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Excerpts taken from: https://www.uptodate.


Sexually transmitted infections (STIs)

STIs are a major public health problem in both resource-rich and limited settings. STIs are frequently asymptomatic and can
lead to various complications. The immediate goal of screening for STIs is to identify and treat infected persons before they
develop complications and to identify, test, and treat their sex partners to prevent transmission and reinfections.
Complications of untreated STIs include upper genital tract infections, infertility, chronic pelvic pain, cervical cancer, and
chronic infection with hepatitis viruses and HIV. The approach to STI diagnosis and management is based upon disease or
symptom-specific syndromes, including vaginal discharge, urethral discharge, ulcerative genital disease, nonulcerative genital
disease, and pelvic pain. However, many patients have asymptomatic disease, which increases the risk of complications and
sustained transmission in the community. Thus, screening is an important approach to identify and treat infected individuals,
who would otherwise go undetected. Routine screening for all potential STIs in all patients is cost-prohibitive; targeted
screening of asymptomatic patients in specified risk groups is more feasible.
Risk factors — Risk factors for STIs include both sexual behavior that increases the risk of exposure to STIs and risk groups that
have a high prevalence of STIs. Behavioral risk factors include:

• New sex partner in past 60 days

• Multiple sex partners or sex partner with multiple concurrent sex partners
• No or inconsistent condom use when not in a mutually monogamous sexual partnership
• Trading sex for money or drugs
• Sexual contact (oral, anal, penile, or vaginal) with sex workers
• Meeting anonymous partners on the internet

Risk groups are demographic groups identified as having a high prevalence of STIs.
• Young age (15 to 24 years old)
• Men who have sex with men (MSM)
• History of a prior STI
• Unmarried status
• Lower socioeconomic status, or high school education or less
• Admission to correctional facility or juvenile detention center
• Illicit drug use

Sexual history: In the assessment of STI risk, it is important to obtain a thorough sexual history including:

• Partners
• Any new sexual partner
• History of multiple sexual partners
• Sexual partners with concomitant partners
• Practices
• History of sexual intercourse with trauma
• Anatomic sites of exposure (this will guide decisions about which mucosal sites to test diagnostically)
• Protection from STIs
• Frequency of condom use
• Past history of STIs
• History of any STIs, including genital ulceration, which can increase the risk of HIV acquisition
The history should be straightforward and non-judgmental with appropriate counseling regarding risk-taking behaviors, as
necessary. Some medical providers do not routinely obtain a sexual history. In one study, only 70 percent reported "always"
or "almost always" obtaining a sexual history in adolescent females.

Excerpts taken from:

Clinical manifestations and diagnosis of Chlamydia trachomatis infections

Chlamydia trachomatis is the most common bacterial cause of sexually transmitted genital infections. The majority of affected
persons are asymptomatic, and thus provide an ongoing reservoir for infection. Moreover, both men and women can
experience clinical syndromes due to infection at common epithelial sites, including the rectum and conjunctivae.

CLINICAL SYNDROMES IN WOMEN — The majority of women with C. trachomatis infection are asymptomatic, the pathogen is
an important cause of several common clinical syndromes, discussed below.

• Genital infection — the cervix is the most commonly infected anatomic site, a proportion of women may also have
infection of the urethra. Untreated, cervical infection can ascend to cause pelvic inflammatory disease and its
sequelae of infertility and chronic pain. Pregnant women with genital chlamydial infection have a high risk for
• Cervicitis — The majority (~85 percent) of women infected at the cervix have neither signs nor symptoms, which is
the rationale for routine annual screening of young sexually active women. When symptoms occur, they are highly
nonspecific, and can easily be confused with vaginitis or endometrial pathology: a change in vaginal discharge,
intermenstrual vaginal bleeding, and post-coital bleeding.
o Abnormal exam findings are found in the minority of women, ~10-20%. When signs are present, they include
classic findings of cervicitis: mucopurulent endocervical discharge, easily induced endocervical bleeding, or
edematous ectopy.
• Dysuria-pyuria syndrome due to urethritis — Chlamydial infection of the female urethra typically occurs in ~25% of
women with cervical infection. Most of these women do not report symptoms specific to the urethral tract, but some
complain of typical symptoms of a urinary tract infection (UTI) such as frequency and dysuria. Urinalysis reveals
pyuria, but no organisms are seen on Gram stain or in bacterial culture. This combination of pyuria but no bacteriuria
in a young, sexually active woman should prompt strong suspicion for chlamydial infection of the urethra.
• Pelvic inflammatory disease (PID) — C. trachomatis can ascend to the upper reproductive tract, where pelvic
inflammatory disease (PID) can result. When symptoms of PID are present, abdominal or pelvic pain are the most
common, and their presence in the setting of cervicitis or a diagnosis of chlamydial infection should prompt strong
suspicion for upper genital tract involvement. Signs of PID include cervical motion and uterine or adnexal tenderness.
PID due to C. trachomatis is associated with higher rates of subsequent tubal infertility, ectopic pregnancy, and
chronic pelvic pain when compared with PID caused by gonorrhea, which typically causes a more acute symptomatic
• Complications of pregnancy — Beyond the risk of future ectopic pregnancy following chlamydia-associated PID,
chlamydial genital infection during pregnancy can increase the risk for premature rupture of the membranes and
preterm delivery.

• Urethritis — C. trachomatis is the most common cause of nongonococcal urethritis in men. The proportion of
asymptomatic cases vary by population and range from 40-96 %. When men do have symptoms, they typically
present with a mucoid or watery urethral discharge, and dysuria is often a prominent complaint. The discharge is
often clear and only seen upon milking the urethra.
• Epididymitis — C. trachomatis is one of the most frequent pathogens in epididymitis among sexually active men <35
years of age, along with N. gonorrhoeae. Men with acute epididymitis typically have unilateral testicular pain and
tenderness, hydrocele, and palpable swelling of the epididymis.
• Proctitis — Chlamydial proctitis, defined as inflammation of the distal rectal mucosa, occurs primarily in men who
have sex with men MSM who engage in receptive anal intercourse. However, anal intercourse is not uncommon
among heterosexuals, and symptomatic proctitis has also been reported in women.
DIAGNOSIS OF CHLAMYDIAL INFECTIONS — The diagnostic test of choice for chlamydial infection of the genitourinary tract is
nucleic acid amplification testing (NAAT) of vaginal swabs for women or first-catch urine for men, although NAAT can also be
performed on endocervical and urethral swab specimens. The NAAT method detects the nucleic acid of the bacteria causing
the infection, the NAAT test amplifies the nucleic acids present, is rapid to perform, and importantly has high sensitivity and
specificity. If NAAT methods are unavailable, antigen detection and genetic probe methods can be applied to endocervical or
urethral swabs to diagnose chlamydia. If non-NAAT-based testing is used for diagnosis or if adequate follow-up cannot be
insured, patients with signs and symptoms consistent with chlamydia should be treated empirically before diagnostic test
results return.
Whom to test for C. trachomatis:
Symptomatic and at-risk asymptomatic patients: Any sexually active individual with signs and symptoms consistent with the
clinical syndromes associated with chlamydia should undergo diagnostic testing. However, because the majority of chlamydial
infections are asymptomatic, routine screening with NAAT should be offered to sexually active patients at high risk of infection
and complications of chlamydia. This includes:

women < 25 yo pregnant have new or MSM and sexually routine annual screening in any patients with
many sexual active HIV-infected sexually active persons with documented
partners individuals of any age HIV, regardless of age gonococcal infection

Coinfection with N. gonorrhoeae — It is important to note that N. gonorrhoeae not only causes similar clinical syndromes as C.
trachomatis but also coexists in a significant proportion of patients with chlamydial infection. Thus, any testing for C.
trachomatis should also prompt testing for N. gonorrhoeae.
DIFFERENTIAL DIAGNOSIS — Other sexually transmitted pathogens, including, N. gonorrhoeae, Trichomonas vaginalis, and
Mycoplasma genitalium, as well as herpes simplex virus (HSV) and syphilis can cause infections similar to C. trachomatis.

Excerpts taken from

Clinical manifestations and diagnosis of Neisseria gonorrhoeae infection in adults and adolescents
Gonorrhea, or infection with the gram-negative coccus Neisseria gonorrhoeae, is a major cause of morbidity among sexually-
active individuals worldwide. In the United States, it is the second most commonly reported communicable disease, with more
than 350,000 cases reported annually, with probably an equal number of cases that remain unreported. Gonorrhea is a major
cause of urethritis in men and cervicitis in women; the latter can result in pelvic inflammatory disease (PID), infertility, ectopic
pregnancy, and chronic pelvic pain. Gonococcal resistance to several classes of antimicrobial agents is widespread.

Urogenital infection in women: Genital infections, in particular cervical infection, are the most common infections associated
with N. gonorrhoea and can ascend to involve the reproductive organs, causing PID and/or complications of pregnancy.

• Cervicitis: Uterine cervix is the most common site of mucosal infection with N. gonorrhoeae in women. Most women
up to 70 %, are asymptomatic. Symptomatic infection typically manifests as vaginal pruritus and/or a mucopurulent
discharge. Some women may complain of intermenstrual bleeding or menorrhagia. Pain is atypical in the absence of
upper tract infection. Abdominal pain and dyspareunia should raise suspicion for upper genital tract disease. On
examination, the cervix may appear normal or show signs of frank discharge. The cervical mucosa is often friable.
o Importantly, these symptoms and signs of gonococcal cervical infection, when present, are indistinguishable
from those observed with acute cervicitis of other causes.
• Urethritis: N. gonorrhoeae can be isolated from the urethra in up to 90 % of women with gonococcal cervicitis.
Among sexually active adolescent females, urinary symptoms alone, such as dysuria, urgency, or frequency, may be
the presenting complaint.
o As with gonococcal cervicitis, urethral involvement is typically asymptomatic. Main symptom, when present,
is dysuria.
• Pelvic inflammatory disease: PID occurs in ~10 to 20 % of women with cervical gonorrhea, and N. gonorrhoeae is
estimated to be the causative organism in 40 percent of cases of PID. Given the high incidence of asymptomatic
gonococcal infection in women, PID can be the first presenting complaint. Symptoms of PID include
pelvic/abdominal pain, abnormal vaginal bleeding, and dyspareunia. Signs of PID on examination include
abdominal tenderness, uterine tenderness, adnexal or cervical motion tenderness, but these do not distinguish
between gonococcal and nongonococcal etiologies.

• Complications of pregnancy: Urogenital gonococcal infections have been associated with chorioamnionitis, premature
rupture of membranes, preterm birth, low birth weight or small for gestational age infants, and spontaneous
abortions in pregnant women.

Urogenital infection in men: Symptomatic urogenital gonococcal infections in men include urethritis and epididymitis.

• Urethritis: N. gonorrhoeae is a common cause of urethritis. Men with gonococcal urethritis may present with
discharge and/or dysuria. The discharge is often present spontaneously at the urethral meatus, purulent or
mucopurulent in color, and copious in amount. However, the discharge may also be indistinguishable on appearance
from the more subtle manifestations that can be seen with nongonococcal urethritis.
• Epididymitis: Acute unilateral epididymitis can be a complication of gonococcal infection, although more commonly
due to C. trachomatis infection, especially in patients <35 years of age. Combined gonococcal and chlamydial
infections of the epididymis are more frequent than epididymal infections caused by N. gonorrhoeae alone. Unilateral
testicular pain and swelling may be the sole presenting complaints of men with epididymitis, with concomitant
urethritis often discovered during the history and physical examination. Additional testing may be warranted to
distinguish infectious causes of epididymitis from other causes of acute testicular pain (eg, torsion, trauma).
Extragenital infection: N. gonorrhoeae can infect the rectum and pharynx, although infections at these sites are typically

• Proctitis: In men, anorectal gonococcal infections typically occur among MSM who engage in anal receptive
intercourse; they are uncommon in heterosexual men. Gonococcal proctitis in MSM is associated with an
approximately threefold increase in the risk of acquisition of HIV infection.
• In women, N. gonorrhoeae can be transmitted to the anal canal via a genital infection due to the proximity of the
vagina, even in the absence of receptive anal intercourse.
• In both men and women, most cases of anorectal gonococcal infection are asymptomatic. Symptoms and signs of
proctitis, when present, include tenesmus, anorectal pain, rectal fullness, constipation, anorectal bleeding, and
mucopurulent discharge. Gonococcal proctitis cannot be distinguished from other infectious causes of proctitis by
symptoms alone.
Differential diagnosis: Other sexually transmitted pathogens, including C. trachomatis, Trichomonas vaginalis, and
Mycoplasma genitalium, as well as herpes simplex virus (HSV) and syphilis can cause infections similar to N. gonorrhoeae.
Non-sexually transmitted pathogens and even non-infectious processes can also cause urogenital, pharyngeal, and rectal
symptoms similar to N. gonorrhoeae.
Diagnostic approach: The clinical syndromes associated with N. gonorrhoeae are typically diagnosed by history and physical
examination, but a microbiologic diagnosis is required due to the lack of sensitivity and specificity of the clinical diagnosis. In
general, NAAT is the test of choice for the initial microbiologic diagnosis of N. gonorrhoeae infection, although culture remains
an important diagnostic tool when antibiotic resistance is suspected.

Disease Pathogen Signs and Symptoms Transmission
Diagnostic Antimicrobial Drugs
Protozoan Infections of the Reproductive Tract
Trichomoniasis Trichomonas Urethritis, vaginal or penile Sexual contact Wet mounts, Metronidazole OR Tinidazole
vaginalis discharge; redness or soreness NAAT of urine or
of female genitalia vaginal samples Sexual partners should be treated
Viral Infections of the Reproductive Tract
Genital herpes Herpes Recurring outbreaks of skin Sexual contact or Viral culture, Acyclovir OR Famcilovir OR Valacyclovir
simplex virus vesicles on genitalia and contact with open PCR, ELISA
(HSV-1 or elsewhere; asymptomatic in lesions Asymptomatic partners benefit from evaluation and counseling.
HSV-2) many individuals Symptomatic patients should be treated in the same manner of
the affected partner
Human Human Genital warts or warts in other Direct contact, Pap smear Imiquimod OR Podofilox OR Sinecatechins
papilloma’s papilloma areas including sexual
virus (HPV)
various strains
Bacterial Infections of the Reproductive Tract
Chancroid Haemophilus Soft painful chancres on Sexual contact or Observation of Azithromycin OR Ceftriaxone OR Erythromycin OR
ducreyi genitals, mouth, or anus; contact with open clinical symptoms Ciprofloxacin
swollen lymph nodes; pus lesions or discharge and negative
discharge tests for syphilis Regardless of whether symptoms of the disease are present,
and herpes sex partners of patients who have chancroid should be
examined and treated if they had sexual contact with the patient
during the 10 days preceding the patient’s onset of symptoms.
Chlamydia Chlamydia Often asymptomatic; Men: Sexual contact or NAAT of urine Azithromycin OR Doxycycline
trachomatis urethritis, epididymitis, orchitis. contact from mother sample, vaginal
Women: urethritis, vaginal to neonate during swab, culture Treating their sex partners can prevent reinfection and infection
discharge or bleeding, pelvic birth of other partners. Sex partners should be referred for evaluation,
inflammatory disease, testing, and presumptive treatment if they had sexual contact
salpingitis, increased risk of with the partner during the 60 days preceding the patient’s onset
cervical cancer of symptoms or chlamydia diagnosis.
Gonorrhea Neisseria Urethritis, dysuria, penile or Sexual contact Urine sample or Ceftriaxone 250 mg intramuscularly with azithromycin 1 gram
gonorrhoeae vaginal discharge, rectal pain culture, NAAT, orally
and bleeding. PCR, ELISA
Women: pelvic pain, Note: Azithromycin is added to the regimen for possible
intermenstrual bleeding, pelvic additional activity against N. gonorrhoeae (to decrease the risk
inflammatory disease, of development of resistance) and for treatment of potential
salpingitis, increased risk of chlamydia coinfection.
infertility or ectopic pregnancy.
Recent sex partners (sexual contact with the infected patient
within the 60 days preceding onset of symptoms or gonorrhea
diagnosis) should be referred for evaluation, testing, and
presumptive dual treatment. If the patient’s last potential sexual
exposure was >60 days before onset of symptoms or diagnosis,
the most recent sex partner should be treated.
Syphilis Treponema Primary: hard chancre; Sexual contact or Darkfield or Parenterally-delivered penicillin G is the treatment of choice for
pallidum Secondary: rash, cutaneous from mother to brightfield silver all stages of syphilis
lesions, condylomata, malaise, neonate during birth stain examination
fever, swollen lymph nodes; of lesion tissue or The dosage, formulation, and duration of treatment depend
Tertiary: gummas, exudate, upon the stage of disease see table below:
cardiovascular syphilis, treponemal and
neurosyphilis non-treponemal
serological testing
Treatment of syphilis
Parenterally-delivered penicillin G is the treatment of choice for all stages of syphilis
Note: The dosage, formulation, and duration of treatment depend upon the stage of disease
Primary Secondary Early Late Tertiary
syphilis syphilis latent syphilis latent syphilis syphilis Neurosyphilis
Early syphilis Late syphilis
Drug of Choice: Drug of Choice: Drug of Choice:
Penicillin G benzathine Penicillin G benzathine Penicillin G
2.4 million units intramuscularly [IM] 2.4 million units intramuscularly [IM] 3 to 4 million units IV
Single dose Once weekly for three weeks Every four hours or continuous infusion, for 10 to 14 days

Note: IM benzathine penicillin that is administered for other stages of

syphilis does not produce measurable cerebrospinal fluid (CSF) levels
of the drug
Alternate Tx: Alternate Tx: Alternate Tx:
Doxycycline OR Tetracycline Doxycycline OR Ceftriaxone Procaine penicillin G (2.4 million units IM once daily) PLUS probenecid
(500 mg orally four times a day) both for 10 to 14 days
Persons who receive syphilis treatment must abstain from sexual contact with new partners until the syphilis sores are completely healed. Persons with syphilis must notify their sex
partners so that they also can be tested and receive treatment if necessary.