Sexually Transmitted
Diseases
JFK pediatric core curriculum
MGH Center for Global Health
Pediatric Global Health Leadership Fellowship
Credits:
CDC, STD Treatment Guidelines, 2006
Discussion outline
• Common Sexually Transmitted Diseases
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Symptoms/signs
Investigations
Treatment
Special notes
• Screening
• Men who have sex with men/women who have
sex with women (MSM/ WSW)
• Vaccinations
• Sexual Assault
Common Sexually Transmitted
Diseases
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Ulcerative disease
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Chancroid
Genital HSV
Granuloma inguinale
Lymphogranuloma venerum
Syphilis
Urethritis/Cervicitis
Vaginal discharge
– Bacterial Vaginosis
– Trichomoniasis
– Vulvovaginal Candidiasis
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Pelvic inflammatory disease
Epididymitis
Genital warts
Ectoparasitic infections
– Pediculosis Pubis
– Scabies
Chancroid (H. ducreyi)
• Symptoms/signs
– Painful genital ulcer, tender suppurative
lymphadenopathy
• Investigations
– Criteria: 1. painful genital ulcer (s) 2. no syphilis 3.
Ulcer exudates HSV (-)
• Treatment
– Azithro 1 g x 1 or CTX 250 mg x1 or Cipro 500 mg po
bid x 3d or erythro 500 mg po tid x 7 day
• Special notes
– 10% co-infected with T. pallidum or HSV
– Cofactor for HIV transmission
Genital HSV
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Symptoms/signs
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Investigations
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DFA or Viral cell cx with typing (low SN for healing lesions)
Neg. virologic test does not rule-out infection due to intermittent shedding
Type-specific serum Ab (after 7wks, persist indefinitely, SN 80-98%, SP>95%)
Treatment
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Mostly no sx
Small, painful, grouped vesicles/ shallow ulcers
Erythema multiforme, neuro sequellae, dissemination
Valacyclovir (1g PO BID) OR famciclovir (250mg PO TID) both have good oral bioavailability,
acyclovir (400mg PO TID OR 200mg PO FID). Duration 7-10d.
Severe (complications, hospitalization, CNS): IV acyclovir
Acyclovir-resistant: ID consult, consider foscarnet/topical cidofovir
Special notes
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Treat patients with initial genital herpes
Consider 2˚ prevention (suppressive or episodic tx if >5 episodes/yr, though does not clear
latent virus)
Counsel re: pregnancy
HSV-2>HSV-1; First-episode likely HSV-1; Recurrence likely HSV-2
Granuloma inguinale (Donovanosis)
(Klebsiella granulomatis)
• Symptoms/signs
– Painless, progressive, beefy-red, vascular ulcerative
lesions, no LAD
• Investigations
– Visualization of dark-staining Donovan bodies on
tissue crush preparation/biopsy
• Treatment
– Doxy 100mg PO BID x3wks/until lesions healed
– Add gentamicin 1mg/kg IV q8h if no early
improvement
• Special notes
– Tx halts lesion progression
Lymphogranuloma venereum
(C. trachomatis L1, L2, L3)
• Symptoms/signs
– Unilateral, tender inguinal/femoral LAD, self-limited
ulcer/papule often gone, proctocolitis if anal exposure
• Investigations
– Urine, genital and/or LN specimens for CT (cx, direct
immunofluorescence, nucleic acid detection)
• Treatment
– Doxy 100mg PO BID x3wks
– Buboes require aspiration
• Special notes
– Tx cures infection and prevents ongoing tissue
damage
Syphilis (T. pallidum)
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Symptoms/signs
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Investigations
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Definitive: Darkfield exam/DFA of lesion
Presumptive:
Non-treponemal (VDRL, RPR) correlate with disease activity/tx response
Treponemal (FTA-ABS, TP-PA)
If neurologic sx:
CSF: VDRL is SP, FTA-ABS is SN, serologies, CSF cell count/protein
Ocular slit-lamp exam
Treatment
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1˚: ulcer/chancre
2˚: rash, mucocutaneous lesions, LAD
3˚: cardiac/ophthalmic, auditory, gumma
Neurosyphilis
Latent: (early latent vs. late latent) no sx
Benzathine PCN G:
2.4 million units IM x1 for 1˚/2˚/early latent (exposure within 1yr)
2.4 million units x3wks for 3˚, late latent
Aqueous crystalline PCN G 18-24 million units/d (q4h or continuous) x10-14d
Presumptive tx for sex partners within 90d (tests may have false-negatives)
Special notes
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Jarisch-Herxheimer rxn: acute febrile rxn with HA, myalgia within 24h of tx
Follow-up evaluation at 6 and 12 mos (and 24 mos. for latent, and q6 mos. for neurosyphilis)
Urethritis/Cervicitis
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Symptoms/signs
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Investigations
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Urethritis: Urethral Gram stain with ≥5 WBC (if GNID then NG), UA leukocyte esterase(+);
Urethral/urine NAAT for CT/NG (urine preferred)
Cervicitis: Cervical/urine NAAT, wet prep, T. vaginalis cx/Ag (swab preferred, urine okay);
leukorrhea by microscopy; GNID on endocervical fluid Gram stain
Treatment
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Urethritis: Mucopurulent discharge, dysuria, pruritis, urgency, nocturia, frequency
Cervicitis: mucopurulent endocervical exudate, dyspareunia, postcoital bleeding, signs of PID
Empiric tx for CT/NG if high risk (≤25yo, new/multiple partners, unprotected sex, poor followup)
NGU: azithro 1g PO x1 OR doxy 100mg PO BID x7d
Special notes
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Abstinence for 7d post-tx + no sx + partner treated
If sx >3mos, consider chronic prostatitis, chronic pelvic pain syndrome
Retest ♀ 3mos. post-tx (both ♂ and ♀ if gonococcal)
Other causes: ureaplasma urealyticum, mycoplasma genitalium, T. vaginalis, HSV, HPV,
adenovirus
Bacterial vaginosis
(Gardnerella, other anaerobes)
• Symptoms/signs
– Homogenous, thin-white, malodorous discharge; pruritis
• Investigations
– Clue cells, pH<4.5, +Whiff test, Gram stain = gold standard, cx is
nonspecific
• Treatment
– Metronidazole 500mg PO BID x7d OR gel 5mg intravaginally QD
x5d OR clindamycin 2% cream 5g intravaginally QHS x7d
• Special notes
– Treating ♀ partners does not reduce recurrence
– Can cause endometritis, PID, post-procedure cellulitis
Trichomoniasis (T. vaginalis)
• Symptoms/signs
– Malodorous, yellow-green discharge, vulvar irritation, or no sx
• Investigations
– nucleic acid probe, SN>83%, SP>97%
– Wet prep 60-70% SN
– Cx most SN/SP
• Treatment
– Metronidazole 2 g x1 or 500 mg bid x7days Tinidazole 2 g po
single dose
• Special notes
– Low level metronidazole resistance in 2-5%; Tinidazole longer
half-life and higher tissue penetration
Vulvovaginal candidiasis (VVC)
(C. albicans or other species)
• Symptoms/signs
– Pruritus, soreness, dyspareunia, external dysuria, abnormal/curdy
discharge
– Vulvar edema, fissures, excoriations
• Investigations
– Saline, 10% KOH wet prep or Gram stain with yeast or pseudohyphae
– Cx for yeast species (for negative wet mounts)
• Treatment
– Immunocompetent/sporadic:short course topicals (single dose and
regimens of 1-3d) or fluconazole 150mg po x1
– Immunocompromised/ severe recurrent: longer courses
• Special notes
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75% of ♀ will have one episode, 40-45% ≥2
10-20% will have VVC
Oil based creams may weaken condoms
Topical azoles more effective than nystatin
Pelvic inflammatory disease
(Mostly C. trachomatis and N. gonorrhoeae)
• Symptoms/signs
– CMT, urterine/ adnexal tenderness, fever, discharge
– Endometritis, salpingitis, TOA, pelvic peritonitis
• Investigations
– Abundant WBC on wet prep, ESR, CRP, microbiology
– Most specific: endometerial bx, transvaginal U/S, laparoscopy
• Treatment
– Cefotetan 2g IV q12h OR cefoxitin 2g IV q12h PLUS doxy 100mg PO or
IV q12h
– After 24h of parenteral abx, continue doxy x14d
– Add metronidazole or clindamycin if +TOA
• Special notes
– Empiric abx prevents long-term sequellae
– Consider oral quinolone regimen + metronidazole if mild disease and no
QRNG suspected
Epidydimitis
(Mostly C. trachomatis and N. gonorrhoeae)
• Symptoms/signs
– Unilateral testicular pain, swelling,
inflammation
• Investigations
– Urine NAAT, urethral Gram stain (>5
WBC/hpf), +leuk esterase on UA
• Treatment
– CTX 250mg IM x1 PLUS doxy 100mg PO BID
x10d
Genital Warts
(HPV types 6 and 11 common)
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Symptoms/signs
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Investigations
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3-5% acetic acid turns infected genital mucosa white, but little evidence
Bx only if dx uncertain, no response to tx, or patient immunocompromised
Treatment
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Flat, papular or pedunculated growths on genital mucosa
Generally asymptomatic, can be painful, friable or pruritic
External: No definitive treatment
Podofilox 0.5% bid x3d, then 4d no therapy, repeat prn ≤ 4 cycles (total area≤10 cm2)
Imiquimod 5% cream QHS, TIW ≤ 16wks
Cryotherapy (various forms)
Podophylin resin 10-25% OR ticholoracetic acid OR bichloroacetic acid
Surgical removal, laser therapy, intralesional interferon
Special notes
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Tx may reduce, does not eliminate infection, unclear impact on transmission
Genital warts not an indication for HPV testing, change in frequency of Pap, or colposcopy
Cervical: exclude HGSIL before tx, consult specialist
Vaginal: liquid nitrogen, TCA/BCA
Urethral meatus: liquid nitrogen or podophyllin
Anal: cryotherapy, TCA/ BCA, surgical removal
Pediculosis pubis (pubic lice)
• Symptoms/signs
– Lice or nits on pubic hair
• Treatment Recommended:
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Permethrin 1% cream or Pyrethrins with piperonyl butoxide
Alternative :
Malathion 0.5% lotion
Ivermectin 250 ug/kg repeated in 2 weeks
• Special notes
– Resistance to pediculides increasing
– Use malathion when treatment failure believed because of
resistance
– Treat sex partners within previous month
Scabies (Sarcoptes cabiei)
• Symptoms/signs
– Classic burrowing rash, pruritus may persist for ≤ 2wks
• Treatment
– Recommended: permethrin cream 5% to all areas of the body from the
neck down, washed off after 8-14h
– Ivermectin 200 ug/kg PO, repeated in 2wks
– Alternative: Lindane 1% total body, neck down (toxicity: aplastic anemia,
seizure)
– Decontaminate bedding/clothing
• Special notes
– Sensitization to Sarcoptes scabiei occurs before pruritus. With 1st
infection takes ≤several wks to develop, may occur ≤24h of reinfection
– In adults usually sexually acquired, but not in children
– Norwegian scabies (i.e., crusted scabies): aggressive infestation occurs
in immunodeficient, debilitated or malnourished persons
Key Points
• Use syndrome classification to simplify
differential diagnosis.
• Most genital ulcer disease in the U.S. is HSV or
syphilis.
• If treating empirically for cervicitis/urethritis, treat
for both NG and CT.
• New diagnoses mandate testing for other STDs,
especially HIV and syphilis.
• Test and treat all sex partners. (not generally
recommended for candidiasis)
Screening
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Includes:
– (1) education/counseling on safe sex,
– (2) identification of asymptomatic infected persons and symptomatic persons
unlikely to seek tx,
– (3) diagnosis/treatment,
– (4) evaluation of sex partners
– (5) preexposure vaccination for those at risk of vaccine-preventable STDs
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Prevention: abstinence, reduction of sex partners, male/female condoms
Partner management: encourage notification, evaluate sex partners within
60d, consider patient-delivered tx
Asymptomatic testing:
– CT: Sexually active ♀ ≤25yo, older ♀ with risk factors
– NG: Sexually active ♀ with increased risk (≤25yo, prior STDs, new/multiple
partners, inconsistent condom use, drug use)
– HIV: Voluntary, universal, opt-out provision. Also consider when other STDs are
found or suspected
– RPR, HBV sAg/sAb, HCV Ab
MSM/WSW
• Consider additional sx: genital and perianal
ulcers, regional LAD, skin rash, anorectal sx
• Annual STD screening for MSM: HIV, RPR,
urine/rectal/pharyngeal testing for CT/NG
depending on history of insertive/receptive
anal/receptive oral intercourse in past year,
consider anal cytology/HPV screening. Screen
q3-6mos if multiple partners or drug use.
• All ♀ require routine Pap and STD screening
regardless of sexual practices.
Vaccinations
• HBV vaccine for all persons evaluated or
treated for STDs and for MSM.
• HAV vaccine for MSM and illegal-drug
users
• HPV vaccination in ♀ ≤26yo
A word about sexual assualut
• Post exposure prophylaxis
(see CDC website for current guidelines)