Introduction to sexually transmitted infections 

Sexually transmitted infections (STIs) are most commonly transmitted through vaginal, anal or oral sexual intercourse. Although, some STIs can be passed on during pregnancy, childbirth, breastfeeding or via contact with infected blood. Many STIs are preventable via practising safe sex techniques, for example, barrier protection.

Bacterial STIs can usually be treated via a course of antibiotics. The most common treatable bacterial STIs include chlamydia, gonorrhoea and syphilis. If left untreated you are at increased risk of infertility, ectopic pregnancies and pelvic inflammatory disease. 

Symptoms displayed vary between individuals and the type of STI they are infected with. Some common overlapping symptoms include:

• Burning sensation during urination
• Unusual discharge
• A rash 
• Lumps and bumps around the genital area
• Itchiness around the genitals
• Unexpected bleeding

It is not uncommon to be infected with an STI and be asymptomatic. Therefore, if you are sexually active, it is recommended that you do regular screenings to catch any infection early to prevent the progression of the disease that may result in more sinister consequences. 

Unlike bacterial STIs, Viral STIs are not as easily treatable and currently, there are no cures for any viral STIs.¹

There is a huge stigma around contracting STIs and many people are too embarrassed to seek help. Lack of education around this topic may be one aspect to blame for this. Taking care of your sexual health is just as important as your physical and mental well-being. In this article, we will explore two viral sexually transmitted infections. 

Genital warts

Condyloma acuminatum, aka genital warts, is the clinical manifestation of an STI caused by subtypes of the Human papillomavirus(HPV).² In 90% of cases subtypes 6 and 11 are responsible for the warts. Both type 6 and 11 are considered low-risk variants of the HPV virus as they are not often linked to the development of malignancy.²

In 2019, there were 50,691 new cases of genital warts diagnosed in England. This makes it one of the most common types of STI present in our society. Individuals aged 20-24 years old are most likely to be affected as younger people tend to have more sexual encounters. Other risk factors include: unprotected intercourse, immunosuppression and a history of other STIs.³ 

The main route of transmission of genital warts is direct skin-to-skin contact usually via penetrative sex. The virus can be spread even without the presence of visible warts. Some individuals may be infected by the virus and never display warts.⁴

A visual examination should suffice to make a diagnosis. The warts present themselves around the genitals and anal area and sometimes on the internal structures of the vagina and anus.² The warts can occur individually or in small clusters. In appearance, they can be raised or flat and sometimes look like cauliflower florets.

Usually, the warts are painless but can become irritated and lead to itchiness and discomfort.² Psychological distress may be the most profound impact of genital warts on a patient. Your GP or local GUM clinic can provide resources to help overcome psychological distress. 

Although there is no cure for the HPV virus that causes genital warts, the body tends to clear the virus within 18-24 months of infection.² Current management strategies aim to remove the lesions from the skin to improve the physical appearance. These treatments include: 

• Topical agents: e.g Podophyllotoxin and imiquimod. Side effects of topical agents include local irritation, bleeding, scarring and pain
• Physical removal of the warts: surgery, cryotherapy, electrocauterization and laser vaporisation

The mode of management depends on the size and location of the warts. Many patients prefer topical agents as a first line of treatment as they are less invasive. Recurrences of warts can occur whilst the HPV virus is still active in the body. 

The HPV vaccine has been attributed to a decline in the incidence of genital warts in the UK. 

Herpes

Genital herpes is a chronic viral STI that clinically manifests itself through recurrent episodes of painful ulcers in the genital area. The Herpes Simplex Virus 2 (HSV-2) is the virus primarily responsible for genital herpes.⁵ The virus enters the body through disruptions to the epidermis and replicates in the epithelial tissue of the dermis.⁶

The virus establishes dormancy in the spinal sensory cord ganglion, but reactivation can occur periodically leading to symptoms.⁵ HSV-1 often is the cause of oral herpes, although this variant of the virus can be associated with genital herpes as well. 

Globally, there are approximately 400 million people affected by the genital herpes. In 2020, England experienced 20,530 new cases which represents 6% of all STI cases recorded in the country. Overall seroprevalence of genital herpes tends to increase among adolescents and young adults, due to the onset and frequency of sexual activity, and plateaus from the age of 30.

The initial infection occurs due to close contact of an uninfected person with an infected person who is actively shedding the virus.⁶ A prodrome(early symptoms) may occur for a couple of hours or days after the initial infection before the painful ulcers appear. Usually, an outbreak lasts around two weeks. 

Reoccurrences tend to be milder than the first outbreak. Several factors can increase the likelihood of an outbreak, including:

• Bouts of ill health
• Smoking and alcohol
• Friction from tight clothing in the genital area
• Stress
• Surgery
• Your menstrual cycle 
• Immunosuppression 

To diagnose a HSV infection your clinician will take a swab of your ulcer and send it to the lab investigations. The lab will determine whether the virus is present in the sample. If you are asymptomatic, a blood test can check for herpes antibodies and indicate a possible infection. 

Unfortunately, there is no cure for genital herpes yet. The primary goals for the treatment of herpes are:

1. Decrease the severity and frequency of recurrent outbreaks 
2. Prevent the transmission of the virus to sexual partners 

Antiviral medication is currently the first line of treatment. Acyclovir is the most commonly prescribed antiviral medication used in the management of genital herpes.⁵ Acyclovir can be administered topically, IV or orally depending on the severity of the outbreak. It can also be used as a viral suppressant and prevents up to 80% of reoccurrences and 90% of viral shedding.⁵ Side effects can include kidney toxicity and neutropenia.

Currently, there is no vaccine for HSV infections. Future research may focus on developing a vaccine to reduce the shedding of the virus and subsequent transmission. 

Summary

To conclude, regular sexual health screenings and the practice of safe sex techniques, such as condom use, can help keep you and your partners safe from contracting and spreading STIs. Genital warts are caused by the subtypes 6 and 11 of the HPV virus. The virus causes small painless bumps in the genital area. Topical agents or physical removal of the warts can improve the appearance of the area, however the virus will remain in the body. Usually, the virus will be cleared from the body after 18-24 months from infection. 

Herpes is a different viral STI which can be caused by both HSV-1 and HSV-2. It results in painful lesions on the surface of the skin in the genital region. Subsequent recurrences are common as the virus remains dormant in surrounding neurons and can be reactivated periodically. Taking antivirals can reduce the frequency and severity of flare-ups and decrease the spread of the virus. 

If you have any more questions or are worried about any topics discussed in this article don’t hesitate to reach out to your GP or local GUM clinic.