2.1 Medicine II_Sexually Transmitted Infections_2014A

July 26 2012

Sexually Transmitted Infections Dr. Panaligan A. B. C.

D. E. F.

A. B. C. D. a. b. A. B.

C. a. b. c. d. e. D. a. b. E. a. b. c. A. B. VII.

I. Urethritis Urethritis in Men a. Approach to Patients with Suspected Urethritis Urethritis and Urethral Syndrome in Women Syndrome Associated With The Presentation Of Disease Local Complications Gonococcal vs. Non-gonoccocal Diagnosis a. Neisseria gonorrhoeae b. Chlamydia trachomatis G. Management II. Vulvovaginal Discharge Cervicitis Vulvovaginal Candidiasis Bacterial Vaginosis Trichomoniasis Complications Treatment III.Genital Ulcers Etiology Syphilis a. Clinical Manifestation i. Primary Syphilis ii. Secondary Syphilis iii. Tertiary Syphilis iv. Latent Syphilis b. Diagnosis c. Treatment Herpes Simplex Primary genital herpes Recurrent genital herpes Diagnosis Principles of Management Treatment Chancroid Diagnosis Treatment Papillomavirus Anogenital Warts Diagnosis Treatment IV. Hepatitis B, Hepatitis C, HIV V. Human Immunodeficiency Virus Risk of Transmission “Drivers” of Increased Transmission VI. Sexual History’s 5Ps STD Prevention and Control

Note from the trans group: Sorry for the first part of this trans. It’s not as complete because we only based it on the recording. We weren’t able to take pictures of the first few slides. Sorry  Note from the editor: Tried to compensate with Harrison and 2013B Trans 

CASE NO. 1

Figure 1. Urethral discharge.

 A 32 year old male, seaman, presented with difficulty of urination. He self-medicated with Ampicillin 500mg 3x/day with only slight relief. It was elicited that he had unprotected sexual activity with a freelance sex worker 9 days ago. On physical examination you would note urethral discharge which was described to be yellowish mucopurulent and there was tenderness on the right scrotum. No masses or no prostatic tenderness noted.

There was right inguinal lymphadenopathy. As the attending physician, your goal of management in the approach of this patient should prioritize on: a) Control signs and symptoms to prevent further transmission b) Establish the presence of urethritis and identification of etiologic agents c) Prevention of complications and sequelae d) Counseling for HIV and other STI work-ups

 Answer: A. The question is just prioritization. Basically, we want first to control the infection and prevent transfer of the infection. But of course, the other answers are also very important; you don’t want complications and sequelae to occur. To prevent and control sexually transmitted infection, you have to do counseling. Tell the patient to STOP any “DIRTY” or unprotected sexual activity. And of course, you should advice the patient to have a diagnostic work-up not only for urethritis but also, for other sexually transmitted infection.

URETHRITIS URETHRITIS IN MEN  CLINICAL CRITERIA o Urethritis in men produces urethral discharge, dysuria, or both, usually without frequency of urination. Discharge could be mucopurulent or it could just be mucous. o Meatal erythema  ETIOLOGIC AGENTS: o Neisseria gonorrhoeae o Chlamydia trachomatis o Mycoplasma genitalium o Ureaplasma urealyticum o Trichomonas vaginalis o Herpes Simplex Virus (HSV)  Both Neisseria gonorrhoeae and Chlamydia trachomatis are the most frequent causes of urethritis in male.  Purulent discharge will point out more to N. gonorrhoeae.  The presence of mucous would make you think of Ureaplasma and Mycoplasma.  Chlamydia trachomatis is the most frequent cause of infertility. It is also one of the most frequent causes of non-gonococcal urethritis in the Philippines  Coliform bacteria can cause urethritis in men who practice insertive anal intercourse Approach to Patient With Suspected Urethritis 1.Establish the presence of urethritis [Harrison]  Proximal-to-distal “milking” of the urethra must express purulent or mucopurulent discharge  If this fails to give a discharge, anterior urethral specimen may be obtained by passage of a small urethrogenital swab 2-3 cm into the urethra

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When performing laboratory tests note for:

Page 1 of 8

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Gram stain of urethral demonstrating >5 WBC/Oil Field (OIF) Pyuria on first void sediment 

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secretions Immersion

Centrifuged sediment of the first 20-30 mL of voided urine, ideally collected as the first morning specimen, demonstrating >10 leukocytes per high power field [Harrison]

Positive Leukocyte Esterase Test

2. Evaluate for complications or alternative diagnoses  A brief history and examination will exclude epididymitis and systemic complications, such as disseminated gonococcal infection (DGI) and Reiter’s syndrome  Men with dysuria who lack evidence of urethritis as well as sexually inactive men with urethritis should undergo palpation, urinalysis, and urine culture to exclude bacterial prostatitis and cystitis. 3. Evaluate for gonococcal and chlamydia infection  Absence of typical gram-negative diplococci on Gram’s-stained smear of urethral exudate containing inflammatory cells warrants a preliminary diagnosis of Non-gonoccocal Urethritis (NGU) and should lead to testing of C. trachomatis 4. Treat urethritis promptly, while test results are pending [Harrison]

 Disseminated Gonococcal Infection (DGI) - Seen especially in sexually active males or even in immunosuppressed individuals [2013B]:  Salpigitis  Bartholin Abscess  Lymphangitis  Periurethral Abscess

GONOCCOCAL VS. NON-GONOCCOCAL URETHRITIS FEATURES Incubation Onset Symptoms

GONORRHOEA 1-7 days Abrupt Prominent (severe discomfort) 2%

NONGONOCCOCA L 3-21 days Gradual Milder

Dysuria Only 27% Discharge 27% 47% Only Both 71% 38% Discharge Purulent (91%) Mucoid (58%) Asymptomati 80% women; 10% 70-75% women URETHRITIS AND URETHRAL SYNDROME IN c men Diagnosis: Presence of gram- negative intracellular WOMEN diplococci  CLINICAL CRITERIA [Harrison] o It is characterized by “internal” dysuria (usually Co-infection rate: 40% without urinary urgency or frequency), pyuria and  The clinical manifestations of gonococcal urethritis are o

absence of E. coli and other uropathogens in urine at counts of >100/mL. In contrast, external dysuria is painful contact of urine with an inflamed or ulcerated labia or introitus in vulvar herpes and vulvar candidiasis.

 ETIOLOGIC AGENTS o C. trachomatis, N. gonorrhoeae, occasionally HSV

SYNDROME ASSOCIATED WITH THE PRESENTATION OF DISEASE  Urethritis  Cervicitis  Proctitis  Pharyngitis – due to the dynamic sexual activity  Conjunctivitis – in infants or children

usually more severe and overt than those of nongonococcal urethritis, including urethritis caused by Chlamydia trachomatis; however, exceptions are common, and it is often impossible to differentiate the causes of urethritis on clinical grounds alone. [Harrison’s]

DIAGNOSIS Neisseria gonorrhoeae  Gram Staining o Presence of gram negative intracellular monococci and diplococci is usually highly specific and sensitive in diagnosing gonococcal urethritis in symptomatic males

 Bartholinitis [2013B]

Majority of the Sexually Transmitted Infections (STI’s) are asymptomatic especially females (up to 60-70% of females).

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It is only about 50% sensitive gonococcal cervicitis. [Harrison]

in

diagnosing

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For women who have Pelvic Inflammatory Disease, the likelihood of having a negative result is very high. But of course, other diseases possibly non-gonococcal can be present in a patient presenting with PID.

LOCAL COMPLICATIONS  Pelvic Inflammatory Disease (PID) o o

Infection that ascends from the cervix or vagina to involve the endometrium and/or fallopian tubes. Infection can extend beyond the reproductive tract to cause pelvic peritonitis, generalized peritonitis, perihepatitis, perisplenitis, or pelvic abscess. [Harrison]

o Usually caused by C. trachomatis  Epididymitis – most common [2014B]  Penile edema  Prostatitis

DeGuzman DeVera Debuque 5 pus cells / OIF (urethral discharge)  > 30 pus cells / OIF (cervical discharge)

 Confirmatory test o Nucleic Acid Amplification Tests (NAATs) 

Early morning first-voided urine is examined [Harrison]

Most useful in detecting Chlamydia trachomatis Cell Culture Antigen Detection Assay 1. Direct Fluorescent Antibody (DFA) – demonstration of “elementary bodies” 

o o

2.

   

 Management of Recurrence [Harrison] o Confirm objective evidence of urethritis, if patient was re-exposed to untreated or new partner, repeat treatment of patient and partner o If patient was not re-exposed, consider infection with Trichomonas vaginalis, or doxycycline-resistant Mycoplasma genitalium or Ureaplasma urealyticum and treat with:  Metronidazole; or  Azithromycin; or  Both

 Management of sexual partners: o Last sexual contact within 60 days before onset of symptoms and diagnosis - treat for both Chlamydia and Neisseria gonorrhoeae o Last sexual contact more than 60 days before onset of symptoms or diagnosis - treat the patient’s recent partner. If patient has multiple sexual partners then treat ALL partners  Treatment and Follow-up considerations [2013B] o To minimize transmission, abstain from sexual intercourse for 7 days after single-dose therapy or after the completion of 7-day therapy o Retesting of all infected women is recommended approximately 3 months after treatment

CASE NO. 2: VULVOVAGINAL DISCHARGE

Enzyme Immunoassay [2013B]

MANAGEMENT OF GONORRHOEA

 

will result to resolution of symptoms in 2 to 3 days.  Dr. Panaligan emphasized that ABSTINENCE is definitely better than taking these drugs. :p

Figure 3. Cervical discharge.

Quinolone Resistant  2 weeks later, the patient came back due to Cefixime 400 mg PO; or Ceftriaxone 125/250 mg IM recurrence of symptoms together with his wife. Plus Chlamydial therapy The wife complained of vulvovaginal discharge. Azithromycin 1gm single dose PO; or Doxycycline 100mg Apparently, he has two partners, the wife and the BID x 7 days CSW he met before. Physical examination done 40% have co-infection so you have to treat both revealed mucopurulent discharge in the cervix as The drug of choice is Cefixime which is a 3rd well as in the vaginal area. What does she have? generation cephalosporin (since Philippines is the A. Cervicitis first country reported to have Penicillin resistant B. Bacterial Vaginosis N. gonorrhoeae). Take a single dose of Cefixime C. Trichomoniasis 400 mg (2 x 200 mg capsules). D. Candidiasis The updated dose of Ceftriaxone is 250mg IM since  Answer: A. Cervicitis, but she can also have the there were many reported failures in the 125mg other 3. dosage.  After sexual contact, you can acquire any organism For quinolone sensitive N. gonorrhoeae, you can use especially males any fluoroquinolone like Ciprofloxacin or  Candidiasis is not sexually transmitted Levofloxacin. If Chlamydia is not ruled out (since it is difficult to  What do you think happened? Why did the wife have similar manifestations with the husband?— rule it out), you have to give any of the two, because even before the patient sought consult, Azithromycin or Doxycycline. he probably had sexual activity with his wife. So Take two 500 mg tablets Azithromycin for the it’s really important to bring the partner. Chlamydial infection along with Cefixime and it

CERVICITIS DeGuzman DeVera Debuque 5.0

 Etiologic Agent: Trichomonas vaginalis o o

 Etiology: associated with Gardnella vaginalis, various anaerobic and/or noncultured bacteria and mycoplasmas [Harrison]

 Diagnosis (Amsel Criteria) – any of 3 of the following: o

o o

Objective signs of increased white homogeneous vaginal discharge [Harrison]

Vaginal discharge pH of >4.5 Positive Whiff test (amine odor) 

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Liberation of a distinct fishy odor (attributable to volatile amines such as trimethylamine) immediately after vaginal secretions are mixed with 10% KOH [Harrison]

Microscopic demonstration of clue cells

DeGuzman DeVera Debuque