1. Prof. Rupali
Mahadik
Sexually transmitted
infections
(STIs)
Prof. Rupali Mahadik
PAMCHRC , Lucknow

2. Prof. Rupali
Mahadik
Need to study ?
• STIs are a major public health problem in most parts of the world.
• They are responsible for a number of acute illnesses,
1. Infertility(troubles conceiving) and turn to assisted reproductive
technologies (ART)
2. Long-term disability, and
3. Premature death,
4. Contributing to an increase in the spread of HIV.

3. Prof. Rupali
Mahadik
WHO
• The global incidence rates in 2016 were estimated to be:-
New cases/1000
Infection Women /1000 Men/1000
Chlamydia 34 33
Gonorrhoea 20 26
Trichomoniasis 40 42
Syphilis 1.7 1.6

4. Prof. Rupali
Mahadik
What Causes STIs?
❏ STIs are caused by-
★ Bacteria,
★ Viruses, &
★ Parasites .
❏ Infections can be found in body fluids such as-
★ Semen,
★ on the skin of the genitals and areas around them,
★ and some also in the mouth, throat, and rectum.
❏ Transmission by- spread from one person to another through
★ Sex- vaginal, oral, or anal sex
★ Also from unsterilized needles, breastfeeding, and blood infusions.

5. Prof. Rupali
Mahadik
some facts-
• The more sexual partners a person has, the greater his or her risk of either becoming
infected with STIs or transmitting STIs.
• Several types of organisms cause STDs.
• Those caused by organisms such as bacteria generally can be cured.
• STIs caused by viruses generally cannot be cured, although they can be treated to
relieve symptoms.

6. Prof. Rupali
Mahadik
STI Type Sexual transmission Nonsexual transmission Curable?
Chlamydia Bacterial
Vaginal and anal sex
Rarely, from genitals to mouth
From mother to child during pregnancy Yes
Gonorrhea Bacterial
Vaginal and anal sex, or contact between
mouth and genitals
From mother to child during pregnancy Yes
Chancroid Bacterial Vaginal, anal, and oral sex None Yes
Syphilis Bacterial
Genital or oral contact with an ulcer,
including vaginal and anal sex
From mother to child during pregnancy or
delivery
Yes
Trichomoniasis Parasite Vaginal, anal, and oral sex From mother to child during delivery
Yes
HPV Viral
Skin-to-skin and genital contact or contact
between mouth and genitals
From mother to child during delivery No
Herpes Viral
Genital or oral contact with an ulcer,
including vaginal and anal sex; also
genital contact in area without ulcer
From mother to child during pregnancy or
delivery
No
HIV Viral
Vaginal and anal sex
Very rarely, oral sex
In blood, from mother to child during
pregnancy or delivery or in breast milk
No
Hepatitis B Viral
Vaginal and anal sex, or from penis to
mouth
In blood, from mother to child during delivery
or in breast milk
No

7. Prof. Rupali
Mahadik
Common Vaginal Infections That May Not Be Sexually
Transmitted
• The most common vaginal infections usually are due to an overgrowth of organisms normally
present in the vagina.
• A vaginal yeast infection, also known as Candidiasis, is a common condition. A healthy vagina
contains bacteria and some yeast cells. But when the balance of bacteria and yeast changes, the
yeast cells can multiply. This causes itching, swelling, and irritation.
• They may or may not be sexually transmitted.
• These infections include -
Candidiasis (also called yeast infection or thrush)and
Bacterial vaginosis.
• Candidiasis is not usually sexually transmitted.

8. Prof. Rupali
Mahadik
Bacterial
Sexually Transmitted Infections

9. Prof. Rupali
Mahadik
Chlamydiae
• Chlamydia is the most commonly STI in the world.
• Chlamydiae are obligate intracellular Gram-negative
bacteria that are surrounded by a rigid cell wall.
• They are able to infect both -
Human (Chlamydia trachomatis and Chlamydia pneumonia)
&
Animals (C.muridarum, C. suis, C. abortus, C.pecorum
C. psittaci, and C. caviae) .
• They depend entirely on the biosynthesis pathways of a host cell to multiply, as they are unable to
synthesize essential nutrients.

10. Prof. Rupali
Mahadik
Chlamydia Trachomatis
⮚There are several types of species of chlamydia that exist , but when
we talk about the most common STI that’s responsible for disease
chlamydia we are talking about Chlamydia trachomatis.
⮚ Trachoma is term to eye infection that occurs due to this.
⮚For human C. trachomatis, there are 19 currently identified serotypes,
determined based on their major outer membrane protein
characteristics-
• serotypes A, B, and C causing- trachoma of the eye,
• serotypes D through to K infecting- urogenital tissue , and
• serotype L being responsible for- lymphogranuloma venereum
(LGV), an infection of the lymphatics and lymph nodes.

11. Prof. Rupali
Mahadik
⮚It is most common and fastest spreading STI .
⮚ Infections are often silent and highly destructive
⮚ Difficult to diagnose-
( most women having Chlamydia infection show no signs and symptoms and it’s quite difficult to find out if
one has Chlamydia infection unless one goes for medical test. Hence Chlamydia infection /disease is also
known as the “silent infection”
⮚Transmission- infection transmitted from one person to another-
• Sex - oral ,vaginal, anal .
• Childbirth –infected mother to child
• Direct contact-
Chlamydia can leave outside of human host for about a few seconds to a minute. So direct contact means
scratching infected organ and then directly touching another part like eye of same person.

12. Prof. Rupali
Mahadik
Chlamydia Trachomatis
Chlamydia usually transmitted through sex- chlamydia is a intracellular organism –it lives-within a cell( human host cell)
( Epithelial cells - bacteria will enter into cell trigger the immune response)
so if infection transmitted from men to female symptoms are due to the WBC that come & attack this bacteria
first target will be female sexual organs attacks target cells that are infected by process called apoptosis
Vagina – (epithelial cells of vagina) Cell death (specifically killing the infected cell)
(multiply and spread to genital tract further up) many chlamydia at a time result in large WBC in genitourinary tract
Cervix due to this-process of inflammation-burning, pain and swelling
same will Spread to nearby organs also urethra vaginitis, cervicitis, urethritis
also these dead WBC / epithelial cells/ bacteria
are been discharged out –
causing abnormal vaginal/cervical/urethra-purulent discharge

13. Prof. Rupali
Mahadik

14. Prof. Rupali
Mahadik
vaginal discharge is
abnormal may include a
different or unpleasant
smell, a darker color, or
a texture
Pain during urination-
dysuria
And
pain during intercourse-
dyspareunia
minor bleeding
after
vaginal intercourse
mild and slowly
progressing lower
back, abdominal, and
pelvic aches- PID
Symptoms in Women Includes:
If infection spreads further
from cervix to uterus and
tubes as we know tubes get
open into abdomen-it will
spread causing PID

15. Prof. Rupali
Mahadik
unusual discharge from
the penis. This discharge
may look watery and
clear, or milky, cloudy,
and yellow-white like pus
burning sensation when
urinating.
feel burning or itching
on or around the
opening of the penis.
pain or swelling in one or both
testicles or the scrotum
Symptoms in Men includes:
If infection spreads further to
prostate it will cause Prostatitis

16. Prof. Rupali
Mahadik
Diagnosis
• C. trachomatis urogenital infection can
be diagnosed in women by testing first-
catch urine or collecting swab specimens
from the endocervix or vagina.
• Diagnosis of C. trachomatis urethral
infection in men can be made by testing
a urethral swab or first-catch urine
specimen

17. Prof. Rupali
Mahadik

18. Prof. Rupali
Mahadik
Treatment
• Treating persons infected with C. trachomatis prevents adverse reproductive health
complications and continued sexual transmission, and treating their sex partners can
prevent reinfection and infection of other partners.
• Treating pregnant women usually prevents transmission of C. trachomatis to
neonates during birth.
• Chlamydia treatment should be provided promptly for all persons testing positive for
infection; treatment delays have been associated with complications

19. Prof. Rupali
Mahadik
⮚ Recommended Regimens
✔ Azithromycin 1 g orally in a single dose (is safe and effective in pregnancy)
OR
✔ Doxycycline 100 mg orally 1 BD X 7 days (Doxycycline is contraindicated in the second
and third trimesters of pregnancy.)
⮚ Alternative Regimens
✔ Erythromycin base 500 mg orally 1 QID X 7 days
OR
✔ Levofloxacin 500 mg orally 1 OD X 7 days
OR
✔ Ofloxacin 300 mg orally 1 BD X 7 days

20. Prof. Rupali
Mahadik
Infertility -
• Chlamydia Trachomatis can cause serious damage to a man’s and woman’s reproductive system
making it tough for women and sometimes impossible to conceive child.
• In very rare cases, Chlamydia causes potentially fatal ectopic pregnancy.
• Men can experience low sperm quality and erectile dysfunction in some cases.

21. Prof. Rupali
Mahadik
Trachoma
⮚From genitalia Chlamydia can further spread elsewhere in the body through blood stream it shows
up at some classic sites-
Eye
From blood stream as well as through direct contact
Conjunctivitis (bumps will accumulate- irritation )
Infection can further spread to
Pupil causing opacity (whitening over pupil )
difficult to see
this is called Trachoma
one of major cause of blindness in developing countries

22. Prof. Rupali
Mahadik
Infective / Reactive Arthritis
Joints- another Site
Knee
through blood stream infection spread into joint capsule - Articular cartilage
chlamydia reinfection
WBC attacks antibodies against
synovial fluid + WBC mistaken proteins into joint are attacked
causing painful movement
WBC s rush to site to help antibodies
Dysarthria Painful joints
Dysarthria Painful joints
Infective arthritis Reactive arthritis

23. Prof. Rupali
Mahadik
Reiter’s Syndrome
• Reiter's syndrome, also known as reactive arthritis, is the
classic triad of conjunctivitis, urethritis, and arthritis occurring
after an infection

24. Prof. Rupali
Mahadik
Neonatal Chlamydial infection
Infants born vaginally to infected
mothers with genital disease are at
risk for acquiring C. trachomatis,
which usually presents as
conjunctivitis and/or pneumonia

25. Prof. Rupali
Mahadik

26. Prof. Rupali
Mahadik
Gonorrhea
greek word- flow of seed
❑ 2nd most frequently reported STD
❑It’s caused by the Gram-negative bacteria - Neisseria gonorrhoeae.
❑ It tends to target warm, moist areas of the body, including the:
• urethra
• eyes
• Throat
• vagina
• anus
• female reproductive tract (the fallopian tubes, cervix, and uterus)

27. Prof. Rupali
Mahadik
•Why these 2 diseases-Chlamydia and Gonorrhea are
often together?
➢ There are 2 reasons-
1. first similar risk factors- which include things like having multiple sexual
partners &/or having frequent unprotected sex.
1. other reason is that infection with one of these bacteria makes the pt body
susceptible to a second infection.

28. Prof. Rupali
Mahadik
❏ Transmission- infection transmitted from one person to another-
❖ Sex - oral ,vaginal, anal .
❖ Childbirth –infected mother to child
❏ Incubation: 3-8 day
Symptoms usually occur within 2 to 14 days after exposure.
However, some people who acquire gonorrhea never develop noticeable symptoms.
It’s important to remember that a person with gonorrhea who doesn’t have symptoms, also called
an asymptomatic carrier, can still spread the infection.
A person is more likely to transmit gonorrhea to other partners when they don’t have noticeable
symptom

29. Prof. Rupali
Mahadik
Gonorrhea
Gonorrhea usually transmitted through sex
( Epithelial cells lining - bacteria will enter into cell trigger the immune response)
symptoms are due to the WBC that come & attack this bacteria
attacks target cells that are infected by process called apoptosis
Cell death (specifically killing the infected cell)
many Gonorrhea at a time result in large WBC in genital/urinary tract
due to this-process of inflammation-burning, pain and itching
vaginitis, cervicitis, urethritis
also these dead WBC / epithelial cells/ bacteria
are been discharged out –
causing pus discharge
vaginal/cervical/urethra
Gonorrhea can infect even
epithelial cells of anus
and high upto rectum
infection of epithelial cells causing
skin infection
called as skin pustules

30. Prof. Rupali
Mahadik
will latch epithelial cells
Gonococci-2 spheres travel together with extension which is called pilus-pili
, pilli of gonococci will grab on to the wall of vagina upwards towards cervix
and deeper
body has immune system which prevents the gonococcus from going
through further and further- WBC attacks
(in other kind of infections usually these wBCs which swallows the bacteria try to
process the proteins present on the organisms to form antibodies - a process to
develop immunological memory -which prevents to infection in future)
In gonococci it cannot develop immunologic memory
WBC which has OPA receptors helping to develop immunologic memory -
gonococci have OPA protein -binds these receptors -prevent the receptors
from working
that’s the reason when every-time a person is infected with gonococcus -
they have to go through process of attacking the bacteria as a new time of
infection all the time

31. Prof. Rupali
Mahadik
Symptoms of Gonorrhea

32. Prof. Rupali
Mahadik
Symptoms in Men
❏Men - Initial site of infection is urethra
❏Symptoms -Develop 2 to 5 days after infection
★ The first noticeable symptom in men is often a burning or painful
sensation during urination-Dysuria.
As it progresses, other symptoms may include:
★ greater frequency or urgency of urination
★ a pus-like discharge (or drip) from the penis (white, yellow, beige, or
greenish)
★ swelling or redness at the opening of the penis
★ swelling or pain in the testicles
★ a persistent sore throat

33. Prof. Rupali
Mahadik
Symptoms in Women
• Gonorrhea symptoms can appear much like common vaginal yeast or bacterial
infections.
• Symptoms include:-
• discharge from the vagina (watery, creamy, or slightly green)
• pain or burning sensation while urinating
• urge to urinate more frequently
• heavier periods or spotting
• sore throat
• pain during sexual intercourse
• sharp pain in the lower abdomen
• fever

34. Prof. Rupali
Mahadik
Diagnosis
swab is taken from site
Gram-stained smear to
identify organism
Culture of discharge -to
identify specific
antibiotics which will
work

35. Prof. Rupali
Mahadik
Treatment
• Gonorrhea can be cured with the right medication.
• The Centers for Disease Control and Prevention (CDC)Trusted
Source recommend a -
single dose of 250 milligrams of intramuscular ceftriaxone
and
1 gram of oral azithromycin.
❖ Untreated gonorrhea can cause serious health problems in both women and men.

36. Prof. Rupali
Mahadik
Complications in women
• PID can cause severe and chronic pain and
damage to the reproductive organs.
• Women may also develop blocking or scarring of
the fallopian tubes, which can prevent future
pregnancy or cause ectopic pregnancy.
● Untreated, the bacteria may ascend up the reproductive tract and involve the uterus, fallopian tubes,
and ovaries- this condition is known as pelvic inflammatory disease (PID)

37. Prof. Rupali
Mahadik
• Occasionally, if the infection is severe enough, a localized area of
infection and pus-like discharge (an abscess) forms
❏ Bartholin’s abscess-very painful
❏ Tubo-ovarian abscess- that can be life-threatening, and major
surgery may be necessary.
• Further complications of the infection can occur during
pregnancy and delivery. Without treatment, it causes an increased
risk of preterm labor or stillbirth.

38. Prof. Rupali
Mahadik
Neonatal infection
●Gonorrhea may also pass to a newborn infant during delivery.
●Some newborns develop conjunctivitis, and gonorrhea is one
possible cause.
The symptoms usually appear 2–4 days after birth and include
❏ red eyes,
❏ thick pus in the eyes,
❏ and swollen eyelids.
● Gonorrhea when pass to the newborn, can also develop a joint
infection, loss of vision, or bacteremia — a life threatening blood
infection — as a result.

39. Prof. Rupali
Mahadik
Complications in Male
• Men may experience scarring of the urethra-stricture -due
to Gonorrhea.
• Gonorrhea may also cause a painful abscess to develop in
the interior of the penis. This can cause reduced fertility
or sterility.
• In males, gonorrhea can lead to epididymitis, which can
cause problems with fertility.

40. Prof. Rupali
Mahadik
• Untreated gonorrhea can lead to a disseminated gonococcal infection-spreads to the bloodstream. This
can be life threatening.
Some signs and symptoms include:
❖ dermatitis, which usually involves a rash or itchy, dry skin
❖ a fever
❖ arthritis
❖ inflammation and swelling around the tendons
❖ heart valve damage,
❖ Meningitis-inflammation of the lining of the brain or spinal cord may occur.
These are rare but serious conditions.
• People with gonorrhea also have a higher risk of contracting or transmitting HIV.
One reason is that either infection can cause open sores, which make it easier for viruses and bacteria to
enter the body.

41. Prof. Rupali
Mahadik
Prevention
• Ways of avoiding gonorrhea include:
✔avoiding sexual activity if there is the possibility of infection.
✔using a barrier method of protection, such as condoms, during vaginal or
anal intercourse.
✔using condoms or dental dams during oral intercourse.
✔only having sexual activity with a mutually monogamous partner who does
not have the infection.

42. Prof. Rupali
Mahadik
Chancroid
• Chancroid ( SHANG-kroyd) is a bacterial -sexually transmitted infection caused
by the fastidious >Gram-negative streptobacillus- Haemophilus ducreyi.
• This pathogen is highly infectious, and disease is characterized by painful sores on
the genitalia.
• Chancroid is the most common cause of genital ulceration .
• Chancroid is a risk factor for contracting HIV

43. Prof. Rupali
Mahadik
• Mode of transmission- solely through sexual contact.
However, there have been reports of accidental infection through another route which is
by the hand.
• H. ducreyi enters skin through microabrasions incurred during sexual intercourse.
• The incubation period of H.ducreyi infection is 10 to 14 days after which there is
progression of the disease.
A local tissue reaction leads to
development of
erythematous papule,
which progresses to
pustule in 4–7 days
It then undergoes central necrosis
to ulcerate.

44. Prof. Rupali
Mahadik
Males Females
• Internal and external surface
of prepuce.
• Coronal sulcus
• Frenulum
• Shaft of penis
• Prepucial orifice
• Urethral meatus
• Glans penis
• Perineum area
• Labia majora is most common site.
"Kissing ulcers" may develop. These are ulcers that
occur on opposing surfaces of the labia.
• Labia minora
• Fourchette
• Vestibule
• Clitoris
• Perineal area
• Inner thighs
Sites For Chancroid Lesions

45. Prof. Rupali
Mahadik
Signs and symptoms
• Chancroid or soft chancre is characterized by one or more genital ulcers and painful inguinal lymphadenopathy
The ulcer characteristically:
• Ranges in size dramatically from 3 to 50 mm
(1/8 inch to two inches) across
• Is painful-do cry
• Has sharply defined, undermined borders
• Has irregular or ragged borders, described as
saucer-shaped.
• Has a base that is covered with a gray or
yellowish-gray material
• Has a base that bleeds easily if traumatized or
scraped.

46. Prof. Rupali
Mahadik
Signs and symptoms
• dysuria (pain with urination) and
• dyspareunia (pain with
intercourse)
About half the cases of genital chancroid manifest inguinal adenitis.
Suppuration of the bubo (inguinal lymph node) may occur despite early antibiotic
therapy.
The lymphadenitis of chancroid, mostly unilateral, is tender and may rupture
spontaneously.
Left untreated, the site of perforation of the broken-down bubo will progress to a
destructive painful ulcer.

47. Prof. Rupali
Mahadik
Diagnosis
• Gram stain: Scrapings from base of ulcer
may show clusters of gram negative rods
(SCHOOL OF FISH).
• Culture : Difficult, special media,
Sensitivity < 80%.
• Serologic tests : None,
Should be tested for syphilis and HIV.
Repeat after 3 months if – ve initially
★Most of the time, the diagnosis is based on presumptive approach using the symptomatology
which in this case includes multiple painful genital ulcers.

48. Prof. Rupali
Mahadik
Management
• Azithromycin 1 gm orally in a single dose
OR
• Ceftriaxone 250 mg IM in a single dose
OR
• Ciprofloxacin 500 mg orally 2 times/day for 3 days
OR
• Erythromycin base 500 mg orally 3 times/day for 7 days
• Re-examination after 3 to 7 days.
• Buboes may need to be aspirated.

49. Prof. Rupali
Mahadik
Complications
• Extensive adenitis may develop.
• Large inguinal abscesses may develop and rupture to form draining
sinus or giant ulcer.
• Superinfection. These later require debridement and may result in
disfiguring scars.
• Phimosis can develop in long standing lesion by scarring and
thickening of foreskin, which may subsequently require circumcision

50. Prof. Rupali
Mahadik
Syphilis
• Syphilis is a sexually transmitted infection (STI) caused by a type of bacteria known
as Treponema pallidum.
• it is a Spirochete bacterium -name for group of bacteria which literally look like spiral.
• it can only live within the cells of human beings.
• Syphilis bacteria can remain dormant in the body for decades if not treated.
• If left untreated it can severely damage the Heart, Brain and other organs and even be
life threatening.

51. Prof. Rupali
Mahadik
Transmission-
❖ Acquired Syphilis - enters via BODY FLUIDS through cuts/breaks in skin or
mucous membranes- external genitalia ,mouth
❏ Sexual contact- Oral ,Anal or Vaginal sex
❏ Contaminated Needles
❏ Direct contact -with a skin lesion( spirochetes)
❖ Congenital Syphilis
(mother has syphilis)- through Placenta during pregnancy
or by vagina during birth

52. Prof. Rupali
Mahadik
Syphilis Clinical Manifestations
• The symptoms are categorised by 4 stages with varied symptoms associated with each stage -
❏ Primary- (Localised)
❏ Secondary- (systemic)
❏ Latent-(Hidden)
❏ Tertiary-(complications)
= Symptomatic
= asymptomatic

53. Prof. Rupali
Mahadik
Primary stage -
• Once a person gets infected it takes 3 weeks to show the symptoms-referred to primary
syphilis.
• majority of symptoms in primary syphilis will be at the site of contact.
Genital organs-Single Chancres appear at site of direct
contact
(penis,anus,rectum,vulva,cervix,perineus,lips,mouth…)
Firm, Painless ,indurated lesions- thick exudate rich in
spirochaetes
LAD- non tender lymph node swelling (inguinal) will be
bilateral.
❖ Chancre and lymphadenopathy tend to heal about 3 to 6 weeks with or without treatment.

54. Prof. Rupali
Mahadik
• After primary stage the disease will further progress to secondary syphilis. After being asymptomatic
for 2-6 months.
• Systemic- spirochetes spreads from genital tract to bloodstream causing systemic symptoms.
❏ Fever-spirochetes like to invade endothelial cells of blood vessels-apoptosis/ release the cytokines in
blood stream and through bloodstream reach the brain- signaling brain to raise temperature -
Fever classic symptom of secondary syphilis.
❏ more lymphadenopathy -regionally as well as elsewhere in body
Secondary stage- Most infectious
❏ classic symptom -very characteristic copper coloured skin rash referred to as a
maculopapular-flat or raised rash that occurs all over body-appears on palms and
even on soles of feet-very few disease can have.it will be bunch of these
representing treponema and wbc fighting -inflammation.
❏ instead of chancre we see large warts called Condyloma lata-painless

55. Prof. Rupali
Mahadik
❏ latent stage can last for years during which the body will have the disease
without symptoms.
❏ no signs/symptoms at this time.
❏ patient test positive for syphilis
❏ not contagious, except when there is lesion
Latent or hidden stage

56. Prof. Rupali
Mahadik
Tertiary or late stage
• About 15-30% of people with syphilis who don’t get treatment will develop
complications known as tertiary syphilis. Significant morbidity/mortality rates
Gummatous syphilis
Gumma- mass of dead and
swollen fibre like tissue -can
occur. in any organ (common
skin , bones , liver)
Cardiovascular syphilis
- aortic aneurysm
- aortic valve disease
Neurosyphilis
- meningitis
- seizures, stroke
- hearing/vision loss
- speech disorder
- dementia..

57. Prof. Rupali
Mahadik
Neurosyphilis can occur anytime after primary infection and is much more common in
patients with HIV infection.
Early infection generally affects meninges and vasculature. late infection progress to
involve the parenchyma of the brain & spinal cord. there are 6 subtypes of neurosyphilis
based on clinical symptoms and structures involved-

58. Prof. Rupali
Mahadik
Congenital Syphilis
Transmission:
- Mother to child transmission via placenta -Spread in utero after 10th
week of pregnancy
or
- contacts with infected lesions during birth
Symptoms:
- Infected mother has a greater risk of miscarriage or a stillbirth or
having a baby who dies shortly after birth or have birth defects (nasal
cartilage destruction, frontal bossing, bowing of tibia…)
- may be asymptomatic at birth. Symptoms within 4 years:
rash,fever,seizures,enlarged liver/ spleen, cranial nerve palsies…

59. Prof. Rupali
Mahadik
Syphilis Diagnostic Studies
❏ As the organism Treponema pallidum cannot be cultured on artificial media the
diagnosis of syphilis depends on the correlation of clinical data with the
detection of the specific antibody by serological tests.
❏ Serologic testing -
➢ Non-specific :
- Rapid plasma reagin (RPR)test
- Venereal disease research laboratory test (VDRL) test
➢ Treponemal tests:
- Treponema pallidum hemagglutination assay(TPHA)
- Fluorescent treponemal antibody absorption test (FTA-ABS)
- Fluorescent treponemal antibody absorption double-staining test (FTA-ABS DS)
- Treponemal enzyme immunoassay(TEIA)

60. Prof. Rupali
Mahadik
Syphilis Treatment
• Drug therapy
Stages 1,2,and early latent
1 injection of intramuscular
Penicillin G Benzathine -2.4 million units
Late latent and stage 3 3 intramuscular injections,once weekly
Neurosyphilis
intravenous Penicillin G aqueous
18-24 million units, daily for 10-14 days
Non pregnant
(with penicillin allergy)
Doxycycline, ceftriaxone, tetracycline
Pregnant
(with penicillin allergy)
desensitization => treat with penicillin
* Jarisch-Herxheimer reaction(JHR)- pts may suffer with this reaction on !st day of Rx : fever,chills,
headache,nausea,pain-subsides within 24 hrs but pts must be observed

61. Prof. Rupali
Mahadik
Protozoal
Sexually Transmitted Infections

62. Prof. Rupali
Mahadik
Trichomoniasis
Trichomoniasis, also called trich, is a most common curable sexually transmitted disease (STD)
Trich is caused by a tiny one-celled protozoan parasite named Trichomonas vaginalis.
Anyone who’s sexually active can get it. trich
Transmission- as name itself suggest-through vaginal sex.
Women typically get the infection in their vulva, vagina, cervix, or urethra.
Men usually get it in their urethra, may also get it in their prostate.

63. Prof. Rupali
Mahadik
Protozoan-parasite having pear shaped body with
nucleus and 4 protein strands called flagella
With help of flagella the parasite climbs and latches the cells
of vaginal wall moves in upward direction
This causes stress to cell membrane overtime causes cell
to die and producing cell fragments
these fragments are eaten by parasite
Body immune response -WBCs are sent into Vagina -
to combat them and release toxins.- engulf and destroy
trichomonas
causing Inflammation
symptoms -dysuria,vaginitis,cervicitis , frothy greenish
maladoros discharge >chronic local irritation

64. Prof. Rupali
Mahadik
Trichomoniasis Symptoms
❏ About 70% of people with trich don’t have symptoms.
❏ In others, the signs might not show up until days or weeks after infection.
❏ Infection is more common in women than in men & older women are more likely infected
then younger.
❏ Women with trichomoniasis may have:
● Vaginal fluid that smells bad and is frothy greenish or yellowish
● Genital itching, burning, redness, or soreness
● Dysuria and increased frequency of micturation
● dyspareunia
● Bleeding after sex

65. Prof. Rupali
Mahadik
Men with trichomoniasis are mostly asymptomatic- mainly carrier.
Sometimes men may have:
● Itching or irritation inside their penis
● A thin white discharge from the penis
● Dysuria and increased frequency of micturition
● Dyspareunia

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Mahadik
❖ Sensitive tests called nucleic acid amplification tests (NAATs) can also spot signs of the
parasite.
Trichomoniasis Diagnosis
Gram staining with vaginal/urethral swab and then culture

67. Prof. Rupali
Mahadik
Trichomoniasis Treatment
Antibiotic medications like-
Metronidazole - a single dose of 2gm or 500 mg 1 BD x 7 days
or
Tinidazole -single 2 g oral dose- 4 tablets taken at the same time -
clear up the infection in most people.
Both Partners have to treat at a same time

68. Prof. Rupali
Mahadik
Complications
❏ Trichomoniasis can increase the risk of getting or spreading other STI’s eg-
trichomoniasis cause genital inflammation that makes it easier to get infected with HIV
or transmit the virus on to a partner.
❏ Without treatment infection can last for months or years- can cause chronic
inflammation leading to Cervical cancer in Women and Prostate Cancer in Men.
❏ Pregnant women with trichomoniasis are more likely to have preterm delivery with low
birth weight babies

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Mahadik
Viral
Sexually Transmitted Infections

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Mahadik
Human Papillomavirus (HPV)
• HPV is so common that almost all sexually active men and woman get
it at some point in their lives
• HPV could take years for someone to notice they have it.
• It usually goes away, but if it doesn’t it causes genital warts or
cancer.
• You can get vaccines at the ages 11 and 12 and is recommended to
get another one at age 21.

71. Prof. Rupali
Mahadik
Group of non-enveloped DNA viruses
❏ Specifically infect human epithelial cells.
❏ There are over 100 different types of HPVs which can be categorised by the
epithelial cells they prefer to infect.
1. Cutaneous epithelial cells of the skin-the face,hands & feet
2. Epithelial cells of Mucous membranes-
• Respiratory tract including the pharynx ,nasal & Oral cavities
• Anal & Genital regions
❏ Some types can cause BENIGN TUMORS called Papillomas or Warts.
❏ some can lead to CARCINOMAS or Cancer of Epithelial Cells.
Human Papillomavirus -HPV

72. Prof. Rupali
Mahadik
Epithelial cells
• Lines the outer surfaces of organs & blood vessels & separate interior of the body
from external world and primarily serve as a protective barrier to invasion by
pathogenic bacteria, fungi, viruses,parasites and water loss.
● In locations like skin,anus,genitals &
respiratory tract they can be stratified
having more than 1 layer of epithelial
cells.
● At the base called Basal cells are well
protected under all those layers .

73. Prof. Rupali
Mahadik
HPV causes uncontrolled cell growth of epithelial cells
Skin to skin contact - if there are cuts/abrasions in the epithelium
HPV
can gain
access to &
infect the
basal cells.
causing
WARTS &
LESIONS
in some types of HPV infections
causes abnormal epithelial cells
Koilocytes -
precancerous lesions
when these abnormal
epithelial cells invade
other tissues
Carcinoma

74. Prof. Rupali
Mahadik
Symptoms
(cutaneous)
• many HPV are Asymptomatic
• vary depending on HPV Type
• non-Genital cutaneous infections involve some kind of Benign Wart.
• Chronic Cutaneous infection can start out as flat Warts Skin Cancer

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Mahadik
Symptoms
(mucous membrane)
• Anal & Genital infections -
can involve numerous warts called Condyloma Acuminata
-tend to be a skin -coloured , range in size & have Cauliflower-
like look to their surface- typically painless, can cause itching
,burning ,local pain or bleeding.
• Infection in Upper Respiratory Tract-
causes respiratory papillomatosis-voice changes & High Pitched Breath sounds if
Larynx is infected.

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Mahadik
❖ HPV types 6 & 11 are responsible for majority of laryngeal papillomatosis
& Genital Warts -considered low risk because they don’t tend to progress
beyond Warts.
❖ HPV types 16 & 18 considered high risk are responsible for transforming
into cancers of cervix, vagina, vulva, penis,anus or upper respiratory tract
over one or two decade.

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Mahadik
Diagnosis
- Endoscope may be needed - infection of Upper
Respiratory Tract is suspected.
- Regular PAP or Acetic acid tests of cervix after 21 yrs
old are recommended even if symptoms are Sub-
clinical.
❖ Definitive diagnosis of HPV cannot be made without Molecular testing of Biopsied
cells for Viral DNA or RNA
• Warts are used to diagnose HPV particularly in Cutaneous infection.
• Infections of mucous membrane may require additional interventions to
visualise the epithelial cells

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Mahadik
Treatment
● Removal of Warts & precancerous lesion
● with frequent re-occurrences, immune modifiers may be used to boost the immune system to
remove the infection on its own
● most HPV infections can resolve on their own overtime, particularly low risk types & in
younger people
Salicylic acid
products
liquid nitrogen
cryotherapy
laser removal surgical removal

79. Prof. Rupali
Mahadik
❖ Prophylaxis against infection is the best course
- limiting contact with HPV potentially infected persons.
- condom use can also be used as a preventable measure.
- receiving the HPV vaccine before 1st exposure to an infection source can be
protective against several strains including high risk type 16 & 18
❖ so in short treatment ranges from allowing the immune system to clear the
infection or mechanical/chemical removal of infected cells

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Mahadik
Why HPV Vaccination?
• Globally-528,000 new cases
• India- 122,800
• 23% of the global burden is in India.
• 90% of Genital Warts in young boys and girls are caused by HPV 6 & 11 (Low risk
Types)

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• These are the chances of high risk- cancers where HPV is
associated or responsible for-

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Mahadik
Which are the available vaccines?
Globally three vaccines available-
• Bivalent vaccine (Cervarix,GSK Biologicals,Belgium) targets HPV 16 & 18
• Quadrivalent vaccine ( Gardasil, Merck,USA) targets HPV 16,18,6 & 11
new vaccine-
• Nonavalent vaccine or 9- valent vaccine (Gardasil-9,Merck,USA) targets
HPV 31,33,45,52 & 58 in addition to HPV 16,18,6 & 11 (FDA approved 2015)
Doses-
*2 dose schedule- for both girls and boys between age 9-14 yrs with 6-12 months gap from 1st dose.
* 3-dose schedule is recommended for people who gets the 1st dose on or after 15th year, and for people
with certain immunocompromising conditions- a 3-dose series, the second dose should be given 1–2
months after the first dose, and the third dose should be given 6 months after the first dose (0, 1–2, 6-month
schedule)

83. Prof. Rupali
Mahadik
Common sites of infection in female

84. Prof. Rupali
Mahadik
Common sites of infection in male

85. Prof. Rupali
Mahadik
Symptoms Possible cause
Discharge from the penis—pus, clear or yellow-green drip
Commonly: Chlamydia, Gonorrhea
Sometimes: Trichomoniasis
Abnormal vaginal discharge or
pain during sex
Chlamydia, Gonorrhea, PID
Burning or pain during urination Chlamydia, Gonorrhea, Herpes
Lower abdominal pain or pain during sex
Chlamydia, Gonorrhea, PID
Swollen and/or painful testicles Chlamydia, Gonorrhea
Itching or tingling in the genital area
Commonly: Trichomoniasis
Sometimes: Herpes
Blisters or sores on the genitals, anus, surrounding areas, or
mouth
Herpes, Syphilis, Chancroid
Warts on the genitals, anus, or surrounding areas Human papillomavirus
Unusual vaginal discharge—changes from normal vaginal
discharge in color, consistency, amount, and/or odor
Most commonly: Bacterial vaginosis,
Commonly: Trichomoniasis
Sometimes: Chlamydia, Gonorrhea

86. Prof. Rupali
Mahadik
• STI should be diagnosed through a process of obtaining the-
Medical and sexual history, Physical examination and Laboratory testing
• History taking- a medical and sexual history and assessing the risk of STIs;
History-taking, especially personal sexual history, is important in understanding the likelihood
that the person has an STI. During history-taking, the person should be asked about the last sexual contact and
sexual contacts before that and their sexual practices, including penilevaginal, penile-anal, oral sex, use of sex
toys and others and whether any protection, such as a condom, was used consistently.
• Performing a physical examination- including abdominal and pelvic examination, to assess for pelvic
inflammatory disease, surgical conditions or pregnancy and external vulvovaginal examination to visualize any
lesions, overt genital discharge or vulval erythema and excoriations
• laboratory testing - of relevant specimens from either the lesion, blood or urine

87. Prof. Rupali
Mahadik
Features Bacterial vaginosis candidiasis Chlamydia/Gonorrhea Trichomoniasis
color &
consistency
(raw egg white)
watery -greyish
sticky and heavier than
usual but homogeneous
frothy
curdy, white or creamy
and thick.
sometimes cottage-
cheese
yellowish vaginal discharge/ pus like
discharge
yellow or greenish and may be
frothy.
infection more likely in older women
ph (<4.5) > 4.5 grows well at a pH of 6
odour(no odour)) Fishy odor lack of odor unpleasant strong
pruritis
(no pruritis)
- +++ most prominent redness and swelling of the genitals,
and a burning or itching of the
vaginal area/penis
++
vulva and vagina no soreness vulva and vaginal
soreness or irritation.
vulval / vaginal erythema
cervix p/s-pooling of vaginal
discharge
The cervix may have punctate
haemorrhages, “strawberry cervix
other features
(its normal
cleansing of body
governed by
hormones)
pain
dysuria
dyspareunia and dysuria dysuria,dyspareunia,
intermenstrual
bleeding,bleeding after
intercourse
heavy periods, lower abdominal
pain
sometimes fever
dysuria,dyspareunia,
bleeding after intercourse
Vaginal Discharge

88. Prof. Rupali
Mahadik
Genital Ulcers
Features Syphilis LGV (lymphogranuloma
Ven
Granuloma inguinale Genital herpes Chancroid
Appearance single
well circumscribed
Hard chancre
small & Shallow
Buboes
Extensive
Base:-Granulation
tissue
bleeds on touch
multiple Shallow
vesicles
(red base)
Base -Erythematous
multiple deep ragged
edges
(greyish base )
Soft chancre
Pain- ulcer
LN
ulcer -painless
LN enlargement -painless
Bilateral
ulcer -painless
LN enlargement -
painful
ulcer -painless
no ——
Lymphadenopathy-
ulcer -painful
mild
Lymphadenopathy
Bilateral
ulcer -painful
LN enlargement -
painful
Unilateral
+
Cause Treponema Pallidium Chlamydia trachomatis Klebsiella
Granulomatis
(Donovanosis)
Herpes Simplex Virus Haemophilus ducreyi
( do Cry)
other unique
features &
treatment
treatment- Penicillin
if allergic to penicillin
a) doxycycline
b) desensitize and then
treat
-in pregnant
-CNS involvement
a) tertiary syphilis-
Ceftriazone
Grooves Sign
Genital Elephantitis,
Sclerosing Fibrosis
treatment-
Doxycycline
Donovan Bodies
Gram
intra cytoplasmic cysts
treatment-
Doxycycline
-Cowdry type A
-multinucleated giant
cells
treatment-
Acyclovir
Clumps of Bacteria
treatment-
Azithromycin
—

89. Prof. Rupali
Mahadik

90. Prof. Rupali
Mahadik
Health education and counselling
The key messages to give during an encounter with a person seeking care for STIs is to
educate them-
• how the infection may have been contracted,
• how to prevent future infections and
• the importance of completing a course of treatment and abstaining from further sexual
intercourse until treatment has been completed and the infection has been controlled or cured.
• However, patients should also be strongly advised to use condoms if abstinence from sex is not
possible
• Go for an vaccination when recommended.

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Mahadik