GYN 12

• Sexually transmitted infections (STIs)


  Infections predominantly transmitted through sexual contact from an infected partner
• Other modes of transmission include placental, blood transfusion, infected needles, or inoculation into the infant's mucosa when it passes through the birth canal
• Gynecological morbidities associated with sexually transmitted diseases (STIs) are high
• Chronic pelvic infection, pain, infertility, ectopic pregnancy, vulvar, and cervical neoplasia are the long-term sequelae
• Transplacental infection (during pregnancy) to the fetus results in high perinatal morbidity and mortality
• There is rising trend of STIs throughout the globe
• With the improvement of diagnostic methods and increased interest on STIs, more and more diseases are included mostly of viral origin (HIV, hepatitis B and C, human papilloma virus)
• Important sexually transmitted diseases

  • Gonorrhea
  • Syphilis
  • Chlamydial Infections
  • Chancroid (Soft Sore)
  • Lymphogranuloma Venereum
  • Granuloma Inguinale (Donovanosis)
  • Bacterial Vaginosis
  • Herpes Genitalis
  • HIV and AIDS
  • Genital warts (Condyloma Acuminata)
  • Molluscum Contagiosum
  • Pediculosis Pubis
  • Scabies
• Reasons for rising incidence of STIs

  • Rising prevalence of viral infections like HIV, hepatitis B and C
  • Increased use of 'pill' and intrauterine contraceptive device (IUCD) which cannot prevent STI and there is an increased promiscuity and permissiveness
  • Lack of sex education and inadequate practice of safer sex
  • Increased rate of overseas travel
  • Increased detection due to heightened awareness
• Gonorrhea


  Caused by Neisseria gonorrhoeae, a gram-negative diplococcus, with an incubation period of 3-7 days
• Gonorrhea


  • The principal site of invasion is the columnar and transitional epithelium of the genitourinary tract
  • The organism may be localized in the lower genital tract to produce urethritis, bartholinitis, or cervicitis
  • Other sites of infection are oropharynx, anorectal region, and conjunctiva
  • Squamous epithelium is resistant to gonococcal invasion, so vaginitis in adult is not possible, but vulvovaginitis is possible in childhood
  • In about 15% of untreated cervicitis, gonococcal infection may ascend up to produce acute pelvic inflammatory disease (PID)
  • Rarely, it may produce septicemia with distant involvement to cause tenosynovitis and septic arthritis
  • Upper genital organs are involved as the infection spreads along the spermatozoa
• Clinical features of acute gonococcal infection

  • Local symptoms: Urinary symptoms, profuse non-irritating vaginal discharge, acute unilateral pain and swelling over the labia due to involvement of Bartholin's gland, rectal discomfort due to associated proctitis
  • Distant or metastatic: Perihepatitis, septicemia with low-grade fever, polyarthralgia, tenosynovitis, septic arthritis, perihepatitis, meningitis, endocarditis, and skin rash
• Acute pelvic inflammation leads to chronic pelvic inflammatory disease, unless adequately treated
• Complications include infertility, ectopic pregnancy (due to tubal damage), dyspareunia, chronic pelvic pain, tubo-ovarian mass, and Bartholin's gland abscess
• Diagnosis of gonorrhea


  Nucleic acid amplication testing (NAAT) of urine or endocervical discharge, Gram stain and culture of secretions from urethra, Bartholin's gland, and endocervix
• Treatment of gonorrhea


  1. Preventive: Adequate therapy for gonococcal infection and meticulous follow up, treat male sexual partner simultaneously, avoid multiple sex partners, use condom till both partners are free from disease

  2. Curative: Single dose regimen of ceftriaxone, azithromycin or doxycycline

  3. Follow up: Cultures 7 days after therapy, repeat monthly for 3 months
• Syphilis


  Caused by the anaerobic spirochete Treponema pallidum, transmitted through direct contact with open primary or secondary syphilitic lesion
• Primary syphilis


  • Incubation period 9-90 days, primary lesion (chancre) is single or multiple, usually located in the labia, fourchette, anus, cervix, or nipples, painless ulcer with raised margins and smooth shiny floor, inguinal lymphadenopathy
• Secondary syphilis


  • Occurs 6 weeks to 6 months after primary chancre, condyloma lata (coarse, flat-topped, moist, necrotic lesions), systemic symptoms like fever, headache, sore throat, maculopapular skin rashes on palms and soles, generalized lymphadenopathy, mucosal ulcers, alopecia
• Latent syphilis


  • Quiescence phase after secondary syphilis, serology positive without symptoms or signs, lasts 2-20 years
• Tertiary syphilis


  • Damages central nervous, cardiovascular, and musculoskeletal systems, cranial nerve palsies, hemiplegia, tabes dorsalis, aortic aneurysm, gummas of skin and bones
• Congenital syphilis is dealt with in the Textbook of Obstetrics
• Diagnosis of syphilis


  History of exposure, identification of Treponema pallidum, serological tests like VDRL, TPHA, FTA-Abs, EIA, immunoblotting, PCR
• Treatment of syphilis


  1. Early syphilis (primary, secondary, early latent): Benzathine penicillin G 2.4 million units IM single dose, or tetracycline/doxycycline for penicillin allergic cases

  2. Late syphilis (>1 year): Benzathine penicillin G 2.4 million units IM weekly for 3 weeks, or doxycycline
• Commended drugs in acute gonorrhea (CDC - 2015)


  • Ceftriaxone
  • Azithromycin
  • Doxycycline
• Alternative regimen for acute gonorrhea

  • Cefixime
  • Doxycycline
• Dosage for acute gonorrhea treatment

  1. 250 mg IM single dose

  2. 1 g PO once

  3. 100 mg PO BID x 7 days

  4. 400 mg single dose

  5. 100 mg PO BID x 7 days
• Treatment for conjunctivitis of the newborn

  1. Ceftriaxone 20-30 mg/kg IM single dose

  2. Gentamicin eye ointment 1%
• Treatment for early syphilis (primary, secondary, and early latent syphilis of less than 1 year duration)

  • Benzathine penicillin G 2.4 million units IM single dose
  • Tetracycline 500 mg PO 4 times a day for 14 days
  • Doxycycline 100 mg BID PO for 14 days
• Treatment for late syphilis (>1 year duration)

  • Benzathine penicillin G 2.4 million units IM weekly for 3 weeks (7.2 million units total)
  • Doxycycline 100 mg orally twice daily for 4 weeks
  • Tetracycline 500 mg orally 4 times a day for 4 weeks
• All women with syphilis should be tested for HIV infection and treated when found positive
• Sexual partners of women with syphilis should be evaluated clinically and serologically and treated presumptively
• Follow up for treatment of early syphilis


  Serological test at 1, 3, 6, and 12 months after treatment
• Follow up for treatment of late symptomatic syphilis

  Serological test annually for life
• Women with simultaneous syphilis and HIV infection may have high rate of treatment failure
• Chlamydia trachomatis


  Causative organism of chlamydial infections, an obligatory intracellular gram-negative bacteria
• Chlamydia has longer incubation period (6-14 days) compared to gonorrhea (3-7 days)
• Chlamydial infection


  • Affects the columnar and transitional epithelium of the genitourinary tract
  • Lesion is limited superficially with no deeper penetration, so pathological changes may not be apparent
• Chlamydial infection is mostly localized in the urethra, Bartholin's gland, and cervix, but can ascend upwards like gonococcal infection to produce acute PID
• Chlamydial infection is often (20-40%) associated with gonococcal infection