Sexullay transmitted diseases د.وسام اللامي
Sexullay transmitted diseases can present as: Genital ulcers, Urethritis, Cervicitis, Vaginal discharge, and Papules. In developed countries, most patients who have genital ulcer have either herpes virus, syphilis, or chancroid. Herpes is the most prevalent.Syphilis
Infection with the causative organism, Treponema pallidum, may be congenital, acquired through transfusion with contaminated blood, or by accidental inoculation. The most important route, however, is through sexual contact with an infected partner.
Congenital syphilis
Congenital syphilis is rare. Otherwise, stillbirth is a common outcome, although some children with congenital syphilis may develop the stigmata of the disease only in late childhood.Acquired syphilis
After an incubation period ( 9 –90 days ), a primary chancre develops at the site of inoculation. Often this is genital, but oral and anal chancres may appear. A typical chancre is a painless, button-like ulcer of up to 1 cm in diameter accompanied by local lymphadenopathy. Untreated it lasts about 6 weeks and then clears leaving scar.The secondary stage may be reached while the chancre is still subsiding. Systemic symptoms and a generalized lymphadenopathy with eruptions that at first are macules, and later papules. Lesions are distributed symmetrically and are of a coppery ham colour. Sometimes they resemble pityriasis rosea or guttate psoriasis. Classically, there are obvious lesions on the palms and soles. Condylomata lata are moist papules in the genital and anal areas. Other signs include a ‘moth-eaten’
alopecia and mucous patches in the mouth. The skin lesions of late syphilis may be nodules that spread peripherally and clear centrally. Gummas are granulomatous areas; in the skin they quickly break down to leave punched-out ulcers that heal poorly, leaving papery white scars.
The diagnosis of syphilis in its infectious (primary and secondary) stages can be confirmed by using dark-field microscopy which can detect spirochaetes in smears from chancres, oral lesions or moist areas in a secondary eruption.
Serological tests for syphilis become positive only some 5 – 6 weeks after infection (usually a week or two after the appearance of the chancre). The non-treponemal (rapid plasma reagin [RPR] and Venereal Disease Research Laboratory [VDRL]) tests are 78 – 86% sensitive in primary and 100% sensitive in secondary syphilis, but may produce false positive results. Positive results are thus confirmed with more specific treponemal tests such as the fluorescent treponemal antibody/absorption (FTA/ABS) and T. pallidum particle agglutination (TPPA) tests, although HIV infection may cause false negative results.
Penicillin G benzathine 2.4 million unit intramuscular once is still the treatment of choice, in early syphilis and weekly for three weeks in late-stage disease or in early syphilis with neurological involvement. Doxycycline 100 mg twice daily for 14 days or azithromycin 2 gm oral once are alternatives for those with penicillin allergy. Patients with concomitant HIV infection need longer treatment and higher doses.
Chancroid
Chancroid (soft chancre) is an infectious, ulcerative STD caused by the Gram-negative bacillus Haemophilus ducreyi . One or more deep or superficial tender ulcers on the genitalia, and painful inguinal adenitis in 50%, which may suppurate, are characteristic of the disease. Chancroid begins as an inflammatory macule or pustule 1-5 days-or rarely as long as 2 weeks-after intercourse. lt generally appears on the distal penis or perianal area in men, or on the vulva, cervix, or perianal area in women. The ulcers appear punched out or have undermined irregular edges surrounded by mild hyperemia. The base is covered with a purulent, dirty exudate. The ulcers bleed easily and are very tender. The definitive diagnosis of chancroid requires identification by culture. Chancroidal genital ulcer disease facilitates the transmission of HIV infection.The treatment of choice for chancroid is azithromycin, 1 g orally in a single dose. Erythromycin, 500 mg four times a day for 7 days; cefotriaxone, 250 mg intramuscularly in a single dose; and ciprofloxacin, 500 mg orally twice a day for 3 days, are also recommended treatments.
Urethritis
Urethritis characterized by urethral discharge of mucopurulent or purulent material and sometimes by dysuria or urethral pruritus. N.gonorrhoeae and C. trachomatis are the principal pathogens.The presence of nongonococcal urethritis is demonstrated by the absence of gram negative intracellular diplococcic, a negative gonococcal culture result, and the detection of inflammatory cells (at least five polymorphonuclear leukocytes) in the urethral smear or in the urine sediment consequently for each patients with clinical symptoms of urethral inflammation.
Gonococcal urethritis
Is a gram negative coccus that infects columnar or cuboidal epithelium. The neutrophilic response create a purulent discharge, and stained smear show large numbers of phagocytosed gonococci in pairs ( diplococcic) within polymorphonuclear leukocytes. Can survive only in moist environment approximating body temperature .It is transmitted only by sexual contact (genital, genital-oral, or genital-rectal ) with an infected person. It is not transmitted through toilet seats. After 3-5 days incubation period, most infected men have a sudden onset of burning frequent urination, and a yellow, thick purulent urethral discharge. infection may spread to the prostate gland, seminal vesicles, and epididymis, but presently these complications are uncommon because most men with symptoms are treated.In females traditionally has been described as an asymptomatic disease, but symptoms of urethritis and endocervicitis found in 40%-60% of the women. Urethritis begins with frequency and dysuria after 3-5 days incubation period. Pus may discharge from the red external urinary meatus or after the urethra is milked with a finger in the vagina. endocervical infection may appear as nonspecific,pale yellow vaginal discharge. cervix may appear normal or show marked inflammatory changes with erosions or pus exuding from the os. The bartholin ducts, which open on the inner surface of the labia majora may, if infected, show drop fo pus at the gland orifice. After occlusion of the infected duct, the patients complains of swelling and discomfort while walking or sitting.
Diagnosis considered only if the gram negative diplococcic are present inside polmorphonuclear leukocytes( because N.catarralis and N sicca normaly inhabit the female genitalia).nucleic acid amplification tests are used on urethra and endocervix samples. Culture may be used for diagnostic problem. Drug of choice in the treatment of gonorrhea is cefixime 400mg, ciprofloxacin 500mg,ofloxacin 400mg or cefotriaxone 500mg intramusculary all in single dose. All patients should also receive a course of treatment effective for Chlamydia.
Non-gonococcal urethritis
Genital chlamydial infection is responsible for about half of NGU . In approximately third of cases no cause found. Ureaplasma urealyticum and Mycoplasma genitalium may cause 10%-30% of NGU cases.
In male urethritis begins with dysuria and urethral discharge. NGU begins 7 to 28 days after sexual contact with a smarting sensation while urinating and a mucoid discharge. In female signs and symptoms in females are even more nonspecific. Nongonococcal cervicictis is asymptomatic or begins with a mucopurulent endocervical exudates or a mucoid vaginal discharge.
Diagnosis is made by confirming the presence of urethritis, demonstrating the presence of C.trachomatis, and excluding gonococcal infection. A gram stain is made of urethral discharge, the presence of polymorphonuclear leukocytes confirm the diagnosis of urethritis, and the absence of gram negative intacellular diplococcic suggest urethritis is nongonococcal. Material for gram stain is most effectively obtained at least 4 hours after urination.
Doxycycline 100 mg twice daily for 7 days or azithromycin 1 gm oral once are the drugs of choice. Alternative drugs include levofloxacin 500mg oral once daily for 7 days or erythromycin 500 mg four time daily for 7 days.