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Sexually Transmitted Infections: Difference between revisions

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***** '''Management'''
***** '''Management'''
****** '''Bed rest and nonsteroidal anti-inflammatory medications.'''
****** '''Bed rest and nonsteroidal anti-inflammatory medications.'''
* '''Chancroid'''
** '''Caused by H. ducreyi (gram-negative coccobacilli)'''
** '''Initial presentation of a papule that may progress to anogenital painful ulceration and lymphadenitis with progression to bubo formation'''
** '''Incubation period: 3-10 days'''
** Most common site of infection: prepuce
** '''Diagnosis and Evaluation'''
*** '''Labs'''
**** '''Definitive diagnosis requires culture on media not routinely available.'''
**** '''Centers for Disease Control and Prevention suggests that a probable diagnosis of chancroid can be made if''':
****# The patient has one or more painful ulcers
****# No evidence of T. pallidum is present on darkfield examination of ulcers or by serologic testing for syphilis performed at least 7 days after onset of the ulcers
****# Ulcers and lymphadenopathy, if present, are typical for chancroid
****# Results of tests for HSV on the ulcer exudate are negative
**** Chancroid, like genital herpes and syphilis, is a risk factor for transmission of HIV; patients should be tested for HIV at the time of diagnosis of chancroid
** '''Management'''
*** '''Options:'''
***# '''Azithromycin 1g in a single dose or'''
***# '''Ceftriaxone 250 mg IM in single dose''' or
***# Ciprofloxacin 500 mg orally BID x 3 days or
***# Erythromycin base 500 mg orally TID x 7 days
* '''Lymphogranuloma venereum'''
** '''Caused by chlamydia'''
** '''A self-limited genital ulcer or papule is sometimes present at the site of infection but usually has disappeared by the time of presentation. The secondary stage is the most common presentation in heterosexuals and is marked by tender inguinal and/or femoral lymphadenopathy, typically unilateral'''
*** Inguinal lymphadenopathy are more common in males because the lymph drainage of the cervix and vagina are to the retroperitoneal rather than the inguinal lymph nodes
** Lymphogranuloma venereum proctocolitis can mimic inflammatory bowel disease, and complications include chronic colorectal fistulas and strictures
** '''Diagnosis and Evaluation'''
*** '''Labs'''
**** '''Swab of lesions or aspiration of buboes from genitals or lymph node''', sent for culture, direct immunofluorescence, '''or nucleic acid detection'''
** '''Management'''
*** '''Doxycycline''' 100 mg orally BID x 21 days
* '''Donovanosis/Granuloma inguinale'''
** '''Caused Klebsiella granulomatis''' (intracellular gram-negative bacterium)
** '''Does not usually occur in the US'''
** '''The disease manifests as painless, slowly progressive ulcers on the genitals and perineum. Despite the name, inguinal involvement is uncommon (10%), but tender if present'''
** '''Lesions'''
*** '''Described as beefy red because of high vascularity, and they bleed easily'''
*** Insert figure
* '''Diagnosis and Evaluation'''
** '''Labs'''
*** '''Requires visualization of''' dark-staining '''Donovan bodies''' on crush preparation or biopsy
* '''Management'''
** '''Doxycycline''' 100 mg PI BID for at least 3 weeks and until all lesions have healed
'''UrologySchool.com Summary of Sexually Transmitted Infections'''
{| class="wikitable"
|'''Disease'''
|'''Infectious agent'''
|'''Lesions'''
'''(Painful x2)'''
|'''Lymphadenopathy'''
'''(Tender x3)'''
|'''Systemic symptoms'''
|'''Testing'''
|'''Treatment'''
|-
|'''Genital herpes'''
|'''HSV-1, HSV-2'''
|'''PAINFUL vesicles, shallow, usually multiple'''
|'''Tender, bilateral inguinal lymphadenopathy'''
|'''Present during primary'''
'''infection'''
|'''NAAT or cell culture, serology for HSV subtype'''
|'''-cyclovir'''
|-
|'''Primary syphilis/chancre'''
|'''Treponema pallidum'''
|'''PAINLESS, indurated, with a clean base, usually singular'''
|'''Non-tender, rubbery, nonsuppurative bilateral lymphadenopathy'''
|'''None'''
|'''Dark field examination, serology'''
|'''Benzathine penicillin G'''
|-
|'''Chancroid'''
|'''H. ducreyi'''
|'''Painful papule, then undermined purulent ulcer, single or multiple'''
|'''Tender, regional, painful, suppurative lymphadenopathy'''
|'''None'''
|'''Culture on media not routinely available'''
|'''Azithromycin'''
|-
|'''Lymphogranuloma venereum'''
|'''Chlamydia'''
|'''Small, PAINLESS, singular, vesicle or papule progresses to an ulcer'''
|'''Tender, matted, large lymphadenopathy with fistulous tracts'''
|'''Present after genital lesion heals'''
|
|'''Doxycycline'''
|-
|'''Donovanosis/Granuloma inguinale'''
|'''Klebsiella'''
|'''PAINLESS, multiple''' '''slowly progressive ulcers on the genitals and perineum'''
|'''Not present'''
|
|'''Donovan bodies'''
|'''Doxycycline'''
|}
===== '''Other genital lesions''' =====
* '''Human papillomavirus (HPV)'''
** '''Pathogen'''
*** '''Double-stranded DNA virus''' (similar to herpes)
**** '''Non-oncogenic subtypes: 6 and 11; account for ≈90% of anogenital warts, also known as condyloma acuminata'''
**** '''Oncogenic subtypes: 16 and 18; account for cervical cancer and other types of anogenital cancer including penile, vulvar, vaginal, anal cancers; subtype 16 more important for penile cancer'''
** Epidemiology
*** > 50% of sexually active persons will become infected at least once in their lifetime
** Natual history
*** ≈70% of HPV infections resolve spontaneously in 1 year and 90% in 2 years, and HPV persistence develops in the remaining persons
** Pathogenesis
*** Transmission can occur from asymptomatic and subclinical patients.
**** Among asymptomatic females in the general population, the prevalence of HPV infection ranges from 2-44%, and among men from 2-35%
*** Risk factors: presence of foreskin, increasing numbers of sexual partners, lack of condom use, and smoking.
** '''Diagnosis and Evaluation'''
*** '''See Figure'''
*** '''HPV warts can also occur in the urethra and can cause hematuria, dysuria, or difficulty voiding'''
** '''Management'''
*** '''The goal of treatment is removal of the warts; treatment will not eradicate the infection.'''
**** '''Treatment is guided by wart size, number, and location, and patient preference.'''
*** '''Options classified as patient-applied vs. provider-administered modalities'''
**** '''Patient-applied (3):'''
****# '''Imiquimod cream'''
****# '''Podofilox cream'''
****# '''Sinecatechins ointment'''
**** '''Provider-administered (4):'''
****# '''Podophyllin''' (less refined form of podofilox)
****# '''Trichloroacetic acid'''
****# '''Cryotherapy'''
****# '''Surgical therapy including direct excision with scissors, tangential shave excision, curettage, or laser therapy using a CO2 laser'''
**** See Table 1 from 2019 CUAJ Penile Lesions Review
*** '''HPV vaccine'''
**** '''Designed to prevent infection and are not effective in clearing an infection once established'''
**** '''Recommended for females AND males age < 26''', preferably to start before onset of sexual activity.
**** '''Gardasil'''
***** '''Quadrivalent HPV vaccine that provides protection against HPV types 6, 11, 16, and 18.'''
**** '''Cervarix'''
***** '''Bivalent HPV vaccine that provides protection against HPV types 16 and 18'''
* '''Scabies'''
** '''Skin infection caused by the mite Sarcoptes scabiei'''
** Pathogenesis
*** The female lays eggs in the skin, and transmission is by person-to-person skin-to-skin contact with passage of pregnant female mites.
*** Incubation period: 2-6 weeks
** Diagnosis and Evaluation
*** History and Physical Exam
**** Most common symptoms are skin rash and '''itching, especially at night''', from an allergic reaction to the mite proteins.
*** Other
**** Microscopic examination of a skin scraping to assess for mites, mite eggs, or fecal matter (scybala)
** '''Management'''
*** '''Permethrin cream''' or ivermectin 200 μg/kg orally
* '''Pediculosis Pubis (Phthirus pubis): Pubic or Crab Louse'''
** Lice are obligate bloodsucking parasites of humans
** Transmission requires close contact
** The typical presentation is pruritus, which is caused by a delayed hypersensitivity reaction to the lice, and is usually worse at night and after baths
** Insert figure
** Management
*** Permethrin 5% cream rinse applied to affected areas and washed off after 10 minutes or pyrethrins with piperonyl butoxide applied to affected areas and washed off after 10 minutes
* '''Molluscum Contagiosum'''
** '''A superficial skin disease caused by the pox virus'''
** Can be sexually transmitted
** '''Characteristic lesions are small, discrete waxy papules 3-5 mm in diameter, with a central depression'''
** Diagnosis is generally on the basis of the characteristic appearance of skin lesions.
** The infection is usually self-limited and spontaneously disappears in 6-12 months, but may take up to 4 years to resolve. However, infection in immunocompromised individuals, such as those with HIV, is typically more severe and extensive.
* '''Candidal infections'''
** The most common clinical syndromes caused by Candida albicans include genital mild burning and pruritus with erythema of the glans and/or the prepuce, and subpreputial discharge.
** '''Risk factors for fungal balanitis (especially Candida balanitis):'''
*** '''Diabetes mellitus'''
*** '''HIV infection'''
*** '''Iatrogenic immunosuppression'''
*** '''Presence of foreskin'''
*** '''Widespread use of antibiotics'''
** Management
*** The guidelines for the treatment of Candida balanitis have not yet been standardized.
*** Treatment options usually involve topical antifungal therapy, either associated or not with systemic antifungal treatment.
**** Azole agents, such as clotrimazole, miconazole, econazole, fluconazole, and itraconazole, are the usually recommended antifungal agents
===== '''Vaginitis''' =====
* Vaginal infections are characterized by discharge, itching, or odor.
** '''Bacterial vaginosis is the most common diagnosis in females seeking care for vaginal symptoms'''
* '''Diseases most frequently associated with vaginal discharge (3):'''
*# '''Bacterial vaginosis (BV)'''
*# '''Trichomoniasis'''
*# '''Candidiasis'''
* '''Bacterial vaginosis''' '''I have no CLUE why there are FISH in my GARDEN'''
** '''Pathogenesis'''
*** '''Caused by replacement of the''' normal hydrogen peroxide–producing '''Lactobacillus species in the vagina with high concentrations of anaerobic bacteria including Prevotella, Mobiluncus, GARDNErella''' vaginalis, Ureaplasma, Mycoplasma, and other fastidious anaerobes.
*** '''Not sexually transmitted'''§''', partner does not need to be treated'''
** '''Diagnosis and Evaluation'''
*** '''Although BV is the most common diagnosis in females seeking care for vaginal symptoms, most females with BV are asymptomatic'''
*** '''Characteristic findings for BV on microscopic examination are CLUE cells; discharge can have FISHY odour'''
** '''Management: metronidazole; partner does not require treatment'''
* '''Trichomoniasis'''
** '''Pathogenesis'''
*** '''Caused by the protozoan T. vaginalis'''
*** '''Sexually transmitted'''
** '''Diagnosis and Evaluation'''
*** '''The discharge is diffuse, malodorous, and yellow green with vulvar irritation'''
*** A strawberry rash on the vulva or strawberry cervix may be seen
*** '''Diagnosis is usually by microscopy of vaginal secretions showing the Trichomonas organisms'''
** '''Management: metronidazole; partner needs to be treated'''
* '''Candidiasis'''
** Pathogenesis
*** Usually caused by Candida albicans but occasionally by other species of Candida or yeasts
** Diagnosis and Evaluation
*** The diagnosis is made via wet prep with saline or KOH, a Gram stain of vaginal discharge that demonstrates yeast, hyphae, or pseudohyphae, or a culture that shows Candida or other yeast species.
**** '''Wet mounts should first be done for all patients, and culture used for those with symptoms with negative wet mounts.'''
** Management
*** Uncomplicated vulvovaginal candidiasis: over-the-counter intravaginal agents including butoconazole or clotrimazole creams, miconazole as a cream or intravaginal suppository, or tioconazole ointment.
===== '''HIV/AIDS''' =====
* '''HIV is a single stranded RNA retrovirus that infects CD4 helper T cells and dendritic cells'''
* '''The HIV envelope precursor protein gp160 is cleaved into gp 120 and gp41'''
* '''Factors associated with increased risk of seroconversion with HIV after a needle stick (4):'''
*# '''Deep as opposed to superficial exposure'''
*# '''Visible blood on the injuring device'''
*# '''Prior placement of the injuring device in an artery or vein'''
*# '''Patient dying within 2 months of the exposure'''
* '''Diagnosis and Evaluation'''
** '''The initial test is a screening test for antibodies, the conventional or rapid enzyme immunoassay (EIA).''' The initial result can be obtained in 30 minutes.
** '''Positive or reactive screening tests must be confirmed by a supplemental antibody test, Western blot and indirect immunofluorescence assay (IFA), or virologic test, the HIV-1 RNA assay. A positive confirmation test result establishes the diagnosis'''
** '''HIV is detectable in 95% of patients within 3 months after infection. During this initial 3-month period, the “window” period, the screening test result may be negative but the person may still be infected. Viral load assay is the best diagnostic test to detect HIV in the acute phase of infection'''
** '''The diagnosis of AIDS is made if the CD4 count is < 200 cells/mm3 or if there is a serious opportunistic infection, neoplasm, or other life-threatening condition.'''
* '''Urologic manifestation of HIV'''
*# '''Infections'''
*## '''Interaction with other STIs'''
*##* '''Testing for HIV is recommended in anyone with a diagnosed STI or who is at risk for an STI'''
*##* Genital ulcers bleed frequently during intercourse, potentially leading to increased infectiousness.
*## '''Kidney infections'''
*##* '''Persons with HIV infection are more likely to develop clinical TB if infected, including renal and other extrapulmonary disease'''
*##** Mycobacterial infection of the kidney is detected at autopsy in 6-23% of AIDS patients
*##* Other kidney infections that occur in AIDS include CMV, aspergillus and toxoplasma
*## '''Prostatitis'''
*##* Prostate infection may be more common in men with HIV
*##* Prostatitis is usually caused by E. coli, but in HIV-infected males, many other organisms can cause prostate infection, including S. aureus, Klebsiella pneumoniae, Pseudomonas aeruginosa, Serratia marcescens, Salmonella Typhi, Mycobacterium tuberculosis and Mycobacterium avium intracellulare, and CMV. Fungal infections also can cause prostatitis, particularly in immunocompromised patients with T-cell counts < 200 cells/μL.
*##* In men with HIV, cultures should be performed not only for the usual bacteria, but also for more atypical organisms including aerobes, anaerobes, fungi, and M. tuberculosis
*## '''UTI'''
*##* Incidence of bacteruria is related to CD4 counts and viral load
*##* Unusual organisms may cause UTIs, including CMV
*# '''Testis, epididymis, and SVs'''
*#* '''HIV in semen is the main vector for transmission and can persist despite high loads of ART'''
*#* '''The most common intrascrotal pathology in men with HIV/AIDS is''' '''testicular atrophy'''. This can arise from endocrine imbalances, febrile episodes, malnutrition, testicular infections, and toxic effects of therapy
*#* '''HIV itself is thought to be cytotoxic to germ and Sertoli cells'''
*#* '''The testes may also be directly infected by opportunistic infections'''
*#* In combination with extra-testicular causes, '''testosterone levels fall''' with progressive HIV disease
*# '''Erectile dysfunction'''
*#* '''Prevalence higher in HIV-infected men than uninfected'''
*#* '''HIV patients taking ART should be started on the lowest dose possible of PDE5 inhibitors'''
*#** PDE5 inhibitors depend on CYP3A for clearance, and all protease inhibitors and non-nucleoside reverse transcriptase inhibitors are inhibitors of CYP3A to some extent. This can lead to a significant increase in the serum dose of PDE5 inhibitors
*#*** See 2018 AUA Erectile Dysfunction Guideline Notes for dosing adjustments required with use of PDE5i
*# '''Renal function'''
*#* The classic clinical presentation of '''HIV-associated nephropathy''' is rapidly progressive azotemia with severe proteinuria, often nephrotic range, and little or no peripheral edema
*#* Polymorphism of Apolipoprotein-1 is associated with development of HIV-associated nephropathy (HIVAN) in African-American patients
*# '''Voiding dysfunction'''
*#* '''Increased incidence of LUTS'''
*# '''Hematuria'''
*#* Higher rate of microscopic hematuria but HIV patients should be evaluated similarly to other individuals
*# '''Stones'''
*#* One of the complications of some medications for treatment of HIV is stone formation. The protease inhibitors specifically may cause stone formation.
*#* Indinavir can form crystals in the urine. '''Indinavir stones are typically radiolucent on both plain film and CT scan but can also be mixed with calcium and appear radiopaque'''
*#* '''Newer inhibitors''' including lopinavir, atazanavir, amprenavir, and nelfinavir '''have also been associated with the development of stones, but with less frequency than reported for indinavir'''
*#* In patients with protease stones and in whom conservative management is possible as a first-line step, discontinuation of the drug and hydration should be tried
*#* '''Another type of stone reported to be more common in HIV patients is ammonium acid urate stones,''' possibly reflecting chronic diarrhea and malnutrition of chronic disease
*# '''Neoplasms'''
*** Compared with the general population, patients with HIV have a greater risk to develop not only non–AIDS-defining cancers with a viral pathogenesis but also non–virus-related cancers
*** '''AIDS-defining cancers (3):'''
***# '''Kaposi sarcoma (KS)'''
***#* '''Most relevant for the urologist given the possibility of KS lesions on the penis'''
***# '''Non-Hodgkin lymphoma'''
***# '''Invasive cervical cancer''' in females
*** '''Kaposi sarcoma'''
**** See Penile Tumors Chapter Notes
**** '''Human herpes virus 8''' (KSHV/HHV-8), a double-stranded DNA virus '''is the causative pathogen in > 90% of cases'''
**** Typically manifests with disseminated pigmented skin lesions, a few millimeters to several centimeters, from pink to purple or brown, often associated with edema and lymph node and visceral involvement in up to 50% of patients
***** See Figure
*** '''Non–AIDS-Defining Urologic Malignancies'''
**** '''HIV is associated with an increased risk of'''
****# '''Testicular tumours'''
****#* HIV-infected men are also at risk for testicular non-Hodgkin lymphoma
****# '''Kidney cancer'''
****# '''Penile cancer'''
****#* '''Note that the 2018 EAU Guidelines on Penile Cancer state that “penile cancer is not linked to HIV or AIDS”'''
**** '''HIV is not associated with increased risk of'''
****# '''Prostate cancer'''
****# '''Bladder cancer'''
****** Use caution in deciding to use intravesical BCG in the treatment of HIV-positive patients. The effectiveness of BCG is dependent on a functioning immune system, and therefore the agent is not typically used in immunocompromised patient
===== Questions =====
# List the ulcerative genital lesions and the associated pathogen.
# Which ulcerative genital lesions present with tender lesion(s)?
# Which ulcerative genital lesions present with lymphadenopathy?
# Which subtypes of HPV are responsible for penile warts?
# What are the treatment options for penile HPV?
# What is the pathogen responsible for Kaposi Sarcoma?
# Which urologic malignancies are associated with HIV?
===== Answers =====
# List the ulcerative genital lesions and the associated pathogen.
## Herpes - HSV
## Syphillis - treponema pallidum
## Chancroid - H. Ducreyi
## Lymphogranuloma venereum - Chlamydia
## Donovanosis/granuloma inguinale - Klebsiella
# Which ulcerative genital lesions present with tender lesion(s)?
## Herpes
## Chancroid
# Which ulcerative genital lesions present with lymphadenopathy?
## Herpes: tender lymphadenopathy
## Syphillis: non-tender lymphadenopathy
## Chancroid: tender lymphadenopathy
## Lymphogranuloma venereum: tender lymphadenopathy
# Which subtypes of HPV are responsible for penile warts?
## 16
## 18
# What are the treatment options for penile HPV?
## Patient-applied (3):
### Imiquimod cream
### Podofilox cream
### Sinecatechins ointment
## Provider-administered (4):
### Podophyllin
### Trichloroacetic acid
### Cryotherapy
### Surgical therapy including direct excision with scissors, tangential shave excision, curettage, or laser therapy using a CO2 laser
# What is the pathogen responsible for Kaposi Sarcoma?
#* Human Herpes Virus 8
# Which urologic malignancies are associated with HIV?
## Testicular cancer
## Kidney cancer
## Penile cancer
===== References =====
* Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, vol 1, chap 15
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