1. Sexually transmitted diseases

2. 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.

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

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

5. 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

6. 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

7. 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.

8. 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

9. 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

10. 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.

11. 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.

12. 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.

13. 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.

14. 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.

15. Opthalmia neonatrum

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

17. 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)

18. 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

19. 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

20. 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

21. Chlamydial infections

22. Caused by chlamydia-C.trachomatis D- K),C.lymphogranulomatis(L1,L2,L3)C.psittacosis. Obligate –intracellular bacteria. Gram negative :lacks muramic acid in peptidoglycan layer. Transmission is through sexual contact and at birth.trachoma caused by hand to eye contact and through flies. Causes lymphogranoloma venerum and trachoma.

23. Clinical manifestations The incubation period varies from 1 week to a few months. Presents in a similar way to gonorrhoea; however, urethral symptoms are usually milder and may be absent in over 50% of cases. Conjunctivitis is also milder than in gonorrhoea. Pharyngitis does not occur. Without treatment, symptoms may resolve but the patient remains infectious for several months.

24. Complications such as epididymo-orchitis and Reiter's syndrome, or sexually acquired reactive arthropathy. The partner(s) of men with chlamydia should be treated even if laboratory tests for chlamydia are negative.

25. CHLAMYDIAL INFECTION IN WOMEN The cervix and urethra are commonly involved. Asymptomatic in about 80% of patients. Vaginal discharge, dysuria, intermenstrual and/or postcoital bleeding. Lower abdominal pain, dyspareunia and intermenstrual bleeding are features of PID. Examination may reveal mucopurulent cervicitis, contact bleeding from cervix, evidence of PID or no obvious clinical signs.

26. PID, with the risk of tubal damage and subsequent infertility or ectopic pregnancy, is an important long-term complication. Other complications include, chronic pelvic pain, conjunctivitis and Reiter's syndrome or SARA(sexually acquired rea. Arthritis). Perinatal transmission may lead to ophthalmia neonatorum and/or pneumonia in the neonate.

27. TREATMENT OF CHLAMYDIAL INFECTION Standard regimens Azithromycin 1 g orally as a single dose or Doxycycline 100 mg 12-hourly orally for 7 days Alternative regimens Erythromycin 500 mg 6-hourly orally for 7 days or 500 mg 12-hourly for 2 weeks or Ofloxacin 200 mg 12-hourly orally for 7 days

28. Lymphogranuloma venereum (LGV) Caused by Chlamydia C.lymphogranulomatis(L1,L2,L3) I.P: 3-30 days primary Genital lesion: Small, transient, painless ulcer, vesicle, papule; often unnoticed. Lymph nodes Tender, usually unilateral, matted, adherent, multilocular, suppurative bubo; inguinal/femoral nodes involved; there may be late sequelae. The genito-ano-rectal syndrome is a late manifestation of LGV. Diagnosis:Serological tests for L1-3 serotypes; swab from ulcer or bubo pus for Chlamydia. Doxycycline 12-hourly orallyfor 21 days or Erythromycin 500 mg 6-hourly orally

29. Chancroid

30. Caused by Hemophilus Ducreyi. Encapsulated gram negative bacillus, nonmotile I.P :3-10 days. chancroid :sexually transmitted disease characterized by genital ulceration and inguinal adenitis. Single or multiple painful ulcers with ragged undermined edges over the genital region. Tender, usually unilateral, matted, adherent, unilocular, suppurative bubo; inguinal nodes involved in ∼ 50%.

31. H. ducreyiChancroid

32. Inguinal buboAxillary bubo

33. Infection is acquired as the result of a break in the epithelium during sexual contact with an infected individual. After an incubation period of 3-10 days, the initial lesion—a papule with surrounding erythema— appears. In 2 or 3 days, the papule evolves into a pustule, which spontaneously ruptures and forms a sharply circumscribed ulcer that is generally not indurated The ulcers are painful and bleed easily(soft sore); little or no inflammation of the surrounding skin is evident.

34. Differential diagnosis Ulcer of chancroid: Primary syphilis Donovanosis Herpes genitalis Buboe : lymphogranuloma venereum

35. Microscopy and culture of scrapings from ulcer or pus from bubo. direct smear may reveal gm. Neg. bacilli The histology of the genital ulcer of chancroid is characterized by perivascular and interstitial infiltrates of macrophages and of CD4+ and CD8+ T lymphocytes. The presence of CD4+ T cells and macrophages in the ulcer may explain, in part, the facilitation of HIV transmission in patients with chancroid

36. Rule out other STIs

37. Treatment Azithromycin 1 g orally once or Ceftriaxone 250 mgi.m. once or Ciprofloxacin 500 mg 12-hourly orally for 3 days or Erythromycin 500 mg 6-hourly orally for 7 days

38. Granuloma inguinale Also known as donovanonis /granuloma venereum Klebsiella granulomatis :intracellular, gram-negative, pleomorphic, encapsulated (when mature) bacterium 3-40 days Initial swelling of inguinal nodes, then spread of infection to form abscess or ulceration through adjacent skin. The disease begins as one or more subcutaneous nodules that erode through the skin to produce beefy red ulcer with granulation tissue in the floor Ulcers are sharply defined, usually painless lesions. These lesions, which bleed readily on contact, slowly enlarges.

39. complications The genitalia are involved in 90% of cases, the inguinal region in 10%, and the anal region in 5– 10%. Genital swelling, particularly of the labia, is a common feature and occasionally progresses to distructions and deformity of genitalia Phimosis and paraphimosis are common local complications, and progressive erosion of affected tissues may completely destroy the penis or other organs.

40. Oral donovanosis, the most common extragenital manifestation, presents as pain or bleeding in the mouth, lesions on the lips, or extensive swelling of the gums and palate. Donovanosis may affect most bones, and sometimes many bones are affected at the same time; the tibia is involved in >50% of such cases. Bony lesions are associated with constitutional symptoms (weight loss, fever, night sweats, and malaise) and are usually found in women. Rarely malignant transformation.

41. Treatment Microscopy :organism appear as intracellular bipolar-inclusion Donovan bodies. Azithromycin1 g weekly orally or 500 mg daily orally or Doxycycline 100 mg 12-hourly orally or Ceftriaxone 1 g i.m. daily or Erythromycin 500 mg 6-hourly orally Treatment for at least 3 weeks and until lesions have healed.