1. Sexually Transmitted Diseases
Prof.Dr.Fehmi Tabak
Cerrahpasa Medical Faculty
Department of Infectious Diseases

2. Topics Background Information “Sores” “Drips”
Role of STDs in HIV Transmission

3. Background Information

4. Background
Epidemiology

5. Syndromes Urethritis Genital ulcer adenopathy syndrome
Mucopurulent cervicitis
Pelvic inflamatuar diseases (PID)
Vaginitis

6. STDs of Concern “Sores” (ulcers) Syphilis
Background
STDs of Concern
“Sores” (ulcers)
Syphilis
Genital herpes (HSV-2, HSV-1)
Others uncommon in the Turkey
Lymphogranuloma venereum
Chancroid
Granuloma inguinale

7. STDs of Concern (continued)
Background
STDs of Concern (continued)
“Drips” (discharges)
Gonorrhea
Chlamydia
Nongonococcal urethritis
Mucopurulent cervicitis
Trichomonas vaginitis / urethritis
Candidiasis (vulvovaginal, less problems in men)
Other major concerns
Genital HPV (especially type 16, 18) and Cervical Cancer

8. Syphilis Genital Herpes (HSV-2, HSV-1)
“Sores”
Syphilis
Genital Herpes (HSV-2, HSV-1)

9. Genital Ulcer Diseases – Does It Hurt?
Sores
Genital Ulcer Diseases – Does It Hurt?
Painful
Chancroid
Genital herpes simplex
Painless
Syphilis
Lymphogranuloma venereum
Granuloma inguinale

10. Primary Syphilis - Clinical Manifestations
Sores
Primary Syphilis - Clinical Manifestations
Incubation: days (average 3 weeks)
Chancre
Early: macule/papule  erodes
Late: clean based, painless, indurated ulcer with smooth firm borders
Unnoticed in 15-30% of patients
Resolves in 1-5 weeks
HIGHLY INFECTIOUS

11. Primary Syphilis -Chancre -LAP
Sores
Primary Syphilis -Chancre -LAP

12. Secondary Syphilis - Clinical Manifestations
Sores
Secondary Syphilis - Clinical Manifestations
Represents hematogenous dissemination of spirochetes
Usually 2-8 weeks after chancre appears
Findings:
rash - whole body (includes palms/soles)
mucous patches
condylomata lata - HIGHLY INFECTIOUS
constitutional symptoms
Sn/Sx resolve in 2-10 weeks

13. Secondary Syphilis Rash Generalized LAP Condylomata lata
CNS involvement
Fever
Glomerulonephritis
Hepatitis
Artralgia

14. Secondary Syphilis Rash
Sores
Secondary Syphilis Rash
Source: Florida STD/HIV Prevention Training Center

15. Secondary Syphilis: Generalized Body Rash
Sores
Secondary Syphilis: Generalized Body Rash
Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides

16. Secondary Syphilis Rash
Sores
Secondary Syphilis Rash
Source: Florida STD/HIV Prevention Training Center

17. Secondary Syphilis Rash
Sores
Secondary Syphilis Rash
Source: Cincinnati STD/HIV Prevention Training Center

18. Secondary Syphilis Sores
Source: Diepgen TL, Yihune G et al. Dermatology Online Atlas

19. Secondary Syphilis – Condylomata Lata
Sores
Secondary Syphilis – Condylomata Lata
Source: Florida STD/HIV Prevention Training Center

20. Tersier and late syphilis
Gom (Syphilitic granulomas)
CNS and CVS involvement

21. Syphilis Latent syphilis Serology (+), Clinic (-)
Varies from several months to several years
More duration less infectivity
Early (<2 years) Late (>2 years)
Neurosyphilis
Any neurological symptom or sign

22. Syphilis - Diagnose
Dark field microscopy
Serology

23. Syphilis - Diagnose Non-spesific serological tests
VDRL
RPR
Spesific serological tests
FTA-ABS
TPHA
MHA-TP
ELISA
- The only positive thing of my life is my VDRL test!!!

24. Genital Herpes Simplex - Clinical Manifestations
Sores
Genital Herpes Simplex - Clinical Manifestations
Direct contact – may be with asymptomatic shedding
Primary infection commonly asymptomatic; symptomatic cases sometimes severe, prolonged, systemic manifestations
Vesicles  painful ulcerations  crusting
Recurrence a potential
Diagnosis:
Tzanck smear
Culture
Serology (Western blot)
PCR

25. Epidemiology of Genital Herpes
Sores
Epidemiology of Genital Herpes
One of the 3 most common STDs, increased 30% from late 70s to early 90s
25% of US population by age 35
HSV-2: 80-90%, HSV-1: 10-20% (majority of infections in some regions)
Most cases subclinical
Transmission primarily from subclinical infection
Complications: neonatal transmission, enhanced HIV transmission, psychosocial issues

26. Genital Herpes Simplex
Sores
Genital Herpes Simplex

27. Genital Herpes Simplex in Females
Sores
Genital Herpes Simplex in Females
Source: Centers for Disease Control and Prevention

28. “Drips” Gonorrhea Nongonococcal urethritis Chlamydia
Mucopurulent cervicitis
Trichomonas vaginitis and urethritis
Candidiasis

29. Gonorrhea - Clinical Manifestations
Drips
Gonorrhea - Clinical Manifestations
Urethritis - male
Incubation: d (usually 2-5 d)
Sx: Dysuria and urethral discharge (5% asymptomatic)
Dx: Gram stain urethral smear (+) > 98% culture
Complications
Urogenital infection - female
Endocervical canal primary site
70-90% also colonize urethra
Incubation: unclear; sx usually in l0 d
Sx: majority asymptomatic; may have vaginal discharge, dysuria, urination, labial pain/swelling, abd. pain
Dx: Gram stain smear (+) 50-70% culture

30. Urethritis

31. Urethral discharge

32. Drips
Gonorrhea
Source: Florida STD/HIV Prevention Training Center

33. Gonorrhea Gram Stain Drips
Source: Cincinnati STD/HIV Prevention Training Center

34. Nongonococcal Urethritis
Drips
Nongonococcal Urethritis
Source: Diepgen TL, Yihune G et al. Dermatology Online Atlas

35. Nongonococcal Urethritis
Drips
Nongonococcal Urethritis
Etiology:
20-40% C. trachomatis
20-30% genital mycoplasmas (Ureaplasma urealyticum, Mycoplasma genitalium)
Occasional Trichomonas vaginalis, HSV
Unknown in ~50% cases
Sx: Mild dysuria, mucoid discharge
Dx: Urethral smear  5 PMNs (usually 15)/OI field Urine microscopic  10 PMNs/HPF Leukocyte esterase (+)

36. Chlamydia Life Cycle Drips
Source: California STD/HIV Prevention Training Center

37. Chlamydia trachomatis
Drips
Chlamydia trachomatis
Responsible for causing:
Cervicitis,
Urethritis
Proctitis
Lymphogranuloma venereum
Pelvic inflammatory disease
Potential to transmit to newborn during delivery
Conjunctivitis, pneumonia

38. Lymphogranuloma venereum
LGV
GROOVE’ s SIGN

39. Drips
Normal Cervix
Source: Claire E. Stevens, Seattle STD/HIV Prevention Training Center

40. Chlamydia Cervicitis Drips
Source: St. Louis STD/HIV Prevention Training Center

41. Mucopurulent Cervicitis
Drips
Mucopurulent Cervicitis
Source: Seattle STD/HIV Prevention Training Center

42. Laboratory Tests for Chlamydia
Drips
Laboratory Tests for Chlamydia
Tissue culture has been the standard
Specificity approaching 100%
Sensitivity ranges from 60% to 90%
Non-amplified tests
Enzyme Immunoassay (EIA), e.g. Chlamydiazyme
sensitivity and specificity of 85% and 97% respectively
useful for high volume screening
false positives
Nucleic Acid Hybridization (NA Probe), e.g. Gen-Probe Pace-2
sensitivities ranging from 75% to 100%; specificities greater than 95%
detects chlamydial ribosomal RNA
able to detect gonorrhea and chlamydia from one swab
need for large amounts of sample DNA

43. Laboratory Tests for Chlamydia (continued)
Drips
Laboratory Tests for Chlamydia (continued)
DNA amplification assays
polymerase chain reaction (PCR)
ligase chain reaction (LCR)
Sensitivities with PCR and LCR 95% and 85-98% respectively; specificity approaches 100%
LCR ability to detect chlamydia in first void urine

44. Chlamydia Direct Fluorescent Antibody (DFA)
Drips
Chlamydia Direct Fluorescent Antibody (DFA)
Source: Centers for Disease Control and Prevention

45. Pelvic Inflammatory Disease (PID)
Drips
Pelvic Inflammatory Disease (PID)
l0%-20% women with GC develop PID
In Europe and North America, higher proportion of C. trachomatis than N. gonorrhoeae in women with symptoms of PID
CDC minimal criteria
uterine adnexal tenderness, cervical motion tenderness
Other symptoms include
endocervical discharge, fever, lower abd. pain
Complications:
Infertility: 15%-24% with 1 episode PID secondary to GC or chlamydia
7X risk of ectopic pregnancy with 1 episode PID
chronic pelvic pain in 18%

46. HPV and Cervical Cancer

47. HPV and Cervical Cancer
Infection is generally indicated by the detection of HPV DNA
HPV infection is causally associated with cervical cancer and probably other anogenital squamous cell cancers (e.g. anal, penile, vulvar, vaginal)
Over 99% of cervical cancers have HPV DNA detected within the tumor
Routine Pap smear screening ensures early detection (and treatment) of pre-cancerous lesions

48. Estimates for HPV-Associated Cancers
HPV and Cervical Cancer
Estimates for HPV-Associated Cancers
Cervical cancer:
In the U.S., an estimated 14,000 cases and 5,000 deaths
Worldwide, an estimated 450,000 cases and 200,000 deaths

49. Perianal Wart HPV and Cervical Cancer
Source: Cincinnati STD/HIV Prevention Training Center

50. HPV Penile Warts HPV and Cervical Cancer
Source: Cincinnati STD/HIV Prevention Training Center

51. HIV Infection Infection of immun system
Seen oppurtunistic infections and neoplastic diseases in the last stage

52. Transmission Risks

53. HBV Infection

54. HBV Carrier : 2-3.000.000 CHB (25%) : 500-750.000
Cihrosis and HCC(ex)/year : 5000

55. 1/3 - %5 CHB – Epidemiology 1/3-%5 HBsAg Prevalance ³8% -HİGH
2-7% - Moderate
<2% - Low 36

56. Genital siğiller HPV (human papilloma virus) etkendir
Erkek ve kadın genital bölgesinde ve anus çevresinde sert, ağrısız, küçük siğillerdir.
•Virüsün 6 ve 11. alt tipleri dış genital bölgede;
•16, 18 ve 31. alt tipleri ise, servikal displazi ve karsinomla ilişkilidir.

57. Teşekkürler... Şüpheli cinsel temastan kaçının Tek eşliliğe yönelin
Korunma yolları
Şüpheli cinsel temastan kaçının
Tek eşliliğe yönelin
Riskli kişilere HBV aşısı uygulayın
Kondom kullanın
Uyuşturucu ve alkol aldıktan sonra şüpheli cinsel temastan kaçının
Teşekkürler...