Basics
Description
Sexually transmitted infections (STIs) can be delineated into 4 categories:
- Diseases characterized by ulcerative and nonulcerative lesions: Herpes, syphilis, chancroid, granuloma inguinale, lymphogranuloma venereum, and human papillomavirus (HPV) infections
- Diseases characterized by cervicitis: Chlamydia trachomatis and Neisseria gonorrhoeae
- Diseases characterized by vaginal discharge: Trichomonas vaginalis, C. trachomatis, and N. gonorrhoeae (Gardnerella vaginalis, Candida albicans not STDs)
- Systemic diseases: HIV, hepatitis A, hepatitis B, and hepatitis C
Risk Factors
- Sexually active:
- Oral, anal, or vaginal sexual contact
- No or inconsistent use of male or female condom
- Women <25 years
- Women with new or more than 1 sexual partner
- History of a prior STI
- Illicit drug use
- Sexual assault
Diagnosis
- Herpes
- A recurrent, life-long viral infection
- Genital HSV-2 is more common than HSV-1.
- HSV-2 is more likely than HSV-1 to cause recurrent infections.
- Most persons with HSV-2 have not been diagnosed.
- The virus is often shed in asymptomatic periods.
- Typically painful multiple vesicular or ulcerative lesions
- Syphilis
- Primary: Ulcer or chancre
- Secondary: Rash, lymphadenopathy, and mucocutaneous lesions
- Tertiary: Cardiac, ophthalmic, auditory abnormalities, and gummatous lesions
- Latent syphilis is seroreactivity without clinical evidence of disease.
- All should be tested for HIV.
- Chancroid
- In the US, 10% coinfected with Treponema pallidum or HSV
- It is a cofactor for HIV transmission.
- Caused by Haemophilus ducreyi
- Difficult to culture and no FDA-approved PCR test
- Probable diagnosis if:
- 1 or more painful genital ulcers
- No T. pallidum or HSV
- 1/3 have painful ulcer and tender inguinal adenopathy; may also have suppurative inguinal adenopathy.
- Granuloma inguinale
- Caused by intracellular gram-negative bacterium Calymmatobacterium granulomatis
- Rare in the US
- Painless, progressive ulcerative lesions without regional lymphadenopathy
- The lesions are highly vascular and bleed easily on contact, but may be hypertrophic, necrotic, or sclerotic.
- Lymphogranuloma venereum
- Rare in the US
- Caused by C. trachomatis serovars L1, L2, or L3
- Tender inguinal or femoral lymphadenopathy usually unilateral
- May cause proctocolitis
- Genital warts
- Visible genital warts are usually caused by the HPV types 6 or 11.
- Rarely associated with invasive squamous cell carcinoma
- Usually asymptomatic, but depending on size and location, they can be painful, friable, and pruritic
- Usually ≤10 genital warts, and the total wart area is 0.5 " 1.0 cm.
History
- Number of sexual partners
- Type of sexual contact: Vaginal, oral, or anal
- Condom use
- Associated symptoms: Pelvic pain, vaginal discharge, and fever
- Contraceptive use and possibility of pregnancy
Physical Exam
- Pelvic examination and STI screening
- Skin exam for rashes
Tests
Lab
- Herpes
- Viral culture sensitivity is approximately 50%.
- Sensitivity declines rapidly as lesions heal.
- PCR is not routinely used for genital HSV.
- Antigen detection tests may not distinguish between HSV-1 and HSV-2 and someone may be positive without clinical disease.
- Tzanck preparation is insensitive and not routinely available in all laboratories.
- Serologic testing is only helpful in confirming a prior infection and does not distinguish between anogenital infections and orolabial infections.
- Syphilis
- 2 types of tests: Nontreponemal needs confirmation with a treponemal test
- Nontreponemal test antibody titers: Venereal disease research laboratory (VDRL) and rapid plasma reagin (RPR)
- Treponemal tests: Fluorescent treponemal antibody absorbed (FTA-ABS) and T. palladium particle agglutination (TP-PA)
- Chancroid
- Culture for H. ducreyi has poor sensitivity and the culture medium not readily available in many labs.
- Granuloma inguinale
- Difficult to culture
- Diagnosis requires visualization of dark staining Donovan bodies on biopsy.
- Treatment halts progression of lesions but prolonged treatment may be necessary for re-epithelialization.
- Lymphogranuloma venereum
- Complement fixation titers ≥1:64 are consistent with the diagnosis of lymphogranuloma venereum.
- HPV infections
- A biopsy may be indicated if the lesions are large or not responsive to therapy.
Differential Diagnosis
- Genital herpes, syphilis, and chancroid are the most common.
- Non-STD causes include: Vasculitis, Beh งet disease, trauma, EBV, and malignancies.
Treatment
Medication
- Herpes (1)[A]
- Medications do not eradicate the latent virus.
- Treatment regimens differ for the first (F) episode 7 " 10 days, recurrent (R) episodes 5 days, and suppressive (S) therapy daily.
- Acyclovir (F): 400 mg PO t.i.d.; (R) 800 mg PO b.i.d.; (S) 400 mg PO b.i.d.
- Famciclovir (F): 250 mg PO t.i.d.; (R) 125 mg PO b.i.d.; (S) 250 mg PO b.i.d.
- Valacyclovir (F): 1 g PO b.i.d.; (R) (S) 1 g/day PO
- Syphilis
- Benzathine penicillin G: 2.4 million units IM in a single dose for primary, secondary, and early latent syphilis
- If penicillin allergy
- Doxycycline: 100 mg PO b.i.d. 14 days OR
- Tetracycline: 500 mg PO q.i.d. 14 days
- Late latent syphilis or unknown duration:
- Benzathine penicillin G: 2.4 million units IM every week for 3 weeks
- Penicillin allergy in pregnancy: Patient must be desensitized and treated with penicillin.
- Chancroid
- Azithromycin: 1 g PO in a single dose
- Ceftriaxone: 250 mg IM in a single dose
- Ciprofloxacin: 500 mg PO b.i.d. for 3 days
- Erythromycin: 500 mg PO t.i.d. for 7 days
- Granuloma inguinale
- Treatment is at least 3 weeks of antibiotics:
- Doxycycline: 100 mg PO b.i.d. OR
- Alternative regimens:
- Ciprofloxacin: 750 mg b.i.d. OR
- Erythromycin: 500 mg q.i.d. OR
- Azithromycin: 1 g/day
- Trimethoprim-sulfamethoxazole DS PO b.i.d.
- Lymphogranuloma venereum
- Doxycycline: 100 mg PO b.i.d. for 21 days
- Alternative regimen:
- Erythromycin: 500 mg q.i.d. for 21 days
- HPV infections
- May resolve without treatment
- Change treatment modality if not improved substantially after 3 provider-administered treatments or if not resolved after 6 treatments
- Treatment may lead to hypo- or hyperpigmentation.
- Patient-applied:
- Podofilox: 0.5% applied b.i.d. for 3 days then 4 days no therapy for up to 4 cycles
- Imiquimod: 5% cream apply once at night 3 times a week for up to 16 weeks; wash area with soap and water 6 " 10 hours after treatment
- Sinecatechins: 15% ointment applied to wart t.i.d for up to 16 weeks
- Provider-administered include: Cryotherapy, podophyllin resin, trichloroacetic acid, and surgical removal
- The quadrivalent vaccine is not a treatment but provides protection against HPV types 6 and 11. It is recommended for girls and women ages 9 " 26.
Additional Treatment
Issues for Referral
If lesions do not improve or increase in size despite therapy then referral for biopsy to rule out malignancy may be necessary.
Ongoing Care
Follow-Up Recommendations
Management of sex partners
- Herpes
- Latex condoms can reduce the risk for genital herpes when infected areas are covered.
- May be infectious when asymptomatic
- No prophylactic treatment available
- Syphilis
- Follow nontreponemal titers at 6 and 12 months for a 4-fold decrease
- Failure to fall 4-fold by 6 months is probable treatment failure
- Transmission only occurs when mucocutaneous lesions are present.
- Sex partners should be treated presumptively if exposed within 90 days preceding the diagnosis of primary, secondary, or early latent syphilis.
- Chancroid
- Re-examine 3 " 7 days after treatment
- If no improvement may be (a) wrong diagnosis, (b) coinfected with another STD, (c) patient has HIV, (d) treatment not taken, and (e) H. ducreyi resistant to treatment
- Large ulcers may take >2 weeks to heal.
- Sexual partners should be examined and treated if sexually active within 10 days of onset of symptoms.
- Granuloma inguinale
- Sexual partners within 60 days of symptoms should be examined and offered therapy.
- Lymphogranuloma venereum
- Follow until signs and symptoms resolved
- Sexual contacts in the 30 days preceding symptoms should be tested for chlamydial infections and treated.
- Genital warts
- Recurrences are most common in the first 3 months following treatment.
- Genital warts are not an indication to change the frequency of Pap testing.
- Examination of sex partner is not necessary for genital wart management but may be beneficial for education and STD screening.
Complications
Recurrence
References
1 Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59(RR-12):1 " 110. [View Abstract]
Codes
ICD9
- 054.10 Genital herpes, unspecified
- 091.0 Genital syphilis (primary)
- 099.9 Venereal disease, unspecified
- 099.0 Chancroid
- 099.2 Granuloma inguinale
- 099.1 Lymphogranuloma venereum
- 078.11 Condyloma acuminatum
- 079.88 Other specified chlamydial infection
- 098.0 Gonococcal infection (acute) of lower genitourinary tract
ICD10
- A51.0 Primary genital syphilis
- A60.00 Herpesviral infection of urogenital system, unspecified
- A64 Unspecified sexually transmitted disease
- A57 Chancroid
- A58 Granuloma inguinale
- A55 Chlamydial lymphogranuloma (venereum)
- A63.0 Anogenital (venereal) warts
- A56.2 Chlamydial infection of genitourinary tract, unspecified
- A54.02 Gonococcal vulvovaginitis, unspecified
SNOMED
- 8098009 sexually transmitted infectious disease (disorder)
- 427578006 Herpes simplex of female genitalia (disorder)
- 186847001 primary genital syphilis (disorder)
- 266143009 chancroid (disorder)
- 28867007 granuloma inguinale (disorder)
- 186946009 lymphogranuloma venereum (disorder)
- 266113007 genital warts (disorder)
- 428015005 Chlamydia trachomatis infection of genital structure (disorder)
- 237095000 gonococcal vulvovaginitis (disorder)
Clinical Pearls
- If herpes does not respond to treatment consider treatment for chancroid.
- Remember to discuss STI prevention after giving results. Patients may be embarrassed and rush out of the office.
- Syphilis and chancroid are reportable diseases in every state.