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Fifth stage
Gynecology
Lec-5
.د
ولدان
16/3/2016
STD & Genital tract ulcers
Chlamydia trachomatis
Is the commonest bacterial sexually transmitted infection which is commonly a
symptomatic.
It is small bacterium an obligate intracellular pathogen
Serovars D-K cause genital infections
Clinical feature
80% asymptomatic
Postcoital and intermenstrual bleeding
Lower abdominal pain
Purulent vaginal discharge
Mucopurulent cervicitis & or contact bleeding
Risk factors
Age < 25 years
Multiple sexual partners
More with those using cocp
Termination of pregnancy
Complication
PID and subsequent Fitz-Hugh-Curtis syndrome
Tubal damage, ectopic pregnancy, infertility, and chronic pelvic pain
Transmission to the neonate causing conjunctivitis and pneumonia
Arthritis and Reiter's
Diagnosis
Endocervical, urethral, and vaginal swab for culture but are not sensitive
ELIZA test on endocervical smear
Direct fluorescent antibody test
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Management
Doxycycline 100 mg twice a day for 7 days
Azithromycin 1 g as single dose
Ofloxacine 400 mg daily for 7 days
In pregnancy:
o Azithromycin 1 g as single dose
o Erythromycin 500 mg twice a day for 14 days
Partner should be fully screened and treated
Gonorrhoea
It is a STD
Caused by gram negative diplococcus N.gonorrhoeae .
Sites of infection are mucous membrane of urethra, endocervix, rectum, pharynx, and
conjunctiva
Vertical transmission from the mother to the fetus may occur during labour
Clinical Features
50% asymptomatic
50% increased or altered vaginal discharge
25% lower abdominal pain
12% dysuria
Rare intermenstrual bleeding or menorrhagia due to endometritis
Clinical sign
< 50% mucopurulent endocervical discharge and bleeding
< 5% pelvic or lower abdominal tenderness,
In the infant cause sever conjunctivitis (ophthalmia neonatorum)
Complications
Spread of m.o. cause PID < 10%
Haematogenous spread causing skin infection, arthralgia, and arthritis
Diagnosis
Endocervical and urethral swab for culture is the most reliable diagnostic-test
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Recommeded treatment
Ampecillin 1 g + probenecid 2 g as single dose
Ciprofloxacin 500 mg as single dose
Spectinomycin 2 g I.M. as single dose
Azithromycin 1 g as single dose
Ceftriaxone 250 mg as single dose
Cefixime 400 mg as single dose
More than 50% has concomitant chlamydial infection, therefore, treatment for the
patient and partner should be done
The partner should be screened for the infection and treated
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
Genital herpes
STD
Herpes simplex virus type 1 (HSV-l) [ the usual cause of oro-labial herpes, or HSV-2
Primary herpis
3 weeks after acquisition
Involve vulva, vagina and cervix
Painful vesicle coalesce into multiple ulcers
Periurethral involvement cause pain and retention of urine
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Diagnosis confirmed by culture, or electrical microscope of swab from the lesion
Treatment:
analgesia, lignocaine gel
aciclovir 200 mg 5 times a day for 5 days
Recurrent herpis
Following primary infection, virus colonizes the neurons in the dorsal root ganglia,
causing a latent infection.
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.
diagnosis by swabbing the ulcer
patient usually has recurrent episodes requesting treatment, by prescribing long term
suppression with aciclovir 400 mg twice a day
Complications
Psychological distress
Neurological involvement like aseptic meningitis and transverse myelitis
Herpes keratitis causing corneal scarring and blindness.
Syphilis
Primary syphilis:
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
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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
Doxycycline 100 mg twice a day for 14 days
Erythromycin 500 mg, four times a day for 14 days
o There is risk of vertical transmission, causing intrauterine death or severely
affected neonate, therefore; neonate at risk should be evaluated and received
penicillin injection
o Less sever 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
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Chancroid
Caused by ducreyi bacilli
Small, shallow ulcers, multiple and painful with irregular edge
Localized lymphadenopathy
Treatment co-trimoxazole or tetracyclin
Granuloma inguinale
Caused by klebsiella granulomatis
Discrete papules on the skin or vulva which enlarge and form beefy red painful ulcers
Healing end with fibrosis lead to lymphoedema and elephantiasis
Treatment by tetracycline
Anogenital warts
Aetiology:
Warts are benign epithelial skin tumours are caused by the human papillomavirus
(HPV), subtypes 6 and 11
The mode of transmission is sexual, but may be transmitted perinatally and also from
digital lesions
Clinical features:
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
Management:
Treatment is painful, uncomfortable, with failure and relapse rate
Soft poorly keratinized warts respond to podophylin, and trichloroacetic acid
Keratinized lesion treated with physical ablative therapies like cryotherapy, excision
and electrocautery
In pregnancy podophylin should be avoided and we should reduce neonatal exposure
to the virus