TABLE 1372 Clinical Features of Genital Ulcers

GENITAL WARTS Human papillomaviruses (HPVs) are DNA viruses that cause genital warts by direct transmission. Different genotypes also have been implicated in cervical cancer, but the relationship is far from clear. The warts usually appear after an incubation period of 3 to 4 months and may coalesce to form condylomata acuminata. Although painless, their location or size may cause discomfort.

Diagnosis Diagnosis is clinical, with care to exclude other STDs.

Treatment Treatment decisions are based on the size and number of lesions, the amount of discomfort they are causing, and patient preferences. Recommended treatment is podofilox 0.5% solution or gel applied with a cotton swab or a finger to the visible warts twice a day for 3 days, followed by 4 days of no therapy, with the cycle repeated up to 4 times. Also recommended is imiquimod 5% cream applied at bedtime 3 times a week for up to 16 weeks. The treatment area should be washed 6 to 10 h after treatment with Imiquimod. Cryotherapy in a physician's office is also a common therapy.

SYPHILIS INFECTIONS Treponema pallidum, a spirochete, is the causative agent of syphilis as well as yaws and pinta. It enters the body through mucous membranes or nonintact skin. It remains very sensitive to penicillin; thus diagnosis rather than treatment is the main difficulty in controlling this disease. The last 7 years has seen a marked increase in syphilis thought to be secondary to behavior associated with drug use. Syphilis occurs in three stages.

1. Primary. The initial stage of infection is characterized by a painless chancre with indurated borders on the penis, vulva, or other areas with sexual contact. The incubation period is about 21 days, with lesions then disappearing after 3 to 6 weeks. There are no constitutional symptoms, and a lesion may even be absent with primary disease.

2. Secondary. This stage, which occurs 3 to 6 weeks after the end of the primary stage, includes nonspecific symptoms such as sore throat, malaise, fever, and headaches. Rash and lymphadenopathy are the most common symptoms. The rash often starts on the trunk and flexor surfaces, spreading to the palms and soles. It takes on many forms but is often dull red and papular. This stage also resolves spontaneously.

3. Tertiary (latent). Involvement of the nervous and cardiovascular systems is characteristic of this stage, which may occur years after the initial infection. Specific manifestations range from acute meningitis, dementia, and neuropathy (tabes dorsalis) to thoracic aneurysm. Tertiary syphilis is uncommon.

Diagnosis Dark-field microscopy can be used to identify treponemes from primary lesions as well as from secondary lesions. Several serologic tests are available, including nontreponemal tests (rapid plasma reagin, VdRl) and specific treponemal antibody tests (fluorescent treponemal antibody absorption, or FTA-ABS). Nontreponemal tests are positive about 14 days after the appearance of the chancre and false positive in 1 to 2 percent of the population. FTA-ABS tests are slightly more sensitive and specific but more difficult to perform.

Treatment Given the multiple stages and manifestations of syphilis, considering the diagnosis is the most crucial part of treatment. Benzathine penicillin G 2.4 million units IM in a single dose has remained the standard of care. Doxycycline 100 mg Po bid for 2 weeks may be used for allergic individuals. Treatment of latent syphilis is usually three doses of penicillin as above, given 1 week apart.

HERPES SIMPLEX INFECTIONS Herpes simplex virus type 2 (HSV-2) or HSV-1 can cause genital herpes infections by infection of mucosal surfaces or nonintact skin. Primary infections are characterized by painful pustular or ulcerative lesions occurring 8 to 16 days after contact with an infected individual (although infections can be asymptomatic). Systemic symptoms are common and include fever, headache, and myalgias. Dysuria is common, whereas urinary retention secondary to swelling and pain is not uncommon. Approximately 80 percent of patients also have lymphadenopathy, and aseptic meningitis can occur. The untreated illness lasts 2 to 3 weeks to complete healing. Unfortunately, the virus remains latent, and recurrent infections occur in 60 to 90 percent of patients. These are usually milder and of shorter duration.

Diagnosis Clinical diagnosis of the painful vesiculopustular lesions is often possible. A smear may be taken of the lesions and stained to demonstrate large intranuclear inclusions, although this is less sensitive than direct culture. Viral cultures can be done and are positive in 1 to 4 days. New assays using ELISA and polymerase chain reactions are being developed.

Treatment For a first clinical episode, treatment is with acyclovir 400 mg PO tid for 7 to 10 days, acyclovir 200 mg PO 5 times a day for 7 to 10 days, famciclovir 250 mg PO tid for 7 to 10 days, or valacyclovir 1 g PO bid for 7 to 10 days. Treatment duration can be extended if the lesions persist. For treatment of proctitis or oral infections, higher doses are used (acyclovir 400 mg five times a day for 7 to 10 days). Acyclovir at 5 to 10 mg/kg of body weight may be given IV every 8 h for 5 to 7 days to patients requiring hospitalization.

Episodic recurrent infection should be treated for 5 days with acyclovir 400 mg PO tid, acyclovir 800 mg PO bid, famciclovir 125 mg PO bid, or valacyclovir 500 mg PO bid.

CHANCROID Hemophilus ducreyi is a pleomorphic gram-negative bacillus that causes genital ulcers and lymphadenitis. It is much more common in developing countries but has seen a resurgence in recent years in the United States. After an incubation period of 3 to 10 days, a tender papule appears at the site of infection, followed by ulceration of the lesion. Multiple lesions may be present in up to 50 percent of patients and may include bubo formation and spontaneous rupture. There are few constitutional symptoms.

Diagnosis Diagnosis can be made on clinical grounds, but other diseases such as syphilis need to be excluded. A swab of a lesion or pus from a bubo can be cultured but only with limited success.

Treatment Azithromycin 1 g PO in a single dose, ceftriaxone 250 mg IM in a single dose, ciprofloxacin 500 mg PO bid for 3 days, and erythromycin base 500 mg PO

qid for 7 days are all recommended treatments.

LYMPHOGRANULOMA VENEREUM Specific serotypes of C. trachomatis cause this disease, which although endemic in other parts of the world is seen only sporadically in the United States. The primary lesion can take on many forms and be confused with other STDs (see Table 137-2). Ten days to 6 months following the initial lesion, an inguinal bubo forms (unilateral in 60 percent). The buboes continue to grow, either rupturing or forming firm inguinal masses.

Diagnosis Serologic tests and culture are the mainstays of diagnosis.

Treatment Doxycycline 100 mg PO bid for 21 days is the usual regimen. Table.137-1 gives alternative treatments. TREATMENT DURING PREGNANCY

Pregnant patients with STDs should be referred to the physician providing their prenatal care. In general, penicillin, ceftriaxone, azithromycin, cefixime, metronidazole, and acyclovir are felt to be safe for use during pregnancy. If the safety of treatment is in doubt, an obstetrician should be consulted.

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