Sexually Transmitted Infections (STIs) and Drug Medical Treatment

Introduction

Sometimes called the nation's "hidden epidemic," sexually transmitted infections, or STIs (also known as sexually transmitted diseases or STDs), frequently exhibit no symptoms. The United States has the highest rates of STIs in the industrialized world. According to the Center of Disease Control (CDC), the United States alone has an estimated 15 million new cases of STIs reported each year. Women suffer more frequent and more serious complications from STIs than men. Despite their common occurrence, STIs continue to be one of the least discussed health issues. Sexually transmitted infections can have serious health consequences ranging from pain and discomfort to infertility or complications in pregnancy.

Five of the most commonly encountered STIs are chlamydia, gonorrhea, syphilis, genital herpes, and trichomoniasis.

*Keep in mind that HIV is one of the most frequently occurring STI, but it is covered in depth in its own section here.

What is it?

An STI is any disease transmitted by sexual intercourse or sexual contact. Sexually transmitted infections can affect men and women from all backgrounds and economic levels, with approximately two-thirds of cases occurring in individuals less than 25 years of age. Sexually transmitted infections are one of the most common infectious diseases in the United States with more than 20 different types identified and an estimated 15 million new cases reported each year.

The 5 most commonly occurring STIs; chlamydia, gonorrhea, syphilis, genital herpes, and trichomoniasis.

Chlamydia is the most frequently reported STI. An estimated 2.8 million Americans get chlamydia each year, but not even half get reported. Chlamydia infections are spread by sexual contact through oral, vaginal, or anal routes with an infected partner.

Gonorrhea is a STI that you can get if you have oral, anal, or vaginal sex with someone who has gonorrhea. Gonorrhea infections are spread by sexual intercourse or contact through oral, vaginal, or anal routes with an infected partner.

Syphilis is an STI that has often been called "the great imitator" because so many of the signs and symptoms are indistinguishable from those of other diseases. Syphilis is also spread by sexual contact through oral, vaginal, or anal routes with an infected partner. Syphilis is not spread by contact with toilet seats, doorknobs, swimming pools, hot tubs, bathtubs, shared clothing, or eating utensils.

Trichomoniasis, also called "trick," is a common STI that affects both women and men, although symptoms are more common in women. This disease is spread through sexual activity.

Genital Herpes is a STI that spreads from person to person through sexual contact. Individuals who get this disease may have only minimal signs or symptoms from the infection. When signs do occur, they typically appear as one or more blisters on or around the genitals or rectum. The blisters break, leaving tender ulcers (sores) that may take two to four weeks to heal the first time they occur.

Complications of Chlamydia and Gonorrhea

Potential Complications in Women:

1. Salpingitis, or inflammation of the fallopian tubes. The fallopian tubes are the connection between the ovaries and the uterus. The symptoms of salpingitis include pain in the lower chest, especially when you move or walk, pain during a vaginal exam, fever, and an increase in the need to urinate.

2. Infertility, or the inability to conceive.

3. Pelvic Inflammatory Disease (PID), an infection in the female reproductive organs (fallopian tubes, uterus, and ovaries). Normally, the cervix prevents bacteria that normally live in the vagina from migrating into the reproductive organs; however, if the cervix becomes infected with unfamiliar bacteria such as chlamydia or gonorrhea, the unfamiliar bacteria can travel up through to other organs. The reproductive organs can then become infected and inflamed, which can potentially lead to infertility. The symptoms of PID may differ among women, and some women may not experience symptoms. Symptoms of PID include the following:

Stomach ache, or dull pains in the stomach
Tenderness of the stomach area
Vaginal discharge (yellow or green in color that may have an unusual odor)
Irregular menstruation (extra long periods, spotting or cramps throughout menstrual cycles)
Chills
High fever
Nausea
Vomiting
Pain during sexual intercourse

4. Ectopic pregnancy is a pregnancy that takes place outside of the uterus, where pregnancy normally takes place. The most common site of an ectopic pregnancy is in one of the fallopian tubes; however, the pregnancy can develop in the ovary, abdominal cavity or cervix. Ectopic pregnancies are usually diagnosed within the first 2 months of pregnancy, possibly before a woman realizes that she is pregnant. The symptoms may be mild such as a missed period, abnormal vaginal bleeding, and pain in the lower abdomen or pelvis, or there could be symptoms similar to pregnancy such as breast tenderness or morning sickness. More serious and life-threatening symptoms are associated with a rupture of an ectopic pregnancy and may include a sudden increase in pain in the abdomen or pelvic area, pale skin, fast heart rate, and dizziness with possible fainting.

If you notice that you are experiencing any of these symptoms, it is important that you contact your doctor as soon as possible. Ectopic pregnancies will eventually rupture and can be life threatening.

5. Conjunctivitis is another complication of chlamydia and gonorrhea. Conjunctivitis is the inflammation of the lining of the eye. When this occurs, the eye becomes red, swollen, and produces a watery or pus-like discharge. It is not considered to sight-threatening condition. It can become chronic, although most cases resolve spontaneously after a few months if not treated.

Potential Complications in Men:

1. Epididymitis, or inflammation of the epididymides. The epididymides are the tubes that are connected to the testes. When sperm is released from the testes, sperm pass through the epididymides into the vas deferens to urethra upon ejaculation. The symptoms of epididymitis are pain, swelling, and redness of the scrotum.

2. Infertility, or the inability to produce conception.

3. Conjunctivitis is inflammation of the lining of the eye. The eye becomes red, swollen, and produces a watery or pus containing discharge. It is not considered a sight-threatening condition. It can be chronic, but most cases resolve spontaneously after a few months.

Complications of Syphilis

Potential Complications for Men, Women, and Children/Newborns:

1. Neurosyphilis is syphilis that affects the nervous system - the brain, spinal chord, and nerves. There are four types of neurosyphilis that range from a patient being asymptomatic (showing no symptoms) to experiencing symptoms such as headaches, incontinence (inability to control passage of urine, memory loss, delusions, and muscle paralysis. Neurosyphilis occurs in about 8% of individuals who go untreated. It can appear at any time, from 5 to 35 years after the onset of primary syphilis. Neurosyphilis affects men more frequently than women and Caucasians more than African-Americans.

2. Cardiovascular syphilis can lead to a heart attack, scarring of the valves in the heart, heart failure, or the formation of an aortic aneurysm (an abnormal blood-filled expansion of a blood vessel resulting from disease of the vessel wall). Cardiovascular syphilis usually begins within 5 to 10 years after initial infection, but it may not occur until 20 to 30 years after the initial syphilis infection.

3. Benign Late Syphilis begins 3 to 10 years after the initial infection and is characterized by the development of gummas. Gummas are rubbery tumor-like growths that are most likely to involve the skin or long bones but may also develop in the eyes, throat, liver, or stomach.

4. Periosteal inflammation or inflammation of the membrane surrounding the bone. Individuals may experience pain due to the inflammation. This inflammation leads to thickening of the bone. This thickening is most often seen on the skull, leg bones, breastbone, and ribs.

5. Skin damage including scaling of the skin and alopecia (loss of or thinning of the hair, eyebrows and beard).

Complications of Trichomoniasis

Low birth weight and immaturity of infant--trichomoniasis in pregnant women may cause premature rupture of membranes and preterm delivery.
Urinary tract infections can also occur in women with trichomoniasis infections.
High risk of HIV exposure -The genital inflammation caused by trichomoniasis can increase a woman's susceptibility to HIV infection if she is exposed to the virus. Having trichomoniasis may increase the chance that an HIV-infected woman passes HIV to her sex partner(s).

Complications of Genital Herpes

Recurrent painful genital sores can frequently occur.
Mother-infant transmission - a fetus can acquire herpes in utero, and herpes can be passed to a baby during birth. The risk is greatest if the mother's first outbreak was during pregnancy. Later outbreaks still pose some risk to the fetus.
Premature birth - a fetus with herpes is often delivered early.
Neonatal complications - a newborn may have various health problems; some newborns with herpes have a poor prognosis leading to neonatal death.
HIV exposure - Herpes may play a role in the spread of HIV, the virus that causes AIDS. Herpes can make individuals more susceptible to HIV infection, and it can make HIV-infected individuals more infectious.

What causes it?

Chlamydia
Chlamydia is caused by the bacterium, Chlamydia trachomatis. This bacterium may infect men, women, and newborns. If symptoms occur, they usually appear approximately 7 to 21 days after infection. Chlamydia can also be passed from an infected mother to her newborn child during childbirth. If symptoms occur in a newborn, they usually appear 7 to 14 days after delivery and pneumonia may result when the infant is 2 to 3 weeks old.

Gonorrhea

Gonorrhea is caused by the bacterium, Neisseria gonorrhoeae. The bacterium may infect men, women, children and newborns. The bacteria can grow in moist areas of the reproductive tract, including the cervix (opening to the uterus), uterus, and fallopian tubes (fallopian tubes connect the ovaries to the uterus) in females and in the urethra (the canal through which urine passes to the outside of the body) in both males and females. The bacteria can also grow in the eyes, mouth, throat, and anus. Gonorrhea can also be passed from an infected mother to her newborn child during childbirth.

Syphilis

Syphilis is caused by the bacterium, Treponema pallidum. This bacterium may infect men, women, children, and newborns. Symptoms of infection generally occur between 10 and 90 days after contact with an infected partner. Syphilis can also be passed from an infected mother to her newborn infant during childbirth.

Trichomoniasis

Trichomoniasis is caused by the single-celled protozoan parasite called Trichomonas vaginalis. It is caused by a parasite that can be passed from one person to another. The parasite is sexually transmitted through penis-to-vagina intercourse or vulva-to-vulva contact with an infected partner. The vulva is the genital area outside the vagina. Women can get the disease from infected men or women.

While trichomoniasis is usually passed sexually, it may be picked up from contact with damp or moist objects such as towels, wet clothing, or a toilet seat, if the genital area gets in contact with these damp or moist objects. The vagina is the most common site of infection in women, and the urethra is the most common site of infection in men.

Herpes

Genital herpes is almost always sexually transmitted. It is an infection caused by the herpes simplex virus, one of the same family of viruses that causes chicken pox, cold sores, and mononucleosis. Two different types of herpes simplex viruses can cause herpes.

Herpes simplex virus type 1 (HSV-1) usually causes oral herpes (cold sores or fever blisters) on the face and mouth. HSV-1 infection of the genitals can be caused by oral-genital or genital-genital contact with a person who has HSV-1 infection. Genital HSV-1 outbreaks recur less regularly than genital HSV-2 outbreaks.

Herpes simplex virus type 2 (HSV-2) usually causes genital herpes. Genital HSV-2 infection is more common in women (approximately one out of four women) than in men (almost one out of five). This may be due to male-to-female transmissions being more likely than female-to-male transmission.

Who has it?

Chlamydia
Chlamydia is the most frequently reported infectious disease in the United States. The U.S. Centers for Disease Control and Prevention (CDC) reported 783,424 cases of chlamydia in 2001. In 2004, the number jumped to 929,462 cases of chlamydial infections. Based on CDC data, the number of reported cases of chlamydia has more than doubled in the past 10 years. Of those cases reported, 4 out of every 5 occurred in individuals under 25 years of age. Among teenagers, approximately 15% of sexually active girls and 5% to 10% of sexually active boys have chlamydial infections.

Gonorrhea

Gonorrhea is the second most frequently reported STI in the United States, following chlamydia. According to the CDC, 361,705 gonorrhea cases were reported in 2001 but was decreased to 330,132 cases in 2004. Although this trend seems favorable, gonorrhea still remains prevalent in the Southwestern states, especially among minorities and adolescents of racial and ethic groups. The highest rates of gonorrhea infection are seen in blacks, Hispanic, and Native American populations, with Asian/Pacific being the lowest (less than 100 cases per 100,000 people). The highest rates of infection are usually found in women 15 to 19 years of age and men age 20 to 24 years.

Syphilis

In 2004, primary and secondary syphilis cases reported to CDC increased to 7,980 from 7,177 in 2003, an increase of 11.2%.More cases probably occur each year than what is actually reported to health officials. Syphilis occurs primarily in individuals aged 20 to 39 years, and the reported rate in men was 1.5 times greater than the rate in women. The incidence of syphilis was highest in women aged 20 to 29 years and in men 30 to 39 years of age.

Trichomoniasis

Any sexually active person can be infected with trichomoniasis. According to the CDC, 221,000 cases were reported, an increase of 23 percent from 2003. About 5 million Americans develop trichomoniasis every year. It has been found in:

5%-15% of women at gynecology clinics
50%-75% of prostitutes in the United States

It is often diagnosed in patients who are already infected with other STIs such as gonorrhea.

Genital Herpes

According to the CDC, 269,000 cases were reported in 2004, an increase of 32 percent from 2003. About 45 million Americans, age 12 and older have had genital herpes in their lifetime. It?s estimated that up to one million people become infected each year. Genital herpes (HSV-2) is more common in women than men.

What are the risk factors?

Risk factors are characteristics that may increase your chance for developing a condition. The more risk factors you have, the more likely you are to develop the condition. Any of the following may increase your risk for contracting chlamydia, gonorrhea, or syphilis, genital herpes, and trichomoniasis:

Age less than 25 years (individuals at greatest risk are women between the ages of 15 and 20 years and men younger than 25 years)
Sexual intercourse or sexual contact with an infected partner (whether protected or not)
Having other STIs such as genital herpes (having one STI increases the risk for contracting other STIs)
Injection drug users (sharing needles with an infected person)

Using safe sex measures may help decrease your risk but will not completely void the risk. Some safe sex measures include:

Know your partner. Before having sex, first establish a committed relationship that allows trust and open communication.
Properly use latex condoms to avoid contact with semen, vaginal fluids, or blood. Both male and female condoms dramatically reduce the chance you will get or spread an STI.
Stay sober. Alcohol and drugs impair your judgment, communication abilities, and ability to properly use condoms or lubricants.
Be responsible. If you have an STI, like syphilis or herpes, advise any prospective sexual partner. Allow him or her to decide what to do. If you mutually agree on engaging in sexual activity, use latex condoms and other measures to protect the partner.
If pregnant, take precautions. If you have an STI, learn about the risk to the infant before becoming pregnant. Ask your provider how to prevent the fetus from becoming infected.

What are the symptoms?

Symptoms of STIs vary depending on the specific sexually transmitted infection. Learn more about the specific symptoms that can accompany each STI:

Symptoms of Chlamydia

Chlamydia is known as a "silent" disease because 75 percent of infected women and at least half of infected men have no symptoms. Since symptoms are rare, it often goes untreated and undetected until complications occur. If symptoms do occur, they tend to appear within 7 to 21 days of exposure.

Symptoms that may occur in women include the following:

Mucus or pus-like vaginal discharge
Burning sensation when urinating
Lower abdominal pain
Low back pain
Nausea
Fever
Pain during sexual intercourse
Bleeding between menstrual periods

Symptoms that may occur in men include the following:

White or clear discharge from the penis
Burning sensation when urinating
Burning or itching around the opening of the penis
Pain and swelling in the testicles

Symptoms that may occur in newborns (if transmitted during birth) include the following:

Conjunctivitis (inflammation of the lining of the eye) along with redness of the eye and a discharge containing pus
Pneumonia

Symptoms of Gonorrhea

The symptoms of gonorrhea depend on the age and sex of the infected person. The symptoms of gonorrhea are often mild and start to develop within 10 to 24 days after exposure. Gonorrhea infections among newborns often develop within 2 to 5 days after birth.

Symptoms that may occur in women include the following:

Thick, yellow vaginal discharge
Burning pain when urinating
Bleeding or spotting between menstrual periods
Heavy menstrual periods
Abdominal pain
Pain during sexual intercourse
Fever
Pharyngitis (inflammation of the throat)
Urethritis (inflammation of the urethra, the canal through which urine passes to the outside of the body)

Symptoms that may occur in men include the following:

Thick, yellow discharge from the penis
Burning sensation when urinating
Urge to urinate often
Discharge from the penis (thick, yellow)
Painful or swollen testicles
Pharyngitis (inflammation of the throat)
Urethritis (inflammation of the urethra, the canal through which urine passes to the outside of the body)

Symptoms that may occur in newborns (if transmitted during birth) include the following:

Conjunctivitis (inflammation of the lining of the eye)
Uveitis (inflammation of the iris which is the color part of the eye)
Scalp lesions

Symptoms of Syphilis

There are four stages of syphilis, each of which is associated with distinct symptoms.

1. Primary syphilis is the stage of the bacteria's entry into the body.

The classic sign of primary syphilis is a chancre (pronounced 'kang ker'). A chancre is a red, painless although sometime tender, skin lesion that appears at the location where the bacteria enter the body. The chancre develops approximately 14 to 21 days after a patient has been infected. The base of the chancre is usually smooth, and the borders are raised and firm. The chancre is usually a single lesion but multiple chancres can occur, especially in people infected with human immunodeficiency virus (HIV). Chancres occur in up to 60% of patients infected with syphilis and are usually seen in the genital, anal, or oral areas; however, any part of the body may be affected. If untreated, the chancre will heal typically on it's own within 3 to 8 weeks.
During primary syphilis individuals are infectious. Being infectious means that you may pass the disease to other individuals through sexual contact or contact with a chancre.

2. Secondary syphilis results when the bacteria actually enter the bloodstream. It occurs approximately 4 to 10 weeks after the initial appearance of the primary chancre. Sometimes, secondary syphilis may occur at the same time as primary syphilis. During secondary syphilis patients are infectious, meaning that the disease can be transmitted to other individuals through sexual contact. Signs and symptoms of secondary syphilis may include the following:

Skin rash is typically the first symptom of secondary syphilis. The rash is red or reddish-brown in color, and usually involves the trunk, legs, and palm of the hands and soles of the feet. The rash is usually scaly in appearance but sometimes appears smooth and can be mistaken as psoriasis.
Increased or decreased skin color
Circular lesions which appear mainly on the face of dark-skinned individuals and are described as looking like "clean-cut ham" or having a coppery tint color
Swelling of all lymph nodes
"Condyloma latum" which are one or more large, raised, whitish or gray warty-like lesions usually found in warm, moist areas such as around the vulva (opening of the vagina) or anus
Loss or thinning of hair, eyebrows or beard
Flu-like symptoms such as fever, weight loss, headache, muscle aches, or sore throat

3. Latent syphilis is the hidden (or latent) stage of syphilis.

It generally begins when the secondary symptoms spontaneously resolve after a period of 3 to 12 weeks, leaving an individual free of symptoms. Even though the secondary symptoms resolve, the bacteria remain in the body and may begin to damage the brain, nerves, eyes, heart, blood vessels, liver, bones, and joints. This damage may not appear until many years later, until the late or tertiary stage of syphilis. Damage that may occur during the latent stage though may be serious enough to cause death.
Individuals are infectious during latent syphilis, meaning that the disease can be transmitted to other individuals through sexual contact.

4. Tertiary Syphilis, is the last stage, " the destructive stage," of the disease.

Symptoms of tertiary syphilis may develop 2 or more years following the latent period. Late stage signs and symptoms include not being able to coordinate muscle movements, paralysis, numbness, gradual blindness and dementia. Complications (such as neurosyphilis, cardiovascular syphilis, late benign syphilis, periosteal inflammation, or skin damage) of syphilis typically occur in this stage. These complications can be serious and even life threatening. To learn more about the complications from syphilis, read the What is it? section concerning the complications of syphilis.
Individuals are not infectious during tertiary syphilis.

Symptoms of Trichomoniasis

Many people with trichomoniasis experience no symptoms. The symptoms differ between women and men.

Symptoms for women are:

Itching
Burning
Vaginal or vulval redness
Unusual vaginal discharge
Frequent and/or painful urination
Discomfort during intercourse
Abdominal pain

Symptoms tend to worsen after menstruation. Symptoms usually appear within 5 to 28 days of exposure in women.

Symptoms for men are:

Unusual penile discharge
Painful urination
Tingling inside the penis

*An interesting point to note is that 70 - 90 percent of women and 40 ? 50 percent of men who have an STI have NO noticeable symptoms.

Symptoms of Genital Herpes

The symptoms of genital herpes may include:

A rash, bumps, blisters, cuts, or sores in or around the genital area (vagina, vulva, anus, penis, or scrotum)
Itching, burning, tingling, or swelling in or around the genital area
Aches or pains in or around the genital area
Discharge from the penis or vagina
Burning and/or pain when urinating
Flu-like symptoms such as headache, fever, and swollen glands (lymph nodes) in the groin
Not everyone has symptoms during every outbreak

How is it treated?

Chlamydia, gonorrhea, syphilis, and trichomoniasis are bacterial infections and are treated and cured with antibiotics (medications used to treat infections caused by bacteria). Treatment is crucial to prevent the spread of these STIs. The treatment of all sexual partners (past and present) helps prevent re-infection and further spread of the disease. It is also important to treat pregnant women to prevent transmission to infants during birth. Since most people infected with gonorrhea are often also infected with chlamydia, it is now recommended that all patients being treated for gonorrhea also be treated for chlamydia.

The selection of an antibiotic to treat an STI will depend on several factors. These include the following:

The actual bacteria causing the infection
Allergies you have to various antibiotics
Severity of the infection
Resistance to antibiotics that you may have because of past treatment

Treating Chlamydia

For most cases of uncomplicated chlamydial infections, doxycycline 100mg orally twice a day for 7 days or azithromycin 1,000mg orally one time is the treatment of choice. For patients who can not take these medications, or in cases where complications are apparent, oral antibiotics including erythromycin, ofloxacin, amoxicillin, and sulfisoxazole may be used. Another alternative is ceftriaxone, which is given by injection into a muscle as a one time dose.

Treating Gonorrhea

Most cases of uncomplicated gonorrheal infections can be effectively treated with ceftriaxone 125mg given by injection into a muscle as a one time dose, or cefixime 400 mg orally in a single dose. Each of these treatment regimens should be accompanied by a treatment regimen for chlamydia (those treatments are discussed above). Ongoing data from the CDC demonstrate that gonorrheal infections have become resistant to fluoroquinolone antibiotics, such as ciprofloxacin and ofloxacin. As a consequence, as of 2007 this class of antibiotics is no longer recommended for the treatment of gonorrhea in the United States.

Treating Syphilis

Penicillin, given either as an injection into the muscle (intramuscular - IM) or as an injection directly into a vein (intravenous - IV) is the treatment of choice for all stages of syphilis. For patients who cannot take penicillin, oral antibiotics such as doxycycline, tetracycline, or erythromycin may be used.

Treating Trichomoniasis

The usual treatment is a single large dose of oral metronidazole, or split doses over the course of a week. Sexual partners of an infected individual must also be treated, to prevent the infection being passed back and forth. Treatment is important because studies suggest that trichomoniasis may increase a pregnant woman?s risk of premature delivery and may also increase the risk of HIV transmission.

Women who are taking antibiotics for other illnesses should speak to their health care provider about the possible effects of the medication(s) on the balance of organisms in their vagina. There are a certain amount of ?good? bacteria that live in the vagina, and the more metronidazole or other antibiotics you take the more the chance your ?good? bacteria is abolished leaving your vaginal area vulnerable to other infections.

Regardless of the chosen antibiotic, it is important to remember to take the entire course of antibiotics prescribed by your physician. Many individuals take their medication only until they feel better, and this can allow an infection to return with even greater severity in the near future. Not finishing the full course of treatment may also prevent that antibiotic from working well in the treatment of other individuals. To learn more about the different types of antibiotics used to treat chlamydia, gonorrhea, and syphilis, click on the drug class links below.

Treating Genital Herpes

There is no treatment that can cure genital herpes; the virus will always be in your body. Certain drugs such as acyclovir, valacyclovir, and famciclovir can shorten outbreaks and make them less severe, or stop them from occurring. Depending on your needs, your doctor can give you drugs to take right after getting outbreak symptoms or drugs that you can take on a regular basis to try to stop outbreaks from occurring. When used along with safe sex practices, valacyclovir can also help prevent you from passing the infection to someone else. Talk to your doctor about which treatment plan is best for you.

During outbreaks, these steps can speed healing and prevent spreading of the infection to other sites of the body or to other people.

Keep the infected area clean and dry.
Try not to touch the sores.
Wash hands after contact.
Avoid sexual contact from the time the symptoms are first noticed until the sores have healed.

Friday, May 30, 2008

Sexually Transmitted Infections (STIs) and Drug Medical Treatment