18 - Sexually Transmitted Diseases

Authors: Macfarlane, Michael T.

Title: Urology, 4th Edition

Copyright 2006 Lippincott Williams & Wilkins

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Chapter 18

Sexually Transmitted Diseases

The incidence, prevalence, and variety of sexually transmitted diseases have increased remarkably in recent years. These include the five classic venereal diseases (gonorrhea, syphilis, chancroid, lymphogranuloma venereum, and granuloma inguinale), together with urethritis, vaginitis, hepatitis, genital herpes virus, and acquired immunodeficiency syndrome (AIDS). Serious consequences of these diseases have also increased: spontaneous abortions, ectopic pregnancies, pelvic inflammatory disease, infertility, cervical carcinoma, and death. Additionally, 60% of patients who have one sexually transmitted disease have been shown to have another. In light of these facts, examination and treatment of all sexual partners are strongly recommended.

Nongonococcal Urethritis

Chlamydia trachomatis is believed to be the most common cause of nonspecific urethritis in males (followed by Ureaplasma urealyticum, Mycoplasma hominis, and Trichomonas vaginalis). It has a prolonged incubation of 5 to 21 days and produces a watery or mucoid, whitish discharge with or without dysuria.

Diagnosis

Diagnosis of nongonococcal urethritis requires exclusion of gonorrhea and demonstration of urethritis (Gram stain of urethral swab showing more than four polymorphonucleocytes per oil immersion field). Confirmation with chlamydial culture should be attempted.

Treatment

Azithromycin 1 g orally (PO) in a single dose, doxycycline 100 mg PO twice a day (bid) for 7 days, or ofloxacin (Floxin) 300 mg PO

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bid for 7 days is appropriate for chlamydia or U. urealyticum. If T. vaginalis is suspected, then metronidazole 2 g PO in a single dose or 250 mg PO three times a day (tid) for 7 days should be given.

Reiter's Syndrome

Reiter's syndrome is a rare complication of nongonococcal urethritis caused by C. trachomatis, which presents with arthritis, conjunctivitis, balanitis circinata, or keratodermia blennorrhagia.

Gonorrhea

Gonorrhea is caused by a gram-negative intracellular diplococcus, Neisseria gonorrhoeae. It has a short incubation of 2 to 8 days and most often produces a purulent, yellowish, urethral discharge with dysuria. (Up to 45% of males with gonococcal urethritis will also be infected with C. trachomatis.) Complications of gonorrhea in males include epididymitis, prostatitis, seminal vesiculitis, and urethral strictures.

Diagnosis

Diagnosis is based on a history of sexual contact, a purulent discharge with dysuria, and a positive Gram stain (intracellular gram-negative diplococci within polymorphonuclear leukocytes) and/or culture. The specimen for culture and the Gram stain must be carefully taken from within the urethra using a calcium alginate urethrogenital swab (Calgiswab) at least 1 hour after the patient last voided. A modified Thayer-Martin culture medium should be directly inoculated followed by prompt incubation. After culture inoculation, the swab should be rolled onto a clean microscope slide that is then air dried, heat fixed, and Gram stained. The presence of intracellular gram-negative diplococci makes the diagnosis. Routine urine cultures should also be obtained.

Treatment

Treatment should not await culture results even if the Gram stain is negative when suspicion is high. Appropriate regimens include ceftriaxone 250 mg intramuscularly (IM), ciprofloxacin 500 mg PO, or ofloxacin 400 mg PO. Chlamydia coverage is also recommended with doxycycline 100 mg PO bid for 7 days.

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Syphilis

The spirochete Treponema pallidum is the causative pathogen in syphilis. It usually gains entrance through the intact skin or mucous membranes of the penis. Syphilis has been called the great imitator because of its varied manifestations as it progresses through defined stages.

Primary syphilis is characterized by the chancre, a painless, shallow ulcer with indurated borders that appears 10 to 30 days following infection. It generally is solitary and lasts for 1 to 5 weeks.

Secondary syphilis is characterized by highly infectious macular papular or papulosquamous skin eruptions involving the palms and soles, the oral cavity, and the anogenital areas with generalized adenopathy.

Latent syphilis is without signs or symptoms of the disease; however, the spirochete has persisted in the body and has invaded all organs, most characteristically the cardiovascular and central nervous systems (e.g., tabes dorsalis). The patient remains potentially infectious for approximately the first 2 years of the disease.

Diagnosis

Identification of the spirochete by darkfield microscopic examination of fresh material from a chancre is diagnostic. Positive rapid plasma reagin test, which is replacing the VDRL (Venereal Disease Research Laboratory), is serologic evidence of syphilis. Serologic titers develop between 3 weeks and 3 months after infection. It is almost 100% positive in secondary syphilis. The fluorescent treponema antibody-absorption (FTA-ABS) test is the most specific and sensitive test available for syphilis.

Treatment

Benzathine penicillin G 2.4 10⁶ units IM in a single dose is the drug of choice for primary, secondary, or latent syphilis of less than 1 year. Doxycycline 100 mg PO bid or tetracycline 500 mg PO four times a day (qid) for 15 days is an alternative for penicillin-allergic patients.

Chancroid

Chancroid or soft chancre is caused by Haemophilus ducreyi, a gram-negative rod that enters abraded skin or mucous

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membranes, usually during coitus. It has a short incubation of 1 to 5 days and can spread by autoinoculation. Its clinical features are soft, painful, dirty, malodorous penile ulcers, often associated with tender, unilateral, matted inguinal adenopathy. Chancroid must be differentiated from syphilis, lymphogranuloma venereum, and granuloma inguinale.

Diagnosis

Diagnosis is often made clinically; however, attempts to culture the organism should be made despite the difficulty of doing so. A Gram stain smear from the base of the ulcer may show gram-negative coccobacilli in chains with a school of fish appearance.

Treatment

Ceftriaxone 250 mg IM once or erythromycin 500 mg PO qid for 7 days is effective. An alternative regimen is ciprofloxacin 500 PO bid for 3 days or trimethoprim-sulfamethoxazole DS (160/800) PO bid for 7 days. Fluctuant inguinal abscesses should be drained by aspiration rather than incision to avoid a chronic discharging sinus.

Lymphogranuloma Venereum

Lymphogranuloma venereum is caused by the obligate intracellular organism C. trachomatis and is acquired primarily during coitus. It has an incubation of 1 to 12 weeks, resulting in a painless primary papule, erosion, or vesicular lesion that heals quickly. Eventually, unilateral inguinal adenopathy appears with matted nodes fixed to the skin that will ultimately drain purulent exudate through multiple sinus tracts. Extension to deep perirectal pelvic nodes can result in proctitis and rectal strictures. Fistulae involving the rectum, bladder, and vagina can arise.

Diagnosis

Diagnosis is usually made on clinical grounds by exclusion of syphilis, chancroid, and granuloma inguinale or by culture of C. trachomatis. The Frei test is no longer used.

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Treatment

Doxycycline 100 mg PO bid for 21 days or tetracycline or erythromycin 500 mg PO qid for 3 weeks is recommended. Fluctuant lymph nodes should be drained by aspiration and not incision to avoid chronic draining fistulae.

Granuloma Inguinale

Granuloma inguinale is caused by the gram-negative rod Calymmatobacterium granulomatis, also referred to as Donovan's body. Its exact mode of transmission is unknown; however, it generally presents as a hypertrophic genital lesion with rolled, everted, and raised edges and has been associated with sexual contact. The pathologic lesion is the result of hypertrophic granulation tissue that bleeds easily and often involves the inguinal nodes. An association with squamous cell carcinoma has been noted.

Diagnosis

Diagnosis requires demonstration of Donovan's body, usually within large mononuclear cells, by Wright- or Giemsa-stained smears of scrapings or biopsy specimens. A biopsy must be performed to rule out carcinoma.

Treatment

Tetracycline or erythromycin 500 mg PO qid for 3 weeks or trimethoprim-sulfamethoxazole (one double strength PO bid) is the treatment of choice.

Condylomata Acuminata (Venereal Warts)

Condyloma acuminatum is a wartlike papilloma or cauliflower-like lesion of the skin caused by a human papillomavirus (HPV) and is transmitted by direct sexual contact. HPV is strongly associated with cervical cancer and cancer of the penis. The goal of treatment is removal of exophytic warts and resolution of signs and symptoms but not eradication of HPV. No therapy has been shown to eradicate HPV; thus, there is no benefit in treating patients with subclinical HPV infection.

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Presentation

Condylomata are typically found on the external genitalia but may also occur in the urethra. Patients with urethral involvement will often have visible lesions around the meatus. Hematuria and irritative symptoms, including frequency and dysuria, are common signs and symptoms suggesting intraurethral lesions in males with visible warts.

Diagnosis

Identification of visible lesions is straightforward. Biopsy and examination of the histopathology of larger lesions should be considered. Cystourethroscopy should be performed if intraurethral involvement is suspected. Use of 5% acetic acid painted on the external genitalia may show subclinical, flat condylomata appearing as whitish areas; however, the usefulness of this is unclear.

Treatment

Mucocutaneous condylomata acuminata are most common and are best treated by cryotherapy with liquid nitrogen or direct application of 10% to 25% podophyllin in tincture of benzoin or 50% trichloracetic acid (TCA). The podophyllin must be washed off within 6 hours to prevent serious irritation. TCA can be painful, and use of 5% lidocaine/prilocaine (EMLA) cream before application of TCA can be helpful. Excision with scissors and local anesthesia cream (EMLA) is a simple surgical option for small lesions. More extensive lesions can be managed by laser ablation. Less than 5% of patients will develop urethral disease, 90% of which will involve only the external meatus and distal penile urethra. If only a few lesions are noted within the urethra and none is circumferential, then excision or fulguration with a resectoscope or Bugbee electrode is appropriate. When extensive or circumferential areas of the urethra are involved, daily instillation of 5-fluorouracil cream (5% Efudex) with a cone-tip applicator for 7 days is recommended. Particularly severe or persistent cases may necessitate exteriorization of the urethra, for application of podophyllin, with a second-stage urethroplasty. (Podophyllin should not be used intraurethrally.)

The most frequent complication of all condylomata acuminata is recurrence or reinfection; 10% to 25% podophyllin in benzoin,

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TCA 50%, or bichloracetic acid should all be applied in the physician's office. Some questions have been raised about prolonged use of crude podophyllin and carcinogenesis.

Home Therapy

Podofilox gel (Condylox) is 0.5% podophyllin apply bid for 3 days/week for up to 4 weeks (do not use if patient is pregnant). Apply imiquimod cream (Aldara) at bedtime (qhs) for 3 days per week for up to 16 weeks.

Genital Herpes Simplex

Herpes simplex virus (HSV) infection occurs by direct inoculation of skin or mucosal surfaces. Two species of HSV exist: HSV type I (oral) and HSV type II (genital). Both can infect genital or oral regions. HSV travels up sensory nerve roots and establishes a latent infection in the dorsal root ganglion. Viral shedding occurs primarily from ruptured vesicular skin lesions but also can occur during asymptomatic periods.

Presentation

Primary infections will often have systemic symptoms including fever, headaches, malaise, myalgias, or lymphadenopathy. Urinary retention secondary to local pain or sacral radiculopathy is not uncommon. Recurrent infections are generally less severe and are manifested primarily by the characteristic skin lesions (grouped vesicles, erosions, and/or crusted lesions) lasting 4 to 15 days.

Diagnosis

Cytologic diagnosis by Papanicolaou smear demonstrating intranuclear inclusions or viral culture is most effective. The Tzanck cytologic smear of skin lesions is quick and effective when positive; however, a negative result should be followed up by direct immunofluorescence with anti-HSV antibodies. Serologic tests cannot prove active disease, only previous viral exposure. A negative serologic test rules out infection.

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Treatment

Oral famciclovir has replaced acyclovir. It is not virucidal or curative, but it does block viral replication and is clinically effective in treating primary and recurrent infections by decreasing their severity, frequency, and duration. Famciclovir 125 mg PO for 5 days is given tid for first episodes and bid for recurrences.

Acquired Immunodeficiency Syndrome

The urologist is unlikely to play a major role in managing AIDS; however, urologic consultations will occur. It is wise for all physicians to keep abreast of current information about this rapidly evolving disease.

Etiology

The etiologic agent in AIDS is the human immunodeficiency virus (HIV). The HIV retrovirus affects primarily the helper T lymphocytes (CD4+ T cells), causing depletion of CD4+ T cells and impaired immunologic function. HIV infection can produce a spectrum of clinical manifestations ranging from asymptomatic infection to severe immunodeficiency and neurologic disease. The virus is spread by sexual contact with an infected individual, sharing a contaminated needle, and receipt of infected blood or blood products and transmission from mother to unborn child.

Blood Transfusions

All blood is tested for the presence of anti-HIV antibodies by enzyme-linked immunosorbent assay (ELISA), and all units testing positive are discarded. ELISA was purposefully designed to be sensitive to minimize false negatives; however, this has resulted in a high false positive rate of up to 90%. ELISA positive units are tested by Western blot electrophoresis for confirmation of anti-HIV antibodies and detection of viral core or envelope antigens before notifying the donor. Unfortunately, transfusion-associated HIV infection from a seronegative donor can occur and has been reported. Patients undergoing surgery should be informed of the risk of AIDS. The use of autologous blood transfusion should be made available for elective surgery.