Dr. Alyaa
2016/2017
Genital infections in gynaecology
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 (Warty lesions on the
vulva, vagina, cervix and perianal area).
- Warts may be exophytic, single or multiple, keratinized or not keratinized,
broad base or pedunculated, and some are pigmented
Diagnosis
- Usually identified by clinical appearance.
- Biopsy & Histology of removed wart
- Non-wart HPV infection often diagnosed by characteristic appearance on
cervical cytology (smear tests) or colposcopy (whitening on topical
application of acetic acid).
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 due to the latent virus in the
surrounding epithelial cells.
Clinic treatment
• Cryotherapy.
• Trichloroacetic acid.
• Electrosurgery/scissors excision/laser.
Home treatment (both contraindicated if pregnancy risk):
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• 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.
- Soft poorly keratinized warts respond to podophylin, and trichloroacetic acid,
while keratinized lesion treated with physical ablative therapies like
cryotherapy, excision and electrocautery
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.
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• Painful vesicles and multiple ulcerations on vulva
• urinary retention.
Recurrent attacks
are thought to result from reactivation of latent virus in the
dorsal root ganglia, and are normally shorter and less severe. They can be
triggered by many factors including:
- 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
• No cure for genital herpes. Symptomatic relief with simple analgesia, saline
bathing, and topical anaesthetic(eg.local lignocaine gel).
• Oral aciclovir (200mg 5x day for 5 days), double dose/length if
immunosuppressed.
• Topical aciclovir is not beneficial.
• Condoms/abstinence whilst prodromal/symptomatic (unless history of HSV in
both partners) may reduce transmission rates.
• patient usually has recurrent episodes requesting treatment, by prescribing long
term suppression with aciclovir 400 mg twice a day
• Suppressive antiviral treatment—considered if >6 recurrences/year.
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Syphilis
Primary syphilis:
caused by Treponema pallidum
• First manifestation of syphilis which is painless ulcer (chancre) at the site of
inoculation
• 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 demonstrating the organism by darkfield microscope from
the ulcer serum exudates
• 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
• 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
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
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• 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 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: Usually following pulmonary tuberculosis through blood and
lymphatics. 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.