SEXUALLY
TRANSMITTED
INFECTIONS
Dr Sushruti Kaushal
Assistant Professor
Obstetrics and Gynecology
Includes infections transmitted mainly through sexual contact
from an infected partner
ually Other modes of transmission
nsmitted
placental (HIV, syphilis)
blood transfusion
ctions infected needles (HIV, hepatitis B or syphilis)
inoculation into the infant’s mucosa when it passes through the birth
canal (gonococcal, chlamydial, herpes)
Gonorrhea
Causative organism - Neisseria gonorrheae (gram negative
diplococcus)
Incubation period 3-77 days
Principal site of invasion is the columnar and transitional epithelium o
the genitourinary tract.
norrhoea Primary sites of infection are endocervix, urethra, Skene’s gland, and
Bartholin’s gland.
Gonococci attach to the spermatozoa and are carried up
Endometritis and salpingitis are common
Rarely: Pelvic Inflammatory disease, tenosynovitis, septic arthritis.
One-third
third of such cases are associated with chlamydial infection
Other sites of infection are oropharynx anorectal region, and
conjunctiva
50% asymptomatic
Local
Dysuria, vaginal discharge, Bartholinitis, Proctitis, phar
intermenstrual bleeding
Local signs of inflammation, Speculum examination rev
congested ectocervix with increased mucopurulent cerv
mptoms: secretions escaping out through the external os.
Distant/ Metastatic
Perihepatitis – spread of infection to liver capsule
Septicemia: low grade fever, polyarthralgia, tenosynov
septic arthritis, perihepatitis, meningitis, endocarditis,
skin rash.
PID
Acute pelvic inflammation
Chronic pelvic inflammatory disease
Infertility
ectopic pregnancy (due to tubal damage)
mplications dyspareunia
chronic pelvic pain
Tubo-ovarian
ovarian mass
Bartholin’s gland abscess
Nucleic Acid Amplification Testing (NAAT)
Urine (first void sample)
Endocervical discharge
gnosis Gram stain and culture
Secretions from urethra, endocervix and Bartholin Gland
Gram negative intracellular diplococci
Culture on Thayer
Thayer-Martin Medium
Ceftriaxone 500 mg im single dose for persons weighinf <150 kg
OR
Gentamicin 240 mg im single dose plus Azithromycin 2g orally in single
dose
Cefixime 800 mg orally in single dose
atment If chlamydial infection has not been excluded: treat for chlamydia with
doxy 100 mg BD for 7 days
The patient with gonorrhea must be suspected of having syphilis or
chlamydial infection.
Treat adequately the male sexual partner simultaneously
Use condom till both the sexual partners are free from disease
Cultures should be made 7 days after the therapy.
Repeat cultures are made at monthly intervals following menses
ow Up for three months.
If the reports are persistently negative, the patient is declared
cured
Treponema Pallidum-
Pallidum anaerobic spirochete
By direct contact with other person who has open primary or
Syphilis secondary syphilitic region
Transmission occurs through the abraded skin or mucosal surface.
The incubation period ranges between 9 and 90 days
Usually single
Labia, Fourchette, anus, cervix, and nipple
A small papule is formed, which is quickly eroded to form an ulcer.
The margins are raised with smooth shiny floor.
mary Lesion The ulcer is painless without any surrounding inflammatory
ancre) reaction.
The inguinal glands are enlarged, discrete, and painless.
The primary chancre heals spontaneously in 1–8
1 weeks leaving
behind a scar.
The tubes are not affected and infertility does not occur
Secondary Lesion
Within 6 weeks to 6 months from the onset of primary chancre, the
secondary syphilis may be evidenced in the vulva in the form of
condyloma lata.
These are coarse, flat--topped, moist, necrotic lesions and teeming with
treponemes.
ondary Patients may present with systemic symptoms like fever, headache,
and sore throat.
hilis Maculopapular skin rashes are seen on the palms and soles.
Other features include generalized lymphadenopathy, mucosal ulcers,
and alopecia.
The primary and secondary stage can last up to two years and during
this period, the woman is a source of infection
It is the quiescence phase after the stage of secondary syphilis has
resolved.
ent Syphilis
It varies in duration from 2 to 20 year
About one-third
third of untreated patients progress from late latent
stage to tertiary syphilis.
It damages the central nervous, cardiovascular, and musculoskeletal
systems.
Patient may present with cranial nerve palsies (III, VI, VII, and VIII),
hemiplegia, tabes dorsalis, aortic aneurysm, and gummas of skin
tiary and bones.
The important pathology is endarteritis and periarteritis of small and
hilis medium-sized
sized vessels.
Tertiary syphilis is characterized by gumma.
A gummatous ulcer is a deep punched ulcer with rolled out margins.
It is painless with a moist leather base.
Serpiginous outline may also be produced.
1) Identification of the organism—Treponema
organism pallidum
A smear is taken from the exudate which is obtained after teasing
the primary chancre (base and edge) with a swab dipped in normal
saline.
gnosis It is examined under dark ground illumination through a
microscope.
The treponemata appear as motile bluish-white
bluish cork-screw
shaped organisms
2) Serological tests:
a) VDRL: Most common test, positive after 6 weeks of initial
infection
b) Specific tests :
Treponema pallidum hemagglutination (TPHA) test
Treponema pallidum enzyme immunoassay (EIA)
gnosis fluorescent treponemal antibody absorption (FTA-abs)
(FTA
Treponema pallidum immobilization (TPI) test
test
c) Immunoblotting and PCR tests are being evaluated as more
sensitive and confirmatory tests.
After successful treatment, non-specific
non tests become negative,
whereas specific tests remain positive.
Early syphilis (primary, secondary, and early latent syphilis of less
than 1 year duration)
Benzathine penicillin G 2.4 million units is given intramuscularly in a
single dose, half to each buttock.
In penicillin allergic cases, tetracycline 500 mg, 4 times a day or
Doxycycline 100 mg BID PO for 14 days is effective
atment Late syphilis
Benzathine penicillin G 2.4 million units is given IM weekly for 3
weeks (7.2 million units total)
Alternative regimen: Doxycycline 100 mg orally twice daily or
Tetracycline 500 mg orally 4 times a day for 4 weeks.
Serological test is to be performed 1, 3, 6, and 12 months after
treatment of early syphilis.
In late symptomatic cases, surveillance is for life; the serological
ow-up test is to be done annually.
All women with simultaneous syphilis and HIV infection may have
high rate of treatment failure
Causative Organism - Chlamydia trachomatis (of D-K serotypes),
an obligatory intracellular Gram-negative
Gram bacteria
Incubation Period: 6-14
6 days
The organisms affect the columnar and transitional epithelium of
the genitourinary tract. The lesion is limited superficially.-
superficially. may be
amydia asymptomatic
The infection is mostly localized in the urethra, Bartholin’s gland,
and cervix.
May ascend and cause PID and may be associated with gonorrhea
Asymtomatic – 75%
Dysuria, dyspareunia, postcoital bleeding and intermenstrual
bleeding
Findings: mucopurulent cervical discharge, cervical edema,
ical cervical ectopy, and cervical friability
tures Complications:
Bartholinitis
Emdometritis,, salpingitis – infertility
Perihepatitis – Fitz--Hugh-Curtis Syndrome- chlamydia is more
common than gonorrhea
Sample from urethra and endo-cervical
endo glands
Nucleic acid amplification and detection by PCR-
PCR 95% specific
Chlamydia antigen (lipopolysaccharide) can be detected by ELISA
gnosis technique.
Chlamydia can be demonstrated in tissue culture.(McCoy cell
monolayers). It is 100% specific. It is expensive, technically difficult
and takes 3–77 days to obtain result.
doxycycline — 100 mg orally bid × 7 days or
azithromycin — 1 g orally single dose or
atment
Levofloxacin — 500 mg orally od × 7 days or
Partner treatment should be done simultaneously
Gram-negative
negative streptobacillus—Hemophilus
streptobacillus ducreyi.
Incubation period – 3-5 days
Clinical presentation:
Multiple vesico-pustules
pustules over vulva, vagina and cervix.
ncroid Slough to form shallow ulcers circumscribed by inflammatory zone
t sore) Tender lesion with foul purulent and hemorrhagic discharge
There may be cluster of ulcers
Unilateral inguinal lymphadenitis may be present – may suppurate
Discharge from ulcers or pus from lymph glands collected
Shoal of fish appearance in gram staining
gnosis Difficult to grow on culture
Ceftriaxone 250 mg IM single dose is effective.
Azithromycin 1 gm by mouth single dose.
atment Erythromycin 500 mg by month every 8 hours for 7 days can also
be given
Sexual partner should also be treated.
Chlamydia trachomatis – L serotype
Obligatory intracellular, gram intermediate organism
Incubation period – 3-30 days
Initial lesion is a painless papule, pustule or ulcer in the vulva,
hogranuloma urethra, rectum or the cervix.
The inguinal nodes are involved and feel rubbery.
eum
There is acute lymphangitis and lymphadenitis.
The glands become necrosed and abscess (bubo) forms.
Within 7–15
15 days, the bubo ruptures and results in multiple draining
sinuses and fistulas.
The healing occurs with intense fibrosis with lymphatic
obstruction.
The secondary phase is noted by painful adenopathy.
hogranuloma The classical clinical sign of LGV is the “groove sign”, a depression
eum between the groups of inflamed nodes.
The lymphatic obstruction leads to vulval swelling where as
lymphatic extension to the vulva, vagina, or rectum leads to
ulceration, fibrosis, and stricture of the vagina or rectum.
(i)) vulval elephantiasis,
(ii) perineal scarring and dyspareunia,
mplications
(iii) Rectal stricture
(iv) sinus and fistula formation.
a) Culture and isolation (Lymph node aspiration): of LGV (Chlamydia
serotypes L1,2,3) is confirmatory.
(b) Detection of LGV antigen in pus obtained from a bubo with specific
monoclonal antibodies using immunofluorescence method.
nosis
(c) Detection of LGV antigen by ELISA method
(d) LGV complement fixation test—when
test positive with rising titer (>1 :
64).
(e) Intradermal Frei test is non-specific
non and unreliable.
Doxycycline 100 mg BID for at least 21 days.
Alternatively, azithromycin 1 g PO weekly for 3 weeks
or erythromycin 500 mg orally every 6 hours for 21 days is given
(indicated for pregnant women).
atment Sexual partner should also be treated.
Surgical treatment:
(i)) Abscess should be aspirated but not be excised.
(ii) Manual dilatation of the stricture
Causative Organism - Gram-negative intracellular bacillus—
Calymmatobacterium granulomatis (Donovania granulomatis).
Incubation Period – 10-80 days
Clinical Presentation:
nuloma The lesion starts as pustules, which breakdown and erode the
adjacent tissues through continuity and contiguity.
uinale The ulcer looks hypertrophic (beefy red) due to indurated
novanosis) granulation tissue.
The margins are rolled and elevated.
Biopsy may be needed to exclude neoplasia.
The lymph nodes do not undergo suppuration and abscess
formation
Demonstrating the Donovan bodies within the mononuclear cells
in material (scrapings) from the ulcer when stained by the Giemsa
method.
gnosis
Donovan bodies are clusters of dark-staining
dark bacteria with a
bipolar (safety pin) appearance found within the mononuclear
cells.
Azithromycin 1g orally once/ week or 500 mg daily for > 3 weeks
and until all lesions have completely healed
Doxycycline 100 mg BID for at least 3 weeks and until all lesions
have completely healed
Erythromycin base 500 mg orally 4 times/ day for > 3 weeks and
atment until all lesions have completely healed
Trimethoprim/sulfamethoxazole one double strength (160mg/800
mg) tab orally 2 times/ day for > 3 weeks and until all lesions have
completely healed
The residual destructive lesion in the vulva may require plastic
surgery or vulvectomy.
G vaginalis, anaerobic organisms such as Bacteroides species,
Peptococcus species, mobiluncus, and Mycoplasma hominis act
synergistically to cause vaginal infection.
There is marked decrease in lactobacilli.
Clinical Features:
terial Malodorous vaginal discharge
ginosis Vaginosis- no vaginal inflammation
The discharge is homogeneous, greyish-white
greyish and adherent to the
vaginal wall.
Clinical implications of BV, in pregnancy are, preterm rupture of
membranes, preterm labor, and chorioamnionitis
(i)) Recurrent infection leading to PID.
(ii) Development of PID following abortion
mplications
(iii) vaginal cuff cellulitis following hysterectomy
(iv) Pregnancy complications: second trimester miscarriage, PROM,
preterm birth, endometritis
Amsel’s Criteria:
(1) Homogeneous vaginal discharge.
(2) Vaginal pH > 4.5 (litmus paper test).
(3) Positive whiff tests.
gnosis (4) Presence of clue cells (> 20% of cells).
Gram Stained Vaginal Smear:
Presence of more Gardnerella or mobiluncus morphotypes with few
or absent lactobacilli.
Whiff test: Fishy (amine) odor when a drop of discharge is mixed
with 10 percent potassium hydroxide solution
Clue cells: A smear of vaginal discharge is prepared with drops of
normal saline on a glass slide and is seen under a microscope.
Vaginal epithelial cells are seen covered with these coccobacilli and
the cells appear as stippled or granular.
gnosis At times, the cells are so heavily stippled that the cell borders are
obscured.
These stippled epithelial cells are called “clue cells”
Presence of clue cells ( >20% of cells) is diagnostic of BV.
Metronidazole 500 mg two times a day for 7 days
Clindamycin cream (2%) and metronidazole (0.75%) gel for vaginal
application daily for 5 days
The patient’s sexual partner should be treated simultaneously.
atment OR
Clindamycin 300 mg BD for 7 days
Clindamycin 100 mg intravaginally once at bedtime for 3 days
Causative Organism: Herpes Simplex Virus 1 and 2
Incubation Period- 2-14
14 days
Clinical presentation:
Red painful inflammatory are appears commonly on the clitoris, labia,
vestibule, vagina, perineum ,and cervix.
Multiple vesicles appear which progress into multiple shallow ulcers and
pes Genitalis ultimately heal up spontaneously by crusting.
It takes about 3 weeks to complete the process.
Inguinal lymphadenopathy occurs.
Constitutional symptoms include fever, malaise, and headache.
There may be vulvar burning, pruritus, dysuria, or retention of urine.
First episodes are severe compared to the recurrent disease.
Frequency of recurrent infection is high with HSV-2
HSV
(a) Virus tissue culture and isolation — confirmatory.
(b) Detection of virus antigen by ELISA or immunofluorescent
gnosis method.
(c) PCR test to identify the HSV DNA is the rapid, specific, and most
accurate test
Increased risks of miscarriage and pre-term
pre labor.
Transfer of infection from mother to neonates during vaginal
delivery, if primary (50%) or recurrent (5%).
Baby may suffer from damage to central nervous system.
ks
Primary genital herpes is not an indication for MTP .
Anomaly scan should be done at 20 weeks gestation.
Delivery by cesarean section is indicated with primary genital
herpes infection at the time of delivery
Acyclovir 400 mg 3 times a day for 7-10
7 days
Valaciclovir 1g BID for 7-10
7 days
atment Famciclovir 250 mg orally thrice daily for 7-10
7 days can be used
alternatively.
Saline bath may relieve local pain
Causative organism – Human Immunodeficiency Virus 1 &2
Retrovirus (double stranded RNA family)
Modes of transmission:
Heterosexual and homosexual contact
/AIDS Intravenous drug use
Transmission of contaminated blood
Use of contaminated needles
Perinatal transmission
Breastfeeding
Infection of the genital tract is high due to progressive
immunodeficient state
ecological Vaginitis due to recurrent candidiasis. There may be oral,
esophogeal candidiasis also.
ptomatology
Pelvic Inflammatory Diseases—with
Diseases other STIs (gonorrhea,
chlamydia, syphilis) are more likely
Neoplasms of the genital tract are increased
Increased incidence of CIN and carcinoma of the cervix. Colposcopy
and cervical cytology screening should be routinely done.
Increased incidence of vulval intraepithelial neoplasia (VIN).
Increased morbidity following gynecological surgery
ecological Menstrual abnormality: Menorrhagia, amenorrhea, or abnormal
ptomatology uterine bleeding may be due to associated weight loss,
thrombocytopenia or opportunistic infections or neoplasms
Fertility is not generally affected.
Pregnancy does not worsen the disease neither the disease affect
pregnancy adversely
ntraception Barrier contraception is a must
Human Papilloma Virus 6 & 11
Usually multiple
nital warts Grow in clusters along a narrow stalk-
stalk cauliflower appearance
ndyloma Anatomic distribution of anogenital HPV infection is: Cervix 70%,
minata) Vulva 25%, Vagina 10% and Anus 20%.
Predisposing Factors: Immunosuppression, diabetes, pregnancy,
and local trauma.
HPV vaccines can prevent 90% infections
for urethral and cervical warts:
Cryotherapy with liquid nitrogen
surgical removal
Trichloro-acetic
acetic acid or bichloroacetic acid 80-90% solution
atment For external Ano-genital
genital warts: can also use
Imiquimod 3.75% or 5% cream
Podofilox 0.5% solution or gel
Sinecatechins 15% oint
Pox virus
Caused by body contact of towel or clothing
Lesions: Size upto 1 cm, dome-shaped,
dome pearly-white in color and
luscum often umbilicated
Multiple, anywhere in skin or genitalia
tagiosum Microscopic appearance reveals numerous inclusion bodies
(molluscum bodies) in the cytoplasm of the cells with Giemsa
stain.
Evacuation of caseous material from the nodule under local
anesthetic is done.
The floor of the nodule is then treated chemically with ferric sub-
sub
atment sulphate or trichloroacetic acid (85%) solution.
Cryotherapy with liquid nitrogen is applied until a halo of ice is
formed around the lesion. Repeat application may be necessary
Causative agent- Phthirus pubis
The louse along with its eggs are attached to the hair
It is transmitted by sexual contact or infected clothes
Treatment:
iculosis Permethrin cream (1%) is applied over the affected area and
washed off after 10 minutes
is Gamma-benzene
benzene Hexachloride
Malathion 0.5% applied on affected areas and washed off after 8-
8
12 hrs
Ivermectin 250mcg/kg body weight orally, repeated. In 7-14
7 days
Treat contact and sterilize clothing by boiling
Causative organism: Sarcoptes scabei
Intense itching and excoriation of skin
bies Permethrin 5% and malathion 0.5% applied to all areas of body
below neck and washed off after 8-14
8 hours
The clothing should be boiled. The family members are also to be
treated simultaneously to prevent reinfection.
Thank you
