Sexual consequencies of STIs:Chicken or egg. Dr Philip Kell Sexual Medicine Consultant UK

Transcription

1 Sexual consequencies of STIs:Chicken or egg Dr Philip Kell Sexual Medicine Consultant UK

2 Obrigado por me terem convidado para falar na bela cidade de São Paulo

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4 Subjects to be covered HIV Chlamydia/Gonorrhoea Syphilis/HSV Prostatitis/Pelvic pain syndromes Candida and Bacterial Vaginosis Warts and other skin problems

5 Female triangle Decreased desire Sexual pain Decreased arousal/orgasm

6 Male triangle ed Loss of libido pe

7 Consequences of STIs Embarrassment Blame Sometimes pain Fear of sequelae Fear of transmission All leading potentially to SD

8 HIV Psychological Behavioural Physical Side effects of medication Metabolic

9 Psychological Fear of transmission Depression Loss of friends who have died Loss of spontaneity associated with condom use Changes in body image

10 Behavioural ED >inability to use condoms >increase receptive AI Fear of rejection from social group if HIV status known leading to increased casual partners and hence STIs

11 Physical\Metabolic Lipodystrophy HIV related co mordities Infection stigmata Associated diseases such as diabetes Aging (Rio cohort)

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16 Medications?HAART > SD especially ED (Swiss cohort study showing no particular class of ART)?Treatment for ED > increased HIV transmission (Cook et al 2009 no increase). May be the opposite

17 Interactions PIs and PDE5s ART and COC ART and SSRIs ART and recreational drugs (cocaine and poppers)

18 HIV and SD(men) ED (associated with age/ metabolic syndrome /psychological issues Loss of libido (or occasionally hypersexuality) associated with insulin resistance/neuropathy/hypogonadism

19 HIV and SD (women) Genital arousal disorders (associated with insulin resistance/neuropathy Desire disorder (associated with body image Sexual pain (associate with hypooestrogenism/increased hsv/atrophic vagina

20 Chlamydia Chlamydia continues to be the most frequently reported STI in Europe In 2012: cases of chlamydia reported from 26 EU/EEA Member States Overall rate of 184 per population Rate of 211 per in women and 153 per in men 68% of all chlamydia cases reported in young people (15 24 years); highest rates among women aged 20 to 24 years (1 684 cases per ) Heterosexual transmission accounted for 88% of cases.

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22 Gonorrhoea In 2012: gonorrhoea cases were reported in 29 EU/EEA Member States Overall rate of 15.3 per population Reported more often in men than in women: rate of 25.7 per in men and 9.2 in women 41% of cases reported among young adults Transmission among men who have sex with men accounted for 38 % of cases Since 2008, rate of gonorrhoea increased by 62%; most EU/EEA countries report increasing trends. Trends must be interpreted with caution due to the heterogeneity in national reporting and healthcare systems.

23 Normal Cervix with Ectopy Epidemiology Source: Seattle STD/HIV Prevention Training Center at the University of Washington/ Claire E. Stevens 23

24 Drips Chlamydia Cervicitis Source: St. Louis STD/HIV Prevention Training Center

25 Drips Pelvic Inflammatory Disease Source: Cincinnati STD/HIV Prevention Training Center

26 Pathogenesis Normal Human Fallopian Tube Tissue Source: Patton, D.L. University of Washington, Seattle, Washington 26

27 Pathogenesis C. trachomatis Infection (PID) Source: Patton, D.L. University of Washington, Seattle, Washington 27

28 CT Scan Findings Acute PID Thickened Fallopian tube Thickened Fallopian tube

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30 Chlamydia and GC and SD In men painand discharge leading loss of interest In women sexual pain in form of deep dysparunia as well as other factors

31 Genital Ulcer Diseases Sores Painful Chancroid Genital herpes simplex Painless Syphilis Lymphogranuloma venereum Granuloma inguinale

32 Syphilis In syphilis cases were reported in 30 EU/ EEA Member States Rate of 7.7 per in men and 1.7 in women Young people between 15 and 24 years of age account for only 15 % of cases 48% of the syphilis cases reported among men who have sex with men In many countries, however, dramatic increases were noted, appearing to be mainly among older MSM. Estimated that having syphilis increases chance of HIV transmission 5 8x

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34 Sores Primary Syphilis Chancre Source: Florida STD/HIV Prevention Training Center

35 Sores Primary Syphilis Source: Centers for Disease Control and Prevention

36 Sores Secondary Syphilis Rash Source: Florida STD/HIV Prevention Training Center

37 Sores Secondary Syphilis Rash Source: Cincinnati STD/HIV Prevention Training Center

38 Secondary Syphilis Condylomata Lata Sores Source: Florida STD/HIV Prevention Training Center

39 Herpes Simplex Virus (HSV) Not done in asymptomatic screens Serology only useful in certain circumstances Culture difficult if >48 hours into a recurrence

40 Herpes Viruses

41 Sores Genital Herpes Simplex in Females Source: Centers for Disease Control and Prevention

42 Sores Genital Herpes Simplex Source: Florida STD/HIV Prevention Training Center

43 GUD and SD In men and women pain /fear of transmission/concerns re asymptomatic shedding/ concerns re criminalisation

44 Genital warts and Non infectious skin problems Genital warts Lichen scleosis Vulvodynia Abacterial prostatitis

45 Human Papilloma Virus

46 HPV Penile Warts HPV and Cervical Cancer Source: Cincinnati STD/HIV Prevention Training Center

47 Intrameatal Wart of the Penis (and Gonorrhea) HPV and Cervical Cancer Source: Florida STD/HIV Prevention Training Center

48 Lichen sclerosus

49 Indications for Circumsicion Balanitis Xerotica Obliternans BXO Balanitis Zoons

50 Vaginal discharge\pain Red vagina cândida tv atrophic Normal colour bv\physiological Ph >4.5 bv tv atrophic Ph<4.5 bv\physiological

51 General Approach to Vaginal Discharge/Pain Normal Ph of Candida Ph of BV and TrichPh>4.5. Signs of vulval inflammation and minimal D/C in the absence of vaginal pathogens suggest possible mechanical, chemical, allergic or other noninfectious causes.

52 Trichomonas Vaginalis. TV is a flagellate protozoan Vaginal D/C is reported in 50 75% of patients. The D/C may vary from the classic yellowish green frothy type to a grayish or even no D/C at all. Other symptoms include: vulvovaginal soreness/irritation, pruritis, dysuria, malodorous D/C, dyspareunia.

53 Trichomonas Vaginalis Cont. Gyn exam reveals the classic strawberry cervix in only 2% of patients with diffuse erythema seen in 10 33%. The diagnosis is made with microscopy revealing flagellated trichomonads. Cultures are approx. 95% sensitive and should be considered in symptomatic patients with elevated ph >4.5 and excess PMNs absent of motile tichomonads and clue cells.

54 Trichomonas Vaginalis Cont. Metronidazole is still the cornerstone of treatment. There is a 90% cure rate with either the single dose or 7 day course. Treatment: Metronidazole 2gm po single dose or 500mg po bid for 7 days.

55 Colpitis macularis, or strawberry cervix. (Courtesy, CDC.). Swygard H et al. Sex Transm Infect 2004;80: by BMJ Publishing Group Ltd

56 TV and sexual dysfunction Soreness and redness in both men and women

57 Bacterial Vaginosis BV is a clinical syndrome that occurs when the normal H2O2 producing lactobacillus species in the vagina are replaced by high concentrations of anaerobic bacteria, G. vaginalis and Mycoplasma hominis. BV is the most common cause of a malodorous D/C, but more than half of the women who meet criteria for diag. are asymptomatic.

58 Clinical picture White homogeneous discharge Fishy smell Not sore or itchy Often asymptomatic

59 Emerging insights Rapid shifts of flora with changes in genital tract environment : ph menses coitus other infections

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62 Treatment Recommended regimens: Metronidazole 400mg twice daily for 5 7 days or Metronidazole 2g single dose or Intravaginal metronidazole gel (0.75%) once daily for 5 days or Intravaginal clindamycin cream (2%) once daily for 7 days or _ Lactic acid gel Alternative regimes Tinidazole 2g single dose Clindamycin 300mg twice daily for 7 days

63 BV and sexual dysfunction Don t underestimate Fishy discharge resulting from sex leading to withdrawal from vaginal intercourse

64 Candida Vaginitis It is estimated that 75% of women in childbearing years will experience at least one yeast infection. The organism can be isolated from up to 20% of asymptomatic women of childbearing years, some of whom are celibate. Candida vaginitis infection is not considered to be a STD but can be spread sexually.

65 Candida Vaginitis Cont. Factors that favor increased rates of asymptomatic vaginal colonization are pregnancy, oral contraceptives, uncontrolled DM, and frequent STD clinic visits. C. albicans strains account for 85 92% of those strain isolated from the vagina. C. glabrata and C. tropicalis are the commonest nonalbicans strains and are more resistant to conventional therapies.

66 Candida Vaginitis Cont. Candida organisms gain access to the vaginal lumen and secretions predominately from the adjacent perianal area. Risk factors for yeast infections are: loss of normal vaginal flora (po antibiotics), diminished glycogen stores (DM, pregnancy, BCP, and hormone replacement), increase of vaginal ph (menstrual blood or semen) or tight fitting undergarments causing increase temp, moisture, and local irritation.

67 Candida Vaginitis Cont. Clinical symptoms include leukorrhea, severe vaginal pruritus, external dysuria, and dyspareunia. Odor is unusual. Gyn exam may reveal vulvar erythema and edema, vaginal erythema, and thick cottage cheese D/C. The diagnosis is made by have a normal ph4 4.5 and positive results on microscopic exam (yeast buds and pseudohyphae). Culture is only use with symptomatic patients with negative findings on microscopic exam.

68 Candida and sexual dysfunction Soreness and redness in both men and women

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70 Atrophic Vaginitis During menarche, pregnancy, lactation and after menopause the vaginal epithelium lack estrogen stimulation. The maturation of the vagina and urethra mucosa depends on the presence of estrogen. Menopause results in a vaginal mucosa that is attenuated, pale, and almost transparent as a result of decreased vascularity.

71 Atrophic Vaginitis Thus the vagina loses it rugae, the squamous epithelium atropies, glycogen content decreases, and the ph increases ( ), thus possibly causing atrophic vaginitis. When symptomatic vaginitis occurs the vaginal epithelium is thin, inflamed, and ulcerated.

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73 Atrophic Vaginitis and SD Vaginal soreness, dyspareunia, and occasional spotting or D/C. Resultant sd in men

74 Hephaestus, when he tried to initiate intercourse with Aphrodite; spilled his seed upon her leg.

75 CP/CMPP (NIH 3) and SD Rarely due to a STI Painful ejculation Associated with PE but cause or effect? Association with ED less clear Associated with penile/urthral/perineal pain Not just the prostate!

76 CFPP/Chronic PID Not frequently associated with STI Can lead to deep dyspaunia Often not PID!

77 Consequences of STIs Embarrassment Blame Sometimes pain Fear of sequelae Fear of transmission All leading potentially to sexual dysfunction