Sexually Transmitted Disease

Aka: Sexually Transmitted Disease, STD, Sexually Transmitted Infection, STI, Expedited Partner Treatment, STI Screening, STD Screening

1. See Also
   1. Postexposure Prophylaxis for HIV
   2. Postexposure Prophylaxis for Hepatitis B
   3. Rape Management
2. Risk Factors: High Risk Groups for STD
   1. Adolescents
      1. Multiple partners
      2. Sequential monogamy
      3. Unconcerned
      4. Uniformity
   2. Racial or ethnically skewed
      1. Black: Chlamydia more common
   3. Homosexual men or women
   4. Coasts or Ports of entry
   5. Prostitutes
   6. Teenage runaways
   7. Immigrants
   8. Low income in urban setting
   9. Prison Inmate (current or former)
   10. Military recruits
   11. Mental Illness
   12. Injection drug user (IV Drug Abuse)
   13. Sexual Abuse history
3. Pathophysiology: Transmission
   1. Contact
      1. Secretions
      2. Mucus membrane
      3. Skin Abrasion
   2. Intercourse not necessary for STD transmission
      1. Herpes Simplex Virus
      2. Condyloma
      3. Gonorrhea
      4. Chlamydia
4. Causes
   1. Sexually Transmitted Disease Genital Ulcers
      1. See Genital Ulcers (Mnemonic: CHISEL)
         1. E in CHISEL is drug eruption
      2. Painful Ulcers
         1. Chancroid
         2. Herpes Genitalis
         3. Trichomonas may also cause labial ulcerations
      3. Non-Painful Ulcers
         1. Granuloma Inguinale
         2. Syphilis (Early)
         3. Lymphogranuloma venereum
   2. Sexually Transmitted Disease Non-ulcerative
      1. Non-Gonococcal Urethritis
      2. Pelvic Inflammatory Disease
      3. Gonorrhea
      4. Chlamydia
      5. Syphilis (Secondary or tertiary)
      6. Human Papillomavirus (HPV) and Cervical Dysplasia
      7. Human Immunodeficiency Virus (HIV)
      8. Hepatitis BVirus
      9. Parasitic Infection
         1. Pediculosis Pubis
         2. Scabies (pruritic genital bumps awaken patient)
5. Symptoms: Women
   1. Vaginal Discharge
   2. Postcoital spotting
   3. Dyspareunia
6. Signs: Women
   1. Genital Ulcers
   2. Cervicitis
      1. Erythema of Cervix
         1. 
      2. Mucopurulent discharge from Cervical os
7. Lab: Screening
   1. First-line studies
      1. Chlamydia DNA probe
      2. Gonorrhea DNA probe
      3. Vaginal Wet prep
      4. Consider Urinalysis
   2. Additional studies to consider
      1. HIV Test
      2. Syphilis (RPR)
      3. Hepatitis B Testing (if not immunized)
8. Lab: Wet Mount microscopic exam of cervical swab
   1. Positive: Polymorphonuclear Leukocytes (PMNs) >10/hpf
   2. Positive test should be followed by specific testing
      1. Chlamydia trachomatis
      2. Neisseria gonorrhoeae
   3. Efficacy
      1. Test Sensitivity: 90%
      2. Test Specificity: 87%
   4. Reference
      1. Bohmer (1999) Am J Obstet Gynecol 181:283-7 [PubMed]
9. Pitfalls
   1. Pharyngeal Gonorrhea in Men who have Sex with Men
      1. Morris (2006) Clin Infect Dis 43: 1284-9 [PubMed]
10. Management
    1. Emergency department empiric treatment
       1. Initiating empiric treatment for suspected STD prior to results (often delayed days) is appropriate
       2. Despite risk of overtreatment, treat for suspected Chlamydia and Gonorrhea (prevents spread, complications)
          1. Gonorrhea management
             1. Ceftriaxone 500 mg IM/IV for 1 dose (1 gram IM/IV if weight > 150 kg, dose increased in 2020) OR
             2. Gentamicin 240 mg IM and Azithromycin 2 g orally for one dose OR
             3. Cefixime 800 mg orally once is an alternative but NOT recommended due to Antibiotic Resistance
          2. Chlamydia management if not excluded (not indicated for Gonorrhea treatment without Chlamydia as of 2020)
             1. Doxycycline 100 mg twice daily for 7 days (preferred as of 2020) OR
             2. Azithromycin 1 g orally for 1 dose
          3. References
             1. Cyr (2020) MMWR Morb Mortal Wkly Rep 69(50): 1911-6 [PubMed]
                1. https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm
    2. Rescreening
       1. Routinely Rescreen positive STD cases in 3 months to identify new STD infections
       2. Peterman (2006) Ann Intern Med 145:654-72 [PubMed]
    3. Expedited Partner Treatment
       1. Precaution: Legality of Expedited Partner Treatment varies by State in the United States
          1. http://www.cdc.gov/std/ept/legal/
       2. Patients may anonymously notify their partner
          1. https://tellyourpartner.org/
       3. Ideally sexual partners are seen for their own medical evaluations
          1. However: Delaying their treatment until evaluation risks re-exposing treated patients
       4. CDC asks physicians to consider treating sexual partners of STD patients without a visit
          1. Employ in cases where sexual partner is unlikely to present for medical care
          2. Prescription for sexual partner's STD treatment is given to the patient being treated
          3. Some states may allow prescription labeled for "EPT" or "partner"
          4. Do not double up on prescription quantity for one patient (write 2 separate prescriptions)
       5. Example protocol for partner (prescriptions given to patient to bring to partner)
          1. Provider should ask about partner's medication allergies, other medications and pregnancy
          2. Cefixime 800 mg (if partner will be seen, Ceftriaxone 500 mg IM/IV is preferred) AND
          3. Azithromycin 1 gram orally (or preferred option is Doxycycline 100 mg twice daily for 7 days)
          4. Patient and their partner should abstain from sex for 7 days after completing course
       6. References
          1. (2015) Presc Lett 22(8)
          2. Golden (2005) N Engl J Med 352:676-85 [PubMed]
          3. (2015) MMWR Recomm Rep 64(RR-03): 1-137 +PMID:26042815 [PubMed]
11. Prevention: Screening Asymptomatic Patients (USPTF guidelines)
    1. See Risk Factors listed above
    2. Behavioral counseling (proper Condom use, safe sex, difficult sexual situations)
       1. All sexually active adolescents
       2. Adults at risk for Sexually Transmitted Infection
    3. Gonorrhea and Chlamydia screening
       1. Sexually active adolescents 24 years old and younger
       2. Women at risk for Sexually Transmitted Infection
    4. HIV Screening
       1. All patients ages 15 years old to 65 years old (or if risks)
       2. All pregnant women at first Prenatal Visit (or at time of delayed presentation)
    5. Hepatitis BVirus Screening
       1. All pregnant women at first Prenatal Visit (or at time of delayed presentation)
       2. Patients at risk of infection
          1. Immigrants from sub-sahara Africa, Central and Southeast Asia, China (esp. unimmunized)
          2. Household HBV Contacts
    6. Syphilis
       1. All pregnant women at first Prenatal Visit (or at time of delayed presentation)
       2. Patients at risk of infection
    7. Herpes Simplex Virus Infection
       1. USPTF and AAFP
          1. Do NOT routinely screen HSV serology in asymptomatic patients
       2. CDC and ACOG
          1. Consider type-specific serology in women at time of STI evaluation (esp. if multiple partners)
    8. References
       1. Lee (2016) Am Fam Physician 94(11): 907-15 [PubMed]
12. Resources: Patients
    1. CDC National STD Hotline (CDC)
       1. http://www.cdc.gov/std/
       2. Phone: 800-232-4636
    2. Expedited Partner Treatment (CDC)
       1. http://www.cdc.gov/std/ept/
    3. Information from your Family Doctor: Prevent AIDS
       1. http://www.familydoctor.org/healthfacts/005/
    4. Inspot.Org (annonymously notify others of STD exposure)
       1. https://inspot.org/
    5. DontSpreadIt.Com (annonymously notify others of STD exposure)
       1. https://dontspreadit.com/
13. References
    1. Workowski (2006) MMWR Recomm Rep 55: 1-94 [PubMed]