CHAPTER 184
Sexually Transmitted Diseases
Sexually transmitted (venereal) diseases are infections that are typically, but not exclusively, passed from person to person through sexual contact.
sexually transmitted diseases may be caused by bacteria, viruses, or protozoa.
some infections can be spread through kissing or close body contact.
Some infections may spread to other parts of the body, sometimes with serious consequences.
Using condoms can help prevent these infections.
Sexual intercourse provides an easy opportunity for organisms to spread (be transmitted) from one person to another because it involves close contact and transfer of genital and other body fluids. Sexually transmitted diseases (STDs) are relatively common. For example, an estimated 360,000 cases of gonorrhea and over 1 million chlamydial infections are reported, and even more probably occur every year in the United States—making them the two most common STDs.
TYPES OF SEXUALLY TRANSMITTED DISEASES
| TYPE | DISEASE |
| Bacterial | Chancroid Chlamydial urethritis and cervicitis Gonorrhea Granuloma inguinale Lymphogranuloma venereum Syphilis |
| Viral | Genital herpes simplex (see page 1245) Genital warts (caused by the human papillomavirus) Molluscum contagiosum (see page 1325) Human immunodeficiency virus (HIV) infection or AIDS (see page 1254) |
| Parasitic (protozoan) | Trichomoniasis |
| Insect | Pubic lice infestation Scabies (due to burrowing mites) |
Causes
Many infectious organisms—from tiny viruses, bacteria, and parasites to visible insects (such as lice)—can be spread through sexual contact. Some hepatitis and Salmonella infections (which causes diarrhea) can be transmitted during sexual activity, but they are often spread in other ways. Thus, they are not typically considered STDs.
Transmission: Although STDs usually result from having vaginal, oral, or anal sex with an infected partner, genital penetration is not necessary to spread an infection. Some STDs can be spread in other ways, including
Kissing or close body contact—for pubic lice infestation, scabies, and molluscum contagiosum
From mother to child before or during birth—for syphilis, herpes, chlamydial infection, gonorrhea, human immunodeficiency virus (HIV) infection, and human papillomavirus (HPV) infection
Breastfeeding—for HIV infection
Contaminated medical instruments—for HIV infection
Symptoms
Symptoms vary greatly, but the first symptoms usually involve the area where the organisms entered the body. For example, sores may form in the genital area or mouth. There may be a discharge from the penis or the vagina, and urination may be painful.
Complications: When STDs are not diagnosed and treated promptly, some organisms can spread through the bloodstream and infect internal organs, sometimes causing serious, even life-threatening problems. Such problems include heart and brain infections due to syphilis, AIDS due to HIV, and cervical cancer due to HPV.
In women, some organisms that enter the vagina can move up the vagina to the cervix (the lower part of the uterus), enter the uterus, and reach the fallopian tubes and sometimes the ovaries (see art on page 1492). Damage to the uterus and fallopian tubes can result in infertility or a mislocated (ectopic) pregnancy. The infection may spread to the membrane that lines the abdominal cavity (peritoneum), causing peritonitis. These infections are considered pelvic inflammatory disease (see page 1541).
In men, organisms that enter through the penis may infect the tube that carries urine from the bladder through the penis (urethra). Complications that can result from chronic infection of the urethra include the following:
Tightening of the foreskin, so that it cannot be pulled over the head of the penis
Narrowing of the urethra, blocking the flow of urine
Development of an abnormal channel (fistula) between the urethra and the skin of the penis
Occasionally in men, organisms spread up the urethra through the tube that carries sperm from the testis (ejaculatory duct and vas deferens) to infect the epididymis (the coiled tube on top of each testis—see art on page 1466).
In both sexes, some STDs can cause persistent swelling of the genital tissues or infection of the rectum (proctitis).
Diagnosis
Doctors often suspect an STD based on symptoms. To identify the organism involved and thus confirm the diagnosis, doctors may take a sample of blood, urine, or discharge from the vagina or penis and examine it. The sample may be sent to a laboratory for the organisms to be grown (cultured) to aid in identification. Sometimes genetic testing is required to identify the organism’s unique genetic material. Other tests vary depending on the STD suspected.
Prevention
The following can help prevent STDs:
Regular and correct use of condoms
Avoidance of unsafe sex practices, such as frequently changing sex partners or having sexual intercourse with partners who have other sex partners or with prostitutes
Circumcision (which can reduce the spread of HIV from women to men)
Prompt diagnosis and treatment of STDs (to prevent spread to other people)
Identification followed by counseling or treatment of the sexual contacts of infected people
The only vaccines available are those for HPV infection and hepatitis A and B.
Treatment
Most STDs can be effectively treated with drugs. However, some new strains of bacteria and viruses, such as HIV, have become resistant to some drugs, making treatment more difficult. As new drugs are developed and more people are treated, resistance to drugs is likely to increase (see page 1188).
How to Use a Condom
Use a new condom for each act of sexual intercourse.
Use the correct size condom.
Carefully handle the condom to avoid damaging it with fingernails, teeth, or other sharp objects.
Put the condom on after the penis is erect and before any genital contact with the partner.
Place the rolled condom over the tip of the erect penis.
Leave 1/2 inch at the tip of the condom to collect semen.
With one hand, squeeze trapped air out of the tip of the condom.
If uncircumcised, pull the foreskin back before unrolling the condom.
With the other hand, roll the condom over the penis to its base and smooth out any air bubbles.
Make sure that lubrication is adequate during intercourse.
With latex condoms, use only water-based lubricants. Oil-based lubricants (such as petroleum jelly, shortening, mineral oil, massage oils, body lotions, and cooking oil) can weaken latex and cause the condom to break.
Hold the condom firmly against the base of the penis during withdrawal, and withdraw the penis while it is still erect to prevent slippage.
People who are being treated for a bacterial STD should abstain from sexual intercourse until the infection has been eliminated from them and their sex partners. Thus, sex partners should be tested and treated simultaneously.
Viral STDs, especially herpes, hepatitis B and C, and HIV infection, usually persist for life. Antiviral drugs can control but not yet cure all of these infections, except hepatitis C, which can be cured in some people after prolonged treatment.
Chancroid
Chancroid is a sexually transmitted disease caused by the bacteria Haemophilus ducreyi, which causes painful genital sores.
In developed countries, chancroid is rare, but it is a common cause of genital ulcers throughout much of the developing world, where it may be acquired by men from prostitutes. Because chancroid causes genital sores, people who have it are more likely to become infected with and to spread human immunodeficiency virus (HIV).
Symptoms
Symptoms begin 3 to 7 days after infection. Small, painful blisters form on the genitals or around the anus and rapidly rupture to form shallow sores. These sores may enlarge and run together. The lymph nodes in the groin may become tender, enlarged, and matted together, forming collections of pus (abscesses) called buboes. The skin over the abscess may become red and shiny and may break down and discharge pus from the lymph nodes onto the skin. Sores may form in other areas of the skin.
Diagnosis and Treatment
Doctors suspect chancroid in people with genital sores that have no obvious cause. Tests for chancroid are not readily available, but blood tests may be done to exclude other causes.
Several antibiotics are effective for chancroid. The following may be used:
Ceftriaxone in a single injection
Azithromycin taken by mouth in a single dose
Ciprofloxacin taken by mouth for 3 days
Erythromycin taken by mouth for 7 days
Chlamydial and Other Infections
Chlamydial infections include sexually transmitted diseases of the urethra and cervix that are caused by the bacteria Chlamydia trachomatis. Less commonly, other bacteria, such as Ureaplasma and mycoplasmas, cause infection of the urethra.
Symptoms include a discharge from the penis or vagina and painful or more frequent urination.
If unnoticed or untreated in women, these infections can result in infertility, miscarriage, and an increased risk of a mislocated pregnancy.
DNA tests of a sample of the discharge or of urine can detect chlamydial infection.
Antibiotics can cure the infection, and sex partners should be treated at the same time.
Several bacteria can cause diseases that resemble gonorrhea. These bacteria include Chlamydia trachomatis, Trichomonas vaginalis, Ureaplasma, and several types of mycoplasmas. Laboratories can identify chlamydiae but have difficulty identifying the other bacteria. So the infections caused by these other bacteria are called nongonococcal, nonchlamydial infections, usually of the urethra (urethritis).
Chlamydial infection is the most commonly reported sexually transmitted disease (STD). In the United States, over 1 million cases were reported in 2006. Because the infection frequently causes no symptoms, the number of infected people may be 4 times higher. In men, chlamydiae cause about half of the urethral infections not caused by gonorrhea. Most of the remaining urethral infections in men are probably caused by Ureaplasma urealyticum or mycoplasmas. In women, chlamydiae account for virtually all of the cervical infections (cervicitis) that produce pus and that are not caused by gonorrhea. Sometimes both sexes have gonorrhea and chlamydial infection at the same time.
Symptoms
In men, symptoms of chlamydial urethritis start 7 to 28 days after the infection is acquired during intercourse. Typically, men feel a mild burning sensation in their urethra during urination and may have a clear or cloudy discharge from the penis. The discharge is usually less thick than the discharge in gonorrhea. The discharge may be small, and symptoms mild. However, early in the morning, the opening of the penis is often red and stuck together with dried secretions. Occasionally, the infection begins more dramatically—with a frequent urge to urinate, painful urination, and a discharge of pus from the urethra.
Many women with chlamydial cervicitis have few or no symptoms. But some have frequent urges to urinate, painful urination, and secretions of yellow mucus and pus from the vagina.
Complications: If the infection spreads up women’s reproductive tract, it may infect the tubes that connect the ovaries to the uterus (fallopian tubes). This infection, called salpingitis or pelvic inflammatory disease, causes severe lower abdominal pain. In some women, the lining of the abdominal cavity (peritoneum) becomes inflamed. This inflammation, called peritonitis, causes more severe pain in the lower abdomen and sometimes in the area around the liver, in the right upper abdomen.
If the anus is infected, people may have rectal pain or tenderness and a yellow discharge of pus and mucus from the rectum.
Chlamydiae may be transferred to the eye, causing infection of the conjunctiva (conjunctivitis).
Chlamydial genital infections occasionally cause a joint inflammation called reactive arthritis (previously called Reiter’s syndrome—see page 570). Reactive arthritis typically affects several joints at once. The lower limbs are affected most often. The inflammation seems to be an immune reaction to the genital infection rather than spread of the infection to the joints. Symptoms typically begin 1 to 3 weeks after the initial chlamydial infection.
If chlamydial urethritis is not treated, symptoms usually disappear in 4 to 6 weeks. However, if untreated, a chlamydial infection can cause complications, especially in women who have been infected a long time. Complications include chronic abdominal pain and scarring of the fallopian tubes. The scarring can cause infertility and a mislocated (ectopic) pregnancy (see page 1644).
In men, chlamydial infections may cause epididymitis, which causes painful swelling of the scrotum on one or both sides (see page 1472). Other bacteria from the intestine also contribute to these complications probably by infecting areas that have been damaged by chlamydiae.
Did You Know…
Chlamydial infections are the most common sexually transmitted disease.
Because chlamydial infection and gonorrhea often occur together, people with one of them are routinely treated for both.
Diagnosis
Doctors suspect these infections based on symptoms, such as a discharge from the penis or cervix. In most cases, doctors diagnose chlamydial infections by doing tests that detect the bacteria’s unique genetic material (DNA or RNA). Usually, a sample of the discharge from the penis or cervix is used. For some types of these tests, a urine sample can be used. Thus, people can avoid the discomfort of having a swab inserted into the penis or having a pelvic examination to obtain a sample.
Gonorrhea, which is often also present, can be diagnosed using the same sample. Specific tests for genital infections with Ureaplasma and mycoplasmas are not usually done. These infections are sometimes diagnosed in people with characteristic symptoms after gonorrhea and chlamydial infections are ruled out.
Screening: Because chlamydial infection is so common and because many infected women have no symptoms, these tests are recommended for sexually active women aged 15 to 25 to screen for STDs.
Treatment
Chlamydial, ureaplasmal, and mycoplasmal infections are treated with a single dose of azithromycin or with doxycycline or levofloxacin taken by mouth for 7 days. At the same time, an antibiotic such as ceftriaxone, injected into a muscle, is given to treat gonorrhea because the symptoms of the two infections are similar and because many people have both infections at the same time. Pregnant women are given azithromycin instead of tetracycline or doxycycline, which must be avoided during pregnancy. If symptoms persist or return, treatment is repeated for a longer period.
Possible Complications of Chlamydial and Ureaplasmal Infections
IN MEN
Infection of the epididymis
Narrowing (stricture) of the urethra
IN WOMEN
Infection of the fallopian tubes (salpingitis)
Infection of the membrane that lines the abdominal cavity (peritonitis)
Infection of the surface of the liver
IN MEN AND WOMEN
Infection of the membrane that covers part of the eye (conjunctivitis)
IN NEWBORNS
Conjunctivitis
Pneumonia
Infected people should abstain from sexual intercourse until they have completed treatment to avoid infecting their sex partners. Sex partners should be treated simultaneously if possible and should abstain from sexual intercourse until they complete treatment. The risk of another chlamydial infection or another STD within 3 to 4 months is high enough that people should be screened again at that time.
Genital Warts
Genital warts (condylomata acuminata) are growths in or around the vagina, penis, or rectum caused by the human papillomavirus, which is sexually transmitted.
Some types of human papillomavirus (HPV) cause visible genital warts, and other types cause less visible warts that increase the risk of cancer.
Genital warts grow rapidly and sometimes cause burning pain.
Doctors identify visible warts based on their appearance, and they examine the cervix and anus to check for less visible warts.
Vaccines can prevent most types of HPV infection that can cause cancer.
Visible warts can usually be removed with a laser or by freezing (cryotherapy) or surgery, but sometimes drugs are applied to the warts.
In the United States, about 1.4 million people have genital warts, which are caused by HPV. An estimated 24 million people have an HPV infection, and 5.5 million are infected each year. About 50% of women have been infected at least once by age 50. Most infections go away within 1 to 2 years, but some persist. Persistent infection can increase the risk of certain types of cancer.
There are over 70 known types of HPV. Some types cause common skin warts. Other types cause different types of genital infections:
External (easily seen) genital warts: These warts are caused by certain types of HPV, especially types 6 and 11. These types are transmitted sexually and infect the genital and rectal areas.
Internal (less visible) genital warts: Other HPV types, especially types 16 and 18, infect the genital area but do not cause easily visible warts. They cause tiny flat warts on the cervix or in the anus, which may be visible only with a magnifying instrument called a colposcope. These less visible spots usually cause no symptoms, but the HPV types that cause them increase the risk of developing cervical, bladder, and rectal cancer and therefore should be treated.
HPV can also be spread during oral sex, causing infections of the mouth and increasing the risk of oral cancer.
Did You Know…
Some types of the virus that causes genital warts can also cause cancer.
Symptoms
In men, warts usually occur on the penis, especially under the foreskin in uncircumcised men, or in the urethra. In women, genital warts occur on the vulva, vaginal wall, cervix, and skin around the vaginal area. Genital warts may develop in the area around the anus and in the rectum, especially in people who engage in anal sex. Warts cause no symptoms in many people but cause occasional burning pain in some.
The warts usually appear 1 to 6 months after infection with HPV, beginning as tiny, soft, moist, pink or gray growths. They grow rapidly and become rough, irregular bumps, which sometimes grow out from the skin on narrow stalks. Their rough surfaces make them look like a small cauliflower. Warts often grow in clusters.
Warts may grow more rapidly and spread in pregnant women and in people who have a weakened immune system, such as those who have human immunodeficiency virus (HIV) infection.
Diagnosis
Genital warts usually can be diagnosed based on their appearance. If warts look unusual, bleed, become open sores (ulcerate), or persist after treatment, they should be removed surgically and examined under a microscope to check for cancer.
If women have warts on the cervix, a Papanicolaou (Pap) test is done to rule out other abnormalities (such as cervical cancer—see page 1575). If genital warts are diagnosed, women should have a Pap test and colposcopy of the vagina and cervix (using a magnifying instrument) twice a year so that any abnormalities can be identified and treated promptly.
Colposcopy is done to check for less visible warts on the cervix or in the anus. A stain may be applied to the area so that warts can be seen more easily. A sample taken from a wart may be analyzed using tests, such as the polymerase chain reaction (PCR). This test produces many copies of a gene, which may enable doctors to identify HPV’s unique genetic material (DNA). These tests help confirm the diagnosis and enable doctors to identify the type of HPV.
Prevention
A vaccine for HPV is available that protects against the two types of HPV (types 6 and 11) that cause about 80% of genital warts. This vaccine also protects against the two types of HPV (types 16 and 18) that are believed to cause the majority (about 70%) of cervical cancers. The HPV vaccine has been recommended for girls and women 9 to 26 years old for prevention of initial infection. Three doses are given, preferably at age 11 to 12 years. The vaccine should be administered before the onset of sexual activity, but girls and women who are sexually active should still be vaccinated. The vaccine’s role in preventing HPV in boys and men has not been established.
Because of the location of these warts, condoms do not fully protect against infection.
Treatment
If the immune system is healthy, it often eventually controls HPV and eliminates the warts and the virus, even without treatment. HPV infection is gone after 8 months in half of people and lasts longer than 2 years in fewer than 10%. If people with genital warts have a weakened immune system, treatment is required, and the warts often return.
No treatment for external warts is completely satisfactory, and some treatments are uncomfortable and leave scars. External genital warts may be removed with a laser or by freezing (cryotherapy) or surgery. A local or general anesthetic is used.
Alternatively, podophyllin toxin, imiquimod, or trichloroacetic acid can be applied directly to the warts. However, this approach requires many applications over weeks to months, may burn the surrounding skin, and is frequently ineffective. After treatment, the area may be painful. Imiquimod cream causes less burning but may be less effective. The warts may return after apparently successful treatment.
For warts in the urethra, a viewing tube (endoscope) with surgical attachments may be the most effective way to remove them. It requires a general anesthetic. Or drugs, such as thiotepa inserted into the urethra or the chemotherapy drug 5-fluorouracil injected into the wart, are often effective. Interferon-alpha injections into the wart or into a muscle are somewhat effective, but they must be given several times a week for many weeks and are expensive.
All sex partners should be examined for warts and other STDs and treated, if necessary. Sex partners should also have regular examinations to check for HPV infection.
Gonorrhea
Gonorrhea is a sexually transmitted disease caused by the bacteria Neisseria gonorrhoeae, which infect the lining of the urethra, cervix, rectum, and throat or the membranes that cover the front part of the eye (conjunctiva and cornea).
Gonorrhea is usually spread through sexual contact.
People have a discharge from the penis or vagina and may need to urinate more frequently and urgently.
Rarely, gonorrhea infects the joints, skin, or heart.
Microscopic examination and culture of a sample of the discharge or DNA tests of urine can detect the infection.
Antibiotics can cure the infection.
In the United States, the number of gonorrhea cases reported each year has decreased by 75% since it peaked at nearly 900,000 in 1985. However, the number appears to have leveled off for about the last 10 years, with about 360,000 cases reported in 2006.
Gonorrhea is almost always spread through sexual contact. After one episode of vaginal intercourse with an infected person, the chance of spread from women to men is about 20%. The chance of spread from men to women may be higher. If pregnant women are infected, the bacteria can spread to the eyes of the fetus during birth. However, in most developed countries, infection is prevented because all newborns are routinely treated after delivery with medicated eye ointment.
Many people with gonorrhea have other sexually transmitted diseases (STDs), such as chlamydial infection, syphilis, or human immunodeficiency virus (HIV) infection.
Did You Know…
If pregnant women have gonorrhea, the eyes of the fetus may become infected, so newborns are routinely treated to prevent this infection.
Symptoms
In men, symptoms begin within about 3 to 10 days after infection. Usually, gonorrhea causes symptoms only at the sites of initial infection. In some people, infection spreads through the bloodstream to other parts of the body, especially to the skin, joints, or both.
Men feel mild discomfort in the urethra, followed a few hours later by mild to severe pain during urination, a yellow-green discharge of pus from the penis, and a frequent urge to urinate. The opening at the tip of the penis may become red and swollen. The bacteria sometimes spread to the epididymis (the coiled tube on top of each testis), which swells and feels tender to the touch.
About 10 to 20% of infected women have minimal or no symptoms. Thus, the infection may be detected only during routine screening or after diagnosis of the infection in their male partner. Symptoms typically do not begin until at least 10 days after infection. Some women feel only mild discomfort in the genital area and have a puslike discharge from the vagina. However, other women have more severe symptoms, such as a frequent urge to urinate, pain during urination, and fever because the urethra may also be infected.
Bacteria commonly spread up the genital tract and infect the tubes that connect the ovaries to the uterus (fallopian tubes). This infection, called salpingitis or pelvic inflammatory disease, causes severe lower abdominal pain, especially during intercourse. In some women, the lining of the abdominal cavity (peritoneum) becomes inflamed. This inflammation, called peritonitis, causes severe pain in the entire abdomen. Infection in the abdomen may concentrate around the liver. This infection, called perihepatitis or Fitz-Hugh-Curtis syndrome, causes pain in the upper right part of the abdomen. Women who have had pelvic inflammatory disease have an increased risk of infertility and mislocated (ectopic) pregnancies.
Anal sex with an infected partner may result in gonorrhea of the rectum, which makes bowel movements painful. Other symptoms include constipation, itching, bleeding, and a discharge from the rectum. The area around the anus may become red and raw, and stool may be coated with mucus and pus. When a doctor examines the rectum with a viewing tube (anoscope), mucus and pus may be visible on the wall of the rectum.
Oral sex with an infected partner may result in gonorrhea of the throat (gonococcal pharyngitis). Usually, the infection causes no symptoms uncommonly a sore throat.
If infected fluids come into contact with the eyes, gonococcal conjunctivitis may develop, causing swelling of the eyelids and a discharge of pus from the eyes. In adults, often only one eye is infected. Newborns usually have infection in both eyes. Blindness may result if the infection is not treated early.
Gonorrhea in children usually results from sexual abuse. In girls, the genital area (vulva) may be irritated, red, and swollen, and they may have a discharge from the vagina. If the urethra is infected, children, mainly boys, may have pain during urination.
Rarely, the infection spreads through the bloodstream to other parts of the body, especially the skin and joints. Joints become swollen, tender, and extremely painful, limiting movement. The skin over infected joints may be red and warm. If the bloodstream is infected, people may have a fever, feel generally ill, and develop arthritis in one or more joints. Red spots may appear on the skin. This infection is called disseminated gonococcal infection or arthritis-dermatitis syndrome.
Joint, bloodstream, and heart infections can be treated, but recovery from arthritis may be slow.
Diagnosis
In more than 90% of infected men, gonorrhea may be diagnosed within an hour by identifying the bacteria (gonococci) in samples of the discharge examined under a microscope. The sample is usually obtained by inserting a small swab a few centimeters into the urethra. However, identifying bacteria in a sample of discharge from the cervix is more difficult. The bacteria can be seen in only about half of infected women.
The sample of discharge is also sent to a laboratory for tests. Such tests are very reliable in both sexes but take longer than a microscopic examination. If a doctor suspects an infection of the throat, rectum, or bloodstream, samples from these areas are sent for culture (to be grown in a laboratory).
Other highly sensitive tests can be done to detect the DNA of gonococci and of chlamydia (which are often also present). Laboratories can test for both infections in a single specimen. For some of these tests, urine samples can be used. Thus, these tests are convenient for screening men and women who have no symptoms or who are unwilling to have fluid samples taken from their genitals.
Because many people have more than one STD, doctors may test samples of blood and genital fluids for other STDs, such as syphilis and HIV infection.
If a joint is red and swollen, doctors draw fluid from the joint using a needle. The fluid is sent for culture and other tests.
Treatment
A single injection of a cephalosporin antibiotic, such as ceftriaxone, into a muscle or a single dose of cefixime taken by mouth, cures most people. Some antibiotics (such as penicillin, ciprofloxacin, levofloxacin, and ofloxacin) are no longer used because many strains of gonococci have developed resistance to them. Usually, people with gonorrhea are also given antibiotics to kill chlamydiae because people are often infected with both. A single dose of azithromycin is most commonly used. A single high dose of azithromycin can cure both gonorrhea and chlamydial infection if people are allergic to cephalosporins, but the required dose often causes stomach upset.
If gonorrhea has spread through the bloodstream, people are usually treated in the hospital and given antibiotics intravenously.
If symptoms recur or persist after treatment, doctors may take samples for culture to make sure people are cured and do tests to determine whether the gonococci are resistant to the antibiotics used.
People with gonorrhea should abstain from sexual activity until treatment is completed to avoid infecting sex partners. All sex partners who have had sexual contact with infected people in the past 60 days should be tested for gonorrhea and other STDs and, if the tests are positive, should be treated. People who were exposed to gonorrhea within 2 weeks are treated for it without waiting for test results.
Granuloma Inguinale
Granuloma inguinale is a rare sexually transmitted disease that is caused by the bacteria Calymmatobacterium granulomatis and that leads to chronic inflammation and scarring of the genitals.
Granuloma inguinale is extremely rare in developed countries but still occurs in Papua New Guinea, Australia, southern Africa, and parts of Brazil and India.
Symptoms
Symptoms usually begin 1 to 12 weeks after infection. The first symptom is a painless, red nodule that slowly enlarges into a round, raised lump. The lump then breaks down to form a sore near the site of the initial infection:
Penis, scrotum, groin, and thighs in men
Vulva, vagina, and surrounding skin in women
Face in both sexes
Anus and buttocks in people who have anal intercourse
Sores may spread to other areas. They heal slowly and cause scarring. Occasionally, the infection spreads through the bloodstream to the bones, joints, or liver.
Diagnosis and Treatment
Diagnosis is suspected in people who live in areas where the infection occurs and who have sores typical of the infection. To confirm the diagnosis, doctors take a sample of fluid scraped from the sore and examine it under a microscope.
Trimethoprim-sulfamethoxazole or doxycycline taken by mouth for at least 3 weeks is effective.
Lymphogranuloma Venereum
Lymphogranuloma venereum is a sexually transmitted disease that is caused by Chlamydia trachomatis and that causes painful, swollen lymph glands in the groin and sometimes infection of the rectum.
Lymphogranuloma venereum is caused by types of Chlamydia trachomatis other than those that usually cause infection of the urethra (urethritis) and cervix (cervicitis). The infection occurs mostly in tropical and subtropical areas and is rare in the United State. In Western Europe, this infection has become a common cause of rectal infection (proctitis) in homosexual men.
Symptoms begin 3 or more days after infection. A small, painless, fluid-filled blister develops, usually on the penis or in the vagina. Typically, the blister becomes a sore that quickly heals and is often unnoticed. Then, lymph nodes in the groin on one or both sides may swell and become tender. The enlarged, tender lymph nodes (called buboes) attach to the deeper tissues and the overlying skin, which becomes inflamed. If infection lasts a long time or recurs, lymphatic vessels (which drain fluids from tissues) may be blocked, causing genital tissues to swell. Rectal infection may cause scarring, which can narrow the rectum.
Lymphogranuloma venereum is suspected based on its characteristic symptoms. The diagnosis can be confirmed by a blood test that identifies antibodies against Chlamydia trachomatis.
If given early in the infection, doxycycline, erythromycin, or tetracycline, taken by mouth for 3 weeks, cures the infection, but swelling may persist if lymphatic vessels are irreversibly damaged.
Syphilis
Syphilis is a sexually transmitted disease caused by the bacteria Treponema pallidum.
Syphilis can occur in three stages of symptoms, separated by periods of apparent good health.
It begins with a painless sore at the infection site and, in the second stage, causes a rash, fever, fatigue, and loss of appetite.
If untreated, syphilis can damage the heart, brain, spinal cord, and other organs.
Doctors usually do two types of blood tests—one to screen for and one to confirm the infection.
Penicillin can eliminate the infection, but people can be reinfected.
In the United States, the annual number of people with symptoms diagnosed for the first time peaked in 1990, when there were about 50,000 cases. Only about 6,000 such cases were reported in 2000, but the number went up to about 9,700 in 2006. Most people with syphilis are men, often homosexual men, living in cities. The percentage of blacks infected is 3 times that of other ethnic or racial groups.
Syphilis causes symptoms in three stages (primary, secondary, and tertiary), separated by periods when no symptoms occur (latent stages).
Syphilis is highly contagious during the primary and secondary stages. Infection is usually spread through sexual contact. A single sexual encounter with a person who has early-stage syphilis results in infection about one third of the time. The bacteria enter the body through mucous membranes, such as those in the vagina or mouth, or through the skin. Within hours, the bacteria reach nearby lymph nodes, then spread throughout the body through the bloodstream.
Syphilis can also be spread in other ways. It can infect a fetus during pregnancy (see table on page 1706), causing birth defects and other problems. It can also be spread through contact with skin. However, the bacteria cannot survive long outside the human body.
People with syphilis often have other infections, including other sexually transmitted diseases (STDs).
Symptoms
Each stage of symptoms (primary, secondary, and tertiary) is progressively worse. If not treated, syphilis can persist without symptoms for many years and may damage the heart or brain, possibly leading to death. If detected and treated early, syphilis can be cured, and there is no permanent damage.
Primary Stage: A painless sore (called a chancre) appears at the infection site—typically the penis, vulva, or vagina. A chancre may also appear on the anus, rectum, lips, tongue, throat, cervix, fingers, or other parts of the body. Usually only one chancre develops, but occasionally several develop. Symptoms usually start 3 to 4 weeks after infection but may start from 1 to 13 weeks later.
The chancre begins as a small red raised area, which soon turns into a painless open, deep sore. The chancre does not bleed and is hard to the touch. Lymph nodes in the groin usually swell and are also painless. About half of infected women and one third of infected men are unaware of the chancre because it causes few symptoms. Chancres in the rectum or mouth, usually occurring in homosexual men, are often unnoticed. The chancre usually heals in 3 to 12 weeks. Then, people appear to be completely healthy.
Secondary Stage: The bacteria spread in the bloodstream, causing a widespread rash, swollen lymph nodes, and, less commonly, symptoms in other organs. The rash typically appears 6 to 12 weeks after infection. About one fourth of infected people still have a chancre at this time. Usually, the rash does not itch or hurt. It varies in appearance. Unlike rashes caused by most other diseases, this rash commonly appears on the palms or soles. It may be short-lived or may last for months. Even without treatment, the rash eventually resolves, but it may recur weeks or months later. If a rash develops on the scalp, hair may fall out in patches, making it appear moth-eaten.
Did You Know…
A single sexual encounter with a person who has syphilis results in infection about one third of the time.
About half of the women and one third of the men who have the initial sore of syphilis do not notice it.
Raised bumps called papules (condylomata lata) may develop in moist areas of the skin, such as the armpits, genital area, and anus. These painful papules are very infectious. They may break open and weep. As they resolve, they flatten and turn a dull pink or gray. Mouth sores develop in more than 80% of people.
Secondary-stage syphilis can cause fever, fatigue, loss of appetite, and weight loss. About 50% of people have enlarged lymph nodes throughout the body, and in about 10%, the eyes become inflamed. About 10% of people have inflamed bones and joints that ache. In some people, the skin and whites of the eyes turn yellow (called jaundice) because hepatitis develops. Some have headaches or problems with hearing or vision because the brain, inner ears, or eyes are infected.
Latent Stage: After the secondary stage, people recover and have no symptoms for a time, which may last from years to decades. During this time, the infection is inactive (latent) and is not contagious. However, the bacteria are still present, and tests for syphilis are positive. The latent stage is classified as early (if the initial infection occurred within the previous 12 months) or late (if the initial infection occurred more than 12 months previously).
Tertiary (Third) Stage: Symptoms range from mild to devastating. Tertiary syphilis has three main forms: benign tertiary syphilis, cardiovascular syphilis, and neurosyphilis.
Benign tertiary syphilis usually develops 3 to 10 years after the initial infection. It is rare today. Soft, rubbery growths called gummas appear on the skin, most commonly on the scalp, face, upper trunk, and legs. They also often develop in the liver or bones, but they can develop in virtually any organ. They may break down, forming an open sore. If untreated, gummas destroy the tissue around them. In bone, they usually cause deep, penetrating pain. Gummas grow slowly, heal gradually, and leave scars.
Cardiovascular syphilis usually appears 10 to 25 years after the initial infection. The bacteria infect the heart and the blood vessels connected to it, including the aorta (the largest artery in the body). The following may result:
The wall of the aorta may weaken, forming a bulge (aneurysm). The aneurysm may press on the windpipe or other structures in the chest, causing difficulty breathing, a cough, and hoarseness.
The valve leading from the heart to the aorta (aortic valve) may leak.
The arteries that carry blood to the heart (coronary arteries) may narrow.
These problems can cause chest pain, heart failure, and death.
Neurosyphilis (which affects the brain and spinal cord) occurs during the first 5 to 10 years after infection. It develops in about 5% of all people with untreated syphilis. It occurs in the following forms:
Meningovascular: The arteries of the brain or spinal cord become inflamed, causing a chronic form of meningitis. At first, people may have a headache and a stiff neck. They may feel dizzy, have difficulty concentrating and remembering things, and have insomnia. Vision may be blurred. Muscles in the arms, shoulders, and eventually legs may become weak or even paralyzed. This form can cause strokes.
Paretic: This form usually begins when people are in their 40s or 50s. The first symptoms are gradual changes in behavior. For example, people may become less careful about personal hygiene, and their moods may change abruptly. They may become irritable and more and more confused. They may have delusions of grandeur. Headaches, insomnia, difficulty concentrating, poor judgment, and fatigue are common. Tremors may occur in the mouth, tongue, outstretched hands, or whole body. Usually, dementia eventually results.
Tabetic (tabes dorsalis): The spinal cord progressively deteriorates. Symptoms begin gradually, typically with an intense, stabbing pain in the legs that comes and goes irregularly. Walking becomes unsteady. People may feel like they are walking on foam rubber. People usually become thin. Erectile dysfunction is common. Eventually, people have difficulty controlling urination (incontinence) and may become paralyzed.
Diagnosis
Health care practitioners suspect primary syphilis if people have a typical chancre. They suspect secondary syphilis if people have a typical rash on the palms and soles. Laboratory tests are needed to confirm the diagnosis. Two types of blood tests are used:
A screening test, such as the Venereal Disease Research Laboratory (VDRL) or the rapid plasma reagin (RPR) test, is done first. Screening tests are inexpensive and easy to do. But they may need to be repeated because for 3 to 6 weeks after the initial infection, results can be negative even though syphilis is present. Such results are called false-negative. Screening test results are sometimes positive when syphilis is not present (false-positive) because another disorder is present.
A confirmatory test must usually be done to confirm a positive screening test. This blood test measures antibodies specific to the bacteria that cause syphilis, Treponema pallidum. Results of confirmatory tests may also be false-negative during the first few weeks after initial infections and thus may need to be repeated.
Screening test results may become negative after successful treatment, but the confirmatory test results stay positive indefinitely.
In the primary or secondary stages, syphilis may also be diagnosed using darkfield microscopy. A sample of fluid is taken from a skin or mouth sore and examined using a specially equipped light microscope. The bacteria appear bright against a dark background, making them easier to identify.
In the latent stage, antibody tests of blood and spinal fluid are used to diagnose syphilis.
In the tertiary stage, the diagnosis is based on symptoms and antibody test results. Depending on which symptoms are present, other tests are done. For example, a chest x-ray may be taken or another imaging test may be done to check for an aneurysm in the aorta. If neurosyphilis is suspected, a spinal tap (lumbar puncture) is needed to obtain spinal fluid, which is tested for antibodies to the bacteria.
Treatment
Penicillin given by injection is the best antibiotic for primary, secondary, and early latent syphilis. For primary and secondary stages of syphilis, one dose of a long-acting penicillin is all that is needed. However, some people need another dose 1 week later. For late latent stage and some forms of the tertiary stage, three doses are given, separated by 1 week.
If syphilis affects the eyes, inner ears, or brain, penicillin may be given intravenously every 4 hours for 10 to 14 days. People who are allergic to penicillin may be given other antibiotics such as ceftriaxone (given by injection daily for 10 days) or doxycycline (taken by mouth for 14 days).
Because people with primary or secondary syphilis can pass the infection to others, they must avoid sexual contact until they and their sex partners have completed treatment. If people have primary-stage syphilis, all their sex partners of the previous 3 months are at risk of being infected. If they have secondary-stage syphilis, all sex partners of the previous year are at risk. Such sex partners require a blood test for antibodies to the bacteria. If test results are positive, the sex partners need to be treated. Some doctors simply treat all sex partners without waiting for test results.
More than half of people with syphilis in an early stage, especially those with secondary-stage syphilis, develop a reaction 2 to 12 hours after the first treatment. This reaction, called a Jarisch-Herxheimer reaction, causes fever, headache, sweating, shaking chills, and a temporary worsening of the sores caused by syphilis. Doctors sometimes mistake this reaction for an allergic reaction to penicillin. Rarely, people with neurosyphilis have seizures or become paralyzed. Symptoms of this reaction usually subside within 24 hours and rarely cause permanent damage.
After treatment, examinations and blood tests are done periodically until no infection is detected. If treatment of primary, secondary, or latent-stage syphilis is successful, most people have no more symptoms. But treatment of tertiary-stage syphilis cannot reverse any damage done to organs, such as the brain or heart. People with such damage usually do not improve after treatment. People who have been cured of syphilis do not become immune to it and can be infected again.
Trichomoniasis
Trichomoniasis is a sexually transmitted infection of the vagina or urethra that is caused by the protozoa Trichomonas vaginalis and that causes vaginal irritation and discharge.
Women may have a greenish yellow, frothy, fishy-smelling vaginal discharge with irritation and soreness in the genital area.
Men are less likely to have symptoms but may have a frothy, puslike discharge from the penis, and urination may be painful and frequent.
Examination of a sample of the discharge under a microscope usually enables doctors to identify the infection.
A single dose of an antibiotic cures most women, but most men need to take an antibiotic for 7 days.
Trichomonas vaginalis commonly causes a sexually transmitted disease (STD) of the vagina in women and an STD of the urinary tract in men and women. Women are much more likely to develop symptoms. About 20% of women develop trichomoniasis of the vagina (trichomonas vaginitis) during their reproductive years (see page 1539). Many people with trichomoniasis also have gonorrhea or other STDs.
Symptoms
In women, the infection usually starts with a greenish yellow, frothy, fishy-smelling vaginal discharge. In some women, the discharge is slight. The vulva may be irritated and sore, and sexual intercourse may be painful. In severe cases, the vulva and surrounding skin may be inflamed, and the labia swollen. Urination may be painful or frequent, as occurs in a bladder infection. Urinary and vaginal symptoms may occur alone or together.
Most men with trichomoniasis of the urethra have no or only mild symptoms, but they can still infect their sex partners. Some men have a frothy, puslike discharge from the penis, pain during urination, and an urge to urinate frequently, usually early in the morning. Rarely, the epididymis (the coiled tube on top of each testis) and prostate gland are infected.
Did You Know…
About 1 of 5 women develop trichomoniasis of the vagina.
Most men with trichomoniasis have no symptoms, but they can still infect their sex partners.
Diagnosis
Doctors suspect trichomoniasis in women with vaginal infections, in men with urethral infections, and in their sex partners.
The organism is much more difficult to detect in men than in women. In women, the diagnosis can usually be made quickly by examining a sample of the vaginal discharge with a microscope and identifying the organism. If results are unclear, the sample is cultured for several days. In men, a sample of the discharge from the end of the penis (obtained in the morning, before urination) may be examined under a microscope and sent to the laboratory for culture. Occasionally, microscopic examination of the urine detects Trichomonas, but identification is more likely if a urine culture is done.
Tests for other STDs are usually also done because many people with trichomoniasis also have gonorrhea or a chlamydial infection.
Treatment
A single dose of metronidazole or tinidazole (which are antibiotics), taken by mouth, cures up to 95% of infected women. However, their sex partners must be treated simultaneously, or women may be reinfected. Whether single-dose treatment is effective in men is unclear. But men are usually cured after taking the antibiotic for 7 days.
If taken with alcohol, metronidazole may cause nausea and flushing of the skin. The drug may also cause a metallic taste in the mouth, nausea, or a decrease in the number of white blood cells. Women who take the drug may be more susceptible to vaginal yeast infections (vaginal candidiasis). Metronidazole is best avoided during pregnancy, at least during the first 3 months.
Infected people should abstain from sexual intercourse until the infection is cured, or they can infect their partners.
Other Sexually Transmitted Diseases
Some bacteria (Shigella, Campylobacter, and Salmonella), viruses (hepatitis A, B, and C), and parasites (Giardia and some amebas) are sometimes transmitted during sexual intercourse, although they are typically transmitted in other ways. These organisms, except for hepatitis B and C viruses, typically infect the digestive tract and are acquired when people consume contaminated food or water. In the digestive system, the organisms multiply and are excreted from the body in the feces. They can be spread through contact with the anus or feces of an infected person—for example, during anal sex.
Symptoms vary depending on the organism. They may include diarrhea, fever, abdominal pain or bloating, nausea, vomiting, and jaundice.
Infections recur frequently, especially in homosexual men with many sex partners. Some infections cause no symptoms but may have serious long-term complications, such as chronic hepatitis B or C.