1. SEXUALLY TRANSMITTED DISEASES
Dr. Haider A. Al-Sabak
April-May 2013

2. INTRODUCTION
Sex: normal physiological role of human…..offspring, but abuse …… medical & social problem. Veneariology: (syphilis, GC, chancroid) STD: GUM: genito-urinary medicine, include: 1. STD caused by microbes. 2. Genital skin problems. 3. Bladder & Vaginal problems. 4. Prostate problems. 5. Anal problems. 6. Scrotal & Testicular problems. 7. Erectile dysfunctions, Sterility & Infertility.

3. SEXUALLY TRANSMITTED AND TRANSMISSIBLE PATHOGENS
Bacteria …………..………………………………..Neisseria gonorrhoeae
Treponema pallidum
Haemophilus ducreyi
Chlamydia trachomatis
Mycoplasma hominis, M. genitalium
Ureaplasma urealyticum
Gardnerella vaginalis
Atopobium vaginae
Mobiluncus curtisii, M. mulieris
Klebsiella (Calymmatobacterium) granulomatis
Shigella spp.
Campylobacter spp.
Helicobacter cinaedi, H. fennelliae
Viruses ……………………………….Human immunodeficiency virus, types 1 and 2
Herpes simplex virus, types 2 > 1
Human papillomavirus
Hepatitis viruses, B > C and (via fecal-oral contact) A
Cytomegalovirus
Molluscum contagiosum virus
Human T-cell leukemia/lymphotrophic virus, types I and II
Human herpesvirus, type 8
Protozoa ……….…………………………………..Trichomonas vaginalis
Entamoeba histolytica
Giardia lamblia
Fungi …………………………………………………………..Candida albicans
Ectoparasites……………….………………………… Phthirus pubis
Sarcoptes scabiei
BOLOGNIA, 3rd ed. 2012

4. Q: How the STD pt. presented to us?
…localized, generalized or both
A- Localized Manifestations:
1. Pruritis:
a- Scabies:
b- Pediculosis Pubis:
c- Trichomonitis Vaginalis:
d- Candida Albicans:
e- Other Medical Problems Causes Itching:

5. 2. Ulcer on Genitalia:
It is either in external or internal locations of genital organs.
a- primary Chancre of syphilis….
*Rare, relatively com. In Iraq
*causative spirochaete.. Treponema pallidum subsp. pallidum
*c/f: Initial lesions..single papule but rapidly ulcerate.. skin or mucous membrane surface..external genitalia.
regularly edged, regularly based, hard and button-like ulceration measuring up to 1 cm in diameter, primary sores are not painful. ulcer is surrounded by a narrow, red border 1–2 mm wide.
‘Kissing’ ulcers…
Could be mutiple, self limited, not recurrent, not bleed on squeezing
*site: In men, glans penis, shaft, pubic region,
In MSM, anus and rectum,
In women, vulvar chancre in labia minora or majora, around the urethral orifice, clitoris or, posterior commissure

6. Multiple chancres in a woman
Penile chancre
Multiple chancres in a woman

7. Ulcus molle, soft chancre, Ducrey’s disease
b- Chancroid….
Ulcus molle, soft chancre, Ducrey’s disease
*cause…. Haemophilus ducreyi ….Gr. –ve bacillus
*c/f: I.P 3-10 days, papule at inoculation site—micropus.-ulcer, multiple, up to 1cm, tender, purulent base, bleed easily., uncircumcised men,
Vaginal introitus or labia, 1/3 cases LAP--- Bubo formation—abscess
Other rare feature ulceration---gent. Deformity
Extragent. Lesions…autoinoculation to finger & thigh
*HIV infection and chancroid….
*Dx: -Direct detection by microscopy of smears…. ‘shoal of fish’
-Specimens for culture or for PCR
-Serological tests…….epidemiology
*Rx:
• Azithromycin 1 g orally in a single dose
• Ceftriaxone 250 mg i.m. in a single dose
• Ciprofl oxacin 500 mg orally in a single dose
• Ciprofl oxacin 500 mg orally twice a day for 3 days
• Erythromycin base 500 mg orally four times a day for 7 days

8. Chancroidal penile ulceration

9. c- Herpes Simplex…. chronic dormant infection, commonest cause of genital ulcer all over the world (commonly in AIDS) *c/f : grouped vesicles---- superficial ulcer for 7-14 days glans & shaft of penis, aroud vulva, around anus, vaginal, intravaginal urethra, and intraurethral recurrent 2-6 times/year, no cure, but we can induce recovery *in females…… cesarean section Herpes Simplex Genitalis (type 2). Herpes Simplex Hominis *Rx: Aciclovir: 200mg 5 times/day for 5 days, or 400mg 3 times/day Valciclovir: 500mg twice/day for 3 days Famciclovir: 125mg twice/day for 5 days -Prophylaxis: A. 400mg twice/day V. 250mg twice/day or 1g once/day F. 125mg 3 times/day or 250mg twice/day

10. resulting in large erosions Scattered lesions on penile shaft
Confluent lesions
resulting in large erosions
Scattered lesions on penile shaft

11. d- Lymphogranuloma Venerium…
d- Lymphogranuloma Venerium…. *caused by Chlamydia trachomatis serovars L1, L2 and L3… *c/f: LGV.. 3 stages -primary stage, 3–30 days-----herpetiform ulcer, unnoticed,heal no scar -secondary stage, 2–6 weeks, inguinal syndrome, ‘sign of the groove’ -In MSM----anorectal syndrome -tertiary stage, fibrosis &lymphatic obstruction, Elephantiasis, *Dx: -detection of the L serovar of C. trachomatis from site of infection -bubo aspirate..less com., -nucleic acid amplification tests and confirmation by real-time PCR assays for LGV-specific DNA -serology - CT or MRI scan

12. Rx: -Bubos may require repeated aspiration
*Rx: -Bubos may require repeated aspiration. -complications, fistulae and strictures-- surgery to alleviate symptoms. • Doxycycline 100 mg twice daily orally for 21 days • Tetracycline 500 mg four times daily for 21 days • Minocycline 300 mg loading dose followed by 200 mg twice daily for 21 days • Erythromycin 500 mg four times daily orally for 21 days

13. Lymphogranuloma venereum
Lymphogranuloma venereum. Inguinal syndrome showing ‘sign of the groove’

14. e- Granuloma inguinale…. Or called Donovanosis,
e- Granuloma inguinale…. Or called Donovanosis, *caused by Calymmatobacterium granulomatis *c/f: papule or subcutaneous nodule---ulcerates multiple, large beefy-red, non-tender granulomatous ulcers..bleed easily and gradually extend inf.--- necrotic, foul-smelling, deep ulcers, spont.healing--dry, fibrotic *site.. uncircumcised men.. coronal sulcus or inner aspect of prepuce in females.. labia or vaginal introitus, Cervical.. CA & TB G. I --pseudo-elephantiasis, Malignant change..longstanding lesions *Dx: - Microscopy… ‘safety-pin appearance, Histology…, Culture…, PCR.. *Rx: - Azithromycin, WHO 1g orally mg daily.. 3 weeks or healing or 1 g orally at weekly intervals.. 3 weeks - co-trimoxazole 960 mg twice daily, ciprofloxacin 750 mg twice daily, or doxycycline 100 mg twice daily for 3 weeks, gentamicin 1 mg/kg i.v. every 8 h

15. Granuloma inguinale. Vulval granulomas
Granuloma inguinale. Beefy-red penile granuloma
Granuloma inguinale. Vulval granulomas

16. e- other non-infectious causes:. Bechet's Disease…
e- other non-infectious causes: *Bechet's Disease…. Males > females; site: on shaft penis or scrotum in males, and on labia majora or minora in females. Residual scarring is common. **Trauma…

17. Behçet’s disease. An aphtha is present on the penis

18. 3- Mass on Genitalia or called papulonodular lesions: a- Venereal warts…. Caused by HPV-6 75%, HPV-11 rare Condylomata Acuminate (condyloma = knuckle, acuminatum = pointed) -Usually STD, high infectivity 2/3 of sexual contacts, -Transmission: in adult….sexual contact in children…….. -c/f: I.P. 3 weeks to 8 months, average 2.8 months often asymptomatic, discomfort, discharge, bleeding Typically.. soft, pink, elongated, filiform or pedunculated Classically…acuminate form 2/3 of cases Other….flat or pigmented

19. -In children, warts often more hyperkeratotic caused by HPV types associated with cutaneous disease as well as HPV types 6 and 11. -Recurrences can be expected in about 25% of cases, 2 m.- 23 yrs -The development of large protuberant masses, induration, pain or serosanguinous discharge should arouse suspicion of malignant change (including Buschke–Löwenstein tumour), requiring prompt excision or biopsy and also assessment of immune status. -Histopathology…extreme acanthosis and papillomatosis, horny layer is parakeratotic and not very thick. Koilocytes …limited in distribution and not found in all sections connective tissue very oedematous, capillaries tortuous and increased.

20. Classical condylomata acuminata
This pigmented lesion was confirmed histologically to be a viral wart
Classical condylomata acuminata

21. Perianal warts

22. Treatment: 1. Podophyllin and podophyllotoxin -Both used in anogenital warts more effective in mucosal > keratinized -Mech. Of action: antimitotic -purified podophyllotoxin 0.5% in ethanol twice/day for 3-5days > Podophyllin cure rate 60-70% -self app. of podophyllotoxin sol. or cream > Podophyllin - Podophyllin resin sol. of 10-25% in tincture of benzoin app. Then dry few mints. Then washed off after 4 hrs. / week…. S/E local irritation, vomiting, diarrhoea, liver damage, renal damage, coma, peripheral neuropathy, bone-marrow suppression and death. 2. Interferon Refractory genital warts, Intralesional monotherapy give 36-63% , oral give better.

23. 3. Imiquimod Topical Imiquimod 5% cream twice/day upto 24 wks S/E: irritation, discomfort, erosion, & vitiligo 4. Antiviral therapy cidofovir…..infusion 5mg/kg once weekly local 1% cream or gel intralesional 2.5mg/ml S/E nephrotoxicity, bone marrow suppression, and local treatment of mucosal lesions can produce erosion and pain 5. Therapeutic vaccination Type 6, 11, 16 &1. 6. Other Green tea extract

24. Buschke–Löwenstein tumour (giant condyloma, verrucous carcinoma) -develops from a pre-existing, benign warty lesion Ext. anogenital tract, the mouth, oesophagus or upper respiratory syst. -rare in childhood,.. HPV-6 or -11mutated locally invasive, well-differentiated rarely becomes aggressively invasive -Treatment is usually surgical, Others…aggressive cryotherapy, photodynamic therapy, bleomycin, 5-fluorouracil, recombinant IFN-á, imiquimod and systemic retinoid,

25. Buschke–Löwenstein tumour

26. b- Syphilitic Condylomata Lata….
2nd stage of syphilis as rash..moist, worm area. pale flat anemic smooth papules, smear or biopsy..lot of spirochetes inside Condylomata Lata. if without treatment disapp . Or go to 3rg stage of syphilis.
c- Molluscum Contagiosum….
Cause Poxvirus family, genus molluscipox
-Types… mainly MCV-1 & MCV-2, rarely MCV-3 & MCV-4
STD in adults, commonly seen on the face or neck of children (not STD).
- I.P. (14 days – 6m.)
-c/f Shiny, pearly white, hemispherical, umbilicated papule which may show a central pore, size reach to 5–10 mm in 6–12 weeks.
Cheesy material---virus part.
d- Other causes….Lichen Planus, Psoriasis, Tumors and Cysts

27. 4- Discharge: 3 types of discharge a- Urethral discharge…
4- Discharge: 3 types of discharge a- Urethral discharge…. mainly male (because female has short urethra) *Gonococcal Gonorrhea (GC). *Non-specific Urethritis (NSU). *(E-Coli may cause gonorrhea picture so culture is the solution). -it can be differentiated from physiological discharge especially in male which is mucous (clear mucous) similar to saliva so called saliva of sex .in female such discharge with the same circumstances called leucorrhea. b- Vaginal discharge….either *Candidiasis (little discharge)------itching, burning sensation & thrush *Trichomonitis (tremendous discharge)---- in female white discharge while male is carrier c- Rectal discharge (MSM)…. burning, itching, tenismus, & discharge dysentery-like picture (diarrhea).

28. B- Systemic Manifestations:
1- Secondary rash of syphilis:
common in females….
2- Jaundice (Hepatitis Virus):
generalized itching of the skin and yellowish discoloration as in hepatitis B & C viruses.
3-Intestinal worm (nematode):
transmitted by MSM
4- AIDS:
Clinically for e.g. in lung as Pneumonia (Pneumocystic Carini) or generalized rash, diarrhea, encephalitis or Kaposi's sarcoma.
* In Iraq: Kaposi sarcoma common among elderly people with Immun compromization…

29. THE END 4- Disseminated Gonorrhea:
sign and symptoms of septicemia as arthritis (septic arthritis) and rash as small hemorrhagic pustule and papule.
5- Reiter's Disease:
NSU... presented with arthritis, urethritis (urethral discharge), eye problems (conjunctivitis) & GIT problems, genital ulceration with ankylosing spondylitis.
THE END

30. THANKS FOR LISTENING