Sexually Transmitted Infections
Sexually transmitted infections and infections (also called STD’s or STI’s) are infections that can be passed through sexual contact. Sexual promiscuity and unsafe sexual practices can significantly increase the likelihood of contracting an STI. However, STI’s can be contracted in a monogamous relationship if one partner has the infection.
Many think that sexual contact means intercourse; however, sexual contact means any sexual contact with the genitals, including oral sex. The greatest risk factor for contracting an STI includes having multiple sexual partners. Other than abstinence, having a stable sexual relationship with one person who does not have an STD, or appropriate use of condoms are the safest way to prevent the spread of or contracting an STI.
In this section we will discuss some of the most common sexually transmitted infections (STI’s):
Urethritis – inflammation of the urethra that can migrate down to the epididymis and testicle causing epididimo-orchitis
Balanitis – inflammation of the foreskin and glans of the penis in uncircumcised men
Genital Warts/Human Papilloma Virus (HPV)
Human Immunodeficiency Virus (HIV)
Hepatitis Virus B (Hep B)
(Chlamydia & Gonorrhea)
There are two main causes of urethritis – chlamydia and gonorrhea. And oftentimes, the two diseases go hand in hand at the same time. These are the two most common STI’s. The greatest risk factor is having multiple sexual partners – as the infection is spread from one person to the other.
Men often present in the early stages with burning while urinating due to inflammation of the urethra. In some men, the inflammation can be so severe that they will have a discharge (pus) released from the tip of the penis during the first two weeks after becoming infected. The pus is often white or cloudy and somewhat watery, but in men with gonorrhea, this discharge often turns to a yellow and even eventually to a green color.
If left untreated, the infection can spread down the urethra to the ejaculatory duct and vas deferens and infect the epididymis and testicle – causing epididymo-orchitis. If the bacteria enter the anus, it can cause proctitis or inflammation of the anus. Since the bacteria that cause these STI’s lives on skin surfaces, they can get on the hands during foreplay and if the hands are not washed appropriately they can infect other areas of the body the hands touch (especially the eyes if someone rubs their eyes after touching an infected person’s genitals). Treatment is fairly simply – typically a one-time oral antibiotic called azithromycin. For people also infected with gonorrhea, a one-time shot of antibiotic (oftentimes ceftriaxone) is added to the oral medication therapy. If the infection has spread to the testicles, then a longer course of antibiotics is often needed to fight the bacteria and inflammation in the epididymis and testicles.
Chlamydia and gonorrhea are perhaps a leading cause of infertility, especially in women. Inflammation from the disease can cause the fallopian tubes to become inflamed and scared thus reducing fertility (since the fallopian tubes are where conception occurs). In men, the inflammation in the epididymis and testicles can likewise cause scaring which can lead to infertility issues. This is one reason why preventing an STI as well as treating an STI as soon as possible are so important.
Syphilis[i] is a STI caused by bacteria that can be easily treated. However, if left untreated it can cause severe disability and even death. In addition, it can be passed from an infected mother to the infant and cause death in the infant. Syphilis is spread by coming into contact with a sore called a chancre on the genitals of a sexual partner (even contact from simply touching the sore, not necessarily from sexual intercourse). These sores often look like a popped blister but are often painless. In men, these sores are almost always on the penis. In a woman they can be less obvious and hidden in the hair of the labia or in the inner surfaces of the labia minora or vagina which may not be visible. However, syphilis sores can also occur on the mouth and lips of people who engage in oral sex.
There are multiple stages to the disease itself.
Primary Stage - Typically three weeks after an infection a sore or chancre will develop. This usually occurs on the genitals or mouth if engaging in oral sex. As already stated, in women this may be difficult to notice if the chancre develops in an area that isn’t visible. There is usually no pain or discomfort so this stage can often go untreated. Three to six weeks later the chancre will heal whether treatment is provided or not – so it is common for people to not seek treatment when the chancre disappears. Below is an image of a chancre on the lips. Chancres on the penis often appear moist - to see a medical image click HERE.
Secondary Stage – Typically starts as the chancre is healing or a few weeks after the chancre has healed. In this stage, a rash or sores will appear on certain areas of the body – mouth, anus, vagina, palms of the hands, bottoms of the feet, mouth, groin, torso, or armpits are common places. The person may develop a fever, swollen glands, a sore throat, muscle aches, fatigue, headaches, and even patchy hair loss. Some mistake this as a mild case of the flu and don’t seek treatment. Like the primary stage, this stage will resolve itself whether or not treatment is given or not.
Latent Stage – During this stage the infection goes dormant. It may stay dormant for years – so often individuals move on with life still infected, but not having any symptoms.
Late Stage – This stage is when syphilis really shows its nasty side. After 10-30 years, 15% of patients in the latent stage will resurface into the late stage. This is where neurological (nerve and brain damage) starts occurring. These people can have muscle movement problems, numbness, become paralyzed, gradually go blind, and start having difficulties with memory. Organs can also become damaged, including the heart, brain, liver, and bones, which can eventually leads to death.
Perhaps one of the biggest risks of syphilis is that in pregnant women. Nearly 40% of babies born to a woman with syphilis will either be stillborn or die shortly after birth. Most healthcare providers screen for syphilis at the beginning of pregnancy so treatment can be given. For babies born to mothers with syphilis, testing and treatment is also given. Treatment is actually quite simply – it involves an injection of penicillin. Oftentimes, just one shot is all that is needed to kill the syphilis bacteria. However, in later years of latent stage syphilis up to three injections over a period of time may need to be given to kill the bacteria.
Unlike other STI’s, balanitis is a disease is almost always passed from woman to man, rather than from man to woman. Women can be susceptible to fungal infections of the vagina caused by a fungus called candida. In women, these infections are called yeast infections and typically cause burning and inching. In addition, women who have bacterial vaginosis (a bacterial infection of the vagina) can also pass bacteria onto their male sexual partner. Men who are not circumcised can trap the yeast or bacterial infection between the foreskin and the glans in the prepudial sac. Men who are circumcised rarely get balanitis or catch a yeast or bacterial vaginosis-type infection during sex because all surfaces of the penis are open to the air and stay relatively dry, thus preventing the yeast or bacteria from growing and spreading.
Balanitis caused by these infections causes severe itching of the foreskin and glans. White flakes are often visible on the glans of the penis and sometimes pus from the infection can weep or ooze from under the foreskin of the penis. This pus is often white and creamy in color (a medical image can be seen by clicking HERE). Treatment typically involves giving the man a one-time oral dose of an anti-infective such as fluconazole or metronidazole, depending on what infectious agent is causing the balanitis. Keeping the foreskin and glans clean and dry should go along with this medication therapy.
Genital herpes[ii] is caused by herpes simplex virus type 2 (HSV2). They affect nearly 1 in 6 adults. HSV2 is related to the herpes virus that cause cold sores (HSV1) on the mouth; however, they are a different strain. Genital herpes appear first as small red bumps then progress to white blisters that are often mistaken as an ingrown hair or other small skin issue.
These blisters eventually break and form sores which can be painful and often ooze or bleed. After this, the lesions scab over and eventually “heal” – although the infection never goes away. The virus is spread by coming in contact with the virus usually through the sores themselves; however, even if someone doesn’t have visible sores they may still infect others. An illustration of genital herpes is shown below. To see a medical image showing examples of genital herpes, click HERE.
These blisters/sores are often found on the urethra, genitals, and can even be found on the thighs in men. In women they can appear on the vulva, vagina, and even high in the vaginal area on the cervix where they are unseen and can be easily spread. They may also appear on the buttocks or even the mouth if they were spread by oral sex or transferred from the genitals to the mouth by contaminated hands (even the eyes can become infected if the eyes are rubbed by contaminated hands).
Oftentimes, these lesions will come and go in “outbreaks” – appearing, breaking, and then healing. Outbreaks are more severe and more frequent in the year or so after the initial infection, and usually become less severe and less frequent over time. However, once infected, there is no cure – only antiviral therapy can prevent or minimize an outbreak. On the first outbreak, antivirals such as acyclovir, valcyclovir, or famcyclovir are given for around 10 days. On subsequent outbreaks, larger doses are given for 2 days to reduce the time spent with an outbreak. Lower doses of these same medications can be given on a daily basis to prevent new outbreaks from occurring. However, just because outbreaks are not occurring doesn’t mean that the patient can’t transfer the infection to their sexual partner.
HUMAN PAPILLOMA VIRUS
Human[iii] papilloma virus or HPV is the most common sexually transmitted infection. For many people (men especially), they don’t have any symptoms. However, some people with HPV will develop genital warts. The warts themselves often resemble other types of warts and can be rounded or flat or even grow in clusters like cauliflower. In men, they usually develop on the shaft of the penis and they may come and go. They can even appear on the scrotum or even near the anus. Topical medications can be prescribed to help remove the warts or they can by frozen off by in a healthcare provider’s office (click HERE to see a medical image of HPV warts and the freezing process).
Perhaps one of the most concerning things about HPV is that the virus can cause changes in the body’s cells which can lead to cancer. HPV is the leading cause of cervical cancer in women and can cause penile cancer in men. People with HPV should use condoms to prevent spreading the disease to their sexual partner. In recent years, a vaccine against HPV has been developed (brand name is Gardasil) typically in girls and boys. This vaccine is effective against most HPV strains to prevent contracting and passing HPV. However, since the vaccine doesn’t cover all types of HPV viruses, it still requires responsible sexual behavior.
Human Immunodeficiency Virus (HIV) affects the immune system and can be spread through sexual contact – namely through blood and sexual fluids (semen, pre-ejaculate fluid, and vaginal secretions). Failure to receive antiviral therapy can lead to a progression of the infection which can result in AIDS – a disease in which the immune system is severely depressed. This can increase the risk of infections that can ultimately be fatal. Treatment options have come a long way with multiple drug therapies to suppress the HIV virus, thus delaying or preventing progression to AIDS and prolonging life.
Hepatitis B (Hep B) is another type of virus that can be spread through sexual fluids as well as blood. Hep B attacks the liver and can cause serious effects. Like HIV, there are antiviral agents and other medications often used to combat Hep B. These require a prescription and should be administered as soon as possible after infection.
[ii] https://www.cdc.gov/std/herpes/stdfact-herpes.htm (12/21/2016)
[iii] https://www.cdc.gov/std/hpv/stdfact-hpv-and-men.htm (12/21/2016)
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