Sexually transmitted infections (STIs) in men can be caused by bacteria, viruses, or parasites. Patients present primarily with urethritis or skin manifestations. The most common STIs affecting men include gonorrhea; chlamydia; Mycoplasma and Ureaplasma infections; trichomoniasis; syphilis; chancroid; mpox (monkeypox); and infections with human papillomavirus; herpes simplex virus; hepatitis A, B, and C viruses; and HIV. Primary and secondary prevention strategies include vaccination, preexposure prophylaxis, condom use, and routine screening to reduce transmission and improve clinical outcomes. A thorough sexual history should be obtained from patients using the Centers for Disease Control and Prevention’s 5Ps framework (ie, partners, practices, protection from STIs, past history of STIs, pregnancy intention). The National Coalition for Sexual Health has suggested a sixth P—plus—that represents pleasure, problems, and pride. The latest recommendations for prevention measures include doxycycline postexposure prophylaxis (doxy PEP) for certain high-risk groups.
Case 4. GD, a 28-year-old cisgender man, presents with dysuria and purulent urethral discharge. He reports having multiple sexual partners in the past 6 months and using condoms inconsistently. Results of initial laboratory tests, including nucleic acid amplification tests for Neisseria gonorrhoeae and Chlamydia trachomatis, are positive for gonorrhea.
Background
EPIDEMIOLOGY
In 2023, more than 2.4 million cases of gonorrhea, syphilis, and chlamydia were diagnosed and reported in the United States. Between 2022 and 2023, the number of sexually transmitted infections (STIs) decreased overall by 1.8%, inclusive of a decrease in gonorrhea cases (7.2%), an increase in syphilis cases (all stages with congenital syphilis included, 1%), and a stable trend in chlamydia cases (1% decrease).1
SEXUAL HISTORY
Documentation of a thorough sexual history using the 5Ps framework from the Centers for Disease Control and Prevention (CDC) can assist clinicians with risk-factor mitigation and patient counseling.2 The 5Ps are: partners, practices, protection from STIs, past history of STIs, and pregnancy intention. The National Coalition for Sexual Health suggests a sixth P—plus—that includes pleasure, problems, and pride.3
RISK FACTORS
Risk factors for STIs include anal, vaginal, or oral sex without a condom or other protective measures, multiple sex partners, anonymous sex partners whose STI status is unknown, and sexual contact under the influence of alcohol or other substances. Most STIs are spread via vaginal, oral, or anal sex, but skin-to-skin contact can also transmit certain pathogens.4
SCREENING RECOMMENDATIONS
Recommended STI screening intervals for various groups and individuals are listed in Table 1.5 The US Preventive Services Task Force (USPSTF) concluded there is insufficient evidence to assess the balance of benefits and harms of screening for chlamydia and gonorrhea in men. Evidence is lacking that screening in men reduces infection complications and transmission or acquisition of these organisms or HIV.6 However, men younger than 29 years who have sex with women should be screened for syphilis. Although the exact age ranges differ between the USPSTF and CDC recommendations, male adolescents and men should be screened for HIV, and men should be screened for hepatitis C.7–9
Table 1 CDC-Recommended STI Screening Intervals for Various Groups and Individuals
| Group | STI | Recommended screening interval/comments |
|---|---|---|
| All sexually active individuals ages 13-64 years | HIV | At least once |
| Sexually active women < 25 years | Gonorrhea, chlamydia | Annually |
| Women ≥ 25 years with risk factors (eg, new partners, multiple partners, partner with an STI) | Gonorrhea, chlamydia | Annually |
| Sexually active men who are gay or bisexual and other MSM | Syphilis, chlamydia, gonorrhea | At least annually, more frequent testing (eg, every 3-6 months) for patients with multiple or anonymous partners |
| HIV | At least annually, may benefit from more frequent testing (eg, every 3-6 months) | |
| Hepatitis C | At least annually if HIV infection also present | |
| Individuals who share injection drug equipment | HIV | At least annually |
| Individuals who have had oral or anal sex | Throat, rectal infections | Patients should discuss throat and rectal testing options with their physician |
CDC = Centers for Disease Control and Prevention; MSM = men who have sex with men; STI = sexually transmitted infection.
Information from reference 5.
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