Sexually Transmitted Diseases

What are Sexually Transmitted Diseases?

Sexually transmitted diseases or better known as STD or venereal disease is not uncommon. It is one of the commonest illness in the world with extensive impact to public health care and socially. As the rate of sexual activities increases with higher high risk sexual behaviour and not practicing safe sex, the incidence of STD s increases steadily each year. The World Health Organization estimates that 340 million people are infected each year by a curable STD.  STDs are mostly seen in young men and women, more in homosexual or bisexual men.

Although it could be very traumatising or embarrassing to seek medical help, it is very important to do so if suspected the sign and symptoms of STD. The healthcare staff also should be alert and be sensitive to ensure privacy and confidentiality.


  • Causes of STDs
  • Symptoms of STDs
  • Diagnosis and Investigation of STD
  • Treatment Chlamydia Trachomatis
  • STD Prevention
  • Conclusion

Causes of STDs

There is a long list of causes for STD, commonly bacteria, viruses, fungi and even parasites. These infections can be spread by all types of unprotected sexual activity that involves semen and vaginal discharges. It is not uncommon that one could get infected by multiple pathogens especially in those with high risk sexual behaviour.

A high risk sexual behaviour is characterized by multiple sexual partners, frequent sexual partner changes and unprotected sex.  STD has also been shown have higher incidence in young people, homo or bi-sexual men, recreational drug use, alcohol and frequent travels.

Bacterial STD

The commonest cause is Chlamydia Trachomatis, a intracellular obligate bacteria and Neiserria Gonorrhea, a intracellular diplococcic bacteria that infects epithelium of conjunctiva, pharynx, urogenital tract and rectum. They usually coexist together, thus the STD screening includes these 2 organisms.

Another common organism is Treponema Pallidum, a motile spirochetes that is not limited to genitourinary system but could cause systemic illness if not treated early. The common name for this infection is syphilis. It is acquired by close sexual contact and transplacentally to neonates.

A less common bacteria is Klebsiella Granulomatis,a gram negative bacillus, also known as granuloma inguinale.

Video of STD

Viral STD

The commonest virus is Human Papillomavirus (HPV) 6,11,16 and 18 that causes genital warts. Most HPV is acquired by direct sexual contact and neonates acquired them from the infected birth canal. Neonates may have anogenital warts or laryngeal papillomas from inhalation.

Another common viral STD is Herpes Simplex Virus (HSV) 1 and 2 that causes genital herpes. They are spread by mucosal exposure or non intact skin surface to the virus. Most genital herpes are cause by HSV 2 and oral lesion by HSV 1. With the increasing practice of oral sex, HSV 1 and HSV 2 are no longer confined to oral cavity or genitals.

Hepatitis B (HBV) and Hepatitis C (HCV) are DNA viruses that are spread by blood products and sexual contact. Although there are vaccinations, HBV and HCV remains endemic in Asia.

Human Immune Deficiency Virus (HIV) is RNA retrovirus that is transmitted by blood product, bodily fluid and sexual contact.  The acute infection is often asymptomatic or just a mild viral fever. The symptoms of illness are mainly due to complications of immunodeficiency.


Fungi STD

In women, vaginal infection of Candida Albicans is common and not necessary signify STD. However, it is not common for men to be infected. So, if a men presents with candida infection, he most likely contracted it during sexual activity.

Parasite STD

Phthirus pubis is a blood sucking insect, known as lice that cause pediculosis pubis. They are transferred by close contact to the host where they are attached to the pubic hair. These lice can also be found at the eyelashes and eyebrows.

Sarcoptes Scabiei, also known as mites is spread by close sexual contact or within the same household. It can affect any part of the body but rarely the face.

Trichomonas Vaginalis, a flagellates protozoa causes trichomoniasis, mostly in women. They are less common but has high prevalence of coinfection with other STDs.

Symptoms of STDs

There are many symptoms of STD, but the common symptoms that are presented are painful or painless urethral discharge in men, vaginal discharge and genital ulceration. Some women will have itching and redness at the vagina.

The common causative agents for urethral discharge in men are Neiserria Gonorrhea, Chlamydia Trachomatis, Trichomonas Vaginalis, HPV, HSV and Treponema pallidum.

The common causative agents for vaginal discharge in women are Neiserria Gonorrhea, Chlamydia Trachomatis, Trichomonas Vaginalis, HSV and Candida Albicans.

Genital Ulcerations in STD are caused by Treponema Pallidum, Chalamydia Trachomatis, HPV and HSV infection.

STD also causes miscarriages and fetal abnormalities. Pelvic Inflammatory Disease (PID) is the complication of untreated STD.

Chlamydia Trachomatis

In men, 50% of Chlamydia infections are asymptomatic. The symptomatic infection will cause anterior urethritis(inflammation of urethra) with dysuria and urethral discharge.  If the infection is not treated, it will ascends and cause epididymitis. Men who practise anoreceptive intercourse may experience proctitis.

In women, up to 80% are asymptomatic as infection in endocervix is difficult to be notices. Some will have vaginal discharge, lower abdominal pain or post coital bleeding. If left untreated, the infection will ascend to cause acute salphingitis. Most women will experience dysuria (pain during urination).

Neonates can acquire this infection through the birth canal and presents with mucopurulent conjunctivitis or pneumonia.

Neiserria Gonorrhea

In men, 90% are symptomatic with anterior urethritis is and urethral discharge. The ascending infection leads to epididymitis and proctatitis. Rectal infection causes pain, itch and discharges.

In women, up to 50% are asymptomatic. The infected site is usually the endocervix that could cause vaginal discharge. Ascending infection leads to dysuria, pelvic pain and intermenstrual bleeding. The complications of gonorrhoea include Bartholin’s abscess and Fitzhugh Curtis Syndrome that develops perihepatitis.  Gonorrhea is also the leading cause of infertility in women.

Neonates acquire gonorrhoea from their infected mothers and presents with opthalmia neonatorum, similar to conjunctivitis.

Treponema Pallidum

Treponema Pallidum is better known as Syphilis, which is a chronic systemic disease with 3 stages. The early stage of disease, or primary syphilis manifest as painless hard chancre(at infected site, usually at penile shaft or vulva) and painless regional lymphadenopathy. This lesion will resolve spontaneously.

If not treated, secondary syphilis will occur after 3 to 6 weeks with fever, rash, malaise and generalised lymphadenopathy.  The rash is red or brown in colour, non itching, usually starts from trunk and spread to the extremities, palms and soles.

Tertiary syphilis can occur 3 to 20years after primary syphilis. There will be generalised granulomatous lesions(gumma) at skin, bones and viscerals. Cardiovascular involvement manisfest as thoracic aneurysm or aortic regurgitation. Neurosyphilis includes meningitis and tabes dorsalis.

Congenital syphilis could cause still birth. Babies who survive often fail to thrive, has nasal discharge and mucous membranous lesion similar to secondary syphilis. In late stages, commonly after 2 years old, there could be facial gumma, Hutchinson’s teeth, abnormalities of long bone and uveitis.

 Klebsiella Granulomatis

The symptoms start late after an incubation period of 1 to 6 months. It begins with subcutaneous nodules at the genitals and subsequently progress to beefy red painless ulcerative lesion that is highly vascular and is easy to bleed. Commonly involve the genitalia, but any mucosa membrane can be affected, including mouth and anus. Painless lymphadenopathy accompanies too.


In men, warts (small painless nodules) develop at the penile shaft and subpreputial space and sometimes involving urethra and meatus. In immunosuppressed or men who practise anoreceptive intercourse, warts can be found in the perianal region and rectum.

In women, warts starts at the external genitalia and perianal region, and could ascend up to the vagina and cervix.


Genital Herpes is one of the commonest STD and the symptoms are easy to recognize.  Primary genital herpes starts with low grade fever, generalised malaise, myalgia and headache for a day. Then, the painful vesicles (blister like) starts to appear at the genitalia, crust after a few days and finally heal without scarring. The painful vesicles can also be found at thigh, buttock and perianal region. While both men and women will develop vesicles, most women will experience severe dysuria that could cause urinary retention.

Tender inguinal lymphadenopathy is often present. Aseptic meningitis can happen as neurological complication.


Hepatitis B & Hepatitis C

Around 50% of infected people will experience acute infection. They cause fever, generalized malaise, jaundice and hepatomegaly. Lymphadenopathy is also present with abdominal pain. Most acute infections are simple and not life threatening. It is the complication that is disabling. After acute infection, most will resolve, some will be chronic carriers with chronic hepatitis causing liver cirrhosis or liver failure. This predispose to hepatocellular carcinoma, or liver cancer.



Acute infection is often symptomatic. After seroconversion, most will have maculopapular rash, generalized myalgia, malaise and fever. Most will recover completely after 1-2 weeks. Some will proceed to have constitutional symptoms such as loss of appetite, loss of weight and night sweats. Few years later, or even later when the CD4 count drops, if untreated they will have symptomatic HIV infection, or AIDS – Acquires Immune Deficiency Syndrome. AIDS is defined by a list of infection or condition. Some common examples of AIDS defining conditions are candidiasis in trachea or lungs, extrapulmonary Cryptococcus infection,CMV, chronic HSV, Kaposi’s sarcoma, Burkitt’s lymphoma, disseminated tuberculosis, toxoplasmosis encephalopathy and many more.


Trichomonas Vaginalis

In men, they are usually asymptomatic. But some do complaint of mild urethral discharge and urinary frequency.

In women, some may be asymptomatic but most will experience offensive vaginal discharge and vaginal irritation.

Candida Albicans

In men, the affected region is usually around the foreskin causes itching and pain.

In women, itchiness and pain at the vulva is the commonest symptom. Depending on each individual, vaginal discharge may or may not be present. The vaginal discharge are curdy white thick discharges.

Phthirus Pubis

The symptoms usually start early with itching at the pubic area in both men and women. Very tiny bugs could be seen at the pubic hair or from undergarments.


Similar to pubic lice, the symptoms are intense itching at the pubic area in both men and women. Small moving bugs could be seen at the pubic hair or undergarments. Itchy papules and pustules are often seen with linear skin burrows.


Diagnosis and Investigation of STD

It is important to seek medical care if you suspect yourself being exposed to STD.  As most infections can be asymptomatic, it is crucial to be investigated early before being symptomatic or complications set it. Often times, STD could have multiple causative organism at once.

The investigations vary between symptomatic and asymptomatic individuals.

In asymptomatic women

A high vaginal swab is taken and tested for Gonorrhoea and Chlamydia by culture. A urine test is also done by Nuclei Acid Amplification Test (NAAT) for Gonorrhoea and Chlamydia. There are also simple urine test kits that can be taken at home if she feels shy to go to a clinic.

Blood test is taken for serology test of syphilis, HIV and Hepatitis.

In asymptomatic men

A urethral swab is taken for culture and also urine NAAT to test for Gonorrhoea and Chlamydia.

Blood test is taken for serology test of syphilis, HIV and Hepatitis.

In asymptomatic homosexual men

A urethral, rectal and oropharyngeal  swab is taken for culture and also urine NAAT to test for Gonorrhoea and Chlamydia.

Blood test is taken for serology test of syphilis, HIV and Hepatitis.


In symptomatic men

Swabs are taken from urethra, rectum and the oropharynx to test for Gonorrhea, Chlamydia and Trichomonas. Urine test for Chlamydia is taken as well as blood for seroly test of HIV, Hepatitis, HSV and Syphilis.

In symptomatic women

Swabs are taken from cervix, vagina, rectum and the oropharynx to test for Gonorrhea, Chlamydia and Trichomonas. Urine test for Chlamydia is taken as well as blood for seroly test of HIV, Hepatitis, HSV and Syphilis.

In the symptomatic patients will ulcers, a sample will be taken for microscopy examination to determine Treponema and Klebsiella, and also culture for HSV.

Other test that can be done for women includes a pregnancy test and cervical cytology – pap smear.



Chlamydia Trachomatis

1st line treatment is with single oral Azithromycim or oral Doxycycline for a week. Erythromycin, Oflaxacin and Levofloxacin can be used as alternatives for a week.

Neiserria Gonorrhea

1st line treatment is single oral Cefixime or intramuscular injection of Ceftriaxone. Other alternatives are intramuscular injection of Cefotaxime, Cefoxitin and Ceftizoxime.

Treponema Pallidum

A single dose of intramuscular injection of Penicillin G is the treatment. Oral Doxycycline and Tetracycline can be used as alternatives for 2 weeks.

Klebsiella Granulomatis

Oral Doxycycline for 3 weeks or longer; until complete healing of the ulcers. Other alternatives are oral Azithromycin, Ciprofloxacin and Trimethoprim-sulfamethoxazole.


There is no cure for HPV, therapies are only to reduce the size of warts. Topical cream of Podofilox, Imiquimod can be used externally. Cryotherapy and trichloroacetic acid can be administered by dermatologist.


Oral Acyclovir for 10 days is the standard treatment. Some centres uses Famciclovir which is equally potent.

Hepatitis B & Hepatitis C

There is only supportive treatment for infectious hepatitis. For chronic HBV carrier, Lamivudine is given depending on the case.


There is no cure for HIV. Highly Active Antiretroviral therapy (HAART) aims to supress the HIV RNA concentration to ensure immune function of the patient.  There are many other drugs that are still in experimental phase for better outcome.

Trichomonas Vaginalis

Single dose of oral Metronidazole is effective or some will opt for a week.

Candida Albicans

A single dose of vaginal pessary – Clotrimazole is sufficient or an oral dose of Fluconazole. Antifungal cream for external genitalia in men and women help with the itching.

Phthirus Pubis & Scabies

5% Permethrin is used to treat entire household and sexual partners. It is to be applied over whole body including neck and scalp, wash off only after 12 hours. The process has to be repeated a week later.



For pregnant patients, they should be cared in a combined prenatal clinic consist of infectious physician and also an obstetrician.  Oral penicillin, Ceftriaxone, Azithromycin and Metronidazole are safe in pregnancy.


Sexual Assault

For sexually assaulted patients, prophylaxis should be given after the investigations are done.  They will be given a single dose of IM Ceftriaxone, oral Doxycycline, Metronidazole and Azithromycin.  Hepatitis B vaccination should be given, and to complete a course of 3 injections. HIV prophylaxis is depending on the case.


STD Prevention

Sexual promiscuity is the main cause of STD. So, the prevention starts from avoiding sexual promiscuity, practicing monogamous sexual relationship.

Practicing safe sex with condoms has 90% protection from STD. This is because close sexual contact is not protected by a condom.

It is important to have regular check-up and early investigation if suspected STD. Vaccinations for Hepatitis B and Human Papillomavirus are available.



Prevention of STD is better than cure as some diseases are incurable.  Most of the common STD can be cured with simple medical treatment. So, it is important to seek help immediately if you suspect yourself having STD.


We will be expanding on this important topic in future articles. While I recommend you to register to download an e-book: “Adult Prevention Guide” for better health, a FREE

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