STDs

Question 1

What is the most common cause of preventable infertility?

Answer 1

STIs

Question 2

What are the routine STD screening recommendations?

Answer 2

• annual screening for all sexually active women age 24 and younger for chlamydia and gonorrhea
• annual screening for chlamydia and gonorrhea in asymptomatic women over age 24 who are at high risk for infection
• HIV screening for females aged 13-64 at least once in their lifetime and annually thereafter based on risk factors

Question 3

What is expedited partner therapy?

Answer 3

treatment of a STD-positive patient’s sexual partner despite the partner not undergoing physical evaluation or testing

Question 4

Chlamydia trachomatis

Answer 4

• a gram-negative, obligate intracellular bacterium which preferentially infects columnar epithelial cells
• the most frequently reported infectious disease in the US
• often asymptomatic but may present with mucopurulent cervicitis, watery vaginal discharge, or irregular intermenstrual vaginal bleeding
• may be complicated by an ascending infection leading to mild salpingitis, PID if left untreated, or Reiter’s syndrome of uveitis, urethritis, and arthritis
• diagnosis is based on nucleic acid amplification tests of endocervical swab specimens
• sexually active women under the age of 24 should be screened annually
• treat using macrolides or tetracyclines and add ceftriaxone to treat presumed co-infection with gonorrhea; patients should be abstinent for seven days and until all partners are treated
• test of cure is not recommended unless patients have persistent symptoms or the provider suspects non-adherence
• all women should be retested 3 months after treatment or at their well-woman exam due to the risk of reinfection

Question 5

What is unique about serotypes A-C of chlamydia?

Answer 5

they are transmitted via hand-to-eye contact or via fomites and cause trachoma, a chronic infection leading to blindness (#1 cause of blindness worldwide)

Question 6

What is unique about serotypes D-K of chlamydia?

Answer 6

they are sexually transmitted and cause urethritis/PID with a watery discharge, ectopic pregnancy, neonatal pneumonia with staccato cough, and neonatal conjunctivitis

Question 7

What is unique about serotypes L1-L3 of chlamydia?

Answer 7

they cause lymphogranuloma venereum, which manifests as a painless genital ulcer followed weeks later by painful inguinal lymphadenopathy

Question 8

Neisseria gonorrhea

Answer 8

• a gram-negative intracellular diplococcus
• risk factors are inconsistent condom use, previous or coexisting STD, and exchange of sex for money or drugs
• in men, it presents as urethritis, prostatitis, or orchitis, typically with a mucopurulent or purulent discharge
• in women, signs and symptoms are often mild and overlooked but classically includes a thick, white, purulent discharge
• may be complicated by PID or Fitz-Hugh Curtis syndrome; may cause asymmetric septic arthritis; and infection facilitates transmission of HIV
• diagnosed based on culture, nucleic hybridization, or NAAT; gram stain can be used for diagnosis of symptomatic men but is not recommended for asymptomatic men or for women
• treat with IM ceftriaxone plus an oral dose of azithromycin for presumed chlamydial infection

Question 9

PID

Answer 9

• an infection of the upper genital tract as a result of direct spread of a pathogen along mucosal surfaces from the cervix
• primarily caused by C. trachomatis and N. gonorrhoeae
• the greatest risk factor is prior PID but a recently placed IUD also conveys some risk; protective factors are OCPs and infection during the progesterone-dominant phase of the menstrual cycle when the endocervical mucus is thick
• may present with vaginal discharge, abnormal vaginal bleeding, guarding, cervical motion tenderness, rebound tenderness, adnexal tenderness, fever or chills, or elevated WBC count
• may be complicated by adhesions and infertility, tubal damage, hydrosalpinx, TOA, or Fitz-Hugh-Curtis syndrome
• treatment is with ceftriaxone and azithromycin
• hospitalization with IV therapy is suggested for patients in which surgical emergencies cannot be excluded, are pregnant, doesn’t respond to oral therapy, is non-adherent, has severe symptoms, or has a TOA
• because it is often asymptomatic empiric treatment is recommended for sexually active young women with no other cause of illness who are also found to have uterine tenderness, adnexal tenderness, or cervical motion tenderness

Question 10

Describe the presentation of tubo-ovarian abscesses.

Answer 10

patients present as acutely ill with high fever, tachycardia, severe pelvic and abdominal pain, and nausea and vomiting

Question 11

What are the criteria for diagnosing acute salpingitis?

Answer 11

• cervical motion, uterine, or adnexal tenderness
• plus temperature, mucopurulent discharge, abundant WBCs on microscopy of vaginal fluid, elevated ESR, elevated CRP, or laboratory confirmation of N. gonorrhea or C. trachomatis infection

Question 12

What is Fitz-Hugh-Curtis syndrome?

Answer 12

a complication of gonorrheal or chlamydial PID in which there is fibrosis and scarring of the anterior surface of the liver following ascension of the infection from the pelvis through the right paracolic gutter

Question 13

Genital Herpes

Answer 13

• caused by infection with a DNA virus
• HSV-2 is more common and is more likely to cause a recurrence; however, HSV-1 genital infections are becoming more common
• the primary infection is typically most severe and includes a flu-like syndrome with neurologic involvement after which painful vesicles appear, which lyse and progress to shallow, painful ulcers with a red border before resolving after one week; some patients then experience aseptic meningitis with fever, headache, and meningismus
• the virus remains dormant in the dorsal root ganglia and recurrences present as vesicular lesions that are less painful and persist for only 2-5 days often with a prodrome of burning or vulvar pain
• viral shedding occurs for up to three weeks after lesions appear
• diagnosis is made based on viral culture and PCR
• first-episode treatment includes acyclovir, famciclovir, or valacyclovir for 7-10 days; warm water baths, analgesics, and topical lidocaine can relieve the pain
• recurrent therapy is most effective when initiated during the prodrome and is typically administered for 3-5 days; patients with frequent occurrences may be offered daily suppressive therapy, which reduces frequency and likelihood of transmission to uninfected partners
• antivirals reduce the duration of viral shedding and shorten the symptomatic disease course but do not affect the long-term disease course or likelihood of recurrence
• pregnant women with a history of genital herpes require special care during the prenatal course

Question 14

How do HSV-1 and HSV-2 differ?

Answer 14

• HSV-1 is associated with cold sore lesions of the mouth
• HSV-2 is more commonly associated with genital infections
• HSV-1 genital infections are far less likely to have recurrences

Question 15

How should herpes be managed during pregnancy?

Answer 15

• routine antepartum genital HSV testing in asymptomatic patients is not recommended
• however, pregnant women with a history of genital herpes should be screened throughout the prenatal course
• those with recurrences should be offered daily suppression therapy beginning at 36 weeks of gestation
• c-section is indicated for women with active lesions or a typical herpetic prodrome at the time of delivery

Question 16

Condyloma Acuminata

Answer 16

• caused by low-risk serotypes of HPV including 6 and 11
• they present as soft, fleshy growths, which may be single or multiple and cause few symptoms
• if present during pregnancy, there is a slight risk of transmission, which would lead to development of laryngeal papillomata
• treated with application of trichloroacetic acid, podophyllin resin in tincture of benzoin, cryosurgery, excision, laser surgery, or interferon injection

Question 17

What are the low risk and high risk forms of HPV?

Answer 17

• low risk, associated with condylomas, are 6 and 11

- high risk, associated with cervical dysplasia and cancer, are 16, 18, 31, and 33

Question 18

Syphilis

Answer 18

• caused by Treponema pallidum, a motile, anaerobic spirochete, which can rapidly invade intact moist mucosa
• the primary stage is defined by a painless chancre at the site of entry, which has a firm, punched-out appearance with rolled edges; there may be concurrent adenopathy or other mild systemic symptoms; heals in 3-6 weeks
• the secondary stage is characterized by a rough, red, or brown lesion on the palms and soles with accompanying lymphadenopathy, fever, headache, weight loss, fatigue, muscle aches, and patchy hair loss; there are often highly infective secondary eruptions called mucocutaneous mucous patches; flat-topped papules may appear and coalesce to form condyloma lata
• the secondary stage is generally followed by a latent stage during which it is less contagious
• tertiary syphillus presents with soft growths with firm necrotic centers known as gummas, aortitis leading to “tree-barking” and possibly a thoracic aortic aneurysm, damage to the posterior columns known as tabes dorsalis, and Argyll Robertson pupils, which accommodate but do not react to light
• presumptive diagnosis can be made with non-treponema tests like VDRL and RPR; diagnosis is confirmed with treponemal-specific tests, dark-field microscopic visualization of spirochetes, or by direct fluorescent antibody tests; an LP with VDRL performed on spinal fluid is required if neurosyphilis is suspected
• treat with penicillin G and monitor the patient with quantitative VDRL titers

Question 19

How do we differentiate condyloma acuminata from condyloma lata?

Answer 19

condyloma lata are caused by syphilis and are distinguished by their broad base and flatter appearance

Question 20

Where are HIV-1 and HIV-2 most prevalent?

Answer 20

• HIV-1 is the most common type in the US

- HIV-2 is the most common in West African countries

Question 21

How do we screen for HIV? How do we confirm the diagnosis?

Answer 21

• screen using an ELISA and tests for antibodies against HIV-1, HIV-2, and HIV P24 antigen
• confirm with an HIV ½ antibody differentiation assay

Question 22

What is the typical drug regimen for patients with HIV?

Answer 22

two nucleoside reverse transcriptase inhibitors and a third drug from another class

Question 23

Lymphogranuloma Venereum

Answer 23

• a necrotizing granulomatous inflammation of the inguinal lymphatics and lymph nodes caused by the L1-L3 serotypes of C. trachomatis
• presents with inguinal or femoral lymphadenopathy and a self-limited vesicle or ulcer at the site of infection when transmitted vaginally
• may present with anal bleeding, purulent anal discharge, constipation, and anal spasms when transmitted anally
• eventually heals with fibrosis, which may cause rectal stricture if there was perianal involvement
• diagnosed based on clinical suspicion and a positive test for Chlamydia trachomatis

Question 24

Granuloma Inguinale

Answer 24

• also known as Donovanosis, it is caused by sexual transmission of the gram-negative bacterium Klebsiella granulomatis
• presents as painless, raised, red, ulcerative lesions that are vascular bleed easily on contact
• diagnosed based on clinical suspicion; confirmed with Wright or Giemsa-stained biopsy tissue or visualization of dark-staining Donovan bodies

Question 25

Chancroid

Answer 25

- caused by Haemophilus ducreyi - usually occurs in discrete outbreaks and is characterized by painful genital ulcers and tender suppurative inguinal adenopathy - it is associated with high rates of HIV co-infection and is a cofactor for HIV transmission - diagnosis is based on clinical criteria and made after ruling out syphilis and HSV; culture is difficult and PCR is used as confirmation of the clinical diagnosis

Question 26

Molluscum Contagiosum

Answer 26

- caused by a highly contagious DNA poxvirus - presents with small, painless, pearly, umbilicated papules - treated with cryotherapy or topical preparations such as pdophyllotoxin cream, iodine, or salicylic acid

Question 27

Pediculosis Pubis

Answer 27

- also known as pubic lice - the agent is Phthirus pubis - presents with itching, which may be delayed by several weeks as the individual becomes sensitized to the antigens; itching may be immediate after reinfection - can sometimes identify lice or nits on the pubic hair - preferred treatment is permethrin