Genital Discharge :
1st : Gonococcal (specific) cause
2nd : Nongonococcal (nonspecific)
cause
GONORRHEA (GC)
causative agent and Pathogenesis
*Albert Ludwig Sigismund Neisser 1879
*Neisseria gonorrhoeae Gram-negative, aerobic diplococci intracellular
*mode of transmssion: sexual contact ,poor hygiene or medical use of
urine, vertical transmssion
*virulent factors:
PilC and Opa, adhesins and sphingomyelinase, IgA proteases,
lipooligosaccharide endotoxin
*disseminated infection:
Delays in antibiotic treatment,
physiologic changes in host defenses,
resistance to immune responses,
and highly virulent strains of bacteria
Clinical Findings
*LOCALIZED DISEASE (MEN):
I.P 2-8 d…..2wks, 10% asymptomatic
- urethritis: cloudy or purulent discharge from the penile meatus,
painful urination and surrounding redness and swelling, Testicular
pain and swelling may indicate epididymitis or orchitis
Proctitis, rectal mucopurulent discharge, pain on defecation,
constipation, and tenesmus in MSM
higher risk of acquiring HIV infection… damaged epithelial integrity
Pharyngitis caused by N. gonorrhoeae is rare, asymptomatic
* LOCALIZED DISEASE (WOMEN):
50% asymptomatic
Sterility, urethritis…mucopurulent discharge, vaginal pruritus, and
dysuria
sites of infection: commonly endocervix, Bartholin's and Skene's glands
upper genital tract… PID (10-40%)
Cervicitis
urethritis
*PID: fever, lower abdominal pain, back pain, vomiting, vaginal
bleeding, dyspareunia, and adnexal or cervical motion tenderness
Sequelae…tubo-ovarian abscesses, subsequent ectopic pregnancies,
chronic pelvic pain, and infertility due to chronic inflammation with
resultant scarring
*Fitz-Hugh-Curtis syndrome: inflammation of the liver capsule, up
to one-fourth of women with PID caused by either N. gonorrhoeae or
C. trachomatis.
c/f: right upper quadrant pain and tenderness with abnormal liver
function tests
*DISSEMINATED DISEASE:
DGI...0.5-3% classical tried dermatitis, migratory polyarthritis, and
tenosynovitis
Skin features 40-70% small macules or hemorrhagic pustules on an
erythematous base located on palms and soles, erythema nodosum
or erythema multiforme like.
(a) Early macular lesion
*Disseminated gonococcal infection
(c) Papule with central necrosis
(b) Haemorrhagic pustule
(d) Arthritis of the foot
Laboratory Tests
1. Culture & Gram stain
Culture is “gold standard” dx test for years
modified Thayer-Martin medium
In men done on secretions or urethral swabs, in women done on
endocervical and endourethral specimens
2. FDA approved chemiluminescent DNA probes
3. nucleic acid amplification tests (NAATs)….
In DGI culture from blood, joint fluid, and skin lesions
Complications
-infertility as a result of untreated PID
-DGI can lead to septic arthritis….permanent joint damage.
Meningitis and endocarditis are rare manifestations of DGI.
fever, malaise, and perihepatitis (Fitz-Hugh-Curtis syndrome)
Prognosis and Clinical Course
excellent with appropriate antibiotics
DGI good prognosis if treated before permanent damage
Treatment
10-30% of people with gonococcal infection are co-infected with
Chlamydia..routine dual therapy with doxycycline and azithromycin
decreases the development of antimicrobial resistance in bacteria
Treatment of Localized, Uncomplicated Gonococcal Infection
Single dosage of any of the following:
Cefixime, 400 mg PO
Ceftriaxone, 125 mg IM
Ciprofloxacin, 500 mg
Ofloxacin, 400 mg PO
Levofloxacin, 250 mg PO
Patients allergic to cephalosporins or quinolones may be treated with
spectinomycin, 2 g in a single IM dose.
In dual therapy for chlamydia, add:
Azithromycin, 1 g orally in a single dose
Doxycycline, 100 mg orally twice a day for 7 days
Management of Disseminated Gonococcal Infection
Recommended regimen: Ceftriaxone 1 g IM or IV every 24 h
Alternative regimens: Cefotaxime 1 g IV every 8 h or
Ceftizoxime 1 g IV every 8 h or
Ciprofloxacin 400 mg IV every 12 h or
Ofloxacin 400 mg IV every 12 h or
Levofloxacin 250 mg IV daily or
Spectinomycin 1 g IM every 12 h
All of the preceding regimens should be continued for 24-48 h after
improvement begins, at which time therapy may be switched to one
of the following regimens to complete at least 1 wk of antimicrobial
therapy:
Cefixime 400 mg PO twice daily or
Ciprofloxacin 500 mg PO twice daily or
Ofloxacin 400 mg PO twice daily or
Levofloxacin 500 mg PO once daily
Treatment of Gonococcal Infection in Neonates
Ceftriaxone, 25-50 mg/kg/day IV or IM in a single daily dose for 7 days,
with duration of 10-14 days if documented meningitis
or
Cefotaxime, 25 mg/kg IV or IM every 12 h for 7 days, with duration of
10-14 days if documented meningitis
Gonococcal ophthalmia neonatorum should be treated with ceftriaxone,
25 to 50 mg/kg IV or IM, not to exceed 125 mg in a single dose
Contraindications
Pregnant woman……tetracyclines or quinolones
Rx cephalosporin or a single 2-gram dose of spectinomycin can be used
for gonococcal infection, and erythromycin or amoxicillin for
chlamydia
NGU
-50% ….Chlamydia
-10-30% ….Ureaplasma urealyticum & Mycoplasam
genitalium
-less than 10%....Herpes v., T. vaginalis, Haemophilus
sp., Anaerobic bact.
-1/3 of cases….. No infectious cause found
CHLAMYDIA
causative agent and Pathogenesis
chlamys means “cloak draped around the shoulder.”
C. trachomatis is a nonmotile, Gram-negative, obligate intracellular
organism with 15 serotypes:
A through C cause chronic conjunctivitis
D through K cause urogenital tract infections
L1 though L3 cause lymphogranuloma venereum
I.P 1-3 weeks
Modes of transmission: oral, anal, vaginal
Co-infection com. with GC
Type G …….SCC
Life cycle:
elementary body (infectious form)
host cell (by endocytosis)
Replication by binary fission
(inside host cell) using ATP
secondary
differentiation
primary differentiation
reticulate bodies
hundreds of reticulate bodies
Large intracytoplasmic inclusions
Clinical Findings
asymptomatic infection 80% of women and 50% of men
Urethritis….a watery or mucoid discharge from the urethra that may be
accompanied by dysuria in both men and women.
Rectal infection may result in proctitis in both men and women
& chronic prostatitis.
In women...intermenstrual, postcoital bleeding & lower abdominal pain
PID & sterility
5-10% perihepatitis (Fitz-Hugh-Curtis syndrome)
In Newborns…conjunctivitis ophthalmia neonatorum
…. Pneumonia after 1 to 3 months
Laboratory Tests
1. Traditionally… tissue culture from endocervix in women, urethra in
men, rectum, or conjunctivae
2. direct fluorescent antibody test
3. Enzyme immunoassays
4. nucleic acid amplification, such as PCR and ligase chain reaction
Complications
Reactive arthritis syndrome Reiter’s syndrome 1-3% …1 month after
NGU, classic triad NGU, arthritis, and conjunctivitis, HLA-B27
Additionally fever, malaise, myalgias, asymmetric joint stiffness, lower
back pain, cutaneous lesions involving the genitals, and aortic
regurgitation
Prognosis and Clinical Course
Early treatment… excellent prognosis 95% eradicating infection
Sexual contact should be avoided
Treatment of Chlamydia Infection
Azithromycin, 1 g PO in a single dose
or
Doxycycline, 100 mg PO twice a day for 7 days
Recommended treatment for pregnant women:
Erythromycin, 500 mg PO four times a day for 7 days
Amoxicillin, 500 mg PO three times a day for 7 days
GENITAL MYCOPLASMAS
causative agent and Pathogenesis
self-replicate extracellularly, colonizing the respiratory and urogenital
tracts
Disseminated infection is rare…in immunocompromised hosts
M. genitalium and Ureaplasma sp…. isolated from lower urogenital
tracts of men with urethritis and women with cervicitis and PID
M. hominis…. isolated from cases of salpingitis
Clinical Findings
May be undiagnosed
urethritis, cervicitis, PID, endometritis, salpingitis, and chorioamnionitis
Laboratory Tests
Limited…….reference laboratories
M. hominis and U. urealyticum,…..cultured on special media
PCR assay……detect M. genitalium
Complications
disseminated disease, especially in immunocompromised hosts….
respiratory tract invasion, osteomyelitis, or infectious arthritis
Prognosis and Clinical Course
Prognosis in immunocompetent hosts is excellent with appropriate
treatment and prompt diagnosis.
Treatment
similar to treatment for chlamydia.
Fluoroquinolones….an alternative treatment against M. hominis and
Ureaplasma sp. in cases of resistance to other antibiotics
TRICHOMONAS VAGINALIS
causative agent and Pathogenesis
STD caused by parasitic protozoa
Women….vagina, urethra, cervix, Bartholin and Skene glands, bladder
Men…external genital area, ant. urethra, epididymis, prostate, semen
I.P… 4 and 28 days
Women…..asymptomatic carrier state to inflammatory vaginitis
Most men are asymptomatic carriers
Clinical Findings
Women…malodorous, yellow-green vaginal discharge, vulvar pruritus
and erythema, dyspareunia, lower abdominal discomfort, or dysuria
On exam., punctate hemorrhages…vaginal wall and cervix.
colpitis macularis or strawberry cervix.…specific sign of trichomoniasis,
1- 2% percent of women during a regular pelvic exam
45% of cases with use of colposcopy.
Men…balanitis, epididymitis, and prostatitis
Co-infection with other STDs
Laboratory Tests
1. saline wet mount of a vaginal swab…common diagnostic test
2. microscopically…ovoidshaped protozoa….phase contrast or dark-field
3. anaerobic culture….positive within 48 hours
4. PCR
Complications
premature delivery, early rupture of membranes, and low birth weight
in newborns
increased risk of HIV transmission,& atypical PID
Prognosis
Excellent…. after appropriate treatment
Treatment of sexual partners is important to avoid re-infection
Treatment of Trichomoniasis
Metronidazole, 2 g PO in a single dose
or
Metronidazole, 500 mg PO twice a day for 7 daysa
Alternative recommendations
Tinidazole, 2 g PO in a single dose
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