Major Sexually Transmitted Diseases (STDs) in Nepal

Introduction / Epidemiology in Nepal

1. Gonorrhoea

• Causative agent: Neisseria gonorrhoeae (gram-negative intracellular diplococci)
• Transmission: Sexual contact; neonatal conjunctivitis via infected birth canal
• Clinical features:
  • Males: Dysuria, urinary frequency, and mucopurulent urethral discharge within 2-14 days
  • Females: Often asymptomatic; vaginal discharge, lower pelvic pain; may cause cervicitis
  • Complications: Epididymitis, orchitis, PID, infertility, ectopic pregnancy, disseminated gonococcal infection (arthritis, skin lesions)
• Diagnosis: Gram stain (intracellular diplococci), NAAT, culture
• Treatment: Ceftriaxone 250 mg IM (single dose) + azithromycin (for co-existing chlamydia)

2. Syphilis

• Causative agent: Treponema pallidum (spirochete)
• Transmission: Sexual contact, transplacental (congenital syphilis), blood transfusion
• Stages:
  • Primary: Painless, indurated ulcer (chancre) at site of inoculation + non-tender regional lymphadenopathy; incubation 9-90 days (average 21 days)
  • Secondary: Occurs weeks after chancre heals; maculopapular rash (palms, soles), condyloma lata, lymphadenopathy, mucous patches, constitutional symptoms
  • Latent: Asymptomatic; early (<1 year) and late latent
  • Tertiary: Gummas (granulomatous lesions), cardiovascular syphilis (aortic aneurysm), neurosyphilis (tabes dorsalis, general paresis)
• Diagnosis: Darkfield microscopy (primary), VDRL/RPR (screening), TPHA/FTA-ABS (confirmatory)
• Treatment: Benzathine penicillin G 2.4 MU IM (single dose for primary/secondary); doxycycline if penicillin allergic

3. Chlamydial Infection

• Causative agent: Chlamydia trachomatis (serovars D-K)
• Most common STI worldwide; prevalence 3-5x that of gonorrhoea
• Clinical features:
  • Males: Non-gonococcal urethritis (NGU), epididymitis
  • Females: Mucopurulent cervicitis, PID, infertility, ectopic pregnancy; mostly asymptomatic
  • Neonates: Conjunctivitis and pneumonitis
• Diagnosis: NAAT (highly sensitive and specific); urine sample or endocervical swab
• Treatment: Azithromycin 1 g single dose PO (preferred) OR doxycycline 100 mg BD x 7 days

4. Chancroid

• Causative agent: Haemophilus ducreyi
• Prevalent in developing countries including Nepal
• Clinical features: Painful genital ulcer(s) with ragged/undermined edges + tender suppurative inguinal lymphadenopathy (bubo)
• Differential diagnosis: Syphilitic chancre (painless), genital herpes, LGV
• Diagnosis: Clinical; Gram stain shows "school of fish" pattern
• Treatment: Azithromycin 1 g single dose OR ciprofloxacin 500 mg BD x 3 days OR ceftriaxone 250 mg IM

5. Herpes Genitalis

• Causative agent: Herpes Simplex Virus type 2 (HSV-2); occasionally HSV-1
• Worldwide: ~520 million aged 15-49 years infected with HSV-2
• Clinical features: Painful vesicles on genitalia that ulcerate; dysuria, inguinal lymphadenopathy; primary episode more severe than recurrences; may be asymptomatic shedder
• In pregnancy: 30-50% risk of neonatal transmission in third trimester; neonatal herpes can be disseminated or CNS disease
• Diagnosis: Viral culture, PCR, Tzanck smear (multinucleate giant cells)
• Treatment: Acyclovir 400 mg TID x 7-10 days (primary); valacyclovir 1 g BD x 7-10 days; suppressive therapy for recurrent disease

6. Lymphogranuloma Venereum (LGV)

• Causative agent: C. trachomatis serovars L1, L2, L3
• Clinical features: Small painless papule/ulcer (often missed) followed by painful inguinal lymphadenopathy (groove sign - above and below inguinal ligament); may cause proctitis, rectal stricture
• Diagnosis: NAAT/serology; complement fixation titre >1:64
• Treatment: Doxycycline 100 mg BD x 21 days

7. Granuloma Inguinale (Donovanosis)

• Causative agent: Klebsiella granulomatis (formerly Calymmatobacterium granulomatis)
• Clinical features: Progressive, painless, beefy-red genital ulcer; no lymphadenopathy; characteristic Donovan bodies (intracellular organisms in macrophages)
• Diagnosis: Tissue smear showing Donovan bodies
• Treatment: Azithromycin 1 g weekly OR doxycycline 100 mg BD for minimum 3 weeks

8. HIV/AIDS

• Causative agent: Human Immunodeficiency Virus (HIV-1 and HIV-2)
• In Nepal: A concentrated epidemic; high-risk groups include injecting drug users (IDUs), female sex workers (FSWs), men who have sex with men (MSM), and migrant workers
• Nepal's National Strategic Plan targets ending AIDS epidemic as a public health threat by 2030, including elimination of vertical (mother-to-child) transmission
• Management: ART (antiretroviral therapy) - standard of care

9. Trichomoniasis

• Causative agent: Trichomonas vaginalis (flagellated protozoan)
• Clinical features: Females: Frothy, yellow-green vaginal discharge with "strawberry cervix"; dysuria, pruritus; Males: Usually asymptomatic
• Diagnosis: Wet mount microscopy (motile trophozoites), NAAT
• Treatment: Metronidazole 2 g single dose (treat partner simultaneously)

Nepal-Specific Control Measures

Sources: Robbins & Kumar Basic Pathology, Sherris & Ryan's Medical Microbiology 8th Ed, Harrison's Principles of Internal Medicine 22E, Nepal NCASC National STI Guidelines 2022, WHO STI Fact Sheet