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Sexually Transmitted Diseases

are infections that are passed from one person to another through sexual contact

infection

w MO but no sx

most commonly used in the medical field

px can be contagious and carry the potential for the disease to develop

not all STIs could develop into a disease

disease

w MO and w sx

all STDs are preceded by STI

Causes

bacteria, parasites, yeast, and viruses

most STDs affect both men and women, but in many cases, the health problem they
cause can be more severe in women

pregnant woman and have STD → serious health problem in babies

reproductive system in women is more complex → a lot of target sites and

organs for diseases to develop

STDs

Syphilis

Gonorrhea

Chlamydia

Genital Herpes

Human Papilloma Virus

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 Trichomoniasis

caused by a protozoan (parasite)

women → foul-smelling vaginal discharge, genital itching, painful

urination

treatment = Metronidazole 500mg bid for 7d

men → typically don't have sx

treatment = Metronidazole 2g sid po for 7d

alternative for metronidazole = Tinidazole 2g po sid

📌 there are more than 20 different types of STIs

Syphilis
aka The Great Imitator

sx will look like other diseases

can be mistakenly diagnosed if you are just looking at the manifestation

Causative agent

Treponema pallidum

cork-screw shaped spirochete

thrives in moist regions of the body and survives and reproduces only
when there is very little O2 present

easily killed by heat, drying, sunlight, disinfectants

cant be infected by having contact w toilet seats, contaminated bath

towels, or beddings

can live in collected blood for 24 hrs

rare cases of transmission during blood transfusion

Transmission

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 only about 1 in 10 people exposed to the bacterium will develop syphilis

ppl w syphilis can acquire HIV more easily and are transmitted to others

Close personal contact

Sexual contact — horizontal spread

9 out of 10 cases of Syphilis

Transplacental infection of the fetus — vertical spread

mother → baby

Enters minute abrasions/mucous membrane

There are 4 types of Treponema spp.

venereal

T. pallidum

sexual contact

nonvenereal/endemic trepanomatoses

nonsexual diseases

other 3 spp.

Incubation Period — 3 weeks

4 Stages of T. pallidum infection (Primary, Secondary, Latent, Tertiary)

not all patients go through all stages

can infect the genitalia, anus, urethra, lips, mouth

Primary Stage

positive for lesions

chancre — 3 weeks after infection

can take up to 90 days

highly contagious cuz the open wound is steaming w

spirochetes

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 SIGNS AND SYMPTOMS

Swelling of the groins in the glands but not usually sore or tender

painless sore or open sore — aka wet ulcer — will develop

one to a few chancres

Sore heals after a few weeks without treatment

lasts for 3-6 weeks w/o treatment

chancres can appear in the genitalia, cervix, lips, mouth, anus

swollen glands

Transmission

contact w the ulcer

highly contagious stage = presence of open sores

if pregnant → can cross the placenta (ToRCHeS)

birth defect, stillbirth, miscarriage

Secondary Stage

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 the latent period of 3-30 yrs

other symptoms appear 3-6 weeks after the sores appear

after open sores heal

SIGNS AND SYMPTOMS

headaches, general aches

loss of appetite and maybe a fever

fatigue, sore throat, weight loss, swollen glands, muscle pain

dark red rash for a few weeks or months (backs, legs, arms, hands,
feet)

body rash that will last for 2-6 weeks (palms of the hands and
soles of the feet)

Latent (hidden) Stage

1 out of 3 ppl who had untreated syphilis could suffer serious damage to
the nervous system

MO can go to the heart, brain, and other organs

Latent syphilis can last for years

occurs 1-20 years after the start of the infection

a period of time when there are no visible signs or symptoms of syphilis

cuz sores and rashes have already gone, but still have the infection

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 Without tx, the infected person will continue to have syphilis in their
body even though there are no signs or symptoms.

Early latent infection occurred within the past 12 months

early 12 months

Late latent syphilis is where infection occurred more than 12 months ago

late 12 months

important to know the stage cuz tx may differ among the stages

Tertiary Stage

disease may recur

painful permanent ulcers on the skin

lesions on ligaments, joints, and on bones

can attack the nervous system, the heart, and blood vessels that results in
blindness, paralysis, and insanity

neurosyphilis — invasion of the nervous system

at any stage of the infection, syphilis can invade the nervous

system and cause a wide range of symptoms including altered
behavior, headache, difficulty in coordinating muscle movements,
paralysis, sensory deficits, dementia

ocular syphilis can also occur at any stage of the infection

involve almost any eye structure

vision changes, decrease in visual acuity, permanent blindness

Congenital Syphilis

It is acquired after the 1st three months of pregnancy

pregnant mother → fetus or unborn baby

can result in stillbirth, prematurity, and a wide spectrum of clinical

manifestations

Manifestations

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 Serious infection resulting in intrauterine death

Congenital abnormalities, which may be obvious at birth

Silent infection, which may not be apparent until about two years of age

Diagnosis

T. pallidum can’t be grown in vitro

exception of Koch‘s Postulates

obligate internal parasite

requires a mammalian host to survive

absence of mammalian cells, T. pallidum will be killed by the absence of

nutrients, exposed to heat and O2

rabbits are the animal model that is almost exclusively studied in the
laboratory

monkeys are expensive

unlike mice, rabbits develop the s/sx of human primary and

secondary syphilis

testes of rabbits were shown to be particularly susceptible to T.

pallidum infection

📌 the Wassermann reaction for syphilis – actually utilizes a

nontreponemal lipid antigen, cardiolipin, and measures an antibody
that is incapable of interacting with the offending pathogen

Microscopic identification

Dark-field microscopy

Direct fluorescent antibody testing on the specimen (lesions, placenta,

umbilical cord)

Can’t be seen in gram stain

nucleic acid-based amplification assay

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 PCR (polymerase chain reaction) that are used in specialized labs

Serology for screening

VDRL

RPR

Non-Specific Tests

VDRL — Venereal Disease Research Lab

measures the Ab produced when the px comes in contact w T. pallidum

RPR — Rapid Plasma Reagin

measures the Ab

check the progress of tx for active syphilis

after the course of effective antibiotic therapy

see the number of Ab dropping cuz of the lower number of T.

pallidum

antigens are not in treponemal in origin — allows the detection of

antibodies

blood or spinal fluid samples

not specific — can detect HIV, malaria, lupus, and certain types of
pneumonia

need confirmatory test if (+) result

Shows (+) result within 4-6 wks of infection (or 1-2 wks after the primary
chancre appears)

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 A negative test is normal = no Ab present

doesn't necessarily mean the px doesn't have syphilis cuz the Ab may not
be detectable during the early period

not detectable up to 3 months after the infection

depend on the stage of the disease

the test sensitivity to detect syphilis is high — 98% — if it is in the

middle stages

not that sensitive during the early stages

A positive test result may mean you have syphilis

If the test is positive, the next step is to confirm the results with an FTA-
ABS test, which is a more specific

need to confirm cuz it may cross-react if px have other illness

Specific Tests

Treponemal antigens extracted from T. pallidum

FTA-ABS

Fluorescent Treponemal Antibody Absorption

Px’s serum is first absorbed with nonpathogenic treponemes to

remove cross-reacting antibodies before reaction with T. pallidum

pre-absorbed px’s serum is added to the slide and if the px has

been infected w syphilis → Ab will be present → Ab will cross-
react w the antigens added (antigen containing T. pallidum)

with Direct Fluorescent Antibody Testing

a solution containing an antibody and a fluorescent dye is added

to the sample of the cell

if the organism is present in the sample, the Ab sticks and will glow
when viewed under a fluorescent microscope

glow = T. pallidum is present

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 considered as the confirmatory assay w high specificity and
sensitivity

TPHA

T. pallidum hemagglutination Assay

same with T. pallidum Particle Agglutination Assay (TPPA)

Confirms a (+) result with the non-specific test is truly due to syphilis

fewer false (+) results

Treatment

Drug of choice

Penicillin (Benzathine Penicillin G)

long-acting Benzathine Penicillin can cure early stages of syphilis

(primary, secondary, and early latent)

CDC recommends 3 doses of long-acting Benzathine Penicillin at

weekly intervals for late latent or latent syphilis of unknown
duration (dk if early or late)

Tetracycline or Doxycycline (for patients allergic to penicillin)

only acceptable alternatives for late latent or latent syphilis of

unknown duration

Doxycycline 100mg po bid

Tetracycline 500mg po qid for 28 days

Primary and secondary syphilis among px w HIV

Benzathine Penicillin 2.4 million units IM in a single dose

confirmed or highly probable congenital syphilis

aqueous crystalline Pen G (aka Procaine Pen G) is given via IM in a

single daily dose for 10days

if Procaine Penicillin cant be given, alternative is Tetracycline and

Doxycycline

don't give Tetracycline to babies cuz of SE so Doxycycline

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 A person usually cannot transmit syphilis 24 hours after starting
treatment

treatment will cure the infection but will not repair any damage that had
already been done

only prevent further damage

management of sex partners

anyone treated w syphilis should not have sex until there are sores
or rashes that are not yet completely healed cuz still contagious
even after treatment

can have reinfenction

sexual transmission of T. pallidum is thought to occur when

mucocutaneous syphilitic lesions are present

person exposed to a px having primary, secondary, or early latent syphilis

should be evaluated

inform sexual partner confidentially

need to undergo clinical and serological test for them to be treated

Gonorrhea
colloquially known as the “clap”

clap refers to the old Frecnh term “clapier”, which means brothel

gonorrhea was thought to be easily spread in these places

“Tulo” in Filipiino

common infection in young ppl

Causative agent

Neisseria gonorrhoeae

a gm (-) diplocococcus

Transmission

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 not spread by kissing, hugging, sharing of bath towels, use of swimming pools,
toilet seats, sharing of cutleries or plates cuz they cant survive outside the body

Sexual contact from person to person

Infected mother to the baby during childbirth

does not cross the placenta

only when they pass thru the birth canal

Risk of Infection after single intercourse:

50% — women

acquisition site involves multiple mucosal sites in the lower female

genitalia (urethra, cervix, bartholin glands, ractal, pharynx, conjunctiva)

20% — men

Symptoms

sometimes, ggonorrhea may not exhibit symptoms but can cause serious health
problems even w/o sx

Develops within 2-7 days of infection

Women –— almost always asymptomatic (or mild sx) — or usually mistaken

as a bladder or milder vaginal infection

vaginal discharge

pelvic inflammatory disease (PID)

many organs in the reproductive system are inflamed

Chronic pelvic pain

heavy bleeding during menstruation, bleeding between menstrual periods,

pain during sexual contact, pain or burning when passing urine

Men — urethral discharge (TULO) and dysuria

Infertility

especially in women (PID)

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 infection in women’s reproductive organs above the cervix,
nagkakaroon ng damage or inflammation in the fallopian tubes or
ovary

untreated gonorrhea (esp w PID) → infertility, pregnancy problem,

pelvic pain

Diagnosis

Microscopy and culture of discharges and other specimens

gm (-) intracellular diplococci

swab sample

part of the body infected (cervix, urethra, penis, rectum, throat)

urine test

gram staining

Antibiotic susceptibility test

performed cuz of the development of resistance of N. gonorrheae to a lot

of antibiotics

Serologic tests are unsatisfactory

Treatment

The incidence of resistance is increasing

recommended antibiotics

Penicillin — previously DOC of N. gonorrheae

discovered to have developed resistance mediated by plasmid

production of beta-lactamase

Ciprofloxacin

tx w quinolones (e.g. levofloxacin) — mainstay tx for N.

gonorrheae in the US

removed cuz of resistance

*Ceftriaxone

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 CDC recommends a single dose of 500mg IM Ceftriaxome

Alternatives

Gentamicin + Azithromycin

cephalosporin allergy

Cefixime

if Ceftriaxome is not available

Cefixime 800mg po in a single dose

Prophylactic use has no effect in preventing sexually acquired gonorrhea

Ophthalmic antibacterial agents are effective for babies born to mothers with
gonorrhea — gonorrheal ophthalmia neonatorum

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 Prevention if the mother is known to have gonorrhea and the baby is born
(normal or cesarean birth)

lower risk if birth thru cesarean section

C section is advised when the mother is known to have STD

Erythromycin is given immediately after birth

little risk of developing uncomplicated gonococcal infection among infants

and children

Chlamydia
most widely commonly reported STD in the US — along w Herpes

easy to cure, but when left untreated, can lead to infertility in women

Causative agent

Chlamydia trachomatis

gm (-) bacterium

infects the epithelium of the cervix, urethra, rectum, lungs, and eyes

cause of most frequently reported STD and most ppl w this infection are
asymptomatic

untreated infection → PID → infertility, ectopic pregnancy

Serotypes

A, B, Ba, C — eye infection (trachoma) → blindness

D-K — urethritis, PID, ectopic pregnancy, neonatal pneumonia or neonatal

conjunctivitis

cause genital infection and associated ocular and respiratory

infections

L1, L2, L3 — LGV (Lymphogranuloma venereum)

px may notice changes in the genital area

genital papules, ulcers, swelling of the lymph glands

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 Transmission

sexual intercourse

ocular-genital contact through the birth canal

Clinical Effects

most women are asymptomatic but can cause PID → urethritis, cervicitis,
salpingitis, conjunctivitis, bartholinitis

salpingitis — inflammation of the fallopian tubes

bartholinitis — infection of the Bartholin’s glands (located on either

side of the vagina behind the labia)

symptomatic in men (urethritis, epididymitis, proctitis, conjunctivitis)

epididymitis — inflammation of the epididymis (tube located at the

back of the testicle where the tube stores and carries sperm)

proctitis — inflammation of the lining of the rectum

Diagnostic Tests

cell culture

direct antigen detection (Direct EIA)

aka Enzyme Immunoassay (EIA), Enzyme-Linked Immunoassay

detection of chlamydial antigen in the specimen

microscopically

stained with fluorescein-conjugated monoclonal antibodies and viewed

by UV microscopy — direct fluorescent antibody (DFA)

fluorescein is an organic compound that is used as a synthetic

coloring agent

nucleic acid amplification test (NAAT)

amplification of the DNA that is present in Chlamydia trachomatis

more sensitive and more specific than other tests for chlamydia

performed w the use of urine from both men and women

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 eliminates the need for pelvic examination in women

Treatment

chinecheck if may other STI para combination ibibigay

Chlamydia is not susceptible to beta-lactam antibiotics

in pregnancy or breastfeeding

Azithromycin, Erythromycin, Amoxicillin

Doxycycline/Tetracycline — which is also recommended for patients infected

with gonorrhea

Erythromycin should be used for babies

3-5 weeks after the medication, the physician usually recommends another test
for chlamydia to ensure that the tx has been effective and the infection has
been cleared

if it is deemed safe for the px = single dose of Azithromycin, 1-week course

of Amoxicillin or Erythromycin

Genital Herpes
commonly caused by HSV through sexual contact

after the initial infection, the virus will lie dormant in the body and become reactive
several times a year

can cause pain, itching, and sores in the genital area

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 Causative agent

HSV1

transmitted by saliva causing oropharyngeal infection in children and

later life, after reactivation, cold sores

oral herpes → cold sores, blisters around the mouth, fever

can spread from the mouth → genitalia

HSV2

venereal route

transmitted thru sexual intercourse

Transmission

open sores

saliva from a partner w an oral herpes infection

genital fluid

skin in the oral area of a partner w oral herpes

skin in the genital area of a partner w genital herpes

Clinical Manifestations

no to mild symptoms (can go unnoticed) or mistaken for other skin conditions

(pimples)

usually appear 1 or more blisters around the genitals, mouth, and rectum
— blister outbreak

can leave a painful sore that may take a week or more to heal

Primary genital lesion (penis or vulva) 3 – 7 days after infection

Vesicles that break down to form painful ulcers

Local lymph nodes are swollen

Fever, headache, malaise

Diagnosis

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 ulcer swabs

ELISA method

detect and measure Ab in the blood

Ab related to the condition

screening tool before an in-depth test is ordered

sample will be added w an antigen related to the condition it is being tested

if blood has Ab → react w antigen added to the sol’n

have to check if Ab bound to the antigen by adding an enzyme

enzyme usually changes color when the Ab in the sample reacts w

the antigen

reporter enzyme — report the presence of Ab bound to antigen

by the change in color

Clinical appearance

Treatment

no cure cuz its a virus

symptomatic treatment only

Acyclovir

oral to reduce the frequency of recurrence

IV for systemic complications

Famciclovir, Valacyclovir

Human Papilloma Virus

common STI

Papillomavirus can infect the skin or mucosal surfaces

Types 6, 11, 12, 16, 18 and 31

some types can cause health problems from genital warts to severe cancer

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 Transmission

vaginal or anal sex

close skin to skin contact during sexual intercourse

can be contagious even w/o sx

Transmitted sexually and cause genital warts

Warts (condylomata acuminata) appear on the penis, vulva, and perianal

regions

Best removed by a laser, acetic acid wash, and cauterization

Associated with cervical cancer (types 16 and 18)

Papanicolaou

George Papanicolou pioneered the cytopathology and early cancer detection

who developed the pap smear test

A pap smear is used to detect abnormal cells which may develop into cancer

screening for cervical cancer

the doctor will insert a speculum (metal or plastic), which helps in holding
the walls of the vagina apart to allow a clear view of the cervix

sample of the mucus and cells will be scraped off from the cervix or
endocervix using a spatula or small surgical brush

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 sample of cells is evenly applied on a glass slide → spray a fixative →
microscopic examination

Pap smear result

(-) = normal cervical cells

(+) = abnormal or unusual cells

doesn't always mean px has cancer, needs confirmatory

depends on the type of cells

atypical squamous cell of undetermined significance

thin and flat cells that grow on the surface of a healthy cervix

squamous intraepithelial lesions

pre-cancerous

may take years to become cancerous

minor changes in the size, shapes, and characteristics of the

cells

atypical glandular cell

unclear if cancerous

further testing will be required to check if the cell is cancerous

squamous cell cancer

sure cancer

pap smear that is so abnormal that the cytologist is almost

sure that cancer is present

basta abnormal cell → doctor will perform colposcopy

procedure in which a special magnifying instrument, a

colposcope, is used to examine tissues in the cervix, vulva, and
vagina to rule out if cancer or noncancer type

A cervical examination to detect warts and other abnormal growths which

become visible as white patches of skin

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 STD

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