1. Max Brinsmead MB BS PhD May 2015 S EXUALLY T RANSMITTED D ISEASES (STD’ S )

2. 75% of the world’s STD’s occur in developing countries because...  They have a greater proportion of young adults  Urban migration  Practices such as..  Polygamy  High bride prices  Use of traditional remedies  Health resources are limited  Self treatment and incomplete treatment →  Drug resistance  War and civil disturbances

3. Burden of Illness  WHO worldwide estimates for 1995...  Syphilis  12,000 cases  Gonorrhoea  62,000 cases  Chlamydia  88,000 cases  There are marked regional variations especially for the less common STD’s  Chancroid, Lymphomagranuloma venereum & Donovanosis

4. Symptoms of STD  Vaginal discharge or irritation  Dysuria and Dyspareunia  Genital ulceration or other lesions  Lower abdominal or testicular pain  HOWEVER  May be asymptomatic in carriers  And early symptoms ignored in others

5. Diagnosis of STD  Requires a high index of suspicion  And a knowledge of common local presentations  When ONE sexually transmitted disease is diagnosed...  Always consider the possibility of others  In this context pregnancy and abnormal cervical cytology should be regarded as STD’s  Lack of diagnostic resources may require an empiric approach to treatment

6. Principals of Management  Best dealt with by a network of detection, treatment and follow up facilities coordinated by Specialist Clinics  Should operate in conjunction with resources for HIV  Such centres should provide...  Patient friendly resources  Confidentiality  Single dose treatment regimens...  Optimises compliance  Reduces the risk of emerging drug resistance  Offers the best prophylaxis against long term complications

7. There is a potentially long list of STD’s  Syphilis  Gonorrhoea  Chlamydia  Lymphogranuloma venereum  Chancroid  Donovanosis  Genital Herpes  Genital warts  Bacterial vaginosis

8. S YPHILIS  A sexually transmitted infection caused by the spirochetal bacterium Treponema pallidum  Incubation period usually 14 – 28 days  Recognised in 3 stages in adults… Primary = typically a painless genital ulcer with non tender rubbery lymphadenopathy. Will be tender if 2 0 infection occurs. May go unrecognised Secondary = Fever, rash, anorexia, aches & pains, and condyloma lata Occurs 2 – 8 weeks in only 1:3 individuals after primary infection and resolves spontaneously Tertiary = can affect any body organ including heart, bones and brain

9. D IAGNOSIS OF S YPHILIS  Diagnosed by a serological test for reagin – a lipid released from cells that are attacked by T. pallidum  This test is sensitive and should revert to negative after treatment but… It is not positive until up to 12w after infection It is non-specific and there is a large number of conditions that cause a false positive test  Tests that detect antibodies to Treponema are more specific, appear before reagin but… Usually negative with the primary chancre They are present for life even after successful treatment Yaws (and Pinta) will also be positive to these tests Rapid test used at PMGH is an antibody test  Dark field microscopy of the organism possible

10. S YPHILIS IN P REGNANCY  Typically does not cross the placenta until >20 weeks  Fetal effects include… Stillbirth Intrauterine growth restriction Prematurity  Neonatal effects include… Hepatosplenomegaly Pneumonia Anaemia & Jaundice Skin lesions Osteochondritis

11. T REATMENT OF S YPHILIS  In the mother with a positive STS = serological test for syphilis Give 3 doses of Benzathine penicillin 2.4 mU weekly Erythromycin 500 mg 4 x daily for 15 – 30 days for true penicillin allergy  For a neonate Adequate treatment >28 days before delivery should prevent neonatal syphilis But “safety net” treatment commonly practised 25,000 IU/Kg Penicillin twice daily for 10 days If the baby is clinically affected at birth the prognosis is poor – see paediatric texts diagnosis & treatment Ideally all babies born to STS-positive mothers should be followed with reagin tests until negative

12. F OLLOW - UP AND C ONTACT T RACING  For a patient with a positive STS… Contact and test/treat all partners for previous 12m Other children may require testing  Follow up by a specialist clinic by reagin testing is desirable to ensure that this test returns to negative (or titre stabilises) after appropriate therapy is confirmed It is desirable to document this and give this to the patient to present at future health encounters

13. Gonorrhoea and Chlamydial Infections  Share a number of features in common  Gonorrhoea is caused by...  Neisseria gonorrhoea  Whereas Chlamydia trachomatis...  Subtypes D – K  Preferentially infect columnar and transitional epithelium of the male and female genital and urinary tracts  Both may spread within the peritoneal cavity  But only N. gonorrhoea is blood-borne spread to joints whereas C. trachomatis can cause neonatal pneumonia

14. Gonorrhoea and Chlamydial Symptoms  50% of females are asymptomatic  So it is an important cause of chronic PID and infertility  Acute symptoms include...  Vaginal discharge  Dysuria (males and females)  RUQ in women  Can cause proctitis, pharyngitis, arthritis & dermatitis  Tends to flare in the post menstrual week in ♀ or after abortion/D&C etc.

15. Diagnosis of Gonorrhoea and Chlamydia  Requires gram stain for N. gonorrhoea  Look for gram negative diploccoci  Ideally also culture and test for antibiotic sensitivity  The best test for Chlamydia is PCR (Polymerase Chain Reaction)  Can be performed on the first passed urine from both females and males  Where it has high sensitivity for genital tract infection  And high specificity

16. Follow up for Gonorrhoea and Chlamydia  Retesting not required after adequate single dose testing  But trace and test or treat all sexual contacts of the last two months after the diagnosis of acute infection

17. Neisseria and Chlamydia in the Neonate  N. gonorrhoea causes an acute conjunctivitis within 5 days  Whereas C. trachomatis causes conjunctivitis at 5 – 14 days  And can cause a pneumonia and otitis  Untreated the conjunctivitis causes keratitis and blindness  Treatment is by a single dose of IM antibiotics  Check local protocols  Or use universal prophylaxis with AgNO3 drops (need to be made up fresh), Tetracycline or Erythromycin ointment

18. Lymphogranuloma venereum Caused by Chlamydia trachomatis Subtypes L1-3  Incubation period 7 – 28 days  Causes a genital vesicle or papule → shallow ulcer with inguinal lymhadenopathy  Can cause lower abdominal pain and PID  Untreated results in fistula, stricture and lymphatic obstruction → elephantoid change in the genitals  Consult your local laboratory for possible tests  DD includes...  Chancroid, Syphilis and Herpes when acute  Donovanosis, TB, Filiarisis, Actinomycosis, Crohns and neoplasm

19. Lymphogranuloma venereum

20. Lymphogranuloma venereum Treatment  Doxycycline or Erythromycin for not less than 21 days  May require reconstructive surgery  And Caesarean delivery in a few

21. Donovanosis Caused by Calymmatobacterium granulomatis  Incubation period 8 – 90 days  Causes chronic slowly-growing granulomatous ulceration of the anogenital region and groin  Begins as a painless indurated ulcer that grows into a beefy granuloma with a rolled edge with moderate lymphadenopathy  Secondary infection and surface bleeding common  It then becomes painful, foul and locally erosive or sometimes neoplastic  May also cause fibrosis, stenosis and elephantoid change

22. Donovanosis

23. Donovanosis (cont’d)  Diagnose by Leishman stain of crushed material from the lesion  Look for Donovan bodies in cytoplasmic vacuoles of enlarged mononuclear cells  Treat with...  Trimethoprim/Sulfamethaxozale  Doxycycline or Erythromycin for 3 weeks or until healed  Combination therapy with Gentamicin, Chloramphenicol or Streptomycin may be required

24. Donovanosis Diagnosis

25. Chancroid Caused by Haemophilus ducreyi (Gram neg Bacterium)  Incubation period 1 – 8 days  Causes a painful genital ulcer with inguinal buboes  Tender papules → Pustule → Ulcer with ragged red margin & granulomatous slough in the base  Main DD is syphilis – negative to dark field illumination  Mostly diagnosed in men  Women are presumably carriers  Contact and treat partners of the preceding 10 days  Treatment  Considerable regional variation in antibiotic sensitivity so check local protocols

26. Chancroid

27. Genital Herpes 66% is due to Type 2 Herpes simplex and 33% is due to Type 1 of this virus  More or less reversed for oral Herpes  Affects ≈ 5% of the population  Spread by direct contact (genital, oral or other)  The virus established latency in neurones from where recurrences occur  The Primary Attack  Incubation period 2 – 10 days  Erythema, itching & burning then vesicles  Severe generalised vulvovaginitis is common with the 1 st attack

28. Genital Herpes

29. Genital Herpes (cont’d)  Primary Attack (cont’d)  Urinary retention common  May be systemic features with fever, arthralgia etc.  Secondary Attacks  Occur in 50% of individuals  Troublesome “cold sores” at varying intervals  Causes great psychological distress  Diagnosis  Usually clinical aided by PCR and viral culture

30. Genital Herpes

31. Treatment of Genital Herpes  Primary Attack  Good hygiene, Sitz bathes etc  Analgesia  Bladder catheterisation  Responds to Acyclovir (and similar antiviral agents)  Secondary Attacks  Counselling and maintaining good health  Topical Acyclovir  There is a role for oral Acyclovir in prophylaxis

32. Genital Herpes during Pregnancy  Genital herpes at the time of vaginal delivery carries a risk of neonatal Herpes – Mother to Child Transmission  This is a very serious generalised infection with high mortality and risk of long term morbidity  (See Herpes in Pregnancy)  Risk from primary infection is 25 – 56%  Risk from secondary infection is only 1 – 3%  Caesarean section (provided that membranes have not ruptured >4 hrs) reduces the risk of MTC of Herpes

33. A Word About HIV  The most important STD of our time  It is the Syphilis of the 21 st century  All STD’s (with the possible exception of gonorrhoea and Chlamydia) but particularly those with genital ulceration will greatly increase the risk of HIV transmission  And concurrent HIV makes many of the STD’s much worse, especially the viral ones due to Human Papilloma virus and Herpes simplex

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