STD

1. STD Sexually Transmitted disease

2. Sexually Transmitted and Sexually Transmissible Microorganisms Transmitted in Adults Predominantly by Sexual Intercourse Bacteria • Neisseria gonorrhoeae • Chlamydia trachomatis • Treponema pallidum • Haemophilus ducreyi • Calymmatobacterium granulomatis(Klebsiella granulomatis) • Ureaplasma urealyticum • Viruses • HIV (types 1 and2 ) • Human T-cell lymphotropic virus type I • Herpes simplex virus type 2 • Human papillomavirus (multiple genotypes) • Hepatitis Bvirus • Molluscum contagiosum virus • Othera • Trichomonas vaginalis • Phthirus pubis

3. Sexual Transmission Repeatedly Described but Not Well Defined or Not the Predominant Mode • Bacteria • Mycoplasma hominis • Mycoplasma genitalium • Gardnerella vaginalisand other vaginal bacteria • Group BStreptococcus • Helicobacter cinaedi • Helicobacter fennelliae • Viruses • Cytomegalovirus • Human T-cell lymphotropic virus type II • Hepatitis C, D (?)viruses • Herpes simplex virus type 1 • Epstein-Barr virus?)) • Human herpesvirus type 8 • Othera • Candida albicans • Sarcoptes scabiei

4. Transmitted by Sexual Contact Involving Oral-Fecal Exposure • Bacteria • Shigellaspp. • Campylobacterspp. • Viruses • Hepatitis A virus • Othera • Giardia lamblia • Entamoeba histolytica

5. Major STD Syndromes and Sexually Transmitted males Urethritis: • Neisseria gonorrhoea • Chlamydia trachomatis • Mycoplasma genitalium • Ureaplasma urealyticum • subspeciesurealyticum? • Trichomonas vaginalis • HSV • perhaps adenovirus • Coliform bacteria can cause urethritis in men who practice insertive anal intercourse. Epididymitis • C. trachomatis • N. gonorrhoeae

6. Urethritis in Men • Urethritis in men produces urethral discharge, dysuria, or both, usually without frequency of urination. • Until recently, C. trachomatiscaused ~30–40% of cases of nongonococcal urethritis (NGU); however, the proportion of cases due to this organism may have declined in some populations served by effective chlamydial-control programs, and older men with urethritis appear less likely to have chlamydial infection. • HSV andT. vaginaliseach cause a small proportion of NGU cases • Recently, multiple studies have consistently implicatedM. genitaliumas a probable cause of manyChlamydia-negative cases.

7. Urethritis in Men • Fewer studies than in the past have implicatedUreaplasma; the ureaplasmas have been differentiated intoU. urealyticumandU. parvum, and a few studies suggest thatU. urealyticum—is associated with NGU.

8. Urethritis in Men • bacteria can cause urethritis in men The initial diagnosis of urethritis in men currently includes specific tests only for N. gonorrhoeae and C. trachomatis. The following summarizes the approach to the patient with suspected urethritis:

9. Establish the presence of urethritis • If proximal-to-distal "milking" of the urethra does not express a purulent or mucopurulent discharge, even after the patient has not voided for several hours (or preferably overnight), a Gram's-stained smear of overt discharge or of an anterior urethral specimen obtained by passage of a small urethrogenital swab 2–3 cm into the urethra usually reveals 5 neutrophils per 1000xfield in areas containing cells; in gonococcal infection, such a smear usually reveals gram-negative intracellular diplococci as well.

10. Establish the presence of urethritis • Alternatively, the centrifuged sediment of the first 20–30 mL of voided urine—ideally collected as the first morning specimen—can be examined for inflammatory cells, either by microscopy showing10 leukocytes per high-power field • Patients with symptoms who lack objective evidence of urethritis may have functional rather than organic problems and generally do not benefit from repeated

11. Evaluate for complications or alternative diagnoses. • A brief history and examination will exclude epididymitis and systemic complications, such as disseminated gonococcal infection (DGI) and Reiter's syndrome. • Although digital examination of the prostate gland seldom contributes to the evaluation of sexually active young men with urethritis. • men with dysuria who lack evidence of urethritis as well as sexually inactive men with urethritis should undergo prostate palpation, urinalysis, and urine culture to exclude bacterial prostatitis and cystitis.

12. Evaluate for gonococcal chlamydial infection • An absence of typical gram-negative diplococci on Gram's-stained smear of urethral exudate containing inflammatory cells warrants a preliminary diagnosis of NGU and should lead to testing of the urethral specimen for C. trachomatis. • However, an increasing proportion of men with symptoms and/or signs of urethritis are simultaneously assessed for infection with N. gonorrhoeae and C. trachomatis by "multiplex" nucleic acid amplification tests (NAATs) of early-morning first-voided urine.

13. Evaluate for gonococcal and chlamydial infection • Culture or NAAT for N. gonorrhoeae may be positive when Gram's staining is negative • certain strains of N. gonorrhoeae can result in negative urethral Gram's stains in up to 30% of cases of urethritis.

14. Evaluate for gonococcal and chlamydial infection • Results of tests for gonococcal and chlamydial infection predict the patient's prognosis • can guide both the counseling given to the patient and the management of the patient's sexual partner(s). • Treat urethritis promptly, while test results are pending.

15. Acute epididymitis • Acute epididymitis, almost always unilateral, produces pain, swelling, and tenderness of the epididymis, with or without symptoms or signs of urethritis. • This condition must be differentiated from testicular torsion, tumor, and trauma.

16. Acute epididymitis • Torsion, a surgical emergency, usually occurs in the second or third decade of life and produces a sudden onset of pain, elevation of the testicle within the scrotal sac, rotation of the epididymis from a posterior to an anterior position, and absence of blood flow on Doppler examination or scan.

17. Acute epididymitis • Persistence of symptoms after a course of therapy for epididymitis suggests the possibility of testicular tumor or of a chronic granulomatous disease, such as tuberculosis.

18. Acute epididymitis • In sexually active men under age 35, acute epididymitis is caused most frequently by C. trachomatis and less commonly by N. gonorrhoeae and is usually associated with overt or subclinical urethritis. • Acute epididymitis occurring in older men or following urinary tract instrumentation is usually caused by urinary pathogens. • epididymitis in men who have practiced insertive rectal intercourse is often caused by Enterobacteriaceae. • These men usually have no urethritis but do have bacteriuria.

19. Lower genital tract infections: females Vulvitis Candida albicans HSV Vulvovaginitis C. albicans T. vaginalis Bacterial vaginosis associated bacteria urethritis • C. trachomatis • N. gonorrhoeae, • HSV Mucopurulent cervicitis • C. trachomatis, • N. gonorrhoeae • M. genitalium

20. Urethritis and the Urethral Syndrome in Women • C. trachomatis, N. gonorrhoeae, and occasionally HSV cause symptomatic urethritis—known as the urethral syndrome in women—that is characterized by "internal" dysuria (usually without urinary urgency or frequency), pyuria, and an absence ofEscherichia coliand other uropathogens in urine at counts of100/mL. • In contrast, the dysuria associated with vulvar herpes or vulvovaginal candidiasis (and perhaps with trichomoniasis) is often described as "external," being caused by painful contact of urine with the inflamed or ulcerated labia or introitus

21. Urethritis and the Urethral Syndrome in Women • Acute onset, association with urinary urgency or frequency, hematuria, or suprapubic bladder tenderness suggests bacterial cystitis. • Among women with symptoms of acute bacterial cystitis, costovertebral pain and tenderness or fever suggests acute pyelonephritis. • management of bacterial urinary tract infection.

22. Urethritis and the Urethral Syndrome in Women • An STI etiology of the urethral syndrome is suggested by young age, -more than one current sexual partner. -a new partner within the past month. -a partner with urethritis. - coexisting mucopurulent cervicitis . • Gonorrhea and chlamydial infection should be sought by specific tests (nucleic acid amplification tests =NAATs). • Among dysuric women with sterile pyuria caused by infection withN. gonorrhoeaeorC. trachomatis, appropriate treatment alleviates dysuria.

23. Urethritis and the Urethral Syndrome in Women • Signs of vulvovaginitis, coupled with symptoms of external dysuria, suggest vulvar infection (e.g., with HSV orCandida albicans • The finding of a single urinary pathogen, such asE. coliorStaphylococcus saprophyticus, at a concentration of100/mL in a properly collected specimen of midstream urine from a dysuric woman with pyuria indicates probable bacterial UTI, • whereas pyuria with <100conventional uropathogens per milliliter of urine ("sterile" pyuria) suggests acute urethral syndrome due toC. trachomatisorN. gonorrhoeae.

24. Mucopurulent cervicitis • C. trachomatis, • N. gonorrhoeae • M. genitalium

25. Mucopurulent cervicitis (MPC) • MPC in women represents the "silent partner" of urethritis in men, being equally common and often caused by the same agents (N. gonorrhoeae, C. trachomatis, or—as shown by case-control studies—M. genitalium); however, MPC is more difficult than urethritis to recognize. • As the most common manifestation of these serious bacterial infections in women. • MPC can be a harbinger or sign of upper genital tract infection, also known aspelvic inflammatory disease(PID)

26. Mucopurulent cervicitis (MPC) • In a prospective study consecutive patients with MPC [defined on the basis of yellow endocervical mucopus or30polymorphonuclear leukocytes (PMNs)/1000xmicroscopic field] • who were seen slightly more than one-third of cervicovaginal specimens tested forC. trachomatis, N. gonorrhoeae, M. genitalium, HSV, andT. vaginalisrevealed no identifiable etiology

27. MG/GC 2% MG/GC/CT 1% MG/CT 2% HSV 5% GC/CT 7% No organism 35% MG 8% TV 10% GC 13% CT 17% Organisms detected among female STD clinic patients GC-gonococcus CT-Chlamydiatrachomatis MG-Mycoplasma genitalium TV-Trichomonas vaginalis HSV-herpes simplex virus

28. Mucopurulent cervicitis (MPC) • The diagnosis of MPC rests on the detection of yellow mucopurulent discharge from the cervical os or of increased numbers of PMNs(20) in Gram's-stained or Papanicolaou-stained smears of endocervical mucus. • MPC due toC. trachomatiscan also produce edematous cervical and endocervical bleeding upon gentle swabbing. • Detection of intracellular gram-negative diplococci in carefully collected endocervical mucus is quite specific but50% sensitive for gonorrhea. • cervicitis caused by HSV produces ulcerative lesions on the epithelium of the exocervix.

29. Ulcerative lesions of the genitalia • HSV-1, HSV-2, • Treponema pallidum, • Haemophilus ducreyi. • C. trachomatis(LGV strains) • Calymmatobacterium granulomatis

30. Ulcerative lesions of the genitalia • Genital ulceration reflects a set of important STIs, most of which sharply increase the risk of sexual acquisition and shedding of HIV. • In a study of genital ulcers PCR testing of ulcer specimens demonstrated - HSV in 62% of patients. -Treponema pallidumin 13%. -Haemophilus ducreyiin 12–20%. • Today, genital herpes probably represents an even higher proportion of genital ulcers in the industrialized countries.

31. Ulcerative lesions of the genitalia • In Asia and Africa, chancroid was once considered the most common type of genital ulcer, followed in frequency by primary syphilis and then genital herpes. • With increased efforts to control chancroid and syphilis, together with more frequent recurrences or persistence of genital herpes attributable to HIV infection, PCR testing of genital ulcers now clearly implicates genital herpes as the most common cause of genital ulceration in most developing countries. • LGV and donovanosis (granuloma inguinale) continue to cause genital ulceration in developing countries.

32. Ulcerative lesions of the genitalia Other causes of genital ulcer include • candidiasis and traumatized genital warts(both readily recognized) • lesions due to genital involvement by more widespread dermatoses. • cutaneous manifestations of systemic diseases, such as genital mucosal ulceration in Stevens-Johnson syndrome or Behçet's disease.

33. Ulcerative lesions of the genitalia diagnosis • Although most genital ulcerations cannot be diagnosed confidently on clinical grounds alone, clinical findings plus epidemiologic considerations can usually guide initial management pending results of further tests. • Clinicians should order a rapid serologic test for syphilis in all cases of genital ulcer. • a dark-field or direct immunofluorescence test (or PCR test, where available) forT. pallidumin all lesions except those highly characteristic of infection with HSV (i.e., those with herpetic vesicles). • All patients presenting with genital ulceration should be counseled and tested for HIV infection.

34. Ulcerative lesions of the genitalia HSV • Typical vesicles or pustules or a cluster of painful ulcers preceded by vesiculopustular lesions suggests genital herpes. • These typical clinical manifestations make detection of the virus optional; however, many patients want confirmation of the diagnosis, and differentiation of HSV-1 from HSV-2 has prognostic implications, since the latter causes more frequent genital recurrences.

35. Ulcerative lesions of the genitalia HSV • Atypical" or clinically trivial ulcers may be more common manifestations of genital herpes than classic vesiculopustular lesions. Specific tests for HSV in such lesions are therefore indicated. • HSV infection is best confirmed in the laboratory by detection of virus, viral antigen, or viral DNA in scrapings from lesions. • HSV DNA detection by PCR, when available, is the most sensitive laboratory technique.

36. Ulcerative lesions of the genitalia HSV • Type-specific serologic tests for serum antibody to HSV-2, now commercially available, may give negative results, especially when patients present early with the initial episode of genital erpes or when HSV-1 is the cause of genital herpes. Furthermore, a positive test for antibody to HSV-2 does not prove that the current lesions are herpetic. • a positive HSV-2 serology does enable the clinician to tell the patient that he or she has probably had genital herpes, should learn to recognize symptoms, should avoid sex during recurrences, and should consider use of condoms or suppressive antiviral therapy, both of which can reduce transmission to a sexual partner.

37. Ulcerative lesions of the genitaliaSyphilis • Painless, nontender, indurated ulcers with firm, nontender inguinal adenopathy suggest primary syphilis. • If dark-field examination and a rapid serologic test for syphilis are initially negative and the patient will comply with follow-up and sexual abstinence. • the performance of two more dark-field examinations on successive days before treatment is begun will improve the sensitivity of the diagnosis of syphilis. • repeated serologic testing for syphilis 1 or 2 weeks after treatment of seronegative primary syphilis usually demonstrates seroconversion.

38. Ulcerative lesions of the genitaliachancroid • ulcers are painful and purulent especially if inguinal lymphadenopathy with fluctuance or overlying erythema is notedor • if the patient has recently had a sexual exposure elsewhere in a chancroid-endemic area (e.g., a developing country). • Enlarged, fluctuant lymph nodes should be aspirated for culture or PCR tests to detectH. ducreyias well as for Gram's staining and culture to rule out the presence of other pyogenic bacteria.

39. Ulcerative lesions of the genitalia donovanosis, carcinoma, and other nonvenereal dermatoses • When genital ulcers persist beyond the natural history of initial episodes of herpes (2–3 weeks) or of chancroid or syphilis (up to 6 weeks) and do not resolve with syndrome-based antimicrobial therapy. • then—in addition to the usual tests for herpes, syphilis, and chancroid—biopsy is indicated to exclude donovanosis, carcinoma, and other nonvenereal dermatoses. • HIV serology should also be undertaken, since chronic, persistent genital herpes is common in AIDS.

40. Ulcerative lesions of the genitalia • Usual causes • Herpes simplex virus (HSV2) • Treponema pallidum(primary syphilis) • Haemophilus ducreyi(chancroid)

41. Ulcerative lesions of the genitalia • Usual initial laboratory evaluation • Dark-field exam, direct FA, or PCR forT. pallidum • RPR or VDRL test for syphilis (if negative but primary syphilis suspected, repeat in 1 week) • culture, direct FA, ELISA, or PCR for HSV • consider HSV-2-specific serology. • In chancroid-endemic area: PCR or culture forH. ducreyi

42. Major STD Syndromes and Sexually Transmitted Intestinal infections Proctitis • C. trachomatis, N. gonorrhoeae, HSV, T. pallidum Proctocolitis or enterocolitis • Campylobacterspp., Shigellaspp., Entamoeba histolytica, other enteric pathogens Enteritis • Giardia lamblia

43. Proctitis, Proctocolitis, Enterocolitis, and Enteritis • Sexually acquiredproctitis,with inflammation limited to the rectal mucosa (the distal 10–12 cm), results from direct rectal inoculation of typical STD pathogens • proctocolitisinflammation extending from the rectum to the colon. • enterocolitisinflammation involving both the small and the large bowel. • enteritisinflammation involving the small bowel alone. • proctocolitis ,enterocolitis ,enteritis can result from ingestion of typical intestinal pathogens through oral-anal exposure during sexual contact.

44. Proctitis, Proctocolitis, Enterocolitis, and Enteritis • Anorectal pain and mucopurulent, bloody rectal discharge suggest proctitis or protocolitis. • Proctitis commonly produces tenesmus (causing frequent attempts to defecate, but not true diarrhea) and constipation. • whereas proctocolitis and enterocolitis more often cause true diarrhea. • In all three conditions, anoscopy usually shows mucosal exudate and easily induced mucosal bleeding sometimes with petechiae or mucosal ulcers. • Exudate should be sampled for Gram's staining and other microbiologic studies.

45. proctitis • Acquisition of HSV, N. gonorrhoeae, orC. Trachomatis during receptive anorectal intercourse( causes most cases of infectious proctitis in women and homosexual men). • Primary and secondary syphilis can also produce anal or anorectal lesions, with or without symptoms. • Gonococcal or chlamydial proctitis typically involves the most distal rectal mucosa and is clinically mild, without systemic manifestations. • primary proctitis due to HSV produce severe anorectal pain and often cause fever.

46. Enteritis and proctocolitis • Diarrhea and abdominal bloating or cramping pain without anorectal symptoms and with normal findings on anoscopy and sigmoidoscopy occur with inflammation of the small intestine (enteritis) or with proximal colitis. • In homosexual men without HIV infection, enteritis is often attributable toGiardia lamblia. • Sexually acquired proctocolitis is most often due toCampylobacterorShigellaspp.

47. proctocolitis • Two species initially isolated in association with intestinal symptoms in homosexual men are now known as Helicobacter cinaedi and Helicobacter fennelliae. • both have subsequently been isolated from the blood of HIV-infected men with a syndrome of multifocal dermatitis and arthritis .

48. The End