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SEXUALLY TRANSMITTED INFECTIONS

- Infections transmitted through sexual behaviours: anal, oral, vaginal
- 5 out of 10 CDC (Centre for Disease Control and Prevention) are STIs
Chlamidiya, Gonorrhoea, Syphillis, Hep B, HIV
- A public health (epidemiological) implication: STIs can coexist, increasing antimicrobial
resistance

Common STIs: (red covered in this lecture)

Class Infection

Bacterial Non gonococcal:

Chlamydia
Chancroid
Lymphogranuloma venereum (LGV)
Donovanosis

Gonorrhoea (NGO)

Syphilis (chancre)
Shigella, Campylobacter
Parasitic Trichomonads
Giardia
Amoebiasis

Viral HPV (Human papilloma virus)

HSV (Herpes simplex virus)
Hepatitis (Hepatitis B/C virus)
HIV 1/2 (Human immunodeficiency virus)

Fungal Candidiasis (thrush)

Arthropod infestations Pediculosis pubis

Scabies

Risk factors:
- Ages: 15 - 30yo
- Early sexual activity
- Low education level, lack of access to healthcare facilities
- Contraceptives: Barrier methods used less than OC pills
- Multiple/high risk partners
- Increased international mobility
- Recreational drug use, prostitution, alcohol
- Asymptomatic carriers: multiple infections can co-exist

Sexual health services:

- Primary, secondary and tertiary care
- Key aspects in STIs:
Confidentiality
Privacy
Contact tracing
Co-existing infections

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Taking a sexual health history:
- Two key purposes:
1. Establish the potential source of infection
2. Assess level of risk (for multiple infections)
- Gynaecological (menstrual), obstetric, and contraceptive history
- Drug history: allergies, contraceptives
- Past medical history
- Key things to establish in the history:
Number, gender and type of sexual contacts (anal, oral, vaginal); with dates
Partners sex
Regular or casual partner
Use of condoms / other contraception
Previous history of STIs including dates and contraceptions used
HIV testing and HBV vaccination status
Travel history
Presentation to clinics:
- Common presentation of STIs:
Discharge: vaginal/urethral, vulval/perineal soreness
Gential ulcers, warts
UTI symptoms (hesitancy, dysuria, frequency etc.)
Fever, pain, itch, rash, joint pains and eye symptoms
Examination of patients:
- General examination of: mouth, throat, skin and lymph nodes
- Inguinal, genital and peri-anal areas
- Groins - lymphadenopathy
- External genetalia: look for erythema, fissures, ulcers, chancres, pigmented or hypo-
pigmented areas and warts
- Signs of skin trauma
- Men:
Foreskin retracted: balanitis, ulcerateion, warts or tumours
Urethral meatus: redness, discharge
Scrotum, testes and epididymis
Rectal examination/protoscopy: if rectal symptoms or those who practice ano-receptive
intercourse
Peri-anal lesions
Regional lymph nodes
- Women:
Vulval: Bartholins glands
Walls of vagina for warts
Cervix: ulceration, discharge, bleeding and ectopy
Bimanual pelvic examination: adnexal tenderness or masses, cervical tenderness, the
position, size and motility of the uterus
Rectal examination and proctoscopy performed if the patient has symptoms or practices
ano-receptive intercourse

Causes of urethral discharge:

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Infective Non-infective

Neisseria gonorrhoeae Physical or chemical trauma

Chlamydia trachomatis Urethral stricture
Mycoplasma genitalium Non-specific (unknown aetiology)
Ureaplasma urealyticum
Trichomonas vaginalis
Human papillomavirus
Herpes simplex virus
Urinary tract infection (rare)
Treponema pallidum (meatal chancre)

Causes of genital ulceration:

Infective Non-infective

- Syphilis - Behcets syndrome

Primary chancre - Toxic epidermal necrolysis
Secondary mucous patches - Stevens-Johnson Syndrome
Tertiary gumma - Carcinoma
- Chancroid - Trauma
- LGV
- Donovanosis
- Herpes simplex (primary or recurrent)
- Herpes zoster

Causes of vaginal discharge:

Infective Non-infective

- Bacterial vaginosis - Cervical polyps

- Candida albicans - Neoplasms
- Trichomonas vaginalis - Retained products (e.g. tampons)
- Chlamydia trachomatis - Chemical irritation
- Neisseria gonorrhoeae
- Herpes simplex

STIs: Lab investigations:

- Discharge/swab
Gram stain MCS
Wet preps
- Urine: PCR
- Serology
- Molecular PCR/NAAT (Nucleic Acid Amplification test)
NAAT - used to detect a particular pathogen (viral or bacterial) in a specimen of blood/body
tissue/body fluid, by detecting or amplifying the pathogens DNA or RNA (i.e. making extra
copies of its nucleic acid
Representative sample
Quick transport
Proper storage

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1. Gonorrhoea
- Ophthalmological symptoms
- Organism: Neisseria gonorrhoeae
Gram -ve diplococchi
- Normal flora in: Lower genital tract, rectum, oropharynx and eyes
- Incubation period: within a week (1-2 days)
- Presentation:
Males:
- Purulent, creamy, urethral discharge, dysuria, frequency, urethritis, prostatitis,
epididymitis, arthritis
- 50% males are asymptomatic (90% of females are asymptomatic > need to do contact
tracing)
Females:
- Vaginal discharge, dysuria, dyspareunia (painful sexual intercourse), abnormal menses
- 90% asymptomatic
-
Conjunctivitis Creamy, purulent discharge

Epididymo-orchitis

Salpingo-oophoritis

Investigations:
- Microscopy, culture and sensitivity of infected secretions
Rapid screening test: Urine NAAT/PCR > less invasive, dual organisms tests
(Chlamidya), costly, false positives, no antibiotic sensitivity
Use first part of urine stream: contains urethral cells from back of urine tract
Mid-stream: bladder cells (looked at in cystitis)
Home kits: Tubes with urine taken at home can be sent for NAAT and PCR (due to stigma
patients may feel)
- Smears/swabs for culture: urethral, cervical, rectal, throat, eye
- Gram stain: typical intracellular gram -ve dipplococci

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Treatment:
Penicillin, Ciprofloxacin, Tetracyline - but increasing resistance
Cefixime (single dose)
- Need to repeat cultures after a week to confirm efficacy of treatments
- Rule out or co-treat with azithromycin for Chlamydia infections

Prognosis:
- Delay in treatment leads to complications
Males: Epididymo-orchitis (inflammation of epididymus and testes), prostatitis, urethral
stricture
Females: Salpingo-oophoritis (due to pus, ovaries fuse to fallopian tube), pelvic
inflammatory diseases, infertility

Prevention:
- Use of condoms
- Contact tracing and treatment

2. Chlamydia trachomatis

- Gastroenterological symptoms
- Organism: Chlamydia trachomatis (D-K)
- Development of symptoms 2-3 weeks after sexual contact
- Most common non-gonococcal STI. One of the highest
reported notifiable diseases in Australia since 2009, esp. in
Indigenous populations of NT, WA and QLD
- Silent epidemic: asymptomatic
- Highly infective: 50% transmission rate after one
unprotected sexual encounter, compared to 0.3%
transmission rate of HIV
- Early diagnosis: NAAT and PCR, not cultured by routine
methods (bacteria cant be grown)

Life cycle:

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- Elementary body: spore-like, hard particle that is infective > attaches to urethral cell, is
engulfed by phagocytes and converts to a reticular body (metabolically active form >
replicative)
4 classifications/species of Chlamydia:
C . trachomatis: Oculo genital
Serovar L1 L2 L3 : LGV
Serovar : A B Ba C : Ocular trachoma > cause of chronic conjunctivitis
Serovar D-K : Oculo genital > gives genital symptoms
C. pneumoniae : Respiratory
C. psittaci: Veterinary /Zoonotic
C. pecorum: Veterinary

Clinical presentation:
- Usually seen young adults, 15-29yo
- Women:
Asymptomatic (80%)
Post coital or intermittent bleeding
Lower abdominal pain
Purulent vaginal discharge
- Men:
Asymptomatic (50%)
Urethral discharge
Proctitis
Dysuria
Proctitis: inflammation/painful Proctocolitis: Complication: ectopic pregnancy
sores around rectum and anus

Diagnosis:
- Males: urine (first catch, morning sample) and urethral discharge swab
- Women: endo-cervical swab, urine, vaginal swabs
- Self collection kits for urine or low vaginal swabs
- Screening: Nucleic acid amplifaction techniques likes PCR detects cryptic plasmid (mobile part
of chromosome that can be detected in urine) in urine or secretions
- Live inside urethral cells and are difficult to culture - slow to grow as obligate intracellular and
and special tissue culture cells are needed
- Tissue culture cells: for genital swabs not urine
- Immunofluorescence: to see reticular bodies; Chlamydial inclusion bodies in tissue cell culture
using labelled monoclonal antibodies

Treatment:
- Azithromycin 1 g stat single dose
- Doxycycline 100 mg bd for 7 days
- Ofloxacin

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- Abstain from unprotected sex for a week

Complications:
- Untreated, 5-10% progress into complications
- Females:
Pelvic inflammatory disease
Infertility (25%, common course)
Ectopic pregnancy (15%)
Premature delivery/IUGR (Intrauterine growth restriction: when an unborn baby is smaller
than it should be because its not growing at a normal rate inside the womb)
- Males:
Proctocolitis
Epididymo-orchtis
Prostatitis
Reactive arthritis (HLA B27)

3. Lymphogranuloma venereum (LGV)

- Dermatological symptoms/infection of lymphatics
- Organism: Chlamydia trachomatis: gential
Serovar L1 L2 L3: LGV
- Transmitted primarily anal sex (men > men)
- Australian cases: 5/year, and are acquired overseas. Notifiable. Restricted areas: Asia, Africa,
Central America
- Incubation period: 4 weeks

Clinical presentation:
- Starts as painless genital ulcer
- Ulcer heals and goes unnoticed as painless
- 4-6 weeks develops as painful, swollen inguinal lymph nodes (buboe)
- Discharging lymph nodes
Painless ulcer for 2
weeks

Buboe

Painful inguinal lymph

node

Diagnosis:
- Pus/gential swab for PCR
- Active lesions: biopsy
Granulomatous lesions

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Treatment:
- As for Chlamydia

4. Chancroid
- Organism: Haemophilus ducreyi (its so painful, you do cry)
Gram -ve rod
- Tropical/sub-tropical countries: Asia/Africa/Carribean
Prostitutes
Cofactor in HIV/STI transmission
Notifiable in Australia but very rare

Clinical presentation:
- Soft chancre: red and soft ulcer base (contrast with hard chancre found in Syphillus)
- Painful, irregular, genital ulcers with exudate (pus)
- Inguinal adenopathy
- LNs +++
Painful penile ulcer with Soft chancre
enlarged inguinal lymph
nodes

Gram -ve rods

Diagnosis:
- Aspirate gram -ve bacilli
- Growth is 9 days (long), so multiplex PCR used to rule out co-existing STIs (detects multiple
organisms)

Treatment:
- Azithromycin 1 g stat OR
- Ciprofloxacin OR
- Ceftriaxone

5. Trichomoniasis
- Organism: Trichomonas vaginalis
Parasite, not bacteria

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Flagellated pear shaped protozoan

Trichomonas vaginalis is motile

in wet prep
H/E stain

Incubation period: 4-28 days

Clinical features:
- Most common STI in elderly females
- Women:
Characteristic thin, frothy, copious discharge
Vaginitis
Strawberry cervix
- Men:
Urethritis
Bacterial vaginosis

Thin, frothy, copious discharge

Treatment:
- Must treat BOTH partners simultaneously with oral metronidazole for 7 days as
Asymptomatic carriers
High recurrence rate

Bacterial Vaginosis
- NOT sexually transmitted, but to do with changes in vaginal pH
Vaginal pH is normally acidic due to lactobacilli (normal flora); but during aging or excessive
douching/use of bath salts/perfumes, pH decreases and clue cells can be seen
- Organism: Gardnerella Vaginalis
- Clinical features:

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Reproductive age in females
Grey, thin, serous, fishy discharge
Vulval soreness but not itching
HAYS CRITERIA (to differentiate between parasite and STI - Trichomoniasis)
1. pH <4.5: normal vaginal pH is 4, acidic to keep bacterial growth low
2. + whiff test: fishy odour enhanced with KOH
3. clue cells (Garnderella vaginalis clinging to urethral cell)
4. decrease in lactobacilli
- Treatment:
Not sexually transmitted
Metronidazole 400 mg tds 7d
Complication: if acquired during pregnancy > premature labour

6. Candida
- Organism: Candida albicans (80-90% infections)
Others: Candida glabrata, Candida tropicalis, Candida kruseiand Candida parapsilosis
Clinical features:
- Foul, thick, curd-like discharge
- Usually in immunocompromised patients (stressed, diabetes, chemotherapy or other anti-
cancer drugs)

Treatment:
Topical Nystatin gel - 7 d.
Fluconazole orally - if severe
Look for co-morbidities.

7. Syphilis
- Organism: Treponema pallidum
Spirochete
Thin, tightly coiled, motile bacteria
Cant be seen on gram stain, need dark field microscopy

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Fastidious growth (needs specific factors to survive); cannot survive drying or disinfectants
Transmission: through skin abrasions and mucous membranes from close contact of an
infected person. Not through fomites (i.e. sharing bathroom wont transmit infection)
- Vertical transmission: i.e. from mother > fetus
- Incubation period: 3-4 weeks (average 3); as multiply slowly

Clinical features:
- 4 stages: primary, secondary, tertiary or quaternary syphilis. Rare to show all 4
I. PRIMARY SYPHILIS
Localised disease presenting with painless, hard chancre (clean, punched out edges, hard
base)
- Primary lesion: papule that breaks down into hard chancre on genitals (penis/cervix) or
rectum/lips/hands
Regional lymph nodes: enlarged, rubbery, painless
Lesions heal spontaneously in 2-6 weeks, hence go unnoticed
II. SECONDARY SYPHILIS
2-10 weeks after primary chancre
Spreads through lymphatics and bloodstream
Dissemintated disease with constitutional symptoms; generalised maculopapular rash
(palms and soles involved)
Generalised lymphadenopathy, fever, malaise
Smooth, moist, painless wart-like lesions on genitals
Patchy hair loss
Highly infective stage
Heal spontaneously
III. LATENT SYPHILIS
After infection of secondary syphilis, there is a latent asymptomatic phase which can last
3-30 years > organisms dormant in liver, spleen or CNS > cant detect > can
progress to tertiary syphilis
IV. TERTIARY SYPHILIS
3-30 years after primary lesions in 30% cases
Gumma: granulomatous nodules in skin, mucous membranes or bones > disrupted nasal
bones
- Break down to form punched out ulcers (hard chancre)
Late syphilis:
- Cardiovascular: aortic aneurysm (vaso vasorum destruction)
- Neuroshyphilis: Paresis, Tabes dorsalis (motor ataxia: gait unsteadiness, lightning pains,
urinary incontinence); Argyll Robertson pupil (constricts with accommodation but isnt
reactive to light; also called prostitutes pupil since it accommodates but doesnt react)
Signs: broad based ataxia, + Romberg, Charcot joint, stroke without hypertension
V. CONGENITAL SYPHILIS
Presents with facial abnormalities such as rhayader (linear scars at angle of mouth), nasal
discharge, saddle nose, notched (Hutchinson) teeth, mulberry molars, short maxilla, sober
shins; CN VIII deafness

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To prevent, treat mother early in pregnancy as placental transmission typically occurs after
first trimester

T. pallidum on dark field

microscopy
Penile ulcer Ulceration + erythema
around anus

Maculo-papules around palms

(and soles)

Hard chancre
Secondary syphilis -
generalised macula-papular
rash Gumma - disrupted nasal
bones
Diagnosis:
- Mainly serological: 2 types
- Nonspecific tests (non treponemal): SCREENING
Detect antibody like substance reagin and not trepenemal antibodies hence non specific
tests
VDRL
RPR
- Specific tests: CONFIRMATORY tests as detect treponemal antibodies
TPPA, FTA-ABS, ELISA
- Serological tests need to be properly interpreted with signs and symptoms to determine
clinical status as these tests cannot differentiate between past and recent infection
Treatment:
IM benzathine/Procaine Penicillin, Ceftraixone or oral DoxycyclineTreatment:

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