Sexually Transmitted Infections

Question 1

Long term health consequences of STIs:

Answer 1

1) Reproductive tract cancers
2) Impaired fertility
3) Adverse pregnancy outcomes
4) HIV acquisition and transmission

Question 2

Genital, anal, or perianal ulcers:

Answer 2

Genital herpes (common) or syphilis (rare)
Diagnosis involves: culture, DFA, or PCR for herpes, darkfield examination, DFA, or serology for syphilis. HIV testing is recommended, especially in patients with syphilis.
Genital warts cause non-ulcerating lesions.

Question 3

Urethritis and cervicitis:

Answer 3

Urethritis usually presents with dysuria and penile discharge in men, and is often caused by gonorrhea or chlamydia. Non-gonococcal urethritis (NGU) describes other possible causes of urethritis beyond gonorrhea and chlamydia.
Cervicitis may be asymptomatic or present with abnormal discharge or vaginal bleeding.

Question 4

Vaginitis:

Answer 4

Vaginal discharge or vulvar itching and irritation. Usually caused by candida, bacteria (too many anaerobes), or trichomoniasis.

Question 5

Pelvic inflammatory disease (PID):

Answer 5

Manifests as lower abdominal pain, adnexal tenderness, and cervical motion tenderness. It may represent endometritis, salpingitis, tubo-ovarian abscess, or pelvic peritonitis.
Usually chlamydia or gonorrhea, but can be due to anaerobes.

Question 6

Proctitis:

Answer 6

Rectal pain, tenesmus, discharge, or constipation associated with gonorrhea, HSV, chlamydia, syphilis or genital warts.

Question 7

Epididymitis/Prostatitis:

Answer 7

Unilateral scrotal pain and swelling (epididymitis) or rectal pain (prostatitis) associated with gonorrhea, chlamydia, or enteric flora.

Question 8

Chlamydia microbiology and pathophysiology:

Answer 8

IT IS THE MOST PREVALENT STD IN DEVELOPED AND UNDERDEVELOPED COUNTRIES.
Obligate, intracellular bacteria with multiple serotypes. Types D-K are sexually transmitted pathogens. Types L1-L3 cause lymphogranuloma venerum. Exist is elementary bodies and reticulate bodies. Chlamydia is taken up by receptor-mediated endocytosis. It is a major cause of infertility, and can cause perinatal infection.

Question 9

Chlamydia clinical syndromes:

Answer 9

Asymptomatic, urethritis, cervicitis, epididymitis, proctitis, PID (leading to infertility), and reactive arthritis. In infants: inclusion conjunctivitis (cobblestoning without exudate), and interstitial pneumonia.

Question 10

Chlamydia diagnosis and treatment:

Answer 10

Diagnosis: nucleic acid amplification test (NAAT) performed on vaginal swab sample or first catch urine.
Treatment: AZITHROMYCIN or DOXYCYCLINE
Test of cure (3-4 wks after treatment) recommended in pregnant women or those with compliance issues, persistent symptoms, or possible reinfection.

Question 11

Gonorrhea microbiology and pathophysiology:

Answer 11

Neisseria is a fastidious gram-negative diplococci that requires a warm, moist, CO2 rich environment for growth. It attaches to mucosal surfaces by pili. Majority of women are asymptomatic, most men are symptomatic.

Question 12

Gonorrhea clinical syndromes:

Answer 12

Urethritis, cervicitis, epididymitis, prostatitis, anorectal infections, pharyngeal infections, conjunctivitis (exudative) in children and adults. May also cause PID, perihepatitis (FITZ-HUGH-CURTIS SYNDROME), disseminated gonococcal infection, and septic arthritis.

Question 13

Gonorrhea diagnosis and treatment:

Answer 13

Diagnosis: Gram stain of discharge, NAAT on vaginal swabs or first-catch urine, culture using Thayer-Martin agar.
Treatment of simple infection: CEFTRIAXONE (anogenital or oropharyngeal) or CEFIXIME (anogenital only), and AZITHROMYCIN (single dose only).
Treatment of complicated infection: CEFTRIAXONE and AZITHROMYCIN.
Azithromycin is for clinically silent Chlamydia co-infection.
Test of cure is not indicated.
If GC is diagnosed, test for syphilis and HIV.

Question 14

Syphilis microbiology and pathophysiology:

Answer 14

Treponema pallidum is a thin, coiled spirochete. Darkfield microscopy and direct immunofluorescence are required for visualization. Organisms penetrate mucous membranes and disseminate through the blood.

Question 15

Stages of syphilis infection:

Answer 15

1) Incubation period (~3 weeks)
2) Primary syphilis (chancre) - 2-4 weeks
3) Secondary syphilis (mucocutaneous lesions and lymphadenopathy) - 6-24 weeks after infection
4) Latent syphilis (may last years)
5) Tertiary syphilis (gummas, aortitis, and neurosyphilis).
* NEUROSYPHILIS may occur at any point during the disease process, and may present as stroke, dementia, or tabes dorsalis.*

Question 16

Syphilis diagnosis and treatment:

Answer 16

Diagnosis: Darkfield microscopy, VDRL and RPR, treponemal specifc antibody, syphilis IgG assay.
Treatment: Parenteral (IV or IM) penicillin. Doxycycline in the penicillin-allergic patient.
Screening for all pregnant women.

Question 17

Populations at risk for the development of STDs:

Answer 17

Youth, minorities, multiple sexual partners, those living on social margins (runaways, homeless, incarcerated, migrant workers), those native to STD endemic areas.

Question 18

Important points about STD treatment/screening:

Answer 18

Screen for multiple agents
Treat for asymptomatic infections
Treat as if patient will be lost to follow-up
Treat sexual partners
Report to state health departments, when appropriate
CONFIRM SUCCESS OF THERAPY
Educate patients
Treat adolescents confidentially without parental consent

Question 19

Gonorrhea is more likely to cause ____, while Chlamydia is more likely to cause ____.

Answer 19

Septic arthritis, reactive arthritis.