Sexually transmitted infections

Azeb Kebede(MD)
 Introduction
• STI – Infections acquired through sexual
intercourse which may be symptomatic or
asymptomatic
• STD – Symptomatic disease acquired through
sexual intercourse
• STI is most commonly used because it applies
to both symptomatic and asymptomatic
infections

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• STDs can be classified and managed in two
different ways ( approaches )

1. Etiologic approach
2. Syndromic approach
 Etiologic approach
• Advantages:
– Accurate diagnosis, accurate treatment, proper use
of antibiotics
– Decreases over treatment and antibiotic resistance
– It is the better way to diagnose and treat
asymptomatic infections
• Disadvantages:
– Needs lab support and expertise , expensive (cost
may be incurred due to lab tests ) and it is time
consuming
 Syndromic approach

• Advantages:
– Treatment can be given immediately,
– Mixed infection may exist and may be addressed,
– There is no need for laboratory diagnosis and
– The treatment can be given by middle level health professionals.
– A good alternative for in resource limited settings.
• Disadvantages:
– Over treatment with antibiotics,
– There is risk of creating antibiotic resistance and decreased
compliance.
– There is also increased cost of drugs.
– Moreover asymptomatic infection missed.
 STI Syndromes

• Urethral discharge Syndrome

• Vaginal discharge
• Genital ulcer
• Inguinal bubo
• Scrotal swelling
• Lower abdominal pain
• Neonatal conjunctivitis
 1. Urethral discharge
• Urethral discharge is the most common
presenting compliant of men with STD.
• the discharge is often accompanied by dysuria
or urethral discomfort.
• It may lead to epididymitis and complications
such as infertility and urethral stricture.
 Etiology

• Nisseria gonorrhea
– present with abundant and purulent discharge
– Tend to produce more severe urinary tract
infection symptoms like dysuria, urgency and
frequency.
• Chlamydia trachomatis
– Has scanty to moderate, white, mucoid or serous
discharge.
– Mild urinary tract infection symptoms
 Laboratory
• Gram stain--- intracellular diplococci
(N.gonorrhea.)
• Pus cells without intracellular diplococci =
Nongonococcal urethritis
 Treatment
• Gonococcal Urethritis:
– Ceftriaxone 250mg IM stat OR
– Ciprofloacin 500mg PO stat
• NGU: Doxycycline 100mg PO BID for 7 days
• When there is no Etiologic diagnosis:
Treatment should cover both gonococccal and
chlamydial infections (combine the above
treatments)
 2.Vaginal Discharge
• Could be due to either vaginitis or cervicitis
• Etiology
– N.gonorrhea
– Chlamydia trachomatis
– Trichomonas vaginalis,
– Candida albicans
– Bacterial vaginosis (Gardnerella vaginalis and other anaerobes)
• The first three are sexually acquired and the last two are
endogenous infections.
• The first two cause cervicitis while the last three cause
vaginitis.
Bacterial Vaginosis
• Amsel criteria for diagnosis of BV,
– Thin, grayish-white discharge that smoothly coats
the vaginal walls
– Vaginal pH greater than 4.5
– Positive whiff test, defined as the presence of a
fishy odor when 10 % KOH is added to a sample of
vaginal discharge
– Clue cells (vaginal epithelial cells studded with
adherent coccobacilli ) on saline wet mount
• Trichomoniasis
– present with profuse, runny, mal-odorous
discharge.
– Wet mount- motile flagellated protozoa
– clue cells may be seen
– Whiff test may be positive
– Increased vaginal PH
– Culture is the gold standard
• Vaginal candidiasis
– often present with white, «Cheese-like» discharge
and pruritis
– Vaginal PH is usually normal
– wet mount is normal
– KOH- fungal elements
– Culture for definitive Dx
• Cervicitis:
– The presence of purulent exudates from the cervical
os indicates infection with N.gonorrhea and
C.trachomatis.
• Complications of Cervicitis and Vaginitis
– PID
– Premature rapture of membrane
– Preterm labor
– Infertility
– Chronic pelvic pain
Rx. of vaginal discharge syndrome
• Ciprofloxacin 500 mg PO stat Plus
• Doxycycline 100 mg PO BID for 7 days Plus
• Metronidazole 500mg Po ID for 7 days

• Clotrimazole vaginal tabs 200mg at bed time

for 3 days for candidiasis
 3. Genital Ulcer
• Genital ulcers may be painful or painless and are
frequently accompanied by inguinal
lymphadenopatly.
• Common Etiologic agents:
– Treponema pallidum (syphilis)
– Haemophilus ducreyi (chancroid)
– Granuloma inguinale
– C.trachomatis serovar L1-L3 (Lymphogranuloma
venereum or LGV)
– Herpes simplex virus
 Syphilis
• Genital ulcer occurs in the primary stage of the
diseases
• It starts as a small popular lesion that rapidly
ulcerates to produce a non tender indurated
lesion with a clean base and raised margins
known as chancre
• Chancres may appear at any point of contact
(genitals, anus, mouth, lips )
• Swollen lymph nodes may appear
 Syphilitic chancre(non classic)
Syphilitic chancre(classic)

Courtesy of the Division of STD Prevention/CDC

 Genital Herpes
• HSV virus has two types
– HSV-2 causes dominantly genital disease
– HSV-1 causes dominantly oral disease
• Herpetic ulcers
– Are usually painful and multiple
– Starts as clear vesicle and becomes pustule, which
later erodes to an ulcer
– Heals spontaneously after 2-3 weeks
Herpes vesicles Severe Chronic HS ulcer

© Slice of Life and Suzanne S. Stensaas

 Chancroid
• Caused by Haemophilus ducreyi
• It is painful progressing from a small papule
to pustule and then ulcer with soft margins
described as soft chancre
• Inguinal adenopathy ( Inguinal bubo ) follows
the ulcer within 1-2 weeks
• Complication: Penile autoamputaion
Ulcer of chancroid - Painful, soft margin
Diagnosis
•Gram stain
• Culture -growth of h.
ducreyi in special media

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 Lymphogranuloma Venereum (LGV)
• Caused by L1, L2 and L3 serovars of Chlamydia
trachomatis
• Major pathology occurs in the lymphatic system
• Primary stage is marked by a painless vesiculo-
papular ulceration at the site of inoculation
• Primary lesion is usually not noticed.
• The secondary stage is described as the inguinal
syndrome
– A painful inguinal lymphadenitis--causing inguinal and
femoral lymphadenitis.
• Inguinal adenopathy is usually unilateral (2/3 of
cases)
• Nodes initially discreet later becomes fluctuant and
suppurative developing multiple draining fistulas
• Bubo may be grooved by the inguinal ligament
("groove sign" of LGV)
• Late complications include
– Genital elephantiasis
– Adhesion
– Stricture and fistula of the penis, urethra and the rectum
GROOVE SIGN

LG.VENEREUM-
C.TRACHOMITIS L1 L2 L3

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 Granuloma Inguinale (Donovanosis)

• Etiology: Calymmatobacterium granulomatisa

gram-negative intra-cellular bacteria
• Transmission –sexual and non-sexual contact
• Non suppurative genital lesion which
develops from a small firm papule to painless
ulcer
• Lesion bleeds easily, expand gradually
• 50% women have lesion on cervix
 Inflammatory nodule-
Ulcer of g.inguinale vascular beefy red ulcer
and lesion along lymphatic
drainage
Dx -microscopic evaluation
of tissue biopsy

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• Complications of Granuloma Inguinale
– Genital pseudo-elephantiasis of labia
– Adhesion
– Urethral , vaginal or rectal stenosis
 Management of Genital Ulcer
(syndromic)
• Recommended treatment for non-vesicular genital
ulcer
– Benzanthine penicilline 2.4 million units IM stat
or
– Doxycycline 100 mg bid for 15 days and Ciprofloxacin
500mg, po, bid for 3 days, or
– Erythromycin 500 mg, po, QID for 7 days
• Recommended treatment for vesicular or recurrent
genital ulcer
– Acyclovir 200 mg five times per day for 10 days, or
– Acyclovir 400 mg TID for 10 days
 …GUD
Etiologic mgt
• Syphilis:
– Benzanthine penicillin 2.4million IU IM stat OR
– Procaine penicillin 1.2million IU IM daily for 10 days.
– In penicillin allergic patients, doxycycline 100mg PO BID for 15
days
• Treatment of chancroid:
– Ceftriaxone 250mg 1M stat or
– Erythromycin 500mg PO TID for 7 days
• Treatmen of LGV:
– Doxycycline 100mg PO BID for 14 days or
– Tetracycline 500mg PO QID for 14 days
• Treatment of Granuloma inguinale
– Cotrimoxazole 02 tab PO BID for 14 days
 4. Lower Abdominal Pain Due to PID
(Pelvic Inflammatory Disease)
• PID is ascending infection of the upper genital
tract (uterus, tubes, ovaries etc) from the
cervix or vagina
• Common etiologies:
– Sexually transmitted: Neisseria gonorrhea,
Chlamydia trachomatis
– Others (non-STI): streptococci, E. coli, etc
• Vaginal discharge is often present

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• Rule out other cause of lower abdominal pain
in women such as appendicitis , ectopic
pregnancy and Cholecystitis
• Complications
– Peritonitis and intra-abdominal abscess
– Adhesion and Intestinal obstruction
– Ectopic Pregnancy
– Infertility
 Treatment
• Most patients with mild to moderate PID can
be treated as an out patient
• Indications for admission are
– Uncertain diagnosis
– Pelvic abscess suspected
– Pregnant patients
– Co infection with HIV
 Recommended Treatment PID
Out patient Inpatient
Ciprofloxacin 500mg PO Ceftriaxone 250mg IV BID,
stat plus
plus Doxycycline 100mg BID for
Doxycycline 100mg BID for 14 days
14 days plus
plus Metronidazole 500mg BID
Metronidazole 500mg BID for 14 days,
for 14 days
Admit the patient if there is
no improvement within 72
hours
 5. Inguinal Bubo
• Swelling of inguinal lymph nodes as a result of
STIs (or other causes)
• Common causes:
– Treponema pallidum (syphilis)
– Chlamydia trachomatis (LGV)
– Hemophylus ducreyi (chancroid)
– Calymatobacterium granulomatis (granuloma
inguinale)
Inguinal Bubo

Courtesy of CDC/ Susan Lindsley

 …inguinal Bubo
• Recommended treatment:
– Ciprofloxacin 500mg PO BID for 3 days
and
– Erythromycin 500mg PO QID for 14 to 21 days
or
– doxycycline, 100 mg orally, twice daily for 14 days
 6. Scrotal Swelling syndrome
• Common STI causes of scrotal swelling are
similar to those of urethral discharge
– Neisseria gonorrhea
– Chlamydia trachomatis
• Exclude non-STI causes of scrotal swelling:
– TB
– Inguinal hernia
– Testicular torsion, etc

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• Recommended treatment for Scrotal swelling
– Ciprofloxacin 500 mg PO stat PLUS
– Doxycycline 100 mg PO BID for 7 days
 7. Neonatal Conjunctivitis
• Infection of the eyes of the neonate as a result of genital
infection of the mother, transmitted during birth
• Causes:
– Neisseria gonorrhea
– Chlamydia trachomatis
• Treatment:
– Spectinomycin 50mg/kg IM stat or ceftriaxone 125mg IM stat
plus
– Erythromycin 50mg/kg PO in 4 divided doses for 10 days
• May lead to blindness if not treated properly
 Comprehensive Case Management

 Is vital approach for controlling STIs.

 So health care providers should undertake the
following measures besides treating individual
patients
1. Partner notification and management
2. Condom promotion and supply
3. Health education and risk reduction counseling
4. Linkage with HIV counseling and testing
5. Follow-up visits for patients with STI
Thank you