SEXUALLY TRANSMITTED DISEASES (STD’s)

Part I & II

by Maj. M. P. Vora.(R)

Vikram Cottage, 50, Pali Hill Road, Bombay- 400050.

Maharashtra Medical Journal

Part I – Volume No. XXXV, Number. 2 of February 1988.

Page No. 34 to 38.

Part II – Volume No. XXXV, Number. 3 of March 1988

Page No. 66 to 69.

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 than in the past and have completely overtaken the earlier venereal diseases. There are more than 35 different specific etiologic pathogens or agents that can be spread by the sexual route. The newer bacteria Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma hominis, several viruses and protozoa have become important sources of diseases. To the list can be added viruses like hepatitis B Cytomegalovirus, Epstin – Bar, papillma, molluscum contagiosum, herpes hominis type 1 and 2, entamoeba histolytica, Giardia lamblia, B-coli, Pseudomonas, Mima polymorph, Herellae vaginicola, Bacteroids, Fusobacterium, Shigella, B. crassus, enterococcus bacteria, streptococcus fecalis, Hemophilus ducreyi, Gardnerella vaginalis, B group streptococcus, Corynebactorium diphtheria, Microbacterium tuberculosus etc. Implications of these organisms in the causation of venereal complaints cannot be readily ruled out without adequate and painstaking investigations for a clear etiologic diagnosis. In fact, the precise role of some of these agents in the etiology of STDs is difficult to evaluate correctly in absence of adequate, comprehensive and reliable facilities and trained and experienced personnel, which are pre-requisites 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 far-reaching changes in its attitude and behaviour and longer life span or increased longevity,
• changes in attitudes to sex- pre and post-marital, are becoming frequent and regular,
• changes in sexual practices such as orogenital, anogenital homosexual, bisexual and hetero sexual 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.,
• quite a number of infections can be symptomless,
• increased travel, tourism, jet-age have caused fast and wide spread infections,
• emergence of resistant strains of organisms,
• indiscrete or inadequate use of antibiotics,
• neglect of regular post-treatment tests of ‘cure’,
• ignorance and apathy about growing number of STDs among the high risk groups and among most medical practitioners, and
• sustained want of highly trained and experienced personnel, reliable devoted experts in these diseases, well-equipped laboratories and fully trained and dependable technicians for accurate diagnostic procedures,
• failure of contact-tracing and simultaneous treatment of sexual partners,
• 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 infection, clinical consequences and advances in current understanding, 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.Ds- have also become frequent and endemic. The sudden increase in the incidence of sexually transmitted diseases caused by Chlamydia trachomatis, Ureaplasma urelyticum, HTLAV III/HIV/LAV causing AIDS, Herpes simplex virus type 1 and 2 etc. is quite apparent in advanced countries like America, Europe etc. Pelvic inflammatory disease (PID) due to Chlamydia, N. gonorrhoea, Mycoplasma hominis and Ureaplasma, with diminishing frequency and resultant infertility with repeated attacks of PID have become serious throughout the advanced world. However, they are much less obvious in most backward countries on account of the 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 is increased but also the number of agents transmitted sexually and asexually such as hepatic virus B, Cytomegalovirus, B group streptococcus, enteric pathogens, Mima herellea etc. 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 accept the new sex styles with gusto. The concept of virtue and vice have oft fluctuated over decades. Multiplicity of partners and unusual sexual practices such as oral, anal, homosexual and bisexual have added new dimensions to the problem. While the proportion 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 diseases as well as ignorance about them have helped to expand fast the sphere of the 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. Their 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 programmes for the prevention of infant and maternal mortality, infertility and morbidity be related to these diseases. This will naturally require a rapid action and a close cooperation between various health programme-planners and executors in different areas of health, medical education and training of all categories of personnel. All this tends to support the urgent need to recognise venereology as an important monospeciality to make full justice to the expanding and growing subject of great importance. Isn’t repugnant to allow it to continue as a part of dermatology? Is there the slightest justification to continue this harmful policy that has denied natural development and full maturity to the subject? The subject warrants special study. The general practitioners in medicine need continuous education and training with the older venereal diseases as well as the newer venereal diseases. They are in need of through knowledge, comprehension and practical experience in these diseases, methods of diagnosis, treatment, follow-up procedures, contact tracing, test of cure, record-keeping and maintaining correct statistics etc.

The etiological classification of STDs – Each of the pathogen listed below has been implicated or likely to implicate as a factor in the transmission of a sexual diseases although there is little evidence in support of sexual transmission of certain agents such as Cytomegalovirus, B group streptococcus, Scistosomia haematobium etc.

• BACTERIAL AGENTS AND MANIFESTATIONS
• Neisseria gonococcus- Acute or chronic urethritis, proctitis, Cowperitis, stricture urethra, epididymitis, pharyngitis, conjunctivitis, cervicitis, bartholinitis, endocervicitis, skeinitis, endometritis, salphingitis, pelvic peritonitis, periurethral abscess, perihepatitis (Titz Huge Curtis syndrome), arthritis, premature delivery, foetal infection on amniocentesis, ophthalmitis etc.
• Chlamydia trachomatis- urethritis, epididymitis, proctitis, cervicitis, prostatitis, salingitis, trachoma, otitis media, lymphogranuloma venerum, inclusion conjunctivitis, pneumonia, dysparunia, dysuria, urinary frequency, perihepatitis, Bartholinitis, foetal and neonatal mortality, post partum endometritis, cervical dysplasia, abortion, endocarditis, PID, sterility etc.
• Mycoplasma hominis- urethritis, salphingitis, oral ulcers, post-partum fever, PID, pneumonia, vasculitis etc.
• Ureaplasma urealyticum – urethritis, PID, sterility, cervicitis, choriomeningitis, low birth weight infant.
• B. crassus- ulcus acuminatus valvae rapidly progressing, usually in young girls between 15 to 20 age.
• Treponema pallidum- syphilis, congenital syphilis, cardiovascular and neurosyphilis, optic atrophy, gumma, condylomata lata, skin rashes etc.
• Haemophyllus ducreyi- chancroid, bubo, phagedena.
• Haemophylis veginitis- vaginitis, vulvitis, vaginal discharge.
• Haemophylus influenzae- genital tract infection, conjunctivitis, pharyngitis, laryngitis, arthritis etc.
• Calymmatobacterium granulomatis- (Donovanosis) or granuloma inguinale, papule, ulcer prepuce, glans, perianal lesion, labia in women, bone involvement
• Shigella- shigellosis, sexually transmitted in homosexual men, colitis, arthritis, diffuse mucosal inflammation and ulcers, person-to person spread.
• B group streptococcus- urethritis, ulceration, genitourinary infection.
• Fusospirochte or Fusobacterium- gangrenous genital ulcer, phagedena, vulval ulcer.
• Corynebacterium diphtheria- genital, vaginal, cervical ulceration, eyes, nasal lesions.
• Streptococcus faecalis- enterococcus- genitourinary infection.
• Microbacterium tuberculosis- In the male- genital tract, seminal vesicle, epididymis, vas deference lesions, sterility, urethritis. In the female, fallopian tubes, sterility, peritonitis, dyspareunia, cervicitis etc.
• Escheria coli- urinary tract infection, hepatobiliary, gastroenteritis, “opportunistic” invader.
• Pseudomonas – urinary tract and skin- anogenital area infection when the primary pathogen has been eradicated with antibiotics, when host resistance is diminished, by steroids or antineoplastic drugs, Person to person infection can be transmitted by humans, cornealulcers, conjunctivitis gangrenous ulcers in the ano-genital region.
• Mima Herellea- Mima polymorph- Penicillin – resistant urethritis, vaginitis, conjunctivitis etc. Herella vagicla – vaginal infection, ulcers.
• Bacteroids- vagnitis, Skien’s or Bartholinitis oral ulcerations.

• VIRAL INFECTIONS-
• Herpes virus hominis type-1 follicular conjunctivitis, naso-pharynx lesions, inclusion conjunctivitis, lesions on the glans penis, shaf penis ulcers.
• Herpes virus hominis type 2- Uniformally acquired venereally, genitalia, cervix, vagina, vulva infection, premalignancy stage of cervix, burning urination.
• Herpes zoster- skin and mucous membrane lesions, viremia encephalomyelitis, encephalitis, conjunctivitis.
• Hepatitis B virus- acute or chronic or fulminating hepatitis with immune complex phenomenon.
• Cytomegalovirus- congenital infection, birth defects, infant mortality, mental retardation, cervicitis, immunosupression, infectious mononucleosis,
• Papilloma virus- genital warts, condyloma acuminata
• Pox virus group- Molluscum contagiosa affecting skin and mucous membrane, anogenital area.
• HTLAV III/LAV/HIV- Acquired Immune Deficiency Syndrome (AIDS)
• Epstin- Bar virus- Infectious Mononucleosis, Transfer of virus by oro-pharyngeal route or during close personal contacts.

III 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, this can be transmitted in homosexual relations
• Entamoeba histolytica- Amoebiasis, sexual transmitted among homosexual males.

IV FUNGAL AGENTS

• Candida albicans – vulvovaginitis, balanitis, posthitis, urethral infection
• Gardnerella vaginalis- vaginitis, vulvitis

V ECTOPARASITES

• Phthirus pubis- pubis louse infection, pruritus ulceration
• Sarcoptis scabiei- Pruritus, ulcers. There is often a danger of primary syphilis escaping the detection or being overshadowed by scabies.

VI INTESTINAL NEMATODE

Entrobius vermicularis or Enterobiasis- In females, threadworms can enter vagina, can get access to peritoneal cavity through fallopian tubes, vaginal discharge, chronic granulomatous salpingtis, endometritis, pruritus, perineal eczema, pyogenic infection.

VII TREMATODES- SCHISTOSOMIA HAEMATOBIUM

Genitourinary infection, pedunculated papillomas about the urethral orifice, fibrosis of the urinary bladder, hydronephritis, pyelonephritis, prostatitis, seminal vesiculitis, elephantiasis genitalia, cervix and vagina get involved from the bladder carcinoma, secondary infection. There has been no evidence for person-to-person transmission of infection.

With the high incidence and wide-spread nature of STDs, medical practitioners have to face today uncommon and difficult problems. Though STDs are of main concern to venereologists, they are also important for general medical practitioners and other specialists in medicine like obstetricians and gynecologists etc. 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 and unfolding of growing suspicion of new virus- bacterial induced diseases prompt one to look to the new era of antiviral/antibacterial prophylaxis and new chemotherapies. The compelling need is to develop rapid means of precise diagnosis- both the viral and bacterial. This has added new burdens on doctors- diagnostic, therapeutic and control of diseases. It is therefore, necessary for doctors to have a thorough knowledge and comprehension of these diseases. An urgent need is to develop general guidelines for the management of these cases. Accurate appraisal of STDs demands familiarity with these diseases, perfect understanding, methods of diagnosis, treatment and control, tracing contacts of patients. The ability of the medical practitioner alone can enhance his capabilities.

The spectrum of agents and so the number of diseases caused by them have expanded vastly. This has to match equally with our progress in diagnostic and therapeutic technology. From the point of management of these diseases, there is often overlapping in clinical presentation; this makes very essential to determine the specific etiology. However, this facility has not received an adequate attention in most hospitals in our country. Provision of adequate and reliable laboratory services today is a sine qua non for STDs. It is quite possible that these diseases will continue to have high incidence in the country, for majority of STDs do not provide protective immunity to patients. Hence it is all the more urgent to organise effective measures to combat the challenge of STDs.

With the present day tendency to prescribe high dosage or 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 infections cropping up. They can unmask latent diseases and aggravate pre-existing disease. A high incidence of bacterial infections plus the tendency to recurrence of infections is associated with hereditary immune deficiency either cellular or humoral defects. Similarly, patients with multiple episodes of pulmonary infections should have an immunologic survey to detect immune deficiency diseases. Isn’t thorough knowledge and practical experience about STDs of vital importance? However, there is invariable dislike and neglect, though venereal diseases play an important part in medical sciences. A lack of proper health services for venereal patients is very common in most hospitals in India. No attention is given to the cardinal principles in the management of STDs. Privacy during the physical examination of patients, his or her interrogation and respect for the individual are invariably unknown. There is an unfortunate tendency to prescribe without precise diagnosis. Contact-tracing, follow-up tests of cure, case records, maintenance of statistics and neglect of internationally accepted criteria, procedures are conspicuously neglected. Notable advances in the subject are usually ignored. Excellent methods of prevention and treatment have to be developed. Diagnostic procedures for the newer diseases are highly specialised and cannot be denied to the STD centres. Venereal diseases deserve at least as much attention, care and finance as AIDS. The most neglected subject in the country is venereology. For it, nothing is conceded or received with grace. Its increased 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, various universities and medical colleges in India have maintained an amazing silence on very poor standards of medical education and medical services, to venereal patients.

It is doubtful whether the medical health planners and executive authorities are adequately and perfectly qualified to sift, sort and check to arrive at the right decision or struggle in confusion. It is general observation that their views are self-concentrated, sketchy and often shallow and not related to the basic truth as far as V.Ds are concerned. They hardly meet the venereologist’s view-point, that demands the establishment of a separate chair for venereology in every medical college. The refusal to concede this demand can only result in a continuance of unmistakable decline in standards of medical education and venereal services to patients. Importance of special care unit cannot be devalued. Venereal patients require expert care in terms of monitoring and therapy. Such requirements are best satisfied in a unit specially devoted to the care of such patients. The importance of this point increases in view of the fact that STDs are most common form of diseases currently. They need speedy diagnosis and treatment. Delay means opportunities for their spread. The authorities thinking and decision are likely to be defective because they are venereologically illiterate. An experienced venereologists solely devoted to his subject can be in a better position to suggest proper solutions which are beyond the scope of an ordinary person. The medical policy makers have shown a scant attention to the experts’ views and suggestions and thereby done 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.