Sexually Transmitted Diseases

Kristin A. Englund

Carlos M. Isada

RAPID BOARD REVIEW—KEY POINTS TO REMEMBER:

Nongonococcal Urethritis

Chlamydia trachomatis in 50%, Ureaplasma urealyticum, Trichomonas vaginalis, and herpes simplex virus (HSV) in 15%, no etiology in 35% of cases.
Complications include epididymitis and reactive arthritis.
Partner notification is important because female sexual partners are at high risk for chlamydial infection.
Urethritis can be diagnosed
- on clinical grounds alone when a purulent urethral discharge is present.
- by ≥5 polymorphonuclear leukocytes per oil immersion field on the swab smear.
- by a positive leukocyte esterase test from a first-void urine specimen with ≥10 white blood cells per highpower field. Confirm with Gram stain.
Submit routinely for the detection of Neisseria gonorrhoeae and Chlamydia trachomatis.

Mucopurulent Cervicitis

The major infectious include C. trachomatis, N. gonorrhoeae, and HSV.
The diagnosis is supported by the visualization of a yellow or green endocervical mucopus on a white swab (positive swab test result).
Treatment should cover both C. trachomatis and N. gonorrhoeae.

C. trachomatis Infection

The CDC recommends routine annual screening for C. trachomatis
- in all sexually active adolescents and sexually active women ≤25 years.
- in older women with risk factors (new sexual partner or multiple partners).
Women with documented chlamydial infections undergo routine rescreening 3 to 12 months after the completion of treatment (CDC).

Gonorrhea

In women, gonococcal infections are often asymptomatic.
Quinolone use is not recommended because of quinolone-resistant N. gonorrhoeae.
Suspect disseminated gonococcal infection when hemorrhagic pustules, symptoms of tenosynovitis, or oligoarthritis are present.

Genital Ulceration with Regional Lymphadenopathy

GENITAL LESIONS	INCUBATION	TYPE	PAIN	NUMBER	DURATION
Primary syphilis (Treponema pallidum)	3-90 days	Clean ulcer, raised	No	Usually single	3-6 weeks
Primary herpes simplex virus (HSV-1 or -2)	1-26 days	Grouped papules, ulcers, vesicles, pustules,	Yes	Often multiple	1-3 weeks
Chancroid (Haemophilus ducreyi)	1-21 days	Purulent ulcer, shaggy border	Yes	Single in men, multiple in women	Progressive
Lymphogranuloma venereum (Chlamydia trachomatis)	3-21 days	Papule, vesicle, ulcer	No	Usually single	Few days
Granuloma inguinale (Calymmatobacterium granulomatis)	8-80 days	Nodules, coalescing granulomatous ulcers	No	Single or multiple	Progressive
INGUINAL ADENOPATHY	ONSET	TYPE	PAIN	FREQUENCY	CONSTITUTIONAL SYMPTOMS
Primary syphilis	Same time	Firm	No	80%, 70% bilateral	Absent
Primary herpes simplex virus	Same time	Firm	Yes	80%, usually bilateral	Common
Chancroid	Same time	Fluctuant, may fistulize	Yes	50-65%, usually unilateral	Uncommon
Lymphogranuloma venereum	26 weeks later	Indurated, fluctuant, may fistulize	Yes	Unilateral, 1/3 bilateral	Common
Granuloma inguinale	Variable	Suppurating pseudobubo	10%	15%
HSV, herpes simplex virus.

SYPHILIS

Primary Syphilis