SEXUALLY

TRANSMITTED
DISEASES
(STD’S)
 75% of the world’s STD’s occur in
developing countries because...
 They have a greater proportion of young adults
 Urban migration
 Practices such as..
 Polygamy
 High bride prices
 Use of traditional remedies
 Health resources are limited
 Self treatment and incomplete treatment →
 Drug resistance
 War and civil disturbances
 Burden of Illness

 WHO worldwide estimates for 1995...

 Syphilis
 12,000 cases

 Gonorrhoea
 62,000 cases

 Chlamydia
 88,000 cases

 There are marked regional variations especially for the

less common STD’s
 Chancroid, Lymphomagranuloma venereum & Donovanosis
 Symptoms of STD

 Vaginal discharge or irritation

 Dysuria and Dyspareunia
 Genital ulceration or other lesions
 Lower abdominal or testicular pain
 HOWEVER
 May be asymptomatic in carriers
 And early symptoms ignored in others
 Diagnosis of STD

 Requires a high index of suspicion

 And a knowledge of common local presentations
 When ONE sexually transmitted disease is
diagnosed...
 Always consider the possibility of others
 In this context pregnancy and abnormal cervical
cytology should be regarded as STD’s
 Lack of diagnostic resources may require an empiric
approach to treatment
 Principals of Management

 Best dealt with by a network of detection, treatment

and follow up facilities coordinated by Specialist Clinics
 Should operate in conjunction with resources for HIV
 Such centres should provide...
 Patient friendly resources
 Confidentiality

 Single dose treatment regimens ...

 Optimises compliance
 Reduces the risk of emerging drug resistance
 Offers the best prophylaxis against long term complications
There is a potentially long list of STD’s

 Syphilis
 Gonorrhoea
 Chlamydia
 Lymphogranuloma venereum
 Chancroid
 Donovanosis
 Genital Herpes
 Genital warts
 Bacterial vaginosis
 SYPHILIS

 A sexually transmitted infection caused by the

spirochetal bacterium Treponema pallidum
 Incubation period usually 14 – 28 days
 Recognised in 3 stages in adults…
 Primary = typically a painless genital ulcer with non
tender rubbery lymphadenopathy. Will be tender if 20
infection occurs. May go unrecognised
 Secondary = Fever, rash, anorexia, aches & pains, and
condyloma lata Occurs 2 – 8 weeks in only 1:3
individuals after primary infection and resolves
spontaneously
 Tertiary = can affect any body organ including heart,
bones and brain
 DIAGNOSIS OF SYPHILIS
 Diagnosed by a serological test for reagin – a lipid released
from cells that are attacked by T. pallidum
 This test is sensitive and should revert to negative after
treatment but…
 It is not positive until up to 12w after infection
 It is non-specific and there is a large number of
conditions that cause a false positive test

 Tests that detect antibodies to Treponema are more

specific, appear before reagin but…
 Usually negative with the primary chancre
 They are present for life even after successful treatment
 Yaws (and Pinta) will also be positive to these tests
 Rapid test used at PMGH is an antibody test

 Dark field microscopy of the organism possible

 SYPHILIS IN PREGNANCY

 Typically does not cross the placenta until >20 weeks

 Fetal effects include…
 Stillbirth
 Intrauterine growth restriction
 Prematurity

 Neonatal effects include…

 Hepatosplenomegaly
 Pneumonia
 Anaemia & Jaundice
 Skin lesions
 Osteochondritis
 TREATMENT OF SYPHILIS
 In the mother with a positive STS = serological test for
syphilis
 Give 3 doses of Benzathine penicillin 2.4 mU weekly
 Erythromycin 500 mg 4 x daily for 15 – 30 days for true
penicillin allergy

 For a neonate
 Adequate treatment >28 days before delivery should
prevent neonatal syphilis
 But “safety net” treatment commonly practised
 25,000 IU/Kg Penicillin twice daily for 10 days
 If the baby is clinically affected at birth the prognosis is
poor – see paediatric texts diagnosis & treatment
 Ideally all babies born to STS-positive mothers should be
followed with reagin tests until negative
 FOLLOW-UP AND CONTACT
TRACING
 For a patient with a positive STS…
 Contact and test/treat all partners for previous 12m
 Other children may require testing

 Follow up by a specialist clinic by reagin testing is

desirable to ensure that this test returns to negative
(or titre stabilises) after appropriate therapy is confirmed
 It is desirable to document this and give this to the
patient to present at future health encounters
Gonorrhoea and Chlamydial Infections
 Share a number of features in common
 Gonorrhoea is caused by...
 Neisseria gonorrhoea

 Whereas Chlamydia trachomatis...

 Subtypes D – K

 Preferentially infect columnar and transitional

epithelium of the male and female genital and urinary
tracts
 Both may spread within the peritoneal cavity
 But only N. gonorrhoea is blood-borne spread to joints
whereas C. trachomatis can cause neonatal pneumonia
Gonorrhoea and Chlamydial Symptoms

 50% of females are asymptomatic

 So it is an important cause of chronic PID and infertility
 Acute symptoms include...
 Vaginal discharge
 Dysuria (males and females)
 RUQ in women
 Can cause proctitis, pharyngitis, arthritis & dermatitis
 Tends to flare in the post menstrual week in ♀ or after
abortion/D&C etc.
 Diagnosis of Gonorrhoea and
Chlamydia

 Requires gram stain for N. gonorrhoea

 Look for gram negative diploccoci
 Ideally also culture and test for antibiotic sensitivity

 The best test for Chlamydia is PCR (Polymerase Chain

Reaction)
 Can be performed on the first passed urine from both
females and males
 Where it has high sensitivity for genital tract infection
 And high specificity
 Follow up for Gonorrhoea and
Chlamydia

 Azithromycin 1G stat is as effective (97%) as

Doxycycline 100 mg BD for 7 days (100%)

 Trace and test or treat all sexual contacts of

the last two months after the diagnosis of an
acute infection
 Neisseria and Chlamydia in the
Neonate

 N. gonorrhoea causes an acute conjunctivitis within 5

days
 Whereas C. trachomatis causes conjunctivitis at 5 – 14
days
 And can cause a pneumonia and otitis

 Untreated the conjunctivitis causes keratitis and blindness

 Treatment is by a single dose of IM antibiotics
 Check local protocols

 Or use universal prophylaxis with AgNO3 drops (need to

be made up fresh), Tetracycline or Erythromycin ointment
 Lymphogranuloma venereum
Caused by Chlamydia trachomatis Subtypes L1-3
 Incubation period 7 – 28 days
 Causes a genital vesicle or papule → shallow ulcer with
inguinal lymhadenopathy
 Can cause lower abdominal pain and PID
 Untreated results in fistula, stricture and lymphatic
obstruction → elephantoid change in the genitals
 Consult your local laboratory for possible tests
 DD includes...
 Chancroid, Syphilis and Herpes when acute
 Donovanosis, TB, Filiarisis, Actinomycosis, Crohns and
neoplasm
Lymphogranuloma
venereum
 Lymphogranuloma venereum
Treatment

 Doxycycline or Erythromycin for not less than 21 days

 May require reconstructive surgery
 And Caesarean delivery in a few
 Donovanosis
Caused by Calymmatobacterium granulomatis
 Incubation period 8 – 90 days
 Causes chronic slowly-growing granulomatous ulceration
of the anogenital region and groin
 Begins as a painless indurated ulcer that grows into a beefy
granuloma with a rolled edge with moderate
lymphadenopathy
 Secondary infection and surface bleeding common
 It then becomes painful, foul and locally erosive or
sometimes neoplastic
 May also cause fibrosis, stenosis and elephantoid change
Donovanosis
 Donovanosis (cont’d)
 Diagnose by Leishman stain of crushed material from the
lesion
 Look for Donovan bodies in cytoplasmic vacuoles of
enlarged mononuclear cells

 Treat with...
 Trimethoprim/Sulfamethaxozale
 Doxycycline or Erythromycin for 3 weeks or until healed
 Combination therapy with Gentamicin, Chloramphenicol or
Streptomycin may be required
Donovanosis Diagnosis
 Chancroid
Caused by Haemophilus ducreyi (Gram neg Bacterium)
 Incubation period 1 – 8 days
 Causes a painful genital ulcer with inguinal buboes
 Tender papules → Pustule → Ulcer with ragged red margin
& granulomatous slough in the base
 Main DD is syphilis – negative to dark field illumination
 Mostly diagnosed in men
 Women are presumably carriers
 Contact and treat partners of the preceding 10 days
 Treatment
 Considerable regional variation in antibiotic sensitivity so
check local protocols
Chancroid
 Genital Herpes
66% is due to Type 2 Herpes simplex and 33% is due to Type 1
of this virus
 More or less reversed for oral Herpes
 Affects ≈ 5% of the population
 Spread by direct contact (genital, oral or other)
 The virus established latency in neurones from where
recurrences occur
 The Primary Attack
 Incubation period 2 – 10 days
 Erythema, itching & burning then vesicles
 Severe generalised vulvovaginitis is common with the 1st
attack
Genital Herpes
 Genital Herpes (cont’d)
 Primary Attack (cont’d)
 Urinary retention common
 May be systemic features with fever, arthralgia etc.

 Secondary Attacks
 Occur in 50% of individuals
 Troublesome “cold sores” at varying intervals
 Causes great psychological distress

 Diagnosis
 Usually clinical aided by PCR and viral culture
Genital Herpes
 Treatment of Genital Herpes
 Primary Attack
 Good hygiene, Sitz bathes etc
 Analgesia
 Bladder catheterisation
 Responds to Acyclovir (and similar antiviral agents)

 Secondary Attacks
 Counselling and maintaining good health
 Topical Acyclovir
 There is a role for oral Acyclovir in prophylaxis
Genital Herpes during Pregnancy

 Genital herpes at the time of vaginal delivery carries a risk

of neonatal Herpes – Mother to Child Transmission
 This is a very serious generalised infection with high
mortality and risk of long term morbidity
 (See Herpes in Pregnancy)
 Risk from primary infection is 25 – 56%
 Risk from secondary infection is only 1 – 3%
 Caesarean section (provided that membranes have not
ruptured >4 hrs) reduces the risk of MTC of Herpes
 A Word About HIV

 The most important STD of our time

 It is the Syphilis of the 21st century
 All STD’s (with the possible exception of gonorrhoea and
Chlamydia) but particularly those with genital ulceration
will greatly increase the risk of HIV transmission
 And concurrent HIV makes many of the STD’s much
worse, especially the viral ones due to Human Papilloma
virus and Herpes simplex
ANY QUESTIONS OR
COMMENTS?