Sexually Transmitted Infections
Terra Safer, MD
Internal Medicine/Pediatrics
Associate Clinical Professor
Patient case
• 72 yo F with hx HTN here for annual physical.
• In regards in GYN/GU history: no vaginal d/c,
itch nor odor. No vaginal bleeding.
• Social hx: Patient is married but…
Learning Objectives
• Understand epidemiology/burden of STI
– Adolescents
• Differentiate between different STI
– Clinical presentation
– Diagnostic testing
– Treatment
• Know Screening guidelines
Epidemiology
• Sexually transmitted infections (STIs) cause
significant morbidity and mortality in the
United States each year.
• CDC estimates 19 million new infections/yr in
US
– almost one half of which occur in 15 to 24 yo
• Estimated 2.8 million new chlamydia infxn
• 1.6 million new genital herpes infxn
Risk to Adolescents
• 40% of Chlamydia and Gonorrheal infxn/yr in adol
• ½ of people<25 yo have STI
• Behavior
– Early intercourse
• 47% reported sexually active by the end of high school (down)
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–
–
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Multiple partners (with multiple partners)
New partners
Inconsistent condom use
Alcohol/drug use
• Biology
– Cervical ectopic/immaturity
STI
• Ulcers
– Syphilis
– Herpes Simplex
– Lymphogranuloma
venereum
– Chancroid
• Other
– HPV
– HIV
• Discharge
– Gonorrhea
– Chlamydia
– Nongonococcal
nonchlamydial urethritis
and cervicitis
– Trichomonias
– Candida
– Bacterial vaginosis
Gonorrhea
• Sx: within 10 days of
exposure F; 1-14d M
• F: up to 70% asx, dysuria,
vaginal/urethral d/c,
pruritus, intermenstrual
bleed, pelvic pain
• M: up to 60% asx or mild
sx, swollen testes, penile
d/c, dysuria, epididymitis
(unilateral)
• Throat and rectum
• PID
• Bacteremic/disseminated
– purulent arthritis or triad
tenosynovitis, dermatitis,
polyarthralgia
• Dx:
• Exam: Mucopurulent d/c
from cervix, friable cervix
• PAP or swab or urine
NAAT; GS;
• check chlamydia
Gonorrhea
• Gram Stain: PMN with
intracellular Gram neg
diplococci
• Culture
– if resistance suspected;
– if cont sx post treatment
• Tx: Increasing resistance:
ceftriaxone 250mg IM x1
azithromycin 2nd line
–
–
–
–
No need test for cure
Retest 3 months
Expedited partner therapy:
oral cefixime and
azithromycin for GC
Chlamydia
• Sx: often ax—85% female and 40-96% male
• F: burn/pruritus of GU, d/c, dysuria, abnl vaginal bleeding
• M: mucoid watery urethral d/c and dysuria,
– freq cause epididymitis <35yo, may cause chronic prostatitis
• Complications: PID; can affect the throat or rectum
• Dx: exam: 10-20% abnl exam; mucopurulent endocervical
d/c; easy to bleed or edematous cervix
• NAAT of vaginal swab or urine
• Tx: Azithromycin 1g x1 or doxycycline 100mg bid x 7day
• No need test for cure unless pregnant or cont with sx
Pelvic Inflammatory Disease
• Acute infection of upper female genital tract
structure including uterus, oviducts, ovaries
• Risk: hx of PID; adol 50% more likely to recur
• Cause: GC, Chlamydia, nl vaginal flora
including enteric Gram neg rod, Strep,
Gardnerella may play role
– Up to 10% untreated GC and 20% unrx Chl dev PID
• Sx: lower abdominal pain with new vaginal
d/c, dysuria, painful defecation, f/c,
perihepatitis
Fitz Hugh Curtis Syndrome
• Perihepatitis: infxn of liver capsule and
peritoneal surfaces of anterior RUQ
• Patchy purulent and fibrinous exudate in acute
phase (violin string adhesions) affecting
primary ant surface of liver (not parenchyma)
• Sx: sudden severe RUQ pain with distinct
pleuritic component, sometimes to R shoulder
• LFT normal or sl increased
PID
• CDC minimal CRITERIA: CMT or uterine or adnexal tender
– supportive dx: fever with cervical/vaginal d/c with lower
abd/pelvic pain
• Lab: ESR, WBC, microexam, Cervical cx, bHCG and u/a, HIV
• Pelvic US for acutely ill to r/o abscess
• Complications: tubo ovarian abscess, infertility, chronic
pelvic pain, ectopic preg
• Risk complication increase with # episodes and severity of
PID
– Infertility increased with
Chlamydia, delay in rx, number of PID
– Rx may NOT prevent long term sequellae
scarring and adhesions with healing
TREATMENT OF PID with broad spectrum abx with anaerobic coverage if recent
instrumentation or severe/complicated PID (abscess)
Inpt severe/complicated: 2nd generation cephalosporin cefoxitin or cefotetan
and doxy OR clinda and gent, oral post 24 hr improved
Oupt: Ceftriaxone 250mg IM and doxy x 14 days, recheck 72 hrs (+/- flagyl)
Trichomoniasis
• Protozoa: Trichomonas vaginalis
• Sx: F: 50% asx; yellow green thin d/c and odor, itch or
burning vaginal, pain with intercourse, dysuria
• M: asx, minor d/c or dysuria/urethritis
• 5-28 day post infection sx develop
• Dx: Exam: abnl d/c with strawberry cervix
• Wet Mount: motile trichomonads, hi pH and PMNs
• Culture, NAAT testing
• Tx: metronizadole 2gm or tinidazole 2gm x1
• Untreated: urethritis, cystitis, atypical PID, infertility,
more susceptible to HIV, preterm labor/low birth wt
Trichomonas vaginalis
Bacterial Vaginosis
• Polymicrobial clinical syndrome
• Change normal vaginal flora with decrease nl H2O2
producing lactobacilli
• Increase other organisms—esp Gardnerella vaginalis
• Sx: 50-75% ax; off white, creamy or foamy thin
malodorous (fish smelling) discharge
– increase post SA and in menses
• Dx: 3 of 4 Amsel criteria:
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–
–
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clue cells >20% of epi cells on wet mount;
homogenous thin gray white d/c coating vaginal walls;
pH >4.5 vaginally;
+whiff amine test: fishy odor when 10% KOH added
Nl wet mount vs clue cells
Bacterial Vaginosis
• Tx: Metronidazole 500 bid x 7day
or gel 0.75 qhs x 5 days;
Clindamycin
• 30% recur within 3 months, 50%
recur within 12 months
• Relapse: change abx, longer
course, boric acid; metronidazole
2/week x 4-6 mos
• Complications: preterm labor;
birth risk, plasma cell
endometritis, postpartum F, post
abortion infection, PID, increase
risk other STI
Candidiasis
• Normal flora but overgrowth and penetration of
superficial epithelial cells
• Candida albicans 80-92% of vulvovaginitis
– C glabrata next common
• Sx: vulvar pruritus (main), vulvar burning,
soreness, irritation, dysuria, dyspareunia
• Dx: exam: vulva and vaginal erythema,
excoriation and fissures with d/c: little or white,
thick adherent, clumpy with minimal odor
• Candida on wet mount or GS or culture
– Cx if persistent, recurrent sx (nonalbicans resistant to
azoles)
• Tx: asx no req rx, no rx partner
• Uncomplicated: <3/yr, mildmod sx, C albicans, nonpreg
(>80%)
– oral and topical comparable
cure Fluconazole 150mg x1
• Complicated: DM, preg,
immunosuppressed,
debilitated
– fluconazole 150mg q3 day x2
– C glabrata boric acid x 2 weeks
• Recurrent: (>4/yr): suppress
fluconazole 150mg q3day x 3
then qwk x 6 months
Syphilis
• Chronic infxn by spirochete Treponema pallidum
• Stages: early, 1, 2, early latent: within first yr
– latent: asx with + serology
• Primary: Chancre: painless ulcer with mild/mod
regional LAD (unnoticed 15-30%)
• Secondary: Hematogenous dissemination
– systemic sx: malaise, fever, HA
– rash on soles of feet/palms/body; hair loss
– Condylomata lata (grey moist raised patch)
Treponema pallidum
Primary Syphilis
Secondary Syphilis
Secondary Syphilis
Late/Tertiary Syphilis
• 3-10 yrs post initial infection
• Gummatous syphilis: involve any body part
• skin (ulcerative lesion), bone, internal organ (like
mass), CV (aortic root leading to AI, coronary art
involvement can lead to thrombosis and MI)
– PCN G 2.4 million U qwk x 3 wk
• Neurosyphilis: invasion of CSF
• meningitis, general paresis, tabes dorsalis,
meningovasc dz
– Dev post 1 yr up to 25 yrs later
– Treatment PCN G 24 million U/day x 14 days
Argyll Robertson Pupil
Syphilis
• Dx: Clinical, Darkfield, Serologic testing
• Nontreponemal: semiquantative, titer of Ab
– RPR, VDRL
– Height of Ab=activity of dz, follow with treatment
• Treponemal test: either reactive or nonreactive
– once +, stays for extended time; FTA antibodies
• Tx: benzathine PCN G 2.4 million U once
• Late latent or unknown: 3 doses weekly of above
• Severe PCN all: doxy or azithromycin
Syphilis
• Post rx: test clinical, serologic at 6, 12 mos
– four fold decrease in titer of nontrep= +response
• If no appropriate decline in titer, another
course of PCN and check HIV and LP
• Jarish-Herxheimer rxn: Acute febrile reaction
with HA, myalgia within 24hr of rx with PCN
(more common with early syphilis)
– supportive treatment
Chancroid
• Hemophilis ducreyi, small fastidious Gm neg rod
• Rare in US: Africa and Asia
• Sx: painful lumps in GU that progress to open
sores (deep undermined purulent ulcer) with LAD
– Infected LN: buboes
• Incubate 4-10 days (range 1-35 days)
• Dx: sx since special media for cx needed
– Also check HSV, RPR
• Tx: Azithromycin 1gm or CTX 250mg
• Buboes may require surgery to drain
Herpes Simplex Virus
• Direct contact, genital: HSV 2 (60-70%)
• Sx: Vesicles into painful ulcerations then, crusted sores
on GU area/buttock/thigh, anus
• Primary infxn: painful ulcers with constitutional sx or
mild/asx
• Clinical recurrence genital HSV common but less severe
• Asx intermittent shedding without lesions
• Increase risk HSV acquisition with male source partner
• Dx: confirm by PCR, viral cx; serology
HSV treatment
• Antiviral: famciclovir and valacyclovir have
improved bioavailability vs acyclovir
• >6 recurrence/yr and/or severe sx: chronic
suppressive antiviral (<6 or mod sx, episodic
antiviral rather than chronic)
– lysine
• 50% on suppression remain recurrence free,
others 70-80% decrease freq recurrence and less
asx shedding
– Patient considerations: psychosocial, adherence, cost,
risk to uninfected partner
Lymphogranuloma Venereum
• Chlamydia trachomatis serovars L1, L2, L3
• In tropical and subtropical areas
• Sx: Ulcer at site of inoculation then lymphoproliferative
rxn with direct extension from primary infxn site to
draining LN
– fever, HA, anal sores, rectal d/c or pain or bleed/proctitis
(anal sex)
• Dx: cx low yield; serology low specificity; NAAT for LGV
• Tx: doxy 100mg bid x 21 day or azithromycin 1 gm qwk
x 3wk
• Buboes may require I&D/aspiration to avoid sinus
tract/rupture
Human Papilloma Virus (HPV)
• Small double stranded DNA virus
• Only infect humans with skin to skin
• Associated with squamous neoplasia of
anogenital region and oropharynx
• No need to have sexual intercourse to get
• Type 16-18 70% of cervical cancers (16: 60%)
• Type 6,11 90% of genital warts
HPV
• Dx: Clinical, Cytology, NAAT
– Acetic Acid, Colposcopy (acid, green filter, iodine)
•
•
•
•
Tx: Wart: chemical destruction
Provider destructive (cryo, electrocautery)
Colposcopy: biopsy
Prevention
– Gardasil Quadrivalent Vaccine 6,11,16,18
– Cervarix Bivalent 16,18
• 25 yo F presents with change in vaginal d/c
with itch and odor.
• On exam there is thin gray d/c vaginally with
fish odor…
• Bacterial Vaginosis
• 60 yo M presents with rash that has
developed on his palms and soles. Also
noticed hair loss recently which he assumed
was due to his age…
• Secondary Syphilis
• PCN
20 yo M presents with hot red
swollen knee.
Gonorrheal arthritis
• 24yo male present with right testicular pain.
• On exam you notice swelling and pain over the
epididymis.
• Which 2 organisms do you need to treat while
awaiting results of testing?
• A. Gonorrhea
• B. Treponema
• C. Chlamydia
• D. Gardnerella
• E. Trichomonas
30 yo M notices ulcer on penis,
painless.
If not treated, what
can the patient
expect?
A. Recurrence
B. Enlarging LN
C. Body rash
• 18 yo F presents for her annual exam. Patient
has no complaints, specifically no vaginal d/c,
itch, odor nor dysuria.
• On exam you notice
• Trichomonias
• 32 yo M presents with
complaints of painful
lesions on his penis.
• What treatment would
you offer him?
• Valacyclovir
• 62 yo M presents in clinic since his wife stated
his pupils look different.
• On exam his pupil does not react to light on
the right, but does accommodate.
• Treat with PCN G x 3 doses weekly