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STDs and UTIs commonly affect the urinary system and because of that, there is overlap in the symptoms and signs of STDs and UTIs. So, many patients present to you with a complaint of burning with urination or dysuria and that can be a manifestation of numerous infectious causes, as you all know. Sometimes the urethral syndrome which we sometimes call the presentation of dysuria or burning with urination comes from cystitis. It can be associated with pyelonephritis, gonorrhea, chlamydia, trichomonas, M. Ureaplasma and herpes. Of course, you can also see this in the presence of vaginitis.
Sometimes the associated symptoms can give you some clues as to whether you are dealing with an STD or a UTI. If the patient has associated flank pain, nausea, vomiting and fever, you may suspect pyelonephritis. Whereas the presence of concomitant vaginal symptoms.
Patients with STD urethritis may tell you that they have had a new sex partner within a few days of the symptom onset. They may report a purulent urethral discharge and, of course, this is much more copious and common with gonorrhea than it is with chlamydia.
In patients with vaginitis, they may complain of vaginal discharge and external dysuria where the pain is not so deep and dull but located more about the labia or the urethral orifice in the case of women.
STDs still have major importance. That is, the STDs other than HIV. There is quite a dramatic increase from the ‘70s through the ‘90s and quite a dramatic increase in ectopic pregnancy mostly because of fallopian tube infections. 25% of couples take more than a year to conceive. Treatment of that is extremely expensive and with a single episode of fallopian tube infection there is a 20% infertility rate and a 7% ectopic pregnancy rate.
Gonorrhea and chlamydia cost more than $5 billion dollars per year to diagnose and treat and you may find it surprising that even though these are not ulcerative STDs, gonorrhea, chlamydia and even Trichomonas have been shown to facilitate the transmission of HIV. So maintaining good control of the non-HIV STDs will actually have a big impact on transmission of HIV. So this also needs to be part of our approach in controlling the HIV epidemic. But I think from those figures you can see that STDs are a problem of mammoth proportions.
Gonorrhea, of course, is caused by Neisseria gonorrhoeae which is a Gram negative diplococcus. It has special growth requirements. Kind of a body temperature environment with an elevated CO2 level facilitates growth. If you are culturing a sterile body site, you can just culture on chocolate Agar but most of the time we are talking about a genital specimen and so we are going to use special media – Thayer-Martin – which is chocolate Agar containing antimicrobials.
If you are doing a gonococcal culture, you should plate the specimen at the bedside. If you don’t have a CO2 incubator handy, you can put the plate in a candle jar which is just a large jar that you light a candle in and close the lid and let the flame generate CO2. You can put that in a regular incubator and then transport it to central laboratory facility later if you don’t have a CO2 incubator handy. As we’ll talk about, there are some other diagnostic tests.
How prevalent is gonorrhea? 82% of the cases occur in the age groups from 15-29. There is a very significant incidence of asymptomatic infection in women but this does not happen very often at all in men. But if you’re not thinking about it in a sexually active woman, especially if you don’t take a history and find out her risk factors, you may miss the asymptomatic infection and she may become symptomatic later resulting in ectopic pregnancy or infertility.
It is easier for transmission to occur from a male to a female (50% after a single exposure) than it is the reverse. If you remember one thing from this part of the lecture, I want you to remember that coinfection with Chlamydia trachomatis is extremely common in both men and women who have gonorrhea and that’s why we recommend epidemiologic treatment of everyone with gonorrhea with an agent that is effective for chlamydia. So whenever you diagnose gonorrhea, you should always treat the patient for chlamydia as well.
I will just make one more comment. I put a lot of numbers up on that slide and I don’t think it’s worth remembering the numbers but you should remember the trends. Adolescents are high risk. Asymptomatic infections are more common in women and chlamydia is a very common coinfection.
I’m going to move on to clinical manifestations of gonorrhea. In males, acute anterior urethritis is the most common manifestation. Incubation period is usually a few days and usually there is a very copious purulent discharge. Remember, only 1-3% are asymptomatic. In females, cervicitis is the most common manifestation and the incubation period is much more variable for women. Urethral colonization is usually present in these women as well but it is unusual for the urethra to be
Rectal infection occurs in 35-50% of women who have cervicitis and this is not because of practices of anal receptive intercourse. It’s just because the anorectal opening is relatively adjacent to the vaginal opening. However, in males, the presence of proctitis generally does indicate anal receptive intercourse and it may be
Upper genital tract infection – endometritis or fallopian tube infection – occurs in about 20% of cases. They present with lower abdominal pain, they may report pain during sexual intercourse and they may report abnormal menses or bleeding. On exam, they have tenderness in the lower abdomen. They may have
If you move the cervix during a bimanual exam, it elicits the "chandelier sign" which is the classic sign for PID where it is so painful the patient wants to jump off the table and grab the chandelier and it can cause exquisite tenderness. But most people recommend that because PID is difficult to diagnose on clinical grounds alone
This is a Gram negative intracellular diplococcus and a group of polymorphonuclear leukocytes and that is what you are looking for on Gram stain.
Treatment of gonorrhea. The CDC just updated their guidelines in January for the treatment and diagnosis of all STDs and you can find that at their web site. I have the address for any of you who are interesting in having that. They didn’t really change their recommendations from the ’93 one for gonorrhea. Ceftriaxone as a single IM injection. Cefixime, ofloxacin or Cipro are all considered adequate therapy but you’ve got to keep your eyes open over the next few years for rising
You also need to treat for Chlamydia trachomatis and that would be with a single dose of azithromycin or seven days of doxycycline. Azithromycin does have an indication for the treatment of gonorrhea but it’s in a 2 gm dose which patients don’t tolerate very well. The CDC elected not to endorse single dose azithromycin as treatment for gonorrhea so they still would recommend two drugs – one for gonorrhea and one for chlamydia. The azithromycin dose for chlamydia is
I’m not going to go over all the possible regimens for PID because I think there are many that are adequate. What you have to remember is that you are not only treating for gonorrhea and chlamydia but also anaerobes, Gram negative rods and Streptococci which seem to join in the party once the infection has been initiated by gonorrhea and chlamydia. Of course, also never forget that you should treat and screen sexual partners of people with
Chlamydia is not identifiable on Gram stain because it is an intracellular parasite, it doesn’t have a cell wall and so on. They are energy parasites and they can’t make their own ATP. So if you are going to grow them, you have to have access to cell culture techniques. That’s really not very widely available and so
Like gonorrhea, cervicitis is the most common manifestation in women. Sometimes they have mucopurulent cervicitis but you’ve got to know that only one-third of women with chlamydia infections will actually have symptoms or signs of infection. So that means up to two-thirds of women with chlamydia infection have no evidence, either on history or physical exam, that they are infected. So that’s why you need to find out whether they have risk factors, multiple partners, etc. or
This is hypertrophic ectopy that can be seen with chlamydia infection. This is the cervix and you can just see the heaped up nature of the tissue around the cervical opening which is not readily apparent on that picture. Culture has generally been the gold standard but it’s probably only between 80 and 90% sensitive. So the
We often use mucopurulent cervicitis in the absence of gonorrhea as presumptive evidence of chlamydia. But most people recommend treating based on test results unless you think you’re not going to see the patient again. If you think you’ll never get a chance to see them again, you should go ahead and treat them
I mentioned treatment of chlamydia. Doxycycline for seven days is the traditional therapy but a single gram of azithromycin is just as effective. Now that we have single dose therapy for gonorrhea and chlamydia, we ought to be able to do a much better job of ensuring treatment of those infections because you can observe them taking the medicine in your office. Always ask about partners and if the patient doesn’t want to tell you who it is, you can provide names to th
I will just tell you that the differentiating effect of herpes, chancroid and syphilis has to do with the presence of symptoms. This is herpes. Syphilis gives you painless ulcers and painless lymphadenopathy. Chancroid gives you a painful ulcer and tender adenopathy and that is