Download - Genital ulcer disease (gud)
GENITAL ULCER DISEASE
Genital Ulcer Disease (GUD)
Objectives:
1. Discuss the epidemiology and etiology of GUD.
2. Describe the clinical manifestations according to the etiologic agent involved.
3. Choose the appropriate diagnostic evaluation.
4. Select the appropriate treatment.
5. Discuss the follow-up of patients and the management of sexual partners.
6. List potential complications.
Genital ulcer disease
Definition:
Ulcerative, erosive, pustular or vesicular lesions on the genitalia with or without lymphadenopathy
Etiology
A. STD-related etiologies and organisms:
1. Genital herpes: Herpes Simplex Virus Type 1 and Type 2
2. Primary syphilis: Treponema pallidum var. pallidum
3. Chancroid: Haemophilus ducreyi
4. Lymphogranuloma venereum (LGV): Chlamydia trachomatis serovars L1-L3
5. Granuloma inguinale (Donovanosis): Calymmatobacterium granulomatis
Etiology cont’dB. Non STD-related etiologies:
1. Non-STD infectious causes of GUD: Candidiasis/balanitis, scabies, common skin infections (e.g. Staph).
2. Non-infectious causes of GUD: aphthous ulcers, Behcet’s syndrome, fixed drug eruption, Reiter’s syndrome, trauma/abrasions.
Etilogy cont’d
C. No etiology is found in 20% to 30-50% of GUD cases
- related to the sensitivity of the laboratory tests
. affected by self-medication, . duration of lesion , . technology of the test
EPIDEMIOLOGY
Incidence• In developed countries (In the USA and Europe)
• The most frequent cause of GUD is Herpes (62 %), followed by syphilis (13 % ) then by chancroid (12-20 %) . LGV very rare Donovanosis is almost never encountered in USA • GUD may comprise ~5% STD visits in USA
• Estimated number of GUD (herpes + syphilis +chancroid ) is 1/50th combined number of reported cases of gonorrhea and Chlamydia
Epidemiology cont’d
2. In developing world:
• The most frequent cause of GUD is Chancroid followed by syphilis, then by genital herpes
• There are reports (studies) indicating that HSV is increasing, being the leading cause of GUD
• Granuloma Inguinale – endemic in India, Papua New Guinea, central Australia, Southern Africa and Brazil. • In sub-Saharan Africa and Asia GUD can account for 20%- 70% STD clinic visits.
DIAGNOSTIC APPROACH
Patient history:
1. Lesion history: - prodrome,
- initial presentation (especially presence of vesicles, recurrence) - duration of lesions
- presence of pain & other symptoms
- use of systemic or topical remedies
- any history of similar symptoms in the past
- partners with similar symptoms
2. Medical history: HIV status, skin conditions, drug allergies, medication
3. Sexual history:
Gender of partners
Number of partners (New, etc)
Commercial sex exposure
Partners with signs and symptoms
Partners with known HSV or recent syphilis diagnosis
Physical Examination
1. General examination: • Thorough examination of the oral cavity, skin of torso, palms and soles and neurological examination, including cranial nerves2. exam of the groins Lymph nodes: note and location of enlarged lymph nodes size tenderness presence of bubo 3. Genital exam: exam genital and perianal area for: a. ulcerative lesion: - exam for - appearance, - distribution, - size, - number, - induration, - depth - tenderness b. other lesions
Clinical features - Clinical presentation may overlap or be atypical. - Co infections may occur in up to 10% cases.
Characteristics of GUD associated with the different etiologic agents:
Typical presentation:
1. Genital Herpes: Type of lesions: Duration L/nodes Vesicles, then ulcer 17-20 days firm, Number- multiple & clustered (primary ) tender bilateral few ulcers (recurrent) 5-10 days Borders- erythematous Base- red, smooth, w/o indurations Depth- Superficial Painful
2.Primary syphilis
Type of lesions duration l/nodes
Enlarged,Papule, then ulcer 1—6 wks Bilateral Number- usually single, mobile rarely multiple lesions, firm discrete Borders- demarcated, rolled non-tender
Base-indurated, red, smooth, clean
Depth- Superficial Painless.
3. Chancroid incubation 3-10 days
Types of lesion Duration L/nodes Papules, Pustules, then ulcer 2 -3 weeks or more enlarged, Number- usually one, tender multiple lesions matted Borders- ragged, undermined Base- Soft with purulent exudates suppurative, Depth- Deep unilateral Painful
LGV Incubation -3-30 days
Types of lesion Duration (1-2 wks) Lymph nodes Often presenting symptoms.
rarely presents as GUD multiple enlarged matted, tender may suppurate “Groove sign” –(30-40% ) Papules, then ulcer Number usually one Borders- variable Base- w/o indurations Depth- Superficial Painless
Donovanosis incubation not precisely known (few days-months)
Types of lesion Lymph nodes Firm, papules or Subc. Nodules L/nodes are not involved then, ulcer Swelling in the groin Number- usually single, multiple resembling bubo- suppurative
Borders- variable pseudobubo Base- fleshy, beef-red granulomatous ( this is subcut granuloma) breaks to form un ulcerNon-indurated, bleeds profusely on touch
Non-tender
Genital UlcerEvaluation
Diagnosis based on medical history and physical examination often inaccurate
Serologic test for syphilis
Culture/antigen test for herpes simplex
Haemophilus ducreyi culture in settings where chancroid is
prevalent
Biopsy may be useful
Treatment
Genital Herpes
First Clinical Episode
Acyclovir 400 mg tidor
Famciclovir 250 mg tid or
Valacyclovir 1000 mg bid
Duration of Therapy 7-10 days
Genital Herpes Episodic Therapy
Acyclovir 400 mg three times daily x 5 daysor
Acyclovir 800 mg twice daily x 5 daysor
Famciclovir 125 mg twice daily x 5 daysor
Valacyclovir 500 mg twice daily x 3-5 daysor
Valacyclovir 1 gm orally daily x 5 days
Syphilis
Primary, Secondary, Early Latent
Recommended regimen Benzathine Penicillin G, 2.4 million units IM
Penicillin Allergy* Doxycycline 100 mg twice daily x 14 days
or Ceftriaxone 1 gm IM/IV daily x 8-10 days (limited studies)
or Azithromycin 2 gm single oral dose (preliminary data)
*Use in HIV-infection has not been studied
ChancroidAzithromycin 1 gm orally
orCeftriaxone 250 mg IM in a single dose
orCiprofloxacin 500 mg twice daily x 3 days
orErythromycin base 500 mg tid x 7 days
Lymphogranuloma Venereum
Recommended regimen
Doxycycline 100 mg twice daily for 21 days
Alternative regimen
Erythromycin base 500 mg four times daily for 21 days
Granuloma Inguinale
Doxycycline 100 mg twice dailyor
Trimethoprim-sulfamethoxazole 800 mg/160 mg twice daily
Minimum treatment duration three weeks
Granuloma Inguinale
Ciprofloxacin 750 mg twice daily or
Erythromycin base 500 mg four times daily or
Azithromycin 1 gm orally weekly
Minimum treatment duration three weeks
Alternative regimens