Approach To STDS2

APPROACH TO STDs
DR. PUBALAN MUNIANDY

SENIOR CONSULTANT
DERMATOLOGIST
SARAWAK GENERAL HOSPITAL
KUCHING
APPROACH
STDS ARE COMMON
ONLY 4 NOTIFIABLE STDs
GROSS UNDER REPORTING OF STDs
MISDIAGNOSIS REMAINS A PROBLEM
HISTORY REMAINS THE MOST
IMPORTANT TOOL – CONSIDER STD IN
ALL SEXUALLY ACTIVE PEOPLE
IS THE PRESENTATION THAT OF AN STD?
MANAGEMENT
CONFIRMED DIAGNOSIS
INFORM PATIENT AND COUNSELLING
RELEVANT TREATMENT – USE
TREATMENT OF CHOICE AND BEST
PRACTICE
NOTIFICATION
PARTNER NOTIFICATION
PREVENTION METHODS
HISTORY AND EXAMINATION
WHAT ARE THE COMMON STDS AND ITS
PRESENTATION?
THE INCUBATION PERIOD OF THE
DISEASES
MULTIPLE STDS MAY OCCUR IN ONE
SETTING
ALWAYS ASSESS RISK FACTORS
COMMON PRESENTATIONS
VAGINAL DISCHARGE
URETHRAL DISCHARGE
GENITAL ULCER DISEASE
WART VIRUS INFECTION OR MOLLUSCUM
GENITAL PRURITUS
– THERE MAY BE NON STDS RESPONSIBLE FOR THE

PRESENTATION
– ALWAYS CONSIDER NON STDS IN YOUR
DIFFERENTIALS IN RELEVANT SITUATIONS
– THOROUGH EXAMINATION IS IMPORTANT IN GOOD
LIGHT
GENITAL ULCER DISEASE
STDS
– PRIMARY SYPHILIS
– CHANCROID
– HERPES SIMPLEX
NON STDS
– TRAUMATIC ULCER
– IRRITANT CONTACT DERMATITIS
– FIXED DRUG ERUPTION
– VASCULITIS
– ANAEROBIC BACTERIAL INFECTIONS
– MALIGNANCIES
APPROACH
HISTORY OF THE ULCER
RELATION TO SEXUAL ACTIVITY MUST BE
ESTABLISHED
YOU MAY EXAMINE THE ULCER AND THEN TAKE
A HISTORY
– DURATION OF ULCER
– IS IT PAINFUL
– IS IT RECURRENT
– SINGLE OR MULTIPLE
– CLEAN OR SLOUGHY
– CHARACTER OF THE ULCER – PUNCHED OUT
– SHOULD A MALIGNANCY BE SUSPECTED
– ANY SPECIAL FEATURES?
APPROACH
RELEVANT INVESTIGATIONS
DIRECT LAB INVESTIGATIONS
SMEARS, CULTURES AND IMF
INITIAL BLOOD WORKUP
VDRL, TPHA, HIV, HEP B AND C
FOLLOW UP INVESTIGATIONS
BLOOD INVESTIGATIONS
VDRL, HIV, HEP B AND C
URETHRAL DISCHARGE
SUBPREPUTIAL
– UNCIRCUMCISED
– CANDIDIASIS
– SMEGMA
– BACTERIAL INFECTION
– REITERS
– WARTS
– HERPES
URETHRAL
URETHRAL DISCHARGE
CHLAMYDIA
GONORRHOEA
CONSIDER PHYSIOLOGICAL CAUSES
SPERMATORRHOEA
PHOSPHATURIA
PROSTATORRHOEA
ANY MUCUS SECRETING GLAND ALONG THE
URETHRA
VAGINAL DISCHARGE
PHYSIOLOGICAL CAUSES
PATHOLOGICAL CAUSES
– Vaginal vault
Candidiasis
Bacterial vaginosis
Trichomoniasis
Staph aureus infections
– Endocervix
Chlamydia
Gonorrhoea
GENITAL WARTS
Prevalence
In the population at large.

1% present with lesion.
2-5% of PAP tests.
10% have HPT-DNA by Southern blot.
40-50% have HPV-DNA by PCR.*
2000 – Estimation:
75% of sexually active population is
infected.
*JAMA, 265:472, 1991
The Clinical Problem
HPV types 16, 18, 31, 33, and 35 have

been found in genital warts and are
associated with SIN.
types 16 and 18 are associated most
strongly with malignant potential.
also associated with vaginal, anal,
and cervical intraepithelial dysplasia,
and sq cell ca.
Role of HPV-DNA in
Malignant Onchogenesis
Patients with HPV 16-18 have a rapid
progression to C.I.N. and invasion.
HPV-DNA found in 90+% of genital
cancers
– 60% type 16
– 18% type 18
– 20% other
– 2% negative
GENITAL:
Spiked
Vaginal
Condyloma
MANAGEMENT OF GENITAL
WARTS
Treatment Options and Methods.
Untreated visible genital warts may
resolve spontaneously.
remain the same, or increase in size.
The primary treatment goal is removal
of symptomatic warts.
Some evidence suggests that treatment
also may reduce the persistence of HPV
DNA in genital tissue, and therefore
may reduce infectivity.
HPV Vaccines in Large Clinical Trials
HPV-16,18 (Cervarix, GlaxoSmithKline)

– Designed to prevent cervical cancer, other
malignancies
HPV-6,11,16,18 (Gardasil, Merck)
– Designed to prevent cervical cancer and
other malignancies, genital warts
– Efficacy evaluated in 4 placebo-controlled,
double-blind, randomized Phase II and III
clinical studies of 20,541 women 16-26 yrs
Licensing by FDA
Gardasil: FDA approved
– Indications
Prevention of cervical cancer and genital warts
caused by HPV 6, 11, 16, and 18 as well as
precancerous lesions (CIN, VIN, VaIN), in girls
and women 9-26 years of age
– Given as three IM injections in upper arm
over 6 months (0, 2, 6 months)
– Cost US$ 360.00
Cervarix: GSK expected to submit application
2006
ACIP Recommendations: Gardasil
Routine vaccination of all 11-12 year-old girls

Catch-up of 13 to 26-year-old girls and women
9-10 year-old girls at provider’s discretion
Not recommended for use in pregnancy, but
category B (no evidence of adverse outcomes)
Contraindicated in those with immediate
hypersensitivity to yeast, any vaccine
component
THE COURSE OF UNTREATED SYPHILIS
9 – 90 days 6 weeks – 6 months First 2 years 2 years to a lifetime
SPONTANEOUS
CURE
E
X
P
O
S
U
R
E
EARLY
PRIMARY SECONDARY LATENT LATE LATENT SYPHILIS
SYPHILIS SYPHILIS SYPHILIS
CARDIO
NEURO
GUMMA VASCULAR
SYPHILIS
SYPHILIS
PROBLEMS
TREPONEMAL PERSISTENCE
SERORESISTANCE
DIFFICULTIES IN STD MANAGEMENT
CONFIRMATION OF DIAGNOSIS
STDs IN THE HIV ERA
SOCIAL AND PSYCHOLOGICAL STIGMA
INFORMING THE DIAGNOSIS
CONFIDENTIALITY
DEALING WITH PATIENTS WITH ABNORMAL
BLOOD TESTS FOR STDs
TO KEEP UP TO DATE WITH LATEST TREATMENT
USE OF GENERIC DRUGS – HOW GOOD ARE
THEY?
LOST IN FOLLOW UP

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APPROACH TO STDs

DR. PUBALAN MUNIANDY

– THERE MAY BE NON STDS RESPONSIBLE FOR THE

In the population at large.

HPV types 16, 18, 31, 33, and 35 have

HPV-16,18 (Cervarix, GlaxoSmithKline)

Routine vaccination of all 11-12 year-old girls

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