Sexually Transmitted Diseases (STDs)

Introduction
Genital Tract Portal of Entry for Infection Diseases (Venereal,
Non-Venereal)
Venereal Disease = STD (includes all diseases spread by Sexual
Intercourse)
Causative Agents
Bacteria
Treponema pallidum
N. gonorrhoea
H. ducreyi
Gardnerella vaginalis
Donovania granulomatis
Chlamydia trachomatis
Mycoplasma genitalium
Ureaplasma urealyticum
Virus
HSV
HPV
Hep. B
HIV
Protozoa
Trichomonas vaginalis
Others
Fungi
Arthropods

Syphilis
Gonococcal urethritis
Chancroid
Bacterial vaginosis
Granuloma inguinale
NGU, Cervicitis, LGV
NGU
NGU
Genital herpes
Genital warts (condylomata
acuminate)
Hepatitis
AIDS
Trichomonas vaginitis, NGU

STD
Spread through Sexual Contact mucous membrane, breach in
skin
Other Modes of Transmission
Mother-to-Child

Pregnancy

Delivery

After Birth

Breast Milk (HIV only)

Transfusion or contact with Blood, Blood Products
STD Patients, especially ulcerative types
Risk Infected with HIV
(Require effective, complete treatment of STD to HIV Risk)
Public Health Problem
Consequences - Health, Social, Economic
Serious Sequale
Pelvic Inflammatory Diseases
Impaired Fertility
Ectopic Pregnancy
Cervical Cancer
Affect Fetus, Infant
HIV Infection
Facilitate HIV transmission by
Disruption of Normal Epithelial Barrier by Genital Ulceration
Accumulation of pools of HIV susceptible, HIV-infected cells in
(Lymphocytes, Macrophages)
Semen, Vaginal Secretion
Challenges
Asymptomatic (many cases)
Female (especially)
Continue to be infected, infectious to others
Reluctant to seek health care
Stigma
Lack of Confidentiality, Privacy
Difficult to Notify Spouse, Sex Partner
Unavailability, Unsuitability of STD Services
Ignorance of STD
Causes, Symptoms, Cures, Consequences
Prescribed Treatment is substandard
Clinical Features
Vaginal Discharge
Trichomonas Vaginitis
Vaginal Candidiasis
Gonococcal Endocervicitis
Genital Ulcer

Urethral Discharge +/Dysuria (Male)

Gonorrhea
Post Gonococcal Urethritis
Non Specific Urethritis

Syphilis
Chancroid
Genital Herpes
Neonatal Conjunctivitis
Gonococcal Conjunctivitis
Chlamydia Conjunctivitis
Bacterial Conjunctivitis

Epidemiology
Global Estimates (WHO 1999)

Epidemiology

Incidence Rate of STD in Kelantan (2000-2004)

STD
2000
2001
2002
2003
Syphilis
2.87
1.41
1.26
1.3
Gonococcal
1.71
0.82
0.37
0.9
340 Million New Cases of STIs have occurred worldwide in 1999
Largest number of new infections occurred in region of

South, Southeast Asia

Sub-Saharan Africa

Latin America, Caribbean

Malaysia
Exact size of the problem is unknown

Underreporting

Underdiagnosis

Asymptomatic manifestation of disease

Existing Act (Prevention & Control of Infectious Act 1988)

require notification of only Syphilis, Gonorrhea, Chancroid,
HIV

Reluctance to seek health care

Most STD patients go to Private Doctors (not reported to

MOH)

2004
0.74
0.61

Cases of STD Reported in Malaysia (1996-2000)

Syphilis

Classification
Definition
Primary
Secondary
Latent
Late
Communicable Disease, Caused by Treponema pallidum (Spirochaetaceae family)
Tertiary
Treponema = Turning Thread (Greek Term)
Quaternary
Not all patients go through all these stages
Treponema pallidum
Corkscrew appearance, 20 um in length, Moves in spiralling/ spinning
motion

Primary Syphilis (1)

Pathogenesis
T. pallidum enter body

Penetrating intact mucous membrane

Invading through epithelial abrasions

Grows, Multiplies in a Localized Area

Spread to Lymph Node, Blood Stream

Secondary Syphilis (2)

Pathogenesis
Develops 6-8 weeks after 1
manifestation

Due to Reaction of Circulating

Spirochetes
with specific antibodies
to form immune complexes

Spirochetes spread throughout the body

Infectious Lesions occur on

Skin, Mucous Membrane
Incubation Period 10 - 90 days (3
weeks)
Typical 1 lesion (Chancre)
A Single Painless Ulcer
(with border, indurated base)
Chancre represents an Intense
Inflammatory response to Bacterial
Invasion

Skin, Mucous Membrane Lesions

Skin Lesions (can involve Palms, Soles)

Macular

Papular

Occasional Pustular

Nodular type rashes

Patchy Alopecia
Condylomata Lata
Mucous Patches
Mouth Ulcers

Chancre on
Lower Lip

Penile
Chancre
Painless Enlargement of Lymph Node
Extra Genital Chancre (5%)
Lips
Mouth
Nipple

Systemic Symptoms
Fever, Rash, Generalized
Lymphadenopathy, Arthritis, Iritis,
Retinitis

Latent Syphilis
An Asymptomatic state
(persist if Early Infection is not
cured)
Slow Tissue Damage
CSF Protein Level
Mild Pleocytosis
Develop Late Manifestation of the
disease (many patients - eventually)

Tertiary Sy
Pathogenesis
After a Latent Perio
Lon

Represents a H
Reac
to small numbe
that Grow, Pe
(symptoms de
occurr

Non Con
Destruc
1. Gummatous Sy
common)
Develops in 15% of
(within 1-10 years
Localized granulom
eventually Necrose
Mainly in Skin, Bon

2. CVS Syphilis
Occurs in 10% of u
(within 10-40 years
infection)
Aneurysm of Ascen
Arch
Necrosis of Medi
Due to Chronic Infla

Transmitted by Kissing (Extremely

contagious)
Ulcer, Condyloma Lata
Chancre disappears within 2-6 weeks
(whether or not Treatment is given)

Lasts for Weeks Months,

then Gradually Subsides

Laboratory Test for Syphilis

Direct Detection
Dark Field Microscopy

Indicated in 1, 2, Early Congenital Syphilis

Specimen Fluid (Exudate), Tissue from an open sore

(1 chancre, condyloma latum, mucous patch)

A Lesion should be considered Non-Syphilitic only after 3 ve

examinations have been made
Advantage
Disadvantage
-ve results do not rule out
Test does not work well on
syphilis
Dry Sores
Direct Detection

Immunoflourescence
Serological Test
Screening
Non-Specific
Cardiolipin (Reagin) Antibody
Test

Venereal Disease Reference

Laboratory (VDRL) slide test
Rapid Plasma Reagin (RPR) test
Automated Reagin Test (ART)
Toluidine Red Unheated Test
(TRUST)

VDRL/ RPR
Screen for Syphilis
Monitor Treatment
Detect Ab to Cardiolipin in
patients with Syphilis
Done using

Serum Sample

Spinal Fluid
Not useful in

Very Early Detection

Advanced Stages
Syphilis
False +ve Cardiolipin Test

Infectious

Electron Microscopy
Confirmatory
Specific
Treponemal Antibody Test

Treponema pallidum
Haemagglutination Test (TPHA)
Treponema pallidum Particle
Agglutination Assay (TPPA)
Fluorescent Treponemal
Antibody Absorption Test (FTAAbs)
Microhaemagglutination assay
for antibodies to Treponema
pallidum (MHA-TP)

TPHA
Sheep RBC coated with T.
Pallidum are agglutinated by
Patients Ab

FTA-Abs
Test is more difficult to do
Detects specific Antibodies
to bacteria that cause
Syphilis
Can detect Syphilis in All
Stages (except during 1st 3-4

small arterioles sup

Wall of Aorta Spl
Blood dissects thro
media layer

3. Neurosyphilis
Expressed in 8% of
(within 5-35 years
Manifested as - M
Meningovascular sy
dorsalis, General Pa
Robertson Pupil
Arg
Pu
Sm
Siz
Abs
refl
Pro
Acc
refl
Pup
(wi
mononucleosis
weeks)

SLE
Done using

Viral Pneumonia

Blood Sample

Pregnancy

Spinal Fluid

Narcotic addiction

Autoimmune diseases

Leprosy

Malaria

Vaccination
Isolation of Treponema pallidum
T. pallidum cannot be cultivated on artificial media
Inoculation of Laboratory Animals (Higher Primates, Rabbit
Testes) is the only mean presently available to isolate organism
Treatment
Penicillin Treatment of choice for all form of Syphilis
Alternatives if Patients Allergic to Penicillin
Tetracycline
Doxycycline
Erythromycin
Jarisch-Herxheimer Reaction
Inflammatory response to Spirochete Antigen
Occurs within hours of 1st Antibiotic Dose with

Fever

Exacerbation of Inflammation
Can be Minimized by starting Dose Penicillin or adding
Corticosteroid

Interpretation of Serology Result

VDR
TPHA Interpretation
L
Almost Indicate Treponemal Infection
+
+
Other Test Rarely Needed
Probably Indicates biologically False +ve
+
Verification Test Indicated (eg. FTA-Abs)
Probably Indicate Old, Treated Infection
+
Verification Necessary. False +ve TPHA < 2%
Syphilis Unlikely (FTA in suspected cases)
Rarely Late, Early Primary Syphilis
Characteristics Serological Result
Clinical
Specim
VDRL
en
Primary
Serum
- or +
Secondary
Serum
Strongly
+
Latent
Serum
Usually +
Late
Serum
- or +
Neurosyph
CSF
Usually +
ilis
Recent
Serum
- or
Treated
weekly +

TPHA

FTA Abs

- or +
+

Usually +
+

+
+
+

+
+
+

Gonorrhoea
Definition
Neisseria gonorrhoea (GNDC, intracellular)
Incubation 1-10 days
Clinical Features
Urethritis
Rectal gonorrhoea
Pharyngeal gonorrhoea
Complications
Prostatitis
Epididymo-orchitis
Bacteraemia
Skin Rash
Septic Arthritis
Gonorrhoea
Ophthalmia Neonatorum
Discharge (Pus) from Penis
PID
Female
Male
Majority Asymptomatic
Majority Symptomatic
(Reservoir)
Pathogenesis
Gonococci attach to
Mucosal Cells by means of Pili

Persistent Untreated
Infection
Chronic Inflammation
Fibrosis

Non-Venereal Treponemal Disease

3 Subspecies of pathogenic T. pallidum causing diseases
Endemic
Yaws
Pinta
Syphilis (Bejel)
T. pallidum
T. pallidum
T. pallidum
subspecies
subspecies
subspecies
pertenue
endemicum
carateum
Cannot be distinguished

Serologically

Morphologically
Have not been successfully Cultivated on Artificial Media

Bacteria rapidly Multiply

Spread through Cervix
Up the Urethra in Men

Inflammation
Pus Formation
Virulence Factors
Pili
Adherence to Epithelial cells
Mediate resistance to Phagocytosis
Outer Membrane Protein
Antigenically variable, Expressed by strains that Resist Serum
Killing
Cause Disseminated Gonococcal Infection (usually)
Others
Lipooligosaccharide
(LOS)
IgA
Protease
Capsule

Laboratory Diagnosis
Specimen
Urethral discharge
Cervical, Pharyngeal, Rectal
Swab
Blood Cultures
Gonococci rapidly died on
swab
(unless suitable transport
medium)
(Amies medium)
Culture
Chocolate Agar
Selective Media
Thayer Martin VCT Agar
Added CO2
Rectal Swab in Female 40-60%
Blood Culture indicated in
Gonococcal Epididymo-orchitis
PID
Skin, Joint Infection

Microscopy Examination
Gram-stains
GN Diplococci Intracellular
in Pus cells

Gonorrhoea

+ve

Treatment
IM Ceftriaxone 125mg (single dose)
Penicillin G

 Sensitivity (due to Penicillinase producing Gonococcal

Strains)
Doxycycline, Azithromycin
Treat for C. Trachomatis (50% of patients concurrently infected)

Chlamydia Trachomatis
Definition
Very small bacteria, Obligate Intracellular Parasite
Can exist in different forms
Elementary Body (EB)
Reticulate Body (RB)
Adapted for Extracellular
Adapted for
Survival
Intracellular Multiplication
Initiation of Infection

Clinical Presentation
Lymphogranuloma Venereum (LGV)
Urogenital Infection (NGU)
Ocular Trachoma
Perinatal Infection
Lymphogranuloma venereum (LGV)
Chlamydia trachomatis serovars L1, L2, L3
(topical countries)

1 Lesion
Painless, Small Genital Ulcer
(passes unnoticed at site of inoculation)(incubation 1-4 weeks)

Lesion heals rapidly

Chlamydiae proceed to infect draining Lymph Node

Painful Enlarged Inguinal Nodes

Multiple Abscess Formation

Ruptured

Extensive Ulceration to Genitalia

Pelvic Infection

Years later, Perineal, Inguinal Fibrosis occur

Rectal Stricture, Genital Lymphoedema

1 Genital Ulcer does not coexist with Lymph Node enlargement

Genital Lymphoedema
Groove Sign (man with LGV)
Treatment
Doxycycline (100mg bd for 3 weeks)
Urogenital Infection (NGU)
Thinner Mucoid Purulent Urethral discharge
Clinically impossible to differentiate from Gonorrhoea (some
mixed infection)
Chlamydial NGU does not respond to Penicillin
Lab Diagnosis
Specimens - Urethral discharge, Endocervical scraping, Urine
Direct Detection
Antigen
Antibodies
from Urogenital
Detection
Detection
Specimen
Specific IF monoclonal
Rapid antigen
Complement
antibody of Chlamydia
assay
Fixation Test
(Glass slide)
Immunochromatogr
Culture
aphy
McCoy,
EIA
Chic embryo
tissue
PCR
Urogenital
DFA (Direct Fluorescent
Assay)
specimen
+ve
-ve
Urine
10
EBs

Free of EB

At least 10
columnar cell
present

Iodine Stain
Presence of

Inclusion Body in cell

Treatment
Doxycycline (100mg bd for 7 days)
Abstinence Sexual Intercourse during treatment
Alternative Azithromycin (1gm single dose orally)
Follow up of treated cases for at least 3 months

Viral Infection
Herpes Simplex Virus
Human Papilloma Virus
Human Immunodeficiency Virus (HIV)*
Hepatitis B Virus*
Herpes Simplex Virus
Definition
HSV-1
HSV-2
Spread by contact Infected
Transmission
Saliva
Sexually
Associated with
Maternal genital infection
Oropharyngeal lesions
newborn
Recurrent attacks of Fever
1 infects genital mucosa
Genital Herpes
Blisters
(Cold Sores)
Oral Herpes
Can also cause Genital
Herpes
Orogenital contact
Can Cause
Neurologic disease
Severe Neonatal Herpes Infection
Clinical
1 Illness - Can be severe (lasting 3 weeks)
Vesico-ulcerative lesions
Lesions
Very Painful
Associated with
Fever
Malaise
Dysuria
Inguinal Lymphadenopathy
Cluster of Vesicles
Break Down

Painful Ulcer

2 Infection
Viral Excretion persists 3 weeks
Recurrences of genital herpetic infections

Common

Tend to be Mild, Asymptomatic

HSV-2 Recurs often than HSV-1
Laboratory Diagnosis
Direct Microscopy
Specimen scrapings from base of vesicle
Stain with Wright, Giemsa (Tzanck smear)
Quick results (cannot differentiate HSV-1 from HSV-2)
Viral Culture from Vesicle Material
Gold Standard
Antigen Detection
EIA
IF
Antibody Detection
EIA
PCR
Treatment
Acyclovir (viral DNA synthesis Inhibitor)
May
Suppress Clinical Manifestation
Time to Healing
Recurrences
HSV Latent in sensory ganglia cannot be eliminated

Parasites Infection
Trichomonas vaginalis
Scabies (Sarcoptes scabiei)
Ptriasis pubis
Trichomonas vaginalis
Definition
Trichomoniasis
Trichomonas vaginitis
Urethritis (NGU) (occasionally)
Copious Watery Frothy vaginal discharge with Offensive
Smelling
Associated with
Vulva irritation
Dysuria
Dyspareunia
Abdominal Pain
Male Partner Asymptomatic
Can Infect Neonates during passage through an infected birth
canal
Examination

Erythematous, Purulent
Frothy Vaginal Discharge
Vulva, Vestibular, Vagina

Strawberry appearance
(mucosa)
Mucosal capillary dilatation

Laboratory Diagnosis
Fluid from Posterior Fornix for
immediate Wet Mount by
microscopy

Protozoa larger than

Leukocyte

Pear shape

Motile

Flagellated
Urine
Treatment
Metronidazole
Treat partner regardless of symptoms
(if not recurrence may occur)

Prevention of STD
Primary (1)
Health promotion behaviour
Education
Promotion
Promote Healthy Lifestyle
Safe Sexual Practice
Barrier method (Condom)
HSV, HIV, Hep B Virus
Sex Education in Schools
Vaccination
Hepatitis B Virus (the only one available)

Secondary (2)
Screening
Asymptomatic persons ( Risk STD)

Multiple Sex partners

History of STDs

Sex partner that has multiple sexual

contacts
(known, suspected to have STD)
Antenatal Mothers
Health Care
Accessibility, Affordability to Health Care
Competencies to early diagnosis,
treatment
(Health Staff)
Prompt Treatment
Partner Notification, Management
Done in 1 and 2 STD Prevention
Primary (1)
Secondary (2)
Risk of acquiring
Infected Sex
infection by
Partners can receive
uninfected partners
prompt medical
treatment
Changing
Behaviours

Tertiary (3)
Treat Complication that arose
Palliative care for terminally ill