SEXUALLY TRANSMITTED
INFECTIONS
DR MEMOONA F REHMAN
ASSISTANT PROFESSOR
OBGYN,JSMU
Sexually Transmitted Infections
• VIRAL HSV & HPV
• BACTERIAL
Chlamydia and gonorrhea
Syphilis
Optional (chancroid, LGV, Granuloma inguinale)
• FLAGELLATES
Trichomonas
• Blood borne (HIV,HBV,HCV)
Sexually Transmitted Infections
1. Partner notification and treatment
2. Best treated at a specialist GUM clinic
3. Provides counselling and support
4. Confidentiality paramount
Risk Factors for STIs
• Multiple partners (2 or more in the last year)
• Concurrent partners
• Recent partner change (in the past 3 months)
• Non-use of barrier protection
• STI in partner
• Younger age (particularly aged <25 years)
• Involvement in the commercial sex industry
History
• Symptoms: lumps, bumps, ulcers, rash, itching, IMB or PCB, low
abdominal pain, dyspareunia, sudden/distinct change in discharge
• Past history of STIs/GUM clinic attendance/last HIV-ve test
• All sexual partners in past 12 months/ Bisexual male partners
• Risk Factors for Blood-Borne Viruses(HIV,HBV,HCV)
• IV drug use
Incubation Period
• Incubation period before tests for STIs become positive
can give false negative after a single episode of sex
• For bacterial STIs, this is 10-14 days
Tests should be done at the time of presentation
• For HIV and syphilis, it may be up to 3 months
Chlamydia
Chlamydia trachomatis obligate intracellular parasite
Commonest bacterial STI in the UK
• Symptoms
Dysuria, vaginal discharge, or irregular bleeding (MB or ICB but
70% of cases are asymptomatic)
Complications
Pelvic inflammatory disease (10-40% result in PID)
Perihepatitis (Fitz-Hugh-Curtis syndrome)
Reiter's syndrome (men): arthritis, urethritis, conjunctivitis
Tubal infertility
Risk of ectopic pregnancy
Chlamydia - Diagnosis
• Vulvovaginal or endocervical swab for nucleic
acid amplification test (NAAT)
Treatment
Azithromycin 1g single dose or doxycycline
100mg bd for 7 days
Both have similar efficacy of >95%
Contact tracing and treatment of partners
HERPES SIMPLEX VIRUS
Herpes simplex virus (HSV) is a DNA
virus that causes genital and orolabial
infections.
HSV type 1 ……. Orolabial inections
HSV type 2 ……. genital infections
.
HSV PRIMARY INFECTION
Symptoms
• Primary HSV infection is severe
• presents with a prodrome of tingling/itching
of the affected area.
• Patients may also experience a flu-like illness,
inguinal lymphadenopathy, vulvitis, and pain
(which may cause urinary retention).
• Small vesicles are a characteristic feature of genital
herpes, but the rash can be present
Recurrent HSV infections
• occur due to reactivation of the latent virus in the sacral ganglia
• normally shorter and less severe.
• triggering factors for recurrent attacks, including stress, sexual
intercourse, & menstruation.
Complications of HSV Infections
• Meningitis
• sacral radiculopathy
• transverse myelitis
• disseminated infection.
Diagnosis
• usually based on the appearance of the typical
rash.
• The gold standard for diagnosis is PCR testing of
vesicular fluid.
• Culture of vesicular fluid is also used for
diagnosis.
• Serum antibody tests are not useful for
diagnosing primary herpes.
HSV: Treatment and Prevention
• There is no cure for genital herpes,
• symptomatic relief with analgesia, saline bathing, and topical anaesthetics.
• Oral acyclovir (200mg 5x day for 5 days) is used for primary and recurrent
attacks, and double
• Condoms/abstinence should be used while prodromal/symptomatic
(unless both partners have a history of HSV) to reduce transmission
• Suppressive antiviral treatment is considered if there are more than six
recurrences per year.
Gonorrhea
- Neisseria gonorrhoeae:
intracellular Gram-ve diplococcus
Symptoms of Gonorrhoea
• mostly asymptomatic
Can present with vaginal discharge, low abdominal pain, IMB or
PCB
• Diagnosis of Gonorrhoea
- Endocervical or vulvovaginal swab with NAAT
- Urethral, pharyngeal, and rectal swabs if contact with
gonorrhoea
- Culture for sensitivity testing should be taken from all sites prior
to antibiotic treatment if diagnosed on NAAT
Complications of Gonorrhoea
• PID (-10% of infections result in PID)
• Bartholin's or Skene's abscess
• Disseminated gonorrhoea may cause fever,
pustular rash, migratory polyarthralgia, septic
arthritis
• Tubal infertility
• Risk of ectopic pregnancy
Treatment of Gonorrhoea
• Ceftriaxone 500mg IM stat, plus azithromycin
1g PO stat
• Spectinomycin 2g IM, plus azithromycin 1g PO
stat (if severe penicillin allergy)
Contact tracing and treatment of partners
Syphilis
• Treponema pallidum-spirochaete
• PRIMARY SYPHILIS: painless, genital ulcer (chancre), may pass unnoticed
on the cervix, inguinal lymphadenopathy
• SECONDARY SYPHILIS: generalized polymorphic rash affecting palms,
generalized lymphadenopathy, genital condyloma lata, anterior uveitis
• TERTIARY SYPHILIS: presents in up to 40% of people infected for at least
2yrs, but may take 40+yrs to develop. Neurosyphilis, cardiovascular
syphilis, gummata
Diagnosis and Treatment of Syphilis
• Specific treponemal enzyme immunoassay (EIA) for screening (gG IgM)
• 1° lesion smear may show spirochaetes on dark field microscopy
• Quantitative cardiolipin (non-treponemal) tests, ie, rapid plasma reagin
(RPR)/VDRL are useful in assessing need for and response to treatment
• TREATMENT
- Benzathine benzylpenicillin 2.4 MU single dose IM
Erythromycin
- Doxycycline 100mg bd PO for 14 days
Contact tracing
Trichomonas
• flagellated protozoan that can cause infections in the urogenital tract.
SYMPTOMS
• Trichomonas infects vaginal ,urethral and para-urethral glands
• punctate hemorrhages and a strawberry appearance.
- Up to 50% of cases may be asymptomatic, but symptoms can include
offensive smelling vaginal discharge, aching and soreness.
DIAGNOSIS
- Trichomonas can be diagnosed by direct observation of the organism
in a wet smear
- Culture media can diagnose up to 80% of cases
-NAATs
Complications
• Trichomonas infection may enhance the risk of HIV transmission.
• TREATMENT
• - Metronidazole is the recommended treatment for trichomonas,
with 2g orally in a single dose
or 400-500mg bd for 5-7 days.
• - Contact tracing and treatment of partners is also recommended.
HUMAN PAPILLOMA VIRUS(HPV)
• HPV is a DNA virus
• Subtypes 6 and 11 genital warts /condylomata acuminata
• subtypes 16 and 18 high-grade CIN & cervical neoplasia.
- 25% of people presenting with warts have other concurrent STIs.
SYMPTOMS
- HPV infections are often asymptomatic, but can present as painless
lumps anywhere in the genitoanal area.
- Perianal warts are common in the absence of anal intercourse.
Diagnosis And Treatment (HPV)
• HPV can usually be identified by clinical appearance
• HPV infection (Non warts)on cervical cytology or colposcopy.
TREATMENT for genital warts involves removal of the visible
wart with high rates of recurrence
• Cryotherapy
• trichloroacetic acid
• electrosurgery, scissors excision, laser
• - Podophyllotoxin cream
• imiquimod cream
• Routine HPV vaccination is recommended for all girls(12-13
yrs to prevent HPV-related diseases(warts & cervical cancer)
CHANCROID
• Caused by H.ducreyi gram negative rod,
• painful & tender genital ulcer
• suppurative inguinal adenopathy
• Highly contagious
• Treated with ceftriazone and azithromycin
GRANULOMA INGUINALE
Also called DONOVANOSIS, caused by Klebsiella
granulomatis
• Painless, ulcerative vulvitis
• Chronic /recurrent
• No lymphadenopathy
TREATMENT
• azithromycin or erythromycin
• Ciprofloxacin
• doxycyclin
LYMPHOGRANULOMA VENEREUM
• Caused by aggressive serotypes of Chlamydia
trachomatis
• Tender inguinal lympadenopathy
• Genital ulcer not evident often
TREATMENT
Azithromycin
Tetracyclin(doxycyclin)
Thank you
