What Are Sexually Transmitted Infections?
Sexually transmitted infections (STIs) are infections that are primarily or solely transmitted by sexual contact with an infected person. Many STI infectious organisms enter the body through mucosal membranes of the genitals, through oral contact with the mucosal membranes of the genitals or anus, and through open sores on, or in the region of, the genitalia. Some sexually transmitted diseases can be transmitted by body secretions as well.
Sexually Transmitted Infections:
- Herpes simplex I and II
- HIV and AIDS
- Hepatitis B & C (not exclusively sexual in transmission)
- HPV–human papilloma virus causing cervical cancer and genital warts
- Trichomoniasis vaginal protozoan infection.
- Bacterial vaginosis (not exclusively sexual in transmission)
- Molluscum contagiosum.
- and others (tuberculosis, lymphogranuloma venereum, etc.)
Complications from Sexually Transmitted Infections:
- Abdominal pain
- Severe febrile states
- Infertility and permanent sterility
- Ectopic pregnancy
- Perinatal and neonatal transmission
- Malignancy (from hepatitis cirrhosis: hepatic cancer; and HPV: cervical and throat cancer)
- Psychological impact: guilt, shame, depression
- Sociological impact: separation, divorce, and crimes of passion
- Pelvic adhesive disease with abdominal pain and obstruction
- Sepsis intra-abdominal abscess, and death
Herpes simplex virus (HSV) is very communicable. Although the skin lesions come and go, the virus continues to reside in the dorsal root ganglion of the nerves at the spine. Whatever area of the skin is innervated by this nerve will be the area where eruptions of very painful blisters will occur. It cannot be cured, but episodes of eruptions can be made less frequent and the severity lessened by treatment with antivirals such as acyclovir and valacyclovir. HSV can be passed on to an infant at delivery, which can be life-threatening to the newborn.
Different Human Papilloma Virus (HPV) strains cause cervical and throat cancer and/or genital warts, depending on which type one contracts–usually by direct skin-to-skin contact, oral relations, and vaginal or anal intercourse.
Bacterial vaginosis, which can develop without sexual contact, can also be acquired by intercourse. The majority of cases have no symptoms, diagnosed incidentally at the time of a routine GYN visit. Treatment is with antibiotics or antibiotic vaginal cream. When symptomatic, a vaginal discharge is noted.
Trichomonas: infection with a protozoan, which can lead to preterm labor in pregnancy, and vaginal discharge, spotting, and pain in non-pregnant women. Treatment is with antibiotics.
Chlamydia: this is a bacterium that infects men and women, often without symptoms, causing infertility years later in women. Symptoms of it can include pain, burning with urination, painful intercourse, and fever. It is diagnoses with a culture and treated with antibiotics. Untreated, it can cause adhesions in the female reproductive tract that can cause ectopic pregnancy or infertility.
Gonorrhea: this is almost always symptomatic with a purulent discharge from the vagina or penis and severe dysuria (pain with urination). In the woman, it can rise into the pelvis to involve the uterus (endometritis), Fallopian tubes (salpingitis), and ovaries–tubo-ovarian abscess. Untreated, it can lead to life-threatening sepsis or it can even burn itself out, leaving adhesions that cause ectopic pregnancy or infertility.
Syphilis comes in three waves of presentation:
- Painless ulceration at the site of contact with an infected person, usually on the vulva in the woman or the penis or scrotum of a man. This is called Primary Syphilis and the ulcer goes away spontaneously.
- A rash on the palms of the hands and soles of the feet, although it can occur elsewhere as well. This is called Secondary Syphilis and its rash goes away spontaneously.
- Tertiary Syphilis is central nervous system involvement, leading eventually to ataxia (uncoordinated movements), delirium, and death.
HIV/AIDS: The Human Immunodeficiency Virus is the cause of Acquired Immune Deficiency Syndrome. The previous 100% mortality has been significantly reduced. Currently the virus is treated and often kept in check at the HIV stage, followed by a count called the “viral load.” Patients infected have an impaired immune system that can make other infections and malignancy more likely.
Hepatitis: Hepatitis B and C can manifest as mild involvement of the liver all the way to hepatic failure and death. Also, hepatitis can lead to liver cancer. Jaundice in the absence of alcoholism can occur.
The most common cause of ectopic (tubal) pregnancy is an STD, with both gonorrhea and chlamydia being the most frequent offenders.
Pelvic Inflammatory Disease, or “PID,” is a general term for infected pelvic organs from any STD, such as gonorrhea or chlamydia. It is associated with generalized pelvic pain and tenderness and a purulent vaginal discharge.
How Are Sexually Transmitted Infections Diagnosed?
Diagnoses of some STIs are difficult. Chlamydia is asymptomatic and the mild symptomatology of syphilis in its early stages insidiously progress to cognitive impairment. Hepatitis may not be apparent without testing until there is impairment of hepatobiliary function. The rest of the STIs in general present with painful or disturbing signs and symptoms that prompt patients to seek care:
Herpes is exquisitely painful. The notoriety of HIV has raised a public sensibility toward testing after any unprotected sexual encounter. Trichomonas and bacterial vaginosis, in women, cause vaginal discharge, odor, and discomfort. Genital warts and molluscum contagiosum cause skin lesions that are innocuous but cosmetically disturbing and psychologically upsetting.
50% of those with an STI have an additional STI or more. For this reason, those at risk are screened for the elusive Chlamydia, syphilis, HPV, and hepatitis diagnosis whenever a patient is tested for any of the others.
The “exposure” panel for STIs include the following:
- HPV: Pap smear and HPV DNA testing in women for human papilloma virus. HPV in the cervix of women is tested as to its HPV “type,” as some cause cervical cancer while others only genital warts (condylomata).
- Trichomonas and bacterial vaginosis: A microscopic evaluation of vaginal and/or penile discharge.
- Chlamydia and gonorrhea: Cultures from the urethra and anus in men and the urethra, cervix, vagina, vaginal glands, and anus of women.
- Syphilis: A blood test that serves as a screen, and if positive, definitive antibody blood testing.
- Herpes simplex I and II: Cultures directly from the lesion.
- Hepatitis B and C: Blood work for the hepatitis antigens.
- Molluscum contagiosum: Simple inspection of the classic structures of this infection.
When patients present with later stages of an STI, advanced diagnostics are used. For example, gonorrhea spreading to the joints can be determined by joint fluid aspiration of a swollen, inflamed joint. Intra-abdominal cultures are possible during surgery for ovarian abscesses or infertility due to chlamydia or gonorrhea.
How Can I Manage Sexually Transmitted Infections?
Management and treatment of STIs depend on the infectious organism:
- Herpes simplex I & II: Oral antivirals (acyclovir, valcyclovir, and others) will not eradicated the HSV but will limit the frequency of outbreaks and reduce their severity.
- HIV and AIDS: Treated with antiviral regimens and symptomatic support, respectively. Effectiveness of treatment is quantified by blood tests for “viral load” response.
- Hepatitis B: Untreated, hepatitis B leads to liver failure, cirrhosis, and increased risk for liver cancer. Treatment with antivirals is begun depending on the presence of cirrhosis and HBV antibody levels. Resistance and breakthrough make hepatitis B very dangerous even with treatment. Counseling is advised to instruct patients on how to delay further liver damage by the avoidance of alcohol and having a hepatitis A vaccination.
- Hepatitis C: Untreated, hepatitis C becomes a chronic hepatitis which can involve the kidneys, skin, thyroid, and has been associated with the development of diabetes. State-of-the-art antiviral regimens have logged an excellent success rate in treating hepatitis C.
- Gonorrhea, Chlamydia, and syphilis: treatment is by antibiotics, with diagnostic tests after treatment to document a “test of cure.”
- HPV: Human papilloma virus may never cause a problem, but it can cause cervical cancer, metastatic disease, and death if untreated in women. Cigarette smoking is considered a co-carcinogen in this process. HPV disease also may stop progressing in the dysplasia (pre-cancerous) stage. This allows women with early disease to be followed conservatively via observation (colposcopy–magnified views of the cervix) and colposcopically-directed biopsies as outpatients. More advanced lesions and carcinoma-in-situ can be destroyed via excision, cryosurgery, or laser ablation.
For genital warts, an immunological cream (imiquimod) can be used to enhance the immune response against the virus. They can also be destroyed via chemical (painted podophyllotoxin) or electrical cautery. Excision and laser vaporization are additional options. All of these methods have a high failure and/or recurrence rate if the HPV in the cervix is not eradicated.
● Trichomoniasis and bacterial vaginosis: Treated with oral antibiotics (men and women) or antibiotic suppositories or vaginal cream in women.
● Molluscum contagiosum: These small, harmless, solid, raised papules are simply scraped off of the skin. Repeated sessions are necessary to catch lesions that are missed initially.
A crucial part of any treatment includes follow-up for a “test of cure” in the bacterial and syphilis infections, repeat Pap smears and colposcopy for surveillance of previous HPV infections, and serial determinations of viral load for HIV and hepatitis.
How Can I Prevent Sexually Transmitted Infections?
Abstinence is the only guaranteed method of STI prevention. Aside from that, prevention depends on two approaches:
- Barrier methods.
- Scrupulous sexual partner selection and avoidance of high-risk sexual behaviors, such as promiscuity, multiple sex partners, drug abuse (which can also cause hepatitis B and C and HIV/AIDS).
Condom use by men, although not guaranteed and the success of which depends on the correct implementation of it, offers the advantage of an immediate protective measure in unpredicted intimate encounters. A “female” condom is also available, but it is difficult to find and is cumbersome enough to discourage its use. The female diaphragm offers no protection from STIs, nor do other contraceptive methods such as hormonal birth control pills, injections, IUDs or implants.
Sexual intimacy, traditionally and formally, entails a special physical bond within committed couples and a method of reproduction. The physical reward of instant gratification and the hormonal drive in humans, especially the young, also make it a recreational activity.
The more sexual partners one has, the more likely one or more STIs will be contracted. Other conditions also raise risk, such as:
- Adolescence with the associated sense of invulnerability,
- Brief sexual relationships and casual sex
- Inconsistent condom use
- Sequestered young persons at risk, such as detention centers, rehab units, etc
- Drug abuse
The short-term benefit does not balance the long-term risk of promiscuity or unprotected sexual activity, which include expense, pain, infertility, and risk to life from immunological or neurological complications, or malignancies. Prevention is guaranteed with abstinence, but otherwise relies upon avoidance of high-risk activities, scrupulous barrier methods, and a high threshold for selection choice of sexual partners.