Sexually Transmitted Infections

Prioritize same-day evaluation for pelvic or lower-abdominal pain with concern for pelvic inflammatory disease, pregnancy with suspected or confirmed STI, acute proctitis, genital ulceration, ocular symptoms after sexual exposure, sexual assault, and possible disseminated infection. Untreated STIs in women are associated with pelvic inflammatory disease, infertility, chronic pelvic pain, ectopic pregnancy, pregnancy loss, stillbirth, and neonatal transmission. PubMed+1PubMedClinical Updates in Sexually Transmitted Infections, 2024PubMedSexually Transmitted Infections - StatPearls - NCBI Bookshelf

Take a site-specific sexual exposure history rather than inferring exposure from identity: urethral/penile, vaginal/cervical, rectal, pharyngeal, ocular, and skin-to-skin exposure. Obtain NAAT specimens from each exposed mucosal site for gonorrhea and chlamydia when testing is indicated; NAATs are the diagnostic standard and have reported sensitivity and specificity of 95% to 99%. Extragenital infection is frequently asymptomatic, so urine-only testing can miss rectal or pharyngeal infection. Wiley+1WileyDiagnosing sexually transmitted infections in resourceScienceDirectSexually transmitted causes of urethritis, proctitis, pharyngitis, vaginitis and cervicitis - ScienceDirect

For symptomatic patients, add HIV testing and testing for other prevalent STIs at the same encounter. In patients with urethritis, cervicitis, proctitis, pharyngitis, vaginitis, or genital lesions, interpret a positive organism-specific test in an anatomic and syndromic context because concurrent infection with more than one pathogen is common. ScienceDirect+1ScienceDirectSexually transmitted causes of urethritis, proctitis, pharyngitis, vaginitis and cervicitis - ScienceDirectPubMedSexually Transmitted Infections - StatPearls - NCBI Bookshelf

Gonorrhea, chlamydia, syphilis, trichomoniasis, Mycoplasma genitalium, herpes simplex virus, lymphogranuloma venereum, and noninfectious conditions can produce overlapping urethral, cervical, rectal, pharyngeal, and genital symptoms. When quality-assured molecular testing is available, use laboratory-supported diagnosis to select current evidence-based treatment rather than relying on syndromic management alone. ScienceDirect+1ScienceDirectSexually transmitted causes of urethritis, proctitis, pharyngitis, vaginitis and cervicitis - ScienceDirectWHOSexually transmitted infections (STIs)

Use the current CDC STI treatment guideline or its current updates to select organism-specific regimen, dose, route, and follow-up because resistance patterns and recommendations change. This is particularly important for gonorrhea, where antimicrobial susceptibility is a continuing clinical and public-health concern, and for persistent Mycoplasma genitalium infection. JAMA+3JAMADiagnosis and Treatment of Sexually Transmitted InfectionsJAMASexually Transmitted InfectionsPubMedClinical Updates in Sexually Transmitted Infections, 2024PubMedSexually Transmitted Infections Treatment Guidelines, 2021

For patients with genital herpes, routine serologic screening is not recommended, including during pregnancy. Evaluate clinically apparent lesions and use the CDC STI treatment guidance for antiviral treatment and counseling. PubMedPubMedClinical Updates in Sexually Transmitted Infections, 2024

Persistent or recurrent symptoms after treatment should trigger reassessment of adherence, re-exposure from an untreated partner, infection at an untested anatomic site, coinfection, and an alternative infectious or noninfectious diagnosis. Do not assume microbiologic failure solely from ongoing symptoms. ScienceDirect+1ScienceDirectSexually transmitted causes of urethritis, proctitis, pharyngitis, vaginitis and cervicitis - ScienceDirectPubMedClinical Updates in Sexually Transmitted Infections, 2024

Routine laboratory screening is indicated for sexually active adolescents, and screening strategies should account for age, pregnancy, sexual practices, community prevalence, and disease-specific sequelae. An opt-out approach can reduce dependence on sexual-history disclosure and may improve case detection among adolescents and young adults. PubMed+1PubMedSexually Transmitted Infections Treatment Guidelines, 2021PubMedUpdates on Testing, Treatment, and Prevention of Sexually Transmitted Infections in the United States, 2025

During pregnancy, screen at the first prenatal visit according to CDC recommendations. For gonorrhea, screen pregnant patients at risk, including those younger than 25 years and those 25 years or older with a new sex partner, multiple partners, a partner with concurrent partners, a partner with an STI, or residence in a community with high gonorrhea rates. Treat identified infection during pregnancy and retest in 3 months, in the third trimester, or at delivery as indicated. PubMedPubMedSexually Transmitted Infections Treatment Guidelines, 2021

Do not use routine serologic screening for genital herpes in pregnancy. CDC-based pregnancy screening guidance does not recommend routine testing for bacterial vaginosis, herpes, HPV, or trichomoniasis in pregnancy. PubMed+1PubMedClinical Updates in Sexually Transmitted Infections, 2024PubMedSexually Transmitted Infections - StatPearls - NCBI Bookshelf

For persons with ongoing exposure risk, align repeat STI screening with the risk pattern and anatomic exposure sites. In people using doxycycline postexposure prophylaxis, perform syphilis and gonorrhea/chlamydia screening at all sites of exposure every 3 to 6 months. Oxford AcademicOxford AcademicUtilization of Doxycycline Postexposure Prophylaxis at a Midwestern United States HIV/PrEP Clinic | Open Forum Infectious Diseases | Oxford Academic

Recommend condoms for vaginal, oral, and anal sex; consistent correct use provides effective protection against STIs, including HIV, but does not fully protect against infections transmitted from uncovered ulcerated skin, including syphilis and genital herpes. WHOWHOSexually transmitted infections (STIs)

Review hepatitis B and HPV immunization status. Safe and effective vaccines are available for hepatitis B and HPV, and vaccination should be incorporated into STI prevention visits rather than reserved for primary care follow-up. WHOWHOSexually transmitted infections (STIs)

Use each bacterial STI diagnosis as a prompt to assess HIV testing needs and HIV prevention, including preexposure prophylaxis when risk warrants. All patients presenting with STI symptoms should be screened for HIV and other prevalent STIs. PubMedPubMedSexually Transmitted Infections - StatPearls - NCBI Bookshelf

Address sex partners at the same visit: identify recent partners, facilitate notification, arrange testing and treatment, and counsel patients that untreated partners are a major driver of reinfection. Partner notification and partner treatment are established elements of STI case management. PubMed+1PubMedUpdates on Testing, Treatment, and Prevention of Sexually Transmitted Infections in the United States, 2025WHOSexually Transmitted Infections - IRIS

CDC guidance released in 2024 recommends counseling gay, bisexual, and other men who have sex with men and transgender women with a bacterial STI diagnosed during the past 12 months about doxycycline postexposure prophylaxis and offering it through shared decision-making. The regimen evaluated in trials is doxycycline 200 mg orally within 72 hours after sex. JAMAJAMADoxycycline Postexposure Prophylaxis and Bacterial Sexually Transmitted Infections Among Individuals Using HIV

Doxycycline PEP has reduced chlamydia and syphilis incidence in trials among persons assigned male sex at birth who were living with HIV or using HIV PrEP; gonorrhea benefit has been less consistent, plausibly reflecting tetracycline resistance in Neisseria gonorrhoeae. JAMA+1JAMADoxycycline Postexposure Prophylaxis and Bacterial Sexually Transmitted Infections Among Individuals Using HIVNEJMDoes Meningococcal Group B Vaccination in the Setting of DoxyPEP Reduce Incidence of Gonorrhea? | NEJM Clinician

At initiation and every 3 to 6 months, reassess ongoing use, perform syphilis serology and gonorrhea/chlamydia testing at every exposed anatomic site, and test for HIV in persons without HIV according to current recommendations. Prescribe the number of doses through individualized shared decision-making. Oxford AcademicOxford AcademicUtilization of Doxycycline Postexposure Prophylaxis at a Midwestern United States HIV/PrEP Clinic | Open Forum Infectious Diseases | Oxford Academic

Discuss antimicrobial-resistance uncertainty explicitly. Wider doxycycline PEP use may increase resistance selection, including concern about co-transmission of gonococcal cephalosporin resistance with tetracycline resistance; this risk must be balanced against prevention of syphilis and chlamydia. JAMAJAMADoxycycline Postexposure Prophylaxis Could Accelerate the Emergence of Gonococcal Ceftriaxone Resistance—Reply