SUBJECT Medicine TOPIC Sexually Transmitted Infections LECTURER Dr. Gabriel (June 23, 2008) TRANSGROUP Kapitan Boom and Friends STD STATISTICS

 WHO has estimated about 315 million

cases of the curable STD occur each year in the world  SOUTHEAST ASIA estimate between 9-17% of individuals aged 15-49 may acquire an infection in any one year  USA STD Cases o CDC estimates 19 million new infection occur each year o About 8.5 million among young people ages 15 to 24 yrs o $14.7 billion for direct medical cost each year in US o In 2006, chlamydia, gonorrhea & syphilis are the three notifiable STD in US  STD Cases Worldwide o Certain STD’s (syphilis, gonorrhea, HIV, Hep B, chancroid) are most concentrated within “core populations” having high rates of partner change, concurrent partners or “dense” sexual networks like prostitutes and their clients and persons involved in the use of illicit drugs. EPIDEMIOLOGY OF STD Factors that determine the spread of STD’s 1. rate of exposure 2. efficiency of transmission per exposure 3. duration of infectivity of those infected Host factors on the spread of STD 1. Risk behaviors 2. Socio-economic 3. Beliefs & Gender identification “PHILIPPINES have started to provide STI data which might be under reported. “Guesstimate suggest that STD are quite common” Current problems of STI detection in the Philippines Reports from social hygiene clinics were obtained from select high risk groups

Social hygiene clinics do not have laboratory capability to perform diagnostic screening test  Lack of equipment and reagents for STD testing  Private practitioner were reluctant to report STD to DOH  Problems on data result from inadequate training of doctors, nurses & midwife STD in the Philippines  In Philippines, STI prevalence from 1999 to 2002 of chlamydia infection among high risk group (registered female sex workers) was 27-36%; and in general population group was 5.75% in women and 4.4% in men.  Factors related to transmission include extramarital relationships, multiple sex partners and low condom use in men. Young people have relatively high prevalence.  Most men would never divulge their STI status to their partners, thus, making women more vulnerable to STIs.  Transmitted in Adults by Sexual Intercourse Viruses Others Neisseria Trichomonas gonorrhea HIV 1 & 2 vaginalis Chlamydia Phthirus trachomatis HTLV 1 pubis Herpes Treponema simplex palidium Type 2 Human Hemophylus papilloma ducreyi virus Calymmatobacter ium granulomatis Hepatitis B Molluscum Ureaplasma contagiosu urealyticum m Risk-behavior Practices Multiple Partners Men Having Sex with men STD SURVEILLANCE Number of STD Cases per Year (1999 - 2004) 19 20 20 20 20 2
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SUBJECT Medicine TOPIC Sexually Transmitted Infections LECTURER Dr. Gabriel (June 23, 2008) TRANSGROUP Kapitan Boom and Friends 99 Gonorrhea Syphilis Nonspecific Trichomoni asis Candidiasis Bacterial Vaginosis Herpes Venereal Wart Hepatitis B 11 23 268 38 3 155 10 859 00 198 99 2 376 11 516 17 2 13 9 01 211 129 2 404 4 399 24 3 31 31 02 266 108 4 321 8 491 24 2 18 24 03 257 65 7 534 2 163 1 1 29 25 2 63 28   STD CLASSIFICATION      Urethritis & Urethral discharges in men Vaginal discharges Genital ulcers Genital lesions Blood-borne STIs  Bleeding between periods Creamy or green, pus-like or bloody vaginal discharge Excessive bleeding during menstrual period Irritation of the vulva Lower abdominal pain Pain during intercourse Painful urination Gonorrhea in Women 004 221 64 7 371 0 62

 

CLINICAL STDs Genital Discharges Gonococcal Urethritis

 

 Caused by Neisseria gonorrhea which can
be cured with antibiotics

 Spread is through vaginal, anal, or oralgenital contact with an infected person

 Most women and an increasing no. of men
exhibit no symptoms at all

 Impossible to catch Gonorrhea from toilet
seats, towels, drinking cups, etc.

 If symptoms do appear, they will be 2
days to 2 weeks after sexual contact

Neisseria gonorrhoeae Cervix, Urethra, Rectum Treatment:
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 Copious

and grossly sometimes blood- stained



Cefixime 400 mg Ceftriaxone 125 IM

SUBJECT Medicine TOPIC Sexually Transmitted Infections LECTURER Dr. Gabriel (June 23, 2008) TRANSGROUP Kapitan Boom and Friends Ciprofloxacin 500 mg Ofloxacin 400 mg/Levofloxacin 250 mg Target Popula tion High Risk Groups Monzo n, 1991
13 % N=936 Manila FSW

FHI, 1994
17.3 % N=311 Manila 22.7 %; N=297

Agdama g, 1996
15.5 % FSW

FHI, 1999
36% N=450 Angeles City FSW

PLUS Chlamydial therapy if infection not ruled out

Femal e

Chlamydia Infection

 The most prevalent STD worldwide & can
coexist with gonorrhea and other STD

Cebu FSW

 Prevalence is highest in younger age 1525 years and most likely to experience complications and long term sequelae.  In women: over 50% with gonorrhea and 70% with Chlamydia had no symptoms In men: 68-92% with gonorrhea and 92% with Chlamydia reported no symptoms In men, the infection may cause urethritis, epidimytis, proctitis, Reiter’s syndrome (arthritis) and infertility.


12 % N=100 Angeles City; 16% N=100 FSW

Target Popula tion

Low Risk Groups FHI, 1994
5.6 % N=203 Antena tal women

Agdam ag, 1996
2.5 %

Aplasca, 1998
11.7 % N=308 Antenata l Baguio; 9.6% N=343 Cebu; 7.5 %

FHI, 2002
5.75 % N=300 Gen pop; Selected sites; 7.7% youth

Femal e

Prevalence Studies on Chlamydia Trachomatis Infection Among Population Groups

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SUBJECT Medicine TOPIC Sexually Transmitted Infections LECTURER Dr. Gabriel (June 23, 2008) TRANSGROUP Kapitan Boom and Friends
N=349 Davao


4.6 % N=349 Baguio; 2.1% N=343 Cebu; 2.3% N=349 Davao

4.4 % N=300 Gen pop; selected sites; 9 % youth

Since transmitted through sexual intercourse, babies can also be infected while passing through the birth canal of an infected mother.

Treatment Azithromycin 1 gm in a single dose or Doxycycline 100 mg bid x 7 days

Clinical Features  Gonorrhea bacteria and chlamydia are both

  In women, symptoms include: genital itching and burning, vaginal discharge, dull pelvic pain, bleeding between periods, and cervical inflammation men, symptoms include: mucus discharge from the penis (gradual onset five to twenty-one days after exposure) and painful urination

The symptoms of gonorrhea chlamydia are very similar


Men and women often complain of a discharge, frequent urination, or burning when they urinate In gonorrhea the discharge is often white or yellow, in chlamydia the discharge is usually clear Both gonorrhea and chlamydia are spread by coming in contact with the discharge

 In

 Again, these symptoms may be so mild
that a man may not notice them  Women can develop Pelvic Inflammatory Disease (PID) trachomatis predisposes women to develop PID secondary to prolonged colonization of the microorganism to the pelvic region since most cases are asymptomatic and did not receive treatment. At the same time, the proliferation of Chlamydia at the cervix and vagina predisposes the child to be infected affecting the mucous membrane of the child. Increased danger of having an ectopic pregnancy

 If a woman is not treated for either of
these diseases, it could lead to a severe infection in her reproductive organs which could cause infertility

 Chlamydia

Bacterial Vaginosis

Gray or discharge




mixed with 10% KOH  Change of vaginal ph to alkaline (>4.5)

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 Fishy or musty odor after sex or when

SUBJECT Medicine TOPIC Sexually Transmitted Infections LECTURER Dr. Gabriel (June 23, 2008) TRANSGROUP Kapitan Boom and Friends    Clue cells Lack of lactobacillus Multiple partners

 Douching

 In severe cases the vaginal walls and
cervix show the classical “strawberry” appearance with punctate bleeding erosions

Treatment Recommended: Metronidazole 500mg PO BID x 7 days Alternative: Metronidazole gel 0.75% or 1 full applicator (5gms) intravaginally at HS x 7days Treatment Regimens Trichomoniasis Agent and Regimen Metronidazole PO   Yellowish, frothy, fishy odor Severely itchy, vulva becomes edematous and excoriated vaginal and cervical punctate hemorrhages, asymptomatic Highly associated with gonorrhea Highly motile vaginalis flagella: Trichomonas Candidiasis
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2g single dose 500 mg BID x 7 days Metronidazole intravaginal Clotrimazole intravaginal

82-88% 95% <50% 25-60%

 

 

Severe itchiness Whitish curdlike discharges

SUBJECT Medicine TOPIC Sexually Transmitted Infections LECTURER Dr. Gabriel (June 23, 2008) TRANSGROUP Kapitan Boom and Friends
   Vulva is thickened due to chronic scratching Seen in 20% of healthy childbearing women Source: anal area, GIT

It is contagious as long as the infected person has any open sores Spread can be prevented by use of condoms, limit the number of sex partners, wash the genitals after sexual relations & if infected AVOID SEXUAL CONTACT

Treatment o Intravaginal Agents
Clotrimazole 1% cream, 5gms intravaginally x 7-14 days or Clotrimazole 100mgs vaginal tablet x 7 days


Oral Medication
Fluconazole 50 mgs OD x 7 days

GENITAL ULCERS Genital Ulcer Disease… Does It Hurt?  Painful – – – Chancroid Granuloma inguinale Genital herpes Treatment Azithromycin 1 gm orally or Ceftriaxone 250 mg IM in a single dose or Ciprofloxacin 500 mg twice daily x 3 days or  – – Painless Syphilis Lymphogranuloma venereum Management Considerations  Re-examination 3-7 days after treatment  Time required for complete healing related to ulcer size  Lack of improvement: incorrect diagnosis, co-infection, noncompliance, antimicrobial resistance  Resolution of lymphadenopathy may require drainage  Examine and treat partner whether symptomatic or not if partner contact < 10 days prior to onset Syphilis Erythromycin base 500 mg tid x 7 days

Chancroid ( Soft Chancre )

Common among sexually active men, particularly uncircumscised males Painful sores that eventually rupture leaving open sores Symptoms usually appear four to seven days after exposure

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SUBJECT Medicine TOPIC Sexually Transmitted Infections LECTURER Dr. Gabriel (June 23, 2008) TRANSGROUP Kapitan Boom and Friends –  Syphilis is caused by a bacterium Treponema Pallidum In US, over 32,000 reported cases in 2002, highest among women 20-24 years of age, in men 35-39 years of age Syphilis is passed from person to person through direct contact with syphilis sore Sores occur mainly on the external genitals, vagina, anus & can occur on lips and mouth Syphilis cannot be spread through contact with toilet seats, doorknobs, swimming pools, bath tubs, towels and eating utensil HIGHLY INFECTIOUS

2. Secondary Syphilis  Clinical Manifestations • Represents hematogenous dissemination of spirochetes • • – – – – Usually 2-8 weeks after chancre appears Findings: rash - whole body (includes palms/soles) mucous patches condylomata INFECTIOUS lata HIGHLY

 Clinical symptoms will be based on
different stages: primary secondary and tertiary  stage,

Complications can occur based on the severity of the infection even affecting pregnancy

constitutional symptoms Sn/Sx resolve in 2-10 weeks

1. Primary Syphilis  Clinical Manifestations • • Incubation: 10-90 days (average 3 weeks) Chancre

Early: macule/papule → erodes

Late: clean based, painless, indurated ulcer with smooth firm borders Unnoticed in 15-30% of patients Resolves in 1-5 weeks
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– –

SUBJECT Medicine TOPIC Sexually Transmitted Infections LECTURER Dr. Gabriel (June 23, 2008) TRANSGROUP Kapitan Boom and Friends *Use in HIV-infection has not been studied

Syphilis Treatment: Latent Stage Recommended regimen Benzathine penicillin G 2.4 million units IM at one week intervals x 3 doses Penicillin allergy* Doxycycline 100 mg orally twice daily or Tetracycline 500 mg orally four times daily -Duration of therapy 28 days; close clinical and serologic follow-up; data to support alternatives to pcn are limited GENITAL LESIONS Syphilis Treatment: Primary, Secondary, Early Latent Recommended regimen Benzathine Penicillin G, 2.4 million units IM Penicillin Allergy* Doxycycline 100 mg twice daily x 14 days or Ceftriaxone 1 gm IM/IV daily x 8-10 days (limitedstudies) or Azithromycin 2 gm single oral dose (preliminary data) Genital Herpes

3. Tertiary Syphilis  Clinical Manifestations • The latent (hidden) stage of syphilis begins when secondary symptoms disappear. Even without signs & symptoms in this stage, the infection may subsequently damage the brain, nerves, eyes, heart, bones and joints

 Caused by Herpes Simplex Virus (HSV1 &
  HSV2) but most genital herpes is caused by HSV2 Typically occur as one or more blisters on or around the genitals & rectum The blisters break resulting to ulcerative form which may take two to four weeks to heal the first time to occur Genital HSV2 is more common in women than in men, however transmission is more to men-to-female Complications are recurrent painful genital sores in many adults Genital HSV can cause potentially fatal infections in babies Diagnosis: PE. Culture, Serology, PCR Preventive measures: correct and consistent use of condoms

   

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SUBJECT Medicine TOPIC Sexually Transmitted Infections LECTURER Dr. Gabriel (June 23, 2008) TRANSGROUP Kapitan Boom and Friends HPV Infection in Men: o One or more growths on the penis, testicles, groin, thighs or anus o Warts maybe raised, flat or cauliflower usually may appear within weeks or months after sexual contact o If ever there are symptoms, they are anal bleeding, itching or discharge o Transmission: genital contact, most often during vaginal and anal sex HPV Infection in Women o Warts affect the vulva, cervix, groin, anus and thighs o Transmission: sexual contact or through oral sex o Routine Pap smear screening in the U.S. has decreased cervical cancer incidence by more than 70%. o HPV vaccine is recommended for girls between 9 – 26 but the schedule is best between 11- 13 years

Treatment o Acyclovir 400 mg tid o Famciclovir 250 mg tid o Valacyclovir 1000 mg bid o Duration: 7-10 days Granuloma Inguinale Chronic infection caused by a rodshape bacterium  Common among tropical countries, where it is associated with poverty and poor hygiene  Most affected are ages between 20-40 years  2:1 (male to female)  Incubation Period: 8 days – 12 weeks  Disease growing slowly beginning as a pimple or lumpy eruption 


Treatment o Doxycycline 100 mg twice daily x 3 weeks or more o Trimethoprim-sulfamethoxazole 800 mg/160 mg twice daily x 3 weeks or more o Minimum treatment duration three weeks Human Papilloma Virus

Hepatitis B

 Implicated to STD’s & HIV through
semen and saliva

 Possibly by very intimate sexual
contact through perinatal transmission

 Causally associated with cervical
cancer and other anogenital squamous cell cancers (anal, vulvar, vaginal, penile) Over 99.7% of cervical cancers are associated with HPV
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SUBJECT Medicine TOPIC Sexually Transmitted Infections LECTURER Dr. Gabriel (June 23, 2008) TRANSGROUP Kapitan Boom and Friends

HIV in Body Fluids

Blood 18,000

Semen 11,000

Vaginal Fluid 7,000

Amniotic Fluid , 4000

Saliva 1

Average number of HIV particles in 1 ml of these body fluids


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