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Sexually transmitted diseases may be
caused by bacterial, viral, or paracitic organisms. Common principles should be applied
when caring for any patient with a presumed STD. The patient's sexual practices may help
identify risk factors for particular infections. The physical examination and
microbiologic studies should be directed toward the mouth area, rectal, urinary, and
genital areas. Because infection with multiple organisms is common, studies for gonorrhea
and syphilis should be included when evaluating these patients. In addition, HIV testing
is recommended. When possible, cultures should also be obtained from sexual contacts, as
treatment of individuals without symptoms carrying the disease may prevent the spread of
infection. Treatment of sexual contacts is indicated in cases of syphilis. Follow-up
cultures or serologic studies should be obtained after completion of therapy. An STD
apparently refractory to treatment may represent reinfection, a concomitant previously
undiagnosed STD, or antimicrobial resistance.
Syphilis
Syphilis may present in primary, secondary, or tertiary
forms. The disease continues to pregress from the primary to the tertiary form unless it
is cured. If untreated, the disease could cause serious damage to the body including
death. Of particular importance, are the progressive, disabling, and life-threatening
complications when the disease affects the central nervous system and/or the
cardiovascular system. Commonly, however, infection is discovered through serologic
screening tests in the latent stages (early, within 1 year of infection, or late, 1 or
more years following infection). The incubation period for the primary lesion is usually
2-6 weeks. Manifestations of secondary syphilis usually appear 2-12 weeks later and may
occur several times during subsequent years. Both primary and moist secondary lesions are
infectious. Diagnosis can be made by dark-field microscopy of the primary or moist
secondary lesions, or by serologic testing. All patients with syphilis should be tested
for HIV infection. The bacteria responsible for syphillis is treponema pallidum.
Symptoms
1. Symptoms of primary syphillis include painless ulcer on the genital area, pharynx,
rectum, tongue, lip, or elsewhere, two to six weeks after exposure. In addition, the
glands (lymph nodes) in the area involved are enlarged and not painful.
2. Symptoms of secondary syphillis include rash, patchy and ulcerative lesions in the
mucus membranes, multiple papules in moist skin areas (condylomas), swolen glands
throughout the body, inflammation of brain tissue, hepatitis, arthritis, etc.
3. Early in the course of tertiary syphillis, there are no physical signs. However, later
in this stage, the disease is characterized by the possible presence of tumors of skin,
bones, liver. In addition, inflammation of the aorta (the largest artery in the body), the
widening of the aorta at various portions, valvular disease in the heart, and central
nervous system disorders may occur. Almost any tissue and organ may be involved in the
late stage of this disease.
Diagnosis
A. Serologic tests
Serologic tests are of major importance in diagnosis but present difficulties in
interpretation, because false-positive results occur in many nonsyphilitic conditions.
1. Nontreponemal tests (tests not using the bacteria) are useful for screening. They
require a minimum of 1-3 weeks from the onset of infection to turn positive, are usually
positive in primary syphilis, and are invariably positive in secondary syphilis. However,
biologic false-positive tests may occur.
2. Treponemal tests (tests using the bacteria) reduce the number of false positive
results. Their greatest value is thus in distinguishing false-positive from true-results
and in diagnosing late syphilis.
Treatment
1. Early syphilis is treated by means of one Penicilline (PCN) injection. PCN-allergic
patients can be treated with doxycycline given by mouth for two weeks.
2. Syphilis exceeding 1 year's duration. For latent syphilis of more than 1 year's
duration, and for cardiovascular syphilis, recommended therapy is PCN injections given
weekly for a period of 3 weeks. In patients who are allergic to PCN, doxycycline, can be
given for 28 days by mouth if the central nervous system (CNS) has not been affected. When
the CNS has been affected, the best treatment is PCN injections given daily, several times
a day, for fourteen days.
3. Syphilis in HIV-infected patients. In the majority of patients with HIV infection,
serologic tests for syphilis are accurate, although there are reports of false-negative
tests. Current Center for Disease Control guidelines recommend that primary and secondary
syphilis in HIV-infected patients be treated as described above, although some experts
advocate more prolonged therapy and a spinal fluid examination prior to treatment for all
HIV-infected patients with syphilis, regardless of stage. All HIV-infected patients with
latent syphilis, regardless of duration, should undergo spinal fluid examination. Such
patients with normal spinal fluid can be treated with 3 weekly injections of PCN.
Gonorrhea
Gonorrhea is a bacterial infection caused by an organism
by the name of Neisseria gonorrhoeae. Humans are the only reservoir. Both sexes, but women
in particular, may have the disease without symptoms.
Symptoms
Gonorrhea usually presents as an inflammation of the urethra with puss in men and as
inflammation of the urethra or cervix in women after an incubation period of 2-8 days. In
men, there is initially burning on urinaton and a serous or milky discharge. 1-3 days
later, the pain is more pronounced and the discharge becomes yellow, creamy, and increased
in amount, sometimes blood tinged. Infection in women often becomes symptomatic during
menstruation. Wome may have burning on urination, urinary frequency and urgency, with a
discharge from the urethra containing pus. Infection may be without symptoms, with only
slightly increased vaginal discharge and moderate inflammtion of the cervix on
examination.
Diagnosis
Analysis of the urethral discharge showing the bacteria is the best immediate
diagnostic test. Cultures for the bacteria should also be obtained.
Treatment
1. Several antibiotic regimens have been shown to be safe and effective for the treatment
of gonorrhea. These include the cephalosporines, amoxicillin,ampicillin, etc. Routine
treatment of sexual partners of men with this disease is recommended.
Nongonococcal urethritis
Nongonococcal urethritis (NGU) refers to urethral
inflammation in men that is not attributable to gonorrhea. It cannot be differentiated
from gonorrhea on the basis of symptoms. Chlamydia trachomatis is the organism responsible
for up to 40% of NGU seen in the United States and Western Europe. Other organisms may
also be responsible for this disease.
Symptoms
(see gonorrhea)
Diagnosis
The diagnosis is based on the analysis of the discharge. This disease should be diagnosed
if the analysis of this discharge for gonorrhea and subsequent cultures are negative in a
person with symptoms characteristic of gonorrhea. A specific diagnosis for this disease
can be made by direct testing of urethral secretions for chlamydia or chlamydial antigens.
However, this is complicated and is not usually performed.
Treatment
Treatment is doxycycline, erythromycin, azithromycin, etc. Routine treatment of sexual
partners of men with NGU is recommended.
Genital herpes simplex infection
Herpes simplex is caused by a virus called the herpes
simplex virus. There are two types of herpes simplex virus referred to as type I and type
II. Over 85% of adults have evidence of type I infection, most often, aquired without
symptoms in childhood (appears before onset of sexual activity). About 25% of the US
population has evidence of infection with type II, appearing after the onset of sexual
activity. Genital herpes is usually caused by type II infection.
Symptoms
Genital herpes simplex infection usually presents with painful vesicles or shallow
ulcerations involving the vulva, labia, or cervix in women, or the penis in men. The first
appearanceof genital herpes may be associated with fever and swolen glands in the
inguinal area, whereas recurrent disease rarely produces generalized symptoms in the body.
Diagnosis
The diagnosis of herpes simplex virus infection is done by culture analysis of the
affected area. Culture first episode legions is recommended, but culture of recurrent
lesions is not necessary if the presentation is characteristic.
Treatment
There is no cure for genital herpes. However, treatment with Acyclovir, can reduce the
frequency and severity of disease. In addition, it can reduce viral shedding, alleviate
pain, and shorten the interval to healing f the disease. However, the effect on recurrance
or rate of recurrances is less substantial.
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