• causative agent: N. gonorrhea
• highest incidence in developing countries (lowest in Europe)
• higest in 15-19 yr olds
• more cases reported in men

• perinatal
• sexual contact
  • F to M: 20% per contact (60-80% after 4 or more exposures
  • M to F: 50% per contact

• incubation: 2-10 days
• men: purulent discharge, dysuria, urethritis, or may be asymptomatic
• women: vaginal discharge, dysuria, cervicitis, 90% may be asymptomatic
• anorectal- proctitis, purulent discharge
• pharyngeal disease (may be asymptomatic)
• conjunctivitis of newborn- purulent exudate within week of delivery

• 10-20% get ascending infection: PID, endometritis, salpingitis, tubo-ovarian abscess
• bartholinitis
• acute epididymitis
• disseminated disease with arthritis-dermatitis syndrome
  • migratroy polyarthritis/tenosynovitis and dermititis (hemorrhagic papules/pustules)
• synovial fluid reveal septic arthritis, but only 50% have blood or joint fluid that are positive

• gram stain: specific for genital lesions
• culture with selective media (Thayer Martin)
• nucleic acid probes

• widespread penicillin R
• coinfection with chlamydia in some pts
• most cases resolve spontaneously
• uncomplicated infection
  • single dose cephalosporin, quinolone, otherwise multiple doses

• substantially less transmissible than gonorrhea
• transmitted by sexual contact and perinatally
• many men and most women are asymptomatic
• high incidence of co infection with N. gonorrhea

causative agent: Chlamydia trachomatis

• urethritis: causes many NGU cases
• in men: dysuria, urethral dischage (less purulent), epididymitis/prostatitis, proctitis, rectal strictures, fistulae, abscesses
• in women: cervicitis, urethritis, mild dischange, bartholinitis, endometritis, salpingitis, PID
• reactive arthritis- immune mediated and aseptic (part of Reiter's syndreom)
• infants: conjunctivitis, pneumonia
• in developing world, lymphogranuloma venereum

• endemic- SE Asia, Africa, Carribean
• primary lesion- asymptomatic papule or ulcer, heals rapidly, occurs 3-30 days post infection
• secondary (days to weeks)- adenopathy which progresses to an inflammatory mass and drains

• stained smears (insenstive EXCEPT in conjunctivitis): intracytoplasmic inclusions
• serology
• culture (labor intensitve)
• nucleic acid amplification tests

• azithro
• doxycycline

• protozoan parasite
• self limited in a good amount of men
• recovered from the majority of female partners of infected men and a good amount of male partners of infected women

• symptoms often begin or exacerbate during menstration
• vaginal discharge (yellow, thick), vulvovaginal irritation, dyspareunia, urethritis, cervicitis
• complications
  • premature rupture of membranes
  • low birth weight
• men usually asymptomatic and some women are asymptomatic as well

• dx
  • wet prep: 80% sensitive and highly specific
  • culture in liquid medium (Diamond's medium)
  • rapid Ag test
• tx- oral metronidazole

• epidemiology
  • major outbreaks recently in US
  • only 10% reported in women (inapparent carrier state)
• causative agent: Haemophilis ducreyi

• incubation period 1 day to sever weeks
• generally confined to genitalia
• initially begins as tender papule with surrounding erythema, becomes pustular and forms painful undermined ulcer (ulcers can be single or multiple)
• tender regional adenopathy (cases which can suppurate and form draining sinuses)
• superinfection can occur

• dx
  • culture, gram stain
    • gram negative rods in characteristic "school of fish: pattern (not very sensitive)
  • PCR
• tx
  • single dose azithro
  • single dose ceftriaxone
  • ciprofoxacin

• most common cause of vaginitis
• caused by replacement of normal flora with anaerobes (ex: Gardnerella vaginalis)
• found in 2/3 of women without signs and symptoms of infection
• male sexual partners are usually colonized by asymptomatic

• clinical manifstation- increased vaginal discharge with a "fishy" odor
• dx
  • gram stain of vaginal fluid reveals clue cells
    • epithelial cells covered with small coccobacilliary forms
    • culture less useful
  • IFA
    DNA probe- vaginitis panel- test for Gardnarella, Candida, Trichomonas
• tx- metronidazole

• causative agent- Treponema pallidum
• epidemiology and transmission
  • highly infectious
  • transmitted by venereal contact, transplacentally, transfusion, needle stick, most infectious early in desease
  • majority of cases 15-30 age range

• penetrates skin and spread through blood and lymphatics
• any organ can be invaded, including CNS
• it can cause obliterative endarteritis or large granulomatous lesions (gummas)

• chancre form at site of inoculation
  • initially painless papule, erodes with rasied borders
  • heals in 3-6 wks
• can be multiple, atypical, or absent
• can be on cervix, mouth, perianal area
• accompanied with adenopathy

• 2-8 wks after appearance of chancre
• disseminated diases
• maculopapular rash can involve any surface of body, presence on palms and soles is highly suggestive
• papules can coalesce to form gray-white highly infectious plaques called condylomata lata
• highly infectious patches teeming with spirochetes can form on mucous membranes
• constitutional symptoms common: enlargement of epitrochlear nodes highly suggestive
• CNS involvement in some cases: CN involvement, meningitis
• glomerulonephritis, hepatitis, uveitis, proctitis, synovitis

• progressive inflammatory disease can affect any organ
  • neurosyphilis
    • no symptoms in some cases
    • dx- abnormalities of CSF if tested
      • elevatred CSF WBC
      • elevated protein
      • low glucose
      • positive VDRL
  • CV syphilis- endarteritis cause aortitis and aneurysm formation
  • late benign syphilis (gummas)- granulomatous lesions can be seen in any organ
  • syphilitic otitis- asymmetric deafness, tinnitis
  • CN palsies- VII, VIII most common

• meningovascular (inflammatory) endarteritis oblinterans, involving small bv's, leading to multiple small infarcts, progressive neurological deficits, seizures
• parenchematous (degenerative) leading to neruologic symptoms and psyc disease

• PARESIS (constellation of psyc and neuro symptoms)
  • personality
  • affect
  • refelxes
  • eyes (Argyll Robinson pupil, optic atrophy)
  • sensorium
  • intellect
  • speech
• tabes dorsalis- demyeliniation of DRG
  • ataxic gait
  • foot slap
  • paresthesias
  • incontinence
  • impotence
  • Charcot joints as resulte of sensory loss

• darkfield examination
• serologic tests- nonspecific, nontreponemal reaginic tests: VDRL and RPR
  • used to screen, most reliable for secondary syphilis, false positives can occur
  • become positive 3-6 weeks after inoculation
  • titers decrease with tx, length of time for the test to become negative depnds on severity of illness and interval between contact and therapy initiation
• specific treponomal tests: FTA-Ab and MHA-TP
  • remain positive for live despite tx
  • less incidence of false positive

• positive VDRL is proof of CNS involvement
• negative VDRL does not rule out neurosyphilis (only 30-40% with neurosyphilis will have positive VDRL)
• RPR negative in 25% of pts with late syphilis
• dx often made in suspected individual with positive RPR and or FTA and CSF abnormalities

• tx best studied with penecilin
• early disease- IM injections (one shot) but if recurrent or neurosyphilis, give them 3 shots
• neurosyphilis is IV penicillin
• alternatives: doxycycline, ceftriaxone

• recent dramatic increase in prevalance of disease
• 2/3 of sexual contacts develop disease
• in kdis, respiratory papillamatosis
• infection often asymptomatic

• 6 and 11 associated with external genital warts and minimal risk of malignancy
• other HPV's associated with flat warts and increase risk of carcinoma of cervic, vagina, vulva, anus, and penis

• fresh to gray colored papules either sessile or pedunculated, they may merge into plaques
• in men: usually on penile shaft, urethra may be involved
• in women, usually posterior interoitus, labia
• flat condylomas on cervix, vagina
• perianal warts

• application of acetic acid solution
• colposcopy
• biopsy (characteristic histopathology)
• Pap smear to rule out dsyplasia
• HPV DNA detection

• no tx is predictably curative and relapses are common
  • cryotherapy
  • laser ablasion
  • podophyllin
  • interlesional IFN
  • imiquimod cream
  • 5-fluorouracil

• vaccine approaved recently
• protect against types 6,11,16,18 (protect against a lot of cancers and most warts)
• ideally administered before individual becomes sexually active
• close to 100% efficacy