Genital infections in gynaecology lec.3 Dr. Alyaa 2016/2017

Other genital infections: Human papillomavirus Epidemiology • DNA virus, many subtypes. • Subtypes 6 and 11 cause genital warts (condylomata acuminata). • 25% of people presenting with warts have other concurrent STIs. • Commonest viral STI in England. • Subtypes 16 and 18 associated with CIN and cervical neoplasia. Symptoms - Majority asymptomatic. - Irritation. - Painless lumps anywhere in the genitoanal area - Warts may be exophytic, single or multiple, keratinized or not keratinized, broad base or pedunculated, and some are pigmented

Genital warts

Florid vulval warts

Cervical warts

Diagnosis - clinical appearance Diagnosis - clinical appearance. - Biopsy & Histology of removed wart - on cervical cytology (smear tests) or colposcopy Complications HPV 16 and 18 associated with high-grade CIN and cervical neoplasia. Smoking and immunosuppression both affect viral clearance thereby increasing the risk.

Treatment for genital warts Removal of the visible wart. High rate of recurrence Clinic treatment • Cryotherapy. • Trichloroacetic acid. • Electrosurgery/scissors excision/laser. Home treatment (both contraindicated if pregnancy risk): • Podophyllotoxin cream or solution: this is self-applied and must be used for about 4–6wks. • Imiquimod cream: this is also a self-applied immune response modifier. It may need to be used for up to 16wks.

Implications in pregnancy • Genital warts tend to grow rapidly in pregnancy, but usually regress after delivery. • Very rarely, babies exposed perinatally may develop laryngeal or genital warts so we should reduce neonatal exposure to the virus & it is not an indication for CS.

Genital ulcer disease Classification of genital ulcers Infective causes: - Herpes simplex - Primary syphilis - Lymphogranuloma veneri - Chancroid - HIV Non infective causes - Aphthous ulcer - Trauma - Skin disease - Bahcet syndrome - Sarcoidosis

Herpes simplex Epidemiology • DNA virus—herpes simplex type 1 (orolabial/genital) and type 2 (genital only). • Third most common STI in England in 2010. Symptoms Primary HSV infection is usually the most severe Involve vulva, vagina and cervix, and often results in: • Prodrome (tingling/itching of skin in affected area). • Flu-like illness +/– inguinal lymphadenopathy. • Painful vesicles and multiple ulcerations on vulva • urinary retention.

Primary herpes of vulva

Vulval herpis infection

Recurrent attacks : result from reactivation of latent virus in the dorsal root ganglia, and are normally shorter and less severe. triggered by: - Stress. - Sexual intercourse. - Menstruation • The spectrum of severity is: • asymptomatic shedding of the virus. • Ulcers resembling small abrasions on the vulva. • Localized clusters of vesicles & ulcers 1-2 cm in diameters • Wide spread or chronic ulceration, like primary one seen in pregnant women. • Large atypical chronic ulcers in immunosuppresed patient.

Complications of HSV infection (usually of primary infection) • Psychological distress • Neurological involvement like aseptic meningitis and transverse myelitis • Herpes keratitis causing corneal scarring and blindness. • Sacral radiculopathy—causing urinary retention and constipation. • Disseminated infection. Diagnosis • Usually from appearance of the typical rash. • PCR testing of vesicular fluid (most sensitive—gold standard). • Culture of vesicular fluid. • Serum antibody tests are of no use for diagnosing primary herpes.

Treatment • Symptomatic relief with simple analgesia, saline bathing, and topical anaesthetic. • Oral aciclovir (200mg 5x day for 5 days), double dose/length if immunosuppressed. • Topical aciclovir is not beneficial. • Condoms/abstinence may reduce transmission rates. • If recurrent episodes: long term suppression with aciclovir 400 mg twice a day • Suppressive antiviral treatment—considered if >6 recurrences/year.

Syphilis Primary syphilis: • First manifestation is painless ulcer (chancre) • The chancre is in form of shallow punched-out ulcer with well defined edges &smooth shiny floor with rubbery consistency &exudes serous discharge. • Usually single but can be multiple • regional lymph nodes enlargement • common site is cervix • it arise 3-6 weeks after infection • resolve spontaneously without treatment after few weeks • diagnosis done by - darkfield microscope. - serological test: specific like (FTA) test, and (TPHA) test or non specific test like (VDRL) test can be used.

chancre

Secondary syphilis • occur 6 months after the disappearance of chancre • systemic non itchy maculopapular rash, involving the palms and soles • florid lesions resembling warts (condylomata lata) mainly in peri-anal area • mucous patch and linear ulcers (snail track) on the mucosal surfaces • generalized lymphadenopathy • alopecia, arthritis and meningitis • diagnosis by serological test which are positive with VDRL titer 1/32 or more

Syphilis: condylomata lata

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 • Treatment of choice is penicillin like: - procaine penicillin 1.2 MU daily i.m., for 12 .days or - Benzathine penicillin 2.4 MU i.m. repeated after 7 days. • Doxycycline 100 mg twice a day for 14 days • Erythromycin 500 mg, four times a day for 14 days 5 • There is risk of vertical transmission, neonate at risk should be evaluated and received penicillin injection • Less severe infection occur late in life manifest as a congenital syphilis including nerve deafness, interstitial keratitis, and- abnormal teeth.

Lymphogranuioma venereum • It is caused by specific serovars of Chlamydia trachomatis( L1- L3) • Small superficial ulcer slowly increase in size • Enlarged inguinal lymph nodes which can matted together and discharging pus forming bubo • Treatment by tetracycline and surgical interference Chancroid • Caused by Haemophilus Ducreyi bacilli • Small, shallow ulcers, multiple and painful with irregular edge • Localized lymphadenopathy • Diagnosed via Specialized culture, Isolation of Ducrey’s bacillus on biopsy • Treatment either by Single oral dose of azithromycin 2 g, Ceftriaxone, or Erythromycin

Granuloma inguinale • Caused by Klebsiella granulomatosis • Discrete papules on the skin or vulva which enlarge and form beefy red painful ulcers • Healing end with fibrosis lead to lymphoedema and elephantiasis • Diagnosis :Donovan bodies: intracellular inclusions seen in phagocytes or histiocytes. • Treatment by Erythromycin.

Genital tuberculosis • Caused by Mycobacterium tuberculosis • clinical features:.1. Amenorrhoea (affects endometrium). 2. Infertility (affects tube). 3. Acute/chronic pelvic pain. 4. Frozen pelvis due to severe multiple adhesions. • diagnosis: 1. Histological confirmation from endometrium and Fallopian tube. 2. Mantoux test. 3. Heaf test. 4. Chest x-ray. • Treatment: Rifampicin, Isoniazid, Pyrazinamide. Treatments can last from six to 12 months.