Sexually Transmitted Infections Rontgene M. Solante, MD Internal Medicine-Infectious Diseases

Objectives: To present common cases of STIs To review current methods in the approach to the diagnosis and management of these STIs.

Case 1 32 year old, male, seaman, presented with a complaint of difficulty of urination Self-medication with Ampicillin 500 mg 3x daily with only slight relief (+) unprotected sex with a freelance sex worker 9 days ago

Case 1: Physical Exam urethral discharge, yellowish mucopurulent tenderness right scrotum, (-) masses no prostatic tenderness (+) right inguinal lymphadenopathy

As the attending physician, your goal of Management in the approach of this patient should prioritize on: controlling the signs and symptoms to prevent further transmission b. establish the presence of urethritis and identification of etiologic agents c. prevention of complications and sequelae d. counseling for HIV and other STI work-up

Urethral discharge (mucopurulent) Urethritis in Men Clinical Criteria: Urethral discharge (mucopurulent) + Dysuria , Meatal erythema Presumptive Laboratory Criteria: (1) Urethral Gram stain >5 WBC’s/oif (2) Pyuria (>10 WBC’s/hpf )on first voided urine sediment (3) Positive leukocyte esterase (LE )test on FVU

What organisms are the most likely pathogens you consider in males with urethritis? Neisseria gonorrheae Chlamydia trachomatis Ureaplasma and Mycoplasma Herpes and Trichomonas A and B only

Urethritis in Male Etiology Neisseria gonorrhoeae Chlamydia trachomatis Ureaplasma urealyticum Mycoplasma genitalium T. vaginalis, HSV, and adenovirus Enteric bacteria: (E.coli, Proteus sp) anal sex, instrumentations,UTI

Cervicitis/Urethritis in Women Etiology Neisseria gonorrhoea Chlamydia trachomatis Trichomoniasis and genital herpes (especially primary HSV-2 infection) no etiology, non-infectious- majority of cases Non-infectious: (persistent abnormality of vaginal flora, douching or exposure to chemical irritants, or idiopathic inflammation in the zone of ectopy)

Clinical Features of Gonococcal and Nongonococcal Urethritis in Men Gonorrhea Nongonococcal Incubation 1 - 7 days 3-21 days Onset Abrupt Gradual Symptoms Prominent Milder Dysuria only 2% 27% Discharge only 27% 47% Both 71% 38% Discharge Purulent (91%) Mucoid (58%) Asymptomatic 80% women 70-75% women 10% men Co-infection rate 40% Mandell’s Prin Pract of Inf Dse 2005

Sensitivity and Specificity of Gram-stained Smear for the Detection of Genital or Anorectal Gonorrhea Site and Clinical Setting Sensitivity Specificity Urethra Men, symptomatic urethritis 90-95% 95 – 100% Men, asymptomatic urethritis 50-70% 95 – 100% Endocervix Uncomplicated gonorrheae 50-70% 95-100% Pelvic inflammatory disease 60-70% 95-100% Anorectum Blind swabs 40- 60% 95-100% Anoscopically obtained specimen 70-80% 95-100% Hansfield et al, Sexually Trans Dse: 3rd Edition 1999

Neisseria gonorrheae Culture and Isolation - uses highly selective media Thayer Martin - definitive diagnosis , objective isolation - drug sensitivity assessment Non-Culture Method of Diagnosis highly sensitive and specific • ANTIGEN DETECTION Enzyme Immunoassay • DNA HYBRIDIZATION : GenProbe • NUCLEIC ACID Amplification (PCR) advantage: urine/urethral specimen : asymptomatic diagnosis

Chlamydia trachomatis Screening test: Gram stain • 15 or more pus cells/hpf (urine) • > 5 pus cells / OIF (urethral discharge) • > 30 pus cells / OIF (cervical discharge) • absence of gram negative diplococci Confirmatory tests: CELL CULTURE ANTIGEN DETECTION ASSAY - Direct Flourescent Antibody (DFA) - Enzyme ImmunoAssay NUCLEIC ACID AMPLIFICATION test(NAAT) : asymptomatic diagnosis

Treatment: Neisseria gonorrhoeae Cervix, Urethra, Rectum Quinolone Resistant:(Philippines) Cefixime 400 mg or Ceftriaxone 125/250 mg IM PLUS Chlamydial therapy Azithromycin 1 gm single dose Doxycycline 100 mg bid x 7days

Treatment: Neisseria gonorrhoeae Cervix, Urethra, Rectum Quinolone-Sensitive: Ciprofloxacin 500 mg orally in a single dose* OR Ofloxacin 400 mg orally in a single dose* Levofloxacin 250 mg orally in a single dose* PLUS TREATMENT FOR CHLAMYDIA IF CHLAMYDIAL INFECTION IS NOT RULED OUT

Case 2: Vulvovaginal Discharge Women 2 weeks later, the patient came back because of recurrence of urethritis together with her wife who also complained of vaginal discharge. PE done and revealed: Vaginal wall Cervix OS

Vulvovaginal Discharge Etiology CANDIDIASIS (Candida albicans) BACTERIAL VAGINOSIS TRICHOMONIASIS (Trichomonas vaginalis)

Vulvovaginal Candidiasis vulvar pruritus vulvar erythema, edema,tenderness thick, white, curdy plaques burning sensation during urination

Bacterial Vaginosis profuse,malodorous, non-irritating discharge offensive odor asymptomatic in 50% of cases disappearance of lactobacilli & increase number of Gardnerella Mycoplasma & anaerobic gm(-) rods like:Mobiluncus sp., Prevotella

Bacterial Vaginosis High Specific Sign clue cells Amine Odor Diagnosis: High Specific Sign clue cells WHIFF TEST: Amine Odor Less Specific Signs vaginal pH >4.5 lactobacilli fewer than bacteria homogenous discharge

Trichomoniasis Most common non-viral STI in women purulent, homogenous, or frothy discharge urinary symptoms: frequency & dysuria vaginal pruritus dyspareunia offensive genital odor

Trichomoniasis Diagnosis: Microscopy : Wet Mount - 92% sensitivity (+) clumps of WBC cells and motile trichomonads Culture: Modified Diamond media Feinberg-Whittington

Complications: BV and Trichomoniasis Preterm labor PROM Low birth weight infabts Chorioamnionitis Postpartum endometritis Post-abortion infection

Treatment: BV and Trichomoniasis Metronidazole 2 gm p.o. single dose ALTERNATIVE Metronidazole 500mg 2x daily x 7 days

Case 3 : Genital Ulcers 34 year old, male, call center agent, presented with a complaint of genital lesions for almost 2 weeks. (-) dysuria, (-) urethral discharge Self-medication with Ciprofloxacin but no relief noted (+) unprotected sex with the same gender, being both the insertive and recipient partner a month ago

Case 2: PE Shallow, non-painful ulcers indurated border solitary (+) inguinal lymphadenopathy

Case 2: Genital Ulcers Etiology: Herpes simplex Treponema pallidum Haemophilus ducreyi

Non-genital lesions of syphilis palms/ soles mouth palate “rashes” “patches/ rashes” “ulcers”

Primary and Secondary Syphilis (rashes and condyloma lata)

Non-Genital Manifestations of Syphilis (syphilis gumma)

Diagnosis Serologic a. Screening: RPR , VDRL -uses non-treponemal antigen (cardiolipin, lecithin, cholesterol) - determine disease activity (>1:4) - monitor treatment response b. Confirmatory: TPPA / TPHA/FTA-Abs - uses treponemal antigen - confirms a positive RPR/VDRL - positive for lifetime

Syphilis Primary, Secondary, Early Latent Recommended regimen Benzathine Penicillin G, 2.4 million units IM Penicillin Allergy* Doxycycline 100 mg twice daily x 14 days Latent Syphilis Benzathine penicillin G 2.4 million units IM at one week intervals x 3 doses

Case 2: Herpes simplex, males Primary herpes, male Recurrent herpes, male

Herpes Simplex Principles of Management Antiviral chemotherapy offers benefits to majority of symptomatic patients Antiviral drugs can partially control signs and symptoms of first clinical, and recurrent episodes or when used as daily suppressive therapy Counseling regarding natural history and transmission is integral to management

Genital Herpes First Clinical Episode Acyclovir 400 mg tid Famciclovir 250 mg tid Valacyclovir 1000 mg bid Duration of Therapy 7-10 days

Chancroid: Haemophilus ducreyi Chancroid ulcers Chancroid - regional adenopathy

Treatment: Chancroid Azithromycin 1 gm orally or Ceftriaxone 250 mg IM in a single dose Erythromycin base 500 mg tid x 7 days

Papillomavirus: male

Papillomavirus: female

Papillomavirus Patient-applied Podofilox 0.5% solution or gel or Imiquimod 5% cream Provider-administered Cryotherapy Podophyllin resin 10-25% Trichloroacetic or Bichloroacetic acid 80-90% Surgical removal

Papillomavirus Vaginal warts Cryotherapy or TCA/BCA 80-90% Urethral meatal warts Cryotherapy or podophyllin 10-25% Anal warts

STD Prevention and Control Education and counseling to reduce risk of STD acquisition Detection of asymptomatic and/or symptomatic persons unlikely to seek evaluation Effective diagnosis and treatment Evaluation, treatment, and counseling of sexual partners Preexposure vaccination--hepatitis A, B, HPV vaccination (serotype 16,18,6 and 11)

References: Mandell’s Prin Practice of Inf Dse 2005. 6th ed MMWR CDC STD Treatment Guideline Aug2006 vol 55 Harrison’s Prin of Internal Medicine 2005. 6th ed Washington Manual Inf Dse Consult 2005 SACCL Data