Clinical update in sexually transmitted disease –2014
ABSTRACTSexually transmitted diseases (STDs) and their associated syndromes are extremely common in clinical practice. Early diagnosis, appropriate treatment, and partner management are important to ensure sexual, physical, and reproductive health in our patients.
KEY POINTS
- Anyone can have an STD, although the prevalence is higher in some groups, such as younger sexually active people, certain racial and ethnic minorities, men who have sex with men, and people who engage in risky sexual behavior.
- Preexposure vaccination is one of the most effective ways to prevent human papillomavirus, hepatitis A virus, and hepatitis B virus infections.
- The risk of acquiring human immunodeficiency virus is two to five times higher if the patient has a genital ulcerative disease such as syphilis or herpes at the time of exposure.
- Chlamydia trachomatis and Neisseria gonorrhoeae are major players in urethritis, cervicitis, and proctitis.
- The most common conditions associated with vaginitis include bacterial vaginosis, trichomoniasis, and candidiasis.
CERVICITIS: CHLAMYDIA, GONORRHEA, OTHERS
Cervicitis is frequently asymptomatic, but signs on pelvic examination may include purulent or mucopurulent endocervical exudate and sustained endocervical bleeding easily induced by passage of a cotton swab through the cervical os.26
In most cases, the pathogen cannot be identified.49 When an organism is isolated, it is typically C trachomatis or N gonorrhoeae. Others that may cause cervicitis include the organisms responsible for bacterial vaginosis, T vaginalis, HSV, and possibly M genitalium.50
Diagnostic workup for cervicitis
Diagnostic workup for cervicitis should include microscopic evaluation of an endocervical specimen and testing for C trachomatis and N gonorrhoeae. A finding of leukorrhea (> 10 white blood cells per high-power field on microscopic examination of vaginal fluid) has been associated with chlamydial and gonococcal infection of the cervix.8 In the absence of inflammatory vaginitis, leukorrhea might be a sensitive indicator of cervical inflammation, with a high negative predictive value.
Nucleic acid amplification testing for C trachomatis and N gonorrhoeae can be performed on urine, endocervical, or vaginal swab specimens collected by the clinician or self-collected.51 The performance of C trachomatis nucleic acid amplification testing on patient-collected vaginal swab specimens has similar sensitivity and specificity to those performed on cervical and first-void urine samples.26,44,52
Women with cervicitis also should be evaluated for bacterial vaginosis and trichomoniasis, and if the organisms that cause these conditions are detected, treatment is advised. Microscopy has a low sensitivity (approximately 50%) for detecting T vaginalis; if the organism is not identified, further testing such as culture may be performed to exclude it as the pathogen.
Women with cervicitis should also be evaluated for clinical signs of pelvic inflammatory disease, including uterine, adnexal, and cervical motion tenderness, and fever.
Cervicitis can be treated presumptively
Women with cervicitis who should receive presumptive therapy include those at higher risk of chlamydial infection (ie, those with new or multiple sex partners, those age 25 or younger, and those who engage in unprotected intercourse, especially if follow-up cannot be ensured).8
Recommended therapy is either azithromycin 1 g orally in a single dose or doxycycline 100 mg orally twice a day for 7 days. The clinician should consider dual therapy to cover gonorrhea if the prevalence of gonorrhea is more than 5% (ie, in younger patients).8 If bacterial vaginosis or T vaginalis infection is diagnosed, these conditions should be treated at the time of clinical evaluation (see vaginitis section for more detail). For women in whom presumptive therapy is deferred, the results of diagnostic testing should guide appropriate treatment.
Repeat testing 3 to 6 months after treatment is recommended for all women diagnosed with chlamydia or gonorrhea,53 and all sex partners in the past 60 days should be referred for evaluation and receive treatment for the STDs for which the index patient received treatment. In states where it is allowed, patient-delivered partner therapy should be considered if the patient indicates her partner is unlikely to seek medical evaluation.
VAGINITIS: NOT JUST YEAST
Women with vaginitis may present with complaints of discharge, pruritus, or a bad vaginal odor. A careful medical history, including information on sexual behaviors and vaginal hygiene practices (ie, douching), should be conducted in addition to physical examination and diagnostic testing.
The most common conditions associated with vaginitis are bacterial vaginosis, trichomoniasis, and candidiasis. However, vulvovaginal candidiasis, most often caused by Candida albicans, is not transmitted sexually and will not be reviewed further here. Although bacterial vaginosis is associated with known risk factors for STDs (eg, new or multiple sex partners), the cause of the microbial alteration that precipitates it is not known.44 Co-infection with T vaginalis is extremely common.54
BACTERIAL VAGINOSIS: VERY COMMON
Bacterial vaginosis is the most common genital infection in reproductive-age women.55 It is a polymicrobial syndrome in which anaerobic bacteria (Prevotella and Mobiluncus species), Gardnerella vaginalis, Ureaplasma, and Mycoplasma replace the normal vaginal flora.
Diagnosis of bacterial vaginosis
Bacterial vaginosis can be diagnosed by clinical criteria or Gram staining. Clinical diagnosis requires three of the following clinical criteria proposed by Amsel et al56:
- Clue cells
- Vaginal fluid pH > 4.5
- Fishy odor before or after addition of 10% potassium hydroxide
- Thin, homogeneous, white discharge that smoothly coats the vaginal walls.
The clinical utility of PCR for diagnosing G vaginalis remains unclear, and culture is not recommended because it has low specificity. Gram staining can be used to determine the concentration of lactobacilli, small gram-negative or variable rods (G vaginalis and anaerobic rods), and curved gram-negative rods (ie, Mobiluncus species).
Treatment of bacterial vaginosis: Metronidazole or clindamycin
Treatment is recommended to relieve vaginal symptoms, with the potential benefit of reducing the risk of acquiring chlamydia, gonorrhea, and HIV and other viral STDs.8
Recommended treatment is with metronidazole 500 mg orally twice a day for 7 days, metronidazole gel 0.75% vaginal suppository once a day for 5 days, or clindamycin cream 2% vaginal suppository once a day for 7 days.44 A meta-analysis of several trials found that clindamycin and metronidazole have equivalent effectiveness for eradicating bacterial vaginosis symptoms.57 Accordingly, providers can consider patient preference, co-infections, and possible side effects when selecting a regimen. Alternative regimens include tinidazole or clindamycin orally or in vaginal ovules.
Women should be advised to refrain from sexual intercourse during treatment. Routine treatment of male or female sexual partners is not warranted.
Bacterial vaginosis commonly recurs, and limited data exist regarding optimal management of recurrences. Using a different treatment regimen may be an option in patients who have a recurrence; however, re-treatment with the same topical regimen is an acceptable approach for treating recurrent bacterial vaginosis during the early stages of infection.58 One study suggests that metronidazole for 7 days, followed by intravaginal boric acid for 21 days, and then, for those in remission, suppressive metronidazole gel for 16 weeks may be another option.59 For women with multiple recurrences, metronidazole gel twice weekly for 4 to 6 months has been shown to reduce recurrences, although its benefit may not persist after it is stopped. The therapeutic role for probiotics remains unclear.60
