Sexually Transmitted Infections

Sexually-transmitted infections (STIs) constitute a major health burden in the U.S., and reported incidence among adolescents is increasing. These diseases are frequently asymptomatic and are most often caused by viruses or bacteria.

Tabs Content

Clinical Overview

Diagnosis

Indications for Testing

Symptomatic individuals
- Urgency, frequency, dysuria in the absence of a documented urinary tract infection (UTI)
- Vaginal or penile discharge
- Pelvic pain
- Prostatitis symptoms
- Genital lesions – painful vesicles, nonpainful shallow ulcer
Asymptomatic individuals – see Screening for testing recommendations

Laboratory Testing

CDC – testing recommendations
Refer to the following ARUP Consult topics for sexually transmitted infection (STI) testing recommendations for
- Human papillomavirus (HPV)
- Treponema pallidum
- HIV
- Hepatitis B (HBV)
- Hepatitis C (HCV)
- Herpes simplex virus (HSV)
STI testing methods
- Wet mount
  - Bacterial vaginosis – presence of clue cells is diagnostic in appropriate clinical setting
- Nucleic acid amplification testing (NAAT)
  - Preferred for detecting Chlamydia trachomatis and Neisseria gonorrhoeae in a variety of specimens (U.S. Preventive Services Task Force [USPSTF], 2014; CDC, 2014)
  - Most sensitive test for Trichomonas vaginalis
  - Highly sensitive and specific
  - Specimen collection – for optimal specimen types and collection instructions, refer to ARUP's Sample Collection for the Diagnosis of STD Using Nucleic Acid Amplification Tests
- Culture
  - C. trachomatis
    - Not recommended for routine detection
    - May be considered for anatomic locations for which amplified testing has not been validated
    - May be used in medicolegal settings and to assess suspected treatment failure
    - High specificity; less sensitive than NAAT
  - N. gonorrhoeae
    - Not recommended for routine detection
    - Recommended in combination with antimicrobial susceptibility testing in cases of suspected or documented treatment failure
    - May be considered for anatomic locations for which amplified testing has not been validated
    - Sensitivity dependent on transport time – viability declines rapidly during transport
  - T. vaginalis – not recommended for routine detection
- DNA probes and direct fluorescent antibody (DFA)
  - Not recommended for routine detection
  - Lower sensitivity than NAAT

Differential Diagnosis

UTI
Vaginitis/cervicitis
Vulvovaginal candidiasis
Malignancy – ovarian cancer, cervical cancer
Nephrolithiasis
Ectopic pregnancy
Diverticulitis
Inflammatory bowel disease
Appendicitis
Pregnancy
Ovarian cyst

Screening

Specimen Collection

For optimal specimen types and collection instructions for sexually transmitted infection (STI) screening tests, refer to ARUP's Sample Collection for the Diagnosis of STD Using Nucleic Acid Amplification Tests

Women

STI screening recommendations for sexually active nonpregnant women

STI Screening Recommendations for Sexually Active Nonpregnant Women
STI	USPSTF/AAFP (Lee, 2016)^a	CDC, 2015
Chlamydia	Sexually active women <25 yrs and women ≥25 yrs at increased risk^b	Sexually active women <25 yrs and sexually active women ≥25 yrs at increased risk^d
Gonorrhea	Sexually active women <25 yrs and women ≥25 yrs at increased risk	Sexually active women <25 yrs and sexually active women ≥25 yrs at increased risk^d,e
Syphilis	Persons at increased risk	No specific recommendations
Trichomonas	No specific recommendations	Consider for women in areas of high prevalence (eg, STD clinics and correctional facilities) and in women at high risk^f
HIV	All persons 15-65 yrs regardless of risk and patients <15 yrs and >65 yrs at increased risk^b	All women 13-64 yrs and all who seek evaluation
HBV	Persons at increased risk	Women at increased risk^g
HCV	No specific recommendations	Women born 1945-1965 Other women with risk factors^h
HSV	Do not screen asymptomatic persons	Consider type-specific testing for women who seek evaluation
HPV	No specific recommendations	Women 21-29 yrs every 3 yrs with cytology Women 30-65 yrs every 3 yrs with cytology or every 5 yrs with cytology/HPV testing
Bacterial vaginosis	No specific recommendations	No specific recommendations
AAFP = American Academy of Family Physicians; CDC = Centers for Disease Control and Prevention; HBV = hepatitis B virus; HCV = hepatitis C virus; HPV = human papillomavirus; HSV = herpes simplex virus; STI = sexually transmitted infection; STD = sexually transmitted disease; USPSTF = U.S. Preventive Services Task Force ^aUSPSTF has determined that there is inadequate evidence to determine the optimal interval for repeat screening; clinicians should rescreen patients when their sexual history reveals new or persistent risk factors ^bUSPSTF defines persons at increased risk of STIs as those who have more than one sex partner, a new sex partner, or a sex partner with concurrent partners, and those who are not in mutually monogamous relationships and have inconsistent condom use; the risk is even higher in persons who have a sex partner with an STI, those who have a previous or current STI, and those who exchange sex for drugs or money ^cAAFP recommends routine screening for HIV infection starting at 18 years of age ^dCDC defines persons at increased risk as those who have a new sex partner, more than one sex partner, a sex partner with concurrent partners, or a sex partner who has a sexually transmitted infection ^eAdditional risk factors for gonorrhea include inconsistent condom use among persons who are not in mutually monogamous relationships, previous or coexisting sexually transmitted infections, and exchanging sex for money or drugs; clinicians should consider the communities they serve and may opt to consult local public health authorities for guidance on identifying groups that are at increased risk ^fEg, those with multiple sex partners, exchanging sex for payment, illicit drug use, and a history of STD ^gFor HBV, those at increased risk include persons born in regions of high endemicity (≥2% prevalence), injection-drug users, persons on immunosuppressive therapy, hemodialysis patients, HIV-positive individuals, and others ^hFor HCV, risk factors include past or current injection drug use, receipt of blood transfusion before 1992, long-term hemodialysis, born to mother with HCV, intranasal drug use, receipt of an unregulated tattoo, and other percutaneous exposures

STI screening recommendations for pregnant women

STI Screening Recommendations for Pregnant Women
STI	USPSTF/AAFP (Lee, 2016)^a	CDC
Chlamydia	All pregnant women <25 yrs and women ≥25 yrs with risk factors^b	All pregnant women <25 yrs and those ≥25 yrs who are at increased risk^c; retest in third trimester for women <25 yrs or those at risk^c
Gonorrhea	All pregnant women <25 yrs and women ≥25 yrs with risk factors	All pregnant women <25 yrs and those ≥25 yrs who are at increased risk^c
Syphilis	All pregnant women	All pregnant women at first prenatal visit; retest in third trimester and at delivery for women at high risk
HIV	All pregnant women at first prenatal visit	All pregnant women at first prenatal visit; retest in third trimester for women at high risk^d
HBV	All pregnant women	Screen all at each first prenatal visit; retest at delivery if at high risk^e
HCV	No specific recommendations	Women born 1945-1965 Pregnant women with risk factors^f
HSV	Do not screen asymptomatic patients	Consider type-specific serologic testing
HPV	No specific recommendations	Women 21-29 yrs every 3 yrs with cytology Women 30-65 yrs every 3 yrs with cytology or every 5 yrs with cytology/HPV testing
Bacterial vaginosis	No specific recommendations	No specific recommendations
AAFP = American Academy of Family Physicians; CDC = Centers for Disease Control and Prevention; HBV = hepatitis B virus; HCV = hepatitis C virus; HPV = human papillomavirus; HSV = herpes simplex virus; STI = sexually transmitted infection; STD = sexually transmitted disease; USPSTF = U.S. Preventive Services Task Force ^aUSPSTF has determined that there is inadequate evidence to determine the optimal interval for repeat screening; clinicians should rescreen patients when their sexual history reveals new or persistent risk factors ^bPersons at increased risk of STIs include those who have more than one sex partner, a new sex partner, or a sex partner with concurrent partners, and those who are not in mutually monogamous relationships and have inconsistent condom use; the risk is even higher in persons who have a sex partner with an STI, those who have a previous or current STI, and those who exchange sex for drugs or money ^cCDC defines persons at increased risk as those who have a new sex partner, more than one sex partner, a sex partner with concurrent partners, or a sex partner who has a sexually transmitted infection ^dCDC defines persons at high risk as those with multiple sex partners, exchanging sex for payment, illicit drug use, and a history of STD ^eFor HBV, those at increased risk include persons born in regions of high endemicity (≥2% prevalence), injection-drug users, persons on immunosuppressive therapy, hemodialysis patients, HIV-positive individuals, and others ^fFor HCV, risk factors include past or current injection drug use, receipt of blood transfusion before 1992, long-term hemodialysis, born to mother with HCV, intranasal drug use, receipt of an unregulated tattoo, and other percutaneous exposures

Men

U.S. Preventive Services Task Force (USPSTF) (2004; reaffirmed 2016)
- No screening if not engaging in high-risk behaviors
- If engaging in high-risk behaviors, screen for syphilis and HIV

Extragenital Sites

Women (CDC, 2014)
- No recommendations due to scarcity of published studies; however, available data suggests rectal and oropharyngeal infections are not uncommon in women
- Consider screening women with known risk factors
Men (CDC, 2014)
- Extragenital infections are common and mostly asymptomatic – most frequent for men who have sex with men (MSM) with multiple or anonymous sexual partners
- Screening recommended at least annually in MSM
  - Rectal specimen for men who have receptive anal intercourse
  - Pharyngeal specimen for men who have receptive oral intercourse

CDC STI screening recommendations for MSM

CDC STI Screening Recommendations for MSM
STI	CDC Recommendation
Chlamydia	Annually at sites of contact Every 3-6 mos if at increased risk^a
Gonorrhea	Annually at sites of contact Every 3-6 mos if at increased risk^a
Syphilis	Annually Every 3-6 mos if at increased risk^a
HIV	Annually if individual or partner have had new partner since previous test
HBV	All MSM
HCV	All MSM born 1945-1965, those at risk^b Annually for MSM with HIV
HSV	Consider type-specific testing
CDC = Centers for Disease Control and Prevention; HBV = hepatitis B virus; HCV = hepatitis C virus; HSV = herpes simplex virus; MSM = men who have sex with men; STI = sexually transmitted infection ^aAll MSM including those with HIV infection if risk behaviors persist or if they or their sexual partners have multiple partners ^bHCV risk factors include past or current injection drug use, receipt of blood transfusion before 1992, long-term hemodialysis, born to mother with HCV, intranasal drug use, receipt of an unregulated tattoo, and other percutaneous exposure

HIV-Positive Individuals

CDC STI Screening Recommendations for HIV-Positive Individuals
STI	CDC Recommendation
Chlamydia	All sexually active individuals at first HIV evaluation, then at least annually More frequent screening may be appropriate depending on risk behaviors and local epidemiology
Gonorrhea	All sexually active individuals at first HIV evaluation, then at least annually More frequent screening may be appropriate depending on risk behaviors and local epidemiology
Syphilis	All sexually active individuals at first HIV evaluation, then at least annually More frequent screening may be appropriate depending on risk behaviors and local epidemiology
Trichomonas	Sexually active women at entry to care, then at least annually
HBV	Test for HBsAg and anti-HBc and/or anti-HBs27
HCV	All persons at initial evaluation of HIV Annually for MSM
HSV	Consider type-specific testing
HPV	All women within 1 yr of sexual activity or initial HIV diagnosis with conventional or liquid-based cytology; repeat 6 mos later
CDC = Centers for Disease Control and Prevention; HBV = hepatitis B virus; HCV = hepatitis C virus; HPV = human papillomavirus; HSV = herpes simplex virus; MSM = men who have sex with men; STI = sexually transmitted infection

Women Who Have Sex with Women (WSW)

Due to high rates of heterosexual activity in this population, STI screening should reflect individual partner type and reported activity (Wangu, 2017)

Transgender Individuals

STI screening should be based on current anatomy and sexual practices (Wangu, 2017)

Background

Most Common Viral STIs

Most Common Bacterial STIs

Chlamydia trachomatis

Epidemiology
- Incidence – 643/100,000 for females; 262/100,000 for males (CDC, 2014); most common reportable STI in U.S. and worldwide
- Age – highest incidence in 15-24 years
- Gram-negative obligate intracellular parasite

Risk factors
- >1 sex partner, a new sex partner, or a sex partner with multiple partners
- Sex partner with an STI
- Intermittent or lack of condom use
- Previous or current STI
- Exchange of sex for money or drugs

Clinical presentation
- Asymptomatic in >50% of infected patients
- Urethritis, salpingitis, epididymo-orchitis, prostatitis
- Oropharyngeal disease
- Pelvic inflammatory disease (PID)
- Infection during pregnancy increases risk of
  - Premature rupture of membranes
  - Preterm delivery
  - Low birth weight
  - Neonatal conjunctivitis
  - Neonatal pneumonia
- Complications
  - Ectopic pregnancy
  - Tubal factor infertility

Bacterial vaginosis (BV)

Epidemiology
- Prevalence – 10-30% of pregnant women (American Pregnancy Association, 2015); most common form of vaginitis (≥50% of women with BV are asymptomatic)
- Polymicrobial – caused by a combination of Gardnerella vaginalis with anaerobic bacteria overgrowth at the expense of commensal lactobacilli

Risk factors
- Douching
- Nonuse of barrier methods
- Multiple sex partners (>2)

Clinical presentation
- Malodorous vaginal discharge (fishy odor)
- Vulvovaginitis, cervicitis, salpingitis
- Infection during pregnancy increases risk of
  - Acquisition and transmission of HIV
  - Preterm labor
  - Premature rupture of membranes
  - Postpartum endometriosis

Neisseria gonorrhoeae

Epidemiology
- Incidence – 108/100,000 for females; 106/100,000 for males (CDC, 2014)
- Age – highest incidence in 15-24 years
- Nonmotile gram-negative diplococcus

Risk factors
- >1 sex partner, a new sex partner, or a sex partner with multiple partners
- Sex partner with an STI
- Intermittent or lack of condom use
- Previous or current STI
- Exchange of sex for money or drugs

Clinical presentation
- Cervicitis, urethritis, salpingitis
- Pelvic inflammatory disease (PID)
- Oropharyngeal disease
- Neonatal infection
- Proctitis (predominantly in men who have sex with men)

Treponema pallidum (syphilis)

Most Common Parasitic/Protozoan STI

Trichomonas vaginalis

Epidemiology
- Prevalence – ~3 million in U.S. (CDC, 2015)
- Age – highest incidence in 30-50 years
- Flagellated protozoan

Risk factors
- >1 sex partner, a new sex partner, or a sex partner with multiple partners
- Sex partner with an STI
- Intermittent or lack of condom use
- Previous or current STI
- Exchange of sex for money or drugs
- Coinfection with gonorrhea or HIV

Clinical presentation
- In females, symptoms include malodorous vaginal discharge, strawberry cervix, dysuria, vulvar irritation, vaginitis, and cervicitis
  - >50% of women with T. vaginalis infections have minimal or no symptoms
  - Trichomaniasis accounts for 15-20% of cases of vulvovaginitis
- In males, T. vaginalis causes urethritis, epididymitis, prostatitis
- Infection during pregnancy increases risk of
  - HIV transmission
  - Preterm labor
  - Premature rupture of membranes
  - Low birth weight

ARUP Lab Tests

Tests generally appear in the order most useful for common clinical situations. Click on number for test-specific information in the ARUP Laboratory Test Directory.

Chlamydia trachomatis and Neisseria gonorrhoeae (CTNG) by Transcription-Mediated Amplification (TMA) with Reflex to CT/NG Confirmation 2011164
Method: Qualitative Transcription-Mediated Amplification

Recommended Use

Detect Chlamydia trachomatis and Neisseria gonorrhoeae in a variety of specimens

Positive results are confirmed using an alternate nucleic acid target

Refer to Sample Collection for the Diagnosis of STD Using Nucleic Acid Amplification Tests for optimal specimen types and collection instructions

Limitations

Culture may be required in certain clinical contexts for diagnosing C. trachomatis and N. gonorrhoeae infections

Sexually Transmitted Disease Panel 1 by Transcription-Mediated Amplification 2006258
Method: Qualitative Transcription-Mediated Amplification

Recommended Use

Preferred test for detecting C. trachomatis, N. gonorrhoeae, and Trichomonas vaginalis in variety of specimens

Refer to Sample Collection for the Diagnosis of STD Using Nucleic Acid Amplification Tests for optimal specimen types and collection instructions

Chlamydia trachomatis and Neisseria gonorrhoeae by Transcription-Mediated Amplification (TMA) 0060241
Method: Qualitative Transcription-Mediated Amplification

Recommended Use

Preferred test for detecting C. trachomatis and N. gonorrhoeae in variety of specimens

Requires APTIMA collection kit

Does not include confirmation of positive results by an alternate nucleic acid target; if confirmation of positive results by an alternate nucleic acid target is required, please refer to C. trachomatis and N. gonorrhoeae by transcription-mediated amplification (TMA) with confirmation

Refer to Sample Collection for the Diagnosis of STD Using Nucleic Acid Amplification Tests for optimal specimen types and collection instructions

Limitations

Culture may be required in certain clinical contexts for diagnosing C. trachomatis and N. gonorrhoeae infections

Chlamydia trachomatis and Neisseria gonorrhoeae by Transcription-Mediated Amplification (TMA) with Reflex to Chlamydia trachomatis L serovars (LGV) by PCR 2013767
Method: Qualitative Transcription-Mediated Amplification/Qualitative Polymerase Chain Reaction

Recommended Use

Preferred test for suspected lymphogranuloma venereum

Screen for C. trachomatis and N. gonorrhoeae

Reflex pattern – if C. trachomatis and N. gonorrhoeae by TMA result is positive for C. trachomatis, polymerase chain reaction (PCR) testing for L1-L3 serovars is added

Refer to Sample Collection for the Diagnosis of STD Using Nucleic Acid Amplification Tests for optimal specimen types and collection instructions

Chlamydia trachomatis and Neisseria gonorrhoeae by Transcription-Mediated Amplification (TMA), ThinPrep 0060734
Method: Transcription-Mediated Amplification

Recommended Use

Detect C. trachomatis and N. gonorrhoeae in ThinPrep specimens

Refer to Sample Collection for the Diagnosis of STD Using Nucleic Acid Amplification Tests for optimal specimen types and collection instructions

Limitations

Culture may be required in certain clinical contexts for diagnosing C. trachomatis and N. gonorrhoeae infections

Trichomonas vaginalis by Transcription-Mediated Amplification (TMA) 2005506
Method: Qualitative Transcription-Mediated Amplification

Recommended Use

Detect T. vaginalis in various specimens

Refer to Sample Collection for the Diagnosis of STD Using Nucleic Acid Amplification Tests for optimal specimen types and collection instructions

Limitations

Performance of test on self-collected vaginal swab specimens and those from pregnant women has not been evaluated

Chlamydia trachomatis by Transcription-Mediated Amplification (TMA) 0060243
Method: Qualitative Transcription-Mediated Amplification

Recommended Use

Preferred test for detecting C. trachomatis in a variety of specimens

Refer to Sample Collection for the Diagnosis of STD Using Nucleic Acid Amplification Tests for optimal specimen types and collection instructions

Limitations

Culture may be required in certain clinical contexts for diagnosing C. trachomatis and N. gonorrhoeae infections

Neisseria gonorrhoeae by Transcription-Mediated Amplification (TMA) 0060244
Method: Qualitative Transcription-mediated Amplification

Recommended Use

Preferred test for detecting N. gonorrhoeae in a variety of specimens

Refer to Sample Collection for the Diagnosis of STD Using Nucleic Acid Amplification Tests for optimal specimen types and collection instructions

Limitations

Culture may be required in certain clinical contexts for diagnosing C. trachomatis and N. gonorrhoeae infections

Chlamydia trachomatis L serovars (LGV) by PCR 2013768
Method: Qualitative Polymerase Chain Reaction

Recommended Use

Detects but does not differentiate C. trachomatis L1-L3 serovars

Chlamydia trachomatis Culture 0060850
Method: Cell Culture/Immunofluorescence

Recommended Use

Not recommended for routine detection of C. trachomatis

Use to detect C. trachomatis in medicolegal settings and to assess suspected treatment failure

May be considered for anatomic locations for which amplified testing has not been validated

Limitations

Nucleic amplification testing is recommended for detection of C. trachomatis from endocervical or urethral specimens; refer to C. trachomatis by TMA

Unusual Organism Culture 0060714
Method: Culture

Recommended Use

Can detect N. gonorrhoeae in specimens not approved for nucleic acid amplification testing

Preferred testing is combined C. trachomatis and N. gonorrhoeae by TMA

Medical Reviewers

Fisher, Mark A., PhD, D(ABMM), Medical Director, Bacteriology, and Special Microbiology, Antimicrobial Susceptibility Testing, at ARUP Laboratories; Associate Professor of Clinical Pathology, University of Utah

Schlaberg, Robert, MD, MPH, Medical Director, Microbial Amplified Detection, Virology, and Fecal Chemistry; and Assistant Medical Director, Virology and Molecular Infectious Disease at ARUP Laboratories; Assistant Professor of Clinical Pathology, University of Utah

References

Guidelines

Cantor AG, Pappas M, Daeges M, Nelson HD. Screening for syphilis: updated evidence report and systematic review for the U.S. Preventive Services Task Force. JAMA. 2016;315(21):2328-2337.

Geisler WM. Management of uncomplicated Chlamydia trachomatis infections in adolescents and adults: evidence reviewed for the 2006 Centers for Disease Control and Prevention sexually transmitted diseases treatment guidelines. Clin Infect Dis. 2007; 44 Suppl 3: S77-83. PubMed

Lee KC, Ngo-Metzger Q, Wolff T, Chowdhury J, LeFevre ML, Meyers DS. Sexually Transmitted Infections: Recommendations from the U.S. Preventive Services Task Force. Am Fam Physician. 2016; 94(11): 907-915. PubMed

Newman LM, Moran JS, Workowski KA. Update on the management of gonorrhea in adults in the United States. Clin Infect Dis. 2007; 44 Suppl 3: S84-101. PubMed

Recommendations for the Laboratory-Based Detection of Chlamydia trachomatis and Neisseria gonorrhoeae - 2014. Recommendations and Reports, Vol. 63, No. 2. Centers for Disease Control and Prevention. Atlanta, GA [Published: Mar 2014; Accessed: Dec 2017]

U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 2015 Sexually Transmitted Diseases Treatment Guidelines. Screening Recommendations. Centers for Disease Control and Prevention. Atlanta, GA [Last updated: Aug 2016; Accessed: Aug 2017]

U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015. June 5, 2015, 64(RR3);1-137. Centers for Disease Control and Prevention. Atlanta, GA [Last updated: Jun 2015; Accessed: Aug 2017]

van Schalkwyk J, Yudin MH, Infectious Disease Committee. Vulvovaginitis: screening for and management of trichomoniasis, vulvovaginal candidiasis, and bacterial vaginosis. J Obstet Gynaecol Can. 2015; 37(3): 266-274. PubMed

Wangu Z, Burstein GR. Adolescent Sexuality: Updates to the Sexually Transmitted Infection Guidelines. Pediatr Clin North Am. 2017; 64(2): 389-411. PubMed

Zakher B, Cantor AG, Pappas M, Daeges M, Nelson HD. Screening for gonorrhea and Chlamydia: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2014; 161(12): 884-93. PubMed

General References

Beharry MS, Shafii T, Burstein GR. Diagnosis and treatment of chlamydia, gonorrhea, and trichomonas in adolescents. Pediatr Ann. 2013; 42(2): 26-33. PubMed

Copeland NK, Decker CF. Other sexually transmitted diseases chancroid and donovanosis. Dis Mon. 2016; PubMed

de Vries HJ. Sexually transmitted infections in men who have sex with men. Clin Dermatol. 2014; 32(2): 181-8. PubMed

Frenkl TL, Potts J. Sexually transmitted infections. Urol Clin North Am. 2008; 35(1): 33-46; vi. PubMed

Garner AL, Schembri G, Cullen T, Lee V. Should we screen heterosexuals for extra-genital chlamydial and gonococcal infections? Int J STD AIDS. 2015; 26(7): 462-6. PubMed

Gaydos CA, Ferrero DV, Papp J. Laboratory aspects of screening men for Chlamydia trachomatis in the new millennium. Sex Transm Dis. 2008; 35(11 Suppl): S45-50. PubMed

Hobbs MM, Seña AC. Modern diagnosis of Trichomonas vaginalis infection. Sex Transm Infect. 2013; 89(6): 434-8. PubMed

Markle W, Conti T, Kad M. Sexually transmitted diseases. Prim Care. 2013; 40(3): 557-87. PubMed

Mishori R, McClaskey EL, WinklerPrins VJ. Chlamydia trachomatis infections: screening, diagnosis, and management. Am Fam Physician. 2012; 86(12): 1127-32. PubMed

Quan M. Vaginitis: diagnosis and management. Postgrad Med. 2010; 122(6): 117-27. PubMed

Verstraelen H, Verhelst R. Bacterial vaginosis: an update on diagnosis and treatment. Expert Rev Anti Infect Ther. 2009; 7(9): 1109-24. PubMed

Workowski K. In the clinic. Chlamydia and gonorrhea. Ann Intern Med. 2013; 158(3): ITC2-1. PubMed

Wright HR, Turner A, Taylor HR. Trachoma. Lancet. 2008; 371(9628): 1945-54. PubMed

Educational Videos

(5 min)

Content Review:

August 2017

Last Update: May 2018


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