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1

Gonorrhea

Caused by infection with Neisseria gonorrhea

  • Transmission: contact with exudates from the mucous membranes of infected persons
  • Intercourse, oral or anal sex
  • Can be transmitted to fetus by infected mother
  • Males:  Urethra
  • Untreated can lead to epididymitis in 1-2%
  • Females:  Endocervical canal, urethra, bartholin and skene glands
  • Can ascend to the uterus, fallopian tubes 

Symptoms in Females

  • Symptoms usually within 10 days
  • 50% asymptomatic
  • May have purulent vaginal discharge, bleeding, dysuria
  • Friable cervix, discharge from glands

Symptoms in Males

  • Symptoms after 3-10 day incubation period
  • Symptoms of urethritis, including dysuria, purulent urethral discharge
  • Disseminated Gonococcal Infection (DGI)
  • 2% of those untreated; fever, rash, arthritis

Females:  Salpingitis, PID

  • 10% of untreated; fever, chills, n/v, abd. Pain, rebound tenderness; infertility

Males: prostatitis, epididymitis, lymphangitis

  • urethral stricture, infertility

Treatment

  • Screen for HIV and chlamydia
    • 20% men and 50% women with chlamydia also infected with gonorrhea
  • Partners need to be treated as well
  • Ceftriaxone IM; can use azithromycin if PCN allergy

2

Gonorrhea 

Treatment

Treatment

  • Screen for HIV and chlamydia
    • 20% men and 50% women with chlamydia also infected with gonorrhea
  • Partners need to be treated as well
  • Ceftriaxone IM; can use azithromycin if PCN allergy

3

Chlamydia

Leading cause of preventable infertility and ectopic pregnancy

Symptoms

  • Many asymptomatic
  • Symptoms nearly identical to gonorrhea

Symptoms in Females

  • Leading cause of tubal infertility
  • Acute urethral syndrome
  • Bartholin glands can become infected
  • Chlamydial cervicitis- friable, beefy red
    • Can cause post-coital bleeding

Symptoms in Males

  • Accounts for 50-60% of non-gonococcal urethritis; milder than gonorrheal urethritis
  • Epididymitis- fever with unilaterally painful and swollen scrotum
  • Proctitis- rectal bleeding, mucus discharge, diarrhea

Partner must be treated, avoid intercourse for 14 days

4

Syphilis

Risks:  poverty, lack of access to health care, living in urban areas, high-risk behaviors, MSM

4 stages

Primary

  • Chancre develops at site of treponemal entry, a few mm to 2cm in diameter
    • Painless
    • Can develop secondary infection
    • Heals in 2-8 weeks without scar
    • Enlarged, non-tender regional lymph nodes
  • Consider syphilis with any unexplained open lesion

Secondary

  • Develop ~6 weeks after chancre
  • Low-grade fever, malaise, sore throat, anorexia, HA, joint pain, lymphadenopathy, alopecia, pruritus
  • Rash-Usually papulosquamous, can be macular, papular, pustular
    • Condylomata lata:  flat, moist, wart-like, highly contagious
  • Latent:  No symptoms, transmission still possible.  1 year to lifetime

Tertiary

  • Sx vary widely based on organs involved
  • Gummas:  soft, tumor-like balls of inflammation, affect the skin, bone, and liver most commonly
  • Cardiovascular:  Syphilitic aortitis-leads to aneurysm formation
  • Neurosyphilis:  Can present as meningitis, apathy, seizures, general paresis, dementia, tabes dorsalis

Treatment

  • Treatment for all stages is IM benzathine penicillin G
    • Single dose if signs/sx for less than 1 year; 3 weekly injections if present for more than 1 year
    • All individuals should have f/u testing
  • Partner must be treated

5

Syphilis Treatment

Treatment

  • Treatment for all stages is IM benzathine penicillin G
    • Single dose if signs/sx for less than 1 year; 3 weekly injections if present for more than 1 year
    • All individuals should have f/u testing
  • Partner must be treated

6

HSV

Genital herpes can be caused by either HSV-1 or HSV-2, although most are HSV-2

CAN BE TRANSMITTED EVEN WHEN ASYMPTOMATIC

No cure

  • Neonatal infections can occur intrauterine or, more commonly, during birth; can be life threatening

Pathophysiology

  • Virus enters mucocutaneous site or abraded skin, undergoes replication in dermis and epidermis
  • Cell destruction, transudation, vesicle formation
  • Virus transported intra-axonally to dorsal root
    • Trigeminal ganglion for oral infection; dorsal sacral nerve roots for genital infection
  • Latent infections become reactivated and cause recurrent infection with similar symptoms
    • May be due to physical, hormonal, and immunologic stimuli
    • Triggering events-menstruation, stress, sun exposure
  • First episode-may be asymptomatic, or may have multiple vesicular lesions, often painful and pruritic.  Wet lesions shed virus for 10-14 days.
  • Recurrent infections-mild local symptoms, although can be severe in immunocompromised
    • Often milder than first episode, fewer lesions
    • Viral shedding of shorter duration
    • HSV-2 more likely to have recurrence, avg. 5-8/yr

7

HSV Treatment

Treatment

Acyclovir (Zovirax), famciclovir (Famvir), and valacyclovir (Valtrex):  Antivirals

  • Given for outbreaks or for prevention
  • Valtrex (500mg/day), a prodrug of acyclovir can decrease transmission by 50%, decreases frequency of outbreaks, costs about $1300/year
  • SE:  Very well tolerated, few SE, except in immunocompromised patients-increased risk of TTP (thrombotic thrombocytopenic purpura; increase in small clots forming throughout body, leading to decrease in platelet count)
  • Should be given in last 4 weeks of pregnancy

8

HPV 

Strains 16 and 18, 6 and 11

High-risk types 16 and 18- 1/2 of cervical dysplasia

High-risk type 18-adenocarcinoma of cervix

  • Types 6 and 11-genital warts
  • Manifestations 2-3 months from infection
  • Condylomata acuminata-soft, skin colored growths
    • Types 6, 11
  • Usually not painful but are friable, may be pruritic
  • Types 16 and 18 do not manifest as symptoms other than cervical dysplasia
  • Increased risk of oropharyngeal cancer
  • Increased risk of rectal cancer 

Gardisil (HPV-4)

  • Immunization again strains 6,11,16,18
  • Must be given before infection
    • Boys and girls starting at age 9
  • Series of 3 injections
  • May need booster
  • Still need pap smears

9

Trichomoniasis

  • Found in both sexual partners, often coexists with gonorrhea
  • In women, infects vagina, urethra, Bartholin and Skene glands
  • In men, infects urethra-often cleared with ejacuation, so usually self-limiting 
  • Vaginal:  Asymptomatic to severe
    • Vaginal discharge:  Frothy, malodorous, yellow-green to gray-green
    • Pruritus
    • Dyspareunia and dysuria
  • Men:  Scant intermittent discharge, slight pruritus, mild dysuria

Treatment

  • Single dose of metronidazole (Flagyl)
  • Partners must be treated

10

Bacterial vaginosis

A sexually associated condition

  • Non-specific overgrowth of bacteria, usually Haemophilus, Corynbacterium, or Gardnerella
  • Occurs almost exclusively in sexually active females

Signs and symptoms

  • Thin, grey, homogenous, malodorous discharge
    • Discharge may be frothy and copious
    • Odor is fishy, worsens with menstruation or sexual intercourse due to contact with alkaline secretions
  • No signs of vaginal or cervical inflammation
  • Males may carry the organisms but have no signs of disease

Microscope

  • Positive amine odor:  drop of KOH solution added to slide, amine odor released
  • Presence of clue cells on wet mount:  vaginal epithelial cells covered with bacteria

Treatment

  • Oral metronidazole (Flagyl) for 7 days
  • Flagyl vaginal gel for 5 days
  • No evidence for treating partner

11

PID

Risk factors

Risk factors:  multiple partners, younger age (immaturity of cervix), unprotected sex, IUD use, douching, 

May involve any organ(s) of the upper genital tract-uterus, fallopian tubes, ovaries

  • Salpingitis:  Inflammation of fallopian tubes
  • Oophoritis:  Inflammation of the ovaries

STIs that migrate from the vagina cause most cases of PID, especially gonorrhea and chlamydia

Can lead to infertility (10-15%), ectopic pregnancy, abscess formation, peritonitis, chronic pelvic pain

After one episode of infection, 15-25% experience long-term sequelae, and increases with each infection

  • Infertility, ectopic pregnancy, chronic pelvic pain, dyspareunia, pelvic adhesions, perihepatitis, tuboovarian abscess, septic shock, death

Constellation of symptoms

  • History, abdominal tenderness with or without rebound tenderness, presence of uterine or cervical movement tenderness, mucopurulent discharge at os, WBCs on gram stain, leukocytosis, increased ESR

Treatment

  • Treatment is aggressive due to known complications
  • Bed rest, avoidance of intercourse
  • Antibiotic therapy:  IV with hospitalization in up to half of cases
    • Cefotetan, cefoxitin, clindamycin, gentamicin IV
    • Ofloxacin, levofloxacin, flagyl, ceftriaxone PO
    • Partners also treated if STI identified (not IV)

12

Effects of decreased estrogen

Vasomotor symptoms (hot flashes and night sweats), sleep disturbances, urogenital atrophy, bone loss, increased LDL and total cholesterol with decreased HDL

13

Compare and contrast replacement with estrogen alone, and combination estrogen + progestin

  • Estrogen alone (estrogen therapy, ET):  Lower risk
  • Estrogen + progestin (EPT):  Progestin given to counteract effect of estrogen on endometrium (reduces endometrial cancer risk).  Progestin can increase risk of breast and increases risk of cardiac events

Benefits of Hormone Replacement Therapy (HRT)

  • Relief of vasomotor symptoms
  • Management of urogenital atrophy 
  • Prevention of osteoporosis
  • Prevention of colorectal cancer:  EPT only
  • Other benefits:  Improved wound healing, tooth retention, glycemic control

14

Estrogen alone, and combination estrogen +  Progestin

Adverse Effects

  • Cardiovascular events:  due to increase in clotting, not atherosclerosis.  ET safer than EPT; lower risk when given closer to onset of menopause
  • Endometrial cancer:  Only with ET
  • Breast cancer:  EPT
  • Ovarian cancer
  • Gallbladder disease
  • Dementia:  EPT and likely ET
  • Urinary incontinence

15

Oral contraceptives

Progestin only (Minipill)

Combination progestin and estrogen

  • Monphasic - constant dose of estrogen and progestin
  • Biphasic - estrogen constant but progestin increased in second half of cycle
  • Triphasic - both estrogen and progestin may vary

Mechanism of action:  Decreased fertility by inhibition of ovulation, thickening of cervical mucus, and modifying endometrium so it is less favorable for implantation

  • With perfect use, failure rate is less than 0.1%, but with “typical” use, increases to 3-5%

Adverse Effects

  • Thromboembolic disorders – due to estrogen
    • Risk increases in smokers and women over 35
    • Long-term possible cardiovascular benefit
  • Cancer – promotes breast cancer growth only in those with BRCA1, protects against ovarian and endometrial cancer
  • HTN – due to estrogen
  • Abnormal uterine bleeding
  • Stroke in women with migraines
  • Contraindicated during lactation

Other uses/benefits

  • Decreased risk of ovarian cancer, endometrial cancer, ovarian cysts, PID, fibrocystic breast disease, iron deficiency anemia, acne; favorable changes in menstrual cycle; can help with menstruation-associated migraines

16

IUD-differentiate between Mirena and copper IUD

  • Mirena: T-shaped plastic device with Progestin; inserted in uterus, can remain up to 5 yrs.  
  • Copper IUD has no pharmacological contraceptives
  • Perfect use: 99.8%  Typical use:  99.2-99.8%   *Safe during lactation.

17

Vaginal ring

  • NuvaRing: estrogen + progestin, 3 weeks in/1 week off
  • Perfect use: 99%  Typical use:  92%

18

Transdermal patch

  • Ortho Evra:  estrogen + progestin, 1 patch/week for 3 weeks.  Increased exposure to estrogens so increased risk of VTE.  Not as effective in obese women
  • Perfect use:  99.7%  Typical use:  92%

19

Implanon Vs. depo-provera

Subdermal

Implanon:  progestin only. 

  • Rod inserted under skin, provides contraception for 3 years, can be removed. 
  • SE:  irregular bleeding. 
  • Safe during lactation. 
  • Perfect use: 99.1%  Typical use:  99.1%

Depo Provera: medroxyprogesterone. 

  • Intramuscular injection, every 12 weeks.  Fertility will return within 3-18 months. 
  • SE: reversible BMD loss.  Perfect use: 99.7%  Typical use 94%

20

Plan B

  • 1 high-dose progestin tablet; delaying or stopping ovulation
  • Tablet must be taken within 72 hours of intercourse (sooner is better)
    • Reduces odds of pregnancy by 89% (95% if taken within 24 hours)
  • Side effects- Nausea and vomiting

21

Hypospadias

Termination of urethra on VENTRAL side of penis

Affects 1 in 300 males

  • Testes undescended in 10%
  • Chordee (ventral bowing) and inguinal hernia also accompany
  • Foreskin used for surgical repair

22

Epispadias

Termination of urethra on DORSAL side of penis

  • Much less common
  • Often associated with exstrophy of bladder 

23

Phimosis

tightening of the foreskin that prevents retraction over glans

  • Normally cannot fully tract until age 3
  • Leads to increased risk for infection and penile cancer

24

Paraphimosis

foreskin is too tight to cover glans

  • Can constrict blood supply to glans and leads to ischemia and necrosis
  • Can be the result of prolonged retraction, such as during catheterization

25

Balanitis

Acute or chronic inflammation of the glans penis

  • More common in uncircumcised men, especially with phimosis
    • Accumulation of smegma, cellular debris
  • Commonly caused by chlamydia, mycoplasma
    • smears /cultures for causative organism

26

Erectile dysfunction 

organic causes 

Neurogenic:  Parkinson’s, stroke, cerebral trauma, peripheral neuropathy (diabetes), spinal cord injury

Hormonal:  Decreased androgen levels, hypoprolactinemia, 

Vascular:  HTN, HL, smoking, diabetes, and pelvic radiation can affect vasculature; trauma

Medications:  antidepressants, antipsychotics, antihypertensives; smoking can induce vasoconstriction; ETOH can cause transient ED

27

Drug interactions of sildenafil (Viagra)

Enhances hardness and duration of erection for men with ED.  No effect for men without ED, women

  • Side effects:  Hypotension, especially if taking alpha blockers; priapism; nonarteritic ischemic optic neuropathy (NAION), sudden hearing loss, HA, flushing
  • Drug interactions:  Nitrates-life threatening hypotension; alpha-blockers-severe hypotension

28

Priapism

Involuntary, prolonged, abnormal, painful erection not associated with sexual excitement

Causes

Primary:  Trauma, infections, neoplasms

Secondary:  leukemia, sickle cell disease, stroke, spinal cord injuries; medications such as anticoagulants, antihypertensives, marijuana, drugs for ED

29

Cryptorchidism

Undescended testes-one or both testicles fail to move down into the scrotal sac

  • May remain in the  lower abdomen or at a point of descent in the inguinal canal
  • Infants who are premature or SGA have highest incidence
    • Most descend by 6 months of age
  • Can lead to infertility and malignancy
  • High rate of testicular cancer-5-40x greater chance

30

Hydrocele

Excess fluid between the layers of the tunica vaginalis

  • 2-layered serous pouch, derived from peritoneum, covers testes and epididymis

Acute or chronic

Acute: local injury, epididymitis, orchitis, gonorrhea, lymph obstruction, germ cell testicular tumor, side effect of radiation

Chronic:  more common, gradual.    Unknown cause, usually in men over 40 y/o

  • Relatively benign, no treatment if asymptomatic; if secondary, treat underlying cause