Diseases of the Urinogenital System - Sexually transmitted diseases

The name of Venus, the Roman goddess of love, is preserved in the term venereal disease because they are transmitted by sexual contact. But today the broader phrase sexually transmitted disease (STD) is more commonly used to refer to both venereal and other diseases that may be passed from one person to another during sexual activity. STDs include some diseases, among them acquired immunodeficiency syndrome , or AIDS (see “AIDS” in Ch. 19, Other Diseases of Major Importance ), that had not been identified as separate disorders until the 1970s or 1980s.

Sexually transmitted diseases were spreading at epidemic rates by the middle 1980s. Because all are contagious by definition, and can often cause serious complications, the symptoms should be treated without delay. At least two of the STDs, AIDS and genital herpes, or herpes simplex type II, are incurable. Some drugs and medications can, however, ameliorate specific symptoms of both diseases.

Except for pelvic inflammatory disease (PID), a serious complication among women, STDs afflict both men and women. Of the 11 most common STDs, chlamydia is the most prevalent. Public health officials believe the disease has spread because it has no obvious symptoms and victims can live for years without realizing they have it.

AIDS

Although not strictly speaking an STD or a disease of the urinogenital tract, the fact that acquired immunodeficiency syndrome (AIDS) is commonly transmitted sexually merits its inclusion in this section. Because the disease may be transmitted by intravenous needles that are shared by drug abusers as well as through sexual contact and contaminated blood it cannot strictly be called an STD. The disease strips the body of its acquired immunity against infection and leaves its victims susceptible to a variety of opportunistic infections. These include a rare form of pneumonia and Kaposi's sarcoma, a rare type of cancer. AIDS is uniformly fatal.

A virus called the human immunodeficiency virus (HIV) is thought to be the cause of AIDS. Researchers speculate, however, that more than one virus may be the causative agent in AIDS. Exposure to the disease does not mean inevitably that a person will contract AIDS. Perhaps no more than 10 to 20 percent of the individuals who have been exposed to HIV will develop full-blown cases of AIDS. Many will develop what has been termed ARC, AIDS-related complex, which is less often fatal and not considered by authorities to be AIDS per se.

Symptoms and Diagnosis

The symptoms of AIDS range across a broad grouping of complaints that are common to various illnesses. Because these complaints are so common, diagnosis becomes even more difficult. The symptoms include night sweats, diarrhea, fatigue, weight loss of 10 or more pounds over a short period, swollen lymph nodes, fever, and loss of appetite. The symptoms may appear from six months to five years or more after infection.

The ELISA (enzyme-linked immunosorbent assay), or HIV antibody test is used to detect the presence of antibodies to the AIDS virus in blood. Laboratories also use the Western Blot test to verify positive ELISA test results. Physicians also use the HIVAG-1 test to detect the AIDS virus and monitor its development. In 1996, a viral load test was approved that can identify the minutest evidence of HIV in the blood. This test, used in conjunction with tests that monitor white blood cell counts, will enable physicians to more closely monitor the progression of the virus. Two home tests for HIV, Confide and Home Access Express Test, have recently been approved by the FDA. They allow people to take a blood sample at home, mail it to a laboratory for testing, and learn within days if they have tested positive for HIV. Those with positive tests receive the news from counselors, who give them information on medical treatment and long-term counseling.

Treatment

Although AIDS remains a fatal, incurable disease, a new class of drugs called protease inhibitors can reduce the presence of HIV in the blood to undetectable levels when taken in combination with nucleoside analogs such as AZT, dd1, ddC, d4T, and 3TC. Protease inhibitors include indinavir, nelfinavir, ritonavir, and saquinavir; others are being developed. Despite the success of this therapy, most researchers believe HIV remains ultimately ineradicable. Even though the new drugs have brought tremendous relief to many patients, they have not been shown to work for everyone, they sometimes have serious side-effects, and they are so expensive that they are not practical for treating the disease in the developing world, where it is spreading the fastest.

Chlamydia

Chlamydia is a bacterial infection that can cause sterility in men and women and is the leading sexually transmitted disease in the United States today. Most women with the disease have no obvious symptoms. For that reason, physicians suggest that sexually active women undergo tests for chlamydia at least once a year. The disease is spreading more rapidly than any other STD.

Persons at highest risk of contracting chlamydia are under 35 years of age. A bacterium, Chlamydia trachomatis , causes the disease, which is spread to adults during sexual contact and to babies of infected mothers during birth. Complications affect both sexes: both men and women may become infertile, and women may have pregnancy problems that could kill a fetus. In some cases the disease may be fatal for the mother. Babies infected during birth may develop infections of the eyes, ears, or lungs.

Diagnosis

A new diagnostic technique has led to hope that chlamydia can be brought under control. The technique, antigen detection testing , is a relatively simple and painless laboratory procedure.

Symptoms that indicate the possibility of chlamydia may or may not appear. Men may experience a discharge from the penis or a burning sensation while urinating. Women may have vaginal itching, bleeding between menstrual periods, and chronic abdominal pain. The symptoms may appear two to four weeks after infection.

Treatment

Even though chlamydia is spreading more rapidly than other STDs, it ranks among the lesser STD threats. Treatments involve drug therapies with tetracycline or doxycycline. Erythromycin has also been used successfully. The drugs usually take effect in about seven days. The partner of a person who is undergoing treatment for chlamydia should also be treated.

Prevention

Because chlamydia often occurs without symptoms, those who are infected may unwittingly pass the bacteria to their partners. Many physicians recommend that those who have more than one sex partner be tested regularly for the infection. The use of condoms or diaphragms during sexual acidity may reduce the transmission of this bacteria.

Gonorrhea

The second most common STD, gonorrhea , has afflicted humankind for centuries. Gonorrhea, caused by the bacteria gonococcus, lives in the mucous membranes of the body, including the vagina, rectum, throat, or hollow of the cheek. Cervical, penile, or rectal gonorrhea are contracted through intercourse; oral sex may lead to throat gonorrhea. Women may acquire gonorrhea in a single contact with an infected male; but men face only about a 20 to 40 percent risk of contracting the disease from a female.

Untreated, gonorrhea can lead to various complications. Women can suffer from pelvic inflammatory disease. In relatively unusual cases gonococci can enter the bloodstream and cause blood poisoning. The babies of infected mothers may be born blind. Gonococci settling in joints may cause arthritis. Very rarely the disease leads to endocarditis , an inflammation of the lining of the heart, or to meningitis , an inflammation that destroys the membrane surrounding the brain and spinal cord.

Except for PID, men experience most of the basic symptoms of untreated gonorrhea. Thus male problems can range from back pains to sterility.

Diagnosis

Two tests, gram stain and culture, are used to diagnose gonorrhea. Women are cautioned against douching before a visit to a physician or public health clinic; nor should self-treatment with antibiotics be attempted. In either case diagnosis may become more difficult.

Gonorrhea is more difficult to detect in women than in men. As many as four out of five women infected with cervical gonorrhea may not realize for days or weeks that they have the disease. When symptoms do appear, they include vaginal discharges and discomfort when urinating. These symptoms, appearing three to eleven days after exposure, may become steadily worse. Urinating may become extremely painful. With rectal gonorrhea, burning sensations, bleeding or mucous discharges may accompany defecation. Approximately nine of ten males know within a week to ten days that they have been infected. Male symptoms are, commonly, a puslike discharge from the penis and a burning sensation while urinating.

Treatment

Penicillin is the most effective treatment for gonorrhea. For persons allergic to penicillin, physicians usually prescribe tetracycline or erythromycin in oral doses. All three drugs are effective in most cases.

Researchers believe the possibility that they will find a vaccine for gonorrhea is strong. Experimental vaccines have been successfully tested on laboratory animals.

Prevention

Gonorrhea is highly contagious, yet it may cause no symptoms in those affected. The use of condoms during sexual intercourse is a very effective way of preventing the spread of the disease. The use of diaphragms during intercourse also provides some protection from infection.

Genital Herpes

Genital herpes, or herpes simplex type II, is transmitted by physical—usually sexual—contact. The virus is one of the herpes viruses that also cause shingles, mononucleosis, or chicken pox. The disease is transmitted through skin-to-skin contact with herpes sores or the secretions of an infected person. The virus enters the body through the mucous membranes of the genitals, mouth, or anus.

The first attack of genital herpes usually occurs one to two weeks after exposure. Sores may appear; the afflicted person may have difficulty urinating or defecating. The symptoms usually disappear in ten days to three weeks, but for most herpes victims a recurrence can be expected within six months. Later attacks may be milder, but the disease is incurable and can be transmitted even when no symptoms are visible.

Stress and depression, authorities say, can trigger herpes attacks. Women suffering from the disease face increased risks of cervical cancer. They may also pass the virus to babies during delivery. So exposed, the babies may die within a few weeks; some newborns are deformed, blind, or mentally handicapped. Because of the danger that the herpesvirus poses to newborns, women with genital herpes should alert their obstetricians so that delivery can be by caesarian section. By avoiding vaginal mucous membranes, the infant will not be exposed to the virus.

Diagnosis

Physicians can usually diagnose herpes by visual examination while the characteristic sores are evident. A physician may also take a herpes culture from the base of the lesion.

Treatment

While no cure for genital herpes exists, the drug acyclovir has been found to reduce the severity of the flareups. Acyclovir is applied as a topical ointment, usually for initial outbreaks. In an oral form the drug alleviates subsequent attacks. The oral preparation has been reported to be effective in about seven cases out of ten.

Whether treated or not, later outbreaks of herpes are generally shorter and less severe than the first. Physicians agree that acyclovir effects improvement in the majority of cases, but some reserve judgment concerning the drug's long-term effects.

Prevention

Those with early signs of herpes or visible sores should refrain from having sexual intercourse until the sores have healed. Condoms should be used between occurrences and during intercourse, in order to protect against transmission of the virus.

Trichomoniasis

A type of leukorrhea, trichomoniasis is caused by the Trichomonas vaginalis , an organism that causes an irritating itching condition in women. Men usually have no symptoms. The organism, a parasite, favors warm, moist areas, such as genital tissues; but some experts believe it can sometimes survive in damp cloths, douching syringes, towels, around toilet seats, on beaches, and around swimming pools. Thus the disease can, it is believed, be spread without sexual contact.

Complications can follow trichomoniasis. Women victims experience discomfort and pain. Chronic infection, according to some researchers, may make a woman more susceptible to cervical cancer. Constant irritation of the cervix is said to produce such susceptibility.

Diagnosis

The trichomoniasis leukorrhea consists of a yellow to green frothy discharge. The itching that accompanies the infection tends to begin or worsen immediately after a menstrual period. Some women report a burning sensation when they urinate. In diagnosis the physician uses a test similar to a Pap smear (see “Pap Smear” in Ch. 25, ), made with a specimen taken from the vagina. Under a microscope the trichomonas organisms are easy to identify because they are pear-shaped and have three to five whiplike tails.

Treatment

Several drugs are available for treating trichomoniasis. They include tablets taken orally and suppositories inserted in the vagina. Most commonly prescribed is metronidazole. Cures may be effected quickly. One dose of two grams (eight 250 mg tablets) may be adequate for both the victim and his or her partner. The oral medication may, however, be continued for weeks or months if the infection resists the drug.

Trichomoniasis victims have reported such side effects as nausea, depression, and hives. Because many persons are allergic to metronidazole, physicians may suggest the use of vaginal douches made up of vinegar and water, or of vaginal suppositories. The latter relieve trichomoniasis symptoms, but do not cure the disease.

Venereal Warts

Venereal warts , also called genital warts , may be painless but they can be serious and thus require medical attention. If left untreated, researchers say, venereal warts can increase the risk of penile cancer in men and cervical cancer in women. A pregnant woman with these growths may transmit the virus to her infant during delivery. Warts may then develop in the newborn's windpipe, causing later breathing problems.

The human papilloma viruses cause venereal warts, which may appear in a variety of places in the pubic area. The growths are usually small pink bumps, but they can grow together to resemble tiny cauliflowers. In most cases, the growths itch and produce a foul-smelling discharge.

Diagnosis

A physician can usually diagnose venereal warts from their external appearance. To make certain that the warts are not syphilis growths, however, the physician may take a biopsy. A tiny part of the wart is removed for study under a microscope. The papilloma virus can then be identified.

Women with external venereal warts may also have the growths on the cervix. A Pap test is required for detection of these internal warts.

Treatment

The drug podophyllin can be used in solution to remove venereal warts. The solution is painted on the growths, left for six hours, then washed off. The warts usually disappear within a few days. The treatment may have to be repeated several times. If any wart cells remain, the problem will most likely recur.

Podophyllin is not effective in all cases. Where it cannot achieve a cure, other methods, including surgery, may have to be attempted. Among these other methods, which are not always successful, are freezing and burning of the growths. Some studies have indicated that the hormone interferon can prevent recurrences of the disease. Interferon therapy may, however, produce such flulike side effects as fatigue and fever.

Prevention

If genital warts are present, sexual activity should be avoided until the warts can be medically treated. Again, use of a condom during intercourse may provide some protection against infection.

Syphilis

Historically, syphilis has ranked among mankind's chief health scourges. Modern medicine has brought it largely under control, but it can still be life-threatening.

Syphilis strikes men about three times as often as women. Approximately half of the male victims are homosexuals. A spiral-shaped bacterium called Treponema pallidum causes the disease. Transmittal takes place during sex with a person in the infectious stage in which open sores or rashes are typical symptoms. The Treponema bacteria fill the sores and in infecting another person invade the mucous membranes of the genitals, mouth, or rectum. The spirochete , or spiral bacterium, succumbs to heat, dryness, ordinary antiseptics, or even soap and water. But it can tolerate cold and survive freezing.

Stages

Unless it is treated early, syphilis progresses from a primary to secondary and sometimes tertiary stages. In the primary stage, the victim may have a painless chancre, or ulcer, that may be small, single, or multiple and that may look like any common skin ulcer. The reddish-brown ulcers generally appear between ten days and three months after exposure to the disease, with a typical incubation time of three weeks.

The secondary and latent stages of syphilis can lead to serious complications unless treatment is undertaken. A month to six weeks after the first ulcers appear, secondary lesions may develop, taking the form of a rash or almost any other kind of skin eruption. The lesions may appear on the trunk of the body, on the face, the arms and legs, or the palms of the hands and soles of the feet. The lesions may or may not itch, and they may not appear at all. The victim may, however, experience fevers and flu symptoms as well as hair loss. A latent stage of many years’ duration follows untreated secondary syphilis. In this stage only a blood test can reveal the presence of the bacteria in the body.

If still untreated, late or tertiary-stage syphilis follows the secondary and latent stages in about one case in four. Tertiary syphilis involves the gradual destruction of the central nervous system, the heart, the bones, the liver, the stomach, or other organs . The bacteria can cause paralysis, convulsions, heart failure, insanity, and even death. Attacking the circulatory system, syphilis can cause an aneurysm , dilated section, of the aorta just above the heart. The blood flow to the heart is reduced; a ruptured aneurysm can produce a fatal hemorrhage. While gummas, rubbery syphilitic tumors inside organs, may respond to antibiotics in the late stage of syphilis, damage to the heart valves and arteries may be irreversible.

General Paresis

Permanent tissue damage to the brain and nerves can result from syphilitic invasion of the central nervous system; this the chronic, progressive form of syphilis known as general paresis . The damage occurs gradually, and early symptoms may include headaches, a tendency to forget things, or difficulty in concentrating. Mental effects may progress from memory loss to psychotic symptoms of delusions of grandeur.

Tabes Dorsalis

Late syphilis involving deterioration of the sheaths of spinal nerves (demy-elination) and other destructive changes in the spinal cord is known as tabes dorsalis . The patient may become uncoordinated in movement. Tremors of the hands and fingers may be noticed, as well as tremors of the lips and tongue. Vision may be affected, and sensory effects can range from sharp sudden pains to a loss of feeling. The patient may lose control of bladder function or the ability to walk.

Congenital Syphilis

The latent syphilitic condition is not uncommon, and it is a period of great danger to the fetus if an infected woman, especially a recently infected woman, becomes pregnant at this time. The fetus can acquire syphilis through the placenta and be born with congenital syphilis. Or it can be stillborn or die shortly after birth. Some of the signs of syphilis in an infant born with the congenital form of the disease are similar to those of secondary syphilis. Others are very different, more closely resembling tertiary syphilis. Because of the hazards to the child, most physicians test the mother's blood for the presence of the spirochete during the first three months of pregnancy and during the last three months; syphilis acquired during pregnancy is especially likely to affect the fetus. Treatment of the mother has the added benefit of treating the fetus. Treatment begun before the eighteenth week of pregnancy will prevent syphilis from developing; treatment begun after the eighteenth week will cure the fetus of syphilis.

Diagnosis

Because the symptoms of syphilis may appear sporadically or not at all, and because they so closely resemble the symptoms of other diseases, diagnosis usually calls for a blood test. If a chancre has developed, the physician may take a scraping from the lesion and order a special microscopic examination.

Treatment

Long-lasting penicillin, given by intravenous injection, usually cures syphilis. But the disease can, as noted, cause irreversible damage if allowed to spread unchecked. For persons who are allergic to penicillin, physicians may prescribe tetracycline or erythromycin. Both are effective as treatments.

Prevention

Contact with infectious sores, body tissue, and fluids should be avoided to prevent the spread of the disease. The use of condoms during sexual intercourse will provide some protection from infection.

Pelvic Inflammatory Disease

Pelvic inflammatory disease (PID) is a serious complication of STDs. It affects women as a result of infection from a number of diseases including chlamydia and gonorrhea. To produce PID, a disease has to progress to the point where it leads to inflammation and abscesses of a victim's Fallopian tubes, ovaries, and pelvis.

One woman in about seven who contract PID becomes infertile. On the average, three of four women experiencing attacks of the disease will be unable to conceive.

Diagnosis and Treatment

Physicians can diagnose PID by conducting abdominal and pelvic examinations as well as various laboratory tests.

Antibiotics are prescribed in some cases. In more severe cases, surgery may be necessary. The surgery usually results in infertility.

Lymphogranuloma Venereum

This disease, also known as LGV and lymphogranuloma inguinale , is a venereal disease that produces a primary lesion like a small blister, which ruptures to form a small ulcer. It is caused by a virus that is spread by sexual intercourse, although sexual contact is not necessary for transmission of the disease. It can be acquired by contact with the fluid excreted by a lesion.

The primary lesion usually appears in the genital area within one to three weeks after contact with an infected person. It may appear only briefly or be so small as to go unnoticed. But the disease spreads to neighboring lymph nodes, where the next sign of the disorder appears 10 days to a month later. The swelling of the lymph nodes (forming buboes ) is often the first symptom to be noted by the patient; the lymph nodes become matted together and hard, forming channels (or fistulas ) through which pus drains to the surface of the skin. Enlargement of the lymph nodes may produce painful swelling of the external genitalia. The lymph-node involvement may spread to the anal region, leading to rectal constriction and painful bowel movements.

Diagnosis and Treatment

Because the lesions of lymphogranuloma venereum may resemble those of syphilis, chancroid, or certain non-venereal diseases, physicians usually make a number of tests to determine whether or not the condition is, in fact, LGV. Therapy includes administration of antibiotics and sulfa drugs for a period of about a week to a month, depending on the severity of the infection.

Prevention

Early treatment of such sexually transmitted diseases as chlamydia and gonorrhea will limit one's chance of developing a much more serious illness such as pelvic inflammatory disease. Those who suspect that they have any sexually transmitted disease, should see a physician immediately. Again, use of a diaphragm or insisting that one's partner use a condom is the best way for sexually active people to prevent contraction of such diseases.

Chancroid

Chancroid , or soft chancre , is a venereal disease transmitted by a bacterium that causes a tender, painful ulcer. The ulcer, which may erode deeply into the tissues, follows the formation of a primary pustule at the site of infection. The pustule appears within five days after contact with an infected person. While essentially a venereal disease, like other venereal diseases it is transmissible without sexual intercourse. Physicians, for example, have been known to develop a soft chancre on a finger after examining an infected patient.

Diagnosis and Treatment

Physicians usually do tests to make sure that the lesion is not a syphilitic chancre. Although the disease can spread from the genital region to other parts of the body, the soft chancre generally is self-limiting. Therapy consists of administration of sulfa drugs or tetracycline.

Granuloma Inguinale

Granuloma inguinale , also called granuloma venereum , is not the same, in spite of the similarity in name, as lymphogranuloma venereum. The former is an insidious, chronic venereal disease that produces lesions on the skin or mucous membrane of the genital or anal regions. The first sign of the infection may be a painless papule or nodule that leaves an ulcer with a reddish granular base. If untreated, the lesions tend to spread to the lower abdomen and thighs. In time, the sores produce a sour, pungent odor.

Treatment

Antibiotics such as streptomycin and tetracycline are prescribed. Relapses may occur and cure may be slow, especially in cases of long standing.

External Venereal Maladies

The two conditions described below, one related to viruses and one a parasitic infestation, may generally be considered sources of discomfort and disfigurement rather than threats to general health. Both of these STDs are transmissible by other means besides sexual contact.

Molluscum Contagiosum

A viral disease transmitted during sexual intercourse is known by the medical term molluscum contagiosum . The disease can also be transmitted by ordinary person-to-person contact, as between members of a family or children in a classroom. The virus causes raised lesions containing a waxy white material. The lesions, which may be very small or as large as an inch in diameter, occur on the skin or mucous membranes, commonly in the anal or genital area but sometimes on the face or torso. The lesions may last for several months or several years, then disappear spontaneously, or they may be removed by medications or surgery.

Pubic Lice

Infestations of pubic lice constitute a unique kind of venereal disease. Pubic lice, known popularly as crabs, are a species somewhat larger than body and head lice but still almost invisible to the naked eye. These whitish, oval parasites usually remain in the hair of the anal and genital regions, but they may sometimes be found attached to the skin at the base of any body hair, including eyelashes and scalp. A very few pubic lice in the anal and genital areas can cause intense irritation and itching. The itching results in scratching which, in turn, produces abrasions of the skin. The lice may also produce patches of bluish spots on the skin of the inner thighs and lower abdomen. Another sign of their presence is the appearance of tiny brown specks deposited by the lice on the inside of undergarments.

Pubic lice are commonly spread by sexual contact, but they can be acquired from toilet seats, clothing, towels, bedclothes, combs, or any article of intimate use. Creams or ointments containing various parasiticides are available for disinfestation. They are applied every night for several nights, but overuse should be avoided because of the danger of injury to the tender tissues of the genital and anal region. Some physicians recommend soaking the infested part of the body several times daily in a mild solution of potassium permanganate. Lice on the eyebrows and eyelashes may have to be removed individually with a pair of tweezers. Treatment must be repeated after one week to kill the nits (eggs) that have hatched since the first treatment. Clothing and other contaminated materials must be cleaned to prevent reinfestation.

Complications of an infestation of pubic lice include intense itching (known medically as pruritus ) and secondary infections from scratching. These may require special medical care and administration of antibiotics, corticosteroid creams, or other appropriate remedies.

Prevention

All who have been in close contact with someone who has pubic lice, including close friends, family, and sexual partners, must be treated to make sure that all the lice have been eradicated.