Sexually Transmitted

Infections

Dr Harinarayan Radhakrishna
FoCP / ICP 23/11/2018
Plan
Learning outcomes
Sexual history taking
Urethritis – gonococcal, chlamydia, non-gonococcal
Genital ulcers – Herpes, Syphilis, Lymphogranuloma
venereum
Learning Outcomes
• Demonstrate knowledge and understanding of the
range of presentation of STIs
• Demonstrate the ability to construct a plan for the
initial management of a patient presenting with
possible STI: including relevant contact history;
investigation and treatment.
 CORE CONDITIONS:
UTI, Systemic Infection [any cause]
CORE PRESENTATIONS
Difficult micturition and dysuria,
Infection [symptoms of]
Lymphadenopathy
Scenario
• A 25 year - old male presents to your GUM clinic with urethral
discharge and painful micturition.

What further history would you want to obtain?

Minimum sexual history for symptomatic Minimum sexual history for symptomatic
female patient attending for STI testing. male patient attending for STI testing.

Source: BASHH
Urethritis
Symptoms: Discharge per urethra, dysuria, urethral itching, orchalgia
Signs: Urethral discharge, meatitis
Transmission: Sexually acquired in the majority of (but not all) cases.
Aetiology:
Gonococcal urethritis (GCU) Non-gonococcal urethritis (NGCU)
Neisseria gonorrhoeae Chlamydia trachomatis
Mycoplasma genitalium
Ureaplasma urealyticum
Herpes Simplex Virus (HSV)
Trichomonas vaginalis (TV)
 Urethritis
Diagnosis & Investigations
• A mucopurulent or purulent urethral discharge
• Urethral smear - five leukocytes per oil immersion field on microscopy
• First-voided urine specimen that demonstrates leukocyte esterase on
dipstick test or at least 10 WBCs per high-power field on microscopy
• All patients with urethritis should be tested for Neisseria
gonorrhoeae and Chlamydia trachomatis.
• Urethral smear gram-negative diplococci on gram stain. (N. gonorrhoeae)
• Urethral culture for N gonorrhoeae and C trachomatis
• Nucleic acid amplification tests (NAAT) for gonococcal
urethritis, Chlamydia, Mycoplasma species, Ureaplasma species, and T
vaginalis
 Urethritis
Diagnosis & Investigations
• A mucopurulent or purulent urethral discharge
• Urethral smear - five leukocytes per oil immersion field on
microscopy
• First-voided urine specimen that demonstrates leukocyte
esterase on dipstick test or at least 10 WBCs per high-power field
on microscopy
• All patients with urethritis should be tested for Neisseria
gonorrhoeae and Chlamydia trachomatis.
• Urethral smear gram-negative diplococci on gram stain. (N.
gonorrhoeae)
 Urethritis
Diagnosis & Investigations
• Urethral culture for N gonorrhoeae and C trachomatis
• Nucleic acid amplification tests (NAAT) for gonococcal
urethritis, Chlamydia,
Mycoplasma species, Ureaplasma species, and T vaginalis
• Other STIs testing – HSV, syphilis and HIV serology
• Nasopharyngeal and/or rectal
• Pregnancy testing: Women who have had unprotected
intercourse
Urethritis
Treatment of non-gonococcal urethritis
• Doxycycline 100mg twice daily PO for 7 days or
Azithromycin 500mg stat then 250mg once daily PO for the
next four days.

• Other preventive measures, advice, partner notification,

screening.
Gonococcal Urethritis
Aetiology: Gram – ve biscuit shaped diplococci, Neisseria
gonorrhoeae.
Incubation period: 2-7 days
 GCU Symptoms
Women Men
Vaginal discharge : most common, vaginal discharge from endocervicitis Urethritis: major manifestation. Initial - burning micturition, serous
- thin, purulent, mildly odorous; however, many patients have minimal discharge →→ becomes more profuse, purulent, may be blood tinged.
or no symptoms.
Dysuria Acute epididymitis: Usually unilateral, often in
Intermenstrual bleeding conjunction with a urethral
Dyspareunia exudate. Testicular pain.
Mild lower abdominal pain Urethral strictures: uncommon in the antibiotic
If the infection progresses to pelvic inflammatory disease (PID), era, but can present with
symptoms may include: ↓and abnormal urine stream
Lower abdominal pain: Most consistent symptom of PID & with the secondary
↑↑ vaginal discharge / mucopurulent urethral discharge complications of prostatitis
Dysuria: Usually without urgency / frequency and cystitis
Cervical motion tenderness Rectal infection: pain, pruritus, discharge,
Adnexal tenderness (usually bilateral) or adnexal mass tenesmus
Intermenstrual bleeding
Fever, chills, nausea, and vomiting (less common)
Disseminated gonococcal infection (DGI) : arthritis-dermatitis syndrome. Joint / tendon pain - most common presenting complaint in early stage.
2nd stage of DGI - septic arthritis. The knee is the most common site of purulent gonococcal arthritis.
Neonates: bilateral conjunctivitis (ophthalmia neonatorum) often follows vaginal delivery from an untreated mother with a gonococcal infection.
Symptoms of gonococcal conjunctivitis: eye pain, redness, purulent discharge.
 GCU Signs
Women Men
Mucopurulent / purulent vaginal, urethral / cervical Mucopurulent / purulent urethral discharge:
discharge Obtained by milking the urethra along the shaft of
Vaginal bleeding; vulvovaginitis in children the penis
Cervical friability - Tendency to bleed upon Epididymitis: Unilateral epididymal tenderness and
manipulation oedema, with / without penile discharge / dysuria
Cervical motion tenderness during bimanual pelvic Penile oedema without other inflammatory signs
examination Urethral stricture: uncommon
Fullness and/or tenderness of the adnexa, unilateral
or bilateral (eg, ovaries, fallopian tubes)
Lower abdominal pain/tenderness, with / without
rebound tenderness
Low back pain - More common in progression to
PID
RUQ abdominal tenderness (with perihepatitis)
Disseminated gonococcemia, acral pustules

Gonococcal conjunctivitis of the right eye

Fitz-Hugh-Curtis Syndrome which is
perihepatitis caused by inflammation of
Glisson’s capsule surrounding the liver
resulting in RUQ pain.
GCU - Investigations
• Microscopy of Gram-stained genital specimens allows direct
visualization of N. gonorrhoeae as monomorphic Gram-
negative diplococci within polymorphonuclear leukocytes.
• NAAT- High sensitivity (96%) in both asymptomatic and
symptomatic infection. Equivalent sensitivity in urine and
urethral swab specimens from men and in vaginal and
endocervical swabs from women.
• Culture continues to offer a specific, sensitive and cheap
diagnostic test at genital sites.
• Screening for coincident STIs should routinely be performed
in patients with or at risk of gonorrhoea
GCU - Rx
Treatment for uncomplicated anogenital infection
Ceftriaxone 500 mg IM as a single dose
with
Azithromycin 1 g oral as a single dose
Treatment of Gonococcal PID
Ceftriaxone 500mg IM
immediately followed by 14 days
Oral doxycycline 100mg twice daily
plus
Metronidazole 400mg twice daily

Treatment of Gonococcal epididymo-orchitis

Ceftriaxone 500 mg IM
plus 10–14 days
Doxycycline 100 mg twice daily
GCU - Rx
• Treatment of Gonococcal conjunctivitis
• 3 day systemic regimen is recommended as the cornea may be
involved and is relatively avascular.
• The eye should be irrigated with saline/water
• Ceftriaxone 500 mg intramuscularly daily for three days

Treatment of disseminated gonococcal infection

• Ceftriaxone 1 g IM or IV every 24 hours or cefotaxime 1 g IV every
eight hours or ciprofloxacin 500 mg IV every 12 hours or
spectinomycin 2g IM every 12 hours for 7 days
GCU - Rx
• Other preventive measures, advice, partner
notification, screening.
 GCU - Complications
Women Men
Tubal scarring and infertility. Urethral strictures - less common
Tubo ovarian abscess, endometritis, Fitz-Hugh-Curtis Rare: penile lymphangitis, periurethral abscess,
syndrome (perihepatitis) acute prostatitis, seminal vesiculitis, infection of the
Incidence of ectopic pregnancy ↑ 7- 10 fold in Tyson and Cowper glands.
women with previous salpingitis.
Gonococcal urethritis
Infection of periurethral (Skene) or Bartholin glands.

Most common cause of arthritis in the adolescent. (septic or reactive)

Corneal scarring after ocular gonococcal infections
Destruction of cardiac valves in gonococcal endocarditis
Death from congestive heart failure related to endocarditis
Central nervous system complications of gonococcal meningitis
Chlamydia
Aetiology
• Gram –ve, ovoid, obligate intracellular bacterium C. trachomatis.
• Most commonly reported curable bacterial STI in the UK.
Incubation period: 1-3 weeks
 Chlamydia - Symptoms
Women Men
- Untreated infections may persist for months Asymptomatic in up to 98%
- Usually asymptomatic Epididymitis – testicular pain.
- Urethritis: Urethritis
- Dysuria - ‘Sterile Pyuria Syndrome’ - Mild to moderate, clear or white urethral
1.Persistent dysuria and pyuria discharge
2.No frequency / urgency
3.-ve urine culture
Others
- Cervicitis
1. post-coital bleeding (Friable Cervix)
2. MP discharge from cervix
- Vaginitis
Vaginal Discharge (no odour, mucous)
- Pelvic Pain
Pelvic Inflammatory Disease
 Chlamydia - Signs
Women Men
Cervical friability (easy bleeding on Mucopurulent urethral discharge (elicited by
manipulation) having the examiner or patient milk the
Intermenstrual bleeding urethra)
Mucopurulent cervical or vaginal discharge Mucopurulent rectal discharge (from anal
Urethral discharge (usually thin and mucoid) intercourse)
Mucopurulent rectal discharge (from anal Urinary frequency or urgency
intercourse) Dysuria
Cervical motion tenderness Scrotal pain, tenderness, or swelling
Dysuria (sometimes unilateral)
Adnexal fullness or tenderness, associated with Perineal fullness (related to prostatitis)
progression to PID
Lower abdomen tender to palpation
Upper right quadrant abdominal tenderness
(Fitz-Hugh-Curtis syndrome)
Chlamydia cervicitis
 Chlamydia - Management
Investigations
NAAT
PCR
Urine for chlamydia
Swab C & S for Chlamydia
Urinalysis Leukocyte Esterase test
Urine Chlamydia Antigen
Gram Stain findings
Everted inner lid swab for Chlamydia PCR (neonates)
Screening for coincident STIs
Rx
Azithromycin 1 g PO single dose or
Doxycycline 100 mg PO bd x 7 days
Other preventive measures, advice, partner notification, screening.
Chlamydia - complications
• Pelvic Inflammatory Disease
• Infertility
• Preterm labour
• Perinatal transmission to new born
- Chlamydia Conjunctivitis
- Neonatal Chlamydia Pneumonia
• Epididymitis (men)
Chlamydia - complications
• Reiter's Syndrome (more common in men)
- Arthritis, conjunctivitis, urethritis
• Fitz-Hugh-Curtis Syndrome (rare) - Perihepatitis Syndrome
presents with right upper quadrant pain
• Extra-genital infections
- Chlamydia Conjunctivitis
- Pharyngitis (oral sex)
- Anal infection (Receptive anal intercourse)
- Trachoma - most common infective cause of blindness
 Genital Ulceration
‘CHISEL’

• Painful Ulcers • Painless Ulcers

Chancroid Granuloma
Herpes Genitalis Inguinale
Syphilis (Early)
Lymphogranuloma
venereum
Genital Herpes
Aetiology
• Herpes simplex viruses 1 and 2 (HSV-1 and HSV-2)
• Transmitted via contact with infected skin and subsequent inoculation
of mucous membranes or defects in the skin, causing a primary
infection.
• The virus reaches sensory and autonomic nerve endings and remains
latent in nerve cell bodies of ganglion neurons.
• This allows for reactivation, and recurrent signs and symptoms.
1. HSV II: 80-90% of genital herpes
2. HSV I: 10-20% of genital herpes (orofacial disease common)
3. Associated with stressors.
Incubation period: 3-7 days
Genital Herpes
Definitions
A. Initial episode
First episode with either herpes simplex virus type 1 (HSV-1) or type 2 (HSV-
2).
Dependent on whether the individual has had prior exposure to the other
type, this is further subdivided into:

Primary infection: first infection with either HSV-1 or HSV-2 in an individual

with no pre-existing antibodies to either type.

Non-primary infection: first infection with either HSV- 1 or HSV-2 in an

individual with pre-existing antibodies to the other type.

B. Recurrent episode: recurrence of clinical symptoms due to reactivation of

pre-existent HSV-1 or HSV-2 infection after a period of latency.
Genital Herpes
Symptoms
• Prodrome (precedes genital lesions) - fever, headache, malaise,
myalgia
• Painful lesions, genitalia.
• Dysuria, discharge (urethritis)
Signs
• Multiple vesicular lesions on foreskin, labia, vagina or anus.
Umbilicates with central depression.
• Multiple, grouped lesions common, may coalesce.
• Painful shallow ulcers when vesicles rupture. Present for 4-15 days.
Crusts and then re-epithelises without scarring. Complete lesion
healing: 19-21 days.
• Tender, inguinal lymphadenopathy (primary infection)
Genital herpes of the vulva
Genital Herpes
Complications
Superinfection of lesions with candida and streptococcal
species (typically occurs in the second week of lesion
progression).
Autonomic neuropathy, resulting in urinary retention.
Autoinoculation to fingers and adjacent skin e.g. on thighs.
Autoinoculation into damaged and inflamed skin has been
shown to occur in both acquisition and recurrent disease.
Aseptic meningitis
Management
Investigations
• NAAT
• Viral culture swab
• HSV Polymerase chain reaction (HSV PCR)
• HSV Viral Culture of vesicular fluid - vesicles most concentrated with
virus within 1st 48 hrs
• HSV serology
• Screening for coincident STIs
Management
Treatment of 1st episode
• General advice
. Saline bathing
. Analgesia
. Topical anaesthetic agents
• Aciclovir 400 mg PO three times daily for 5 days or
Valaciclovir 500 mg PO twice daily for 5 days
• Alternative regimens:
Aciclovir 200 mg PO five times daily for 5 days or
Famciclovir 250 mg PO three times daily for 5 days
Management
Treatment of recurrent episodes
• Aciclovir 800 mg three times daily for 2 days or
Famciclovir 1 g bd for 1 day or
Valaciclovir 500 mg bd for 3 days

• Alternative 5-day treatment regimens:

Aciclovir 200 mg five times daily or
Aciclovir 400 mg three times daily for 3–5 days or
Valaciclovir 500 mg twice daily
Management
Suppression therapy (at least six recurrences per annum)
• Aciclovir 400 mg twice daily or
Aciclovir 200 mg four times daily or
Famciclovir 250 mg twice daily or
Valaciclovir 500 mg once daily
• Should be discontinued after a maximum of a year to reassess
recurrence frequency.

• Other preventive measures, advice, partner notification, screening.

Syphilis
• Caused by spirochete bacterium Treponema pallidum subspecies
pallidum.
• Transmission: by direct contact with an infectious lesion or by vertical
transmission during pregnancy.
Syphilis
Stages
• Primary Syphilis
• Secondary Syphilis
• Latent Syphilis
• Tertiary/Late Syphilis
1. Syphilitic Gumma
2. Cardiovascular Syphilis
3. Neurosyphilis
Primary Syphilis
• Incubation period: 21 days
• Lesions involve glans penis in males and vulva or cervix in
females.
• Other sites - anus, fingers, oropharynx, tongue, nipples,
fingers, or other extragenital sites.
• Regional non tender lymphadenopathy.
• Chancres are usually painless, solitary, raised, firm, red papules
that are indurated with clean base, non-purulent and can be
several centimetres in diameter that progress from a single
papule.
• Chancre erodes to create an ulcerative crater within the
papule, with slightly elevated edges around the central ulcer.
• Heal within 4-8 weeks, with or without therapy.
Painless chancre of Primary Syphilis with raised edges.
Secondary Syphilis
• If primary syphilis is untreated 25% will develop secondary syphilis
• Occurs 4-10 weeks after initial chancre
Symptoms
• Malaise, fatigue, headache, fever, pharyngitis, arthralgia, myalgia
Signs
• Highly infectious lesions on mucus membrane
• Generalized Lymphadenopathy
• Papulosquamous Dermatosis
Morphology, configuration: Pale, pink to red discrete, round, macular to
papular / plaques with scaling over the
surface
Distribution: Symmetrical, palms, soles and trunk
Secondary syphilis – papulosquamous lesions
Secondary Syphilis
Signs (cont.)
• Condyloma Lata
Wart-like lesions. Papules coalesce, macerate and may form flat,
moist, infectious lesions → become large, flat highly contagious
lesions Involving moist areas, genitalia and intertriginous areas.

• Syphilitic Alopecia - alopecia with moth-eaten appearance

Warty, mucoid, plaque-like perianal lesions of condylomata lata
Secondary Syphilis
Complications
• Lues Maligna (Ulceronodular Syphilis, Malignant
Syphilis)
• Severe form of Secondary Syphilis (esp. in
immunosuppressed)
• Hepatitis
• Periostitis
• Nephropathy
• Uveitis / Iritis
• Syphilitic Alopecia
Latent Syphilis
Signs
• None

Types
1. Early Latency (First year after infection)
2. Late Latency (Latent infection >1 year)
• No symptoms of primary or secondary syphilis
• Only infectious in pregnancy and transfusion
Late / Tertiary Syphilis
Slowly progressive, may affect any organ. The
disease is generally not thought to be infectious
at this stage.
Divided into gummatous, cardiovascular and
neurological complications.
Pathophysiology
• Low-level syphilis infection with strong immune
response
Tertiary Syphilis - Gumma
Management of syphilis:
Investigations
• Dark ground microscopy
• Polymerase chain reaction
• Treponemal EIA/CLIA
• Venereal Disease Research Laboratory (VDRL)
• Rapid Plasma Reagin (RPR)
• Automated Reagin Test (ART)
• Standard Test for Syphilis (STS)
• Fluorescent Treponemal Antibody (FTA-ABS)
• Microhemagglutination - Treponema pallidum (MHA-TP)
• Confirmation of positive Screening Test - Fluorescent Treponemal Antibody (FTA-
ABS)
• Lumbar Puncture with CSF Exam for neurosyphilis
• Screening for coincident STIs
Treatment
Early syphilis (primary, secondary and early latent)
• Benzathine penicillin G 2.4 MU IM single dose
Late latent, cardiovascular and gummatous syphilis
• Benzathine penicillin 2.4 MU IM weekly for three weeks (three doses)
Neurosyphilis including neurological/ophthalmic involvement in early
syphilis
• Procaine penicillin 1.8 MU–2.4 MU IM OD plus probenecid 500mg PO
QID for 14 days OR
• Benzylpenicillin 10.8–14.4g daily, given as 1.8–2.4g IV every 4h for 14
days
Treatment
• Other preventive measures, advice, partner
notification, screening.
Lymphogranuloma venereum (LGV)
• Caused by one of three invasive serovars (L1, L2 or L3)
of Chlamydia trachomatis, though L2 is the most
common strain involved.
• Characterized by self-limiting genital papules or ulcers
followed by painful inguinal and/or femoral
lymphadenopathy.
• Transmission: direct contact with the skin or mucous
membranes of an infected partner. Does not
penetrate intact skin.
Lymphogranuloma venereum (LGV)
Clinical features
3 stages:
First stage (Primary LGV)
• Incubation period: 3-30 days.
• Small, painless papule or pustule that may erode to form a small,
asymptomatic herpetiform ulcer that usually heals rapidly without
scarring.
• Men: coronal sulcus, prepuce, glans, and scrotum.
• Rarely, urethritis.
• Women: posterior vaginal wall, posterior cervix, fourchette, and
vulva.
• The initial lesion, especially in women, often goes unnoticed by the
patient.
Lymphogranuloma venereum (LGV)
Clinical features
Second stage (secondary LGV)
• Begins 2-6 weeks after the primary lesion.
• Painful regional lymphadenopathy (usually in the inguinal and/or
femoral lymph nodes).
• Painful, swollen lymph nodes coalesce to form buboes, which may
rupture or harden, then slowly resolve.
• Inguinal lymphadenopathy (esp. males), deep iliac or perirectal nodes
involvement (females) - may only present with non-specific back
and/or abdominal pain.
• Constitutional symptoms.
Inguinal and femoral lymphadenopathy of 2nd stage LGV showing ‘Groove sign’
Lymphogranuloma venereum (LGV)
Clinical features
Second stage (secondary LGV)
• Systemic spread may lead to the following conditions:
Arthritis
Ocular inflammatory disease
Cardiac involvement
Pulmonary involvement
Aseptic meningitis
Hepatitis or perihepatitis
Lymphogranuloma venereum (LGV)
Clinical features
Third stage (tertiary LGV)
• ‘Genitoanorectal syndrome’.
• More common in women.
• Characterized by proctocolitis.
• Symptoms include the following conditions:
Bloody purulent discharge
Rectal pain
Tenesmus
Lymphogranuloma venereum (LGV)
Complications
• Destruction of lymph nodes may result in genital
lymphoedema (elephantiasis) with persistent
suppuration and pyoderma.
• An association with rectal cancer has been
reported.
Lymphogranuloma venereum (LGV)
Investigations
• Nucleic acid amplification tests (NAAT)
• Rectal polymorphonuclear leucocytes (PMNLs)
from rectal swabs in LGV proctitis
• Urethral swab or first-catch urine specimen for
urethritis
• Screening for coincident STIs
Lymphogranuloma venereum (LGV)
Treatment
•Doxycycline 100 mg twice daily PO for 21
days or Tetracycline 2 g daily PO for 21 days
•Other preventive measures, advice, partner
notification, screening.
Further reading
• Genital warts – HPV
• Bacterial vaginosis
• Vulvovaginal candidiasis
• Scabies
Useful Resources
• British Association for Sexual Health and HIV
https://www.bashh.org/guidelines