Pharmacotherapy of sexually transmitted Infection

1. Lesson 6
Sexually transmitted infections
Tsegaye Melaku (BPharm, MSc)
Assistant Professor of Clinical Pharmacy
tsegayemlk@yahoo.com or tsegaye.melaku@ju.edu.et +251913765609December, 2020

2.  Session Tips:
– Therapeutic relationship(communication matters!)
– Explain the routes of transmission and risk factors
– Behavioral considerations & importance of contraception
– ―Patient-delivered partner therapy‖
– Common causative microorganisms
– Corresponding clinical signs and symptoms
– Diagnostic procedures/techniques
– Treatment regimens & ‗‘Syndromic management approach‘‘
– Monitoring the Rx outcome
2

3.  Aka sexually transmitted diseases (STDs) or venereal diseases
 > 30 different infections transmitted mainly through:
– Sexual contact via the exchange of semen, vaginal fluid, blood &
other fluid
– Direct contact with the affected body areas of people with STIs
 Its social and economic burden is high
– Loss of employment
– Broken marriages
3

4. 1. Sexual transmission: most common mode
Vaginal or anal sex
– In Ethiopia: vaginal route
– Heterosexual transmission: common
3. Mother-to-child
– During pregnancy (e.g. HIV & syphilis),
– At delivery (e.g. gonorrhoea & chlamydia),
– During breastfeeding (e.g. HIV)
3. Unsafe use of unsterile needles or injections
4. Contaminated blood or blood products (e.g. syphilis, HIV and hepatitis).
4

5.  Biological factors
– Age, sex and immune status
 Behavioural factors
– Unprotected sexual intercourse
– Frequent changing of sexual partners(multi-partner)
– Use of drug of abuse   ↑ risk of unsafe sexual acts
 Socio-cultural factors
– Gender bias of a community
– Women‘s economic dependence on men
– Young marriage
5

6.  WHO estimates 357 million new cases of four curable STIs in 15-49
year-old
Curable STIs: chlamydia, gonorrhea, syphilis, trichomoniasis
Source: WHO. Global incidence and prevalence of selected curable sexually transmitted infections - 2012.
> 1 million new cases of
STI / day

7.  In Ethiopia:
– At ANC sentinel surveillance
– The prevalence of syphilis is 1% (2012), 2.7% (2007) and
2.3% (2009)
– HIV (2014): 1.14%, Projection estimate [2018]: 0.96%
– In 2013 at selected facilities
– Vaginal discharge (50%), urethral discharge (31%), genital
ulcerative disease (9%), lower abdominal pain (7.3%)
– 16% co-infection with HIV
– Age group, 20-34 yrs, (highly affected); female 61%
7

8.  Infertility,
 Foetal wastage,
 Ectopic pregnancy,
 Anogenital cancer,
 Premature death,
 Neonatal & infant infections
8
HIV versus STI relationship

9. – History taking,
– Physical examination
– Correct diagnosis
– Early & effective treatment
– Advice/counsel on sexual
behaviour
– Offer HIV counselling and
testing
9
– Promotion and/or provision of condoms
– Partner notification and treatment
– Case reporting & clinical follow-up
– Advise to return in 7 days
– Refer (if necessary)
 Components of case management:

10.  3 Rx approach
– Etiologic, clinical and syndromic approach
 Based on groups of symptoms & easily recognized signs (syndromes)
– Etiological diagnosis of STI is problematic in many settings.
 ―The syndromic approach is not scientific.‖
– It is based on a wide range of epidemiological studies
 ―The syndromic approach results in a waste of drugs, because patients
are being over-treated.‖ Do you agree ?????
10

11. 11

12.  Recommended syndromic treatment
– Therapy for uncomplicated gonorrhoea
PLUS
– Therapy for chlamydia
 If persistent/recurrent urethral discharge
– Suspect re-infection or poor compliance or Trichomonas vaginalis
12

13.  Recommended syndromic treatment
– Therapy for syphilis PLUS
– Therapy for chancroid OR
– Therapy for granuloma inguinale OR
– Therapy for lymphogranuloma venereum (LGV)
13

14.  Recommended syndromic treatment
– Therapy for uncomplicated gonorrhoea
PLUS
– Therapy for chlamydia
 In older people, with low risk of STI E.coli, Klebsiella spp. or p.
aeruginosa.
14

15.  Cervical infection
Recommended syndromic treatment
 Therapy for uncomplicated gonorrhoea
 PLUS
 Therapy for chlamydia
15
 Vaginal infection
Recommended syndromic treatment
 Therapy for bacterial vaginosis PLUS
 Therapy for Trichomonas vaginalis AND,
 Therapy for Candida albicans

16.  Evaluate for all sexually active women presenting with symptoms of
lower abdominal pain.
– Salpingitis and/or endometritis – pelvic inflammatory disease (PID)
– Signs & Symptoms:
– Abdominal pain, bleeding,
– Dyspareunia, vaginal discharge,
– Menometrorrhagia, dysuria,
– Pain associated with menses,
– Fever, nausea & vomiting,
– Uterine tenderness on pelvic exam
16

17.  Etiology for PID
– N. gonorrhoeae, C. trachomatis, anaerobic bacteria (Bacteroides
spp. & Gm(+) cocci)
 Recommended syndromic treatment
– Single-dose therapy for uncomplicated gonorrhoea (ceftriaxone
usually) PLUS
– Doxycycline 100mg PO BID x14 days PLUS
– Metronidazole 500mg PO BID x 14 days.
17

18. 18

19. Cophxoo/ጨብጥ
 Cause: Gm(-) intracellular diplococcus: Neisseria gonorrhoeae
 Aka ‗‘the Clap‘‘
 Incubation: 1–14 days; Average: 2–5 days
19

20. Common cause of urethritis in men & cervicitis in women.
 2nd most common bacterial STI
– Incidence (US): ~700,000 per year
 Common in adult in both sex (15- to 24-years)
– More case report: in male
 Contributing/risk factors
– Low socioeconomic status
– Illicit drug use
– Age, Ethnic minorities
 Associated sequelae: urethritis, cervicitis, or dysuria
20

21. 21
Rates of reported cases by year, US, 1941–2017

22. Rates of reported cases by sex, US, 2008–2017

23. 23
Rates of reported cases by age group and sex, US, 2017

24. 24
Rates of reported cases among women aged 15–44 years by
age group, US, 2008–2017

25. 25
Rates of reported cases among men aged 15–44 years by age
group, US, 2008–2016

26.  Ethiopia
– Among symptomatic STI patient
20.8% (Gondar); Rozina et, 2017
43% (Addis Ababa); Elisabeth et al, 1995
26

27.  Bacteria attachment to mucosal epithelium   penetration to
submucosal tissue(within 1-2 days)
 Epithelium slough off (due to neutrophil response)   submucosal
microabscesses   exudation of pus.
27

28.  Common
– Purulent & profuse discharge
– Urinary frequency
– Persistent sore throat ! ! !
28
 Men
– Asymptomatic case!
– Acute urethritis (common)
– Urethral discharge + dysuria ±
urinary frequency or urgency
– Painful or swollen testicles
– Unilateral testicular pain and
swelling: indicative of
epididymitis and/or epididymo-
orchitis.
 Women
– Cervicitis, urethritis,
– Increased vaginal discharge,
– Dysuria, Intermenstrual bleeding
– Abdominal pain
– Tubal scarring
– Dyspareunia, and pelvic pain

29. 29
Male Urethritis.

30. 30
Female Urethritis.
Cervicitis

31. 31
Hyperacute Conjunctivitis Skin Lesions

32. 32
Bartholin Abscess Disseminated gonorrhea - skin lesion

33.  Epididymitis
 Epididymo-orchiditis
 Salpingitis & PID (involve upper genital tract)
 Tubo-ovarian abscess (late PID)   infertility(due to tubal scarring)
33

34.  Clinical presentations
 Diagnostics
– Gram-stain, endocervical or vaginal specimens
– Culture, DNA hybridization probe
– Urethral specimen (male): PMN leukocytes; diplococci N. Gonorrhea
Stain: large numbers of gonococci within a few neutrophils
– If test +ve: test for other STIs is needed ! !
– NB: In asymptomatic don‘t use gm (-) stain to rule out infection
34

35.  Can occur in the rectum, pharynx, and conjunctiva.
 DGI classically presents as either
– A triad of polyarthritis, tenosynovitis, and dermatitis, or
– Septic arthritis(Knee most affected).
 Disseminated gonococcal meningitis and endocarditis(rare)
35

36.  Depends on clinical presentation
 Evaluate for co-infection of C. trachomatis (often)
 Preferred: Cephalosporins + Azithromycin (same day)
 Alternatives: Cephalosporins + Doxycycline
36

37.  Pharyngeal, cervix, urethra, & rectum infection
– Ceftriaxone 250 mg IM OR Cefixime 400 mg PO OR cefotaxime
500mg IM stat + Azithromycin 1 g PO stat OR Doxycycline 100 mg
PO BID X 7 days.
 Co-infection C. trachomatis (always do not forget)
– Ceftriaxone 250 mg IM stat + Azithromycin 1 g PO.
37

38.  Regimen should be given for 24-48hrs
– Ceftriaxone 1 g IM/IV QD + Azithromycin 1 g PO stat or
– Cefotaxime 1 g IV TID + Azithromycin 1 g PO stat or
– Ceftizoxime1 g IV TID + Azithromycin 1 g PO stat
 PID
– Ceftriaxone + Doxycycline ± Metronidazole
38

39. 39
Neisseria gonorrhoeae — Percentage of Isolates with Elevated Azithromycin Minimum
Inhibitory Concentrations (MICs) (≥2.0 µg/ml), Elevated Ceftriaxone MICs (≥0.125
µg/ml), and Elevated Cefixime MICs (≥0.25 µg/ml), Gonococcal Isolate Surveillance
Project (GISP), 2008–2017
NOTE: Isolates not tested for cefixime susceptibility in 2008.

40. Neisseria gonorrhoeae — Prevalence of Tetracycline, Penicillin, or Fluoroquinolone
Resistance* or Elevated Cefixime, Ceftriaxone, or Azithromycin Minimum Inhibitory
Concentrations (MICs)†, by Year — Gonococcal Isolate Surveillance Project (GISP), 2000–
2017
* Resistance: Fluoroquinolone (ciprofloxacin) = MIC≥ 1.0 µg/mL; Penicillin = MIC≥ 2.0 µg/mL or B-lactamase positive; Tetracycline = MIC≥ 2.0 µg/mL.
† Elevated MICs: Azithromycin = MIC≥ 1.0 µg/mL (2000–2004); ≥ 2.0 µg/mL (2005–2017); Ceftriaxone = MIC≥ 0.125 µg/mL; Cefixime = MIC≥ 0.25 µg/mL.
NOTE: Cefixime susceptibility was not tested in 2007 and 2008.
ADAPTED FROM: Kirkcaldy RD, Harvey A, Papp JR, et al. Neisseria gonorrhoeae antimicrobial susceptibility surveillance — The Gonococcal Isolate
Surveillance Project, 27 Sites, United States, 2014. MMWR Surveill Summ 2016; 65(7):1–24.

41. Distribution of primary antimicrobial drugs used to treat gonorrhea among participants, gonococcal
Isolate Surveillance Project (GISP), 1988–2017
NOTE: For 2017, “Other” includes azithromycin 2g (0.3%), no therapy (0.3%), and other less frequently used drugs (0.1%).

42.  Pregnancy
– 3rd generation cephalosporin + Azithromycin
– Cephalosporin intolerant: Azithromycin 2g PO stat
 Ophthalmic Neonatorum Prophylaxis
– Erythromycin 0.5% ointment or
– Ceftriaxone 25–50 mg/kg IV/IM (max125 mg) stat
 Gonococcal Conjunctivitis:
– Ceftriaxone 1 g IM/IV + Azithromycin 1 g PO stat
 Allergy, tolerance, or adverse reactions
– Based on specific offending agents (You are drug therapy expert)
42

43. 43

44.  Caused by Chylmadia trachomatis[Gm(-)anaerobic bacteria]
 Causes NGU (non-gonococcal urethritis in men; cervicitis in females)
 Most common cause of non-gonococcal urethritis
 8 serotypes.
 Incubation period-7-21 days
 Its transmission risk is lower than gonorrhea.
 Complications
– Male: Epididymitis
– Female: Pelvic inflammatory disease
44

45. 2-3x more prevalent than gonorrhea
 Most cases are asymptomatic (under reported)
– Annual screening recommended
 Most common among young people
– 67% among age 15 to 24 yrs
 Rectal infection common among MSM.
45

46. Rates of Reported Cases by Sex, US, 2000–2017

47. Rates of Reported Cases by Age Group and Sex, US, 2017

48. Rates of Reported Cases Among Women Aged 15–44 Years by
Age Group, US, 2008–2017

49. Rates of Reported Cases Among Men Aged 15–44 Years by Age
Group, US, 2008–2017

50.  It lives inside a host in order to reproduce & survive[replicate inside
eukaryotic cells].
 Has two developmental forms.
– Elementary bodies (EB) & reticulate bodies (RB)
 EB (infectious version)
 Metabolic inactive (EB) enter to host cell through endocytosis RB
(growth version) formed  used host cell  multiple RB(binary
fission)  form EBs infect more cells   cell rupture and
death
50

51. 51

52.  Mostly asymptomatic
 Women: Beefy red cervix that bleeds easily
Watery urethral discharge (less purulent)
52
CervicitisMale Urethritis

53. 53

54. 54

55.  Specimen:
– Women: urine or endocervix swab
– Men: urethral swab or urine specimen.
 Tests
– Nucleic acid amplification test
– Culture
– Enzyme immunoassay
– DNA hybridization probe or
– Direct fluorescent monoclonal antibody test.
55

56.  Genital/Urethral/Endocervical chylmadia(uncomplicated)
– Preferred:
Azithromycin 1 g PO stat or
Doxycycline 100 mg PO BID x 7days
– Alternative:
Erythromycin 500 mg PO QID x 7 days
Levofloxacin 500 mg QD x 7 days or
Ofloxacin 300 mg BID (or 600 mg QD) x 7 days
56

57.  Reactive arthritis(chronic)
– Doxycycline 100 mg PO BID + rifampin 300 mg QD x 6 months
 Anorectal/rectal chylmadia
– Azithromycin 1 g PO stat
– Doxycycline 100 mg PO BID x 7 days or
57

58.  Special cases
– Pregnancy
Azithromycin 1 g PO stat or Amoxicillin 500 mg PO TID x 7 days
or
Erythromycin 500 mg QID x 7 days or 250 mg QID x14 days.
– Infant infection [ophthalmia neonatorum or pneumonia]
Erythromycin 50 mg/kg/day PO divided into four doses daily x
14 days
58

59. 59

60.  Aka the great imitator
 Causative Agents: Treponema pallidum (gram-negative spirochete)
Incubation: 10–90 days, Average: 3 weeks
 Infections can be chronic
 Progress through 4 stages: 1˚, 2˚, latent, & 3˚.
60
Fanxoo ቂጥኝ

61.  Following penicillin, its incidence & prevalence ↓ed
– However, raised following HIV occurrence
 In the US, MSM are at ↑risk of acquiring the infection.
 Can also be acquired congenitally
 More common among men and black
61

62. Rates of reported cases by stage of infection, US, 1941–2017
NOTE: Data collection for syphilis began in 1941; however, syphilis became nationally notifiable in 1944. Refer to the National Notifiable Disease
Surveillance System (NNDSS) website for more information: https://wwwn.cdc.gov/nndss/conditions/syphilis/.
HIV patients, pregnant women and blood donors had a syphilis
prevalence of 9.46% (95%CI; 6.52-12.4), 1.74% (95%CI; 0.96-
2.52), and 0.69% (95%CI; 0.42-0.97)

63. 1˚ & 2˚ syphilis — Distribution of Cases by Sex and Sexual Behavior, US,
2017

64. 1˚ & 2˚ syphilis — rates of reported cases by sex and male-to-
female rate ratios, US, 1990–2017

65. 1˚ & 2˚ syphilis — reported cases by sex and sexual behavior, US, 2013–
2017
* 37 states were able to classify ≥70% of reported cases of primary and secondary syphilis as either MSM, MSW, or women for each year during 2013–2017.
ACRONYMS: MSM = Gay, bisexual, and other men who have sex with men (collectively referred to as MSM); MSW = Men who have sex with women only.

66. 1˚ & 2˚ syphilis — rates of reported cases by age group and sex,
US, 2017

67. 1˚ & 2˚ syphilis — rates of reported cases among women aged 15–44 years
by age group, US, 2008–2017

68. 1˚ & 2˚ syphilis — rates of reported cases among men aged 15–44 years by
age group, US,2008–2017

69.  Ethiopia
– It reaches up to 18.8%; Assefa et al, 1997
– Pooled prevalence: among infected HIV patients ~12.4%; pregnant
women ~ 2.52%; blood donors~0.97%; Siraj et al, 2019
– Among pregnant women: 1.9% (95 CI, 0.5-3.5%) Gondar area;
Getachew et al, 2019; 2.9% in Addis Ababa, Kebede et, 2000
– 10 years trend (2005-2014): 2.5% to 1.1% among pregnant
women; Desta et al, 2019
69

70. 70

71. 71

72. 73
1˚
• Solitary, painless chancre
• Occur after 3 weeks (@site of infection)
• Highly infectious; spirochetemia
2˚
• Advancement of 1˚ syphilis (if not Rx)
• Fatigue, diffuse rash, fever, lymphadenopathy, genital or perineal condyloma latum.
• Skin most affected; Rash can be macular, macropapular, or pustular lesions
Latent
• Can be early and late infection
• Asymptomatic; Previous lesions will resolve
• But, sero + for T.Pallidum
3˚
• Occurs years after infection
• Affect any of body parts

73.  Infection of fetus by T.Pallidum
 Symptoms: hepatomegaly, jaundice, and bone changes
 Transmission
– Hematogenous spread from an infected mother
– Direct contact with the infectious genitalia of the mother
– Especially during 1˚ syphilis
74

74.  Usually solitary, round-to-oval, painless genital ulcer.
 Ulcer may be slightly painful, and several lesions are sometimes seen.
 The base of the genital ulcer is dry in males, moist in females
 Purulent fluid in the base is uncommon
 The borders of the ulcer are often indurated
Bilateral, non-tender, non-fluctuant adenopathy
75

75. 76
Primary syphilitic chancre

76. 77
Secondary syphilis Papulosquamous rash of trunk, palms, soles and feet, Hyperkeratotic plantar rash

77. 78
Mucous Patches. Condyloma Lata.secondary syphilis

78. 79
Hutchinson Teeth

79.  Neurosyphilis:
– Seizures, paresis, meningitis, stroke, hyperreflexia, visual
disturbances, hearing loss,
– Neuropathy, or loss of bowel and bladder function.
– Vascular lesions (meningovascular)
80

80.  Clinical symptoms
 Physical examination …..Very important
 Laboratory
– Microscopy
– Venereal Disease Research Laboratory [VDRL]
– Rapid plasma reagin [RPR] test)
– T. pallidum hemagglutination test
– Fluorescent treponemal antibody test
– Enzyme-linked immunosorbent assay [ELISA])
81

81.  1˚ syphilis
– Benzathine penicillin, 2.4 million units IM [50,000 units/kg] stat.
– Alternative:
Doxycycline 100 mg PO BID x 14 days or
Tetracycline 500 mg PO BID x 14 days or
Ceftriaxone1g IM or IV QD x 10 days or
Azithromycin 2 g PO stat
 2˚ syphilis & early latent syphilis (< 1-year duration)
– As 1˚ syphilis
82

82.  Late Latent Syphilis & 3˚ syphilis
– Benzathine penicillin 2.4 million units IM (50,000 units/kg) once
weekly for 3 weeks.
– Alternatives
Doxycycline 100 mg PO BID x 28 days or
Tetracycline 500 mg PO QID x 28 days
 Gummatous and Cardiovascular Syphilis
– As 3˚ syphilis
83

83.  Neurosyphilis
– Ceftriaxone1g IM or IV QD x 8 to 10 days or
– Crystalline penicillin G 3 to 4 million units IV q4 hrs or continuous
infusion for 10 to 14 days
84

84.  Congenital Syphilis
– Mother Rx
Benzathine penicillin 2.4 million units IM (50,000 units/kg) once
weekly for 3 weeks or
Ceftriaxone1g IM or IV QD x 8 to 10 days
– Neonates Rx (asymptomatic)
Benzathine penicillin G 50,000 units/kg IM stat
– Neonates Rx (symptomatic)
Crystalline penicillin G 50,000 units/kg BID IM for the first 7
days of life, then TID for 3 days or
Procaine penicillin G 50,000 IU/kg IM QD for 10 days.
85

85. 86

86. 87

87. 88

88. It is the most common STD
An infection with a tiny parasite spread by sexual contact
Causative agent: Trichomonas vaginalis (anaerobic flagellated
single-celled protozoa parasite)
The human genital track is the only reservoir for this species.
It is transmitted through sexual/genital contact
Aka Trich, Trichomonas Vaginalis, TV
Incubation: 4–28 days
89

89.  Prevalence: More > > than C. trachomatis or N. gonorrhoeae.
In US: 3.7 million people
– 2.1% among women ages 14-59
– 0.5% among men
7.4 million cases reported every year
180 million people infected worldwide
50% asymptomatic carriers
90

90. A risk for preterm delivery
 Ethiopia
– Among symptomatic STI patient:14.2% (Gondar); Rozina et, 2017
– Among pregnant women: 4.98% [Jimma(JMC)]; Zeleke et al, 2013
91

91. Trichomonas vaginalis and Other Vaginal Infections Among Females, US,
1966–2016
NOTE: The relative standard errors for Trichomonas vaginalis infection estimates range from 23% to 17% and for other vaginal infection
estimates range from 13% to 8%. See Section A2.5 in the Appendix and Table 44.
SOURCE: National Disease and Therapeutic Index, IMS Health, Integrated Promotional Services™, IMS Health Report, 1966–2016. The 2017 data
were not obtained in time to include them in this report.

92.  Risk of infection
– Younger age at first sex
– Greater number of sex partners
– History of chlamydia infection in the past 12months
93

93. 94
Vaginal epithelium
(rich in glycogen)
Lactic Acid
Non-pathogenic
The vaginal secretions :
pH 3.8 - 4.4
Women under
normal condition
Bacilli (normal flora)
Convert

94. 95

95. 96

96.  It is not an invasive parasite
 It remains adherent to the squamous epithelium but not columnar
epithelium
 Protozoan attachment to cells   inflammatory response  
discharge (contain high PMN leukocytes)
 Direct damage to epithelium   ulceration(micro)
97

97.  Cause more symptoms in women than in men
– 50% of infected women are symptomatic compared to 25% of
infected men.
– Women often develop symptoms over time
– Men can often clear the infection spontaneously
 Pelvic pain, dysuria, dyspareunia, vaginal burning, itching, and a scant,
frothy green, malodourous discharge.
 On speculum exam, the cervix may have punctate hemorrhages  
aka ―strawberry cervix.‖
98

98.  Diffuse, malodorous, yellow-green vaginal discharge with vulvar irritation.
 Asymptomatic (some women)
 Signs
– Strawberry cervix/Colpitis macularis(women)
– Prostatitis or epididymitis (men)
 Symptoms
– Vaginal/vulvar erythema
– Excessive yellow-green discharge
– Vulvar itching
99
– Vaginal odor
– Urethral discharge/irritation
– Dysuria
– Vaginal pH >4.5

99.  In women
– Discomfort during intercourse
– Itching of the inner thighs
– Vaginal discharge (thin, greenish yellow, frothy or foamy)
– Itching or swelling of the labia
– Vaginal odor (foul or strong smell)
 In men
– Burning after urination or ejaculation
– Burning of urethra
– Slight discharge from urethra
100

100.  Clinical signs and symptoms
 Physical exam: Small red ulceration (sores) on the vaginal walls
 Laboratory:
– On saline wet mount or Papanicolaou smear(Vaginal scrapping)
– Nucleic acid amplification tests
– Rapid antigen detection tests
– Culture
– Vaginal pH >4.5
101
Pap smear

101.  Metronidazole 2g PO stat (especially for pregnant) or
 Metronidazole 500 mg PO BID X 7 days or
 Tinidazole 2g PO stat
– For Metronidazole-resistant trichomoniasis
 Current sex partners should be referred for treatment.
Avoid sexual intercourse until treatment is complete.
102

102. 103

103.  Aka Condyloma Acuminata
 Causative agents: human papillomavirus (HPV)
– Very contagious/small bumps
– Small, non-enveloped, double-stranded DNA viruses
– >150 types: 6 & 11 genital warts; 16 & 18  cervical cancer.
– Some infect cutaneous or keratinized squamous epithelial cells  skin
warts.
– Some (>40 types) infect the mucosa or non-keratinized squamous
epithelium   have oncogenic potential[squamous cell carcinoma].
104

104. Size from 1 to 4 mm
 Skin-to-skin contact (i.e, vaginal, anal, or oral) during sexual activity
with an infected person.
 Asymptomatic can transmit the disease.
 May be seen or felt by patients or their sexual partners
 Effectiveness of condom is questionable: virus can infect areas not
covered by a condom.
105

105.  ~50% of sexually active persons infected at least once in their lifetime.
– ~ 90% naturally cleared by immune system
 US
– Prevalence: >50%
– Incidence: >14 million/year
– ~50% cases: among person age 15 to 24 years
106

106.  Most people do not develop symptoms[usually asymptomatic]
– But, can be painful or pruritic
 Rough, thick, cauliflower-like lesions
 Signs
– Black dots within warts
– Disrupted surface
 Symptoms
– Anogenital pruritus
– Burning
– Vaginal discharge or bleeding
– Dyspareunia (in vulvovaginal condyloma)
107

107. 108
Genital Warts—Male. Cauliflower-like appearance Genital Warts—Male

108. 109
Genital Warts—Female
Perianal Condyloma Acuminata

109. 110
Giant Warts—Male Genital Warts—Female

110. 111
Condyloma acuminata, anal Condyloma acuminata, meatal

111.  Clinical signs and symptoms
 Physical exam[visual inspection]
– Classic condyloma acuminata; keratotic warts; flat warts
 Laboratory
– DNA, RNA, or capsid protein detection
– Tissue biopsy or viral typing
– Colonoscopy
112

112.  Goal of therapy
– Remove visible warts & ↓ of infectivity
– Alleviation of physical symptoms & cosmetic improvement
 ~>50% resolve spontaneously within 9-12 months
113

113.  Podofilox 0.5% gel or solution:
– Apply BID for 3 days then 4 days of drug free day (repeat till no
visible warts) or for 1 month
– Don‘t use in the vagina, anus, or during pregnancy
 Imiquimod 5% cream;
– Apply at bedtime, 3x a week for up to 16 weeks or
– Apply every other day for three applications
114

114.  Podophyllin resin [10% to 25% solution]
– Apply once weekly
– CI in pregnancy
 Caustic agents
– Includes Bichloroacetic (BCA) and Trichloroacetic (TCA) Acids
– Apply once a week
 Ablative Therapy
– Cryotherapy with liquid nitrogen or
– Cryoprobe, surgical removal by excision, and vaporization
 Prevention: vaccination[Gardasil vaccine]
115

115. 116

116.  Causative agents: herpes simplex virus (HSV) (HSV- 1 & HSV-2 )
– No cure (lifelong/chronic)
 Transmission: oral to oral contact
 HSV-2: cause for recurrent infection, especially genital herpes.
 Incubation (initial presentation): 4 to 7 days after sexual exposure
117

117.  US
– Prevalence: ~50 million
– HSV-2 infection: ~16.2% among 14–49 years age.
– Incidence: 500,000 cases/year
 Common among PLHIV
118

118.  HSV only found in humans
 Almost all cases acquired sexually
 Transmission from secretion  mucosal surfaces (i.e, cervix or urethra)
 Transmission from abrasion: direct contact with an active lesion
 Asymptomatic case: a key factor for transmission.
 Can be transmitted to neonate during delivery
119

119.  Most asymptomatic
 Signs
– Vesicular lesions(last up to 21 days)
– Small, cluster painful blisters vesicles (filled with fluid) (erythematous
base)
– 1st outbreak heal within 2-4 wks (severe presentation).
– Later presentation (attacks) are less severe
 Symptoms
– Itching, Burning, Tingling, Groin lump, Dysuria
– Dyspareunia, ↑urinary frequency
– Ulcerative lesions, fissures, cervicitis
120

120. 121
Herpes, female Primary herpes, female

121. 122
Same patient, four days later
Herpes cervicitis

122. 123
Primary Lesions—Male. Multiple genital
vesicles of primary genital herpes
Primary Lesions—Male. Confluence of ulcerations on an
erythematous base in a patient with primary herpes simplex
type II

123.  Clinical signs and symptoms
 Physical exam[visual inspection]
 Laboratory
– Virologic typing, serology, RDT antigen detection, ELISA, PCR
124

124.  Test for HIV: epidemiologic synergy
 No cure
– Rx reduce s & sxs, a number of attacks
 Focus on the first episode (4- 7 days, but can occur after years)
– If Rx: favorable outcome in terms of lesion healing time, viral
shedding, & reduction in pain
125

125.  Suppressive therapy
– To control symptoms
 Preventive Therapy
– Valacyclovir 500 mg PO QD +
– Counsel on safe sex practices
– Provision of condom for new/uninfected partner
126

126. 127

127. 128

128.  Non-pharmacologic Rx & related
– Lukewarm baths 3-4 x/days[ease itching & pain]
– Pat dry affected areas
– Wear loose-fitting underwear (aid drying of sore)
– Avoid sexual contact
129

129.  Pregnant women[prevention of neonatal infection]
– CS + antiviral therapy
– Acyclovir 200 to 400 mg TID
– [Start at 36/38 weeks‘ gestation continue till delivery]
 Neonates
– If s & sxs: fever, poor feeding, lethargy, or seizures
– Disseminated & CNS disease
– Acyclovir 20 mg/kg/day IV in three divided doses x 21 days
– Skin, eyes, & mucous membranes involvement
– Acyclovir 20 mg/kg/day IV in three divided doses x 14 days
130

130. 131

131.  Infection that ascends from the cervix or vagina to involve the
endometrium and/or fallopian tubes.
 Inflammatory disorders of the upper female genital tract
 Common cause: C. trachomatis & N. gonorrhoeae
 Other causes: Anaerobes, enteric Gm(-) rods, & CMV
– Mycoplasma genitalium
– Bacteroides species
– E. coli
– H. influenza
– Streptococcus
132

132.  Affects young, sexually active women
– Minority women, with multiple sex partners
 US:
– >800,000 cases/year
– Highest in 1st time mothers & teens
133

133.  Mov‘t of bacteria from Vagina  pass cervix  reach internal
reproductive organs.
 Bacteria component aid its pathogenesis and cause tissue damage.
– Example: Heat-shock protein & cytotoxins from chylmadia
134

134.  Ectopic pregnancy
 Infertility (10% to 15% of PID)
 Tubo-ovarian abscess
 Chronic pelvic pain
 Peritonitis and intra-abdominal abscess
135

135.  Signs & symptoms
– Uterine tenderness
– Cervical motion tenderness
– Painful urination
– Lower abdominal pain
– Painful intercourse(Dyspareunia)
– Adnexal tenderness
– Fever> 38.3°C (101°F)
– Abnormal cervical or vaginal
discharge (green or yellow)
– Presence of WBC in vaginal secretions
– ↑ESR, ↑CR
136
– Inter-menstrual or post coital
bleeding
– Backache

136.  Clinical signs and symptoms
 Physical exam
 Test for HIV (all women)
 Laboratory
– N. gonorrhoeae or C. trachomatis
137

137. 138

138. 139

139.  Ethiopian guideline
140

140. What is the only 100 % effective way of
preventing STIs and pregnancy?

141.  Donovanosis (granuloma inguinale)
 Chancroid
 Neonatal conjunctivitis
 Inguinal bubo
 Pediculosis pubis (Pubic louse)
142

142. 143