JAS

N
RAI
S
FAR
SUBJECT Medicine
TOPIC Sexually Transmitted Infections
HUA

LECTURER Dr. Gabriel (June 23, 2008)

JOS
CO
MAR TRANSGROUP Kapitan Boom and Friends
ISAY
DY
CAN STD STATISTICS
 WHO has estimated about 315 million Social hygiene clinics do not have
NG

laboratory capability to perform diagnostic
KRI
EISA cases of the curable STD occur each year
E in the world screening test
ANN  SOUTHEAST ASIA estimate between 9-17%  Lack of equipment and reagents for STD
H of individuals aged 15-49 may acquire an testing
KYT
infection in any one year  Private practitioner were reluctant to
ON
 USA STD Cases report STD to DOH
 Problems on data result from inadequate
AAR
HE o CDC estimates 19 million new
ALP infection occur each year training of doctors, nurses & midwife
LA o About 8.5 million among young STD in the Philippines
KAR people ages 15 to 24 yrs  In Philippines, STI prevalence from 1999
G o $14.7 billion for direct medical cost to 2002 of chlamydia infection among
PEN
each year in US high risk group (registered female sex
KC
o In 2006, chlamydia, gonorrhea & workers) was 27-36%; and in general
population group was 5.75% in women
ADI
syphilis are the three notifiable
and 4.4% in men.
N
MAA STD in US
AM  STD Cases Worldwide  Factors related to transmission include
A o Certain STD’s (syphilis, gonorrhea, extramarital relationships, multiple sex
MON HIV, Hep B, chancroid) are most partners and low condom use in men.
F
concentrated within “core Young people have relatively high
BUF
populations” having high rates of prevalence.
DIE
partner change, concurrent  Most men would never divulge their STI
status to their partners, thus, making
GOL
partners or “dense” sexual
women more vulnerable to STIs.
A
EZR networks like prostitutes and their
KIX clients and persons involved in the
RIZ use of illicit drugs. Transmitted in Adults by Sexual Intercourse
EY Viruses Others
LAIN Neisseria Trichomonas
N EPIDEMIOLOGY OF STD gonorrhea HIV 1 & 2 vaginalis
Chlamydia Phthirus
XTIA

Factors that determine the spread of trachomatis HTLV 1 pubis

CES

Herpes
PS
HOO STD’s
E 1. rate of exposure Treponema simplex
VINC 2. efficiency of transmission per exposure palidium Type 2
E 3. duration of infectivity of those infected Human
ESS Hemophylus papilloma
DEN Host factors on the spread of STD ducreyi virus
LLE
1. Risk behaviors Calymmatobacter
CECI
2. Socio-economic ium granulomatis Hepatitis B
3. Beliefs & Gender identification Molluscum
JAM

Ureaplasma contagiosu
Y KC
PIPO
H urealyticum m
RIC “PHILIPPINES have started to provide STI Risk-behavior
HEIN data which might be under reported. Practices
T “Guesstimate suggest that STD are quite Multiple Partners
BAR common” Men Having Sex
RYL
with men
SHE
Current problems of STI detection in
the Philippines STD SURVEILLANCE
LH
RAP
 Reports from social hygiene clinics were
Page 1

TINA
AIN obtained from select high risk groups Number of STD Cases per Year (1999 - 2004)
ALL 19 20 20 20 20 2
TTE
YVE
ARY
M
 SUBJECT Medicine
TOPIC Sexually Transmitted Infections
LECTURER Dr. Gabriel (June 23, 2008)
TRANSGROUP Kapitan Boom and Friends

99 00 01 02 03 004
Gonorrhea 268 198 211 266 257 221
Syphilis 38 99 129 108 65 64
Non- 3 2 2 4 7 7
specific 155 376 404 321 534 371
Trichomoni 10 11 4 8 2 0
asis
Candidiasis 859 516 399 491 163 62
Bacterial 17 24 24 1
Vaginosis
Herpes 2 3 2 1 2 Gonorrhea in Women
Venereal 11 13 31 18 29 63
Wart
Hepatitis B 23 9 31 24 25 28
 Bleeding between periods

 Creamy or green, pus-like or bloody

STD CLASSIFICATION vaginal discharge
 Urethritis & Urethral discharges in men  Excessive bleeding during menstrual
 Vaginal discharges
period
 Genital ulcers
 Genital lesions  Irritation of the vulva
 Blood-borne STIs
 Lower abdominal pain
CLINICAL STDs  Pain during intercourse
Genital Discharges
Gonococcal Urethritis  Painful urination

 Caused by Neisseria gonorrhea which can

be cured with antibiotics

 Spread is through vaginal, anal, or oral-

genital contact with an infected person

 Most women and an increasing no. of men

exhibit no symptoms at all

 Impossible to catch Gonorrhea from toilet

seats, towels, drinking cups, etc.

 If symptoms do appear, they will be 2

Neisseria gonorrhoeae
days to 2 weeks after sexual contact
Cervix, Urethra, Rectum
 Copious and grossly purulent and
Treatment:
sometimes blood- stained
Cefixime 400 mg
Page 1

Ceftriaxone 125 IM
 SUBJECT Medicine
TOPIC Sexually Transmitted Infections
LECTURER Dr. Gabriel (June 23, 2008)
TRANSGROUP Kapitan Boom and Friends

Ciprofloxacin 500 mg Target High Risk Groups

Popula
Ofloxacin 400 mg/Levofloxacin 250 mg tion Monzo FHI, Agdama FHI,
n, 1994 g, 1996 1999
1991

PLUS Chlamydial therapy if infection not ruled out Femal 13 % 17.3 % 15.5 % 36%
e
N=936 N=311 FSW N=450

Manila Manila Angeles

Chlamydia Infection
City
FSW 22.7 %;
FSW
N=297
 The most prevalent STD worldwide & can
Cebu
coexist with gonorrhea and other STD
FSW
 Prevalence is highest in younger age 15-
25 years and most likely to experience Male 12 %
complications and long term sequelae.
N=100

 In women: over 50% with gonorrhea and Angeles

70% with Chlamydia had no symptoms City;

 In men: 68-92% with gonorrhea and 92% 16%

with Chlamydia reported no symptoms
N=100
 In men, the infection may cause urethritis,
FSW
epidimytis, proctitis, Reiter’s syndrome
(arthritis) and infertility.

Target Low Risk Groups

Popula
tion FHI, Agdam Aplasca, FHI,
1994 ag, 1998 2002
1996

Femal 5.6 % 2.5 % 11.7 % 5.75 %

e
N=203 N=308 N=300

Antena Antenata Gen

tal l Baguio; pop;
women
9.6% Selected
Prevalence Studies on Chlamydia sites;
Trachomatis Infection Among Population N=343
Groups 7.7%
Cebu; youth
Page 1

7.5 %
 SUBJECT Medicine
TOPIC Sexually Transmitted Infections
LECTURER Dr. Gabriel (June 23, 2008)
TRANSGROUP Kapitan Boom and Friends

N=349  Since transmitted through sexual

intercourse, babies can also be infected
Davao
while passing through the birth canal of an
Male 4.6 % 4.4 % infected mother.

N=349 N=300

Baguio; Gen Treatment

pop;
2.1% selected Azithromycin 1 gm in a single dose or
sites;
N=343 Doxycycline 100 mg bid x 7 days
9 %
Cebu; youth
2.3%
Clinical Features
N=349
 Gonorrhea and chlamydia are both
Davao bacteria

 The symptoms of gonorrhea and

 In women, symptoms include: genital
itching and burning, vaginal discharge,
dull pelvic pain, bleeding between periods,
and cervical inflammation
chlamydia are very similar
 Men and women often complain of a
discharge, frequent urination, or burning
when they urinate

 In men, symptoms include: mucus  In gonorrhea the discharge is often white

discharge from the penis (gradual onset or yellow, in chlamydia the discharge is
five to twenty-one days after exposure) usually clear
and painful urination
 Both gonorrhea and chlamydia are spread
 Again, these symptoms may be so mild by coming in contact with the discharge
that a man may not notice them
 If a woman is not treated for either of
 Women can develop Pelvic Inflammatory these diseases, it could lead to a severe
Disease (PID) infection in her reproductive organs which
could cause infertility
 Chlamydia trachomatis predisposes
women to develop PID secondary to
prolonged colonization of the
microorganism to the pelvic region since Bacterial Vaginosis
most cases are asymptomatic and did not
receive treatment. At the same time, the
proliferation of Chlamydia at the cervix  Gray or white sticky homogenous
and vagina predisposes the child to be discharge
infected affecting the mucous membrane
of the child.  Fishy or musty odor after sex or when
Page 1

mixed with 10% KOH

 Increased danger of having an ectopic
pregnancy  Change of vaginal ph to alkaline (>4.5)
 SUBJECT Medicine
TOPIC Sexually Transmitted Infections
LECTURER Dr. Gabriel (June 23, 2008)
TRANSGROUP Kapitan Boom and Friends

 Clue cells

 Lack of lactobacillus

 Multiple partners

 Douching

 In severe cases the vaginal walls and

cervix show the classical “strawberry”
appearance with punctate bleeding
erosions

Treatment

Recommended: Metronidazole 500mg PO

BID x 7 days

Alternative: Metronidazole gel 0.75% or 1

full applicator (5gms) intravaginally at HS
x 7days

Treatment Regimens

Trichomoniasis Agent and Regimen Efficacy

Metronidazole PO

2g single dose 82-88%

 Yellowish, frothy, fishy odor
500 mg BID x 7 days 95%
 Severely itchy, vulva becomes edematous
and excoriated vaginal and cervical Metronidazole <50%
punctate hemorrhages, asymptomatic intravaginal

 Highly associated with gonorrhea Clotrimazole 25-60%

intravaginal
 Highly motile flagella: Trichomonas
vaginalis

Candidiasis
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 Severe itchiness

 Whitish curdlike discharges

 SUBJECT Medicine
TOPIC Sexually Transmitted Infections
LECTURER Dr. Gabriel (June 23, 2008)
TRANSGROUP Kapitan Boom and Friends

 Vulva is thickened due to chronic scratching  It is contagious as long as the infected

person has any open sores
 Seen in 20% of healthy childbearing women

 Source: anal area, GIT  Spread can be prevented by use of

condoms, limit the number of sex
partners, wash the genitals after sexual
relations & if infected AVOID SEXUAL
Treatment
CONTACT
o Intravaginal Agents

Clotrimazole 1% cream, 5gms intravaginally

x 7-14 days or

Clotrimazole 100mgs vaginal tablet x 7 days

o Oral Medication

Fluconazole 50 mgs OD x 7 days

GENITAL ULCERS
Treatment
Genital Ulcer Disease… Does It Hurt? Azithromycin 1 gm orally
 Painful
or
– Chancroid
Ceftriaxone 250 mg IM in a single dose
– Granuloma inguinale
or
– Genital herpes
Ciprofloxacin 500 mg twice daily x 3 days

or
 Painless Erythromycin base 500 mg tid x 7 days

– Syphilis
Management Considerations
– Lymphogranuloma venereum  Re-examination 3-7 days after
treatment
 Time required for complete healing
Chancroid ( Soft Chancre ) related to ulcer size
 Lack of improvement: incorrect
diagnosis, co-infection, non-
compliance, antimicrobial resistance
 Common among sexually active men,  Resolution of lymphadenopathy may
particularly uncircumscised males require drainage
 Examine and treat partner whether
 Painful sores that eventually rupture symptomatic or not if partner contact
leaving open sores < 10 days prior to onset
Page 1

 Symptoms usually appear four to seven Syphilis

days after exposure
 SUBJECT Medicine
TOPIC Sexually Transmitted Infections
LECTURER Dr. Gabriel (June 23, 2008)
TRANSGROUP Kapitan Boom and Friends

– HIGHLY INFECTIOUS

 Syphilis is caused by a bacterium

Treponema Pallidum

 In US, over 32,000 reported cases in

2002, highest among women 20-24
years of age, in men 35-39 years of
age

 Syphilis is passed from person to

person through direct contact with
syphilis sore

 Sores occur mainly on the external

genitals, vagina, anus & can occur on
lips and mouth 2. Secondary Syphilis
 Clinical Manifestations
 Syphilis cannot be spread through • Represents hematogenous
dissemination of spirochetes
contact with toilet seats, doorknobs,
swimming pools, bath tubs, towels and • Usually 2-8 weeks after chancre
eating utensil appears

 Clinical symptoms will be based on • Findings:

different stages: primary stage,
– rash - whole body (includes
secondary and tertiary palms/soles)

 Complications can occur based on the – mucous patches

severity of the infection even affecting
pregnancy – condylomata lata - HIGHLY
INFECTIOUS

– constitutional symptoms
1. Primary Syphilis – Sn/Sx resolve in 2-10 weeks

 Clinical Manifestations

• Incubation: 10-90 days (average

3 weeks)

• Chancre

– Early: macule/papule → erodes

– Late: clean based, painless,

indurated ulcer with smooth
firm borders
Page 1

– Unnoticed in 15-30% of patients

– Resolves in 1-5 weeks

 SUBJECT
TOPIC
LECTURER Dr. Gabriel (June 23, 2008)
TRANSGROUP Kapitan Boom and Friends
3. Tertiary Syphilis
 Clinical Manifestations
• The latent (hidden) stage of
syphilis begins when secondary
symptoms disappear.
• Even without signs & symptoms
in this stage, the infection may
subsequently damage the brain,
nerves, eyes, heart, bones and
joints
Syphilis Treatment: Primary, Secondary, Early
Latent
Recommended regimen
Benzathine Penicillin G, 2.4 million
units IM
Penicillin Allergy*
Doxycycline 100 mg twice daily x
14 days
or
Ceftriaxone 1 gm IM/IV daily x
8-10 days (limitedstudies)
or
Azithromycin 2 gm single oral
dose (preliminary data)
Medicine
Sexually Transmitted Infections
*Use in HIV-infection has not been studied
Syphilis Treatment: Latent Stage
Recommended regimen
Benzathine penicillin G 2.4
million units IM at one week
intervals x 3 doses
Penicillin allergy*
Doxycycline 100 mg orally twice
daily
or
Tetracycline 500 mg orally four
times daily
-Duration of therapy 28 days; close clinical
and serologic follow-up; data to
support alternatives to pcn are limited
GENITAL LESIONS
Genital Herpes
 Caused by Herpes Simplex Virus (HSV1 &
HSV2) but most genital herpes is caused
by HSV2
 Typically occur as one or more blisters on
or around the genitals & rectum
 The blisters break resulting to ulcerative
form which may take two to four weeks to
heal the first time to occur
 Genital HSV2 is more common in women
than in men, however transmission is
more to men-to-female
 Complications are recurrent painful genital
sores in many adults
 Genital HSV can cause potentially fatal
infections in babies
 Diagnosis: PE. Culture, Serology, PCR
 Preventive measures: correct and
consistent use of condoms
Page 1
 SUBJECT
TOPIC
LECTURER Dr. Gabriel (June 23, 2008)
TRANSGROUP Kapitan Boom and Friends
Treatment
o Acyclovir 400 mg tid
o Famciclovir 250 mg tid
o Valacyclovir 1000 mg bid
o Duration: 7-10 days
Granuloma Inguinale
 Chronic infection caused by a rod-
shape bacterium
 Common among tropical countries,
where it is associated with poverty and
poor hygiene
 Most affected are ages between 20-40
years
 2:1 (male to female)
 Incubation Period: 8 days – 12 weeks
 Disease growing slowly beginning as a
pimple or lumpy eruption
Treatment
o Doxycycline 100 mg twice daily x 3 weeks
or more
o Trimethoprim-sulfamethoxazole 800
mg/160 mg twice daily x 3 weeks or more
o Minimum treatment duration three weeks
Human Papilloma Virus
 Causally associated with cervical
cancer and other anogenital squamous
cell cancers (anal, vulvar, vaginal,
penile)
 Over 99.7% of cervical cancers are
associated with HPV
Medicine
Sexually Transmitted Infections
- HPV Infection in Men:
o One or more growths on the penis,
testicles, groin, thighs or anus
o Warts maybe raised, flat or cauliflower
usually may appear within weeks or
months after sexual contact
o If ever there are symptoms, they are anal
bleeding, itching or discharge
o Transmission: genital contact, most often
during vaginal and anal sex
- HPV Infection in Women
o Warts affect the vulva, cervix, groin, anus
and thighs
o Transmission: sexual contact or through
oral sex
o Routine Pap smear screening in the U.S.
has decreased cervical cancer incidence
by more than 70%.
o HPV vaccine is recommended for girls
between 9 – 26 but the schedule is best
between 11- 13 years
Hepatitis B
 Implicated to STD’s & HIV through
semen and saliva
 Possibly by very intimate sexual
contact through perinatal transmission
Page 1
 SUBJECT Medicine
TOPIC Sexually Transmitted Infections
LECTURER Dr. Gabriel (June 23, 2008)
TRANSGROUP Kapitan Boom and Friends

HIV in Body Fluids

Blood
Semen
18,000 Vaginal
11,000
Fluid Amniotic
7,000 Fluid
, 4000 Saliva
1

Average number of HIV particles in 1 ml of these body fluids

The Four C’s In Preventing STI’s

• COUNSELLING/EDUCATION
• COMPLIANCE
• CONTACT TRACING
• CONDOM

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