Sexual transmitted infections Dr. Alia kareem

Sexual transmitted infections Is an infection acquired primarily through sexual contact

Patient at high risk of STI Sex workers Multiple sexual partener Homo sexual men Drug abusers Early sexual activity

General measures for management of patient with STIs Screening for other STIs Tracing & screening of all sexual partners Protective intercourse or abstinence during disease Follow up of patient

gynecological manifestations of STI Genital Ulcer Mass Lesions abnormal vaginal discharge Lower abdominal pain Dysuria Vulval itching

STD causing genital ulcer Genital herpes Syphilis Chancroid Lymph granuloma venerum Granuloma inguinali

Genital Herpes Is caused by herpse simplex virus(HSV) HSV is ds DNA virus, belong to herpse family is a chronic viral infection with lifelong latency in dorsal root ganglion Spontaneous reactivation by various events results in virus shedding, with or without lesion formation.

Genotype of HSV Two types of herpes simplex virus, HSV-1 and HSV-2. Both types can cause genital herpes. Type 2 HSV is found more typically with genital lesions,

herpseClinical manifestation of genital depends primarily on prescence of antibody from previous exposure primary infection(no antibodies) recurrent infection( with previous exposure)

Menifestation of primary infection incubation peroid 3-7 days Systemic manifestation (fever,malaise,) Local manifestation: is usually widespread involvement of the vulva, and the vagina and cervix Cluster of painful vesicles which coalesce into multiple superficial ulcers,then crusting and heal` Peri-urethral involvement may cause urinary retention duto sever pain and due to involvement of the sacral nerve. Firm, tender, often bilateral Regional LAP lesion healing requires 2 to 3 weeks

Herpetic genital ulcer

Recurrent herpes Asymptomatic shedding of virus. Heralding paresthesias are frequently described as pruritus or tingling in the area prior to lesion formation Localized clusters of painful vesicles and ulcers over an area of 1-2 cm diameter. recurrences are more limited, with only about a week of symptoms

Herpes Simplex in Women with AIDS Speaker Notes: The above picture shows Herpes simplex in woman with AIDS, CD4 cell count <50. Again note the coalescence of the lesions and consequent ulcer formation, this particularly occurs in patients who are severely immunocompromised. Credit: Jean R. Anderson, MD

diagnosis tissue culture Polymerase chain reaction Serologic type-specific glycoprotein G– based assays are available to detect HSV-1 and HSV-2 antibodies

treatment General measures Antiviral drugs

General measures analgesics bathing in saltwater. Lignocaine gel can be applied sore areas. Protective intercourse during the prodrome symptome or lesions screening for other STD

Antiviral treatment ( hasten healing and decrease severity of symptoms) 1.primary episode Acyclovir 400 mg three times daily for 7 to 10 days   or   Acyclovir 200 mg five times daily for 7 to 10 days       2.    recurrent episode Acyclovir 400 mg three times daily for 5 days   or   Acyclovir 800 mg twice daily for 5 days    3.    daily suppression(>6 attacks/ y)  Acyclovir 400 mg twice daily

syphilis is a chronic, complex systemic disease produced by the spirochete, Treponema pallidum. Treponema pallidum, is a slender spiral-shaped organism with tapered ends, is anearobic bacteria.

Clinical manifestation The natural history of syphilis in untreated patients can be divided into four stages: 1-Primary 2-Secondary 3-latent 4-tertiary

a chancre, at the site of inculation primary syphilis . a chancre, at the site of inculation is an isolated nontender ulcer with raised smooth rounded borders and clean indurated base

Secondary syphilis is associated with bacteremia develops 6 weeks to 6 months after a chancre appears. in30% of untreated primary syphilis

Maculopapular rash

Condylomata lata

The latent stage of syphilis follows the secondary stage and varies in duration from 2 to 20 years . a woman has a positive serology without symptoms or signs of her disease early latent syphilis: a period less than 2 years after the initial infection. Late latent syphilis : a period greater than 2 years after the initial infection.

The tertiary phase of syphilis Tertiary syphilis develops in approximately 20% of patients who are not appropriately treated during the primary, secondary, or latent phases of the disease . The manifestations are optic atrophy, tabes dorsalis, generalized paresis of insane aortic aneurysm, gummas of the bone , skin

Diagnosis Definitive diagnosis can be made by dark-field examination or direct fluorescent antibody testing of lesion exudate. . Serologic tests are the principal means for diagnosis: Nontreponemal test: VDRL, RPR Treponemal tests: TPI, FTA-ABS, MHA-TP

Diagnosis Nontreponemal: VDRL, RPR Quantitative results correlate with disease activity, therefore helpful in screening and follow up after treatment. Titers rise when disease is active, fall when treatment is adequat These tests become non- reactive within a few months of adequate treatment.

Non-treponemal testing Detects antibodies against a cardiolipin- cholestrol- lecithin complex, not specific for syphilis. False Positives: Only in serum, not in CSF testing :False negatives certain viral infection: infectious mononucleosis, hepatitis, varicella, measles lymphoma, TB, malaria, endocarditis, connective tissue disease pregnancy Very early or late diseases HIVpostive Reinfection

Confirmatory Testing Treponemal Tests: TPI, FTA-Abs, MHA-TP Detect specific treponemal antibody They become positive soon after initial infection and usually remain positive for life, even with adequate therapy. They do not correlate with disease activity, and are not quantified. Not 100% specific for syphilis: other spirochetal dz.

Treatment Recommended Treatment of Syphilis: Primary, secondary, early latent (<1 year) syphilis Recommended regimen:   Benzathine penicillin G, 2.4 million units IM once Alternative oral regimens (penicillin-allergic, nonpregnant women):   Doxycycline 100 mg orally twice daily for 2 weeks or   Tetracycline 500 mg orally four times daily for 2 weeks Late latent, tertiary, and cardiovascular syphilis   Benzathine penicillin G, 2.4 million units IM weekly times 3 doses Alternative oral regimen (penicillin-allergic, nonpregnant women):   Doxycycline 100 mg orally twice daily for 4 weeks

Follow up after treatment Following treatment of primary or secondary syphilis) the titre of VDRL should fall twofold every 3 months, b coming negative within 2 years.

Chancroid is a sexually transmitted, acute, ulcerative disease of the vulva It appears as local outbreaks predominantly in black and Hispanic males. It is caused by a nonmotile, nonspore- forming, facultative, gram-negative bacillus, Haemophilus ducreyi.

an erythematous papule that becomes pustular and within 48 hours, ulcerates Edges of these painful ulcers are usually irregular with erythematous nonindurated margins. The ulcer bases are usually red and granular

half of patients will develop unilateral or bilateral tender inguinal lymphadenopathy. If large and fluctuant, they are termed buboes. These may occasionally suppurate and form fistulas, the drainage from which will result in other ulcer formation. Definitive diagnosis requires growth of H ducreyi on special media

Recommended Treatment of Chancroid Azithromycin 1 g orally or Ceftriaxone 250 mg intramuscularly Ciprofloxacin 500 mg orally twice daily for 3 days Erythromycin base 500 mg orally three times daily for 7 days

Granuloma Inguinale is also known as donovanosis, is caused by the intracellular gram- negative bacterium Calymmatobacterium (Klebsiella) granulomatis.

Granuloma inguinale presents as painless inflammatory nodules that progress to highly vascular, beefy red ulcers that bleed easily on contact. If secondarily infected they may become painful. These ulcers heal by fibrosis, which can result in scarring resembling keloids.

Diagnosis is confirmed by identification of Donovan bodies during microscopic evaluation of a specimen following Wright-Giemsa staining

Doxycycline 100 mg twice daily for a minimum of 3 weeks and until lesions have completely healed Azithromycin 1 g orally once a week as above Ciprofloxacin 750 mg orally twice daily as above Erythromycin base 500 mg

Lymphogranuloma Venereum (LGV) This ulcerative genital disease is caused by Chlamydia trachomatis, serotypes L1, L2, and L3.

This infection is commonly divided into three stages as follows: stage 1—small vesicle or papule; stage 2—inguinal or femoral lymphadenopathy; and stage 3—anogenitorectal syndrome

A serologic titer that is greater than 1:64 can support the diagnosis. lymph node specimens obtained by swab or aspiration may be tested by immunofluorescence or PCR.

doxycycline, 100 mg orally twice daily for 21 days doxycycline, 100 mg orally twice daily for 21 days. Alternatively, one may use erythromycin base, 500 mg orally four times daily

STD causing mass lesions Genital warts Moll scum contagiusm

Genital warts are caused by HPV types 6 and 11 Genital warts display ranging from flat papules to the classic verrucous, exophytic lesions, termed condyloma acuminata external genital warts may develop at sites in the lower reproductive tract, urethra, anus, or mouth.

Condylomata acuminata

Diagnosis by clinical inspection

Podofilox 0. 5% solution or gel Podofilox 0.5% solution or gel. should not exceed 10 cm2, and the total volume of podofilox should be limited to 0.5 mL per day. Imiquimod 5% cream. Cryotherapy with liquid nitrogen or cryoprobe. Repeat applications every 1 to 2 weeks. Podophyllin resin 10 to 25 percent . Trichloroacetic acid (TCA) or Bichloroacetic acid (BCA) 80 to 90 percent. or Surgical removal either by tangential scissor excision, tangential shave excision, curettage, or electrosurgery. Intralesional interferon Laser surgery

Mollescum contagiosum Flesh-colored, dome-shaped papules with central umbilication

It`s caused by DNA virus It`s diagnosed by clinical inspection Lesions may spontaneously regress over 6 to 12 months It`s treated by: cryotherapy, electrosurgical needle coagulation, sharp needle-tip curettage of a lesion's umbilicated center. topical application of agents used in the treatment of genital warts