sexually transmitted diseases

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Sexually Transmitted Diseases:

Sexually Transmitted Diseases Presenter. Dr. Deepak Kumar

Sexually Transmitted Diseases:

Sexually Transmitted Diseases A group of communicable diseases Transmitted by sexual contact

Transmitted in Adults Predominantly by Sexual Intercourse :

Transmitted in Adults Predominantly by Sexual Intercourse Bacteria Neisseria gonorrhoeae Chlamydia trachomatis Treponema pallidum Haemophilus ducreyi Calymmatobacterium granulomatis Ureaplasma urealyticum Viruses HIV (types 1 and 2) Human T-cell lymphotropic virus type I Herpes simplex virus type 2 Human papillomavirus Hepatitis B virus Molluscum contagiosum virus Others Trichomonas vaginalis Phthirus pubis

Sexual Transmission Described but Not Well Defined or Not the Predominant Mode :

Sexual Transmission Described but Not Well Defined or Not the Predominant Mode Bacteria Mycoplasma hominis Mycoplasma genitalium Gardnerella vaginalis and other vaginal bacteria Group B Streptococcus Mobiluncus spp. Helicobacter cinaedi Helicobacter fennelliae Virus Cytomegalovirus Human T-cell lymphotropic virus type II Hepatitis C, D viruses Herpes simplex virus type 1 (?) Epstein-Barr virus Human herpesvirus type 8 Others Candida albicans Sarcoptes scabiei

Transmitted by Sexual Contact Involving Oral-Fecal Exposure; of Declining Importance in Homosexual Men :

Transmitted by Sexual Contact Involving Oral-Fecal Exposure; of Declining Importance in Homosexual Men Bacteria Shigella spp. Campylobacter spp. Virus Hepatitis A virus Others Giardia lamblia Entamoeba histolytica

Risk Of Acquiring STDs in Two Individuals Contemplating Unprotected Sexual Intercourse:

Risk Of Acquiring STDs in Two Individuals Contemplating Unprotected Sexual Intercourse

Gonorrhoea:

Gonorrhoea Caused by neisseria gonorrhoeae A gram-negative, diplococcus Epidemiology Around 60 million new cases/year worldwide Highest rates of infection occur in young persons In their early twenties Clinical features Onset 1–5 days after sexual contact Males Acute urethritis Dysuria accompanied by purulent discharge

Gonorrhoea:

Gonorrhoea MSM Gonococcal proctitis Asymptomatic Rectal pain, tenesmus and discharge Exudative pharyngitis and cervical lymphadenopathy Commonly asymptomatic Females Excessive vaginal discharge, dysuria, deep dyspareunia and intermenstrual bleeding Ophthalmia neonatorum Gonococcal conjunctivitis In first week after birth

Gonorrhoea:

Gonorrhoea Complications Periurethral abscess Fistula formation and subsequent urethral stricture Men Acute prostatitis Acute epididymo-orchitis Women Pelvic infl ammatory disease Tubo -ovarian abscess Tubal-factor infertility Acute perihepatitis ( fitz – hugh curtis syndrome Either gonorrhoea , chlamydia or mixed infections

Gonorrhoea:

Gonorrhoea Disseminated gonococcal infection (DGI) Common in women than men Dermatitis–arthritis syndrome Skin lesions are small, tender and maculopapular Central vesicle or pustule → necrosis Lesions occur in crops near affected joints Joint or tendon pain Migratory polyarthralgia , affecting the knees, Elbows, wrists, metacarpophalangeal and ankle Suppurative arthritis Pericarditis, endocarditis, meningitis

Gonorrhoea:

Gonorrhoea Diagnosis Microscopy Culture NAATs ( nucleic acid amplifi cation tests) Management Ceftriaxone 250 mg i.m. as a single dose Cefixime 400 mg orally as a single dose screen for other STIs and HIV

Genital Chlamydia infections:

Genital Chlamydia infections Chlamydia trachomatis D–K strain Intracellular Prevalence: 10% of sexually active people aged less than 25 years Clinical feature Males Asymptomatic 50% Anterior urethritis Mucopurulent urethral discharge and dysuria MSM Proctitis

Genital Chlamydia infections:

Genital Chlamydia infections Females Asymptomatic 70% Post-coital bleeding Vaginal discharge Abdominal pain Extragenital Follicular conjunctivitis Complications Males Periurethral abscess & urethral stricture Epididymo-orchitis Women Pelvic inflammatory disease (PID)

Genital Chlamydia infections:

Genital Chlamydia infections Diagnosis Nucleic acid amplification tests (NAATs ) Cell culture Direct fluorescent antibody (DFA ) Monoclonal antibodies targeted at C. trachomatis elementary bodies . Treatment Tetracycline Macrolide Single-dose azithromycin

Genital Chlamydia infections:

Genital Chlamydia infections

Lymphogranuloma venereum:

Lymphogranuloma venereum Chlamydia trachomatis serovars L1, L2 and L3 Primarily infect the lymphatics Clinical features Primary stage 3–30 days after transmission Transient herpetiform ulcer Heals rapidly without scar In males, lesion usually on Coronal sulcus, prepuce, or glans penis In females on Posterior wall of the vagina, vulva, or cervix

Lymphogranuloma venereum differential diagnosis:

Lymphogranuloma venereum differential diagnosis Primary stage Ulcerogenital diseases Herpes simplex virus, chancre, chancroid , granuloma inguinale Neisseria gonorrhoeae and Common chlamydial urogenital infection Non-infectious causes: Trauma, zoon balanitis , fixed drug eruption

Lymphogranuloma venereum:

Lymphogranuloma venereum Secondary stage (inguinal syndrome) Occurs after 2–6 weeks Characterized by painful inguinal lymphadenitis Constitutional symptoms Progresses to suppurative bubos with multiple fistulae Sign of the groove Differential diagnosis Syphilis, chancroid , Granuloma inguinale, Cat-scratch disease, Tularaemia , plague, Mycobacterial disease Lymphoproliferative disorders

Lymphogranuloma venereum:

Lymphogranuloma venereum Secondary stage ( anorectal syndrome) MSM Mucopurulent anal discharge, rectal pain and bleeding Tenesmus and constipation Tertiary stage Years after initial stages Rectal stricture Elephantiasis of the external genitalia With ulcers and fistulas Due to fibrosis and lymphatic obstruction Diagnosis Nucleic acid amplification tests Confirmation by PCR for Lgv -specific DNA

Lymphogranuloma venereum:

Lymphogranuloma venereum Differential diagnosis Tertiary stage Malignancy Filariasis and other parasitic infections Pseudoelephantiasis (no lymphadenitis) of tuberculosis and granuloma inguinale Deep fungal infection Hidradenitis suppurativa Trauma

Lymphogranuloma venereum:

Lymphogranuloma venereum Management First line Oral doxycycline 100 mg bid 3 wk Second line Oral erythromycin 500 mg qid 3 wk Third line Oral azithromycin 1 g/once weekly 3 wk

Chancroid:

Chancroid Haemophilus ducreyi Gram negative bacteria Genital ulcer disease (GUD) Clinical features Incubation period 3 to 10 days Papule at site of inoculation In which micropustules develop Then progress to ulcers Usually multiple, 1 cm diameter Tender, ragged undermined edge Purulent base, and bleed easily.

Chancroid:

Chancroid Common in uncircumcised men Site Men Coronal sulcus Inner aspect of the prepuce MSM Perianal Women Vaginal introitus or on the labia Inguinal lymphadenitis In one-third cases

Chancroid:

Chancroid Clinical Variants of Chancroid Giant chancroid Single lesion extends peripherally and extensive ulceration. Large serpiginous ulcer Lesions become confluent. groin or thigh may be involved ( ulcus molle serpiginosum ). Phagedenic chancroid Variant caused by superinfection with fusospirochetes . Rapid /profound destruction of tissue ( ulcus molle gangrenosum ). Transient chancroid Small ulcer resolves spontaneously in a few days ( French: chancre mou volant ). Follicular chancroid Multiple small ulcers occur in a follicular distribution. Papular chancroid Granulomatous ulcerated papule resemble that of donovanosis or condylomata lata ( ulcus molle elevatum ).

Chancroid:

Chancroid Diagnosis Culture PCR Direct microscopy Management

Granuloma inguinale:

Granuloma inguinale Donovanosis Calymmatobacterium ( klebsiella ) granulomatis Clinical features A papule or subcutaneous nodule That ulcerates Large beefy-red, non-tender Granulomatous ulcers Bleed easily Site Men Coronal sulcus Inner aspect of the penile prepuce MSM Anus

Granuloma inguinale:

Granuloma inguinale Females Labia or vaginal introitus Lymphadenopathy is not usual Subcutaneous extension of granulomas Mimic enlarged lymph nodes Complication Pseudo-elephantiasis Malignant change Differential diagnosis Other causes of genital ulcer Genital amoebiasis and tuberculosis, Crohn’s disease, and Genital cancers

Granuloma inguinale:

Granuloma inguinale Diagnosis Microscopy Donovan bodies in macrophage Bipolar staining (safety-pin appearance) Culture PCR

Granuloma inguinale:

Granuloma inguinale First line Azithromycin 1 g once followed by 500 mg daily 1 g weekly for 4-6 wk 500 mg once daily for 1 wk Second line Doxycycline 100 mg once or twice daily for 3 wk Trimethoprim/sulfamethoxazole 800 mg/160 mg twice a day for 3 wk Ciprofloxacin 750 mg twice a day for 3 wk Erythromycin base 500 mg orally four times a day for 3 wk

Genital mycoplasmas:

Genital mycoplasmas M. hominis Ureaplasma sp In men NGU (Non- Gonococal Urethritis) Females Cervicitis PID Complication Disseminated disease in immunocompromised Treatment Azithromycin Doxycycline

Trichomonas vaginalis:

Trichomonas vaginalis Trichomoniasis (protozoa) Affect 180 million women worldwide Clinical features Women Vaginal discharge Yellow green, malodorous Vulvar pruritus, erythema Dyspareunia, lower abd . Pain Punctate hemorrhages on cervix Strawberry cervix Newborn During vaginal delivery Men Balanitis , Epididymitis, Prostatitis Treatment Metronidazole 2 Gm oral single dose

Bacterial vaginosis:

Bacterial vaginosis Most common vaginal infection in childbearing age There is imbalance of bacterial flora Not transmitted sexually

Molluscum contagiosum:

Molluscum contagiosum Poxvirus family Genus, molluscipox Commonly causing disease in childhood. Incidence peak in young adults Due to sexual transmission Incubation period 14 days to 6 months Lesion is a shiny, Pearly white, hemispherical, umbilicated papule With a central pore Self-limiting within 6–9 months Can persist 4 years

Molluscum contagiosum:

Molluscum contagiosum Distribution In sexually transmitted infection Anogenital region In children Common on the limbs Immunosuppression Face Treatment aim Destroy infected epidermal cells, Stimulate immunological response Act directly against the virus.

Molluscum contagiosum:

Molluscum contagiosum Curettage Squeezing the contents Cryotherapy Carbon dioxide or pulsed dye lasers Photodynamic therapy Topical agents Cantharidin , Trichloroacetic acid and Diluted liquefied phenol Salicylic acid preparations Tretinoin , adapalene Potassium hydroxide

Herpes simplex:

Herpes simplex Herpes simplex Type 1, facial infections Type 2, genital infections Acquired by Direct contact Droplets Infected secretions via skin or mucousa Type 2 Transmitted sexually In adults If in children Sexual abuse

Herpes simplex:

Herpes simplex Clinical features Primary infection In a previously seronegative individual In men Penile ulceration (common) On the glans, prepuce and Shaft of the penis. MSM Common in the perianal area May extend into the rectum Women Vulva, vagina and cervix

Herpes simplex:

Herpes simplex Recurrent infection 95% of type 2 HSV Triggered by Minor trauma, or by infections Ultraviolet radiation Dermabrasion or laser resurfacing Emotional stress Six times per year Clusters of small vesicles Non-indurated ulcers Diagnosis Culture from vesicle fluid Immunofluorescence In scrapings from lesions

Herpes simplex:

Herpes simplex Treatment of genital herpes Aciclovir Primary infection Oral dose is 200 mg five times daily for 5 or more days Recurrent infection Long-term prophylactic Dose of 400 mg twice daily for 4–6 months Famciclovir Valaciclovir Vaccines Under development

Human papillomaviruses (HPV):

Human papillomaviruses (HPV) Small 50 to 55-nm-diameter DNA viruses Infect squamous epithelia Causing cell proliferation (warts) 100 types Vary in their specificity for Anatomical sites Anogenital warts Type 6(75%) Type 11

Human papillomaviruses (HPV):

Human papillomaviruses (HPV) Warts HPVs can infect any site in stratified squamous epithelium Either keratinizing (skin) or Non-keratinizing ( mucosa ) Incubation period Few weeks to more than a year Modes of transmission Direct or indirect contact Impairment of epithelial barrier function Trauma Maceration Genital warts Sites subject to greatest coital friction

Human papillomaviruses (HPV):

Human papillomaviruses (HPV) Typical anogenital wart is Soft, pink, elongated Sometimes filiform or pedunculated Usually multiple Often asymptomatic Large malodorous masses Vulvar and perianal skin Commonest sites Men Frenulum Corona and glans Women Posterior fourchette

Human papillomaviruses (HPV):

Human papillomaviruses (HPV) Non-mucosal surfaces Warts are Pigmented Penile shaft, pubic skin, Perianal skin and groins Management Cytotoxic agent Podophyllotoxin 0.5% solution , 0.15% cream Physical destruction Cryotherapy (liquid nitrogen, cryoprobe ) Trichloroacetic acid (TCA) 80–90% solution Electrosurgery Scissors excision Laser vaporization Immunomodulatory Imiquimod 5% cream

Human papillomaviruses (HPV):

Human papillomaviruses (HPV) For Anal Warts Cryotherapy TCA 80 %–90 % Surgical removal For External Genital Warts Patient-Applied: Podofilox Imiquimod 5% cream Provider-Administered: Cryotherapy Podophyllin resin 10%–25% Trichloroacetic acid (TCA) 80%–90%. Surgical removal

Human papillomaviruses (HPV):

Human papillomaviruses (HPV) For Vaginal Warts Cryotherapy TCA 80 %–90% For Urethral Meatus Warts Cryotherapy Podophyllin 10%–25%

Human papillomaviruses (HPV):

Human papillomaviruses (HPV) FLAT OR PAPULAR NODULAR Consider ▪ Condylomata acuminata ▪ Bowenoid papulosis ▪ Sebaceous glands ▪ Pearly penile papules ▪ Lichen planus ▪ Lichen sclerosus et atrophicus Rule Out ▪ Erythroplasia ▪ Extramammary Paget's disease ▪ Condylomata lata of secondary syphilis Consider ▪ Nevi ▪ Seborrheic keratosis ▪ Angiokeratoma ▪ Skin tags Rule Out ▪ Squamous cell carcinoma ▪ Amelanotic melanoma Differential Diagnosis of Genital Warts

Thank you:

Thank you

STI Syndromic Case Management:

STI Syndromic Case Management Patient complains of urethral discharge or dysuria Take history and examine Milk urethra if necessary Discharge confirmed? Treat for gonorrhoea and chlamydia Any other genital disease? Yes No flowchart for urethral discharge

STI Syndromic Case Management:

STI Syndromic Case Management