Sexual transmitted diseases
• These include :
• 1. chlamydia
• 2. gonorrhea
• 3. trichomoniasis
• 4. syphilis
• 5. HPV
• 6. HIV / AIDS
• 7. herpes
• NEISSERIA GONORRHEA :
• Is a gram negative diplococcus which means
that when a sample of cervical discharge is
spread & fixed on a slide the bacteria can be
seen on microscopy as pairs of red kidney
shaped organisms, mostly sitting within
polymorphs.
• N.gonorrhea initially infects the cervix but
ascends to the upper genital tract in 10-20%
of untreated cases.
• Around half of women are asymptomatic, but
when symptoms are present the vaginal
discharge tends to be thick & purulent.
• CHLAMYDIA TRACHOMATIS :
• It is an unusual bacterium as it requires a host
cell to grow( obligate intracellular organism ) ,
behaving in some ways more like a virus.
• Chlamydia , like gonorrhea, initially infects the
cervix & sometimes also the urethra.
• Over two thirds of women with chlamydia
infection are asymptomatic.
• Syphilis :
• Caused by Treponema pallidum (a spirochete),
it is transmitted sexually & vertically in
pregnancy, therefore the condition can be
acquired & congenital.
• Acquired syphilis can be divided into early &
late , early is further subdivided into primary
& secondary & early latent (less than 2 years
infection).
• The subdivisions of late infection include late
latent ( more than 2 years) & tertiary which
includes gummatous , cardiovascular &
neurological involvement.
• Congenital is divided into early (1
st
2 years ) &
late.
• Clinical features:
• Primary syphilis is characterised by an ulcer
(the chancre)& regional lymphadenopathy.
• The chancre is classically a single , painless &
indurated ulcer with a clean base discharging
clear serum & usually in the anogenital region.
• However ,it may also be atypical , multiple ,
painful, purulent, destructive & occur at
extragenital sites.
• DDx.of anogenital ulceration:
• 1. herpes simplex
• 2. syphilis
• 3. chancroid
• 4. lymphogranuloma venereum
• 5. donovanosis
• 6. candidiasis (sever)
• 7. Behcet’s disease
• 8. scabies - excoriated
• Secondary syphilis is characterised by
multisystem involvement occuring within the
1
st
2 years of infection.
• The features include a generalized
polymorphic rash, often affecting the palms &
soles , mucocutaneous lesions , generalized
lymphadenopathy & other rare multisystem
manifestations.
• Early latent syphilis is characterised by positive
serological tests for syphilis with no clinical
evidence of treponemal infection within the
1
st
2 years of infection.
• Dx.:
• Is made by direct demonstration of T.P. from
lesions or infected lymph nodes in early
syphilis by dark field microscopy , direct
fluorescent antibody testing & tests based
upon the PCR.
• Serological tests include:
• .cardiolipin tests: Veneral Diseases Research
Laboratory (VDRL)
• .carbon antigen test/rapid plasma reagin (RPR)
• .specific tests: treponemal EIA to detect IgG ,
IgG & IgM , T.pallidum haemagglutination
assay ( TPHA) & others.
• Rx:
• The mainstay of Rx is parentral pencillin ,
suitable approaches include procaine pencillin
or Jenacillin or long acting Biclinicillin i.m. for
10 days.
• Doxycycline may also be given
• Pregnancy:
• 70-100% of the infants of pregnant women
with untreated early syphilis will be infected &
1/3 will be still born.
• Genital Herpes:
• Is acquired by sexually transmitted infection
with either herpes simplex type 1 virus (HSV-
1) which is the usual cause of oro-labial
herpes , or herpes simplex type 2 virus (HSV-2)
• The infection may be primary or non primary,
symptomatic or asymptomatic.
• After primary infection , the virus becomes
latent in local sensory ganglia , periodically
reactivating to cause symptomatic lesions or
asymptomatic but infectious viral shedding.
• Clinical features : acute infections
• Symptoms: painful ulceration,dysuria, vaginal
discharge , fever, myalgia ( flu-like symptoms) ,
may be asymptomatic.
• Signs: blistering & ulceration of vulva &/or cervix,
preceded by vesicles , inguinal lymphadenopathy.
• The acute phase lasts for 4-5 days , the lesions
heal over 8-10 days & then a latent period
ensues.
• Dx.: swabs taken from the base of a lesion for
culture , serology is not commonly used for
Dx.
• Complications :
• 1. urinary retention caused by autonomic
neuropathy or sever pain due to the local
reaction around the urethra & vulva.
• 2. chronic pelvic pain due to post herpetic
neuralgia.
• Rx.: primary herpes:
• 1. General advice: saline bathing & analgesia
with combination of NSAIDs & topical
anesthetic gels.
• 2. Antiviral drugs: indicated if commenced
within 5 days of the start of the episode & if
lesions are still developing.
• Acyclovir 200mg five times daily
• Valacyclovir 500mg twice daily
• Famcyclovir 250mg three times daily
• Recurrent herpes: are generally less sever
than primary attacks & self limitting,
supportive & episodic antiviral therapy may be
given.
• Mx. In pregnancy:
• As above with oral or i.v acyclovir; unless
there are other complications , vaginal
delivery can be anticipated.
• CS should be considered for those developing
symptoms after 34 weeks as the risk of viral
shedding during labor is very high & thus also
the risk of vertical transmission to the
neonate.
• Condylomata Acuminata (genital warts):
• Warts are benign epithelial skin tumors
caused by the human papilloma virus (HPV).
• The mode of transmission is most often
sexual,but it may be transmitted perinatally &
also from digital lesions.
• HPV subtypes 6 & 11 are particularly
associated with condylomata.
• Clinical features:
• Anogenital warts may cause irritation but
generally present as ‘lumps’ which women
find disfiguring & psychologically distressing ,
they can occur at any site in the genital area.
• Occult lesions may also occur in the vagina &
cervix , extragenital lesions may occur on the
oral mucosa, larynx, conjunctiva & nasal
cavity.
• Warts may be exophytic , single or multiple ,
keratinized & non-keratinized , broad based or
pedunculated & some are pigmented.
• Dx.:
• Is made by naked eye examination , any doubt
should prompt biopsy under local anasthesia.
• Rx.:
• Podophyllin ,podophyllotoxin & trichloracetic
acid are used in soft, poorly keratinized warts,
whereas keratinized lesions are better treated
with ablative therapies such as cryotherapy,
excision & electrocautery.
• Lesions may recur.
• Rx. In pregnancy:
• Podophyllin & podophyllotoxin should be
avoided because of their possible teratogenic
effect.The objectives of Rx.in pregnancy are to
minimize the number of lesions present at
delivery & to reduce neonatal exposure to the
virus.
• Very rarely a CS is indicated due to blockage of
the vaginal outlet.
• HIV :
• It is an extremely important, fatal disease
worldwide.
• It increases the susceptibility to other
infectious diseases such as TB , with a huge
impact on morbidity & mortality.
• It is transmitted sexually, in blood products &
to the fetus vertically & through breast
feeding.
• The aims of Rx.are to prolong life & improve
quality of life by maintaining suppression of
virus replication for as long as possible.
• Rx.is recommended for patients with primary
HIV infection, asymptomatic HIV infection &
symptomatic HIV infection ; however Rx.is not
indicated in patients with asymptomatic HIV
infection with a CD4 count that is high ( >350
cells/ml).
• The dramatic fall in AIDs-related mortality
seen in the developed world coincided with
the introduction of highly active antiretroviral
therapy (HAART) regimens.
• HAART consists of 3 drugs which can be from
a variety of types : protease inhibitors, non-
nucleoside reverse trasnscriptase inhibitors or
nucleoside reverse transcriptase inhibitors.
• HIV & pregnancy:
• There is a small increased risk of abortion, still
birth & IUGR.There is a vertical transmission
risk of 25% .
• The use of Zidovudine reduce the risk from
25% to 8% .
• CS is shown to be protective in terms of
transmission, also there is increased risk with
breast feeding & formula feeding is advocated.
• HIV & contraception:
• Using condoms as well as reliable hormonal
method to prevent pregnancy.
• Women are adviced that there is decreased
efficacy of the oral contraceptive pills with
protease & non-nucleoside reverse
transcriptase inhibitors , this is also important
with progesterone only methods as POP,
depot & delivery systems.