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.