Sexually Transmitted Diseases and

Pelvic Inflammatory Disease

Salih H. MD
Assistant Professor in Obstetrics and Gynecology
Addis Ababa University
 Outline
• Introduction
• Epidemiology
• Classification of STDs
• Clinical diagnosis and evaluation
• Prevention and control of STDs
• Management approaches for STDs
• Pelvic inflammatory disease
 Introduction
• A variety of clinical syndromes and infections caused by
pathogens that can be acquired and transmitted through
sexual activity (CDC)
• Have significant health social and economic consequences
• Among the health impacts – cervical cancer, PID, infertility,
ectopic pregnancy, CPP, congenital syphilis, neonatal
conjuctivitis and pneumonia
• Social and economic impacts – marital dysharmony, cost
 Epidemiology
• More than 1 million STIs are acquired every day worldwide
• The largest number of new infections occur in regions of
south and south east Asia (45.6%) followed by Sub Saharan
Africa (19.7%).
• In developing countries STDs accounted 8.9% of disease
burden in reproductive aged women excluding HIV
• There is limited data on the prevalence of STIs in Ethiopia
– EDHS 2011 – 1% for each men and women
 Effect of HIV and STDs on eachother
• Described as epidemiological synergy
– Both share the same risk factors
• STIs enhance the transmission and acquisition of HIV
infection
– Ulcer diseases disrupt the biological barrier
– Inflammatory STIs produce a weak barrier for HIV
– STIs increase HIV viral shading
– Effective treatment of STIs reduce HIV transmission
…
• HIV infection changes antimicrobial susceptibility of STI
pathogens
• HIV infection increases susceptibility for STIs
• HIV causes atypical presentation of most STIs
– Persistent and sever herpetic lesions
– Syphilis rapidly progresses to neurosyphilis
• HIV infection is associated with increased chance of
treatment failure in most STIs
 Classification of STDs
• Based on their clinical presentation: syndromes
– Ulcerative diseases: syphilis, herpes, chancroid, donovanosis …
– Vaginal discharge: ghonococcus, clamydia, …
– Inguinal bubos: LGV …
– Lower abdominal pain:
– Utrethral discharge:
– Scrotal swelling:
– Neonatal conjuctivitis:
 Clinical Diagnosis and Evaluation
• History and physical examination
– Symptoms – based on the syndromes and characterization
– STD risk assessment
• Behavioral risk: sexual behavior
• Biologic risk: HIV infection
– Sexual history:
• Respectful, compassionate and non judgmental
• Use open ended questions
• Normalizing language
• The 5 P’s approach: partner, practice, prevention of pregnancy, protection for STD,
and past history of STD
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• Examination
– General examination
– Abdominal examination – tenderness, guarding, mass
– Pelvic examination –
• External genital examination:
• Speculum examination and discharge sampling
• Bimanual examination
• Femoral and inguinal node examination
• Diagnostic tests
– Guided by the type of syndrome and presentation and presence of complications
…
• Genital ulcer disease:
Genital HSV infection
– Chronic life-long infection
– HSV-1 and HSV-2 can cause genital herpes
– Diagnosis: painful multiple vesicles that ulcerate and crust
• Virologic tests: cell culture and PCR,
• Tzanck preparation – insensitive and nonspecific
• Type specific serologic tests
…
– Antiviral treatment does not eradicate the virus but effective for:
• 1st episode of infection
• Recurrent episodes
• Frequent attacks - as a suppressive therapy
– Reduce recurrence by 70-80%
• IV antivirals for severe disease
– Partner treatment
• Evaluation and counseling, treat symptomatic disease
– Pregnancy
• Transmission to the new born with active disease near delivery 30-50%
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Syphilis
– A systemic diseases caused by Treponema Pallidum
– Clinical stages:
• Primary syphilis: painless genital ulcer with raised round borders
• Secondary syphilis: mucocutaneous lesion – condylomata lata
• Tertiary syphilis: cardiovascular, CNS and muskulosckeletal
• Latent syphilis: lack of clinical symptoms; early and late
• Neurosyphilis: involvement of CNS at any stage
…
– Diagnosis depends on the stage of the disease
• Primary syphilis: dark field examination
• Secondary syphilis: typical mucocutaneous rash, dark field
examination
• Latent syphilis: serology
– Non-treponemal: VDRL and RPR - screening
– Treponemal: FTA-ABS and TP-PA - diagnosis
• Tertiary syphilis: serology tests
• Neurosyphilis: CSF analysis – cell count and VDRL
…
– Treatment also depends on the stage
• Primary, secondary and early latent:
– Benzanthine penicilline im 2.4 mIU stat
• Late latent and Tertiary syphilis: same dose weekly for 3 weeks
• Neurosyphilis: aquous crystaline penicilline 3-4 mU Q4 hr for 10-14 days
– Partner treatment: for 1o, 2o and early latent
• Clinical evaluation, serology and treatment
• Within 90 days – presumptive treatment for early syphilis
• > 90 days – presumptive treatment if serology positive or not available
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– Follow-up
• Clinical and serologic evaluation at 6 and 12 months
– Additional at 24 months for latent syphilis
– CSF cell count every 6 month for neurosyphilis untill normal
• Treatment failure:
– Persistent signs and symptoms
– 4x increase in non treponemal titer for 2 weeks
– Failure of non-treponemal test to decline 4x in 6-12 months
– Failure of CSF cell count to decrease at 6 month or normal at 2 years
– Retreatment: Benzanthine penicilline 2.4mIU im weekly for 3 weeks
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Granuloma Inguinale (Donovanosis)
– Caused by gram negative intracellular bacteria called Klebsiella
granulomatis (Calymmatobacterium granulomatis)
– Painless slowly progressive ulcers with subcutaneous granulomas
(pseudobubos) and no inguinal lymphadenopathies
– Diagnosis is on clinical appearance and Donovan bodies on biopsy
– Treatment: Azithromycine 1g weekly or 500mg daily at least 3
weeks; alternative Doxycycline 100mg bid for 3 weeks
– Partner treatment: examine and treat if contact in the past 60 days
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Lymphogranuloma venereum (LGV)
– Caused by Clamydia Trachomatis serobars L1-3
– Characterized by self limited ulcer with tender inguinal and femoral
lymphadenopathy (groove sign)
– Rectal exposure can lead to proctocolitis
– Diagnosis: clinical suspicion and exclusion of other causes
– Treatment: Doxycycline 100 mg po BID for 21 days
– Partner treatment: evaluated and presumptive treatment
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Chancroid:
– Caused by Hemophilius Ducreyi
– Less common
– Diagnosis is based on painful gegnital ulcers with inguinal
lymphadenopathy
– Definitive diagnosis need a special culture media
– Should exclude herpes and syhilis
– Treatment is Azithromycine 1g oral, or Ceftriaxone 250mg im single
dose or Erythromycine base 500 mg po QID for 7 days
…
• Vaginal discharge syndrome
– Can be caused either by vaginitis or cervicitis
– Cervicitis is infection of the columnar endocervical epithelium
– Major diagnostic signs: mucopurulent discharge, endocervical
bleeding; leukorrhea (>10 WBCs/hpf) can be supportive
– It is typically caused by C. Trachomatis or N. Gonorrheae
– Vaginitis is infection and inflammation of the vaginal epithelium
– Typically caused by Bacterial vaginosis, T. Vaginalis and Candidiasis
…
Chlamydial infection
– The most common infection
– Asymptomatic infection is common – screening
– Have serious sequelae - PID, ectopic pregnancy, infertility
– Diagnosis: cervicitis, NAATs
– Treatment: Azithromycine 1g stat (DOT), Doxycycline for 7 days
– Partner treatment: in the past 60 days
• evaluation and presumptive treatment
– Pregnancy: doxycycline is contraindicated
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Gonococcal Infection
– The second most common communicable disease
– Caused by N. Gonorrheae
– Presents with cervicitis but can be asymptomatic in women
– Diagnosis: culture and NAATs; gram staining – diagnostic but …
– Treatment: dual therapy – antimicrobial resistance
• Ceftriaxone 250mg im stat plus Azithromycine 1g po stat
– Partner therapy: in the last 60 days or most recent
• Presumptive dual treatment
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Trichomoniasis
– The most common non-viral STI
– Caused by the protozoa Trichomonas Vaginalis
– Most persons have minimal or no symptoms - vaginitis
– Associated with increased risk of HIV transmission, preterm birth
– Diagnosis: NAATs, wet mount (poor sensitivity, low cost)
– Treatment: Metromidazole 2g or Tinidazole 2g po stat
– Partner treatment: current partners – presumptive therapy (EPT)
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Bacterial vaginosis
– A polymicrobial clinical syndrome
– The most prevalent cause of vaginal discharge
– Caused by replacement of Lactobacillus spp. by anaerobic bacteria
– Risk factors: multiple sexual partners … , douching, lack of
Lactobacilli …
– Women with no sexual activity can rarely be affected.
– Increases risk of HIV acquisition and transmission, surgical site
infections following gynecologic surgery, preterm delivery …
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– Diagnosis: clinical criteria – Amsel’s criteria or gram staining
• Amsel’s criteria – 3 of 4 criteria
– Homogeneous, thin discharge coating the vagina
– Clue cells on microscopy (at least 20%)
– Vaginal pH >4.5
– Fishy odor with or without KOH (whiff test)
• Gram stain (Nugent Score)– determine relative concentration of
lactobacilli
– Treatment: recommended for symptoms
• Metronidazole 500mg po bid for 7 days
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Vulvovaginal Candidiasis
– Caused by C. albicans and other candida species
– Symptoms include pruritis, vaginal soarness, dyspareunia, external
dysuria, and thick curdy vaginal discharge.
– More common in obese, diabetic and immun-compromised women
– Uncomplicated VVC: sporadic, mild to moderate, albicans, immun-
competent host
– Complicated VVC: recurrent, severe, non-albican and immun-
compromised host
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– Recurrent VVC is defined by 4 or more episodes per year
– Diagnosis: symptoms and culture / wet mount (KOH) / Gram stain
• Candida infection is associated with normal pH (<4.5)
• Culture is needed for complicated VVC
– Treatment: antifungals
• Uncomplicated VVC – Short course topical antifungals (1 – 3 days)
• Recurrent VVC – topical antifungal (7 – 14 days) or oral fluconazole
• Maintainance - oral fluconazole
 Prevention and control of STDs
• Five major strategies:
– Accurate risk assessment, education and counseling
– Pre-exposure vaccination of vaccine preventable STDs
– Identification of asymptomatic and symptomatic persons
– Effective diagnosis, treatment, counseling and follow up of infected
persons
– Evaluation, treatment and counseling of sex partners
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• Primary prevention
– Abstinence
– Correct and consistent use of condom
– Safe sex practice
– Mutual monogamy
– Pre-exposure vaccination
• Secondary prevention
– Promoting STI care seeking behavior
– Early diagnosis and treatment
– Case finding and screening – including partner notification
 Management Approaches for STDs
• Three approaches:
Clinical – use clinical experience to identify etiology and treat
– Advantage: Saves time, reduces lab. Expense
– Disadvantage: high clinical skill, mixed and asymptomatic missed
Etiologic – use laboratory tests to isolate and treat the etiology
– Advantage: avoids over treatment, used for screening
– Disadvantage: expensive, time consuming, not suitable primary
health care, mixed infections can be missed
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Syndromic – identify syndromes and treat all possible etiologies
– Advantages: simple, rapid , inexpensive, mixed infections are
addressed, avoids unnecessary referrals, can be completed with
one visit
– Disadvantages: over treatment, requires prior epidemiologic
knowledge, asymptomatic infections are missed, low specificity for
cervical infections
– Uses flowcharts (algorithms): components
• The clinical problem, the decision and the action
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• Syndromic management of genital ulcer disease
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• Syndromic management of vaginal discharge syndrome
 Pelvic Inflammatory Disease
• PID is infection of the upper female genital organs
– endometritis, salpingitis, tubo-ovarian abscess and pelvic peritonitis
• Most cases are initiated by sexually transmitted organisms
– Ascending infection
• Gonococcus, chlamydia, T. vaginalis …
• Some cases can be by blood born pathogens
– Pelvic tuberculosis
…
• Diagnosis
– Can be acute PID, Silent PID and chronic PID
Silent PID – asymptomatic continuous low grade infection
– Diagnosed as tubal factor infertility with grossly normal tubes
Acute PID – symptomatic
– Symptoms usually develop following mensus.
– Lower abdominal/pelvic pain, vaginal discharge (mucopurulent
cervicitis), and systemic symptoms
– On examination there will be lower abdominal/pelvic tenderness
…
– Presumptive diagnosis – one major and one minor criteria
– High index of suspicion is important
• Major – uterine, adnexal or cervical motion tenderness
• Minor –
– Fever
– Muco-purulent vaginal discharge
– Leukorrhea on microscopy
– Elevated ESR or C-RP
– Cervical gonococcal or chlamydial infection
…
– Diagnostic testing: confirming diagnosis and excluding differentials
• Urine hCG
• CBC
• Urine analysis
• Cervical swab
• Screening for STDs
• Endometrial biopsy
• Ultrasound – hydrosalpinx and excluding other causes
• Laparoscopy – definitive diagnosis
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Chronic PID
– Clinical utility is limited
– Diagnosed with a history of acute PID and chronic pelvic pain
– Hydrosalpinx may indicate chronic PID
Tubo-ovarian abscess
– PID is an important cause – appendicitis, diverticulitis, surgery …
– Present with signs of PID and cul-de-sac or adnexal complex mass
…
• Treatment
– Goal of treatment is to alleviate symptoms and prevent sequelae
– Presumptive treatment is recommended on clinical diagnosis
Out patient or Oral treatment
– Mild to moderate symptoms
– Regimen:
• Ceftriaxone 250mg IM stat + Doxycycline 100 mg PO BID for 14 days
• With or without Metronidazole 500mg PO BID for 14 days
– Reevaluate after 72 hours
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Hospitalization or Parentral treatment
– Criteria:
• Pregnancy, adolescent
• Severe disease (temp.>38.3oC, WBC >15,000/mm3)
• Suspected TOA or generalized peritonitis
• Uncertain diagnosis
• Failed or intolerance to outpatient treatment
– Regimen:
• Cefotetan or cefoxitine + Doxycycline po/iv OR
• Clindamycine + Gentamicine iv
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Tubo-ovarian abscess
– Treated as PID with parentral antibiotics
– Treatment continued for 24 hours after afebrile (48 -72 hours)
– Transition to oral therapy – doxycycline with metronidazole or
clindamycin for 14 days
– Surgical drainage – consider
• Initially if size is >8cm
• Rupture of abscess
• No improvement after 48 -72 hours
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• Syndromic management of lower abdominal pain syndrome