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Sexually Transmitted Infections

Basics

Description

- 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

- 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.

- 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.

- 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.

- 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

- 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.

- 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

- 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.

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 contactNo or inconsistent use of male or female condomWomen <25 yearsWomen with new or more than 1 sexual partnerHistory of a prior STIIllicit drug use
  • Sexual assault

Diagnosis

  • HerpesA recurrent, life-long viral infectionGenital 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
  • SyphilisPrimary: Ulcer or chancreSecondary: Rash, lymphadenopathy, and mucocutaneous lesionsTertiary: Cardiac, ophthalmic, auditory abnormalities, and gummatous lesionsLatent syphilis is seroreactivity without clinical evidence of disease.All should be tested for HIV.
  • ChancroidIn the US, 10% coinfected with Treponema pallidum or HSVIt is a cofactor for HIV transmission.Caused by Haemophilus ducreyiDifficult to culture and no FDA-approved PCR testProbable diagnosis if:1 or more painful genital ulcersNo T. pallidum or HSV1/3 have painful ulcer and tender inguinal adenopathy; may also have suppurative inguinal adenopathy.
  • Granuloma inguinaleCaused by intracellular gram-negative bacterium Calymmatobacterium granulomatisRare in the USPainless, progressive ulcerative lesions without regional lymphadenopathyThe lesions are highly vascular and bleed easily on contact, but may be hypertrophic, necrotic, or sclerotic.
  • Lymphogranuloma venereumRare in the USCaused by C. trachomatis serovars L1, L2, or L3Tender inguinal or femoral lymphadenopathy usually unilateralMay cause proctocolitis
  • Genital wartsVisible genital warts are usually caused by the HPV types 6 or 11.Rarely associated with invasive squamous cell carcinomaUsually asymptomatic, but depending on size and location, they can be painful, friable, and pruriticUsually ≤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

  • HerpesViral 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.
  • Syphilis2 types of tests: Nontreponemal needs confirmation with a treponemal testNontreponemal 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)
  • ChancroidCulture for H. ducreyi has poor sensitivity and the culture medium not readily available in many labs.
  • Granuloma inguinaleDifficult to cultureDiagnosis requires visualization of dark staining Donovan bodies on biopsy.Treatment halts progression of lesions but prolonged treatment may be necessary for re-epithelialization.
  • Lymphogranuloma venereumComplement fixation titers ≥1:64 are consistent with the diagnosis of lymphogranuloma venereum.
  • HPV infectionsA 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
  • SyphilisBenzathine penicillin G: 2.4 million units IM in a single dose for primary, secondary, and early latent syphilisIf penicillin allergyDoxycycline: 100 mg PO b.i.d. 14 days ORTetracycline: 500 mg PO q.i.d. 14 daysLate latent syphilis or unknown duration:Benzathine penicillin G: 2.4 million units IM every week for 3 weeksPenicillin allergy in pregnancy: Patient must be desensitized and treated with penicillin.
  • ChancroidAzithromycin: 1 g PO in a single doseCeftriaxone: 250 mg IM in a single doseCiprofloxacin: 500 mg PO b.i.d. for 3 daysErythromycin: 500 mg PO t.i.d. for 7 days
  • Granuloma inguinaleTreatment is at least 3 weeks of antibiotics:Doxycycline: 100 mg PO b.i.d. ORAlternative regimens:Ciprofloxacin: 750 mg b.i.d. ORErythromycin: 500 mg q.i.d. ORAzithromycin: 1 g/dayTrimethoprim-sulfamethoxazole DS PO b.i.d.
  • Lymphogranuloma venereumDoxycycline: 100 mg PO b.i.d. for 21 daysAlternative regimen:Erythromycin: 500 mg q.i.d. for 21 days
  • HPV infectionsMay resolve without treatmentChange treatment modality if not improved substantially after 3 provider-administered treatments or if not resolved after 6 treatmentsTreatment 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 cyclesImiquimod: 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 treatmentSinecatechins: 15% ointment applied to wart t.i.d for up to 16 weeksProvider-administered include: Cryotherapy, podophyllin resin, trichloroacetic acid, and surgical removalThe 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

  • HerpesLatex condoms can reduce the risk for genital herpes when infected areas are covered.May be infectious when asymptomaticNo prophylactic treatment available
  • SyphilisFollow nontreponemal titers at 6 and 12 months for a 4-fold decreaseFailure to fall 4-fold by 6 months is probable treatment failureTransmission 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.
  • ChancroidRe-examine 3 " 7 days after treatmentIf 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 treatmentLarge 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 inguinaleSexual partners within 60 days of symptoms should be examined and offered therapy.
  • Lymphogranuloma venereumFollow until signs and symptoms resolvedSexual contacts in the 30 days preceding symptoms should be tested for chlamydial infections and treated.
  • Genital wartsRecurrences 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.