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Guidelines

• Malaysian Guidelines in the treatment ofSexually Transmitted Infections

Ministry of Health 3rd edition 2008

www.moh.gov.my/images/galleryGarispanduan/malaysian_guidelines_in_treatment_of_STI_pdf  

• British Association for Sexual Health

(BASHH) Guidelines

www.bashh.org/guidelines 

• CDC 2010 STD treatment Guidelineswww.cdc.gov/std/treatment/2010/toc.htm 

http://www.moh.gov.my/images/galleryGarispanduan/malaysian_guidelines_in_treatment_of_STI_pdfhttp://www.moh.gov.my/images/galleryGarispanduan/malaysian_guidelines_in_treatment_of_STI_pdfhttp://www.bashh.org/guidelineshttp://www.cdc.gov/std/treatment/2010/toc.htmhttp://www.cdc.gov/std/treatment/2010/toc.htmhttp://www.bashh.org/guidelineshttp://www.moh.gov.my/images/galleryGarispanduan/malaysian_guidelines_in_treatment_of_STI_pdfhttp://www.moh.gov.my/images/galleryGarispanduan/malaysian_guidelines_in_treatment_of_STI_pdf

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World wide prevalence

3

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4

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 Common STIs

• Chlamydia

• Gonorrhoea

• Genital Herpes (Herpes Simplex Virus)

• Human Papilloma Virus (HPV)

• Trichomoniasis

• Syphilis• Hepatitis B

• HIV

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 Data source: KC60 statutory returns 

% change

2008 2007-2008 1999-2008

Chlamydia 123,018 1% 116%

Genital warts 92,525 3% 29%

Genital herpes 28,957 10% 65%

Gonorrhoea 16,629 - 11% 1%

Syphilis 2,524 - 4% 1,032%

Number of new diagnoses of STIs,

GUM clinics, United Kingdom: 2008

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Consequences of poor sexual health

• Unintended pregnancies• Sexually transmitted infections

• Congenital/Neonatal infection

•  Adverse pregnancy outcomes – miscarriages, low birth weight,

preterm labour

• Pelvic Inflammatory Disease

• Ectopic pregnancies

• Infertility

• Chronic Pelvic Pain

• Neurological/Cardiovascular problems• Chronic liver disease

•  Anogenital cancers

• Increased HIV transmission

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Groups vulnerable to poor

sexual health• Young people

• Female Sex Workers (FSW)

• Clients of Female Sex Workers

• Transgenders• Men who have sex with men (MSM)

• Those involved in jobs which separate them from their

regular sexual partner for long periods e.g lorry drivers,

soldiers• Refugees

• HIV positive patients

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Patient 1

•  26 year-old woman in a steady

relationship with her boyfriend of 1 year.

She presents complaining of a vaginal

discharge for the past week.

• She describes increased discharge,

change in color, and a foul odor.

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 A. What other questions would you like to

ask her?

B. Is this a sexually transmitted infection?

C. What are the likely causative organisms?

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Vaginal Discharge

• Common causes:

 – Neisseria gonorrhoeae

 – Chlamydia trachomatis

 – Trichomonas vaginalis

 – Bacterial vaginosis

 – Candida albicans

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Patient complains

of vaginal discharge or

vulval itching/ burning

Abnormal discharge present

Take history, examine patient(external speculum and bimanual)

and assess risk

Lower abdominal tenderness

or cervical motion tenderness

Was risk assessment positive?

Is discharge from the cervix?

Vulval edema/curd like discharge

Erythema excoriation presentTreat for bacterial vaginosis

and trichomoniasis

Treat for chlamydia, gonorrhea,

bacterial vaginosis and trichomoniasis

Use flow chart for lower abdominal pain

Educate

Counsel

Promote and provide condomsOffer VCT

Educate

Counsel

Promote and provide condoms

Offer VCT

Treat for

candida albicans

No

 Yes

 Yes

 Yes

No

No

No

 Yes

Vaginal Discharge

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Sexual History

• Symptoms (including duration)

• Last sexual intercourse

• Sex of partner

• Relationship with partner (casual, longterm)

• Use of condoms

• Sites of exposure (oral, vaginal, anal)

• Last previous partner or partner changes (in the last 3 months)

• Partner’s symptoms 

• Previous STIs• Previous testing of STIs including HIV

• HIV risk assessment

• In women, cervical cytology, gynaecology, and contraception history

•  ALWAYS ASSESS RISK OF PREGNANCY

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Taking a sexual history

• Must be non-judgemental

• Establish rapport and trust with patient

• Reassure regarding confidentiality

• Explain why a sexual history is needed – ask

patient if he/she minds about being asked very

personal questions

•  Acknowledge that many people find it difficult todiscuss their sexual lives openly

• Ideally interview patient alone

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General rules

• Confidentiality

• Chaperone.

• Contact tracing• Health education and counselling

•  Abstain from sex until completed treatment

and partner notification• Follow up of infections

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Syndromic Approach to STI Management

• Identification of clinical syndrome

• Giving treatment targeting all the locally

known pathogens which can cause the

syndrome

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Syndromic Approach to STI Management

Advantages

 – Simple, rapid and

inexpensive

 – Complete care offered at

first visit

 – Patients are treated for

possible mixed infections

 –  Accessible to a broad

range of health workers

 –  Avoids unnecessary

referrals to hospitals

Disadvantages

 – Over-treatment

 –  Asymptomatic infections

are missed

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Gonococcal Urethritis:

Purulent Discharge

Source: CDC Training SLIDES 

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Neisseria gonorrhoea

• Gram negative

intracellular

diplococcus

• Infects mucousmembranes

• Pharyngeal infection

 – 90%

• Incubation 3-5 days

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Gonorrhoea (women)

•  Asymptomatic (50%)

• 16-19 yr women most

common

• Vaginal discharge

• Lower abdo pain

• Dysuria

• IMB/PCB• Pharyngitis

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Opthalmia neonatorum

Rates of diagnoses of uncomplicated genital chlamydial infection

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Sexually Transmitted Infections, HPA Centre forInfections

Rates of diagnoses of uncomplicated genital chlamydial infection

by sex and country

GUM clinics, United Kingdom: 1999 - 2008

Routine GUM clinic returns 

MalesFemales

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Chlamydial Cervicitis

Source: CDC

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Chlamydia

(women)

•  Asymptomatic (80%)

•  Abnormal bleeding-

PCB/IMB

• Lower abdominal pain

• Vaginal discharge

• Dysuria

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Chlamydia trachomatis

• Most common STI in the under 25’s

• Most prevalent - Women 16-19yr, Men 20-24yr

• Women – 80% asymptomatic

• Men – 50% asymptomatic

• Incubation – 7 to 21 days

• COMPLICATIONS- PID, Reiter’s syn,conjunctivitis, chronic pelvic pain, infertility,ectopic pregnancy

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Trichomonas vaginalis

• Flagellated protozoan

• 10-50% asymptomatic

• Vaginal discharge (70%)

 – offensive, frothy, yellow.

• Vulvovaginitis

 –  Itching, dysuria

• Strawberry cervix – 2 %

• Urethritis

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Strawberry cervix/TV

Clinial Manifestations

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Primary Syphilis- Penile Chancre

Clinial Manifestations

Source: CDC

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Secondary syphilis

s

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Secondary Syphilis:

Palmar/Plantar Rash

s

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Secondary Syphilis - Alopecia

Source: CDC/ NCHSTP/ Division of STD Prevention, STD Clinical Slides

Pathogenesis

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Treponema pallidum on

darkfield microscopy

Pathogenesis

Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides

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Congenital syphilis

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Congenital syphilis

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Congenital syphilis

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Congenital syphilis

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Syphilis

• Primary syphilis  – 9-90 days incubation• Caused by treponema pallidum

• Solitary well-circumscribed ano-genitalulceration (chancre) with regional

lymphadenopathy• Typically painless, may be multiple and

extragenital (oral)

• Secondary syphilis  – 6 weeks to 6 months

• Multisystem involvement• Generalized rash (palms and soles), fever,

lymphadenopathy, condylomata lata (moist wartlike lesions)

•  Arthralgia, alopecia, hepatitis, glomerulonephritis

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Other clinical syndromes

• Early latent  – within first 2 years of

infection

• Late Latent syphilis - > 2 years after initial

infection

• CVS/ Neurosyphilis/ Gummatous disease

• Congenital syphilis  – rare. All pregnant

women currently screened

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Syphilis in pregnancy

• 33 year old Malay,18/40 pregnant,

 Asymptomatic

• RPR 1: 128

• TPPA : Reactive

• WHAT IS THE DIAGNOSIS?

• WHAT WOULD YOU LIKE TO ASK HER?

• WHAT WOULD YOU DO?

• HOW WOULD YOU MONITOR HER TREATMENT

RESPONSE?

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• Likely primary or secondary syphilis given high RPR titre

•  Always repeat syphilis serology to confirm

• Examine for chancre, rash involving palms and soles

• Has she been tested or treated for syphilis in the past?

• Has her partner got symptoms?• Treat with Benzathine Penicillin 2.4 MU X 1

• If penicillin allergic- treat with erythromycin but need to

treat baby

• Screen partner and treat him epidemiologically•  Alert paediatrician

• Repeat syphilis serology in 1, 3, 6 and 12 months-

quantitative RPR

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HSV

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Genital Herpes: Recurrent Ulcer

Source: CDC

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Genital Herpes: Primary Lesions

Source: CDC

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Herpes Simplex

• Most common cause of genital ulceration worldwide

• Type 1 – oro-genital

• Type 2 – genital

• Incubation period 3-14 days• HSV 2 prevalence 80% in HIV positive African

population

• Estimated HSV 2 prevalence 20-40% in EU/USA

• Disproportionate Increase in HSV1 as cause of GH espin young females over past 10 years

• 70% of new infections acquired from asymptomatic viral

shedders

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Symptoms

•  Asymptomatic

• Constitutional symptoms/prodrome

(tingling)

• Painful Vesicles/ulcers (multiple)

• Dysuria

• vaginal discharge

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Clinical syndromes

• Primary episode – most painful, can last 3/52

• Recurrences – may be mild

•  Asymptomatic viral shedding

• DIAGNOSIS – clinical, HSV IF, culture, PCR

• TREATMENT – saline baths, analgesia

•  Antivirals- Acyclovir,Valaciclovir

• Consider suppressive therapy for recurrences>6 episodes/year

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HSV in pregnancy-Case

•  A 32 year old woman 36 weeks pregnant

in her 2nd pregnancy presents at your

clinic.

• She feels unwell, has inguinal

lymphadenopathy and has painful genital

ulcers which look typical of genital herpes

• How would you manage this case?

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• The greatest risk of transmission is

amongst those women who shed the

virus at term and who have acquired

HSV in pregnancy for the first time (31-40%)

• Should consider Caesarean Section for all

women especially those entering labourwithin 6 weeks of the first episode as the

risk of viral shedding is high

y oes a pr mary ep so e

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y oes a pr mary ep so ecarry such a great risk?

• Cervicitis ( in 70% of first episodes)

• Large quantity of virus

• There is no passively acquired protective

antibody

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Genital Ulcer Disease

Differentials

Herpes simplex*

Syphilis

LGV

Chancroid*

Granulomainguinale

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Genital Warts

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Genital Warts

• Benign epithelial skin tumors

• Caused by human papilloma virus (HPV)

• >100 subtypes of HPV of which 40 strains affect the genital tract

• Most (90%) ano-genital warts are caused by HPV 6 & 11 (non-oncogenic subtypes)

• Transmitted by unprotected vaginal, anal or oral sex or by direct skin to skin contact

• Estimated US annual incidence of 1% of the adult population• Genital HPV DNA is found in 10-20% of those aged 15-49 years

• Most cases of HPV infection are subclinical

• Most HPV infections are transient and 95 % resolve on their own within 2 years

• Condoms have been shown to protect against HPV acquisition and genital warts

• For some patients, the psychological impact of the warts is the worst aspect of the

disease•  All treatments have significant failure and relapse rates

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HPV Vaccination

• Name 2 types of HPV vaccines available in the

market

• What do HPV vaccines protect the individual

against?• Is there a national HPV programme?

• If you were a parent, would you vaccinate your

child against HPV?

• Give another example of a vaccine which is

used to prevent an STI

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Protection beyond the cervix

HPV associated cancers• Cervical (43.5%)

• Vaginal (2.4%)

• Vulval (9.1%)•  Anorectal (12.1%)

• Oropharyngeal (29.5%)

• Penile

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ASK

Questions

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Thank You