1. Sexually transmissible infections Dr Ursula Nusgen SpR in Microbiology St. James’s Hospital

2. Medical students don’t practise safe sex on holiday “Less than half of male students interviewed at St George’s Hospital Medical School, London, who have sex with a new partner when on holiday always use a condom.” Family Practice (2003;20:93) in STUDENTBMJ September 2003

3. NDSC Ireland, 2003 Increase of 9.4% for all STI’s in 2001 Of all notified cases in 2001, 61.5% were in the 20 to 29 year old category

4. NDSC Ireland, 2004 Irish Times, 7/12/04 “Big increase in numbers of syphilis and HIV” Notified STIs increased by 8% from 2001 to 2002 10% increase in HIV cases “Chlamydia is just rising and rising” “The highest for any years on record”

5. NUI Galway Acute lack of knowledge of relevant issues related to student’s sexual health Unawareness of individual risk of being infected with an STI Risky sexual behaviour WESTfile, October 2003 Western Health Board Department of Public Health

6. Microorganisms causing STI Bacteria: Neisseria gonorrhoeae Chlamydia trachomatis Treponema pallidum Gardnerella vaginalis Viruses: Human immunodeficiency virus (HIV) Herpes simples virus (HSV) Hepatitis B virus, Hepatitis C virus Human papillomavirus (HPV) Protozoa: Trichomonas vaginalis Fungi: Candida albicans Ectoparasites: Phtirus pubis Sarcoptes scabei

7. STI ?

8. STI Often asymptomatic Complications of untreated infections Chronic pelvic infection Infertility Ectopic pregnancy Mother to child transmission Recurrent infections Systemic infection, many organs may be involved Consequences may be longterm/lifelong Early treatment important

9. STI Correct diagnosis important Get the right specimens the first time Urethral/endocervical (NOT vaginal) swabs, blood tests, others Two or more STIs may be present at a time

10. STI - Management Appropriate treatment simple treatment schedule Risk reduction advise Change risky behaviour Limit number of partners Safer sex practices (condoms) Partner notification

11. STI - Symptoms Unusual discharge from penis or vagina Dysuria Unusual blisters in the genital area Itching or irritation in the genital area Dyspareunia Lower abdominal pain OFTEN ASYMPTOMATIC

12. Urethritis Gonococcal urethritis Neisseria gonorrhoeae Non-gonococcal urethritis (NGU) Chlamydia trachomatis (50-70% of cases) Ureaplasma urealyticum Mycoplasma genitalium Other infectious causes Non-infectious causes

13. Gonorrhoea Neisseria gonorrhoeae (gonococcus) Urethral/vaginal discharge Pain (worse than chlamydia) May disseminate Or no symptoms Complications of untreated infection

14. Gonorrhoea - urethritis

15. Gonorrhoea - cervical

16. Gonorrhoea - disseminated

17. Gonorrhoea Specimens from urethra, uterine cervix, rectum and pharynx Specimens need to get to the lab quickly Microscopy and culture Treat: Penicillin, Ciprofloxacin, Ceftriaxone Note: Increasing resistance worldwide

18. Gonorrhoea

19. Chlamydia trachomatis Very common Major cause of female infertility Urethritis/cervicitis/NO SYMPTOMS Special swabs from urethra/ endocervix Diagnosis by molecular methods (PCR or LCR) Treatment: Azithromycin, Doxycycline

20. Chlamydia Species Hosts Main disease Serotypes C. trachomatis Humans Oculogenital D-K 2 biovars C. pneumoniae Humans C. psittaci Birds C. abortus Sheep/Goat LGV L1-3 Trachoma A-C

21. Lymphogranuloma venereum Mainly in tropical countries Papule/ulcer on genitalia Regional lymphadenopathy (painful/discharge) +/- painful bloody rectal infection Compl.: permanent damage to bowels and genital disfigurement (elephantiasis) Diagnosis difficult, send to specialist laboratories Early treatment with tetracycline, doxycycline, erythromycin

22. Lymphogranuloma venereum

23. Syphilis Treponema pallidum Stage 1: painless ulcer Stage 2: Fever and rash, condylomata lata Stage 3: Gummata Cardiovascular/Neurosyphilis

24. Syphilis – Stage 1

25. Syphilis – Stage 2

26. Syphilis – Stage 3

27. Syphilis - cardiovascular

28. Treponema pallidum

29. Syphilis - Diagnosis Darkfield microscopy/immunofluorescence stains from active lesions Serology standard non-treponemal tests (VDRL, RPR) specific treponemal antibody tests

30. Syphilis Mother to child transmission Antenatal screening Penicillin Different regimens according to stage of disease

31. Genital Herpes Herpes simplex virus (HSV1 > HSV2) Lifelong latency Periodic recurrences THERE IS NO TREATMENT TO ERADICATE THE LATENT STAGE

32. Herpes

33. Herpes - cervicitis

34. Herpes

35. Prompt antiviral treatment to relieve systemic symptoms (e.g. acyclovir) Cannot prevent latency Reactivations throughout life Special viral swabs from active lesions for diagnosis Mother to child transmission Condom may fail to prevent infection Unpredictable, distressing, lifelong illness

36. Viruses with significant sexual and non-sexual transmission HIV Transmission of HIV is enhanced in the presence of other STIs Hepatitis B

37. Genital warts Human papilloma virus (HPV) Mostly benign HPV type 16 and 18 associated with cancer of uterine cervix Treatment: Chemical applications (creams), surgery, cryotherapy, electrosurgery, laser treatment

38. Genital warts

39. Molluscum contagiosum

41. Trichomoniasis Very common STI Vaginal discharge (frothy, yellow) Diagnosis by microscopy and culture Treatment: Metronidazole

42. Trichomonas vaginalis

43. Phthirus pubis

44. Phthirus pubis - egg

45. Phthiriasis of pubic hair

46. Sarcoptes scabei

47. Scabies

48. Candidiasis

49. Candida - vaginitis

50. Candida - balanoposthitis

51. Bacterial vaginitis Is not usually an STI Inflammation of the vagina, with vaginal discharge/irritation Overgrowth of normal bacteria Gardnerella vaginalis (may be an STI)

52. Bacterial vaginosis Common Vaginal discharge of fishy odour Absence of inflammatory signs Overgrowth of G. vaginalis /other anaerobes Vaginal pH >6.0 Clue cells Complications in pregnancy

53. Bacterial vaginosis

54. STI - Summary More than one STI at a time There may be no symptoms Take correct specimens to get diagnosis right Most can be cured if treated early Longterm consequences if not treated Mother to child transmission Barrier contraceptives (condoms) Partner notification

55. Recommended reading Sexually Transmitted Diseases Treatment Guidelines 2002 MMWR May 10, 2002/51 (RR06); 1-80 http:// www.cdc.gov