Sexually Transmitted Diseases

in Older Adults
Margaret-Mary G. Wilson, MD, MRCP (UK)

Corresponding author
and sexual activity are encouraged in older adults with
Margaret-Mary G. Wilson, MD, MRCP (UK)
Division of Geriatric Medicine, St Louis University Health Sciences relatively little emphasis placed on creating a “safe sex”
Center, 1402 South Grand Boulevard, Room M238, St. Louis, culture among elders. This trend, which paradoxically
MO 63104, USA. would be considered irresponsible and dangerously per-
E-mail: [email protected] missive in younger adults, may have contributed to the
Current Infectious Disease Reports 2006, 8:139 –147 significant rise in the prevalence of sexually transmitted
Current Science Inc. ISSN 1523-3847 disease (STD) in older adults.
Copyright © 2006 by Current Science Inc.
In the United States, over 65 million people have an
incurable STD. The annual incidence of STDs is 15 million,
of whom approximately 50% will develop lifelong infections.
Health professionals are frequently reluctant to recognize
Geriatric health professionals must become increasingly
or investigate the sexuality of their older patients. Thus,
aware of the likelihood of sexually transmitted disease as a
sexual health may never be addressed, even among older
differential diagnosis in their older patients [4,5].
adults who come into frequent contact with health care
professionals. As the dominant culture continues to shift
toward a more realistic view of aging that supports the
expression of sexuality among older adults, evaluation of
Common Sexually Transmitted Diseases
sexual health will become a critical component of com-
in Older Adults
Urethritis in men
prehensive assessment of the geriatric patient. This article
Gonococcal urethritis is caused by Neisseria gonorrhoea,
reviews the clinical features and management of common
a gram-negative intracellular diplococcus. The diagnosis
sexually transmitted diseases in the older adult.
of nongonoccocal urethritis (NGU) is made when
N. gonorrhoea is not identified on urethral smears. Com-
mon causative organisms of NGU include Chlamydia
Introduction trachomatis, Ureaplasma urealyticum, and Mycoplasma geni-
Most adults over the age of 60 years are sexually active. talium. Intensive chlamydial screening programs have led
Seventy-one percent of men in their sixties and over 50% to marked decline in NGU due to C. trachomatis [6–10].
of women in the same age group report that they are still The exact prevalence of other causes of NGU is unclear,
sexually active. Over fifty percent of adults over the age as laboratory testing in most cases of nongonococcal,
of 60 years engage in some form of sexual activity at least nonchlamydial urethritis is precluded by cost and rarely
once a month. Similarly, over one quarter of persons over alters management.
the age of 80 years describe themselves as sexually active. Urethritis usually presents with either dysuria or urethral
Discussion of sexuality in older adults is no longer consid- pruritus associated with a mucopurulent urethral discharge.
ered anathema among the lay population. Increasing social Clinical diagnosis of urethritis is established by the pres-
activism among “baby boomers” aimed at eliminating ence of any of the following criteria: 1) mucoid or purulent
marginalization of the aging segment of society has created urethral discharge, 2) positive leukocyte esterase test on the
a more permissive atmosphere. Thus, issues relating to initial portion of voided urine or the presence of more than
geriatric sexuality are now relatively openly addressed and 10 white blood cells (WBCs) on microscopic examination of
acknowledged [1,2•,3]. the sample, or 3) positive results on gram staining.
Nevertheless, vestiges of societal discomfort with the Urethral secretions from affected patients usually
concept of sex and older adults are manifest in the inap- contain more than 5 WBCs per high-powered oil immer-
propriate medicalization of geriatric sexuality. Emphasis sion field. If gram-negative intracellular diplococci are not
is more likely to be placed on sexual dysfunction and identified on microscopy, specific testing using polymerase
negative stereotypes depicting the “impotent elder.” chain reaction (PCR) techniques should be conducted to
Perhaps in an attempt to counter such images, intimacy screen for chlamydia [11,12].
140 Sexually Transmitted Diseases

Table 1. Common sexually transmitted diseases: Recommended treatment regimens

Diagnosis First-line therapy Alternative therapies
Gonorrhea Certiaxone 125 mg IM—single dose Any of the following:
Cefixime 400 mg orally—single dose
Ciprofloxacin 500 mg orally—single dose
Levofloxacin 250mg orally—single dose
Chlamydia trachomatis Azithromycin 1 g orally—single dose Doxycycline 100 mg orally twice daily for 14 days
Trichomoniasis Metronidazole 2 g orally—single dose Metronidazole 500 mg twice daily for 7 days
Bacterial vaginosis Any of the following: Any of the following:
Metronidazole 500 mg orally twice daily Metronidazole 2 g orally—single dose
for 7 days
Metronidazole gel (0.75%) 5 g intravaginally Clindamycin 300 mg orally twice daily for 7 days
once daily for 5 days
Clindamycin cream (2%) 5 g intravaginally once Clindamycin ovules 100 g intravaginally once at
daily for 7 days bedtime for 3 days
Vulvovaginal candidiasis Fluconazole 150 mg orally—single dose Any of the following:
Intravaginal azole topical formulations (butocon-
azole, clotriamazole, miconazole, terconazole)
Nystatin (100,000 units) 1 vaginal tablet daily
for 14 days
Genital herpes Any of the following (for the first clinical episode): Any of the following (for recurrent episodes):
Acyclovir 400 mg orally three times daily Acyclovir 300 mg orally three times daily
for 7–10 days for 5 days
Acyclovir 200 mg orally five times daily Acyclovir 200 mg orally five times daily for 5 days
for 7–10 days
Famcyclovir 250 mg orally three times daily Acyclovir 800 mg orally twice a day for 5 days
for 7–10 days
Valacyclovir 1 g orally twice a day for 7–10 days Famcyclovir 125 mg twice a day for 5 days
Valacyclovir 1 g orally once a day for 5 days
Genital herpes— Any of the following: N/A
chronic suppression
Acyclovir 400 mg orally twice a day
Famcyclovir 250 mg orally twice a day
Valacyclovir 500 mg orally once a day
Valacyclovir 1 g orally once a day
IM—intramuscularly; N/A—not available.

Because persons infected with N. gonorrhoea have a the preferred choice for the empirical treatment of con-
high prevalence of co-infection with C. trachomatis, treat- comitant chlamydial infections as single-dose therapy
ment for gonorrhea must be accompanied by simultaneous allows for direct observation of treatment [13,14].
treatment for genital C. trachomatis infection (Table 1). Persistent or recurrent symptoms, following treatment,
Patients should instruct all sexual contacts within 60 days should prompt repetition of the initial course of therapy
of symptom onset or their most recent sexual partner to if noncompliance is suspected. In compliant patients,
be screened for N. gonorrhoea and C. trachomatis infections. Trichomonas vaginalis or U. urealyticum are the most likely
Following diagnosis, sexual intercourse should be avoided causes of persistent or recurrent symptoms. Recommended
for at least 1 week after treatment and complete resolution treatment in such cases is a single dose of 2 grams of met-
of symptoms. High-risk and potentially noncompliant ronidazole and a 7-day course of erythromycin [15–17].
patients should be treated empirically. Sexual partners of Use of quinolones as first line therapy should be discour-
such persons should also be offered empirical treatment. aged due to the increasing incidence of quinolone resistant
Additionally, in poorly compliant patients, azithromycin is N. gonorrhoae [18,19].
 Sexually Transmitted Diseases in Older Adults Wilson 141

Vaginitis and cervicitis gel achieves subtherapeutic perivaginal and urethral levels
Annually, 12 million women are diagnosed with vagi- resulting in a cure rate of less than 50%. Use of the gel
nitis or cervicitis. Affected women are more likely to be formulation is no longer recommended for the treatment
teenagers or young adults (< 40 years). Data are lack- of trichomoniasis [26,27] (Table 1).
ing regarding the incidence of these diseases in older Affected male sexual partners may be asymptomatic or
women. However, symptom reporting among older complain of only mild dysuria or urethral discharge. Thus,
women may be hampered by factors such as embarrass- all sexual partners of affected women should be treated,
ment, poor attention to sexual health, and cognitive regardless of symptoms. Patients should abstain from sexual
or functional impairment. Thus, health care providers intercourse until treatment is complete and symptoms have
must routinely ask their patients about the presence of resolved. Follow-up examination is not recommended for
such symptoms. patients who are asymptomatic after treatment.
Presenting symptoms of vaginitis and cervicitis
include local pruritus, pain, and/or foul-smelling vagi- Gonococcal and chlamydial cervicitis
nal discharge. Vaginitis and cervicitis are not readily Most women with gonoccocal or chlamydial cervicitis
distinguishable by history taking as the most common are asymptomatic. Consequently presentation may be
symptom of both syndromes is an abnormal vaginal delayed until complications such as infertility or pelvic
discharge. Thus, comprehensive pelvic examination and inflammatory disease arise. Approximately one third of
appropriate laboratory testing must be carried out on any women will complain of abnormal vaginal discharge,
woman with abnormal vaginal symptoms. bleeding, or dysuria. Pelvic examination usually reveals
The most common sexually transmitted vaginal and a swollen, erythematous cervix with purulent endocervi-
cervical infections are trichomoniasis, gonorrhea, and cal, urethral discharge, and/or evidence of complicating
chlamydial infections. The latter must be differentiated adnexitis. Clinical features of chlamydial infection are
from other syndromes of infectious vaginitis such as can- indistinguishable from those caused by gonococcal cer-
didiasis and bacterial vaginosis which are not primarily vicitis. Microbiologic diagnosis of either gonoccocal or
sexually transmitted infections [20,21••]. chlamydial cervicitis is made by microbiologic culture or
using nucleic acid amplification tests [9–11,28,29].
Trichomoniasis Treatment recommendations are identical to those
Trichomoniasis is caused by a sexually transmitted outlined for the management of gonococcal urethritis
protozoan, T. vaginalis, which results in vaginal and in men (Table 1). Dual treatment for both chlamydia
ectocervical infection. Presenting symptoms include and gonorrhea is recommended. All recent sexual part-
irritation around the vulva and vagina, copious foul- ners should be evaluated and treated. Thereafter, the
smelling vaginal discharge, and dyspareunia. Some patient and all sexual partners should abstain from sex
patients may complain of a burning sensation around until 7 days after treatment and complete resolution of
the vulva during micturition due to local perineal symptoms [9–11].
inflammation. Dysuria resulting from concomitant
urethritis or cystitis may also result from T. vaginalis Bacterial vaginosis
infection. Pelvic examination usually reveals the pres- Normal adult vaginal commensal flora is made up mainly
ence of a characteristic thin, frothy greenish-yellow of hydrogen peroxide–producing lactobacilli that serve to
vaginal discharge and an erythematous vulva and suppress the growth of pathogenic anaerobic organisms.
vagina. Direct inspection of the cervix reveals the clas- When this protective mechanism fails anaerobes—such
sical “strawberry cervix” characterized by punctate as Gardnerella vaginalis, Mycoplasma hominis, Prevotella, and
hemorrhagic lesions on the ectocervix. Microscopic Mobiluncus species—proliferate. This alteration in vaginal
examination of a wet-mount preparation of the vagi- flora results in the clinical syndrome of bacterial vagino-
nal discharge reveals polymorphonuclear leukocytosis sis. Pathophysiologic mechanisms that trigger this change
and motile trichomonads. False negative results are in vaginal flora are poorly understood. Observational
not uncommon as microscopic examination has a sen- studies indicate that bacterial vaginosis may be precipi-
sitivity of less than 70%. Thus, the gold standard for tated by vaginal douching and multiple sexual partners.
diagnosis is culture of vaginal secretions [22,23]. Although it may be argued that there is insufficient evi-
Traditionally considered a disease of women, T. vaginalis dence that bacterial vaginosis is a sexually transmitted
should also be considered in sexually active men with disease, this syndrome occurs most often among sexu-
symptoms of urethritis but with little or no discharge ally active women and in populations with an increased
on physical examination [24,25]. prevalence of sexually transmitted disease. Nonetheless,
Metronidazole is the only available agent approved by bacterial vaginosis frequently occurs in women who have
the Food and Drug Administration (FDA) for treatment of never had sexual intercourse [30–32].
trichomoniasis in the United States. Oral metronidazole Bacterial vaginosis is the most common cause of
achieves cure rates of approximately 95%. Metronidazole foul-smelling vaginal discharge in women, accounting
142 Sexually Transmitted Diseases

Table 2. Clinical features and recommended treatment for syphilis

Clinical features Treatment
Primary syphilis (9–90 Chancre, nontender regional lymphadenopathy Benzathine penicillin G 2.4 million units
days after exposure) IM—single dose
Secondary syphilis Mucocutaneous ulcers, generalized Benzathine penicillin G 2.4 million units
(6 wk–6 mo lymphadenopathy, palmar and plantar rash, IM—single dose
after exposure) condylomata lata, meningitis, peripheral and
cranial neuropathy, hepatitis, iritis, uveitis
Latent syphilis Positive serology Early latent: benzathine penicillin G 2.4 million
units IM—single dose
No clinical features Late latent or late of unknown duration: benzathine
penicillin G 7.2 million units IM in 3 divided doses of
2.4 million units at weekly intervals
Tertiary syphilis (several Gummas, aoritis, aortic aneurysms, Neurosyphilis: Aqueous crystalline penicillin G 18–24
years after exposure) coronary stenosis, neurosyphilis million units daily in 6 divided doses or continuous
infusion; or procaine penicillin 2.4 million units IM
once daily + probenecid 500 mg orally 4 times daily
for 10–14 days
Tertiary syphilis with no evidence of neurosyphilis:
benzathine penicillin G 7.2 million units IM, in 3
divided doses of 2.4 million units at weekly intervals
IM—intramuscularly.

for approximately half of all cases of infectious vaginitis. Genital ulcers

Affected women complain of a thin frothy grayish vagi- In the United States, approximately 5% of patients who
nal discharge with an odor often described as “fishy.” contact STDs present with genital ulcers. Prompt detection
Bacterial vaginosis is a noninflammatory condition, and treatment of genital ulcer disease (GUD) is especially
so accompanying symptoms such as dysuria or dyspa- critical to reduction of the risk of HIV transmission. As
reunia are usually absent. Vaginal pH is usually greater clinical diagnosis of GUD is unreliable, empirical therapy
than 4.5. The “whiff test” has a diagnostic sensitivity is ill-advised and appropriate diagnostic tests should be
and specificity of 87% and 98% respectively. Addition conducted in all patients. All sexual contacts of patients
of potassium hydroxide (10% KOH) to a sample of the with genital ulcers should be screened [37,38].
vaginal discharge resulting in intensification of the
characteristic “fishy” odor, caused by release of amines Genital herpes
induced by alkalinization, is the hallmark of a positive Genital herpes, caused by herpes simplex virus type 2,
“whiff test.” Wet-mount examination of the discharge is the most common sexually transmitted GUD in the
reveals pathognomic “clue cells” which are vaginal United States and in women over the age of 50 years.
epithelial cells studded with bacteria. There is a striking Additionally, over 20% of young adults in the United
paucity of polymorphonuclear cells due to the absence States have genital herpes.
of inflammation. Objective diagnosis of bacterial vagi- Following an incubation period that ranges from 2 to
nosis can be made based on the presence of three of the 20 days, symptomatic women may experience localized
aforementioned four criteria namely 1) typical vaginal perineal or vulval itching. Affected men complain of pru-
discharge, 2) vaginal discharge pH greater than 4.5, ritus affecting the penile glans or shaft. Within a few days,
3) positive whiff test, and 4) clue cells [33,34]. a vesicular eruption may appear which eventually evolves
All symptomatic women should be treated. Any of into a crop of painful, small and superficial ulcers. Coales-
the recommended first-line treatment metronidazole cence of these ulcers often produces a large superficial
regimens may be used and have been shown to be and irregular ulcer that may confound clinical diagnosis.
equally effective (Table 2). Vaginal clindamycin and Notably, approximately two thirds of infected persons may
other alternative regimens are less effective. Follow-up never develop ulcers for reasons which are unclear. Sys-
screening is not recommended for women who respond temic symptoms such as fever, sweats, lethargy and painful
to treatment with resolution of symptoms. Available lymphadenopathy, may co-exist with the primary infection.
data do not show any benefit from concomitant treat- Skin lesions usually resolve within 14 days of onset.
ment of sexual partners. Thus, evaluation or treatment PCR testing is the preferred diagnostic modality for
of asymptomatic sexual partners is not routinely genital herpes with excellent sensitivity even in the pres-
advised [35,36]. ence of healing lesions. In contrast, the sensitivity of
 Sexually Transmitted Diseases in Older Adults Wilson 143

standard viral culture techniques is poor unless intact occur within 6 weeks to 6 months of initial exposure.
vesicles are sampled. The Tzanck test has a diagnostic Clinical manifestations of secondary syphilis usually
sensitivity for genital herpes of less than 50%. This test resolve even without therapy. However, if untreated,
involves the examination of ulcer scrapings for the pres- the patient enters into the latent phase of syphilis infec-
ence of multinucleated giant cells using Wright’s, Giemsa, tion characterized by positive serologic testing in the
or Papanicolaus’s staining techniques [39,40]. Treatment absence of clinical features. Early latent syphilis refers
guidelines are as recommended by the CDC (Table 1). to infections obtained within the preceding 12 months.
All other cases of latent infection are described as late
Chancroid latent syphilis or latent syphilis of unknown duration.
Due to the paucity of accurate diagnostic techniques, Syphilis is most infectious during the primary and sec-
the exact prevalence of chancroid is not known. How- ondary stages, although sexual transmission can occur
ever, chancroid is more common in large urban cities, during the phase of latent infection.
especially in areas where poverty, prostitution, and drug Dark-field microscopic examination of exudate or
use prevail. tissue biopsy specimens from identified lesions may
Following infection with the causative organism, reveal the causative spirochaete, Treponema pallidum.
Hemophilus ducreyi, there is an incubation period of 4 to Serologic diagnostic tests for syphilis are classified
7 days following which a pustule appears at the portal as treponemal or nontreponemal. Treponemal tests
of infection. In women the portal of infection is usually include fluorescent treponemal antibody absorbed
perilabial, whereas men tend to develop lesions near (FTA-ABS) and T. pallidum particle agglutination tests
the prepuce, frenulum, or coronal sulcus. Rupture of the (TP-PA). Nontreponemal tests include Venereal Disease
pustule, which usually occurs within 72 hours, results Research Laboratory (VDRL) and Rapid Plasma Reagin
in multiple discrete purulent ulcers with friable bases tests (RPR). Nontreponemal tests screen for antibodies
and ragged edges. Typically, these ulcers are painful and to treponemal lipoidal antigens and correlate with dis-
bleed easily upon touch. Two thirds of patients also have ease activity, thereby permitting quantitative reporting
painful inguinal regional lymphadenopathy. When such of results. However, the sensitivity of nontrepone-
nodes are complicated by abscess formation, the resulting mal tests is about 80% and false-positive results may
pathognomic lesions are described as bubos. Spontane- result from diseases such as connective tissue disease,
ous bubo rupture may occur, leading to an inguinal ulcer. hepatitis, and viral infections. The occurrence of false-
Clinically, a probable diagnosis of chancroid can be made if positive results, which is also more common in older
all of the following criteria are present: 1) painful genital adults, mandates confirmation of positive tests with
ulcers, 2) suppurative inguinal adenopathy, and 3) negative treponemal tests, which detect antibodies to trepo-
diagnostic testing for syphilis and genital herpes. nemal organelles. Following successful treatment,
Culture of swabbed specimens from the ulcer base or treponemal antibody tests remain positive for life.
bubo aspirate is the most reliable method of laboratory In contrast, successful treatment results in at least a
diagnosis. Gram staining alone may reveal the organism, fourfold reduction in the levels of nontreponemal anti-
but both the sensitivity and specificity of this method are bodies. Notably, similar reductions in nontreponemal
less than 50%. PCR techniques have proved highly sensi- antibody titers may occur spontaneously without treatment
tive and may establish the diagnosis in culture negative in progressive disease [43••,44].
cases. Single-dose azithromycin (1 g) or intramuscular Neurosyphilis is a recognized cause of impaired cog-
ceftriaxone (250 mg) are equally effective treatment nitive function in older adults. In cognitively impaired
strategies [41,42]. older adults positive serologic tests mandate cerebrospi-
nal fluid (CSF) evaluation to assess for neurosyphilis.
Syphilis Lymphocytic pleocytosis is typically evident on micro-
Clinically, syphilis is classified as primary, second- scopic examination of the CSF. CSF VDRL testing is the
ary, latent, or tertiary (Table 2). The incubation period standard diagnostic test in patients with positive trepo-
ranges from 9 to 90 days, with an average of about 20 nemal antibody tests and no history of prior treatment
days. Primary syphilis is heralded by the appearance of a for syphilis. Nonreactive CSF VDRL results should be
chancre. This lesion is a macule that appears at the portal confirmed with a CSF FTA-ABS which has been shown to
of entry usually on genitals, cervix, or extragenital sites have greater sensitivity [45–47].
(anus or rectum) and subsequently evolves into a well- Current treatment guidelines recommend repeat
circumscribed, painless, solitary ulcer with an indurated examinations of CSF at six monthly intervals in patients
base. Discrete nontender regional lymphadenopathy with CSF pleocytosis on initial diagnosis (Table 2).
usually accompanies the chancre. Spontaneous resolu- Patients with neurosyphilis who demonstrate increasing
tion of the chancre without residual scarring generally CSF pleocytosis over 6 months or persistence of pleocytosis
occurs within 3 to 6 weeks. Following resolution of the after 2 years should be considered for a repeat course
primary lesion, symptoms of secondary syphilis may of treatment.
144 Sexually Transmitted Diseases

HIV/AIDS at increased risk for HIV transmission. There is a rela-

Available data indicate that approximately 70,000 Ameri- tively low rate of condom use among sexually active older
cans over the age of 50 years are living with HIV/AIDS, adults, even though postmenopausal vaginal atrophic
accounting for 10% of all HIV infections. Additionally, changes place older women at greater risk for HIV trans-
evidence suggests that persons over the age of 60 years mission as the vaginal mucosa is more likely to be injured
account for 2% of cases. However, the true prevalence of during sexual intercourse. Providers must overcome their
HIV/AIDS in older adults is likely grossly underestimated reluctance to discuss HIV/AIDS and related risk factors
due to misdiagnosis and significant underreporting of with their older patients to facilitate effective screening
this disease as HIV/AIDS is rarely included in the differ- and preventive strategies.
ential diagnoses of disease encountered in older adults
in routine clinical practice. It is not unlikely that several Diagnosis
older adults die from AIDS related disease without ever Cornerstones of effective management are inclusive
being diagnosed as HIV positive [48]. preventive strategies, practical screening techniques
Sexual contact is the leading mode of transmission and early disease detection. A comprehensive geriatric
among elders, accounting for 60% of cases in adults over evaluation must always include a detailed sexual history
the age of 50 years. Of all cases transmitted through targeting relevant risk factors. Detailed enquiry should
sexual contact, over 80% are attributed to men having be made into the cause of death of spouses and sexual
sex with men. However, older men who are homosexual partners of older patients.
are less likely to disclose their sexual preferences for fear At-risk older adults should be encouraged to have HIV
of social stigmatization. Mandatory testing of blood testing. In addition, all older adults who present with any
products instituted in 1985 has resulted in a marked STD should be offered HIV testing. As in younger adults,
reduction in the rate of transfusion acquired HIV cases. the spectrum of HIV disease in older patients ranges from
Among older adults, less than 15% of patients contacted nonspecific symptoms to AIDS-defining illnesses and
HIV through blood transfusions. Intravenous drug use, opportunistic infections (Tables 3 and 4). However older
as a risk factor, is less common in older adults, account- patients remain undiagnosed for longer and are more
ing for 16% of cases. However, the aging of the “baby likely to receive treatment for misdiagnosed diseases such
boomer” generation is expected to result in an increase as pneumonia, occult malignancy, and Alzheimer’s dis-
in the number of older adults living with AIDS acquired ease. Delayed diagnosis resulting from such misdirected
through recreational intravenous drug use. Significantly, management places the older patient at increased risk of
17% of infected adults over age 60 years have no reported death from AIDS.
risk factors [49,50]. Pneumocystic carinii pneumonia, Mycobacterium tuber-
Patients over the age of 50 when diagnosed with culosis, Mycobacterium avium complex, herpes zoster, and
AIDS are more likely to die than their younger counter- cytomegalovirus infection are the most common diseases
parts. Available data suggest that physiologic age-related in older adults. Older patients who manifest with symp-
immunocompromise may result in a more aggressive and toms consistent with these illnesses must be evaluated for
rapidly progressive disease phenotype. Older adults also HIV infection (Table 4). Similarly, older adults who pres-
tend to have a higher viral load following seroconversion ent with unexplained weight loss, cognitive impairment,
and exhibit reduced tolerance of antiretroviral agents. anemia, recurrent Candida infections, or bizarre skin
Unrelated co-existing chronic illness has been shown lesions be carefully evaluated for AIDS [53,54].
to worsen outcomes in patients with AIDS. Thus, older Typically young patients with progressive multifo-
adults are at an added disadvantage as they are more cal leucoencephalopathy (PML) present with focal
likely to have a high burden of unrelated comorbidity. motor deficits, gait abnormality, and visual field
Inadequate screening and a relatively low index of sus- defects that often progress to blindness. However,
picion among health care providers delay diagnosis and cognitive impairment and delirium are common pre-
appropriate intervention further worsening outcomes. senting symptoms of HIV infection in the elderly. In
Older patients are more likely to already have progressed contrast to the clinical course of cognitive dysfunction
to AIDS at the time of diagnosis of HIV infection. Addi- arising from Alzheimer’s disease, PML-related cogni-
tionally, the diagnosis of AIDS is usually considered only tive dysfunction progresses very rapidly with extensive
after extensive investigation and failure of the patient deterioration occurring over a period of months.
to respond to treatment for other diseases. Thus, older Unlike PML, AIDS-related dementia may be difficult
adults with AIDS are more likely to die within 30 days of to distinguish from Alzheimer’s disease. Patients with
diagnosis and postmortem diagnosis of AIDS in the older AIDS-related dementia are more likely to have coex-
patient is not unusual [51,52]. isting focal neurologic deficits, extrapyramidal signs,
Popular misconception that older adults are not at ataxia, behavioral changes, and peripheral neuropathy.
risk for HIV infection probably accounts for the decreased Health professionals should familiarize themselves
awareness among elders of practices that may place them with the distinguishing features [50,51].
 Sexually Transmitted Diseases in Older Adults Wilson 145

Table 3. Clinical presentations of HIV infection Table 4. Clinical features of common AIDS-
in older adults related opportunistic infections in older adults
Infections Herpes zoster
Community-acquired pneumonia Painful vesicles
Pneumocystis carinii pneumonia Multiple or bilateral dermatome involvement
Varicella zoster infections Protracted clinical course
Tuberculosis Fever and malaise
Cytomegalovirus infections Cytomegalovirus infections
Constitutional Floaters
Cachexia Reduced visual acuity/constricted visual field
Fever of undetermined origin Anorexia, dysphagia, vomiting, diarrhea
Anorexia Cachexia
Diarrhea Peripheral neuropathy
Malaise Pneumocystis carinii pneumonia
Hematologic Subacute or chronic onset
Anemia Fever and malaise
Thrombocytopenia Nonproductive cough
Leucopenia Marked dyspnea and exercise intolerance
Coagulation abnormalities Exercise-induced hypoxia
Neoplastic Cachexia
Lymphoma Mycobacterium tuberculosis
Kaposi’s sarcoma Fever
Cervical carcinoma Cachexia
Neurologic Hemoptysis
Dementia Night sweats
Depression Mycobacterium avium complex
Delirium Fever
Meningo-encephalitis Cachexia
Cranial and peripheral neuropathy Nausea, vomiting, diarrhea
Dermatologic Night sweats
Seborrheic dermatitis
Atypical mucocutaneous candidiasis the Western blot or by immunofluorescence assay. Acute
Psoriasis retroviral syndrome should be considered in at-risk older
adults who present with fever of undetermined origin
Pruritus
and negative screening tests. In such cases nucleic acid
testing should be conducted to detect and quantify HIV
PML is the index AIDS-related illness in 25% of plasma RNA [57].
patients who are HIV positive, regardless of age. Nota-
bly, older adults with PML are more likely to exhibit Management
extrapyramidal symptoms. PML should, therefore, be Few HIV/AIDS intervention studies have specifically
considered in the differential diagnosis of Parkinson’s targeted cohorts of older patients. Current treatment rec-
plus syndromes [55,56]. ommendations are generally extrapolated from treatment
Screening and diagnostic guidelines for older adults strategies that are effective in younger patients. Available
are identical to those for younger patients. Antibody data suggest that these strategies may be equally effective
testing for both HIV-1 and HIV-2 should be conducted in the treatment of older patients, especially when initi-
using a screening test of acceptable sensitivity, such as ated early. However, there is a disproportionate increase
the enzyme linked immunoassay. Positive screening tests in the incidence of drug toxicity and adverse drug reac-
should then be confirmed with more specific tests such as tions in older patients. This is due to age-related changes
146 Sexually Transmitted Diseases

in pharmacodynamics, increased burden of comorbidity References and Recommended Reading

and more advanced disease in older patients. Addition- Papers of particular interest, published recently,
ally, the increased likelihood of polypharmacy in older have been highlighted as:
adults increases the potential for drug interactions. Thus, • Of importance
the older patient should be fully informed of the risks and •• Of major importance
anticipated outcomes of antiretroviral therapy. In addi-
1. Carret ML, Fassa AG, da Silveira DS, et al.: [Sexually
tion, consultation with an infectious diseases specialist transmitted diseases symptoms in adults: prevalence and
is desirable in view of the range of highly active retroviral risk factors]. Rev Saude Publica 2004, 38:76–84.
therapies available. Physicians should be encouraged to 2.• Xu F, Schillinger JA, Aubin MR, et al.: Sexually transmitted
diseases of older persons in Washington State.
adhere to standard geriatric principles when initiating Sex Transm Dis 2001, 28:287–291.
drug therapy, beginning with the lowest effective dose A good overview of the epidemiologic characteristics and present-
and titrating upwards in small increments, with close ing features of STDs in older patients.
3. Kalter DC, Rosen T: Sexually transmitted diseases.
monitoring for adverse effects. Emerg Med Clin North Am 1985, 3:693–716.
In frail elders with limited life expectancy, pos- 4. Diseker RA III, Peterman TA, Kamb ML, et al.: Circumcision
sible adverse effects of drug therapy should be carefully and STD in the United States: cross sectional and cohort
weighed against quality-of-life issues. In some cases, a analyses. Sex Transm Infect 2000, 76:474–479.
5. Hogben M, Bloom F, McFarlane M, et al.: Factors associated
more conservative approach or indeed palliative therapy with sexually transmitted disease clinic attendance.
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