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SEXUALLY TRANSMITTED DISEASES

The term sexually transmitted diseases (STDs) is used to describe disorders spread by intimate contact. Although this usually means sexual intercourse, it also includes close body contact, kissing, cunnilingus, anilingus, fellatio, mouth–breast contact, and anal intercourse. Many STDs can also be transmitted to the fetus in utero by transplacental spread or passage through the birth canal and via lactation during the neonatal period. The organisms involved are adapted to growth in the genital tract and are present in body secretions or blood. Having one STD increases the risk of coinfection with other STDs; therefore, full screening should be offered to all patients with a new STD diagnosis.

Physicians have a critical role in the prevention and treatment of STDs. The clinician’s role is to understand the microbiology of STDs in order to appropriately diagnose and treat patients. Treatment is aimed at alleviating symptoms and preventing future sequelae, as well as the prevention of transmission to others and providing appropriate patient education and counseling, as the mainstay of prevention is through lifestyle and behavioral modification. Multiple cohort studies have demonstrated the protective effects of both male and female condoms in the prevention of most STDs. Most treatment regimens detailed below are based on guidelines issued by the US Centers for Disease Control and Prevention (CDC).

VULVAR LESIONS & GENITAL ULCERS

Genital herpes, syphilis, and, less commonly, chancroid and donovanosis are the most prevalent genital ulcerative lesions in the United States. The diagnosis is difficult to make by physical examination alone. Thus, the work-up for all genital ulcers should include (1) serologic screening, dark field microscopy or polymerase chain reaction (PCR) testing for syphilis; (2) culture antigen testing or PCR for genital herpes; (3) serologic testing for type-specific herpes simplex virus antibody; and (4) culture for Haemophilus ducreyi in areas where chancroid is prevalent. More than 1 infectious etiology may be present in a single lesion. Biopsies can be helpful in cases of ulcers that are difficult to classify or when ulcerations do not respond to treatment. HIV testing should also be performed on all persons with genital, vulvar, or perianal ulcers without a known diagnosis of HIV.

HERPES SIMPLEX

ESSENTIALS OF DIAGNOSIS

  • Most commonly caused by HSV-2 but increasingly also caused by HSV-1

  • Painful genital ulcers

  • Chronic, lifelong, relapsing condition

  • Transmissible even in the absence of lesions

  • Antivirals improve symptoms, speed healing of lesions, and may decrease asymptomatic viral shedding

Pathogenesis

Genital herpes simplex virus (HSV) is a chronic viral infection cause by 2 types of virus: HSV-1 and HSV-2. Most cases of recurrent genital herpes are caused by HSV-2, and at least 50 million persons in the United States are infected with this type of genital herpes. However, an increasing proportion of genital herpes infections in some populations (eg, young women and men who have sex ...

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