Sexually transmitted diseases

Sexually transmitted infections (STIs) are a group of contagious conditions whose principal mode of transmission is by intimate sexual activity involving the moist mucous membranes of the penis, vulva, vagina, cervix, anus, rectum, mouth and pharynx, along with their adjacent skin surfaces.

PRESENTING PROBLEMS IN MEN URETHRAL DISCHARGE GENITAL ITCH AND/OR RASH GENITAL ULCERATION GENITAL LUMPS PROCTITIS IN MEN WHO HAVE SEX WITH MEN

PRESENTING PROBLEMS IN WOMEN VAGINAL DISCHARGE LOWER ABDOMINAL PAIN GENITAL ULCERATION GENITAL LUMPS CHRONIC VULVAL PAIN AND/OR ITCH

THOSE AT PARTICULAR RISK FROM STIs Sex workers, male and female Clients of sex workers Men who have sex with men Injecting drug users Frequent travellers

INVESTIGATIONS FOR SEXUALLY TRANSMITTED INFECTIONS IN HETEROSEXUAL MALES Urethral swab for gonococci- Urethral swab or first void urine (FVU) for chlamydia Serological test for syphilis (STS), e.g. enzyme immunoassay (EIA) for anti-treponemal IgG antibody HIV test

INVESTIGATIONS FOR SEXUALLY TRANSMITTED INFECTIONS IN MEN WHO HAVE SEX WITH MEN Pharyngeal, urethral and rectal swabs for gonococci Urethral swab, and rectal swab for chlamydia Serological tests for hepatitis A/B. HIV test.

INVESTIGATIONS FOR SEXUALLY TRANSMITTED INFECTIONS IN WOMEN Urethral and cervical swabs for gonococci Cervical swab for chlamydia Wet mount for microscopy or high vaginal swab (HVS) for culture of Trichomonas Serological test for syphilis (STS) HIV test

GONORRHOEA Caused by Neisseria gonorrhoeae. Mode of transmission: a.vaginal, anal or oral sex. b.Untreated mothers may infect their babies during delivery, resulting in ophthalmia neonatorum. c.Gonococcal conjunctivitis may be the result of accidental infection from contaminated fingers

N. Gonorrhea Gram negative kidney bean shaped diplococci. Non capsulated, nonmotile, non-spore-forming. Cultured on thayer-Martin medium. Mode of transmission is mostly through sexual contact and may be during birth. Has got pili that helps in attachment to mucosal surfaces and thus inhibits phagocytic uptake. Has got outer membrane proteins that helps in typing and IgA protease that helps in colonization.

Clinical features The incubation period is usually 2-10 days. In men :Acute urethritis is the most common clinical manifestation of gonorrhea in males. anterior urethra is commonly infected, causing urethral discharge and dysuria. But in 10%cases are asymptomatic. The discharge initially is scant and mucoid but becomes profuse and purulent within a day or two. On examination:mucopurulent or purulent urethral discharge. anal discomfort, discharge or rectal bleeding. Proctoscopy may reveal either no abnormality, or clinical evidence of proctitis such as inflamed rectal mucosa and mucopus.

In women: The urethra, paraurethral glands/ducts, Bartholin's glands/ducts or endocervical canal may be infected. The rectum may also be involved either due to contamination from a urogenital site or as a result of anal sex. About 80% of women who have gonorrhoea are asymptomatic vaginal discharge or dysuria. Lower abdominal pain, dyspareunia and intermenstrual bleeding may be indicative of PID. Clinical examination : May show no abnormality or pus may be expressed from urethra, paraurethral ducts or Bartholin's ducts. The cervix may be inflamed, with mucopurulent discharge and contact bleeding.

Pharyngeal gonorrhoea is the result of receptive oro genital sex and is usually symptomless. Gonococcal conjunctivitis is an uncommon complication, presenting with purulent discharge from the eye(s), severe inflammation of the conjunctivae and oedema of the eyelids, pain and photophobia. Gonococcal ophthalmia neonatorum presents similarly with purulent conjunctivitis and oedema of the eyelids. Conjunctivitis must be treated urgently to prevent corneal damage.

Opthalmia neonatrum The most common form of gonorrhea in neonates is ophthalmia neonatorum, which results from exposure to infected cervical secretions during parturition. An initial nonspecific conjunctivitis with a serosanguineous discharge is followed by tense edema of both eyelids, chemosis, and a profuse, thick, purulent discharge. Corneal ulcerations that result in nebulae or perforation may lead to anterior synechiae, anterior staphyloma, panophthalmitis, and blindness. Infections described at other mucosal sites in infants, including vaginitis, rhinitis, and anorectal infection, are likely to be asymptomatic. Any STI in children beyond the neonatal period raises the possibility of sexual abuse.

Opthalmia neonatrum

Treatment Ophthalmia neonatorum Ceftriaxone (25–50 mg/kg IV, single dose, not to exceed 125 mg).

Disseminated gonococcal infection Initial therapy Patient tolerant of -lactam drugs Ceftriaxone (1 g IM or IV q24h; recommended) or Cefotaxime (1 g IV q8h) or Ceftizoxime (1 g IV q8h Patients allergic to -lactam drugs Spectinomycin (2 g IM q12h) Continuation therapy Cefixime (400 mg PO bid)

Complications Disseminated gonococcal infection (DGI) is seen rarely, and typically affects women with asymptomatic genital infection. Symptoms include arthritis of one or more joints, pustular skin lesions and fever. Gonococcal endocarditis has been described. COMPLICATIONS OF DELAYED THERAPY IN GONORRHOEA Acute prostatitis Epididymo-orchitis Bartholin's gland abscess PID (may lead to infertility or ectopic pregnancy) Disseminated gonococcal infection

Treatment Cefixime 400 mg stat or Ciprofloxacin 500 mg orally stat 1, 2 or Ofloxacin 400 mg orally stat 1, 2 or Amoxicillin 3 g plus probenecid 1 g orally stat 3 Quinolone resistance Ceftriaxone 250 mg i.m. stat or Spectinomycin 2 g i.m. stat 4

Pregnancy and breastfeeding Cefixime 400 mg stat or Ceftriaxone 250 mg i.m. stat or Amoxicillin 3 g plus probenecid 1 g orally stat or Spectinomycin 2 g i.m. stat Pharyngeal gonorrhoea Cefixime 400 mg stat or Ceftriaxone 250 mg i.m. stat or Ciprofloxacin 500 mg orally stat or Ofloxacin 400 mg orally stat