Now comes the V-Day aftermath—sexually transmitted infections
V should be for Valentines, not venereal diseases
CLINICAL MATTERS
February is the month of hearts, and Valentine’s Day means many couples hook up and consummate their relationships. The succeeding weeks post-Valentine’s are typically quite busy for infectious diseases doctors and other physicians who treat sexually transmitted infections (STIs).
STIs used to be referred to as venereal diseases. The term “venereal” refers to Venus, the Roman goddess of love, referring to the sexual nature of the disease. Nowadays, the term STI is preferred because “disease” usually means that there are symptoms.
A lot of STIs however are asymptomatic or have nonspecific manifestations. Since ancient times, STIs have been the bane of civilization. People were so disgusted with them that they usually named them after their erstwhile enemies. For instance, the Italians named syphilis the “French disease.”
The mode of transmission is pretty much the only thing that different STIs have in common. STIs can be caused by viruses, bacteria, parasites, and protozoans. Sexually transmitted viruses include herpes simplex, HIV, and monkeypox (now called MPox). Bacterial STIs include syphilis, gonorrhea, and chlamydia. Trichomoniasis is caused by a protozoan. Some parasites like pubic lice can be transmitted to sexual partners. It is fairly common for more than one STI to be transmitted at a time since the risk factors overlap.
The three most common reasons people consult their doctor for a possible STI are: a risky exposure; presence of a symptom of an STI such as a penile discharge or a rash; or a positive test like syphilis or HIV on a routine screening test.
Risky exposures usually occur when people neglect to use protection like condoms. It can also happen when a condom breaks or slips off. The worse ones are when a partner does what is called “stealthing,” in which he removes the condom surreptitiously without the partner being aware. When a risky exposure occurs, depending on the risk, we may go ahead and prescribe antibiotics to cover gonorrhea and chlamydia even if there are no symptoms. Testing for gonorrhea and chlamydia can be done using molecular PCR techniques but these can be quite expensive. Testing for syphilis and HIV can be done at baseline but if negative, a repeat test should be done in six to eight weeks because it can take that long for the tests to become positive.
Perhaps the most alarming way to find out that you have an STI is pus coming out of your penis. This is almost always gonorrhea. When we see patients with a penile discharge, we not only treat for gonorrhea but also for chlamydia. Chlamydia is more likely to be asymptomatic or cause some discomfort with a scant discharge. For women and for those who are anal-receptive partners, the discharge for either gonorrhea or chlamydia can be easily missed. Other STIs such as syphilis can present with a painless chancre, which is a round sore on the penis. Herpes simplex can present with a vesicular rash, fluid-filled blisters much like chicken pox. This is why doctors treating STIs will do a genital exam and anal exam to check for any abnormalities. For women, a pap smear and an internal exam along with a pregnancy test is a must. It is imperative that the partner or partners of a person diagnosed with an STI also be treated. Otherwise, he or she will just get reinfected when they, he, or she has sex with the untreated partner.
The following lists five of the most common STIs and their characteristics. This is not an exhaustive list and it is important to consult a doctor before taking any antibiotics.
1. Gonorrhea — This is caused by bacteria. For men this usually presents with pus from the penis. It is less obvious for women. It can be prevented with condoms. It can be treated with antibiotics but drug resistance is increasing.
2. Chlamydia — This shows up as scant discharge or may be completely asymptomatic. It’s particularly risky for women because it can cause pelvic inflammatory disease (PID) and infertility. It can be prevented with condoms. It can be treated with antibiotics. PID may need surgical drainage by a gynecologist.
3. Syphilis — This can cause a painless chancre on the penis, usually missed. It is less obvious in women. Some people develop secondary syphilis, which shows up as a rash all over the body, including the palms. A lot of these asymptomatic patients are detected during routine screening for overseas employment, when the blood tests RPR or VDRL may be positive. Some countries won't accept people with a positive RPR for employment even after treatment. RPR takes a while to go down while TPPA/TPHA remains positive for life. It can be prevented with condoms and treated with antibiotics; benzathine penicillin injections in the butt are a real pain. Untreated, over time syphilis can cause insanity by eating into your brain. It can also damage heart valves and cause blood vessel disease and a long list of other nasty complications.
4. HIV — Acute HIV can be a flu-like illness after two weeks from exposure, sometimes with enlarged lymph nodes and a rash, but this is very nonspecific. Pre-exposure prophylaxis (PrEP) can decrease risk by over 90 percent along with condoms. Information on PrEP and whether you qualify for free medication can be obtained at the nearest HIV treatment hub. If infected, treatment is available for free, but there is still no cure for now. Without treatment, most people living with HIV (PLHIV) will die in eight to ten years when their immune systems shut down. With effective treatment, especially if diagnosed early, this is a survivable disease. PLHIV on an effective antiretroviral regimen with a suppressed viral load are unable to transmit the virus but can still get other STIs.
5. Herpes simplex — This should not to be confused with herpes zoster, which is not an STI and is caused by the chicken pox or varicella zoster virus. Herpes simplex (HSV) is a viral infection that is like localized chicken pox in the genital area. It is very painful and can cause significant scarring. Antivirals like valacyclovir or acyclovir can decrease the duration of illness but it is not curable. HSV can cause recurrent episodes. Infection can be prevented with condoms, although active lesions in the pubic area that are not covered with the condom can still be contagious.
There are many other STIs but these five are among the most common. Always protect yourself especially when having sex with a new partner. If it doesn’t work out, however, please see your doctor.