Trichomoniasis
Trichomonas vaginalis was first discovered by a young Frenchman in 1838. Interestingly enough, he thought he had discovered the causative organism for gonorrhea, and the differentiation of the two organisms took another 50 years. Both are caused by organisms, gonorrhea by a gram negative intracellular diplococci, originally called Neisseria gonorrhea, and trichomonas by a protozoa.Before antibiotic therapy developed, trichomoniasis was dramatically different from what it is today; patients sometimes came in with difficulty walking because the genital area was irritated, and the vaginal discharge was so profuse that it literally ran down their legs when they stood up. The discharge, when viewed with the aid of a vaginal speculum, was seen to be thick, frothy, and yellow-green, and it was extremely smelly.
The diagnosis for this particular infection is made by the physician on the spot, who does a microscopic test called a “wet mount,” using a slide with either saline or a stained laboratory vehicle for easier microscopic identification. The protozoa can be easily seen moving around on relatively low-power magnification of the microscope. There are occasional false-negative readouts, probably due to overwhelming activity by the body’s white blood cells, so that no actual trichomonal organisms can be seen during a test, but are visible at a later examination. This particular test usually gives an instant diagnosis.
The disease is easily treated using metronidazole. This particular drug has been used worldwide for over a quarter of a century. It has an inherent clinical safety record, never having caused death. When a woman who walks into the gynecologist’s office has a trichomoniasis diagnosis made and is given the proper medication, that medication is doubled in amount so as to include her sexual partner (or tripled if there is more than one sexual partner). The same procedure is followed for a man at the urologist’s office. The urologist writes a prescription not only for the man but also for the woman if she is not being seen by her physician.
Trichomoniasis is not a reportable disease. It is, however, a disease that can be fairly drug resistant, so in the United States the patient is asked to return to the office for a repeat test to make sure that the problem has been solved.
Chlamydia
Another common STD seen in the health care practitioner’s office is chlamydia trachomatis. Public health experts currently list this particular disease as the most common disease in the United States, with more than five million new cases discovered and treated each year. Until recently, it was not a reportable infection. One of the reasons it was not reportable is that many if not most physicians treat it on the basis of a sexual and social history, combined with the suspicious physical and microscopic findings. They do this because it is extremely difficult to obtain a good culture result (the cultures have a very high percentage of false-negative readouts). The CDCP and the U.S. Public Health Service have now asked that positive serologic tests for chlamydia be reported. Experts on this particular infection indicate such serologic tests are sometimes reported falsely as positive. This can cause legal problems for the patient and the physician.The real problem with this obligate intracellular parasite is that it causes infertility in women. It is, however, easily treated. The use of tetracycline for seven to ten days by both partners will clear up this infection. If the tetracycline, a most inexpensive drug, causes severe stomach discomfort or other side effects, erythromycin or doxycycline will achieve the same result. However, chlamydia has a strong silent component to its clinical picture; it is often ignored or interpreted by the person who has acquired it as something else. Consequently, no physician is consulted or asked to run a confirmatory culture, and the infected individual unwittingly spreads the disease to others.
Because it is so common, its presence should always be considered, and, of course, the presence or absence of this particular infection is always considered in the many infertility clinics. Women who have the disease and are unaware of its presence may experience significant damage to the interior of the Fallopian tubes. Normal Fallopian tubes are necessary for fertilized-ovum transport. If that reproductive highway has been destroyed, the patient is rendered unable to have a fertilized egg move down her tubes and into her uterine cavity to begin a pregnancy.
Men with chlamydia may see a urethral discharge, so this infection is a common reason for their seeking medical advice. It is not now presently known whether most of the physicians in the United States who treat this problem of chlamydia discharge in men either double the medication and insist that the woman be also treated, or refer her elsewhere.
A variation (there are three variants of this particular infectious disease) is capable of producing blindness, since it causes a disease of the eyes called trachoma. The presence of chlamydia trachomatis is the most common cause of blindness throughout the world. The United States has several well-known research centers working on this disease. One is at the University of California at San Francisco, and the other is at Indiana University-Purdue University Medical Center in Indianapolis, Indiana.
Herpes
Another common sexually transmitted infection in the United States is herpes genitalis. In 1980, when herpes occurred in an epidemic form, its presence made the cover of Time magazine and the front page of the Wall Street Journal. It is a viral infection transmitted by sexual activity that causes blistering discomfort. Acyclovir is effective in suppressing the circulating activity of the herpes virus, decreasing the discomfort and making the individual less likely to transmit the infection to others.It is almost uncivilized in the current era, with acyclovir available, to know that one has herpes and yet to deliberately not take the medication and hence infect others. It is an STD that has active states and inactive states, and the level of discomfort varies widely among individuals. Some men have only mild urinary complaints and do not know they have the disease until they accidentally infect a new female sex partner. The infected woman most often experiences flulike symptoms, has pain urinating, and is covered with blisters on her swollen genital area. The resultant discharge is frequently infected with other organisms and can be quite odoriferous.
If the individual is careless in personal habits and touches the areas of the genitals that are involved, then rubs his or her eyes, the disease can be transmitted to the eye, causing a severe form of conjunctivitis that produces blindness. The problem with the eyes can be arrested by using intravenous acyclovir, but it certainly requires the expert attention of an ophthalmologist just to save the eyesight. If one acquires this infection, soap-and-water hand washing and scrupulous attention to all the details of personal cleanliness are extremely important to confine the blisters and the disease activity to the original site.
The disease can produce mental problems or a severe headache, as well as the aforementioned generalized flulike picture. It is also capable of affecting the long nerves of the legs so as to produce sciatica plus a pain with bowel movements.
Herpes is seen in the office involving all ages and all kinds of health complaints and problems. Clinical diagnosis can be made quickly by anyone who has spent several years practicing medicine. Inexperienced nurses and physicians may, however, misdiagnose it as a chronic yeast infection. However, the obverse of this statement is also true: women with chronic yeast vulvar infections will present the clinical picture similar to a chronic deteriorating herpes infection. The test for herpes is a positive vaginal culture. The culture, however, is not 100 percent correct. It is perfectly possible to have herpes and have a negative culture. This can be a serious problem for the pregnant woman, because if the mother has an acute attack of herpes while she is in labor, the infant, who has no immunity to the disease, will acquire the herpes, and before the advent of intravenous acyclovir therapy most would die.
With acyclovir, herpes has come to be an annoying accompaniment to sexual activity, and its only serious problem now is the transmission of an active infection to a newborn infant. Herpes was originally proposed as the infection causing cancer of the cervix, but that has been demonstrated to be scientifically untrue. Herpes is not now believed to cause cancer.
Gardnerella
Another commonly acquired bacterial infection with a reputation for easy diagnosis (i.e., not requiring an expensive laboratory culture test) is gardnerella vaginalis. For many years, this infection was known as hemophilus vaginalis, but Eldon J. Gardner, a physician who spent his life observing, collecting data, and testing for this infection, was honored posthumously by having his name attached to the genus of bacterium involved. Gardner argued that this was an important reproductive tract organism although often overlooked by many practicing physicians and a real troublemaker for a newborn infant. He felt that it was a major cause of problems in the reproductive system and that it could be very easily diagnosed by well-trained physicians when alerted by the presence of a unique vaginal, fish-like odor.Prior to the work of Gardner, physicians in positions of authority promoted the infection as a silent infection, or an organism that was thought to be a normal inhabitant of the vaginal vault. Such descriptions still exist and are extremely confusing to laypeople doing library research and to medical students and residents trying to figure out how a troublemaker could be normal. It is not a reportable infection. It is easy to treat using metronidazole (see trichomoniasis, above).
Group B. Beta Hemolytic Streptococcus
A very important infection, which also has the distinction of arising from a bed of disinformation labeled “normal vaginal flora” (and similar confusing clinical designations), is group B. Beta hemolytic streptococcus. The importance of this infection to Americans was worked out by the National Institutes of Health and the U.S. Public Health Service under the influence of Dorland J. Davis, an epidemiologist. In the early 1940s, the disease was observed as a cause of death in new-born infants at Harvard’s clinical facilities and at Johns Hopkins Hospital, in Baltimore, with the number of infant deaths attributed to it hovering around 40 a year. As the years went by and constant and progressive observation of the clinical phenomena occurred, it became obvious that the behavior of the organism was that of a sexually transmittable bacteria. Gradually, the number of deaths rose to between 3,000 and 4,000 a year, a number that, unfortunately, still prevails in spite of extensive literature and extensive publicity concerning its damaging effects on new-born children. Apparently, a major reason for the indifference to the presence of such a harmful disease was lack of a requirement to report the infection, a problem now remedied. It is a major cause of mental retardation, cerebral palsy, and deafness. Some of the confusion about the disease is because it is a common inhabitant of the prepuce in the uncircumcised male infant as well as the uncircumcised adult male, in whose foreskin it flourishes. The lack of circumcision frequently predisposes young boys to hospital stays for severe urinary tract and kidney infections.The acquisition by the woman of unusual forms of group B. Beta hemolytic streptococcus, subdivided into categories by Roman numerals, does not occur until they become sexually active, unless unusual circumstances prevail. Since it can be an STD, both sexual partners, or more if there are other partners, must be treated for this organism simultaneously. The organism remains sensitive to penicillin products, and so far it has not developed the usual picture of antibiotic resistance. If the acquisition of the infection occurs at the end of the pregnancy, or if it has been acquired in a form that absolutely refuses to be cured by means of antibiotics, the woman in labor can be given intravenous ampicillin, and the presence of that medication at the time of labor prevents the child from acquiring the infection. Until very recently, the newborn who acquired the infection died as quickly as the infants who acquired herpes from their infected mothers. Fortunately, it has been recently discovered that attention to the hydration of the infant victim gives a greater chance of survival.
The disease itself can cause a localized vulvar skin infection that looks like psoriasis, cervicitis with an abnormal pap smear, or involvement of the Fallopian tubes, so that the victim will end up with ectopic pregnancies as well as urinary and kidney infections, especially in a pregnant woman. Recent work at Parkland Hospital, in Dallas, suggests that it is a major cause of stillbirths in the United States.
Syphilis
Syphilis first appeared in Europe following the return of Columbus from his voyages. There have been extensive arguments as to whether it was a New World disease that was then carried back to the people of Europe. The answer, of course, lies hidden from our view forever. Suffice it to say that an enormous epidemic of syphilis occurred shortly after Columbus’s voyage.The disease was regarded as revolting because it caused huge bony exostoses that were hideous to look at. In the immediate past, syphilis was the major cause of stillbirth and a variety of congenital malformations. It is so highly infectious that doctors and nurses could get syphilis delivering a newborn baby from an infected mother. The baby itself was highly infectious. Syphilis remained a major medical and social problem until the development of Salvarsan by Paul Ehrlich and S. Hata in 1910. Salvarsan rendered the victim of syphilis noninfectious, but the treatment demanded weekly doses of the drug intramuscularly for at least six to eight weeks. The ability of people to comply with such a laborious regimen was a major problem. The other problem was that the laws of the United States would not allow open discussion of this overwhelming health problem. Finally, in 1936, the surgeon general of the United States, Thomas Parran, was allowed to use the word “syphilis” during a radio broadcast, and the push was on, with federal laws creating clinics and funding for discovery of infected partners.
With the arrival of penicillin 50 years ago and the discovery that it could cure syphilis, public health service interest in this particular disease began to fade. In the 1980s, however, it was realized that individuals who suffer from AIDS are especially susceptible to acquiring syphilis, or vice versa. Syphilis has become a marker for the AIDS infection itself. In addition, the cheapness of crack cocaine and other addictive drugs has increased the number of young women prostitutes who fail to use adequate protection, with the result that syphilis is increasing in urban areas.
Syphilis, a reportable disease, starts out with a hard ulcer, called a chancre, which quickly heals on its own, but the spirochete then spreads throughout the body. In the second stage of the disease, it produces a rash, which can be seen even on the palms of the hands and the soles of the feet, but quite often people are not aware of their rash. The organism then starts to invade the tissues of the central nervous system (including the brain), the heart, and the bones and begins to do its chronic disabling feats of work. Syphilis, in fact, can invade every organ system and imitate almost any disease known to humans. It can, however, be diagnosed inexpensively by a blood test which today is called RPR. This test, approved by the CDCP, has many false-positives so that if the test is positive, another test, the FTA-ABS test, which is both more accurate and more expensive, is given. Sometimes early in the disease, the spirochetes themselves can be lifted out of the hard chancre and placed under the microscope in a visual process called a dark field examination where the spirochete can easily be identified by an expert microscopist, but not by amateurs or the family physician or nurse.
Treatment is by means of antibiotic therapy with very large doses of intramuscular penicillin still being the drug of choice. Treatment schedules and alternative medications are outlined in the guidelines for STDs published approximately every three years by the CDCP.
Gonorrhea
Gonorrhea, acquired in conjunction with syphilis, was also very common in the first part of the 20th century. The Frenchman who discovered the original trichomonad thought he had found the causative organism for gonorrhea. It was not until the German bacteriologist Albert Neisser identified the gonococcus in 1879 that this gram negative diplococcus was precisely defined.Although gonorrhea can be identified in the doctor’s office because of its characteristic yellow discharge and the bacteria easily identified through a gram stain, a culture should always be done to confirm the diagnosis. A reportable disease, it, like chlamydia, is often asymptomatic in women, but it, like chlamydia, can spread into the internal pelvic organs, causing pelvic inflammatory disease. Unrecognized gonorrhea can be spread to newborn infants, causing conjunctivitis and blindness. Because of this, the practice of instilling silver nitrate drops into the eyes of newborns was made mandatory early in the 20th century. In men, gonorrheal urinary tract infections are acutely uncomfortable, so men are likely to seek medical attention. The incidence of gonorrhea fell after the antibiotics became available in the middle of the 20th century and the U.S. Public Health Service mounted a campaign to bring both syphilis and gonorrhea under control. However, success with the campaign brought complacency, and the incidence of both syphilis and gonorrhea has increased. Gonorrhea is as prevalent now as it was 50 years ago.
Venereal Warts
The most commonly discussed but least researched of the worldwide STDs is venereal warts, known since antiquity. Confusion, of course, can reign because there are some 60 different varieties of wart viruses, with each one affecting a specific site on the body. Some of the viruses that create warts in the genital region and around the rectum are not sexually transmitted. As a result, when laypeople set themselves up as experts on the subject of STD and discover that a small child has perirectal warts, guardians, friends, and parents are often falsely accused of childhood sexual abuse because of the widespread ignorance among the general public on the subject. The public is aware of the sexual connotation but totally ignorant of the natural history of the entire spectrum of the disease. We do not consider perirectal warts in little boys and girls sexually transmitted. They are ordinarily due to skin-contact organisms picked up by the child by touching a playmate on the hand or cheek, for example.The causative organism of genital warts is a papilloma virus; certain strains of this virus are very dangerous and others are not. Although papilloma virus number 6 and papilloma virus number 11 are common causes of genital-area warts, they seldom spread to other parts of the reproductive system, and they cause little lasting damage. The viruses that cause urethral warts in the male are wart virus numbers 53, 54, 55, and 56, and they are not transmitted to the female during sexual activity. The wart viruses that produce cervical cell changes and abnormal pap smears are papilloma virus numbers 16 and 18, with a scattering in some of the other numerical categories; however, those two viruses (16 and 18) are the ones currently identified as being the main troublemakers associated with cervical cancer.
There is presently no cure for the virus and no vaccine to prevent acquisition of the virus. Currently available are various techniques for removing the warts when they grow. Since 50 percent of the people who have the virus do not grow the warts, the transmission of these warts is thoroughly confusing to ordinary people. It seems as though they simply drop out of the sky.
Removal of the obvious wart does not cure the systemic viral disease, so that other new warts can show up as time goes by. This reoccurrence is particularly depressing to the victims. They are extremely upset that the disease will not permanently go away and that repetitive surgical or chemical removal procedures have to be done. Podophyllin is considered to be the first-line office treatment in the nonpregnant female. Interestingly enough, when the warts are removed from the outside of the woman’s genital area with the use of laser surgery, that procedure sensitizes the warts to podophyllin treatment—an ancient American Indian remedy—so that, fortunately, in most cases, the subsequent reoccurrence of wart forms can be treated using that particular chemical after laser therapy. There is some evidence that getting rid of a yeast infection, keeping the area clean and dry, and taking vitamin A is also helpful. Podophyllin is now available for home self-treatment by prescription as Condylox.
Molluscum Contagiosum
Another common and frequently seen viral-caused skin involvement is called molluscum contagiosum. This is also a disease of great antiquity, whose early beginnings confuse observers. Quite often, it is mistaken for early new venereal warts when the skin lesions are small, and the white punched-in look in the center of a very red pimple is its common picture. The lesions become raised, and they will not disappear with any antibiotic therapy.One cannot cure these skin spots (and often there are many) with antibiotics because the cause of the problem is a virus. It will, however, go away by itself. Sometimes, cryotherapy or cutting and lifting out the white plug will speed things up. The small white umbilicated lesions go away principally on their own. They are highly contagious. Cleanliness is important. It is spread by scratching.
Yeasts: Candida Albicans et al.
Candida albicans, one of the yeastlike funguses that reproduce by budding, was formerly called Monilia albicans. Yeast infections are considered by the World Health Organization as well as by the CDCP as an STD, although some women do have a few Candida as persistent inhabitants of their vaginas, and they develop infections when they take antibiotics for some other medical reason. The antibiotic kills the normal bacterial flora of the vagina, which has been inhibiting the overgrowth of yeast, and this allows the yeast to take over and run rampant.The classification of various infectious agents as capable of sexual transmission is not made to encourage people to categorize themselves or others as good or bad people, but to force the treating practitioners to be aware of the fact that the sexual partners of the individual on whom the diagnosis is made must be considered. If the woman has a yeast infection, not only must she be treated, but inquiries must be made as to whether or not the individuals with whom she is having sexual activity are on antibiotics or have Candida infections of the mouth or genital organs, which should be treated to avoid a cycle of reinfection.
Yeast infections are diagnosed in the office with a wet mount using potassium hydroxide (KOH). Treatment is ordinarily with suppositories or creams containing one of the fungicides: nystatin, clotromazole, miconazole, or terconazole. New forms are being constantly introduced and some are available without prescription.
Mycoplasma and Ureaplasma Infections
Mycoplasma and ureaplasma organisms acquired with sexual activity can persist for years without their victims being aware of any problem whatsoever until they try to get pregnant and find themselves sterile, due to mycoplasma and ureaplasma. The natural history and clinical importance of these organisms are still a matter of argumentation within the medical profession only because they are organisms that are relatively difficult to identify in the laboratory. Hence, their true incidence is probably currently unknown, although it is believed that they are common and are considered a major cause of infertility. Treatment involves long-term antibiotic therapy. The infection can be silent or it can cause pelvic inflammatory disease or Reiter’s disease, as well as postpartum fever, kidney stones, male sterility, habitual abortion, and stillbirth. The diagnosis is made by laboratory tests.Any individual walking into an infertility clinic is thoroughly checked for the presence of these infections. Their importance lies in the fact that if they are present, generic antibiotic treatment for seven or ten days will not even begin to cure them. The amount of time that must be spent taking the brand-name oral antibiotic Vibramycin is from four to six weeks. Therefore, the identification of these particular infections can be important to a woman, especially to make sure that she preserves her future fertility. Their presence in the male creates urinary problems. The diagnosis in the woman is made by vaginal culture.
Donovanosis
Donovanosis is a chronic destructive infection of the genitals, also called granuloma inguinale or granuloma venereum. It is sometimes misdiagnosed by untrained people as cancer or syphilis. It is prominent in New Guinea, Australia, India, the Caribbean, and Africa. It is only mildly contagious and apparently repeated sexual exposure is needed for infection. Long-term antibiotic therapy is needed. It seems, at this time, not to be an American problem.Chancroid
The most common of the STDs worldwide is chancroid, caused by a gram negative bacillus, Hemophilus ducreyi. Although it is not a common infection in the United States, occasionally new emigrants from Latin America bring the disease in with them. It is treated with sulfa drugs, although it can be controlled with just about any antibiotic. It produces a soft, destructive ulcer and painful infections of the groin that can grow and rupture. If it goes untreated, it can destroy the genitals of the man but not those of a woman.Viral Hepatitis
Hepatitis is a viral inflammation of the liver, characterized by jaundice. It is transmitted by contaminated food, needles, or sexual activity or from a mother to infant. Fecal contamination of food or water supplies and rectal or anal intercourse should be considered when the individual is seen in the office. Reports of hepatitis research are constantly updated in a data base at the National Library of Medicine, in Bethesda, Maryland. A vaccine has been developed for the type B form. Immune globulin given promptly after exposure will prevent hepatitis type A. Most hepatitis, however, is non-A, non-B, so prevention by the use of condoms for anal intercourse is important. Fatal fulminant hepatitis can occur. Even though this infection can be acquired in many ways, it is considered a major STD. This only emphasizes that an STD is not always transmitted by sexual activity.Cytomegalovirus Infections
This infection was uncommon in Northern Europe and North America until the 1980s, when the virus was found in urine, saliva, breast milk, semen, feces, cervical mucous, and blood. Close interpersonal contact is necessary to be infected. It can be transmitted to an unborn child, causing severe problems. It can cause hepatitis, heterophile negative mononucleosis, pneumonitis, and Guilliain-Barre ascending paralysis. Anemia and its effects can be devastating in people who are immunocompromised. It has been related to Kaposi’s sarcoma in homosexuals who have AIDS. There is no cure.Pubic Lice and Scabies
These microscopic insects move from person to person with intimate contact or through the wearing of another person’s dirty underwear. They burrow under the skin, causing a rash and intense itching. They can be visualized using an ordinary magnifying glass. Scabies is a great imitator, and its existence can be covered up by corticosteroid creams and lotions. It is cured with topical applications of lindane or Eurax. Over the counter treatments for pubic lice are available.Enteric Infections
Giardiasis and amebiasis are due to rectal-oral sexual activity. They are diagnosed by special laboratory tests and are cured with the same therapy used for the treatment of trichomoniasis. Camplyobacteria are a major cause of the gay bowel syndromes of diarrhea and dysentery, or gastroenteritis in homosexual men. Identification is by laboratory culture. Antibiotic therapies are available for the cure. The infections can be transmitted to women, and pregnant women can transmit the infection to their newborn child.AIDS
Finally, the last and currently most publicized STD is AIDS. This virally caused STD was first discovered among the male homosexual communities of the major cities of the United States—Miami, New York, and San Francisco. It was early determined using epidemiological methods that it was an STD. Eventually, because of the death and disease pattern, the male homosexual act, especially rectal intercourse, was held to be responsible for the transference of the infection to the uninfected. However, that pattern is now changing, as more women are being infected by heterosexual contact and newborns are exposed to in utero infection.AIDS seems to be caused by a retrovirus that is constantly changing its characteristics, making it difficult to create a vaccine against the disease, because the moment the vaccine is created, the type and variety of virus involved in the epidemic turns out to be totally different from the one utilized in making the vaccine. (The flu vaccine, for example, acts similarly in that it is different every year.)
Treatment is palliative with various drugs, the original one being AZT, which arrests the replication of the virus. All of these drugs are, however, toxic products and, unfortunately, do not make the person who has AIDS incapable of passing the disease on. Therefore, the current treatment not only prolongs the life of the victim of AIDS but also allows him or her a great deal more time in which to spread the disease. The AIDS virus can also contaminate or attach itself to dirty needles that are used by drug addicts. It can be transmitted through blood transfusion as well as by infected semen. The spread of AIDS can be prevented with the use of condoms, especially those with Nonoxyl 9 plus vaginal contraceptive foam (either in tablet form or in pressurized containers). Condoms made of animal membranes do not work in preventing AIDS since microscopic pores exist in the animal membrane that allow the virus to escape.
Death is from one of the several diseases, which attack the body because of the compromised immune system. Such diseases include pneumocystitis carina, Kaposi’s sarcoma, tuberculosis, yeast infections, or other opportunistic infections.
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