LEARNING OBJECTIVES

Upon completion of this course, you will be able to:

• Discuss basic information and common issues about sexually transmitted diseases.
• Classify the organisms causing the most common genital STDs in the United States.
• Explain the principles of and special requirements for prevention of STDs.
• Describe the most common genital STDs in the United States.
• Discuss the treatment of each of the most common STDs in the United States.
• Explain the main ways by which STDs can be controlled.

Ironically, sexual activity, a universal source of human ecstasy, is linked to some of the most feared diseases of humankind. To combat these disorders, many cultures have regulated sexual practice, denied its pleasures to multitudes, and limited its inquiry. Nonetheless, in recent years scientific study has revealed the causes of sexually transmitted diseases, the conditions in which they thrive, effective treatments, and means for preventing their spread. Such knowledge is vital to the health and wellbeing of people everywhere, especially for providers of healthcare.

OVERVIEW

During sexual contact, skin and mucous membranes are rubbed together. These surfaces are warm and moist, and they often have small cuts, fissures, or abrasions. This makes sexual contact an ideal mode for passing certain microorganisms from person to person. Illnesses that develop from organisms acquired through sexual contact are called STDs, sexually transmitted diseases.

Sexual contact is pervasive, and sexually transmitted diseases are widespread. STDs are common reasons for patients to visit doctors' offices, clinics, urgent care centers, and emergency departments. In the United States, there are about 19 million new STD cases each year. These diseases are not limited by race, geography, or economic status. Age, however, is an important correlate of STDs: most STDs occur in people younger than 25 years old (CDC, 2007a).

STDs tend to coexist. Situations that facilitate the acquisition of one STD also facilitate the acquisition of other STDs, and people simultaneously have two or more STDs more often than would be predicted by chance. Genital warts (condyloma acuminata), for instance, often occur with genital herpes infections, and chlamydial infections are frequently found with gonorrhea.

STDs are especially common in underdeveloped countries and in other places where people live in closely crowded conditions. In these places, STDs are under-diagnosed and under-treated, and the victims of STDs are thus more likely to suffer serious long-term health consequences (Shoemaker et al., 2007). For instance, it has been estimated that more than 90 million people worldwide are infected with chlamydia each year (Starnbach & Roan, 2008). Chlamydial infections can be cured by antibiotics, but untreated infections can lead to pelvic inflammatory disease (PID), ectopic pregnancies, premature deliveries, and infertility, all of which are more common in underdeveloped countries.

Direct, individual medical treatment is a key part of the attempt to slow the spread of STDs. As a rule, bacterial infections can be cured by a visit to the doctor's office, and with the cooperation of public and private health workers, the rate of acquisition of bacterial STDs has been decreasing in the United States. Most viral infections, on the other hand, cannot be cured by medicines, and the rate of acquisition of viral STDs is increasing (Frenkl & Potts, 2007).

More than the treatment of individual patients is needed to slow the spread of STDs. Therefore, the control of STDs must have both an individual and a societal focus. For individual patients, the medical goal is to protect the patient's health and to ensure their ability to have future children if they wish. For society, the medical goal is to protect uninfected people by:

• Making sufficient care available to treat infected individuals quickly, effectively, and affordably
• Encouraging the notification of potentially infected sexual partners
• Teaching people that barrier methods of protection (eg., condoms) are important safeguards during their sexual contacts

The microorganisms that spread through sexual contact can cause disease at a variety of locations in the body. In this course, we will focus on those sexually transmitted infections that cause most of their clinical problems locally—that is, in the genital and lower urinary tracts. The genital STDs include, for example, chlamydial infections and gonorrhea.

In contrast, other STDs cause most of their clinical problems systemically or at a distance from where the microorganisms first entered the body. HIV/AIDS, for instance, disables the immune system and causes clinical problems throughout the body, and hepatitis B, which can be spread by sexual intercourse, causes primarily liver diseases. These systemic and non-genital STDs are only touched on in the present course, and they are discussed more fully in other courses.

A Note about Terminology: STD versus STI

Sexually transmitted diseases are illnesses that are spread by sexual contact. These diseases were formerly called venereal diseases.

Today, the most notorious sexually transmitted disease is AIDS (Acquired Immune Deficiency Syndrome). AIDS is the disease—that is, the symptomatic medical illness—that can eventually result from an HIV (human immunodeficiency virus) infection.

HIV is usually spread via sexual contact. People who have the virus are called HIV-positive, meaning that they have a sexually transmitted infection. Without drug treatment, HIV-positive people typically develop AIDS in, on average, about ten years. However, HIV-positive patients who take antiretroviral drugs can slow the onset of AIDS. Here, identification of the pre-disease infection is important for managing the eventual disease and for preventing its spread.

This lesson has been generalized, and some health workers talk about STIs—sexually transmitted infections, which may or may not become symptomatic diseases. These workers point out, for example, that less than half of the STIs of the bacterium Chlamydia trachomatis will end up causing the symptomatic disease (STD) chlamydial cervicitis.

The distinction between STD and STI can be confusing. In this course, we will continue to use the old terminology, lumping both sexually transmitted infections and their diseases into one category called sexually transmitted diseases, or STDs.

EPIDEMIOLOGY: THE DISTRIBUTION OF STDs

STDs are ubiquitous, and they are among the most common infectious diseases in the world. Developing countries are especially hard-hit by STDs. In some Third World countries, HIV/AIDS has become the leading cause of death (Frenkl & Potts, 2007).

In the United States, it is estimated that there are approximately 19 million new cases of STDs each year. Some STDs last a long time, and some STDs are incurable; therefore, the prevalence of STDs is much higher than their incidence (CDC, 2007a). Most new STDs—approximately half of the 19 million—occur in adolescents and young adults. Rates of new STD infections in the United States are among the highest in the developed world (Holmes, 2008).

Within the United States, some STDs, such as chlamydia, genital HPV, and genital herpes, are distributed widely and homogeneously. In contrast, gonorrhea, chancroid, HIV, and hepatitis B are concentrated in closely interacting networks of people who have many sexual partners. In all areas and groups, adolescents and young adults acquire STDs at disproportionately high rates.

Viral STDs do not always produce overt symptoms. Estimates suggest that tens of millions of Americans (perhaps one-fifth of the American population) have viral sexually transmitted infections, mainly HPV and HSV; genital HPV is the most common sexually transmitted microbe in the country. Fewer Americans have bacterial and protozoal STDs, which, in contrast to viral infections, are curable.

The actual numbers of STD infections can only be estimated. Although the frequency of new cases of certain STDs is monitored by the Centers for Disease Control and Prevention (CDC), figures for the prevalence and incidence of even the monitored STDs are inexact.

Age

People of all ages can have STDs. At one end of the age spectrum, children can get STDs through sexual abuse. At the other end, the elderly can get STDs by not using barrier protections (condoms). However, most new STDs are acquired by teens and young adults. For example, half of all new HIV infections occur in people between the ages of 16 to 24 years. In this same age group, at any one time 16 to 32% of people have a chlamydial infection, and 2 to 10% have gonorrhea (Canning & Nguyen, 2007; Balaji et al., 2008; Shetty & Maldonado, 2008).

Young people continue to get STDs at a high rate. In spite of public talk of abstinence, half of all high school students have had sexual intercourse and 15% have had intercourse with greater than three different partners. Rates of oral and anal sex are rising among teenagers. These figures indicate that when young people come to the health system with medical problems of the genital tract, the lower urinary tract, the perineum, or the anorectal area, STDs should always be considered in the differential diagnosis (Dewar, 2007; Shortliffe, 2007; Gindi et al., 2008).

Gender

Overall, more females than males are diagnosed with STDs (AVERT, 2008). In part, this difference is because STDs tend to be more overtly symptomatic in females. In addition, females acquire certain STDs, such as gonorrhea, more easily than males.

As an example, high school–age girls are three times as likely to be diagnosed with chlamydia as are high school–age boys; this is partly because chlamydial infections are more likely to be symptomatic in women than in men.

Racial and Ethnic Subpopulations

Currently, STDs occur more frequently in certain identifiable subpopulations. Specifically, there are "higher rates of all STDs among minority racial and ethnic populations when compared to whites" (CDC, 2008a).

Among the regularly tallied STDs, however, new cases of chlamydia, gonorrhea, and syphilis are most frequent in African Americans, less frequent in Hispanics, and least frequent in whites (CDC, 2007a). Comparative statistics are not available for all STDs.

THE ORGANISMS THAT CAUSE GENITAL STDs

In the United States, more than thirty different infectious agents are commonly transmitted sexually. Of these, eleven are responsible for the most common STDs of the genitals and the genital area (Hampton, 2006; CDC, 2007a, 2008a; Frenkl & Potts, 2007; Holmes, 2008; Rein, 2008).

Bacteria

Four bacteria are frequent causes of genital STDs in the United States: Haemophilus ducreyi, Chlamydia trachomatis, Neisseria gonorrhea, and Treponema pallidum.

• Haemophilus ducreyi. H. ducreyi is the bacterial cause of chancroid, an STD characterized by tender, ragged genital ulcers, and tender, enlarged lymph nodes. In the United States, chancroid is not common. It appears in limited outbreaks, and it is usually associated with heterosexual prostitution.
• Chlamydia trachomatis. C. trachomatis is an intracellular parasitic bacterium that infects the lining of the urethra, cervix, epididymis, and Fallopian tubes; in the lining of the urethra, it causes the most common form of nongonococcal urethritis (NGU) (Stamm, 2008). Chlamydial infections are quite common, especially among teens and young adults, but the infections are not always symptomatic. Screening studies have found that from 5% to greater than 10% of asymptomatic young women and from 3% to greater than 10% of asymptomatic young men have a chlamydial infection. In women, untreated chlamydial infections can cause pelvic inflammatory disease (PID), potentially leading to infertility or ectopic pregnancies.
• Neisseria gonorrhoeae. N. gonorrhoeae is a diplococcus that causes gonorrhea, which can infect the urethra, Bartholin's glands, cervix, epididymis, and Fallopian tubes. Oral sex can lead to gonococcal pharyngitis and anal sex to gonococcal proctitis. In women, untreated gonococcal infections can cause pelvic inflammatory disease (PID), potentially leading to infertility or ectopic pregnancies. Gonorrhea is about one-tenth as common as chlamydial infections, although the two infections are frequently found to coexist in an infected person (Ram & Rice, 2008).
• Treponema pallidum. T. pallidum is the bacterium causing syphilis, an STD that usually begins with a single, painless genital skin chancre (i.e., an ulcer). Syphilis goes through quiescent stages, and if untreated, the chancre will eventually disappear; but in 15% of people the infection eventually damages the brain, nerves, eyes, heart, blood vessels, liver, bones, or joints, sometimes decades later. In the United States, there are approximately 33,000 new cases of syphilis each year (Lukehart, 2008), and these cases tend to be concentrated in large urban areas.

Viruses

Four viruses—herpes simplex virus, human immunodeficiency virus, human papillomavirus, and molluscum contagiosum virus—cause most of the viral genital STDs in the United States.

• Herpes simplex virus (HSV). HSV comprises two types, HSV-1 and HSV-2. HSV-1 causes cold sores, and HSV-2 causes most of the genital sores. Yet both HSV-1 and HSV-2 can be sexually transmitted and both can cause genital ulcers. People who have genital HSV infections can have recurring outbreaks of the disease (genital herpes), which appears as clusters of vesicular lesions that rupture into painful ulcers. Genital herpes can occur throughout the anogenital and perineal region. People infected with genital HSV can shed the virus and transmit the disease even when they have no apparent skin lesions (Corey, 2008).
• Human immunodeficiency virus (HIV). HIV infections deplete the immune system of cells, including a subclass of T lymphocytes called CD4 cells. Eventually, the immune system can become so ineffective that cancers and secondary infections by other organisms can get a foothold and spread. At this stage, the HIV-infected person is said to have developed acquired immunodeficiency syndrome (AIDS) (AVERT, 2008). HIV can be transmitted through sexual contact, and if AIDS develops, the secondary urinary and genital tract diseases that can develop include opportunistic infections of the vulva, vagina, cervix, prostate, epididymis, and testis, and cancers of the cervix and testis. An HIV infection also makes the acquisition of other STDs more likely.
• Human papillomavirus (HPV). More than forty types of HPV infect humans, and HPV infections are the most common STDs in the United States. It is estimated that six million Americans acquire a genital HPV infection each year, although these infections are usually not symptomatic. Greater than half of all sexually active Americans will acquire a genital HPV infection during their lifetimes. The common types of genital HPV infections can cause anogenital warts, called condyloma acuminata. Less common types of genital HPV infections appear to cause cervical, vulvar, or penile cancer (Reichman, 2008). HPV infections often disappear spontaneously.
• Molluscum contagiosum virus (MCV). MCV causes a common, mild, and self-limiting skin disease (molluscum contagiosum) of children, characterized by small, dimpled papules or vesicles. In adults, MCV also causes genital skin lesions that can be spread through sexual contact. Genital molluscum contagiosum is usually treated by destroying the skin lesions. People with HIV infections are more likely to acquire molluscum contagiosum. With HIV, the molluscum contagiosum lesions cover larger areas, they spread beyond the genital and inguinal region, and they are difficult to eradicate unless the person maintains or has regained sufficient numbers of immune cells.

Protozoa

One protozoan, Trichomonas vaginalis, commonly causes genital STDs.

• Trichomonas vaginalis. T. vaginalis lives inside cells along the lower genital tract of females and along the urethra and the prostate of males. Symptoms of trichomoniasis are more common in women, where vaginitis is the typical clinical manifestation (Weller, 2008; Szumigala & Alvero, 2009). Trichomoniasis can be cured with oral antiprotozoal drugs.

Exoparasites

Two body surface parasites cause common STDs: pubic lice (Phthirus pubis) infestations and itch mite (Sarcoptes scabiei) infestations.

• Phthirus pubis. Pubic lice, also called crabs or pediculus pubis, live alongside coarse human hairs on which they lay their eggs (nits). Pubic lice cause itching and skin irritation, and an infestation of pubic lice is treated with topical insecticides.
• Sarcoptes scabiei. Itch mites cause the skin disease scabies. In scabies, mites burrow into the upper layer of the skin, where they lay eggs and cause a rash and intense itching. Scabies is also treated with topical insecticides.

Characteristics of the Organisms Causing Genital STDs

STDs are infections that can be acquired through sexual contact. Genital STDs have at least two special characteristics. First, the microbes causing genital STDs are not normal residents of the human urogenital tract. Second, STD microbes are especially dependent on sexual contact for transmission (Corigliano & Alvero, 2009b).

Non-STD urogenital infections usually do not have these two characteristics. For example, Candida albicans causes vaginitis (a yeast infection), and it can sometimes be transmitted sexually; nonetheless, candida is not usually categorized as an STD. This is because candida is normally found in the human urogenital tract, where it is a normal inhabitant of the vagina (as well as the rectum and the mouth). Candida is such a ubiquitous organism that it is very difficult to completely eradicate from an individual. Moreover, sexual contact is not usually involved in the development of candidal vaginitis, which also develops regularly in celibate women (Edwards JE, 2008; Corigliano & Alvero, 2009a). Instead, the development of candidal vaginitis is triggered by changes in the chemical balance of the vagina, allowing an overgrowth of candida.

STDs tend to be finicky, and they thrive in only limited environments. Their dependence on sexual contact derives from:

• The nature of sexual contact, in which warm, moist skin and mucous membranes are rubbed together.
• The potential porousness of the contacting body surfaces, which easily acquire small abrasions, cuts, tears, or fissures.

Coexistent Genital Infections

Besides STDs, genital infections can be caused by a range of non-STD organisms that should also be considered when determining a diagnosis. These other organisms include actinomycetes, Haemophilus spp., Staphylococcus aureus, Enterobacteriaceae, group A and group B streptococci, Candida spp., Gardnerella, Ureaplasma urealyticum, and a variety of anaerobes (Gill et al., 2005). Patients can, of course, concurrently have a genital STD and a non-STD infection.

The presence of one STD makes the coexistence of another STD more likely. For example, gonorrhea and chlamydia are found together so often that a patient diagnosed with gonorrhea is routinely treated for chlamydia with no other supporting evidence (Rein, 2008).

STD clinics and other medical facilities that specialize in treating STDs should remember that typical STD symptoms can be caused by non-STD organisms and that the identification of one STD does not rule out the concurrent existence of other STDs or non-STD infections.

GENERAL DIAGNOSIS AND SYMPTOMS

Worrisome symptoms usually send patients to a doctor, and since people with sexually transmitted infections often have symptoms, they will seek medical care. On the other hand, many sexually transmitted infections are asymptomatic. Typically, asymptomatic people seek care only when they have been advised by someone else to see a doctor. This advice may come as a result of a routine screening test that suggests that the person has an asymptomatic STD. Another common source of the advice to see a doctor is when a person's sexual partner is diagnosed with an STD.

Whether symptomatic or asymptomatic, a patient's medical care begins the same way. For a person with a possible STD, the initial work-up has these three parts:

• History. The medical care of a person with a possible STD begins with a medical history that puts extra emphasis on assessing the patient's risk of having a sexually transmitted infection.
• Physical Examination. When a patient may have a genital STD, their anogenital region is examined thoroughly, and when appropriate, their mouth and pharynx is also examined.
• Laboratory Tests. With STDs, clinical judgment can often make an educated guess as to the infectious agent, but lab tests (microbiological or serological) are usually needed for a definitive diagnosis (Holmes, 2008).

History

The medical history begins with a chief complaint and then describes the nature and time course of this problem.

THE CHIEF COMPLAINT

When they have symptoms, people with genital STDs usually present complaining of discharges or dermatologic lesions. The discharges can come from the urethra, the vagina, or occasionally the rectum. The dermatologic lesions can cause pain, tenderness, bumps, or itching in the inguinal or anogenital region. Some genital STDs will also cause swollen and tender inguinal lymph nodes. Most genital STDs do not produce a fever or other systemic symptoms. In addition, genital STDs can cause discomfort on intercourse, urination, or defecation.

QUESTIONS TO ASK

The medical history will often point toward the cause of the patient's problem. For any complaint, it is important to ascertain:

• A complete description of the problem
• Whether there are additional symptoms
• When the problem began, and if the beginning correlated with an illness, injury, or another event in the patient's life
• The ups, downs, and changes in the symptoms since their beginnings
• What the patient has tried to do to relieve the symptoms and whether these attempts have helped
• Whether other people around the patient have similar symptoms
• Whether the patient has ever had this problem before
• What the patient thinks may be the cause of their problem

For genitourinary complaints, these specific questions often generate useful diagnostic information:

• Has the patient had itching or pain in the perineum or inguinal region?
• Has the patient noticed sores, bumps, or warts in the anogenital region?
• Has the patient had unusual discharge from the penis, urethra, vagina, or anus?
• Does the patient have burning, itching, or other discomfort when urinating?
• Does the patient's urine contain blood or have an unusual color or odor?
• Is the patient sexually active?
• Does the patient have pain or other discomfort during intercourse?
• What birth control methods does the patient use?
• For men, is there pain or an unusual mass in the scrotum?
• For women, is there bleeding between periods or after intercourse?
• For women, is it possible that they are pregnant? (Lentz, 2007a)

When the patient's presenting complaint involves the perineum, genitals, reproductive tract, urinary tract, rectum, or anus, the medical history should include a more detailed sexual history than usual. A thorough sexual history can go a long way toward making the diagnosis of a sexually transmitted infection (Lentz 2007a).

A detailed sexual history should include answers to:

• Are you sexually active with men, women, or both?
• Have you had sexual contact in the past month? With how many different people? In the past three months? With how many different people?
• Have you had oral sex in the past month—as recipient, giver, or both?
• Have you had anal sex in the past month—as recipient, giver, or both?
• Have you used any sex toys or sex aids in the past month?
• Have you used any protective methods in the past month?
• Have you ever had sexual contact without protection?
• Have you ever had an STD?
• Do you know if any of your sexual partners have ever had STDs?

THE INTERVIEW SETTING

Talking to patients about their sexual life can feel intrusive to them. It can be especially uncomfortable for adolescents. This discomfort can be eased by taking the history in a private setting where the patient does not feel that someone else might overhear the conversation. Ideally, the patient can be clothed during the initial interview to reduce the vulnerability they feel when wearing an examination gown (Kingsberg, 2006).

More importantly, the interviewer should be supportive and nonjudgmental yet straightforward and honest. Also, the interviewer should be certain to take sufficient time to listen. Teenagers, like other patients, emphasize that in sexual interviews they would most like the doctor or nurse to listen carefully to them, even in the hurried environment of an emergency department or urgent care clinic (Miller et al., 2007).

It is helpful to remember three important principles:

• Spend time alone with the patient
• Explain the confidentiality of the entire medical visit, from interview through treatment
• Ask about and listen carefully to the patient's concerns (Miller et al., 2007).

The sexual interview is difficult for the patient, but it can also be uncomfortable for the interviewer. Primary care providers should look at their own feelings honestly, because ideas and attitudes that they hide can still affect their practice. It has been shown that practitioners who are uncomfortable caring for prostitutes, drug users, or homosexuals provide worse healthcare for patients with STDs (Khan et al., 2008).

Physical Examination

When the presenting complaint is genital, the physical examination of the inguinal and anogenital region should be thorough. Gloves are required, and good illumination is important. In addition, a hand lens is often helpful.

GENITAL EXAMINATION OF A FEMALE

For genital exams, the examiner should always explain in detail what will be happening. Male doctors should have a female assistant such as a nurse with them during the exam.

Begin the exam by closely inspecting the anogenital area. This is difficult when the woman is sitting on the exam table, even when she is at a 45-degree angle, so it is usually best for the patient to be lying on her back. The lithotomy position with the patient's legs in stirrups gives the best view of the entire perineum.

Use the genital exam as an opportunity to educate the patient about her anatomy and physiology. Offer to raise the head of the exam table, and give the patient a hand mirror so that she can see what you are describing.

First, study the pubic hair, looking for evidence of lice or mites. Then, examine the skin from the front (the mons pubis) to the back (the perianal region and between the buttocks), looking for redness, cuts, ulcers, vesicles, warts, and scratches (excoriations).

Now examine the urethral opening (meatus), and palpate and milk the urethra, taking a specimen of any exuded mucus or pus. Feel for tender or enlarged Skene's glands and Bartholin's glands. Check for enlarged or tender inguinal lymph nodes.

After palpation, do a speculum exam. (See box, "Omitted or Deferred Speculum Exams" below.) First, look at the vaginal walls and take samples of exudates or secretions. Next, inspect the cervix. When appropriate, take a Pap smear and swab the endocervical canal for samples of discharge to send to the lab. After removing the speculum, bimanually palpate the cervix, uterus, and adnexa. Lastly, with a fresh glove, palpate the rectal canal (Lentz, 2007a).

GENITAL EXAMINATION OF A MALE

There is no standard position for examining the anogenital region of a male. However, the anterior inguinal region, penis, scrotum, and pubic area are best examined with the patient standing facing the physician, who is seated on a low stool. The perianal region and the areas between the buttocks are best examined with the patient bending forward (supported by the exam table) and the physician seated on a low stool behind the patient.

Begin by inspecting the skin of the inguinal region, genitals, and perineum, looking for redness, cuts, ulcers, vesicles, warts, and scratches (excoriations). Also, palpate the inguinal areas for enlarged or tender lymph nodes.

Next, examine the glans of the penis, pulling back the foreskin when it is present. Take a swab of the inner urethral walls and send it to the lab. Palpate the penis for tenderness, which, among other things, can be a symptom of urethritis or periurethritis. Look in the pubic hair at the base of the shaft of the penis for evidence of lice or mites.

Now, examine the skin of the scrotum. Then, gently palpate each testis for swelling, tenderness, or internal hard spots or densities.

Finally, have the patient bend over the exam table. Inspect the perianal area and the skin between the buttocks. With a fresh, lubricated glove, palpate the prostate digitally for tenderness, fluctuant areas, general enlargement, irregularities, or hard spots and densities (Gerber & Brendler, 2007).

Diagnostic Laboratory Tests

The history and the physical exam will usually lead to a small list of possible diagnoses for a sexually transmitted disease. Definitive diagnoses and diagnoses of infections in asymptomatic people require laboratory tests. When sending a sample to the lab, the physician or nurse should indicate the most likely diagnoses. When possible, the sender should also suggest specific tests that they would like the lab to carry out (Gill et al., 2005; Greer & Wendel, 2008).

THE ADVANTAGE OF RAPID TESTS

To prevent the spread of STDs, it would be ideal to be able both to diagnose and to treat the diseases during the same visit. This immediacy safeguards against patients not returning for a second visit. It also reduces the time during which patients are infective.

Definitive lab diagnoses are the steps that slow treatment. Many standard tests, such as cultures of organisms, require more than a day to produce results, and when using these tests, patients must return for a second visit to learn the diagnosis and to receive treatments.

Efforts are being made to devise faster lab tests. Currently, rapid tests that can be done in a clinic in less than thirty minutes are available for syphilis, gonorrhea, chlamydia, HIV, and genital herpes. The high cost of some of these rapid tests, however, makes them difficult to use for large-scale screening programs (Greer & Wendel, 2008).

COLLECTING TEST SAMPLES

The laboratory should be asked in advance for written instructions on specimen collection, storage, and transport. These requirements should be reviewed and understood by the primary care providers; and sufficient swabs, blood drawing equipment, and containers should be available in the examining rooms.

In testing for genital STDs, specimens are usually taken on swabs from the cervix, urethra, vagina, anal canal, or skin lesions. In addition, blood samples, urine samples, or samples of vaginal or urethral discharge can be taken. It is important to provide sufficient sample material for the tests, and when more than one test is requested (eg., microscope slides and cultures or simultaneous tests for two different infectious agents), more than one swab of each sample should be sent.

Most swab and discharge specimens for STD testing need to be packaged in media or containers appropriate for the suspected organism, and these specimens should then be sent to the lab as soon as possible. Therefore, appropriate containers need to be on hand for all examinations. For urine samples, the amount needed and the storage conditions both depend on the particular test being used, so the examiner needs to have guidelines available ahead of time.

PREGNANCY TESTING

Beyond tests for a range of STDs and non-STD infections, specific situations will call for additional lab tests. For instance, when treating a woman for an STD, as for many other medical conditions, it is important to know if she could be pregnant. Therefore, a urine pregnancy test is commonly added to other STD tests for women in their reproductive years.

Common Presenting Syndromes of Genital STDs

Sexually transmitted infections give rise to a range of anogenital and lower urinary tract diseases. The signs and symptoms of these diseases cluster into about eight clinical syndromes. These are:

1. Genital itching
2. Genital ulcers
3. Genital warts
4. Urethritis
5. Vaginal and cervical infections
6. Epididymitis
7. Pelvic inflammatory disease
8. Anorectal infections

Here is a brief overview of each of these presentations.

GENITAL ITCHING

One manifestation of genital STDs is the new appearance of genital itching. When patients complain of itching, they sometimes include the sensations of irritation, prickling, or crawling. A new onset of genital itching can signal an infection (Corigliano & Alvero, 2009c; Ferri & Wachtel, 2009); however, in women, mild itching, irritation, or inflammation of the external genital area, vulva, or vaginal vestibule more often results from dermatitis than an infection (McCormack, 2005).

The common STDs that cause genital itching include genital herpes, genital warts, molluscum contagiosum, pubic lice, scabies, and other STDs that cause urethritis or vaginitis. Of these, pubic lice and scabies tend to cause the most intense itching (Augenbraun, 2005).

Anogenital infections that are not STDs also cause itching. Common examples are bacterial vaginosis, group B streptococci, pinworms, Staphylococcus aureaus, and yeast infections (Candida spp.). Moreover, acute anogenital itching can be caused by problems other than infections, such as irritation of the anogenital skin, an allergic reaction to something that contacts the anogenital skin, and chronic skin diseases. Therefore, even in an STD clinic, a broad set of causes should be considered when evaluating a complaint of anogenital itching.

When evaluating genital itching, the medical history will usually give important clues, but a careful, methodical examination of the pubic hair, skin, and mucous membranes is necessary for a diagnosis.

Nonspecific treatments can be given to relieve the itching temporarily; however, any underlying infection should be diagnosed and treated (Edwards L, 2008).

GENITAL ULCERS

Genital ulcers are sores on the skin or mucous membranes; if caused by an STD, the ulcers are usually shallow. In women, ulcers from STDs can also be found on the lining of the vagina and on the surface of the cervix. In both genders, oral sex can lead to ulcers of the lips and mouth, especially from HSV or syphilis (Rein, 2008).

In the United States, most genital ulcers are caused by one of three infectious agents: herpes simplex virus, Haemophilus ducreyi, and Treponema pallidum. Each microbe is associated with a different typical presentation (Augenbraun, 2005).

• Herpes simplex virus causes genital herpes. In genital herpes, the skin ulcers are typically very shallow erosions that follow the rupture of tender vesicles or blisters. The ulcers are painful and tender and are often found in clusters. As they heal, herpes ulcers become crusty. Genital herpes is a common STD.
• Haemophilus ducreyi is the bacterium that causes chancroid. In chancroid, the skin ulcers are variable in size with ragged edges and with a grayish, purulent, necrotic inner base. The ulcers are painful and tender, and they are preceded by painful papules. Chancroid often produces groups of ulcers.
• Treponema pallidum is the bacterium that causes syphilis. In syphilis, the skin ulcers are round with a firm (indurated) rim and a smooth base. Syphilitic ulcers are painless and nontender, and most often only one ulcer—called a chancre—is present.

These are the characteristic presentations of the three most common ulcerative genital STDs, but there can be considerable variation. When identifying the cause of genital sores, it is important to remember that more than one type of microbe can simultaneously be causing the lesions (Frenkl & Potts, 2007).

Infections are the most common causes of genital ulcers. Other causes include chemical burns, mechanical trauma, skin diseases, neoplasms, and immune reactions (Augenbraun, 2005).

Some form of lab testing is usually needed for a definitive diagnosis of a case of genital ulcers (Augenbraun, 2005; Holmes, 2008); however certain presentations of genital ulcers can be diagnosed clinically as genital herpes. When genital ulcers are present, syphilis and HIV testing should be included in the lab work. While awaiting definitive lab results, genital ulcers are frequently treated based on the tentative clinical diagnosis (Holmes, 2008).

GENITAL WARTS

Genital warts are also called condyloma acuminata or venereal warts. Genital warts are pink or flesh-colored growths on the skin or mucous membranes of the anogenital region—the groin, thigh, penis, scrotum, vulva, vagina, cervix, and perianal areas. The warts can take many different forms, from tiny flat "tags" to wrinkled papules to masses that look like small cauliflowers.

Although genital warts are usually asymptomatic and nontender, they can itch or burn; when rubbed, they can get irritated and sometimes bleed. Most genital warts will eventually disappear without treatment, but the general practice is to remove them.

Genital warts are caused by certain forms of the human papillomavirus (HPV). HPV infections are common, and they can be sexually transmitted even when an infected person has no visible signs of an infection. More than forty types of HPV infect humans. The HPV forms that cause genital warts seem to cause no other serious symptoms. Other forms of HPV are more dangerous, however, and some types of HPV occasionally cause or facilitate the development of cervical cancer.

URETHRITIS

Infections of the urethra do not always present symptoms. When symptoms are present, they include a whitish-yellowish mucus discharge from the urethra, and on urination, there can be pain, irritation, or itching. In women, when these symptoms occur in combination with urinary urgency or frequency, there is often a concurrent bladder infection.

STDs cause some of the common forms of urethritis. The classical presentation of gonorrhea is as urethritis, and infectious urethritis has been traditionally divided into gonococcal and nongonococcal urethritis (NGU) (Krieger, 2008). In the United States and other parts of the developed world, nongonococcal is more common than gonococcal urethritis. However, in patients of urban American STD clinics, gonorrhea can be the most common cause of urethritis.

Chlamydia trachomatis is the STD that causes most cases of NGU. Two other bacteria, Ureaplasma urealyticum and Mycoplasma genitalium, are also common causes of NGU. It is not clear to what extent these latter infections are sexually transmitted, and urethritis due to U. urealyticum or M. genitalium is not usually classified as an STD. Other STDs that sometimes cause urethritis are trichomoniasis and primary HSV infections (McCormack & Rein, 2005).

To definitively diagnose the cause of urethritis, urethral discharge must be examined microscopically or with specific lab tests (Holmes, 2008). Samples of discharge are obtained either by expressing the discharge from the urethra or by swabbing the inner walls of the urethra. (Urination will temporarily wash the discharge from the urethra; therefore, recent urination can defeat an attempt at obtaining a discharge sample.) To identify the organism causing a case of urethritis, the discharge sample can be spread on a microscope slide and stained, subjected to microbiologic tests, or cultured.

Both bacterial and protozoal urethral infections are treated with oral antimicrobials. Sexual partners of patients with urethritis should also be treated, even when the partner is asymptomatic.

VAGINAL AND CERVICAL INFECTIONS

In women, lower genital tract infections—vaginitis and cervicitis—typically produce a vaginal discharge, irritation of the vulvae, and sometimes a bad odor. There can be pain or discomfort during urination or during intercourse, and there is occasional postcoital bleeding. On the other hand, many, and perhaps most, infections of the vagina and cervix are asymptomatic (MacKay, 2009).

The STDs that most commonly cause vaginitis or cervicitis are chlamydia, gonorrhea, trichomoniasis, and HSV. Common non-STD infections causing vaginitis or cervicitis include yeast infections (Candida spp.) and overgrowths of normal bacterial flora.

As a general principle, a pelvic exam is recommended for diagnosing lower genital tract infections in women. Vaginitis will produce reddened, edematous vaginal walls with exudate. Cervicitis appears as a reddened edematous cervix with purulent, yellowish exudate, and gently rubbing a cotton swab in the cervical os will produce bleeding. Definitive diagnoses usually require examining and testing swab specimens of exudate or discharge. When the cause of the signs and symptoms is an infection, the examination of a Gram stain of the exudate will show ten or more polymorphonuclear leukocytes per microscopic field at 1,000-times magnification (Rein, 2008).

Normally, the cervix is an effective barrier between the bacteria-filled vagina and the microbe-free upper genital tract (uterus and Fallopian tubes). Cervical infections, however, can infiltrate the uterus and lead to pelvic inflammatory disease (Holmes, 2008).

Sexually Transmitted Bacteria That Cause Vaginitis Or Cervicitis

Chlamydia trachomatis and Neisseria gonorrhoeae can cause mucopurulent cervicitis. Typically, neither infection produces a particularly bad odor in the vaginal discharge.

Although chlamydial infections are common, in 40 to 60% of women with mucopurulent cervicitis, no pathogenic bacteria are found in the cervical exudate. To prevent PID and to slow the transmission of STDs, it is recommended that certain patients be treated for bacterial cervicitis solely on clinical criteria. The CDC (2006b) recommends treating at-risk women (i.e., those under 25 years old, with new or multiple sex partners, or having unprotected sex), if they have clinical signs and symptoms of bacterial cervicitis.

Sexually Transmitted Viruses That Cause Vaginitis Or Cervicitis

During the primary infection, and sometimes during recurrent outbreaks, herpes simplex viruscan cause cervicitis that includes vesicles and ulcers. There is usually no mucopurulent exudate with herpes cervicitis.

Sexually Transmitted Protozoa That Cause Vaginitis Or Cervicitis

Trichomonas vaginalis infections can produce a profuse, frothy, and purulent (yellow or yellow-green) discharge that has a "fishy" odor. This exudate is sufficiently copious that it will usually be seen at the vaginal opening before a speculum examination. As with candidiasis, trichomoniasis often irritates the vulvae, causing an itching or burning sensation.

In a speculum exam, the vaginal walls and cervix appear reddened in trichomoniasis. Occasionally, the cervix has pinpoint hemorrhages, making it look like a strawberry. Rapid lab tests for trichomoniasis allow a definitive diagnosis on the first visit, and oral, single-dose drugs can be given at the time of diagnosis.

EPIDIDYMITIS

The epididymis is a coiled tube that caps each testis and in which sperm mature and attain the capability of fertilizing ova. Infections of the epididymis produce unilateral pain and swelling of the scrotum (Dewar, 2007). Epididymitis arises when untreated urethritis spreads back through the male genital system, and the same microbes causing urethritis also cause epididymitis. The most common STD causing epididymitis in young sexually active men is chlamydia; gonorrheal epididymitis infections are less common. Bacterial epididymitis is treated with antibiotics (Holmes, 2008).

UPPER FEMALE GENITAL TRACT INFECTIONS: PID

Infections of the upper female genital tract—the endometrium and Fallopian tubes—are usually grouped under the umbrella term pelvic inflammatory disease (PID), a condition that can also include infection of the surrounding peritoneum. Upper genital tract infections do not always produce dramatic symptoms, but there is usually lower abdominal tenderness, cervical tenderness, and tenderness of the adnexa when palpated bimanually. Sometimes, PID will produce a fever (greater than 38.3°C), an elevated white blood cell count, an elevated erythrocyte sedimentation rate (ESR), or elevated C-reactive protein (CRP) in blood tests. PID can lead to infertility, tubo-ovarian abscesses, and ectopic pregnancies (Eckert & Lentz, 2007b; Bagley & Trent, 2008; Rein, 2008).

A discussion of infections of the upper female genital tract is beyond the scope of this course; nonetheless, the specter of PID looms over many STDs in women. PID often results from untreated lower genital tract STDs, notably chlamydial infections and gonorrhea. PID can also be caused by infectious agents that are not primarily transmitted sexually.

ANORECTAL INFECTIONS

Anal intercourse can transmit infections that lead to proctitis in the receptive partner. Proctitis is an infection of the anorectal walls. It produces anorectal pain, irritation, and itching; rectal discharge (mucopurulent and bloody); and tenesmus, the feeling of incomplete rectal evacuation and the frequent urge to defecate. If the infection invades farther, it can cause proctocolitis, which adds the symptoms of diarrhea and abdominal cramps (Nelson, 2008; Nelson & Cima, 2008).

In a patient with proctitis, anoscopy, sigmoidoscopy, or colonoscopy will show local inflammation and exudate, and the intestinal walls will bleed when gently swabbed. For a specific diagnosis, the exudate must be sampled and tested for evidence of infection. In both men and women, the most common STDs causing anorectal infections are Chlamydia trachomatis, Neisseria gonorrhoeae, and HSV.

Besides proctitis, anorectal STDs include HPV infections, which cause anogenital warts (condyloma acuminata) or, rarely, anorectal cancers (Dewar, 2007).

DIAGNOSIS AND RECOMMENDED TREATMENT OF COMMON STDs

Most STDs are a threat to both the health of the patient and the health of the community, and treatment is always recommended.

STDs present with a variety of syndromes, but their treatment depends on the specific agent causing the problems. STDs can be caused by organisms across the full spectrum of infectious agents, including bacteria, viruses, protozoa, and external parasites (exoparasites). Following are the current recommended treatments for common genital STDs.

The drugs and administration regimens offered below are examples of common recommendations, but actual treatments must be tailored to the specific patient. Changes in the standard recommendations are continually reported by the CDC at http://www.cdc.gov/std/treatment/.

Chancroid

Chancroid is caused by the bacterium Haemophilus ducreyi and is an STD that produces ragged genital ulcers. H. ducreyi are small, Gram-negative, rod-shaped bacteria that grow in chains or strands (Murphy, 2008).

EPIDEMIOLOGY OF CHANCROID

Chancroid is one of the most common STDs in the Third World, and it is found widely throughout Africa, Asia, South America, and the Caribbean. Chancroid tends to be most common in areas with a high prevalence of HIV infections.

In the United States, fewer than forty cases a year are reported in the latest CDC statistics (CDC, 2007a). Because H. ducreyi is difficult to culture and diagnose, it is estimated that the actual yearly number of cases of chancroid is a few thousand. Chancroid cases are found in clusters that occur in situations associated with prostitution, illegal drug use, and HIV infections. Recently, small chancroid outbreaks have been reported in California, Florida, Georgia, Louisiana, Mississippi, and New York (CDC, 2007a; Eckert & Lentz, 2007a; Frenkl & Potts, 2007).

DIAGNOSIS OF CHANCROID

Typical Course and Clinical Signs

H. ducreyi cannot invade normal intact skin. Therefore, people become infected when the bacteria are rubbed into skin cuts or abrasions. These small skin injuries can themselves be the result of sexual contact, and the susceptible injured skin is usually on the penis or the vulvovaginal surfaces.

Three to six days after the bacteria penetrate the injured skin, a surface papule develops. The papule becomes a pustule that then ruptures to form a painful, friable, soft ulcer. Chancroid ulcers have a bad odor, a necrotic, grayish, or yellowish ("dirty") purulent base, and irregular edges. Chancroid ulcers can be quite painful (Eckert & Lentz, 2007a; Frenkl & Potts, 2007; Murphy, 2008).

A number of chancroid ulcers along the shaft and on the glans of the penis. (CDC, 2008d.)

A patient can have more than one chancroid ulcer, and these ulcers can be small or can merge into a single large sore. Ulcers inside the vagina or on the cervix can be painless and go unnoticed by patients. Half of the chancroid patients develop large tender inguinal lymph nodes that can become fluid-filled and that sometimes rupture (Eckert & Lentz, 2007a).

The combination of painful genital ulcers and tender, fluctuant inguinal lymph nodes should put chancroid on the list of a patient's possible diagnoses. However, the specific presentation of chancroid varies from patient to patient, and it cannot always be distinguished by clinical appearance from syphilis or genital herpes.

Lab Tests

Clinical appearance is not a reliable way to diagnose chancroid. Sometimes, a light microscopic examination can be diagnostic; in chancroid, a stained smear of lesion exudate will show many short strands of H. ducreyi—small Gram-negative coccobacilli. Most times, however, definitive diagnosis depends on culturing the bacteria, which requires specialized culture media (Eckert & Lentz, 2007a; Frenkl & Potts, 2007; Murphy, 2008).

Patients with chancroid lesions may have concurrent genital herpes. Chancroid patients should also be tested for syphilis and HIV.

TREATMENT OF CHANCROID

Chancroid responds to antibiotics. As with all STDs, compliance is best assured by giving the full treatment in a single dose (CDC, 2006b; Eckert & Lentz, 2007a; Frenkl & Potts, 2007; Murphy, 2008).

After taking antibiotics, chancroid patients should notice subjective improvement within three days, and patients should be clinically re-examined five to six days after the antibiotic regimen.

Chancroid ulcers will usually heal completely. Most ulcers heal within a week, although large ulcers can take a month to heal; the glans on uncircumcised males tends to heal more slowly. Patients with HIV also heal slowly and may require a longer course of antibiotic.

The antibiotic susceptibility of H. ducreyi has been found to vary geographically. When chancroid ulcers do not heal, bacterial cultures should be tested to identify the most effective antibiotic. Nonhealing ulcers may also be due to the presence of other infectious agents.

Occasionally, chancroid patients develop large, fluctuant lymph nodes, called buboes. These swell and become painful, and they can be drained by incision.

Treating Sexual Partners

Men with chancroid have usually been infected by heterosexual contact with prostitutes. All people who have had sex with chancroid patients during the two weeks preceding the appearance of genital lesions should be identified and treated, even when those sexual partners are asymptomatic (Eckert & Lentz, 2007a; Frenkl & Potts, 2007). Vigorously treating H. ducreyi infections is one factor in the battle against AIDS, because chancroid lesions make a person more susceptible to acquiring HIV infections.

Chlamydial Infections

Chlamydial urethritis, cervicitis, and PID are cause by the bacterium Chlamydia trachomatis. Chlamydia are parasitic bacteria that can only survive inside cells. The species C. trachomatis comprises a number of substrains, which are identified by the letters A through L. DNA-based antibody tests are used to definitively identify Chlamydia trachomatis and to distinguish substrains (Frenkl & Potts, 2007).

EPIDEMIOLOGY OF CHLAMYDIAL INFECTIONS

Of the reportable diseases, chlamydial infections are the most common STDs in the United States (Corigliano & Alvero, 2009c). (Not all STDs are reportable and tallied nationally by the CDC; see box "Statistical Monitoring" above.)

Chlamydial infections are most prevalent among sexually active teens and young adults. Overall, 5 to 15% of women aged 14 to 25 years have chlamydial infections at any one time. Chlamydial infections are most common in women between the ages of 15 and 24. High-risk populations (such as young women visiting public health clinics and young African American women) have infection rates of 10 to 30%. Reinfection is common: one study found that half the women had been reinfected within a year after being treated (Niccolai et al., 2007). In young men, chlamydial infections are the most common cause of epididymitis.

Each year, more than a million cases of chlamydia are reported in the United States. Because most cases are undiagnosed, the actual yearly total of new cases has been estimated to be 2.8 million. For women, screening for asymptomatic cases is important, because 40% of untreated chlamydial infections develop into pelvic inflammatory disease (CDC, 2007a).

DIAGNOSIS OF CHLAMYDIAL INFECTIONS

Typical Course

Chlamydial infections are sexually transmitted, and they produce genital or lower urinary tract infections. After a person acquires a chlamydial infection, there is a 1- to 3-week incubation period before the organism produces symptoms, but about half of infected men and more than three-quarters of infected women remain asymptomatic.

In men, symptomatic chlamydial infections show up as urethritis or epididymitis.

In women, symptomatic chlamydial infections show up most often as cervicitis (mucopurulent). When untreated, chlamydial cervicitis can spread and cause pelvic inflammatory disease (PID), which can then lead to infertility or ectopic pregnancies (Corigliano & Alvero, 2009b).

During vaginal births, pregnant women can pass chlamydial infections to their newborns. The resulting infection can cause pneumonia or conjunctivitis in the infant.

Women who have chlamydial infections are six and a half times more likely to develop cervical cancer than women without the infection.

Clinical Signs

Chlamydial urethritis produces a gray, white, or yellow discharge, pain on urination, and urethral itching. Men sometimes also get epididymitis, with pain and swelling around a testicle.

Chlamydial cervicitis produces a gray, white, or yellow vaginal discharge, pain on urination or during intercourse, and vaginal bleeding after intercourse or between periods. Alternately, chlamydial cervicitis sometimes gives no other findings than a friable cervix on speculum examination.

Chlamydia and gonorrhea can appear clinically similar, and lab tests are needed to distinguish them. It is also common for people to have both infections simultaneously. (Corigliano & Alvero, 2009b)

Cervical os with a chlamydial infection (speculum view). Chlamydial cervicitis produces a whitish discharge and an edematous, friable cervix. If untreated, this will sometimes progress to pelvic inflammatory disease. (PHIL, 2008.)

Lab Tests

Chlamydia is most accurately diagnosed using nucleic acid amplification tests (NAATs). Chlamydia testing was formerly done by culturing the organism or by using antigen matching, but NAATs have been found to detect twice as many asymptomatic infections as the earlier methods. NAAT assays that will detect and distinguish both N. gonorrhea and C. trachomatis are commonly available (Handsfield & Sparling, 2008).

Chlamydia grows inside human cells, and to be certain that test samples will give accurate results, the samples should contain mucosal cells. Cell samples can be obtained by rubbing a slightly abrasive swab (Dacron, rayon, or calcium alginate) along the urethra or the endocervix. A sample of only the discharge will not always provide sufficient Chlamydia trachomatis for a diagnosis.

A NAAT using PCR technology is a sensitive and noninvasive way to use urine samples to screen men and women for chlamydial infections. Gonorrhea has a presentation that is clinically similar to chlamydia, and the diagnostic procedures that are used to identify chlamydia should also include tests for gonorrhea (Shoemaker et al., 2007).

TREATMENT OF CHLAMYDIAL INFECTIONS

Oral antibiotics are the standard treatment for chlamydial infections, with cure rates of approximately 95% (Eckert & Lentz, 2007a; Corigliano & Alvero, 2009b). Patients with chlamydial infections should not have sexual intercourse until a week after the beginning of their treatment regimen (CDC, 2006b).

Treating Sexual Partners

For chlamydial infections, the patient's sexual partners should be tested and, if appropriate, treated for any STDs. Ideally, the partners should be medically evaluated in person; however, this is not always feasible. When it is possible that the sexual partners will not get treatment, patients can sometimes be enlisted to deliver antibiotic therapies as medicines or prescriptions. Studies have shown that patient-delivered therapy is more effective than having the patients simply advise their sexual partners to seek medical evaluation (Hodge et al., 2008).

PREVENTING THE RECURRENCE AND SPREAD OF CHLAMYDIAL INFECTIONS

Educating Patients

The doctor or nurse's best opportunity to prevent the recurrence of a chlamydial infection is at the time of the patient's diagnosis. Health workers should explain to the patient that barriers (eg., condoms) are needed to protect against this and other STDs and that other birth control methods will not prevent STD infections. Patients should also be reminded that if their partners are not monogamous, then STDs can enter the relationship between two previously uninfected people (Bamberger, 2008).

Healthcare providers should describe the long-term risks of chlamydial infections. To both men and women, it should be emphasized that untreated chlamydial infections can lead to PID in women, with the possible consequence of infertility. Patients should also be told that, although antibiotics will cure them, there is a high risk of reinfection; therefore, patients should return to the clinic or office to be retested in 3 to 4 months.

Screening for Chlamydia

Chlamydial infections are frequently asymptomatic, but even asymptomatic infections can lead to PID in women. Therefore, the U.S. Preventive Services Task Force (USPSTF, 2007) recommends yearly chlamydia screenings for:

• All sexually active young women aged 24 years or younger
• Women older than 24 years who are at increased risk of STDs (eg., women with new sexual partners or with more than one sexual partner)

Routine screening has been shown to reduce the number of cases of PID. To make widespread screening practical, urine specimens and self-obtained vaginal swabs can be used because they provide effective samples for chlamydia screening tests (Wiesenfeld et al., 2001; Miller et al., 2007; Niccolai et al., 2007).

Gonorrhea

Neisseria gonorrhoeae is the bacterium that causes gonorrhea, an STD producing urethritis or cervicitis. N. gonorrhoeae, sometimes called gonococci, are Gram-negative, aerobic, paired cocci (i.e., diplococci) (Bamberger, 2008; CDC, 2008a).

EPIDEMIOLOGY OF GONORRHEA

Four- to five-tenths of one percent of young American adults aged 18 to 26 years have gonorrhea. This means that the prevalence of gonorrhea is about one-tenth the prevalence of chlamydial infections, which are the STDs that most commonly cause urethritis and cervicitis. Gonorrhea and chlamydia often co-exist, and as many as 45% of patients with gonorrhea have a concurrent chlamydial infection.

In the United States, gonorrhea is most prevalent in the South, although it has been increasingly seen in the West. In 2006, approximately 360,000 cases of gonorrhea were reported, a rate of 121 cases per 100,000 people (Bamberger, 2008; Handsfield and Sparling, 2008).

Rates of occurrence of new cases of gonorrhea are approximately the same in men and women. Men, however, are less easily infected from a single sexual encounter: a man has a 20% chance of acquiring gonorrhea from an infected woman, whereas a woman has a 50% chance of acquiring gonorrhea from an infected man. The rate of occurrence of new cases of gonorrhea among blacks is eighteen times the rate among whites (CDC, 2007a).

DIAGNOSIS OF GONORRHEA

Typical Course and Clinical Signs

Gonorrhea is an infection of mucous membranes that have been in direct contact with an infected person. After the initial exposure, gonorrhea takes two to five days to produce symptoms (Bamberger, 2008).

In men, N. gonorrhoeae causes gonorrheal urethritis, which is nicknamed "the clap." Most men with gonorrheal urethritis have symptoms, which include pain or discomfort on urination and a purulent urethral discharge. In men, untreated gonorrheal urethritis can develop into epididymitis.

In women, N. gonorrhoeae that have invaded the urethral opening produce gonorrheal urethritis, and N. gonorrhoeae that have invaded the vagina produce gonorrheal cervicitis. Most women with urethral or cervical gonorrhea have mild or no symptoms. When symptoms do occur, they can include purulent vaginal discharge (Eckert & Lentz, 2007a; Bamberger, 2008), vaginal bleeding after intercourse, and pain or discomfort on urination. Gonorrhea can also infect the Bartholin's glands. Untreated gonorrheal cervicitis sometimes ascends into the uterus and leads to PID, which typically presents with lower abdominal pain. On speculum examination, gonorrheal cervicitis appears as a swollen, friable cervix with a mucopurulent exudate. 

Approximately 40% of women with gonorrheal cervicitis also develop gonorrheal proctitis because the disease can spread from the vagina even when there has been no anal intercourse (Handsfield & Sparling, 2008). From anal or oral intercourse, both men and women can get gonorrheal proctitis or pharyngitis. Gonorrheal proctitis and gonorrheal pharyngitis tend to be asymptomatic.

Fewer than 3% of patients with a gonorrheal infection develop gonorrheal bacteremia with fever and, occasionally, septic arthritis.

Gonorrhea and chlamydial infections are difficult to distinguish clinically. Traditionally, a gonorrheal discharge has been said to be more purulent than a chlamydial discharge, but this distinction is not reliable, and lab tests are needed to make a definitive diagnosis. It is also common for patients with gonorrhea to have trichomoniasis.

Discharge from the penis caused by gonorrheal urethritis. (CDC, 2008d.)

Gonorrheal infection of cervix (speculum view). Exudate, erythema, and swelling of the cervical os caused by gonorrheal cervicitis. (CDC, 2008d.)

Lab Tests

Light microscopic examination of a sample of urethral discharge can be used to diagnose gonorrhea in men. In male gonorrheal urethritis, stained microscope slides will show Gram-negative diplococci inside neutrophils (Shoemaker et al., 2007; Handsfield & Sparling, 2008).

For women, a more sensitive and specific test is needed, and nucleic acid amplification tests (NAATs) of urine or of a swab of the affected area are the preferred test techniques.

Urine samples can be used to test for urethritis in both genders. Recent urination will have washed gonorrheal discharge from the urethra; therefore, to collect sufficient discharge, urine samples should be taken at least an hour after the patient's last urination.

Vaginal swab specimens are used to test for cervicitis. Gonorrheal cervicitis produces sufficient discharge that swabs need not be taken by speculum examination; instead, they can be collected blindly by the patient herself.

For oral or anal gonorrhea, pharyngeal or rectal swabs are taken and sent to the lab for culturing. N. gonorrhoeae is a relatively fragile organism, so all swab samples must be put in the appropriate media, transported to the lab quickly, and never refrigerated.

TREATMENT OF GONORRHEA

As with many STDs, the highest rates of successful treatments come when the antimicrobial medicines can be taken in single doses administered at the time of diagnosis. For oral medicines, it is best to have the patient take the drug in the office, because people with STDs sometimes fail to fill the prescription or fail to take the drug as directed. Gonorrhea can be cured in greater than 95% of cases with single-dose, on-site treatments (CDC, 2006b; Eckert & Lentz, 2007a; Bamberger, 2008).

Cephalosporins are the only antibiotics now recommended by the CDC (2007b) for treatment of gonorrhea. Fluoroquinolones (i.e., ciprofloxacin, levofloxacin, or ofloxacin), which were previously the first-line drugs, are no longer recommended in the United States because resistant strains of gonorrhea have become increasingly common over the past decade. Updated recommendations are available at http://www.cdc.gov/std/gonorrhea/arg.

Patients with gonorrhea often have other STDs and should also be tested for HIV, chlamydia, trichomoniasis, and syphilis. They should be offered hepatitis B vaccination if they have not already been vaccinated.

Treating Sexual Partners

Most people avoid sexual contact with partners who show obvious signs of an STD. For this reason, newly infected but asymptomatic people usually have no reason to seek medical treatment unless they are told that their sexual partner was a carrier of an STD.

Clinicians and their STD patients should work together to notify the patient's recent sexual partners that they may have been infected. The sexual partners of gonorrhea patients should be tested for a range of STDs, including gonorrhea, syphilis, and HIV infection. If test results will be delayed, then the sexual partners should be treated prophylactically for gonorrhea and chlamydia during their first medical evaluation.

Many circumstances can make sexual partners' testing and treatment uncertain. One attempt to improve treatment rates is called expedited partner therapy (EPT). Here, patients with an STD such as gonorrhea are asked to deliver educational materials, advice, and medications or prescriptions to their recent sexual partners.

Research studies have shown that EPT is more effective than simply having patients advise their sexual partners to seek treatment (Hodge et al., 2008). Doctors should be aware, however, that in some states it many not be legal to prescribe medicine for patients who have not been evaluated directly.

PREVENTING THE RECURRENCE AND SPREAD OF GONORRHEA

Although treatment for gonorrhea is usually successful, 20% of treated gonorrhea patients become reinfected. Therefore, as for people with chlamydial infections, patients treated for gonorrhea are advised to return in three to six months for rescreening. In women, urine samples or self-obtained vaginal swabs can be tested without the need for a speculum examination (Bamberger, 2008).

Two subpopulations should have regular gonorrheal screenings and be counseled about the importance of using condoms:

• Sexually active women younger than 25 who have had STDs, who have new or multiple partners, who are prostitutes, who are drug users, or who do not always use condoms
• Men who have sex with men and who live in locations with relatively high rates of gonorrhea (here, the screening should be for rectal and pharyngeal gonorrhea) (Bamberger, 2008; Handsfield & Sparling, 2008)

Syphilis

Treponema pallidum is the bacterium that causes syphilis, an STD that, if untreated, can seriously damage organs throughout the body many years after the infection.

T. pallidum is a motile bacterium that is too thin to be seen in the standard Gram-stained smears used to identify Chlamydia or N. gonorrhoeae. One notable characteristic of T. pallidum is that it grows quite slowly; this makes it necessary to continue treating the infection for a relatively long period (Hook, 2008; Shah, 2008; Corigliano & Alvero, 2009d).

EPIDEMIOLOGY OF SYPHILIS

Recently, there have been about three cases of syphilis diagnosed per 100,000 people in the United States each year; all told, almost 10,000 cases of syphilis were reported in 2006. More cases of syphilis are reported in the South than in the North. Syphilis tends to be most common in large cities.

The disease is associated with people who use drugs, who have anonymous sex, or who have had more than two sexual partners in the last two months. Ethnically, syphilis is most common among African Americans, less common among Hispanics, and least common among non-Hispanic whites (CDC, 2008a).

Men are five times more likely to be diagnosed with syphilis than are women, and the peak age range for syphilis infections in men is between 30 and 45 years (Hook, 2008). Recently, the largest increase in cases of syphilis has been among men who have sex with men (CDC, 2008a).

DIAGNOSIS OF SYPHILIS

Typical Course

Syphilis is transmitted by sexual contact. It can also be passed at birth from mother to child, as the newborn rubs along the birth canal.

A syphilis infection begins locally and slowly spreads systemically. Over time, untreated syphilis will go through stages that give different signs and symptoms (Hook, 2008). Initially, a person may come to a doctor with primary syphilis (i.e., a local genital infection) or, a few months later with secondary syphilis (i.e., a systemic infection) (Corigliano & Alvero, 2009d). The stages of syphilis infection are as follows:

1. Primary syphilis. Primary syphilis is a local infection. Its hallmark is the appearance of an ulcer, called a chancre. Typically, there is only one chancre, located at the site of infection: the penis, vulva, cervix, perianal region, or oral mucosa. The chancre appears a few weeks after T. pallidum bacteria have invaded the skin. (The incubation period is between 10 and 90 days.) A syphilis chancre has firm, raised edges and a smooth internal base, and it is painless. Local lymph nodes may be enlarged. If untreated, chancres heal spontaneously in two to six weeks, leaving faint scars (Shah, 2008, Frenkl & Potts, 2007; Hook, 2008).
2. Secondary syphilis. When primary syphilis is not treated, the chancre disappears for a few weeks. The disease then reappears as secondary syphilis. Secondary syphilis is a systemic infection with flu-like symptoms—a low-grade fever, headache, malaise—generalized lymphadenopathy, and a widespread, symmetrical, non-itchy maculopapular rash, first on the trunk and arms and later on the palms and soles. The genital area may also have wart-like papules. During secondary syphilis, a person can develop syphilitic hepatitis or syphilitic glomerulonephritis (Frenkl & Potts, 2007).
3. Latent syphilis. When secondary syphilis is untreated, the symptoms usually fade and the disease becomes quiescent—it "goes underground." This asymptomatic interim stage is called latent syphilis.
4. Tertiary syphilis (late-stage syphilis). In approximately a third of the patients who have latent syphilis, the disease reemerges and causes symptomatic damage to a variety of organs. This, the final form of the disease, is called tertiary or late-stage syphilis. Tertiary syphilis can take many years, even decades, to become symptomatic. It produces granulomatous or necrotic lesions that can involve the skin, eyes, central nervous system, heart, aorta, or bones. Today, tertiary syphilis is rare except in patients with a concurrent HIV infection (Shoemaker et al., 2007).

Pregnant women with syphilis can transmit the disease to their newborn baby at the time of birth. The infant can then develop congenital syphilis, which, when untreated, can delay development, cause seizures, or even be fatal (CDC, 2008a).

A chancre of primary syphilis below the glans of the penis. (CDC, 2008d.)

A chancre of primary syphilis below the vulva (beyond and to the left of the tip of the tongue blade). (CDC, 2008d.)

Lab Tests

The most common tests for syphilis are blood tests in which the patient's serum is screened for antibodies likely to have been produced against Treponema pallidum. The two first-line screening techniques use either the rapid plasma reagin (RPR) test or the Venereal Disease Research Laboratory (VDRL) test. It usually takes at least a week after a patient acquires syphilis for these antibody tests to become positive (LaSala & Smith, 2006; Shah, 2008).

The RPR and VDRL are called nontreponemal serologic tests because they are not specific for syphilis. False positive nontreponemal serologic tests occur in patients with autoimmune disorders such as systemic lupus erythematosus and in a few other special populations.

To rule out false positives, those blood samples that give a positive result on either the RPR or VDRL test are confirmed by a more specific antibody test. The two available second-level tests are the fluorescent treponemal antibody absorption (FTA-ABS) test and the microhemagglutination-T. pallidum (MHA-TP) test. These second-level tests are called treponemal serologic tests. Besides being more specific than the RPR or the VDRL tests, treponemal tests are more sensitive in recognizing latent and tertiary (late-stage) syphilis. Ferri (2008) gives a useful algorithm for the steps in using the various lab tests to diagnose syphilis.

TREATMENT OF SYPHILIS

Intramuscular slow-release penicillin G is the treatment of choice for syphilis (Frenkl & Potts, 2007; Corigliano & Alvero, 2009d).

In the first days after syphilis treatments, some people get a Jarisch-Herxheimer reaction—i.e., fever, myalgia, tachycardia, headaches, and hypotension—informally called Herx. Reacting patients should have bed rest and should be given nonsteroidal anti-inflammatory agents.

People who have syphilis are more likely to also have acquired other STDs. Therefore, patients with syphilis should be tested for HIV, hepatitis B and C, chlamydia, and gonorrhea.

Treating Sexual Partners

Patients with early syphilis—i.e., primary, secondary, or early latent syphilis—are contagious. People who in the preceding three months have had sexual contact with a patient with early syphilis should be notified and treated. Treatment is recommended even for those contacts with no clinical or serologic evidence of the disease because these people have a 30% chance of developing syphilis (Hook, 2008; Shah, 2008).

PREVENTING THE RECURRENCE AND SPREAD OF SYPHILIS

After treatment, patients should be retested at six, twelve, and twenty-four months for the presence of nontreponemal antibodies. Within a year, the patient's nontreponemal antibody titers should have decreased at least fourfold; otherwise, the patient should probably be retreated. On the other hand, tests for treponemal antibodies will remain positive even after adequate therapy.

After treatment, pregnant women should be retested monthly until delivery.

People at higher risk for syphilis should be screened regularly. High-risk groups include men who have sex with men without condoms or with multiple partners, male and female prostitutes, adults in correctional facilities, and people who trade sex for drugs (Frenkl & Potts, 2007).

Genital Herpes

Herpes simplex virus (HSV) causes genital herpes, a disease characterized by recurring clusters of small painful ulcers. HSV is a DNA virus that is occurs in two forms, designated HSV-1 and HSV-2. Both types of HSV can infect the genital region and cause ulcers, although most genital infections are caused by the HSV-2 form (Eckert & Lentz, 2007a; Ferri, 2009a).

EPIDEMIOLOGY OF GENITAL HERPES

Infections of HSV are very common. At least 65% of American adults have an HSV-1 infection, and at least 25% of Americans have an HSV-2 infection.

Herpes is usually a localized disease. HSV-1 commonly causes oral or facial herpes, while HSV-2 commonly causes genital herpes. Not all HSV infections cause symptoms, so, for example, only 1 in 4 people who have genital herpes are aware of their infection (Eckert & Lentz, 2007a; Shoemaker et al., 2007). More than 45 million adult Americans have genital herpes.

The epidemiology of genital HSV-2 infections differs from that of genital HSV-1 infections. Women are more likely than men to have a genital HSV-2 infection. In addition, recurrent outbreaks of HSV-2 herpes lesions are more common than are recurrent outbreaks of HSV-1 (Frenkl & Potts, 2007; Mell, 2008).

DIAGNOSIS OF GENITAL HERPES

Typical Course and Clinical Signs

Genital herpes is acquired by contact with skin, mucosal membranes, or fluid droplets that contain the HSV virus. HSV-1 herpes is typically acquired from the saliva of an infected person; HSV-2 herpes is typically acquired from direct skin-to-skin or mucous membrane-to-skin contact. The two types of herpes infections are clinically indistinguishable (Eckert and Lentz, 2007a).

Genital herpes is very contagious: 75% of sexual partners of infected people contract the disease. Most people (80%) who have genital herpes are asymptomatic and unaware of their infection, and these asymptomatic infected people can shed HSV and infect others. Asymptomatic people with HSV-2 infections are more likely to shed the virus than asymptomatic people with HSV-1 infections (Ferri, 2009a).

When activated, a genital herpes infection produces skin lesions. The initial episode of activation, at the time of acquisition of the virus, is called the primary stage of infection. On its own, the primary stage will spontaneously resolve, and the infection will become quiescent. The HSV virus can then be reactivated by stresses that temporarily affect the immune system; reactivation leads to a bout of symptoms that will again resolve spontaneously.

Symptoms of the primary stage of infection (i.e., the initial episode) begin 3 to 7 days after contact with the virus. There can be systemic symptoms (low-grade fever, headaches, and muscle aches) along with the typical local symptoms of genital herpes (pain, burning, itching, and tingling followed by skin or mucous membrane vesicles). Herpetic vesicles or blisters are of similar sizes and surrounded by a ring of erythema. They rupture into ulcers in about 48 hours, and later, the ulcers become crusted as they heal. Herpes lesions heal fully in 2 to 3 weeks and usually leave no scars (Frenkl & Potts, 2007).

After the primary stage of infection subsides, the HSV virus remains quiescent in the sensory nerve ganglia of the region; for genital herpes, these nerve ganglia are the dorsal root ganglia of spinal nerves S2, S3, and S4. When the latent virus is reactivated, it travels down the nerve to infect the same skin patches as before. HSV-2 is more likely to cause recurrent episodes of genital herpes than is HSV-1, but recurrent episodes of both HSV strains occur much less frequently as time passes.

The recurrent episodes of genital herpes typically begin with a 12- to 24-hour prodrome of local burning and tingling, followed by the appearance of clusters of lesions. Occasionally, there are also systemic symptoms (fever, headache, malaise, and lymphadenopathy). As in the primary infection, complete healing of the skin ulcers takes 2 to 3 weeks (Mell, 2008).

Genital herpes causes painful vesicles that rupture in a few days, leaving tender ulcers. During a symptomatic episode of genital herpes, patients present with one or more clusters of vesicles. Common sites include the shaft and the glans of the penis in men and the labia and the buttocks in women. These skin lesions sometimes spread along the perineum, buttocks, and thighs; women tend to have more widespread lesions than men. People with genital herpes can also develop lesions outside the genital region. Along with the surface vesicles, there are usually enlarged, tender inguinal lymph nodes bilaterally (Eckert & Lentz, 2007a; Frenkl & Potts, 2007).

Clinical diagnosis of genital herpes is not always clear-cut. Genital herpes can present atypically, and, especially in women, there can be itching, abrasions, or fissures without the classic ulcers being visible. It is not possible to distinguish HSV-1 infections from HSV-2 infections clinically.

Genital herpes (HSV) vesicles on the shaft of the penis. (CDC, 2008d.)

Genital herpes (HSV) vesicles on the labia. (CDC, 2008d.)

The effect of herpes lesions goes beyond physical discomfort. People who know that they are infected with genital herpes also suffer psychological symptoms. Infected people feel socially isolated, and because recurrent episodes of the disease are not predictable, people with HSV infections are hesitant to have sexual relationships.

Lab Tests

Lab tests can confirm a clinical diagnosis of genital herpes. Swab specimens from vesicles or ulcers can be cultured, and diagnostic results are available in two to seven days using standard techniques and in one to two days using direct immunofluorescent antibody (DFA) stains (Mell, 2008; Ferri, 2009a). PAP smears can also be used to look for HSV infected cells.

The fastest and most reliable tests for HSV infections are blood tests that search for HSV antibodies; blood tests are also available to distinguish between HSV-1 and HSV-2. Because HSV-1 infections are so widespread, only blood tests for the less common HSV-2 antibodies are diagnostically helpful in most cases.

When genital herpes is suspected, the patient should also be tested for other STDs.

TREATMENT FOR GENITAL HERPES

Currently, no treatments cure genital herpes infections. The treatment goals are to moderate symptoms, to reduce the number of recurrences (outbreaks), and to shorten the times of heavy viral shedding.

Antiviral drugs can reduce the effects of genital herpes. The primary episode of a herpes infection is usually the worst, and treatment is suggested for all primary genital herpes infections. The recommended therapies are the same for HSV-1 and HSV-2 (Eckert & Lentz, 2007a; Frenkl & Potts, 2007; Mell, 2008; Ferri, 2009a).

Treatment for recurrences is most effective when it is begun as soon as the prodrome symptoms appear, before the herpes vesicles develop. Therefore, patients with genital herpes are often given an antiviral drug prescription that can be filled immediately when the disease begins.

The frequency of recurrent episodes of genital herpes decreases significantly over time. The CDC (2006b) recommends that doctors with patients on daily antiviral treatments should reevaluate periodically (eg., yearly) the need for daily medication.

It is important that patients with genital herpes understand that when they are asymptomatic or on daily antiviral medications, they can still shed the HSV virus, and they should protect their sexual partners by using condoms.

PREVENTING THE SPREAD OF GENITAL HERPES

Not only should health care providers talk with their genital herpes patients about the disease, but doctors, nurses, and clinics should give these patients written information detailing specific information about how to avoid spreading genital herpes. The written information should include these points:

• A person with genital herpes should tell all recent and future sexual partners about their infection. The sexual partners should understand that they are at risk for acquiring genital herpes even when the patient is asymptomatic.
• All forms of genital contact—vaginal, anal, or oral-genital—can transmit herpes.
• Using condoms and taking daily antiviral medications will reduce the risk of transmitting genital herpes.
• Sexual contact should be avoided entirely from the time an infected person has the prodromal symptoms of a herpes outbreak until after the sores have healed and new skin has formed.
• During a herpes outbreak, an infected person should avoid touching their sores and should wash their hands after each time they have contact with the lesions.
• Once a person's body has had time to make antibodies, blood tests can determine whether the person has an HSV-2 infection. A person who is unsure whether they have acquired an HSV-2 infection can be tested two weeks or longer after sexual contact with an infected partner.
• During their third trimester, pregnant women who do not have HSV should avoid sexual contact with partners who have an HSV infection. Pregnant women who have or who may have genital herpes should inform their healthcare providers. (Eckert & Lentz, 2007a; Mell, 2008; Ferri, 2009a)

Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS)

[HIV infections and the subsequent development of AIDS are discussed in other Wild Iris Medical Education courses. HIV infections will only be summarized here, with a focus on the genital aspects of the infection.]

Human immunodeficiency virus (HIV) causes acquired immunodeficiency syndrome (AIDS), an STD that makes the body excessively susceptible to opportunistic infections and cancers. HIV, which are retroviruses and which use immune cells as their hosts, are fragile viruses and cannot survive for long outside the body (Opal & Masci, 2009a, 2009b).

EPIDEMILOGY OF HIV/AIDS

In the United States, 62 out of every 100,000 individuals are infected with HIV. In 2006, more than 56,000 new cases were diagnosed, which is a rate of about 19 new cases per 100,000 people each year (AVERT, 2009).

Eighty-five percent of the HIV-infected Americans live in large cities, but the specific concentrations of HIV cases vary widely by region. HIV infections are three to four times more common among men than among women, although the percentage of women with this STD is rising. HIV/AIDS hits African Americans more commonly than whites (Opal & Masci, 2009a, 2009b).

The death rate from HIV infections has been declining the United States. In 2006, approximately 437,000 Americans were living with advanced HIV infections (i.e., AIDS) (CDC, 2008a).

DIAGNOSIS OF HIV/AIDS

Varying levels and concentrations of HIV have been found in most bodily fluids of infected persons, including blood, semen, saliva, tears, breast milk, and vaginal and cervical secretions. However, only blood, semen, breast milk, and vaginal and cervical secretions have been proven to transmit HIV infection.

Although the mechanisms of HIV and how it affects the immune system are not fully understood, the primary event is the HIV invasion of the body's CD4⁺ cells (T-Helper lymphocytes, also called T4 cells), white blood cells essential to the function of the immune system in fighting infection. HIV infects and destroys the T4 cells and damages their ability to initiate antibody production. Thus it steadily deactivates the immune system, leading to dysfunction of various organ systems, including the endocrine, gastrointestinal, and nervous systems (Evans, 2008).

AIDS is an advanced state of the HIV infection. A person is said to have AIDS when an HIV infection has depleted their body of immune cells to such an extent that life-threatening opportunistic infections can thrive and rare cancers can develop. Some AIDS-permitted infections and cancers involve the genitourinary tract. These urogenital diseases include:

• In Men: Opportunistic infections of the prostate, epididymis, and testis; atrophy of the testes; and testicular tumors.
• In Women: Opportunistic vulvovaginal infections and cervical cancer
• In Both Genders: Opportunistic urethritis, inguinal and perineal skin infections and cellulitis, severe outbreaks of genital herpes, extensive and treatment-resistant genital warts, HPV-induced anal cancer, quickly progressing and treatment-resistant syphilis, treatment-resistant chancroid, and extensive molluscum contagiosum. (Krieger, 2007)

Clinical Signs

Clinically, HIV infections can be asymptomatic. Over time, however, the depletion of immune cells takes its toll, and when AIDS develops, the person will often have fever, weight loss, and anorexia, and opportunistic infections or malignancies can arise. These infections and malignancies are called indicator diseases, the most common of which are:

• Respiratory infections (eg., Pneumocystis jiroveci [Pneumocystis carinii] pneumonia, tuberculosis, bacterial pneumonia, fungal infections)
• CNS infections (eg., toxoplasmosis, cryptococcal meningitis, tuberculosis)
• GI infections (eg., cryptosporidiosis, isosporiasis, cytomegalovirus)
• Eye infections (eg., cytomegalovirus, toxoplasmosis)
• Kaposi's sarcoma
• Various lymphomas (Opal & Masci, 2009a, 2009b).

Lab Tests

An HIV infection is diagnosed using blood antibody tests. The AIDS stage of an HIV infection is identified by the patient's degree of immune cell depletion; specifically, a patient with an HIV infection has AIDS when their count of CD4 cells is less than 200/mm³ or less than 14% of the total lymphocyte count.

TREATMENT OF HIV/AIDS

Management of HIV infections is an evolving specialty. The principles of HIV treatment include:

• Continuous prophylaxis against certain infections (eg., Pneumocystis pneumonia and tuberculosis) and suppressive therapy for other infections (eg., cytomegalovirus and Cryptococcus)
• Daily antiretroviral therapy
• Highly active antiretroviral therapy (HAART) when immune cell counts fall too low
• Early and aggressive treatment of opportunistic infections and malignancies (Krieger, 2007; Hay, 2008).

The presence of other STDs makes both the transmission and the acquisition of an HIV infection more likely. Therefore, when patients are diagnosed with any STD, they should probably be tested for HIV. Similarly, patients with other STDs should be advised to be especially careful because they can get (and give) the AIDS virus more easily than people without an STD (Opal & Masci, 2009a, 2009b).

PREVENTING THE SPREAD OF HIV

A large and public effort has gone into slowing the spread of HIV infections. Awareness of the disease and the use of condoms are making inroads. Nonetheless, HIV prevention efforts in the United States have had mixed results. As the AIDS charity AVERT (2009) reports:

Of all the industrialized countries in the world, America is home to the largest number of people living with HIV. Tens of thousands of people are newly infected with HIV in America every year, and although infection rates have declined among injecting drug users, there has been an alarming increase among men who have sex with men.

The success of prevention efforts in America has been variable. One area where efforts have been particularly successful is the prevention of mother-to-child transmission. Routine HIV testing for pregnant women in many states, and good preventive interventions, mean that diagnoses of HIV in babies have dropped dramatically.

In other areas, prevention efforts have had less of an effect, and while combination antiretroviral treatment has helped to dramatically reduce the number of people developing and dying of AIDS in America, there are still around 56,000 new HIV infections every year.

Over 17,000 people died of AIDS in 2005 alone, yet increasingly AIDS is seen as an 'overseas' or an 'African' problem, rather than something that directly affects American citizens. … With the exception of the reduction in mother-to-child transmission in recent years, the news is rarely good. AIDS continues to affect marginalized groups and continues to receive nowhere near the attention or funding that is required to effectively tackle the problem.

Genital HPV Infections

Human papillomavirus (HPV) is a family of viruses that cause genital (anogenital) warts and, much less frequently, cervical cancer.

Human papillomaviruses are small DNA viruses. More than 100 HPV types have been characterized, and approximately forty of these can infect humans (Markowitz et al., 2007; CDC, 2008a; Douglas, 2008). Many HPV infections are asymptomatic, but some types of HPV infections cause common skin warts and plantar warts, while other types of HPV infections occasionally cause malignant skin and mucous membrane lesions (Stehman, 2007).

Benign HPV lesions such as genital warts are caused by low-risk types of HPVs (eg., HPV types 6 and 11). Rarer, malignant HPV lesions such as cervical cancer and cancers of the anus, penis, vagina, or vulva can be caused or facilitated by high-risk types of HPV (eg., HPV types 16 and 18) (Mutch & DiSaia, 2007; Sharp & Angermeier, 2007; Slomovitz & Coleman, 2007).

EPIDEMIOLOGY OF GENITAL HPV INFECTIONS

It is estimated that 2% of the U.S. population gets a new infection of genital HPV each year. Most new genital HPV infections occur in young, sexually active people; about three-quarters of the new cases occur in people who are between the ages of 15 and 25. Genital HPV infections are usually not noticed, and they are gone within less than a year. Ten percent of genital HPV infections last longer than two years, and it is from these persistent infections that cancers can occasionally develop (Markowitz et al., 2007; Douglas, 2008).

HPV is quite contagious, and by some estimates, it is the most common sexually transmitted infection in the United States (Weller & Stanberry, 2007). Between one-half and four-fifths of all sexually active adults will have had at least one genital HPV infection during their lives. Women are more susceptible to acquiring genital HPV infections than are men, and greater than four-fifths of all sexually active women will have had a genital HPV infection during their lives. The highest infection rates occur in young women: approximately 45% of women in the 20- to 24-year-old age range have genital HPV infections. As with other sexually transmitted infections, HPV infections are most common in people with more than one sexual partner.

DIAGNOSIS OF GENITAL HPV INFECTIONS

Typical Course

Genital HPV infections are quite contagious. Greater than half the sexual partners of a person with HPV lesions will become infected. Most genital HPV infections are acquired through sexual intercourse; other forms of genital contact can transmit HPVs, but infection by nongenital contact is less common.

Genital warts can develop beyond the genitals. Perianal genital warts can be acquired by skin-to-skin contact, but intra-anal genital warts are transmitted through anal intercourse. Newborns can be infected by HPV during the birth process (Markowitz et al., 2007).

Most HPV infections are short-lived; they spontaneously disappear in less than a year, and they cause no clinical problems. The serious health problems, such as cervical cancers, appear to be caused by uncommonly persistent infections when the persistent HPV is a high-risk type (eg., HPV type 16). In these cases, the HPV infection may persist for decades before a cancer develops (CDC, 2008a).

HPVs invade surface cells, where they cause aberrant cell growth. The most common lesions caused by HPVs are thickened epithelial overgrowths called warts. Genital warts (condylomata acuminata) can occur on the external genitalia, vagina, anus, rectum, and cervix. Approximately 90% of genital warts are caused by HPV type 6 or HPV type 11, although not all people infected with these low-risk types of HPV develop warts. When they do occur, genital warts appear two to three months after a person has been infected (Eckert & Lentz, 2007a).

The aberrant cell growth caused by other types of HPVs—the high-risk HPVs—leads to squamous cell dysplasias (eg., cervical dysplasia) and eventually to neoplasms, such as cervical intraepithelial neoplasias (CIN), squamous cell cancers, or adenocarcinomas. HPV dysplasias in the cervix can usually be detected by Pap tests.

Occasionally, high-risk HPVs cause anal squamous cell cancers. Besides cervical and anal cancer, high-risk HPVs appear to be involved in the development of certain vulvar, vaginal, penile, and urethral cancers (Monk & Krishnansu, 2007; Pettaway et al., 2007; Sharp & Angermeier, 2007; Culkin et al., 2008; Douglas, 2008).

Clinical Signs

In the majority of cases (greater than 70%), genital HPV infections produce no symptoms. Those genital HPV infections that do produce symptoms give rise to genital warts or to cervical dysplasia (Eckert & Lentz, 2007a; Shoemaker et al., 2007; Douglas, 2008).

Genital warts, like cutaneous warts, can usually be diagnosed by their appearance, their symptoms, and their history. Genital warts caused by low-risk HPVs such as types 6 and 11 are soft, raised, skin-colored, and nontender. Most genital warts are asymptomatic, although sometimes they cause itching or burning.

Genital warts vary widely in size. They can be as tiny as a pinhead or as large as a small cauliflower (1–2 cm in diameter), and they can occur singly or in clusters. The small warts tend to be on stalks. Genital warts are typically found on moist surfaces and on surfaces that are rubbed frequently, such as the labia, vagina, cervix, urethra, bladder, perianal skin, or anus.

In women, the walls of the vagina and the surface of the cervix can have genital warts (which are often flat patches), and when external warts are present, women should have a speculum exam to search for internal warts.

In both men and women, genital warts can grow along the internal walls of the urethra or bladder. Large or extensive warts around the urethral meatus indicate that the internal urinary tract should also be examined for warts.

Genital warts on and surrounding the glans of the penis. (CDC, 2008d.)

Genital warts on the vulvae. (CDC, 2008d.)

HPV infections can also cause squamous cell dysplasias of the surface cells in which the viruses live. Most commonly, these dysplasias occur on the cervix, but sometimes they occur in the perianal region and occasionally on the vulva, vagina, penis, or urethra. HPV dysplasias are microscopic, but cervical lesions can be diagnosed from cytologic screening exams, i.e., Pap tests. When dysplasias are discovered, biopsies are used to further categorize the lesion (Monk & Krishnansu, 2007)

Lab Tests

HPV cannot be cultured. On the other hand, DNA from HPV viruses can be tested to determine whether the virus is one of the high-risk types. DNA testing and type classing are used to make judgments about dysplasias with unclear cytologic test results, and DNA tests are also a common adjunct to Pap testing of women older than 30 years of age (Creasman, 2007; DiSaia, 2007).

TREATMENT OF GENITAL HPV INFECTIONS

HPV infection itself cannot be treated, but lesions caused by the virus are treated by removal (Eckert & Lentz, 2007a; Markowitz et al., 2007; Shoemaker et al., 2007; Douglas, 2008).

Genital warts. About a quarter of all genital warts will disappear on their own; nonetheless, most physicians and patients elect to treat the lesions. Treatment consists of removal of the wart. After treatment, virus is still left in the surrounding epithelium, and approximately a third of patients will have a recurrence of the warts. In addition, HPV infections are commonly reacquired from the patient's sexual partner(s).

Squamous cell lesions. For squamous cell dysplasias, treatment is usually excision. Dysplasias should be referred to a specialist for medical management (CDC, 2006b; Creasman, 2007). "Female partners of male patients who have squamous cell carcinoma in situ are at high risk for cervical abnormalities," and these women should be screened and evaluated for cervical malignancies or premalignancies (CDC, 2006b).

PREVENTING THE SPREAD OF GENITAL HPV INFECTIONS

The consistent use of condoms will reduce the risk of contracting and spreading HPV infections. A vaccine against four types of HPV (types 6, 11, 16, and 18) is recommended for the immunization of females ages 11 to 26 years. Ideally, the vaccination should be given before a female has become sexually active because it does not protect against existing HPV infections (Markowitz et al., 2007; Douglas, 2008). The current HPV vaccine does not protect against all potentially cancer-causing types of HPV. Therefore, all women—even those who have been vaccinated against HPV—should have regular PAP tests. (See also "HPV Vaccination of Young Women" below.)

Routine Screening for Genital HPV Infections

HPV infections are quite common, and using blood tests to screen asymptomatic people does not usually help to control the spread of HPV infections. In contrast, routine Pap testing is very effective at reducing cervical cancers. A variety of policy groups suggests that all women should have a Pap test to screen for cervical cancer within three years of beginning sexual activity or by the age of 21 years (whichever occurs first) and at least every three years thereafter (Lentz, 2007a).

Molluscum Contagiosum

Molluscum contagiosum virus (MCV) causes molluscum contagiosum, which is usually a benign, superficial skin disease. MCV is a poxvirus, a DNA virus that is so large that it can be seen with a light microscope. Four types of MCV have been identified; MCV-1 is the most common. MCV has very specific requirements and can live only in keratinocyte cells of human skin (Mark & Buller, 2004; Eckert & Lentz, 2007a; Frenkl & Potts, 2007; Fort et al., 2009).

EPIDEMIOLOGY OF GENITAL MOLLUSCUM CONTAGIOSUM

In children, molluscum contagiosum is a relatively common infection. Molluscum contagiosum limited to the genital region is an adult disease that is most common among 20- to 40-year-old sexually active individuals. Exact incidence and prevalence figures are not available, but it is probable that genital molluscum contagiosum occurs in less than 0.2% of the U.S. adult population and accounts for less than 3% of the sexually transmitted diseases seen in the United States (Mark & Buller 2004).

Adults with immunodeficiencies are much more likely to suffer from molluscum contagiosum. Six to eight percent of patients with HIV infections have molluscum contagiosum lesions. When HIV infections progress to AIDS, as many as a third of the patients acquire the disorder. In immunodeficient people, molluscum contagiosum can spread to all body surfaces. Immunocompetent adults do not get molluscum contagiosum lesions far from the genital area. The appearance of molluscum contagiosum on the face of an adult is a good indicator that they have an HIV infection or some other immunosuppressive condition (Rhea, 1996).

DIAGNOSIS OF MOLLUSCUM CONTAGIOSUM

Typical Course

Genital molluscum contagiosum infections are transmitted through direct contact with skin lesions. Occasionally, the disease has been acquired by contact with the virus on damp surfaces, towels, or washcloths. The incubation period of molluscum contagiosum skin lesions is between two and seven weeks (Frenkl and Potts, 2007; Fort et al., 2009).

In adults, molluscum contagiosum is most often an asymptomatic infection of the genital skin. When symptoms do appear, they take the form of small rounded papules that are flesh-colored and shiny. These skin lesions are usually painless, although they may itch. When undisturbed, the skin lesions disappear on their own within two to three months and leave no scars.

Inside the skin papules, there is a waxy substance that contains MCV particles. If the papules are scraped and broken open, the virus particles can be spread to other body surfaces in a process called autoinoculation. In such cases, people can reinfect themselves, and the disease and the lesions can persist for as long as a few years.

Immunodeficient patients, such as those infected with HIV, do not combat MCV effectively, and the molluscum contagiosum lesions can spread widely over the body and face (Mark & Buller, 2004; CDC, 2006a; Eckert & Lentz, 2007a).

Unlike in adults, molluscum contagiosum lesions in children can appear over the entire body, usually on the face, trunk, or limbs. Molluscum contagiosum is common in children, but localized genital molluscum contagiosum in children may be due to sexual abuse.

Clinical Signs

Molluscum contagiosum can usually be accurately diagnosed by the appearance of the skin lesions. In immunocompetent individuals, the MCV virus creates small clusters of pearly or flesh-colored skin papules. These papules or nodules are smooth, round, and 2–5 mm in diameter. There is usually a small central indentation (umbilification) in each papule, although a magnifying lens may be needed to see this dimple. Inside the papules, there is a white cheesy or waxy material that contains virus particles. Typically, the papules are painless (Mark & Buller, 2004; Eckert & Lentz, 2007a).

A molluscum contagiosum skin papule with a central dimple. (CDC, 2008d.)

Molluscum contagiosum lesions (papules) occur with three general distributions:

• In children, the lesions are found on the face, neck, trunk, or limbs. (Genital lesions may be the result of sexual abuse.)
• In immunocompetent teenagers and adults, the virus has usually been transmitted sexually, and the lesions are found in the genital and inguinal regions.
• In immunodeficient people, the lesions tend to cover larger areas, typically on the face, neck, scalp, or upper body.

Lab Tests

A clinical diagnosis of molluscum contagiosum can be confirmed by a skin biopsy. Sometimes, a simple light microscopic examination of the white material expressed from a papule will confirm the diagnosis, when the skin cells are seen to contain intracellular inclusions (molluscum bodies) characteristic of invading MCV (CDC, 2006a; Frenkl & Potts, 2007; Fort et al., 2009).

Patients with molluscum contagiosum should be tested for other STDs and should be examined for coexisting genital warts or pubic lice.

TREATMENT OF MOLLUSCUM CONTAGIOSUM

In immunocompetent individuals, molluscum contagiosum lesions will usually disappear without treatment. The spontaneous resolution of molluscum contagiosum typically takes six to twelve months, although in some cases, it can take years. Treatment is recommended for genital lesions in sexually active patients to reduce the chance of transmission (Mark & Buller, 2004; CDC, 2006a; Eckert & Lentz, 2007a; Frenkl & Potts, 2007; Fort et al., 2009).

The treatment of genital molluscum contagiosum is similar to the treatment of genital warts. Immediate or rapid removal of the lesions can be done by physicians using cryotherapy, curettage, or laser therapy. Slower removal of the lesions can be done by the patients themselves by applying topical ointments or creams.

In patients with immunosuppressive conditions, such as AIDS, molluscum contagiosum does not always resolve with the standard treatments, and the recurrence of lesions is common. Molluscum contagiosum lesions are most likely to resolve if the patient's immune status can be improved; this might happen, for example in AIDS patients, as a response to highly active antiretroviral therapy (HAART).

PREVENTING THE SPREAD OF MOLLUSCUM CONTAGIOSUM

It is important to explain to patients how molluscum contagiosum is transmitted. The virus is acquired only by direct contact with infected areas of the body or by contact with damp items, such as towels or washcloths, that have directly contacted infected areas of the body and have not yet been cleaned (CDC, 2006a).

Patients should keep skin lesions covered with clothing or with a bandage when other people might brush against those areas of skin. They should wash their hands after touching the lesions. Male condoms will not protect against the acquisition of molluscum contagiosum because sexual interactions include skin-to-skin contact outside the region enclosed by the condom.

Trichomoniasis

Trichomonas vaginalis is the protozoan that causes trichomoniasis, a sexually transmitted form of vaginitis or urethritis. T. vaginalis is a microscopic oval organism that lives inside human cells as a parasite. T. vaginalis is not a normal inhabitant of the vagina (McCormack, 2005; McCormack & Rein, 2005; Eckert & Lentz, 2007a; Pearson, 2008).

EPIDEMIOLOGY OF TRICHOMONIASIS

Trichomoniasis is a common infection. About 5% of women will have a new symptomatic infection each year, while 3 to 10% of women will have an asymptomatic infection. For women, trichomoniasis is most common during the reproductive years, and those women with more than one sexual partner or with another STD are the most likely to get trichomoniasis (Eckert & Lentz, 2007a).

DIAGNOSIS OF TRICHOMONIASIS

Typical Course

T. vaginalis infects the vagina and the Skene's ducts of women and the lower urinary tract of both men and women. The organism is spread by sexual contact; during birth, infected mothers can also pass the protozoa to their newborn daughters. T. vaginalis can survive for up to twenty-four hours outside the body in a moist environment; therefore, trichomoniasis is occasionally acquired by contact with damp towels or damp underclothes (Eckert & Lentz, 2007a; Pearson, 2008).

Trichomoniasis is very contagious, and two-thirds of partners will acquire the infection after one sexual contact with an infected person. Symptoms take from four to twenty-eight days to appear, although many people with the infection remain asymptomatic. When present, symptoms include a profuse purulent homogeneous (i.e., not clumped) discharge. In women, there can also be an abnormal odor and irritation of the vulvae.

Clinical Signs

Approximately half of the women with trichomoniasis are asymptomatic. When symptoms are present, the most common symptom is a copious, watery vaginal discharge that is sometimes bubbly or frothy and that makes the underwear wet. The discharge can be white, gray, yellow, or green and typically has an unpleasant odor (Holmes, 2008).

On speculum examination, the vaginal vestibule and vaginal walls can appear inflamed and edematous. The cervix may also be edematous and red, and sometimes the cervix has tiny pinpoint hemorrhages, giving it the appearance of the skin of a strawberry.

Most men with trichomoniasis are asymptomatic. When symptoms do occur, the infection produces urethritis.

Trichomoniasis of the cervix (speculum view). Typically, trichomoniasis produces a copious whitish discharge. Here, the discharge fills the cervical os. (PHIL, 2008.)

Trichomoniasis occasionally produces a distinctive hemorrhagic spotting on the cervix, resembling the surface of a strawberry (speculum view). (PHIL, 2008.)

Lab Tests

Traditionally, trichomoniasis has been diagnosed by putting a sample of vaginal or urethral discharge on a warm microscope slide with physiologic saline and then examining the slide at high power. In trichomoniasis, the discharge will contain many white cells and epithelial cells, and T. vaginalis protozoa can be seen, appearing as ovoid organisms that wiggle when their flagella twitch (Eckert & Lentz, 2007a).

For vaginal secretions, laboratory tests are more sensitive than microscopic diagnoses. Two common tests, an immunochromatographic test and a nucleic acid probe, give diagnostic results in less than forty-five minutes (CDC, 2006b).

Patients with trichomoniasis are likely to also have other STDs, and trichomoniasis increases the likelihood of the transmission and the acquisition of HIV. Therefore, patients with trichomoniasis should be offered screening tests for a range of STDs.

TREATMENT OF TRICHOMONIASIS

Oral, not topical, antimicrobials are recommended for treating trichomoniasis (Pearson, 2008).

Treating Sexual Partners

Trichomoniasis is easily transmitted sexually, and sexual partners of patients with trichomoniasis should always be treated, even when they are asymptomatic (McCormack & Rein, 2005). It is recommended that all asymptomatic individuals who test positive for trichomoniasis in STD screenings should be treated (Holmes, 2008).

Pubic Lice

Phthirus pubis is the species of louse that prefers living among coarse human hair, such as pubic hair. An infestation of pubic lice produces the STD called pediculosis pubis, a local skin condition marked by intense itching. Pubic lice are also called crab lice, and a case of pediculosis pubis has been informally called the crabs. They are exoparasites, or creatures living on the surface of the human body; they can be transmitted from person to person through sexual contact.

Pubic lice are grey, oval, six-legged arthropods. Each is 1 to 2 mm long, making pubic lice smaller than head lice, which are a different species. Pubic lice lay their eggs (called nits) on coarse body hair—i.e., pubic hair, perianal hair, thigh hair, abdominal hair, axillary hair, beards, and eyelashes. The adult lice live by sucking blood and do not move far from their eggs (Frenkl & Potts, 2007; Leone, 2007; Link, 2007).

EPIDEMIOLOGY OF PUBIC LICE INFESTATIONS

Figures of the prevalence and incidence of pediculosis pubis are mostly estimates. One detailed study (Simms et al., 2006) found an incidence of approximately 33 cases of pediculosis pubis yearly per 100,000 people, with twice as many men as women having pubic lice infestations. As with other STDs, pediculosis pubis is most common in young adults. In Great Britain, the yearly incidence is 74 cases per 100,000 people in the 15- to 24-year-old age group (Simms et al., 2006), which is twice the rate of infestation that is found in the population as a whole.

DIAGNOSIS OF PUBIC LICE INFESTATIONS

Typical Course

Pubic lice can be acquired by close physical contact with a person who has lice or by contact with recently lice-infested towels or bedding. Lice that are not in contact with a person will usually die in less than twenty-four hours.

Pediculosis pubis is quite contagious, and a person who has sex with an infected partner will acquire pubic lice greater than 90% of the time. Condoms will not prevent transmission of pubic lice (Eckert & Lentz, 2007a; Frenkl & Potts, 2007; Leone, 2007; Shoemaker et al., 2007).

Louse eggs (nits) are shiny and translucent and are secreted onto human hair shafts. Adult lice live and feed at the base of the hairs. When lice feed on blood they inject saliva, and the saliva causes a continuous itching that is especially troublesome at night. The patient's scratching further inflames the infested area. Skin in an infested area will have pale blue spots from tiny underlying hemorrhages.

The itching of pediculosis pubis is produced by an allergic sensitization to louse antigens, and this allergic reaction takes time to develop. From the first time a person becomes infected with pubic lice, severe itching may take five to fifteen days to begin, but reinfestations will begin to itch within twenty-four hours.

Pubic lice tend to remain in place and not travel far. An infestation from sexual contact is usually limited to the pubic hair. On hairy people, the lice sometimes spread through contiguous patches of hair to the thighs, abdomen, chest, axillae, and even to the beard. When pubic lice are found on children, especially on the head or the eyelids, it can be an indication of sexual abuse.

Clinical Signs

Patients with pediculosis pubis present with unrelenting itching. A close examination of the infected area will find translucent eggs on the lower portions of shafts of hair; the eggs can be best seen using a magnifying lens. The lice themselves are grey or brown, and when engorged with blood, they become reddish. Under magnification, the lice can be seen to have small heads and three pairs of clawed, jointed legs (Eckert & Lentz, 2007a; Frenkl & Potts, 2007; Leone, 2007; Link, 2007; Shoemaker et al., 2007).

Skin in the infected area may have a red macular or maculopapular rash. There will be pale blue hemorrhagic spots left at points where the lice have been feeding, and excretions from the lice typically dot the area like tiny pepper grains. The patient's scratching can cause secondary marks and infections. Serious infestations can lead to scaly skin.

A case of pediculosis pubis. Lice live at the bases of pubic hairs, and translucent eggs (nits) stick to the hair shafts, looking like tiny water droplets. (CDC, 2008d.)

Lab Tests

Pediculosis pubis is diagnosed using clinical criteria. However, when pubic lice are found on a patient, the person should be tested for other sexually transmitted diseases, because a third of the patients with pubic lice have additional STDs, including HIV.

TREATMENT OF PUBIC LICE INFESTATIONS

Topical insecticides are used to treat lice infestations (Leone, 2007). For symptomatic relief from itching, the patient can be given antihistamines or, in some cases, topical corticosteroids. Besides treating the person, the patient's bedding and clothes should be decontaminated. Dry cleaning or machine washing in hot water and drying in a hot cycle are usually sufficient. Afterward, these items should not be allowed in contact with the patient for at least three days.

Treating Intimate Contacts

People who have had intimate contact (sexual or otherwise) with the patient in the past month should also be treated. Treated people should avoid intimate contact with anyone until they have been reexamined, usually five to seven days after treatment (Frenkl & Potts, 2007; Leone, 2007).

Scabies

Sarcoptes scabiei is the species of mite that causes the itchy skin infestation scabies. S. scabiei are short, stubby-clawed arthropods; each itch mite is tiny, only 0.15 to 0.35 mm long, which is about a tenth the size of a pubic louse.

Itch mites live their entire lives on humans. The females make wavy burrows in the human epidermis, where they their lay eggs; the maturing larvae live on the surface of the skin (Leone, 2007).

EPIDEMIOLOGY OF SCABIES

Scabies is a common disease throughout the world, and it is endemic in tropical countries. For the United States, statistics are inexact, but rough estimates suggest that between 0.05% and 0.5% of the population may get a case of scabies each year (Leone, 2007; Lapeere, 2008).

In the United States, scabies outbreaks occur more often in the winter and in locales where living conditions are crowded, such as in dense urban areas and in prisons, nursing homes, long-term care facilities, and childcare centers. Severe or crusted scabies is most often a disease of immune-compromised people. For unknown reasons, blacks are less likely than whites to get scabies.

DIAGNOSIS OF SCABIES

Typical Course

Scabies is acquired through close skin-to-skin contact. Between adults, scabies is often transmitted through intimate contact, such as via sexual interactions, but scabies is not only transmitted sexually. Scabies will spread in a household or among any group of people who share close direct physical contact (Eckert & Lentz, 2007a; Frenkl & Potts, 2007; Leone, 2007; Link, 2007).

After moving to a new person, the female itch mite chews a wavy burrow just beneath the surface of the skin. The burrowing leads to intense itching produced by the person's allergic reaction to mite antigens. During a person's first infestation, it may take weeks to develop the itchy allergic response, but in subsequent infestations, the response will occur within a day.

Itch mites move around more than pubic lice, and they wander throughout the body. Moreover, unlike lice, itch mites do not limit themselves to hairy patches of skin. Itch mites prefer thin skin, and they can be found along the penis and scrotum in men, along the vulva and the nipples in women, and along the finger webs and the flexor surfaces of wrists, axillae, waist, feet, and ankles in both genders.

Typical scabies infestations include only a few mites, usually five to ten. Occasionally, however, people get crusted scabies, which is an infestation of millions of mites. Crusted scabies is most often found in immune-compromised patients. This form of scabies can involve extensive areas of skin, and the infested person is extremely contagious.

Clinical Signs

The hallmark of scabies is severe itching that gets worse at night or after bathing. In sexually transmitted scabies, the genital areas become itchy, but even when scabies has been acquired sexually, skin elsewhere on the body can become infected and itchy. People with sexually transmitted scabies commonly have itchy hands, wrists, breasts, and buttocks. Skin in the infected area is marked by thin, wavy raised tunnels (burrows). The tunnels look like curvy gray, white, or erythematous skin papules, and they can be from 1 to 10 millimeters long (Eckert & Lentz, 2007a; Leone, 2007).

A scabies infestation can look like many other pruritic dermatologic conditions, and the diagnosis of scabies is made by finding the itch mites. The larvae and the eggs cannot be seen without magnification, but the female mites are sometimes just large enough to be seen with the naked eye.

The clearest identification can be made from scrapings of the skin papules. Using the edge of a sharp blade, the papule is scraped, and the collected material is put on a microscope slide in a drop of mineral oil. At 1,000x magnification, mites, eggs, and bits of excrement should be visible when the dermatologic condition is scabies.

TREATMENT OF SCABIES

Scabies is treated with an insecticide that kills adults, larvae, and eggs (Eckert & Lentz, 2007a; Frenkl & Potts, 2007; Leone, 2007).

Itching can persist for weeks after a successful treatment. For symptomatic relief from itching, the patient can be given antihistamines or, in some cases, topical corticosteroids.

Besides treating the person, the patient's bedding and clothes should be decontaminated. Dry cleaning or machine washing in hot water and drying in a hot cycle are usually sufficient. Afterward, these items should not be allowed in contact with the patient for at least three days.

Treating Intimate Contacts

Treat sexual partners and other close contacts of patients who have scabies. To avoid reinfection, it is best to treat all close contacts at the same time, even if they do not have symptoms.

PUBLIC HEALTH: PREVENTING THE SPREAD OF GENITAL STDs

Sexually transmitted infections affect all corners of society and burden public health systems throughout the world. In the United States, estimates of the yearly incidence of sexually transmitted infections include 37,000 new cases of syphilis, 56,000 new HIV diagnoses, 350,000 new cases of gonorrhea, and more than a million new cases of chlamydia. Almost 440,000 Americans are now living with HIV/AIDS (Piper, 2008; AVERT, 2009).

Sexual relations are a continual, essential, and private part of human populations, and society's attempts to guide and influence sexual relations require individuals to voluntarily modify their private behaviors. In this regard, public health programs to control the spread of STDs target people's voluntary behavior in three realms: before, during, and after sexual relations (Holmes, 2008). Similarly, based on the special characteristics of STDs, a few basic principles guide the public health programs that have been designed to reduce the spread of STDs.

Practical Principles Guiding STD Prevention Programs

The dependence of STDs on the particular features of sexual contact leads to a few practical principles, which are the basic guides used by healthcare workers when they plan ways to protect people from acquiring STDs:

• Uninfected sexual partners are at high risk of acquiring STDs from infected partners.
• The specific sites of sexual contact are likely to be the locations at which STDs begin.
• Barriers to direct skin-to-skin, skin-to-mucous membrane, and mucous membrane-to-mucous membrane contact will interfere with or stop the transmission of STDs.

These simple principles are valid for STD transmission beyond heterosexual vaginal intercourse; they also apply to oral intercourse, anal intercourse, and all other sexual contacts between heterosexual or homosexual partners.

Before: Preemptive Protections

In theory, it should be possible to eradicate a sexually transmitted agent by vigilantly finding and treating every case. Antibiotics can eliminate certain bacteria (eg., Treponema pallidum, Neisseria gonorrhoeae, and Chlamydia trachomatis) from a single person's body. However, antibiotic resistance makes it unlikely that the bacteria can be eradicated in large human populations. Viruses are even more difficult to eradicate because the current antiviral drugs do not kill viruses in vivo but only limit viral replication (Starnbach & Roan, 2008).

At the moment, therefore, the major preemptive control on the spread of STDs cannot depend on vigorous treatment. Instead, preemptive control depends on the development and the use of vaccines that can immunize people against the acquisition of sexually transmitted infections.

PRE-EXPOSURE VACCINATIONS

Certain widespread infectious diseases—notably, diphtheria, measles, polio, smallpox, and whooping cough—have been dramatically reduced or eradicated through the use of pre-exposure vaccinations, not by using antimicrobial drugs. Public health officials hope that pre-exposure vaccinations can similarly slow the spread of STDs, although only a few such vaccines are currently available (Holmes, 2008; Rein, 2008).

Hepatitis B Virus (HBV). Hepatitis B is an STD that causes liver dysfunction. Vaccination against HBV is recommended for all people who are being evaluated for any STD or who are at high risk for acquiring HBV (eg., drug users, men who have sex with men, and incarcerated people) (Holmes, 2008). A vaccine against hepatitis A is also available, and it is recommended for men who have sex with men and for users of illegal drugs (Rein, 2008).

Human Papillomavirus (HPV). A vaccine that is effective against four types of HPV (types 6, 11, 16, and 18) is recommended as routine protection for females aged 9 to 26 years. The optimal window for immunization is before girls become sexually active, and the recommended optimal time for vaccination is when girls are between 11 and 12 years old. (See also box, "HPV Vaccination of Young Women" above.)

CIRCUMCISION

In the United States, 61% of neonatal males are circumcised. Circumcision may reduce the person's later risk of developing penile cancer and urinary tract infections. Population studies suggest that circumcision may also reduce the risk of developing HIV infections and genital ulcers (Elder, 2007).

EDUCATING PEOPLE AT RISK

Many of the changes that individuals must make to protect society from STDs are voluntary. Giving people clear and complete Information about STDs and their prevention has been shown to reduce those people's risky sexual behaviors and to slow the spread of STDs.

A variety of structured programs that include interactive discussions, counseling, peer group discussions, and video presentations have been documented to slow the spread of STDs (Jemmott et al., 2008; Piper, 2008; Rein, 2008). These programs cost money and absorb the time of professionals. With limited time, money, and personnel, the strategy has been to focus resources on high-risk populations and to emphasize the first-line types of STD protection, such as barrier methods (i.e., condoms). Likewise, the expensive screening tests for STDs have been aimed at high-risk populations to get the best results with limited resources (CoA-AAP, 2007).

In the U.S., certain subpopulations are disproportionately plagued by STDs, and it is especially to these groups that education campaigns are directed.

Adolescents

Among adolescents, rates of sexual intercourse and pregnancy have been decreasing during the last two decades. Nonetheless, more than 46% of all high school students reported having already had sexual intercourse at least once, and in the United States, adolescents and young adults have a higher rate of STDs than any other age group.

Recent programs that focus on abstinence from sexual intercourse have not significantly reduced teen pregnancies or decreased the acquisition of STDs by adolescents. Instead, it has been found that "comprehensive sex education programs do a better job of delaying initiation of sex, reducing the number of partners, improving condom use, and reducing pregnancy" (Hampton, 2008).

The goal is to influence adolescents' voluntary and private behavior, and for this, adolescents need to be given facts. They should be told which STDs are common, how STDs are transmitted, and what symptoms signal an STD. They should be told what the consequences of an STD are and how transmission of STDs can be prevented. They also need firm advice about what to do and what not to do, and they need practical examples of how to carry out this advice. Specifically, discussions with teens should emphasize:

• The use of condoms is essential. Nonetheless, condoms do not completely protect a person from acquiring or transmitting STDs.
• Some STDs (eg., genital herpes and genital warts) can be transmitted through any form of sexual contact; sexual intercourse is not necessary.
• Oral and anal sex can transmit STDs, which can infect the mouth, throat, anus, or rectum.
• Sexual contact is not the only way to have an intimate and romantic relationship. (CoA-AAP, 2007)

African Americans

In the United States, only 13% of the population is African American, but 49% of people with AIDS are African American. African American women are 23 times more likely to develop a new HIV infection than are white women. Well thought out and pretested programs are available to disseminate critical information to inner-city African American women and other sectors of this hard-hit population (Jemmott et al., 2008).

Patients with Existing STDs

People who currently have STDs are another at-risk population because they are more likely to be reinfected or to acquire additional STDs. Randomized trials have shown that risk-reduction counseling of patients with STDs significantly lowers their subsequent chances of acquiring an STD. This kind of preventive counseling should now be considered a standard component of the treatment of all patients with an STD (Holmes, 2008).

During: Condoms Can Protect against STDs

Abstinence and the restriction of sexual relations to long-term monogamous relationships are the best protections against sexually transmitted diseases. The second best protection is putting a physical barrier between the contacting couple (USPSTF, 2008).

Barriers—male and female condoms—are the best protections against the transmission and acquisition of STDs during sexual contact. In theory, female condoms cover more areas of contact during sexual activity than do male condoms, but neither type of condom prevents all skin-to-skin contact.

In general, condoms are more effective in preventing those STDs that are transmitted via fluids (eg., chlamydia, gonorrhea, HIV, trichomoniasis) than those STDs that are transmitted via direct skin contact (eg., chancroid, genital herpes, genital warts, syphilis) (Peipert et al., 2007; Rein, 2008; Warner et al., 2008).

To be most protective, condoms must be used correctly and all the time. Healthcare workers should not assume that patients know how to use condoms, and it is always appropriate to demonstrate how to put a condom on a penis or in a vagina using a physical model.

People should not use male and female condoms simultaneously. As a rule, male condoms are preferred, because they have proven to be effective, they are easily available, and they are inexpensive.

CURRENT USE OF CONDOMS IN THE UNITED STATES

• Among adolescents, condoms are used more frequently today than fifteen years ago; in 1991, 46% of high school students reported using a condom during their last sexual intercourse, while the figure was 63% in 2005 (CoA-AAP, 2007; Godeau et al., 2008).
• At the other end of the age spectrum there are no exact statistics, but it has been shown that elderly adults are less likely to use condoms than younger people (Bodley-Tickell et al., 2008; Drew & Sherrard, 2008; Kuehn, 2008).
• Overall, condoms are used consistently only 19% of the time in heterosexual intercourse (Peipert et al., 2007).

MALE CONDOMS

Male latex condoms are a good form of both contraception and disease prevention when used correctly. The steps in proper usage are:

• Store condoms at room temperature.
• Every act of intercourse requires a new condom.
• If the condom feels sticky or brittle or if it looks damaged, toss it out.
• Begin by putting the condom on the head of the penis when the penis is erect.
• Squeeze the condom tip so it does not fill with air.
• Roll the condom all the way down the shaft of the penis, leaving a space in the tip to collect semen.
• If any lubricant is used, it should be saliva- or water-based, not oil- or petroleum-based.
• After ejaculation, withdraw the penis while it is still erect and hold the rim of condom to avoid spilling semen.
• Remove the condom at a distance from the woman's genital area.
• For contraceptive protection, "if the condom breaks or semen spills or leaks, immediately insert contraceptive foam, jelly, or film into the vagina, and use emergency contraception as soon as possible, up to 120 hours" after intercourse (Feldman E, 2006).

Condoms do not provide protection if they are used incorrectly or inconsistently. Incorrect use is a major cause of a condom's failure to prevent contraception or disease. Common problems are, for example, that men delay putting on a condom or that they remove it too early. Even with the best of intentions, the failure rate is 3% during the first year when a couple is consistently using male condoms (Warner et al., 2008).

A larger problem is the inconsistent use of condoms. Women who have frequent intercourse, who use hormonal contraceptives, or who have uncooperative male partners are the most likely to have sexual intercourse without using the protection of a condom (Peipert et al., 2007).

FEMALE CONDOMS

Female condoms are less well-known than male condoms, however they are available over the counter, and they allow women a measure of control over their protection against conception and disease. Female condoms are more expensive than male condoms, and some women find them awkward to use or romantically unappealing.

When used properly, female condoms reduce the likelihood of infectious agents being transferred between the man's penis and the woman's mucous membranes during vaginal intercourse.

After: Screening At-Risk Populations

Reducing public health threats, such as STDs, takes the cooperation of doctors, clinics, and hospitals. For STDs, extra efforts at screening for asymptomatic or unrecognized infections are important ways to contain the infections' spread.

One simple screening opportunity is to routinely include STD screening and risk-assessment questions when taking all patients' medical histories.

Beyond incorporating STD questions into routine medical histories, special efforts should be made to check certain subpopulations. Many infected individuals are missed by routine STD screening because they do not develop or are not aware of symptoms, and thus they do not present themselves to the healthcare system. Other individuals avoid the healthcare system because they are hesitant about acknowledging or reporting symptoms. For these reasons, additional plans should be made to routinely screen certain high-risk people, such as:

• Young adults between the ages of 18 and 28 (This is the age group with the highest rates of STD infections.)
• Returning international travelers (STDs are one of the top five health risks for international travelers.)
• Sexually active women, including women who have sex with women

In the United States, there are widely agreed-upon screening recommendations for at least four sexually transmitted infections: chlamydia, gonorrhea, syphilis, and HIV.

CHLAMYDIA SCREENING

In some regions of the United States, selective screening of young women for cervical chlamydial infections has reduced the prevalence of the disease by 60%. A yearly clinical screening is recommended for:

• All sexually active females less than 26 years of age (The test should be done yearly, and this can conveniently be done at the time of the patient's annual Pap smear.)
• Sexually active women 26 years of age or older when they: 1) have two or more sexual partners, 2) have begun a new sexual relationship, or 3) acquire some other STD

GONORRHEA SCREENING

Routine screening is recommended for:

• Sexually active teens and young women in areas with a high prevalence of gonorrhea
• Teens and young women presenting to STD clinics for any reason
• Patients with newly diagnosed chlamydial infections

Tests that combine screening for gonorrhea and chlamydia are commonly available.

SYPHILIS AND HIV SCREENING

Routine screening is recommended for:

• Patients with any newly diagnosed STD
• Patients at high risk for STDs
• All pregnant women

Epidemiological Treatments: Expedited Partner Therapy

There is no simple way for public health officials to identify all people who have sexually transmitted infections, and infected individuals do not always identify themselves because:

• Sexually transmitted infections are not always symptomatic, and infected people are not always aware of an infection.
• Symptomatic people can be too embarrassed, too poor, or too afraid of lack of confidentiality see a doctor.

As a counterbalance, patients who are diagnosed with an STD provide a means of identifying some of the still undiagnosed cases of the disease. Specifically, the recent partners of STD patients are a pool of potentially infected individuals. Examining and treating these "hidden" cases is one way to limit the spread of STDs.

With the cooperation of their patients, healthcare workers should try to find and treat sexual contacts who may have an STD. This effort is a form of epidemiologic treatment. Epidemiologic treatment uses population studies and statistical risk assessments to make educated guesses as to which sexual partners of patients are likely to also be infected.

Patients should be asked to notify their sexual partners and to encourage the partners to see a physician. Some local health departments have programs to help patients to notify their partners and to arrange confidential treatment and counseling (Holmes, 2008).

Unfortunately, this form of multi-step notification and treatment does not always work. Obstacles include:

• Patients are embarrassed about having to tell sexual partners that they may have a sexually transmitted infection.
• When partners are notified, they may be asymptomatic and not seek medical evaluation.
• The partners may be too embarrassed to see a physician.

Some of these difficulties can be overcome by having the patients deliver the therapy—either a prescription or a medication—directly to their sexual partners. This has been called patients' delivery of partners' therapy (PDPT) or expedited partner therapy (EPT). In controlled studies, EPT was found to be more effective than the conventional multistep notification and treatment approach (Hodge et al., 2008; Holmes, 2008). Currently, however, EPT cannot always be used, because not all states allow physicians to prescribe medications without directly examining the patient (Hodge et al., 2008).

STD PROTECTION FOR VICTIMS OF SEXUAL ASSAULT

Along with physical injury and psychological trauma, sexual assault brings fears of pregnancy and STDs. Victims of sexual assault worry about having acquired an infectious disease. Overall, the chances of a victim getting an STD from a sexual assault are not high. For example, from a sexual assault, the general risk of contracting gonorrhea is 6 to18%, of contracting chlamydia is 4 to 17%, of contracting syphilis is 0.5 to 3%, and of contracting HIV infection is less than 1%. The actual risk, however, varies by region and by the type of attack (Slaughter, 2006).

The best treatment for sexual assault victims is given by a sexual assault response (SAR) team, which includes members with special training in forensics and psychological therapy. All treatments and examinations should be done with the victim's consent, and SAR teams should have the appropriate consent forms on hand (Slaughter, 2006; Lentz, 2007b; CoA-AAP, 2008).

The Initial Evaluation

The initial examination of a person who has been sexually assaulted combines patient care with the collection of criminal evidence. The examination should be thorough and should recognize that from 40 to 80% of sexual assault victims sustain injuries outside the anogenital area. The person's mouth, anus, and rectum should be examined when appropriate.

Testing For and Treating STDs

Decisions about testing for and treating STDs should be made in discussions with the patient. Together, the victim and the health team can usually formulate a plan that combines testing and preventive treatment and that includes scheduled follow-up visits to monitor the victim's health. The treatment plan is sometimes broadened to include HPV vaccinations if the victim is a young woman who has not yet been immunized.

The medical and psychological plans should be written and copies should be given to the patient along with written information about STDs, pregnancy, and the psychological effects of sexual assault.

Testing for STDs poses complications for the protection of sexual assault victims. In some situations, defense lawyers have used positive test results as an opportunity to explore the victim's sexual history. For this and other reasons, many providers of acute care prefer to give victims of sexual assaults preventive or prophylactic treatment rather than to wait for (and make records of) definitive diagnoses before treating the patient (Lentz, 2007b).

Preventive treatment usually includes antibiotics against the two highest risk STDs: gonorrhea and chlamydia. Preventive treatment also includes vaccination against hepatitis B when the victim either has not already been immunized or is not certain about their immunization history. With preventive therapy, prophylaxis against trichomoniasis, syphilis, or HIV is typically decided on a case-by-case basis. The result of a urine pregnancy test is used to guide the choice of preventive drugs.

Follow-Up Care

In all cases, the medical team should arrange a follow-up visit in 1 week so that the physical and psychological healing of the victim can be monitored. At this time, some testing or retesting for STDs may be appropriate. A visit at two weeks can include another pregnancy test, rescreening for bacterial infections, and blood tests for viral infections (HSV, hepatitis B, HIV, and cytomegalovirus). It is recommended that victims who are concerned about syphilis or HIV infection should be retested at six weeks, three months, and six months after the assault (Lentz, 2007b).

SUMMARY

Sexually transmitted diseases (STDs) are infections that are efficiently transmitted through sexual contact. The range of the infectious agents of STDs is broad and includes bacteria, viruses, protozoa, and tiny arthropods (lice and mites). A common characteristic of most agents causing STDs is that they do not tolerate dry, cool environments but instead thrive in warm, moist mucous membranes.

For certain organisms, sexual contact is the main way that they are transmitted from person to person; this is the case, for example with chlamydial infections and with gonorrhea. For other organisms, sexual contact is a minor component of their mode of acquisition; candida (yeast) infections are examples of these organisms. The latter diseases—i.e., diseases in which sexual contact is not a major mode of transmission—are usually not classified as STDs.

For systemic STDs, such as HIV infections, the genital regions are mainly points of entry into the circulation. For other more local STDs, such as HPV infections, the genital region becomes the primary site of lesions. This course has focused on local STDs.

The Epidemiology of STDs

STDs are quite common. It is estimated that 19 million new cases of STDs occur each year in the United States, mostly among young people between the ages of 15 and 24 years (CDC, 2007a).

Although they are major public health concerns, some widespread STDs have not been quantified by exact statistics. For example, human papillomavirus(HPV) infection, the cause of genital warts, is thought to be the most widespread sexually transmitted disease in the United States, with an estimated 20 million people infected at any one time and 5.5 million new infections each year (Rein, 2008). Nonetheless, the numbers of HPV infections remains only an estimate.

Common Presenting Syndromes

Symptomatic STDs of the genitals present as a variety of syndromes. These include:

• Urethritis (urethral discharge and dysuria), caused most often by Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis. (Common non-STD causes include Ureaplasma urealyticum and Mycoplasma genitalium.)
• Genital ulcers (skin or mucous membrane sores), caused most often by herpes simplex virus (HSV), Haemophilus ducreyi (chancroid), or Treponema pallidum (syphilis).
• Genital warts (protuberant growths on the skin or mucous membranes), caused most often by human papillomavirus (HPV).
• Lower genital tract infections in women (vaginal discharge, irritation of the vulvae, and dysuria), caused most often by Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, or herpes simplex virus (HSV). (Common non-STD causes include Candida albicans and bacterial vaginosis.)
• Upper genital tract infections (PID) in women (lower abdominal pain, adnexal and cervical tenderness), caused most often by Chlamydia trachomatis or Neisseria gonorrhoeae. (Common non-STD causes include Gardnerella vaginalis, Haemophilus influenzae, and enteric gram-negative organisms, such as E. coli.)

Sexual contact includes contact between genitals, mouth, and anus. Therefore, STDs can also present with oral/pharyngeal or anal/rectal symptoms.

Principles of Treatment

When an STD is diagnosed, it is important that it be treated quickly to reduce the risk of the patient spreading the disease. When possible, it is ideal to use medicines for which the entire treatment regimen can be administered in one dose that can be given during the patient's first visit.

Patients with an STD should also be tested for other STDs because the presence of one STD makes the existence of a second STD more likely. Anyone who comes into the health system to be tested for an STD should be screened for an HIV infection.

STDs are treated according to the type of infectious organism, not the type of presenting syndrome. Often, clinical diagnoses cannot definitively identify the causative organisms, and lab tests are needed to verify or to pinpoint the diagnosis.

Common causes of genital STDs and the range of syndromes that each infectious agent can present are as follows:

BACTERIA

• Chlamydia trachomatis: nongonococcal urethritis, purulent hypertrophic cervicitis, epididymitis, salpingitis, conjunctivitis, trachoma, pneumonia, perihepatitis, lymphogranuloma venereum, Reiter's syndrome
• Haemophilus ducreyi: chancroid
• Neisseria gonorrhoeae: urethritis, cervicitis, bartholinitis, proctitis, pharyngitis, salpingitis, epididymitis, conjunctivitis, perihepatitis, arthritis, dermatitis, endocarditis, meningitis, amniotic infection syndrome
• Treponema pallidum: primary, secondary, latent, and tertiary syphilis

VIRUSES

• Herpes simplex virus (HSV): genital herpes, proctitis, meningitis, disseminated infection in neonates
• Human immunodeficiency virus (HIV): acquired immunodeficiency syndrome (AIDS) and related illnesses
• Human papillomavirus (HPV): condyloma acuminata; cervical and perianal warts; cervical, vulvar, and penile cancer
• Molluscum contagiosum virus (MCV): molluscum contagiosum

PROTOZOA

• Trichomonas vaginalis: trichomonal vaginitis, occasional urethritis

EXOPARASITES

• Phthirus pubis: pubic lice
• Sarcoptes scabiei: scabies (Rein, 2008)

The current recommended treatments are given by the U.S. Centers for Disease Control and Prevention in updates to its "STD Treatment Guidelines" (CDC, 2006a).

Protecting the Public

From a public health standpoint, it is best to treat the sexual partners of a patient with an STD at the same time as the primary patient. Therefore, STD patients should be encouraged to notify their sexual partners of the possibility that they may also be infected. Both patient and partner should be told that infected people can often be asymptomatic and that screening with lab tests should be done even when an at-risk person seems to be perfectly healthy. For certain STDs, the chances of transmission are so high that sexual partners should be treated prophylactically, even without testing.

Besides treating infected patients and their sexual partners, public health programs work to reduce the overall transmission and acquisition of STDs. These programs educate people, especially those people who are at high risk (such as teens and young adults), by explaining what STDs are, how they are acquired, how they can be prevented, and how they are treated. One principle that should be stressed is that, for sexually active people, condoms are the best safeguard against transmitting or acquiring many of the STDs and that other forms of contraception do not protect against disease.

Another key public health effort is large-scale vaccination against STDs. Currently, it is recommended that young women be vaccinated against HPV and that people at risk for STDs be vaccinated against hepatitis B.

Reaching out to sexual partners, making extra efforts at patient education, and vaccinating young women are examples of public health care that can be done at the level of individual patients. Primary care providers must take on these responsibilities, which go beyond the acute treatment of their patients, to protect the community from STDs.

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