Sexually Transmitted Diseases
Dr. Robert P. Hoffman
Chairman, Infectious Diseases
Mercy Medical Center
300 Stafford Street, Suite 306
Springfield, MA 01104 USA
In Collaboration with Women's Health & Education Center (WHEC)
Sexually transmitted diseases (STDs) represent a prevalent and compelling problem for women. As such, healthcare providers need to take a proactive approach in identifying vaginal symptoms, diagnosing infections, treating these conditions effectively, and maintaining careful follow-up with patients to help reduce the risk of recurrence or re-exposure. We hope that these materials provide valuable information and ideas that can be used to enhance the everyday care of the patients. The Centers for Disease Control and Prevention (CDC) and its expert panel have broken down the guidelines into "Recommended Treatment" and "Alternative Regimen" categories for the various diseases described.
The purpose of this document is to reflect emerging clinical and scientific advances in understanding sexually transmitted diseases (STDs). Clinicians treating female adolescents should be prepared to offer confidential and comprehensive counseling, screening, and treatment according to established guidelines. They should also work within their communities and at the state and national levels to ensure access to medical care for all adolescents. Most importantly, clinicians can help to address this problem when caring for adolescent patients. Specifically, when providing health care for adolescents who have not yet become sexually active, abstinence from all risky behaviors should be encouraged.
Sexually Transmitted Diseases (STDs) in Adolescents:
Adolescence is a period during which life-long health behaviors are established. It is, therefore, a critical time for promoting responsible behaviors and reducing risks through health promotion and prevention strategies. STDs are a primary cause of short and long-term morbidity in adolescents that can result in infertility, chronic pelvic pain, ectopic pregnancy, vertical transmission to newborns, malignancy, chronic illness, and even death. Female adolescents face numerous obstacles to care and experience a disproportionate burden related to the sequelae of sexually transmitted diseases. Approximately 18.9 million new cases of STDs occurred in 2000 in United States of which 9.1 million (48%) were among persons aged 15-24 years. The CDC estimates that more than 1 in 10 sexually active female adolescents have chlamydial infection. In 2002, as in previous years, females aged 15-24 years had the highest rates of gonorrhea compared with females in all other age categories. Prevalence of human papilloma virus infection in sexually active young women ranges from 17% to 84%, with most studies reporting prevalence greater than 30%. Although many of the issues pertaining to high-risk sexual behavior and STDs are common to both adolescents and adults, they often are intensified among adolescents and contribute to their high prevalence rates of STDs. This is caused by developmental changes that affect adolescents physically, behaviorally and emotionally, as well as access-related and financial barriers to healthcare.
Screening and Prevention Recommendations in Adolescents:
The provision of health guidance, screening and preventive healthcare services is an essential component of reproductive health care for adolescents that should begin between the ages 13 years and 15 years. According to the American College of Obstetricians and Gynecologists (ACOG) Committee Opinion (2004), sexually active adolescents should receive screening annually for the following conditions:
- Gonorrhea and chlamydia -- Urine screening should be considered when adolescents are reluctant to have pelvic examinations or are seen where pelvic examinations are not feasible.
- Cervical neoplasia -- This screening should start approximately 3 years after first vaginal-penile coitus, but no later than age 21 years.
- STDs
- Multiple sexual partners or high-risk sexual partner
- Exchange of sex for drugs or money
- Intravenous drug use
- Blood transfusion before 1985 (HIV only)
- Admittance to jail or other detention facility
- Live in areas with high prevalence of HIV and syphilis
Reporting and Partner Notification:
Success in controlling STDs requires vigorous ongoing prevention efforts, accurate identification, administration of appropriate treatments, and timely reporting of partner notification and treatment. Healthcare providers should encourage their patients to make partners aware of potential STD risk and urge them to seek diagnosis and treatment. Many local or state health departments offer assistance in partner notification specifically for patients who have received the diagnosis of HIV, syphilis, gonorrhea, chlamydia, and hepatitis B virus (HBV). Health departments protect the privacy of patients in partner notification services, and in some cases, this is preferable to direct communication between the patient and her partner. In the United States, syphilis, gonorrhea, and acquired immunodeficiency (AIDS) are reportable diseases in every state. Reporting may be provider initiated or laboratory based or both. All clinicians should be familiar with their local STD reporting requirements. Sexually transmitted disease and HIV test results are maintained in the strictest of confidence and in most jurisdictions are protected by statute from subpoena.
Chlamydial Infections:
Chlamydia trachomatis is an obligate intracellular bacteria (250 -- 500 nm in diameter) with eight serotypes. In about 50% of cases of Non-gonococcal urethritis the causative organism is chlamydia trachomatis. T-mycoplasma (Ureaplasma urealyticum), a gram-negative organism 200-1,000 nm in diameter is implicated in anywhere from 5%-40% of cases. Length of incubation is 7 to 21 days. Sometimes it is difficult to determine in women because infection may be asymptomatic.
In men the symptoms are; urethral itching, paresthesia (about 10% are asymptomatic), frequency of micturition, dysuria and mucoid to watery uretheral discharge, though not as profuse as in gonococcal infection.
In women the infection may be asymptomatic or pelvic examination reveal cervicitis, mucopurulent cervical discharge, chronic pelvic pain, tenderness in adnexa.
In newborns; chlamydial conjunctivitis appears between 5th and 14th day after delivery and commonly manifest by a mucopurulent discharge milder than gonococcal conjunctivitis. Chlamydial pneumonia occurs between 4 and 12 weeks after delivery, manifested by staccato cough, usually low-grade or no fever and patchy infiltration on chest x-ray.
Diagnosis is mostly by direct immunofluorescence - show monoclonal antibodies of cervical smear or urethral smear. In newborn smear and culture of purulent discharge of conjunctivitis or cell culture from tracheal aspirates, nasopharynx, and lung biopsy can confirm the diagnosis.
Treatment:
Adult/Adolescent
Recommended Rx -- Azithromycin 1 gm in a single dose or doxycycline 100 mg orally twice a day for 7 days.
Alternative Rx -- Erythromycin base 500 mg four times a day for 7 days or ofloxacin 300 mg orally twice a day for 7 days or levofloxacin 500 mg orally for 7 days.
Pregnant Women
Recommended Rx -- Erythromycin base 500 mg orally four times a day for 7 days or amoxicillin 500 mg orally three times a day for 7 days.
Alternative Rx -- Erythromycin base 250 mg orally four times a day for 14 days or erythromycin ethylsuccinate 800 mg orally four times a day for 7 days or erythromycin ethylsuccinate 400 mg orally four times a day for 14 days or Azithromycin 1 g orally, single dose.
Children (<45 kg) -- Urogenital, rectal infection
Recommended Rx -- Erythromycin base 50 mg/kg/day orally (4 divided doses) daily for 14 days
Neonates -- Opthalmia neonatorum, pneumonia
Recommended Rx -- Erythromycin base 50 mg/kg/day orally (4 divided doses) daily for 14 days or
erythromycin 50 mg/kg/day orally (4 divided doses) daily for 14 days.
Gonococcal Infections
Gonorrhea primarily involves the mucous membranes of the genito-urinary tract, pharynx and anus. The disease has persisted throughout history. The causative organism, Neisseria gonorrhoeae was discovered in 1879 by Albert Neisser and later found to be gram-negative via the dye developed by Gram. The first pure cultures of the gonococcus were grown in 1885. Neisseria gonorrhoeae, a gram-negative diplococcus is a human pathogen. In a stained smear, the organism is found in polymorphonuclear leukocytes. Length of incubation ranges 1-14 days; average 3-5 days.
In 1976, strains of gonococci were found to contain an extachromosomal DNA, a plasmid, which produces beta-lactamase that inactivates penicillin. Similar stains of penicillinase-producing N. gonorrhoeae (PPNG) have since been reported worldwide. Recently, another resistant strain of gonococcus has been identified, which is beta-lactamase negative. Chromosomally medicated resistant N. gonorrhoeae (CMRNG) has intranuclear DNA that renders the cell membrane impermeable to penicillin. Both PPNG and CMRNG respond to therapy with either spectomycin or a third generation cephalosporin. More recently CMRNG strains resistant to tectracycline and spectomycin have been found.
In men the symptoms are of urethritis, frequency of micturition, dysuria, early mucoid urethral discharge, tender inguinal adenopathy and perimeatal erythema.
In women the symptoms are dysuria, purulent cervical discharge, red and swollen cervix, pelvic pain.
In men, women, and children via orogenital exposure signs of pharyngitis -- diffuse edema and erythema are seen. In neonates signs and symptoms of opthalmia neonatorum, conjunctivitis, profuse purulent discharge is seen.
Diagnosis is by gram-stained smear of urethral, cervical or discharge from any source reveals gram-negative intracellular diplococci. Cultures such as Thayer-Martin VCN are used and direct fluorescent antibody test or sugar fermentation of culture is sometimes helpful.
Treatment:
Adults/Adolescents/ Children >45 kg -- Urogenital and rectal infection
Recommended Rx -- Cefixime 400 mg orally in a single dose, or ceftriaxone 125 mg IM in a single dose, or ciprofloxacin 500 mg orally in a single dose, or ofloxacin 400 mg orally in single dose, or levofloxacin 250 mg orally in a single dose. If chlamydia infection is not ruled out; Azithromycin 1 g orally in a single dose, or doxycycline 100 mg twice a day for 7 days.
Alternatives -- spectinomycin 2 g IM in a single dose or single-dose cephalosporin or quinolone
Adults/Adolescents -- Conjunctivitis
Recommended Rx -- ceftriaxone 1 g IM in a single dose; irrigate infected eye with saline solution once.
Children (<45 kg) -- Urogenital, rectal, pharyngeal
Recommended Rx -- ceftriaxone 125 IM in a single dose (maximum 2 g)
Alternatives -- spectinomycin 40 mg/kg IM in a single dose
Neonates -- opthalmia neonatorum infants born to infected mothers
Recommended Rx -- 25-50 mg/kg IV or IM in a single dose (maximum 125 mg)
Syphilis
Chancroid
Until recently, chancroid was disappearing disease in the United States; immigrants have reintroduced it on the east coast from the Caribbean and on the west coast by people coming from Mexico and Southeast Asia. The causative organism is Hemophilus ducreyi. it is a short, fine, gram-negative, bipolar-staining streptobacillus with rounded ends, measuring 1-1.5 microns long and 0.6 microns wide. Average length of incubation is 3-5 days; range 1-14 days.
Clinical picture : the primary lesion is a painful erythematosus papule that rapidly becomes pustular, and ruptures to form an irregularly shaped, ragged ulcer with an erythematosus halo. The ulceration is deep, not shallow as in herpes and spreads laterally, giving the lesions the characteristic undermined edges. The ulcer(s) are soft and tender. Characteristic of chancroid is its ability to infect apposing and contiguous areas of the skin -- that is, autoinoculation. One or more necrotizing, painful ulcers appear on the genitals at the point of inoculation, frequently accompanied by tender inguinal adenopathy with or without suppuration. The inguinal adenopathy appears within the first week in more than half the patients, more often unilaterally than bilaterally. The nodes are visibly enlarged, tender, soft, and with time matted. Scratching may inoculate the lower abdomen and sites distant from the original area of infection.
Diagnosis: chancroid is essentially a clinical diagnosis based on the morphology of the lesions. The laboratory work-up consists of - smear from the lesion taken from the undermined edges and stained with Gram's, Wright's or Pappenheimer's stain; culture of ECA-V medium; biopsy at the edge of lesion; blood test for syphilis such as the Rapid Plasma Reagin (RPR) test. It is advised to test for other STDs and HIV.
Treatment: Patents and their partners may be treated with any of the following:
Ceftriaxone one 250 mg dose IM; or trimethoprim 160 and sulfamethoxazole 800 one tablet every 12 hours orally for 14 days, or erythromycin 500 mg four times a day for 14 days, or ciprofloxacin 250 mg every 12 hours orally for 7 days or 500 mg every 12 hours for 3 days (do not prescribe for children or adolescents under age 18).
Granuloma Inguinale (Donovanosis)
This chronic, mildly communicable, granulomatous disease is relatively rare in the United States, fewer than 50 cases are reported annually. It is diagnosed almost exclusively in blacks, seldom in Caucasians or Orientals. It appears more frequently in homosexual men than in women. Although occasionally found in young boys and older men, the disease is most commonly seen in individuals age 20-45. The causative agent is Calymmatobacterium granulomatis. It is a gram-negative rod measuring 1.5 x 0.5 microns, found as encapsulated inclusions in enlarged histiocytes. The length of incubation period ranges from 8 days to 3 months. Major body areas affected are skin and mucous membrane of the genitals, groin, and perineal area.
Clinical picture: primary lesion is a beefy-red, moist papule that appears on the corona and shaft of the penis, the labia majora or fourchette. Papule enlarges to a nodule and breaks down to form an irregularly shaped ulcer. Original lesion spreads along the warm, moist skin folds and creases to the inguinal and perianal areas via direct extension and autoinoculation. Lesions become granulomatuous and coalesce forming elevated borders. Longstanding untreated lesions may give rise to squamous cell carcinoma. This STD must be differentiated from syphilis, condyloma lata, chancroid and lymphogranuloma venereum.
Diagnosis: examination of scrapings from the lesion or biopsy-crushed smear, using Wright's or Giemsa's stain. C.granulomatis found in large histiocytes and plasma cells are bright red with bipolar staining and resemble a closed safety pin. In biopsy specimens the organism is better visualized with Giemsa's or silver stain.
Treatment - patients may be treated with any of the following antibiotics:
Tetracycline 500 mg orally four times a day for at least 14 days; or doxycycline 100 mg twice a day for 14 days; or minocycline 100 mg twice a day for 14 days; or erythromycin 500 mg four times a day for 14 days or trimethoprim-sulfamethoxazole one double-strength tablet of 160 mg trimethoprim and 800 mg of sulfamethoxazole every 12 hours for at least 14 days.
Lymphogranuloma Venereum (LVG)
LVG is a disease of relatively low frequency in the United States. Its incidence is greater in Southeast Asia, Africa, Central and South America and the Caribbean. It is more prevalent in homosexual males and most patients are between ages 20-40. The causative agent is Chlamydia trachomatis serotypes L-1, L-2 and L-3. The primary lesion appears within 3 to 30 days of exposure, often within 3-4 weeks. The inguinal adenitis syndrome develops one to two weeks after the primary lesion. In patients first seen with inguinal adenitis, therefore, the incubation period is approximately 6 weeks following exposure.
Clinical picture: Primary lesion is a painless papule, vesicle or erosion that heals without scarring after two to three days. Fever, headache, nausea and generalized myalgia and/or arthralgia may be present. Inguinal syndrome -- the site of the primary lesion determines which group of lymph nodes will be involved. If the lesion is on the penis, labia, or perianal area, the inguinal nodes will be affected. If the primary lesion appears on the cervix or in the rectum, the perirectal and deep iliac nodes will enlarge. The inguinal syndrome presents with nodes that are initially hard, tender, and non-movable; these subsequently become enlarged, elongated like almonds and extremely painful. The skin breaks down to form multiple sinuses that discharge serosanguineous and seropurulent material; these sinuses may drain for months leaving irregular linear scars after they heal.
Diagnosis: testing for syphilitic reagin may be reactive but treponemal tests for antitreponemal antibodies non-reactive. LGV complement fixation test titers are positive at 1:80 or higher; acute and convalescent blood tests one week apart show a four-fold or greater rise. Microimmunofluorescent (MIF) test is more sensitive than the complement fixation test. Culture is the most reliable test if positive. Direct fluorescent antibody (DFA) is sensitive and specific. Test for other STDs.
Treatment: tetracycline 500 mg orally four times a day for 14 days, or doxycycline 100 mg orally twice a day for 14 days, or minocycline 100 mg orally twice a day for 14 days, or erythromycin 500 mg four times a day for 14 days, or trimethoprim-sulfamethoxazole double strength 160 mg trimethoprim and 800 mg sulfamethoxazole one tablet orally every 12 hours for 14 days. Surgical evaluation for late stages.
Condylomata Acuminata (Genital Warts)
It is one of the most common sexually transmitted diseases in the world. It is not a reportable disease in the United States, but the incidence has increased in both clinics and private practice. The disease affects both sexes and all races and occurs most commonly in patients age 15-40. The causative agent is human papilloma virus (HPV). It measures 52-55 microns and there are about 60 different DNA types of HPV; four are specific to the urogenital tract. HPV types 6 and 11 are considered low risk for cancer; serotypes 16 and 18 appear on the cervix and may pose a high risk for cervical cancer. The length of incubation ranges from 1-20 months; the average is four months.
Clinical picture: red or pink or dirty gray warts appearing on the moist areas of the genitals and anal area, warts may be singular of more often present in clusters of digitating, papular, pedunculated lesions resembling a cauliflower. Warts bleed easily when traumatized and base of wart may be broad or pedunculated. Biopsy may be necessary if morphologic appearance is unusual.
Treatment: External genital and perianal warts
Recommended Rx -- Patient Applied: podofilox 0.5% solution or gel, apply to visible warts twice a day for 3 days, rest 4 days, 4 cycles maximum; or imiquimod 5% cream apply once in the night wash off after 6-10 hours three times a week for 16 weeks maximum.
Provider Administered -- liquid nitrogen or cryoprobe, or podophyllin resin 10%-25% apply small amount, dry, wash off in 1-4 hours, repeat weekly of necessary; or trichloroacetic acid or bichloroacetic acid 80%-90% apply small amount, dry, apply weekly if necessary; or surgical removal.
Alternatives -- intralesional interferon injection: alferon N injection 0.05 ml (250,000 IU) per wart twice weekly for up to 8 weeks, maximum dose per treatment session 0.5 ml (2.5 million IU), recommended duration of treatment -- maximum of 8 weeks (No further therapy for 3 months after initial 8-week course of treatment unless warts enlarge or new warts appear).
Or Laser surgery.
Genital Herpes Simplex
Scabies
Scabies is a disease of antiquity. In biblical times, it was known as "the itch". Scabies tend to occur in times of war, social upheaval, among crowded populations and in the presence of poor hygiene. The causative agent is Sarcoptes scabiei, a burrowing mite measuring 400 microns (1/60th of an inch) in length with a rounded body and four pairs of legs. Newly hatched eggs mature into adulthood within 10 days. Specifically the eggs hatch into adulthood in 3 to 4 days, and then molt to produce nymphs three days later. In another 3 days, the nymphs reach adulthood. The adult mite can crawl 2.5 cm (one inch) per minute and will die within two days without a blood meal. The male dies after impregnating the female. The latter then digs a hole into the keratin layer of the host's epidermis down to the stratum granulosum and excavates a burrow in which she lays two to three eggs per day for two months. Sensitization and itching may take up to four weeks to develop after initial infestation. Itching starts within 24 hours on reinfestation.
Scabies is spread both sexually and non-sexually via intimate contact with an infected person. Severe itching of the skin becomes more intense during the first two hours after retiring. Skin lesions -- pruritic papule, vesicle, and excoriations with pin-point blood crusts, burrows seen from the point of penetration as thin, short, grayish-white, slightly elevated and thread-like. Laboratory determination -- microscopic examination of scrapings or shave excision of suspected skin for eggs, larvae, adult mites or feces; testing for other STDs.
Treatment:
Recommended Rx -- permethrin 5% crème, apply to all areas of body from neck down, wash off after 8-14 hours.
Alternatives -- lindane 1%; 1 oz of lotion or 30 g of cream, applied thinly to all areas of the body from the neck down, wash off after 8 hours; or ivermectin 200 micro g/kg orally, repeated in 2 weeks.
Pediculosis Pubis
Pediculosis pubis or crab lice occurs worldwide and affects all socio-economic classes and age groups. Peak incidence occurs during periods of war, population migration and social upheaval. The causative agent is Phthirus pubis or crab louse. Females measure 1.0 mm to 1.2 mm; adult males 0.8 mm to 1.0 mm. The nits or eggs hatch in one week, develop into immature lice or nymphs in two weeks and live as adult lice for four weeks. Females lay two to three eggs daily. Both the immature and mature lice die within 24 hours without a blood meal. Pubic lice will crawl 10 cm (four inches) in 24 hours. Length of incubation is within 24 hours of exposure. Upon initial infestation, it may take up to one week before the patient becomes sensitized and itches. On reinfestation, itching begins within 24 hours. Principally it is transmitted via intimate body contact. Pubic lice inhabit the pubic and anogenital area, upper inner thighs and inguinal regions. Patient reports removal of louse from pubic area or intense pruritus. Adult lice can be found attached to pubic hair. Nits (small oval glistening and white) can be found attached to pubic hair; these are best observed under Wood's light. Sometimes microscopic examination of adult lice and nits from plucked hair is essential to make the diagnosis. Testing for other STDs is essential.
Treatment:
Recommended Rx -- permethrin 1% crème rinse apply to affected area and wash off after 10 minutes; or lindane 1% shampoo apply to affected area and wash off after 4 minutes; or pyrethrins with piperonyl butoxide apply to affected area and wash off after 10 minutes. Change all bed linens; wash all under clothing in boiling water and preferably heat dry in an electric dryer. Hang all outer clothing not laundered by dry cleaning in the closet for two weeks. No sexual intercourse for 48 hours after treatment. One week follow up after the treatment if any live nits are still present.
Acquired Immune Deficiency Syndrome (AIDS)
Victims of Sexual Assault:
Identification of STDs after a sexual assault is important for the psychologic and medical treatment of the patient. It is helpful to have a trained counselor available during the examination or to provide a referral for counseling. Appropriate sensitive care should be offered. Legal reporting requirements vary by state depending on the age of the victim and her relationship with the perpetrator. Provision of emergency contraception should be considered if the sexual assault occurred within 72 hours before the examination. Screening for chlamydia, gonorrhea, syphilis, hepatitis screening and HIV are routinely recommended. Among high-risk patients repeat testing should be done.
Summary:
For sexually active adolescents, it is crucial to promote safe sexual behaviors, provide contraceptive information, encourage condom use, perform recommended STD screenings, prescribe appropriate antimicrobial therapies for infections, follow requirements for reporting and partner notification, and ensure continued support and follow-up care. It is especially important when treating an adolescent for an STD to use on-site single-dose antibiotics whenever possible and to give presumptive treatment because of the difficulties in getting adolescents to return for treatment. Confidential notification of sexual partners is an important component for STD treatment.
Suggested Readings:
- World Health Organization
Sexually Transmitted Diseases Diagnostic Initiative
Sexually Transmitted Infections
- National Institutes of Health (NIH)
Sexually Transmitted Diseases
- Center for Disease Control and Prevention (CDC)
Sexually Transmitted Diseases
- The World Bank
HIV/AIDS in Africa ACT Africa
Published: 23 September 2009
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