Sexually Transmitted Disease (STD)

The Venereal Diseases Act of 1917 defined 3 such diseases. They were syphilis, gonorrhoea and chancroid. In the UK chancroid is unimportant and often forgotten although it is still troublesome in some parts of Africa. Syphilis ebbed but has been resurgent and the prevalence of gonorrhoea is often taken as an index of the degree of promiscuity in the community.

The generic term for the venereal diseases (VD) was changed to sexually transmitted diseases (STD) and the VD clinics became special clinics as new euphemisms were devised to hide the embarrassment of society. More recently the speciality was called genito-urinary medicine (GUM). They are also referred to as sexually transmitted infections (STI). The range of diseases that would meet that classification is now much wider than the 3 that were named in the early part of the last century.

After a surge in sexually transmitted diseases during the First World War there was a lull between wars and another surge during the Second World War. When young men are about to go off to war and there is a realistic chance that they may never return, there is a great urge to "take comfort" before embarkation and this may not be under judicious conditions.

The 1960s saw an unprecedented ease in contraception with the ready availability of the pill and a soaring rate of promiscuity, without barrier contraception. The slogan of the young was "make love, not war", judgment was often impaired by chemicals and perhaps there was an unrealistic feeling that antibiotics could cure such diseases.

The advent of AIDS was a chilling reminder of the limitation of antibiotics and whilst promiscuity fell, as indicated by the incidence of gonorrhoea, this lull was only temporary.

To make a meaningful analysis of the facts and figures, it is important to look at the various ways by which the diseases may be spread. There may be heterosexual activity.There may be homosexual activity. Not all such diseases are always spread by sexual activity. There may be drug taking activity that leads to transmission of such diseases. The geographical variation in the importance of various forms of transmission with regard to acquired immune deficiency syndrome, was discussed in the article. Such means of dissemination are not discrete as people may be bisexual, indulging in sexual activity with both sexes and intravenous drug abusers may turn to prostitution to feed their habit. A number of diseases can be vertically transmitted from mother to child.

Another very important group is those who harbour sexually transmitted diseases but they are unaware that they have the disease or have refused to present for diagnosis and treatment. Such people can account for a very large discrepancy between the number known to have the disease and the number who are actually infected. With regard to HIV infection, they may represent more than 30% of cases. They are a particular problem because, if they are unaware of the infection, they are more liable to spread it.

In many cases, infection remains undiagnosed as the individual is asymptomatic. The disease may be more likely to produce symptoms in one sex than the other, but it remains contagious. A man may readily see a primary chancre of syphilis on his glans whilst a woman is unaware of one on her cervix. Candida may cause vaginal discharge and pruritis vulvae but often in men it causes no symptoms.

The Health Protection Agency's report for 2005,¹ based on figures from 2004, gives much cause for concern. To summarize much of it:

• There is:
  • An undiminished and high level of transmission of HIV and other STIs among homosexuals
  • A steady increase in the number of HIV-infected black Africans in the UK
  • Limited but compelling evidence that heterosexual transmission of HIV within the UK is slowly rising
  • Continuing high transmission of other STIs, especially chlamydia among young people.
• By the end of 2004 there were an estimated 58,300 people living with HIV in the UK, of whom 34% were unaware of their infection.
• The incidence of gonorrhoea also remained high amongst homosexuals in 2004, with 3,977 infections diagnosed. More than a quarter were resistant to ciprofloxacin. The epidemic of syphilis in this group continued to grow, and there has been a significant increase in the number of cases of lymphogranuloma venereum (LGV). The last was previously thought of as a rare disease.
• Young people in the UK have a high prevalence of chlamydia, gonorrhoea and genital warts. Rates of diagnoses continued to increase among young people in 2004, with the highest rates of gonorrhoea diagnoses seen among men aged 20-24 and women aged 16-19. Three-quarters of chlamydia diagnoses in women were in young women, and 56% of diagnoses in men were in young men. Some of the increases in gonorrhoea and chlamydia diagnoses among young people may reflect increased attendance of young people at GUM clinics, and for chlamydia, increased and more sensitive testing. Diagnoses however, will underestimate the true level of infection in the UK, as many infections are asymptomatic.
• HIV, gonorrhoea and syphilis have marked variation in geographical distribution within the British Isles and within England. For chlamydia, genital warts and genital herpes simplex virus (HSV), there was much less variation across the UK.

The risk of acquiring sexually transmitted diseases is greatest in those who are promiscuous, especially if they do not use barrier contraceptives. Those who are celibate or who have a faithful, monogamous, long-standing relationship are not at risk. This applies to both homosexuals and heterosexuals. However, it is possible to acquire such diseases by other means.

The following may be seen as relative risk factors, although no group should be seen as immune:

• Being young
• Homosexuals
• Substance abusers
• People from sub-Sahara Africa
• Social deprivation
• Failure to use barrier contraceptives

Nowadays most prostitutes will insist that their clients wear a condom but if their motive is to feed a drug habit, they may be less discriminating. Hence they are at great risk of both getting and giving sexually transmitted diseases and they are at risk of having acquired a sexually transmissible disease from their intravenous drug abuse.

The number of diseases that are usually transmitted by sexual intercourse or which may be transmitted by that route, is much greater than the 3 defined by the Venereal Disease Act. Some on this list may seem a little surprising to be classified as sexually transmitted diseases:

• Syphilis
• Gonorrhoea
• Chancroid
• HIV/AIDS
• Chlamydia
• Nonspecific urethritis (NSU) including Reiter's disease
• Lymphogranuloma venereum
• Genital herpes simplex
• Genital warts
• Carcinoma of cervix
• Vaginal candidiasis
• Hepatitis B and, to a rather lesser extent, hepatitis C
• Pelvic inflammatory disease
• Trichomonas Vaginalis
• Epididymo-orchitis

Many of these diseases have their own articles that will give a much fuller account. Each will be discussed quite briefly here, with especial regard to sexual transmission. Most STIs are best treated in a GUM clinic as they have expertise in diagnosis and treatment as well as the ability to perform contact tracing.

Anyone who is being treated for a STI should abstain from sexual activity until treatment is complete. It is commonly believed by the lay public, that anyone who is receiving a course of antibiotics should avoid alcohol although metronidazole is the only antibiotic with an adverse reaction with alcohol. The group of doctors who most commonly give this advice is GUM specialists. This may be because they believe that those who indulge in alcohol are more likely to transmit the disease before it is fully treated. There is a great tendency to treat such disease with a single dose of antibiotics where possible, to improve compliance.

Syphilis

The origins of syphilis are uncertain, as described in the final section. It has long been known to be a sexually transmitted disease that can also be passed from mother to child. It can also be transmitted by blood transfusion but blood is routinely screened for the disease. Pregnant women are also routinely screened for syphilis. If not stopped by adequate treatment, it can produce a variety of conditions and over the years the disease became known as the great mimicker.

The introduction of penicillin transformed the management of the disease and it declined. In the 1960s around 70% of syphilis was in homosexuals. There would be no reliable figures about the number who caught in from homosexual practices before that time as such a confession would make the patient liable to imprisonment. In recent decades, syphilis has become resurgent, including in the heterosexual population. It is not uncommon for it to be acquired at the same time as other sexually transmitted diseases and as it has an incubation period of around 21 days, it may not have presented when other diseases are diagnosed.

It is a disease that is very easy to overlook these days, whereas 50 years ago the great mimicker would have been in almost every differential diagnosis. If a patient has an unexpected reaction to an antibiotic, it is worth bearing in mind that this could be a Jarisch-Herxheimer reaction due to latent syphilis. Another disease that can also give that reaction and can also be difficult to diagnose is Lyme disease.

Gonorrhoea

Gonorrhoea has almost certainly been around for many centuries and possibly back to biblical times although it is impossible to be certain. The incubation period is 3 to 5 days. Men tend to suffer urethral discharge, frequency of micturition and dysuria. Women tend to get purulent vaginal discharge, frequency of micturition and anorectal discomfort. There may be bartholinitis. Men are usually symptomatic but only around 60% of infected women show the characteristic features. However, they may develop salpingitis and even the Fitz-Hugh-Curtis syndrome. Because of variety of sexual practice, swabs should be taken from the endocervix, the urethra in both men and women, the throat and anus. Anal infection can cause proctitis. A suitable transport medium must be used. Co-infection with Chlamydia is common and should be sought.

A number of complications have been mentioned above, including pelvic inflammatory disease. Arthritis may also occur. It is generally polyarticular and migratory, usually settling in one or two joints. The knees are most often involved, followed by the ankles, wrists, tarsi, MTP joints and dorsal tendon sheaths of the fingers. Infection from the mother's genital tract can cause ophthalmia neonatorum.

Treatment is usually a single, high dose of antibiotic. Amoxicillin is no longer favoured and resistance patterns may make ciprofloxacin obsolete in favour of a new generation cephalosporin such as cefixime.

Chancroid

This is the 3rd of the classical "venereal diseases". Chancroid is caused by the Gram-negative bacillus Haemophilus ducreyi. It may be difficult to isolate in culture, but can be seen microscopically as short Gram-negative rods. Chancroid presents as a soft, painful chancre that resembles the lesions of genital herpes. It is endemic in Africa, Asia and South America, and is more common in men, particularly uncircumcised men. HIV may also be present in as many as 60% in Africa. It may facilitate infection with HIV. Other common co-existing infections are syphilis and HSV-2. Painful lymphadenopathy in the groin occurs in 50%.

There are a number of treatment regimes including azithromycin 1gram as a single dose and ciprofloxacin 500mg, also as a single dose.

HIV/AIDS

HIV/AIDS has replaced syphilis as the STD to be most feared in that it is both a killer disease and a great mimic. Highly active antiretroviral therapy² (HAART) has transformed the prognosis but it remains a disease that has annihilated many people in Africa and, as explained in the article on the subject, unless it is taken very much more seriously in the UK, it will kill many more here too.

Chlamydia

Genitourinary chlamydia infection is a disease whose importance is being recognised much more recently. It can cause PID and infertility in women and non-gonococcal urethritis in men. It is symptomatic in only around 80% or women and 50% of men. There is evidence that a screening programme would be useful and cost-effective. At present there are a series of pilots with the intention to establish a national programme based upon their results by 2007. There is more information in the relevant article. The recommended treatment is doxycycline 100mg twice daily for 7 days or azithromycin 1g as a single dose.

Non-specific Urethritis

Non-specific urethritis (NSU) is also called non-gonococcal urethritis. It affects males with symptoms of dysuria and possibly urethral discharge. It does not affect females although the implicated organisms affect females in other ways. Usually chlamydia is involved although the term NSU is often reserved for when there is male urethritis but neither the gonococcus nor chlamydia can be isolated. It is usually successfully treated with tetracycline or erythromycin.³

Reiter's syndrome is a form of reactive arthritis. It can result from a number of infections, one of which is chlamydia. There is symmetrical oligoarthritis, urethritis and conjunctivitis. It can arise after food poisoning or after a sexually transmitted infection. It is one of the seronegative arthropathies associated with the HLA-B27 antigen.

Lymphogranuloma venereum

This is a disease caused by a type of chlamydia.⁴ It is rare in the UK but the HPA has reported outbreaks amongst homosexual men. It derives its name from painful, swollen inguinal lymph nodes.

Herpes genitalis

The herpes simplex virus has two types, HSV1 and HSV2. As a general rule, HSV1 causes cold sores on lips whilst HSV2 causes genital herpes but occasionally their role can be reversed, especially after oro-genital sex. The HSV1 virus is very common in children but the HSV2 is more indicative of sexual transmission. Genital herpes simplex is discussed in much greater detail elsewhere.

Genital Warts

They are caused by the human papilloma virus. They may affect the genitals or anus and are also known as condylomata acuminata. Human papilloma virus and genital warts is discussed more fully elsewhere.

Carcinoma of Cervix

For many years it has been known that carcinoma of the cervix is associated with an early age of onset of sexual intercourse and multiple partners. It is also more common in smokers. About 95% of cases show evidence of infection with the HPV virus types 16 and 18. Types 31 and 33 may also be implicated. This has led to the proposition that the disease is sexually transmitted. A vaccine against HPV16 has been developed⁵ and it could be in part of the immunisation schedule for all girls at around the age of 12. Needless to say, this has brought outrage from the usual quarters, suggesting that girls will see it as a permit for sexual promiscuity. It has been suggested that it may eventually make cervical smears unnecessary. There is no plan to give it to boys although boys spread the virus to girls. This is reminiscent of the early days when rubella vaccine was given only to girls.

Candidiasis

Candida albicans is a common commensal and may become dominant and cause symptoms when the ecology is upset as after a course of antibiotics. The reason for including it in this list is as a reminder that if a woman who is sexually active gets the infection, it is essential to treat her partner too or they will reinfect each other. It should not normally be seen as one of the STIs. For example, if a child gets a disease that is normally sexually transmitted, there is a very strong inference of sexual abuse but if a girl gets vaginal candida after a course of antibiotics, this is no cause for alarm. Candida is far more likely to cause symptoms in the female than the male.

Viral Hepatitis

Hepatitis A is usually spread by the faeco-oral route whilst hepatitis B and C are most often spread through body fluids, especially amongst intravenous drug abusers. However, the sexual transmission of hepatitis B is well established (as explained in Prevention of Hepatitis B). In England and Wales from 1995 to 2000 laboratory data suggested that the annual incidence of HBV infection was 7.4 per 100,000,⁶ with injecting drug use as the commonest cause of transmission. The number of cases attributed to heterosexual contact was fairly stable, whereas the number of cases in homosexual men decreased.

Sexual transmission of the hepatitis C virus is possible but uncommon.⁷ Less than 5% of the regular sexual partners of people with HCV infection will become infected. This means that infectivity by the sexual route is fairly low. It does not mean that it does not occur.

There are specify guidelines for the management of hepatitis B with HIV⁸ and hepatitis C with HIV.⁹

Pelvic Inflammatory Disease

Most cases of pelvic inflammatory disease are acquired from ascending infection from the genital tract. The gonococcus and chlamydia are most commonly involved. There is often mixed infection. It can cause chronic pelvic pain and infertility.

Trichomonas vaginalis

Trichomonas vaginalis is a flagellated protozoan that may be found in the urethra and genital tract of both men and women. It is asymptomatic in up to 50% of both sexes but may cause vaginal discharge, vulval itching, dysuria, or an offensive odour in women. Sometimes the presenting complaint is of low abdominal discomfort. In men it may cause urethral discharge and dysuria but discharge is rarely profuse. Vaginal discharge occurs in up to 70% of women, but the classical discharge of frothy yellow occurs in only 10 to 30%. Vulvitis and vaginitis are reported. Around 10% have no abnormalities on examination. Men may have urethral discharge. Treatment is metronidazole, 400mg twice daily for 5 to 7 days or 2g as a single oral dose.

Epididymo-orchitis

Epididymo-orchitis is usually sexually transmitted in men of less than 35 years old. Chlamydia trachomatis and Neisseria gonorrhoeae are the common organisms. There is unilateral testicular pain and swelling and sometimes urethral discharge if it was sexually transmitted. A scrotal support and NSAIDs give symptomatic relief but antibiotics should be ceftriaxone 250mg intramuscularly as a single dose or ciprofloxacin 500mg as a single oral dose plus doxycycline 100mg twice daily, orally for 10 to 14 days.

Sexually transmitted diseases occur as a result of sexual promiscuity. They do not occur within faithful monogamous relationships or in celibacy. Hence, when such diseases are diagnosed, society's response can be both sanctimonious and punitive. Fortunately, a great deal of pragmatism has prevailed. In the armed forces, contracting a sexually transmitted disease used to be an offence punishable at court marshall. This did not stop servicemen from taking injudicious rest and recreation but it did mean that they would hide the disease if it occurred rather than presenting to the medical officer for treatment.

The social stigma of having a sexually transmitted disease is enormous and the GUM clinics, since their origin, have been discrete and kept anonymity for their patients. Patients are often given a number so that they do not have to present with a name. They tend to have a discrete entrance in a distant part of the hospital and, to ensure compliance, the drugs they dispense are exempt from prescription charges. It is the only part of the NHS that will not routinely inform the patient's GP that he has attended.

Despite this cloak of secrecy and anonymity, they will attempt to trace contacts of those with sexually transmissible diseases. This is a very important role that must require the utmost tact and diplomacy.

Prevention of sexual transmission of diseases must depend upon education and attitude. Getting the content right for sex education is not easy. A number of factors have been identified as contributing to a successful programme.¹⁰ Adverse attitudes to the wearing of condoms must also be overcome. As explained in the article on AIDS, the Roman Catholic Church has much to answer for in terms of spreading disinformation about condoms.^11,12 They even advocate that if one of a married couple have HIV that it is better for the other partner to catch the disease than for them to use condoms.¹³

There is uncertainty about the origins of syphilis. Some people claim that it was brought back from America by Columbus' sailors but others argue that it originated in the Old World. An archeological find of the bones of an Essex woman suggested that she had advanced syphilis, between 1300 and 1450. This would predate Columbus' voyage of 1492.

It is often claimed that Henry VIII died of syphilis but the evidence for or against is poor. In those days any ulceration was called pox and syphilis was the great pox. The ulcer on his leg that failed to heal may well have been from type 2 diabetes.
The legendary Giacomo Casanova (1725-1798) was said to have invented the condom, fashioned from a sheep's intestine, not as a contraceptive but as protection against syphilis. He may have used them but he was not the first. Condoms appear in some of the pictures of A Harlot's Progress by William Hogarth (1697-1764). This series of paintings was completed in 1731, when Casanova would have been 6 years old.

The term syphilis was not part of the English language until 1717, following the translation of an Italian work. The disease had been the pox and in London rhyming slang, the acquisition of any GUM infection is still referred to as "a dose of the Surrey Docks". The clap refers to gonorrhoea, from the old French word clapier, meaning a brothel. It was long thought that the two diseases were one. In 1767, John Hunter inoculated a subject with matter of gonorrhoea on the prepuce and glans but the inoculum was from a patient suffering from both diseases and syphilis developed.¹⁴ In 1793, Benjamin Bell, an Edinburgh surgeon confirmed that the diseases were distinct as a result of experimentation on medical students. This was in the days before Local Research Ethics Committees. The eminent Guy's surgeon Sir Asley Cooper recognised the two diseases as distinct and in 1824 he wrote in The Lancet "a man who gives mercury in gonorrhoea deserves to be flogged out of the profession because he must be quite ignorant of the principle in which the disease is cured."

The etymology of gonorrhoea is probably from the Greek for seed flow in that it was assumed that the urethral discharge was semen. Folk etymology suggests an association with the biblical town of Gomorrah. Its equally evil neighbour, Sodom, is the origin for the term for anal intercourse. In the Book of Genesis, chapters 18 and 19 outline the evils of those towns and their unpleasant end in a hail of fire and brimstone.

In 1864 Parliament passed the Contagious Diseases Act. This legislation allowed policeman to arrest prostitutes in ports and army towns and bring them in to have compulsory checks for venereal disease. If the women were suffering from sexually transmitted diseases they were placed in a locked hospital until cured. It was claimed that this was the best way to protect men from infected women. Many of the women arrested were not prostitutes but they still were forced to go to the police station to undergo a humiliating medical examination.

During the First World War, with so many servicemen abroad, it is unsurprising that sexually transmitted diseases were rife. A Royal Commission on Venereal Diseases had been set up in 1913, before the outbreak of war and it was this that led to an Act of Parliament in 1917. It identified 3 diseases that were in the original classification that were euphemistically referred to as venereal diseases (VD), after Venus, the Roman goddess of love.

The traditional treatment for syphilis was heavy metals such as bismuth and mercury. They are of dubious efficacy but highly toxic. Hence the adage "one night with venus and a lifetime with mercury." The discovery that penicillin can treat syphilis has revolutionized its management.