Gynecology 5th year, 2nd lecture (Dr. Sindus)

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The lecture has been given on Nov. 8th, 2010 by Dr. Sindus.

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  • Gynecology 5th year, 2nd lecture (Dr. Sindus)

    1. 1. Sexually transmittedSexually transmitted infectionsinfections
    2. 2. II NonII Non –– Herpetic Genital ulcerHerpetic Genital ulcer 11 –– Syphilis :Syphilis : Is a systemic sexually transmissible infectionIs a systemic sexually transmissible infection caused by trepanoma pallidum.caused by trepanoma pallidum. Other trepanomas include :Other trepanomas include : 11 –– T. Paertenue causes Yaws.T. Paertenue causes Yaws. 22 –– T. Pallidum endemicum causes endemicT. Pallidum endemicum causes endemic syphilis.syphilis. 33 –– T. Carateum causes pinta .T. Carateum causes pinta . The last three ( Tropical Trepanomatosis ) are notThe last three ( Tropical Trepanomatosis ) are not sexually transmitted.sexually transmitted.
    3. 3. Clinical features :Clinical features : The first manifestation of venereal syphilis is aThe first manifestation of venereal syphilis is a painless ulcer ( chancre ) at the site of inoculation.painless ulcer ( chancre ) at the site of inoculation. These can be multiple. The regional lymph nodesThese can be multiple. The regional lymph nodes become enlarged.become enlarged. In women the commonest site for a chancre is on theIn women the commonest site for a chancre is on the cervix. It may therefore pass unnoticed. It usually arisecervix. It may therefore pass unnoticed. It usually arise 3-6 weeks after infection. It is painless and resolve3-6 weeks after infection. It is painless and resolve spontaneously without treatment after a few weeks. Itspontaneously without treatment after a few weeks. It has a rubbery consistency and accompanied by inguinalhas a rubbery consistency and accompanied by inguinal lymphadenopathy.lymphadenopathy.
    4. 4. Secondary syphilis can appear as the chancreSecondary syphilis can appear as the chancre disappear or up to 6 months later , manifestations bydisappear or up to 6 months later , manifestations by systemic eruption, most often a non itchingsystemic eruption, most often a non itching maculopapular rash. It is symmetrical and involve themaculopapular rash. It is symmetrical and involve the palms of the hands and soles of the feet. More floridpalms of the hands and soles of the feet. More florid lesions resembling warts, condylomata lata are seen inlesions resembling warts, condylomata lata are seen in intertriginous areas particularly perianally. Mucousintertriginous areas particularly perianally. Mucous pathos and lines ( snail track ) ulcers are seen on thepathos and lines ( snail track ) ulcers are seen on the mucosal surface. There may be generalizemucosal surface. There may be generalize lyphadenopathy.lyphadenopathy. 0ther manifestations include :0ther manifestations include : 11 –– alopecia.alopecia. 22 –– Arthritis.Arthritis. 33 –– Meningitis.Meningitis.
    5. 5. Mucous patches, oralMucous patches, oral
    6. 6. Diagnosis :Diagnosis : 11 –– Diagnosis of primary syphilis is made byDiagnosis of primary syphilis is made by demonstrating the organism by dark field microscopy.demonstrating the organism by dark field microscopy. The lesion is cleaned and mildly abraded, so that clearThe lesion is cleaned and mildly abraded, so that clear serum exude from the base, mixed with a drop ofserum exude from the base, mixed with a drop of saline on a microscope slide. Slide viewed under highsaline on a microscope slide. Slide viewed under high power ( 3800 X ) using dark field illumination.power ( 3800 X ) using dark field illumination. 22 –– Serological tests :Serological tests : a/a/ Fluorescent trepanoma Ab ( FTA )Fluorescent trepanoma Ab ( FTA ) Most sensitive and specific test for syphilis.Most sensitive and specific test for syphilis. b/b/ Trepanoma pallidum haemagglutination assay (Trepanoma pallidum haemagglutination assay ( TPHA ) or Trepanoma pallidum agglutination (TPPA )TPHA ) or Trepanoma pallidum agglutination (TPPA ) c/c/ Venereal disease reference laboratory ( VDRL )Venereal disease reference laboratory ( VDRL ) test is a reaginic or nontest is a reaginic or non –– specific test.specific test.
    7. 7. d/d/ Rapid plasmen reagin ( RPR ) tests are used,Rapid plasmen reagin ( RPR ) tests are used, titration done such as 1 in 64 at the threshold oftitration done such as 1 in 64 at the threshold of reaction of the test.reaction of the test. In primary syphilis, however the serological test mayIn primary syphilis, however the serological test may all beall be ––ve.ve. 33 –– Biopsy from lesion, sepcilized stain, such as silver,Biopsy from lesion, sepcilized stain, such as silver, reveal the presence of spirochate.reveal the presence of spirochate. * In secondary syphilis, the serological tests are* In secondary syphilis, the serological tests are positive with a VDRL titer of usually 1 in 32 or greater.positive with a VDRL titer of usually 1 in 32 or greater.
    8. 8. * Following treatment of primary or secondary* Following treatment of primary or secondary syphilis the titer of VDRL should fall two foldsyphilis the titer of VDRL should fall two fold every 3 months, becomingevery 3 months, becoming ––ve within 2 years.ve within 2 years. * Following resolution of secondary syphilis, a* Following resolution of secondary syphilis, a period of latency occurs. No outwardperiod of latency occurs. No outward manifestation of infection, only detected onmanifestation of infection, only detected on serological testing. It may relapse up to 2 yearsserological testing. It may relapse up to 2 years during which Infection can be transmitted toduring which Infection can be transmitted to several partners. Called early latent syphilis.several partners. Called early latent syphilis. * Primary and secondary syphilis are not life* Primary and secondary syphilis are not life threatening. The importance of diagnosis :threatening. The importance of diagnosis : 11 –– rest on the risk of late tertiary syphilis,rest on the risk of late tertiary syphilis, neurosyphilis can be manifested within 5 years ofneurosyphilis can be manifested within 5 years of infection in the form of menoingovascular syphilisinfection in the form of menoingovascular syphilis presents with stroke. This may progresspresents with stroke. This may progress subsequently to tabes dorsalis or general paresissubsequently to tabes dorsalis or general paresis of insane .of insane .
    9. 9. 22 –– Another risk is vertical transmission whichAnother risk is vertical transmission which may cause intrauterine death ( IUD ) on a severelymay cause intrauterine death ( IUD ) on a severely affected neonate.affected neonate. Less severe infection may present during lateLess severe infection may present during late childhood with the stigmata of congenital syphilischildhood with the stigmata of congenital syphilis including eighth nerve deafness, interstitial keratitisincluding eighth nerve deafness, interstitial keratitis and abnormal teeth. The risk of congenital infection isand abnormal teeth. The risk of congenital infection is highest ( 70% ) with primary and secondary syphilis.highest ( 70% ) with primary and secondary syphilis. The effect of late congenital infection are not preventedThe effect of late congenital infection are not prevented unless the mother is treated before 20 weeks ofunless the mother is treated before 20 weeks of gestation.gestation.
    10. 10. Treatment :Treatment : The treatment of choice is penicillin, a variety ofThe treatment of choice is penicillin, a variety of regimens are used.regimens are used. 11 –– Procaine penicillin 1.2 mu daily by IM injection forProcaine penicillin 1.2 mu daily by IM injection for 12 days.12 days. 22 –– Benzathine penicilline 2.4 mu by IM injectionBenzathine penicilline 2.4 mu by IM injection repeated after 7 days .repeated after 7 days . 33 –– Doxycycline 100 mg two times a day for 14 days.Doxycycline 100 mg two times a day for 14 days. 44 –– Erythromycine 500 mg four times a day for 14Erythromycine 500 mg four times a day for 14 days.days. If infection has been present for more than 1 year,If infection has been present for more than 1 year, treatment is extended for 21 days for penicillinetreatment is extended for 21 days for penicilline regimen and 28 days for oral regimen.regimen and 28 days for oral regimen. In pregnancy the absorption of erythromycin isIn pregnancy the absorption of erythromycin is unreliable.unreliable. Partners notification is essential. Children may needPartners notification is essential. Children may need to be tested, and sibling of congenital infection isto be tested, and sibling of congenital infection is possible.possible.
    11. 11. III Tropical Genital Ulcer Disease :III Tropical Genital Ulcer Disease : 11 –– Lymphogranuloma venereum ( LGV ) :Lymphogranuloma venereum ( LGV ) : LGV is caused by specific serovars ( LLGV is caused by specific serovars ( L11 –– LL33 ) of) of chlamydia trachomata, found in the far eats, subchlamydia trachomata, found in the far eats, sub –– saharan Africa and south America.saharan Africa and south America. In early stagesIn early stages –– small superficial ulcer that slowlysmall superficial ulcer that slowly increase in size but often goes unnoticed, more obviousincrease in size but often goes unnoticed, more obvious are enlarged LN which become compressed by theare enlarged LN which become compressed by the inguinal ligament leading to the ( Grooving sign ),inguinal ligament leading to the ( Grooving sign ), sometimes matted together and discharge pus, formingsometimes matted together and discharge pus, forming a Bubo. In women sever proctitis can progress toa Bubo. In women sever proctitis can progress to fistulae and stricture.fistulae and stricture.
    12. 12. Diagnosis :Diagnosis : Confirm serologically by complement fixation test.Confirm serologically by complement fixation test. Treatment :Treatment : 11 –– Doxycycline 100 mg bd for 21 days.Doxycycline 100 mg bd for 21 days. 22 –– Erythromycin 500 mg four times a day for 21Erythromycin 500 mg four times a day for 21 days.days.
    13. 13. 22 –– Chancroid :Chancroid : Is an infection acquired by Haemophilus ducreyi.Is an infection acquired by Haemophilus ducreyi. The geographical distribution is similar to LGV. It startThe geographical distribution is similar to LGV. It start with small shallow ulcers usually multiple and painful,with small shallow ulcers usually multiple and painful, the edges are irregular and with localized LAP.the edges are irregular and with localized LAP. The organisms can only be grown on specializedThe organisms can only be grown on specialized culture medium and ideally the medium should beculture medium and ideally the medium should be inoculated directly from the patient. Even so it may beinoculated directly from the patient. Even so it may be difficult to obtain a positive culture.difficult to obtain a positive culture. Treatment :Treatment : 11 –– Azithromycine 1 gram .Azithromycine 1 gram . 22 –– Ceftriaxone 250 mg IM.Ceftriaxone 250 mg IM. 33 –– ciprofluxacine 500 mg twice a day for 3 days.ciprofluxacine 500 mg twice a day for 3 days.
    14. 14. 33 –– Granuloma inguinale ( Donovanosis ) :Granuloma inguinale ( Donovanosis ) : Caused by Klebsiella granulomatis ( previously knowCaused by Klebsiella granulomatis ( previously know as calymmatobacterium granulomatis ), it is endemicas calymmatobacterium granulomatis ), it is endemic in India, new Guinea and southern Africa.in India, new Guinea and southern Africa. It start with discreet papules on the skin or vulvaIt start with discreet papules on the skin or vulva which can enlarge to form a beefy red painful ulcer,which can enlarge to form a beefy red painful ulcer, these may spread slowly around the perineum and thethese may spread slowly around the perineum and the genitalia. As healing occur, fibrosis develop which maygenitalia. As healing occur, fibrosis develop which may lead to lymphoedema and elephantiasis.lead to lymphoedema and elephantiasis. Diagnosis :Diagnosis : Confirmed by biopsy or a crush preparation I nConfirmed by biopsy or a crush preparation I n which donovan bodies are visible.which donovan bodies are visible.
    15. 15. TTreatment :reatment : 11 –– Ciprofluxacine 750 mg bd for 21 days minimum.Ciprofluxacine 750 mg bd for 21 days minimum. 22 –– Cotrimoxazole 960 mg bd for 21 days minimum.Cotrimoxazole 960 mg bd for 21 days minimum. 33 –– Doxycyclline 100 mg bd for 21 days minimum.Doxycyclline 100 mg bd for 21 days minimum. 44 –– Erythromycin 500 mg four times a day for 21 daysErythromycin 500 mg four times a day for 21 days minimum.minimum.
    16. 16. Other viral infections :Other viral infections : 1- Human papilloma virus :1- Human papilloma virus : More than 70 different types of human papillomaMore than 70 different types of human papilloma virus ( HPV ) have been described. There are certainvirus ( HPV ) have been described. There are certain genital strains preferentially infect the genital mucosagenital strains preferentially infect the genital mucosa and these thought to be sexually transmitted.and these thought to be sexually transmitted. Infection is often established asymptomatically andInfection is often established asymptomatically and may be carried for years, probably life long. The virusmay be carried for years, probably life long. The virus can infect the skin of the vulva, perineum, vagina,can infect the skin of the vulva, perineum, vagina, cervix and rectum. Warts are frequently multiple andcervix and rectum. Warts are frequently multiple and slowly increase in size. They can spread directly to theslowly increase in size. They can spread directly to the perianal skin without anal intercourse being practiced.perianal skin without anal intercourse being practiced. The majority of genital warts are caused by HPV typeThe majority of genital warts are caused by HPV type 6-11 which have little oncogenic potential. HPV types6-11 which have little oncogenic potential. HPV types 16-18 may cause flat warts and have been linked with16-18 may cause flat warts and have been linked with the development of cervical carcinoma.the development of cervical carcinoma.
    17. 17. www.skinchoice.com
    18. 18. Treatment :Treatment : Visible warts are usually treated with :Visible warts are usually treated with : 11 –– Physical methods such as cryotherapy.Physical methods such as cryotherapy. 22 –– Application of podophyllin once or twice / weekApplication of podophyllin once or twice / week for up to 6 weeks.for up to 6 weeks. 33 –– Surgical treatment is used for intractable cases,Surgical treatment is used for intractable cases, employing lasers, electrocautery or scissor excision.employing lasers, electrocautery or scissor excision. Traditionally patients with warts have been advisedTraditionally patients with warts have been advised to use barrier methods of contraception duringto use barrier methods of contraception during treatment and for the subsequent three months.treatment and for the subsequent three months. Sexual partner should be examined and treated ifSexual partner should be examined and treated if have warts.have warts. What ever treatment is used, the warts will recurWhat ever treatment is used, the warts will recur until the immune response control growth of theuntil the immune response control growth of the warts virus. This can take several weeks or evenwarts virus. This can take several weeks or even months.months.
    19. 19. 22 –– Molluscum contagiosum :Molluscum contagiosum : this POX virus produce Painless pearly lesions with athis POX virus produce Painless pearly lesions with a dimple up to 5 mm in diameter, they are common indimple up to 5 mm in diameter, they are common in childhood and clear after few months. Adults maychildhood and clear after few months. Adults may acquire infection during sexual intercourse andacquire infection during sexual intercourse and sometimes mistaken for genital warts.sometimes mistaken for genital warts. Treatment :Treatment : Cryotherapy or following curettage and applicationCryotherapy or following curettage and application of phenol.of phenol. The fluid from the vesicle is infectious and patientsThe fluid from the vesicle is infectious and patients should be warned not to pick at them.should be warned not to pick at them.
    20. 20. Molluscum contagiosumMolluscum contagiosum
    21. 21. 33 –– HIV infection :HIV infection : Acquired immune deficiency syndrome ( AIDS )Acquired immune deficiency syndrome ( AIDS ) Was first described in San Francisco in 1983 causedWas first described in San Francisco in 1983 caused by infection with human immunodeficiency virus ( HIV )by infection with human immunodeficiency virus ( HIV ) it is a devastating disease because of stigmata ofit is a devastating disease because of stigmata of sexual transmission and the risk of verticalsexual transmission and the risk of vertical transmission to children.transmission to children. The onset of immunodeficiency can be manifest inThe onset of immunodeficiency can be manifest in any organ system, so that a high index of suspicionany organ system, so that a high index of suspicion required.required.
    22. 22. Virology :Virology : HIV is a retrovirus, single stranded RNA. ReverseHIV is a retrovirus, single stranded RNA. Reverse transcriptase is carried within the core to enabletranscriptase is carried within the core to enable proviral DNA to be produced in an infected cells. Itproviral DNA to be produced in an infected cells. It usually bind to CDusually bind to CD44 receptors on Treceptors on T –– helper lymphocytes,helper lymphocytes, macrophages, dendretic cells and microglia.macrophages, dendretic cells and microglia. Current antiretrovial drugs target reverseCurrent antiretrovial drugs target reverse transcriptase or viral protease. The aim of these is totranscriptase or viral protease. The aim of these is to decrease the level of virus in the plasma to zero, with adecrease the level of virus in the plasma to zero, with a combination of anticombination of anti –– retroviral agents. If totalretroviral agents. If total suppression not achieve , resistant strain will develop.suppression not achieve , resistant strain will develop.
    23. 23. Diagnosis :Diagnosis : The test should be performed only with informedThe test should be performed only with informed consent from the patient.consent from the patient. 11 –– By finding Ab to gp 120.By finding Ab to gp 120. 22 –– During seroconversion p24 Ag is detectable inDuring seroconversion p24 Ag is detectable in serum before Abserum before Abss are produced.are produced. 33 –– We monitor the disease by measuring CDWe monitor the disease by measuring CD44 lymphocyte level in peripheral blood ( normal level >lymphocyte level in peripheral blood ( normal level > 0.5 /l ).0.5 /l ). Transmission :Transmission : In developing countries, principally spread throughIn developing countries, principally spread through vaginal intercourse.vaginal intercourse. In developed countries, majority of infectionIn developed countries, majority of infection acquired through homosexual sex or IV drug use.acquired through homosexual sex or IV drug use.
    24. 24. Natural history and principles of treatment :Natural history and principles of treatment : 20% of infected individuals experience acute20% of infected individuals experience acute seroconversion illness a few weeks after acquistion,seroconversion illness a few weeks after acquistion, clinical features include fever, LAP, pharyngitis andclinical features include fever, LAP, pharyngitis and conjunctivitis.conjunctivitis. Without Antiretroviral the median time to theWithout Antiretroviral the median time to the development of AIDS is ten years defined by the onsetdevelopment of AIDS is ten years defined by the onset of lifeof life –– threatening opportunistic infection orthreatening opportunistic infection or malignancies associated with immune deficiency.malignancies associated with immune deficiency.
    25. 25. Treatment :Treatment : Usually combination of Antiretroviral agents :Usually combination of Antiretroviral agents : 11 –– Nucleoside analoque reverse transcriptase inhibitorNucleoside analoque reverse transcriptase inhibitor such as Zidovidine.such as Zidovidine. 22 –– NonNon –– nucleoside reverse transcripotase inhibitornucleoside reverse transcripotase inhibitor such as Nevirapine.such as Nevirapine. 33 –– Protase inhibitor such as Nelfinavir.Protase inhibitor such as Nelfinavir. Immune deficiency has already occur, treatment andImmune deficiency has already occur, treatment and prevention of opportunistic infection is needed.prevention of opportunistic infection is needed.
    26. 26. Gynecological manifestations of HIV :Gynecological manifestations of HIV : Include :Include : 11 –– Persistent warts despite aggressive surgicalPersistent warts despite aggressive surgical treatment.treatment. 22 –– Chronic HPV, result in development of cervicalChronic HPV, result in development of cervical carcinoma or vulvar intraepithelial neoplasia andcarcinoma or vulvar intraepithelial neoplasia and Bowen's disease. So prefer annually pap smear inBowen's disease. So prefer annually pap smear in women with HIV.women with HIV. 33 –– Eruption of secondary herpes may becomeEruption of secondary herpes may become widespread, severe and persistent for weeks if notwidespread, severe and persistent for weeks if not diagnosed and treated.diagnosed and treated. 44 –– Post partum endometritis is common in thesePost partum endometritis is common in these women.women.
    27. 27. Kaposi’s sarcoma )Cancer associated with AIDS( Oral Thrush (yeast infection( Common infection associated with AIDS Oral Leukoplakia
    28. 28. Vertical transmission :Vertical transmission : Occur in 25Occur in 25 –– 40 % of pregnancies if no intervention40 % of pregnancies if no intervention is used to reduce the risk.is used to reduce the risk. 3 interventions have been shown to reduce the risk3 interventions have been shown to reduce the risk of vertical transmission :of vertical transmission : 11 –– Avoid breast feeding ( not in poor countries )Avoid breast feeding ( not in poor countries ) 22 –– Elective C/S .Elective C/S . 33 –– Antiviral medication prescribed during the latterAntiviral medication prescribed during the latter half of pregnancy and to the neonate for 6 weeks.half of pregnancy and to the neonate for 6 weeks. By these the risk of transmission, less than 3%.By these the risk of transmission, less than 3%.

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