General Management

• a.
  

  Genital herpes, syphilis, and chancroid have been associated with an increased risk for human immunodeficiency virus (HIV) acquisition and transmission. Because early treatment decreases the possibility of transmission, public health standards require healthcare providers to presumptively treat any patient with a suspected case of infectious syphilis at the initial visit, even before test results are available.

Chancroid

• a.
  

  Caused by Haemophilus ducreyi . Infection might still occur in some regions of Africa and the Caribbean.

  
  
• b.
  

  The combination of a painful genital ulcer and tender suppurative inguinal adenopathy suggests the diagnosis of chancroid.

  
  
• c.
  

  A definitive diagnosis of chancroid requires the identification of H. ducreyi on special culture media that are not widely available from commercial sources; even when these media are used, sensitivity is <80%. A probable diagnosis of chancroid can be made if all of the following criteria are met: (1) the patient has one or more painful genital ulcers; (2) the clinical presentation, appearance of genital ulcers and, if present, regional lymphadenopathy are typical for chancroid; (3) the patient has no evidence of Treponema pallidum infection by darkfield examination of ulcer exudate or by a serologic test for syphilis performed at least 7 days after onset of ulcers; and (4) a herpes simplex virus (HSV) polymerase chain reaction (PCR) test or HSV culture performed on the ulcer exudate is negative.

  
  
• d.
  

  Azithromycin 1 g orally in a single dose or ceftriaxone 250 mg intramuscular (IM) in a single dose or ciprofloxacin 500 mg orally twice a day for 3 days or erythromycin base 500 mg orally three times a day for 7 days. Azithromycin and ceftriaxone offer the advantage of single-dose therapy. Worldwide, several isolates with intermediate resistance to either ciprofloxacin or erythromycin have been reported. Patients should be reexamined 3 to 7 days after initiation of therapy. If treatment is successful, ulcers usually improve symptomatically within 3 days and objectively within 7 days after therapy. If no clinical improvement is evident, the clinician must consider whether (1) the diagnosis is correct; (2) the patient is coinfected with another sexually transmitted disease (STD); (3) the patient is infected with HIV; (4) the treatment was not used as instructed; or (5) the H. ducreyi strain causing the infection is resistant to the prescribed antimicrobial.

Genital HSV Infections

• a.
  

  HSV-1 and HSV-2: most cases of recurrent genital herpes are caused by HSV-2.

  
  
• b.
  

  The painful multiple vesicular or ulcerative lesions typically associated with HSV are absent in many infected persons. Recurrences and subclinical shedding are much more frequent for genital HSV-2 infection than for genital HSV-1 infection.

  
  
• c.
  

  The clinical diagnosis of genital herpes should be confirmed by type-specific laboratory testing. Both type-specific virologic and type-specific serologic tests for HSV should be available in clinical settings that provide care to persons with or at risk for STDs.

  
  
• d.
  

  First clinical episode of genital herpes: acyclovir 400 mg orally three times a day for 7 to 10 days or acyclovir 200 mg orally five times a day for 7 to 10 days or valacyclovir 1 g orally twice a day for 7 to 10 days or famciclovir 250 mg orally three times a day for 7 to 10 days.

  
  

  Note that treatment can be extended if healing is incomplete after 10 days of therapy.

  
  

  Suppressive therapy for recurrent genital herpes: acyclovir 400 mg orally twice a day or valacyclovir 500 mg orally once a day (valacyclovir 500 mg once a day might be less effective than other valacyclovir or acyclovir dosing regimens in persons who have very frequent recurrences [i.e., ≥10 episodes per year]) or valacyclovir 1 g orally once a day or famciclovir 250 mg orally twice a day.

  
  

  Episodic therapy for recurrent genital herpes: acyclovir 400 mg orally three times a day for 5 days or acyclovir 800 mg orally twice a day for 5 days or acyclovir 800 mg orally three times a day for 2 days or valacyclovir 500 mg orally twice a day for 3 days or valacyclovir 1 g orally once a day for 5 days or famciclovir 125 mg orally twice daily for 5 days or famciclovir 1 g orally twice daily for 1 day or famciclovir 500 mg once, followed by 250 mg twice daily for 2 days.

  
  

  Daily suppressive therapy in persons with HIV: acyclovir 400 to 800 mg orally twice to three times a day or valacyclovir 500 mg orally twice a day or famciclovir 500 mg orally twice a day.

  
  

  Episodic infection in persons with HIV: acyclovir 400 mg orally three times a day for 5 to 10 days or valacyclovir 1 g orally twice a day for 5 to 10 days or famciclovir 500 mg orally twice a day for 5 to 10 days.

  
  

  Suppressive therapy of pregnant women with recurrent genital herpes: acyclovir 400 mg orally three times a day or valacyclovir 500 mg orally twice a day.

  
  

  Note that treatment is recommended to start at 36 weeks of gestation.

Lymphogranuloma Venereum

• a.
  

  Caused by Chlamydia trachomatis serovars L1, L2, L3.

  
  
• b.
  

  The most common clinical manifestation of lymphogranuloma venereum (LGV) among heterosexuals is tender inguinal and/or femoral lymphadenopathy that is typically unilateral. A self-limited genital ulcer or papule sometimes occurs at the site of inoculation. However, by the time patients seek care, the lesions have often disappeared. Rectal exposure in women or men who have sex with men can result in proctocolitis mimicking inflammatory bowel disease, and clinical findings may include mucoid and/or hemorrhagic rectal discharge, anal pain, constipation, fever, and/or tenesmus.

  
  
• c.
  

  Genital lesions, rectal specimens, and lymph node specimens (i.e., lesion swab or bubo aspirate) can be tested for C. trachomatis by culture, direct immunofluorescence, or nucleic acid detection. Nucleic acid amplification tests (NAATs) for C. trachomatis perform well on rectal specimens.

  
  
• d.
  

  Recommended regimen: doxycycline 100 mg orally twice a day for 21 days.

  
  

  Alternative regimen: erythromycin base 500 mg orally four times a day for 21 days.

Syphilis

• a.
  

  The spirochete T. pallidum is causative.

  
  
• b.
  

  The disease has been divided into stages based on clinical findings, helping to guide treatment and follow-up. Persons who have syphilis might seek treatment for signs or symptoms of primary syphilis infection (i.e., ulcers or chancre at the infection site), secondary syphilis (i.e., manifestations that include, but are not limited to, skin rash, mucocutaneous lesions, and lymphadenopathy), or tertiary syphilis (i.e., cardiac, gummatous lesions, tabes dorsalis, and general paresis). Latent infections (i.e., those lacking clinical manifestations) are detected by serologic testing. T. pallidum can infect the central nervous system and result in neurosyphilis, which can occur at any stage of syphilis. Early neurologic clinical manifestations (i.e., cranial nerve dysfunction, meningitis, stroke, acute altered mental status, and auditory or ophthalmic abnormalities) are usually present within the first few months or years of infection.

  
  

  Late neurologic manifestations (i.e., tabes dorsalis and general paresis) occur 10 to 30 years after infection.

  
  
• c.
  

  Darkfield examinations and tests to detect T. pallidum directly from lesion exudate or tissue are the definitive methods for diagnosing early syphilis. Although no T. pallidum detection tests are commercially available, some laboratories provide locally developed and validated PCR tests for the detection of T. pallidum DNA. A presumptive diagnosis of syphilis requires use of two tests: a nontreponemal test (i.e., venereal disease research laboratory [VDRL] or rapid plasma reagin [RPR]) and a treponemal test (i.e., fluorescent treponemal antibody-absorbed [FTA-ABS] tests, the T. pallidum passive particle agglutination [TP-PA] assay, various enzyme immunoassays [EIAs], chemiluminescence immunoassays, immunoblots, or rapid treponemal assays). Use of only one type of serologic test is insufficient for diagnosis and can result in false-negative results in persons tested during primary syphilis and false-positive results in persons without syphilis. False-positive nontreponemal test results can be associated with various medical conditions and factors unrelated to syphilis, including other infections (e.g., HIV), autoimmune conditions, immunizations, pregnancy, injection-drug use, and older age. In a person with neurologic signs or symptoms, a reactive cerebrospinal fluid (CSF)-VDRL (in the absence of blood contamination) is considered diagnostic of neurosyphilis. When CSF-VDRL is negative despite the presence of clinical signs of neurosyphilis, reactive serologic test results, and abnormal CSF cell count and/or protein, neurosyphilis should be considered. In this instance, additional evaluation using FTA-ABS testing on CSF may be warranted. The CSF FTA-ABS test is less specific for neurosyphilis than the CSF-VDRL but is highly sensitive.

  
  

  Neurosyphilis is highly unlikely with a negative CSF FTA-ABS test, especially among persons with nonspecific neurologic signs and symptoms.

  
  
• d.
  

  Primary and secondary syphilis in adults: benzathine penicillin G 2.4 million units IM in a single dose.

  
  

  Primary and secondary syphilis in children: benzathine penicillin G 50,000 units/kg IM, up to the adult dose of 2.4 million units in a single dose.

  
  

  Early latent syphilis in adults: benzathine penicillin G 2.4 million units IM in a single dose.

  
  

  Late latent syphilis or latent syphilis of unknown duration in adults: benzathine penicillin G 7.2 million units total, administered as three doses of 2.4 million units IM each at 1-week intervals.

  
  

  Early latent syphilis in children: benzathine penicillin G 50,000 units/kg IM, up to the adult dose of 2.4 million units in a single dose.

  
  

  Late latent syphilis in children: benzathine penicillin G 50,000 units/kg IM, up to the adult dose of 2.4 million units, administered as three doses at 1-week intervals (total 150,000 units/kg up to the adult total dose of 7.2 million units).

  
  

  Tertiary syphilis with normal CSF examination: benzathine penicillin G 7.2 million units total, administered as three doses of 2.4 million units IM each at 1-week intervals.

  
  

  Recommended regimen for neurosyphilis and ocular syphilis: aqueous crystalline penicillin G 18 to 24 million units per day, administered as 3 to 4 million units IV every 4 hours or continuous infusion, for 10 to 14 days.

  
  

  Alternative regimen for neurosyphilis and ocular syphilis: procaine penicillin G 2.4 million units IM once daily plus probenecid 500 mg orally four times a day, both for 10 to 14 days.

  
  

  Note that persons with HIV infection and neurosyphilis should be treated according to the recommendations for HIV-negative persons with neurosyphilis.

  
  

  Primary and secondary syphilis in persons with HIV infection: benzathine penicillin G, 2.4 million units IM in a single dose.

  
  

  Recommended regimen for early latent syphilis in persons with HIV infection: benzathine penicillin G, 2.4 million units IM in a single dose.

  
  

  Recommended regimen for late latent syphilis in persons with HIV infection: benzathine penicillin G, at weekly doses of 2.4 million units for 3 weeks.

Granuloma Inguinale (Donovanosis)

• a.
  

  The intracellular gram-negative bacterium Klebsiella granulomatis (formerly known as Calymmatobacterium granulomatis ).

  
  
• b.
  

  Painless, slowly progressive ulcerative lesions on the genitals or perineum without regional lymphadenopathy; subcutaneous granulomas (pseudobuboes) also might occur.

  
  
• c.
  

  Visualization of dark-staining Donovan bodies on tissue crush preparation or biopsy.

  
  
• d.
  

  Recommended regimen: zithromycin 1 g orally once per week or 500 mg daily for at least 3 weeks and until all lesions have completely healed.

Alternative regimens: doxycycline 100 mg orally twice a day for at least 3 weeks and until all lesions have completely healed or ciprofloxacin 750 mg orally twice a day for at least 3 weeks and until all lesions have completely healed or erythromycin base 500 mg orally four times a day for at least 3 weeks and until all lesions have completely healed or trimethoprim-sulfamethoxazole one double-strength (160 mg/800 mg) tablet orally twice a day for at least 3 weeks and until all lesions have completely healed.

General Management

• a.
  

  If point-of-care diagnostic tools are not available, drug regimens effective against both gonorrhea and chlamydia should be administered. Further testing to determine the specific etiology is recommended to prevent complications, reinfection, and transmission, because a specific diagnosis might improve treatment compliance, delivery of risk reduction interventions, and partner notification.

Nongonococcal Urethritis

• a.
  

  Nongonococcal urethritis (NGU) is a nonspecific diagnosis that can have many infectious etiologies. NGU is caused by C. trachomatis in 15% to 40% of cases. Mycoplasma genitalium , which can be sexually transmitted, is associated with symptoms of urethritis as well as urethral inflammation and accounts for 15% to 25% of NGU cases in the United States. Trichomonas vaginalis can cause NGU in heterosexual men, but the prevalence varies substantially by region of the United States and within specific subpopulations. In some instances, NGU can be acquired by fellatio, sometimes because of specific pathogens such as HSV, Epstein-Barr virus, and adenovirus; data supporting other Mycoplasma species and Ureaplasma as etiologic agents are inconsistent.

  
  
• b.
  

  Symptoms, if present, include dysuria; urethral pruritis; and mucoid, mucopurulent, or purulent discharge. Signs of urethral discharge on examination can also be present in persons without symptoms.

  
  
• c.
  

  NGU is confirmed in symptomatic men when staining of urethral secretions indicates inflammation without gram-negative or purple diplococci. All men who have confirmed NGU should be tested for chlamydia and gonorrhea even if point-of-care tests are negative for evidence of gonorrhea. NAATs for chlamydia and gonorrhea are recommended because of their high sensitivity and specificity; a specific diagnosis can potentially reduce complications, reinfection, and transmission.

  
  

  Testing for T. vaginalis should be considered in areas or populations of high prevalence.

  
  
• d.
  

  Recommended regimens: azithromycin 1 g orally in a single dose or doxycycline 100 mg orally twice a day for 7 days.

  
  

  Alternative regimens: erythromycin base 500 mg orally four times a day for 7 days or erythromycin ethylsuccinate 800 mg orally four times a day for 7 days or levofloxacin 500 mg orally once daily for 7 days or ofloxacin 300 mg orally twice a day for 7 days.

Cervicitis

• a.
  

  When an etiologic organism is isolated in the presence of cervicitis, it is typically C. trachomatis or Neisseria gonorrhoeae . Cervicitis also can accompany trichomoniasis and genital herpes (especially primary HSV-2 infection). However, in most cases of cervicitis, no organism is isolated, especially in women at relatively low risk for recent acquisition of these STDs. Limited data indicate that infection with M. genitalium or bacterial vaginosis (BV) and frequent douching might cause cervicitis.

  
  
• b.
  

  A purulent or mucopurulent endocervical exudate visible in the endocervical canal or on an endocervical swab specimen (commonly referred to as mucopurulent cervicitis) or sustained endocervical bleeding easily induced by gentle passage of a cotton swab through the cervical os. Either or both signs might be present. Cervicitis frequently is asymptomatic, but some women complain of an abnormal vaginal discharge and intermenstrual vaginal bleeding (e.g., after sexual intercourse).

  
  
• c.
  

  Because cervicitis might be a sign of upper genital-tract infection (endometritis), women with a new episode of cervicitis should be assessed for signs of pelvic inflammatory disease (PID) and should be tested for C. trachomatis and for N. gonorrhoeae with NAAT; such testing can be performed on either vaginal, cervical, or urine samples.

  
  

  Women with cervicitis also should be evaluated for the presence of BV and trichomoniasis. Because the sensitivity of microscopy to detect T. vaginalis is relatively low (approximately 50%), symptomatic women with cervicitis and negative microscopy for trichomonads should receive further testing.

  
  
• d.
  

  Azithromycin 1 g orally in a single dose or doxycycline 100 mg orally twice a day for 7 days.

Chlamydia

• a.
  

  C. trachomatis is an obligate intracellular organism found worldwide.

  
  
• b.
  

  Asymptomatic infection is common among both men and women. Several sequelae can result from C. trachomatis infection in women, the most serious of which include PID, ectopic pregnancy, and infertility. Some women who receive a diagnosis of uncomplicated cervical infection already have subclinical upper reproductive-tract infection.

  
  
• c.
  

  C. trachomatis urogenital infection can be diagnosed in women by testing first-catch urine or collecting swab specimens from the endocervix or vagina. Diagnosis of C. trachomatis urethral infection in men can be made by testing a urethral swab or first-catch urine specimen. NAATs are the most sensitive tests for these specimens and therefore are recommended for detecting C. trachomatis infection. Rectal and oropharyngeal C. trachomatis infection in persons engaging in receptive anal or oral intercourse can be diagnosed by testing at the anatomic site of exposure.

  
  
• d.
  

  Recommended regimens: azithromycin 1 g orally in a single dose or doxycycline 100 mg orally twice a day for 7 days.

  
  

  Alternative regimens: erythromycin base 500 mg orally four times a day for 7 days or erythromycin ethylsuccinate 800 mg orally four times a day for 7 days or levofloxacin 500 mg orally once daily for 7 days or ofloxacin 300 mg orally twice a day for 7 days.

  
  

  Recommended regimens in pregnancy: azithromycin 1 g orally in a single dose.

  
  

  Alternative regimens in pregnancy: amoxicillin 500 mg orally three times a day for 7 days or erythromycin base 500 mg orally four times a day for 7 days or erythromycin base 250 mg orally four times a day for 14 days or erythromycin ethylsuccinate 800 mg orally four times a day for 7 days or erythromycin ethylsuccinate 400 mg orally four times a day for 14 days.

Gonorrhea

• a.
  

  N. gonorrheae , a gram-negative diplococcus.

  
  
• b.
  

  Urethral infections caused by N. gonorrhoeae among men can produce symptoms that cause them to seek curative treatment soon enough to prevent sequelae, but often not soon enough to prevent transmission to others. Among women, gonococcal infections are commonly asymptomatic or might not produce recognizable symptoms until complications (e.g., PID) have occurred. PID can result in tubal scarring that can lead to infertility and ectopic pregnancy.

  
  
• c.
  

  Culture and NAAT are available for the detection of genitourinary infection with N. gonorrhoeae ; culture requires endocervical (women) or urethral (men) swab specimens. NAAT allows for the widest variety of US Food and Drug Administration (FDA)-cleared specimen types, including endocervical swabs, vaginal swabs, urethral swabs (men), and urine (from both men and women). Culture is available for detection of rectal, oropharyngeal, and conjunctival gonococcal infection, but NAAT is not FDA-cleared for use with these specimens. Because of its high specificity (>99%) and sensitivity (>95%), a gram stain of urethral secretions that demonstrates polymorphonuclear leukocytes with intracellular gram-negative diplococci can be considered diagnostic for infection with N. gonorrhoeae in symptomatic men. However, because of lower sensitivity, a negative gram stain should not be considered sufficient for ruling out infection in asymptomatic men.

  
  

  Detection of infection using gram stain of endocervical, pharyngeal, and rectal specimens also is insufficient and is not recommended.

  
  
• d.
  

  Recommended regimen for uncomplicated gonococcal infections of the cervix, urethra, and rectum: ceftriaxone 250 mg IM in a single dose plus azithromycin 1g orally in a single dose.

  
  

  Alternative regimens for uncomplicated gonococcal infections of the cervix, urethra, and rectum: if ceftriaxone is not available, cefixime 400 mg orally in a single dose plus azithromycin 1 g orally in a single dose.

  
  

  Uncomplicated gonococcal infections of the pharynx: ceftriaxone 250 mg IM in a single dose plus azithromycin 1 g orally in a single dose.

  
  

  Gonococcal conjunctivitis: ceftriaxone 1 g IM in a single dose plus azithromycin 1 g orally in a single dose.

  
  

  Recommended regimen for arthritis and arthritis-dermatitis syndrome: ceftriaxone 1 g IM or intravenous (IV) every 24 hours plus azithromycin 1 g orally in a single dose.

  
  

  Alternative regimens for arthritis and arthritis-dermatitis syndrome: cefotaxime 1 g IV every 8 hours or ceftizoxime 1 g IV every 8 hours plus azithromycin 1 g orally in a single dose.

  
  

  Gonococcal meningitis and endocarditis: ceftriaxone 1 to 2 g IV every 12 to 24 hours plus azithromycin 1 g orally in a single dose.

Sexually transmitted organisms, especially N. gonorrhoeae and C. trachomatis , are implicated in many cases. Recent studies suggest that the proportion of PID cases attributable to N. gonorrhoeae or C. trachomatis is declining; of women who received a diagnosis of acute PID, less than 50% test positive for either of these organisms. Microorganisms that comprise the vaginal flora (e.g., anaerobes, G. vaginalis , Haemophilus influenzae , enteric gram-negative rods, and Streptococcus agalactiae ) have been associated with PID. In addition, cytomegalovirus (CMV), M. hominis , U. urealyticum , and M. genitalium might be associated with some PID cases. Newer data suggest that M. genitalium might play a role in the pathogenesis of PID and might be associated with milder symptoms, although one study failed to demonstrate a significant increase in PID following detection of M. genitalium in the lower genital tract.

PID comprises a spectrum of inflammatory disorders of the upper female genital tract, including any combination of endometritis, salpingitis, tuboovarian abscess, and pelvic peritonitis. Acute PID is difficult to diagnose because of the wide variation in symptoms and signs associated with this condition. Many women with PID have subtle or nonspecific symptoms or are asymptomatic.

Presumptive treatment for PID should be initiated in sexually active young women and other women at risk for STDs if they are experiencing pelvic or lower abdominal pain, if no cause for the illness other than PID can be identified, and if one or more of the following minimum clinical criteria are present on pelvic examination:

• ■
  

  cervical motion tenderness

  
  
• ■
  

  uterine tenderness

  
  
• ■
  

  adnexal tenderness.

  
  

  One or more of the following additional criteria can be used to enhance the specificity of the minimum clinical criteria and support a diagnosis of PID:

  
  
• ■
  

  oral temperature >101°F (>38.3°C)

  
  
• ■
  

  abnormal cervical mucopurulent discharge or cervical friability

  
  
• ■
  

  presence of abundant numbers of WBCs on saline microscopy of vaginal fluid

  
  
• ■
  

  elevated erythrocyte sedimentation rate

  
  
• ■
  

  elevated C-reactive protein

  
  
• ■
  

  laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis.

  
  

  If the cervical discharge appears normal and no WBCs are observed on the wet prep of vaginal fluid, the diagnosis of PID is unlikely, and alternative causes of pain should be considered.

  
  

  The most specific criteria for diagnosing PID include:

  
  
• ■
  

  endometrial biopsy with histopathologic evidence of endometritis

  
  
• ■
  

  transvaginal sonography or magnetic resonance imaging techniques showing thickened, fluid-filled tubes with or without free pelvic fluid or tuboovarian complex, or Doppler studies suggesting pelvic infection (e.g., tubal hyperemia)

  
  
• ■
  

  laparoscopic findings consistent with PID.

The decision of whether hospitalization is necessary should be based on provider judgment and whether the woman meets any of the following suggested criteria:

• ■
  

  surgical emergencies (e.g., appendicitis) cannot be excluded

  
  
• ■
  

  tuboovarian abscess

  
  
• ■
  

  pregnancy

  
  
• ■
  

  severe illness, nausea and vomiting, or high fever

  
  
• ■
  

  unable to follow or tolerate an outpatient oral regimen

  
  
• ■
  

  no clinical response to oral antimicrobial therapy.

  
  

  Parenteral regimens: cefotetan 2 g IV every 12 hours plus doxycycline 100 mg orally or IV every 12 hours or cefoxitin 2 g IV every 6 hours plus doxycycline 100 mg orally or IV every 12 hours or clindamycin 900 mg IV every 8 hours plus gentamicin loading dose IV or IM (2 mg/kg), followed by a maintenance dose (1.5 mg/kg) every 8 hours. Single daily dosing (3–5 mg/kg) can be substituted.

  
  

  Alternative parenteral regimen: ampicillin/sulbactam 3 g IV every 6 hours plus doxycycline 100 mg orally or IV every 12 hours

  
  

  Intramuscular/oral regimens: ceftriaxone 250 mg IM in a single dose plus doxycycline 100 mg orally twice a day for 14 days with or without metronidazole 500 mg orally twice a day for 14 days or cefoxitin 2 g IM in a single dose and probenecid, 1 g orally administered concurrently in a single dose plus doxycycline 100 mg orally twice a day for 14 days with or without metronidazole 500 mg orally twice a day for 14 days or other parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime) plus doxycycline 100 mg orally twice a day for 14 days with or without metronidazole 500 mg orally twice a day for 14 days.

  
  

  Note that the recommended third-generation cephalosporins are limited in the coverage of anaerobes. Therefore, until it is known that extended anaerobic coverage is not important for treatment of acute PID, the addition of metronidazole to treatment regimens with third-generation cephalosporins should be considered.

Among sexually active men aged under 35 years, acute epididymitis is most frequently caused by C. trachomatis or N. gonorrhoeae . Acute epididymitis caused by sexually transmitted enteric organisms (e.g., Escherichia coli ) also occurs among men who are the insertive partner during anal intercourse. In men aged 35 years and over who do not report insertive anal intercourse, sexually transmitted acute epididymitis is less common. In this group, the epididymis usually becomes infected in the setting of bacteriuria secondary to bladder outlet obstruction (e.g., benign prostatic hyperplasia).

Acute epididymitis is a clinical syndrome consisting of pain, swelling, and inflammation of the epididymis that lasts less than 6 weeks. Sometimes the testis is also involved—a condition referred to as epididymo-orchitis. A high index of suspicion for spermatic cord (testicular) torsion must be maintained in men who present with a sudden onset of symptoms associated with epididymitis, as this condition is a surgical emergency.

All suspected cases of acute epididymitis should be evaluated for objective evidence of inflammation by one of the following point-of-care tests.

• ■
  

  Gram or methylene blue or gentian violet stain (MB/GV) of urethral secretions demonstrating 2 or more WBC per oil immersion field. These stains are preferred point-of-care diagnostic tests for evaluating urethritis because they are highly sensitive and specific for documenting both urethral inflammation and the presence or absence of gonococcal infection. Gonococcal infection is established by documenting the presence of WBC-containing intracellular gram-negative or purple diplococci on urethral gram stain or MB/GV smear, respectively.

  
  
• ■
  

  Positive leukocyte esterase test on first-void urine.

  
  
• ■
  

  Microscopic examination of sediment from a spun first-void urine demonstrating ≥10 WBC per high power field.

  
  

  All suspected cases of acute epididymitis should be tested for C. trachomatis and for N. gonorrhoeae by NAAT. Urine is the preferred specimen for NAAT testing in men. Urine cultures for chlamydia and gonococcal epididymitis are insensitive and are not recommended. Urine bacterial culture might have a higher yield in men with sexually transmitted enteric infections and in older men with acute epididymitis caused by genitourinary bacteriuria.

Acute epididymitis most likely caused by sexually transmitted chlamydia and gonorrhea: ceftriaxone 250 mg IM in a single dose plus doxycycline 100 mg orally twice a day for 10 days.

Acute epididymitis most likely caused by sexually transmitted chlamydia and gonorrhea and enteric organisms (men who practice insertive anal sex): ceftriaxone 250 mg IM in a single dose plus levofloxacin 500 mg orally once a day for 10 days or ofloxacin 300 mg orally twice a day for 10 days.

Acute epididymitis most likely caused by enteric organisms: levofloxacin 500 mg orally once daily for 10 days or ofloxacin 300 mg orally twice a day for 10 days.

Approximately 100 types of human papillomavirus (HPV) infection have been identified, at least 40 of which can infect the genital area.

Most HPV infections are self-limited and are asymptomatic or unrecognized. Most sexually active persons become infected with HPV at least once in their lifetime. Oncogenic, high-risk HPV infection (e.g., HPV types 16 and 18) causes most cervical, penile, vulvar, vaginal, anal, and oropharyngeal cancers and precancers, whereas nononcogenic, low-risk HPV infection (e.g., HPV types 6 and 11) causes genital warts and recurrent respiratory papillomatosis.

Anogenital warts are usually asymptomatic, but depending on the size and anatomic location, they can be painful or pruritic. They are usually flat, papular, or pedunculated growths on the genital mucosa. Anogenital warts occur commonly at certain anatomic sites, including around the vaginal introitus, under the foreskin of the uncircumcised penis, and on the shaft of the circumcised penis. Warts can also occur at multiple sites in the anogenital epithelium or within the anogenital tract (e.g., cervix, vagina, urethra, perineum, perianal skin, anus, and scrotum). Intraanal warts are observed predominantly in persons who have had receptive anal intercourse, but they also can occur in men and women who have not had a history of anal sexual contact.

Diagnosis of anogenital warts is usually made by visual inspection. The diagnosis of anogenital warts can be confirmed by biopsy, which is indicated if lesions are atypical (e.g., pigmented, indurated, affixed to underlying tissue, bleeding, or ulcerated lesions).

External anogenital warts (i.e., penis, groin, scrotum, vulva, perineum, external anus, and perianus)

Patient-applied: imiquimod 3.75% or 5% cream (might weaken condoms and vaginal diaphragms) or Podofilox 0.5% solution or gel or sinecatechins 15% ointment (might weaken condoms and vaginal diaphragms).

Provider-administered: cryotherapy with liquid nitrogen or cryoprobe or surgical removal either by tangential scissor excision, tangential shave excision, curettage, laser, or electrosurgery or trichloroacetic acid (TCA) or bichloroacetic acid (BCA) 80% to 90% solution.

Note that many persons with external anal warts also have intraanal warts. Thus, persons with external anal warts might benefit from an inspection of the anal canal by digital examination, standard anoscopy, or high-resolution anoscopy.

Urethral meatus warts: cryotherapy with liquid nitrogen or surgical removal.

Vaginal warts: cryotherapy with liquid nitrogen or surgical removal or TCA or BCA 80% to 90% solution. (The use of a cryoprobe in the vagina is not recommended because of the risk for vaginal perforation and fistula formation.)

Cervical warts: cryotherapy with liquid nitrogen or surgical removal or TCA or BCA 80% to 90% solution. (Management of cervical warts should include consultation with a specialist; for women who have exophytic cervical warts, a biopsy evaluation to exclude high-grade squamous intraepithelial lesion (SIL) must be performed before treatment is initiated.)

Intraanal warts: cryotherapy with liquid nitrogen or surgical removal or TCA or BCA 80% to 90% solution. (Management of intraanal warts should include consultation with a specialist.)