Genital Infections

1. Genital Infections James Huffman, PGY-1 11.2.2006

2. Objectives • Focus on approach and resources • Discuss work-up and diagnostic studies • Review treatments • Focus on Canadian 2006* STD Guidelines • (PID/HIV/HSV/HPV/sexual assault/urologic diseases not covered) *http://www.phac-aspc.gc.ca/std-mts/sti_2006/pdf_2006_e.html

3. Resources • Calgary STD Clinic • www.calgaryhealthregion.ca/hecomm/std/std.htm • 403-944-7575 • #404 - 906 - 8th Avenue SW • Canadian 2006 STD Guidelines • Preview available on Public Health Agency of Canada’s website (link from STD clinic)

4. Genital Infections in the ED DiseaseImplicated organism Gonorrhea Neisseria gonorrhea Chlamydia Chlamydia trachomatis Syphilis Treponema pallidum Chancroid Hemophilus Ducreyi Gardnerella Gardnerella vaginalis Genital herpes Herpes simplex virus Genital condylomata Human papilloma virus Trichomonas Trichomonas vaginalis Scabies Sarcoptes scabiei

5. Case: • 18♂ with 3 day history of burning on urination and urethral discharge. • 3 sexual partners (all within the last year). Most recently a one night stand 1/52 ago – worried he “caught something” from her. No GP. • What now?

6. Taking a sexual history: • Explain rationale and ask permission • Current and prev symptoms (duration) • Prior Hx of STI’s • Recent sexual contacts • Use of contraceptives • Types of sexual practices • Need menstrual Hx in women • Don’t forget about abuse!!!

7. Physical exam • Must do it…might as well do it well. • Feel for nodes, retract foreskin, palpate scrotum, skin lesions, look in folds, inspect perianal region, speculum exam +/- bimanual • Have patient milk urethra • Include oropharyngeal exam • Don’t forget about joints

8. Approach to genital infections Ulcerative Nonulcerative (usually have discharge) • Primary syphilis • Herpes genitalis • Chancroid • Lymphogranuloma venereum • Granuloma inguinale • Molluscum contagiosum • Genital warts • Scabies • Pediculosis • Gonorrhea • Chlamydia • Nongonococcal urethritis • Secondary/tertiary syphilis • Candidal vaginitis • Trichomonas • Bacterial vaginosis • Endometriosis

9. Don’t forget about… Non-infectious causes of genital discomfort: • Allergic or chemical vaginitis • Atrophic vaginitis • Pediculosis pubis • Vaginal foreign bodies • Latex allergy

10. Any Guesses? How much was Marilyn Monroe paid for her nude calendar photos? • Nothing  • $50.00  • $550.00  • $1,750.00 

11. Diagnostic tests to consider: • Urinalysis • Urethral C&S/Gram stain • Cervical/Vaginal C&S & Gram Stain (female) • ELISA/DNA probe testing for Chlamydia • (nucleic acid amplification urine test in Calgary) • +/- HIV, HEP B&C, Syphilis, HSV, and HPV • +/- pharyngeal/rectal C&S

12. Urethral swabs: • Unnecessary if adequate discharge present with milking of the urethra (ie discharge C&S adequate for gonorrhea but not for chlamydia) and urine nucleic acid amplification techniques available (PCR/LCR) – i.e. Calgary

13. Urethral swabs: • Ideally patient should not have voided x 2hrs • Moisten tip with water • Should go in slowly 3-4 cm (males) or 1-2 cm (females) rotate slowly  withdraw gently prepare smear  innoculate culture medium/place in transport medium

14. Disorders with discharge:i.e. Urethritis • Tend not to have ulcerations or significant lymphadenopathy • Chlamydia and Gonorrhea most common • Also: non-gonococcal urethritis, trichomoniasis, BV, candidiasis and PID

15. Chlamydia (Chlamydia trachomatis) • >56 000 cases in 2002 (179/100 000) • Underdiagnosed  most pts asymptomatic • Risk Factors: • Sexual contact with infected individual • New sexual partner or >2 in past year • Previous STI’s • High risk populations

16. Chlamydia (Chlamydia trachomatis)

17. Chlamydia (Chlamydia trachomatis) Bonus Points Name for the perihepatitus caused by C.trachomatis? Fitz-Hugh-Curtis syndrome

18. Chlamydia (Chlamydia trachomatis) Major Sequelae: • Females • PID • Ectopic • Infertility • Chronic pelvic pain • Reiter Syndrome • Males • Epididymo-orchitis • Reiter Syndrome

19. Chlamydia (Chlamydia trachomatis) Diagnosis: • Nucleic Acid Amplification Tests (NAATs) • Can be performed on swabs (endocervical and urethral) and urine • Best as it is hard to culture an intracellular pathogen • Better if patient hasn’t voided x 2hrs • Collect only the initial 10-15mL of urine • 98% sensitive and 100% specific (better than culture) • Culture in sexual abuse cases

20. Chlamydia (Chlamydia trachomatis) Treatment indicated when: • Positive chlamydia test • Diagnosis of a syndrome compatible with a chlamydial infection • Diagnosis of chlamydial infection in a sexual partner • Diagnosis of N gonorrhoeae is made

21. Chlamydia (Chlamydia trachomatis) Treatment (non-pregnant, non-lactating adults) • Doxycycline 100mg PO bid x 7 days OR • Azithromycin 1g PO as a single dose Confirmatory testing not routinely recommended unless pregnant

22. Any Guesses? The first vibrators were invented in ______ as treatment for what was known then as hysteria. • 1755 • 1869  • 1904  • 1946 

23. Gonorrhea (Neisseria gonorrhoeae) • 127 cases/100 000 • Penicillin-resistant organisms >1% nationally • HIV transmission is enhanced with concomitant Gonorrhea infection • Risk factors similar to those for Chlamydia • 1-14d incubation period • Assume co-infection with Chlamydia

24. Gonorrhea (Neisseria gonorrhoeae)

25. Gonorrhea (Neisseria gonorrhoeae) Major sequelae the same as Chlamydia with the addition of disseminated infection

26. Gonorrhea (Neisseria gonorrhoeae) Diagnosis: • Culture is the preferred method (may be negative in first 48h) • NAATs (avail but do not provide sensitivities) • Urethral gram stain with intracellular diplococci generally diagnostic • All sites aside from urethra and cervix require culture or NAAT (no gram stain)

27. Gonorrhea (Neisseria gonorrhoeae) Management: Test results available

28. Gonorrhea (Neisseria gonorrhoeae) Management: Test results unavailable

29. Gonorrhea (Neisseria gonorrhoeae) Treatment Urethral, endocervical, rectal and pharyngeal infection • Cefixime 400mg PO single dose OR • Ciprofloxacin 500mg PO single dose OR • Ofloxacin 400mg PO single dose OR • Ceftriaxone 125mg IM single dose Gonococcal ophthalmia/disseminated infection • Ceftriaxone 2g/day IV/IM AND azithromycin/doxycycline • Consultation/Admission

30. Gonorrhea (Neisseria gonorrhoeae) • Follow up cultures for test of cure are indicated 4-5days after completion of therapy • NAATs are not recommended for test of cure

31. Nongonococcal Urethritis • Urethral discharge, dysuria or urethral pruritis • C.trachomatis implicated in many cases • All patients should be evaluated for both gonorrhea and chlamydia • If no cause is found, treatment is the same as indicated for chlamydia

32. Primary Prevention “When in doubt, pass out! It’ll keep you from getting ‘the HIV’”.

33. Disorders with Ulcers • Patients will refer to just about anything “down there” as a “sore” • Good history and physical exam are key • Attention to the characteristics of the lesion(s), presence of adenopathy and presence of systemic symptoms • Most common: Herpes, Syphilis, HIV

34. Syphilis (Treponema pallidum) • The “Great Imitator” – ability to infect any organ of the body • ~3.4 cases/100 000 (nationally) • Current outbreak in Calgary • Primary mode of transmission is sexual contact (vaginal, oral, anal) • 1°, 2° and early latent phases are considered infectious

35. Syphilis (Treponema pallidum) Manifestations: • Primary Phase • Chancre, regional adenopathy • Incubation period ~3 weeks (3-90d) • Lasts 2-6 weeks then resolves spontaneously

36. Syphilis (Treponema pallidum) Manifestations: • Secondary Phase • Rash, fever, malaise, lymphadenopathy, mucous lesions, condylma lata, alopecia, meningitis, headaches, uveitis • Also resolves spontaneously

37. Syphilis (Treponema pallidum) Manifestations: • Latent Phase • Asymptomatic – lab testing is only way to identify • Early latent phase (infected <1 year prior) • Late latent phase (all others) • Lasts at least 3-4 years

38. Syphilis (Treponema pallidum) Manifestations: • Tertiary Phase • CV Syphilis – Ao aneurysm, AR • Neurosyphilis – meningitis, peripheral neuropathy (tabes dorsalis) • Gumma – tissue destruction of any organ

39. Syphilis (Treponema pallidum) Diagnosis: • Darkfield examination – 80% sens. • Serologic testing • Non-treponemal (RPR) *may be non-reactive! • Treponemal (MHA-TP, FTA-BS) • Both types required for definitive diagnosis

40. Syphilis (Treponema pallidum) Treatment: • Primary and Secondary phases: • Obtain material for Dark-field microscopy, test ulcers for HSV, serology (both NT and T tests) • Referral to Calgary STD clinic • Latent Phase: • Serology and PE for tertiary findings • Referral to STD clinic

41. Syphilis (Treponema pallidum) Treatment: • Tertiary phase: • Serology and CSF • If CSF negative, treat as late latent phase • If CSF positive, treat as neurosyphilis

42. Syphilis (Treponema pallidum) Treatment 1°, 2° and early latent phase: Benzathine penicillin G 2.4million units IM single dose *Only available from the STD clinic Penicillin Allergy: Doxycycline 100mg PO bid x 14 days

43. Syphilis (Treponema pallidum) Treatment: Late latent phase & Non-neurosphyilis tertiary Benzathine penicillin G 2.4million units IM q7d x 3 doses Neurosyphilis Penicillin G 3-4million units IV q4h x 10-14 days

44. Back to the case… • Hx: as before. Not using condoms. • PE: Mucopurulent urethral discharge and tender testicle (mostly around epididymis). Nil else. • Labs: Urine NAAT positive for Gonorrhea. • Patient treated for Gonorrhea and Chlamydia. STD clinic/Public Health notified.

45. Resources • Calgary STD Clinic • www.calgaryhealthregion.ca/hecomm/std/std.htm • 403-944-7575 • #404 - 906 - 8th Avenue SW • Canadian 2006 STD Guidelines • Preview available on Public Health Agency of Canada’s website (link from STD clinic)

46. Questions?