Sexually Transmitted diseases
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Assist. Prof. Dr. Adil A. Noaimi
Dept. of Dermatology &Venereology, College of Medicine, University of
Baghdad
Sexually Transmitted Disorder(STD):
Dealing with this subject in dermatology because of patient with
venereal diseases might present initially to dermatological clinics.
Veneral it means God of Venous (God of Love).
1
st
venereology includes: syphilis, gonorrhea, chancroid. Then many
diseases were added to this branch which not resulted from sexual
contact way. Still many other diseases added to this branch of medicine
affecting genital and urinary organs whether sexually transmitted or not
so called Genitourinary medicine which deal with:
These disorders include:
* Sexually transmitted diseases (STD).
*Sexual medicine.
* Skin diseases in genital area.
* Diseases of bladder and vagina (Vaginal problems, cervicitis, chancre
(syphilitic ulcer) problems.
* Prostate diseases.
*Disease of anus and anal canal.
*General testicular problems.
* Erectile dysfunctions, Sterility & infertility.
Causative organisms that are responsible for STD:
1- Spirochetes (Bacterial):
Mainly
Treponema Palladium which cause ordinary syphilis and
endemic syphilis (bejil).
Other bacteria:
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a- Niesseria Gonorrhoeae = gonorrhea.
b- Haemophilius Ducrey's = chancroid.
c-Donovania granulomatis =granuloma inguinale.
d-Chlamydia
Trachomatis=causes
LGV
(lymph
granuloma
veneleum), NSU (non speciefic urethritis)&Conjonctivites (trachoma).
e-Mycoplasma Hominis = post partum fever.
f-Ureaplasma Urealiticum = non-gonococcal urethritis.
g- Mycoplasma Genitalium = non-gonococcal urethritis.
h- Gardenella Vaginalis = Vaginosis.
* Shigella Species =shigellosis in homosexual individual.
* Campylobacter species = enteritis & colitis in MSM.
* Helicobacter = proctocolitis.
Note:
(MSM)=Men-Sexual-Men
causing
diseases
in
rectum
and anus.
2- Viruses:
* HIV =AIDS.
* Herpes Simplex Virus (HVS) = Herpes Simplex facials, Herpes
Simplex Genitalis.
* Human Papilloma Virus (HPV) =Venereal viral warts, laryngeal
papilloma, CA cervix, vaginal, vulvalar carcinoma.
* Hepatitis A, B & C Virus > acute, chronic active hepatitis in
MSM.
* Cytomegalovirus (CMV) =infectious mononucleosis.
* Pox Virus = Molluscum Contagiosum
*Human
T-cell
Lymphotrophic
Virus=Human
T-cell
Leukemia 1&2.
* Human Herpes= Kaposi's sarcoma.
* Body Cavity Lymphoma (castleman disease), Multiple
Myloma.
3- Protozoa:
* Trichomonas Vaginalis = vaginal trichomoniasis, non-gonococcal
urethritis (NSU).
* Entamoeba Histolytica= amoebiasis in MSM.
* Giardia Lamblia= giardiasis in MSM.
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4- Fungi:
*
Candida Albicans= thrush especially vaginal or oral.
5- Parasites:
* phthirus Pubis = pediculosis pubis.
* Sarcotopes Scabie= Scabies.
The Clinical Presentation of patient with STD:
It could be localized or generalized.
A- Localized Manifestations:
1- Pruritis:
-Many genital diseases whether STD or not can causes
itching and it's itching either localized to genital area or
generalized in additional to involvement of genital area).
Causes of itching:
a- Scabies:
* It usually STD but when it is epidemic it is mostly
not STD.
* Caused by direct contact.
* The patient had itching mainly at night (nocturnal itching)
and it is generalized.
* Any patient presented with itching we must exclude scabies
first before continuation of diagnosis.
b- Pediculosis Pubis:
قم
ل
العانة
* Mostly STD.
* Itching mainly in genital area.
* Caused by direct contact to infected person.
* Dx. by Rash: black spot which is (Nits) on hairy
area of the pubis which represent (Lice) which firmly
attached to the skin and we may see blood spots on
inner clothes which is blood in feces of lice.
c- Trichomonitis Vaginalis:
* Disease of females mainly.
* Presented with very severe genital itching with
profuse watery discharge.
* Males act only as carriers.
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d- Candida Albicans:
* Commonest cause of itching and vaginal discharge.
* In males (thrush of penis) which causes urethritis
and only thrush in adjacent area.
* In females causes severe itching and white thick
discharge from vagina.
* Normally Candida Albicans is in the lower third of
vagina but more in immune suppressive patients
(e.g. DM, steroids user).
e- Other Medical Problems Causes Itching:
* Contact Dermatitis of genital area.
* Lichen Planus.
* Psychogenic itching in female= vulva while in male=
scrotum.
* Psoriasis in both sexes.
2- Ulcer on Genitalia:
It is either in external or internal locations of genital organs.
*Syphilis (primary chancre): it is a rare disease but in Iraq relatively
common, presented by single painless not tender, indurated
button like, could be multiple, usually didn't bleed when
squeezing, self limited, not recurrent.
* Chancroid: painful, soft (soft chancre), usually bleed on
touching or squeezing, not indurated, multiple might
recurrent.
* Herpes: It is chronic dormant infection and difficult to eradicated.
It is commonest cause of genital ulcer all over the world (common in
patients with AIDS).
The patient presented with grouped vesicles that rupture easily to form
superficial ulcer for 7-14 days, then heal
spontaneously & recur again.
Commonly affect the shaft of penis, aroud vulva, around anus, vaginal,
intravaginal urethra, and intraurethral.
It's usually secondary infection to involvement of trigeminal ganglia
once the patient get stress or other infections ,fatigues the
microorganism transmit along the nerve roots to reach the
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genital area and causes ulcer, so it's recurrent apposite to
chancroid and primary chancre (syphilis ).
There is no cure, but we can induce recovery (usually ended
with recurrence).
In females during delivery might infect baby and causes
encephalitis that's why cesarean section in patient with HSV on
genitalia to avoid fetal infections.
It could be type 1 or.
* Herpes Simplex Genitalis (type 2).
* Herpes Simplex Hominis:
- Type 1 (labialis) on the lips.
- Type 2 (genatalis) on genetalia.
- Type 1&2 present as group of small blisters &
superficial ulcers, presented on shaft of
*Lymphogranuloma Venerium: not common in Iraq. the patient
presented with transient, small grouped vesicles similar to
HSV but healed within 2-3days and most of the patients not
presented to us with this problem but usually after months –
years had secondary or tertiary problems .After weeks they
may had enlargement of inguinal lymph nods (Groove
sign's)(bubo formation)(1
st
stage) then after months the
patient had anal or genital conditions like fibrosis. So,
primary presentation is rare.
* Differential diagnosis of Genital Ulcer:
1- Bechet's Disease: it is disease of male (Recurrent oral and
painless genital ulcer with other features like: recurrent
DVT, recurrent erythema nodosum, recurrent irritis, boil
orchitis…etc).
2- Trauma: (Zip-fasting trauma) produce an ulcer similar to
chancre.
*****Any ulcer in genital area syphilis should be excluded.
3- Mass on Genitalia or called papulonodular lesions:
* Venereal warts: caused by human papilloma virus, called also
(Condylomata Acuminate).
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Usually STD, involve males and females, shaft of penis, around
vulva, around anus, vaginal, intra-vaginal urethra, and intra-urethral.
Pigmented or may be grayish- whitish in color covered with
projections resembling cauliflower.
* Syphilitic Condylomata Lata: it occur the secondary stage of
syphilis as secondary rash appear in the moist ,worm area.
The mass are pale flat anemic smooth papules, if we take
smear or biopsy we see a lot of spirochetes inside
Condylomata Lata. Disappear when left without treatment or
when pass 3
rd
stage.
* Molluscum Contagiosum: It is STD in adults while commonly
seen on the face or neck of children (not STD).
Patient presented with shiny, grayish or whitish, pear-like, umbilicated
papule (depression in the center), caused by a pox virus.
When puncture it the cheesy material will come out which is
virus particle.
* Other causes: Lichen Planus, Psoriasis, Tumors and Cysts.
4- Discharge:
* Physiological: (saliva of sex) which is clear and not sticky.
We have 3 types of discharge:
* Urethral discharge: mainly male (not female because female
has short urethra.
- Gonococcal Gonorrhea (GC).
- Non-specific Urethritis (NSU).
- (E-Coli may cause gonorrhea picture so culture is the
solution).
-it can be differentiated from physiological discharge especially
in male which is mucous (clear mucous) similar to saliva so
called saliva of sex .in female such discharge with the same
circumstances called leucorrhea.
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* Vaginal discharge: in female especially
- Candidiasis (little discharge). Candida is a normal flora of
the lower 3
rd
of vagina so any change lead to pathological condition
=vaginal discharge which presented as itching, burning sensation and
thrush.
- Trichomonitis (tremendous discharge) in female white
discharge while in male is carrier.
* Rectal discharge: (MSM) burning, itching, tenismus, and
discharge dysentery-like picture (diarrhea). As in gonorrhea and NSU,
intra-rectal chancre, chancroid
* Oral discharge: in pharyngitis or tonsillitis with GC.
B- Systemic Manifestations:
Some diseases not present as genital manifestations but presented
by systemic manifestations. Like:
1- Secondary rash of syphilis: common in females because readily
women presented with chancre (hidden in cervix) so didn't
noticed until she developed 2ndry rash appear, while in male
the chancre is seen.
2- Jaundice (Hepatitis Virus): generalized itching of the skin and
yellowish discoloration as in hepatitis B virus transmitted
among MSM.
3-Intestinal worm (nematode) could be transmitted by MSM.
4- AIDS:
* 1
st
found could be in lung as Pneumonia (Pneumocystic
Carini) or generalized rash, diarrhea, encephalitis or tumor of the skin
(Kaposi's sarcoma).
* In Iraq: Kaposi sarcoma common among elderly people with
(Renal failure, DM, lymphoma, patients taking cytotoxic
drugs or steroid for long time, Immuncomprommized).
4- Disseminated Gonorrhea: sign and symptoms of septicemia as
arthritis (septic arthritis) and rash as small hemorrhagic
pustule and papule.
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5- Reiter's Disease: disease with NSU. The patient presented with
arthritis, urethritis (urethral discharge), eye problems (conjunctivitis)
and GIT problems,genital ulceration with ankylosing spondylitis.
* Urethritis
: could be gonococcal urethritis present with profuse
urethral discharge after short IP or Non-Gonococcal Urethritis
(NGU).
Causes of Non-Gonococcal Urethritis(NSU):
1- Bacterial:
* Chlamydia trachomitis (50%) other are: E.Coli, Klebsiella,
proteus, hemophylus vaginalis,mycoplasma .it is important to know the
cause of urethritis by using culture of discharge to prove that is GC or
not.
2- Protozoal:
* Trichomonitis characterized by urethral discharge. It present in 5-
10% of cases in male with long incubation period +mucoid discharge.
3- Viral:
* Herpes Simplex causes
*Viral warts.
Both locations were intraurethral
.
4- Fungal:
* Candidiasis in male may cause discharge
5- Chemical:
Common in obsessive persons who clean all body parts with irritant
detergents as detol.
6- stricture
: very rare cause urethritis.
7- Food and drugs allergy:
* Sulpha drugs by fixed drug eruption intraurethral.
8-Normal physiological discharge.
9- Idiopathic:
* 50% of Non-Gonococcal Urethritis also called (true non-specific
urethritis) and it is without obvious causes (30-40%).
Post-Gonococcal Urethritis:
or called double infections.
In this case the patient had gonococcal infection which appears after 2-
3days then treated with antibiotics .after few weeks came complaining
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from sign & symptoms of NS (mainly chlamydial or idiopathic) which
masked by gonococcal infection, so treat from the start GC and NSU.
In general the diagnosis of STD by the following:
1- Hx &examination.
2- Direct stain of swab.
3- Culture and sensitivity
4- Dark field microscopic examination for Treponema Palladium.
5- PCR.
6- Further investigative tools accordingly if needed.