Medical professionals are trained to communicate with patients, partners, and families to be able to understand their chief complaint and formulate a differential diagnosis effectively. At the same time, taking a detailed history is mandatory, whether it occurs in a primary clinic or the Emergency Department. Our role as a provider is to be able to communicate with the patient who presents with signs and symptoms of an undiagnosed sexually transmitted infection or infections. As a provider, you should be aware that all adolescents below the age of 18 have the right to an STI screening and treatment without parental consent.[6] Further details should be investigated with individual state health care systems or reference the "Sexually transmitted disease treatment guidelines 2015" that was distributed by the CDC. While performing the sexual history collection, an easy pneumonic that can help guide your questions can be remembered as the "other 5 P's".[16]

1. Partners
2. Practices 
3. Prevention against pregnancy
4. Protection against sexually transmitted infections
5. Past history of sexually transmitted infections

The physical exam should be guided by the presenting chief complaint and symptoms collected in the review of systems.[7] Physical exam should be done in a private setting with a chaperone at the bedside who you can then document their name in your EHR. The physical exam, along with the history, will provide a concise differential diagnosis and guide the evaluation, treatment, and management plan of the suspected disease process.[8] At the end of your exam, present the patient with an open-ended question to ensure that there is an open dialogue, and if the patient has any other details about their sexual practice, you as the provider should know.[18]

The physical exam will be broken down by the most common signs and symptoms, the most common physical exam finding, and diagnosis.

HIV

• Females and Males: 
• Signs and symptoms: Patients may present asymptomatic or with an acute viral syndrome to include systemic like symptoms: malaise, fatigue, anorexia, fever, chills, arthralgias, myalgias, or cutaneous presentations.[6]
• Physical Exam: Depending on the chief complaint will guide the physical exam. In general, pt should have a thorough history and physical exam to rule out a broad differential diagnosis.[7]

Gonorrhea

• Females:
• Signs and symptoms: Patients may present with dysuria, urgency, urinary frequency, lower pelvic pain, and abnormal vaginal bleeding.[11]
• Physical Exam: If suspecting systemic infection, a thorough physical exam should be performed.[9]
• Genitourinary exam: May include inflammation of the external vagina causing excoriations from pruritus, mucopurulent discharge, and friable inflamed mucosal tissue of the cervix.[17]
• Males: 
• Signs and symptoms: Patients may present with testicular pain, dysuria, purulent discharge from meatus, pain with defecation secondary to inflammation of the rectal area, and or prostate.[16] Although the provider should observe systemic signs and symptoms consistent with disseminated gonococcal infection i.e., sore throat, or redness of eyes, joint pain, cutaneous lesions. [9]
• Physical Exam: Genitourinary exam: There may be palpable tenderness over the epididymis, purulent discharge from the meatus, Palpable tenderness to the prostate or rectum.[16] As the provider and you are concerned about disseminated gonococcal infection, the provider should perform a thorough physical exam.[9]

Chlamydia

• Females:
• Signs and symptoms: Most infections can be asymptomatic but may present with vaginal discharge, abnormal vaginal bleeding, lower pelvic pain, urinary frequency, or dysuria.[18] If systemic infection is present, the patient may be febrile, with abdominal pain, nausea, vomiting, fatigue, and malaise. 
• Physical Exam: Genitourinary exam: inflammation of the cervix with mucopurulent discharge, ectropion, vaginal discharge, tenderness of the cervix, tenderness of the adnexal regions, and abdominal tenderness.[18] If systemic and Fitz-Hugh-Curtis syndrome is on your differential, there may be right upper quadrant tenderness secondary to perihepatitis.[11]
• Males: 
• Signs and symptoms: The most common presenting symptoms are dysuria, testicular pain, pain with defecation secondary to inflammation of the rectal area, and or prostate.[11]
• Physical Exam: Genitourinary exam: tenderness to the testicles specifically over the epididymis, tenderness with palpation to the prostate, or rectum region.[11]

HPV:

• Females and Males:
• Signs and symptoms: Most complaints are cosmetic in nature or an incidental finding due to the asymptomatic nature of HPV types 6 and 11. Patients may also present with ulcerative lesions secondary to oncogenic HPV types 16 and 18 
• Physical Exam: On exam, there may be an exophytic lesion described as a cauliflower-like growth known as condylomata acuminata.[12] Lesions can be observed over the external genital region, perineum, and or perianal area. Exam for females entails a speculum exam with screening to rule out cervical cancer.[19]

Syphilis:

• Females and males:
• Signs and symptoms: Presenting symptoms of a syphilis infection depends on the phase of the infection at the current state of evaluation. Symptoms can be broken down by primary, secondary, latent, and tertiary phases, which are best detailed and discussed in the referenced article "Syphilis."[13]
• Physical Exam: The physical exam is dependent on the presenting phase of the syphilis infection. 
• Primary: Presents with a painless well-demarcated lesion/ulcer known as a chancre at the site of inoculation.[13]
• Secondary: Presents with systemic symptoms involving a cutaneous lesion and rash. Lesions known as condylomata lata are wart-like lesions that present and resolve during the secondary phase. The rash is specific for palmar regions of the hands and feet.[13]
• Latent: Seroconversion of the patient to have positive syphilis serum screenings.[13]
• Tertiary: presentation can be within months or years from inoculation. Systemic symptoms can range to cardiovascular, neurologic, and cutaneous symptoms described as gummatous lesions. Neurosyphilis can present with stroke-like symptoms, cranial nerve deficits, a change in mental status, general paresis, or tabes dorsalis.[20]

 Herpes

• Females and males: 
• Signs and symptoms: Primary infections tend to induce systemic symptoms, including vesicular lesions over affected areas, pruritus, dysuria, fever, headaches, malaise, and lymphadenopathy. Reactivation usually presents with a prodromal phase to include tingling, itching, and rash consistent with vesicular lesions.[14] Recurrent infections tend to be less intense with a shorter duration.[21]
• Physical Exam: The provider should focus on the affected area, whether it is localized or systemic. A primary herpes infection tends to be worse and diffuse symptomatically involving various symptoms. Females may have diffuse vesicular lesions to the internal and external vaginal area.[21] Males may have diffuse vesicular lesions to the glans of the penis, penile shaft, scrotum, perineal/perianal area, and the external/internal rectum. A recurrent herpes infection isolated vesicular lesions over a neuronal tract where the virus is dormant.[22]

Trichomoniasis

• Females:
• Signs and symptoms: Female can remain asymptomatic with trichomonas vaginalis infection but at times may present with a complaint of foul-smelling discharge, pruritus, dyspareunia, dysuria, and vaginal spotting. 
• Physical Exam: The exam will show irritation of the external and internal vagina, including classic physical findings "strawberry cervix" as known as colpitis macularis. A foul frothy vaginal discharge may be present on the exam.[23]
• Males: 
• Signs and symptoms: Males can remain asymptomatic with a trichomonas vaginalis infection but can also present with testicular pain, dysuria, or rectal pain. 
• Physical Exam: Tenderness with palpation to the epididymis and prostate on rectal exam. No overlying skin lesions or inflammatory processes will be seen.[23] 

Granuloma Inguinale

• Females and males:
• Signs and symptoms: Patients will present with highly vascularized lesions over the genitals, perineum that tend to be painless.[24]
• Physical Exam: Exam will show ulcer-like lesions that are beefy red consistent with high vascularization that bleeds easily with manipulation. 4 main lesions can be seen on the exam: (1) Ulcerovegetative: large painless ulcer present on the patients physical exam. (2) Nodular: soft and erythematous that tend to ulcerate throughout the infectious process. (3) Cicatricial: dry ulcerations that tend to transition into plaques. (4) Hypertrophic: lesions are thick and painless.[25]

Lymphogranuloma venereum (LGV)

• Females and males: 
• Signs and symptoms: Patients will present with painful lymphadenopathy localized to the inguinal area. Patients may note the initial presentation of a pustule that gradually progressed to large painful ulceration.[26]
• Physical Exam: LGV presents with two stages: Primary phase is a small painless papule/pustule that will ulcerate and can be visualized throughout the affected genital area. During the secondary phase, patients present with unilateral lymphadenopathy that is fluctuant with palpation or maybe suppurative in a presentation known as Buboes.[24] Buboes tend to rupture in the acute phase and progress to a thickened mass.[27]

Mycoplasma Genitalium

• Females
• Signs and symptoms: Patients may present with pelvic pain, dysuria, similar type symptoms as gonorrhea or chlamydia infection. Vaginal irritation, discharge, or foul smell.[28] 
• Physical Exam: Exam will show irritation of the external and internal vagina, vaginal discharge, cervical tenderness, adnexal tenderness, or abnormal vaginal spotting.[29]
• Males: 
• Signs and symptoms: Patients may present with suprapubic pain, dysuria, urinary frequency, urgency, or testicular pain.
• Physical exam: Exam can be benign or tenderness to the epididymis with palpation or tenderness to the prostate on rectal exam.[30]

This is a brief overview of the most common signs and symptoms, physical exam findings, and diagnosis of sexually transmitted infections that can be evaluated in an acute setting such as the emergency department or a routine visit with the patient's primary care provider. The information and references cited should be used for a more in-depth approach to the signs and symptoms of a sexually transmitted infection.

Screening recommendations can be found in a detailed presentation through “Sexually transmitted disease treatment guidelines 2015,” that was distributed by the CDC.[6] The information provided will be extrapolated from the guidelines and should be used at the discretion of the provider in conjunction with the patient. 

Depending on the clinical presentation of the patient and acuity, a patient with a primary complaint concerning a sexually transmitted infection should involve ruling out localized versus a systemic infection. Initial diagnostic testing will be guided by the presenting sexually transmitted infection concerning the CDC Sexually transmitted disease treatment guidelines that were updated in 2015.[21][8][31] 

Most common laboratory testing performed include:

• Nucleic Acid Amplification Test (NAAT)
• Cerebrospinal Fluid (CSF)
• Fluorescent Treponemal Antibody Absorption Test (FTA-ABS)
• Rapid Plasma Reagin (RPR)
• Treponema pallidum Particle Agglutination (TP-PA)
• Venereal Disease Research Laboratory (VDRL)

Chlamydia:[32]

• Female: Diagnosis with the use of NAAT vaginal swab or first catch urine sample or self endocervical swab. 
• Male: Diagnosis with the use of NAAT of a first catch urine sample or urethral sample. 

Gonorrhea[9]

• Female: Diagnosis with the use of NAAT vulvovaginal or endocervical swab. 
• Male: Diagnosis with the use of NAAT of a first catch urine sample or urethral sample. 

Trichomoniasis[33]

• Female: Diagnosis with the use of NAAT of the vagina, endocervical swab, urine analysis, or urethral sample. A wet mount will show motile flagellated protozoa to assist with the diagnosis. 

Genital Herpes[21]

• Female/Male: Diagnosis by clinical examination, NAAT from genital ulceration, or viral culture.

Genital Warts[12]

• Female/Male: Diagnosis by clinical examination or biopsy if warranted.

Syphilis[13]

• Female/Male: Diagnosis will be guided by dark field microscopy and serologic tests to include RPR, VDRL, FTA-ABS, or TP-PA. Each test is performed in an algorithmic process. Patients who are presenting with neurosyphilis will need a cerebral spinal fluid sample to assist with the diagnostic workup.

HIV[7][6]

• Female/Male: Diagnosis with the use of blood sample or saliva for antibodies as a preliminary test then followed up with more specific tests, including PCR or specific assays. PCR for diagnostic and confirmation of HIV infection. Specific assays to isolate antibodies or specific viral antigen for confirmation.

When approaching treatment and management of a sexually transmitted infection (STI) previously termed as a sexually transmitted disease (STD). During the year 2013, the Center for Disease Control (CDC) and Prevention initiated a goal to update the Sexually Transmitted Treatment Guidelines 2015 with persons who are experts in the field. There are specific sections in this treatment guideline that direct specific care for select populations such as pregnant women, adolescents, persons in correctional facilities, men who have sex with men, women who have sex with women, and transgender men/women.[6] These topics should be explored and reviewed on a case by case issue.

The treatment and management of the patient should be supported by the history and physical exam, whether the patient is evaluated in the Emergency Department or a primary care office. Primary treatments will be discussed, and further reference articles will be cited for further management options for providers.[8] If the primary treatment is not tolerated or the patient is allergic, providers should consult their pharmacy department for further recommendations. 

HIV: Primary treatment and management consist of establishing viral load, CD4 count, and starting a patient on highly active antiretroviral therapy (HAART).[34]

• HAART included the following classes. Through the guidance of an Infectious disease physician should medications be started? If a patient is seen for an acute concern such as sexual assault or exposure to an STI through high-risk sexual activity with a concern for HIV, a single combination medication should be started with close primary care followup.[7]
• Nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs)
• NRTI fixed-dose combinations
• Integrase inhibitors
• Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
• CC chemokine receptor five inhibitors (CCR5 Inhibitor)
• Protease Inhibitors

Chlamydia: Primary treatment and management should be supported by history, the physical exam, and clinical presentation. Consideration of coinfections with the most common sexually transmitted infections should be considered and treated simultaneously.[11]

• One dose of azithromycin 1 gram needs to be taken by mouth or doxycycline 100 milligrams to be taken by mouth for seven days. Other formulations can be taken but should be evaluated on a case by case presentation along with the concerns of the patient.
• After initial treatment, follow up tests should be discussed with the patient. 

Gonorrhea: Primary treatment and management should be supported by history, the physical exam, and the clinical presentation. Consideration of coinfections with the most common sexually transmitted infections should be considered and treated simultaneously.[9]

• One dose of 3rd generation cephalosporin, specifically ceftriaxone 250 milligrams to be given by intramuscular injection. One dose of azithromycin 1 gram to be taken by mouth to treat possible coinfection of chlamydia. 
• After initial treatment, follow up tests should be discussed with the patient. 

Syphilis: Treatment and management of secondary, latent, and tertiary syphilis should be independent on the treatment of primary syphilis infection. 

• Primary, secondary, and early syphilis infection can be treated with Penicillin G Benzathine 2.4 million units to be given by intramuscular injection.[13]
• Tertiary syphilis should be treated as an inpatient due to the three doses of penicillin G benzathine 2.4 million units once a week for a total of 3 weeks.
• Neurosyphilis should be treated as an inpatient with intravenous penicillin G aqueous 18-24 million units daily divided into 3 to 4 million units every 4 hours or a continuous infusion for a total of 14 days.[8]

Genital Herpes: Treatment and management of a primary infection should include systemic infection followed by symptomatic treatment and starting antiviral medications. The provider and patient should discuss medication options, including the financial strain that may hinder appropriate treatment. Treatment of reactivation herpes infection should be treated with what medication works best for the patient.

• Acyclovir, valacyclovir, and famciclovir are three types of primary treatment that can be started on patients. There are various formulations and treatment courses that should be started after the best management plan is discussed with the patient.[8]

Trichomoniasis: Treatment and management should be established with that patient after diagnosis.[23]

• One dose of metronidazole 2 grams to be taken by mouth
• Metronidazole 500 mg by mouth twice daily with food for seven days
• One dose of tinidazole 2 grams to be taken by mouth

Granuloma inguinale: Treatment and management should be guided by history, the physical exam, and clinical presentation as granuloma inguinale is not very common in the United States. [25]

• Azithromycin 1 gram to be taken by mouth once per week until lesions resolve completely. Other formulations and dosages can be taken depending on clinical presentation and the guidance of an infectious disease specialist.[8]

LGV: Treatment and management should be guided by history, the physical exam, and clinical presentation as LGV is not very common in the United States.

• Doxycycline 100 milligrams taken by mouth twice daily for 21 days.[8]

Mycoplasma genitalium: Concern for an M. genitalium infection should be considered if the patient is suspected of a chlamydia or gonorrhea infection.[30]

• One time dose of azithromycin 500 milligrams taken by mouth plus continued azithromycin regimen at 250 milligrams once daily for four days

A broad differential should be approached when evaluating a patient, whether in an Emergency Department or a primary care setting. Sexually transmitted infections can be localized to the oropharynx, integumentary system, external and internal genitals depending is a male or female, perianal/perineal, and rectum. As the provider, you should establish primary concern and differentiate other diagnoses that may be present. A thorough history, the physical exam, and the clinical presentation should support the definitive diagnosis and also rule out your differential diagnosis.

When approaching a differential diagnosis specifically for sexually transmitted infections, the provider should evaluate each system i.e., cardiovascular, respiratory, gastrointestinal, genitourinary, central nervous system, musculoskeletal, and the integumentary system. By breaking it down into systems specifically for each sexually transmitted infection will help you as a provider to determine if it is the primary infectious process associated with the STI or a secondary associated symptom of a systemic infectious process. You should also recognize if there is a superimposed infection along with the primary sexually transmitted infection.[35]

Differential STIs should be assessed by system and symptomatology: Each of the following systems can be affected by STIs, leading to direct or indirect involvement. 

• Cardiovascular: HIV, Syphilis, HSV-1/HSV-2
• Respiratory: HIV, chlamydia
• Gastrointestinal: HIV, HSV-1/HSV-2, chlamydia, gonorrhea, HPV
• Genitourinary: HIV, HSV-1/HSV-2, chlamydia, gonorrhea, HPV
• Central nervous system: HIV, syphilis, HSV-1/HSV-2, gonorrhea, HPV
• Musculoskeletal: HIV, HSV-1/HSV-2, chlamydia, gonorrhea, HPV
• Integumentary system:HIV, HSV-1/HSV-2, chlamydia, gonorrhea, HPV

The use of different resources should be entertained to understand why a differential diagnosis is important and how to use the differential to better serve your patient population.[36]

Throughout this article and literature reviewed, the prognosis depends on the diagnosis of the disease and the progression of the disease at the time of diagnosis. If the disease process is found in the acute phase and can be treated effectively with antivirals, antibiotics, or antifungals, the outcome is dependent on the treatment course. Medication adherence plays a primary role in the prognosis of an infection that is treatable or a chronic condition such as HIV, HSV-1/HSV-2, partially treated STIs, or asymptomatic STIs that continue untreated.[2]

Sexually transmitted infections (STIs) that remain untreated lead to systemic infections leading to prolonged medical recovery also to include psychological, financial, and general health complications. STIs complications arise from partially treated or untreated infections. Medically underserved populations show an increase in undiagnosed untreated STIs due to the fact they have no attainable healthcare system. An increase of complications can be seen if resources are not allocated to the public sector, such as planned parenthood to provide needed resources to educate people of safe sex practices to included prevention, treatment, and health promotion.[31]

There is a wide array of complications from STIs if left untreated. Females tend to be at higher risk for complications from STIs to include systemic infection from untreated PID, sterility, and infertility from complicated gonorrhea/chlamydial infections. Females, while pregnant, have a higher percentage of preterm labor if they are positive for certain STIs. Females and males have a risk of neoplasm secondary to certain HPV strain types.[37] HIV infections, if not properly managed, will progress to AIDS, a fatal late complication of the infection secondary to a severely immunocompromised state.

Healthcare providers should understand the most common sexually transmitted diseases and should be comfortable with counseling patients on modifiable human behavior while providing a gold standard of care in line with the presenting disease process. Patients should be provided information on prevention, counseling, and proper treatment for their sexually transmitted infections.[31]

Key pearls for sexually transmitted infections is to be able to have an open dialogue with your patients regarding their sexual history and current practices. Establishing a good relationship creates a neutral environment and optimizes the treatment course. Do not shame or judge a person's sexual history or sexual practices because this can lead to reservations by the patient to discuss their general and sexual health.

Whether a patient is seen in the emergency department or a primary care office the disposition of the patient should be determined on the clinical presentation. If the patient has a complicated systemic infection admission is most likely warranted but if they have a self-limiting complaint that can be easily treated with proper follow up the patient should be discharged home. Pitfalls a provider may encounter would most likely be limited education with the prevention, treatment, and limited resources for their patient population.

Sexually transmitted infections are a worldwide concern and issue as they go untreated patients succumb to their disastrous effects, including health, financial burden, psychological, and physical. Data collection for STIs is limited by area. Having access to a national data collection service can help with the prevalence and incidence of certain STIs to allocate resources directed towards prevention and treatment. Continued resources such as planned parenthood would include an interprofessional team and care coordinators to provide these services.[38] Whether patients are seen in the emergency department or their primary care office, patient-centered care should remain the priority.