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Sexually Transmitted Disease
Aka: Sexually Transmitted Disease, STD, Sexually Transmitted Infection, STI, Expedited Partner Treatment, STI Screening, STD Screening, Chlamydia trachomatis and Neisseria gonorrhoeae Infections
- See Also
- Postexposure Prophylaxis for HIV
- Postexposure Prophylaxis for Hepatitis B
- Rape Management
- Gonorrhea
- Chlamydia
- Chancroid
- Syphilis
- Herpes Genitalis
- Trichomonas
- Anogenital Condyloma (Human Papillomavirus)
- Human Immunodeficiency Virus
- Hepatitis BVirus
- Pediculosis Pubis
- Scabies
- Pelvic Inflammatory Disease
- Non-Gonococcal Urethritis
- Mycoplasma Genitalium
- Risk Factors: High Risk Groups for STD
- Adolescents and young adults (ages 15 to 24 years old)
- Multiple partners
- Sequential monogamy
- Unconcerned
- Uniformity
- Inconsistent Condom use
- Racial or ethnically skewed
- Black: Chlamydia more common
- Homosexual men (or Men who have Sex with Men)
- Transgender Person
- Coasts or Ports of entry
- Prostitutes
- Teenage runaways
- Immigrants
- Low income in urban setting
- Prison Inmate (current or former)
- Military recruits
- Mental Illness
- Injection drug user (IV Drug Abuse)
- Sexual Abuse history
- Sexually Transmitted Infection history
- Pathophysiology: Transmission
- Contact
- Secretions
- Mucus membrane
- Skin Abrasion
- Intercourse not necessary for STD transmission
- Herpes Simplex Virus
- Condyloma
- Gonorrhea
- Chlamydia
- Causes
- Sexually Transmitted Disease Genital Ulcers
- See Genital Ulcers (Mnemonic: CHISEL)
- E in CHISEL is drug eruption
- Painful Ulcers
- Chancroid
- Herpes Genitalis
- Trichomonas may also cause labial ulcerations
- Non-Painful Ulcers
- Granuloma Inguinale
- Syphilis (Early)
- Lymphogranuloma venereum
- Sexually Transmitted Disease Non-ulcerative
- Non-Gonococcal Urethritis
- Pelvic Inflammatory Disease
- Gonorrhea
- Chlamydia
- Syphilis (Secondary or tertiary)
- Human Papillomavirus (HPV) and Cervical Dysplasia
- Human Immunodeficiency Virus (HIV)
- Hepatitis BVirus
- Parasitic Infection
- Pediculosis Pubis
- Scabies (pruritic genital bumps awaken patient)
- Findings: Genitourinary Gonorrhea or Chlamydia (Male)
- Symptoms
- Dysuria
- Urinary Frequency
- Urethral meatus discharge
- Urethral Pruritus
- Painful ejaculation
- Signs
- Mucopurulent Urethral discharge
- Unilateral Testicular Pain
- Complications
- Acute Prostatitis
- Epididymitis
- Findings: Genitourinary Gonorrhea or Chlamydia (Women)
- Symptoms
- Vaginal Discharge
- Postcoital spotting
- Dyspareunia
- Signs
- Genital Ulcers
- Cervicitis
- Erythema of Cervix

- Mucopurulent discharge from Cervical os
- Complications
- Pelvic Inflammatory Disease
- Fever, uterine and Adnexal tenderness, cervical motion tenderness, Vaginal Discharge
- Perihepatitis (Fitz-Hugh-Curtis Syndrome)
- Pelvic Pain and right upper quadrant pain with fever, Vomiting and abnormal LFTs
- Findings: Extra-Genital Gonorrhea or Chlamydia
- Oropharyngeal Findings
- Pharyngitis
- Oropharyngeal exudate
- Cervical Lymphadenitis
- Anorectal Findings (also caused by syphillis, HSV, in addition to GC and Chlamydia)
- Anal Pruritus
- Rectal Pain
- Pain with anorectal intercourse
- Rectal Bleeding
- Rectal discharge
- Tenesmus
- Reactive Arthritis (Reiter's Syndrome)
- Aseptic Arthritis
- Conjunctivitis
- Urethritis
- Lymphogranuloma venereum (Chlamydia)
- Unilateral, swollen and tender inguinal or femoral Lymph Nodes
- Ulcer or Papule overlying Lymph Nodes may be present
- Fever
- Rectal symptoms
- Rectal Bleeding
- Rectal mucoid discharge
- Rectal Pain
- Tenesmus
- Constipation
- Disseminated Gonococcal Infection
- Migratory polyarthritis (asymmetric, Pauciarticular)
- Tenosynovitis
- Fever
- Dermatitis (distal extremity necrotic lesions)
- May be complicated by endocarditis or Meningitis
- Precautions
- Dysuria is not synonymous with Urinary Tract Infection (UTI)
- Consider Sexually Transmitted Infection (STI) in sexually active women presenting with Dysuria
- Urine White Blood Cells and positive Leukocyte esterase are seen in both UTIs as well as STIs
- Extra-genital sites of Gonorrhea and Chlamydia infection are often missed
- Ask a Sexual History including practices, and screen oropharynx and Rectum as indicated
- Urine-Only screening may miss Sexually Transmitted Infection in >80% of patients
- Marcus (2011) Sex Transm Dis 38(10): 922-4 [PubMed]
- Pharyngeal Gonorrhea in Men who have Sex with Men
- Morris (2006) Clin Infect Dis 43: 1284-9 [PubMed]
- Pharyngeal and Rectal Gonorrhea, and Rectal Chlamydia in women who have sex with men
- Bamberger (2019) Sex Transm Dis 46(5): 329-34 [PubMed]
- Pregnancy-related Sexually Transmitted Infection
- See Chorioamnionitis
- See Postpartum Endometritis
- See TORCH Infection
- STI in pregnancy is high risk for complications (e.g. IUGR, PROM, Stillbirth, preterm birth, neonatal infection)
- Universal screening in all pregnant women under age 25 years at first Prenatal Visit (and often in all women)
- Rescreen pregnant women in 4 weeks after completing STI treatment, and again in 3 months, and third trimester
- Neonatal and Perinatal Sexually Transmitted Infection
- See Perinatal HIV Transmission
- See Neonatal Herpes Simplex Virus
- See Perinatal Hepatitis B Exposure
- See Congenital Syphilis
- Gonorrhea
- Perinatal Gonorrhea infection affects up to 0.4 cases in 100,000 U.S. live births
- Risk of gonococcal Ophthalmia Neonatorum (risk of newborn blindness if prophylaxis is not used)
- Risk of disseminated Gonorrhea infection in newborns (e.g. Septic Arthritis, Meningitis, Pneumonia)
- Chlamydia
- Risk of chlamydia Ophthalmia Neonatorum (later presentation than with Gonorrhea)
- Risk of Neonatal Chlamydia Pneumonia
- Labs: Screening First-Line
- Genitourinary Gonorrhea and Chlamydia Testing
- Tests
- Chlamydia DNA Probe
- Gonorrhea DNA probe
- Sources
- First-Stream Urine without Urethral Cleansing ("Dirty Urine")
- Preferred sample in men and women (equivalent to endocervical, vaginal or Urethral swabs)
- Other sources
- Endocervical swab on female speculum exam
- Provider or patient performed vaginal swabs
- Urethral swabs (men)
- References
- Lunny (2015) PLoS One 10(7): e0132776 [PubMed]
- Ronn (2019) BMJ Open 9(1): e022510 [PubMed]
- Extragenital Testing (pharynx, Rectum) for Gonorrhea and Chlamydia
- Several DNA and NAAT are approved for extragenital testing (e.g. Aptima Combo 2, Xpert CT/NG)
- Point-of-care tests are available for Gonorrhea and Chlamydia genitourinary and extra-genital testing
- Vaginal Exam
- Trichomonas DNA probe
- Vaginal Wet prep
- Positive: Polymorphonuclear Leukocytes (PMNs) >10/hpf
- Positive test should be followed by specific DNA testing for Chlamydia and Gonorrhea
- Efficacy
- Test Sensitivity: 90%
- Test Specificity: 87%
- Reference
- Bohmer (1999) Am J Obstet Gynecol 181:283-7 [PubMed]
- Broad STI Screening in those at risk, including those testing positive for Gonorrhea and Chlamydia
- HIV Test
- Syphilis (RPR)
- Hepatitis B Testing (if not immunized)
- Other Testing to consider
- Consider Urinalysis
- Consider Urine Pregnancy Test
- Differential Diagnosis
- Conjunctivitis
- See Bacterial Conjunctivitis
- See Conjunctivitis in Newborns
- Urethritis
- See Urethritis
- See Urethritis in Women
- See Urethritis in Men
- See Epididymitis
- See Acute Prostatitis
- Vaginitis
- See Vaginitis
- See Acute Cervicitis
- See Pelvic Inflammatory Disease
- Other Findings
- See Pharyngitis Causes
- See Proctitis
- See Inguinal Lymphadenopathy
- See Polyarticular Arthritis
- Management
- Emergency department empiric treatment
- Initiating empiric treatment for suspected STD prior to results (often delayed days) is appropriate
- Despite risk of overtreatment, treat for suspected Chlamydia and Gonorrhea (prevents spread, complications)
- Gonorrhea management
- Ceftriaxone 500 mg IM/IV for 1 dose (1 gram IM/IV if weight > 150 kg, dose increased in 2020) OR
- Gentamicin 240 mg IM and Azithromycin 2 g orally for one dose OR
- Cefixime 800 mg orally once is an alternative but NOT recommended due to Antibiotic Resistance
- Chlamydia management if not excluded (not indicated for Gonorrhea treatment without Chlamydia as of 2020)
- Doxycycline 100 mg twice daily for 7 days (preferred as of 2020) OR
- Azithromycin 1 g orally for 1 dose
- References
- Cyr (2020) MMWR Morb Mortal Wkly Rep 69(50): 1911-6 [PubMed]
- https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm
- Avoid sexual contact until antibiotic course is completed
- Rescreening
- Routinely Rescreen positive STD cases in 3 months to identify new STD infections
- Rescreen pregnant women in 4 weeks after completing treatment, and again in 3 months, and in third trimester
- Only other indicated early rescrening at 7 to 14 days (screening for cure) is for pharyngeal Gonorrhea
- Peterman (2006) Ann Intern Med 145:654-72 [PubMed]
- Clinic Visits
- Symptomatic patients should have in-person clinical examinations
- Consider Telemedicine for Sexually Transmitted Infection screening in asymptomatic patients
- At-home Chlamydia trachomatis and NeisseriaGonorrhea tests are available (not FDA approved)
- Medical provider or nurse instructed sample self-collection can be instructed on Telemedicine
- At home Test Sensitivity may be lower, but allows for screening more patients with fewer barriers
- Canevale (2021) Sex Transm Dis 48(1): e11-4 [PubMed]
- Fajardo-Bernal (2015) Cochrane Database Syst Rev (9):CD011317 [PubMed]
- Kersh (2021) J Clin Microbiol 59(11): e0264620 [PubMed]
- Management: Expedited Partner Treatment
- Empiric STI treatment for an asymptomatic sexual partner of a patient being seen for STI
- Patient positive for Chlamydia or Gonorrhea in last 60 days (or last sexual partner if >60 days)
- Symptomatic sexual partners should be medically evaluated
- Precaution: Legality of Expedited Partner Treatment varies by State in the United States
- http://www.cdc.gov/std/ept/legal/
- As of 2022, permitted in 46 states
- Patients may anonymously notify their partner
- https://tellyourpartner.org/
- Ideally sexual partners are seen for their own medical evaluations
- However, delaying their treatment until evaluation risks re-exposing treated patients
- CDC asks physicians to consider treating sexual partners of STD patients without a visit
- Employ in cases where sexual partner is unlikely to present for medical care
- Prescription for sexual partner's STD treatment is given to the patient being treated
- Some states may allow prescription labeled for "EPT" or "partner"
- Do not double up on prescription quantity for one patient (write 2 separate prescriptions)
- Example protocol for partner (prescriptions given to patient to bring to partner)
- Provider should ask about partner's medication allergies, other medications and pregnancy
- Written instructions should be given to the patient to convey to their sexual partner
- Patient and their partner should abstain from sex until both have completed antibiotic course
- Regimen
- Cefixime 800 mg (if partner will be seen, Ceftriaxone 500 mg IM/IV is preferred) AND
- Azithromycin 1 gram orally (or preferred option is Doxycycline 100 mg twice daily for 7 days)
- References
- (2015) Presc Lett 22(8)
- Golden (2005) N Engl J Med 352:676-85 [PubMed]
- (2015) MMWR Recomm Rep 64(RR-03): 1-137 +PMID:26042815 [PubMed]
- Prevention: Screening Asymptomatic Patients (USPTF guidelines)
- See Risk Factors listed above
- Behavioral counseling (proper Condom use, safe sex, difficult sexual situations)
- All sexually active adolescents
- Adults at risk for Sexually Transmitted Infection
- Emphasize barrier protection (e.g. Condoms) as best method to prevent Sexually Transmitted Infection during sex
- Gonorrhea and Chlamydia screening
- All sexually active adolescents 24 years old and younger every year (and repeated 3 months after positive testing)
- Women at risk for Sexually Transmitted Infection
- Pregnancy age <= 24 years or any age if high risk (at first visit, and if risk then repeat in third trimester)
- Men who have Sex with Men (consider rectal and pharyngeal screening as well)
- Correctional facilities at intake (men age <30 years, women age <35 years)
- HIV Screening
- All patients ages 15 years old to 65 years old (or if risks)
- All pregnant women at first Prenatal Visit (or at time of delayed presentation)
- Hepatitis BVirus Screening
- All pregnant women at first Prenatal Visit (or at time of delayed presentation)
- Patients at risk of infection
- Immigrants from sub-sahara Africa, Central and Southeast Asia, China (esp. unimmunized)
- Household HBV Contacts
- Syphilis Screening
- All pregnant women at first Prenatal Visit (or at time of delayed presentation)
- Patients at risk of infection
- Herpes Simplex Virus Infection Screening
- USPTF and AAFP
- Do NOT routinely screen HSV Serology in asymptomatic patients
- CDC and ACOG
- Consider type-specific Serology in women at time of STI evaluation (esp. if multiple partners)
- References
- Lee (2016) Am Fam Physician 94(11): 907-15 [PubMed]
- Prevention
- Consistent Condom Use
- Vaccination
- Hepatitis A Vaccine
- Hepatitis B Vaccine
- Human Papilloma Virus Vaccine (HPV Vaccine, Gardasil)
- Other measures
- HIV Preexposure Prophylaxis (HIV PrEP)
- Expedited Partner Treatment (see above)
- Resources: Patients
- CDC National STD Hotline (CDC)
- http://www.cdc.gov/std/
- Phone: 800-232-4636
- Expedited Partner Treatment (CDC)
- http://www.cdc.gov/std/ept/
- Information from your Family Doctor: Prevent AIDS
- http://www.familydoctor.org/healthfacts/005/
- Inspot.Org (annonymously notify others of STD exposure)
- https://inspot.org/
- DontSpreadIt.Com (annonymously notify others of STD exposure)
- https://dontspreadit.com/
- References
- Workowski (2006) MMWR Recomm Rep 55: 1-94 [PubMed]
- Workowski (2021) MMWR Recomm Rep 70(4): 1-187 [PubMed]
- Dalby (2022) Am Fam Physician 105(5): 514-20 [PubMed]
- Yonke (2022) Am Fam Physician 105(4): 388-96 [PubMed]