Sexually transmitted diseases (STDs) are a group of diverse infections caused by heterogeneous microbial agents. While sexual contact is epidemiologically important and a frequent mode of transmission, it is not the only mechanism by which certain conditions classified as STDs may be spread. The full range of sexual conduct must be considered in diagnosing STDs, including heterosexual and homosexual genital, oral–genital, oral–anal, and genital–anal behaviors. Common clinical features across infectious agents allow groupings of vaginitis, cervicitis, urethritis, and genital lesions as STDs.

Note: For information on HIV infection, AIDS, and Hepatitis, please see the Integrative Medicine Access monographs entitled "HIV and AIDS" and "Hepatitis, Viral." 

Vaginitis:

• Candida spp, primarily albicans; sexual transmission is not the only or even the main mode of contraction
• Trichimonas vaginalis; may be asymptomatic
• Gardnerella vaginalis and other forms of bacterial vaginosis including mycoplasma; associated with risks for STDs but not necessarily sexually transmitted
• Herpes simplex virus (HSV)

Cervicitis:

• Neisseria gonorrhea
• Chlamydia trachomatis– most common cause of cervicitis by identified organism
• Herpes simplex virus (HSV)
• Idiopathic – i.e., organism not identified; up to 50% of cases

Urethritis:

• Gonococcal urethritis—N. gonorrhea; decreased incidence in industrialized countries over the last decade 
• Nongonococcal urethritis—all other etiologies, including C. trachomatis (30-40% of cases of nongonococcal urethritis), Ureaplasma urealyticum, Trichomonas vaginalis, HSV, Mycoplasm genitalium
• Reiter's syndrome, sporadic form of chlamydial infection

Genital lesions:

• HSV
• Syphilis—Treponema pallidum 
• Chancroid—gram-negative rod Haemophilus ducreyi; common in Africa and Asia
• Genital warts—Human papillomavirus (HPV)
• Scabies—Sarcoptes scabiei
• Lymphogranuloma venereum (LGV) and Granuloma inguinale – very rare in Europe and North America
• Trauma rarely causes genital ulcers (See section entitled Differential Diagnosis)

• Sexual partner with known history of STD
• Asymptomatic sexual partner with undiagnosed STD
• Multiple sexual partners, or a partner with multiple sexual partners
• Unprotected intercourse or sexual practices
• H/O one STD increases the likelihood (up to 60%) of contracting another, including HIV
• Adolescents have highest risk for new acquisition
• Lower socioeconomic status, inner city, racial minorities – e.g., syphilis and chancroid
• Homosexuality—for HIV, gonorrhea, hepatitis, syphilis
• Immunosuppressive diseases
• Prostitution
• Illicit drug use

Vaginitis:

• Vaginal and vulvar pruritus, irritation, burning
• Creamy or curd-like vaginal discharge; nonodorous; increased amount of discharge
• Red, painful vaginal mucous membranes
• Dysuria
• Dyspareunia
• Satellite lesions (pustules spreading to thighs and anus)

Cervicitis:

• May be asymptomatic
• May have normal-appearing cervix or erythema around cervical os or diffusely friable cervix with exocervical ulcers as in the case of HSV
• Purulent or mucopurulent discharge coming from the cervical os—gonococcal or chlamydial infection
• Hypertrophic cervicitis—erythema, bleeding lesion; often with chlamydial infection
• Abdominal pain—suggestive of HSV
• Rectal infection and proctitis—gonorrhea

Urethritis:

• May be asymptomatic
• Men—mucopurulent discharge, erythema at the meatus, dysuria with pruritus
• Women—often unaware of discharge; dysuria and frequent urination; pyuria
• Rectal infection and proctitis—gonorrhea

Genital lesions:

• HSV—fever, myalgias; pruritus; dysuria; vaginal and urethral discharge; inguinal lymphadenopathy; vesicular lesions of the external genitalia, cervix, and urethra; pain and/or burning preceding the appearance of lesions
• Syphilis—ulcerative lesions (chancres) on the genitalia, mouth, anus; regional, generally painless, adenopathy. Secondary syphilis—systemic illness, maculopapular rash, contagious lesions (Condylomata lata). Late-stage syphilis—destructive lesions of skin and bone, dementia; lymphocytic meningitis
• Chancroid—painful ulcers and inguinal adenopathy; fluctuant or ruptured nodes
• Genital warts—soft, small papules on external genitalia, urethra, vagina, cervix, or pubic or perianal regions
• Scabies—mite in unexcoriated papules or burrows, causing severe pruritus

• Vaginitis—gonorrhea; cystitis
• Cervicitis—mucopurulent cervicitis clinically similar to urethritis; cystitis
• Urethritis—with gonococcal diagnosis, concurrent diagnosis of nongonococcal urethritis must be assumed; epidydimitis; disseminated gonococcal infection; cystitis; prostatitis; pyelonephritis
• Genital lesions—clinical overlap among lesion types; morphologic features are important; chancroid often over diagnosed; vaginitis; malignant lesions; trauma

(See section entitled Signs and Symptoms for additional information)

Vaginitis:

• Vagina—hyperemic, bright red, with curd-like plaques or without erythema
• Discharge—creamy or curd-like; may be yellow or gray in color

Cervicitis:

• Cervix—normal, erythematous, or displaying ulcers in the case of HSV; discharge visible from cervical os, yellow and mucopurulent
• Friable cervix that bleeds easily with gentle swabbing – particularly in case of HSV

Urethritis:

• Men—mucopurulent discharge occurs with both gonococcal and nongonococcal urethritis; in nongonococcal type, the discharge is completely clear or there is a crusting at the meatus; stained underwear; discharge is extracted by gently stripping the urethra
• Women—dysuria with urethritis (internal) and vulvovaginitis (external)

Genital lesions:

• History, incubation period
• Presence or lack of pain
• Cyclic or persistent lesions

Vaginitis:

• Microscopic wet mount—one scraping of vaginal plaque, discharge or vulva is mixed with 10% potassium hydroxide (KOH), another with saline; examine for WBC's, yeast, spores, pseudohyphae, motile trichomonoas (easy to miss), and clue cells; 50% to 70% accuracy rate
• Gram's stain
• pH

Cervicitis:

• Gram's stain—inaccuracies dictate treatment for both gonorrhea and chlamydia
• Pap smear may reveal infection
• Culture—for gonorrhea, HSV
• Chlamydial culture using fluorescein-conjugated monocolonal antibody—requires experienced technician

Urethritis:

• Culture
• Gram's stain of swab inserted into urethra looking for presence (gonococcal) or absence (nongonococcal) of intracellular gram-negative diplococci
• Nongonococcal urethritis—nucleic acid hybridization test
• Polymerase chain reaction (PCR)
• Voided urine can be examined for WBC's

Genital lesions:

• HSV—culture shows multinucleated giant cells; PCR for CNS infections; serologic assays; Tzank prep only sensitive in presence of intact vesicles
• Syphilis—serologic tests include nontreponemal tests (Venereal Disease Research Laboratory [VDRL] and rapid plasma reagin [RPR]); and treponemal tests (fluorescent treponemal antibody absorption [FTA-ABS] test—most sensitive); dark-field microscopic examination; if tests negative and no other organism identified, repeat in 1 to 2 weeks and again in 6 weeks
• Chancroid—culture for H. ducreyi; Gram's staining
• Genital warts—biopsy; 3% to 5% acetic acid swab of epithelial turns infected area white
• Scabies—shave biopsy and light microscopic examination

Vaginitis:

• Pustule lesion—appears like hyperplastic indurated plaques, atrophic inflamed plaques, or a leukoplakic area
• Accumulation of scale and inflammatory cells
• pH discharge—normal

Cervicitis:

• Gram-negative intracellular diplococci—gonococcal
• Pap test to identify cervical changes associated with HPV
• Presence of polymorphonuclear neutrophils (PMNs)

Urethritis:

• Presence of PMNs
• Gram-negative intracellular diplococci in gonococcal urethritis

Genital lesions:

• HSV—latent state maintained by nerve ganglion cells
• Syphilis—multiplication of spirochetes; regional adenopathy can be aspirated and cultured
• Chancroid—inguinal adenopathy; purulent granulated tissue
• Genital warts—papillomavirus DNA identifiable near lesion

Cervicitis:

• Immunofluorescence microscopy—chlamydia, HSV
• DNA probes—chlamydia

Urethritis:

• Nongonococcal: Enzyme-linked immunosorbent assay (ELISA); immunofluorescent testing; DNA probe
• Examination of synovial fluid if signs of acute arthritis present

Genital lesions:

• HSV—testing of cerebrospinal fluid (CSF) and imaging in case of suspected encephalitis and/or meningitis
• Syphilis—testing of CSF when there are neurologic signs
• Genital warts—electron microscopy; immunohistochemistry; nucleic acid hybridization
• Scabies—hand lens

Presumptive therapy is generally given to sexual partners. Because of increased association and susceptibility, HIV testing is encouraged for patients with any STD. Importance of compliance with treatment must be stressed. Sexual abstinence or use of condoms is typically recommended until infection resolves. Drug treatment is administered. Whenever gonorrhea is identified, simultaneous treatment for chlamydia should be given.

Vaginitis:

• Candidal infections—topical polyenes (e.g., nystatin) 1 vaginal suppository bid for 2 weeks or azole (e.g., miconazole) derivative cream for 1 to 5 days; oral treatment of choice is fluconazole (150 mg given once)
• Trichimonas—metronidazole 2.0 gm po x one dose or 500 mg po bid x 7 days; during pregnancy, clotrimazole vaginal suppository qhs x 2 weeks should be used instead
• Gardnerella—metronidazole 500 mg po bid x 7 days or metronidazole gel 1 applicator applied intravaginally bid x 5 days; during pregnancy, clindamycin 2% cream bid x 1 week

Cervicitis—treated based on clinical diagnosis, i.e. before presence of organism is confirmed:

• Gonorrheal—ceftriaxone (125 to 250 mg IM) given once; plus treatment for chlamydia
• Chlamydial—doxycycline (100 mg bid x 7 days); azithromycin 1.0 gm po x one dose; during pregnancy, erythromycin 500 mg qid x 7 days
• Sexual partners should be examined and treated

Urethritis:

• Gonococcal—ceftriaxone (125 to 250 mg IM once); plus treatment for nongonococcal urethritis; same treatment for anogenital or pharyngeal gonococcal infection
• Nongonococcal—doxycycline (100 mg bid x 10 days); azithromycin 1.0 gm po x one dose; during pregnancy, erythromycin 500 mg qid x 7 days

Genital lesions:

• HSV—acyclovir 200 to 400 mg/tid for 10 days; in the case of HSV encephalitis, acyclovir 10 mg/kg IV q 8 hours for 14 to 21 days
• Syphilis—benzathine penicillin G (2.4 million units IM) given once or once a week for 3 consecutive weeks for syphilis extending beyond a year; aqueous crystalline penicillin G (12 to 24 million units IV) given for up to 14 days with neurosyphilis
• Chancroid— ceftriaxone (250 mg IM) given once; erythromycin 500 mg po qid x 7 days; azithromycin 1.0 gm po given once
• Genital warts—physician-applied podophyllin; podofilox 0.5% solution bid for 3 days, then none for 4 days; repeat cycle up to four times; cryotherapy, surgical removal, or electrocautery may be performed by a specialist; intralesional interferon alfa-n3 for refractory cases
• Scabies—apply to all areas of the body: permethrin 5% cream for 8 to 14 hours; lindane 1% lotion or cream for 8 hours
• LGV—doxycycline 100 mg po bid x 21 days; erythromycin 500 mg qid x 21 days
• Granuloma inguinale—doxycycline 100 mg po bid x 1 to 4 weeks; during pregnancy, erythromycin 500 mg qid x 14 days

CAM therapies show promise in the treatment of STDs, including those that have become resistant to conventional drugs. Combining antioxidant nutrients with herbs, acupuncture, or conventional medications may effectively treat many STDs.

Chlamydia trachomatis infections have been shown to generate reactive oxygen species associated with the formation of lipid peroxides in host cell membranes. Experimental studies have demonstrated the release of highly reactive oxygen species with marked peroxidation of host membrane lipids in chlamydial infections. Treatment of infected cells with ascorbic acid, a powerful antioxidant, prevented such lipid peroxidation. This study suggests, therefore, that ascorbic acid, as well as other antioxidant nutrients known for their free radical scavenging abilities, may ultimately prove useful for improving treatment outcomes of chlamydial infections when taken in conjunction with standard antibiotic therapy (Azenabor and Mahony 1999).

Clinically, many recommend Lactobacillus acidophilus in either food or supplement form to aid in restoration of normal flora in the case of candidal infections or following antibiotic use; please see the monograph on Lactobacillus acidophilus for additional information.

Several antimicrobial herbal formulations have demonstrated effectiveness in the treatment and/or prevention of STDs. For example, studies performed using Praneem polyherbal vaginal suppository (PR-048), containing purified leaf extract from Azadirachta indica, purified saponins from Sapindus mukerossi, and Mentha citrata oil as well as polyherbal cream (CH-005), containing purified saponins from Sapindus mukerossi, Mentha citrata oil, and a natural polycationic polymer evaluated effectiveness of these substances against cultures of clinical isolates containing various pathogenic strains inoculated in mouse vaginal models. PR-048 did not demonstrate activity against Candida species; however, the CH-005 cream was found to be effective against C. albicans, C. krusei, and C. tropicalis. Both formulations inhibited all strains of urinary tract E. coli, including those that were multidrug resistant, and they both exhibited anti-HIV activity in vitro. In addition, mouse vaginal models pretreated with the herbal formulations were less likely to become infected when challenged with C. trachomatis or HSV-2. In fact, vaginal application of the herbal formulations prevented the formation of herpes lesions. Both inhibited the growth of clinical isolates of N. gonorrhea, including penicillin-resistant strains. While the clinical application is not yet completely understood from these animal models, these formulations show great potential for speeding recovery, arresting growth, and inhibiting the transmission of STDs (Talwar et al. 2000).

Propoli is rich in flavonoids and has antimicrobial and anesthetic properties, making it a potentially ideal topical treatment for herpes infections. A single-blind, randomized, controlled multicenter study was undertaken to compare the effectiveness of a Canadian propolis ointment to acyclovir as well as placebo ointments in 90 patients with recurrent chronic genital HSV-2. Treatment began in the blister phase of infection and patients were assessed on the 3rd, 7th, and 10th days of treatment. Propolis was found to be markedly superior to both acyclovir and placebo in resolution of lesions and decreased time to heal (Vynograd et al. 2000).

An herbal immunoadjuvant and antitumor formula was evaluated for effectiveness against active herpes lesions. WTTC, containing Wisteria floribunda, Terminalia chebulae, Trapa natans, and Coicis semen was combined with Ganoderma lucidum and Elfuinga applanata. Oral administration of the formula to four patients with recurrent herpes labialis and one with genital herpes resulted in complete recovery within 3 to 7 days. The authors suggest that the combined extracts may be helpful in inhibiting reactivation of HSV, reducing pain, and hastening recovery (Hijikata and Tsukamoto 1998).

Topical herbs used in clinical practice that have not yet been validated by scientific investigation include licorice root (Glycyrrhiza glabra) and lemon balm (Melissa officinalis) for HSV; thuja (Thuja occidentalis) for HPV; and garlic (Allium sativum) and essential oils of oregano (Oreganum vulgare), lavender (Lavandula augistifolia), and tea tree (Melaleuca alternifolia) for HPV and Candida species. For best care, patients with STDs should be advised to see a licensed naturopathic doctor or other specialist trained and certified in the use of herbal remedies.

Homeopathic remedies are widely used in clinical practice for the treatment of STDs although scientific studies have not yet investigated this modality for such use. Patients should be referred to a licensed, certified homeopathic doctor who can help in both the acute and chronic phases of many STDs.

Four hundred five reports of men with nongonococcal urethritis treated with acupuncture were considered cured or significantly improved in 86% of cases. Cases were collected over a 21-month period from June 1988 to April 1990. During a daily treatment lasting 1 hour, needles were inserted into four particular acupuncture points and manipulated every 10 minutes. Points that were needled were zhaohai (KI 6, bilateral, by the reduction method), zhongji (RN 3, by the reinforcing method), taichong (LR 3, bilateral, by the reduction method), and sanyinjiao (SP 6, bilateral, by the reinforcement method). Following each course of 10 treatments, a urethral smear was evaluated and a 5-day rest period was instituted before commencing the next course. Patients were asked to abstain from all sexual activity during treatment and for 1 month following the completion of treatment; in addition, the patients' sexual partners were treated as well (Wang 1997).

Of the 405 cases, 261 (64.4%) were cured (i.e., clinical symptoms resolved, urine became clear, and smear of fluid obtained from prostatic massage was negative). Treatment appeared markedly effective in 50 of the 405 subjects (12.4%) (i.e., symptoms resolved, urine was clear, and prostatic massage secretion showed only a very small amount of bacteria). Thirty-seven (9.1%) cases were considered improved (i.e., symptoms markedly reduced except rare urethral secretions persisted). Smears of prostatic fluid were weakly positive, e.g., some baccilli. Fifty-seven (14.1%) cases failed (i.e., symptoms alleviated by less than one-third and positive or strongly positive prostatic smears). The total rate of some degree of effectiveness was 85.9% (348 cases) (Wang 1997).

Several successful cases of treatment of herpes simplex viral infections with acupuncture have been reported in the literature. For example, two researchers report their findings treating two patients with herpes oral-labialis and three with herpes genitalis. The acupuncture points were selected from those generally employed for treatment of skin conditions, including dazhui (DU 14), fengmen (UB 12), fengchi (GB 20), huantiao (GB 30), fengshi (GB 31), yangfu (GB 38), xuanzhong (GB 39), hegu (LI 4), quchi (LI 11), jianyu (LI 15), zhongwan (REN 12), zusanli (ST 36), sanyinjiao (SP 6), xuehai (SP 10), quze (P 3), and weizhong (UB 40). Resolution of active recurrent infections in this group of patients required between one and four sessions. Although these findings are too preliminary to generalize, the results suggest that acupuncture helped to promote the healing of skin lesions, lengthen remission, and inhibit recurrences in the five patients studied with HSV infections (Liao and Liao 1991).

One hundred sixteen patients with gonococcal arthritis (see section entitled Complications/Sequelae) were treated with a combination of acupuncture (dazhui, DU 14; quchi, LI 11; zusanli, ST 36), garlic moxibustion, pricking bloodcupping, and joint aspiration. Of the 116 patients, 74 were considered cured (63.8%) (defined as complete disappearance of clinical symptoms, restoration of normal function, and negative joint aspiration); treatment was markedly effective in 13 (11.2%) (defined as resolution of clinical symptoms, recovery of normal function, but joint aspiration weakly positive); 11 improved (9.5%) (defined as improvement in clinical symptoms, recovery of function, but weakly positive or positive joint aspiration); and 18 failed (15.5%) (less than 30% resolution of symptoms and return of function with persistently positive joint aspiration). A therapeutic course consisted of 10 days of treatment with a 2- to 3-day interval between courses. Of the 74 patients who were cured, 21 (28.4%) recovered after one course; 34 (45.9%) after two courses, and 19 (25.7%) after three courses (Wang 1996).

[Note: Reinforcing or tonifying in acupuncture refers to the building up of deficient yin, yang, or qi in an organ by a needling technique that stimulates energy flow in the corresponding meridian. Reducing or dispersing refers to the opposite, i.e., the draining away of excessive or stagnant energy that has accumulated because of blocked circulation in the affected area (Kaplan 2000).]

Women should have regular pap smears annually if sexually active, particularly with more than one partner and/or with change of partner; consider routine screening for certain STDs in sexually active young men and women between the ages of 14 and 20 as well as older adults with more than one partner and/or other risk factors.

Vaginitis:

• Monitor for recurrence only
• Strict control for diabetics is critical

Cervicitis and urethritis:

• Gonorrhea is reportable in all U.S. states
• Monitor for recurrence and noncompliance with treatment

Genital lesions:

• Syphilis—follow-up serologic tests at 3 and 6 months until titers stabilize; every 6 months thereafter
• Chancroid—draining of fluctuant buboes prevents rupture
• Genital warts—patients with diabetes or poor circulation should be monitored for infection
• Scabies—retreatment in 1 week is generally recommended if pruritus is not improved (but pruritus can continue for weeks despite adequate treatment)

• Education—modes of disease transmission, risk reduction, recurrence patterns
• Assumptive treatment of sexual partner
• Detection of asymptomatic partner
• Sexual abstinence for some infections (e.g., HSV) is essential as condoms do not necessarily prevent transmission
• Use of condoms and other prophylactic devices
• Treat symptomatic balanitis in men to prevent vaginitis in women
• Reduction of number of sexual partners as well as decreased rate of change in sexual partners
• Early detection and treatment
• Screening of high risk individuals during routine exams
• Wise use of prophylactic antibiotics prevents development of resistant strains

• Antibiotic resistance of etiologic agent may occur
• Many infectious agents increase the risk of contracting HIV
• Gonococcal infections can result in acute arthritis

Vaginitis:

• HIV infection and diabetes predispose to chronic infections
• May be early sign of Toxic Shock Syndrome
• Presence early in pregnancy may be independent predictor of preterm labor

Cervicitis:

• Uncontrolled chlamydial or gonococcal infections may result in pelvic inflammatory disease (PID), potentially leading to infertility; possible obstetric complications (see section entitled Pregnancy)

Urethritis:

• Gonococcal type can coexist with nongonococcal type; detected by gram-negative diplococci and persistence of PMNs
• PID can lead to infertility or ectopic pregnancy
• Gonococcal urethritis—urethral stricture or abscess; perforation of the peritoneal scrotum; pharyngeal infection

Genital lesions:

• HSV— primary infections may be associated with encephalitis and meningitis
• Syphilis—neurosyphilis occurs more rapidly and is harder to treat with HIV; 50% of patients with primary syphilis and nearly 100% with secondary syphilis have Jarisch-Herxheimer reaction (fever, increased rash, adenopathy) 1 to 6 hours after antibiotic administration; the reaction is self-limited and is treated with anti-pyretics, but patients should be forewarned
• Chancroid—predisposes to HIV; lesions spread to other parts of body or coalesce to form giant ulcers
• Genital warts—strains of HPV (6 & 11), which commonly cause venereal warts, are generally not associated with cervical cancer; strains of HPV associated with dysplasia and cancer are not usually visible but may cause a mild cervicitis; again, all sexually active women should undergo routine pap smears
• Scabies—atypical and severe forms occur with HIV

Vaginitis:

• Candida may resolve spontaneously or may become chronic
• Recurrence is common

Cervicitis: Prognosis is generally good if appropriately treated, but may lead to PID.

Urethritis: Recurrence is common. Prognosis is good if appropriately treated.

Genital lesions:

• HSV—recurrences are usually milder; suppressive therapy is considered for when there are more than six episodes a year; resolution without sequelae is typical except in neonates and immuno-compromised persons
• Syphilis—chronic infection, earlier stages resolve latently, reappearing in later stage
• Chancroid— recurrent episodes lasting 1 to 3 weeks
• Genital warts—resolution takes 20 weeks or more; no known therapy to completely eradicate HPV
• Scabies—no sequelae with adequate treatment

Some STDs may result in permanent damage to reproductive organs and infertility, particularly in the case of cervicitis leading to PID. Standard drugs for treatment of STDs may be teratogenic (e.g., metronidazole). Finally, presence of STDs often has potential ramifications for the neonate.

Vaginitis:

• Discharge more copious, incidence twice as high, therapy twice as long
• Fluconazole and metronidazole are contraindicated in pregnancy; see section entitled Drug Therapies for alternatives

Cervicitis:

• Rx of choice during pregnancy for chlamydia—erythromycin—500 mg po qid x 7 days; do not use doxycycline
• Perinatal chlamydia can cause neonatal pneumonia or conjunctivitis
• Gonococcal infection may spread to eyes of neonate

Urethritis:

• Rx of choice during pregnancy—erythromycin 500 mg po qid x 7 days or Amoxicillin 500 mg po tid x 7 days

Genital lesions:

• HSV—primary infection during delivery may result in neurologic defects in the neonate or death of the neonate; if visible lesions present, neonate is delivered via cesarean section
• Syphilis—desensitization in case of penicillin allergy; erythromycin unreliable for fetal cure; Jarisch-Herxheimer reaction can precipitate labor
• Chancroid—Rx of choice during pregnancy is erythromycin 500 mg po qid x 7 days
• Genital warts—avoid podophyllin; vaginally delivered neonate may develop laryngeal papillomatosis; cryotherapy safe during pregnancy
• Scabies—avoid lindane

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