Overview STD's are one of the most common gynecologic ER presentations All sexually active partners should be screened for STDs Risk factors incude multiple sexual partners unprotected sexual intercourse young age at first intercourse men who have sex with men Common presentations are ulcerations of the vulvovaginal region abnormal vaginal discharge inguinal rashes inguinal lyphadenopathy abdominal pain 25-50% have multiple genital tract infections Disease Introduction Presentation Evaluation Treatment Primary syphilis Caused by Treponema pallidum (spirochetes) Appears in 2-10 weeks Painless genital ulceration (chancre) Dark field microscopy, VDRL/RPR (a rapid but nonspecific screening test), and/or a FTA-ABS (specific and diagnostic, the gold standard) Penicillin Secondary syphilis Caused by Treponema pallidum (spirochetes) Appears 1-3 months after primary infection Maculopapular rash on palms and soles, fever, headache, and generalized lyphadenopathy Condylomata lata (moist lesions on the genitals which are highly infectious) - Penicillin Tertiary syphilis Caused by Treponema pallidum (spirochetes) Aortic aneurysm and aortic regurgitation Granulomatous gummas of the CNS, heart and great vessels - Penicillin Gonorrhea Caused by Neisseriae gonorrhoeae Dysuria, urinary frequency, and purulent yellow-green discharge May progress to PID, high rate of coinfection with with chlamydia Can cause proctitis in the setting of anal intercourse Evaluation should include cervical and urethral cultures for chlamydia and gonorrhea Clean catch urine culture to rule out UTI Saline/KOH/Gram stain of vaginal discharge All sexually-active women 24 years of age or younger should be screened Ceftriaxone, also treat for presumed chlamydia infection If urethritis is refractory to azithromycin, consider Trichomonas and treat with metronidazole Chlamydia Caused by Chlamydia trachomatis serotypes D-K Often asymptomatic, but may cause dysuria, cervicitis, PID, lymphogranuloma venereum, or infertility Chlamydia antigen test All sexually-active women 24 years of age or younger should be screened Tetracycline/doxycycline, azithromycin for cervicitis Use erythromycin base or amoxicillin in pregnancy Do not need to routinely treat for presumed gonorrhea infection, but should in patients with confirmed gonorrhea or high risk patients Venereal warts (condylomata acuminata) External lesions associated with HPV 6,11, endocervical warts caused by HPV 16, 18, 31, 33. Transmitted sexually and have a incubation period of 1 to 6 months Painless, soft, fleshy, "cauliflower like lesion" Lesion can be on the vulva, vaginal wall, the cervix, and the perineum Biopsy lesion with 5% acetic acid to detect condylomata acuminata No treatment is satisfactory. Relapse is frequent and requires retreatment Treatment modalities include podofilox (an antimiotic), cryotherapy, laser surgery, or electrocauterizations, and biopsy, imiquimod (interferon inducer) are widely used but require multiple applications and frequently fail Presence during pregnancy does not require cesarian section Herpes Caused by HSV-2 Parasthesias and burning followed by painful vesicles and ulcerations In primary infections patients may present with fever, malaise, and adenopathy A Tzanck smear for lesions suspicious of HSV Topical acyclovir ointment during flare-up, oral acyclovir to decrease rate and severity of recurrence