19.3 Sexually Transmitted Diseases

Sexually transmitted diseases (STDs), also called sexually transmitted infections (STIs), appear within Associated Clinical Sciences because chiropractors encounter them during history-taking and because several infections produce musculoskeletal complaints — reactive arthritis, sacroiliitis, and tabes dorsalis — that present as back or joint pain. The board tests organisms, hallmark signs, staging, complications, and the scope-appropriate response: recognize, protect confidentiality, and refer.

Gonorrhea

Gonorrhea is caused by Neisseria gonorrhoeae, a gram-negative intracellular diplococcus. Men typically develop purulent urethral discharge and dysuria within 2–5 days. Women are frequently asymptomatic or have mild cervicitis — which is why gonorrhea is a leading cause of silent pelvic damage.

Untreated gonorrhea in women ascends to cause pelvic inflammatory disease (PID) — tubo-ovarian abscess, infertility, and ectopic pregnancy. In men, epididymitis is a common complication. Disseminated gonococcal infection (DGI) presents with migratory polyarthralgia, tenosynovitis, and pustular skin lesions — a classic musculoskeletal mimic in the chiropractic office.

Antibiotic resistance is a growing concern; the CDC regularly updates treatment guidelines. Dual therapy covering chlamydia is standard because co-infection is common.

Syphilis

Syphilis is caused by Treponema pallidum, a spirochete. Staging is exam-critical:

Primary Syphilis

A painless, indurated chancre at the inoculation site appears 10–90 days after exposure and heals spontaneously in 3–6 weeks even without treatment.

Secondary Syphilis

Weeks to months later: diffuse maculopapular rash involving palms and soles (a high-yield distinguishing feature), condyloma lata (moist plaques in intertriginous areas), generalized lymphadenopathy, and constitutional symptoms.

Latent Syphilis

Positive serology without clinical signs. Early latent is within the first year; late latent is beyond one year or of unknown duration.

Tertiary Syphilis

Years to decades later: gummas (granulomatous lesions), cardiovascular syphilis (aortitis), and neurosyphilis including tabes dorsalis (dorsal column degeneration causing lightning pains, ataxia, and Argyll Robertson pupils).

Serology

• Nontreponemal tests (RPR, VDRL) — screen and monitor treatment response; may be falsely positive
• Treponemal tests (FTA-ABS, TP-PA) — confirm; remain positive for life in most patients

HIV and AIDS

Human immunodeficiency virus (HIV) targets CD4+ T lymphocytes. Acute retroviral syndrome 2–4 weeks after infection mimics mononucleosis: fever, pharyngitis, lymphadenopathy, rash, and myalgia.

AIDS is defined by:

• CD4 count below 200 cells/µL, OR
• An AIDS-defining opportunistic illness regardless of CD4 count

High-yield opportunistic infections and conditions:

Post-exposure prophylaxis (PEP) must begin within 72 hours of exposure. Chiropractors do not prescribe antiretrovirals but must recognize risk and refer.

Chlamydia

Chlamydia trachomatis is the most common bacterial STD in the United States. Like gonorrhea, it is often asymptomatic in women, ascending to cause PID, ectopic pregnancy, and infertility. Men may have urethritis with clear or mucoid discharge.

Reactive arthritis (Reiter syndrome) — the triad of urethritis, conjunctivitis, and asymmetric oligoarthritis — is associated with chlamydia and other enteric pathogens. A young man with sacroiliac pain and recent urethritis should raise suspicion.

Lymphogranuloma venereum (LGV) — caused by C. trachomatis serovars L1–L3 — produces a painless genital ulcer followed by painful inguinal lymphadenopathy (buboes).

Herpes Simplex

Herpes simplex virus (HSV) produces grouped vesicles on an erythematous base.

• HSV-1 — traditionally oral (cold sores) but genital HSV-1 is increasingly common
• HSV-2 — traditionally genital

Primary infection is often severe with systemic symptoms; recurrences are milder. Asymptomatic viral shedding drives transmission. Neonatal herpes from maternal genital shedding at delivery is catastrophic — another reason accurate sexual history matters in prenatal patients.

Herpes zoster is reactivation of latent varicella-zoster virus, not an STD, but appears in the same domain because of vesicular morphology and dermatomal distribution.

Other Sexually Transmitted Diseases

Chiropractic Scope and Clinical Approach

Chiropractors do not diagnose or treat STDs, but they must:

1. Take a nonjudgmental sexual history when clinically relevant — number of partners, condom use, prior STDs, HIV status if known
2. Recognize musculoskeletal presentations — reactive arthritis, DGI tenosynovitis, tabes dorsalis gait disturbance
3. Maintain confidentiality — STD information is protected health information under HIPAA
4. Refer for testing and treatment — appropriate providers include primary care, infectious disease, and public health departments
5. Report when legally required — some jurisdictions mandate reporting of certain STDs to public health authorities; know your state rules
6. Practice standard precautions — gloves when contact with blood or body fluids is possible; do not adjust through active herpetic vesicles

When a patient discloses an STD or risk factors during history, document factually, avoid stigmatizing language, and ensure they are connected to medical care. Continuing to adjust without addressing a suspected disseminated infection or untreated syphilis is a patient-safety failure the boards will test.