Sexually transmitted diseases-part1

1. Sexually transmitted diseases-part1 Lianjun Chen Huashan Hospital

2. Introduction • The term “venereal diseases” was historically used, now referred to as “sexually transmitted diseases” (STDs) or “sexually transmitted infections” (STIs) • A group of diseases which are mainly spread by sexual contact, although other routes, such as blood transfusion and horizontal transmission, are not uncommon. • Classical STD : syphilis, gonorrhea, chancroid, lymphogranuloma venereum, and granuloma inguinale.

3. Sexually transmitted and transmissible pathogens • Bacteria • Neisseria gonorrhoeae • Treponema pallidum • Haemophilus ducreyi • Chlamydia trachomatis • Mycoplasma hominis, M. genitalium • Ureaplasma urealyticum • Gardnerella vaginalis • Atopobium vaginae • Mobiluncus curtisii, M. mulieris • Klebsiella (Calymmatobacterium) granulomatis • Shigella spp. • Campylobacter spp. • Helicobacter cinaedi, H. fennelliae

4. Virus • Human immunodeficiency virus, types 1 and 2 • Herpes simplex virus, types 2 > 1 • Human papillomavirus • Hepatitis viruses, B > C and (via fecal-oral contact) A • Cytomegalovirus • Molluscum contagiosum virus • Human T-cell leukemia/lymphotrophic virus, types I and II • Human herpesvirus, type 8 • Protozoa • Trichomonas vaginalis,Entamoeba histolytica,Giardia lamblia • Fungi • Candida albicans • Ectoparasites • Phthirus pubis,Sarcoptes scabiei

5. Five most common STD • gonorrhea • nongonococcal urethrites • condyloma acuminatum • genital herpes • syphilis

6. GONORRHEA

7. Definition • Gonorrhea is referred to as purulent infection due to Neisseriagonorrhoeae, which mainly occurs in urogenital system, but may also present as gonorrheal ophthalmia, pharyngitis, rectitis, pelvic inflammation or disseminated infection.

8. Etiology • Pathogen is Neisseria gonorrhoeae, calling diplococcus gonorrhoeae or gonococcus for short, first found in stained smears from vaginal, urethral and conjunctival exudates in 1879 by Albert Neisser. • In acute phase of the infection, the pathogens are detected in cytoplasm of leukocytes in the discharges of the patients, while in chronic phase, extracellular gonorrhoeae are more often seen.

9. Morphology and Staining： The gonococcus is a Gram-negative , diplococcal, pink bacterium ,appearing kidney or lima bean shape.

10. Growth property • For optimal growth, it requires a moist medium with temperature of 35 ℃ -36 ℃, and a 3–5% CO2 atmosphere. • Gonococcus is fastidious organism that grow well in culture media including animal protein. • Gonococcus die easily in dry and hot circumstances • Normal disinfectant or soap can cause it lose motoricity. • Biochemical event • Gonococcus can create oxidase during growing process, so oxidase test is meaningful in initial diaganosis.

11. Drug resistance of Gonococcus • It’s reported continuously that PPNG and non-PPNG resistance strains and spectinomycin、norfloxacin and ofloxacin resistance strains have been found in China in recent year.Most of Gonococcus strains popular in China are sensitive to Ceftriazone. • Mechanism of Drug resistance • Gonococcus create PPNG which can split Beta-Lactam cycle of penicillin through plasmid, that can cause it lose antibiotic effect. • Drug resistance strains caused by chromatosomemutation can change permeability of bacteria cell wall which cause the resistance to penicillin increase to 2-4 times • The Mechanisms above have cooperation action.

12. Epidemiology • Humans are the only natural hosts of Gonococcus, and the patients are the only sources of infection. • Transmission of adult gonorrhea is almost entirely by sexual contact,and transmission through nonsexual contact is extremely rare. • Epidemic tendency： Cases of gonorrhea in developed countries have been unchangeable or decreased, but increased year by year in many developing countries. Gonorrhea are the first place of all STDs in our country.

13. Clinical menifestation • Gonorrhea can be divided into three types: • Simple gonorrhea (gonorrhea without complications) • Complicated gonorrhea (gonorrhea with complications) • Disseminated gonorrhea

14. Simple Gonorrhea • Single infection of genitourinary tract or other local mucous membrane, including: • Gonococcal urethritis • Gonococcal cervicitis • Gonococcal conjunctivitis • Gonococcal pharyngitis • Gonococcal Proctitis • Child gonorrhea

15. Gonorrheal urethiritis • Outbreak is often during 2 to 10 days (averagely 3 to 5 days) after an unprotected sexual intercourse • Redness and swelling at urethral orifice with wild stimulation can be presented, followed by yellow mucus or purulent discharge from urethra with frequent micturition, urgent micturition and urodynia. • The symptoms can be aggravated within the first 2 weeks but then alleviated. In untreated cases, the infection can be spread to posterior urethra and later into blood, thus complications or systemic symptoms will manifest.

16. Gonorrheal Cervicitis • The endomembrane of cervix can be the primary infection site in female patients, except urethritis . • Symptoms are unobvious in more than 70% patients, which causes an obscure latency. • In symptomatic cases, complaints includes increase or abnormality of vaginal discharge, purulent leucorrhea and itch at vulvae. Physical examination shows erosion, congestion and swelling of cervix with haphalgesia. Increasing purulent leucorrhea can also be found .

17. Complicated gonococcal infection • Simple gonorrhea combined with gonorrheal infection in other organs. • In male patients, the complications include gonorrheal prostatitis, epididymitis, seminal vesiculitis, urethral stricture,balanitis,parafrenal glands adenitis、Skene's gland adenitis, and so on. • In female patients, complications often present as bartholinitis, abscess of Bartholin gland, eustachiansalpingitis,pelvic inflammation, abscess of ovary or fallopian tube oviduct,peritonitis,perihepatitis, and so on.

18. Disseminated gonorrhea • Gonorrheal bacteremia caused by dissemination of gonorrhea through blood. • Uncommon, mainly happens in female patients and homosexual male patients with no treatment because of unobvious symptoms. • In females, menses and pregnancy can be of higher risk of the dissemination. • The manifestations include fever, rash, arthralgia. The course can be divided into two phases, bacteremia and purulent toxic arthritis. The bacteremia phase is characterized by fever, chills, polyarticular gonorrheal arthritis and diagnostic rashes, including papulovesicles on erythema or with hemorrhage, blood culture of gonorrhea is positive in this phase. While in the phase of purulent toxic arthritis, one particular large joint is often involved, with obvious effusion but scarcely rashes or slight systemic symptoms, the blood culture is often negative.

19. Acute gonorrheal urethiritis

20. Acute gonorrheal urethiritis

21. Acute gonorrheal urethiritis

22. Parafrenal glands adenitis/abcess

23. Acute gonorrheal urethiritis

24. Gonorrheal Cervicitis

25. 尿道口脓性分泌物

26. Purulent exedute

27. 阴 茎 中 缝 脓 肿

28. Cyst of Bartholin gland

29. Gonococcal conjunctivitis

30. Gonococcal conjunctivitis

31. Laboratory examination • Microscopic examination of smear • The presence of Gram-negative diplococci within polymorphonuclear leukocytes • on stained smears of the male urethral discharge(sensitivity of 95% ); on samples of female cervical discharge . • Culture of gonococcus • Applied to all samples from male or female genitourinary tract and other area. Doing initial identification according to the form of colony，Gram staining and oxidase test. • It’s the only recommended method to finally diagnose gonorrhea .

34. Diagnosis • History • Unprotected sexual contact has been performed with high-risk sexual partner(s) or infected partner(s), or contact with the discharge of gonorrhea patients through other routes, several days before the outbreak. • Clinical manifestations • Characterized by stimulation of urethra or bladder, pus in urethra or purulent discharge of cervical orifice or vaginal orifice, though patients can be asymptomatic or with only slight discomfort. • Laboratory findings • Typical findings by smear and microscopy is of diagnostic significance in males but of less value in female, thus culture of the bacteria should be performed to confirm the infection.

35. Prevention&Treatment • Treating early and regularly, using corresponding therapeutics according to different conditions. Follow-up and cure judgment after treatment. • Paying attention to co-infections of chlamydia and other STD pathogens. Treating sexual partner at the same time. • Paying attention to genital sanitation and insulation. Sexual intercourse being forbidden during treatment.

36. Treatment • The treatment of gonococcal urethritis • Spectinomycin 2g(cervicitis 4g ) im as single dose • Ceftriazone250mg im as single dose • The treatment of complicated gonococcal infection • Spectinomycin 2g ,im qd for 10 days • Ceftriazone250mg,im qd for 10 days • The treatment of disseminated gonococcal infection • Ceftriazone 1g, iv qd for 7 days • Cure criterions：two weeks after the end of treatment without sexually contact • Extinction of all the symptoms and signs. • Negative results of smear and culture at 4-7 days after the treatment.

37. NONGONOCOCCAL URETHRITIS (NGU)

38. Nongonococcalurethritis(NGU) • A group of urethritis due to infection through sexual intercourse with obvious symptoms but no evidence for gonococcal infection in laboratory findings. • NGU can also be called non-specific genital infection (NSGI), for genital inflammation often accompany urethritis in female patients.

39. Etiology • The most common pathogen is chlamydiatrachomatis (CT) (found in 25~55% NGU patients) • The second most common is ureaplasmaurealyticum (UU) (found in 20~40%). • Trichomonadvaginalis has been found in 2~5% • Infection due to Herpes simplex virus has been occasionally reported. • In some cases, the pathogen is yet to be known.

40. Chlamydia • Chlamydia is a kind of prokaryotic microorganism that parasitize strickly in cells with a special developmental cycle and can pass through the bacterial filter. • Three biovarieties of chlamydia: • trachoma biovariety, venereal lymphogranulomabiovariety（LGV）and mouse biovariety. • Trachoma biovariety can be devided into 12 serotypes from A to K, A、B、Ba、C4 serotypes cause trachoma，D-K 8 serotypes cause infection of genitourinary system. • LGV can be devided into 3 serotypes : L1,L2 and L3 that cause venereal lymphogranuloma.

41. Mycoplasma • Mycoplasma is a kind of prokaryotic and pleomorphic microorganisms belonged to class of soft bark that have no cell wall and precursor . It can pass through the bacterial filter. • Mycoplasma has the similar thermal resistance of bacteria, but some may be less resistant. • Mycoplasma may be part of the genital tract normal flora, and it could be conditional pathogenic bacteria sometimes. Its pathogenicity may be relevant with some types.

42. Transmission and Epidemiology • Route of transmission: mainly through sexual intercourse, a few through the sexual contact infection. • NGU is the most common sexually-transmitted diseases in Euro-American with the highest incidence. • NGU has increased continuously in our country recent years , in some regions the incidence have exceeded that of gonorrhea and taken the first place.

43. Clinical manifestation • NGU in males • The symptoms are similar to those in gonorrheal urethritis but usually more slight, including itching or burning of urethra, dysuria and, in some cases, frequent micturition. • The urethral orifice may be slightly red and swelling, urethral discharge, serousor purulent, thin and in a small amount, and usually need to be squeezed out. In case that a patient does not urinate for a long time or at the morning, the pasty discharges can obstruct the urethral orifice ,which is called “paste mouth” • In about 30~40% patients, the infection may be asymptomatic or without typical symptoms, which results in high rate of misdiagnosis.

45. Clinical manifestation • NGU in females or NSGI • The infection is often without obvious symptoms or even asymtomatic. • When urethra is involved, about 50% patients may complain of frequent micturition or urgent micturition, with small amount of urethral discharge, but scarcely obvious dysuria. • mucopurulent cervicitis :more leukorrhea,edema or erosion of cervix, but the clinical symptom is not evident or with mild itching of vagina and pruritus vulvae. Discomfort of lower abdomen may also appear, but easily be mistaken for other gynecopathies.

46. Collection of specimens • For male patients, a swab is sent into the urethra as deep as 2~4 cm from the orifice, rubbed and rotated by force, to collect the specimen. • For female patients with NSUI, one swab is used to clean up the cervix, then another swab, together with a brush, is sent into the cervical tube as deep as 1~1.5 cm from the orifice and rotated by force to collect the specimen.

47. Laboratory findings • Laboratory examination of Chlamydia trachomadis • Tissue culture regarded as the gold standard,however, the low positive rate and susceptibility limited its use. • Antigen detection methods widely used for the convenience. • Nucleic acid assays: considered more flexible and more specific , especially nucleic acid amplification tests (NAAT), such as PCR, LCR and TMA. • Laboratory examination of Ureaplasma urealyticum • Culture of the pathogen • PCR assay high sensitivity and short time

48. Diagnosis • History • an unprotected sexual contact with high-risk or infected partner(s), 1~3 weeks before the outbreak. • Clinical manifestations • Typical symptoms and signs of NGU or NSGI are suggestive. • Laboratory findings • Exclusion of gonoccocal infection • Presence of ≥5 polymorphonuclear leucocytes /1000 times high-power field in smear of the discharge, or presence of ≥ 15 polymorphonulear leucocytes /400 times high-power field in sediment of first voided morning urine 15 ml, would be of diagnostic significance. • Positive detecting assays of C trachomadis or U urealyticum would be strong evidence.

49. Treatment(1) • Recommended Regimens • Azithromycin 1 g orally in a single dose • Doxycycline 100 mg orally bid for 7 days • Alternative Regimens • Erythromycin base 500 mg orally qid for 7 days • Erythromycin ethylsuccinate 800 mg orally qid for 7 days • Levofloxacin 500 mg orally qd for 7 days • Ofloxacin 300 mg orally bid for 7 days

50. Treatment(2) • Recurrent and Persistent Urethritis • Recommended Regimens • Metronidazole 2 g orally in a single dose • Tinidazole 2 g orally in a single dose PLUS • Azithromycin 1 g orally in a single dose (if not used for initial episode) • Cervicitis • Recommended Regimens • Azithromycin 1 g orally in a single dose (if not used for initial episode) • Doxycycline 100 mg orally twice a day for 7 days