Sexually Transmitted Diseases

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Sexually Transmitted Diseases

• Seema Izfar, MD
• 2/15/12

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Sexually Transmitted Diseases

• there are more than 25 diseases spread primarily
  by sexual means
• distal anoderm, perinanal skin, anoderm - can
  either be from anal intercourse or contiguous
  spread from other genitalia

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Sexually Transmitted Diseases

• hard to diagnose
• usually symptom of an organ rather than organism
• often presence of more than one organism
• true pathogen vs colonizing organism
• lack of rapid sensitive diagnostic tests

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Anorectal Immunology

• anal health requires integrity of skin and mucosa
• immunoglobulin A (rectal mucosa)
• cell-mediated immunity Langherhan cells, T cells
• HPV invades and increases Langherhan cells
• HIV destroys LCs
• HPV and HSV invade cell and destroy nm
  surveillance
• HIV, HAART, /- HSV may increase HPV-related
  dysplasia

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Gonorrhea

• gram-negative diplococci
• most common bacterial STD involving anorectum
• occurs in columnar, cuboidal epithelium
• frequently asymptomatic - incubation 3d - 2wks
• 35-50 of women with cervical gonorrhea have
  rectal gonorrhea (contiguous spread)

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Gonorrhea
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Gonorrhea

• symptoms pruritus, tenesmus, bloody or
  mucopurulent discharge, pain
• can have external erythema or superficial
  ulceration
• anoscopy/proctoscopy with thick purulent
  discharge or nonspecific proctitis
• lube may decrease yield of cxs
• treat cephalosporin or quinolone (penicillin G
  resistance high)

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Chlamydia/Lymphogranuloma Venereum

• obligate intracellular organism
• simultaneous infection with gonorrhea common -
  treat both
• LGV serovars - more aggressive infection with
  perianal, anal, and rectal ulceration
• anoscopy/proctoscopy with friable rectal mucosa -
  can be difficult to distinguish from Crohns
• rectal gram stain - PMNs without visible
  diplococci

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Chlamydia/Lymphogranuloma Venereum

• can do direct fluroescent Ab detection or ELISA
• or treat empirically - azithromycin one dose 1g
  orally, or doxy 100mg BID x 7days
• LGV - doxy for 21 days
• HIV and LGV may require longer therapy

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Syphilis

• spirochete Treponema pallidum
• primary (chancre or proctitis), secondary
  (condyloma lata) or tertiary
• anal chancre - small papule that ulcerates -
  painful (differs from genital chancre)
• can be difficult to distinguish from anal fissure

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Anal Syphilis
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Syphilis

• primary within 2-10 wks exposure, secondary
  4-10wks after primary lesion
• secondary - hematogenous dissemination fever,
  malaise, arthralgias, wt loss
• findings maculopapular rash, condyloma lata
• symptoms resolve 3-12 wks rather, 25 relapse
  (early latent syphilis)

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Syphilis

• diagnosis visualization of spirochetes on
  dark-field microscopy
• also may be demonstrable on Warthin-Starry silver
  stain
• RPR, VDRL - false neg 25
• treatment penicillin G 2.4 million units IM,
  pen-allergic treated w doxy 100 BID x 14d
• failure treated with re-dose pen G x 3 wks
• f/u serology (RPR or VDRL) at 6 mos, re-check at
  3mos for HIV positive pts

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Syphilis
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Haemophilus Ducreyi

• gram-neg facultative anaerobe - causes ulcerating
  STD
• more common in developing countries (only
  6million global incidence)
• tender papules with erythema --gt pustules --gt
  erosions
• painful LAD - more common in males
• facilitates transfer of HIV (ulcerations, open
  sores)

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Haemophilus Ducreyi

• diagnosis by GS - nonmotile GNRs in groups
• difficult to culture
• PCR more sensitive
• treatment - single-dose azithromycin 1g or
  ceftriaxone 250mg IM

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Danovanosis Inguinale

• ulcerating lesion of genitalia - sexual and
  nonsexual transmission - C. granulomatosis or
  Donovania granulomatosis
• more common in Africa, SA, Australia
• subsequent sclerotic lesions can cause anal
  stenosis
• cannot be cxed but can see macrophage inclusions
  on smear (Donovan bodies)
• doxy 100 BID x 7 days or 3 wks azithro, cipro, or
  erythro

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Herpes Simplex Virus

• DNA virus - same family as EBV, CMV, VZV
• 20 population seropositive (50 in black
  females)
• increasing HSV-1 genital transmission (30)
• clinical systemic (fevers, HA, malaise), pina,
  vesicles, coalescence, healing

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Herpes Simplex Virus

• HSV second most common cause of proctitis in
  homosexual males
• distal 10cm - friable
• sacral radiculopathy, urinary retention,
  constipation, impotence
• tender LAD in 1/2 of pts
• latency in host cell nuclei (sensory ganglia)

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Herpes Simplex Virus

• diagnosis by clinical picture
• pap smear or Tzank prep multi-nucleated giant
  cells with inclusion bodies - ground glass
• cxs from swabs or biopsies
• direct immunofluorescence

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Herpes Simplex Virus

• treatment of symptoms
• can have shortened course of herpes proctitis
  with 10d acyclovir
• IV acyclovir for severe symptoms
• gtfive recurrences/yr considered for suppressive
  treatment - valyclovir, acylovir
• daily valcyclovir suppression has show to lower
  transmission rate

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HPV

• DNA papovirus - most common STD
• 80 subtypes - 16 and 18 have highest risk of anal
  dysplasia
• anoscopy - involvement above dentate line rare
• destruction and fulguration of all gross disease
  - recurrence 20-30
• burn superficial condyloma without intruding on
  deep dermis or fat

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HPV

• topical agents like podofilox or imiquimod not
  approved for us inside anal canal
• podofilox - BID x 3 days, off 4 days - cycle one
  month
• clearance 35-80 with recurrence 10-20
• imiquimod - increases local interferon production
  - 3x/wk x 16 wks
• response in 50, recurrence in 11

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HPV

• Bushke-Lowenstein tumor - giant condyloma, risk
  for underlying squamous or in situ SCC, excise
  with 1cm margins
• chemorads for poor surgical candidates
• can do APR if involving the sphincters

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Molluscum Contagiosum

• poxvirus - benign papular condition
• 2 to 6mm umbilicated papules
• excisional bx with enlarged epithelial cells with
  intracytoplasmic molluscum bodies
• treatment with eradication, can also use
  podophyllin or imiquimod

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HIV

• 5 pt with anorectal complaints HIV pos
• several studies with poor wound healing and
  increased morbidity after anorectal procedures in
  HIV pts
• assoc with presence of AIDS, dec. leukocytes,
  dec. CD4
• Morandi et al - 50 AIDS pts p hemorrhoidectomy
  with nonhealing wounds at 32 wks

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HIV

• HIV anal fissures and ulcers - need to
  distinguish from STD ulceration like HSV or
  syphilis
• HIV-related ulcers more proximal in anal canal
  (above dentate line) - surgical debridement, bx,
  cx, can inject with steroids to help w pain