Genital ulcers

Presentation include some details on genital ulcers and typical features, differential diagnosis, causing organisms, diagnosis and treatment.
Presentation prepaired and done by 3rd year medical students of Faculty of Medicine, University of Ruhuna, Sri Lanka during STI appointment under the guidance of Consultant Venereologist, STI clinic Mahamodara, Galle.
Done by
Dias P G N J
Dilanka I W G M
Dinuraji K S H

1. Genital Ulcers Dias P G N J Dilanka I W G M Dinuraji K S H

2. GENITAL ULCER, D efined as single or multiple vesicular, ulcerative or erosive lesions of the genital area, with or without inguinal lymphadenopathy, cause by number of sexually transmitted infections and non sexually transmitted conditions.

3. Primary Syphilis Genital herpes(HSV) Chancroid LGV(lymphogranuloma venereum ) Granuloma inguinale ( Donovanosis ) CLASSIFICATION Trauma Carcinoma Behcet’s syndrome Drug erruptions

4. Cause by Treponema pallidum Transmission – Sexual V erticle (in utero/during passage) Blood transfusion(rarely) 3 stages Primary, Secondary & Tertiary Syphilis

5. Primary Syphilis Primary lesion or “chancre” develops at the site of inoculation Chancre progresses from macule to papule to ulcer typically painless, indurated and has a clean base(no necrosis) highly infectious heals spontaneously within 3-6 weeks multiple lesions can occur Regional lymphadenopathy Classically rubbery painless bilaterally

6. Secondary syphilis Secondary lesions occur several(2-12weeks) after primary chancre appears Lasts weeks to months Clinical manifestations skin and mucous membranes macular or pustular rash(can occur throughout the body- centripetal and can occur soles and palms) condylamata lata (in between skin folds) alopecia Systemic lymphadenopathy malaise arthralgia fever

7. Latent syphilis Positive serological tests without clinically apparent disease In between 2ry and tertiary early latent less than 2 year duration high chance of relapses Late latent 2 year or more than 2 year relapses unlikely

8. Tertiary syphilis May develop decades later 30% of untreated patients progress to tertiary stage Manifestations Gummatous lesions granulomatous inflammation in skin, bones or mucocutaneous tissues Cardiovascular syphilis Neurosyphilis acute syphilitic meningitis ocular involvements general of paresis insane tabes dorasalis

9. Congenital syphilis Occurs due to transplacental transmission and during delivery from infected birth canal. Can occur during any stage of syphilis. Risk is much higher during 1ry and 2ry syphilis, present as a bullous rash Fatal infection can occur during any trimester of pregnancy.

10. Diagnosis Clinical history symptoms suggestive of primary syphilis (painless ulcer) previous history of syphilis unprotected risky sexual exposer Examination painless , indurated hard ulcer regional lymphadenopathy

11. Laboratory Diagnosis Direct microscopy F resh exudate from the primary chancre should be examined under Dark field microscopy immediately after collection look for T. pallidum morphology and motility. thin delicate helically coil corkscrew shape organism. rapid rotation around its long axis and slow forward- backward motion.

12. Serological tests Non specific antibodies VDRL RPR Specific antibodies FTA TPHA TPPA

13. TREATMENT Benzathine penicillin G 2.4MU i.m single dose Alternative treatment , In penicillin allergy & Non Pregnant Doxycycline 100mg bd for 2 weeks or Tetracycline 500mg 4 times/ day for 2 weeks Contact Tracing & Epidemiological Treatment should b e done

14. Prevention Contact tracing and epidemiological treatment. Screening pregnant women at least at 1 st prenatal visit. In high prevalence communities or patients at risk, test twice during 3 rd trimester and at delivery. Safe sex

15. Genital Herpes Organism - Herpes simplex virus Most common cause of genital ulceration Two types 1 . HSV 1 infection 2. HSV 2 infection(most common type) Transmission Sexually oral, vaginal and anal intercourse Non sexually contact with herpes ulcer, saliva or genital secretions

16. CLINICAL FEATURES Local pain, tenderness, itching Papules on a red erythematous base rapidly develop into vesicles which ulcerate. superficial non indurated tender ulcer with erythematous edges. painful shallow multiple ulcers. heal in about 3weeks. Can be associated with fever and regional lymphadenopathy Can cause urethritis Recurrences are common

17. Complications Encephalitis Neuralgia Urinary retention Pharyngitis-oral sex Extra genital lesions-auto inoculation Can be a co factor with HPV for development of cervical cancer During pregnancy trans placental transmission Result in stillbirth or teratogenic effect High risk if acquired near the time of delivery Risk is low in recurrences

18. Diagnosis D irect smear for giant cell Tzanck smear- Tzank cells can be seen specimen- swab taken from the base of ulcers or vesicle fluid Virus isolation in cell culture Genome detection HSV DNA detection using PCR Serological tests ELISA-HSV specific IgG NOT DIAGNOSTIC

19. Management Primary Episodes Acyclovir 400mg oral tds for 7-10days or Valacycolvir 1g oral bd for 7-10days Recurrent Episodes Episodic therapy Acyclovir 400mg oral tds for 5days or Valacycolvir 500mg oral bd for 3days Suppressive therapy (for 1 year) Acyclovir 400mg oral bd or V alacyclovir 1g oral once a day

20. Prevention Avoid contact with lesions ware gloves Safe sex Prevent neonatal herpes EL-LSCS for mothers with active infection(genital ulcers at the time of delivery -4weeks)

21. Lymphogranuloma Venereum (LGV) Organism – Chlamydia trachomatis ( L1, L2, L3 serotypes) I P 3-30 days Endemic in certain areas(Africa, southeast Asia, I ndia, South America) Clinical features Primary stage Small painless and vesicular lesion ulcer at the site of infection usually single elevated irregular edges superficial or deep may have fever, headache and myalgia

22. Secondary Stage marked inflammation in draining lymph node enlarged nodes become painful(buboes-collection of inflamed lymph nodes) and can rupture Tertiary Stage genital lymphedema destructive lesions Rectal exposure in women or MSM can result in proctocolitis Mucoid and/or hemorrhagic rectal discharge, anal pain, constipation, tenesmus If untreated early can lead to chronic colorectal fistulas and strictures

23. Diagnosis Nucleic acid amplification test for LGV serova - PCR Serological tests(not reliable ) 1. complement fixation test 2. Microimmunoflurescent test Cell culture Cytology swabs from genital lesions and lymph node aspirate for the presence of cells with inclusion bodies (stain with iodine) (Other STI should be exclude)

24. Treatment Doxycycline 100mg bd for 21 days or Erythromycin 500mg four times daily 21 days Epidemiological treatment to the partner A bstain from the sex till the patient and the partner complete the treatment Surgical drain some times require

25. Chancroid Organism - Haemophilus ducreyi Distribution-Less common prevalent in Africa & Asia Co-infection with syphilis Incubation period : 3-10 days Clinical manifestation painful non indurated soft ulcer tender suppurative inguinal lymphadenopathy

26. ULCER Common sites- men-prepuce & frenulum women-labia majora / minora & perinium Initial lesion is a pustule or papule Then breakdown into a ulcer Can be single or multiple Irregular borders Base-gray or yellowish grey material Painful soft ulcer Bleed easily No induration

27. Diagnosis Microscopy – gram stain show the characteristic Gram-negative coccobacilli resembling rail road tracks or school of fish specimens scraping from the base of ulcer , lymph node aspiration Culture on special culture media with X factor PCR Antigen detection and serology(for rearch purposes)

28. Treatment Azithromycin-1g oral single dose or Ceftriaxone-250mg IM single dose or Ciprofloxacin 500mg oral bd for 3days or Erythromycin 500mg oral tds for 7 days C ontact tracing and epidemiological treatment

29. Granuloma Inguinale ( Donovanosis ) Organism – Klebsiella granulomatis ` gram negative bacilli with characteristic bipolar staining I.P. 1-12 weeks Distribution-Less common now. But endemic in tropics & subtropics. Eg , Caribbean, South India

30. ULCERS Initially small painless nodules Slowly progressive ulcerative lesions without regional lymphadenopathy Then they burst creating open, fleshy, oozing ulcer Progressed by internal and external tissue destruction Lesions are highly vascular bleed easily on contact Characteristic rolled edge of granulation tissue

31. Diagnosis Visualization of dark staining Donovan bodies(numerous bacilli in the cytoplasm of macrophages demonstrated with Giemsa or silver stain) on tissue crushed perforations or biopsy from base or edge of the ulcer Organism difficult to culture PCR

32. Treatment Doxycycline-100 mg oral bd for at least 3 weeks or until all lesions have completely heal Alternative regimes Azithromycin 1g oral once per weeks at least 3 weeks or Ciprofloxacin 750mg oral bd for at least 3 weeks Partners should also be examined & treated Epidemiological treatment

33. References... Kumar and Clark's clinical medicine 9th edition . Medical microbiology Greenwood 18th edition . ABC of sexually Transmitted Infections 5 th edition . www.medscape.com www.cdc.gov www.bash.org

34. THANK YOU!