CHAPTER SEVEN

SEXUALLY
TRANSMITTED
DISEASES
I N T R O D U C T I O N TO S T D s
 The diseases belonging to this group are
usually transmitted during sexual intercourse.
 During sexual intercourse, there is close body
contact which is an ideal situation for
transmission.
 The causative organisms of the STDs are very
easily killed by drying or by cooling to below
body temperature.
 Therefore transmission of these agents from
one person to another can only occur under
very special circumstances (mostly during
sexual intercourse).
I N T R O D U C T I O N TO S T D s
 STDs are very common in adults but they are
often hidden for fear of the opinion of others.
 Single young men are a high–risk group for
STDs as they satisfy their sexual needs with
women who have many sexual partners
(promiscuity).
 They may be professional prostitutes,
barmaids, or persons who in other ways gain
from casual sexual relationships. This group
is called the promiscuous women pool
(PWP).
RISK FACTORS ARE:
 Age: 15 years and older.
 Marital status:
 Unmarried people who often change their sexual partners
are more frequently exposed.
 Most of the women in the PWP are unmarried or divorced.
 Occupation:
 Soldiers, policemen, students, seasonal labourers, and
other people who are temporarily away from home tend to
expose themselves more easily.
 Residence:
 Due to industrialization and consequent urbanization there
is usually a large group of single young men in towns.
 Women in towns may have more difficulty in earning their
daily living and may take up prostitution for money.
 Promiscuity
SYPHILIS (HARD CHANCRE)
Definition:
 It is systemic venereal disease caused by
spirochetal bacteria called Treponema
pallidum.
 It is characterized by:
A primary lesion (chancre)
A later secondary eruption on the skin and
mucus membranes
Then a long period of latency and
Finally late lesions of skin, bones, viscera,
CNS and cardiovascular systems.
SYPHILIS (HARD CHANCRE)
Epidemiology:
 Worldwide spread.
 Primarily involving sexually active people
between 20 & 29 years.
 More common in urban than rural areas.
 CONT…

Reservoir:
 Humans

Mode of transmission:
 By direct contact with lesion mainly during
sexual intercourse.
 Accidentally by touching infective tissues.
 Blood transfusion
 Congenital (may occur before birth) from
infected mother.
Incubation period:
 10 days to 3 months (usually 3 weeks).
 CONT…

Period of communicability:
 Variable and indefinite.
 Transmission is high during primary and secondary
stages and during the first 4 years of latency.
 Extent of communicability through sexual activity
during latent period is not established.
 Adequate penicillin treatment usually ends
infectivity within 24 – 48 hours.
Susceptibility and resistance:
 Susceptibility is universal although only
approximately 30% of exposures result in infection.
 Infection leads to developing immunity against T.
pallidum gradually.
CLINICAL MANIFESTATION:
The clinical presentation is divided into three
groups:
A. Primary syphilis:
 Hard chancre (the primary lesion of syphilis)

Single
Painless ulcer on the genitalia or
elsewhere (lips, tongue, breasts) and
Heals spontaneously in a few weeks
without treatment.
 Regional lymphadenitis (bilaterally enlarged

and not painful).

 No suppuration.
CLINICAL MANIFESTATION:
B. Secondary syphilis:
 Occurs after 4 – 6 weeks of the primary

infection:
 Generalized secondary eruption

(condylomata lata) which are:

Symmetrical
Quickly passing and do not itch.
Highly infective and many spirochetes
are demonstrated in them.
 Mild constitutional symptoms:

Fever and headache

CLINICAL MANIFESTATION:
C. Tertiary syphilis:
Characterized by destructive, non-infectious
lesions of the skin, bones, viscera, and
mucosal surfaces  “Gumma”
Other disabling manifestations occur in the
cardiovascular system:
 Aortic incompetence

 Aneurysms

Central nervous system:

 Dementia paralytica

 Tabes dorsalis
CLINICAL MANIFESTATION:
D. Syphilis in pregnancy:
 Congenital abnormalities

 Still birth

 Repeated spontaneous abortions.

DIAGNOSIS:
 Serologicaltest – will be positive
6 to 8 weeks after infection.

 Dark field microscopy of smears

from primary lesion or secondary
stage
TREATMENT
Primary and secondary syphilis:
 Benzathin penicillin 2.4 M IU IM stat or
 Tetracycline or Erythromycin 500mg PO QID for 2
weeks for penicillin sensitive people.
Tertiary syphilis:
 Benzathin penicillin 2.4 M IU IM single dose every
week for 3 consecutive weeks or
 Tetracycline or Erythromycin for one month for
penicillin sensitive individuals.
Early congenital syphilis:
 Crystalline penicillin 50,000 IU/ Kg per dose IV or
IM bid in the first 7 days of life and TID then after
for 10-14 days.
PREVENTION AND CONTROL:
 Treatment of cases.
 Treatment of contacts and source of
infection.
 Health education on safe sex.
 Controlling STDs among commercial sex
workers.
 Monthly check up and treatment of cases.
 Provision of condom.
 Screening of pregnant women and early
treatment to prevent congenital syphilis.
 Screening of blood before transfusion.
CHANCROID (SOFT CHANCRE)
Definition:
 It is an acute bacterial infection localized in the
genital area.
 Characterized by single or multiple painful
narcotizing ulcers at the site of infection.
Infectious agent:
 Haemophilus ducreyi

Epidemiology:
 Endemic in many developing countries.
 The commonest cause of genital ulcer.
 Most frequently diagnosed in men, especially those
who frequently prostitutes.
Reservoir: Humans
 CONT…
Mode of transmission:
 By direct sexual contact with discharges
from open lesion and pus from buboes.

 Infected males don’t pass the infection

farther because of the painful ulcer.

Incubation period:
 From 3 to 5 days, up to 14 days after
sexual contact.
 CONT…
Period of communicability:
 Until healed and as long as the infectious agent
persists in the original lesion or discharging
regional lymph nodes.
 Lasts for several weeks or months without antibiotic
treatment.
 Antibiotic therapy eradicates H. ducreyi, and lesions
heal in 1 – 2 weeks.
Susceptibility and resistance:
 Susceptibility is general.
 The uncircumcised are at higher risk than the
circumcised.
 No evidence of natural resistance.
 CONT…
Clinical manifestation:
 Classic chancroid ulcer begins as a tender papule that
ulcerates within 24 hours.
 The ulcer is painful, irregular and sharply demarcated from
the nearby skin.
 About 50% of men will have single ulcer.
Diagnosis:
 Clinical
 Gram stain of smear from ulcer
 Culture
Treatment:
 Cotrimoxasol or
 Erythromycin or
 Tetracycline can be used
PREVENTION AND CONTROL:
 Case treatment.
 Investigation of contacts, source of infection
and treatment.
 Thorough washing of genitalia with soap and
water promptly after intercourse is very
effective.
 Controlling STDs among commercial sex
workers
 Sex education for high risk groups
LYMPHO-GRANULOMA VENEREUM (LGV)
Definition:
 It is a venereal disease caused by chlamydia
microorganisms and most commonly manifested by
acute inguinal lymph adenitis.
Infectious agent:
 Chlamydia trachomatis (Ll L2 and L3)

Epidemiology:
 Common in most parts of the world but very
common in tropical and subtropical regions of
Africa and Asia.

 Its incidence is more common in males than females,

and is lower than Gonorrhea and Chancroid.
 CONT…

Reservoir:
 Humans often asymptomatic (particularly in
females)
Mode of transmission:
 Direct contact with open lesions of infected people
(usually during sexual intercourse).
Incubation period:
 Variable with a range of 3 – 30 days for a primary
lesion.
Period of communicability:
 Variable from weeks to years (presence of active
lesions).
Susceptibility and resistance:
CLINICAL MANIFESTATION:
 Lymphadenopathy with non-specific symptoms of
fever, chills, headache, malaise, anorexia and weight
loss.
 Regional lymph nodes undergo suppuration
followed by extension of inflammatory process to the
adjacent tissues.
 In the female, inguinal nodes are less frequently
affected and involvement is mainly of the pelvic
nodes with extension to the rectum and recto vaginal
septum resulting in proctitis, stricture of the rectum
and fistula.
 Elepthantiasis of genitalia, scrotum and vulva
occur in either sex.
 CONT…

Diagnosis:
Clinical presentation (i.e. presence of bubo.)
Culture of bubo aspirate.

Treatment:
Tetracycline or
Erythromycin or
Cotrimoxazole can be used
Aspiration of fluctuating bubo and wound care
PREVENTION AND CONTROL:
 Early diagnosis and treatment of cases.

 Investigation of contacts, source of

infection and treatment.

 Control STDs among commercial sex

workers.

 Sex education for high risk groups.

H E R P E S G E N I TA L I A
Definition:
 It is a viral infection characterized by a localized
primary lesion, latency and a tendency to localized
recurrence.

Infectious agent:
 Herpes simplex virus (HSV) type 2
H E R P E S G E N I TA L I A
Epidemiology:
 Worldwide.

 HSV 2 infection usually begins with

sexual activity and is rare before
adolescence, except in sexually abused
children.

 Prevalence can up to 60% in lower

socio-economic groups and persons with
 CONT…
Reservoir:
 Humans.

Mode of transmission:
 Usually by sexual contact.
 Transmission to the neonate usually occurs
via the infected birth canal but less
commonly occurs intrauterine or postpartum

Incubation period:
 2 – 12 Days
 CONT…

Period of communicability:
 Patients with primary genital lesions are
infective for about 7 –12 days, with
recurrent disease for 4 days to a week.
 Reactivation of genital herpes may
occur repeatedly in > 50% of women.

Susceptibility and resistance:

 Humans are universally susceptible.
CLINICAL MANIFESTATION:
 Fever, headache, malaise and myalgia.
 Pain, itching, dysuria, vaginal and urethral
discharge, and tender inguinal lymphadenopathy
are the predominant local symptoms.
 Bilateral lesions of the external genitalia that may
be vesicles, pustules, or painful erythematous
ulcers.
 Cervix and urethra are involved in more than 80%
of women with first episode infection.
 Clear mucoid discharge
 Occasionally endometritis and salpingitis in women
and by prostatitis in men.
TREATMENT:

1. Oral acyclovir is effective

PREVENTION AND CONTROL:
 Consistent use of condom
is an effective means of
reducing the risk of
transmission of HSV – 2.
CANDIDIASIS
Definition:
 It is a mycosis usually confined to the
superficial layers of skin or mucus membrane
presenting clinically as oral thrush or
vulvovaginitis.
Infectious agent:
 Candida albicans (most common cause)
 Candida tropicalis (rare cause)

Epidemiology:
 Worldwide.
 Candida albicans is often part of the normal
 CONT…

Reservoirs:
 Humans

Mode of transmission:
 Contact with secretions or excretions of
mouth, skin, vagina and feces, from patients
or carriers.
 Passage from mother to neonate during
childbirth.
Incubation period:
 Variable.

Period of communicability:
 Presumably while lesions are present.
SUSCEPTIBILITY AND RESISTANCE:
 Susceptibility is very low except in low
host defence such as:
Diabetes

HIV- infected
Women in the third trimester of pregnancy
Oral contraceptive users
Individuals with prolonged steroid therapy
CLINICAL MANIFESTATION:
 Severe vulvar pruritis (prominent feature)
 Vaginal discharge (scanty, whitish, yellow, thick to
form curds, non-offensive)
 Sore vulva due to itching
 Speculum examination shows thick whitish plugs
attached to vaginal wall
 Vaginal epithelium bleeds when the plug is removed
but the cervix is normal.
 CONT…
Diagnosis:
 Based on clinical grounds
 Microscopic demonstration of pseudohyphae or yeast
cells in infected tissue or body fluids (vaginal discharge)
 Culture (vaginal discharge)

Treatment:
 Nystatine vaginal pessary or
 Miconazole or clotrmazele creams or
 Keto conazole or
 Fluconazele in recurrent cases

Prevention and control:

 Case treatment.
 Treatment of underlying medical conditions or
predisposing factors.
GONORRHEA
Definition:
 It is an acute or chronic purulent infection of the
urogenital tract.
Infectious agent:
 Neisseria gonorrhea, the gonococcus

Epidemiology:
 Occurrence – worldwide, affecting both genders,
especially sexually active adolescents and young adults.
 Common in rural areas.
 Prevalent in communities of low socio-economic status.
 In most industrialized countries, the incidence has
decreased during the past two decades.
 CONT…
Reservoir:
 Strictly a human disease

Mode of transmission:
 Almost always as a result of sexual activity

Incubation period:
 Usually 2-7 days

Period of communicability:
 May extend for months in untreated individuals.
 Effective therapy ends communicability within
hours.
Susceptibility and resistance:
 Susceptibility is general.
 No immunity following infection and reinfection is
CLINICAL MANIFESTATIONS:
 Males:
 Usuallyinvolves the urethra resulting
in purulent discharge, dysuria and frequency.
 Females:
 Usually asymptomatic.
 Vaginal discharge is common.
 Most common site of infection is cervix, urethra, anal
canal and pharynx.
 Bartholinitis and Salpingitis as a complication occurs in
20% of women.
 Neonates borne to infected mothers:
 Purulent eye discharge
 Edematous and erythematous eyelid 2 -3 days
postpartum.
URETHRAL DISCHARGE

42
 CONT…
Diagnosis:
 Gram stain of discharge (urethral, cervical,
conjuctival discharge)
 Culture on selective media

Treatment:
1. Cotrimoxazole or
2. Erythromycin or
3. Ceftriaxone can be used for severe cases
Prevention and control:
1. The same as syphilis
2. Application of 1% tetracycline in both eyes of
new borne as soon as delivered.
TRICHOMONIASIS
Definition:
 It is a common and persistent protozoal
infection of the genito-urinary tract.
Infectious agent:
 Trichomonas vaginalis, a flagellate protozoan

Epidemiology:
 Worldwide (affect all continents and all
races)
 Affect primarily adults (highest incidence
among females 16 - 35 years).

 CONT…
Reservoir:
 Humans.

Mode of transmission:
 By contact with vaginal and urethral discharges of infected

people during sexual intercourse.

 Indirectly through contact with contaminated articles and
clothes.
Incubation period:
 4 - 20 days, average 7days.

Period of communicability:
 The duration of the persistent infection (which may last for

years).
Susceptibility and resistance:
 Infection is general, but clinical disease is seen mainly in

females.
CLINICAL MANIFESTATION:
 Most men remain asymptomatic although
some develop:
Urethritis
Epididymitis
Prostatitis
 Infection in women is usually symptomatic
and manifests with:
Yellowish and malodorous vaginal discharge
Vulvar erythema
Itching dysuria or urinary frequency (in 30 - 50%
of cases)
Dyspareunia
 CONT…
Diagnosis:
 Microscopy of wet mounts of vaginal or prostatic
secretions – demonstrates motile trichomonads
 Culture (most effective) takes 3 - 7 days.

Treatment:
 Metronidazole 500 mg bid for 7 days
 Clotrimazole vaginal tabs 200 mg at bed time for 3
days.
Prevention and control:
 Case detection and treatment
 Condom use
 Educate public to seek medical help whenever there is
an abnormal discharge from the genitalia and to refrain
from sexual intercourse until investigation and treatment