Genital ulcer disease (gud)


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Genital ulcer disease (gud)

  2. 2. 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.
  3. 3. Genital ulcer disease Definition: Ulcerative, erosive, pustular or vesicular lesions on the genitalia with or without lymphadenopathy
  4. 4. 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
  5. 5. Etiology cont’d B. 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.
  6. 6. 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
  7. 7. 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
  8. 8. 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.
  9. 9. 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
  10. 10. 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
  11. 11. Physical Examination 1. General examination: • Thorough examination of the oral cavity, skin of torso, palms and soles and neurological examination, including cranial nerves 2. 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
  12. 12. 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
  13. 13. 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.
  14. 14. 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
  15. 15. 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
  16. 16. 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 ulcer Non-indurated, bleeds profusely on touch Non-tender
  17. 17. Genital Ulcer Evaluation 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
  18. 18. Treatment
  19. 19. Genital Herpes First Clinical Episode Acyclovir 400 mg tid or Famciclovir 250 mg tid or Valacyclovir 1000 mg bid Duration of Therapy 7-10 days
  20. 20. Genital Herpes Episodic Therapy Acyclovir 400 mg three times daily x 5 days or Acyclovir 800 mg twice daily x 5 days or Famciclovir 125 mg twice daily x 5 days or Valacyclovir 500 mg twice daily x 3-5 days or Valacyclovir 1 gm orally daily x 5 days
  21. 21. 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
  22. 22. Chancroid Azithromycin 1 gm orally or Ceftriaxone 250 mg IM in a single dose or Ciprofloxacin 500 mg twice daily x 3 days or Erythromycin base 500 mg tid x 7 days
  23. 23. Lymphogranuloma Venereum Recommended regimen Doxycycline 100 mg twice daily for 21 days Alternative regimen Erythromycin base 500 mg four times daily for 21 days
  24. 24. Granuloma Inguinale Doxycycline 100 mg twice daily or Trimethoprim-sulfamethoxazole 800 mg/160 mg twice daily Minimum treatment duration three weeks
  25. 25. 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
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