Discussing sexually transmitted diseases, types, prevention and management

1. Sexually TransmissibleSexually Transmissible
DiseasesDiseases
Almataria Teaching Hospital, Nasser InstituteAlmataria Teaching Hospital, Nasser Institute
Cairo, EgyptCairo, Egypt
Dr. Mamdouh SabryDr. Mamdouh Sabry
MD. Ain Shams, Ph.D. FranceMD. Ain Shams, Ph.D. France
Consultant Ob. & Gyn.Consultant Ob. & Gyn.

2.  The sexual freedom, the earlier onset ofThe sexual freedom, the earlier onset of
sexual activity and the evolution insexual activity and the evolution in
contraceptive pattern during the last 3contraceptive pattern during the last 3
decades generated the virtual revolutiondecades generated the virtual revolution
of sexually transmitted diseases (STDs).of sexually transmitted diseases (STDs).
 The more effort we try to do to prevent orThe more effort we try to do to prevent or
manage, the more the diseases we findmanage, the more the diseases we find
the more difficult the treatment is !? it isthe more difficult the treatment is !? it is
linked to the most intimate humanlinked to the most intimate human
behavior.behavior.

3.  From the classic five venereal diseaseFrom the classic five venereal disease
(gonorrhea, syphilis, chancroid,(gonorrhea, syphilis, chancroid,
lymphogranuloma venereum and granulomalymphogranuloma venereum and granuloma
inguinale) the number of STD agents hasinguinale) the number of STD agents has
grown to over 25.grown to over 25.
 The risk of transmission is growing fromThe risk of transmission is growing from
couples to contacts, newborn and healthcouples to contacts, newborn and health
care workers.care workers.

4. Sexually transmitted pathogensSexually transmitted pathogens
Bacterial agents:Bacterial agents:
N. gonorrhoeaeN. gonorrhoeae
C. trachomatisC. trachomatis
T. pallidumT. pallidum
H. ducreyiH. ducreyi
Shigella spp.Shigella spp.
CompylobacterCompylobacter
Group B streptococcusGroup B streptococcus
G. vaginalisG. vaginalis
Genital mycoplasmasGenital mycoplasmas
M. hominisM. hominis
U. urealyticumU. urealyticum
Fungal agentsFungal agents
C. albicansC. albicans
Other fungiOther fungi
Viral agentsViral agents
Herpes simplex virusHerpes simplex virus
Human papilloma virusHuman papilloma virus
HIVHIV& ZIKA viruses& ZIKA viruses
Hepatitis A, B, C, D, G ±Hepatitis A, B, C, D, G ±
Molluscum contagiosum VMolluscum contagiosum V
Epstein – Barr virusEpstein – Barr virus
Human herpes V. type EHuman herpes V. type E
Human lymphotropic Vs.Human lymphotropic Vs.
Protozoan agentsProtozoan agents
T. vaginalisT. vaginalis
E. histolyticaE. histolytica
G. lambiaG. lambia
EctoparasitesEctoparasites
P. pubisP. pubis
P. scabieiP. scabiei

5. Major Sexually transmitted diseasesMajor Sexually transmitted diseases
Syndrome/ complication STD Agent (s)
AIDS HIV
Pelvic inflammatory disease N.G., C.T., M.hom.,….
Female lower genital tract infection
Vulvitis C. albicans, herpes simplex V.
Vaginitis C. albicans, T. vaginalis
Cervicitis N.G., C.T., H.S. V.
Urethritis N.G., C.T.
Bacterial vaginosis G.V., Bact. spp., Peptos. spp., M.hom.
Genital warts HPV
Male genital tract
Urethritis sp. & non sp. N.G., C.T., U.U.,T.V
Epididymitis C.T., N.G.,T.V
Proctitis N.G., HSV, C.T.
Genital ulceration HSV, T.P., H.D., C.T (LGV)
Hepatitis HAV, HBV, HCV, CMV
Acute arthritis N.G., C.T.
Enterocolitis G.L., E.H., Shigella, Compylobacter

6. PREVENTION

7. The primary prevention is directed to;The primary prevention is directed to;
prevent disease in future patient, contactprevent disease in future patient, contact
and treat infected individuals.and treat infected individuals.
 Abstain from sexual intercourse (contactAbstain from sexual intercourse (contact
and infected )and infected )
 Monogamous relation ship (marriage)Monogamous relation ship (marriage)
 Prevention by ; drugs, vaccines andPrevention by ; drugs, vaccines and
barriers as ♂ Condom, ♀ Condom andbarriers as ♂ Condom, ♀ Condom and
vaginal spermicides + cervical barriers.vaginal spermicides + cervical barriers.

8. The probability of transmission per act of sexualThe probability of transmission per act of sexual
intercourse is different regarding each virus, not bacteriaintercourse is different regarding each virus, not bacteria
Couple:Couple:
 Male condom:Male condom:
 HIVHIV :: →→ risk 0.55 / 100 person / yearrisk 0.55 / 100 person / year
 HSVHSV :: →→ no protection !!!no protection !!!
 HPVHPV :: →→ controversialcontroversial
 Hep. B.Hep. B. :: →→ no controlled studies ?!no controlled studies ?!
 Hep. C.Hep. C. :: →→ lack of protection!!!lack of protection!!!
 Female condomFemale condom
 MicrobicideMicrobicide
 Bacterial, others,Bacterial, others, ♂- ♀, plus other factors.♂- ♀, plus other factors.

9. AFTER EXPOSURE
• SCREENING
• PROPHYLAXIS
• HCWs
• TREATMENT

10.  Screening for STDsScreening for STDs
 All individual attending STI clinics.All individual attending STI clinics.
 All patients with another STI. e.g. genital warts.All patients with another STI. e.g. genital warts.
 Patients with recurrent vaginal discharge or vulvalPatients with recurrent vaginal discharge or vulval
symptoms.symptoms.
 Patients complaining of lower abdominal pain.Patients complaining of lower abdominal pain.
 Patients with recurrent urethral discharge, dysuria.Patients with recurrent urethral discharge, dysuria.
 Patients complaining of genital sore or ulcer.Patients complaining of genital sore or ulcer.
 Patients complaining of scrotal swelling or pain.Patients complaining of scrotal swelling or pain.
 Mothers of infants with Chlamydia conjunctivitisMothers of infants with Chlamydia conjunctivitis
 Before IVFBefore IVF

11.  Prophylaxis
Post-exposure (sexual assault)
• NG, Ch.T, TV, S. ;
• Ceftriaxone 125 mg x1 im
Plus
• Azithromycin 1 gm x1 or
doxycycline 100 mg x 2
x7 Plus
• Metronidazole 2 gm x1
• Penicillin
• HIV
• Zidovudine and
• Lamuvudine or
• Didanosine and
• Stavudine + ?
• Nelfinavir or
• Indinavir
• All for 28 days.
• HBV, HPV, HSV, HCV
and ZIKA viruses.

12. Viral InfectionViral Infection
Specific TestSpecific Test
Negative, soNegative, so
ProtectProtect
Positive, soPositive, so
Immune or infectedImmune or infected
Re-test 3-12 monthsRe-test 3-12 months
if risk continuesif risk continues
ConfirmConfirm
If +veIf +veIf ImmuneIf Immune
No tttNo ttt TTT OFTTT OF
infectioninfection

13. ManagementManagement
The care of HIV positive women or otherThe care of HIV positive women or other
viral diseases requires a team consistingviral diseases requires a team consisting
of experts in virology , an obstetrician andof experts in virology , an obstetrician and
pediatrician.pediatrician.
Target groups:Target groups:
I.I. Mother & fetus.Mother & fetus.
II.II. Husband.Husband.
III.III. Health care workers (HCW).Health care workers (HCW).

14. Mother + FetusMother + Fetus
Risk of vertical transmission: HIVRisk of vertical transmission: HIV
exampleexample Untreated 15 - 45% (Untreated 15 - 45% ( 70% at delivery - 30% in utero)70% at delivery - 30% in utero)
 TreatedTreated  according to timing of delivery.according to timing of delivery. ±±1.6%1.6%
During pregnancyDuring pregnancy LabourLabour LactationLactation
ART.:ART.:
• ZidovudineZidovudine
• NevirapineNevirapine
• Zidov. + lamivudineZidov. + lamivudine
• Nevirapine + Zidov.Nevirapine + Zidov.
• Avoid 1Avoid 1stst
trimester ttttrimester ttt
• C.S 38 wks./if viralC.S 38 wks./if viral
loadload >> 1000 copies/ml1000 copies/ml
• Avoid PROMAvoid PROM
• If NVD; no interventionIf NVD; no intervention
• Antiseptic bath to babyAntiseptic bath to baby
• Bl. Trans. (CMV. -veBl. Trans. (CMV. -ve
blood)blood)
• RiskRisk >> 14%14%
• No lactationNo lactation
• 6 wks. ART.6 wks. ART.
after deliveryafter delivery
• contraceptioncontraception

15. Measures to reduce the risk of verticalMeasures to reduce the risk of vertical
transmissiontransmission
 Cesarean section to women with viral loads of 1000 orCesarean section to women with viral loads of 1000 or
more at 38 weeks of gestationmore at 38 weeks of gestation
 Maximize the chance of a term deliveryMaximize the chance of a term delivery
 Avoid invasive fetal proceduresAvoid invasive fetal procedures
 Avoid scalp electrodes, fetal scalp sampling, artificialAvoid scalp electrodes, fetal scalp sampling, artificial
rupture of membranes, operative vaginal deliveriesrupture of membranes, operative vaginal deliveries
 Avoid episiotomiesAvoid episiotomies
 Wash the infant in an antimicrobial bath as soon asWash the infant in an antimicrobial bath as soon as
possible and immediatelypossible and immediately beforebefore administratingadministrating
parenteral medication or obtaining bloodparenteral medication or obtaining blood
 Avoid breastfeedingAvoid breastfeeding
Keep mother’s viral load at 50 copies or less (undetectable)Keep mother’s viral load at 50 copies or less (undetectable)

16. HIV is not a highly infectious virus when compared toHIV is not a highly infectious virus when compared to
others, Intact skin forms an effective barrier even ifothers, Intact skin forms an effective barrier even if
exposed to blood with high virus titre.exposed to blood with high virus titre.
Health care workers:Health care workers:
 HIVHIV :: →→ needle stickneedle stick →→ 0.3%;0.3%; →→ mucous memb. 0.09%mucous memb. 0.09%
 HBVHBV : 30 % HSV:most prevalent STD.: 30 % HSV:most prevalent STD.
 HCVHCV : 3 % shedding &: 3 % shedding &
transmissiontransmission
keeping in mind other factorskeeping in mind other factors

17. Universal precautionUniversal precaution
necessarynecessary
Universal precaution notUniversal precaution not
necessarynecessary unlessunless
contaminated with bloodcontaminated with blood
Body fluids and universal precautionsBody fluids and universal precautions
BloodBlood
SemenSemen
Vaginal secretionsVaginal secretions
TissueTissue
FluidsFluids
AmnioticAmniotic
PeritonealPeritoneal
PericardialPericardial
PleuralPleural
SynovialSynovial
CerebrospinalCerebrospinal
Breast milkBreast milk
UrineUrine
SputumSputum
SweatSweat
VomitusVomitus
FecesFeces
Nasal secretionNasal secretion
TearsTears
salivasaliva

18.  At least one blood exposure can beAt least one blood exposure can be
documented in over 30% of surgicaldocumented in over 30% of surgical
proceduresprocedures →→ 75% of which may have75% of which may have
been preventable.been preventable.
 Guide lines to reduce exposure withGuide lines to reduce exposure with
needles or sharp instruments must beneedles or sharp instruments must be
followed.followed.

19. To reduce exposure with sharp instrumentsTo reduce exposure with sharp instruments
 Observe universal precautions.Observe universal precautions.
 Do not recap needles.Do not recap needles.
 Wear double gloves.Wear double gloves.
 Place sharps box where sharps are used.Place sharps box where sharps are used.
 Announce sharp instruments at passing.Announce sharp instruments at passing.
 Pass sharp instruments in a basin.Pass sharp instruments in a basin.
 Use instruments to load needles.Use instruments to load needles.
 ““One wound, one surgeon”.One wound, one surgeon”.
 Check hourly for disruptions of protectiveCheck hourly for disruptions of protective
barriers.barriers.

20.  TreatmentTreatment
Drug selected for treating STIs should fulfill theDrug selected for treating STIs should fulfill the
following criteria:following criteria:
 High efficacy at least 95%High efficacy at least 95%
 Low costLow cost
 Acceptable toxicity and toleranceAcceptable toxicity and tolerance
 Single dose as much as possibleSingle dose as much as possible
 Oral administration as possibleOral administration as possible
 No contraindicationNo contraindication
 Organism resistance is unlikely to developOrganism resistance is unlikely to develop

21. ConclusionConclusion

22.  Certain STIs as gonorrhea , syphilis, HBV and HPV areCertain STIs as gonorrhea , syphilis, HBV and HPV are
more readily transmitted than others e.g. HIV; whilemore readily transmitted than others e.g. HIV; while
others are affecting body silently e.g. Ch.T.others are affecting body silently e.g. Ch.T.
 Sexual practice plays an important roll in enhancing orSexual practice plays an important roll in enhancing or
reducing the chance of infectionreducing the chance of infection
 In simple words, prevention is better than cure, no safeIn simple words, prevention is better than cure, no safe
sex is available outside marriage, no barriers cansex is available outside marriage, no barriers can
protect, enough vaccines are not availableprotect, enough vaccines are not available
 Tell your pts. (To go home, sleep in your bedrooms,Tell your pts. (To go home, sleep in your bedrooms,
thank God for your wives and husbands, love themthank God for your wives and husbands, love them
tenderly because safe sex is unavailable outside).tenderly because safe sex is unavailable outside).

23. Thank You
Best Wishes