Sexually Transmitted
Diseases
Introduction
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.
Guidelines
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.
Common Sexually Transmitted
Diseases
Ulcerative diseases See the Genital Ulcer
Chapter for herpes, syphilis, etc.
Urethritis (Non-gonococcal)
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
Treatment options
Chlamydia
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
-
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
Trichomoniasis
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
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:
-
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
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.
Prepared by CAPT Kathleen Fischer, MC, USN, Naval Medical Center San Diego.
*Algorithms developed by CAPT Bill Berg, CAPT Kathleen Fischer, CDR Bill Redmond, and LCDR
(ret) Gail Regan. Review and revisions by LCDR Jeffrey Quinlan, MC, USN, Naval Hospital
Camp Pendleton, CA (1999).
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Preface
· Administrative Section
· Clinical Section
The
General Medical Officer Manual , NAVMEDPUB 5134, January 1, 2000
Bureau
of Medicine and Surgery, Department of the Navy, 2300 E Street NW, Washington, D.C.,
20372-5300
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web version of The General Medical Officer Manual, NAVMEDPUB 5134 is provided by
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material in this version is unclassified. This formatting © 2006
Medical Education Division,
Brookside Associates, Ltd.
All rights reserved.
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