The Specialist Forum Volume 13 No 11 November 2013 | Page 20
SEXUAL HEALTH
Table IV: Differential for genital ulcers
Disease
Incubation time (days) Clinical lesion
Diagnosis
Organism
Chancroid
3-10
Purulent, multiple ulcers, painful
Culture
H. Ducreyi
Herpes
3-7
Vesicles, erosions, ulcers, painful and
recurrent
Tsanck smear,
culture, PCR
HSV 1,2
Primary syphillis
10-90
Usually single, painless, indurated
ulcer
Serology, Dark field Trepanoma pallidum
microscopy
Lymphogranuloma venerum
3-12
Transient painless ulcer
Serology
Chlamydia trachomatis
Donovanosis
14-60
Chronic indurated red fleshy ulcer
Smears, Histology
C. Granulomatis
of genital ulcers in our South African guidelines. Though HIV positive patients respond better to the use of acyclovir for syndrome management, it
should be used in all patients.
Genital herpes presents as multiple papules or vesicles which can have
a burning, painful feeling. These break down to form a slow healing ulcer
with recurrences at the previously affected site. The management entails
the use of acyclovir tabs 400mg tablets t.d.s for five to seven days or famciclovir tablets 250mg t.d.s for five days.
During the past few years, there has been an increasing awareness of
the human papilloma virus (HPV 16, 18) and its association with cervical
cancer. It is mostly sexually transmitted and can lead to warts in the genital
region, cervix cancer as well as squamous cell carcinomas of the penis,
vulva or rectum. Once established, the treatment of genital warts can be
very challenging with frequent relapses and cure is rare. Fortunately nowadays we have two vaccines, gardasil and cervarix, which can be used to
immunise young females between the ages of 10 to 26 years against HPV
16, 18, thereby decreasing the chance of having cervix cancer, as well as
prevention of genital warts. It has been proven to decrease the incidence
of genital warts in young males as well. See table V for treatment options.
Molluscum contagiosum
Molluscum contagiosum is caused by a ‘pox virus’ and is very commonly encountered in our clinic. It presents as small umbilicated papules
which is commonly mistaken for warts. Areas commonly affected are the
perineum, upper thighs or penis. It is highly contagious. Early treatment
with podophyllin, cryotherapy or cautery can cure the disease.
One should not forget that there are hundreds of skin diseases that
can affect the genital area and if unsure, the patient needs to be referred
to a dermatologist for a proper diagnosis. Diseases like Lichen planus,
Behcet’s disease or Pemphigus vulgaris can commonly be the cause for
genital ulcers. Unspecific rashes in the genital area can include eczema;
psoriasis, contact dermatitis; extramammary Paget’s disease, candida
and many others.
At the DISA clinic, we are seeing a growing trend of psychological problems secondary to exposure to STIs and this should not be ignored. After
an encounter, many patients get a fright and can end up having penile
pre-occupation or vaginal pre-occupation. This is more common in men,
where they take regular breaks at work to examine their private parts to
ascertain whether something has grown from the time of the last inspection or if there is a rash. These patients make regular visits to their doctors
fully convinced that they have caught a disease, and become sexually
withdrawn, despite having no clinical signs or negative serological tests.
Psychological help through counselling may benefit some.
Conclusion
In conclusion, STIs have been described from antiquity and are here to
stay. However with the evolution of society, availability of information and
access to treatment most of the morbidities can be prevented. HIV still
remains on top of the list and still requires the most attention. However, the
rest of the diseases can be easily managed using the syndromic management guidelines from the Department of Health.
References available on request.? SF
Table V: Treatment options
Physical destruction:
Cryotherapy: Use of liquid nitrogen can have up to 50% success rate.
It is a simple procedure with two freeze-thaw cycles, leading to wart
necrosis. It does have a high recurrence rate over a three month cycle.
Electrocautery: Slightly more painful, however not always practical
in the rooms. An area of approximately 2mm around the wart should
also be treated. It has a chance of causing scars and recurrence rate
is around 30%-40% within three months.
Trichloroacetic acid: 70%-90% solution is a cheap and effective
method to treat genital warts. It is safe in pregnancy, however, can
be quite painful. Recurrence rate is similar to other physical methods.
Laser vaporisation: This is usually performed in theatre and is very
costly. A carbon dioxide is usually used. Success rate is similar to the
other methods listed above.
Cytotoxic or Antiviral agents:
Podophyllin or podophyllatoxin solutions: This is highly effective for
warts in the anogenital region. It is applied with a cotton earbud and ??\?Y??Y?\???\? ??]?[??H ?\X]Y?[ \??]H^\?B??X?\??[??H ?]H\?\??[? ? KL? H ?][? ?YH[? ???[?^X?[?[??X?[??Y? HY??X?]?K Z[??[[???? K???Y??\? IH?X[N??? ?Y[ H]?Z[X?H[??K??? [?\?X?[?X[N??[?[ ???H \?Y[? H?[?][ ?Y?[??]\?H??????X?H??[? ?H? \?K]\?] ?[ ?\? ???]?\? H ?X??\?? ?]H\?\??[?
L H[? H ?Y?[???[[][??[? []?N??[Z\]Z[[??]\??Y[??Z[YY ??H ?\?HY??X?]?H???H[?\??][?[?? YY\??[? ?[\?[?[[??X?[?? ?]?[?YH?][\ ?[?Y?[??\?H\???]X?^ \?Y[??H[? H??[ ?] [????]?\? ? YY\??Z[H \?? H?X\?[??H ?]]?[??X\?[??H?\?[ [? ?X]Y\?[????X?\??[??H ?]H\?????[?\??][?[???\?[??H??RQ?[??\?[?Y??X?B??LLHX?[X?\???\H????Y?H ?BBBBBBBBBB????[X?\? ? L? H?X?X[\???[B??