General Medical Officer (GMO) Manual: Clinical Section

Sexually Transmitted Diseases

Department of the Navy
Bureau of Medicine and Surgery

Sexually transmitted diseases (STDs) are the most frequently reported category of communicable diseases in the U.S., and are an ongoing problem in military populations. Prevention and control of STDs is based on five major concepts:

• Education for those at risk can help modify sexual behaviors that place them at risk (primary prevention).

• Detection of asymptomatic infections (secondary prevention).

• Effective diagnosis and treatment of those who are infected.

• Notification and treatment of sex partners.

• Provide pre-exposure vaccination against vaccine preventable STDs (Hepatitis B).

Risk reduction counseling

In addition to interrupting transmission by treating persons with bacterial STDs, clinicians have the opportunity to provide education and counseling to help patients change sexual behaviors that place them at risk. Many studies show that physicians do not feel adequately trained in sexual history taking and therefore counsel infrequently. Underestimation of patients' risk behaviors is also a factor. Twenty-five percent of all personnel in the Navy have had an STD at least once. Less than 50 percent of sexually active unmarried Navy personnel used a condom at their last sexual encounter (even among those with multiple partners). During overseas deployments, personnel continue to report having multiple sexual contacts with prostitutes. The need for effective risk-reduction counseling is critical. As a GMO, you should be prepared to provide this information, both as one-to-one counseling and during general military training for your command.

The following text and the attached algorithms provide a guideline for signs, symptoms, and treatment of the most common STDs as well as an outline for the diagnosis of the most common STD syndromes. Based on BUMED and Centers for Disease Control and Prevention (CDC) guidelines, these algorithms should help you make a presumptive diagnosis for most patients. Additional tests add little to the diagnosis except expense and delay. Current guidelines for treatment of STDs are contained in the CDC publication Sexually Transmitted Diseases Treatment Guidelines; you can obtain a copy from the CDC by calling the Voice Information System at (404) 639-1819. Navy-specific changes to these guidelines are detailed in BUMEDINST 6222.10.

• All STD patients must be interviewed to obtain epidemiological information on sexual contacts to ensure appropriate contact tracing. Local preventive medicine personnel can provide guidance.

Background/Signs

• Characterized by mucopurulent or purulent discharge

• Greater than or equal to 5 WBCs/High Power Field should be seen on gram stain

• A leukocyte esterase positive result is typically seen on the first morning, voided urine.

Testing

• gram stain of discharge should be done looking for gram negative diplococci

• Culture or DNA testing for gonorrhea and chlamydia

Treatment options

• Azithromycin 1 gram as a single dose OR

• Doxycycline 100 mg BID for 7 days

Background/Signs

• Asymptomatic infections are common in both males and females.

• Symptomatic individuals have a mucopurulent discharge from the urethra or cervix.

• Sexually active females in their teens and twenties should be screened during their annual exam.

• Screening should be aggressive since sequelae are harmful (PID, transmission to fetus, etc).

• A sample is obtained with sterile cotton tipped applicator from either urethra (male) or cervical canal (female). Place this sample in the appropriate media.

Treatment Options

• Azithromycin 1 gram as single dose

• Doxycycline100 mg BID for 7 days

• Erythromycin 500 mg QID for 7 days

• Erythromycin ethyl succinate 800 mg QID for 7 days

Gonorrhea

Background/Signs

• There are at least 600,000 new infections per year in the United States.

• Most males are symptomatic; many infections in females are asymptomatic.

• Symptomatic patients have purulent discharge from the urethra or cervix.

• A high frequency of co-infection can occur with chlamydia. When gonorrhea is diagnosed, treat the patient for gonorrhea and chlamydia simultaneously.

• Testing is done with sterile cotton tipped applicator from either urethra or cervical canal then plated on appropriate agar or media.

Treatment Options

• Cefixime 400 mg by mouth as single dose

• Ceftriaxone 125 mg IM as single dose

• Ciprofloxacin 500 mg by mouth as single dose

• Ofloxacin 400 mg orally as a single dose

Bacterial Vaginosis

Background/Signs

• Most prevalent cause of vaginal discharge

• Clinical criteria requires 3 of the following 4:

• Homogeneous, white discharge that smoothly coats the vaginal walls.

• Clue cells seen on microscopic examination.

• Vaginal pH of >4.5

• Vaginal discharge with a fishy odor before or after addition of 10% KOH (whiff test).

Treatment options

• Metronidazole 500 mg BID for 7 days

• Clindamycin cream 2% one applicator per vagina QHS for 7 nights

• Metronidazole gel 0.75% one applicator per vagina BID for 5 days

• Metronidazole 2 grams orally as single dose

• Clindamycin300 mg BID for 7 days

Background/Signs

• Caused by the protozoan T. vaginalis

• Males are usually asymptomatic.

• In females, trichomonas infection usually causes a diffuse, malodorous, yellow green discharge with vulvar irritation.

• Diagnosis is made by seeing motile protozoan on a wet prep (T. vaginalis is approximately the same size as a WBC)

Treatment options

• Metronidazole 2 grams orally as single dose

• Metronidazole 500 mg BID for 7 days

Pelvic Inflammatory Disease

Background/Signs

• May refer to several inflammatory illnesses including endometritis, salpingitis, and tubo-ovarian abscesses.

• Symptoms may be subtle and difficult to diagnose.

• Minimum criteria:

• Lower abdominal tenderness.

• Adnexal tenderness.

• Cervical motion tenderness.

• Additional criteria (giving support to diagnosis):

• Temp > 101° F.

• Cervical or vaginal discharge.

• Elevated erythrocyte sedimentation rate.

• Elevated C-reactive protein.

• Laboratory evidence of gonorrhea or chlamydia.

Criteria for inpatient therapy

• Cannot rule out a surgical emergency (e.g. appendicitis).

• Pregnancy.

• No response to oral treatment within 48-72 hours.

• Patient cannot follow or tolerate oral medications.

• Severe illness, nausea, vomiting, or high fever.

• Tubo-ovarian abscess (TOA).

• Patient is immunocompromised.

• Patient has never been pregnant (questionable criteria).

Inpatient treatment options

• Cefotetan 2 grams IV every 12 hours OR Cefoxitin 2 grams IV every 6 hours AND Doxycycline 100 mg IV or PO every 12 hours.

• Clindamycin 900 mg IV every 8 hours AND Gentamicin 2 mg/kg IV loading dose, then 1.5 mg/kg IV every 8 hours.

Outpatient treatment options

• Ofloxacin 400 mg BID for 14 days AND Metronidazole 500 mg BID for 14 days

• Ceftriaxone 250 mg IM once AND Doxycycline 100 mg BID for 14 days

Final notes

CDC guidelines do not currently recommend "Tests of Cure" for any sexually transmitted disease if the above guidelines are followed for treatment. Always consider appropriate evaluation and treatment for ALL sexual partners. Always consider coinfection with other STDs including HIV and Hepatitis B.

• Female Routine Screening Algorithm

• Vaginal Discharge Algorithm

• Female Abdominal Pain Algorithm