Sexually-Transmitted Diseases

 

HIV / AIDS / SIDA. Not surprisingly, this disease is in the front of people's minds. There is a worldwide epidemic and things are still going to get worse. There are good treatments now, though expensive, no cure and no vaccines. The only chance to avoid a billion cases is if a good cheap vaccine is invented quickly, because spread will continue unless everyone in the world suddenly starts practising either safe sex or strict monogamy, which seems unlikely.

We cannot summarise symptoms here, and it would not help much because there may not be a typical pattern. There is no localised sign of infection. Diagnosis is mostly by blood tests. Infection with the common kind of virus, HIV1, can be virtually ruled-out by a test for antibodies, but not for sure until 6 months after exposure. Diagnosis of an active case can usually be made much earlier than that, so it is worth testing earlier if there are clinical or other reasons for doing so, and then the test may be for antibodies, for the virus itself or for changes in the blood cells (CD4 and CD8 T-lymphocytes), depending on circumstances. All these early tests are much more expensive and are also less reliable than the HIV antibody test. Tests for HIV2 are also available.

Elaborate counselling is often provided for people who come forward to take a test for HIV. We agree that it is a terrible blow to learn that one is HIV-positive. We don't agree that HIV/AIDS should be treated differently from other diseases that are fatal or potentially fatal to the patient concerned, and there are some other diseases just as bad in that respect. So the approach at 21st Century Clinics is sympathetic but not over the top; we expect you to know your own mind and that you want the result as quickly as we can do it and still get it right.

Syphilis. Four and five hundred years ago, even one hundred years ago, the public notions about syphilis were much like those on HIV/AIDS today. Then treatments were discovered and when penicillin came in fresh cases almost disappeared. Not quite, however, and the disease is now making a comeback, though treatment with penicillin is still usually successful.

There can be a local sign, typically a painless 'sore' called a 'chancre', but often enough the sore is painful or nothing is ever seen, so we cannot rely on that. We cannot describe all the possible symptoms either, because syphilis is notorious for the variety of ways it can appear, mimicking other diseases.  In the old days it was said: "If you know your Syphilis you know your Medicine."

Diagnosis as for HIV/AIDS is almost always through blood tests for antibodies (VDRL and/or TPHA), though local tests on an open chancre are still sometimes done.

Gonorrhea. (Sometimes called Clap, though this word has also been used for syphilis.) The classic case presents with discharge of pus from the penis, pain on passing urine and pain in the area of the testicles, though infections can exist without these. Diagnosis may sometimes be possible by laboratory tests that are done while the patient is still in the clinic, or bacterial culture may be necessary to show the organism (taking 48 hours or more) and this will be done on a swab taken from inside the penis and therefore painful. Antibody tests are difficult and still unreliable. Though resistance to penicillin is common now, treatment with this or other antibiotics is usually successful. This disease may give rise to infertility, so must be treated promptly.

Chlamydia. The bacterium that causes this infection was discovered relatively recently, because it is difficult to grow in the laboratory. Typically, a case is expected to present with discharge from the penis. Often that does not happen, more so than with gonorrhea, though as with gonorrhea the infection can cause infertility. Diagnosis is best by laboratory tests for the bacterial DNA or other bacterial products done on a swab (collected as for gonorrhea, though a special kind of swab must be used, varying with the exact test) or on a specimen of urine, again collected in a special way (First-Pass Urine). Antibody tests may also be useful to detect recent or past infection but are less useful in finding whether the infection is current. Treatment is with suitable antibiotics. Lymphogranuloma venereum is a distinct disease from the clinical viewpoint, that is to say it does not resemble the condition described above, but is caused by certain variants of the same bacterium (Chlamydia trachomatis)    -    the L serovars.

Herpes. The two main types of herpes virus involved are Herpes I and II. Each may be spread sexually or non-sexually, though Herpes I is less commonly involved in a sexual infection and is often the underlying cause of the common 'cold sore' (on the lips). Because of this overlap in method of spread, the use of antibodies in diagnosis can be misleading; they can tell us about the existence of recent or past infection, but not whether the channel was sexual.

The typical local sign is a group of small and usually painful blisters (which then burst to form ulcers and at the same time release fluid containing infective virus. It may be possible to detect the virus in this blister fluid and so clinch the diagnosis, (though that is an expensive alternative since the clinical appearance is enough in most cases.) Healing will then follow spontaneously. However, (and this is a troublesome thing about all the Herpes family of viruses including simple chickenpox), the virus remains in the body, hiding within the DNA of the nerve cells that are connected to where it first gained entrance. Two main consequences are that it can come back in fresh outbreaks without fresh infection, just like with the common cold sore (these repeat attacks of genital herpes usually get less severe as time goes by), and that the virus cannot be totally eliminated from the body.

The most serious occurrence of strictly genital Herpes is in the case where a woman with open ulcers gives birth to a baby. Infection with either type of virus can run riot in immuno-suppressed patients (e.g. HIV). Treatment is with drugs that suppress the virus, and this may be needed in a serious case or to prevent recurrences if these become a nuisance.

Hepatitis B. There are other kinds of hepatitis virus but this is the one easiest to spread via sexual intercourse, though also spread by other means, and just worth including here. Severity varies enormously, the consequences can be very serious and yet many people never know they've got it. Long-term infectivity is the biggest worry from the point of view of Public Health and all health workers nowadays are tested for this: it is less likely to happen if you catch the virus as an adult, more likely if you are infected as an infant as is still common in underdeveloped countires. Roughly speaking, if you have antibodies (to the 'surface antigen' or 'Australia antigen') you cannot also have active virus (though that may not be enough to protect you from infection later). It is a good plan to be immunised, but testing is needed first.

In our STD screen, which is for a strictly limited purpose, we test for the antibodies if the specimen is negative for the active virus (surface antigen).

Lymphogranuloma venereum    -    see under Chlamydia. The disease presents as inflamed, swollen lymph glands in the groin which may break down to give ulcers, or within the anus (proctitis). It was rare in developed countries but has become more common recently, especially in homosexual men.

Non-specific urethritis (NSU). 'Non-specific' here is to convey that we may not know exactly in a particular case what is the cause of the urethritis and discharge. We now realise that most of the cases formerly labelled as NSU in this country were really due to Chlamydia. Now the term would be reserved for cases caused by tiny bacteria called mycoplasma or ureaplasma, or by viruses that often are not possible to identify.

Genital Warts, Molluscum contagiosum, etc. The name says it all, though the warts themselves are often bigger and more florid and faster growing than warts elsewhere. Warts are caused by infection with a particular virus. There is no truly specific treatment though various local applications including podophyllin may be of benefit. Great care is needed because of the irritant properties of such applications.

Crab Lice, scabies, etc. Though not confined to the genitals, infection by crabs is mostly during sexual contact of one kind or another; scabies may be spread by any kind of close contact.

Chancroid. Due to the bacterium Haemophilus ducreyi. Uncommon in Britain.

Granuloma inguinale. Due to infection by Donovania granulomatis. Uncommon in Britain