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Sexually Transmitted

Infections
An Overview
Raja Iskandar Shah
Infectious Disease Unit
Department of Medicine
UMMC

Guidelines
Malaysian Guidelines in the treatment of
Sexually Transmitted Infections
Ministry of Health 3rd edition 2008
www.moh.gov.my/images/galleryGarispanduan/malaysi
an_guidelines_in_treatment_of_STI_pdf

British Association for Sexual Health


(BASHH) Guidelines
www.bashh.org/guidelines

CDC 2010 STD treatment Guidelines


www.cdc.gov/std/treatment/2010/toc.htm

World wide prevalence

Common STIs

Chlamydia
Gonorrhoea
Genital Herpes (Herpes Simplex Virus)
Human Papilloma Virus (HPV)
Trichomoniasis
Syphilis
Hepatitis B
HIV

Number of new diagnoses of STIs,


GUM clinics, United Kingdom: 2008
% change
2008

2007-2008

1999-2008

Chlamydia

123,018

1%

116%

Genital warts

92,525

3%

29%

Genital herpes

28,957

10%

65%

Gonorrhoea

16,629

- 11%

1%

Syphilis

2,524

- 4%

1,032%

Data source: KC60 statutory returns

Consequences of poor sexual health

Unintended pregnancies
Sexually transmitted infections
Congenital/Neonatal infection
Adverse pregnancy outcomes miscarriages, low birth weight,
preterm labour
Pelvic Inflammatory Disease
Ectopic pregnancies
Infertility
Chronic Pelvic Pain
Neurological/Cardiovascular problems
Chronic liver disease
Anogenital cancers
Increased HIV transmission

Groups vulnerable to poor


sexual health

Young people
Female Sex Workers (FSW)
Clients of Female Sex Workers
Transgenders
Men who have sex with men (MSM)
Those involved in jobs which separate them from their
regular sexual partner for long periods e.g lorry drivers,
soldiers
Refugees
HIV positive patients

Patient 1
26 year-old woman in a steady
relationship with her boyfriend of 1 year.
She presents complaining of a vaginal
discharge for the past week.
She describes increased discharge,
change in color, and a foul odor.

A. What other questions would you like to


ask her?
B. Is this a sexually transmitted infection?
C. What are the likely causative organisms?

Vaginal Discharge
Common causes:
Neisseria gonorrhoeae
Chlamydia trachomatis
Trichomonas vaginalis
Bacterial vaginosis
Candida albicans

Patient complains
of vaginal discharge or
vulval itching/ burning

Vaginal Discharge

Take history, examine patient


(external speculum and bimanual)
and assess risk

Abnormal discharge present

No

Yes
Lower abdominal tenderness
or cervical motion tenderness

Yes

Educate
Counsel
Promote and provide condoms
Offer VCT
Use flow chart for lower abdominal pain

No
Was risk assessment positive?
Is discharge from the cervix?

Yes

Treat for chlamydia, gonorrhea,


bacterial vaginosis and trichomoniasis

No
Treat for bacterial vaginosis
and trichomoniasis

Vulval edema/curd like discharge


Erythema excoriation present
No
Educate
Counsel
Promote and provide condoms
Offer VCT

Yes
Treat for
candida albicans

Sexual History

Symptoms (including duration)


Last sexual intercourse
Sex of partner
Relationship with partner (casual, longterm)
Use of condoms
Sites of exposure (oral, vaginal, anal)
Last previous partner or partner changes (in the last 3 months)
Partners symptoms
Previous STIs
Previous testing of STIs including HIV
HIV risk assessment
In women, cervical cytology, gynaecology, and contraception history
ALWAYS ASSESS RISK OF PREGNANCY

Taking a sexual history

Must be non-judgemental
Establish rapport and trust with patient
Reassure regarding confidentiality
Explain why a sexual history is needed ask
patient if he/she minds about being asked very
personal questions
Acknowledge that many people find it difficult to
discuss their sexual lives openly
Ideally interview patient alone

General rules

Confidentiality
Chaperone.
Contact tracing
Health education and counselling
Abstain from sex until completed treatment
and partner notification
Follow up of infections

Syndromic Approach to STI Management

Identification of clinical syndrome


Giving treatment targeting all the locally
known pathogens which can cause the
syndrome

Syndromic Approach to STI Management


Advantages
Simple, rapid and
inexpensive
Complete care offered at
first visit
Patients are treated for
possible mixed infections
Accessible to a broad
range of health workers
Avoids unnecessary
referrals to hospitals

Disadvantages
Over-treatment
Asymptomatic infections
are missed

Gonococcal Urethritis:
Purulent Discharge

Source: CDC Training SLIDES

Neisseria gonorrhoea
Gram negative
intracellular
diplococcus
Infects mucous
membranes
Pharyngeal infection
90%
Incubation 3-5 days

Gonorrhoea (women)
Asymptomatic (50%)
16-19 yr women most
common
Vaginal discharge
Lower abdo pain
Dysuria
IMB/PCB
Pharyngitis

Opthalmia neonatorum

Rates of diagnoses of uncomplicated genital chlamydial infection


by sex and country
GUM clinics, United Kingdom: 1999 - 2008
Males

Routine GUM clinic returns

Females

Sexually Transmitted Infections, HPA Centre for


Infections

Chlamydial Cervicitis

Source: CDC

Chlamydia
(women)
Asymptomatic (80%)
Abnormal bleedingPCB/IMB
Lower abdominal pain
Vaginal discharge
Dysuria

Chlamydia trachomatis
Most common STI in the under 25s
Most prevalent - Women 16-19yr, Men 2024yr
Women 80% asymptomatic
Men 50% asymptomatic
Incubation 7 to 21 days
COMPLICATIONS- PID, Reiters syn,
conjunctivitis, chronic pelvic pain, infertility,
ectopic pregnancy

Trichomonas vaginalis
Flagellated protozoan
10-50% asymptomatic
Vaginal discharge (70%)
offensive, frothy, yellow.

Vulvovaginitis
Itching, dysuria

Strawberry cervix 2 %
Urethritis

Strawberry cervix/TV

Clinial Manifestations

Primary Syphilis- Penile Chancre

Source: CDC

Secondary syphilis

Secondary Syphilis:
Palmar/Plantar Rash

Secondary Syphilis - Alopecia

Source: CDC/ NCHSTP/ Division of STD Prevention, STD Clinical Slides

Pathogenesis

Treponema pallidum on
darkfield microscopy

Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides

Congenital syphilis

Congenital syphilis

Congenital syphilis

Congenital syphilis

Syphilis
Primary syphilis 9-90 days incubation
Caused by treponema pallidum
Solitary well-circumscribed ano-genital
ulceration (chancre) with regional
lymphadenopathy
Typically painless, may be multiple and
extragenital (oral)
Secondary syphilis 6 weeks to 6 months
Multisystem involvement
Generalized rash (palms and soles), fever,
lymphadenopathy, condylomata lata (moist wart
like lesions)
Arthralgia, alopecia, hepatitis, glomerulonephritis

Other clinical syndromes


Early latent within first 2 years of
infection
Late Latent syphilis - > 2 years after initial
infection
CVS/ Neurosyphilis/ Gummatous disease
Congenital syphilis rare. All pregnant
women currently screened

Syphilis in pregnancy
33 year old Malay,18/40 pregnant,
Asymptomatic
RPR 1: 128
TPPA : Reactive

WHAT IS THE DIAGNOSIS?


WHAT WOULD YOU LIKE TO ASK HER?
WHAT WOULD YOU DO?
HOW WOULD YOU MONITOR HER TREATMENT
RESPONSE?

Likely primary or secondary syphilis given high RPR titre


Always repeat syphilis serology to confirm
Examine for chancre, rash involving palms and soles
Has she been tested or treated for syphilis in the past?
Has her partner got symptoms?
Treat with Benzathine Penicillin 2.4 MU X 1
If penicillin allergic- treat with erythromycin but need to
treat baby
Screen partner and treat him epidemiologically
Alert paediatrician
Repeat syphilis serology in 1, 3, 6 and 12 monthsquantitative RPR

HSV

Genital Herpes: Recurrent Ulcer

Source: CDC

Genital Herpes: Primary Lesions

Source: CDC

Herpes Simplex

Most common cause of genital ulceration worldwide


Type 1 oro-genital
Type 2 genital
Incubation period 3-14 days
HSV 2 prevalence 80% in HIV positive African
population
Estimated HSV 2 prevalence 20-40% in EU/USA
Disproportionate Increase in HSV1 as cause of GH esp
in young females over past 10 years
70% of new infections acquired from asymptomatic viral
shedders

Symptoms
Asymptomatic
Constitutional symptoms/prodrome
(tingling)
Painful Vesicles/ulcers (multiple)
Dysuria
vaginal discharge

Clinical syndromes

Primary episode most painful, can last 3/52


Recurrences may be mild
Asymptomatic viral shedding
DIAGNOSIS clinical, HSV IF, culture, PCR
TREATMENT saline baths, analgesia
Antivirals- Acyclovir,Valaciclovir
Consider suppressive therapy for recurrences
>6 episodes/year

HSV in pregnancy-Case
A 32 year old woman 36 weeks pregnant
in her 2nd pregnancy presents at your
clinic.
She feels unwell, has inguinal
lymphadenopathy and has painful genital
ulcers which look typical of genital herpes
How would you manage this case?

The greatest risk of transmission is


amongst those women who shed the
virus at term and who have acquired
HSV in pregnancy for the first time (3140%)
Should consider Caesarean Section for all
women especially those entering labour
within 6 weeks of the first episode as the
risk of viral shedding is high

Why does a primary episode


carry such a great risk?
Cervicitis ( in 70% of first episodes)
Large quantity of virus
There is no passively acquired protective
antibody

Genital Ulcer Disease


Herpes simplex*
Syphilis
Differentials

LGV
Chancroid*
Granuloma
inguinale

Genital Warts

Keratinized Warts

Genital Warts

Benign epithelial skin tumors


Caused by human papilloma virus (HPV)
>100 subtypes of HPV of which 40 strains affect the genital tract
Most (90%) ano-genital warts are caused by HPV 6 & 11 (non-oncogenic subtypes)
Transmitted by unprotected vaginal, anal or oral sex or by direct skin to skin contact
Estimated US annual incidence of 1% of the adult population
Genital HPV DNA is found in 10-20% of those aged 15-49 years
Most cases of HPV infection are subclinical
Most HPV infections are transient and 95 % resolve on their own within 2 years
Condoms have been shown to protect against HPV acquisition and genital warts
For some patients, the psychological impact of the warts is the worst aspect of the
disease
All treatments have significant failure and relapse rates

HPV Vaccination
Name 2 types of HPV vaccines available in the
market
What do HPV vaccines protect the individual
against?
Is there a national HPV programme?
If you were a parent, would you vaccinate your
child against HPV?
Give another example of a vaccine which is
used to prevent an STI

Protection beyond the cervix


HPV associated cancers

Cervical (43.5%)
Vaginal (2.4%)
Vulval (9.1%)
Anorectal (12.1%)
Oropharyngeal (29.5%)
Penile

ASK
Questions

Thank You