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

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

3. 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

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

5. 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

6. 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

7. 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

8. 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

9. 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)

10. Clinical Features of Gonococcal and Nongonococcal Urethritis in Men
Gonorrhea Nongonococcal Incubation 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

11. 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% – 100%
Men, asymptomatic urethritis % – 100%
Endocervix
Uncomplicated gonorrheae 50-70% %
Pelvic inflammatory disease 60-70% %
Anorectum
Blind swabs % %
Anoscopically obtained
specimen % %
Hansfield et al, Sexually Trans Dse:
3rd Edition 1999

12. 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

13. 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

14. 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

15. 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

16. 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

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

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

19. 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

20. 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

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

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

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

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

25. 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

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

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

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

29. Primary and Secondary Syphilis (rashes and condyloma lata)

30. Non-Genital Manifestations of Syphilis (syphilis gumma)

31. 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

32. 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

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

34. 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

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

36. Chancroid: Haemophilus ducreyi
Chancroid ulcers
Chancroid - regional adenopathy

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

38. Papillomavirus: male

39. Papillomavirus: female

40. 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

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

42. 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)

43. 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 th ed
Washington Manual Inf Dse Consult 2005
SACCL Data