HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Nusbaum, M. R.H. Articles by Kondrad, E. C. Search for Related Content PubMed PubMed Citation Articles by Nusbaum, M. R.H. Articles by Kondrad, E. C.

Address correspondence to: Margaret R.H. Nusbaum, DO, MPH, Associate Professor, Department of Family Medicine, 101 Manning Dr, CB 7595, Chapel Hill, NC 27514-7595.E-mail: mnusbaum{at}med.unc.edu

The incidence of trichomoniasis (Trichomonas vaginalis) in the United States is estimated at 5 million cases annually; chlamydia (Chlamydia trachomatis) at 3 million; gonorrhea (Neisseria gonorrhoeae), 650,000; and syphilis (Treponema pallidum), 70,000. However, most sexually transmitted infections (STIs) are asymptomatic—contributing to underdiagnosis estimated at 50% or more. Diagnosis of an STI signals sexual health risk because an STI facilitates the transmission and acquisition of other STIs, including human immunodeficiency virus (HIV). In fact, comorbid STIs increase patients' susceptibility of acquiring and transmitting HIV by two- to fivefold. Several studies have shown that aggressive STI prevention, testing, and treatment reduces the transmission of HIV. The authors discuss common clinical presentations, screening, diagnosis, and treatment for trichomoniasis, chlamydia, gonorrhea, syphilis, and herpes simplex virus.

Most STIs are asymptomatic, contributing to widespread underdiagnosis estimated at 50% or higher.² In the United States, the annual incidence of trichomoniasis (Trichomonas vaginalis) is estimated at 5 million; chlamydia (Chlamydia trachomatis) at 3 million; gonorrhea (Neisseria gonorrhoeae), 650,000, and syphilis (Treponema pallidum), 70,000.³ This article discusses the common clinical presentations, screening, diagnosis, and treatment for trichomoniasis, chlamydia, gonorrhea, syphilis, and herpes simplex virus.

Clinical Presentation
Urethritis, Epididymitis, and Proctitis
In men, STIs usually remain confined to the urethra. Symptoms of urethritis include urethral discharge, dysuria, or urethral itching. The discharge of nongonococcal urethritis (NGU) is often slight, and may not be apparent without massaging the urethra. Discharge of NGU is usually minimal and gray, white, or mucoid rather than yellow. Discharge that is yellow and present in greater volume most often signals infection with N gonorrhoeae.

Epididymitis presents as acute unilateral testicular pain and swelling. Clinical findings include tenderness of the epididymis and ductus deferens, erythema and edema of the overlying scrotal skin, urethral discharge, and dysuria. Swelling and tenderness may be localized or may extend to the entire epididymis and surrounding areas, making the epididymis less distinct in the inflammatory mass.

Proctitis presents as anorectal or perineal itching, anorectal pain, and discharge.

Trichomoniasis tends to be asymptomatic in men, while chlamydia and gonorrhea present as acute urethritis or epididymitis. In sexually active men, however, C trachomatiscauses 30% to 50% of cases of NGU,⁴ an even higher proportion of postgonococcal urethritis, and the majority of cases of epididymitis. Ureaplasma urealyticum appears to be causative in the remaining cases, although the cause is undetermined in approximately one third of men who have NGU. Routine screening for U urealyticum is not recommended as NGU is often associated with infection from C trachomatis and N gonorrhoeae.

Other urinary tract pathogens, including Escherichia coli and Pseudomonas aeruginosa, can be causative agents in men who are older, have structural abnormalities of the urethra, have recently undergone a urinary tract procedure or manipulation, or engage in anal intercourse.

Although ascending infection to the epididymis is rare, most cases of epididymitis are caused by STIs. In addition to infectious causes, differential diagnoses should also include trauma, testicular torsion, and tumor.

Positive results for leukocyte esterase on urinalysis can indicate C trachomatis, N gonorrhoeae, or other urinary tract pathogens. Chlamydia trachomatis or T vaginalis should be suspected in the absence of gram negative intracellular diplococci on Gram stain. Patients presenting with epididymitis should be examined and tested for chlamydia and gonorrhea. In the case of proctitis, cultures should be taken from the symptomatic area.

In women, urethritis can be a manifestation of C trachomatis, herpes simplex virus (HSV), N gonorrhoeae, or T vaginalis. As in men, proctitis in women presents as anorectal or perineal itching, or anorectal pain and discharge.

Vaginitis and Cervicitis
Etiologic agents of vaginitis and cervicitis include C trachomatis, N gonorrhoeae, HSV, and T vaginalis. More than half of endocervical infections do not cause sufficient inflammation to result in clinical signs and symptoms, however. When present, symptoms can include dysuria, vaginal discharge, dyspareunia, perineal itching, and pelvic discomfort or pain. Erythema multiforme and swelling of the vulva or labia suggest trichomonal or HSV infection.

Trichomonal discharge is usually copius, frothy, and yellow-green or occasionally gray. The vaginal walls are often erythematous and granular in appearance, while punctate hemorrhages of the cervix give it the classic "strawberry" appearance.

Perineal swelling, cervical vesicles, or venereal (or dendriform) ulcers, suggest HSV infection. Alternatively, swelling, tenderness, and drainage in glandula vestibularis major (ie, Bartholin's gland) sites suggest gonorrheal infection. A friable cervix and mucopurulent vaginal discharge can be seen with gonorrhea and chlamydia.

Because chlamydia, gonorrhea, and trichomoniasis, may present similarly with mucopurulent vaginal discharge, drainage from the cervix, or a friable cervix, physicians should screen for all three—as well as for bacterial vaginosis. Ulcerative lesions should be tested for HSV. A definitive diagnosis of trichomoniasis requires identifying T vaginalis on a Trichomonas wet prep test.

Pelvic Inflammatory Disease
With the exceptions of T vaginalis and HSV, pathogens in the lower genital tract in women frequently and rapidly ascend to the endometrium and adnex uteri, causing pelvic inflammatory disease (PID) and pelvic adhesive disease. Manifestations of PID include endometritis, salpingitis, tuboovarian abscess, and pelvic peritonitis.

Physical symptoms of PID include perineal and urethral itching or burning, vaginal discharge and odor, spotting with intercourse, insertional or deep dyspareunia, pelvic pain, abdominal pain, worsening dysmenorrhea, or systemic symptoms including chills, fever, malaise, or myalgia. Cervical motion tenderness on bimanual pelvic examination can indicate PID.

Fitz-Hugh–Curtis syndrome presents as PID with pain in the right upper quadrant and hepatic tenderness with palpation. Fever, increased pulse rate and blood pressure, and enlarged, painful inguinal lymph nodes can also be present. Leukocytosis and elevated erythrocyte sedimentation rate also support a diagnosis of PID.

Pelvic inflammatory disease can lead to infertility, ectopic pregnancy, and chronic pelvic pain. Because PID can potentially cause significant damage to women's reproductive health, clinicians should have a low threshold for diagnosis and treatment of PID.

Genital Ulcerative Disease
Herpes simplex virus is the most common single cause of genital ulcers in the United States. Herpetic ulcers appear on the external genital, urethral, and anorectal areas as well as in the vagina and on the cervix. About 10% of ulcers are the result of more than one etiologic agent, however. The clinical features of ulcers can be altered in immunosuppressed individuals. Differential diagnosis includes syphilis and herpes zoster as well as noninfectious causes such as trauma, contact dermatitis, lichen sclerosis, and Behçet's syndrome.

The primary lesion of syphilis, the chancre, is usually painless. It is a solitary ulcer with raised, well-defined borders and a clean, indurated base. The chancre occurs at the site of infection and is usually associated with nontender regional lymphadenopathy and heals spontaneously and without scarring in 3 to 6 weeks.

Secondary syphilis occurs 4 to 10 weeks after the primary lesion of syphilis appears—and goes untreated. Symptoms of secondary syphilis include myalgia, arthralgia, malaise, low-grade fever, and generalized lymphadenopathy. A nonpruritic, maculopapular eruption affecting the trunk, limbs, palms, and soles is present in 10% to 75% of patients. Condylomata lata, fleshy lesions that may be broad-based, flat, or raised, may be seen in the mucous membranes (eg, anus, external genitals, mouth).

In up to one third of patients with secondary syphilis, the primary chancre is still present, increasing the likelihood of transmission to any additional sexual contacts.

Left untreated, syphilis becomes latent with no readily apparent clinical findings. Without therapy, approximately one third of those infected will develop tertiary syphilis 10 to 30 years after the initial infection. The manifestations of tertiary syphilis include gummas, aortitis and other cardiovascular disease, and neurosyphilis.

Suspected Exposure to Sexually Transmitted Infections
Patients may initially present to physicians' offices with concerns about STI exposure for numerous reasons. Some patients fear the results of not using protective barriers with a new sexual partner or they are apprehensive about the failure of such barriers during sexual contact. Some patients seek screening and medical care after they have been informed by a sexual partner or public health official of their possible contact with an STI. Still other patients may have recently discovered that their intimate relationship was not mutually monogamous.

The practitioner should test for all STIs from all sites of contact, begin treatment for any known exposure to STIs, and offer hepatitis A and B vaccinations. Physicians should also consider retesting patients for T pallidum and review HIV serology 12 weeks after most recent sexual contact. For all suspected STI exposures, assess if the patient is a candidate for emergency contraception. It is important for physicians to be fully prepared to provide patient education and supportive counseling.

For victims of sexual assault when no condom was used, consider presumptive treatment for chlamydia, gonorrhea, and trichomoniasis. Presumptive treatment, although controversial, can alleviate patients' fears while they await the results of cultures. As pathogens may not be present in sufficient quantities on initial testing, physicians should consider repeat examinations and serology 12 weeks after the assault. The risk of acquiring HIV is less than 0.1% for mucous membrane exposure to blood.

For drug injection–related or sexual contact exposures to HIV, there is no conclusive data on the effectiveness of postexposure therapy. The physician should consider postexposure therapy if the source is HIV positive, if there is a high risk of transmission (eg, no condom or a torn one, vaginal or anal penetration), or if other factors increase the risk of transmission (eg, anal or vaginal tears, bleeding, ulcers on the anus or external genitals, or evidence of an STI).

Therapy is probably most effective when initiated within 1 to 2 hours after contact and is probably not effective by 24 to 36 hours after exposure. Therapy is difficult, required for at least 30 days, and expensive. Side effects are common, but adherence to therapy is critical for both effectiveness and prevention of drug-resistance.

Screening and Diagnostic Testing
Because the majority of STIs are asymptomatic, deciding when to screen patients is critical. People often underestimate their risk of exposure to STIs and HIV and don't understand safe sexual practices. One third of all sexually active adults have never been tested for HIV.⁵ Because self-reported sexual history is often an unreliable indicator of the actual risk of infection, consider broader screening of populations in which prevalence of STIs is high.

In general, all patients with one STI should be considered candidates for additional screening, and all patients at risk for STIs should be offered testing in accordance with recommendations on screening for C trachomatis, N gonorrhoeae, T pallidum, and HIV. The positive predictive value of STI testing increases with the prevalence and risk of STIs. In asymptomatic persons, where prevalence and sexual health risk is low, very sensitive nonculture tests, such as the antinuclear antibody test (ANA) or the direct fluorescent antibody test (DFA) can return false positive results. Sexually active adults aged 25 years and younger are at the highest risk for chlamydial infection.

Properties of available tests for the most prevalent STI pathogens are summarized in Table 1. As noted, clinicians should check with their supporting laboratory as to preferred methods of testing. Culture is often the preferred testing method when screening for chlamydia and gonorrhea in victims of sexual assault and abuse. Screening, confirmations, and gold standards in testing patients for chlamydia, gonorrhea, HSV, and syphilis are listed in Table 2.

Treatment
Table 3 summarizes treatment for the STIs covered in this review. Treatment failures are usually due to reinfection, failure to treat infected sexual partners, or nonadherence to therapy. When STIs are suspected by history, physical examination, or preliminary laboratory test results, therapy should be administered while awaiting laboratory confirmation. Because of the potential for significant damage to women's reproductive health, physicians are encouraged to maintain a low threshold for diagnosis and treatment.

Very ill-appearing women may require intravenous antibiotics, fluids, and pain management. Additionally, nonsteroidal anti-inflammatory medications are helpful for controlling the inflammation and pain associated with epididymoorchitis (level of evidence, B). A summary of levels of evidence by risk group for clinical effectiveness in the screening and treatment of patients for STIs is provided in Table 4.

Hepatitis B vaccine is recommended for patients diagnosed with any STI as well as for those in groups at high risk for STIs, including persons with multiple partners within the previous six months, intravenous drug users and their sexual partners, and men who have anal intercourse with men (level of evidence, A).⁴ Hepatitis A vaccine is recommended for men who have anal intercourse with men, and all intravenous and street drug users (level of evidence, B).⁴ The combined hepatitis A and B vaccine has similar efficacy to the individual vaccines.⁶ Hepatitis B immunoglobulin and hepatitis B vaccine should be administered within 14 days of sexual contact with persons infected with hepatitis B. Hepatitis A immunoglobulin should be administered intramuscularly at a dose of 0.02 mL per kilogram of body weight within 14 days of sexual exposure to persons with hepatitis A; hepatitis A vaccination is not recommended as postexposure prophylaxis, however.⁷

Patient Education
Because STIs are commonly asymptomatic and can go undiagnosed for many years, physicians who must inform patients of a new STI diagnosis should be extremely careful not to implicate the patient's current or most recent sexual partner (often a spouse); a different sexual partner could have transmitted the STI many years ago.

Improved patient education is crucial to reducing the transmission of STIs. When speaking to patients, physicians should discuss sexual health risks—including the risks inherent in choices of new sexual partners—and emphasize the importance of developing and adhering to safe sexual practices.

Patient education includes informing patients about the diagnosis and transmission of STIs, use of medication, and the responsibility and importance of notifying past sexual partners when an infection is diagnosed. Although patients are often afraid or ashamed to notify past sexual partners, they should be counseled regarding the risks of untreated infection and strongly encouraged to help former partners avoid further spread of infection and long-term health effects.

Reviewing safer sexual practices in a professional and empathetic manner is imperative for patient confidence and compliance. Physicians should aim to empower patients to negotiate safer sexual practices with their partners and to negotiate the kinds of sexual activity they are willing to participate in with their partners.

Latex condoms reduce transmission of many STI pathogens when used during vaginal, anal, and oral sexual activities. Physicians should ask if patients are hypersensitive to latex or spermicide and be ready to provide alternative suggestions for protective barriers if such "allergies" exists.

Although condom availability and/or sexual health education does not promote increased sexual activity, availability of condoms has been shown to increase the likelihood of condom use.⁸ Explain that the correct use of condoms (see http://www.plannedparenthood.org/bc/condom.htm for more information) includes the use of water-based lubricants instead of petroleum-based lubricants, which can result in latex breakdown and reduced efficacy.⁸

The female condom should be used when the male condom will not be used, and, additionally, appears effective in reducing STIs for receptive anal intercourse.⁹

Testing for HIV infection should be done before the initiation of sexual activity with a new partner and barrier methods should be continued until both partners are able to repeat HIV testing at least 6 months into a mutually monogamous relationship and test results prove both partners to be seronegative.

It is important for physicians to be prepared to provide supportive counseling for patients' emotional responses. People with STIs often have to deal with feelings of guilt, anxiety, anger, tension, and preoccupation. The diagnosis of an STI can be traumatic, altering self-image and affecting the dynamics of current and future relationships.

Comment
Sexually transmitted infections are commonly asymptomatic. Individuals tend to underestimate their risk for exposure to STIs, including HIV. Sexually transmitted infections, especially gential ulcerative disease, increase the probability of acquiring HIV by altering tissue integrity. Symptomatic infections present as genitourinary, anal, skin, and systemic signs and symptoms. Diagnostic tests are reliable. Presumptive treatment for concurrent STIs is prudent given long-term sequela. Thorough treatment includes patient education and supportive counseling.

From the Department of Family Medicine in the School of Medicine at the University of North Carolina at Chapel Hill.

References
1. HIV prevention through early detection and treatment of other sexually transmitted diseases—United States. Recommendations of the Advisory Committee for HIV and STD Prevention. MMWR Recomm Rep. 1998;47(RR-12);1 -24.[Medline]

2. Turner CF, Rogers SM, Miller HG, Miller WC, Gribble JN, Chromy JR, et al. Untreated gonococcal and chlamydial infection in a probability sample of adults. JAMA.2002; 287:726 -733.[Abstract/Free Full Text]

3. Centers for Disease Control and Prevention. Tracking the hidden epidemics. Trends in STDs in the United States 2000. April 2001. Available at: http://www.cdc.gov/nchstp/dstd/Stats_Trends/Trends2000.pdf. Accessed September 27, 2004.

4. Centers for Disease Control and Prevention. HIV counseling and testing in publicly funded sites. Annual report 1997 and 1998. 2001. Available at: http://www.cdc.gov/hiv/pubs/cts98.pdf. Accessed September 27, 2004.

5. US Preventive Services Task Force. Guide to Clinical Preventive Services. 2nd ed. Baltimore, Md: Williams & Wilkins; 1996;287-302,325-346. Available at: http://www.ahcpr.gov/clinic/cpsix.htm. Accessed September 27, 2004.

6. FDA approval for a combined hepatitis A and B vaccine. MMWR Morb Mortal Wkly Rep. 2001;50:806-807. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5037a4.htm. Accessed September 24, 2004.

7. National Guideline Clearinghouse. Vaccine preventable STDs. Sexually transmitted diseases treatment guidelines 2002. Available at: http://www.ngc.gov/summary/summary.aspx?doc_id=3242&nbr=2468&string=hepatitis. Accessed September 24, 2004.

8. Kaplan DW, Feinstein RA, Fisher MM, Klein JD, Olmedo LF, Rome ES, et al; Committee on Adolescence. Condom use by adolescents. Pediatrics.2001; 107:1463 -1469.[Abstract/Free Full Text]

9. Gross M, Buchbinder SP, Holte S, Celum CL, Koblin BA, Douglas JM Jr. Use of reality "female condoms" for anal sex by US men who have sex with men. HIVNET Vaccine Preparedness Study Protocol Team. Am J Public Health.1999; 89:1739 -1741.[Abstract/Free Full Text]

This article has been cited by other articles:

				L. Zeitlin, M. Pauly, and K. J. Whaley Second-generation HIV microbicides: Continued development of griffithsin PNAS, April 14, 2009; 106(15): 6029 - 6030. [Full Text] [PDF]

				A E Brown, S E Tomkins, L E Logan, D S LaMontagne, H L Munro, V D Hope, A Righarts, J E Blackham, B D Rice, T R Chadborn, et al. Monitoring the effectiveness of HIV and STI prevention initiatives in England, Wales, and Northern Ireland: where are we now? Sex Transm Inf, February 1, 2006; 82(1): 4 - 10. [Abstract] [Full Text] [PDF]

				C. E. Cameron, N. L. Brouwer, L. M. Tisch, and J. M. Y. Kuroiwa Defining the Interaction of the Treponema pallidum Adhesin Tp0751 with Laminin Infect. Immun., November 1, 2005; 73(11): 7485 - 7494. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Nusbaum, M. R.H. Articles by Kondrad, E. C. Search for Related Content PubMed PubMed Citation Articles by Nusbaum, M. R.H. Articles by Kondrad, E. C.