Key Points in Course Material
Section 1.
The Clinical Approach to STD Patients
1.0 Taking a Sexual
History
When taking a sexual history, remember
the
following considerations:
- Make no assumptions about a patient's
behavior based on his/her marital, educational, or socioeconomic status
- Reinforce confidentiality
- Avoid leading questions and use gender
neutral terms
- Use words appropriate for the level of
understanding and be clear
2.0 Physical Examination of the Female
For Examination Techniques:
- Explain examination procedure before
undressing the patient
- Touch a "non-genital" area
of the body first
- Make eye contact
- Talk to the patient during exam, but
avoid talking down
- Watch for signs of discomfort (facial
expressions, not relaxed, guarding)
- Avoid lengthy discussions when patient
is in a compromising position
- Remove examination light off of genital
area as soon as possible
- Examine painful areas last
2.1 Examination
2.1.1 Prepare the Patient for the Pelvic Examination
Remember:
- The pelvic examination usually evokes much anxiety,
even for the woman who is not concerned about an STD. Therefore, every
effort should be made to increase comfort during the examination.
3.0 Physical Examination of the Male
Examination Techniques
- Explain exam procedure before undressing
the patient
- Touch a "non-genital" area
of the body first
- Make eye contact
- Talk to the patient during the exam
- Watch for signs of fainting, i.e., sweaty
palms, weak knees, excessive perspiration
- Avoid lengthy discussions when patient
is in a compromising position
- Remove exam light off of genital area
as soon as possible
- Examine painful areas last
Section 2. Syphilis
1.2 Epidemiology
1.2.0 Incidence Trends in the USA
- Syphilis is not evenly distributed in
US.
- Incubation period up to 90 days (average
21 days)
- Most infectious early in the disease (primary,
secondary, early latent)
1.3 Clinical Manifestations
- Primary syphilis: painless, indurated ulcer; may be
multiple in 25% of cases
- Secondary syphilis: rash, constitutional symptoms, condyloma
lata, mucous patches, generalized adenopathy.
- Latent syphilis: defined as a positive serology in
the absence of symptoms
- Early latent: infection of < 1 year duration, as
evidenced by one of the following: documented seroconversion, unequivocal
signs/symptoms of primary or secondary syphilis or sexual contact with
case of primary, secondary or early latent syphilis
- Late latent: infection of > 1
year duration
1.3 Clinical Manifestations
1.3.4 Tertiary Syphilis
- Treponemal invasion of CNS common in early
syphilis, but most do not develop neurosyphilis
- Symptomatic neurosyphilis may occur at
any stage of infection
- CSF VDRL not 100% sensitive, so must evaluate
for CSF pleocytosis or increased protein
1.3 Clinical Manifestations
1.3.5 Syphilis and Concomitant HIV Infection
- Genital ulcerations are a risk factor
in the development of HIV infection. An increased incidence of HIV infection
has been noted in patients with syphilis and vice versa.
- All patients with syphilis should be counseled
on HIV infection, and HIV testing should be recommended. In addition, all
patients who are HIV positive should be tested for syphilis.
1.4 Laboratory Diagnosis
1.4.2 Serological Testing
- Nontreponemal tests: RPR, VDRL
- Nonspecific, must be confirmed by treponemal
test
- Lack of sensitivity in primary syphilis
- Treponemal tests: FTA-ABS, TP-PA
- More specific, fewer false positives
- Often positive for life, so not to be
used to assess response to Treatment
1.6 Treatment for Syphilis
1.6.3 
Recommended Treatment for Syphilis during Pregnancy
Penicillin is the only recommended treatment for
syphilis during pregnancy. Pregnant women infected with syphilis who are
allergic to penicillin should be desensitized under observation in the hospital
and treated with penicillin.
1.7 Follow-up
Recommended Follow-up after Treatment
of Syphilis (non pregnant
HIV negative patients)
Primary and Secondary Syphilis
- VDRL or RPR at 6 and 12 months
- Fourfold drop in titers generally expected after
6 months
Latent Syphilis
- VDRL or RPR at 6, 12 and 24 months
- a titer of > 1:32
should fall 4-fold within 12-24 months
Pregnancy
- VDRL or RPR in the third trimester and at delivery,
monthly if at high risk of reinfection or area of high prevalence of syphilis.
Response should be the same as for non-pregnant persons.
HIV infection
- VDRL or RPR at 3, 6, 19, 12 and 24 months for
primary and secondary syphilis, and 6, 12, 18 and 24 months for latent
syphilis.
- Expect a fourfold decrease within 6 to
12 months for primary and secondary syphilis, and within 12 to 24 months
for latent syphilis.
Section 3. Gonococcal Infections
1.3.0 Epidemiology
Incidence in the USA
Following a 74% decline in the reported rate of
gonorrhea in the USA from 1975 to 1997, rates increased in 1998 and have
since decreased more slowly. However, the infection is not
uniformly distributed in the US. Rates are higher among adolescents,
minorities, and persons residing in large cities or in the Southern US. The
incubation period for gonorrhea averages 2 to 7 days, with a range of 1 to
14 days.
1.4.0 Clinical Manifestations
The clinical manifestations of gonococcal infections
are generally more pronounced than those of chlamydial infections. The discharge
associated with urethritis is purulent and the dysuria is generally intense.
However, one should not make a diagnosis on clinical manifestations
alone as that can be misleading. Laboratory confirmation is required.
1.5.2 Culture
The culture remains the gold standard for
the detection of Neisseria gonorrhoeae. Atmospheric and transport
conditions must be respected for optimal sensitivity. Nucleic acid tests
require no viable organisms and have very good test performance characteristics.
However, they cannot be used for all anatomical sites, for test of cure
nor for antibiotic susceptibility testing.
1.6 Treatment
- Resistance to penicillin and tetracycline is
common among US isolates
- Fluoroquinolone resistance is very common in
SE Asia as well as Hawaii and California, and is spreading in other areas
of the United States. It is more common among MSM cases.
- Treatment for concomitant infection with Chlamydia
is recommended if lab results are not available, high prevalence area,
patient unlikely to return for results.
Section 4. Chlamydial Infections
1.2 Epidemiology
1.2.0 Incidence in the USA
- Chlamydia is the most common reportable STD
in the US
- More geographic distribution than gonorrhea
or syphilis
- Rates highest in adolescent women
1.3 Clinical Manifestations
- Asymptomatic infection is common in both men
and women
- Chlamydia and gonorrhea can infect the same
anatomic sites, but symptoms tend to be milder with chlamydia
- Clinically differentiating GC from CT is inaccurate,
so laboratory confirmation is recommended
1.4 Laboratory
Diagnosis
- Amplified nucleic acid tests are currently the
most sensitive laboratory methods for the detection of Chlamydia trachomatis.
Urine specimens can also be used with these new technologies.
- Rapid in-office tests do not, as of yet, offer
an adequate sensitivity and so are not currently recommended.
1.4 Laboratory Diagnosis
1.4.2 Culture
- Culture has low sensitivity, but 100% specific
and can be used for any anatomic site
- Antigen detection systems lack in sensitivity
- Non-amplified DNA probe less sensitive for CT
than GC
- Amplified nucleic acid tests new gold standard,
highly sensitive, can be used on urines, but not approved for all anatomic
sites
1.8 Screening and Prevention
1.8.0
Women
- The
,
the USPSTF,
and many other professional organizations recommend that all sexually active
women aged 25 or less be screened for Chlamydia trachomatis.
Section 5. Human Papillomavirus Infections
1.1.1 Natural History of Infection
- Natural history varies among individuals depending on viral and host
factors
- Many have asymptomatic infection
- Genital warts can regress spontaneously in 10% to 30%
- Reoccurrences common after treatment (up to 60%).
1.2 Epidemiology
1.2.0 Prevalence in the USA
- HPV is the most frequent viral STD, estimated to infect 20-40 million
adults in the US
- Rates highest in young, sexually active population, with peak prevalence
in 20-24 year olds
1.2 Epidemiology
1.2.1 Transmission and Incubation
- Transmission of HPV probably requires contact with viable HPV and microtrauma
to the skin/mucous membranes.
- It can occur from asymptomatic and subclinical patients.
- Prior HPV infection at other sites does not appear to convey protection.
- Incubation period can be long, and subclinical infections predominate.
1.3.0 Clinical
Manifestations
The spectrum of clinical manifestations
of HPV includes:
- Subclinical infection
- Benign Lesions (condyloma acuminata, dome-shaped
papules, keratotic warts and flat warts)
- Premalignant lesions (Bowenoid papulosis, intraepithelial
neoplasis)
- Malignant lesions (cancer - vulvar, cervical,
anal, penile)
1.3 Clinical Manifestations
1.3.2 Men
- Visual inspection usually adequate for diagnosis of genital warts; biospy
recommended for atypical appearance (pigmented, fixed, indurated or ulcerated).
- Acetic acid staining not generally recommended.
- Cervical cytology, by standard or liquid-based methods, recommended
annually for sexually-active women.
- HPV DNA testing and typing not generally recommended, but may be useful
for triaging ASCUS
1.6 Treatment
- Goal of treatment is removal of symptomatic
warts; no treatment modality will eradicate the virus.
- Small lesions may regress on their own in immunocompetent
patients.
- Treatment of warts may or may not lower infectivity,
and does not influence the risk of developing cervical cancer.
- Cervical cytology screening is not recommended
any more frequently in women with genital warts.
- Recurrence of genital warts after treatment
is common.
Section 6. HSV Infections
1.2 Epidemiology of Genital Herpes Infections
1.2.0 Global Significance
- HSV is the most common overall cause
of genital ulceration in the world.
- In US, most genital herpes caused by HSV-2,
but up to 10-50% caused by HSV-1
- Prevalence of HSV-2 infection in US approximates
22%, but most to the infections are subclinical or asymptomatic.
1.2 Epidemiology of Genital Herpes Infections
1.2.3 Transmission & Incubation
Period
- Prior infection with HSV-1 attenuates severity of subsequent HSV-2 infection.
- Risk of acquiring infection from an infected partner approximates 10%
per year
- Most transmission occurs in the absence of clinical lesions.
1.3.0 Definition
of Terms
Initial
(Primary) Infection:
Symptomatic initial (primary) infection
characterized by:
- Incubation period 2-12 days
- Multiple, usually bilateral lesions often accompanied by systemic symptoms
- Total duration 2-4 weeks.
Recurrent
Infection
Recurrent outbreaks characterized
by:
- Milder symptoms and fewer lesions, usually unilateral and localized
- Total duration 5 -10 days
- May have atypical appearance, lacking classic vesicular lesions
- Average number of recurrences 5/year for HSV-2, < 1 per year for
HSV-1.
Asymptomatic
Shedding
- Asymptomatic shedding common with HSV-2 infection
- Can occur up to 28% of days in first two years
after infection
- Becomes less frequent with established infection
1.4 Laboratory Diagnosis
1.4.0 Viral Culture
- Viral culture generally sensitive early in infection/outbreak,
but negative culture does not rule out infection
- Older serologic test not specific for HSV-2,
so not helpful
- New type-specific serologies based on glycoprotein
G, and G2 (Western Blot, type-specific ELISA) may be useful, for the diagnosis
of atypical or subclinical infections
1.6 HSV in Pregnancy
1.6.0 Risk of Mother to Infant Transmission
- Risk of transmission
is highest for primary maternal infection (30-60%), and is much lower
for recurrences (< 1%)
- Most cases occur in infants or women without
signs or symptoms of HSV infection during pregnancy.
- Cesarean section is indicated if active lesions
and/or prodomal symptoms are present at the time of delivery
- Acyclovir suppression may be useful for cases
of primary infection during pregnancy
Section 7. Syndromic Approach to the Management of
STDs
Cervicitis
1.1 Etiology
1.1.0 Infectious Causes
Cervicitis can be caused
by C. trachomatis or N. gonorrhoeae, although in most
cases, neither organism can be isolated.
- Most commonly identified microbial etiologies
are CT or GC, but often no etiology is found
- May lead to PID if GC or CT present
1.2 Clinical Manifestations
- The diagnosis of MPC is made by visualization
of mucopurulent discharge in the endocervical canal.
- When seen on an endocervical swab the finding
is referred as a positive swab test.
- Friability alone may also be diagnostic for
MPC.
1.3 Laboratory
Diagnosis and Clinical Evaluation
- Laboratory evaluation of MPC should include
testing for GC and CT, wet mount for Trichomonas vaginalis,
and testing for HSV if indicated
- Treatment decisions should be based on preliminary
evaluation, prevalence of disease in the geographic area, and patient compliance
with follow-up
Urethritis
2.0 Definition
Urethritis is defined by a urethral inflammation most
often manifested by urethral discharge and/or dysuria and/or itching.
Urethritis is confirmed by one of 3
criteria:
- Presence of purulent or mucopurulent discharge
- > 5 WBCs per
oil immersion field (1000X) on gram stain of mucopurulent discharge.
- FVU with > 1+
leukocyte esterase or > 10 WBCs per high dry
(400X) in sediment of spun urine
2.4 Laboratory Diagnosis
- GU typically has an abrupt onset with severia
dysuria and discharge
- NGU typically has a gradual onset with mild dysuria
and discharge
- Distinguishing GU from NGU on clinical grounds
alone is not reliable
- Test all cases of urethritis for both GC and
CT
Genital Ulcerative Disease
3.2 Clinical Manifestations
While the clinical presentation of
GUD differs based on etiology, laboratory confirmation of diagnosis is
necessary because:
- Clinical presentations may overlap or be atypical
- Physical diagnosis is neither sensitive nor specific
for GUD (inaccurate)
- Coinfections may occur in up to 10% of cases
Pelvic Inflammatory Disease (PID)
4.1 Epidemiology
Incidence and Prevalence
- PID mainly affects women aged 15 - 24
- Associated with GC or CT infection, but is often
polymicrobial
- Sequelae include chronic pelvic pain, infertility
and increased ectopic pregnancy risk
- Risk for sequelae unrelated to severity of the
disease, which is often milder for CT
4.5 Treatment
- Treatment regimens should cover gonorrhea, chlamydia,
anaerobes, gram negative facultative bacteria and streptococci.
4.7 Sequelae of PID
- Approximately 25% of women with a single episode
of PID will experience sequelae, including ectopic pregnancy, infertility,
and chronic pelvic pain.
- The risk of ectopic pregnancy in a subsequent pregnancy is increased
6 to 10 fold.
- Tubal infertility occurs overall in 20% of salpingitis patients.
Vaginitis
5.0.2 Etiology and Epidemiology
Most Frequent Etiologies of Abnormal
Vaginal Discharge
- The most frequent etiologies of vaginal discharge/vaginitis
are bacterial vaginosis, candidiasis and trichomoniasis.
5.1.1 Pathogenesis
-
Bacterial vaginosis is
characterized by a reduction in lactobacilli and an increase in the
number of anaerobic bacteria, G. vaginalis, M. hominis and Mobiluncus.
-
Most cases of yeast infections
(50%) are caused by Candida albicans.
5.3 Diagnosis
Diagnostic Criteria
- Assessment of vaginal discharge, pH determination
and wet preparations (saline and KOH) of vaginal secretions are the recommmended
first line of approach.
Section 8. Viral Hepatitis
Viral Hepatitis
1.0 Comparison of Viral Hepatitides
- Sexually transmitted viral hepatitides are primarily
A and B, and to a much lesser degree, C.
Hepatitis A
2.0 Epidemiology
2.0.0 Global Incidence
- The primary mode of transmission of Hepatitis
A virus appears to be fecal-oral.
- Sexual practices involving oral-anal/oro-genital
contact may facilitate exposure.
- Prevalence of anti-HAV antibodies is higher
among MSMs compared to men who have sex with women.
- HAV infected individuals can be considered infectious
from 2 weeks before to 1 week after the onset of illness.
- Incubation period of Hepatitis A virus is on
average 4 weeks.
2.2 Laboratory Diagnosis and Clinical Evaluation
- The diagnosis of acute hepatitis A requires
the presence of IgM.
- The presence of IgG in the absence of IgM signals
immunity either by remote infection or successful vaccination.
- In a patient with recent onset of acute hepatitis,
the absence of IgM(anti-HAV) generally rules out Hepatitis A as a cause
of current symptoms.
2.6 Prevention and Pre-Vaccination Screening
- Two HAV vaccines are licensed in the USA but
neither is approved for children less than 2 years of age.
- Both have a two dose regimen for adults with
the second dose given 6-12 months after the first dose.
Viral Hepatitis- Hepatitis B
3.0 Epidemiology
3.0.2 Modes of Transmission, Incubation period,
and Infectivity
- Blood borne exposure is the most effective vehicle of transmission for
HBV.
- Sexual transmission of HBV has also been well documented and is the
most commonly reported mode of transmission.
3.1 Clinical Manifestations
3.1.1 Natural History and Complications
- Persistent infection (chronic carrier state) is defined by a positive
HBsAg >6 months.
- Up to 10% of persons infected with HBV will become chronic carriers
and this is inversely related to age.
- One third of chronic carriers develop chronic hepatitis with fibrosis,
which, in 40% of cases, will lead to cirrhosis.
3.2 Laboratory Diagnosis
3.2.0 HBV Viral Markers
- The presence of HBsAg identifies HBV infected patients who are infectious.
- A "window" period" exists when anti-HBC (IgM and total
IgG) maybe the only marker present.
Viral Hepatitis- Hepatitis C
4.1 Modes of Transmission and Incubation Period
- HCV is primarily transmitted through large or repeated direct percutaneous
exposures to blood.
- Sexual transmission appears inefficient.
- Vertical transmission occurs in 5-6% of HCV positive mothers, and in
14-17% in mothers co-infected with HIV.
4.3 Laboratory Diagnosis
- Anti-HCV RIBA is used to confirm a positive anti-HCV EIA.
- HCV RNA may be detected transiently during the course of chronic HCV
infection.
- Most persons (70%) with HCV are infected with Geno-type 1 in the United
States.
4.5 Screening
- Recommendations for screening are based on the risk of infection.
- Persons who ever injected illegal drugs, including those who injected
once or a few times many years ago, and do not consider themselves as drug
users, are at risk and should be offered screening.
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