Sexually Transmitted Infections (STIs)

Pathophysiology

Portals of entry: Mucosal epithelium or breaks in skin (mouth, genitalia, rectum, urinary meatus)
Chlamydia: Obligate intracellular bacterium with affinity for columnar mucus-producing cells. Causes low-grade inflammation. Most common bacterial STI. Often silent
Gonorrhea: Aggressive pyogenic (pus-forming) bacterium affecting mucous membranes. Can cause gonococcal arthritis
Syphilis: Spirochete infection (Treponema pallidum) progressing through predictable stages — primary (painless chancre), secondary (systemic rash on palms/soles), latent, tertiary (cardiovascular and CNS destruction)
Herpes simplex (HSV-2): Neurotropic virus lying dormant in sacral dorsal root ganglia. Recurrent blisters. Cannot be cured
HPV: Causes proliferative lesions of squamous epithelium. Certain strains linked to cervical, anal, and oropharyngeal cancer
Major complications: PID (from chlamydia/gonorrhea — leading to infertility, ectopic pregnancy), gonococcal arthritis, Reiter syndrome (urethritis + conjunctivitis + arthritis triad after chlamydia)
Vertical transmission: Syphilis crosses the placenta after 16 weeks. Chlamydia and gonorrhea can infect the newborn during delivery

Chlamydia: Often silent. Mucopurulent discharge. Burning on urination
Gonorrhea: Creamy yellow discharge. Painful intercourse. "strawberry spots" on cervix
Syphilis: Painless chancre (primary). Brownish rash on palms and soles (secondary — indicates systemic stage)
HSV-2: Recurrent clusters of painful blisters on a red base
HPV: Small, solid, painless growths (warts) on or near genitalia
Trichomoniasis: Copious, frothy, malodorous green/yellow discharge. Vaginal itching

Acute pelvic pain with high fever (>101F) — requires urgent medical evaluation to rule out PID or sepsis
Syphilis rash on palms and soles — indicates secondary systemic stage. Client is highly contagious. Refer immediately
Reactive arthritis triad (joint pain + urethritis + conjunctivitis) — may indicate post-chlamydial Reiter syndrome. Refer for evaluation
Condoms do not fully protect against syphilis, HPV, or molluscum contagiosum (transmitted through skin-to-skin contact in areas not covered by condoms)

General rule: Massage is safe and appropriate once an infection has been identified and is under medical control
Acute systemic phases: Rigorous circulatory massage is contraindicated during active systemic phases (syphilis secondary rash, systemic fever)
Local contraindications: Active sores (syphilis chancres), blisters (herpes), or growths (genital warts) due to pain and skin-to-skin transmission risk
Standard precautions: Therapists must cover any open lesions on their own hands (finger cots or liquid bandages) to prevent autoinoculation
Referral trigger: Acute pelvic pain with high fever requires urgent medical evaluation to rule out PID or sepsis
Privacy and sensitivity: STI diagnosis carries significant stigma. Maintain strict confidentiality. Do not make assumptions based on presentation

Know characteristic presentations: painless chancre (syphilis), creamy discharge (gonorrhea), silent infection (chlamydia)
Syphilis rash on palms and soles indicates secondary systemic stage
PID with acute pelvic pain and high fever requires urgent medical referral
Reiter syndrome (urethritis, conjunctivitis, arthritis) can develop after chlamydial infection
Condoms do not fully protect against syphilis, HPV, or molluscum contagiosum

STIs are classified as curable (bacterial: chlamydia, gonorrhea, syphilis) or incurable but manageable (viral: HIV, HSV, HPV, hepatitis B).
Many STIs are asymptomatic early. 75% of women with chlamydia have no symptoms.
Massage is safe once infection is identified and under medical control. Active lesions and acute systemic phases are contraindications.
PID is a serious complication of untreated chlamydia/gonorrhea that can cause permanent scarring, ectopic pregnancy, and infertility.
Therapists must use standard precautions and cover their own open skin lesions to prevent autoinoculation.