Sexually transmitted infection

Dr. Mulugeta
June 2023
 Sexually transmitted infection
• Any infection that is transmitted
through sexual activity and / or
intimate contact
• STIs and RTIs are overlapping
categories
• 448 million new STI/ year
• 75-85% : in developing
• Accounts for 40% of gynecologic visit
• Major health consequences
• Increased cost to health system
 Sexually transmitted infection
• Risk groups
• Street children, Adolescents
• Multiple partners
• Sex worker and their clients
• Staying away from families for long time
• Factors increasing infection
• Personal sexual behavior
• Status of women in society , Sexual violence , Child marriages
• Age / sex, Immune status
• Woman higher than men
• Biological differences
• Use of vaginal douches
• Different socio-cultural norms form men and women
 STI : causative agents
Bacterial Viral Protozoal Fungal Ectoparasites

Neisseria gonorrhea: Gonorrhea Molluscum Trichomonas ?candida albicans Sarcoptes

Contagiosum virus vaginalis : balanitis scabiei: scabies

Chlamydia trachomatis: chlamydia Herpes simplex virus

Treponema pallidum : syphilis Human

papillomavirus

Hemophilus ducreyi : Chancroid HIV

Caymatobacterium Hepatitis
granulomatous: Donovasis

Cytomegalovirus
 Trichomoniasis
• Caused by single celled parasite: Trichonomas vaginalis
• Common cause of vaginitis
• Most prevalent non-viral STD ( in USA)
• Most cases are asymptomatic ( 20-50%)
• Predilection for epithelial cells
• Foul smelling creamy/ yellow – green frothy discharge
• Erythematous, edematous ,excoriated vulva;
“ strawberry spots” on vaginal wall and the cervix
• Lab Dx: saline wet mount
• Mx: Metronidazole
 Gonorrhea
• Etiology: Neisseria gonorrhea
• Affects:
• Cervix, salipingitis ,urethra, anal canal ,Eye, pharynx
• Systemic infection: Joint, endocardium, meninges
• 3-5 days incubation period , mostly asymptomatic
• Presented as:
• Yellow green discharge (urethral/vaginal)
• Urinary and anorectal complaints
• Acute pharyngitis or tonsillitis , conjunctivitis
• Systemic infection: arthritis, tenosynovitis, dermatitis , Endocarditis, meningitis
 Gonorrhea
• Lab Dx : Gram staining, Culture (Thayer Martin media ), NAAT
• Complication:
• Female: salipingitis and its complication (PID)
• Male: prostate abscess, Urethral stricture and BOO
• Infant: eye blindness
• Treatment
• Uncomplicated infection: Ceftriaxone, Cefixime, Azithromycin, Fluoroquinolones(
ciprofloxacilline or Ofloxacin), Spectinomycine
• Disseminated
• Ceftriaxone 1gm IM /IV daily for 24-48 hrs.
• Cefotaxime or ceftizoxime 1gm IV TID for 24-48 hrs.
• Cefixime 400mg BID for 1 week
 Chlamydia
• Etiology: chlamydia trachomatis
• Affects:
• Cervix, salipingitis ,urethra, anal canal ,Eye, pharynx
• Systemic infection: Joint, chronic infection
• Mostly asymptomatic
• Presented as:
• Mucopurulent discharge (urethral/vaginal)
• Urinary and anorectal complaints
• Acute pharyngitis or tonsillitis , conjunctivitis
• Lower abdominal pain, abnormal vaginal bleeding
 Chlamydia
• Lab Dx : Culture, Serology, NAAT
• Complication:
• Female: PID and its complications( ectopic, infertility, chronic pelvic pain)
reactive arthritis, perihepatitis (Fitz-Hugh Curtis)
• Pregnant: premature delivery, postpartum infection
• Infant: Pneumonitis, Otitis media, inclusion conjunctivitis
• Treatment
• Azithromycin single dose or Doxycycline 100mg BID per day for 7 days
• Erythromycin 500mg PO QID per day for 7 days
• Levofloxacin OD for 7 days
• Ofloxacin BID per day fro 7 days
 Pelvic inflammatory disease
• An acute to chronic infectious of the upper female genital tract
• Ethology :
• Gonorrhea and chlamydia
• Commonly polymicrobial (vaginal flora organisms )
• Risk factors:
• Risky sexual behavior
• IUD use, instrumentation
• Delivery and abortion
• Presentation:
• Bilateral dull aching lower abdomen pain
• Vx Discharge, fever ,Nausea, vomiting , AUB
 Pelvic inflammatory disease
• Physical examination
• Fever ( specially T> 101F )
• RUQ pain / tenderness ( Fitz-Hugh-Curtis syndrome)
• Lower abdomen* tenderness
• Cervical motion*, Uterine* or adenexial tenderness*
• Mucopurulent discharge
• Investigation
• CBC, β-HCG, ESR or C-reactive protein
• Endocervical swap
• Transvaginal ultrasound: TOC/ TOA
• Laparoscopy: in case of diagnosis is in question
• Endometrial biopsy: only useful for laparoscopy negative for salipingitis
 Pelvic inflammatory disease: DDX

• Ectopic pregnancy • Appendicitis

• Ruptured corpus luteam cysts
with hemorrhage
• Torsion of Adenexial mass
• Degenerated myoma
• Endometriosis
• Diverticulitis
• Urinary tract infection
• Interstitial cystitis
• Regional enteritis or ulcerative
colitis
 Pelvic inflammatory disease
• Minimum criteria
• Cervical motion tenderness
• Uterine tenderness
• Adenexial tenderness
• Additional criteria to increase sensitivity of diagnosis
• Oral temperature > 1010 F
• Elevated WBC or ESR or CRP
• Abnormal cervical or vaginal mucopurulent discharge
• Documented chlamydial or gonorrhea infection
• Abundant WBCs on microscopy of vaginal secretions
 Pelvic inflammatory disease: Treatment
• Treatment: empiric, broad spectrum, and as soon as possible
• Most patients can be treated outpatient.
• Indications for inpatient treatment:
• Sever illness, high fever ( T >101F) , WBC> 15,000
• Suspected abscess or TOC/TOA , Generalized peritonitis
• Nausea and vomiting precluding PO treatment
• Non-compliant one (Adolescent, Drug abuse)
• Failed outpatient treatment
• Recent instrumentation and IUD
• HIV patients
• If other acute abdomen causes can not be ruled out
 Pelvic inflammatory disease: Treatment
Out
• e patient
• Ceftriaxone IM once + doxycycline for 14 days with or with out
metronidazole 500mg Po BID for 14 days or
• Cefoxitin 2gm IM once with probenecid acid1gm once + doxycycline for 14
days with or with out metronidazole 500mg Po BID for 14 days

NB
• Azithromycin may be substituted for patients allergic to cephalosporin
• Doxycycline is contraindicated during pregnancy
• Quinolone agent is no longer indicated as emergence of resistances
• If cephalosporin are not feasible
• Levofloxacin 500mg OD or Ofloxacin 400mg BID for 14 days can be considered
• Patient should be evaluated after 72 hrs. to confirm Dx and consider admission if no response
 Pelvic inflammatory disease: Treatment
In patient treatment
1)Regimen A
Cefotetan 2gm IV BID or ceftriaxone 2gm IV
every 6hrs plus
Doxycycline 100mg PO or IV BID
2)Regimen B
• Clindamycin 900mg IV TID plus
• Gentamycin loading dose of 2mg/kg
followed by maintenance dose 1.5mg/kg
every TID ( or single daily dose 3-5mg/kg )
3)Alternatives
• Augmentin 3gm IV QID plus
• Doxycycline 100mg PO or IV BID
NB
• Patient with IUD do not necessarily have
to remove the IUD
• IUD with Actinomyces Israeli
• IUD should be removed and treated with
penicillin or doxycycline or
• Abscess: prolonged IV therapy and
drainage of abscess
• Indication for surgical treatment
• Ruptured tubo-ovarian abscess
• Generalized peritonitis
• Abscess more than 8cm
• TOA/TOC not improving with medical treatment
• Uncertain regarding the diagnosis
• Pelvic abscess dissecting the rectovaginal septum
 Syphilis
• Etiology: Treponema pallidum
• Pathogenesis and presentation :
• Occurs in multiple stage.
• Treponema Pass through intact Mucocutaneous or abraded skin
• Primary
• Hallmark is chancre : painless , round with raised borders ulcer
• Develops: 10-90 days later ( average 21 days)
• Resolves spontaneously after about 6 weeks
• Highly infectious
• Diagnosed by dark field microscopy
• Positive serologic test In 70% of cases
 Syphilis
• Secondary
• Two weeks to 6 months( average 6 weeks) after primary
• Spread Hematogenously and Highly infectious
• Mucocutaneous rush: all the body (also palm and sole & mucous
membrane)
• Condyloma lata
• Systemic symptoms: diffuse lymphadenopathy
• Latent
• After resolution of secondary infection
• Early latent with the preceding 1 year
• Late latent or unworn : all other cases
• No lesion, or minimal symptoms :History or reactive serologic
evidence (titer may bel low )
• Minimal infectious: Infectious for 1 to 2 year
 Syphilis

• Tertiary :
• Gumma , Neurosyphilis , Cardiovascular syphilis
• Syphilis during pregnancy
• Transmission high in 20 syphilis , fetal involvement rare < 18 weeks
• Still birth or preterm delivery , Congenital infection
• Placental infection: large and hydropic placenta
• Polyhydramnios
• Congenital syphilis
• Similar to secondary syphilis: Hepatosplenomegaly, Osteochondritis, Jaundice,
anemia, skin lesion , Rhinitis, lymphadenopathy, Neurologic involvement
 Syphilis

• Complication
• Skin or bone guma,
• Aortic aneurysm or insufficiency,
• Meningitis, tabes dorsalis, paresis
• Lab Dx
• Identification of the organism
• Dark filed microscopy: from cutaneous of lesions ( exudate)
• Immunofluurescent techniques: for dried smears
• Silver staining for T.pallidum : biopsy, placental sections or autopsy
• Serologic test
• NON Treponema tests : VDRL; RPR, TRUST
• Treponemal tests: FTA- ABS,MHA-TP
 Syphilis

• Rx
• Early syphilis: Benzathine penicillin G 2.4 M IM single dose
• Late syphilis: Penicillin 2.4M IM weekly total of three doses
• Neurosyphilis: crystalline penicillin IV/ procaine penicillin 10-14 days
• Allergic to penicillin: doxycycline or erythromycin for 14 days
• Neurosyphilis: 3- 4 M units every 4 hrs. for 10-14 days or 2.4 million IU
IM OD with probenecid 500mg orally QID a day for 10-14 days
• Congenital syphilis: penicillin with different preparation
 Herpes Genitalis
• Etiology
• Herpes simplex virus (85% type 2)
• Virus replicates in the dermis & epidermis
• Highly contagious open lesion
• Still contagious after the lesion healed
• Stays latent in a near by nerve ganglion
• Life long infection with period reactivation
• Severity and duration : Virus status and immune
status
• Both recurrent & asymptomatic : +ve serologic test
 Herpes Genitalis
Diagnosis
• Itching and burning ( as prodrome) and constitutional symptoms
• Burning on urination
• Many small vesicles followed by painful ulcer
• Physical exam : Multiple painful vesicle, ulcerative with crust ,
• Investigation
• HSV culture :from fluid, ulcer or erosion (Gold standard)
• PCR : lesion ( more sensitive but more expensive)
• Cytology: multinucleated giant cells with intra-nuclear inclusion
 Herpes Genitalis
Diagnosis
• Itching and burning ( as prodrome)
• Many small vesicles followed by painful ulcer
• Burning on urination
• Physical exam : multiple vesicles, ulcer with crust
• Investigation
• HSV culture :from fluid, ulcer or erosion (Gold standard)
• PCR : lesion ( more sensitive but more expensive)
• Cytology: multinucleated giant cells with intra-nuclear inclusion
 Herpes Genitalis
• Complication
• Urinary retention
• Disseminated infections: pneumonitis, hepatitis or meningoencephalitis
• Vertical transmission
• Increase risk of HIV acquisition
• Treatment:
• Pain relief :warm/cold water bath, analgesic
• Antiviral : acyclovir, famciclovir, valacyclovir
• Prevention
• Suppression therapy
• Cesarean section delivery
 Chancroid
• Etiology: Haemophilus ducreyi
• Incubation period 10 days
• Clinical presentation:
• Painful erythematous papule
• Ulcer: red, ragged , non-indurated edges, soft and tender
• Patient have typically more than one ulcer
• Exclusively confined to genitalia
• May tender inguinal LN: may produce fluctuant buboes
 Chancroid
• Complication
• Inguinal scaring and fistula
• Lab Dx
• Culture
• Treatment:
• Antibiotics: Azithromycin, ceftriaxone, ciprofloxacilline or erythromycin
• Local : fluctuant buboes: needle aspiration
 Granuloma Inguinale
• Etiology: Klebsiella granulomatis
(Calymmatobectrerium granulomatis)
• Pathogenesis: chronic ulcerative granulomatous
• Clinical presentation:
• Papule or nodule ,beefy red Ulcer with clean and
sharp edge
• Ulcer easily bleeds ; may form granulation
• May have malodorous discharge if cervix / ux
involved
• Lymph nodes usually uninvolved
 Granuloma Inguinale
• Complication
• Scarring (keloid-like scar)
• Coital, walking, and sitting difficulty

• Lab Dx
• Wright’s or Giemsa staining: Donovan bodies
• Biopsy: granulation and cytoplasmic inclusion bodies

• Treatment:
• Doxycycline , Ciprofloxacilline, erythromycin, Co-trimexazole( 2-3 weeks)
• Azithromycin 1gm weekly for 3 weeks or more
 Lymphogranuloma venereum
• Etiology: Chlamydia trachomatis serotypes: L1,L-2.L-3
• Clinical presentation
• Painless vesicles or papule or ulcer
• Painful and tender lymphadenopathy
• Unilateral inguinal/ femoral usually forming the “ groove sign”
• Anorectal syndrome
• Mucoid / hemorrhagic discharge, constipation, tenesmus
• Systemic: fever, headache, arthralgia, chills & abdominal cramp
 Lymphogranuloma venereum
• Complication
• Vaginal narrowing, vulvar elephantiasis
• Colorectal fistula and strictures
• Lab Dx
• Serology: Compliment fixation test ( titer of >1:64)
• Serology: Microimmuno fluorescent
• Treatment
• Antibiotics: Doxycycline/Erythromycin for 21 days
• Local: abscess should be aspirated
 Human papilloma virus
• Different variant: >70 and 1/3 of which causes genital problems
• Precancerous lesion and cancer : HPV 16,18,31,45
• Genital warts ( 6 and 11) :Condyloma Acuminatum
• Diagnosis: clinical →Solid mass ;Biopsy: recurrent, recalcitrant cases
• Flat papules or verrucous/cauliflower
• May be flesh –colored or keratotic ( white/ gray)
• Treatment
• Spontaneous resolution
• Medical: Imiquimod, Podofilox/podophylin, Trichloracetic acid
• Surgical: Electrosurgical excision, lase ablation, Cryotherapy
 Ectoparasites
• Pubic lice
• Transmission: sexual contact , infected linen or clothing
• Symptoms: little to sever itching
• Treatment : Lindane; launder linens & clothing
• Scabies
• Transmission: sexual contact , infected linen or clothing
• Symptoms: small, red rash around primary lesions , intense itching
• Treatment: scabicide ,launder or dry clean & clothing
 STI : Diagnosis and management
• Clinical
• Etiologic
• Syndromic
• Diagnosis is based on the identification of syndromes
• For each syndrome most common Organisms assigned
• Treatment : first contact to health facility
• Comprehensive patient education
• Many advantages
• Highly effective, first contact treat, easy , inexpensive
• Disadvantages
• Over treatment, over use of expensive drugs, missed asymptomatic infections
 Sexually transmitted infection : Diagnosis
• Vaginal discharge syndrome
• Urethral discharge syndrome
• Scrotal swelling
• Lower abdominal pain
• Inguinal Bubo
• Ulcerative genitalia
• Neonatal conjunctivitis
Syndromic management : Flow charts
 Urethral Discharge

• Ceftriaxone 250mg IM once or Ciprofloxacilline 500mg PO once or

Spectnomycin 2gm IM once
Plus
• Azithromycin 1gm po once or Doxycycline 100mg po BID for 7 days
or Erythromycin 500mg po QID for 7 days
Syndromic management : Flow charts
 Scrotal swelling

• Ceftriaxone 250mg IM once or Ciprofloxacilline 500mg PO once or

Spectnomycin 2gm IM once
Plus
• Azithromycin 1gm po once or Doxycycline 100mg po BID for 7 days
or Erythromycin 500mg po QID for 7 days
Syndromic management : Flow charts
 Vaginal discharge
Low risk assessment
• Clotrimazole 100mg suppository
or fluconazole 150 po once
Plus / minus
• Metronidazole 500mg po BID
for 7 days
• Ceftriaxone 250mg IM once or
Ciprofloxacilline 500mg PO once or
Spectnomycin 2gm IM once
Plus
• Azithromycin 1gm po once or
Doxycycline 100mg po BID for 7
days or Erythromycin 500mg po
QID for 7 days
Plus
• Metronidazole 500mg PO BID for 7
days
Syndromic management : Flow charts
 Lower abdominal pain
Out patient
• Ceftriaxone IM once + doxycycline
for 14 days with or with out
metronidazole 500mg Po BID for 14
days or
• Cefoxitin 2gm IM once with
probenecid acid1gm once +
doxycycline for 14 days with or
with out metronidazole 500mg Po
BID for 14 days
In patient treatment
1)Regimen A
Cefotetan 2gm IV BID or ceftriaxone 2gm IV every
6hrs plus
Doxycycline 100mg PO or IV BID
2)Regimen B
• Clindamycin 900mg IV TID plus
• Gentamycin loading dose of 2mg/kg followed
by maintenance dose 1.5mg/kg every TID ( or
single daily dose 3-5mg/kg )
3)Alternatives
• Augmentin 3gm IV QID plus
• Doxycycline 100mg PO or IV BID
Syndromic management : Flow charts
Inguinal Bubo
 Inguinal bubo

• Ciprofloxacilline 500mg PO BID for 3 days or

Plus
• Azithromycin 1gm po weekly for 3 weeks or Doxycycline 100mg po
BID 14-21 days or Erythromycin 500mg po QID for 14-21 days
Syndromic management : Flow charts
 Conjunctivitis

• Ceftriaxone IM once or
Plus
• Azithromycin po once or Erythromycin po QID for 7 days
Syndromic management : Flow charts
 Genital ulcer

• Acyclovir
±
• B. penicillin
Plus
• Azithromycin 1gm po once or Ciprofloxacilline or Erythromycin
500mg po QID for 7 days or Doxycycline 100mg po BID for 7 days or
Sexually transmitted infection : preventive

• Abstinence
• Mutually faithful
• Use condom regularly and consistently
• Partner tracing and treatment
• Health education
• Early treatment and diagnosis