Genital Ulcers
• The causative agent in most patients with genital ulcers is herpes virus or syphilis. Less common causes of sexually transmitted genital ulcers are chancroid, lymphogranuloma venereum, and granuloma inguinale. In all of these, the risk of HIV infection increases and co-treatment is mandatory in all these diseases.
Serological tests for syphilis should be performed absolutely in patients with genital ulcers.
• After syphilis has been ruled out, culture for HSV or antigen detection and culture for H.ducreyi should be performed.
Genital Herpes (HSV)
• It is a DNA virus. Although it is mostly caused by Herpes simplex virus Type 2 (85%), Type 1 (15%) infections can also develop. It is the most common genital ulcer.
Clinic
► Primary infection begins with fever, malaise and painful inguinal LAP. A feeling of stinging, burning, and itching predominates in the vulva and cervix 24 hours before the typical eruptions develop. In this region, multiple small vesicles develop primarily on the erythematous background.
► Later, with the opening of the vesicles, superficial, recessed, very painful ulcers occur. Although ulcers heal after a while, recurrences occur in 75% of cases. Following primary infection, HSV remains localized in the sacral ganglion and dermis in a latent state. Lesions are less numerous and less painful in recurrent infections.
Diagnosis
► Culture of the material taken from the lesion is the gold standard. If culture cannot be performed, the detection of multinucleated giant cells (hourglass cells) with intranuclear eosinophilic inclusion bodies in the cytological examination of the swab is helpful in the diagnosis.
Treatment
► Acyclovir, famciclovir or valaciclovir are used.
► In the presence of active herpetic lesions in pregnant women, viral load is reduced by using acyclovir or valacyclovir after 36 weeks. Acyclovir can also be given systemically during pregnancy.
If there are active herpetic lesions during the labor period, cesarean section is recommended to prevent transmission to the fetus. Infection of the newborn is 60% mortal and causes neuroophthalmic sequelae in at least half of the surviving cases.
syphilis
• It is caused by Treponema pallidum, a spirochete. It is an anaerobic bacterium that can never be reproduced. Because it is very mobile, it can be seen in samples by dark field microscopy.
Clinic
► Early Syphilis: It is the infectious stage and is divided into 2 periods.
0 Primary syphilis: After the first contact, a painless, indurated and hard ulcer (chancre) occurs. Chancre is contagious and will heal on its own within a few weeks. Painless LAP develops 1-2 weeks after the appearance of the chancre. Serological syphilis tests are negative in this period.
Secondary syphilis: It begins 2-10 weeks after the primary lesion. In this period, generalized LAP, ulcerable papillary lesion (condyloma lata) development is typical and very infective. Serological tests are positive during this period.
► Latent Syphilis: In this stage, which can last for one or two years, the diagnosis can be made only by serological tests. While nontreponemal tests become negative, treponemal serological tests remain reactive.
► Late (Tertiary) Syphilis: Years after the onset, the gommatous period begins, which affects all organs and progresses slowly. In this period, granulomatous lesions called gom commonly cause organ involvement. There are no bacilli in the gums and there is no transmission.
Diagnosis
Non-treponemal Tests
Among these tests, which are screening tests for syphilis, the most used ones are:
VDRL (Venerial Disease Research Laboratory)
RPR (Rapid Plasma Reagin)
Treponemal Tests
They become positive from the second week and are diagnostic tests.
FTA-ABS (Fluorescent Treponemal Antibody ABSorbtion) is the first positive test that is reliable.
MHA-TP (Microhemagglutination assay for antibodies to T.pallidum) is more useful.
Treatment
► The drug of choice is penicillin.
Chancroid (Soft Chancr, Ulcus Molle)
Caused by Haemophilus ducreyi, a Gram-negative, coccobacillus bacterium
Chancroid is a cofactor for HIV transmission.
Clinic
► Initially, erythematous, papular lesions are observed. Later, tender inguinal LAP develops with 1-3 ulcers that are vesicular, fragile, easily bleeding and very painful. Ulcers do not have induration. 50% of the cases with lymphadenopathy are suppurated, therefore, if the LAP is fluctuating, chancroid should be considered.
Diagnosis
► Chocolate can be produced on agar. In Gram staining of the material taken from the ulcer edge, the train path pattern of coccobacillus can be seen.
Treatment
► Azithromycin, ceftriaxone, ciprofloxacin, erythromycin
Lymphogranuloma Venereum
• It is produced by serotypes L1,2,3 of Chlamydia trachomatis. Like other serotypes of chlamydia, they do not remain localized and cause systemic disease, especially by involving lymphoid tissue. It is a disease that can lead to the development of vulvar carcinoma.
Clinic
► It occurs in 3 different stages 1-3 weeks after it is taken by sexual contact.
@ Vulvar vesicle or papule period
@ Lymphatic period (characterized by boobs)
@ Anorectal stage (rectal stricture and fistula formation)
► Subclinical primary infection is common and presents as a painless vulvar ulcer that heals spontaneously. This is the initial stage of the disease. One or more ulcers come together to form an inguinal bubo. Painful inguinal lymphadenopathy is observed.
► Since the skin between the enlarging lymph nodes appears sunken, this is called a groove sign and is pathognomonic. Lymphedema is present because lymphatic drainage is impaired.
Diagnosis
It is established by culture study of purulent fluid aspirated from the painful lymph node or by the presence of monoclonal chlamydial antibodies in the aspirated fluid.
Treatment
Azithromycin, doxycycline, ofloxacin, levofloxacin
Granuloma inguinale (donovanosis)
• Its causative agent is Calymmatobacterium (Klebsiella) granulomatis, a small encapsulated bacterium in Gram-negative coccobacillus structure.
Clinic
► It starts as a small nodule or papule on the vulva, then enlarges and turns into painless, easily bleeding ulcers.
► Generally, ulcers are not accompanied by LAP.
Diagnosis
► Gram-negative bipolar rods are seen within mononuclear leukocytes when a direct smear from the ulcer base is stained with Wright or Giemsa; these are called Donovan bodies and are pathognomonic.
► If the smear is negative, the diagnosis is made by biopsy taken from the lesion. Mikulicz cells with rod-shaped cytoplasmic inclusion bodies, scattered large macrophages and granulation tissue infiltrated by plasma cells are observed.
Treatment
Tetracycline, TMP-SMX, ciprofloxacin, erythromycin, azithromycin
Penicillins are not effective in treatment.
diagnostic features in genital ulcers
1. If there is painless induration and a single ulcer, it suggests syphilis.
2. The presence of grouped vesicles with small ulcers, especially the presence of similar lesions in the anamnesis, is almost always pathognomonic for genital herpes. Despite this, a laboratory diagnosis of genital herpes should be made. Culture is the most sensitive and specific test in the vesicular phase.
3. 1-3 extremely painful ulcers accompanied by sensitive and fluctuating inguinal LAP are definitely chancroid.
Genital Papules
Condyloma Acuminata
• Its causative agent is Human Papilloma Virus {HPV}, one of the DNA viruses. Types 6 and 11, which are non-oncogenic, are responsible for genital warts. It is highly contagious and is the most common STD.
• It is transmitted to the partner through sexual intercourse or to the baby vertically. The initiation of the disease is the disruption of the integrity of the epithelial basement membrane due to traumas such as sexual intercourse and the entry of the virus into it. With the effect of HPV, the division of cells forming the basement membrane is stimulated and papillomas develop. Recurrence is due to reactivation of subclinical infection rather than reinfection from the partner.
Clinic and Diagnosis
► Diagnosis is made clinically. Multiple, soft, cauliflower-like, painless lesions occur in wet, moist areas around the vulva, vagina, and anus. Sometimes, flattened lesions, flat condylomas, can be seen on the cervix. These lesions must be examined with biopsy for possible cancer.
► Squamous cells with halo around the pycnotic nucleus in the smear are typical for the diagnosis (koilocytosis). Typing can also be done by DNA hybridization.
Treatment
► The aim is to remove the lesions. It is not possible to eliminate the viral infection.
► In the treatment, podophylline, topical 5-fluorouracil, imiquimod (5% cream), cinecacetin, trichloroacetic acid, bichloroacetic acid, cryotherapy, electrocautery, laser or surgical excision are used. In persistent cases, interferon, photodynamic therapy or topical cidofovir should be tried.
Among these treatments, electrocautery is the most effective, while Imikimod reduces the risk of recurrence the most.
► Growth and spread of condylomas may accelerate during pregnancy. In cases where the lesions are small, no treatment is required. However, trichloroacetic acid can be applied 4 weeks before delivery or electrocoagulation, cryotherapy or laser before 32 weeks of gestation so that cesarean section is not mandatory in large lesions.
In pregnancy, the use of podophylline and imiquimod is contraindicated due to possible cytotoxic effects on the fetus.
Molluscum contagiosum
• Its causative agent is a DNA virus in the Poxviridae group. It is a highly contagious infection transmitted by close sexual or non-sexual contact or auto-inoculation. It is common in crowded environments, close contact sports, public bathrooms and infected towels.
Clinic
► There are slow-growing, 1-5 mm in diameter, pitted, pink, dome-shaped papules. The lesions are contagious until they disappear.
Diagnosis
► It is diagnosed by microscopic observation of the white waxy material in the papule. Wright or Giemsa staining of molluscum bodies (intracytoplasmic eosinophilic inclusion bodies) in the cytoplasm confirms the diagnosis.
Treatment
► Iodine or ferric subsulfate {Monsel solution)
practice is done. Cryotherapy with liquid nitrogen can also be applied.