1. Interstitial Cystitis and Sexually Transmitted Diseases
Daniel Shoskes MD, MSc, FRCSC
Professor of Urology
Cleveland Clinic Department of Urology
Glickman Urological and Kidney Institute

2. Information for Home Study
Slide show text is reproduced in handout
Chapters in Textbook of Board Review
Outline on AIDS (a few notes on other STDs)
Relevant pages from 2010 MMWR on STDs
AUA Guidelines for IC/BPS are on the web site and on your USB drive

3. CDC Guidelines “one stop” internet site http://www.cdc.gov/STD/
latest update December 2010
urethritis and mycoplasma
NAAT diagnosis in urine
Hep C transmission through intercourse
wall charts, pocket guides, iPhone and eBook versions

4. INTERSTITIAL CYSTITIS PAINFUL BLADDER SYNDROME BLADDER PAIN SYNDROME

5. Why so many names? Disadvantages of IC name
No agreement on a clinical IC definition
(NIDDK criteria from 1980s were for research)
“Interstitial cystitis” not scientifically correct,
especially for patients without Hunner lesions
May lack bladder inflammation
May not involve bladder interstitium
Different subspecialty groups had their own ideas

6. Painful Bladder Syndrome ICS Definition*
The complaint of suprapubic pain related to bladder filling, accompanied by other symptoms such as increased daytime and night-time frequency, in the absence of proven urinary infection or other obvious pathology
*Abrams P, Neurourol Urodynamics 2002

7. Bladder Pain Syndrome ESSIC Definition*
> 6 months pelvic pain, pressure, or discomfort perceived to be related to urinary bladder
At least one other urinary symptom such as persistent urge to void or frequency
Must exclude confusable diseases
*van de Merwe JP, Nordling J, Eur Urol 2008

8. IC/BPS SUFU Definition* Used in AUA Guidelines
An unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than 6 weeks duration, in the absence of infection or other identifiable causes
*Hanno P, Neurourol Urodynamics 2009

9. Does the Name Matter? Research: nuances in enrollment criteria
Clinical: pros of IC name
Do PBS and BPS sound like real diseases?
2 treatments FDA-approved for IC, 0 for PBS
IC recognized for Social Security disability
Clinical: cons of IC name
Stigma? Consider put Sx (e.g. urgency) on bill
Focus on bladder may forget other causes

10. AUA Guidelines All expert opinion or clinical principles
Diagnostic principles
Baseline assessment: history, physical exam, laboratory to exclude other disorders
Obtain baseline symptom and pain levels, including frequency-volume chart > 1 day
Cystoscopy and urodynamics unnecessary for diagnosis in uncomplicated presentations when diagnosis is clear
(I disagree: if you don’t look for ulcers you won’t find them)

11. Main Goal of H and P is to look for other causes of symptoms and systemic features
Bladder tumor
Bladder or distal ureteral stone
Urethral diverticulum
External cause for dysuria (eg herpes)
Pelvic floor muscle spasms
Irritable bowel syndrome
Vulvodynia

12. Lab Studies Everyone Urine Cytology if urinalysis, urine culture
smoker
unevaluated hematuria

13. AUA Diagnosis Guidelines
Cystoscopy, urodynamics appropriate when diagnosis remains in doubt after basic assessment
Potassium sensitivity test
should not be used as a
diagnostic tool in clinical
practice because results
do not change management
or treatment approach

14. AUA Guidelines on Cystoscopy and Hydrodistension
Cystoscopy is useful if you are looking for:
Other causes for symptoms (stone, tumor, etc.)
Hunner lesions
Hydrodistention
Not useful for making diagnosis
No value in seeing glomerulations or not
May create more injury and subsequent scarring
May identify end-stage, low capacity bladder

15. Hunner Lesion
A positive finding that can confirm the diagnosis in patients who meet the definition criteria
Phases
Acute: inflamed, friable, denuded area
Chronic: blanched, non-bleeding area
Direct treatment of Hunner lesion is recommended (fulguration, steroid injection)

16. From AUA Guidelines Slide Set
Hunner Lesion
From AUA Guidelines Slide Set

17. Glomerulations
Finding of glomerulations on hydrodistention is variable and not related to clinical presentation
Absence of glomerulations can lead to false negative assessment of patients who present with clinical IC/BPS
Seen in many clinical situations including radiation therapy, defunctionalized bladders, bladder cancer, chemotherapeutic or toxic drug exposure, normal bladders

18. Glomerulations Photo shown for academic interest only;
Not recommended for
ruling in or ruling out
diagnosis of IC/BPS!
*Photo from AUA Guidelines Slide Set

19. A 41y/o ♀ has frequent urination and pain with bladder filling
A 41y/o ♀ has frequent urination and pain with bladder filling. Which of these findings will affect your treatment plan?
A. Past history of genital herpes, rare outbreaks
B. Levator muscles tender to palpation
C. Inability to void on urodynamics
D. Positive potassium sensitivity test
E. Glomerulations after bladder distention

20. A 41y/o ♀ has frequent urination and pain with bladder filling
A 41y/o ♀ has frequent urination and pain with bladder filling. Which of these findings will affect your treatment plan?
A. Past history of genital herpes, rare outbreaks
B. **Levator muscles tender to palpation**
C. Inability to void on urodynamics
D. Positive potassium sensitivity test
E. Glomerulations after bladder distention

21. FDA Approved Treatments
Almost all treatments are off-label uses
FDA approved for IC
Oral pentosanpolysulfate
Intravesical DMSO
No treatments FDA-approved for PBS or BPS

22. Treatment Guideline Tiers
1. Education, self-care
2. Oral and intravesical medicines,
physical therapy, pain management
3. Bladder distention or Hunner lesion treatment
4. Sacral/pudendal nerve stimulation*
5. Cyclosporine orally, botulinum toxin injection*
6. Substitution cystoplasty or urinary diversion*
*Only for experienced, committed IC/BPS providers

23. Clinical Treatment Principles
Begin with more conservative therapies
Major surgery only for:
End-stage, small fibrotic bladders
Conservative measures have been exhausted and quality of life is poor
Initial treatment type and level depend on symptom severity, clinician judgment, and patient preference
Stop ineffective therapies after clinically meaningful period

24. Clinical Treatment Principles
Multiple, simultaneous treatments may be considered if in the best interests of the patient. Reassess to document efficacy
Continuously assess pain management. If inadequate, consider multidisciplinary approach
Reconsider diagnosis if no improvement after multiple treatment approaches

25. AUA Tier 1 Therapies
Education: normal bladder function, IC/BPS knowledge base, risk/burdens of available therapies, may need to try multiple treatments
Self-care practices
Behavioral modifications that can improve symptoms
Stress management to improve coping and manage stress-induced symptom exacerbations

26. AUA Tier 2 Therapies Clinical principle: physical therapy if available
Target trigger points and tissue restrictions
Avoid pelvic floor strengthening exercises!
Expert opinion: multimodal pain management
Options (alphabetical order; no preference implied)
Intravesical DMSO, heparin, lidocaine
Oral amitriptyline, cimetidine, hydroxyzine, pentosanpolysulfate

27. Intravesical Therapies
Numerous combinations, ingredients may include:
DMSO
Local anesthetic
Na bicarbonate
Heparin or other GAGs
Cortisol or triamcinolone
Antibiotic
AUA Guidelines mention them
Minimal research comparing one vs. another

28. AUA Tier 3 Therapies Option: cystoscopy and bladder distention
Under full general or regional anesthesia
Less than 10 minutes duration
60-80 cm water pressure
Hunner lesion
Recommendation for direct treatment
(should be offered, level C evidence)
Fulguration (laser or electrocautery) or triamcinolone injection

29. Tier 4: Sacral or Pudendal Nerve Stimulation
Not FDA-approved for IC/BPS
Sacral stimulation approved for urgency-frequency
An option, with caveats:
Only if more conservative options have failed
A treatment for frequency, not for pain!
Not for general use, but limited to providers experienced with IC/BPS and willing to provide long term care of the patient after intervention

30. Tier 5 Therapies Options Oral cyclosporine (“low dose”)
Intradetrusor botulinum toxin injection
(patient must be willing and able to do CIC)

31. Tier 6: Major Surgery Two options Substitution cystoplasty
Urine diversion +/- cystectomy
For “carefully selected patients for whom all other therapies have failed to provide adequate symptom control and quality of life”
Better outcome after diversion associated with:
Small bladder capacity under anesthesia
Absence of neuropathic pain

32. Augmentation Cystoplasty
Not listed as an option in the AUA Guidelines
Why it is a bad idea
Pain likely to persist
(urine remains in contact with bladder)
Likely to have urinary retention
CIC is painful for many IC/BPS patients

33. Treatments to Avoid per Guidelines
Standards (A or B evidence)
Long-term antibiotics
Intravesical BCG
Intravesical resiniferatoxin
Recommendations (C evidence)
High pressure, long duration bladder distention
Long-term systemic corticosteroids

34. In AUA IC/BPS Guidelines, 2nd tier treatments include all of these except:
A. Pelvic floor strengthening exercises
B. Pain management
C. Oral pentosanpolysulfate
D. Oral amitriptyline
E. Intravesical DMSO

35. In AUA IC/BPS Guidelines, 2nd tier treatments include all of these except:
A. **Pelvic floor strengthening exercises**
B. Pain management
C. Oral pentosanpolysulfate
D. Oral amitriptyline
E. Intravesical DMSO

36. A 62 y/o ♀ has severe pain, frequency, 8x nocturia
A 62 y/o ♀ has severe pain, frequency, 8x nocturia. Cystoscopy shows a patch of erythema; biopsy & cytology negative for cancer. AUA Guidelines recommend:
A. Oral pentosanpolysulfate
B. Intravesical DMSO
C. Trial of sacral nerve stimulation
D. Fulgurate the patch of erythema
E. Cystectomy and urinary diversion

37. A 62 y/o ♀ has severe pain, frequency, 8x nocturia
A 62 y/o ♀ has severe pain, frequency, 8x nocturia. Cystoscopy shows a patch of erythema; biopsy & cytology negative for cancer. AUA Guidelines recommend:
A. Oral pentosanpolysulfate
B. Intravesical DMSO
C. Trial of sacral nerve stimulation
D. **Fulgurate the patch of erythema**
E. Cystectomy and urinary diversion

38. In the AUA IC/BPS Guidelines, all of these should be avoided except:
A. Long-term antibiotics
B. Oral corticosteroids
C. Oral cyclosporine
D. Intravesical BCG
E. 30-minute bladder distention

39. In the AUA IC/BPS Guidelines, all of these should be avoided except:
A. Long-term antibiotics
B. Oral corticosteroids
C. **Oral cyclosporine**
D. Intravesical BCG
E. 30-minute bladder distention

40. Personal Observations
Male IC vs Prostatitis/CPPS
Pain linked to the voiding cycle
Suprapubic Pain/Tenderness
Intravesical instillations less likely to be effective
Sequential vs Staged Therapy
When treating a syndrome, best to identify clinical phenotype and individualize therapy
UPOINT (upointmd.com)

41. SEXUALLY TRANSMITTED DISEASES
HIV/AIDS
AND OTHERS

42. Prevention
Especially newly sexually active and the elderly

43. HIV/AIDS

44. AIDS: Basic Pathophysiology
HIV virus invades cell through the CD4 receptor
Macrophages and some T cells have CD4
CD4 is needed to process most types of antigen
Binding also requires chemokine receptor CCR5 on macrophage; mutation is protective
Loss of CD4 cells = immune deficiency
Indices of disease severity
Decreased CD4 cell count
Increased amount of HIV RNA in bloodstream

45. AIDS: Typical Clinical Course
Initial infection
May have acute illness similar to mono
Unlikely to present to a urologist
Asymptomatic carriage of virus: average 10 years
Immune deficiency leads to opportunistic infections
Use of highly active antiretroviral therapy (HAART) makes HIV a chronic illness not a terminal disease

46. HIV Diagnosis Acute infection:
Not enough time for antibodies to develop
Order viral load assay (HIV RNA in blood)
If more than 3-6 weeks after exposure:
ELISA can be done with blood, urine or saliva
6 FDA-approved point-of-service tests
Confirm positive ELISA with Western blot

47. HIV Virus Replication RNA is viral genetic material
Reverse transcriptase makes DNA from viral RNA
DNA integrates into host genome
Host DNA replicates, making new viral RNA
RNA is translated to protein precursors
Protease cleaves precursors, leaving viral proteins
New virus is assembled & released from host cell

48. AIDS Treatments Drugs that prevent HIV virus fusing to CD4 cell
Enfuvirtide binds to virus, prevents fusion
Maraviroc blocks CCR5 receptor
Reverse transcriptase inhibitors
Nucleoside or nucleotide analogs
Non-nucleoside drug
Integrase inhibitor prevents integration of viral DNA into host genome (raltegravir)
Protease inhibitors

49. Initial HIV Treatment 2010 CDC guidelines* recommend
Emtricitabine + tenofovir (NRTIs) PLUS either:
Enfiravenz (a non-nucleoside RT inhibitor)
Raltegravir (integrase inhibitor)
Ritonavir-boosted protease inhibitor
Atripla® = emtricitabine+ tenofovir +enfiravenz,
one pill a day *

50. Protease Inhibitors: Relevance to Urology
Booster action: inhibit Cyt P450
Some can form stones (especially indinavir)
Indinavir is nephrotoxic

51. Protease Inhibitor Stones
Indinavir
Classic test question
Uncommon in real world; other PIs safer
May form crystals, leading to acute renal failure
Might not be seen on CT scan
Usually resolve with stopping the drug, hydration, +/- urine acidification
Indications for stent: persistent fever, intractable pain, solitary kidney

52. Caveat: AIDS Patients also Form the Usual Types of Stones
Of 14 patients taking indinavir who had stones, only 4 patients' stones contained indinavir
Reasons for stone formation include:
Malnutrition, diarrhea, dehydration
Acid urine, hypocitraturia
Complete metabolic evaluation is indicated

53. Urologic Manifestations of AIDS
Opportunistic infections of GU tract
Examples: TB, fungi, herpes, viral cystitis
Severe infections (e.g. abscess, Fournier’s)
Increased incidence of malignancies
Kaposi’s sarcoma may involve genitalia
Squamous genital cancers
Testis cancer (germ cell tumors & lymphomas)
Renal cancer

55. Urologic Manifestations of AIDS (2)
Hypogonadism: testosterone replacement is recommended for patients with weight loss
Adrenal insufficiency; may need stress steroids
Neurogenic bladder (any type)
*Combined bladder + bowel dysfunction with back pain/sciatica: consider CMV polyradiculopathy, may be reversible if treated early

56. HIV and Prostate Cancer
Screen and treat same as men without HIV
Life expectancy on HAART usually > 20 years
For localized cancer, outcomes similar for men with vs. without HIV
Laparoscopic surgery involves less exposure to the operating team than open surgery

57. Circumcision and HIV 3 randomized trials in Africa
Men having vaginal sex with women
Infection rates 60% lower if circumcised
Possible reasons:
Inner foreskin rich in Langerhans cells and other HIV target cells
Inner foreskin gets tears/abrasions
Thicker keratin barrier if circumcised

58. AIDS: Other Key Points for Urologists
Use universal precautions and double glove!!!
Workers with exudative skin lesions (even acne) should not participate in invasive procedures
Being HIV-positive does not require that a surgeon stop operating
Urine not considered infectious unless bloody

59. HIV: Postexposure Prophylaxis
Most important thing: avoid exposure!!!
Double glove
Eye shields
Impervious gowns, boots
Care with sharps
Why? Also avoid hepatitis
Hepatitis virus more easily transmitted than HIV
Hepatitis C 3-4x more common than HIV in US

60. HIV: Postexposure Prophylaxis
Good news:
Risk of AIDS from a single sharps injury is low, even from a known HIV+ source
Usual regimen: 2 or 3 drugs combined, for 4 weeks, must start < 4hrs after exposure
USA National Post-Exposure Prophylaxis Hotline PEPline

61. Protease inhibitors: A. Are the backbone of modern HAART regimens
B. Prolong the duration of action of vardenafil
C. Form stones that are easily seen on CT scan
D. Form stones that dissolve if urine is alkalinized
E. Should be kept in operating rooms for immediate post-exposure prophylaxis in case of sharps injury

62. Protease inhibitors: A. Are the backbone of modern HAART regimens
B. **Prolong the duration of action of vardenafil**
C. Form stones that are easily seen on CT scan
D. Form stones that dissolve if urine is alkalinized
E. Should be kept in operating rooms for immediate post-exposure prophylaxis in case of sharps injury

63. Which of the following has proven efficacy in decreasing HIV transmission?
A. Avoid contact with urine of HIV-positive patients
B. HAART started the day after a sharps injury
C. Circumcision (for men having vaginal coitus)
D. Forbid HIV-positive surgeons to operate
E. Encourage screening the general population at
community health fairs

64. Which of the following has proven efficacy in decreasing HIV transmission?
A. Avoid contact with urine of HIV-positive patients
B. HAART started the day after a sharps injury
C. **Circumcision (men having vaginal coitus)**
D. Forbid HIV-positive surgeons to operate
E. Encourage screening the general population at
community health fairs

65. SEXUALLY TRANSMITTED DISEASES OTHER THAN HIV/AIDS

67. STD’s by Presentation Male urethritis Male genital ulcers
Women with STDs usually present to primary care providers or gynecologists, so are not included in this overview.

68. Which STDs are Reportable?
Reportable in every state:
Syphilis
Gonorrhea
Chlamydia
Chancroid
HIV infection and AIDS
Other STDs: reporting requirements vary by state

69. Male Urethritis Symptoms: dysuria, itch, discharge
Most common organisms: NG
Chlamydia
Others
(Mycoplasma, Ureaplasma, Gardnerella, etc.)

70. Male Urethritis Diagnosis
Urine nucleic acid test for NG and Chlamydia
Urethral swab
Seldom used but source of exam questions
Gram stain
Intracellular G-neg diplococci = gonorrhea
WBC no bacteria: non-gonococcal urethritis
Culture in Thayer-Martin medium
Inhibits growth of other microbes
Allows growth of Neisseria

72. Male Urethritis: Simplest Treatments
Uncomplicated gonorrhea
Ceftriaxone 125 mg IM or cefixime mg 400 po,
also azithromycin 1g (30% have Chlamydia)
No quinolones! Too much resistance
Nongonococcal urethritis
Goal: cover Chlamydia and Ureaplasma
Azithromycin lg single dose

73. Male Urethritis: Partner Treatments
Longstanding recommendation: evaluate and treat all partners exposed within 60 days; if none, evaluate and treat the most recent partner
New idea: expedited partner therapy
Give patient Rx or meds, to take to partner
Advantage: partner more likely to be treated
Some states don’t allow this
CDC web site

74. Genital Ulcers STDs Remember: not all ulcers are STDs! Can also be:
Carcinoma
Erythema multiforme
Fixed drug eruption
Bechet’s disease
Lichen planus

75. STDs With Genital Ulcers
Uncommon in USA
Granuloma inguinale
Lymphogranuloma venereum
Common in USA
Painless: 1o syphilis (unless superinfected)
Painful
Chancroid
Herpes

76. Ulcer STDs Uncommon in USA
To remember for test, both have:
Granuloma in their names
1st line treatment doxycycline > 3 weeks
Different ulcer appearances
Granuloma inguinale (painless ulcer)
Lymphogranuloma venereum
Ulcer may resolve before patient presents
Often presents as inguinal adenopathy

77. Granuloma Inguinale Rare in USA, common in tropics
Cause: Klebsiella granulomatis (formerly called Calymmatobacterium granulomatis) an intracellular gram-negative bacterium
Main symptom is ulcer
Usually painless
Beefy red, bleeds easily (very vascular)

78. Granuloma Inguinale Diagnosis Cannot be cultured
Biopsy or “crush prep” ulcer
Donovan bodies in monocytes
Treatment
Doxycycline > 3 weeks until all lesions healed
Examine partners

80. Lymphogranuloma Venereum
Rare in USA
Caused by Chlamydia trachomatis (L1-3 strains)
Symptoms at presentation
Small ulcer may have resolved
Large, suppurative lymph nodes
If acquired rectally may get proctocolitis and colorectal fistulas and strictures (this is an invasive infection)

81. Lymphogranuloma Venereum
Diagnosis:
Swab genital lesion or aspirate lymph node; test this for C. trachomatis by culture, direct immunofluorescence, or nucleic acid detection
If these are not available, OK to treat empirically based on symptoms/signs
Treatment
Doxycycline 100 bid 3 weeks
May need incision & drainage of lymph nodes
Treat partners (1 g azithroymcin x 1 is OK)

82. Lymphogranuloma venereum
Bilateral bubos

83. Ulcer STDs Common in USA
Painful
Herpes simplex
Chancroid
Syphilis is usually painless unless superinfected

84. Genital Herpes: Diagnosis
A group of vesicles on erythematous base that does not follow a neural distribution: pathognomonic*
Other tests:
Virus culture of lesions
PCR more sensitive but not FDA-approved
Point of care blood tests are good but 2 caveats
Negative early (before antibodies form)
Positive for life (current vs past infection?)

86. Genital Herpes: Treatment
Acyclovir po (topical not effective)
Newer drugs with better oral bioavailability
Valacyclovier (valine ester of acyclovir)
Famciclovir
The same drugs can also be used for recurrences
PRN dosing
Chronic suppression
Counsel patient (see next slide)

87. Genital Herpes: Patient Counseling
Expect recurrences
Possible transmission to baby during delivery
Ways to decrease risk of transmission to partners
Abstain during symptoms (problem: may shed virus even if not having symptoms)
Condoms
Valacyclovir 500 mg daily taken by patient

88. Chancroid (Haemophilus ducreyi)
Symptoms
One or more painful ulcers
1/3 have tender or suppurative nodes
Diagnosis
Specialized culture is not widely available
PCR test available but not FDA-approved
OK to treat painful ulcer if not herpes or syphilis
Simplest treatment
Azithromycin lg po single dose
Treat partners

90. Syphilis (Treponema pallidum) 1o stage is painless ulcer

91. STDs with Ulcers: Sorted by Appearance
Painful vesicles: herpes
Bubos, ulcer small or absent:
lymphogranuloma venereum:
Typical raw ulcer
1o syphilis
Chancroid
Granuloma inguinale

92. STDs with Typical Ulcers: Diagnosis
Painful: chancroid
No diagnostic test
r/o syphilis and treat empirically
Painless
1o syphilis
Blood tests detect antibodies
If early, ulcer scrape or biopsy is only test
Granuloma inguinale
Biopsy is the only diagnostic test
Donovan bodies

93. Syphilis (Treponema pallidum) Stages and Symptoms
1o: painless ulcer (chancre)
2o: nongenital skin lesions, adenopathy
3o: cardiac, neuro, eye, ear, etc.
Latent: no symptoms

95. Syphilis Diagnosis
Scrape base of ulcer, look for spirochetes by dark-field microscope or fluorescent antibody
Best test for primary syphilis
Many docs lack equipment*
Serum antibody tests
Nontreponemal (anti-cardiolipin antibodies)
Treponemal (antibodies against Treponema)
* Dowell D, Clinical Infectious Diseases 2009

96. Diagnosis of Syphilis
Recent change in recommendations due to high false positive with non-treponemal test
now recommend starting with treponemal assay (syphilis IgG) and if reactive confirm with RPR
If IgG positive and RPR negative use second treponemal assay (TPPA or FTA antibody) to confirm and differentiate latent vs historical

97. Treatment of 1 and 2° Syphilis
Benzathine penicillin G 2.4 million units IM
Bicillin L-A (benzathine PCN)
Not Bicillin C-R (benzathine- procaine PCN)
If allergic to penicillin, can use tetracycline or doxycycline 2 weeks, but only if:
Not pregnant
Reliable for follow-up

98. Situations in Which Penicillin is the Only Treatment Option for Syphilis (If Allergic, Desensitize)
Pregnancy
Syphilitic eye disease
Neurosyphilis (MMWR says ceftriaxone OK)
Patients not compliant and reliable for follow-up with a 2-4 week oral tetracycline regimen

99. Treatment of 1 and 2° Syphilis
Recheck VDRL or RPR using same test and same lab at 6 and 12 months; if not decreased, suspect:
Treatment failure
Re-infection
Tertiary syphilis
HIV
All patients with syphilis should be tested for HIV

100. All of the following STDs in men can be treated by single-dose antibiotics except:
A. Primary syphilis
B. Chlamydial urethritis
C. Gonococcal urethritis
D. Chancroid
E. Granuloma inguinale

101. All of the following STDs in men can be treated by single-dose antibiotics except:
A. Primary syphilis
B. Chlamydial urethritis
C. Gonococcal urethritis
D. Chancroid
E. **Granuloma inguinale**

102. Which of the following STDs involves a painful ulcer?
A. Primary syphilis
B. Lymphogranuloma venereum
C. Human papilloma virus
D. Chancroid
E. Granuloma inguinale

103. Which of the following STDs involves a painful ulcer?
A. Primary syphilis
B. Lymphogranuloma venereum
C. Human papilloma virus
D. **Chancroid**
E. Granuloma inguinale

104. Donovan bodies are seen on:
A. Ulcer scraping in primary syphilis
B. Lymph node aspiration in lymphogranuloma
venereum
C. Thayer-Martin medium in gonorrhea
D. Ulcer biopsy in granuloma inguinale
E. Urethral swab in Chlamydia urethritis

105. Donovan bodies are seen on:
A. Ulcer scraping in primary syphilis
B. Lymph node aspiration in lymphogranuloma
venereum
C. Thayer-Martin medium in gonorrhea
D. **Ulcer biopsy in granuloma inguinale**
E. Urethral swab in Chlamydia urethritis

106. If state laws allow it, expedited partner therapy is recommended for:
A. Gonorrhea
B. Primary syphilis
C. Genital warts
D. Chancroid
E. Genital herpes

107. If state laws allow it, expedited partner therapy is recommended for:
A. **Gonorrhea**
B. Primary syphilis
C. Genital warts
D. Chancroid
E. Genital herpes

108. HPV Over 40 serotypes that can infect
Common, most asymptomatic, self limited
HPV 16 and 18 oncogenic
cervical, penile, vaginal, oropharyngeal, anal
possible link to low grade TCC
Pathology. 41:245, 2009
HPV 6 and 11 cause 90% of warts, low cancer risk

109. HPV Lesions

110. Summary of Genital Wart Therapy
Patient-Applied
Podofilox 0.5% solution or gel
Imiquimod 5% cream
Sinecatechins 15% ointment
Provider–Administered
Cryotherapy with liquid nitrogen or cryoprobe. Repeat applications every 1–2 weeks.
Podophyllin resin 10%–25%
Surgical removal either by tangential scissor excision, tangential shave excision, curettage, or electrosurgery.

111. HPV Prevention
Quadrivalent vaccine (Gardasil) against 6, 11, 16, 18 (70% cancers, 90% warts)
Must be started before sexually active
Approved for females aged 9-26 (series of 3 injections)
Safe/effective in males
NEJM 364(5):401-11, Feb 2011
Current debate cost benefit
improve disease reduction in females
anogenital cancer reduction mostly in MSM but must be given at young age