stis o & g
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Guidelines
• Malaysian Guidelines in the treatment ofSexually Transmitted Infections
Ministry of Health 3rd edition 2008
www.moh.gov.my/images/galleryGarispanduan/malaysian_guidelines_in_treatment_of_STI_pdf
• British Association for Sexual Health
(BASHH) Guidelines
www.bashh.org/guidelines
• CDC 2010 STD treatment Guidelineswww.cdc.gov/std/treatment/2010/toc.htm
http://www.moh.gov.my/images/galleryGarispanduan/malaysian_guidelines_in_treatment_of_STI_pdfhttp://www.moh.gov.my/images/galleryGarispanduan/malaysian_guidelines_in_treatment_of_STI_pdfhttp://www.bashh.org/guidelineshttp://www.cdc.gov/std/treatment/2010/toc.htmhttp://www.cdc.gov/std/treatment/2010/toc.htmhttp://www.bashh.org/guidelineshttp://www.moh.gov.my/images/galleryGarispanduan/malaysian_guidelines_in_treatment_of_STI_pdfhttp://www.moh.gov.my/images/galleryGarispanduan/malaysian_guidelines_in_treatment_of_STI_pdf
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World wide prevalence
3
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4
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Common STIs
• Chlamydia
• Gonorrhoea
• Genital Herpes (Herpes Simplex Virus)
• Human Papilloma Virus (HPV)
• Trichomoniasis
• Syphilis• Hepatitis B
• HIV
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Data source: KC60 statutory returns
% change
2008 2007-2008 1999-2008
Chlamydia 123,018 1% 116%
Genital warts 92,525 3% 29%
Genital herpes 28,957 10% 65%
Gonorrhoea 16,629 - 11% 1%
Syphilis 2,524 - 4% 1,032%
Number of new diagnoses of STIs,
GUM clinics, United Kingdom: 2008
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Consequences of poor sexual health
• Unintended pregnancies• Sexually transmitted infections
• Congenital/Neonatal infection
• Adverse pregnancy outcomes – miscarriages, low birth weight,
preterm labour
• Pelvic Inflammatory Disease
• Ectopic pregnancies
• Infertility
• Chronic Pelvic Pain
• Neurological/Cardiovascular problems• Chronic liver disease
• Anogenital cancers
• Increased HIV transmission
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Groups vulnerable to poor
sexual health• Young people
• Female Sex Workers (FSW)
• Clients of Female Sex Workers
• Transgenders• Men who have sex with men (MSM)
• Those involved in jobs which separate them from their
regular sexual partner for long periods e.g lorry drivers,
soldiers• Refugees
• HIV positive patients
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Patient 1
• 26 year-old woman in a steady
relationship with her boyfriend of 1 year.
She presents complaining of a vaginal
discharge for the past week.
• She describes increased discharge,
change in color, and a foul odor.
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A. What other questions would you like to
ask her?
B. Is this a sexually transmitted infection?
C. What are the likely causative organisms?
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Vaginal Discharge
• Common causes:
– Neisseria gonorrhoeae
– Chlamydia trachomatis
– Trichomonas vaginalis
– Bacterial vaginosis
– Candida albicans
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Patient complains
of vaginal discharge or
vulval itching/ burning
Abnormal discharge present
Take history, examine patient(external speculum and bimanual)
and assess risk
Lower abdominal tenderness
or cervical motion tenderness
Was risk assessment positive?
Is discharge from the cervix?
Vulval edema/curd like discharge
Erythema excoriation presentTreat for bacterial vaginosis
and trichomoniasis
Treat for chlamydia, gonorrhea,
bacterial vaginosis and trichomoniasis
Use flow chart for lower abdominal pain
Educate
Counsel
Promote and provide condomsOffer VCT
Educate
Counsel
Promote and provide condoms
Offer VCT
Treat for
candida albicans
No
Yes
Yes
Yes
No
No
No
Yes
Vaginal Discharge
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Sexual History
• Symptoms (including duration)
• Last sexual intercourse
• Sex of partner
• Relationship with partner (casual, longterm)
• Use of condoms
• Sites of exposure (oral, vaginal, anal)
• Last previous partner or partner changes (in the last 3 months)
• Partner’s symptoms
• Previous STIs• Previous testing of STIs including HIV
• HIV risk assessment
• In women, cervical cytology, gynaecology, and contraception history
• ALWAYS ASSESS RISK OF PREGNANCY
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Taking a sexual history
• Must be non-judgemental
• Establish rapport and trust with patient
• Reassure regarding confidentiality
• Explain why a sexual history is needed – ask
patient if he/she minds about being asked very
personal questions
• Acknowledge that many people find it difficult todiscuss their sexual lives openly
• Ideally interview patient alone
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General rules
• Confidentiality
• Chaperone.
• Contact tracing• Health education and counselling
• Abstain from sex until completed treatment
and partner notification• Follow up of infections
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Syndromic Approach to STI Management
• Identification of clinical syndrome
• Giving treatment targeting all the locally
known pathogens which can cause the
syndrome
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Syndromic Approach to STI Management
Advantages
– Simple, rapid and
inexpensive
– Complete care offered at
first visit
– Patients are treated for
possible mixed infections
– Accessible to a broad
range of health workers
– Avoids unnecessary
referrals to hospitals
Disadvantages
– Over-treatment
– Asymptomatic infections
are missed
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Gonococcal Urethritis:
Purulent Discharge
Source: CDC Training SLIDES
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Neisseria gonorrhoea
• Gram negative
intracellular
diplococcus
• Infects mucousmembranes
• Pharyngeal infection
– 90%
• Incubation 3-5 days
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Gonorrhoea (women)
• Asymptomatic (50%)
• 16-19 yr women most
common
• Vaginal discharge
• Lower abdo pain
• Dysuria
• IMB/PCB• Pharyngitis
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Opthalmia neonatorum
Rates of diagnoses of uncomplicated genital chlamydial infection
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Sexually Transmitted Infections, HPA Centre forInfections
Rates of diagnoses of uncomplicated genital chlamydial infection
by sex and country
GUM clinics, United Kingdom: 1999 - 2008
Routine GUM clinic returns
MalesFemales
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Chlamydial Cervicitis
Source: CDC
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Chlamydia
(women)
• Asymptomatic (80%)
• Abnormal bleeding-
PCB/IMB
• Lower abdominal pain
• Vaginal discharge
• Dysuria
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Chlamydia trachomatis
• Most common STI in the under 25’s
• Most prevalent - Women 16-19yr, Men 20-24yr
• Women – 80% asymptomatic
• Men – 50% asymptomatic
• Incubation – 7 to 21 days
• COMPLICATIONS- PID, Reiter’s syn,conjunctivitis, chronic pelvic pain, infertility,ectopic pregnancy
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Trichomonas vaginalis
• Flagellated protozoan
• 10-50% asymptomatic
• Vaginal discharge (70%)
– offensive, frothy, yellow.
• Vulvovaginitis
– Itching, dysuria
• Strawberry cervix – 2 %
• Urethritis
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Strawberry cervix/TV
Clinial Manifestations
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Primary Syphilis- Penile Chancre
Clinial Manifestations
Source: CDC
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Secondary syphilis
s
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Secondary Syphilis:
Palmar/Plantar Rash
s
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Secondary Syphilis - Alopecia
Source: CDC/ NCHSTP/ Division of STD Prevention, STD Clinical Slides
Pathogenesis
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Treponema pallidum on
darkfield microscopy
Pathogenesis
Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides
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Congenital syphilis
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Congenital syphilis
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Congenital syphilis
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Congenital syphilis
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Syphilis
• Primary syphilis – 9-90 days incubation• Caused by treponema pallidum
• Solitary well-circumscribed ano-genitalulceration (chancre) with regional
lymphadenopathy• Typically painless, may be multiple and
extragenital (oral)
• Secondary syphilis – 6 weeks to 6 months
• Multisystem involvement• Generalized rash (palms and soles), fever,
lymphadenopathy, condylomata lata (moist wartlike lesions)
• Arthralgia, alopecia, hepatitis, glomerulonephritis
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Other clinical syndromes
• Early latent – within first 2 years of
infection
• Late Latent syphilis - > 2 years after initial
infection
• CVS/ Neurosyphilis/ Gummatous disease
• Congenital syphilis – rare. All pregnant
women currently screened
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Syphilis in pregnancy
• 33 year old Malay,18/40 pregnant,
Asymptomatic
• RPR 1: 128
• TPPA : Reactive
• WHAT IS THE DIAGNOSIS?
• WHAT WOULD YOU LIKE TO ASK HER?
• WHAT WOULD YOU DO?
• HOW WOULD YOU MONITOR HER TREATMENT
RESPONSE?
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• Likely primary or secondary syphilis given high RPR titre
• Always repeat syphilis serology to confirm
• Examine for chancre, rash involving palms and soles
• Has she been tested or treated for syphilis in the past?
• Has her partner got symptoms?• Treat with Benzathine Penicillin 2.4 MU X 1
• If penicillin allergic- treat with erythromycin but need to
treat baby
• Screen partner and treat him epidemiologically• Alert paediatrician
• Repeat syphilis serology in 1, 3, 6 and 12 months-
quantitative RPR
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HSV
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Genital Herpes: Recurrent Ulcer
Source: CDC
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Genital Herpes: Primary Lesions
Source: CDC
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Herpes Simplex
• Most common cause of genital ulceration worldwide
• Type 1 – oro-genital
• Type 2 – genital
• Incubation period 3-14 days• HSV 2 prevalence 80% in HIV positive African
population
• Estimated HSV 2 prevalence 20-40% in EU/USA
• Disproportionate Increase in HSV1 as cause of GH espin young females over past 10 years
• 70% of new infections acquired from asymptomatic viral
shedders
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Symptoms
• Asymptomatic
• Constitutional symptoms/prodrome
(tingling)
• Painful Vesicles/ulcers (multiple)
• Dysuria
• vaginal discharge
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Clinical syndromes
• Primary episode – most painful, can last 3/52
• Recurrences – may be mild
• Asymptomatic viral shedding
• DIAGNOSIS – clinical, HSV IF, culture, PCR
• TREATMENT – saline baths, analgesia
• Antivirals- Acyclovir,Valaciclovir
• Consider suppressive therapy for recurrences>6 episodes/year
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HSV in pregnancy-Case
• A 32 year old woman 36 weeks pregnant
in her 2nd pregnancy presents at your
clinic.
• She feels unwell, has inguinal
lymphadenopathy and has painful genital
ulcers which look typical of genital herpes
• How would you manage this case?
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• The greatest risk of transmission is
amongst those women who shed the
virus at term and who have acquired
HSV in pregnancy for the first time (31-40%)
• Should consider Caesarean Section for all
women especially those entering labourwithin 6 weeks of the first episode as the
risk of viral shedding is high
y oes a pr mary ep so e
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y oes a pr mary ep so ecarry such a great risk?
• Cervicitis ( in 70% of first episodes)
• Large quantity of virus
• There is no passively acquired protective
antibody
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Genital Ulcer Disease
Differentials
Herpes simplex*
Syphilis
LGV
Chancroid*
Granulomainguinale
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Genital Warts
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Genital Warts
• Benign epithelial skin tumors
• Caused by human papilloma virus (HPV)
• >100 subtypes of HPV of which 40 strains affect the genital tract
• Most (90%) ano-genital warts are caused by HPV 6 & 11 (non-oncogenic subtypes)
• Transmitted by unprotected vaginal, anal or oral sex or by direct skin to skin contact
• Estimated US annual incidence of 1% of the adult population• Genital HPV DNA is found in 10-20% of those aged 15-49 years
• Most cases of HPV infection are subclinical
• Most HPV infections are transient and 95 % resolve on their own within 2 years
• Condoms have been shown to protect against HPV acquisition and genital warts
• For some patients, the psychological impact of the warts is the worst aspect of the
disease• All treatments have significant failure and relapse rates
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HPV Vaccination
• Name 2 types of HPV vaccines available in the
market
• What do HPV vaccines protect the individual
against?• Is there a national HPV programme?
• If you were a parent, would you vaccinate your
child against HPV?
• Give another example of a vaccine which is
used to prevent an STI
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Protection beyond the cervix
HPV associated cancers• Cervical (43.5%)
• Vaginal (2.4%)
• Vulval (9.1%)• Anorectal (12.1%)
• Oropharyngeal (29.5%)
• Penile
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ASK
Questions
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Thank You