EXPANSION OF S.T.D. (Sexually Transmitted diseases)

By

Maj. M. P. Vora, (R)

Current Medical Practice

A monthly journal devoted to modern medicine and surgery

Vol.No.31, No.6 of June 1987

Pages: 145-151

Venereology today comprises not only the five classical venereal diseases of the past i.e. syphilis, gonorrhoea, chancroid, lymphogranuloma venereum and granuloma inguinale but also a number of newly recognised sexually and non-sexually transmitted diseases, whose importance has been increasingly perceived and felt in the last few years. In fact, newer diseases are diagnosed more frequently in the present than in the past and have completely overtaken the earlier group of V.D. There are more than 35 different specific etiologic pathogens or agents that can spread by sexual contact. The newer bacteria Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma hominis, several viruses and protozoa have become important sources of venereal diseases. To the list, can be added hepatitis B virus, Cytomegalovirus, Epstein-Barr virus, papilloma virus, molluscum contagiosa virus, herpes, virus hominis type 1 and 2, Entamoeba histolytica, Giardia lamblia, B.coli, Pseudomonas, Mime polymorph, Herellae vaginicola, Bacteroids Fusobactereum, Shigella, B crassus, enterococcus bacteria, streptococcus faecalis, Haemophilus ducreyi, Gardernella vaginalis, B group streptococcus, Corynebacterium diphtheria, Mycobacterium tuberculosis etc. Implications of these organisms in the causation of venereal complaints cannot be easily ruled out without adequate and painstaking laboratory investigations for the clear etiologic diagnosis. In fact, the precise role of some these agents in the etiology of STDs is difficult to evaluate correctly in absence of adequate, comprehensive and reliable facilities for the investigations and trained and experienced personnel, which are prerequisites for precise diagnosis. A definitive diagnosis of STD has assumed a great importance.

The factors that contribute to the rising incidence of STDs are

• increasing population with longer life span, (2) changes in attitudes to sex, pre and/or post marital, are becoming frequent and regular, (3) changes in sexual practices such as orogenital, anogenital, homosexual, bisexual and heterosexual with multiple partners. Apart from genitalia, several new sites and areas have been implicated and need to be carefully considered and examined such as oropharynx, eyes, anus, rectum etc, (4) number of infections can be silent or symptomless, (5) increased travel, tourism, jet-age have caused wide-spread infections, (6) emergence of resistant strains of organisms, (7) indiscrete or inadequate use of antibiotics, (8) neglect of regular post-treatment observations and tests of ‘cure’, (9) ignorance and apathy about growing number of STDs among high risk groups and among most medical practitioners, (10) sustained want of highly trained and experienced personnel, reliable and devoted experts in these diseases, well equipped laboratories and fully trained and dependable technicians for accurate diagnostic procedures, (11) failure of contact-tracing and simultaneous treatment of sexual partners, (12) absence of proper case reports and compiled statistics and follow-ups.

Because of increased awareness, improved laboratory techniques, knowledge of epidemiology, methods of transmission of infections, clinical consequences and advances in current understandings, these diseases are better appreciated today than in the past. Just as acute gonorrhoea has been wide-spread and endemic throughout the world, many of the newly recognised sexually and asexually transmitted diseases, so called the second generation of V. D s, have also become and endemic. The sudden increase in the incidence of sexually transmitted diseases caused by Chlamydia trachomatis, Ureaplasma urealyticum, HIV/ LAV causing AIDS, Herpes simplex virus type 1 and 2 etc is quite apparent in advanced countries like Europe and America. Pelvic inflammatory disease (PID) due to Chlamydia, N.gonococcus, Mycoplasma hominis, and Ureaplasma, with diminishing frequency, resultant infertility following repeated attacks of PID, has become serious throughout the advanced world. However, they are much less obvious in most backward countries, on account of lack of awareness, paucity of proper diagnostic facilities, poor collection of statistics and precise surveillance data. Not only has the total incidence of many STDs increased but also the number of agents transmitted sexually and asexually. The proportion of newer type infections transmitted sexually has increased as the human sexual behaviour has become modified and more promiscuous than in the past and is generally accepted without a whimper. With the change in social attitudes, more and more people are accepting the new sex style with gusto. The concept of virtue and vice has of fluctuated over decades. Multiplicity of partners and unusual sexual practices such as oral, anal, homosexual and bisexual with multiple partners have added new dimensions to the problem. While the number of victims of older venereal diseases has declined in advanced countries (not in India) to some extent because of continuing public education, improved socio-economic conditions, better hygiene and sanitation, greater emphasis on prevention, early diagnosis and treatment. However, indifference towards older and newer venereal disease in the country as well as ignorance about them among the people has helped to expand the sphere of venereology. The economic cost in terms of health care expenditure, lost productivity and human sufferings, morbidity and mortality from these diseases must be enormous indeed. The impact on maternal and infant health, human reproduction and loss of fertility in both sexes have been realised only recently. Not vainly scientists express with strong conviction and plead that urgent programme for the prevention of infant and maternal mortality, infertility and morbidity is related to these diseases. This will naturally require a rapid action and a close co-operation among various health programme planners and executers in different areas of health, medical education and training of all categories of personnel. All these facts tend to support the urgent need to recognise venereology as an important monospeciality to make full justice to the expanding and growing subject in importance. Isn’t it repugnant to allow it to continue as a part of dermatology? Is there the slightest justification to stay on this harmful policy? It has denied the subject its natural development and full maturity. The subject warrants special study, it’s no wonder that it has lagged far behind many other medical specialities. The general practitioner in medicine needs continuous education and training not only in the older venereal diseases but also in the newer venereal diseases. Doctors are in need of though knowledge, comprehension and practical experience in these diseases, methods of diagnosis, treatment, follow-up procedures, contact-tracing, test of cure proper record-keeping, maintenance of statistics etc. The components do not constitute anything new to devoted doctors. Venereal diseases are serious and need early diagnosis and treatment, an important task for doctors. The patient must remain as the primary focus of the doctor’s care. He needs compassion and attention to his emotional needs.

The etiologic classification of STDs. Each of the pathogen listed below has been implicated or likely to implicate as a factor in the transmission of sexual diseases, although there is little evidence in support of sexual transmission of certain agents such as Cytomegalovirus, B group streptococci, Schistosomia haematobian, Corynebacterium diphtheria, mycobacterium tuberculosis etc. However, genital complaint or manifestation is very likely.

• Bacterial agents and manifestations:

• Neisseria gonococcus - Acute or chronic urethritis, proctitis, prostatitis, Cowperitis, epididymitis, stricture urethra, arthritis, pharyngitis, conjunctivitis, cervicitis, Bartholinitis, Skeneitis, endocervicitis, endometritis, salpingitis, pelvic peritonitis, periurethral abscess, perihepatitis (Fitzhugh Curtis syndrome), premature delivery, foetal infection on amniocentesis, ophthalmitis, etc.

• Chlamydia trachomatis - Urethritis, epididymitis, proctitis, cervicitis, prostatitis, salpingitis, trachoma, otitis media, lymphogranuloma venereum, inclusion conjunctivitis, pneumonia, dyspareunia, dysuria, urinary frequency, perihepatitis, Bartholinitis, foetal and neonatal mortality, post partum endometritis, cervical dysplegia, abortion endocarditis, PID, sterility, Reiter’s syndrome etc.

• Mycoplasma hominis - urethritis, salpingitis, oral ulcers, post-partum fever, PID, pneumonia, vasculitis, Reiter’s syndrome etc.

• Ureaplasma urealyticum - urethritis, PID, sterility, cervicitis, choriomeningitis, and low birth weight infant etc.

• B Crassus - ulcus acuminatus vulvae, rapidly progressing ulcer in young girls between 15 to 20 age.

• Treponema pallidum - acquired syphilis, congenital syphilis, cardiovascular and neurosyphilis, optic atrophy, gumma, condylomata lata, skin rashes, bone and joint affections etc.

• Haemophilus ducreyi - chancroid, bubo, phagedena, fever.
• Haemophilus vaginitis - vaginitis, vulvitis, vaginal discharge.

• Haemophilus influenza - genital tract infection, conjunctivitis, pharyngitis, laryngitis, arthritis etc.

• Calymmatobacterium granulomatis (Donovanosis) granuloma inguinale, ulcers,, papules on the genital or anal region, labia in women, bone involvement, secondary infection.

• Shigella-shigellosis sexually transmitted in homosexuals, colonitis, arthritis, diffuse mucosal inflammation, ulcers, and a person-to-person spread.

• B group streptococcus - urethritis, ulceration, genito-urinary infection.

• Streptococcus faecalis - enterococcus, genitourinary infection.

• Fusospirochaete - gangrenous genital ulcer, phagedena, vulval ulcer.

• Corynebacterium diphtheria - genital, vulval cervical ulcerations, nasal and eyes lesions.

• Mycobacterium tuberculosis - In the male lesions of genital tract - seminal vesiculitis, epididymitis, vas deference, sterility, urethritis, in the female - fallopian tube inflammation, blocking, sterility, peritonitis, cervicitis, dyspareunia etc.

• Escherichia coli - urinary tract infection, cystitis, hepatobiliary and gastroenteritis, it is an ‘opportunistic’ infection.

• Pseudomonas - urinary tract infection, skin in the anogenital area infection, super infection when primary pathogens have been eradicated with antibiotics, when host resistance is diminished by steroids or antineoplastic drugs. Person to person infection can be transmitted by humans, corneal ulcers, conjunctivitis, and gangrenous ulcers in the anogenital region.

• Mima Herellae

• Mima polymorph - penicillin-resistant urethritis, vaginitis, conjunctivitis.

• Herellae vagicola - vaginal infection, ulcers etc.

• Bacteroids - vaginitis, Skeneitis or Bartholinitis.

• Viral infections :

• Herpes virus hominis type 1 - follicular conjunctivitis, lesions on the glans penis, nasopharynx, inclusion conjunctivitis etc.

• Herpes virus hominis type 2 - This is uniformly acquired venereally, infections of genitalia, cervix, vagina or vulva, pre malignancy stage of the cervix, burning urine.

• Herpes zoster - the skin and mucous membrane lesion, severe pain before the outbreak of vesicles, viraemia, encephalitis, encephalomyelitis, conjunctivitis.

• Hepatitis B virus - acute or chronic on fulminating hepatitis with immune complex phenomenon, its complications.

• Cytomegalovirus - congenital infection, birth defects, infant mortality, mental retardation, cervicitis, immunosuppression, infectious mononucleosis, and urethritis.

• Papilloma virus - genital warts, condylomata acuminata.

• Pox virus group - Molluscum contagiosa affects the skin and the mucous membrane, anogenital area, affects man and children.

• LAV/HIV - Acquired Immune Deficiency Syndrome (AIDS).

• Epstein-Barr virus - Infectious mononucleosis, transfer of virus by oro-pharyngeal route or during close personal contacts.

• Protozoal Agents

• Trichomonas vaginalis - Often transmitted by sexual intercourse urethritis, balanitis, prostatitis, vaginitis, a new born infant of the infected mother can get infected.

• Giardia lamblia - giardiasis, it can be transmitted in homosexual relations.

• Entamoeba histolytica - Amoebiasis, it can be transmitted along homosexual males or women by anal infections.

• Fungal Agents

• Candida albicans - vulvo-vaginitis, balanitis, posthitis, urethral

infection.

• Gardernella vaginalis - Affects men and women by sexual

contacts, causes vaginitis, vulvitis, balanitis. Both partners need to be

treated simultaneously.

• Epidermatophyton, Trichophyton - Epidermophytosis, Dermatophytosis.

• Ectoparasites

• Pathirus ( pediculosis) pubis - pubic louse infection, pruritus, ulceration.

• Sarcoptis scabei - Pruritus, ulcers. There is often a danger of primary syphilis escaping the detection or being overshadowed by scabei.

• Intestinal nematode

Enterobiasis / Enterobius vermicularis - In females - threadworms can enter the vagina; can get access to peritoneal cavity through fallopian tubes, vaginitis, discharge, chronic granulomatous salpingitis, endometritis, pruritus, perianal eczema, secondary pyogenic infection, pruritus ani.

• Trematodes

Schistosomia haematobian - genitourinary infection, Pedunculated papillomas about the urethral orifice, fibrosis of the urinary bladder, hydronephritis, pyelonephritis, prostatitis, seminal vesiculitis, elephantiasis genitalia, involvement of the cervix, vagina, carcinoma. However, there is no evidence of person to person transmission of infection.

• Miscellaneous Bacillary or Chlamydia or Mycoplasma T strain or Tricagent - Reiter’s Syndrome

With the high incidence and wide-spread nature of STDs, medical practitioners have to face today uncommon, abstruse and difficult problem. Though STDs are of main concern to venereologists, they are also equally important for general practitioners, other specialists in medicine like obstetricians and gynaecologists. Doctors who undertake to treat these patients must at all times bear in mind their responsibilities to their patients and the community at large. Rapidly spreading viral diseases, growing profound suspicion of new virus AIDS and unfolding of bacterial induced diseases prompt one to look for the new era of antiviral, antibacterial or biochemical prophylaxis and therapeutics. These diseases have duel significance i.e. sexual and non-sexual. This helps the doctor to keep alert and emphasizes the need of broad knowledge of medicine. The compelling need is to develop rapid means of precise diagnosis of both the viral and bacterial. This has added new burden on doctors, diagnostic, therapeutic and control of their spread. It is, therefore, necessary for doctors to have a thorough knowledge and comprehension of theses diseases. An urgent need is to develop general guide lines for the management of these cases and to enforce them all over the clinics. Accurate appraisal of STDs demands familiarity with these diseases, epidemiology, treatment, their control, tracing contacts of patients etc. Early diagnosis and treatment of patients and their contacts are the unique task of every doctor and to recognise the fact that every patient is at significant risk of contagious disease. The ability of the doctor alone can enhance his capabilities.

The spectrum of agents and so the number of diseases caused by them have expanded and grown world-wide within a decade. This vast spread and the deadly nature of some diseases have to be matched equally with our progress in diagnostic and therapeutic technologies. From this point of management of these diseases, there is a wide variability in their clinical expressions and often overlapping in clinical presentations, this makes very essential to determine the specific etiology of every disease. However, this facility has not received an adequate attention in most hospitals in the country. Provision of perfect and reliable laboratory services, today, is a sina qua non for STD clinics. It is quite possible that these diseases will continue to have high incidence in the country, for majority of STDs do not provide any preventive immunity to patients. Hence it is all the more urgent to organize effective measures to combat the STDs challenge.

With the present day tendency to prescribe high dosage long-term steroids or antibiotics, infections due to ‘opportunistic’ low virulence pathogens must be constantly kept in the mind. Similarly when steroid therapy is combined with other immunosuppressive agents, one has to be constantly alert about new inflammations cropping up. They can unmask latent diseases and aggravate pre-existing disease. A high incidence of bacterial infections plus the tendency to recurrence of infection is associated with hereditary immune deficiency of other cellular or humeral defects. Likewise patients with multiple episodes of pulmonary infections should have an immunologic survey to detect immune deficiency disease. A thorough knowledge and practical experience about STDs is of vital importance? However, there is invariable dislike, disinclination and neglect, though these diseases play an important part in medicine. A lack of proper health services for venereal patients is very common in most hospitals in India. In fact, the dignity of human life has been downgraded. No attention is given to the cardinal principles of management os the diseases. Privacy during physical examination of patients and respect for the individual are invariably unknown. Often no adequate and proper space is made available for physical examination. There is an unfortunate tendency to prescribe without precise diagnosis. Contact-tracing, follow-up of cure, case records, maintenance of statistics and total neglect of internationally accepted criteria and procedures are conspicuously neglected. Notable advances in the subject are usually ignored. This the writer says without fear of contradiction. Excellent methods of prevention and treatment have to be developed. Diagnostic procedures for the newer diseases are highly specialised and cannot be denied to STD clinics. Diagnosis and treatment of AIDS is a subject for the skilled and experienced doctors in conjunction many other specialists. The present tendency to concentrate all attention and help on AIDS and to establish diagnostic laboratories at some places separately or not joined to the clinics and neglect of other venereal diseases and clinics in general are certainly full of dangers. Other venereal diseases deserve at least as much attention, care and finance as those for AIDS. The most neglected subject in the country is venereology and venereal patients. For it, nothing is conceded or received with grace. This has its root in the unhappy conception of the past regarding V.D. Their increased incidence and importance has failed to cause a resurgence of interest in these diseases. V.D. control has remained a distant goal. It is very disappointing that States and prestigious bodies like the Indian Medical Council, universities and medical colleges in India have been maintaining an amazing silence on very poor standards of medical education with regard to venereology and medical services to venereal patients. I see no evil attitude in the wake of mounting incidence of V.D. in the country is very strange, indeed.

It is doubtful whether the medical health planners and executors are adequately and perfectly qualified to sift, sort and check and arrive at the right decision or struggle in confusion. It is general observation that their views are self-centered, sketchy and often shallow and verily not related to the basic truth as far as venereal disease are concerned. Many well known experts in venereology, national and foreign, who happened to survey conditions in the country, made publicly valuable suggestions to improve conditions on several occasional but these suggestions have remained invariably and persistently ignored. The authorities’ actions hardly meet the venereologists’ view-point that demands the establishment of a separate chair for venereology in every medical college. The refusal to concede this vital demand can only result in a continuance of unmistakable decline in standards of medical education as regards venereology and venereal services to patients and research. Importance of special care units cannot be devalued. These patients require the expert care in terms of monitoring education, therapy, follow-up, records, statistics etc whose requirements can best served satisfactorily in a unit specially devoted to the care of such patients. The importance of this point increases, in view of the fact that V.Ds or STDs are the most common form of diseases currently. They need speedy and precise diagnosis and treatment. Delay means opportunities for their spread and complications. Thinking or decisions of the authorities is likely to be defective or incorrect because they are venereologically illiterate. An experienced venereologist solely devoted to his subject can be in a better position to suggest proper solution, which is beyond the scope of an ordinary person. The medical policy makers have shown a scant attention to the experts’ view and suggestions and therapy done is a great disservice and injustice to the medical studies related to STDs, and services to venereal patients. This trend has to be reversed to improve the present conditions. This ought to be a subject of deep concern to the medical educationists and health administrators. The writer would appeal to health ministers and others interested in the welfare of these unfortunate patients to make a point to visit incognito, the places where these patients are treated, how they are dealt with and to know their urgent and poorly understood needs and improved conditions. This is the only way for them to find actual state of affairs. Will they do me a favour? They will know the main reason why majority of the patients hate to seek medical guidance and help from these place. Only out of sheer necessity they are forced to have recourse to them.

(The writer will be glad to send authentic views of expert on V.D. education and medical services in India, if requested).