herpes Simplex -

Clinical Manifestations
• Transmission through direct contact – may be with
asymptomatic shedding
• Primary infection commonly asymptomatic;
symptomatic cases sometimes severe, prolonged,
systemic manifestations
• Vesicles ⇒ painful ulcerations ⇒ crusting
• Recurrence a potential

25
 HSV-2 Infection: Who knows it?
% % Reporting Sensitivity
Seropositive history of
for HSV-2 genital herpes
NHANES III 21.9 2.6 9.2
Black 3.7
Hispanic 3.8
White 12.2
Suburban MD Office 25.5 4.3 11.9
Project Respect 41 5 12

JCDH STD-males 45 6 36
(3 questions)
Fleming et al. NEJM 1997; 337:1105. Gottlieb et al. JID 2002; 186:1381-89. Leone P et al. Sex
Transm Dis. 2004; 31(5): 311-316. Sizemore et al, Sex Trans Inf , 2005;81:303-5. 26
 HSV: Diagnosis and Treatment
 Diagnosis:
 Culture
 Serology (Western blot)
 PCR

 Treatment:
 Acyclovir
 Valacyclovir
 Famciclovir
 Sores

Genital Herpes Simplex

Source: Diepgen TL, Yihune G et al. Dermatology Online Atlas 28

 Sores

Genital Herpes Simplex

Source: CDC/NCHSTP/Division of STD, STD Clinical Slides 29

 Sores

Genital Herpes Simplex in

Females

Source: Centers for Disease Control and Prevention 30

 Sores

Genital Herpes Simplex

Source: Florida STD/HIV Prevention Training Center 31

 “Drips”
Gonorrhea
Nongonococcal urethritis
Chlamydia
Mucopurulent cervicitis
Trichomonas vaginitis and urethritis
Bacterial vaginosis
32
 Drips

Gonorrhea - Clinical Manifestations

• Urethritis - male
– Incubation: 1-14 d (usually 2-5 d)
– Sx: Dysuria and urethral discharge (5% asymptomatic)
– Complications

• Urogenital infection - female

– Endocervical canal primary site
– 70-90% also colonize urethra
– Incubation: unclear; sx usually in l0 d
– Sx: majority asymptomatic; may have vaginal discharge,
dysuria, urination, labial pain/swelling, abdominal pain
– Complications

33
 Drips

Gonorrhea

Source: Florida STD/HIV Prevention Training Center 34

 Drips

Gonorrhea Gram Stain

Source: Cincinnati STD/HIV Prevention Training Center 35

 Drips

Nongonococcal Urethritis

Source: Diepgen TL, Yihune G et al. Dermatology Online Atlas 36

 Drips

Nongonococcal Urethritis
• Etiology:
– 20-40% C. trachomatis
– 20-30% genital mycoplasmas (Ureaplasma
urealyticum, Mycoplasma genitalium)
– Occasional Trichomonas vaginalis , HSV
– Unknown in ~50% cases
• Sx: Mild dysuria, mucoid discharge
• Dx: Urethral smear ≥ 5 PMNs (usually ≥15)/OI field
Urine microscopic ≥ 10 PMNs/HPF
Leukocyte esterase (+)

37
 Drips

Mucopurulent Cervicitis

Source: Seattle STD/HIV Prevention Training Center 38

 Drips

Chlamydia Life Cycle

Source: California STD/HIV Prevention Training Center 39

 Drips

Chlamydia trachomatis
• Clinical Manifestations:
– Mostly asymptomatic
– cervicitis, urethritis, proctitis, lymphogranuloma
venereum, and pelvic inflammatory disease

• Complications: Potential to transmit to

newborn during delivery
– Conjunctivitis, pneumonia

40
 Drips

Normal Cervix

Source: Claire E. Stevens, Seattle STD/HIV Prevention Training Center 41

 Drips

Chlamydia Cervicitis

Source: St. Louis STD/HIV Prevention Training Center 42

 Drips

Laboratory Testing: CT and GC

• Gram stain (gonorrhea)
• Culture
• Non-culture non-amplified tests
• Commercially available NAATs include:
– Becton Dickinson BDProbeTec®
– Gen-Probe AmpCT, Aptima®
– Roche Amplicor®
• Specimen types: urine, cervical, urethral,
vaginal, liquid PAP (not as sensitive)
• Serology (CT in setting of LGV) 43
 2010 CDC STD Treatment
Guidelines: Gonorrhea
• Recommended
– Ceftriaxone 250 mg IM x 1
OR IF NOT AN OPTION…
– Cefixime 400 mg PO x 1 Or
– Single-dose injectible cephalosporin regimens
PLUS
– Azithromycin 1gm PO x 1 Or
– Doxycycline 100mg PO BID x 7d
44
2010 CDC STD Treatment Guidelines
Chlamydia/NGU

Recommended:
Azithromycin 1gm po x 1 Or
Doxycycline 100mg po BID x 7d

Alternative:
Erythromycin base 500mg po QID x 7d Or
Erythromycin EES 800mg po QID x 7d Or
Levofloxacin 500mg po qd x 7d Or
Ofloxacin 300mg po BID x 7d
45
 Drips

Pelvic Inflammatory Disease (PID)

• 10%-20% women with GC develop PID
• In Europe and North America, higher proportion of
C. trachomatis than N. gonorrhoeae in women with
symptoms of PID
• CDC minimal criteria
– uterine adnexal tenderness, cervical motion
tenderness
• Other symptoms include
– endocervical discharge, fever, lower abdominal pain
• Complications:
– Infertility: 15%-24% with 1 episode PID secondary to
gonorrhea or chlamydia
– 7X risk of ectopic pregnancy with 1 episode PID
– chronic pelvic pain in 18%
46
 Drips

Pelvic Inflammatory Disease

Source: Cincinnati STD/HIV Prevention Training Center 47

 Drips

C. trachomatis Infection (PID)

Normal Human
Fallopian Tube Tissue PID Infection

Source: Patton, D.L. University of Washington, Seattle, Washington 48

 2010 CDC STD Treatment Guidelines:
PID Outpatient Treatment

 Ceftriaxone 250mg IM x 1 PLUS doxycycline 100mg po

BID x 14d +/- metronidazole 500mg po BID x 14d
 Cefoxitin 2g IM x 1 and probenecid 1g po x 1 PLUS
doxycycline 100mg po BID x 14d +/- metronidazole
500mg po BID x 14 d
 Other parenteral third generation cephalosporin PLUS
doxycycline 100mg po BID x 14d +/- metronidazole
500mg po BID x 14d

49
 Trichomonas vaginalis
• Sexually transmitted parasite
• Most common treatable STD
• Estimated prevalence:
– 7.9-13% in the general female population
• Prevalence increases with age
• Highest rates in AA (20.2%)
• Highest rates in southeast (14.4%)
– 6.1% to 33% prevalence in HIV+ women using wet prep +/-
culture; up to 52.6% with nucleic acid amplification testing
• Several studies support the epidemiological
association between TV and HIV and decreased genital
HIV shedding with treatment of TV
Watts 2006, Mostad 1997, Moodley 2003, Magnus 2003, Cu-Uvin 2002, Miller 2008, Kissinger
2009, Gaydos, 19th annual ISSTDR 2011 50
 Clinical Manifestations of
T. vaginalis

MOST TRICHOMONAL INFECTIONS ARE ASYMPTOMATIC!!! 51

 Diagnostic Tests for TV
• Females • Males
– Wet prep – Culture (multiple
– Culture specimen types)
– OSOM Trichomonas Rapid – Gen-Probe APTIMA
Test (Genzyme Combo 2®
Diagnostics, Cambridge, – Roche COBAS Amplicor
Massachusetts) PCR
– Affirm™ VP III (Becton
Dickenson, San Jose,
California) T. vaginalis , G.
vaginalis , and C. albicans .
– Gen-Probe APTIMA
Combo 2®
– Roche COBAS Amplicor
PCR
52
 2010 CDC STD Treatment Guidelines:
Trichomonas vaginalis

Recommended:
• Metronidazole 2gm PO x 1 dose Or
• Tinidazole 2gm PO x 1 dose

Alternative:
• Metronidazole 500mg PO BID x 7d*

*Consider as preferred in HIV-infected women 53

 Bacterial Vaginosis
• Polymicrobial clinical syndrome characterized by loss of
H2O2-producing lactobacillus sp.
• Most common cause of vaginitis/osis
• Prevalence varies by population:
– 5%-25% among college students; 12%-61% among STD patients

• Complications:
– Premature rupture of membranes, premature delivery, low birth-
weight delivery, acquisition of HIV, development of PID, post-
operative infections after gynecological procedures

54
 Bacterial Vaginosis
• 50% asymptomatic
• Signs/symptoms when present:
– malodorous (fishy smelling) vaginal
discharge
• Diagnosis:
– Amsel Criteria, vaginal Gram stain, rapid
tests

55
Indication to treat BV:

Symptoms!

56
 Bacterial Vaginosis Treatment
CDC-recommended regimens:
• Metronidazole 500 mg orally twice a day for 7 days
• Metronidazole gel 0.75%, one full applicator (5 grams)
intravaginally, once a day for 5 days
• Clindamycin cream 2%, one full applicator (5 grams)
intravaginally at bedtime for 7 days
Alternative regimens:
• Tinidazole 2gm po qd x 2 days
• Tinidazole 1gm po qd x 5 days
• Clindamycin 300 mg orally twice a day for 7 days
• Clindamycin ovules 100 g intravaginally once at bedtime
for 3 days
57
 HPV: Epidemiology
• Among sexually active women*:
– >50% have been infected with one or more
genital types
– 15% have current infection
• 50-75% of these are high-risk
• 1% have genital warts
• Prospective study of young women#
– 36mo incidence rate of 43%
• NHANES survey – 26.8% women 14-59 with
detectable HPV DNA (vaginal swabs)
*Koutsky. Am J Med 1997; Koutsky et al. Sex Trans Dis 1999. Svare et al JID 1997, Wideroff et al JID 1996;
*#Ho et al. NEJM. 1998 58
 HPV
• Transmission: skin-to-skin contact

• High-risk (16, 18 etc) vs low-risk (6, 11 etc) types

– Low-risk types: genital warts
– High-risk HPV infection is causally associated with cervical
cancer and other anogenital squamous cell cancers (e.g.
anal, penile, vulvar, vaginal)

• Diagnosis: Clinical exam, cytology, nucleic acid

amplification methods (in conjunction with
cytology for high-risk HPV types)

• Treatment: Topical and destructive modalities

59
 HPV-Associated Cervical Cancer

• 400,000-500,000 cases of cervical cancer

per year world-wide

• In US, rates down but still 12,280 cases and

4,021 deaths from cervical cancer in 2007

http://www.cdc.gov/cancer/cervical/statistics accessed 2/24/12 60

 Anal SCCA
• Incidence of squamous cell cancer of the anus
(SCCA) in the United States has increased by
~96% in men and ~39% in women
• Incidence of anal cancer in MSM estimated to be
35 cases / 100,000 population
– This is comparable to the incidence of cervical
cancer before the introduction of routine pap
screening

Chiao E, Giordano T, et al “Screening HIV-Infected Individuals for Anal Cancer Precursor Lesions:
A Systematic Review” CID 2006:43(15 July) 61
 HPV and Cervical Cancer

Perianal Warts

Source: Cincinnati STD/HIV Prevention Training Center 62

 HPV and Cervical Cancer

HPV Penile Warts

Source: Cincinnati STD/HIV Prevention Training Center 63

 HPV and Cervical Cancer

Intrameatal Wart of the Penis

(and Gonorrhea)

Source: Florida STD/HIV Prevention Training Center 64

 HPV and Cervical Cancer

HPV Cervical Warts

Source: Cincinnati STD/HIV Prevention Training Center 65

 HPV and Cervical Cancer

HPV Warts on the Thigh

Source: Cincinnati STD/HIV Prevention Training Center 66

 HPV and Cervical Cancer

Possible HPV on the Tongue

Source: Cincinnati STD/HIV Prevention Training Center 67

 HPV Vaccines - Females
CervarixTM – GSK GardasilTM - Merck
• HPV 16 and 18 • HPV types 6,11,16,18
• 0, 1, 6mo dosing • 0, 2, 6mo dosing
• Females 10-25yrs • Females 9-26yrs
• Approved 10/09
• Approved 6/06

Efficacy approximately 100% against

precancerous lesions caused by specific
types in the vaccine!
68
 Gardasil for Males
• Initial study demonstrated 90% efficacy
for preventing external lesions caused by
HPV types 6, 11, 16 and 18 in men 16-26y

• FDA approved (10/09) for males 9-26 for

prevention of genital warts

69
Gardasil for Anal Cancer Prevention

• HPV associated with approximately

90% of anal cancer
• Vaccine approved for new indication
December 22, 2010
• Males and females 9-26 years of age
• Prevention of anal cancer and
associated precancerous lesions
caused by HPV types 6, 11, 16, 18
70
 Questions?

National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

Division of STD Prevention