Sexually Transmitted Diseases (STDs) Dr.MOHAMED NASR Lecturer Of Dermatology & Venereology Zagazig University Sexually Transmitted Diseases (STDs)

Introduction Communicable disease transmitted mainly by sexual activity including genital-genital contact, anal-genital contact & oral-genital contact. May also be transmitted by blood & during birth.

Spectrum of STDs: Viral: Bacterial: HIV infection Syphilis Genital wart Herpes genitalis Hepatitis B Cytomegalovirus Bacterial: Syphilis Gonorrhoea Non-gonococcal urethritis Chancroid Lymphogranuloma venereum Donovanosis (Granuloma inguinale) 3

Parasitic: Fungal: Protozoa: . Candidiasis (Moniliasis) . Trichomonas vaginalis Parasitic: Pediculosis pubis Scabies 4

Urethritis Painful urethral discharge & testicular swelling are the most common presentations of symptomatic STDs in ♂.

Classification of urethritis Gonococcal urethritis. Non gonococcal urethritis. Non-gonococcal urethritis (NGCU) is > common than gonococcal urethritis.

Urethritis (Clinical Features) Urethral discharge often worse in morning, dysuria, urethral itching. GC urethritis NGCU Organism(s) Gram (-)ve intracellular diplococci. Chlamydia trachomatis. Ureaplasma urealyticum. Trichomonas vaginalis. HSV: rare. Incubation period < 1 week 2-3 weeks Discharge Amount Color +++ Yellowish-green (purulent) Often slight Gray, white, mucoid

Gonorrhoea About 62 million cases of gonorrhoea are diagnosed each year worldwide. The causative organism, Neisseria gonorrhoeae, is a Gram negative diplococci. Infects non-cornified epithelium Cervix Urethra Rectum Pharynx Conjunctiva

Transmission Gonorrhoea is always sexually transmitted in adults. Transmission is more efficient from males to females. The risk of acquisition from a single act of sexual intercourse with an infected partner is estimated at 30 - 70%. Vertical transmission also occurs. About 30% of babies born to infected mothers develop ophthalmia neonatorum, typically presenting in the first week after birth.

Gonococcal Infections in Women Cervicitis Urethritis Proctitis Accessory gland infection (Skene, Bartholin) Pelvic inflammatory disease (PID) Peri-hepatitis (Fitz-Hugh-Curtis) Pregnancy morbidity Conjunctivitis Many infections asymptomatic Pharyngitis DGI

Gonococcal Cervicitis Incubation 3-7 days Symptoms: Vaginal discharge Dysuria Vaginal bleeding Cervical signs : Erythema Friability Purulent exudate

Pelvic Inflammatory Disease Symp.: bilateral lower abdominal pain. Signs: uterine/ adnexal tenderness, +/- fever. Laparoscopy may show hydrosalpinx, inflammation, abscess, adhesions. Adhesions Tube PID often silent

Bartholin’s Abscess Tender swelling in the lower 3rd of the labia with difficulty in walking & sitting. Treatment: antibiotic, analgesic, drainage followed by marsupialization.

Gonococcal Infections in Men Urethritis Epididymitis Proctitis Conjunctivitis Abscess of Cowper’s/Tyson’s glands Seminal vesiculitis Prostatitis Many infections asymptomatic Pharyngitis DGI Urethral stricture Penile edema

Gonococcal Urethritis Incubation 2-5 days. Abrupt onset of severe dysuria. Yellowish-green purulent urethral discharge.

Epididymitis Swollen painful epididymis usually unilateral. Epididymal tenderness or mass on exam.

Extra-genital gonococcal infection 1. Ano-rectal gonorhoea: * It results from rectal sex with an infected partner. * It is often asymptomatic but there may be a burning pain, tenesmus, pain on defaecation & bloody or mucopurulent stools.

2. Gonococcal pharyngitis * It always results from oro-genital coitus. * There is sore throat & pain on swallowing.

3. Gonorrhoea in children a. Ophthalmia neonatorum: * gonococcal eye infection of the newborn during passage through the birth canal. * it develops within 7 days of birth, always bilateral. * Lid edema, erythema and marked purulent discharge.

b. Gonococcal vulvo-vaginitis * before puberty, the vulval and vaginal epithelium is immature stratified squamous epithelium, this allows gonococcal infection to occur. * discharge on child’s underclothing. * vulva is red & oedematous.

4. Disseminated gonorrhoea (DGI) “Dermatitis-arthritis syndrome” Arthritis: 90% Characterized by fever, chills, skin lesions, arthralgia, tenosynovitis Less commonly, hepatitis, myocarditis, endocarditis, meningitis Rash characterized as macular or papular, pustular, hemorrhagic or necrotic, mostly on distal extremities.

Complications of gonorrhoea

Local complications in men Para-urethral duct infection Tysonitis (infection of sebaceous glands) Periurethral abscess Epididymitis Penile oedema Prostatitis. Seminal vesiculitis.

Local complications in women Bartholinitis Skenitis (para-urethral gland infection) Endometritis Salpingitis, which may lead to peritonitis and tubo-ovarian abscesses Perihepatitis

Less commonly, disseminated infection occurs by haematogenous spread: Septicaemia Arthritis Dermatitis Endocarditis Meningitis

GC Diagnostic Methods Gram stain smear Culture: - Enriched media e.g. Mcleod’s chocolate agar. - Selective media e.g. Thayer-Martin media. Antigen Detection Tests: EIA & DFA Nucleic Acid Detection Tests: Probe Hybridization Nucleic Acid Amplification Tests (NAATs) Hybrid Capture

Gonorrhea Treatment Genital & Rectal Infections in Adults Recommended regimens: Cefixime 400 mg PO x 1 or Ceftriaxone 125 mg IM x 1 or Ciprofloxicin 500 mg PO x 1 or Ofloxacin 400 mg PO x 1 or Levofloxacin 250 mg PO x 1 PLUS if chlamydia is not ruled out: Azithromycin 1 g PO x 1 or Doxycycline 100 mg PO BID x 7 d All sex partners within past 60 days need evaluation and treatment

Gonorrhea Treatment Genital & Rectal Infections in Adults Alternative regimens: Ceftizoxime 500 mg IM x 1 Cefotaxime 500 mg IM x 1 Cefoxitin 2 g IM x 1 plus probenecid 1 g PO x 1 Gatifloxacin 400 mg PO x 1 Lomefloxacin 400 mg PO x 1 Norfloxacin 800 mg PO x 1 Spectinomycin 2 g IM x 1

Gonorrhea Treatment Pregnancy Must avoid quinolones & tetracycline Recommended regimens: Cefixime 400 mg PO x 1 Ceftriaxone 125 mg IM x 1 PLUS if chlamydia is not ruled out: Azithromycin 1 g PO x 1 Other appropriate chlamydial regimen Test of cure in 3-4 weeks

Gonorrhea Treatment Neonates Ophthalmia neonatorum prophylaxis: Silver nitrate 1% aqueous solution topical x 1 Erythromycin 0.5% ointment topical x 1 Tetracycline 1% ointment topical x 1 Ophthalmia neonatorum treatment: Ceftriaxone 25-50 mg/kg IV or IM x 1 NTE 125 mg NTE = not to exceed

Gonococcal conjunctivitis: Ceftriaxone 1 gm single IM once

Disseminated Gonococcal Infection (DGI) Ceftriaxone 1 g IM or IV every 24 hours Alternative Regimens Cefotaxime 1 g IV every 8 hours OR Ceftizoxime 1 g IV every 8 hours OR Ciprofloxacin 400 mg IV every 12 hours OR Ofloxacin 400 mg IV every 12 hours OR Levofloxacin 250 mg IV daily OR Spectinomycin 2 g IM every 12 hours All of the preceding regimens should be continued for 24–48 hours after improvement begins.

Gonorrhea Treatment Children Uncomplicated genital infection: > 45 kg: same as adults < 45 kg: ceftriaxone 125 mg IM x 1 (alternative spectinomycin 40 mg/kg IM x 1) Disseminated Gonococcal Infection: Ceftriaxone 25-50 mg/kg/d x 7 d Treat for 10-14d if child weights > 45 kg

Thank You 37