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Penyakit Menular Seksual

(PMS)

Nurrachmat Mulianto, MSc, SpKK
FK UMS

Pemeriksaan pd PMS
• ANAMNESIS :
- keluhan saat dtg
- keadaan umum dirasakan
- riwayat seksual (Coitus Suspectus)
* kontak seksual, di dlm/luar nikah, gonta-ganti
pasang atau kontak seksual multipel
* kontak seks dg pasangan stl gejala
* Frekuensi & jenis kontak seks (homo/hetero)
* Cara hub seks (genito, oro, anal)
* apakah pasangan gejala sama?
- Riwyt peny dahulu yg berhub dg PMS
- Rwyt keluarga : diduga PMS yg ditularkan lwt ibu kpd bayi
- keluhan yg berkaitan dg komplikasi
- Riwyt Alergi Obat

organ genital tdp di rogga pelvis  posisis litotomi.Pemeriksaan Fisik • Inspeksi & Palpasi Pria : tdp kesatuan saluran genital. dg spekulum . organ mudah diraba Wanita : pemisahan saluran urinarius dg genital.

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tetracyclin and spectinomycin • No resistance has yet been reported to ceftriaxone . resulted resistance to penicillin.Gonococcal Infection in The Adults Etiologic Agent : Neisseria gonorrhoeae • Gram negative diplococcus • Non motile • Non spore forming • Some types have independent chromosomal mutation.

Clinical Manifestations • • • • Urethral infection in men Urogenital infection in women Rectal infection Pharyngeal infection .

Complications • Local (Men) :  Epididymitis  Penile lymphangitis  Generalized penile edema  Urethral stricture  Periurethral abscesses .

Complications • Local (Women) : Acute salphingitis Pelvic inflammatory disease Infertility Ectopic pregnancy Bartholin’s gland abscess .

Arthalgia or tenosynovitis 4.Complications • Systemic 1. Disseminated gonococcal infection : skin lesion and joint pain 2. Frank arthritis • Gonococcal endocarditis • Meningitis . Skin lesion is a tender. bullae or echymoses 3. necrotic pustule on an erythematous base.

Treatment : Uncomplicated
• Ceftriaxone 250 mg i.m once
• Cefixime 400 mg orally once
• Cyprofloxacin 500 mg once
• Ofloxacin 400 mg once
Plus
Coinfection with C. Trachomatis
Doxycycline 100 mg orally 2 times a day for 7
days
Alternative regimen :
 Spectinomycin 2 gr i.m single dose

Treatment
Disseminated Gonococcal
Infection :
• Hospitalization
• Ceftriaxone 1 gr/24 hours for 7 days

Or
• Cefotaxime 1 gr/8 hours i.v
• Ceftizoxime 1gr/8 hours i.v
• Spectinomycin 2 gr/12 hours

 for a week

Treatment
Gonococcal Meningitis :
Ceftriaxone 1 – 2 gr/12
hours for 14 days
Gonococcal Endocarditis :
At least 4 weeks

Chlamydia Trachomatis Infection in The Adults Etiologic agent : Chlamydia trachomatis strain D – K • Obligate intracelluler • An unique growth cycle : Elementary body Reticulate body .

Polakisuria 3. Reiter’s syndrome : a) Uretritis b) Conjunctivitis c) Arthritis d) Mucocutaneous lesion .Clinical Manifestations • Men : 1. Discar seropurulen 4. Disuria ringan 2.

Nyeri di daerah pelvis 5. Asimptomatik 2. Disuria ringan 3. Sering kencing 4. Disparenia .Clinical Manifestations • Women : 1.

i.d for 7 days • Erythromycin ethyl succinate 800 mg q.d for 7 days .Treatment Recomended regimen : • Doxycycline 100 mg twice for 7 days • Azithromycin 1 gr orally once Alternative regimen : • Ofloxacin 300 mg twice for 7 days • Erythromycin base 500 mg q.i.

SIFILIS • Syphilis is a systemic infx dis caused by Treponema Pallidum • The infx is acquired trough : – sexual contact with infected lesion or body fluids – Transplacentally (less common) – Blood transfusion – Accidental innoculation – Puncture  tatto .

STRUKTUR TREPONEMA • btk helically coiled • Sel corkscrew-shaped pembuka tutup botol • panjang 6-15 m. & silinder protoplasmik Treponema dibagi mjd spesies yg patogen & non patogen . lebar 0.2 m • mempunyai outer membrane dikelilingi flagella. membr sitoplasma peptidoglikan.1-0.

Spesies yg patogen • Treponema palidum subs pallidum  sifilis • Treponema palidum subs pertenue  frambusia • Treponema palidum subs endemicum  sifilis endemik • Treponema carateum  pinta Non patogen  sbg flora normal Pada GIT. oral cavity. genital . tract.

2. blood transfusion • In endemic treponematosis  direct or indirect non-veneral contact in early childhood .Transmission of Infection 1. 4. Congenital Non-venereal Doctor/nurses without gloves. Sexual Accidental : 3. Laboratory workers.

recc stage and early latent stage.Classification of Syphilis (for therapeutic/epidemiologic) • Early Infectious phase (diagnosed in first year of infx) : S I. . S II. of • Late non-infectious (dx after the end first year infx): late latent stage and tertiary stage.

12 wk ) Early Latent  relapsing ( in 25%) ( 1 yr from contact ) Late Latent ( more than 1 yr ) Remission ( 2/3 ) Late Benign (16 %) Cardiovascular (9. Secondary organ involvement) ( mucocutanoues ( 4 .5%) Tertier (1/3) .STAGES OF SYPHILIS: Contact (1/3 become infected) ( 10-90 days) Primer ( Chancre) ( 3-12 wk) lesion.6 %) Neurosyphilis (6.

reguler. rubbery borders .1. sharply demarcated. PRIMARY SYPHILIS • Incubation period  10-90 days ( 3 weeks)  dusky red macules  papules  chancre wt ulcerate in center • Chancre  round/oval. raised. firm. Ø 1 cm.

Primary Syphilis: Early chancre presenting as a flat. cleaned based . indurated borders & smooth. eroden papule with raised.

erosive balanitis.6 wk After tx : resolve within 1 – 2 wk  heal without scarring • Deviation : -the classic “hunterian” chancre (60% cases) -multiple chancre  47 % cases. + edema.lymphangitisand thrombophlebitis dorsal vena.• Untreated chancre : persist 1 . phimosis. .

Classic “Hunterian” chancre with raised, indurated
borders and slightly hemorrhagic necrotic base.

• MEN  any parts of external genetalia :
– Coronal sulcus
– Inner surface of prepuce
– Glands
– Shaft of penis
– Intra urethral rare
– Anal  anal sex

• WOMAN
– labia, fourchett, urethra, perineum
– Edema indurativum  unilateral labial
swelling with rubbery consistency &
intact surface
– Kissing chancre  common in areas
skin to skin contact as the vulva

Chancre in a female. An ulcers covered with fibrin & necrotic slough at the orifice of the urethra .

Erosive candidal vulvitis or balanitis . Chancroid (ulcus mole) 2. Traumatic ulcer Concider : 1. Herpes simplex 3.DD of Primary Syphilis Most likely: 1. Early LGV 2. Granuloma inguinale 4. Fixed-drug eruption 5. Squamous cell carc/ basal cell carc 4. Behcet disease 3.

SECONDARY SYPHILIS • Erupt 3-12 wk after appearance of chancre • Usually recedes in 2-12 wk • Not all patients present classic symptoms & clinical findings .2.

myalgia.• Symptoms : • Mild fever. arthralgia • Anorexia • Skin rash (80-95% cases) • Swollen lymph nodes • Bone pain • Deafness  rare . malaise • Headache.

SIFILIS Lesi kulit pada S II : • Makula eritem • Makulo papuler – Di mukosa : 'mucous patch' • Papuler / folikuler / papuloskuamosa – Alopesia 'moth eaten' – Kondilomata lata • Ulserasi pustuler: papulonekrotikan • S II rekuren : lesi anuler .

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SIFILIS Erupsi papuloskuamus pd punggung. hrs dibedakan dgn psoriasis gutata /pitiriasis rosea .

papul lunak. basah.Kondilomata lata. merah muda pd perineum & perianal .

patchy.– Moth eaten Alopecia : Irregular. eyebrow or beard . nonscarring on the occipital scalp.

• Non-cutaneous Secondary Syp – Lymphoreticular system: lymph nodes > cases) (50-80% – Opthalmologic: iritis (3%)->pain. relative lymphopenia and sedimentation rate > – Renal : glomerulonephritis  nephrotic syndr – Hepatic : luetic hepatitis (9. leukocytosis.lacrimation – Auditory: sensorineural hearing loss – Musculoskeletal – Hematologic : anemia.7%) – Gastric : epigastric pain .

erythema multiforme. Drug eruption/ viral eruption 4. eczema. Condyloma acuminata 3. Psoriasis 5. Reiter syndrome • Consider 1. Dermatophytosis 4. Lichen planus. Pityriasis rosea 2. leukoplakia 3. sarcoid. 2.DD of Secondary Syphilis • Most likely 1. etc . Balanitis vulvitis.

3. LATENT SYPHILIS • Secondary stage is followed  asymptomatic stage wt no clinical findings  but reactive serologic test • Latency may remain indefinitely  be interrupted by relaps of chancres or eruption of S II ( 6 mo/ first y/2 y) or progress to the tertiary stage .

4. Cardiovascular syphilis C. Late benign syphilis B. TERTIARY SYPHILIS • 1/3 of patients wt untreated latent syphilis  TERTIARY SYPHILIS • 3 principal presentation : A. Neurosyphilis .

A. Late Benign Syphilis • Include  any symptomatic syphilitic manifestations after the secondary & relapsing stage that does not involve the cardiovascular or nervous system • The lesions caused  CMI response to a small number of treponemes present in affected tissue .

2. Granulomatous nodule Psoriasiform granulomatous nodules Gummas . 3.• Skin lesions of late benign syphilis  3 types : 1.

pretibial Late benign syphilis: Disfiguring gummatous infiltration of the glabela and forehead with scattered ulceration.• Gumma : – Non tender pink to dusky-red nodules or plaques – Diameter : mm to cm – Scalp. buttocks.forehead. . presternal.

plakat dg ulserasi. asimptomatis.SIFILIS Sifilis III. berkrusta. tepi serpeginosa . tipe ulkusnoduler.

Destruction of nasal cartilage & bone by gumma  SADDLE NOSE .

6% of men and 8.B.2% affected women) • Symptoms & sign develop 15 -30 years after initial infection • • • . Cardiovascular Syphilis New cases of CV Sy still to be reported In early Sy : rare Commonly in tertiary syphilis (13.

C. Neurosyphilis • Hematogenous invasion of the meninges by T. pallidum occurs early in Sy • 25% untreated primary or secondary syphilis  spirochetes dormant in CNS (after adequate tx. 99% imunocompetent indiv  eradicate fr CNS) • Symptoms develop  5-35 years after initial infection .

klinis Mikroskopis TSS selalu reaktif • S laten: TSS reaktif.SIFILIS Diagnosis : • S I: mikroskopis TSS treponemal & nontreponemal • S II: Gamb. tak ada lesi • S III: biopsi organ TSS darah & /cairan otak .

SIFILIS Tes serologi sifilis (TSS)  presumptive diagnostic: • TSS treponemal : bersifat spesifik – TPHA – FTA . RPR .ABS • TSS nontreponemal (reagin): Tdk spesifik – Wasserman – VDRL.

C  Perenteral Penicilline .o.TREATMENT • D.

V . – Allergy : • Doxycycline 2 x 100 mg. 8-10 d. (DepKes RI 2006). 30 days • Ceftriaxone 250 mg/d or 1 gr every other day.4 millions IU. Early Syphilis : Primary. Secondary & early latent.M / I.G) : 0. alternativ: – Benzilpenicillin proc.6 million /day im for 10 d. I.1.(Procain Pen. (without Neurologic/Opthalmologic/Auditory involvement) – Single dose Benzathine Penicilin 2. im.

Late Syphilis : Late latent. 30 – 60 days . Late Benign Syphilis) – Benzathine penicilline G 2.4 million units.M. – Allergy : • Doxycycline 2 x 100 mg. I. (DepKes RI 2006). Tertiary Syphilis (Cardiovascular. 30 – 60 days or • Tetracycline 4 x 500 mg. 1 wk apart for 3 doses.3.

.• Treatment in Pregnancy : – The penicilline regimen appropriate for the stage of infx – A second Bezathine penicilline injection 1 week later is recommended ( in Primary. Secondary & Early Latent syphilis ) – Allergy : Erythromycine:4x500mg/d  15 d (early) 4x500mg/d 30 d (late).

mainly C..Vulvovaginal Candidiasis Etiologic agent : Yeast family. Albicans Predisposing factors : •Pregnancy •Oral contraceptives •Diabetes mellitus •Antibiotics . Candida spp.

Clinical Manifestations • Acute pruritus and vaginal discharge • As typically cottage cheese like .

Treatment Recomended treatment : • Miconazole nitrat (vaginal supp) 200 mg at bed time for 3 days • Clotrimazole (vaginal tab) 200 mg at bed time for 3 days • Bufoconazole (2% cream 5 gr) intravaginally at bed time for 3 days • Terconazole (80 mg supp) at bed time for 3 days .

i.d for 3 days .Treatment Alternatives : •Fluconazole 150 mg orally single dose •Itraconazole 400 mg orally single dose •Itraconazole 100 mg b.

3. Discar berbau. Eritema vulva difus 3. berbusa 4. iritasi/gatal. Inflamsi dind vag 5.Trichomoniasis Penyebab : T. vaginalis Keluhan 1. Strawberry cervix . Discar >> kuning. Dispareunia 4. hijau. Tdk ada 2. Disuria 5. Tdk ada 2. Rasa tdk enak perut bawah Gejala 1.

Strawberry cervix .

Jenis pemeriksaan • pH >4.5 • Sniff test positif • Dg sediaan basah (NaCl)  pergerakan trichomonas khas • Fluorescent antibodi • Pap smear .

5 gr selama 7 hari • Klindamisin 2 x 300mg slm 7 hari .Terapi • Metronidazol 2 gram dosis tunggal • Metronidazol 2 x 0.

2 • Sekret menggumpal wrn putih atau keabu-abuan melekat pd dinding vag. • Clue cells pd mikroskop . Bacteroides Spp.Bakterial Vaginosis • Penyebab : Gardnerella vaginalis. Mycoplasma hominis • Dpt tanpa gejala • Bau spt ikan (amin yg menguap) • pH 7.

antibiotic therapy: metronidazole or clindamycin for 7 days .Clue cells: squamous epithelial cells covered primarily with gardnerella which then take on this fuzzy appearance called "clue cell" as seen on wet mount of vaginal fluid.

adherent cocci.5 4.5 < 4. flocculent Thin. Trichomo Vulvov nas ag 3.5 (usually ) Discharge White. pseudoh yphae Vaginal pH Miroscopic .8 . "cottage cheese"  Amine odor  "whiff" test Absent fishy fishy Absent Lactobacilli. gray Yellow.thin. WBC's >10/hpf  Budding yeast. white (milky).Differential Diagnosis of Vaginal Infections Diagnostic Criteria Normal Bacterial Vaginosi s Vaginitis Cand. epithelial cells Clue cells. frothy White. green. curdy.2 > 4. hyphae. no WBC's Trichomonad s.4.

Virus Human Papilloma (HPV/Papova) • Beberapa bersifat onkogenik • Tumbuh lambat dan replikasi dalam nukleus • Pd IMS krn HPV  kondiloma akuminata .

Papova virus (kondiloma akuminata) Giant condyloma pd HIV .

virus papova (kondiloma akuminata) .

Terapi : • Elektrocauterisasi • Ablasi kimia (podophylin) • Bedah beku .

Herpes genital • Disebabkan HSV 1 12-50% • Disebabkan HSV2 >50% • HSV2 infeksi I  H.genitalis(klinis) atau subklinis sbg “carrier” menular atau rekuren sifatnya laten pd ggl radix dorsalis .

Herpes genital -Eritema -Vesikula -Ulcus .

Herpes genital .

HERPES GENITAL pd penderita imunocompromise Udem Vesikel / ulserasi Nyeri .

5 hari -valacyc 2 X 500mg/hari. 7-10 hr -famsiklovir 3 X 250mg/hari. 7-10 hari -bl ada kmplikasi iv 3X 5mg/kgBB.7-10hr -valasiklovir 2 X 500-1000mg/hari. 5 hari -famcycl 2 X 125-250mg/hari.TERAPI  Infeksi primer (episode pertama): -simptomatik: analgetik. 5 hari. 7-10 hr  Infeksi rekurens: -ACV 5 X 200mg po.dan atau kompress -Asiklovir 5 X 200 mg/hari 7-10 hari (p o) atau 3 X 400mg/hr. .

L3)  bakteri intraseluler obligat • Inkubasi : 3 .4 mgg • Penyakit sistemik terutama pd sistem limfatik .LGV (Lymphogranuloma Venereum) • E/: Chlamydia trachomatis (L1 .

unilat.4 hr sembuh 1-4mgg • Std II: ♂ kel. estiomen (elefantiasis genital)] .LGV (Lymphogranuloma Venereum) Gambaran klinis : • CS (kontak seksual) 7-10 hari • Std I : papul tdk nyeri. atas  kelenjar inguinal bg. fistul. inguinal >. femoral: 'sign of groove‘  ‘etage bubo’ ♀ bg. ♂ homo: sindr anogenital  kelj perirektal • Std III: Sekuele [striktur. ulkus berderet2 pd penis (‘saxophone penis’) 3 . sakit kel. bawah  kelenjar iliaka profunda ♀.

LGV (Lymphogranuloma Venereum) LGV. limfadenopati pd pemb limfe femoral & inguinal (‘sign of groove’) .

• Bentuk lain .

LGV (Lymphogranuloma Venereum) Diagnosis : • Tes kulit Frei • Tes fiksasi komplemen • Tes mikro imuno fluoresen • Kultur jaringan • Tes antibodi monoklonal konjugasi fluoresen .

21 hr • Sulfisoksazol 4 x 500 mg / hr. 21 hr • Eritromisin 4 x 500 mg / hr.cegah kerusakan jaringan • Doksisiklin 2 x 100 mg / hr. 21 hr • Azitromisin 1 g/mgg 3 mgg • Bubo fluktuatif : aspirasi – Tidak boleh insisi  sikatrik  deformitas • Striktur rektum : dilatasi.LGV (Lymphogranuloma Venereum) Terapi : . kolostomi .menyembuhkan .

GI (Granuloma Inguinale) • E/: Donovania granulomatis Gram negatif  di jar  kapsul ’badan Donovan’ • Inkubasi : 14 -15 hari • Derajat penularan : rendah .

labia mayora • Nodul eritem. tdk sakit.GI (Granuloma Inguinale) Gambaran klinis : • Lokasi lesi : batang penis.) • Limfadenopati • Destruktif  fistel • Ulkus btk seperti sosis . granulomatus • Lesi satelit tepi polisiklis • Gej. sistemik ( .

ulkus granulomatus • Hipertrofik/verukus: tepi ulkus meninggi & verukoid • Nekrotik: destruksi ulseratif. eksudat berbau • Sklerotik/sikatrikal: parut di sekeliling genital .GI (Granuloma Inguinale) Varian klinis : • Ulserovegetatif: bentuk tersering.

tipe ulserovegetatif. skrotum & penis . ulserasi & skar pd perineum. jar granulasi luas.GI (Granuloma Inguinale) GI.

serologi .GI (Granuloma Inguinale) Diagnosis : • Spesimen dr tepi granulomatus  lesi yg aktif • Wright / Giemsa :basil bipolar dlm sel mononuklear • Tdk ada pemeriks .kultur .

4 mgg .GI (Granuloma Inguinale) Terapi : • Tetrasiklin 4 x 500 mg/hari ± 3 mgg (s/p lesi sembuh ) • Alternatif lain : – Trimetoprim 160 mg + Sulfametoksazol 800 mg 2 x/hari – Kloramfenikol 3 x 500 mg/hari – Gentamisin 1mg/kg/hr im  2 .

ULKUS MOLE DEFINISI UM – penyakit infeksi genital – akut. lokalisata. disebabkan oleh kuman Streptobacillus ducreyi (Haemophilus ducreyi) Gejala khas – ulkus nekrotik. nyeri – di tempat inokulasi & srg disertai dg supurasi KGB regional .

tdk berwarna. ramping. berderet = rantai  Streptobacillus  School of Fish Epidemiologi • Endemis: kota & pelabuhan • Tropis & subtropis • Penularan : kontak seksual & autoinokulasi • ♀ < ♂ . ujung bulat • Gram negatif. berspora • Berkelompok. d/ sulit atau carrier (WTS) .Etiologi = Haemophilus (Unna) ducreyi = • Batang pendek.

. • Hasil penyelidikan  adanya respons hipersensitivitas lambat & respons antibodi pd pasien dg chancroid. • Respons imun yg berhub dg patogenesis & kerentanan peny .  kuman penetrasi ke dlm epidermis. • Limfadenitis yang terjadi akibat infeksi Haemophilus ducreyi disertai dengan supurasi.ULKUS MOLE PATOGENESIS • Dg adanya trauma / abrasi. aglutinasi. • Antibodi (+) dg pem fisaksi komplemen.tidak diketahui. presipitasi & tes fluoresens antibodi indirek.

ULKUS MOLE Gambaran klinis : • Papul ulkus yang sakit & lunak – Batas tegas – Dinding menggaung. bergerigi – Dasar : eksudat • Autoinokulasi lesi berhadapan (‘Kissing lession’) • Adenopati inguinal unilat & sakit  supurasi  pecah  bubo (limfadenitis bubo) .

lidah  Jari tangan  Payudara & umbilicus  Konjungtiva . vestibulum * serviks & anus preputium. klitoris.Predileksi Genital  ♀ : * labia. frenulum * sulcus coronarius * batang penis  ♂: * Ekstra Genital  Bibir.

ulkus yang sangat nyeri dgn eritema & edema disekelilingnya .ULKUS MOLE Ulkus mole.

ULKUS MOLE Ulkus mole. sangat nyeri pd vulva krn otoinokulasi . ulkus multipel.

Bentuk lain Chancroid di penis. kissing effect Ulkus mole dg ulkus di KGB inguinal Multiple ulceration of the sulcus corona .

V. Diagnosis • Lesi khas : H.Diagnosis Banding • Ulkus durum (S1) • Ulkus mikstum (Rollet) • Sifilis III • Herpes genitalis • Ulkus vulvae akutum • L.ducreyi  .G.

t / • Eritromisin basa 4 x 500 mg/7 hr • Ulkus sakit sekali ?  kompres dingin • Aspirasi kelenjar inguinal .ULKUS MOLE Terapi : • Azitromisin 1 g oral d.tunggal / • Seftriakson 250 mg im d.

K. Rx.T.B Ulkus Mole Ulkus Durum 1 – 7 hr (± 3 hr) 10 hr – 10 mgg (3 – 5 mgg) Multipel Soliter (kdg. keras Tepi . M. tak teratur Tepi teratur Polisiklis Tidak pernah Permukaan kotor Bersih + nanah Serous + 10 – 50 % Hampir slrh pend Unilat. 2. Btk ulkus 3. lunak Tidak nyeri. Lab 5. (kdg bilat.) Bilateral/ generalisata Nyeri Tidak nyeri Limfangitis Limfadenitis + Limfadenopati generalisata + melunak Keras Perforasi 4. 2) Sgt nyeri.1.G. serologis – Gram Burri Mikroskop biasa Mikroskop lapangan gelap Tidak spesifik Khas: VDRL & TPHA .

Setia dg pasanga Itu lebih baik .