Sexually transmitted infection with Neisseria gonorrhoea causes gonorrhoea, the symptoms of which occur after an incubation period of 2 – 30 (mostly 4 – 6) days. A few per cent of males and between 30 – 60% of females are asymptomatic or have subclinical disease.
The symptoms in males include a yellowish urethral pus discharge (Figure 1), associated with dysuria and sometimes an increased frequency of micturition. Involvement of the prostate, seminal vesicles, and epididymis causes pain and fever. Examination may show a reddened external urethral meatus.
Figure 1. Urethral discharge in gonorrhoea
The image is kindly lent out from the Department of Dermato-venerology, Odense University Hospital
Symptomatic women may have vaginal discharge, dysuria, bleeding, or lower abdominal discomfort but symptoms may well be ignored. The cervix may appear normal or inflamed with pus. The combination of urethritis and cervicitis on examination supports the diagnosis of gonorrhoea, as both sites are infected in most females. The localized infection may be complicated by pelvic inflammatory disease with spread to the uterus, fallopian tubes, and ovaries causing cramps and pain, bleeding between menstrual periods, vomiting, or fever.
Symptoms in both sexes may also occur in other organs: Rectal signs and symptoms include anal itching, pus-like discharge from the rectum, spots of bright red blood on toilet tissue and having to strain during bowel movements. Gonorrhoeal conjunctivitis may cause eye pain, sensitivity to light, and pus-like discharge from one or both eyes. Signs and symptoms of a throat infection may include a sore throat and swollen lymph nodes in the neck. In septic arthritis, the affected joints may be warm, red, swollen and extremely painful, especially with movement of the joint.
Untreated, gonorrhoea can lead to infertility in both sexes and urination problems in males.
Men have a 20% risk of infection from vaginal intercourse with a woman infected with gonorrhoea. Women have a 60-80% risk of infection from vaginal intercourse with a man infected with gonorrhoea.
Gonorrhoea is diagnosed by bacterial culture and microscopy of a Gram stained smear, both of which, however, may not be feasible on a ship without doctor or laboratory equipment.
The increasing resistance of gonococci to several antibiotics has resulted in difficulties with treatment. In some countries less than half of the cases are sensitive to penicillin and Fluoroquinolones are also no more recommended due to high levels of resistance. Both can be administered as tablets. Cephalosporins (oral cefixime or injectable ceftriaxone) used to be effective against all gonococci but currently there is a small but increasing resistance. Consequent to the different pattern of resistance in various parts of the world, the choice of antibiotic depends of the geographical area.
The use of condom is protective. Contacts to patients after unprotected sex should be examined and treated if positive. In some parts of the world such as in the Nordic countries, there has been a rapidly decreased incidence in gonorrhoea since the 1980’s, which, however, has been followed in the new millennium by another rise in cases. In other parts of the world – notably in Eastern Europe and parts of Africa and Asia – the incidence is high and increasing.
Chancroid is a rare bacterial infection caused by the Haemophilus ducreyi, a Gram-negative streptobacillus that is primarily associated with low socioeconomic groups and CSW’s in developing countries.
After an incubation period of one day to two weeks, chancroid begins with one or more small papules that rapidly develop into painful 3 – 50 mm large ulcers with an easily bleeding base. One-third of infected individuals will develop almost-diagnostic suppurative inguinal adenopathy that may rupture and drain through the skin (buboes). About half of infected men have only a single ulcer while women may have several. The ulcers appear in specific locations, such as the coronal sulcus in men.
Chancroid can be distinguished from syphilitic chancres by having a soft edge, and by being painful and accompanied by pus.
Treatment consists of a single dose (1 gram) of oral azithromycin or intramuscular ceftriaxone, or a one-week course of oral erythromycin.
Chlamydia infection caused by the bacterium Chlamydia trachomatis, an obligate intracellular organism, is one of the most common STD’s worldwide.
Chlamydia urethritis may be asymptomatic in half of infected males and three-quarters of women. It therefore spreads rapidly, especially among young people. Symptomatic males have urethral burning and itching accompanied by a white penile discharge (less viscous and lighter in colour than gonorrhoea) that may be accompanied by dysuria. The testes may be swollen or tender and fever can occur. Symptoms in females are due to cervicitis (vaginal bleeding or discharge, abdominal pain, dyspareunia, fever), and urethritis (dysuria, urgency).
Chlamydia infection frequently spreads to the fallopian tubes in women (about half of women with asymptomatic infection) or to the epididymis in men. Consequently, if untreated, reproductive problems may occur in both sexes. Chlamydia may also cause spontaneous abortion as well as premature birth.
Trachoma, conjunctivitis due to C. trachomatis, is a common cause of blindness worldwide, although currently rapidly declining. The infection can be spread from eye to eye by fingers, shared towels, coughing and sneezing, and by flies, or vertically to neonates.
Up to half of infants born to infected mothers may contract conjunctivitis or pneumonia. Reactive arthritis may be part of a triad (Reiter’s syndrome) that includes conjunctivitis and urethritis, especially affecting young men.
C. trachomatis is also the cause of lymphogranuloma venereum, which usually presents with a painless genital ulceration and mostly unilateral swelling of the inguinal lymph nodes. It may also manifest as proctitis and fever.
A nucleic acid amplification test of urine or cervical (women) or urethral (men) swabs is diagnostic.
C. trachomatis infection can be effectively cured with antibiotics such as a single oral dose (1 gram) of azithromycin or 100 milligrams of doxycycline twice daily for 7 to 14 days.
Granuloma inguinale tropicum (donovanosis, granuloma venereum) caused by Klebsiella granulomatis is endemic in many developing countries.
Small, painless nodules appear at the region of contact after an incubation period of 10 – 40 days. Later the nodules burst, creating open, fleshy, oozing lesions. The infection will continue to destroy the tissue until treated. The microorganism spreads through contact with the open sores. Super infection by other pathogens is common.
Physical examination reveals a painless, "beefy-red ulcer" with a characteristic rolled edge of granulation tissue. In most cases there are no swollen inguinal lymph nodes.
The demonstration of Donovan bodies in a Wright-Giemsa stained tissue biopsy is diagnostic.
Treatment for three weeks with erythromycin, streptomycin, or tetracycline, or 12 weeks with ampicillin is effective.
Syphilis caused by the spirochete Treponema pallidum is mostly transmitted through sexual contact, although it can be transmitted vertically from mother to child in utero or during birth.
The prevalence has decreased in western European countries but increased in Russia and Eastern Europe.
Primary syphilis is typically acquired via direct sexual contact with infectious lesions. From 10 to 90 days following the initial exposure (on average 3 weeks), a “hard chancre” (a firm, painless skin ulceration with sharp raised edges) appears at the initial point of contact, which is usually the genitalia, but can be anywhere. Multiple lesions are rarely present. After 4 to 6 weeks, the lesion usually heals spontaneously. Local lymph node swelling may occur. During this initial period, patients are otherwise asymptomatic and therefore many do not seek medical care.
If left untreated, the secondary stage develops 1–6 months (mostly 6 to 8 weeks) after the primary infection. A symmetrical reddish-pink non-itchy rash may develop on the trunk (Figure 2) and on the extremities including the palms (Figure 3) and the soles of the foot. In moist areas of the body (usually vulva or scrotum), the rash develops into flat, broad, whitish, wart-like lesions (condylomata lata). Mucous patches may also appear on the genitals or in the mouth. All of these lesions are infectious. Other symptoms common at this stage include fever, sore throat, malaise, weight loss, headache, and enlarged lymph nodes.
Figure 2. Second phase of syphilis. Trunk
Courtesy of Department of Dermato-venerology, Odense University Hospital
Figure 3. Second phase of syphilis. Palms
Courtesy of Department of Dermato-venerology, Odense University Hospital
The early latent phase (first 1-2 years) is characterized by occasional relapses back to the symptoms of the secondary phase of syphilis. More than 2 years after the start of the latent phase, there is serologic proof of infection but no signs or symptoms of disease, and generally the condition is not infectious. Fifty per cent of those with latent syphilis will progress into tertiary syphilis, 25% will stay latent, and 25% will recover fully.
Tertiary syphilis occurs 1-10 years after the initial infection. This stage is characterized by the formation of gummas, which are soft chronic granulomas that represent an inability of the immune system to completely clear the organism. They may appear almost anywhere in the body.
The more severe manifestations of untreated tertiary syphilis include neurosyphilis and cardiovascular syphilis.
Neurological complications at this stage can be diverse but include neuropathic joint disease, a degeneration of joint surfaces resulting from loss of sensation and proprioception. Other manifestations include psychiatric abnormalities such as emotional and personality changes. Focal intermittent or slowly progressing cerebral deficits cause organic brain disease with dementia. Tabes dorsalis, a disorder of the spinal cord, results in a characteristic shuffling gait. Before the advent of antibiotics, neurosyphilis was seen in a quarter of patients with syphilis but is now mostly seen in patients with HIV infection. Approximately 35 – 40% of persons with secondary syphilis have asymptomatic central nervous system involvement.
Cardiovascular complications include infectious arteritis such as aortitis with aneurysm formation and aortic regurgitation. The arterial narrowing may involve the coronary and cerebral arteries.
Dark field microscopy of fluid from the primary or secondary lesion can identify treponemes with high accuracy but other treponemes may be confused with T. pallidum. Current screening tests are cheap and fast but not entirely specific. Therefore, screening tests should always be followed up by a more specific treponemal test.
T. pallidum may cross through intact mucosa but can also penetrate damaged skin on body parts that cannot be protected by a condom. Therefore proper and consistent condom use reduces, but cannot completely eliminate, transmission through sexual contact. Syphilis cannot be contracted through toilet seats, daily activities, hot tubs, or sharing eating utensils or clothing.
Individuals sexually exposed to a person with primary, secondary, or early latent syphilis within 90 days should be assumed to be infected and treated for syphilis, even if sero negative. If the exposure was more than 90 days before the diagnosis, presumptive treatment is recommended if serologic testing is not immediately available or if follow-up is uncertain. All patients with syphilis should be tested for HIV.
The first-choice treatment for syphilis remains penicillin G. For early syphilis, one dose of penicillin is sufficient. With late latent syphilis and infection of unknown duration and no evidence of neurosyphilis, weekly doses are administered for 3 weeks. Neurosyphilis requires intravenous treatment.