1. Sexually Transmitted Diseases I
February 19, 2009
Sexually Transmitted Diseases I
H. Hunter Handsfield, MD
I’d like to welcome everyone to the I-TECH HIV/AIDS Clinical Seminar Series. We have with us today Dr. Hunter Handsfield. Dr. Handsfield is a Senior Research Leader at Battelle Research, a private nonprofit agency active in public health research, and Clinical Professor of Medicine at the University of Washington Center for AIDS and STD. For 25 years he directed the STD Control Program for Public Health - Seattle & King County and has frequently consulted with CDC in strategies for STD/HIV prevention and therapy. As a visiting scientist at CDC, he was instrumental in developing the current recommendations for provider-initiated HIV testing as a core prevention strategy, as well as guidelines for use of expedited partner therapy for gonorrhea and chlamydial infection. In recent years, he has become active in HIV/STD prevention research in Zimbabwe, including consultation with the Zimbabwe Ministry of Health and Child Welfare.
Today Dr. Handsfield will present on HIV and Sexually Transmitted Diseases.
Before we begin, I’d like to ask all the sites to type in how many participants are at their sites. If you are an individual, please type “1”.

2. I-TECH STD Update Series H. Hunter Handsfield, MD Devika Singh, MD
Genital syndromes in men: Urethritis and related conditions
Genital syndromes in women I: Cervicitis, vaginal infections
Genital syndromes in women II: PID, STD and pregnancy, HPV and cervical cancer
Genital ulcer disease: Herpes, syphilis, and miscellaneous STDs

3. VD, STD, STI: What’s the Difference?
Venereal Disease: Syphilis, gonorrhea, LGV, chancroid, donovanosis
“VD” clearly became pejorative and scientifically limited
Sexually Transmitted Disease: NGU, chlamydia, cervicitis, herpes, etc
An improvement, but what about “disease”?
Sexually Transmitted Infection: Asymptomatic HSV, HPV, HIV not viewed as “disease”
However, it is now undertood that Sx and Asx infections have equal clinical and epidemiologic implications
But perhaps “infection” is less stigmatizing than “disease”

4. STDs are Sexist
Transmission efficiency greater male to female than the reverse
More women asymptomatic or with atypical, nonspecific Sx; delayed care
Diagnosis more difficult in women
Complications more frequent in women, often severe or permanent

7. Male Genital Infections Case 1
PRESENTATION
27 year old man
History
2 days mildly painful urination
1 day staining of underwear, “maybe a drip from my penis”
Unprotected vaginal sex with a new female partner 5 days ago, “but I didn’t pay her”
Last void 2 hours prior to exam
EXAMINATION

9. Male Genital Infections Case 1
DIFFERENTIAL DIAGNOSIS OF URETHRITIS
Gonorrhea
Nongonococcal urethritis (NGU)*
Nonsexually acquired
Trauma
Schistosomiasis
Coliforms, Enterococcus, coag-neg staph, etc
Other
* Same as nonspecific urethritis (NSU)

12. Gonorrhea Etiology: Neisseria gonorrhoeae (gonococcus)
Main manifestations: Urogenital inflammation (urethra, cervix, rectum, fallopian tubes, epididymis)
Women: Cervicitis, urethritis, pelvic inflammatory disease, infertility, tubal pregnancy
Men: Urethritis, epididymitis, reactive arthritis
Newborns: Eye infections
Treatment: Antibiotics, primarily cephalosporins; quinolones (resistance problems)
Prevention and control
Personal: Safe sex, condoms
Public: Screening, esp. women

13. Gonococcal Isolate Surveillance Project (GISP) — Percent of Neisseria gonorrhoeae isolates with resistance or intermediate resistance to ciprofloxacin, 1990–2003
Note: Resistant isolates have ciprofloxacin MICs ≥ µg/ml. Isolates with intermediate resistance have ciprofloxacin MICs of µg/ml. Susceptibility to ciprofloxacin was first measured in GISP in 1990.

14. Treatment of Uncomplicated Gonorrhea
RECOMMENDED
Ceftriaxone mg IM
Cefixime 400 mg PO
Cefpodoxime 400 mg PO
Ciprofloxacin 500 mg PO
Ofloxacin 400 mg PO
Levofloxacin 250 mg PO
PLUS
Azithromycin or
Doxycycline
No longer recommended
Include as syndromic
management of urethritis

15. Male Genital Infections Case 2
PRESENTATION
22 year old man
History
1 week scant urethral discharge
No pain
Unprotected vaginal sex intermittently with 2 partners in preceding 3 months, last sex “about 2 weeks ago”
EXAMINATION

20. Male Genital Infections ETIOLOGY OF NGU
INITIAL, NON-RECURRENT, DOCUMENTED URETHRITIS
Chlamydia trachomatis %
Mycoplasma genitalium %
Other and unknown %
Ureaplasma urealyticum? 10-30%?
Normal flora (oral, vaginal)? 10-20%?
U. parvum
Trichomonas vaginalis %
Adenovirus %
Herpes simplex virus %
See Bradshaw et al, JID 2006;193:336-45

21. Clinical Diagnosis of Urethritis
Abnormal discharge observed: purulent, mucopurulent
Preferably examine >4 hr since last urination
In absence of visible discharge
Symptoms: Discharge + dysuria
Documented urethral inflmmation
Gram stained smear (preferred)
WBC or leukcocyte esterase in first-void urine

22. Etiologic Diagnosis of Urethritis
Gram stained smear of urethral secretions
>5 WBC per 500x microscopic field
ICGND for gonorrhea
Sensitivity 90-95%
Specificity 90-95%
Microbiology, if available and cost effective
N. gonorrhoeae (Culture or NAAT)
C. trachomatis (NAAT)
U. urealyticum NOT RECOMMENDED
M. genitalium? NAAT not readily available
Other (T. vaginalis, HSV, others: not practical)
Symptomatic; lower if asx
Dependent on experience

25. Treatment of NGU Azithromycin 1.0 g, single dose
Chlamydia efficacy %
Clinical efficacy ~90%
M. genitalium: Usually effective but apparent risk of inducible resistance
Doxycycline 100 mg po BID x 7 days
Chlamydia efficacy >98%
Clinical efficacy ~90%
M. genitalium Not effective
Alternatives: Other tetracyclines, erythromycin, fluoroquinolones

26. Gonorrhea versus NGU GC NGU Incubation period 2-5 d 7-14 d Dysuria
Prominent
Mild or absent
Discharge amount
Copious
Scant to moderate
Discharge type
Purulent
Mucoid, mucopurulent

29. NGU Counterparts in Female Partners
Gonorrhea
Chlamydia
Trichomoniasis
Herpes
No others are certain
M. genitalium? (active research)
Ureaplasma: probably none
Some NGU may be caused by partner’s normal flora
No female or male partner morbidity has ever been reported for nonchlamydial NGU

30. Management of Sex Partners of Men with NGU
Goals
Treat/prevent chlamydia
Prevent reinfection
Treat with same regimen as index case
Examine for other STDs, if practical
Partner treatment of unknown benefit in recurrent or persistent NGU

31. Recurrent and Persistent NGU
Symptoms may take days to completely resolve
Symptoms persist or recur within 4-6 weeks in 10-15%
Evaluation
Document urethritis
Otherwise, no treatment
Treatment
Retreat with opposite drug (AZM or doxy)
Metronidazole or tinidazole
No documented need to retreat partners

32. Male Genital Infections Case 3
PRESENTATION
33 year old HIV infected married man
Outwardly healthy, CD4 500 cells/mm3, not on ART
History
2 days severe dysuria
“Maybe a little” urethral discharge
Monogamous with wife, regular unprotected vaginal and oral sex
Wife not known to have HIV, but “we assume she has it”
EXAMINATION

34. Bacterial verus Viral NGUMG
Adeno
HSV
Mod/severe dysuria
28%
20%
69%
78%
Meatal erythema
33%
26%
92%
89%
Concider acyclovir in patients with proiment dysuria and meatal inflammation?
Bradshaw C et al. JID 2006;193:336-45

35. Male Genital Infections Case 4
PRESENTATION
34 year old HIV infected man
Intermittent ART, CD4 100 cells/mm3, chronic diarrhea, weight loss, cough
History
Scant urethral discharge, mild dysuria 2 weeks
Painful, swollen R testicle 7 days, increasing
Claims monogamous with wife (evasive)
Night sweats and “maybe a little fever” 2-3 weeks

36. Male Genital Infections Case 4
EXAMINATION
Slim, thenar wasting, dishydrosis
Temperature 38.2
Right testicle diffusely enlarged, 3+ tenderness, indurated; uncertain localization to epididymis
Testicle not obvlously elevated in scrotal sac
No visible urethral discharge

38. Male Genital Infections Case 4
DIAGNOSIS AND MANAGEMENT?
Evaluate for urethritis
Urethral gram stained smear etc
Increased WBC, no ICGND
Urine culture if available
Initial therapy
Ceftriaxone or other single-dose GC regimen
plus either
Ofloxacin 300 mg PO BID x 14 days or
Doxycycline 100 mg PO BID x 14 days
Evaluate for tuberculosis

39. Acute Testicular Enlargment 1
Epididymitis
Chlamydia, gonorrhea
Age <35
Sexually active
Nonsexually transmitted UTI pathogens (E. coli, Enterococcus, Pseudomonas, etc)
Age >35
Insertive anal sex
Urethral instrumentation
Anatomic anomalies, e.g. urethral stricture
Drugs
Amiodarone, e.g.

40. Acute Testicular Enlargment 2
THE FOUR T’s
Trauma
History usually is obvious
Torsion
Age 12-20
Sudden onset, often during sleep
Elevation of testicle
Surgical emergency to salvage testicle
Tuberculosis (and mycoses)
Local epidemiology
Individual risk, e.g. HIV
Usually gradual onset
Tumor (i.e., testicular cancer)
Usually not tender

43. Complications of Male Urethritis

50. Male Genital Infections Case 5
PRESENTATION
27 year old man, not known to have HIV
History
Mongamous 5 yr apart from condom-protected vaginal sex with CSW 6 weeks ago
Vague pain in groin, testicles, penile “tingling” started the next morning, worsening in past 2 weeks
Two episodes of “semen” (“cloudy, like mucus”) from penis during defecation
“STD panel” 1 week after exposure: Negative urine for GC/CT, neg blood for HIV, syphilis, HSV-2, HBV, HCV
Self treatment with amoxycillin, minocycline, ciprofloxacin
“I must have chlamydia or herpes, doctor! I can’t have sex with my wife. Please help!”

51. Male Genital Infections Case 5
EVALUATION
External genital examination normal
Digital rectal examination normal except “boggy” prostate; prostate evaluation replicates testicular and low abdominal pain
Three glass urine: No WBC in any specimen
What is your diagnosis?
What further evaluation is warranted?

52. Chronic Pelvic Pain Syndrome
CLASSIFICATION OF PROSTATITIS (NIH)
Acute prostatitis: Acute pain, fever, + toxicity
Chronic bacterial prostatitis
Chronic prostatitis/chronic pelvic pain syndrome
IIIA. Inflammatory
IIIB. Noninflammatory
Probably >60% of cases, especially in young men
Prostate probably not involved (Potts, World J Urol 2003;21:54)
Apparent psychogenic origin (pevic muscle tension?)
Antibiotics ineffective
No known long-term health effects other than pain, stress
Asymptomatic inflammatory prostatitis
CHRONIC PROSTATITIS/CPPS HAS NOT BEEN RELIABLY SHOWN TO BE DUE TO ANY STD

53. Thank You!
CONTACT
Clinical consults, scientific inquires, and suggestions for this talk and the I-TECH STD series all are welcome!
H. Hunter Handsfield, M.D.
(office)
(mobile)

54. Listserv: itechdistlearning@u.washington.edu
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