Sexually Transmitted
Diseases
Peter Tran, D.O
Garden City Hospital
Objectives
 HSV
 Chancroid
 Syphilis
 Lymphogranuloma Venereum
 Chlamydia/Gonorrhea
 Trichomoniasis
 HPV
 Molluscom Contagiosum
 Scabies
 Pubic lice
Epidemiology
 15 million new cases reported each year

65 million infected with incurable viral STD
 HPV




Prevalence – 20 million
Incidence – 6.2 million
½ of all men and women acquire at some
point in their lives
At 50 y/o, 80% of women would acquire HPV.
Epidemiology
 Chlamydia


Rates steadily rising
2003 – 900,000 cases reported

2x the reported cases of gonorrhea
Chlamydia — Reported rates: United States, 1984–2001
Rate (per 100,000 population)
300
240
180
120
60
0
1984
86
88
90
92
94
96
98
2000
Chlamydia — Rates by state: United States and outlying areas, 2001
231.3
212.7
104.9
165.4
217.9
169.2
156.3
303.6
241.2
169.9
244.5
194.7
231.0
187.3
241.8
307.8
279.6
331.7
352.0 250.9
134.5
301.0
343.8
225.0
303.7
129.7 259.1
249.3
219.7
274.6
273.5
272.3
382.1
Guam 278.4
414.6
326.6
413.4
334.5
399.2
437.7
VT
NH
MA
RI
CT
NJ
DE
MD
312.8
235.4
Rate per 100,000
population
(n= 7)
<=150
150.1-300 (n= 29)
(n= 17)
>300
332.7
Puerto Rico 72.2
104.8
111.9
163.8
277.8
226.6
193.9
356.4
295.3
Virgin Is. 120.6
Note: The total rate of chlamydia for the United States and outlying areas
(including Guam, Puerto Rico and Virgin Islands) was 275.5 per 100,000
population.
Chlamydia — Rates by sex: United States, 1984–2001
Rate (per 100,000 population)
450
360
270
Men
Women
180
90
0
1984
86
88
90
92
94
96
98
2000
Chlamydia — Age- and sex-specific rates: United States, 2001
Men
3,000
Rate (per 100,000 population)
2,400
1,800
1,200
600
0
9.9
375.9
604.9
284.7
140.4
70.3
37.1
15.9
5.5
2.2
114.2
Age
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-54
55-64
65+
Total
Women
0
600
1,200
1,800
2,400
3,000
139.8
2,536.1
2,447.0
824.6
301.9
119.1
51.4
18.1
5.1
2.9
436.3
Epidemiology
 Gonorrhea




Rates have decreased slightly since 1998.
Higher for non-hispanic blacks (24x the rate
for whites)
High for homosexual men
Fluoroquinolone resistance increasing

Not recommend in Hawaii and Calif.
Gonorrhea — Reported rates: United States, 1970–2001 and the
Healthy People year 2010 objective
Rate (per 100,000 population)
500
Gonorrhea
2010 Objective
400
300
200
100
0
1970
73
76
79
82
85
88
91
94
97
Note: The Healthy People 2010 (HP2010) objective for gonorrhea is 19.0 cases
per 100,000 population.
2000
Gonorrhea — Rates by state: United States and outlying areas, 2001
50.7
11.5
11.1
8.7
33.4
54.9
5.9
112.1
38.3
15.6
117.5
48.5
116.0
69.5
87.9
74.2
76.4
186.4
193.4 114.7
9.8
68.8
57.2
VT
12.5
NH
14.2
MA
50.6
RI
79.2
CT
74.8
NJ 106.0
DE 221.2
MD 178.0
172.3
99.3
138.6
40.5
155.9
156.7
88.8
206.0
178.3
172.2
269.3
Guam 31.0
272.8
251.4
231.1
Rate per 100,000
population
144.0
274.2
72.9
134.7
<20
20-100
>100
(n= 9)
(n= 21)
(n= 23)
49.9
Puerto Rico 15.5
Virgin Is. 31.3
Note: The total rate of gonorrhea for the United States and outlying areas
(including Guam, Puerto Rico and Virgin Islands) was 126.9 per 100,000
population. The Healthy People year 2010 objective is 19.0 per 100,000
population.
Gonorrhea — Rates by region: United States, 1981–2001 and the
Healthy People year 2010 objective
Rate (per 100,000 population)
600
West
Midwest
Northeast
South
2010 Objective
480
360
240
120
0
1981
83
85
87
89
91
93
95
97
99
2001
Gonorrhea — Rates by sex: United States, 1981–2001 and the
Healthy People year 2010 objective
Rate (per 100,000 population)
600
Male
Female
2010 Objective
480
360
240
120
0
1981
83
85
87
89
91
93
95
97
99
2001
Gonorrhea — Rates by race and ethnicity: United States, 1981–2001
and the Healthy People year 2010 objective
Rate (per 100,000 population)
2,500
2,000
White
Black
Hispanic
Asian/Pac Isl
Am Ind/AK Nat
2010 Objective
1,500
1,000
500
0
1981
83
85
87
89
91
93
95
97
99
2001
Gonorrhea — Age- and sex-specific rates: United States, 2001
Men
750
Rate (per 100,000 population)
600
450
300
150
0
8.2
307.5
563.6
328.4
203.9
134.3
90.5
46.8
17.2
4.5
128.6
Age
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-54
55-64
65+
Total
0
Women
150
300
450
600
750
51.8
703.2
664.1
249.4
112.7
57.8
31.2
9.4
2.0
0.9
128.5
Gonococcal Isolate Surveillance Project (GISP) — Percent of
Neisseria gonorrhoeae isolates with resistance or intermediate
resistance to ciprofloxacin, 1990–2001
Percent
3.0
2.4
Resistance
Intermediate resistance
1.8
1.2
0.6
0.0
1990
91
92
93
94
95
96
97
98
99
Note: Resistant isolates have ciprofloxacin MICs >1 mg/mL. Isolates with
intermediate resistance have ciprofloxacin MICs of 0.125 - 0.5 mg/mL.
Susceptibility to ciprofloxacin was first measured in GISP in 1990.
2000
01
Epidemiology
 Syphilis





Rates have remained steady since 2000
Incidence 2.5/100,000 people in 2003.
27% increase in males
21% decrease in females
Higher in southern states and among blacks
Primary and secondary syphilis — Reported rates: United States,
1970–2001 and the Healthy People year 2010 objective
Rate (per 100,000 population)
25
P&S Syphilis
2010 Objective
20
15
10
5
0
1970
73
76
79
82
85
88
91
94
97
Note: The Healthy People 2010 (HP2010) objective for primary and secondary
syphilis is 0.2 case per 100,000 population.
2000
Primary and secondary syphilis — Rates by state: United States and
outlying areas, 2001
1.0
0.0
0.1
0.0
0.4
0.7
0.1
0.4
0.1
0.2
1.6
0.2
0.8
0.6
0.4
0.5
3.3
1.6
0.5
3.5
0.9
1.7
1.0
2.5
0.7
0.3
0.5
1.4
1.2
5.5
5.8
1.8
5.9
Guam 7.8
4.9
3.2
5.1
2.3
3.9
0.0
VT
NH
MA
RI
CT
NJ
DE
MD
4.3
3.0
Rate per 100,000
population
<=.2
.21-4
>4
1.0
Puerto Rico 6.4
0.5
0.1
0.7
0.9
0.4
1.6
1.8
5.0
Virgin Is. 0.0
Note: The total rate of primary and secondary syphilis for the United States
and outlying areas (including Guam, Puerto Rico and Virgin Islands) was 2.2
per 100,000 population. The Healthy People year 2010 objective is 0.2 per
100,000 population.
(n= 10)
(n= 34)
(n= 9)
Primary and secondary syphilis — Counties with rates above and
counties with rates below the Healthy People year 2010 objective:
United States, 2001
Rate per 100,000
Population
<=0.2 (n=2,533)
>0.2
(n=606)
Primary and secondary syphilis — Rates by region: United States,
1981–2001 and the Healthy People year 2010 objective
Rate (per 100,000 population)
50
West
Midwest
Northeast
South
2010 Objective
40
30
20
10
0
1981
83
85
87
89
91
93
95
97
99
2001
Primary and secondary syphilis — Rates by sex: United States,
1981–2001 and the Healthy People year 2010 objective
Rate (per 100,000 population)
25
Male
Female
2010 Objective
20
15
10
5
0
1981
83
85
87
89
91
93
95
97
99
2001
Primary and secondary syphilis — Rates by race and ethnicity:
United States, 1981–2001 and the Healthy People year 2010
objective
Rate (per 100,000 population)
150
White
Black
Hispanic
Asian/Pac Isl
Am Ind/AK Nat
2010 Objective
120
90
60
30
0
1981
83
85
87
89
91
93
95
97
99
2001
Primary and secondary syphilis — Age- and sex-specific rates:
United States, 2001
Men
Rate (per 100,000 population)
7.5
6.0
4.5
3.0
1.5
0.0
0.0
1.4
5.0
5.9
6.4
7.2
5.3
3.4
1.4
0.4
3.0
Age
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-54
55-64
65+
Total
0.0
Women
1.5
3.0
4.5
0.2
2.5
3.8
3.1
3.0
2.9
2.0
0.9
0.2
0.0
1.4
6.0
7.5
STD’s with Genital Ulcers
Disease
Lesion
Lymphadeopathy
Systemic Symptoms
Primary Syphilis
Painless, indurated,
single, clean base
Non-tender, B/L
None
Genital Herpes
Painful vesicles,
multiple
Tender, B/L
Primary lesion
Chancroid
Tender, painful
papules
Tender, B/L,
suppurative
None
Lymphomgranuloma
Small, painless
vesicle or papules
Painful, matted,
possible fistula
After genital lesions
heal
HSV





HSV-2
 50 million in US HSV-1/HSV-2
 85-90% of cases
HSV-1
 Cold sores
 Can also be transmitted during oral sex
Incubation period - 1 week
Typically presents as painful ulcers of the genitalia or anus and bilateral painful
inguinal adenopathy.
 A group of vesicles on an erythematous base that does not follow a neural
distribution is pathognomonic.
 Often associated with flu-like symptoms
 Urethral lesions can cause retention
Asymptomatic viral shedding can occur 3 months after presentation
HSV
HSV


Diagnosis
 Classic presentation occurs in a small percentage of patient.
 Women can present with atypical lesions
 abrasions, fissures or itching
 Viral culture with subtyping
 Sensitivity - 30-95%
 Depends on stage of lesion and whether primary or recurrence.
Treatment
 Antiviral
 acyclovir, valacyclovir, and famciclovir
 Used as first episode, episodic or suppressive
 If episodic, must be used during the prodrome phase or 1 day of onset of
lesions.
Chancroid




Caused by H.ducreyi
 Most common STD worldwide
 M:F – 3:1
Incubation – 1-3 weeks
10% are co-infected with HSV or syphilis
Painful, nonindurated ulcer with a friable base.
 Can spread laterally by apposition to the inner thighs.
 It is associated with inguinal adenopathy that is typically unilateral and
tender with tendency to become suppurative and fistulize.
 H. ducreyi is fastidious and difficult to culture.
 Gram-stain more helpful.
 gram-negative streptobacilli, which are usually arranged in short,
parallel chains
Chancroid
Chancroid
 Treatment
Azithromycin 1g PO
 Rocephin 250mg IM
 Cipro 500mg BID 3 days
 Erthromycin 500mg qid x 7 days
 Treat sexual partners
 Relief of inguinal tenderness by I&D/needle aspiration of the buboes.

Syphilis




Caused by the spirochete Treponema Pallidum
 Direct contact with lesion, body fluids or in utero.
Incubation – 10 days – 3 months
Primary syphilis is characterized by a single painless, indurated ulcer occurring
at the site of inoculation that appears about 3 weeks after inoculation and
persists for 4 to 6 weeks.
 associated with bilateral, nontender inguinal or regional lymphadenopathy
 Often goes unnoticed since its asymptomatic and heals without
treatment
Latent syphilis
 Defined as seroreactivity with no clinical evidence of disease.
 Early latent – within 1 year
 Late Latent – beyond 1 year or unknown duration
Syphilis
Secondary Syphilis
 Typically presents several months – 2 years
from initial infection


Mucocutaneous, constitutional symptoms
Maculopapular rash



Trunks, palms, soles
Generalized nontender lymphadenopathy
Condyloma lata – very infectious
Secondary Syphilis
Tertiary Syphilis

1/3 of untreated patients will develop tertiary syphilis
 systemic disease that can affect almost any organ or system, especially the
cardiovascular, skeletal, and central nervous systems, and skin. Aortitis,
meningitis, uveitis, optic neuritis, general paresis, tabes dorsalis, and
gummas of the skin and skeleton.
Syphilis
 Tests
 Non-treponemal
 RPR & VDRL
 Sensitivity (78% and 86% in primary) about 100% in
secondary/tertiary.
 Correlate with disease activity.
 Negative after 1 year
 4-fold decrease titer represents successful Tx
 Treponemal
 TP-PA
 FTA-ABS
 + results stay for life. Does not correlate with disease
activity.
Syphilis

Treatment
 Primary/Secondary
 2.4 mil units Benzthiazide PCN G IM
 Jarisch-Herxheimer Rxn
 Allergic
 Doxy 100mg BID x 14 days
 Tertiary
 Aqueous crystalline PCN G 3-4 mil units IV q4h x 14 days or Procaine
PCN G IM 2.4 mil units qd with probenecid 500mg qid x 14 days
Lymphogranuloma Venereum

Caused by Chlamydia trachomatis types L1, L2, L3.




Rare in the US. Mostly tropical regions.
Incubation – 3 days – 1 month
Presents as single painless ulcer on the genitalia.
 Painful unilateral, suppurative inguinal lymphadenopathy and constitutional
symptoms that occur 1 month after ulcer heals.
 Can lead to significant tissue damage with anorectal fistula formation,
elephantiasis, urethral destruction.
Treatment


Doxycycline 100 bid x 3 weeks
Erythromycin 500mg qid x 3 weeks
Lymphogranuloma Venereum
Chlamydia Trachomatis







Types D-K
Most common bacterial STD in US and worldwide.
Most common cause of epididymitis in young men.
40% of untreated infection in women will lead to PID.
Over half of infected men and women are asymptomatic.
Tests
 PCR & endocervical or urethral cultures
 Can be done on urine samples
Treatment
 Primary
 Zithromax 1g
 Doxycycline

Alternatives



Erythromycin, levaquin, amoxicillin
Treat sexual partners
Treat for gonorrhea coinfection
Chlamydia Trachomatis
N. Gonorrhea



Caused by intracellular gram-negative diplococci.
Incubation – 1-2 weeks
Symptoms include LUTS and pelvic discomfort or dysuria in women.


Can lead to PID
Rare but can manifests as systemic disease

Reiter’s Syndrome



Often coinfected with C. trachomatis
Tests



“Can’t see, can’t pee, can’t climb a tree” (arthritis, urethritis, conjuctivitis)
PCR/culture
Can be obtained from urine
Treatment





Primary - Rocephin 125mg IM
Flouroquinolones except in parts of Asia, Pacific, Hawaii, Calif.
Pregnancy – Rocephin or Spectinomycin 2gm IM
Treat for coinfection with C. trachomatis
Treat all sexual partners within 2 months of contact
N. Gonorrhea
Trichomoniasis





Most common STD worldwide
Caused by the flagellated protozoan Trichomonas vaginalis
Incubation – Days – 1 month
½ of infected women are asymptomatic
 Men can present with LUTS/discharge
Clinically presents with frothy white-green foul-smelling vaginal discharge



“strawberry cervix”
Vaginal wet-mount or microscopic exam of urine
Treatment

Flagyl 2g or 500mg
Trichomoniasis
Genital Warts



Caused by HPV via direct skin-skin contact
 Over 100 different types
 Type 6,11 are common

Low risk for conversion to invasive carcinoma
 Type 16,18,31,33,35,39,45,51 associated with cervical dysplasia and neoplasm in
women and SIN in men

>85% of cervical/anal cancer caused by type 16, 18
Diagnosis
 Visual – nontender cauliflower like genital lesions
 Acetic acid 3-5% may show subclinical infection
 ? Limited cystoscopy for urethral lesions
Treatment
 Patient-Applied

Podofilox 0.5%

Imiquimod 5% cream

Physician-Applied

Cryosurgery, laser, electrosurgery, surgical excision, TCA, BCA
HPV
Molluscum Contagiosum




Caused by MCV-1 virus
Incubation – 2 weeks – 2 months
Considered an STD in adolescents and adults
Diagnosis
 Smooth, round, papule 2-5mm with central umbilication
 Biopsy


Henderson-Patterson bodies
Treatment


Benign and self-limiting. Lesions usually resolve by 1 year.
Can be treated by cryo, laser, cautery.
Molluscum Contagiosum
Scabies





Caused by mites – Sarcoptes Scabiei
 Usually STD, but not in children
Incubation 2-6 weeks
Symptoms
 Pruritis (“7 year itch”) due to an immune reaction to the mites or their
eggs/feces
 Wavy, elongated, erythematous papules due to mite burrows
Microscopic exam for the mites or their eggs
Treatment


5% permethrin cream
1% lindane lotion/cream


Ivermectin 200mcg po x 1


Not indicated in children < 2y/o, after a bath, pregnant/lactating women, or severe
dermatitis
Equally effective as the creams
Clean all bed linen and clothing
Scabies
Pediculosis Pubis


Pubic lice (Phthirus pubis)
 Nits and lice can be found mostly on areas with hair
 Saliva of lice causes intense pruritis
 Lice or their eggs can be seen with the naked eye
Treatment
 5% permethrin cream
 1% lindane shampoo
 Bactrim?
 Clean clothing, linen.
 Treat sexual partners
Pediculosis Pubis