Transcript Genital ulcer disease

classification
Infective causes :
1. Herpes simplex
2-Primary syphilis
3-Lymphogranuloma venerium
4-Chancroid
5-HIV
Non infective causes
1-Aphthous ulcer
2-trauma
3-skin disease
4-bahcet syndrome
5-sarcoidosis
6-dermatitis artifacta
Herpes simlex virus
There are two main types
-HSV -I usually cause Herpes labialis ,
-HSV- II which cause Herpes genitalis ,
-there are many cases caused by HSV-I
Primary Herpes
*Presents up to three weeks after
contacts
*painful vesicles develop which
coalesce into
multiple ulcers ,
*these vesicles appear most commonly on the
vulva but may occur on the vaginal wall &
cervix, perianal skin & thighs,
*peri-urithral involvement cause severe pain&
urinary retention.
* In the initial attack there is often fever,malaise
& the inguinal lymph nodes may be
enlarged
diagnosis
is made on
*clinical examination
*&confirmed by culture
*or electron microscopy of swabs taken from
the lesions
treatment
includes
- analgesics & bathing in sault water.
- Lignocaine can be applied to the sore areas.
-Anti-viral therapy is used to stop viral
replication. Aciclovir 200 mg five times a
day for five days ,healing occurs over
the following week
Recurrent Herpes
Following primary infection the virus colonize
the neurons in the dorsal root ganglia
establishing a latent infection
productive infection occurs intermittently when
virus particles are produced & track down the
axons to the skin
vesicles & ulcers then occurs usually in the same
area
The spectrum of severity varies:
1-Asymptomatic shedding of virus.
2-Trivial ulcers resembling small abrations on
the vulva.
3-Localized clusters of vesicles&ulcers over an
area of I-2cm diameter.
4-Widespread or chronic ulceration resembling
the primary infection can be seen in
pregnancy.
5-if a woman is immuno suppressed ,large
atypical chronic ulcers may develop as in AIDS
Diagnosis
can be made by swabbing the ulcers &culture for
herpes.
Although recurrent attacks may be
milder&shorter than the first attack they cause
much discomfort &the patient should be warned
that they are infectious whenever any lesions are
evident &woman should have annual cervical
smear
patient usually has recurrent episodes requesting
treatment, by prescribing long term suppression
with aciclovir 400 mg twice a day
complications
1-psychological distress:
which may necessate councelling.
2-neurological involvement:
during primary herpes which is uncommon
&include meningitis
myelitis&neuropathy&their resolution take one
to two months
3-herpes keratitis:
is aserious condition that can produce cornual
scarring &blindness ,both HSVI&HSVII can
infect eyes
4-serious problems can arise in pregnancy:
*infection in early pregnancy may cause abortion,
*if the primary attack occurs in the last weeks
there may be transplacental spread of the virus
to the fetus which subsequently may cause
damage to the central nervous system with high
neonatal mortality.
* If there is evidence of active lesion in last weeks
of pregnancy or at the onset of labour it may be
wise to carry out caesarean section rather than
contaminating the fetus in the birth canal.
SYPHILIS
Is asystemic sexually transmitted infection
caused by a spirochaete
Treponema pallidum.
Primary acquired syphilis
-the first manifestation is apainless ulcer called
chancre
-which can be multiple ,
-the regional lymph nodes become enlarged
-the most common site is the cervix but may occur in
the labia.
The chancre is in form of a shallow punched-out ulcer
with well defined edges &smooth shiny floor with
rubbery consistancy &exudes aserous discharge ,
-it arise 3-6 weeks after infection
-resolve spontaneously without treatment after
few weeks
diagnosis
diagnosis done by
- demonstrating the organism by dark field illumination
microscope from the ulcer serum exudates when T.
pallidum are seen as tightly wound spiral organisms
-specific serological test like fluorescent terponemal
antibody (FTA) test, and treponema pallidum
haemagglutination test (TPHA)
-or non specific test like venereal disease reference
laboratory (VDRL) test can be used, although it
may be negative
Secondary syphilis
-can arise as the chancre disappear
-or up to six months later which is
-manifested by
*asystemic non-itchy maculopapular symmetrical
rash involving palms of hands &soles of feet.
*More florid lesions resembling warts [condylomata
lata] are seen in the intertriginous areas
especially around vulva& anus.
* Linear ulcers are seen on the mucosal surfaces
[snail track].
*generalized lymphadenopathy
*alopecia, arthritis and meningitis
Diagnosis:is by serological test
Tertiary syphilis
*A firm elastic tumours may occur in skin,
mucosa, bones & viscera called
gummata
*neurosyphilis manifest within 5 years of
infection in form of meningovascular
syphilis with stroke
*20% has cardiovascular syphilis like
thoracic aortic aneurysm or aortic
regurgitation
treatment
-penicillin either by procaine penicillin 1.2
MU daily by IM injection for twelve days or
benzathine penicillin 2.4 MU repeated after
one week.
-Doxycycline lOOmg twice daily for 14 days - ---Erythromycin 500mg four times daily for 14
days can be used
-There is risk of vertical transmission, causing
intrauterine death or severely affected neonate,
therefore; neonate at risk should be evaluated and
received penicillin injection
-Less sever infection occur late in life manifest as
a congenital syphilis including nerve deafness,
interstitial keratitis, and- abnormal teeth
HUMAN PAPILLOMA VIRUS
Anogenital warts
Warts are benign epithelial skin tumours are
caused by the human papillomavirus (HPV),
subtypes 6 and 11
this virus can infect the skin of vulva &perineum
,vagina,cervix&rectum which is mainly caused by
HPV subtypes 6,1 1,16&18.
Cervical precancer is thought to be due to HPV
16&18.
The mode of transmission is* sexual, but may be
transmitted *perinatally and also* from digital
lesions
Clinical features
*on the dry area the warts are small & flat
*although on warm moist areas they may be
much larger
*It may cause irritation or present with lumps
*It can occur at any time in the genital area
*Occult lesion may occur in the vagina and
cervix
*Warts may be exophytic, single or multiple,
keratinized or not keratinized, broad
base or pedunculated, and some are
pigmented
Diagnosis
by clinical examination and biopsy if there is
any doubt.
Speculum examination for cervix and vagina
should be done
treatment
*soft lesions
Local application 10-25%of podophyllin twice
weekly for up to six weeks..
*Keratinized lesion
treated with physical ablative therapies like
cryotherapy, excision and electrocautary
LYMPHOGRANULOMA
VENERIUM[LGV]
Is caused by serovars [L1 -L3]of chlamydia
trachomatis,found in far east,Africa&south
America.
In early stages there is small painless superficial
ulcer increased gradually in size,the inguinal
lymph nodes are enlarged & may break down
to form multiple sinuses.
the ulcer is gradually heal leaving irregular
scars, the urethra may be destroyed & the
rectum may have stenosis with recto vaginal
fistula. Diagnosis is by complement fixation
test. Treatment is by tetracycline with
surgical intervention.
Diagnosis
is by complement fixation test.
Treatment
-by tetracycline
-with surgical intervention
CHANCROID
It is caused by Haemophilis ducreyii with similar
geographical distribution to t LGV
-start with small shallow ulcers which are
multiple & painful with irregular edges
-Localized lymph-adenopathy which are
soft&tender that may can be suppurate
Diagnosis
the micro organismgrown on specialized culture
media
Treatment
is by co- trimoxazole or tetracycline.
GRANULOMA INGUINALE
infection caused by Klebsiella granulomatis
is found in lndia,Guinea&southern America.
ls usually start with discrete papules on skin
of vulva which enlarged to form painful
ulcers spread slowly
aroundgenitalia&perineum,
with healing&fibrosis
lymphoedema&elephantiasis may develop.
Diagnosis
is by biopsy
treatment
is by streptomycin or tetracycline.