Vulvar infections: beyond sexually transmitted infections

The vulva is an under‐studied area of the female genitourinary tract which is prone to maceration, overgrowth of organisms, and atypical presentations of common dermatologic conditions. In current practice, dermatologists must recognize and manage vulvar infections and infestations beyond the more commonly recognized sexually transmitted infections. Herein, this article reviews the literature on a selection of under‐recognized viral, bacterial, fungal, and parasitic vulvar infections and infestations.     

Pregnancy and sexually transmitted viral infections

Viral infections in pregnancy are a major cause of morbidity and mortality for both mother and fetus. Viral STIs occur as surface infection and then gradually infect immunologically protected sites. Therefore, these are asymptomatic, hidden and hence underdiagnosed, persistent and difficult to treat. HSV, HPV, HBV, HIV and CMV (cytomegalovirus) are the common ones. Most of these are transmitted during intrapartum period. Proper screening, identification and treatment offered during prenatal period may help in preventing their complications. Twenty five percent of women with a history of genital herpes have an outbreak at some point during the last month of pregnancy. Acyclovir is the accepted efficacious and safe therapy for HSV in pregnancy. Globally, HPV infection is the most common sexually transmitted infection. Neonatal transmission can occur in the absence of clinically evident lesions. HPV 6 or 11 may lead to Juvenile Onset Recurrent Respiratory Papillomatosis (JORRP). TCA, liquid nitrogen, laser ablation or electrocautery can be used to treat external genital HPV lesions at any time during pregnancy. Cesarean section is recommended only if the lesions are obstructing the birth canal. Mother to child transmission (MTCT) in HIV accounts for 15-30% during pregnancy and delivery, and a further 5-20% of transmission occurs through breastfeeding. HBV infection during pregnancy does not alter the natural course of the disease. In women who are seropositive for both HBsAg and HBeAg, vertical transmission is approximately 90%. Pregnancy is not a contraindication for HBV vaccination. Cytomegalovirus (CMV) is the most common intrauterine infection. Cytomegalic inclusion disease (CID) is the most severe form of congenital CMV infection. Treatment is supportive.     

Prevalence of sexually transmitted infections among sexually active Jordanian females

OBJECTIVES: To determine the prevalence of the most important sexually transmitted infections among women of child bearing age in Jordan. GOAL: To assess the need for screening programs to detect sexually transmitted infections. STUDY DESIGN: This is a cross-sectional study wherein consecutive symptomatic and asymptomatic women presenting to gynecology and family planning clinics from different areas in Jordan were tested for reproductive tract infections caused by Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pallidum, and Trichomonas vaginalis. RESULTS: The prevalence of C. trachomatis infection was 0.6% and 0.5%, among symptomatic and asymptomatic women respectively, that of N. gonorrhoeae was 0.9% and 2.2%, that of T. pallidum 0.0% and 0.0%, and that of Tr. vaginalis was 0.7% and 0.5%. These prevalence rates did not differ significantly between symptomatic and asymptomatic women. CONCLUSIONS: Based on the low prevalence of sexually transmitted infections detected in this study among Jordanian women, the need for screening programs for such infections is questioned.     

Clustering of seropositivities for sexually transmitted infections

BACKGROUND: Serology for different sexually transmitted infections (STIs) is useful for epidemiologic studies on the spread of STIs in different populations. Studying whether seropositivities for different STIs cluster could be useful, both for development of improved serologic markers of sexual behavior in populations and for understanding how STIs may differ in terms of the dynamics of their spread. GOAL: To evaluate the degree of clustering of different STIs in relation to sexual history. STUDY DESIGN: An age- and sexual history-stratified subsample of 275 women from a survey of healthy Swedish women seeking contraceptive advice was tested for human papillomavirus (HPV) types 6, 11, 16, 18, and 33; Chlamydia trachomatis; herpes simplex virus 2 (HSV-2); and human herpesvirus 8. RESULTS: Significant clustering was observed only for HPV types 6 and 11; for HPV types 16, 18, and 33; and for C trachomatis and HSV-2. The serologic marker that correlated best with lifetime number of sex partners was HPV type 16 (odds ratio [OR], 10.2; 95% CI, 3.8-27.6). The combined serologic marker that correlated most highly with sexual history was joint positivity for HPV types 16 and 33 (OR, 25.5; 95% CI, 5.4-120.4). CONCLUSIONS: The degree of clustering between different STIs varies from nonexistent to strong, implying that different STIs commonly have very different transmission dynamics. Certain combinations of STI serologic tests may be useful in epidemiologic studies for predicting sexual behavior in groups.     

A global look at sexually transmitted infections

This paper will give a resume of many of the important factors, which form the immense problems in sexually transmitted infections in the world in 2007. STI is the term used to include sexually transmitted diseases and HIV/AIDS. It aims to enlighten both the specialist dermato-venereologist as well as all interested readers.     

Epidemiology of sexually transmitted diseases and infections

Sexually transmitted diseases and infections (STDIs) are known to have a major socioeconomic and biologic impact, par notticularly on women (e.g., sterility, ectopic pregnancies, neo notplasms, etc.) and fetus (intrauterine and perinatal mortality, infection, malformations). Sex work noters do not use health services appropriately and are a high-risk category. Despite this evidence, data on prostitution and STDIs in some countries are limited. Sexual health medicine is involved in the community by identifying and minimizing the STDI problems through laboratory screening, diagnostic testing, education, and research.     

Skin as an indicator for sexually transmitted infections

Cutaneous signs and skin conditions associated with sexually transmitted infections (STIs) are discussed. Syphilis, condyloma acuminata, and scabies are well-known STIs with cutaneous manifestations. Chlamydia and gonorrhea can also cause specific muco-cutaneous signs and symptoms. HIV often manifests itself through skin conditions. Dermatologists are pivotal in the timely diagnosis of HIV infection and play an important role in the disease prognosis and ongoing transmission. Anal intra-epithelial neoplasia (AIN), an HPV related precursor of anal carcinoma affecting HIV positive men, is a relatively new condition that many dermatologists will face in the future. STIs should be involved in the differential diagnosis when dermatologists are confronted with anogenital dermatoses, especially in patients with an increased risk for STIs.     

Genital ulcers and concomitant complaints in men attending a sexually transmitted infections clinic: implications for sexually transmitted infections management

BACKGROUND: Although genital herpes has emerged as the most common cause of genital ulcers in Southern Africa, treatment for herpes is not available routinely in the region. This study was performed to determine the etiology of genital ulcers in men in Durban and assess other sexually transmitted infections-related symptoms, presentation, and treatment patterns in this group. METHODS: Polymerase chain reaction (PCR) tests were performed on specimens from consecutive male patients with genital ulcers to detect sexually transmitted pathogens. PCR was also performed for the detection of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis on urethral specimens from consecutive subjects with dysuria or urethral discharge. Antibody tests for syphilis and herpes simplex virus type-2 (HSV-2) and human immunodeficiency virus antibodies were performed. RESULTS: Of 162 patients enrolled with genital ulcers, 77.7% were human immunodeficiency virus-positive and 84.6% had antibodies to HSV-2. PCR results showed the following prevalences: HSV-2 53.7%, lymphogranuloma venereum 13.6%, Treponema pallidum 3.7%, Hemophilus ducreyi 1.2%, mixed infections 6.2%, and no pathogens identified 33.3%. One case of donovanosis was diagnosed clinically. In men with HSV-2 ulcers, delay before attendance recorded for 68 men was 1 to 3 days (24%), 4 to 7 days (47%), 8 to 14 days (12%), 15 to 30 days (12%), and >30 days (6%). History-taking using prompting increased the sensitivity but decreased the specificity and positive predictive value of reported genital ulceration when assessed against ulcers seen on examination. CONCLUSIONS: Men at risk of genital ulcers should be asked about relevant symptoms with and without prompting and examined clinically to maximize the likelihood of correct diagnosis and treatment. The finding of a high prevalence of HSV-2 and associated dysuria cautions against providing empirical treatment for gonorrhoea and chlamydia in ulcer patients with dysuria but without urethral discharge. Innovative strategies to limit the burden of HSV-2 infection in this population are required.     

Differences between nonnational and indigenous patients with sexually transmitted infections in Italy and insight into the control of sexually transmitted infections

BACKGROUND: To determine the health needs non-nationals, information on disease occurrence is fundamental.GOALS The goal of this study was to assess the clinical and behavioral characteristics of non-Italians with a new sexually transmitted infection (STI). METHODS: Data were taken from Italy's National STI Surveillance System (1991-1999). RESULTS: Of the 61,798 STI cases reported from January 1991 to December 1999, 6847 (11.2%) were diagnosed among non-Italians, 47.1% of whom were Africans. Being a non-Italian patient with an STI was associated with male gender (adjusted odds ratio [AOR], 1.19; 95% confidence interval [CI], 1.11-1.27), youngest age (AOR, 1.71; 95% CI, 1.43-2.04), no formal education (AOR, 20.25; 95% CI, 17.51-23.42), and having contracted the STI abroad (AOR, 13.98; 95% CI, 12.59-15.54). The HIV-1 prevalence among non-Italian patients with STIs was 5.5% (95% CI, 4.9-6.2), with large differences by continent of origin. The highest prevalence was found among European injecting drug users (54.1%; 95% CI, 37.1-70.1), South American homosexual men (41.6%; 95% CI, 32.0-51.8), and heterosexuals from Sub-Saharan Africa (8.9%; 95% CI, 7.2-10.8). CONCLUSIONS: Non-Italian patients with STIs seem to consist mainly of migrants, and STI transmission patterns differ from those among Italians; this information is important for developing targeted STI prevention efforts.     

The evolution of sexually transmitted infections in the Ukraine

OBJECTIVES: To evaluate trends in the national and regional reporting of syphilis, gonorrhoea, chlamydia, genital herpes, trichomoniasis, and HIV in Ukraine. METHODS: Annual notification rates of infection per 10(5) population in three regions of Ukraine--Donetsk, Mikolaiv, Chernivtsi--and also among children, adolescents, and pregnant women were used as indicators for the spread of sexually transmitted infections (STIs) in the Ukraine from 1994 to 2000. The estimates were based on a review of medical literature, reported data from STD clinics, and local epidemiological surveys. An analysis of the trends was made. RESULTS: The notification rate of trichomoniasis rose from 284.3 in 1997 to 330.8 in 2000. The same for syphilis was 68.7 per 100,000 population in 1994 peaked in 1996 with 150.9 falling to 91.5 in 2000. The reported incidence of gonorrhoea has been falling recently to 52.7/10(5) in 2000 (a 104.6% decrease since 1994). Chlamydia notification rates, however, rose 2.4-fold between 1995 and 2000 (16.1/10(5) to 54.2/10(5)). In the same period there was a 218% increase the reported incidence of genital herpes. STIs are more common in the eastern industrial regions. In the period 1994-7 there was a dramatic 179-fold increase in the prevalence of HIV/AIDS which has plateaued in subsequent years. By January 2001 a total of 36,600 cases of HIV infection (including 2040 people with AIDS) have been reported. The proportion of HIV acquired through injecting drug use is falling (72.7% in 1997 to 54.2% in 2000) in relation to that acquired through sexual contact. CONCLUSIONS: STIs and HIV are a common cause of morbidity in Ukraine.     

Adolescent women underestimate their susceptibility to sexually transmitted infections

OBJECTIVES: Adolescent females are at significant risk for sexually transmitted infections (STI) and may not accurately incorporate indicators of risk into their perceptions of susceptibility. The objectives of the current analyses were to: (1) examine the relation between perceived susceptibility and indicators of risk; and (2) investigate the relation between perceived susceptibility and actual STI diagnosis. METHODS: Participants were 209 sexually active adolescent females. Indicators of STI risk included STI history, recent symptoms, and sexual risk behaviour (that is, recent unprotected sex and numbers of sexual partners). Chlamydia and gonorrhoea infection were assessed at baseline, 6, and 12 months post-baseline using urine based ligase chain reaction testing. RESULTS: Most participants perceived little or no chance that they would be diagnosed with an STI in the following year. There was no relation between almost all STI indicators and perceptions of susceptibility. Among those receiving a positive chlamydia or gonorrhoea test (n=49) at baseline or in the year following, almost all (81.3%) had perceived themselves to be at little or no risk. CONCLUSION: The adolescent females in this sample did not accurately perceive their susceptibility to STI. They must be enabled to more effectively assess and modify their risk.