Sexually Transmitted Infections Flashcards
Important Terminology
SEXUALLY TRANSMITTED INFECTION (STI) – an infection spread MAINLY via SEXUAL CONTACT
SEXUALLY TRANSMITTED & BLOODBORNE INFECTION (STBBI) – an infection transmitted via the blood OR sexual
The stigma associated with STIs makes our choice of terminology/phrasing IMPORTANT with patients!
Discomfort in Discussing Sexually Transmitted Infections
KEY LEARNING POINT
If you are uncomfortable discussing STIs as a healthcare
provider – imagine how the patient feels!
Reluctance to discuss STIs as a provider combined with
reluctance on the part of the patient due to fear of making
you uncomfortable will lead to these problems going
untreated for much longer than necessary
The onus is on US as healthcare providers to identify, address and counsel on these issues.
Sexually Transmitted Infections: Epidemiology & Mortality
- Rates of STI have increased dramatically
over the past decade - Between 2008 and 2017:
- Chlamydia increased by 39%
- Gonorrhea increased by 109%
- Syphilis increased by 167%
- Pan-Canadian Sexually Transmitted and
Blood-borne Infection Framework for
Action - Comprehensive approach to address STBBI
- Strategic goals include reducing incidence;
improving access to testing, treatment and
ongoing care; reducing stigma and
discrimination
Hundreds of thousands of patient acquire STIs annually in Canada, only about 50% are aware of it.
Sexually Transmitted Infections: Impact of COVID-19
Since the start of the COVID-19 pandemic
– the number of STIs reported was 51%
less than expected. This CANNOT be
described solely by reduced rates from
restrictions and social distancing, which
means that STIs are going under-reported
and UNDER-TRACKED.
Re-emergence of STIs in many countries
may be un-monitored in many cases and
this can lead to problems that are going
undetected.
We will see an apparent sharp rise in STIs post-pandemic, but probably it will reflect undetected disease.
Sexually Transmitted Infections: Why are Rates Increasing?
Many STIs may be ASYMPTOMATIC for long periods of time (e.g., syphilis, but even gonorrhea or
other STIs in men).
Lack of holistic/comprehensive sexual education, especially RE: condom use!
Disparities and lack of access to healthcare
Why are YMSM at an increased risk for STIs?
* # of partners (variable)
* Frequency of sex without a condom (highlights importance of education RE: condom use!)
* Overlapping sexual networks (when rates of STIs are higher in men, infection rate is higher in MSM)
* Frequency of anal sex
There many be a component of better diagnostic testing/screening that factors into rising rates!
Sexually Transmitted Infections: Why Are We Concerned?
Beyond the morbidity of the STI itself (causing symptoms,
distress and morbidity on its own) – STIs have a profound
impact on sexual and reproductive health worldwide and
can lead to:
1. Fertility issues (i.e., pelvic inflammatory disease in
women and epididymo-orchitis in men with gonorrhea
and chlamydia)
2. Increased risk of HIV acquisition (with barrier-disrupting
STIs like gonorrheae, syphilis and herpes)
3. Vertical transmission of STIs (causing stillbirth, neonatal
death, low-birth weight, prematurity, sepsis)
4. Increased risks of cancer (e.g., with HPV, cervical cancer
being the 4th most common cancer in women)
STIs can have significant impact on reproductive health and require CAREFUL management.
Sexually Transmitted Infections: A Sexual History – Many WRONG Ways to Approach!
The 5 Ps are useful for taking a sexual history: but there are many WRONG ways to approach a sexual history.
1. Partners (#)
* How many partners have you had?
* Who are the clients’ partners? (men, women or both?) – NOT requiring orientation
2. Practices
* What types of sex does the patient engage in? (vaginal, anal, oral; not assuming any based-on clients’
partners or orientation)
3. Protection
* Does the patient use barrier methods? How frequently?
4. Past History of STIs
5. Prevention of Pregnancy?
* Using birth control or consistent condom use?
Discussing sexual health & sexual behavior is a sensitive topic! Confirm confidentiality!
Sexually Transmitted Infections: An Overview
see slide12
SEXUALLY TRANSMITTED
INFECTIONS
URETHRITIS / CERVICITIS (urethral discharge, pain with sex, dysuria)
Gonorrhea
Chlamydia
Trichomoniasis
Mycoplasma &
Ureaplasma
GENITAL WARTS & Ectoparasites
HPV Public lice
PAINLESS ULCERS
Syphilis
Granuloma
inguinale
PAINFUL ULCERS
Genital Herpes
Chancroid
LGV
Antimicrobials Are For PATHOGENS
Kill the PATHOGEN
that is CAUSING
the disease! This
means we always
need to be
thinking: “what
pathogens are at
play in my specific
patient”?
A Case of Urethritis
Recognition of the right pathogen is important to select the right treatment!
https://www.alberta.ca/notifiable-disease-guidelines.aspx#jumplinks-4
A 23-year-old woman presents to the sexually
transmitted infection (STI) clinic with vaginal discharge,
left ocular discharge, and blurry vision. A urine sample of
the vaginal discharge and ocular discharge both show
abundant white blood cells and numerous gramnegative intracellular diplococci.
Q: What is the most likely pathogen at play?
Recognition of the right pathogen is important to select the right treatment!
Neisseria gonorrhea
Gonorrhea: Epidemiology & Morbidity
- Second most frequently reported notifiable STI in
Alberta and Canada - Gonorrhea outbreak declared in Alberta in 2016 due to
rising cases - Global and national concern about the continuing
emergence of drug resistant strains of gonorrhea - Noticed more frequently in males (more likely
symptomatic), increasing rates in MSM) - Risk factors: multiple/new partners, unprotected sex,
alcohol/substance use, sex workers & street-involved
youth
Around 25-30% of patients with gonorrhea are COINFECTED with Chlamydia!
Gonorrhea: The Causative Pathogen & Transmission
PATHOGEN: Neisseria gonorrhoeae (gram-negative
diplococcus)
TRANSMISSION:
* Contact via sexual activity (fluids/direct contact, oral,
vaginal or anal sex)
* Possible increased rate of MALE > FEMALE (but any if
receptive sex, anal/vaginal?)
* Transmission possible PERINATAL
* Incubation Period: 2-7 days
Increases rates of HIV acquisition!
* Urethritis increases VIRAL SHEDDING of HIV (i.e.,
contact with blood/mucous membranes via sexual
activity)
MEN are typically more SYMPTOMATIC than females!! (detected via exam/testing more frequently in females)
Urethritis: Gonococcal vs. Non-Gonococcal
GONOCOCCAL
URETHRITIS
(aka. Gonorrhea)
NON-GONOCOCCAL
URETHRITIS (NGU)
Referring mostly to Chlamydia, but also
technically to the much less common
Mycoplasma/Ureaplasma urethritis
Urethritis: inflammation of the urethra, causing discharge, dysuria, and possibly itchiness or irritation.
Patients may refer to this as the drip or “the clap” (reference to “the clapier” referring to brothels)
Gonorrhea: Oropharyngeal & Conjunctival Gonorrhea
Hyperacute gonococcal conjunctivitis can lead to CORNEAL ULCERATION AND BLINDNESS!
v
Gonorrhea: Neonatal Gonorrheal Conjunctivitis
Neonatal gonorrheal infection predominantly occurs
from perinatal exposure to the mother’s infected cervix
during birth. This can therefore be prevented with
routine prenatal screening!
The most common manifestations include:
* Ophthalmia neonatorum (gonococcal
keratoconjunctivitis) – CAUSES BLINDNESS
* Neonatal sepsis/meningitis
Despite negative screening we still GIVE ALL
NEWBORNS erythromycin 0.5% ung OU x 1
Routine erythromycin ointment application at birth is STILL given to reduce preventable blindness.
Gonorrhea: Disseminated Gonococcal Infection (DGI)
Disseminated gonococcal infection (DGI) can
occur through hematogenous spread of Neisseria
but only occurs in <1% of all cases, predominantly
in women.
Organ systems that can be involved include:
* Skin (cutaneous findings)
* Tendon sheaths/joints (tenosynovitis)
* Pericardium (pericarditis)
* Endocardium (infective endocarditis; RARE)
* Meningitis
* Bacterial hepatitis
Samples of arthritis can be STERILE – so careful attention to history of primary gonorrhea is important!
Migratory polyarthralgia
. Specifically, it seems to be mostly their hands, and they can be bilateral.
Then, when you do a joint t of these of these patients, typically they’ll be culture negative, but they’ll have swab positive, or urine culture positive gonorrhea,
