Sexually Transmitted Diseases by John H. Dirckx, M.D. significant proportion of the modern practice of adult using condoms and avoiding high-risk behaviors such as anal gynecology and urology is devoted to the prevention, intercourse—and by limiting the number of sex partners. Adiagnosis, and treatment of sexually transmitted dis- The overall incidence of sexually transmitted infections eases (STDs), because of both the high prevalence of these has increased substantially during the past generation, and diseases and their almost exclusive involvement of the repro- some diseases have shown a marked increase. Several factors ductive systems in both sexes. have contributed to these changing statistics. The discovery in A sexually transmitted disease is any infectious disease the 1940s that penicillin could cure syphilis and gonorrhea and that is transmitted from one person to another through sexual the development during the 1950s of safe and effective oral contact, taking that phrase in its broadest sense. Venereal dis- contraceptives paved the way for the sexual revolution of the ease (VD), a synonymous term, has now largely fallen out of 1960s. Against a background of civil unrest, widespread drug use, as has the euphemism social disease. It is worth empha- abuse, and radical feminism, that revolution led to social sizing that the only thing all STDs have in common is their acceptance of sexual promiscuity, popularization of oral and mode of transmission. In other respects they vary widely anal sex, and definition of overt homosexuality as normal among themselves. The common tendency to lump them all behavior. together yields a biologically invalid concept that invites con- Other factors favoring sexual promiscuity have been the fusion and misunderstanding. legalization of abortion on demand, the decline of the family Although any infection that is capable of being transmit- as the basic unit of society, the widespread rejection of tradi- ted through sexual contact may be called an STD, that need tional faith-driven morality, and the increasing freedom and not be its only mode of transmission. While it is true, for mobility of young people. Sex education in elementary and example, that AIDS and hepatitis B are often acquired through secondary schools, designed to reduce illegitimate pregnancies sexual contact, nonsexual transmission through sharing of nee- and STDs, has in the opinion of some observers had the oppo- dles by IV drug abusers is also important in their epidemi - site result. ology. The diagnosis and treatment of STDs are rendered more All of the classically recognized STDs can be transmitted difficult by the reluctance of most people to discuss their sex- through vaginal intercourse. Most of them can also be trans- ual behavior with health professionals and by the refusal of mitted through oral-genital contact and anal intercourse, with many patients to believe that a sexual partner has become resulting oropharyngeal, anorectal, or systemic infection. infected by some third person. Diagnosis often demands alert- STDs affecting the skin (genital warts, genital herpes) or ness and a high degree of suspicion on the part of the health- transmitted through the skin (AIDS, syphilis) can be acquired care worker. History-taking must be searching but during intimate contact even though genital exposure is nonthreatening and nonjudgmental. Often the most suggestive avoided or a condom is used. point in the history is exposure to a new sexual partner within STDs are statistically more likely to occur in persons a month or so before the appearance of symptoms. under 25 years of age, in members of ethnic minorities, in In treating any patient with an STD, the physician must persons of low socioeconomic status, in persons with many reckon with two epidemiologic realities: the fact that at least sexual partners (especially prostitutes), and in sexually active one of the patient’s sexual partners (and possibly all of them) gay men (but not in sexually active lesbians). The incidence is also infected, and the statistical probability that a person of STDs is higher in urban areas. with one STD has other STDs. Failure to treat sexual partners The only absolute protection against acquiring an infec- prophylactically will lead to eventual reinfection of most tion through sexual contact is lifelong celibacy or maintenance patients. Moreover, unless both partners in a relationship are of a permanently and mutually monogamous sexual relation- treated at the same time, they may keep reinfecting each ship. In this context, the term sexual promiscuity is rigor- other, a phenomenon known as “ping-ponging.” Screening ously defined as “having more than one sexual partner in a tests—that is, tests for certain STDs in persons who do not lifetime.” Some degree of protection against STDs is afforded have symptoms of those STDs—are routinely performed on by practicing “safe (or safer) sex”—which basically means sexually active patients in a variety of healthcare settings. John H. Dirckx, M.D., Sexually Transmitted Diseases, The SUM Program Obstetrics/Gynecology Advanced Medical Transcription Unit, 2nd ed. ©2011, Health Professions Institute, www.hpisum.com In both sexes gonorrhea occasionally develops into a Because a woman infected with gonor- disseminated form with focal or widespread skin lesions, rhea may have only mild, nonspecific gen- arthritis, meningitis, or endocarditis. Oropharyngeal and rec- itourinary symptoms, or none at all, most tal forms of infection result from oral and anal sex. Gonorrhea cases of gonorrhea in women go untreated. can cause severe eye infection, resulting in blindness, in an infant born to an infected mother. As many as 20% of women with untreated The diagnosis of gonorrhea can be made by identification gonorrhea will eventually develop acute of gram-negative intracellular diplococci in a stained smear of salpingitis, also called pelvic inflammatory urethral discharge or of material obtained from the pharynx, disease (PID), due to spread of infection to endocervix, or rectum; by culture of such material on Thayer- Martin agar, which is designed to favor the growth of gono- one or both uterine tubes. cocci; or by DNA probe, whose sensitivity is markedly enhanced by polymerase chain reaction (PCR) and ligand chain reaction (LCR) technology. The sensitivity of laboratory Urethritis and Pelvic Inflammatory Disease: diagnosis, particularly in women, can be improved by doing Gonorrhea and Chlamydia rectal as well as cervical cultures, because even without a his- tory of anal intercourse, the organism often migrates to the Gonorrhea is an infection of genital mucous membranes rectum from a genital site of infection. or other tissues in either sex caused by Neisseria gonorrhoeae, The technique of obtaining material for testing is crucial. a gram-negative diplococcus. This disease has been known for Because organisms are intracellular, specimens must contain centuries and goes by the colloquial name of “clap.” mucosal cells, not merely mucus or pus. The presence of Physicians often refer to the causative organism as the gono- blood, including menstrual discharge, impairs the sensitivity coccus, GC for short, and that abbreviation frequently stands of molecular biology testing and requires culturing. Thayer- for the disease itself in medical slang. After an incubation Martin plates must be refrigerated for storage but warmed to period (interval between acquisition of infection and appear- room temperature before inoculation, and incubated in an ance of symptoms) of just 3-5 days, gonorrhea attacks the atmosphere of carbon dioxide. Screening for gonorrhea is rou- mucosal lining of the urethra in men and the urethra and endo- tine in STD clinics, in pregnancy, and in high-risk female cervical canal in women. patients undergoing pelvic examination for any reason. In men, gonococcal urethritis typically presents as a thick At one time gonorrhea could easily be eradicated with yellowish-green discharge with severe pain on urination. penicillin. During the 1970s, penicillin-resistant strains Complications of untreated gonorrhea in men include acute brought back from Asia by Vietnam War veterans became epididymitis (infection of the epididymis, part of the spermatic epidemiologically significant in the U.S. These organisms, duct system adjacent to the testicle) and chronic scarring of called PPNG (penicillinase-producing Neisseria gonorrhoeae), the urethra resulting in stricture formation. Even asympto- are similar to resistant strains of staphylococcus in being able matic inflammation of the male genitourinary tract associated to break down some penicillins (and some cephalosporins) by with gonorrhea can increase susceptibility to HIV infection. producing the enzyme penicillinase (now more often called Because a woman infected with gonorrhea may have only beta-lactamase because it inactivates the penicillin molecule by mild, nonspecific genitourinary symptoms, or none at all, breaking it at its beta-lactam ring). most cases of gonorrhea in women go untreated. As many as During the 1980s a second type of penicillin-resistant 20% of women with untreated gonorrhea will eventually gonococcus was recognized in several geographic clusters in develop acute salpingitis, also called pelvic inflammatory the U.S. Called chromosomally-mediated-resistant Neisseria disease (PID), due to spread of infection to one or both uter- gonorrhoeae (CMRNG), these organisms do not produce ine tubes. An acute attack of PID is more likely to occur