Genital Ulceration

Syphilis

Description

This is an infection caused by spirochaetes called Treponema pallidum, a corkscrew-shaped organism with an incubation period of 9 to 90 days.

Signs and Symptoms

Primary:
- Painless papule/ulcer called a chancre found on the glans penis, shaft, anus and rectum in men, whereas in women it is found on the vulva, cervix and perineum.
- Bilateral inguinal
Secondary:
- Cutaneous rashes may affect the soles and
- Patchy hair loss
- Oral ulcers
- Condylomata lata
- Generalised lymphadenopathy
- Uveitis)
- Arthritis
- Meningitis
- Glomerulitis
Tertiary:
- Aortic aneurysm
- Aortic valvular insufficiency
- Dementia

Manic syndrome
Congenital syphilis presents with clinical features as those of secondary syphilis in adults.

Investigations

Screening: VDRL (Venereal Disease Research Laboratory), RPR (Rapid Plasma Reagin)

Confirmatory test: Treponema Palidum Haemaglutinin Assay (TPHA)

Treatment

STI Syndrome	Recommended Actions	Preferred drugs	Alternative drugs
	Treat for Vaginal candidiasis	Fluconazole 150mg PO stat	Clotrimazole vaginal pessaries 200mg OD for 3 days OR Miconazole vaginal pessaries 200mg for 3 days OR Nystatin pessary 100,000 units Nocte for 14 days
	Treat for Bacterial vaginosis	Metronidazole 400mg PO BD for 7 days OR Metronidazole 0.75% 5g gel (full applicator) intravaginally OD for 5 days OR Clindamycin cream 2% one full applicator (5g) intravaginally OD for 7 days	Clindamycin 300mg PO BD for 7 days OR Tinidazole 2g PO BD for 3 days OR Tinidazole 1g PO OD for 5 days
	Treat for trichomoniasis	Metronidazole 2g PO stat OR Metronidazole 400mg PO BD for 7 days For children ≤17 years 5mg/kg PO TDS for 7 days	Tinidazole 2g PO stat
Genital Ulcer	Treat for syphilis	Benzathine penicillin 2.4 MU IM stat as a single injection split as 1.2 MU given in each buttock PLUS Azithromycin 1g PO Stat PLUS Doxycycline 100mg PO BD for 21 days PLUS Acyclovir 400mg PO TDS for 7 days	Erythromycin 500mg PO QID for 14 days (in pregnant or lactating woman)
	Treat for chancroid
	Treat for Lymphogranuloma venerium (LGV) Treat for Herpes simplex
Urethral Discharge Syndrome	Treat for gonorrhoea	Ceftriaxone 500mg IM stat PLUS Doxycycline 100mg PO BD for 7 days, Metronidazole 2g PO stat (to treat Trichomonas vaginalis) PLUS Doxycycline 100mg PO BD for 7 days followed by Azithromycin 1g PO stat, then 500mg PO OD for 3 days (to treat M. genitalium)	Cefixime 400mg PO stat Azithromycin 1g PO Stat OR Erythromycin 500mg PO QID for 7 days
	Treat for chlamydia
	If urethral discharge persists after 7 days despite adequate treatment and no history of re-exposure to STI then treat with

Treatment of Genital Ulcers

Most patients with primary or secondary syphilis infection have Jarisch - Herxheimer reaction within 6 hours to 12 hours of initial treatment. The reaction is manifested by generalized malaise, fever, headache, sweating, rigours and a temporary exacerbation of syphilitic lesions. This usually subsides within 24 hours and poses no danger other than the anxiety it produces.

Chancroid

Description

This is an acute, localized, contagious disease characterised by painful genital ulcers and suppurative inguinal
lymph nodes caused by Haemophilus ducreyi

Signs and Symptoms

Small, painful papules
Shallow ulcers in various sizes with ragged undermined edges, painful non-indurated, with a reddish
Enlarged, tender and matted inguinal lymph nodes (Bubo)
The skin over the abscess can become red and shiny and may break down to form a

Complications

Phimosis, Urethral stricture, Urethral fistula
Severe tissue destruction leading to a phagedenic ulcer which may grow rapidly and cause auto amputation of the penis. Biopsy the ulcer to distinguish from squamous cell carcinoma.

Lymphogranuloma Venereum

Description

This is characterized by transitory primary ulcerative lesion followed by suppurative lymphadenitis. It is
caused by serotypes of Chlamydia trachomatis L1, L2, L3 which are distinct from those causing trachoma,
urethritis, cervicitis and inclusion conjunctivitis.

Signs and Symptoms

A small, transient, non-indurated vesicular rapidly healing ulcer
Unilateral, tender enlarged inguinal lymph nodes, with groove
Multiple sinuses with purulent or bloodstained
Constitutional symptoms of fever, malaise, joint pain, anorexia, and
Backache is common in women in whom the lesion may be on the cervical or upper vagina resulting in the enlargement and suppuration of perirectal and pelvic lymph nodes. This results in the formation of rectovesical and rectovaginal fistulas.

Aspirate suppurating glands with a wide bore needle through intact skin. Avoid incision and drainagethrough a fluctuant area which results in chronic sinus formation

Herpes Genitalis

Description

Herpes Genitalis is an infection of the genital or anogenital area by herpes simplex virus (herpesvirus hominis type 2). Lesions usually develop 4 to 7 days after sexual contact. The condition tends to recur because the virus establishes a latent infection of the sacral sensory nerve from which it reactivates and re-infects the skin

Signs and Symptoms

A small group of painful vesicles develops, they erode and form several superficial, circular ulcers with a red areola, which coalesce.
The ulcers become crusted after a few days and generally heal with scarring in about 10
The inguinal lymph nodes are usually slightly
Tender lesions in men may occur on the prepuce, glans penis, and penile shaft whereas in women may occur on the labia, clitoris, perineum, vagina and cervix.
Generalized malaise, fever, difficulty in micturition or difficulties in

Investigations

RDT for Herpes
Tissue
Skin Scraping for Cytology

Complications

Aseptic meningitis
Transverse myelitis
Autonomic nervous dysfunction involving the sacral region leading to urinary

Granuloma lnguinale (Donovanosis)

Description

This is a chronic granulomatous condition usually involving the genitalia and spreads by sexual contact caused by Klebsiella granulomatis.

Signs and Symptoms

Painless, multiple beefy-red nodule which coalesce to form a large elevated, velvety, ulcerated lesion appearing in menon penis, scrotum, groin and thighs, whereas in women on the vulva, vagina and perineum
There is no

Investigations

Do a punch biopsy of the lesion for histology

Treatment

• Erythromycin 500mg orally 6 hourly for 14 to 21 days
OR
• Azithromycin 1g PO once weekly times 3doses

Genital Growth (Condylomata Acuminata)

Description

This is a fleshy growth found around the anogenital region caused by Human papillomavirus infection HPV6 and 11

Signs and Symptoms

Lesions can be subclinical or overt anogenital warts
Fleshy multi-focal growth of the lower genital tract
For Cervical Warts DO NOT CAUTERISE

Investigations

Biopsy

Treatment

Refer to the Table 134 below

Recommended treatment regimens for syndromic treatment of STIs

The following is the list of recommended treatment regimens for syndromic treatment of STIs:

STI

Syndrome

Recommended Actions

Preferred drugs

Alternative drugs

Vaginal Discharge

Treat for gonorrhoea

Ceftriaxone 500mg IM

Stat (to treat gonococcal infection) Children and Adolescents (≤17 years) Ceftriaxone

25-50mg/kg body weight IM stat

If ≥45kg, use adult

dose

Cefixime 400mg PO stat Children/adolescents <17 years Cefixime 8mg/kg body

weight PO stat

Note: If patient allergic to Cephalosporin use

Gentamycin 240mg IV stat

Treat for chlamydia

Doxycycline 100mg PO BD for 7 days

Azithromycin 1g PO stat

OR

Erythromycin 500mg PO QID 7 days (in pregnant or lactating woman)

STI Syndrome	Recommended Actions	Preferred drugs	Alternative drugs
	Treat for Vaginal candidiasis	Fluconazole 150mg PO stat	Clotrimazole vaginal pessaries 200mg OD for 3 days OR Miconazole vaginal pessaries 200mg for 3 days OR Nystatin pessary 100,000 units Nocte for 14 days
	Treat for Bacterial vaginosis	Metronidazole 400mg PO BD for 7 days OR Metronidazole 0.75% 5g gel (full applicator) intravaginally OD for 5 days OR Clindamycin cream 2% one full applicator (5g) intravaginally OD for 7 days	Clindamycin 300mg PO BD for 7 days OR Tinidazole 2g PO BD for 3 days OR Tinidazole 1g PO OD for 5 days
	Treat for trichomoniasis	Metronidazole 2g PO stat OR Metronidazole 400mg PO BD for 7 days For children ≤17 years 5mg/kg PO TDS for 7 days	Tinidazole 2g PO stat
Genital Ulcer	Treat for syphilis	Benzathine penicillin 2.4 MU IM stat as a single injection split as 1.2 MU given in each buttock PLUS Azithromycin 1g PO Stat PLUS Doxycycline 100mg PO BD for 21 days PLUS Acyclovir 400mg PO TDS for 7 days	Erythromycin 500mg PO QID for 14 days (in pregnant or lactating woman)
	Treat for chancroid
	Treat for Lymphogranuloma venerium (LGV) Treat for Herpes simplex
Urethral Discharge Syndrome	Treat for gonorrhoea	Ceftriaxone 500mg IM stat PLUS Doxycycline 100mg PO BD for 7 days, Metronidazole 2g PO stat (to treat Trichomonas vaginalis) PLUS Doxycycline 100mg PO BD for 7 days followed by Azithromycin 1g PO stat, then 500mg PO OD for 3 days (to treat M. genitalium)	Cefixime 400mg PO stat Azithromycin 1g PO Stat OR Erythromycin 500mg PO QID for 7 days
	Treat for chlamydia
	If urethral discharge persists after 7 days despite adequate treatment and no history of re-exposure to STI then treat with

STI Syndrome	Recommended Actions	Preferred drugs	Alternative drugs
Inguinal Bubo†	Aspirate FLUCTUANT bubo with a large bore needle through normal skin Treat for chancroid Treat for LGV	Azithromycin 1g PO stat PLUS Doxycycline 100mg PO BD for 21 days	Ceftriaxone 500mg IM stat OR Cefixime 400mg PO stat If pregnant or lactating woman use Erythromycin 500mg PO QID 21 days (Note: Do not use Doxycycline)
Female Lower Abdominal Pain (PID) Outpatient	Treat for gonorrhoea, chlamydia and anaerobic bacteria at the same time	Ceftriaxone, 500mg IM stat PLUS Doxycycline 100 mg PO BD for 14 days PLUS Metronidazole 400mg PO TDS 14 days OR Metronidazole 2g PO stat (to treat anaerobic bacteria)	Cefixime 400mg PO stat PLUS Erythromycin 500mg PO QID for 14 days
Female Lower Abdominal Pain (PID) Inpatient	Treat for gonorrhoea, chlamydia, and Anaerobic bacteria at the same time	Ceftriaxone 1g IV stat PLUS Doxycycline 100mg PO BD for 14 days PLUS Metronidazole 500mg PO TDS for 14 days OR Metronidazole 500mg IV BD for 7 days Note: Switch to oral treatment upon clinical improvement and continue up to 14 days	Cefixime 400mg PO stat PLUS Erythromycin 500mg PO QID for 14 days
Genital Growth	Treat for Condylomata acuminata (ano- genital warts	Podophyllin 25% tincture. Apply topically weekly up to 12 weeks (protect surrounding normal skin with Vaseline jelly before application by health care provider) Imiquimod cream 5% applied at bedtime 3 times a week up to a duration of 8-12 weeks	Cauterization, Trichloroacetic Acid (weekly), Cryotherapy (fortnightly) Surgical excision of warts for isolated lesions
	Treat for Condylomata lata	Benzathine Penicillin 2.4 MU IM stat

STI Syndrome	Recommended Actions	Preferred drugs	Alternative drugs
Scrotal Swelling	Treat for donorrhoea	Ceftriaxone 500mg IM stat PLUS Doxycycline 100mg PO BD for 14 days	Cefixime 400mg PO stat
	Treat for Chlamydia		Azithromycin 1g PO weekly for 2 weeks (Total of 2 doses) OR Erythromycin 500mg PO QID for 14 days
Neonatal Conjunctivitis	Treat for gonorrhoea and chlamydia	Ceftriaxone 25 – 50mg/kg body weight (max. 125mg) IM stat PLUS Erythromycin syrup, 50mg/kg body weight PO daily in 4 divided doses for 14 days PLUS Saline lavage of eyes	Cefotaxime 100mg per kg/body weight IV/IM stat

Risk The vaginal discharge algorithm is not very sensitive for predicting presence of cervical infection (Gonorrhoea and Chlamydia). Speculum examination improves its diagnostic utility. However, presence of certain risk factors increases the sensitivity and specificity of the algorithm for predicting cervicitis. Routine use of risk assessment is therefore recommended in all cases of vaginal discharge where speculum examination is not available or feasible. Consider risk assessment to be positive if the client is sexually active and has one or more of the following:
1. Has engaged in sex with multiple partners in last three months
2. Has had a new sex partner in the last three months
3. Has a current partner with an STI
4. Has a history of an inappropriately treated STI
5. Is a victim of sexual assault

Inguinal bubo accompanied with genital ulcer(s) should receive treatment as for genital ulcer disease.

Zambia

Genital Ulceration

Syphilis

Chancroid

Lymphogranuloma Venereum

Herpes Genitalis

Granuloma lnguinale (Donovanosis)

Genital Growth (Condylomata Acuminata)