Sexually Transmitted Diseases in the Male: Clinical Perspectives

 Benjamin Peng, M.D.

 (presented at the CAMS 2003 Annual Scientific Meeting)

         Currently 15 million Americans become infected with sexually transmitted diseases each year. As per the 2002 Sexually transmitted diseases treatment guidelines, essential points directed towards prevention and control include: 1)Education and counseling to reduce the risk of STD acquisition, 2)Detection of asymptomatic  and symptomatic persons unlikely to seek evaluation, 3) Effective diagnosis and treatment, 4)Evaluation, treatment and counseling of sexual partners, 5)Pre-exposure vaccinations for high risk patients (Hep B).

 The most common and easily available method of prevention is barrier protection via correct usage of male latex condoms. Condoms are more likely to be effective in prevention of infections transmitted by fluids from mucosal surfaces such as gonorrhea(GC), Chlamydia, trichomonas and HIV compared to those transmitted by skin to skin contact such as Herpes simplex virus(HSV), Human papillomavirus(HPV), Syphilis and Chancroid.

 Classic male STD’s can be categorized by Urethritis-Gonococcal(GU) and Nongonococcal(NGU). Genital Ulcers- Genital Herpes, Syphilis, Chancroid, Lymphogranuloma Venereum(LGV) and Granuloma Inguinale. Genital Warts and Scabies.

 The clinical presentation of Gonococcal urethritis is a painful, yellowish, purulent urethral discharge, quite often associated with penile swelling and inguinal adenopathy. The diagnosis is made by gram stain demonstrating gram-negative intracellular diplococci. Additionally urethral cultures and urine DNA probes can confirm the diagnosis. Primary treatment includes single dose oral Cefixime, Ciprofloxacin, Ofloxacin or Levofloxacin. Emergence of fluoroquinolone resistant Neisseria gonorrhea in Southeast Asia, Hawaii and California requires diligent surveillance and utilization of single dose Ceftriaxone IM.

 The majority of Nongonococcal urethritis is caused by Chlamydia trachomatis, but less common pathogens include Ureaplasma urealyticum, Mycoplasma genitalium, Trichamonas vaginalis or coliform bacteria. The clinical presentation is subtle, often being just a scant slightly uncomfortable discharge. Asymptomatic carriers exist in 40-60% of the cases and reinfection with the initial organism from the same untreated sexual partner is common. Primary treatment of NGU is either single dose Azithromycin or one week of doxycycline and must include the partner. Alternative regimens include either Erythromycin or Fluoroquinolones.

 Genital Herpes lesions in the male usually appear on the penis as discrete, small vesicular lesions on an erythematous base and they are often itchy and painful. Five-30% of primary infections is caused by HSV 1 and 99% of recurrent infections are caused by HSV 2. Thus new HSV serologic glycoprotein G1and G2 are able to make the correct diagnosis of genital herpes with 80-98% sensitivity and 96% specificity. Initial treatment with Acyclovir, Famciclovir or valacyclovir is for 7-10 days. Episodic or suppressive therapy with the same agents is often required since herpes lesions recur frequently. The current recognition that HSV reactivation is highest in the first 6 months with subclinical shedding of the virus for 20-35% of the days suggests utilization of either abstinence or condoms during this period.

Syphilis is caused by the spirochete Treponema pallidum. The classic clinical presentation is that of solitary deep nonpainful well-demarcated ulcer; however, it has also been termed the great imitator. Definitive diagnosis is obtained through darkfield examination or immunofluorescent antibodies of the lesion exudate. Presumptive serologic diagnosis includes Treponemal- FTA or MHATP, which are positive for life, or Nontreponemal-VDRL and RPR where titers reflect disease activity. Treatment includes Penicillin G IM or single dose Azithromycin or two weeks of  Doxycycline taken orally.

 Chancroid is caused by the gram-negative bacillus Haemophilus ducreyi. The presentation includes painful multiple irregular ulcers associated with inguinal adenopathy. Diagnosis is obtained by growing H. ducreyi on culture. Treatment includes single dose Azithromycin PO or Ceftriaxone IM or Ciprofloxacin for three days or Erythromycin for one week.

Lymphogranuloma Venereum (LGV) is characterized by a transient genital ulcer followed by persistent inguinal and/or femoral ulcerative adenopathy. The organism is Chlamydia trachomatis serotypes L1, L2, L3 is diagnosed by cultures for the lymph node, or microimmunofluorescent antibodies. Treatment includes Doxycycline or Erythromycin for 21 days.

 Granuloma Inguinale is caused by Calymmatobacterium granulomatis a gram-negative intracellular bacillus. The lesion is characterized by a beefy red elevated papule. Diagnosis is obtained by demonstrating Donovan bodies-bipolar staining rods in monocytes. Treatment includes either Doxycycline or Trimethoprim-sulfamethoxazole for three weeks.

(Dr. Peng isClinical Assistant Professor of Urology, NYU Medical School)