Sexually Transmitted Infections (updated 2023) - CRASH! Medical Review Series

Summary

This video discusses sexually transmitted infections (STIs), focusing on their global prevalence, diagnostic approaches, and treatment options. The speaker covers common STIs like gonorrhea, chlamydia, herpes, syphilis, and genital warts, emphasizing the importance of obtaining a comprehensive sexual history from patients and conducting thorough exams. It also highlights the geographic disparities in STI rates, particularly between the US and the global South. Treatment strategies have evolved, with a focus on updated guidelines for antibiotics and antiviral medications. The speaker stresses patient education, safe sex practices, and the importance of preventing STI transmission.

Takeaways

• 😀 STI (Sexually Transmitted Infections) is the preferred term over STD (Sexually Transmitted Disease), and it is a crucial topic for USMLE exams.
• 😀 Geographic disparities in STI prevalence exist, with higher rates in the Global South, especially Africa and the Indian subcontinent, often due to lack of sexual education.
• 😀 In the US, STI rates also vary by region, with states like New Hampshire having significantly lower rates than Mississippi, highlighting cultural and educational influences.
• 😀 A thorough sexual history is essential in diagnosing STIs. It's crucial to create a comfortable environment for the patient and ask about sexual practices rather than orientation.
• 😀 When performing an intimate exam, medical legal guidelines recommend having another person present, especially for male providers.
• 😀 The most common STIs in the US include gonorrhea, chlamydia, genital herpes, and syphilis. A comprehensive exam and proper testing are vital for accurate diagnosis and treatment.
• 😀 Gonorrhea and chlamydia often co-occur, and the treatment involves antibiotics like ceftriaxone for gonorrhea and doxycycline for chlamydia, with special considerations for pregnant patients.
• 😀 Pelvic inflammatory disease (PID) is a significant complication of untreated gonorrhea and chlamydia, potentially leading to infertility in women.
• 😀 Herpes simplex virus (HSV) causes painful genital lesions. PCR testing is the best diagnostic method, and treatment often includes acyclovir or valacyclovir.
• 😀 Syphilis progresses through primary, secondary, and tertiary stages, with painless genital ulcers in primary syphilis, skin rashes in secondary, and severe neurological symptoms in tertiary syphilis. Penicillin remains the treatment of choice.

Q & A

What is the difference between STI and STD?

STI (Sexually Transmitted Infection) is the preferred term now, as it reflects that an infection can be present without causing disease. STD (Sexually Transmitted Disease) was the former term, but STI is more accurate because it focuses on the infection itself, which may or may not result in disease.

Why is there a geographic disparity in STI rates within the U.S.?

Geographic disparities in STI rates within the U.S. are largely influenced by factors such as socioeconomic conditions, access to sexual education, and religious influences, which can affect attitudes towards safe sex and sexual health education.

How should a healthcare provider approach taking a sexual history from a patient?

Healthcare providers should approach sexual history with a nonjudgmental, open, and reassuring attitude to ensure that patients feel comfortable disclosing sensitive information. Questions should focus on the number of sexual partners, sexual practices (oral, anal, vaginal), and the gender of partners, rather than asking about sexual orientation or promiscuity.

What are the key differences between gonorrhea and chlamydia in terms of symptoms and treatment?

Gonorrhea and chlamydia both present with similar symptoms like dysuria, discharge, and urgency, but gonorrhea is more likely to cause complications such as epididymitis in men and pelvic inflammatory disease in women. Gonorrhea is treated with ceftriaxone, while chlamydia is typically treated with doxycycline (unless the patient is pregnant, in which case azithromycin is used).

What is epididymitis, and how is it diagnosed and treated?

Epididymitis is an inflammation of the epididymis, often caused by STIs like gonorrhea, chlamydia, or mycoplasma genitalium. It presents with unilateral scrotal pain, erythema, and sometimes fever. Diagnosis is clinical, supported by urine tests or Gram stain, and treatment includes ceftriaxone and doxycycline, with adjustments for specific sexual histories.

How is herpes simplex virus (HSV) diagnosed and treated?

Herpes is diagnosed through PCR testing, which is more sensitive than the older Zank smear, or viral culture, which can also provide viral sensitivity. Treatment typically involves acyclovir, with valacyclovir for chronic suppression. If acyclovir-resistant strains are identified, foscarnet may be used.

What are the stages of syphilis, and how is it diagnosed and treated?

Syphilis progresses through three stages: primary (painless ulcer), secondary (rash, flu-like symptoms), and tertiary (tabes dorsalis, gummas). Primary syphilis is diagnosed with darkfield microscopy, while secondary and tertiary stages are diagnosed using RPR or FTA tests. Treatment is with benzathine penicillin, with IV penicillin for tertiary syphilis, and doxycycline as an alternative for those allergic to penicillin.

What are the main differences between chancroid and lymphogranuloma venereum (LGV)?

Chancroid presents as painful ulcers with painful lymphadenopathy, caused by *Haemophilus ducreyi*. LGV, caused by *Chlamydia trachomatis* serovars L1-L3, typically starts with a painless genital ulcer followed by painful lymphadenopathy. LGV is less common in the U.S. than chancroid.

What are the typical symptoms and treatment options for genital warts caused by HPV?

Genital warts are characterized by cauliflower-like, pedunculated growths that can appear on the genital or anal area. The diagnosis is clinical, and treatment may involve imiquimod or cryotherapy, depending on the severity and patient preference. Vaccination for HPV can help prevent genital warts.

Why is safe sex education so important in the prevention of STIs, and what are the most effective prevention methods?

Safe sex education is crucial in reducing the spread of STIs, as it encourages the use of protective measures such as condoms and promotes open discussions about sexual practices. Condoms and abstinence are the most effective ways to prevent STI transmission, while methods like pulling out or birth control do not protect against STIs.