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New Treatments for Sexually Transmitted Diseases

The syndromes and complications that we see from sexually transmitted diseases include salpingitis, infertility, ectopic pregnancy, and they may affect the children of the mother; Chlamydia can cause conjunctivitis and pneumonia and possibly perinatal death. A lot of the sexually transmitted diseases are now incriminated with premature rupture of membranes and prematurity. A lot of studies have been done with HPV and the question of inflammation and infection of the female urogenital tract. Risk factors include multiple sexual partners, failure to use barrier contraception, sexual partner with other sexual contacts.

The clinical prevention guidelines tell us that first we must educate those at risk and then look at those who have no symptoms but who are infectious and they keep passing infection from one person to another; then we must have effective diagnosis and treatment for those infected.

What are the clinical clues that someone has a sexually transmitted disease? Post coital bleeding, change in discharge - color or odor, itching, pain with intercourse, pain with urination, lower abdominal pain, pain with bowel movements, sores in the vagina, labia, anus or mouth, irregular growth warts in the genital region, pain or swelling of the glands in the groin, rash.

We will start with Neisseria gonorrhea, which is an intracellular diplococcus that is coffee bean-shaped. This is a very small organism that has a wall which is made up of mucopolysaccharides and it has pilae, which is the way it attaches to the columnar epithelium and infects cells; all of the Neisseria genus do that. Once it infects, the problem starts. It can cause urethral and Skene gland infection or infection of the Bartholin glands, or it could cause upper genital tract infection and then pelvic inflammatory disease and so on.

The treatment is hospitalization; it is easy to treat and the main thing is to make sure that they do not have endocarditis or any signs of meningitis. Treat with ceftriaxone one gram IM or IV every 24 hours. Patients do fine with this. You could also use cefotaxime or ceftizoxime; these are the CDC recommendations. For those who are allergic to beta lactams, you could use Cipro or

The story can be different, as you see this a lot in college students. If you see a granular cervicitis, when you touch it with a cotton tip, it will bleed. If you happen to take a culture, you will find what we call Chlamydia. Chlamydia is a very lazy organism; it needs other cells to live on, because it does not form ATP. To diagnose it, you have to do a culture. This is a very cumbersome process and it takes 48 to 72 hours for the culture to come back positive. Once it is positive, you find the infective bodies; they infect the cell, after awhile the cell bursts and then

Trichomonas is a common sexually transmitted disease. It is a flagellated protozoa that thrives in bacteria. You see it with gonococcus, chlamydia and other infections. You even see it with bacterial vaginosis. If you look at it, the vaginal discharge is alkaline more than 5, there are a lot of white cells and a lot of bacteria, which may be anaerobes. The discharge is frothy, greenish-yellow and there is a lot of irritation . This organism has been incriminated in rupture of membranes and preterm labor. The treatment for it is metronidazole, which is the only thing available in the United States. There are other things available in Canada. The dosing regimen is

Herpes genitalis in the female cervix is difficult to see, especially if the patient is pregnant. The problem is that after exposure, the infection gets in the skin and causes local infection. After that, it goes into the posterior ganglia and stays dormant until for one reason or another it gets reactivated. The reactivation of type I or type II actually is increased if the patient's immune

The characteristics of the types include either primary, nonprimary or recurrent. The primary is the first time they have an ulcer and have no antibodies. Nonprimary is the first time they have ulcers, but they do have antibodies. Recurrent is the one that comes again. Patients with recurrent infection are the ones that have the problem. This is very important in managing pregnant ladies . If she comes to you and says that she has a tingling sensation, you may have to do a C. section if she comes into labor; even if she doesn't have the lesions, she has the prodrome. They all have lesions and they all have fever, malaise and other symptoms. Typical characteristics of genital herpes include headache, malaise, what appears to be a flu. If you have

In patients who have lesions, the lesions are either herpes, syphilis or chancroid. Chancroid is a very painful lesion. Syphilis has no pain. With herpes, you have lymph nodes in the groin that are very painful; with chancroid, you have lymph nodes in the groin that are painful and big; and with syphilis, you really don't see much in the way of lymph nodes in the groin.

Treatment for clinical episodes according to CDC recommendations, include acyclovir, 200 mg five times a day or 400 mg three times a day for 10 days; or famciclovir, 250 mg three times a day for 7 to 10 days. If you are treating for recurrence, then you use any of the recommendations approved by the CDC. For suppressive therapy, you use either acyclovir or famciclovir in any dosage you are comfortable with. I like to use once a day dosing for a week

A few words about herpes in pregnancy. These patients can end up with hepatosplenomegaly and meningitis. These are the conditions that we try to avoid. The recommendation up until now was that if the patient has herpes and has lesions and goes into labor, she has to have a cesarean section. If she has the prodrome, she has to have a cesarean section. If she has no lesions or

Syphilis is a word that actually came from the Greek poet Syphilis, who was afflicted with the disease. Syphilis, as we know, can be primary and the hallmark of that is the chancre; it is on the external genitalia in the male and internal genitalia in the female. It can be present at other sites also. It is usually 10 to 90 days after exposure to the T. Pallidum; it is a spirochete. By the way, spirochetes need a moist area to live; once they are placed in a dry environment, they die within a few hours. They incubate for three weeks and they heal spontaneously. They will not even leave a scar. So 10 to 90 days after exposure, you get the chancre; the chancre stays for two to six weeks and then heals completely and you do not even see a scar. You need a dark field

Secondary syphilis is once the chancre heals and you have bacteremia involving all the major organs of the body. It appears between six weeks and six months after the chancre disappears and it persists again for two to six weeks. It produces a skin rash all over the body, including the palms, soles and mucous membranes; no area is left untouched. It also produces condylomas which are brown and sessile; we call these condylomatas. Secondary syphilis causes fever,

Once the secondary stage disappears, we enter latent syphilis, which usually has no clinical symptoms. If it has been less than one year, it is early and if it is more than one year, it is late. Tertiary syphilis has been identified up to 20 years after latency and it occurs in one-third of untreated patients. It causes progressive damage and involves the cardiovascular system, mainly causing aortic aneurysm, aortic insufficiency and it does cause generalized paresis, tabes dorsalis, aortic atrophy and the Argyll Robertson pupil. Tertiary syphilis is twice as common in

Looking at the stages of syphilis and the tests that we have, the specificity and sensitivity of these is very important. In looking at primary disease, you find that sometimes early in the game your antibody test is negative. The best thing here is to use the dark field. In secondary syphilis, the

Urosyphilis is a different ball game. Once you hit the nervous system, you go to aqueous crystalline penicillin and use almost 24 million units a day, using 3 to 4 million units IV q.4h. for 14 days, or you could give them 2.4 million units of procaine penicillin IM daily with probenecid, 500 mg q.i.d. for 10 to 14 days. Once treated, you follow the patient with the VDRL every four months for one year. If there is no decrease in titers - no four-fold decrease within six months

Moving from syphilis to the human papilloma virus, there are 25 that affect the human genital tract - 16, 18, 30, 31 and 35 are the ones that we are more interested in, because these are the ones that cause cervical and vulvar cancer. They could be symptomatic or asymptomatic. Genital warts of the cervix, vagina and urethra are causes by 6 and 11; they are rarely associated with invasive squamous cell carcinoma of the external genitalia. There is no evidence

A few words about bacterial vaginosis as a sexually transmitted disease. There is an argument about whether bacterial vaginosis is a sexually transmitted disease or not. The people who claim that it is a sexually transmitted disease say that it has been found in patients who have multiple sexual partners and in people who have problems with other sexually transmitted diseases. The other argument is that you find it in people such as virgins and nuns who do not have sex. Bacterial vaginosis is a syndrome made up of multiple organisms - anaerobes, Bacteroides, Gardnerella, Haemophilus homini and others. Altogether, these organisms increase the milieu of