Sports Medicine Rounds
January 25, 2007
Paul W. Baumert, Jr., M.D., FAAFP
UI Student Health Service
Topics
Background Information
Sores
Drips
Role of STIs in HIV Transmission
SHS Services
STIs of Concern
Actually, all of them
Sores (ulcers)
Syphilis
Genital herpes (HSV-2, HSV-1)
Others uncommon in the U.S.
Lymphogranuloma venereum
Chancroid
Granuloma inguinale
STIs of Concern (continued)
Drips (discharges)
Gonorrhea
Chlamydia
Nongonococcal urethritis /
mucopurulent cervicitis
Trichomonas vaginitis / urethritis
Candidiasis (vulvovaginal, less
problems in men)
Other major concerns
Genital HPV (especially type 16,
18) and Cervical Cancer
Sores
Syphilis
Genital Herpes (HSV-2, HSV-1)
Genital Ulcer Diseases
Does It Hurt?
Painful
Chancroid
Genital herpes simplex
Painless
Syphilis
Lymphogranuloma venereum
Granuloma inguinale
Herpes Simplex Virus (HSV)
Epidemiology of Genital Herpes
One of the 3 most common STDs,
increased 30% from late 70s to early 90s
25% of US population by age 35
HSV-2: 80-90%, HSV-1: 10-20%
(majority of infections in some regions)
Most cases subclinical
Transmission primarily from
subclinical infection
Complications: neonatal
transmission, enhanced HIV transmission, psychosocial issues
Symptoms of
Genital Herpes
Numerous painful lesions (sores)
On the penis, vagina, anus, buttocks, thighs, mouth, or finger
Last up to 4 21 days
Other symptoms include headache, fever, muscle aches, swollen lymph
nodes, and difficult urination.
Symptoms may or may not come back.
Genital Herpes Without Symptoms
Many people with herpes do not have any symptoms or do not recognize that
they have symptoms.
Most people with herpes can pass the virus to sex partners even when they
do not have symptoms.
Herpes in a Man
Herpes in a Woman
Genital Herpes Simplex
You can get herpes anywhere . . .
Testing & Treatment for
Genital Herpes
Can be detected by:
culturing the lesion
blood test
Herpes cannot be cured, but
symptoms can be treated with medicines called antivirals.
You can still spread herpes even
if you are taking antiviral medicine!
Do Patients Want to Know?
92.4% wanted to know if they were infected
90.8% wanted to know if their partners were infected
65% expected the test as part of STD screening
Syphilis
Syphilis
Syphilis is sometimes called bad blood , pox, lues, or a zipper cut
Syphilis is caused by a bacteria
Incubation Period: 10-90 days (average 21 days)
Can cause infections in men, women, and unborn babies during pregnancy
Symptoms of Syphilis
Primary Stage
A painless sore called a chancre
may be located on the genitals, lips, anus, or other area of direct contact
The chancre will last 1-5 weeks
and heal without treatment
The person can easily pass it on
to sex partners
Primary Syphilis Chancre in a Man
Primary Syphilis Chancre in a Woman
Oral Primary Syphilis Chancre
Symptoms of Syphilis
Secondary Stage
Skin rashes lasting 2 6 weeks
(average of 4 weeks) on the palms of the hands, bottoms of the feet, or any part
of the body
Other symptoms include fever,
swollen lymph glands, headache, hair loss, and muscle ache
Symptoms will go away without
treatment
The person may be able to pass it
on to sex partners
Secondary Syphilis Body Rash
Secondary Syphilis Rash
Secondary Syphilis Palm Rash
Symptoms of Syphilis
Late Stage
Paralysis
Insanity
Blindness
Damage to knee joints
Personality changes
Impotency
Aneurysm (ballooning of a blood
vessel)
Tumor on the skin or internal
organs
Testing & Treatment for Syphilis
Easily detected by a blood test; and
Easily cured with antibiotics;
Any damage done to the body cannot be repaired.
Drips
Gonorrhea
Chlamydia
Nongonococcal urethritis
Mucopurulent cervicitis
Trichomonas vaginitis and urethritis
Candidiasis
Gonorrhea
Gonorrhea
Gonorrhea is sometimes called
clap, drip, dose, strain, gleet or the whites
Incubation period: 1 14 days
A bacteria causes gonorrhea
Can cause infections in men,
women, and new babies
The person can easily pass it on
to sex partners and babies during childbirth
Gonorrhea Symptoms in Men
Complications in Men
Swollen or tender testicles (epididymitis)
Disseminated gonococcal infection (DGI)
Disseminated Gonococcal (Gonorrhea) Infection
Gonorrhea Symptoms in Women
Complications in Women
Bartholins Abscess
Pelvic inflammatory disease (PID)
Disseminated gonococcal infection (DGI)
Testing & Treatment for Gonorrhea
Easily detected by a urine test or
swab; and
Easily cured with antibiotics; but
Any damage to the body cannot be
repaired.
Chlamydia
Chlamydia
Can cause infection in men, women, and newborn babies
Chlamydia is caused by a bacteria
Incubation Period: 2-3 weeks
The person can pass it on to sex partners and to babies during childbirth
Symptoms of Chlamydia
Symptoms in Women:
Usually asymptomatic
Abnormal vaginal discharge
Pain during sex
Complications, if not treated:
Pelvic inflammatory disease (PID)
Symptoms in Men:
Usually asymptomatic
Discharge from the penis (may be
runny, whitish)
Burning on urination
Complications, if not treated
Swollen and tender testicles
(epididymitis)
Chlamydia Symptoms in Men
Chlamydia Symptoms in Women
Mucopurulent Cervicitis
Testing & Treatment for Chlamydia
Easily detected by a urine test or
a swab; and
Easily cured with antibiotics; but
Any damage to the body cannot be
repaired
Laboratory Tests for Chlamydia
Tissue culture has been the
standard
Specificity approaching 100%
Sensitivity ranges from 60% to 90%
Non-amplified tests
Enzyme Immunoassay (EIA), e.g.
Chlamydiazyme
sensitivity and specificity of 85%
and 97% respectively
useful for high volume screening
false positives
Nucleic Acid Hybridization (NA
Probe), e.g. Gen-Probe Pace-2
sensitivities ranging from 75% to
100%; specificities greater than 95%
detects chlamydial ribosomal RNA
able to detect gonorrhea and
chlamydia from one swab
need for large amounts of sample
DNA
Laboratory Tests for Chlamydia
(continued)
DNA amplification assays
polymerase chain reaction (PCR)
ligase chain reaction (LCR)
Sensitivities with PCR and LCR 95%
and 85-98% respectively; specificity approaches 100%
LCR ability to detect chlamydia in
first void urine
Nongonococcal Urethritis
Nongonococcal Urethritis
Etiology:
20-40% C. trachomatis
20-30% genital mycoplasmas (Ureaplasma urealyticum, Mycoplasma
genitalium)
Occasional Trichomonas
vaginalis, HSV
Unknown in ~50% cases
Sx: Mild dysuria, mucoid
discharge
Dx: Urethral smear
³
5 PMNs (usually ³15)/OI
field
Urine microscopic
³
10 PMNs/HPF
Leukocyte esterase (+)
Human Papillomavirus (HPV)
Human Papillomavirus
Many types of Human Papillomavirus (HPV), some of which infect the
genital area
Incubation period unclear
Can infect men, women, and newborns
The person can easily pass it on to sex partners
Genital HPV: Two Types
The types of HPV that infect the genital area are labeled low-risk or
high-risk depending on whether they can cause cancer or not.
Low-risk HPV types can cause genital warts.
High-risk HPV types can cause serious cervical lesions, cervical cancer,
and other genital cancers.
Symptoms of Genital HPV Infection
Usually asymptomatic and brief (6
12 months)
Genital warts (usually infection
with low-risk type of HPV)
Warts on the penis, vagina, anus
or urethra
Rarely may have itching, bleeding,
burning, or pain along with the warts
May go away on their own, stay
about the same, or get worse
Symptoms of Genital HPV Infection
Cervical lesions (usually
infection with high-risk type of HPV)
Usually no symptoms
Detected by Pap smear
Most will go away on their own
Some will persist and need to be
followed by health care provider
Most women with high-risk HPV
types do not get cervical cancer
HPV Penile Warts
Genital Warts in a Woman
Perianal Wart
Testing & Treatment for
Genital Warts
Genital Warts
No tests for genital warts
Several types of treatment are
available
Warts may come back
Cervical lesions and cervical
cancer
Regular Pap smears are best way to
detect serious lesions and prevent cervical cancer
Pap smear screening is recommended
for all sexually active women
HPV and Cervical Cancer
HPV and Cervical Cancer
Infection is generally indicated
by the detection of HPV DNA
HPV infection is causally
associated with cervical cancer and probably other anogenital squamous cell
cancers (e.g. anal, penile, vulvar, vaginal)
Over 99% of cervical cancers have
HPV DNA detected within the tumor
Routine Pap smear screening
ensures early detection (and treatment) of pre-cancerous lesions
Estimates for HPV-Associated Cancers
Cervical cancer:
In the U.S., an estimated 14,000
cases and 5,000 deaths
Worldwide, an estimated 450,000
cases and 200,000 deaths
Intrameatal Wart of the Penis
(and Gonorrhea)
Role of STIs in HIV Transmission
Role of STIs in HIV Transmission Summary
At least 2 to 5-fold increased
risk of HIV seroconversion confirmed by data from 4 continents
Attributable risk of STIs for HIV
transmission substantial in some populations
HIV susceptibility likely
increased through endocervical CD4 recruitment by nonulcerative STIs, as well as
through portal of entry created by ulcers
Role of STIs in HIV Transmission Summary
Greater infectiousness because of
prevalence & magnitude of HIV shedding increased by STIs; STI treatment reduces
shedding to baseline levels
40% reduction in HIV incidence
achieved in randomized trial of treatment of symptomatic STIs in Tanzania
STI Treatment for HIV Prevention in the US -
Where Do We Start?
Access to & quality of STI
clinical services
Early & effective STI-related
health care behaviors
Surveillance systems to monitor
STI/HIV trends & interrelationships
STI Treatment for HIV Prevention Early,
Effective Health Care Behavior
Sexual risk reduction counseling PLUS
Messages for at-risk persons & providers
Other STIs increase HIV spread
Recognize & act on symptoms/sign
Most STIs asymptomatic; regular screening critical
Specific information on sources of care
STI Testing Available at SHS
Gonorrhea
Chlamydia
Syphilis
Herpes
HPV (pap smears)
Hepatitis B
Hepatitis C
HIV
STI Services at SHS
Confidential
Evaluation
Testing (e.g. blood, urine,
lesions)
Counseling
Prevention (e.g. vaccines)
STI Treatment Available at SHS
GC/chlamydia/other
State program meds (No charge)
Rx
HPV
Cryotherapy
TCA
Counseling
Cost of STI Services at SHS
No charge
Evaluation
Routine GC/chlamydia
screen/testing
State program medications for
treatment
STI serology (serum testing), not
including HIV
$5
HIV
$20 for Orasure (saliva HIV
testing)
$25 for serum HIV testing
(includes other serologies)
HPV
Variable, can be EXPENSIVE!
Patient assistance programs
Summary
Inform athletes about:
Availability of services
Cost
NOT covered by athletics
Confidentiality
Safe sex precautions
There is no 100% safe sex method, except for abstinence!