Infection
Year
2000
2009
2013
Chlamydia
Total cases
702,039
1,244,180
1,401,906
Rate
257.5
405.3
446.6
Cases in women
563,206
912,718
993,348
Rate
404.0
586.7
623.1
Cases in men
137,049
328,783
405,652
Rate
102.8
217.1
262.6
Gonorrhea
Total cases
358,995
301,174
333,004
Rate
131.6
98.1
106.1
Cases in women
178,854
162,568
163,208
Rate
128.3
104.5
102.4
Cases in men
179,375
137,819
169,130
Rate
134.6
91.0
109.5
Chlamydia
The total case rate for Chlamydia trachomatis infection in 2013 decreased by 1.5 % compared to the rate in 2012; this is the first time since nationwide reporting for chlamydia began that the overall rate of reported cases of chlamydia has decreased. The rate in women decreased 2.4 %, while the rate in men increased 0.8 %. During 2009–2013, the chlamydia rate in men increased 21 %, compared with a 6.2 % increase in women during this period [3]. In 2013, 949,270 cases of chlamydial infection were reported among persons aged 15–24 years of age, representing 68 % of all reported chlamydia cases.
Figure 10.1 shows the rates of reported cases of chlamydia in the USA by year, and Fig. 10.2 shows the rates of chlamydia infection by state in 2013. Figure 10.3 shows the rates of chlamydia by age and gender in 2013.
The larger number of chlamydia cases in women reflects the impact of screening for this infection; however, the increased use and availability of urine testing helps to explain the increased infection rate in men. The lower rate among men also suggests that many of the sex partners of women with chlamydia are not receiving a diagnosis of chlamydia or being reported as having chlamydia [3].
Gonorrhea
Following a 74 % decline in the rate of reported Neisseria gonorrhea during 1975–1997, overall gonorrhea rates in the USA plateaued for 10 years. After the decline halted for several years, gonorrhea rates decreased further to 98.1 cases per 100,000 population in 2009, the lowest rate since recording of gonorrhea rates began. Since then, the rate of gonorrhea has fluctuated from year to year with an overall trend toward a slight increase. In 2013, the rate of reported gonorrhea was higher in men than in women for the first time since 2000 [3]. This increase may be due to increased disease transmission or may be due to increased detection of cases due to screening high-risk patient populations or to the ease of urine-based diagnostic testing compared to urethral swab testing.
The highest rates of gonorrhea tend to be in the southern and southeastern USA; in 2013, the rate of reported gonorrhea was higher in men than in women for the first time since 2000, corresponding to the similar trend with reported chlamydia. In 2013, as in previous years, men aged 20–24 years had the highest rate of gonorrhea (459.4 cases per 100,000 males) compared with males across other age groups.
Syphilis
After declining throughout the 1990s, the rate of primary and secondary (P&S) syphilis reported in the USA increased each year from 2001 through 2009 and has continued a slower increase from 2010 through 2013 [3]. The increased rates are due almost solely to an increased rate in men; in 2013, men accounted for 91 % of all P&S syphilis cases, and 75 % of these cases are in MSM. In this population, about one-half of MSM patients with syphilis also were infected with HIV, whereas the coinfection rate during the same time was approximately 10 % in men who have sex with women (MSW) and 5 % in women. During 2000–2013, the rate of P&S syphilis among men 20–24 years old increased from 4.3 to 27.7 cases per 100,000, representing the highest rate of P&S syphilis among any age group in men. From the standpoint of STI and sexual health care in men, syphilis has once more become an important disease to consider when assessing patients’ STI risk factors. Figure 10.4 shows the reported cases of syphilis by gender and sexual behavior from 2007 to 2013.
HPV
Prevalence data on genital warts due to human papillomavirus (HPV ) were compiled by information via provider diagnosis or by documentation from the physical examination. Gay, bisexual, and other MSM and men who have sex with women only (MSW) were defined by self-report or by reported sex partners. Between 2010 and 2013, among patients in STI clinics who were diagnosed with genital warts, 17.0 % were women, 20.5 % were MSM, and 62.5 % were MSW.
In 2013, the prevalence of diagnosed genital warts among MSM was 3.0 times that of women, and the prevalence among MSW was 4.0 times that of women [3]. During 2010–2013, prevalence of genital warts among MSW increased (6.8–7.4 %), while prevalence among MSM decreased (6.3–5.5 %). The proportion of women diagnosed with genital warts decreased slightly over time, from 1.9 % in 2010 to 1.6 % in 2013. Figure 10.5 shows the rates of genital warts by age and gender.
HSV
Herpes simplex virus 2 (HSV2) is essentially ubiquitous in the US population and throughout the world and is an important cause of genital ulcer disease and genital herpes. Genital ulcer disease is associated with an increased risk of acquiring HIV disease, presumably due to exposure of mucosal surfaces that allow increased transmission of infection. Since genital herpes is not a reportable illness, it is impossible to create similarly detailed epidemiologic data and assessments compared to other STIs; the CDC reports only HSV -related physician visits rather than complete case data which is unavailable. Approximately 90 % of patients who are HSV seropositive are unaware of this [3]. Serology for HSV2 is not generally useful in predicting clinical symptoms or transmission, but is often used as a surrogate in place of more specific epidemiologic data. In general, while HSV-2 seroprevalence is increasing, HSV-related physician visits are increasing, possibly due to increased recognition and awareness of infection [3]. Figure 10.6 shows the seroprevalence of HSV2 by age group, ethnicity, and year.
Clinical Features of STIs in Men
The common STIs produce generally predictable clinical syndromes; the presenting features and symptoms of these infections differ from men to women, and a review of the key clinical features of these disorders specific to men can help physicians maintain an appropriate index of suspicion for STIs in patients with various presenting complaints.
During sexual intercourse or other contact, STIs are typically transmitted at the site of breaks in mucosal surfaces that are exposed to STI-causing organisms [4]. Women have a greater exposed mucosal surface than do men, and these surfaces are subjected to greater trauma, which in part explains the increased risk women have for STIs.
Men’s physical examination to evaluate for evidence of STIs is easier and less invasive than in women, in whom the vagina and cervix must be visualized. Despite this, the ready availability of urine-based STI testing may limit the actual physical examination of men for STIs, particularly in “express treatment” STI clinics that rely heavily on urine-based testing and forego the clinical examination. One study found an increased rate of missed STI diagnoses in men presenting to an STI clinic with symptoms (10.4 %) compared to the group of asymptomatic patients (2.6 %) and the group of patients presenting after identification of an STI in a sexual contact (4.5 %) [5]. This suggests that even when a diagnosis of urethritis seems evident based on history and can be confirmed on urine testing, a physical examination is still important to identify other or unsuspected STIs or genital infections, such as balanitis, scabies, epididymitis, penile warts, or genital herpes, as well as a disseminated gonococcal infection and the small proportion of primary syphilis cases [5].
Clinical Syndromes
The clinical syndromes for STIs in men include the following: urethritis, presenting with urethral discharge or irritation; genital ulcer disease; HPV causing genital warts; and disorders presenting with irritative voiding. Table 10.2 lists the most common clinical syndromes and causative organisms for STIs in men.
Table 10.2
Clinical syndromes and causative organisms for male STIs
Syndrome | Agent |
---|---|
Urethritis | N. gonorrhoeae, C. trachomatis, herpes simplex virus (HSV), T. vaginalis, M. genitalium |
Epididymitis | C. trachomatis, N. gonorrhoeae |
Genital ulceration | HSV, T. pallidum, H. ducreyi, Klebsiella granulomatis, C. trachomatis (LGV strains) |
Nonulcerative genital skin lesions | T. pallidum, C. albicans, HSV |
Genital warts | Human papillomavirus (HPV) types 6 and 11 |
Molluscum contagiosum | Pox virus |
Ectoparasite infestations | Sarcoptes scabiei, Phthirus pubis |
Cervical intraepithelial neoplasia, carcinoma | HPV types 16 and 18 and other oncogenic HPV types |
Anal carcinoma | HPV types 16 and 18 and other oncogenic types |
Hepatocellular carcinoma | Hepatitis B |
Kaposi’s sarcoma | HIV, HHV-8 |
Hepatitis | Hepatitis A, B and C viruses, cytomegalovirus, T. pallidum |
Acquired immune deficiency syndrome (AIDS) | HIV-1, HIV-2 |
Acute arthritis with urogenital or intestinal infection | N. gonorrhoeae, C. trachomatis, Shigella sp., Campylobacter sp. |
Urethritis
Chlamydia trachomatis infection in men is often asymptomatic but is more often symptomatic than in women. Chlamydia in men typically presents with urethral pain and dysuria rather than urethral discharge. These symptoms of urethritis are the most common presentation for STIs in men. Gonorrheal infections behave similarly in terms of clinical presentation in men, although they are more commonly symptomatic. Post-gonococcal urethritis is a syndrome of recurrent urethral discharge and/or dysuria following single-dose treatment for gonococcal urethritis and likely represents untreated chlamydia infection [7, 8].
Epididymitis/Orchitis
Ascending infection with chlamydia or gonorrhea can cause clinical syndromes of epididymitis or orchitis ; these syndromes are more commonly due to STI-causing organisms in men younger than 35 years of age, while in men older than 35 years they are most often due to E. coli or other gastrointestinal organisms. An infection with a systemic inflammatory response, for example, due to N. gonorrhea, can cause reactive arthritis. Some serovars of chlamydia can cause proctitis in MSM, resulting in rectal pain or discharge [9].
Extragenital manifestations of chlamydia and gonorrhea include pharyngitis, which usually presents as an exudative pharyngitis; laboratory testing is required since the physical exam cannot confirm the causative organism. Chlamydia, gonococcal, and trichomonas infections have in the past been thought to be causative factors in the development of chronic prostatitis, but subsequent research has not found a clear association between STIs and prostatitis syndromes. Some authors proposed that most chronic prostatitis syndromes are inflammatory and not bacterial/infectious in nature and antibiotic therapy is often unsatisfying in symptom resolution [2].
Genital Warts
In men, genital warts present as flesh-colored lesions on the skin of the penis, perianal region, or urethral mucous membrane. They can appear as flat, verrucous, or pedunculated lesions and may range in size from 1 mm to 10 cm or more. Associated symptoms may include discomfort, pain, bleeding, or difficulty with sexual intercourse, although these symptoms are more common with larger, cauliflower-like lesions that may develop. Urethral lesions may impair the passage of urine or semen and lead to obstructive symptoms in severe cases [2].
Genital Herpes
The primary infection with herpes simplex virus (HSV) is often accompanied by prodromal viral symptoms of headache, fever, malaise, and myalgias, with subsequent outbreak of painful vesicles on the external genitalia that may then ulcerate or erode. Infection is transmitted by direct contact with infected mucosa or secretions, and the incubation period ranges between 2 and 20 days. New outbreaks may occur in the second week after the primary infection and is commonly associated with tender regional lymphadenopathy. In men, lesions occur on the penile shaft, glans, and prepuce. Men who engage in receptive anal intercourse can develop HSV proctitis with pain, tenesmus, and rectal discharge/fecal incontinence [2].
Assessing STI Risk
Interventions to prevent STIs depend upon an accurate assessment of a man’s STI risks as well as on epidemiologic and clinical understanding of the disorders involved. Clinical recommendations regarding behavioral counseling, screening, and other preventive health measures are often recommended for men considered to be at “high risk” for STIs, and it is critical to effectively assess these risk factors in men in primary care practices, urgent or emergency care, or STI clinic settings. As with women, STI risk factors include modifiable risks (e.g., sexual behavior) and non-modifiable risk factors (e.g., ethnicity, demographics); STI risk assessment for men should also address the patient’s social context including work and/or living arrangements as possible risk factors that can guide preventive health interventions. Table 10.3 lists modifiable and non-modifiable as well as contextual STI risk factors for men; many of these are the same risk factors as for women.
Table 10.3
STI risk factors in men
Modifiable risk factors |
---|
Sexually active adolescents |
Current or recent (1 year) STI |
Multiple sexual partners |
No consistent condom use |
Men who have sex with men (MSM) |
Exchanging sex for money or drugs |
Current or former intravenous drug use |
Demographic risk factors |
---|
African Americans |
Native Americans, Latinos |
History of sexual abuse |
Situational risk factors |
---|
Low income living in urban setting |
Current or former inmate |
Military recruits |
Mental illness or disability |
Patients seen at STI clinics |
Additional behavioral and contextual risk factors have been investigated; for example, in one study, first leaving the parental home, poor self-regulation or planning skills, emotional distress and hostility, poor attitudes toward condom use, and alcohol binge drinking predicted unprotected sexual contact in rural African American men, but not in women [11]. These factors suggest that obtaining a detailed and patient-centered social history, including an understanding of patient beliefs regarding sexual behavior and STI risks, represents an important area for determining a patient’s overall STI risk profile.
A number of scoring systems and risk calculators (including online scoring systems or cell phone “apps” such as http://www.stdriskcalculator.com/ or http://www.medindia.net/patients/calculators/hiv-risk-calculator.asp) have been developed in an attempt for providers or patients themselves to quantify their degree of STI risk [12]. However, the studies on which such scoring systems have been conducted vary widely in their patient population, baseline STI risk, methods and outcomes assessment, and other factors. As such it is nearly impossible to determine a useful quantitative risk profile for various STI risk factors, and attempts to calculate or quantify such risks have not performed well outside very limited settings.
Physicians and other health-care providers should, instead of attempting to quantify STI risk, simply be aware of the multiple possible risk factors that patients might have for STIs and should try to elicit these details in their history-taking. Assessing an individual patient’s overall STI risk becomes more of a subjective global risk assessment based on the patient’s unique social and medical history, rather than a more quantifiable or scientific risk estimate.
Male Circumcision
Male circumcision has long been felt to have a protective effect against acquiring STIs, particularly HIV and particularly in MSM. Different studies have had variable results, largely as a result of varying patient populations and varying sexual practices. A meta-analysis of 15 studies of over 500,000 MSM [13] found that the odds of being HIV positive were lower in circumcised than in non-circumcised MSM, but the difference was not statistically significant; this study also found that there was no evidence of a protective effect against other STIs.
This study noted that earlier trials showing a protective effect from circumcision were conducted before the advent of highly active antiretroviral therapy (HAART) for chronic HIV disease and that changes in sexual behavior and/or disease transmission may limit the actual current protective effect of circumcision. Also, it is possible that male circumcision can still provide an aggregate protective effect in areas where STI prevalence is high and circumcision prevalence is low (<50 %).
Obtaining the Sexual Health History
Applying a knowledge of STI epidemiology, clinical features, and risk factors depends on eliciting a medical and sexual health history from the patient. Obtaining the sexual history requires the physician to take extra time to ensure that the environment and the physician communication are optimal to protect patient privacy and confidentiality, so that the most effective history and counseling can be conducted. Effective history-taking and communication can be thought of in the following steps:
1.
Ensuring an appropriate setting
2.
Obtaining basic information
3.
Obtaining more detailed information
4.
Using appropriate communication methods
5.
Attending to specific patient circumstances (e.g., MSM, gay, cultural concerns, gender difference, etc.)
Appropriate Setting
Ensuring an environment and setting conducive to an effective discussion of sexual health and STI risks or treatment is vital for obtaining the necessary information from patients as well as increasing the likelihood of behavioral change or adherence to treatment. Arranging such a setting typically entails limiting external interruptions such as nursing questions and personal phone use (by physician or patient) and ensuring that physician and patient have sufficient time for the discussion. Providers should also pay attention to nonverbal communication issues. Taking active steps to sit down, setting the physical chart or electronic record aside, and actively demonstrating an active interest in the patient are critical to convey to the patient that their health needs are the focus of the discussion. Having the patient seated in an exam room chair, rather than on the end of the exam table, can also help ensure that the discussion is a productive one among equal partners, rather than a more formalized physician advice which may not be followed.
Other aspects of ensuring an appropriate setting include assessing patient’s competency to make decisions (or have a suitable surrogate decision-maker present) and discussing in advance an agreed-upon method of giving results of diagnostic testing, particularly for HIV testing.
Basic Information
Once a suitable conversation setting is ensured, providers should obtain basic health history information ; clearly this includes fundamental information such as the patient’s symptoms, agenda of questions or concerns, and/or reason for presentation for medical attention, as well as their general medical history, current medications and allergies, and full social history. The history data to be obtained regarding STI risks or treatment should also include any previous history of STIs and any previous immunizations against STIs such as vaccination against HBV or HPV. The focused sexual health and STI discussion however will address additional information pertinent to these areas.
This history can be triggered or initiated based on a number of different factors:
Men presenting with sexual health symptoms or symptoms suggesting an STI
Men presenting to an STI clinic
As part of a routine health maintenance visit that includes questions specifically to assess sexual health or as part of a “review of systems”
When prompted by factors in the social history (e.g., new partner, multiple partners, history of previous STI, etc.)
A medical encounter conducted while the patient is in the military, in prison, or in institutionalized settings that represent a situational risk factor for STIs
A number of guidelines [1, 14] describe the content for a basic sexual health history and STI risk assessment when evaluating male patients. The content of the basic STI/sexual health history includes the following data elements or questions:
Last sexual contact, partner’s gender, anatomic sites of exposure, and sexual practices used
Previous sexual partners and sexual practices used, if in the last 3 months, and a note of total number of partners in the last 3 months if more than two
Any suspected infection, infection risk, or symptoms in recent partners
Previous STIs
Methods used to prevent STIs and methods used to prevent female partner from becoming pregnant, if any (including condom use)
Blood-borne virus risk assessment and vaccination history for those at risk
Reproductive history, including history of previous fathered children, and any plans for future children
When obtaining the sexual health history, physicians should allow sufficient time to obtain all of the above information and should inform patients that this will be used to help address the patient’s concerns and improve their overall health.
Detailed Information
Either as part of a routine sexual health history or when prompted by patient-specific concerns or known medical history, it is often necessary to ask more in-depth questions pertaining to a patient’s sexual health and STI risks. While the above basic data pertains to most or all patients, the following data will likely be obtained only when prompted by various patient factors:
History of domestic or intimate partner violence
History of alcohol and/or drug use or abuse
Mental health history including history of mental health disorders
Any history of trading sex for money or drugsStay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree