CHAPTER 20

 

 

SEXUALLY TRANSMITTED DISEASES

 

Judith Absalon, M.D.

Table of Contents

 

 

Sexually transmitted diseases (STDs) are a common medical problem throughout the world. They affect men and women across a wide range of ages and socioeconomic classes and are a topic of discomfort for many patients as well as clinicians. For many, sexually transmitted diseases continue to carry an associated stigma and are felt to be a “private” matter.  As a result these vastly curable diseases persist in epidemic numbers. 

 

There are over 12 million new sexually transmitted disease cases in the U.S. each year; of the top ten most common infectious diseases reported to the CDC in 1995, five were sexually transmitted diseases.[i] The STDs comprise a group of greater than 25 organisms and a variety of clinical syndromes that lead to significant morbidity and mortality. The United States is estimated to spend $10 million a year on STD diagnosis and treatment (excluding the costs attributable to HIV).

 

While the incidences of some STDs have steadily declined in the US for the past ten to twenty years (gonorrhea, early syphilis), rates of new infection have increased dramatically for others (chlamydia, HIV, herpes).  In addition, the United States continues to have overall rates of STDs that are at least double those in other “developed” countries such as England, Sweden, Germany, and Canada.[ii]

 

Routine discussion of sexual history, behavior and risk, as well as thorough genital examination are critical components of ambulatory medicine.  This chapter will familiarize you with the clinical (diagnosis, symptoms and treatment) aspects of the major sexually transmitted disease syndromes.  I have also included a section on the sexual history.  For a more complete discussion please refer to Sexually Transmitted Diseases by K. Holmes et al, 3^rd edition, 1999.   A chart of treatment guidelines for the major syndromes is provided at end of the chapter; the NYC Department of Health Website is an additional resource (www.ci.nyc.ny.us/health). HIV will be discussed in Chapter 21.

The Sexual History

 

A thorough sexual history should always be taken as part of your routine general medical evaluation.  This includes patients of all age groups – it is an error to assume that patients beyond a certain age are not sexually active. Because of the sensitivity of the topic many patients will not volunteer the information, and the provider must ask specific closed-ended questions. In addition, it is essential to remember that different people have different sexual practices. For example, do not assume that a female patient has male partners or that she does not have both male and female partners. The most important factor in this process is to make the patient feel at ease. Questions that allow room for “atypical” responses are best, as is “cultivating a listening stance.” Do not suggest answers (“you don’t have any sexual problems, do you?”), interrupt patients, or signal discomfort with the topic. Finally, asking and accepting a patient’s responses without any moral judgment will enable an ongoing relationship and hopefully permit patients to present with concerns about their sexual health at subsequent visits. 

 

Some examples of important questions include:

·        Start the transition into the sexual history with a statement like: “I am now going to ask you some questions about your sexual history. This is a routine part of the evaluation and I ask everyone the same questions, so please don’t be offended. I know that this is a very personal subject, but it is important.”

·        “When was the last time you had sex?” (Note that many patients do not consider oral sex to be “real sex.”)

·        “Do you have vaginal sex? oral sex? anal sex?” Take care that patients understand the terms “oral” and “anal” – it may be clearer to say “sex with the mouth” or “sex in the rectum.”

·        “Did you use a condom? If no, why not?”

·        “In the past six months how many partners have you had?”

·        “Did you use condoms (or other contraception) with all or some of them?”

·        “Do you sleep with men women or both?”

·        “Have you ever had any sexually transmitted diseases?” Ask specifically about chlamydia, gonorrhea, herpes, syphilis, hepatitis, trichomonas, pelvic inflammatory disease (PID), warts and date of diagnosis and treatment.

·        “Do you now have or have you had any discharge from the vagina/penis recently?” If yes explore further re: symptoms, time course and prior evaluation/treatment and symptoms of partners.  If not previously evaluated, patients should be examined to assess source of complaints.

·        Do you have any pain with intercourse? Any difficulty with arousal or erection?

 

In women a brief gynecologic history should be obtained:

·        “When was your last menstrual period?”

·        “How many times have you been pregnant?”

·        “When was your last Pap smear?”

·        “When was your last gynecologic or pelvic examination?”

·        “Do you use any type of contraception besides condoms?”

Genital Examination

 

A complete examination to assess the presence of sexually transmitted disease should include careful examination of the genitalia, as well as the skin, including palms and soles.  In addition, many manifestations of STDs include abnormalities in the anus and lymph nodes; these areas must be carefully examined

 

Genital Herpes

 

Epidemiology:

Genital herpes is a common disease.  Its prevalence has increased steadily since the 1960’s. It is a recurrent, incurable viral infection, affecting over 45 million people in the United States alone. Most cases of genital herpes are caused by herpes simplex virus type 2 (HSV2), but as much as 30 percent of genital herpes infections are due to HSV1. 

 

Clinical Syndromes:

“Classic” symptoms are divided into the symptoms of primary infection and those of recurrent infection.  In primary infection (the first episode of genital herpes in a patient who has never been infected with HSV1 or HSV2), 95 to 99 percent of patients have multiple, bilateral painful ulcers on an erythematous base, which start as papules or vesicles and spread. The ulcers heal after two to three weeks. Patients often have prolonged systemic symptoms: fever, pharyngitis, myalgia, headache, malaise, tender lymphadenopathy, and cervicitis. The latter is seen in 70 to 90 percent of women. Patients whose first episode of genital herpes has been preceded by oral HSV1 infection may have a milder clinical course of first episode genital herpes.

 

Recurrent genital herpes is characterized by symptoms that are localized to the genitalia, unilateral lesions and a smaller area of involvement. Symptom duration is shorter – usually less than two weeks – and 90 percent of patients have prodromal symptoms. “Atypical” genital herpes is actually very common – patients have small linear ulcerations rather than the classic ulcer; these can be mistake for scratches or cuts. Immunocompromised patients, such as those with HIV, can have a prolonged clinical course and more frequent recurrences.

 

            Pelvic inflammatory disease is rarely caused by genital herpes, but serious complications can include bacterial superinfection, extragenital lesions, dissemination, aseptic meningitis, transverse myelitis and sacral radiculopathy.

 

Diagnosis:

            The painful ulcers of genital herpes are so characteristic of the disease that it is most often diagnosed clinically. Other modalities include the Tzanck smear, which is highly sensitive and specific but must be performed within hours of collection. Viral culture is also an accurate tool, but sensitivity decreases as the lesions age. Serologic studies are rarely clinically useful, since they do not distinguish between current and prior HSV infection. We recommend viral culture if the patient presents within the first two to three days of symptoms; the culture medium (and viral culture request forms) are available from the nursing staff.

 

Treatment and Partner Management:

There is no curative therapy for genital herpes. In immunocompetent patients with primary genital HSV, treatment with acyclovir, famciclovir or valacyclovir increases the rate of healing but does not prevent recurrences. Similarly, recurrences (“flares”) can be treated to speed resolution of symptoms. Patients with frequent (4-12) episodes of genital herpes each year may consider chronic suppressive therapy (see treatment guidelines at end of this chapter).  Partners are not routinely evaluated by the Department of Health, but it is important to inform patients that transmission occurs both in the presence of lesions and two to three days prior to the eruption.

 

Human Papillomavirus

Epidemiology

Human Papillomavirus (HPV) comprises over 100 types of HPV and greater 35 infect the genitalia.  HPV infection is an extremely prevalent disease and likely greater than 50% of sexual active adults are HPV positive.   Data on incidence of disease is not readily available because many patients are asymptomatic, do not seek care (genital warts) or have had infection for an undetermined length of time when they present for evaluation (cervical, anorectal cancer). 

 

Clinical Syndrome

Symptoms are often absent, unrecognized or subclinical.  The most common manifestations are genital warts, which occur most commonly on penis, scrotum, urethral meatus, introitus, vulva, perineum and perianal areas.  Genital warts are most commonly caused by HPV types 6 and 11.

·         Condylomata acuminata – cauliflower appearance

·         Papular warts – small dome shaped flesh colored – 1-4mm in size

·         Keratotic – thick, crusty

·         Flat topped papules – macular and slightly raised

Certain types of HPV infection (HPV types 16, 18, 31, 33, 35) can lead to transformation of the cervical squamocolumnar junction in women known as squamous intraepithelial lesions (SIL), a precursor to cervical cancer.   Women are screened annually (or every other year) in the United States with the Pap smear to detect these pathologic changes.  Please refer to the oncology section for a more in depth discussion.

 

Diagnosis

·         Primarily via clinical exam

·         Pap smear in women

·         Colposcopy in women if Pap smear is abnormal

 

Follow-up and Partner Management

A follow-up examination (for genital warts) is not necessary once treated unless symptoms persist and alternative therapies need to be considered. Partners are not routinely examined.

 

Syphilis

Epidemiology:

Syphilis is a systemic disease caused by Treponema pallidum. It is spread through sexual contact with an infected source and manifests as a series of clinical and sub-clinical stages. Syphilis is currently at an all time post WWII low in the United States. The most recent available data to date about incidence of primary, secondary and early latent syphilis rates in NYC is <1case per 100,000 population.[iii]  Rates of early syphilis however are markedly higher in certain areas of the Southern United States.  In October of 1999, the Centers for Disease Control and Prevention (CDC) launched a national plan to eliminate syphilis in the US.  While the disease will not be eradicated, this is an effort to drive new cases of early syphilis in all parts of the US to a significantly low level and to markedly decrease transmission of early infection. 

 

Clinical Syndrome

Primary Stage: After exposure to an infected source (someone with primary or secondary syphilis), a painless, papule appears at the site of inoculation (incubation 2 – 6 weeks, average ~3 weeks).  The papule grows into an indurated painless ulcer (chancre) with clear base and without exudate.  While single ulcers are classic, multiple syphilitic chancres can frequently occur.  Bilateral regional lymphadenopathy is present in the majority of patients.  Without treatment the chancre will heal spontaneously in 3  – 6 weeks.  Remember a syphilitic chancre can occur at any site!

 

Secondary Stage: This is the disseminated stage of disease and can occur at the same time as the primary stage or up to 6 months following healing of the chancre. Manifestations may include fever, malaise, headache, generalized lymphadenopathy, a generalized rash (classically papular, discrete, scaly) with involvement of the palms and soles, mucous patches in the oral or genital regions, wart like growths in moist intertringinous regions (condyloma lata), and alopecia.  This stage resolves in 3 – 12 weeks. There may be recurrence of the secondary stage in 25% of untreated patients.  

 

Latent Stage: Latent syphilis is the period of infection when patients are seroreactive for syphilis but are without clinical symptoms or signs.  Patients who have acquired syphilis within one year are classified as having early latent syphilis.  In general these patients are not infectious, however, the 25% of untreated patients who have a recurrence of secondary syphilis, will have it occur within one year of acquisition of primary disease.  Patients who acquired primary syphilis greater than one year prior are classified as having late latent syphilis.  While patients in latency are asymptomatic and non-infectious, treatment of this stage is required to prevent long-term sequelae.

 

Tertiary Stage: This stage occurs in up to 30% of untreated patients and can occur from months to decades after the primary infection. Tertiary syphilis can involve multiple organ systems: CNS (asymptomatic, meningeal involvement, cerebrovascular involvement, parenchymatous, gummatous) [iv]; Cardiovascular (aortic aneurysm, coronary artery disease, aortic valve disease, myocardial gummas); Musculoskelatal (gummas of skin, bones, gummas of mucous membranes - esophagus, tongue, mouth)

 

Neurosyphilis: This includes any patient with evidence of neurologic involvement and can occur during any stage of syphilis. 

 

Diagnosis

Darkfield Microscopy (DF):

This method is used to identify organisms when a primary or secondary lesion is present using a microscope with an inverted condenser which allows the small organism to be view over a dark background.   Any suspicious lesion should be sampled for DF, if possible, as this is the diagnostic test of choice in primary syphilis.

 

Serology:

Nontreponemal tests: RPR , VDRL

These are non-specific test, which test for a common mammalian protein (cardiolipin) on the organism. This protein is also present in other diseases and non-diseased states and can result in positive tests in a patient without syphilis (SLE, anti cardiolipin syndrome, pregnancy, HIV among others).  These are used for screening and require a confirmatory test for the diagnosis.  They are quantitatively performed and thus also used to monitor response to therapy.  RPR or VDRL may be negative in primary syphilis if the lesion if seen early.  The RPR is more commonly used in the US because many samples can be run simultaneously and is a less laborious test to perform that VDRL. One third of patients may revert to a negative non-treponemal test after adequate treatment for syphilis. 

 

Treponemal tests: MHA-TP (TPHA), FTA-ABS

These are specific tests for T. pallidum and measure surface antibody to a laboratory synthesized (non-virulent) form of T. pallidum.  MHA-TP is a hemagglutination test and FTA-ABS is a fluorescent labeled antigen-antibody complex identification method.  Once reactive these tests remain positive for life. They are qualitative tests only.  MHA-TP is an easier and less expensive test than FTA-ABS.

 

Culture:

There is no culture available for T. pallidum.

 

HIV patients may have extremely high serologic titers when infected with syphilis.  Titers may also take longer to decrease appropriately and may require repeat treatment.  The RPR alone may be falsely elevated in HIV patients and thus a confirmatory FTA-ABS must always be done.  Neurosyphilis should be considered in all HIV infected individuals.

 

Follow-up and Partner Management

An adequately treated patient is one in which the RPR or VDRL decreases by two serum dilutions (or fourfold).  Note response to therapy cannot be determined using different tests (i.e. pretreatment using VDRL and post-treatment using RPR).  Patients should be evaluated clinically and serologically at 6 months and 12 months for response.  Patients who have a two serum dilution (fourfold) increase in titer have failed treatment or were re-infected (less common) and should be retreated after evaluation for HIV infection.  All cases of syphilis should have their partners notified and evaluated serologically and clinically for disease.

 

Gonorrhea

Epidemiology

Gonorrhea caused by Neisseria gonorrhea, is a sexually transmitted infection of the columnar or cuboidal noncornified epithelial cells of mucous membranes.  Accurate data on incidence of gonorrhea worldwide is difficult as most countries have poor reporting systems for gonorrhea. There are over 600,000 new infections of gonorrhea per year in the United States.  While this STD has had declining incidence over the past forty years it is still much more common in the US as compared with other developed countries.  Gonorrhea is most prevalent in 15 – 29 year olds.  Women are much more likely to have asymptomatic infections.  The highest rates of infection occur in late summer and there is an increased association in people with lower socioeconomic status and higher level of sexual activity.

 

Clinical  Syndrome

Multiple clinical manifestations are associated with gonoccocal infection including:

·         urethritis

·         cervicitis

·         pharyngitis

·         proctitis

·         epididymitis                                          

·         salpingitis/PID

·         dissemination

·         conjunctivitis (rare in adults)

·         penile lymphangitis (bull’s head clap)

·         1° cutaneous infection (rare)

Diagnosis

Culture

urethral or cervical specimen on a modified Thayer Martin culture medium has 80 – 95% sensitivity

Non-culture Methods

DNA hybridization – uses single stranded of DNA probe to hybridize to N. gonorrhea rRNA ~ sensitivity 89 – 97%, specificity 99%.

Nucleic Acid Amplification – LCR, PCR – highly sensitive and specific, can be used on urine samples

 

Follow-up and Partner Management

Once treated neither follow-up nor test of cure is required.  All partners with sexual contact within the previous 60 days must be contacted and treated empirically for gonorrhea and chlamydia as many patients infected with gonorrhea are co-infected with chlamydia.  In cases where the last sexual encounter was longer than 60 days, the last known sexual partner should be treated.  While N. gonorrhea is relatively resistant to penicillins, and tetracyclines there is low occurrence of quinolone resistance in the United States.  In those who have recently visited Asia, quinolone resistant N. gonorrhea should be considered. 

 

Chlamydia trachomatis

Epidemiology

Sexually transmitted infections caused by Chlamydia trachomatis are currently the most common bacterial sexually transmitted disease in the United States.  New York City has particularly high rates.  Annual rates of infection have been estimated anywhere from 4 - 5 million cases across the nation, with a large percentage of these infections in both men and women being asymptomatic.[v] Prevalence data is variable, however published data have given estimates from 5% to 24% depending on the population studied[vi],[vii],[viii].  In 1995 the cost of treating chlamydial infections were estimated at $2.4 billion. 

 

Clinical Syndrome

Clinical symptoms are very similar to gonnoccal infections.  They include:

·         urethritis

·         cervicitis

·         pharyngitis

·         proctitis

·         epididymitis      

·         NGU[ix]

·         Reiters syndrome

·         Salpingitis

·         Reactive arthritis

·         Bartholinitis

·         Acute urethral syndrome in women

·         perihepatitis