Sexually Transmitted Disease CME KKSK 19.11.2021 (1)-1.pptx

STD, sexually transmitted disease

1. Sexually Transmitted Disease & Modified Syndromic Approach CME KK Seri Kembangan 19.11.2021

2. Contents Taking Sexual History Notifiable STD and STD screening at KKSK Syphilis Genital herpes Gonorrhoe Chlamydia Trachomatis Genital warts Epididymo–Orchitis Trichomoniasis Anogenital candidiasis Bacterial vaginosis Pelvic Inflammatory Disease Chancroid Lymphogranuloma venereum Modified Syndromic Approach

3. Taking Sexual History Ensure privacy and confidentiality Adopt polite, friendly, non-judgmental attitude Dialogue with patient: “ I am going to ask you a few questions about your sexual health and sexual practices. I understand that these questions are very personal, but they are important for your overall health.” “Just so you know, I ask these questions to all of my adult patients, regardless of age, gender, or marital status. These questions are as important as the questions about other areas of your physical and mental health. This information is kept in strict confidence. Do you have any questions before we get started?”

4. The 5 “P”s 1. Partners 2. Practices 3. Protection from STDs 4. Past history of STDs 5. Prevention of pregnancy

5. 1. Partners - number and gender of sex partners for the past 3 months - Relationship to partner (s) (spouse, regular non-spouse, casual) - Duration of sexual relationship (for regular partners) - Partner’s risk factors e.g concurrent partners, past sex partners and drug use 2. Practices - Type of exposure (oral, vaginal, anal) & role ( insertive , receptive) - Date of last intercourse - Last episode of unprotected anal/vaginal intercourse

6. 3. Protection from STD - condom use (frequency, reason for not using) - vaccination: HPV, Hep A/B, PrEP 4. Past history of STDs - for patient and partner: STD’s Test and diagnosis - partner’s HIV status 5. Prevention of pregnancy - Trying to conceive, contraception. information about contraception. LMP

7. STD’s Symptoms Male: o Dysuria, frequency o Urethral discharge o Genital ulceration o Abnormal growth or mass in genital area o Acute scrotal swelling, pain o Perianal pain o Anal discharge o Inguinal lymphadenopathy * A person may be infected, and may potentially infect others, without showing signs of disease Female: o Vaginal discharge o Genital ulceration o Dysuria, frequency o Vulval itching o Abnormal growth or mass in genital area o Dyspareunia (pain during sexual intercourse) o Post-coital bleeding o Intermenstrual bleeding o Perianal pain o Anal discharge o Inguinal lymphadenopathy o Lower abdominal pain

8. Prevention Methods Abstinence Mutual monogamy- both partners having sex with only one another. Using PrEP Proper and consistent condom use Regular STD screening

9. Notifiable STD Syphilis Gonorrhoea Chancroid HIV Viral Hepatitis STD screening at KKSK HIV RTK- repeat at 3 months for window period HBsAg Anti HCV Ab VDRL (TPPA if positive) Gram stain for gonorrhoea High vagina swab for candidiasis

10. Syphilis- Treponema Pallidum Early syphilis (<2 years) 1. Primary - incubation period: 9-90 days - solitary, non-tender , indurated and well circumscribed ulcer (chancre) with regional lymphadenopathy Dx : clinical, Dark-field microscopy for T. pallidum from ulcer base, VDRL/ TPHA 2 . Secondary - incubation period: 6 weeks - 6 months - generalized non-irritating skin lesion involving the palms and soles with or without generalized lymphadenopathy - less common: condyloma lata , pathcy alopecia, symptoms of bacteremia e.g anterior uveitis, meningitis, cranial nerve palsies, hepatitis, splenomegaly, periosteitis and glomerulonephritis. Dx : clinical, VDRL and TPPA

11. 3. Early latent positive serology without symptoms and signs in a person known to be sero -negative in the previous 2 years Usually detected by screening (ANC, STD, blood donors, contact tracing)

12. Solitary, indurated chancre condyloma lata

13. secondary syphilis

14. Treatment and Follow up Early syphilis : Benzathine penicillin, 2.4 mega units I.M. in a single dose Allergic to penicillin: Oral doxycycline 100mg bd for 14 days Epidemiological treatment: for asymptomatic contact, Benzathine penicillin 2.4 MU I.M. single dose Abstinence until 1 week after patient and partner have completed treatment Contact tracing: early syphilis: 3 months, secondary syphilis: 6 months VDRL follow-up at months 1, 2, 3, 6 and 12, then 6 monthly until negative or low titre , 1:8 or less

15. Late syphilis (>2 years) 1. Late Latent Syphilis - Syphilis of more than 2 years duration; diagnosed by positive serology without any symptoms 2. Tertiary Syphilis (Gumma) 3. Cardiovascular Syphilis 4. Neurosyphilis

16. Treatment & Follow up Late syphilis : Benzathine penicillin, 2.4mega units I.M. weekly X 3 weeks (3 doses ) - Allergic to penicillin: Oral doxycycline 100mg bd for 30 days - VDRL follow up: 6 monthly intervals for 2 years and annually till seronegative or stable at a low titre 1:4 or less.

17. Genital Herpes Aetiology : Herpes simplex viruses (HSV) types 1 and 2 Incubation period: 2-5 days Single/ multiple p ainful vesicles , ulceration, dysuria, vaginal or urethral discharge Once infected with HSV, the virus achieves latency in the nerve roots and is usually lifelong infection Reactivation cause symptomatic lesions or asymptomatic, but infectious, viral shedding milder than primary infection factors may precipitate an attack: trauma, menstruation, concurrent infection or fever, immune suppression, stress, and UV light

18. 80% asymptomatic. Shedding of virus may occur from intact epithelial surface in the absence of symptoms Responsible for transmission of HSV in majority of cases (70%) Complications: - Neuropathic bladder (initial episode) - Psychosexual morbidity - Enhanced HIV transmission - Neonatal herpes (acquisition in last trimester of pregnancy)

19. Investigations: Swab of base of ulcer or de-roofed vesicle for NAAT, viral culture, antigen detection First episode: Aciclovir 400mg tds for 5-10 days Recurrent episodic : 400 mg t.d.s . P.O. for 5 days Recurrent suppressive : If very frequent (≥ 6 per year), severe, prolonged, or with psychosocial problems - acyclovir 400mg bd for 6 months - review six monthly as recurrences usually become less frequent and severe with time

20. Other management: - analgesia and antipyretics - Saline/ sitz bathing - Topical lignocaine reduces pain from erosions - Urinating in a bath or shower relieves superficial dysuria - Neuropathic bladder requires catheterisation until resolution - Encourage condom use with ongoing partners - Abstinence during recurrences or prodromes - counselling to help cope with infection and prevent sexual and perinatal transmission

21. Gonorrhoea Incubation period Neisseria gonorrhoeae: 2-5 days Investigations: Gram stain of urethral, cervical or rectal exudates - Gram negative intracellular diplococci other tests: Thayer Martin culture, NAAT and PCR Treatment: Ceftriaxone 500 mg I.M. AND Azithromycin 1g as a single dose

22. Gram negative intracellular diplococci

23. Advise no sexual contact for 7 days after treatment is administered. Contact tracing: 3 months Follow up: - Assess for symptom resolution - Confirm contact tracing has been undertaken - Provide further sexual health education and prevention counselling.

24. Non Gonococcal urethritis (NGU)/ Chlamydia Trachomatis Commonest STI, greatest risk at <30 years Incubation period: 7-21 days Investigations: urethra or endocervical swab, first void urine for gram stain, culture, NAAT, enzyme immunoassay (EIA) Treatment: Doxycycline 100 mg b.d . for 7 days; or Azithromycin 1 g single dose Contact screening: 6 months

25. Genital Warts Human papilloma virus (HPV) Genotypes 6 & 11 causes > 90% of cases Genotypes 16 & 18: oncogenic and can lead to anogenital cancer Incubation Period: 2 weeks – 8 months (usually 3 months) Very infectious – more than 75% of sexual partners develop warts when exposed Diagnosis: naked eye examination Treatment: 40% resolved spontaneously. - cosmetic rather than curative. - HIV infection: genital warts can have a poor response to treatment and may require longer cycles of treatment and are more likely to recur

26. Epididymo- Orchitis Inflammation of the epididymis, and occasionally the testis Usually under 35 year of age ; caused by a sexually transmitted pathogen e.g. Chlamydia trachomatis and N. gonorrhea. Over 35 years of age ; usually due to non sexually transmitted gram negative enteric organisms e.g. E.coli. Anatomical and functional abnormalities are often present in this group and should be further investigated. Other causes: Mumps, Tuberculosis Symptoms - unilateral pain and swelling of the testes - Dysuria - Usually no urethra discharge - Suprapubic pain, frequency, and nocturia- Suggests urinary pathogen rather than STI Signs - Palpable swelling of the epididymis - Tenderness on palpation - erythema / edema of the scrotum, urethral discharge and pyrexia.

27. Important differential diagnosis: Torsion of testes – it is a surgical emergency; it should be considered in all patients and be excluded first Investigations - As for gonorrhoea and chlamydia - Urine FEME and culture Treatment: Ceftriaxone 500mg stat plus Azithromycin 1g PO Bed rest, scrotal support and analgesia Contact tracing if STI related: 6 months Complications: Hydrocele, Abscess formation, Infarction of testes and Infertility

28. Pelvic Inflammatory Disease A syndrome comprising a spectrum of inflammatory disorders of the upper female genital tract, including any combination of endometritis , salpingitis , tubo -ovarian abscess and pelvic peritonitis. Polymicrobial Up to 70% of cases have an unidentified cause STIs (e.g. Neisseria gonorrhoeae , Chlamydia trachomatis, Mycoplasma genitalium implicated)

29. Diagnosis & Investigations Examination is important to make an accurate diagnosis. New onset of pelvic pain among women <25 years is highly predictive of PID Risks include: recent partner change, partner with STI or symptoms of an STI, recent uterine instrumentation or pregnancy Exclude ectopic pregnancy and surgical emergencies e.g. appendicitis The presence of STI supports the diagnosis, but no organism is identified in 70% of cases. Bimanual examination: to elicit cervical motion tenderness and adnexal or uterine tenderness. Speculum examination: mucopurulent discharge All women of reproductive age with new onset abdominal pain should have the following investigations - Urine pregnancy test and, if positive, urgent pelvic ultrasound - Testing for STIs as indicated in diagnosis - Urinalysis

30. Trichomoniasis Aetiology : Trichomonas vaginalis Incubation Period: 4 days to 4 weeks Presentation - Female: Diffuse, malodorous, frothy, yellow-green vaginal discharge with vulval itching. Strawberry cervix (punctate cervical erythema) ± dyspareunia, ± dysuria, vulvo -vaginal soreness ( vulvitis and vaginitis) - Male: Usually asymptomatic Complications: Premature rupture of membranes, Low birth weight and Preterm delivery

31. Investigations: High vagina swab for saline wet smear (motile flagellates), PCR Treatment: Metronidazole 400 mg b.d for 5 – 7 days or 2 gram stat dose Pregnancy: published data suggest no increased risk of teratogenicity in normal dose Contact tracing: examine and investigate sex partner, treat sex partner epidemiologically No sexual intercourse or alcohol until one week treatment completed

32. Anogenital Candidiasis Aetiology : Candida albicans 80 – 92% Female: Vulval itching & soreness, thick white curdy vaginal discharge that is worse before menses Male: Rash on glans penis, penile soreness/itch, fissures, superficial erosions Investigation: Smear from lateral wall of vagina - 10% KOH microscopy (sensitivity 70%) - Gram stain for Gram-positive yeast-like cells (sensitivity 65 – 68 %)

33. Thick white curdy discharge Excoriation, erythema and fissures

34. Candida Balanitis Superficial fissures Superficial erosions

35. Treatments: Clotrimazole pessaries 500 mg single dose/ 200 mg on for 3 days Pregnancy: Topical therapies recommended for a longer period Advice: Avoid local irritants e.g. perfumes, soap and tight fitting synthetic clothing Recurrent: 4 or more episodes of symptomatic candidiasis annually. Predisposing factors: diabetes mellitus, HIV, corticosteroid use, frequent broad spectrum antibiotic use, immunosuppression Treatments: Fluconazole 150 mg P.O. weekly for 6 months; OR Clotrimazole vaginal pessary 500 mg weekly for 6 months; OR Itraconazole 400 mg P.O. monthly for 6 months

36. Bacterial vaginosis Mixed flora consisting of Gardnerella vaginalis and other anerobes such as mycoplasma hominis Is not a STI but can be acquired through sexual activity and frequently detected during STI screening

37. Investigation: Amsel’s criteria, diagnosis is made by the presence of any 3 out of the 4 features given below:- 1. Homogeneous, thin, white discharge that smoothly coats the vaginal walls 2. Presence of clue cells on microscopic examination 3. pH of vaginal fluid >4.5 4. Fishy odor of vaginal discharge before or after addition of 10% KOH (the Amine’ Sniff test )

38. Treatment: - Symptomatic women - Women undergoing gynecological procedures - Pregnant women Treatment: Metronidazole 400 mg b.d . for 5 to 7 days or 2 gram stat Advice: avoid vaginal douching, use of shower gel, antiseptic soap and shampoos in baths Follow up: If treatment is prescribed in pregnancy to reduce the risk of preterm birth, a repeat test should be made after 1 month and further treatment is offered if there is evidence of recurrence of bacterial vaginosis

39. Chancroid Aetiology: Haemophilus Ducreyi Rare form of painful necrotizing genital ulcer presents with or without bubo formation (purulent abscess of the inguinal lymph nodes) Screen for other causes of genital ulcers: Treponema pallidum, Genital herpes, Lymphogranuloma venereum (LGV), HIV Treatment: - Azithromycin 1g PO, OR Ceftriaxone 500mg OR Ciprofloxacin 500mg PO, BD for 3 days

40. Bubo Formation

41. Lymphagranuloma Venereum (LGV) Aetiology: Chlamydia trachomatis, serovars L1-3 mainly MSM communities and those with HIV- usually present with proctitis Symptom of proctitis: rectal pain, bleeding, rectal discharge, tenesmus and changed bowel habit Diagnosis: clinical suspicion, epidemiological information, and the exclusion of other etiologies of genital or rectal ulcers, inguinal lymphadenopathy,or proctocolitis LGV specific NAAT Treatment: Doxycycline 100mg PO BD for 21 days

42. Painful anal ulcer Painful penile ulcer. All tests were negative, except Chlamydia trachomatis, LGV genotype

43. Modified Syndromic Approach (MSA) In 1991, WHO endorsed a simple, cost effective approach : Syndromic approach of STI management STIs managed based on the clinical presentation, and treatment can be given without the laboratory test Treatment is according to clinical syndromes and patients treated for all the important causes of the syndrome using combinations of antimicrobials MOH in 1999 adapted WHO recommendation on the 3 syndromes for local use at primary health care level

44. Advantages of MSA Treating more than one infection at a time (estimated 60% of patients had >1 infection at one time) Treating patients at first visit without the labaratory test Client friendly service Counselling and advice given to patient Prevent self treatment Reduced possibility of drug resistance Reduce risk of transmission Minimum lab investigations needed

45. Disadvantages of MSA Cost of over treatment when multiple anti-microbials given to patient with none or only one infection may cause less precise diagnosis may cause antibiotic resistant if not manage properly

46. References 1. A Guide to Taking a Sexual History. Center for disease Control and Prevention 2. Malaysian Sexually Transmitted Infections Guidelines 2015 3. Australian STI Management Guidelines 4. STI Atlas 5. Modified Syndromic Approach (MSA) D alam R awatan J angkitan P enyakit Kelamin , Kementerian Kesihatan Malaysia

47. Thank You