GENITAL ULCERS

Genital Herpes Granuloma Inguinale (Donovanosis) Lymphogranuloma Venereum Chancroid Syphilis

General  Incurable and highly contagious  Chronic, ulcerative, bacterial  Chronic infxn of lymphatic tissue  Sexually transmitted, acute, ulcerative  A chronic, complex systemic disease
Characteristics  Asymptomatic shedding that leads to transmission may infection of the skin and SQ tissue produced by C. trachomatis dss of the vulva  Early syphilis – cofactor in the transmission and acquisition of
occur as frequently as once in 5 days of the vulva  Most occur in men  Common in developing countries HIV
 Types:  Tropical climates  Tropics  H. ducreyi  T. pallidum  penetrates skin or mucous membranes
o HSV-1  Spread through both sexual and  Vulva  most common site; urethra,  Genital ulcers of chancroid facilitate the  Incubation: 10-90 days; ave 3 wks
 Oral-genital or genital-genital close nonsexual contact rectum, and cervix may be involved transmission of HIV infection  Moderately contagious:
 Women < 25  Not highly contagious  L1, L2, L3 serotypes  Incubation period: 3-6 days o 3-10% - single sexual encounter
 75% of sexual partners of infected individuals  Chronic exposure is necessary with  Incubation period: 3-30 days  Tissue trauma and excoriation precede o 30% 1 month exposure with primary or secondary
contracting the disease a variable incubation period 1-12 infection because it can’t penetrate and  Transmission: kissing or touching a person with active lesion;
 80% are unaware that they are infected wks invade normal skin oral-genital

Clinical  Vulvar skin paresthesia preceding eruption of multiple  Initial nodule progresses into a 3 distinct phases:  Initial lesion: small papule and always Primary Syphilis
Manifestations painful vesicles  progress to shallow, superficial ulcers painless, slowly progressing ulcer Primary painful and tender  2-3 wks after exposure, painless papule appears at
over a large area of the vulva surrounded by granulation tissue  Shallow, painless ulcer  48-72H  papule evolves into a pustule inoculation site and soon ulcerates to produce classic chancre
 Multiple ulcer crops for 2-6 weeks (heal without  Ulcer has beefy red appearance,  Heals rapidly w/o therapy and subsequently ulcerates – painless ulcer 1-2cm w/ raised indurated margin and
scarring) bleeds easily when touched,  Vestibule or labia typically  Ulcers are usually in vestibule, shallow, nonexudative base
 Viral shedding for 2-3 2ks painless w/o regional adenopathy  Periurethral or perirectal region extremely painful, char. Ragged edge,  1st wk  Solitary, painless, and found on the vulva, vagina, or
o Positive cultures  Multiple nodules are typically occasionally and have a dirty, gray, necrotic, foul- cervix w/ nontender and firm regional adenopathy
 Symptoms of vulvar pain, pruritus, and discharge peak present, resulting in ulcers that smelling exudate and lack induration at  2-6 wks  painless ulcer heals spontaneously
between days 7-11 of primary infxn grow and coalesce Secondary the base (the soft chancre)  Not often dx during this stage
 Severe sx  14 days  Chronic dss destroys the normal  1-4wks later  Within 2 wks of an untreated infxn, 50%
vulvar architecture with scarring  Painful inguinal and perirectal develop unilateral bubo Secondary Syphilis
and lymphatic obstruction  adenopathy  Fluctuant nodes should be tx by needle  6wks – 6 mos: Hematogenous dissemination  systemic dss
marked enlargement of the vulva  50% develop systemic s/m aspiration to prevent rupture or by that develops in approx. 25%
Recurrent genital herpes
 w/o tx, infected nodes become incision and drainage if >5cm  Untreated attack: lasts 2-6 wks; multitude of systemic s/m
 Less severe symptoms
 Unilateral involvement ave 7 days increasingly tender, enlarged, matted  Classic rash: red macules and papules over the palms and
 Common feature: prodromal phase of sacroneuralgia, together and adherent to overlying soles
vulvar burning, tenderness, and pruritus few hours to 5 skin, forming a bubo (tender LN),  Vulvar lesions: large, raised, flattened, grayish white areas
days before vesicle formation double genitocrural fold or groove  Wet surfaces: soft papules often coalesce to form ulcers
sign  Most infectious during first 1-2 years; decreasing infectivity
thereafter
Tertiary
 extensive tissue destruction of the Latent-stage Syphilis
external genitalia and anorectal  Positive serologic testing w/o s/m
region  2-20 years
 elephantiasis, multiple fistulas, and  When most women are dx
stricture formation of the anal canal a. Early latent  1 year or less
and rectum b. Late latent or latent syphilis of unknown duration

Tertiary Syphilis
 33% not appropriately tx
 Devastating
 Optic atrophy, tabes dorsalis, generalized paresis, aortic
aneurysm, gummas of the skin and bones

Diagnosis  Made clinically by simple inspection Donovan bodies  clusters of dark-staining  Culture, direct immunofluorescence, Definitive: ID on special culture but not Detection: noncultivable; dark-field microscopy, direct fluorescent
 Viral cultures: useful in primary episodes, when culture bacteria with a bipolar (safety pin) or nucleic acid detection from the widely available antibody tests, or serologic testing
sensitivity is 80%; less useful in recurrent episodes appearance pus or aspirate from a tender lymph Presumptive dx and screening:
 PCR assay: most accurate and sensitive node  dx Clinical dx in a woman with painful vulvar a. Nonspecific nontreponemal
 Serologic: determine whether a woman was infected in  Serologic testing  supportive ulcers after excluding other common STIs  VDRL and RPR card test
the past; considered for ppl presenting for an STI (MSP  Inexpensive and easy to perform
or HIV)  Positive 4-6 wks after exposure
 Western-blot: for antibodies; most specific but not  Useful index of tx response
widely available and difficult to perform  False positive: extremely low titers
  Screening for genpop is not indicated  False negative
o women w/ excess of anticardiolipin
antibody in the serum (prozone
phenomenon)
o immunocompromise
b. Specific antitreponemal antibody tests
 More sensitive
 False-positive in women with lupus erythematosus
 FTA-ABS and MHA-TP
Management Azithromycin 1g orally once a week or In the absence of dx testing, tx based on Azithromycin 1g orally in a single dose  DOC: parenteral pen G
500mg daily for 3 weeks and until all lesions clinical presentation Ceftriaxone 250mg IM single dose o Farisch-herxheimer reaction
have healed Ciprofloxacin 500mg PO BID 3 days  60% of women develop an acute febrile
CDC: Erythromycin base 500mg PO TID 7 days reaction asso. w/ flulike s/m within the first
Surgical excision if medical therapy fails  Doxycycline 100mg BID for 21 days 24H
 Cures bacterial infection and Sexual partners should be tx in a similar
Sex partners should be examined if they prevents further tissue destruction fashion Follow up
 Daily suppressive therapy when the woman has 6 or have had sexual contact during the 60 days Early Syphilis
more episodes annually or for psychological distress preceding onset of symptoms Fluctuant nodes should be aspirated to  Reexamine clinically and serologically at 6 and 12 mos. After
o Viral shedding can still occur prevent sinus formation therapy
o Women who are HSV-seronegative are 3x as  Titer should decline four-fold in 6 mos. and negative in 12
likely to acquire HSV infection from mos
seropositive males compared w/ seronegative
males acquiring from infected female partners Latent Syphilis
 CDC – acyclovir d/c after 12 months  Quantitative nontreponemal serologic tests 6,12,24 mos after
therapy
 VDRL titer will become nonreactive or at most be reactive
with lower titer w/in 1 year
 Treatment failure: 1-2% chance w/ no fourfold titer decline
 > 1y  VDRL titers for 2 years
 FTA-ABS  reactive indefinitely

Partner tx
 Evaluate clinically and serologically
 ID at-risk sex partner: 3 months plus duration of s/m for
primary and secondary; 1 year for latent
 Exposed within 90 days: tx presumptively
 Bacterial Vaginosis Trichomonas Vaginal Infection Candida Vaginitis Fungal Vulvovaginits
General  Most prevalent cause of symptomatic: 15-50%  Anaerobic flagellated protozoon  Ubiquitous, airborne, gram-positive fungus  Primarily a disease of the childbearing years
Characteristics  Shift in vaginal flora  marked decrease in lactobacilli  Most prevalent nonviral, nonchlamydial STI of women  >90%  C. albicans  Common: ¾ women will have at least 1 ep
 7-fold increase in mixed flora (genital mycoplasmas, G. vaginalis,  Cause of acute vaginitis in 5-50%  5-10%  C. glabrata or C. tropicalis  Recurrence rate: 20-80%
anaerobes, peptostreptococci  Highly contagious STI  Candida spp.  25% part of normal flora  3-5% women experience recurrent valvulovaginal
 Origin is elusive  not classified as STI but “sexually associated” o Single sexual contact  2/3 become infected  Prevalence in rectum is 3-4x greater; in the candidiasis (RVVC)  4 or more episodes in 1 year
 Associations  Incubation period: 4-28 days mouth 2x greater than vagina
o Upper tract infections  Hardy organism and will survive for up to 24H on a wet towel ; 6H  Filamentous albicans  penetrate mucosal
 Endometritis, PID, postoperative vaginal cuff on a moist surface surface and become intertwined w/ host cells
cellulitis  2’ hyperemia and limited lysis of tissue
o Pregnancy Associations near the site of infxn
 PROM, endomyometritis, decreased success  Upper GTI  PMN  correlates w/ s/m but does not result
w/ in vitro fertilization, increased pregnancy o Infxns after delivery, surgery, abortion, PID, preterm in clearance
loss of less than 20 wks gestation delivery, infertility, cervical dysplasia tx
Risk factors
Risk factors:  Hormonal factos (pregnancy, immediately
 New or multiple sex partners preceding and after menses
 WSW  Depressed cell-mediated immunity
 Lesbian couples who share sex toys w/ each other w/o cleaning (corticosteroid users, HIV)
toys between use  Antibiotic use, especially those that destroy
 Douching at least monthly or w/in prior 7 days and social lactobacilli (penicillin, tetracycline,
stressors (homelessness, threats to personal safety, insufficient cephalosporins)
financial resources  Obesity and debilitating disease
 Lack of hydrogen peroxide

Recurrent BV
 3 or more episodes in the previous year
 20% of women
Clinical  “musty or fishy”  Profuse vaginal discharge; feeling “wet”  primary s/m Predominant s/m: pruritus
Manifestations  Unpleasant odor stronger after sex  50% of symptomatic women detect abnormal vaginal odor and
vulvar pruritus May have vulvar burning, external dysuria, and dyspareunia
Clinical dx (3 out of 4 for presumptive dx)  Dysuria in 1 of 5 women
1. A homogenous vaginal discharge  Chronic  malodorous discharge as only complaint Vaginal signs: pH < 4.5
 Thin and gray – white, mildy adherent to the vaginal  Many are s/m-free and can remain for years
walls  PE
Discharge: variable in amount, white or whitish gray, highly
 Frothy in approx. 10% o Erythema and edema of the vulva and vagina
viscous, granular or floccular, no odor
 Rare to have associated pruritus or vulvar irritation o Limited to vestibule and labia minora (vs candida
2. Discharge: pH of 4.5 or higher vulvovavaginitis)
Speculum: cottage cheese-type discharge, adherent clumps and
3. Amine-like odor when mixed with Koh (Whiff test)  Discharge color
plaques (thrust patches)
4. Wet smear of the vaginal discharge demonstrates clue cells o white, gray, yellow, or green
(vaginal epithelial cells with clusters of bacteria adherent to their o frothy (with bubbles) and w/ unpleasant odor
external surfaces)  strawberry appearance in <10% Vulvar signs: erythema, edema, fissuring

Diagnosis Culture has no role NAATs Dx:

 performed on vaginal secretions or urine in s/m and as/m px Wet smear mixed KOH
Histo  absence of inflammation in biopsy; few leukocytes on wet  3-5x more sensitive than wet prep Growth = 3 to 4+  80%
mount  Pap smear  50% error rate Growth = 2+  20%
Gram staining  excellent dx method Negative smear does not exclude vulvovaginitis
Calorimetric test  detects proline aminopeptidase for office use
Molecular dx test  FDA-approved Vaginal fungal culture
Elevated enzyme levels in vaginal fluid  Useful when wet mount is negative for hyphae but has
s/m
 Or women who have recently tx w/ antifungal
 Up to 90% have negative culture within 1 wk after tx
Management Concurrent tx w/ male partner is not recommended Nitroimidazoles  only drugs recommended
Alternative therapies such as oral or vaginal lactobacillus  not Primary: single oral dose (2g) metronidazole or tinidazole Uncomplicated Complicated
efficacious Alternative: metronidazole, 500mg PO BID for 7 days Topical antifungal Topical azoles for 7-
Warning: (-) ethanol metabolism (avoid alcohol for 24H after metro and agents for 1-3 days 14 days or PO
72H after tinidazole to avoid disulfram-like reax
Single oral dose of Second fluconazole
Topical therapy  NOT RECOMMENDED bcs it doesn’t eliminate disease fluconazole dose (150mg) given
reservoirs in Bartholin and skene glands 72H after first dose

As/m ID’d in lower GUT  tx! (1 of 3 as/m women will become s/m after 3 RVVC: longer duration of therapy
mos)  7-14 days of topical therapy or 3 doses of oral fluconazole
3 days apart (1,4,7)
HIV acquisition is increased  Maintenance therapy: oral fluconazole (100-, 150-, 200-
 500mg BID 7 days mg dose) wkly for 6 mos or topical tx intermittently as a
maintenance regimen
Tx of partner is important and increases cure rates
Recurrent  vaginal fungal culture to determine spp and
Rescreen w/ NAAT in 3 mos bcs of high reinfxn rates sensitivity

Boric acid capsules (600mg in 0 gelatin capsules)

 min of 14 days (symptomatic cure rate of 70% w/ non-
albicans) inhibits fungal cell wall growth
 suppression in women w/ RVVC
 after 10 days of therapy, 1 600mg capsule intravaginally
2x/wk for 4-6 mos decreases symptomatic recurrences
 toxic if ingested