Genital ulcers and uretrits

(Last Updated On: 8 March 2020)

Introduction:

• These are all bacterial, viral, parasitic or mycosic conditions transmitted sexually

Bacteria: Syphilis, soft canker, Donovanose, Nicolas-Favre's disease

Virus: genital herpes, venereal vegetation (HPV), HIV

Yeasts: Genital Candidiasis

• Responsible microorganisms are cosmopolitan
• Higher prevalence in tropical countries and Africa.
• In these regions, STIs are characterized by a higher incidence of complications

 

Genital ulcers

Definition

• Loss of substance, skin-mucous membrane, single or multiple, of infectious origin
• Eliminate:

Causal, traumatic (mechanical or physical) ulceration by interrogation

Genital aphtosis that most often sits on the scrotum and performs a widening ulceration,

clear, recurrent and painful limits associated with episodes of oral aphtosis

Primitive/secondary neoplastic ulceration

 

Primary Syphilis

• Syphilitic inoculation chancre: Treponema pallidum, exulceration (superficial ulceration) or

erosion of 5-15 mm in diameter, unique, clean-bottomed, rosé, undured or cardboard to palpation,

painless, 3-6 weeks

Seat: most often at the genital level:

▪ In humans: balano-preputial furrow, more rarely on the

acorn or sheath of the penis

▪ In women: at the outer part of the vulva, ulceration can also sit at the vaginal or extra-vaginal level: oral, oropharyngeal or anorectal

Adenopathy: it is non-inflammatory (painless, non-ulcerated), it is in fact a packet of adenopathies in which we find a large ganglion, usually unilateral on the same side as the canker, it never evolves towards fistulization

Evolution: Primary syphilis spontaneously progresses to regression without sequelae within a few weeks, regular and smooth scar

Paraclinical diagnosis:

▪ Highlighting pale treponeme: by a direct examination under a black-bottomed microscope: scraping the serouss at the bottom of the canker, pale treponemes are observed as spiral, shiny and mobile bacteria

▪ Serology: there are two types:

Specific serology (treponemic serology): TPHA is mainly used

Non-specific serology (reagenic serology): it is VDRL

In practice, you should always ask for a TPHA and a VDRL

 

 

 

 

 

 

 

Serology is positive a few days after the onset of canker: TPHA is positive between the 7th and 10th day, the VDRL is positive between the 10th and 15th day of the canker

Treatment:

▪ Benzathine Benzyl Penicillin (Extencillin®): 2.4 million units im injection

single dose, sometimes repeated after 1 week

In case of penicillin allergy: the treatment will be Doxycycline 100 mg 2x/d

15 days

▪ Surveillance after treatment: it is done on quantitative VDRL at 3 months, 6 months, 1 year and 2 years. Antibody levels should gradually decrease and negative after one year

 

Herpes

• Viral disease due to Herpes simplex, high frequency, significant risk during pregnancy

(neonatal herpes)

• Clinical diagnosis:

First-year herpetic infection: young adult, woman and man are affected, incubation varies

2 to 60 days with an average of 6 days

▪ In Women:

Erosive acute vulvitis: Erythematous edemamatosus edemaous and inflammatory background develop multiple vesicles, which will rupture giving way to erosions

Seat: large lips, inner face of the

small lips

Functional signs: intense, pain,

burns and urination gene

Adenopathies: inguinal, bilateral,

complete this picture

Evolution: is moving towards the disappearance of

lesions in 3 to 4 weeks

▪ In men: the clinical picture is that of an acute bladder and then erosive balanite, less painful and less sensitive than in women.  Healing is faster

Recurrent genital herpes: after the first infection, the virus migrates to the corresponding lymph node, it remains latent but likely to reactivate

▪ Triggering factor: it may be sex, menstruation,

Stress…

▪ Prodromes: it may be a burning sensation, a cooking sensation or a

Pruritus

▪ Then appears a rash made of a rash quickly covered with several vesicles grouped in bouquets. These vesicles will rupture giving way to erosions that dry out and disappear without leaving scars

• Paraclinical diagnosis: necessary in atypical or complicated forms, in women

pregnant, newborn and immunosuppressed. One can highlight herpes simplex virus after culture on cell media (this is the current reference method), PCR (HSV1, HSV2), cytodiagnosis (evidence of ballooned cell, confirms the diagnosis of an infection with a HSV group)

 

 

 

 

 

 

 

• Treatment:

Symptomatic treatment: avoid overinfection, dry lesions, never give alcoholic products on mucous membranes and erosions, never ointment as it macerates, never dermocorticoid

▪ By general means: painkillers can be used for pain

▪ Locally: antiseptics can be used as a watery solution

Antiviral treatment: Acyclovir (tablets at 200 mg, 1 tablet 5 x/d, for 10 days), new antivirals (Valcyclovir, Fanacyclovir)

 

Soft chancre

• Tropical contamination, endemic in black Africa, Latin America
• It is a sexually transmitted genital ulceration due to Ducrey's bacillus, Gram bacillus (-), it

is highly contagious and self-inoculable

• It is more common in men than in women
• Clinical diagnosis: incubation is short (3-7 days), followed by canker (deep ulceration)

1 cm, dirty bottom, hemorrhagic, undurable, irregular edges, shredded)

Protected palpation: regains a soft base and highlights the painful nature of

this ulceration, multiple in 50% of cases

Adenopathy: is unique, one-sided, voluminous and inflammatory (red, hot and

painful)

Evolution: it evolves towards fistulization by a single orifice

• Paraclinical diagnosis: although the diagnosis of soft canker is clinical, Haemophilus ducreyi

can be highlighted: direct examination after toluidine blue coloring, culture, PCR

• Treatment: You can use:

Erythromycin: 2 g per day, per bone, for 10 days

Ciprofloxacin: 500 mg, 2x/d, for 3 days

 

	Syphilis Primary	Soft chancre	Lymphogranuloma venerated	Donovanose	Herpes Genital
Etiology	Treponema Pallidum	Haemophilus ducreyi	Chlamydia Trachomatis	Calymmatobacterium granulomatosis	Herpes virus Hominis
Incubation	21 d	4-5 d	7-12 d	8-80 d	First: 2-12 d Recurring…
Ulceration	Clean, undulatly, painless	Dirty Multiple Painful	Minimal, unnoticed	Granulomatous, clean, painless	Superficial, polycyclic, painful
Duration evolution	3-6 weeks.	Indefinite (months)	2-6 d	Indefinite (years)	7-10 d
Lymphadenopathy Regional	Painless, non-painless ulcerated	Painful, ulcerated	Painful, ulcerated	Absent	Inconsistent
Diagnosis	Review Direct Serology	Culture	Culture on cells, serology	Direct review, histology	Culture on Cells

 

 

 

 

 

 

 

Other STIs

• Venereal vegetation: these are HPV-induced lesions, some of which are oncogene, hence the need

to destroy this type of lesion

• STI without genital impairment: hepatitis B, C that puts the patient at risk of cirrhosis that is the bed

liver cancer

• Aids

 

Therapeutic recommendations

• Any genital ulceration should be considered syphilis and treated as follows:

Benzathine Penicillin G (1 IM injection of 2.4 MUI systemically)

Erythromycin (2 g per bone, in 4 daily intakes) or Azithromycin (1 g per bone, single intake) while waiting for the results of the check-up, to treat an associated Chlamydia trachomatis urethritis, soft canker, Nicolas-Favre disease, overinfection streptococcal associated

Valaciclovir (500 mg, 2x/d, for 10 days) in case of high suspicion of Herpes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Urtrians

Definition

• These are inflammations, of infectious and sexual origin, that require management

because of their contagiousness and the accompanying complications,

especially infertility

• They are characterized by a urethral flow, several pathogenic germs are involved in urethrtis; however, Neisseria gonorrhoeae (NG) in the Third World and Chlamydia trachomatis (CT) and M. genitalium in developed countries share most cases.
• Their association is proven in nearly 10% of cases, incubation is 2-5 days for NG and 1-5

weeks for CT

 

classification

We have three groups of uretrites:

• Gonococcal Urtrites: The agent responsible is Neisseria Gonorrhoeae
• Non-gonococcal Uretrites: Chlamydia trachomatis (50%, infertility), Mycoplasmes,

Trichomonas vaginalis

• Mixed Urtrites: gonococcal – non-gonococcal

 

 

 

 

Clinical diagnosis

• It is evident when there is a spontaneous flow through the meat, very

painful and out of urination.

Plenty of flow, yellow, thick, staining the washing line

de NG

Translucent, low-intensity, low-painful flow

evocative CT or Mycoplasma

• Diagnosis is more difficult when symptomatology is poor to type

isolated morning flow, glued meat, urination burns,

canal or dysury pruritus

• In these conditions, two exams are important because they perform well:

Uretral rubs: is positive in 75% of NG and 25% of CTs

Examination of the centrifugation of the first urinary jet: which allow to define biological urethritis by the existence of 5 leukocytes/field, is positive in 95% of NG and 75% of CT

• In the face of any urethritis, it is necessary to look for complications or pathological associations: epididymite, orchi-epididymite, prostatitis, conjunctivitis, skin-joint signs, female genital damage

 

Treatment

 

Urtrians Cervicites	Neisseria gonorrhoeae	Penicillin, Spectinomycin, Cephalosporin, Thiamphhenecol
	Chlamydia trachomatis	Tetracyclines, Erythromycin
Urtrians	Mycoplasma hominis Ureaplasma urealyticum	Tetracyclines
	Mycoplasmaium genital	Azithromycin: J1: 500 mg, J2-J5: 250 mg/d

 

• Treatment of 2 partners at the same time
• Therapeutic recommendations:

Uncomplicated infection

 

Chlamydia trachomatis:

 

Azithromycin (1 g, per bone,

single dose) or Doxycycline

(per bone, 100 mg 2x/d, during

7 days)