Sexually Transmitted Diseases: Overview & Management

Scope and Problem

  • CDC estimates that there are approximately 19{,}000{,}000 new cases of STDs each year.
  • Almost half of these cases are young persons between the ages of 15{-}24 years.
  • STDs have a direct economic impact: costs an estimated 15.3\times 10^9 USD annually.
  • Serious physical and psychological impact.

Bacterial STDs

  • Gonorrhea: causative agent is Neisseria gonorrhoeae.
  • Chlamydia: causative agent is Chlamydia trachomatis.
  • Syphilis: causative agent is Treponema pallidum.

Viral STDs

  • Herpes Genitalis: caused by Herpes Simplex Virus Type II (HSV-2).
  • Genital Warts: caused by Human Papillomavirus (HPV).
  • Acquired Immunodeficiency Syndrome (AIDS) relates to Human Immunodeficiency Virus (HIV).

Parasitic STDs

  • Trichomonas (trichomoniasis).
  • Pediculosis (pubic lice).

Diagnosing Gonorrhea in the Patient

  • Clinical signs and symptoms: may be asymptomatic; ↑ vaginal discharge; dysuria, frequent urination; abnormal uterine bleeding.
  • Diagnostic tests: Gram stain; culture; DNA technology.

Gonorrhea (Complications)

  • Uncomplicated genitourinary tract infection: urethritis and cervicitis.
  • Upper genital tract infections: endometritis and pelvic inflammatory disease (PID).
  • Disseminated gonorrhea: can be associated with arthritis; more common in pregnant than nonpregnant women.
  • Endocarditis and meningitis (rare but serious).

Division of STD Prevention (Gonorrhea)

  • Diagnostic emphasis includes gram stain of urethral discharge and other CDC guidance.
  • Notation: CDC = Centers for Disease Control and Prevention.

Gonococcal Urethritis

  • Emphasizes gram stain of urethral discharge as a diagnostic clue.
  • CDC reference and prevention guidelines.

Gonococcal Cervicitis

  • CDC reference and prevention guidelines.

Disseminated Gonorrhea

  • Skin lesions commonly present; CDC reference and prevention guidelines.

Diagnosing Chlamydia in the Patient

  • Clinical signs and symptoms:
    • May be asymptomatic.
    • Increased vaginal discharge.
    • Purulent cervical discharge with friability.
  • Diagnostic testing:
    • Culture of discharge.
    • ELISA testing (antigen detection).
    • Other antigen-detection methods.

Diagnosing Herpes Simplex Virus II

  • Clinical signs and symptoms:
    • Local symptoms: itching, pain, dysuria, vaginal or urethral discharge.
    • Lesion progression: papules → vesicles → pustules → ulcers → crusts → healing.
    • Systemic symptoms: fever, myalgia, headache, malaise, urinary retention.
    • Illness lasts 2{-}4\text{ weeks}.
  • Diagnostics:
    • Viral culture best obtained from vesicle fluid.
    • ELISA testing.

Division of STD Prevention: Herpes

  • Primary herpes, male; Recurrent herpes, male; Herpes, female; Primary herpes, female.
  • Notes indicate four days later follow-up in the same patient (recurrence scenario).

Herpes cervicitis

  • Documented in female patients as part of genital herpes involvement.

Human Papillomavirus (HPV)

  • HPV types: 6, 11, 42, 43, and 44 are associated with Condyloma Acuminata (genital warts).
  • Severe genital wart outbreaks are associated with HPV types 16, 18, 31, 33, and 35.
  • Transmission: sexually, via intimate contact, and via fomites.

HPV Diagnosis

  • Clinical signs and symptoms:
    • Lesions may increase during pregnancy.
    • Lesions are often in moist perineal areas.
    • Lesions may be flat, pink, white, tan, cauliflower-like masses; may be single or in clusters.
  • Diagnostic testing:
    • Pap smear.
    • DNA testing (very expensive).

Condyloma acuminata locations (CDC references)

  • Penile (including meatal)
  • Vulva
  • Meatal, vulvar, and vaginal wall lesions

Syphilis

  • Causative agent: Treponema pallidum, a spirochete.
  • Transmission: penetrates intact skin or mucous membrane; transmitted by direct contact with an open skin lesion or blood during sexual relations.
  • Epidemiology: ↑ in women, especially ages 15{-}24 yrs.
  • Congenital infection: Treponema pallidum can cross the placenta.

Diagnostic laboratory tests for Syphilis

  • VDRL (Venereal Disease Research Laboratory).
  • RPR (Rapid Plasma Reagin).
  • ART (Automated Reagin Test).
  • FTA-ABS (Fluorescent Treponemal Antibody Absorption).
  • Darkfield microscopy.

Diagnosis of Syphilis – Clinical Stages

  • Primary syphilis:
    • Incubation several weeks to 90\,\text{days}.
    • Chancre develops: painless, indurated lesion.
    • Highly infectious; resolves spontaneously.
  • Secondary syphilis:
    • Occurs 6{-}8\text{ weeks} after chancre resolution.
    • Systemic involvement with palmar/plantar rash; condyloma lata; mucous patches; highly infectious.
  • Latent syphilis: infection > 1\text{ year}; early stage may be asymptomatic.
  • Cardiovascular syphilis: aortitis with involvement of coronary ostia (aortic root changes).
  • Neurosyphilis: spirochetes in neural tissue.

Diagnosis of Syphilis (Ongoing)

  • Clinical signs and symptoms guide staging; laboratory tests confirm infection.

Parasitic Infection: Trichomonas (Trichomoniasis)

  • Patient complaints and signs:
    • Gray or yellow-green odorous discharge.
    • Extreme vaginal pruritus.
    • Dyspareunia and dysuria.
    • Strawberry cervix (cervical friability) and vaginal erythema.

Bacterial Vaginosis (BV)

  • Clinical picture: milky white/gray discharge; odorous.
  • Diagnostic indicators:
    • Wet prep with clue cells.
    • Positive whiff test (amine odor).

WHIFF TEST

  • A diagnostic test used to support BV diagnosis.

Pediculosis Pubis (Pubic Lice)

  • Clinical signs and symptoms:
    • Lice and nits present in pubic hair.
    • Severe pruritus in the pubic region.
  • Treatment guidelines:
    • Permethrin 1% crème rinse applied to affected areas and washed off after 10 minutes.
    • Pyrethrins with piperonyl butoxide applied to affected areas and washed off after 10 minutes.
    • Malathion 0.5% lotion applied for 8–12 hours and washed off.

Division of STD Prevention: Pediculosis Pubis

  • Meatal, penile, vulvar, and vaginal wall infections noted in CDC references.

Scabies

  • Clinical signs and symptoms:
    • Blisters and redness between fingers, toes, and other folds on the body.
    • Severe pruritus, especially at night.
  • Treatment guidelines:
    • Elimite 5% cream applied from neck down; rinse off with soap and water after 8–14 hours.
    • Ivermectin 200 µg/kg orally, repeated in 2 weeks.

Division of STD Prevention: Scabies

  • CDC references for scabies include multiple body sites and treatment protocols.

Division of STD Prevention Overview

  • Throughout the slides, the CDC’s Division of STD Prevention is cited as the primary reference for diagnosis, prevention, and management guidelines.

Quick cross-links and practical implications

  • Many infections are asymptomatic, especially Chlamydia and Gonorrhea in some patients; routine screening is essential in appropriate populations.
  • Some STDs (e.g., Syphilis, BV) have distinctive clinical signs (chancre, strawberry cervix, clue cells) that guide targeted testing.
  • Pregnancy can influence presentation and management (e.g., HPV wart outbreaks, cervicitis complications, recurrence patterns).
  • Preventive strategies emphasize early diagnosis, partner notification, education on transmission, and adherence to CDC guidelines for treatment regimens.

Key definitions and terms

  • Chancre: a painless, indurated ulcer seen in primary syphilis.
  • Condyloma lata: highly infectious wart-like lesions seen in secondary syphilis.
  • Condyloma acuminata: genital warts caused by HPV.
  • Clue cells: vaginal epithelial cells with adherent bacteria seen on microscopic exam, associated with BV.
  • Diasseminated gonorrhea: disseminated infection with systemic features such as skin lesions and arthritis.
  • Strawberry cervix: erythematous cervix with punctate hemorrhages seen in Trichomonas infection.