The Specialist Forum Volume 13 No 11 November 2013

SEXUAL HEALTH Chancroid This is caused by the sexually transmitted gram-negative, anaerobic bacteria, Haemophilius ducreyi. Fortunately it is not that commonly encountered in our clinic. It is characterised by acute genital ulcers and the development of ingunal adenitis and buboes. In men the lesion starts as a papule, surrounded by erythema and soon progresses to a pustule and later forms a painful ulcer. The edges of the ulcer tend to be sharply demarcated. There can be a presence of several ulcers and with time they may coalesce. Most lesions are located on the internal or external surfaces of the prepuce or around the frenulum and can be accompanied by oedema of the prepuce. In women the majority of lesions are within the introital area, however, they may also occur on the cervix or vaginal wall as well as the peri-anal region. In both men and women a painful ingunal lymphadenitis is common and may be unilateral. The inguinal buboes may lead to ulceration and sinus formation. Diagnosis is made clinically and culture of a swab taken from the ulcer can be used as a confirmatory test. One should always be aware of differential of infective causes of genital ulcers which is listed in table III. As for the treatment, the syndromic management approach for genital ulcers is still recommended. Chancroid responds to erythromycin 500mg per mouth qid for seven days. With the HIV epidemic in our country, more and more cases are being detected nowadays. Every now and then, it is encountered as a painless genital ulcer in a venerology clinic or a diffuse non-specific rash of secon ary syphilis, in a dermatology clinic. However due to the routine d use of anti iotics, most doctors will never encounter tertiary syphilis in b their practice. Table III: Disease description Clinical Primary syphilis Tests Painless chancre, begins as a 2mm-3mm papule, undergoes necrosis and erodes. Firm, indurated and rarely tender. Occurs on the penile area or around the cervix. Lymphadenophy develops in one to two weeks. Heals spontaneously within three to eight weeks. Most reliable test is darkfield examination of fluid from the ulcer. Lymphogranuloma venereum Lymphogranuloma venereum is an STI caused by the bacteria Chlamydia trachomatis. In our clinic, many patients tend to have a history of a sexual encounter with somebody from England or other parts of Europe, where the incidence is rising. This disease typically progresses through three stages whereby after the initial infection of the genital mucosa, there is inguinal lymphadenopathy which is commonly unilateral. Thereafter the lymph nodes can coalesce and become a firm mass, with the formation of draining sinuses. This is followed by involution, proctocolitis and involvement of peri-rectal lymphatic tissues. If left untreated, relapses may occur, leading to anal fistulae and rectal strictures. Rarely, meningeal irritation, hepatitis and arthritis can occur due to systemic spread. Inguinal adenopathy is observed in only one third of females and proctitis and pain in the lower abdomen may be the only symptoms. Diagnosis is made clinically, by polymerase chain reaction (PCR) of lesional tissue or serology which can differentiate it from chancroid, Catscratch disease or any other causes of genital ulcers are listed in table III. Crohn’s disease needs to be excluded in cases of ano-genital – rectal involvement, which does not respond to antibiotics. Treatment involves the use of doxycycline caps 100mg b.d for seven days. Donovanosis Donovanosis is caused by the gram negative bacteria, Calymmatobacterium granulomatis. It primarily causes genital ulcers on the glans penis or the vulvar area, which have a characteristic beefy red appearance. Extragenital lesions rarely occur due to auto-inoculation or dissemination and have been observed in the skin, bones and oral cavity. The diagnosis can be confirmed by the demonstration of Donovan b odies in tissue smears. This disease should be treated for a longer period of time, with doxycycline caps 100mg b.d for three weeks or until all lesions are completely healed. Syphilis Other sexually transmitted infection of bacterial origin includes syphilis. The Specialist Forum | November 2013 FTA-IgM is positive after two weeks. RPR is a screening test, titres can be positive for live and can be used to evaluate response to therapy. A falling titre shows that the disease is cured. VDRL can also be used for testing. Secondary Systemic, cutaneous and syphilis mucosal signs as well as weight loss. Generalised nonpruritic, pink, scaling, papular rash in over 80% of patients. Symmetric, hyperpigmented, oval papules with a collarete scale appears on the palms and soles of most patients. Patient can also have alopecia, pigmentary disturbances and anal condyloma lata( highly infectious). 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The Specialist Forum Volume 13 No 11 November 2013 | Page 19