STI, STD, Genital Ulcer

By: Andualem G.(MSc)

Lecturer, SLU
Sept-2022
 Sexually Transmitted Diseases
• The term denote disorders spread
principally by intimate contact:-
1. Sexual intercourse,
2. Close body contact, kissing, and anal
intercourse.
3. Transplacental spread,
4. Passage through the birth canal, and
5. Lactation during the neonatal period
 Terminology
• WHO recommends that the term STD
be replaced by the term STI.
• STI has been adopted since 1999 as it
better incorporates asymptomatic
infections.
• Has also been adopted by a wide
range of scientific societies &
publications.
 Introduction
• the most common infectious diseases in the
most parts of the world

• five key points about all STDs today:

1. STDs affect men and women of all
backgrounds and economic levels.
- They are most prevalent among
teenagers and young adults.
- Nearly two-thirds of all STDs occur in
people younger than 25 years of
age.
 continued
2. The incidence of STDs is rising
- Because in the last few decades, young people have
become sexually active earlier yet are marrying later.
- In addition, divorce is more common.
- The net result is that sexually active people today are more
likely to have multiple sex partners during their lives and
are potentially at risk for developing STDs.
 continued
3 Most of the time, STDs cause no symptoms,
particularly in women.
- When and if symptoms develop, they may be
confused with those of other diseases not
transmitted through sexual contact.
- Even when an STD causes no symptoms, however,
a person who is infected may be able to pass the
disease on to a sex partner.
- recommend periodic testing or screening for
people who have more than one sex partner.
 continued
4, STDs tend to be more severe and more frequent
for women than for men,
- because the frequency of asymptomatic
infection - many women do not seek care until
serious problems have developed.
- Some STDs can spread to cause PID, which in
turn  infertility & ectopic (tubal) pregnancy.
- may be associated with cervical cancer; HPV
- causes genital warts
- other genital cancers.
 continued
5. STDs can be passed from a mother to her baby
before, during, or immediately after birth;
- When diagnosed and treated early, many STDs
can be treated effectively.
- Some infections have become resistant to the
drugs used to treat them and now require newer
types of antibiotics.
 STD; microorganisms
• Long list
1. Transmitted by sexual route
(conventional STI)
2. Transmission described but less
defined evidence
 Cont’d; Organisms transmitted sexually

• Bacteria • Viral
1. N. gonorrhea 1. HIV
2. C. trachomitis 2. HSV
3. T. pallidum 3. HBV
4. H. ducreyi 4. HPV
5. C. granulomatis 5. Molluscom
6. U. urealyticum contagiosum virus
• Others
1. T. vaginalis
STDs; described but less defined for sexual transmission

• Bacteria • Viral
1. M.hominis 1. CMV
2. G. vaginalis 2. HCV
3. HSV type 8
4. EBV
• Others
1. C. albicans
2. S. scabiei
 Sexually transmissible
1. Gonococci and Chlamydia
infections
2. Syphilis
3. Genital herpes
4. Papilloma virus infection
5. LGV, Chancroid and GI
6. Miscellaneous causes
 Approaches to STD Dx & Rx
Three approaches
1. Laboratory based
2. Clinical without laboratory support
3. Syndromic Approach
 Background

• Traditional approach to STD Dx and Rx

relies on laboratory diagnosis to
determine etiologic agents
Expensive
Involves delay in Dx and Rx
Depends on technician and lab
accuracy
Often not available in resource poor
settings
 …Background
• Alternative approach – Clinical Dx
Presumptive Dx of one etiology based
on clinical findings
Often inaccurate and incomplete
•Similarities of Sn and Sx
•Misses Co-infection
•Atypical presentation - HIV
 Definition
• Syndromic Management is a management
approach that uses clinical algorithms on an STD
Syndrome, the constellation of patient symptoms
and clinical signs to determine therapy.
• Algorithms are adapted to local STD prevalence
• Chooses antimicrobial agents to cover all the
possible pathogens responsible for the syndromes in
the specific geographic area.
 Syndromic Management

History
 In 1991 WHO developed and started
advocating the syndromic approach
to address the limitation of aetiological
(lab) & presumptive(clinical) Dx & Mx
 …Syndromic Management
Based On
 Recognition of relatively consistent and characteristic
combinations of easily elicited Sx and easily
recognized Sn (Syndromes) with which STD commonly
presents
 Knowledge of the most common etiologies of
different syndromes
 Knowledge of antimicrobial susceptibility pattern
 Knowledge of behavioral & demographic
characteristics of people with STD
 …Syndromic Management
Components
1. Identification and Rx of the Syndrome
2. Education and counseling on
- Rx compliance
- Risk reduction including condom use
3. Partner notification
4. Provision of condoms
5. VCT for HIV
 Advantages
• Expedited care
• Cost savings – less technically demanding
• Increased client satisfaction
• Treatment at first visit
Decreases further transmission
Decreases complication
Eliminates need for return visit
• Decrease incidence of HIV (by 42% in
Tanzania)
 …Advantages
• Uses flow charts in case Mx which
Standardizes Dx,Rx, referral and
reporting
Improves surveillance
Improves programme Mx
• High sensitivity
• Gives emphasis to non-medical
aspects of STD care
 Disadvantages
• Inevitable over treatment (multiple
antimicrobials for single infection)
• Does not address subclinical and
asymptomatic STI
• High sensitivity is at the cost of specificity
• Doesn’t address poor health care seeking
behavior for STD Sx
• Works well with some syndromes (GU,UD)
but not as well with others (VD)
 …Disadv.
• Rx with multiple drug might be expensive
and
• The recommended drugs may not be
available
• But, cost effectiveness increases further
when
 Applied to high STD prevalence areas
 Long term cost of STD is considered
 Increased HIV transmission and
Major STD Clinical Syndromes
• Genital ulcer
• Urethral discharge
• Abnormal vaginal discharge
• Lower abdominal pain
• Bubo inguinale
• Scrotal swelling
• Neonatal conjuctivitis
 Genital Ulcer Disease (GUD)
• Algorithms for GUD try to identify presence
of
1. Herpes,
2. Syphilis and/or
3. Chancroid
• Frequency of causative agents differ in
different parts
• Review – syndromic treatment without lab
support showed high cure rate
 100% - Cote D’ivore
 64% - Zambia
 Herpes Simplex Virus
– DNA virus
• remain in latent form
• other members of the family includes VZ, CMV ,EBV
• there are different antigenic strains
• but are divided in two:-
• Type1 = oral
• Type2 = genital

– primary infection occurs in child hood

– latent infection resides in the sensory ganglion of trigeminal,
sacral & vagal
– 50 -100% of adults have serologic evidence of HSV1
– 20-80% type2
 HSV Cont…
• transmission = only by direct contact
• clinical disease
• painful papule followed by vesicle ,ulceration
crusting & healing
• more sever in women
• Primary Vs Recurrent
• primary episode
– more symptomatic
– incubation range 2-14 days
– there is fever & lymphadenities
– viral shedding & healing prolonged
 HSV Cont…
• recurrent episode
– frequently have prodromal period signaling active
viral replication,
– lesions are often localized
– shedding is shorter
– recurrences is not usually from re infection but are
reaction of latent viruses
• Diagnosis
= mainly clinical
– Tissue culture
• best method but lengthy and costly
– ELISA testing 70%
– Direct immunofluoresent staining 75%
sensitive
= both the negative culture and smear
don't exclude infection
 Syphilis
• organism characteristics & microbiology
– By treponema pallidum
– is tightly coiled a spirochete that can not be grown
– can invade intact mucous membrane or area of abraded
skin .

• incidence and epidemiology

– the incidence is rising
– only 30% of patients exposed acquire the disease
– in those infected patients not taking medication 60% do
develop immune defense sufficient to control the infection
– the remaining will go to late and tertiary syphilis
• Clinical diseases
1. EARLY SYPHILIS
A = primary syphilis,
• painless chancre is the whole mark
• it occurs at the site of inoculation
• there is regional lymphadenopathy
• incubation period 10-90 days
B = 20 syphilis
- mucocutaneous skin lesion 6-8weeks after
the original inoculation
- alopacia, hepatitis & nephrotic syndrome
 continued
2. Latent syphilis
– characterized by serologic evidences but no clinical signs
&symptoms
– most patients are not infectious about 25% could have
recent skin lesion
– arbitrary division of this stage but has no clinical
significance with regard to treatment
– early latency (< 4 years from initial infection )
– late latency (>4 years )
 continued
3. LATE SYPHILIS
• 5-30 years after initial infection
– there are three divisions
1. benign disease(gummas) - lesion occur in vital organs
– can be life threatening if they compromise the organ
2. cardiovascular disease - involvement of the heart and the aorta
are frequent dysfunction may cause serious problem
3. neurological diseases - three clinical syndromes of neurological
involvement
– asymptomatic disease no neurological manifestations but
abnormal CSF
– meningovascular disease the commonest manifestation is paresis
,(tabis dorsalis)
– parenchymatous disease dementia the commonest
manifestation
• Diagnosis
A. Non treponemal specific test:-
• RPR (rapid plasma reagin) test,
• standard VDRL slide test,
B. Treponemal specific test;
• FTA-ABS; fluorescent treponemal antibody absorbed (used
commonly for adults ),
• MHA_TP micro haemagglutination assay( for neonates)
C. Dark field microscopy
• the higher the titer the higher the inflammatory reaction
• false +ve tests in chronic illnesses
– e.g. leprosy - auto immune diseases( lupus)
– pregnancy - drug addiction
 Chancroid
• Haemophilus ducreyi :- a gram negative
bacteria
• is a painful soft chancre ragged with raised
borders
• kissing ulcers do occur
• unilateral lymphadenopathy that may
suppurate
• incubation period is 2-5 days
• the organism is fastidious
 …GUD
Genital ulcers
Patient complains of genital sore or ulcer

Examine -Educate
No Vesicular/recurrent No -Counsel if
Ulcer present? needed
lesion(s) present? -Promote/provide
Yes
Yes condoms
-Treat for syphilis and
chancroid -Management of
-Educate herpes
-Counsel if needed -Educate
-Promote/provide condoms -Counsel if needed
-Partner management -Promote/provide
-Advise to return in 7 days condoms
 …GUD
• Syphilis
 Recommended regimen
Benzantine Penicillin 2.4miu im singledose
Alternative regimen
Procaine Penicillin 1.2miu im for ten days
Penicillin allergy– TTC 500mg po qid/15d
or doxycycline 100mg po bid/15d
 …GUD
• Chancroid
Recommended regimen
Erythromycin 500mg po qid/7days
Alternative regimen
Ciprofloxacin 500mg single dose or
Ceftriaxone 250mg im single dose or
Spectinomycin 2gm im single dose
 …GUD
• Herpes – to modify course of symptoms
• 1st episode – acyclovir 200mg 5x per day /7
days(doesn’t appear to influence natural Hx
of recurrent disease)
• Recurrence – acyclovir 200mg tid
continuously for frequently recurring
outbreaks(>6 per year)
 Inguinal Bubo
• Inguinal adenopathy
• LGV (L1,L2,L3),
• Chancroid,
• G I (donovanosis) is
– Klebsiella granulomatis, formerly known as
Calymmatobacterium granulomatis
• Common in the tropics as a cause of genital ulcer
• Men affected more than females
• Prostitution is reservoir
• Painful adenopathy
 Inguinal Bubo, cont’d
• Rare systemic symptoms except LGV
• Common predisposing factor for the
spread of HIV
• Complications:
– Abscess formation
– PID
– Lymphatic obstruction
– Stenosis
– Infertility
 Differential Diagnosis
• Infection in the lower limbs and
perineum
• Malignancy
• Herpes genitalis
• Syphilis
 Inguinal Bubo

Enlarged and/or painful inguinal lymph nodes?

Examine
Yes
Ulcer(s) present? Use genital ulcers flow chart
No
-Treat for lymphogranuloma
venereum
-Educate
-Counsel if needed
-Promote/provide condoms
-Partner management
-Advise to return in 7 days
 …Inguinal Bubo
• Recommended regimen (LGV)
Doxycycline 100mg po bid/14 days or
TTC 500mg po qid/14 days
• Alternative regimen
Erythromycin 500mg po qid/14 days or
Sulfadiazine 1gm qid/ 14 days
• Aspirate fluctuant lymph nodes through
normal skin
• Incision and drainage or excision of nodes is
contraindicated
 Vaginal Discharge (VD)

• Most difficult syndrome to diagnose

• Either vaginitis or cervicitis
• Cervicitis- N.gonorrhea
- C.trachomatis
• Vaginitis - Trichomonas vaginalis
- Candida albicans
- Bacterial vaginosis
• Effective management of cervicitis is more important
from patient point of view b/c of serious sequele
 …VD
• VD is not an adequate indicator of any
particular STD making it a poor algorithm
entry point
• Use of risk assessment has shown to improve
performance of syndromic management
algorithms
• The probability of correct Rx of STI relative to
probability of overtreatment is increased
 …VD
• Risk scores use variables that are common
risk predictors for STD
Young age less than 21
Multiple partners
Partner has urethral discharge
New partner in the past three
months
Patient is single
• Need adaptation to local,social and
behavioral conditions and should be
periodically updated
 …VD
Vaginal Discharge
Patient complains of vaginal discharge
(vaginal itching)

partner symptomatic or
No
specific risk factors positive? -Treat for vaginal infection
-Educate
Yes -Counsel if needed
-Promote/provide condoms
-Treat for cervical and vaginal infections
-Educate
-Counsel if needed
-Promote/provide condoms
-Partner management
-Return if necessary
 …VD
Vaginal Discharge (with speculum)
Patient complains of vaginal discharge
(vaginal itching)

partner symptomatic or specific

risk factors positive? No

Yes
Treat for cervical infection plus vaginal infection Speculum and bimanual
according to speculum examination findings vaginal examinations

Mucopus from Profuse Curd-like No Cervical

Cervix? VD? VD? discharge? motion
-Educate tenderness
-Treat for cervical & -Treat for trichomonas -Treat for present?
-Counsel if
vaginal infections & bacterial vagionosis candida needed
-Educate -Educate -Educate -promote/prov-
-Counsel if needed -Counsel if needed -Counsel if ide condoms Use flow-
-Promote/provide -Promote/provide needed chart for
condoms condoms -Promote/provide lower
-Partner Mx -Partner Mx condoms abdominal
-Return if necessary -Return if necessary -Return if necessary pain
 …VD
Treatment
Cervicitis (Gonorrhea & Chlamydia)
Recommended regimen
Ciprofloxacin 500mg po single dose or
Ceftriaxone 250mg im single dose or
Cefixime 400mg po single dose or
Spectinomycin 2gm im single dose

Plus
Doxycycline 100mg po bid/7 days or
TTC 500mg po qid / 7 days or
Erythromycin (pregnant)
 …VD
Vaginitis
Recommended regimen
metronidazole 2gm PO single dose or
metronidazole 500mg PO bid/7 days
plus
Nystatin 100,000 IU intra vaginally once/14 d,
or
Clotrimazole 200mg once daily/3 days, or
Clotrimazole 500mg single dose
 Lower Abdominal Pain (LAP)
Patient complains of lower abdominal pain

Take history and examine

(abdominal and vaginal)
Temp 38°C or Pain during No Follow
examination (on moving cervix) up if
Missed/overdue No
or Vaginal discharge pain
period or Yes persists
Recent delivery
-Treat for PID
/abortion or -Educate
Rebound -Counsel if needed
tenderness or -Promote/provide condoms
Guarding or -Partner management
Vaginal bleeding
Follow up after 3 days or
Yes sooner if pain persists
Refer No Refer
Yes
Continue Rx Improved?
 PID
• PID refers to acute infection of the upper
genital tract (above the internal cervical
os)
• community-acquired Vs Iatrogenic
• USA - annually 2.5 million outpatient visits,
• 200,000 hospitalizations, and
• 100,000 surgical procedures
• incurs an annual total expense of more
than $5 billion
• Acute PID= attributed to an ascending
spread of microorganisms from the
vagina and endocervix.
• Acute PID Vs Acute salpingitis
– are often used interchangeably,
– but PID is not limited to tubal infection
only.
• A more descriptive term = (UGTI).
– Severity & Extent of disease
• This is differentiated from (LGTI)
because response to treatment
appears to be different in these two
entities.
 Etiology
• Neisseria gonorrhoeae and
Chlamydia trachomatis serovars D-K
• common cause of PID = 1/3rd each;
• However, most = polymicrobial
infection caused by ascending
infection
• 15% of infections occur after
procedures that break the cervical
mucous barrier
• C. trachomatis etiologic role is very
different from N. gonorrhea
 N. Gonnorrhea C.Trachomatis
• Gram-negative IC • is a slow-growing
diplococcus intracellular
• rapid cycle 20 to 40 organism.
minutes to divide • lack of
• rapid and intense mitochondria
inflammatory • growth cycle 48 to
response 72 hours
• Less complication • does not induce a
• Early Rx rapid or violent
inflammatory
response
• destruction by
rupture
 Initial PID →
• tissue damage provides fertile ground
for the growth of secondarily infecting
aerobic and anaerobic bacteria.
• This necrotic tissue is an excellent
growth medium, and
• the epithelial damage enhances the
breakdown of the surface defense
mechanisms
 Classification:-
• Post STI / menustral
• Post abortal
• Post Partum
• Post Instrumentation
• IUD – Related
• Secondary PID
• Risk Factors
1. STI
2. Age
– Adolescent 1:8 Vs 1:80 for a sexually active >24,
b/c columnar epithelium
3. Contraceptives
– IUDs = threefold to fivefold
– Barriers = ↓ 60%
– OCP = ↓ risk, good Px fertility
– previous tubal ligation = 1/450;
4. Instrumentation ex. 1/200 induced abortion
5. Previous acute PID = 25 %,
- partner treatment
• Criteria for the Diagnosis:-
Major Criteria:-
• Cervical motion tenderness or
• Lower abdominal / uterine tenderness or
• Adnexal tenderness
Other minor criteria:-
• Oral temperature >101°F (>38.3°C)
• Abnormal cervical or vaginal mucopurulent
discharge
• Presence of abundant numbers of WBC on saline
microscopy of vaginal secretions
• Elevated ESR
• Elevated C-reactive protein
• Laboratory documentation of cervical infection
with N. gonorrhoeae or C. trachomatis
 The most specific criteria:-
• Endometrial biopsy with histopathologic
evidence of endometritis
• Transvaginal sonography or MRI
• Laparoscopic abnormalities consistent with
PID
• Doppler studies suggesting pelvic infection
(e.g., tubal hyperemia)
 DDX:-
• Acute appendicitis,
• Endometriosis,
• Torsion or rupture of an adnexal mass,
• Ectopic pregnancy, and
• LGTI
• Complication:-
Early
• Sepsis → MOF → Death( ruptured TOA
= 10 %)
• Surgical morbidity (TOA)
Late
• Infertility = 20%
• Ectopic Pregnancy = 6-10X higher; 12
%
• Chronic pelvic Pain = 20%
• Chronic PID
• Psychological consequences
 Fitz-Hugh-Curtis syndrome,
• Perihepatic inflammation and adhesions,
• develop in 1% to 10% of acute PID.
• RUQ- pain & tenderness, pleuritic pain,
• DDX = acute cholecystitis or pneumonia.
• Develop from vascular or transperitoneal
dissemination of either N. gonorrhoeae or C.
trachomatis to produce the perihepatic
inflammation.
Treatment
• based on the consensus that PID is
polymicrobial in cause.
• Empirical antibiotic protocols should
cover a wide range of bacteria
• Oral therapy can be considered for
women with mild to moderately severe
acute PID
 Grading of severity

Clinical system
Grade I: Disease limited to the adnexae
Grade II: PID with an inflammatory mass
Grade III: Ruptured tubo-ovarian abscess
Operative system
Mild: Erythema and edema of the
adnexae
Moderate: Purulent exudate from fallopian
tubes
Severe: Pyosalpinx, inflamatory complex, TOA
CDC-Recommended Treatment Regimens for
Oral Therapy
• Regimen A
- Levofloxacin 500 mg orally once daily for 14 days
OR
- Ofloxacin 400 mg orally once daily for 14 days
WITH OR WITHOUT
- Metronidazole 500 mg orally twice a day for 14 days

• Regimen B
- Ceftriaxone 250 mg IM in a single dose
PLUS
- Doxycycline 100 mg orally twice a day for 14 days
WITH OR WITHOUT
- Metronidazole 500 mg orally twice a day for 14 days
 Criteria for Hospitalization
• Surgical emergencies (such as appendicitis)
cannot be excluded.
• Pregnant.
• No response clinically to oral therapy.
• Unable to follow or tolerate oral regimen.
• Has severe illness, nausea and vomiting, or
high fever.
• The patient has a tuboovarian abscess.
• Adolescents
• HIV / Aids
 CDC-Recommended Parenteral
Treatment
Regimen A
- Cefotetan 2 g IV every 12 hours
OR
- Cefoxitin 2 g IV every 6 hours
PLUS
- Doxycycline 100 mg orally or IV every 12 hours
Regimen B
- Clindamycin 900 mg IV every 8 hours
PLUS
- Gentamicin
• D/C IV 24 hours after a patient improves clinically;
• Continue oral therapy
– doxycycline 100 mg orally twice a day or
– Clindamycin 450 mg orally four times a day
• complete a total of 14 days of therapy
• Male sex partners of women with PID
should be examined and treated
• Education for the prevention of
reinfection,
• Proper contraception
Surgical Mx
• Laparascopy
• Laparatomy
• Colpotomy
• Percutaneous drainage
 Pelivic Tuberculosis
• it is a frequent cause of chronic PID
and infertility in developing world
• produced primarily by either: -
– Mycobacterium tuberculosis or
– Mycobacterium bovis
• The fallopian tubes = predominant site
• spread to the endometrium → ovaries.
 Female reproductive tract are usually
infected by:-
1. Hematogenous miliary spread from a
primary pulmonary lesion,
2. Hematogenous spread from a secondary
miliary site
3. Lymphatic spread from a primary
pulmonary site to intestinal lymph nodes
and then to the pelvis,
4. Direct extension from adjacent abdominal
organs
5. A venereal transmission
 Pathology of Pelvic Tuberculosis
• Both fallopian tubes are involved
• Tuberculous endometritis = 50%.
• Tuberculosis of cervix is present in 5%
• The vagina and vulva = 2%
• Ovaries = only surface involvment.
• The mucosa of tubes may not be involved
• 38% of women with genital tuberculosis had
previously had tuberculosis in other organs,
usually the lungs
 Clinical Features
• most often = 20 and 40 years
• Chronic pelvic pain,
• Inflammatory Pelvic Mass
• General malaise, low grade fever
• Menstrual irregularity (50%), and infertility
• Amenorrhea or oligomenorrhea = 27%
• Failure of fever to subside with high doses of
broad-spectrum antibiotic
• 10-20 % of pts with pulmonary Tb have pelvic
Tb
 Diagnosis
• Mainly clinical
• Biopsy
– dilatation and curettage or endometrial
biopsy
– From cervical ulcer
• HSG
• Culture – menstrual blood, luteal
phase
• Laparatomy / Laparoscopy
• Acid-fast stains of tissue
• Other studies ex. CXR, Culture etc…
• Treatment
A. Medical
• Daily INH, RIF, and PZA for 8 wk, followed by
16 wk of INH and RIF daily or 2 - 3 times/wk
• Other DOT regimens ex.:-
• Daily INH, RIF, PZA, and SM or EMB for 2 wk,
then administer the same drugs 2 times/wk
for 6 wk (by DOT).
– Next, administer INH and RIF 2 times/wk for 16 wk
(by DOT).
• B. Surgical
1. Persistence or enlargement of an adnexal
mass after 4 to 6 months of antituberculous
antibiotic therapy.
2. Persistence of pelvic pain or recurrence of
pelvic pain while on medical therapy
3. Primary unresponsiveness of the
tuberculous infection to antibiotic therapy
4. Difficulty in obtaining patient cooperation
for continued long-term therapy
Thank You