Penyakit Menular Seksual

(PMS)

Nurrachmat Mulianto, MSc, SpKK

FK UMS

Pemeriksaan pd PMS
ANAMNESIS :
- keluhan saat dtg
- keadaan umum dirasakan
- riwayat seksual (Coitus Suspectus)
* kontak seksual, di dlm/luar nikah, gonta-ganti
pasang atau kontak seksual multipel
* kontak seks dg pasangan stl gejala
* Frekuensi & jenis kontak seks (homo/hetero)
* Cara hub seks (genito, oro, anal)
* apakah pasangan gejala sama?
- Riwyt peny dahulu yg berhub dg PMS
- Rwyt keluarga : diduga PMS yg ditularkan lwt ibu kpd bayi
- keluhan yg berkaitan dg komplikasi
- Riwyt Alergi Obat

Pemeriksaan Fisik

Inspeksi & Palpasi

Pria
:
tdp kesatuan saluran
genital,
organ mudah diraba
Wanita :
pemisahan saluran
urinarius
dg genital, organ genital tdp
di rogga pelvis
posisis litotomi, dg
spekulum

Gonococcal Infection in The

Adults
Etiologic Agent :
Neisseria gonorrhoeae
Gram negative diplococcus
Non motile
Non spore forming
Some types have independent

chromosomal mutation, resulted

resistance to penicillin, tetracyclin and
spectinomycin
No resistance has yet been reported to
ceftriaxone

Clinical Manifestations

Urethral infection in men

Urogenital infection in women
Rectal infection
Pharyngeal infection

Complications
Local (Men) :
Epididymitis
Penile lymphangitis
Generalized penile edema
Urethral stricture
Periurethral abscesses

Complications
Local (Women) :
Acute salphingitis
Pelvic inflammatory disease
Infertility
Ectopic pregnancy
Bartholins gland abscess

Complications
Systemic
1. Disseminated gonococcal infection :

skin lesion and joint pain

2. Skin lesion is a tender, necrotic pustule
on an erythematous base, bullae or
echymoses
3. Arthalgia or tenosynovitis
4. Frank arthritis

Gonococcal endocarditis
Meningitis

Treatment : Uncomplicated
Ceftriaxone 250 mg i.m once
Cefixime 400 mg orally once
Cyprofloxacin 500 mg once
Ofloxacin 400 mg once
Plus
Coinfection with C. Trachomatis
Doxycycline 100 mg orally 2 times a day for 7
days
Alternative regimen :
Spectinomycin 2 gr i.m single dose

Treatment
Disseminated Gonococcal
Infection :
Hospitalization
Ceftriaxone 1 gr/24 hours for 7 days

Or
Cefotaxime 1 gr/8 hours i.v
Ceftizoxime 1gr/8 hours i.v
Spectinomycin 2 gr/12 hours

for a week

Treatment
Gonococcal Meningitis :
Ceftriaxone 1 2 gr/12
hours for 14 days
Gonococcal Endocarditis :
At least 4 weeks

Chlamydia Trachomatis
Infection in The Adults
Etiologic agent :
Chlamydia trachomatis strain D K
Obligate intracelluler
An unique growth cycle :

Elementary body
Reticulate body

Clinical Manifestations

Men :
1. Disuria ringan
2. Polakisuria
3. Discar seropurulen
4. Reiters syndrome :
a) Uretritis
b) Conjunctivitis
c) Arthritis
d) Mucocutaneous lesion

Clinical Manifestations
Women :
1. Asimptomatik
2. Disuria ringan
3. Sering kencing
4. Nyeri di daerah pelvis
5. Disparenia

Treatment
Recomended regimen :
Doxycycline 100 mg twice for 7

days
Azithromycin 1 gr orally once

Alternative regimen :
Ofloxacin 300 mg twice for 7 days
Erythromycin base 500 mg q.i.d for

7 days
Erythromycin ethyl succinate 800
mg q.i.d for 7 days

SIFILIS
Syphilis is a systemic infx dis caused
by Treponema Pallidum
The infx is acquired trough :
sexual contact with infected lesion or
body fluids
Transplacentally (less common)
Blood transfusion
Accidental innoculation
Puncture tatto

STRUKTUR TREPONEMA

btk helically coiled

Sel corkscrew-shaped pembuka tutup botol
panjang 6-15 m, lebar 0,1-0,2 m
mempunyai outer membrane dikelilingi flagella,
membr sitoplasma peptidoglikan, & silinder
protoplasmik
Treponema dibagi mjd spesies yg patogen &
non patogen

Spesies yg patogen
Treponema palidum subs pallidum sifilis
Treponema palidum subs pertenue frambusia
Treponema palidum subs endemicum sifilis endemik
Treponema carateum pinta

Non patogen sbg flora normal

Pada GIT, oral cavity, tract. genital

Transmission of Infection

1.
2.

Sexual
Accidental :

3.
4.

Congenital
Non-venereal

Doctor/nurses without gloves,

Laboratory workers, blood transfusion

In endemic treponematosis direct or

indirect non-veneral contact in early
childhood

Classification of Syphilis

(for therapeutic/epidemiologic)

Early Infectious phase (diagnosed in

first
year of infx) : S I, S II, recc stage and early
latent stage.
of
Late non-infectious (dx after the end
first year infx): late latent stage
and
tertiary stage.

STAGES OF SYPHILIS:

Contact (1/3 become infected)

( 10-90 days)

Primer ( Chancre)
( 3-12 wk)

lesion,

Secondary

organ involvement)

( mucocutanoues
( 4 - 12 wk )

Early Latent relapsing ( in 25%)

( 1 yr from contact )

Late Latent

( more than 1 yr )

Remission ( 2/3 )
Late Benign (16 %)
Cardiovascular (9.6 %)
Neurosyphilis (6.5%)

Tertier (1/3)

1. PRIMARY SYPHILIS
Incubation period 10-90 days ( 3
weeks) dusky red macules papules
chancre wt ulcerate in center
Chancre round/oval, 1 cm, sharply
demarcated, reguler, raised, firm,
rubbery borders

Primary Syphilis: Early chancre presenting as a flat,

eroden papule with raised, indurated borders &
smooth, cleaned based

 Untreated chancre : persist 1 - 6 wk

After tx : resolve within 1 2 wk heal without

scarring

Deviation :
-the classic hunterian chancre (60% cases)
-multiple chancre 47 % cases, + edema,
phimosis,erosive balanitis,lymphangitisand
thrombophlebitis dorsal vena.

Classic Hunterian chancre with raised, indurated

borders and slightly hemorrhagic necrotic base.

 MEN any parts of external genetalia :

Coronal sulcus
Inner surface of prepuce
Glands
Shaft of penis
Intra urethral rare
Anal anal sex

 WOMAN
labia, fourchett, urethra, perineum
Edema indurativum unilateral labial
swelling with rubbery consistency &
intact surface
Kissing chancre common in areas
skin to skin contact as the vulva

Chancre in a female. An ulcers covered with

fibrin & necrotic slough at the orifice of the
urethra

DD of Primary Syphilis
Most likely:
1. Chancroid (ulcus mole)
2. Herpes simplex
3. Granuloma inguinale
4. Traumatic ulcer
Concider :
1. Early LGV
2. Behcet disease
3. Squamous cell carc/ basal cell carc
4. Fixed-drug eruption
5. Erosive candidal vulvitis or balanitis

2. SECONDARY SYPHILIS
Erupt 3-12 wk after appearance of
chancre
Usually recedes in 2-12 wk
Not all patients present classic
symptoms & clinical findings

 Symptoms :

Mild fever, malaise

Headache, myalgia, arthralgia
Anorexia
Skin rash (80-95% cases)
Swollen lymph nodes
Bone pain
Deafness rare

SIFILIS
Lesi kulit pada S II :
Makula eritem
Makulo papuler
Di mukosa : 'mucous patch'

Papuler / folikuler / papuloskuamosa

Alopesia 'moth eaten'
Kondilomata lata

Ulserasi pustuler: papulonekrotikan

S II rekuren : lesi anuler

SIFILIS

Erupsi papuloskuamus pd punggung,

hrs dibedakan dgn psoriasis gutata
/pitiriasis rosea

Kondilomata lata, papul lunak, basah,

merah muda pd perineum & perianal

 Moth eaten Alopecia :

Irregular, patchy, nonscarring on the occipital
scalp, eyebrow or beard

 Non-cutaneous Secondary Syp

Lymphoreticular system: lymph nodes >
cases)

(50-80%

Opthalmologic: iritis (3%)->pain,lacrimation

Auditory: sensorineural hearing loss
Musculoskeletal
Hematologic : anemia, leukocytosis, relative
lymphopenia and sedimentation rate >
Renal : glomerulonephritis nephrotic syndr
Hepatic : luetic hepatitis (9.7%)
Gastric : epigastric pain

DD of Secondary Syphilis
Most likely
1. Pityriasis rosea
2. Condyloma acuminata
3. Drug eruption/ viral eruption
4. Psoriasis
5. Reiter syndrome
Consider
1. Lichen planus, eczema, sarcoid, erythema multiforme,
2. Balanitis vulvitis, leukoplakia
3. Dermatophytosis
4. etc

3. LATENT SYPHILIS
Secondary stage is followed
asymptomatic stage wt no clinical findings
but reactive serologic test
Latency may remain indefinitely be
interrupted by relaps of chancres or
eruption of S II ( 6 mo/ first y/2 y) or
progress to the tertiary stage

4. TERTIARY SYPHILIS
1/3 of patients wt untreated latent
syphilis TERTIARY SYPHILIS
3 principal presentation :
A. Late benign syphilis
B. Cardiovascular syphilis
C. Neurosyphilis

A. Late Benign Syphilis

Include any symptomatic syphilitic
manifestations after the secondary &
relapsing stage that does not involve
the cardiovascular or nervous system

The lesions caused CMI response to

a small number of treponemes present
in affected tissue

Skin lesions of late benign syphilis

3 types :

1.
2.
3.

Granulomatous nodule
Psoriasiform granulomatous nodules
Gummas

 Gumma :
Non tender pink to dusky-red
nodules or plaques
Diameter : mm to cm
Scalp,forehead, buttocks,
presternal, pretibial

Late benign syphilis: Disfiguring

gummatous infiltration of the glabela and
forehead with scattered ulceration.

SIFILIS

Sifilis III, tipe ulkusnoduler, asimptomatis,

berkrusta, plakat dg ulserasi, tepi
serpeginosa

Destruction of nasal cartilage & bone by

gumma SADDLE NOSE

B. Cardiovascular Syphilis
New cases of CV Sy still to be reported
In early Sy : rare
Commonly in tertiary syphilis (13.6% of
men and 8.2% affected women)
Symptoms & sign develop 15 -30 years
after initial infection

C. Neurosyphilis
Hematogenous invasion of the meninges by
T. pallidum occurs early in Sy
25% untreated primary or secondary
syphilis spirochetes dormant in CNS
(after adequate tx, 99% imunocompetent
indiv eradicate fr CNS)
Symptoms develop 5-35 years after
initial infection

SIFILIS
Diagnosis :
S I: mikroskopis
TSS treponemal & nontreponemal
S II: Gamb. klinis
Mikroskopis
TSS selalu reaktif
S laten: TSS reaktif, tak ada lesi
S III: biopsi organ
TSS darah & /cairan otak

SIFILIS
Tes serologi sifilis (TSS) presumptive
diagnostic:
TSS treponemal : bersifat spesifik
TPHA
FTA - ABS

TSS nontreponemal (reagin): Tdk

spesifik
Wasserman
VDRL, RPR

TREATMENT

D.o.C Perenteral Penicilline

1. Early Syphilis : Primary, Secondary & early

latent.
(without Neurologic/Opthalmologic/Auditory involvement)

Single dose Benzathine Penicilin 2.4 millions IU, im.

(DepKes RI 2006), alternativ:

Benzilpenicillin proc.(Procain Pen.G) : 0,6 million /day

im for 10 d.

Allergy :
Doxycycline 2 x 100 mg, 30 days
Ceftriaxone 250 mg/d or

1 gr every other day, 8-10 d, I.M / I.V

3. Late Syphilis : Late latent, Tertiary

Syphilis (Cardiovascular, Late Benign Syphilis)
Benzathine penicilline G 2.4 million units, I.M,
1 wk apart for 3 doses. (DepKes RI 2006),
Allergy :
Doxycycline 2 x 100 mg, 30 60 days
or
Tetracycline 4 x 500 mg, 30 60 days

 Treatment in Pregnancy :
The penicilline regimen appropriate for the
stage of infx
A second Bezathine penicilline injection 1 week
later is recommended ( in Primary, Secondary
& Early Latent syphilis )
Allergy :
Erythromycine:4x500mg/d 15 d (early)
4x500mg/d 30 d (late).

Vulvovaginal Candidiasis
Etiologic agent :
Yeast family, Candida spp.,
mainly
C. Albicans
Predisposing factors :
Pregnancy
Oral contraceptives
Diabetes mellitus
Antibiotics

Clinical Manifestations
Acute pruritus and vaginal

discharge
As typically cottage cheese
like

Treatment
Recomended treatment :
Miconazole nitrat (vaginal supp)
200 mg at bed time for 3 days
Clotrimazole (vaginal tab) 200 mg
at bed time for 3 days
Bufoconazole (2% cream 5 gr)
intravaginally at bed time for 3
days
Terconazole (80 mg supp) at bed
time for 3 days

Treatment
Alternatives :
Fluconazole 150 mg orally
single dose
Itraconazole 400 mg orally
single dose
Itraconazole 100 mg b.i.d for 3
days

Trichomoniasis
Penyebab : T. vaginalis
Keluhan
1. Tdk ada
2. Discar berbau,
iritasi/gatal.
3. Dispareunia
4. Disuria
5. Rasa tdk enak
perut bawah

Gejala
1. Tdk ada
2. Eritema vulva
difus
3. Discar >>
kuning, hijau,
berbusa
4. Inflamsi dind
vag
5. Strawberry
cervix

Strawberry cervix

Jenis pemeriksaan
pH >4,5
Sniff test positif
Dg sediaan basah (NaCl)
pergerakan trichomonas khas
Fluorescent antibodi
Pap smear

Terapi
Metronidazol 2 gram dosis tunggal
Metronidazol 2 x 0,5 gr selama 7
hari
Klindamisin 2 x 300mg slm 7 hari

Bakterial Vaginosis
Penyebab : Gardnerella vaginalis,
Bacteroides Spp, Mycoplasma hominis
Dpt tanpa gejala
Bau spt ikan (amin yg menguap)
pH 7,2
Sekret menggumpal wrn putih atau
keabu-abuan melekat pd dinding vag.
Clue cells pd mikroskop

Clue cells: squamous epithelial

cells covered primarily with
gardnerella which then take on
this fuzzy appearance called
"clue cell" as seen on wet mount
of vaginal fluid.
antibiotic therapy: metronidazole or clindamycin for 7 days

Differential Diagnosis of Vaginal Infections

Diagnostic
Criteria

Normal

Bacterial
Vaginosi
s

Vaginitis
Cand.
Trichomo
Vulvov
nas
ag

3.8 - 4.2

> 4.5

4.5

< 4.5
(usually
)

Discharge

White,thin,
flocculent

Thin, white
(milky),
gray

Yellow,
green,
frothy

White,
curdy,
"cottage
cheese"

Amine
odor
"whiff"
test

Absent

fishy

fishy

Absent

Lactobacilli,
epithelial
cells

Clue cells,
adherent
cocci, no
WBC's

Trichomonad
s, WBC's
>10/hpf

Budding
yeast,
hyphae,
pseudoh
yphae

Vaginal pH

Miroscopic

Virus Human Papilloma

(HPV/Papova)

Beberapa bersifat onkogenik

Tumbuh lambat dan replikasi dalam
nukleus
Pd IMS krn HPV kondiloma
akuminata

Papova virus (kondiloma akuminata)

Giant condyloma pd HIV

virus papova (kondiloma akuminata)

Terapi :
Elektrocauterisasi
Ablasi kimia (podophylin)
Bedah beku

Herpes genital
Disebabkan HSV 1 12-50%
Disebabkan HSV2 >50%
HSV2 infeksi I H.genitalis(klinis)
atau subklinis sbg carrier
menular atau rekuren sifatnya laten
pd ggl radix dorsalis

Herpes genital
-Eritema
-Vesikula
-Ulcus

Herpes genital

HERPES GENITAL pd penderita imunocompromise

Udem
Vesikel / ulserasi
Nyeri

TERAPI
Infeksi primer (episode pertama):
-simptomatik: analgetik,dan atau kompress
-Asiklovir 5 X 200 mg/hari 7-10 hari (p o)
atau 3 X 400mg/hr, 7-10 hari
-bl ada kmplikasi iv 3X 5mg/kgBB,7-10hr
-valasiklovir 2 X 500-1000mg/hari, 7-10 hr
-famsiklovir 3 X 250mg/hari, 7-10 hr
Infeksi rekurens:
-ACV 5 X 200mg po, 5 hari
-valacyc 2 X 500mg/hari, 5 hari
-famcycl 2 X 125-250mg/hari, 5 hari.

LGV (Lymphogranuloma
Venereum)

E/: Chlamydia trachomatis (L1 - L3)

bakteri intraseluler obligat
Inkubasi : 3 - 4 mgg
Penyakit sistemik terutama pd
sistem limfatik

LGV (Lymphogranuloma
Venereum)
Gambaran
klinis :

CS (kontak seksual)
7-10 hari
Std I : papul tdk nyeri, ulkus berderet2 pd penis
(saxophone penis) 3 - 4 hr sembuh
1-4mgg
Std II: kel. inguinal >, unilat, sakit
kel. femoral: 'sign of groove etage
bubo
bg. atas kelenjar inguinal bg. bawah

kelenjar iliaka profunda

, homo: sindr anogenital kelj
perirektal
Std III: Sekuele [striktur, fistul,
estiomen
(elefantiasis genital)]

LGV (Lymphogranuloma
Venereum)

LGV, limfadenopati pd pemb limfe

femoral & inguinal (sign of groove)

 Bentuk lain

LGV (Lymphogranuloma
Venereum)

Diagnosis :
Tes kulit Frei
Tes fiksasi komplemen
Tes mikro imuno fluoresen
Kultur jaringan
Tes antibodi monoklonal konjugasi fluoresen

LGV (Lymphogranuloma
Venereum)

Terapi : - menyembuhkan
- cegah kerusakan jaringan
Doksisiklin 2 x 100 mg / hr, 21 hr
Eritromisin 4 x 500 mg / hr, 21 hr
Sulfisoksazol 4 x 500 mg / hr, 21
hr
Azitromisin 1 g/mgg 3 mgg
Bubo fluktuatif : aspirasi
Tidak boleh insisi sikatrik
deformitas

Striktur rektum : dilatasi, kolostomi

GI (Granuloma Inguinale)
E/: Donovania granulomatis
Gram negatif di jar kapsul
badan Donovan
Inkubasi : 14 -15 hari
Derajat penularan : rendah

GI (Granuloma Inguinale)
Gambaran klinis :
Lokasi lesi : batang penis, labia mayora
Nodul eritem, tdk sakit, granulomatus
Lesi satelit tepi polisiklis
Gej. sistemik ( - )
Limfadenopati
Destruktif fistel
Ulkus btk seperti sosis

GI (Granuloma Inguinale)
Varian klinis :
Ulserovegetatif: bentuk tersering,
ulkus granulomatus
Hipertrofik/verukus: tepi ulkus
meninggi & verukoid
Nekrotik: destruksi ulseratif,
eksudat berbau
Sklerotik/sikatrikal: parut di
sekeliling genital

GI (Granuloma Inguinale)

GI, tipe ulserovegetatif, jar granulasi luas,

ulserasi & skar pd perineum, skrotum &
penis

GI (Granuloma Inguinale)
Diagnosis :
Spesimen dr tepi granulomatus
lesi yg aktif
Wright / Giemsa :basil bipolar dlm
sel mononuklear
Tdk ada pemeriks - serologi
- kultur

GI (Granuloma Inguinale)
Terapi :
Tetrasiklin 4 x 500 mg/hari
3 mgg (s/p lesi sembuh )
Alternatif lain :
Trimetoprim 160 mg +
Sulfametoksazol 800 mg 2 x/hari
Kloramfenikol 3 x 500 mg/hari
Gentamisin 1mg/kg/hr im 2 - 4
mgg

ULKUS MOLE
DEFINISI
UM penyakit infeksi genital akut,
lokalisata, disebabkan oleh kuman
Streptobacillus ducreyi
(Haemophilus ducreyi)
Gejala khas ulkus nekrotik, nyeri
di tempat inokulasi & srg disertai
dg supurasi KGB regional

Etiologi
= Haemophilus (Unna) ducreyi =
Batang pendek, ramping, ujung bulat
Gram negatif, tdk berwarna, berspora
Berkelompok, berderet = rantai
Streptobacillus
School of Fish

Epidemiologi
Endemis: kota & pelabuhan
Tropis & subtropis
Penularan : kontak seksual & autoinokulasi
< ; d/ sulit atau carrier (WTS)

ULKUS MOLE
PATOGENESIS
Dg adanya trauma / abrasi, kuman penetrasi
ke dlm epidermis.
Limfadenitis yang terjadi akibat infeksi
Haemophilus ducreyi disertai dengan supurasi.
Respons imun yg berhub dg patogenesis &
kerentanan peny - tidak diketahui.
Hasil penyelidikan adanya respons
hipersensitivitas lambat & respons antibodi pd
pasien dg chancroid.
Antibodi (+) dg pem fisaksi komplemen,
aglutinasi, presipitasi & tes fluoresens antibodi
indirek.

ULKUS MOLE
Gambaran klinis :
Papul ulkus yang sakit & lunak
Batas tegas
Dinding menggaung, bergerigi
Dasar : eksudat

Autoinokulasi lesi berhadapan

(Kissing lession)
Adenopati inguinal unilat & sakit
supurasi pecah bubo (limfadenitis
bubo)

Predileksi
Genital
: * labia, klitoris,
vestibulum
* serviks & anus
preputium,
frenulum
* sulcus
coronarius
* batang penis

: *

Ekstra Genital
Bibir, lidah
Jari tangan
Payudara &
umbilicus
Konjungtiva

ULKUS MOLE

Ulkus mole, ulkus yang sangat nyeri

dgn eritema & edema disekelilingnya

ULKUS MOLE

Ulkus mole, ulkus multipel, sangat

nyeri pd vulva krn otoinokulasi

Bentuk lain

Chancroid di penis, kissing effect

Ulkus mole dg ulkus di KGB inguinal
Multiple ulceration of the sulcus
corona

Diagnosis Banding

Ulkus durum (S1)

Ulkus mikstum (Rollet)
Sifilis III
Herpes genitalis
Ulkus vulvae akutum
L.G.V.
Diagnosis

Lesi khas : H.ducreyi

ULKUS MOLE
Terapi :
Azitromisin 1 g oral d.tunggal /
Seftriakson 250 mg im d.t /
Eritromisin basa 4 x 500 mg/7 hr
Ulkus sakit sekali ? kompres
dingin
Aspirasi kelenjar inguinal

1. M.T.
2. Btk ulkus

3. K.G.B

Ulkus Mole

Ulkus Durum

1 7 hr ( 3 hr)

10 hr 10 mgg (3 5
mgg)

Multipel

Soliter (kdg. 2)

Sgt nyeri, lunak

Tidak nyeri, keras

Tepi , tak teratur

Tepi teratur

Polisiklis

Tidak pernah

Permukaan kotor

Bersih

+ nanah

Serous

+ 10 50 %

Hampir slrh pend

Unilat. (kdg bilat.)

Bilateral/ generalisata

Nyeri

Tidak nyeri

Limfangitis
Limfadenitis +

Limfadenopati
generalisata

+ melunak

Keras

Perforasi
4. Lab
5. Rx.
serologis

Gram

Burri

Mikroskop biasa

Mikroskop lapangan gelap

Tidak spesifik

Khas: VDRL & TPHA

Setia dg pasanga
Itu lebih baik