Sexually transmitted disease: Difference between revisions

	Sexually transmitted disease Microchapters
Patient Information
Overview
Classification Chlamydia Gonorrhea Human Immunodeficiency Virus (HIV) Human papillomavirus (HPV) Herpes Simplex Virus (HSV) Mycoplasma genitalium Syphilis Trichomonas vaginalis Zika Virus Hepatitis B Hepatitis C Bacterial vaginosis
Differential Diagnosis
Treatment

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Latest revision as of 18:03, 10 December 2020

For patient information click here

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Carla Vorsatz, M.D.[2]; Associate Editor(s)-in-Chief: Tarek Nafee, M.D. [3]

Synonyms and keywords: Sexually transmissible disease; STD; VD; STI; sexually transmitted infection; venereal disease.

Overview

Sexually transmitted diseases (or STDs) are bacterial, viral, fungal, or protozoal infections that are transmitted via sexual contact. Sexual contact may entail non-penetrative contact of the genitalia, performing or receiving oral sex (cunnilingus, anilingus, or fellatio), and insertive or receptive vaginal or anal sexual intercourse. Sexually transmitted infections may have a variety of clinical presentations including dermatological manifestations, generalized symptoms, or urogenital tract symptoms such as discharge and dysuria. Some infectious agents may be transmitted primarily through sexual contact while others may less frequently be transmitted sexually.

The CDC reported updated Surveillance data on sexually transmitted diseases from 2018 in the United States, which included chlamydia, gonorrhea, and syphilis.^[1] Complications of STDs depend on the causative pathogen and may range from genital or oral pruritis and discomfort to more serious complications such as pelvic inflammatory disease, primary CNS lymphoma, cervical cancer, as well as cardiac and neurological complications. If left untreated, some STDs may progress to septic shock and death.

Most STDs have well-established risk factors and preventative measures. If followed appropriately, most STD transmissions can be avoided.

Classification

Table below provides a concise comparison of various sexually transmitted diseases:^[1]

Transmission	Clinical Presentation	Disease	Diagnosis		Mother to Child Transmission		Most Serious Complications
Transmission	Clinical Presentation	Disease	Laboratory Studies	Clinical Diagnosis	Vertical Transmission	Trans-vaginal Transmission	Most Serious Complications
Primarily sexually transmitted	Genital Dermatological Manifestation (e.g., ulcers, chancre, vesicles, warts, balanitis etc.)	HPV	✔	✔			Cervical Cancer
		''Herpes simplex'' 1 and 2	✔	✔	✔	✔	Moderate to severe pruritis/discomfort, superinfection
		Syphilis	✔	✔	✔		Neurosyphilis Cardiosyphilis
		Scabies	✔	✔			Moderate to severe pruritis/discomfort
		Pubic lice	✔	✔			Moderate to severe pruritis/discomfort
		Candidiasis (in males)		✔			Mild to moderate pruritis/discomfort
	Generalized Symptoms (e.g., constitutional symptoms)	HIV	✔		✔		Primary CNS Lymphoma Immunosuppression (AIDS)
	Generalized Symptoms (e.g., constitutional symptoms)	Syphilis	✔	✔	✔		Neurosyphilis Cardiosyphilis
	Urogenital infections (e.g., Vaginitis, Urethritis, Cervicitis, and PID)	Gonorrhea	✔	✔		✔	PID
		Chlamydia	✔	✔		✔	PID
		Syphilis	✔	✔	✔		Neurosyphilis Cardiosyphilis
		Mycoplasma genitalium	✔	✔	unknown	unknown	PID
		''Trichomonas vaginalis''	✔	✔			PID
Less frequently sexually transmitted	Generalized Symptoms (e.g., constitutional symptoms)	Zika Virus	✔		✔		Vertical transmission and congenital abnormalities
		Hepatitis B	✔	✔	✔		Hepatocellular Carcinoma
		Hepatitis C	✔	✔	✔		Liver cirrhosis, Hepatocellular Carcinoma
	Urogenital Infections (e.g., Vaginitis, Urethritis, Cervicitis, and PID)	''Gardnerella vaginalis''	✔	✔			Moderate to severe discomfort
		Candidiasis (in females)		✔			Moderate to severe pruritis/discomfort
		Ureaplasma urealyticum	✔	✔			Moderate to severe pruritis/discomfort

Differential Diagnosis

Table below provides differential diagnosis of sexually transmitted diseases:^[1]

Disease	Symptoms
Disease	Discharge	Dysuria	Vaginal odor	Dyspareunia	Genital skin lesion	Genital pruritis	Fever	Lymphadenopathy	Other symptoms
Chlamydia	✔	✔		✔		✔	✔	✔	Cough, shortness of breath, red eye with discharge (neonate), joint pain
Gonorrhea	✔	✔	✔	✔			✔		Sore throat, polyarthralgia, tenosynovitis, rash, eye discharge (neonates)
HIV	✔	✔					✔	✔	Fever, lymphadenopathy, rash, fatigue, myalgia, arthritic pain, headache
Herpes simplex	✔	✔			✔		✔	✔	Fatigue, myalgia, painful oral ulcers
HPV	✔	✔		✔	✔	✔			Weight loss, hoarseness (adults), altered cry, stridor (infants)
Hepatitis B							✔	✔	Fever, fatigue, nausea, vomiting, loss of appetite, abdominal pain, dark urine, clay-colored stools, joint pain, yellowish discoloration of the eyes and skin, skin rash, muscle pain
Hepatitis C							✔	✔	Fever, fatigue, anorexia, arthralgia, nausea, vomiting
Bacterial vaginosis	✔		✔						None
Mycoplasma genitalium	✔	✔		✔		✔			None
Zika virus							✔		Conjunctivitis, rash, joint pain, myalgia

Treatment

To view the treatment of chlamydia infection click here.
To view the detailed treatment of gonorrhea click here.
To view the detailed treatment of herpes simplex click here.
To view the detailed treatment of mycoplasma genitalium infection click here.
To view the detailed treatment of syphilis click here.
To view the detailed treatment of trichomoniasis click here.
To view the detailed treatment of bacterial vaginosis click here.
To view the detailed treatment of human papillomavirus click here.

References

↑ ^1.0 ^1.1 ^1.2 CDC Sexually Transmitted Disease Surveillance 2018 STDs in the United States. The Centers for Disease Control and Prevention. https://www.cdc.gov/std/stats18/toc.htm Accessed on January 25, 2020.

[CDCFact-1] 1.0 ^1.1 ^1.2 CDC Sexually Transmitted Disease Surveillance 2018 STDs in the United States. The Centers for Disease Control and Prevention. https://www.cdc.gov/std/stats18/toc.htm Accessed on January 25, 2020.

[1]

@@ Line 2: / Line 2: @@
 '''For patient information click [[{{PAGENAME}} (patient information)|here]]'''
 {{Sexually transmitted disease}}
-{{CMG}}}; {{AE}}{{TarekNafee}}<br>
+{{CMG}}{{cv}}; {{AE}} {{TarekNafee}}<br>
 {{SK}} Sexually transmissible disease; STD; VD; STI; sexually transmitted infection; venereal disease.
 ==Overview==
-Sexually transmitted diseases (or STDs) are [[bacterial]], [[viral]], [[fungal]], or [[protozoal]] infections that are transmitted via sexual contact. Sexual contact may entail non-penetrative contact of the genitalia, performing or receiving oral sex (cunnilingus, anilingus, or fellatio), and insertive or receptive vaginal or anal [[sexual intercourse]]. Sexually transmitted infections may have a variety of clinical presentations including dermatological manifestations, generalized symptoms, or urogenital tract symptoms such as [[discharge]] and [[dysuria]]. Some infectious agents may be transmitted primarily through sexual contact while others may less frequently be transmitted sexually.
+[[Sexually transmitted diseases]] (or STDs) are [[bacterial]], [[viral]], [[fungal]], or [[protozoal]] infections that are transmitted via sexual contact. Sexual contact may entail non-penetrative contact of the genitalia, performing or receiving oral sex (cunnilingus, anilingus, or fellatio), and insertive or receptive vaginal or anal [[sexual intercourse]]. [[STD|Sexually transmitted infections]] may have a variety of clinical presentations including dermatological manifestations, generalized symptoms, or urogenital tract symptoms such as [[discharge]] and [[dysuria]]. Some infectious agents may be transmitted primarily through sexual contact while others may less frequently be transmitted sexually.
-On October 19, 2016, the CDC reported a new peak prevalence of sexually transmitted diseases in the United States. Complications of STDs depend on the causative pathogen and may range from genital or oral [[pruritis]] and discomfort to more serious complications such as [[pelvic inflammatory disease]], [[primary CNS lymphoma]], [[cervical cancer]], as well as cardiac and neurological complications. If left untreated, some STDs may progress to [[septic shock]] and mortality.
+The CDC reported updated Surveillance data on [[sexually transmitted diseases]] from 2018 in the United States, which included [[chlamydia]], [[gonorrhea]], and [[syphilis]].<ref name=CDCFact> CDC Sexually Transmitted Disease Surveillance 2018 [[STDs]] in the United States. The Centers for Disease Control and Prevention. https://www.cdc.gov/std/stats18/toc.htm Accessed on January 25, 2020. </ref> Complications of [[STDs]] depend on the causative pathogen and may range from genital or oral [[pruritis]] and discomfort to more serious complications such as [[pelvic inflammatory disease]], [[primary CNS lymphoma]], [[cervical cancer]], as well as [[cardiac]] and [[neurological]] complications. If left untreated, some [[STDs]] may progress to [[septic shock]] and death.
-Most STDs have well-established risk factors and preventative measures. If followed appropriately, most STD transmissions can be avoided.
+Most [[STDs]] have well-established risk factors and preventative measures. If followed appropriately, most [[STD ]]transmissions can be avoided.
+==Classification==
-==Synopsis==
+Table below provides a concise comparison of various sexually transmitted diseases:<ref name=CDCFact> CDC Sexually Transmitted Disease Surveillance 2018 [[STDs]] in the United States. The Centers for Disease Control and Prevention. https://www.cdc.gov/std/stats18/toc.htm Accessed on January 25, 2020. </ref>
 {| style="border: 0px; font-size: 90%; margin: 3px;" align=center class="wikitable" style="border: 2; background: none;"
 ! colspan="1" rowspan="2" style="border: 1; background: 1;"| Transmission
@@ Line 23: / Line 22: @@
 ! colspan="1" rowspan="2"| Most Serious Complications
 |-
-! colspan="1" rowspan="1"| Laboratory studies || Clinical Diagnosis || Vertical Transmission || Trans-vaginal transmission
+! colspan="1" rowspan="1"| Laboratory Studies || Clinical Diagnosis || Vertical Transmission || Trans-vaginal Transmission
 |-
 ! colspan="1" rowspan="13"| Primarily sexually transmitted
@@ Line 29: / Line 28: @@
 | colspan="1" rowspan="1"| [[HPV]] || ✔ || ✔ ||  ||  || [[Cervical Cancer]]
 |-
-| colspan="1" rowspan="1"| [[Herpes simplex]]-2 || ✔ || ✔ || ✔ || ✔ || Severe [[pruritis]]/discomfort
+| colspan="1" rowspan="1"| [[''Herpes simplex'']] 1 and 2 || ✔ || ✔ || ✔ || ✔ || Moderate to severe [[pruritis]]/discomfort, superinfection
 |-
 | colspan="1" rowspan="1"| [[Syphilis]] || ✔ || ✔ || ✔ ||  ||
-*Neurosyphilis<br>
+*[[Neurosyphilis]]<br>
-*Cardiosyphilis
+*[[Cardiosyphilis]]
 |-
-| colspan="1" rowspan="1"| [[Scabies]] || ✔ || ✔ ||  ||  || Moderate to Severe [[pruritis]]/discomfort
+| colspan="1" rowspan="1"| [[Scabies]] || ✔ || ✔ ||  ||  || Moderate to severe [[pruritis]]/discomfort
 |-
-| colspan="1" rowspan="1"| [[Pubic lice]] || ✔ || ✔ || ||  || Moderate to Severe [[pruritis]]/discomfort
+| colspan="1" rowspan="1"| [[Pubic lice]] || ✔ || ✔ || ||  || Moderate to severe [[pruritis]]/discomfort
 |-
 | colspan="1" rowspan="1"| [[Candidiasis]]<br>(in males) ||  || ✔ || ||  || Mild to moderate [[pruritis]]/discomfort
 |-
-! colspan="1" rowspan="2"| '''Generalized Symptoms<br>(e.g. constitutional symptoms'''
+! colspan="1" rowspan="2"| '''Generalized Symptoms<br> (e.g., constitutional symptoms)'''
 | colspan="1" rowspan="1"| [[HIV]] || ✔ ||  || ✔ ||  ||
 *[[Primary CNS Lymphoma]]<br>
@@ Line 47: / Line 46: @@
 |-
 | colspan="1" rowspan="1"|  [[Syphilis]] || ✔ || ✔ || ✔ ||  ||
-*Neurosyphilis<br>
+*[[Neurosyphilis|Neurosyphilis<br>]]
-*Cardiosyphilis
+*[[Syphilis|Cardiosyphilis]]
 |-
-! colspan="1" rowspan="5"| '''Urogenital infections<br> (e.g.,[[Vaginitis]], [[Urethritis]], [[Cervicitis]], and [[PID]])'''
+! colspan="1" rowspan="5"| '''Urogenital infections<br> (e.g., [[Vaginitis]], [[Urethritis]], [[Cervicitis]], and [[PID]])'''
 | colspan="1" rowspan="1"| [[Gonorrhea]] || ✔ || ✔ ||  || ✔ || [[PID]]
 |-
@@ Line 56: / Line 55: @@
 |-
 | colspan="1" rowspan="1"| [[Syphilis]] || ✔ || ✔ || ✔ ||  ||
-*Neurosyphilis
+*[[Neurosyphilis]]
-*Cardiosyphilis
+*[[Cardiosyphilis]]
 |-
-| colspan="1" rowspan="1"| [[Mycoplasma genitalium infection|Mycoplasma genitalium]] || ✔ || ✔ || unknown || unknown || [[PID]]
+| colspan="1" rowspan="1"| [[''Mycoplasma genitalium'' infection |''Mycoplasma genitalium'']] || ✔ || ✔ || unknown || unknown || [[PID]]
 |-
-| colspan="1" rowspan="1"| [[Trichomonas vaginalis]] || ✔ || ✔ || ||  || [[PID]]
+| colspan="1" rowspan="1"| [[''Trichomonas vaginalis'']] || ✔ || ✔ || ||  || [[PID]]
 |-
 ! colspan="1" rowspan="6"| Less frequently sexually transmitted
-! colspan="1" rowspan="3"| '''Generalized Symptoms<br>(e.g. constitutional symptoms)'''
+! colspan="1" rowspan="3"| '''Generalized Symptoms<br> (e.g., constitutional symptoms)'''
-| colspan="1" rowspan="1"| [[Zika virus infection|Zika Virus]] || ✔ ||  || ✔ ||  || [[Vertical transmission]] and Congenital abnormalities
+| colspan="1" rowspan="1"| [[Zika virus infection|Zika Virus]] || ✔ ||  || ✔ ||  || [[Vertical transmission]] and congenital abnormalities
 |-
 | colspan="1" rowspan="1"|  [[Hepatitis B]] || ✔ || ✔ || ✔ ||  || [[Hepatocellular Carcinoma]]
 |-
-| colspan="1" rowspan="1"| [[Hepatitis C]] || ✔ || ✔ || ✔ ||  || [[Liver cirrhosis]]
+| colspan="1" rowspan="1"| [[Hepatitis C]] || ✔ || ✔ || ✔ ||  || [[Liver cirrhosis]], [[Hepatocellular Carcinoma]]
 |-
-! colspan="1" rowspan="3"| '''Urogenital Infections <br> (e.g.,[[Vaginitis]], [[Urethritis]], [[Cervicitis]], and [[PID]])'''
+! colspan="1" rowspan="3"| '''Urogenital Infections <br> (e.g., [[Vaginitis]], [[Urethritis]], [[Cervicitis]], and [[PID]])'''
-| colspan="1" rowspan="1"| [[Gardnerella vaginalis]] || ✔ || ✔ ||  || || Moderate to severe discomfort
+| colspan="1" rowspan="1"| [[''Gardnerella vaginalis'']] || ✔ || ✔ ||  || || Moderate to severe discomfort
 |-
-| colspan="1" rowspan="1"|  [[Candidiasis]]<br>(in females) ||  || ✔ ||  ||  || Moderate to severe [[pruritis]]/discomfort
+| colspan="1" rowspan="1"|  [[Candidiasis]]<br> (in females) ||  || ✔ ||  ||  || Moderate to severe [[pruritis]]/discomfort
 |-
-| colspan="1" rowspan="1"| [[Ureaplasma urealyticum |Ureaplasma urealyticum]] || ✔ || ✔ ||  ||  || Moderate to severe [[pruritis]]/discomfort
+| colspan="1" rowspan="1"| [[''Ureaplasma urealyticum'' | ''Ureaplasma urealyticum'']] || ✔ || ✔ ||  ||  || Moderate to severe [[pruritis]]/discomfort
 |-
 |}
-==Common Symptoms==
+==Differential Diagnosis==
+Table below provides differential diagnosis of sexually transmitted diseases:<ref name=CDCFact> CDC Sexually Transmitted Disease Surveillance 2018 [[STDs]] in the United States. The Centers for Disease Control and Prevention. https://www.cdc.gov/std/stats18/toc.htm Accessed on January 25, 2020. </ref>
 {| class="wikitable" style="border: 2; background: none;"
 |-
@@ Line 86: / Line 86: @@
 ! rowspan="1" colspan="9" | Symptoms
 |-
-! rowspan="1" | Discharge || Dysuria || Vaginal odor || Dyspareunia || Genital skin lesion || Genital pruritis || Fever || Lymphadenopathy || Other symptoms
+! rowspan="1" | [[Vaginal discharge|Discharge]] || [[Dysuria]] || Vaginal odor || [[Dyspareunia]] || Genital skin lesion || Genital pruritis || [[Fever]] || [[Lymphadenopathy]] || Other symptoms
 |-
-| [[Chlamydia]] ||✔  ||✔  || ||✔  || ||✔  ||✔  ||✔||[[Cough]], shortness of breath, red eye with discharge (neonate), joint pains
+| [[Chlamydia]] ||✔  ||✔  || ||✔  || ||✔  ||✔  ||✔||[[Cough]], [[shortness of breath]], [[red eye]] with discharge (neonate), [[joint pain]]
 |-
-| [[Gonorrhea]] ||✔||✔||✔||✔|| || ||✔|| ||Sore throat, polyarthralgia, [[tenosynovitis]], rash, eye discharge (neonates)
+| [[Gonorrhea]] ||✔||✔||✔||✔|| || ||✔|| ||[[Sore throat]], [[polyarthralgia]], [[tenosynovitis]], [[rash]], eye discharge (neonates)
 |-
 | [[HIV]] ||✔||✔|| || || || ||✔||✔||[[Fever]], [[lymphadenopathy]], [[rash]], [[fatigue]], [[myalgia]], arthritic pain, [[headache]]
 |-
-| [[Herpes simplex]] ||✔||✔|| || ||✔|| ||✔||✔||Fatigue, myalgias, painful oral ulcers
+| [[Herpes simplex]] ||✔||✔|| || ||✔|| ||✔||✔||[[Fatigue]], [[myalgia]], painful oral ulcers
 |-
-| [[HPV]] ||✔||✔|| ||✔||✔||✔|| || ||Weight loss, [[hoarseness]] (adults), altered cry, [[stridor]](infants)
+| [[HPV]] ||✔||✔|| ||✔||✔||✔|| || ||[[Weight loss]], [[hoarseness]] (adults), altered cry, [[stridor]] (infants)
 |-
-| [[Hepatitis B]] || || || || || || ||✔||✔||[[Fever]], [[fatigue]], [[nausea]], [[vomiting]], [[loss of appetite]], [[abdominal pain]], dark urine, [[acholic stools|clay-colored bowel movements]],[[joint pain]], yellowish discoloration of the eyes and skin, [[skin rash]], [[muscle pain]]
+| [[Hepatitis B]] || || || || || || ||✔||✔||[[Fever]], [[fatigue]], [[nausea]], [[vomiting]], [[loss of appetite]], [[abdominal pain]], [[dark urine]], [[acholic stools|clay-colored stools]], [[joint pain]], yellowish discoloration of the eyes and skin, [[skin rash]], [[muscle pain]]
 |-
 | [[Hepatitis C]] || || || || || || ||✔||✔||[[Fever]], [[fatigue]], [[anorexia]], [[arthralgia]], [[nausea]], [[vomiting]]
@@ Line 107: / Line 107: @@
 | [[Mycoplasma genitalium]] ||✔||✔|| ||✔|| ||✔|| || ||None
 |-
-| [[Zika virus]] || || || || || || ||✔|| ||[[Conjunctivitis]], [[rash]], [[joint  pains]]
+| [[Zika virus]] || || || || || || ||✔|| ||[[Conjunctivitis]], [[rash]], [[joint pain]], [[myalgia]]
 |}
+==Treatment==
-==Risk Factors==
+* To view the treatment of [[chlamydia infection]] [[Chlamydia infection medical therapy|click here]].
-Risk factors for acquiring a sexually transmitted disease may vary depending on the disease. However, most sexually transmitted diseases share common risk factors including:
+* To view the detailed treatment of [[gonorrhea]] [[Gonorrhea medical therapy|click here]].
-*Multiple sexual partners
+* To view the detailed treatment of [[herpes simplex]] [[Herpes simplex treatment|click here]].
-*Prostitution
+* To view the detailed treatment of [[mycoplasma genitalium infection]] [[Mycoplasma genitalium infection#Medical Therapy|click here]].
-*Illicit drug use or I.V. drug use
+* To view the detailed treatment of [[syphilis]] [[Syphilis medical therapy|click here]].
-*Unprotected sex
+* To view the detailed treatment of [[trichomoniasis]] [[Trichomoniasis medical therapy|click here]].
-*Men who have sex with men
+* To view the detailed treatment of [[bacterial vaginosis]] [[Bacterial vaginosis medical therapy|click here]].
-*Residence in highly prevalent areas
+* To view the detailed treatment of [[human papillomavirus]] [[Human papillomavirus medical therapy|click here]].
-*Underlying [[Human Immunodeficiency Virus (HIV)|HIV]] infection as a risk for other STDs
+==References==
-*Presence of other [[STI]]s
-*Previous history of STIs
-*Intravenous drug use
-*Low socioeconomic status
-*Health care professionals who are predisposed to occupational risk with infected patients
-==Prevention==
-The most effective way to prevent sexual transmission of STIs is to avoid ''contact'' of body parts or fluids which can lead to transfer. ''Abstinence is one method of avoiding contact''. Ideally, both partners should get tested for STIs before initiating sexual contact, ''or if a partner engaged in contact with someone else''.
-===Vaccines===
-Vaccines are available that protect against some viral STIs, such as Hepatitis B, Hepatitis C, Herpes simplex vaccine (both Herpevac and ImmunoVex), and some types of HPV. Vaccination before initiation of sexual contact is advised to assure maximal protection.
-===Barrier Protection===
-[[Condoms]] only provide protection '''when used properly as a barrier''' and to and from the area that it covers.  ''Uncovered areas are still susceptible to many STD's''.  In the case of HIV, sexual transmission routes almost always involve the penis, as HIV cannot spread through unbroken skin, thus ''properly shielding the insertive penis with a properly worn condom from the vagina and anus effectively stops HIV transmission''.  An infected fluid to broken skin borne direct transmission of HIV would not be considered "sexually transmitted", but can still theoretically occur during sexual contact, this can be avoided simply by not engaging in sexual contact when having open bleeding wounds.
-Condoms are designed, tested, and manufactured to never fail if used properly.  There has not been any documented case of an HIV transmission due to an improperly manufactured condom.  However, there have been cases of condom recall, as in a case in South Africa.
-Proper usage entails:
-*Not putting the condom on too tight at the end, and leaving 1.5 cm (3/4 inch) room at the tip for [[ejaculate]].  Putting the condom on snug can and often does lead to failure.
-*Wearing a condom too loose can defeat the barrier.
-*Avoiding inverting, spilling a condom once worn, whether it has ejaculate in it or not.
-*Avoiding condoms made of substances other than latex or polyurethane, as they don't protect against HIV.
-*Avoiding the use of oil based lubricants (or anything with oil in it) with latex condoms, as oil can cause thinning and perforation of the material.
-Not following the five guidelines above perpetuates the common misconception that condoms are not appropriately designed or tested.
-In order to best protect oneself and the partner from STI's, a condom used by an infected individual and its contents should be assumed to be still infectious.  Therefore the used condom must be properly disposed off.  A new condom should be used for each act of intercourse, as multiple usage increases the chance of breakage, defeating the primary purpose as a barrier and increases risk of disease transmission.
 {{Reflist|2}}
+[[Category:Disease]]
+[[Category:Urology]]
-{{WH}}
-{{WS}}
 [[Category:Infectious disease]]
+[[Category:Primary care]]