•Thorough sexual history and physical exam is essential

•Many STDs are characterized by genital ulcer or infection of the cervix, urethra or both

•Inguinal region, vulva, perineum and perianal areas should be inspected

•Bartholin glands, Skene ducts and urethra should be evaluated

•In patients with urinary symptoms the urethra should be gently milked to express any discharge

•Vagina and cervix should be inspected for lesions and discharge

•Oral cavity and cervical lymph nodes should be evaluated

•Education:

      Delaying sexual activity

        Limiting number of sexual partners

        Use of condoms

•Immunizations to prevent or reduce some STI:

        HPV, Hepatitis B

•Patient notification- when an STD is diagnosed the patient’s partner should be evaluated

•Expedited Partner Therapy- patient’s sexual partner receives drug therapy for an STD without undergoing physical evaluation or testing 

If chlamydia goes untreated, what can you develop?

what can it also cause?

PID

Also responsible for nongonoccal urethritis and inclusion conjunctivitis 

True or False:

Pts with chlamydia are usually symptomatic.

FALSE

ASYMPTOMATIC USUALLY

         -cervicitis with mucopurulent discharge and intermittent cervical bleeding

         -Ascending infection causing salpingitis

       - Chlamydia frequently found in conjunction with gonorrhea

What does the ACOD recommend for screening?

Who should be screened?

Who should be screened for HIV?

ACOD STD Screening Recommendations

Routine Screening:

•Sexually active women 25 years and younger should be routinely screened for Chlamydia infection

•All sexually active adolescents should be routinely screened for gonorrhea

•Women with developmental disabilities should be screened for STDs

•HIV screening is recommended for all women who are or ever been sexually active. (Physicians should be aware of and follow their states’ HIV screening requirements)

Would you screen this person:

•Women with a history of multiple partners or a sexual partner with multiple contacts, sexual contact with culture-proved STDs, a history of repeated episodes of STDs, or attendance at clinics for STDs 

Would you screen this pt? And for what?

•Asymptomatic women aged 26 and older who are at high risk for infection 

Lab testing include:

•Culture

•Direct immunofluorescence,

•enzyme immunoassay (EIA)

•Nucleic acid hybridization tests

•Nucleic acid amplification tests (NAATs) of endocervical swab specimens

NAATS are the most sensitive tests for endocervical swab specimens and are FDA-approved for use with vagina swab specimens

Patients reluctant or unable to have pelvic exams can be tested with urine screening

•Antibiotics (azithromycin or doxycycline)

•Alternative antibiotic therapies include erythromycin, ofloxacin or levofloxacin

•Patients with persistent symptoms or suspected to be noncompliant with treatment or who have become re-infected should have test of cure (repeated testing) 3-4 weeks after initial treatment is completed

Gram-negative intracellular diplococcus

•Second most common STD in the U.S. 

True or False.

Gonorrhea is NOT a reportable disease in all states.

FALSE

IT IS A REPORTABLE DISEASE

male pt presents with urethritis, a mucopurulent or purulent discharge from the urethra

What are you thinking?

Female pt presents with purulent discharge from the urethra, Skene duct, cervix, vagina, or anus

What could it be?

In terms of gonorrhea:

What is the most widely used testing modality for specimens obtained from the pharynx or rectum?

Why?

Male urethral specimens may be tested by______ in symptomatic men, but not recommended as definitive testing for women or asymptomatic men

Male urethral specimens may be tested by Gram-stain in symptomatic men, but not recommended as definitive testing for women or asymptomatic men

What's the treatment for gonorrhea?

What's no longer used?

•Quinolone antimicrobials no longer used because of quinolone-resistant strains

•Antimicrobials currently used are Ceftriaxone, cefixime, ciprofloxacin

Involves infection of the upper genital tract (endometrium fallopian tubes, ovaries and pelvic peritoneum) as a result of direct spread of pathogenic organisms along mucosal surfaces after initial  infection of the cervix.

What is this?

These organisms are associated with what disease?

Mycoplasma, Streptococcus, Staphylococcus, Haemophilus, Escherichia Coli, bacteroides, Peptostreptococcus, Clostridium and Actinomyces

•Greatest risk is prior PID

•Adolescence

•Multiple sexual partners

•Not using condoms

•10%-40% of women with untreated Chlamydia or gonorrhea develop PID

•Infertility occurs in approximately 15% of patients after first episode of salpingitis increasing to 75% after three or more episodes

Female pt presents with the following symptoms.What could it be?

muscular guarding, cervical motion tenderness, rebound tenderness

•Purulent cervical discharge is often seen

•Adnexa are often very tender, and enlarged

•Fever and chills may be present

•White count is often elevated

What is this? What is it associated with?

inflammation leading to localized fibrosis and scarring of the anterior surface of the liver and adjacent peritoneum

If a patient becomes acutely ill with fever, chills, tachycardia, nausea and vomiting..what could it be?

All three of the following are necessary:

1-Abdominal tenderness with/without rebound

2-Adnexal tenderness

3-Cervical motion tenderness

Plus

One of more of the following:

Gram stain of endocervix positive for gram-negative, intracellular diplococci

Temperature >/= 38 Celsius

WBC > 10,000

Pus on culdocentesis or laparoscopy

Pelvic abscess on bimanual exam or sonogram

Mild or moderate cases can be managed with oral antibiotics

•Many patients require hospitalization for adequate care

•Hospitalization allows for high-dose IV antibiotic therapy covering aerobic and anaerobic organisms

•TOA may need to be drained or removed  if favorable response is not obtained

•Rupture of a TOA with septic shock is a life-threatening complication with mortality approaching 10%

•Surgical emergencies (e.g.., appendicitis) cannot be excluded.

•The patient is pregnant

•The patient does not respond clinically to oral antimicrobial therapy

•The patient is unable to follow or tolerate and outpatient oral regimen

•The patient has a severe illness, nausea and vomiting, or high fever

•Two types:

     HSV-1 associated with cold sores but can cause genital lesions and

     HSV-2 often associated with genital infections

What type of herpes is becoming more common among adolescent and young women?

True or false.

The first episode of herpes is the most severe.

Recurrent outbreaks may be milder

What is this:

Painful vesicular and ulcerated lesions appear on the vulva, vagina, cervix, often extending to perianal area and buttocks, 3-7 days after exposure and usually resolve in 1 week

•Vesicles lyse and progress to shallow, painful ulcers with a red border

Aseptic meningitis with fever, headache and meningismus occurs in some patients 5-7 days after genital lesions appear

True or False

Recurrences are usually milder, may be unilateral as opposed to bilateral and may appear as fissures or irritation rather than vesicular in appearance

TRUE

What is the lab test most often used for herpes diagnosis?

pros vs cons

viral culture

Culture is highly specific but not very sensitive, with a 25% false-negative rate with primary infections and 50% with recurrent infection

What three types of medication are used in treatmetn of genital herpes?

How long?

•Antiviral drugs-mainstay of treatment

•Reduces duration of viral shedding and shorten the initial symptomatic disease course

•Does not affect the long term course or cure disease

•Acyclovir, famciclovir or valacyclovir usually used for 7-10 days or longer if necessary

Genital herpes in pregnant woman:

what do you worry about happening to the fetus?

True or False

HPV spreads quickly into sequelae.

CONDYLOMA ACUMINATA

Pt presents with

Soft, fleshy growths, on vulva, vagina, cervix, urethral meatus, perineum, and anus

•Can also be found on the tongue or oral cavity

How do you diagnose?

What's treatment?

CONDYLOMA ACUMINATA

Diagnose: Diagnosis by visual inspection or biopsy

Treatment includes: chemical treatment, cautery, and immunologic treatments

True or False:

ACOG currently recommends that all girls and women aged 9 to 26 years be immunized against HPV.

Pt presents with chancre that is small firm and painless, with punched out appearance and rolled edges.

What could it be?

In primary syphillis, serologic testing can confirm your diagnosis.

True or false?

Secondary syphillis:

symptoms appear _-_ weeks after primary chancre

What stage of syphillis could this be?

This stage is characterized by skin rash appearing as rough red or brown lesions on the palms of hands or soles of the feet.

Lymphadenopathy, fever, headache, weight loss, fatigue, muscle aches and patch hair loss.

What type of patches occur in 30% of pts?

Secondary Syphillis

Mucocutaneous mucus patches, highly contagious eruptions occur in 30% of patients in this stage

What type of syphillis:

Patient has no signs or symptoms but serologic tests are positve

How could pt have gottten it?

What type of organ systems could be impacted?

Transmission is unlikely except by transfusion or placental transfer

Central nervous and cardiovascular system as well as ophthalmic and auditory abnormalities may develop

destructive, necrotic, granulomatous lesions may develop 1-10 years after tertiary syphillis infection.

What is this called?

If you find this: what is it associated with?

Identification of motile spirochetes on dark-field microscopic examination and direct fluorescent antibody tests of material from primary and secondary lesions or lymph nodes

how do you diagnose syphillis?? What tests?

What will remain positive irresptive of treatment or activity of the disease?

•Presumptive diagnosis is possible with nontreponemal tests (Venereal Disease Research Laboratory [VDRL] and rapid plasma reagin [RPR] and treponemal tests (e.g., fluorescent treponemal antibody absorption [FTA-ABS] and Treponema pallidum particle agglutination

•The use of only one serologic test is insufficient; false-positive nontreponemal tests results are sometimes associated with medical conditions unrelated to syphilis

•Positive treponemal test will usually remain positive for life irrespective of treatment or activity of the disease

Syphillis Treatment

•Benzathine Penicillin G

•Serial quantitative VDRL titers at 3,6, 12 months

•Sexual abstinence until lesions are completely healed

What type of HIV is most common in US?

What type is most common in Western Africa?

What type of HIV is most common in US? HIV 1

What type is most common in Western Africa? HIV 2

Prevention

•Condoms

•Safe sex practices

Drug therapy

•Nucleoside reverse transcriptase inhibitors (NRTIs)

•Nonnucleoside reverse transcriptase inhibitors (NNRTIs)

•Antiretroviral therapy consisting of at least three agents is recommended because of development of drug resistance