This chapter covers the major sexually transmitted diseases (STDs) in the United States, with the exception of human immunodeficiency virus, which is discussed in Chapter 92. Vaginitis and pelvic inflammatory disease (PID) are covered separately in Chapters 63 and 64, respectively.
Multiple STDs infections frequently occur concurrently, compliance and follow-up are often limited or unreliable, infertility and other long-term morbidities may result from lack of treatment. When an STD is suspected, treat with single-dose regimens whenever possible. Ascertain pregnancy status and consider an obstetrics consultation if the patient is pregnant. Screen for other STDs (HIV infection, syphilis, and hepatitis) in the ED or through follow-up. Provide counseling for STD prevention in the ED and assure HIV testing in the ED or through follow-up as indicated. Advise that the partner(s) seek treatment and counsel on the appropriate time to reengage in sexual relations. Arrange follow-up as local resources allow.
Chlamydia trachomatis causes urethritis, epididymitis, orchitis, proctitis, or Reiter syndrome (nongonococcal urethritis, conjunctivitis, and rash) in men and urethritis, cervicitis, PID, and infertility in women. In both sexes, asymptomatic infection is common. There is a high incidence of coinfection with Neisseria gonorrhoeae. The incubation period is 1 to 3 weeks, with symptoms varying from mild dysuria with purulent or mucoid urethral discharge to sterile pyuria and frequency (urethritis). Women may present with mild cervicitis or with abdominal pain, findings of PID, or peritonitis. Men may present with a tender swollen epididymis or testicle.
Diagnosis and Differential
Diagnosis is best made with indirect detection methods such as enzyme-linked immunosorbent assay or DNA probes, which have a sensitivity of 75% to 90%. The Centers for Disease Control and Prevention (CDC) recommends a nucleic acid amplification test to be used as screening tests for Chlamydia. Culture is possible but difficult and produces a low yield.
Emergency Department Care and Disposition
Azithromycin 1 gram PO as a single dose or doxycycline 100 milligrams PO twice daily for 7 days is the treatment of choice for uncomplicated urethritis or cervicitis.
Alternatives include 7-day treatment with erythromycin 500 milligrams PO 4 times a day, ofloxacin 300 milligrams twice daily, or levofloxacin 500 milligrams PO daily.
Neisseria gonorrhoeae (GC) is a gram-negative diplococcus that causes urethritis, epididymitis, orchitis, and prostatitis in men and urethritis, cervicitis, PID, and infertility in women. Rectal infection and proctitis with mucopurulent anal discharge and pain can occur in both sexes. The incubation period ranges from 3 to 14 days. Women tend to present with nonspecific lower abdominal pain and mucopurulent vaginal discharge with findings of cervicitis and possibly PID. Eighty percent to 90% of men develop symptoms of urethritis: dysuria and purulent penile discharge within 2 weeks. Men also may present with acute epididymitis and orchitis or prostatitis. Occasionally, GC can be isolated from ...