SEXUALLY

TRANSMITTED
DISEASES(STD’S)
AUTLINE
Definition
-Penile discharge(Urethral D)
-Vaginal Discharge
-Genital Ulceration
Epidemiology.
Investigation
Management
DEFINITION OF STD’S
Sexual transmitted infections are diseases transmitted via intercourse
especially unprotected anal, oral and vaginal sex. STI are spread to children
as well during pregnancy and childbirth.
 URETHRAL DISCHARGE
SYNDROME?
Penile Discharge coming from the
urethral meatus
May be frank pus, mucopurulent, or serous
(clear)
 Occasionally discharge will
be white in colour
Urethritis in the male is frequent, and is
A most always sexually transmitted
It is classically divided into gonorrhea, and
Non gonococcal urethritis. By definition, men
with gonorrhea have Neisseria gonorrhoeae
present, but approximately 20% also have Chlamydia trachomatis.
EPIDEMIOLOGY
The peak period of onset of urethritis in men is from age 20 to
24years,
urethritis occurs in post pubertal men of all ages
The major risk factor for development of urethritis is sexual
activity
1.GONOCOCCAL URETHRITIS
Definition: It is an STI characterized by
presence of secretions (pus) from anterior urethral accompanied by burning
urethral
discomfort when passing urine. Gonorrhea is
transmitted through vaginal, anal and oral
intercourse or prenatally.
Cause
- Neisseria gonorrhoeae a Gram negative
intracellular diplococcus.
CONT,,,
Signs and Symptoms
- In men
• Acute arthritis
• Dysuria
• Urethral purulent discharge
• Prostatitis
• Epedidimitis
NON GONOCOCCAL URETHRITIS

.Chlamydia Infections
 Definition: Chlamydia infection is an STI
characterized by urethral discharge
Cause
- infection with Chlamydia trachomatis
SIGNS AND SYMPTOMS
- In men
• Most of the time, asymptomatic
• Dysuria
• Mucopurulent discharge
• Itching sensation inside the urethra
 Complications
- Pelvic inflammatory disease (low abdominal
pain)
- Infertility
INVESTIGATION AND
MANAGEMENT
 Investigations
- Culture
- Serology
 Management
- First choice
• Azithromycin 1 g orally as one dose Or
• Doxycycline 200 mg orally daily for 10 days
for patients allergic to macrolide (azithromycin)
RECOMMANDATION
 Recommendations
- All sexual partners should be notified and
treated
- Patients should be advised against sexual
intercourse until both patient and the partner(s) are treated.
VAGINAL DISCHARGE
• Cause
N. gonorrhoea
• C. trachomatis Bacterial
vaginosis
• T. vaginalis
• Herpes simplex
• Candida albicans
• Gardenerella vaginalis
• Mycoplasma
Vaginitis
H& E
History
Menstrual history
Nature & type of discharge -
(amount, smell, consistency)
Genital itching, Burning micturation,
frequency
Ulcer / swelling, Low backpain
Examination
Discharge in vaginitis
Trichomoniasis – greenish frothy
Candidiasis – curdy white
Bacterial vaginosis – adherent discharge
Mixed infection – atypical discharge
Cervicitis
Erosion, ulcer, mucopurulent discharge
Bimanual pelvic examination to R/O PID
If speculum examination is not possible treat for
both vaginitis and cervicitis
INVESTIGATION
• vaginalis - Wet mount microscopy
•albicans – 10% KOH
• Vaginosis – gram stain – clue cells
• gonorrhoeae – gram stain – gonococci
•Whiff test
MANAGEMENT
Vaginitis (TV + BV + Candida)
T. Secnidazole 2g single dose (or)
T. Tinidazole 500mg BD 5D
T. Metoclopropramide 30mts before T. secnidazole to
prevent GI
Candidiasis
T. Fluconazole 150mg single dose (or)
Clotrimazole 500mg pessaries once
MGT….
Cervicitis (chlamydia + gonorrhoea)
T. Cefixime 400mg single dose +
T. Azithromycin 1g 1 hour before lunch
If vomiting < 1 hour – anti emetic & repeat
Avoid douching
Recurrent infection – consider pregnancy, diabetes & HIV
Follow up after a week
PELVIC INFLAMMATORY
DISEASE
Causative organisms
N. gonorrhoeae
C. trachomatis
Mycoplasma, gardnerella, anaerobic bacteria
(Bacteroides sp.gram +ve cocci)
H&E
History
Lower abdomen pain, Fever
Vaginal discharge, Menstrual irregularities
Dysmenorrhoea, Dyspareunia
Low backache, IUD
Examination
Per speculum – vaginal / cervical
discharge, congestion or ulcer
Lower abdominal tenderness / guarding
MANAGEMENT
Cover C / G & anaerobes
T. Cefixime 400mg BD x 7D +
T. Metronidazole 400mg BD x 14D +
T. Doxycycline 100mg BD x 14D
T. Ibubrufen + T. Ranitidine
Remove IUD under antibiotic cover
Abstinence , use of condom
SCROTAL SWELLING
Common STI causes of scrotal swelling are
• Neisseria gonorrhea
• Chlamydia trachomatis
Exclude non-STI causes of scrotal swelling:
• TB
• Inguinal hernia
• Testicular torsion, etc
HISTORY
Scrotal swelling & pain
Pain or burning micturation
Malaise, fever
Oro-genital sex
EXAMINE AND DIAGNOSIS
EXAMINATION
Scrotal swelling
Redness and edema of skin
Tenderness – epididymis & V.
deferens
Discharge, ulcer, inguinal nodes
Trans-illumination test
DIFFERENTIAL DIGNOSIS
Scrotal swelling – Infectious causes
TB, filariasis, coliforms,
pseudomonas, mumps
Non infectious causes
Trauma, hernia, hydrocoele, T.
torsion/ tumour
MANAGEMENT
TREATMENT OF PREGNANT
medication
PARTNER
T. Cefixime 400mg single dose X 7 Doxycycline &
Days +
Erythromycin esolate (hepatotoxic)
C. Doxycycline 100mg BD X 14
Days Contraindicated
Erythromycin base
Long term parental : complicated G.
infection (or) erythromycin ethyl succinate
Delay in treatment : scarring / sub- (or) amoxicillin can be used
fertility
INGUINAL BUBO
couse image

Chancroid- Haemophilus
ducreyi
• LGV - C. trachomatis
(L1,L2,L3)
EXAM& HISTORY
History Examination

Inguinal swelling (painful) Enlarged inguinal nodes – tender /

fluctuant
Preceding ulcer / discharge
Redness and edema of skin
Malaise, fever
Multiple sinuses
Oro-genital sex
Odema – genital & lower limb
Genital ulcer / discharge
MANAGEMET
. Doxycycline 100mg BD X 21 days

Chancroid T. Azithromycin single dose (or)

T. Ciprofloxacin 500mg BD X 3 days
Never incise a bubo – fistula
Surgical intervention – severe vulval edema
ORAL & ANAL STI
Causative Organism HISTORY

N. gonorrhoea Unprotected oral sex with

pharyngitis
C. trachomatis
Unprotected anal sex with anal
T. pallidum discharge/ tenesmus, diarrhoea,
H. ducreyi blood in stool, abdominal cramping,
nausea, bloating,rectal pus
K. granulomatis
H. simplex
CONT,,,,
Examination Investigation

Oral ulcers, pharyngitis Syphilis

Genital or anorectal ulcer – RPR / VDRL
Vesicles Gonorrhoea (gram stain)
Rectal pus gram –ve intracellular diplococci
Proctoscopy
IMAGE Condylomata lata
- sec syphilis

Split Papules
Oral candidiasis
- sec syphilis
EPIDIDYMITIS
Acute epididymitis is characterized by pain, swelling, and inflammation of the
epididymis that lasts less than 6 weeks
The testis is usually involved (epididymo-orchitis).
Chronic epididymitis is characterized by more than 6 weeks of pain in the
scrotum, testicle, and epididymis
Cause
Escherichia coli and Pseudomonas as a result of anal intercourse
C. trachomatis or N. gonorrhoeae.
acute epididymitis is usually also accompanied by urethritis
GENITAL ULCERS
Granuloma inguinale (K. granulomatis)
Chancroid (Haemphilus ducreyi)
Genital Herpes (Herpes simplex)
Syphilis (Treponema pallidum)
GENITAL ULCERATION
1. Chancroid
Definition: Chancroid is a Sexual Transmitted
(STI) characterized by painful necrotizing genital ulcers
accompanied by usually unilateral adenopathy.
 Chancroid is transmitted sexually by direct
contact with purulent lesions and by
autoinoculation to non sexual sites such eyes and skin
COUSES
 Cause
- Haemophilus ducreyi (gram-negative bacterium)
 Risk factors
- Endemic area
- Low economic status
- Prostitution
SIGNS AND SYMPTOMS
 Signs and Symptoms
- Lesions start as a tender papules that became pistular then
erodes to form an extremely
painful and deep single or multiple ulcers
- Tender, unilateral lymph node
COMPLICATIONS
- Phimosis
- Urethral stricture
- Urethral fistula
- Super infection of ulcers with rapid destruction of genitalia
known as a phagedenic chancroid
INVESTIGATION AND
MANAGEMENT
Investigations
- Gram stain of ulcer exudates
- Culture
 Management
- First choice
• Ciprofloxacin 500mg twice daily orally for 5 days OR
• Erythromycin 500mg orally 6 hourly for 7 days
Alternative
• Sulfamethaxole (400mg)- trimetoprim (80mg)
GLANULOMA INGUINAL
/DENOVANOSIS
 Definition: Granuloma inguinale is a chronic
bacterial infection that affect the skin and mucus membrane in the
genital lesions
 Cause
- Gram negative calymatobacterium granulomatis (klebsiella
granulomatis)
SIGNS AND SYMPTOMS
-Nodule and papules at the site of inoculation
- Single or multiples ulcerations of genital area
- No adenopathy
-Absence of healing if no treatment
Complications
- Elephantiasis swelling of the external genital area
- Extra genital involvement by auto inoculation
or direct extension of lesions
 Investigation
- Gram stain of ulcer exudates
MNGT
Management
- Sulphametoprim (400mg)-trimetrprim(80mg),
2x2 /days /10-20 days Or
- Doxycycline 100 mg, 200mg a day for 10 days
LYMPHOGRANULOMA
VENEREUM
Definition: LymphoGranuloma Venereum is a cutaneous and sometime systemic STI that
affects primarily lymphatic tissues of the groin
 Cause
Infection with Chlamydia trachomatis
 Signs and Symptoms
- First stage
• A small painless, papule/ulcers
- Second stage
• Lymph node involvement resulting in painful buboes.
• Enlargement of lymph nodes above and below the inguinal ligament result in the classic
“groove sign.”
CONT….
- Third stage
• Rectal fistulas, especially in women,
resulting in scarring and chronic lymphatic obstruction
 Complications
- Scarring and local tissues destruction with fistula and stricture formation
- Rectal stenosis
- Elephantiasis of genital organs
- Systemic spread
INVESTIGATION AND
MANAGEMENT
 Investigations
- Samples for culture
- Serology
 Medical therapy
• First-line treatment is usually with
doxycycline 100mg twice-daily for 21 days, Or
• Erythromycin 500 mg 4 times daily for 21 days
Surgical therapy
• Buboes may be drained percutaneously to relieve symptoms.
• Surgical excision is best avoided due to the risk of sinus or fistula formation
REFERENCE
Schwebke andHook, 2003).
Guidelines on Urological infections (European Association of Urology 2009)
http://www.uroweb.org/
Campbell-Walsh urology 11th Ed.
Bailey and Love's short practice of surgery
Townsend: Sabiston Textbook of Surgery,18th edition