STD / Proctitis




Sexually Transmitted Infections
  • Chlamydia
  • Gonorrhea
  • NonChlamydia NonGonorrheal Uretrhitis and Cervicitis
    • Mycoplasma genitalium causes 10-25% of nongonococcal urethritis (NGU).
    • Ureaplasma urealyticum, 
    • Trichomonas vaginalis
    • herpes simplex virus or 
    • adenovirus, but 
    • the etiology of NGU is often unknown 
  • BV
    • Organism: Gardnerella Vaginalis, Mobiluncus, various anaerobic bacteria and M. hominis 
    • Pathogenesis:
      • Normal H2O2 producing Lactobacillus sp. species are replaced by BV causing organism; loss of H2O2 production, means pH rises 
      • Role of sexual transmission is unclear
    • Diagnosis:  AAFP 2011
      • Amsel criteria (3 /4 should be present
        • Thin, homogenous vaginal discharge
        • Vaginal pH greater than 4.5
        • Positive whiff test (fishy amine odor when 10 percent potassium hydroxide solution is added)
        • At least 20 percent clue cells (vaginal epithelial cells with borders obscured by adherent coccobacilli on wet-mount preparation or Gram stain)
    • Treatment
      • Metronidazole or Tinidazole
      • Even clindamycin works as these organisms are anaerobic bacteria
      • Unlike Trichomoniasis, local metronidazole is effective as well
      • Recurrence after treatment is common
        • Can be treated with same or alternate agent
        • Symptomatic second reoccurrence, that occurs can be treated with Metronidazole Gel as suppressive therapy
        • Infected Male counterpart has not been found, and Treating Male partner, does not reduce the risk of subsequent reoccurrence 
    • Reference:
  • Trichomoniasis  
    • Organism: Trichomonas Vaginalis
    • Site of infection: Squamous Epithelial Tissue of Urogenital tract i.e vagina, urethra, and paraurethral glands. 
      • Less frequently involved sites include: Cervix, Bladder, Prostrate, Bartholin Glands
    • Mode of infection:
      • Humans are the only natural host, and is always transmitted sexually. 
        • Identified in 70 % of male sexual partners of infected women 
    • Treatment: 
      • Both symptomatic and asymptomatic patient and partner must be treated 
      • The 5-nitroimidazole drugs (metronidazole or tinidazole) are the only class of drugs that provide curative therapy of trichomoniasis. 
        • Only PO metronidazole works (Vaginal Metronidazole is not as effective)
        • Resistance to Metronidazole, especially high-grade resistance is rare
        • Tinidazole is better tolerated than Metronidazole
          • Tinidazole is also effective against Metronidazole resistence 
      • Patient and partner should avoid intercourse until they and their partners have completed treatment and are asymptomatic, which generally takes about a week. 
    • References:
  • Chancroid
  • Genital Warts
  • Syphilis
  • Genital Herpes
  • Proctitis: DDx:
    • Non-Infectious Etiology
    • Infectious Etiology
      • MSM (4 Most prevalent DDx are)
        • Gonorrhea
        • HSV
        • Chlymadia Trachomatis
          • Serovar D through K: 
            • Most common cause of nongonoccal urethritis, and mucopurulent cervicitis
            • Can cause procitis, usually mild and responds to one dose of Azithro
            • Treatment: Single 1-g dose of azithromycin (eg. Zithromax) or 7 days’ treatment with doxycycline (eg. Vibramycin) 
          • Serovar L1, L2, L3: lymphogranuloma venereum (LGV)
            • Usually cause more severe disease
            • 3 Stages of LGV produce 3 distinct clinical syndromes
              • Primary (painless ulcer that usually resolves spontaneously)
              • Secondary (10-30 days, hallmark is lymphadenitis)
                • Inguinal or Femoral Lymphadenitis (or both; may suppurate and form abscess, sinus or fistula) if Penis or Vagina is a site of inoculation 
                • Proctitis( If rectum is a site of inoculation
                  • Treatment: 3 week course of Doxycyline
              • Tertiary (fibrosis and strictures leading to chronic genital ulceration, genital elephantiasis, anal fistulae and strictures, frozen pelvis, and infertility)
        • Syphilis
      • Ongoing infectious colitis also causing proctitis
        • Bacteria: shigella, Escherichia coli, Clostridium difficile 
        • Protozoa: amoebiasis 
        • Virus: CMV
    • Case 2-2006: A 31-Year-Old, HIV-Positive Man with Rectal Pain (DDx of Proctitis)
STDs Treatment Guidelines (Pharmacology)

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