Gynecology Topic 18. Sexually transmitted diseases in female

I. General Approach

Definition

• Sexually transmitted diseases/infections (STD/STI): diseases transmitted through sexual contact.
• Other routes: transplacental, birth canal, breastfeeding, blood exposure.
• Having one STI → increased risk of another STI → screen for co-infections.
• Main pathogens: Chlamydia, gonorrhea, syphilis, Trichomonas, Mycoplasma genitalium, HSV, HPV, HIV, hepatitis B/C.

Risk factors and general work-up

• Risk factors: age <25, new/multiple partners, unprotected intercourse, previous STI, partner with STI, sexual assault.
• History: symptoms, partner history, contraception, pregnancy possibility, assault risk.
• Examination: vulva/vagina/cervix, discharge, ulcers, warts, inguinal nodes, pelvic tenderness.
• Pregnancy: STIs may cause fetal/neonatal infection → screen and treat promptly.

Tests and treatment principles

• Pregnancy test when relevant; exclude PID if pelvic pain/cervical motion tenderness.
• NAAT/PCR: routine sensitive test for Chlamydia, gonorrhea and Trichomonas.
• Culture: important for gonorrhea resistance or treatment failure.
• Serology: syphilis, HIV, hepatitis B/C.
• Wet mount/pH/KOH: useful for vaginitis differential.
• Treat patient and indicated partners; abstain until treatment completed and symptoms resolve.
• Screen for co-infections: HIV, syphilis, HBV/HCV, Chlamydia, gonorrhea.

II. Cervicitis and Vaginal STI

Cervicitis

• Cervicitis pathogens: Chlamydia trachomatis and Neisseria gonorrhoeae most important.
• Symptoms/signs: often asymptomatic; mucopurulent discharge, friable cervix, postcoital bleeding, dysuria, dyspareunia, pelvic pain.
• Ascending infection → endometritis → salpingitis/PID → infertility, ectopic pregnancy, chronic pelvic pain.
• Diagnosis: NAAT/PCR for Chlamydia and gonorrhea; exclude PID if pelvic pain or cervical motion tenderness.
• Empiric treatment may be needed when follow-up is uncertain or STI risk is high; treat partners according to pathogen.

Chlamydia

• Chlamydia: Gram-negative obligate intracellular bacterium with biphasic life cycle.
• Incubation: about 1-3 weeks; asymptomatic in many women.
• Serotypes D-K: urogenital infection; L1-L3: lymphogranuloma venereum.
• Female disease: urethritis/cervicitis → dysuria, mucopurulent discharge; proctitis; PID/salpingitis.
• Complications: infertility, ectopic pregnancy, miscarriage risk, Fitz-Hugh-Curtis syndrome, reactive arthritis.
• Neonate: conjunctivitis and pneumonia after delivery.
• Diagnosis: NAAT/PCR from vaginal/cervical swab or first-catch urine; culture not routine.
• Treatment: doxycycline 100 mg PO 2x/day for 7 days if nonpregnant; azithromycin in pregnancy/adherence contexts.
• LGV: transient painless ulcer → tender inguinal nodes/abscess/fistula; doxycycline for 3 weeks.

Gonorrhea

• Pathogen: Neisseria gonorrhoeae = gram-negative intracellular diplococcus.
• Sites: urethra, endocervix, rectum, pharynx, conjunctiva; incubation about 2-7 days.
• Women: often asymptomatic; urethritis/cervicitis/vaginitis → dysuria, profuse thick purulent discharge, pelvic pain/PID.
• Diagnosis: NAAT from urethra/endocervix/rectum/pharynx; Gram stain may show gram-negative diplococci in neutrophils; culture for resistance/treatment failure.
• Treatment: IM ceftriaxone; add doxycycline if Chlamydia not excluded.
• Complications: PID, Bartholin abscess, Fitz-Hugh-Curtis syndrome, infertility.
• Disseminated gonorrhea: fever, migratory polyarthralgia/arthritis, tenosynovitis, pustular rash → IV ceftriaxone.
• Neonate: ophthalmia neonatorum; erythromycin eye prophylaxis/treatment according to neonatal protocol.

Trichomoniasis

• Pathogen: Trichomonas vaginalis = flagellated protozoon; STI.
• Clinical features: profuse yellow-green malodorous/frothy discharge, vulvar irritation, dysuria, dyspareunia.
• Strawberry cervix: spotted cervical erythema; vaginal pH increased, often 5-6.
• Diagnosis: NAAT most sensitive; wet mount may show motile trichomonads.
• Treatment: metronidazole; tinidazole alternative; treat sexual partner(s).
• Pregnancy: associated with preterm delivery and low birth weight.

Mycoplasma / Ureaplasma

• Mycoplasma genitalium: intracellular bacterium causing persistent/recurrent cervicitis, urethritis, PID; resembles Chlamydia.
• Diagnosis: NAAT when suspected.
• Treatment: doxycycline initially; moxifloxacin if resistant/persistent according to protocol.

III. Genital Ulcers

Syphilis

• Pathogen: Treponema pallidum pallidum = spirochete.
• Transmission: sexual contact, direct lesion contact, transplacental.
• Neurosyphilis can occur at any stage.

1. Primary syphilis

• Incubation: 10 days-3 months; median about 3 weeks.
• Chancre: painless, indurated ulcer; heals spontaneously in 3-6 weeks.
• Regional painless lymphadenopathy → asymptomatic period.

2. Secondary syphilis

• Usually 2-3 months after infection.
• Systemic symptoms: fever, headache, myalgia, malaise; pharyngitis/hepatitis possible.
• Generalized painless lymphadenopathy.
• Maculopapular copper-colored rash, especially palms and soles.
• Condyloma lata: flat moist white papules/erosions in anogenital or oral mucosa; highly infectious.
• Alopecia may occur.

3. Latent and late syphilis

• Latent: asymptomatic + positive serology; early latent is sexually infectious, late latent mainly maternal-fetal risk.
• Tertiary: years later → gummas in skin/bone/liver/organs; cardiovascular syphilis with aortitis/ascending aortic aneurysm.
• Neurosyphilis: meningitis, Argyll Robertson pupil, general paresis/dementia, tabes dorsalis with loss of proprioception.

• Congenital syphilis: miscarriage, stillbirth, prematurity, hydrops; early rash/hepatomegaly/jaundice; late Hutchinson teeth + interstitial keratitis + sensorineural hearing loss.
• Diagnosis: clinical exam, pregnancy screening; dark-field/PCR from chancre if available; no routine culture.
• Non-treponemal tests: RPR/VDRL → screening and treatment follow-up; fourfold titer decrease suggests response; false positives possible.
• Treponemal tests: TPHA/TPPA, FTA-ABS, ELISA → specific confirmation; often remain positive for life.
• Treatment: benzathine penicillin G IM for primary/secondary/latent syphilis; 1 dose for early disease, weekly 3 doses for late latent/unknown duration.
• Neurosyphilis: IV penicillin G for 10-14 days.
• Pregnancy: penicillin is required/proven fetal-protective therapy; allergy usually needs desensitization.
• Jarisch-Herxheimer reaction: acute fever/headache/myalgia/hypotension after treatment from spirochete breakdown; warn and monitor pregnancy.

Genital herpes

• Pathogen: HSV-2 most common; HSV-1 also possible.
• Latency: sacral dorsal root ganglia → reactivation.
• Transmission: skin/sexual contact, vertical perinatal infection; asymptomatic shedding possible.
• Clinical features: painful anogenital vesicles → ulcers, pruritus/burning, discharge, dysuria; fever and painful inguinal nodes in primary infection.
• Complications: urethritis, proctitis, neurogenic pain, keratoconjunctivitis, meningoencephalitis.
• Diagnosis: PCR/NAAT from vesicle/ulcer; Tzanck smear shows multinucleated giant cells but is historical.
• Treatment: acyclovir or valacyclovir; suppressive therapy for frequent recurrences.
• Pregnancy: active genital lesions or prodrome during labor → cesarean delivery.

Other ulcerative STIs: quick differential

• HSV: painful grouped vesicles/ulcers on erythematous base.
• Syphilis: painless hard chancre + painless nodes.
• Chancroid: painful soft ragged ulcer + tender suppurative lymphadenopathy.
• LGV: transient painless ulcer → painful inguinal lymphadenopathy, abscesses, fistulas, genital elephantiasis.
• Donovanosis: painless beefy-red destructive ulcer; rare in Europe.

IV. Viral STIs and Prevention

Human Papillomavirus (HPV)

• HPV: DNA virus infecting skin keratinocytes and mucosal epithelium.
• Low-risk types: HPV 6, 11 → genital warts (condyloma acuminata).
• High-risk types: HPV 16, 18, 31, 33 → CIN and cervical/vulvar/vaginal/anal/oropharyngeal cancer.
• Pathogenesis of cancer: persistent high-risk HPV → E6/E7 oncogene activity → dysplasia → carcinoma over years.
• Condyloma acuminata: cauliflower-like anogenital warts.
• Diagnosis: clinical for warts; Pap smear/HPV test/colposcopy/biopsy for cervical disease.
• Treatment: no specific eradication of HPV; warts treated by cryotherapy, imiquimod, electrosurgery/laser or excision.
• Prevention: recombinant HPV vaccine, e.g. Gardasil 9, plus cervical screening; vaccination advisable regardless of sex.

HIV, Hepatitis B/C

• Transmission: sexual contact, blood exposure, vertical transmission; HIV can also transmit through breast milk.
• HIV: screen with Ag/Ab test; antiretroviral therapy markedly reduces vertical transmission.
• Hepatitis B: preventable by vaccination; screen pregnant women.
• Hepatitis C: screen according to risk/pregnancy protocol; treat outside pregnancy as indicated.