Infective genital ulcer disease

كلية الطب ? جامعة بابل المرحلة الخامسة د-نسرين مالك
Gynaecology

Genital Tract Infections

(III)-Infective genital ulcer disease:-

I-Genital herpes:-Genital herpes is a sexual transmitted disease caused by the herpes simplex virus (HSV), of which there are two types.
Herpes simplex virus type 1 (HSV-1) usually causes orolabial herpes ( an infection of the lips , mouth, pharynx), and eyes .Is often acquired in childhood.
Herpes simplex virus type 2 (HSV-2) causes most cases of genital herpes infections. However, HSV-1 has increased in frequency and is estimated to be responsible for up to 30 to 40 percent of new genital HSV infections ,as HSV-1 can spread from the mouth to the genitals during oral sex. Still, in most cases, genital herpes is caused by the second type of herpes virus (HSV-2) .

Types of infections:- The clinical designations of genital HSV infection are: primary, non primary first episode, and recurrent .
Primary infection:- refers to infection in a patient without preexisting antibodies to HSV-1 or HSV-2.
Non-primary :-first episode infection refers to the acquisition of genital HSV-1 in a patient with preexisting antibodies to HSV-2 or the acquisition of genital HSV-2 in a patient with preexisting antibodies to HSV-1.
Recurrent infection :- refers to reactivation of genital HSV in which the HSV type recovered in the lesion is the same type as antibodies in the serum.
The majority of initial infections are asymptomatic, although the individual may still be
infectious, and subsequent recurrences may be symptomatic. Recurrence rates are significantly higher
with HSV-2 and reduce in frequency with time.
Clinical manifestation:- Symptoms include genital pain and dysuria, Peri-urethral involvement may cause severe pain , and can cause urinary retention; this may also be partly due to involvement of the sacral nerves.and on examination there are typically multiple superficial tender ulcers with regional lymphadenopathy (although this may be limited to the initial infection).

Diagnosis:-HSV infection can be diagnosed by viral culture, polymerase chain reaction (PCR), direct fluorescent antibody testing. Although less sensitive culture methods are
still used in some centers. Type-specific serology, testing for immunoglobulin (Ig) G and IgM to HSV-1and -2, can be helpful in establishing whether or not an individual is at risk of infection or if the infection is primary, non-primary or a recurrence.
Treatment:- Treatment of the symptoms of genital herpes is a course of aciclovir, which is very safe and effective including in pregnancy, or a related compound (such as valaciclovir).
Primary infection :- Treatment include analgesia and bathing in salt water. Lignocaine gel can be applied to particular sore areas. acyclovir therapy (200 mg PO five times daily for 5 days) to reduce the duration of active lesions and viral shedding.
Recurrent infection :-Among non-pregnant patients, antiviral therapy of recurrent episodes is most likely to be effective if started within the first 24 hours when prodromal symptoms arise( like burning). Long term suppressive therapy (400 mg PO twice daily) this is considerably reduces the frequency of attacks specially for those how have more than 6-8 attacks per year ,although they can still occur and the infection can still be transmitted to partners.
Using a latex barrier (condom ) during sex may protect from herpes, but only if it covers the area where the virus is shedding, and should avoid the sex if there is visible sores on the genitalia.

Neonatal herpes is a devastating infection with a mortality rate of up to 30% and consequent lifelong
neurological morbidity in up to 70%. It is most often acquired during delivery if the mother has primary or non-primary initial infection within the third trimester and especially the last 6 weeks, when reported neonatal infection rates are as high as 41%. IgG to the virus in the serum crosses the placenta and provides neonatal protection from infection, and the risk of neonatal herpes when the mother has lesions of recurrent infection present at delivery is less than 3%. For this reason the recommended mode of delivery for women with first-acquisition genital herpes in the third trimester is prelabour caesarean section, and in those with proven recurrent lesions, vaginal delivery may be anticipated if other obstetricfactors allow.

II-Syphilis:-
Syphilis is a chronic infection caused by the bacterium Treponema pallidum. Syphilis is a highly contagious disease spread primarily by sexual activity, including oral and anal sex. Occasionally, the disease can be passed to another person through prolonged kissing or close bodily contact. Although this disease is spread from sores, the vast majority of those sores go unrecognized. The infected person is often unaware of the disease and unknowingly passes it on to his or her sexual partner. Pregnant women with the disease can spread it to their baby. This disease, called congenital syphilis, can cause abnormalities or even death to the child.
Syphilis cannot be spread by toilet seats, door knobs, swimming pools, hot tubs, bath tubs, shared clothing, or eating.
The manifestations of disease are occurring in any one individual in three distinct stages over time:-
Incubating syphilis:- The median incubation period before clinical manifestations is 21 days (range 3 to 90 days).
Primary syphilis :- The first manifestation of syphilis is a papule, which is typically painless, at the site of inoculation. This soon ulcerates to produce the classic chancre(s) of primary syphilis, a 1 to 2 centimeter painless ulcer with a raised, indurated margin that may be genital or extragenital. The ulcer is associated with mild to moderate regional lymphadenopathy that is often bilateral. Chancres heal spontaneously within three to six weeks, even in the absence of treatment.

Secondary syphilis :- Secondary syphilis is a disseminated systemic process that begins six weeks to six months after the appearance of the chancre in approximately 25 percent of untreated patients. A generalized maculopapular skin rash involving the palms and soles and mucous membranes, but usually sparing the face, is characteristic of this stage of the infection. Generalized lymphadenopathy accompanies the skin rash. Additional clinical features include fever, pharyngitis, weight loss, and large genital lesions called condylomata lata. Although spirochetes can be found in the cerebrospinal fluid (CSF) of around 40 to 50 percent of patients with early syphilis , neurologic manifestations are rare. The rash of secondary syphilis typically resolves spontaneously within two to six weeks.
Latent syphilis :- Latent disease is usually subclinical, although clinical relapses may occur. Syphilis is rarely transmitted during the latent phase, with the exception of perinatal transmission during pregnancy.
Tertiary syphilis:- Tertiary syphilis occurs in approximately one-third of untreated patients, but is now rarely seen since most patients are treated either deliberately or inadvertently when receiving penicillin for other indications. Tertiary syphilis is characterized by slowly progressive signs and symptoms, usually develop 5 to 20 years after the disease has become latent. These includes:-
1-Gummatous lesions: granulomatous, locally destructive lesions typically affecting skin and bone .
2-Cardiovascular involvement: usually affecting the ascending aorta, resulting in aortic valve
incompetence
• 3-Neurological involvement: classified as meningovascular disease, tabes dorsalis and a progressive dementing illness, general paresis .
Diagnosis:-1-Darkfield microscopy:- Diagnosis requires the demonstration of morphologically compatible organisms that display the characteristic motility associated with T. pallidum. A positive slide has delicate, corkscrew-shaped organisms with rigid, tightly wound spirals that move via a forward and backward motion with rotation about the longitudinal axis.
2-Serologic testing :- Two types of serologic testing are available: specific treponemal and non-treponemal antibody tests.
A-Treponemal antibody tests (eg, fluorescent treponemal antibody absorption [FTA-ABS] test, the microhemagglutination assay for antibodies to Treponema pallidum [MHA-TP], and the Treponema pallidum particle agglutination assay [TPPA]) are confirmatory tests that detect antibodies specifically directed at treponemal cellular components. These tests are sensitive and specific, but expensive and correlate poorly with disease activity, since they remain positive despite treatment although reinfection results in the non-treponemal titre rising rapidly. These treponemal tests may also be negative in the very early stages of disease, and should be repeated if negative 4–6 weeks later if this is suspected.
B-Nontreponemal antibody tests (eg, Venereal Disease Research Laboratory [VDRL] test and the Rapid Plasma Reagin [RPR] test) are performed on serum and used as the screening test for syphilis in most settings.
3-Cerebrospinal fluid examination :- CSF examination is essential if there is any clinical evidence
to suggest neurosyphilis.
Treatment:-
Penicillin is the gold standard for the treatment of syphilis in both pregnant and non pregnant individuals. Procaine penicillin 1.2 million units daily , intramuscularly ,for 12 days.or benzathine penicillin 2.4 MU by intramuscular injection, repeated after 7 days.

Penicillin allergy :- Non pregnant women with a history of penicillin allergy may be treated with alternative antibioticseg, erythromycin (500 mg four times per day for 14 das), or tetracycline(100 mg twice per day for 14 days) ,. The only satisfactory treatment for penicillin-allergic pregnant patients with syphilis is desensitization followed by penicillin therapy,because the tetracycline is contraindicated, and the erythromycin is not transfer through the placenta and therefore it can not treat the affected fetus. If the infection have been present for more than 1 year , treatment is extended to 21 days for penicillin regimens and 28 days for oral regimens.

References:-1-Margaret Kingston, Genitourinary problems Gynecology by Ten Teachers, 2 0th Edition ,9,177-195.
2-Jonathan D.C. Ross, Acute Pelvic Infection,Dewhurst’s Textbook of Obstetrics & Gynaecology Ninth Edition ,2018;45: 611-620.