AssessmentsSexually transmitted infections: Clinical practice
USMLE® Step 1 style questions USMLE
USMLE® Step 2 style questions USMLE
A 31-year-old woman comes to the gynecology clinic because of pelvic pain. She has had 2-weeks of intermittent pain, worse on the right, and radiating to her groin which has worsened and is more consistent. She denies urinary symptoms including burning, blood, urgency, and frequency. She had two sexual partners in the past month with intermittent condom use. Examination shows a temperature of 37.4°C (99.4°F), with normal vitals otherwise. There is pain to palpation in the right and left lower quadrants without rebound. A speculum examination demonstrates purulent discharge from the cervical os. Which of the following would most likely be present upon microscopic examination of the discharge?
Content Reviewers:Rishi Desai, MD, MPH
Sexually transmitted infections or STIs are infections that get transmitted through sexual fluids or skin-to-skin contact during sexual intercourse.
Generally, with STIs, all partners with whom there has been sexual contact in the 60 days prior to the diagnosis should be evaluated and treated.
Okay, let’s start with infections that mainly affect the genital organs like Neisseria gonorrhoeae- which causes gonorrhea, Chlamydia trachomatis which causes chlamydia, and Mycoplasma genitalium - an increasingly recognized pathogen.
These infections are usually asymptomatic, but in females, they can cause cervicitis and urethritis.
Cervicitis causes changes in vaginal discharge, pruritus in the genital area, intermenstrual vaginal bleeding, or post-coital bleeding.
If left untreated, these bacteria can ascend in the reproductive tract and cause pelvic inflammatory disease or PID- which is the inflammation of the uterus, fallopian tubes, the ovaries and of course, the cervix.
Acute PID causes lower abdominal pain that worsens during sexual intercourse or sudden movement, post-coital bleeding, and intermenstrual bleeding.
Chronic PID causes a low grade fever, weight loss, and abdominal pain.
Sometimes, PID can be complicated by a tubo-ovarian abscess which can involve the fallopian tubes, ovaries, or other nearby pelvic organs.
If Chlamydia trachomatis and Neisseria gonorrhoeae come into contact with anal or rectal mucosa, they can cause proctitis, and symptoms include tenesmus, anorectal pain, anorectal bleeding, and constipation.
Neisseria gonorrhoeae can also cause pharyngitis, leading to sore throat, pharyngeal exudates, and cervical lymphadenitis.
The gold-standard for diagnosing these infections is the nucleic acid amplification testing or NAAT from secretions.
Vaginal or endocervical swabs are done for females, and urine samples or urethral swabs are done for males.
In males, a Gram stain is performed on the urethral swab and is examined for the presence of white blood cells or WBCs and for bacteria.
The presence of more than 2 WBCs per high power field or HPF suggests urethritis.
In addition, the first-void urine should be checked and in urethritis, leukocyte esterase is positive on the dipstick test, and there are more than 10 WBC per HPF on microscopy.
Finally, HIV testing is also done for all individuals.
Azithromycin is given, because individuals with gonococcal infections often have chlamydial infections as well.
For individuals with epididymitis or proctitis, empirical treatment for both Chlamydia trachomatis and Neisseria gonorrhoeae infection is done with a single intramuscular dose of 250 milligrams ceftriaxone and oral doxycycline for 10 days- in the case of epididymitis, and for 7 to 21 days for proctitis depending on severity.
For Mycoplasma genitalium infection, treatment is a single oral dose of 1 gram azithromycin.
After 24 hours, parenteral therapy is usually switched to oral therapy with only doxycycline for 14 days.
Okay, now moving on to Human papillomavirus infection or HPV infection and some serotypes - like 16, 18, 52 and 56- are associated with cancer.
They can cause cervical, vulvar, vaginal, anorectal and oropharyngeal cancer in females and penile cancer, along with anorectal and oropharyngeal cancer in males.
Now, there are some serotypes- like 6 and 11- that cause benign lesions in the genital and anal area called anogenital warts or Condylomata accuminata.
Anogenital warts can be located on the vulva, penis, groin, perineum, perianal skin, and sometimes on the suprapubic skin.
The warts can be single or can come in groups, can have different shapes- they can be dome-shaped, plaque-like, pedunculated, verrucous, or lobulated, and they can have different colors- they can be white, skin-colored, or erythematous.
The diagnosis is made based on the appearance of the warts. If there’s any uncertainty, the wart can be biopsied.
Treatment includes topical administration of imiquimod or sinecatechins.
If the lesions persist, then surgical excision, electrosurgery, cryotherapy, or treatment with trichloroacetic acid can be done.
Next is Trichomonas vaginalis infection, which causes a protozoan infection called trichomoniasis.
In females, symptoms include a bad-smelling, purulent and thin vaginal discharge, along with burning and pruritus in the genital area.
Additionally, there can also be dysuria, frequency, lower abdominal pain, post-coital bleeding and dyspareunia- which is painful sexual intercourse.
In males, the infection is usually asymptomatic, but it can cause symptoms like urethral discharge and dysuria.
The gold-standard for identifying Trichomonas vaginalis is by performing NAAT on a vaginal or urethral swab.
Additionally, in females, microscopy of the vaginal secretion is done and this shows motile trichomonads.
Treatment is done with a single 2 gram oral dose of either tinidazole or metronidazole.
Next are infections that get transmitted through skin-on-skin contact, such as Pediculosis pubis infections- most commonly known as crabs- and Sarcoptes scabiei infections- which cause scabies. Both of these can infect the pubic area during sexual intercouse.
The main symptom with both infections is pruritus that can involve the genital and perianal areas.
With scabies, there are usually multiple small erythematous papules.
If the diagnosis is uncertain, then microscopic examination of hair shafts can confirm the diagnosis of crabs and microscopic examination of a small sample of skin can confirm scabies.
In addition, a first-line treatment for scabies is a single 200mg dose of oral ivermectin, followed by a repeat dose in one to two weeks.
With crabs, the nits should be removed with a nit comb or tweezers.
Another example of genital infections transmitted through skin-on-skin contact is Herpes simplex virus - or HSV - infection.
Now, the symptoms depend upon whether a person has anti-herpes simplex virus antibodies. If they don’t already have those antibodies, then it’s called a primary infection.
In a primary infection, there are painful vesicles that form on an erythematous base, pruritus in the genital area, dysuria, and inguinal lymphadenopathy.
Systemic symptoms include fever, headaches, and myalgias.
Now, if the individual does have antibodies from a prior asymptomatic infection, then it’s called a nonprimary infection. In this case, symptoms are generally less severe.
Finally, HSV can linger in the neurons and can reactivate from time to time, and when that happens the symptoms are usually more mild.
Depending on the type of sexual intercourse, herpes simplex virus can also cause proctitis, which presents with tenesmus and anorectal pain.
Serology can also be done in order to identify anti-HSV antibodies which diagnoses a past or present HSV infection.
Treatment of primary and nonprimary HSV infections is done with either oral acyclovir- 400 milligrams three times daily or oral famciclovir- 250 milligrams three times daily or oral valacyclovir- 1 gram twice daily. Duration of treatment is 7 to 10 days.
Treatment of recurrent HSV infections depends upon the frequency of recurrent episodes and severity of symptoms.
In individuals with more than 6 recurrent episodes per year or individuals with more severe symptoms, treatment includes long-term use of oral valacyclovir 500 milligrams daily.
Okay, another infection that’s transmitted through skin-to-skin contact is Haemophilus ducreyi infection.
It’s thought that the microabrasions in the skin that can occur during sexual contact can create a path for Haemophilus ducreyi to infect the tissues, because this bacteria doesn’t typically infect intact skin.
The skin lesion starts as an erythematous papule that evolves into a painful ulcer that’s about 1 to 2 centimeters in diameter that bleeds when scraped. This is called a chancroid ulcer, and usually a few ulcers develop in the genital area.
In males, there’s usually inguinal lymphadenopathy.
In order to diagnose the infection, a gram stain, culture and PCR can be done using exudate from the ulcer. The gram stain can sometimes show gram-negative rods in a chain, also called “school of fish”.
Treatment is a single dose of 250 milligrams of IM ceftriaxone or 1 gram of oral azithromycin.
Now let’s switch gears and talk about infections that can affect the whole body. First, there's Treponema pallidum infection which causes syphilis.
Syphilis is divided into early and late stages.
The early stage is further subdivided into primary syphilis and secondary syphilis.
With primary syphilis, there’s a localized skin lesion called a chancre.
The skin lesion starts as an erythematous papule that evolves into a pain-free ulcer that’s about 1 to 2 centimeters in diameter.
Usually a few chancre ulcers develop in the genital area.
In the absence of treatment, the chancre heals within 3 to 6 weeks, but bacteria will spread throughout the body and cause a systemic infection.
Within weeks to a few months after a chancre develops, secondary syphilis can occur, which is a systemic infection.
General symptoms include fever, headache, malaise, anorexia, myalgias and unintentional weight loss.
Most individuals with secondary syphilis have lymphadenopathy in the posterior cervical, axillary, inguinal, and femoral regions.
Often there’s a maculopapular rash that’s symmetrical and diffuse and involving the trunk and extremities.