STDs (Sexually Transmitted Diseases), important info

source : STD

Overview

A sexually transmitted disease (STD) is a disease caused by a pathogen (e.g., virus, bacterium, parasite, fungus) that is spread from person to person primarily through sexual contact. STDs can be painful, irritating, debilitating, and life threatening. More than twenty sexually transmitted diseases have been identified.

Incidence and Prevalence
STDs occur most commonly in sexually active teenagers and young adults, especially those with multiple sex partners. An estimated 200 to 400 million people worldwide are infected-representing men and women of all economic classes.

According to the U.S. Department of Health and Human Services, in the United States more than 13 million people are infected each year and more than 65 million have an incurable STD. Generally, STD incidence has declined in the United States over the past 15 years, although rates among certain populations, including men who have sex with men, have increased.

Characteristics
Most STDs cause relatively harmless disease, producing few or no symptoms. However, some produce persistent asymptomatic or minimally symptomatic disease (e.g., chlamydia). Some people carry the disease for days or weeks, while others carry the disease for longer periods, even for life. During this time, an infected individual, or carrier, can spread disease.

In persistent infection, the pathogen evades detection by the immune system and remains fairly inactive, causing no overt disease. This inactivity is called latency. However, certain triggers (e.g., stress, immune suppression, injury) can reactivate latent pathogens. In some cases, reactivated disease is asymptomatic (e.g., chlamydia); in others, overt (e.g., genital herpes); and in still others, severe and even fatal (e.g., HIV/AIDS).

Complications of STD infection include pelvic inflammatory disease (PID) and inflammation of the cervix (cervicitis) in women, inflammation of the urethra (urethritis) and inflammation of the prostate (prostatitis) in men, and fertility and reproductive system problems in both sexes.

Possible consequences to an infant infected while in the womb or during birth, include stillbirth, blindness, and permanent neurological damage.

A person infected with an STD is more likely to become infected with HIV, and a person infected with HIV and another STD is more likely to transmit HIV.

Treatment

Viral STDs, such as genital herpes (HSV) and human immunodeficiency virus (HIV), cannot be cured, but symptoms can be managed with medication. Bacterial STDs, such as gonorrhea and chlamydia, can be cured with antibiotics. Fungal (e.g., vaginal yeast infection) and parasitic (e.g., trichomoniasis) diseases can be cured with antifungal and antihelminthic agents, respectively. Early diagnosis and treatment increase the chances for cure.

Prevention

The only sure way to avoid becoming infected with an STD is monogamy with an uninfected partner. It is important for partners to discuss their sexual and STD history before having sex. Prevention is possible only if sexually active individuals understand STDs and how they are spread.

The risk for transmission is dramatically reduced with the use of condoms. The following behaviors and conditions can increase the risk for STDs:

Engaging in sexual activity when either partner has unhealed lesions (e.g., genital herpes sores, genital warts)
Enema or rectal douching before rectal intercourse
Rectal or vaginal irritation or infection
Sexual activity that may damage the mucosal lining of the vagina or rectum
Tampon use (Tampons can cause vaginal dryness and cellular abnormalities. Sanitary napkins, either disposable or washable cotton pads, are recommended.)
Vaginal dryness (Water-based lubricant is recommended.)
If you suspect you have an STD, see your physician immediately.

Yeast Infection

As many as 75% of women experience genital candidiasis, also known as vulvovaginal candidiasis (VVC), candidal vaginitis, monilial vaginitis, monilial infection, and vaginal yeast infection during their lifetime. Overgrowth of the fungus Candida albicans, normally present in vaginal flora, causes an allergic reaction that produces symptoms. It most commonly occurs in sexually active young women and is the most commonly diagnosed vaginal infection.

Genital yeast infection generally is not considered to be a sexually transmitted disease, but it is possible to acquire infection from a partner with genital or oral colonization. Men with genital yeast infection are usually asymptomatic.

Causes and Risk Factors

Vulvovaginal candidiasis is an opportunistic infection associated with risk factors that disrupt the body's natural defense against proliferation and infection, such as the following:

Broad-spectrum antibiotic use
Diabetes mellitus
Douching
Immunodeficiency
IUDs
Pregnancy
Scented feminine hygiene products
Steroid use
Signs and Symptoms
Itching, burning, and vulvovaginal pain, irritation, and inflammation are common symptoms of yeast infection. Thick, white, cottage-cheesy vaginal discharge may coat the vaginal walls. There is no foul odor. Urination and intercourse may be painful.

Diagnosis

Cultures, a pH level check, and microscopic examination of vaginal secretions are usually performed to confirm the diagnosis and help rule out other possible infections.

Treatment

A single dose of fluconazole or antifungal vaginal cream containing miconazole or clotrimazole is typically prescribed. Creams usually are used for 3 to 7 days. Chronic yeast infection may be treated with oral antifungal drugs for an extended period of time.

Most physicians discourage women from diagnosing and treating themselves with over-the-counter medications, because symptoms may be produced by more serious vaginal infections, such as bacterial vaginosis or trichomoniasis. Some over-the-counter medications contain ingredients that relieve symptoms but do not effectively treat the infection.

Chancroid

Chancroid is a highly infectious bacterial disease caused by Haemophilus ducreyi that affects the skin and mucous membranes of the penis, vulva, urethra, and anus. It produces painful irregularly shaped nonsyphilitic ulcers (called chancroids, soft chancres, or soft sores) that may heal without treatment.

Incidence and Prevalence
THe number of new cases of chancroid in the United States dropped to approximately 140 in 1999. Chancroid is most common in men aged 25 to 35. Some tropical regions, Canada, and some European countries have experienced recent outbreaks.

Causes and Risk Factors

A person who has a chancroid sore may transmit the disease during vaginal, anal, or oral sex. Ejaculation is not necessary for infection to spread. An uncircumcised man is more likely to contract the disease, because foreskin may hinder hygiene, hide sores, and promote the spread of bacteria. The disease cannot be spread to infants during childbirth.

Signs and Symptoms

First signs of infection typically appear 3 to 5 days after exposure, although symptoms can take up to 2 weeks to appear. Initially, a tender bump develops at the site of contact. After 1 or 2 days, the bump develops into one or more shallow sores (ulcers) that break open, deepen, and become inflamed. Ulcers are pus filled, painful, and may persist for several weeks. In men, they are most common at the base of the head of the penis (glans), though they can appear on the penis shaft. In women, ulcers are typically found on the labia and near the clitoris.

Less commonly, infection spreads to the scrotum, perineum (between scrotum or vagina and anus), anus, rectum, and thighs. Touching the ulcers can transfer bacteria to the fingers, which can transfer bacteria to other areas, including the mouth, during contact. Anal sores may bleed and cause pain during defecation. Men often develop one to four sores on the penis, and foreskin may swell. Women may develop ulcers around the vagina and rectum and may experience vaginal discharge. Painless sores can also develop on the cervix.

In about 50% of cases, mostly men, the lymph nodes in the groin develop into inflamed, pus-filled swellings (buboes) that can develop and enlarge until they burst the skin. They drain continuously, remain open, and can become infected by other bacteria. The infection can spread to other parts of the body by scratching or rubbing. A burst bubo can take months to heal completely. Open ulcers increase the risk for contracting other STDs, including HIV.

Diagnosis

The presence of Haemophilus ducreyi, seen under a microscope, indicates the disease. Diagnosis is often confirmed by a culture or biopsy of an ulcer. Although the bacteria do not enter the bloodstream, a blood test is performed to rule out or identify the presence of other STDs, including syphilis and genital herpes.

Treatment

Chancroid has become resistant to penicillin and tetracycline. Regular doses of erythromycin, trimethoprin, or ciprofloxacin are given for up to 2 weeks. Alternatively, azithromycin or ceftriaxone may be given in a single dose. A follow-up examination is typically required 7 days after starting treatment. Healing usually takes 10 to 11 days, but may take 2 weeks. Buboes may need to be drained with a needle (aspirated) under local anesthesia and scarring may occur from those that burst on their own.

Chancroid is a local infection that has no long-term effects. Recurrence is experienced in less than 10% of cases and may result from improper use of medication (e.g., not taking the entire prescription), a weakened immune system, or re-exposure to the bacteria through recently healed skin.

Chlamydia

Nongonococcal urethritis (NGU) is a nongonorrheal bacterial infection of the urethra (tube that carries urine out of the body) in men. NGU involves Chlamydia trachomatis, which causes chlamydia. The term NGU refers to the condition in men and chlamydia refers to the condition in women.

Incidence and Prevalence
According to the Centers for Disease Control and Prevention (CDC), chlamydia is the most common bacterial infection in the United States. The CDC estimates that 3 million new cases occur each year; however, because as many as 75% of infected women and 50% of infected men do not experience symptoms, only about 500,000 cases are reported annually.

Chlamydia is most prevalent among teenagers. Nearly 75% of all new cases occur in women under the age of 25. By age 30, 50% of sexually active women have been exposed to chlamydia. NGU is the most commonly diagnosed sexually transmitted disease in men in the United States.

Causes

Bacteria are spread through direct sexual contact involving the genitals, anus, or mouth. Several types of bacteria cause NGU and many are undetectable during diagnosis. The most common are Chlamydia trachomatis (causes 50% of cases), Mycoplasma genitalium, and Ureaplasma urealyticum.

Signs and Symptoms

Most people who develop NGU for the first time do so 1 to 3 weeks after having sex with a new partner. Symptoms may be similar to those of gonorrhea and include yellow or clear urethral discharge; pain and tenderness in the genitals; pain, burning, and itching during urination; and low-grade fever. Orogenital or oral-anal contact can result in throat infection (pharyngitis) and inflammation of the rectum (proctitis). Some women experience pain or cramping in the lower abdomen, especially during intercourse, and bleeding between menstrual periods.

Inflammation of the cervix (cervicitis) with discharge is common. Notably, most infected women and 50% of infected men experience no symptoms.

Complications
In men, untreated NGU can cause epididymitis, inflammation of the reproductive system that may result in fertility problems. Symptoms resolve in about 60% of untreated chalmydial infections.

About 40% of women with untreated chlamydia develop pelvic inflammatory disease (PID), which creates a risk for infertility, endometriosis, and other reproductive tract problems.

Pregnant women with chlamydia are at increased risk for miscarriage and premature detachment of the placenta (abruptio placentae). Babies born to infected women may suffer eye, ear, genital, and lung infections; serious infection can be fatal to an infant.

Women with chlamydia are 3 to 5 times more likely to become infected with HIV if they are exposed to the virus.

Diagnosis

Diagnosis involves observing signs and symptoms and analyzing urethral discharge (usually at least 4 hours after urination). Urine is usually collected in the morning. Urethral inflammation may be noticeable. If discharge is present, a sample is collected and cultured to determine the presence of and identify bacteria. Blood tests are performed to check for signs of infection. A small cotton swab is inserted just inside the urethra to collect cells to check for other STDs.

Because infection may be asymptomatic, people with multiple sex partners should be tested annually, even if they feel fine.

Treatment

Antibiotics are used to fight the infection; treatments may vary for men and women. A single dose of azithromycin (Zithromax�) or a 7-day course of doxycycline (Periostat�) usually is prescribed. Erythromycin is the preferred treatment for pregnant women, nursing mothers, infants, children, and adults unable to tolerate tetracycline. Recurrent NGU that is not associated with re-exposure may be treated with a drug that was not previously used. Ofloxacin (Floxin�) may be used for recurrent NGU if the white blood cell count is high.

Gardnerella Vaginitis

Bacterial vaginosis (BV) is characterized by the overgrowth of certain bacteria in the vagina, including Gardnerella vaginalis, Gardneralla mobiluncus, and Mycoplasma hominis. Bacterial vaginosis is grossly underdiagnosed because many women assume they have a yeast infection and treat symptoms with over-the-counter medications.

Incidence and Prevalence
Bacterial vaginosis accounts for 60% of vulvovaginal infections. Young adult women, particularly those who are sexually active, are most commonly affected.

Causes and Risk Factors

BV is caused by a change in the natural balance of bacteria in the vagina. Lacotbacillus, helpful bacteria, metabolizes glycogen to lactic acid in the vagina and maintains normal vaginal pH, which provides a natural defense against unhealthy bacteria proliferation.

When the defense is weakened, other bacteria present in the vagina (e.g., Bacteroides sp, Peptostreptococcus sp, Gardnerella vaginalis, G. mobiluncus, Mycoplasma hominis) proliferate and cause symptoms. Aboout 50% of women have G. vaginalis in their vaginal flora but do not develop infection.

Broad-spectrum antibiotics may destroy healthy bacteria, disrupt the vagina's normal flora, and promote infection. Douching, overused or retained tampons, intrauterine contraceptive devices (IUDs), diaphragms, contraceptive sponges, and products containing nonoxynol-9 may also disrupt the balance.

Bacterial vaginosis also is associated with having multiple sex partners, a new monogamous sexual relationship, and a history of STDs.

Signs and Symptoms

A fishy vaginal odor, itching, and irritation are common signs of BV and may be particularly noticeable after intercourse or menses. It may be accompanied by a smooth, sticky white or gray discharge 4 days to 4 weeks following exposure. Elevated vaginal pH level is also a symptom.

Complications
BV is associated with pelvic inflammatory disease (PID), infertility, tubal (ectopic) pregnancy, premature birth, and low birth weight in infants born to infected mothers.

Diagnosis

Diagnosis is usually made by visual observation and by smell. A pelvic examination is performed to determine whether the cervix is producing abnormal secretions and to check for other diseases.

Vaginal fluid may be treated with a 10% solution of potassium hydroxide (KOH), which makes the characteristic odor more pronounced. A sample is usually taken for microscopic examination to confirm the presence of bacteria, and pH levels are checked. Most physicians recommend a full STD screening.

Treatment

Antibiotics such as metronidazole and clindamycin are generally prescribed, as oral (pill) or topical (cream) treatments. When used topically, these medications may cause side effects such as stinging, burning, and irritation. Douching should be avoided.

Sex partners may require treatment if infection recurs.

Genital Warts

Overview

Human papillomavirus (HPV) is a group of viruses that produce warts on the skin (cutaneous) and on the membranes that line body passages (mucosal) for which there is no cure.In many cases, HPV infection goes away on its own.

More than 70 types of HPV have been identified; types 6, 11, 16, 18, 31, and 35 are transmitted sexually and cause anogenital warts, also called genital warts.

Anogenital warts caused by types 6 and 11 typically appear externally, on the penis, vulva, or anus. Types 16 and 18 cause warts on the mucous membranes (epithelium) that line the vagina, cervix, rectum, or urethra and are associated with cervical cancer and rectal or anal cancer. Infection is serious, although most cases do not lead to cancer.

Anogenital warts may be located deep in the epithelium of the vagina, urethra, or rectum and may be confined to an early isolated outbreak, depending on their type. For these reasons, up to 50% of infected people are unaware that they have genital warts. Untreated genital warts can eventually grow, spread, and form large clusters.

Incidence and Prevalence
According to the Centers for Disease Control and Prevention (CDC), an estimated 20 million people in the United States are infected with HPV and about 5.5 million are exposed to the virus each year. Approximately 1% of sexually active adults in the United States have genital warts.

Infection is most common in people aged 15 to 40 and affects men and women equally. As many as 50-75% of sexually active people are infected with HPV during their lifetime, and in most cases, the infection causes no symptoms and resolves without treatment.

Approximately 90% of men infected with HIV also have HPV. Persistent HPV infection in women is the primary risk factor for cervical cancer.

Causes and Risk Factors

The human papillomavirus is transmitted through vaginal, oral, and anal sex. Many researchers believe that cultural norms for sexual behavior (more people having sex at a younger age and with multiple sex partners) have led to the increase in HPV infection. Because symptoms can be slow to appear and are usually painless, infected people can spread HPV unknowingly.

Those with a suppressed immune system are at higher risk for contracting infection that produces warts.

Signs and Symptoms

Anogenital warts usually appear 3 or 4 months after exposure, typically on the vulva, cervix, penis, scrotum, anus, or inside the vagina or rectum. Oral sex may lead to warts in the mouth and throat. Warts may be red, pink, whitish, or gray. They are usually soft, flat, and irregularly shaped and are usually painless unless irritated by contact. Itching and burning are common once warts become irritated. Discomfort may increase as the warts enlarge, become raised, multiply into cauliflower-shaped clusters, or ulcerate. Ulcerated warts may bleed, itch, and produce a discharge with an unpleasant odor. Warts that develop inside the vagina may cause painful intercourse.

Various health complications may develop, depending on where the warts are located. Symptoms range from localized discomfort and pain to bleeding and difficulty in urination, defecation (if they form in the urethra, penis, vagina, anus, or rectum), or swallowing (if they form in the mouth or throat). Infected pregnant women can pass infection to their infants.

High-risk HPV can take 5 to 30 years to progress to cancer.

Diagnosis

External warts are usually diagnosed visually. A procedure called colposcopy involves treating otherwise hard-to-see warts with vinegar (acetic acid), which causes them to whiten and stand out. This is particularly useful in women. A biopsy, in which a sample of the wart is removed for analysis, may be performed to detect cancer. Vaginal and anal Pap smears are commonly performed to check for cancerous cells in both men (anal) and women.


Treatment

There is no cure for HPV. In many cases, infection goes away on its own. Management involves removing warts and monitoring for the development of cancer cells. Removal may involve freezing with liquid nitrogen (cryotherapy), burning (electrocautery), laser removal, or surgical removal (excision). Cryotherapy is typically used to remove cervical warts, while larger external warts are often surgically removed. Side effects include local irritation, ulceration, and, sometimes, scarring.

Interferon-∂, (alpha interferon, a drug derived from a chemical made in the body) is injected directly into warts (sometimes after the wart is burned with electrocauterization) to eliminate or significantly reduce them. Injections are usually given 3 times a week for a few weeks.

Creams and chemical gel treatments, such as podophyllin and trichloracetic acid (TCA), are applied weekly to external warts by a physician to destroy tissue. Self-applied, prescription treatments such as imiquimod (Aladra®) and podofilox (Condylox®) are typically used 2 or 3 times weekly for several weeks, but no more than 3 or 4 months. Local skin irritation is a common side effect. These treatments are not approved for internal warts.

Regardless of the treatment method, recurrence is common because the virus lies dormant in skin cells after the warts are removed. Removing warts may reduce the risk for HPV transmission, but there is no evidence for this.

Prevention

Routine Pap smears are recommended for women and for men who have sex with men (anal Pap smear) to ensure early detection and effective treatment. Barrier contraception (e.g., condom, diaphragm) is recommended to help prevent disease transmission.

In June of 2006, the Food and Drug Administration (FDA) approved a cervical cancer vaccine for girls and women between the ages of 9 and 26. This vaccine (Gardasil®) has been shown to protect against the human papillomavirus (HPV).

Gonorrhea

Overview

Gonorrhea is one of the most commonly occurring STDs. It affects the mucous membranes of the urethra, cervix, rectum, mouth, throat, and eyes.Both men and women may carry the disease without experiencing symptoms. Gonorrhea frequently occurs with chlamydia/nongonoccal urethritis (NGU).

Incidence and Prevalence
According to the Centers for Disease Control and Prevention (CDC), approximately 650,000 people in the United States are infected with gonorrhea each year. This rate indicates about 50% of annual infections because as many as one-half of cases are unreported.

Incidence of gonorrhea in the United States declined from 1985 to 1996 and increased 9% from 1997 to 1999. In 1999, the incidence was about 132 per 100,000 people.

About 75% of cases occur in people between the ages of 15 and 29. The highest incidence is among women aged 15–19 and men aged 20–24. Depressed socioeconomic areas typically have the highest incidence, particularly where illicit drug use and prostitution are common. Gonorrhea occurs more frequently in men who have sex with men than in heterosexual men.

Causes and Risk Factors

Gonorrhea is caused by the bacterium Neisseria gonorrhoeae, which enters the body and multiplies rapidly. It is usually transmitted by direct contact with an infected person during vaginal, anal, or oral sex, or during birth. Oral sex is probably the least common mode of transmission. Infected pregnant women can pass the disease to newborns (called vertical transmission), where it can cause conjunctivitis and blindness due to corneal scarring.

Signs and Symptoms

Symptoms may appear within 5 to 21 days, usually earlier in men than in women. In men, inflammation of the urethra (urethritis), yellow or green discharge with pus, painful urination, and burning and itching are common symptoms. The opening at end of penis (meatus) may become reddened and inflamed. As infection travels up the urethra, frequency and urgency of urination develops.

In women, symptoms may be mild at first and often go unnoticed until sudden and severe onset. Inflammation and reddening of the cervix is common and bleeding between menstrual periods may occur. Urethritis causes painful, frequent urination and thick, yellow discharge. In later stages, the ducts and glands in the genital region and the rectum are affected.

In children who contract gonorrhea through vertical transmission, genital irritation and inflammation occurs and may be accompanied by a discharge.

Complications
Untreated gonorrhea may cause abdominal pain, vomiting, fever, sore throat (pharyngitis), arthritis, skin lesions, and discharge from the eyes. Anal and rectal itching, anal discharge, painful bowel movements, and painful anal sex may occur. Gonorrhea can affect the prostate and testicles in men. In women, gonorrhea can cause pelvic inflammatory disease (PID), which may lead to infertility, and tubal (ectopic) pregnancy.

Longstanding untreated infections can enter the bloodstream (bacteriuria) and affect the joints (gonococcal arthritis), heart, and brain, though this is rare. A hallmark of gonorrhea is the recurrence of infection.

Diagnosis

Gonorrhea is diagnosed by observing symptoms and by taking a thorough history of sexual activity. In men, a sample of the discharge is cultured and examined microscopically to confirm the presence of the bacteria (gonococci); infection can usually be diagnosed immediately. In women, a sample of the discharge is usually taken from the cervix, and the culture may require incubation for 2 days before an accurate diagnosis can be made.

Treatment

Gonorrhea is resistant to penicillin, ampicillin, and amoxicillin. In some countries, gonorrhea is resistant to the antibiotics that cure strains found in the United States.

Medications that effectively treat uncomplicated gonorrhea include cefixime, ceftriaxone, spectinomycin, and ofloxacin. Ceftriaxone is usually injected intramuscularly in a single dose. Side effects include nausea, rash headache, itching, and pain and redness at the injection site.

Because NGU or chlamydia occurs simultaneously with gonorrhea in up to one-half of infected patients, ceftriaxone is often given and oral tetracycline, doxycycline, minocycline, or erythromycin prescribed. These oral medications are typically taken for 7 to 10 days. Side effects include nausea, mild abdominal pain, and diarrhea. Pregnant women should consult their physician before taking these drugs. A follow-up examination is recommended 3 to 5 days after completing treatment.

Infants are routinely given an antibacterial antibiotic immediately after birth to treat possible infection and thus

Granuloma

Overview

Granuloma inguinale, also known as granuloma venereum or donovanosis, is a chronic, mildly contagious STD caused by the bacterium Calymmatobacterium granulomatis, which contaminates food and water. It produces thick, puffy, red sores on and around the genitals and anus and, occasionally, in nongenital areas.

Incidence and Prevalence
Granuloma inguinale occurs most commonly in underdeveloped tropical regions (i.e., parts of India, South America, Australia, southern Africa, and the Caribbean) where irrigation and agriculture are chiefly unregulated. Fewer than 20 cases are reported each year in the United States, and these probably were contracted while traveling in an endemic area. It usually occurs in heterosexual men between the ages of 20 and 40.

Causes and Risk Factors

The bacterium that causes granuloma inguinale is found in contaminated food or water and, once digested, is then sexually transmitted, often through anal or oral-anal sex. The disease also can be transmitted from mothers to newborns during delivery.

Though only moderately contagious, it is transmitted most easily before symptoms appear.

Signs and Symptoms

Donovanosis may first cause gastrointestinal problems, such as diarrhea and rectal pain. Its primary symptom is the development of lesions that resemble ulcers caused by chancroid, syphilis, or herpes, but are typically larger. Lesions usually appear on the skin or mucous membranes of the genitals, anus, and groin 2 weeks to 3 months after infection.

In men, sores usually first appear on the head (glans) or shaft of the penis; in women, they appear at the entrance to the vagina or on the inner labia. The sores are not especially painful, but often spread along the warm, moist folds of skin throughout the groin to the anus, and cause discomfort. Re-infection to other parts of the body through touching or scratching is possible, but uncommon.

Untreated donovanosis can spread throughout the groin, leading to inguinal (i.e., inner thigh area) subcutaneous tissue swelling that resembles lymph node infection. Longstanding lesions can cause scarring.

Diagnosis

Diagnosis involves visual observation of physical signs, sexual and travel history, and biopsy, in which a lesion tissue sample is collected and examined microscopically. Blood tests are performed to identify the bacterium and differentiate it from other STDs that produce sores.

Treatment

Antibiotics are prescribed for at least 3 weeks or until lesions heal, which may take months. Doxycycline, minocycline, erythromycin, and sulfamethoxazole are common treatments. Sores generally begin to clear within a week after initiating treatment and often heal completely in 5 weeks. Observation is necessary for about 6 months after successful treatment.

Herpes

Overview

There are five types of herpesvirus. Herpes simplex-1 (HSV-1) and herpes simplex-2 (HSV-2, the most common type) are considered sexually transmitted diseases. Herpesvirus can be transmitted from a mother to her developing fetus, which may impair neurological development and can be fatal.

HSV-1 causes cold sores and fever blisters on the mouth and has been found in genital lesions as well. HSV-2, commonly called genital herpes, causes internal and external genital sores and blisters.

Herpes is a lifelong, incurable disease but can be managed with antiviral drugs and safer sex practices. The virus resides deep in nerve cells and it may never produce symptomatic disease or may actively recur throughout a person's lifetime. The latent nature of the virus contributes to its insidious spread.

Incidence and Prevalence
According to the Centers for Disease Control and Prevention (CDC), about 45 million people in the United States over the age of 12 are infected with HSV-2. Genital herpes is more common in women (approx. 1 out of 4) than men (approx. 1 out of 5) and more common in African Americans (46%) than Caucasians (18%). Men who have sex with men have a higher incidence of HSV-2 infection than heterosexual men.

Incidence of genital herpes in the United States has increased 30% over the past 20 years. The largest increase has occurred in Caucasians between the ages of 12 and 19 (5 times more common) and ages 20–29 (twice as common). About 1 million new cases occur each year.

Genital herpes can be managed with antiviral drugs and safer sex practices. Transmission to a developing fetus can impair neurological development and can be fatal.

Causes and Risk Factors

Genital herpes is transmitted when an active herpes lesion or its secretion comes into direct contact with a break in the skin or the moist membranes of the mouth, penis, vagina, urethra, anus, or cervix. Stress on the immune system, emotional or physical stress, illness, fatigue, menstruation, and even exposure to sunlight are associated with recurrence of the disease.

Genital herpes is highly contagious when sores are present. Patients can re-infect themselves by touching an active herpes sore and scratching or rubbing another area of broken skin on the body.

Pregnant women infected with genital herpes should consult a physician for advice on precautions to take during pregnancy and labor.

Signs and Symptoms

Most people infected with herpesvirus remain asymptomatic. Others notice symptoms in 2 to 20 days. Initially, there may be flu-like symptoms, including swollen lymph nodes, chills, fever, body aches, fatigue, and nausea.

Small (2-5 mm), fluid-filled lesions on the genitals, buttocks, anus, and adjacent areas are the telltale sign of infection. They are painful and often occur in clusters. They can also develop inside the vagina, on the cervix (where they cause inflammation), or in the rectum. Lesions break open and ooze for a few days before crusting over and healing.

Other symptoms may include:

* Abdominal pressure
* Aching
* Burning or tingling
* Itching
* Localized tenderness
* Pain in the groin or inner thighs
* Painful urination (particularly in women)
* Vaginal discharge
* Unexplained urethral discharge in men

The first symptoms (primary infection) can last 3 weeks and are usually severe. Symptoms disappear as the virus retreats to the nerve cells near the sacral region of the spine and becomes latent until reactivated by a trigger. The virus then travels down the nerve cell to the skin, where new sores erupt. Many people experience itching, tingling, or heightened sensitivity and tenderness in the area of the original infection a few hours before the sores appear. Some experience pain in the buttocks or knees.

Recurrent symptoms may be frequent and severe, lasting about a week. Most people experience a decrease in the intensity of symptoms and duration of outbreaks over time.

Diagnosis

Though herpes lesions can be seen with the naked eye, a specimen swabbed or scraped from a lesion is cultured and examined with a microscope to distinguish the virus from other disease-causing microorganisms (e.g., syphilis, chancroid). A blood test can distinguish between HSV-1 and HSV-2 infection and detect proteins that fight infection to the virus (antibodies), which are present during outbreak.

Treatment

Systemic antiviral drugs, such as acyclovir (Zovirax®), famciclovir (Famvir®), and valacyclovir (Valtrex®), are taken daily to control outbreaks, prevent the virus from multiplying, and reduce recurrence. Side effects include nausea, headache, and vomiting.

Sores should be kept clean and dry, and antiviral ointment may be applied to reduce pain. Loose-fitting cotton underwear decreases moisture in the infected areas, allowing the sores to dry and heal. Tight-fitting clothing, such as pantyhose, should be avoided. Patients are advised to be aware of subtle symptoms, which may include irritation or pain near the site of previous outbreaks.

Prevention

Sex partners should be examined and tested as soon as symptoms of primary herpes appear.

Lymphogranuloma

Overview

Lymphogranuloma venereum (LGV), also known as lymphogranuloma inguinale, tropical bubo, Nicholas-Favre disease, and sixth venereal disease, is an infection caused by a variety of the bacterium Chlamydia trachomatis. It primarily causes painful swelling of the lymph nodes located closest to the site of infection. If left untreated, it can cause serious tissue damage, scarring, rectal or intestinal blockages, and extreme swelling of the genitals (elephantiasis). In severe cases, it attacks the central nervous system.

Incidence and Prevalence
LGV is relatively rare in the United States and most industrialized countries, where it infects an average of 250 to 400 people a year, mostly men, between the ages of 15 and 24. Prevalence is highest in Southeast Asia, Africa, Central and South America, and the Caribbean, hence "tropical bubo."

Causes

LGV is spread by direct sexual contact with the genitals, rectum, or mouth. Once in the body, bacteria reproduce in the lymph nodes. It may be most closely associated with anal sex and men who have sex with men. Newborns can contract the disease from infected mothers during birth.

Signs and Symptoms

Sores resembling pimples or blisters may appear where the bacteria entered the body, but not always. They often heal quickly, without leaving a scar. Discharge from the penis or vagina is a common early stage symptom. These signs usually appear within 3 days to 1 month after exposure.

Second-stage symptoms are more pronounced and generally begin 1 to 2 weeks after early-stage symptoms appear. The lymph nodes located closest to the site of infection, usually in the groin, swell and form a painful, pus-filled swelling (bubo). Buboes can grow as large as a lemon, and the skin over them may turn blue. They are usually accompanied by throbbing pain, fever, malaise, or headache. In about 30% of cases, the bubo breaks through the skin, drains continuously, remains open, and becomes infected by other bacteria. A burst bubo can take months to heal completely and often leaves a scar.

Buboes may form near the throat, neck, anus, rectum, and cervix. Involvement of the rectum and anus can cause rectal discharge and cause the lining of the rectum to swell, bleed, and erode. If erosion spreads to the colon, the rectum may swell almost closed. Women may experience backache if buboes form on the cervix or in the upper vagina. Chronic inflammation of the lymph nodes can lead to genital elephantiasis, narrowing of the rectal passage (stricture), perirectal abscess, and abnormal rectal channels or tunnel-like lesions (fistulas).

Diagnosis

Physicians typically diagnose LGV by visual observation and blood tests that identify bacteria and antibodies produced by the body to fight the infection. Blood tests also rule out or identify other STDs, such as herpes, syphilis, chancroid, and gonorrhea. A sample of the discharge may be taken to be cultured.

Treatment

A 3-week course of antibiotics, usually tetracycline, doxycycline, or erythromycin, is prescribed to kill bacteria. Buboes may remain after infection is cured and are usually surgically drained with a needle. Surgical repair of fistulas and erosion may be necessary. In cases of elephantiasis, plastic surgery may be helpful. Physicians routinely observe patients for about 6 months after treatment.

Molluscum

Overview

Molluscum contagiosum is a viral infection that produces small, painless blisters that may, at first, resemble genital warts. It may cause serious complications in people with immunodeficiency disorders (e.g., AIDS).

Incidence and Prevalence
Molluscum contagiosum accounts for fewer than 3% of STDs in the United States. It usually occurs in people 20 to 40 years old.

Causes

The disease is most often spread through direct skin-to-skin contact. Transmission through shared items (e.g., towels, gym equipment) occurs infrequently in adults. Scratching, picking, or breaking the blisters can spread the infection to other areas of the body. Molluscum contagiosum also is spread through sexual contact and commonly affects the pubic area, groin, thighs, buttocks, and external genitalia.

Infected children often spread the disease by scratching the blisters and touching one another; blisters usually appear on the face. Salivary transmission occurs among young children.

Signs and Symptoms

Blisters, or papules, usually appear about 6 weeks after exposure but may appear within 1 week. They form at the location where the virus entered the body, usually on the genitals, thighs, or lower abdomen. A person with a weakened immune system may experience outbreaks on the face or scalp. The blisters are waxy and raised, with a dimple on top. They can be flesh-colored, white, pink, yellow, or clear. Single papules may appear first, then multiply to form clusters that sometimes resemble genital warts. Itching is common, but pain is rare. A few patients experience red, scaly skin around the blisters.

Individual blisters may resolve on their own in about 2 months, but an outbreak can last 6 months to 3 years.

Diagnosis

The blisters are distinctive, so diagnosis is typically made by observation. Doctors confirm the diagnosis with a biopsy and microscopic examination of biopsied tissue. Often, a physician removes ("unroofs") the top of a blister and push out its core. Molluscum contagiosum blisters have a characteristic white core and bleed following unroofing.

Treatment

Although the virus remains in the body, a healthy person's immune system usually controls outbreaks and suppresses blister formation. Outbreaks can recur, and they are usually associated with a weakened immune system. There is no specific treatment. Blisters may be removed surgically by cutting, burning, chemical destruction, or freezing with liquid nitrogen. These procedures are done in the office under local anesthetic. Retinoids (e.g., Retin A®), an acne treatment, also may be used. Increased sun sensitivity is a common side effect.

Scabies

Overview

Scabies, also known as sarcoptic itch and acariasis, is the highly contagious infestation with Sarcoptes scabiei, a tiny, whitish-brown, eight-legged mite that burrows into the skin to lay its eggs. Burrowing, egg laying, and feces deposition cause severe skin irritation, eruption, and itchy rash.

Scabies mites live for about 30 days, during which time the female mite can lay two or three eggs a day. Eggs hatch quickly and the nits grow to maturity in about 10 days, continuing the cycle of infestation.

Incidence and Prevalence
An estimated 300 million cases of scabies occur worldwide. It is most prevalent among people in close contact with others, especially children, mothers, and the elderly in nursing homes. Children under 2 years of age are at highest risk.

Causes

The mite that causes scabies is capable of moving about 1 inch per minute. Scabies infestations are spread through both casual and sexual contact, when the mite migrates from one host to another. One can be infected by contact with contaminated clothing, towels, upholstery, or bedding. Poor hygiene is associated with increased risk for contraction.

Signs and Symptoms

The scabies itch is often severe and usually worse at night and while bathing. Visible symptoms include rash and bumps between the fingers; inside the wrists, elbows, or knees; in the skin creases of the buttocks and groin; around the navel and nipples (especially in women); on the feet; and on external genitalia.

The bumps contain nests for hatching and growing mites. They can become inflamed, crusty, and hard, and can persist for weeks after treatment. The burrows may appear as short, zigzag, grayish lines under the skin. Scabies is a local infection with no known systemic complications. The itching and rash will intensify and spread without treatment. Scratching often produces secondary bacterial infection, pus-filled lesions, and cracks in the skin.

Diagnosis

Diagnosis is made by physical examination. Scabies lesions can be scraped to obtain a sample of tissue, which is mixed with potassium hydroxide (KOH) and examined under a microscope for eggs, feces, and mites. This test confirms the diagnosis and rules out other skin diseases that cause itching.

Treatment

Self-treatment with over-the-counter cortisone creams is discouraged. Topical prescription medications are used to treat scabies infestations, including lotions that contain lindane or crotamiton, which are applied from the neck down. Lindane is a pesticide that is associated with neurological damage, poisoning, cancer, and environmental contamination. Its use in adults is controversial and it is no longer used in children.

Coating the body with a mixture of petroleum jelly and 5% sulfur for 3 consecutive nights has also proven beneficial. Itching caused by the absorption of mites and their feces into the body can last for weeks, leading people to believe they are still infected.

The lesions caused by scabies should be kept clean to prevent infection. Physicians may advise wearing cotton gloves during and after treatment to prevent breaking the skin by scratching, which can cause secondary infection.

The parasites cannot survive away from the body for more than a few days, so contaminated clothing and bedding can be sanitized by thorough washing in hot water and storing for 1 or 2 weeks.

Syphilis

Overview

Syphilis is a persistent, highly infectious STD that can have devastating consequences. It is caused by the spiral-shaped bacterium (spirochete) Treponema pallidum, which can live almost anywhere in the body and spreads rapidly. The disease progresses through four distinct stages—primary, secondary, latent, and tertiary—each of which can last for several years. Serious health complications are common and can be fatal in late-stage, or tertiary, syphilis.

Transmission
Syphilis is spread through vaginal, oral, and anal sex during the infection's primary, secondary, and early latent stages. The bacterium is usually transmitted by direct contact between mucous membranes of the genitals, mouth, or anus; or by broken skin coming into contact with open syphilitic sores. An infected mother can pass syphilis through the placenta to her developing fetus. Reinfection after cure is possible.

Incidence and Prevalence
The worldwide incidence of syphilis has decreased significantly over the last 15 years. The lowest incidence in history was recorded for 1998, when almost 80% of countries reported no new cases. Recent outbreaks among men who have sex with men account for one-third of new cases.

According to the Centers for Disease Control, the incidence of syphilis in the United States has declined since 1990 by 88% to 2.5 reported cases per 100,000 people. About 6700 new cases of primary and secondary syphilis were reported to the CDC in 1999, compared to 8600 in 1997. These are thought to represent approximately 80% of newly acquired infections.

Syphilis occurs in women between the ages of 20 and 39 and in men between the ages of 35 to 39; slightly more men than women are affected. Incidence is 30 times higher in African Americans than in Caucasians and the incidence of primary and secondary syphilis in Hispanic men increased by 20% from 1997 to 1999. Poverty, lack of education, and lack of access to health care are associated with the prevalence of syphilis among African Americans (75%).

Signs and Symptoms

Manifestations of syphilis vary according to the stage of the disease and the immune status of the infected person. Each of the four stages marks a change in the course of infection. If left untreated, or if treated in the late latent or tertiary stage of disease, syphilis causes irreversible neurological and cardiovascular damage.

Stages

Primary syphilis
The first sign of syphilis usually appears 2 to 10 weeks following exposure. A red, oval sore, called a chancre (pronounced shanker) develops at the site where the bacteria entered the body. The lesion typically looks clean, is not pusfilled, and is often painless. It may develop into an ulcer that secretes clear mucus when disturbed.

Most chancres appear on the penis, anus, and rectum in men, and on the vulva, cervix, and between the vagina and anus (perineum) in women. Less commonly, they form on the lips, hands, or eyes. Sores in the vagina and rectum may go undetected unless seen by a physician. Swelling and hardening of lymph nodes in the inner thighs and groin is also common and may cause tenderness. Lesions usually heal without treatment within 6 weeks.

Secondary syphilis
In this stage, the pathogen spreads through the blood to the skin, liver, joints, lymph nodes, muscles, and brain. A rash frequently appears about 6 weeks to 3 months after the chancre has healed. The rash may cover any part of the body, but tends to erupt on the palms or soles of the feet. It does not itch. Multiple painless lesions may also form in mucous membranes of the mouth and throat and on the bones and internal organs. At this time, the disease is highly infectious, because bacteria are present in the secretions from the lesions.

The rash usually heals without treatment within 2 to 6 weeks. Other symptoms may include fever, sore throat, fatigue, headache, neck ache, joint pain, malaise, and patches of hair loss. A significant number of patients do not develop symptoms at this stage of the disease.

Latent syphilis
This asymptomatic stage occurs in two phases: early (within 1 year of infection) and late (after 1 year), and follows secondary syphilis. Late latent syphilis is noninfectious. The bacteria remain inactive in the lymph nodes and the spleen. Latency can last 3–30 years and may or may not progress to the final, or tertiary, syphilis. About 30% of infected people persist in a latent state.

Tertiary syphilis
The final stage, also called "late" syphilis, begins 3 or more years after infection. About 30–40% of infected people progress to this stage. At this stage, the person may no longer be contagious, but the bacteria reactivate, multiply, and spread throughout the body, damaging the heart, eyes, brain, nervous system, bones, and joints. Tumors may develop on skin, bone, testes, and other tissues; cardiovascular symptoms such as aortic aneurysm and aortic valve insufficiency may develop; degenerative central nervous system disease can produce dementia, tremors, loss of muscle coordination (ataxia), paralysis, and blindness. Damage is irreversible.

Diagnosis

Primary syphilis is diagnosed when the syphilitic chancre on the genitals is observed and by reviewing the patient's sexual history. However, many patients with secondary and latent syphilis have no signs or symptoms of the disease. Blood, serum, and plasma tests, collectively called serologic tests, produce a definitive diagnosis.

The venereal disease research laboratory (VDRL) test and rapid plasma reagin (RPR) are used to detect the antibody called reagin, which is produced by the immune system's response to Treponema pallidum infection. "False negative" results may occur when these tests are performed during the first 3 to 6 weeks following infection (primary syphilis); negative results do not rule out syphilis during this time. The fluorescent treponemal antibody absorption (FTA) test is also routinely performed to detect treponemal-specific antibodies. FTA is a more sensitive test and thus a more reliable diagnostic tool during all stages of the disease.

Treatment

A single intramuscular injection of penicillin is the standard treatment for primary, secondary, and early latent syphilis. For those allergic to penicillin, antibiotics such as tetracycline, doxycycline, minocycline, erythromycin, and ceftriaxone may be used, though they may be less effective. Follow-up is necessary for about 1 year or until no bacteria are found in blood tests.

About 50% of people with primary and secondary syphilis experience immediate, temporary worsening of symptoms, including malaise, anxiety, and exacerbated lesions (called the Jarisch-Herxheimer reaction), when treatment begins.

Penicillin also can be used to treat tertiary, or late stage, syphilis, but cannot reverse damage that has occurred. Also, bacteria located in the central nervous system may not respond to penicillin during the tertiary stage, even when high doses are administered intravenously.

Prognosis

Primary, secondary, and early latent syphilis can be treated successfully with antibiotics. Late latency (more than 1 year after the secondary stage) is difficult to treat. Tertiary syphilis has a very high mortality rate due to the far-reaching effects of the disease on the central nervous system.

Transmission of syphilis in utero can cause miscarriage and stillbirth. Infected infants often have irreversible central nervous system and multiorgan damage. Asymptomatic infants may develop inflammation of the cornea (keratitis), arthritis, deafness, and central nervous system damage later in life.

Prevention

Any person who discovers that they have a genital lesion should regard it as potentially syphilitic, should be examined by a physician as soon as possible, and should stop all sexual activity.

The use of a condom during sexual intercourse helps prevent the spread of syphilis, but chancres can be on areas of the body that are not covered by the condom. Persons undergoing treatment should abstain from sexual activity until they are no longer contagious. Sex partners must be notified so that they can be tested and, if necessary, treated.

Trichomoniasis

Overview

Trichomoniasis, or "trich," is a parasitic infection that occurs in both men and women. In men, symptoms occur in the tube that carries urine out of the body (urethra). In women, the vagina and cervix are affected. Infected, asymptomatic men commonly infect their partners, though women carriers can also be symptom free. Trichomoniasis often occurs with other STDs, such as gonorrhea and nongonococcal urethritis (chlamydia), particularly in women.

Incidence and Prevalence
Incidence of trichomoniasis in the United States is higher in women than men. An estimated 5 million new cases occur each year and it is present in about 10% of women who seek treatment for an STD.

In 2000, the Centers for Disease Control and Prevention (CDC) reported that trichomoniasis is the most common curable STD in young sexually active women.

Causes

Trichomoniasis is caused by the parasite Trichomonas vaginalis, which is transmitted principally through direct sexual contact. It also can be spread during mutual masturbation and by sharing sex toys.

Signs and Symptoms

Symptoms generally appear 4 to 20 days after infection. Women may experience a profuse, frothy, yellow-green or gray vaginal discharge, sometimes with bleeding, an unpleasant vaginal odor, and vulvovaginal itching and discomfort. Painful and frequent urination, vulvovaginal swelling, discomfort during sexual intercourse, and abdominal pain may also occur. Cervical hemorrhaging is uncommon.

Symptoms in men are rare and include a pale white discharge from the penis and painful or difficult urination.

Complications
Untreated trichomoniasis has been linked to an increased risk for HIV infection. Infected pregnant women are at risk for premature birth, low birth weight, and infection or rupture of the placenta. Inflammation of the prostate (prostatitis) and inflammation of the bladder (cystitis) are associated with trichomoniasis in men.

Diagnosis

Culturing a sample of discharge is the most reliable method of diagnosis. A swab is passed through a man's urethra or a woman's vagina to collect a sample. It takes 10 days to obtain results.

In women, a microscopic examination of vaginal fluid, Pap smear, and urinalysis are performed. The cervix is examined for hemorrhaging. Because trichomoniasis often occurs with other STDs, patients are screened for chlamydia, gonorrhea, syphilis, and HIV.

Treatment

Metronidazole (Flagyl®) and tinidazole (Tindamax®) are used to treat trichomoniasis. These drugs usually are administered in a single dose. People taking them should avoid alcohol immediately after treatment, because a chemical reaction causing nausea and vomiting can result. Side effect include nausea, headache, and abdominal cramping. Seizures and neurological damage have been reported in some people taking metronidazole, although these cases are rare. Pregnant women should consult a physician before taking these medications.

While symptoms in men usually resolve on their own within a few weeks, an asymptomatic man can spread infection to sex partners, so treatment is advised and routinely prescribed.