Sexually Transmitted Diseases - STD Diagnosis and Treatment

Emergency Department Diagnosis and Treatment of Sexually Transmitted Diseases

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Table of Contents
About This Issue

Sexually transmitted disease can cause severe outcomes for patients, their partners, and their unborn babies, and swift and accurate diagnosis and treatment is essential to reduce morbidity and minimize the potential public health risks.

How can you be sure you’re asking the right questions when taking a history in a patient with suspected STDs?

Syphilis can present in primary, secondary, and tertiary stages. What are the presenting signs for each, and how will diagnosis and treatment differ?

Do you need to do a pelvic exam when STD is suspected?

Which STDs increase the chances of pelvic inflammatory disease, HIV, and cancer?

Should you order clean-catch urine samples, urethral or vaginal swabs, or blood sample?

Which STDs have FDA approval for NAAT testing? Should wet mounts be used for trichomoniasis?

What are the particular risks of STDs in pregnant women, and what are optimal treatments?

When can expedited partner therapy be used?

Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Etiology and Pathophysiology
    1. Chlamydia trachomatis Infection
    2. Gonorrhea
    3. Syphilis
    4. Bacterial Vaginosis
    5. Granuloma Inguinale
    6. Lymphogranuloma Venereum
    7. Mycoplasma genitalium
    8. Genital Herpes
    9. Human Papillomavirus
    10. Trichomoniasis
  6. Differential Diagnosis
  7. Prehospital Care
  8. Emergency Department Evaluation
    1. History
    2. Physical Examination
      1. Physical Examination Findings in Chlamydia
      2. Physical Examination Findings in Gonorrhea
      3. Physical Examination Findings in Syphilis
      4. Physical Examination Findings in Bacterial Vaginosis
      5. Physical Examination Findings in Granuloma Inguinale
      6. Physical Examination Findings in Lymphogranuloma Venereum
      7. Physical Examination Findings in Genital Herpes
      8. Physical Examination Findings in Human Papillomavirus
      9. Physical Examination Findings in Trichomoniasis
  9. Diagnostic Studies
    1. Chlamydia Testing
    2. Gonorrhea Testing
    3. Syphilis Testing
    4. Bacterial Vaginosis Testing
    5. Granuloma Inguinale Testing
    6. Lymphogranuloma Venereum Testing
    7. Mycoplasma genitalium Testing
    8. Genital Herpes Testing
    9. Human Papillomavirus Testing
    10. Trichomoniasis Testing
  10. Treatment
    1. Chlamydia Treatment
    2. Gonorrhea Treatment
    3. Syphilis Treatment
    4. Bacterial Vaginosis Treatment
    5. Granuloma Inguinale Treatment
    6. Lymphogranuloma Venereum Treatment
    7. Mycoplasma genitalium Treatment
    8. Genital Herpes Treatment
    9. Human Papillomavirus Treatment
    10. Trichomoniasis Treatment
  11. Special Populations
    1. Pregnant Women
      1. Chlamydia
      2. Gonorrhea
      3. Syphilis
      4. Bacterial Vaginosis
      5. Genital Herpes
      6. Human Papillomavirus
      7. Trichomoniasis
    2. Persons in Correctional Facilities
  12. Controversies and Cutting Edge
    1. Ceftriaxone Administration Route for Treatment of Gonorrhea
    2. Strategies for Partner Therapies
      1. Chlamydia
      2. Gonorrhea
      3. Syphilis
      4. Bacterial Vaginosis
      5. Genital Herpes
      6. Human Papillomavirus
      7. Trichomoniasis
  13. Disposition
  14. Summary
  15. Risk Management Pitfalls in Management of Sexually Transmitted Diseases in the Emergency Department
  16. Time- and Cost-Effective Strategies
  17. Case Conclusions
  18. Clinical Pathway for Management of Sexually Transmitted Diseases in the Emergency Department
  19. Tables, Figures and Appendixes
    1. Table 1. Sexually Transmitted Diseases Differential
    2. Table 2. Diagnostic Sample Options
    3. Table 3. Recommended Treatments for Sexually Transmitted Diseases
    4. Figure 1. Chlamydial Cervicitis
    5. Figure 2. Chlamydial Conjunctivitis
    6. Figure 3. Gonorrhea Penile Discharge
    7. Figure 4. Disseminated Gonorrhea
    8. Figure 5. Primary Syphilis: Chancres
    9. Figure 6. Secondary Syphilis: Rash
    10. Figure 7. Secondary Syphilis: Condylomata lata
    11. Figure 8. Tertiary Syphilis: Gummatous Lesion
    12. Figure 9. Bacterial Vaginosis Discharge
    13. Figure 10. Granuloma Inguinale Lesion
    14. Figure 11. Lymphogranuloma Venereum
    15. Figure 12. Female Herpes Lesions
    16. Figure 13. Male Herpes Lesions
    17. Figure 14. Traditional Syphilis Serologic Screening Algorithm
    18. Figure 15. Reverse Sequence Syphilis Screening
    19. Appendix 1. Physical Examination Findings for Sexually Transmitted Diseases: Eyes, Ears, Mouth/Throat/Nose, Skin, and Lymph
    20. Appendix 2. Physical Examination Findings for Sexually Transmitted Diseases: Cardiac, Pulmonary, Abdominal, Musculoskeletal, Neurological, and Psychiatric
    21. Appendix 3. Physical Examination Findings for Sexually Transmitted Diseases: Pelvic, Genital, Anal/Rectal
  20. References



Sexually transmitted diseases are a growing threat to public health, but are often underrecognized, due to the often nonspecific (or absent) signs and symptoms, the myriad diseases, and the possibility of co-infection. Emergency clinicians play a critical role in improving healthcare outcomes for both patients and their partners. Optimizing the history and physical examination, ordering appropriate testing, and prescribing antimicrobial therapies, when required, will improve outcomes for men, women, and pregnant women and their babies. This issue reviews the latest evidence in the diagnosis and treatment of sexually transmitted diseases, focusing on efficient and safe strategies to optimize outcomes.


Case Presentations

You are getting close to the end of your busy shift, but you have time to pick up 1 more low-acuity patient triaged with the chief complaint of urinary tract infection. On review of her chart, you note reassuring vital signs, with a blood pressure of 120/63 mm Hg; heart rate of 71 beats/min; respiratory rate of 18 breaths/min; oxygen saturation of 100% on room air; and temperature of 37°C (98.6°F). Nurse triage note states: “Patient presents today with 3 weeks of dysuria, urinary frequency, and lower abdominal pain despite a full course of nitrofurantoin prescribed by a local urgent care clinic, followed by a full course of ciprofloxacin prescribed by her primary care provider.” When you examine the patient, she claims mild improvement in her symptoms 2 days prior, but now has persistent dysuria again. Initial physical exam is positive only for mild suprapubic discomfort with palpation. Urinalysis is notable for negative pregnancy test, small leukocyte esterase, and negative nitrite. You wonder whether to prescribe a third antibiotic and send a urine culture, or if there is something else you should be considering . . .

Just as you are walking out of the first patient’s room, you are called urgently to the room of a 50-year-old man who is agitated, aggressive, and profoundly tachycardic. The patient had been brought in by family for a “psychiatric eval.” His family reports a history of worsening bizarre behaviors, staying up all night, and hallucinations. These symptoms have been worsening over several weeks, but they brought him to the ED tonight after his brother realized that he had not slept in 3 days. The family is unaware of any recent fevers or infectious symptoms. They are also unaware of any recent alcohol or drug use, but his brother notes that he had a “wild” youth. The family is unaware of any history of psychiatric illness. On exam, the patient appears disheveled and is fidgeting frequently. He appears to be responding to internal stimuli. He is oriented to person only and states that he is not sure why his family brought him to the ED. He is able to recall 0 of 3 objects at 5 minutes. He denies recent drug or alcohol use, and there are no track marks visible on his arms. He has an ataxic gait and diminished reflexes in his lower extremities. You decide to pursue further medical evaluation before calling psychiatry. Basic metabolic panel and CBC are unremarkable. A CT scan shows mild atrophy, but no acute findings. You decide to perform a lumbar puncture for evaluation and wonder if there are any specialized tests you should consider…

The charge nurse approaches you and asks if you are willing to stay past your shift to assist with management of a local college student who has just presented stating that she was sexually assaulted at a party 3 nights ago. On arrival, the 19-year-old otherwise healthy woman is hysterical, stating that she does not know what happened. She believes she was “drugged” by someone at the fraternity party and only remembers waking up with no clothing. She is refusing a sexual assault exam and evidence collection kit, but is asking for STD treatment. You wonder about the current recommendations for treatment and the drugs of choice . . .



Sexually transmitted diseases (STDs), sometimes referred to as sexually transmitted infections (STIs), are common diseases involving the transmission of an organism between sex partners through vaginal intercourse, anal sex, or oral sex. STDs continue to be underrecognized by the public and by healthcare professionals and continue to lead to devastating health consequences including infertility and facilitation of HIV transmission.1 In addition to the tremendous health impacts, the high prevalence and rising rates of STDs in the United States continue to be a significant economic burden on the healthcare system. Data suggest that there are an estimated 20 million new STD diagnoses in the United States each year, leading to a direct cost of treating STDs of $16 billion annually.2

The prevalence of STDs continues to be very high, due partly to the fact that many infected patients have minimal or no symptoms and can unwittingly pass these diseases to their partners. Emergency clinicians and primary care providers are positioned to identify these patients, to treat and counsel infected persons, and to potentially treat sex partners who are infected. Diagnosis and treatment can help prevent serious, life-threatening complications of STDs including infertility, ectopic pregnancy, spontaneous abortion, chronic pelvic pain, and chronic infections. At the same time, emergency clinicians must be aware of growing antibiotic resistance, especially in the treatment of gonorrhea. This issue of Emergency Medicine Practice presents a comprehensive review of the current evidence and best-practice guidelines of the evaluation and treatment of STDs and complements the February 2016 issue, “The HIV-Infected Adult Patient in the Emergency Department: The Changing Landscape of Disease.


Critical Appraisal of the Literature

A literature search was performed using PubMed and the Cochrane Database of Systematic Reviews, with the search terms, sexually transmitted disease, sexually transmitted infection, bacterial vaginosis, chlamydia, genital herpes, gonorrhea, human papillomavirus, syphilis, trichomoniasis, and expedited partner therapy. The search was focused on articles published in the English language that are relevant to the emergency clinician, those published after 1990, and on articles that discussed current STD first-line treatment, management, and diagnostic evaluation. Priority was given to clinical trials, evidence-based guidelines, and high-quality reviews, which resulted in the 107 references cited. The National Guideline Clearinghouse was also accessed and identified guidelines that provide recommendations general to all STDs, including the key resource published by the United States Centers for Disease Control and Prevention (CDC), Sexually Transmitted Diseases Treatment Guidelines 2015.3 When available, recommendations in this article are evidence-based; however, most of the studies are retrospective, with the prospective studies focused primarily on treatment.


Risk Management Pitfalls in Management of Sexually Transmitted Diseases in the Emergency Department

4. “I’m unsure about giving high-dose penicillin to my patient with primary syphilis because I have heard about the signs and symptoms associated with the Jarisch-Herxheimer reaction.” Although these symptoms are unpleasant, they are self-limited, and concern about the development of the Jarisch-Herxheimer reaction should not delay treatment. Penicillin G benzathine remains the most effective treatment for syphilis and should be given to all patients without confirmed allergy. In patients with a penicillin allergy, desensitization should be considered.

8. “Why does this patient keep coming back with a UTI?”

Avoid the misdiagnosis of a UTI and perform a pelvic examination or genital examination in patients with overlapping symptoms and inconclusive urine studies. The pelvic examination and associated diagnostic studies can lead to the accurate STD diagnosis and prevent potential complications and repeat visits to the ED. A urine culture should be sent if there is any continued concern for recurrent UTI.

9. “The patient says that she does not want to take acyclovir for the new HSV-2 diagnosis because she is nursing her baby.”

The use of acyclovir is safe in lactating mothers. There is no evidence that acyclovir causes any adverse effects in breast-fed infants. The United States National Library of Medicine at the National Institutes of Health maintains the LactMed database to assist providers with information regarding medications to treat STDs during breastfeeding.



Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.

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  3. Workowski KA, Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015;64(Rr-03):1-137. (Expert guidelines/systematic review)
  4. Centers for Disease Control and Prevention. Sexually transmitted disease surveillance 2017. 2017 STD Surveillance Report 2017. Accessed March 10, 2019. (CDC report)
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  8. Centers for Disease Control and Prevention. Sexually transmitted disease surveillance 2017: syphilis. 2019. Accessed March 10, 2019. (CDC guidelines)
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  42. Hobbs MM, van der Pol B, Totten P, et al. From the NIH: proceedings of a workshop on the importance of self-obtained vaginal specimens for detection of sexually transmitted infections. Sex Transm Dis. 2008;35(1):8-13. (Expert guidelines/workshop review)
  43. Cook RL, Hutchison SL, Ostergaard L, et al. Systematic review: noninvasive testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Ann Intern Med. 2005;142(11):914-925. (Systematic review; 29 studies)
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  45. Renault CA, Hall C, Kent CK, et al. Use of NAATs for STD diagnosis of GC and CT in non-FDA-cleared anatomic specimens. MLO Med Lab Obs. 2006;38(7):10. (Guidelines and review)
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  72. Mehta SD. Systematic review of randomized trials of treatment of male sexual partners for improved bacteria vaginosis outcomes in women. Sex Transm Dis. 2012;39(10):822-830. (Systematic review of 8 randomized controlled trials)
  73. Homayouni A, Bastani P, Ziyadi S, et al. Effects of probiotics on the recurrence of bacterial vaginosis: a review. J Low Genit Tract Dis. 2014;18(1):79-86. (Systematic review)
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  79. Chosidow O, Drouault Y, Leconte-Veyriac F, et al. Famciclovir vs. aciclovir in immunocompetent patients with recurrent genital herpes infections: a parallel-groups, randomized, double-blind clinical trial. Br J Dermatol. 2001;144(4):818-824. (Randomized controlled study; 204 patients)
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Publication Information

Camiron L. Pfennig-Bass, MD, MHPE; Elizabeth Page Bridges, MD

Peer Reviewed By

Joelle Borhart, MD, FACEP, FAAEM;James Castellone, MD, MBA, FACEP, CHCQM

Publication Date

April 1, 2019

Pub Med ID: 30908000

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