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Sexually Transmitted Diseases

Terms in this set (16)

1. Anaerobic once-celled protozoan with flagella
2. Inhabits vagina in women; Urethra in men
3. Vaginitis symptoms 4-35%
4. 10 times higher in black women than white
5. Transmitted during vaginal-penile intercourse or vulva-to-vulva contact
6. Facilitates HIV transmission
7. Can be asymtomatic or
8. SYMPTOMS include: yellow to greenish, frothy, mucopurulent, copious ,malodorous discharge. Inflammation of the vulva, vagina or both may be present. Irritation, pruritus, dysuria or dyspareunia; discharge worsens during and after menstruation.
9. ASSESSMENT includes: Ph > 4.5, positive whiff test and saline wet-mount microscopic evaluation that identifies motile trichomoniads. Inspection of the external genitalia for excoriation, erythema, edema, ulceration and lesions; speculum exam notes the quantity, color, consistency and any odor of the vaginal discharge. Often the cervix and vaginal walls will demonstrate characteristic "strawberry spots" or tiny petechiae. Cervix friability noted. Vaginal walls and cervix may be inflamed. Ph is ELEVATED.
10. DIAGNOSIS is made by wet prep visualization of the typical one-celled flagellate trichomonads. Slide must be viewed immediately to ensure optimal results. Also increased number of white cells. Culture is highly sensitive and specific method of diagnosis; not routinely performed.
11. All patients should be tested for other STI's including HIV.
12. TREATMENT is 2gm metronidazole orally once or tinidazole 2gm orally once. If infection persists then metronidazole 500mg orally bid for 7 days. If infection still persists then metronidazole 2g orally for 5 days. If infection still persists then specialty consult is recommended. NO ALCOHOL USE; ETOH will cause disulfiram reaction; abdominal distress, nausea, vomiting and headache. ETOH abstinence should continue 24 hours after completing metronidazole treatment and 72 hours after completing tinidazole treatment. Treatment of all partners and sexual abstinence until treatment is complete and everyone is asymptomatic.
1. Caused by Chlamydia trachoma tis
2. Most common
3. Sexually active adolescents and women aged 14-24 years of age have 3 times the prevalence.
4. 5 times greater in black women than white
5. High risk includes multiple partners and failure to use barrier methods.
6. Serious complication is PID
7. ASSESSMENT - usually pt is asymptomatic or can include spotting or post-coital bleeding, mucoid or purulent cervical discharge, urinary frequency, dysuria, lower abdominal pain or dysparenunia. Bleeding results from inflammation and erosion of the cervical columnar epithelium. Cervical friability. Discharge is mucopurulent. During bimanual exam-cervical motion tenderness; adnexal fullness and uterine tenderness.
All sexually active women aged 25 years and younger should be screened annually. Screened via urine or swab specimens from the endocervix or vagina. Screening procedures are nucleic acid amplifications tests (NAATs), cell culture, direct immunofluorescence, enzyme immunoassay (EIA), nucleic acid hybridization tests. NAATS are preferred-higher sensitivity. Positive urine test should have a pelvic exam to ID complications such as PID. Should be tested for other STIs including gonorrhea, syphilis and HIV.
8. DDx gonorrhea, trichomoniasis, PID, appendicitis and cystitis.
9. TREATMENT azithromycin 1 gm orally in a single dose OR Doxycycline 100 mg orally twice a day for 7 days. OR Erythromycin base 500 mg orally four times a day for 7 days OR Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days OR Levaquin 500 mg orally once daily for 7 days OR Ofloxacin 300 mg orally twice a day for 7 days. Treatment of sexual partners is imperative. A test of cure is 3-4 weeks after treatment-not necessary unless patient is pregnant, has persistent symptoms or may have reinfection. Pts should abstain from intercourse until all partners have been treated and to wait 7 days after single-dose treatment or until completion of a 7-day regime. Patients should be advised to be tested every 3 months.
1. Caused by the aerobic, gram-negative diplococcus Neisseria gonorrheoeae.
2. Second most common next to chlamydia.
3. Slightly higher in women than men.
4. Most common age group 15-24
5. Greater in black women than white.
6. Exclusively transmitted through genital to genital contact; also oral to genital and anal to genital.
7. Sites of infection include cervix, urethra, oropharynx, Skene's glands and Bartholin's glands.
8. Other risk factors include early onset of sexual activity and multiple partners
9. Main complication is PID. Also pelvic abscess or Bartholin's abscess. Also Disseminated gonococcal infections (DGI) which is rare and results from not being treated. The first stage of DGI is characterized by bacteremia with chills, fever, and skin lesions; it is followed by the second states during which the patient experiences acute septic arthritis with characteristic effusions most commonly of the wrists, knees and ankles.
10. ASSESSMENT, may be asymptomatic or include dyspareunia, a change in vaginal discharge, unilateral labial pain and swelling or lower abdominal discomfort. Later in the infection's course includes purulent, irritating vaginal discharge or rectal pain and discharge. Menstrual irregularities may be the presenting symptoms, with longer, more painful menses. Chronic or acute lower abdominal pain. Unilateral labial pain and swelling may indicate Bartholin's gland infection and periurethral pain and swelling may indicate inflamed Skene's glands. Infrequently, dysuria, vague abdominal pain, or low backache prompts women to seek care. Later symptoms include fever, n/v, joint pain and swelling or upper abdominal pain (liver involvement). Rectal involvement also possible; rectal itching, fullness, pressure and pain also blood in stool.
11. Testing with NAATs with endocervical swab; need to make sure specimen type is ok for testing type.
12. TREATMENT Ceftriaxone 250 mg single dose; Cefixime 400 mg orally as single dose OR ceftizoxime 500 mg IM cefoxitin 2 g IM with probenecid 1 bm orally or cefotaxime 500 mg IM PLUS Azithromycin 1 gm orally in a single dose OR Doxycycline 100 mg orally twice a day for 7 days. No quinolone's due to resistance. Test of cure 3-4 weeks after treatment and is not necessary; possible cephalosporin-resistant strains. Pts with out symptom relief should be tested for antibiotic resistance.
1. Patho includes endometritis, salpingitis, tubo-ovarian abscess and pelvic peritonitis.
2 Adolescents have a higher risk because of decreased immunity to infectious organisms and increased risk of gonorrhea and chlamydia.
3. Multiple organisms cause PID and include; N. gonorrhoeae and C. trachomatis. Patients with BV may be at higher risk for PID causative organism may facilitate ascent of microbes into upper genital tract.
4. Complications includeFitz-Hugh-Curtis syndrom (perihepatitis). Chronic pelvic pain increased risk of ectopic pregnancy, infertility and recurring PID.
5. Infection can be acute, subacute or chronic. Clinicians should have a high suspicion for PID and a low threshold for its diagnosis.
6. ASSESSMENT history includes recent pelvic surgery, abortion, childbirth, dilatation of the cervix or IUD insertion (within the last month).Thorough sexual risk history should be obtained, including current or most recent sexual activity, numbers of partners and method of contraception. Reported symptoms include; abdominal, pelvic, and low back pain; abnormal vaginal discharge; intermenstrual or postcoital bleeding; fever; nausea and vomiting; urinary frequency. Report levels of pain include minimal discomfort to dull, cramping and intermittent pain to severe, persistent and incapacitating pain. Pelvic pain exacerbated by valsalva maneuver, intercourse or movement. Need vital signs and physical examination reveals adnexal tenderness, abdominal tenderness, uterine tenderness and tenderness with cervical movement. Pelvic tenderness is usually bilateral. May or may not be a palpable adnexal swelling or thickening. A pelvic mass suggests tubo-ovarian abscess.
7. TESTING includes pH test and wet mount of the vaginal secretions; tests for GC and chlamydia; negative test does not completely r/o PID. CBC; ESR. All patient's should be tested for syphilis and HIV. Pelvic us should be performed in patients requiring hospitalization and those with a pelvic mass found on exam.
8. DDx ectopic pregnancy, endometriosis, ovarian cyst with torsion, pelvic adhesions, inflammatory bowel disease and acute appendicitis.
9. TREATMENT first line is prevention. Reasons to hospitalize include pregnancy, no clinical response to oral antimicrobial therapy; inability to follow or tolerate an outpatient oral regimen, severe illness, nausea and vomiting or high fever and tubo ovarian abscess. BROAD SPECTRUM antibiotic is administered; substantial improvement should be noted within 72 hours of treatment initiation. For specific treatments see Schuiling and Likis page 518
10. Minimal pelvic exams should be done during the acute phase of the disease. Recovery phase should restrict activity and adequate rest encourage them to comply with all therapy; any barriers to treatment should be identified early on in the therapy. Should have repeat testing 3-6 months after treatment.
1. Systemic disease caused by Treponemal pallidum a motile spirochete.
2. Higher in blacks and hispanics than whites. Greater in men than women.
3. Characterized by periods of active symptoms and latency.
4. Can affect any tissue or organ.
Transmission is thought to be by entry into the subcutaneous tissue through microscopic abrasions that occur during intercourse; kissing, biting or oral genital sex.
5. STAGES (Schuiling and Likis page 520) PRIMARY is characterized by a primary lesion or CHANCRE; painless papule at the site of inoculation and then erodes to form a contender, shallow, indurated, clean ulcer that is serial millimeters to a few centimeters in size. The CHANCRE is loaded with SPIROCHETES; mostly on the genitalia but can occur on the cervix, perianal area or mouth. SECONDARY is characterized by a widespread, symmetrical maculopapular rash on the pals and soles and generalized lymphadenopathy. Women may experience fever, headache and malaise. Condylomatalata or warlike lesions may develop on the vulva, perineum or anus. UNTREATED enter the latent phase; if untreated the patient is likely to develop tertiary syphilis. TERTIARY symptoms include; chest pain, cough, multiple nodules or ulcers, arthritis, myalgia, mositis, headache, irritability, impaired balance, memory loss, tremor. Can develop into neurologic complications ; meningitis, meningovascular syphilis, general paresis and tabes dorsalis, shifting from traditional symptomatic forms of neurosyphilis to asymptomatic cps involvement with subtler, less well defined syndromes.
6. ASSESSMENT primary may report an anogenital lesion-raised painless and indurated. Secondary syphilis sore throat, malaise, headache, fever myalgias, arthralgias, hoarseness and anorexia; skin rashes on the trunk, extremities, palms and soles which may be pruritic. Others include c/o alopecia and have a moth-eaten look or lose the lateral one third of an eyebrow, low-grade fever. LOOK FOR ALOPECIA; RASH ON HANDS OR FEET AND CONDYLOMATA LATA; PHARYNGEAL-ENLARGED LYMPH NODES. EXTERNAL GENITALIA -VULVAL LESIONS AND CHANCRE. SPECULUM EXAM-LESIONS ON VAGINAL WALLS/CERVIX AND FOR VAGINAL ANC CERVICAL DISCHARGE. BIMANUAL EXAMINATION TO ASSESS UTERINE SIZE, SHAPE, CONSISTENCY, MOBILITY AND TENDERNESS; PALPATE FOR ADNEXAL MASSES AND TENDERNESS. DARK FIELD AND DIRECT FLUORESCENT AB FO T. PALLIDUM OF LESIONS EXUDATES OR TISSUE. SEROLOGY TEST FOR ANTIBODIES (TREPONEMAL AND NONTREPONEMAL) MAY NEED 2 TESTS. VDRL and RPR (Nontreponemal) are used as screening tests-inexpensive, sensitive, moderately nonspecific and fast. False positives are not unusual and occur in increased age, autoimmune disorders, malignancy, pregnancy, injection drug us and recent vaccination. A high tier more than 1:16 indicates active disease. A fourfold change in the tiers considered clinically significant. TREPONEMAL test fluorescent treponemal antibody absorbed (FTA-ABS) test and the T. palladium passive particle agglutination (TP-PA) assay are used to confirm positive nontreponemal test results. Seroconversion takes 6-8 weeks repeat testing for reasonable suspicion. CSF for suspicion of neurosyphilis. TEST for HIV as well.
7. TREATMENT with Pen G for all stages may require treatment for 3 weeks. Repeat testing will likely be necessary. Partner treatment is imperative.
1. The MOST common STI in the US.
2. Double stranded SNA virus with more than 100 known serotypes; more than 40 can infect the genital tract; external genitalia, vagina urethra and anus.
3. SYMPTOMS; asymptomatic, many clear spontaneously.
4. HPV types 6 and 11 carry a low risk for triggering invasive cancer
5. HPV types 16, 18, 31, 33 and 35 that are found in genital warts are associated with cervical intraepithelial neoplasia. Two high risk types , 16 and 18 cause 70% of cervical cancers.
6. AKA condylomata acuminata or condyloma
7. ASSESSMENT most commonly seen in the posterior part of the introits; can also be found on the buttocks, vulva, vagina, anus and cervix. Size 2mm-15mm in height, soft papillary swelling occurring singularly or in cluster ons the genital and anal-rectal region. Warts are flesh color or slightly darker on Caucasian women, black on African American women and brownish on Asian women. Infections of long duration may appear as a cauliflower-like mass. In moist areas the lesions may appear to have multiple, fine, fingerlike projections. Flat-topped papules 1-4mm in diameter are sometimes seen on the cervix (need magnification). Generally painless but may be uncomfortable (if they are large and/or inflamed). Chronic vaginal discharge, pruritus or dyspareunia can occur as well. PROFUSE, IRRITATING VAGINAL DISCHARE, ITCHING, DYSPAREUNIA OR POSTCOITAL BLEEDING. "BUMPS ON HER VULVA OR LABIA. SPECULUM EXAMINATION MAY BLOCK SOME LESIONS ROTATE SPECULUM TO SEE ALL SURFACES. LESIONS ARE DIAGNOSED BY THEIR DESCRIPTION BUT SOME MAY BE TOO SMALL TO VISUALIZE. CAREFUL TO NOT SPREAD LESIONS WITH EXAM.
8. Primary prevention through vaccination. Bivalent and quadrivalent vaccine protect against HPV types 16-18. Gardasil protects agains 6 and 11 as well which covers a majority of the genital warts (also some protection against vulvar and vaginal cancers and pre cancers)
Vaccination can start at age 9 and is recommended ages 11-26 years. should occur before becoming sexually active. Cannot be given during pregnancy-can be given during lactation. Will not treat existing disease. 3 doses 1-2 months apart for the first and 6 months after the second dose. Same vaccine should be given for all doses.
9. DDx; molluscum contagiosum, condylomata lata, carcinoma (squamous cell carcinoma, carcinoma in situ and malignant melanoma.
10. TREATMENT see Schuiling and Likis page 500.
1. Recurrent, incurable viral infection characterized by painful vesicular eruption of the skin and mucosa of the genitals.
2. Two types HSV-1 and HSV-2. HSV-1 nonsexually and HSV-2 sexually
3. Increases woman's risk of acquiring HIV by at least three-fold.
4. Not reportable.
5. Transmitted by individuals that do not know they have it.
6. SYMPTOMS primary or initial infection systemic and local symptoms that last 3 weeks. Flu-like symptoms with fever, malaise, and myalgia after 1 week peak at 4 days and subside over the next week. Multiple genital lesions develop at the site of infection , usually the vulva. Other affected parts are the perianal area, vagina, and cervix. Begin as small painful blisters or vesicles that become unroofed leaving ulcerations. Also bilateral tender, inguinal lymphadenopathy, vulvar edema, vaginal discharge and severe dysuria. Ulcerative lesions last 4-15 days before crusting over. New lesions may develop over 10 days during the course of the infection. The cervix may appear norma or it may be friable reddened ulcerated or necrotic. A heavy, watery to purulent vaginal discharge is common. Extragenital lesions may be present because of auto inoculation. Urinary retention and dysuria may occur secondary to autonomic involvement of the sacral nerve root. Recurrent episodes are usually localized; prodromal genital tingling is common; lesions are unilateral and less severe, usually last 7-10 days without prolonged viral shedding.
7. ASSESSMENT for inguinal and generalized lymphadenopathy and elevated temperatur. Carefully inspect the entire vulvar, perinea, vaginal and cervical areas for vesicles or ulcerated or crusted areas. A speculum exam may be difficult due to pain. Any lesion that is extremely tender should be tested for HSV. Diagnosis confirmed via HSV PCR. Culture is less sensitive. Antibodies are present within the first several weeks after infection and persist indefinitely.
8. DDx syphilis, chancroid, lymphogranuloma venereum, granuloma inguinale as well as non-STI vulvar lesions.
9. TREATMENT Acyclovir, valacyclovir and famciclovir systemic. Topical antiviral therapy is not recommended due to its minimal benefits.
10. Systemic treatments should be given to all patients experiencing their first genital herpes episode. Recurrent lesions can be treated daily with suppressive therapy. Episodic therapy should be started within on day of when the lesion begins or during the prodromal symptoms if present. Should be provided with a prescription prior to infection so therapy can be started as soon as symptoms begin. Cleansing the lesions twice per day with a saline solution can help prevent secondary infection. ASA or ibuprofen for discomfort. No cortisone ointments. Warm sits baths with baking soda, dry lesions with hair dryer, wearing cotton underwear and loose clothing, applying cold milk or witch hazel compresses flowed by aloe vera gel or Burrows solution to lesions four times a day for 30 minutes, oatmeal baths, applying cool, wet black tea bags to lesions and applying compresses with an infusion of cloves or peppermint oil and clove oil to lesions, amino acid L-lusine has been used for active lesions and suppression; inhibitory effect on the amino acid arginine which supports HSV infection. Minimizing consumption of th foods that contain arginine including coffee, grains, chicken, chocolate, corn, dairy products, meat, peanut butter, nuts and seeds and citrus foods. Herbal remedies including zinc (orally or topically-intravaginal sponge), Honey, propolis and aloe vera are applied as creams or ointments, Calendula ointment, echinacea extract has antiviral properties orally or can be applied locally to reduce inflammation and pain (used at the first indication of a herpes outbreak). Goldenseal my be taken by capsule, tea or extract to decrease inflammation and pain. Myrrh can be applied locally as a diluted tincture or as a compress to decrease pain and inflammation also has a drying effect. Tea oil stimulates the immune system and can be applied locally or added to bath water.
11. Women should be taught how to examine themselves for herpetic lesions using a mirror and good light source to look and a wet cloth or finger covered with a finger cot to rub lightly over the labia. Also can be spread by fomites.
1. Bacterial infection of the genitourinary tract caused by the gram-negative bacteria known as Haemophilus ducreyi.
2. Uncommon in the US
3. Increases risk for HIV infection
4. Genital ulcer
5. Acquired through sexual activity or trauma. Infection through auto inoculation of fingers or other sites occasionally occurs.
6. Incubation period is generally 7 days but could be as long as weeks.
7. SYMPTOMS Presents with a painful macule on the external genitalia that rapidly changes to a pustule and then to an ulcerated lesion. May develop unilateral or bilateral inguinal nodes known as buboes. After one to two weeks, the skin overlying the lymph node becomes erythematous, the center necroses and the node becomes ulcerated.
8. ASSESSMENT one or more painful genital ulcers are present; there is no evidence of syphilis (per dark-field examination of ulcer exudate or serologic testing at least 7 days after ulcer onset); the clinical presentation , ulcer appearance, and regional lymphadenopathy are typical for chancroid; also HSV testing of the exudate is negative. Organism can be identified only by culture on a special medium that is not used routinely; sensitivity is still less than 80%. Should also test for syphilis and HIV.
9. DDx syphilis , HSV, lymphogranuloma venereum, folliculitis, metastatic genital cancer and other vulvar lesions
10. TREATMENT azithromycin 1 gm orally in a single dose; ceftriaxone 250 mg IM in a single dose; cipro 500 mg po bid for 3 days; erythromycin 500 mg po aid for 7 days. Should be reexamined in 3-7 days after beginning therapy. All sexual partners within 10 days preceding infection should be evaluated regardless of symptom presentation
1. Pediculosis humanus capitis (head louse infecting the scalp)
2. Pediculosis humanus corporus (body or clothing louse infecting the trunk)
3. Phthirus pubis (pubic lice or "crabs") May be found in other hair-bearing areas of the body, including th eaxillae chest, thighs, eyelashes and head. A woman may be infected through contact with infected clothing or bedding and by sexual transmission.
4. ASSESSMENT pt presents with pruritus caused by the lice ingesting saliva and then depositing digestive juices and feces into the skin. H/o shared clothing, bathing equipment or bedding may also be given. Diagnosis is made by direct examination of the egg cases (nits) in the involved area. a hand lens and light can be helpful in identifying the nits (too small to see). Black dots (excreta) may be visible on the surrounding skin and underclothing and crusts or scabs may be seen in the pubic area. Women should be tested for other STI's.
5. DDx anogenital eczema and pruritus, seborrheic dermatitis, pruritus vulvae, folliculitis, tinea crusris and scabies.
6. TREATMENT permethrin 1% cream rinse or pyrethrins with piperonyl but oxide applied to the affected areas and washed off after 10 minutes If symptoms do not resolve within one week and treatment failure is thought to be due to drug resistance an alternative regimen consists of Malathion 0.5% lotion applied for 8-12 hours then washed off. Oral ivermectin (250 mcg/kg) repeated in 2 weeks is another alternative. Advise patients to wash all clothing, bed linens and towels in hot water and to dry these items thoroughly on the hot cycle to destroy lice and nits.
1. Most common cause of vaginal infections in childbearing women
2. Formally known as Gardnerella/Haemophilus vaginalis or Corynebacterium vaginitis
3. Is a dysbiosis of vaginal bacteria.
4. Disturbance is caused by diminished or absent Lactobacillus species which allows for overgrowth of anaerobic and facultative bacteria.
5. A healthy vagina flora involves a predominance of Lactobacillus species
6. During episodes of BV, the vaginal flora is shifted toward a preponderance of anaerobic bacteria.
7. The bacterial imbalance is associated with sexual contact but is not usually spread through sex.
8. Risk factors include: Smoking, menstruation, douching, sexual contact without a condom, low level of education and engaging in oral or anal sex, menopausal women.
9. Associated with preterm birth, postoperative infections, endometritis following pregnancy and acquisition of other STI's.
10. Symptoms include; fishy odor after unprotected sex with men or asymtomatic.
11. ASSESSMENT Presence of a thin homogenous discharge that adheres to vaginal walls. Presence of clue cells on the normal saline prepared slide. pH of the vagina or vaginal discharge >4.5. Positive whiff test which signals the release of an amine "fishy"odor when vaginal discharge contacts alkaline KOH.
12. TREATMENT see page 438 Metronidazole; clindamycin or tinidazole orally or per vagina. Probiotics; condoms during intercourse. Relapses are common after menstruation. Chronic infection warrants further investigation and more intense treatments.
1. Overgrowth of candida in vagina, vulva, groin and other moist areas of the body.
2. Uncomplicated; most common-mild to moderate symptoms
3. Complicated when occurs more than 4 times per year or in women who are immunocompromised. Requires more intensive treatment.
4. Factors that make conditions favorable for Candida growth and increase the chance of candidiasis: Vulva is kept moist because of non breathable clothes or very humid or warm living conditions. The hormonal changes during pregnancy or while taking contraceptives. Diabetes. Antibiotics that alter the vaginal flora. Immunosuppressed.
5. Can be passed to partner but is not contagious.
6. SYMPTOMS include vaginal itching, burning, irritation, dyspareunia and increased vaginal discharge.
7. ASSESSMENT vulva may be erythematous and slightly swollen and have areas of redness with 1-2 satellite lesions extending from the affected area on external examinations. Vagina is also red and edematous. Vaginal discharge is thick, white and curd-like but can also be thin and watery or adherent to vaginal walls.
8. SEVERE candidiasis widespread and severe erythema, skin fissure, edema and excoriations.
9. WET MOUNT may reveal a lack of lactobacillus or the presence of hyphae and pseudo-hyphae with a saline or KOH preparation-yeast buds.
10 TREATMENT see page 440
11. PREVENTION decrease vulvar moisture; wearing cotton underwear, avoid tight-fitting clothing, avoiding plastic backed panty liners and pads unless necessary, drying the vulva thoroughly after bathing without causing abrasions. Decreasing consumption of of refined sugars and yeast products.
12. Recurrent = 4 or more occurrences in 1 year.