STIs

STIs
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2. Non- ulcer forming
1. Ulcer forming
- Bacterial vaginosis
- Herpes simplex I & II - Trichomonal vaginalis
- Candidiasis
- Condylomata acuminata
- Gonorrhoea
- Chancroid - Chlamydial infections
- Pediculosis pubis
- Granuloma inguinale
- Scabies (sarcoptes scabiei)
- Syphilis - Hepatitis
- Molluscum contagiosum virus
- Lymphogranuloma
- Cytomegalovirus
venereum - Group B streptococcus
HIV -
Routes of spread
- Sexual intercourse (principal)
- Close body contact
- Kissing
- Mouth-breast contact
- Anal intercourse
- Oral sex
- Transplacental
- Birth canal (genital tract)
- Lactation

Clinician’s role in preventing and
treating STIs
- Understand microbiology of STIs for appropriate diagnosis & treatment
- Alleviate symptoms & prevent future sequelae.
- Prevent transmission to others
- Patient education & counseling.

HERPES SIMPLEX
By HSV 1&2, ( Approx 85% due to HSV type 2)
 Occurs through direct contact with secretions or mucosal surfaces
contaminated with virus.
o Can enter skin with or without cracks
o Initially replicates in dermis or epidermis-along peripheral sensory nerves-
dorsal root ganglion-latent infection established.
 Incubation period 2-7 days.

Signs & symptoms
o Prodromal -tingling, burning or itching sensation
o Vesicular eruptions – painful ulcers in small parts but can be wider.
o Urinary symptoms including dysuria or retention.
o Severe infections – fever, malaise& bilateral inguinal adenopathy.
o Herpetic cervicitis – profuse watery discharge
o Rarely disseminated infection or could be asymptomatic.
• May persist 2-6 weeks with no subsequent scarring

Primary herpes, male

Recurrent herpes, male

Herpes, female

Primary herpes, female

Same patient, four days later

Herpes cervicitis

 Diagnosis
- Clinical presentation
- Laboratory
 Culture organisms from vesicular fluid in acute phase.
 Pap smear ulcer scraping – giant cells indicative of viral infection.
 serology – 85%& of patients develop IgM antibodies to type 2 virus within 4 days of
exposure.
 Recurrence- occurs despite adequate humoral & cell-mediated immunity.
- Type2 more likely to recur than type 1.
- Ulcers smaller, fewer and confined to one area in vulva, vagina or cervix.
- Healing in 1-3 weeks
- Generally no inguinal adenopathy and systemic symptoms.
- Extragenital sites such as fingers, buttocks & trunk (eczema herpeticum) have been described.

Treatment
 Lesions self-limiting
 Symptomatic treatment
- good genital hygiene
- Loose-fitting undergarments
- Cold compress or sitz baths
- Oral analgesics
• Antivirals
- acyclovir 400mg tds 7 – 10 days
- Famciclovir 250mg bd 7 – 10 days
- Valacyclovir 100mg bd x 10/7

Prevention
- No precautious in absence of active lesions
- Small lesions away from oral or vaginal orifices to be covered with adhesive or paper tape during
coitus
- A non immune partner usually will be infected.

CONDYLOMATA ACUMINATA (VENEREAL WARTS)
 Caused by human papillomavirus(HPV)
 Papillary growths tend to coalesce and form large cauliflower-like masses
 Incubation- 3 months or longer
 During treatment – keep area clean ,avoid sex or use condom with partner
 Has oncogenic potential – pap smear ± biopsy.
 Treatment modes
- Cover with bichloroacetic or trichloroacetic acid weekly till warts are gone.
- Cryosurgery
- Electrosurgical destruction (cauterization)
- Excision
- Self-administered e.g. podofilex 0.5% solution or gel.

Condyloma acuminata, penile

Condyloma acuminata, anal

Condyloma acuminata, meatal

Condyloma acuminata, vulva

Condyloma acuminata, vaginal wall

CHANCROID (SOFT CHANCRE)
Painful, tender genital ulcer with inguinal adenitis, with erythema or fluctuance.
Causative organism Haemophilus ducreyi
Exposure usually through coitus but accidentally acquired on hands have occurred.
Incubation period less than 5 days
Cofactor for HIV transmission.
10% of patients may have coinfection with herpes or syphilis.

Signs and Symptoms
 Vesicopustule lesion generating to saucer-shaped ragged
ulcer circumscribed by an inflammatory wheel
 Very tender with heavy ,contagious foul discharge
 Inguinal adenitis may become necrotic and drain
spontaneously.

Chancroid ulcers

Chancroid Male - regional adenopathy

Chancroid - ruptured node

Chancroid - gram stain of H. ducreyi

Lab
Less reliable than clinical diagnosis
Isolation of H. ducreyi in less than 1/3 of cases
Polymerase chain reaction (PCR) becoming widely available.
Differential diagnosis
Syphilis, granuloma inguinale ,herpes simplex and
lymphogranuloma venereum.

Management
 Good personal hygiene
 Antimicrobial agents vary by locality (regimens)
- Azithromycin 1gm start oral
- Cefriaxone 250mg 1m start
- Erythromycin 500mg tds× 1/52
- Ciprofloxacin 500mg bd × 3/7
 Fluctuant lymph nodes may need aspiration through adjacent normal skin
 NB: I/D not recommended as will delay healing,

Prognosis
 Untreated or poorly managed – may persist and develop secondary
infection – deep scarring
 Improvement within 7-10 days, if not – co infection, HIV, resistant strains
or non-compliance.

GRANULOMA INGUINALE ( DONOVANOSIS)
 Chronic ulcerative granulomatous disease

 Usually develops in vulva , perineum , or inguinal regions
 May occur in cervical, uterine, oral and ovarian
 Causative organism – calymmatobacterium granulomatis
• ( Donovan body- ie bacteria encapsulated in mononuclear leukocyte)
 Transmission through coitus.

Signs and symptoms
 Malodorous discharge
 Papule – ulceration with development of a beefy-red granular zone with clean sharp
edges.
 Ulcer shows little tendency to heal
 Usually no local or systemic symptoms.
 Inguinal swelling common with late formation of abscesses (buboes)
 Chronic cervical lesions rare – redness , ulceration or granulation tissue with fibrosis
 Healing with fibrosis
 Co-existence of another venereal disease often

Granuloma inguinale, male

Granuloma inguinale, female

Granuloma inguinale, chronic destructive
lesion

Granuloma inguinale with
both active and healed lesions

Granuloma inguinale, Donovan bodies

• Lab
 Biopsy or smear material stained with Wright’s , Giemsa’s or silver stain –
large mononuclear cells with one or more cystic inclusions ( Donovan
bodies – small round or rod-shaped particles that stain purple in H/E
(haematoxylin & eosin preparations)

• Prevention
 Personal hygiene
 Therapy immediately after exposure
• Treatment modes
 Trimethoprim –sulphamethoxazole 1 double- strength tab bd for 3 weeks
 Doxycycline 100mg bd for 3 weeks
 Ciprofloxacin 750mg bd for 3 weeks
 Erythromycin 500mg qid for 2-3 weeks
 Azithromycin 1gm weekly for 3 weeks
• Treat partner with whom she had sexual contact 60 days prior to onset of symptoms

LYMPHOGRANULOMA VENEREUM
 Caused by one of the aggressive L serotypes (L1,L2 or L3) of
Chlamydia trachomatis
 Sexual transmission, men more frequently affected than
women.
 Incubation period 7-21 days

Signs and symptoms
 Early vesicopustular eruption may go unnoticed.
 Inguinal and vulval ulceration, lymphoedema and secondary bilateral invasion –
growth very tender and has a hard red to purplish- blue cutaneous induration 10-
30 days after exposure.
 Anorectal lymphoedema (defaecation painful and stool may be blood streaked)
 Later as lymphoedema and ulceration undergo cicatrization – rectal stricture and
vaginal narrowing and distortion – difficult defaecation and severe dyspareunia.
 Late phase systemic symptoms –fever, headache, athralgia, chills and abdominal
cramps.

LGV primary lesion

Chronic lymphogranuloma venereum in
female. Genital elephantiasis

LGV lymphadenopathy

Lab
 Complement fixation using a heat-stable antigen – group specific for all
Chlamydia species,
 Test positive at titres ≥ 1:16 in more than 80% cases of LGV.
 Possible isolation of C. trachomatis from appropriate specimens
confirming immunotype (seldom available).
 Microimmunofluorescent test .

Differential Diagnosis
 As disseminated disease – meningitis, arthritis, pleurisy or peritonitis.
 As cutaneous lesion – granuloma inguinale, tuberculosis, early syphilis and chancroid.
 As colonic lesion ( proctoscopy and mucosal biopsy ) – carcinoma, schistosomiasis and
granuloma inguinale.
Complication
 Perianal scarring and rectal strictures –can involve entire sigmoid colon.
 Vulvar elephantiasis – marked distortion of external genitalia.
Prevention
 Condom
 Refrain from coitus
 Treat exposure with sulphonamides or tetracyclines.

Treatment
a)Chemotherapy
 Doxycycline 100mg bd ×3/52 ( repeat if disease persists)
 Erythromycin 500mg qid×3/52
b) Local surgical treatment.
 Dilate anal strictures manually at weekly interval
 Severe stricture may require diversionary colostomy
 Aspirate abscesses
 If disease arrested – complete vulvectomy for cosmetic reasons

SYPHILIS
1) By Treponema pallidum by direct contact with an infectious moist lesion.

2) T. pallidum pass through intact mucous membrane or abraded skin.

Signs and symptoms
1. Primary syphilis
 Painless genital sore (chancre ) on labia, vulva, vagina, cervix,
anus, lips or nipples.
 Painless, rubbery, regional lymphadenopathy followed by
generalized lymphadenopathy in 3rd - 6th week.
 Darkfield microscopic findings – T.pallidum
 Positive serological tests in 70% of cases.

2. Secondary syphilis
 Bilateral symmetrical extragenital papulosquamous eruption
 Condyloma lata in perineal area
 Mucous patches
 Systemic manifestation including patchy alopecia, hepatitis and
nephritis.
 Darkfield microscopy findings in moist areas.
 Positive serological test for syphilis.
 Lymphadenopathy
3. Latent syphilis
 Absence of lesions
 Serologic test usually reactive; titre may be low.
4. Tertiary syphilis
• Cardiac – aortic aneurysms or insufficiency.
• Neurologic – mostly during latent phase.
•Ophthalmic and auditory systems involvement
•Cranial nerve palsy and meningitis.
• Skin or bone (gummas )
Syphilis - Treponema pallidum

Primary syphilis-chancre

Primary syphilis - chancre


Primary syphilis - chancre of anus


Secondary syphilis - papulosquamous rash

Secondary syphilis - papulo-pustular rash

Secondary syphilis

Secondary syphilis

Secondary syphilis

Secondary syphilis - alopecia

Late syphilis - serpiginous gummata of
forearm

Late syphilis - ulcerating gumma

Cardiovascular syphilis - narrowing of
coronary ostia in aorta

Neurosyphilis - spirochetes in neural tissue

Congenital syphilis - mucous patches

Congenital syphilis - - Hutchinson’s teeth

Congenital syphilis - perforation of palate

Lab
Serological Tests (for syphilis) - Positive several weeks after primary lesion appears
a) Non-treponemal tests
 Flocculation tests including VDRL, rapid reagin test, and automated reagin test.
 False positives:- collagen diseases, malaria, infections mononucleosis, febrile diseases, leprosy,
vaccination, drug addiction
b) Treponemal antibody tests
 Fluorescent treponemal antibody absorption (FTA – ABS) test
 Microhaemagglutination assay for T. pallidum (MHA – TP)
 Both more sensitive and specific than non-treponemal tests (except for MHA – TP in primary
disease)
• Remain positive despite therapy so no use as titres or therapy follow up

Differential diagnoses
1.Primary syphilis
• – chancroid, granuloma inguinale, lymphogranuloma
• venereum, herpes genitalis, carcinoma, scabies, trauma, lichen planus,
psoriasis, drug eruption, mycotic infections & Reiter’s syndrome.
2. Secondary syphilis
– psoriasis, lichen planus, tinea versicolor, drug eruption, iritis, neurorerinitis,
condyloma acuminata, infectious mononucleosis, alopecia etc

Treatment
 Primary, secondary and early latent (less than 1 year duration)
- Benzathine penicillin G 2.4 million 1m start
- Tetracycline chloride 500mg qid X 2/52
- Doxycycline 100mg bd X 2/52
- Avoid erythromycin estolate in pregnancy (potential drug – related hepatotoxicity)
 Late syphilis (except neurosyphilis)
Benzathine penicillin G 2.4 million units 1m weekly X 3/52
Tetracychrine and doxycycline as above.

VAGINITIS
 Clinical syndrome characterized by
- Vaginal discharge
- Vulvar irritation or
- Malodorous discharge
 Divided into two

- Infectious vaginitis
- Atrophic vaginitis

•Infectious vaginitis
1. Bacterial vaginosis
o Most frequent but 50% of women asymptomatic
 Loss of lactobacilli
 Increase in vaginal pH (>4.5)
 Increase in multiple aerobic and anaerobic bacteria
o Causes
 Gardnerella vaginalis (formerly corynebacterium vaginale and haemophilus
vaginalis)
 Anaerobic bacteria (fishy oduor) such as Bacteroids and peptostreptococus spp;
and genital mycoplasmas

o Clinical criteria for diagnosis
 Homogeneous white, non-inflammatory discharge
 Microscopic pressure of >20%
 Vaginal discharge with Ph > 4.5 (vaginal cells with G.
vaginalis)
 Fishy odour with or without addition of potassium
hydroxide (KOH)

o Diagnosis
 Wet preparation (unstained exfoliated vaginal cells with many small dark particles
– set up referred to as “clue cells)
 Culture
 Gram’s stain
o Treatment -oral
 Metronidazole 400mg, bd for 7 days
 Metronidazole 2g stat
 Clindamycin 300mg bd for 7 days

2. Trichomonas vaginitis
o By Trichomonas vaginalis
o Persistent profuse, extremely frothy, greenish at times foul – smelling vaginal
discharge
• Generalized vaginal erythma with multiple petechiae (strawberry spots)
• Urinary symptoms
• Tests
• Wet mount with normal saline (motile flagellates)
• Pap smear (may get false positives
• Culture (gold standard – 95% specificity and 100% specificity)
• Treatment
• Metronidazole 2g stat
• Associations
• Perinatal complications
• Increased transmission of HIV
Candidiasis
o C. albicans (commonest of candida species)
o Frequently inhabits mouth, throat, large intestine and vagina normally.
o Clinical infection may be associated with:-
- Systematic disorder (mellitus, HIV, Obesity)
- Pregnancy
- Medication (antibiotics, corticosteroids, oral contraceptives)
- Chronic debilitation

S/S
- Intense vulvar pruritis
- A white curd-like, cheesy vaginal discharge
- Vulvar erythma
- Burning sensation on micturation
Tests
- Vaginal secretions mixed with 10% KOH show
pseudohyphae
- Vaginal culture (gold standard)

Treatment options
Chemical and dyes
 1% gentian violet (aniline dye) painted over vaginal surfaces weekly.
 Boric acid pessary (600mg)
Imidazole
 Clotrimazole
 Oral preparations e.g ketaconazole, fluconazole
• Creams may be combined with steroids to reduce inflammation if patient
remains symptomatic

GONORRHOEA
o By Neisseria gonorrheae
o Columnar and transitional epithelium of genitourinary
tract principal site of invasion
o Patients at risk of incubating syphilis
o 20 – 40% also have Chlamydia
o Incubation period 3 -5 days

•Clinical findings
o Vaginal/ urethral discharge with possible inflammation of vulva, vagina, cervix and urethra
o Dysuria
o Lower abdominal pain
o Fever, chills, nausea, and vomiting
o Bartholinitis
o Anorectal inflammation more often by perineal spread of vaginal secretions rather than anal
intercourse
o Disseminated infections
 Commonly polyarthralgia, tendosynovitis and dermatitis
 May be purulent arthritis without dermatitis
 Endocarditis and meningitis have been described
o Conjunctivitis
 In adults usually autoinculation
 Olphthalmia neonatorum

Gonococcal urethritis

Gonococcal cervicitis

Gonorrhea - gram stain of urethral discharge

Bartholin’s abscess

Bartholin’s abscess

Gonococcal ophthalmia

Disseminated gonorrhea - skin lesion

Disseminated gonorrhea - skin lesion

Lab findings
o Thayer – martin or Transgrow media show oxidase –
positive gram – negative diplococci
o Enzyme immunoassay from cervical swab or urine
specimens
o Gram stain
Complications
 Salpingitis
 Tubal scarring
 Infertility
 Ectopic pregnancy
Treatment
o Suspect other STIs,
o Cover for N. gonorhoeae, C. trachomatis and incubating syphilis
Regimens for non-complicated
• Ceftriazone 125mg 1M once then Doxycycline 100mg orally bd X
7 days (for non-pregnant patients)
• Azithromycin 1g orally as single dose
• Cefixime 0.4g orally stat then Docycycline or Azithromycin
• Ofloxacin 0.4g, levoflaxin 0.25g or ciproflozacin 0.5g orally once
for non-pregnant women. Once then Doxycycline or azithromycin
• Can use β - Lactamase inhibitors
Regimens for complicated
•Acute salpingitis – peritonitis
•Disseminated infections
Ceftriaxone 1g (1m or IV)
Ceftizoxime 1g IV 8 hourly
If B – Lactamase allergy, spectinomycin 2g 1m 12 hourly.
Oral medications include Ceftizoxime 0.4g 12 hourly, Ciprofloxacin
0.5g 12hrly, Ofloxacin 0.4g 12 hrly or Levofloxacin 0.5g OD in non-
pregnant or lactating women.
•Neonates and children with untreated gonorrheae
• Ceftriaxome 25 – 50mg/kg IV or 1m maximum 125mg. give with
caution with prematurity or hyperbilirubinaemia infants
The End
Thank You


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KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

 Chronic ulcerative granulomatous disease

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

1) By Treponema pallidum by direct contact with an infectious moist lesion.

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE

KENYA MEDICAL TRAINING COLLEGE