STIs: Testing, Cervicitis, PDI, Ulcers/HSV, HPV

Question 1

STIs Characterized by Genital Ulcers (5)

Answer 1

1. Herpes simplex
2. Syphilis
3. Chancroid – Mainly found among sex workers
4. Granuloma inguinales
5. Lymphogranuloma venereum

Question 2

Non-Ulcer Organisms (6)

Answer 2

1. Chlamydia
2. Gonorrhea
3. Human Papilloma virus
4. T. Vaginalis
5. Vaccine preventable STI’s (Ex: Hepatitis B)
6. HIV infection

Question 3

Screening Sexually Active Adolescents

Answer 3

Annual screening done with urine at least once a year, particularly if young age and sexually active

Question 4

USPHS/CDC Recommended Screening

Answer 4

1. Annual screen for Chlamydia if under 25.

2. High risk women should be screened for GC as well.

Question 5

High risk screening (7)

Answer 5

1. Previous STI
2. Young age and sexually active
3. Multiple sexual partners
4. Inconsistent or erratic condom use
5. New partners since last screened.
6. Partners of IV drug users, rape
7. Sex in exchange for good or services

Question 6

Screening for men having sex with men (MSM) (7)

Answer 6

1. HIV serology
2. Syphilis serology
3. Urethral infection (insertive intercourse),
   • Gonorrhea/chlamydia
   • (nucleic acid amplification–urine is preferred
4. Rectal infection (receptive anal intercourse),
   • Gonorrhea/chlamydia–nucleic acid amplification) –
5. Pharyngeal infection (receptive oral intercourse),
   • Gonorrhea–nucleic acid amplification)
6. Hepatitis A, B (vaccination if nonimmune) –
7. Sexual transmission of Hepatitis C (MSM with HIV)
8. Recent or concurrent STI and HIV
   • More frequent STI screening dependent on risk behavior (3-6 months)

Question 7

Nucleic Acid Amplification Test (NAAT)

Answer 7

1. Amplify DNA over 1 million fold
2. Most sensitive tests for C. trachomatis infection
3. NAATs that are FDA-cleared for use with vaginal swab specimens and urine specimens
   o Provider or self-collected (equivalent to provider).
4. Optimal urogenital specimen types for chlamydia screening using NAAT include first catch-urine (men) and vaginal swabs (women)
5. Rectal and oropharyngeal C. trachomatis infection in persons engaging in receptive anal or oral intercourse can be diagnosed by testing at the anatomic site of exposure.
   - NAATs are not FDA-cleared for use with rectal or oropharyngeal swab specimens.
   - But NAATs have been demonstrated to have improved sensitivity and specificity compared with culture for the detection of C. trachomatis at rectal sites and at oropharyngeal sites among men

Question 8

NAAT TESTS (4)

Answer 8

1. APTIMA (Gen‐Probe)*
   - Transcription‐mediated amplification (TMA)
   - Older test not as effective as NAAT
2. Cobas Amplicor (Roche)
   - Polymerase chain reaction (PCR)
3. BD ProbeTec ET (Becton, Dickson)*
   - Strand displacement amplification (SDA)
4. All offer combined test for GC and chlamydia

Question 9

Urine Testing (6)

Answer 9

1. All NAAT approved for urine testing for chlamydia in both genders
2. TMA, SDA approved for urine testing for gonorrhea in both genders
3. PCR is approved for urine testing for GC in males only
4. Appropriate for asymptomatic males and females for both GC and Chlamydia
5. Appropriate for symptomatic males
6. Symptomatic females should have more complete evaluation
   * They must have a pelvic exam done to check for PID or an abscess

Question 10

Urine Testing: First Catch Specimen (5)

Answer 10

1. Must be one hour since last void
2. NOT CLEAN Catch! → you want the first urine specimen
3. First 5‐10 of urine stream collected in sterile specimen cup
4. The patient voids the rest of the urine in the toilet
5. May be left for 24 hours at room temperatures

Question 11

Vaginal Swabs (4)

Answer 11

1. Equivalent sensitivity to endocervical swabs in most students
2. Equivalence between physician collected and patient collected
3. Minimal difference between dry specimen and those in buffer
4. Most show superiority to urine

Question 12

Cervicitis

Answer 12

1. Non‐specific symptoms: abnormal vaginal discharge, intermenstrual bleeding, dysuria, lower abdominal pain, or dyspareunia
2. Clinical findings: mucopurulent or purulent cervical discharge, easily induced cervical bleeding
3. 50% of women with clinical cervicitis have no symptoms
4. Incubation period unclear, but symptoms may occur within 10 days of infection

Question 13

PID Incidence (3)

Answer 13

1. Commonly associated with symptoms
2. l0%‐20% women with GC develop PID
3. In Europe and North America, higher proportion of C. trachomatis than N. gonorrhoeae in women with symptoms of PID

Question 14

PID Minimal Criteria (2)

Answer 14

1. Uterine adnexal tenderness

2. Cervical motion tenderness

Question 15

PID Other Symptoms and Complications (3,3)

Answer 15

Other symptoms include

1. Endocervical discharge
2. Fever
3. Lower abdominal pain

Complications:

1. Infertility: 15%‐24% with 1 episode PID secondary to GC or chlamydia
2. 7X risk of ectopic pregnancy with 1 episode PID
3. Chronic pelvic pain in 18%

Question 16

Trichomonas Vaginalis (5)

Answer 16

1. Trichomoniasis is the most prevalent nonviral sexually transmitted infection in the United States, affecting an estimated 3.7 million persons (CDC 2015)
2. Flagellated anaerobic protozoa
3. Only protozoan that infects the genital tract
4. T. vaginalis has four free flagellae and one flagella embedded in an undulating membrane.
5. Flagellae are responsible for the jerky motility of this organism that is seen under a microscope.

Question 17

Trichomonas Vaginalis Prevalence (4)

Answer 17

1. Most infected persons (70%–85%) have minimal or no symptoms, and untreated infections might last for months to years
2. 13% of black women are affected compared with 1.8% of non-Hispanic white women
3. Affects >11% of women aged ≥40 years
   •26% of symptomatic women and 6% of asymptomatic women in STD clinic patients
   •9% to 32% of incarcerated women
   • 2%–9% of incarcerated men
4. MSM: Low prevalence

Question 18

Trichomonas Vaginalis Risk Factors (4)

Answer 18

1. Multiple sexual partners
2. Low SE status
3. History of STDs
4. Lack of condom use

Question 19

Infection with Trichomonas vaginalis is associated with (4)

Answer 19

1. Adverse pregnancy outcomes, including premature rupture of membranes and pre-term labor
2. Pelvic inflammatory disease
3. Increased risk for HIV infection
4. If + for T. vaginalis, should test for HIV (CDC, 2015)

Question 20

Diagnosis of Trichomonas Vaginalis: Wet Mount (

Answer 20

1. Trichomonads may closely resemble white blood cells (WBCs), especially if the specimen is old (the trichomonads become sluggish).
2. Must be done within one hour
3. Motility is required for positive identification.
4. Vaginal pH >4.5
5. Sensitivity of wet mount is low (51%–65%) in vaginal specimens
6. Lower in specimens from men (e.g., urethral specimens, urine sediment, and semen)
7. Need to use highly sensitive and specific tests

Question 21

Gold standard Diagnosis of Trichomonas Vaginalis

Answer 21

Culture!

Question 22

NAAT TESTS FOR T. Vaginalis (4)

Answer 22

1. In women, NAAT is highly sensitive, detecting 3 to 5 times more T. vaginalis infections than wet-mount microscopy (poor sensitivity (51%–65%)
   • APTIMA T. vaginalis assay
   • FDA-cleared-vaginal, endocervical, or urine specimens from women
   • In men, the sensitivity of self-collected penile-meatal swabs (80%) was higher than that of urine (39%)
2. BD Probe Tec TV Qx Amplified DNA Assay
   • FDA-cleared for detection of T. vaginalis from endocervical, vaginal, or urine specimens from women
3. OSOM Trichomonas Rapid Test (Sekisui Diagnostics, Framingham, MA
   • Point of care, approximately 10 minutes, with sensitivity 82%–95% and specificity 97%–100%
4. Affirm VP III (Becton Dickinson, Sparks, MD),
   • DNA hybridization probe test that evaluates for T. vaginalis, G. vaginalis, and Candida albicans

Question 23

T. Vaginalis treatments (3)

Answer 23

1. Metronidazole 2g orally in a single dose
   OR
2. Tinidazole 2g orally in a single dose
3. Alternative Regimen: Metronidazole 500 mg twice a day for 7 days

Question 24

Genital Ulcer Disease: Painful (2) vs. Painless (3)

Answer 24

Painful

1. Chancroid
2. Genital herpes simplex → pain= classic sign of herpes simplex

Painless

1. Syphilis → painless ulcers = most common sign of syphilis
2. Lymphogranuloma venereum
3. Granuloma inguinale

Question 25

Genital Herpes Simplex Manifestations (4)

Answer 25

1. Direct contact – may be with asymptomatic shedding 2. Primary infection commonly asymptomatic; symptomatic cases sometimes severe, prolonged, systemic manifestations 3. Vesicles → painful ulcerations → crusting 4. Recurrence a potential

Question 26

Genital Herpes Simplex Dx (3)

Answer 26

i. Culture ii. Serology (Western blot) iii. PCR

Question 27

Genital Herpes Simplex Transmission (4)

Answer 27

1. HSV‐2 is transmitted sexually and perinatally. 2. Most sexual transmission occurs while source case is asymptomatic. 3. Efficiency of sexual transmission is greater from men to women than from women to men i. Women are more susceptible 4. Incubation period after acquisition is 2‐12 days (average is 4 days).

Question 28

Genital Herpes Simplex Pathology (4)

Answer 28

1. The virus remains latent indefinitely. i. Will break out in the same area that it has before 2. Reactivation, precipitated by multiple known and unknown factors, induces viral replication. 3. The re‐activated virus may cause a cutaneous outbreak of herpetic lesions. 4. Up to 90% of persons seropositive for HSV‐2 antibody have no clinical history of anogenital herpes outbreaks.

Question 29

Genital Herpes Simplex First Clinical Episode (6)

Answer 29

"Primary infection" 1. First infection ever with either HSV‐1 or HSV‐2 2. Primary disease is more severe than recurrent disease 3. No antibody present when symptoms appear 4. Characterized by multiple lesions that are more severe, last longer, and have higher titers of virus than recurrent infections 4. Illness lasts 2‐4 weeks 6. Often associated with systemic symptoms including fever, headache, malaise, and myalgia

Question 30

Genital herpes simplex lesion progression

Answer 30

papules → vesicles → pustules → ulcers → crusts → healed

Question 31

Genital Herpes Simplex Recurrent Infection (2)

Answer 31

1. Disease usually mild and short in duration | 2. Antibody present when symptoms appear

Question 32

Genital Herpes Simplex Asymptomatic infection (2)

Answer 32

1. No known history of clinical outbreaks | 2. Serum antibody is present

Question 33

Recurrent Infection without Treatment

Answer 33

1. Prodromal symptoms (localized tingling, irritation) in ~50% begin 12‐24 hours before lesions 2. Illness lasts 5‐10 days a. First episode can last for up to three weeks 3. Symptoms tend to be milder, less severe than in primary infection 4. Usually there are no systemic symptoms 5. HSV‐2 primary infection more prone to recur than HSV‐1 primary infection 6. Want to use acyclovir for symptomatic shedding a. Over 16 years old though → use valcyclovir

Question 34

Asymptomatic Viral Shedding (2)

Answer 34

1. Acyclovir chemo-suppression dramatically reduces shedding. 2. Most common sites of asymptomatic shedding are vulva and perianal areas in women and penile skin and perianal area in men.

Question 35

Genital Herpes Simplex – Virologic Tests: Viral Culturing (2)

Answer 35

GOLD STANDARD 1. Preferred test for patients with genital ulcers or other mucocutaneous lesions 2. Sensitivity is low in recurrent disease

Question 36

Genital Herpes Simplex – Virologic Tests: ELISA (3)

Answer 36

1. Type specific serologic tests - HerpeSelect HSV-2 ELISA may be false + at low index values (1.2-3.5) - Confirm with Biokit or Western Blot 2. HerpeSelect HSV-1 ELISA insensitive for HSV-1 (80%) - Head to head comparison of type specific assays vs. Western BlotCytology (Tzanck or Pap) 3. Insensitive and nonspecific and should not be relied on for HSV diagnosis

Question 37

Genital Herpes Simplex – Virologic Tests: PCR

Answer 37

Preferred test for detecting HSV in spinal fluid

Question 38

Genital Herpes Simplex – Virologic Tests: Type Specific Serology Tests (5)

Answer 38

1. Type‐specific and nonspecific antibodies to HSV develop during the first several weeks following infection and persist indefinitely. 2. Presence of HSV‐2 antibody usually indicates anogenital infection. 3. Presence of HSV‐1 does not distinguish anogenital from orolabial infection. 4. Culture medium must be refrigerated 5. Results come back w/i 48 hours but treat before results

Question 39

Antiviral Medications for HSV (4)

Answer 39

Systemic antiviral chemotherapy includes 3 oral medications: 1. Acyclovir 2. Valcyclovir 3. Famciclovir 4. Topical antiviral treatment has minimal clinical benefit and is not recommended.

Question 40

HSV Patient Counseling and Education (5)

Answer 40

Counseling should include: 1. Nature of the infection 2. Transmission - Importance of using condoms 3. Treatment issues 4. Risk‐reduction strategies 5. Emphasize potential for recurrent episodes, asymptomatic viral shedding, and sexual transmission.

Question 41

HPV First Line Treatments (3)

Answer 41

1. Imiquimod (3.75%) applied daily for genital warts 2. Case reports of inflammatory responses to 5% imiquimod 3. Worsened inflammatory and autoimmune skin disease

Question 42

HPV Alternative Treatments (3)

Answer 42

1. Podophyllin resin 10-25%, reports of systemic toxicity (including death) 2. No clear efficacy benefit when compared with podophyllotoxin 3. Contraindicated in pregnancy